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LIMB DEFICIENCY AND PROSTHETIC MANAGEMENT

Limb Deciency and Prosthetic Management. 2. Aging With Limb Loss

Katherine M. Flood, MD, Mark E. Huang, MD, Toni L. Roberts, DO, Paul F. Pasquina, MD, Virginia S. Nelson, MD, MPH, Phillip R. Bryant, DO
ABSTRACT. Flood KM, Huang ME, Roberts TL, Pasquina PF, Nelson VS, Bryant PR. Limb deciency and prosthetic management. 2. Aging with limb loss. Arch Phys Med Rehabil 2006;87(3 Suppl 1):S10-4. This self-directed learning module highlights the issues faced by people aging with limb loss. It is part of the study guide on limb deciency and vascular rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article specically focuses on the impact that limb loss has on health and physical function throughout the life span. Case examples are used to illustrate what effect limb loss in childhood or young adulthood has on the incidence and management of new impairments or disease processes commonly associated with aging. Overall Article Objective: To discuss the impact of earlylife limb loss on the incidence and management of physiologic and functional changes associated with aging. Key Words: Aging; Amputation; Articial limbs; Complications; Outcome assessment (health care); Rehabilitation. 2006 by the American Academy of Physical Medicine and Rehabilitation 2.1 Educational Activity: To describe the anticipated rehabilitation and prosthetic needs of a 14-year-old girl who sustains a traumatic transfemoral amputation.
1

trauma and 25% caused by neoplasm or other disease.2 There is a 2:1 male-to-female ratio of acquired amputation in the pediatric age group.1 Sixty percent of pediatric acquired amputations involve the lower limb, with transtibial being the most common level of limb loss. In order of incidence, transtibial is followed by transfemoral, transradial, and ankle disarticulation levels of limb loss.2 The most common etiologies of pediatric traumatic amputations in the United States are lawnmowers,1 farming equipment, and power tools, followed by vehicular collisions, gunshot wounds, explosions, railroad in-

N THE PEDIATRIC POPULATION, congenital limb loss is reported to outnumber acquired limb loss by a 2:1 ratio, I with 75% of pediatric acquired amputations being caused by

From the Physical Medicine and Rehabilitation Program, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA (Flood); Department of Physical Medicine and Rehabilitation, Rehabilitation Institute of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, IL (Huang); Physical Medicine and Rehabilitation Service, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT (Roberts); Physical Medicine and Rehabilitation Service, Walter Reed Army Medical Center, Washington, DC (Pasquina); Department of Physical Medicine and Rehabilitation, University of Michigan Medical School, Ann Arbor, MI (Nelson); and Good Shepherd Rehabilitation Hospitals, Allentown, PA (Bryant). No commercial party having a direct nancial interest in the results of the research supporting this article has or will confer a benet upon the author(s) or upon any organization with which the author(s) is/are associated. Reprint requests to Katherine M. Flood, MD, VA Pittsburgh Healthcare System, 132Y-A, University Drive C, Pittsburgh, PA 15240, e-mail: vze2zn62@verizon.net. 0003-9993/06/8703S-10536$32.00/0 doi:10.1016/j.apmr.2005.11.023

