Development and pilot administration of the amputation-related pain and sensation assessment tool.

PURPOSE: To develop and administer an assessment tool for facilitating patient-clinician discussions regarding amputation-related pain and sensation. MATERIALS AND METHODS: An assessment tool was developed to measure the impact of different types of amputation-related pain and sensation on a patient's life. The tool first provides patients with written descriptions and images of three common types of amputation-related pain or sensations: residual limb pain, phantom limb sensation, and phantom limb pain. The tool then asks them to rate the frequency, intensity, and interference of each experience. Participants were also asked to provide qualitative descriptions of these experiences. RESULTS: Fifty Veterans with lower limb amputation participated in the study. In the past month, 74% reported experiencing residual limb pain, 76% reported phantom limb sensation, and 84% reported phantom limb pain, with 52% reporting all three. Participants' descriptions of some experiences were distinct, while others (e.g., "tingling") were common between experiences. Phantom limb pain had the most varied descriptions. CONCLUSIONS: The amputation-related pain and sensation assessment tool can be used to identify and measure the effects of different experiences on patients' lives, thereby improving the specificity of diagnosis and informing clinical treatment recommendations. Further development of this tool should include evaluating its psychometric properties.

The amputation-related pain and sensation assessment tool was developed for use in patient­clinician discussions to identify and measure residual limb pain, phantom limb sensation, and phantom limb pain.In our sample, participants used common words to describe all three experiences.The use of illustrations in combination with descriptions may aid in differentiating these distinct experiences.Next steps for this assessment tool include further development of illustrations to represent patient diversity as well as evaluation of psychometric properties.

The effect of carbon fiber custom dynamic orthosis use and design on center of pressure progression and perceived smoothness in individuals with lower limb trauma.

BACKGROUND: Carbon-fiber custom dynamic orthoses are used to improve gait and limb function following lower limb trauma in specialty centers. However, the effects of commercially available orthoses on center of pressure progression and patient perception of orthosis smoothness during walking are poorly understood. METHODS: In total, 16 participants with a unilateral lower extremity traumatic injury underwent gait analysis when walking without an orthosis, and while wearing monolithic and modular devices, in a randomized order. Device alignment, stiffness, participant rating of perceived device smoothness, center of pressure velocity, and ankle zero moment crossing were assessed. FINDINGS: The modular device was approximately twice as stiff as the monolithic device. Alignment, smoothness ratings, peak magnitude of center of pressure velocity, and zero moment crossing were not different between study devices. The time to peak center of pressure velocity occurred significantly later for the modular device compared to the monolithic and no orthosis conditions, with large effect sizes observed. INTERPRETATION: Commercially available orthoses commonly used to treat limb trauma affect the timing of center of pressure progression relative to walking without an orthosis. Despite multiple design differences, monolithic and modular orthoses included in this study did not differ with respect to other measures of center of pressure progression. Perceived smoothness ratings were approximately 40% greater with the study orthoses as compared to previous studies in specialty centers, which may be due to a more gradual center of pressure progression, as indicted by lower peak magnitude of center of pressure velocity with both study orthoses.

Impact of the COVID-19 pandemic on the rate of lower limb amputation in Veterans.

BACKGROUND: The COVID-19 pandemic led to changes in health care, including postponement of nonurgent appointments. These changes, combined with overall decreased activity levels, may have placed individuals with vascular disease at increased risk for skin ulceration and amputation. OBJECTIVE: To determine the rates of lower limb amputation in Veterans due to complications of diabetes and/or vascular disease in the year following onset of the COVID-19 pandemic (March 2020-March 2021) compared to the previous 3 years (March 2017-March 2020). DESIGN: Retrospective chart review. SETTING: Minneapolis Veterans Affairs Health Care System. PARTICIPANTS: Veterans with a vascular consult appointment note between March 1, 2017, and February 28, 2021. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Primary outcome was lower limb amputation rate in the year following onset of the COVID-19 pandemic compared to the previous 3 years. Secondary outcome was the rate of lower limb wounds in the same time frame. We hypothesized that rates of lower limb amputation and wounds increased during the pandemic. RESULTS: Vascular consult appointments (n = 4183) were reviewed between March 1, 2017, and February 28, 2021. Significantly higher rates of amputation (7.52% vs. 5.19%; p = .006) and wound presence (16.77% vs. 11.66%; p < .001) were found 1 year postpandemic compared to the previous 3 years. Amputation and wound rates did not significantly increase between pairs of consecutive years prior to the pandemic but significantly increased between the year preceding the pandemic and the first year of the pandemic (amputation p = .047; wound p = .004). CONCLUSIONS: Increased rates of amputation and wounds in Veterans following the onset of the COVID-19 pandemic are likely due to disruption of care, lifestyle changes, and other pandemic-related factors. Awareness of COVID-19-related negative health effects is imperative for health care providers to ensure appropriate allocation of resources and alternate models for care delivery for amputation and preventative care as part of disaster response.

