Gerardus M. Rommers

Epidemiology of lower limb amputees in the north of the Netherlands: Aetiology, discharge destination and prosthetic use

The aim of this study was to give a retrospective review of all lower limb amputations performed in the 3 northern provinces of the Netherlands in 1991–1992. Assembled data were compared with the existing information in the National Medical Register (NMR) over the same period. With the participation of all regional hospitals, 473 lower limb amputations from transpelvic to transmetatarsal level were identified. Of the amputations 94% were performed for vascular pathology, 3% for trauma, and 3% for oncologic reasons. After surgery a prosthesis was provided to 48% of the amputees. The actual number of performed amputations exceeds the number of amputations registered by the NMR by 9%. Incidence rates of lower limb amputations in the Netherlands are 18–20/100,000 over the last 12 years. These numbers are lower than in other areas and show no sharp decrease in frequency compared with other countries in Western Europe.

Short and Long Term Mortality Rates after a Lower Limb Amputation

OBJECTIVE To determine mortality rates after a first lower limb amputation and explore the rates for different subpopulations. METHODS Retrospective cohort study of all people who underwent a first amputation at or proximal to transtibial level, in an area of 1.7 million people. Analysis with Kaplan-Meier curves and Log Rank tests for univariate associations of psycho-social and health variables. Logistic regression for odds of death at 30-days, 1-year and 5-years. RESULTS 299 people were included. Median time to death was 20.3 months (95%CI: 13.1; 27.5). 30-day mortality = 22%; odds of death 2.3 times higher in people with history of cerebrovascular disease (95%CI: 1.2; 4.7, P = 0.016). 1 year mortality = 44%; odds of death 3.5 times higher for people with renal disease (95%CI: 1.8; 7.0, P < 0.001). 5-years mortality = 77%; odds of death 5.4 times higher for people with renal disease (95%CI: 1.8; 16.0,P = 0.003). Variation in mortality rates was most apparent in different age groups; people 75-84 years having better short term outcomes than those younger and older. CONCLUSIONS Mortality rates demonstrated the frailty of this population, with almost one quarter of people dying within 30-days, and almost half at 1 year. People with cerebrovascular had higher odds of death at 30 days, and those with renal disease and 1 and 5 years, respectively.

Mobility of people with lower limb amputations: scales and questionnaires: a review

Objective and design: A systematic literature review to compare mobility scales used for lower limb amputees. A literature search was carried out by computerized search of biomedical literature including Medline and Embase. The studies included were published between 1978 and 1998 and including the following keywords: amputation, artificial limbs, prosthesis, lower limb, activities of daily living, mobility. Results: Thirty-five studies were identified; 19 had a measurement of separate levels of mobility comparable to each other. Sixteen studies used ordinal and ratio scales without separate levels of mobility. The widest range of measurement found was the scale from ‘walking with prosthesis without a walking aid’ to ‘totally confined to bed’. The Stanmore Harold Wood mobility scale was published most frequently. None of the 35 studies presented give a continuous measurement of mobility. Conclusion: A multitude of measurement scales and questionnaires are available for differ in methods and measuring range. Measuring mobility by a scale has been shown to have limitations. Several authors did extensive research but they all measure only a number of aspects of mobility. Consensus about the measurement of mobility of lower limb amputees is not available in the recent literature.

