Disability and Rehabilitation: Assistive Technology

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Functional capacity of elderly with lower-limb

amputation after prosthesis rehabilitation: a
longitudinal study

Alana das Mercês Silva, Graziella Furtado, Isaias Pimentel dos Santos, Cecília
Barbosa da Silva, Larissa Rocha Caldas, Kionna Oliveira Bernardes & Daniel
Dominguez Ferraz

To cite this article: Alana das Mercês Silva, Graziella Furtado, Isaias Pimentel dos Santos,
Cecília Barbosa da Silva, Larissa Rocha Caldas, Kionna Oliveira Bernardes & Daniel Dominguez
Ferraz (2019): Functional capacity of elderly with lower-limb amputation after prosthesis
rehabilitation: a longitudinal study, Disability and Rehabilitation: Assistive Technology, DOI:
10.1080/17483107.2019.1684581

To link to this article: https://doi.org/10.1080/17483107.2019.1684581

Published online: 05 Nov 2019.

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DISABILITY AND REHABILITATION: ASSISTIVE TECHNOLOGY
https://doi.org/10.1080/17483107.2019.1684581

ORIGINAL RESEARCH

Functional capacity of elderly with lower-limb amputation after prosthesis

rehabilitation: a longitudinal study
Alana das Merc^es Silvaa, Graziella Furtadoa, Isaias Pimentel dos Santosa, Cecılia Barbosa da Silvab,
Larissa Rocha Caldasb, Kionna Oliveira Bernardesa and Daniel Dominguez Ferraza
a
Department of Physiotherapy, Federal University of Bahia, Salvador, Brazil; bState Center for the Prevention and Rehabilitation of Persons with
Disabilities, Salvador, Brazil

ABSTRACT ARTICLE HISTORY

Objectives: Elderly amputees are a specific clientele because of the interaction of this disease with the Received 6 March 2019
ageing process. The objective of this study was to determine the impact of prosthesis rehabilitation on Accepted 21 October 2019
the functional capacity of elderly with lower-limb amputation (LLA) in short and long time.
KEYWORDS
Materials and methods: A quasi-experimental study was developed. The sample consisted of 29 elderly
Aged; amputation; activities
with LLA who finished the prosthesis rehabilitation programme. Gait capacity was evaluated by of daily living; artificial
Functional Ambulation Classification Scale (FAC), ability to perform basic activities of daily living (ADL) limbs; physical
was evaluated by Barthel Index (BI) and Pfeffer Questionnaire was used to evaluate the capacity to exe- therapy modalities
cute instrumental ADL. Statistical inference was done by t-test, t-student test and chi-squared test. The
significance level was fixed at 5% (p < 0.05).
Results: In the transtibial group (n ¼ 15) no difference (p ¼ 0.108) was found between BI score before
amputation and after 3 months of follow up. The transfemoral group (n ¼ 14) improved significantly
(p ¼ 0.045) the FAC before starting and after 3 months of discharge from ambulatory rehabilitation. Both
groups increased the time of prosthesis use during the day after 3 months of follow up. However, no
group has achieved FAC and Pfeffer Questionnaire pre-amputation performance.
Conclusion: Although elderly with LLA improved functional capacity after 3 months of a prosthesis
rehabilitation programme, they did not achieve their pre-amputation functionality.

ä IMPLICATIONS FOR REHABILITATION

 Lower-limb amputation causes a significant socioeconomic impact and decreases functional capacity,
autonomy and quality of life. Elderly people with a lower-limb amputation impose a heavy burden
on health resources, requiring extensive rehabilitation and long term care. The specific presentation
of elderly persons with lower-limb amputation, with multiple physical, psychological, cognitive, and
social comorbidities, imposes unique challenges to ongoing care. The potential bias from the inclu-
sion of younger patients into a study with an elderly population with lower-limb amputation sup-
ports the need for independent investigation.
 In our study we verified that although elderly with transfemoral or transtibial amputation have
improved their functional independence after lower-limb prosthesis rehabilitation, they could not
achieve their functional capacity before amputation. This improvement especially occurred for the
basic activities of daily living, however elderly patients with transfemoral amputations presented
greater difficulty in improving functional capacity.
 These results support that being able to better select elderly by their mobility potential and environ-
mental barriers, is an important goal for future research to aim toward those who will achieve and
maintain prosthetic walking or those who could better focus on regaining nonprosthetic mobility.

