Pain site and impairment in individuals with amputation pain

OBJECTIVE: To determine the association between pain site and pain interference with activities of daily living (ADLs) among persons with acquired amputation. DESIGN: Survey. SETTING: Community-based survey from clinical databases, flyer postings, and an advertisement in the inMotion magazine. PARTICIPANTS: Persons with lower-limb amputations (N=478). INTERVENTIONS: Six or more months after lower-limb amputation, participants completed an amputation pain questionnaire that included several standardized pain measures. MAIN OUTCOME MEASURES: Numeric rating scale measures of average phantom limb, residual limb, and back pain and pain-related impairment as measured by a modified version of the Pain Interference Scale of the Brief Pain Inventory. RESULTS: Phantom limb, residual limb, and back pain intensity ratings, as a group, accounted for 20% of the variance in pain interference. The pain intensity ratings associated with each individual pain site made a statistically significant contribution to the prediction of pain interference with ADLs even after controlling for the pain intensity of the other 2 sites. CONCLUSIONS: Pain in each of 3 sites (phantom limb, residual limb, back) appears to be important to pain-related impairment and function. Measurement of the intensity of pain at each site appears to be required for a thorough assessment of amputation pain-related impairment.     

Disability evaluation of extremity fractures

Most fractures heal with restoration of bone and joint function. Disability is generally temporary in these instances, and there is no permanent impairment to be rated in the majority of cases. However, multiple complications can occur that can lead to loss of skeletal function, restricted range of motion, and associated soft tissue injuries, and neurovascular damage can dramatically and severely compromise function and performance. Clearly, not all fractures heal within the timeframes as outlined in Table 2, and determination of the point of maximum medical improvement, which must be achieved in order to declare an impairment as permanent, can be challenging in these cases. Some individuals with fractures that demonstrate bone union radiologically may develop long-term disability; nearly 30% of individuals with a unilateral lower extremity fracture will not return to work within 12 months of injury. In the absence of a complicating soft tissue injury, the explanation for this discrepancy between impairment and disability can be elusive. During the past 10 years, improved systems of trauma care have reduced mortality rates in the United States. As greater numbers of persons survive motor vehicle accidents and other major trauma, the possibility exists that increasing numbers of fractures leading to impairment or disability may be seen. Recognition of how and when fractures heal, possible complications that may arise, risk factors for long-term disability, and the correlation of vocational and avocational physical demands with the resultant outcome will enable the clinician to appropriately and accurately assess disability status, design a rehabilitation program, and assign an impairment rating.     

Sexuality in persons with limb amputation: a meaningful discussion of re-integration

PURPOSE: Rehabilitation professionals do not appear to be sufficiently prepared to deal with the sexual issues of people with a physical disability, although they have recognized the value of discussing them during the rehabilitation process. This commentary argues that the sexuality of people with a disability should be evaluated from the two viewpoints of sexual function and sexual concern. With regard to people with a limb amputation, their sexual life has not attracted researchers' or clinicians' interest because their sexual function is usually preserved, is the same as that of able-bodied persons, and there is a perception that assistance is not required. Indeed, the number of published studies on the sexuality of this population is apparently fewer than the number of studies on the sexuality of persons with central nervous system impairment. CONCLUSION: Investigation of the body image of people with a limb amputation and recognition of their needs are considered to be necessary for further discussion of this theme. Discussion of sexuality with some realistic statistical figures should also have great value in assisting with the re-integration of people with a limb amputation.     

Sexuality in persons with limb amputation: A meaningful discussion of re-integration

Purpose: Rehabilitation professionals do not appear to be sufficiently prepared to deal with the sexual issues of people with a physical disability, although they have recognized the value of discussing them during the rehabilitation process. This commentary argues that the sexuality of people with a disability should be evaluated from the two viewpoints of sexual function and sexual concern. With regard to people with a limb amputation, their sexual life has not attracted researchers' or clinicians' interest because their sexual function is usually preserved, is the same as that of able-bodied persons, and there is a perception that assistance is not required. Indeed, the number of published studies on the sexuality of this population is apparently fewer than the number of studies on the sexuality of persons with central nervous system impairment.

