Abstract
This systematic review has contributed to the understanding of the occupational therapy practice in the rehabilitation of older adults with lower limb amputations. It has highlighted gaps in evidence that occupational therapists need to address urgently in order to inform their rehabilitation programmes with this client group.
Introduction
In the United Kingdom major reforms are occurring within health and social care. Targets, such as waiting and readmission time, will be replaced with the collection of quality of care data related to five key aims:
reventing people from dying prematurely;
enhancing the quality of life of people with long-term conditions;
helping people to recover from episodes of ill health or following injury;
ensuring that people have a positive experience of care;
treating and caring for people in a safe environment and protecting them from avoidable harm. 1
In regards to older adults with lower limb amputations these aims should be particularly welcomed as many of them have not been achieved. Still, most of these aims may be met if older adults have access to, and receive adequate and skilled rehabilitation from, dedicated and trained professionals.
The importance and the value of rehabilitation have been highlighted as key factors to ensure the health and well-being of older adults.2-4 Indeed, Harris et al. 5 have emphasized the need for ‘aggressive rehabilitation’ for older adults to achieve their rehabilitation goals. Singh et al. 6 have suggested that during the rehabilitation phase, when the individual learns new skills and regains independence, signs of anxiety and depression significantly reduce. However, there is evidence that older adults are discharged before reaching their optimal level of functioning and are more likely to develop new functional deficits during hospitalization.7,8 Similar findings have been reported for older adults who have experienced a lower limb amputation. Frykberg et al.’s 9 study of 41 patients over 80 years old showed that the postoperative functional status remained unchanged in 40% and worsened in 55% of the participants, while the residential status was unchanged in 68% and worsened in 32% of participants. A study by Bäck-Pettersson and Björkelund 10 conducted in Sweden showed that the older patients who survived six months after amputation had permanent problems in the area of nutrition, elimination, skin ulceration, sleep, pain and pain alleviation. The patients who died during hospitalization and within six months after amputation (13 out of 45 adults over 60 years of age) had also reported problems in these areas. These findings raise the importance of provision of adequate rehabilitation during hospital stay and community care after discharge so that the needs of older adults with lower limb amputations are met.
In addition there is a growing body of literature which highlights the importance of falls management for people with lower limb amputations. One study found that 20% of service users were likely to have a fall following amputation, mostly occurring between 7 am and 3 pm, with 18% of those resulting in injury. 11 Moreover, the mean survival of older patients with lower limb amputations is very low ranging between two and five years. 12 Hence, it has been suggested that health professionals need to focus on early coordinated postamputation rehabilitation programmes to avoid risk of further deterioration and failure among older adults with amputations and increase longevity. 13
The United Kingdom’s National Amputee Statistical Database (NASDAB) indicates that between April 2006 and March 2007 over half of all people referred were aged over 65 years, with more than a quarter aged 75 and over. With an increasing number of older adults undergoing lower limb amputations we need to ensure that they receive and have access to skilled rehabilitation professionals. 14 While occupational therapists are thought to be integral to the rehabilitation process of people with amputations, the effectiveness of the occupational therapy intervention for older adults with lower limb amputations has not been investigated. This is essential to facilitate the rehabilitation process. It will highlight areas of further research to clinicians and more importantly it will assist service users and their families to make evidence-based decisions regarding their rehabilitation programmes. The objective of the present systematic review is to identify the effectiveness of the occupational therapy practice with older adults with lower limb amputations.
Method
The following protocol was devised for this systematic review:
definition of the keywords and of the inclusion criteria;
search of the relevant published papers;
screening of the identified titles and abstracts;
full-text reading of the papers that passed through the screening;
critique of the papers that were found to be eligible from stage four – data extraction and analysis.
Definition of keywords and inclusion criteria and literature search
A group of expert clinicians and two academics were involved in the definition of the inclusion criteria and the keywords relevant to the occupational therapy practice. The studies which met the following inclusion criteria were considered as eligible:
Research studies using a quantitative, qualitative or mixed method.
Research studies of any design.
Studies including participants with unilateral or bilateral lower limb amputation (at least 40% of the whole sample in case of a mixed population).
Studies including participants aged 65 years and older.
Studies that were researching the occupational therapy practice with this population.
Research published in English.
Research published in peer-reviewed journals.
