Liliana E. Pezzin

Rehabilitation and the long-term outcomes of persons with trauma-related amputations

OBJECTIVE To examine the long-term outcomes of persons undergoing trauma-related amputations, and to explore factors affecting their physical, social, and mental health and the role of inpatient rehabilitation in improving such outcomes. DESIGN Abstracted medical records and interview data sought for a retrospective cohort of persons who had undergone a lower-limb trauma-related amputation. PARTICIPANTS Patients identified with a principal or secondary diagnosis of a trauma-related amputation to the lower extremity at the University of Maryland Shock Trauma Center between 1984 and 1994. Patients with spinal cord injury or traumatic brain injury were excluded. RESULTS Of 146 patients who had trauma-related amputations to the lower limb at the University of Maryland Shock Trauma Center during the study period, nearly 9% died during the acute admission and 3.5% died after discharge. About 87% of all trauma-related amputations involved males, and roughly three quarters involved white persons. About 80% of all amputations occurred before age 40. The health profile of traumatic amputee subjects interviewed in the study (n = 78, 68% response rate) was systematically lower than that of the general US population for all SF-36 scores. The differences in profiles were largest among SF-36 scales sensitive to differences in physical health status, particularly physical functioning, role limitations due to physical health, and bodily pain. About one fourth of persons with a trauma-related amputation reported ongoing severe problems with the residual limb, including phantom pain, wounds, and sores. The number of inpatient rehabilitation nights significantly improved the ability of patients with amputation to function in their physical roles, increased vitality, and reduced bodily pain. Inpatient rehabilitation was also significantly correlated with improved vocational outcomes. CONCLUSIONS These findings suggest a substantial effect of inpatient rehabilitation in improving long-term outcomes of persons with trauma-related amputations.

Use and satisfaction with prosthetic devices among persons with trauma-related amputations. A long-term outcome study

Dillingham TR, Pezzin LE, MacKenzie EJ, Burgess AR: Use and satisfaction with prosthetic devices among persons with trauma-related amputations: a long-term outcome study. Am J Phys Med Rehabil 2001;80:563–571. ObjectiveTo document and examine the use, satisfaction, and problems with prosthetic devices among persons who suffered a trauma-related lower limb amputation. DesignAbstracted medical records and follow-up interview data were collected for a retrospective cohort of persons with a lower limb trauma-related amputation who received their acute care at the University of Maryland R. Adams Cowley Shock Trauma Center, Baltimore, MD, between 1984 and 1994. Patients with spinal cord injury, traumatic brain injury, or only toe amputations were excluded. ResultsThere were 146 patients identified. Of those, 9% died during the acute admission and 3.5% died after discharge. Seventy-eight amputees were available for interview (68% response rate). The majority of those interviewed were male (87%), and two-thirds had undergone amputation before age 40 yr. Nearly 95% had a prosthesis and wore it an average of 80 hr (SD = 33) per week. Despite high use, only 43% reported being satisfied with the comfort of their prosthesis. About one-quarter of all users reported problems with wounds, skin irritation, or pain. Traumatic amputees used an average of four prostheses since injury, about one new prosthesis every 2 yr. Statistical analyses revealed that males reported higher prosthetic use (P < 0.01). Higher Injury Severity Score negatively impacted on prosthetic use (P < 0.01). Phantom pain negatively influenced reported satisfaction with the prosthesis (P < 0.03) ConclusionsAlthough almost all persons living with trauma-related amputations use prosthetic devices, the majority are not satisfied with prosthetic comfort. Phantom pain and residual limb skin problems are also common afflictions in this population.

Parental marital disruption and intergenerational transfers: An analysis of lone elderly parents and their children

Although one of the most marked demographic trends observed over the twentieth century is the increased rate of divorce, relatively little research has explored the effects of these changing marital patterns in the context of an aging society. Using a sample of lone elderly parents and their adult children, we analyze the direct and indirect effects of marital disruption on four important dimensions of intergenerational transfers: coresidence, financial assistance, adult children’s provision of informal care, and parental purchase of paid care. Our findings suggest that divorce has deleterious effects on intergenerational transfers, particularly for elderly fathers. Remarriage further reduces exchange. Our results reveal that parents engage in lower levels of transfers with stepchildren relative to biological children. Moreover, intergenerational transfers are sensitive to characteristics of biological children but not to those of stepchildren. Taken together, these results suggest that exchange at the end of the life course continues to be adversely affected by marital disruption

Does Publicly Provided Home Care Substitute for Family Care?: Experimental Evidence with Endogenous Living Arrangements

This paper analyzes the extent to which publicly provided formal (paid) home care substitutes for unpaid care provided informally by family and friends. Unlike most previous research, we recognize that the choice among alternative combinations of formal and informal care depends on the type of living arrangement chosen, and that these living arrangement choices in turn are influenced by the public provision of formal home care. Using data from a social experiment, we find that a generous public home care program significantly increases the probability that unmarried persons will live independently and reduces the probability of living in shared households or in nursing or personal care homes. However, any substitution effects-either direct effects on provision of informal care given living arrangement or indirect effects due to living arrangement changes-appear to be small.

