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Tools to Measure Outcome of People with a Lower Limb Amputation: Update on the PPA and LCI

Gauthier-Gagnon, Christiane MSc; Grisé, Marie-Claude MSc

JPO Journal of Prosthetics and Orthotics: January 2006 - Volume 18 - Issue 6 - p P61-P67
Outcome Measurement Tools
Free

Over the last decade, efforts have been made to develop disease-specific instruments to evaluate prosthetic and rehabilitation outcomes of people with lower limb amputations. This paper is an update of two instruments developed by the authors: the Prosthetic Profile of the Amputee (PPA) and the Locomotor Capabilities Index (LCI). The objective of the PPA is to evaluate prosthetic wear and active use of the prosthesis and to identify the factors that predispose to, enable, and reinforce prosthetic use. The LCI computes the global, basic, and advanced locomotor skills of the lower limb amputee with the prosthesis and assesses level of independence. The conceptual development of the instruments is discussed, the domains investigated, scales used are described, and psychometric properties are reported. Recent developments and studies are presented.

CHRISTIANE GAUTHIER-GAGNON, MSc, is affiliated with the Department of Rehabilitation, Faculty of Medicine, University of Montreal, Montreal, Canada.

MARIE-CLAUDE GRISÉ, MSc, is affiliated with Locomotor Amputee Program, Institute of Rehabilitation of Montreal, Montreal, Canada.

Correspondence: Christiane Gauthier-Gagnon, Department of Rehabilitation, Faculty of Medicine, University of Montreal, C.P. 6128, succursale Centre Ville, Montréal, Québec, Canada H3C 3J7; e-mail: christiane.gauthier-gagnon@umontreal.ca

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INTRODUCTION

Improvement of mobility and reintegration in the community are the ultimate goals of amputee rehabilitation programs. In rehabilitation medicine, there is an increasing demand to objectively report outcomes of different rehabilitation programs offered to persons with lower limb amputation. Therefore, it is essential to use appropriate outcome measures. Members of the rehabilitation team often question the impact of prosthetic fitting and training of the lower limb amputee, citing serious concerns about the subsequent behavioral pattern of prosthetic use and the problems encountered by persons with lower limb amputation in the months and years after discharge from the rehabilitation center. Little is known about the use of the prosthesis after discharge and if the attained function is maintained thereafter.

In the province of Québec, this issue is extremely important because prosthetic and rehabilitation services are funded entirely by the government. To ensure cost-effective use of resources, realistic goals must be set for people with a lower-limb amputation. This requires an awareness of factors that are likely to influence outcome.

Over the last 15 years, a variety of instruments have been developed and validated to measure specific outcomes of rehabilitation of people with lower limb amputation (Table 1).1–14 Some are concerned with the burden of care, others with prediction of prognosis, planning of care, functional status, disability in the community, perception of self, satisfaction with services and the prosthesis, and quality of life. The Prosthetic Profile of the Amputee (PPA) and embedded Locomotor Capabilities Index (LCI) were developed to delineate the prosthetic profile of the person with lower limb amputation but more specifically to identify the factors related to prosthetic use or nonuse. The theoretical framework called PRECEDE (Predisposing, Reinforcing and Enabling Causes in Educational Diagnosis and Evaluation) was used to structure the identification and classification of factors potentially related to prosthetic use of people with lower limb amputation.15

Table 1

Table 1

The interest of this model lies in its “diagnostic chain theory,” which includes three categories of factors with the potential for affecting voluntary health behaviors (Figure 1) and are modifiable by educational interventions. This model was developed by Green and coworkers15 on the basis “that any given health behavior may be seen as a function of the collective influence of three distinct groups of factors: predisposing, reinforcing and enabling factors” (pp. 14–15). Predisposing factors represent any characteristic of a person that motivates a specific behavior, for instance, prosthetic use. The predisposing factors were defined in the PPA as items concerning physical condition, demographic profile, rehabilitation program, and motivation. Reinforcing factors refer to social as well as physical benefits contributing to the persistence or extinction of the behavior. In the PPA, these benefits are associated with satisfaction, social interaction, and social environment. Enabling factors allow an aspiration to be realized. They are related to any skill or resource required to attain a behavior; the absence of skills may block the behavior. The enabling factors considered in the conception of the PPA concerned locomotor skills with the prosthesis and prosthetic resources available.

