Journal of NeuroEngineering and Rehabilitation

modality types mentioned in this review [ 31 , 32 ] . The dependence of this review and CPG on direct spirometry limits the clinical applicability at this time. Further re- search correlating indirect estimation of VO 2 and direct spirometry in the population with LEA is needed. Conclusions A systematic review of literature regarding the use of exer- cise testing in treatment of the population with limb loss was completed. Data was synthesized into six empirical evidence statements and founded the basis for a CPG de- veloped by a multi-disciplinary research team. Both con- tinuous maximal lower extremity ergometer and intermittent sub-maximal upper extremity ergometer pro- tocols were found to be viable methods of evaluating car- diorespiratory fitness and function in persons with limb loss. Additional modalities included combined upper and lower extremity ergometers and rowing machine protocols. VO 2max reported as a percent of a normalized predicted value was the most commonly reported outcome and 50%VO 2max was repeatedly found to be a reliable threshold for successful ambulation with a prosthesis. Achievement of a sustained workload of 30 W on the upper extremity ergometer protocol was also found to be a reliable correl- ate to successful prosthetic ambulation. The development and presentation of this clinical practice guideline may provide an alternative method of functional level classifica- tion of patients with history of limb loss and its adoption should only be used to increase access to prosthetic inter- ventions and rehabilitation for these individuals. Additional file Additional file 1: Dear Physician Letter. (PDF 469 kb) Abbreviations CPG: Clinical practice guideline; EES: Empirical evidence statement; HR: Heart rate; LEA: Lower extremity amputation; SLE: Single-leg ergometry; UEE: Upper extremity ergometry; UK-NSF: United Kingdom National Service Framework for Long-Term Conditions; VO 2 : Oxygen consumption Acknowledgements American Orthotics and Prosthetics Association for their support of orthotic and prosthetic research. Miranda R. Klenow, MS, CRNA, for her operational support of the project. Funding The publication cost of this article was funded by the American Orthotic & Prosthetic Association (AOPA). Availability of data and materials Included articles are made available at the discretion of the respective publishers. About this supplement This article has been published as part of Journal of NeuroEngineering and Rehabilitation Volume 15 Supplement 1, 2018: Advancements in Prosthetics and Orthotics: Selected articles from the Second World Congress hosted by the American Orthotic & Prosthetic Association (AOPA). The full contents of the supplement are available online at https://jneuroengrehab.biomedcentral.com/ articles/supplements/volume-15-supplement-1 . Authors ’ contributions Project purpose: TDK, PS, LM, MJH. Literature Search: TDK, MJH. Critical Assessment of Literature: TDK, MJH. CPG pathway development: TDK, PS, LM, GL, OH, MJH. Critical review and approval of manuscript: TDK, PS, LM, GL, CR, OH, RRG, MJH. All authors have read and approved the final manuscript. Authors ’ information Tyler D. Klenow, MSOP, CPO, LPO, CPT is the Lead Practitioner for the Port Charlotte location of Orthotic & Prosthetic Centers, Inc. Port Charlotte, FL, USA. Larry J. Mengelkoch, PhD, PT, is a Professor in the Doctor of Physical Therapy Program, at the University of St. Augustine for Health Sciences, St. Augustine, FL, USA. Phillip M. Stevens, MEd, CPO, FAAOP is a Director within Hanger Clinic ’ s Department of Clinical and Scientific Affairs and Adjunct Faculty in the School of Physical Medicine and Rehabilitation at the University of Utah, Salt Lake City, UT, USA. Owen T. Hill, PhD, PA is a clinical epidemiologist for the Extremity Trauma & Amputation Center of Excellence, Fort Sam Houston, San Antonio, TX, USA. Dr. Hill serves as a Lieutenant Colonel in the US Army SP Corps. Gail A. Latlief, DO, FAAPMR is the Director of the Regional Amputation Center at the James A. Haley Veterans Hospital, Tampa, FL, USA. Rodrigo Ruiz-Gamboa, MD, is a board-certified and fellowship-trained vascu- lar surgeon for Lee Physician Group, Fort Myers, FL, USA. M. Jason Highsmith, PhD, DPT, CP, FAAOP is Deputy Chief of Research & Surveillance for the Extremity Trauma & Amputation Center of Excellence, James A. Haley Veterans Hospital, and is Associate Professor for the School of Rehabilitation Sciences, Morsani College of Medicine, University of South Florida, Tampa, FL, USA. Dr. Highsmith serves as a Captain in the US Army Reserves. Ethics approval and consent to participate N/A Consent for publication All authors have approved this manuscript for publication. This manuscript is not previously published or pending publication elsewhere. Competing interests The authors declare they have no competing interests. The findings of this work are those of the authors and do not necessarily reflect those of the U.S. Department of Defense, U.S. Department of the Army, U.S. Department of Veterans Affairs, any other department of the U.S. federal government, Lee Physician Group, Hanger Clinic, or Orthotic & Prosthetic Centers, Inc. Publisher ’ s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Author details 1 Orthotic & Prosthetic Centers, Inc, 3005 Caring Way, Suite 3, Port Charlotte, FL 33952, USA. 2 University of St. Augustine for Health Sciences, St. Augustine, FL, USA. 3 Hanger Clinic, Salt Lake City, UT, USA. 4 University of Utah School of Medicine, Physical Medicine and Rehabilitation, Salt Lake City, UT, USA. 5 Center for the Intrepid, Department of Orthopaedics and Rehabilitation, Brooke Army Medical Center, Fort Sam Houston, TX, USA. 6 Extremity Trauma & Amputation Center of Excellence (EACE), San Antonio Medical Center, Fort Sam Houston, TX, USA. 7 Department of Veterans Affairs, Veterans Health Administration, Regional Amputation Center, James A. Haley Veterans Hospital, Tampa, FL, USA. 8 Lee Physician Group, Department of Vascular Surgery, Fort Myers, FL, USA. 9 Extremity Trauma & Amputation Center of Excellence (EACE), James A. Haley Veterans Hospital, Tampa, FL, USA. 10 University of South Florida. Morsani College of Medicine, School of Physical Therapy & Rehabilitation Sciences, Tampa, FL, USA. 11 Army Reserves. 319th Minimal Care Detachment, Pinellas Park, FL, USA. Published: 5 September 2018 References 1. GCS Administrators, LLC. Lower limb prostheses. In: Local coverage determination. Center for medicare and medicaid services; 2015. https:// www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId= 33787 . Accessed 20 Apr 2017. Klenow et al. Journal of NeuroEngineering and Rehabilitation 2018, 15 (Suppl 1):64 Page 19 of 72