Introduction Coronary artery disease, peripheral vascular disease, retinop-

Ageing population is a worldwide process that has accelerated in
Brazil since 1960 [1]. According to the Brazilian Institute of
Geography and Statistics [2], the number of individuals over
60 years of age has increased substantially. A decrease in infec-
tious disease incidence and increasing of chronic diseases are
some ageing consequences for health [3]. Among chronic dis-
eases, diabetes mellitus (DM) stands out for its high incidence in
the world [4]. It is estimated that there are more than 171 million
diabetic people in the world and this number can reach 366 mil-
lion by 2030 [5].
athy, nephropathy and neuropathy are chronic DM complications
[6]. Peripheral neuropathy is closely linked to lower-limb injuries,
and diabetic foot is one of the main complications of DM and
results in a large number of amputations and hospitalizations in
this population [7].
It was estimated that 10–25% of patients with DM have a
lower-limb lesion and 14–24% suffer an amputation [8]. Lower-
limb amputation (LLA) causes a significant socioeconomic impact
and decreases functional capacity, autonomy, and quality of life
[9]. The therapeutic intervention is multidisciplinary and plays an

CONTACT Daniel Dominguez Ferraz danieldf@ufba.br Departamento de Fisioterapia, Instituto de Ci^encias da Sa
ude, Avenida Reitor Miguel Calmon, s/n,
Canela, Salvador, Bahia 40231-300, Brazil
ß 2019 Informa UK Limited, trading as Taylor & Francis Group
2 A. M. SILVA ET AL.