Figure 1.

Figure 1.

The frame of reference of the PPA to measure rehabilitation outcome with the prosthesis was the International Classification of Impairment, Disability, and Handicap (ICIDH) published by the World Health Organization.16 The ICIDH was originally developed as a tool for classification of the consequences of disease and of their implications in the lives of the individuals and to provide a common international cross-disciplinary methodological basis. The ICIDH evolved into what is now known as the International Classification of Functioning, disability and health (ICF).17 The ICF is based on the conceptual model of functioning and disability (body functions, activity, and participation), as was initially proposed by the ICIDH, but the framework further reflects the interaction between functioning and disability, health conditions (disorders, disease, injuries, trauma), and contextual factors (personal and environmental factors). The PPA emphasizes the activity and participation components of this classification as well as the contextual factors. For example, the section on “Your prosthetic use” of the PPA gives insight into the activity component of the ICF, the section on “Your leisure activities” pertains to the participation component of the model, and the section on “Your environment” as well as questions 5 and 6 on satisfaction and adaptation refer to personal and environmental factors related to prosthetic use. Hence, the PPA can point out the problems encountered by the person with LLA and their impact on activity level with the prosthesis and social interactions.

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OBJECTIVE

The objective of this paper is to present the PPA and its index on locomotor skills called the LCI, in terms of objectives, domains investigated, and scaling. The psychometric properties of these tools will also be delineated as well as their strengths, weaknesses, and ongoing improvements.

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PROSTHETIC PROFILE OF THE AMPUTEE

DESCRIPTION

The PPA was designed by Grisé and Gauthier-Gagnon in 19934,11 to evaluate the prosthetic use of the person with LLA in terms of weekly frequency of prosthetic wear and functional level of prosthetic use after discharge from the rehabilitation center. More importantly, the PPA elicits information on the factors predisposing to reinforcing and enabling use or nonuse.

Conception, design, validity, and reliability of the PPA have been fully reported.4,11 In summary, the PPA was based on Green's theoretical framework.15 The factors potentially related to prosthetic use were identified, categorized, and prioritized by a multidisciplinary group of 13 experts (health professionals and persons with lower limb amputation). The predisposing factors were grouped into “motivation,” “rehabilitation program,” “demographic characteristics,” and “physical health status” subcategories. The enabling factors were classified under “locomotor abilities with the prosthesis,” “integration of locomotor abilities,” “resources and accessibility to resources,” and “physical environment,” Reinforcing factors were grouped into “satisfaction with the prosthesis,” “social environment,” “integration,” and “maintenance of physical status and abilities” subcategories. The questionnaire was structured according to Dillman's Total Design Method.18

The PPA questionnaire consists of 44 closed-ended questions in which measurement scales are qualitative, nominal, and ordinal scales with a few quantitative ratio scales. The questions of the PPA questionnaire are grouped into six basic sections: the physical condition (4 questions, 20 items), the prosthesis (5 questions, 21 items), the prosthetic capabilities (7 questions, 23 items), the environment (10 questions, 22 items), the leisure activities (6 questions, 13 items), and demographic characteristics (5 questions, 5 items). In addition to the factors being evaluated, the questionnaire also includes questions pertaining to the behavior of prosthetic use (6 questions, 27 items). Two questions are specific to nonusers. Examples of questions are presented in Figures 2–5. The actual prosthetic use was defined in terms of the weekly frequency of prosthetic wearing and active use of the prosthesis indoors and outdoors (Figure 4).

Figure 2.

Figure 2.

Figure 3.

