Motor control of any movement task involves the integration of neural, muscular and skeletal systems. This integration must occur throughout the sensorimotor system and focus its efforts on controlling the system endpoint, e.g. the foot during locomotion. A person with a uni-lateral trans-tibial amputation has lost the foot, ankle joint, and muscles crossing those joints, hence the residuum becomes the new terminus of the motor system. The amputee must now adjust to the additional challenges of utilizing a compromised motor system as well as the challenges of controlling an external device, i.e. prosthesis, through the mechanical interface between the residuum and prosthetic socket. The obvious physical and physiologic asymmetries between the sound and amputated limbs are also involved in strategies for locomotion involving kinematic and kinetic asymmetries (Winter&Sienko, 1988). There are many questions as to why these asymmetric locomotor strategies are selected and what factors may be influencing that strategy. Factors influencing a change in locomotor strategy could be related to 1) the central nervous system accounting for the loss of sensorimotor feedback, 2) the altered mechanics of this new human/prosthetic system, or some combination of these factors. Understanding how the human motor system adjusts to the amputation and to the addition of an external mechanical device can provide useful insight into how robust the human control system may be and to adaptations in human motor control. This research uses a group of individuals with a uni-lateral trans-tibial amputation and a group of intact individuals using an Ankle Foot Orthosis (AFO) performing a cycling task to understand the "motor adjustments" necessary to utilize an external device for locomotion. Results of these experiments suggest 1) the motor system does account for the activation-contraction dynamics when coordinating muscle activity post amputation, 2) the motor system also changes joint kinetics and muscle activity, 3) these changes are related to control of the interface between the limb and the external device, and 4) the motor system does not alter kinetic asymmetries when kinematic asymmetries are minimized, contrary to a common practice in rehabilitation (Kapp, 2004). Results suggest that control of the external device, i.e. prosthesis or AFO, via the interface between the limb and the device reflect "motor adjustments" made by the nervous system and may be viewed in the context of tool use. Clinical goals in rehabilitation currently focus on minimizing gait deviations whereas the clinical application of these results suggest these deviations from normal locomotion are motor adjustments necessary to control a tool, i.e. prosthesis, by the motor system. Examining amputee locomotion in the context of tool use changes the clinical paradigm from one designed to minimize deviations to one intended to understand this behavior as related to interface control of the device thereby shifting the focus to improving function of the limb/prosthesis system. Kapp SL. (2004) Atlas amp limb def: surg pros rehab princ. 3rd ed: 385 - 394. Winter&Sienko. (1988) J Biomech, 21: 361 - 367.

Made available in DSpace on 2015-07-22T20:49:33Z (GMT). No. of bitstreams: 0 Previous issue date: 2011-11-24 / Objetivo: avaliar pessoas com amputações de membros inferiores e descrever as variáveis sociodemográficas e clínicas, além de identificar quais dessas influenciam a qualidade de vida e alterações psíquicas. Métodos: estudo transversal, que incluiu pessoas submetidas a amputações de membros inferiores em todos os níveis e etiologias, sendo excluídas as que apresentaram idade inferior a 14 anos. Foram utilizados os questionários SF-36 e SRQ-20 para avaliar a qualidade de vida e as alterações psíquicas respectivamente em relação a variáveis sociodemográficas e clínicas. Resultados: foram entrevistadas 138 pessoas, com idade média de 62 anos, baixa renda e escolaridade, o SF-36 mostrou que apenas as que não eram casadas apresentaram escores médios de várias dimensões significantemente maiores e a avaliação das condições psíquicas foram influenciadas pelo gênero feminino, não ser casado, não ser independente, tempo de amputação e número de doenças associadas, porém depois da regressão logística, apenas o número de doenças associadas e independência mostraram-se significativas. Conclusões: as alterações na qualidade de vida estiveram associadas à presença de condições mórbidas e ao fato de ter um companheiro; 43% dos pacientes apresentaram doença psíquica, que estiveram associadas com o número de doenças crônicas e o fato de não serem independentes; além disso, foram excluídos do mercado de trabalho, não foram reabilitados. / Objective: To evaluate people with lower limb amputations in community base and describe the demographic and clinical variables, and identify which of these influence the quality of life and psychological disorders. Methods: A cross-sectional study that included people who undergone amputation at all levels and etiologies; were excluded younger than 14 years. Was used the SF-36 and SRQ-20 to assess quality of life and the psychological changes respectively in relation to demographic, social and clinical variables. Results: 138 low income and education people was interviewed; the SF-36 showed that only those who were not married had average scores significantly higher in several dimensions and assessment of psychological conditions were influenced by women, not being married, not independent, time of amputation, and number of associated diseases, but after logistic regression, only the number of associated diseases and independence were significant. Conclusions: changes in quality of life were associated with the presence of morbid conditions and to having a partner, 43% of patients had mental illness that were associated with the number of chronic diseases and that they were not independent and, moreover, ware excluded labor market and ware not being rehabilitated. / TEDE / BV UNIFESP: Teses e dissertações

