- Email: [email protected]
Influencing factors and ambulation outcome in patients with dual disabilities of hemiplegia and amputation
14
Influencing Factors and Ambulation Outcome in Patients With Dual Disabilities of Hemiplegia and Amputation Chun-Chieh Chiu, MD, Cheng-Erh Chen, MD, Tyng-Guey Wang, MD, Ming-Chuan Lin, MD, I-Nan Lien, MD ABSTRACT. Chiu C-C, Chen C-E, Wang T-G, Lin M-C, Lien I-N. Influencing factors and ambulation outcome in patients with dual disabilities of hemiplegia and amputation. Arch Phys Med Rehabil 2000;81:14-7. Objective: To determine the ambulatory outcome and predictive factors of successful ambulation training in patients with both hemiplegia and lower extremity amputation. Design: A retrospective study. Setting: A rehabilitation center of a university hospital. Patients: Twenty-three patients with dual disabilities consecutively admitted to the rehabilitation center from 1984 to 1994. Main Outcome Measures: Ambulatory outcome was measured using physical therapists’ and physicians’ notes at discharge or the last available clinical visit. Ambulation ability was graded as community and noncommunity ambulation, which included indoor ambulation and nonambulation. Several clinical features were reviewed to assess their association with ambulation outcome. Results: About two thirds of the 23 patients could be trained to be ambulatory: 10 (43.8%) achieved community ambulation and 5 (21.7%) achieved indoor ambulation. Of the clinical factors, only mental status showed a statistically significant association with good ambulation outcome ( p ⬍ .05). When odds ratios were considered, several factors, including mild motor involvement, transtibial amputation, amputation before cerebrovascular accident, age younger than 60 years, and the presence of ipsilateral hemiplegia and amputation, showed trends toward association with increased ambulation achievement, although these associations were not statistically significant. Conclusion: Impaired mental status seemed to be the most influential negative predictive factor of achieving community ambulation. If subjects with dual disabilities are properly selected, satisfactory results of ambulation training will be obtained. Key Words: Ambulation; Amputation; Hemiplegia; Rehabilitation. r 2000 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation
H
EMIPLEGIA AND AMPUTATION are common issues in the field of rehabilitation. The combination of these two disabilities often complicates rehabilitation, prolonging the
From the Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei, Taiwan, R.O.C. Submitted for publication December 31, 1998. Accepted in revised form April 28, 1999. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated. Reprint requests to Tyng-Guey Wang, MD, Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, Taiwan. r 2000 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation 0003-9993/00/8101-5397$3.00/0
Arch Phys Med Rehabil Vol 81, January 2000
process, increasing the cost, and even reducing the success rate of self-care and ambulation abilities.1 With increased life expectancy, more patients are expected to develop the dual disabilities of hemiplegia and amputation.2,3 An important issue in the rehabilitation of patients with dual disabilities is deciding which patients have the potential to be trained successfully. Awareness of the factors likely to influence rehabilitation outcome may help rehabilitate these patients effectively. Several factors have been studied to determine their influence on the rehabilitation outcome3-10 of patients with dual disabilities, including age, side and level of amputation, sequence of dual disabilities, neurologic and mental status of patients, and laterality of the disabilities. The results, however, have not been conclusive.5,8,10 For example, Varghese and associates10 stated that patients with right hemiplegia had better functional levels of ambulation, but O’Connell and Gnatz8 had a different outcome. The different results may be attributable to small patient samples and to differences in the severity of the patients’ disabilities. In this study, we investigated ambulation outcome in the rehabilitation of dually disabled patients and attempted to determine which factors influence their ambulation outcome. MATERIALS AND METHODS From 1984 to 1994, 1,158 patients were admitted to our rehabilitation department for cerebrovascular accident (CVA) and 264 patients were admitted for lower extremity amputation. From this pool, 23 consecutive patients with the dual disabilities of hemiplegia and amputation were identified. Because patients with poor medical conditions or no rehabilitation potential were not admitted to our department and were not included in our series, selection bias did exist in this study. All 23 patients received a comprehensive rehabilitation program that included prosthesis fitting and ambulation training. The training program was designed and closely monitored by the rehabilitation team, which consisted of physiatrists, physical therapists, occupational therapists, speech pathologist, rehabilitation nurses, psychologists, and the patient’s family. The charts of these patients were reviewed by a physiatrist. The factors that might influence the prognosis of rehabilitation outcome were selected and studied, including severity of hemiplegia, mental status, level of amputation, sequence of the disabilities, age, laterality of the disabilities, side of hemiplegia, and etiology of CVA. The severity of hemiplegia was defined using Brunnstrom’s stage,11 a method widely used to evaluate motor status of CVA patients. We defined lower limb involvement classified as Brunnstrom’s stage V or VI as ‘‘mild’’ motor impairment and stage IV or below as ‘‘moderate to severe’’ motor impairment. Patients were divided into two categories according to their mental status evaluated by a physiatrist and a psychologist. The patients who were alert and had normal judgment, orientation, memory, abstract thinking, and calculation, with the ability to comprehend and learn, were defined as having ‘‘intact’’ mental status. Those who showed decreased alertness, disorientation, or decreased ability of learning were regarded as having ‘‘impaired’’ mental status.
