I^IAART 1977 F I S I O T E R A P I E 9 MPUTEE REHABILITATIO N A QUESTION OF TIME B E R N IC E K E G E L , B.Sc. P h ysio. (R an d), R .P .T . A su rve y o f 127 p a tie n ts seen a t the U n iv e r sity o f C h ic a g o o v e r th e p a st th re e y e a r s is p r e s e n te d in an attem pt to d isc o ve r a n d b re a k d o w n th e le n g th o f tim e i n v o l v e d in a m p u te e re h a b ilita tio n as w e ll as th e results achieved. Sex P a tie n ts stu d ie d in c lu d e d 51 fe m a le s a n d 76 m ales. m a t e r i a l s a n d m e t h o d # D uring the p a s t th re e y e ars th e U n iv e rsity o f C h ica g o " aS seen 127 p a tie n ts w ith a to ta l o f 152 a m p u ta tio n s . All the p a tie n ts w e re seen a t th e A m p u ta tio n C linic, som e on a c o n su lta tiv e b a sis m a n y y ears a f te r c o m p le tio n o f rehabilitation a n d so m e d u rin g re h a b ilita tio n . T h e U n i­ versity o f C h ica g o is p rim a rily an a c u te c a re fa cility . A ll Surgery a n d P h y s ic a l T h e ra p y w ere n o t ne ce ssa rily achieved a t th is facility . F a c to r s c o n sid ere d in c lu d e d age, sex, level o f a m p u ta tio n , a e tio lo g y fo r a m p u ta tio n , a n d associated m ed ic al p ro b le m s c o m p lic a tin g re h a b ilta tio n . The survey w as re tro s p e c tiv e in design r a th e r th a n experim ental. In th is w ay, p e rs o n a l b ia s is re d u c e d . D a ta collected w ere su b je c te d to analysis. V a ria tio n s in to ta l case n u m b e rs a re re la te d to e ith e r a bsence o f d a ta fro m the m ed ic al c h a rts , o r r e h a b ilita tio n w h ic h is still in progress. RESULTS Age T he p a tie n ts ’ ages ra n g e d fro m b irth to 90 y e a rs w ith a m ean o f 54,2 y e ars. T w e n ty -e ig h t p e r c e n t o f the patients w ere in th e se v e n th d e c a d e o f life a t th e tim e o f am p u ta tio n . F ifte e n p a tie n ts in th is g ro u p h a v e since expired. P e rio d o f tim e tra n s p ire d b e tw e e n a m p u ta tio n and d e ath ra n g e d fro m th r e e w eeks to 23 years. M A L E F E M A L E Figure 2: Sex distribution L evel o f A m p utation T h e re w ere 97 b e lo w knees a m p u te e s, 45 a b o v e knee a m p u te e s a n d 10 u p p e r e x tre m ity a m p u te e s. S ta tistic a l differences b e tw e e n le ft a n d rig h t sided in v o lv e m e n t w ere in significant. CD 2 10 20 30 to 50 60' 70 SO A G E A T T I M E O F A M P U T A T I O N Fig. 1: A g e at tim e o f A m p utation F O R E Q U A R T E R a b o v e e l b o w B E L O W E L B OW P A R T I A L HAND h e m I P E L V E C T O M Y H I P D I S A R T I C U L A T I O N A B O V E K N E E b e l o w k n e e k n e e d i SART i c u l a t ION S Y M E S T R A N S M E T A T A R S A L 20 to 60 £0 100 N U M B E R O F A M P U T A T I O N S F igure 3: D etailed Breakdow n o f L e v e l o f A m p utation R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 10 P H Y S I O T H E R A P Y M ARCH , 1977 Cause fo r A m p utation S e v e n ty -tw o p e r c e n t o f th e a m p u ta tio n s w ere d o n e due to v a s c u la r p ro b le m s. O f th e 99 v a s c u la r a m p u ta tio n s , 56 p a tie n ts h a d d ia b e