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KERSTIN HAGBERG 2006,Tryck Intellecta DocuSys V stra Fr lunda 2006. ISBN 91 628 6942 6, 2 Transfemoral Amputation Quality of Life and Prosthetic Function. Abstract 4,List of publications 5,Abbreviations and Definitions 6. Background 8,1 Lower limb amputation and prosthetics 8. 2 Prosthetic function 11,3 Health Related Quality Of Life 14.
4 Outcome measures targeted at individuals with LLA 15. 5 Osseointegration 15,Material and Methods 19,Measurements and Procedures 22. 1 Self report questionnaies 22,2 Physical assessments 25. 3 Measurement properties 27,Statistical analyses 29. Ethical Approval 31,Results and comments 32,1 HRQL as measured by SF 36 32. 2 Measurement properties of Q TFA 34,3 Prosthetic Use 37.
4 Subjective complaints 39, 5 Prosthetic mobility walking performance and PCI 41. 6 Global score and overall situation 43,7 Hip range of motion 44. General Discussion 46,Future Research 54,Conclusions 55. Svensk sammanfattning Summary in Swedish 56,Acknowledgements 58. References 60,Appendix 73,Papers I V, Transfemoral Amputation Quality of Life and Prosthetic Function 3.
Background Individuals who have undergone a norms Daily use of the socket prosthesis was. transfemoral amputation TFA due to causes reported by 82 A large number of subjective. other than peripheral vascular disease PVD complaints reducing the HRQL were reported. constitute a sub group of all amputees This The most common were heat perspiration. group is usually of young age at the amputation 72 and sores skin irritation 62 with the. Conventionally prosthetic suspension is achiev socket Further 48 reported phantom limb. ed with a socket Using the osseointegration pain 47 back pain and 44 uncomfortable. method prostheses can be attached directly to sitting with the prosthesis The energy cost was. the bone OI prostheses without a socket increased by 77 compared with controls The. hip ROM was reduced with the socket prosthe, Aim The overall aim was to investigate the sis while individuals with an OI prosthesis had. health related quality of life HRQL and no restriction in hip ROM Prospective results. prosthetic function in persons with a unilateral for the treatment with OI prostheses revealed. TFA due to causes other than PVD with socket that 17 18 used the prosthesis and reported an. prostheses and OI prostheses increase in general physical HRQL and more. prosthetic use better prosthetic mobility fewer,Material methods and results General HRQL was. problems and better global health at the two,assessed using the SF 36 For condition specific. year follow up compared with the preoperative,HRQL a new self report questionnaire was con. structed the Questionnaire for Individuals with, a Transfemoral Amputation Q TFA It pro Conclusions For persons with an established.
vides results for four scores prosthetic use TFA for reasons other than PVD the general. prosthetic mobility problems and global health HRQL is lower than that of healthy norms and. and adequate levels of validity and reliability a considerable number of specific problems are. were demonstrated Paper II Physical assess perceived The Q TFA is a valid and reliable tool. ments included measurement of the energy cost for assessments of this population Treatment. using the Physiological Cost Index and hip range with OI prostheses represents a promising deve. of motion ROM lopment in the rehabilitation of individuals with. The HRQL and prosthetic function are de TFA who report improved general and condi. scribed for 97 persons 62 male 38 female tion specific HRQL at the two year follow up. mean age 48 years mean time since amputation, 22 years cause 55 trauma 35 tumour Keywords Artificial limb Energy cost Health. 10 other Paper I The energy cost was related quality of life Lower limb amputation. investigated for 41 individuals with socket Osseointegration Prosthetics Range of motion. prostheses Paper III while hip ROM was SF 36 Transfemoral amputation. investigated for 43 persons with socket prosthes, es and 20 with OI prostheses Paper IV Finally Correspondence to Kerstin Hagberg RPT. prospective results at the two year follow up for Department of Orthopaedics. the first 18 consecutive patients treated with an Sahlgrenska University Hospital. OI prosthesis within a clinical investigation are SE 413 45 G teborg Sweden. reported Paper V E mail kerstin hagberg vgregion se. For the study group Paper I the general, HRQL was reduced compared with healthy ISBN 91 628 6942 6. 4 Transfemoral Amputation Quality of Life and Prosthetic Function. List of publications, I Consequences of non vascular trans femoral amputation a survey of quality of life. prosthetic use and problems,K Hagberg R Br nemark,Prosthet Orthot Int 2001 25 3 186 194.
