Use of the Early Walking Aid as a "Geriatric Prosthesis" in the Community
R. Dickstein
L. Halevy
H. Meir
R. Bigon
The early walking aid for lower extremity amputated patients facilitates and enhances their ambulation.1,2 The device is composed
of a leather or polyethylene socket with an ischial seat, double uprights with locked knee joints (releasable for sitting), an ankle joint with
one degree of freedom, and afoot-piece. A pelvic belt and metal hip joint are used for attachment around the waist. The socket of the device
is open distally, and weight-bearing is through the ischial seat (Figure 1)
. Devas2 described the routine application of the early walking
aid in rehabilitation of lower extremity geriatric patients, especially in cases of above-knee amputees. The advantages of the aid lay in its
simple structure, the lack of pressure on the residual limb, the ease of its construction, its light weight, and its low price. Patients trained
to ambulate with the aid started to walk earlier than those who had to wait for a permanent prosthesis. They were frequently discharged
to their homes ambulating with the walking aid rather than with a conventional above-knee prosthesis.
In 1982, the early walking aid was introduced in geriatric rehabilitation in Israel as either a temporary or a permanent substitute for the
conventional above-knee prosthesis. The initiative for this step came from the National Institute for Prosthetics and Orthotics, and it was driven by evaluative studies demonstrating diminished longevity3,4 and low rate of use of the conventional above-knee
prosthesis among aged patients.5 This data, weighed against the high costs of public money invested in prosthetic rehabilitation of aged
above-knee amputees, led to the decision to try to rehabilitate these patients with the early walking aid, which was named the "geriatric
prosthesis." Subsequently, patients who gained independent ambulation in the rehabilitation center received the geriatric prosthesis for
home use and for outdoor activities. In addition, each of these patients also received a walking frame (walker) or two four-point canes and
a wheelchair. Those patients who were not able to demonstrate sufficient walking ability were discharged in a wheelchair without any
walking aid. The decision whether to discharge a patient with or without a walking aid was made after a thorough appraisal by the
rehabilitation team, which was composed of a physiatrist, a physical therapist, and a social worker.
The purpose of this study was to evaluate the use of the geriatric prosthesis in the natural environment of its recipients. Although several
authors have reported satisfactory use of the device at home,2,3 a systematic study of the subject has not been reported. Since three years have elapsed from the time the first devices were given for home use, assessment of their use was required.
Method
Subjects
The survey included all above-knee amputated subjects in Israel who were rehabilitated with the geriatric prosthesis between March,
1982 and January, 1986 and who were living at their homes between April and August, 1986. The data was retrieved from the files of
the National Institute for Prosthetics and Orthotics. Twenty-four subjects fulfilled the admission criterion to the study. In all cases, the
patients' amputations were due to deficient vascular supply to the involved leg. Following amputation, each one of the participants
underwent an active rehabilitation program in which optimal use of the geriatric prosthesis was achieved.
Procedures
The data was collected during a home visit to each participant. The first three patients were visited by two physiotherapists, the rest
by one of them. In the first three visits, consistency of measurements of the two reviewers was verified; inter-rater reliability was found
to be higher than 90%.
Investigation of each subject was accomplished through three evaluative tools: (1) questionnaire, (2) physical examination, and (3)
observation of several predetermined activities.
The oral questionnaire investigated the following items: independence in donning the device, independence in personal hygiene as well
as in dressing and bathing, ability to climb and descend stairs, ambulatory confines, frequency of outdoor ambulation, duration of prosthetic
use during the day, and patient's opinion and comments on the device.
The physical examination consisted of examination of the sound leg and the residual limb. Items checked and noted in the sound leg
were: (1) Skin appearance: the presence of dryness, hair loss, gangrenous ulcers and varicose veins; (2) Edema, checked by observation
and palpation; (3) Function of superficial touch sensation in the foot and shank and proprioception in the toes, according to Mahalon et
al.6; (4) Pain at rest or during ambulation; and (5) Pulse of the dorsalis pedis artery. Magnitude of the pulse was defined as either normal,
weak, or absent.
