<i><b>And in the end, its not the years in your life that\r\ncount. Its the life in your years.<\/b><\/i>\r\n\r\n<img style="float: right;" src="https:\/\/opedge.com\/Content\/OldArticles\/images\/2004-07_01\/Untitled-1.jpg" hspace="4" vspace="4" \/>\r\n\r\nThis 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\r\nrestore 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.\r\n\r\nHowever, 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.\r\n\r\nThe 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\r\nthroughout the body, including vessels in vital organs--thus other co-morbid factors affect the rehabilitation outcome.\r\n<table class="clsTableCaption" style="float: right; width: 23.7894%;">\r\n<tbody>\r\n<tr>\r\n<td style="width: 100%;"><img src="https:\/\/opedge.com\/Content\/OldArticles\/images\/2004-07_01\/MunicPaulMD.jpg" alt="Paul Muchnic, MD" \/><\/td>\r\n<\/tr>\r\n<tr>\r\n<td style="width: 100%;">Paul Muchnic, MD<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\nPerhaps 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.\r\n\r\nPaul 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."\r\n\r\nMuscle mass loss that is generally common to the aging process\r\npresents another challenge. "As we age, we lose muscle mass,"\r\nMuchnic explains. "We can lose up to 10 percent each decade after\r\nage 40."\r\n\r\n"Another common occurrence following lower-limb amputation is\r\nthe loss of usual muscle strength, decrease in endurance, and the\r\nchanges in biomechanics of lower-limb function," Meier\r\nobserves.\r\n\r\nFlexion contractures are a worry to Kevin Carroll, MS, CP,\r\nFAAOP, vice president of prosthetics, Hanger Prosthetics &\r\nOrthotics, Bethesda, Maryland. Carroll points out that contractures\r\nare especially dangerous to the elderly, since they increase the\r\ndanger of falling and fracturing the femur bone. Hip flexion\r\ncontractures increase the danger of falling, due to the patient's\r\ncenter of gravity now being behind the knee axis. "Younger people\r\ntypically can recover from a fall; older people often don't." In\r\nfact, the fall can lead to death, Carroll points out as he\r\nemphasizes that prosthetists have to be especially careful about\r\ncomponent selection, fitting, and training of their geriatric\r\npatients. "We have to be very cautious and take our work very\r\nseriously."\r\n<h2>Promoting Successful Prosthetic Use<\/h2>\r\n<i>What can be done to promote successful prosthetic use,\r\nfunction, and mobility for older amputees?<\/i>\r\n\r\nThe process starts with evaluation. Muchnic describes his\r\napproach: "I usually already have their charts and history from\r\nprevious clinics, but sometimes they are referred from one of our\r\nother hospitals." Muchnic is most interested in the amputee's\r\ngeneral medical condition. "It would be nice if we could just look\r\nat the residual limb and fit the prosthesis, but life is just not\r\nthat way," he observes. "We check their cardiac condition to see if\r\nthey are able to handle a prosthesis. If not, we counsel them and\r\nlook for other ways for them to have mobility and perform\r\nactivities of daily living." If a patient is marginal, Muchnic\r\nalerts them to the danger of putting more strain on a heart that is\r\nalready experiencing problems, pointing out that prosthetic\r\nintervention could perhaps kill them--"not what we're supposed to\r\ndo," he adds dryly.\r\n\r\nHaving the necessary strength, cognitive function, and balance\r\nskills necessary to don and doff a prosthesis is another\r\nconsideration, Muchnic noted. If the patient is unable to do this,\r\nthe physician must be sure there is someone in the home to\r\nassist.\r\n\r\nIf transtibial amputees are able to stand with the aid of a\r\nwalker or crutches, they usually can use a prosthesis, at least for\r\ngetting from bed to bathroom, etc., Muchnic explains. Regarding\r\nbilateral transtibial amputees, they generally can walk, but\r\nstudies have shown that bilateral transfemoral amputees, or\r\namputees with one above-knee and one below-knee amputation that are\r\nover age 60 are rarely functional users of prostheses, Muchnic\r\nnotes. "However, we can fit their below-knee side with a prosthesis\r\nthat they can use for transfers." And, of course, being able to\r\nambulate or at least being able to make transfers helps\r\ncaregivers.