Christopher Kevin Wong

Preliminary Assessment of Balance With the Berg Balance Scale in Adults Who Have a Leg Amputation and Dwell in the Community: Rasch Rating Scale Analysis

Background Self-report measures of balance and multidimensional mobility assessments are common for people with a leg amputation, yet clinical assessment of balance ability remains less explored. The Berg Balance Scale (BBS), typically used for other populations with impaired balance, has been used for young people with a high level of functioning after traumatic amputation but rarely for older people after vascular amputation. Objective The study objective was to examine the psychometric properties of the BBS with Rasch rating scale analysis to determine the validity and utility of the BBS in assessing balance ability in adults who have a leg amputation and dwell in the community. Design Rating scale analysis was applied to BBS scores obtained from a single assessment. Methods Adult volunteers (men and women) who had a leg amputation (any level and etiology) and dwelled in the community were recruited from a hospital-based community support group and a prosthetic clinic. Rating scale analysis of the BBS was used to assess unidimensionality, internal validity, goodness of fit, structural integrity, and person and item analyses. Results The study participants were 40 people (26 men and 14 women; 57.8 [SD=9.7] years old) with leg amputations (24 transtibial, 13 transfemoral, and 3 bilateral) of mixed etiology (32 vascular and 8 nonvascular). The psychometric properties of the BBS confirmed that it measures the unidimensional construct of balance ability with adequate validity and with goodness of fit and structural integrity that meet the acceptability criteria. Person measures revealed that some participants scored near the top of the BBS, suggesting a ceiling effect; item measures revealed that participants with leg amputations had the most difficulty performing the following tasks: standing with 1 leg in front, turning 360 degrees, and placing alternate foot on a stool. Limitations Limitations included a convenience sample and a lack of rater reliability testing. Conclusions The BBS cohered with the unidimensional construct of balance ability and had strong internal validity for use in a variety of people with leg amputations.

Interrater Reliability of the Berg Balance Scale When Used by Clinicians of Various Experience Levels to Assess People With Lower Limb Amputations

Background People with lower limb amputations frequently have impaired balance ability. The Berg Balance Scale (BBS) has excellent psychometric properties for people with neurologic disorders and elderly people dwelling in the community. A Rasch analysis demonstrated the validity of the BBS for people with lower limb amputations of all ability strata, but rater reliability has not been tested. Objective The study objective was to determine the interrater reliability and intrarater reliability of BBS scores and the differences in scores assigned by testers with various levels of experience when assessing people with lower limb amputations. Design This reliability study of video-recorded single-session BBS assessments had a cross-sectional design. Methods From a larger study of people with lower limb amputations, 5 consecutively recruited participants using prostheses were video recorded during an in-person BBS assessment. Sixteen testers independently rated the video-recorded assessments. Testers were 3 physical therapists, 1 occupational therapist, 3 third-year and 4 second-year doctor of physical therapy (DPT) students, and 5 first-year DPT students without clinical training. Rater reliability was calculated using intraclass correlation coefficients (ICC [2,k]). Differences in scores assigned by testers with various levels of experience were determined by use of an analysis of variance with Tukey post hoc tests. Results The average age of the participants was 53.0 years (SD=15.7). Amputations had occurred at the ankle disarticulation, transtibial, and transfemoral levels because of vascular, trauma, and medical etiologies an average of 8.2 years earlier (SD=7.9). Berg Balance Scale scores spanned all ability strata. Interrater reliability (ICC [2,k]=.99) and intrarater reliability of scores determined in person and through video-recorded assessments by the same testers (ICC [2,k]=.99) were excellent. For participants with the lowest levels of ability, licensed professionals assigned lower scores than did DPT students without clinical training. Limitations Intrarater reliability calculations were based on 2 testers. Conclusions Berg Balance Scale scores assigned to people using prostheses by testers with various levels of clinical experience had excellent interrater reliability and intrarater reliability.

