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Life Habits and Prosthetic Profile of Persons With Lower-Limb Amputation During Rehabilitation and at 3-Month Follow-Up
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ORIGINAL ARTICLE
Life Habits and Prosthetic Profile of Persons With Lower-Limb Amputation During Rehabilitation and at 3-Month Follow-Up Diana Zidarov, PT, MSc, Bonnie Swaine, PT, PhD, Christiane Gauthier-Gagnon, PT, MSc ABSTRACT. Zidarov D, Swaine B, Gauthier-Gagnon C. Life habits and prosthetic profile of persons with lower-limb amputation during rehabilitation and at 3-month follow-up. Arch Phys Med Rehabil 2009;90:1953-9. Objective: To assess performance of life habits among persons with lower-limb amputation at admission, at discharge, and 3 months after rehabilitation discharge and describe their prosthetic profile at discharge and follow-up. Design: Case series. Setting: Inpatient rehabilitation. Participants: Unilateral persons with lower-limb amputation (N⫽19; 14 men; mean age, 53.4⫾14.6y). Intervention: Interdisciplinary rehabilitation. Main Outcome Measures: Life habits performance and prosthetic profile. Results: In the daily activities subdomain, the lowest performances were observed for mobility and housing at all evaluation times. Within the social role subdomain, employment, recreation, and community life scores were the lowest for the 3 evaluations. Mean scores for all activities of daily living subdomain categories significantly increased (P⬍.05) during rehabilitation except for personal care and communication. Only community life (social roles subdomain) significantly increased during rehabilitation; life habits remained unchanged after discharge. Fifty-eight percent of patients at discharge versus 68.4% at follow-up used their prosthesis for more than 9 hours a day, and this increased significantly postdischarge (P⫽.017). Locomotor capability with prosthesis was similarly high at discharge and follow-up. Conclusions: Among persons with lower-limb amputation, social role life habits appear to be more disturbed than those associated with activities of daily living. At discharge, prosthetic wear and locomotor capabilities with prosthesis were high and tended to improve on return to the community. Key Words: Activities of daily living; Amputation; Rehabilitation. © 2009 by the American Congress of Rehabilitation Medicine
From the School of Rehabilitation, University of Montreal (Zidarov, Swaine, Gauthier-Gagnon); Montreal Rehabilitation Institute (Zidarov, Swaine); and Center for Interdisciplinary Research in Rehabilitation of Metropolitan Montreal (Swaine), Montreal, QC, Canada. Supported by the Montreal Rehabilitation Institute Foundation, the Fonds de la recherche en santé du Québec, the Ordre professionnel des physiothérapeutes du Québec, and the Faculté des études supérieures of the Université de Montréal. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated. Correspondence to Diana Zidarov, PT, MSc, 3600 Av. Darlington, Montreal, QC, Canada, H3S 2J4, e-mail: [email protected]. Reprints are not available from the author. 0003-9993/09/9011-00983$36.00/0 doi:10.1016/j.apmr.2009.06.011
HE ULTIMATE AIM of rehabilitation programs is to T return persons with lower-limb amputation to their own environments and to enable them to regain the ability to accomplish usual life habits as independently as possible in order to achieve optimal social participation. Thus, to assess the overall effectiveness of rehabilitation, one must determine whether and how persons with lower-limb amputation accomplish their usual life habits after rehabilitation. Life habits are defined as the daily activities and social roles that ensure the survival and development of a person in society throughout the person’s life.1 Daily activities refer to basic and advanced activities of daily living. Basic ADLs such as transfers, feeding, and dressing have been assessed with persons with lowerlimb amputation using the BI2,3 and the FIM.4-7 In general, these studies have shown significant gains from admission to discharge during rehabilitation3,5-7 but not between discharge and follow-up.4 Furthermore, both tools present high scores at discharge, indicating ceiling effects.2-4 With regards to advanced ADLs such as domestic chores, leisure activities, gainful work, and household/car maintenance, the FAI8 has been used with persons with lower-limb amputation. The mean FAI score obtained with persons with lower-limb amputation (n⫽53; mean age, 70y) with peripheral vascular disease as the main cause of amputation (81.1%) was 16.8 of 45,9 where a score of 20 or higher could indicate a very good level of independence after the rehabilitation program. In a more recent study10 assessing the biometric properties of the FAI with persons with lower-limb amputation, higher scores were recorded (mean score, 29.1 of 45), but 59.5% of the sample was composed of young, traumatic amputees, amputated between 0 and more than 5 years previously (mean age, 56.5y; n⫽84). Together, these studies revealed that average FAI scores were low, and even lower in vascular and older persons with lower-limb amputation. Globally, the BI, FIM, and FAI evaluate either basic or advanced ADLs, not both, and do not cover all usual life habits. However, rehabilitation programs encompass many interdisciplinary interventions whose common ultimate goals are to attain optimal accomplishment of usual life habits, basic as well as advanced. Furthermore, none of these scales offers specific information about the impact of a lower-limb amputation on a person’s social roles (ie, family responsibilities or interpersonal relationships), nor do they consider the impact of the use of a prosthesis or the environmental adaptations in the
List of Abbreviations ADLs BI FAI LCI LIFE-H PPA
activities of daily living Barthel Index Frenchay Activity Index Locomotor Capabilities Index Assessment of Life Habits Prosthetic Profile of the Amputee
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LIFE HABITS OF PERSONS WITH LOWER-LIMB AMPUTATION, Zidarov
performance of life habits. For example, a person with lowerlimb amputation responsible for meal preparation (ie, who assumes this social role) may be independent in performing a cooking activity when using a wheelchair because the kitchen counters are lowered (eg, the person sits in wheelchair to cut vegetables) and openings have been made under the sink (eg, to wash the dishes), yet may stand with the prosthesis when cooking on the stove. The tool developed by Noreau et al,11 LIFE-H, documents the person’s performance in daily activities and social roles, hence it documents the quality of social participation. However, the LIFE-H was not developed specifically for persons with lower-limb amputation and generally considers the use of prosthesis as an assistive device. Because prosthetic training is an important component of rehabilitation to help persons with lower-limb amputation resume their previous life habits, an amputee-specific measure should be used concurrently with the LIFE-H to document accurately the daily use of the prosthesis. To our knowledge, there are no longitudinal studies describing the accomplishment of life habits of persons with lowerlimb amputation during and after receiving inpatient rehabilitation. The combination of a generic tool assessing usual life habits, like the LIFE-H, with a specific tool assessing the use the prosthesis, like the PPA, will give complementary information that should accurately assess these major rehabilitation outcomes. The objectives of the present study were (1) to assess the performance of life habits of persons with lower-limb amputation at admission, at discharge, and 3 months after discharge from inpatient rehabilitation; and (2) to describe their prosthetic profile at discharge from rehabilitation and 3 months later. METHODS Study Sample This exploratory longitudinal study was conducted with persons with lower-limb amputation who were consecutively admitted to the Montreal Rehabilitation Institute in Quebec, Canada, for inpatient rehabilitation between September 2005 and December 2006. Patients received an individualized program from a multidisciplinary team. This program includes daily physical and occupational therapy for preprosthetic and prosthetic training and psychologic support to the patient and the family. Additional family support and sociovocational orientation is provided by a social worker, and leisure activities are offered in and out of the rehabilitation center. Inclusion criteria were (1) being 18 years or older and having a unilateral transtibial or transfemoral amputation from any cause except congenital, (2) having sufficient cognitive skills and comprehension of French or English to be able to complete the questionnaires accurately, and (3) being admitted for a first prosthetic training. This last criterion was meant to reduce the effects of confounding variables caused by multiple admissions and prosthetic trainings (eg, subsequent amputation of the residual limb or amputation of the contralateral lower limb). The research protocol was approved by the Research Ethics Committee of the Center for Interdisciplinary Research in Rehabilitation, of which the Montreal Rehabilitation Institute is a site. Subjects signed an informed consent form prior to participating. Procedure Data using the tools described in this article and other quality of life tools (results presented elsewhere12) were collected at 3 Arch Phys Med Rehabil Vol 90, November 2009
