EFFECTIVENESS AND EQUITY IN COMMUNITY- AND HOME-BASED REHABILITATION INTERVENTIONS ON OUTCOMES OF TRANSFEMORAL AND TRANSTIBIAL AMPUTATION: A SYSTEMATIC REVIEW

A.M. Wijekoon^1,2, S. Jayawardana², R. Milton-Cole¹, J. Amy³, S. Cook⁴, E. Morrison³, K.J. Sheehan¹

Background: Transfemoral (TFA) and transtibial (TTA) amputations account for the majority of lower-limb amputations. Rehabilitation following TFA or TTA is considered a lifelong process with regular follow-up to identify any additional rehabilitation needs required to maintain adequate quality of life and regain a level of pre amputation functional independence. However, optimal community- or home-based rehabilitation after TFA and TTA is unknown. There is an observed mismatch between randomised controlled trial (RCT) and practice adherence for community- and home-based rehabilitation which may be due to equity factors in eligibility criteria of these RCTs. Findings of this review will inform development of a community-based rehabilitation intervention for adults after TFA and TTA.

Purpose: To synthesize the literature on the effectiveness of community- and home-based rehabilitation interventions for adults after TFA and TTA and determine the role of equity factors in eligibility criteria of the RCTs.

Methods: Embase, MEDLINE, PEDro, Cinhal, Global Health, PsycINFO, Open Grey, and ClinicalTrials.gov were searched from inception to February 10th 2020 for RCTs of community- and home-based rehabilitation interventions for adults after TFA or TTA. RCTs of inpatient rehabilitation, interventions without exercise, or not published in English were excluded. Two authors completed screening and quality appraisal in Covidence using the Cochrane Risk of Bias Tool. Data extraction was completed on templates defined a priori and using the PROGRESS-PLUS framework for equity factors. Results were analysed using a narrative review approach.

Results: We identified 7 published, 2 protocol, and 1 registered ongoing trial (453 participants across trials). All were conducted in high or upper-middle income countries after 2015. Good quality evidence demonstrated effectiveness of community- and home-based rehabilitation interventions in improving pain and functional outcomes for adults after TFA and TTA compared to usual care or active control. Interventions included cognitive behavioural therapy and video games combined with exercise. There was heterogeneity in the frequency, intensity, time, and type of exercise as well as outcomes studied. Overall, 418 (66.7%) potential participants were excluded from trials due to equity-related factors.

Conclusion(s): Community- and home-based rehabilitation interventions which incorporate exercise improved pain and functional outcomes after TFA and TTA. There was heterogeneity in interventions and outcomes limiting the ability to determine optimal rehabilitation parameters. Potential participants were excluded based on equity factors which may influence reported effectiveness and adherence. No trials were completed in lower-middle- and low-income countries limiting the generalizability of trial findings reported in the current review.

Implications: There is good quality evidence for clinicians to incorporate exercise into the long-term management of adults after TFA or TTA. However, further research is needed to determine the optimal frequency, intensity, type and timing of an exercise intervention. There is a need for a common core outcome set for trials following TFA or TTA to enable future meta-analysis. Finally, the effectiveness of these interventions in the underlying population is uncertain due to inequities in eligibility criteria and should be explored.

Funding, acknowledgements: This study was funded by the Commonwealth Scholarship Commission.

Keywords: lower-limb, adults, inequity

Topic: Disability & rehabilitation

Did this work require ethics approval? No

Institution: N/A

Committee: N/A

Reason: The study is a systematic review