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PubMed1989

Hemiplegia and amputation: rehabilitation in the dual disability.

About 10% of all elderly dysvascular amputees have had cerebrovascular accidents at some time. This is an often overlooked but important fact which significantly impacts the outcomes of their rehabilitation, especially where prosthetic ambulation is attempted. This study reviews the rehabilitation outcomes of 46 patients with the dual disability of hemiplegia and amputation. The mean age of the patients was 63 years (range 49 to 84). Forty-one (89%) could participate in a trial of physical therapy, and 25 (54%) in a comprehensive rehabilitation program. Seventeen (37%) were fitted with a prosthesis, and 12 (26%) became independent ambulators. Eighteen (39%) achieved independence in their activities of daily living (ADL) and transfers. Patients were reviewed to establish those features predictive of a good outcome. The following factors were associated with regaining independent ambulation: the presence of a mild hemiparesis with residual hand function (p less than 0.001), a below-knee amputation (p less than 0.01), and a history of ambulation before the second disability (p = 0.05). The ADL independence was associated with a mild hemiparesis (p less than 0.001), and age less than 60 years (p less than 0.05). Incontinence of bowel or bladder was strongly predictive of failure to achieve independence in either ADL or ambulation (p less than 0.001). Of those patients who did achieve independent ambulation, 73% were still ambulating a mean of 16.5 months later. These findings should be considered when planning rehabilitation goals for patients with the dual disability of hemiplegia and amputation.

Activities of Daily Living↗
PubMed1992

Exercise testing and training of persons with dysvascular amputation: safety and efficacy of arm ergometry.

Recent studies indicate that most persons with dysvascular amputation also have moderate to severe cardiovascular disease with impairment in functional capacity. This may limit the ability to achieve optimal function with their prosthesis because of inadequate conditioning. We developed an exercise testing and training program using arm ergometry in conjunction with standard rehabilitation for persons with acute dysvascular amputation who were profoundly deconditioned after complicated perioperative courses. The program consisted of daily arm ergometry, performed on an interval basis, at an intensity individually optimized through exercise testing. Twenty-five patients, with a mean age of 63 years, completed the inpatient program with pretest and discharge work performance assessment. There was no significant difference between pretest and discharge assessment of baseline or peak heart rate, systolic blood pressure, diastolic blood pressure, or Borg rating of perceived exertion. Peak systolic blood pressure was elevated at discharge compared to admission testing (p less than .04). Heart rate responses were decreased during the early stages of testing when comparing discharge telemetry to admission findings. The duration of exercise increased from 12.6 minutes to 16.3 minutes (p less than .0004), and the maximum work output increased from 17.1 watts to 23.5 watts (p less than .0004). There was no significant morbidity associated with either arm ergometry testing or the exercise program. We conclude that arm ergometry testing and training is a safe and effective method for improving the efficiency of arm work in the patient with acute dysvascular amputation.

Aged↗
PubMed1993

Prosthetic profile of people with lower extremity amputation: conception and design of a follow-up questionnaire.

A questionnaire, the Prosthetic Profile of the Amputee (PPA), is described both in terms of its conceptualization and design. The objectives of the questionnaire (mail and telephone versions) were to evaluate and to determine the factors potentially related to prosthetic use by a person with a lower extremity amputation after discharge from rehabilitation. The PRECEDE theoretical model (Predisposing Reinforcing and Enabling Causes in Educational Diagnosis and Evaluation) was adapted to the present study and served as a guide for the conceptual basis of the instrument. A multidisciplinary group of 13 experts and another group of eight persons with lower limb amputation were involved in the identification, classification, and priority rating of the factors related to prosthetic use. The design of the questionnaire was structured according to Dillman's Total Design Method. To ensure the content validity of the instrument, the pertinence of each question with regard to the questionnaire's objectives was assessed by the group of experts. Pretesting of the questionnaire was then conducted with a random sample of 26 people with lower extremity amputations. The preliminary version of the instrument has already demonstrated the potential for clinical and research use.

