Hemiplegia and amputation: Rehabilitation in the dual disability

451

Hemiplegia and Amputation: Rehabilitation in the Dual Disability Paul G. OConnell,

MB, Steven Gnatz, MD

ABSTRACT. OConnell P, Gnatz S: Hemiplegia and amputation: rehabilitation in dual disability. .Irch Phys Med Rehabil 70:451454, 1989. l 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 841. 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 @
of daily living; Amhulution; Amputatior~; Hemiplegin

Hemiplegia and lower extremity amputation are common disabilities seen in rehabilitation practice. The concurrence of these two disabilities in the same patient is increasingly being recognized as a significant and unique rehabilitation problem.‘.“.” Data on the prevalence of stroke among patients with amputation suggest that about 10% of elderly dysvascular amputees have suffered a stroke at some time, although figures as low as 4% and as high as 29% have been reported.h,y.‘2.‘h It is important to recognize the presence of dual disability in these patients since even a mild residual hemiparesis impacts significantly on their subsequent rehabilitation. The patient with dual disability poses a rehabilitation challenge different from that posed by a patient with either disability alone. Cost-effective use of resources demands that realistic goals be set for patients. This requires an awareness of factors that are likely to influence outcome, especially of those which can be evaluated early in the course of therapy. Previous studies have identified the severity of hemiplegia and the level of amputation as important predictors of rehabilitation outcome, in both single and dual disability states.‘.5,X,“‘-‘3.‘7,‘y Uncertainty prevails regarding the relative importance of age, side of hemiparesis. and the sequence and laterality of the disabilFrom the Dcpartmcnt uf PhysIcal Medicine. Baylor College of Medicine,

Hous-

'011, TX.

Suhmitted for publication February 1. 1%+X. Accepted in revised form August 17, 198X. No commercial party having a direct or indirect interest in the subject matter of this article has conferred or will confer a financial benefit upon the authors or upon any organization with which the authors are associated. This paper was presented in part at the combined annual meetings of the American Academy of Physical Medicine and Rehabilitation and the American Congress of Rehabilitation Medicine in Orlando. FL. October 21. 1987. Reprint requests to Dr. OConnell. who is now affiliated with the Department of Rehabilitation Medicine. National Institutes of Health. Building 10. Room hS2?. Bethesda. MD 20X92.

ities in predicting outcome in dual disability.‘,” We review these and other factors potentially influencing the outcome ot rehabilitation in this patient population. MATERIALS

AND

METHODS

By reviewing the clinical charts and using a computer-assisted search of medical records, 46 patients with the dual disability of hemiplegia and amputation were identified who had been evaluated and treated during the years 1980 to 1986. The charts of these patients were retrospectively reviewed, and the clinical features noted in table 1 were recorded. The rehabilitation endpoints chosen for evaluation were independence in ambulation and independence in activities of daily Table 1: Summary

of Data ___~ Reviewed

Age at second disability Side of hemiplegia Side of amputation Sequence of disabilities Time interval between disabilities Severity of hemiplegia* Level of amputation Ambulatory status before second disahilill Bowel and bladder continence Concurrent medical diagnoses Fitting of a prosthesis Functional outcome of rehabilitati~m .- ambulaiion _ ADI~ *Severity of hemiplegia was graded as follows: Mild-residual weakness (24/s), but aorne functional use retained in both affected extremities including the affected hand: Moderate-weakness or spasticity interfering wirh functlonal use of affected upper but not lower extremities; Severe-weakness or spasticity interfering with tunctional use of hoth upper and lower affected extremitie?.

