Geriatric Physical Therapy 3rd edition

392 CHAPTER 20  Management of Urinary Incontinence in Women and Men impairment in older adults.44,124 Persons taking other quicker recovery compared to the open retropubic colpo- anticholinergic drugs may experience a load effect, exac- suspension. However, it appears to be more costly and erbating certain side effects, such as dry mouth and takes more time to perform.128 Short-term outcomes are constipation. This cumulative effect may cause slowed similar between the two procedures. However, long-term gastrointestinal motility and poor absorption of other success rates appear to be less promising for the laparo- important medications.44 Therefore, the physical thera- scopic procedure.127,128 pist needs to be alert to and report to the managing physician any suspected drug-related changes in the Anterior vaginal repair, or anterior colporrhaphy, patient’s status. uses a vaginal surgical approach. The vaginal mucosa is dissected below the urethra and sutures are placed in Urethral Bulking Agents and Surgical the periurethral tissue and pubocervical fascia to lift Interventions for Stress Urinary and support the bladder neck.42,129 Although this pro- Incontinence cedure results in lower rates of new or recurrent pro- lapse, it is less effective compared to open retropubic Peri- or transurethral injection of collagen or other syn- colposuspension.42,127 thetic bulking agents into the urethral mucosa creates an artificial urethral seal similar to that provided normally The traditional suburethral sling operation combines by the submucosal vasculature and urethral smooth both an abdominal and vaginal approach.42 The surgeon muscle.125 Bulking agents are also recommended for men places strips of material (synthetic or biological) under with stress UI following prostatectomy.37 These agents the urethra and attaches them to the rectus muscle or can be helpful in reducing stress UI in the short to the iliopectineal ligaments. Each time the woman term.15,68,125,126 However, two to three injections may be strains, the sling tightens, supporting the bladder.42,130 needed to see results. In addition, the durability of this The tension-free vaginal tape (TVT) procedure is a less intervention beyond 12 months is unknown.15,37,125,126 invasive sling procedure and is sometimes performed using only local anesthesia. The TVT utilizes a self-fixing Interventions recommended for postprostatectomy polypropylene mesh inserted around the midurethra.130 UI are usually conservative, not involving surgery.80 A recent Cochrane systematic review concluded that Therefore, only those surgical options for female stress there is a lack of information to judge whether or not UI are discussed here. Surgery for female stress UI is suburethral sling procedures are as effective as open ret- typically offered to patients after a trial of more conser- ropubic colposuspension, or better or worse than other vative treatment options has failed. The most common surgical procedures or conservative management options surgical procedures for female stress UI include the open for UI.130 However, one large multicenter, randomized retropubic colposuspension, anterior vaginal repair, lap- surgical trial found that the suburethral sling, using aroscopic colposuspension, suburethral sling procedure, autologous rectus fascia, yielded higher success rates but and tension-free vaginal tape (a less invasive suburethral greater morbidity than the open retropubic colposuspen- sling procedure). These procedures reduce stress UI by sion (specifically, the Burch colposuspension) in women correcting urethral closure deficiencies and improving with stress UI.131 urethrovesical junction support. Recognized complica- tions associated with surgery include new symptoms of CASE EXAMPLE urgency and urge incontinence, voiding difficulties, new or recurrent POP, and the need for additional stress UI History and Interview surgery.42 At the time of interview, Mrs. J was a 63-year-old white Colposuspension involves lifting the tissues near the woman with a diagnosis of mixed UI. She had been bladder neck and proximal urethra in the area of the referred to physical therapy by her gynecologist. She was pelvis behind the anterior pubic bones. It can be per- living alone and independently in a two-story town formed through a lower abdominal incision (open retro- house, and working full-time as an administrative assis- pubic colposuspension) or laparoscopically (laparoscopic tant to the principal of a nearby high school. Her colposuspension).126,127 Retropubic colposuspension is reported height and weight were 64 inches and 170 lbs, considered the gold standard surgery for female stress UI, respectively. as it is most effective and results in fewer complications. A recent Cochrane review concluded that this procedure When asked about symptoms, Mrs. J indicated that yielded an overall continence rate of 85% to 90%. In her UI began about 10 years previously, with worsened addition, approximately 80% of women should expect to symptoms over the past 6 months. She indicated a strong be continent up to 5 years following this surgery.127 The sensation of urge associated with UI episodes. Especially, laparoscopic procedure varies from the open procedure when she stood up and walked to the bathroom. with regard to number of sutures applied, the possible use of staples or mesh, and the site of anchor. Given the Mrs. J voided every hour throughout the day and smaller incision, patients may have less pain and a evening. In addition, she woke up three times to void every night. She leaked urine every time she walked to the bathroom, coughed, and sneezed. She classified the

CHAPTER 20  Management of Urinary Incontinence in Women and Men 393 leaks as medium to large. To avoid embarrassment, she assistive device on level ground. She ascended and used three to four maxi pads/day. She denied fecal incon- descended 10 steps with a handrail independently. She tinence but strained and experienced pain while having complained of slight knee pain descending the stairs and bowel movements. However, she moved her bowels moving from sit to stand. daily without enemas or laxatives. She reported a diet rich in whole-grain cereals, bread, fruits, and vegetables. The pelvic floor examination was performed after She consumed three to four 8-oz cups of coffee and two receiving written consent. External examination of the 12-oz bottles of diet caffeinated soda per day. perineum revealed no signs of inflammation or vaginal discharge. Sensation about the perineum was intact to Mrs. J was not receiving any other medical treatment light touch. Episiotomy scar was noted. No pain or for her UI. She indicated that her mixed UI caused her to tenderness was elicited from palpation of tissues around restrict physical activities and long-distance travel. She the perineum. When asked to contract her PFMs, the previously walked 2 miles per day. She was not in an clinician observed an anal wink. intimate relationship. Internal vaginal examination revealed intact sensation Systems Review to touch on the lateral, anterior, and posterior vaginal walls. Mrs. J reported 5/10 pain in response to palpation During systems review, Mrs. J denied smoking, allergies, of the left levator ani muscle. Levator ani muscle bulk chronic cough, or respiratory disease. She also denied was symmetrical bilaterally. PFM strength, rated accord- kidney, other bladder (cancer, painful urination, diffi- ing to the Brink scale, was 7/12 (pressure score 5 2, verti- culty initiating urine stream, or frequent urinary tract cal displacement score 5 2, and contraction duration infections), liver, blood, skin, and neurologic disease/ score 5 3).50 She demonstrated the ability to contract her disorders. Gastrointestinal problems included straining PFMs without accessory hip muscle contractions. She to have a bowel movement. She denied history of cancer required cues to fully relax her PFMs between repeated and hearing or vision loss. She indicated arthritis in both contractions. Examination of the anterior and posterior knees that caused pain when moving from sitting to vaginal walls during cough assessment revealed no visible standing and walking down stairs. She denied injuries to POP. A rectal examination was not performed because of the back or lower extremities. She reported occasional Mrs. J’s request. When asked to “bear down” as for a depression and anxiety but was not seeking medical bowel movement, Mrs. J demonstrated tightening instead treatment for either condition. Her medical history was of relaxation of the external anal sphincter. positive for high blood pressure. Evaluation Mrs. J’s obstetric history included two full-term preg- nancies and two operative (episiotomy) vaginal deliver- Mrs. J’s symptom profile was consistent with the diagno- ies. She became postmenopausal at age 53 years. sis of mixed UI. She reported frequent urination, UI during situations of increased abdominal pressure and Mrs. J’s medical management included b-blocker associated with a strong sense of urgency, and nocturia. (Lopressor) for high blood pressure, ibuprofen for knee Possible contributing UI risk and lifestyle factors for pain, and estradiol (Estrace) for vaginal dryness. Past Mrs. J included age, race, estrogen loss, obesity, and surgical history included hysterectomy at age 55 years excessive caffeine and carbonated beverage intake. and cholecystectomy at age 47 years. Relevant impairments included PFM weakness, the in- ability to relax the external anal sphincter during a Mrs. J’s goals for physical therapy were to become Valsalva maneuver, and a painful left levator ani muscle. “dry” and to reduce the number of trips she made to the Her knee pain and muscle weakness, although not bathroom per day. She was anxious to resume her walk- directly related to her mixed UI, was a relevant factor for ing program as she gained 15 lbs in the past year. intervention planning. Mrs. J’s symptoms affected her ability to sleep, exercise, and travel. Examination Diagnosis and Prognosis Based on Mrs. J’s symptoms, functional limitations, and reported disability, the examination included all items The physical therapy diagnoses for Mrs. J were muscle listed in Box 20-3 under “General Examination” and weakness, mixed urinary incontinence, and urinary fre- “Specific Examination of Female Clients.” Significant quency. The physical therapy prognosis for Mrs. J was examination findings included the following. Blood pres- good. She demonstrated a weak but coordinated PFM sure was 130/84 in sitting. Lower extremity knee flexion contraction, was motivated to improve, and willing to was limited to 100 degrees bilaterally. Knee extension make lifestyle changes that could positively affect her strength was 4/5 bilaterally. Sensation to light touch was outcome. Based on several studies, a 76% to 86% reduc- intact throughout all LE dermatomes bilaterally. Lower tion in UI may be expected from a multicomponent extremity proprioception was intact, and DTRs were 21 intervention program for mixed UI.77-79 bilaterally. Mrs. J was independent with bed mobility and sit to stand. She walked independently without an

394 CHAPTER 20  Management of Urinary Incontinence in Women and Men Goals and Outcome Measures instructed to perform a single PFM contraction each time she stood up throughout the course of her day. Mrs. J and the clinician agreed on the following physical therapy goals: (1) 80% reduction in urine leakage epi- The first three physical therapy visits included a sodes, (2) voiding interval of every 2 to 3 hours during 10-minute session of biofeedback. Given Mrs. J’s painful day and evening hours, (3) wake to void once per night, left levator ani muscle, biofeedback was used to ensure (4) use of pads for bedtime only, (5) 0/10 pain with full relaxation between PFM contractions. This was es- bowel movements, (6) reduction in symptom-related sential to prevent exacerbation of pain during exercise distress, and (7) improved quality of life. and to alleviate straining during defecation. To measure intervention outcomes, the clinician se- At Visit 2, the clinician recommended that Mrs. J lected a 3-day bladder diary and the PFDI- and PFIQ- begin to practice the urge suppression strategy.73,78 She short forms (Urinary and Colorectal-Anal subscales was advised to initially practice this strategy at home. only).49,58 The bladder diary allowed Mrs. J to record the After gaining success at home, she was told to use the time of each void/24 hours, occurrence of each urine loss strategy at work. She was also educated in use of the episode, and pad usage. The PFDI- and PFIQ-short forms stress strategy.73,74 She was advised to contract her PFMs were selected to measure changes in bladder and bowel quickly and strongly just prior to and during a cough or symptoms, symptom-associated distress, and symptom sneeze. impact on quality of life following intervention. It was important to initiate bladder training only after Implications for Plan of Care Mrs. J reported success using the urge suppression strat- egy. By Visit 4, Mrs. J began increasing voiding intervals Based on Mrs. J’s symptoms, impairments, and symptom by 10- to 15-minute increments. Her chosen voiding impact on quality of life, the clinician implemented a interval goal was 2.5 hours. multicomponent plan of care that included PFM exer- cise, biofeedback, bladder training, stress and urge Evidence-based lifestyle changes were also recom- strategy training, and education in proper defecation mended. Mrs. J agreed to decrease, but not eliminate, techniques. her intake of coffee and diet caffeinated soda. Over the course of 9 weeks, she was able to reduce her caffeine Pelvic floor muscle exercises were prescribed to intake by drinking two 8-oz cups of decaffeinated and improve Mrs. J’s continence mechanisms. They were only one 8-oz cup of caffeinated coffee. She also replaced critical to increase her PFM strength, improve urethral one serving of carbonated soda with an 8-oz glass of support, and promote skill and success in using the water. stress strategy to prevent/stop stress UI episodes. Improving PFM function would also enable her to Given that Mrs. J’s weight may have contributed to apply the urge strategy to inhibit bladder contractions, her mixed UI and knee pain, the clinician recommended prevent urge UI episodes, and promote bladder train- she investigate a medically supervised weight loss ing. After practicing muscle contractions during the program. Mrs. J expressed the desire to lose weight. initial session, the clinician educated Mrs. J in a home However, she desired to pursue weight loss after she exercise program. The program consisted of ten con- completed all of her physical therapy sessions. tractions, three times per day. The clinician recom- mended she hold each contraction for 3 seconds Outcomes followed by 6 seconds of relaxation. The clinician chose this contraction/relaxation ratio based on After 9 weekly visits, Mrs. J was discharged from physi- Mrs. J’s weak muscles, incomplete muscle relaxation, cal therapy. She met all of her initial goals. In addition, and painful left levator ani. Over the course of therapy, she exceeded the 80% reduction in UI episodes by 10%. the clinician gradually increased the muscle contrac- Her PFDI and Colorectal-Anal (decreased from 50 to 28) tion/relaxation ratio to 10 seconds/20 seconds; and the and Urinary Distress scale (decreased from 79 to 37) number of contractions to a maximum of 45 per day. scores verified symptom improvement. Similarly, her This exercise intensity paralleled studies that observed PFIQ (UDI-7) score (decreased from 67 to 27) indicated a mean 76% to 86% reduction in UI episodes in improved quality of life.58 Mrs. J resumed walking 1 mile women with urge UI and mixed UI.77-79 By the seventh three times per week. visit, Mrs. J was able to perform 45 10-second PFM contractions per day without pain. Initially, Mrs. J REFERENCES exercised in the supine position. By the fifth visit, Mrs. J performed exercises in sitting, standing, and To enhance this text and add value for the reader, all while walking. Repeated PFM contractions performed references are included on the companion Evolve site during sit to stand or step-ups were not prescribed that accompanies this text book. The reader can view the because of Mrs. J’s knee pain. Instead, Mrs. J was reference source and access it online whenever possible. There are a total of 131 cited references and other gen- eral references for this chapter.