Submitted by Renata Lopes (renatasil82@gmail.com) on 2016-05-11T18:15:59Z No. of bitstreams: 1 mariliamendesdonascimentogarcia.pdf: 3241001 bytes, checksum: a1cee556b27ae439afc5e2b3142d4e76 (MD5) / Approved for entry into archive by Adriana Oliveira (adriana.oliveira@ufjf.edu.br) on 2016-06-27T19:25:41Z (GMT) No. of bitstreams: 1 mariliamendesdonascimentogarcia.pdf: 3241001 bytes, checksum: a1cee556b27ae439afc5e2b3142d4e76 (MD5) / Made available in DSpace on 2016-06-27T19:25:41Z (GMT). No. of bitstreams: 1 mariliamendesdonascimentogarcia.pdf: 3241001 bytes, checksum: a1cee556b27ae439afc5e2b3142d4e76 (MD5) Previous issue date: 2013-05-15 / CAPES - Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / Introdução: A marcha de amputados de membros inferiores (MMII) envolve maior consumo de oxigênio (VO2), justificado por meio das alterações biomecânicas. Apesar dos estudos não associarem as variáveis cardiovasculares e a capacidade física com o maior VO2 durante a marcha de amputados de MMII, esses indivíduos possuem alterações autonômicas e cardiovasculares em repouso e diminuição da capacidade aeróbia. Objetivo: Testar a hipótese que os amputados transtibiais traumáticos apresentam maior VO2 em repouso, que, associado às alterações cardiovasculares, interferem no VO2 durante a marcha e exercício aeróbio envolvendo os membros superiores. Métodos: Foram avaliados 22 indivíduos adultos, do sexo masculino, 11 com amputações transtibiais unilaterais traumáticas, comparados a 11 indivíduos sem amputações. Os voluntários foram avaliados em relação à frequência cardíaca (FC), pressão arterial (PA) e VO2, este por meio do analisador de gases K4 b² Cosmed. Todos os indivíduos foram avaliados em repouso, na postura supina e ortostática, em um protocolo de marcha na esteira rolante e em um protocolo contínuo no cicloergômetro de membros superiores (MMSS). Para comparação entre os grupos, foi utilizado o teste t de Student e o de Mann Whitney, este para o VO2 e, para correlacionar as variáveis, a Correlação de Spearman (p<0,05). Resultados: Na postura supina e ortostática, os amputados apresentaram maiores valores de PA, FC e VO2. O VO2 obtido na postura ortostática dos amputados foi correlacionado de forma positiva com a FC obtida nessa postura e com o VO2 em supino. Durante a marcha, os amputados apresentaram maior FC, PA, VO2 e este correlacionou-se positivamente com o VO2 na postura supina e com a FC durante a marcha. Durante o protocolo contínuo de MMSS, os amputados apresentaram maior VO2 e PAS. Conclusão: Os amputados transtibiais traumáticos apresentaram alterações cardiovasculares e metabólicas em repouso, que interferiram no VO2 durante a marcha e postura ortostática. Confirmando a presença de alterações não mecânicas, relacionadas ao VO2, os amputados transtibiais também apresentaram maior VO2 e FC durante a atividade aeróbia que não envolveu os MMII. / Introduction: The gait of lower limb amputees involves a higher oxygen consumption (VO2), justified by the biomechanical alterations. Although the studies do not associate the cardiovascular variables and the physical capacities with the higher VO2 during the gait of lower limb amputees, these subjects have autonomic and cardiovascular alterations in rest and decrease in the aerobic capacity. Aim: Test the hypothesis that the transtibial traumatic amputees show higher VO2 at rest, which associated with cardiovascular alterations, interfere on the VO2 during the gate and aerobic exercise involving the upper limbs. Methods: Were assessed 22 adult subjects, male, 11 with one-sided transtibial traumatic amputations, compared to 11 subjects with no amputations. The volunteers were assessed through the heart rate (HR), blood pressure (BP) and VO2, by the gases analyzer K4 b² Cosmed. All the subjects were assessed in rest, in the supine and orthostatic position, in a gait protocol on the treadmill and in a continuous protocol on the upper limbs cycle ergometer. For comparison between the groups, were used the t-Student and the Mann Whitney tests, for the VO2, and to correlate the variables, the Spearman Correlation. Results: On the supine and orthostatic position, the amputees showed higher values of BP, HR and VO2. The VO2 obtained on the amputees’ orthostatic position was correlated positively with the HR obtained in this position and with the VO2 in supine. During the gait, the amputees showed higher HR, BP and VO2, this correlated positively with the VO2 on the supine position and with the HR during the gait. During the continuous protocol of upper limbs, the amputees showed higher VO2 and BP Conclusion: The transtibial traumatic amputees showed cardiovascular and metabolic alterations at rest, which interfered in the VO2 during the gait and orthostatic position. Confirming the presence of non mechanic alterations, related to the VO2, the transtibial amputees also showed higher VO2 and HR during the aerobic activity that did not involve the lower limbs.