juries, household accidents, burns, and electric injuries.2 In children under the age of 10 years, power lawnmower injury is the most common cause of amputation.2 Immediate postoperative management of the pediatric patient includes control of pain, edema, and infection; promotion of healing; and prevention of deconditioning, muscle atrophy, and joint contracture. Immediate postsurgical tting of lowerlimb amputations is not recommended in young children because of the higher potential for wound dehiscence from nonadherence to weight-bearing restrictions.2 However, an adolescent, like an adult, may benet from immediate or early postoperative tting with a temporary prosthesis.3 Prosthetic tting should be delayed if the residual limb develops wound infection or skin breakdown. It may also be deferred if the residual limb requires secondary closure, repeated dbridement, or skin grafting.3 Appearance of the prosthetic device may be a primary concern for this 14-year-old girl. The most commonly prescribed socket is the ischial containment design. It is reportedly more functional for most active people with transfemoral amputations. Use of a exible socket design will also improve comfort and appearance. Initial use of an elastomeric liner with interlocking pin will allow the prosthesis to be suspended without the encumbrance of belts or straps. Full suction suspension should be considered when residual limb size and shape have stabilized. There are a wide range of prosthetic components to choose from for patients with transfemoral amputations. Variables to be considered in selecting components should include each patients anticipated activity level; preamputation vocational and avocational activities and interests; anticipated exposure of the device to moisture, dust, and repetitive stresses; body morphology; and access to prosthetic services for adjustments and repairs. Insurance coverage or other nancial resources must be considered when prescribing a prosthesis, particularly for those patients with nancial constraints. The characteristics, indications, advantages, and disadvantages of the various types of prosthetic components for transfemoral amputation are outlined in the 2001 Study Guide.4 This patient will benet from a knee unit that allows for variable cadences and will provide stance stability during initial gait training. Options may include a simple hydraulic knee, a simple pneumatic knee, or a microprocessor-controlled hydraulic or pneumatic knee unit. Considerations regarding the foot and ankle components should include the ability to accommodate uneven terrain, energy storage, and weight of the device. Options include a dynamic response or multiaxial foot. People who consistently walk on uneven terrain may prefer the multiaxial foot, whereas a track athlete may prefer the stability of a dynamic response foot. Ideally, the patient will have the opportunity to choose among cosmetic nishes. A reasonable initial prosthetic prescription for this patient would have 4 components: (1) a exible, ischial-containment socket; (2) a thin elastomeric liner with interlocking pin suspension; (3) a microprocessor-controlled hydraulic knee; and (4) a dynamic response foot.

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Continuation of preamputation interests and activities should be considered during prosthetic prescription. After the patient becomes procient with the initial prosthesis, consideration should be given to prescription of 1 or more special use devices such as a swim/shower leg or a prosthesis for specic sports activities (eg, one with a tibial rotation component for golng). The limitations of the microprocessor knee, including intolerance of dust or moisture, and its increased requirement for maintenance and repair should be carefully considered and communicated to the patient. Sports and recreational activities for people with limb deciencies were discussed in a previous Study Guide.5 An adolescent will typically require assessment and possible adjustment of prosthetic t and alignment every 3 to 4 months and replacement of prosthetic components approximately every 3 years.2 Fitting the initial socket with a thicker elastomeric liner may increase the life of the socket. Instead of remolding the socket as growth occurs, the thickness of the liner can be decreased. Replacing the pylons can lengthen a prosthesis that otherwise still ts and functions. Components such as knee and foot-ankle units can be incorporated into new prosthetic devices as the child grows or activity needs change. Loss of the knee joint, as in this patient, will result in approximately a 68% increase in total energy consumption per unit distance. To compensate for this increased energy demand, walking speed is proportionally reduced to achieve a rate of expenditure comparable to that of an unimpaired gait pattern.6 Maintaining physical activity is extremely important, not only to prevent weight gain and deconditioning but also to promote psychologic and emotional health.3 This patient is expected to ambulate without an assistive device and to become independent in prosthetic management, and she should be taught falling techniques that prevent injuries.7 A person with unilateral lower-limb loss is generally capable of driving a vehicle with automatic transmission that is adapted so that the intact limb (not the prosthesis) is used to operate the foot pedals.8 Vocational planning should consider physical limitations such as decreased standing tolerance, reduced ability to climb or descend stairs, and impaired balance. Literature regarding vocational satisfaction of people with limb loss is limited. Schoppen et al9 found that dissatisfaction among people with lower-limb loss correlated signicantly with higher comorbidity, lower mobility level, and the desire for more modications in the work place. However, in this same study, people with lowerlimb loss were, overall, more satised with their jobs than their coworkers without limb loss. Psychosocially, at 14 years of age, this female patient is developing emotional independence from her family. She is testing limits and autonomy and is deciding her future orientation and plans. Infants, toddlers, and younger children would be more dependent on family, both physically and emotionally. Although peer relations and acceptance are already important in middle (6 12y) childhood, this adolescent most likely will show an elevated degree of self-consciousness and be very concerned regarding her self-image in relation to her peers. The need to t in with her peers assumes a high, if not the highest, priority at this stage. She will have to integrate her limb loss and the prosthetic device into her identity. She may cope with her loss with denial, hyperactivity, and/or withdrawal. To work effectively with this young woman, the rehabilitation team must be aware of and respect her individuality, privacy needs, and condentiality. They must be open to discussion of her individual needs and concerns when the opportunity presents itself and must encourage or even require that she be involved in decisions about treatment and choice of prosthetic device(s), recognizing the priority of appearance as well as function.10 Reac-

