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BACKGROUND The rate of indoor prosthetic use in people with lower limb amputation (LLA) is lower than that of outdoor use. Very few studies of indoor prosthetic use have been conducted, and no studies have focused on the perspective of instrumental activities of daily living (IADLs). OBJECTIVES To assess the indoor prosthetic use of individuals with unilateral LLA from the perspective of IADLs. STUDY DESIGN Cross-sectional study. METHODS A total of 162 people with LLA participated in this study. Based on the information obtained from a questionnaire and medical records, the relationships between each outcome and indoor prosthetic use were assessed by univariate analysis and multivariate logistic regression analysis. RESULTS Of the 110 respondents (72.8%), 6 participants did not use the prosthesis or used it for cosmesis. With respect to the prosthetic users (n = 104), 74 (71.2%) used their prosthesis indoors and outdoors and 30 (28.8%) used it only outdoors, but none used it indoors only. On univariate analysis, five items were identified: household size, amputation level, domestic chores and outdoor activities of the Frenchay Activities Index, and difficulty donning/doffing the prosthesis. Small household, transtibial amputation, and a high score on the domestic chores of the Frenchay Activities Index (cutoff value 9.0 points) were independently associated with indoor prosthetic use. CONCLUSIONS Training of motions that are desirable to use the prosthesis and participation in domestic chores frequently based on IADLs before hospitalization may increase the frequency of prosthesis use in people with transfemoral amputation who use their prosthesis outdoors.

Background: Previous studies show that people with lower limb amputation (LLA) have a sedentary lifestyle, reduced walking capacity, and low cardiorespiratory fitness (VO2peak). There is, however, no knowledge on the relationship between cardiorespiratory fitness and objectively measured level of physical activity in daily life. Objectives: To investigate the relationship between upper-body VO2peak, physical activity levels, and walking capacity in persons with LLA. Study design: Correlational and descriptive study. Methods: Fourteen participants with LLA performed an assessment of VO2peak on an arm-crank ergometer and walking capacity (preferred walking speed and 2-minute walking test). Level of physical activity was measured over 7 days with a step activity monitor (number of steps; sedentary time; and proportion of low-intensity, moderate-intensity, high-intensity, and peak-intensity activity level). Results: VO2peak correlated significantly with number of steps per day (r = 0.696, p = 0.006), sedentary time (r = −0.618, p = 0.019), high-intensity activity level (r = 0.769, p = 0.001), and peak-intensity activity level (r = 0.674, p = 0.008). After correcting for age, correlations were still large and significant. Large correlations were also found between VO2peak, preferred walking speed (r = 0.586, p = 0.027), and 2-minute walking test (r = 0.649, p = 0.012). Conclusions: We provide the first evidence of the strong relationships between upper-body VO2peak, sedentary behavior, high-intensity activity level, and walking capacity in persons with LLA. Further research is needed to investigate the potential effect of upper-body cardiorespiratory fitness on the level of activity in daily life, or vice versa. This work was financially supported by the Research Council of Norway and Oslo Metropolitan University/Faculty of Technology, Art, and Design/Faculty of Health Sciences. The funded project is “Patient-Centric Engineering in Rehabilitation (PACER)” and project No. is 273599.

Many people with lower limb amputation experience mobility impairment and reduced quality of life. Mobility clinics are designed to improve mobility and quality of life for people with lower limb amputation, but their effectiveness is unknown.To compare changes in mobility prior to, and 12 weeks following participation in mobility clinic for people with lower limb amputation, and to explain whether changes in mobility explained changes in quality of life. To determine whether the PLUS-M™ was sensitive to the effects of participation in the mobility clinic, and to estimate the sample size required for a definitive study.Longitudinal observational.Electronic versions of the PLUS-M and SF-36v2There was a significant increase in mobility from baseline to 12 weeks post participation in the clinic (For people with lower limb amputation, mobility increased after participation in the clinic and this explained improvements in SF-36v2 mental component summary. The PLUS-M was sensitive enough to detect a change in mobility over time.This preliminary data indicated that participation in a mobility clinic improved mobility and the mental components of quality of life for people living with lower limb amputation. The PLUS-M™ seems sensitive to changes in mobility as a result of participation in a mobility clinic.

