Prescription of prostheric ankle-foot mechanisms after lower limb amputation

BACKGROUND: A prosthesis can be divided into several components: the prosthetic socket; the prosthetic ankle‐foot mechanism; and for higher levels of amputation, the prosthetic knee. This review focuses on the prosthetic ankle‐foot mechanism, which forms an important part of the prosthesis in terms of mobility. A correct prosthetic prescription can be derived by matching the functional abilities of the individual with a lower limb amputation with the technical and functional aspects of the various prosthetic ankle‐foot mechanisms. However, there seems to be no clear clinical consensus on the precise prescription criteria for the various prosthetic ankle‐foot mechanisms in relation to the functional abilities of individuals with a lower limb amputation. OBJECTIVES: To obtain information about aspects of prosthetic ankle‐foot mechanisms and daily functioning of individuals with a lower limb prosthesis, for appropriate prosthetic prescription criteria. SEARCH METHODS: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (April 2006), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, Issue 2), MEDLINE (1966 to April 2006), EMBASE (1983 to April 2006), CINAHL (1982 to April 2006), AMED (Allied and Complimentary Medicine) (1985 to April 2006), and reference lists of articles. No language restrictions were applied. SELECTION CRITERIA: All randomised controlled trials and quasi‐randomised controlled trials comparing different ankle foot mechanisms for lower limb amputation in adults. No language restrictions were applied. DATA COLLECTION AND ANALYSIS: Two review authors independently identified potential articles from the literature search. Methodological quality was assessed using a checklist comprising 13 criteria. The reviewers extracted data using pre‐defined extraction forms. MAIN RESULTS: Twenty‐six trials were included, with a total of 245 participants. The numbers of participants in the included trials ranged from three to sixteen. The methodological quality was moderate. Only one study was of high quality. All included studies used cross‐over designs allowing sufficient control for confounding. In individuals with a transtibial amputation, there seems to be a small tendency towards a greater stride length when walking with the Flex‐foot in comparison to the SACH (solid‐ankle cushioned heel) foot. When walking speed was increased, the energy cost was lower. In high activity individuals with a transfemoral amputation, there is limited evidence for the superiority of the Flex foot during level walking compared with the SACH foot in respect of energy cost and gait efficiency. AUTHORS' CONCLUSIONS: There is insufficient evidence from high quality comparative studies for the overall superiority of any individual type of prosthetic ankle‐foot mechanism, although there is a small trend towards the Flex‐foot in comparison with the SACH foot for greater stride length and lower energy cost in individuals with a transtibial amputation, and improved gait efficiency and lower energy cost in high activity individuals with a transfemoral amputation. In prescribing prosthetic‐ankle foot mechanisms for individuals with a lower limb amputation, practitioners should take into account availability, patient functional needs, the type of knee mechanism to be prescribed and the inter‐relationship with ankle‐foot mechanisms, and cost

Even low alcohol concentrations affect obstacle avoidance reactions in healthy senior individuals

<p>Abstract</p> <p>Background</p> <p>Alcohol is a commonly used social drug and driving under influence is a well-established risk factor for traffic accidents<abbrgrp><abbr bid="B1">1</abbr></abbrgrp>. To improve road safety, legal limits are set for blood alcohol concentration (BAC) and driving, usually at 0.05% (most European countries) or 0.08% (most US states, Canada and UK). In contrast, for walking there are no legal limits, yet there are numerous accounts of people stumbling and falling after drinking. Alcohol, even at these low concentrations, affects brain function and increases fall risk. An increased fall risk has been associated with impaired obstacle avoidance skills. Low level BACs are likely to affect obstacle avoidance reactions during gait, since the brain areas that are presumably involved in these reactions have been shown to be influenced by alcohol. Therefore we investigated the effect of low to moderate alcohol consumption on such reactions.</p> <p>Thirteen healthy senior individuals (mean(SD) age: 61.5(4.4) years, 9 male) were subjected to an obstacle avoidance task on a treadmill after low alcohol consumption. Fast stepping adjustments were required to successfully avoid suddenly appearing obstacles. Response times and amplitudes of the m. biceps femoris, a prime mover, as well as avoidance failure rates were assessed.</p> <p>Findings</p> <p>After the first alcoholic drink, 12 of the 13 participants already had slower responses. Without exception, all participants' biceps femoris response times were delayed after the final alcoholic drink (avg ± sd:180 ± 20 ms; <it>p </it>< 0.001) compared to when participants were sober (156 ± 16 ms). Biceps femoris response times were significantly delayed from BACs of 0.035% onwards and were strongly associated with increasing levels of BAC (<it>r </it>= 0.6; <it>p </it>< 0.001). These delays had important behavioural consequences. Chances of hitting the obstacle were doubled with increased BACs.</p> <p>Conclusions</p> <p>The present results clearly show that even with BACs considered to be safe for driving, obstacle avoidance reactions are inadequate, late, and too small. This is likely to contribute to an increased fall risk. Therefore we suggest that many of the alcohol-related falls are the result of the disruptive effects of alcohol on the online corrections of the ongoing gait pattern when walking under challenging conditions.</p