te s as w ell. N in e p e r c en t o f the a m p u ta tio n s w ere d o n e fo r tu m o u rs w h ic h in c lu d e d G ia n t C ell L y m p h o m a , C h o n d ro s a rc o m a , S y n o v ia l S a rc o m a , A m e la n o tic M a lig n a n t M e la n o m a , F ib ro s a rc o m a , S q u a ­ m o u s C ell C a rc in o m a a n d R h a b d o m y o s a rc o m a . T ra u m a , 1 0 % in c lu d e d b u rn s, g u n s h o t w o u n d s , m o to r ve h ic le acci­ d e n ts, tra in a n d m o to r c ycle a cc id e n ts as w ell as m u ltip le fra c tu re s . F iv e p e r c e n t o f th e a m p u ta tio n s w e re d one fo r in fe c tio n , m a in ly o ste o m y e litis. V e ry few c o n g e n ita l a m p u ta tio n s w ere seen, p ro b a b ly b e c a u se m o st c h ild ren a re re fe rre d to sp e c ia lised Ju v e n ile A m p u te e C linics. C O N G E N I T A L I N F E C T I O N TR AU MA TUMOUR D I A B E T 1C V A S C U L A R D I S E A S E P E R I P H E R A L V A S C U L A R 0 1 S E A S E F R O S T B I T E UN KN OWN 0 10 20 30 UQ 50 60 N U M B E R O F C A S E S F igu re 4. Cause o f A m p utation A ssociated M ed ical P rob lem s C om p licatin g R ehab ilitation B e a rin g in m in d t h a t th e m a jo r r e a s o n f o r a m p u ta tio n w as v a s c u la r insufficiency, a n d re m e m b e rin g t h a t th is is u su a lly a g e n e ra lise d c o n d itio n , th e sa m e fa c t lim its re h a b ilita tio n . T h irty -o n e p e r c e n t o f th e p a tie n ts h a d c a rd io v a s c u la r p ro b le m s in c lu d in g M y o c a rd ia l In fa rc tio n , C e re b ro v a s c u la r a c c id e n ts, C o n g e stiv e H e a r t F a ilu r e a n d H y p e rte n s io n . Seven p e r c e n t h a d p o o r v isio n o r b lin d ­ ness. T w e lv e p e r c e n t h a d d e la y e d w o u n d h e a lin g , a n d 6 % d e v e lo p e d c o n tra c tu re s . O th e r fa c to rs c o n trib u tin g to d e la y e d r e h a b ilita tio n w e re R h e u m a to id A rth ritis , P so ria sis, B o n y O v e rg ro w th a n d p r o f o u n d w eight changes. Length o f T im e B etw een A m p utation and Prescription N in e ty -o n e p a tie n ts w e re fo llo w ed up. L e n g th o f tim e v a rie d fro m o n e m o n th t o 36 m o n th s w ith a m e a n of f o u r m o n th s . T ype o f Prescription S e v e n ty -o n e p e r c e n t o f th e b e lo w k n e e a m p u te e s w ere fitted w ith p a te lla te n d o n b e a rin g t o ta l c o n ta c t so ck ets w ith so ft le a th e r lin e rs, s u p ra c o n d y la r stra p s, w a ist b elt, a n d sach feet. F o u r te e n p e r c e n t w e re fitte d w ith p a te lla te n d o n s u p r a c o n d y la r p ro s th e s e s a n d 15% h a d th e o ld e r p lu g fit w ith th ig h la c e rs. T h e a b o v e k n e e a m p u te e s w ere fitted w ith q u a d r ila te r a l to ta l c o n ta c t so c k e ts, 50% w ith suction,, 5 0 % w ith o u t. T h e m a jo rity h a d b o c k sa fe ty knees. T h r e e p a tie n ts h a d M a u c h S .N .S . h y d ra u lic knees. T im e E lapsed B etw een Prosthetic Prescription and D elivery S e v e n ty -fo u r p a tie n ts w e re fo llo w e d up. T im e elapse(j ra n g e d fro m o n e m o n th to 12 m o n th s w ith a m ean 0f 