21C H A P T E R Conservative Pain Management for the Older Adult Katherine Beissner, PT, PhD INTRODUCTION of persistent pain, and effective treatment addresses these aspects of pain, in addition to symptom relief.2 Pain is a universal experience that has received increas- ing recognition as a major public health problem and its Noting that classification of pain according to its pre- impact on declining function and prolonging rehabilita- sumed source may help guide treatment, the American tion for millions of people.1 Health professionals often Geriatrics Society Panel on Persistent Pain in Older Per- talk about the “pain experience,” recognizing that pain sons identified four categories of pain based on the pre- has biological, psychological, and social components sumed source of the pain: nociceptive, neuropathic, that result in individualized responses to unpleasant mixed or unspecified, and psychiatric.5 Nociceptive pain stimuli. Pain is also described as having both a “disease” arises from stimulation of pain receptors; neuropathic and an “illness” component. The disease component pain from pathology in the peripheral or central nervous involves the nociceptive and central nervous system pro- system; mixed or unspecified pain from multiple or cessing of pain; illness reflects the suffering and behav- unknown sources; and in rare cases, pain from a psychi- iors associated with pain. atric disorder, such as a conversion reaction.5 In the case of psychogenic pain, treatment with analgesic mecha- Loeser describes four major types of pain, each re- nisms is not indicated but psychiatric treatment may be quiring a different approach to clinical management: beneficial. transient, acute, chronic cancer pain, chronic noncancer pain.2 Transient pain, such as stubbing a toe or a needle A comprehensive taxonomy of “chronic pain” devel- prick, is an everyday experience that rarely warrants oped by the International Association for the Study of health care intervention. It is a brief activation of noci- Pain categorizes a patient’s pain according to five attri- ceptors with negligible tissue damage. Acute pain is the butes: pain location, body system involved (e.g., respira- unpleasant sensation typically associated with direct tis- tory, musculoskeletal), pattern of occurrence (e.g., con- sue injury. Acute pain usually resolves readily through tinuous, recurring), intensity, and etiology.6 Other the healing process. Postsurgical pain and pain following taxonomies have been developed to classify pain experi- a musculoskeletal injury are examples of acute pain. enced by patients with particular conditions, such as Breakthrough pain, often considered a type of acute cancer,7 neuropathies,8 spinal cord injury,9 and to incor- pain, is an increase in pain above a tolerable level of porate the psychosocial aspects of pain into classification ongoing pain.3,4 Chronic pain due to cancer is associated systems.10,11 Although these classification systems may with tissue damage due to the disease process and/or help to categorize pain types, research into the validity cancer treatment. It is distinguished clinically from other and reliability of the classification systems is mixed, and types of pain because the focus of treatment is often on a valid taxonomy of pain that can be used to guide treat- palliative care.2 Chronic pain due to nonmalignant dis- ment is not yet available.12 eases presents a different clinical management problem. Chronic pain and persistent pain are terms used inter- SCOPE OF THE PROBLEM: PREVALENCE, changeably to reflect an unresolved pain problem that CHALLENGES, AND COSTS OF PAIN persists after the normal period of tissue healing, con- MANAGEMENT IN OLDER ADULTS tinuing because of some factor other than the original injury or illness. Persistent pain is becoming the more Prevalence commonly used term, and will therefore be used through- out this chapter. Psychological, environmental, and so- It is estimated that annually more than 76 million people cial factors play a large role in the clinical manifestations in the United States experience pain, with incidence peaking in middle age (45 to 64 years) and declining in Copyright © 2012, 2000, 1993 by Mosby, Inc., an affiliate of Elsevier Inc. 395

396 CHAPTER 21  Conservative Pain Management for the Older Adult the older population.13 The 2008 report on health in of older adults seen in a large geriatric pain clinic in the United States shows that 48.2% of respondents aged Australia between 1991 and 1999 revealed that more 65 years and older report joint pain (excluding the back than 50% of the subjects had three or more organ sys- or neck) in the 30 days prior to the survey, and almost tems affected by comorbid conditions,31 with the most 32% of older adults reported low back pain lasting 24 common conditions involving the cardiac (54.4% of hours or more in the prior 3 months.14 subjects) and gastrointestinal systems (35.9%). Those with more medical conditions reported lower levels Because persistent pain lasts extended periods of time, of physical activity, and higher pain intensity, with and may never resolve fully, the term prevalence rather approximately 50% of subjects also reporting high levels than incidence is used in discussing the extent to which of depressive and anxiety symptoms.31 Patients with populations are affected with this type of pain. Differ- persistent pain and depressive symptoms report higher ences in populations studied and in definitions of persis- levels of disability and diminished physical performance tent pain yield large differences in estimates of its preva- than patients without depressive symptoms.32 A dose– lence, from about 20%15 to 49%,16 and even higher response relationship exists between the severity of de- among residents of nursing homes.17 On average, older pression and pain-related activity limitations.33,34 Treat- adults have longer pain duration18 and more pain sites19 ment interactions are seen as well. In a large randomized than working-age adults, factors associated with higher clinical trial of older adults with pain and depression, levels of functional impairment.20 Although acute pain is treatment directed only at decreasing depression yielded reported more by middle-aged adults, older adults have a small but significant treatment effect for pain and pain- a higher prevalence of chronic health conditions associ- related disability.35 ated with persistent pain. Epidemiologic studies that categorized prevalence of pain by disease type show that Pain has a detrimental impact on function. For exam- prevalence of rheumatic diseases such as polymyalgia ple, a high level of postoperative pain following surgical rheumatica, giant cell arteritis, and gout, rise dramati- stabilization of hip fractures limits early mobility and is cally after age 65.21 Arthritis, predominantly osteoar- associated with longer hospital stays. Morrison et al, in a thritis, is reported by approximately 50% of adults aged study of patients post–hip fracture, found that patients 65 years and older, and activity limitations associated with high postoperative pain levels not only had impaired with arthritis are reported by 22.4% of this popula- mobility during hospitalization but also that this impaired tion.21 Diagnoses of back and neck pain decrease after a mobility persisted 6 months after hospital discharge.36 In peak in middle age,22 but severe back pain increases with a study of older adults (aged 75 to 105 years of age) in advanced age.23 southern Sweden, 51% of the oldest old (951 years) reported pain-related difficulty in functional activities in Pain Management Challenges the prior 3 months, as compared to 36% of the youngest group in the study (aged 75 to 79 years).37 Pain management is complex, and it is well recognized that pain is undertreated in the older population (Box The type of functional limitations experienced depends, 21-1).24-26 Older adults, concerned with addiction or the in part, upon the location of the pain. Limitation in mobil- potential side effects of drugs, often alter the medication ity, the most common limitation reported among older regimen prescribed by their physician.27,28 Even when adults, is associated with lower extremity pain.38 Older taken as prescribed, medication side effects such as fa- women with low back pain experienced difficulty with tigue, sedation, dizziness, and confusion can limit a light housework, shopping, and activities of daily living.39 person’s ability to participate in therapy, thereby delay- Those with widespread pain (upper and lower extremities, ing progress and potentially contributing to other seri- and trunk) have greater likelihood of having severe diffi- ous health concerns. culties in activities of daily living (ADLs), walking, and lifting.40 It is common for older adults to have one or more chronic health conditions that limit the range of analge- Although the reported prevalence of pain in older sic options to manage multiple conditions.29,30 A study adults with significant cognitive impairment varies widely, there is agreement that the prevalence is high.41 BO X 2 1 - 1 Challenges of Pain Management Accurately assessing pain is particularly challenging in in Older Adults the presence of significant cognitive impairment,41,42 and accurate pain assessment is key to appropriate pain man- • Underreporting and undertreatment of pain agement. • Medication adherence and adverse effects • Impact of pain on function and mobility Another important challenge in understanding pain • Comorbid conditions—physical and mental health and pain management is the association of pain with • Comorbid cognitive impairment socioeconomic factors. Those with lower education lev- • Association of socioeconomic factors with pain incidence and els and income report higher incidence of pain-related disability,38,43-46 and cultural aspects of coping also impact affect patients’ pain experience.47,48 Individuals with lower educational levels tend to use more passive coping

CHAPTER 21  Conservative Pain Management for the Older Adult 397 strategies (e.g., hoping, praying, and catastrophizing) increase in payments for steroid injections and almost which are less effective than positive, active coping strat- 42% increase in payments for magnetic resonance imag- egies (e.g., positive self-talk, exercise) in terms of impact ing (MRI) or computed tomographic (CT) scans. A on disability.46,47 It is proposed that individuals with recent analysis reported a staggering 423% increase in higher educational levels have a greater sense of self- Medicare payments for opiates for patients with low efficacy, have more positive interactions with health care back pain between 1997 and 2004.62 In 2004 alone al- providers, and assume greater responsibility for pain most 20 million prescriptions for these drugs were paid management through active coping strategies, thereby for Medicare beneficiaries with spinal pain conditions.62 reducing pain-related disability despite comparable Despite this increased expenditure, there are also in- levels of pain intensity.46 creasing numbers of individuals reporting limitations in physical and social function associated with pain.63 The gender differences in pain and pain impact are well documented in the literature. Women experience BIOPSYCHOSOCIAL MODEL pain at greater intensity,49 more locations,50 and with OF PERSISTENT PAIN greater impact on function21,38 than men. Women have a higher prevalence of persistent back pain,51 fibromyal- The biopsychosocial model describes pain as a multidi- gia,52 and arthritis,21 including arthritic changes in the mensional experience that incorporates biological (noci- lower spine.53 This pattern is true in patients with pri- ception), psychological (thoughts and emotions), and mary neurologic diagnoses as well. Among patients with social (interactions with family or work) mechanisms. Parkinson’s disease54 and multiple sclerosis,55 female Although acute pain certainly has social and psychologi- gender is associated with greater pain and pain-related cal impacts that may require a multidisciplinary approach disability. The mechanisms underlying gender differ- for some patients, the ongoing nature of persistent pain ences in pain intensity and impact are not fully under- makes these more pronounced, requiring a more uni- stood, and more research is needed into the potential formly multidimensional approach to care. causes and potential gender-based treatment protocols.56 Biological mechanisms include the activation of pain Cost of Pain Management in Older Adults receptors, transmission along complex neural pathways, perception of pain, and internal pain suppression mecha- In addition to the human aspects of pain prevalence and nisms. A recent summary article highlights neuroscience impact, the enormous costs of pain treatment are a uni- evidence of genetic factors predisposing individuals to versal concern. Costs of chronic or persistent pain man- persistent pain and implicates imbalances in neurotrans- agement, including lost productivity, increased health mitters and receptors as contributory toward the devel- care visits, medication use, and diagnostic procedures opment and maintenance of a persistent pain state.1 It is are burdensome both on the individual patient and the also clear that pain fluctuates in accordance with the payor system.57-60 In the United States, it is estimated patient’s mood state through the impact of hormones on that more than 50 million people annually seek help for neurotransmitters.1 persistent pain problems, at cost greater than $70 billion in terms of medical care and lost productivity.1 The psychological aspects of persistent pain are thus recognized as being intertwined with the biological com- It is difficult to accurately measure the monetary cost ponents through the impact of thoughts and emotions of pain management in the older adult population. How- on the stress regulatory systems, both in terms of height- ever, by examining figures for patients with spinal pain ening sensitivity to noxious stimulation but also in the problems, it is clear that the cost of treating patients impact of positive mood states on resilience. Studies with pain is growing at an extraordinary rate. Prevalence examining the management of persistent pain focus on of persistent back pain and recent attention to the previ- the factors with a negative effect on pain intensity and ously widespread undertreatment of the problem has pain-related disability,64 including the associations be- resulted in an astronomical increase in the money spent tween depression and persistent pain65 and the impact of treating and diagnosing this problem. Although research maladaptive cognitions on emotions and pain behaviors provides some evidence of advances in effective treat- (e.g., activity avoidance).66 Although there has been ment protocols, these advances are not associated with a much debate on the direction of causality among depres- proportionate improvement at the population level, and sion, anxiety, anger, and persistent pain, it is clear that the prevalence of persistent back pain continues to rise.57 these factors present concomitantly and all play a role in Medicare expenditures for epidural steroid injections the patient’s pain experience. and magnetic imaging studies for patients with low back pain have increased disproportionately to the increase in Although the “social” aspect of the biopsychosocial numbers of patients with these conditions.61 Interest- model of persistent pain is the least well studied, there is ingly, increases in payment for physical therapy services evidence that the relationship between persistent pain for Pennsylvania Medicare recipients increased a nomi- and social or intimate relationships is bidirectional. Per- nal 0.2% between 2000 and 2003, but there was a 59% ceived social support improves persistent pain coping67 whereas conflict within social networks is associated

