Jai Kulkarni | University Teaching Hospital South Manchester (original) (raw)

Papers by Jai Kulkarni

Diabetes Care, Feb 1, 2001

OBJECTIVE: To assess the efficacy of a specialist foot care program designed to prevent a second ... more OBJECTIVE: To assess the efficacy of a specialist foot care program designed to prevent a second amputation and to assess peripheral vascular disease (PVD) and peripheral neuropathy in diabetic unilateral lower-limb amputees.RESEARCH DESIGN AND METHODS: Investigations were carried out in 143 diabetic lower-limb unilateral amputees referred to a subregional rehabilitation center for prosthetic care from a catchment area of approximately 3 million people. Peripheral vascular and nerve assessment, education, and podiatry were provided for each patient.RESULTS: For the patients referred to the foot care program, there were no baseline differences between the patients who proceeded to a bilateral amputation (n = 22) and those who remained as unilateral amputees (n = 121) in their level of foot care knowledge and mean neuropathy scores. Mean ankle-brachial pressure index was significantly lower for the bilateral amputees (0.75 +/- 0.04) compared with the unilateral amputees (0.90 +/- 0.03, mean +/- SEM, P < 0.05), but there was no difference in the level of oxygen in the skin. However, the level of carbon dioxide was significantly lower in patients with bilateral amputation (24.21 +/- 2.16 vs. 31.20 +/- 0.85 mmHg, P < 0.03). Overall, the establishment of a specialist foot care program made no impact on contralateral limb amputation (22 of 143, 15.4%) compared with matched patients without the program (21 of 148, 14%) over a 2-year outcome period for each patient.CONCLUSIONS: PVD is more closely associated with diabetic bilateral amputation than neuropathy or level of foot care knowledge. Preventative foot care programs for diabetic unilateral amputees should therefore place greater emphasis on peripheral vascular assessment to identify patients at risk and on the development of timely intervention strategies.

The Foot, 1995

14 patients with partial foot amputations were treated with individually customised total contact... more 14 patients with partial foot amputations were treated with individually customised total contact silicone partial foot prostheses aiming towards comfort and near normalisation of gait. Subjective parameters and objective comparative gait analysis suggest that total contact silicone partial foot prostheses are a worthy option to consider in partial foot amputations.

Amputation, Prosthesis Use, and Phantom Limb Pain, 2009

This study investigated how toe clearance was affected when trans-tibial amputees switched from u... more This study investigated how toe clearance was affected when trans-tibial amputees switched from using their habitual prosthetic foot, with rigid or elastic 'ankle', to using an Echelon with a hydraulically articulating 'ankle'. Findings indicate that use of a hydraulic device led to increased minimum toe clearance on both limbs, potentially reducing trip-risk. INTRODUCTION

Journal of rehabilitation medicine, 2014

Evaluate changes in active and passive function with onabotulinumtoxinA + standard of care within... more Evaluate changes in active and passive function with onabotulinumtoxinA + standard of care within goal-oriented rehabilitation programmes in adults with focal post-stroke spasticity. Prospective, 24-week double-blind study with an open-label extension. Subjects were randomized to onabotulinumtoxinA + standard of care or placebo + standard of care, at baseline and at 12 weeks, if judged appropriate, with follow-up to 52 weeks. The primary endpoint was the number of patients achieving their principal active functional goal at 24 weeks (or 10 weeks after an optional second injection). Secondary endpoints included achievement of a different active or a passive goal at this timepoint. The intent-to-treat population comprised 273 patients. The proportion of patients achieving their principal active functional goal and secondary active functional goal with onabotulinumtoxinA + standard of care was not statistically different from placebo + standard of care. Significantly more patients achi...

Clinical biomechanics (Bristol, Avon), 2014

If a prosthetic foot creates resistance to forwards shank rotation as it deforms during loading, ... more If a prosthetic foot creates resistance to forwards shank rotation as it deforms during loading, it will exert a braking effect on centre of mass progression. The present study determines whether the centre of mass braking effect exerted by an amputee's habitual rigid 'ankle' foot was reduced when they switched to using an 'Echelon' hydraulic ankle-foot device. Nineteen lower limb amputees (eight trans-femoral, eleven trans-tibial) walked overground using their habitual dynamic-response foot with rigid 'ankle' or 'Echelon' hydraulic ankle-foot device. Analysis determined changes in how the centre of mass was transferred onto and above the prosthetic-foot, freely chosen walking speed, and spatio-temporal parameters of gait. When using the hydraulic device both groups had a smoother/more rapid progression of the centre of pressure beneath the prosthetic hindfoot (p≤0.001), and a smaller reduction in centre of mass velocity during prosthetic-stance (...