Arch Phys bled Rehabil Vol70,

June 1989

HEMIPLEGIA AND AMPUTATION, OConnell

452

living (ADL). Physical therapists’ and physicians’ notes were used to identify patients who were independent in ambulation, and occupational therapists’, nurses’, and physicians’ notes were used to determine ADL independence. Patients were considered independent in ambulation if they could don and doff their prostheses and ambulate independently, with or without a gait aid. This definition was chosen to distinguish ambulators from two patients for whom a prosthesis was prescribed purely to assist with transfers. Independence in ADL was defined as the patients’ ability to feed, bathe, and dress themselves and to transfer without assistance. To be classed as independent in ADL, a patient had to be able to perform all the aforementioned tasks without the assistance of another person, although adaptive equipment was permitted. Where possible, follow-up data were obtained on patients through hospital charts and clinic records until December 1986. General medical status including subsequent cerebrovascular accident (CVA), amputation, or death was obtained to latest discharge summary or clinic note. Functional status of ambulating patients was determined from record of last available amputee clinic visit. Statistical analysis of the data was done using the Pearson chisquare with Yeates correction. RESULTS

Patient Population The mean age of the patients was 63 years (range 49 to 84). Of the 46 patients, eight were women and 38 were men. The predominance of men reflects the patient population at the Veterans Administration Hospital, which contributed 63% of patients. The etiology of the hemiparesis was a thromboembolic CVA or intracerebral hemmorrhage in 43, subdural hematoma in two, and subarachnoid hemmorrhage in one patient. Amputation was secondary to diabetes in 26 patients, nondiabetic peripheral vascular disease in 19, and traumatic in one patient. Of the 46 patients, 41 (89%) were able to participate in a trial of physical therapy and 2.5 (54%) participated in a comprehensive rehabilitation program. The average initial rehabilitation length of stay was 33 days; however, most patients had either ongoing outpatient rehabilitation or a subsequent inpatient stay. This reflects the trend toward staged rehabilitation and shorter lengths of stay in our departments. Rehabilitation

Outcome

A prosthesis was fitted for anticipated ambulation in 17 (37%) patients, and 12 (26%) actually achieved independence in ambulation and in donning and doffing the prosthesis. Included as ambulators were two patients who were initially discharged independent in ADL but unable to ambulate due to hemiparesis. Both were subsequently readmitted, after further neurologic recovery, and trained to ambulate. The degree of ambulation varied from household ambulation (nine patients) to community ambulation (three patients). All patients required some form of gait aid. Two patients returned to work. The interval between the first disability and the second was not significantly different between those who ambulated independently (mean ==31 months) and those who did not Arch Phys Med Rehabll Vol70,

June 1989

(mean=33 months). Eighteen of 46 patients (39%) became independent in ADL after completing rehabilitation. Factors potentially influencing the outcome of rehabilitation are reviewed in the following sections. Inpatient vs Outpatient

Rehabilitation

As noted above, many patients received a combination of inpatient and outpatient therapy. Eight patients had primarily outpatient rehabilitation; of these, five became independent in ambulation and six in ADL. Seventeen patients had mainly inpatient rehabilitation; seven of these became ambulators, and ten became ADL independent. The decision to manage as an inpatient or an outpatient was based on multiple considerations. Patients who lived locally and who had milder deficits, and good social support were more likely to be managed as outpatients; those with more complex problems were managed as inpatients. Therefore, the somewhat better results for outpatients probably reflects patient selection and not a true difference. Age Nine of 14 patients (64%) aged less than 60 years achieved independence in ADL, but only nine of 32 (28%) of those older than 60 years did. This difference was statistically significant (p ~0.05). A similar trend was present for independence in ambulation but did not achieve statistical significance. Six of 14 (43%) aged less than 60 years achieved independent ambulation; only six of 32 (19%) older than 60 years did 0, = O.l8)(table 3). Sequence of Disability The hypothesis that those patients who undergo amputation before the onset of hemiplegia do better than other patient groups was not confirmed (JJ>0.05). Even the outcome of patients with simultaneous onset of disabilities (defined here as onset within three months) was not substantially different (table 2). Table 2: Association of Selected Clinical Features With Rehabilitation Outcome* Feature

Number of patients

Sequence Hemiplegia first Amputation first Simultaneous

29 10 7

8 (28) 2 (20) 2 (29)

10 (34) 5 (50) 3 (43)

26 13

6 (23) 5 (38)

10 (38) 7 (54)

7

1 (14)

1 (14)

21 25 46

5 (24) 7 (28) 12 (26)

9 (43) 9 (36) 18 (39)

Laterality of Disability Ipsilateral Contralateral Bilateral amputation Side of Hemiplegia Right Left Ail Patients

Ambulators

(%)

*No statistically significant differences were seen.

