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VOLUME 4, ISSUE 1 

 2021 

 

RESEARCH ARTICLE 

Pousett B, Budzinski C, Labbé D, Miller WC. A mixed-methods study on prosthesis use among older Canadians with lower-limb amputations. Canadian 

Prosthetics & Orthotics Journal. 2021;Volume 4, Issue 1, No.10. https://doi.org/10.33137/cpoj.v4i1.36833 

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https://doi.org/10.33137/cpoj.v4i1.36833


 

1 

Pousett B, Budzinski C, Labbé D, Miller WC. A mixed-methods study on prosthesis use among older Canadians with lower-limb amputations. Canadian Prosthetics 
& Orthotics Journal. 2021;Volume 4, Issue 1, No.10. https://doi.org/10.33137/cpoj.v4i1.36833 

 

 

 
RESEARCH ARTICLE 

 

A MIXED-METHODS STUDY ON PROSTHESIS USE AMONG OLDER CANADIANS WITH LOWER-

LIMB AMPUTATIONS 

Pousett B1, Budzinski C2, Labbé D3,4,5, Miller WC3,4 

 

1 Barber Prosthetics Clinic, Vancouver, British Columbia, Canada. 
2 Holy Family Hospital, Providence Health Care, Vancouver, British Columbia, Canada. 
3 Department of Occupational Science and Therapy, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada. 
4 Rehabilitation Research Program, Vancouver, British Columbia, Canada. 
5 Department of Disability and Human Development, University of Illinois at Chicago, Chicago, Illinois, USA. 

 

 

 

 

  

 

 

 

 

 

 

 

 
 

 

INTRODUCTION   

In 2011, 7708 lower limb amputations (LLA) were performed 

in Canada, largely on individuals between the ages of 50-

74 (54.9%) due to complications from diabetes (65%).1 

More than half of these amputations were major 

amputations (from ankle disarticulations to pelvis 

amputations)  with  transtibial  amputations  being  the  most  

 

common (30.9%).1  However,  only  approximately  20% of 

individuals with major amputations received inpatient 

rehabilitation, which provides multidisciplinary care to help 

integrate the prosthesis into their daily life to improve 

functional mobility and social participation.2 Moreover, 

prosthetic rehabilitation requires significant health care and 

economic  investments,  especially  for  older  adults3  thus 

increasing interest in exploring the breadth of prosthetic use 

after discharge both in terms of quantity (e.g. wear time) and 

quality (e.g. type of use, experience).2,4 

How prosthetic use is defined varies between different 

studies. Its definition ranged from wear time, functional 

activity, participation in community or employment, and the 

 
OPEN  ACCESS Volume 4, Issue 1, Article No.10. 2021 

 

 

Journal Homepage: https://jps.library.utoronto.ca/index.php/cpoj/index 

 

ABSTRACT 

BACKGROUND: The prevalence of lower-limb amputations (LLA) in older adults is increasing. Due to 

the substantial resources required for rehabilitation, there is growing interest in exploring prosthesis use 

as well as the factors that impact use for individuals with LLA.  

OBJECTIVES: To examine how older adults, those over 50 years old, with a new LLA use their 

prostheses following rehabilitation and to identify factors that increase or decrease prosthesis use after 

discharge from a rehabilitation hospital.  

METHODS: The StepWatch Activity Monitor, the Prosthetic Profile of the Amputee Questionnaire, and 

a semi-structured interview were used to measure prosthesis use and factors affecting use at 12 weeks 

post-discharge from a rehabilitation hospital. Descriptive statistics were calculated for the quantitative 

data and the qualitative interviews were analyzed using the International Classification of Functioning 

and Disability.  

RESULTS: Two user profiles emerged from the 11 participants’ use patterns. The Regular Users 

integrated their prosthesis into their lives, using it for various types of activities, while the Strategic Users 

wore their prosthesis to perform specific activities of daily and instrumental activities of daily living tasks. 

Body functions (e.g., pain), personal (e.g., feeling of independence), and environmental factors (e.g., 

home adaptations or social support) impacted prosthesis use.  

CONCLUSIONS: The emergence of profiles suggests variability in how older adults with LLA use their 

prosthesis after rehabilitation. However, the factors affecting prosthesis use were similar between the 

profiles. Therefore, while it is important for rehabilitation teams to consider patients’ individual needs 

when setting goals for prosthetic training, they must also consider common factors affecting prosthesis 

use. 

ARTICLE INFO 

Received: June 26, 2021 

Accepted: August 6, 2021 

Published: August 16, 2021 

CITATION 

Pousett B, Budzinski C, Labbé D, 

Miller WC. A mixed-methods 

study on prosthesis use among 

older Canadians with lower-limb 

amputations. Canadian 

Prosthetics & Orthotics Journal. 

2021;Volume 4, Issue 1, No.10. 

https://doi.org/10.33137/cpoj.v4i1.

36833   

KEYWORDS 

Prosthesis, Rehabilitation, Lower 

Limb Amputation, Prosthetist, 

Older Canadians, Amputation  

 

 

* CORRESPONDING AUTHOR 

William C Miller, 
University of British Columbia, Vancouver, British Columbia, Canada.  
E-Mail: bill.miller@ubc.ca 

ORCID ID: https://orcid.org/0000-0003-3060-0210 

https://doi.org/10.33137/cpoj.v4i1.36833
https://jps.library.utoronto.ca/index.php/cpoj/index
https://doi.org/10.33137/cpoj.v4i1.36833
https://doi.org/10.33137/cpoj.v4i1.36833
mailto:bill.miller@ubc.ca
https://orcid.org/0000-0003-3060-0210


 

2 

Pousett B, Budzinski C, Labbé D, Miller WC. A mixed-methods study on prosthesis use among older Canadians with lower-limb amputations. Canadian Prosthetics 
& Orthotics Journal. 2021;Volume 4, Issue 1, No.10. https://doi.org/10.33137/cpoj.v4i1.36833 

ISSN: 2561-987X 
PROSTHESIS USE AMONG OLDER CANADIANS WITH LOWER-LIMB AMPUTATIONS 

Pousett et al. 2021 CPOJ 

 
number of steps taken.5-11 Moreover, the way it is measured 

varied between studies. Quantitative studies have used 

activity monitors,5,6 functional performance measures,8,10 

self-reported wear time,7,8 and validated questionnaires7-10 

to measure prosthesis use, while qualitative studies focused 

more on the type of activities done with the prosthesis, 

quality of life, and the experience of the prosthesis 

users.4,11-14 The quantitative studies measured prothesis 

use at different times ranging from discharge to 15 months 

after rehabilitation and their results varied both in terms of 

the quantity and quality of prosthesis use.7-14 For instance, 

some studies found a declined of use6,10 restricted 

functioning in mobility,10 leisure and social role such as 

employment,8,9 and limited autonomy outdoors while 

others7-8 reported increase prosthesis use overtime and 

higher functioning in activities of daily living. A qualitative 

meta-synthesis13 of the literature reported that most studies 

focused on adaptation to the amputation and the prosthesis, 

the role of social relationships, and the impact of the 

prosthesis on identity. However, how individuals use their 

prosthesis in specific life contexts, and the meaning of living 

with a prosthesis has not been fully been examined.14 

Moreover, only a few studies10,11 combined quantitative 

measure of use with the qualitative study of the experience 

and meaning of living with a prosthesis, which likely 

provides a more nuanced understanding of prosthesis use.  