Activities of Daily Living↗
PubMed1981

Functional reorganization of adult raccoon somatosensory cerebral cortex following neonatal digit amputation.

Amputation of a forepaw digit in raccoons 2-8 weeks of age produced dramatic changes in the functional organization of somatosensory cortex examined electrophysiologically 9-12 months later. The cortical region normally representing the digit that was amputated received widely overlapping input from the entire forepaw, with local disruption of somatotopic organization. Compared with normal animals, the receptive fields of cortical neurons in amputated animals were larger, often included both glabrous and hairy skin, sometimes involved discontinuous skin regions, and were much more variable in peripheral location as a function of recording distance across the cortex and of depth within the cortex.

Aging↗
PubMed1986

Corticospinal neurons 25 weeks after right hind limb amputation.

Neuronal cell death in embryos and adult animals is seen after removal of target tissue. Transsynaptic cell death has been described in the mammalian visual system and suggested as a possible mechanism for loss of upper motor neurons in amyotrophic lateral sclerosis. We previously demonstrated that amputation of a hind limb decreased the number of motor neurons in the rat spinal cord. Careful counts of corticospinal neurons in these rats 25 weeks after amputation failed to demonstrate any loss of corticospinal neurons. Although amputation caused a loss of ventral horn neurons, no subsequent loss of upper motor neurons was detected at 25 weeks.

Amputation, Surgical↗
PubMed1986

Axon and neuron numbers after forelimb amputation in neonatal rats.

It seems a paradox that more primary sensory neurons are lost but recovery is better after peripheral nerve injury in neonates as compared to adult mammals. A possible explanation is that surviving neurons sprout in the neonate. To test this, forelimbs in neonatal rats were amputated, which caused the death of many primary sensory neurons. The number of neurons in the dorsal root ganglia, and the number of myelinated and unmyelinated fibers in the dorsal and ventral roots were determined on the amputated and contralateral normal sides. On the amputated side, soma loss in the ganglia was 30%, and the fiber numbers were decreased by 16% in the dorsal root and increased by 20% in the ventral root. These data are compatible with the hypothesis that there is axonal branching or sprouting from surviving sensory neurons. In addition, morphometric analyses showed a changed myelin-axon relationship for central processes of sensory cells whose distal processes have been cut.

Amputation, Surgical↗
PubMed1989

How successful is below-knee amputation for injury?

This study analyses how successfully young adults rehabilitate after below-knee amputation for injury. Twenty-five patients referred to Bristol Artificial Limb and Appliance Centre and aged under 45 years at the time of amputation were investigated 2-12 years after operation by a review of their records, a questionnaire and, in a few cases, by interview. Most did extremely well. All without serious disabilities were able to work, most requiring little or no sick leave because of their amputations. Prostheses were worn by 84 per cent of patients for more than 13 h a day and only 32 per cent had left them off for more than 4 days in the previous 12 months. One mile could be walked by 72 per cent, nearly all (84 per cent) drove cars, and the majority could use public transport with relative ease. Of the patients 84 per cent regarded themselves as only slightly or not at all disabled. However, it takes about 1 year to reach this satisfactory 'present state' and 72 per cent remain troubled by phantom limb or stump pain.

Activities of Daily Living↗
PubMed1992

Sarcomas of the flexor fossae in children: is amputation necessary?

Successful management of sarcomas of the extremities in children implies not only achievement of local control but also satisfactory function and maintenance of the growth potential. The popliteal and antecubital fossae, because of their complex neurovascular anatomy, all of which is essential, make resection with satisfactory margins difficult. We reviewed our experience with 14 patients (3 to 20 years old; median, 13 years) with soft tissue sarcomas arising in the popliteal (11 patients) or antecubital (3 patients) fossae. There were four rhabdomyosarcomas (3 alveolar, 1 embryonal) and 10 other sarcomas, the most frequent being synovial sarcoma (5 patients). Chemotherapy was given to all patients with rhabdomyosarcomas. The one patient presenting with metastatic disease was treated, after biopsy of the primary, by chemotherapy and radiation and survived 21 months. In three patients, the primary management was an above-the-knee amputation and two of three survived (3 and 43 months). In 10 patients a wide local excision of the primary tumor was performed. Radiation therapy was administered to five, either as external beam (3 patients) or as brachytherapy (2 patients). In this group, there were no local recurrences. Four patients remain free of disease (4 months to 18 years) and one developed pulmonary metastasis. Among the five non-irradiated patients, three developed local recurrences, requiring above-the-knee amputation for disease. The fourth patient relapsed in the lung and only one of the five is free of disease at 36 months. Of the 8 patients not treated with amputation, one acquired a leg length discrepancy, which required correction, and one has a minimal extension deficit of the knee.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1986

Sources of trophic factors that induce limb regeneration and prevent amputation-induced neuronal death.

Segments of 2-, 4-, 6- and 8-day neural tube, or of 15-day peripheral nerve were implanted longitudinally into limb stumps of 4-day chick embryos whose right-wing buds were amputated at the future elbow region. Stumps of amputated limbs (ALs) implanted with 7-day heart or without implant served as controls. Effects of progressively older neural tube implants (NTIs) upon ALs and host spinal cord neurons were analyzed by area measurements of the peripheral limb field (PLF) and NTI and by cell counts of the host lateral motor column (LMC). Nine days postamputation, 2- and 4-day NTIs contained many neurons and induced epimorphic regeneration in more than one-fourth of the embryos. Six-day NTIs contained few neurons and induced only tissue regeneration. Eight-day NTIs and peripheral nerve containing only non-neuronal cells were as ineffective as controls in stimulating regeneration, although peripheral nerve did cause a significant increase in the peripheral field. The NTIs of all ages and implants of peripheral nerve were equally effective in protecting LMC neurons from amputation-induced cell death in the host spinal cord. The results may indicate that neurons of the implant induce limb regeneration and non-neuronal cells of the implant protect against LMC neuronal death.

Age Factors↗
PubMed1992

Physiological analysis of motor reorganization following lower limb amputation.

It is now known that amputation results in reorganization of central motor pathways, but the mechanism for the changes is unclear. One possibility is alteration of the excitability of the alpha motoneurons. We studied motor reorganization and excitability of alpha motoneurons to Ia input in 6 subjects with unilateral lower limb amputation. A Cadwell MES-10 stimulator was used to deliver transcranial magnetic stimuli through a circular coil centered on the sagittal axis 4 cm anterior to Cz and through an 8-shaped coil positioned over scalp locations 1 cm apart along the coronal axis. Surface EMG was recorded bilaterally from quadriceps femoris, the first muscle immediately proximal to the site of amputation. Excitability of the spinal alpha motoneuron pool to Ia afferents was assessed by determining the ratio of the maximal H reflex to the maximal M response (H/M ratio) elicited in the quadriceps femoris. Stimuli of equal intensity delivered to optimal scalp positions recruited a larger percentage of the alpha motoneuron pool in muscles ipsilateral to the stump than in those contralateral to the stump (P less than 0.01). Mean onset latencies of motor evoked potentials were shorter in ipsilateral muscles than in contralateral muscles (P less than 0.01). Muscles ipsilateral to the stump showed a trend toward activation from a larger number of scalp positions than those contralateral to the stump (P = 0.06). There was no difference in the quadriceps H/M ratios (7.2% ipsilateral vs. 10.9% contralateral). The absence of changes in the excitability of the alpha motoneuron pool in the presence of motor reorganization targeting muscles proximal to the stump suggests that reorganization occurs proximal to the alpha motoneuron level.

Adult↗
PubMed1991

The onset of pain related behaviours following partial beak amputation in the chicken.

