The validity of forceplate data as a measure of rapid and targeted volitional movements of the centre of mass in transtibial prosthesis users

Purpose: To validate outcome variables from the limits of stability protocol that are derived from the center of pressure with those same variables derived from the center of mass during rapid, volitional responses in transtibial prosthesis users.

Method: Prosthesis users (n?=?21) and matched controls (n?=?21) executed movements while force and motion data were collected. Correlation coefficients were used to investigate relationships between center of pressure and center of mass for: x/y coordinates positions, limits of stability outcome variables and muscular reaction times.

Results: Significant differences were seen in correlation between x/y coordinate positions toward the intact limb (mean effect size of differences: r?=?.38). Limits of stability variables were positively correlated (reaction time and maximum excursion range r_s: .585–.846; directional control and mean velocity range r_s: .307–.472). Muscular reaction times correlated weakly with those from center of pressure (mean r_s prosthesis users: .186 and controls: .101).

Conclusions: Forceplate measures are valid in describing rapid, volitional movements in unilateral transtibial prosthesis users. Limits of stability outcomes extracted from center of pressure and center of mass are highly correlated, but can be sensitive to direction. Muscular reaction time correlates very little with reaction times extracted from the other variables.

• Implications for rehabilitation

• Rehabilitation programs utilizing limits of stability are valid measures of postural control in transtibial prosthesis users.

• Clinicians interpreting the outcomes from limits of stability need to be aware of their varying validity.

• Muscular reaction times correlate weakly with other measures of reaction time, highlighting the complexity of rapidly coordinating volitional movements in prosthesis users.

     

Identifying successful outcomes and important factors to consider in upper limb amputation rehabilitation: an international web-based Delphi survey

Abstract

Purpose: To identify and gain agreement on successful outcomes of and important factors to consider in rehabilitation following upper limb absence (ULA). Method: Fifty-three participants consisting of multi-disciplinary rehabilitation professionals, and individuals with ULA were invited to complete a three-round modified Delphi iterative survey. Following three Delphi questionnaire rounds, participants clarified the definitions of success in three areas (prosthesis use, activities and participation and self-image). In addition, participants identified and agreed the important factors to consider in rehabilitation after ULA. Results: Results showed that participants reached agreement (having a SD <1) over the three rounds on 78 out of 81 rated items. Of these, 54 rated items were “accepted” as important by panel members (mean score of 4 on a five-point Likert scale). Twenty-four items were rejected. Only three rated items had not reached agreement by the third round. Conclusions: Clarification of successful outcomes and factors that should be taken into consideration in a patient’s rehabilitation allows a clearer evaluation of what should be the focus of rehabilitation. The findings from the Delphi study can help form the basis for a screening tool for clinicians to be able to identify areas of concern and subsequent treatment for a patient in their care.

• Implications for Rehabilitation

• To date, there has been no definitive guidance on which outcomes should be assessed in amputation rehabilitation.

• This study identified the seven core domains of importance regarding the rehabilitation of individuals with ULA and created a starting point for developing a new portfolio of research that aims to address all relevant aspects of patients’ rehabilitation.

• This study reached a consensus and enabled an insight into what defines successful prosthesis use, self-image and activities and participation, and provided evidence that the current definition of prosthesis use in the literature does not sufficiently capture what RPs and individuals with ULA consider important, such as specific use of the prosthesis, as often as an individual wishes, while using it as intended.

• This study provided RPs and individuals with ULA an opportunity to communicate their opinions and knowledge anonymously regarding the important areas to consider in rehabilitation.

     

Adaptations from the prosthetic and intact limb during standing on a sway-referenced support surface for transtibial prosthesis users

Abstract

Purpose: To investigate the bilateral postural adaptations as a result of standing on an increasingly unstable sway-referenced support surface with both the intact and prosthetic limb for transtibial prosthesis users (TPUs).

Method: TPUs (n = 14) and matched controls (n = 14) stood quietly in multiple foot placement conditions (intact foot, prosthetic foot and both feet) on a sway-referenced support surface which matched surface rotation to the movement of the centre of pressure (CoP). Force and motion data were collected and used to analyse CoP mean position, displacement integral and force components under intact and prosthetic limbs.