Role of balance ability and confidence in prosthetic use for mobility of people with lower-limb loss

For people with lower-limb loss, impaired balance is common and limits prosthetic function within the community. This cross-sectional study (1) analyzed relationships among prosthetic use for mobility, balance ability and confidence, and amputation-related variables and (2) determined multivariate models to identify level of prosthetic use. Subjects included 46 community-dwelling adults (mean age 56.2 yr) with limb loss (91.3% unilateral) of varied levels (52.2% transtibial) and etiologies (69.6% vascular). A three-variable linear regression model including balance ability, balance confidence, and years since amputation explained 63.7% of variance in the Houghton scale of prosthetic use score. A logistic regression model including the 14-task Berg Balance Scale, balance confidence, years since amputation, age, and number of comorbidities correctly differentiated between people who had reached a satisfactory level of prosthetic use or not 89.1% of the time. The first three variables demonstrated moderate accuracy with positive likelihood ratios from 2.34 to 4.35. The regression model was further reduced to correctly classify 87.0% of cases with three balance ability tasks (retrieving objects from floor, turning to look behind, and placing alternate foot on stool), balance confidence, and numbers of comorbidities. Logistic models that include balance ability, balance confidence, and numbers of comorbidities can identify level of prosthetic use in people with lower-limb loss. Increased balance confidence and ability when retrieving objects from floor, turning to look behind, and placing alternate foot on stool were most indicative of successful prosthetic use for mobility.

BAlANCE ABIlITy MEASURED WITh ThE BERg BAlANCE SCAlE: A DETERMINANT OF FAll hISTORy IN COMMUNITy-DWEllINg ADUlTS WITh lEg AMPUTATION

OBJECTIVEnFalls are common among adults with leg amputations and associated with balance confidence. But subjective confidence is not equivalent with physical ability. This multivariate analyses of community-dwelling adults with leg amputations examined relationships among individual characteristics, falls, balance ability and balance confidence.nnnDESIGNnCross-sectional study.nnnSUBJECTS/PATIENTSnCommunity-dwelling adults with leg amputations recruited from a support group and prosthetic clinic.nnnMETHODSnSubjects provided self-reported medical/fall history, prosthetic functional use, and Activities-specific Balance Confidence (ABC) questionnaire data. Balance ability was assessed with the Berg Balance Scale (BBS). Fall incidence was categorized as any fall (one or more) and recurrent falls (more than one). Multivariate logistic regression analyzed relationships within the two fall categories. Cross tabulations and ANOVA analyzed differences among subcategories.nnnRESULTSnFifty-four subjects (mean age 56.8) with various etiologies, amputation levels, and balance abilities participated. 53.7% had any fall; 25.9% had recurrent falls. Models for both fall categories correctly classified fall history in >u200970% of subjects with combinations of the variables ABC, BBS, body-mass-index, and amputation level.nnnCONCLUSIONnFalls occurred regardless of clinical characteristics. Total BBS and select item scores were independent determinants of fall history. Unlike other balance-impaired populations, adults with leg amputation and better balance ability had greater odds of falling.

Risk of fall-related injury in people with lower limb amputations: a prospective cohort study

OBJECTIVEnTo assess fall-related injury risk and risk factors in people with lower limb amputation.nnnDESIGNnProspective longitudinal cohort with follow-up every 6 months for up to 41 months.nnnSUBJECTSnCommunity-dwelling adults with lower limb amputations of any etiology and level recruited from support groups and prosthetic clinics.nnnMETHODSnDemographic and clinical characteristics were obtained by self-reported questionnaire and telephone or in-person follow-up. Fall-related injury incidence requiring medical care per person-month and adjusted hazard ratio of fall-related injury were calculated using multivariable proportional hazards regression modeling.nnnRESULTSnA total of 41 subjects, with 782 follow-up person-months in total, had 11 fall-related injury incidents (14.1/1,000 person-months). During follow-up, 56.1% of subjects reported falling and 26.8% reported fall-related injury. Multivariable proportional hazard modeling showed that women were nearly 6 times more likely as men to experience fall-related injury and people of non-white race were 13 times more likely than people of white race to experience fall-related injury. The final predictive model also included vascular amputation and age.nnnCONCLUSIONnRisk of fall-related injury requiring medical care in people with lower limb amputation appears to be higher than in older adult inpatients. Intervention programs to prevent fall-related injury in people with lower limb amputation should target women and racial minorities.