times: on admission to the inpatient rehabilitation program (T1), at discharge (T2), and at 3-month follow-up (T3). All data were collected using questionnaires administrated during interviews conducted by the same evaluator (D.Z.), a senior physical therapist with over 10 years of experience. Information was also extracted from the patient’s medical chart: age, highest level of completed education, level and date of amputation, duration of prosthetic training, duration of rehabilitation stay, associated medical conditions, and marital and employment status at the time of amputation. Measurement Instruments Assessment of life habits. The LIFE-H is a generic questionnaire whose concept was based on the Disability Creation Process.1 This instrument evaluates a person’s social participation by measuring performance in carrying out life habits in terms of difficulty and assistance required.11 In this study, we used the shortened version of the tool (LIFE-H 3.1) composed of 77 items covering the 12 categories of the Disability Creation Process nomenclature: nutrition, fitness, personal care, communication, housing, mobility, responsibility, interpersonal relationships, community life, education, employment, and recreation. The first 6 categories refer to the daily activities subdomain, while the remainder refer to social roles. In the present study, items concerning education were excluded because no one was a student. Scoring is done using a 10-level continuous scale based on the degree of difficulty (no difficulty or with difficulty) and the type of assistance needed (no assistance, assistive device, adaptation, human assistance) by the person to perform each life habit in the person’s current environment. Scores for each item range from 0 to 9 where 0 indicates that the life habit is not accomplished and 9 indicates that it is performed without difficulty and without assistance. A score for each category (mean of applicable items) as well as a total score (mean of all applicable items) and subscores for daily activities and social roles can be calculated. The validity and the reliability of the LIFE-H were demonstrated to be acceptable with various populations with and without disabilities (eg, persons with spinal cord injury, persons with traumatic brain injury, older adults with and without functional limitations).11 Even if the psychometric properties of the LIFE-H were not studied with persons with lower-limb amputation, the items contained in this tool appear to be directly related to persons with lower-limb amputation rehabilitation goals and the clinical interventions provided to attain them. In this study, the LIFE-H was administrated by an interview lasting 30 to 45 minutes. Prosthetic profile of the amputee. The PPA is a conditionspecific questionnaire developed to determine the predisposing, enabling, and facilitating factors potentially related to prosthetic use of the persons with lower-limb amputation.13,14 The factors were operationalized into 44 close-ended questions grouped into 6 sections: physical condition, prosthesis, prosthetic capabilities, environment, leisure activities, and demographic characteristics. The PPA was originally developed and validated in French and English and can be administrated by mail or interview. The PPA is a follow-up instrument, but most of the sections are applicable at discharge from the rehabilitation center.15 The validity and reliability of the PPA have been fully reported and seem acceptable for clinical and research use.14 Construct validity of the PPA was demonstrated compared with analogous constructs of the Reintegration of Normal Living (r⫽.56 –.64; P⬍.01).14 Test-retest reliability for categorical data was good: Cohen kappa varied from .46 to .84.14 To evaluate the ambulatory skills of persons with lower-limb amputation with the prosthesis, an index of locomotor capabil-
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LIFE HABITS OF PERSONS WITH LOWER-LIMB AMPUTATION, Zidarov Table 1: Clinical and Sociodemographic Characteristics of the Sample (Nⴝ19) Variable
Cause of amputation Vascular Traumatic Tumor Infection Marital status Married/committed Single Divorced/widowed Education Primary Secondary Postsecondary Employment status at the amputation Employed Retired
n
Frequency (%)
12 3 2 2
63.2 15.8 10.5 10.5
9 5 5
47.4 26.3 26.3
2 10 7
10.5 52.7 36.8
12 7
63.2 36.8
Variable
Mean ⫾ SD
Range
Age (y) Duration of rehabilitation stay (d) Duration of prosthetic training (d)
53.4⫾14.6 84.3⫾23.3 49.2⫾19.2
26–78 59–146 29–105
ities (LCI) was developed (question 11 of the PPA). The LCI has a maximum score of 42 and contains 2 subscales (basic and advanced capabilities). A higher score indicates greater locomotor capabilities with the prosthesis. Because the PPA is an extensive questionnaire covering various aspects, which makes it lengthy, with the permission of authors, only items about the condition of the stump, the locomotor capabilities, the prosthetic use, and leisure activities were selected (questions 4, 6, 7, 10 –14, 16, 18, 19, 21, 33–39). Data Analysis Descriptive statistics were computed for the continuous variables (age, duration of stay and prosthetic training, LIFE-H scores, hours of prosthetic use), while frequency and percentages were calculated for categorical variables mostly found in
the PPA. Changes in LIFE-H scores for each category, the 2 subdomains, and the total scores at the 3 evaluation times were examined using a 1-way repeated-measures analysis of variance with time of measurement as a within-subjects factor. When significant results were obtained (P⬍.05), post hoc comparisons were performed using the Bonferroni correction for multiple comparisons. Paired t tests examined differences in the mean number of hours of prosthetic use between discharge and follow-up. All analyses were performed with SPSS version 14.0 for Windows.a RESULTS Demographic and Clinical Variables Of the 114 persons with LLA admitted to the program during the study period, only 29 (26%) met the eligibility criteria. Of the 85 remaining, 30% were readmissions, 34% had a bilateral amputation, 11% insufficiently understood French or English, 16% had important cognitive or psychiatric problems, and 9% were not considered potential prosthetic wearers. Of the 29 eligible subjects, 6 (21%) refused to participate, 1 died at follow-up, and 3 had an unplanned discharge. Data for the 3 evaluation times were obtained for 19 participants. Table 1 summarizes their clinical and sociodemographic characteristics. Fourteen were men, and 16 had a transtibial amputation. Prior to admission, 52.6% were hospitalized in acute care centers, while 47.4% were at home, waiting to be admitted to rehabilitation. Comorbidities were as follows: 52.6% had hypertension, 42.1% had visual problems, 21.1% had hearing problems, and 26.3% had chronic kidney failure. The mean duration of stay and the mean duration of prosthetic training did not significantly differ (P⬎.05) according to level of amputation or cause of amputation. Assessment of Life Habits Data related to the degree of accomplishment of life habits are presented by category for the 3 evaluation times (table 2). Concerning the ADLs subdomain, the lowest degree of performance was observed for the mobility (3.91– 6.22) and housing (3.68 – 6.50) categories at all 3 evaluation times. Personal care activity scores (eg, body washing, dressing, using bathroom) were high even on admission. Similar results were found for
Table 2: Life Habits Mean Scores (of 9) Obtained for 11 Categories of the LIFE-H at Admission, Discharge, and 3-Month Follow-Up
Daily activities Nutrition Fitness Personal care Communication Housing Mobility Daily activities subscore Social roles Responsibility Interpersonal relations Community life Employment Recreation Social roles subscore Total score
Admission Mean ⫾ SD (n⫽23)
Discharge Mean ⫾ SD (N⫽19)
3-Month Follow-Up Mean ⫾ SD (n⫽19)
P*
5.70⫾2.11 7.04⫾1.17 7.63⫾1.00 7.95⫾1.38 3.68⫾2.19 3.91⫾2.11 6.21⫾1.12
7.43⫾1.73 8.04⫾0.74 8.10⫾0.75 8.45⫾0.57 5.90⫾1.68 5.13⫾1.95 6.10⫾0.46
8.06⫾0.98 8.21⫾1.00 8.09⫾0.88 8.35⫾0.87 6.50⫾1.22 6.22⫾1.65 6.10⫾0.39
⬍.001 ⬍.001 .018 .025 ⬍.001 ⬍.001 .500
7.63⫾1.64 8.09⫾0.94 3.75⫾3.14 1.41⫾2.17 1.86⫾2.45 4.70⫾1.25 5.52⫾1.06
7.63⫾1.86 8.19⫾0.91 6.41⫾2.48 1.63⫾2.21 3.18⫾2.47 5.79⫾1.38 6.62⫾0.95
8.66⫾0.66 8.18⫾1.18 7.27⫾1.48 3.42⫾2.74 5.45⫾2.54 6.89⫾0.99 7.26⫾0.68
.038 .400 ⬍.001 .014 .001 ⬍.001 ⬍.001
*P associated with analysis of variance. Significant results indicate differences in scores across the 3 evaluation periods.
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LIFE HABITS OF PERSONS WITH LOWER-LIMB AMPUTATION, Zidarov
Table 3: Pairwise Comparisons for Significant Analysis of Variance Results Pertaining to the Difference Between Mean Scores for Different Categories of the LIFE-H (Nⴝ19) Mean Difference (T2 – T1) (P)
Daily activities Nutrition Fitness Personal care Communication Housing Mobility Daily activities subscore Social roles Responsibility Interpersonal relations Community life Employment Recreation Social roles subscore Total score
95% CI
Mean Difference (T3 – T2) (P)
95% CI
Mean Difference (T3 – T1) (P)
95% CI
1.44 (.008) 1.08 (.02) NS NS 2.34 (.002) 1.63 (.022) NS
0.35–2.54 0.19–1.97 NS NS 0.84–3.84 0.21–3.06 NS
NS NS NS NS NS NS NS
NS NS NS NS NS NS NS
2.04 (.001) 1.18 (.001) NS NS 2.73 (⬍.001) 2.53 (⬍.001) NS
0.83–3.25 0.46–1.90 NS NS 1.47–4.00 1.36–3.70 NS
NS NS 3.41 (.001) NS NS 1.45 (.003) 1.28 (⬍.001)
NS NS 1.34–5.48 NS NS 0.47–2.44 0.59–1.96
NS NS NS NS NS NS NS
NS NS NS NS NS NS NS
0.94 (.038) NS 4.03 (⬍.001) 2.36 (.013) 3.46 (.002) 2.37 (⬍.001) 1.79 (⬍.001)
0.05–1.84 NS 2.10–5.95 0.49–4.23 1.21–5.71 1.61–3.13 1.29–2.28
Abbreviations: CI, confidence interval; NS, not significant.
