Interventions for motor rehabilitation in people with below

Key messages

– There is little research in the field of motor rehabilitation in people with amputation due to vascular causes.

– The studies reported some positive results, but we have little confidence in the results due to small numbers of participants and limited data.

What is amputation and what can happen after amputation?

Amputation is the removal of an external part of the body. Amputations due to vascular causes are commonly associated with diabetes and peripheral arterial disease. Peripheral arterial disease is caused by fatty deposits on the walls of the arteries (also called atherosclerosis) that leads to narrowing of the arteries (also called stenosis) and obstructions in the major blood vessels supplying the lower legs.

After lower-limb amputation the rehabilitation process requires physical adaptation. Motor rehabilitation aims to enhance the rehabilitation process and prosthetic use improving mobility, allowing the return to usual activities, with minimum functional loss and better quality of life. Strength training (elaborated to build strength in one muscle group at a time) is a commonly used technique for motor rehabilitation following lower-limb amputation. Strength training includes exercises for the surrounding hip muscles and muscles of the residual limb aiming to increase muscular strength. Recent interventions which might enhance the rehabilitation process can be performed at home. These include motor imaging (simulated movement or mentally rehearsing the action without really performing the movement), virtual environments (computer-generated simulations) and proprioceptive neuromuscular facilitation (stretching the muscles, aiming to achieve maximal static flexibility).

What did we want to find out?

We wanted to find out if these interventions were effective for motor rehabilitation as the convenience of home training and lower costs may be attractive for healthcare practitioners and patients.

What did we do?

We searched medical databases for well-designed studies in people with below-knee amputations resulting from peripheral arterial disease or diabetes comparing different interventions for motor rehabilitation against each other. The interventions could have been given alone or combined with usual care (for example, wound dressing and stump care).

What did we find?

We found two randomised controlled trials (studies in which the participants were divided between treatment groups through a random method) with 30 participants (most recent search 9 January 2023). One study with eight participants evaluated motor imaging combined with walking versus walking alone. One study with 22 participants compared two different gait training protocols (one focused on impairment level versus one focused on task level). We found no studies that used other interventions such as virtual environments.

Main results

There was no clear difference in mobility assessment between motor imaging combined with walking and walking alone.

Both gait training protocols may slightly improve from baseline to after treatment for mobility assessment. There was little or no difference in side effects comparing the two different gait training protocols.

What are the limitations of the evidence?

We are not confident in the evidence because it was based on only two trials with a small number of participants. People knew which treatment they received, which could have affected the study's results.

How up to date is this evidence?

The most recent search was 9 January 2023.

Overall, there is a paucity of research in the field of motor rehabilitation in dysvascular amputation. We identified very low-certainty evidence that gait training protocols showed little or no difference between the groups in mobility assessments and adverse events. MI combined with physical practice of walking versus physical practice of walking alone showed no clear difference in mobility assessment (very low-certainty evidence). The included studies did not report mortality, QoL, and phantom limb pain, and evaluated participants already using prosthesis, precluding the evaluation of prosthesis use.

Due to the very low-certainty evidence available based on only two small trials, it remains unclear whether these interventions have an effect on the prosthesis use, adverse events, mobility assessment, mortality, QoL and phantom limb pain. Further well-designed studies that address interventions for motor rehabilitation in dysvascular transtibial amputation may be important to clarify this uncertainty.

Amputation is described as the removal of an external part of the body by trauma, medical illness or surgery. Amputations caused by vascular diseases (dysvascular amputations) are increasingly frequent, commonly due to peripheral arterial disease (PAD), associated with an ageing population, and increased incidence of diabetes and atherosclerotic disease. Interventions for motor rehabilitation might work as a precursor to enhance the rehabilitation process and prosthetic use. Effective rehabilitation can improve mobility, allow people to take up activities again with minimum functional loss and may enhance the quality of life (QoL). Strength training is a commonly used technique for motor rehabilitation following transtibial (below-knee) amputation, aiming to increase muscular strength. Other interventions such as motor imaging (MI), virtual environments (VEs) and proprioceptive neuromuscular facilitation (PNF) may improve the rehabilitation process and, if these interventions can be performed at home, the overall expense of the rehabilitation process may decrease. Due to the increased prevalence, economic impact and long-term rehabilitation process in people with dysvascular amputations, a review investigating the effectiveness of motor rehabilitation interventions in people with dysvascular transtibial amputations is warranted.

To evaluate the benefits and harms of interventions for motor rehabilitation in people with transtibial (below-knee) amputations resulting from peripheral arterial disease or diabetes (dysvascular causes).

We used standard, extensive Cochrane search methods. The latest search date was 9 January 2023.

We included randomised controlled trials (RCT) in people with transtibial amputations resulting from PAD or diabetes (dysvascular causes) comparing interventions for motor rehabilitation such as strength training (including gait training), MI, VEs and PNF against each other.

We used standard Cochrane methods. Our primary outcomes were 1. prosthesis use, and 2. adverse events. Our secondary outcomes were 3. mortality, 4. QoL, 5. mobility assessment and 6. phantom limb pain. We use GRADE to assess certainty of evidence for each outcome.

We included two RCTs with a combined total of 30 participants. One study evaluated MI combined with physical practice of walking versus physical practice of walking alone. One study compared two different gait training protocols. The two studies recruited people who already used prosthesis; therefore, we could not assess prosthesis use. The studies did not report mortality, QoL or phantom limb pain. There was a lack of blinding of participants and imprecision as a result of the small number of participants, which downgraded the certainty of the evidence.

We identified no studies that compared VE or PNF with usual care or with each other.

MI combined with physical practice of walking versus physical practice of walking (one RCT, eight participants) showed very low-certainty evidence of no difference in mobility assessment assessed using walking speed, step length, asymmetry of step length, asymmetry of the mean amount of support on the prosthetic side and on the non-amputee side and Timed Up-and-Go test. The study did not assess adverse events.

One study compared two different gait training protocols (one RCT, 22 participants). The study used change scores to evaluate if the different gait training strategies led to a difference in improvement between baseline (day three) and post-intervention (day 10). There were no clear differences using velocity, Berg Balance Scale (BBS) or Amputee Mobility Predictor with PROsthesis (AMPPRO) in training approaches in functional outcome (very low-certainty evidence). There was very low-certainty evidence of little or no difference in adverse events comparing the two different gait training protocols.