Bakgrund: Att förlora ett ben innebär en påfrestning på livet och livskvalitén sänks. Amputation betyder att skadad vävnad och skelett avlägsnas och det kan bero på trauma, cirkulatorisk svikt eller infektioner. Syfte: Var att beskriva upplevelsen av att ha förlorat en nedre extremitet genom amputation. Metod: Allmän litteraturöversikt användes för att sammanställa och skapa en översikt över befintlig forskning. Analysmodellen var induktiv utifrån Fribergs trestegsmodell. Resultat: Fem huvudkategorier med tillhörande underkategorier sammanställdes. De fem huvudkategorierna var; upplevelser av hur livet förändrats och hur andra ser på en själv, upplevelsen av information och stöd från sjukvården, hjälpmedel som hinder eller möjlighet till självständighet, att behöva socialt stöd på vägen mot ett nytt liv och positivt tänkande – en nyckelfaktor. Diskussion: Litteraturstudien visade att behovet av information var av stor vikt under hela amputationsprocessen, de amputerade upplevde att det var lite information som gavs ut och det skulle vara relevant att ge ut information både muntligt och skriftligt. Litteraturstudien visade också att protesen spelade en stor roll för synen på framtiden. Många såg den som nyckeln tillbaka till det tidigare livet och till ökad självständighet. Vidare föreslås mer forskning med kvalitativt tillvägagångssätt avseende de psykiska aspekterna hos såväl de amputerade som deras anhöriga.

Bakgrund: Ortopedingenjören har som uppgift att med sin kompetens och erfarenhet tillhandahålla en ortopedteknisk lösning som motsvarar patientens behov och önskemål. Handlingsutrymmet är det utrymme som en ortopedingenjör har till att ta självständiga beslut i sin yrkesutövning och är därmed summan av kompetens, bedömningar och rutiner inom verksamhetens ramar.  Syfte: Syftet med examensarbetet är att öka kunskapen om ortopedingenjörens upplevda handlingsutrymme i Sverige och Norge i relation till förskrivningsregler för protes på nedre extremiteter.  Metod: Examensarbetet baserades på en enkätundersökning med frågor gällande ortopedingenjörens upplevda handlingsutrymme utifrån mixed method. Enkäten publicerades via SOIF, Facebook gruppen Ortopedteknik i Sverige och NITO ortopedi.  Resultat: Faktorer som formade handlingsutrymmet, i situationer när ortopedingenjören upplevde stort inflytande, var främst patientrelaterade. De faktorer som beskrevs forma handlingsutrymmet vid upplevelsen av mindre inflytande var främst ekonomi och lagar/riktlinjer. Majoriteten av ortopedingenjörerna upplevde att de ofta kunde uppfylla patientens önskemål med avseende på sitt handlingsutrymme. Det förekom en delad mening om en förändring i förskrivningsprocessen behövde ske eller ej. En stor del av ortopedingenjörerna upplevde att de alltid haft möjlighet att påverka ett beslut vid förskrivning av en protes eller proteskomponent, medan ett mindre antal ortopedingenjörer har upplevt en eller flera situationer där beslutet inte kunnat påverkats. Slutsats: Ortopedingenjörer har varierande upplevelser gällande sitt handlingsutrymme, faktorer som formar handlingsutrymmet och möjligheten att påverka handlingsutrymmet vid förskrivning av proteser för nedre extremiteter. / Background: The task of the prosthetist is to provide an orthopaedic solution that meets the patient´s needs and wishes with expertise and experience. The discretion of action is the space that a prosthetist must make independent decisions in his professional practice and are thus the sum of skills, assessments and procedures within the discretion of the business. Purpose: The purpose of the study was to increase knowledge of the prosthetist perceived discretion in Sweden and Norway in relation to the prescription rules for lower limb prosthetics.  Method: The study was based on a survey that addressed questions regarding prosthetist perceived discretion for action through a mixed method. The survey was published via SOIF, the Facebook group Orthopaedics in Sweden and NITO orthopaedics. Results: Factors that affected the action of discretion, in situations when the prosthetist experienced great influence, were mainly related to the patient. In opposite, when the prosthetist experienced less influence, the main factors that affected a decision regarding a prosthetic where economy and laws/guidelines. The majority of prosthetists felt that they were often able to fulfil the patient’s request regarding to their discretion of action. In consideration to if the prescription process were in need of change or not, the opinion was divided. Many of the prosthetists have always experienced that they’re in charge of decision making or at least have been able to affect the decision. While a small number of prosthetists have experienced one or multiple situations where they could not affect the decision.  Conclusion: Prosthetists have varying experiences regarding their discretion, factors that shape the discretion and the ability to influence the discretion when prescribing prosthetics for lower limb.