social roles related to responsibilities and interpersonal relationships. Scores for the employment, recreation, and community life categories were the lowest for the 3 evaluations times within the social role subdomain. Globally, when looking at the subscores, after a lower-limb amputation, the accomplishment of social roles was more restricted than the accomplishment of ADLs and this, up to 3 months after returning to the community. During rehabilitation (between admission and discharge), mean scores for all of the categories in the ADLs subdomain significantly increased except for the personal care and communication categories, which were already high at admission (table 3). Only the mean scores for community life of the social roles subdomain significantly increased during rehabilitation. Globally, there was a significant increase in the mean total scores of the LIFE-H and in the social roles subscores during rehabilitation. Performance of life habits did not change between discharge and follow-up. Prosthetic Profile of the Amputee Descriptive statistics of the prosthetic profile of the sample at discharge and follow-up are presented in table 4. The most frequently reported problem with the nonamputated leg for both evaluation times was poor circulation (42.1%, n⫽8 at T2; 31.6%, n⫽6 at T3). Phantom pain was experienced by 63.2% (n⫽12) and 57.9% (n⫽11) of the patients at discharge and follow-up, respectively. The more frequent problem caused by the use of the prosthesis at discharge was an increase in stump pain (31.6%; n⫽6), while at follow-up, skin irritation was more problematic (26.3%; n⫽5). More than 90% of subjects could don their prosthesis without difficulty at discharge and at follow-up. Ninety-five percent (n⫽18) wore their prosthesis daily at discharge versus 90% (n⫽17) at follow-up. Fifty-eight percent of patients (n⫽11) at discharge versus 68.4% (n⫽13) at follow-up used their prosthesis for more than 9 hours a day. Furthermore, there was a significant increase in the number of hours of prosthetic use a day between discharge and follow-up (t⫽2.64; df⫽17; P⫽.017). The locomotor capability scores with the prosthesis (basic and advanced) were high at discharge and follow-up and did not differ significantly. At discharge, 63% of patients Arch Phys Med Rehabil Vol 90, November 2009
(n⫽12) used their prosthesis for more than 75% of their indoor activities and 53% (n⫽10) for more than 75% of their outdoor activities. At follow-up, these percentages were 58% (n⫽11) and 90% (n⫽17), respectively. Forty-two percent of patients (n⫽8) did not need a walking aid indoors at discharge, while
Table 4: Descriptive Statistics Pertaining to Subjects’ Prosthesis Profile at Discharge and Follow-Up (Nⴝ19)
Prosthetic wear Days/week Hours/day LCI LCI basic (/21) LCI advanced (/21) LCI total (/42) Standing and/or walking around 0–50% 75–100% Assistive devices used indoors Walker Crutches 2 Canes 1 Cane None Assistive devices used outdoors Walker Crutches 2 Canes 1 Cane None Distances walked outside without stopping Between 10 and 30 steps ⬎30 Steps but less than 1 block 1 Block Not limited in the walking distances NOTE. Values are mean ⫾ SD or n (%).
Discharge
Follow-Up
6.8⫾0.9 8.1⫾3.6
6.8⫾0.5 11.0⫾3.5
19.5⫾3.2 15.6⫾7.0 35.1⫾9.6
20.5⫾2.1 17.6⫾6.2 38.1⫾7.8
16 (84.2) 3 (15.8)
17 (89.4) 2 (10.6)
6 (31.6) 2 (10.5) 1 (5.3) 2 (10.5) 8 (42.1)
3 (15.8) 0 0 4 (21.1) 12 (63.2)
6 (31.6) 3 (15.8) 3 (15.8) 4 (21.1) 3 (15.8)
3 (15.8) 0 0 10 (52.6) 6 (31.6)
2 (10.5) 1 (5.3) 10 (52.6) 6 (31.6)
0 1 (5.3) 7 (36.8) 11 (57.9)
LIFE HABITS OF PERSONS WITH LOWER-LIMB AMPUTATION, Zidarov
this number grew to 63.2% (n⫽12) at follow-up. A walker was the most frequently used assistive device for indoor walking at discharge, while 1 cane was most frequently used at follow-up. At discharge, most patients could walk at least 1 block (5– 6 houses) without stopping, while at follow-up, most reported not being limited in their walking distances. Concerning the number of falls, at discharge, only 2 (10.5%) patients reported falling with their prosthesis during rehabilitation, while the number of patients who fell once home doubled (21.1%). Regarding leisure activities, at both evaluation periods, only 47.4% (n⫽9) of patients were practicing physical activities (eg, walking, fishing, swimming, cycling), yet all patients had some type of recreational activity (eg, reading, watching television, playing cards, arts and crafts, social events). Finally, at discharge, 73.6% (n⫽14) of patients reported that they were quite well adapted or completely adapted to the amputation, while at follow-up, this percentage increased to 79% (n⫽15). Seventy-nine percent of patients (n⫽15) at discharge reported being well adapted or completely adapted to their prosthesis; the percentage dropped to 74% (n⫽14) at follow-up. DISCUSSION To our knowledge, this is a first study to report in a detailed way the accomplishment and the evolution of life habits of persons with lower-limb amputation during and after a period of intensive inpatient rehabilitation. Use of the LIFE-H enabled us to identify, for our sample, the life habits that could and could not be accomplished without major difficulties after a lower limb amputation. With regards to the daily activities domain, patients’ performances were lowest in the mobility and housing categories, and mostly on admission. However, performance improved significantly thereafter. At admission, the low performance in mobility was likely a result of the chronic impairment caused by the lower-limb amputation, while the improvement observed at discharge could be a result of the interventions received during rehabilitation. In fact, during their rehabilitation stay, all patients were trained, according to their abilities, in unipodal ambulation with assistive devices and wheelchair mobility, and thereafter received prosthetic training. The low score for the housing category at admission may be explained by a lack of mobility at that time and mostly because any typically required adaptation to a patient’s home had not yet begun. Indeed, during inpatient rehabilitation, occupational therapists assess the accessibility (in and outdoor) of a patient’s residence and recommend adaptations that are, for the most part, completed by discharge. Persons with lower-limb amputations are only slightly restricted in the degree of accomplishment of their personal care activities, as shown by the high scores obtained at the 3 evaluation time points. Similarly high scores were obtained by Panesar et al4 with 34 inpatient persons with lower-limb amputation using the FIM. The grooming, bathing, dressing, and toileting items of the FIM are similar to those contained in the personal care category of the LIFE-H. In the study by Panesar,4 patients’ median score was 7 of 7 at admission and discharge for grooming and dressing, 5 of 7 at admission, and 6 of 7 at discharge for bathing, and 6 of 7 at admission and discharge for toileting. Patients reported more important restrictions in their performance of social roles, particularly those concerning employment, recreation, and community life. Employment scores were very low and did not change significantly during rehabilitation. This is likely because of the mission of the intensive rehabilitation center; interventions focusing on vocational evaluation and integration are not provided, and patients with
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vocational needs are referred to other rehabilitation centers specializing in this domain. In our sample, 12 patients were employed at the time of the amputation and were subsequently referred to vocational rehabilitation at discharge. This explains the significant increase in employment mean scores at follow-up and the significant change in these scores between admission and follow-up. Participation in recreation activities remained low at admission and at discharge. It was surprising that there were no significant changes in scores except between admission and follow-up despite the numerous recreational activities offered to patients during their rehabilitation stay. In fact, structured recreational activities (eg, bowling, outings to museums and cinemas) are offered regularly by the recreation therapy department, and once a month, an interdisciplinary team member also attends the activity to provide specific interventions related to mobility, walking endurance, and social interaction. However, a close look at the participants’ scores showed that, at admission as well as at discharge, most of the 7 items in the leisure category were not accomplished yet. In fact, when an activity is not accomplished but is part of the usual life habits of the person, a score of 0 of 9 is given. Furthermore, 2 items refer to travel-related or outdoor recreational activities (eg, hiking, camping), which obviously patients could not have accomplished at admission or at discharge. Low scores for these activities tend to lower the scores in the leisure category because these activities could be part of the patient’s usual life habits. These results suggest that maybe more various (indoors and outdoors, artistic, cultural, sports activities) and more frequent recreational activities should be offered to persons with lower-limb amputation during their rehabilitation stay in order to enhance their participation in leisure activities. Community life is another domain in which the participation of the persons with lower-limb amputation was rather low at admission. However, subjects’ scores increased significantly after discharge, reaching a mean score of 7.27 of 9. This is not surprising when one looks at the items contained in this LIFE-H domain. They refer to the ability to go to, walk to, and use public services (eg, banks, stores), all activities requiring a relatively high level of mobility. Therefore, the improvements in the person’s involvement in community life are most likely a result of improvement in mobility outdoors (use of a prosthesis and assistive devices, including use of a wheelchair). Also, existing environmental adaptations in the community were reported by patients (eg, presence of access ramps, automatic doors) to facilitate their activities and mobility in the community. Globally, after a lower-limb amputation, participation in social roles appears to be more restricted compared with the accomplishment of daily activities, and it seems that this limitation may be caused essentially by a lack in mobility. The accomplishment of certain valued social roles (eg, working, going to social events) cannot simply be carried out by others (eg, assistance for cooking, cleaning, toileting) and give the person a sense of fulfillment. Therefore, important restrictions in the accomplishment of such activities may reflect the real consequences of a lower-limb amputation and the impact on a person’s life. Similar results were found by Pell et al,16 who suggest that impaired mobility may account for much of the social isolation reported by amputees, which will result in a negative impact on their overall quality of life. Nissen and Newman17 also found that poor reintegration in daily life after a lower-limb amputation occurred mostly in the areas of participation in recreational and work activities and ambulation in the community. Consequently, inpatient rehabilitation interArch Phys Med Rehabil Vol 90, November 2009