While home-based exergames help overcome accessibility barriers to rehabilitation, it is unclear what constitutes effective intervention design in using exergames to support self-efficacy and engagement.Examine usage of an in-home exergame, compared to control, unsupervised after supervised training by older persons with lower-limb amputation.Secondary analysis of a multi-site parallel evaluator-masked randomized control trial.WiiNWalk uses the WiiFit and teleconferencing for in-home group-based exergame therapy with clinical supervision. Participants engaged in a 4-week supervised training phase followed by a 4-week unsupervised phase in experimental (WiiNWalk) and attention control groups. Usage between phases and between groups was compared using unsupervised/supervised ratio of session count (over 4 weeks) and session time (mean min/session over 4 weeks) for each phase.Participants: n=36 experimental, n=28 control, unilateral lower-limb amputation, age50 years, prosthesis usage ≥ 2 hours/day. Session count ratio unsupervised/supervised, median and interquartile range (IQR), was less than parity (Unsupervised exercise duration remained consistent with supervised, but frequency was reduced. Social and clinical guidance features may remain necessary for sustained lower-limb amputation exergame engagement at home.This study provides context regarding when prosthesis users are more likely to use exergames such as Wii Fit for exercise therapy. Clinicians may consider our results when applying exergames in their practice or when developing new exergame intervention strategies.

Background: Sufficient cardiorespiratory fitness has been regarded a prerequisite for prosthetic walking. In order to improve cardiorespiratory fitness, adequate strain ought to be placed on the system during training. Objectives: To determine cardiorespiratory fitness at the start and end of inpatient rehabilitation after lower limb amputation and determine the physical strain experienced during conventional prosthetic rehabilitation. Study design: Multicenter prospective cohort study. Methods: Cardiorespiratory fitness was assessed using a peak one-legged cycle exercise test. Physical strain was assessed during a minimum of three full rehabilitation days using heart rate recordings. Physical strain was expressed in the time per day that heart rate exceeded 40% of heart rate reserve. Results: At the start of rehabilitation, peak aerobic capacity was on average 16.9 (SD, 6.5) mL/kg/min (n = 33). Overall, peak aerobic capacity did not improve over the course of rehabilitation (n = 23, p = 0.464). Fifty percent of the patients experienced a physical strain level that satisfies minimum criteria for maintaining cardiorespiratory fitness (>40% heart rate reserve for 30 min/day). Conclusion: Cardiorespiratory fitness was low and did not increase during conventional prosthetic rehabilitation. On average, the physical strain during rehabilitation was insufficient to elicit potential improvements in aerobic capacity. Results stress the need for dedicated physical training modules at the individual level. Clinical relevance: This study shows that clinicians ought to be aware of the relatively low cardiorespiratory fitness of people who have undergone lower limb amputation and that improvements during rehabilitation are not always obtained. Results stress the need for physical training modules in which intensity is imposed at the individual level.

People with lower limb amputation report the need to concentrate on walking. Dual-task paradigms are often used to study such interactions between cognition and the control of balance and gait in people with lower limb amputation.To summarize evidence related to dual-task standing and walking in people with lower limb amputation and discuss implications for future research.Structured review.A structured search was completed in PubMed, CINAHL, and Web of Science from database inception to May 2017. Eligible articles were in English, included participants with lower limb amputation, and assessed dual-task standing or walking. Study information was extracted by one reviewer and assessed for accuracy by a second.A total of 12 articles met eligibility criteria. Seven examined differences in dual-task standing or walking, and five assessed dual-task walking across microprocessor-controlled and non-microprocessor-controlled prosthetic knee conditions.Results suggest that (1) dual-task interference in standing is greater for people with lower limb amputation than non-amputees and (2) the use of microprocessor-controlled knees improves dual-task performance for people with limited mobility compared to non-microprocessor-controlled knees. The small number of studies, diversity of dual-task methods, and methodological limitations challenge the synthesis of study results. Future research should assess specific clinical characteristics that can affect dual-task performance in people with lower limb amputation.Understanding how people with lower limb amputation use increased attention in balance and gait to compensate for limb loss can inform prosthetic interventions and training. Dual-task research suggests that people with amputation use increased cognitive control for standing compared to controls and microprocessor-controlled knees improve dual-task walking in people with limited mobility.

