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Despite the increasing incidence and prevalence of amputation across the globe, individuals with acquired limb loss continue to struggle with functional recovery and chronic pain. A more complete understanding of the motor and sensory remodeling of the peripheral and central nervous system that occurs postamputation may help advance clinical interventions to improve the quality of life for individuals with acquired limb loss. The purpose of this article is to first provide background clinical context on individuals with acquired limb loss and then to provide a comprehensive review of the known motor and sensory neural adaptations from both animal models and human clinical trials. Finally, the article bridges the gap between basic science researchers and clinicians that treat individuals with limb loss by explaining how current clinical treatments may restore function and modulate phantom limb pain using the underlying neural adaptations described above. This review should encourage the further development of novel treatments with known neurological targets to improve the recovery of individuals postamputation. [ABSTRACT FROM AUTHOR]

If the alignment of a leg prosthesis is inadequate there will be the danger of arthritic defects occurring in the preserved knee joint. Acoustic-kinetic joint analysis in orthopaedic technology allows monitoring of the knee joint of an amputee after the alignment of a leg prosthesis and to recognize early joint defects resulting in adaptation of the alignment of the prothesis. A test rig was developed which includes acoustic emission analysis of the knee, video-based gait analysis, ground reaction force measurement and the measurement of the holding forces of the hands. During the examination a subject must do 3 one-legged knee bends during 10 sec with the preserved leg. To support the subject two grab handles were fixed with force sensors to a frame. A series of 6 measurements were recorded with breaks of 2 min. The recorded forces of the leg show a double hump pattern during the knee bend. The rising edge of the flexion phase was not uniform. The forces show no conclusive uniform pattern. The fitness of the probands acts as an indicator for the pattern of the force signals. The signals of the measurements show the necessity of the support for both hands to execute a one-legged knee bend. The understanding of the 3 measured forces is important for the arthritic diagnosis of the knee joint. [ABSTRACT FROM AUTHOR]

The kinematics of the body center of mass (bCoM) may provide crucial information supporting the rehabilitation process of people with transfemoral amputation. The use of magneto-inertial measurement units (MIMUs) is promising as it may allow in-the-field bCoM motion monitoring. Indeed, bCoM acceleration might be obtained by fusing the estimated accelerations of body segments' centers of mass (sCoM), the formers being computed from the measured accelerations by segment-mounted MIMUs and the known relative position between each pair of MIMU and underlying sCoM. This paper investigates how erroneous identifications of MIMUs positions impact the accuracy of estimated 3D sCoM and bCoM accelerations in transfemoral amputee gait. Using an experimental design approach, 215 simulations of erroneous identifications of MIMUs positions (up to 0.02 m in each direction) were simulated over seven recorded gait cycles of one participant. MIMUs located on the trunk and sound lower limbs were shown to explain up to 77% of the variance in the accuracy of the estimated bCoM acceleration, presumably due to the higher mass and/or angular velocity of these segments during gait of lower-limb amputees. Therefore, a special attention should be paid when identifying the positions of MIMUs located on segments contributing the most to the investigated motion. Sensitivity of the estimated vertical body center of mass acceleration to erroneous identifications of MIMU positions in the anteroposterior (AP), mediolateral (ML), and vertical (V) directions, expressed in percentage of the total variance of the estimation accuracy. [ABSTRACT FROM AUTHOR]

Introduction: Patients who undergo extremity amputation have historically used socket prosthetics to ambulate and perform daily functions; however, these prosthetics can be limited by poor terminal control and wear issues. In patients who have difficulty wearing their prostheses or with upper extremity amputations, osseointegrated implants may offer better function and quality of life. The Osseointegrated Prostheses for the Rehabilitation of Amputees (OPRA) was the first such device to become commercially available. Clinical trials have demonstrated benefit in patient gait, prosthetic use, and overall well-being, and new implants may be applied for various amputation levels. Areas covered: The OPRA, the most studied osseointegrated prosthetic stem, is reviewed, presenting indications, surgical procedure, complications, and results of clinical studies. Expert commentary: Osseointegration for amputees is an expanding field that has the potential to enhance rehabilitative potential. The OPRA implant is an effective device with a long life-span and low complication profile. [ABSTRACT FROM AUTHOR]

Background: Prosthetic alignment is used to optimize prosthetic functioning and comfort. Spatio-temporal and kinematic gait parameters are generally observed to guide this process. However, they have been shown to be influenced by compensations, which reduces their sensitivity to changes in alignment. Alternatively, the use of moments working at the base of the prosthetic socket, external socket reaction moments (ESRM), has been proposed to quantify prosthetic alignment.Research Question: To investigate if a predetermined kinetic alignment criterion, 0Nm averaged over the stance phase, can be used to fine-tune prosthetic alignment.Methods: 10 transtibial amputees were included in this intervention study. Firstly, their prostheses were aligned using conventional alignment procedures. Kinetic parameters and Socket Comfort Score (SCS) were measured in this initial alignment (IA) condition. Subsequently, the coronal plane ESRM during gait was presented to the prosthetist in real time using a Gait Real-time Analysis Interactive Lab. The prosthetist iteratively adapted the prosthetic alignment towards a predetermined average ESRM during the stance phase of 0 Nm. At the Final Alignment (FA), kinetic parameters and SCS were measured again and a paired sample t-test was performed to compare ESRMs and SCSs between alignments.Results: A significant (p < 0.001) change was found in the absolute coronal plane ESRM (mean ± SD) from IA (|0.104| ± 0.058 Nm/kg) to FA (|0.012| ± 0.015 Nm/kg). In addition a significant (p < 0.001) change of the external coronal adduction knee moments was observed from IA (-0,127 ± 0.079 Nm/kg) to FA (-0.055 ± 0.089 Nm/kg), however this change was more variable among participants. On average, no significant (p = 0.37) change in the SCS was observed.Significance: While this study shows the potential of quantifying and guiding alignment with the assistance of kinetic criteria, it also suggests that a sole reliance on the ESRM as a single alignment criterion might be too simple. [ABSTRACT FROM AUTHOR]

