Vol. 18 No. 2-3 of Technology & Innovation, which was published in September, features 13 open-access studies devoted to lower- and upper-limb prostheses and rehabilitation of patients with amputations. This special issued was edited by M. Jason Highsmith, PhD, DPT, CP, FAAOP, with the School of Physical Therapy & Rehabilitation Sciences, University of South Florida; the Extremity Trauma & Amputation Center of Excellence (EACE), U.S. Department of Veterans Affairs, Tampa, Florida; and the 319th Minimal Care Detachment, U.S. Army Reserves, Pinellas Park, Florida. Summaries of each study’s conclusions follow.
Economic Evaluations of Interventions for Transtibial Amputees: A Scoping Review of Comparative Studies: Six cost-identification or cost-consequence articles were eligible for scoring in three topical areas: care models, prosthetic treatment, and prosthetic sockets. From these, five evidence statements were synthesized, with one supported by sufficient evidence to provide moderate confidence regarding comparable cost between total contact and specific weight bearing socket designs when clinic visits, adjustments, and initial costs are considered in the short term. Further and more sophisticated economic analyses of transtibial prosthetic interventions are needed to determine value related to device provision and maintenance, outcomes, and health. Guidance from the profession may be useful in devising a strategy for how to assure economic analyses are a routine element of prosthetic science in the future.
Gait Training Interventions for Lower Extremity Amputees: A Systematic Literature Review: Eight evidence statements were synthesized over two general areas of gait training therapy: overground and treadmill training. Overground training with verbal or other auditory, manual, and psychological awareness interventions was found to be effective at improving gait. Treadmill-based training was found to be effective as a supplement to overground training, independently when augmented with visual feedback and/or body weight support, or as one part of a home exercise plan. Gait training approaches studied improved multiple areas of gait, including sagittal and coronal biomechanics, spatiotemporal measures, and distance walked. No adverse or safety events were reported in connection with the studied interventions.
Interventions to Manage Residual Limb Ulceration Due to Prosthetic Use in Individuals with Lower Extremity Amputation: A Systematic Review of the Literature: This systematic review indicates that continued prosthetic use is a viable option to manage a residual limb with minor early-stage ulceration in the compliant patient lacking comorbidities that would likely delay healing. Conversely, prosthetic discontinuance is also a viable method of residual limb ulcer healing in the presence of multiple comorbidities that delay healing, such as chronic heavy smoking, intractable pain, rapid volume and weight change, history of chronic and complex ulceration, systemic infections, or advanced dysvascular etiology. Surgery, physical rehabilitation, or other interventions may also be necessary in such cases to achieve restored prosthetic ambulation. High-quality prospective research with larger samples is needed to determine the most appropriate course of treatment when the residual limb of a person with an amputation develops an ulcer associated with prosthetic use.
Predicting Walking Ability Following Lower Limb Amputation: An Updated Systematic Literature Review: In this literature review, body mass index, motivation, gender, and smoking are among the factors with minimal support to assist in determining candidacy for a prosthesis. Moderately supported factors for prosthetic candidacy included cognition/mood disturbance, etiology, physical fitness, ability to stand on one leg, and preamputation living status. The most strongly supported factors for considering prosthetic candidacy were amputation level, age, physical fitness, and comorbidities. These factors are mostly supported in an earlier literature review and should be strongly considered in a complete history and physical examination by a multidisciplinary team. Prosthetic over-prescription is preferred to under-prescription because the cost of a less active and less healthy patient, limited by technologies and therapies that adversely impacts his or her function and mobility, far outweighs the cost of a higher-level prosthesis.
Effects of the Genium Knee System on Functional Level, Stair Ambulation, Perceptive and Economic Outcomes in Transfemoral Amputees: Accommodation and use of the Genium knee system compared with the C-Leg improved stair walking performance, multidirectional stepping, functional level, and perceived function. Genium was also preferred compared to the C-Leg in this group of high-functioning community ambulators with unilateral transfemoral amputations. Finally, Genium is a more costly microprocessor knee system but, in this group of patients, is worth funding due to significant differences in functional performance with activities of daily living.
