Audrey Zucker-Levin

Background: Walking aids for non-weightbearing (NWB) ambulation are often arbitrarily provided with no evidence that physical assessment predicts ambulatory performance. Purpose: We sought to determine if convenient physical assessment measures could guide NWB walking aid prescription and to determine how age impacts ambulatory performance. Methods: This prospective randomized crossover study examined 22 healthy adults, recruited from Saskatoon, Saskatchewan, and surrounding area through flyers and word of mouth. Inclusion criteria were independent unrestricted community dwellers with no self-reported neuromusculoskeletal or cardiovascular conditions who were age 18 years or older. Participants were stratified into 2 age cohorts: younger (age <50 years) and older (age ≥50 years). Physical assessment measures included triceps and latissimus dorsi strength, single lower-limb balance, and arm endurance. Performance measures included distance traversed, rate of perceived exertion, and peak stance limb plantar force (SLPF) evaluated among 4 walking conditions: unaided, NWB with crutches, standard walker, and wheeled knee walker. Two analyses were performed, one using the entire sample population and another split by age. Results: There were no differences in physical assessment measures between the younger and older cohort, yet distance traversed in the older cohort was highly dependent on all physical assessment measures when using crutches or a standard walker. Peak SLPF was reduced in the younger cohort when using the wheeled knee walker, but not in the older cohort. In the younger participants, reducing peak SLPF was highly dependent on arm endurance when using a standard walker or crutches and latissimus dorsi strength when using the wheeled knee walker. Surprisingly, older participants with stronger latissimus dorsi strength reported a higher rate of perceived exertion when using the wheeled knee walker compared to other devices. Conclusion: Arm strength, single lower-limb balance, and arm endurance should be considered when prescribing walking aids in older adults, and the wheeled knee walker should be considered in younger adults in need of reduced peak SLPF. Level of Evidence: Level III, prospective randomized comparative study.

Canada lacks a national data source on individuals with limb loss and limb difference (LLD), which limits understanding of incidence, prevalence, risk factors, etiology, and healthcare outcomes. In the absence of standardized data collection, the provision of LLD healthcare services in Canada remains inconsistent. The objective of this study was to gather key interest groups’ perspectives on the development of a Canadian LLD registry. Invitees were identified through professional networks and snowball recruitment techniques. A two-round modified Delphi approach was utilized to identify key LLD registry domains via a pre-meeting survey followed by a virtual workshop on February 14, 2024. Of 96 invitees, 53 completed the survey, and 64 attended the workshop (63 from Canada and 1 from the United States). Five key LLD registry domains were identified: representation, standardization, practice-based evidence, research and innovation, and policy and funding. Inclusivity of diverse populations, national outcome measures adoption, and integration of psychosocial and clinical data was emphasized. Foreseen challenges included privacy concerns, necessary infrastructure, and resources to ensure long-term sustainability. Despite these challenges, a Canadian LLD registry could support advocacy, strengthen practice-based evidence, enhance research collaboration, improve clinical care, and inform population-level policies. Efforts to develop the registry are ongoing. Layman's Abstract Canada currently lacks a national registry of individuals with limb loss and limb difference (LLD), which limits our understanding of how many Canadians have limb loss or limb difference, and the effectiveness of healthcare services. Without consistent national data collection, it is impossible to understand regional differences in care, including prosthetic interventions and rehabilitation. This initiative gathered insights from representatives of the LLD community on establishing a Canadian LLD registry to improve research, healthcare delivery, and advocacy. Ninety-six LLD experts and professionals were identified to participate in a two-stage process that included a survey and virtual workshop. Fifty-three individuals (55%) completed the survey. On February 14, 2024, 64 (67%) individuals (63 Canadian and 1 American) attended the virtual workshop. The workshop included presentations on the development of the American Limb Loss and Preservation registry and the Canadian Rick Hansen Spinal Cord Injury registry, and measuring Canadian LLD outcomes. The meeting explored the feasibility, vision, and strategies for creating a Canadian LLD registry. Findings from the survey and workshop showed strong support for the registry, and workshop attendees discussed a number of critical areas for its development and sustainability. While some challenges regarding privacy, infrastructure, and sustainability still need to be addressed, there was agreement among meeting attendees on a strategy to start planning a registry. A Canadian registry would support advocacy efforts, enhance clinical care, encourage collaborative research, and provide essential data about care nationwide to ensure that the health and social care needs of the LLD community are met. Work is continuing to create and fund a Canadian LLD registry. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/46909/34865 How To Cite: Mayo A.L, Hitzig S.L, Zidarov D, MacKay C, Kaufman K.R, Noonan V.K, et al. A national strategy for a Canadian limb loss and limb difference registry. Canadian Prosthetics & Orthotics Journal. 2026; Volume 9, Issue 1, No. 3. https://doi.org/10.33137/cpoj.v9i1.46909 Corresponding Author: Dr. Amanda L. Mayo, MD, MHSc, FRCPC, Affiliations: 1) St. John’s Rehab, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; 2) St. John’s Rehab Research Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; 3) Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.E-Mail: amanda.mayo@sunnybrook.caORCID ID: https://orcid.org/0000-0001-7061-2529

