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Functional Assessment of Lower Limb Amputees

S P Peweek, M E Condie National Centre for Orthotics and Prosthetics, Uniuersity of Strathclyde, Glasgow

The use of outcome measures in lower limb amputee rehabilitation is becoming increasingly important. Functional assessment is of particular importance since much of the rehabilitation process is associated with improving mobility and personal independence.

The Scottish Physiotherapy Amputee Research Group (SPARG) has investigated three measures of functional outcome: the Barthel index, Russek's classification and a modified version of the Prosthetic Profile for Amputees (+PA) developed in Canada. A functional assessment is carried out at discharge as part of a standardised da ta collection system developed by SPARG and used throughout Scotland.

Of 493 trans-tibia1 and 249 trans-femoral amputees assessed using t h e Barthel index, 73% and 52% respectively were scored as fully independent when using a prosthesis. Ceiling effects, where a large proportion of those assessed have a maximum score, makes the Barthel index of limited use for amputees. Russek's classification demonstrates a higher level of sensitivity but suffers from interrater variability. This classification showed a statistically significant differ- ence (p < 0.001) between amputees above and below 40 years of age but was unable to show any significant differences between trans-tibia1 and trans-femoral amputees. The recently introduced modified PPA is a promising measure being both sensitive and objective. It is less ambiguous than Russek's classification and initial results show greater differences in outcome between patients undergoing amputation at different levels. It is anticipated that this new measure will be a useful tool when comparing the rehabilitation programmes of centres throughout Scotland.

Measuring the Outcomes of Specific Stroke Subtypes Using Simple Mobi I ity Milestones

M T Smith Western General Hospital, Edinburgh

G D Baer Queen Margaret College, Edinburgh

This paper describes the detailed outcomes of a popu- lation of 229 consecutive stroke in-patients admitted to the Western General Hospital, Edinburgh, over a two-year period. All patients had physiotherapy and were managed by a multi-disciplinary stroke team. They were classified according to the Oxfordshire Community Stroke Project classification described by Bamford et al (1991) and were differentiated as haem- orrhagic or infarctive cerebrovascular events by CT scan. There were five possible categories within which patients could be grouped: 1. Primary intracerebral haemorrhage (PICH):

2. Total anterior circulation infarction (TACI): 44 (19.2%). 3. Partial anterior circulation infarction (PACI): 81 (35.4%). 4. Lacunar infarction (LACI): 61 (26.6%). 5. Posterior circulation infarction (POCI): 15 (6.6%). The following measures were developed to reflect clin- ically relevant milestones in the recovery of mobility: One minute unsupported sitting balance. Ten seconds unsupported standing balance. Ten independent steps. Ten metres timed walk.

Detailed descriptive protocols were developed in order to standardise each measure and data were gathered

28 (12.2%1).

in the form of days since onset of stroke to achieve each milestone.

Data analysis showed that for the overall group, mean outcome values were as follows: 216 (94.3%) achieved sit t ing balance i n 3 days (sd = 6.81, 197 (86.0%) achieved standing balance in 11.1 days (sd = 21.1), 187 (81.7%) achieved 10 steps walking in 22.5 days (sd = 39.8) and 180 (78.6%) achieved 10 metres walking in 27.1 days (sd = 47.1).

More detailed analyses revealed that the TACI group were by far the most profoundly physically compro- mised of the population, taking significantly longer to reach the milestones and achieving fewer than the other stroke categories (p > 0.05). Walking outcomes in the TACI group were comparatively poor with less than 37% of these patients achieving 10 steps walking or 10 metres walking (29.5%) in comparison with 90% of the subjects classified as PACI, LACI or POCI.

Mean timescales €or the recovery of each mobility milestone are reported for each sub-group of stroke patients and the implications of using such milestones to formulate goal-setting strategies in the multi-disci- plinary rehabilitation environment are discussed.

Our results compare favourably with other similar populations in terms of the recovery of sitting balance (Partridge et al , 1993), standing balance (Kent et al, 1993) and walking (Gresham, 1992).

References Bamford, J, Sandercock, P, Dennis, M , Burn, J and Warlow, C (1 991). 'Classification and natural history of clinically identifiable subtypes of cerebral infarction', Lancet, 337, 1521-26. Gresham, G E (1992). 'The rehabilitation of the stroke survivoI' in: Barnett, H J M ef a/ (eds) Stroke: Pathophysiology, Diagnosis and hanagernent, Churchill Livingstone, Edinburgh, 2nd edn. Kent, P, Hill, K and Bernhart, J (1993). 'Functional prediction post-stroke', Australian Journal of Physiotherapy, 39, 4,

Partridge, C J and Morris, L W (1993). 'Recovery from physical disability after stroke: Profiles for different levels of starting severity', Clinical Rehabilitation, 7, 21 0-21 7.

281 -289.

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Physiotherapy, July 1997, vol 83, no 7