525186 research-article2014

POI0010.1177/0309364614525186Prosthetics and Orthotics InternationalKulkarni et al.

INTERNATIONAL SOCIETY FOR PROSTHETICS AND ORTHOTICS

Original Research Report

Bariatric amputee: A growing problem? Jai Kulkarni1, Dominic P Hannett2 and Steven Purcell2

Prosthetics and Orthotics International 1­–6 © The International Society for Prosthetics and Orthotics 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0309364614525186 poi.sagepub.com

Abstract Background: This study reviewed prevalence of patients with lower limb amputations with above normal weight profile, with body mass index over 25, in seven disablement services centres managing their amputee rehabilitation in the United Kingdom. Objectives: To review two clinical standards of practice in amputee rehabilitation. Ambulant lower limb amputees should have their body weight recorded on an electronic information system, with identification of cohort with body weight >100 kg. Lower limb amputees to be provided with suitable weight-rated prosthesis. Study design: Observational study of clinical practice. Methods: Data were collected from the Clinical Information Management Systems. Inclusion criteria – subjects were ambulant prosthetic users with some prosthetic intervention in the last 5 years and had at least one lower limb amputation. Results: In 96% of patients, the weight record profile was maintained. In addition, 86% were under 100 kg, which is the most common weight limit of prosthetic componentry. Of 15,204 amputation levels, there were 1830 transfemoral and transtibial sites in users with body weight over 100 kg. In 60 cases, the prosthetic limb build was rated to be below the user body weight. Conclusions: In 96% of our patients, body weight was documented, and in 97%, the prosthetic limb builds were within stated body weight limits, but this may not be the case in all the other disablement services centres in the United Kingdom. Also, the incidence of obesity in the United Kingdom is a growing problem, and the health issues associated with obesity are further compounded in the amputee population. Clinical relevance Prosthetic componentry has distinct weight limits which must be considered during prescription. As people with amputation approach the limits of specific components, clinicians are faced with the challenge of continued provision in a safe and suitable manner. This article reviews the amputee population and the current national profile to consider trends in provision and the incidence of these challenges. Keywords Bariatric amputees, prosthetic rehabilitation, artificial limb Date received: 2 September 2013; accepted: 27 January 2014

Background The rate of obesity in the United Kingdom is rising significantly with almost a quarter of all adults in the United Kingdom being classed as obese on body mass index (BMI; normal: 19–25; obese: >30) in 2008. Studies have also shown that waist circumference, which is another strong health indicator, was increasing alongside this with 39% of adults presenting with increased waist circumference in 2008 as compared to 23% in 1993.1,2 The problem appears to be affecting all age ranges with 16.8% of boys and 15.2% of girls aged 2–15 years, classed as obese, an increase from 11.1% and 12.2%, respectively, in 1995–2010.3 The health impact of increased body weight is well known with cardiovascular morbidity issues such as increased cardiac strain, increased energy expenditure,

risk of myocardial infarction, diabetes and stroke. From a mechanical perspective, there is also a demonstrable increase in the presentation of osteoarthritis and biomechanical cost of ambulation. Additionally, from a psychosocial point of view, there is a significant increase in risk of depression, infertility and shortened life expectancy. 1Disablement

Services Centre (DSC), University Hospitals of South Manchester, Manchester, UK 2Opcare Ltd, Manchester, UK Corresponding Author: Jai Kulkarni, Disablement Services Centre (DSC), University Hospitals of South Manchester, Cavendish Road, Manchester, M20 1LB, UK. Email: [email protected]

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In the amputee population, most of the increased risk factors are already present in this vulnerable dysvascular cohort, with or without diabetes. Along with the associated health factors and co-morbidities of amputees with increased body mass, there are mechanical implications to consider with the provision of a suitable prosthesis with component weight limitations. Modern-day prostheses are modular in construction, and each component must be tested to a specific weight limit to ensure that they can withstand the forces applied by prosthetic users. These tests form part of the International Standards Organisation (ISO) standard 10328. These standards are enforced by the UK Medical Devices Directive (MDD). Increased body weight beyond the specified weight limits of available prosthetic componentry presents a clinical risk that has to be considered carefully to balance the risk to the patient, along with the benefits of increasing function and activity of the individual. The range of components that are available at higher weight limits is restricted, presenting reduced functional options to the user and prescribing team. There is also a notable risk of litigation in inappropriate prosthetic component prescriptions. Prosthetic fitting also becomes more challenging with increased load to transmit through the prosthetic socket in limited pressure–tolerant anatomical areas. We reviewed the prevalence of ambulant patients with lower limb amputations with above normal weight profile with BMI over 25 in seven disablement services centres (DSC) managing their amputee/prosthetic rehabilitation in the United Kingdom. Average body weight loss in a unilateral transtibial (below knee) amputee is 7% of body weight, while in transfemoral cases, it is 16% of body weight.4

Aims The aim of the study was to review two clinical standards of practice in amputee rehabilitation/prosthetic provision: 1. Ambulant lower limb amputees should have their body weight recorded on an electronic information system, with identification of cohort with body weight >100 kg. 2. Lower limb amputees should be provided with suitable weight-rated prosthesis.

Methods Data were obtained from the Clinical Information Management System (CIMS) databases from seven prosthetic clinics in the United Kingdom. The data were anonymised and secure. A total of 23,850 amputation were identified with 18,596 of them relating to the lower limb amputations (Figure 1). Inclusion criteria were that the subject was an ambulant prosthetic user, namely, had some kind of prosthetic intervention in the last 5 years and had at

Amputation Level Details

Total

Ankle Disarticulation

715

Congenital Limb Deficiency

519

Knee Disarticulation Gritti-Stokes

633

Trans pelvic / Hindquarter

68

Hip Disarticulation

177

Partial Foot

415

Trans Femoral

4911

Transtibia

11138

Grand Total

18596

Figure 1.  Data from the Clinical Information Management System.

least one lower limb amputation. Major bilateral lower limb amputees made up 10% of all lower limb amputees cohort, of which 2% were noted to have limited ambulation. Upper limb amputees were excluded as the focus of the investigation related to weight-bearing prostheses. The weight of each individual user, age, activity level, amputation site(s), cause of amputation and limb build type were recorded for each amputation. The mean age was 55 with a range of 0–98 years, and the mean recorded weight as 75.4 kg with a range of 6–179 kg. Prosthetic components tend to be limited to a weight limit of 100 kg. There are some minor exceptions to this with paediatric limb systems, but these are used infrequently. Hence, users of less than 100 kg were excluded. To enable review, the subjects were split into six distinct weight range groups: •• •• •• •• •• ••

Group 1  Group 2  Group 3  Group 4  Group 5  Group 6 

Bariatric amputee: A growing problem?

This study reviewed prevalence of patients with lower limb amputations with above normal weight profile, with body mass index over 25, in seven disabl...
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