15
AMBULATION OUTCOME OF DUAL DISABILITIES, Chiu
Sequence of disability was classified as follows: the CVA occurred before the amputation (15 patients); the amputation occurred before the CVA (6 patients); or the CVA and amputation both occurred within 3 months (2 patients). Rehabilitation outcome was assessed according to ambulation ability, because the capacity to ambulate seemed to be the most challenging issue for these dually disabled patients. Ambulation ability was identified using physical therapists’ and physicians’ notes and divided into community and noncommunity ambulation, which including indoor ambulation and nonambulation. Patients were considered community ambulators if, after being fitted with prostheses, they were able to ambulate independently inside and outside the house, with or without assistive devices, for at least 500 meters. Indoor ambulation was defined as being able to walk around only inside the house. Nonambulating patients could not walk or could walk only a few steps with assistance, for a distance less than 3 meters. The ambulation status of all patients was determined from their status at discharge or from records of the last available clinical visit, with average rehabilitation periods of 76.7 ⫾ 47.7 days. Fisher’s exact test was used for statistical analysis between the clinical factors and the ambulation outcome and p ⬍ .05 was considered significant. The odds ratio (OR) also was used to evaluate the advantages of several factors in ambulation training. RESULTS The 23 patients included 7 women and 16 men. Their mean age was 65.5 ⫾ 9.1 years (range, 50 to 80yrs). The average interval between the first and second disability was 4.9 ⫾ 6.4 years (range, 1mo to 27yrs). Causes of hemiplegia or hemiparesis were thromboembolic CVA in 19 patients and intracerebral hemorrhage in 4. The causes of amputation were diabetes in 11 patients and nondiabetic peripheral vascular disease in 12.
Fifteen subjects had transtibial (below-knee) amputation and 8 had transfemoral (above-knee) amputation (table 1). The patients with dual disabilities represented 8.7% of the 264 lower extremity amputation patients and 2% of the 1,158 CVA patients admitted from 1984 to 1994. Ambulation outcome. All the patients were unable to ambulate before rehabilitation. Of the 23 patients, 10 (43.5%) achieved community ambulation and 13 (56.5%) became noncommunity ambulators, including 5 (21.7%) indoor ambulators and 8 (34.8%) nonambulators. Association between selected clinical features and ambulation outcome. The achievement of community ambulation and statistical results in each selected group are shown in table 2. Of the selective clinical features, only mental status related to the ambulation outcome with statistical significance ( p ⬍ .05). None of the five patients with impaired mental status achieved community ambulation. Considering the OR, we found that patients with certain factors had a higher success rate of community ambulation, although this trend was not statistically significant. These factors were mild motor involvement, transtibial amputation, amputation occurring before CVA, age younger than 60 years, and the presence of ipsilateral hemiplegia and amputation. For example, the chance of achieving community ambulation in the group of patients with mild motor involvement seemed to be 3.8 times higher than the other group (OR ⫽ 3.8). The side of hemiplegia and the etiology of CVA were not related to the patients’ ability to ambulate. DISCUSSION To our knowledge, there has been no study on the incidence of CVA patients who subsequently have an amputation or the incidence of amputation patients who subsequently experience a CVA, although the prevalence of persons with lower extremity amputation who have suffered a stroke at some time has
Table 1: Data of the Subjects Age (yrs)
Hemiplegia
Community ambulation
56 65 52 56 64 77 58 69 72 50
Severe Mild Mild Severe Mild Mild Severe Mild Mild Mild
Intact Intact Intact Intact Intact Intact Intact Intact Intact Intact
Indoor ambulation
74 54 62 69 67
Mild Severe Mild Severe Severe
