Geriatric Amputees: Enhancing Quality of Life

And in the end, its not the years in your life that count. Its the life in your years. This statement, attributed to Abraham Lincoln, points out a unique benefit that prosthetists can help provide for older amputees--increased mobility, function, and thus quality of life. "It should be the desire of the rehabilitation program to restore the individual to the optimal level of function in their home and community," says Robert H. Meier III, MD, director, Amputee Services of America, Thornton, Colorado. However, many challenges confront both these patients and their prosthetists in achieving this goal, such as other medical issues the amputee may have and his or her overall physical condition, not to mention what funding and resources are available for that particular patient. The majority of lower-limb amputees in the US are over age 50; the largest percentage of these have undergone amputation due to occlusive arterial vascular disease, often associated with diabetes, says Meier. The vascular disease is usually generalized throughout the body, including vessels in vital organs--thus other co-morbid factors affect the rehabilitation outcome. Paul Muchnic, MD Perhaps the most important factors affecting rehabilitation outcomes are the increased energy expenditure needed for prosthetic use, coupled with the decrease in cardiopulmonary reserve seen with aging, Meier adds. Paul Muchnic, MD, an orthopedic surgeon with Kaiser Permanente and the Harbor UCLA Medical Center, Los Angeles, California, agrees. He notes that prosthetic use requires about 40 percent more oxygen for a transfemoral amputee; about 20 percent more for a transtibial amputee; and for Symes amputees, another 510 percent, according to research findings. "One of our biggest enemies is congestive heart failure," he says. "If they can't take in enough air, they can't walk." Muscle mass loss that is generally common to the aging process presents another challenge. "As we age, we lose muscle mass," Muchnic explains. "We can lose up to 10 percent each decade after age 40." "Another common occurrence following lower-limb amputation is the loss of usual muscle strength, decrease in endurance, and the changes in biomechanics of lower-limb function," Meier observes. Flexion contractures are a worry to Kevin Carroll, MS, CP, FAAOP, vice president of prosthetics, Hanger Prosthetics & Orthotics, Bethesda, Maryland. Carroll points out that contractures are especially dangerous to the elderly, since they increase the danger of falling and fracturing the femur bone. Hip flexion contractures increase the danger of falling, due to the patient's center of gravity now being behind the knee axis. "Younger people typically can recover from a fall; older people often don't." In fact, the fall can lead to death, Carroll points out as he emphasizes that prosthetists have to be especially careful about component selection, fitting, and training of their geriatric patients. "We have to be very cautious and take our work very seriously." Promoting Successful Prosthetic Use What can be done to promote successful prosthetic use, function, and mobility for older amputees? The process starts with evaluation. Muchnic describes his approach: "I usually already have their charts and history from previous clinics, but sometimes they are referred from one of our other hospitals." Muchnic is most interested in the amputee's general medical condition. "It would be nice if we could just look at the residual limb and fit the prosthesis, but life is just not that way," he observes. "We check their cardiac condition to see if they are able to handle a prosthesis. If not, we counsel them and look for other ways for them to have mobility and perform activities of daily living." If a patient is marginal, Muchnic alerts them to the danger of putting more strain on a heart that is already experiencing problems, pointing out that prosthetic intervention could perhaps kill them--"not what we're supposed to do," he adds dryly. Having the necessary strength, cognitive function, and balance skills necessary to don and doff a prosthesis is another consideration, Muchnic noted. If the patient is unable to do this, the physician must be sure there is someone in the home to assist. If transtibial amputees are able to stand with the aid of a walker or crutches, they usually can use a prosthesis, at least for getting from bed to bathroom, etc., Muchnic explains. Regarding bilateral transtibial amputees, they generally can walk, but studies have shown that bilateral transfemoral amputees, or amputees with one above-knee and one below-knee amputation that are over age 60 are rarely functional users of prostheses, Muchnic notes. "However, we can fit their below-knee side with a prosthesis that they can use for transfers." And, of course, being able to ambulate or at least being able to make transfers helps caregivers. Besides heart condition, Muchnic also evaluates muscle strength and mental condition. Meier also points out that there may be decreased mental function that inhibits the ability to learn the new skills required for prosthetic use. Kevin Carroll, MS, CP, FAAOP Evaluation isn't limited to physicians. Prosthetists and physical therapists have responsibilities in this area also. "It