While rehabilitation professionals are historically trained to place emphasis on the restoration of mobility following lower limb amputation, changes in healthcare dynamics are placing an increased emphasis on the limb loss patient's quality of life and general satisfaction. Thus, the relationship between these constructs and mobility in the patient with lower limb loss warrants further investigation.To determine the relationship between mobility of the patient with lower limb loss and both (1) general satisfaction and (2) quality of life.Retrospective chart analysis.A retrospective chart review of the Prosthetic Limb Users Survey of Mobility and the Prosthesis Evaluation Questionnaire-Well-Being subsection. Pearson correlations were used to test relationships.Data from 509 patients with a lower limb prosthesis were included. Mobility was found to be positively correlated with quality of life ( r = 0.511, p 0.001, 95% confidence interval (0.443, 0.569)) and general satisfaction ( r = 0.475, p 0.001, 95% confidence interval (0.403, 0.542)), as well as their arithmetic mean (i.e. Prosthesis Evaluation Questionnaire-Well-Being) ( r = 0.533, p 0.001, 95% confidence interval (0.466, 0.592)).This study provides evidence of a strong positive correlation between mobility and both quality of life and general satisfaction. Thus, in the holistic care of a patient with lower limb loss, maximizing mobility would correlate with greater quality of life and general satisfaction. Clinical relevance There is growing emphasis on the quality of life and general satisfaction experienced by patients undergoing prosthetic rehabilitation. The results of this study underscore the importance of providing prosthetic rehabilitation that maximizes the patient's mobility, noting that these individuals also report greater quality of life and general satisfaction.

Background: Studies suggest that the energy expenditure of healthy persons (control) during walking with the preferred walking speed in steady-state conditions is dominated by fat oxidation. Conversely, carbohydrate and fat oxidation during walking is little investigated in transfemoral amputees. Objectives: To investigate carbohydrate and fat oxidation, energy cost of walking, and percent utilization of maximal aerobic capacity (%V·O2max) during walking. Study design: Eight transfemoral amputees and controls walked with their preferred walking speed and speeds 12.5% and 25% slower and faster than their preferred walking speed. Methods: Energy expenditure and fuel utilization were measured using a portable metabolic analyzer. Metabolic values are means ± standard deviation. Results: For transfemoral amputees (37.0 ± 10.9 years) and controls (39.0 ± 12.3 years), fat utilization at the preferred walking speed was 44.8% ± 7.2% and 45.0% ± 7.2% of the total energy expenditure, respectively. The preferred walking speed of the transfemoral amputees and controls was close to a metabolic cross-over speed, which is the speed where carbohydrate utilization increases steeply and fat utilization decreases. When walking fast, at 90 m min−1 (preferred walking speed plus 25%), transfemoral amputees utilized 70.7% ± 5.6% of their V·O2max , while the controls utilized 30.9% ± 4.5% (p