Adaptive sports programs (ASPs) are important for enhancing the physical, psychological, and social aspects of life for amputee combat veterans while reducing the risk of depression and anger. Although the role of ASPs in improving quality of life (QoL) has been researched in relation to amputee combat veterans of World War II, the Korean War, and the Vietnam War, there has been limited examination of the role of ASPs in improving QoL among veterans of Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation Noble Eagle (OND). Therefore, the purpose of this study was to assess the effects of ASPs on the QoL of amputee veterans of OEF, OIF, and OND using logistic regression as well as 3 surveys assessing QoL and life satisfaction in combat veterans who suffered traumatic amputations between 2003 and 2013. The dependent and independent variables included psychosocial and behavioral factors for those amputees who participated in an ASP versus those amputees who did not. There was a statistically significant association (ï?£2(4) = 13.44, p < 0.003) between gender and perception of overall health. Likewise, there was a statistically significant association (ï?£2(2) = 15.63, p < 0.000) between enjoying life and having a meaningful life and participation in an ASP. The findings indicate that participation in ASPs may help improve QoL and overall health for amputee veterans. Public health programs and policies aimed at improving the overall health and wellbeing of amputee veterans should consider ASPs as essential therapeutic interventions for promoting health in amputee veteran populations.

In this paper we use multivariate statistical techniques to gain insights into how adaptive gait involving obstacle crossing is regulated in lower-limb amputees compared to able-bodied controls, with the aim of identifying underlying characteristics that differ between the two groups and consequently highlighting gait deficits in the amputees. Eight unilateral trans-tibial amputees and twelve able-bodied controls completed adaptive gait trials involving negotiating various height obstacles; with amputees leading with their prosthetic limb. Spatiotemporal variables that are regularly used to quantify how gait is adapted when crossing obstacles were determined and subsequently analysed using multivariate statistical techniques. There were fundamental differences in the adaptive gait between the two groups. Compared to controls, amputees had a reduced approach velocity, reduced foot placement distance before and after the obstacle and reduced foot clearance over it, and reduced lead-limb knee flexion during the step following crossing. Logistic regression analysis highlighted the variables that best distinguished between the gait of the two groups and multiple regression analysis (with approach velocity as a controlling factor) helped identify what gait adaptations were driving the differences seen in these variables. Getting closer to the obstacle before crossing it appeared to be a strategy to ensure the heel of the lead-limb foot passed over the obstacle prior to the foot being lowered to the ground. Despite adopting such a heel clearance strategy, the lead-foot was positioned closer to the obstacle following crossing, which was likely a result of a desire to attain a limb/foot angle and orientation at instant of landing that minimised loads on the residuum (as evidenced by the reduced lead-limb knee flexion during the step following crossing). These changes in foot placement meant the foot was in a different part of swing at point of crossing and this explains why foot clearance was considerably reduced in amputees. The results highlight that trans-tibial amputees use quite different gait adaptations to cross obstacles compared with controls (at least when leading with their prosthetic limb), indicating they are governed by different constraints; seemingly related to how they land on/load their prosthesis after crossing the obstacle. / Yes