Results: Significant differences were found between prosthesis users and controls in CoP mean position in anteroposterior (1.5 (95% CI, 1.2–1.8) cm) and mediolateral directions (3.1 (95% CI, 0.5–5.7) cm. CoP displacement integrals were significantly different greater for prosthesis user group in the anteroposterior direction. Force components differences were found in all planes (anteroposterior: 0.6 (95% CI, 0.4–0.8 N); mediolateral: 0.1 (95% CI, 0.0–0.2 N & 0.3 (95% CI, 0.2–0.4) N, inferosuperior: 2.2 (95% CI, 1.4–3.0) N).

Conclusions: TPUs have bilateral static and dynamic postural adaptations when standing on a sway-referenced support surface that is different to controls, and between prosthetic and intact sides. Results further support evidence highlighting importance of the intact limb in maintenance of postural control in prosthesis users. Differences indicate clinical treatment should be directed towards improving outcomes on the intact side.

• Implications for rehabilitation

• Prosthesis users have bilateral adaptations when standing on a sway referenced support surface

• These adaptations are different to controls, and between prosthetic and intact sides.

• The intact limb is the major contributor to maintenance of postural control in prosthesis users.

• Clinical treatment should account for this when interventions are designed.

     

Á priori alignment of transtibial prostheses: a comparison and evaluation of three methods

Purpose: The objectives of this study were to compare three á priori alignment methods and evaluate them based on initial gait quality and further alignment changes required to optimize gait. Á priori alignment is requisite for monolimbs, transtibial prostheses in which the socket and pylon are made from one piece of plastic, because monolimbs have no alignment adjustability. Method: The three methods investigated were traditional bench alignment (TRAD), vertical alignment axis (VAA) and anatomical based alignment (ABA). Endoskeletal components were utilized for the study, rather than monolimbs, so that alignment could be experimentally manipulated. Three endoskeletal prostheses were aligned, one according to each á priori method, for each of seven subjects. Gait and alignment data were captured, dynamic alignment was performed to optimize gait, and data were captured again. Results: VAA and TRAD methods required less change compared to ABA in socket flexion angle. Looking at subjects individually, VAA produced a better alignment and better gait for the greatest number of subjects. Conclusions: A new refined method of á priori alignment is proposed based on the results of this study, and is applicable for á priori alignment of monolimbs or any type of transtibial prosthesis.

Implications for Rehabilitation

• This study shows that there is a wide range of acceptable alignments for a transtibial prosthesis.

• Using the best possible alignment for a monolimb could produce a high-quality transtibial prosthesis at a great cost savings.

     

Knowledge translation in physical therapy: from theory to practice

Abstract

Purpose: Knowledge translation (KT) has emerged as a concept that can lead to a greater utilization of evidence-based research in systems of care. Despite a rise in KT research, the literature on KT in relation to physical therapy practice is scarce. This article provides physical therapists (PTs) with recommendations that can support the effective implementation of new knowledge and scientific evidence in clinical practice. Method: Recommendations are grounded in the Ottawa Model of Research Use and in the literature in KT in the health professions. Results: A well-established KT process, which is supported by a planning model, is essential to guide the implementation of scientific evidence. Consensus among all stakeholders about what evidence will be implemented must be reached. Context-related barriers and facilitators should be assessed and tailored active and multi-component interventions should be considered. Participation from individuals in intermediary positions (e.g. opinion leaders) supports implementation of KT interventions. Monitoring of the process and assessment of intended outcomes should be performed in order to assess the success of the implementation. Conclusion: Five major recommendations grounded in the Ottawa model are provided that can assist PTs with the complex task of implementing new knowledge in their clinical practice.

• Implications for Rehabilitation

• In order to support EBP, knowledge translation interventions can be used to support best practice.

• Implementation of new knowledge should be guided by a framework or a conceptual model.

• Consensus on the evidence must be reached and assessment of context-related factors should be done prior to the implementation of any KT intervention.

• Intervention strategies should be active, multi-component and include individuals with intermediary positions that can facilitate the KT process.