Use of the Houghton Scale to Classify Community and Household Walking Ability in People With Lower-Limb Amputation: Criterion-Related Validity

OBJECTIVEnTo examine the criterion-related validity of using the self-reported Houghton Scale to classify community-dwelling people with lower-limb amputation according to the suggested score ranges for independent community (Houghton Scale score ≥9), household and limited community (Houghton Scale scores 6-8), and limited household (Houghton Scale score ≤5) walking ability categories as referenced to performance-based balance ability and walking speed criteria.nnnDESIGNnCross-sectional cohort study.nnnSETTINGnCommunity-based wellness walking programs in 8 states in the Mid-Atlantic, Midwest, and Southeast regions of the U.S.nnnPARTICIPANTSnVolunteers (N=180; 66.5% men, n=118; mean age, 55.5±16y) 7.1±13.1 years since amputation, with transtibial-level amputation in 47% (n=79) and amputation caused by vascular disease in 49.4% (n=89).nnnINTERVENTIONSnNone.nnnMAIN OUTCOME MEASURESnSelf-reported data: Houghton Scale, Prosthetic Evaluation Questionnaire mobility subscale, and Activities-specific Balance Confidence (ABC) Scale. Clinical performance-based measures: balance ability assessed with 3 Berg Balance Scale (BBS) items and walking ability assessed with the timed Up and Go (TUG) test and 2-minute walk test (2MWT). The primary reference criteria were performance-based balance ability measured with the 3 BBS items and gait speed calculated from the 2MWT.nnnRESULTSnOn the Houghton Scale, 45.9% (78/170) of the participants scored ≥9, 30.6% (52/170) of the participants scored between 6 and 8, and 23.5% (40/170) of the participants scored ≤5. The Houghton Scale correlated with the Prosthetic Evaluation Questionnaire mobility subscale (r=.73), ABC Scale (r=.76), balance ability (r=.67), TUG test (r=-.67), and 2MWT (r=.73). The 3 Houghton Scale ability categories differed significantly from each other (P<.05) for all outcome measures: Prosthetic Evaluation Questionnaire mobility subscale, ABC Scale, balance ability, TUG test, and 2MWT.nnnCONCLUSIONSnThe Houghton Scale demonstrated criterion-related validity by differentiating community-dwelling people with lower-limb amputation into community, limited community/household, and household ability categories that corresponded to performance-based balance and walking criteria. Average prosthetic walking speeds for each category compared with similar walking ability categories defined in other patient populations.

Natural history of frozen shoulder: fact or fiction? A systematic review

BACKGROUNDnIn 1940s, it was proposed that frozen shoulder progresses through a self-limiting natural history of painful, stiff and recovery phases, leading to full recovery without treatment. However, clinical evidence of persistent limitations lasting for years contradicts this assumption.nnnOBJECTIVESnTo assess evidence for the natural history theory of frozen shoulder by examining: (1) progression through recovery phases, and (2) full resolution without treatment.nnnDATA SOURCESnMEDLINE, PubMed, EBSCO CINAHL and PEDro database searches augmented by hand searching.nnnSTUDY SELECTIONnCohort or randomised controlled trials with no-treatment comparison groups including adults with frozen shoulder who received no treatment and reporting range of motion, pain or function for ≥6 months.nnnDATA EXTRACTIONnReviewers assessed study eligibility and quality, and extracted data before reaching consensus. Limited early range-of-motion improvements and greater late improvements defined progression through recovery phases. Restoration of normal range of motion and previous function defined full resolution.nnnRESULTSnOf 508 citations, 13 articles were reviewed and seven were included in this review. Low-quality evidence suggested that no treatment yielded some, but not complete, improvement in range of motion after 1 to 4 years of follow-up. No evidence supported the theory of progression through recovery phases to full resolution without treatment. On the contrary, moderate-quality evidence from three randomised controlled trials with longitudinal data demonstrated that most improvement occurred early, not late.nnnLIMITATIONSnLow-quality evidence revealed the weakness of longstanding assumptions about frozen shoulder.nnnCONCLUSIONnContradictory evidence and a lack of supporting evidence shows that the theory of recovery phases leading to complete resolution without treatment for frozen shoulder is unfounded.

Determining 1-Yr Prosthetic Use for Mobility Prognoses for Community-Dwelling Adults with Lower-Limb Amputation: Development of a Clinical Prediction Rule.