important role in functional re-education, stimulating patients to A descriptive statistical analysis was carried out. The distribu-
overcome their limitations [10]. tion of variables was assessed by Shapiro–Wilk test. Quantitative
The lower-limb prosthesis (LLP) plays an important role in variables were reflected in mean and standard deviation and
restoring and/or improving physical capacity, body image and the qualitative variables in absolute and relative frequencies.
ability to carry out activities of daily living (ADL) independently Statistical inference was done by t-test, t-student test and chi-
[11]. A good prognosis depends on physical and cognitive aspects squared test. The significance level was fixed at 5% (p < 0.05). The
and prosthesis adaptation [11]. statistical programme used was Statistical Package for the Social
Elderly people with an LLA impose a heavy burden on health Sciences (SPSS version 22, IBM, Armonk, NY).
resources, requiring extensive rehabilitation and long term care
[12]. The specific presentation of elderly persons with LLA, with
Results
multiple physical, psychological, cognitive, and social comorbid-
ities, imposes unique challenges to ongoing care [12]. During the recruitment process, 35 elderly individuals were
The potential bias from the inclusion of younger patients into invited, 1 candidate declined to participate and 34 volunteers
a study with an elderly population with LLA supports the need were evaluated and divided into two groups: group 1 (G1) com-
for an independent investigation [13]. There are few studies that posed by elderly with transtibial amputation (n ¼ 15) and group 2
have investigated epidemiological and functional aspects of the (G2) composed by elderly with transfemoral amputation (n ¼ 14).
elderly with LLA after rehabilitation process. Thus, this study Four participants were lost because of phone contact inconsisten-
aimed to verify functional capacity of the elderly people with LLA cies and a total of 29 elderly participated in the study.
before amputation, during the discharge period from ambulatory The two groups presented comparable epidemiological meas-
rehabilitation and after one and 3 months of follow up. urements, education level and the number of fallers. However,
there were more women in G1 (n ¼ 9) than in G2 (n ¼ 5). The G1
also presented a worse body mass index compared with G2
Materials and methods (Table 1).
This is a quasi-experimental study conducted in a public centre After 3 months of follow up, 86.7% of the participants with
for the prevention and rehabilitation of people with disabilities. transtibial amputation and 78.6% of the participants with transfe-
Data collection occurred between June 2016 and February 2018. moral amputation were using the LLP to walk. Both groups
The study was carried out in accordance with the Declaration of improved the time of prosthesis use over time and the capacity
Helsinki and approved by an Ethics Human Research Committee to walk out of the neighbourhood. Table 2 presents results about
(ref no. 1.486.323). All participants provided voluntary written the use of LLP by the participants.
informed consent. Both groups decline significantly BI, FAC and Pfeffer
The sample consisted of the elderly with transtibial or transfe- Questionnaire after the amputation. Only G2 presented significant
moral amputation. All participants were receiving discharge from improvement on FAC after 3 months of follow up. No group
ambulatory rehabilitation and complied with the inclusion and improved the capacity to develop instrumental ADL. Table 3
exclusion criteria. The inclusion criteria were: 60 years of age, shows BI, FAC and Pfeffer Questionnaire data before and after the
transfemoral or transtibial amputation and telephone contact. The amputation, and after 1 and 3 months of LLP rehabilita-
exclusion criteria were: total impairment of vision or hearing, cog- tion process.
nitive impairment, and bilateral amputation. Total impairment on There was no significant difference between G1 and G2 in BI,
vision or hearing should be biased because it could interfere with FAC and Pfeffer Questionnaire scores before and after LLA, and
the participants’ functionality. also after 1 and 3 months of follow up (Table 4).
Data collection included the patient’s name, age, sex, address,
telephone number, marital status, educational level, occupation, Discussion
weight, height, body mass index (BMI), the occurrence of falls and
In this study, the elderly with transtibial and transfemoral amputa-
amputation level. A form was employed in the last week of ambu-
tion had a significant reduction in their gait capacity and ability
latory rehabilitation discharge by only one evaluator.
to perform basic and instrumental ADL. In addition, although
Gait was evaluated by Functional Ambulation Classification
these participants improved their gait capacity and functional
Scale [14]. This instrument has 6 levels: level 0 (no ambulation),
level 1 (non-functional ambulation), level 2 (household ambula-
Table 1. Epidemiological data of participants with transtibial and transfe-
tion), level 3 (neighbourhood ambulation), level 4 (autonomous
moral amputation.
community ambulation) and level 5 (normal ambulation) [14].
Transtibial (n ¼ 15) Transfemoral (n ¼ 14)
The functional capacity to perform basic ADL was evaluated by mean (±SD) mean (±SD)
Barthel Index (BI) [15]. This instrument assesses the level of Variable n (%) n (%) p-Value
dependence for activities such as: feeding, bathing, personal Age (years) 69 (±7) 70 (±7) 0.645
hygiene, dressing, evacuating, urinating, using the toilet, climbing BMI (Kg/cm2) 27 (±5) 23 (±4) 0.024
stairs and transfers [15]. Sex
Male 6 (40) 9 (64.3) 0.191
The Pfeffer Questionnaire was implemented by the family or Female 9 (60) 5 (35.7)
caregiver to assess the level of functional independence to per- Schooling
form instrumental ADL [16]. This instrument is composed of 10 Illiterate 3 (20) 1 (7.1) 0.613
items and a total of 30 points. Participants with 5 points or more <8 years 2 (13.3) 4 (28.6)
8 years 6 (40) 4 (28.6)
were considered to be dependent on instrumentals ADL. This 8–11 years 2 (13.3) 1 (7.1)
questionnaire is validated for the Brazilian elderly population [16]. 11 years 2 (13.3) 4 (28.6)
All data referring to 1 and 3 months of follow up were gath- Fallers 6 (40) 9 (64.3) 0.191
ered through a telephone call. BMI: body mass index; SD: standard deviation.
 ELDER AFTER LOWER-LIMB PROSTHESIS REHABILITATION 3

