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Rehabilitation and Prosthetic Intervention Pathways in Managing the Dysvascular Patient

Lisa Schoonmaker, CPO

ABSTRACT

According to the American Diabetes Association, each year more than 56,000 amputations are performed on people with diabetes. Diabetes has no cure, and indications are that the number of people affected by this disease will continue to climb. Diabetic individuals have an increased chance of developing peripheral vascular disease (PVD) and nerve damage leading to amputation.¹ It is estimated that 90% of limb amputations in the Western world are a consequence of PVD/diabetes.² For these reasons, it is imperative that prosthetic practitioners educate themselves about the most appropriate pathways to follow when treating the dysvascular patient.

This article addresses the prosthetist's treatment options when working with a dysvascular individual and includes discussions concerning postoperative removable semirigid dressings, preparatory prostheses, and definitive prosthetic prescription. Patient education and the clinical team approach are also included as important issues affecting the rehabilitation of the dysvascular amputee.

Key Words: Diabetes; peripheral vascular disease; prosthetics; patient education.

Introduction

PVD is caused by the formation of cholesterol plaque deposits in arteries, decreasing their blood-carrying capacity. Blocked arteries in the heart result in intense pain-angina-that is often the preliminary warning of heart attack. Obstructed arteries of the lower extremities result in pain called claudication, a symptom that is also a precursor to potentially life-threatening complications. People older than 45 who smoke and have a family history of artery disease are at higher risk of developing PVD.³ Although individuals with PVD are not necessarily diabetic, individuals with diabetes are at higher risk for PVD. Very often diabetes and vascular disease accompany each other.^1,3

What is diabetes and why are affected individuals typically older people? There are two versions of diabetes: the auto-immune disease in which the body does not produce insulin (type I) and the metabolic disorder resulting from the body's inability to make enough, or properly use, insulin (type II). Approximately 90% to 95% of diabetics are type II, and the risk for type II diabetes increases with age. Type II diabetes is now reaching epidemic levels in the United States as the number of older people increases and there is a greater prevalence of obesity and low-activity lifestyles.¹

Discussion

The first step in managing a patient with dysvascular amputation is the application of a removable polyethylene semirigid dressing (PSRD). The PSRD course of treatment promotes healing and provides trauma protection, edema prevention, pain reduction, and residual limb maturation. Fitting takes place one week postoperatively, at which time the patient practices donning and doffing the device with the practitioner's guidance. Socket flexibility is an advantage of the PSRD over a rigid cast. Most often the newly amputated limb is bulbous. The flexible proximal socket allows the larger distal end to pass easily and facilitates donning (Figure 1) .

The early use of a PSRD allows the patient to participate actively in his or her own rehabilitation while the practitioner observes the amputee's progress. The patient learns about the application of residual limb socks and shrinker, donning and doffing procedures, and proper hygiene. The prosthetist uses the PSRD as an evaluation tool. Once the patient demonstrates compliance with the PSRD, the next step is a preparatory prosthesis.⁴

When a PSRD has been used successfully, the dysvascular patient is less likely to have problems dealing with volume loss in the preparatory prosthesis. The residual limb has already begun the maturation process, and the amputee understands prosthetic care. These results are particularly helpful to diabetic/dysvascular patients who are predisposed to developing skin abrasions caused by rapid shrinkage of the limb during ambulation and poor residual limb care.⁴

The design of the preparatory prosthesis must include a variable-volume socket, which is lightweight and custom-made for the patient. A socket with variable volume has several benefits. Much like the PSRD, an adjustable socket facilitates donning when the residual limb is still bulbous (Figure 2) . The two-piece design makes it possible to don and doff the prosthesis without subjecting the dysvascular limb to unnecessary shear. The patient can adjust the socket itself as well as vary the sock ply to maintain proper fit. Socket adjustability eliminates the need to replace the preparatory socket several times before stabilization occurs.⁵ The prosthetic components should be lightweight and sufficiently durable to accommodate the patient's increasing activity during rehabilitation. The mode of suspension needs to be effective yet not cause proximal constriction.