tions of family and peers and the circumstances of the injury leading to the amputation must be considered. They will signicantly affect the emotional adjustment and rehabilitation outcome of any child sustaining limb loss. Support for re-entry into her social milieu may include education of her peers regarding the abilities and expectations of people with limb amputation. It should not be assumed that at age 14 the patient has already asked for and received adequate information about sexuality, sexual activity, and contraception. A survey of women with physical disabilities (primarily neurologic impairments) showed that adolescents who sustained disabling injury after the age of 14 years were less likely to request or be offered information regarding contraception. When information was received, women with onset of disability after the age of 14 years reported feeling that the information provided was neither adequate nor specic to their disability.11 A transfemoral amputation will not affect the patients ability to conceive and bear children. There is limited literature regarding pregnancy in women with transfemoral amputation; however, issues such as edema and change in body morphology during pregnancy may require prosthetic alterations or adjustments or even use of alternative mobility strategies (crutches, wheelchair). People with amputation at the hemipelvectomy level have been reported to successfully carry a pregnancy to term, but may require a custom support sling during pregnancy to replace the removed pelvic oor muscles and pelvis.12 Labor and delivery should not present any unique problems for a person with unilateral amputation, although there is a single case report of phantom limb pain during labor in a woman with transfemoral amputation.13 The vast majority of young transfemoral amputees will ambulate without assistive devices, so their ability to care for an infant will not be affected in this regard. However, childcare during the night, when the prosthesis is removed, may present challenges. A wheelchair to allow mobility while carrying an infant in the lap can be helpful. The Amputation Coalition of America provides educational resources for children, adolescents, and their parents as well as for adults concerned about amputations. There are also multiple links to peer groups and other organizations. The web address is http://www.amputee-coalition.org. 2.2 Educational Activity: To discuss the rehabilitation management of this patient when she is 55 years old and presents with contralateral knee and hip pain interfering with mobility.

There is evidence that physiologic changes occur with the normal aging process. Lean body mass usually decreases because of muscle atrophy and increased adiposity. There is a loss of bone density and changes occur in cardiac and renal function, hormonal regulation, and cerebral function. Changes in gait may include decrease in trunk and associated movement caused by degenerative arthritis, contractures, or neurologic impairments. Changes in step length, cadence, excursion of the leg during swing, swing-to-stance ratio, and maneuvers to increase the base of support may be associated with limitations of joint range of motion at the hips or knees, instability associated with neurologic disorders, limited vision, or fear of falling. Increased vertical displacement of the center of mass may be associated with muscle weakness resulting in knee and hip instability. These changes may result in a slower gait and increased energy cost of ambulation. Chronic diseases such as arthritis, impaired hearing and/or vision, diabetes, heart disease, and cognitive disorders become more common with aging
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and may also negatively affect functional mobility. People who have sustained limb loss in childhood or young adulthood experience aging effects superimposed on their existing impairments and disabilities.14 New impairments may be the consequence of prosthetic-related problems, new disease processes, or both. Onset of symptoms after a change in the design or alignment of the prosthesis may suggest gait alteration leading to new stresses on the contralateral limb. On the other hand, an insidious onset of symptoms without change in activities or prosthetic device may suggest that the primary problem lies in the symptomatic limb. Musculoskeletal disorders, such as osteoarthritis, tendinitis, bursitis, or occult fracture, usually present with localized ndings. Symptoms that resolve quickly with rest or sitting down may suggest vascular or neurogenic claudication. Specic myotomal weakness or dermatomal sensory impairment with or without back pain may suggest a radiculopathy. Once a differential diagnosis is developed, appropriate diagnostic testing can be planned and treatment initiated. In this case, the likely diagnosis is degenerative joint disease affecting the hip and/or knee. An increased prevalence of accelerated degenerative joint disease has been reported in people with transtibial or transfemoral amputations.15-18 Studies regarding management of osteoarthritis either in the remaining joints of the amputated limb or of the intact limb are sparse. Management should include careful assessment of the prosthetic limb and adjustment to minimize gait deviation and to unload the affected joints. Management may require an interdisciplinary approach and should include the following goals: improve or maintain joint range of motion; promote muscle strengthening and conditioning; minimize joint stress by the use of assistive or mobility devices; and address pain control. Weight control is an important but frequently neglected issue in the management of osteoarthritis of weight-bearing joints. There is some conict in the literature regarding a relation between traumatic amputation and obesity, but reports using U.S. populations show an increased incidence of obesity and increase in body fat in people sustaining lower limb loss. Rose et al19 reported that a population of 19 Vietnam veterans with bilateral above-knee amputations compared with a control group with unilateral below-elbow amputation had signicantly higher body weight and percentage of body fat. Ryder20 cites data indicating a clearly signicant increase in weight in people with lower-limb amputation, with a greater prevalence the more proximal the amputation. Joint replacement is commonly performed in people without limb loss for advanced osteoarthritis that is nonresponsive to less invasive measures. The literature regarding joint replacement in people with limb amputation is limited to case reports that indicate success with knee arthroplasty on both the amputated and intact sides.21 2.3 Educational Activity: To discuss the management of a 65-year-old man with previous transtibial amputation who undergoes transfemoral amputation on the contralateral side secondary to nonhealing of a diabetic foot ulcer.