Items checked in the residual limb were:
(1) Adhesions in the surgical scar - by observation; (2) Wounds or pressure points on the residual limb - by observation; and (3) Hip flexion contracture by the Thomas test.7
The observational procedures were undertaken in order to verify some of the information that the subjects gave about their use of the geriatric prosthesis. The following activities were
observed by the visiting physiotherapist: (1) Donning of the device; (2) Getting up from sitting; (3) Walking in the room; and (4) Descending and ascending stairs.
Operational Definitions and Data Analysis
Descriptive statistics were used to describe the findings. The Odd Ratio Test8 was used to inquire about possible relationships between use of the geriatric prosthesis and either the status
of the residual limb or the nonamputated leg.
A satisfactory status was assigned to the non-amputated leg when no more than two of the signs checked by the physiotherapist were positive, excluding the presence of ulcers, which had
to be negative. Therefore, an unsatisfactory status was assigned to a leg
having either ulcers and/or at least three other positive findings.
The status of the residual limb was defined as satisfactory when all signs were negative; one or more positive findings indicated that the status of the residual limb was unsatisfactory.
Prosthetic use was defined by three ordinal categories indicating either optimal, moderate, or negligible use. The information by which each of the three categories of prosthetic use was
determined was derived from the responses to the questionnaire and from the observational techniques employed by the reviewers. This data is presented in Table 1
.
Results
Subjects' Characteristics
The study population included 17 men and 7 women. Mean age was 69.15 (sd = 6.8) years. Twenty-three patients had an above-knee amputation of one leg, while one subject had bilateral
above-knee amputations. All patients had more than one pathology:
Sixty-two percent of the subjects suffered
from Diabetes Mellitus, 58% had cardiac disorders, 29% suffered a recent CVA, and the same percentage suffered also from hypertension. Another 17% of the patients had impaired vision.
Prosthetic Use
No discrepancies were found between the information gained from the oral questionnaire and the observations of the reviewers. Prosthetic use was optimal among five (20.83%) of the
subjects. It was moderate in eight cases (33.33%), and minimal or absent in the remaining eleven (45.83%) patients. Women seemed to make better use of the device than men: only one
woman out of the seven participants (12.3%) belonged to the category of "minimal or no use" (see definition in Table 1
) while ten men (48.73% of the male subjects) belonged to that group.
Examination of prosthetic use in relation to the time that elapsed from its receipt revealed that optimal use prevailed only in patients who had the device for less than one year. In that time,
70% of the subjects used the device for ambulation. In contrast, most of the subjects who had the walking aid more than one year (73%) were not using it. This data is presented in Table 2
.
Status of the Non-amputated Leg
The frequency of positive findings in the physical examination of the "sound" leg is
presented in Table 3
(Column 1). Based on this data, the status of the sound leg was defined as satisfactory in 11 (45.83%) patients and unsatisfactory in the rest (54.17%). Application
of the Odd Ratio Test to these data in relation to use of the device indicated a significant relationship between the two: patients whose non-amputated leg was in satisfactory condition were
using the device ten times more than those whose non-amputated leg was in unsatisfactory condition.
Status of the Residual Limb
Physical findings relating to the status of the residual limb are given in Table 3
(Column 2). Based on these data, the status of the residual limb was defined as satisfactory in one third of
the patients, and unsatisfactory in the rest. However, this variable was not significantly related to prosthetic use (the Odd Ratio Test).
Independence in ADL
Only 25% of the subjects reported complete independence in the activities of self hygiene, dressing, and bathing. Another 25% reported partial dependence, i.e., needed some assistance,
while the remaining half of the respondents said they were completely dependent on assistance of another person. The majority of these dependent patients were those who were also unable
to ambulate independently.
Patients' Comments
Thirteen patients (56%) stated that the device was uncomfortable, referring specifically to its excessive weight. Eleven subjects (46%)
declared that, because of their physical handicap, they were not using it at all. However, only four (16%) were ready to give it back without
getting an alternative walking aid. Twelve patients (50%) expressed a wish for another more "suitable" device, most of them (eight
patients) emphasizing the desire for improved cosmetic appearance.
