Expectations of rehabilitation following lower limb amputation: a qualitative study.

To explore the expectations of patients about to undergo prosthetic rehabilitation following a lower limb amputation

Testing the credibility, feasibility and acceptability of an optimised behavioural intervention (OBI) for avoidant chronic low back pain patients: protocol for a randomised feasibility study

Background: Chronic back pain continues to be a costly and prevalent condition. The latest NICE guidelines issued in 2009 state that for patients with persistent back pain (of between six weeks and twelve months duration), who are highly distressed and/or disabled and for whom exercise, manual therapy and acupuncture has not been beneficial, the evidence supports a combination of around 100 hours of combined physical and psychological treatment. This is costly, and may prove unacceptable to many patients. A key recommendation of these guidelines was for further randomised controlled trials (RCTs) of psychological treatment and to target treatment to specific sub-groups of patients. Recent trials that have included psychological interventions have shown only moderate improvement at best, and results are not maintained long term. There is therefore a need to test theoretically driven interventions that focus on specific high-risk sub-groups, in which the intervention is delivered at full integrity against a credible control. Methods/design: A feasibility study of a pragmatic randomised controlled trial comparing psychologist-delivered Contextual Cognitive Behavioural Therapy (CCBT) against Treatment As Usual (TAU) physiotherapy delivered by physiotherapists for the treatment of chronic lower back pain in ‘avoidant’ patients. Ninety-two patients referred for physiotherapy will be recruited and randomised on a 1:1 basis to receive CCBT or TAU. Treatment groups will be balanced by centre and pain interference score. Primary outcomes include assessing the credibility and acceptability of the intervention, and to demonstrate proof of principle through a greater change in pain acceptance in the CCBT arm, measured by the Acceptance and Action –II and the Chronic Pain Acceptance questionnaires. In addition, the feasibility of carrying out a full trial will be explored with reference to recruitment and follow-up rates including the assessment of the burden of outcome measure completion. Secondary patient outcomes include disability, pain, fear of movement, mood, quality of life, and global recovery. Outcomes are measured at three and six months post-randomisation. Discussion: This paper details the rationale, design, therapist training system and recruitment methods to be used in a feasibility study which will inform the design and efficient implementation of a future definitive RCT

Patient and family experience of physical rehabilitation on the intensive care unit: a qualitative exploration

ObjectivesTo explore the experience of physical rehabilitation in the intensive care unit (ICU), from the perspective of patients and relatives.DesignExploratory, qualitative study.ParticipantsFive former ICU patients and five family members of former ICU patients recruited from ICU support groups across the UK.InterventionsSemi-structured interviews.Main outcome measuresParticipants’ experiences of physical rehabilitation in the ICU. Data were analysed using an iterative thematic approach.ResultsFour main themes were identified: Trust and Rapport, Necessity (of treatment), Psychological Benefit, and Goal Setting: Whose goal is it anyway? Despite a lack of enjoyment, patients tend to comply with physical rehabilitation, due in part to a positive patient–therapist relationship. There was agreement across participants that physical rehabilitation should be started as soon as possible after admission to ICU and exhaustion was highlighted as the biggest challenge to participation. In addition to aiding physical recovery, physical rehabilitation in the ICU may also provide psychological support for both patients and relatives. Finally, participants described a desire for therapists to direct goal setting in the early stages of recovery as they felt unable to engage in the process due to other priorities.ConclusionsThe experience of physical rehabilitation on ICU may be influenced by key aspects of person-centred care. This study suggests that patients and relatives are keen for physical rehabilitation to start as soon as possible, which is a crucial new finding to support the practice of early rehabilitation in the ICU

Exploring meaningful outcome domains of recovery following lower limb amputation and prosthetic rehabilitation: the patient’s perspective

Purpose: there is currently no consensus regarding what outcome domains to measure following lower limb prosthetic rehabilitation. Prosthetic users have a unique insight into important outcome domains, little is currently known about their critical viewpoint. Materials and methods: a total of 37 participants who underwent lower limb amputation in the last five years were recruited from UK limb fitting centres and social media. Data were collected using focus groups and interviews and analysed using reflexive thematic analysis. Results: five themes were identified. 1) The ability to participate in important activities, 2) how participants were able to undertake these activities, i.e., independently, with ease, safely and with minimal equipment. 3) A comfortable, easy-to-use prosthesis, 4) the importance of managing pain and finally, 5) adjusting and accepting their new normal. These five themes, or outcome domains, did not exist in isolation, but appeared to interact with each other, contributing to, or inhibiting the participant’s holistic sense of recovery. Conclusions: understanding important outcome domains that define what recovery means to people following amputation can help to inform domain consensus, as well as direct the focus of rehabilitation. Domain consensus would guide the selection of measurement tools that evaluate prosthetic interventions in a meaningful way.IMPLICATIONS FOR REHABILITATION There is currently no consensus around which outcome domains should be measured following prosthetic rehabilitation. Outcome domains of importance from a patient’s perspective focus on participation in important activities, prosthesis comfort, pain management, and acceptance of their new normal. Identifying these domains can help direct the focus of rehabilitation as well as inform outcome measurement practice. The interrelated nature of these domains suggests the need for a physical and psychosocial multi-domain approach to outcome measurement in prosthetic rehabilitation, with patient priorities at its centre.</p

Non-oncological outcomes following limb salvage surgery in patients with knee sarcoma: a scoping review

