March 3, 2010

1. Physical and Psychological Impact of Limb Loss Among Haiti Earthquake Survivors Clinician Outreach and Communication Activity (COCA) Conference Call March 3, 2010

2. Continuing Education Disclaimer In compliance with continuing education requirements, all presenters must disclose any financial or other relationships with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters as well as any use of unlabeled product(s) or product(s) under investigational use. CDC, our planners, and our presenters wish to disclose they have no financial interests or other relationships with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters. This presentation does not involve the unlabeled use of a product or product under investigational use.There is no commercial support.

3. Accrediting Statements CME: The Centers for Disease Control and Prevention is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The Centers for Disease Control and Prevention designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit. Physicians should only claim credit commensurate with the extent of their participation in the activity. CNE: The Centers for Disease Control and Prevention is accredited as a provider of Continuing Nursing Education by the American Nurses Credentialing Center's Commission on Accreditation. This activity provides 1 contact hour. CEU: The CDC has been approved as an Authorized Provider by the International Association for Continuing Education and Training (IACET), 8405 Greensboro Drive, Suite 800, McLean, VA 22102. The CDC is authorized by IACET to offer 0.1 CEU's for this program. CECH: The Centers for Disease Control and Prevention is a designated provider of continuing education contact hours (CECH) in health education by the National Commission for Health Education Credentialing, Inc. This program is a designated event for the CHES to receive 1 Category I contact hour in health education, CDC provider number GA0082.ACPE: CDC is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.  This program is a designated event for pharmacist to receive 1.0 Contact Hours in pharmacy education.

4. Today’s Presenters Terrence P. Sheehan, MD Chief Medical Officer and Director of Amputee Rehabilitation Program Adventist Rehabilitation Hospital Rockville, Maryland Medical Director Amputee Coalition of America (ACA) Chair, ACA Medical Advisory Committee Stephen T Wegener, PhD, ABPP Director, Division of Rehabilitation Psychology and Neuropsychology Associate Professor of Physical Medicine and Rehabilitation Associate Professor of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University   Baltimore, Maryland Moderator: Mary Helen Witten, Project Officer for Amputee Coalition of America in the National Center on Birth Defects & Developmental Disabilities at the Centers for Disease Control and Prevention

5. Objectives At the conclusion of this hour, each participant should be able to: Describe epidemiology, physiology and classifications of limb loss. Compare and Contrast the incidence and management of limb loss in the United States with Post Earthquake Haiti. Identify amputee pre-operative predictors of outcome for rehabilitation and lifelong follow through Discuss essential information for the management of psychosocial issues following limb loss.

6. Physical Issues Following Limb Loss:Adapting in the Context of a Natural Disaster Terrence P.Sheehan, MD

7. Physicians For Peace www.amputee-coalition.org

8. Statistics • In the US, there are approximately 1.9 million people living with limb loss • Congenital Amputations: ~ 5% • Tumor: ~ 5% • Traumatic: ~ 15% • Males > females • Vascular and Diabetic: ~ 70-80% • Over half of these are diabetic • 82% of discharges are vascular related NLLIC ACA Fact Sheet

9. Amputee • Rate of major amputations because of vascular disease has decreased • 75% of all amputations occur in those older than 65yrs • Amputations in the geriatric population in the U.S. will probably double by 2030

10. Amputee • Peripheral Vascular Disease • Risks: • Diabetes Mellitus • Smoking • Hypertension • Hyperlipidemia • Obesity • Inactive Lifestyle • Family history of CAD or PVD

11. Every Day in the U.S. • 225 people have amputations due to the complications of diabetes • 55 people with diabetes lose their eyesight • 120 people with diabetes get end-stage kidney disease • 580 people die from diabetes and its complications • REMEMBER THAT IS EVERY SINGLE DAY!

12. Don’t Neglect Your Diabetes – don’t be a statistic

13. AMPUTATION should not be thought of as a failure of treatment, but as a treatment of choice.

14. Pre-Operative Evaluation and Amputation Surgery • Physiatric Pre-operative Evaluation • Co-morbid factors • Three “unaffected” extremities • Opposite foot • Affected extremity • Range of motion • Strength • Sensation • Vocation • Avocation

15. Prior to Earthquake, most limb loss from trauma and infection Men Motorcycle, gunshot Post earthquake Estimates of 2000 to 3000 people with limb loss Majority are women and children Majority below knee amputations Numbers will grow over the next months to year because of poor infection treatment from trauma Haiti

17. Major Differences When Thinking About Upper and Lower Extremities for Salvage Lower Extremity: • Weight bearing Mandatory • Functions poorly w/o sensation • “Assistive” limb not useful • Needs to be relatively pain free • Needs durable skin and soft tissue coverage. Base decision on limb that can tolerate weight bearing, have sensation to provide protective feedback, and have durable skin and soft tissue cover.

18. THE SURGEON SHOULD PLAN FOR THE PROSTHESIS AT THE TIME OF SURGERY • Incision Placement Shape • Bone • Beveling distal end • Length • To bridge or not to bridge • Soft tissue • Securing the Muscle Over the Bone • Adequate coverage

19. Limb Amputation • Stabilizing the distal insertion of muscle can improve residual limb function and comfort. • Myodesis is the direct suturing of muscle or tendon to bone. • Myoplasty involves suturing of muscles to periosteum. • Myoplasty does not provide as secure a distal stabilization of the muscle as does Myodesis.