Figure 3.

Figure 4.

Figure 4.

Figure 5.

Figure 5.

The PPA was initially built for self-administration (postal version), but it can also be used for face-to-face and telephone interview. A guide is available and an “information chart” was developed to compile precollected data from the respondents’ medical chart (i.e., age, sex, cause of amputation, and so forth). The “information chart” complements the PPA. The PPA is a follow-up tool that can be completed in 25 minutes. Most sections are applicable at discharge from the rehabilitation center.

The PPA was initially developed and validated in French and English. It is now available in six languages: Dutch, English, French, Italian, Spanish, and Portuguese. All versions were translated using Del Greco's back-translation technique.19 The PPA was also reported as having been used in Iran.20

Except for question 11, which is an index on locomotor capabilities, no composite score can be computed for the PPA or for the six basic sections. To trace the profile of the person with LLA for each of the three factors and sort out the most significant variables related to prosthetic use, associations between the outcome variable and various factors may be done using appropriate statistical analyses such as regression analysis.

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VALIDITY

CONTENT VALIDITY

The PPA was assessed for content validity by a group of 13 experts and a group of 8 fitted lower limb amputees.4 To ensure the content validity of the instrument, the pertinence of each question with regard to the questionnaire's objectives was assessed. The pertinence of the 44 questions was high and the PPA was found to cover all relevant aspects of amputee rehabilitation. Thereafter, pretesting of the questionnaire was conducted with a random sample of 26 lower limb amputees.4

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CONSTRUCT VALIDITY

The Reintegration to Normal Living (RNL)21 scores of 70 lower extremity amputees were correlated with data collected from the PPA.11 The results confirmed convergence of analogous constructs of the RNL and the PPA questionnaire. The data of the “physical performances” construct of the PPA and the “daily activities” subscale of the RNL converged fairly to moderately well (r = 0.56, p < 0.01). Fairly good correlations (r = 0.64, p < 0.01) were also observed between the “acceptance of amputation and prosthesis” construct of the PPA and the RNL “perceptions of self” subscale.

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RELIABILITY

TEST-RETEST RELIABILITY

For continuous data, test-retest reliability was considered excellent.11 The intraclass coefficient for the weekly use of the prosthesis item was 0.92 (p < 0.001) and 0.80 (p < 0.001) for the LCI. For categorical data, Cohen's kappa varied from 0.46 to 0.84. For some ordinal variables, weighted kappa was used and moderate to substantial agreements were computed (κ = 0.44 to 0.73). High agreements were obtained for nominal variables (κ = 0.60 to 0.86). For almost all factual information questions regarding health problems, condition of the nonamputated limb and residual limb, prosthetic problems, and activities of daily living, test-retest agreements were high.

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INTER-RATER RELIABILITY

Inter-rater reliability was not assessed because it was not pertinent for the postal version. When using the telephone version, training of the interviewers is necessary.

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OUTCOME WITH THE PPA

The PPA questionnaire is valid and reliable for clinical and research use. It is the only tool reported in the literature that is specific to the factors related to prosthetic use by the lower limb amputee. A provincial study in Québec, Canada, on factors predisposing to prosthetic use has shown that adaptation to the amputation and prosthesis and level of amputation were significantly correlated to prosthetic wear and active use indoors and outdoors.22 Presence of arthritic problems in the nonamputated limb was negatively related to prosthetic wear. For activities outdoors, muscle cramps and sores were the limiting factors. Long delays in limb fitting, prolonged training, cardiac and respiratory problems, and constant residual limb pain were significantly related to nonuse of the prosthesis.23 Further results demonstrated that the ability to don the prosthesis, the locomotor capabilities with the prosthesis, walking distances, automaticity of gait, and assistive devices used were the main enabling factors related to prosthetic wear and active use of the prosthesis.22 People with transfemoral amputation reported greater difficulties in donning their prosthesis and a significantly higher rate of falls.22

Results of PPA use in the Netherlands showed remarkable resemblance with the Québec population in terms of prosthetic use.23 In the Netherlands, 94% of the fitted lower limb amputees did wear their prosthesis daily, 76% wore it more than 9 hours per day and 63% used it during the majority of their indoor activities and 71% for outdoor activities. The Dutch researchers also observed that the amputee profile remained stable over a period of 2 months after discharge. Factors influencing prosthetic use were not reported.