     

Biopsychosocial predictors of prognosis in musculoskeletal disorders: a systematic review of the literature (corrected and republished)

Purpose: To review the prognostic factors of musculoskeletal disorders while adopting a multidimensional perspective and including studies on various pertinent outcomes to the adjustment process. We also aimed to highlight the overall and phase-specific evidence. Method: We searched the Psychinfo and Ovid Medline(R) databases as well as pertinent periodicals and reviews and retained prospective studies of subjects suffering from specific or non-specific musculoskeletal pain that adopted multivariate statistical analysis. Results: We selected 105 studies, of which 68 included biopsychosocial and sociodemographic variables. For those studies using a biopsychosocial framework, we determined the level of evidence for every prognostic factor with each outcome. Strong evidence was found for recovery expectations and disability management with work participation outcomes. With disability outcomes, strong evidence was also found for recovery expectations, coping and somatization. Comorbidity and duration of episode strongly predicted pain outcomes. Some differences coinciding with phases of chronicity were also identified. Conclusion: Although uncertainty remains about the role of many prognostic factors, we found strong evidence to support the predictive value of clinically significant variables. There is, however, a need for additional research and replication, adopting more homogenous models and measurement methods.

Implications for Rehabilitation

• Despite numerous studies, it remains difficult to identify a clear set of prognostic factors in musculoskeletal disorders.

• Outcomes in musculoskeletal disorders are determined by biopsychosocial prognostic variables although psychosocial factors appear predominant, as early as in the acute phase.

• There appears to be negligible differences between prognostic factors in acute, subacute and chronic phases and a biopsychosocial approach should be considered from the acute phase in rehabilitation practice.

• Outcomes in rehabilitation practice should also be evaluated from a biopsychosocial perspective.

     

Prosthesis rejection in acquired major upper-limb amputees: a population-based survey

Purpose: To estimate the rates of primary and secondary prosthesis rejection in acquired major upper-limb amputees (ULAs), to describe the most frequently reported reasons for rejection and to estimate the influence of background factors on the risk of rejection. Method: Cross-sectional study analysing population-based questionnaire data (n?=?224). Effects were analysed by logistic regression analyses and Cox regression analyses. Results: Primary prosthesis rejection was found in 4.5% whereas 13.4% had discontinued prosthesis use. The main reasons reported for primary non-wear were a perceived lack of need and discrepancies between perceived need and the prostheses available. The main reasons reported for secondary prosthesis rejection were dissatisfaction with prosthetic comfort, function and control. Primary prosthesis rejection was more likely in ULAs amputated at high age and in ULAs with proximal amputations. Secondary prosthesis rejection was more likely in proximal ULAs and in women. Conclusions: Clinicians should be aware of the increased risk of rejection in proximal ULAs, elderly ULAs and in women. Emphasising individual needs will probably facilitate successful prosthetic fitting. Improved prosthesis quality and individualised prosthetic training may increase long-term prosthesis use. Further studies of the effect of prosthetic training and of the reasons for rejection of different prosthetic types are suggested.

Implications for Rehabilitation

• Most acquired major upper-limb amputees (ULAs) are fitted with prostheses after the amputation.

• This population-based study shows that proximal ULAs, elderly ULAs and women have an increased risk of prosthesis rejection.

• Emphasising individual needs may facilitate successful prosthetic fitting.

• Improved prosthesis quality and individualised prosthetic training may increase long-term prosthesis use.

     

Emotional well-being and adjustment to vision loss in later life: a meta-synthesis of qualitative studies

Purpose: To review perceived emotional well-being in older people with visual impairment and perceived factors that inhibit/facilitate psychosocial adjustment to vision loss. Method: The databases of MEDLINE, EMBASE, PsycINFO and CINAHL were searched for studies published from January 1980 to December 2010, which recruited older people with irreversible vision loss, and used qualitative methods for both data collection and analysis. Results sections of the papers were synthesised using a thematic-style analysis to identify the emergent and dominant themes. Results: Seventeen qualitative papers were included in the review, and five main themes emerged from the synthesis: 1) the trauma of an ophthalmic diagnosis, 2) impact of vision loss on daily life, 3) negative impact of visual impairment on psychosocial well-being, 4) factors that inhibit social well-being, and 5) factors that facilitate psychological well-being. We found the response shift model useful for explaining our synthesis. Conclusions: Acquired visual impairment can have a significant impact on older people’s well-being and make psychosocial adjustment to the condition a major challenge. Acceptance of the condition and a positive attitude facilitate successful psychosocial adjustment to vision loss as well as social support from family, friends and peers who have successfully adjusted to the condition.