Table 2. Using lower-limb prosthesis by elderly with transtibial and transfemoral amputation after rehabilitation for 1 and 3 months after follow up.
Transtibial (n ¼ 15) Transfemoral (n ¼ 14)
n (%) n (%)
Variable After LLP rehabilitation After 1 month After 3 months After LLP rehabilitation After 1 month After 3 months
Participants who use LLP 15 (100) 14 (93.3) 13 (86.7) 14 (100) 14 (100) 11 (78.6)
How many time use LLP
<1 h per day 8 (53.3) 2 (14.3) 2 (15.4) 7 (50.0) 5 (35.7) 1 (9.1)
1–10 h per day 5 (33.3) 10 (71.4) 5 (38.5) 5 (35.7) 5 (35.7) 7 (63.6)
>10 h per day 2 (13.3) 1 (7.1) 3 (23.1) 1 (7.1) 2 (14.3) 1 (9.1)
Take away the prosthesis only to sleep 0 (0) 1 (7.1) 3 (23.1) 1 (7.1) 2 (14.3) 2 (18.2)
Where LLP is used
Only at home 13 (86.7) 10 (71.4) 4 (33.3) 8 (57.1) 8 (57.1) 4 (36.4)
Around the neighbourhood 2 (13.3) 1 (7.1) 3 (25.0) 2 (14.3) 1 (7.1) 1 (9.1)
Out of the neighbourhood 0 (0) 3 (21.4) 5 (41.7) 4 (28.6) 5 (35.7) 6 (54.5)
Use of orthosis
Yes 13 (86.7) 12 (85.7) 10 (76.9) 14 (100.0) 13 (92.9) 12 (92.3)
No 2 (13.3) 2 (14.3) 3 (23.1) 0 (0.0) 1 (7.1) 1 (7.7)
Which orthosis
Standard walker 6 (46.2) 6 (50.0) 4 (40.0) 8 (57.1) 6 (46.2) 4 (33.3)
Walker with wheels 1 (6.7) 1 (8.3) 1 (10.0) 0 (0.0) 1 (7.7) 1 (8.3)
1 or 2 Crutches 6 (46.2) 5 (41.7) 5 (50.0) 6 (42.9) 6 (46.2) 7 (58.3)
LLP: lower-limb prosthesis; SD: standard deviation.

