Sheila Clemens

Background and Objective: This study investigates gender differences in mobility, quality of life (QoL), and self-esteem among individuals with unilateral lower limb amputation in Iran, with a focus on mediating roles of education, self-esteem, and time since amputation. Study Design: In this cross-sectional study, 100 participants (52 women, 48 men) completed validated measures assessing locomotor function locomotion capability index, QoL (12-item short form survey), and self-esteem (Rosenberg Self-Esteem Scale). Result: The sample consisted of 100 individuals (52 women, 48 men) with 44 ± 16 mean age for women and 45 ± 15 years for men. Mean years of education was 9.36 years an average duration of 13.32 years since amputation. Regarding the level of amputation, most participants had below-knee amputations (61%), followed by above-knee (21%), knee (11%), ankle (5%), and hip (2%) amputations. The primary causes of amputation were trauma (57%). Although no significant gender differences were found in mobility or overall QoL, women reported significantly lower self-esteem than men. Higher education levels were linked to enhanced self-esteem and better QoL. Mediation analyses revealed that gender influenced QoL indirectly through self-esteem, education, and time since amputation. Specifically, self-esteem was a key mediator linking gender to mental health outcomes, with women’s lower self-esteem associated with reduced QoL. Conclusion: These findings suggest that cultural and societal factors in Iran may disparately affect women’s psychological adjustment to amputation. The study highlights the importance of gender-sensitive rehabilitation strategies that address self-esteem and other aspects of psychosocial well-being for women with amputation in Iran.

Background: Ideally, an individual will undergo rehabilitation to optimize functional abilities with a prosthetic leg after lower-limb amputation (LLA). Using standardized outcome measures capable of capturing changes in prosthetic mobility provides the clinical utility necessary to evaluate treatment efficacy. Objective: To assess the potential of the component timed-up-and-go (cTUG) in evaluating changes in basic prosthetic mobility tasks after a structured prosthetic training program. Study Design: Retrospective cohort. Methods: Pre- and post-intervention data was analyzed from individuals referred to a prosthetic training program. Specific subtasks of cTUG were assessed (the 180° turn and sit-to-stand transitions), as well as the total time to perform the test. Results: Complete data from 85 adults with unilateral LLA were analyzed. The study sample consisted of 75.3% of individuals with acquired LLA because of dysvascular causes, and 41.2% had transfemoral amputation. Individuals with transtibial amputation exhibited significantly faster performance of cTUG subtasks and total times than those with transfemoral amputation (P < 0.02). Stratified by amputation level, both groups exhibited significantly better cTUG scores upon final performance compared with initial performance in all subtasks and total time (P < 0.01). Furthermore, comparing cTUG times based on insurer (public or private insurance), individuals with private insurance generally outperformed those with public insurance, although significance varied based on amputation level. Conclusions: cTUG exhibits the ability to capture changes in basic prosthetic mobility in individuals with varied causes and levels of LLA, enhancing confidence in the clinical utility of the test for measuring efficacy of interventions.

Purpose: Investigate the prevalence of pelvic floor disorder symptoms in males and females with unilateral lower limb amputation. Methods: This was a cross-sectional survey-based study. Study surveys were administered online through a study-specific Qualtrics site and participants accessed surveys from the privacy of their own environment. The Pelvic Floor Distress Inventory-20 was utilized to determine the presence and severity of pelvic floor disorder symptoms. Both traditional and contemporary methods of scoring were utilized in reporting results, with the newer scoring method offering a severity of distress classification. Results: Respondents were 135 individuals with unilateral lower limb amputation who utilize a prosthetic limb for daily mobility. Preliminary results indicate that 98% of participants are experiencing some level of distress from pelvic floor disorder symptoms. Additionally, 71.9% of participants reported previous medical treatment for low back pain and 59.3% reported falling in the past year. Correlation between traditional and contemporary scoring techniques was strong (r_s = 0.97, P < .001). Female participants, and those with previous low back pain or falls presented with significantly higher scores (P < .01). Discussion: This is the first study to explore the magnitude of pelvic floor disorders in males and females with lower limb amputation. Results indicate that a high percentage of individuals with unilateral major leg amputations are experiencing some level of distress due to pelvic floor symptoms, with concomitant reports of low back pain and falls. Continued investigation is warranted to further identify the effects of pelvic floor symptoms on functioning and quality of life.

Employment status is considered a determinant of health, yet returning to work is frequently a challenge after lower limb amputation. No studies have documented if working after lower limb amputati...

Background: Over a million people live with lower limb amputation (LLA) in the United States, and many of them will experience a fall in the next year. The aim of this study was to use existing theoretical frameworks in an attempt to organize the complex interactions of reported fall history and prosthetic mobility in community-ambulating people with LLA. Methods: Self-reported fall rate and fall circumstances were recorded in a cross-section of people with unilateral LLA due to nondysvascular causes. Self-report and performance-based standardized outcome measures assessed prosthetic mobility and balance confidence. All variables were considered and appropriately placed within a proposed International Classification of Functioning, Disability, and Health framework while using a fall-type classification framework to classify fall circumstances. Results: Information from 69 participants was analyzed. The reported fall rate was at 46%, with those with transfemoral amputation reporting significantly more falls than those with transtibial amputation (P = 0.001). Tripping over an object was the most common cause (62.5%), and fallers reported significantly lower perceived prosthetic mobility than nonfallers (P = 0.001). Despite reporting high levels of balance confidence, results indicate that all groups of fallers and nonfallers are at increased fall risk according to performance-based prosthetic mobility score cutoffs. Conclusions: Community-dwelling people with nondysvascular LLA are at increased fall risk. Classifying fall-related variables using theoretical frameworks provides a means to structure more informative fall risk surveys for people with LLA in an attempt to identify those at greater risk for falling and its potential detrimental effects.

