Amputation Triggered by Gefitinib: An Unusual Clinical Presentation.

Gefitinib is an epidermal growth factor tyrosine kinase inhibitor used as a targeted chemotherapeutic agent in the treatment of lung cancer and other solid malignancies. The most common adverse effects of gefitinib include dermatological side effects and gastrointestinal symptoms, with rare reports of vascular side effects such as myocardial infarction and stroke. We recently reported a case of a patient with diabetes and multiple comorbidities who developed a serious lower limb vascular adverse event after gefitinib treatment, ultimately leading to amputation surgery. This is the first reported case of lower extremity amputation following gefitinib therapy in a patient with type 2 diabetes mellitus and lung adenocarcinoma. This case highlights the potential risk of amputation in diabetic patients receiving targeted therapies like gefitinib, especially in those with vascular complications. It emphasizes the importance of exercising extra caution when dealing with these patients.

Transitioning from hospital to home after a major lower extremity amputation: Interview study on patients' and relatives' perspectives.

INTRODUCTION: Patients often feel unprepared and concerned about their new life after a major lower extremity amputation (LEA). Therefore, we implemented an integrated care program, Safe Journey, to optimize the quality and continuity of care for patients with LEA due to vascular disease when transitioning from hospital to home. This study aims to illuminate and explore the experiences of patients with LEA and their relatives with the transition from hospital to home after implementing Safe Journey. MATERIAL AND METHODS: This qualitative, exploratory study individually interviewed six patients with a major LEA and four relatives and jointly interviewed eight patients with their relatives. RESULTS: The participants' experiences transitioning from hospital to home were centered around two major themes: (1) Going home: mixed emotions and confusion, and (2) bridging the gap. The main themes encompassed six subthemes: (1) simultaneously expectant and worried, (2) a lack of knowledge creating uncertainty, (3) an unexpressed but pending need for psychosocial support, (4) reassurance but safety comes at a price, (5) navigating the system, and (6) lack of involvement. CONCLUSION: Transitioning from hospital to home after a major LEA creates mixed emotions. Knowledge, feeling involved, and being prepared and cared for were highlighted as important during the transition. The Safe Journey program made patients and relatives feel physically reassured and safe, but all the home visits strained the families. The program's benefits are consistent with existing knowledge on patients with complex needs benefitting from integrated care models. However, a more individualized and person-centered approach is needed.

Prosthetic Rehabilitation After Transfemoral Amputation in a Patient With an Ipsilateral Girdlestone Hip: A Case Report.

To date, there have been no reported cases of patients walking with a prosthesis after receiving an ipsilateral transfemoral amputation following the Girdlestone procedure. We administered a four-month prosthetic rehabilitation program to a 66-year-old man after his transfemoral amputation following the Girdlestone procedure. As a result, he was able to walk using the prosthesis for his daily activities. The prosthesis socket featured a quadrilateral configuration. The patient's ability to ambulate after the Girdlestone procedure was attributed to his ischial tuberosity serving as the primary load-bearing site in the transfemoral prosthesis. With appropriate prosthetic design, fabrication, and rehabilitation, patients can walk using a transfemoral prosthesis even in cases of transfemoral amputation following the Girdlestone procedure.

Using mobile eye tracking to measure cognitive load through gaze behavior during walking in lower limb prosthesis users: A preliminary assessment.

