To Fit or Not To Fit?

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Considerations When Fitting Elderly Dysvascular Patients with a Prosthesis


Regardless of an amputation's etiology, fitting a prosthesis is no easy feat. Every patient has different needs and preferences, and part of the prosthetist's job is to translate those needs and preferences into a comfortable, functional device that the patient will use. Elderly dysvascular patients who have undergone amputation present a particularly complex mix of considerations when it comes to the decision about whether to fit the patient with a prosthetic device, ranging from balance issues and comorbidities to the patient's emotional state. The O&P EDGE asked several experts to discuss issues that impact the decision about whether or not to fit an elderly dysvascular patient with a prosthesis, and while their "front of mind" considerations vary, they agree that once the patient is past the acute stage following amputation, most can benefit from a prosthesis.

Friedly

Major Considerations

Janna L. Friedly, MD, rehabilitation physician at Harborview Medical Center, Seattle, Washington, and assistant professor of rehabilitation medicine at the University of Washington, Seattle, says that elderly dysvascular patients who have had an amputation as a result of complications from diabetes, peripheral vascular disease, or a combination of the two "have a number of challenges and medical issues that are...distinct from younger traumatic amputees. So the factors that we consider when helping the patient through the rehabilitation process and making each of those major decisions are somewhat unique."

The main factors to consider when working with an elderly dysvascular amputee patient, Friedly says, include the following:

  • Comorbidities: Elderly dysvascular patients often have diabetes, cardiac disease, or respiratory or neurological conditions that can affect their ability to use a prosthesis safely and effectively.
  • Premorbid function: Was the patient able to walk before amputation? If he or she had a chronic ulcer, wound, or other issue that led to the amputation, how long had this been going on, and did it impact the patient's functional abilities and health?
  • Current medical issues: Does the patient have complications from the amputation, such as loss of range of motion in his or her hips or knees from sitting or lying in bed and not walking, or weakness in either the upper or lower limbs?
  • When is the patient ready for prosthetic fitting? Initiation of prosthetic fitting depends on skin integrity and being ready functionally. Older dysvascular amputees take longer to heal and often have difficulty with wounds, which delays prosthetic fitting.

"The basic criteria we use to decide if someone is ready to start prosthetic training is that they are able to move around in bed independently, are able to go from sitting to standing without assistance, and are able to walk on their intact leg using a walker or in parallel bars at least a few steps," Friedly says. "If they aren't able to do these basic things, they are not ready to start prosthetic fitting.

"Typically, this is two to three months after an amputation for a dysvascular amputee, while for young, traumatic amputees, this can start in six to eight weeks," she continues. "It's not uncommon for six or more months to pass for the skin to heal and the elderly person to gain enough strength to be ready for prosthetic fitting."

Once the patient is ready for prosthetic fitting, one of the main considerations when selecting a device type is fall risk. Falls are extremely common among all amputees, Friedly says, but older amputees with vascular disease and other comorbidities "are at very high risk. They often are being treated with blood thinners, which makes it even more risky if they fall," she says. "So choosing prosthetic components and the design of the prosthesis must take into consideration safety first to minimize the risk of falling."

Another key consideration is the ability to easily don and doff the prosthesis. "[Patients] must be able to put the prosthesis on correctly," Friedly says. "Often, older adults have difficulty with vision, hand function, cognitive function, and memory, which can impair their ability to put prosthetics on correctly."

Edema in the legs and fatigue are also major considerations. Because of these difficulties, some patients, she says, "either do not benefit from a prosthesis or may find the prosthesis unsafe." Given the increased metabolic cost of walking with a prosthesis, and depending on the level of amputation, the fatigue may make it too difficult for them to walk. For those patients, a wheelchair may be the best option.

"The fall risk...may outweigh the benefits of using a prosthesis for some patients," Friedly says.