Yes / Passive prosthetic devices are set up to provide optimal function at customary walking speed and thus may function less effectively at other speeds. This partly explains why joint kinetic adaptations become more apparent in lower-limb amputees when walking at speeds other than customary. The present study determined whether a trans-tibial prosthesis incorporating a dynamic-response foot that was attached to the shank via an articulating hydraulic device (hyA-F) lessened speed-related adaptations in joint kinetics compared to when the foot was attached via a rigid, non-articulating attachment (rigF). Eight active unilateral trans-tibial amputees completed walking trials at their customary walking speed, and at speeds they deemed to be slow-comfortable and fast-comfortable whilst using each type of foot attachment. Moments and powers at the distal end of the prosthetic shank and at the intact joints of both limbs were compared between attachment conditions. There was no change in the amount of intact-limb ankle work across speed or attachment conditions. As speed level increased there was an increase on both limbs in the amount of hip and knee joint work done, and increases on the prosthetic side were greater when using the hyA-F. However, because all walking speed levels were higher when using the hyA-F, the intact-limb ankle and combined joints work per meter travelled were significantly lower; particularly so at the customary speed level. This was the case despite the hyA-F dissipating more energy during stance. In addition, the amount of eccentric work done per meter travelled became increased at the residual knee when using the hyA-F, with increases again greatest at customary speed. Findings indicate that a trans-tibial prosthesis incorporating a dynamic-response foot reduced speed-related changes in compensatory intact-limb joint kinetics when the foot was attached via an articulating hydraulic device compared to rigid attachment. As differences between attachment conditions were greatest at customary speed, findings indicate a hydraulic ankle-foot device is most effectual at the speed it is set-up for.

Yes / Background Previous research has shown that use of a dynamic-response prosthetic foot (DRF) that incorporates a small passive hydraulic ankle device (hyA-F), provides certain biomechanical benefits over using a DRF that has no ankle mechanism (rigA-F). This study investigated whether use of a hyA-F in unilateral trans-tibial amputees (UTA) additionally provides metabolic energy expenditure savings and increases the symmetry in walking kinematics, compared to rigA-F. Methods Nine active UTA completed treadmill walking trials at zero gradient (at 0.8, 1.0, 1.2, 1.4, and 1.6 of customary walking speed) and for customary walking speed only, at two angles of decline (5° and 10°). The metabolic cost of locomotion was determined using respirometry. To gain insights into the source of any metabolic savings, 3D motion capture was used to determine segment kinematics, allowing body centre of mass dynamics (BCoM), differences in inter-limb symmetry and potential for energy recovery through pendulum-like motion to be quantified for each foot type. Results During both level and decline walking, use of a hyA-F compared to rigA-F significantly reduced the total mechanical work and increased the interchange between the mechanical energies of the BCoM (recovery index), leading to a significant reduction in the metabolic energy cost of locomotion, and hence an associated increase in locomotor efficiency (p < 0.001). It also increased inter-limb symmetry (medio-lateral and progression axes, particularly when walking on a 10° decline), highlighting the improvements in gait were related to a lessening of the kinematic compensations evident when using the rigA-F. Conclusions Findings suggest that use of a DRF that incorporates a small passive hydraulic ankle device will deliver improvements in metabolic energy expenditure and kinematics and thus should provide clinically meaningful benefits to UTAs’ everyday locomotion, particularly for those who are able to walk at a range of speeds and over different terrains. / Engineering and Physical Sciences Research Council(EPSRC, reference EP/H010491/1).

Amputation patients have a great deal more than just physical recovery to contend with and the extent and scope of this condition is largely unknown in South Africa. Rehabilitation programmes for amputees, specifically at state institutions are characterised by lack of resources, lack of information provided to patients and the patients themselves seem to experience lack of support on an emotional and psychological level. This study investigates the experience of self of the amputation patient through a review of the literature available and from an ecosystemic-postmodernist viewpoint. In addition, guided imagery is examined as a technique that could add value to rehabilitation programmes for amputation patients. Health care professionals in two state hospitals in Pretoria were interviewed by means of semi-structured questionnaires to obtain additional information on current rehabilitation programmes as well as the experience of the amputation and the subsequent process for the amputee. Themes extracted from these questionnaires were used to design a suggested rehabilitation programme. This programme, based on the findings of the research, suggests certain enhancements to existing programmes and is focussed on supporting the experience of the process for the amputee through inclusion of specific guided imagery texts. / Psychology / M.A.(Clinical Psychology)