Background: Major lower-limb amputation (LLA) predisposes patients post-operatively to a significant decline in daily-life functioning. The physical condition of amputee patients prior to surgery is significantly deteriorated due to chronic peripheral vascular disease (PVD) and diabetes, which accounts for the majority of LLAs in the adult population. A common strategy called pre-rehabilitation has been used in multiple patient populations to prepare the patient for undergoing a surgical event and to improve post-operative patient outcomes. Pre-rehabilitation might enhance the outcome of dysvascular LLA patients and reduce the high post-operative mortality rates. However, experience of experts with pre-rehabilitation and feasibility of a pre-rehabilitation program in this group remains unknown. Objective: To investigate the experiences of medical professionals and researchers in the field of LLA with the use of pre-rehabilitation in general and in particular PVD patients. Additionally, the study examines their opinions regarding need for and feasibility of a pre-rehabilitation program for dysvascular patients at risk for an LLA. Methods: Two explorative focus group discussions were organized with in total 16 experts in the field of treatment and research of LLA. Transcribed data were coded using the Atlas.ti software package. Thematic analysis with inductive approach was opted to arrange and interpret codes. Results: The experiences of the experts with pre-rehabilitation in dysvascular patients were scarce. The experts described dysvascular patients at risk for an LLA as a difficult group for pre-rehabilitation due to short time window prior to surgery, older age, multiple co-morbidities and lack of motivation for behavioral change. The experts concluded that a pre-rehabilitation program should focus on patients who have sufficient time in advance before the amputation for pre-rehabilitation and who are motivated to participate. Conclusion: Although in general the effects of pre-rehabilitation are promising, pre-operative rehabilitation in dysvascular patients at risk for an LLA seems not feasible. Future research could focus on a better monitoring of dysvascular patients and the development of pre-rehabilitation in subgroups of younger dysvascular LLA patients. [ABSTRACT FROM AUTHOR]

This investigation compared stance, swing, and double support times of a recent below-the-knee amputee (BKA) child's gait with the gait of normal children and with that of experienced BKA children. Kinematic data were collected for 11 normal children, 2 experienced BKA children, and a novice BKA child. Results indicated there were significant differences between the steps of prosthetic and nonprosthetic limbs and between normals and BKAs. Initially the gait of the novice BKA differed from that of experienced BKAs. After 94 days the gait of the novice BKA was not significantly different from that of the experienced BKAs. It was concluded that since the structure and function of the prosthetic limb is not the same as normal, (a) it may be appropriate for the BKA child to have an asymmetrical gait pattern, and (b) rehabilitation may be directed toward teaching the recent BKA child to walk more like experienced BKAs than like normal children. [ABSTRACT FROM AUTHOR]

Background: People with lower limb amputation may experience walking limitations on slopes because of missing musculoskeletal and neuromuscular systems. Elevated vacuum suspension could benefit transtibial amputee gait for slope walking, but research is lacking to inform clinical practice.Methods: Twelve people with unilateral transtibial amputation were fitted with the Unity elevated vacuum suspension system (Össur) and Pro-Flex XC foot. 3D motion analysis was performed for 7° incline, 7° decline, and level walking within a CAREN-Extended system virtual Park environment. Randomized and blinded walking trials were completed with the vacuum active or inactive.Results: Statistically significant differences (p < 0.05) were found between vacuum conditions when walking uphill or downhill for temporal spatial, kinematic, and kinetic gait parameters; however, effect sizes were small (r≤0.35). Prosthetic step length decreased for both vacuum conditions on downhill compared to uphill walking. Symmetry index was <10% for step length, step time, and stance time for both vacuum condition during downhill walking, indicating acceptable symmetry. During incline walking, step length was only symmetrical with active vacuum. Knee range of motion was not restricted, for both conditions.Conclusion: Active vacuum improved gait symmetry for incline walking, but the other differences between vacuum conditions were small and may not be clinically significant. Therefore, the Unity system approach for elevated vacuum suspension had a positive, but small, effect on walking and should maintain appropriate walking even with vacuum failure, until limb volume changes adversely affect socket fit (i.e., elevated vacuum helps control limb volume fluctuations over time). [ABSTRACT FROM AUTHOR]

Background: Daily ambulation with a prosthesis often involves turning to negotiate within the home and community environments, however how people with lower limb loss perform turns is infrequently studied. Administering a common clinical outcome measure to capture turn performance data provides a convenient means of assessing this ubiquitous activity.Research Question: What temporal-spatial parameters are exhibited by people with unilateral lower limb amputation while performing a 180˚ turn task?Methods: Forty community-ambulating subjects with unilateral lower limb amputation (20 transtibial amputees, 20 transfemoral amputees) performed the Component Timed-Up-and-Go (cTUG) test turning once in each direction, both toward the intact and toward the prosthetic limb. An instrumented walkway captured temporal-spatial parameters during performance of the 180˚ turn task of the cTUG, while a custom iPad application recorded time and number of steps to perform the turn. Comparisons between turn direction and level of amputation during the cTUG and temporal-spatial results were assessed.Results: People with lower limb amputation spent more time on their intact limb while turning than their prosthetic limb regardless of the position of the intact limb, and those with transfemoral amputation spent significantly more time over the intact limb than those with transtibial amputation. Additionally, subjects with transfemoral amputation performed the turn significantly faster when turning with an inner intact limb.Significance: Amputees use different movement strategies with altered temporal-spatial characteristics to turn depending on the direction of the turn and the level of amputation. Clinical use of the cTUG could provide evidence supporting prosthetic prescription practice and introduction of novel physical therapy interventions for individuals with lower limb amputation. [ABSTRACT FROM AUTHOR]