Nonambulation
57 74 72 58 66 78 80 77
Severe Mild Mild Severe Severe Mild Severe Severe
Outcome
Mental Status
Sequence
Etiology
Side of CVA
Amputation (Side)
I I I I I II II II II III
TE TE ICH ICH TE TE TE TE TE TE
R R R R L L R L R R
TT (R) TT (R) TF (R) TT (R) TT (L) TT (L) TT (R) TT (L) TT (L) TF (L)
Intact Impaired Intact Intact Intact
I I I I I
TE ICH TE TE TE
L R L R R
TT (L) TT (L) TF (L) TT (R) TT (R)
Impaired Intact Intact Impaired Impaired Intact Intact Impaired
I I I I I II II III
TE TE TE ICH TE TE TE TE
R L R R L R R R
TT (R) TF (R) TF (R) TT (R) TF (L) TF (L) TT (L) TF (L)
Abbreviations: I, CVA before amputation; II, Amputation before CVA; III, both within 3 months; TE, thromboembolic CVA; ICH, intracerebral hemorrhage; R, right; L, left; TT, transtibial amputation; TF, transfemoral amputation.
Arch Phys Med Rehabil Vol 81, January 2000
16
AMBULATION OUTCOME OF DUAL DISABILITIES, Chiu Table 2: Association Between Selected Clinical Features and Community Ambulation Outcome Community Fisher’s Exact Patients Ambulators Test Odds n n (%) p Value Ratio
Feature
Severity of hemiplegia Mild Others Mental status Intact Impaired Amputation level Transtibial Transfemoral Sequence Amputation first Hemiplegia first Simultaneous Age ⱕ60yrs ⬎60yrs Laterality of disability Ipsilateral Contralateral Side of hemiplegia Right Left Etiology of hemiplegia Thromboembolic Intracerebral hemorrhage
12 11
7 (58.3%) 3 (27.3%)
.21
3.8
18 5
10 (55.6%) 0 (0.0%)
⬍.05
13.6
15 8
8 (53.3%) 2 (25.0%)
.38
3.4
6 15 2
4 (66.7%) 5 (33.3%) 1 (50.0%)
.33
4.0
8 15
5 (62.5%) 5 (33.3%)
.22
3.3
16 7
8 (50.0%) 2 (28.6%)
.41
2.5
16 7
7 (48.8%) 3 (42.9%)
1.00
1.0
19 4
8 (42.1%) 2 (50.0%)
.60
0.7
been reported to be from 4% to 42%.1,8,12-14 In our series, dual-disability patients were 8.7% of total amputation patients and 2% of total CVA patients admitted to our institution from 1984 to 1994. In the early 1960s, the rehabilitation outcome of patients with dual disabilities was considered poor. Hoover15 stated that hemiplegia superimposed with amputation made ambulation unusually difficult and frequently contraindicated prosthetic fitting. Russek16 reported that neurologic weakness in the remaining limbs was a negative factor for prosthetic rehabilitation. Since 1978, some authors have shown better results of prosthesis fitting in the CVA patients, and they believe that patients with dual disabilities can benefit from rehabilitation training.10 In the reported series,5,8,10 from 26% to 46% of patients with dual disabilities have been trained to be ambulatory, including community and indoor ambulation (table 3). Independent ambulation is an important step in the independence of patients. Varghese10 documented that the achievement of indoor ambulation could also much improve the independence of patients in their daily lives. In the present study, 43.8% of the 23 patients achieved community ambulation, and 21.7% Table 3: Ambulation Outcomes of Patients With Dual Disabilities in Previous Studies and Present Study Number of Cases Series
Total
Prosthesis Training
Varghese10 O’Connell8 Altner5 Present study
30 46 52 23
30 17 30 23
Ambulation Outcome (%) Community
Limited/ Indoor
Ambulatory Total
3 (10%) 3 (7%) 8 (15%) 10 (44%)
10 (33%) 9 (20%) 16 (31%) 5 (22%)
13 (43%) 12 (26%) 24 (46%) 15 (65%)
Arch Phys Med Rehabil Vol 81, January 2000
achieved indoor ambulation. In all, two thirds of our patients achieved some ambulation. This result supports the idea that patients with dual disabilities can benefit from rehabilitation. The better success rate of ambulation in the present study than that reported in earlier studies might be explained by two reasons—the advancement of rehabilitation medicine in the past 10 years, and our selection of cases. Our study only included the patients who were admitted to our institute. Consequently, because some patients with poor medical condition or with no potential for rehabilitation were excluded from our series, we could expect that our rate of successful ambulation would be higher than in the general dual-disability population. Nevertheless, our