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LOCOMOTOR CAPABILITIES INDEX

DESCRIPTION

The LCI was designed to trace a comprehensive profile of ambulatory skills of the lower limb amputee with the prosthesis and to evaluate their level of independence while performing these activities. The LCI refers to question 11 of the PPA but can be used independently. It is composed of 14 items that measure one general construct: locomotor capabilities of the lower limb amputee with the prosthesis.4 Two subscales emerge from this general construct: basic (7 items) and advanced (7 items) locomotor capabilities with the prosthesis (Figure 5). The person is asked whether or not he/she wears the prosthesis and whether he/she would be able to do the activities listed with the prosthesis. Hence, when self-administered at follow-up, the LCI measures the perceived capacity and not the actual performance. On the other hand, clinicians have also been using the index during the course of the rehabilitation program to observe the actual performance of the person over time. When applied at the beginning of the prosthetic training, the LCI allows the clinician and the person with the LLA to set goals and later to review progress during rehabilitation and at follow-up.

The LCI is easily administered (self-administered, face-to-face, or telephone interview) and may be completed in 5 minutes. Respondents are asked to indicate the statements that best describe their situation at the moment the LCI is filled out. The LCI is composed of 4-point ordinal scales and provides an aggregated score for the 14 items. Each item is scored from 0 (not able to) to 3 (yes alone). A total score of 42 may be calculated and maximum subscores of 21 may be obtained for the basic and advanced capabilities subscales. Franchignoni et al.24 transformed the original scale of the LCI into a 5-level version, the LCI-5. The upper ordinal level of each LCI item "Yes, alone" was split into 2 levels: "Yes, alone, with ambulation aids" (score: 3 points) and "Yes, alone, without ambulation aids" (score: 4 points). Hence, the total score of the index was 56 with maximum subscores of 26. The LCI and LCI-5 were found to be highly and significantly correlated (r = 0.89, p < 0.001).

A new method of presenting results from the LCI has been developed by Geake et al.25 to facilitate interpretation of the scores by the clinicians. A computerized system uses graphical presentation of the capabilities of the patient by items and scores and indicates which of the locomotor activities needs further attention.

The LCI is available in seven languages: Dutch, English, French, Italian, Portuguese, Spanish, and Swedish. All versions were translated using Del Greco's back-translation technique and are valid for research and clinical use.19 The LCI was reported having been used in Iran and Korea,19,26 although no information is available as to the translation technique used in those two countries.

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VALIDITY

CONTENT VALIDITY

The items of the LCI were identified by a team of health professionals and persons with LLA and represent skills facilitating use of the prosthesis.4

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CONSTRUCT VALIDITY

The LCI is part of the Prosthetic Profile of the Amputee (PPA) questionnaire that was tested for construct validity.5 Data confirmed convergence of analogous constructs such as the locomotor capabilities construct of the PPA questionnaire and the daily activities construct of the RNL index. Convergent validity was also evidenced when the LCI was compared with the 2-minute walk test, the Timed Up-and-Go, and the Activity Balance Confidence scale.27

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CONCURRENT VALIDITY

The LCI, the Functional Independence Measure (FIM), and the Amputee Activity score (AAS) were found to correlate significantly (χ2 = 57.28, p < 0.01).28 The LCI also correlated significantly with the Rivermead Mobility Index (Spearman coefficient =0.752), the Timed Walking test (Spearman coefficient =0.667), and the FIM (Spearman coefficient =0.617).24