Mobility in Elderly People With a Lower Limb Amputation: A Systematic Review

Elderly people with a lower limb amputation impose a heavy burden on health resources, requiring extensive rehabilitation and long term care. Mobility is key to regaining independence; however, the impact of multiple comorbidities in this patient group can make regaining mobility a particularly challenging task. An evidence-based prognosis for mobility is needed for rehabilitation and long term care planning. This systematic review summarizes the prosthetic and nonprosthetic mobility outcomes achieved by elderly people with a lower limb amputation, to determine whether an accurate prognosis for mobility can be made. MEDLINE, EMBASE, and CINAHL were searched for studies published before May 2010 in English, German, Dutch, or French, using keywords and synonyms for elderly, mobility, rehabilitation, and amputation. Mobility focused on actual movement (moving from one place to another) and was limited to long-term measurements, 6 months after amputation or 3 months after discharge from rehabilitation. The 15 included studies featured a diversity of objective outcome measures and mobility grades that proved difficult to compare meaningfully. In general, studies that included selected populations of prosthetic walkers showed that advanced prosthetic mobility skills can be achieved by the elderly person with a lower limb amputation, including outdoor/community walking. Studies that included all subjects undergoing a lower limb amputation reported that less than half of the elderly population achieved a household level of prosthetic mobility. The predominant findings from the included studies were incomplete reporting of study populations and poor reporting of the reliability of the mobility measures used. The strength of conclusions from this review was therefore limited and the prognosis for mobility in elderly people after lower limb amputation remains unclear. Further research into mobility outcomes of this population is needed to provide evidence that enables more informed choices in rehabilitation and long term care.

Clinical rehabilitation of the amputee: A retrospective study

The aim of this study was to determine the rehabilitation outcome of lower limb amputee patients after clinical rehabilitation. Altogether 183 amputee patients admitted for clinical rehabilitation in the years 1987–1991 were reviewed by retrospective analysis of medical record data. Three groups of amputee patients were identified by reason for amputation. The vascular group: (N = 132), mean age 67 years, mean admission time 119 days, 85% prosthetic fitting. The oncology group (N = 15), mean age 55 years, mean admission time 77 days, 60% prosthetic fitting. The traumatic amputee group: (N = 14), mean age 41 years, mean stay 134 days and 100% prosthetic fitting. Some 22 patients were bilateral amputees and were assessed separately. The most important reasons for not fitting a prosthesis were oncological metastases, stump and wound healing problems. After rehabilitation 86% of all patients could be discharged home. These results are more favourable than those seen in previous studies.

Lower limb amputation in Northern Netherlands: Unchanged incidence from 1991-1992 to 2003-2004

Background: Investigating population changes gives insight into effectiveness and need for prevention and rehabilitation services. Incidence rates of amputation are highly varied, making it difficult to meaningfully compare rates between studies and regions or to compare changes over time. Study Design: Historical cohort study of transtibial amputation, knee disarticulation, and transfemoral amputations resulting from vascular disease or infection, with/without diabetes, in 2003–2004, in the three Northern provinces of the Netherlands. Objectives: To report the incidence of first transtibial amputation, knee disarticulation, or transfemoral amputation in 2003–2004 and the characteristics of this population, and to compare these outcomes to an earlier reported cohort from 1991 to 1992. Methods: Population-based incidence rates were calculated per 100,000 person-years and compared across the two cohorts. Results: Incidence of amputation was 8.8 (all age groups) and 23.6 (≥45 years) per 100,000 person-years. This was unchanged from the earlier study of 1991–1992. The relative risk of amputation was 12 times greater for people with diabetes than for people without diabetes. Conclusions: Investigation is needed into reasons for the unchanged incidence with respect to the provision of services from a range of disciplines, including vascular surgery, diabetes care, and multidisciplinary foot clinics. Clinical relevance This study shows an unchanged incidence of amputation over time and a high risk of amputation related to diabetes. Given the increased prevalence of diabetes and population aging, both of which present an increase in the population at risk of amputation, finding methods for reducing the rate of amputation is of importance.

The mobility scale for lower limb amputees: The SIGAM/WAP mobility scale

Purpose. To translate the SIGAM mobility scale into the Dutch language and to test and validate its properties in everyday practice. Method. The SIGAM mobility scale as published by Ryall et al. was translated into the Dutch language with the local used verbs for prosthetic use. The translated Dutch text was reviewed by several authors and a panel of professionals. The retranslation by a native speaker was reviewed by the original author who suggested modifications. The Dutch trial version of the mobility scale was presented to a panel of prosthetic users and therapists who advised slight modifications for better understanding of the questionnaire. IN training sessions prosthetic teams across The Netherlands were trained in the use of the translated SIGAM/WAP mobility scale. Results. During the translation there were problems with slang words and the use of specific words in the care of amputee patients. The instruction of team members and the test scoring of the questionnaire and the algorithm showed no difficulties. There was good to perfect agreement between scores in case training sessions with perfect inter observer reliability. Conclusions. With this instrument we have a specific measurement tool in the English and Dutch language to measure mobility in lower limb amputees.

