Functional Considerations for Prosthetic Candidacy

Lisa U. Pascual, MD Assistant Clinical Professor Department of Orthopaedic Surgery University of California, San Francisco
October 29, 2010

Will My Patient Be Able to Walk?

(And What Should I tell Her to Expect?)

What do I Tell My Patient?

65 yo M, now s/p R transfemoral amputation DM, HTN, ESRD, CAD, h/o mi, h/o previous transtibial amputation on same side Wheelchair bound for short distances on level surfaces Transfers with assist Limited ambulation prior to recent surgery as had difficulty with ulcer to RLE

Objectives
To be able to understand the impact of: Premorbid Medical Concerns
Comorbidities Age Psychosocial Concerns

Premorbid Functional Status

Gait Energy Expenditure

The Interdisciplinary Team

When am I getting a prosthesis?

Assumes when, not if. Is the patient a prosthetic candidate?

Prosthetic Candidacy: Premorbid Medical Concerns

Comorbidities Age Psychosocial Status

Prosthetic Candidacy
Premorbid Medical Concerns Comorbidities Age Psychosocial Status Premorbid Functional Considerations Energy Expenditure Functional Abilities

Prosthetic Candidacy: Premorbid Medical Concerns

Comorbidities: (598 arteriosclerotic amputees) Ischemic Heart Disease, or Hemiplegia, or Bronchitis, or Bilateral amputation Performed worse at 12 months than amputees without these diseases in the Walking Ability Index

Prosthetic Candidacy: Premorbid Medical Concerns

Comorbidities:

Severe Cardiopulmonary Disease

May be a major consideration for withholding prosthetic use given the energy expenditure required for ambulation

Compromise of the Contralateral Foot

Relative contraindication

Prosthetic Candidacy: Premorbid Medical Concerns

Comorbidities:

Dialysis (N=19 with ESRD + 19 without) Previously shown to perform worse than those without Similar outcomes for dysvascular amputees with ESRD compared to those without
Successful prosthetic ambulators Cost of total length of hospital stay (acute + rehabilitation) Mortality

Comorbities higher for ESRD

Czyrny et al, Am J Phys Med Rehabil. 1994 Sep-Oct;73(5):353-7.

Prosthetic Candidacy: Premorbid Medical Concerns

Comorbidities: 434 with major lower limb amputation due to Peripheral Arterial Disease
Prosthetic use Maintenance of ambulation Survival Maintenance of independent living status

American Surgeon, 2006.

Prosthetic Candidacy: Premorbid Medical Concerns

Comorbidities:

Obesity: No correlation between outcomes for overweight patients vs. normal patients BMI failed to correlate with functional outcome Of note, looked specifically at PAD, excluded amputations d/t DM

Prosthetic Candidacy: Premorbid Medical Concerns

Comorbidities: Compliance is a significant criteria for successful prosthetic use
Muellar, et al. Physical Therapy, 1985.

Prosthetic Candidacy: Premorbid Medical Concerns

Age: Fit Trends Throughout the Years

25 yrs + ago, more transfemoral amputations were being performed in older dysvascular patient to ensure healing 1959: 55.3% of major lower extremity amputees were fit with prostheses, only 2-3% were elderly (Chapman, et al. 1959)

Prosthetic Candidacy: Premorbid Medical Concerns

Age: Fit Trends

Potential contraindications: Cognitive dysfunction (learning and training) Severe neurologic impairment (CVA, Parkinsons) COPD, CHF, Angina limiting exercise tolerance Irreducible knee and hip contractures FU Study: Concurrent medical disease or mental deterioration

Steinberg, et al. J Am Geriatr Soc, 1974. Steinberg, et al. Arch Phys Med Rehab, 1985

Prosthetic Candidacy: Premorbid Medical Concerns

Age: Fit Trends Throughout the Years

More recently, less transfemoral amputations, more transtibial amputations Higher success rates with rehabilitation of elderly amputees
73% of elderly were fitted and met their rehabilitation goals, comparing favorably with other age groups (Harris, et al. J Cardiovasc Surg, 1991.) 1846 amputees (majority being elderly dysvascular), > 80% were successfully fitted with prostheses (Stewart, et al. Prosthet Orthot Int, 1993.)

Prosthetic Candidacy: Premorbid Medical Concerns

Age Wanted to determine the rate of successful prosthetic fit in geriatric amputees and determine predictors Looked at all pts with amputees, including those who were not referred for fitting Success rates for those selected for fit were high Success rates from other studies may overestimate rate of successful fit

Prosthetic Candidacy: Premorbid Medical Concerns

Age Prior screening to referral to an amputee clinic may contribute to success of prosthetic fit Factors that adversely affected fit: increased age, cerebrovascular disease, dementia, transfemoral amputation

Prosthetic Candidacy: Premorbid Medical Concerns

Age Mobility rates one year after prosthetic provision for unilateral transtibial amputations, transfemoral amputations worsen with increasing age at amputation and a higher level of amputation 25% of transfemoral amputations in this study >50 yo achieved community mobility and this figure decreased with advancing age
Prosthetics and Orthotic International, 2003.