The comorbidities associated with diabetes mellitus are discussed in section 4.2 of this Study Guide. In assessing the rehabilitation needs and potential of this patient, the following factors should be considered: limited activity tolerance because of underlying atherosclerotic heart disease (with symptomatic or silent ischemia); peripheral vascular disease and diabetic nephropathy; unstable residual limb volume because of uctuating weight, renal disease or congestive heart failure; impaired cognition or other neurologic decits because of cerebrovasArch Phys Med Rehabil Vol 87, Suppl 1, March 2006

cular disease; sensorimotor decits caused by peripheral nerve dysfunction; and visual impairment as a result of diabetic retinopathy or other ophthalmic disorders. The literature indicates that people with lower-limb amputations are at increased risk of cardiovascular disorders.18,19,22,23 A transfemoral amputation caused by vascular disease is reported to increase the metabolic cost of ambulation approximately 100% per unit of distance.6 The combination of a transtibial and transfemoral amputation is expected to have an additive effect with respect to energy cost and therefore will severely limit the potential for functional ambulation. Studies of the prosthetic outcome of major lower-limb loss are difcult to interpret and compare. There are few prospective studies where populations and the surgical and rehabilitative management of specic populations are well dened. Many outcome studies are limited only to patients who were referred for rehabilitation.24 A reported predictor of successful prosthetic outcome in people with 1 transfemoral and 1 transtibial amputation is prior successful ambulation with a transfemoral prosthesis.16 If prosthetic use and ambulation were limited by angina, exertional dyspnea, joint or spine pain, or other impairments before the transfemoral amputation, then functional ambulation with a second transfemoral prosthesis may not be a viable goal. Rehabilitation intervention will be directed toward alternative mobility and use of the transtibial prosthesis for transfers. This patient may not initially appreciate the challenges involved in using bilateral prostheses. Realistic goals should be established before considering prescription of a transfemoral prosthesis.25 Goals should focus on demonstration of adequate balance, upper- and lower-body muscle strength, joint range of motion, and aerobic capacity to meet the demands of using the prosthetic devices. Specic goals may include achieving independent transfer skills, manual wheelchair mobility and endurance, and arising and standing with upper-body support and partial weight bearing through the previously tted prosthesis. Even with this approach, it may be difcult to determine if the patient will be able to ambulate functionally with the prostheses. In this case, tting with a preparatory or temporary prosthesis may be appropriate. A population study by Fletcher et al26 identied age more than 64 years, dementia, and transfemoral amputation as negative predictive factors for successful prosthetic tting, whereas presence of a family member at home and marriage were reported as positive univariate predictors. In this study, only 14.5% of subjects undergoing unilateral transfemoral amputation caused by vascular disease were successfully tted with a permanent prosthesis. Of 6 subjects with transfemoral and transtibial amputations, only 1 was successfully tted with prosthetic limbs. Physiatric evaluation and intervention is valuable even for patients who are identied as inappropriate for prosthetic tting. The newly amputated residual limb should be monitored for wound healing, management of edema, and pain control. Early pain management may prevent the development of chronic pain syndromes.27,28 If the patient is nonambulatory, he may be able to use his transtibial prosthesis for transfers. He may need initial evaluation for an appropriate wheelchair or modications to an existing wheelchair to prevent skin breakdown and maintain proper sitting posture. He may require modications to his home to make it wheelchair accessible. He may require other adaptive equipment such as a hospital bed, bathroom equipment (eg, grab-bars, raised toilet seat), and other durable medical equipment. If the patient cannot achieve independence, caregivers will need training and support if the patient is to successfully return to his home and community.