Age has been identified as an important factor affecting 

prosthesis use.7,15 Research has suggested that prosthesis 

use is influenced by a variety of factors associated with 

aging. These factors include multiple comorbidities, 

cognitive impairment, compromised vasculature to the 

amputated side, significant deconditioning, and fear of 

falling.3,11,16 For instance, Webster et al.7 identified that 

adults older than 55 years old with LLA experienced greater 

functional restrictions and increased psychological distress 

than younger individuals. However, many studies only 

measured self-reported wear time, which did not reflect 

accurately the activity level.17 In addition, these studies did 

not always collect information about the lived experience of 

older users, or in what context the prosthesis was used 

which would help to understand how to support their 

prosthesis use, that might be different than for younger 

users. A systematic review concluded that many older 

prosthesis users demonstrated improved mobility in their 

home environment, but that more research was needed 

regarding prosthesis use of older adults in the community.3  

To better understand the context prosthesis use, it is 

important to document the factors that impact it. The 

individual and environmental factors affecting prosthesis 

use have been explored in literature, albeit mostly with 

qualitative studies. Findings generally suggest that those 

with increased independence and confidence tended to use 

their prosthesis more.10,12,15,18-20 Additionally, factors such 

as support from family and friends, a multidisciplinary 

healthcare team approach, a strong patient/prosthetist 

relationship can all positively influence prosthesis 

use.7,10,12,20 Conversely, the presence of pain, multiple 

comorbidities, impaired balance, decreased cognitive 

function, emotional challenges, and low daily requirements 

for standing/ambulating could reduce prosthesis use.9,12,19 

Moreover, one recent study conducted in Australia20 

suggested that terrain, climate, and transport systems could 

contain barriers to community walking for prosthesis users 

of all ages. However, such factors have not yet been 

explored in a Canadian context, which has different physical 

environments and rehabilitation systems. Moreover, studies 

included individuals with amputations of all ages and did not 

necessarily address factors that were unique to older adults 

with amputations.15,21 

Purpose of Study 

Building on previous research,10,11 this study used a mixed 

method approach to examine both prosthesis use 

quantitatively and the lived experience of older adults, 

defined to be over the age of 50. It also sought to identify 

personal and environmental factors that increase or 

decrease prosthetic use in the community after discharge 

from a rehabilitation program. This mixed method approach 

provides a deeper and more nuanced understanding10 of 

prothesis use by older adults with LLA.   

METHODOLOGY 

Study Design 

This study employed a mixed methods approach to 

examine prosthesis use, including the frequency of steps 

taken by participants, how they use their prosthesis and 

their experience of using a prosthesis. The research ethics 

boards of the University of British Columbia Ethics Review 

Committee approved the study protocol.  

Participants 

Participants were older adults with LLA who were 

completing inpatient prosthetic rehabilitation at a Canadian 

rehabilitation hospital. Participants had to: 1) be over 50 

years of age when they acquired their amputation, 2) have 

a unilateral transtibial or transfemoral amputation, 3) be 

fitted with their first prosthesis, 4) be participating in the 

individualized inpatient prosthetic rehabilitation program, 

and 5) speak English or be able to participate using an 

interpreter. The age inclusion criteria was chosen because 

more than half of the people with LLAs in Canada are 

between ages 50–74 and they often present comorbidities 

associated with aging.1 All eligible participants had recently 

acquired their amputation and had been assessed by an 

interdisciplinary team, consisting of a physiatrist, 

physiotherapist, occupational therapist, social worker and 

prosthetist, and deemed to be a prosthetic candidate. 

https://doi.org/10.33137/cpoj.v4i1.36833


 

3 

Pousett B, Budzinski C, Labbé D, Miller WC. A mixed-methods study on prosthesis use among older Canadians with lower-limb amputations. Canadian Prosthetics 
& Orthotics Journal. 2021;Volume 4, Issue 1, No.10. https://doi.org/10.33137/cpoj.v4i1.36833 

ISSN: 2561-987X 
PROSTHESIS USE AMONG OLDER CANADIANS WITH LOWER-LIMB AMPUTATIONS 

Pousett et al. 2021 CPOJ 

 
Participants who were not deemed to be a prosthetic 

candidate were not included in this study.  Eligible inpatients 

were invited to participate through a brochure and those 

interested met with a physical therapist (second author) for 

more information. Informed written consent was provided by 

all participants.  

Data Collection 

Data were collected from the week prior to discharge (T0) 

to 12 weeks after discharge (T2). Data collection included 

demographic and medical information, the StepWatch 

Activity Monitor (Modus Health Washington, USA), The 

Prosthetic Profile of the Amputee questionnaire,22 and 

individual semi-structured interviews.  

The StepWatch Activity Monitor (SAM) (Modus Health 

Washington, USA) was used to objectively measure 

prosthesis use midway through the study (T1) and at 12 

weeks post discharge from inpatient rehabilitation (T2), as it 

was anticipated that users had then acclimated to living in 

their home environment. These data included the number of 

steps per day, minutes of active prosthetic use, and the 

number of days steps occurred on for each participant. The 

Stepwatch was placed on the participant's prosthesis 

(around the distal pylon) at T0 and collected data until it was 

removed at T2.  Data were downloaded at six weeks (T1) 

as the StepWatch can only store 50 days of data. The 

StepWatch was chosen as it is an accurate tool for 

measuring step count and activity over an extended period 

of time for people with a variety of conditions.23-25 The 

reliability and validity of the StepWatch have been 

established for people with amputations and it has been 

found to be over 99% accurate.26,27  

The Prosthetic Profile of the Amputee questionnaire 

(PPA)22,28 is comprised of 44 closed-ended questions, 

divided into six sections. The PPA was administered at T0 

and T2. Information from the PPA was used to complete the 

medical records on physical conditions and the prosthesis 

(Q1-9), home environment (Q24-30), and other 

demographics such as level of education and occupation 

(Q40-44). The PPA was also used to measure prosthesis 

use, which includes activities done with the prosthesis, the 

wear time, and the reasons affecting prosthesis use (Q10-

17). Finally, the PPA questions on the use of the prosthesis 

for leisure and social activities (Q34 to 39) at T2 was used 

to complement the information gathered during the 

interviews. Some questions of the PPA did not apply to the 

participants in this study (i.e., Q22-23 are only completed if 

the individual does not use a prosthesis) while others were 

redundant (i.e., both the StepWatch and the PPA (Q12) 

record how many days a week the prosthesis is worn) and 

were not included in the analysis.  The PPA has an excellent 

test-retest reliability (between 0.80 and 0.92).29 It was 

administered in person or over the phone. The PPA was 

pilot tested with two older adults with LLA to verify if using 

the self-completed online version was an option. They had 

a hard time completing it by themselves and left many 

questions blank, the team thus decide to use the paper 

version in person. Pilot test data were not included in the 

analysis. 

