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Bilateral Lower Limb Amputee Rehabilitation A Retrospective Review MARGARITA M. TORRES, MD and ALBERTO ESQUENAZI, MD, Philadelphia, Pennsylvania

We retrospectively reviewed 61 cases of bilateral lower limb amputations in patients admitted to a regional amputee rehabilitation program. Of the 61 cases, 41 were analyzed as to functional outcome on discharge, at 1 month, and at 3 months; 20 were not included owing to transfers to acute care or loss to follow-up. There were 41 men and 20 women, the average age was 61.5 years, and 47 patients (77%) were discharged to home. There were 25 bilateral below-knee, 14 above-knee and below-knee, 12 bilateral above-knee, 5 below-knee and partial-foot, 3 above-knee and partial-foot, and 2 bilateral partial-foot amputations. The average length of stay for all levels was 24.2 days. Most of the patients at the time of discharge achieved a level of limited household walking with the exception of those with bilateral above-knee amputations. A significant improvement in function was noted for all patients at 3-month follow-up, with most patients achieving household ambulation level, but 10 remained independent at wheelchair level for mobility. (Torres MM, Esquenazi A: Bilateral lower limb amputee rehabilitation-A retrospective review, In Rehabilitation Medicine-Adding Life to Years [Special Issue]. West J Med 1991 May; 154:583-586)

T he appraisal of functional status is routine in medical rehabilitation, including ambulation status after inpatient rehabilitation programs. '-13 A review of the recent literature, however, failed to show reports of functional outcomes for bilateral lower limb amputation. 1 n 1984 a seven-year retrospective review of the population admitted to a major metropolitan rehabilitation center described the characteristics of patients with lower limb amputation.14 The review, when compared with national surveys done one and two decades previously,'516 indicated an increase in mean age, an increase in the number of belowthe-knee over other amputation levels, and an increasing number of amputees readmitted for bilateral prosthetic

training. Sakuma and co-workers reported in 1974 their study of 53 elderly patients who had undergone bilateral lower extremity amputations.'7 They found that 50% of amputees with preservation of at least one knee joint could become ambulatory with prostheses for self-care purposes. They also concluded that a rehabilitation program was beneficial for both users and nonusers of prostheses. Also in 1974, Kerstein and associates reported their study of 194 major amputations over a ten-year period.'8 Of the total group, 23 % had bilateral amputations. At the conclusion of a 22-week postamputation rehabilitation program, 80% of the patients were able to return home and 70% of all patients were able to walk with just the use of a single cane orwithout aids. The purpose of this study was to document patients' functional results after bilateral lower limb amputation on discharge from an inpatient rehabilitation program and at one month and three months after discharge. As the number of patients with bilateral lower limb amputations increases, there is a greater need to examine closely the efficacy of rehabilitation programs that have ambulation training as a goal. 4

Patients and Methods All patients with bilateral lower limb amputations who presented to a regional amputee rehabilitation center over an 18-month period (from July 1988 through December 1989) were selected. The outpatient records were reviewed retrospectively for the following information: patient demographics, including age and sex, amputation levels, length of inpatient rehabilitation stay, and disposition on discharge; and functional mobility on discharge, at one month, and at three months after discharge. 30 *BK/BK 25

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Figure 1.-The frequency of levels of lower extremity amputations is shown. AK=above the knee, BK=below the knee, PF=partial foot

From the Moss Rehabilitation Hospital and the Temple University Hospital, Temple University School of Medicine, Philadelphia, Pennsylvania. Reprint requests to Margarita M. Torres, MD, Moss Rehabilitation Hospital, 1200 W Tabor Rd, Philadelphia, PA 19141-3099.

584

BILATERAL LOWER LIMB AMPUTATIONS

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Figure 2.-The graph shows the average length of stay in days for inpatient rehabilitation for all lower extremity amputations, bilateral lower extremity amputations, and per level of amputations. AK=above the knee, BK=below the knee, PF=partial foot, *=corrected after 1 case omitted

The levels of amputation were defined as partial-foot, to include toe, Syme's, and transmetatarsal amputations; below-knee; and above-knee amputations. During the 18month period, none of these patients had hemipelvectomy or hip disarticulation as their secondary amputation site. Patients' functional status was examined on discharge and at one and three months after discharge in 41 cases; 20 were not included in this portion of the analysis because of transfers to acute care hospitals or loss to outpatient

follow-up. Patients' functional status falls into the following five groups: * A limited household ambulator is a person who can use a prosthesis only in the home to ambulate independently and perform self-care activities. The distance for a limited household ambulator is less than 37 m (120 ft). 20

