Exploring the Impact of Cognition on Prosthetic Rehabilitation for Lower Limb Amputees - PowerPoint Presentation

1. Exploring the Impact of Cognition on Prosthetic Rehabilitation for Lower Limb AmputeesA Literature ReviewBy Lucy Pearce

2. BackgroundLiterature review undertaken as an assignment for pre-registration BSc. (Hons) course at London South Bank UniversityInspired through experience within both in-patient and community prosthetic rehabilitation settings during clinical practice placement

3. Introduction

4. IntroductionLoss of a limb has significant physical, psychological and social impact on a person’s life.(Horgan & MacLachlan, 2004)Prosthetic rehabilitation aims to minimise the impact of amputation on a person’s life.(van Velzen et al., 2006; Fielder et al., 2014)Occupational therapists work with amputees to overcome the physical & cognitive challenges of prosthetic use, to enable achievement of functional goals (Kurichi et al., 2007)Evidence-based guidelines produced to support OTs working with lower limb amputees(College of Occupational Therapists, 2011 )

5. Lower Limb Amputation & Occupational TherapyEvidence-based guidelines to inform practiceRecommendations for:Functional rehabilitationEnvironmentPsychologyProsthetic useAssessment tools & outcome measuresCognitionWorkLeisure & recreation

6. Evidence-Based Guidelines & CognitionSupporting research was scarce at time of initial publication(Spiliotopoulou & Atwal, 2011)Inequality within areas of recommendationsMay not reflect contribution to clinical practiceMajority of lower limb amputations result from dysvascular diseaseAssociated with deteriorating cognitive function(Limbless Statistics, 2013; Rafnsson et al., 2009)Use of a prosthesis places a significant demand on cognitive function(Fuhrer & Keith, 1998; O’Neill et al., 2010)

7. Aims

8. AimsTo explore the impact of cognition on the prosthetic rehabilitation of lower limb amputeesWith a view to…Build upon the findings and recommendations of the current evidence-based guidelines (COT, 2011)Acknowledge and justify the contribution of cognition to the outcomes of lower limb amputee rehabilitation

9. Method

10. Literature SearchConducted in two-stagesComputer aided using databases:CINAHLMedlineScienceDirectPreliminary search:Identified literature relevant to research topicInclusion & exclusion criteria:Implemented to address a focus research question

11. Preliminary SearchesFocused on studies since publication of evidence-based guidelinesIdentified relevant studies using keyword/phrases:‘lower limb amputation’‘prosthesis’ / ‘prosthetic limb’‘cognition’ / ‘cognitive assessment’Search broadened with additional keywords due to limited results:‘peripheral arterial disease’‘peripheral vascular disease’ / ‘PVD’

12. Screening of Search ResultsAdults (18+)Lower limb amputeesProsthesisDiagnosis of PVDValidated measure of cognitive function and/or functional mobility Primary researchPublished in EnglishPublished since 2000Children (0-17)Upper limb amputeesLower limb amputees without prosthesisCognitive impairment or symptomsNon-validated assessments of cognitionSecondary research & critical reviews Not published in EnglishPublished before 2000Inclusion CriteriaExclusion Criteria

13. Data Extraction & Critical Appraisal8 research articles identified using inclusion/exclusion criteriaCritically appraised using CASP cohort study checklist (Critical Appraisal Skills Programme (CASP), 2017)Strengths and limitations identified

14. Findings

15. Impact of Cognition on Prosthetic RehabilitationAuthorsParticipantsPurposeFindingsLimitationsFrengopoulos et al. (2016)n=176Lower limb amputeesTo determine whether cognitive function is related to prosthetic functional mobilityLower MoCA scores were associated with lower functional mobilitySmall sampleRetrospective designLength & intensity of rehab not standardisedLarner et al. (2003)n=43Lower limb amputees with PVDTo determine whether psychological tests are predictive of prosthetic usePoor learning skills were associated with poor prosthetic useSmall sampleSingle geographical areaWilliams et al. (2014)n=87Lower limb amputation related to PVDTo determine whether cognitive screens are predictive of functional mobility with a prosthesisBetter performance on cognitive screens was associated with better functional mobility prosthetic useSmall sampleNon-standardised contact method of assessmentO’Neill & Evans (2009)n=34Lower limb amputeesTo determine the impact of cognitive function on prosthetic rehab outcomesMemory and cognition are predictors of functional mobility & prosthetic useSmall sample sizeSingle geographical area71% participation rateSansam et al. (2012)n=95Lower limb amputeesTo determine if simple clinical measures predict prosthetic walking abilityAge, sex, amputation level, contracture, balance & cognition predict prosthetic walking abilitySmall sampleIncomplete data on functional mobilityInconsistent follow up