Purpose: Limb salvage surgery is a surgical procedure for tumour resection in bone and soft-tissue cancers. Guidelines aim to preserve as much function and tissue of the limb as possible. Surgical outcome data is routinely available as part of surgical reporting processes. What is less known are important non-oncological outcomes throughout recovery from both clinical and patient perspectives. The objective of this review was to explore non-oncological outcomes in patients diagnosed with sarcoma around the knee following limb salvage surgery.Materials and Methods: A scoping review methodology was used, and results analysed using CASP checklists.Results: Thirteen studies were included and following appraisal and synthesis, three themes emerged as providing important measures intrinsic to successful patient recovery: (1) physical function, (2) quality of life and, (3) gait and knee goniometry. Specifically, patients develop range of motion complications that alter gait patterns and patients often limit their post-operative participation in sport and leisure activities.Conclusions: This study has shown the importance of exploring confounding factors, adopting a holistic view of patient recovery beyond surgical outcomes, proposing evidence-based guidance to support and inform healthcare providers with clinical decision-making. This review highlights the paucity and lack of quality of research available, emphasising how under-represented this population is in the research literature

An investigation of proprioception illusion using a stimulator with feedback control

It is possible to create illusions of limb movements using vibrations over the skin. If a muscle is vibrated it can feel as if the limb is moving while it remains still. These illusions have been studied for decades but it is not yet entirely clear how to create them effectively and repeatedly. In this study, three parameters were varied; the frequency of the vibration, the stimulation site and the arm position. A closed loop control of the vibration frequency was used to ensure a fixed frequency over the stimulation time and across the participants. The experiment included twenty-five able-bodied participants (mean age 32±7 years, 9 females). A hanging arm position was introduced with the aim to increase the success rate of illusions compared to other studies. Twenty-four participants felt an illusion across all scenarios. The results highlight that tactile feedback affects the illusion

From outcome measurement to improving health outcomes following lower limb amputation - A narrative review exploring outcome measurement from a clinical practice perspective

Background: Outcome measurement is essential to understand the impact of clinical interventions and the performance of services. Despite national and professional body encouragement, and successful examples of system level outcome measurement within some health care settings, many barriers still exist preventing outcome measurement from becoming embedded in clinical practice. Objectives: To explore the status of outcome measurement in prosthetic rehabilitation, as applied in clinical practice, with a view to identifying areas of future work aimed at making outcome measurement in prosthetic rehabilitation a meaningful and useful reality. Study Design: Narrative review Methods: A literature search of four databases was undertaken, following the PRISMA principals appropriate to narrative reviews, and using the search terms outcome, measure*, tool, scale, instrument, prosthe*, amput* and limb loss. A total of 1116 papers were identified. Following screening 35 papers, focusing on four main themes, were included in the review. Results: The four themes were 1) What outcomes should be measured? 2) How can these outcomes be measured? 3) What are the barriers to outcome measurement? and 4) What examples of routine outcome measurement currently exist in prosthetic practice? Conclusions: Successful outcome measurement in clinical practice is multifaceted. Understanding and embedding value at every step is key to success. Addressing the questions of `why’, `what’ and `how’ we measure outcome may move us closer to a consensus. Routine outcome measurement at the clinical level should ensure data collection is valuable to clinical practice, makes use of IT solutions and has all important organisational buy in

Ethical considerations and approaches for conducting clinical research studies related to prosthetics, orthotics and wheelchair technology in the low- and middle-income countries

Rapid developments in prosthetics, orthotics and wheelchair technology have increased clinical research and development initiatives worldwide. Testing technology involving human subjects / participants creates ethical concerns that are under-explored and become a critical issue for prosthetists, orthotists,researchers and their clients, especially those in the low- and middle-income countries. While some research initiatives have aligned with existing institutions, companies, and service providers; some research emerging from institutions / organisations with non-clinical and non-assistive technology backgrounds have raised considerable foundation for concerns. It is essential to develop, apply andpromote appropriate and clear guiding principles for institutions / organisations conducting clinical research studies or trials, particularly in the low- and middle-income countries. Thus, practicing professionals can enable people with disabilities (often among the most excluded and vulnerable group in the society) to provide informed consent, make informed choices, and facilitate their active engagement in clinical research studies or trials without physical, psychological, and socioeconomic harm.The outcome of the consultation between ISPO and Exceed Research Network (ERN) has led to the development of the guiding principles, laid out below, specifically directed towards the clinical research studies or technology trials involving people with disability (not on broader research into disability-relatedissues)

Learning about the changing needs for prosthetics service provision from routinely collected digital centre management data: an exemplar study across three clinics in Cambodia

Background: Prosthetic service development and delivery rely on data describing population needs. These needs are context-specific, but most existing data come from high-income countries or small geographic areas, which are often not comparable. This study analysed routinely collected digital patient record data at multiple time points to provide insights into characteristics of people accessing Cambodian prosthetic services. Methods: We investigated trends in birth year, sex, year and reason for limb absence, and prosthesis type, over three decades. Then, we observed data from 2005 and 2019 indicating how the population actively accessing prosthetics services has changed. Results: Temporal trends in prosthetics service user demographics corresponded with events in Cambodia's socio-political history. The predominant historical reason for limb absence prior to 2000 was weapon trauma during and following conflict. Since 2000, this was replaced by non-communicable disease and road accidents. Transtibial remained the most prevalent amputation level but transfemoral amputation had higher incidence for people with limb loss from road accidents, and people with limb loss due to disease were older. These observations are important as both transfemoral and older-aged groups experience particular rehabilitation challenges compared to the young, transtibial group. Conclusions: The study shows how standardised, routinely collected data across multiple clinics within a country can be used to characterise prosthetics service user populations and shows significant changes over time. This indicates the need to track client characteristics and provides evidence for adapting services according to population dynamics and changes in patient need.</p