When asked what problems arise most often among her dysvascular amputee patients, Friedly cites pain, which can be from poor blood supply or poor socket fit and constriction of the limb, falls, and overuse injuries to other joints. "The prosthesis needs to fit well, and ongoing adjustments need to be made to the socket to fit intimately with the residual limb," she says.

Still, the benefits of using a prosthesis are huge, particularly for elderly patients. Being able to engage in social activities and independence provide big psychological boosts, she says. Walking and being more active in general helps these patients improve their cardiovascular health. For some people, the prosthesis even provides a cosmetic benefit-another psychological bonus.

Kannenberg

Considerations to Optimize Prosthetic Success

Andreas Kannenberg, MD, director of medical affairs at Ottobock, Duderstadt, Germany, agrees that many elderly patients with vascular problems will benefit from prostheses; however, he stresses that the decision about whether or not to fit these patients with a prosthesis is not a decision that should be made lightly.

The key factors to consider, he says, are the patient's overall health, comorbidities that affect the nervous and cardiovascular systems, and peripheral neuropathy, which could impair perception and motor control of the prosthesis.

Like Friedly, Kannenberg cites balance as a main concern, saying that it may be impaired as a result of vestibular neuropathy.

"Cardiovascular comorbidity may impact overall physical and walking capabilities and thus rehabilitation capacity," he says.

"Moreover, vascular amputees usually are more prone to develop residual-limb wounds as their capacity to tolerate poor socket fit is limited."

Complications with prosthetic device use are common among elderly amputees, in part because these patients are less capable of controlling and securing their prosthesis than younger traumatic amputees, he says. "They tend to stumble and fall more frequently in everyday situations and usually require a safer prosthesis in terms of biomechanical alignment and components," Kannenberg says.

From a physician's perspective, approving an elderly amputee with vascular disease for a prosthetic device also depends, in part, on the reason for the amputation. For instance, if the reason is isolated atherosclerosis of the leg arteries that hasn't affected the rest of the body, the prognosis for the patient to be able to walk again is better than for a patient with diabetes and several comorbidities.

"The more comorbidities, the poorer the prognosis of the patient," Kannenberg says.

The emotional health of the patient should also be assessed. A patient who is depressed will have less motivation, "which has a tremendous influence on rehabilitation and thus prognosis," he says.

When the patient has been provided with a properly aligned prosthesis composed of safe prosthetic components but he or she still cannot safely operate a prosthesis, Kannenberg agrees with Friedly's assertion that a wheelchair is needed. He adds that for those patients who have been fit with a prosthesis but must rely on a wheelchair to navigate longer distances safely, the wheelchair could be used as an adjunct to the prosthesis.

"Walking is a bigger demand on the cardiovascular system than wheelchair mobility and thus has a positive influence on cardiovascular and overall health," Kannenberg says. "Not all places are easily accessible for wheelchair users but may be accessed by prosthesis users who are able to walk. If a patient is able to use a prosthesis, he or she should do so, if necessary, in combination with a wheelchair."

Carroll

Residual-Limb Volume Changes

Kevin Carroll, MS, CP, FAAOP, vice president of prosthetics at Hanger Clinic, headquartered in Austin, Texas, says that one of the main complications he sees with elderly dysvascular patients is residual-limb volume changes. He advises his fellow prosthetists to manage volume fluctuations carefully.

"We do this through encouraging the patient to wear a shrinker socket at night," Carroll says. Another option is to use liners of various thicknesses. The patient can also add a sock over the liner, if needed.

Pain and discomfort that stem from the patient's vascular issues should also be continually evaluated. Carroll advises prosthetists to communicate with the patient's vascular physician and stay on top of disease-related pain and discomfort issues. He encourages his patients to do the same thing.

Carroll says that he relies on the vascular surgeon's expertise to help protect against adverse reactions. If the surgeon recommends a prosthesis, he says, "It's rare we have an adverse reaction."