The semi-structured interview was conducted at T2 to learn 

more about the participants’ experience with prosthesis use. 

The interview was developed by the research team and it 

was piloted with two older adults with LLA. The pilot data 

were not included in the analysis. The interview was 

conducted by the third author who has extensive qualitative 

expertise. The interview included open-ended questions to 

explore: 1) the activities the participant was using their 

prosthesis for (e.g., “Can you share with me what your 

typical day looks like? Can you please share with me what 

it is like for you to wear a prosthesis?”); 2) the personal and 

environmental factors facilitating or hindering these 

activities (e.g., “Are there are certain things that encourage 

you to wear your prosthesis more?”); and 3) participants’ 

experience with the rehabilitation professionals (“Since 

going home have you had any outpatient physiotherapy? If 

yes, how were these visits helpful?”). The interviews were 

conducted at T2 with each participant either in person (n=8) 

or over the phone (n=3). They were audio recorded and 

lasted between 20 to 40 minutes.  

Demographic and medical information was extracted from 

hospital medical records, including age, sex, marital status, 

comorbidities, amputation level, length of stay, residence 

type, and the Montreal Cognitive Assessment (MoCA) 

scores.  

Data Analyses 

From the StepWatch data, the number of steps per day was 

calculated for the prosthetic side only, therefore the total 

number of steps per day is twice the StepWatch collected 

value. The data from the 5th week (T1) as well as the seven 

days before 12 weeks (T2) are presented in this paper. Data 

from an adjacent week was chosen for two participants (#5 

and #9) who were unable to wear their prosthesis for the 

last week of the study due to medical complications or 

issues with the prosthetic fit. The StepWatch also provided 

information on the number of days on which steps occurred, 

and wear patterns, particularly what time the participant first 

used the prosthesis, such as early morning or mid-day, and 

how activity was distributed throughout the day.  

For the questions from the PPA on the physical condition, 

prosthesis, home environment, demographics, and leisure 

activities, descriptive scores were computed based on the 

guidelines for this tool to provide descriptive information.22 

In terms of prosthesis use, scores for question 11, which 

assesses independence during a variety of tasks, were 

calculated for both time points, where higher scores (to a 

maximum of 42) indicate increased independence. The 

scores for questions 14 & 16 were only calculated at T2 

https://doi.org/10.33137/cpoj.v4i1.36833


 

4 

Pousett B, Budzinski C, Labbé D, Miller WC. A mixed-methods study on prosthesis use among older Canadians with lower-limb amputations. Canadian Prosthetics 
& Orthotics Journal. 2021;Volume 4, Issue 1, No.10. https://doi.org/10.33137/cpoj.v4i1.36833 

ISSN: 2561-987X 
PROSTHESIS USE AMONG OLDER CANADIANS WITH LOWER-LIMB AMPUTATIONS 

Pousett et al. 2021 CPOJ 

 
because these questions were not applicable to inpatient 

rehabilitation (e.g., What percentage of the time do you use 

the prosthesis [inside] or [outside]?). 

The interviews were transcribed verbatim. A content 

analysis approach30 was used to identify, analyze, and 

interpret patterns in the participants’ responses. The first 

five interviews were reviewed by the entire research team 

and an initial coding grid was developed. The coding grid 

was created following the International Classification of 

Functioning, Disability and Health construct (ICF)31 to 

provide codes from the domain of activities and participation 

to qualify the experience of prosthesis use, and from the 

domains of Body Functions and Environmental Factors to 

identify components impacting use. The coding grid also 

included codes for Personal Factors codes that were 

mentioned by participants but are not categorized by ICF. 

Two team members then independently coded the complete 

interview data set with this coding grid, added codes if 

needed, and discussed all coding to reach a consensus. 

The final coding grid was applied to all interviews. 

Different trustworthiness strategies were used such as 

reflective commentary, and triangulation.32 The primary 

author took interview notes to reflect on the interview's 

context and her initial impressions and personal bias. No 

member checking was done. Data triangulation was 

supported using different sources of data (interviews, 

questionnaires, step watch). The triangulation of different 

researchers' perspectives during the content analysis also 

helped ensure credibility.  

Integration of Data and Development of Profiles 

Through a series of collaborative discussions between the 

research team, the entire data set was analyzed and 

integrated to develop two profiles reflecting prosthesis using 

styles of older adults with LLA in their community. Those 

profiles provide an archetypical case studies of prosthesis 

use that illustrate commonality found among the 

participants, as used in a previous study on power 

wheelchair use.33 To create each profile, the team grouped 

the participants based on information from a combination of 

all the data collected: the number of days worn, steps per 

day, and observable patterns of use were used; satisfaction 

and adaptation to the prosthesis and type of usage as 

measured by the PPA, and based on the narratives by the 

participants of their usage and experiences with the 

prosthesis as shared during the interviews.  

RESULTS 

Participants 

Between December 2015 and August 2017, 59 older adults 

with LLA were admitted to the rehabilitation program - 13 

consented to participate and 11 completed the study. One 

participant was discharged unexpectedly and the other 

withdrew for medical reasons. We achieved theoretical 

saturation with this number of participants, which suggests 

we obtained a sufficient number of representative 

participants to answer the research question.34 The 

participants’ demographic and clinical information are 

described in Table 1. The sample had an equal distribution 

 

Table 1: Clinical and sociodemographic characteristics of the participants. 