BACKGROUND: Lower limb amputation does not affect only physical and psychological functioning but the use of a prosthetic device can also lead to increased cognitive demands. Measuring cognitive load objectively is challenging, and therefore, most studies use questionnaires that are easy to apply but can suffer from subjective bias. Motivated by this, the present study investigated whether a mobile eye tracker can be used to objectively measure cognitive load by monitoring gaze behavior during a set of motor tasks. METHODS: Five prosthetic users and eight able-bodied controls participated in this study. Eye tracking data and kinematics were recorded during a set of motor tasks (level ground walking, walking on uneven terrain, obstacle avoidance, stairs up and ramp down, as well as ramp up and stairs down) while the participants were asked to focus their gaze on a visual target for as long as possible. Target fixation times and increase in pupil diameters were determined and correlated to subjective ratings of cognitive load. FINDINGS: Overall, target fixation time and pupil diameter showed strong negative and positive correlations, respectively, to the subjective rating of cognitive load in the able-bodied controls (-0.75 and 0.80, respectively). However, the individual correlation strength, and in some cases, even the sign, was different across participants. A similar trend could be observed in prosthetic users. INTERPRETATION: The results of this study showed that a mobile eye tracker may be used to estimate cognitive load in prosthesis users during locomotor tasks. This paves the way to establish a new approach to assessing cognitive load, which is objective and yet practical and simple to administer. Nevertheless, future studies should corroborate these results by comparing them to other objective measures as well as focus on translating the proposed approach outside of a laboratory.

The association between tobacco smoking and systolic toe pressures in active foot ulceration.

Smoking may increase the risk of diabetic foot disease and ulceration. It does so by impairing glycaemic control and promoting the formation of advanced glycated end-products. Additionally, smoking is known to delay surgical wound healing and accelerate peripheral arterial disease. We aimed to determine whether toe pressures differed in smokers with a foot ulcer, when compared to non-smokers and ex-smokers, as well as ulcer outcomes at 12 months, among patients attending Blacktown Hospital High Risk Foot Service (HRFS). This study is a retrospective analysis of our prospectively collected clinic database. Eligible participants were adults attending the HRFS between June 2020 and April 2022. Participants were included if they had an ulcer, at least one systolic toe pressure reading completed at their initial visit and attended at least one follow-up visit. Participants were followed until healing, loss to follow-up or a minimum of 12 months. A total of 195 participants were included; 36 smokers, 82 ex-smokers, and 77 controls who had never smoked. Smoking status was by self-report. Current smokers were significantly younger at initial presentation (p = .002) and tended towards lower socioeconomic status (p = .067). Current smokers were significantly more likely to have ischaemic grade 3 toe pressures (< 30 mmHg) of their left foot (p = .027), suggestive of reduced perfusion. At the end of follow up period, smokers had the numerically highest rates of minor amputations. In conclusion, smokers ulcerate younger and are more likely to have grade 3 ischaemia. Collecting information about the brachial artery pressures and the time since the last cigarette may clarify any relationship between smoking and toe pressures.Trial registration: WSLHD HREC ethics approval 2111-02 and ANZCTR registration 382470. Registered on 15/09/2021.

Reliable in vitro method for the evaluation of the primary stability and load transfer of transfemoral prostheses for osseointegrated implantation.

Osseointegrated transfemoral prostheses experience aseptic complications with an incidence between 3% and 30%. The main aseptic risks are implant loosening, adverse bone remodeling, and post-operative periprosthetic fractures. Implant loosening can either be due to a lack of initial (primary) stability of the implant, which hinders bone ingrowth and therefore prevents secondary stability, or, in the long-term, to the progressive resorption of the periprosthetic bone. Post-operative periprosthetic fractures are most often caused by stress concentrations. A method to simultaneously evaluate the primary stability and the load transfer is currently missing. Furthermore, the measurement errors are seldom reported in the literature. In this study a method to reliably quantify the bone implant interaction of osseointegrated transfemoral prostheses in terms of primary stability and load transfer was developed, and its precision was quantified. Micromotions between the prosthesis and the host bone and the strains on the cortical bone were measured on five human cadaveric femurs with a typical commercial osseointegrated implant. To detect the primary stability of the implant and the load transfer, cyclic loads were applied, simulating the peak load during gait. Digital Image Correlation was used to measure displacements and bone strains simultaneously throughout the test. Permanent migrations and inducible micromotions were measured (three translations and three rotations), while, on the same specimen, the full-field strain distribution on the bone surface was measured. The repeatability tests showed that the devised method had an intra-specimen variability smaller than 6 µm for the translation, 0.02 degrees for the rotations, and smaller than 60 microstrain for the strain distribution. The inter-specimen variability was larger than the intra-specimen variability due to the natural differences between femurs. Altogether, the measurement uncertainties (intrinsic measurement errors, intra-specimen repeatability and inter-specimen variability) were smaller than critical levels of biomarkers for adverse remodelling and aseptic loosening, thus allowing to discriminate between stable and unstable implants, and to detect critical strain magnitudes in the host bone. In conclusion, this work showed that it is possible to measure the primary stability and the load transfer of an osseointegrated transfemoral prosthesis in a reliable way using a combination of mechanical testing and DIC.