16. AuthorsParticipantsPurposeFindingsLimitationsLaukka et al. (2013)n=550PVDTo determine whether PVD is associated with cognitive performancePVD is associated with poor cognitive performanceDifferent size cohortsSelf-report used to determine participant eligibility Less stringent statistical analysisMangiafico et al. (2006)n=164PVDTo determine whether cognitive function is impaired in individuals with PVDPVD is associated with reduced cognitive functionSmall sampleBrain imaging not used to exclude underlying cognitive pathologyPrice et al. (2006)n=717PVDTo examine the association between PVD and cognitive performancePVD was associated with deteriorating cognitive functionApproach to cognitive testing not standardised – varying locationLoss of participants at follow-up testingImpact of Peripheral Vascular Disease on Cognition

17. Impact of Cognition on Prosthetic Rehabilitation5 studies considered the contribution of cognition to prosthetic rehabilitation outcomesDifferent cognitive assessment tools used

18. Findings in SummaryBetter performance in cognitive assessments is associated with better functional mobility outcomes with a prosthesisDeficits within a range of cognitive domains can impact prosthetic rehabilitation outcomesParticularly memory, attention & verbal fluencyPVD, as a pre-cursor of lower limb loss is also associated with impairments in cognitive functionImpacts a range of cognitive domains

19. Discussion

20. DiscussionCognition – often taken for granted until functional difficulties presentOccupational therapists recognise the impact of cognitive impairment on functional performanceInterventions designed to reduce this impact (Unsworth, 2010)Individuals with cognitive impairment face significant challenges in prosthetic rehabilitationLearning new informationRetaining/Recalling informationCognitive measures to assess multiple cognitive domains are advantageousMore informed intervention planning for better functional outcomes

21. Limitations of this ReviewLimited literature availableOf the available literatureSmall scale studiesUndertaken in single geographical location

22. Implications for PracticeCognitive function should be routinely screened within prosthetic rehabilitationCognitive assessments should explore a variety of cognitive domainsMoCA is a useful initial cognitive screenAll members of MDT to be aware of findings from multi-domain screens

23. Implications for ResearchLack of available literatureDemonstrates need for further research!More rigorous approach to future research methodologyLarger sample sizeMore geographically diverse samplesStudies to explore the value of different cognitive assessmentsEssential to develop future guidelines for practice!

24. ConclusionCognitive function plays an important role in prosthetic rehabilitation outcomesCognition is under-represented within current evidence-based guidelines Further research needed to explore evidence-gaps and contribute to development of more contemporary evidence-based guidelines

25. ReferencesBritish Society of Rehabilitation Medicine (BSRM) (2003) Amputee and rehabilitation – standards and guidelines. 2nd ed. London: BSRM.College of Occupational Therapists (COT) (2011) Occupational therapy with people who have had lower limb amputations: Evidence-based guidelines. London: COT.Critical Appraisal Skills Programme (CASP) (2017) CASP cohort study checklist. Available from: http://www.casp-uk.net/casp-tools-checklists [Accessed 07 March 2017].Fiedler, G., Akins, J., Cooper, R., Munoz, S. and Cooper, R. A. (2014) Rehabilitation of people with lower-limb amputations, Current Physical Medicine and Rehabilitation Reports, 2 (4), pp. 263-272.Frengopoulos, C., Burley, J., Viana, R. Payne, M. W. and Hunter, S. W. (2016) Association between montreal cognitive assessment scores and measures of functional mobility in lower extremity amputees after inpatient rehabilitation, Archives of Physical Medicine and Rehabilitation, DOI: 10.1016/j.apmr.2016.06.012.Fuhrer, M. and Keith, R. A. (1998) Facilitating patient learning during medical rehabilitation: a research agenda, American Journal of Physical Medicine and Rehabilitation, 77 (6), pp. 557-561.Hobson, J. (2015) Questionnaire review: the Montreal Cognitive Assessment (MoCA), Occupational Medicine, 65 (9), pp. 764-765. Horgan, O. and MacLachlan, M. (2004) Psychosocial adjustment to lower-limb amputation: a review, Disability and Rehabilitation, 26 (14/15), pp. 837-850.Kurichi, J. E., Kwong, P. L., Reker, D. M., Bates, B. E., Marshall, C. R. and Stineman, M. G. (2007) Clinical factors associated with prescription of a prosthetic limb in elderly veterans, Journal of the American Geriatrics Society, 55 (6), pp. 900-906.Laferrier, J. Z., McFarland, L. V., Boninger, M. L., Cooper, R. A. and Reiber, G. E. (2010) Wheeled mobility: factors influencing mobility and assistive technology in veterans and servicemembers with major traumatic limb loss from Vietnam war and OIF/OEF conflicts, Journal of Rehabilitation Research and Development, 47 (4), pp. 349-360. Larner, S., van Ross, E. and Hale, C. (2003) Do psychological measures predict the ability of lower limb amputees to learn to use a prosthesis?, Clinical Rehabilitation, 17, pp. 493-498. Laukka, E. J., Starr, J. M. and Deary, I. J. (2014) Lower ankle-brachial index is related to worse cognitive performance in old age, Neuropsychology, 28 (2), pp. 281-289.

