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PREDICTING WALKING ABILITY AFTER AMPUTATION 131

finding a statistically significant association between independent negative predictor of walking ability up
patient “motivation” and the ability to learn to walk to 18 years after surgery. A significant association
with a prosthesis (5). between post-operative ADLs and walking ability
after rehabilitation with a prosthesis has also been
Social Support described (5). Therefore, it seems the preponderance
Webster et al. identified greater levels of baseline of evidence suggests that independence in completion
social support were associated with more hours of of ADLs is a factor worth considering when deter-
prosthetic walking and identified a need to build in mining prosthetic candidacy.
social support structures for patients that have lim-
itations in this regard (18). Greater perceived social Time to Rehabilitation
support as a predictor of higher mobility was not a Stineman et al., in two separate high quality stud-
well-supported predictive factor in previous studies ies, reported that patients who had early rehabilitation
(5). initially made higher motor gains than those individ-
Smoking uals who had later rehabilitation (21). Additionally,
Wong et al. reported smoking was associated with patients who received acute postoperative inpatient
rehabilitation, compared to those with no evidence of
significantly poorer outcomes in diabetic transtibial inpatient rehabilitation, had an increased likelihood
amputation (TTA) patients (19). Czerniecki et al. of one-year survival and home discharge. Prosthetic
reported smoking status and reported a likely rela- limb procurement did not differ significantly between
tionship between smoking and a more proximal level groups (22). Sansam et al. found a shorter time inter-
amputation, which is discussed later. Although smok- val between surgery and admission for rehabilitation
ing is implicated in the etiology of many amputations, is related to better walking potential. Similarly, the
Sansam et al. reported that it is unlikely to have a length of time taken from surgery to fitting for a
significant impact on mobility outcome (5).
prosthesis is significantly associated with outcome,
Stump Factors and Pain with those waiting longer having poorer walking
van Eijk et al., in a medium quality article, reported ability at one year (5).
that the presence of phantom pain was significantly Race
associated with the ability to use a prosthesis (20). In two high quality studies, race was reported
Phantom limb pain specifically was not reported as a as not significant in affecting the outcome of TTA
predictive factor outcome measure in previous stud- patients or being a predictive factor (18,19). Race was
ies.
not reported as a predictive factor outcome measure
Predictive Factors Supported with Two in previous studies.
References in This Literature Review
Vascular Intervention
Independence in Activities of Daily Living In a high quality study, Suckow et al. reported it is
van Eijk et al., in a medium quality article, reported possible, based on preoperative patient characteris-
preoperative Barthel Index (BI) as a measure of one’s tics, to identify patients undergoing lower extremity
ability to perform basic ADLs. It is reported as evalu- bypass surgery who are most or least likely to achieve
ation of the functional status at baseline. In addition, good functional outcomes even if a major amputation
the preoperative BI was estimated based on history is ultimately required. These findings may assist in
taking and was significantly positively associated patient education and surgical decision making in
with prosthetic use (20). Further, BI was a signifi- patients who are poor candidates for lower extremity
cant indicator of the ability to complete the Timed bypass (23). Wong et al. found indicators of poor
Up and Go (TUG) test. However, Wong et al., in a vascularity, such as absence of popliteal pulse and
high quality study, found no correlation between low Ankle Brachial Index (ABI), were significantly
independence in ADLs and outcome in TTA patients associated with poor clinical outcomes (19). Vascular
(19). This is inconsistent with the previous report of intervention was not reported as a predictive factor
dependency for self-care prior to amputation as an outcome measure in previous studies.