In principle, lower limb bone-anchored prostheses could alleviate expenditure associated with typical socket manufacturing and residuum treatments due to socket-suspended prostheses.This study reports (a) the incremental costs and (b) heath gain as well as (c) cost-effectiveness of bone-anchored prostheses compared to socket-suspended prostheses.Retrospective individual case-controlled observations and systematic review.Actual costs were extracted from financial records and completed by typical costs when needed over 6-year time horizon for a cohort of 16 individuals. Health gains corresponding to quality-adjusted life-year were calculated using health-related quality-of-life data presented in the literature.The provision of bone-anchored prostheses costed 21% ± 41% more but increased quality-adjusted life-years by 17% ± 5% compared to socket-suspended prostheses. The incremental cost-effectiveness ratio ranged between -$25,700 per quality-adjusted life-year and $53,500 per quality-adjusted life-year with indicative incremental cost-effectiveness ratio of approximately $17,000 per quality-adjusted life-year. Bone-anchored prosthesis was cost-saving and cost-effective for 19% and 88% of the participants, respectively.This study indicated that bone-anchored prostheses might be an acceptable alternative to socket-suspended prostheses at least from a prosthetic care perspective in Australian context. Altogether, this initial evidence-based economic evaluation provided a working approach for decision makers responsible for policies around care of individuals with lower limb amputation worldwide. Clinical relevance For the first time, this study provided evidence-based health economic benefits of lower limb bone-anchored prostheses compared to typical socket-suspended prostheses from a prosthetic care perspective that is essential to clinicians and decision makers responsible for policies.

Spina bifida is an uncommon cause for lower limb amputation. The causes and level of amputation and mobility outcome for these patients have not been reported previously.To identify the causes and level of amputation and the mobility outcome for amputee patients with spina bifida.Retrospective case series.Chart review of patients identified by computer as having an amputation secondary to neurological or congenital cause. Additional patients identified from the Regional Spina Bifida Medical Clinic. Demographics, cause and level of mobility pre- and post-amputation recorded from the prosthetic notes.In total, 16 patients were identified who had a diagnosis of spina bifida and a lower limb amputation. Mean age at the time of amputation was 28.5 years. In total, 15 patients had a transtibial amputation. In total, 14 patients post-amputation were able to maintain their mobility, wheelchair or walking, without any change in type of aid needed.Patients with spina bifida appear to require lower limb amputation at a younger age than patients with peripheral vascular disease. Almost all patients had prior chronic skin infection/osteomyelitis as precursors for amputation. The most common level for amputation was transtibial. Mobility was maintained for all patients, albeit for two in a more supported way. Clinical relevance Spina bifida is an uncommon reason for amputation. Patients, are often younger and medically complicated. Chronic skin ulceration, was the most common indication for amputation. Wheelchair or walking ambulance was maintained at the same level for most patients.

Amputation of lower limb results in limitations in mobility which are amenable to multiple rehabilitation interventions. The challenges faced by the persons with lower limb amputation vary internationally. The International Classification of Functioning, Disability and Health provides a common language to describe the function of persons with lower limb amputation across various countries.This article reports the concepts in mobility important to persons with lower limb amputation across six countries using the International Classification of Functioning, Disability and Health.Qualitative study using focus groups and individual interviews.Focus groups and individual interviews of persons with lower limb amputation were organised across six countries to identify the issues faced by patients with an amputation during and after their amputation, subsequent rehabilitation and on an ongoing basis in their daily life. Meaningful concepts were extracted from the responses and linked to suitable second-level and where applicable third-level International Classification of Functioning, Disability and Health categories. International Classification of Functioning, Disability and Health categorical frequencies were analysed to represent the prevalence and spread of International Classification of Functioning, Disability and Health categories by location.A total of 133 patients were interviewed. A large percentage (93%) of the identified concepts could be matched to International Classification of Functioning, Disability and Health categories for quantitative analysis.The important concepts in mobility were similar across different countries. The comprehensiveness of International Classification of Functioning, Disability and Health as a classification system for human function and its universality across the globe is demonstrated by the large proportion of the concepts contained in the interviews from across the study centres that could be matched to International Classification of Functioning, Disability and Health categories. Clinical relevance The activity and participation restrictions faced by a person with lower limb amputation vary internationally and are amenable to multiple rehabilitation interventions. The International Classification of Functioning, Disability and Health may provide a common language to report and quantify the various concepts important to the patient in their rehabilitation journey.

