Rehabilitation in Amputees Dr Sue Inglis MBBS FAFRM DipEdClinEd Myers Street Medical Group
Bran Nue Leg
A limb lost every 3 hours: can Australia reduce amputations in people with diabetes? Shan M Bergin, Jan B Alford, Bernard P Allard, Joel M Gurr, Emma L Holland, Mark W Horsley, Maarten C Kamp, Peter A Lazzarini, Vanessa L Nube, Ashim K Sinha, Jason T Warnock and Paul R Wraight. Med J Aust 2012; 197 (4): 197-198.
30% Increase in diabetes in the last decade 8% of diabetic related deaths are due to foot disease
Indigenous people aged 25 49 years with diabetes Minor amputations were 27 times more likely Major amputations 38 times more likely Paul E Norman, Deborah E Schoen, Joel M Gurr and Marlene L Kolybaba MJA Volume 192 Number 7 5 April 2010
Diabetic Complications Wound healing Renal dysfunction Autonomic neuropathy Hypoglycaemia with exercise
Level Choosing Factors Treat underlying disease Consider functional potential Preserve length Fast healing Avoid further surgery
Energy Consumption in Amputees Level of amputation (Traumatic) BKA BKA + BKA AKA AKA + BKA AKA + AKA Increased energy above normal 20-25% (Short-40%) (Long-10%) 41% (Gonzalez-1974) 60-70% 118% (Traugh-1975) 260% (Huang 1979)
Rigid Dressings Immediate oedema control Possible weight-bearing Need appropriate personnel Application immediately post-operatively
Range of Motion Pain control pre and post op Avoid propping on pillows, prolonged sitting in flexion Prone lying daily
Phantom Pain Anticonvulsants (gabapentin / pregabalin) Adjuvants antidepressants, antiarhythmics, SSRI? topical modalities Total contact shrinkers
Early Patient Involvement Pre-op counselling if possible Realistic goal setting Learn to touch, massage and wrap stump Managing prosthesis Risk factor modification
Falling and Fear of Falling (lower extremity amputees) Arch Phys Med Rehabil 2001 Aug;82(8):1031-7, Miler et al 52% fell past year 49% fear of falling
References 1. Australian Institute of Health and Welfare. Diabetes: Australian facts 2008. Canberra: AIHW, 2008. (AIHW Cat. No. CVD 40; Diabetes Series No. 8.) http://www.aihw.gov.au/publicationdetail/?id=6442468075 (accessed Mar 2012). 2. Payne CB. Diabetes-related lower-limb amputations in Australia. Med J Aust 2000; 173: 352-354. 3. International Diabetes Federation; International Working Group on the Diabetic Foot. International consensus on the diabetic foot and practical and specific guidelines on the management and prevention of the diabetic foot. Noordwjerhout, Netherlands: IDF, 2011. 4. National Health and Medical Research Council. National evidence-based guideline on prevention, identification and management of foot complications in diabetes (part of the guidelines on management of type 2 diabetes). Canberra: NHMRC, 2001.http://www.nhmrc.gov.au/guidelines/publications/di21 (accessed Mar 2012). 5. Menz HB. Utilisation of podiatry services in Australia under the Medicare Enhanced Primary Care Program, 2004-2008. J Foot Ankle Res 2009; 2: 30-35. 6. Lavery LA, Higgins KR, Lanctot DR, et al. Preventing diabetic foot ulcer recurrence in high risk patients: use of temperature monitoring as a self-assessment tool. Diabetes Care 2007; 30: 14-20. 7. Wraight PR. Improving clinical outcomes for patients with diabetes related foot complications [PhD thesis]. Melbourne: The University of Melbourne, 2005. 8. Sydney Health Projects Group, School of Public Health. Chronic and complex priority healthcare programs: evaluation of the Diabetic Foot Disease Program. Sydney: University of Sydney, 2004. 9. Santamaria N, Carville K, Ellis I, Prentice J. The effectiveness of digital imaging and remote expert wound consultation on healing rates in chronic lower leg ulcers in the Kimberley region of Western Australia. Primary Intention 2004; 12: 62-70. http://www.awma.com.au/journal/1202_01.pdf(accessed May 2012). 10. Norman PE, Schoen DE, Gurr JM, Kolybaba ML. High rates of amputation among Indigenous people in Western Australia [letter]. Med J Aust 2010; 192: 421. 11. NYU School of Medicine, Rusk Rehabilitation Department. 40 th Annual Comprehensive Review of Physical Medicine and Rehabilitation [text book]. 2015.