Implications for Rehabilitation

• Visual impairment can have a profound negative impact on individuals’ psychosocial well-being.

• The emotional needs of those with visual impairment should not to be neglected, particularly those recently diagnosed.

• Referrals to services may be appropriate for individuals with vision loss (e.g. counselling and peer support groups).

• It may also be appropriate to discuss with individuals the factors that inhibit/facilitate psychosocial adjustment to vision loss.

     

Prosthesis use in adult acquired major upper-limb amputees: patterns of wear,prosthetic skills and the actual use of prostheses in activities of daily life

Purpose: To describe patterns of prosthesis wear and perceived prosthetic usefulness in adult acquired upper-limb amputees (ULAs). To describe prosthetic skills in activities of daily life (ADL) and the actual use of prostheses in the performance of ADL tasks. To estimate the influence of prosthetic skills on actual prosthesis use and the influence of background factors on prosthetic skills and actual prosthesis use. Method: Cross-sectional study analysing population-based questionnaire data (n?=?224) and data from interviews and clinical testing in a referred/convenience sample of prosthesis-wearing ULAs (n?=?50). Effects were analysed using linear regression. Results: 80.8% wore prostheses. 90.3% reported their most worn prosthesis as useful. Prosthetic usefulness profiles varied with prosthetic type. Despite demonstrating good prosthetic skills, the amputees reported actual prosthesis use in only about half of the ADL tasks performed in everyday life. In unilateral amputees, increased actual use was associated with sufficient prosthetic training and with the use of myoelectric vs cosmetic prostheses, regardless of amputation level. Prosthetic skills did not affect actual prosthesis use. No background factors showed significant effect on prosthetic skills. Conclusions: Most major ULAs wear prostheses. Individualised prosthetic training and fitting of myoelectric rather than passive prostheses may increase actual prosthesis use in ADL.

Implications for Rehabilitation

• Arm prostheses are important functional aids for adult acquired major upper-limb amputees (ULAs).

• Despite being mainly satisfied with their prostheses, reporting their prostheses as useful and showing good prosthetic skills, prosthesis-wearing major ULAs do not use their prostheses for more than about half of the activities of daily life (ADL) tasks carried out in everyday life.

• In unilateral ULAs, individualised and targeted prosthetic training may increase optimal, active prosthesis use in ADL.

• Fitting the amputee with myoelectric rather than passive prostheses may increase prosthesis use in ADL, regardless of amputation level.

     

Kinematic comparison of the wrist movements that are possible with a biomechatronics wrist prosthesis and a body-powered prosthesis: a preliminary study

Purpose: This study examined the kinematic differences between a body-powered prosthesis and a biomechatronics prosthesis as a transradial amputee performed activities that involve flexion/extension and supination/pronation of the wrist.

Method: The subject’s wrist movements were calculated and compared as he completed a wrist range of motion test involving simulated flexion/extension and supination/pronation.

Results: The results revealed that, under the test conditions, the body-powered prosthesis limits an individual’s ability to complete four different tasks of wrist movement especially when it comes to complete the supination/pronation movement. Conversely, while using biomechatronics wrist prosthesis, the user was able to compensate for limited wrist motion through an ability to achieve a greater range of wrist movement.

Conclusions: The biomechatronics wrist prosthesis provides a greater degree of freedom of wrist flexion/extension and supination/pronation movements.

Implications for Rehabilitation

• Body powered prosthesis for transradial amputees involved the wrist movement that focus on flexion/extension and supination/pronation.

• The biomechatronics wrist prosthesis is a combination of controller that controlled the servo motor at the wrist.

• The biomechatronics wrist prosthesis provides a greater degree of freedom of wrist flexion/extension and supination/pronation movements compare to the body powered prosthesis.