Clinician perspectives on postamputation pain assessment and rehabilitation interventions.

OBJECTIVE: The purpose of this study was to explore self-reported Veterans Affairs (VA) amputation clinician perspectives and clinical practices regarding the measurement and treatment for amputation-related pain. STUDY DESIGN: Cross-sectional survey with 73 VA rehabilitation clinicians within the VA Health Care System. RESULTS: The most frequent clinical backgrounds of respondents included physical therapists (36%), prosthetists (32%), and physical medicine and rehabilitation specialist (21%). Forty-one clinicians (56%) reported using pain outcome measures with a preference for average pain intensity numeric rating scale (generic) (97%), average phantom limb pain intensity numeric rating scale (80%), or Patient-Reported Outcomes Measurement Information System pain interference (12%) measures. Clinicians' most frequently recommended interventions were compression garments, desensitization, and physical therapy. Clinicians identified mindset, cognition, and motivation as factors that facilitate a patient's response to treatments. Conversely, clinicians identified poor adherence, lack of belief in interventions, and preference for traditional pain interventions (e.g., medications) as common barriers to improvement. We asked about the frequently used treatment of graded motor imagery. Although graded motor imagery was originally developed with 3 phases (limb laterality, explicit motor imagery, mirror therapy), clinicians reported primarily using explicit motor imagery and mirror therapy. RESULTS: Most clinicians who use standardized pain measures prefer intensity ratings. Clinicians select pain interventions based on the patient's presentation. This work contributes to the understanding of factors influencing clinicians' treatment selection for nondrug interventions. Future work that includes qualitative components could further discern implementation barriers to amputation pain rehabilitation interventions for greater consistency in practice.

Veteran Perspectives on Phantom Limb Pain and Non-Drug Interventions.

Background: Phantom limb pain (PLP) commonly occurs post-amputation and can negatively affect the daily functioning of persons with amputation. Best practices for medication and non-drug management remain unclear. Objective: To better understand the PLP experience and patients' familiarity with treatments, phone interviews were conducted at the Minneapolis Veterans Affairs Regional Amputation Center in Veterans with amputations. Methods: Fifty Veteran participants (average age 66, 96% male) with lower limb amputation were recruited for phone-based data collection of patient-reported outcomes (ie, demographics using the Trinity Amputation and Prosthesis Experience Scales-Revised (TAPES-R) and pain experience using the Phantom Phenomena Questionnaire) to characterize the population and a semi-structured interview. Notes taken during interviews were analyzed using the Krueger and Casey constant comparison analysis method. Results: Participants had an average of 15 years since amputation, and 80% reported PLP as identified with the Phantom Phenomena Questionnaire. Investigators identified several core themes from the qualitative interviews including 1) high variability in the experience of PLP, 2) acceptance and resilience, and 3) PLP treatment perceptions. The majority of participants reported trying common non-drug treatments with none endorsed consistently as highly effective. Conclusion: More research is needed to inform identification and implementation of clinical best practices for non-drug interventions for PLP and understand the factors that influence engagement in non-drug interventions. The participants in this study were largely male, so these results may not be generalizable to females.

Determining educational assessment criteria for patellar-tendon-bearing impressions for transtibial prosthetic sockets: A Delphi study.

BACKGROUND: Validated criteria to guide assessment of student performance in clinical tasks in prosthetics and orthotics education have not been established. Lack of established criteria and assessment methods presents challenges in evaluating student performance on clinical tasks, such as taking impressions for patellar-tendon-bearing (PTB) sockets. OBJECTIVES: To establish assessment criteria for the PTB impression process for use in educational settings. STUDY DESIGN: Delphi consensus process. METHODS: Initial Delphi survey items were based on interviews with prosthetic instructors and focus groups with prosthetic students. Expert prosthetic educators were then identified by purposive sampling to complete multiple-round Internet-based Delphi surveys. The Delphi surveys asked experts to indicate their level of agreement on various assessment methods and criteria in PTB education. Consensus for survey items was reviewed after each survey round and used to determine the content of and need for subsequent rounds. RESULTS: Fourteen experts completed two Delphi survey rounds. Items were categorized into educational materials/strategies, impression stages/materials, measurement tools, measurements taken, assessment during impression, assessment after impression, feedback, student self-assessment, and grading. In two survey rounds, 40 items guiding assessment methods and criteria for PTB impressions achieved 80% consensus. CONCLUSIONS: A high level of consensus was achieved in two survey rounds. Lower levels of consensus were reached on specific objective criteria, such as use of measurement thresholds when evaluating student impressions. Standardized assessment of student performance on PTB impression-taking instead relies primarily on qualitative assessments based on instructor expertise.