Conclusion: Investigation of the body image of people with a limb amputation and recognition of their needs are considered to be necessary for further discussion of this theme. Discussion of sexuality with some realistic statistical figures should also have great value in assisting with the re-integration of people with a limb amputation.     

Sexuality in persons with limb amputation: A meaningful discussion of re-integration

Purpose:?Rehabilitation professionals do not appear to be sufficiently prepared to deal with the sexual issues of people with a physical disability, although they have recognized the value of discussing them during the rehabilitation process. This commentary argues that the sexuality of people with a disability should be evaluated from the two viewpoints of sexual function and sexual concern. With regard to people with a limb amputation, their sexual life has not attracted researchers' or clinicians' interest because their sexual function is usually preserved, is the same as that of able-bodied persons, and there is a perception that assistance is not required. Indeed, the number of published studies on the sexuality of this population is apparently fewer than the number of studies on the sexuality of persons with central nervous system impairment.

Conclusion:?Investigation of the body image of people with a limb amputation and recognition of their needs are considered to be necessary for further discussion of this theme. Discussion of sexuality with some realistic statistical figures should also have great value in assisting with the re-integration of people with a limb amputation.     

LOWER LIMB AMPUTATION FOR CHRONIC PAIN AND/OR FUNCTIONAL IMPAIRMENT

ObjectiveTo evaluate the impact of a lower limb amputation for chronic pain and/or functional impairment on pain and participation in daily living activities and to assess the use of prostheses. To improve decision-making for this controversial treatment.DesignSurvey.SettingUniversity hospital.SubjectsPatients who had an amputation of a lower limb for chronic pain and/or functional impairment.ResultsEighty-one percent of the patients were satisfied with the amputation and would decide to undergo an amputation again under the same conditions. Sixty-nine percent of the patients reported an improvement in pain, 69% an improvement in mobility, 75% in daily living activities, and 56% an improvement in sleep. Seventy-five percent of the patients used their prosthesis on a daily basis.ConclusionMost patients who underwent an amputation in our hospitals for chronic pain and/or functional impairment of a lower limb were satisfied and reported an improvement in function and pain.LAY ABSTRACTTherapeutic decision-making for chronic pain and/or functional loss in a lower limb is a complex problem. Many articles have been devoted to chronic pain, and current guidelines mention a lot of treatment options. However, patients can still experience a lot of pain and/or functional loss after having tried many treatments. Some of these patients request an amputation. Most physicians refrain from this treatment, since it is very drastic, irreversible, and there is a lack of evidence regarding the outcome. To our knowledge only a few case reports and a select number of case series have been published to date about amputation for chronic pain and/or functional loss in a lower limb, and these show variable results. This study followed a small group of patients in University Hospitals Leuven, Belgium, who underwent a lower limb amputation for this complex problem. Most of these patients were satisfied with their amputation. They reported an improvement in function and pain, and would decide to undergo an amputation again under the same conditions.     

Exercise testing and training of persons with dysvascular amputation: safety and efficacy of arm ergometry.

Recent studies indicate that most persons with dysvascular amputation also have moderate to severe cardiovascular disease with impairment in functional capacity. This may limit the ability to achieve optimal function with their prosthesis because of inadequate conditioning. We developed an exercise testing and training program using arm ergometry in conjunction with standard rehabilitation for persons with acute dysvascular amputation who were profoundly deconditioned after complicated perioperative courses. The program consisted of daily arm ergometry, performed on an interval basis, at an intensity individually optimized through exercise testing. Twenty-five patients, with a mean age of 63 years, completed the inpatient program with pretest and discharge work performance assessment. There was no significant difference between pretest and discharge assessment of baseline or peak heart rate, systolic blood pressure, diastolic blood pressure, or Borg rating of perceived exertion. Peak systolic blood pressure was elevated at discharge compared to admission testing (p less than .04). Heart rate responses were decreased during the early stages of testing when comparing discharge telemetry to admission findings. The duration of exercise increased from 12.6 minutes to 16.3 minutes (p less than .0004), and the maximum work output increased from 17.1 watts to 23.5 watts (p less than .0004). There was no significant morbidity associated with either arm ergometry testing or the exercise program. We conclude that arm ergometry testing and training is a safe and effective method for improving the efficiency of arm work in the patient with acute dysvascular amputation.     