Background: Individuals with transfemoral amputation (TFA) have difficulty in descending ramps. Although individuals with TFA who descend ramps are speculated to have greater biomechanical demands, this has not been quantified.Research Question: How do individuals with TFA wearing a prosthetic knee without a stance control mechanism adapt their gait biomechanics to a slightly declined surface?Methods: We retrospectively analyzed data of level walking and ramp descent (5° decline) from six subjects with TFA who used a prosthesis without a stance control mechanism. Ground reaction force and joint moment, power, and kinematics were derived from three-dimensional motion capture, combined with force measurement. Kinematic and kinetic variables were compared during level walking and ramp descent using the paired tests.Results: Compared with level walking, ramp descent increased the maximum contralateral vertical ground reaction force by 16% of the body weight, on average (standard deviation: 20%). Ramp descent tended to induce smaller concentric hip power during late swing and greater hip eccentric power on the prosthetic-side during late stance. Greater biomechanical demands during ramp descent were indicated by increased maximum medial ground reaction force on both sides, and eccentric joint power of the contralateral ankle during stance.Significance: For individuals with TFA using a prosthetic knee without a stance control mechanism, descending a ramp can increase loading on the contralateral limb during the loading response; slower walking may alleviate the effect. Ramp descent can change prosthetic-side hip muscles' control of the swinging prosthetic limb, eccentric work on the contralateral ankle plantarflexors during stance, and mediolateral balance. All of these factors should be taken into consideration when individuals with TFA learn to descend a ramp. [ABSTRACT FROM AUTHOR]

Introduction: Traditional prosthetic solutions expose the amputee to numerous problems that limit his ability to safely perform the normal activities of daily life. In order to eliminate the problems related to the use of the traditional prosthesis with socket, a new technique was developed for fixing the prosthesis to the amputees based on the principle of osseointegration. The aim of this paper is to study and analyze the stress distribution on the interface between a trans-humeral osseointegrated prosthetic implant and the residual bone, identifying the most stressed areas and thus foreseeing possible failure phenomena of the entire prosthetic system and, after, to compare the stress distribution on three different prosthetic designs that differ from each other for some geometric characteristics.Materials and Methods: A healthy individual mimics two fall scenarios of which the trans-humeral amputees can most likely be victims: Static fall and Dynamic fall. A force platform (P-6000, BTS Bioengineering) is required for load data acquisition. The CAD model of the trans-humeral osseointegrated implant was created following the guidelines of the OPRA implant. The bone model was created starting from the CAT scan of a left humerus. The FEM simulation was conducted throught a linear analysis.Results: Both during static fall and dynamic fall, similar trends have been observed for the reaction force Fz, the torque moment Tz, the bending moments Mx and My. From the analysis of the von Mises stress distribution it was found that the stress distribution is more homogeneous in the case where the thread of the fixture is made by a triangular profile with height of the thread equal to 0.5 mm. However, it can be seen that, when passing from a thread with height of 0.5 mm to a 1 mm, there is a slight decrease in the stress on the whole contact zone between the fixture and the humerus. The same improvement can also be seen in the case of trapezoidal threading.Conclusion: By modifying the height and/or by varying the thread profile, are obtained slightly better results with respect to the case with a 0.5 mm height triangular thread. [ABSTRACT FROM AUTHOR]

Recent studies have shown the ability of transhumeral amputees to generate surface electromyography (sEMG) patterns associated to distinct phantom limb movements of the hand, wrist and elbow. This ability could improve the control of myoelectric prostheses with multiple degrees of freedom (DoF). However, the main issue of these studies is that these ones record sEMG from sites that cannot always be integrated in a prosthesis socket. This study aims to evaluate the classification accuracy of eight main upper limb phantom movements and a no movement class in transhumeral amputees based on sEMG data recorded exclusively on the residual limb. A sub-objective of this study is to evaluate the impact of kinematic data on the classification accuracy. Five transhumeral amputees participated in this study. Classification accuracy obtained with an artificial neural network ranged between 60.9% and 93.0%. Accuracy decreased if the number of DoF considered in the classification increased, and/or if the phantom movements became more distal. Adding a kinematic feature produced an average increase of 4.8% in accuracy. This study may lead to the development of a new myoelectric control method for multi-DoF prostheses based on phantom movements of the amputee and kinematic data of the prosthesis. [ABSTRACT FROM AUTHOR]

Military members with war-related lower limb amputation experience a range of acute and chronic pain symptoms. The purpose of this study was to evaluate pain during 12 weeks of a military amputee rehabilitation program ( MARP) pre- and post-prosthesis. The data for this study were drawn from a randomized clinical trial comparing MARP supplemented with neuromuscular electrostimulation ( MARP + NMES, n = 23) to MARP alone ( n = 21) for service members with unilateral transtibial amputation. The McGill Pain Questionnaire ( MPQ) and phantom limb pain/sensations were assessed at baseline, 3, 6, 9, and 12 weeks. Changes within- and between-groups were analyzed with generalized mixed models. Participants reported mild-to-moderate pain at all visits, and improved significantly on the MPQ and frequency of phantom limb pain/sensations ( p < .001 for effect of time). Group by time interactions were not significant, indicating both groups showed similar improvement. Univariate tests showed the NMES + MARP group had lower pain intensity than MARP-only group at weeks 3 and 6. Participants in MARP demonstrated good overall pain control and reported reduced pain and fewer days with phantom limb pain/sensations over 12 weeks. Adding NMES to MARP may be beneficial in early rehabilitation, and NMES could potentially enhance physical therapy participation by decreasing pain. [ABSTRACT FROM AUTHOR]

Background: The majority of lower limb amputations are undertaken in people with peripheral arterial occlusive disease, and approximately 50% have diabetes. Quality of life is an important outcome in lower limb amputations; little is known about what influences it, and therefore how to improve it.Objectives: The aim of this systematic review was to identify the factors that influence quality of life after lower limb amputation for peripheral arterial occlusive disease.Methods: MEDLINE, EMBASE, CINAHL, PsycINFO, Web of Science and Cochrane databases were searched to identify articles that quantitatively measured quality of life in those with a lower limb amputation for peripheral arterial occlusive disease. Articles were quality assessed by two assessors, evidence tables summarised each article and a narrative synthesis was performed.Study Design: Systematic review.Results: Twelve articles were included. Study designs and outcome measures used varied. Quality assessment scores ranged from 36% to 92%. The ability to walk successfully with a prosthesis had the greatest positive impact on quality of life. A trans-femoral amputation was negatively associated with quality of life due to increased difficulty in walking with a prosthesis. Other factors such as older age, being male, longer time since amputation, level of social support and presence of diabetes also negatively affected quality of life.Conclusion: Being able to walk with a prosthesis is of primary importance to improve quality of life for people with lower limb amputation due to peripheral arterial occlusive disease. To further understand and improve the quality of life of this population, there is a need for more prospective longitudinal studies, with a standardised outcome measure. Clinical relevance This is of clinical relevance to those who are involved in the rehabilitation of persons with lower limb amputations. Improved quality of life is associated with successful prosthetic use and focus should be directed toward achieving this. [ABSTRACT FROM AUTHOR]