398 CHAPTER 21  Conservative Pain Management for the Older Adult with higher levels of pain.68 Small qualitative studies body functional limitations than younger adults but have shown that some patients with persistent pain con- lower rates of depression, lower use of passive coping ditions experience increased tension and conflict in on- strategies, and higher scores for perceived control and going relationships.69,70 overall mental health.75 However, in another study of 340 patients between 17 and 93 years of age, 25% of AGE-RELATED CHANGES: IS PAIN the older subjects were found to have maladaptive cop- IN OLDER ADULTS DIFFERENT? ing strategies in which relatively low levels of pain were associated with high levels of depression and disability, Age differences in the presentation of acute pain and the a combination not seen in younger age groups.76 prevalence of persistent pain conditions have led to re- search investigating whether there are aging-related ana- EXAMINATION AND EVALUATION tomic and physiological changes in pain reception, con- OF THE PATIENT WITH PAIN duction, and perception. Six factors are proposed that may alter the perception of pain in older adults: decreased no- The examination and evaluation of older patients with ciceptor density, changes in the conductivity of nociceptive pain, whether acute or persistent, is similar to the evalu- afferents, changes in central coding of pain, changes in ation of younger adults. Although the same components segmental nociceptive reflexes, alterations in descending of the evaluation are important, it may be necessary to inhibition of pain, and psychosocial influences that alter modify testing procedures for older adults with other the meaning and impact of pain.71 health concerns. For example, a patient with chronic obstructive pulmonary disease may be unable to lie flat Laboratory research with experimentally induced ther- in either a supine or prone position for muscle testing mal pain confirms that older adults have slower response and range of motion measurement, and will need to have times than younger adults, but this change in response the position modified. This same patient may require times is seen only in A-delta fibers. A-delta transmission is frequent rests between testing procedures to avoid associated with “first pain” perception—the initial detec- fatigue or shortness of breath. Also note that some of tion of a noxious stimulation. There is no evidence of the standardized pain assessment instruments that assess slowing of transmission in the unmyelinated C fibers, pain-related disability may use language biased toward which yield perception of longer, ongoing pain.72 Others working adults. These may not be relevant for older have found that older adults take longer to report pain adults who have retired. Further, it may be difficult than younger adults and that point tenderness takes lon- to discern whether limitations identified with these in- ger to resolve in older subjects.73 Aside from these changes struments are caused by the pain or by other health in A-delta conduction velocity and slowed pain resolu- problems. tion, studies of changes in sensory perception and pain threshold in older adults using experimentally induced Clinically, the experience of nurses and emergency pain models have produced conflicting results but are health workers show that some older adults do not com- known to reflect a different pattern of decline than seen in plain of pain despite the presence of painful conditions, other sensory systems (e.g., hearing, vision).71 The extent whereas others complain continuously.77 Clearly, all older to which these changes in nerve conduction velocity adults are not alike, and in an individualized approach to impact the patient’s pain experience is not clear. However, evaluation and treatment planning a variety of factors in discussing persistent pain in older adults, Karp et al must be considered when developing a program geared refer to the state of pain homeostenosis—the limitation of toward reducing pain and maximizing function. an aging person’s ability to adjust (physiologically, psy- chologically, socially) to pain stresses. These authors pro- A full history and physical examination are essential, pose that age-related changes in central and peripheral as the primary purposes of the examination and evalua- processing of pain combined with other losses associated tion process are the identification of physical pathologies with aging (including narrowed social networks, depres- that may give rise to pain, and the identification of any sion, or cognitive decline), exacerbate physiological re- associated functional limitations. Comprehensive de- serve decline, which, in turn, further decreases the per- scriptions of the examination and evaluation process as- son’s capacity to adapt to physical, emotional, and sociated with impairments in cardiopulmonary endur- environmental stressors.74 ance, motor function, joint mobility, motor control, and posture are found elsewhere in this text. The following It is interesting to note that older adults with persis- discussion of the examination focuses on aspects related tent pain have more physical limitations in health and to the patient’s pain. function, but for the most part actually show better mental health and better pain coping skills than younger Patient History adults with similar pain problems.75 In this large study (n 5 6147, 19.8% aged 60 years and older) drawn A comprehensive patient history is essential in guiding the from patients at three multidisciplinary pain centers in physical examination of the patient and should include the United States, older adults reported greater lower social history, current work/volunteer status, living

CHAPTER 21  Conservative Pain Management for the Older Adult 399 environment, general health perceptions, behavioral risk words (e.g., dull, aching, throbbing, stabbing) can be factors, medical/surgical history, current medications, and provided, with instructions to circle the words that best functional status/activity level. For patients with a chief describe their pain. Words with dramatic impact (e.g., complaint of pain, particular attention to past medical punishing, cruel, vicious) give cues to the emotional im- history is important in identifying conditions that may pact of the pain. give rise to pain, affect pain perception, or identify contra- indications (e.g., history of cancer) to various interven- Intensity, or the amount of pain perceived, is the most tions. There is consensus that physical therapists should commonly evaluated aspect of pain. When measuring screen for “red flags” (signs and symptoms associated pain, patients’ self-report of pain intensity is preferred, with an increased risk of a serious medical condition that because caregivers often underestimate pain intensity. warrants referral out to the appropriate medical practitio- Pain intensity is most commonly measured with the ner).78 However, there is concern regarding the lack of Numerical Rating Scale (NRS), Verbal Numerical empirical evidence on the diagnostic accuracy of many red Scale (VNS), Verbal Descriptor Scale (VDS), Visual flags and the potential escalation in costs if every patient Analog Scale (VAS), and the Faces Pain Scale (FPS).82 with a “red flag” sign or symptom is referred for addi- Figure 21-1 illustrates these pain intensity instruments. tional testing.79 In a comparison study of these scales using experimen- tally induced pain, although the VAS had an acceptable In 1994 the Agency for Health Care Policy and interrater reliability, the reliability was the lowest among Research (AHCPR) published guidelines for the manage- the five tools (93.5% agreement compared to 100% ment of acute low back pain in adults, identifying red agreement with the NRS, VDS, VNS, and FPS). The VAS flags for cancer or infection, spinal fracture, and cauda also showed the highest “failure” rate, measured as the equina syndrome.80 A more recent set of evidence-based frequency of incomplete or incorrect completion (e.g., guidelines developed by a European Commission fo- more than one mark made on a single scale). Each scale cused on acute low back pain identified 12 red flags: age was used seven times, and across these testing sessions of onset (less than 20 or greater than 55); history of the VAS had a failure rate of 19.1% for older subjects trauma; thoracic pain; fever; structural deformity; pro- (age range 65 to 94, n 5 89) compared to 2.2% for the longed use of corticosteroids; drug abuse, immunosup- NRS and lower failures for all other scales.83 A recently pression, HIV; widespread neurologic signs; previous developed pain intensity tool is the Iowa Pain Thermom- history of malignancy; systemically unwell; unexplained eter (IPT), which uses a shaded thermometer alongside weight loss; and constant progressive, nonmechanical seven verbal pain descriptors ranging from no pain to pain (pain that is not altered by movement or changes in the most intense pain imaginable (Figure 21-2). Patients position).81 Although developed for use with patients use the visual cue of the thermometer to select verbal with spinal pain problems, these red flags may be rele- descriptors of pain intensity. In a study using a sample of vant to patients with extremity problems as well. Bois- 97 subjects with chronic pain (including 36 older adults sonnault, in a recent textbook focused on primary care aged 65 to 87 years), five pain scales (IPT, NRS, VNS, physical therapy, provides a list of red flags for each VAS, and FPS) were compared in terms of failure, scale major body region and recommends that physical thera- sensitivity, and subject preference. The IPT was judged pists screen for applicable red flags as part of every pa- to be superior to other scales because of its low failure tient assessment.78 Many of these red flags involve pain rate and high patient preference rating. However, with symptoms. the exception of the VAS, the other scales also showed strong performance and provide good options for use in Pain History the older population.82 For all patients for whom pain limits function, it is im- Location: identifying the primary pain locations, as portant to obtain a brief pain history that provides char- well as locations of referred pain is important in deter- acteristics of pain, past pain history, prior treatment mining the potential source(s) of the pain impairment. approaches, and the outcome of each approach. When Pain location is most commonly assessed by having the working with older adults with visual or hearing impair- patient indicate painful areas on a body diagram, or by ments, slight modifications to usual procedures may having the patient point to the painful area(s). need to be made. It is important to ensure that the ex- amination area has adequate lighting, that any hearing Aggravating and easing factors are the positions and aid is working properly, and that any written materials movements that increase or relieve the patient’s pain. are available in large print. Important dimensions of Relevant questions include determining which posi- pain to be included in the pain history include the tions or movements give rise to pain (or increase pain following. intensity), and the length of time spent in the position (or movement) before the pain begins. Questions re- Quality of pain is evaluated in terms of the words the garding the positions or actions that decrease or allevi- patient uses to describe the pain. Patients can be asked ate the pain symptoms provide information on appro- to describe the pain using their own words; or a list of priate treatment programs and resting positions for patients.

400 CHAPTER 21  Conservative Pain Management for the Older Adult 9LVXDO$QDORJ6FDOH9$6 1R 3DLQDVEDG DVLWFRXOG $ SDLQ SRVVLEO\\EH FIGURE 21-1  P​ ain intensity scales. A, Visual 9HUEDO'HVFULSWRU6FDOH Analog Scale (Adapted from Joyce CR, Zutshi DW, Hrubes V, Mason RM. Comparison of fixed interval and visual analogue scales for 1R 0LOG 0RGHUDWH 6HYHUH 9HU\\ :RUVW rating chronic pain. Eur J Clin Pharmacol % SDLQ SDLQ SDLQ SDLQ VHYHUH SRVVLEOH 1975;8:415-20). B, Verbal Descriptor Scale SDLQ SDLQ (Data from Melzack R, Torgerson WS. On​ the language of pain. Anesthesiology 1971;34:50-9). C, Numerical Rating Scale (Data from Downie WW, Leatham PA, Rhind 1XPHULFDO5DWLQJ6FDOH VM, Wright V, Branco JA, Anderson JA. Stud- ies with pain rating scales. Ann Rheum​ Dis 1978;37:378-81). D, Face Pain Scale Revised (Hicks CL, von Baeyer CL, Spafford          PA, van Korlaar I, Goodenough B. The​ 1R 0RGHUDWH :RUVW Faces Pain Scale-Revised: toward a common SDLQ & SDLQ SRVVLEOH SDLQ metric in pediatric pain measurement. Pain 2001;93:173-83.) )DFHV3DLQ6FDOH5HYLVHG 6FRUH '       O Most Intense Standardized Pain Instruments.  ​For patients with Pain Imaginable chief complaints of pain, or with persistent pain that limits function, therapists should consider using a multi- O dimensional pain inventory as a means for documenting pain symptoms and their impact on function. These O Very Severe Pain instruments are commonly used as outcome measures to quantify the extent to which patients improve over the O course of treatment. The Brief Pain Inventory84-87 and the McGill Pain Questionaire88,89 are among the more O Severe Pain widely used inventories. The McGill Pain Questionnaire is the most well-known instrument, composed of multi- FIGURE 21-2  I​owa pain O ple items assessing the intensity, quality, and behavior of pain, along with the impact of various conditions (e.g., thermometer.  (Courtesy O Moderate Pain liquor, weather changes, bright lights). Scores on this Keela Herr, The University of instrument range from 0 to 78, with higher scores indi- Iowa.) O cating greater pain severity.88 A short form of this instru- ment consists of 15 pain descriptors, for which patients O Mild Pain rate intensity on a 0 to 3 scale (none to severe), with score range from 0 to 45.90 Tests of the responsiveness of O the Norwegian version of this instrument with patients ranging in age from 23 to 86 indicate that a 51 change O Slight Pain in score represents a clinically important change.91 A new revision of the short-form McGill Pain Question- O naire has been developed by expanding the number of O No Pain Iowa Pain Thermometer