20. Post Earthquake Haiti ampsurg.org The Amputation Surgery Education Center Dedicated to helping surgeons improve technique and patient outcomes

21. Post-Operative and Pre-Prosthetic Management Overview • Wound care • Edema control • Therapy program • Pain control • Psychological issues • Disposition planning • Education

22. Early Rehabilitation:Post-Amputation Goals - Physical • Minimize muscle atrophy, maintain muscle strength in affected limb, • Maintain muscle strength in unaffected limbs • Maintain body symmetry • Maintain some two-handed function. • Adequate pain control • Decrease post surgical edema • Promote wound healing • Decrease pain • Mold residual limb • Prevent flexion contractures in surrounding joints

23. Post-Operative and Pre-Prosthetic Management Wound Care • If the wound is clean and dry, protect it with non-adherent dry, sterile dressing daily • If the wound is moist or open, use saline gel or antibiotic ointment dressing twice daily • For burns or skin grafts, use xeroform or petroleum dressing daily • Staples usually removed after 2-3 weeks for trauma, or 3-6 weeks for dysvascular patients • Wounds heal faster if edema is controlled

24. Post-Operative and Pre-Prosthetic Management: Edema Control Options • Ace Wrap • Compression dressing – ace-wrapping • 24 hr/d until staples out, then switch to shrinker • Must be wrapped correctly or it may make edema worse • Must be re-wrapped several times a day to change dressing or simply check the wound • Prefer shrinker garment once staples removed • Rigid Options • IPOP • Traditional IPOP is simply a rigid dressing with a pylon and foot attached for early mobilization (partial-weight-bearing only)

26. Post-Operative and Pre-Prosthetic Management • Therapy Program • Strengthening of shoulder depressors, elbow extensors, hip extensors and abductors, knee flexors and extensors, ankle DF/PF • AAROM at hip extension, knee extension, ankle DF • Back program (lumbar mobs, core strength) • Early mobilization to wheelchair, then progressive ambulation

27. Stretching

28. Stretching

29. Post-Operative and Pre-Prosthetic Management • Therapy Program • Residual limb care for shaping/shrinking, soft tissue mobilization and scar management if appropriate, desensitization • Education regarding edema control, limb positioning, exercise program, future prosthetic rehab program • Driving assessment and training when appropriate

30. Residual Limb Pain • Post-surgical • Edema • Infection • Neuroma • Bone spurs • Prosthetic related

31. Post-Operative and Pre-Prosthetic Management • Pain Control • Distinguish surgical pain, phantom pain, phantom sensation • Surgical pain requires narcotics, but short-term only • Phantom sensation requires no meds, just re-assurance that it is normal • Phantom pain may require meds, but try to avoid narcotics

32. Common Examples of Phantom Sensation Gnawing/eating Stabbing Burning Squeezed Painfully twisted Terrible cramps Shocking/shooting Sherman, Richard A.  Phantom Pain.  New York: Plenum Press, 1997

33. Post-Operative and Pre-Prosthetic Management • Phantom Pain • Most common choice drug now is gabapentin, dosage range 300-3000/d • Tri-cycles still used as adjunct meds • TENS is worth trying and provide home unit if it works • De-sensitization by tapping, rubbing, massage of residual limb • Compression with prosthesis or shrinker helps

34. Towel Pull

35. Other Accepted Physical Treatments • Heat/cold • Topical applications • Increasing muscle tone in residual limb • Maintain well-fitting prosthesis • Stretching, • massaging, • Isometric exercises • TENS • Acupuncture, Acupressure, • Chiropractic

36. Heterotopic Bone

37. Heterotopic Bone

38. Heterotopic Bone

39. Prosthetic Fitting Determining factors in choice of prosthetic system: • Length of limb • Condition of skin • Strength • Range of motion • Cognitive & physical ability

40. Types of Prosthesis:

41. Patella Tendon Medial Flare Medial Shaft of Tibia

42. Trans Femoral Suspension • Belts and Straps • Liners with Locking Pin • Suction Liner • Vacuum pump • Total Suction • Wet Fit

43. Foot and Ankle Systems • SACH • Single Axis • Multi-Axial • Dynamic Response • Hybrid • Adjustable Heel Height • Microprocessor

44. Technical Barrier to Productivity • Need custom socket • Customized alignment • Time-consuming • Restoring functional gait to the amputee

45. Prosthetics • Monolimb-Socket, pylon, and foot unit form one unit • Single episode of alignment • Wide tolerance of acceptable alignments • $20 foot • Single Sheet Polymer • Lightweight

46. TEAM AMPUTEE Correct surgery, immediate rehabilitation/training, and a well-fitting prosthesis are all equallyimportant! Rehabilitation should be both: • Physical • Psychological

47. Amputation Levels • Disarticulations tend to provide more serviceable levels in the upper extremity. • Shoulder • Elbow • Wrist • Carpal-Metacarpal

48. Upper Limb Amputation Surgeon needs limb • sufficient sensation to provide protective feedback • durable soft tissue cover • used to interact with environment • function with modern prosthetic

49. Upper Limb Amputation New Techniques • Myocutaneous transfers • Skin expansion and bone lengthening • One stage procedure better than multi-step procedure • Early prosthetic fitting (1-4 mths)

50. Upper Limb Amputation Levels of Amputation Trans-humeral amputation performed at three levels: • long, medium, short residual limbs • long-arm residual limb is preferred for optimal prosthetic restoration • prosthetic components can be externally powered, body powered, passive, or a combination of these