II Questionnaire for Persons with a Transfemoral Amputation Q TFA Initial validity. and reliability of a new outcome measure,K Hagberg R Br nemark O H gg. J Rehabil Res Dev 2004 41 5 695 706, III Physiological cost index PCI and walking performance in individuals with trans. femoral prostheses compared to healthy controls,K Hagberg E H ggstr m R Br nemark. Disability and Rehabilitation 2006 in press, IV Socket versus bone anchored trans femoral prostheses Hip range of motion and sitting. K Hagberg E H ggstr m M Uden R Br nemark,Prosthet Orthot Int 2005 29 2 153 163.
V Osseointegrated transfemoral amputation prostheses Prospective results of general and. condition specific quality of life in 18 patients with 2 year follow up. K Hagberg R Br nemark B Gunterberg B Rydevik, Transfemoral Amputation Quality of Life and Prosthetic Function 5. Abbreviations and Definitions, In this thesis the following abbreviations and definitions are used. BMI Body Mass Index The index was approximated by adding 12 of the. weight of the individual with TFA without wearing the prosthesis to the. CI Confidence interval,CWS Comfortable walking speed. Energy cost A measure describing the efficiency of walking by the amount of oxygen. consumed per unit distance walked,IC socket Ischial containment socket design. ICC Intraclass Correlation Coefficient,HRQL Health Related Quality of Life.
KD Knee disarticulation amputation through the knee joint. LCI Locomotor Capability Index,LLA Lower limb amputation. Non elderly Person with amputation performed at younger ages in contrast to the. group of geriatric amputees, Non vascular Amputation performed due to causes other than PVD including diabetes. OI prosthesis Osseointegrated prosthesis i e a bone anchored prosthesis using the. method of osseointegration, OPRA Osseointegrated Prostheses for the Rehabilitation of Amputees Name of. a clinical investigation, Osseointegration Direct anchorage of an implant by the formation of bony tissue around it. without growth of fibrous tissue at the bone implant interface Dorland. and Anderson 2003,PCI Physiological Cost Index, Phantom limb pain Painful sensation perceived in the missing limb.
Prosthetic user A person who wears a prosthesis at least once a week. PVD Peripheral vascular disease,QL socket Quadrilateral socket design. Q TFA Questionnaire for Persons with a Transfemoral Amputation. ROM Range of motion,SD Standard deviation, 6 Transfemoral Amputation Quality of Life and Prosthetic Function. SF 36 Short Form 36 Health Survey Includes eight scales and two summary. PF Physical Functioning,RP Role Physical Functioning. BP Bodily Pain,GH General Health,VT Vitality,SF Social Functioning. RE Role Emotional Functioning,MH Mental Health,PCS Physical Component Score.
