Can new evidence improve Clinical Practice Guidelines for upper limb amputation rehabilitation?

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Frossard, Laurent
Sheehan, Beth
Tønnevold, Nils
Sexton, Sandra
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Leipzig, Germany


Summary*: This study aimed at reviewing the literature associated with the current Clinical Practice Guidelines for upper limb amputation rehabilitation and, more importantly, identified possible ways to improve their recommendations. Introduction/Basics*: The ability of individuals living with upper limb absence to use a prosthetic device largely depends on their residuum health. Practically, clinicians prescribe bespoke surgical, medical, rehabilitation and prosthetic care interventions in the hope of maintaining satisfactory residuum health. Clearly, the development of Clinical Practice Guideline (CPG) is essential to ensure that end-users receive high-quality, evidence-based care, promote safety, and standardize rehabilitation practices.[1] Kwah et al (2019) have conducted one of the most comprehensive systematic reviews focusing solely on CPG for upper limb amputation rehabilitation.[2] However, more than 1,200 articles related to this topic have been published since. This study aimed at reviewing the literature associated with the current CPGs for upper limb amputation rehabilitation and, more importantly, identified possible ways to improve their recommendations. Material/methods*: Clinical guidelines, literature reviews and observational studies focusing on upper limb rehabilitation were considered. Searches for references published in English only between 2017 and mid-2023 ended in Sept 2023. Permutations of keywords related to population (e.g., upper limb end-users), intervention (e.g., fitting of attachment, passive, body-powered, external powered, hybrid and activity-specific components), comparator (e.g., sound limb, able-bodied participants) and outcomes (e.g., pain, satisfaction, handedness, functions) were inputted into seven guidelines (e.g., National Institute for Health and Clinical Excellence, National Guideline Clearinghouse) as well as two scientific databases (i.e., Google Scholar, PubMed). Guidelines and literature reviews were selected based on their relevance by two raters. References focusing on interventions and outcomes and were paired automatically using occurrences of keywords in titles and abstracts regardless of level of evidence.
Results: Over 500 references were screened. Preliminary extraction of the information showed a limited number of CPGs published since 2019 including the ones produced by the British Society of Rehabilitation in 2018 and the most recent created by the US Departments of Veteran Affairs and Defense.[3, 4] As outlined in Crunkhorn et al (2023), this guideline made 14 recommendations related to surgery and pre-prosthetic care (3), rehabilitation care (3), prosthetic restoration (5), outcomes (1), psychosocial considerations (2) but only 4 (29%) recommendations were supported with sufficient evidence (i.e., use of mirror therapy, use of a body-powered or externally powered prosthesis, screening service-users for mental health and pain, offering peer support services).[5] A total of 481 (96%) references selected focused on fitting of attachment (10, 2%), passive (6, 1%), body powered ( 41, 8%) and externally powered (175, 35%) components and pain (48, 10%), satisfaction with fitting (364, 73%), handedness (14, 3%) and function (419, 83%). These references included over 30 literature reviews focusing on fitting of attachment (1), passive (1), body powered (3), externally powered (7) components as well as pain (1), satisfaction with fitting (26, 73%), and function (33).
Overall, 35 (7%), 118 (24%), 11 (2%), 65 (13%), 14 (3%), 3 (1%) and 1 references associated on 1, 2, 3, 4, 6, 8 and 9 aspects of interventions and outcomes (Table 1). Discussion/Conclusion for clinical practice*: These outcomes seem to indicate that the relationships between the pain or handedness and fitting interventions are overlooked. However, theses outcomes might be considered separately and/or encompassed in the outcomes related to satisfaction of fitting and level of function. In all cases, the literature is led by references focusing on the satisfaction of fitting (129, 26%) and level of function (155, 31%) with myoelectric prostheses. Further analyses are required to confirm (A) the recruitment bias toward US Veterans, (B) the lack of standardisation of outcomes measures due to the polysemy of key terms, and (C) the benefits of emerging bionics solutions. Hopefully, mining these references will provide deeper insights into the current knowledge gaps and future research opportunities. This will benefit end-users, healthcare providers, and the healthcare system as a whole by improving outcomes and the efficiency of care delivery during rehabilitation and beyond.

Acknowledgements: IC2A would like to acknowledge the European Union’s Horizon 2020 research and innovation program that has funded this work. Literature references:

  1. Heyns, A., et al., Systematic Review of Clinical Practice Guidelines for Individuals With Amputation: Identification of Best Evidence for Rehabilitation to Develop the WHO's Package of Interventions for Rehabilitation. Arch Phys Med Rehabil, 2021. 102(6): p. 1191-1197.
  2. Kwah, L.K., et al., Quality of Clinical Practice Guidelines for Management of Limb Amputations: A Systematic Review. Phys Ther, 2019. 99(5): p. 577-590.
  3. Hanspal, R. and I. Sedki, Amputee and Prosthetic Rehabilitation – Standards and Guidelines (3rd Edition). 3rd ed. 2018, London.
  4. Affairs, U.D.o.V., VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation – Provider Summary in Department of Veterans Affairs, Department of Defense. 2022.
  5. Crunkhorn, A., et al., Management of Upper Limb Amputation Rehabilitation: Synopsis of the 2022 US Department of Veterans Affairs and US Department of Defense Clinical Practice Guideline for Acquired Amputation. Am J Phys Med Rehabil, 2023. 102(3): p. 245-253.
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OTWorld International Trade Show and World Congress 2024

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Frossard, L; Sheehan, B; Tønnevold, N; Sexton, S, Can new evidence improve Clinical Practice Guidelines for upper limb amputation rehabilitation?, OTWorld International Trade Show and World Congress 2024, 2024