\r\n\r\nBesides heart condition, Muchnic also evaluates muscle strength\r\nand mental condition.\r\n\r\nMeier also points out that there may be decreased mental\r\nfunction that inhibits the ability to learn the new skills required\r\nfor prosthetic use.\r\n<table class="clsTableCaption" style="float: right; width: 27.3839%;">\r\n<tbody>\r\n<tr>\r\n<td style="width: 100%;"><img src="https:\/\/opedge.com\/Content\/OldArticles\/images\/2004-07_01\/CarrollKevin.jpg" alt="Kevin Carroll, MS, CP, FAAOP" \/><\/td>\r\n<\/tr>\r\n<tr>\r\n<td style="width: 100%;">Kevin Carroll, MS, CP, FAAOP<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\nEvaluation 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."\r\n\r\n"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.\r\n\r\nMelissa Wolff-Burke, PT, EdD, ATC, works with a substantial\r\nnumber of patients aged 60-plus. Most of these lost a limb as a\r\nresult of diabetes and have spent time at home in a wheelchair,\r\nlosing strength. Among other things, Wolff-Burke checks for\r\ncardiovascular fitness. "We try to get a picture of where they are\r\nnow and what they want to be doing--what their goals are. We look\r\nat their general health condition and decide what steps we can take\r\ntogether to get them moving again."\r\n<h2>Needs of Non-Users<\/h2>\r\nWhat if the patient is unable to use a prosthesis or simply does\r\nnot want one? Someone who is familiar with wheelchairs and other\r\nmobility aids and assistive devices is needed, Muchnic points out.\r\n"General practitioners and others often shy away from ordering\r\nthese, but someone has to figure out what they need--which\r\nwheelchairs, which walkers to order, etc."\r\n\r\nPhysical therapists also can benefit these non-users through\r\nrehabilitation care that helps them get around better in\r\nwheelchairs and make transfers, says Wolff-Burke, who teaches\r\nphysical therapy at Shenandoah University, Winchester, Virginia,\r\nand practices at the Winchester Rehabilitation Center.\r\n\r\nWhat should be the determining factor in deciding whether or not\r\nto use a prosthesis should be whether a person has the capability\r\nto improve his function with the prosthesis, says Wolff-Burke. "If\r\nsomeone can do better with a prosthesis, he should be able to get\r\none and be trained to use it." However medical complications,\r\nproblems with family or social support, and insurance coverage can\r\nbe factors in the decision from both healthcare provider and\r\npatient perspectives, she adds.\r\n<h2>Reaching the Goal<\/h2>\r\n<i>How can optimal outcomes be attained?<\/i>\r\n\r\nMeier sets the ideal goal as achieving the level of function the\r\namputee had before the onset of the medical condition leading to\r\nthe amputation. For instance, dysvascular amputees may not have\r\nbeen very active or mobile before amputation in an attempt to heal\r\na vascular foot ulcer. "What would happen if all persons with\r\nvascular symptoms in their leg or foot were placed in a\r\ncardiopulmonary conditioning program when their level of mobility\r\nwas decreased?" Meier asks. "Would this decrease their time in\r\nhospital, shorten their prosthetic training time, and even enhance\r\ntheir eventual level of prosthetic training?"\r\n\r\nMany older persons can benefit from an aerobic conditioning\r\nprogram even if they have had cardiac or pulmonary problems, Meier\r\npoints out. "However, few are ever placed in this type of program,\r\nsince the emphasis is usually on the leg muscles used for walking\r\nwith a prosthesis," he continues. "Use of a pool program can be a\r\nwonderful way to improve heart and lung function without the need\r\nfor two legs."\r\n\r\nRegarding preprosthetic physical therapy, Wolff-Burke asks and\r\nanswers rhetorically, "Do physical therapists like to do this? Yes.\r\nDo we get the opportunity to do it as often as we'd like? No."\r\nHowever, patients who have physical therapy before amputation "are\r\na step ahead," she says, "because we can start working on their\r\nconditioning and strengthening, and we can educate them about their\r\namputation and prosthetic use."