is important for the prosthetist to understand what is really going on with this person medically," says Carroll. "If he has a heart condition and we push him too hard, he could die in our office. Often, it is difficult to get in contact with the doctor for this information, so we have to get the information from the patient or other healthcare providers." "When patients come in, we ask them to complete a form asking what condition led to the amputation, what medications they are on, and what other health problems they have," he continues. However, since conditions can change, it might be wise to have them do this each time they come in for the recommended follow-up every six months, he points out. Melissa Wolff-Burke, PT, EdD, ATC, works with a substantial number of patients aged 60-plus. Most of these lost a limb as a result of diabetes and have spent time at home in a wheelchair, losing strength. Among other things, Wolff-Burke checks for cardiovascular fitness. "We try to get a picture of where they are now and what they want to be doing--what their goals are. We look at their general health condition and decide what steps we can take together to get them moving again." Needs of Non-Users What if the patient is unable to use a prosthesis or simply does not want one? Someone who is familiar with wheelchairs and other mobility aids and assistive devices is needed, Muchnic points out. "General practitioners and others often shy away from ordering these, but someone has to figure out what they need--which wheelchairs, which walkers to order, etc." Physical therapists also can benefit these non-users through rehabilitation care that helps them get around better in wheelchairs and make transfers, says Wolff-Burke, who teaches physical therapy at Shenandoah University, Winchester, Virginia, and practices at the Winchester Rehabilitation Center. What should be the determining factor in deciding whether or not to use a prosthesis should be whether a person has the capability to improve his function with the prosthesis, says Wolff-Burke. "If someone can do better with a prosthesis, he should be able to get one and be trained to use it." However medical complications, problems with family or social support, and insurance coverage can be factors in the decision from both healthcare provider and patient perspectives, she adds. Reaching the Goal How can optimal outcomes be attained? Meier sets the ideal goal as achieving the level of function the amputee had before the onset of the medical condition leading to the amputation. For instance, dysvascular amputees may not have been very active or mobile before amputation in an attempt to heal a vascular foot ulcer. "What would happen if all persons with vascular symptoms in their leg or foot were placed in a cardiopulmonary conditioning program when their level of mobility was decreased?" Meier asks. "Would this decrease their time in hospital, shorten their prosthetic training time, and even enhance their eventual level of prosthetic training?" Many older persons can benefit from an aerobic conditioning program even if they have had cardiac or pulmonary problems, Meier points out. "However, few are ever placed in this type of program, since the emphasis is usually on the leg muscles used for walking with a prosthesis," he continues. "Use of a pool program can be a wonderful way to improve heart and lung function without the need for two legs." Regarding preprosthetic physical therapy, Wolff-Burke asks and answers rhetorically, "Do physical therapists like to do this? Yes. Do we get the opportunity to do it as often as we'd like? No." However, patients who have physical therapy before amputation "are a step ahead," she says, "because we can start working on their conditioning and strengthening, and we can educate them about their amputation and prosthetic use." A holistic, team approach is best, Carroll believes. Wolff-Burke too favors the team approach. A physiatrist and prosthetist are in the same rehabilitation center where Wolff-Burke practices. "If the patient is associated with them, we have a team right here." However, she also has referrals from other physicians and has patients who go to other prosthetists. But even 50 miles away, "We can still function as a team--a long-distance team." Wolff-Burke sometimes can accompany a patient to the prosthetist's office for a joint evaluation, plus communicating via phone and e-mail. "Although we all may not be all in the same location, if we are on the same page' about caring for the patient, we can still function as a team," she explains. For the prosthetist and physical therapist to work best together, "We need to talk to each other openly and communicate well as to what we're seeing with the patient and what is or isn't working," she says. She also appreciates it when prosthetists educate physical therapists about different components and about prosthetic care. "And I can do the same about what we do," she adds. "Bird-dogging" any problems amputees have with their prostheses and solving these promptly can lead to better outcomes and less cost down the road, Muchnic points out. Regular follow-ups by the physician and prosthetist are very important, Muchnic and Carroll note. In addition, Carroll says that amputees "should have some physical therapy