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ventions should include more mobility interventions in real-life environments, such as shopping for groceries or other items or going to the bank, to promote participation in community life. In addition, rehabilitation interventions should include the evaluation and adaptation of important leisure activities for persons with lower-limb amputation, and when not possible, reorientation toward new leisure activities better adapted to their new condition. Currently there is no criterion standard or norm for ideal or optimal participation,18 so clinicians may wonder whether it is realistic to aim for a perfect score (9 of 9) for all life habits when setting patients’ rehabilitation goals. As discussed by several authors, measuring only a person’s performance of life habits without considering which activities or roles the individual values and how the activity is performed by the person in relation to the person’s reality, will not provide an accurate picture of the person’ social participation.18,19 A person’s reality is determined by both personal and environmental factors.19 Receiving assistance when performing a chosen life habit (eg, house cleaning), should not mean that the person has a lower performance than others in this task even if the score is low. On the contrary, receiving assistance to accomplish an activity may enable the person to engage in additional meaningful activities (eg, leisure) that would not have been possible otherwise. Indeed, it is difficult to portray optimal performance accurately with a score. Rather, it should reflect the perfect fit between a person’s reality (how life habits are actually performed) and expectations (how the person wishes to accomplish these life habits). Consequently, a client-centered approach, a core value in rehabilitation, should ideally include the person’s choices about how and which life habits the person wants to accomplish when setting rehabilitation goals. Prosthetic Profile of the Amputee Our results concerning the locomotor capabilities with the prosthesis (LCI scores), and the number of hours a day and the number of days a week that the prosthesis is used, are very similar to those obtained by the authors of the PPA.20 However, in our study, at follow-up, more persons with lower-limb amputation (89.5%) used their prosthesis for 75% or more of their outdoor activities compared with those in the study by Gauthier-Gagnon et al21 (64%). One possible explanation for this difference may be a result of differences in the sociodemographic characteristics of the 2 samples. Our sample was younger (mean age, 53.4y vs 62.3y), with a lower percentage of transfemoral (16% vs 42.4%) and vascular amputees (63.3% vs 76.8%). Several literature reviews22-24 pointed out that advanced age, higher level of amputation, and medical comorbidities are associated with less prosthetic use. Vascular amputees also have more associated medical conditions that can affect their prosthetic use.22,23 Furthermore, fewer subjects (58% at T2 and 68% at T3) used their prosthesis for more than 9 hours daily compared with the Gauthier-Gagnon20 study (75%). As shown in our results, this frequency increased considerably between discharge and follow-up. However, Gauthier-Gagnon’s20 participants had been using their prosthesis 1 to 5 years postdischarge and hence were more experienced prosthetic users. Future studies with longer follow-up periods could possibly identify increases in the number of hours of prosthetic use beyond 3 months postdischarge. Additionally, more subjects in our sample reported not being limited in their distances walked outside without stopping at both evaluation periods (27.5% in the Gauthier-Gagnon20 study). This can again be explained by the characteristics of our sample: younger age, more persons with lower-limb amputation as a result of trauma, cancer, or infection and fewer transfemoral amputees. Finally, adaptation Arch Phys Med Rehabil Vol 90, November 2009
to the amputation and the prosthesis was found to be better (higher scores in our sample). It is not clear why a later decline in this area was observed by Gauthier-Gagnon.20 Similar results regarding prosthetic use were obtained by Streppel et al25 at discharge and 2 months later. The only 2 major differences concern the number of hours a day that the prosthesis was worn (8.1 vs 10.1) and the percentage of patients who wear their prosthesis for more than 9 hours (58% vs 76%), which were both higher in the Streppel25 study. These differences may be related to the fact that the duration of stay in the Streppel25 study was almost doubled (165d vs 84d). Longer rehabilitation stays may imply longer prosthetic training and consequently grater prosthetic ability, which may ultimately lead to a better adaptation and integration of the prosthesis in daily life. Study Limits and Clinical Implications This study was carried out with a small sample of subjects who were candidates for prosthetic fitting and were consecutively admitted to 1 center offering inpatient rehabilitation. Our study did not include measures related to rehabilitation provided beyond this point. The inclusion criteria were relatively stringent. Hence, our results may not be generalizable to the total population of persons with lower-limb amputation, including those who never received a prosthesis. The LIFE-H can be used in clinical settings to set individualized rehabilitation goals for persons with lower-limb amputation, to document their evolution in the accomplishment of their life habits, and to evaluate programs.11 However, the tool can be burdensome to clinicians because the interview can exceed 30 minutes. Furthermore, calculating scores is quite complex; data are gathered and analyzed with software. Our experience with this tool also revealed that persons with lowerlimb amputation have difficulties understanding the questionnaire, particularly the measurement scale. However, once the questionnaire was completed and analyzed, the responses were deemed very useful to the clinical team to set individualized rehabilitation goals. It may be helpful to determine, earlier than usual during the rehabilitation process, the need for assistive devices or adaptations in the person’s home according to the life habits that the person would be performing routinely. The specificity of the PPA provided clinicians with very useful information concerning the prosthetic profile of the person with lower-limb amputation. When used at discharge and at follow-up, the various domains covered by the questionnaire allowed them to detect any deterioration in the prosthetic profile of the patient, enabling the interdisciplinary team to intervene promptly. Because this questionnaire is mostly descriptive (or qualitative) and lengthy, we recommend, with others,25 that team members, with permission from authors, select only the questions related to specific treatment outcomes of interest to them. This will promote its use in clinical practice and for program evaluation. CONCLUSIONS Among persons with lower-limb amputation, life habits associated with social roles appear to be more disturbed than those associated with ADLs. This appears to be true throughout the rehabilitation process and as far as 3 months after returning to the community. During inpatient rehabilitation, performance in ADLs, except the personal care and communication categories, improved significantly, while the accomplishment of social roles did not improve significantly except for the community life category. Our findings thus underscore the importance of focusing care on social role issues, such as community life,
LIFE HABITS OF PERSONS WITH LOWER-LIMB AMPUTATION, Zidarov
recreation, and employment, during rehabilitation of persons with lower-limb amputation. Improving outdoor mobility of persons with lower-limb amputation with appropriate training, including prosthetic training and provision of adequate assistive devices, could enhance their accomplishment of social roles, especially in community life. At discharge, prosthetic wear, active use of the prosthesis indoors and outdoors, and locomotor capabilities with the prosthesis were high and tended to continue improving once the person was back in the person’s own environment. Additionally, most of the patients in this study reported being quite well to completely adapted to their amputation and prosthesis, and this phenomenon seems to improve 3 months after returning home. All patients reported having some sedentary leisure activities, but less than half were involved in sports activities 3 months after returning home. Finally, accomplishment of life habits and prosthetic and locomotor capabilities reflects most of the aims of multidisciplinary interventions offered during the rehabilitation process. As such, the instruments used in this study appear to be promising outcome measures for a rehabilitation program or daily clinical practice. References 1. Fougeyrollas P, Noreau L, Bergeron H, Cloutier R, Dion SA, St-Michel G. Social consequences of long term impairments and disabilities: conceptual approach and assessment of handicap. Int J Rehabil Res 1998;21:127-41. 2. Treweek SP, Condie ME. Three measures of functional outcome for lower limb amputees: a retrospective review. Prosthet Orth Int 1998;22:178-85. 3. O’Toole DM, Goldberg RT, Ryan B. Functional changes in vascular amputee patients: evaluation by Barthel Index, PULSES profile and ESCROW scale. Arch Phys Med Rehabil 1985;66: 508-11. 4. Panesar BS, Morrison P, Hunter J. A comparison of three measures of progress in early lower limb amputee rehabilitation. Clin Rehabil 2001;15:157-71. 5. Muecke L, Shekar S, Dwyer D, Israel E, Flynn JP. Functional screening of lower-limb amputees: a role in predicting rehabilitation outcome? Arch Phys Med Rehabil 1992;73:851-8. 6. Leung EC, Rush PJ, Devlin M. Predicting prosthetic rehabilitation outcome in lower limb amputee patients with the functional independence measure. Arch Phys Med Rehabil 1996;77:605-8. 7. Dodds TA, Martin DP, Stolov WC, Deyo RA. A validation of the Functional Independence Measurement and its performance among rehabilitation inpatients. Arch Phys Med Rehabil 1993;74: 531-6. 8. Holbrook ME, Skilbeck CE. An activities index for use with stroke patients. Age Ageing 1983;12:166-70. 9. Datta D, Ariyaratnam R, Hilton S. Timed walking test—an all embracing outcome for measure for lower limb amputees? Clin Rehabil 1996;10:227-32.
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10. Miller WC, Deathe AB. Measurement properties of the Frenchay Activities Index among individuals with a lower limb amputation. Clin Rehabil 2004;18:414-22. 11. Noreau L, Fougeyrollas P, Vincent C. The LIFE-H: assessment of the quality of social participation. Technol Disabil 2002;14:113-8. 12. Zidarov D, Swaine B, Gauthier-Gagnon C. Quality of life of persons with lower limb amputation during rehabilitation and at 3 month follow up. Arch Phys Med Rehabil 2009;90:634-45. 13. Grisé MC, 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: 862-70. 14. Gauthier-Gagnon C, Grisé MC. Prosthetic profile of the amputee questionnaire: validity and reliability. Arch Phys Med Rehabil 1994;75:1309-14. 15. Gauthier-Gagnon C, Grisé MC. Tools to measure outcome of people with a lower limb amputation: update on the PPA and LCI. Proceedings of the outcome measures in lower limb prosthetics. Chicago: Lippincott Williams and Wilkins; 2005. p 61-7. 16. Pell JP, Donnan PT, Fowkes FG, Ruckley CV. Quality of life following lower limb amputation for peripheral arterial disease. Eur J Vasc Surg 1993;7:448-51. 17. Nissen SJ, Newman WP. Factors influencing reintegration to normal living after amputation. Arch Phys Med Rehabil 1992;73: 548-51. 18. Hammel J, Magasi S, Heinemann A, Whiteneck G, Bogner J, Rodriguez E. What does participation mean? an insider perspective from people with disabilities. Disabil Rehabil 2007;30:1-16. 19. Rochette A, Korner-Bitensky N, Levasseur M. Optimal participation: a reflective look. Disabil Rehabil 2006;28:1231-5. 20. Gauthier-Gagnon C, Grisé MC, Potvin D. Predisposing factors related to prosthetic use by people with a transtibial and transfemoral amputation. J Prosthet Orthot 1998;10:99-109. 21. 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;80:706-13. 22. Pernot HF, De Witte LP, Lindeman E, Cluitmans J. Daily functioning of the lower extremity amputee: an overview of the literature. Clin Rehabil 1997;11:93-106. 23. Kent R, Fyfe N. Effectiveness of rehabilitation following amputation. Clin Rehabil 1999;13(Suppl 1):43-50. 24. Geertzen JH, Martina JD, Rietman HS. Lower limb amputation part 2: rehabilitation—a 10 year literature review. Prosthet Orth Int 2001;25:14-20. 25. Streppel KR, 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;24:251-6. Supplier a. SPPS Inc, 233 S Wacker Dr, 11th Fl, Chicago, IL 60606.