CHAPTER 21  Conservative Pain Management for the Older Adult 401 descriptors to capture aspects of neuropathic pain.92 The these instruments, and others, have been widely used in Brief Pain Inventory (BPI) is a 32-item questionnaire that clinical research and practice with older adults and are ef- incorporates questions on medical care, location of pain, fective in identifying clinically meaningful change. For ex- pain intensity (current, most intense in past week, least ample, the WOMAC was found to be more responsive to intense in past week, average over the past week), pain meaningful changes in patient status than the generic quality, and the impact of the pain on function, mood, health status instrument (SF-36) in comparisons of drug and sleep. The BPI-Short Form is a nine-item question- versus placebo treatments of adults (mean age 61.5 years) naire with subquestions, incorporating items on pain with osteoarthritis of the hip,106 and among 697 patients intensity, location, impact, and current treatment.87 Both with knee osteoarthritis (mean age 5 70 years, range 5 38 versions of the BPI have demonstrated validity and reli- to 90).107 A large study (n 5 1362) determined the mini- ability and have been used for patients with a variety of mally clinically important improvement in WOMAC pain diagnoses, including cancer, osteoarthritis,86,87 and scores for outpatients with hip or knee osteoarthritis general residential care.84 (mean age 5 64.6 and 67.9 years, respectively) to be –7.9 for hip arthritis and –9.1 for knee arthritis.108 Other standardized instruments used in clinical set- tings are the Pain Disability Index (PDI) and the Geriat- The Patient Specific Functional Scale (PSFS) provides ric Pain Measure (GPM). The PDI is a self-report instru- individualized assessment of a patient’s progress accord- ment on which patients rate the extent to which their ing to functional activities important to the individual.109 painful condition interferes with seven areas of life func- The PSFS has been found to be more responsive to tion (e.g., recreation, sexual behavior, and family func- changes in functional status than more standardized as- tion), using a numerical rating scale from 0 (no disabil- sessment tools.110,111 In the initial examination, the pa- ity) to 10 (worst disability). Summed scores yield a total tient is asked to identify three areas in which she or he is disability score ranging from 0 to 70. The PDI demon- having difficulty as a result of their chief complaint. strates acceptable validity and reliability93-95 and has Then each activity is rated on a scale of 0 (unable to been used in outcomes studies for patients with persis- perform activity) to 10 (able to perform activity at the tent back pain,96,97 and subacute neck pain98 as well as same level as prior to the illness or injury) and scores for other disorders. No research reports were found that the three activities are averaged. At subsequent evalua- used the PDI specifically in the older adult population. tions, the same items are rated and compared to the initial score. The PSFS has been used in clinical research The Geriatric Pain Measure (GPM) was specifically that included older patients,109,110,112 though potential developed for use with older adults in an attempt to mea- age-group differences in instrument sensitivity and sure self-reported pain intensity, and the impact of pain specificity have not been studied. Because functional on functional ability, mood, and quality of life.99,100 The criteria for improvement are individualized, the PSFS is instrument was developed based upon literature review appropriate for use with any population and is consid- of the existing pain instruments, with items taken from ered to be an effective means of documenting clinical scales shown to have good face validity. Further develop- changes.113,114 ment was based on expert panel review and pilot testing Screening Tools.  ​Because of the relationship of thoughts with a sample of older adults. The instrument consists and emotions on pain and pain behaviors, particularly in of 22 items scored dichotomously (yes 5 1, no 5 0) to patients with persistent pain problems, it is important to measure the impact of pain on social interaction and screen patients with persistent pain for selected psycho- function, and two items related to pain intensity, scored logical attributes, such as depression, fear avoidance on a scale of 0 to 10.100 Item scores are summed to gener- behavior, self-efficacy, and coping. ate scores ranging from 0 to 42, where lower scores indicate less pain. A 12-item version of the GPM includes Depression is commonly seen in patients with persis- the pain intensity items and ten items related to pain tent pain, so screening for depressive symptoms within impact (scored yes 5 2, no 5 0), with a summed score this patient population is advisable, with referral to an range from 0 to 40.101 Both versions of the GPM have appropriate practitioner if a significant depression is sug- demonstrated aspects of validity and reliability100,101 and gested. Recent review articles115,116 highlight the impor- a self-administered version has been tested in a sample of tance of depression screening for patients with persistent 1072 older adults in Europe. However, as a relatively pain and describe several screening tools appropriate for new instrument, use in research studies is limited, and as older adults. Chapter 8 provides a detailed discussion of yet, no standards are set for detecting minimally clinically commonly available screening tools for depression. meaningful changes in GPM scores. The Fear Avoidance Beliefs Questionnaire (FABQ) is Other options for assessing the impact of a plan of care a useful instrument that can help to identify whether on patient outcomes include disease-specific instruments patients have thoughts and beliefs that lead to maladap- such as the WOMAC arthritis disability index,102 the tive coping strategies such as activity limitation.117 The Roland-Morris Disability Questionnaire for low back instrument assesses the extent to which patients believe pain,103,104 or the Neck Disability Index.105 Although not that physical activity affects their pain using two sub- initially developed specifically for use in older populations, scales, one for the impact of work on pain and the other

402 CHAPTER 21  Conservative Pain Management for the Older Adult for general physical activity. Designed for working-age Persistence, Exercise/Stretching). The CPCI has been adults with low back pain, FABQ–work scores are as- validated for use in patients with chronic141,142 and sub- sociated with self-reported physical disability118 and are acute143 pain conditions. The Guarding scale is the predictive of treatment outcomes for patients receiving strongest predictor of disability among all scales from workers’ compensation.119 The FABQ–physical activity the CPCI and CSQ,138,143 and although overall the CPCI scale has been shown to be predictive of gait speed120 is a better predictor of disability than the CSQ, it is less and exercise training outcomes in patients not receiving sensitive to the detection of depression.138,143 Thus, workers’ compensation.121 Little research is available on based on research comparing the use of these two instru- the use of the FABQ with older populations. ments, the Catastrophizing scale from the CSQ and the Guarding scale from the CPCI appear to be the most The Tampa Scale for Kinesiophobia122 also assesses helpful in identifying depressive mood and future dis- the degree to which fear of movement affects disability, ability status.138,143 but it has not been examined for use with older adults. Pain Assessment in Patients with Dementia.  ​There is Research with younger populations shows this instru- speculation that difficulty accurately assessing pain leads ment to be useful in assessing the outcomes of rehabili- to a particularly high prevalence of undertreatment of tation programs for patients with a variety of pain individuals with cognitive impairment. However, pain problems.123-127 intensity tools such as the Iowa Pain Thermometer, Visual Analog Scale, Visual Analog Scales with verbal Self-efficacy belief, especially as related to an individ- descriptors, Numerical Sequence Scale, and Verbal ual’s perceived ability to cope with a chronically painful Rating Scales have all been used with older adults with condition, is associated with rehabilitation outcomes. cognitive impairments with some success. In a study of The Arthritis Self-Efficacy Scale (ASES) consists of 160 French-speaking older adults admitted to inpatient 20 items related to an individual’s beliefs that she or he dementia units in Geneva, Switzerland, 88% of the can manage pain associated with particular tasks.128 sample was able to explain and use at least one pain Each item is rated on a scale indicating the certainty with intensity scale. Highest comprehension was found for which the person can perform each task, ranging from visual analog scales with verbal descriptors, and the low- 0 (very uncertain) to 100 (very certain). Scores on the est comprehension was found on the Faces Pain Scale.144 ASES are associated with functional performance for Similarly, Ware et al found that their U.S. sample of patients with a variety of conditions, including knee os- English-speaking subjects with dementia (n 5 28) were teoarthritis,129,130 fibromyalgia,131 and rheumatoid ar- all able to complete at least one intensity scale.145 Inter- thritis.132 This instrument may be useful for patients estingly, all subjects were able to use the Faces Pain who have persistent pain problems that will require Scale, and 90% were able to use the Numerical Rating ongoing self-management. Scale. Because it appears that many adults with dementia are able to provide valid responses to pain intensity Coping scales are used to measure how patients react scales, use of self-report instruments is advised. Clini- to, and cope with, pain. Use of maladaptive coping strat- cians should consider having several scale options avail- egies may interfere with progress in therapy, so identifi- able to find the one that works best for each patient. cation of coping strategies is indicated when patients appear to have substantial difficulty dealing with their When using self-report measures of pain intensity for pain. Two self-report instruments are most commonly adults with severe dementia, there is always some con- used: the Coping Strategies Questionnaire (CSQ) and the cern over the validity of the ratings. Given that older Chronic Pain Coping Inventory. The CSQ is a 50-item adults with cognitive impairment have similar facial/ questionnaire assessing the use of five cognitive coping behavioral responses to evoked pain as older adults with strategies (coping self-statements; catastrophizing; dis- no cognitive impairment,146 a number of observation traction; ignoring pain sensations; and reinterpreting tools have been developed to determine the extent and pain sensations) and two behavioral responses (praying/ intensity of pain for those with severe cognitive impair- hoping, and increasing activities). For each item, patients ment. Recent review articles147-149 provide excellent rate the frequency of their use of each coping strategy on summaries of the instruments that have been used a 7-point scale, from never (0) to always (6).133,134 CSQ with cognitively impaired older adults. Each review con- scales correlate well with other measures of adjustment cludes that more research into the psychometric qualities and well-being135,136 and are predictive of disability.137,138 of the instruments is needed, but the Pain Assessment In particular, the “catastrophizing” scale appears to be Checklist for Seniors with Limited Ability to Communi- particularly helpful in identifying patients with intense cate (PACSLAC) and the DOLOPLUS2 have been judged pain, depression, and disability.138 to have the best psychometric qualities.147 Unfortunately, neither seems appropriate for use within physical therapy There are two versions of the Chronic Pain Coping treatment sessions. The PACSLAC is a 60-item instru- Inventory (CPCI), composed of either 65139 or 42 ment requiring ratings based upon four dimensions: items.140 Both versions are composed of two parts, one facial expressions, activity/body movement, social/ focused on illness behaviors (Guarding, Resting, and Asking for Assistance) and the other on positive coping behaviors (Coping Self-Statements, Relaxation, Task

CHAPTER 21  Conservative Pain Management for the Older Adult 403 personality/mood, and physiological/sleeping/eating. 149a impairments while using other interventions to help con- The DOLOPLUS2 is a ten-item scale requiring observa- trol pain in order to enhance functional recovery. tion over an extended period of time rather than current pain level. Physical therapists may work in clinical set- Information from imaging studies is often available to tings in which these scales are used and may contribute physical therapists, and this information may be helpful observations/ratings as part of a team evaluating patients as an adjunct to the physical therapy examination. How- with complex pain problems. ever, it is important to apply the results of such studies cautiously, as anatomic abnormalities identified on ra- Recent studies provide support for the validity and diographs or scans may not give rise to a patient’s signs reliability of the Pain Assessment in Advanced Dementia and symptoms. In a prospective study of asymptomatic (PAINAD) instrument,150 a tool designed for use in adults with no history of low back pain or sciatica, 57% clinical settings. The PAINAD is based on two more of the MRI lumbar scans on subjects aged 601 had ab- comprehensive pain assessment tools, and includes five normal results (36% with herniated nucleus pulposus, items (breathing, negative vocalization, facial expres- 21% spinal stenosis).153 Keeping this in mind, informa- sion, body language, and consolability) which are rated tion from any imaging study should be considered along- on a 0 to 2 scale. Summed scores, assigned by a health side the results of the examination in the determination care provider, range from 0 to 10, with higher numbers of the physical therapy diagnosis. taken to be reflective of more intense pain. Scores on the PAINAD correlated well with numerical response scales PROGNOSIS AND PLAN OF CARE for patients with and those without cognitive impair- OF THE PATIENT WITH PAIN ment, and scores were higher during activities antici- pated to elicit pain (e.g., during transitional movements). The patient’s prognosis for recovery is dependent upon Although easy to use, only three of the six categories of many factors, including age, scope and severity of im- nonverbal pain behaviors recommended to be assessed5 pairments, chronicity of the problem, psychological are included in the instrument, and the limited scope of and socioeconomic factors, and overall health status. In the assessment leaves questions regarding its sensitivity general, younger patients tend to recover more rapidly to changes.148 than older patients, though other factors play a large role in the recovery process. Patients with acute pain Perhaps a more important weakness of the PAINAD that is easily localized and with an identifiable incident and other instruments that use summation of pain be- of onset have a better prognosis for recovery than those haviors to yield a pain intensity score is the underlying with a widespread persistent pain problem of insidious assumption that more pain behaviors means more in- onset. Subjects with chronic medical conditions that tense pain. Pasero and McCaffery caution that instru- give rise to pain (e.g., osteoarthritis, spinal stenosis) ments that provide checklists are useful in determining may learn compensation strategies such as strengthen- whether pain behaviors decrease after an intervention, ing surrounding musculature and minimizing stressors but are not useful in determining the amount of pain the on the affected area. These strategies are likely to de- patient experiences.151 However, at this point summa- crease pain but unlikely to completely alleviate pain. tion of pain behavior appears to be the best indicator Note also that other comorbid health conditions affect we have for pain intensity in populations with severe full participation in rehabilitation. For example, walk- dementia.152 ing programs or other conditioning exercises are rec- ommended for patients with chronic pain. A patient Physical Examination who has chronic back pain and heart disease or chronic obstructive pulmonary disease (COPD) may require a Upon conclusion of the history and assessment of pain, more gradual increase in walking time/distance than a thorough physical examination should be conducted to would be seen in others without such health problems. identify impairments related to joint mobility, motor Those with a substantial psychosocial component to function, muscle performance, sensory integrity, integu- their pain may require longer interdisciplinary treat- mentary integrity, and cardiopulmonary function. ment to address their multifaceted pain problem, and Through tests and measures, the therapist will be able to patients with significant socioeconomic disadvantages identify impairments that may contribute to the patient’s may experience higher levels of challenge to program pain. Throughout the physical examination, it is impor- adherence and progress. tant to note what positions, motions, and activities give rise to pain as this information will assist in arriving at a By weighing these and other factors identified through diagnosis. Because many patients who have persistent the history and examination with the patient’s specified pain problems limit their activity and exercise as a result treatment goals, the therapist will make a determination of concerns with pain, it is likely that impairments in of the patient’s expected treatment outcomes. The plan muscle performance, joint mobility, and cardiovascular of care is then developed, specifying the long-term endurance will be identified in the physical examination. and short-term goals, expected treatment outcomes, and A comprehensive treatment plan will focus on these interventions.