STUDY DESIGN: Retrospective cohort study.BACKGROUND: Persons with a lower limb amputation can regain mobility using a prosthetic device. For fast and adequate prescription of prosthetic components, it is necessary to predict the mobility outcome early in rehabilitation. Currently, prosthetic prescription is primarily based on empirical knowledge of rehabilitation professionals.OBJECTIVE: In this study, we explored motor ability tests, to be completed without a prosthetic device, which have predictive value for mobility outcome at the end of rehabilitation.METHODS: For this study, data of 82 patients with a lower limb amputation were included. The Single-limb standing balance test (Balance test), the Lower-Extremity Motor Coordination Test and the Amputee Mobility Predictor Assessment Tool (AMPnoPRO) were used as measures for motor ability. Mobility outcome was measured using the Timed Up and Go Test, the Two-Minute Walking Test and K levels were used.RESULTS: The explained variance of the Balance test, the Lower-Extremity Motor Coordination Test and the AMPnoPRO was, respectively, 0.603, 0.534 and 0.649 on the Two-Minute Walking Test (linear regression); 0.597, 0.431 and 0.624 on the Timed Up and Go Test (linear regression); and 0.432, 0.420 and 0.526 on the K levels (logistic regression).CONCLUSION: The AMPnoPRO predicted mobility outcome statistically (largest amount of explained variance).CLINICAL RELEVANCE: This study explored the possibility of statistically predicting mobility outcome in lower limb amputees at the end of rehabilitation, using motor ability tests conducted in early rehabilitation. This study suggests the use of the AMPnoPRO to predict mobility outcome in lower limb amputees.

Few studies have explored the effects of exercise on gait performance in people with lower limb amputations.To (1) summarize the effects of exercise programs on gait performance and (2) assess the overall quality of the evidence for adults ambulating with leg prostheses.Systematic review.Six databases were searched for one- and two-group studies published through June 2013 reporting effects of exercise on gait speed, a universal measure of performance in lower limb prosthetic users. The search adhered to a predetermined protocol following Cochrane Collaboration guidelines.In all, 623 citations were reviewed and eight studies included. The quality level of the combined evidence was low with few randomized control trials and multiple sources of bias evident within the heterogeneous group of studies. The 11 exercise programs, including three control conditions, demonstrated small to large effect size improvements in self-selected gait speed. Use of exercise to improve gait speed was supported by low-quality level evidence, with low-moderate quality evidence to suggest that specific functional exercise programs were more effective than supervised walking.Using exercise to improve gait speed in people with lower limb amputation received a B grade recommendation. Future high-quality research is required.Supervised walking, muscle strengthening, balance exercises, gait training, and functional training programs demonstrated small to large effect size gait performance improvements in people with lower limb amputation. Self-selected gait speed was the most consistent outcome measure. Exercise programs emphasizing resisted gait and functional training were more effective than supervised walking.

Turning is an inherent problem in all lower limb amputees and more so in older dysvascular amputees. This study aimed to compare the turning performance of dysvascular amputees with that of the traumatic amputees.Six dysvascular transtibial amputees (69.83 ± 6.3 years) and six traumatic transtibial amputees (68.3 ± 6.6 years) completed the Step Quick Turn test of the NeuroCom(®) Balance Master and the Timed Up and Go Test. The measures used for comparison were as follows: turn time and turn sway of Step Quick Turn test, turning 180° to both the prosthetic and sound side and time taken to complete the Timed Up and Go Test.The Mann-Whitney U test demonstrated a significant difference (p0.05) between the dysvascular and traumatic groups in turn sway to the prosthetic (70.7 ± 14.2 and 43.3 ± 9.7) and sound sides (72.5 ± 16.1 and 43.5 ± 8.2). Similar results were observed in turn time to the prosthetic (4.1 ± 1.4 and 1.7 ± 0.46) and sound sides (4.0 ± 1.3 and 2.1 ± 0.5). No significant difference was observed for the Timed Up and Go Test.The observed differences suggest that dysvascular amputees are less able to adapt to the challenges associated with turning. More attention is required in the rehabilitation of dysvascular amputees in turning tasks particularly towards the prosthetic side.