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SENSITIVITY

Using the LCI, it is possible to discriminate between groups of persons with LLA for cause of amputation, levels of amputation, age, walking distance, ambulation aids, and automatism of gait.5,24,27,29 The sensitivity of the advanced activity subscale is similar to that of the full index. Effect size was computed by Miller et al.,27 and values for the LCI were larger than 0.8, thus implying a good ability to detect differences. Rushton and Miller30 reported medium effect size (value of 4.7); however the latter study included only 10 subjects.

tk;4Ceiling effects are observed with the basic activity subscale, but these appear to be reduced when using scores of the full index, specifically with the scores of the advanced activity subscale.5,29 Ceiling effects were associated with younger, more active amputees. The LCI cannot monitor change in individuals with higher locomotor capabilities. For example, it does not take into consideration the eventual reduced dependency on ambulatory aids. The LCI appears to be more appropriate for active yet elderly amputees with multiple comorbidities. To counteract the ceiling effect, Franchignoni et al.24 used the LCI-5, where the upper ordinal level of the original LCI was split into two levels that identified ambulatory aids users and nonusers. Top scores were reduced by one half, and the variability detected in the person's capabilities increased.

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RELIABILITY

INTERNAL CONSISTENCY

Internal consistency estimates and exploratory factor analysis showed evidence of homogeneity among the 14 items of the LCI.5 A Cronbach alpha of 0.95 was obtained. Two underlying factors, or subscales, were identified, and factor 1 explained 59.1% of the observed variance. The two subscales (each of seven items) were also shown to be internally consistent, with Cronbach alpha coefficients of 0.91 and 0.91, respectively.5 Miller et al.27 and Franchignoni et al.24 confirmed homogeneity among items of the LCI. Cronbach alpha coefficients were equal to 0.89 and 0.95, respectively. Other analyses using the Rasch Model confirmed homogeneity of the 14 items and the presence of the same two subscales (A.W. Heinemann, personal communication, 2000). The 4-point rating scale was found useful in distinguishing functional levels.

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TEST-RETEST RELIABILITY

To evaluate test-retest reliability of the LCI,4 subjects were asked to complete the LCI twice, 4 weeks apart. This delay was considered long enough to minimize carry-over effects and short enough to expect that the health and functional status of respondents would be stable. Excellent test-retest agreements were obtained for the total score of the LCI (intraclass coefficient = 0.80). Therefore, a high level of agreement exists between the two sets of scores. Excellent correlation (r > 0.75) was also found when each item of the LCI was tested individually for reliability. The reliability of the total score of the LCI was also reported to be high by Miller et al.27 and Franchignoni et al.,24 with intraclass coefficients of 0.88 and 0.98, respectively. Miller et al.27 used a 4-week interval, whereas Franchignoni et al.24 preferred a 1-day interval. Repeatability of the LCI is at a more than acceptable level.

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INTER-RATER RELIABILITY

Inter-rater reliability was not examined because it is not pertinent for self-administration. Inter-rater reliability was not reported for face-to-face or telephone interview and was not demonstrated for evaluators in a clinical setting. Further study is required.

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OUTCOME WITH THE LCI

High scores on the LCI reflect greater locomotor capabilities with the prosthesis and less dependence on external assistance.31 In the province of Québec, 1 to 5 years after discharge, prosthetic users had maintained a high level of independence with the prosthesis and were capable of managing most of the basic and advanced activities with the prosthesis.31 Global scores and basic scores did not differ significantly for people with transtibial and transfemoral amputations, but advanced scores did. The advanced activities most often reported by prosthetic users as “cannot do” were climbing and descending stairs without handrails, walking outdoors on uneven ground, and walking during inclement weather.31 These results were corroborated by other authors.23,24

Nonusers were found to have significantly lower global scores than prosthetic users, in particular for advanced activities.31 The difficulties reported by nonusers were also those reported by transfemoral amputees. Transfemoral amputees were shown to have significantly (p < 0.005) more difficulties than transtibial amputees with five of the seven advanced activities: picking up objects from the floor (Figure 5), going up and down stairs without handrails, carrying objects while walking with the prosthesis, and walking outside in inclement weather. All the difficulties identified concerned activities performed in an open environment where the amputee must predict and adapt rapidly to environmental changes or activities requiring greater stability and motor control because the center of mass is critically moved over and out of the base of support. Hence, people with scores on the advanced activities subscale equal to or lower than 6 may be at risk of eventual nonuse of the prosthesis in the years after discharge. Special attention should be given to the identified difficult activities during rehabilitation. Yet, at follow-up, the LCI measures perception of a capacity and not the actual performance of the LLA. As Franchignoni et al.24 argued, it would be interesting to assess the actual difference between capability and performance.

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CONCLUSION

The PPA is a valid and reliable instrument to assess prosthetic use and to help understand the predisposing, enabling, and reinforcing factors associated with prosthetic use or nonuse. Domains investigated concern the physical condition, the prosthesis, adaptation to the amputation and the prosthesis, and the physical and social environment. It is a follow-up questionnaire, but it may be used at discharge from the rehabilitation center to measure the evolution of the lower limb amputation condition over time after rehabilitation. The LCI, which is part of the PPA, evaluates locomotor capabilities of the fitted lower limb amputation. It encompasses two underlying constructs: basic and advanced locomotor capabilities. It was initially developed for follow-up but is currently used in daily clinical practice. Global and partial scores may be derived for rapid display and interpretation of the results. Both the PPA and LCI are available in several different languages.

