Cheriel J. Hofstad

Stump management after trans-tibial amputation: A systematic review

In order to achieve stump healing after trans-tibial amputation, various methods are applied, such as soft dressings followed by elastic wrapping of the stump, rigid dressings, semi-rigid dressings, and more recently the application of silicon or gel-liners. A systematic literature search was performed to identify the optimal post-amputation management. The methodological quality of the studies was systematically evaluated by using a predefined list of criteria. Only 11 controlled studies were identified and evaluated for their methodological quality. From these studies, no studies were classified as A-level studies, whereas three were classified as B-level, and 8 were classified as C-level studies. Relevant literature appears heterogeneous with respect to patient selection, intervention and outcome measures. Despite the large variability of included studies, this review reveals a trend in favour of rigid and semi-rigid dressings for achieving stump healing and reduction of stump volume. No conclusions can be drawn with regard to the effect on functional outcome. The literature is not conclusive on the effects of early weight bearing on stump healing, volume reduction, and functional outcome. More research is needed for the development of evidence-based clinical practice guidelines concerning management after trans-tibial amputation.

Use of the Delphi Technique for developing national clinical guidelines for prescription of lower-limb prostheses

The aim of this project was the development of evidence- and consensus-based clinical practice guidelines for lower-limb prosthesis prescription for achieving transparency and consensus among clinicians, manufacturers, and insurance companies. This article describes a modified Delphi Technique, which is based on different methods of collecting evidence, and its role in the development of national clinical guidelines for prosthesis prescription. We used a multimethod approach to develop guidelines for the clinical practice of prosthesis prescription for lower-limb amputees. The Delphi Technique was central in the process, and the panel was made up of experts from three key disciplines on a national level. Our approach involved various methods: a systematic review, a survey of national clinical practice on prosthesis prescription, and interviews with experts. These activities resulted in 45 postulates about prosthesis prescription. The views of the national expert panel were then presented at a consensus development conference. The participants in the Delphi Technique sessions reached a consensus on 37 of the postulates on prosthesis prescription for lower-limb amputees. The postulates were categorized according to amputation level and partitioned into different domains. The total process resulted in the development of draft clinical guidelines comprising guidance for prescribing prostheses for the lower limb. The scope and applicability of these guidelines will have to be measured and evaluated in future work.

Evidence for bilaterally delayed and decreased obstacle avoidance responses while walking with a lower limb prosthesis

OBJECTIVE To examine whether the increased failure rates in obstacle avoidance of patients with lower limb amputation can be understood on the basis of increased delay and/or decreased amplitudes of obstacle avoidance responses. METHODS Subjects performed obstacle avoidance on a treadmill while EMG recordings were made of several major muscles of the leg. RESULTS It was found that subjects with a lower limb amputation have delayed responses (e.g. delays of 20 ms for the Biceps Femoris) and have decreased response amplitudes (36-41% smaller). Furthermore, such changes were observed not only on the prosthetic side, but also on the sound side. The decreased amplitudes were associated with increased failure rates in the obstacle avoidance task. CONCLUSIONS It is concluded that the bilaterally delayed and reduced responses in persons with a lower limb prosthesis reflect a basic reorganization within the central nervous system aimed at providing synchronized activity in both lower limbs, even though the peripheral deficit involves only one limb. SIGNIFICANCE The present results on obstacle avoidance responses can be used to evaluate future prosthetic training involving obstacle crossings for amputee rehabilitation.

From satisfaction to expectation: the patient's perspective in lower limb prosthetic care.

