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Poster 159 Critical care pathway for lower limb amputation
ACADEMY ANNUAL ASSEMBLY ABSTRACTS
extensors, and hand intrinsics with less than antigravity strength in his deltoids and biecps. The patient was unable to bring his hand to his face for hygiene, grooming, or feeding. A deltoid aid, an Ultraflex, and a surgical tubing type orthosis were tried but the patient lacked sufficient strength in his biceps or deltoids to use any of these. A Dynamic Triceps Driven Orthosis (DTDO) was designed to address this patient's functional impairment. This orthosis utilizes a cable attached to wristbands on each wrist that is then threaded though special housings mounted on a padded shoulder harness. The cable length is adjusted so that it is only long enough to allow one arm to be positioned in extension, while the opposite limb is flexed at the elbow. With ipsilateral triceps extension, the contralateral limb is passively pulled into elbow flexion. This DTDO permits the patient to feed himself, brash his teeth and hair, use the telephone, read a book, and function more independently in the home. He also uses the orthosis for active assistive biceps strengthening exercises. The DTDO design is simple, inexpensive, and can be made from materials available in most therapy, orthotics, or bioengineering shops.
Poster 159 "Critical Care Pathway for Lower Limb Amputation." Robert H. Meier HI, MD (University of Colorado Health Sciences Center, Denver, CO), Monica Ritzdorf, AAS; Lynn Riippi, RN; Beth McEIroy, BS, MPT; K a r e n Ksiazek, MD. Critical care pathways are being developed in rehabilitation to decrease the cost of care and enhance the delivery of quality care. Our amputee center, in an acute medical/surgical center, had a unique opportunity to develop an amputee rehabilitation pathway that can begin in the preoperative phase. It follows amputees using outcome measures through the phase of community integration. This pathway was developed through 28 weeks of interdisciplinary team meetings representing 347 hours. The personnel costs represent $41,000. The per diem charge in acute rehabilitation is $1,200. The acute postsurgical phase is limited from 5 to 7 days with discharge home, to acute rehabilitation or a subacute setting at that point. If we avoid 34 days of inpatient rehabilitation, we will have in effect paid for the development of the pathway. Using the TSI software program, the hospital has estimated the actual costs of providing each portion of care, including nursing and therapy provision. The pathway allocates the idealized services on each postoperative day with specific outcome measures for each day of hospitalization. The outcomes for discharge following the surgery are: pain control on oral medication, satisfactory wound healing, independence in ADLs, independent mobility, acute patient education completed and psychosocial interventions completed. Using this pathway, only 15% of all lower limb amputations from all causes have been admitted for inpatient rehabilitation. These patients represent those with multiple comorbid factors or bilateral lower limb amputations. Eighty-five percent are therefore discharged from the acute postoperative phase to their home setting and their prosthetic rehabilitation is provided on an outpatient basis. A second outpatient pathway has been developed that also measures outcomes using the Functional Independence Measurement (FIM) and the Community Integration Questionnaire (CIQ). Phases for outpatient amputee rehabilitation have been developed with patient educational materials for each of these phases. The inpatient and outpatient actual costs of care in each phase are analyzed. Utilizing these pathways, the amputee can achieve the highest level of function and integration in a cost effective manner.
Poster 160 "Successful Prosthetic Fitting of an Elderly Hip Disarticulation Amputee Patient With Cardiopulmonary Disease." Manouchehr Refaeian, MD (The University of Texas Health Science at San Antonio, San Antonio, TX); Robert D. McAneHy, MD; Dennis G. O'Connell, PhD; Gregory D. PoweH, MD; Nicolas E. Walsh, MD. Patients with hip disarticulation (HD) require high energy expenditure for successful prosthetic ambulation. Thus, older patients are rarely fitted with a HD prosthesis. To our knowledge, there are no reports of successful prosthetic fitting of an elderly HD amputee patient with cardiopulmonary disease. We report the case of a successful prosthetic ambulation in a 73-year-old man with HD secondary to histiosarcoma, and medical history significant for stable angina, COPD, and diabetes mellitus. The patient underwent gait training with an endoskeletal prosthesis, and achieved ambulation to 400 feet with bilateral forearm
1071
crutches. Vicon kinematic gait analysis revealed cadence of 44 steps/ min (112 steps/min normal), velocity of 0.20m/s (1.17rn/s normal), stride length of 0.52m (1.23m normal), and double stance of 44% (26% normal). Metabolic measurements using a Quinton cart found VO2 of l l.0mL/kg/min at velocity of .35m/s. These compare with published figures for HD VOw_of 10.73mL/min/kg at velocity of 0.93m/s. At oneyear follow-up, the patient continues to walk with the prosthesis. We conclude that one should consider trial fitting of a HD prosthesis on an individual basis in the elderly.