404 CHAPTER 21  Conservative Pain Management for the Older Adult PHYSICAL THERAPY INTERVENTIONS knee osteoarthritis generated greater force during iso- TO ADDRESS PAIN kinetic exercise, suggesting that alleviation of pain en- hances muscle performance.168 Changes in peak torque Optimally, first-line interventions should directly address generated following application of thermal agents were the source of pain.5 A comprehensive examination of the most dramatic in measurements of knee extension, with patient to identify impairments associated with the pain- the advantage of the treatment groups over the control ful condition will direct those interventions. Such inter- group ranging from 3.35 N-m to 16.05 N-m, depending ventions may include therapeutic exercise,154 joint mobi- upon the treatment group and angular velocity tested.168 lization or manipulation,155-157 and orthotic or supportive These results support the use of thermal agents prior to devices.158-160 These interventions reduce stress and cor- exercise training to enhance performance during the ex- rect malalignments of joint structures, correct muscle ercise session, although the long-term effects of this ap- imbalances, and enhance the shock absorption capacity proach to exercise training have not been studied. of tissue structures. Selection of appropriate treatments must include consideration of contraindications associ- Thermal agents are commonly used in the self- ated with the patient’s comorbid conditions (e.g., osteo- management of chronic pain. In a study of 272 com- porosis or osteopenia), and may necessitate adjustment munity-dwelling adults aged 72 years and older, 28% of usual treatment parameters to accommodate comor- reported some relief of chronic pain using heating or bid conditions and the patient’s current functional status. cooling agents.169 Among low-income, urban-minority older adults, heating agents were cited as helpful for Although correction of the cause of pain is always controlling arthritis pain for 33% of black and 40% of desirable, it is sometimes not possible. Even a thorough Hispanic subjects.170 Because heating and cooling assessment may not clearly reveal the source of the pa- agents carry some risk of injury, educating patients tient’s pain, or, even if the source is revealed, it may not about their appropriate use is an important role for be possible for physical therapy interventions to directly physical therapists. General procedures for the appli- address the underlying cause of the pain (e.g., osteoar- cation of thermal agents are provided elsewhere.171-173 thritis). In these cases, direct treatment of the patient’s pain symptoms may increase the patient’s ability to tol- Manual Therapy erate active interventions that address other impairments limiting the patients’ function. Passive treatment mo- We typically think about mobilization and manipulation dalities focused solely on temporarily decreasing pain for their role in the restoration of joint mobility. How- symptoms (e.g., heat treatments, cryotherapy, transcuta- ever, they also have a role in the control of pain. neous electrical nerve stimulation [TENS]) should be Although there is scant evidence on the use of joint mo- used sparingly as part of the physical therapy interven- bilization and manipulation specifically for older adults, tion. These modalities should be a means to an end, the research has addressed the use of these treatments for end being decreasing pain to a sufficient extent to allow knee and hip osteoarthritis, conditions common in older patients to participate in subsequent active treatments adults. A recent qualitative systematic review of 39 stud- aimed at positively affecting functional abilities. ies174 revealed Level B (fair) evidence to support the use of manipulative therapy in combination with exercise Thermal Agents for the treatment of knee osteoarthritis, and Level C (limited) evidence in support of the use of the combina- Although thermal agents are frequently used in the physi- tion of manipulation and exercise for patients with hip cal therapy treatment of patients with pain,161-163 the lit- osteoarthritis. Limited evidence is also found for the use erature on the effects of thermal agents on pain in older of these treatments for foot and ankle problems. In one adults is limited. The Philadelphia Panel, an interdisciplin- example of a study protocol yielding beneficial effects ary group of experts convened to develop evidence-based for patients with hip osteoarthritis, the treatment group guidelines for treatment of musculoskeletal disorders, receiving a program combining thrust and non-thrust found a lack of evidence to support the use of thermal manipulations to the hip joint was almost twice as likely agents (including ultrasound) for the treatment of low to achieve beneficial outcomes as those in an exercise back,164 knee,165 and neck pain,166 but indicated that there group. The benefits in terms of pain intensity, function, is evidence that ultrasound is effective in treatment of and range of motion were retained for more than calcific tendinitis in the shoulder.167 Although studies 6 months.175 In another randomized controlled study of that included older adults were included in the review patients with knee osteoarthritis, large-amplitude oscil- process, the majority of the literature reviewed focused lations of the tibia on the femur improved knee pressure on younger populations and there was no analysis of pain threshold about 21% more than a manual contact potential differential treatment effects according to sub- control treatment. Knee mobilization also decreased the ject age. time required to move from sit to stand by more than 5% over pretreatment times, a 13% difference from More recent research has shown that when physical changes seen in the nontreatment control group that, in agents were applied prior to exercise, older women with

CHAPTER 21  Conservative Pain Management for the Older Adult 405 contrast, demonstrated an 8% increase in sit to stand single site, especially when stimulation is applied at dif- time.176 Because only immediate posttreatment measure- ferent frequencies (i.e., high frequency at one site and low ments were taken, it is not clear how long these treat- frequency at the second site).192 ment effects are sustained. In laboratory research with rats, both high-frequency A Cochrane review of research on headache treatment and low-frequency TENS were found to decrease ex- concludes that, despite considerable limitations in the perimentally induced pain. However, the low-frequency design of the studies included in the review, there is evi- effect was not seen when naltrexone (an opiate inhibitor) dence to support the use of spinal manipulation for the was administered prior to treatment while the impact of prophylactic treatment of a variety of headache types. It high-frequency TENS was not affected by pretreatment is important to note that subject ages for studies in- with naltrexone.193 This indicates that low-frequency cluded in this review extended to age 78 years.177 The and high-frequency TENS achieve pain control through American Pain Society’s clinical practice guidelines indi- different mechanisms, with low-frequency TENS activat- cate that there is good evidence that spinal manipulation ing release of endogenous opiates.193 is effective for the management of persistent spinal Persistent Pain.  T​ he evidence for use of TENS in the pain,178 and a recent study of younger patients (aged 18 management of persistent pain is less conclusive. A small to 45 years) demonstrates benefit of thoracic spine ma- study of older adults with persistent pain demonstrated nipulation for management of patients with acute neck that TENS is tolerated by older adults, and results in a pain.179 A Cochrane systematic review concludes that short-term decrease in pain with both high-frequency manual therapy alone is insufficient in the management “conventional” TENS and burst-mode applications.194 of persistent neck pain. However, there is strong evi- Despite concerns of insufficient evidence to differentiate dence that either manipulation or mobilization com- relative effectiveness among various categories of TENS bined with exercise is effective in reducing pain, with up applications (e.g., “acupuncture-like” vs. high-frequency to a 41% improvement in pain ratings over control con- “conventional” TENS), a Cochrane systematic review ditions. This review also concluded that manual therapy concludes that TENS has positive benefits as an adjunc- with exercise improves function and the patients’ global tive treatment for patients with hand pain due to rheuma- perceived effect of treatment.180 toid arthritis.195 Subjects achieved a 67% decrease in pain at rest after 3 weeks of acupuncture-like TENS, and TENS a statistically significant but not clinically meaningful re- duction in joint tenderness with the application of high- Acute Pain.  R​ ecent studies from the international com- frequency TENS.195 Further, a meta-analysis of the short- munity show increasing support for the use of high- term effects of various treatments for patients with knee frequency TENS (pulse frequency at or greater than 80 per osteoarthritis concludes that TENS (including interferen- second) at high sensory intensity for the treatment of post- tial current therapy) is effective in achieving clinically operative pain. High-frequency sensory level TENS (also important reductions in pain associated with osteoarthri- known as “conventional TENS”) has been shown to be tis of the knee.196 These authors note that the clinically effective in reducing pain intensity and limiting use of pain meaningful changes in pain status were maintained for 1 medications after cardiac surgery181 and posterolateral to 2 months after the treatment period. thoracotomy182,183 and was found to decrease pain and increase performance on spirometry after cardiac sur- Despite these positive conclusions regarding the use gery184 and abdominal surgery.185 TENS has also been of TENS, methodological weaknesses of published stud- shown to decrease pain from postoperative wound dress- ies limit the ability to conclusively support the use of ing changes186 and reduce pain and anxiety among older TENS for persistent pain conditions. A recent systematic adults during ambulance transportation following trau- review of TENS for persistent pain concludes that an matic hip injuries.187 High-frequency TENS appears to be insufficient number of high-quality randomized clinical the most effective TENS application for postsurgical pain trials exist to evaluate the use of TENS for the manage- and can be used with modulating frequencies to control ment of persistent pain.197 neurologic accommodation.188 Table 21-1 summarizes key parameters of the studies examining TENS for manage- Precautions and contraindications important to note ment of postoperative pain. when using TENS are consistent with those for the general population. The use of TENS over the thoracic Studies examining the impact of TENS on pain thresh- region and its use with patients who have implanted old help to highlight the impact of treatment parame- medical devices such as implantable cardioverter defibril- ters.191 High-frequency TENS, maintained at a high sen- lators (ICDs) has been somewhat controversial. There is sory level but below pain threshold, raises experimentally evidence that TENS interferes with electrocardiac moni- induced pain threshold, whereas low-intensity TENS toring, and TENS application was comparable to electro- (maintained just at the sensory threshold) does not,191 cardiographic ventricular fibrillation or ventricular tachy- and high-intensity stimulation at two sites provides cardia. Based upon findings that more than 50% of greater elevation of pain threshold than stimulation at a subjects in a small trial (n 5 30) had disturbance from TENS, whether applied locally or at the hip, the use of

406 CHAPTER 21  Conservative Pain Management for the Older Adult TA B L E 2 1 - 1 Summary of Postoperative TENS Studies Including Older Adult Subjects First Author, TENS Type and Number of Subjects Publication Year Condition Comparison Groups Subject Age Outcomes Emmiler, 2008181 Postoperative cardiac Frequency: 100 Hz N 5 60 TENS group: surgery with Intensity: Strong, Mean age: Decreased pain intensity medial sternotomy Decreased analgesics for CABG on valve comfortable TENS: 59.3 repair Duration: 1 hour, Sham TENS: 63.9 Control: 61.2 repeated once Comparison: TENS Sham TENS Control Erdogan, 2005182 Postthoracotomy TENS frequency: N 5 116 TENS group: 100 Hz Age range 5 20-70 Decreased pain intensity (VAS) at rest Solak, 2007183 Postthoracotomy Intensity below motor N 5 40 and with coughing threshold Mean age: Decreased opioid use Improved pulmonary function (FEV1) Comparison: TENS: 47.3 No complications TENS Control: 53.7 Low-intensity TENS TENS group: Decreased postoperative pain TENS frequency: 3 Hz Decreased pain intensity on postoper- Intensity to 12 mA ative days 4-60 30 minutes Decreased analgesics use Comparison: No side effects TENS PCA Cipriano, 2008184 Cardiac surgery TENS frequency: N 5 45 Decreased pain intensity (VAS) (medial 80Hz Age range 5 41-74 Improved vital capacity and tidal sternotomy) High intensity (sensory) N 5 75 volume Hargreaves, 1989186 Postoperative 34 hours Mean age: 56.9 years abdominal Comparison: Decreased pain intensity during wound dressing dressing changes change TENS Sham TENS Comparison: High-frequency TENS Sham TENS No treatment Rakel, 2003188 Postoperative Modulated high N 5 44 TENS group achieved: Breit, 2004189 abdominal frequency Age range 5 20-77 Decreased pain during walking Gilbert, 1986190 surgery (50/100 Hz) Mean: 40 Increased vital capacity, increased gait Unilateral total knee Intensity to highest n 5 22 (Mean 5 71.5) speed arthroplasty tolerance n 5 25 (Mean 5 75.4) Increased gait distance tolerated n 5 22 (Mean 5 72.2) Postoperative inguinal Comparison groups: No between-group differences in herniorrhaphy TENS n 5 40 amount of analgesics used No intensity TENS Age range: 24-76 Control No difference in pain intensity, medication use, or peak expiratory TENS: Intensity to flow rate tolerance 3 24 hours No frequency data Comparison groups PCA TENS 1 PCA Sham TENS 1 PCA Frequency: 70 Hz Intensity to maximum tolerable PCA, patient-controlled analgesia; TENS, transcutaneous electrical nerve stimulation; VAS, Visual Analog Scale.

CHAPTER 21  Conservative Pain Management for the Older Adult 407 TENS with patients with ICD is not recommended.198 in Older Persons recommends that all older adults with For patients with pacemakers, electrocardiographic mon- persistent pain participate in a physical activity program itoring of the patient during TENS application is recom- individualized to the patient’s needs and incorporating mended prior to independent use by patients. flexibility, strengthening, and endurance exercises. The panel cites strong evidence (Level I) in concluding that Low-Level Laser Therapy (LLLT) clinicians should always incorporate this recommenda- tion.5 The decision then rests in the selection of which Studies regarding the use of low-level laser therapy exercises to incorporate into the treatment program. (LLLT) for the treatment of pain associated with knee Clearly, exercises specific to patients’ impairments in osteoarthritis have been generally small. However, a re- muscle function and joint mobility are indicated. As rec- cent systematic review and meta-analysis of five studies ommended earlier, other components should also be in- with an average subject age of 66.7 years concludes that corporated. The following is a brief summary of research LLLT, when applied with the assumed optimal parame- regarding the impact on pain of flexibility, aerobic, and ters, results in a clinically perceptible improvement in strengthening exercises. pain (24.2% more improvement in pain intensity than Flexibility Exercise.  I​n one study, stretching/flexibility placebo controls).196 The supported parameters are exercise was found to have a more beneficial impact on doses of 2 to 12 J for 904-nm laser, and 20 to 48 J for bodily pain than a program focused on endurance and 830-nm laser, applied to two to eight points over the strength training.208 However, other research has shown joint capsule.196 that strength training programs provide a better reduc- tion of pain in older adults with arthritis.209 Based upon Other research with a younger sample found LLLT moderate-quality evidence, yoga is among the nonphar- effective in reducing pain associated with temporoman- macologic interventions recommended by the American dibular joint dysfunction.199 A Cochrane systematic re- College of Physicians and the American Pain Society for view found mixed results for the treatment of nonspe- the management of low back pain.210 cific back pain,200 and a controlled study found LLLT Aerobic Exercise.  ​Although a relatively early study of ineffective in reducing shoulder pain in patients with older adults with a history of arthritis found that joint rheumatoid arthritis.201 Therefore, at this time, LLLT for symptoms were neither exacerbated nor reduced with the management of pain other than that associated with either cycling, strength training, or a combination of the knee osteoarthritis is not supported by the literature. two,211 other research shows more favorable outcomes. A small study incorporating a 12-week bicycling pro- Protective and Supportive Devices gram for older adults with persistent back pain yielded improved physical function and decreased back pain There is some evidence that protective and supportive symptoms.212 Individuals with osteoarthritis and comor- devices yield a decrease in pain and increase in function bid medical conditions had improved pain levels follow- for patients with joint instability or malalignment. Ther- ing an 18-month aerobic exercise program, whereas no apeutic taping for patellar realignment is effective in re- such improvement was found for participants in a ducing pain and improving function in patients with weight training program.213 Walking programs have osteoarthritis of the knee.158,160 Patients with metatarsal- been shown to produce health benefits and improved gia associated with rheumatoid arthritis experienced pain scores,214,215 yet sustaining a walking program is decreased pain using custom-fitted foot orthosis,202 and problematic, and cessation of the program results in a patients with sternal surgery or sternal separation expe- loss of the program benefits.216 Higher levels of program rience decreased pain using an external support to stabi- adherence are related to improved outcomes of exercise lize the sternum.159 However, while the use of supportive programs.215 devices to prevent glenohumeral subluxation after stroke Strengthening Exercise.  ​Although physical therapy delays the onset of pain, there is no evidence that such consisting of light exercise (isometrics, sit to stand, devices are effective in preventing pain or reducing pain squats, step-ups), massage, taping, and joint mobilization intensity.203 Decisions regarding the use of protective or for patients with knee osteoarthritis was no more effec- supportive devices should therefore be individualized to tive at reducing pain and disability than sham ultra- the patient based upon information gained in the exami- sound,217 a 4-month home-based progressive strengthen- nation. ing exercise program yielded improved self-reported physical function and decreased pain.218 This program Exercise used squats and step-up exercises and open-chain exer- cises using ankle cuff weights, with a targeted range of Expert consensus statements and review panels consis- perceived difficulty for the exercises between 6 and 8 on tently indicate that exercise is safe and effective in improv- a 0 to 10 scale. Resistance was increased by extending the ing the health of older adults, including decreasing levels range of squats/steps, and by increasing the cuff weights of pain.164-167,204-207 In reviewing the available evidence, in 1-lb increments, up to a maximum of 20 lbs per leg. the American Geriatrics Society’s Panel on Persistent Pain

