D. Datta

Functional outcome of patients with proximal upper limb deficiency–acquired and congenital

Objective: To investigate the functional outcome of patients with proximal upper limb deficiency – acquired and congenital (elbow disarticulation, transhumeral, shoulder disarticulation and forequarter level). Design: Cohort observational study. Subjects: All proximal upper limb amputees and patients with congenital upper limb absence currently registered with the Sheffeld Mobility and Specialised Rehabilitation Centre. Methods: A self-administered postal questionnaire and medical records were used to collect data. The questionnaire obtained information about demographic details, dominancy of the amputated arm and independence and participation in activities of daily living (ADL), domestic and recreational activities. The prevalence of pain in the phantom limb and stump, and information regarding the remaining arm was also obtained. The Hospital Anxiety and Depression Scale (HADS) was used to evaluate the psychological state of the subjects. Results: Trauma was the commonest cause of proximal upper limb loss (71.25%). Transhumeral amputation was the predominant level (78.75%). Although 73.2% returned to work following amputation, 66.6% had to change job. Overall rejection rate of prosthesis was 33.75%. Twenty-five per cent of patients found the prosthesis beneficial for driving and a small proportion used the prosthesis for employment and recreational activities, but the vast majority used the prosthesis primarily for cosmesis. Pain in the phantom limb was reported in 60% of our patients but there was no significant correlation between this and depression. Symptoms of overuse injury in the nonamputated limb were higher than expected in the normal population. Conclusion: As many as 33.75% of patients with proximal upper limb deficiency rejected their prostheses and many who continue to wear them do not find them useful in ADL and employment, etc. It is vital that rehabilitation programmes should focus on both prosthetic and nonprosthetic training to achieve maximal independence.

Mobility outcome following unilateral lower limb amputation

This study investigated mobility outcome following unilateral trans-tibial or trans-femoral amputation. It was an observational study at the sub-regional amputee rehabilitation centre in Sheffield, UK. All unilateral trans-tibial or trans-femoral amputees referred during the study period were included. The Harold Wood Stanmore mobility grade was recorded approximately one year following initial assessment at the centre. Of the 357 amputees referred, complete outcome data was available for 281 (78.7%). The mean age was 68 years (range 16–95), 70.1% were male, and the aetiology of the amputation was vascular or diabetic in 87.5% of cases. Trans-tibial amputations accounted for 50.5% and trans-femoral 49.5%. Almost all trans-tibial and trans-femoral amputees aged 50 and under achieved functional household and community mobility. Approximately 50% of the trans-tibial amputees aged over 50 years gained independent community mobility and around 60% household mobility. There was a significant worsening of community mobility rates with increasing age but for household mobility the differences did not reach statistical significance. Fewer than 25% of trans-femoral amputees aged over 50 achieved community mobility and around 50% achieved household mobility. There was a statistically significant deterioration in both community and household mobility levels with increasing age. This study concludes that mobility rates one year after prosthetic provision for unilateral transtibial and trans-femoral amputees worsen with increasing age at amputation and a higher level of amputation.

A comparative evaluation of oxygen consumption and gait pattern in amputees using Intelligent Prostheses and conventionally damped knee swing-phase control

Objective: To compare the gait of amputees wearing conventionally damped pneumatic swing-phase control knees and microchip-controlled Intelligent Prostheses. Design: Crossover trial. Setting: An amputee rehabilitation centre in a teaching hospital. Participants: Ten established unilateral transfemoral prosthetic users were asked to participate in the trial; all agreed. Interventions: The amputees were assessed wearing pneumatic swing-phase control knees and then with the Intelligent Prosthesis. Main outcome measures: Oxygen consumption while walking at different speeds on a treadmill, video-recording of gait assessed by a panel and temporal–spatial parameters of gait whilst walking at slow, fast or normal speeds in a gait laboratory. Results: Mean oxygen cost for all subjects at 0.69 m/s was 0.33 ml/kg.m with the conventional limb and 0.30 ml/kg.m with the Intelligent Prosthesis (p–0.01). At 1.25 m/s the mean oxygen cost for the conventional limb was 0.24 ml/kg.m and for the Intelligent Prosthesis was 0.22 ml/kg.m (not significant). The ANOVA analysis showed that oxygen cost was similar at normal walking speeds but increased more at lower speeds for the pneumatic swing-phase control leg compared to the Intelligent Prosthesis (p<0.02). There were no significant differences in subjective gait evaluation or temporal and spatial gait parameters. Conclusion: At lower speeds oxygen cost was lower with the Intelligent Prosthesis. Gait analysis detected no significant changes between the two legs.

A pilot study comparing the cognitive demand of walking for transfemoral amputees using the Intelligent Prosthesis with that using conventionally damped knees

Objective: To compare the cognitive demand of walking when using a conventional prosthesis with that using a microprocessor-controlled prosthesis. Design: Ten unilateral transfemoral amputees wearing conventional pneumatic swing phase control (conventional prosthesis) prostheses walked on a treadmill which enforced a pattern of constantly varying speeds. The subjects simultaneously performed a simple or a complex distracting task. Following a period of accustomization, the subjects performed the same test wearing a prosthesis with microprocessor control of swing phase damping (the Intelligent Prosthesis). Outcome measures: The three-dimensional trajectory (sway) of a retroreflective marker attached to the forehead was measured by a video-based motion analysis system, and used as a measure of gait quality. The ratio of the sway for the complex task over the simple task (the ‘automation index’) was used as a measure of the degree of automation of gait. Results: No significant differences were found in the automation index between the two devices. However, the total sway for the conventional prosthesis was significantly higher. Sway during the complex distracting task was significantly higher than during the simple task. Conclusions: The microprocessor-controlled prosthesis was not found to be less cognitively demanding than a conventional prosthesis.