Poster 161 "Falls in a High Risk group in a Rehabilitation Setting." Edward C. Burnetta, MD (The Graduate Hospital, Philadelphia, PA); Francis J. Bonner Jr., MD. From a group of 76 high risk patients who fell in their bathroom/ bedroom areas during their inpatient stay on a restraint-free rehabilitation floor, a retrospective study was performed to determine if the presence of a bedside commode influenced the likelihood of falling or injuries from falling. Data were acquired from incident reports of falls over a one-year period. Because a majority of falls happen in bedroom and bathroom areas, only falls in these areas were included. Patients were included in the high risk group if their medical record showed 2 or more risk factors for falls from the admission summary. A total of 109 fall events occurred in this group. Of these, 93 (85%) took place without a bedside commode, whereas 16 (15%) occurred with a bedside commode present. Without quantifying severity, injuries ensued in one third of cases in both groups. Twenty (18.3%) falls took place in the bathroom, whereas 89 (81.6%) happened in the patient's room. Only 1 (5%) of the bathroom falls occurred with bedside commode present. Findings are suggestive of a protective effect with placement of a bedside commode in a high risk population, since falls were reported 6 times more frequently in those without a bedside commode. This is particularly striking in the case of bathroom falls.
Poster 162 "Rehabilitation of Quadrimemberal Amputees Following Pneumococcal Sepsis." Lance L. Goetz, MD (University of Michigan Medical Center, Ann Arbor, MI); Jason Jennings, CO; James A. Leonard Jr., Nil). Multiple limb amputation is a recognized complication of diffuse intravascular coagulopathy associated with systemic sepsis. The rehabilitation course for two patients hospitalized after episodes of pneumococcal sepsis with multiorgan system failure, disseminated intravascular coagulopathy, and severe extremity iscbemia is presented. Gangrene and severe soft tissue loss requiting 4 limb amputation and skin grafting occurred in each case. The 2 patients shared a common history of splenectomy following trauma as children but had not received prophylactic vaccination before their sepsis. Prolonged wound healing, contractures, and short residual limb length complicated prosthetic rehabilitation management. Both patients have been successfully fit with bilateral upper and lower extremity prostheses and are functional users of all four prostheses. The prosthetic restoration and rehabilitation course of each patient is described. Discussion regarding incidence, treatment, and outcome after pneumococcal sepsis is briefly discussed. Current recommendation regarding pneumococcal vaccination after splenectomy is also reviewed.