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2.4

Educational Activity: To discuss the anticipated longterm rehabilitation needs and vocational implications for a 27-year-old male carpenter with a traumatic transhumeral amputation.

Dillingham et al29 reported that between 1988 and 1996, upper-limb amputations accounted for only 3% of all limb amputations but represented 68.6% of all traumatic amputations. Vascular disease and tumor accounted for 3% and 23% of all upper-limb amputations, respectively. Nearly three quarters of the traumatic upper-limb amputations were at the level of the nger (51.2%) or thumb (12.4%), whereas 3% were at the transradial level and 2% were at the transhumeral level. The remaining traumatic upper-limb losses included hand, wrist, through-elbow, shoulder, or forequarter amputations. There were 0.3% bilateral traumatic upper-limb amputations. Dillingham29 also reported that men were at higher risk for traumatic limb loss (upper vs lower limb not specied) in all age groups. Incidence of traumatic limb loss (upper vs lower limb not specied) increased steadily with age, reaching its highest level in those aged 85 years and older. Upper-limb prosthetic components and prescriptions were previously discussed in the 2001 Acquired Limb Deciencies Study Guide.4 Advances in prosthetic devices will be discussed in the focused review section of this Study Guide. Specialized prosthetic devices may facilitate the performance of a wide variety of bimanual activities. Childcare may require the use of a padded or soft terminal device for safety and comfort. Specic vocational or avocational activities may require taskspecic prosthetics components. A wide range of task-specic terminal devices are available for activities such as for bowling, golng, and shing. Hooks with custom-designed curves and pincers, which are useful for people engaged in farming tasks, carrying heavy loads, and so forth, are also available. People with upper-limb amputation may want 1 prosthetic device for social activities and a second prosthesis for functional or vocational activities. Prosthetic prescription must take into account all aspects of the patients life and it is unlikely that a single device will fulll all needs.30 Return to work as a carpenter may be possible but would most likely require signicant accommodations and specialized prosthetic devices. The loss of the elbow joint will further complicate accommodation and the patient may nd it more practical to retrain in an area not requiring as much bimanual dexterity. If he does return to carpentry or similar work, he would benet from having more than 1 prosthetic devicea work arm and a leisure or social arm. The work arm might have a laminated nish to withstand trauma and heavy use in the work place. If the work environment is dusty or if there is risk of exposure to moisture, externally powered components may be contraindicated. A rotational wrist unit with exion capability, a quick disconnect unit and multiple specialized terminal devices may be required in the workplace. On the other hand, in social situations the patient most likely will prefer a more cosmetically appealing device. He may wish to exclude the relatively heavy but adaptable wrist unit and opt for a simpler constant-frictiontype of device with a cosmetic hand. Pinzur et al31 reported that, in a series of 19 people with traumatic upper-limb amputation, 15 were employed at the time of the amputation. At an average of 52 months after amputation, 5 had returned to the same or similar job, 5 were employed in a job that required less manual dexterity, 1 was employed in a job that seemed to require more bimanual dexterity, and 4 were unemployed.31 Acceptance and use of upper-limb prosthetic devices are uniformly reported as less than of lower-limb prosthetic de-