408 CHAPTER 21  Conservative Pain Management for the Older Adult Similarly, a center-based (with home exercise follow-up) widespread availability of such programs and their low Fit and Strong program incorporating conditioning, cost may make these interventions worthwhile endeav- stretching, and strengthening components resulted in ors for patients with persistent pain conditions. improved 6-m walk time and decreased joint stiffness. The strengthening component of Fit and Strong used re- COGNITIVE–BEHAVIORAL APPROACHES sistance bands and cuff weights, increased in 0.5-lb incre- TO PAIN MANAGEMENT ments according to a standardized protocol.219 Patient Self-Management Programs.  A​ meta-analysis Cognitive–behavioral therapy (CBT) seeks to enhance of the impact of exercise on adults with osteoarthritis patients’ control over pain using diverse psychological revealed that exercise alone does not produce improve- techniques.233 Underlying this therapy is the notion that a ments in the psychological well-being of program par- person’s beliefs, attitudes, and behaviors play a central ticipants, suggesting the need for other interventions to role in determining his or her overall experience of pain; address the mental burden of persistent joint disease.220 that thoughts and emotions influence pain perception and Given the high impact of pain on psychological and so- pain behaviors; and that patients can learn adaptive ways cial well-being, incorporating therapies to address these of thinking and feeling.234 Standard CBT pain protocols aspects of pain are appropriate for self-management. seek to (1) teach patients specific cognitive and behavioral skills to better manage pain; (2) teach patients to recog- The most well-known and well-studied self-management nize specific thoughts, beliefs, emotions, and behaviors program for patients who have a chronic health condi- (activity avoidance) that have an effect on pain; and tion is the Arthritis Foundation Self-Help program.221 (3) emphasize the primary role that patients can play in This group intervention teaches individuals with ar- controlling their own pain. CBT is provided by psycho- thritis or related diseases how to reduce the impact of therapists and has proven efficacious for reducing pain their disease on their daily functioning. Educational and disability levels among persons with diverse persistent sessions are led by trained laypeople, who teach par- pain disorders.235-242 Specific interventions for pain man- ticipants specific coping skills like relaxation, visual agement include instruction in pain theory (e.g., pain does imagery, and the use of heating and cooling agents. not equal harm, impact of thoughts/emotions on pain Sessions also include information on medication man- perception and behaviors), relaxation training, distraction agement, nutrition, stress reduction, and methods for techniques (e.g., pleasurable activity scheduling, visual reducing joint stresses such as using assistive devices imagery), and cognitive restructuring (reinterpreting pain and pacing activities. A substantial body of research sensations, controlling pain catastrophizing). Although verifies that this program raises participants’ self- numerous efficacy studies have demonstrated the benefits efficacy for managing their disease,222-226 reducing of this particular therapy, few older adults use cognitive– pain,223,226,227 decreasing disability,227 improving exercise behavioral techniques for managing pain.169,243 Although performance,224,225 and reducing physician visits.223,226 some cognitive–behavioral techniques are incorporated Other self-help programs, such as one combining into self-help programs (e.g., relaxation and imagery are the Arthritis Foundation program with an exercise taught in Arthritis Foundation self-help courses), more program,228-230 a program addressing multiple chronic intensive training for these techniques may not be widely health conditions,222,224,231 and an array of other available, limiting their use for pain management. Com- self-help programs232 provide benefits in terms of pain mon barriers associated with nonuse of relaxation tech- reduction, improved self-management efficacy, and re- niques as a form of CBT-informed self-management duced disability in older adults with persistent pain among older adults included lack of access to the inter- conditions. The key messages highlighted by these ventions and internal factors such as time conflicts, and studies are as follows. First, patient education in self- concerns with treatment efficacy.244 care strategies for managing pain flare-ups, utilizing coping strategies (e.g., use of home-administered heat- Although not qualified as cognitive–behavioral ing or cooling agents, relaxation, imagery), and reduc- therapists, physical therapists are able to adopt a ing joint stresses through assistive devices is likely to cognitive–behavioral perspective when treating pa- decrease the patient’s dependence on health care pro- tients234 by incorporating a cognitive–behavioral ap- viders, increase his or her self-efficacy, and improve proach to instruction and practice on specific coping function. Second, therapists should consider referring skills such as diaphragmatic breathing, relaxation patients/clients to local group self-management pro- techniques, and visual imagery. Other coping strategies grams. Group programs allow participants to learn associated with both CBT and physical therapy include from each other, put their own problems into perspec- the concept of pacing activities to avoid pain flare-ups tive, and enjoy social support with their peers. Al- and progressive goal setting. Although the literature though a meta-analysis of reports on the Arthritis from both self-management and psychology validates Foundation programs revealed that the effect sizes for the effectiveness of these interventions for pain man- reducing pain and disability were small (effect size for agement, currently most physical therapists do not use pain reduction 5 0.12, for disability 5 .07),227 the these techniques as pain management strategies.161

CHAPTER 21  Conservative Pain Management for the Older Adult 409 It is important to note that some patients with pain use of TENS, and he continued to use it on an as-needed problems have substantial psychological distress and basis until hospital discharge on the third post-operative may require treatment by a psychologist or counselor day. At the time of discharge, Mr. G. was able to inde- skilled in working with patients with pain problems. pendently apply electrodes and adjust machine parame- High levels of anxiety, depression or catastrophizing, ters, was using the TENS unit while ambulating 751 feet and verbalizations of despair are indicators that the pa- with a rolling walker, and ascending/descending 6-in. tient may need referral to a psychologist and manage- curbs; and a 1-month TENS rental was arranged, and ment from an interdisciplinary perspective. Standardized home health physical therapy was arranged to ensure measures such as the Fear Avoidance Beliefs Question- continuity of care. naire117 or depression scales may help to identify pa- tients who would benefit from referral to a mental health Case Study 2 professional skilled in using CBT in the management of pain. Mrs. O is a 72-year-old retired school teacher who just moved to a retirement community in the mountains CASE STUDIES of Vermont. She lives with her husband and enjoys an active retirement, playing tennis twice a week, treadmill Case Study 1 walking three times a week, participating in a biweekly weight training class, and taking 2- to 5-mile hikes each Mr. G is a 75-year-old man who fell 2 weeks ago and weekend. She was evaluated in an outpatient physical sustained a left femoral neck fracture. Prior to this therapy clinic with chief complaints of right anterior injury, the patient lived independently in a one bedroom knee pain that interferes with her ability to “charge the apartment in a senior housing complex. Mr. G has net” in tennis and hike in hilly areas. Pain increases on emphysema and mild depression. His previous medical ascending stairs or hills, and decreases with rest. Mrs. O history is uncomplicated and medications prior to hospi- reports no prior history of knee injuries, and assumes talization included albuterol and a multivitamin. The that this problem is due to “old age.” Previous medical fracture was stabilized with a compression screw and history includes conservative treatment of shoulder side-plate fixation.245 Postoperatively Mr. G reported a impingement with physical therapy 10 years ago, osteo- high level of pain and was begun on patient-controlled penia diagnosed 8 years ago, and a recent diagnosis of a analgesia (PCA) with hydromorphone. The initial physi- mild hearing impairment for which she has sought no cal therapy examination took place on the first postop- treatment. Mrs. O takes alendronate (Fosamax) and a erative day. Mr. G complained of intense pain during calcium and vitamin D supplement for her osteopenia, a passive range of motion and mobility testing, reporting generic multivitamin, and acetaminophen as needed for deep pain in the hip and at the surgical site, which he pain. She reports that the knee pain has caused her to rated a 6 of 10 on a numerical rating scale. Despite the decrease the length of her hikes and to play tennis more use of PCA, Mr. G continued to complain of intense pain cautiously. She wishes to return to a more rigorous exer- when his left lower extremity was moved passively, and cise schedule primarily due to her concern about her he was unwilling to initiate active movement because of bone strength. She reports that her physician ordered pain. Mr. G refused further work on transfers or exercise routine radiographs of her knee, with findings of degen- until his pain level was reduced. erative changes consistent with “mild” DJD. Given the known benefits of early physical therapy Pain is described as “stiff” and “achy.” Using a nu- following hip fracture surgery,36,246,247 Mr. G’s physical merical rating scale, she rated her pain on initial exami- therapist was concerned that delayed rehabilitation nation as 3 of 10 and reports a highest-intensity pain of would adversely affect his prognosis for return to inde- 5 of 10 following long hikes. pendent living. High-frequency (100 Hz) TENS was Physical Examination.  ​Vital signs: Blood pressure 5 applied using a dual-channel stimulator with one set of 125/78 mmHg; respiratory rate 5 12 breaths/min; heart 2 3 4-in. electrodes at the incision site (one channel) and rate 5 74 beats/min. Palpation reveals mild warmth on a second set on the anterior and posterior aspects of the the anterior aspect of the right knee as compared to the hip joint (second channel). Intensity was adjusted to a left. Posture exam shows slight forward head position strong but tolerable level below the motor threshold. with the head tilted slightly to the right. Weight is shifted The patient was instructed to increase TENS intensity slightly to the left of center. The right patella is noted to as needed to maintain the strong sensation. After be positioned slightly lateral to midline in standing. The 20 minutes of TENS application, the patient was able to patient ambulates independently without an assistive de- tolerate active-assisted range of motion of the left lower vice with slightly decreased stance time on the right. extremity, and transfer to sitting on the side of the bed. Quick tests show decreased ability to squat, with weight In the afternoon of the first postoperative day Mr. G. shifted to the left lower extremity during this task. Active transferred to a chair using a rolling walker and assis- range of motion testing reveals limitations in right knee tance of his physical therapist. He was instructed in the extension. Passive range of motion measurement at the