Copyright of Medical Rehabilitation / Rehabilitacja Medyczna is the property of Medical Rehabilitation and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background: This novel case report describes the problems of prescribing a prosthetic socket in a left transfemoral amputee secondary to chronic patellofemoral instability compounded by complex regional pain syndrome. Case Description and Methods: Following the amputation, complex regional pain syndrome symptoms recurred in the residual limb, presenting mainly with oedema. Due to extreme daily volume fluctuations of the residual limb, a conventional, laminated thermoplastic socket fitting was not feasible. Findings and Outcomes: An adjustable, modular socket design was trialled. The residual limb volume fluctuations were accommodated within the socket. Amputee rehabilitation could be continued, and the rehabilitation goals were achieved. The patient was able to wear the prosthesis for 8 h daily and to walk unaided indoors and outdoors.Conclusion: An adjustable, modular socket design accommodated the daily residual limb volume fluctuations and provided a successful outcome in this case. It demonstrates the complexities of socket fitting and design with volume fluctuations. Clinical relevance Ongoing complex regional pain syndrome symptoms within the residual limb can lead to fitting difficulties in a conventional, laminated thermoplastic socket due to volume fluctuations. An adjustable, modular socket design can accommodate this and provide a successful outcome. [ABSTRACT FROM AUTHOR]

Background: To overcome the challenges of rehabilitation of bilateral transfemoral amputees, we developed a novel "hip prosthesis in the sitting posture." Case Description and Methods: A 64-year-old male bilateral transfemoral amputee was transferred for rehabilitation 4 months following a burn injury. His wounds remained unhealed for 20 months; thus, he was unable to participate in standing training with the standard prosthetic sockets. Hip prosthesis in the sitting posture has very little friction between the sockets and residual limbs, which facilitated our patient to begin standing and walking exercises. Findings and Outcomes: The patient's refractory wounds healed 1 month after initiating exercises using hip prosthesis in the sitting posture, and he could begin rehabilitation with the standard prostheses.Discussion and Conclusion: Hip prosthesis in the sitting posture enabled a bilateral transfemoral amputee with unhealed residual limbs to stand, walk, and begin balance training. Hip prosthesis in the sitting posture is an effective temporary prosthesis to prevent disuse until wounds are healed and to continue rehabilitation with standard prostheses. Clinical relevance Hip prosthesis in the sitting posture is useful for bilateral transfemoral amputees with unhealed residual limbs after burn injuries to prevent disuse and maintain motivation for walking. [ABSTRACT FROM AUTHOR]

Background: Most amputees live with their prostheses for a long time. Therefore, quality of life is an important outcome for lower limb amputees.Objective: To translate the Prosthesis Evaluation Questionnaire (PEQ) and evaluate psychometric properties.Study Design: Methodological research.Methods: Lower limb amputees responded to electronic versions of the PEQ and SF-36v2 at baseline (n=64), after two weeks (n=51), and after 12 weeks (n=50). Reliability was assessed using Cronbach's alpha and intraclass correlation coefficient (ICC) analyses of the baseline and two weeks test-retest data. Estimates for standard error of measurement (SEM) were calculated based on reliability estimates. Construct validity was evaluated by testing using hypotheses testing.Results: Reliability estimates (ICC/Cronbach's alpha) for the nine subscales were: Social Burden (0.85/0.76), Appearance (0.85/0.72), Residual Limb Health (0.80/0.69), Well-Being (0.78/0.90), Utility (0.76/0.89), Frustration (0.74/0.90), Perceived Response (0.62/0.80), Ambulation (0.61/0.94), Sounds (0.51/0.65). Construct validity was supported in three out of four subscales evaluated.Conclusions: The subscales Social Burden, Appearance, Well-Being, Utility and Frustration had consistent high reliability, supporting their use in assessing the prosthesis related quality of life in lower limb amputees. Results were mixed on three other scales (Residual Limb Health, Perceived Response, and Ambulation), while one scale, Sounds, had consistent low reliability. Clinical relevance For the first time a patient reported disease specific quality of life measure for lower limb amputees is available in Danish. Health care providers can now identify patients with reduced quality of life and measure treatment and rehabilitation effects over time. [ABSTRACT FROM AUTHOR]

The purpose of this study is to develop a myoelectric hand that determines hand posture and estimates grip force simultaneously like human hands. Methods for simultaneous hand posture determination and grip force estimation typically yield unsatisfying results because of the complex characteristics of electromyogram (EMG) signals. In this study, the authors developed a myoelectric hand that is able to control both force and posture using a method proposed in our previous study. Tests of the grasp ability of the myoelectric hand conducted with healthy men and an amputee showed that the proposed method can be used to control both grip force and hand posture simultaneously with sufficiently accuracy in a real environment. In conclusion, it was suggested that the hand that control posture and force simultaneously improve the dexterity of amputees. [ABSTRACT FROM AUTHOR]