Epidemiology of limb loss and congenital limb deficiency: A review of the literature

OBJECTIVE To examine the state of research on population-based studies of the incidence of limb amputation and birth prevalence of limb deficiency. DATA SOURCES A total of 18 publication databases were searched, including MEDLINE, CINAHL, and the Cochrane Library. STUDY SELECTION The search was performed by using a hierarchical process. Articles were reviewed for inclusion by 3 reviewers. Inclusion criteria included defined catchment area, calculation of population-based incidence rates, defined etiology of limb loss, and English language. Review articles, animal studies, case reports, cohort studies, letters, and editorials were excluded. DATA EXTRACTION Figures on the estimated incidence of amputation and birth prevalence of congenital limb deficiency were gleaned from selected reports and assembled into a table format by etiology. DATA SYNTHESIS The studies varied in scope, quality, and methodology, making comparisons between studies difficult. Incidence rates of acquired amputation varied greatly between and within nations. Rates of all-cause acquired amputation ranged from 1.2 first major amputations per 10,000 women in Japan to 4.4 per 10,000 men in the Navajo Nation in the United States between 1992 and 1997. Consistent among all nations, the risk of amputation was greatest among persons with diabetes mellitus. CONCLUSIONS Surveillance of congenital limb deficiency exists in much of the developed world. Existing studies of acquired amputation suffer from a host of methodologic problems. Future efforts should be directed toward the application of standardized measures and methods to enable trends to be evaluated over time and comparisons to be made within and between countries.

Incidence, acute care length of stay, and discharge to rehabilitation of traumatic amputee patients: An epidemiologic study

OBJECTIVE To examine patterns of trauma-related amputations over time by age and gender of the patient and by level and type of amputation, and to explore factors affecting acute care length of stay and discharge to inpatient rehabilitation. DESIGN Population-based hospital discharge data for Maryland from 1979 through 1993. PARTICIPANTS Patients (N = 6,069) discharged with either (1) a principal or secondary diagnosis of a trauma-related amputation to the upper or lower extremity or (2) a procedure code for a lower or upper limb amputation in combination with a principal diagnosis of an extremity injury or injury-related complication. RESULTS Incidence of major amputations declined 3.4% (p < .05) annually from 1.88 per 100,000 in 1979 to 1.07 per 100,000 in 1993. Incidence of minor amputations declined 4.8% (p < .05) annually from 10.8 per 100,000 in 1979 to 4.7 per 100,000 in 1993. Acute care length of stay for trauma-related amputations declined 40% over the study period and was significantly affected by the patients payer source, amputation level, and injury characteristics. Of the patients with a major amputation, 15% were discharged to inpatient rehabilitation; 60% were discharged directly home. More proximal amputation levels, presence of severe injuries to other body systems, and acute care at a designated trauma center significantly increased the likelihood of disposition to inpatient rehabilitation. The leading causes of trauma-related amputation were injuries involving machinery (40.1%), powered tools and appliances (27.8%), firearms (8.5%), and motor vehicle crashes (8%). CONCLUSIONS Findings suggest a substantial decline in incidence rates of both major and minor amputations over the 15-year study period, a low rate of disposition to inpatient rehabilitation services of patients sustaining major amputations, and an apparent role of firearms as a cause of trauma-related amputations in patients younger than 25 years of age. The consequences of increasingly shorter acute care hospital stays and low rates of discharge to inpatient rehabilitation on the long-term outcomes of persons who have had traumatic amputation should be examined.

The relation between stress fractures and bone mineral density: evidence from active-duty Army women.

OBJECTIVE To determine if bone mineral density (BMD) is associated with the probability of stress fractures in premenopausal women. DESIGN Case-control study. SETTING Large Army post, Fort Lewis, WA. PARTICIPANTS Twenty-seven active duty Army women with documented stress fractures within the last 2 years and 158 female controls. METHODS AND MAIN RESULTS All subjects were examined and interviewed. BMD of the femoral neck and posteroanterior lumbar spine (L2-L4) was measured using dual energy X-ray absorptiometry. Univariate comparisons revealed no significant differences in BMD of the femoral neck or lumbar spine between groups. Women with stress fractures had a significantly higher exercise intensity (428 vs 292 minutes per week, p<.05) and were more likely to be entry-level enlisted soldiers (63% vs. 44%, p<.05) than those without stress fractures. Multivariate analyses revealed a strong negative association between femoral neck BMD and the probability of stress fractures (lower BMD, higher risk). Exercise intensity and body mass index had a significant positive effect on BMD of the femoral neck and lumbar spine, yet both were associated with an increased probability of stress fractures. CONCLUSIONS Femoral neck BMD was significantly associated with the probability of stress fractures. Optimal training programs should balance the beneficial indirect effect of increased exercise (through increased BMD) with its detrimental direct effect on stress fractures.