The literature search was completed in two blocks. The first search used the keywords: ‘occupational therapy and lower limb amputation’ and ‘occupational therapy and lower limb amputation and older adults/elderly’. The second search used the keywords: ‘lower limb amputation’ in combination with one of the following keywords: ‘older adults/elderly’, ‘multidisciplinary’, ‘activities of daily living’, ‘bathing’, ‘self care’, ‘domestic’, ‘quality of life’, ‘rehabilitation’, ‘driving’, ‘housing’, ‘leisure’, ‘transfer’, ‘wheelchairs’, ‘prosthesis’, ‘outcome’, ‘cognition’, ‘falls’, ‘home visits’, ‘work’, ‘phantom pain’, ‘occupation’, ‘social’ and ‘skin’. In both blocks, the following electronic databases were searched: PUBMED, CINAHL, OT SEEKER and OTDBASE between January 1985 and January 2011. Occupational therapy is viewed as an emerging profession with a growing evidence base; therefore the shelf life of research articles is considered to be current even if these are around 20 years old.
Screening of the identified titles and abstracts and full-text reading
Two reviewers did the screening of the identified titles and abstracts and the full-text reading of those identified as eligible. Where there was debate or uncertainty, both reviewers met and decided which articles should be included in the final review. In order to further determine eligibility of the identified research papers, the reviewers reflected on the following questions:
Are occupational therapy practices with older adults with bilateral or unilateral lower limb amputation directly mentioned in the paper?
Are interventions/outcomes or assessments that are of relevance to occupational therapy mentioned?
Critique of the eligible full-text papers – data extraction and analysis
Both reviewers critiqued independently the full-text eligible papers. The following data were extracted from the identified papers:
the name of the author(s);
location of the study;
study objectives;
design, method and type of the study;
number and characteristics of the participants;
setting where the study took place;
ways of data collection;
outcome measures used in the study;
all reported results on outcomes and type of statistical analysis used.
After critiquing each paper, the limitations of the study, its quality score and the level of evidence were also reported. The quality score and the level of evidence were assessed based on the typology developed for this review. This typology involved a mixed methodology using designation of levels of evidence and markers related to the quality of the evidence. The designation of levels of evidence was used as a guide to summarize study designs according to their generally perceived capacity for causing bias. This was adapted from the
Each study was assessed for its quality based on the guidance suggested in the NSF. 16 Possible scores ranged from 0 to 10, with higher scores indicating a better study quality. The characteristics being assessed were:
clarity of the research question and research design of the study;
its methodological strengths and weaknesses;
the soundness of the statistical analysis;
the integrity of the study’s conclusions;
the potential for generalization of its results.
Each one of these characteristics was qualified for a maximum of two points. Further guidance was provided using the McMaster’s guiding questions on various designs and methods in quantitative and qualitative research.17,18
Results
The two searches yielded a total of 2,664 potential publications (533 in CINAHL and 2,131 in PUBMED). No relevant articles were identified in OTSEEKER or in OTDBASE. After the screening of their titles and abstracts four studies were identified as potentially eligible and their full-texts were retrieved.19-22 Two of these papers were excluded after reading the whole text20,21 as they did not meet the inclusion criteria with two papers qualifying for final inclusion.19,22 These papers were critiqued independently by both reviewers. There were no discrepancies on its quality assessment between the two appraisers.
Bilodeau et al. 19 conducted a quantitative cross-sectional survey. This was primary research of ‘level V’ evidence. They studied factors such as physical and mental health, rehabilitation, physical independence and satisfaction with the prosthesis to understand usage of prosthesis. In total, 65 unilateral vascular amputees were recruited through four hospitals of one semi-urban area in Canada. Eligible participants were of 60 years and older without severe cognitive problems, had been living at home, had received a prosthesis and were English or French speakers. Data were collected through the following methods:
medical records were searched for demographic information and frequency of therapy sessions;
telephone interviews were conducted to provide information on prosthesis use, physical independence, cognitive and physical health status;
ostal questionnaires were circulated to evaluate depressive moods and satisfaction.