Hemodynamic and Metabolic Responses to Moderate and Vigorous Cycle Ergometry in Men Who Have Had Transtibial Amputation.

Adults who have had an amputation face barriers to having an active lifestyle which attenuates cardiorespiratory fitness. Prior studies in amputees typically involve treadmill walking or arm ergometry, yet physiological responses to bilateral leg cycling are less understood. This study assessed the hemodynamic and metabolic responses to moderate and vigorous cycle ergometry in men who have had a transtibial amputation (TTA). Five men who had had a unilateral TTA (age = 39 ± 15 yr) and six controls (CONs) without an amputation (age = 31 ± 11 yr) performed two 20 min bouts of cycling differing in intensity. Cardiac output (CO), stroke volume (SV), and oxygen consumption (VO2) were measured during moderate intensity continuous exercise (MICE) and high intensity interval exercise (HIIE) using thoracic impedance and indirect calorimetry. In response to MICE and HIIE, the HR and VO2 levels were similar (p > 0.05) between groups. Stroke volume and CO were higher (p < 0.05) in the CONs, which was attributed to their higher body mass. In men with TTAs, HIIE elicited a peak HR = 88%HRmax and substantial blood lactate accumulation, representing vigorous exercise intensity. No adverse events were exhibited in the men with TTAs. The men with TTAs show similar responses to MICE and HIIE versus the CONs.

Can Early Post-Operative Scoring of Non-Traumatic Amputees Decrease Rates of Revision Surgery?

Background and Objectives: Medical registries evolved from a basic epidemiological data set to further applications allowing deriving decision making. Revision rates after non-traumatic amputation are high and dramatically impact the following rehabilitation of the amputee. Risk scores for revision surgery after non-traumatic lower limb amputation are still missing. The main objective was to create an amputation registry allowing us to determine risk factors for revision surgery after non-traumatic lower-limb amputation and to develop a score for an early detection and decision-making tool for the therapeutic course of patients at risk for non-traumatic lower limb amputation and/or revision surgery. Materials and Methods: Retrospective data analysis was of patients with major amputations lower limbs in a four-year interval at a University Hospital of maximum care. Medical records of 164 patients analysed demographics, comorbidities, and amputation-related factors. Descriptive statistics analysed demographics, prevalence of amputation level and comorbidities of non-traumatic lower limb amputees with and without revision surgery. Correlation analysis identified parameters determining revision surgery. Results: In 4 years, 199 major amputations were performed; 88% were amputated for non-traumatic reasons. A total of 27% of the non-traumatic cohort needed revision surgery. Peripheral vascular disease (PVD) (72%), atherosclerosis (69%), diabetes (42%), arterial hypertension (38%), overweight (BMI > 25), initial gangrene (47%), sepsis (19%), age > 68.2 years and nicotine abuse (17%) were set as relevant within this study and given a non-traumatic amputation score. Correlation analysis revealed delayed wound healing (confidence interval: 64.1% (47.18%; 78.8%)), a hospital length of stay before amputation of longer than 32 days (confidence interval: 32.3 (23.2; 41.3)), and a BKA amputation level (confidence interval: 74.4% (58%; 87%)) as risk factors for revision surgery after non-traumatic amputation. A combined score including all parameters was drafted to identify non-traumatic amputees at risk for revision surgery. Conclusions: Our results describe novel scoring systems for risk assessment for non-traumatic amputations and for revision surgery at non-traumatic amputations. It may be used after further prospective evaluation as an early-warning system for amputated limbs at risk of revision.