Background: Community living individuals with lower limb amputation have low balance confidence but the level of balance confidence in the first six months after discharge from prosthetic rehabilitation is not known. Objectives: To determine if balance confidence levels differ after discharge from prosthetic rehabilitation and to determine if balance confidence at discharge predicts social activity at three months post-discharge while controlling for important covariates such as walking ability. Study Design: Prospective study. Methods: Subjects (n ¼65) experiencing their first unilateral transfemoral or transtibial amputation were recruited and followed-up one and three months post-discharge. Measures of balance confidence (Activities-specific Balance Confidence Scale) and walking ability (L Test) collected at discharge were used to predict social activity (Frenchay Activities Index) at follow-up. Results: Despite a 14-second mean improvement in walking ability the mean balance confidence scores did not change significantly between discharge (71.2/100) and at three-month follow-up (69.4/100). Confidence scores and basic walking ability at discharge were the two strongest predictors of three-month social activity. Multiple regression modelling indicated that balance confidence and walking ability explained 64% of the variance (standardized beta ¼0.34 and 0.37 respectively) in social activity (adjusted R 2 ¼39%). Conclusions: Balance confidence after discharge from prosthetic rehabilitation for lower limb amputation is low and scores do not improve over the first three months post-discharge despite improvements in walking ability. Discharge balance scores confidence independently predicts three-month social activity scores. Clinical relevance Our experience suggests that balance confidence is not directly addressed during prosthetic rehabilitation despite evidence suggesting that mean balance confidence of this population is low. Some change in confidence may be indirectly obtained through traditional rehabilitation; however, programmes augmented with strategies based on Bandura’s theory may increase confidence further promoting improved social activity.

The International Classification of Functioning, Disability and Health (ICF) is comprehensive but difficult to use in clinical practice. ICF Core Sets are one method of increasing the use of the ICF in clinical practice. To develop a condition-specific core set requires identification of the concepts measured in current clinical practice.To identify and quantify concepts contained in functional measurements used in published clinical studies utilising the ICF as a reference, for individuals with an amputation of the lower limb.Systematic literature review.The concepts of published clinical and outcome measures used in individuals with a lower limb amputation were extracted and linked to the categories of ICF.The 113 outcome measures identified in the literature search contained 2210 functional concepts. Of the identified concepts, nearly 90% could be linked to ICF categories. The identified concepts linked to 44 categories in the domain of body functions and structures, 56 categories in the domain of activities and participation and 30 categories in the domain of environment.Using the ICF as a reference, we could identify and quantify the majority of concepts in the outcome measures used in published clinical studies. The ICF categories identified will assist in the development of ICF Core Sets for persons with an amputation.The ICF is available in over 25 languages. Improving the usefulness of the classification for clinicians will assist in standardising clinical practice and in comparison of outcomes nationally and internationally. ICF Core Sets are designed to use a manageable number of categories from the ICF to allow application in day-to-day clinical practice.

The purpose of this study was to identify factors that predict an individual's subjective quality of life (QoL) after having a lower limb amputation.Cross-sectional descriptive study design.A total of 415 unilateral, above knee (27.0%) and below knee (73.0%) amputees with an average age of 61.9 years (SD = 15.7) who had lost their limb related to vascular (53.0%) or non-vascular (47.0%) etiology.Medical chart review, questionnaires (Frenchay Activities Index, Interpersonal Support Evaluation List, the Center for Epidemiology Studies - Depression scale, Prosthetic Evaluation Questionnaire mobility subscale, and the Activities-specific Balance Confidence Scale) and a QoL Visual Analogue Scale were assessed using multiple linear regression analysis.The analysis revealed seven significant factors (depression, perceived prosthetic mobility, social support, comorbidity, prosthesis problems, age and social activity participation) as predictors of subjects' perceived QoL. Depression explained 30% of the variation, while the full model explained 42% of the variation.Several modifiable characteristics influence QoL after lower limb amputation including depression and participation in daily living. This finding suggests the importance of addressing individuals' affective status to regain or maintain QoL.

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 transfemoral 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 trans-tibial and trans-femoral amputees worsen with increasing age at amputation and a higher level of amputation.