Background: Capturing the variability that exists among patients attending an amputee clinic using standardized paper-based questionnaires is time-consuming and may not be practical for routine clinical use. Electronic questionnaires are a potential solution; however, the benefits are dependent on the feasibility and acceptance of this mode of data collection among patients.Objective: To determine the feasibility and patient preference/comfort in using a tablet-based questionnaire for data collection in an outpatient amputee rehabilitation clinic compared to a traditional paper-based questionnaire.Study Design: Observational study.Methods: In all, 48 patients with major extremity amputations completed both tablet and paper questionnaires related to their amputation and prosthetic use. Both trials were timed; patients then completed a semi-structured questionnaire about their experience.Results: In all, 20.5% of patients needed hands-on assistance completing the paper questionnaire compared to 20.8% for the tablet. The majority of participants (52.1%) indicated a preference for the tablet questionnaire; 64.6% of patients felt the tablet collected a more complete and accurate representation of their status and needs. In all, 70.8% of participants described themselves as comfortable using the tablet.Conclusion: Despite comorbidities, patients with amputations demonstrated excellent acceptance of the electronic tablet-based questionnaire. Tablet questionnaires have significant potential advantages over paper questionnaires and should be further explored. Clinical relevance A custom electronic questionnaire was found to be beneficial for routine clinic use and was well received by patients in an amputee rehabilitation clinic. Development of such questionnaires can provide an efficient mechanism to collect meaningful data that can be used for individual patient care and program quality improvement initiatives. [ABSTRACT FROM AUTHOR]

Background: Balance is an important variable to consider during the rehabilitation process of individuals with trans-tibial amputation. Limited evidence exists on the balance abilities of people with trans-tibial amputation due to vascular causes.Objective: The purpose of this article is to review literature and determine if standing balance is diminished in people with trans-tibial amputation due to vascular causes.Study Design: Literature review.Methods: Data were obtained from PubMed, Google Scholar, OandP.org , CINHAL, and Science Direct. Studies were selected only if they included standing balance assessment of people with unilateral trans-tibial amputation due to vascular causes.Results: The review yielded seven articles that met the inclusion criteria. The general test methodology required participants to stand still on force platforms, with feet together, while center of pressure or postural sway was recorded.Conclusion: According to the findings of this review, individuals with trans-tibial amputees due to vascular causes have diminished balance abilities. Limited evidence suggests their balance might be further diminished as compared to individuals with trans-tibial amputation due to trauma. Although the evidence is limited, because of the underlying pathology and presence of comorbidities in individuals with trans-tibial amputation due to vascular causes, one cannot ignore these findings, as even a minor injury from a fall may develop into a non-healing ulcer and affect their health and well-being more severely than individuals with trans-tibial amputation due to trauma. Clinical relevance Individuals with trans-tibial amputation due to vascular causes have diminished balance abilities compared to healthy individuals and individuals with trans-tibial amputation due to trauma. This difference should be considered when designing and fabricating prostheses. Prosthetists and rehabilitation clinicians should consider designing amputation cause-specific rehabilitation interventions, focussing on balance and other functional limitations related to comorbidities of amputation. [ABSTRACT FROM AUTHOR]

Background: Individuals with transtibial amputation are at increase risk of falling. The absence of an ankle joint and the associated musculature in these individuals can reduce clearance between the prosthetic foot and ground during the swing phase of gait, which may increase the risk of stumbling and in turn falling.Objectives: To associate minimum toe clearance during gait in the laboratory with community-based, trip-related stumbles by individuals with transtibial amputation using conventional feet.Study Design: Prospective cohort design; following quantitative gait analysis, participants completed electronic surveys to prospectively report stumbles and falls for 1 year thereafter.Methods: General community with gait analysis conducted within a motion analysis laboratory and prospective tracking of stumbles occurring in the community. A volunteer sample of eight unilateral, transtibial amputees that were K3 or K4 level ambulators and current patients at a local prosthetic clinic. All participants completed the entire 1-year follow-up study. Prosthetic-side minimum toe clearance while walking on a level treadmill at self-selected speed and self-reported trip-related stumbles in the community. Minimum toe clearance was defined as a local minimum of the vertical displacement of the toe from toe-off to heelstrike relative to its position during midstance.Results: Prosthetic-side minimum toe clearance was more than 50% lower for participants who reported one or more trip-related stumbles on that side compared with participants who reported zero trip-related stumbles on the prosthetic side (minimum toe clearance = 12.3 ± 0.8 mm vs 25.6 ± 5.4 mm, respectively; p = 0.036).Conclusion: This is the first study relating laboratory-based measures to prospective stumbles by prosthesis users. The results suggest that prosthesis users with low minimum toe clearance may be at increased risk of experiencing a trip-related stumble in the community. Given that frequent stumbling increases the risk of falling, future work is warranted on the effectiveness of interventions focused on minimum toe clearance on reducing fall risk. Clinical relevance Interventions to increase minimum toes clearance, which could include prescription of active dorsiflexing prostheses or gait training, may help reduce the risk of trip-related falls for individuals who report a history of trip-related stumbles. [ABSTRACT FROM AUTHOR]

Background: 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.Objectives: 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.Study Design: Qualitative study using focus groups and individual interviews.Methods: 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.Results: 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.Conclusion: 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. [ABSTRACT FROM AUTHOR]

The article considers the use of martial arts-based high intensity interval training (MA-HIIT) in the rehabilitation of combat amputees in the U.S. armed forces. Topics discussed include the benefits of a MA-HIIT program, the barriers to successful rehabilitation of the combat amputee, and some advances to the rehabilitation of the combat amputee that have been developed since the onset of the hostilities after the attacks of September 11, 2001.