Prosthetic prescription in the Netherlands:an observational study

Prosthetic prescription for lower limb amputees and the methodology used are primarily based on empirical knowledge. Clinical expertise plays an important role that can lead to an adequate prescription; however, a clear evidence based motivation for the choices made cannot be given. This can lead to local prescription variations with regard to overuse or underuse of prosthetic care and a lack of transparency for consumers and health insurance companies. Hence a clinical guideline may lead to a more consistent and efficient clinical practice and thus more uniformly high quality care.The purpose of this study was to get insight into potential similarities in prescription criteria in clinical practice in the Netherlands. Secondly, the authors were interested to know if prosthetic prescription was primarily based on the level of activity or intended use of the prosthesis.As part of the development of a consensus-based clinical guideline a multi-centred, cross-sectional study was carried out in order to observe the prosthetic prescription for a group of lower limb amputees. Therefore prescription data were collected from 151 amputees with trans-femoral amputation, knee disarticulation or trans-tibial amputation.Results of the multiple logistic regression show no relationship between the activity level and any of the variables included in the equation such as the hospital or medical doctor in Physical and Rehabilitation Medicine (MD in P&amp;RM), prosthetic components, age of the amputee or reason of amputation. The criteria used are merely based on the clinical expertise and local experience whereas the actual prescriptions differ from location to location.In conclusion the development of a clinical guideline for prosthetic prescription in lower limb amputation is recommended. The information gained from this observational study will be used in a clinical guideline procedure for prosthetic prescription in the Netherlands.</p

Multiple case study to describe influencing factors on effectiveness of an interdisciplinary in-patient intervention for feeding problems in children

In children with chronic feeding problems diagnoses and physical, cognitive and behavioral impairments vary enormous. In addition to these variables, we hypothesize that personal and environmental factors also contribute to the success of intervention for feeding problems. This exploratory study describes the effectiveness and influencing factors of an intensive, multidisciplinary child and parent centered intervention on calorie intake and solid food consumption. The intervention included a behavioral program, oral motor training, parental coaching and dietary support. The children participating in the intervention could be separated into three groups: tube-fed (n=12), selective food refusal by texture (n=6) and unpredictable food refusal (n=11). For each group we present a descriptive representative case study. Outcome measures were calorie intake and amount of solid food consumed. The average duration of the in-patient feeding intervention was 4.3 weeks (SD 1.4 weeks). Three months after discharge, 50% of the children receiving tube feeding had complete oral intake. Children with selective food refusal by texture made small progresses during the intervention but solid food intake had increased at follow-up. Children with unpredictable food refusal increased their oral intake already during the intervention and maintained these gains at home. The intensive interdisciplinary intervention showed increased calorie and oral intake in most children and reduced tube feeding, but was less successful in children with metabolic dysfunction. Recovery time was longest in the tube feeding group but results varied considerably per child. Successful feeding intervention in children needs to take into account a child's underlying physical and behavioral and environmental factors

Does Centralization of Radical Prostatectomy Reduce the Incidence of Postoperative Urinary Incontinence?