Low back pain (LBP) is a common cause of activity limitation in individuals that can result in socioeconomic costs up to $200 billion per year. Most cases of LBP lack a known underlying pathology. The L4/L5 motion segment is the most impaired lumbar segment, likely due to high load-bearing function. The ability to model L4/L5 compressive loading from surface electromyography (sEMG) data during dynamic activity may add to the understanding of LBP. Eight volunteers with no history of LBP participated in this study. Muscle activity of the erector spinae, rectus abdominus, and external obliques were recorded by a wireless EMG system (Trigno, Delsys, Natick, MA, USA) during a straight-leg stoop-to-stand task. L4/L5 compressive loading was estimated using a subject-specific sEMG model and validated by comparison with an AnyBody model and publicly available data from OrthoLoad. A specific trendline showed a significant decrease in percent error of estimated force for all muscles. Significantly lower impulse values were estimated by the AnyBody model than the sEMG subject-specific model (p = 0.007). Although our sEMG model was subject to high variability, loading values largely remained within those reported in the literature. Significant variation was found comparing the sEMG model with the AnyBody model, which may validate continued development and testing of personalized measurements of L4/L5 loading.

Background: Diabetes-related lower limb amputation (LLA) is a leading cause of disability globally, impacting individuals’ physical and mental health, and ultimately their quality of life. Physical activity can reduce risk of chronic disease and mortality while improving quality of life. However, people with LLA often have reduced balance and walking ability resulting in sedentary behaviour. We co-created a physical activity intervention, IMproving Physical Activity through Coaching and Technology following Lower Limb Loss (IMPACT-L3), to support physical activity behaviour change in people with dysvasular LLA. To date, no studies have assessed a peer-led physical activity behaviour change intervention for people with LLA. Prior to launching a large trial, a pilot study is required to assess feasibility and optimize design of a future trial. Methods: This pilot study is a parallel group randomized controlled trial (RCT) with an embedded qualitative component. The intervention group will have access to once-weekly virtual peer coaching sessions with a peer trained in brief action planning; web-based physical activity modules; and a wearable activity monitor for 8 weeks. The control group will continue usual care and be offered the intervention at the end of the follow-up period. Data on feasibility will be collected including assessment of process, resource, management and treatment indicators. The proposed primary outcomes will be measured at baseline, post-intervention and one month later: total physical activity counts per day measured by the ActiGraphTM activity monitor and self-efficacy measured by the Self-efficacy for Exercise scale. Secondary measures include patient reported outcome measures of physical activity, mobility, depression, social participation, balance confidence and quality of life. Semi-structured interviews will explore feasibility and acceptability of the intervention to participants and peers. Discussion: This study will inform the design of a definitive RCT to determine the effectiveness of a peer-led physical activity intervention for people with dysvascular LLA.

Background: The clinical landscape of limb loss rehabilitation across Canada is poorly delineated, lacks standard rehabilitation guidelines, and is without a shared clinical database. Objective: To address these gaps, the objective of the present study was to undertake an environmental scan of the rehabilitation centers across Canada that provide inpatient and/or outpatient services to the limb loss community. Study Design: An environmental scan was conducted to describe the rehabilitation service structure, program services, and outcome measures of sites across Canada. Methods: A survey was sent to 36 rehabilitation centers providing care to people with amputations. Results: Of the 36 centers, 31 completed the survey (11 = Ontario; 8 = Quebec; 6 = British Columbia; 2 = Saskatchewan; 2 = New Brunswick; 1 = Alberta; 1 = Manitoba). Twenty-five provided both inpatient and outpatient services, 1 provided inpatient care only, and 5 provided only outpatient services. Interprofessional services were provided to a wide range of upper extremity amputation and lower extremity amputation patient populations. Range of motion was the most commonly collected outcome for both patients with upper extremity amputation and lower extremity amputation. With regard to prosthetics and orthotics fabrication, 9 of the sites had these services on-site while 15 had off-site fabricators, 6 had both, and 1 provided no response. Conclusions: Our findings highlight that limb loss rehabilitation and prosthetic care delivery is variable across Canada with respect to clinical team members, locations of services, and complementary services such as mental health treatments and peer support groups.

A knee ankle foot orthosis (KAFO) may be prescribed to the person with severe neuromusculoskeletal impairment of the lower limb to promote walking stability. The locked knee ankle foot orthosis (L-KAFO) is among the KAFO's routinely prescribed; however, long-term use of the L-KAFO is associated with musculoskeletal (arthrogenic and myogenic) and integumentary changes, and gait asymmetry with increased energy expenditure. Consequently, the risk of developing low back pain, osteoarthritis of the lower limbs and spinal joints, skin dermatitis, and ulceration increases, all of which impact quality of life. This article synthesizes the iatrogenic biomechanical and physiological perils of long-term L-KAFO use. It promotes using recent advances in rehabilitation engineering to improve daily activities and independence for proper patient groups.