results also show that patients with dual disabilities have a good chance to achieve functional ambulation if properly selected and rehabilitated. In this study, only mental status was statistically associated with ambulation outcome, even though our sample group was small. None of the patients with impaired mental status in our series achieved community ambulation. A similar finding was documented in a study by O’Connell and Gnatz.8 Of 19 incontinent patients who were generally considered as having cognitive deficits and impaired mental status, only one achieved independent ambulation. This finding is understandable given that ambulation training for patients with dual disabilities is complex and requires more skills and learning ability. O’Connell and Gnatz8 reported that mild hemiparesis and transtibial amputation were statistically significant factors associated with regaining independent ambulation. Altner and colleagues5 stated that good to fair neuromuscular status was the deciding factor for good ambulation. In the series reported by Varghese,10 patients with transtibial amputation had better ambulatory achievement than those with transfemoral amputation, but Varghese did not report the status of neuromuscular involvement. In the present study, we discovered a trend toward better ambulation achievement in subjects with mild motor involvement and transtibial amputation. Similar to our result, Varghese10 stated that patients with amputation before CVA, age younger than 60 years, and ipsilateral hemiplegia and amputation had a trend toward better ambulation outcome. In the series by O’Connell and Gnatz,8 however, as well as in the series by Altner,5 no association with these factors was found; they even had some opposite results. The influences of these three factors, therefore, are still debatable, and further study in a well-controlled series is necessary. Regarding the side of hemiplegia, O’Connell and Gnatz8 and Altner5 had the same results as in our series. No association was found between hemiplegic side and ambulation outcome. In conclusion, impaired mental status seemed to be the most influential negative predictive factor of achieving community ambulation in dual-disability patients. We also consider severity of hemiplegia and amputation level to be influencing factors on the ambulation outcome of dual-disability patients. Furthermore, 65.5% of the patients with dual disabilities in our series were able to achieve community or indoor ambulation. Rehabilitation for patients with the dual disabilities of hemiplegia and amputation is beneficial, and patients can achieve satisfactory results if properly selected and trained. Acknowledgment: The authors thank Wen-Yi Shau, MD, from the Institute of Epidemiology of National Taiwan University for his statistical counseling.
AMBULATION OUTCOME OF DUAL DISABILITIES, Chiu
References 1. Kerstein MD, Zimmer H, Dugdale FE, Lerner E. Associated diagnoses complicating rehabilitation after major lower extremity amputation. Angiology 1974;25:536-47. 2. Esquenazi A. Geriatric amputee rehabilitation. Clin Geriatr Med 1993;9:731-43. 3. Kanakamedala R, Chaudhuri G, Sundaram P, Milewski M. Rehabilitation of patients with dual disability of hemiplegia and amputation [abstract]. Arch Phys Med Rehabil 1980;61:495. 4. Abadee P, Kern P, Hong CZ. Rehabilitation in dual disability of hemiplegia and upper extremity amputation: two case reports. Arch Phys Med Rehabil 1987;68:226-8. 5. Altner PC, Rockley P, Kirby K. Hemiplegia and lower extremity amputation: double disability. Arch Phys Med Rehabil 1987;68: 378-9. 6. Badwey TM, Rice JC, Kerstein MD. Amputation as a consequence of stroke. J Cardiovasc Surg 1988;29:563-6. 7. Garrison JH, Shankara B, Mueller MJ. Stroke hemiplegia and subsequent lower extremity amputation: which side is at risk. Arch Phys Med Rehabil 1986;67:187-9. 8. O’Connell PG, Gnatz S. Hemiplegia and amputation: rehabilitation in the dual disability. Arch Phys Med Rehabil 1989;70:451-4. 9. Philip PA, Philip M, Wiesner S. Dual disability of hemiplegia and
10. 11. 12.