\r\n\r\nA holistic, team approach is best, Carroll believes. Wolff-Burke\r\ntoo favors the team approach. A physiatrist and prosthetist are in\r\nthe same rehabilitation center where Wolff-Burke practices. "If the\r\npatient is associated with them, we have a team right here."\r\nHowever, she also has referrals from other physicians and has\r\npatients who go to other prosthetists. But even 50 miles away, "We\r\ncan still function as a team--a long-distance team." Wolff-Burke\r\nsometimes can accompany a patient to the prosthetist's office for a\r\njoint evaluation, plus communicating via phone and e-mail.\r\n"Although we all may not be all in the same location, if we are on\r\nthe same page' about caring for the patient, we can still function\r\nas a team," she explains.\r\n\r\nFor the prosthetist and physical therapist to work best\r\ntogether, "We need to talk to each other openly and communicate\r\nwell as to what we're seeing with the patient and what is or isn't\r\nworking," she says. She also appreciates it when prosthetists\r\neducate physical therapists about different components and about\r\nprosthetic care. "And I can do the same about what we do," she\r\nadds.\r\n\r\n"Bird-dogging" any problems amputees have with their prostheses\r\nand solving these promptly can lead to better outcomes and less\r\ncost down the road, Muchnic points out. Regular follow-ups by the\r\nphysician and prosthetist are very important, Muchnic and Carroll\r\nnote. In addition, Carroll says that amputees "should have some\r\nphysical therapy every year for the rest of their lives." Carroll\r\nstrongly appreciates the role of physical therapists in successful\r\noutcomes: "Every prosthetist should have a therapist he or she\r\nworks with very, very closely."\r\n\r\n"Unfortunately," says Muchnic, "in the real world, it is very\r\ndifficult to get all this coordinated."\r\n<h2>Surgery Lays Groundwork<\/h2>\r\nSurgical techniques can lay the groundwork for prosthetic\r\nsuccess. Muchnic describes a surgical technique that he feels has\r\nworked well for his patients, but which he notes is somewhat\r\ncontroversial and that he is in the minority. For a knee\r\ndisarticulation, he removes the femoral condyle and brings the\r\npatella down over the distal end of the femur. "Since this is\r\nCalifornia," he says with a glint of humor, "patients won't\r\ntolerate a big, funny-looking prosthesis with a knee that sticks\r\nout an extra two inches." With this technique, patients can fully\r\nweight-bear just as well and the prosthesis fits and looks better,\r\nplus maintaining a high level of function, he explains. "I think\r\nthey actually function better, because they have equal working leg\r\nlengths."\r\n\r\nDesigning an amputation level right around the knee or very\r\ndistal femur promotes less energy use, Muchnic said. Retaining as\r\nmuch thigh musculature as possible and certain flap techniques\r\nsaves energy and helps amputees to be strong walkers for many\r\nyears, he added, noting the work of Frank Gottschalk, MD, Dallas\r\nRehabilitation Institute, Dallas, Texas, in developing ways to\r\nretain as much adductor musculature as possible.\r\n\r\nMany amputees also have found that undergoing an Ertl procedure\r\namputation gave them more comfortable prosthetic fittings. (For\r\nmore information, visit <a href="https:\/\/opedge.com\/2782">www.ertlreconstruction.com<\/a>)\r\n<h2>Early Rehab Brings Benefits<\/h2>\r\nBeginning rehabilitation as soon as possible after amputation\r\nsurgery is generally highly beneficial to amputees, interviewees\r\nagreed--with some caveats.\r\n\r\n"By getting people up early, you can often prevent\r\ncontractures," says Muchnic.\r\n\r\n"We really have to encourage patients to get up early--the\r\nearlier the better," Carroll agrees. Early mobility helps prevent\r\nflexion contractures, he notes. "Once they get flexion\r\ncontractures, "they are tough to get rid of. I believe amputees\r\nneed more physical therapy, but Medicare regulations say what you\r\ncan and can't have."\r\n\r\n"Another way to prevent flexion contractures of the legs is to\r\nmobilize the amputee out of the wheelchair and bed as soon as\r\npossible after the amputation," says Meier. "Those kept in a\r\nwheelchair for periods of time either before or after the\r\namputation will be more prone to developing the dreaded flexion\r\ncontractures of the hips and knees that may preclude successful\r\nprosthetic function."