# of 

participants 

Age 

(yrs) 
Sex 

Marital  

Status 

Education 

(yrs) 
Occupation 

Level of 

Amputation 
Cause of Amputation 

Total LOS in rehab 

hospital 

(days) 

Prosthetic 

Training 

(days) 

MoCA 

(on 30) 

1 73 Female Married >12 Working Right TTA Raynauds 167 34 26 

2 76 Male Single >12 Retired Left TTA PVD/Diabetes 100 57 28 

4 87 Male Married 12 Retired Left TTA PVD 117 56 16+1 

5 69 Male Married >12 Retired Left TTA Foot deformity CRPS 71 30 24 

6 66 Female Married >12 Disability Right TTA Diabetes 137 37 NT 

7 66 Female Common-law 12 Retired Left TFA 
Infected knee 

replacement 
183 46 25+1 

9 52 Female Single <12 Retired Right TTA 
Foot deformity 

Radiculopathy 
106 84 24+1 

10 73 Female Married >12 Retired Left TTA PVD 89 56 NT 

11 66 Male Married 12 Retired Right TTA PVD/Diabetes 120 45 NT 

12 60 Male Married >12 Working Left TTA PVD/Diabetes 59 29 NT 

13 58 Male Married >12 Retired Right TTA 
Diabetes/ 

Charcot foot 
66 29 26/30 

 

LOS = length of stay; TTA = transtibial amputation; TFA = transfemoral amputation; NT= not tested; PVD = peripheral vascular disease, CRPS = complex regional 

pain syndrome ; +1 on the MoCA score = 12 years of education 

https://doi.org/10.33137/cpoj.v4i1.36833


 

5 

Pousett B, Budzinski C, Labbé D, Miller WC. A mixed-methods study on prosthesis use among older Canadians with lower-limb amputations. Canadian Prosthetics 
& Orthotics Journal. 2021;Volume 4, Issue 1, No.10. https://doi.org/10.33137/cpoj.v4i1.36833 

ISSN: 2561-987X 
PROSTHESIS USE AMONG OLDER CANADIANS WITH LOWER-LIMB AMPUTATIONS 

Pousett et al. 2021 CPOJ 

 
in terms of sex (6 men,5 women), and the average age was 

67.8 years old.  This is very similar to the typical population 

of patients seen at this facility.   

From the PPA (Q1-9; Q24-30; 40-44), all participants had at 

least four co-morbidities with the most common being 

peripheral vascular disease (PVD), diabetes, hypertension, 

and low back dysfunction. The main problems with their 

non-amputated leg were swelling, poor circulation, and 

cramps. The main problems with the residual limb was 

phantom pain and a few participants (4 out of 11) also 

experienced occasional pain. The majority of participants (9 

out of 11) were quite well or completely satisfied with the 

comfort, appearance, and weight of their prosthesis as well 

as the appearance of their gait while using it. However, they 

experienced some issues with their prosthesis—mainly skin 

irritation and excessive stump perspiration. All the 

participants lived in a house or apartment, with half of them 

having no stairs in or outside their home. 

Are older adults with LLA using their prosthesis? 

All individuals in this study used their prosthesis regularly, 

though wear patterns differed between participants. The 

daily average number of steps taken on the prosthesis at T2 

ranged from 481 to 3031 (Figure 1). Some participants 

walked with their prosthesis every day while others had 

several days where no steps were taken (Figure 2). It should 

be noted that one participant (#11) experienced a foot injury 

towards the end of the study, resulting in a day in which 

there was a large decrease in steps. For one participant 

(participant 2), there were several days where the 

StepWatch was put on the prosthesis upside down and data 

were not recorded.   

 

Figure 1: Daily average number of steps on the prosthesis at T1 

(black) and T2 (grey). 

Table 2 presents the use of the prosthesis based on the 

PPA. First, a mobility score was calculated using the PPA. 

The mobility score represents an individual’s ability to 

complete a series of activities while wearing their prosthesis 

and how much help they required to do so. The PPA 

provided additional information about how participants used 

their prosthesis. It revealed that four participants were part-

time wheelchair (WC) users, mostly inside their homes (i.e., 

used the WC 50 to 75% of the time). The main reasons for 

WC use given by the participants were other health 

conditions such as back or respiratory issues, and problems 

with the prosthesis. 

 

 

Figure 2: Number of days that participants took steps with their 

prosthesis. Black represents days with no steps taken and grey 

represents days with steps taken. 

How are older adults with LLA using their prosthesis? 

When considering how participants were using their 

prosthesis, two distinct user profiles emerged: the Regular 

Users and the Strategic Users.  

 

Regular Users  

Regular Users (participants 4, 6, 7, 10, 11, 12, and 13) had 

integrated their prosthesis into their lives. They wore their 

prostheses from morning to evening, 12 to 16 hours a day, 

seven days a week. The intensity of activity was consistent 

throughout the day and they took 400 - 3000 steps a day on 

their prosthesis. The PPA showed that Regular Users used 

their wheelchairs less to mobilize inside their homes and 

used their prosthesis almost exclusively for outdoor 

mobility. These users also reported higher levels of mobility 

function and independence.  

In the interviews, these participants emphasized the 

frequent use of their prosthesis through comments such as 

“I put it on the first thing in the morning and I take it off the 

last thing at night” (#7, a 66 year-old female with a left TFA). 

The Regulars Users wore their prosthesis for a variety of 

activities: mobility, self-care, and domestic life. In terms of 

mobility, they used their prosthesis to walk short and long 

distances, moving around in and outside their homes, “I 

haven’t had a chance to go for a field run with my new 

prosthetic from yesterday, but I was up to being able to hit 

about 3, 4 kilometers before that was enough for me for a 

day” shared #12, 60 years-old male with a left TTA. 

Participants also mentioned regularly wearing their 

0

500

1000

1500

2000

2500

3000

3500

1 2 4 5 6 7 9 10 11 12 13

#
 P

ro
s
th

e
ti
c
 S

te
p
s
 P

e
r 

D
a
y

Participant #

Prosthesis Use 3 Months Post Discharge

0

10

20

30

40

50

60

70

80

90

1 2 4 5 6 7 9 10 11 12 13

#
 o

f 
D

a
ys

Participant #

Number of Days Steps were Taken on 
Prosthesis

No Steps Taken Steps Taken

https://doi.org/10.33137/cpoj.v4i1.36833


 

6 

Pousett B, Budzinski C, Labbé D, Miller WC. A mixed-methods study on prosthesis use among older Canadians with lower-limb amputations. Canadian Prosthetics 
& Orthotics Journal. 2021;Volume 4, Issue 1, No.10. https://doi.org/10.33137/cpoj.v4i1.36833 

ISSN: 2561-987X 
PROSTHESIS USE AMONG OLDER CANADIANS WITH LOWER-LIMB AMPUTATIONS 

Pousett et al. 2021 CPOJ 

 
prosthesis to conduct self-care activities such as toileting 

and dressing. In terms of domestic life, they used their 

prosthesis when preparing meals or cleaning. Regular 

Users also conducted community, social, and civic life 

activities such as shopping, going to the restaurant, or the 

church using their prosthesis. For instance, one 73 years 

old women with a left TTA (#10) explained “I will do some 

sewing, or I will play the piano […] I’ll try to do a little walking 

in the back garden if the weather is good, or I will do my 

exercises. And in the afternoon […] If the weather is not too 

bad, we’ll go out for a walk… usually, we’re outside for 

maybe an hour and a half and then we stop sometimes to 

the grocery store on the way back”. The Regular Users were 

using their prosthesis both for sports (e.g. golf, curling, 

yoga) and leisure activities (e.g., arts and crafts or 

gardening) as seen in their answers to the section on leisure 

activities in the PPA and their narratives from the interviews. 