13. 14. 15. 16.
17
hip disarticulation: rehabilitation outcome. Arch Phys Med Rehabil 1989;70:916-7. Varghese G, Hinterbuchner C, Mondall P, Sakuma J. Rehabilitation outcome of patients with dual disability of hemiplegia and amputation. Arch Phys Med Rehabil 1978;59:121-4. Brunnstrom S. Movement therapy in hemiplegia. New York: Harper & Row; 1970. 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 Metab Res 1985;15 Suppl:69-73. Huston CC, Bivins BA, Ernst CB, Griffen WO. Morbid implications of above-knee amputations. Report of series and review of literature. Arch Surg 1980;115:165-7. Thornhill HL, Jones GD, Brodzka W, Van Bockstaele P. Bilateral below-knee amputations: experience with 80 patients. Arch Phys Med Rehabil 1986;67:159-63. Hoover RM. Problems and complications of amputees. Clin Orthop 1964;37:47-52. Russek AS. Management of lower extremity amputees. Arch Phys Med Rehabil 1961;42:687-703.
Arch Phys Med Rehabil Vol 81, January 2000
Influencing Factors and Ambulation Outcome in Patients With Dual Disabilities of Hemiplegia and Amputation Chun-Chieh Chiu, MD, Cheng-Erh Chen, MD, Tyng-Guey Wang, MD, Ming-Chuan Lin, MD, I-Nan Lien, MD ABSTRACT. Chiu C-C, Chen C-E, Wang T-G, Lin M-C, Lien I-N. Influencing factors and ambulation outcome in patients with dual disabilities of hemiplegia and amputation. Arch Phys Med Rehabil 2000;81:14-7. Objective: To determine the ambulatory outcome and predictive factors of successful ambulation training in patients with both hemiplegia and lower extremity amputation. Design: A retrospective study. Setting: A rehabilitation center of a university hospital. Patients: Twenty-three patients with dual disabilities consecutively admitted to the rehabilitation center from 1984 to 1994. Main Outcome Measures: Ambulatory outcome was measured using physical therapists’ and physicians’ notes at discharge or the last available clinical visit. Ambulation ability was graded as community and noncommunity ambulation, which included indoor ambulation and nonambulation. Several clinical features were reviewed to assess their association with ambulation outcome. Results: About two thirds of the 23 patients could be trained to be ambulatory: 10 (43.8%) achieved community ambulation and 5 (21.7%) achieved indoor ambulation. Of the clinical factors, only mental status showed a statistically significant association with good ambulation outcome ( p ⬍ .05). When odds ratios were considered, several factors, including mild motor involvement, transtibial amputation, amputation before cerebrovascular accident, age younger than 60 years, and the presence of ipsilateral hemiplegia and amputation, showed trends toward association with increased ambulation achievement, although these associations were not statistically significant. Conclusion: Impaired mental status seemed to be the most influential negative predictive factor of achieving community ambulation. If subjects with dual disabilities are properly selected, satisfactory results of ambulation training will be obtained. Key Words: Ambulation; Amputation; Hemiplegia; Rehabilitation. r 2000 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation
H
EMIPLEGIA AND AMPUTATION are common issues in the field of rehabilitation. The combination of these two disabilities often complicates rehabilitation, prolonging the
From the Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei, Taiwan, R.O.C. Submitted for publication December 31, 1998. Accepted in revised form April 28, 1999. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated. Reprint requests to Tyng-Guey Wang, MD, Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, Taiwan. r 2000 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation 0003-9993/00/8101-5397$3.00/0
Arch Phys Med Rehabil Vol 81, January 2000
process, increasing the cost, and even reducing the success rate of self-care and ambulation abilities.1 With increased life expectancy, more patients are expected to develop the dual disabilities of hemiplegia and amputation.2,3 An important issue in the rehabilitation of patients with dual disabilities is deciding which patients have the potential to be trained successfully. Awareness of the factors likely to influence rehabilitation outcome may help rehabilitate these patients effectively. Several factors have been studied to determine their influence on the rehabilitation outcome3-10 of patients with dual disabilities, including age, side and level of amputation, sequence of dual disabilities, neurologic