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The Challenge of Geriatric Dysvascular Amputee Rehabilitation
Researchers from the Mayo clinics MN recently published a retrospective, population based study about the rehabilitation of elderly, dysvascular amputees that should be required reading for everyone involved in amputee care. One of the authors, Karen Andrews MD, is an old friend and a superb rehab physician who is very knowledgeable about state-of-the-art prosthetic care. This paper is an excellent example of good basic research that this field needs so urgently, and it is as noteworthy for the questions it raises as for the answers it provides. [Trends in rehabilitation after amputation in geriatric patients with vascular disease: implications for future health resource allocation. Fletcher DD, Andrews, KL, Hallet JW, Butters MA, Rowland MS, Jacobsen, SJ. Archives of Physical Medicine and Rehabilitation 2002:83, 1389-93].
One of the shortcomings of our American traditions of individual freedom and information privacy is that these customs make it impossible to determine the answers to such fundamental questions as, "How many amputees are there in the United States and what are their characteristics?" Unlike countries having socialized medicine and federal health care for all citizens, we have no mechanism to correlate all the overlapping bits of data about amputees at every community hospital in this vast land. The Mayo researchers tried to work around this problem by studying all patients in a semi-rural Minnesota county that has only two major hospital systems where amputations can be performed. As they noted in their paper, the subjects were 100% Caucasion, so the results may not generalize universally. But, at least they tried to look at the entire universe of people who underwent major amputation procedures between 1956 and 1999 in this locale.
The subset of interest were only those who were over 65 years of age and required amputation due to peripheral arterial disease: the most difficult population to rehabilitate due to their many comorbities and general debilitation. Based on a chart review, they divided the subjects into a pre-1975 and a 1975 & later group. Many of the findings were not surprising, but supported general clinical impressions. For example, the group was generally elderly [median age 79], generally had heart disease [~75%], and many were diabetic [~50%]. Amputations in the earlier cohort were predominantly transfemoral [55%] while the later cohort were mostly transtibial levels [64%].
The incidence of major amputation increased until 1975, remained level until 1985, and then steadily declined until 1995. This favorable trend may be due to improved limb salvage by vascular bypasses and related medical therapies. During the same time span, the number of county citizens who were older than 65 doubled. But, the number of total amputations did not continue to increase, but remained essentially unchanged from 1985-1995 even though persons older than 85 had increased 500% since 1956. Figure 1 shows these data in two superimposed graphs.
Other findings were more counterintuitive. The median age at amputation did not increase, and there was no statistically significant difference in 30-day mortality between the two groups. Although median survival after amputation increased from 347 days to 559 days in the latter group, this was almost entirely due to the increase in the number of transtibial amputations and their longer survival rate. Successful fittings with a prosthesis all showed a slight trend towards improvement for each age and level, but it was not statistically significant for any patient segment. The overall rate of fitting improved from 26% to 36% but failed to reach statistical significance despite an n = 292 amputees. Not surprisingly, the percentage who used a prosthesis full time decreased with each decade of life. Overall, 47% of the elderly, dysvascular transtibial amputees were successfully fitted with an artificial limb along with 15% of the transfemoral amputees; these level-specific rates did not change significantly between the two groups. Figures 2 & 3, reproduced here, illustrate the success rates for transtibial and transfemoral fittings.
It is important to note that the "percentage successfully fitted" is based on the total universe of amputees. Individuals who were too sick, too debilitated, too confused, too depressed, or otherwise considered not to be candidates for prosthetic fitting are included in the calculations as "unsuccessful". So, if the typical CPO has a much higher personal success rate with his or her patients, the difference is one of perspective: we are only fitting plausible candidates. Because we don't usually see the "non-candidates", this population is essentially invisible to us. The Mayo study is noteworthy in that they deliberately included all amputees in their calculations, and avoided this inherent bias toward success.
These findings will have experts scratching their heads and searching for rational explanations for years to come, since they don't support our [wishful?] thinking that modern technological advancements inevitably enable the elderly to overcome the ravages of age and heart disease and amputation. In fact, they confirm the reality that every front line prosthetist struggles with every day: prosthetic rehabilitation of elderly people who are markedly dysvascular becomes progressively tougher with each decade after 60.
The authors draw a number of conclusions for the future that are supported by these data. It remains very difficult to rehabilitate a dysvascular amputee older than 85 with a prosthesis, particularly if they have lost their biological knee. This suggests a physiologic limit may exist that precludes prosthetic success regardless of the care received, and the comorbidities that are increasing in this population may be the root cause. If this physiologic threshold can be identified, it can serve as a preliminary screen to identify those patients at risk, and it may then be possible to develop therapies to raise the threshold and enable more of the very old dysvascular patients to regain the ability to walk.
Certainly, aggressive medical and surgical efforts to preserve the at-risk limb should continue, since the evidence shows that independence is easier to maintain with a less-than-perfect but essentially intact limb than with a prosthesis, at least for octogenarians. And, since the number of elderly US citizens is expected to double by 2030, the total number of amputees may increase too, although that actual increase will depend on whether or not the incidence continues to decline as precipitously as it did from 1985-1995 in this county.
There are many other pearls that can be teased out of this research, which was supported in part by funding from the National Institutes of Health. I would encourage all readers to contact your local medical library for a copy so you can study this excellent and thought-provoking paper.
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Algorithms for O&P
John,
I thought you might have some insight or be able to refer me to some algorithms specific to prosthetic and orthotic treatment plans. Specifically,
-have you seen any sort of algorithm for diabetic feet at risk for amputation,
- ne... read more
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Re: Algorithms for O&P
Hi Karl- Two great questions: requiring far more space than this email forum will permit. I'll add both to my list of potential topics for future Corners or publications. Short answers: the literature on the at-risk diabetic foot is pret... read more
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Caracteristicas del sistema Hidraulico MAUCH SNS y del sistema C - Leg.
Ciudad de México 20 de Marzo, 2003.
Estimado John Michael, CPO, FAAOP, FISPO:
Un estudiante en prótesis y ortésis desea conocer las características de los sistemas de rodilla hidraulico MAUCH SNS y del sistema de rodilla C - Leg. ¿Existen... read more
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Re: Caracteristicas del sistema Hidraulico MAUCH SNS y del sistema C - Leg.
The similarities and differences between the C-Leg and the Mauch SNS are too complicated for a complete review here, but I will highlight the major distinctions. As you know, the SNS offers yielding hydraulic stance control and hydraulic s... read more
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X Aniversario del Centro de Rehabilitación Integral en Queretaro, Mexico.
Ciudad de México 5 de Marzo, 2003.
Estimado John Michael, CPO, FAAOP, FISPO: le agradecemos nos permita anunciar que el Centro de Rehabilitación Integral para Minusvalidos del Aparato Locomotor en la ciudad mexicana de Queretaro, celebra e... read more
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Re: X Aniversario del Centro de Rehabilitación Integral en Queretaro, Mexico.
Congratulations to the Queretaro Center on their tenth anniversary! --John Michael CPO
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