The Regular Users began to see their prosthesis as part of 

themselves, as one participant said (12, man, 60 years old, 

with a left TTA) “Me and my legs are the same things.” 

Strategic Users 

Strategic Users (participants 1, 2, 5, and 9) viewed their 

prosthesis as a tool to complete specific tasks and activities. 

They used their prosthesis for shorter intervals throughout 

the day: three to seven days a week. From the PPA, these 

individuals frequently mobilized with a wheelchair inside 

their homes (>50% of the time) but outdoor wheelchair use 

varied. Finally, these users reported lower levels of mobility 

function and independence.  

During the interviews, the Strategic Users explained that 

they donned their prosthesis later in the day or used it only 

for specific mobility activities such as short distance walking 

(often as part of their exercise regime) and walking inside 

the home. They rarely used their prosthesis to move around 

outside their homes. The Strategic Users also put on their 

prosthesis for specific self-care activities such as taking 

care of their health by attending physiotherapy 

appointments. They also used it for specific domestic life 

activities such as doing the dishes. They did not use their 

prosthesis to participate in their social or community life. For 

instance, one participant (#1, female 73 years old with a 

right TTA) explained: “Today I put it on at 10. It depends 

what I’m doing, if I’m going out. I don’t usually wear to 

work[…] I take it off for a while and then put it on back on 

because it gets a bit sweaty at times […] in the afternoon”. 

Sometimes stump swelling sometimes forced participants to 

remove their prosthesis. Some participants indicated they 

developed a preference for their wheelchair: “There is 

nothing so cozy and comforting as a wheelchair” (#2, a 76 

year old male with a left TTA ). 

What factors influenced prosthesis use? 

In the interviews, participants identified personal and 

physical and social environmental factors that limited or 

increased their prosthesis use. Those factors did not 

distinguish between the Strategic- and the Regular Users; 

some factors were described as facilitating use by some 

participants but as limiting use by others, while other factors 

were identified as both facilitators and barriers by all 

participants albeit their type of use.  

Regarding personal factors, the feelings of normalcy and 

increased independence associated with wearing the 

prosthesis facilitated prosthesis use. One participant (#4, an 

87-year-old male with a right TTA) said, “The prosthesis 

gives me the freedom to do things”. Some participants had 

not yet experienced those feelings but mentioned that 

regaining their independence and being “normal” again 

 

Table 2: Select questions from the Prosthetic Profile of the Amputee questionnaire. 

 Q.11 Mobility function score  

(Max score of 42) 
Q. 14 Indoor mobility (T2) (%) Q. 16 Outdoor mobility (T2) (%) 

No. In Hospital (T0) 
At Home 

(T2) 
In W/C 

Walking  

with  

prosthesis 

Walking  

without  

prosthesis 

In W/C 

Walking  

with  

prosthesis 

Walking without 

prosthesis 

1 22 24 75% 0% 25% 100% 0% 0% 

2 24 32 75% 25% 0% 0% 100% 0% 

4 33 31 25% 75% 0% 0% 100% 0% 

5 27 42 50% 50% 0% 0% 100% 0% 

6 31 33 25% 75% 0% 0% 100% 0% 

7 36 40 0% 100% 0% 0% 100% 0% 

9 42 41 50% 50% 0% 50% 50% 0% 

10 32 41 0% 100% 0% 0% 100% 0% 

11 42 42 25% 75% 0% 25% 75% 0% 

12 40 42 0% 100% 0% 0% 100% 0% 

13 33 39 0% 100% 0% 0% 100% 0% 
 

T0 = 1 week prior to discharge, T2 = 12 weeks post-discharge, W/C = wheelchair 

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7 

Pousett B, Budzinski C, Labbé D, Miller WC. A mixed-methods study on prosthesis use among older Canadians with lower-limb amputations. Canadian Prosthetics 
& Orthotics Journal. 2021;Volume 4, Issue 1, No.10. https://doi.org/10.33137/cpoj.v4i1.36833 

ISSN: 2561-987X 
PROSTHESIS USE AMONG OLDER CANADIANS WITH LOWER-LIMB AMPUTATIONS 

Pousett et al. 2021 CPOJ 

 
motivated them to wear their prostheses. On the other side, 

co-morbidities such as diabetes or cardiorespiratory 

problems were cited as barriers to prosthesis use by all 

participants.  

The factors of the physical environment concerned the 

assistive technologies and the home environment (product 

and technology) and climate and weather (natural 

environment). Regarding assistive technology, the older 

adults mentioned that using a cane or a walker aided 

walking with the prosthesis. The participants also felt that 

the prosthesis facilitated use when it was fitting well, but was 

a barrier when it was uncomfortable due to poor fit or poor 

sock management. The location of the home was a 

facilitator. For instance, one participant reported using more 

the prosthesis because of the surroundings of his home “We 

live on a hillside. So there is just no way that I would be able 

to use the wheelchair for very much outside” (#12, man, 60 

years old, with a left TTA). Housing modifications made to 

increase accessibility were also reported as facilitating 

prosthesis use, especially bathroom adaptations such as 

handrails and shower benches, or having an elevator inside 

the residence. Conversely, home feature such as stairs 

were limiting prosthesis use. Inclement weather such as 

snow and rain, was perceived as a barrier. Participants said 

they wished they would have been trained to walk in those 

conditions with their prosthesis.  

In terms of the social environment, receiving support from 

friends and family was a factor that promoted prosthesis 

use. One woman (#7, 66 years old with a left TFA) explained 

during her interview “Oh, my girlfriends, they always say, ‘oh 

my gosh, this is the best thing’ and they say ‘you’re really 

good’.” Regarding health care services, systems and 

policies, the participants perceived that the informational 

and emotional support provided by the healthcare 

professionals such as the physiotherapists and prosthetists 

facilitated their prosthesis use. For instance, they perceived 

their inpatient training as useful—participants appreciated 

the reinforcement they received about their progress. One 

older participant said “They are teaching you how to stand 

up straight and learn to walk. And then finally you are 

walking. And you are walking around the gym. And those 

things are very important […] psychologically important, 

because they are teaching you that the things can still be as 

they were. You don’t have to spend the whole rest of your 

life in a wheelchair.” (#4, an 87-year-old male with a right 

TTA).  The rehabilitation professional’s attitude and 

knowledge also motivated participants to use their 

prosthesis. Participants emphasized that advice regarding 

sock management and how to adjust their prosthesis fit was 

particularly helpful.  

DISCUSSION 

This study used a mixed-method approach to examine how 

older adults with LLA use their prosthesis following 

rehabilitation and to identify factors that increase or 

decrease prosthetic use after discharge. The creation of the 

profiles of use, “Regular User” and “Strategic User”, allowed 

for a holistic portrait of prothesis use by older adults with 

LLA.   