Timed walking test — an all-embracing outcome measure for lower-limb amputees?

rehabilitation of patients after leg amputation. Design: Comparison of the results from the 10 m timed walk with the results of other more detailed measures of disability. Setting: A specialist, outpatient amputee rehabilitation follow-up clinic. Subjects: Twenty-six transtibial and 27 transfemoral amputees aged 60-80 years seen at least six months after amputation. Measures: The measures used included a 10 m timed walk which

Outcome of prosthetic management of bilateral lower-limb amputees

This study was designed to evaluate the outcome in 41 bilateral lower-limb amputees admitted to an inpatient unit for prosthetic rehabilitation. Outcome measures were obtained using a simple activities of daily living score, the Frenchay Activities Index, mobility grading, and assessment of home adaptations. Though excellent success rates were obtained after completion of physiotherapy, the majority of the above-knee amputees had abandoned their prostheses by the time of review. Bilateral below-knee amputees, however, continued to do well regarding their prosthetic mobility, and prosthesis users were more independent in their activities of daily living. We believe that inpatient rehabilitation programmes for bilateral amputees are likely to prove more satisfactory than prolonged outpatient physiotherapy.

Gait, cost and time implications for changing from PTB to ICEX® sockets

The ICEX® system (Ossur, Iceland), allows a socket to be manufactured directly onto the stump and is thought to provide improved comfort due to better pressure distribution whilst being easier to fit and manufacture. The aims of this project were to a) compare gait performance by measuring several gait characteristics, b) compare production and fitting times, c) investigate financial implications and d) attempt to gauge the amputees’ subjective opinions of socket comfort. A randomised, controlled trial was conducted on 27 trans-tibial amputees with an existing patellar tendon bearing (PTB) socket on the Endolite™ system (Chas A. Blatchford, UK). Twenty one (21) subjects completed the study. Of these, 10 in the control group received new PTB sockets while 11 in the experimental group received ICEX®. Gait analysis wearing existing sockets was performed and kinetic data obtained from a force plate. This was repeated with the new sockets after a 6 week period of adjustment. Mann-Whitney tests were used in statistical evaluations with a significance level of 5%. Subjects were asked to score their prosthesis for comfort using the Socket Comfort Score (Hanspal et al., 2003) and the frequency of visits for socket adjustments over a three-month period post-delivery of the sockets was recorded. This study demonstrates no significant difference in any of the gait parameters measured. Though the time required to manufacture a PTB prosthesis was found to be considerably longer than the ICEX®, the overall cost for producing the ICEX® was significantly greater. Subjects showed only minor comfort preference for the ICEX® design and there was no significant difference in the mean number of visits for socket adjustments. In view of the considerable additional cost of providing ICEX® and the lack of evidence of improvement in any parameter tested, the routine provision of ICEX® prostheses to unselected trans-tibial amputees cannot be recommended.

Prosthetic rehabilitation of upper limb amputees: a five year review

A review of 55 upper limb amputees, acquired and congenital, referred to a subregional centre for amputee rehabilitation in a five year period is presented. Ninety-six per cent of the amputees were provided with prostheses. Seventy-three per cent of these patients have successfully accepted their prostheses with a minimum follow-up period of two years. The importance of a multidisciplinary approach in providing a comprehensive rehabilitation programme cannot be overemphasized. Patients views and needs must be at the forefront in formulating the rehabilitation programme. Success of the prostheses should not be determined only on the grounds of active use, as cosmetic replacement may also play a major role in the total rehabilitation of upper limb amputees.

A comparative study of oxygen consumption for conventional and energy-storing prosthetic feet in transfemoral amputees

Objective: To compare oxygen consumption for traumatic high-functioning transfemoral amputees wearing initially a conventional prosthetic foot (Multiflex) and then an energy-storing prosthetic foot (Vari-Flex). Setting: A regional prosthetic and amputee rehabilitation tertiary referral centre in a teaching hospital. Study design: Experimental crossover trial. Subjects: Six established unilateral transfemoral prosthetic users. Interventions: Oxygen consumption breath-by-breath analysis at multiple speeds on a treadmill for each amputee wearing initially the Multiflex foot and then repeated wearing the Vari-Flex foot. Results: Mean oxygen consumption across all subjects was lower for the Vari-Flex foot than for the Multiflex foot at all speeds, although the differences were only significant at speeds of 0.83 and 1.1 m/s (P<0.05). ANCOVA analysis across all speeds showed that oxygen consumption with the Vari-Flex foot was significantly lower (P<0.001). The estimated difference across all speeds was 3.54 mL/kg.min. Conclusion: A high functioning transfemoral amputee who wears an energy-storing prosthetic foot may have significantly reduced oxygen consumption at normal walking speeds.

A comparative evaluation of the Adaptive® knee and Catech® knee joints: A preliminary study

The Adaptive® knee joint is a microprocessor-controlled prosthetic knee that incorporates both pneumatic and hydraulic control in one electronic unit. Pneumatic control is said to provide control during swing phase and the hydraulic control during the stance phase of the gait. This hybrid controller is triggered by a computer contained within the knee that responds to input from force, time and angle sensors. The microprocessor then selects an appropriate speed and stability setting. The Catech® knee joint is a conventional hydraulic knee joint. The aim of this study was to compare the Adaptive® and Catech® knee joints in established trans-femoral amputees. The patients meeting the inclusion criteria were all established trans-femoral amputees using the Catech® knee joint. The study was carried out by performing gait analysis, assessing energy requirements using the Physiological Cost Index (PCI) and using questionnaires. There was no significant benefit gained from the use of the Adaptive® knee over the Catech® knee joint in our small study group.