Kevin N. Hakimi

Defining successful mobility after lower extremity amputation for complications of peripheral vascular disease and diabetes

BACKGROUND Information about longer-term functional outcomes following lower extremity amputation for peripheral vascular disease and diabetes remains limited. This study examined factors associated with mobility success during the first year following amputation. METHODS Prospective cohort study of 87 amputees experiencing a first major unilateral amputation surgery. Seventy-five (86%) participants completed 12-month follow-up interview. RESULTS Twenty-eight subjects (37%) achieved mobility success, defined as returning to or exceeding a baseline level of mobility on the locomotor capability index (LCI-5). Forty-three subjects (57%) were satisfied with their mobility. Individuals who were 65 years of age and older (risk difference [RD] = -0.52; 95% confidence interval [CI]: -0.75, -0.29), reported a current alcohol use disorder (RD = -0.37; 95% CI: -0.48, -0.26), had a history of hypertension (RD = -0.23; 95% CI: -0.43, -0.03) or treatment for anxiety or depression (RD = -0.39; 95% CI: -0.50, -0.28) were less likely to achieve mobility success. Mobility success was associated with mobility satisfaction (RD = 0.36; 95% CI: 0.20, 0.53) and satisfaction with life (RD = 0.28; 95% CI: 0.06, 0.50). Although higher absolute mobility at 12 months was also associated with mobility satisfaction and overall life satisfaction, 50% of individuals who achieved success with low to moderate 12-month mobility function reported they were satisfied with their mobility. CONCLUSION Defining success after amputation in relation to an individuals specific mobility prior to the development of limb impairment which led to amputation provides a useful, patient-centered measure that takes other aspects of health, function, and impairment into account.

Prosthetic fitting, use, and satisfaction following lower-limb amputation: a prospective study.

Providing a satisfactory, functional prosthesis following lower-limb amputation is a primary goal of rehabilitation. The objectives of this study were to describe the rate of successful prosthetic fitting over a 12 mo period; describe prosthetic use after amputation; and determine factors associated with greater prosthetic fitting, function, and satisfaction. The study design was a multicenter prospective cohort study of individuals undergoing their first major lower-limb amputation because of vascular disease and/or diabetes. At 4 mo, unsuccessful prosthetic fitting was significantly associated with depression, prior arterial reconstruction, diabetes, and pain in the residual limb. At 12 mo, 92% of all subjects were fit with a prosthetic limb and individuals with transfemoral amputation were significantly less likely to have a prosthesis fit. Age older than 55 yr, diagnosis of a major depressive episode, and history of renal dialysis were associated with fewer hours of prosthetic walking. Subjects who were older, had experienced a major depressive episode, and/or were diagnosed with chronic obstructive pulmonary disease had greater functional restriction. Thus, while most individuals achieve successful prosthetic fitting by 1 yr following a first major nontraumatic lower-limb amputation, a number of medical variables and psychosocial factors are associated with prosthetic fitting, utilization, and function.

Mobility changes in individuals with dysvascular amputation from the presurgical period to 12 months postamputation

OBJECTIVES To describe changes in ambulation among individuals with lower-extremity amputation secondary to peripheral artery disease and/or diabetes prior to surgery through 12 months after surgery. To compare differences in ambulation by amputation level and to examine risk factors for change in ambulation over time. DESIGN Prospective cohort study. SETTING Two Veterans Affairs medical centers, 1 university hospital, and a level I trauma center. PARTICIPANTS Patients with peripheral artery disease or diabetes (N=239) undergoing a first unilateral major amputation were screened for participation between September 2005 and December 2008. Among these, 57% (n=136) met study criteria, and of these, 64% (n=87) participated. INTERVENTIONS Standard of care at each facility. MAIN OUTCOME MEASURES Ambulatory function measured using the Locomotor Capability Index-5. RESULTS Seventy-five of the 87 (86%) subjects enrolled finished their 12-month follow-up interview. Ambulatory mobility declined during the period immediately prior to surgery (premorbid) and remained low at 6 weeks postsurgery. On average, ambulation improved after surgery but did not return to premorbid levels. In the final multivariate model, age and history of lower-extremity arterial reconstruction were significantly associated with a poorer ambulatory trajectory over time, while other factors, such as amputation level, prior alcohol use, and length of disability prior to amputation, were not. CONCLUSIONS The findings highlight the importance of considering premorbid ambulatory function. Informing providers and patients about the trajectory and time course of changes in ambulation can enhance patient education, patient expectations, and treatment planning.

