The role of exercise testing in predicting successful ambulation with a lower extremity prosthesis: a systematic literature review and clinical practice guideline.
Tyler D Klenow, Larry J Mengelkoch, Phillip M Stevens and 5 others
PMID 30255804WHAT IT FOUND
One-leg cycling and arm cycling tests can help judge prosthetic walking success.
In this review, sustaining 50% of predicted maximum oxygen consumption predicted walking 100 m, and 30 W on arm cycling predicted ambulation with a prosthesis.
Key findings
01A single-leg continuous maximal cycle ergometer test using percent of predicted VO2max measured by direct spirometry was found viable for evaluating cardiorespiratory fitness in unilateral lower extremity limb loss.
02Sustaining at least 50%VO2max was a strong predictor of walking 100 m with a prosthesis in elderly people with lower limb loss proximal to the knee, and sustaining at least 60%VO2max was a predictor of ambulation with a prosthesis in elderly non-vascular people with unilateral hip disarticulation.
03Achieving 30 W on an intermittent submaximal upper-extremity cycle ergometer test was a strong indicator of successful prosthetic ambulation in elderly people with transfemoral limb loss secondary to vascular causes.
STILL TO COME
How it was doneWhat they foundWhat it means for PTs
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What it does not show
The review included only 10 studies and 448 amputee subjects, so the guideline rests on a limited evidence base. No meta-analysis was performed because the exercise tests and outcome measures were too heterogeneous. Many single-leg cycling studies came from the same research group and used the same method for predicting VO2max. The evidence statements require direct spirometry to measure VO2, so many physical therapy clinics may not have access. The guideline is intended only when there is reasonable concern of cardiopulmonary compromise, not for every patient with limb loss. No included study tested whether a rehabilitation program can raise a patient from below the recommended testing levels to above them, so the rehabilitation recommendation is expert opinion. The rowing machine finding was based on a systematic review without data aggregation and showed no causative relationship, so it is not ready for guideline use. The review did not stratify functional levels beyond basic candidacy at the K1 level.
The easy way to misread this
Do not use this guideline to deny a prosthesis based on an exercise test. The paper says no included study tested whether an exercise program can raise a patient from below the recommended values to above them, and the rehabilitation recommendation is expert opinion rather than a tested intervention.