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Background: Service members who have experienced combat trauma with resulting amputation are at risk for compromised quality of life postamputation. Monitoring mental and physical health in amputees returning from the war is of paramount importance. This study examined changes in physical and mental health-related quality of life in service members following traumatic unilateral, transtibial amputation (TTA) during a 12-week period of rehabilitation before and after receiving a prosthesis.Method: This study is a secondary analysis from a randomized controlled trial (RCT) of military service members starting Military Amputee Rehabilitation Program (MARP) following a traumatic TTA. The study examined change in SF-36 Physical Component Summary (PCS) and Mental Component Summary (MCS) scores as two aspects of health-related quality of life. Forty-four injured service members, aged 19 to 46, were recruited into the RCT. Participants were randomized into 12 weeks of MARP plus home neuromuscular electrical stimulation therapy (n = 23) or MARP alone (N = 21) and compared at baseline, 6, and 12 weeks on: SF-36 PCS and MCS scores. Linear mixed models examined time and group differences and their interaction for the MCS and PCS scores. A multivariate mixed model tested whether MCS and PCS scores differed.Results: For the combined rehabilitation cohort, MCS did not differ over 12 weeks (p = 0.27) with scores at week 0 of M = 56.7 (SD = 11.9) and at week 12 of M = 52.7 (SD = 11.4), similar to healthy controls (age = 25-34, M = 51.0, SD = 7.6). Scores did not differ between treatment groups (p = 0.28) with no group by time interaction (p = 0.34). The MCS significantly declined over time (p = 0.05) after adjustment for covariates. PCS improved over 12 weeks (p < 0.0001) in the total rehabilitation group with scores at week 0 of M = 34.0 (SD = 8.1) to M = 41.8 (SD = 8.4) at week 12, significantly lower than healthy controls (age = 25-34, M = 54.1, SD = 6.6). Scores did not differ between treatment groups (p = 0.89), and there was no group by time interaction (p = 0.34). An interaction between the PCS and MCS was observed such that the PCS improved over time, whereas the MCS did not significantly change (p = 0.0005).Discussion: War-injured transtibial amputees are at risk for compromised quality of life during rehabilitation. Self-perceived physical health improved as might be expected from rehabilitation. Self-perceived mental health did not. During rehabilitation, physical healing, psychological adjustment, and lifestyle adaptation are occurring simultaneously. However, more attention may need to be directed toward mental health during rehabilitation. [ABSTRACT FROM AUTHOR]

A controller for a powered transfemoral prosthesis is presented, which can coordinate power delivery at the knee with the motion of the crankshaft on a bicycle. The controller continuously estimates the lengths of a four-bar linkage model through the application of a recursive least squares algorithm. The link lengths are used to estimate the angle of the bicycle crankshaft. With this measure, the delivery of knee torque is coordinated with the motion of the user. The controller is implemented on a prosthesis prototype and assessed on a transfemoral amputee subject ( N = 1). The subject exhibited a bilateral work asymmetry of 83.5% when cycling with his daily use prosthesis in a free-swing mode. When 60-N·m peak assistance was provided by the powered prosthesis, the bilateral work asymmetry was reduced to 11.4%. The subject's metabolic energy rate was measured for speed and power-matched cycling while the powered prosthesis provided zero assistance (i.e., turned off and providing its back-drive resistance) or 30-N·m peak assistance. Subject's metabolic energy rate decreased by 16.5% when receiving powered assistance relative to the zero-assistance condition. [ABSTRACT FROM PUBLISHER]

Background: The ability to walk with a prosthesis is the main objective of rehabilitation following amputation, and distance and speed of walking achieved are considered determining factors in amputees' perception of quality-of-life.Objectives: To assess walking abilities and improvement in gait distance and speed parameters in patients undergoing transfemoral amputation with a femoral implant that allows distal support of the residuum.Study Design: Experimental before-and-after study.Methods: Ten transfemoral amputation patients received a titanium implant that allowed distal weight bearing of the residuum within the socket. The post-intervention follow-up period was 14 months. We evaluated the functionality using a 2-min walk test and the physiological cost index.Results: The etiology of amputation was traumatic in six patients (60%). The mean 2-min walk test score was 98.4 ± 19.5 m prior to the femoral implant and 122.5 ± 26.1 m at 14 months ( p < 0.008), representing an improvement of 24.5%. The mean gait speed prior to the femoral implant was 0.82 ± 0.16 and 1.02 ± 0.21 m/s at 14 months ( p < 0.008). The physiological cost index showed no differences ( p < 0.55).Conclusion: The results of this study show an improvement in the distance walked and gait speed in amputees 14 months after having received a femoral implant. Clinical relevance This article provides additional insight into the use of a femoral implant that allows distal support of the residuum to improve walking abilities and gait distance and speed parameters in patients undergoing transfemoral amputation, mainly those of vascular origin. [ABSTRACT FROM AUTHOR]

Background: Traumatic transtibial amputations lead to an early decline in the use and weight bearing of the residual limb. These changes result in progressive quadriceps muscle atrophy with strength loss that affects standing and walking. Neuromuscular electrical stimulation (NMES) may be useful as an adjunct to amputee prosthetic rehabilitation to maintain quadriceps muscle strength and mass. The objective of this pilot study was to compare the effects of a home-based NMES rehabilitation program plus the traditional military amputee rehabilitation program (TMARP) to the effects of TMARP alone on quadriceps muscle strength, functional mobility, and pain in military service members after a combat-related lower extremity amputation.Methods: In total, 44 participants, aged 19 to 46 years, with a unilateral transtibial amputation were randomly assigned to the TMARP plus NMES (n = 23) or to TMARP alone (n = 21). Both groups received 12 weeks of the traditional amputee rehabilitation, including pre- and postprosthetic training. Those in the NMES group also received 12 weeks of NMES, 15 to 20 minutes/day, 5 days a week. Participants were tested at 3-week intervals during the study (baseline, 3, 6, 9, and 12 weeks) for muscle strength and pain. For functional measures, they were tested after receiving their prosthesis and at study completion (weeks 6 and 12).Results: In both groups, residual limb quadriceps muscle strength and pain severity improved from baseline to 12 weeks. The NMES plus TMARP group showed greater strength than the TMARP alone group at 3 weeks, before receiving the prosthesis. However, 6 weeks after receiving their prosthesis, there was no group difference in the residual limb strength. Functional mobility improved in both groups between weeks 6 and 12 with no difference between the two treatment groups.Discussion: A home-based NMES intervention with TMARP worked at improving residual limb strength, pain, and mobility. NMES seemed most effective in minimizing strength loss in the amputated leg before receiving the prosthesis. Further research on amputation rehabilitation is warranted as NMES may accelerate recovery post amputation. [ABSTRACT FROM AUTHOR]