2j m o n th s. Length o f Training S ix ty -eig h t p a tie n ts w e re tra in e d a t th is facility . Most p a tie n ts w ere tre a te d as o u tp a tie n ts , b e in g seen 2-3 times p e r w eek. T ra in in g tim e v a rie d fro m 2 w eeks to 7 m o n th s w ith a m e a n o f 1,9 m o n th s . T w o m o n th s o n the a v era g e w as re q u ire d to p ro s th e tic a lly tra in a b e lo w knee a m p u te e , a n d 3 m o n th s f o r a n a b o v e k n e e am p u te e. L evel o f Independ en ce R each ed E ig h ty -n in e p a tie n ts w e re review ed. T w enty-five per c e n t o f a ll p a tie n ts w a lk e d w ith o u t a n y a ssistive device a n d 42% re q u ire d o n ly one c an e . O n ly 2% o f th e patients w ere w h e e lc h a ir b o u n d . w h e e l c h a i r W A L K E R 1 C A N A D I A N C R U T C H 2 C A N A D I A N C R U T C H E S A X I L L A R Y C R U T C H E S Q U A D C A N E 2 C A N E S 1 C A N E I N D E P E N D E N T N U M B E R O F P A T I E N T S F igure 5: L evel o f Independ en ce A chieved T otal T im e In volved O n th e a v e ra g e it ta k e s e ig h t m o n th s fo r c o m p le tio n of re h a b ilita tio n fro m tim e o f a m p u ta tio n to tim e o f dis­ c h a rg e fro m P h y s io th e ra p y . K e rs te in (1974) re p o rts six m o n th s , b u t d o e s n o t sta te h o w o fte n p a tie n ts w e re seen fo r tre a tm e n t. Breakdow n o f L ength o f T im e from A m p utation to P rescription, L ength o f T raining, Independ en ce Attained according to Sex, A ge, and A e tio lo g y F o r th e p u rp o s e o f sim p lic ity , in d e p e n d e n t am bulation w as c o n sid e re d o f th o se p a tie n ts w a lk in g w ith o u t any e x te rn a l aid, o r u sing ju st a stra ig h t c an e . A ssisted am bu­ la tio n w as c o n sid e re d a n y th in g fro m tw o c a n e s to a w a lk er. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) IV1AART 1977 F I S I O T E R A P I E 11 T ab le I: Sex ' M ale Female Age 0 -3 0 y e a rs 30 -6 0 y e a rs 60 a n d u p Cause F r o s tb ite p e rip h e ra l V a sc u la r D isease D ia b e te s M ellitus T u m o u r T ra u m a I nf e ct i on C o n g e n ita l T i m e F r o m A m b u l a t i o n A m p u t a t i o n to L e n g t h o f I n d e p e n d e n t w ith h r e s c r ip t io n T r a in i n g A m b u l a t i o n A s s is ta n c e 3 m o n th s 1,8 m o n th s 8 4 % 16% 4 ,6 m o n th s 1,8 m o n th s 5 0 % 50% 2 m o n th s 1,9 m o n th s 91 % 9 % i m o n th s 1.6 m o n th s 56 % 4 4 % 3 m o n th s 1,8 m o n th s 69 % 3 1 % N o i n f o r m a t i o n N o i n f o r m a t io n 100% 0 % 3,5 m o n th s 1,9 m o n th s 63 % 37 % 3 ,4 m o n th s 1 ,6 m o n th s 6 5 % 3 5 % 4 m o n th s 1.2 m o n th s 6 6 % 44 J/o 5 m o n t h s 2 ,5 m o n th s 9 0 % 10% 3.5 m o n th s 1 m o n th 50% 50% N o i n f o r m a t i o n N o n e 100% 0% th e tis t on th e staff o f th e R e h a b ilita tio n M e d ic in e D e p a r t ­ m en t, th is tim e lag c o u ld be sign ific a n tly re d u ce d . L e n g th o f tra in in g a v era g ed a t 1,9 m o n th s , re g ard less o f age, sex, o r c a u se o f a m p u ta tio n . R e su lts p re se n te d are th o se fo r p a tie n ts tre a te d o n a n o u t- p a tie n t basis. P e