vices. Also, the more proximal the amputation, the less likely a prosthetic device will be used. Introduction of the prosthetic device as soon as is feasible after amputation is believed to facilitate prosthetic acceptance and use, particularly in a patient with unilateral upper-limb amputation.32 Pinzur31 surveyed 19 people with traumatic upper-limb amputation, most of whom were tted with temporary, body-powered prostheses within 30 days of amputation. Functional prosthetic use was dened as wearing and using the prosthetic device at least 8 hours a day. At an average of 52 months after amputation, 9 of 10 people with amputation at the transradial level, 5 of 6 with amputation at the transhumeral level, and 1 of 2 with amputation at the shoulder disarticulation level reported themselves to be functional prosthetic users. One person with a shoulder disarticulation was lost to follow up. Even people with upper-limb amputations who report wearing a prosthetic device regularly may perform many activities single handed because it is more efcient or convenient. This may raise a concern that overuse and degenerative syndromes in the intact upper limb may lead to future increased impairment and disability. Jones and Davidson33 reported that 50% of people with upper-limb amputations had problems with the intact limb. Problems included an array of overuse syndromes such as epicondylitis, shoulder impingement, tenosynovitis, osteoarthritis, carpal tunnel syndrome, trigger nger, and other nonspecic problems. Only 3 of the 26 reported injury to the intact arm from the accident resulting in the amputation. Data showed a trend toward intact arm pain being more prevalent the more proximal the amputation.33
References 1. Letts M, Davidson D. Epidemiology and prevention of traumatic amputations in children. In: Herring JA, Birch JG, editors. The child with a limb deciency. Rosemont: American Academy of Orthopaedic Surgeons; 1998. p 235-80. 2. Bryant PR, Pandian G. Acquired limb deciencies. 1. Acquired limb deciencies in children and young adults. Arch Phys Med Rehabil 2001;82(3 Suppl 1):S3-8. 3. Folsom D, King T, Rubin JR. Lower-extremity amputation with immediate postoperative prosthetic placement. Am J Surg 1992; 164:320-2. 4. Huang ME, Levy CE, Webster JB. Acquired limb deciencies. 3. Prosthetic components, prescriptions, and indications [published erratum appears in Arch Phys Med Rehabil 2001;82:710]. Arch Phys Med Rehabil 2001;82(3 Suppl 1):S17-23. 5. Webster JB, Levy CE, Bryant PR, Prusakowski PE. Sports and recreation for persons with limb deciency. Arch Phys Med Rehabil 2001;82(3 Suppl 1):S38-44. 6. Czerniecki JM. Rehabilitation in limb deciency. 1. Gait and motion analysis. Arch Phys Med Rehabil 1996;77(3 Suppl):S3-8. 7. Esquenazi A, Meier RH. Rehabilitation in limb deciency. 4. Limb amputation. Arch Phys Med Rehabil 1996;77(3 Suppl):S18-23. 8. Wang CC, Kosinski CJ, Schwartzberg JG, Shanklin AV. Physicians guide to assessing and counseling older drivers. Washington (DC): National Highway Trafc Safety Administration; 2003. ch 9 8. Available at: http://www.ama-assn.org/ama/pub/category/10791. html. Accessed July 1, 2005. 9. Schoppen T, Boonstra A, Groothoff JW, De Vries J, Goeken LN, Eisma WH. Job satisfaction and health experience of people with a lower-limb amputation in comparison with healthy colleagues. Arch Phys Med Rehabil 2002;83:628-34. 10. Michael JW. Prosthetic considerations during the growth period. In: Murdoch G, Wilson AB Jr, editors. Amputation surgical practice and patient management. Oxford: ButterworthHeinemann; 1996. p 232-40.
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11. Neufeld JA, Klingbeil F, Bryen DN, Silverman B, Thomas A. Adolescent sexuality and disability. Phys Med Rehabil Clin N Am 2002;13:857-73. 12. Bergh PA, Bonamo J, Breen JL. Pregnancy after hemipelvectomy: a case report and review of the literature. Int J Gynaecol Obstet 1988;27:277-83. 13. Dureja GP, Sandhya. Phantom limb pain during labour. Anaesthesia 1992;42:1053-4. *14. Leonard JA Jr. The elderly amputee. In: Felsenthal G, Garrison SJ, Steinberg FU, editors. Rehabilitation of the aging and elderly patient. Baltimore: Williams & Wilkins; 1994. p 397-406. *15. Nolan L, Lees A. The functional demands on the intact limb during walking for active trans-femoral and trans-tibial amputees. Prosthet Orthot Int 2000;24:117-25. 16. Currie DM, Gershokoff AM, Cifu DX. Geriatric rehabilitation. 3. Mid- and late-life effects of early-life disabilities. Arch Phys Med Rehabil 1993;74(5 Suppl):S413-6. 17. Kulkarni J, Adams J, Thomas E, Silman A. Association between amputation, arthritis and osteopenia in British male war veterans with major lower limb amputations. Clin Rehabil 1998;12:34853. 18. Norvell DC, Czerniecki JM, Reiber GE, Maynard C, Pecoraro JA, Weiss NS. The prevalence of knee pain and symptomatic knee osteoarthritis among veteran traumatic amputees and nonamputees. Arch Phys Med Rehabil 2005;86:487-93. 19. Rose HG, Schweitzer P, Charoenkul V, Schwartz E. Cardiovascular disease risk factors in combat veterans after traumatic amputations. Arch Phys Med Rehabil 1987;68:20-3. *20. Ryder RA. Amputation of extremities and cardiovascular disease. Bull Prosthet Res 1979;16:21-9. *21. Pasquina PF, Dahl E. Total knee replacement in an amputee patient: a case report. Arch Phys Med Rehabil 2000;81:824-6. 22. Hrubec Z, Ryder RA. Report to the Veterans Administration Department of Medicine and Surgery on service-connected traumatic

