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PREDICTING WALKING ABILITY AFTER AMPUTATION 129

facilities, trauma centers, private sector prosthetic and that new factors would potentially emerge as
practices, and university laboratories. Fifty percent important in candidacy determinations. This hypoth-
of the included studies were prospective, 38% were esis was confirmed, as all but five of the previous
retrospective, and 3% were SRs. Cohort and cross-sec- predictive factors were reported in the updated arti-
tional designs were the most common designs, and cles, with 15 of the same predictive characteristics
only two experimental studies were included. The from the original Sansam article recurring. Three
predominant independent variable was LEA. In addi- new predictive factors were identified in this review
tion to this, prosthetic rehabilitation was commonly that were not previously identified in the original
included as treatment. Sansam review (Table 2).
Since the original Sansam et al. article, the follow- This literature review spans the seven years (2007-
ing factors were each supported by a single reference: 2015, 21 studies) following the original Sansam et al.
BMI, motivation, social support, smoking, and phan- article, whereas the original search included 57 years
tom limb condition. The following predictive factors of literature (1950-2007, 57 studies). This updated
were moderately supported (i.e., two references): study increases the size of the original Sansam et al.
independence in activities of daily living (ADL), time report by including 137% more subjects for a total of
to rehabilitation, race, and vascular intervention. The 21,490 between the two articles. However, the authors
following predictive factors were more strongly sup- caution that, due to poor reporting, it is not clear
ported (i.e., three to five references): ability to stand at times if patients are repeat counted in multiple
on one leg, cognition and mood disturbance, gender, publications. Nevertheless, in terms of prosthetic
pre-amputation living status, and cause of amputa- studies, this is a considerably large study relative
tion. Race, vascular intervention, and pre-amputation to other SRs, which tend to include much smaller
living status were newly identified in this report and samples. For example, a recent comprehensive SR
not identified in the original Sansam et al. article. of microprocessor knees based conclusions on 625
The most strongly supported factors (i.e., ≥6 refer- subjects (15). The patients in this SR had predomi-
ences) emerging from the search when considering nantly lost their lower extremities due to PVD, which
prosthetic candidacy were: amputation level, physical is consistent with epidemiologic data (16). Therefore,
fitness, age, and comorbidities. There is increasing it is plausible that the results of this SR would have
agreement that these identified predictive factors are high generalizability to clinical practice. Given the
important when contemplating prosthetic candidacy predominant setting was the rehabilitation center
and walking ability. or major medical centers, results may be particularly
Meta-analysis was not possible, as the studies of relevant within these types of settings.
like outcome measures did not observe the same Predictive Factors in a Single Study in This
homogeneous patient characteristics; mainly, level, Literature Review
etiology, and mean ages were heterogeneous among
these studies (10-14). BMI
Linberg et al. found demographics (i.e., height,
DISCUSSION weight) did not affect the six-minute walk test
The purpose of this study was to extend the body of (6MWT) (12). This is consistent with previous reports
knowledge—using the same search strategy originally in finding that, when adjusting for medical comorbid-
completed in the Sansam et al. article—of predicting ities, age, and sex, BMI was not a significant predictor
walking ability following lower limb amputation. This of walking ability (5).
SR identifies predictive factors of walking ability and Motivation
updates the findings to include current literature. We Hamamura et al., in a high quality study, found
hypothesized that most factors previously identified significance in motivation as a predictive factor for
as important or predictive in determining prosthetic successful prosthetic ambulation among geriatric
candidacy and walking ability would be reinforced subjects (17). This is consistent with a previous report