How do Cardiopulmonary and/or Cardiovascular Diseases Affect the Treatment of the Amputee: A Clinical Approach

This presentation will include a review of common disorders of the cardiovascular and pulmonary systems that affect successful rehabilitation after amputation: chronic obstructive pulmonary disease (COPD), coronary heart disease (CHD) and peripheral vascular disease (PVD). Common tests, treatments and medications used in the management of each disease will be reviewed with recommendations on how this information can be utilized for clinical decision making, utilizing a case-based approach.

The format will follow an actual patient case. All information will pertain to the specific patient. Following the presentation there will be a discussion with the practitioners in the room regarding recommendations for a prosthetic treatment plan including prosthetic components, PT recommendations, etc.

Coronary heart disease (CHD) is responsible for the highest rate of mortality in the United States. More than two million deaths occur in the U.S. each year. One out of four Americans suffer from some form of cardiovascular disease in his or her lifetime. Modifiable risk factors for CHD are as follows: smoking, hyperlipidemia, hypertension, inactivity, and diabetes. Non-modifiable risk factors include age, race, familial history, and sex.

Working with patients with CHD can be complex. It is imperative prior to treatment of any kind that you obtain an in-depth history (i.e. Medications, blood work, x-ray, post-op report, etc.). After obtaining a history, vital signs such as blood pressure, heart rate, pulse goniometry, and respiratory rate should be taken. This will give the practitioner a base line while working with the patient. Ongoing monitoring during training is key for the patient’s safety. The practitioner can use specific tools to identify shortness of breath using a scale (0-4), angina (0-4) and rating of perceived exertion (0- 10).

Other invasive and non-invasive tests and tools used to predict, monitor, diagnose, and evaluate CHD include but are not limited to: electrocardiogram (EKG), stress test, HsCRP, catheterization, and echocardiogram. They provide information relating to the condition and function of the heart. Understanding these tests and the information they provide is extremely important. Information obtained from tests such as these will be discussed regarding the patient case and directly related to prosthetic use and outcomes. As an example: if 4 to 5 METs is the average energy cost for prosthetic training and if an amputee weighs 250 pounds with advanced heart disease and is severely deconditioned, will the amount of energy required for ambulation place too much of a strain on the compromised heart. Or would this patient be an ideal candidate for cardiac rehab training prior to or along with prosthetic training?

Peripheral vascular disease (PVD) is caused by the same atherosclerotic plaque that causes CAD. As the internal lining of the artery thickens from the plaque the blood vessel becomes increasingly constricted and blood flow diminishes. PVD affects up to 10 million people in the United States. Peripheral artery disease (PAD) is a type of peripheral vascular disease related only with the blood through the arteries. PAD occurs in about 18 percent of persons over 70 years of age. Major risk factors for PAD include; cigarette smoking, diabetes mellitus, older age (older than 40 years), hypertension, and hyperlipidemia.

The diagnosis of PVD and PAD includes patient history and examination. Diagnostic tests include: ankle brachial index (ABI), ultrasound doppler, angiography, and magnetic resonance angiography (MRA). Each will be discussed with an emphasis on interpretation of the results. Ischemia and claudication will also be discussed. All information will relate to patient treatment; medication, exercise, angioplasty with and without stent, and bypass.

Amputees with PAD and PVD can be complicated. Prosthetists tend to focus on the involved extremity with the acquired amputation. Frequently, there is vascular compromise both proximal to the level of amputation and in the contra-lateral extremity. It is important to understand the affect of this disease on the entire body and take into account all issues when determining the most appropriate prosthetic treatment to achieve the most optimum outcome.

COPD is a common pulmonary diagnosis, especially in the aging population. The disease is progressive, and leads to disability due to pulmonary function impairment and symptoms of cough and dyspnea with exertion. Symptoms often lead to decreased activity and progressive loss of endurance and muscle mass due to deconditioning. Maintaining ambulation function after an amputation is a difficult but worthwhile goal. These goals may depend on disease severity and symptoms; however, significant progress can be made if the client is offered appropriate education, conditioning, and prosthetic intervention.

Clinical-decision making is enhanced by understanding the underlying physiology, tests and labs to determine disease severity, measurements of physiological parameters during activity and the corresponding severity of symptoms, and simple interventions to assist the patient overcome respiratory symptoms with effort. Decisions regarding: Is the client a prosthetic candidate? To what degree will this patient be able to ambulate with a prosthesis (community, in home only, or transfers only)? What adaptations can be made to the prosthesis to maximize the patient’s ambulation potential?

Interviewing the client for information on tobacco or substance abuse and preamputation functional status and changes in body weight, body mass index (BMI), chest imaging (chest x-ray), pulmonary function tests (PFTs), arterial blood gas (ABG) analysis, albumin, vital signs (respiratory rate and pulse oximetry) will assist the clinician to make functional and prosthetic clinical decisions. Besides prosthetic care, the client with COPD may benefit from treatments that can affect the success of rehabilitation, including: oxygen therapy, bronchodilator therapy, pulmonary rehabilitation, airway clearance treatments and symptom recovery techniques.