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Functioning in prosthetic users provided with and without a microprocessor-controlled prosthetic knee – relative effects on mobility, self-efficacy and attentional demand
Jönköping University, School of Health and Welfare, HHJ, Dep. of Nursing Science. Jönköping University, School of Health and Welfare, HHJ. ADULT.
2019 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: To undergo a lower limb amputation is a traumatic experience affecting the individual on physical as well as psychological levels and often leading to limitations in a person´s daily life. Following an amputation individual often receive a prosthesis to address impairments in mobility and functioning. The mechanical properties of the prosthesis can vary, and the choice of specific components to include in the device has been demonstrated to influence patient outcomes. Studies investigating the relative effects of different prosthetic knee components have generally focused upon physical and biomechanical outcomes, providing a rather narrow view of health-related states in prosthetic users. There is a need to view health and wellbeing of prosthetic users from a broader perspective by evaluating outcomes that reflect a variety of different factors that can influence their functioning.

Aim: The overall aim of this thesis was to describe and compare functioning in individuals with a trans-femoral amputation or knee disarticulation and to evaluate the relative effects of using non-microprocessor-controlled prosthetic knees (non-MPK) or microprocessor-controlled prosthetic knees (MPK).

Methods: The four studies presented in this thesis used a cross-sectional, quantitative design with different types of data collection methods. These included self-report measures, capacity tests, a survey with two questionnaires and a measure of cortical brain activity during normal level waking and while performing a secondary task. One group of 42 individuals with lowerlimb amputations, using a prosthetic knee with or without microprocessor-control was included in the survey study. Another group of 29 individuals with a lower limb amputation, using a prosthetic knee with or without a microprocessor-control and a control group (n=16) participated in the remaining studies. Statistical tests were used to compare differences between groups using different knee joints, between prosthesis users and controls.

Results: Individuals using a non-MPK had lower self-reported mobility and balance confidence as well as poorer results on mobility tests compared to those using an MPK. Results revealed no significant differences in self-rated health, daily step count or general self-efficacy. Increased cortical brain activity was seen in frontal cortex in individuals using a non-MPK in single-task walking compare to the MPK group and controls. A significant increase in brain activity was also seen in prefrontal cortex in dual-task walking compared to single-task walking in those walking with an MPK and controls.

Conclusion: Combined results of all four studies suggest that persons provided with an MPK had better mobility, both self-rated and objectively evaluated, and better self-rated balance confidence than those who were using a non-MPK. Results also showed that an individual’s belief in their own ability was associated with the number of hours they use their prosthesis per week. Participants using a non-MPK had higher levels of cortical brain activity in the frontal cortex during walking, suggesting that the attentional demand required to walk was greater than for individuals using an MPK. Of particular interest for health professionals involved in prosthetic rehabilitation was the finding that significant increases in attentional demand were not always reflected in temporospatial gait parameters. This suggests that cognitive demands may not always be reflected in variables that are commonly evaluated in the clinical setting.

Abstract [sv]

Bakgrund: En amputation av nedre extremiteten är en traumatisk upplevelse som påverkar den drabbade personen både fysisk och psykiskt och som ofta leder till begränsningar i det dagliga livet. Efter amputationen utprovas vanligen en protes för att möjliggöra mobilitet och god funktion. Protesens mekaniska egenskaper kan variera och valet av specifika proteskomponenter har visat sig påverka individens funktionsförmåga. Studier avseende relativa effekter av olika typer av protesknäleder har generellt sett fokuserat på fysiska och biomekaniska variabler, vilket ger en ganska snäv bild av protesanvändarens hälsorelaterade tillstånd. Det finns ett behov av att bredda perspektivet av hälsa och välmående hos protesanvändare genom att studera en större variation av faktorer som kan påverka individens funktionstillstånd.

Syfte: Det övergripande syftet med avhandlingen var att beskriva och jämföra funktionen hos personer med en transfemoral amputation eller en knädisartikulation och att utvärdera den relativa effekten av att använda en icke-datastyrd protesknäled (non-MPK) respektive en datastyrd protesknäled (MPK).

Metod: Samtliga fyra studier i avhandlingen är kvantitativa tvärsnittsstudier, men innefattar olika datainsamlingsmetoder. Dessa innefattar självskattningsinstrument, funktionstester, enkätstudie med två frågeformulär samt mätning av hjärnaktivitet vid vanligt gående på plan mark samt vid gående med tillägg av en ytterligare samtidig uppgift. En grupp bestående av 42 personer med benamputation som använder en protesknäled med eller utan datastyrning inkluderades i enkätstudien. En annan grupp bestående av 29 personer som använder en protesknäled med eller utan datastyrning samt en kontrollgrupp (n=16) deltog i de övriga studierna. Statistiska analyser utfördes för att jämföra grupperna som använde olika protesknäleder samt för att jämföra protesanvändare och kontroller.