All of the participants in this study used their prosthesis, as 

measured with step counts, which aided their goals. More 

than half of the participants took approximately 500 steps 

per day on their prosthesis which is below the “basal” 

activity level threshold for older adults.35 The Regular Users 

achieved more than 1,250 prosthetic steps per day, which 

is considered a “sedentary” activity level, only two achieved 

the “limited”35 activity level by walking over 2,500 prosthetic 

steps per day. While step count is known to fluctuate for 

reasons secondary to personal and environmental factors 

including seasonal changes, health status, prosthetic fit, 

and life situations, it gives a snapshot of prosthetic use at a 

given time point.5,6,10 The 5 most active participants took 

about 3000 total steps per day, which is similar to other 

studies that found that adults of all ages with LLA or those 

with diabetes averaged more than 3000 steps per day (3 

months after discharge from rehabilitation).17,36   

Despite their variability in use, all the participants improved 

their mobility during the time of the research. This is similar 

to other research that found that prosthesis use in older 

adults, as measured by reported wear time, increased over 

time post amputation.11,16 Individuals may need more time 

to experience using the prosthesis in their home 

environment before truly understanding how they may 

integrate it into their life, suggesting the importance of 

considering a long term follow-up (e.g., at least 6 months) 

in the rehabilitation process.4 Currently, outpatients with 

LLA in Canada receive four to six weeks of outpatient 

rehabilitation, a period when the prosthesis still needs 

adjustments and is not regularly used as our results 

suggest.2 Tools like the PPA22 could also be used when the 

prosthesis user returns for outpatient follow-up to have a 

more complete and objective outcome measure. Moreover, 

multiple follow-ups could help older users with LLA 

consolidate their training by repeating information or 

discussing problem solving, which could be especially 

important as older users may experience decreased 

cognitive functions.19,21   

The two user profiles, distinguished how participants used 

their prosthesis in their daily lives. The identification of 

variance in prosthesis use is similar to previous studies that 

reported heterogenous use patterns after discharge.7,16 For 

instance, when examining older patients with LLA one year 

post-discharge from a rehabilitation program, Hershkovitz et 

al.16 found a distribution including three groups: full time use 

(e.g. most of the days), part time use, and no use. Using 

mixed methods to identify the Strategic- and Regular user 

profiles allowed us to explain the identified pattern of use 

https://doi.org/10.33137/cpoj.v4i1.36833


 

8 

Pousett B, Budzinski C, Labbé D, Miller WC. A mixed-methods study on prosthesis use among older Canadians with lower-limb amputations. Canadian Prosthetics 
& Orthotics Journal. 2021;Volume 4, Issue 1, No.10. https://doi.org/10.33137/cpoj.v4i1.36833 

ISSN: 2561-987X 
PROSTHESIS USE AMONG OLDER CANADIANS WITH LOWER-LIMB AMPUTATIONS 

Pousett et al. 2021 CPOJ 

 
quantitatively by referencing step count and the PPA, as 

well as qualitatively by exploring lived experiences during 

interviews. For instance, while the StepWatch revealed that 

regular users were wearing their prosthesis more and taking 

more steps throughout the day, the PPA and interviews 

confirmed that they used their prosthesis for all their 

activities. Moreover, they perceived their prosthesis as a 

part of their bodies which suggest a higher level of 

integration.13 On the other hand, the shorter periods of 

activity found with Strategic Users’ StepWatch data was 

mostly due to the fact that they used their prosthesis for 

targeted basic activities of daily living (e.g., going to the 

bathroom) or exercise (e.g. walking short distances) as 

explained by the interviews data. The identification of user 

profiles suggests that rehabilitation professionals could 

focus on individualized goals of older adults with LLA, as 

proposed in recent studies.11,20 It suggest the need to 

incorporate various types of training such as ambulating 

outdoors on uneven ground, ramps, and stairs into 

rehabilitation programs to improve mobility outside of the 

home environment – a rewarding experience for many 

individuals which helps to establish a sense of normalcy.11 

Working on individualized goals also mean that the 

rehabilitation professional discusses community 

participation needs20 with prosthesis users. Currently in 

Canada, few rehabilitation facilities offer return-to-work or 

recreational therapy that could support these needs.2  

This study reported several personal and social 

environment factors that help the older adults using their 

prosthesis. As the older adults progress through their 

rehabilitation and increase their mobility, they gained 

confidence and reported an increased sense of freedom 

and independence, similar to users of all ages in previous 

studies.4,18 This was especially true for the regular users 

who integrated their prosthesis into their daily lives and were 

beginning to see it as part of their body. This feeling of 

normality and freedom might be a goal for some older users 

but not necessarily for all. It is thus important for the 

prosthesis user and other rehabilitation professionals to 

discuss what normality and independence mean for the 

users to better support them to reach their “new normal”.14 

As has been found for younger prosthesis users,6,10,12,18,20 

support from family and friends positively affect the 

transition to being a prosthesis user in older age. This 

suggests that including family and/or caregivers in 

rehabilitation may be a valuable way to build a support 

network for the individuals to continue using the prosthesis 

after being discharged.12 Facilitating peer support from 

those who have already made positive adjustments to 

amputation and prosthesis use could also be more 

integrated into the rehabilitation process.13 It could show 

older adults with LLA what is still possible for them to do and 

to identify goals for themselves that they might not have 

thought of.  Our research also supports similar studies 

showing the importance of regular follow-ups with 

prosthetists. Follow-ups helped increase prosthesis comfort 

and allowed participants to develop a relationship with their 

prostheses, factors that facilitate use.10,12,18  

Several personal and physical environmental factors were 

identified that limited older adult participants from using their 

prosthesis. Some of these factors such as discomfort in the 

socket or challenges with outdoor mobility could be 

mitigated by regular follow-ups with the rehabilitation team. 

Our study also underlined the impact of inclement weather, 

such as rain, ice, and snow, adding to previous literature 

only reporting heat as a climatic barrier.9,20 This is 

especially relevant to individuals who completed their 

rehabilitation during the summer months with no exposure 

to wet or slippery environments that are common in Canada 

and other countries with a similar range of weather patterns. 

It reaffirms the importance of long-term follow-up 

rehabilitation to assure that patients do not miss out on 

community outings due to a lack of seasonal preparation. 

As argued by vanTwiller et al,10 it is inevitable that patients 

will encounter barriers. However, individual reactions to 

these perceived barriers could greatly vary. Therefore, it 

would be helpful to teach older prosthesis users about 

positive coping strategies to deal with problematic 

situations, to support their prosthesis use.13  

Limitations 

The limitations of this study include the sample being a 

small number of participants from a single rehabilitation 

setting.  This limits the ability of these findings to be applied 

to other settings and populations.  Collecting data from 

different rehabilitation settings would provide evidence 

regarding the applicability of these results in other settings. 