Pr��vention des chutes chez le patient amput�� de membre inf��rieur de plus de 65 ans pris en charge en ��tablissement de soins

During their rehabilitation, amputees patients have an increase risk of fall (150 falls per year in our case), favored by age over than 75 years, cognitive impairment, amputation within the last 3 months, absence of verticalization for 1 month and multiple amputations. Inform the nursing staff, identify and educate the falling patient, all these items must be considered and will help to stabilize the number of falls amongst amputees patients, with diabete or multiple diseases, during their rehabilitation.     

Developing a polytrauma rehabilitation center: a pioneer experience in building, staffing, and training

The military operations in Iraq and Afghanistan have resulted in patterns of injury not commonly seen in previous conflicts. Improvised explosive devices are the primary weapon, and exposure to blast is the most common mechanism of injury. Blasts can result in polytrauma injury, in which multiple body systems, including the head and brain, are injured. Nursing and rehabilitation care can be further challenged by other blast sequelae such as pain, amputation, blindness or low vision, hearing impairment, and aphasia. This article describes the process by which one Veterans Affairs Medical Center developed its inpatient rehabilitation service into a polytrauma rehabilitation center to meet the medical and rehabilitation needs of these patients. Special attention is given to the education and training program developed to solidify the membership of the center's nursing staff in the interdisciplinary treatment team.     

Measuring participation across impairment groups using the Craig Handicap Assessment Reporting Technique

OBJECTIVE: To assess the efficacy, across a range of disability groups, of the Craig Handicap Assessment and Reporting Technique (CHART), a measure of societal participation. DESIGN: Cross-sectional analysis survey methodology. A total of 1110 community-based, nonhospitalized Coloradans with spinal cord injury, traumatic brain injury, multiple sclerosis, stroke, burn, or amputation were interviewed twice, 2 wks apart, using the CHART and a single administration of the FIM. RESULTS: Across all impairment groups, the intraclass correlation for the total score and the subscales of CHART-R were high. In addition, the CHART-R discriminated among the impairment categories in a direction that parallels increasing disability. CONCLUSIONS: CHART may be an appropriate measure of handicap for a range of physical or cognitive impairments.     

Incontinence in patients with dementia

The high prevalence of incontinence in dementia sufferers will only increase as the population ages (Alzheimer's Society, 2007), but the evidence-based knowledge for management of these long-term disorders combined is lacking (H?gglund, 2010). Management techniques for incontinence need to be developed to ensure that dementia patients receive the best care, as current methods such as behavioural techniques may not be appropriate for people with limited cognitive function. This article will address issues that arise with current incontinence management for dementia sufferers and possible courses of action to tailor them more specifically to those people with cognitive impairment. Quite often, incontinence is just managed with incontinence pads and treatment is not discussed, which can have detrimental effects on the patient (Omli et al, 2010). Nurses have an important role in incontinence treatment and can change this misuse of incontinence pads and ensuring a holistic approach to care will help when treating a patient with dementia. Ethical and legal issues will also be discussed as they must be considered when providing holistic care.     