Resultat: Personer som använde en non-MPK rapporterade sämre mobilitet och tillit till sin balans och hade sämre resultat på funktionstesterna än de som använde en MPK. Resultatet påvisade ingen signifikant skillnad mellan grupperna vad gäller självskattad generell hälsa, tilltro till sin egen förmåga eller antal steg per dag. Resultatet påvisade ökad frontal hjärnaktivitet vid vanligt gående på plan mark hos de individer som använde en non-MPK jämfört med de som använde en MPK och jämfört med kontrollgruppen. 71 Signifikant ökad hjärnaktivitet i prefrontala cortex sågs även hos MPKgruppen och kontrollgruppen då ytterligare en uppgift adderades vid gång i jämförelse med gående utan annan uppgift.

Slutsatser: Det sammanslagna resultatet av de fyra studierna tyder på att personer som har blivit försedda med en MPK har bättre mobilitet, både självskattat och objektivt värderad, samt rapporterar bättre tillit till sin balans än de som är försedda med en non-MPK. Resultatet visar också att hög tilltro till sin egen förmåga är associerat med att man använder sin protes mer. Deltagare som använde en non-MPK uppvisade mer hjärnaktivitet vid gång vilket tyder på att de behöver rikta mer uppmärksamhet åt att gå än de som använde en MPK.

Av särskilt intresse för yrkesverksamma inom protesrehabilitering är de fynd som visade att ökad grad av uppmärksamhet inte belystes i de temporospatiala gångparametrarna. Detta skulle kunna indikera att kognitiv belastning inte reflekteras i de gångvariabler som vanligtvis undersöks i klinisk verksamhet.

Place, publisher, year, edition, pages
Jönköping: Jönköping University, School of Health and Welfare , 2019. , p. 94
Series
Hälsohögskolans avhandlingsserie, ISSN 1654-3602 ; 097
Keywords [en]
amputation, trans-femoral amputation, adaptive prosthetic knee, prosthetic limb, self-report, mobility, self-efficacy, attention, brain, gait, neuroimaging, functional near-infrared spectroscopy, cognitive load, brain activity
National Category
Orthopaedics
Identifiers
URN: urn:nbn:se:hj:diva-43504ISBN: 978-91-85835-96-6 (print)OAI: oai:DiVA.org:hj-43504DiVA, id: diva2:1306249
Public defence
2019-05-24, Forum Humanum, School of Health and Welfare, Jönköping, 13:00 (English)
Opponent
Supervisors
Available from: 2019-04-23 Created: 2019-04-23 Last updated: 2019-04-23Bibliographically approved
List of papers
1. Differences in mobility for individuals using a non-microprocessor-controlled versus a microprocessor-controlled prosthetic knee
Open this publication in new window or tab >>Differences in mobility for individuals using a non-microprocessor-controlled versus a microprocessor-controlled prosthetic knee
(English)Manuscript (preprint) (Other academic)
National Category
Orthopaedics
Identifiers
urn:nbn:se:hj:diva-43502 (URN)
Note

Submitted to journal.

Available from: 2019-04-23 Created: 2019-04-23 Last updated: 2019-04-26
2. Perceived self-efficacy and specific self-reported outcomes in persons with lower-limb amputation using a non-microprocessor-controlled versus a microprocessor-controlled prosthetic knee
Open this publication in new window or tab >>Perceived self-efficacy and specific self-reported outcomes in persons with lower-limb amputation using a non-microprocessor-controlled versus a microprocessor-controlled prosthetic knee
2018 (English)In: Disability and Rehabilitation: Assistive Technology, ISSN 1748-3107, E-ISSN 1748-3115, Vol. 13, no 3, p. 220-225Article in journal (Refereed) Published
Abstract [en]

Purpose: To measure self-efficacy in a group of individuals who have undergone a lower-limb amputation and investigate the relationship between self-efficacy and prosthetic-specific outcomes including prosthetic use, mobility, amputation-related problems and global health. A second purpose was to examine if differences exist in outcomes based upon the type of prosthetic knee unit being used.

Method: Cross-sectional study using the General Self-Efficacy (GSE) Scale and the Questionnaire for Persons with a Transfemoral Amputation (Q-TFA). Forty-two individuals participated in the study. Twenty-three used a non-microprocessor-controlled prosthetic knee joint (non-MPK) and 19 used a microprocessor-controlled prosthetic knee joint (MPK).