Effects of the Genium Microprocessor Knee System on Knee Moment Symmetry During Hill Walking: Accommodation and use of the Genium knee system, compared with the C-Leg, improved knee moment symmetry in slow speed walking up and down a 5 degree ramp. Additionally, the Genium improved knee moment symmetry when walking downhill at a comfortable speed. At a fast walking speed, variance in knee moment symmetry was lower when using the Genium. These results were found in a sample of high functioning patients with unilateral transfemoral amputations; however, the results likely have application in other patients who could benefit from more consistent knee function, such as older patients and others who have slower walking speeds.
Bioenergetic Differences During Walking and Running in Transfemoral Amputee Runners Using Articulating And Non-articulating Knee Prostheses: These findings suggest that, for trained runners with transfemoral amputations, a running prosthesis with an articulating prosthetic knee reduces ambulatory energy costs and enhances subjective perceptive measures compared to using a non-articulating prosthetic knee.
The Effect of Transfemoral Interface Design on Gait Speed and Risk of Falls: The Activity-specific Balance Confidence Scale and two-minute walk test are valid outcome measures that can be used to determine differences among interventions in patients with transfemoral amputations. Alternative transfemoral interface design, such as the HiFi socket, can improve walking capacity and balance confidence in patients with transfemoral amputations who are higher functioning.
Comparative Effectiveness of an Adjustable Transfemoral Prosthetic Interface Accommodating Volume Fluctuation: Case Study: In this case study, the standard of care socket was inferior to the comparative adjustable transfemoral interface in subjective and performance outcomes. This case study demonstrates the need for a well-designed clinical trial using outcome measures comparing the efficacy of an adjustable prosthetic socket interface to the standard of care. There is a lack of clinical trials and evidence comparing socket functional outcomes related to volume fluctuation.
Concurrent Validity of the Continuous Scale-Physical Functional Peformance-10 (CS-PFP-10) Test in Transfemoral Amputees: These findings, combined with the results of a prior study published in 2016 in the Journal of Rehabilitation Research and Development, Functional Performance Differences Between the Genium and C-Leg Prosthetic Knees and Non-amputees, indicate that the CS-PFP-10 has strong psychometric properties. These include the ability to detect change in a small sample clinical trial and concurrent validity in people with transfemoral amputations who are high functioning. To further increase confidence with use of the CS-PFP-10 in patients with transfemoral amputations, additional psychometric properties should be determined, such as test-retest reliability.
Psychometric Evaluation of the Hill Assessment Index (HAI) and Stair Assessment Index (SAI) In High-functioning Transfemoral Amputees: The results of this work established validity and reliability of the upper end of the HAI and SAI in a population of high-functioning subjects with unilateral transfemoral amputations using microprocessor knee systems. The HAI showed moderate sensitivity and specificity. Intra-rater and inter-rater reliability of the HAI were good for uphill and adequate for downhill assessment. Since other ramp gait assessment tools are scarce, the HAI was shown to be a viable assessment tool. The SAI showed excellent and good inter-rater reliability for ascending and descending conditions, respectively, and excellent intra-rater reliability for both. Both HAI and SAI were shown to be stable instruments for both ascending and descending assessments. More research is needed to determine the validity of the SAI and to confirm these results in other populations of patients with amputations.
Play Hands Protective Gloves: Technical Note on Design and Concept: PLAY Hands represent a series of protective hand wear interventions that offer solutions in the areas of self-mutilating behavior, kinematics, and sensation. They will be made available in a range of protective iterations, from a basic glove design to a more structurally robust and protective iteration. They are conceptualized to be cosmetically appealing, protective, and therapeutic and to ultimately improve the quality of life for patients and caregivers.
Radiographic Assessment of Extremity Osseointegration for the Amputee: Radiographic zonal analysis is used in orthopedic intramedullary implant evaluation to clinically assess the location of changes as a result of the implant. Osseointegration (OI) using an intramedullary implant for people with amputations of the extremities may yield similar changes. A classification technique is necessary for establishing treatment guidelines. The OGA [Osseointegration Group of Australia] Zonal analysis addresses this need by adapting a common reference standard to OI for people with amputations.