MCS Mental Component Score, TFA Transfemoral amputation amputation above the knee through the femur. TTA Transtibial amputation amputation below the knee through the tibia. VO2 Oxygen uptake, Transfemoral Amputation Quality of Life and Prosthetic Function 7. Background, 1 Lower limb amputation A lower limb amputation LLA can be divid. ed into a major or minor amputation A major, and prosthetics amputation is one performed through or proxi. An amputation is defined as the removal of a mal to the ankle joint and a minor amputation. limb or other appendage or outgrowth of the is subsequently performed distal to the same. body Dorland and Anderson 2003 The joint The three most common levels for a. amputation of a limb is one of the oldest descri major LLA are transtibial amputation TTA. bed surgical procedures The history and evo transfemoral amputation TFA and knee dis. lution of limb amputation surgery follows the articulation KD respectively Today the majo. history of war to large extent After World War rity of all LLA are performed due to peripheral. II the progression of prosthetic design and spe vascular disease PVD and the reported annu. cific rehabilitation programmes for individuals al incidence ranges between 12 and 44 per. with limb loss was intensified Hierton 1980 100 000 persons with the highest risk among. Bowker and Pritham 2004 Back in 1949 the persons with diabetes mellitus Ephraim et al. American surgeon D B Slocum summarised 2003 In Scandinavia as well as in the rest of. what is still regarded as being of profound the western world PVD with or without dia. importance in the rehabilitation process follo betes mellitus constitutes the reason for an. wing a lower limb amputation amputation in about 80 90 of cases. Pohjolainen et al 1989 Ebskov 1992, While the primary objective of amputa Rommers et al 1997 Witso and Ronningen.
tion surgery is to remove an extremity 2001 Ephraim et al 2003 Eskelinen et al. which is useless or which endangers the life 2004 Johannesson et al 2004 For this group. or health of the individual the ultimate of patients the mean age at the amputation is. goal is the successful rehabilitation of the above 70 years Pohjolainen et al 1989. patient back into the normal life of his Pohjolainen and Alaranta 1998 Eskelinen et al. community This goal can only be realized 2004 Johannesson et al 2004 and the morta. when a satisfactory durable stump has lity rate within two years has been reported to. been formed a comfortable well construc be between 52 and 60 Pohjolainen et al. ted prosthesis has been selected and pro 1989 Eneroth and Persson 1992 Hermodsson. perly fitted and the amputee has been dili 1999 Eskelinen et al 2004 Johannesson et al. gently trained in its effectual use and has 2004 A different group comprises the sub. been carefully guided toward a healthy stantially smaller number of persons under. mental attitude These four factors the going an LLA due to trauma tumour congeni. good stump the functional well fitted tal limb deficiency infection or other reasons. prosthesis proper training in the use of the without any element of PVD This group. artificial limb and sound psychological accounts for about 10 of all major amputa. adjustment are mutually interdependent tions and the largest number of cases are trau. and it cannot be overemphasized that each matic including war victims followed by. is of profound importance malignancy Ebskov 1992 Ebskov 1994. Dillingham et al 2002 Ephraim et al 2003,Slocum D B 1949 An Atlas of Amputations St Louis. The male to female ratio within traumatic,USA The C V Mosby Company page 17. amputations has been reported to be 2 1,Ebskov 1994. 8 Transfemoral Amputation Quality of Life and Prosthetic Function. Owing to the discrepancy between different Bowker and Pritham 2004 The aim of the. groups of individuals with LLA it has been socket is to distribute the load from the resi. argued that the different subgroups should be dual limb to the prosthetic components The. reported separately Hermodsson et al 1994 basic goals for prosthetic fitting are to provi. Pernot et al 1997 Kent and Fyfe 1999 This de comfort function stability and cosmesis. thesis focuses on increasing the general body Schuch and Pritham 1999 and in order to. of knowledge on the subset of persons with an accomplish these goals the best possible fit of. established TFA for reasons other than PVD the socket to the residual limb is essential Lilja. This subset could be approximated as accoun 1998 Legro et al 1999 Kapp 2000 Marks. ting for fewer than 3 of all major LLA and Michael 2001 A TFA socket normally. Ebskov 1992 Rommers et al 1997 contains the total residual limb to the groin. Pohjolainen and Alaranta 1999 Dillingham et and its suspension is most commonly achieved. al 2002 Eskelinen et al 2004 but represen by either suction or a silicon liner Kapp 2000. ting an important group of younger persons Marks and