Advertisement

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

Published:January 04, 2021DOI:https://doi.org/10.1016/j.apmr.2020.11.019

      Abstract

      Objectives

      To report the results of the systematic search performed to identify interventions and related evidence for rehabilitation of individuals with amputation based on the current evidence from clinical practice guidelines (CPG).

      Data Sources

      Pubmed, Pedro, CINAHL, Embase, Google Scholar, and multiple guideline databases (date restriction, 2008-2018).

      Study Selection

      Exclusion criteria were no CPG, not reporting on rehabilitation, published before 2008, developed for health conditions other than amputation, presence of conflict of interest (financial or nonfinancial), lack of information on the strength of the recommendation, and lack of quality assessed by the “Appraisal of Guidelines for Research and Evaluation.”

      Data Extraction

      Data extraction was done using a standardized form, which comprised information on the recommendation, the strength of recommendation and the quality of the evidence used to inform the recommendation.

      Data Synthesis

      We included 4 guidelines, providing a total of 217 recommendations (20 on assessments, 131 on interventions, and 66 on service provision). Most recommendations concerned pain management, education, pre- and postoperative management, and residual limb care. The strength of recommendation was generally weak to intermediate. The level of evidence mostly compromised expert opinions, with only 6.9% (15 of 217) being provided by randomized controlled trials, systematic reviews, or meta-analyses.

      Conclusions

      The field of amputation is well covered for recommended interventions, but the level of evidence is generally low and is based mostly on expert opinion. Some important domains are not covered (eg, vocation and education, sexual and/or intimate relationships, activities of daily living or leisure activities, education concerning socket/liner fitting). There is also a lack of description of the contents of training and rehabilitation programs. This should be taken into account for the development of future guidelines.

      Keywords

      List of abbreviations:

      AGREE (Appraisal of Guidelines for Research and Evaluation), be4rehab (best evidence for rehabilitation), CPG (clinical practice guidelines), LLA (lower limb amputation), ICD-9-CM (International Classification of Diseases, 9th Revision, Clinical Modification), PIR (Package Interventions for Rehabilitation), RCT (randomized controlled trial), UHC (universal health coverage), ULA (upper limb amputation), VaDoD (Veterans Affairs, Department of Defense), WHO (World Health Organization)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • World Health Organization
        Universal health coverage (UHC).
        (Available at:)
        • World Health Organization
        World report on disability. Chapter 4.
        (Available at:)
        • World Health Organization
        Rehabilitation 2030: a call for action.
        (Available at:)
        • Rauch A.
        • Negrini S.
        • Cieza A.
        Toward strengthening rehabilitation in health systems: methods used to develop a WHO package of rehabilitation interventions.
        Arch Phys Med Rehabil. 2019; 100: 2205-2211
        • National Limb Loss Information Center
        Limb loss in the United States: amputation statistics by cause.
        Amputee Coalition of America, Knoxville, TN2008
        • Behrendt C.A.
        • Sigvant B.
        • Szeberin Z.
        • et al.
        International variations in amputation practice: a VASCUNET report.
        Eur J Vasc Endovasc Surg. 2018; 56: 391-399
        • Ziegler-Graham K.
        • MacKenzie E.J.
        • Ephraim P.L.
        • Travison T.G.
        • Brookmeyer R.
        Estimating the prevalence of limb loss in the United States: 2005 to 2050.
        Arch Phys Med Rehabil. 2008; 89: 422-429
        • Lai Y.J.
        • Hu H.Y.
        • Lin C.H.
        • Lee S.T.
        • Kuo S.C.
        • Chou P.
        Incidence and risk factors of lower extremity amputations in people with type 2 diabetes in Taiwan, 2001-2010.
        J Diabetes. 2015; 7: 260-267
        • Paisey R.B.
        • Abbott A.
        • Levenson R.
        • et al.
        South-West Cardiovascular Strategic Clinical Network peer diabetic foot service review team. Diabetes-related major lower limb amputation incidence is strongly related to diabetic foot service provision and improves with enhancement of services: peer review of the South-West of England [published erratum appears in Diabet Med 2018;35:394].
        Diabet Med. 2018; 35: 53-62
        • Imam B.
        • Miller W.C.
        • Finlayson H.C.
        • Eng J.J.
        • Jarus T.
        Incidence of lower limb amputation in Canada.
        Can J Public Health. 2017; 108: e374-e380
        • Sarfo-Kantanka O.
        • Sarfo F.S.
        • Kyei I.
        • Agyemang C.
        • Mbanya J.C.
        Incidence and determinants of diabetes-related lower limb amputations in Ghana, 2010-2015- a retrospective cohort study.
        BMC Endocr Disord. 2019; 19: 27
        • U.S. Department of Veterans Affairs
        VA/DoD clinical practice guidelines: rehabilitation of lower limb amputation (2017).
        (Available at:) (Accessed January 24, 2019)
        • U.S. Department of Veterans Affairs
        VA/DoD clinical practice guidelines: the management of upper extremity amputation rehabilitation (UEAR).
        (Available at:) (Accessed January 24, 2019)
        • AGREE Next Steps Consortium
        Appraisal of guidelines for research & evaluation II: AGREE II Instrument.
        (Available at:) (Accessed January 29, 2019)
        • AGREE Collaboration
        Development and validation of an international appraisal instrument for assessing the quality of clinical practice guidelines: the AGREE project.
        Qual Saf Health Care. 2003; 12: 18-23
        • Atkins D.
        • Best D.
        • Briss P.A.
        • et al.
        Grading quality of evidence and strength of recommendations.
        BMJ. 2004; 328: 1490
        • Van Der Linde H.
        • Conradi M.E.
        • Deckers J.
        • et al.
        Dutch evidence-based guidelines for amputation and prosthetics of the lower extremity: Amputation surgery and postoperative management [Dutch].
        (Available at:) (Accessed January 24, 2019)
        • Smith S.
        • Pursey H.
        • Jones A.
        • Baker H.
        • et al.
        2nd edition- clinical guidelines for the pre and post operative physiotherapy management of adults with lower limb amputations.
        (Available at:) (Accessed January 24, 2019)
        • Negrini S.
        Evidence in rehabilitation medicine: between facts and prejudices.
        Am J Phys Med Rehabil. 2019; 98: 88-96
        • Levack W.M.
        • Malmivaara A.
        • Meyer T.
        • Negrini S.
        Methodological problems in rehabilitation research. Report from a Cochrane rehabilitation methodology meeting.
        Eur J Phys Rehabil Med. 2019; 55: 319-321
        • Negrini S.
        • Arienti C.
        • Pollet J.
        • et al.
        Clinical replicability of rehabilitation interventions in randomized controlled trials reported in main journals is inadequate.
        J Clin Epidemiol. 2019; 114: 108-117
        • Condie E.
        • Scott H.
        • Treweek S.
        Lower limb prosthetic outcome measures: a review of the literature 1995 to 2005.
        JPO. 2006; 18: 13-45
        • Resnik L.
        • Borgia M.
        • Silver B.
        Measuring community integration in persons with limb trauma and amputation: a systematic review.
        Arch Phys Med Rehabil. 2017; 98 (e8): 561-580