Poster 163 "Low Ejection Fraction: A Challenge for Prosthetic Fitting and Ambulation." Jacob L. Lochner, DO (University of Rochester• Strong Memorial Hospital, Rochester, NY); Kanakadurga R. Poduri, MD. Advanced cardiac disease should not preclude prosthetic fitting and ambulation. Ejection fraction (EF) is commonly used as an indicator of cardiac function. Low EF is associated with increased morbidity and mortality. There is a paucity of literature about successful prosthetic use in amputees with low EF. Our case study is comprised of 4 geriatric amputee patients (ages 63 to 78 yrs old) 1 with below knee amputation (BKA), 2 with above knee amputation (AKA), and 1 with both AKA and BKA. Etiology of amputation was peripheral vascular disease in 3 cases; comorbidities included diabetes mellitus, myocardial infarction, congestive heart failure, and cardiomyopathy. The documented EF (as measured by echocardiography) for these subjects was 12%, 18%, 20%,
Arch Phys Med Rehabil Vol 76, November 1995
extensors, and hand intrinsics with less than antigravity strength in his deltoids and biecps. The patient was unable to bring his hand to his face for hygiene, grooming, or feeding. A deltoid aid, an Ultraflex, and a surgical tubing type orthosis were tried but the patient lacked sufficient strength in his biceps or deltoids to use any of these. A Dynamic Triceps Driven Orthosis (DTDO) was designed to address this patient's functional impairment. This orthosis utilizes a cable attached to wristbands on each wrist that is then threaded though special housings mounted on a padded shoulder harness. The cable length is adjusted so that it is only long enough to allow one arm to be positioned in extension, while the opposite limb is flexed at the elbow. With ipsilateral triceps extension, the contralateral limb is passively pulled into elbow flexion. This DTDO permits the patient to feed himself, brash his teeth and hair, use the telephone, read a book, and function more independently in the home. He also uses the orthosis for active assistive biceps strengthening exercises. The DTDO design is simple, inexpensive, and can be made from materials available in most therapy, orthotics, or bioengineering shops.
Poster 159 "Critical Care Pathway for Lower Limb Amputation." Robert H. Meier HI, MD (University of Colorado Health Sciences Center, Denver, CO), Monica Ritzdorf, AAS; Lynn Riippi, RN; Beth McEIroy, BS, MPT; K a r e n Ksiazek, MD. Critical care pathways are being developed in rehabilitation to decrease the cost of care and enhance the delivery of quality care. Our amputee center, in an acute medical/surgical center, had a unique opportunity to develop an amputee rehabilitation pathway that can begin in the preoperative phase. It follows amputees using outcome measures through the phase of community integration. This pathway was developed through 28 weeks of interdisciplinary team meetings representing 347 hours. The personnel costs represent $41,000. The per diem charge in acute rehabilitation is $1,200. The acute postsurgical phase is limited from 5 to 7 days with discharge home, to acute rehabilitation or a subacute setting at that point. If we avoid 34 days of inpatient rehabilitation, we will have in effect paid for the development of the pathway. Using the TSI software program, the hospital has estimated the actual costs of providing each portion of care, including nursing and therapy provision. The pathway allocates the idealized services on each postoperative day with specific outcome measures for each day of hospitalization. The outcomes for discharge following the surgery are: pain control on oral medication, satisfactory wound healing, independence in ADLs, independent mobility, acute patient education completed and psychosocial interventions completed. Using this pathway, only 15% of all lower limb amputations from all causes have been admitted for inpatient rehabilitation. These patients represent those with multiple comorbid factors or bilateral lower limb amputations. Eighty-five percent are therefore discharged from the acute postoperative phase to their home setting and their prosthetic rehabilitation is provided on an outpatient basis. A second outpatient pathway has been developed that also measures outcomes using the Functional Independence Measurement (FIM) and the Community Integration Questionnaire (CIQ). Phases for outpatient amputee rehabilitation have been developed with patient educational materials for each of these phases. The inpatient and outpatient actual costs of care in each phase are analyzed. Utilizing these pathways, the amputee can achieve the highest level of function and integration in a cost effective manner.
Poster 160 "Successful Prosthetic Fitting of an Elderly Hip Disarticulation Amputee Patient With Cardiopulmonary Disease." Manouchehr Refaeian, MD (The University of Texas Health Science at San Antonio, San Antonio, TX); Robert D. McAneHy, MD; Dennis G. O'Connell, PhD; Gregory D. PoweH, MD; Nicolas E. Walsh, MD. Patients with hip disarticulation (HD) require high energy expenditure for successful prosthetic ambulation. Thus, older patients are rarely fitted with a HD prosthesis. To our knowledge, there are no reports of successful prosthetic fitting of an elderly HD amputee patient with cardiopulmonary disease. We report the case of a successful prosthetic ambulation in a 73-year-old man with HD secondary to histiosarcoma, and medical history significant for stable angina, COPD, and diabetes mellitus. The patient underwent gait training with an endoskeletal prosthesis, and achieved ambulation to 400 feet with bilateral forearm
1071
crutches. Vicon kinematic gait analysis revealed cadence of 44 steps/ min (112 steps/min normal), velocity of 0.20m/s (1.17rn/s normal), stride length of 0.52m (1.23m normal), and double stance of 44% (26% normal). Metabolic measurements using a Quinton cart found VO2 of l l.0mL/kg/min at velocity of .35m/s. These compare with published figures for HD VOw_of 10.73mL/min/kg at velocity of 0.93m/s. At oneyear follow-up, the patient continues to walk with the prosthesis. We conclude that one should consider trial fitting of a HD prosthesis on an individual basis in the elderly.
