Amputation rehabilitation and prosthetic restoration ...

DISABILITY AND REHABILITATION,

2004;

VOL.

26,

NO.

14/15, 831–836

Amputation rehabilitation and prosthetic restoration. From surgery to community reintegration ALBERTO ESQUENAZI*

Disabil Rehabil Downloaded from informahealthcare.com by University of Montreal on 11/17/10 For personal use only.

Department of Physical Medicine and Rehabilitation, Moss Rehab Regional Amputee Rehabilitation Centre, Philadelphia, USA

Abstract Purpose: The purpose of this review is to summarize the literature related to the advances that have taken place in the management and rehabilitation care of limb amputation. Results: Prostheses for the lower and upper limb amputee have changed greatly over the past several years, with advances in components, socket fabrication and fitting techniques, suspension systems and sources of power and electronic controls. Higher levels of limb amputation can now be fitted with functional prostheses, which allow more patients to achieve independent life styles. This is of particular importance for the multi-limb amputee. The rehabilitation of more traditional lower limb levels of amputation have also greatly benefited from the technological advances including energy storing feet, electronic control hydraulic knees, ankle rotators and shock absorbers to mention a few. For the upper limb amputee, myoelectric and proportional controlled terminal devices and elbow joints are now used routinely in some rehabilitation facilities. Experimental prosthetic fitting techniques and devices such as the use of osseo-implantation for suspension of the prosthesis, tension control hands or electromagnetic fluids for knee movement control will also be briefly discussed in this paper. Conclusion: It is possible to conclude from this review that many advances have occurred that have greatly impacted the functional outcomes of patients with limb amputation.

Introduction The exact number of people who have had amputations worldwide is difficult to ascertain, as many countries do not keep records of the number of people with limb amputation. Based on information available from the National Center for Health Statistics there are * Author for correspondence; Chair, Department of Physical Medicine and Rehabilitation and Director, Moss Rehab Regional Amputee Rehabilitation Centre. Philadelphia, Pennsylvania, USA. e-mail [email protected]

approximately 50 000 new amputations every year in the USA.1, 2 Extrapolating data from this and other health statistics data available from Europe,3, 4 Asia5 and various countries around the world6 one can determine that the major causes of amputation in order of incidence are trauma, including war related injuries, diseases and congenital limb deficiencies. The causes of amputation vary from country to country.1 – 4 In the developing world, trauma is the leading cause of amputation caused by inadequately treated fractures, motor vehicle accidents (motorcycle and train) and other motorized machinery. In countries with recent history of warfare or civil unrest, trauma can account for up to 80% of all amputations. In developed nations, vascular complications of diabetes are the principal cause of amputations, which, can be aggravated by the use of tobacco. The major diseases that contribute to amputation are atero-occlusive vascular disease, diabetes mellitus and tumor.7, 8 In developed countries like the United States, Denmark and Japan, disease accounts for 68% of all amputations performed each year.1, 2 Trauma related amputations usually occur as a result of motor vehicle, industrial or farming accidents and may account for approximately 30% of new limb amputations. Estimates indicate that there are 135 million people with diabetes around the world and this number will continue to grow rapidly with changes in dietary habits.5, 6. Unless appropriate educational and preventative measures are taken, a further increase in the incidence of limb amputation is likely to occur. Congenital limb deformities account for a small portion of reported limb amputations (up to 3% of reported limb losses).7 The worldwide statistics on amputations by age are very difficult to obtain. In general those individuals with

Disability and Rehabilitation ISSN 0963–8288 print/ISSN 1464–5165 online # 2004 Taylor & Francis Ltd http://www.tandf.co.uk/journals DOI: 10.1080/09638280410001708850


A. Esquenazi limb loss due to disease are older with the amputation occurring after age 60.8 Traumatic amputations occur in a much younger, active and economically productive population. Because of the high number of trauma related amputations and preferential use of tobacco by men, this gender has a higher incidence of limb amputation. Because of the etiology of amputation related to medical co-morbidities more lower limb than upper limb amputations are performed with a ratio of almost 5 to 1. Transtibial level accounts for 39%, transfemoral level 31%, transradial level for 15% and transhumeral level for 8% of all amputations. Hip and shoulder disarticulation, through knee and through elbow and wrist level account for the remaining (see figure 1). For the upper limb the right arm is more frequently involved in work related injuries. Sixty per cent of arm amputees are between the ages of 21 and 64 years and 10% are under 21 years of age.8 Congenital upper limb deficiency has an incidence of approximately 4.1 per 10 000 live births.7 With regard to phases of amputee rehabilitation (see table 1), each of these phases contains specific evaluation items, treatment goals and objectives. Optimal rehabilitation care of the amputee begins, if feasible, prior to the amputation and should be provided by a specialized treatment team. Communication between the members of the team and with the patient and family members is essential and should provide the team with the necessary information to develop a treatment plan from amputation to home discharge. The team should tell the patient what to expect after surgery and rehabilitation taking into account physical status, level of amputation, cognition, premorbid lifestyle and socioeconomic level and prepare the patient with realistic short and long term expectations. The viability of the soft tissues and skin coverage with adequate sensation will usually determine the most distal possible functional level for amputation, whenever possible amputation at the transtibial and transradial