Background: On the basis of previous analyses of the incidence of urinary incontinence (UI) after radical prostatectomy (RP), the hospital RP volume threshold in the Netherlands was gradually increased from 20 per year in 2017, to 50 in 2018 and 100 from 2019 onwards. Objective: To evaluate the impact of hospital RP volumes on the incidence and risk of UI after RP (RP-UI). Design, setting, and participants: Patients who underwent RP during 2016–2020 were identified in the claims database of the largest health insurance company in the Netherlands. Incontinence was defined as an insurance claim for ≥1 pads/d. Outcome measurements and statistical analysis: The relationship between hospital RP volume (HV) and RP-UI was assessed via multivariable analysis adjusted for age, comorbidity, postoperative radiotherapy, and lymph node dissection. Results and limitations: RP-UI incidence nationwide and by RP volume category did not decrease significantly during the study period, and 5-yr RP-UI rates varied greatly among hospitals (19–85%). However, low-volume hospitals (≤120 RPs/yr) had a higher percentage of patients with RP-UI and higher variation in comparison to high-volume hospitals (&gt;120 RPs/yr). In comparison to hospitals with low RP volumes throughout the study period, the risk of RP-UI was 29% lower in hospitals shifting from the low-volume to the high-volume category (&gt;120 RPs/yr) and 52% lower in hospitals with a high RP volume throughout the study period (&gt;120 RPs/yr for 5 yr). Conclusions: A focus on increasing hospital RP volumes alone does not seem to be sufficient to reduce the incidence of RP-UI, at least in the short term. Measurement of outcomes, preferably per surgeon, and the introduction of quality assurance programs are recommended. Patient summary: In the Netherlands, centralization of surgery to remove the prostate (RP) because of cancer has not yet improved the occurrence of urinary incontinence (UI) after surgery. Hospitals performing more than 120 RP operations per year had better UI outcomes. However, there was a big difference in UI outcomes between hospitals.</p

Daily functioning and self-management in patients with chronic low back pain after an intensive cognitive behavioral programme for pain management

Chronic low back pain (CLBP) is associated with persistent or recurrent disability which results in high costs for society. Cognitive behavioral treatments produce clinically relevant benefits for patients with CLBP. Nevertheless, no clear evidence for the most appropriate intervention is yet available. The purpose of this study is to evaluate the mid-term effects of treatment in a cohort of patients with CLBP participating in an intensive pain management programme. The programme provided by RealHealth-Netherlands is based on cognitive behavioral principles and executed in collaboration with orthopedic surgeons. Main outcome parameters were daily functioning (Roland and Morris Disability Questionnaire and Oswestry Disability Questionnaire), self-efficacy (Pain Self-Efficacy Questionnaire) and quality of life (Short Form 36 Physical Component Score). All parameters were measured at baseline, last day of residential programme and at 1 and 12 months follow-up. Repeated measures analysis was applied to examine changes over time. Clinical relevance was examined using minimal clinical important differences (MCID) estimates for main outcomes. To compare results with literature effect sizes (Cohen’s d) and Standardized Morbidity Ratios (SMR) were determined. 107 patients with CLBP participated in this programme. Mean scores on outcome measures showed a similar pattern: improvement after residential programme and maintenance of results over time. Effect sizes were 0.9 for functioning, 0.8 for self-efficacy and 1.3 for physical functioning related quality of life. Clinical relevancy: 79% reached MCID on functioning, 53% on self-efficacy and 80% on quality of life. Study results on functioning were found to be 36% better and 2% worse when related to previous research on, respectively, rehabilitation programmes and spinal surgery for similar conditions (SMR 136 and 98%, respectively). The participants of this evidence-based programme learned to manage CLBP, improved in daily functioning and quality of life. The study results are meaningful and comparable with results of spinal surgery and even better than results from less intensive rehabilitation programmes

Improvement of the classification system for wheelchair rugby: athlete priorities

A representative sample (N=302) of the wheelchair rugby population responded to a survey about the classification system based on prioritized items by International Wheelchair Rugby Federation members. Respondents stated, "The classification system is accurate but needs adjustments" (56%), "Any athlete with tetraequivalent impairment should be allowed to compete" (72%), "Athletes with cerebral palsy and other coordination impairments should be classified with a system different than the current one" (75%), and "The maximal value for trunk should be increased from 1.0 to 1.5" (67%). A minority stated, "Wheelchair rugby should only be open to spinal cord injury and other neurological conditions" (36%) and "There should be a 4.0 class" (33%). Results strongly indicated that athletes and stakeholders want adjustments to the classification system in two areas: a focus on evaluation of athletes with impairments other than loss of muscle power caused by spinal cord injury and changes in classification of trunk impairment.status: publishe