Construct Validity and Test-Retest Reliability of the Climbing Stairs Questionnaire in Lower-Limb Amputees

OBJECTIVE To investigate the construct validity and test-retest reliability of the Climbing Stairs Questionnaire, a patient-reported measure of activity limitations in climbing stairs, in lower-limb amputees. DESIGN A cross-sectional study. SETTING Outpatient department of a rehabilitation center. PARTICIPANTS Lower-limb amputees (N=172; mean +/- SD age, 65+/-12y; 71% men; 82% vascular cause) participated in the study; 33 participated in the reliability study. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE(S) Construct validity was investigated by testing 10 hypotheses: limitations in climbing stairs according to the Climbing Stairs Questionnaire will be greater in lower-limb amputees who: (1) are older, (2) have a vascular cause of amputation, (3) have a bilateral amputation, (4) have a higher level of amputation, (5) have more comorbid conditions, (6) had their rehabilitation treatment in a nursing home, and (7) climb fewer flights of stairs. Furthermore, limitations in climbing stairs will be related positively to activity limitations according to: (8) the Locomotor Capabilities Index, (9) the Questionnaire Rising and Sitting down, and (10) the Walking Questionnaire. Construct validity was quantified by using the Mann-Whitney U test, Kruskal-Wallis test, and Spearman correlation coefficient. Test-retest reliability was assessed with a 3-week interval and quantified using the intraclass correlation coefficient (ICC). RESULTS Construct validity (8 of 10 null hypotheses not rejected) and test-retest reliability were good (ICC=.79; 95% confidence interval, .57-.90). CONCLUSION The Climbing Stairs Questionnaire has good construct validity and test-retest reliability in lower-limb amputees.

Construct Validity and Test-Retest Reliability of the Questionnaire Rising and Sitting Down in Lower-Limb Amputees

OBJECTIVE To investigate the construct validity and test-retest reliability of the Questionnaire Rising and Sitting Down (QR&S), a patient-reported measure of activity limitations in rising and sitting down, in lower-limb amputees. DESIGN Cross-sectional study. SETTING Outpatient department of a rehabilitation center. PARTICIPANTS Lower-limb amputees (N=171; mean age ± SD, 65±12y; 71% men; 83% vascular cause) participated in the study, 33 of whom also participated in the reliability study. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Construct validity was investigated by testing 8 hypotheses: limitations in rising and sitting down according to the QR&S would be: (1) greater in lower-limb amputees who are older, (2) independent of level of amputation, (3) greater in lower-limb amputees with a bilateral amputation, and (4) greater in lower-limb amputees who had rehabilitation treatment in a nursing home. Furthermore, limitations in rising and sitting down will be positively related to activity limitations according to (5) the Locomotor Capabilities Index (LCI), (6) the questions about rising and sitting down in the LCI, (7) the Climbing Stairs Questionnaire, and (8) the Walking Questionnaire. Construct validity was quantified with an independent t test and Pearson correlation coefficient. Test-retest reliability was assessed with a 3-week interval and quantified with the intraclass correlation coefficient (ICC), standard error of measurement, and smallest detectable difference (SDD). RESULTS Construct validity (7 of 8 null hypotheses not rejected) and test-retest reliability were good (ICC=.84; 95% confidence interval, .65-.93; standard error of the measurement=6.7%; SDD=18.6%). CONCLUSIONS The QR&S has good construct validity and good test-retest reliability in lower-limb amputees.

A study of technical changes to lower limb prostheses after initial fitting

There is little published material in recent years about the use of lower limb prostheses in an elderly amputee population. In this study the authors were interested in the technical changes to lower limb prostheses after a first limb fitting procedure in a postrehabilitation population in the Netherlands. The process of fitting a prosthesis and the technical changes to the artificial limb in the first year afterwards are studied.