Introduction: Telehealth is an increasingly common approach to improve healthcare delivery, especially within the Veterans Health Administration and Department of Defense (DoD). Telehealth has diminished many challenges to direct access for clinical follow-up; however, the use of mobile telehealth for specialty rehabilitative care is emerging and is referred to as telerehabilitation. As early adopters of telehealth, the Veterans Affairs and DoD have supported collaborated efforts for programs designed to increase the access and quality of rehabilitative care while improving the functional ability of our service members (SMs) and veterans with lower limb amputation (LLA). The DoD and Veterans Health Administration collaborated on a Mobile Device Outcomes-based Rehabilitation Program (MDORP) to help injured SMs and veterans with LLA. The MDORP project utilized a mobile health system called the Rehabilitative Lower Limb Orthopedic Accommodating Device (ReLOAD) to assess walking quality. The ReLOAD system includes real-time auditory biofeedback to notify the user of their most prominent gait deviation and then recommends exercises that address specific balance and strength impairments. The purpose of this study was to describe the responses to a postintervention survey evaluating the feasibility and usability of ReLOAD completed by SMs and veterans with LLA who used the system for 5 months. Materials and Methods: A link to an anonymous usability survey was emailed to all participants who completed MDORP. The survey was modeled after the System Usability Scale, with agreeableness to items rated on a 5-point Likert-style questionnaire in addition to open feedback. Data visualization of Likert-style questionnaires was conducted using ggplot2 and reshape2 statistical packages and was analyzed using R. We obtained institutional review board approval through both Miami Veterans Affairs Healthcare System and Walter Reed National Military Medical Center. Results: The majority of participants reported that they would use the system again for home rehabilitation (65%) and that auditory biofeedback helped them walk better (59%). Participants also suggested that future work should include a greater variety of exercise options and the use of smart phones for the ReLOAD application in addition to the iPad tablet. Conclusions: The participants provided positive and constructive feedback that will enhance the value and usability of telerehabilitation interventions like the ReLOAD system for future users.

Purpose of Review People living with lower limb amputation are at an increased risk of falling compared with the healthy geriatric population. Factors of increased age and increased number of comorbidities could compound the already increased risk. The purpose of this article is to highlight recent research associated with fall risk in amputees and provide the reader with evidence to help guide clinical interventions. Recent Findings Though research on the topic of falls in people with amputation is becoming more common, there is still a dearth of evidence regarding what contributes to increased fall risk and how to address it in this population. There are recent studies that have examined therapy and prosthetic interventions that could mitigate fall risk in people with amputation, yet there is not enough evidence to develop a consensus on the topic. More research is required to determine what contributes to increased fall rates in people with amputation, and what detriments to an amputee’s function or psyche may result after incurring a fall. Summary Borrowing from what is known about geriatric fall risk and combining the information with novel and existing approaches to fall mitigation in amputees can offer clinicians the opportunity to develop evidence-based programs to address fall risk in their patients with lower limb amputation.

Objective: The modified Clinical Test of Sensory Interaction and Balance (mCTSIB) is used to clinically assess vestibular sensory integration (VSI), the process by which the central nervous system integrates vestibular afference to maintain balance. The rate and effects of impaired VSI (IVSI) on prosthetic mobility in people with lower limb amputation (LLA) is unknown. The objective of this study was to use the mCTSIB to classify VSI in active community ambulators with LLA and to examine the relationship between IVSI and prosthetic mobility, as measured by the Component Timed Up and Go (cTUG) test. Methods: This was a cross-sectional study with a convenience sample of 130 community ambulators with unilateral LLA. Classification of VSI was determined based on a time-based pass/fail mCTSIB performance. Participants were classified as having normal sensory integration (NSI) if they could balance for 30 seconds in every mCTSIB condition. Participants who failed condition 4 exclusively were classified as IVSI. Prosthetic mobility, as measured by the cTUG, was compared between NSI and IVSI groups. Results: Of the 130 participants, 29 (22%) were classified as IVSI and 95 (73%) were classified as having NSI. Prosthetic mobility significantly differed between IVSI and NSI groups, with IVSI participants performing all components of the cTUG significantly slower. Medium to large effect sizes were found between groups during cTUG. Conclusions: These results suggest that 1 in 5 community ambulators with LLA have IVSI, with associated limitations in balance confidence and prosthetic mobility. Impact: The ability to integrate vestibular information was found to have a strong relationship with prosthetic mobility in active community ambulators with LLA, especially with performing a 180-degree step turn. Physical therapists can use the mCTSIB to classify sensory integration during prosthetic rehabilitation and develop an appropriate balance intervention. Lay Summary: Active adults with LLA can use information from their senses to maintain their standing balance. Adults with LLA who have difficulty balancing on foam with closed eyes were slower to get in and out of a chair, walk, and perform a 180-degree step turn.