     

Development and acceptability testing of decision trees for self-management of prosthetic socket fit in adults with lower limb amputation

Purpose: The most common complaint lower limb prosthesis users report is inadequacy of a proper socket fit. Adjustments to the residual limb–socket interface can be made by the prosthesis user without consultation of a clinician in many scenarios through skilled self-management. Decision trees guide prosthesis wearers through the self-management process, empowering them to rectify fit issues, or referring them to a clinician when necessary. This study examines the development and acceptability testing of patient-centered decision trees for lower limb prosthesis users.

Methods: Decision trees underwent a four-stage process: literature review and expert consultation, designing, two-rounds of expert panel review and revisions, and target audience testing.

Results: Fifteen lower limb prosthesis users (average age 61 years) reviewed the decision trees and completed an acceptability questionnaire. Participants reported agreement of 80% or above in five of the eight questions related to acceptability of the decision trees. Disagreement was related to the level of experience of the respondent.

Conclusions: Decision trees were found to be easy to use, illustrate correct solutions to common issues, and have terminology consistent with that of a new prosthesis user. Some users with greater than 1.5 years of experience would not use the decision trees based on their own self-management skills.

• Implications for Rehabilitation

• Discomfort of the residual limb-prosthetic socket interface is the most common reason for clinician visits.

• Prosthesis users can use decision trees to guide them through the process of obtaining a proper socket fit independently.

• Newer users may benefit from using the decision trees more than experienced users.

     

Individuals’ expectations and challenges following total hip replacement: a qualitative study

Purpose: Hip replacements are one of the most common operations for individuals with hip osteoarthritis. There have been numerous quantitative studies investigating the recovery from joint replacement surgery and these show how effective and satisfied patients are. However, little qualitative work has been conducted to explore patients’ actual experiences. Therefore, this study aimed to detail the experiences of individuals undergoing a total hip replacement (THR) to determine whether their expectations were met. Method: The qualitative study was nested within a longitudinal study (n?=?215) that was investigating biomedical and psychosocial outcomes from THR. We interviewed a purposive sample of individuals (n?=?25) 6 months after THR to explore their experiences of having a THR. Findings: Participants were aged 48–82 years. They felt disabled following the THR and some had unrealistic expectations of recovery. Most of them received minimal information and health professional support. Participants had to overcome a number of challenges such as diminished confidence, frustration over slow progress and reduced physical functioning. Conclusion: Individuals undergoing THR need to have the opportunity to discuss their expectations of THR, so there is no “false optimism”. Support requirements, following THR, need to be reviewed as they were often underestimated by patients and health professionals.

Implications for Rehabilitation

• Total hip replacements (THR) due to osteoarthritis are one of the most common operations.

• Patients’ expectations of a THR are high.

• Recovery following a THR is challenging for patients and health professionals need to be aware of their support requirements.

     

Informal caregivers' needs on discharge from the spinal cord unit: analysis of perceptions and lived experiences

Purpose: Spinal cord injuries (SCI) are one of the most complex and disabling diseases, implying severe consequences on aspects of life of people affected by SCI and their caregivers. The aim of our study was to explore the situation of informal caregivers of persons with SCI when discharged home from a SCI Unit, in relation to needs, emotional experiences, difficulties and subsequent reactions to discharge. Methods: A purposive sample of 11 caregivers were interviewed on patients' discharge home from the Spinal Injury Care Unit and at 6 months. The semi-structured interviews were analyzed using a qualitative phenomenological methodology as described by Giorgi. Results: Five main themes emerged from the caregivers' experiences including their implicit and explicit needs. Problems concerning communication with healthcare professionals and the need for an adequate multidisciplinary taking charge of caregivers in order to support their new role emerged within all the themes. Conclusions: Results suggest that greater caregiver involvement in the rehabilitation process and their preparation for discharge are required. Communication with healthcare professionals needs to be enhanced. It would be useful to organize follow-up visits after discharge to assess intervention effectiveness.

• Implications for Rehabilitation

• Understanding the importance of discharge from the spinal cord unit as a meaningful step in the rehabilitation path for both patients and their informal caregivers.

• Orientating healthcare professionals towards a better caregiver involvement during the rehabilitation process.

• Promoting rehabilitation interventions addressed to the patients and their caregivers concerning supportive communication strategies as well as providing meaningful information, psychological and social support, educational intervention besides the physical aspects of care.

• Understanding SCI survivors caregivers' needs can assist healthcare professionals in planning and improving taking charge of this core aspect of nursing care.