Prosthetic Candidacy: Premorbid Medical Concerns

Retrospective analysis of 553 consecutive major lower limb amputation patients

Southern Association for Vascular Surgery, 2005.

Prosthetic Candidacy: Premorbid Medical Concerns

Poorer Outcome

Limited preoperative ambulatory ability Age > or = 70 Dementia ESRD Advanced CAD

Prosthetic Candidacy: Premorbid Medical Concerns

309 consecutive pts s/p transtibial amputation Successful: Wound healing without revision Ambulate with prosthesis > 1 year or until death Survival > 6 months

Prosthetic Candidacy: Premorbid Medical Concerns

Predictors of Decreased Outcome

CAD Cerebrovascular Disease Impaired ambulation prior to transtibial amputation

Prosthetic Candidacy: Premorbid Medical Concerns

Age

Age alone is not a contraindication for prosthetic use, careful consideration of other factors is needed

Prosthetic Candidacy: Premorbid Medical Concerns

Psychosocial Concerns

Varied results/different populations: Return to home varied 20-80% Helm et al, 1986:
Age was associated unfavorably with functional capacity and postoperative outcome Post operative pain was associated with reduced functional ability but not social dependence Decrease in need for help at home post amputation for some amputees
Cutson, et al. 1996. J of American Geriatrics Society: Rehabilitation of the Older Lower Limb Amputee: A Brief Review

Prosthetic Candidacy: Premorbid Medical Concerns

Psychosocial Concerns

Varied results/different populations: Weiss et al, 1990: 29% noted improved health due to less pain post amputation; 25% noted worse health which correlated with decreased ADLs Decrease in quality of life the higher the amputation

Cutson, et al. 1996. J of American Geriatrics Society: Rehabilitation of the Older Lower Limb Amputee: A Brief Review

Prosthetic Candidacy: Premorbid Medical Concerns

Psychosocial Concerns Limited or lack of studies on:
Quality of Life Social network and other environment factors
Although re-operation and social dependency appears to negatively affect outcome

Prosthetic Candidacy: Premorbid Medical Concerns

Morbidity and Mortality: Dysvascular Amputees

15-20% risk of losing contralateral limb 2 years post amputation

Risk increases to 40% at 4 years

5 year survival for lower limb dysvascular amputees averages 30-40% overall Patients with diabetes vs. peripheral vascular disease:
Shorter survival Related to level of amputation

Survival: transtibial amputation > transfemoral amputation (presumably due to more widespread involvement)

Prosthetic Candidacy: Premorbid Medical Concerns

In summary: Adequate data still not available to: Reliably identify all predictors of outcome Look at predictive factors when series include combinations of amputations due to trauma with dysvascular causes (pooled populations) Look at unselected populations

Prosthetic Candidacy: Premorbid Functional Status

It appears that mobility prior to amputation is important in terms of outcome. Why is that? Does it the level of amputation also make a difference? Why is that?

Prosthetic Candidacy: Gait

Prosthetic Candidacy: Gait

Documented kinematics of gait

Prosthetic Candidacy: Gait

Prosthetic Candidacy: Energy Expenditure

Energy Cost of Ambulation Increase (%) No prosthesis, with crutches 50 Unilateral BK with prosthesis 9-28 Unilateral AK with prosthesis 40-65 Bilateral BK with prosthesis 41-100 BK plus AK with prosthesis 75 Bilateral AK with prosthesis 280 Unilateral hip disarticulation with prosthesis 82 Hemipelvectomy with prosthesis 125

MET 4.5 3.3-3.8 4.2-5.8 4.2-6.0 5.3 11.4 5.5 6.75

Normal Gait: 3 METs Waters, Perry, et al. 1976

Prosthetic Candidacy: Energy Expenditure

Correlation of Energy Cost of Ambulation According to Level of Amputation with Estimated Work Capacity According to Cardiac Functional Class Cardiac Class MET Amputee Ambulation MET Class IV <2 ----Class III <2 to <5 Wheelchair 2.0-3.0 Unilateral BK with prosthesis 3.3-3.8 Class II >5 to <7 No prosthesis with crutches 4.5 Unilateral AK with prosthesis 4.2-5.0 Bilateral AK with prosthesis 4.2-6.0 BK plus AK with prosthesis 5.3 Hip disarticulation with 5.5 prosthesis Hemipelvectomy with 6.75 prosthesis Class I >7 Bilateral AK with prosthesis 11.4

Normal Ambulation: 3 METS Cardiac Class I: no limitation; II: sl limitation; III: marked limitation; IV: physical activitydiscomfort; may haveangina at rest DeLisa, PM&R Principles and Practice.