The outcome measures used to collect data were:
a questionnaire on amputee activities developed by Day 23 to evaluate prosthesis’ use;
the Barthel index 24 to measure physical independence with personal care and mobility;
the satisfaction with the prosthesis (SATPRO) questionnaire 25 ;
the short portable mental status questionnaire for the elderly 26 to measure cognitive status;
the geriatric depression scale 27 ;
four self-perception questions from the OARS Multi-dimensional Functional Assessment Questionnaire (OMFAQ) to measure physical health. 28
The study found that 81% of the participants wore their prosthesis every day and 89% of this group wore it at least six hours per day. Prosthesis use was significantly related to the amputee’s physical independence (
This study obtained a 7 out of possible 10 quality score due to the limitations noted. As this was a survey using regression analysis, it explored the relationships between variables but did not determine cause and effect between these variables; therefore, further prospective studies are required to determine a causality pattern. The validity and reliability values of the applied assessment tools were not investigated for the sample of this study, which might raise concerns for the validity of the results. Also, the validity of the Day 23 questionnaire at its development was not reported. The assessment tools used in the study were based on self-reports, which might be a source of bias. The authors did not report conducting a power sample size calculation to justify the number of participants. Small sample sizes may result in an inability to demonstrate statistical significance of the results. Also, the magnitude of the correlation coefficients was not always reported, which made it difficult to interpret significance of the results at times. Further to the analysis of the data, it was not always clarified which statistical test was used for each reported result.
White 22 also conducted a mixed-method cross-sectional survey, which constituted primary research of ‘level V’ evidence. The author investigated the supply of wheelchair stump boards by the Disablement Services Authority (DSA) and their use by therapists and patients with amputation. Data collection was completed through three different ways:
a letter was sent to 14 regional managers of the DSA to supply information on policies and supply of stump boards. This achieved a return rate of 86%;
questionnaires were sent to 30 head occupational therapists to gather information on stump board use reaching 86% return rate;
questionnaires were sent to 12 older adults with amputations to obtain information on stump board use with a 100% response rate.
The findings indicated that all occupational therapists used stump boards with patients having below knee amputations and 50% of therapists used them with through knee amputations. Stump boards were prescribed for the prevention of contractures and the control of oedema. The comfort and protection of stump were also considered to be important factors for their provision. The Kings Mark 11 was the most commonly used stump board despite its reported disadvantages (i.e. being too short to support below knee stumps, obscuring brake lever when swung to the side for transfers, inability to be tilted to accommodate flexion contractures). However, older adults did not report any problems with transfers when using Kings boards. Older adults perceived that using a stump board had increased their comfort in a wheelchair, offered protection to the stump and encouraged them to accept their amputation.
This study obtained a quality score of 4 out of 10, due to the limitations related to its methodology, design and analysis of the results. The methods of the study were not clearly described and there was inadequate information about the characteristics of the patient group and the content of the postal questionnaires. The sample size, particularly of older adults and therapists, was too small resulting in a lack of generalization of the findings. Another major concern was that only percentages were presented for the results and there was no further statistical analysis. This does not allow making inferences about the findings for the wider population of people with amputations.
Discussion
While there is a growing body of research that demonstrates the effectiveness of occupational therapy with older adults,29-31 this systematic review identified only two papers that have evaluated at some level the occupational therapy interventions for older adults with lower limb amputations. This is surprising since occupational therapy has been firmly established within departments working with amputees in the United Kingdom and occupational therapists are regarded as an essential member of the multidisciplinary team for this group population. In March 2011, the College of Occupational Therapists (COT) published evidence-based guidelines for occupational therapists working with people who have had lower limb amputations. 32 The COT guidelines include studies with a broader age range of participants (i.e. 18 years and over) and studies that are of relevance to occupational therapy without necessarily researching specific occupational therapy practices. This was identified as a necessity in producing national guidelines due to the scarcity of evidence directly researching the occupational therapy practices.
The studies of Bilodeau et al. 19 and White 22 that have directly referred to occupational therapy practices reiterated the importance of the specialty in the rehabilitation of older adults with lower limb amputations. Yet, further research is needed in this area to demonstrate the effectiveness of these interventions. Bilodeau et al. 19 demonstrated that the frequency of the occupational therapy sessions was statistically significantly related to prosthesis use. However, the study did not describe the type of occupational therapy intervention that was followed by the various participants and this needs to be researched further so that health professionals are able to target effective rehabilitation programmes. Also, White 22 demonstrated that occupational therapists prescribe stump boards to prevent contractures and control oedema and that service users perceive positive benefits about these practices. However, the small sample size of this study and the lack of inferential statistics do not allow for generalization of these findings.