rh a p s h a v in g th e p a tie n t a d m itte d to th e h o s p ita l fo r s h o rte r, m o re in te n siv e r e h a b ilita tio n w o u ld b e th e s o lu ­ tio n . In v e stig a tio n in to th is m a tte r sh o u ld b e in stig a ted . A lso in te re s tin g to n o te is t h a t it tak es a p p ro x im a te ly th e sa m e le n g th of tim e to tr a in a 2 0 -y e a r-o ld as it d o e s a n 8 0 -y e ar-o ld . T h e r e a s o n fo r th is is p r o b a b ly th a t th e 2 0 -y e ar-o ld is p u sh e d to g re a te r d e g ie e s o f p e rfe c tio n , a n d ta u g h t m an y m o re things. T h e fa c t t h a t 69% o f p a tie n ts o v e r 60 y e ars o f age a tta in e d in d e p e n d e n c e is im pressive. A s can be seen fro m th e in d e p e n d e n c e levels a chieved, in sp ite o f a g e a n d p o o r v a s c u la tu re , p ro s th e tic tra in in g is o b v io u sly w o rth th e effort. I t is a q u e s tio n o f level o f a c h ie v e m e n t v e rsu s p ric e in tim e! C o n tin u e d e m p h a sis is re q u ire d to de cre ase th e tim e in v o lv e d . Discussion E ight m o n th s is a lo n g tim e f o r a n y p a tie n t to w a it to be fu lly a m b u la n t a g ain . E ffo rts sh o u ld be d ire c te d to reduce th a t tim e. L e n g th o f tim e fro m a m p u ta tio n to p re scrip tio n a p p e a rs u n a ffe c te d b y age, sex, a n d original a e tio lo g y fo r a m p u ta tio n . T h e o n ly w ay to decrease th is tim e is im p ro v e d w o u n d h e a lin g a n d sh a p in g of the re sid u a l lim b. S e v e ral re se a rc h p ro g ra m m e s a re under w ay a tte m p tin g to m ak e im p ro v e m e n ts in th is a rea . T w o -a n d - a - h a lf m o n th s fro m p ro s th e tic p re s c rip tio n to delivery is in d e e d excessive. A c tu a l f a b ric a tio n o f the prosthesis tak e s o n ly a few days. T h is is d u e in p a r t to slowness of th ird p a rty p a y m e n t. T h e m a jo r re a s o n fo r this d e la y a p p e a rs p u re ly a d m in istra tiv e in n a tu r e a nd could p ro b a b ly b e de cre ased . A t th is fa cility a p riv a te prosthetic c o m p a n y n o t s itu a te d w ith in th e a c tu a l h o s ­ pital was utilize d . P e rh a p s b y h a v in g a c ertified p ro s- Summary A g ro u p o f a m p u te e s seen a t th e A m p u ta tio n C lin ic o f th e U n iv e rsity o f C h ica g o a re review ed, w ith sp e c ia l re fe re n c e to b re a k d o w n o f le n g th o f tim e in v o lv e d in c o m p le tin g .re h a b ilita tio n , a n d in d e p e n d e n c e levels ach iev e d . A tte m p ts w ere also m a d e to se e i f age, sex a n d c au se f o r in itia l a m p u ta tio n p lay e d a n y r o le in d e te r m in in g ' len g th o f tra in in g o r fu n c tio n a l a b ility achieved. A ckn ow led gem ents I w o u ld like to th a n k th e D ir e c to r a n d staff o f the P h y s ic a l T h e r a p y D e p a rtm e n t a t th e U n iv e rsity o f C h ica g o fo r th e ir a dvice, c riticism a n d a ssista n ce in a c c u m u la tio n o f d a ta . R eferences 1. K e rste in , M . D .; Z im m e r, H .; D u g d a le , F . E .; L e rn e r, E .; “ A m p u ta tio n o f th e L o w e r E x tre m ity ; A S tu d y o f 