Identifying lumbosacral radiculopathies: An optimal electromyographic screen

ObjectiveThe objective of this study was to determine prospectively the optimal electromyographic screening examination of the lower limb that ensures identification of those lumbosacral radiculopathies that can be electrodiagnostically confirmed, yet minimizes the number of muscles studied. DesignA prospective multicenter study was conducted from May 1996 to September 1997. Patients with suspected lumbosacral radiculopathy referred to participating electrodiagnostic laboratories were recruited and examined by needle electromyography using a standard set of muscles. Patients with electrodiagnostically confirmed lumbosacral radiculopathies were selected for analysis. Various muscle screens were tested against this group of patients with radiculopathies to determine the frequency with which each screen identified the patient with radiculopathy. ResultsThere were 102 patients identified. When paraspinal muscles were one of the screening muscles, four-muscle screens identified 88–97% of the radiculopathies, five-muscle screens identified 94–98%, and six-muscle screens 98–100%. When paraspinal muscles were not part of the screen, identification rates were lower for all screens, and eight distal muscles were necessary to identify about 90% of the radiculopathies. ConclusionsSix-muscle screens with paraspinal muscles yielded consistently high identification rates. Studying additional muscles produced no improvements in identification.

Rehabilitation Setting and Associated Mortality and Medical Stability Among Persons With Amputations

OBJECTIVE To estimate the differences in outcomes across postacute care settings-inpatient rehabilitation, skilled nursing facility (SNF), or home-for dysvascular lower-limb amputees. DESIGN Medicare claims data for 1996 were used to identify a cohort of elderly persons with major lower-limb dysvascular amputations. One-year outcomes were derived by analyzing claims for this cohort in 1996 and 1997. SETTING Postacute care after amputation. PARTICIPANTS Dysvascular lower-limb elderly amputees (N=2468). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Mortality, medical stability, reamputations, and prosthetic device acquisition. RESULTS The 1-year mortality for the elderly amputees was 41%. Multivariate probit models controlling for patient characteristics indicated that patients discharged to inpatient rehabilitation were significantly (P<.001) more likely to have survived 12 months postamputation (75%) than those discharged to an SNF (63%) or those sent home (51%). Acquisition of a prosthesis was significantly (P<.001) more frequent for persons going to inpatient rehabilitation (73%) compared with SNF (58%) and home (49%) dispositions. The number of nonamputee-related hospital admissions was significantly less for persons sent to a rehabilitation service than for those sent home or to an SNF. Subsequent amputations were significantly (P<.025) less likely for amputees receiving inpatient rehabilitation (18%) than for those sent home (25%). CONCLUSIONS Receiving inpatient rehabilitation care immediately after acute care was associated with reduced mortality, fewer subsequent amputations, greater acquisition of prosthetic devices, and greater medical stability than for patients who were sent home or to an SNF. Such information is vital for health policy makers, physicians, and insurers.

Measurement Equivalence in ADL and IADL Difficulty Across International Surveys of Aging: Findings From the HRS, SHARE, and ELSA

OBJECTIVE To examine the measurement equivalence of items on disability across three international surveys of aging. METHOD Data for persons aged 65 and older were drawn from the Health and Retirement Survey (HRS, n = 10,905), English Longitudinal Study of Aging (ELSA, n = 5,437), and Survey of Health, Ageing and Retirement in Europe (SHARE, n = 13,408). Differential item functioning (DIF) was assessed using item response theory (IRT) methods for activities of daily living (ADL) and instrumental activities of daily living (IADL) items. RESULTS HRS and SHARE exhibited measurement equivalence, but 6 of 11 items in ELSA demonstrated meaningful DIF. At the scale level, this item-level DIF affected scores reflecting greater disability. IRT methods also spread out score distributions and shifted scores higher (toward greater disability). Results for mean disability differences by demographic characteristics, using original and DIF-adjusted scores, were the same overall but differed for some subgroup comparisons involving ELSA. DISCUSSION Testing and adjusting for DIF is one means of minimizing measurement error in cross-national survey comparisons. IRT methods were used to evaluate potential measurement bias in disability comparisons across three international surveys of aging. The analysis also suggested DIF was mitigated for scales including both ADL and IADL and that summary indexes (counts of limitations) likely underestimate mean disability in these international populations.