Dynamic-response prosthetic feet typically have carbon-fibre heel and forefoot keels. Their defor... more Dynamic-response prosthetic feet typically have carbon-fibre heel and forefoot keels. Their deformation simulates ankle motion: i.e. deformation of the heel-keel during loading response (1 st rocker) simulates plantarflexion while deformation of the forefoot during 2 nd rocker, simulates dorsiflexion. Energy stored as the heel and forefoot keels are deformed is returned aiding progression and push-off respectively. Traditionally such feet have a rigid attachment to the shank. Recently, an ankle device has been developed allowing passive, hydraulically-dampened sagittal plane movement (9° range). This device, located at the top of the foot, attaches it to the prosthetic shank. This study investigates how use of this device affects prostheticlimb ankle kinetics and energy storage and return.

Journal of Rehabilitation Research and Development, 2014

Most clinically available prosthetic feet have a rigid attachment or incorporate an "ankle" devic... more Most clinically available prosthetic feet have a rigid attachment or incorporate an "ankle" device allowing elastic articulation during stance, with the foot returning to a "neutral" position at toe-off. We investigated whether using a foot with a hydraulically controlled articulating ankle that allows the foot to be relatively dorsiflexed at toe-off and throughout swing would increase minimum toe clearance (MTC). Twenty-one people with unilateral transtibial amputation completed overground walking trials using their habitual prosthetic foot with rigid or elastic articulating attachment and a foot with a hydraulic ankle attachment (hyA-F). MTC and other kinematic variables were assessed across multiple trials. When using the hyA-F, mean MTC increased on both limbs (p = 0.03). On the prosthetic limb this was partly due to the device being in its fully dorsiflexed position at toe-off, which reduced the "toes down" foot angle throughout swing (p = 0.01). Walking speed also increased when using the hyA-F (p = 0.001) and was associated with greater swing-limb hip flexion on the prosthetic side (p = 0.04), which may have contributed to the increase in mean MTC. Variability in MTC increased on the prosthetic side when using the hyA-F (p = 0.03), but this did not increase risk of tripping.

Prosthetics and Orthotics International, 2014

Background:This study reviewed prevalence of patients with lower limb amputations with above norm... more Background:This study reviewed prevalence of patients with lower limb amputations with above normal weight profile, with body mass index over 25, in seven disablement services centres managing their amputee rehabilitation in the United Kingdom.Objectives:To review two clinical standards of practice in amputee rehabilitation. Ambulant lower limb amputees should have their body weight recorded on an electronic information system, with identification of cohort with body weight &amp;amp;amp;amp;amp;gt;100 kg. Lower limb amputees to be provided with suitable weight-rated prosthesis.Study design:Observational study of clinical practice.Methods:Data were collected from the Clinical Information Management Systems. Inclusion criteria - subjects were ambulant prosthetic users with some prosthetic intervention in the last 5 years and had at least one lower limb amputation.Results:In 96% of patients, the weight record profile was maintained. In addition, 86% were under 100 kg, which is the most common weight limit of prosthetic componentry. Of 15,204 amputation levels, there were 1830 transfemoral and transtibial sites in users with body weight over 100 kg. In 60 cases, the prosthetic limb build was rated to be below the user body weight.Conclusions:In 96% of our patients, body weight was documented, and in 97%, the prosthetic limb builds were within stated body weight limits, but this may not be the case in all the other disablement services centres in the United Kingdom. Also, the incidence of obesity in the United Kingdom is a growing problem, and the health issues associated with obesity are further compounded in the amputee population.Clinical relevanceProsthetic componentry has distinct weight limits which must be considered during prescription. As people with amputation approach the limits of specific components, clinicians are faced with the challenge of continued provision in a safe and suitable manner. This article reviews the amputee population and the current national profile to consider trends in provision and the incidence of these challenges.

Physiotherapy, 1996

ABSTRACT

Journal of Rehabilitation Medicine, 2011

Objective: this report describes the design of a study aiming to provide evidence for the extende... more Objective: this report describes the design of a study aiming to provide evidence for the extended use of botulinum toxin a (BotoX®, allergan inc.) in focal post-stroke upper and lower limb spasticity and to evaluate the impact of incorporating botulinum toxin a treatment into the rehabilitation of patients with spasticity. Design: international, prospective, randomized, double-blind, placebo-controlled study with an open-label extension. Methods: approximately 300 adults with a stroke occurring ≥ 3 months before screening, presenting with symptoms and signs of an upper motor neuron syndrome and focal spasticity-related functional impairment, were randomized to botulinum toxin a + standard care or placebo + standard care.