every year for the rest of their lives." Carroll strongly appreciates the role of physical therapists in successful outcomes: "Every prosthetist should have a therapist he or she works with very, very closely." "Unfortunately," says Muchnic, "in the real world, it is very difficult to get all this coordinated." Surgery Lays Groundwork Surgical techniques can lay the groundwork for prosthetic success. Muchnic describes a surgical technique that he feels has worked well for his patients, but which he notes is somewhat controversial and that he is in the minority. For a knee disarticulation, he removes the femoral condyle and brings the patella down over the distal end of the femur. "Since this is California," he says with a glint of humor, "patients won't tolerate a big, funny-looking prosthesis with a knee that sticks out an extra two inches." With this technique, patients can fully weight-bear just as well and the prosthesis fits and looks better, plus maintaining a high level of function, he explains. "I think they actually function better, because they have equal working leg lengths." Designing an amputation level right around the knee or very distal femur promotes less energy use, Muchnic said. Retaining as much thigh musculature as possible and certain flap techniques saves energy and helps amputees to be strong walkers for many years, he added, noting the work of Frank Gottschalk, MD, Dallas Rehabilitation Institute, Dallas, Texas, in developing ways to retain as much adductor musculature as possible. Many amputees also have found that undergoing an Ertl procedure amputation gave them more comfortable prosthetic fittings. (For more information, visit www.ertlreconstruction.com ) Early Rehab Brings Benefits Beginning rehabilitation as soon as possible after amputation surgery is generally highly beneficial to amputees, interviewees agreed--with some caveats. "By getting people up early, you can often prevent contractures," says Muchnic. "We really have to encourage patients to get up early--the earlier the better," Carroll agrees. Early mobility helps prevent flexion contractures, he notes. "Once they get flexion contractures, "they are tough to get rid of. I believe amputees need more physical therapy, but Medicare regulations say what you can and can't have." "Another way to prevent flexion contractures of the legs is to mobilize the amputee out of the wheelchair and bed as soon as possible after the amputation," says Meier. "Those kept in a wheelchair for periods of time either before or after the amputation will be more prone to developing the dreaded flexion contractures of the hips and knees that may preclude successful prosthetic function." "If there was more early postoperative prosthetic fitting, I think we would see people moving through rehabilitation a lot faster, even with the geriatric population who may have healing issues," says Wolff-Burke. Although some doctors want to wait for the wound to heal, there are products available which enable easy wound observation, she notes. "It would definitely benefit the patient if there wasn't this delay." After citing advances in prosthetic componentry such as dynamically responsive and multiaxis feet, more comfortable socket designs, enhanced stability in knee units, improved skin/socket interface materials, improved suspension techniques, and specialized components for varied function, Meier points out the need for appropriate therapy. "Just providing these technically advanced components does not substitute for the appropriate therapeutic training of residual muscles and improving the ability of the heart and lungs to respond to the increased energy demands required with prosthetic use. "New preprosthetic and prosthetic therapy programs have been developed to enhance the level of prosthetic function. These programs include traditional strengthening and prosthetic training, but in addition, they include an emphasis on aerobic conditioning and balance training. Many older amputees exhibit sensory deficits in their legs, and they need to be trained to substitute for these sensory disturbances. In addition to basic walking skills, older amputees may now be able to return to their pre-amputation pursuits of recreation and vocation." A study published in the Journal of Rehabilitation Research and Development , July/August 2001, concurs in its introduction: "Rehabilitation that begins soon after surgery has been felt to have a number of advantages, such as minimizing phantom and residual-limb pain and mastering prosthetic ambulation. One study also proposes that immediate post-amputation rehabilitation can be cost-effective by decreasing days spent in acute care." (To read the complete report, visit www.vard.org/jour/01/38/4/munin384.htm ) Early rehabilitation also often gives patients a psychological lifts, notes Muchnic. "When they are fitted and get up and about, it's like giving them a bottle of antidepressants--they seem to perk up." "Even just educating amputees that they can be expected to lead a functional life walking with a prosthesis can help overcome the post-amputation depression that is commonly seen," says Meier. "We need to educate physicians and insurers abut getting patients in and out sooner, so patients can be as functional as they want to be," says Wolff-Burke. Early