•Screening of civilian amputees following ballistic injury to define their injuries and clinical variables that impact on amputation.•MDT review allowing individualized, specialist prescriptions of ...care to be formulated for both stump and prostheses management.•Youth, proximal injury, AKA, psychosocial issues and the need for long-term stump and prosthetic support define this group of amputees.•Evidence-based amputee care with specialists promoting best outcomes, judicious allocation of funds and maximising amputee quality of life.
Ballistic injuries during the Great March of Return (GMR) protests in Gaza have resulted in young, civilian amputees. This article defines this unique population, their injuries and clinical variables that impacted on amputation.
A multidisciplinary team (MDT) assessed 103 lower limb amputees (104 stumps). Individualized prescriptions of care were formulated and applied for both stump and prosthesis management.
The cohort's health state was assessed at screening by applying the EQ-5D-L5 questionnaire. The EQ-5D-L5 will be repeated on completion of the prescription of care.
The population is predominantly young, male, suffering unilateral amputation with an equal ratio of above knee (AKA) to below knee (BKA) amputations. 18% were amputated immediately and 82% with delay. Most amputations occur within 15 days of gunshot wound (GSW).
All tissue elements were affected by the severe, ballistic injury. Division, gapping and tissue loss consolidated the decision for amputation rather than limb salvage. Knee zone injury was common, influencing the high numbers AKAs.
Primary injury ramified beyond the amputated leg: 38% have contralateral leg injuries. 20% had physiological challenges requiring Intensive care unit (ICU) admissions. Infection was reported in 49% of amputees with 12% reporting acute sepsis. Psychologically, 49% reported severe, or extreme, anxiety and depression.
AKAs were associated with greater morbidity: amputees are significantly younger, have more proximal vascular injuries, receive delayed amputations and experience longer time intervals to stump healing. ICU care and contralateral leg injuries were more frequent.
One third of amputees used their prostheses’, one third did not and one third do not have a prosthesis yet. The limiting factor for repair was supply of materials. 11% of amputees needed no adjustment to stump or prosthesis. Surgical stump revision was recommended in 26% of stumps and prosthetic management in 41%. A further 22%, subject to the success or failure of prescribed prosthetic adjustment, could require stump revision.
Youth, proximal injury, high numbers of AKA, psychosocial issues and the need for stump and prosthetic support define this group of amputees. Unifying expertise within a National MDT will promote continuity of care necessary for decades to come.
The ultimate aim is an evidence-based amputee care system in Gaza, with lower limb specialists promoting best outcomes, judicious allocation of funds and maximising amputee quality of life.
To examine participants' experiences with peer-support after lower limb loss (LLL) and the associations between the peer-support experience (perceived benefits and barriers) and mobility outcomes.
...Quantitative and qualitative descriptive study with a cross-sectional design.
National survey (distributed to 169 peer-support groups in 44 states in the US).
The survey was completed by 82 individuals with a major lower limb amputation (53% female, 54% over 55 years of age; N=82).
A 32-item survey to examine respondents' experiences in peer-support activities. Prosthetic mobility was measured using the Prosthetic Limb Users Survey of Mobility (PLUS-M).
Two out of 3 respondents received some forms of peer-support after amputation. Among them 75% reported peer-support having a positive effect on their outlook on life, and 78% reported that information gained from peer-support was helpful. Companionship, altruistic acts, and gaining information on how to cope with amputation were the top themes of why respondents enjoyed the peer-support experience. Nearly all (94%) respondents would recommend peer-support to other people with LLL. Individuals who received peer-support exhibited a trend of greater mobility (55th vs 36th percentile on PLUS-M; P=.055).
Individuals with LLL reported generally positive experiences regarding their engagement in peer-support activities. Peer-support groups are viewed as a helpful source for both information and emotional support, potentially benefiting functional and psychological recovery after amputation. Individuals who have received peer-support also exhibited greater mobility.
The aim of this study was to systematically review the literature to identify factors that may influence quality of life in people with lower-limb amputation (all etiologies). Our primary focus was ...on identifying factors that can be modified, enabling a more concentrated integration of these aspects into the care and treatment of amputated patients.
Medline (via Ovid) and Scopus were searched in January 2023 for studies assessing quality of life for people with lower-limb loss. Studies were included if they reported on factors that could influence quality of life. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed.
Studies were identified and assessed independently by 2 reviewers.
Data were extracted by 2 independent reviewers.