Journal of NeuroEngineering and Rehabilitation, 2013

Background: Passive prosthetic devices are set up to provide optimal function at customary walkin... more Background: Passive prosthetic devices are set up to provide optimal function at customary walking speed and thus may function less effectively at other speeds. This partly explains why joint kinetic adaptations become more apparent in lower-limb amputees when walking at speeds other than customary. The present study determined whether a trans-tibial prosthesis incorporating a dynamic-response foot that was attached to the shank via an articulating hydraulic device (hyA-F) lessened speed-related adaptations in joint kinetics compared to when the foot was attached via a rigid, non-articulating attachment (rigF). Methods: Eight active unilateral trans-tibial amputees completed walking trials at their customary walking speed, and at speeds they deemed to be slow-comfortable and fast-comfortable whilst using each type of foot attachment. Moments and powers at the distal end of the prosthetic shank and at the intact joints of both limbs were compared between attachment conditions.

Disability & Rehabilitation, 2007

This paper describes the design and implementation of a case study based investigation using imme... more This paper describes the design and implementation of a case study based investigation using immersive virtual reality as a treatment for phantom limb pain. Three participants who experienced phantom limb pain (two with an upper-limb amputation, and one with a lower-limb amputation) took part in between 2 and 5 immersive virtual reality (IVR) sessions over a 3-week period. The movements of participants&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; anatomical limbs were transposed into the movements of a virtual limb, presented in the phenomenal space of their phantom limb. Preliminary qualitative findings are reported here to assess proof of principle for this IVR equipment. All participants reported the transferal of sensations into the muscles and joints of the phantom limb, and all participants reported a decrease in phantom pain during at least one of the sessions. The authors suggest the need for further research using control trials.

Diabetic Medicine, 1997

Diabetic peripheral neuropathy is believed to cause postural instability due to abnormal proprioc... more Diabetic peripheral neuropathy is believed to cause postural instability due to abnormal proprioception. We assessed body sway in four groups, each of 20 subjects, matched for age, sex, and BMI: non-diabetic controls, non-neuropathic diabetic controls, subjects with diabetic neuropathy and no history of foot ulceration, and subjects with diabetic neuropathy and a history of foot ulceration. Postural sway was assessed on a Kistler force plate using the Romberg test, measuring the standard deviation of the centre of pressure in both sagittal (antero-posterior movement) and frontal (side to side movement) planes with eyes open and closed. The Romberg test results were log transformed and then analysed using analysis of variance followed by Newman-Keuls test. There was no significant difference in body sway between the two control groups and the first group of subjects with diabetic neuropathy. However, in patients with a history of ulceration, values were significantly higher (p &amp;lt; 0.05) compared to all other groups in both planes and conditions studied. These results are suggestive of a relationship between impaired body sway control and foot ulceration. Postural instability may have clinical significance and increase the risk of minor trauma and ulceration in patients with diabetic neuropathy.

Diabetes Care, 1997

OBJECTIVE -To investigate the effect of peripheral neuropathy on gait in diabetic patients.

Diabetes Care, 2011

OBJECTIVEdTo assess, in the general diabetic population, 1) the prevalence of painful neuropathic... more OBJECTIVEdTo assess, in the general diabetic population, 1) the prevalence of painful neuropathic symptoms; 2) the relationship between symptoms and clinical severity of neuropathy; and 3) the role of diabetes type, sex, and ethnicity in painful neuropathy.

Diabetes Care, 2001

Abbreviations: ABPI, ankle-brachial pressure index; LLA, lower-limb amputation; MNCV, motor nerve... more Abbreviations: ABPI, ankle-brachial pressure index; LLA, lower-limb amputation; MNCV, motor nerve conduction velocity; PVD, peripheral vascular disease; TcpCO 2 , transcutaneous partial pressure of carbon dioxide; TcpO 2 , transcutaneous partial pressure of oxygen; TT, transtibial.