LIMB

AMPUTATIONS

* A household ambulator can walk more than 37 m and performs all of the activities of daily living using prostheses. * A limited community ambulator is a patient who can walk 152 m (500 ft), can participate in some avocational activity, but is not gainfully employed. * A community level ambulator is one who can walk more than 152 m, engages in vocational and avocational activities, including driving with the prosthetic devices, and is gainfully employed. * Although the wheelchair is used by all of them to attain greater mobility within the home or community, a person who uses a wheelchair exclusively for all mobility and activities of daily living is defined for the purposes of this study as a wheelchair user.

24.2 t

LOWER

Results Over an 18-month period, 2,941 patients were admitted to a major metropolitan rehabilitation center. Of these, 314, or 11%, were admitted to the regional amputee rehabilitation program and 61, or 19.4%, had bilateral lower limb amputations. As illustrated in Figure 1, the most frequent level of amputation was below both knees (25 patients or 41%), followed by below and above the knees (14, or 23%), and above both knees (12, or 20%), with less frequency of bilateral partial-foot, partial-foot and below-knee, and partial-foot and above-knee amputations. Of the 61 patients, 41, or 67%, were men. Ages ranged from 29 to 88 years, with the average age being 61.5 years. Figure 2 shows the average length of stay on the inpatient rehabilitation program, which for all amputations was 23.9 days and for bilateral amputations was 24.2 days, with the range being 3 to 78 days. The average length of stay for below-knee and partial-foot amputations was 37.8 days, although one patient's hospital stay was prolonged because of disposition problems, and the patient was eventually placed in a nursing home. The corrected average length of stay for this level of amputation was then 32.7 days. Of the 61 patients, 47, or 77%, were discharged to home, 12 (20%) required transfer to acute care hospitals for medical or surgical complications, and only 2 patients were transferred to a nursing home for long-term care. Of the 47 patients discharged to home, 17, or 36%, achieved a limited household level of ambulation at the time

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Figure 3.-The functional status is shown for 47 patients with bilateaflower extremity amputations, A, at discharge, B, at 1 month, and C, at 3 months after discharge from inpatient rehabilitation; 8 patients were lost to follow-up. lt- limited community ambulation, LH=limited home ambulation, WC=wheelchair only

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level. Most patients achieved limited household ambulation at three months (Figure 3-C). The patients who were functioning at a higher level at the time of discharge were noted to maintain or improve their level of functioning over the three months. Those patients discharged at a wheelchair level were either lost to follow-up or remained at the wheelchair level. Few (3, or 8%) of these advanced to walking at some time in the three-month period. Of the 17 patients with bilateral below-knee amputation (Figure 4), 6 (35%) achieved limited household ambulation at the time of discharge; of these, at the one-month follow-up some had maintained function but others declined. By three months, however, these patients had advanced to household

of discharge, 12 were dependent on a wheelchair for all mobility, while 10 attained a household level of ambulation. Only 8 achieved community ambulation of some level (Figure 3-A). At the one-month follow-up, most patients were at the wheelchair level of function, with the other patients evenly scattered among the other categories. Further analysis of the data revealed that of those patients at a limited household level of ambulation at the time of discharge, 7 (41%) maintained their level of function and 6 advanced to the household level; 8 patients were lost to follow-up (Figure 3-B). At the three-month follow-up, those patients who were previously walking at a limited household level regained this 10

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[._i L_ __. -_-_ I_ B Functional Status at One Month r C Functional Status at Three Months I

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Figure 4.-The functional status is shown for 17 patients with below-knee/below-knee amputations, A, at discharge, B, at 1 month, and C, at 3 months after discharge from inpatient rehabilitation. LC= limited community ambulation, LH = limited home ambulation, WC= wheelchair only 6

0

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.