410 CHAPTER 21  Conservative Pain Management for the Older Adult right knee is 0 to 120 degrees of flexion, compared to 0 to physical therapy. Radiography reports indicate no to 135 degrees on the left. Flexibility testing reveals sign of fracture. shortness in the hamstrings bilaterally. Muscle force mea- surements using a hand-held dynamometer were knee The social history reveals that Mrs. D’s husband died extension L: 50 lbs, R: 35 lbs with pain on testing; knee 4 years ago, and her best friend passed away last year. flexion L: 30 lbs, R: 29 lbs. Strength of gastroc-soleus She lives alone in a small one-level apartment in a senior tested with unilateral heel-ups was L: 10 repetitions; R: 9 housing complex. Pertinent medical history includes repetitions. Mild crepitus was noted bilaterally with test- a diagnosis of osteoarthritis in bilateral knees, degenera- ing of knee extensors and on passive range of motion tive disc disease, and mild central lumbar stenosis. testing. In supine, the right patella is noted to be posi- Mrs. D takes acetaminophen for her pain, and vitamin tioned lateral to midline, but passive mobility allows ap- B12 and calcium supplements. She reports previous trials propriate patellar alignment. of other pain medications but cannot recall which ones. Evaluation.  ​Mrs. O’s signs and symptoms are consis- She said she could not tolerate the other medications tent with the diagnosis of osteoarthritis, but recent in- because they caused drowsiness, dizziness, and constipa- crease in pain in the anterior knee aggravated by stairs/ tion. She also reports concerns that she would become hills, pain on testing knee extensor strength, and lateral dependent upon the drugs, taking them at higher and patella position suggest potential overlying patellofemo- higher doses. Mrs. D reports spending most of her time ral pain syndrome. Given her active lifestyle and motiva- in a recliner doing crossword puzzles. She reports diffi- tion, the prognosis for recovery of premorbid function is culty with housecleaning, shopping, cooking, walking, very good. bathing, and dressing due to pain and indicates that she Plan of Care.  ​Long-term goals include return to tennis has no assistance with these activities. and hiking, with full muscle strength within 1 month. Pain Assessment.  ​Mrs. D describes her pain as intense Mrs. O’s therapist chose to use patellar taping,160 ham- aching sensation throughout bilateral knees and low string stretching, quadriceps strengthening, and walking back, with sharp, shooting, jabbing pain in her back on level surfaces248 as the initial treatment plan. The upon moving from supine to sitting and occasionally on initial treatment included taping the right patella to pro- sit to stand. Her score on the Geriatric Pain Disability vide medial glide, medial tilt, and anteroposterior tilt to Index is 34 out of 42, indicating severe pain problems. the patella followed by exercises including passive Because Mrs. D describes substantial difficulty with a stretching of bilateral hamstrings, squats to ,90 degrees variety of home activities, and reports limited social of knee flexion, knee extension strengthening including interaction, the Geriatric Depression Rating Scale short three sets of 10 repetitions of knee extension at 75% of form was administered. Mrs. D scored 13 of 15 on the her 1 repetition maximum. Mrs. O was instructed to GDRS, indicating severe depression, and 27 of 30 on the leave the tape in place for 1 week, continue her exercises Fear Avoidance Beliefs Questionnaire–physical activity at home and at her fitness center, modify her regular scale, indicating severe fear avoidance beliefs. exercise regimen to include walking on level surfaces for Physical Examination.  A​ n abbreviated initial exami- 30 minutes 3 to 4 days a week instead of the weekend nation was conducted because of Mrs. D’s complaints hikes. The planned progression of treatment included of pain and refusal to attempt formal strength testing. teaching the patient self-taping, progression of strength- Blood pressure is 140/85 mmHg, heart rate 78 beats/ ening exercises as needed, evaluation of balance/stability, min and regular, and respiratory rate 14 breaths/min and progressing walking to include hills with paved sur- and regular. Mrs. D presents as a frail older woman faces, gradually returning to walking hills on hiking who ambulates with a rolling walker using short step trails. lengths. Observation reveals a flexed posture with for- ward head, rounded shoulders, flexion throughout the Case Study 3 spine, hips, and knees. She refuses to attempt a squat due to stated concerns with pain and falling. Mrs. D Mrs. D is an 84-year-old woman seen in physical ther- moves from standing to sitting independently and cau- apy with primary complaints of low back pain present tiously. Sitting to supine is independent but with com- for approximately 3 years but increased in intensity in plaints of pain. Thirty-second repeated chair rise: able the past 2 weeks after she experienced a fall in her to move from sit to stand six times, placing her below home. Mrs. D reports she was able to get up from the the 10th percentile for functional lower body strength. floor by herself using furniture for support, but indi- Flexibility testing reveals shortness in bilateral ham- cates that the process was extremely painful and physi- strings, hip flexors, pectoralis major, and the teres cally draining. She reports that she did not see a physi- major/latissimus dorsi/rhomboid complex. Passive hip cian until 1 week after the fall, when she had a regularly extension lacks 15 degrees of neutral on left and scheduled appointment with her primary care physician. 10 degrees on right. Passive hip flexion is 115 degrees She reports that her physician “insisted” that she come on the left, 110 degrees on right. Knee extension lacks 5 degrees of neutral bilaterally.

CHAPTER 21  Conservative Pain Management for the Older Adult 411 The Timed Up and Go test took 45 seconds using the strengthening exercises into twice-weekly physical ther- rolling walker. She refused the 6 minute walk test. apy sessions. Mrs. D was also instructed in diaphragmatic Evaluation.  ​Mrs. D presents with persistent pain limit- breathing and imagery to promote relaxation during ex- ing all aspects of her function, and presents at risk for acerbations of pain and the use of home heating agents to future falls. Scores on the depression and fear avoidance control pain. A written home activity plan was developed scales indicate the need for interventions to address the to encourage the patient to change her position regularly, psychological aspects of her pain condition. Given the intersperse activity into her daily routine, and to increase extreme nature of these complaints, a referral to a psy- active leisure pursuits outside of her apartment. She was chologist with experience working with individuals with begun on a home exercise program that included practice pain is indicated. The patient’s prognosis for recovery to of relaxation skills, and progressive daily ambulation with a more active lifestyle is guarded, given the psychosocial her rolling walker in the hallways of her building. Coor- components of her condition. However, given her mus- dination with her psychologist allowed reinforcement of culoskeletal impairments, physical therapy interventions physical and psychological interventions to enhance pa- addressing muscle function, flexibility, balance, and mo- tient adherence to the program. bility are also indicated. Plan of Care.  ​Long-term goals include Timed Up and Go REFERENCES score of less than 30 seconds, 6-minute walk test score of 300 m, and ability to complete 12 repetitions of sit to To enhance this text and add value for the reader, all stand in 30 seconds. Goals addressed with her psycholo- references are included on the companion Evolve site gist included increased participation in active leisure ac- that accompanies this text book. The reader can view the tivities, decreased depressive symptomatology, and de- reference source and access it online whenever possible. creased fear avoidance beliefs. Mrs. D’s physical therapist There are a total of 248 cited references and other gen- chose to incorporate stretching, mobility training, and eral references for this chapter.

22C H A P T E R Lower-Limb Orthoses for Older Adults Joan E. Edelstein, PT, MA, FISPO, CPed INTRODUCTION 6.3% of individuals between ages 65 and 74 years and more than 10% of those older than age 75 years have An orthosis is a device worn on the body for a therapeutic had a stroke, the leading cause of disability among older purpose. Splint, brace, and support are alternative terms. adults.2 All orthoses apply forces to the body that can assist or resist motion, or maintain or alter a given posture. The For most patients, the benefit of wearing a lower-limb therapeutic goals of applying these forces, highlighted in orthosis is improved ability to stand and walk effectively. Box 22-1, are typically to decrease pain, improve gait The person who is limited to household ambulation may stability, facilitate mobility, and/or improve endurance. feel safe and comfortable enough to venture outdoors An orthosis can achieve these goals by decreasing or redis- with the aid of an orthosis. An older adult who is a com- tributing forces across weight-bearing structures, enhanc- munity ambulator may increase the distances walked, ing joint stability, or improving alignment among body thereby continuing to enjoy the physiological and psy- segments. chological benefits of greater physical activity. Evidence suggests that using a lower-limb orthosis allows many More commonly, orthoses serve to accommodate, individuals with mobility limitations to walk more rap- modify, or control permanent deformities or movement idly, consuming less oxygen.4-9 These findings may be dysfunctions. Many older adults have deformities that particularly relevant to the candidate for an orthosis who place abnormal stress on joints. Over time, repetitive also has cardiac or pulmonary impairment. stress during weight-bearing activities further damages the joints, resulting in greater pain and instability, thus As suggested above, a wide variety of mobility condi- increasing mobility disability. tions are potentially amenable to orthotic use. This chapter will review the overall principles that can be car- Although we do not have clear evidence of the num- ried across diagnoses. An orthosis functions by remedi- ber of older adults using lower-limb orthoses, we do ating, accommodating, or preventing mobility impair- have good estimates of the number of individuals with ments. An example of the remediation function of an mobility limitations, which is the group typically consid- orthosis is a functional electrical stimulator electrically ered for orthoses. The Centers for Disease Control and activating dorsiflexors and foot everters during gait of a Prevention (CDC) reports that 45% of community- patient recently poststroke to encourage more normal dwelling adults older than age 65 years, and 85% of motor patterns and voluntary control of muscles. Ideally, institution-dwelling older adults older than age 65 years, the amount of electrically delivered motor assistance is have difficulty walking.1 The underlying mobility im- gradually decreased as voluntary control returns, at pairments are usually precipitated by disease or injury, which time the orthosis is discontinued. The patient with such as arthritis and stroke, which occur with increasing an unstable knee from quadriceps paralysis may benefit frequency with advancing age. from an orthosis that provides a counterbalancing force to resist unwanted motion and prevent knee collapse in The CDC’s Summary of Health Statistics for United early stance phase. A knee–ankle–foot orthosis fitted to States Adults2 reports that 40% to 50% of individuals an older woman with knee OA who has developed genu older than age 65 years who responded to a national varum may apply a medially directed force at her knee health interview survey in 2007 indicated they have to control the deformity. Straighter leg alignment pro- arthritis or chronic joint symptoms. Osteoarthritis (OA) vides greater comfort and thus greater ability to increase is predominantly a disease of the weight-bearing joints. activity while preventing or slowing progression of mal­ About 45% of individuals with osteoarthritis have alignment. The septuagenarian with lower-limb arthritis mobility limitation.3 The CDC survey also reports that 412 Copyright © 2012, 2000, 1993 by Mosby, Inc., an affiliate of Elsevier Inc.

CHAPTER 22  Lower-Limb Orthoses for Older Adults 413 B O X 2 2 - 1 Therapeutic Goals of Lower-Limb benefit of an orthosis to remediate or accommodate the Orthotic Use knee instability or prevent deformity. • Decrease pain Data regarding walking speed and distance will pro- • Increase gait stability vide a baseline against which to discuss likely improve- • Facilitate mobility ments with the patient and to judge the impact of the • Improve endurance orthosis as part of an outcome assessment. or metatarsalgia can walk more comfortably with shoes Joint range of motion measurements are essential to that provide shock-absorbing soles, or with a foot ortho- formulate an appropriate orthotic prescription. Some sis that reduces stress on painful foot, knee, hip, or trunk orthoses are fabricated to limit available joint motion structures. and thus enhance stability, whereas others provide forces at the very ends of a limited ROM to gradually increase EXAMINATION OF OLDER CANDIDATES range if worn for a substantial time. Inaccuracy in these FOR AN ORTHOSIS measurements would result in an ineffective orthosis. History and Systems Review Muscle strength testing is a basic assessment tool of physical therapists. An orthosis is often used to compen- The history and systems review help guide the examina- sate for weakness in those muscle groups that contribute tion section of the physical therapist’s assessment. In ad- to normal gait. Prescription of an orthosis to compensate dition to general questions asked of all patients, several for weakness must consider the extent of the weakness additional questions, listed in Box 22-2, should be included and integrate the data from all other examination find- for anyone who might be a candidate for an orthosis. ings such as balance, tactile sensitivity, gait analysis, and cardiopulmonary status. Tests and Measures Relevant to Orthotic Prescription Balance is essential for walking. The ability to main- tain balance during static and dynamic upright activities Observational gait and movement analysis can reveal requires the complex interaction of many body systems. deficiencies that help guide the choice of specific tests and Bearing weight on painful joints, or moving joints effec- measures. These tests and measures can provide mean- tively in the presence of deformities can all contribute to ingful data about the potential for an orthosis to improve balance deficits. Assessment should determine whether the patient’s movement. For example, an observation of the underlying cause of the balance deficit would likely excessive knee flexion in early stance phase leads to a respond to orthotic use. detailed assessment of muscle strength, available range of motion (ROM), and proprioception about the knee. The Tactile sensitivity should also be checked with assessment findings guide decision making about the Semmes-Weinstein filaments, inasmuch as all orthoses are worn on the body. Even though fabric should be B O X 2 2 - 2 General Questions to Ask All Patients interposed between the skin and the orthosis, it may Being Considered for Orthosis Use press excessively, causing discomfort. The patient with proprioceptive deficiency may benefit from stabilizing The patient’s responses contribute substantially to decision making orthoses. However, weight bearing on insensate feet re- about orthotic use. quires careful choice of shoes and orthoses. Hand func- For Those Who Have Worn an Orthosis: tion must also be assessed. Manual dexterity is required • What type of orthosis and how recently? for donning and doffing the orthosis, unless an atten- • What is your opinion of the positive attributes of each orthosis? dant is available to assist the patient. • What is your opinion of the negative attributes of each orthosis? For all Potential Orthosis Users, Regardless of Their Cardiopulmonary status should be assessed to confirm Prior Experience with an Orthosis: that the patient has the endurance to participate in and • What are your expectations regarding effect(s) of wearing an benefit from a gait training program with the orthosis. If visual inspection suggests limb edema, or the patient indi- orthosis? cates fluctuations in limb girth, then limb girth measure- • What are your concerns about orthotic appearance? ments should be recorded. Fluctuations in limb girth • What resources are available for purchasing the orthosis? compromise orthotic comfort and effectiveness. Either the • What means are available for transportation and obtaining edema must be reduced or the orthosis must be adjustable. adjustments and other repairs in the future. DECISION-MAKING CONSIDERATIONS FOR ORTHOTIC USE (EVALUATION, DIAGNOSIS, PROGNOSIS, AND PLAN OF CARE) Successful incorporation of an orthosis into the patient’s overall plan of care depends on several factors. The prac- titioner must be knowledgeable about contemporary