Results: The study sample had quite high GSE scores (32/40). GSE scores were significantly correlated to the Q-TFA prosthetic use, mobility and problem scores. High GSE scores were related to higher levels of prosthetic use, mobility, global scores and negatively related to problem score. No significant difference was observed between individuals using a non-MPK versus MPK joints. Conclusions: Individuals with high self-efficacy used their prosthesis to a higher degree and high self-efficacy was related to higher level of mobility, global scores and fewer problems related to the amputation in individuals who have undergone a lower-limb amputation and were using a non-MPK or MPK knee. Implications for rehabilitationPerceived self-efficacy has has been shown to be related to quality of life, prosthetic mobility and capability as well as social activities in daily life. Prosthetic rehabilitation is primary focusing on physical improvement rather than psychological interventions. More attention should be directed towards the relationship between self-efficacy and prosthetic related outcomes during prosthetic rehabilitation after a lower-limb amputation. 

Place, publisher, year, edition, pages
Taylor & Francis, 2018
Keywords
amputation, prosthetic knee, prosthetic limb, Self-efficacy, trans-femoral amputation
National Category
Orthopaedics
Identifiers
urn:nbn:se:hj:diva-35377 (URN)10.1080/17483107.2017.1306590 (DOI)000438482500002 ()28366038 (PubMedID)2-s2.0-85016483788 (Scopus ID)
Available from: 2017-04-18 Created: 2017-04-18 Last updated: 2019-04-23Bibliographically approved
3. Reduced cortical brain activity with the use of microprocessor-controlled prosthetic knees during walking
Open this publication in new window or tab >>Reduced cortical brain activity with the use of microprocessor-controlled prosthetic knees during walking
2018 (English)In: Prosthetics and orthotics international, ISSN 0309-3646, E-ISSN 1746-1553Article in journal (Refereed) Epub ahead of print
Abstract [en]

Background: Individuals using a lower-limb prosthesis indicate that they need to concentrate on every step they take. Despite self-reports of increased cognitive demand, there is limited understanding of the link between cognitive processes and walking when using a lower-limb prosthesis.

Objective: The objective was to assess cortical brain activity during level walking in individuals using different prosthetic knee components and compare them to healthy controls. It was hypothesized that the least activity would be observed in the healthy control group, followed by individuals using a microprocessor-controlled prosthetic knee and finally individuals using a non-microprocessor-controlled prosthetic knee.

Study Design: Cross-sectional study.

Methods:: An optical brain imaging system was used to measure relative changes in concentration of oxygenated and de-oxygenated haemoglobin in the frontal and motor cortices during level walking. The number of steps and time to walk 10 m was also recorded. The 6-min walk test was assessed as a measure of functional capacity.

Results: Individuals with a transfemoral or knee-disarticulation amputation, using non-microprocessor-controlled prosthetic knee ( n = 14) or microprocessor-controlled prosthetic knee ( n = 15) joints and healthy controls ( n = 16) participated in the study. A significant increase was observed in cortical brain activity of individuals walking with a non-microprocessor-controlled prosthetic knee when compared to healthy controls ( p < 0.05) and individuals walking with an microprocessor-controlled prosthetic knee joint ( p < 0.05).

Conclusion: Individuals walking with a non-microprocessor-controlled prosthetic knee demonstrated an increase in cortical brain activity compared to healthy individuals. Use of a microprocessor-controlled prosthetic knee was associated with less cortical brain activity than use of a non-microprocessor-controlled prosthetic knee.

Clinical Relevance: Increased understanding of cognitive processes underlying walking when using different types of prosthetic knees can help to optimize selection of prosthetic components and provide an opportunity to enhance functioning with a prosthesis.

Keywords
Attention, artificial limb, brain, gait, neuroimaging
National Category
Orthopaedics
Identifiers
urn:nbn:se:hj:diva-42040 (URN)10.1177/0309364618805260 (DOI)30375285 (PubMedID)
Available from: 2018-11-15 Created: 2018-11-15 Last updated: 2019-04-23
4. Cortical brain activity of transfemoral or knee-disarticulation prosthesis users performing single and dual-task walking activities
Open this publication in new window or tab >>Cortical brain activity of transfemoral or knee-disarticulation prosthesis users performing single and dual-task walking activities
(English)Manuscript (preprint) (Other academic)
National Category
Orthopaedics
Identifiers
urn:nbn:se:hj:diva-43503 (URN)
Available from: 2019-04-23 Created: 2019-04-23 Last updated: 2019-04-26

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