The aim of the present study was to find out if it is possible to use the same functional tests for elderly subjects after lower limb amputation who live independently at their homes as for healthy ones. Will these tests discriminate among different problems in subjects with different levels and different causes of amputation and will they discriminate between active and sedentary subjects? The study examined 83 volunteers who lived independently at their homes (55 healthy sedentary, 17 after trans-tibial amputation, 11 after trans-femoral amputation). All subjects were aged 60 or older. All subjects after lower limb amputation were found to have significantly worse results in almost all tests in comparison with the healthy sedentary men. The subjects after transfemoral amputation needed significantly more time at the "up and go" test, walked a shorter distance in 9 minutes. and performed fewer stand-ups from a chair and fewer steps in two minutes than the subjects after trans-tibial amputation. The active subjects after lower limb amputation had better balance, were quicker at the "up and go" test and walked longer in a minute than the sedentary subjects after lower limb amputation. It can be concluded that this test battery can also be used to test subjects after lower limb amputation because it discriminates among different severity of problems in subjects with different level and cause of amputation as well as between active and sedentary ones.

Introduction The ambitious consensus conference of ISPO in 1990 summarised what was up till then the scientifically published state of the art regarding amputation of limbs. The conference report included operating methods with different indications and perioperative regimens for all levels and patient categories. Now, to update on surgical knowledge over the last decade, a Medline search by use of Lower limb + Amputation + Surgery yielded 1,729 references with the time limit of 10 years. With limitation to Amputation + Leg + Methods it produced 135 references including English, French and German languages. This focus will be retained perceiving the different circumstances between war areas and non-war areas both in Africa with infections and tumours (Loro and Franceschi, 1999) and in western societies with dysvascular cases accounting for 90% of all amputations and a mean age twice as high. Why is diabetes still a little less than 50% and mean survival only a little more than 2 years (Ebskov, 1999)? Another very interesting observation on diabetics recently was that amputations were four times more common on the right side than the left both in type 1 and in type 2 diabetes and both at partial foot and at trans-tibial levels in a series of 1,876 patients (Coxon and Gallen, 1999).

To describe for the province of Limburg, the Netherlands, the incidence of lower limb amputation (LLA), the demographic characteristics of the amputees, reason and level of amputation, care the amputees receive, prosthetic supply and functional level after one year.A prospective descriptive cohort study.Anonymized data on all amputees in all nine hospitals were collected during 1994. Follow-up was one year.191 major lower limb amputations in 164 patients. Incidence was 17.1 per 100,000. Amputation levels: 77 trans-tibial, 52 transfemoral and 43 knee disarticulation. Twenty (20) patients died during hospitalisation. Eighty-seven (87) amputees gave permission for followup, 60 could be actually followed. Twenty-two (22) patients received in-patient rehabilitation, 16 primary day-care, 21 went to a nursing home and one went home without rehabilitation. The mean duration of rehabilitation was 35 weeks. In 53 patients a functional prosthesis was indicated. Forty-three (43) of these patients walked with the prosthesis after one year, 7 of whom more than 500 metres. Nineteen (19) amputees performed the Get Up and Go Test (GUGT) safely. Amputees on average have a low level of functioning, as indicated by SIP68 and Barthel Index Scores. The ability to walk is closely related to this daily function and quality of life.After one year the majority of amputees have low walking skills and the walking distance is limited. They are often ADL-dependent and their amputation greatly limits their daily function.

The purpose of this study was to look at the current epidemiological trends of lower limb amputees in 1995 and the trends since 1984 in the area of Southern Finland with 1.3 million inhabitants. During the one-year period, the lower limb amputation was performed on 366 patients. The overall amputation rate has been unchanged since 1984 being 28.0 per 100,000 inhabitants in 1995. The mean age was 71.4 years. The overall amputation rate was 28.0 per 100,000 inhabitants. Of the 366 patients in the study 30% had arteriosclerosis without diabetes mellitus and 49% had diabetes. Diabetes mellitus has become the most common cause of amputation since 1985. Tumours were the cause in 2% and trauma in 4%. The most common unilateral amputations were trans-femoral amputations (29%) followed by trans-tibial amputations (28%) and toe amputations (24%). The unilateral trans-tibial/trans-femoral ratio was 0.54 in 1984 and 0.95 in 1995. The one-year mortality rate was 39% in 1984 and 40% in 1995. The rate of amputation has been relatively constant over the last ten years. The age related incidence in the older age groups has also been unchanged over the last ten years. Better control of diabetes and prophylactic foot care of diabetics can have a positive contribution in prevention of lower limb amputations. The current rehabilitation and prosthetic services of the lower limb amputees can be planned in the south of Finland on the basis of the incidence of 28 per 100,000 inhabitants.