Purpose. To obtain information about the wishes and experiences of patients with a lower limb amputation with regard to prosthetic prescription and their exchange of information with the healthcare providers. Method. Design: Cross-sectional questionnaire. Setting: Outpatient clinic of a Rehabilitation Centre. Study participants: A random sample of patients with a lower limb amputation (n = 81). Main outcome measures: In analogy with the QUOTE questionnaire a focus group technique was used. Prosthetic users formulated 24 specific items, which were of importance according to them. The items were divided into 4 categories: (i) service demand, (ii) prosthetic prescription, (iii) information, (iv) insurance aspects. The questionnaire consisted of two sets (A and B) of 24 items rating importance of items and experience in everyday practice. To identify different dimensions within the 24 items, a factor analysis in SPSS was performed for lists A and B followed by a varimax rotation. Impact factors were calculated by multiplying the mean score of importance on an item with the percentage of patients that experienced this item as negative. Results. A total of 113 questionnaires were sent by e-mail with a response of 73%. The outcomes of the questionnaires resulted in 2 sets of information: One concerning the importance of several items in the process of prosthetic prescription, the other the experience of the prosthetic user about those items. By multiplying the scores on importance by the percentage of negative experience per item (impact score) points of improvement for clinical practice were formulated. Conclusions. A discrepancy between the needs of patients and what they experience in their contacts with clinical professionals as the most important dimension was noticed. A questionnaire with specific items for a homogeneous target group is a good method to formulate points of improvement for clinical practice in healthcare.

Prosthetic prescription in the Netherlands: an interview with clinical experts

In the process of guideline development for prosthetic prescription in the Netherlands the authors made a study of the daily clinical practice of lower limb prosthetics. Besides the evidence-based knowledge from literature the more implicit knowledge from clinical experts is of importance for guideline development. In order to obtain this information the authors performed both an observational study of clinical practice and an interview study with 11 clinical experts from the three key disciplines in this field. The latter study is presented here as a descriptive and qualitative study. The combination of the opinions on prescription criteria given in these semi-structured interviews appeared divided with regard to various options in the prescription of a lower limb prosthesis. However, the implicit knowledge is considered by the authors of importance for the consensus procedure on guideline development. Prosthetic prescription criteria seem to be based on local experience and partly on assumptions. A consensus procedure can lead to improvement of the knowledge about prosthetic prescription.

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&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.

The impact of ankle osteoarthritis. The difference of opinion between patient and orthopedic surgeon

BACKGROUND Outcome measures for ankle osteoarthritis (OA) are created by physicians with little input of the target patient group. The aim of this study was to determine the difference in opinion between patients and orthopedic surgeons concerning the importance of specific symptoms of ankle OA and its impact on daily life and function. METHODS A modified Delphi method was applied, consisting of structured interviews with patient focus groups and experts, followed by a poll using 32 statements. The difference in opinion between patients and orthopedic surgeons was evaluated. RESULTS Forty patients and forty orthopedic surgeons responded to the 32 statements. Statistically significant differences in opinion on symptoms, function and the impact of ankle OA on daily life were found. CONCLUSIONS This study demonstrates a significant difference in opinion between patients and orthopedic surgeons concerning specific symptoms of ankle OA. These results advocate incorporating the needs and demands of the individual patient for new outcome measures.

Are current foot- and ankle outcome measures appropriate for the evaluation of treatment for osteoarthritis of the ankle?: Evaluation of ceiling effects in foot- and ankle outcome measures

BACKGROUND Many PROMs used for evaluation of ankle osteoarthritis are not validated for this purpose. We hypothesize that frequently used PROMs have an early ceiling or floor effect. METHODS We prospectively collected data from patients with ankle osteoarthritis between 2011 and 2013. At baseline visit patients completed the Foot and Ankle Outcome Score, the Ankle Osteoarthritis Score, the American Orthopaedic Foot and Ankle Society scale, a visual analogue scale for pain and quality of life. Outcomes were analyzed for floor or ceiling effects. RESULTS 197 patients were included in the study. A floor effect was present for the AOFAS and VAS for pain in all groups. Floor and ceiling effect are absent for the FAOS outcome measure for all groups. CONCLUSIONS Physicians should be aware of floor or ceiling effects when evaluating treatment using patient reported outcome measures. The FAOS outcome measure lacks early ceiling or floor effects.