194 C a se s” . A rc h . P h y s. M e d . O ct. 1974. T H E P R IN C IP L E O F P H Y S IO T H E R A P Y W O R K SH O P S T he c o n c e p t o f P h y s io th e ra p y W o rk s h o p s w as first p u t to u se b y th e O b s te tric A s so c ia tio n a n d h a s b e e n u se d successfully in r e c e n t m o n th s b y th e S.A .S.P. N o r t h e r n T ransvaal B ra n ch . A W o rk s h o p ta k e s th e fo rm o f a n in fo rm a l, r o u n d ­ table g a th e rin g o f p h y s io th e ra p is ts a t w h ic h b o th th e o ­ retical a n d p ra c tic a l a sp e c ts o f a p a r tic u la r s u b je c t a re th o roughly d iscussed a n d d e m o n s tra te d . T h e su b je c t is introduced b y o n e o r tw o m o re e x p e rie n c e d m em b e rs, after w h ic h a ny m e m b e r m a y p u t fo rw a rd id ea s o n th e subject a n d d e m o n s tra te th e te c h n iq u e fo rth w ith . A trea tm e n t m at, p lin th , a p p a r a tu s o r m a c h in e u n d e r d is ­ cussion can be d isp lay e d a n d u se d a t such a w o rk s h o p . T h e W o rk s h o p le a d e r sum s u p a t th e e n d a n d defines areas o f u n c e r ta in ty w h ic h c a n be r e s e a rc h e d b e fo re a later, re p o rt-b a c k w o rk s h o p . A p a n e l o f e x p e rts m a y also be in vited to g u id e d iscussion. T he a im s o f P h y s io th e ra p y W o rk s h o p s can b e s u m ­ m arised as fo llo w s: 1. to e n a b le p h y s io th e ra p is ts to in te rc h a n g e id ea s a n d le a rn fro m o n e a n o th e r in a n in fo rm a l, p ra c tic a l a tm o s p h e re ; 2 . to define c o n tro v e rs ia l o r u n c e r ta in a re a s o f a s u b ­ je c t re q u irin g re se a rc h , a n d th e ie fo r e 3 . to s tim u la te in te re s t in re se a rc h ; 4 . to c re a te a n o p p o rtu n ity fo r p re s e n tin g a n d disc u ss­ ing a v a ila b le re s e a rc h lite ra tu re w h ic h is oth erw ise o fte n o v e rlo o k e d . . - T h e W o rk s h o p e v en in g s a re c h a ra c te ris e d b y lively c o m m e n t, p a u se s o f fu rio u s c o n c e n tra tio n a n d , n eed less to say, f re q u e n t b a n te rin g w hich, w h ile e n s u rin g a h e a d ­ a ch e o r tw o f o r th e W o rk s h o p le a d e r, m a k e s th e evening b o th e d u c a tio n a l a n d e n jo y a b le . S u b je cts d e a lt w ith so fa r w ere h e m ip leg ia a n d low b a c k p a in . T h e la tte r p ro v e d to o v a st a n a re a , as e x p e rts on th e v a rio u s c a u s e s sp o k e a n d a f te r 2 \ h o u rs t h e C h a ir ­ m a n h a d to i n te r r u p t lively a n d in te re s te d d isc u ssio n a n d p ro m is e a se c o n d session! P h y s io th e ra p y W o rk s h o p s n e ed n o t re p la c e th e m o re c o n v e n tio n a l le c tu re fo rm o f B ra n c h m ee tin g s, b u t do p ro v id e a re fre sh in g v a ria tio n on m a n y a n o ld th em e . W o rk s h o p s h a v e, h o w e v e r, p ro v e d t o b e v e ry p o p u la r w ith a ll c a te g o rie s o f m em b e rs1 a n d a tte n d a n c e a t th ese h a s in c re a s e d b o th in n u m b e rs a n d activ e p a rtic ip a tio n . M R S . G . O O S T H U IZ E N R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )