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

1. Exploring the Impact of Cognition on Prosthetic Rehabilitation for Lower Limb Amputees By Lucy Pearce A Literature Review

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

3. Introduction

4. Introduction • Loss 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 Therapy • Evidence-based guidelines to inform practice • Recommendations for: • Functional rehabilitation • Environment • Psychology • Prosthetic use • Assessment tools & outcome measures • Cognition • Work • Leisure & recreation

6. Evidence-Based Guidelines & Cognition • Supporting research was scarce at time of initial publication (Spiliotopoulou & Atwal, 2011) • Inequality within areas of recommendations • May not reflect contribution to clinical practice • Majority of lower limb amputations result from dysvascular disease • Associated 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. Aims • To explore the impact of cognition on the prosthetic rehabilitation of lower limb amputees With 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 Search • Conducted in two-stages • Computer aided using databases: • CINAHL • Medline • ScienceDirect • Preliminary search: • Identified literature relevant to research topic • Inclusion & exclusion criteria: • Implemented to address a focus research question

11. Preliminary Searches • Focused on studies since publication of evidence-based guidelines • Identified 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. Inclusion Criteria Exclusion Criteria Screening of Search Results • Adults (18+) • Lower limb amputees • Prosthesis • Diagnosis of PVD • Validated measure of cognitive function and/or functional mobility • Primary research • Published in English • Published since 2000 • Children (0-17) • Upper limb amputees • Lower limb amputees without prosthesis • Cognitive impairment or symptoms • Non-validated assessments of cognition • Secondary research & critical reviews • Not published in English • Published before 2000

13. Data Extraction & Critical Appraisal • 8 research articles identified using inclusion/exclusion criteria • Critically appraised using CASP cohort study checklist (Critical Appraisal Skills Programme (CASP), 2017) • Strengths and limitations identified

14. Findings

15. Impact of Cognition on Prosthetic Rehabilitation

16. Impact of Peripheral Vascular Disease on Cognition

17. Impact of Cognition on Prosthetic Rehabilitation • 5 studies considered the contribution of cognition to prosthetic rehabilitation outcomes • Different cognitive assessment tools used

18. Findingsin Summary • Better performance in cognitive assessments is associated with better functional mobility outcomes with a prosthesis • Deficits within a range of cognitive domains can impact prosthetic rehabilitation outcomes • Particularly memory, attention & verbal fluency • PVD, as a pre-cursor of lower limb loss is also associated with impairments in cognitive function • Impacts a range of cognitive domains

19. Discussion

20. Discussion • Cognition – often taken for granted until functional difficulties present • Occupational therapists recognise the impact of cognitive impairment on functional performance • Interventions designed to reduce this impact (Unsworth, 2010) • Individuals with cognitive impairment face significant challenges in prosthetic rehabilitation • Learning new information • Retaining/Recalling information • Cognitive measures to assess multiple cognitive domains are advantageous • More informed intervention planning for better functional outcomes

21. Limitations of this Review • Limited literature available • Of the available literature • Small scale studies • Undertaken in single geographical location

22. Implications for Practice • Cognitive function should be routinely screened within prosthetic rehabilitation • Cognitive assessments should explore a variety of cognitive domains • MoCA is a useful initial cognitive screen • All members of MDT to be aware of findings from multi-domain screens

23. Implications for Research • Lack of available literature • Demonstrates need for further research! • More rigorous approach to future research methodology • Larger sample size • More geographically diverse samples • Studies to explore the value of different cognitive assessments Essential to develop future guidelines for practice!

24. Conclusion • Cognitive function plays an important role in prosthetic rehabilitation outcomes • Cognition 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. References • British 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. References… continued • 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.

27. References… continued • Sansam, 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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