Figure 1

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Incidence of limb amputation by level.

level is preferred. Preserving length of the residual limb to improve prosthetic suspension and force transmission from the residual limb to the socket is a principal responsibility and goal of the surgeon. The residual limb must be surgically constructed with care to optimize the intimacy of fit, maintain muscle balance, and to allow it to assume the stresses necessary to meet its new function.9 Bony prominences, (see figure 2) skin scars, soft tissue traction, shear and perspiration can complicate this function.10 After surgery the patient with a limb amputation should ideally be able to use a prosthesis, be it body or externally powered, during most of the day through a newly created man-machine interface (the socket/ residual limb).10 After limb amputation, fitting of the first prosthesis should be implemented as soon as possible after wound healing. Application of an immediate postoperative rigid dressing can expedite wound healing and maturation. Elastic bandages can also be used for this purpose as seen in figure 3. In the upper limb amputee, this is of particular importance, where there is a direct relationship between the time of fitting and long-term prosthetic use and a 1 – 6 months window of opportunity exists when there is a much greater rate of acceptance and functional integration of the artificial arm for the unilateral upper limb amputee.10, 11 Pain in amputation The pain perceived by the patient with an amputation can be divided into four possible categories. These are post-surgical pain, residual limb pain, prosthetic pain (caused most frequently by standing and ambulating with the prosthesis), and phantom pain (pain perceived as coming from the amputated body part). Each one of these pain categories is described as separate entities but overlap of the different types of pain may occur.12 Pain may originate from other regions in the body unrelated to the amputation and referred to the amputated limb. Such pain may be cardiogenic, neuropathic or radiculopathic in origin. Systemic diseases such as diabetes, ischemia or arthritis can also be the cause of the pain and should be ruled out prior to attempting treatment of the pain complaints. With a wide variety of pain sources and treatment options available, treatment of pain in the amputee must begin with accurate diagnosis. Once the nature of the patient’s pain has been clarified, appropriate interventions can proceed to allow the patient to function comfortably. More in depth discussion of the management of amputation related pain is beyond the scope of this paper. The reader is

Amputation rehabilitation and prosthetic restoration Table 1 Phases of amputee rehabilitation Phase

Hallmark

Preoperative Amputation Surgery/Reconstruction Acute Post surgical Pre prosthetic Prosthetic Prescription Prosthetic Training Community Integration

Assess body condition, patient education, surgical level discussion, postoperative prosthetic plans Length, myoplastic closure, soft tissue coverage, nerve, handling, rigid dressing Wound healing, pain control, proximal body motion, emotional support Shaping, shrinking, increase muscle strength, restore patient locus of control Team consensus on prosthetic prescription and fabrication Increase prosthetic wearing and functional utilization Resumption of roles in family and community activities. Emotional equilibrium and healthy coping strategies. Recreational activities. Assess and plan vocational activities for future. May need further education, training or job modification. Life long prosthetic, functional, medical assessment and emotional support

Vocational Rehabilitation Follow-up


Modified from Esquenazi and Meier.7

Figure 3 Transradial residual limb volume control with elastic bandages. Figure 2 Abnormal bone formation in the distal femur.

directed to other sources for further discussion of this topic.12 Prosthetic components Prosthetic limb choices have increased greatly over the past several years, with improvements in components, for the upper limb prosthetic terminal devices such as hooks and hands, wrist, electronic elbows and electric shoulders; for the lower limb energy storing, multiaxis feet, shock absorbers and rotators as well as computer controlled knee units. There has been improvement in the socket fabrication materials (carbon graphite or high temperature flexible thermoplastics) and fitting techniques (mini frame shoulder disarticulation sockets and ischial containment transfemoral sockets, etc.), suspension systems (silicone, osseo-integration, etc.), and power sources and electronic controls.13, 14 The

more traditional levels of amputation have greatly benefited from the technological advances including the incorporation of myoelectric and proportional controlled terminal devices and slip sensors. The higher levels of upper limb amputation such as the shoulder or hip disarticulation can now be fitted with functional prostheses, which allow more patients to achieve independent life styles. This is of particular importance for the individual with bilateral upper limb amputation, particularly those with very high levels of amputation.10, 15 Prosthetic prescription The prosthetic prescription should be carefully prepared to satisfy the needs and desires of the patient. A team approach to prescription writing should be used whenever possible in close communication with the patient. Appropriate training to be accomplished by a 833