     

Factors promoting sustainable work in women with fibromyalgia

Abstract

Purpose: To examine and describe the factors promoting sustainable work in women with fibromyalgia (FM). Methods: A qualitative interview study. Twenty-seven gainfully employed women with FM participated in five focus group interviews. Their median age was 52 years, ranging from 33 to 62. The interviews were recorded, transcribed verbatim and analysed by qualitative latent content analysis. Results: Four categories were identified describing factors promoting sustainable work: the meaning of work and individual strategies were individual promoters while a favourable work environment and social support outside work were environmental promoters. The meaning of work included individual meaning and social meaning. The individual strategies included handling symptoms, the work day and long-term work life. A favourable work environment included the physical and psychosocial work environment. Social support outside work included societal and private social supports. Conclusions: Promoting factors for work were identified, involving individual and environmental factors. These working women with FM had developed advanced well-functioning strategies to enhance their work ability. The development of such strategies should be supported by health-care professionals as well as employers to promote sustainable work in women with FM.

• Implications for Rehabilitation

• Work disability is a common consequence of fibromyalgia (FM).

• Working women with FM appear to have developed advanced well-functioning individual strategies to enhance their work ability.

• The development of individual strategies should be supported by health-care professionals as well as employers to promote sustainable work and health in women with FM.

     

Barriers and facilitators of sports in children with physical disabilities: a mixed-method study

Abstract

Purpose: This study explored barriers and facilitators of sports participation of children with physical disabilities from the perspective of the children, their parents and their health professionals. Method: Thirty children and 38 parents completed a questionnaire, and 17 professionals were interviewed in a semi-structured way. Data from the three groups were combined in a mixed-method design, after which the results were triangulated. Results: Mean age (SD) of the children was 14.1 (2.9) years old, 58% were boys. Sixty-seven percent of the children had cerebral palsy and 77% participated in sports after school. Most commonly practiced sports were swimming, cycling and football. Children specifically experienced dependency on others as a barrier, parents did not have enough information about sports facilities, and professionals observed that the family’s attitude had influence on the child’s sports participation. Facilitators were health benefits, fun and social contacts. Conclusion: Sports participation of children with physical disabilities is a complex phenomenon because children, their parents and professionals reported different barriers. Sports participation is more physically challenging for children with severe physical disabilities, as their daily activities already require much energy. However, the psychosocial benefits of sports are applicable to all children with physical disabilities.

• Implication for Rehabilitation

• Perceived barriers seemed to differ for children, parents and health professionals, suggesting that sports participation is a complex phenomenon.

• Sports might be more physically challenging for children with severe physical disabilities, as their daily activities already take much energy.

• The psychosocial benefits of sports should be emphasized by rehabilitation professionals when advising children with physical disabilities about sports.

     

“Look and feel your best”: representations of artificial limb users in prosthetic company advertisements

Abstract

Purpose: Artificial limbs (prosthetics) are considered important for keeping the person physically active and avoiding an array of negative health outcomes associated with non-use. Increasingly, the potential users of these limbs are the focus of commercial prosthetic company advertisements. It has been argued that it is important to examine such media representations, not least because people’s beliefs regarding health and illness are often forged from the discourses and constructions available to them in such material, but because these representations mediate individual lived experience. Method: This article provides a thematic analysis, drawing upon discourse analysis and semiotics, of textual–pictorial representations of artificial limb users in the advertisements of prosthetic companies. The data set was comprised of advertisements that appeared over a 2-year period in inMotion, an international magazine produced and distributed by a major amputee advocacy group. Results: The findings indicate that dominant societal constructions of work, gender and family are drawn on in depicting artificial limb users. These offer generally positive representations that draw on socially pervasive stereotypes. Conclusions: The findings are discussed in relation to literature concerning the experience and meaning of prosthesis use, and the implications for health professionals working with this group are set out.

• Implications for Rehabilitation

• People who lose a limb are increasingly being exposed to advertisements from prosthetic companies.

• Such advertisements have the potential to foster unrealistic expectations regarding rehabilitation following amputation.

• Healthcare professionals need to be mindful of how these advertisements mediate lived experience and impact on rehabilitation when planning personal care plans.