After removing duplicates, the search yielded 2616 studies, of which 24 met our inclusion criteria (cross-sectional n = 13; prospective n = 9; retrospective n = 2). The most commonly used quality-of-life instruments were the Short Form 36, followed by the World Health Organization Quality of Life-BREF and the EuroQoL 5 dimension. Younger age, traumatic etiology, unilateral or below-knee amputation, presence of comorbidities, and social integration were found to influence quality of life in people with lower-limb amputation, whereas sex and socioeconomic context do not seem to have a clear influence.
This systematic review of the literature identified several factors that influence quality of life in patients with lower-limb amputation. However, the results are not always consistent across studies and there is still no consensus on some factors. Conclusive findings regarding sex and socioeconomic status remain elusive, primarily because of substantial disparities observed across the literature. Future prospective longitudinal studies with clear a priori inclusion of a wide range of potential factors are needed to clarify the impact of the identified factors. Factors such as age, type of amputation, comorbidities and social integration should be considered in the management of patients with amputation.
Transfemoral amputee often encounters reduced toe clearance resulting in trip-related falls. Swing-phase joint angles have been shown to influence the toe clearance; therefore, training intervention ...that targets shaping the swing phase joint angles can potentially enhance toe clearance. The focus of this study was to investigate the effect of the shift in the location of the center of pressure (CoP) during heel strike on modulation of the swing-phase joint angles in able-bodied participants (n = 6) and transfemoral amputees (n = 3). We first developed a real-time CoP-based visual feedback system such that participants could shift the CoP during treadmill walking. Next, the kinematic data were collected during two different walking sessions-baseline (without feedback) and feedback (shifting the CoP anteriorly/posteriorly at heel strike to match the target CoP location). Primary swing-phase joint angle adaptations were observed with feedback such that during the midswing phase, posterior CoP shift feedback significantly increases (p < 0.05) the average hip and knee flexion angle by 11.55 deg and 11.86 deg, respectively, in amputees, whereas a significant increase (p < 0.05) in ankle dorsiflexion, hip and knee flexion angle by 3.60 deg, 3.22 deg, and 1.27 deg, respectively, compared to baseline was observed in able-bodied participants. Moreover, an opposite kinematic adaptation was seen during anterior CoP shift feedback. Overall, results confirm a direct correlation between the CoP shift and the modulation in the swing-phase lower limb joint angles.
•Gait analyses performed at 0, 2, and 6 months after initial prosthesis use.•Features of knee adduction and flexion moments do not change over six months.•Vertical ground reaction forces do not ...change over six months.
Individuals with unilateral lower limb loss are at increased risk for developing knee osteoarthritis in their contralateral limb. The mechanisms underlying this phenomenon are unknown, but large or unusual loads on the limb are thought to contribute to osteoarthritis development. Yet, to our knowledge, there have been no longitudinal assessments of knee joint kinetics to assist with identifying the origin or progression of such loads.
This study aimed to examine knee joint kinetics of individuals with lower limb loss as a function of time from independent ambulation.
Eight male Service Members with unilateral lower limb loss (3 transfemoral/5 transtibial) completed gait analyses, walking at self-selected speed and cadence, at 0, 2, and 6 months following initial independent ambulation.
Although there was a significant time effect on stride length (p = 0.047), there were no pairwise differences (all p ≥ 0.152). Additionally, there was not a significant effect of time on the peak (p = 0.666), loading rate (p = 0.336), or impulse (p = 0.992) of knee adduction moment (KAM), peak knee flexion moment (KFM) (p = 0.128), or the peak (p = 0.485) or loading rate (p = 0.130) of vertical ground reaction force (VGRF).
The results of the current study demonstrate that major features of knee joint loading do not change over the first 6 months of independently walking with a prosthesis. The magnitude of these loads are similar to loads observed in individuals with lower limb loss further from injury/initial ambulation, but the present results do not imply that no changes occur after 6 months.