Michael 2001 Figure 1 In some. with a life long locomotor disability Clinical cases additional support from a waist belt to. experience indicates that there is a general lack secure the retention of the socket could be nee. of understanding of the specific living condi ded especially if the residual limb is short. tions this particular group of persons have to During the last decades two main TFA sock. deal with in their everyday lives et designs have been used the quadrilateral. The most important difference between a socket QL socket and the ischial contain. TTA and a TFA is related to the loss of the ment socket IC socket Schuch and Pritham. knee joint In addition to the lack of the 1999 Kapp 2000 The most important diffe. human knee the TFA also affects the strength rences between them are the contours of the. and muscle balance around the affected hip proximal brim in which the ischium is outside. joint Ryser et al 1988 Jaegers et al 1995 the QL socket and is contained in the IC sock. Gottschalk 1999 The degree of atrophy of et Additional components of TFA prostheses. the hip muscles is related to the length of the are the prosthetic knee and foot with various. residual limb Jaegers et al 1995 Moreover constructions Cochrane et al 2001 Marks. insufficient muscle strength pain and immo and Michael 2001 Friel 2005 The decision. bility following the amputation increase the regarding the type of socket and the other. risk of developing hip muscle contractures components which are going to be used is. Gailey and Clark 2004 most commonly in based on the needs of the individual patient and. flexion An established contracture counter the empirical knowledge of the clinician van. acts the correct alignment of the prosthetic der Linde et al 2004 A prosthetic limb may. limb and reduces the torque of the involved need to be replaced over the years due to fac. muscles Murnaghan and Bowker 2004 lead tors such as residual limb volume changes bad. ing to a reduction in the prerequisites for fit broken parts or other reasons Recently it. prosthetic walking capacity To create the best has been shown that about one fifth of indivi. possible conditions for prosthetic walking the duals with LLA were fitted with a new prosthe. surgery should include stabilisation of the sis at least once a year Pezzin et al 2004 and. remaining muscles to the shaft of the femur among individuals with LLA due to trauma a. Gottschalk and Stills 1994 Jaegers et al need to be supplied with a new prosthesis every. 1996 Gottschalk 1999 two to three years has been reported Hoaglund. The conventional way to attach a prosthe et al 1983 Dillingham et al 2001 Finally for. tic limb to the body is with a socket Kapp individuals with TFA due to tumour the mean. 1999 Mak et al 2001 The very first socket cost of maintaining a functioning prosthesis. prosthesis was introduced during the 16th cen has been reported to be USD 4 225 per year. tury by the French surgeon Ambroise Par, Transfemoral Amputation Quality of Life and Prosthetic Function 9. computed in 1998 dollars Hoffman et al,2002 In Sweden the cost of the prosthetic.
device is financed through the public health,system and subsequently no costs are charged. directly to the patient In this thesis no analys,es of different prosthetic components and their. relationship to function or costs have been per, Figure 1A Example of a TFA socket prosthesis Figure 1B Close up of the prosthetic socket which. with vacuum suspension contains the recidual limb to the groin. 10 Transfemoral Amputation Quality of Life and Prosthetic Function. 2 Prosthetic function re it is often difficult to extrapolate the find. ings that relate to the subset of individuals, In 1989 Moore and co workers defined with an established TFA due to reasons other. successful prosthetic ambulation as prosthe than PVD and there is a need to investigate this. tic usage for ambulation on a daily basis with group separately. or without external support Moore et al, 1989 A few years later a prosthetic user was Prosthetic use and perceived complaints.
defined as a person who wears a prosthesis at,One outcome that is commonly reported is the. least once a week Grise et al 1993,amount of prosthetic use during the day or. There are some general findings that are,week often described as the mean number of. frequently reported regarding prosthetic func,hours For the majority of individuals with a. tion the group of dysvascular amputees use,non vascular LLA prosthetic use has been.
the prosthesis less than the non vascular cases,reported to be at least 10 hours day Walker et. and those with TFA use the prosthesis less than,al 1994 Burger et al 1997 Dillingham et al. those with TTA Kegel et al 1978 Hoaglund,2001 Hoffman et al 2002 Table 1. et al 1983 Moore et al 1989 Pernot et al,Several studies have shown that wearing a. 1997 Gauthier Gagnon et al 1999,prosthetic socket is often linked with problems.