The Effect of Prosthetic Limb Sophistication and Amputation Level on Self-reported Mobility and Satisfaction With Mobility.

OBJECTIVE: To determine if lower limb prosthesis (LLP) sophistication is associated with patient-reported mobility and/or mobility satisfaction, and if these associations differ by amputation level. DESIGN: Cohort study that identified participants through a large national database and prospectively collected self-reported patient outcomes. SETTING: The Veterans Administration (VA) Corporate Data Warehouse, the National Prosthetics Patient Database, participant mailings, and phone calls. PARTICIPANTS: 347 Veterans who underwent an incident transtibial (TT) or transfemoral (TF) amputation due to diabetes and/or peripheral artery disease and received a qualifying LLP between March 1, 2018, and November 30, 2020. INTERVENTIONS: Basic, intermediate, and advanced prosthesis sophistication was measured by the accurate and reliable PROClass system. MAIN OUTCOME MEASURE: Patient-reported mobility using the advanced mobility subscale of the Locomotor Capabilities Index-5; mobility satisfaction using a 0-10-point Likert scale. RESULTS: Lower limb amputees who received intermediate or advanced prostheses were more likely to achieve advanced mobility than those who received basic prostheses, with intermediate nearing statistical significance at nearly twice the odds (adjusted odds ratio (aOR)=1.8, 95% confidence interval (CI), .98-3.3; P=.06). The association was strongest in TF amputees with over 10 times the odds (aOR=10.2, 95% CI, 1.1-96.8; P=.04). The use of an intermediate sophistication prosthesis relative to a basic prosthesis was significantly associated with mobility satisfaction (adjusted ß coefficient (aß)=.77, 95% CI, .11-1.4; P=.02). A statistically significant association was only observed in those who underwent a TT amputation (aß=.79, 95% CI, .09-1.5; P=.03). CONCLUSIONS: Prosthesis sophistication was not associated with achieving advanced mobility in TT amputees but was associated with greater mobility satisfaction. In contrast, prosthesis sophistication was associated with achieving advanced mobility in TF amputees but was not associated with an increase in mobility satisfaction.

The effectiveness of targeted muscle reinnervation in reducing pain and improving quality of life for patients following lower limb amputation.

BACKGROUND: Globally, over 1 million lower limb amputations are performed annually, with approximately 75% of patients experiencing significant pain, profoundly impacting their quality of life and functional capabilities. Targeted muscle reinnervation (TMR) has emerged as a surgical solution involving the rerouting of amputated nerves to specific muscle targets. Originally introduced to enhance signal amplification for myoelectric prosthesis control, TMR has expanded its applications to include neuroma management and pain relief. However, the literature assessing patient outcomes is lacking, specifically for lower limb amputees. This systematic review aims to assess the effectiveness of TMR in reducing pain and enhancing functional outcomes for patients who have undergone lower limb amputation. METHODS: A systematic review was performed by examining relevant studies between 2010 and 2023, focusing on pain reduction, functional outcomes and patient-reported quality of life measures. RESULTS: In total, 20 studies were eligible encompassing a total of 778 extremities, of which 75.06% (n = 584) were lower limb amputees. Average age was 46.66 years and patients were predominantly male (n = 70.67%). Seven studies (35%) reported functional outcomes. Patients who underwent primary TMR exhibited lower average patient-reported outcome measurement information system (PROMIS) scores for phantom limb pain (PLP) and residual limb pain (RLP). Secondary TMR led to improvements in PLP, RLP and general limb pain as indicated by average numeric rating scale and PROMIS scores. CONCLUSION: The systematic review underscores TMR's potential benefits in alleviating pain, fostering post-amputation rehabilitation and enhancing overall well-being for lower limb amputees.

Squamous cell carcinoma arising from chronic osteomyelitis of the femur: A case report.