In order to determine whether lower limb amputation changes the social life and free time activities of persons who were at the time of amputation young, a questionnaire was sent to 519 persons after trans-tibial or higher level of lower limb amputation who were at the time of amputation younger than 51 years, amputated because of injury, permanently resident in Slovenia and had visited the outpatient prosthetics clinic of the Rehabilitation Institute of Slovenia at least once in the last five years (1989-94). There 228 responses, which were statistically analysed. It was found that after amputation most persons participated less frequently in social activities, especially persons who were older at the time of amputation and also those who are older today. Changes in participation in social activities were not influenced by level of education. Free time activities changed after amputation. Some 93 persons completely changed their free time activities and only 30 were still interested in the same activities as before. The three most frequent free time activities before amputation were cycling, team ball games and farm work. After amputation they were reading, watching television and/or listening to radio and music and housekeeping. It is concluded that lower limb amputation severely changes the social life and free time activities of persons who were young at the time of amputation.

The Danish Amputation Register and the nationwide National Patient Register are presented. Based upon the code numbers in the WHO classification system (ICD), 4 etiology groups i.e. vascular insufficiency, diabetes mellitus, malignant neoplasma and trauma were extracted. The purpose was to analyse the relationship between level of amputation (i.e. foot, below-knee, through-knee, above-knee and hip) and etiology (cause of amputation). The material represents all such amputations in Denmark during the period 1978 to 1989 (n = 25.767). The number of amputations because of vascular insufficiency with and without diabetes mellitus decreased over the period studied. The number of tumour and trauma amputations seemed unchanged. There was a significant reduction in the number of amputations at proximal levels (above-knee) for vascular insufficiency with and without diabetes mellitus and in the trauma group. No such change was found regarding tumour amputations. There was a characteristic pattern in the distribution of level respectively of etiological factors for each etiology group and for each level of amputation.

Sir: Dr J. Kulkarni1 gives a good list of lower limb amputation sequelae with comprehensive information on frequency. However in a clinical setting we suggest that it might be more helpful to class...

A 24-year retrospective study of amputees was conducted at the Prosthetic and Orthotic Unit of the Kowloon Rehabilitation Centre, the first and largest rehabilitation centre in Hong Kong. A review was made of 1821 patients and a rising trend of amputee population was demonstrated probably related to the population growth. The ratio of lower limb to upper limb amputees was 1.83 to 1. The mean age of the amputees was 39 years. The commonest cause of upper limb amputation was trauma (89%) and of lower limb amputation was infection (35%). Vascular diseases were not as common in Chinese as in Caucasian communities. These patterns of amputee population indicate the demand for prosthetic service and provide guide-lines for future development.

A review of smoking habits of 77 vascular related amputees demonstrated a high incidence of smoking significantly greater for men than in the general population. Male smoking amputees with atherosclerosis related peripheral vascular disease were found to have a high risk of having an above-knee amputation. Those with diabetes mellitus whether male or female, smokers or not, had a significantly greater chance of having a below-knee amputation. Overall, non-smokers were found more likely to have a below-knee amputation than an above-knee (p less than 0.05).

This paper records the Dundee experience over 23 years and reports on 42 cases of tumour related lower limb amputations. There were 27 males and 15 females with 37 malignant and 5 benign tumours. Four of the 'benign' tumours proved to be osteoclastoma which were locally malignant. Prosthetic rehabilitation was achieved in all but one case. All patients fitted were able to use their prostheses.