Furthermore individuals with TFA generally,occurring on the residual limb in terms of dis. have poorer functional capacity than those,comfort sores rashes and pain Hoaglund et. with TTA Kegel et al 1978 Hoaglund et al,al 1983 Nielsen 1991 Walker et al 1994. 1983 Holden and Fernie 1987 Medhat et al,Sherman 1999 Lyon et al 2000 Matsen et al. 1990 Walker et al 1994 Gauthier Gagnon et,2000 Dillingham et al 2001 Gallagher et al.
al 1998 Gauthier Gagnon et al 1999 There,2001 Gallagher and Maclachlan 2001. are however some frequent problems when it,Further prosthesis comfort has been stated to. comes to interpreting and comparing the,be of very great importance among artificial. results of prosthetic function in the existing,limb users Nielsen 1991 Legro et al 1999. literature due to the lack of consensus about,Gallagher and Maclachlan 2001 In two sepa.
the outcome measures that should be used,rate investigations performed on US veterans. different periods of follow up and mixed,with LLA the authors concluded that the. groups of patients with amputations reported,most striking finding was the high incidence of. on together Pernot et al 1997 Kent and Fyfe,residual limb discomfort Hoaglund et al. 1999 Geertzen et al 2001 Deathe et al,1983 and that there are significant problems.
2002 For example individuals with amputa,with current methods for attaching prostheses. tions of the upper and lower extremities are,that need to be addressed Sherman 1999. reported together Nielsen 1991 Nicholas et,Another commonly reported problem is. al 1993 Sherman 1999 Pezzin et al 2004,phantom limb pain Hill 1999 Smith et al. and cases with amputations due to PVD are,1999 Among 104 persons with a major LLA.
mixed with cases with non vascular causes,69 reported experiencing phantom limb pain. Medhat et al 1990 Nicholas et al 1993,and the pain situation was worse for those with. Gauthier Gagnon et al 1999 Matsen et al,TFA compared with TTA Gallagher et al. 2000 Moreover those with KDA TFA and,2001 Pain from other body sites such as back. amputations at the hip are grouped together,pain and pain in the joints of the contralateral.
Kegel et al 1978 Medhat et al 1990 and,limb has also been described as occurring fre. patients with newly performed amputations,quently Friberg 1984 Walker et al 1994 Ehde. are reported together with those with an esta,et al 2000 Pezzin et al 2000 Among 92 indi. blished situation Kegel et al 1978 Matsen et,viduals in another study major LLA 63 had. al 2000 As a result in the existing literatu,experienced phantom limb pain 76 residual.