26. Laukka, E. J., Starr, J. M. and Deary, I. J. (2014) Lower ankle-brachial index is related to worse cognitive performance in old age, Neuropsychology, 28 (2), pp. 281-289.Limbless Statistics (2013) Limbless statistics annual report: 2011/2012. Available from: http://limbless-statistics.org/------Home------.php [Accessed 13 March 2017].Mangiafico, R. A., Sarnataro, F., Mangiafico, M. and Fiore, C. E. (2006) Impaired cognitive performance in asymptomatic peripheral arterial disease: relation to C-reactive protein and D-dimer levels, Age and Ageing, 35, pp. 60-65.Nasreddine, Z., Phillips, N. A., Bédirian, V., Charbonneau, S., Whitehead, V., Collin, I., Cummings, J. L. and Chertkow, H. (2005) The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment, Journal of the American Geriatrics Society, 53 (4), pp. 695-699. O’Bryant, S. E., Falkowski, J., Hobson, V., Johnson, L., Hall, J., Schrimsher, G. W., Win, O., Ngo, B. and Dentino, A. (2011) Executive functioning mediates the link between other neuropsychological domains and daily functioning: a project FRONTEER study, International Psychogeriatrics, 23 (1), pp. 107-113.O’Neill, B. F. and Evans, J. J. (2009) Memory and executive function predict mobility rehabilitation outcome after lower-limb amputation, Disability and Rehabilitation, 31 (13), pp. 1083-1091.O’Neill, B., Moran, K. and Gillespie, A. (2010) Scaffolding rehabilitation behaviour using a voice-mediated assistive technology for cognition, Neuropsychological Rehabilitation, 20 (4), pp. 509-527.Ouriel, K. (2001) Peripheral artery disease, Lancet, 358 (2982), pp. 1257-1264.Price, J. F., McDowell, S., Whiteman, M. C., Deary, I. J., Stewart, M. C. and Fowkes, F. G. R. (2006) Ankle brachial index as a predictor of cognitive impairment in the general population: ten-year follow-up of the Edinburgh artery study, Journal of the American Geriatrics Society, 54 (5), pp. 763-769.Rafnsson, S. B., Deary, I. J. and Fowkes, F. G. R. (2009) Peripheral arterial disease and cognitive function, Vascular Medicine, 14 (1), pp. 51-61.References… continued

27. References… continuedSansam, K., O’Connor, R. J., Neumann, V. and Bhakta, B. (2012) Can simple clinical tests predict walking ability after prosthetic rehabilitation?, Journal of Rehabilitation Medicine, 44, pp. 968-974.Skelton-Robinson, M. and Telford, R. (1982) Observations on the object learning test of the Kendrick battery for the detection of dementia, British Journal of Clinical Psychology, 21 (2), pp. 147-148.Spiliotopoulou, G. and Atwal, A. (2011) Is occupational therapy practice for older adults with lower limb amputations evidence-based? A systematic review, Prosthetics and Orthotics International, 36 (1), pp. 7-14.Tamari, T. (2017) Body image and prosthetic aesthetics: disability, technology and paralympic culture, Body and Society, 23 (2), pp. 25-56.Unsworth, C. (2010) Cognitive and perceptual strategies, in: Curtin, M., Molineux, M. and Supyk-Mellson, J. (eds.) (2010) Occupational therapy and physical dysfunction: enabling occupation. 6th ed. London: Elsevier, pp. 607-635.van Velzen, J.M., van Bennekom, C. A., Slootman, J. R., van der Woude, L. H. and Houdijk, H. (2006) Physical capacity and walking ability after lower limb amputation: a systematic review, Clinical Rehabilitation, 20 (11), pp. 999-1016.Williams, R. M., Turner, A. P., Green, M., Norvell, D. C., Henderson, A. W., Hakimi, K. N., Blake, D. J. and Czerniecki, J. M. (2014) Relationship between cognition and functional outcomes after dysvascular lower extremity amputation, American Journal of Physical Medicine and Rehabilitation, DOI: 10.1097/PHM.0000000000000235.

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