A. Esquenazi specialized team of professionals should follow the provision of a prosthetic device and implemented again after new components are prescribed.15 The upper limb device prescription should have a terminal device, wrist, socket, suspension system and if appropriate an elbow mechanism. Selecting between body power, external power or passive components and their activation mode (myoelectric, switch or cable) should be predetermined.10, 15 Similarly for the lower limb device prescription should include a foot, pylon, socket, suspension system and if appropriate a knee mechanism.13, 14, 16


Terminal devices The human hand is a very complex anatomical and physiological structure that cannot be replaced or emulated with current prosthetic technology. The functional activities of the hand are extensive but can be grouped into non prehensile (touching, feeling, tapping, etc.) and prehensile activities (three-jaw, and lateral or key grip, power grip, hook grip and spherical grip). A variety of prosthetic terminal devices are available and include passive, body and external powered hooks and hands (see figure 4). Manipulators are used in less technologically developed environments. They all lack sensory feedback and have limited mobility and dexterity. Prosthetic hands provide a three-jaw chuck pinch and hooks provide the equivalent of lateral or tip pinch. Electric devices can have digital (on/off) or proportional (stronger signal = faster action) control systems.10 Slip control is a recently introduced technology that can increase prehension to prevent accidental dropping of objects.

Feet The human foot is a marvelous physiological structure that can generate significant power to support and propel the human body during walking. The complex anatomy responsible for this function cannot be fully reproduced with the current level of prosthetic technology. A variety of prosthetic feet are available and range from the simple SACH foot to the sophisticated energy storing and multiaxis function of some feet with multiple intermediate devices with many attributes.16 Feet are to be prescribed based on the functional needs of the patient with the intent to allow the highest feasible level of function. Prosthetic elbows The prosthetic elbows available in the treatment of the transhumeral amputee can be passive, body powered or externally powered. The mechanical elbows have a locking mechanism that is manually applied using the contralateral hand, the chin or the ipsilateral shoulder via a cable system. Electric elbows have an electromechanical brake (Utah or Boston Arms) or a switch controlled lock mechanism to maintain the selected position.10 Prosthetic knees The prosthetic knees available in the treatment of the transfemoral amputee can have a single axis or be polycentric. The most basic knee has a locking mechanism that is manually applied to provide knee stability in stance phase. Stability can also be provided through optimal application of the line of force, weight activated brake or a fluid control cylinder. Such knees include the single axis, four and seven bar knee joints. To control the displacement of the limb during the swing phase several options are also available and include friction, springs, and fluid resistance.14 Electronic controllers for the timing and amount of fluid resistance have become recently available (C-Leg) resulting in a less effortful and safer walking pattern (see figure 5). Sockets

Figure 4 External powered hand without cosmetic cover (Otto-Bock) and body powered voluntary opening hook (Hosmer/Dorrance). Reproduced with permission from the manufacturer.

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Old sockets were carved out of wood. With the development of high temperature rigid plastic materials such as polyester resin, sockets could be molded to have total contact with decreased weight and increased durability. Sockets are custom made by obtaining a negative impression of the residual limb (commonly a plaster of

Amputation rehabilitation and prosthetic restoration Community reintegration should include recreation activities and sports and when appropriate work or return to school as part of the rehabilitation program. These are essential characteristics of the successful rehabilitation program for the person with limb amputation.20 A well-integrated and experienced team can better achieve the goal of returning the patient to their highest functional level.15, 21

References


Figure 5 Electronic controlled C-Leg (Otto-Bock). Reproduced with permission from the manufacturer.

Paris wrap). More recently acrylic lamination, the use of carbon graphite and the introduction of flexible thermoplastics have permitted the design of sockets with windows lined with flexible materials that are even more adaptable, comfortable, lighter and durable. Alternative suspension systems such as the constant suction socket, the silicon sleeve and others are all useful in the appropriate clinical case.13, 17 Of recent introduction and considered experimental is the use of osseo-integration as means to suspend a prosthesis directly from the bone. It requires a titanium implant that is externalized and used to directly attach the prosthetic device without the need of a socket. This type of suspension system allows shorter residual limbs to be interfaced with prosthesis without the need of a socket.18, 19 Cosmetic covers The hand terminal device can be covered with a cosmetic glove. These cosmetic covers can range from of the shelf to custom made from a mirror image of the opposite hand. Covers for the leg may be as important and in addition of providing cosmetic appearance can provide water protection if desired. Conclusion Appropriate selection of componentry for prosthetic restoration of the amputee is an extremely important and challenging task in view of the variety and complexity of available prosthetic devices and the functional requirements of our patients. After prescription and fitting of the device, training is indispensable and should include prosthetic management and functional training with the goal of achieving community reintegration.