Poster 161 "Falls in a High Risk group in a Rehabilitation Setting." Edward C. Burnetta, MD (The Graduate Hospital, Philadelphia, PA); Francis J. Bonner Jr., MD. From a group of 76 high risk patients who fell in their bathroom/ bedroom areas during their inpatient stay on a restraint-free rehabilitation floor, a retrospective study was performed to determine if the presence of a bedside commode influenced the likelihood of falling or injuries from falling. Data were acquired from incident reports of falls over a one-year period. Because a majority of falls happen in bedroom and bathroom areas, only falls in these areas were included. Patients were included in the high risk group if their medical record showed 2 or more risk factors for falls from the admission summary. A total of 109 fall events occurred in this group. Of these, 93 (85%) took place without a bedside commode, whereas 16 (15%) occurred with a bedside commode present. Without quantifying severity, injuries ensued in one third of cases in both groups. Twenty (18.3%) falls took place in the bathroom, whereas 89 (81.6%) happened in the patient's room. Only 1 (5%) of the bathroom falls occurred with bedside commode present. Findings are suggestive of a protective effect with placement of a bedside commode in a high risk population, since falls were reported 6 times more frequently in those without a bedside commode. This is particularly striking in the case of bathroom falls.
Poster 162 "Rehabilitation of Quadrimemberal Amputees Following Pneumococcal Sepsis." Lance L. Goetz, MD (University of Michigan Medical Center, Ann Arbor, MI); Jason Jennings, CO; James A. Leonard Jr., Nil). Multiple limb amputation is a recognized complication of diffuse intravascular coagulopathy associated with systemic sepsis. The rehabilitation course for two patients hospitalized after episodes of pneumococcal sepsis with multiorgan system failure, disseminated intravascular coagulopathy, and severe extremity iscbemia is presented. Gangrene and severe soft tissue loss requiting 4 limb amputation and skin grafting occurred in each case. The 2 patients shared a common history of splenectomy following trauma as children but had not received prophylactic vaccination before their sepsis. Prolonged wound healing, contractures, and short residual limb length complicated prosthetic rehabilitation management. Both patients have been successfully fit with bilateral upper and lower extremity prostheses and are functional users of all four prostheses. The prosthetic restoration and rehabilitation course of each patient is described. Discussion regarding incidence, treatment, and outcome after pneumococcal sepsis is briefly discussed. Current recommendation regarding pneumococcal vaccination after splenectomy is also reviewed.
Poster 163 "Low Ejection Fraction: A Challenge for Prosthetic Fitting and Ambulation." Jacob L. Lochner, DO (University of Rochester• Strong Memorial Hospital, Rochester, NY); Kanakadurga R. Poduri, MD. Advanced cardiac disease should not preclude prosthetic fitting and ambulation. Ejection fraction (EF) is commonly used as an indicator of cardiac function. Low EF is associated with increased morbidity and mortality. There is a paucity of literature about successful prosthetic use in amputees with low EF. Our case study is comprised of 4 geriatric amputee patients (ages 63 to 78 yrs old) 1 with below knee amputation (BKA), 2 with above knee amputation (AKA), and 1 with both AKA and BKA. Etiology of amputation was peripheral vascular disease in 3 cases; comorbidities included diabetes mellitus, myocardial infarction, congestive heart failure, and cardiomyopathy. The documented EF (as measured by echocardiography) for these subjects was 12%, 18%, 20%,
Arch Phys Med Rehabil Vol 76, November 1995