Table 3. Functional capacity and gait of elderly with lower-limb amputation Table 4. Comparison of functional capacity and gait of elderly with transtibial
before and after prosthesis rehabilitation process. and transfemoral lower-limb amputation before and after prosthesis rehabilita-
Transtibial (n ¼ 15) Transfemoral (n ¼ 14) tion process.
Variable Mean (±SD) p-Value Mean (±SD) p-Value Transtibial (n ¼ 15) Transfemoral (n ¼ 14)
Barthel Index Variable Mean (±SD) Mean (±SD) p-Value
Before amputation 94.64 (±9.50) 0.032 95.38 (±6.60) 0.001 Barthel Index
After amputation 84.00 (±13.25) 78.93 (±17.12) Before amputation 94.64 (±9.50) 95.38 (±6.60) 0.817
Before amputation 94.64 (±9.50) 0.285 95.38 (±6.60) 0.012 After amputation 84.00 (±13.25) 78.93 (±17.12) 0.378
After 1 month 90.36 (±8.65) 86.92 (±13.00) After 1 month 90.36 (±8.65) 86.92 (±13.00) 0.423
Before amputation 94.64 (±9.50) 0.706 95.38 (±6.60) 0.018 After 3 months 93.08 (±7.78) 86.99 (±13.95) 0.165
After 3 months 93.08 (±7.78) 86.99 (±13.95) FAC
After amputation 84.00 (±13.25) 0.108 78.93 (±17.12) 0.014 Before amputation 4.93 (±0.26) 4.69 (±0.85) 0.307
After 3 months 93.08 (±7.78) 86.99 (±13.95) After amputation 2.67 (±1.40) 2.36 (±1.34) 0.548
FAC After 1 month 2.79 (±0.89) 2.93 (±1.14) 0.715
Before amputation 4.93 (±0.26) <0.001 4.69 (±0.85) <0.001 After 3 months 3.00 (±1.20) 3.07 (±1.00) 0.863
After amputation 2.67 (±1.40) 2.36 (±1.34) Pfeffer Questionnaire
Before amputation 4.93 (±0.26) <0.001 4.69 (±0.85) <0.001 Before amputation 1.33 (±3.01) 2.25 (±5.10) 0.566
After 1 month 2.79 (±0.89) 2.93 (±1.14) After amputation 6.00 (±5.64) 7.91 (±5.43) 0.381
Before amputation 4.93 (±0.26) <0.001 4.69 (±0.85) <0.001 After 1 month 4.61 (±3.69) 7.33 (±6.93) 0.228
After 3 months 3.00 (±1.20) 3.07 (±1.00) After 3 months 3.93 (±4.05) 6.77 (±6.68) 0.190
After amputation 2.67 (±1.40) 0.519 2.36 (±1.34) 0.045 FAC: Functional Ambulation Classification Scale; SD: standard deviation.
After 3 months 3.00 (±1.20) 3.07 (±1.00)
Pfeffer Questionnaire
Before amputation 1.33 (±3.01) 0.016 2.25 (±5.10) 0.001
After amputation 6.00 (±5.64) 7.91 (±5.43)
Before amputation 1.33 (±3.01) 0.023 2.25 (±5.10) 0.005 People with an LLP experience functional restriction and diffi-
After 1 month 4.61 (±3.69) 7.33 (±6.93) culty in joining community activities. This may be explained by
Before amputation 1.33 (±3.01) 0.048 2.25 (±5.10) 0.007 the fact that people with an LLP are more likely to experience the
After 3 months 3.93 (±4.05) 6.77 (±6.68)
After amputation 6.00 (±5.64) 0.366 7.91 (±5.43) 0.498 physical environment as a barrier or challenge [21]. Thus, to take
After 3 months 3.93 (±4.05) 6.77 (±6.68) part in community activities, sufficient mobility and ability to get
FAC: Functional Ambulation Classification Scale; SD: standard deviation. access easily are important facilitating factors. In cities without
accessibility sidewalks and other accessibility issues outside and
inside homes, the focus on improving mobility using wheelchair
training is not the right option for people with LLA. Promoting an
abilities after finished the LLP rehabilitation programme, they did LLP rehabilitation programme should be a way to improve the
not achieve their previous amputation functional conditions. mobility of this population [22]. Nevertheless, in our elderly partic-
People with LLA decreased their functional mobility after the ipants, despite the fact that they have shown a good LLP adapta-
amputation. In accordance with our findings, a study showed a tion after the rehabilitation programme, they did not recover the
significant (˂ 0.001) reduction in daily functioning of 500 partici- functionality and gait capacity they had previously to the amputa-
pants with unilateral LLA [17]. Thus, in order to enhance improve- tion. Indeed, a prosthesis adaptation is not sufficient and a favour-
ments following amputation, other authors suggested that the able functional recuperation after an amputation depends on the
rehabilitation must be focussed on improving mobility in a wheel- postural balance, safety with the prosthesis, amputation time,
chair. De-Rosende et al. also showed that pre-prosthetic ADL comorbidities and individuals’ age [23].
intervention presented good results on independence during self- Walking and climbing stairs are the most difficult ADL for peo-
care activities [18]. However, in addition to motor components, ple with LLA [22]. In this context, an intelligent prosthesis could
the ability to perform basic [19] and instrumental [20] activities promote improvement over a conventional prosthesis, especially
are also linked to the physical/structural environmental factors. while walking at different speeds, walking greater distances, and
4 A. M. SILVA ET AL.
the perceived energy consumption [24]. Microprocessor-controlled
prosthesis when replaced with the old prosthesis (active vacuum
system, pin modular system, hydraulic system and mechanical
modular prosthesis) could provide improvements in ADL of
patients with transfemoral and knee disarticulation [17]. In our
study, old prosthesis should contribute negatively to the ADL
improvements of our participants. The group with transfemoral
amputation was the most affected and did not recover their cap-
acity to develop basic and instrumental ADL. However, although
none of our groups improved their ability to perform instrumental
ADL, the transtibial group tends to be more independent.
Time should be an important factor to improve the LLP use for