Prosthetic Candidacy: Premorbid Functional Status

Unilateral leg stance significant predictor of functional outcome Memory most important mental predictor for function

Prosthetic Candidacy: Premorbid Functional Status

Possible factors: Low number of comorbidities Strong motivation to walk Ability for one leg stance Level of physical fitness as measured by maximal oxygen consumption after amputation
J Int Med Res, 2009.

Prosthetic Candidacy: Premorbid Functional Status

Functional Independence Measure (FIM) as a predictor of functional outcome:

Muecke et al,1992:
FIM scores: poor predictor in pts with lowest function FIM scores: in higher functioning amputees on admission appeared predictive of rehabilitation success

Leung et al, 1996:

FIM not useful as a predictor of outcome Only motor subscore at discharge correlated with use of a prosthesis

Prosthetic Candidacy: Premorbid Functional Status

Gailey et al, 2002.

Amputee Mobility Predictor: designed to measure an amputees functional capacities and predict ability to ambulate with a prosthesis Can be performed with or without a prosthesis Looks at sitting, transfers, sit to stand, standing balance, gait activities Can be performed with and without a prosthesis Can assist in assigning an Medicare Functional Classification Level (MFCL)

Managing Expectations
What kind of prosthesis am I going to get?

Dependent of premorbid level of functioning The prosthesis that is on TV may not be the appropriate one for them

Managing Expectations
Goals of Prosthetic Prescription: To provide the amputee with the ability to return to participating in activities that are important to them in society To provide a prosthesis that is appropriate for their level of activity, ability and weight

Managing Expectations
Energy Storing Feet: Highly subjective satisfaction rates Limited biomechanical evidence of significant benefit Trends suggest increased walking speed, greater stride length, slight decrease in metabolic expenditure at high speeds with energy storing feet, but there is no superiority for level walking

Managing Expectations
Medicare Functional Classification Levels
K0 K Levels Does not have the ability or potential to ambulate or transfer safely with or without assistance and a prosthesis does not enhance the quality of life or mobility. Has the ability or potential to use a prosthesis for transfers or ambulation on levels surfaces at fixed cadence. Typical of the limited and unlimited household ambulator. Has the ability or potential for ambulation with the ability to traverse low level environmental barriers such as curbs, stairs, or uneven surfaces. Typical of the limited community ambulator. Has the ability or potential for ambulation with variable cadence. Typical of the community ambulator who has the ability to traverse most environmental barriers and may have vocational, therapeutic, or exercise activity that demands prosthetic use beyond simple locomotion. Has the ability or potential for prosthetic ambulation that exceeds basic ambulation skill, exhibiting high impact, stress, or energy levels. Typical of the prosthetic demands of the child, active adult, or athlete.

K1

K2

K3

K4

Managing Expectations
Microprocessor knees:

Controls postural stability Varies step cadence Enhances ability to walk on uneven surfaces

Managing Expectations

K Level Description Medicare-Covered Prosthesis K0 Nonambulatory None K Level Description Medicare-Covered Prosthesis K1 Constant-friction knee K0 Household ambulator Nonambulatory None K1 LimitedHousehold ambulator Constant-friction knee K2 community ambulator Constant-friction knee K2 Limited community ambulator Constant-friction knee K3 Fluid-control knee K3 Unlimited community ambulator Unlimited community ambulator Fluid-control knee K4 Very active Very active Fluid-control knee K4 Fluid-control knee Source: Region B Medicare Supplier Bulletin Source: Region B Medicare Supplier Bulletin
Source: Region B Medicare Supplier Bulletin

What do I Tell My Patient?

65 yo M, now s/p R transfemoral amputation DM, HTN, ESRD, CAD, h/o mi, h/o previous transtibial amputation on same side Wheelchair bound for short distances on level surfaces Transfers with assist Limited ambulation prior to recent surgery as had difficulty with ulcer to RLE

It Takes a Village: The Interdisciplinary Team

Key element for successful amputee care program Surgeon, Physiatrist Internist, Nurse, Prosthetist, Physical Therapist, Occupational Therapist, Social Worker, Nutritionist, Psychologist, Primary Care Peer Support, vocational rehabilitation, recreational activities

Physical Medicine and Rehabilitation (Physiatry): Role on the Interdisciplinary Team

A physiatrist may assist the team in determination of amputation level as it relates to function, especially when uncertainty exists Involve the physiatrist during the perioperative period Utilize the physiatrist during the post op period to assist in the prosthetic prescription Utilize the physiatrist when the amputee is in the community

Thank You