To Örebro University

AIMS: Risk factors for lower limb amputation (LLA) in individuals with diabetes have been under-studied. We examined how 1/demographic and socioeconomic, 2/medical, and 3/lifestyle risk factors may be associated with LLA in people with newly diagnosed diabetes.

METHODS: Using the Swedish national diabetes register from 2007 to 2016, we identified all individuals ≥18 years with an incident diabetes diagnosis and no previous amputation. These individuals were followed from the date of diabetes diagnosis to amputation, emigration, death, or the end of the study in 2017 using data from the In-Patient Register and the Total Population Register. The cohort consisted of 66,569 individuals. Information about demographic, socioeconomic, medical, and lifestyle risk factors was ascertained around the time of the first recorded diabetes diagnosis, derived from the above-mentioned registers. Cox proportional hazard models were used to obtain hazard ratios (HR) with 95% confidence intervals (CI).

RESULTS: During the median follow-up time of 4 years, there were 133 individuals with LLA. The model adjusting for all variables showed a higher risk for LLA with higher age, HR 1.08 (95% CI 1.05-1.10), male sex, HR 1.57 (1.06-2.34), being divorced, HR 1.67 (1.07-2.60), smokers HR 1.99 (1.28-3.09), insulin treated persons HR 2.03 (1.10-3.74), people with low physical activity (PA) HR 2.05 (1.10-3.74), and people with an increased foot risk at baseline HR > 4.12. People with obesity had lower risk, HR 0.46 (0.29-0.75).

CONCLUSIONS: This study found a higher risk for LLA among people with higher age, male sex, who were divorced, had a higher foot risk group, were on insulin treatment, had lower PA levels, and were smokers. No significant association was found between risk for LLA and education level, country of origin, type of diabetes, blood glucose level, hypertension, hyperlipidemia, creatinine level, or glomerular filtration rate. Obesity was associated with lower risk for LLA. Identified variables may have important roles in LLA risk among people with diabetes.

Background and aims: Risk factors for lower limb amputation (LLA) in individuals with diabetes have been under-studied. We examined how demographic and socioeconomic, medical and life-style risk factors may be associated with LLA in people with newly diagnosed diabetes.

Materials and methods: We conducted a cohort study using Swedish national register-linked data. We identified, through the Swedish national diabetes register, all individuals 18 years or older with an incident diabetes diagnosis and no previous amputation from 2007 to 2016. These individuals were followed from the date of the diagnosis to amputation, emigration, death, or the end of the study in 2017, whichever occurred first. Several national Swedish registers were used to obtain data on incident LLA and potential risk factors, including demographic and socioeconomic, medical and lifestyle variables. Variables with more than 40% missing data were excluded from the analysis. The cohort consisted of 66,569 individuals, where of 133 hadan amputation. Cox proportional hazards models were used to obtain hazard ratio (HR) with 95% confidence interval (CI) for associations between demographic and socioeconomic, medical and lifestyle vari-ables and amputation risk. Both unadjusted and mutually adjusted models were fitted.

Results: During the median follow-up time of 4 years there were in total 133 LLA. Based on the model mutually adjusting for all variables, higher age, HR 1.08 (95% CI, 1.05 - 1.10) per year, and being divorced compared with being married, HR 1.67 (1.07 - 2.60) showed positive association. Male sex indicated higher risk, HR 1.57 (1.06 - 2.34). Individuals with an increased foot risk at baseline had increased risk for LLA compared to individuals with healthy feet (neuropathy/angiopathy, HR 4.12 (2.84 - 5.98), previous wounds, HR 8.26 (3.29 - 20.74), ongoing severe foot disease, HR 11.24 (4.82 - 26.23). Insulin treatment compared with diet-only treatment showed HR 2.03 (1.10 - 3.74). Hypertension and HbA1c were not statistically significantly associated with LLA risk. People with obesity had a statistically significant lower risk, HR 0.46 (0.29 - 0.75), compared with individuals with normal weight. Smoking was associated with an increased risk compared with no smoking, HR 1.99 (1.28 - 3.09). Finally, low physical activity (<1 time/week) was associated with an increased risk with a HR of 2.05 (1.30 - 3.23) compared with daily physical activity.

Conclusion: This study found a higher risk for LLA among people with higher age, male sex, who were divorced, who had a higher foot risk group, who were on insulin treatment, lower physical activity levels, and who were smoking. Obesity was associated with lower risk for LLA. Thus, these variables may have important roles in LLA risk among individuals with diabetes.

BACKGROUND: There are currently no national competency standards upon which to develop educational objectives for prosthetist/orthotists in Sweden. While standards have been developed in other countries, they cannot be applied without confirming their relevance in a Swedish context.

OBJECTIVES: To describe and obtain consensus on core competencies required for newly graduated prosthetist/orthotists in Sweden.

STUDY DESIGN: Modified Delphi process.

METHODS: A modified Delphi technique was carried out. Focus groups were initially used to identify core competency domains. Two consecutive questionnaires, containing a list of potential competency items, were sent to a group of stakeholders with ties to the prosthetic and orthotic profession. Stakeholders were requested to rate their level of agreement with each competency item and provide written comments. Finally, two focus groups were conducted to obtain feedback on the draft competency standards.

RESULTS: Forty-four competency items, listed under five key domains of practice, were identified as essential for newly graduated prosthetist/orthotists in Sweden.

CONCLUSIONS: Many similarities exist in core competency descriptions for prosthetist/orthotists in Sweden when compared to other countries. Regional differences do however exist, and it is important to confirm the relevance of core competency items at a national level before they are applied. Clinical relevance Competency standards developed in this study can be used to guide development of learning objectives within an undergraduate prosthetic and orthotic program, provide a framework for workforce development, assist professional organizations in understanding the needs of their members, and prepare for international accreditation.

BACKGROUND: Often in balance assessment variables associated with the center of pressure are used to draw conclusions about an individual's balance. Validity of these conclusions rests upon assumptions that movement of the center of pressure is inter-dependent on movement of the center of mass. This dependency is mechanical and is referred to as the Inverted Pendulum Model. The following study aimed to validate this model both kinematically and kinetically, in transtibial prosthesis users and a control group.

METHODS: Prosthesis users (n=6) and matched control participants (n=6) stood quietly while force and motion data were collected under three conditions (eyes-open, eyes-closed, and weight-bearing feedback). Correlation coefficients were used to investigate the relationships between height and excursion of markers and center of masses in mediolateral/anteroposterior-directions, difference between center of pressure and center of mass and the center of mass acceleration in mediolateral/anteroposterior directions, magnitude of mediolateral/anteroposterior-component forces and center of mass acceleration, angular position of ankle and excursion in mediolateral/anteroposterior-directions, and integrated force signals.

FINDINGS: Results indicate kinematic validity of similar magnitudes (mean (SD) marker-displacement) between prosthesis users and control group for mediolateral- (r=0.77 (0.17); 0.74 (0.19)) and anteroposterior-directions (r=0.88 (0.18); 0.88 (0.19)). Correlation between difference of center of pressure and center of mass and the center of mass acceleration was negligible on the prosthetic side (r = 0.08 (0.06)) vs. control group (r=-0.51(0.13)).

INTERPRETATION: Results indicate kinematic validity of the Inverted Pendulum Model in transtibial prosthesis users but kinetic validity is questionable, particularly on the side with a prosthesis.