Discussion
The major finding of this work is the fact that use of the geriatric prosthesis at home
was essentially limited to the first year after discharge from rehabilitation. The significant association between use of the prosthesis and
the status of the non-amputated leg points to the reliance of the subjects on that leg. Considering the systemic nature of the vascular
pathology which also affected the sound leg, combined with excessive loading and multiple related pathologies, cessation of ambulation
is not surprising. In most cases, cessation seemed to result from deterioration in the status of the non-amputated leg, combined with
insufficient cardiovascular reserve. The latter notion is supported by the high prevalence of cardiovascular diseases, which was also
reported by other workers.9 The complaints about excessive weight of the device by more than half of the patients strengthen the same
argument.
Although the low rate of use may be interpreted as undermining the initial decision to supply the device, one cannot ignore the refusal
of most of the nonusers to return it. Furthermore, despite its rare use and despite the high frequency of dependency on another person in
basic ADL activities, almost 50% of the respondents expressed a wish for improved cosmetic appearance of the prosthesis. In other words,
although it is clear from the findings that the frequency of actual use of the device dramatically decreased with passage of time, patients'
comments revealed that its availability as a potential substitute for their lost leg was of crucial importance to them.
Other authors similarly stressed the importance of the cosmetic appearance of a prosthesis for successful rehabilitation.10,11 Isacov
and his peers thought that low use of the conventional above-knee prosthesis at home implicated failure of the prosthetic rehabilitation.5
However, our findings indicate that use for walking should not be the sole determinant for evaluating the outcome of prosthetic
rehabilitation. The role of the geriatric prosthesis in the population of this study was broader than mere ambulation. It seemed to make an
important contribution to the psychological adjustment of the patient to his disability and to his coping within his home. Our
recommendation to teams weighing the pros and cons of supplying a walking device to an aged above-knee amputated patient is to consider
the device not solely as a walking aid, but also as a major psychological support that facilitates the adjustment to the new disability.
R. Dickstein is with the School of Physiotherapy, the Wingate Institute and the Department of Physical Therapy, The Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel 42902.
L. Halevy is a fourth year students, the Department of Phyical Therapy, The Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
H. Meir is a fourth year students, the Department of Phyical Therapy, The Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
R. Bigon is with the National Institute of Prosthetics and Orthotics, Tel Hashomer, Israel.
References:
- Warren, R., 'The Early Rehabilitation of the Arteriosclerotic Amputee," Surgery, 42, 1957, pp.190-197.
- Devis, M., 'The Geriatric Amputee," Geriatne Orthopedics, 1977, Academic Press, London.
- Finch, D.R.A., D.J.T. Macdougal, and P.J. Morris, "Amputation for Vascular Disease: The
Experience of the Peripheral Vascular Unit," Br.
- J. Surg., 67, 1980, pp.233-237.
- Couch, N.P., J.H. David, N.L. Tilney et al., "Natural History of the Leg Amputee," Am. J. Surg., 133, 1979, pp.469-473.
- Isacoy, E., H. Ribs, and Z. Susak, "Rehabilitation of the Vascular Amputee and Prosthesis Utilization," Hrefuah (The Journal of Israel Medical Association), 5, 1985, pp.145-147.
- Mahalon, H. and R.T. Manning, "Major Physical Diagnosis," An Introduction to Clinical Process, 1981, 9th ed., W.B. Saunders Company, Philadelphia.
- Hoppenfeld, S., Physical Examination Spine and the Extremities, 1976, Appelton Century Crafts, New York.
- Abramson, J.H., 'Survey Methods in Community Medicine,'' An Introduction to Epidimiologi(al and Evaluative Studies, 1979, Churchill Livingstone, London.
- Chapman, EC., HF. Palmer, and D.M. Bell, "Follow-up Study on a Group of Older Amputee Patients," J.A.M.A., 170, 1959, pp.1396-1398.
- MaIler, M.J. and A. Dellitto, "Selective Criteria for Successful Long Term Use," Phvs. Ther., 65, 1985, pp.1037-1040.
Levine, A., "The Elderly Amputee," American Family Physican, 29, 1985, pp- 177-182.
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