Form and Function: Rehabilitation Considerations

by: Paul Carlisle MPT, GCS

Rehabilitation Coordinator Laguna Honda Hospital and Rehabilitation Center

Introduction

64 yo male with history of DM Infected toe in March of 2010 Trans-tibial amputation July Days prior to admission had 3-4 falls At least 2 year history of peripheral neuropathy Multiple areas of musculoskeletal pain
Lives alone in 3rd floor apartment no elevator 35 years in the same apartment Self described hoarder On call bartender Art dealer and collector

Themes in the Story

Peripheral neuropathy
Toes Thighs Feet Legs Hands Buttocks Hips Digestive Urinary Sex Organs Ears Pelvis and Low Back Abdomen

Proximal neuropathy

Autonomic neuropathy
Heart and BV

Focal neuropathy
Facial Muscles

Arms

Sweat Glands

Eyes

Diabetic Retinopathy
Mild background retinopathy few warning signs spots in vision, blurring, and side (peripheral) vision loss can change throughout the day, and day to day Severe proliferative retinopathy hemorrhages will form scar tissue between retina & vitreous retinal detachments can occur Secondary visual complications: Cataracts Macular edema Glaucoma

Diabetic Retinopathy

http://en.wikipedia.org/wiki/File:Human_eyesight_two_childr en_and_ball_normal_vision.jpg

http://en.wikipedia.org/wiki/File:Human_eyesight_two_childr en_and_ball_with_diabetic_retinopathy.jpg

Diabetic Retinopathy
Symptoms: Glare sensitivity Decreased accommodation Diplopia Diminished color vision Losses in central and/or peripheral visual fields All ADLs and mobility can be affected

Self-Management
Almost all tasks require vision Areas affected: Monitoring blood glucose RX administration/usage Meal planning Exercise/physical activity Oral health Foot self-care Emotional well-being and adjustment Stress importance of annual eye exams!

QuickTime and a decompressor are needed to see this picture.

Neuropathic Pain
Burning Tingling Pain on contact Pins/needles Shock Numbness/achiness Shooting

Dysesthesias Parasthesias

Muscular

Dull Aches/cramps

Bookmarks
Sensation

Range of Motion

Vision

Function

Balance

Endurance

Strength

Assessment
Functional Potential Component Selection Rehabilitation Programming Success/Potential for Advanced Components

Classification System
K Level 0 Does not have the ability or potential to ambulate or transfer safely with or without assistance, and a prosthesis does not enhance quality of life or mobility Has the ability or potential to use a prosthesis for transfers or ambulation in level surfaces at a fixed cadence. Typical of the limited and unlimited household ambulator. Has the ability or potential for ambulation with the ability to transverse low-level environmental barriers such as curbs, stairs, or uneven surfaces. Typical of the limited community ambulator Has the ability or potential for ambulation with variable cadence. Typical of the community ambulator who has the ability to transverse most environmental barriers and may have vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion. Has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills, exhibiting high impact, stress, or energy levels. Typical of the prosthetic demands of the child, active adult, or athlete. K Level 1

K Level 2

K Level 3

K Level 4

Functional Assessment

Source: HEROS Fall Prevention Project: Balance and Testing in Older Adults, Temple University, College of Health Professions (E-Mail: roberta.newton@temple.edu)

AMP

Source: Gailey RS, Roach KE, Applegate EB, et al. The Amputee Mobility Predictor: an instrument to assess determinants of the lower limb amputees ability to ambulate. Arch Phys Med Rehabil 2002; 83: 613627.

AMP and K Values

K Value AMP

K0
K1 K2 K3 K4

0-8
9-20 21-28 29-36 37-43

Final Chapters
Contralateral Limb Amputation Falls Pain, esp. low back pain Osteoarthritis Osteoporosis Gait Abnormalities Skin Irritation Poor Prosthetic Fit General Deconditioning
Source: Gailey RS, Allen K et al. Review of secondary physical conditions associated with lower-limb amputation and long-term prosthesis use. Journal of Rehabilitation and Research Development. 2008. Volume 45 Number 1, 15-30