Laura A. Swink

To explore behavioral risk factors contributing to fall and near-fall scenarios for Veterans with dysvascular lower-limb amputation. Participants were a convenience sample of Veterans with unilateral dysvascular lower-limb amputation, receiving care at a single Veterans Administration Regional Amputation Center, who participated in an interview (12/2021-04/2023). We used phenomenological research and directed content analysis to explore participant perspectives on fall scenarios. Two frameworks informed a priori codes (The Health Action Process Approach, and the Falls-Type Classification Framework); however, analysis was also inductive, with additional codes emerging. Following an independent and iterative coding process, codes were categorized, and patterns identified to create final themes. Twenty-one veterans completed interviews. Five themes were identified that were salient across a behavioral fall risk factor spectrum from low to high: self-efficacy, trust in the prosthesis, dual-task awareness, participation, and emotional regulation, and one theme pertaining to context surrounding the index fall. Different levels of behavioral fall risk factors exist for Veterans with dysvascular lower-limb amputation. Understanding individuals' perceptions of these behavioral risk factors is important as a first step in developing comprehensive fall-risk management rehabilitation interventions for Veterans with amputation.

Date Presented 03/23/24 Adults with dysvascular lower limb amputation fell into mutual interference or cognitive priority trade-off groups when going from single to dual tasking. There were no significant differences between repeated-fall (n = 15) and nonfall (n = 10) groups. Primary Author and Speaker: Laura A. Swink Contributing Authors: Kathryn A. Nearing, Elizabeth A. Juarez-Colunga, Arlene Schmid, Prudence Plummer, Cory L. Christiansen

Blood flow restriction (BFR) combined with low-load resistance training could minimize exercise barriers and offer strength and mobility improvements for people with advanced Multiple Sclerosis (MS); but patient experience has not been evaluated. The purpose of this study was to assess the satisfaction, acceptability, and impact of combining low-load resistance training with BFR for individuals with advanced MS (Expanded Disability Status Scale: EDSS 6.0-7.0). We used an interpretive phenomenological research design and post-intervention interviews to explore participant experiences of a novel low-load resistance training program with BFR. Interview participants (n = 14) were 55.4 ± 6.2 years old and were diagnosed with MS for 19.1 ± 10.7 years. Four themes were identified (satisfaction, acceptability, impact, program refinement) with 14 subthemes. Satisfaction was mixed based on overall expectations, yet all participants recommended the intervention. Acceptability was evidenced by all participants identifying comfortable/easy aspects, and modifiable elements that could improve comfort. Impact was evidenced with translation to everyday life activities, strength/self-efficacy/psychological improvements, effectiveness, and fatigue reduction. Participants found BFR combined with low-load resistance training to be satisfactory (mixed initial expectations), acceptable (comfortable/easy), and impactful (translating to life improvements). Areas for program refinement were identified that should be targeted in future iterations.

Background: After lower limb amputation, several prosthesis design options exist. However, prosthesis design decisions do not always reflect a prosthesis user’s needs, values, and preferences. Objective: To develop a patient decision aid (PDA) prototype for prosthetists and new prosthesis users facing prosthesis design decisions after lower limb amputation, and to assess its usability, accuracy, and comprehensibility. Study design: Exploratory mixed methods. Methods: PDA development was informed by a qualitative needs assessment and guided by the International Patient Decision Aid Standards. The PDA was evaluated by steering groups of experienced prosthesis users and prosthetic professionals (prosthetists and researchers) to test usability, accuracy, and comprehensibility through focus groups, individual interviews, and rating on a Likert scale ranging from 1 to 10. Results: The resulting PDA included 6 sections: (1) Amputation and Early Recovery, (2) Communication, (3) Values, (4) Prosthesis Design, (5) Preferences, and (6) Prosthetic Journey. Usability, accuracy, and comprehensibility were rated as 9.2, 9.6, and 9.6, respectively, by prosthetic professionals, and 9.4, 9.6, and 9.6, respectively, by prosthesis users. Discussion: The PDA incorporated guidance by relevant stakeholders and was rated favorably, emphasizing a need for shared decision-making support in prosthesis design. One challenge was determining the amount of information in the PDA, highlighting the diversity in end users’ informational needs. Future iterations of the PDA should undergo beta testing in clinical settings. Conclusions: A standardized, iterative method was used to develop a PDA for new lower limb prosthesis users and prosthetists when considering prosthesis design decisions. The PDA was considered useable, accurate, and comprehensible.

Objective: The aim of this study was to understand therapist-identified factors influencing clinical adoption of a telehealth walking self-management intervention for individuals with lower limb amputation. Methods: Semi-structured focus groups were completed with actively practicing physical and occupational therapists treating populations that are medically complex. A qualitative explorative design was employed with conventional content analysis and iterative independent parallel coding using 2 analysts. Themes and subthemes were generated with a consensus building process identifying patterns and collapsing codes to represent participant perspectives. Results: Thematic saturation was met after 5 focus groups (24 therapists). Therapists were on average 34 years old and predominantly female (n = 19; 79%) physical therapists (n = 17; 71%). Three primary facilitator and barrier themes were identified for intervention adoption: system, therapist, and person. System considerations included telehealth support and interprofessional care coordination. Therapist facilitators included self-management programming that overlapped with standard of care and personalization methods. However, limited behavioral theory training was a therapist level barrier. Finally, person factors such as patient activation could influence both positively and negatively. Person facilitators included social support and barriers included the complex health condition. Conclusion: System, therapist, and person facilitators and barriers must be considered to maximize the adoption of similar telehealth walking self-management interventions and prior to larger scale implementation of the current intervention for individuals with lower limb amputation. Impact: A telehealth walking self-management intervention has potential impact for individuals with lower limb amputation and must be considered in terms of optimizing system, therapist, and person level facilitators and barriers to implementation.

