Amputee Early Rehabilita1on

Transcription

1 Amputee Early Rehabilita1on Paul JW Tawney MD Physical Medicine and Rehabilita1on Department of Orthopaedics Duke University North Carolina Orthopaedic Clinic

2 Limb Loss Sta1s1cs References from the Amputee Coali1on 1) Ziegler- Graham K, MacKenzie EJ, Ephraim PL, Travison TG, Brookmeyer R. Es1ma1ng the Prevalence of Limb Loss in the United States: 2005 to Archives of Physical Medicine and Rehabilita1on2008;89(3): ) Owings M, Kozak LJ, Na1onal Center for Health S. Ambulatory and Inpa1ent Procedures in the United States, Hya`sville, Md.: U.S. Dept. of Health and Human Services, Centers for Disease Control and Preven1on, Na1onal Center for Health Sta1s1cs; ) HCUP Na1onwide Inpa1ent Sample (NIS). Healthcare Cost and U1liza1on Project (HCUP). Rockville, MD: Agency for Healthcare Research and Quality; ) Fisher ES, Goodman DC, Chandra A. Dispari1es in Health and Health Care among Medicare Beneficiaries: A Brief Report of the Dartmouth Atlas Project. Robert Wood Johnson Founda1on ) Robbins JM, Strauss G, Aron D, Long J, Kuba J, Kaplan Y. Mortality Rates and Diabe1c Foot Ulcers. Journal of the American Podiatric Medical Associa1on2008 November 1, 2008;98(6): ) Pandian G, Hamid F, Hammond M. Rehabilita1on of the Pa1ent with Peripheral Vascular Disease and Diabe1c Foot Problems. In: DeLisa JA, Gans BM, editors. Philadelphia: Lippinco`- Raven; 1998.

3 Limb Loss Sta1s1cs There are nearly 2 million people living with limb loss in the United States (1) Among those living with limb loss, the main causes are vascular disease (54%) including diabetes and peripheral arterial disease trauma (45%) and cancer (less than 2%) (1). Approximately 185,000 amputa1ons occur in the United States each year (2).

4 Limb Loss Sta1s1cs In 2009, hospital costs associated with amputa1on totaled more than $8.3 billion (3) African- Americans are up to four 1mes more likely to have an amputa1on than white Americans (4)

5 Limb Loss Sta1s1cs Nearly half of the individuals who have an amputa1on due to vascular disease will die within 5 years. This is higher than the five year mortality rates for breast cancer, colon cancer, and prostate cancer (5) Of persons with diabetes who have a lower extremity amputa1on, up to 55% will require amputa1on of the second leg within 2-3 years (6)

6 Timothy R. Dillingham, MD, et al, Limb Amputation and Limb Deficiency: Epidemiology and Recent Trends in the United States, Southern Medical Journal 95 (2002):

7 Inpa1ent Rehabilita1on aker Amputa1on Pa1ents treated in a CIRU were 17% more likely to achieve mobility success. Mul1variate model also showed that achieving mobility success was associated with younger age, higher social support score, no chronic obstruc1ve pulmonary disease and underweight to normal BMI categories. Pa1ents were 23% less likely to achieve mobility success if they had a major depressive episode diagnosed at 4 months or who had a greater alcohol use. Czerniecki JM, Turner AP, Williams RM, et al. The effect of rehabilita1on in a comprehensive inpa1ent rehabilita1on unit on mobility outcome aker dysvascular lower extremity amputa1on. Arch Phys Med Rehabil. 2012;93: Intangibles Team approach is key

8 Inpa1ent Rehabilita1on aker Amputa1on Improved func1onal outcomes in amputees who go through acute inpa1ent rehab Improved mood in amputees who go through acute inpa1ent rehab Higher level discharge disposi1on in amputees who go through acute inpa1ent rehab Dillingham, AJPMR, PM&R 2011, Summary: Encourage comprehensive inpa1ent rehabilita1on op1ons aker amputa1on

9 Inpa1ent Rehabilita1on aker Amputa1on Criteria: WakeMed Rehab Require and be able to par1cipate in physical, occupa1onal, and/or speech therapy, if indicated, at least 3 hours a day, 5 days a week. Need more than one type of rehab therapy and have a poten1al for func1onal improvement. Have a suppor1ve social system and a defined, expected discharge des1na1on other than a skilled nursing facility. Be medically appropriate for an inpa1ent hospital environment and have stable vital signs.