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ORIGINAL ARTICLE
Life Habits and Prosthetic Profile of Persons With Lower-Limb Amputation During Rehabilitation and at 3-Month Follow-Up Diana Zidarov, PT, MSc, Bonnie Swaine, PT, PhD, Christiane Gauthier-Gagnon, PT, MSc ABSTRACT. Zidarov D, Swaine B, Gauthier-Gagnon C. Life habits and prosthetic profile of persons with lower-limb amputation during rehabilitation and at 3-month follow-up. Arch Phys Med Rehabil 2009;90:1953-9. Objective: To assess performance of life habits among persons with lower-limb amputation at admission, at discharge, and 3 months after rehabilitation discharge and describe their prosthetic profile at discharge and follow-up. Design: Case series. Setting: Inpatient rehabilitation. Participants: Unilateral persons with lower-limb amputation (N⫽19; 14 men; mean age, 53.4⫾14.6y). Intervention: Interdisciplinary rehabilitation. Main Outcome Measures: Life habits performance and prosthetic profile. Results: In the daily activities subdomain, the lowest performances were observed for mobility and housing at all evaluation times. Within the social role subdomain, employment, recreation, and community life scores were the lowest for the 3 evaluations. Mean scores for all activities of daily living subdomain categories significantly increased (P⬍.05) during rehabilitation except for personal care and communication. Only community life (social roles subdomain) significantly increased during rehabilitation; life habits remained unchanged after discharge. Fifty-eight percent of patients at discharge versus 68.4% at follow-up used their prosthesis for more than 9 hours a day, and this increased significantly postdischarge (P⫽.017). Locomotor capability with prosthesis was similarly high at discharge and follow-up. Conclusions: Among persons with lower-limb amputation, social role life habits appear to be more disturbed than those associated with activities of daily living. At discharge, prosthetic wear and locomotor capabilities with prosthesis were high and tended to improve on return to the community. Key Words: Activities of daily living; Amputation; Rehabilitation. © 2009 by the American Congress of Rehabilitation Medicine
From the School of Rehabilitation, University of Montreal (Zidarov, Swaine, Gauthier-Gagnon); Montreal Rehabilitation Institute (Zidarov, Swaine); and Center for Interdisciplinary Research in Rehabilitation of Metropolitan Montreal (Swaine), Montreal, QC, Canada. Supported by the Montreal Rehabilitation Institute Foundation, the Fonds de la recherche en santé du Québec, the Ordre professionnel des physiothérapeutes du Québec, and the Faculté des études supérieures of the Université de Montréal. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated. Correspondence to Diana Zidarov, PT, MSc, 3600 Av. Darlington, Montreal, QC, Canada, H3S 2J4, e-mail: [email protected]. Reprints are not available from the author. 0003-9993/09/9011-00983$36.00/0 doi:10.1016/j.apmr.2009.06.011
HE ULTIMATE AIM of rehabilitation programs is to T return persons with lower-limb amputation to their own environments and to enable them to regain the ability to accomplish usual life habits as independently as possible in order to achieve optimal social participation. Thus, to assess the overall effectiveness of rehabilitation, one must determine whether and how persons with lower-limb amputation accomplish their usual life habits after rehabilitation. Life habits are defined as the daily activities and social roles that ensure the survival and development of a person in society throughout the person’s life.1 Daily activities refer to basic and advanced activities of daily living. Basic ADLs such as transfers, feeding, and dressing have been assessed with persons with lowerlimb amputation using the BI2,3 and the FIM.4-7 In general, these studies have shown significant gains from admission to discharge during rehabilitation3,5-7 but not between discharge and follow-up.4 Furthermore, both tools present high scores at discharge, indicating ceiling effects.2-4 With regards to advanced ADLs such as domestic chores, leisure activities, gainful work, and household/car maintenance, the FAI8 has been used with persons with lower-limb amputation. The mean FAI score obtained with persons with lower-limb amputation (n⫽53; mean age, 70y) with peripheral vascular disease as the main cause of amputation (81.1%) was 16.8 of 45,9 where a score of 20 or higher could indicate a very good level of independence after the rehabilitation program. In a more recent study10 assessing the biometric properties of the FAI with persons with lower-limb amputation, higher scores were recorded (mean score, 29.1 of 45), but 59.5% of the sample was composed of young, traumatic amputees, amputated between 0 and more than 5 years previously (mean age, 56.5y; n⫽84). Together, these studies revealed that average FAI scores were low, and even lower in vascular and older persons with lower-limb amputation. Globally, the BI, FIM, and FAI evaluate either basic or advanced ADLs, not both, and do not cover all usual life habits. However, rehabilitation programs encompass many interdisciplinary interventions whose common ultimate goals are to attain optimal accomplishment of usual life habits, basic as well as advanced. Furthermore, none of these scales offers specific information about the impact of a lower-limb amputation on a person’s social roles (ie, family responsibilities or interpersonal relationships), nor do they consider the impact of the use of a prosthesis or the environmental adaptations in the
List of Abbreviations ADLs BI FAI LCI LIFE-H PPA
activities of daily living Barthel Index Frenchay Activity Index Locomotor Capabilities Index Assessment of Life Habits Prosthetic Profile of the Amputee
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performance of life habits. For example, a person with lowerlimb amputation responsible for meal preparation (ie, who assumes this social role) may be independent in performing a cooking activity when using a wheelchair because the kitchen counters are lowered (eg, the person sits in wheelchair to cut vegetables) and openings have been made under the sink (eg, to wash the dishes), yet may stand with the prosthesis when cooking on the stove. The tool developed by Noreau et al,11 LIFE-H, documents the person’s performance in daily activities and social roles, hence it documents the quality of social participation. However, the LIFE-H was not developed specifically for persons with lower-limb amputation and generally considers the use of prosthesis as an assistive device. Because prosthetic training is an important component of rehabilitation to help persons with lower-limb amputation resume their previous life habits, an amputee-specific measure should be used concurrently with the LIFE-H to document accurately the daily use of the prosthesis. To our knowledge, there are no longitudinal studies describing the accomplishment of life habits of persons with lowerlimb amputation during and after receiving inpatient rehabilitation. The combination of a generic tool assessing usual life habits, like the LIFE-H, with a specific tool assessing the use the prosthesis, like the PPA, will give complementary information that should accurately assess these major rehabilitation outcomes. The objectives of the present study were (1) to assess the performance of life habits of persons with lower-limb amputation at admission, at discharge, and 3 months after discharge from inpatient rehabilitation; and (2) to describe their prosthetic profile at discharge from rehabilitation and 3 months later. METHODS Study Sample This exploratory longitudinal study was conducted with persons with lower-limb amputation who were consecutively admitted to the Montreal Rehabilitation Institute in Quebec, Canada, for inpatient rehabilitation between September 2005 and December 2006. Patients received an individualized program from a multidisciplinary team. This program includes daily physical and occupational therapy for preprosthetic and prosthetic training and psychologic support to the patient and the family. Additional family support and sociovocational orientation is provided by a social worker, and leisure activities are offered in and out of the rehabilitation center. Inclusion criteria were (1) being 18 years or older and having a unilateral transtibial or transfemoral amputation from any cause except congenital, (2) having sufficient cognitive skills and comprehension of French or English to be able to complete the questionnaires accurately, and (3) being admitted for a first prosthetic training. This last criterion was meant to reduce the effects of confounding variables caused by multiple admissions and prosthetic trainings (eg, subsequent amputation of the residual limb or amputation of the contralateral lower limb). The research protocol was approved by the Research Ethics Committee of the Center for Interdisciplinary Research in Rehabilitation, of which the Montreal Rehabilitation Institute is a site. Subjects signed an informed consent form prior to participating. Procedure Data using the tools described in this article and other quality of life tools (results presented elsewhere12) were collected at 3 Arch Phys Med Rehabil Vol 90, November 2009
times: on admission to the inpatient rehabilitation program (T1), at discharge (T2), and at 3-month follow-up (T3). All data were collected using questionnaires administrated during interviews conducted by the same evaluator (D.Z.), a senior physical therapist with over 10 years of experience. Information was also extracted from the patient’s medical chart: age, highest level of completed education, level and date of amputation, duration of prosthetic training, duration of rehabilitation stay, associated medical conditions, and marital and employment status at the time of amputation. Measurement Instruments Assessment of life habits. The LIFE-H is a generic questionnaire whose concept was based on the Disability Creation Process.1 This instrument evaluates a person’s social participation by measuring performance in carrying out life habits in terms of difficulty and assistance required.11 In this study, we used the shortened version of the tool (LIFE-H 3.1) composed of 77 items covering the 12 categories of the Disability Creation Process nomenclature: nutrition, fitness, personal care, communication, housing, mobility, responsibility, interpersonal relationships, community life, education, employment, and recreation. The first 6 categories refer to the daily activities subdomain, while the remainder refer to social roles. In the present study, items concerning education were excluded because no one was a student. Scoring is done using a 10-level continuous scale based on the degree of difficulty (no difficulty or with difficulty) and the type of assistance needed (no assistance, assistive device, adaptation, human assistance) by the person to perform each life habit in the person’s current environment. Scores for each item range from 0 to 9 where 0 indicates