Abstract Aim: The purpose of the study was to assess upper limbs’ maximum power and locomotion speed among amputee football (amputee soccer) players. Methods: The 30-s Wingate Anaerobic test and the ...20-m sprint test were performed. Anthropometric measurements and body composition (Body mass index (BMI), percentage of body fat (% BF), and lean body mass (LBM)) were examined. Results: BMI significantly differentiated forwards and defenders (p < 0.05). Peak power (PP) and mean power (MP) were related to LBM (p < 0.05), thus defenders reached higher values of PP, in comparison to forwards. % BF and BMI were related to relative mean power (rMP) (p < 0.05). Field position differentiated players in terms of upper limbs’ relative peak power (rPP) in favour of forwards (p < 0.05). Age was a significant factor for speed velocity on 10 m and 20 m (p < 0.05). There was no relationship between upper limbs’ power and locomotion speed. Conclusion: Body composition, especially % BF may influence on the anaerobic performance of amputee football players.
ABSTRACT
Health care economic science holds great potential for improving the quality of lower-limb prosthetic care. To realize this potential, health care providers need to adopt an outlook that ...economic analysis is not strictly limited to the scrutiny of cost, but includes a better understanding of the value generated in the provision of lower-limb prostheses. Health care providers in the United States currently have a negative perception of cost containment efforts implemented by regulators to rein in health care spending. The United States currently spends more on health care than any other developed country (17.9% of GDP; National Health Expenditure Projections 2017–2026. Centers for Medicare and Medicaid Services; 2017), whereas other countries have reduced cost and increased quality of care through health care economic science.
The clinical outcome of restoring mobility and independence to a person with lower-limb amputation has an appreciable impact on quality of life. By measuring the quality improvement and comparing costs associated with available lower-limb prosthetic alternatives, health care economic science can improve decision making regarding the best use of resources and improve the overall value of care. Although limited economic evidence exists concerning lower-limb prostheses, a better understanding of the purpose of health care economic science can lead health care providers to contribute to the economic research that is needed.
Currently, there is little available in-depth analysis of the biomechanical effect of different prostheses on the musculoskeletal system function and residual limb internal loading for persons with ...bilateral transfemoral/through-knee amputations (BTF). Commercially available prostheses for BTF include full-length articulated prostheses (microprocessor-controlled prosthetic knees with dynamic response prosthetic feet) and foreshortened non-articulated stubby prostheses. This study aims to assess and compare the BTF musculoskeletal function and loading during gait with these two types of prostheses.
Gait data were collected from four male traumatic military BTF and four able-bodied (AB) matched controls using a 10-camera motion capture system with two force plates. BTF completed level-ground walking trials with full-length articulated and foreshortened non-articulated stubby prostheses. Inverse kinematics, inverse dynamics and musculoskeletal modelling simulations were conducted.
Full-length articulated prostheses introduced larger stride length (by 0.5 m) and walking speed (by 0.3 m/s) than stubbies. BTF with articulated prostheses showed larger peak hip extension angles (by 10.1°), flexion moment (by 1.0 Nm/kg) and second peak hip contact force (by 3.8 bodyweight) than stubbies. There was no difference in the hip joint loading profile between BTF with stubbies and AB for one gait cycle. Full-length articulated prostheses introduced higher hip flexor muscle force impulse than stubbies.
Compared to stubbies, BTF with full-length articulated prostheses can achieve similar activity levels to persons without limb loss, but this may introduce detrimental muscle and hip joint loading, which may lead to reduced muscular endurance and joint degeneration. This study provides beneficial guidance in making informed decisions for prosthesis choice.
The L Test is a clinical mobility test used in patients after lower limb amputation. To assess dynamic balance, it should be performed with fast walking speed. Its measurement properties in the ...initial prosthetic training phase are not known yet. The objective of the study was to establish intra- and interrater reliability, concurrent and discriminant validity, minimal detectable change, effect size between the rehabilitation time points and ceiling effect of the L Test with fast walking speed in patients after lower limb amputation in initial prosthetic training phase. The study included 36 inpatients aged 19–86 years who were provided with a prosthesis for the first time. They were assessed repeatedly with the L Test, Ten-meter Walk Test and 6-min Walk Test. The intra- (ICC 3, k = 0.94) and interrater reliability (ICC 2, k = 0.96) of the L Test were excellent. Correlations with the walking tests were very good ( r = 0.75–0.86). Regression analysis with respect to the level of lower limb amputation showed a linear relationship with other variables ( R 2 = 0.55). Influences of age, cause of lower limb amputation and walking aid were statistically significant. The L Test was responsive to change after two weeks of prosthetic training (Cohen’s d = 1.21). No ceiling effect was identified. The L Test with fast walking speed is a feasible, reliable, valid, and responsive measure of basic mobility skills in patients after lower limb amputation in the initial prosthetic training phase.
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