\r\n\r\n"If there was more early postoperative prosthetic fitting, I\r\nthink we would see people moving through rehabilitation a lot\r\nfaster, even with the geriatric population who may have healing\r\nissues," says Wolff-Burke. Although some doctors want to wait for\r\nthe wound to heal, there are products available which enable easy\r\nwound observation, she notes. "It would definitely benefit the\r\npatient if there wasn't this delay."\r\n\r\nAfter citing advances in prosthetic componentry such as\r\ndynamically responsive and multiaxis feet, more comfortable socket\r\ndesigns, enhanced stability in knee units, improved skin\/socket\r\ninterface materials, improved suspension techniques, and\r\nspecialized components for varied function, Meier points out the\r\nneed for appropriate therapy. "Just providing these technically\r\nadvanced components does not substitute for the appropriate\r\ntherapeutic training of residual muscles and improving the ability\r\nof the heart and lungs to respond to the increased energy demands\r\nrequired with prosthetic use.\r\n\r\n"New preprosthetic and prosthetic therapy programs have been\r\ndeveloped to enhance the level of prosthetic function. These\r\nprograms include traditional strengthening and prosthetic training,\r\nbut in addition, they include an emphasis on aerobic conditioning\r\nand balance training. Many older amputees exhibit sensory deficits\r\nin their legs, and they need to be trained to substitute for these\r\nsensory disturbances. In addition to basic walking skills, older\r\namputees may now be able to return to their pre-amputation pursuits\r\nof recreation and vocation."\r\n\r\nA study published in the <i>Journal of Rehabilitation Research\r\nand Development<\/i>, July\/August 2001, concurs in its\r\nintroduction: "Rehabilitation that begins soon after surgery has\r\nbeen felt to have a number of advantages, such as minimizing\r\nphantom and residual-limb pain and mastering prosthetic ambulation.\r\nOne study also proposes that immediate post-amputation\r\nrehabilitation can be cost-effective by decreasing days spent in\r\nacute care." (To read the complete report, visit <a href="https:\/\/opedge.com\/2783">www.vard.org\/jour\/01\/38\/4\/munin384.htm<\/a>)\r\n\r\nEarly rehabilitation also often gives patients a psychological\r\nlifts, notes Muchnic. "When they are fitted and get up and about,\r\nit's like giving them a bottle of antidepressants--they seem to\r\nperk up."\r\n\r\n"Even just educating amputees that they can be expected to lead\r\na functional life walking with a prosthesis can help overcome the\r\npost-amputation depression that is commonly seen," says Meier.\r\n\r\n"We need to educate physicians and insurers abut getting\r\npatients in and out sooner, so patients can be as functional as\r\nthey want to be," says Wolff-Burke.\r\n<h2>Early Rehab: The Caveats<\/h2>\r\n<i>So why isn't rehabilitation more often begun immediately\r\nafter surgery? A number of factors are involved in the\r\nanswer.<\/i>\r\n\r\n"Without a strong, effective team in place, it is probably\r\nbetter to wait for the sake of safety until the suture is well\r\nhealed, although this increases the time for recovery and rehab,"\r\nsays Carroll.\r\n\r\n"I think it's because surgeons want to err on the side of\r\ncaution," says Wolff-Burke. "The person has lost a limb; there may\r\nbe a problem with healing, and they don't want to stress the site\r\ntoo soon." However, she notes that there are physical therapy\r\nactivities that can promote cardiovascular conditioning to help the\r\nperson prepare for prosthetic use, without compromising the\r\nsurgical site. "That's much better than sitting at home, losing\r\nflexibility, conditioning, and motivation."\r\n\r\nInsurance and Medicare\/Medicaid limitations or lack can also be\r\nan issue. "People can fall through the cracks for too many months,"\r\nsays Muchnic. "They get contractures, don't become walkers, and can\r\ngive up life. They get stationed in nursing homes, become shut-ins,\r\nand nobody tries to get them out of that situation. They just sort\r\nof accept it, but it's really unacceptable. Although decisions are\r\nbased on cost, in these situations payers can be looking at a big\r\ncost later--somebody has to take care of them."