Although chronic osteomyelitis (COM) affecting the extremities is a frequently occurring disease, the incidence of squamous cell carcinoma (SCC) arising from COM is rare. Consequently, understanding the diagnosis, treatment and prognosis of such a disorder remains limited. In the present study, a case of COM-associated SCC was demonstrated. A 65-year-old woman arrived to the Southern Medical University Nanfang Hospital (Guangzhou, China) with multiple sinus tracts and skin ulcers in the distal part of her left thigh, persisting for over 50 years following an open pierce injury by an ox horn. A local biopsy confirmed the diagnosis of COM-related SCC. Although limb amputation was recommended, the female patient declined initially. Instead, the female patient underwent focused debridement and wide resection of the tumor, followed by local implantation of calcium sulfate beads loaded with vancomycin and gentamycin, and application of a rail fixator. A total of 10 months later, the cancer recurred, affecting the osseous tissue. Subsequently, the patient underwent amputation of the thigh. At the one-year follow-up, the patient showed satisfactory recovery without signs of local recurrence. Despite its rarity, the severity of this disorder should not be underestimated. Personalized treatment strategies must be tailored to individual circumstances.

Electro-Amputation of Lower Limbs Due to a High-Voltage Shock: Report of an Unusual Case.

Electrical injuries due to high voltage are not frequent but can cause a high mortality rate. The body of a 45-year-old security guard was found at an apartment with an alleged history of being electrocuted while working when he came into contact with a high-voltage transformer. The police brought the body for a post-mortem examination. The autopsy revealed superficial to deep-degree burns with bilateral lower limb amputation. The cause of death was shock due to 80%-85% of the total body surface area being burned due to high-voltage electrocution. This article suggests a new mechanism, i.e., electrocution-induced amputation, called electro-amputation, which is unusual and not reported in the literature to the best of our knowledge. The authors also recommend a forensic surgeon should consider detailed circumstantial findings, a scene of crime visit, and a meticulous post-mortem examination before concluding the exact cause of death as high-voltage electrocution.

Functional Mobility in Individuals With Lower Limb Amputation: An Observational Study.

INTRODUCTION: Amputation leads to a permanent disability and brings a dramatic change in the life and function of the individual, more so in individuals with lower limb amputation. A lower limb amputation reduces mobility and can make persons dependent on assistive devices like crutches or a wheelchair. Restoring mobility and optimal physical functioning of an individual with lower limb amputation is the most important rehabilitation goal. There are very few studies that have quantified mobility deficits with valid outcome measures, especially in the Indian population. Our study aims to quantify the mobility deficit in individuals with lower limb amputation and add to the scant literature available on mobility values in the Indian population. METHODS: This was a cross-sectional study. Individuals with lower limb amputation who attended an orthotic and prosthetic clinic in Vadodara city were recruited for the study. Those individuals who were above 18 years of age and had undergone either unilateral or bilateral amputation, at least six weeks prior to assessment, were included in the study. Those individuals who had total impairment of vision and hearing, cognitive impairment, upper limb amputation, and ankle and foot amputation were excluded from the study. Functional mobility was assessed with the prosthesis worn, using the Timed "Up and Go" (TUG) test. RESULTS: There was a total of 54 individuals with lower limb amputation, 47 males and seven females. The mean age was 47.38±18.83 years. Transtibial (66.67%) was the most common amputation followed by transfemoral (27.8%). The mean TUG score for the total population was 20.19 ± 11.95 sec, for unilateral transfemoral amputation 20.26 ± 12.06 sec, and for unilateral transtibial amputation 20.01 ± 12.31 sec. There was a statistically significant direct relation of the TUG score with age (p=0.02), level of amputation (p<0.01), and length of time prosthesis was used (in years) (p=0.02) and a statistically significant inverse relation of TUG score with the cause of amputation (traumatic, p=0.02, non-traumatic, p=0.03), assistive devices used for mobility (p<0.01), and number of hours the prosthesis was worn in a day (p<0.01). There was a significant negative correlation between the duration of amputation and TUG score (r=-0.282, p<0.05) Conclusion: The functional mobility was reduced in individuals with lower limb amputation. There was a statistically significant direct relation of functional mobility with age, cause of amputation, level of amputation, and length of time of prosthesis used, and a statistically significant inverse relation with the number of hours of use of prosthesis in a day and assistive devices used. Individuals who were old, had a non-traumatic amputation, a higher level of amputation, those wearing a prosthesis for a short duration since amputation, who wore the prosthesis for a shorter duration during the day, and who used assistive devices for ambulation in addition to a prosthesis had longer TUG times. As the duration of amputation increased, the time taken for TUG decreased.