and mental status of patients, and laterality of the disabilities. The results, however, have not been conclusive.5,8,10 For example, Varghese and associates10 stated that patients with right hemiplegia had better functional levels of ambulation, but O’Connell and Gnatz8 had a different outcome. The different results may be attributable to small patient samples and to differences in the severity of the patients’ disabilities. In this study, we investigated ambulation outcome in the rehabilitation of dually disabled patients and attempted to determine which factors influence their ambulation outcome. MATERIALS AND METHODS From 1984 to 1994, 1,158 patients were admitted to our rehabilitation department for cerebrovascular accident (CVA) and 264 patients were admitted for lower extremity amputation. From this pool, 23 consecutive patients with the dual disabilities of hemiplegia and amputation were identified. Because patients with poor medical conditions or no rehabilitation potential were not admitted to our department and were not included in our series, selection bias did exist in this study. All 23 patients received a comprehensive rehabilitation program that included prosthesis fitting and ambulation training. The training program was designed and closely monitored by the rehabilitation team, which consisted of physiatrists, physical therapists, occupational therapists, speech pathologist, rehabilitation nurses, psychologists, and the patient’s family. The charts of these patients were reviewed by a physiatrist. The factors that might influence the prognosis of rehabilitation outcome were selected and studied, including severity of hemiplegia, mental status, level of amputation, sequence of the disabilities, age, laterality of the disabilities, side of hemiplegia, and etiology of CVA. The severity of hemiplegia was defined using Brunnstrom’s stage,11 a method widely used to evaluate motor status of CVA patients. We defined lower limb involvement classified as Brunnstrom’s stage V or VI as ‘‘mild’’ motor impairment and stage IV or below as ‘‘moderate to severe’’ motor impairment. Patients were divided into two categories according to their mental status evaluated by a physiatrist and a psychologist. The patients who were alert and had normal judgment, orientation, memory, abstract thinking, and calculation, with the ability to comprehend and learn, were defined as having ‘‘intact’’ mental status. Those who showed decreased alertness, disorientation, or decreased ability of learning were regarded as having ‘‘impaired’’ mental status.
15
AMBULATION OUTCOME OF DUAL DISABILITIES, Chiu
Sequence of disability was classified as follows: the CVA occurred before the amputation (15 patients); the amputation occurred before the CVA (6 patients); or the CVA and amputation both occurred within 3 months (2 patients). Rehabilitation outcome was assessed according to ambulation ability, because the capacity to ambulate seemed to be the most challenging issue for these dually disabled patients. Ambulation ability was identified using physical therapists’ and physicians’ notes and divided into community and noncommunity ambulation, which including indoor ambulation and nonambulation. Patients were considered community ambulators if, after being fitted with prostheses, they were able to ambulate independently inside and outside the house, with or without assistive devices, for at least 500 meters. Indoor ambulation was defined as being able to walk around only inside the house. Nonambulating patients could not walk or could walk only a few steps with assistance, for a distance less than 3 meters. The ambulation status of all patients was determined from their status at discharge or from records of the last available clinical visit, with average rehabilitation periods of 76.7 ⫾ 47.7 days. Fisher’s exact test was used for statistical analysis between the clinical factors and the ambulation outcome and p ⬍ .05 was considered significant. The odds ratio (OR) also was used to evaluate the advantages of several factors in ambulation training. RESULTS The 23 patients included 7 women and 16 men. Their mean age was 65.5 ⫾ 9.1 years (range, 50 to 80yrs). The average interval between the first and second disability was 4.9 ⫾ 6.4 years (range, 1mo to 27yrs). Causes of hemiplegia or hemiparesis were thromboembolic CVA in 19 patients and intracerebral hemorrhage in 4. The causes of amputation were diabetes in 11 patients and nondiabetic peripheral vascular disease in 12.