10 Inpa1ent Rehabilita1on aker Amputa1on May need a medical condi1on or associated injuries to qualify for inpa1ent services Current Case Example: Fxnl status and assistance level needed - AKA Upper extremity weight bearing status may alter capacity for rehab Concern for radial nerve palsy Diabetes and pulmonary func1on

11 Medical Complica1ons of Amputa1on Skin breakdown & wound complica1ons Joint contracture Medica1on side effects Complica1ons of comorbidi1es (i.e. diabetes) & associated injuries Depression Decondi1oning - Energy Cost of Amputee Gait Robert Waters, O&P Library, Chapter 15 - Atlas of Limb Prosthe1cs: Surgical, Prosthe1c, and Rehabilita1on Principles

12 Energy Expenditure O2 Cost Chapter 15 - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles

13 Energy Expenditure Gait Speed Chapter 15 - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles

14 Edema control and shaping of the residual limb Wound healing Preven1on of Contractures Pre- prosthe1c training that focuses on independence in mobility, transfers & self care Educa1on, Ini1al Amputee Rehab

15 Ini1al Amputee Rehab Pain management Medical management and preven1on of medical complica1ons Save the other limb diabetes, vasculopathy, wounds, infec1on

16 Medical Complica1ons of Amputa1on Renal disease, cardiac issues, history of sepsis, steroid use, COPD, and increased pa1ent age were iden1fied as predictors of mortality aker below- knee amputa1on. Renal disease, cardiac issues, history of sepsis, steroid use, contaminated/infected wounds, and alcohol use were also found to be predictors of postopera1ve complica1ons. WBAMC, NSQIP J Am Coll Surg Sep;213(3): doi: /j.jamcollsurg Epub 2011 Jul 1.

17 Medical Complica1ons of Amputa1on Age alone is not an absolute contraindica1on to prosthe1c limb prescrip1on; however, it does influence the poten1al success of gait retraining. Other factors influencing prosthe1c firng and use include comorbidi1es, premorbid func1on, level of amputa1on, status of the remaining limb and pa1ent mo1va1on. Fleury, Australia. Geriatr Gerontol Int Apr;13(2): doi: /ggi Epub 2012 Dec 26.

18 Medical Complica1ons of Amputa1on Most pa1ents felt out of control and had a poor understanding of the events leading to their ini1al amputa1ons. Preven1on of subsequent amputa1ons will require rehabilita1on programs to address low health literacy and psychosocial obstacles to self- management. Feinglass, Northwestern. Disabil Rehabil. 2012;34(25): doi: / Epub 2012 Apr 25.

19 Amputee Pain Management Phantom pain Awareness of pain in the por1on of the extremity that has been amputated. It may accompany the phantom sensa1on, localizing in the phantom limb rather than in the residual limb. The pain has been described as cramping, aching, burning, and, occasionally lancina1ng

20 Amputee Pain Management E1ology: phantom pain appears to be related to neuron deafferenta1on hyperexcitability. It may be diffuse throughout the en1re limb or may be localized to a single nerve distribu1on. Studies have suggested that 50% to 85% of amputees experience some phantom limb pain.

21 Amputee Pain Management Recent data does not suggest a predisposi1on for phantom limb pain among trauma1c amputees, elderly amputees, or those with pain in the amputated limb before amputa1on. There appears to be no correla1on between phantom pain and amount of 1me aker amputa1on or use of prosthesis.

22 Amputee Pain Management Phantom pain usually diminishes with 1me and chronic phantom pain is rare. The occurrence of phantom pain generally is considered to be a significant long- term problem in only 5% or less of the total amputee popula1on. If pain persists longer than 6 months, prognosis for spontaneous recovery is poor. Phantom pain does not occur in congenital amputa1on.

23 Amputee Pain Management Surgical treatment oken less favorable, with poor long- term success Severe cases may need nerve blocks, steroid injec1ons, or epidural blocks Regional guanethidine or reserpine blocks have been tried with li`le success Sympathectomy and other neurosurgical procedures

24 Amputee Pain Management Tricyclic an1depressants An1convulsants Calcitonin Capsaicin Propanol Mexile1ne Na+ channel blocker

25 Amputee Pain Management Acupuncture Transcutaneous electrical s1mula1on (TENS) Vibra1on Ultrasound

26 Amputee Pain Management Hypnosis Biofeedback Cogni1ve Behavioral therapy Support groups Relaxa1on therapy Voluntary control of the phantom limb (mental imaging) Mirror therapy

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