Exploring the Role of Free Tissue Transfers in the Preservation of Bone Length and Knee Joint Function after Lower Limb Trauma: A Retrospective Analysis.

Lower limb trauma often results in mangled extremities, and in some cases, complete amputation may be necessary. However, limiting the extent of amputation and preserving the major knee joint are crucial to enhance mobility and overall functionality. By providing painless soft tissue coverage on the stump, early prosthesis use and the initiation of physiotherapy become more feasible. Soft tissue transfers hold the potential to benefit patients in two essential aspects: first, resolving soft tissue deficiencies without causing bone shortening, and second, preparing the stump to enhance overall functionality. A retrospective study conducted at Chang Gung Memorial Hospital (2009-2016) focused on lower limb amputation patients who underwent soft tissue transfers at different time periods compared to those without stump reconstruction. Out of the 2391 cases of lower limb injuries treated operatively, 117 amputations were performed in 110 patients (44 above the knee and 73 below the knee). Among them, 12 patients received soft tissue transfers for limb salvage and soft tissue deficiency after amputations. It was observed that patients in this group were typically younger, predominantly female, had longer hospital stays, and underwent a greater number of surgical procedures (p < 0.05). Through the use of soft tissue transfers, successfully preserved tibial bone length and functional knee joint in selected patients was achieved. This approach effectively resolved soft tissue deficiencies following lower limb amputations, optimizing physiotherapy and facilitating functional rehabilitation.

Patient satisfaction after lower limb replantation surgery for traumatic amputation - a qualitative study.

BACKGROUND: The majority of published literature clinically assesses surgical outcomes after lower limb replantation for traumatic amputations. However, patients' satisfaction and quality of life may not be accurately measured through rigid scoring using standardized patient reported outcome measures. PURPOSE: The aim of this study was to qualitatively assess patient satisfaction and factors associated with achieving good outcomes after successful lower limb replantation surgery. METHODS: A semi-structured interview was conducted with 12 patients who underwent lower limb replantation surgery following traumatic amputation injuries. The interview focused on the patients' experience and satisfaction throughout their injury, surgical journey, rehabilitation and reintegration into their communities. An inductive and deductive thematic analysis was applied using the recorded transcripts to evaluate the overall satisfaction of the patients after lower limb replantation surgery. RESULTS: The following observations emerged from the structured themes among all the patients interviewed: (1) Family and social support was significantly associated with improved qualities of life and satisfaction after lower limb replantation; (2) Patients were generally satisfied with their outcomes despite limitations in physical capabilities; (3) Satisfaction was associated with acceptance of their cosmetic deformity; (4) Social integration and being able to participate in a meaningful manner was associated with greater satisfaction after recovery. CONCLUSIONS: Patients who undergo lower limb replantation can have a significantly improved quality of life if they have strong social support, are able to contribute in a meaningful manner to their communities after surgery, and are accepting of their cosmetic deficiencies.

Phantom Limb Pain and Painful Neuroma After Dysvascular Lower-Extremity Amputation: A Systematic Review and Meta-Analysis.