1 National Center for Health Statistics: US Department of Health and Human Services. Current Estimates From The National Health Interview Survey, 1994. 2 National Center for Chronic Disease Prevention and Health Promotion. Statistics: diabetes surveillance; non-traumatic lower extremity amputation. Washington, DC: Center for Disease Control, 1996. 3 Pernot HFM, Winnubst GM, Cluitmans JJ, DeWitte LP. Amputees in Limburg: Incidence, morbidity and mortality, prosthetic supply, care utilization and functional level after one year. Prosthetics and Orthotics International 2000; 24: 90 – 96. 4 Pohjolainen T, Alaranta H. Ten year survival of Finnish lower limb amputees. Prosthetics and Orthotics International 1998; 22: 10 – 16. 5 Ministry of Health Malaysia. Conference of 2nd National Health and Morbidity Survey: Diabetes Mellitus among adults age 30 years and above. Public Health Institute 1997; 9: 81 – 89. 6 Payne CB. Diabetes related lower limb amputation in Australia. The Medical Journal of Australia 2000; 173: 352 – 354. 7 Esquenazi A, Meier R. Rehabilitation in limb deficiency. 4. Limb amputation. Archives of Physical Medicine and Rehabilitation 1996; 77: S18 – S28. 8 Kay HW, Newman JD. Relative incidence of new amputations: Statistical comparisons of 6,000 new amputees. Orthot Prosthet 1975; 29: 3 – 16. 9 Gottachak F. Transfemoral amputation, biomechanics and surgery. Clinical Orthopedic and Related Research 1999; 361: 15 – 22. 10 Esquenazi A. Upper limb amputee rehabilitation and prosthetic restoration. In: RL Braddom (ed) Physical Medicine and Rehabilitation, 2nd edn. Philadelphia, PA: W.B. Saunders Co., 2000; 263 – 278. 11 Malone JM, Fleming LL, Roberson J, et al. Immediate, early, and late postsurgical management of upper-limb amputation. Journal of Rehabilitation Research and Development 1984; 21(1): 33 – 41. 12 Esquenazi A. Pain management post amputation. In: TN Monga, M Grabois (eds) Pain Management in Rehabilitation. New York, NY: Demos Medical Publishing, 2002; 191 – 202. 13 Leornard JA Jr, Meier RH III. Upper and lower extremity prosthesis. In: JA Delisa (ed) Rehabilitation Medicine Principles and Practice 3rd edition, Philadelphia: Lippincott-Raven, 1998; 669 – 698. 14 Michael J. Prosthetic knee mechanisms: PM&R. In: A Esquenazi (ed) PM&R State of the Art Reviews 1994; 8(1): 147 – 164. 15 Esquenazi A, Wikoff E, Lucas M. Amputation rehabilitation. In: M Grabois (ed) Physical Medicine and Rehabilitation – The Complete Approach. Blackwell Science, 2000; 1744 – 1760. 16 Esquenazi A, Torres MM. Prosthetic feet and ankle mechanisms. Physical Medicine and Rehabilitation Clinics of North America 1991; 2(2): 299 – 309. 17 Daly W. Upper extremity socket design options. Physical Medicine and Rehabilitation Clinics of North America 2000; 11(3): 627 – 638. 18 Bra˚nemark R, Bra˚nemark P-I, Rydevik B, Myers RR. Osseointegration in skeletal reconstruction and rehabilitation. Journal of Rehabilitation Research and Development 2001; 38(2): 175 – 181.

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19 Sullivan J, Uden M, Robinson KP, Sooriakumaran S. Rehabilitation of the trans-femoral amputee with an osseointegrated prosthesis: the United Kingdom experience. Prosthetics and Orthotics International 2003; 27: 114 – 120. 20 Esquenazi A, DiGiacomo R. Rehabilitation after Amputation. Journal of the American Podiatric Medical Association 2001; 91(1): 13 – 22.

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21 Treweek SP, Condie ME. Three measures of functional outcome for lower limb amputees: a retrospective view. Prosthetics and Orthotics International 1998; 22: 178 – 185.