Fifteen subjects had transtibial (below-knee) amputation and 8 had transfemoral (above-knee) amputation (table 1). The patients with dual disabilities represented 8.7% of the 264 lower extremity amputation patients and 2% of the 1,158 CVA patients admitted from 1984 to 1994. Ambulation outcome. All the patients were unable to ambulate before rehabilitation. Of the 23 patients, 10 (43.5%) achieved community ambulation and 13 (56.5%) became noncommunity ambulators, including 5 (21.7%) indoor ambulators and 8 (34.8%) nonambulators. Association between selected clinical features and ambulation outcome. The achievement of community ambulation and statistical results in each selected group are shown in table 2. Of the selective clinical features, only mental status related to the ambulation outcome with statistical significance ( p ⬍ .05). None of the five patients with impaired mental status achieved community ambulation. Considering the OR, we found that patients with certain factors had a higher success rate of community ambulation, although this trend was not statistically significant. These factors were mild motor involvement, transtibial amputation, amputation occurring before CVA, age younger than 60 years, and the presence of ipsilateral hemiplegia and amputation. For example, the chance of achieving community ambulation in the group of patients with mild motor involvement seemed to be 3.8 times higher than the other group (OR ⫽ 3.8). The side of hemiplegia and the etiology of CVA were not related to the patients’ ability to ambulate. DISCUSSION To our knowledge, there has been no study on the incidence of CVA patients who subsequently have an amputation or the incidence of amputation patients who subsequently experience a CVA, although the prevalence of persons with lower extremity amputation who have suffered a stroke at some time has
Table 1: Data of the Subjects Age (yrs)
Hemiplegia
Community ambulation
56 65 52 56 64 77 58 69 72 50
Severe Mild Mild Severe Mild Mild Severe Mild Mild Mild
Intact Intact Intact Intact Intact Intact Intact Intact Intact Intact
Indoor ambulation
74 54 62 69 67
Mild Severe Mild Severe Severe
Nonambulation
57 74 72 58 66 78 80 77
Severe Mild Mild Severe Severe Mild Severe Severe
Outcome
Mental Status
Sequence
Etiology
Side of CVA
Amputation (Side)
I I I I I II II II II III
TE TE ICH ICH TE TE TE TE TE TE
R R R R L L R L R R
TT (R) TT (R) TF (R) TT (R) TT (L) TT (L) TT (R) TT (L) TT (L) TF (L)
Intact Impaired Intact Intact Intact
I I I I I
TE ICH TE TE TE
L R L R R
TT (L) TT (L) TF (L) TT (R) TT (R)
Impaired Intact Intact Impaired Impaired Intact Intact Impaired
I I I I I II II III
TE TE TE ICH TE TE TE TE
R L R R L R R R
TT (R) TF (R) TF (R) TT (R) TF (L) TF (L) TT (L) TF (L)
Abbreviations: I, CVA before amputation; II, Amputation before CVA; III, both within 3 months; TE, thromboembolic CVA; ICH, intracerebral hemorrhage; R, right; L, left; TT, transtibial amputation; TF, transfemoral amputation.
Arch Phys Med Rehabil Vol 81, January 2000
16
AMBULATION OUTCOME OF DUAL DISABILITIES, Chiu Table 2: Association Between Selected Clinical Features and Community Ambulation Outcome Community Fisher’s Exact Patients Ambulators Test Odds n n (%) p Value Ratio
Feature
Severity of hemiplegia Mild Others Mental status Intact Impaired Amputation level Transtibial Transfemoral Sequence Amputation first Hemiplegia first Simultaneous Age ⱕ60yrs ⬎60yrs Laterality of disability Ipsilateral Contralateral Side of hemiplegia Right Left Etiology of hemiplegia Thromboembolic Intracerebral hemorrhage
12 11
7 (58.3%) 3 (27.3%)
.21
3.8
18 5
10 (55.6%) 0 (0.0%)
⬍.05
13.6
15 8
8 (53.3%) 2 (25.0%)
.38
3.4
6 15 2
4 (66.7%) 5 (33.3%) 1 (50.0%)
.33
4.0
8 15
5 (62.5%) 5 (33.3%)
.22
3.3
16 7
8 (50.0%) 2 (28.6%)
.41
2.5
16 7
7 (48.8%) 3 (42.9%)
1.00
1.0
19 4
8 (42.1%) 2 (50.0%)
.60
0.7
been reported to be from 4% to 42%.1,8,12-14 In our series, dual-disability patients were 8.7% of total amputation patients and 2% of total CVA patients admitted to our institution from 1984 to 1994. In the early 1960s, the rehabilitation outcome of patients with dual disabilities was considered poor. Hoover15 stated that hemiplegia superimposed with amputation made ambulation unusually difficult and frequently contraindicated prosthetic fitting. Russek16 reported that neurologic weakness in the remaining limbs was a negative factor for prosthetic rehabilitation. Since 1978, some authors have shown better results of prosthesis fitting in the CVA patients, and they believe that patients with dual disabilities can benefit from rehabilitation training.10 In the reported series,5,8,10 from 26% to 46% of patients with dual disabilities have been trained to be ambulatory, including community and indoor ambulation (table 3). Independent ambulation is an important step in the independence of patients. Varghese10 documented that the achievement of indoor ambulation could also much improve the independence of patients in their daily lives. In the present study, 43.8% of the 23 patients achieved community ambulation, and 21.7% Table 3: Ambulation Outcomes of Patients With Dual Disabilities in Previous Studies and Present Study Number of Cases Series