ADL independence (%)

HEMIPLEGIA AND AMPUTATION, OConnell Table 3: Association of Selected Clinical Features With Outcome Number of patients

Feature

Ambulators (%)

ADL independence (%)

‘1 3

12 (57)* (1 (0)

16 (7h)* 2 (8)

Continence Ye\

77

II (41)”

17 (63)

10

1 (5)

1 (5)

72 ‘4

IO (45)*”

I? (55) h (25)

Age i ho years > (,(I years

I3 32

6 (43)

Prior ambulationYC\

13

0 (39)f

Ih

1 (6)

Sh

12 (26)

N0

Amputation

level

BKA Other\

No

All patients */‘
** p
t p~O.05:

?. (8)

fl

(1’))

$ 7 patients with

It would seem unlikely that a patient who failed to ambulate after the first disability would be able to ambulate after the

Incontinence

0 (h3rt

Incontinence of bowel or bladder was strongly predictive of a negative outcome in both ambulation and ADL independence @
C)(‘7X) I2 (57)

i (19) IS (39) simultaneous

Prior Ambulation

second, even with training. This proved to be the case. Nine of 23 patients (39%) who were ambulating before the second disability subsequently achieved independent ambulation. Only one of the 16 patients not ambulating before the second disability was eventually trained to ambulate (E,=0.05) (tahle 3). Seven patients with simultaneous onset of disability were excluded from analysis.

Severity of hemiparesis Mild Others

453

onset of

Laterality of Disability Similarly, the hypothesis that patients with ipsilateral disability do better than those with contralateral disability was not confirmed. No significant difference was noted between groups with ipsilateral and those with contralateral disability (p >0.05). Seven patients with bilateral amputations were excluded from analysis and had, as expected, a poorer outcome (table 2).

Side of Hemiplegia When patients with right and left hemiplegia were compared, no difference in outcome was observed (table 2). The subgroup with right hemiplegia and amputation did not have hetter outcomes, as previously described.”

Severity of Hemiplegia Severity of hemiplegia, graded as shown in table 1, was highly predictive of rehabilitation outcome. Of 21 patients with mild hemiparesis, 12 (57%) became independent in ambulation, and 16 (76%) gained independence in ADL. Among the 12 patients with moderate hemiparesis, there were no independent ambulators, and there were only two (17%) who achieved independence in ADL. None of the 13 patients with severe hemiparesis achieved either goal. The difference observed between the mild group and the others was highly significant for ambulation (p~O.001) and for ADL (/)
Level of Amputation Twenty-two patients had below-knee amputations (BKA); of these, ten (35%) became independent in ambulation and 12 (5.5%‘) in ADL. However, of the 24 patients with other levels (17 above-knee and seven bilateral amputees), only two (8%) became independent in ambulation and six (25%‘) in ADL. Below-knee amputees were statistically more likely to ambulate than other levels (p < 0.05). For ADL independence, however. the difference was not statistically significant @ = 0.09)( table .3).

Associated

Illnesses

A history of heart disease, diabetes. or renal impairment did not adversely affect rehabilitation ourcome. Indeed, four patients with renal impairment, including one patient on dialysis, were trained to be independent ambulators.