Neuropathic pain in patients with upper-extremity nerve injury

Purpose: The purpose of this review was to present an analysis of the literature of the outcome studies reported in patients following traumatic upper-extremity (UE) nerve injuries (excluding amputation), to assess the presence of an association between neuropathic pain and outcome in patients following traumatic UE nerve injuries, and to provide recommendations for inclusion of more comprehensive outcome measures by clinicians who treat these patients.Summary of Key Points: A Medline and CINAHL literature search retrieved 48 articles. This review identified very few studies of patients with peripheral nerve injury that reported neuropathic pain. When pain was reported, visual analogue or numeric rating scales were most frequently used; standardized questionnaires measuring pain or psychosocial function were rarely administered. Recent evidence shows substantial long-term disability and pain in patients following peripheral nerve injury.Recommendation: To better understand neuropathic pain in patients following peripheral nerve injury, future outcome studies should include valid, reliable measures of physical impairment, pain, disability, health-related quality of life, and psychosocial functioning.     

Essentials of the proper diagnoses of mild cognitive impairment, dementia, and major subtypes of dementia

Loss of cognitive function in the elderly population is a common condition encountered in general medical practice. Diagnostic criteria and approaches have become more refined and explicit in the past several years. Precise diagnosis is feasible clinically. In this article, the precursor state and major subtypes of dementia are considered. Mild cognitive impairment is the term given to patients with cognitive impairment that is detectable by clinical criteria but does not produce impairment in daily functioning. When daily functioning is impaired as a result of cognitive decline, dementia is the appropriate syndromic label. Specific causes of dementia tend to have distinctive clinical presentations: the anterograde amnesic syndrome of Alzheimer disease; the syndrome of dementia with cerebrovascular disease; the syndrome of Lewy body dementia with its distinctive constellation of extrapyramidal features, disordered arousal, and dementia; the behavioral-cognitive syndrome of frontotemporal dementia; the primary progressive aphasias; and the rapidly progressive dementias. Because dementia syndromes have distinctive natural histories, precise diagnosis leads to a better understanding of prognosis. As new treatments become available for Alzheimer disease, the most common of the dementias, accurate diagnosis allows the appropriate patients to receive treatment.     

Amputation rehabilitation and prosthetic restoration. From surgery to community reintegration

PURPOSE: The purpose of this review is to summarize the literature related to the advances that have taken place in the management and rehabilitation care of limb amputation. RESULTS: Prostheses for the lower and upper limb amputee have changed greatly over the past several years, with advances in components, socket fabrication and fitting techniques, suspension systems and sources of power and electronic controls. Higher levels of limb amputation can now be fitted with functional prostheses, which allow more patients to achieve independent life styles. This is of particular importance for the multi-limb amputee. The rehabilitation of more traditional lower limb levels of amputation have also greatly benefited from the technological advances including energy storing feet, electronic control hydraulic knees, ankle rotators and shock absorbers to mention a few. For the upper limb amputee, myoelectric and proportional controlled terminal devices and elbow joints are now used routinely in some rehabilitation facilities. Experimental prosthetic fitting techniques and devices such as the use of osseo-implantation for suspension of the prosthesis, tension control hands or electromagnetic fluids for knee movement control will also be briefly discussed in this paper. CONCLUSION: It is possible to conclude from this review that many advances have occurred that have greatly impacted the functional outcomes of patients with limb amputation.     

Acute autonomic neuropathy and the other related diseases]

In 1969, Young et al. described a patient with an acquired, pure pan-dysautonomia of unknown etiology, involving both the sympathetic and the parasympathetic nervous systems without other neurological manifestations. Since then, a number of similar cases have been described. More recently, reports have appeared of predominantly cholinergic dysautonomia, of dysautonomia associated with infection, and of dysautonomia with other impairment of nervous function. As an etiology, immunological disorder has been suggested but the precise mechanism has not been clarified. By accumulating more cases, a more accurate etiology and more satisfactory therapy will be developed.     

