functional considerations for prosthetic candidacy 2010

8/6/2019 Functional Considerations for Prosthetic Candidacy 2010

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Lisa U. Pascual, MD

Assistant Clinical ProfessorDepartment of Orthopaedic Surgery

University of California, San FranciscoOctober 29, 2010

Functional Considerations for

Prosthetic Candidacy


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Will My Patient Be Able to Walk?(And What Should I tell Her to Expect?)


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What do I Tell My Patient?

65 yo M, now s/p R transfemoral amputation DM, HTN, ESRD, CAD, h/o mi, h/o previous

transtibial amputation on same side

Wheelchair bound for short distances on levelsurfaces

Transfers with assist

Limited ambulation prior to recent surgery as haddifficulty with ulcer to RLE


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Objectives

To be able to understand the impact of: Premorbid Medical Concerns

Comorbidities

Age

Psychosocial Concerns

Premorbid Functional Status Gait

Energy Expenditure

The Interdisciplinary Team


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When am I getting a prosthesis?

Assumes when, not if.

Is the patient a prostheticcandidate?


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Prosthetic Candidacy: Premorbid Medical Concerns

Comorbidities

Age

Psychosocial Status


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Prosthetic Candidacy

Premorbid Medical Concerns

Comorbidities

Age

Psychosocial StatusPremorbid Functional Considerations

Energy Expenditure

Functional Abilities


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Comorbidities: (598 arteriosclerotic amputees)

Ischemic Heart Disease, or Hemiplegia, or

Bronchitis, or

Bilateral amputation

Performed worse at 12 months than amputees without these diseases in the WalkingAbility Index


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Comorbidities: Severe Cardiopulmonary Disease

May be a major consideration for withholding prosthetic use giventhe energy expenditure required for ambulation

Compromise of the Contralateral Foot Relative contraindication


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Comorbidities: Dialysis (N=19 with ESRD + 19 without)

Previously shown to perform worse than those without

Similar outcomes for dysvascular amputees with ESRD

compared to those without Successful prosthetic ambulators

Cost of total length of hospital stay (acute + rehabilitation)

Mortality

Comorbities higher for ESRD

Czyrny et al, Am J Phys Med Rehabil. 1994 Sep-Oct;73(5):353-7.


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Comorbidities:

434 with major lower limb amputation due to PeripheralArterial Disease

Prosthetic use

Maintenance of ambulation

Survival

Maintenance of independent living status

American Surgeon, 2006.


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Comorbidities: Obesity:

No correlation betweenoutcomes for overweight

patients vs. normal patients BMI failed to correlate withfunctional outcome

Of note, looked specificallyat PAD, excluded

amputations d/t DM


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Comorbidities:

Compliance is asignificant criteria forsuccessful prostheticuse

Muellar, et al. Physical Therapy,1985.


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Age: Fit Trends Throughout the Years 25 yrs + ago, more transfemoral amputations were being

performed in older dysvascular patient to ensure healing

1959: 55.3% of major lower extremity amputees were fit withprostheses, only 2-3% were elderly (Chapman, et al. 1959)


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Age: Fit Trends Potentialcontraindications:

Cognitive dysfunction (learning and training)

Severe neurologic impairment (CVA, Parkinsons)

COPD, CHF, Angina limiting exercise tolerance

Irreducible knee and hip contractures

FU Study:

Concurrent medical disease or mental deterioration

Steinberg, et al. J Am Geriatr Soc, 1974.

Steinberg, et al. Arch Phys Med Rehab, 1985


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Age: Fit Trends Throughout the Years More recently, less transfemoral amputations, more

transtibial amputations

Higher success rates with rehabilitation of elderly amputees 73% of elderly were fitted and met their rehabilitation goals,

comparing favorably with other age groups (Harris, et al. JCardiovasc Surg, 1991.)

1846 amputees (majority being elderly dysvascular), > 80% weresuccessfully fitted with prostheses (Stewart, et al. Prosthet Orthot

Int, 1993.)


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Age

Wanted to determine the rate of successful prosthetic fit in

geriatric amputees and determine predictors Looked at all pts with amputees, including those who were

not referred for fitting

Success rates for those selected for fit were high

Success rates from other studies may overestimate rate ofsuccessful fit


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Age

Prior screening to referral to an amputee clinic may

contribute to success of prosthetic fit

Factors that adversely affected fit: increased age,

cerebrovascular disease, dementia, transfemoralamputation


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Age

Mobility rates one year after prosthetic provision for unilateral

transtibial amputations, transfemoral amputations worsenwith increasing age at amputation and a higher level of

amputation

25% of transfemoral amputations in this study >50 yo

achieved community mobility and this figure decreased withadvancing ageProsthetics and Orthotic International, 2003.


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Retrospective analysis of 553 consecutive major lower limbamputation patients

Southern Association for Vascular Surgery, 2005.


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Poorer Outcome Limited preoperative ambulatory ability

Age > or = 70

Dementia

ESRD Advanced CAD


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309 consecutive pts s/p

transtibial amputation Successful:

Wound healing withoutrevision

Ambulate with prosthesis> 1 year or until death

Survival > 6 months


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Predictors of Decreased Outcome CAD

Cerebrovascular Disease

Impaired ambulation prior to transtibial amputation


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Age Age alone is not a

contraindication for prostheticuse, careful consideration of other

factors is needed


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Psychosocial Concerns Varied results/different populations:

Return to home varied 20-80%

Helm et al, 1986:

Age was associated unfavorably with functional capacity and

postoperative outcome

Post operative pain was associated with reduced functional

ability but not social dependence

Decrease in need for help at home post amputation for some

amputeesCutson, et al. 1996. J of American Geriatrics Society:

Rehabilitation of the Older Lower Limb Amputee: A

Brief Review


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Psychosocial Concerns Varied results/different populations:

Weiss et al, 1990: 29% noted improved health due to lesspain post amputation; 25% noted worse health which

correlated with decreased ADLs Decrease in quality of life the higher the amputation

Cutson, et al. 1996. J of American Geriatrics Society:

Rehabilitation of the Older Lower Limb Amputee: A

Brief Review


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Psychosocial Concerns

Limited or lack of studies on: Quality of Life

Social network and other environment factors Although re-operation and social dependency appears to

negatively affect outcome


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Morbidity and Mortality: Dysvascular Amputees 15-20% risk of losing contralateral limb 2 years post

amputation Risk increases to 40% at 4 years

5 year survival for lower limb dysvascular amputees averages

30-40% overall Patients with diabetes vs. peripheral vascular disease:

Shorter survival

Related to level of amputation

Survival: transtibial amputation > transfemoral amputation(presumably due to more widespread involvement)


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In summary: Adequate data still not available to:

Reliably identify all predictors of outcome

Look at predictive factors when series include

combinations of amputations due to trauma withdysvascular causes (pooled populations)

Look at unselected populations


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Prosthetic Candidacy: Premorbid Functional Status

It appears that mobility prior to amputation isimportant in terms of outcome.

Why is that?

Does it the level of amputation also make adifference?

Why is that?


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Prosthetic Candidacy: Gait

Documented kinematics

of gait

P th ti C did G it


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Prosthetic Candidacy: Gait

P th ti C did E E dit


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Prosthetic Candidacy: Energy Expenditure

Normal Gait: 3 METs

Waters, Perry, et al. 1976

Energy Cost of AmbulationIncrease (%) MET

No prosthesis, with crutches 50 4.5

Unilateral BK with prosthesis 9-28 3.3-3.8

Unilateral AK with prosthesis 40-65 4.2-5.8

Bilateral BK with prosthesis 41-100 4.2-6.0

BK plus AK with prosthesis 75 5.3

Bilateral AK with prosthesis 280 11.4Unilateral hip disarticulation with prosthesis 82 5.5

Hemipelvectomy with prosthesis 125 6.75


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Prosthetic Candidacy: Energy Expenditure

Normal Ambulation: 3 METS

Cardiac Class I: no limitation; II: sl limitation; III:marked limitation; IV: physical activitydiscomfort;may haveangina at rest

DeLisa, PM&R Principles and Practice.

Correlation of Energy Cost of Ambulation According to Level of Amputation withEstimated Work Capacity According to Cardiac Functional Class

Cardiac Class MET Amputee Ambulation MET

Class IV


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Unilateral leg stance significantpredictor of functional outcome

Memory most important mentalpredictor for function

P th ti C did P bid F ti l St t


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Possible factors:

Low number of comorbidities

Strong motivation to walk

Ability for one leg stance Level of physical fitness as measured by maximal

oxygen consumption after amputation

J Int Med Res, 2009.



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Functional Independence Measure (FIM) as a predictorof functional outcome: Muecke et al,1992:

FIM scores: poor predictor in pts with lowest function

FIM scores: in higher functioning amputees on admission appeared

predictive of rehabilitation success Leung et al, 1996:

FIM not useful as a predictor of outcome

Only motor subscore at discharge correlated with use of aprosthesis


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Managing Expectations


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What kind ofprosthesis am Igoing to get?

Dependent of pre-

morbid level offunctioning

The prosthesis that ison TV may not be theappropriate one for

them



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Goals of Prosthetic Prescription:

To provide the amputee with the ability to return toparticipating in activities that are important to them insociety

To provide a prosthesis that is appropriate for theirlevel of activity, ability and weight



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Energy Storing Feet: Highly subjective satisfaction

rates Limited biomechanical evidence

of significant benefit Trends suggest increased walking

speed, greater stride length, slightdecrease in metabolicexpenditure at high speeds withenergy storing feet, but there isno superiority for level walking


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Microprocessor knees: Controls postural stability

Varies step cadence

Enhances ability to walkon uneven surfaces



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K Level Description Medicare-Covered ProsthesisK0 Nonambulatory NoneK1 Household ambulator Constant-friction kneeK2 Limited community ambulator Constant-friction kneeK3 Unlimited community ambulator Fluid-control knee

K4 Very active Fluid-control kneeSource: Region B Medicare Supplier Bulletin

Source: Region B Medicare Supplier Bulletin

K Level Description Medicare-Covered ProsthesisK0 Nonambulatory NoneK1 Household ambulator Constant-friction kneeK2 Limited community ambulator Constant-friction kneeK3 Unlimited community ambulator Fluid-control knee

K4 Very active Fluid-control kneeSource: Region B Medicare Supplier Bulletin



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65 yo M, now s/p R transfemoral amputation DM, HTN, ESRD, CAD, h/o mi, h/o previous

transtibial amputation on same side

Wheelchair bound for short distances on level

surfaces Transfers with assist

Limited ambulation prior to recent surgery as haddifficulty with ulcer to RLE

It Takes a Village: The Interdisciplinary Team


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It Takes a Village: The Interdisciplinary Team

Key element for successful amputee care program

Surgeon, Physiatrist Internist, Nurse, Prosthetist,Physical Therapist, Occupational Therapist, SocialWorker, Nutritionist, Psychologist, Primary Care

Peer Support, vocational rehabilitation, recreationalactivities


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Thank You

functional considerations for prosthetic candidacy 2010

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