Rehab: The Caveats So why isn't rehabilitation more often begun immediately after surgery? A number of factors are involved in the answer. "Without a strong, effective team in place, it is probably better to wait for the sake of safety until the suture is well healed, although this increases the time for recovery and rehab," says Carroll. "I think it's because surgeons want to err on the side of caution," says Wolff-Burke. "The person has lost a limb; there may be a problem with healing, and they don't want to stress the site too soon." However, she notes that there are physical therapy activities that can promote cardiovascular conditioning to help the person prepare for prosthetic use, without compromising the surgical site. "That's much better than sitting at home, losing flexibility, conditioning, and motivation." Insurance and Medicare/Medicaid limitations or lack can also be an issue. "People can fall through the cracks for too many months," says Muchnic. "They get contractures, don't become walkers, and can give up life. They get stationed in nursing homes, become shut-ins, and nobody tries to get them out of that situation. They just sort of accept it, but it's really unacceptable. Although decisions are based on cost, in these situations payers can be looking at a big cost later--somebody has to take care of them." Short-Term Spending=Long-Term Savings Muchnic points out the shortsightedness of insurance companies and Medicare/Medicaid in being reluctant to pay the cost of prostheses and prosthetic care that can prevent much costlier outlays of funds down the road. He notes the lack of logic in that payers will not blink at a $20,000-$50,000 cost of hospitalization for hip or knee replacement, but will be reluctant to pay for two starter prostheses for a bilateral amputee at $10,000. "However, if the $10,000 is for physical therapy or cancer chemotherapy (therapeutic agents), no one questions it." So, compared with the cost of treating many other diseases and conditions, prosthetic care is a highly cost-effective way to return people to productivity, function, and quality of life, he asserts. Muchnic believes that working with highly qualified professionals is worth the cost. At Kaiser Permanente, he uses three private prosthetic facilities. "Board-[American Board for Certification in Orthotics & Prosthetics]-certified prosthetists who are well-regarded in the community are worth their weight in gold." He points out that getting good people, even if the initial cost is higher, saves money in the long run by preventing costlier medical problems from developing due to poor treatment. Motivating Patients What else can healthcare professionals do to promote successful prosthetic outcomes? "We have to note if there's depression; we have to motivate them--be a cheerleader," Carroll says. He points out that many older amputees suffering from depression or other emotional issues don't want to talk to a psychologist. In their era, seeing a psychologist implied a weakness and carried a stigma. Explaining Medicare functional levels can help, he continues. For instance, he might tell an amputee, "Today you seem like a function level 2, but if you work hard with your therapist, you have the potential to be a function level 3." He adds, "It's like holding a carrot in front of them: You're probably going to get a much better prosthesis if you work with the therapist.'" He tells them, "Don't expect the therapist to do it--you have to do it! Your therapist can only spend a certain amount of time, but you have 24 hours a day you can be stretching and following your program." Motivation can be powerful. Carroll cites the example of an amputee in Colorado who had lost interest in life and even seemed to be dying. "Then she had one granddaughter and then another one. Now she is happy and excited, doing things with her granddaughters, taking them to dance classes, etc. She says that now she's too busy to be sick." Getting amputees together in a group for mutual peer support is very important, Muchnic believes. "Also, we need to be their advocate with insurance companies and federal and state payers. For instance, we need to point out that providing a $600 liner or other equipment might prevent a hospital stay costing $5,000 or better." He feels the physician, who he believes is best to head the rehab team, should take on the advocate role. "We can be more equal with the administrators; we carry more weight when we say, We need this,' and point out that the cost, for instance, may be less than two dialysis treatments." To sum up, these factors contribute to success: a clinical team approach; taking into consideration the amputee's overall health and medical issues when deciding on a course of prosthetic management; beginning rehab as early as possible following amputation, if circumstances permit and not contraindicated; follow-up, including addressing problems promptly; adequate physical therapy; and motivating and advocating for patients. "I'd like to go on being 35 for a long time," former British Prime Minister Margaret Thatcher once said. Although that may not be possible, with skilled, well-planned rehab care, older amputees can enjoy many additional years of enhanced quality of life.

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