Course After Hospital Discharge Information on patient progress was a\,ailable for 34 patients for a mean of 16.1 months (range 7 to I20 months) after hospital discharge. During that period., there were seven deaths, four strokes, and 11 amputations, confirming the high morbidity and mortality experienced by I.his group with extensive vascular disease. However, of the 11 ambulators on whom information was available, eight (73%) continued to ambulate independently at a mean of 16.5 months (range 2 to 60 months, median 5 months). This included one patient who was successfully fitted with a prosthesis and who ambulated after undergoing a second BKA on the opposite side. It appears that the gains made in rehabilitation are maintained, by and large, on short-term follow-up among those who do achieve indcpendent ambulation.

DISCUSSION In this review of 46 patients with the dual disability of hemiplegia and amputation, we found that patients with a mild hemiparesis, a BK amputation, and a history of ambulation before their second disability were statistically more likely to regain the ability to ambulate independently. Incontinent patients were very unlikely to ambulate. Independence in basic self-care and ADL was statistically associated with the presence of a mild hemiparesis, a younger age (less than 60 years), and continence of bowel and bladder. Overall, 26% of all patients ambulated independently, and 39’Y were independent in ADL. These rates are lower than ,those reported in previous studies,‘.” reflecting the severity of the disability among our patient population. Since the study included all patients who were seen and evaluated by the Rehabilitation Service, and not just those completing a comprehensive rehabilitation program, the full spectrum of disability is represented. Arch Phys Med Rehabil Vol70, June 1989

454

HEMIPLEGIA AND AMPUTATION, OConnell

Two previous studies have reviewed in detail the rehabilitation outcome in this population. Varghese and colleagues” studied 30 patients. Although statistical analysis was not performed, it was noted that certain factors were associated with a good outcome. These included age less than 60 years, presence of ipsilateral hemiplegia and amputation, right-sided disability, amputation before hemiplegia, and a below-knee amputation. More recently, Altner and associates1 reviewed 52 dual-disability patients. Trends for increased ambulation were noted among patients with better neuromuscular status, better mental status, and younger age. Self-care and ADL ability were not assessed in this study. Our findings on the severity of hemiplegia and the level of amputation are in keeping with the results of previous studies. Like Varghese and colleagues,” we found that age less than 60 years was associated with a better ADL outcome, but in contrast to their study, we saw no significant association of younger age with ambulation. Like Altner and associates,’ we failed to show any association between side of hemiplegia, sequence of onset or laterality of disabilities, and rehabilitation outcome. This finding is supported by the literature on stroke rehabilitation, where it has generally been found that side of hemiplegia has little effect on outcome,“~“~10~‘3~i4.18 although controversy regarding this exists. 7J’) Incontinence persisting after CVA has been associated with a much poorer prognosis.2~4.1” In our series, incontinence was clearly a marker for more extensive neurologic problems and was often associated with the presence of cognitive deficits. It is therefore not surprising that incontinence is also associated with a poor outcome. Indeed, the only incontinent patient in our series to achieve independence had a diabetic autonomic neuropathy, rather than a central neurologic deficit, as the etiology of his incontinence. A history of ambulation before onset of the second disability is a factor not emphasized by previous studies. Inability to ambulate, like incontinence, is probably most useful as a negative indicator; it is unlikely that a person who failed to walk before the onset of the second disability can be trained to ambulate independently after it has occurred. Similarly, it is only the exceptional patient with an amputation other than a BKA who can be trained to ambulate independently after hemiplegia. Independence in transfers and ADL is at least as important a goal as ambulation. More patients achieved this goal (39%) than were trained to ambulate (26%). Neurologic status, as measured by severity of hemiparesis and status of continence, was most important in determining ADL status. Younger age was associated with ADL independence. While 76% of patients with mild hemiparesis reached ADL independence, only 17% of moderate hemiparetic patients and none with severe hemiparesis reached this level. The increased difficulty in transferring with only one leg appeared to be the main factor limiting several patients with moderate hemiparesis from achieving this goal. This may account for the low level of ADL independence in the moderate hemiparesis group. Overall, it was our impression that neurologic status was the most important factor in rehabilitation outcome. Return of hand function on the affected side seemed particularly important for success in training patients to ambulate with a prosthesis. We speculate that this is because the initial phase of prosthetic training involves the use of parallel bars, walkers,