Transfemoral Amputation Quality of Life and Prosthetic Function 11. limb pain and 71 back pain during the last to be related to poorer quality of life van der. four weeks and close to half had had all three Schans et al 2002. types of pain Smith et al 1999 Further back Another aspect of prosthetic walking is. pain was more common and more bothersome related to velocity There is a large amount of. among persons with TFA than with TTA Smith research showing that individuals with TFA. et al 1999 In the long term an increased risk have a slower self selected or comfortable. of osteoarthritis in the ipsilateral hip and con walking speed CWS than healthy controls. tralateral knee joint Kulkarni et al 1998 and For non vascular TFA cases the CWS has been. a frequent finding of osteopenia in the ipsilate reported to be between 45 and 75 m min James. ral hip Rush et al 1994 has been reported for and Oberg 1973 Waters et al 1976 Huang et. individuals with TFA al 1979 Harris et al 1990 Boonstra et al. Using a prosthetic limb has also been de 1993 Jaegers et al 1993 Boonstra et al 1994. scribed as causing a variety of other perceived Chin et al 1999 Waters and Mulroy 1999. complaints that affect everyday life including while in the case of healthy persons it has been. difficulty donning and doffing do on and reported to be between 60 and 100 m min. do off the prosthesis not being able to rely Huang et al 1979 Waters et al 1988 Harris. on the prosthesis being securely suspended et al 1990 Boonstra et al 1993 Bohannon. difficulties with the choice and or wear of appa 1997 Waters and Mulroy 1999 Sunnerhagen. rel and shoes smell and noise emanating from et al 2000. the artificial limb and of course difficulties Finally the efficiency of prosthetic gait can. relating to mobility with the device Grise et al be described in terms of energy cost also. 1993 Nicholas et al 1993 Legro et al 1999 known as metabolic cost or oxygen cost. Gallagher and Maclachlan 2001 Miller et al which describes the metabolic consequences of. 2001 Again there is a lack of research repor walking in relation to the distance travelled. ting separately on the perceived complaints for Czerniecki 1996 The golden standard for. persons with TFA for reasons other than PVD the assessment is to perform direct measure. ments of the volume of oxygen uptake VO2, Prosthetic walking and express the cost as VO2 per unit of distan. Walking with a TFA prosthesis is often per ce walked In normal walking the highest. formed with a characteristic limp Sj dahl efficiency exists when walking at CWS. Hammarlund 2004 In addition to analyses of Pagliarulo et al 1979 Donn and Roberts. the gait pattern the outcome of different 1992 Waters and Mulroy 1999 For persons. aspects of prosthetic walking is described in the with a TFA socket prosthesis the energy cost. literature in terms of use of walking aids walk has been shown to increase by 40 67 com. ing or mobility skills e g being able to walk on pared with the normal level Waters et al. stairs slopes uneven terrain and so on walk 1976 Huang et al 1979 Boonstra et al 1994. ing distances walking speed and walking Schmalz et al 2002 The analysis of direct. efficiency Again there is no clear consensus on uptake of VO2 is a cumbersome method which. how to define functional walking and how to requires advanced equipment limiting the. present the results Pernot et al 1997 Table 1 assessment to being primarily performed with. illustrates some outcomes reported for indivi in small groups and in a laboratory setting. duals with LLA due to trauma or tumour Another more simple method for estimating. according to various issues with regard to the energy cost based on the registration of. prosthetic use function and problems As heart rate is the Physiological Cost Index PCI. shown in Table 1 limited walking distances are MacGregor 1981. commonly reported Not being able to walk There is a need for research reporting per. 500 m with a prosthetic limb has been shown formance based measures of prosthetic walk. 12 Transfemoral Amputation Quality of Life and Prosthetic Function. Table 1 Examples of outcomes reported for individuals with LLA due to reasons other than vascular disease Wherever possible data for individuals. with TFA are reported separately, Prosthetic use Use of walking aids Walking distance Reported problems. Hoaglund 1983, TTA and TFA trauma n 112 TFA 38 TTA TFA TTA TFA TTA TFA TFA separately. 100 men mean age 47 yr 14 8 h day 24 use cane 8 none or 71 perspiration. 1 39 yr since amp 86 all day part of time only in home 61 phantom limb pain. 61 no aid 45 1 6 blocks 58 back pain,47 6 blocks 50 pain with prosthesis. 45 socket problems,Walker 1994, TFA trauma n 24 4 4 h day 56 1 4 mile on 75 phantom limb pain.