Device choice, he says, is determined by the patient's functional level. Low functionality means a more basic, less expensive prosthesis, while high functionality translates into a more sophisticated prosthesis. "Advanced-style prosthetic devices do very well for active amputees, and oftentimes, these patients return to leading an active, productive lifestyle," Carroll says.

While some studies have shown that contralateral amputations are more likely with elderly dysvascular patients, Carroll says it doesn't always have to be that way. Indeed, a prosthesis can help the patient not to put as much stress on the sound leg.

"We don't see contralateral amputations as much now as we used to," he says. "After undergoing an amputation, patients are more cautious and more educated. They know what to look for, where they may have previously ignored an issue."

Clinicians, he adds, are also more inclined to be proactive when elderly dysvascular patients present with warning signs that could lead to a contralateral amputation.

Physical therapists can help dysvascular patients with amputations to become more active once they have been fitted with a prosthesis by teaching them how to use the prosthesis, better understand their balance, and re-learn how to walk. "Therapy is very critical in the early stages," Carroll says.

Advances in prosthetic technology have also helped to improve the safety of prosthetic devices and relieve some of the physical stress caused by prosthetic use. Ankles are more compliant and provide better balance, and microprocessorcontrolled knees and feet also provide greater balance and help to reduce falls, Carroll says.

Technology has also been part of the answer to help relieve physical stress caused by a prosthesis to these patients. New and advanced sockets provide a better fit and less stress and impact on the skin and the residual limb. Shock-absorbent features on prosthetic devices also reduce the amount of physical stress that results from prosthetic use. Overall, Carroll concludes, elderly dysvascular patients can absolutely benefit from a prosthesis.

"When a person can be up and mobile, it makes them healthier, lets them get out of the house, and allows for a more active lifestyle," he says. "To be mobile is something we all want to be-up and moving around, living life."

An additional, sometimes overlooked advantage of prosthesis use is the benefit for the families, he says. For example, it's much easier on family members who transfer the patient around when the patient can help with the prosthesis. The prosthesis also reduces the cost for the family because they can care for the patient at home and keep the patient out of a nursing home.

Edelstein

Factors Beyond Functional Levels

The Centers for Medicare & Medicaid Services (CMS) has done some of the work when it comes to determining who should receive a prosthesis, according to Joan E. Edelstein, MA, PT, FISPO, adjunct professor of physical therapy and former senior research scientist in the Department of Prosthetics and Orthotics, New York University, New York.

"Medicare has identified five [functional] levels, and the identification only applies to unilateral transtibial or unilateral transfemoral amputation...," Edelstein says. "There is pretty much a consensus as to who those people are."

Deal breakers, she says, are people with cardiac disease, people with advanced dementia, and people with advanced pulmonary disease. Indeed, the key factors she considers when evaluating whether or not a patient will be successful with a prosthesis are the status of the patient's cardiovascular system and the ability of the patient to take care of his or her residual limb and the prosthesis.

Those who benefit from a prosthesis start by being in good health. "Their heart and lungs are reasonably healthy, they have reasonable cognition, and they are motivated," Edelstein says.

"Walking with a prosthesis puts more stress on a person than an able-bodied person would normally sustain," she adds. Thus, it's also critical that the patient is able to care for the residual limb because once healing has occurred, the patient must keep it from sustaining additional abrasions or wounds.

Other deal breakers include people who are severely emotionally depressed and who don't have the finances to pay for the prosthetic device. "Some people fall through the cracks," she says.

And while there is a definite psychological aspect associated with limb amputation, a prosthesis "can work in a positive sense," she says. "In the psychological sphere, amputation is permanent. It's a permanent visible alteration, a reflection of health problems that could not be managed any other way, which of course is very demoralizing. [A prosthesis] restores the person's ability to stand and walk, and it also, incidentally, restores his complete body. He gets to wear a pair of shoes."

Garrison Wells is an award-winning freelance writer and author based in Colorado Springs, Colorado. He has written for newspapers and magazines nationwide and authored five books on martial arts. He can be reached at