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Major extremity limb amputation is a possible consequence of multiple medical conditions, including cancer, diabetes, peripheral vascular disease, and trauma. In 2005 alone, 890,000 Canadians experienced a major limb amputation; an incidence of 30 per 100,000, with no evidence to suggest that these rates are decreasing.1
Residing in Northern Ontario increases the likelihood of having an amputation to approximately 1.5 times than that of counterparts residing in Toronto.2 This may be, in part, related to the higher incidence of diabetes and vascular diseases in Northwestern Ontario, reduced access to primary and specialty care, and higher rates of other risk factors, such as smoking.2 Higher incidence of diabetes and vascular disease in this area has been linked to the higher population of First Nations people, where there is a known increased relative risk.3 Access to regular care for persons with diabetes is an important predictor of amputation.2
The costs associated with amputation are both economical and social. Economically, losses are experienced in terms of work productivity, health care expenses, and ongoing financial support. Socially, the experiences of emotional suffering and loss are staggering.1
The ultimate goal for many patients after amputation is “to walk with a prosthesis out of the rehabilitation unit.” Prosthetic legs have changed dramatically over the years because of advancements in materials and technology. Many studies have demonstrated successful prosthetic fit rates of 60% to 90% for transtibial (TT) amputees; however, this is reduced to only 50% to 70% for transfemoral (TF) amputees.4 Successful fit of a prosthesis, defined as discharge from rehabilitation with a definitive prosthesis, is reported as a minimal requirement for functional prosthetic use.4 Unfortunately, many TF amputees use their prosthesis in a limited manner.
It has been well established that TF amputees are less successful, have higher energy demands, and are less often able to return to their premorbid functional level than their TT counterparts.5–8 In 1991, 396 lower extremity amputees in the province of Quebec were surveyed using the Prosthetic Profile of the Amputee (PPA) by Gauthier-Gagnon et al.6 Eighty-five percent of the participants reported wearing their prosthesis. However, TF amputees wore their prosthesis significantly less of the day and for fewer functional activities than their TT counterparts. Gauthier-Gagnon et al.6 also found that a greater number of TF amputees (37.7%) compared with TT amputees (8.1%) had discarded their prosthesis in the 5 years after discharge from prosthetic training.
Fletcher et al.9 reinforced the importance of the screening process for successful prosthetic fitting. In their 2001 study, only 36% of amputees were fit successfully as measured by a definitive prosthesis on discharge. Positive predictors for successful prosthetic fitting included having a family member at home and being married. Negative predictors included increased age, presence of dementia, and TF amputation.
In Northwestern Ontario, there is only one prosthetist. This may result in limited access to prosthetic services, including receiving prosthetic modifications as required.
Regardless of the research indicating limited use of the TF prosthesis, there are ethical considerations involved in providing every patient with equal access to rehabilitation and prosthetic training. Cost for rehabilitation is approximately $544.00 per day with an average of a 70-day length of stay for inpatient rehabilitation after amputation.10 Members of the rehabilitation team often question the impact of prosthetic fitting and training, citing significant concerns about the subsequent prosthetic use, safety, and problems encountered after discharge.
Given the literature, access issues, and costs, a need to further explore factors influencing the long-term success of TF amputees in Northwestern Ontario was identified. Before the initiation of this study, little information was available about amputees living in Northwestern Ontario. Patients were generally followed only until 6 weeks after discharge from rehabilitation with no further contact unless they accessed the Amputee Clinic themselves with specific, self-identified concerns. Given the literature indicating the difficulties associated with achieving and maintaining successful mobility with a TF prosthesis, data collection regarding prosthetic use in Northwestern Ontario would provide a better understanding of how regional TF amputees were managing with their prosthesis.
The objectives of the present study were to
- Identify the demographics of current TF prosthetic users in Northwestern Ontario,
- Evaluate the frequency of prosthetic wear in hours per day by TF amputees in Northwestern Ontario,
- Evaluate the extent of functional prosthetic use by TF amputees in their home environment at least 3 months after rehabilitation as measured by both the Locomotor Capabilities Index (LCI) and percentage of active indoor use,
- Determine barriers and enabling factors for functional use of TF prosthesis in Northwestern Ontario, and
- To evaluate the face validity of the PPA in Northwestern Ontario where the environment, pedestrian infrastructure, resources, and culture may be different from that experienced in Quebec as reported by Gauthier-Gagnon et al.5,6,11–13
It was anticipated that the results of the study would direct program development to ensure that patients were being screened appropriately for prosthetic training, and were supported in their efforts to maintain their maximal functional independence at a community level.
This study used an observational, cross-sectional, retrospective design. The dependent variables were defined as prosthetic wear in hours per day and days per week, and functional use of the prosthesis as measured by the LCI and percentage of active use indoors. Participants were recruited by convenience sampling.
Eligible participants were sampled from Northland Prosthetic records of individuals treated between the years 1994–2004 according to the following inclusion criteria: at least 18 years of age, unilateral TF amputation, completion of prosthetic training at least 3 months before the study start date, and having been identified as a prosthetic user upon discharge. Those with bilateral amputation and those who were unable to access telephone services were excluded.
As per ethics review board approval, potential participants were contacted by Northland Prosthetics and asked to give permission to release their personal information for the purposes of this study. Participants were offered the services of a translator as required. Written informed consent was obtained. Data were collected through a number of phone interviews. Interviews were conducted in January and February of 2005. A number of the participants indicated that they would prefer to complete the survey in a written format. Surveys were mailed to these participants and returned via regular mail. A follow-up phone call to clarify data and complete the survey was done as required.
The PPA (Appendix A; available online only) questionnaire was developed by Grise and colleagues.11,12 The PPA evaluates prosthetic use and the factors related to use or disuse. The questionnaire consists of 44 close-ended questions investigating six sections: 1) comorbidities of the amputee, 2) satisfaction and adaptation to the prosthesis, 3) prosthetic use, 4) physical and social environment, 5) leisure activities, and 6) demographic characteristics.11,12 The scales are primarily qualitative, nominal, and ordinal ones with a few quantitative ratio scales. The PPA questionnaire has demonstrated both construct validity and reliability.13
The LCI is part of the PPA. The LCI is an ordinal scale used to evaluate the functional use of the prosthesis. The LCI has demonstrated content validity and face validity,13,14 and has been found to be sensitive to change.15 Basic and advanced subscales have been identified and have been shown to be internally consistent (Appendix B; available online only). The Basic subscale includes functional activities, such as getting up from a chair and walking in the house. The Advanced subscale includes more difficult tasks, such as walking outside in inclement weather and going up and down stairs without a handrail. The LCI does seem to have a ceiling effect that is not as sensitive to those with higher levels of function.16,17 Since the time of data collection for this project, a new scale was devised (LCI-5), which has been reported to reduce the impact of the ceiling effect.18
SPSS version 12.0 was used for data analysis. Means, standard deviations, and minimum and maximum values for all outcomes were calculated to describe the participants. Statistics were also calculated to identify barriers and enabling factors to prosthetic use. It has been previously identified that a composite score cannot be computed for the PPA or the six subsections of the PPA.19 To trace the profile of the person with amputation and sort out the most significant variables related to prosthetic use, associations between the outcome variable and various independent variables may be completed. Therefore, to evaluate the relationship between LCI score and factors such as age, frequency of prosthetic wear, and comorbidities, Pearson correlations and backward linear regression analysis were performed. Qualitative data were independently analyzed by two individuals for themes.
Of 55 TF amputees in Northwestern Ontario, 31 agreed to be contacted and 27 people provided consent and completed the survey. Of the four participants who did not complete the survey, one person was deceased and three were unavailable for contact. To contact each participant, up to three phone call attempts were made, and finally, a written copy of the survey was mailed.
In this population (n = 27), the average age was 66.11 ± 14.93 years (34–88 years of age). The mean time since amputation was 20.93 ± 23.53 years (1–77 years; Table 1). Frequencies were calculated for the reason for amputation, comorbidities, living situation, fall history, financial situation, and educational background.
The reasons for amputation included trauma, vascular, cancer, and congenital factors (Figure 1). Four of the 27 participants lived alone. All participants lived in a residential house or apartment. Fifteen participants had stairs to access their home. Twenty-one participants had experienced at least one fall since discharge home although only nine reported a fall in the last month. The most common comorbidity identified within this group was cardiac disease followed by diabetes and respiratory disease (Figure 2).
FREQUENCY OF PROSTHETIC USE
The average wear time for the group was 9.70 ± 5.73 hours (range, 0–18). Four participants were considered nonusers, and one participant reported being a cosmetic user at the time of the survey. Nonusers were defined as those wearing their prosthesis 0 hours/day whereas cosmetic users were defined as those wearing their prosthesis less than 2 hours/day, less than 3 days/week.
FUNCTIONAL USE OF PROSTHESIS
Twenty-two of the 27 (81.48%) participants used their prosthesis indoors. Sixteen of the 27 (59.30%) participants used their prosthesis for 75% to 100% of the time indoors. Twenty of 27 (74.07%) participants used their prosthesis outdoors, 19 (70.37%) of whom used their prosthesis outdoors 100% of the time. No participant reported walking outdoors without their prosthesis.
The mean LCI score for the population was 34.07/42 ± 11.00 (range, 5–42; Table 2). The Basic and Advanced LCI subset means for the total population were 18.78/21 ± 4.95(range, 3–21), and 15.30/21 ± 6.61(range, 0–21), respectively. For users, the Advanced subset mean was 19.91/21 ± 2.9 (range, 11–21), and for nonusers the Advanced subset mean was 12.25/21 ± 9.1 (range, 3–21). These results indicate a higher functional ability for prosthetic users compared with nonusers.
ENABLING FACTORS AND BARRIERS: PREDICTORS OF LOCOMOTOR CAPABILITIES INDEX SCORE
To determine possible predictors of the LCI score, correlation analysis was performed between the total LCI score and various factors. First, the correlation between the total LCI score and prosthetic wear time in hours per day was tested. It was found to be significant with a Pearson score of 0.639 (p < 0.001). There was no difference between days per week of prosthetic wear time compared with hours per day of prosthetic wear time.
The correlation between the total LCI score and time since amputation was subsequently tested and also found to be significant (r = 0.40, p = 0.04).
Backward regression analysis was then performed to determine the importance of the relationship of the total LCI score to multiple independent variables. The dependent variable was identified as total LCI score, and independent variables included gender, age categories, comorbidities, years since amputation, and hours per day of prosthetic wear time. The regression formula below indicates that total LCI score, representing functional mobility, was related to the age category, time since amputation, and the amount of time the amputee wore the prosthesis. Independent variables gender and comorbidities failed to reach significance. These relationships are shown in Figure 3, with the slope of the lines representing the direction and rate of influence of the three independent variables on the dependent variable, total LCI score. In this sample, functional mobility was predicted by three factors: age, time since amputation, and prosthetic wear time.
Additionally, a negative trend was found between the LCI score and the level of gait aids used for household ambulation; for example, a participant using a walker scored lower on the LCI than one using no gait aids. There was also a negative trend found, which did not reach significance, between the number of comorbidities and the LCI score: those with fewer comorbidities scored higher on the LCI than those with more comorbidities (Figure 4). No correlation was found between distance from the prosthetic office and the LCI score.
As part of the survey, participants were asked, in the telephone interview, to reflect on their personal experience of adapting to prosthetic use. Although replies were varied, they primarily revolved around issues of community barriers to mobility, access to services and funds, personal physical challenges, and concerns about maintaining independence while ageing. A common theme was the importance of acceptance and support of family and friends in the process of adaptation.
“I’m expecting to see them [family] and they don’t come here. I think my family is afraid or can’t accept it. Friends you have . . . I have no more. [It’s] hard to acquire new friends. [I’d] like to get involved with others with a disability.”
“[It’s] all in your attitude. [You] have to decide if you are going to do it and go for it. Things aren’t the same but you have to accept it. It really helps if you have supportive people around you.”
“It’s a shock and a certain amount of denial. Clients need to have a talk with another amputee to explain ‘what to expect’ and it can be overcome.”
“Stairs are difficult on the bus. Major barriers are large snow banks. Grocery shopping is difficult, busy shopping situations are challenging, [it is] hard to step aside, balance is at risk in crowds.”
These concerns highlighted the need for advocacy and counseling in the rehabilitation phase to help identify and develop support systems. The value of peer support from others who have experienced an amputation was also an important component of the adaptation process. These findings were consistent with previous studies, indicating that family support was an important indicator of success in prosthetic use.9
FACE VALIDITY OF THE PROSTHETIC PROFILE OF THE AMPUTEE IN NORTHWESTERN ONTARIO
The PPA was satisfactory in the evaluation of the TF amputee prosthetic use in Northwestern Ontario. It included comorbidities, age factors, an objective outcome measure, and barriers to prosthetic use.
However, the PPA did not look at seasonal differences, which are important in Northwestern Ontario. There is a significant environmental difference between winter with snow and ice and summer with warm weather. Seasonal differences may affect falls, balance confidence, and functional outdoor mobility experienced between summer and winter months.
The population included in this study was similar in age to some reported literature,5,6,8,20 but slightly younger than reported in other literature.17,21 As previously indicated, participants in this study wore their prosthesis for an average of 9.7 hours/day; greater than that reported in a study by Munin et al.20 in which prosthetic mean wear time was 5.7 hours/day, but similar to that of both Gauthier-Gagnon et al.5 and Streppel et al.22 in which 75% of participants wore their prosthesis for more than 9 hours/day. Interestingly, all of the participants in the present study lived in a residential house or apartment. This may have been a contributing factor to their successful use. It has been demonstrated that persons living at home use their prosthesis more extensively for their ambulatory activities, inside and out, compared with people residing in seniors’ homes or chronic care facilities.6
Functional mobility is a standard measure of prosthetic training success. The LCI score and the percentage of indoor prosthetic use are both measures of functional mobility. Community mobility goes beyond ambulation tested in a rehabilitation environment. Community mobility requires the ability to generalize activities to a variety of settings, including carpeted floors, busy environments with pets and toddlers, traffic, and grocery shopping.23 Davies and Datta8 found that only 50% of TF amputees achieved household mobility, and further, that only 29% achieved community mobility. In the Northwestern Ontario group, 59.26% achieved household mobility and 70.37% achieved outdoor mobility. However, this rate also includes those individuals who report walking without a prosthesis indoors, whereas outdoors, they reported using their prosthesis and were unable to ambulate without their prosthesis. Of interest, Streppel et al.22 found similar prosthetic use percentages at 63% for indoor use and 71% for outdoor use.
One of the objectives of this study was to determine factors that influenced the outcome of functional mobility; barriers and supporting factors. This sample, and others reported in the literature, demonstrates that increasing age is one of the most powerful prognostic indicator negatively impacting functional mobility in TF amputees.8,21 The relatively young age of this sample is one possible factor accounting for their high success rate compared with other studies.17,20,21
This sample also consisted of an almost equal percentage of participants with vascular complications and traumatic injury as reasons for amputation (Figure 1). Typically, these persons with traumatic amputation are younger in age and have higher functional mobility than those with vascular amputation.21 This may also account for the higher rate successful prosthetic use in the Northwestern Ontario sample.
Other barriers for prosthetic wear and functional use found in both this and other studies include comorbidities,7 specifically cardiac and respiratory problems.5 Although reported in the literature, this sample did not report arthritic problems on the nonamputated side, long delays in limb fitting, prolonged training, or stump pain to be barriers.5 It is possible that with a larger sample size and a higher number of nonusers, the present study would have found similar results, which are also experienced clinically.
This study found strong enabling factors to be the length of time after amputation and longer daily prosthetic wear time. Other enabling factors found in this sample and the literature included absence of vascular impairment on the residual limb, timely admission to rehabilitation, family and peer support, ability to don the prosthesis, walking capability, walking distance, and automaticity of walking and assistive devices used.5,21
Seasonal differences, specifically inclement winter weather in Northwestern Ontario, need to be considered as a potential factor of successful community mobility. The PPA does not address seasonal differences but clinically, amputees report differences in mobility between summer and winter months. Many amputees have reported limited outdoor mobility during winter, as previously described in the qualitative section of this study. This additional information may alter the impact of the barriers and supports to functional mobility.
The identified supporting factors and barriers, while not clinically surprising, are issues that rehabilitation teams need to address to reinforce and enable successful community mobility, and ultimately, successful community reintegration. Nonmodifiable, predisposing factors such as age, number of comorbidities, and stump pain need to be accounted for when considering appropriate prosthetic candidates. Other reinforcing and enabling factors, such as length of time to prosthetic fit, ability to don prosthesis, prosthetic wear time, automaticity of gait, and use of gait aids, need to be addressed during the rehabilitation and discharge planning phases to promote successful community reintegration outcomes. On the basis of the qualitative component of this study, rehabilitation teams may also want to consider supporting a local amputee support group to help persons with the adaptation phase of postamputation.
LIMITATIONS OF OUR STUDY
Amputation statistics were difficult to obtain because “amputation” is considered a treatment, not a diagnostic category in the International Classification of Diseases. Diagnostic categories on admission or discharge would include examples such as nonhealing ulcer, cellulitis, or diabetes. Consequently, it was difficult to compare this sample of convenience with TF amputees not pursuing prosthetic training.
Recruitment of participants was retrospective. A prospective recruitment strategy may have reduced the potential bias toward successful users. Amputees not successfully wearing their prosthesis may have chosen not to participate because of the small town phenomenon, and familiarity with the rehabilitation team and prosthetist.
The PPA was able to identify the frequency of prosthetic use, and factors that influenced successful functional mobility both negatively and positively. Unfortunately, the PPA was unable to capture the prosthetic user’s ability to reintegrate to normal activities or quality of life issues. Premorbid activity levels, a physical activity index, and a quality-of-life measure would be useful in future studies to determine successful community reintegration. Future studies evaluating the regression equation in a larger population would benefit amputee clinics. There continues to be a need for a valid and reliable algorithm to screen prospective prosthetic candidates.
In summary, the trends found in the analysis of this sample population were consistent with the literature and clinical experience. The functional success of the TF amputee was related to younger age, fewer comorbidities, more time since amputation, and the ability to wear and use the prosthesis for most of the day. Screening prosthetic candidates is necessary to provide cost-effective, ethical rehabilitation in Canada’s universal, public health care system. Once prosthetic training has been initiated, it is the responsibility of the rehabilitation team to support clients in their quest to achieve their maximum potential in functional mobility. This study suggests that rehabilitation teams should carefully consider nonmodifiable, predisposing factors such as age and length of time since amputation. Once the client has been considered a prosthetic candidate, increasing daily prosthetic wear time and consistent use of the prosthesis should be encouraged to maximize successful prosthetic use for those persons with TF amputation.
Advice and support from Dr. William Montelpare, Amanda Maranzan, and Elaine Foster-Seargeant was greatly appreciated. The project would not have been possible without the participation and support from Northland Prosthetics and St. Joseph’s Care Group.
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amputation; leg prosthesis; rehabilitation; outcome measures; rural
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