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B Functional Status at One Month

Figure 5.-The functional status is shown for 10 patients with above- and below-knee amputations, A, at discharge, B, at 1 month, and C, at 3 months after discharge from inpatient rehabilitation. LC=limited community ambulation, LH=limited home ambulation, WC=wheelchair only 8 *W 0C

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Figure 6.-The functional status is shown for 1 1 patients with bilateral above-knee amputations, A, at discharge, B, at 1 month, and C, at 3 months after discharge from inpatient rehabilitation (1 patient lost to follow-up). LC= limited community ambulation, LH limited home ambulation, WC= wheelchair only =

BILATERAL LOWER LIMB AMPUTATIONS

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walking and even limited community walking. Those patients achieving on discharge a high level of functional mobility were able to attain and maintain limited community and community ambulation during the three months. Similarly, persons with below- and above-knee amputations (Figure 5) achieved limited household mobility on discharge and advanced to household walking, with few advancing to limited community and community ambulation; about a third remained at the wheelchair level. Although most of the patients with above-knee amputations were independent at the wheelchair level at the time of discharge (Figure 6), some achieved a limited household level of walking and maintained this up to three months after discharge. Conclusion A review of the rehabilitation literature failed to elicit any recent information regarding the functional mobility outcomes of patients with bilateral lower limb amputations. In this limited study, we found that persons with bilateral lower limb amputations deserve a comprehensive rehabilitation program to attain (and maintain) goals of limited household walking. Further studies should examine the role concurrent disease plays in determining the appropriateness for prosthetic management; the cost-effectiveness; and the longterm benefits, both physical and psychosocial, of attaining the highest possible functional level. REFERENCES 1. Varghese G, Hinterbuchner C, Mondall P, Sakuma J: Rehabilitation outcome of patients with dual disability of hemiplegia and amputation. Arch Phys Med Rehabil 1978; 59:121-123

2. Carey RG, Seibert JH, Posavac EJ: Who makes the most progress in inpatient rehabilitation? An analysis of functional gain. Arch Phys Med Rehabil 1988; 69:337343 3. Caradoc-Davies TH, Dixon GS, Campbell AJ: Benefit from admission to a geriatric assessment and rehabilitation unit-Discrepancy between health professional and client perception of improvement. J Am Geriatr Soc 1989; 37:25-28 4. Granger CV, Gresham GE: International Classification of Impairments, Disabilities, and Handicaps (ICIDH) as a conceptual basis for stroke outcome research-A tribute to Philip H.N. Wood. Stroke 1990; 21(Suppl):1166-67 5. Granger CV, Hamilton BB: Measurement of stroke rehabilitation outcome in the 1980s. Stroke 1990; 21(Suppl):1146-47 6. Granger CV, Hamilton BB, Gresham GE: The stroke rehabilitation outcome study-Part 1: General description. Arch Phys Med Rehabil 1988; 69:506-509 7. Armstrong KK, Sahgal V, Bloch R, Armstrong KJ, Heinemann A: Rehabilitation outcomes in patients with posttraumatic epilepsy. Arch Phys Med Rehabil 1990; 71:156-160 8. Wood-Dauphinee SL, Opzoomer MA, Williams JI, Marchand B, Spitzer WO: Assessment of global function: The Reintegration to Normal Living Index. Arch Phys Med Rehabil 1988; 69:583-590 9. Thompson PW: Functional outcome in rheumatoid arthritis. Br J Rheumatol 1988; 27(Suppl):37-43 10. Task Force on Stroke Impairnment, Task Force on Stroke Disability, and Task Force on Stroke Handicap: Symposiunm Recommendations for Methodology in Stroke Outcome Research. Stroke 1990; 21(Suppl):1168-73 I1. Ring H: Stroke outcome research, a multidimensional problem in need of multidimensional answers-The Loewenstein Rehabilitation Center Stroke and Stroke Outcome Research at a crossroad. Stroke 1990: 21(Suppl):1161-63 12. Wade DT: Measurement in rehabilitation. Age Ageing 1988; 17:289-292 13. Santopoalo R: From a LORS advocate. Arch Phys Med Rehabil 1989: 70: 863-864 14. Esquenazi A, Vachranukunkiet T, Torres M, Demopoulos JT: Characteristics of a current lower extremity amputee population: Review of 918 cases. Arch Phys Med Rehabil 1984; 65:623 15. Kay HW, Newman JD: Relative incidences of new amputations. Orthotics Prosthetics 1975; 29:3-16 16. Glattly HW: A statistical study of 12,000 new amputees. South Med J 1984: 57:1373-1378 17. Sakuma J, Hinterbuchner C, Green RF, Silber M: Rehabilitation of geriatric patients having bilateral lower extremity amputations. Arch Phys Med Rehabil 1974; 55: 101-111 18. Kerstein MD, Zimmer H, Dugdale FE, Lerner E: Amputations of the lower extremity: A study of 194 cases. Arch Phys Med Rehabil 1974; 55:454-459