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limb amputations and subsequent mortality from cardiovascular disease and other causes of death. Bull Prosthet Res 1979;16:29-53. Modan M, Peles E, Halkin H, et al. Increased cardiovascular disease mortality rates in traumatic amputees. Am J Cardiol 1998;82:1242-7. Johannesson A, Larsson GU, Oberg T. From major amputation to prosthetic outcome: a prospective study of 190 patients in a dened population. Prosthet Orthot Int 2004;28:9-21. Andrews KL. Rehabilitation in limb deciency. 3. The geriatric amputee. Arch Phys Med Rehabil 1996;77(3 Suppl):S14-7. Fletcher DD, Andrews KL, Butters MA, Jacobsen SJ, Rowland CM, Hallett JW Jr. Rehabilitation of the geriatric vascular amputee patients: a population-based study. Arch Phys Med Rehabil 2001;82:776-9. Dijkstra PU, Geertzen JH, Stewart R, van der Schans CP. Phantom pain and risk factors: a multivariate analysis. J Pain Symptom Manage 2002;24:578-85. Ephraim P, Dillingham T, Sector M, MacKenzie E. A review of pre-operative management of phantom limb pain. Available at: http://www.amputee-coalition.org/llrsp_review_articles/llrsp_review_ articles.html. Accessed July 1, 2005. Dillingham TR, Pezzin LE, MacKenzie EJ. Limb amputation and limb deciency: epidemiology and recent trends in the United States. South Med J 2002;95:875-83. Fryer CM, Stark GE Jr, Michael JW. Body-powered components. In: Smith DG, Michael JW, Bowker JH, editors. Atlas of amputations and limb deciencies: surgical, prosthetic and rehabilitation principles. 3rd ed. Rosemont: American Academy of Orthopaedic Surgeons; 2004: p 117-30. Pinzur MS, Angelats J, Light TR, Izuierdo R, Pluth T. Functional outcome following traumatic upper limb amputation and prosthetic limb tting. J Hand Surg [Am] 1994;19:836-9. Sturup J, Thyregod HC, Jensen JS, et al. Traumatic amputation of the upper limb: the use of body-powered prostheses and employment consequences. Prosthet Orthot Int 1988;12:50-2. Jones LE, Davidson JH. Save that arm: a study of problems in the remaining arm of unilateral upper limb amputees. Prosthet Orthot Int 1999;23:55-8.

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