Clinical Science, 2001

Multiple factors, including peripheral vascular disease and neuropathy, contribute to the develop... more Multiple factors, including peripheral vascular disease and neuropathy, contribute to the development and perpetuation of complications of the lower extremities in diabetes. The main aim of the present study was to assess the peripheral vascular and nerve status of diabetic and non-diabetic subjects that had undergone lower limb amputation. Various non-invasive tests of peripheral vascular and nerve function were carried out on subjects who had undergone unilateral lower limb amputation and were now attending a Rehabilitation Centre. The control group (n l 23), the diabetic amputee group (n l 64) and the non-diabetic amputee group (n l 32) were age-matched. Only the diabetic amputee group had evidence of medial arterial calcification. Transcutaneous oxygen levels were significantly lower in the diabetic amputee group (median 43 mmHg ; interquartile range 33-49 mmHg) than in the control (59 ; 56-74 mmHg) and non-diabetic amputee (57 ; 43-65 mmHg) groups (control compared with diabetic amputee group, P 0.001 ; diabetic amputee compared with non-diabetic amputee group, P 0.01). The same trend was found for carbon dioxide levels in the skin [mmHg : diabetic amputees, 25 (21-37) ; controls, 38 (32-42) ; non-diabetic amputee, 34 (31-39)] (control compared with diabetic amputee, P 0.01 ; diabetic amputee compared with non-diabetic amputee, P 0.05). Vibration and pressure perception measurements (which assess Aβ nerve fibre function) showed that both the diabetic amputee and non-diabetic amputee subjects had significantly greater impairment than the controls. However, measures of Aα and C nerve fibre function were abnormal only in the diabetic amputee group. Thus the peripheral vascular and nerve functions of age-matched diabetic and non-diabetic subjects having undergone lower limb amputation show specific differences, with non-diabetic amputees exhibiting signs of neuropathy. This indicates that factors characteristic of diabetes (such as hyperglycaemia and non-enzymic glycation) are associated with calcification, lower oxygen and carbon dioxide levels in the skin, and abnormal Aα and C nerve fibre function.

Clinical Rehabilitation, 2005

To ascertain the prevalence of back pain amongst traumatic lower limb amputees attending a region... more To ascertain the prevalence of back pain amongst traumatic lower limb amputees attending a regional rehabilitation centre and to determine the possible causes of back pain. All traumatic lower limb amputees given a semi-structured questionnaire to complete and a comparative subgroup of amputees with back pain and without back pain underwent physical examination, gait analysis, magnetic resonance scanning (MRI) and gait/standing stability analysis. A subregional amputee rehabilitation centre. Transfemoral amputees were more likely to suffer from back pain (81 %) than transtibial amputees (62%) (p&amp;lt;0.05) and of those suffering from severe back pain, 89% and 81% also suffered from severe pain in the phantom limb and severe stump pain respectively. In two comparative subgroups of amputees there was no significant difference between back pain and pain-free groups except those with pain were more likely to have a body mass index (BMI) ratio above 50% of the recommended ratio. No difference in degeneration or disc disease between the groups on MR scans was found. Impact ground reaction forces during walking, irrespective of limb, were significantly greater (p &amp;lt; 0.05) in the pain-free group than in the pain group, as was walking speed. Gait asymmetry measures were similar in both groups. Centre of pressure displacement measures during standing were greater in the pain group than in the pain-free group. Low back pain in amputees is a significant problem equal to that of pain in the phantom limb and a biomechanical (myofascial) rather than a degenerative aetiology is suggested.

Clinical Rehabilitation, 1998

To investigate the association between amputation, osteoarthritis and osteopenia in male war vete... more To investigate the association between amputation, osteoarthritis and osteopenia in male war veterans with major lower limb amputations. Specific questions were to determine whether lower limb amputees following trauma are at subsequent risk of developing osteoarthritis (OA) and osteoporosis of the hip on both the amputated and nonamputated sides. Retrospective cohort study in British Male Second World War veterans with major unilateral lower limb amputations. Seventy-five male Second World War veterans with major lower limb amputations known to be alive were invited to participate from a subregional rehabilitation centre. After exclusions, 44 agreed to attend for examination and radiological screening. The presence of hip OA was determined from a single anterior posterior pelvic X-ray using two approaches: minimum joint space and the Kellgren and Lawrence (K&amp;amp;amp;amp;L) scoring system. Bone mineral density (BMD) was measured by a dual energy X-ray absorptiometry (DXA) scan and prosthetic rehabilitation outcome measures were recorded. Twenty-seven (61%) hips on the amputated side and 10 (23%) on the nonamputated side were positive for OA (based on Kellgren and Lawrence grade of &amp;amp;amp;gt;2). Using a minimum joint space threshold of below 2.5 mm, 24 (55%) hips on the amputation side and 8 (18%) on the nonamputated side were also positive for OA. There was a threefold increased risk of OA for those with above-knee compared to a below-knee amputation. By contrast, from published general population surveys only 4 (11%) cases of hip OA would have been expected on both the amputated and nonamputated hips. There was a significant decrease in femoral neck BMD in the amputated side (p &amp;amp;amp;lt;0.0001) and significantly lower BMD in above-knee amputees than in below-knee amputees (p = 0.0027) as compared to normal age- and sex-matched population. Male war veterans with unilateral major lower limb amputations develop significantly more osteoarthritis of the hip than expected on both ipsi- and contralateral sides. Amputation was also associated with loss of bone density. Above-knee amputees develop significantly more hip osteoarthritis and osteopenia of greater severity in the amputated side than below-knee amputees.