The decision to proceed with definitive prosthetic fitting is based on the perception that the patient has reached a plateau in both wearing time and residual limb volume. Limb stabilization may occur after four months, but it is more likely that the process will take approximately one year.⁶ Again, components should be lightweight and capable of functioning appropriately for the patient's activity level. It is imperative that the mode of suspension not inhibit blood flow or allow pistoning. The socket should encourage vascular return and be total-contact in design.⁷ The incorporation of a silicone or urethane gel interface allows the diabetic/dysvascular limb to better tolerate forces within the socket (Figure 3) . Increasing the patient's comfort level while maintaining tissue health will encourage the patient to maximize his or her rehabilitation goals.

A team approach to treating and monitoring the patient with dysvascular amputation serves the best interests of the patient.¹ The range of skills represented in a team increases the probability that all aspects of rehabilitation will be addressed and that none will be overlooked. The team should include not only medical professionals, but also family members, other successfully treated amputees, and, of course, the patient.⁸ Patient education is critical. People with vascular compromise can reduce the risk of complications if they understand their disease. The patient must understand how to care for the amputated limb and the contralateral extremity and how to best control the disease process.¹ An example of a successful team approach for patients with PVD is the PACT (Prevention Amputation Care and Treatment) program now used at the Cleveland Veterans Affairs Medical Center. The PACT program emphasizes patient education and encourages patients to change their attitudes and behaviors voluntarily to promote wellness and prevent disease. The postamputation prevention efforts include rehabilitation referral, psychotherapy for postamputation issues, smoking cessation consultations, and regularly scheduled podiatry follow-ups.⁹ The importance of communication cannot be overemphasized. Effective communication has been shown to increase patient compliance, resulting in improved health outcomes because the patient feels actively involved in his or her own healthcare.¹⁰

Conclusion

The majority of amputations performed in the United States involve diabetic/dysvascular individuals.³ For this reason, prosthetic practitioners must educate themselves about how to treat this group of patients properly. Prosthetic pathways in managing the dysvascular patient should include prosthetists' knowledge of the diagnosed disease process, application of the appropriate prosthetic interventions, and a clinical team approach emphasizing patient education. Early prosthetic intervention means less psychological distress for the patient after amputation. Optimal results can be obtained by integrating the prosthesis into the body image and concentrating on future function rather than past loss.⁸ When prosthetic practitioners express interest in the patient as a whole, rather than simply concentrating on the affected body part, interaction improves and successful health outcomes are more likely.¹⁰

References:

1. American Diabetes Association (www.diabetes.org 1997).
2. Bowker J, Michael J. Atlas of limb prosthetics. In St. Louis: Mosby Year Book. 1992:25.
3. Stagg S. Leg cramps may warn of blocked leg arteries. Cardiovascular Institute of the South. 1998 (www.cardio.com).
4. Swanson V. Below-knee polyethylene semi-rigid dressing. JPO. 1993;5:1:10-15.
5. Wilson A, Schuch C, and Nitsche R. A variable volume below-knee prosthesis. Clinical Prosthetics and Orthotics. 1987;11:1:11-19.
6. Bowker J, Michael J. Atlas of limb prosthetics. In St. Louis: Mosby Year Book. 1992:453.
7. Murphy E. Sockets, linings and interfaces. Clinical Prosthetics and Orthotics. 1984;8:3:4-10.
8. Bowker J, Michael J. Atlas of limb prosthetics. In St. Louis: Mosby Year Book. 1992:709.
9. Robbins J, Ober S, Strauss G, Rusterholtz A. Long-term aftercare and prevention of further amputation. Clinics in Podiatric Medicine and Surgery. 1997;14:4:785-801.
10. Nielsen C, Psonak R, Kalter T. Factors affecting the use of prosthetic services. JPO. 1989;1:4:242-249.