\r\n<h2>Short-Term Spending=Long-Term Savings<\/h2>\r\nMuchnic points out the shortsightedness of insurance companies\r\nand Medicare\/Medicaid in being reluctant to pay the cost of\r\nprostheses and prosthetic care that can prevent much costlier\r\noutlays of funds down the road. He notes the lack of logic in that\r\npayers will not blink at a $20,000-$50,000 cost of hospitalization\r\nfor hip or knee replacement, but will be reluctant to pay for two\r\nstarter prostheses for a bilateral amputee at $10,000. "However, if\r\nthe $10,000 is for physical therapy or cancer chemotherapy\r\n(therapeutic agents), no one questions it." So, compared with the\r\ncost of treating many other diseases and conditions, prosthetic\r\ncare is a highly cost-effective way to return people to\r\nproductivity, function, and quality of life, he asserts.\r\n\r\nMuchnic believes that working with highly qualified\r\nprofessionals is worth the cost. At Kaiser Permanente, he uses\r\nthree private prosthetic facilities. "Board-[American Board for\r\nCertification in Orthotics & Prosthetics]-certified\r\nprosthetists who are well-regarded in the community are worth their\r\nweight in gold." He points out that getting good people, even if\r\nthe initial cost is higher, saves money in the long run by\r\npreventing costlier medical problems from developing due to poor\r\ntreatment.\r\n<h2>Motivating Patients<\/h2>\r\nWhat else can healthcare professionals do to promote successful\r\nprosthetic outcomes? "We have to note if there's depression; we\r\nhave to motivate them--be a cheerleader," Carroll says. He points\r\nout that many older amputees suffering from depression or other\r\nemotional issues don't want to talk to a psychologist. In their\r\nera, seeing a psychologist implied a weakness and carried a\r\nstigma.\r\n\r\nExplaining Medicare functional levels can help, he continues.\r\nFor instance, he might tell an amputee, "Today you seem like a\r\nfunction level 2, but if you work hard with your therapist, you\r\nhave the potential to be a function level 3." He adds, "It's like\r\nholding a carrot in front of them: You're probably going to get a\r\nmuch better prosthesis if you work with the therapist.'" He tells\r\nthem, "Don't expect the therapist to do it--you have to do it! Your\r\ntherapist can only spend a certain amount of time, but you have 24\r\nhours a day you can be stretching and following your program."\r\n\r\nMotivation can be powerful. Carroll cites the example of an\r\namputee in Colorado who had lost interest in life and even seemed\r\nto be dying. "Then she had one granddaughter and then another one.\r\nNow she is happy and excited, doing things with her granddaughters,\r\ntaking them to dance classes, etc. She says that now she's too busy\r\nto be sick."\r\n\r\nGetting amputees together in a group for mutual peer support is\r\nvery important, Muchnic believes. "Also, we need to be their\r\nadvocate with insurance companies and federal and state payers. For\r\ninstance, we need to point out that providing a $600 liner or other\r\nequipment might prevent a hospital stay costing $5,000 or better."\r\nHe feels the physician, who he believes is best to head the rehab\r\nteam, should take on the advocate role. "We can be more equal with\r\nthe administrators; we carry more weight when we say, We need\r\nthis,' and point out that the cost, for instance, may be less than\r\ntwo dialysis treatments."\r\n\r\nTo sum up, these factors contribute to success:\r\n<ol>\r\n \t<li>a clinical team approach;<\/li>\r\n \t<li>taking into consideration the amputee's overall health and\r\nmedical issues when deciding on a course of prosthetic\r\nmanagement;<\/li>\r\n \t<li>beginning rehab as early as possible following amputation, if\r\ncircumstances permit and not contraindicated;<\/li>\r\n \t<li>follow-up, including addressing problems promptly;<\/li>\r\n \t<li>adequate physical therapy; and<\/li>\r\n \t<li>motivating and advocating for patients.<\/li>\r\n<\/ol>\r\n"I'd like to go on being 35 for a long time," former British\r\nPrime Minister Margaret Thatcher once said. Although that may not\r\nbe possible, with skilled, well-planned rehab care, older amputees\r\ncan enjoy many additional years of enhanced quality of life.