Department of Surgery, Universidade Federal de São Paulo, São Paulo, Brazil.
Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil.
Cochrane Database Syst Rev. 2023 Jun 5;6(6):CD013711. doi: 10.1002/14651858.CD013711.pub2.
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.
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.
AUTHORS' CONCLUSIONS: 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.
截肢是指由于创伤、医学疾病或手术而切除身体的外部部分。由血管疾病（缺血性截肢）引起的截肢越来越常见，通常是由于外周动脉疾病（PAD）引起的，这与人口老龄化以及糖尿病和动脉粥样硬化疾病的发病率增加有关。运动康复干预措施可能作为增强康复过程和假肢使用的前奏。有效的康复可以提高活动能力，使人们在最小功能丧失的情况下重新开始活动，并可能提高生活质量（QoL）。力量训练是一种常用于胫骨（膝下）截肢后的运动康复技术，旨在增加肌肉力量。其他干预措施，如运动想象（MI）、虚拟环境（VE）和本体感受神经肌肉促进（PNF），可能会改善康复过程，如果这些干预措施可以在家中进行，那么康复过程的总体费用可能会降低。由于患有血管疾病的截肢患者的患病率、经济影响和长期康复过程增加，因此有必要对血管疾病性胫骨截肢患者的运动康复干预措施的有效性进行综述。
评估针对外周动脉疾病或糖尿病（血管疾病原因）引起的胫骨（膝下）截肢患者的运动康复干预措施的益处和危害。
我们使用了标准的、广泛的 Cochrane 检索方法。最新的搜索日期是 2023 年 1 月 9 日。
我们纳入了比较力量训练（包括步态训练）、MI、VE 和 PNF 等运动康复干预措施的随机对照试验（RCT），这些干预措施针对的是由 PAD 或糖尿病（血管疾病原因）引起的胫骨截肢患者。
我们使用了标准的 Cochrane 方法。我们的主要结局是 1. 假肢使用，2. 不良事件。我们的次要结局是 3. 死亡率，4. QoL，5. 移动性评估，6. 幻肢痛。我们使用 GRADE 评估每个结局的证据确定性。
我们纳入了两项 RCT，共有 30 名参与者。一项研究评估了 MI 结合步行物理练习与单独步行物理练习的效果。另一项研究比较了两种不同的步态训练方案。这两项研究招募的都是已经使用假肢的参与者，因此我们无法评估假肢使用情况。研究没有报告死亡率、QoL 或幻肢痛。由于参与者人数少，存在参与者和结果评估者的偏倚以及不准确性，因此降低了证据的确定性。我们没有发现比较 VE 或 PNF 与常规护理或彼此之间的研究。MI 结合步行物理练习与单独步行物理练习（一项 RCT，8 名参与者）的研究结果表明，在使用步行速度、步长、步长不对称性、假肢侧和非截肢侧的支撑量的平均不对称性以及计时起立行走测试评估的移动性评估方面，两组之间没有差异，证据确定性为极低。研究没有报告不良事件。一项研究比较了两种不同的步态训练方案（一项 RCT，22 名参与者）。研究使用变化分数来评估不同的步态训练策略是否导致基线（第 3 天）和干预后（第 10 天）之间的改善存在差异。在功能结局方面，使用速度、伯格平衡量表（BBS）或假肢活动预测量表（AMPPRO）评估两种不同的步态训练策略，没有明显的差异（证据确定性极低）。在不良事件方面，两种不同的步态训练方案之间的差异证据确定性为极低，表明两组之间差异很小或没有差异。
总体而言，在血管疾病性截肢的运动康复领域，研究相对较少。我们发现，步态训练方案在移动性评估和不良事件方面，两组之间几乎没有差异，证据确定性极低。MI 结合步行物理练习与单独步行物理练习相比，在移动性评估方面没有明显差异（证据确定性极低）。纳入的研究没有报告死亡率、QoL 和幻肢痛，并且评估的参与者已经在使用假肢，排除了对假肢使用的评估。由于仅基于两项小型试验获得的证据确定性非常低，因此尚不清楚这些干预措施是否会对假肢使用、不良事件、移动性评估、死亡率、QoL 和幻肢痛产生影响。进一步的设计良好的研究可能有助于澄清这一不确定性，这些研究可能有助于澄清这一不确定性。