that the life habit is not accomplished and 9 indicates that it is performed without difficulty and without assistance. A score for each category (mean of applicable items) as well as a total score (mean of all applicable items) and subscores for daily activities and social roles can be calculated. The validity and the reliability of the LIFE-H were demonstrated to be acceptable with various populations with and without disabilities (eg, persons with spinal cord injury, persons with traumatic brain injury, older adults with and without functional limitations).11 Even if the psychometric properties of the LIFE-H were not studied with persons with lower-limb amputation, the items contained in this tool appear to be directly related to persons with lower-limb amputation rehabilitation goals and the clinical interventions provided to attain them. In this study, the LIFE-H was administrated by an interview lasting 30 to 45 minutes. Prosthetic profile of the amputee. The PPA is a conditionspecific questionnaire developed to determine the predisposing, enabling, and facilitating factors potentially related to prosthetic use of the persons with lower-limb amputation.13,14 The factors were operationalized into 44 close-ended questions grouped into 6 sections: physical condition, prosthesis, prosthetic capabilities, environment, leisure activities, and demographic characteristics. The PPA was originally developed and validated in French and English and can be administrated by mail or interview. The PPA is a follow-up instrument, but most of the sections are applicable at discharge from the rehabilitation center.15 The validity and reliability of the PPA have been fully reported and seem acceptable for clinical and research use.14 Construct validity of the PPA was demonstrated compared with analogous constructs of the Reintegration of Normal Living (r⫽.56 –.64; P⬍.01).14 Test-retest reliability for categorical data was good: Cohen kappa varied from .46 to .84.14 To evaluate the ambulatory skills of persons with lower-limb amputation with the prosthesis, an index of locomotor capabil-
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LIFE HABITS OF PERSONS WITH LOWER-LIMB AMPUTATION, Zidarov Table 1: Clinical and Sociodemographic Characteristics of the Sample (Nⴝ19) Variable
Cause of amputation Vascular Traumatic Tumor Infection Marital status Married/committed Single Divorced/widowed Education Primary Secondary Postsecondary Employment status at the amputation Employed Retired
n
Frequency (%)
12 3 2 2
63.2 15.8 10.5 10.5
9 5 5
47.4 26.3 26.3
2 10 7
10.5 52.7 36.8
12 7
63.2 36.8
Variable
Mean ⫾ SD
Range
Age (y) Duration of rehabilitation stay (d) Duration of prosthetic training (d)
53.4⫾14.6 84.3⫾23.3 49.2⫾19.2
26–78 59–146 29–105
ities (LCI) was developed (question 11 of the PPA). The LCI has a maximum score of 42 and contains 2 subscales (basic and advanced capabilities). A higher score indicates greater locomotor capabilities with the prosthesis. Because the PPA is an extensive questionnaire covering various aspects, which makes it lengthy, with the permission of authors, only items about the condition of the stump, the locomotor capabilities, the prosthetic use, and leisure activities were selected (questions 4, 6, 7, 10 –14, 16, 18, 19, 21, 33–39). Data Analysis Descriptive statistics were computed for the continuous variables (age, duration of stay and prosthetic training, LIFE-H scores, hours of prosthetic use), while frequency and percentages were calculated for categorical variables mostly found in
the PPA. Changes in LIFE-H scores for each category, the 2 subdomains, and the total scores at the 3 evaluation times were examined using a 1-way repeated-measures analysis of variance with time of measurement as a within-subjects factor. When significant results were obtained (P⬍.05), post hoc comparisons were performed using the Bonferroni correction for multiple comparisons. Paired t tests examined differences in the mean number of hours of prosthetic use between discharge and follow-up. All analyses were performed with SPSS version 14.0 for Windows.a RESULTS Demographic and Clinical Variables Of the 114 persons with LLA admitted to the program during the study period, only 29 (26%) met the eligibility criteria. Of the 85 remaining, 30% were readmissions, 34% had a bilateral amputation, 11% insufficiently understood French or English, 16% had important cognitive or psychiatric problems, and 9% were not considered potential prosthetic wearers. Of the 29 eligible subjects, 6 (21%) refused to participate, 1 died at follow-up, and 3 had an unplanned discharge. Data for the 3 evaluation times were obtained for 19 participants. Table 1 summarizes their clinical and sociodemographic characteristics. Fourteen were men, and 16 had a transtibial amputation. Prior to admission, 52.6% were hospitalized in acute care centers, while 47.4% were at home, waiting to be admitted to rehabilitation. Comorbidities were as follows: 52.6% had hypertension, 42.1% had visual problems, 21.1% had hearing problems, and 26.3% had chronic kidney failure. The mean duration of stay and the mean duration of prosthetic training did not significantly differ (P⬎.05) according to level of amputation or cause of amputation. Assessment of Life Habits Data related to the degree of accomplishment of life habits are presented by category for the 3 evaluation times (table 2). Concerning the ADLs subdomain, the lowest degree of performance was observed for the mobility (3.91– 6.22) and housing (3.68 – 6.50) categories at all 3 evaluation times. Personal care activity scores (eg, body washing, dressing, using bathroom) were high even on admission. Similar results were found for
Table 2: Life Habits Mean Scores (of 9) Obtained for 11 Categories of the LIFE-H at Admission, Discharge, and 3-Month Follow-Up
Daily activities Nutrition Fitness Personal care Communication Housing Mobility Daily activities subscore Social roles Responsibility Interpersonal relations Community life Employment Recreation Social roles subscore Total score
Admission Mean ⫾ SD (n⫽23)
Discharge Mean ⫾ SD (N⫽19)
3-Month Follow-Up Mean ⫾ SD (n⫽19)
P*
5.70⫾2.11 7.04⫾1.17 7.63⫾1.00 7.95⫾1.38 3.68⫾2.19 3.91⫾2.11 6.21⫾1.12
7.43⫾1.73 8.04⫾0.74 8.10⫾0.75 8.45⫾0.57 5.90⫾1.68 5.13⫾1.95 6.10⫾0.46
8.06⫾0.98 8.21⫾1.00 8.09⫾0.88 8.35⫾0.87 6.50⫾1.22 6.22⫾1.65 6.10⫾0.39
⬍.001 ⬍.001 .018 .025 ⬍.001 ⬍.001 .500
7.63⫾1.64 8.09⫾0.94 3.75⫾3.14 1.41⫾2.17 1.86⫾2.45 4.70⫾1.25 5.52⫾1.06
7.63⫾1.86 8.19⫾0.91 6.41⫾2.48 1.63⫾2.21 3.18⫾2.47 5.79⫾1.38 6.62⫾0.95
8.66⫾0.66 8.18⫾1.18 7.27⫾1.48 3.42⫾2.74 5.45⫾2.54 6.89⫾0.99 7.26⫾0.68
.038 .400 ⬍.001 .014 .001 ⬍.001 ⬍.001
*P associated with analysis of variance. Significant results indicate differences in scores across the 3 evaluation periods.
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Table 3: Pairwise Comparisons for Significant Analysis of Variance Results Pertaining to the Difference Between Mean Scores for Different Categories of the LIFE-H (Nⴝ19) Mean Difference (T2 – T1) (P)
Daily activities Nutrition Fitness Personal care Communication Housing Mobility Daily activities subscore Social roles Responsibility Interpersonal relations Community life Employment Recreation Social roles subscore Total score
95% CI
Mean Difference (T3 – T2) (P)
95% CI
Mean Difference (T3 – T1) (P)
95% CI
1.44 (.008) 1.08 (.02) NS NS 2.34 (.002) 1.63 (.022) NS
0.35–2.54 0.19–1.97 NS NS 0.84–3.84 0.21–3.06 NS
NS NS NS NS NS NS NS
NS NS NS NS NS NS NS
2.04 (.001) 1.18 (.001) NS NS 2.73 (⬍.001) 2.53 (⬍.001) NS
0.83–3.25 0.46–1.90 NS NS 1.47–4.00 1.36–3.70 NS
NS NS 3.41 (.001) NS NS 1.45 (.003) 1.28 (⬍.001)
NS NS 1.34–5.48 NS NS 0.47–2.44 0.59–1.96
NS NS NS NS NS NS NS
NS NS NS NS NS NS NS
0.94 (.038) NS 4.03 (⬍.001) 2.36 (.013) 3.46 (.002) 2.37 (⬍.001) 1.79 (⬍.001)
0.05–1.84 NS 2.10–5.95 0.49–4.23 1.21–5.71 1.61–3.13 1.29–2.28
Abbreviations: CI, confidence interval; NS, not significant.
social roles related to responsibilities and interpersonal relationships. Scores for the employment, recreation, and community life categories were the lowest for the 3 evaluations times within the social role subdomain. Globally, when looking at the subscores, after a lower-limb amputation, the accomplishment of social roles was more restricted than the accomplishment of ADLs and this, up to 3 months after returning to the community. During rehabilitation (between admission and discharge), mean scores for all of the categories in the ADLs subdomain significantly increased except for the personal care and communication categories, which were already high at admission (table 3). Only the mean scores for community life of the social roles subdomain significantly increased during rehabilitation. Globally, there was a significant increase in the mean total scores of the LIFE-H and in the social roles subscores during rehabilitation. Performance of life habits did not change between discharge and follow-up. Prosthetic Profile of the Amputee Descriptive statistics of the prosthetic profile of the sample at discharge and follow-up are presented in table 4. The most frequently reported problem with the nonamputated leg for both evaluation times was poor circulation (42.1%, n⫽8 at T2; 31.6%, n⫽6 at T3). Phantom pain was experienced by 63.2% (n⫽12) and 57.9% (n⫽11) of the patients at discharge and follow-up, respectively. The more frequent problem caused by the use of the prosthesis at discharge was an increase in stump pain (31.6%; n⫽6), while at follow-up, skin irritation was more problematic (26.3%; n⫽5). More than 90% of subjects could don their prosthesis without difficulty at discharge and at follow-up. Ninety-five percent (n⫽18) wore their prosthesis daily at discharge versus 90% (n⫽17) at follow-up. Fifty-eight percent of patients (n⫽11) at discharge versus 68.4% (n⫽13) at follow-up used their prosthesis for more than 9 hours a day. Furthermore, there was a significant increase in the number of hours of prosthetic use a day between discharge and follow-up (t⫽2.64; df⫽17; P⫽.017). The locomotor capability scores with the prosthesis (basic and advanced) were high at discharge and follow-up and did not differ significantly. At discharge, 63% of patients Arch Phys Med Rehabil Vol 90, November 2009
(n⫽12) used their prosthesis for more than 75% of their indoor activities and 53% (n⫽10) for more than 75% of their outdoor activities. At follow-up, these percentages were 58% (n⫽11) and 90% (n⫽17), respectively. Forty-two percent of patients (n⫽8) did not need a walking aid indoors at discharge, while
Table 4: Descriptive Statistics Pertaining to Subjects’ Prosthesis Profile at Discharge and Follow-Up (Nⴝ19)
Prosthetic wear Days/week Hours/day LCI LCI basic (/21) LCI advanced (/21) LCI total (/42) Standing and/or walking around 0–50% 75–100% Assistive devices used indoors Walker Crutches 2 Canes 1 Cane None Assistive devices used outdoors Walker Crutches 2 Canes 1 Cane None Distances walked outside without stopping Between 10 and 30 steps ⬎30 Steps but less than 1 block 1 Block Not limited in the walking distances NOTE. Values are mean ⫾ SD or n (%).