ObjectiveThe objective of this study was to develop a prognostic clinical prediction rule to identify people not achieving community walking level prosthetic use after 1 yr. DesignThis is a prospective longitudinal cohort study of community-dwelling adults with lower-limb amputations recruited from support groups and prosthetic clinics. Participants completed Activities-specific Balance Confidence and Houghton prosthetic use for mobility self-report scales and the Berg Balance Scale. The clinical prediction rule was developed using multivariate logistic regression, receiver operating curves, and probability statistics to identify people not achieving community walking level prosthetic use (Houghton scores <9) at 1 yr. ResultsForty (74.1%) of 54 participants provided follow-up data. Participants averaged 57.0 ± 11.9 yrs old, and the most recent amputation had occurred an average of 6.6 ± 11.0 yrs ago. Seventy percent had vascular amputations and 52.5% had transtibial amputations. The clinical prediction rule predicted who would not reach the community prosthetic walking level with excellent accuracy (area under the curve >0.96) using four criteria: initial Houghton, Activities-specific Balance Confidence, and Berg Balance Scale tasks 9 (retrieve object from floor) and 10 (look behind over shoulders). Failure to exceed cutoff scores in two or more criteria yielded posttest probability of not reaching community walking prosthetic use 1 yr later for 90% of participants or higher. ConclusionsAccurate 1-yr prosthetic use for mobility prognoses can be obtained by screening prosthetic use, balance confidence, and balance ability to identify community-dwelling people with lower-limb amputations unlikely to achieve community walking prosthetic use.

A Meta-analysis of Long-term Mortality and Associated Risk Factors following Lower Extremity Amputation

BACKGROUNDnA majority of patients undergoing lower limb amputations have diabetes or peripheral artery disease. Despite improvements in care, there remains a substantial perioperative mortality associated with these procedures. Less well-defined is the mortality risk to these patients going forward, once outside the perioperative period. The aim of this systematic review is to summarize and pool the available data to determine the long-term mortality associated with amputation in the diabetic and peripheral vascular patient, as well as to define specific factors associated with increased mortality risk.nnnMETHODSnFour databases were searched from January 2005 through July 2015 using the Medical Subject Headings terms amputation, lower extremity, and mortality. Inclusion criteria were observational and cohort studies where ≥50% of amputations were attributable to diabetic or vascular etiologies. Final article inclusion was approved by reviewer consensus. Bias was assessed with the Joanna Briggs Institute Critical Appraisal Tool for cohort studies.nnnRESULTSnOf the 365 unique records screened, 43 abstracts and 21 full articles were reviewed and 16 studies ultimately included. The overall mortality rate was 47.9%, 61.3%, 70.6%, and 62.2% at 1-, 2-, 3- and 5-year follow-up, respectively. In addition to diabetes and peripheral vascular disease, comorbid factors associated with at least a 2-fold increased mortality were coronary artery disease, cerebrovascular disease, renal dysfunction, American Society of Anesthesiologists class ≥4, dementia, and nonambulatory status. Surgical factors, including higher amputation level and need for staged surgery with up-front guillotine amputation, were also correlated with increased mortality.nnnCONCLUSIONSnThe overall mortality rate after primary lower limb amputation in the diabetic and peripheral vascular population is substantial, and should not be underestimated when making decisions regarding limb salvage. Similar to patients undergoing revascularization, comorbid conditions associated with higher mortality should be optimized before surgery whenever possible.

Strain counterstrain technique to decrease tender point palpation pain compared to control conditions: a systematic review with meta-analysis.

BACKGROUNDnStrain counterstrain (SCS) is an indirect osteopathic manipulative technique that uses passive positioning to relieve tender point (TP) palpation pain and associated dysfunction.nnnOBJECTIVEnThe purposes of this systematic review with meta-analysis were to 1) determine the pooled effect of SCS on TP palpation pain compared to a control condition and 2) assess the quality of the overall evidence.nnnDATA SOURCEnA search conducted using the MEDLINE with AMED, PUBMED, CINAHL, and SCOPUS databases for publications from January 2002 and April 2012 yielded 29 articles for eligibility screening.nnnSTUDY SELECTIONnIncluded studies were limited to randomized control trials comparing TP palpation pain after isolated SCS treatment compared to control conditions assessed with a visual analog scale. Other study designs or manipulative treatments were excluded.nnnDATA EXTRACTIONnTwo reviewers adhered to a predetermined study protocol following current Cochrane Collaboration recommendations to independently extract the data with standardized extraction forms and assess studies for methodological quality and determine risks of bias.nnnRESULTSnFive randomized control trials were included for qualitative and quantitative analysis. The pooled effect of SCS was a reduction of TP palpation pain (pxa0<xa00.001, 95% CI -0.291 to -0.825). The overall evidence quality was low: while all studies met at least 8 of 12 methodological quality criteria, most were low quality.nnnCONCLUSIONSnThis systematic review and meta-analysis found low quality evidence suggesting that SCS may reduce TP palpation pain. Future studies with larger samples of better quality studies with patient populations that assess long-term pain, impairment, and dysfunction outcomes could enrich the literature.