The number of pecks delivered by birds to an attractive visual stimulus was measured before and again 6, 26 and 32 h after partial beak amputation. There was a significant reduction in the number of pecks by birds 26 h after amputation but not at 6 h after. This reduction was considered to be a quantitative measure of pain related guarding behaviour. The results indicated the presence of a pain-free period immediately following amputation which may last in some birds for as long as 26 h.

Amputation, Surgical↗
PubMed1995

Why bother educating the multi-disciplinary team and the patient--the example of prevention of lower extremity amputation in diabetes.

Amongst all the long-term complications of diabetes it is believed that foot ulceration and amputation are the most preventable: small studies have suggested that more than 50% of amputations should be avoidable by screening and appropriate education. There is ample evidence that simple non-invasive screening tests are not being carried out in many diabetic clinics--one study confirmed that poor patient care was responsible for 50% of heel ulcers in a hospital setting. There is a similar lack of awareness of potential problems in many 'at risk' diabetic patients. Thus, simple screening of diabetic patients should be routine clinical practice: those identified as being at 'high risk' of foot, problems should receive appropriate education in protective foot care. The rewards are potentially great, and include the realization of the St. Vincent target, a 50% reduction in amputation.

Amputation, Surgical↗
PubMedDate not supplied

The fate of an amputated nose after replantation.

Traumatic amputation of the nose is a challenging management problem. We describe the case of a 69-year-old woman who had a dog-bite nasal amputation. The avulsed piece, including the lobule, and approximately half of the columella and alae, was replanted within 2 hours of the trauma. Hyperbaric oxygen therapy was administered for 12 daily sessions. Skin gradually necrosed, and the eschar was tangentially excised. Almost all of the mucosa and of the cartilage layers survived and the final defect was smaller than the original. A 3-stage repair was performed by a paramedian forehead flap to replace cover. Lining was by approximation of native tissues, whereas framework was reinforced by conchal and septal cartilage grafts. The outcome was functionally and aesthetically satisfactory. Our case confirms that replantation of an amputated nose as a composite graft is worthwhile. Although the skin necrosed and required reconstruction, most of the lining and of the cartilage support survived, greatly improving the ease of reconstruction, as well as nasal function.

Aged↗
PubMed2005

[Outcome of early fitting by silicone liner with lock system for dysvascular below-knee amputation: assessment of walking abilities by a specific questionnaire].

PURPOSE: To assess by a specific questionnaire the functional outcome of patients with below-the-knee amputation after early prosthetic fitting by the ICEROSS silicone liner, which had demonstrated improvement of stump healing and length of hospital stay. PATIENTS AND METHODS: In this retrospective study, walking ability was assessed by a specific score resulting from answers on a questionnaire. The outcome variables were walking inside and outside, transfer from sitting, climbing stairs, and use of walking aids. Following amputation, the ICEROSS system was used for compression therapy, then for temporary prosthesis. The questionnaire was administered at the fitting stabilized state. RESULTS: Twenty-nine of 51 patients who underwent trans-tibial amputation were included: 5 women (mean age 72.8+/-4.1 years) and 24 men (mean age: 69+/-7.4 years). The mean total score was 14.5/20 (good functional outcome) for the 22 unilateral amputees and 7.2/20 (intermediate result) for the seven bilateral amputees. Previous studies concerning functional outcome with other contact casts (without a silicon liner with a bolt) had shown similar results. CONCLUSION: Despite its beneficial initial effect, early fitting by the ICEROSS system did not improve walking ability at the steady functional state, which is more linked to advanced age and comorbidities.

Aged↗
PubMed2005

Venous thromboembolism in a rehabilitation setting after major lower-extremity amputation.