gait and ADL by the amputees. Results of a systematic review
showed that up to 70% of people from a selected population
maintained a household level of prosthetic walking for at least
6 months post-amputation or 3 months post-rehabilitation [25].
The elderly participants in our study presented similar findings. In
our study, regardless of the fact that no group achieved walking
ability prior to the amputation after 3 months of LLP rehabilitation
process, participants reported a high LLP dependence to ambu-
late. Three months after the end of the rehabilitation, our elderly
participants maintained their household gait capacity and
improved it around and out of the neighbourhood. These results
may suggest that, in the long term, LLP use positively impacted
the elderly participants’ mobility. Streppel et al. [22] also eval-
uated the use of LLP by 50 amputees, and their results indicated
that 94% of the participants were using LLP during the day, in
which 80% used it on daily activities inside and outside their
home, reinforcing our findings [22]. In contrast, however, three
studies indicated that only 20% of the participants with LLA main-
tained the household prosthetic walking in the long term [26–28].
On the other hand, walking independence with LLP increased
over time. We have observed an increase in walking independ-
ence and safety in our participants after the follow-up. There was
a tendency of changing the wheeled walker with the crutch and,
after 3 months, there were more participants using crutches and
less using walkers to walk. We have also observed a tendency to
stop using orthosis during gait over time in both groups.
Probably this trend for less assistance during gait could be related
to safety improvement, provided by corporal scheme reorganiza-
tion and postural balance improvements. This fact should indicate
a good LLP adaptation in both groups. Indeed, our participants
have presented a progressively LLP adaptation during 3 months
of follow up and no significant difference was found between the
transtibial and transfemoral group.
The percentage of regular use of prosthesis is around 40–70%
for young amputees [29]. Despite the fact that the increasing age
is associated with less use of a prosthesis [30], our elderly partici-
pants were above average. A similar result was noted in Mac Neill
et al. [31] study in the long run. Eighty-five percent of their partic-
ipants also continued using LLP while walking regularly more
than 3 years after the rehabilitation process [31]. In our study, the
time of LLP use and gait capacity of our participants has also
improved in both groups over time. Similar results were also
observed in Sapp and Little’s study [32].
The time use of the prosthesis increases over time. Twenty-
seven percent of our elderly participants with transfemoral ampu-
tation used the LLP for more than 10 h per day 3 months after the
end of their rehabilitation. However, 46% of participants with
transtibial amputation used the LLP for more than 10 h per day at
the same time of follow up. The Sapp and Little’s study evaluated
103 participants after 24 months of the LLP rehabilitation process
and found similar results, suggesting that these results would be
maintained over the long term [32]. In this study, 65% of the par-
ticipants used the prosthesis 9 h a day, 12% for half a day and
16% reported that they were not using the prosthesis [32].
However, another study showed a better result, and 84% of the
participants with LLA reportedly wore the prosthesis for an aver-
age of 12.5 h per day [33].
The provision of a prosthesis and gait training is a costly and
time-consuming process. Rehabilitation efforts should be best tar-
geted depending on the patients’ needs. Thus, being able to
know which elderly will achieve and maintain prosthetic walking
and those who could better focus on regaining no prosthetic
mobility, according their mobility potential and environmental
barriers, is an important goal for future research. The admission
functional level is the most significant predictor of a successful
lower-limb prosthesis fit in a post-acute geriatric rehabilitation
setting [34]. Rehabilitation professionals should make educated
estimates of outcomes at the beginning of the rehabilitation
based on the characteristics of the patients (level of amputation
and functional level on admission) [34].
The small no-probabilistic sample was a limitation of the study.
The use of the telephone to collect data may have impaired com-
munication between the evaluator and the participants. The fol-
lowing studies may investigate the effects of LLP rehabilitation in
quality of life, satisfaction, recreational and sportive activities in
the elderly with LLA. Future prospective longitudinal studies
should go beyond the clinical factors associated with prosthesis
prescription, and concentrate on a successful prosthetic use.
Further research can be done on cost analysis.
Conclusions
Although the elderly with transfemoral or transtibial amputation
have improved their functional independence after LLP rehabilita-
tion they could not achieve the same functional capacity they
had before the amputation. The improvement especially occurred
for the basic ADL, however elderly patients with transfemoral
amputations presented greater difficulty in improving func-
tional capacity.
Disclosure statement
No potential conflict of interest was reported by the authors.
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