The Effect of Rehabilitation in a Comprehensive Inpatient Rehabilitation Unit on Mobility Outcome After Dysvascular Lower Extremity Amputation

OBJECTIVES To (1) compare the total volume of rehabilitation therapy for patients ever attending a comprehensive inpatient rehabilitation unit (CIRU) versus never during the 12 months after amputation; (2) determine whether rehabilitation in a CIRU at any time in the first year after amputation results in greater mobility success compared with other types of rehabilitation environments of care; and (3) determine for those patients treated in a CIRU, which specific patient characteristics were associated with improved mobility outcome. DESIGN Prospective cohort study. SETTING Two Veterans Affairs medical centers. PARTICIPANTS Patients (N=199) with peripheral vascular disease or diabetes undergoing a first unilateral major amputation were screened for participation between September 2005 and December 2008. Among these, 113 (57%) met study criteria; of these, 72 (64%) participated. INTERVENTION Ever attending a CIRU versus never attending a CIRU in first 12 months after amputation. MAIN OUTCOME MEASURES Number of rehabilitation therapy visits, Locomotor Capability Index scores, and mobility success. RESULTS The mean number of all therapy visits for patients ever attending a CIRU was significantly greater than that for those never attending over a 12-month period (48.6 vs 22.6; P=.001). Mean total time per any rehabilitation visit was .83±.27 hours for those ever attending and .60±.20 hours for those never attending (P<.001). Patients who ever were treated in a CIRU were 17% more likely to achieve mobility success than those who were not, controlling for amputation level, major depressive episode, alcohol use, social support, total number of rehabilitation visits, and hospital site (risk difference=.17; 95% confidence interval, .09-.25; P<.001). CONCLUSIONS Rehabilitation in a CIRU resulted in improved mobility success for veterans undergoing major lower extremity amputation secondary to peripheral vascular disease or diabetes. Among those admitted to a CIRU, younger patients with greater social support, healthy weight, and without chronic obstructive pulmonary disease had the greatest probability of mobility success.

Anterior spinal artery syndrome in two children with genetic thrombotic disorders.

Abstract Background: Spinal cord infarction is a well-described, but rare, etiology of myelopathy, especially in children. The most common syndrome, anterior spinal artery syndrome (ASAS), is caused by interruption of blood flow to the anterior spinal artery, producing ischemia in the anterior two-thirds of the cord, with resulting neurologic deficits. Causes of ASAS include aortic disease, thoracolumbar surgery, sepsis, hypotension, and thromboembolic disorders. Methods: Case reports of 2 patients. Results: Two children developed spinal cord infarctions consistent with ASAS, mostly likely caused by previously undiagnosed thrombotic disorders. A child with prothrombin variant experienced acute bilateral lower limb weakness without any preceding event. Magnetic resonance imaging (MRI) revealed increased T2 signal in the anterior cord from midthoracic level to the conus medullaris. A child with protein S deficiency developed lower limb weakness 1 day after a posterior thoracolumbar fusion for idiopathic scoliosis. Computed tomography (CT) myelogram revealed no spinal cord compression. The prothrombin variant mutation is associated with a 2-fold risk of thrombotic events. Individuals with protein S deficiency have an 8-fold increased risk of thrombosis. Conclusion: As knowledge of the coagulation pathways grows, it is likely that more patients with spinal cord infarctions will be diagnosed with genetic thrombotic disorders as the etiology of their injury. We review these two disorders, prothrombin variant and protein S deficiency, and the considerations for longterm anticoagulation.

Electrodiagnosis of Cervical Radiculopathy

Cervical radiculopathy is a common diagnosis with a peak onset in the fifth decade. The most commonly affected nerve root is C7, C6, and C8. The etiology is often compressive, but may arise from noncompressive sources. Patients commonly complain of pain, weakness, numbness, and/or tingling. Examination may reveal sensory or motor disturbance in a dermatomal/myotomal distribution. Neural compression and tension signs may be positive. Diagnostic tests include imaging and electrodiagnostic study. Electrodiagnostic study serves as an extension of the neurologic examination. Electrodiagnostic findings can be useful for patients with atypical symptoms, potential pain-mediated weakness, and nonfocal imaging findings.

The feasibility of hypnotic analgesia in ameliorating pain and anxiety among adults undergoing needle electromyography.