Discharge
Follow-Up
6.8⫾0.9 8.1⫾3.6
6.8⫾0.5 11.0⫾3.5
19.5⫾3.2 15.6⫾7.0 35.1⫾9.6
20.5⫾2.1 17.6⫾6.2 38.1⫾7.8
16 (84.2) 3 (15.8)
17 (89.4) 2 (10.6)
6 (31.6) 2 (10.5) 1 (5.3) 2 (10.5) 8 (42.1)
3 (15.8) 0 0 4 (21.1) 12 (63.2)
6 (31.6) 3 (15.8) 3 (15.8) 4 (21.1) 3 (15.8)
3 (15.8) 0 0 10 (52.6) 6 (31.6)
2 (10.5) 1 (5.3) 10 (52.6) 6 (31.6)
0 1 (5.3) 7 (36.8) 11 (57.9)
LIFE HABITS OF PERSONS WITH LOWER-LIMB AMPUTATION, Zidarov
this number grew to 63.2% (n⫽12) at follow-up. A walker was the most frequently used assistive device for indoor walking at discharge, while 1 cane was most frequently used at follow-up. At discharge, most patients could walk at least 1 block (5– 6 houses) without stopping, while at follow-up, most reported not being limited in their walking distances. Concerning the number of falls, at discharge, only 2 (10.5%) patients reported falling with their prosthesis during rehabilitation, while the number of patients who fell once home doubled (21.1%). Regarding leisure activities, at both evaluation periods, only 47.4% (n⫽9) of patients were practicing physical activities (eg, walking, fishing, swimming, cycling), yet all patients had some type of recreational activity (eg, reading, watching television, playing cards, arts and crafts, social events). Finally, at discharge, 73.6% (n⫽14) of patients reported that they were quite well adapted or completely adapted to the amputation, while at follow-up, this percentage increased to 79% (n⫽15). Seventy-nine percent of patients (n⫽15) at discharge reported being well adapted or completely adapted to their prosthesis; the percentage dropped to 74% (n⫽14) at follow-up. DISCUSSION To our knowledge, this is a first study to report in a detailed way the accomplishment and the evolution of life habits of persons with lower-limb amputation during and after a period of intensive inpatient rehabilitation. Use of the LIFE-H enabled us to identify, for our sample, the life habits that could and could not be accomplished without major difficulties after a lower limb amputation. With regards to the daily activities domain, patients’ performances were lowest in the mobility and housing categories, and mostly on admission. However, performance improved significantly thereafter. At admission, the low performance in mobility was likely a result of the chronic impairment caused by the lower-limb amputation, while the improvement observed at discharge could be a result of the interventions received during rehabilitation. In fact, during their rehabilitation stay, all patients were trained, according to their abilities, in unipodal ambulation with assistive devices and wheelchair mobility, and thereafter received prosthetic training. The low score for the housing category at admission may be explained by a lack of mobility at that time and mostly because any typically required adaptation to a patient’s home had not yet begun. Indeed, during inpatient rehabilitation, occupational therapists assess the accessibility (in and outdoor) of a patient’s residence and recommend adaptations that are, for the most part, completed by discharge. Persons with lower-limb amputations are only slightly restricted in the degree of accomplishment of their personal care activities, as shown by the high scores obtained at the 3 evaluation time points. Similarly high scores were obtained by Panesar et al4 with 34 inpatient persons with lower-limb amputation using the FIM. The grooming, bathing, dressing, and toileting items of the FIM are similar to those contained in the personal care category of the LIFE-H. In the study by Panesar,4 patients’ median score was 7 of 7 at admission and discharge for grooming and dressing, 5 of 7 at admission, and 6 of 7 at discharge for bathing, and 6 of 7 at admission and discharge for toileting. Patients reported more important restrictions in their performance of social roles, particularly those concerning employment, recreation, and community life. Employment scores were very low and did not change significantly during rehabilitation. This is likely because of the mission of the intensive rehabilitation center; interventions focusing on vocational evaluation and integration are not provided, and patients with
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vocational needs are referred to other rehabilitation centers specializing in this domain. In our sample, 12 patients were employed at the time of the amputation and were subsequently referred to vocational rehabilitation at discharge. This explains the significant increase in employment mean scores at follow-up and the significant change in these scores between admission and follow-up. Participation in recreation activities remained low at admission and at discharge. It was surprising that there were no significant changes in scores except between admission and follow-up despite the numerous recreational activities offered to patients during their rehabilitation stay. In fact, structured recreational activities (eg, bowling, outings to museums and cinemas) are offered regularly by the recreation therapy department, and once a month, an interdisciplinary team member also attends the activity to provide specific interventions related to mobility, walking endurance, and social interaction. However, a close look at the participants’ scores showed that, at admission as well as at discharge, most of the 7 items in the leisure category were not accomplished yet. In fact, when an activity is not accomplished but is part of the usual life habits of the person, a score of 0 of 9 is given. Furthermore, 2 items refer to travel-related or outdoor recreational activities (eg, hiking, camping), which obviously patients could not have accomplished at admission or at discharge. Low scores for these activities tend to lower the scores in the leisure category because these activities could be part of the patient’s usual life habits. These results suggest that maybe more various (indoors and outdoors, artistic, cultural, sports activities) and more frequent recreational activities should be offered to persons with lower-limb amputation during their rehabilitation stay in order to enhance their participation in leisure activities. Community life is another domain in which the participation of the persons with lower-limb amputation was rather low at admission. However, subjects’ scores increased significantly after discharge, reaching a mean score of 7.27 of 9. This is not surprising when one looks at the items contained in this LIFE-H domain. They refer to the ability to go to, walk to, and use public services (eg, banks, stores), all activities requiring a relatively high level of mobility. Therefore, the improvements in the person’s involvement in community life are most likely a result of improvement in mobility outdoors (use of a prosthesis and assistive devices, including use of a wheelchair). Also, existing environmental adaptations in the community were reported by patients (eg, presence of access ramps, automatic doors) to facilitate their activities and mobility in the community. Globally, after a lower-limb amputation, participation in social roles appears to be more restricted compared with the accomplishment of daily activities, and it seems that this limitation may be caused essentially by a lack in mobility. The accomplishment of certain valued social roles (eg, working, going to social events) cannot simply be carried out by others (eg, assistance for cooking, cleaning, toileting) and give the person a sense of fulfillment. Therefore, important restrictions in the accomplishment of such activities may reflect the real consequences of a lower-limb amputation and the impact on a person’s life. Similar results were found by Pell et al,16 who suggest that impaired mobility may account for much of the social isolation reported by amputees, which will result in a negative impact on their overall quality of life. Nissen and Newman17 also found that poor reintegration in daily life after a lower-limb amputation occurred mostly in the areas of participation in recreational and work activities and ambulation in the community. Consequently, inpatient rehabilitation interArch Phys Med Rehabil Vol 90, November 2009
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LIFE HABITS OF PERSONS WITH LOWER-LIMB AMPUTATION, Zidarov
ventions should include more mobility interventions in real-life environments, such as shopping for groceries or other items or going to the bank, to promote participation in community life. In addition, rehabilitation interventions should include the evaluation and adaptation of important leisure activities for persons with lower-limb amputation, and when not possible, reorientation toward new leisure activities better adapted to their new condition. Currently there is no criterion standard or norm for ideal or optimal participation,18 so clinicians may wonder whether it is realistic to aim for a perfect score (9 of 9) for all life habits when setting patients’ rehabilitation goals. As discussed by several authors, measuring only a person’s performance of life habits without considering which activities or roles the individual values and how the activity is performed by the person in relation to the person’s reality, will not provide an accurate picture of the person’ social participation.18,19 A person’s reality is determined by both personal and environmental factors.19 Receiving assistance when performing a chosen life habit (eg, house cleaning), should not mean that the person has a lower performance than others in this task even if the score is low. On the contrary, receiving assistance to accomplish an activity may enable the person to engage in additional meaningful activities (eg, leisure) that would not have been possible otherwise. Indeed, it is difficult to portray optimal performance accurately with a score. Rather, it should reflect the perfect fit between a person’s reality (how life habits are actually performed) and expectations (how the person wishes to accomplish these life habits). Consequently, a client-centered approach, a core value in rehabilitation, should ideally include the person’s choices about how and which life habits the person wants to accomplish when setting rehabilitation goals. Prosthetic Profile of the Amputee Our results concerning the locomotor capabilities with the prosthesis (LCI scores), and the number of hours a day and the number of days a week that the prosthesis is used, are very similar to those obtained by the authors of the PPA.20 However, in our study, at follow-up, more persons with lower-limb amputation (89.5%) used their prosthesis for 75% or more of their outdoor activities compared with those in the study by Gauthier-Gagnon et al21 (64%). One possible explanation for this difference may be a result of differences in the sociodemographic characteristics of the 2 samples. Our sample was younger (mean age, 53.4y vs 62.3y), with a lower percentage of transfemoral (16% vs 42.4%) and vascular amputees (63.3% vs 76.8%). Several literature reviews22-24 pointed out that advanced age, higher level of amputation, and medical comorbidities are associated with less prosthetic use. Vascular amputees also have more associated medical conditions that can affect their prosthetic use.22,23 Furthermore, fewer subjects (58% at T2 and 68% at T3) used their prosthesis for more than 9 hours daily compared with the Gauthier-Gagnon20 study (75%). As shown in our results, this frequency increased considerably between discharge and follow-up. However, Gauthier-Gagnon’s20 participants had been using their prosthesis 1 to 5 years postdischarge and hence were more experienced prosthetic users. Future studies with longer follow-up periods could possibly identify increases in the number of hours of prosthetic use beyond 3 months postdischarge. Additionally, more subjects in our sample reported not being limited in their distances walked outside without stopping at both evaluation periods (27.5% in the Gauthier-Gagnon20 study). This can again be explained by the characteristics of our sample: younger age, more persons with lower-limb amputation as a result of trauma, cancer, or infection and fewer transfemoral amputees. Finally, adaptation Arch Phys Med Rehabil Vol 90, November 2009
to the amputation and the prosthesis was found to be better (higher scores in our sample). It is not clear why a later decline in this area was observed by Gauthier-Gagnon.20 Similar results regarding prosthetic use were obtained by Streppel et al25 at discharge and 2 months later. The only 2 major differences concern the number of hours a day that the prosthesis was worn (8.1 vs 10.1) and the percentage of patients who wear their prosthesis for more than 9 hours (58% vs 76%), which were both higher in the Streppel25 study. These differences may be related to the fact that the duration of stay in the Streppel25 study was almost doubled (165d vs 84d). Longer rehabilitation stays may imply longer prosthetic training and consequently grater prosthetic ability, which may ultimately lead to a better adaptation and integration of the prosthesis in daily life. Study Limits and Clinical Implications This study was carried out with a small sample of subjects who were candidates for prosthetic fitting and were consecutively admitted to 1 center offering inpatient rehabilitation. Our study did not include measures related to rehabilitation provided beyond this point. The inclusion criteria were relatively stringent. Hence, our results may not be generalizable to the total population of persons with lower-limb amputation, including those who never received a prosthesis. The LIFE-H can be used in clinical settings to set individualized rehabilitation goals for persons with lower-limb amputation, to document their evolution in the accomplishment of their life habits, and to evaluate programs.11 However, the tool can be burdensome to clinicians because the interview can exceed 30 minutes. Furthermore, calculating scores is quite complex; data are gathered and analyzed with software. Our experience with this tool also revealed that persons with lowerlimb amputation have difficulties understanding the questionnaire, particularly the measurement scale. However, once the questionnaire was completed and analyzed, the responses were deemed very useful to the clinical team to set individualized rehabilitation goals. It may be helpful to determine, earlier than usual during the rehabilitation process, the need for assistive devices or adaptations in the person’s home according to the life habits that the person would be performing routinely. The specificity of the PPA provided clinicians with very useful information concerning the prosthetic profile of the person with lower-limb amputation. When used at discharge and at follow-up, the various domains covered by the questionnaire allowed them to detect any deterioration in the prosthetic profile of the patient, enabling the interdisciplinary team to intervene promptly. Because this questionnaire is mostly descriptive (or qualitative) and lengthy, we recommend, with others,25 that team members, with permission from authors, select only the questions related to specific treatment outcomes of interest to them. This will promote its use in clinical practice and for program evaluation. CONCLUSIONS Among persons with lower-limb amputation, life habits associated with social roles appear to be more disturbed than those associated with ADLs. This appears to be true throughout the rehabilitation process and as far as 3 months after returning to the community. During inpatient rehabilitation, performance in ADLs, except the personal care and communication categories, improved significantly, while the accomplishment of social roles did not improve significantly except for the community life category. Our findings thus underscore the importance of focusing care on social role issues, such as community life,
LIFE HABITS OF PERSONS WITH LOWER-LIMB AMPUTATION, Zidarov
recreation, and employment, during rehabilitation of persons with lower-limb amputation. Improving outdoor mobility of persons with lower-limb amputation with appropriate training, including prosthetic training and provision of adequate assistive devices, could enhance their accomplishment of social roles, especially in community life. At discharge, prosthetic wear, active use of the prosthesis indoors and outdoors, and locomotor capabilities with the prosthesis were high and tended to continue improving once the person was back in the person’s own environment. Additionally, most of the patients in this study reported being quite well to completely adapted to their amputation and prosthesis, and this phenomenon seems to improve 3 months after returning home. All patients reported having some sedentary leisure activities, but less than half were involved in sports activities 3 months after returning home. Finally, accomplishment of life habits and prosthetic and locomotor capabilities reflects most of the aims of multidisciplinary interventions offered during the rehabilitation process. As such, the instruments used in this study appear to be promising outcome measures for a rehabilitation program or daily clinical practice. References 1. Fougeyrollas P, Noreau L, Bergeron H, Cloutier R, Dion SA, St-Michel G. Social consequences of long term impairments and disabilities: conceptual approach and assessment of handicap. Int J Rehabil Res 1998;21:127-41. 2. Treweek SP, Condie ME. Three measures of functional outcome for lower limb amputees: a retrospective review. Prosthet Orth Int 1998;22:178-85. 3. O’Toole DM, Goldberg RT, Ryan B. Functional changes in vascular amputee patients: evaluation by Barthel Index, PULSES profile and ESCROW scale. Arch Phys Med Rehabil 1985;66: 508-11. 4. Panesar BS, Morrison P, Hunter J. A comparison of three measures of progress in early lower limb amputee rehabilitation. Clin Rehabil 2001;15:157-71. 5. Muecke L, Shekar S, Dwyer D, Israel E, Flynn JP. Functional screening of lower-limb amputees: a role in predicting rehabilitation outcome? Arch Phys Med Rehabil 1992;73:851-8. 6. Leung EC, Rush PJ, Devlin M. Predicting prosthetic rehabilitation outcome in lower limb amputee patients with the functional independence measure. Arch Phys Med Rehabil 1996;77:605-8. 7. Dodds TA, Martin DP, Stolov WC, Deyo RA. A validation of the Functional Independence Measurement and its performance among rehabilitation inpatients. Arch Phys Med Rehabil 1993;74: 531-6. 8. Holbrook ME, Skilbeck CE. An activities index for use with stroke patients. Age Ageing 1983;12:166-70. 9. Datta D, Ariyaratnam R, Hilton S. Timed walking test—an all embracing outcome for measure for lower limb amputees? Clin Rehabil 1996;10:227-32.
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10. Miller WC, Deathe AB. Measurement properties of the Frenchay Activities Index among individuals with a lower limb amputation. Clin Rehabil 2004;18:414-22. 11. Noreau L, Fougeyrollas P, Vincent C. The LIFE-H: assessment of the quality of social participation. Technol Disabil 2002;14:113-8. 12. Zidarov D, Swaine B, Gauthier-Gagnon C. Quality of life of persons with lower limb amputation during rehabilitation and at 3 month follow up. Arch Phys Med Rehabil 2009;90:634-45. 13. Grisé MC, 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: 862-70. 14. Gauthier-Gagnon C, Grisé MC. Prosthetic profile of the amputee questionnaire: validity and reliability. Arch Phys Med Rehabil 1994;75:1309-14. 15. Gauthier-Gagnon C, Grisé MC. Tools to measure outcome of people with a lower limb amputation: update on the PPA and LCI. Proceedings of the outcome measures in lower limb prosthetics. Chicago: Lippincott Williams and Wilkins; 2005. p 61-7. 16. Pell JP, Donnan PT, Fowkes FG, Ruckley CV. Quality of life following lower limb amputation for peripheral arterial disease. Eur J Vasc Surg 1993;7:448-51. 17. Nissen SJ, Newman WP. Factors influencing reintegration to normal living after amputation. Arch Phys Med Rehabil 1992;73: 548-51. 18. Hammel J, Magasi S, Heinemann A, Whiteneck G, Bogner J, Rodriguez E. What does participation mean? an insider perspective from people with disabilities. Disabil Rehabil 2007;30:1-16. 19. Rochette A, Korner-Bitensky N, Levasseur M. Optimal participation: a reflective look. Disabil Rehabil 2006;28:1231-5. 20. Gauthier-Gagnon C, Grisé MC, Potvin D. Predisposing factors related to prosthetic use by people with a transtibial and transfemoral amputation. J Prosthet Orthot 1998;10:99-109. 21. 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;80:706-13. 22. Pernot HF, De Witte LP, Lindeman E, Cluitmans J. Daily functioning of the lower extremity amputee: an overview of the literature. Clin Rehabil 1997;11:93-106. 23. Kent R, Fyfe N. Effectiveness of rehabilitation following amputation. Clin Rehabil 1999;13(Suppl 1):43-50. 24. Geertzen JH, Martina JD, Rietman HS. Lower limb amputation part 2: rehabilitation—a 10 year literature review. Prosthet Orth Int 2001;25:14-20. 25. Streppel KR, 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;24:251-6. Supplier a. SPPS Inc, 233 S Wacker Dr, 11th Fl, Chicago, IL 60606.
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