More specifically, this study only includes one participant 

with a transfemoral amputation and as such the findings are 

not generalizable to the transfemoral population.  In 

addition, while this study followed participants in depth for 

the first 12 weeks after discharge from rehabilitation, 

nothing is known about the participants’ long-term 

prosthesis use. Collecting additional data (e.g., six months 

and two years post discharge) could produce rich evidence 

in the long-term benefits and needs of rehabilitation 

programs. Future research could also look at individuals 

from communities where resources and support are limited 

such as rural communities, or from different cultural 

backgrounds to see if they have a different pattern of use.  

CONCLUSION 

The results of this study showed that older adults with lower 

limb amputations are using their prosthesis, but also that 

there is variability in how they are integrated into their daily 

lives. The older adults in both the regular and strategic users 

profiles, used their prosthesis to complete basic and 

instrumental activities of daily living. However, differences 

existed in how the prosthesis is used during community and 

https://doi.org/10.33137/cpoj.v4i1.36833


 

9 

Pousett B, Budzinski C, Labbé D, Miller WC. A mixed-methods study on prosthesis use among older Canadians with lower-limb amputations. Canadian Prosthetics 
& Orthotics Journal. 2021;Volume 4, Issue 1, No.10. https://doi.org/10.33137/cpoj.v4i1.36833 

ISSN: 2561-987X 
PROSTHESIS USE AMONG OLDER CANADIANS WITH LOWER-LIMB AMPUTATIONS 

Pousett et al. 2021 CPOJ 

 
social activities. Moreover, factors impacting use were 

similar across the profiles. Therefore, it is important for 

rehabilitation teams to work with their patients to recognize 

potential barriers and provide the tools to problem solve 

around them, especially once patients can walk and are 

focusing on higher level activities. Follow-up with the 

rehabilitation team once the patient is discharged could help 

ensure the patient’s prosthesis is comfortable and also 

address new concerns that may arise from prolonged use 

of the prosthesis at home and in community environments. 

ACKNOWLEDGEMENTS 

The authors would like to thank the other members of the research 

team including Jami Bennett, Stacey Cave, Ashley Plough, Leah 

Swantje Dr. Elliot Weiss, and Alison Hoens (Mentor).  We would 

also like to thank Aggie Black and her team at the PHC Research 

Challenge;  Zoe Greig, Kate Keetch, and  Laura Beer for their 

administrative assistance, and Providence Health Care and Barber 

Prosthetics Clinic for supporting us conducting this research.   

DECLARATION OF CONFLICTING 

INTERESTS 

The Author(s) declare(s) that there is no conflict of interest. 

AUTHOR CONTRIBUTION 

• Brittany Pousett, contributed to the study design, data 

management and analyses of the step watch data and writing 

of the manuscript and study report. 

 

• Colleen Budzinski, contributed to the development of the 

design and protocol, ethics submission, management of the 

research team,  analyses of the data and editing of the 

manuscript. 

 

• Delphine Labbé, contributed to the recruitment, enrollment, 

data collection, data analyses and writing of the final paper 

and report. Delphine Labbé is now an assistant professor at 

the University of Illinois at Chicago. 

 

• William C Miller, contributed to the development of the design 

and protocol, management of the research team, 

administrative support, analyses of the data and editing of the 

manuscript. 

 

SOURCES OF SUPPORT 

This work was supported by the Providence Health Research 

Challenge. 

ETHICAL APPROVAL 

This study was approved by the University of British Columbia 

Ethics Review Committee. 

REFERENCES 

1.Imam B, Miller WC, Finlayson HC, Eng JJ, Jarus T. Incidence of 

lower limb amputation in Canada. Can J Public Heal. 2017; 108: 

e374–e380. DOI:10.17269/CJPH.108.6093  

2.Imam B, Miller WC, Finlayson HC, Eng JJ, Jarus T.  Lower limb 

prosthetic rehabilitation in Canada: a survey study. Physiother Can. 

2019; 71: 11-21. DOI:10.3138/ptc.2017-39 

3.Fortington LV, Rommers GM, Geertzen JH, Postema K, Dijkstra 

PU. Mobility in elderly people with a lower limb amputation: a 

systematic review. J Am Med Dir Ass. 2012; 13: 319-325. 

DOI:10.1016/j.jamda.2010.12.097 

4.Norlyk A, Martinsen B, Hall E, Haahr A. Being in-between: the 

lived experience of becoming a prosthesis user following the loss 

of a leg. Sage Open. 2016; 6:1-9 DOI:10.1177/2158244016671376 

5.Albert MV, Deeny S, McCarthy C, Valentin J, Jayaraman A. 

Monitoring daily function in persons with transfemoral amputations 

using a commercial activity monitor: A feasibility study. PMR. 2014; 

6: 1120–1127. DOI:10.1016/j.pmrj.2014.06.006  

6.Halsne EG, Waddingham MG, Hafner BJ. Long-term activity in 

and among persons with transfemoral amputation. J Rehabil Res 

Dev. 2013; 50: 515–529. DOI:10.1682/JRRD.2012.04.0066  

7.Webster JB, Hakimi KN, Williams RM, Turner AP, Norvell DC, 

Czerniecki JM. Prosthetic fitting, use, and satisfaction following 

lower-limb amputation: A prospective study. J Rehabil Res Dev. 

2012; 49: 1493-1504. DOI:10.1682/JRRD.2012.01.0001  

8.Zidarov D, Swaine B, Gauthier-Gagnon C. Life habits and 

prosthetic profile of persons with lower-limb amputation during 

rehabilitation and at 3-month follow-up. Arch Phys Med Rehabil. 

2009; 90: 1953–1959. DOI:10.1016/j.apmr.2009.06.011  

9.Gallagher P, O’Donovan MA, Doyle A, Desmond D. 

Environmental barriers, activity limitations and participation 

restrictions experienced by people with major limb amputation. 

Prosthet Orthot Int. 2011; 35: 278–284. DOI:10.1177/ 

0309364611407108  

10.Van Twillert S, Stuive I, Geertzen JH, Postema K, Lettinga AT. 

Functional performance, participation and autonomy after 

discharge from prosthetic rehabilitation: Barriers, facilitators and 

outcomes. J Rehabil Med. 2014; 46: 915–923. DOI:10.2340/ 

16501977-1846  

11.Silva AD, Furtado G, Dos Santos IP, da Silva CB, Caldas LR, 

Bernardes KO, et al. Functional capacity of elderly with lower-limb 

amputation after prosthesis rehabilitation: a longitudinal study. 