Background: In product development for lower limb prosthetic devices, a set of special criteria needs to be met. Prosthetic devices have a direct impact on the rehabilitation process after an amputation with both perceived technological and psychological aspects playing an important role. However, available psychometric questionnaires fail to consider the important links between these two dimensions. In this article a probabilistic latent trait model is proposed with seven technical and psychological factors which measure satisfaction with the prosthesis. The results of a first study are used to determine the basic parameters of the statistical model. These distributions represent hypotheses about factor loadings between manifest items and latent factors of the proposed psychometric questionnaire.Methods: A study was conducted and analyzed to form hypotheses for the prior distributions of the questionnaire's measurement model. An expert agreement study conducted on 22 experts was used to determine the prior distribution of item-factor loadings in the model.Results: Model parameters that had to be specified as part of the measurement model were informed prior distributions on the item-factor loadings. For the current 70 items in the questionnaire, each factor loading was set to represent the certainty with which experts had assigned the items to their respective factors. Considering only the measurement model and not the structural model of the questionnaire, 70 out of 217 informed prior distributions on parameters were set.Conclusion: The use of preliminary studies to set prior distributions in latent trait models, while being a relatively new approach in psychological research, provides helpful information towards the design of a seven factor questionnaire that means to identify relations between technical and psychological factors in prosthetic product design and rehabilitation medicine. [ABSTRACT FROM AUTHOR]

Background: In transfemoral (TF) amputees, the forward propulsion of the prosthetic leg in swing has to be mainly carried out by hip muscles. With hip strength being the strongest predictor to ambulation ability, an active powered knee joint could have a positive influence, lowering hip loading and contributing to ambulation mobility. To assess this, gait of four TF amputees was measured for level walking, first while using a passive microprocessor-controlled prosthetic knee (P-MPK), subsequently while using an active powered microprocessor-controlled prosthetic knee (A-MPK). Furthermore, to assess long-term effects of the use of an A-MPK, a 4-weeks follow-up case study was performed.Methods: The kinetics and kinematics of the gait of four TF amputees were assessed while walking with subsequently the P-MPK and the A-MPK. For one amputee, a follow-up study was performed: he used the A-MPK for 4 weeks, his gait was measured weekly.Results: The range of motion of the knee was higher on both the prosthetic and the sound leg in the A-MPK compared to the P-MPK. Maximum hip torque (HT) during early stance increased for the prosthetic leg and decreased for the sound leg with the A-MPK compared to the P-MPK. During late stance, the maximum HT decreased for the prosthetic leg. The difference between prosthetic and sound leg for HT disappeared when using the A-MPK. Also, an increase in stance phase duration was observed. The follow-up study showed an increase in confidence with the A-MPK over time.Conclusions: Results suggested that, partially due to an induced knee flexion during stance, HT can be diminished when walking with the A-MPK compared to the P-MPK. The single case follow-up study showed positive trends indicating that an adaptation time is beneficial for the A-MPK. [ABSTRACT FROM AUTHOR]

This paper presents a review on design issues and solutions found in active lower limb prostheses. This review is based on a systematic literature search with a methodical search strategy. The search was carried out across four major technical databases and the retrieved records were screened for their relevance. A total of 21 different active prostheses, including 8 above-knee, 9 below-knee and 4 combined knee-ankle prostheses were identified. While an active prosthesis may help to restore the functional performance of an amputee, the requirements regarding the actuation unit as well as for the control system are high and the development becomes a challenging task. Regarding mechanical design and the actuation unit high force/torque delivery, high efficiency, low size and low weight are conflicting goals. The actuation principle and variable impedance actuators are discussed. The control system is paramount for a "natural functioning" of the prosthesis. The control system has to enable locomotion and should react to the amputee's intent. For this, multi-level control approaches are reviewed. [ABSTRACT FROM AUTHOR]

Context: Little is known about Libyan disability and rehabilitation services. Objectives: To describe workforce characteristics of the only functioning disability rehabilitation service in 2012 Libya. This was the Benghazi Rehabilitation and Handicap Center. The focus of the case study was the physical disability services including amputee care. Method: Organizational case study involving site visit, self-report workforce survey, and review of relevant policy, government and peak agency reports relevant to disability services. Results: The case study revealed that disability regulations in Libya focussed on social security entitlements and impairment focussed treatment. Community based rehabilitation or initiatives for social inclusion and participation were scant, creating problems for people requiring long term rehabilitation in the community. The center workforce continued to function in spite of conflict and in difficult circumstances. While expatriate staff left in the 2011 conflict, local staff retention was high. These workers were mono-lingual, had longevity of tenure, and a lack of qualification mobility. Some such as therapists and prosthetic technicians, had highly specialised skills requiring center facilities. The case study revealed: escalating patient demand; bed-block; and problems in supplies, capital and equipment maintenance. There were opportunities to increase capacity through: clinical and administrative staff training; development of inpatient facilities for women; discharge options for long-term male inpatients; and coordinated information systems. Of 232 eligible, n=72 staff, who participated in the survey (mean age was 39.4 years; n=40 males). Most therapists/ prosthetic technicians were male; most nurses/ administrative workers were female (p=.0001). The most common qualification across occupations was secondary school; 28.2% had intermediate secondary and 22.5% university degrees as their highest qualification. A third had been employed at the centre >20 years, >10 years and <10 years respectively. 42% worked as part of a team. Conclusion: The study provides an insight into issues affecting disability services and revealed areas for future post-conflict workforce development and opportunities for disability service capacity building particularly in relation to coordinated information systems, qualification upgrades, in-service training, and development of inpatient discharge options including community based rehabilitation and supported accommodation. [ABSTRACT FROM AUTHOR]

Background: Rehabilitation, which is essential for amputees with myoelectric hands, can improve the quality of daily life by remodeling the neuron network. In our study, we aim to develop a cerebral blood perfusion (CBF) single-photon emission computed tomography computer-aided (SPECT-CA) detection scheme to automatically locate the brain's activated regions after rehabilitation.Results: Five participants without forearms (three male, two female, mean age 51 ± 12.89 years, two missing the right side, and three missing the left side) were included in our study. In the clinical assessment, all of the participants received higher scores after training. The results of the SPM analysis indicated that CBF in the precentral gyrus, postcentral gyrus, frontal lobe, temporal lobe and cerebellum was significantly different among the five participants (P < 0.05). Moreover, SPECT-CA showed that the activated brain areas mainly included the precentral gyrus, postcentral gyrus, cerebellum and extensive cerebral cortex.Conclusion: Our study demonstrated that the CBF SPECT-CA method can detect the brain blood perfusion changes induced by rehabilitation with high sensitivity and accuracy. This method has great potential for locating the remodeled neuron regions of amputees with myoelectric hands after rehabilitation. [ABSTRACT FROM AUTHOR]