Hemiplegia and lower extremity amputation: double disability

A retrospective study of 52 consecutive patients was conducted to determine the influence of certain factors on the ambulatory rehabilitation of patients with hemiplegia and lower extremity amputation. Factors studied included side of hemiplegia, laterality of disability, level of amputation, order of disability (amputation first or hemiplegia first), neuromuscular status, mental status, sex, age. The level of function was defined as independent, limited, or nonambulatory. Of 52 double-disability patients, thirty were fitted with a prosthesis. Eight patients attained independent prosthetic function while 16 patients were limited and six were nonambulatory. Factors such as ipsilateral BK amputation preceding hemiplegia, a good-to-fair neuromuscular status, and an intact mental status have been associated with better functional results. Although producing higher fitting rates, none of these factors has been found in the present study to be associated with statistically higher levels of ambulatory function. A good-to-fair neuromuscular status seemed to be the prime requisite for good ambulation with a prosthesis in a patient with the double disability of amputation and hemiplegia.     

Impairment Ratings for Posttraumatic Headache

SYNOPSIS
No standardized criteria are available for establishing impairment ratings for pain or posttraumatic headache. The AMA Guides to the Evaluation of Permanent Impairment, 3rd Edition, 1988, defines impairment as "the loss of use of, or derangement of any body part, system or function." Headaches may be classified under episodic neurological disorders and impairment based loosely on frequency, severity and duration of attacks and how activities of daily living are affected. Other systems base ratings by physical findings or diagnosis.
Criteria for posttraumatic headache are proposed in the form of a mnemonic: I M P A I R M E N T. Intensity, Medication use, Physical signs/symptoms, Adjustment, Incapacitation, Recreation, Miscellaneous activity of daily living, Employment, Number (frequency), Time (duration of attacks). Each are scored from 0 to 2 points. There are three physician modifiers, scored from 0 to -4 points: Motivation for treatment, Overexaggeration or overconcern, Degree of legal interest. Case examples will illustrate how impairment ratings are determined, along with further details on scoring. Proposed criteria for posttraumatic headache impairment are understandable, easy to utilize and reproducible.     

Electromyogram-based neural network control of transhumeral prostheses

Upper-limb amputation can cause a great deal of functional impairment for patients, particularly for those with amputation at or above the elbow. Our long-term objective is to improve functional outcomes for patients with amputation by integrating a fully implanted electromyographic (EMG) recording system with a wireless telemetry system that communicates with the patient's prosthesis. We believe that this should generate a scheme that will allow patients to robustly control multiple degrees of freedom simultaneously. The goal of this study is to evaluate the feasibility of predicting dynamic arm movements (both flexion/extension and pronation/supination) based on EMG signals from a set of muscles that would likely be intact in patients with transhumeral amputation. We recorded movement kinematics and EMG signals from seven muscles during a variety of movements with different complexities. Time-delayed artificial neural networks were then trained offline to predict the measured arm trajectories based on features extracted from the measured EMG signals. We evaluated the relative effectiveness of various muscle subsets. Predicted movement trajectories had average root-mean-square errors of approximately 15.7° and 24.9° and average R(2) values of approximately 0.81 and 0.46 for elbow flexion/extension and forearm pronation/supination, respectively.     

Amputation rehabilitation and prosthetic restoration. From surgery to community reintegration

Purpose: The purpose of this review is to summarize the literature related to the advances that have taken place in the management and rehabilitation care of limb amputation.

Results: Prostheses for the lower and upper limb amputee have changed greatly over the past several years, with advances in components, socket fabrication and fitting techniques, suspension systems and sources of power and electronic controls. Higher levels of limb amputation can now be fitted with functional prostheses, which allow more patients to achieve independent life styles. This is of particular importance for the multi-limb amputee. The rehabilitation of more traditional lower limb levels of amputation have also greatly benefited from the technological advances including energy storing feet, electronic control hydraulic knees, ankle rotators and shock absorbers to mention a few. For the upper limb amputee, myoelectric and proportional controlled terminal devices and elbow joints are now used routinely in some rehabilitation facilities. Experimental prosthetic fitting techniques and devices such as the use of osseo-implantation for suspension of the prosthesis, tension control hands or electromagnetic fluids for knee movement control will also be briefly discussed in this paper.

Conclusion: It is possible to conclude from this review that many advances have occurred that have greatly impacted the functional outcomes of patients with limb amputation.