Disabil Rehabil: Assist Technol. 2019; 1-5. DOI:10.1080/ 

17483107.2019.1684581  

12.Dunne S, Coffey L, Gallagher P, Desmond D, Ryall N. Beyond 

function: Using assistive technologies following lower limb loss. J 

Rehabil Med. 2015; 47: 561–568. DOI:10.2340/16501977-1962  

13.Murray CD, Forshaw MJ. The experience of amputation and 

prosthesis use for adults: a metasynthesis. Disabil Rehabil. 2013; 

35: 1133-1142 DOI:10.3109/09638288.2012.723790  

14.Jefferies P, Gallagher P, Philbin M. Being “just normal”: a 

grounded theory of prosthesis use. Disabil Rehabil. 2018; 40: 1754-

1763. DOI:10.1080/09638288.2017.1312564  

15.Van Eijk MS, Van der Linde H, Buijck B, Geurts A, Zuidema S, 

Koopmans R. Predicting prosthetic use in elderly patients after 

major lower limb amputation. Prosthet Orthot Int. 2012; 36: 45-52 

DOI: 10.1177/0309364611430885 

16.Hershkovitz A, Dudkiewicz I, Brill S. Rehabilitation outcome of 

post-acute lower limb geriatric amputees. Disabil Rehabil. 2013; 35: 

21-227. DOI:10.3109/09638288.2012.690818  

https://doi.org/10.33137/cpoj.v4i1.36833


 

10 

Pousett B, Budzinski C, Labbé D, Miller WC. A mixed-methods study on prosthesis use among older Canadians with lower-limb amputations. Canadian Prosthetics 
& Orthotics Journal. 2021;Volume 4, Issue 1, No.10. https://doi.org/10.33137/cpoj.v4i1.36833 

ISSN: 2561-987X 
PROSTHESIS USE AMONG OLDER CANADIANS WITH LOWER-LIMB AMPUTATIONS 

Pousett et al. 2021 CPOJ 

 
17.Stepien JM, Cavenett S, Taylor L, Crotty M. Activity levels 

among lower-limb amputees: self-report versus step activity 

monitor. Arch Phys Med Rehabil. 2007; 88: 896–900. 

DOI:10.1016/j.apmr.2007.03.016  

18.Schaffalitzky E, Gallagher P, MacLachlan M, Wegener ST. 

Developing consensus on important factors associated with lower 

limb prosthetic prescription and use. Disabil Rehabil. 2012; 34: 

2085–2094. DOI:10.3109/09638288.2012.671885  

19.Lee DJ, Costello MC. The effect of cognitive impairment on 

prosthesis use in older adults who underwent amputation due to 

vascular-related etiology: A systematic review of the literature. 

Prosthet Orthot Int. 2018; 42: 144–152. DOI:10.1177/ 

0309364617695883  

20.Batten H, Lamont R, Kuys S, McPhail S, Mandrusiak A. What 

are the barriers and enablers that people with a lower limb 

amputation experience when walking in the community? Disabil 

Rehabil. 2019: 1-7. DOI:10.1080/09638288.2019.1597177  

21.Frieden RA. The geriatric amputee. Phys Med Rehabil Clin N 

Am. 2005; 16: 179–195. DOI:10.1016/j.pmr.2004.06.004  

22.Gauthier-Gagnon C, Grise MC. Prosthetic profile of the amputee 

questionnaire: validity and reliability. Arch Phys Med Rehabil. 1994; 

75: 1309-1313. DOI:10.1016/0003-9993(94)90278-X  

23.Resnick B, Nahm ES, Orwig D, Zimmerman SS, Magaziner J. 

Measurement of activity in older adults: reliability and validity of the 

Step Activity Monitor. J Nurs Meas. 2001; 9: 275–290. 

DOI:10.1891/1061-3749.9.3.275  

24.Busse ME, Van Deursen RW, Wiles C. Real-life step and activity 

measurement: Reliability and validity. J Med Eng Technol. 2009; 

33: 33–41. DOI:10.1080/03091900701682606  

25.Floegel TA, Florez-Pregonero A, Hekler EB, Buman MP. 

Validation of consumer-based hip and wrist activity monitors in 

older adults with varied ambulatory abilities. J Gerontol A Biol Sci 

Med Sci. 2017; 72: 229–236. DOI:10.1093/gerona/glw098  

26.Coleman KL, Smith DG, Boone DA, Joseph AW, Del Aguila MA. 

Step activity monitor: Long-term, continuous recording of 

ambulatory function. J Rehabil Res Dev. 1999; 36: 8–18. 

27.Arch ES, Sions JM, Horne J, Bodt BA. Step count accuracy of 

stepwatch and fitbit onetm among individuals with a unilateral 

transtibial amputation. Prosthet Orthot Int. 2018; 42: 518–526. 

DOI:10.1177/0309364618767138  

28.Grise MC, Gauthier-Gagnon C, Martineau GG A. Prosthetic 

profile of people with lower extremity amputation: conception and 

design of a follow-up questionnaire. Arch Phys Med Rehabil. 1993; 

74: 862-870. DOI:10.1016/0003-9993(93)90014-2  

29.Gauthier-Gagnon C, Gris M-C. Tools to measure outcome of 

people with a lower limb amputation: update on the ppa and lci.  J 

Prosthet Orthot. 2006; 18: P61–P67. 

30.Hsieh H-F, Shannon SE. Three approaches to qualitative 

content analysis. Qual Health Res. 2005;15(9):1277-88. 

DOI:10.1177/1049732305276687  

31.International Classification of Functioning, Disability and  

Health (ICF) [Internet]. Geneva: World Health Organization;  

2001, [cited 2021, August 11], Available from:   

https://www.who.int/standards/classifications/international-

classification-of-functioning-disability-and-health 

32.Shenton AK. Strategies for ensuring trustworthiness in 

qualitative research projects. Educ Inform. 2004; 22: 63-75. 

DOI:10.3233/EFI-2004-22201  

33.Mortenson WB, Hammell KW, Luts A, Soles C, Miller WC. The 

power of power wheelchairs: Mobility choices of community-

dwelling, older adults. Scand J Occup Ther. 2015; 22: 394–401. 

DOI:10.3109/11038128.2015.1049289  

34.Varpio L, Ajjawi R, Monrouxe LV, O'Brien BC, Rees CE. 

Shedding the cobra effect: problematising thematic emergence, 

triangulation, saturation and member checking. Medical education. 

2017; 51: 40-50. DOI:10.1111/medu.13124  

35.Tudor-Locke C, Craig CL, Aoyagi Y, Bell RC, Croteau KA, De 

Bourdeaudhuij I. How many steps/day are enough? For older adults 

and special populations. Int J Behav Nutr Phys Act. 2011; 8: 80. 

DOI:10.1186/1479-5868-8-80  

36.Desveaux L, Goldstein RS, Mathur S, Hassan A, Devlin M, 

Pauley T, et al. Physical activity in adults with diabetes following 

prosthetic rehabilitation. Can J Diabetes. 2016; 40: 336-341. 

DOI:10.1016/j.jcjd.2016.02.003 

https://doi.org/10.33137/cpoj.v4i1.36833
https://www.who.int/standards/classifications/international-classification-of-functioning-disability-and-health
https://www.who.int/standards/classifications/international-classification-of-functioning-disability-and-health