Changing demographics in a population may have an inevitable influence on disease incidence including limb amputation. However, the extent to which these changes affect limb amputation (LA) is unknown. Understanding the impact of changing demographics on LA would provide the best opportunity to plan for the future. We assessed the impact of changes in age and sex on limb amputation in Saskatchewan between 2006 and 2019. Retrospective linked Saskatchewan’s LA cases, and demographic characteristics and residents population from 2006–2019 was used. The amputation rate was calculated by dividing the total number of LA cases recorded each year by the annual Saskatchewan resident population and the results expressed per 100,000 populations. Furthermore, decomposition analysis was used to assess the impact of changes in age and sex on LA in a decade (2008–2017) and the Generalized Additive Model (GAM) was employed to examine the linear and non-linear effect of age. We found that in the ten years (2008–2017), the absolute LA rate difference was 9.0 per 100,000 population. Changes in age structure alone contributed 7.7% to the LA rate increase and 92.3% to changes in age-specific LA rates. The decade witnessed a marginal population difference between males and females, but the LA rate was 2.1–2.2 times higher in males than in females. The GAM revealed a non-linear relationship between LA and age, and further indicates that the risk of LA significantly increased as age increases. In a decade, we found that changes in age distribution and age-specific rate substantially impacted the increase in the LA rate observed in the province. This highlights the urgent need for strategized programs to respond to these changes as both the population and diabetes, which is age-dependent and a leading cause of LA, are expected to increase in the province by 2030. As changes in population and demographic factors are inevitable, this study provides data for policy makers on the need for continuous incorporation of the shift in population in the design of future health services.

There is a lack of high-quality evidence about the effects of exercise or physical activity interventions for adults with lower limb amputations (LLAs). A planning meeting involving stakeholders (i...

Background. Knowledge translation (KT) models that represent an individuals perspective are a sign of effective KT. Some common challenges in KT include participant engagement, organization of the team, and time demands of the participants. We implemented a unique tripartite KT program to (1) share current research, (2) inform persons living with multiple sclerosis (pwMS) about the clinical research process, and (3) invite pwMS to immediately participate in clinical research. The primary aim was to determine participants perspectives on the value and acceptability of an experiential research program offered at a patient and family educational conference. Methods. A team of researchers identified factors that would impact the logistics of hosting an experiential research program at a conference and designed a unique tripartite KT program. The local multiple sclerosis (MS) society was engaged to select an appropriate location and invite stakeholders to the conference. A survey to determine participants perspectives on the value and acceptability of the experiential research program was developed and analyzed. Results. 65 pwMS attended the conference, and 44 (67.7) participated in the on-site experiential research program. 72.7 of the participants completed the survey, of which 93.8 stated that they strongly agree or agree with the following statements: Did you feel like participating in research today was a valuable experience to you? and Did you feel like you were contributing to MS research? 100 of the participants agreed or strongly agreed when asked would you like to see more research activities taking place at these kinds of events? Conclusions. This paper describes the logistics and challenges of conducting an experiential KT program, which proved to be rewarding for pwMS. The majority of pwMS attending the conference agreed to participate in the on-site experiential research program and an overwhelming majority of participants felt the experience was valuable.

Young adults often tolerate the increased energy expenditure, coordination, and stance limb discomfort associated with walking aids for nonweightbearing ambulation. Adults aged ≥50 years may not have the same tolerance. Therefore, the objective of this study was to determine how walking aid selection affects stance limb plantar force, walking speed, perceived exertion, and device preference in adults aged ≥50 years. A prospective randomized crossover study was performed using healthy adults, aged ≥50 years, with no use of walking aids within 5 years. Participants walked 200 m in 4 randomized conditions: single nonweightbearing ambulation using crutches, a walker, a wheeled knee walker, and unaided walking. An in-shoe sensor measured stance limb plantar force, a stopwatch timed each walk, perceived exertion was reported using the BORG CR-10 scale, and device preference was identified. Twenty-one participants (7 male; age: 56 ± 5 years; BMI: 26.6 ±1.9) showed stance limb plantar force was lowest when using a wheeled knee walker (P < .001). Walking speed was similar in unaided and wheeled knee walker conditions (1.41 and 1.31 m/s), but slower with crutches or a walker (42%-68%, P < .001). Perceived exertion was similar in unaided and wheeled knee walker conditions (1.6 and 2.8), but higher with crutches or a walker (5.7 and 6.1, P < .001). Most (20/21) participants preferred the wheeled knee walker. Using a wheeled knee walker for nonweightbearing ambulation reduced stance limb plantar force, maintained unaided walking speed and perceived exertion, and was preferred to crutches or a walker. Level II, comparative study.