It is 8 a.m. on a December morning in Jaipur, Rajasthan, India. The day has just begun at Bhagawan Mahavir Vikalanga Sahayata Samithi (BMVSS), a nonprofit organization dedicated to fitting the disabled with artificial limbs (Figure 1). Slowly, patients from across India and neighboring countries gather in the center?s front yard. By the end of the day, more than 35 people will make a long journey back to their homes and communities outfitted with a new prosthetic leg or arm that will promise them a more active and functional future. The entire treatment is free. [ABSTRACT FROM PUBLISHER]

Hand amputation is a traumatic event that dramatically and permanently changes the life of any person who undergoes one. After surgery, the amputee requires a prosthetic device to perform activities of daily living-in particular, tasks requiring grasping and manipulation functions. According to the Washington, D.C.-based Amputee Coalition, there are 1.9 million amputees who use limb prosthetic services and products, and it is estimated that, among them, 500,000 are upper-limb amputees, with approximately 185,000 new amputations every year (www.amputee-coalition.org). The Center for Orthotic and Prosthetic Care, a consortium of providers in Kentucky, Indiana, North Carolina, and New York, says that upper-limb amputations represent 14% of all amputations (www.centeropcare.com). Based on these statistics, we can estimate that, in the European Union, there are a total of 3 million amputees, with 290,000 new cases each year; among these, 40,000 are upperlimb amputations. [ABSTRACT FROM PUBLISHER]

Lower limb amputees can use electrical activity from their residual muscles for myoelectric control of a powered prosthesis. The most common approach for myoelectric control is a finite state controller that identifies behavioral states and discrete changes in motor tasks. An alternative approach to state-based myoelectric control is continuous proportional myoelectric control where ongoing electrical activity has a proportional relationship to the prosthetic joint torque or power. To test the potential of continuous proportional myoelectric control for powered lower limb prostheses, we recruited five unilateral transtibial amputees to walk on a treadmill with an experimental powered prosthesis. Subjects walked using the powered prosthesis with and without visual feedback of their control signal in real time. Amputee subjects were able to adapt their residual muscle activation patterns to alter prosthetic ankle mechanics when we provided visual feedback of their myoelectric control signal in real time. During walking with visual feedback, subjects significantly increased their peak prosthetic ankle power (p = 0.02, ANOVA) and positive work (p = 0.02, ANOVA) during gait above their prescribed prosthesis values. However, without visual feedback, the subjects did not increase their peak ankle power during push off. These results show that amputee users were able to volitionally alter their prosthesis mechanics during walking, but only when given an explicit goal for their residual muscle motor commands. Future studies that examine the motor and learning capabilities of lower limb amputees using their residual muscles for continuous proportional myoelectric control are needed to determine the viability of integrating continuous high-level control with existing finite state prosthetic controllers. [ABSTRACT FROM PUBLISHER]

This paper describes a control approach that provides walking and standing functionality for a powered ankle prosthesis, and demonstrates the efficacy of the approach in experiments with a unilateral transtibial amputee subject. Both controllers incorporate a finite-state structure that emulates healthy ankle joint behavior via a series of piecewise passive impedance functions. The walking controller additionally modifies impedance parameters based on estimated cadence, while the standing controller modulates the ankle equilibrium angle in order to adapt to the ground slope and user posture, and the supervisory controller selects between the walking and standing controllers. The system is shown to reproduce several essential biomechanical features of the healthy joint during walking, particularly relative to a passive prosthesis, and is shown to adapt to various cadences. The system is also shown to adapt to slopes over a range of \pm 15^\circ, providing support to the user, as validated by quasi-static stiffness measurements recorded by the prosthesis. The subject is shown to place more weight on the powered prosthesis than on his passive prosthesis when standing on sloped surfaces, particularly at angles of 10^\circ or greater. The authors also demonstrated that the prosthesis typically began providing support within 1 s of initial ground contact. Further, the supervisory controller was shown to effectively switch between walking and standing, as well as determine ground slope just prior to the transition from the standing controller to the walking controller, where the estimated ground slope was accurate to within 1.25^\circ for all trials. [ABSTRACT FROM PUBLISHER]

Information on the Association of Military Surgeons of the U.S. (AMSUS) Annual Continuing Education Meeting in San Antonio, Texas is presented. Topics include amputee care programs, impact of integrated clinical care with patient-centered approach, and maintenance of amputee care. Speakers include Daniel Metzdorf, Mike Cowan, and Daniel J. Stinner.

Background: The devastating earthquake in Sichuan in 2008 has left many adolescent amputees. However, little research has been focused on the adolescent amputees who have high potential to return to premorbid activity level.Objectives: To investigate daily step activities and prosthesis-related quality of life of the adolescent transtibial and transfemoral amputees after the earthquake.Study Design: A prospective and descriptive study.Methods: A total of 21 adolescent unilateral amputees (11 transtibial and 10 transfemoral amputees) were recruited. Step Activity Monitors and Prosthesis Evaluation Questionnaire were used to assess patients over a 3-month period.Results: The average number of steps per day was 4577 ± 849 and 2551 ± 693 in transtibial and transfemoral amputees, respectively. Transtibial amputees had significantly higher (p < 0.05) levels of step activity than transfemoral amputees in all Step Activity Monitors measures. Prosthetic compliance was good with daily wearing time of above 12 h/day in both groups. Prosthesis Evaluation Questionnaire scores showed no significant difference between two groups.Conclusions: The subjective quality of life is similar for adolescent amputees across transtibial and transfemoral amputation levels. Higher levels of step activity of transtibial amputees suggest that they have had lower energy expenditure and more capacity for ambulation.Clinical Relevance: This article involves a unique subset of young amputees who have sustained traumatic amputations following a major natural disaster. It provides a better understanding on the daily activities and quality of life, and could assist in optimizing the prosthetic outcomes of this subset of populations. [ABSTRACT FROM AUTHOR]