BACKGROUND: Phantom limb pain (PLP) and symptomatic neuroma can be debilitating and significantly impact the quality of life of amputees. However, the prevalence of PLP and symptomatic neuromas in patients following dysvascular lower limb amputation (LLA) has not been reliably established. This systematic review and meta-analysis evaluates the prevalence and incidence of phantom limb pain and symptomatic neuroma after dysvascular LLA. METHODS: Four databases (Embase, MEDLINE, Cochrane Central, and Web of Science) were searched on October 5th, 2022. Prospective or retrospective observational cohort studies or cross-sectional studies reporting either the prevalence or incidence of phantom limb pain and/or symptomatic neuroma following dysvascular LLA were identified. Two reviewers independently conducted the screening, data extraction, and the risk of bias assessment according to the PRISMA guidelines. To estimate the prevalence of phantom limb pain, a meta-analysis using a random effects model was performed. RESULTS: Twelve articles were included in the quantitative analysis, including 1924 amputees. A meta-analysis demonstrated that 69% of patients after dysvascular LLA experience phantom limb pain (95% CI 53-86%). The reported pain intensity on a scale from 0-10 in LLA patients ranged between 2.3 ± 1.4 and 5.5 ± .7. A single study reported an incidence of symptomatic neuroma following dysvascular LLA of 5%. CONCLUSIONS: This meta-analysis demonstrates the high prevalence of phantom limb pain after dysvascular LLA. Given the often prolonged and disabling nature of neuropathic pain and the difficulties managing it, more consideration needs to be given to strategies to prevent it at the time of amputation.

Rasch validation of the German version of the Prosthesis Embodiment Scale for lower limb amputees and proposal of a revised version.

PURPOSE: To perform a detailed psychometric Rasch analysis of the Prosthesis Embodiment Scale (PEmbS) administered in adults with lower limb amputation (LLA). METHODS: A convenience sample of German-speaking adults with LLA (n = 150), recruited from German state agencies' databases, was asked to complete the PEmbS, a 10-item patient-reported scale assessing prosthesis embodiment. RESULTS: The local dependency between two items was resolved by keeping for the global score only the lower score of these two items (#9 and #10). Collapsing the seven response categories to four (two expressing disagreement and two agreement) eliminated disordered thresholds. After that, the PEmbS demonstrated unidimensionality, acceptable item fit, and good reliability indices. A keyform plot was created to transform raw scores into linear measures of prosthesis embodiment, making it possible to compare the individual's item responses with those expected by the Rasch model, and to manage missing responses. CONCLUSIONS: The PEmbS is useful for assessing prosthesis embodiment in people with LLA, both for research and clinical purposes. We propose a revised version of the PEmbS for lower limb amputees; its appropriateness in other LLA contexts requires further investigation.

Prosthesis embodiment has been empirically related to positive clinical outcomes in limb amputees.The Prosthesis Embodiment Scale (PEmbS) is a patient-reported scale that has been recently recommended for use in research on prosthesis embodiment.Rasch analysis showed that the revised version of the German PEmbS is a psychometrically sound instrument for the assessment of prosthesis embodiment in lower limb amputees.The PEmbS thus also allows reliable and valid diagnosis of prosthesis embodiment in clinical and rehabilitation contexts.

Validation of Proprietary and Novel Step-counting Algorithms for Individuals Ambulating With a Lower Limb Prosthesis.

OBJECTIVE: To compare the accuracy and reliability of 10 different accelerometer-based step-counting algorithms for individuals with lower limb loss, accounting for different clinical characteristics and real-world activities. DESIGN: Cross-sectional study. SETTING: General community setting (ie, institutional research laboratory and community free-living). PARTICIPANTS: Forty-eight individuals with a lower limb amputation (N=48) wore an ActiGraph (AG) wGT3x-BT accelerometer proximal to the foot of their prosthetic limb during labeled indoor/outdoor activities and community free-living. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Intraclass correlation coefficient (ICC), absolute and root mean square error (RMSE), and Bland Altman plots were used to compare true (manual) step counts to estimated step counts from the proprietary AG Default algorithm and low frequency extension filter, as well as from 8 novel algorithms based on continuous wavelet transforms, fast Fourier transforms (FFTs), and peak detection. RESULTS: All algorithms had excellent agreement with manual step counts (ICC>0.9). The AG Default and FFT algorithms had the highest overall error (RMSE=17.81 and 19.91 steps, respectively), widest limits of agreement, and highest error during outdoor and ramp ambulation. The AG Default algorithm also had among the highest error during indoor ambulation and stairs, while a FFT algorithm had the highest error during stationary tasks. Peak detection algorithms, especially those using pre-set parameters with a trial-specific component, had among the lowest error across all activities (RMSE=4.07-8.99 steps). CONCLUSIONS: Because of its simplicity and accuracy across activities and clinical characteristics, we recommend the peak detection algorithm with set parameters to count steps using a prosthetic-worn AG among individuals with lower limb loss for clinical and research applications.