Slack D, Nelson L, Patterson D, Burns S, Hakimi K, Robinson L: The feasibility of hypnotic analgesia in ameliorating pain and anxiety among adults undergoing needle electromyography. Am J Phys Med Rehabil 2009;88:21–29. Objective:Our hypothesis was that hypnotic analgesia reduces pain and anxiety during electromyography (EMG). Design:We performed a prospective randomized, controlled clinical trial at outpatient electrodiagnostic clinics in teaching hospitals. Just before EMG, 26 subjects were randomized to one of three 20-min audio programs: education about EMG (EDU) (n = 8); hypnotic induction without analgesic suggestion (n = 10); or hypnotic induction with analgesic suggestion (n = 8). The blinded electromyographer provided a posthypnotic suggestion at the start of EMG. After EMG, subjects rated worst and average pain and anxiety using visual analog scales. Results:Mean values for the EDU, hypnotic induction without analgesic suggestion, and hypnotic induction with analgesic suggestion groups were not significantly different (mean ± SD): worst pain 67 ± 25, 42 ± 18, and 49 ± 30; average pain 35 ± 26, 27 ± 14, and 25 ± 22; and anxiety 44 ± 41, 42 ± 23, and 22 ± 24. When hypnosis groups were merged (n = 18) and compared with the EDU condition (n = 8), average and worst pain and anxiety were less for the hypnosis group than EDU, but this was statistically significant only for worst pain (hypnosis, 46 ± 24 vs. EDU, 67 ± 35; P = 0.049) with a 31% average reduction. Conclusions:A short hypnotic induction seems to reduce worst pain during electromyography.

Pre-Operative Rehabilitation Evaluation of the Dysvascular Patient Prior to Amputation

Lower-extremity amputation secondary to dysvascular disease, including diabetes and peripheral vascular disease, is a major health problem in the United States. Due to the increased comorbidities in this patient population, pre-operative rehabilitation evaluation by a multidisciplinary team is crucial to ensure optimal patient outcomes. This article discusses the key factors that may affect functional outcomes in this patient population and outlines important history and physical examination components that should be evaluated pre-operatively.

Relationship between cognition and functional outcomes after dysvascular lower extremity amputation: a prospective study.

ObjectiveThe aim of this study was to examine associations between a cognitive screen and four neuropsychologic tests administered at both 6 wks and 4 mos after amputation and five functional outcomes measured 12 mos after lower extremity amputation. DesignThis study includes a prospective cohort from four medical centers. Participants were primarily male Veterans experiencing their first lower extremity amputation as a result of complications of diabetes mellitus or peripheral arterial disease. Of those eligible, 87 (64%) enrolled; 75 (86%) were retained at 12 mos. Measures included demographic/health information, four neuropsychologic measures, the Locomotor Capability Index–5, the Gronigen Activity Restriction Scale, prosthetic use, community participation, and social integration. ResultsBetter performance on the Short Portable Mental Status Questionnaire at 4 mos was associated with greater 12-mo mobility and social integration. Better attention and working memory abilities 6 wks after amputation were associated with increased 12-mo prosthetic wear; and at 4 mos after amputation, with greater 12-mo mobility. Better verbal memory at 6 wks was associated with greater 12-mo social integration and community participation as well as increased prosthetic wear. ConclusionsThese findings highlight the potential value in including a brief, formal cognitive assessment in addition to a general mental status screen. Specific domains of cognitive function are differentially associated with functional outcomes and may inform amputation rehabilitation decisions.

Suicidal Ideation Among Individuals With Dysvascular Lower Extremity Amputation

OBJECTIVE To examine the estimated prevalence and correlates of suicidal ideation (SI) among individuals 1 year after a first lower extremity amputation (LEA). DESIGN Cohort survey. SETTING Four medical centers. PARTICIPANTS A referred sample of patients (N=239), primarily men, undergoing their first LEA because of complications of diabetes mellitus or peripheral arterial disease, were screened for participation between 2005 and 2008. Of these patients, 136 (57%) met study criteria and 87 (64%) enrolled; 70 (80.5%) of the enrolled patients had complete data regarding SI at 12-month follow-up. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES SI, demographic/health information, depressive symptoms, mobility, independence in activities of daily living (ADL), satisfaction with mobility and ADL, medical comorbidities, social support, self-efficacy. RESULTS At 12 months postamputation, 11 subjects (15.71%) reported SI; of these, 3 (27.3%) screened negative for depression. Lower mobility, lower satisfaction with mobility, greater impairment in ADL, lower satisfaction with ADL, lower self-efficacy, and depressive symptoms were all correlated with the presence of SI at a univariate level; of these, only depressive symptoms remained significantly associated with SI in a multivariable model. CONCLUSIONS SI was common among those with recent LEA. Several aspects of an amputees clinical presentation, such as physical functioning, satisfaction with functioning, and self-efficacy, were associated with SI, although depression severity was the best risk marker. A subset of the sample endorsed SI in the absence of a positive depression screen. Brief screening for depression that includes assessment of SI is recommended.