Objective: This randomized controlled superiority trial will determine if an 18-month telehealth walking exercise self-management program produces clinically meaningful changes in walking exercise sustainability compared to attention-control education for veterans living with lower-limb amputation. Methods: Seventy-eight participants with lower-limb amputation (traumatic or nontraumatic) aged 50 to 89 years will be enrolled. Two groups will complete 6 one-on-one intervention sessions, and 6 group sessions over an 18-month intervention period. The experimental arm will receive a self-management program focusing on increasing walking exercise and the control group will receive attention-control education specific to healthy aging. Daily walking step count (primary outcome) will be continuously monitored using an accelerometer over the 18-month study period. Secondary outcomes are designed to assess potential translation of the walking exercise intervention into conventional amputation care across the Veteran Affairs Amputation System of Care. These secondary outcomes include measures of intervention reach, efficacy, likelihood of clinical adoption, potential for clinical implementation, and ability of participants to maintain long-term exercise behavior. Impact: The unique rehabilitation paradigm used in this study addresses the problem of chronic sedentary lifestyles following lower-limb amputation through a telehealth home-based walking exercise self-management model. The approach includes 18 months of exercise support from clinicians and peers. Trial results will provide rehabilitation knowledge necessary for implementing clinical translation of self-management interventions to sustain walking exercise for veterans living with lower-limb amputation, resulting in a healthier lifestyle.

Date Presented 04/02/2022 The goal of this qualitative study was to understand barriers and facilitators influencing adoption of the Dysvascular Amputation Self-management of Health (DASH) program. DASH was designed to maximize participation in daily physical activity via targeted self-management of step count. We completed focus groups with OTs and physical therapists to understand DASH adoption, and they identified facility-, clinician-, and patient-level factors to consider for larger scale implementation. Primary Author and Speaker: Laura A. Swink Contributing Authors: Laura A. Swink, Meredith L. Mealer, Matthew J. Miller, Chelsey B. Anderson, Paul F. Cook, Jennifer E. Stevens-Lapsley, Cory L. Christiansen

Background: Prosthesis design is complex and multiple appropriate options exist for any individual with lower-limb amputation. However, there is insufficient evidence for guiding decision-making. Shared decision-making (SDM) offers an opportunity to incorporate patient-specific values and preferences where evidence is lacking for prosthesis design decisions. To develop resources to facilitate SDM, and consistent with the International Patient Decision Aid Standards, it is necessary to identify the decisional needs of prosthetists and prosthesis users for prosthesis design decisions. Objectives: To assess the needs of prosthetists and new prosthesis users for SDM about the first prosthesis design. Study design: Qualitative descriptive design. Methods: Six focus groups were conducted with 38 prosthetists. Individual semistructured interviews were conducted with 17 new prosthesis users. Transcripts were analyzed using directed content analysis, with codes defined a priori using existing frameworks for SDM: the Three Talk Model for SDM and the Ottawa Decision Support Framework. Results: Four main themes were identified among prosthetists and prosthesis users: acknowledging complexity in communication, clarifying values, recognizing the role of experience to inform preferences, and understanding the prosthetic journey. Conclusions: Resources that support SDM for the first prosthesis design should consider methods for identifying individual communication needs, support with clarifying values, and resources such as experience for achieving informed preferences, within the context of the overall course of rehabilitation and recovery following lower-limb amputation. The themes identified in this work can inform SDM to promote collaborative discussion between prosthetists and new prosthesis users when making prosthesis design decisions.

Date Presented Accepted for AOTA INSPIRE 2021 but unable to be presented due to online event limitations. We completed a pilot study of an 8-week Merging Yoga and Occupational Therapy for Parkinson's Disease program (MY-OT for PD). MY-OT for PD was a fall-risk self-management program that merged community-based yoga and group OT. Participants served as their own controls during the pilot study. During the intervention period (as compared with the control period), participants experienced reduced self-reported falls, improved fall management and prevention, and improved balance. Primary Author and Speaker: Laura A. Swink Contributing Authors: Brett Fling, Julia L. Sharp, Christine A. Fruhauf, Karen Atler, and Arlene Schmid

The purpose of this study was to assess feasibility and changes in outcome measures following the Merging Yoga and Occupational Therapy for Parkinson’s Disease (MY-OT for PD) program: a 14-session program which combined community-based yoga for PD, and fall-risk focused group occupational therapy sessions. Seventeen participants completed an 8-week control period consisting of their normal participation, and an 8-week intervention period (14 MY-OT for PD sessions). There were fewer self-reported falls in the intervention (6) vs. control periods (10). One fall risk factor management scale (the Fall Prevention and Management Questionnaire, p=.02), and balance (p<.01) showed significant improvement between the control and intervention. The MY-OT for PD program is an encouraging occupational therapist-led program, which may improve balance and reduce self-reported falls.