Daily steps and stepping cadence increase one-year following prosthesis osseointegration in people with lower-limb amputation.

PURPOSE: People with lower-limb loss participate in less physical activity than able-bodied individuals, which increases the mortality risk and incidence of metabolic syndromes. This study evaluated the effect of lower-limb prosthesis osseointegration on physical activity, including daily steps and stepping cadence. METHODS: Free-living walking activity was assessed from 14 patients scheduled to undergo prosthesis osseointegration at two time points (within 2 weeks prior to osseointegration surgery and 12-months following). Daily step count, stepping time, number of walking bouts, average step cadence per bout, maximum step cadence per bout, and time spent in bands of step cadence were compared before and after osseointegration. RESULTS: Twelve months after prosthesis osseointegration, participants increased daily steps, daily stepping time, average step cadence, and maximum cadence per walking bout compared to pre-osseointegration. CONCLUSIONS: Participants engaged in more daily steps, higher stepping cadence, and longer bouts at higher cadence one year following osseointegration compared to when using a socket prosthesis. As a novel intervention that is becoming more common, it is important to understand walking activity outcomes as these are critical for long-term health.

People with lower-limb loss participate in less physical activity than able-bodied individuals, which increases the mortality risk and incidence of metabolic syndromes.Daily step count, walking bouts, and step cadence during free-living walking activity are promising measures to capture physical functional performance in patients with lower-limb amputation.This study shows that patients with osseointegrated prostheses increase their stepping activity, including daily steps, number of bouts, and stepping cadence compared to when using a socket prosthesis, which has positive implications on overall patient health.As a novel intervention that is becoming more common, it is important for clinicians, patients, and researchers to understand expectations for walking activity outcomes as a critical factor in long-term patient health after prosthesis osseointegration.

Telehealth Walking Self-Management for Individuals With Amputation: A Qualitative Study of Therapist Perspectives on Adoption.

OBJECTIVE: The aim of this study was to understand therapist-identified factors influencing clinical adoption of a telehealth walking self-management intervention for individuals with lower limb amputation. METHODS: Semi-structured focus groups were completed with actively practicing physical and occupational therapists treating populations that are medically complex. A qualitative explorative design was employed with conventional content analysis and iterative independent parallel coding using 2 analysts. Themes and subthemes were generated with a consensus building process identifying patterns and collapsing codes to represent participant perspectives. RESULTS: Thematic saturation was met after 5 focus groups (24 therapists). Therapists were on average 34 years old and predominantly female (n = 19; 79%) physical therapists (n = 17; 71%). Three primary facilitator and barrier themes were identified for intervention adoption: system, therapist, and person. System considerations included telehealth support and interprofessional care coordination. Therapist facilitators included self-management programming that overlapped with standard of care and personalization methods. However, limited behavioral theory training was a therapist level barrier. Finally, person factors such as patient activation could influence both positively and negatively. Person facilitators included social support and barriers included the complex health condition. CONCLUSION: System, therapist, and person facilitators and barriers must be considered to maximize the adoption of similar telehealth walking self-management interventions and prior to larger scale implementation of the current intervention for individuals with lower limb amputation. IMPACT: A telehealth walking self-management intervention has potential impact for individuals with lower limb amputation and must be considered in terms of optimizing system, therapist, and person level facilitators and barriers to implementation.