Total
Prosthesis Training
Varghese10 O’Connell8 Altner5 Present study
30 46 52 23
30 17 30 23
Ambulation Outcome (%) Community
Limited/ Indoor
Ambulatory Total
3 (10%) 3 (7%) 8 (15%) 10 (44%)
10 (33%) 9 (20%) 16 (31%) 5 (22%)
13 (43%) 12 (26%) 24 (46%) 15 (65%)
Arch Phys Med Rehabil Vol 81, January 2000
achieved indoor ambulation. In all, two thirds of our patients achieved some ambulation. This result supports the idea that patients with dual disabilities can benefit from rehabilitation. The better success rate of ambulation in the present study than that reported in earlier studies might be explained by two reasons—the advancement of rehabilitation medicine in the past 10 years, and our selection of cases. Our study only included the patients who were admitted to our institute. Consequently, because some patients with poor medical condition or with no potential for rehabilitation were excluded from our series, we could expect that our rate of successful ambulation would be higher than in the general dual-disability population. Nevertheless, our results also show that patients with dual disabilities have a good chance to achieve functional ambulation if properly selected and rehabilitated. In this study, only mental status was statistically associated with ambulation outcome, even though our sample group was small. None of the patients with impaired mental status in our series achieved community ambulation. A similar finding was documented in a study by O’Connell and Gnatz.8 Of 19 incontinent patients who were generally considered as having cognitive deficits and impaired mental status, only one achieved independent ambulation. This finding is understandable given that ambulation training for patients with dual disabilities is complex and requires more skills and learning ability. O’Connell and Gnatz8 reported that mild hemiparesis and transtibial amputation were statistically significant factors associated with regaining independent ambulation. Altner and colleagues5 stated that good to fair neuromuscular status was the deciding factor for good ambulation. In the series reported by Varghese,10 patients with transtibial amputation had better ambulatory achievement than those with transfemoral amputation, but Varghese did not report the status of neuromuscular involvement. In the present study, we discovered a trend toward better ambulation achievement in subjects with mild motor involvement and transtibial amputation. Similar to our result, Varghese10 stated that patients with amputation before CVA, age younger than 60 years, and ipsilateral hemiplegia and amputation had a trend toward better ambulation outcome. In the series by O’Connell and Gnatz,8 however, as well as in the series by Altner,5 no association with these factors was found; they even had some opposite results. The influences of these three factors, therefore, are still debatable, and further study in a well-controlled series is necessary. Regarding the side of hemiplegia, O’Connell and Gnatz8 and Altner5 had the same results as in our series. No association was found between hemiplegic side and ambulation outcome. In conclusion, impaired mental status seemed to be the most influential negative predictive factor of achieving community ambulation in dual-disability patients. We also consider severity of hemiplegia and amputation level to be influencing factors on the ambulation outcome of dual-disability patients. Furthermore, 65.5% of the patients with dual disabilities in our series were able to achieve community or indoor ambulation. Rehabilitation for patients with the dual disabilities of hemiplegia and amputation is beneficial, and patients can achieve satisfactory results if properly selected and trained. Acknowledgment: The authors thank Wen-Yi Shau, MD, from the Institute of Epidemiology of National Taiwan University for his statistical counseling.
AMBULATION OUTCOME OF DUAL DISABILITIES, Chiu
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Arch Phys Med Rehabil Vol 81, January 2000