Arch Phys Yed Rehabil Vol70,

June 1999

and crutches that must be gripped with both hands for optimal support and balance. In two patients, it was necessary to delay ambulation training until the maximum motor recovery from the stroke had occurred. This experience suggests that staged rehabilitation may be appropriate for some patients. Independence in transfers and self-care would be the initial goal, while ambulation would become the goal after return of neurologic function. References

1. Altner PC, Rockley P, Kirby K: Hemiplegia and lower extremity amputation: double disability. Arch Phys Med Rehabil 68:378379, 1987 2. Anderson TP, Bourestom N, Greenberg FR, Hildyard VG: Predictive factors in stroke rehabilitation. Arch Phys Med Rehabil 55:545-553, 1974 Andrews K, Brochlehurst JC, Richards B, Laycock PJ: Stroke: does side matter? Rheum & Rehabil 21:175-178, 1982 Bourestom NC: Predictors of long term recovery in cerebrovascular disease. Arch Phys Med Rehabil 48:415419, 1967 Clark GS, Blue B, Bearer JB: Rehabilitation of elderly amputee. J Am Geriatr Sot 31:439-448, 1983 Colwell JA, Bingham SF, Abraira C, Anderson JW, Kwaan HC: V.A. cooperative study on antiplatelet agents in diabetic patients after amputation for gangrene: III definitions and review of design and baseline characteristics. Horm Metabol Res (Suppl) 15:6973, 1985 7. Denes G, Semenza C, Stoppa E, Lis A: Unilateral spatial neglect and recovery from hemiplegia: follow up study. Brain 105:543552, 1982 8. Huang CT, Jackson JR, Moore NB, Fine PR, Kuhlemeier KV, Traugh GH, Saunders PT: Amputation: energy cost of ambulation. Arch Phys Med Rehabil 60:18-24, 1979 9. Huston CC, Bivins BA, Ernst CB, Griffen WO: Morbid implications of above-knee amputations. Report of series and review of literature. Arch Surg 115:165-167, 1980 10. Jongbloed L: Prediction of function after stroke: a critical review. Stroke 17:76_5-776, 1986 11. Kegel B, Carpenter ML, Burgess EM: Functional capabilities of lowerextremityamputees. ArchPhysMedRehabil59:109-120.1978 12. Kerstein MD, Zimmer H, Dugdale FE, Lerner E: Associated diagnoses complicating rehabilitation after major lower extremity amputation. Angiology 25:536-547, 1974 13. Kotila M, Waltimo 0, Niemi ML, Laaksonen R, Lempinen M: Profile of recovery from stroke and factors influencing outcome. Stroke 15:1039-1044, 1984 14. Mills VM, DiGenio M: Functional differences in patients with left or right cerebrovascular accidents. Phys Ther 63:481485, 1983 15. Papp A, Endres M, Kullmann L, Kozma D: Hemiplegias es alsovegtag amputalt betegek rehabilitacioja. Magy Traumatol Orthop 21:223-227, 1978 16. Thornhill HL, Jones CD, Brodzka W, Van Bockstaele P: Bilateral below-knee amputations: experience with 80 patients. Arch Phys Med Rehabil 67:159-163, 1986 17. Varghese G, Hinterbuchner C, Mondall P, Sakuma J: Rehabilitation outcome of patients with dual disability of hemiplegia and amputation. Arch Phys Med Rehabil 59:121-123, 1978 18. Wade DT, Hewer RL, Wood VA: Stroke: influence of patient’s sex and side of weakness on outcome. Arch Phys Med Rehabil 65:513-516, 1984 19. Waters RL, Perry J, Antonelli D. Hislop H: Energy cost of walking of amputees: influence of level of amputation. J Bone Joint Surg (Am) 58:42-46, 1976