83 male mean age 29 yr 25 8 12 h day Not reported the flat 45 skin breakdown problem. Mean 15 yr since amp 63 12 h day 50 consider themselves as being. quite to very disabled,Burger 1997,Major LLA trauma n 223 1 no use 31 use aid TTA. TFA 89 14 7 h day indoors 33 500m, 80 men mean age 54 yr 25 7 10 h day 48 use aid TFA Not reported. Mean age at amp 24 yr 60 10 h day outdoors 50 500m. Dillingham 2001, LLA trauma n 78 TFA 16 87 men 95 have a prosthesis 32 use a cane 57 not satisfied with prosthetic comfort. Mean age at injury 33 yr Mean use or crutches most of 24 phantom limb pain. Mean time since injury 7 5 yr 80 h week the time Not reported 24 skin irritation and wounds. 23 perspiration,17 pain from contralateral limb,Hoffmann 2002. TFA tumour n 35 17 not daily 46 use a cane 37 mild phantom limb pain. 54 men mean age 43 yr 26 12 h day or crutches 11 severe phantom limb pain. 2 30 yr since amp 57 12 h day 49 no aid Not reported. Refaat 2002, LLA tumour n 66 TFA 34 91 use prosthesis 83 use aid 30 required pain medication.
Transfemoral Amputation Quality of Life and Prosthetic Function. 62 men mean age 52 yr 26 periodic depression, Mean age at amp 40 yr Not reported 35 with TFA not satisfied with current status. ing for individuals with TFA due to reasons persons with different kinds of health pro. other than PVD and the results of the PCI have blem The value of the generic measure is that. rarely been reported for any individuals with it can be used for comparisons of different. LLA categories of people The condition specific,tool is designed for a targeted group of pati. ents or conditions and gives a more detailed,perspective of HRQL for that specific group. 3 Health Related Quality In most cases the targeted measure is more. Of Life sensitive to detecting changes within the speci. fic group than the generic tool Fayers and,In 1948 the World Health Organisation. David 2000 Cella and Nowinski 2002,declared health to be a state of complete phy.
Beaton and Schemitsch 2003 One common,sical mental and social well being and not. piece of advice is to use both kinds of measu,merely the absence of disease WHO 1978. re in order to best capture the overall situation,Today any evaluation of a new treatment. and change in health due to an intervention,should include evidence of its impact on health. Beaton et al 1997 Hays et al 2002 Beaton,and quality of life Jackowski and Guyatt.
and Schemitsch 2003,2003 Quality of life is a normative concept. The study of HRQL is always a patient,that could mean different things to different. based measure simply because the patient is,people Fayers and David 2000 Cella and. the key source of information and the preferred,Nowinski 2002 Within health outcome re. format to capture the patient s subjective expe,search the concept has been compiled to focus.
rience is self report questionnaires Bussmann,on those aspects that are more directly affec. and Stam 1998,ted by a health condition and facets relating to. In orthopaedic and rehabilitation research,factors such as economic status or social. the relationship between HRQL and physical,surroundings have been excluded This confin. function is obvious The amputation of a limb,ed concept is called health related quality of.
is a dramatic change in the life situation of the,life HRQL and it has been defined to inclu. person involved and limb loss is without doubt,de the perception of an individual of his or her. a chronic condition Several studies have,degree of physical psychological and social. reported a reduction in general HRQL Pell et,well being and the effects that illness and treat. al 1993 Smith et al 1995 Legro et al 1999,ment have on daily life Jette 1993 Muldoon.
Demet et al 2003 an increased incidence of,et al 1998 Patrick and Chiang 2000 It is. depression Kashani et al 1983 and increased,considered especially important to study. social discomfort Rybarczyk et al 1992,HRQL in groups with chronic conditions when. among individuals with LLA The impact of,the goal of care is to make the patient s life as. the amputation on the general and the specific,comfortable functional and satisfying as.
HRQL in the particular subset of individuals,possible Sullivan et al 1999. with TFA for reasons other than PVD is,however not clear. Generic and condition specific measurements of,There are two main types of HRQL measure. general or generic measures and disease or,condition specific measures Streiner and. Norman 1995 Fayers and David 2000 Cella,and Nowinski 2002 Domholdt 2005 A.