While recognizing the scarcity of research that has occurred, we suggest that the findings from published research related to general populations of older adults may be of interest in supporting occupational therapy interventions with older adults with lower limb amputations. The same could be applied to studies that evaluate rehabilitation practices which are of relevance to occupational therapy even if they do not make direct reference to occupational therapy. Such evidence can be matched to the proposed role of the occupational therapist in maintaining and restoring function in activities of daily living for people with disabilities.
Provision of assistive devices and modifications of equipment can be a key intervention in promoting independence in everyday activities, especially as the likelihood of requiring more assistive devises increases with older age.33,34 Occupational therapists are actively involved in the prescription and education of assistive technology. 35 While there has been some debate about its usage, Gitlin et al. 36 found that older adults with lower limb amputation used assistive devices with greater frequency than those with either a stroke or orthopaedic deficit.
Assessment of the home and community physical environment and environmental adaptations can be a major part of the rehabilitation process for older people with lower limb amputations. Over 30 years ago Van de Ven 37 conducted a survey into the management of bilateral leg amputees. The findings are of interest as they demonstrated that functional problems existed after discharge from hospital due to untimely home visits and lack of environmental adaptations. Indeed, Colin et al. 38 demonstrated that those who were partial walkers following a lower limb amputation had lower kitchen and domestic activity scores, which were due to a lack of environmental modifications to accommodate wheelchair use. Beekman and Axtell 39 suggest that older adults with above knee or through knee amputations should have access to a wheelchair during the prosthetic and postprosthetic stage of rehabilitation, which emphasizes the importance of timely environmental modifications to eliminate physical barriers both within and outside of the home.
The type and amount of rehabilitation and age have been acknowledged as critical factors related to functional outcomes for older adults following lower limb amputation.10,11,40,41 Older adults aged 85 and over with amputations may have different rehabilitation goals than those aged between 65 and 88 years. A study by von Faber et al. 42 showed that older adults aged 85 and over value well-being and social functioning higher than physical or psychocognitive functioning. Also, research by Williams et al. 43 suggests that among older persons who live alone and experience limb amputation due to chronic vascular disease or diabetes, interventions aiming to enhance relationship quality are warranted. Other contributing factors to functional decline during hospital stay are excessive bed rest and immobility. 44 There is evidence that therapeutic activities occupy only a minimal proportion of the hospital time and that most of their day is unoccupied.45-48 There is also a growing body of literature which highlights the importance of falls management for people with lower limb amputations.12,49-51 Occupational therapists should ensure that they are aware of the above evidence when they are devising rehabilitation programmes with older adults with lower limb amputations.
Gaps in evidence
There is a scarcity of research in evaluating the occupational therapy practices aiming to promote health and well-being for older adults with lower limb amputations. The key area of future research should focus on exploring the effectiveness of interventions in improving quality of life of the service users. This is of particular importance as quality of life following a lower limb amputation has been found to be lower than that of the general population, with much of this resulting from restricted mobility.52,53 It is also important to explore the occupational therapy outcomes in improving functional independence of the service users, as the findings of the study conducted by Đurović et al. 54 in Serbia challenged the importance of occupational therapy and physiotherapy in this area. The study examined pain characteristics, functional status, social function and living conditions in older adults with dysvascular unilateral amputations. Most participants achieved significant functional improvement and reduction of pain despite the limited access to occupational therapy and physiotherapy. It is also crucial to evaluate the older adults’ perceptions about the type of occupational therapy interventions. Indeed, it has been advocated that the key to understanding adjustment following lower limb amputation is the individual’s experience and preferences. 55
Conclusion
While there is strong evidence from well designed studies about the benefits of occupational therapy with older adults residing in the community,30,56 this systematic review has highlighted that the supporting research evidence for occupational therapy with older adults with lower limb amputations is limited and scarce. Therefore, it is suggested that occupational therapists need to take urgent action to address the identified evidence-based gaps. This would allow the development of informed interdisciplinary care pathways to enhance and maintain the health and well-being of older adults with lower limb amputations.
Footnotes
Acknowledgements
The authors would like to thank the Lower Limb Amputee - Practice Guidelines Development Group of the College of Occupational Therapists for their valuable help in defining key words and inclusion criteria relevant to the occupational therapy practice.
Funding
This work has been funded by the Knowledge Transfer Scheme of Brunel University [grant number KTSS 04/09].
Conflict of interest
The authors report no conflict of interest.