OBJECTIVE: To determine the prevalence of venous thromboembolic disease (VTED) and impact on functional outcome in patients with major lower-extremity (LE) amputation admitted to an inpatient rehabilitation unit. DESIGN: Retrospective medical records review. SETTING: Acute inpatient rehabilitation unit in a tertiary, urban academic medical center. PARTICIPANTS: Fifty consecutive patients admitted to an acute inpatient rehabilitation unit after a major LE amputation. Participants were screened at rehabilitation admission for LE deep vein thrombosis using duplex ultrasonography. INTERVENTIONS: Not applicable. Main outcome measures VTED incidence, FIM instrument, total rehabilitation charges, and length of stay (LOS). RESULTS: Six of 50 patients (12%) had evidence of VTED. The VTED cohort had significantly lower admission and discharge FIM scores than the no-VTED cohort (admission FIM score, 57.2 vs 76.0; discharge FIM score, 66.0 vs 90.1, respectively; P< or =.02). Subjects with VTED had a longer rehabilitation LOS (22.8d vs 13.9d, respectively; P=.02) and higher total rehabilitation charges (28,314 US dollars vs 17,724 US dollars, respectively; P<.05). CONCLUSIONS: In this study, VTED prevalence after LE amputation in a rehabilitation setting was 12%. Subjects with VTED had lower admission and discharge functional status, longer LOS, and higher hospital charges. The utility of screening duplex ultrasound examinations at rehabilitation admission remains unclear.

Aged↗
PubMed2005

Changing dynamics in lower-extremity amputation in China.

OBJECTIVE: To evaluate the current pattern of lower-extremity amputation (LEA) in a Chinese population and to identify independent risk factors for failure to ambulate in the community after LEA. DESIGN: Retrospective study. SETTING: Tertiary hospital. PARTICIPANTS: Consecutive Chinese adults (N=189) who underwent LEA from 1995 to 1997. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Pattern of LEA in comparison with previous data and risk factors for failure to ambulate in the community after LEA. RESULTS: The mean age at amputation was 74.1 years. Vascular occlusive disease and infection accounted for most of the reasons for the LEA. The pattern of LEA had changed significantly. The proportion of patients who were able to ambulate in the community decreased from 66.1% before the LEA to 29.9% 12 months after LEA. Logistic regression analysis showed that major amputation level, presence of diabetes mellitus, hypertension, inability to ambulate in the community before LEA, and failed use of prosthesis were significant independent risk factors for failure to ambulate in the community after LEA. CONCLUSIONS: A more aggressive rehabilitation approach, together with efforts targeted at various levels is required to achieve better functional ambulation level and to improve reintegration into the community after LEA.

Adult↗
PubMed2005

Rehabilitation after the replantation on a 2-year-old girl with both amputated legs.

We had an opportunity to perform replantation of both legs on a 2-year-old girl, and our decision to perform replantation rather than amputation surgery was carefully made taking her age, degree of crushing injury, ischaemic time and level of the amputation into consideration. Painstakingly designed rehabilitation treatments were continuously performed on this girl from the early stage after the operation, and the treatments were comprised of four parts; that is, flexion and extension exercise for the ankle in order to prevent it from stiffness or contracture, functional electrical stimulation (FES) in order to prevent muscular atrophy on the lower extremities, muscle strengthening exercise for the lower extremities, and electrical stimulation to regenerate the damaged nerves and to prevent muscular atrophy from occurring. For an objective assessment of the postoperative conditions, total active motion angles of the ankle joint were measured, and also EMG and NCV were conducted at the end of the first month as well as at the end of the 6th month. Total active motion angles of the ankle joint were increased progressively as time went on, from 15 to 60 degrees on the right and from 10 to 45 degrees on the left. NCV did not show any sensation or response from motor nerves, or amplitude decreased considerably 1 month after the operation; however, at the end of the 6th month conditions improved a great deal with both amplitude and latency. And most muscles that did not show any signals on EMG or showed less than normal at the end of the first month after the operation eventually recovered at the end of the 6th month. The patient had no particular difficulties in walking after 6 months or rather she started running in small steps showing her legs functioning superbly. An infant with both of lower extremities amputated is quite a rare case. We believe that the replantation surgery was successful due to the fact that carefully selected preoperative factors were taken into consideration and well designed postoperative rehabilitation program consisted of four parts was carried out continuously.

Amputation, Traumatic↗