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REFERENCES

1. Breakey JW. Body image: the lower-limb amputee. J Prosthet Orthot 1997;9:58–66.
2. Gailey RS, Roach KE, Applegate EV, et al. The Amputee Mobility Predictor: an instrument to assess determinants of the lower-limb amputee's ability to ambulate. Arch Phys Med Rehabil 2002;83:613–627.
3. Callaghan BG, Sockalingam S, Treweek SP, Condie E. A post-discharge functional outcome measure for lower limb amputees: test-retest reliability with trans-tibial amputees. Prosthet Orthot Int 2002;26:113–119.
4. Grisé MCL, Gauthier-Gagnon C, Martineau GG. Prosthetic profile of people with lower extremity amputation: conception and design of a follow-up questionnaire. Arch Phys Med Rehabil 1993;74:862–870.
5. Gauthier-Gagnon C, Grisé MC. The Locomotor Capabilities Index: content validity.. J Rehabil Outcomes Meas 1998;2:40–46.
6. Hart DL. Orthotics and Prosthetics national office Outcomes Tool (OPOT): initial reliability and validity assessment for lower extremity prosthetics. J Prosthet Orthot 1999;11:101–111.
7. O’Reily C. Orthotics and prosthetics users’ survey (OPUS) ready for nation-wide testing in 2001. Capabilities January 2001; pp 5–9.
8. O’Reilly P. OPUS: orthotics and prosthetics users’ survey outcome measures of O & P services. Capabilities Autumn 2002; pp 5–13.
9. O’Reilly P, Heinemann AW, Body RK. Development and measurement properties of the Orthotics and Prosthetics Users’ Survey (OPUS): a comprehensive set of clinical outcome instruments. Capabilities Summer 2003; pp 4–8.
10. Legro MW, Reiber GD, Smith DG, Del Aguila M. Prosthesis evaluation questionnaire for persons with lower limb amputations: assessing prosthesis-related quality of life. Arch Phys Med Rehabil 1998;79:931–939.
11. Gauthier-Gagnon C, Grisé MC. Prosthetic profile of the amputee questionnaire: validity and reliability. Arch Phys Med Rehabil 1994;75:1309–3914.
12. Hagberg K, Branemark R, Hagg O. Questionnaire for persons with a transfemoral amputation (Q-TFA): initial validity and reliability of a new outcome measure.. J Rehabil Res Dev 2004;41:695–706.
13. Bilodeau S, Hébert R, Desrosiers J. Questionnaire sur la satisfaction des personnes amputées du membre inférieur face à leur prothèse: développement et validation. Occup Ther 1998;66:23–31.
14. Gallagher P, MacLachlan M. Positive meaning in amputation and thoughts about the amputated limb. Prosthet Orthot Int 2000;24:196–204.
15. Green LW, Kreuter MW, Deeds SG, Partridge KB. Health Education Planning, a Diagnostic Approach. Palo Alto: Mayfield Publishing; 1980.
16. World Health Organization. ICIDH: International Classification of Impairments, Disabilities and Handicaps. A manual of classification relating to the consequences of disease. Geneva: WHO: 1980.
17. World Health Organization. ICF: International Classification of Functioning, disability and health. Geneva: WHO; 2001.
18. Dillman DA. Mail and Telephone Surveys, the Total Design Method. New York: Wiley and Sons; 1978.
19. Del Greco L, Walop W, Eastridge L. Questionnaire development: III: translation. Can Med Assoc J 1987;136:699–700.
20. Saeedi H. Prodisposing factors related to prosthetic use by men with a traumatic transtibial and transfemoral amputation. Paper presented at the Int Soc Prosthet Orthot 11th World Congress. Hong Kong, China, August 1–6, 2004.
21. Wood-Dauphinee SL, Opzoomer MA, Williams JI, et al. Assessment of global function: the Reintegration to Normal Living index. Arch Phys Med Rehabil 1988;69:583–590.
22. Gauthier-Gagnon C, Grisé MC. Predisposing factors related to prosthetic use by people with a transtibial and transfemoral amputation. J Prosthet Orthot 1998;10:99–109.
23. Streppel KRM, De Vries J, Van Harten WH. Functional status and prosthesis use in amputees, measured with the Prosthetic Profile of the Amputee (PPA) and the short version of the Sickness Impact Profile (SIP68). Int J Rehabil Res 2001;24:251–256.
24. Franchignoni F, Orlandini D, Ferriero G, Moscato TA. Reliability, validity, and responsiveness of the Locomotor Capabilities Index in adults with lower-limb amputation undergoing prosthetic training. Arch Phys Med Rehabil 2004;85:743–748.
25. Geake T, Hanspal R, Wertheim D, Fulton J. The Stanmore-Kingson Splat: the Locomotor Capability Index in diagram form for goal setting in the rehabilitation of lower limb amputee. Paper presented at the Int Soc Prosthet Orthot 11th World Congress, Hong Kong, China, August 1–6, 2004.
26. Kim JH, Chung SG, Han TR. Gait function, use and satisfaction with prostheses among unilateral transtibial amputees: preliminary study using telephone interview. Paper presented at the Int Soc Prosthet Orthot 11th World Congress, Hong Kong, China, August 1 to 6, 2004.
27. Miller WC, Deathe AB, Speechley M. Lower extremity prosthetic mobility: a comparison of 3 self-report scales. Arch Phys Med Rehabil 2001;82:1432–1440.
28. Panesar BS, Morrison P, Hunter J. A comparison of three measures of progress in early lower limb amputee rehabilitation. Clin Rehabil 2001;15:157–171.
29. Treweek SP, Condie ME. Three measures of functional outcome for lower limb amputees: a retrospective review. Prosthet Orthot Int 1998;22:178–185.
30. Rushton PW, Miller WC. Goal attainment scaling in the rehabilitation of patients with lower-extremity amputations: a pilot study. Arch Phys Med Rehabil 2002;83:771–775.
31. Gauthier-Gagnon C, Grisé MC, Potvin D. Enabling factors related to prosthetic use by people with transtibial and transfemoral amputation. Arch Phys Med Rehabil 1999;80:706–713.
Keywords:

amputation; artificial limbs; lower extremity; outcome assessment; psychometrics; rehabilitation

© 2006 American Academy of Orthotists & Prosthetists