generic tool gives a broader perspective and,could be used on healthy persons as well as on. 14 Transfemoral Amputation Quality of Life and Prosthetic Function. 4 Outcome measures ficial limb attached directly to the residual ske. leton and over the years surgical attempts, targeted at individuals have been made to achieve this Mooney et al. with LLA 1971 Hall et al 1976 Hall 1977 Mooney et,al 1977 Hall 1985. Over the years a number of measures have The discovery that implants made of. been used to describe prosthetic function and commercially pure titanium could provide a. mobility The most common have been simple stable anchorage for the implant in the bone. classification scales in which the level of mobi tissue was made by Professor Per Ingvar. lity is registered by the investigator with no Br nemark during the 1950s and the concept. proof of validity or reliability of the scales of osseointegration has been in successful cli. Rommers et al 2001 Deathe et al 2002 In nical practice for dental applications since. 1981 the Amputee Activity Score which is a 1965 Br nemark et al 1977 Br nemark. validated tool designed to be used in direct 2005 and more than two million dental pati. interviews with the patient was published Day ents have been treated according to the con. 1981 More specific self report questionnaires cept worldwide The word osseointegration is. involving examinations of the HRQL and cap defined as the direct anchorage of an implant. turing the patients own view have been by the formation of bony tissue around it with. requested Kent and Fyfe 1999 Geertzen et al out growth of fibrous tissue at the bone. 2001 Rommers et al 2001 implant interface Dorland and Anderson. Today one internationally established self 2003 At the present time the method is for. report instrument with proven validity and example also used successfully for treatment. reliability is the Locomotor Capability Index with bone anchored hearing aids other. LCI which is included in a larger question defects in the head and neck area Tjellstr m. naire called the Prosthetic Profile of the 1989 Tjellstr m and H kansson 1995 fing. Amputee Gauthier Gagnon and Grise 1994 er joint prostheses Lundborg et al 1993. Gauthier Gagnon et al 1998 However the M ller et al 2004 and thumb amputation. high ceiling effect of the LCI makes this index prostheses Lundborg et al 1996 Treatment. more suitable for use on individuals with lower with major bone anchored amputation. prosthetic mobility capabilities such as those prostheses using osseointegration OI prosthe. with LLA due to PVD Miller et al 2001 ses has been performed in Sweden since 1990. Moreover aspects of HRQL are not included in Br nemark et al 2001 and more recently. this tool Another instrument in which issues also in the United Kingdom Sullivan et al. of HRQL are represented is the Prosthesis 2003 Robinson et al 2004 In 1999 a pro. Evaluation Questionnaire PEQ Legro et al spective clinical investigation named OPRA. 1998 which was developed to measure small Ossseointegrated Prostheses for the. differences in prosthesis function and major life Rehabilitation of Amputees was started at the. domains related to prosthesis function Sahlgrenska University Hospital in G teborg. No self report questionnaire has been designed Sweden on patients treated with TFA OI. to address the needs of non elderly persons with prostheses In accordance with the OPRA pro. a TFA and their condition specific HRQL tocol patients are treated in two surgical. sessions followed by rehabilitation with a,total treatment period of approximately 12. 5 Osseointegration months At the first surgery S1 a titanium. implant fixture is inserted in the residual, The number of problems related to the sus bone and left unloaded for about six months.
pension and comfort of conventional socket At the second surgery S2 a titanium rod. prostheses have led to a desire to have the arti abutment is inserted into the distal end of the. Transfemoral Amputation Quality of Life and Prosthetic Function 15.


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Life Sciences Telematics resource Grade 12 2019 5 Protein synthesis is the process whereby proteins are made in living cells of an organism to form enzymes, hormones and new structures for cells.

DNA & PROTEIN SYNTHESIS (LIVE) 07 APRIL 2015 Section A ...

DNA amp PROTEIN SYNTHESIS LIVE 07 APRIL 2015 Section A

The diagram below represents a part of the process of protein synthesis. 8.1 Name or provide labels for N, P, Q, and Z (4) 8.2 Write down the sequence of the FIRST THREE nitrogenous bases on the DNA strand that led to the formation Z. (2) 8.3 Name the part / stage of protein synthesis that is illustrated in O. (1)