Artificial limb rehabilitation for older people with a leg amputated at or above the knee because of blood circulation problems

Problems with inadequate circulation in the legs (dysvascularity), particularly in people over the age of 60 years, can be so severe that they need a leg amputated. This may be as high as at or above the knee. Accompanying medical conditions (co-morbidities) such as diabetes, cardiovascular or heart disease can affect a person's rehabilitation. When an above or through knee artificial limb (prosthesis) is fitted, it is hard to regain mobility and function and some people choose to use a wheelchair. Motivation, comfort, cosmetic appearance, functionality, reliability, ease of use, previous mobility and the extra exertion needed to use an artificial leg are all potentially important factors that affect a person's independence and their use of the prosthesis. Fear of falling, number of falls, social circumstances, help and support from other people are also important influences. The review authors searched for trials comparing different types of rehabilitation that may benefit the mobility or function in older people using an artificial limb.

Only one controlled trial was found. This had a crossover design and each of the 10 participants had three seemingly identical prosthetic weights added to the prosthesis below the knee in a random order. The participants, nine men and one woman, were over 50 years of age and eight were over 60 years. Over the few hours of the trial, four participants preferred the lightest weight (150 g), five preferred the medium weight (770 g) and one preferred the heaviest weight (1625 g). Seven of the 10 people successfully ranked the weights from lightest to heaviest. The weights did not alter the participant's walking speed in a two-minute walk test.

The small number of participants, short exposure to the different weights in a laboratory setting and the fact that there were differences in weight between people and also their prosthesis limits the usefulness of these findings. The artificial limbs were all modular style prostheses.

Authors' conclusions: 

There is a lack of evidence from randomised controlled trials to inform the choice of prosthetic rehabilitation, including the optimum weight of prosthesis, after unilateral transfemoral amputation in older dysvascular people. A programme of research, including randomised controlled trials to examine key interventions, is urgently required in this area.

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Background: 

Dysvascularity accounts for 75% of all lower limb amputations in the UK. Around 37% of these are at transfemoral level (mid-thigh), with the majority of people being over the age of 60 and having existing co-morbidities. A significant number of these amputees will be prescribed a lower limb prosthesis for walking. However, many amputees do not achieve a high level of function following prosthetic rehabilitation. This is the second update of the review first published in 2005.

Objectives: 

We aimed to identify and summarise the evidence from randomised controlled trials evaluating rehabilitation interventions for prosthetic ambulation following unilateral transfemoral amputation in older dysvascular people, whether community dwelling or institutionalised.

Search strategy: 

For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator (TSC) searched the Specialised Register (last searched July 2014) and Cochrane Register of Studies (CRS) (last searched 2014 Issue 6). No language restrictions were applied.

Selection criteria: 

Randomised and quasi-randomised controlled trials testing prosthetic rehabilitation interventions following a unilateral transfemoral or transgenicular amputation in older (aged 60 years or above) dysvascular people.

Data collection and analysis: 

Two authors independently scanned the search results for potentially eligible studies and on obtaining full reports of these, selected studies for inclusion and exclusion. Two authors independently assessed methodological quality and extracted data. No data pooling was possible.

Main results: 

No new studies were identified for inclusion in this update. Of the full reports obtained for consideration, one trial was included and four excluded. The included trial was a short-term crossover randomised trial which tested the effects of adding three seemingly identical prosthetic weights (150 g versus 770 g versus 1625 g) to the prostheses of 10 participants with unilateral dysvascular transfemoral amputation. Eight participants were over 60 years of age. The trial found that four participants preferred the lightest weight (150 g), five preferred the middle weight (770 g) and one preferred the addition of the heaviest weight (1625 g).

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