414 CHAPTER 22  Lower-Limb Orthoses for Older Adults orthotic designs and the interaction of patient history easier to maintain than those upholstered with leather. and physical examination with the appliance. The prac- Nevertheless, leather remains a useful material for some titioner must select a design that addresses all factors orthoses as it presents a very comfortable interface be- outlined in Box 22-3. The primary components of or- tween the person’s skin, with a thin fabric covering, and thotic prescription included in a physical therapist’s ex- the leather interior of the orthosis. Leather is also popu- amination and evaluation may focus on (1) making a lar for the upper portion of shoes because it is somewhat determination about the need for an orthosis; (2) assess- porous and conforms very well to the contour of the ing the fit, benefit, and training needs with a newly fab- dorsum of the foot. An orthosis that requires a great deal ricated orthosis; or (3) reassessing appropriateness of an of care by the patient or caretaker is likely to be aban- existing orthosis. The patient being considered for an doned if the amount of care is perceived as outweighing orthosis may be categorized within multiple preferred the benefit. practice patterns of the Guide to Physical Therapist Practice.10 The underlying preferred practice pattern di- Integrating an orthosis with the patient’s other equip- agnostic category is likely to be within a musculoskeletal ment and environment can challenge the rehabilitation or a neuromuscular category. team. The patient who relies on a wheelchair for com- munity mobility needs a chair with swinging leg rests to The first decision point in making a judgment about enable transferring to and from the wheelchair while the appropriateness of an orthosis requires that the prac- wearing an orthosis. The home environment is another titioner determine whether the primary goal of the or- consideration. Many older people live in quarters thosis is remediation, accommodation, or prevention of crowded with a lifetime’s accumulation of objects that a mobility impairment. Then, the physical therapist must can occupy the floor area otherwise available for walk- identify the major mechanism through which an orthosis ing with the orthosis. A hot, humid climate can make would contribute to the achievement of this goal. The wearing an orthosis with broad plastic bands uncom- impact of comorbid health conditions and the progres- fortable. Patients may prefer a metal/leather orthosis sive nature of any disease states must be considered, with more narrow bands that will still provide adequate particularly the effect of an orthosis on the patient’s ca- structural stability. Mud, snow, and frequent rainstorms pacity to sustain increased mobility activities. influence selection of materials for the orthosis. Carbon fiber and plastic components resist water better than Orthoses apply force to the body. The basic self- metal ones. contained force system found in an orthosis is the three- point system, consisting of one force and two counter- Cost is a practical and necessary consideration with forces.11 For example, the person who has knee instability orthotic prescription. Funds must be available, not only is likely to benefit from an orthosis that applies a poste- to defray the purchase price of the device but also to riorly directed force at or near the knee and anteriorly support physical therapy visits in most instances so that directed counterforces above and below the knee.12 the patient can access the professional expertise that contributes to the maximum advantage of using the de- Evaluation of an older adult’s capacity for donning and vice. Although Medicare reimburses most of the cost of doffing the orthosis is imperative if the physical therapist orthoses, each older adult’s situation is unique. Conse- is considering long-term use of a device. The individual quently, the cost of the orthosis and the physical therapy must be able to don the orthosis accurately, indepen- required to enable the patient to achieve maximum ben- dently, and quickly or have another person readily avail- efit may not be fully covered. Although most orthoses able and willing to assist. Otherwise, the patient is likely are reasonably durable, repairs may be another financial to abandon the device. Selection of fastenings, for exam- outlay. Generally, the preferred orthosis is the simplest, ple, straps rather than lacing, contributes to donning ease. least expensive design that will address the purposes identified for the patient. For adults with diabetes and Care of the skin and the orthosis is another, and related disorders, Medicare covers the cost of appropri- sometimes neglected, prescription issue. Bands and ate shoes on an annual basis.13 Coverage generally can straps should be wide enough to minimize pressure con- be applied to one of three options: a pair of extra-depth centration yet not be overly bulky. Excessively wide shoes plus three pairs of mass-produced or custom-made bands and straps may cause the person to perspire exces- inserts; a modified pair of extra-depth shoes and two sively. Streamlined plastic or carbon fiber orthoses are pairs of inserts; or a pair of custom-made shoes. BOX 22-3 Decision about Orthotic Prescription CHARACTERISTICS OF ORTHOSES and Design Must Consider the Extent to Which the Orthosis Orthotic Terminology • Improves the patient’s function Orthoses worn on the foot are classified as foot orthoses • Fits the patient’s environment and motivation (FOs), including shoes worn for therapeutic purposes • Can be efficiently donned, doffed, and cared for with or without modifications or inserts. A device that • Is within the patient’s financial resources

CHAPTER 22  Lower-Limb Orthoses for Older Adults 415 extends from the foot to the proximal leg is an ankle– J foot orthosis (AFO). The orthosis that extends from the foot to the thigh is a knee–ankle–foot orthosis (KAFO). AE Addition of a pelvic band and hip joint converts the KAFO to a hip–knee–ankle–foot orthosis (HKAFO). An BI orthosis that extends from the foot to the trunk is a trunk–hip–knee–ankle–foot orthosis (THKAFO). Identi- H fying the orthosis in a standard manner expedites com- C munication among the patient, family, and clinicians. This generic terminology is preferred, rather than nam- D ing orthoses by the person who invented or popularized a given device. F G Orthotic Materials FIGURE 22-1  B​ asic parts of a shoe. The upper is made up of the Most contemporary orthoses are made of plastic, which is molded over a model of the patient’s limb.14 Ther­ quarter (A) and its reinforcing counter (B), which stabilizes the rear- moplastics, such as polypropylene, polyethylene, and foot within the shoe; the closure (E), the tongue (J) across the acrylic, can be heated and shaped; when cool they will midfoot; the vamp (I) and the toe box (H) which encloses the fore- retain the shape. Because the process can be repeated foot. The outsole (F) is often reinforced with a shank (D) and is at- indefinitely, thermoplastic orthoses can be adjusted to tached to the upper at the welt (G). The standard heel (C) is accommodate changes in the contour of the patient’s ¾ in. high. (From Lusardi MM: Orthotics and prosthetics in reha- limb. Orthoses made of thermoplastics are generally bilitation, ed 2, St Louis, 2007, Saunders.) white, pink, or amber. ventilation of the foot. An upper made of thermo- An alternative to thermoplastic are thermosetting molded leather can be heated and adjusted to accom- plastics, such as polyester laminate. Once the chemical modate bunions and hammer toes. The type of closure reaction has occurred, the plastic can only be altered by influences the ease of donning the shoe. Laces are more mechanical means, such as adding material, or grinding adjustable than straps; however, straps, especially if away material. As a group, thermosetting plastics are they include hook and pile (Velcro), are easier to man- more rigid than thermoplastics of comparable dimension age. The Blucher closure features a distal separation and can be tinted to match the patient’s skin color. Both between the two flaps that have eyelets through which thermoplastics and thermosetting plastics are used for laces are drawn, or the flaps that are joined by straps. the shells and bands of orthoses. This closure provides great adjustability in the snugness of shoe fit. The extra-depth upper terminates below the Carbon fiber is a popular material for fabricating malleoli; because it includes two insoles, the shoe is orthoses because it is extremely strong and can be used to more spacious than ones with other upper designs. The reinforce weaker materials. Some AFOs are made entirely top insole can be removed to accommodate foot defor- of carbon fiber. Carbon fiber is usually black. Aluminum, mities, dressings, or an orthosis. steel, titanium, and magnesium are used in orthoses, par- ticularly for the uprights. Some orthoses also include The sole, composed of an insole and outsole, lies be- leather and fabric, especially for straps.15 neath the plantar surface of the foot. The insole is in close contact with the sock-clad foot. The outsole con- ORTHOTIC COMPONENTS tacts the walking surface. Of particular concern with older adults is an outsole made of material offering suf- Components of lower-limb orthoses are described below ficient traction to reduce the risk of slipping, and resil- with emphasis on their distinctive characteristics and ient enough to absorb the shock of stance phase.16 The relative advantages and disadvantages for specific groups shoe heel is attached to the sole beneath the anatomic of older adults. heel. The higher the heel, the greater the load on the forefoot.17,18 Shoes and Foot Orthoses The shoe is typically reinforced in three places: poste- Virtually all patients wear shoes, particularly when out- riorly, under the midfoot, and over the toes. The counter doors. The basic parts of a clinically suitable shoe (up- reinforces the back of the shoe around the posterior por- per, sole, heel, and reinforcements) are described below tion of the upper. The counter should fit snugly so that and depicted in Figure 22-1. the shoe does not abrade the foot during late stance. The shank reinforces the sole under the midfoot. If the shoe The upper designates the part of the shoe that covers is to be part of an orthosis having a riveted attachment, the dorsum of the foot. Both leather and canvas are ap- the shank should be made of corrugated steel. The toe propriate because they are porous, permitting some box, located at the distal end of the upper, protects the toes from trauma. Inserts and internal modifications lie inside the shoe, affecting the forces applied to the plantum.19 Inserts are

416 CHAPTER 22  Lower-Limb Orthoses for Older Adults removable and can be used in other shoes that have the weight bearing to the lateral or medial side of the heel, same heel height. They may be mass produced or custom respectively. A shoe modified with a medial or lateral made, and include heel inserts, three-quarter inserts that wedge may redirect forces on the knee.28-35 Both the do not reduce space for the toes, and full-length inserts beveled and the resilient heel facilitate weight transfer that do not slip inside the shoe. Internal modifications, from initial contact to midstance. The resilient heel also which apply the same forces as inserts, are glued or sewn absorbs shock in the early stance phase. Rocker bars into the shoe. Although they are not removable, internal (Figure 22-4) also enable weight transition through the modifications ensure that they are used with shoes of stance phase.36,37 The apex of the rocker bar is poste- appropriate design and proper fit. rior to the metatarsophalangeal joints. A metatarsal bar on the sole shifts weight posteriorly and, because Among the most commonly used inserts and internal the bar is rigid, reduces motion at the metatarsophalan- modifications are resilient full-length inserts. Because they geal joints. Heel and sole elevations reduce leg length absorb shock and distribute pressure over the entire plan- discrepancy; when used by an individual who has tum, they are often used in shoes for people with diabetes length discrepancy and an immobilized knee, the lift or arthritis.19-23 Trotter and Pierrynowski have demon- lessens fatigue during walking.38 strated that although both custom-made and prefabri- cated inserts typically have an immediate positive effect Ankle–Foot Orthoses on gait economy, only custom-molded ones have an effect that lasts at least 4 weeks.21 An internal heel wedge shifts Plastic orthoses are lighter, more durable, and easier to weight bearing medially or laterally, depending on the clean than metal and leather alternatives.15 wedge shape. A longitudinal arch support applies upward force on the medial border of the foot (Figure 22-2); the The foundation of an AFO is usually a plastic insert apex should be at the sustentaculum tali of the calcaneus. that conforms to the contour of the plantar surface of Community-dwelling older adults (mean age 5 70 years) the foot. The insert is lightweight, compatible with any using arch supports for 6 weeks were found to have in- shoe having the same heel height as the shoe for which creased comfort in lower-limb joints and improved walk- the insert was originally made, and easy to don. An ing.24 For older adults, the arch supports should maximize insert foundation, however, requires that the patient the weight-bearing surface, accommodating any malalign- wear shoes spacious enough to accommodate the insert. ment rather than correcting foot posture. Although the shoe usually terminates below the malleoli, it should fasten relatively high on the dorsum to secure A metatarsal (MT) pad is a teardrop-shaped pad the orthosis to the foot. (Figure 22-3) with its convexity over the metatarsal shafts. It transfers load from the painful metatarsopha- The alternate foundation is a stirrup (Figure 22-5) langeal joints to the relatively insensate shafts.25-27 A riveted through the shoe sole, the shank piece, and in- small change in the location of the MT pad can have a sole. In addition to anchoring the orthosis, the stirrup large effect on pressure relief across the MT heads.25 ensures that, if the orthosis is worn, it will be used with A toe crest is placed under the plantar surfaces of the a suitable shoe. The stirrup may be a one-piece solid toes to increase the bearing area, thereby reducing pres- stirrup for utmost stability or a split stirrup. The split sure on the toe tips. stirrup consists of three portions, with the central part riveted to the shoe shank. The patient can don the shoe, External modifications are additions to the outside then insert the side portions of the split stirrup in the of the shoe, particularly the shoe sole. Heel modifica- central section. The split stirrup facilitates donning tions include medial and lateral heel wedges that shift FIGURE 22-2  L​ ongitudinal arch supports.

CHAPTER 22  Lower-Limb Orthoses for Older Adults 417 FIGURE 22-3  M​ etatarsal pads of various sizes. FIGURE 22-5  S​ olid stirrup. A because the shoe can be separated from the proximal parts of the orthosis; however, the split stirrup is heavier and bulkier than the solid stirrup and, in rare instances, the side portions may separate inadvertently from the central portion. Ankle control is the primary purpose of most AFOs. The most common indication is inadequate dorsiflexion control during swing phase, which can result in toe drag with the risk of tripping. Dorsiflexion assist can be achieved with a plastic or carbon fiber posterior leaf spring (Figure 22-6). The spring recoils during swing phase, maintaining the ankle in the neutral position, yet allows slight plantar flexion during the early part of FIGURE 22-4  ​Rocker bar. (From Hsu JD, Michael J, Fisk J: AAOS FIGURE 22-6  P​ osterior leaf spring ankle–foot orthosis. atlas of orthoses and assistive devices, ed 4, St Louis, 2008, Mosby.)

418 CHAPTER 22  Lower-Limb Orthoses for Older Adults stance phase, enabling the wearer to obtain a stable posi- orthoses should be worn with a shoe with a resilient or tion.39 A steel coil spring has the same biomechanical beveled heel to facilitate the transition between initial effect, namely, keeping the foot in neutral position dur- contact and midstance. Propulsion in mid- and late ing swing phase and permitting plantar flexion during stance is aided by a rocker bar that reduces the distance early stance phase.40 Tension of the spring can be ad- on the shoe sole through which the individual must pass justed with a screw. The drawback of the dorsiflexion body weight; stance phase virtually ends when body spring assist is that it is part of a stirrup foundation. weight passes the apex of the rocker bar. Rather than spring control, the AFO may have steel Hinged AFOs, however, are bulkier and more fragile or plastic plantar flexion stops that prevent plantar flex- than solid-ankle AFOs. A pair of limited-motion stops as ion throughout the gait cycle. The stop is simpler than part of a stirrup will also limit dorsiflexion and plantar the spring assist; however, it imposes a posterior moment flexion. of force on the knee in early stance. The knee, therefore, may flex excessively. Some AFOs have a steel BiCAAL Foot control can be obtained with a solid-ankle AFO (bichannel adjustable ankle control) joint (Figure 22-7) that restricts mediolateral, as well as sagittal and trans- consisting of anterior and posterior coil springs or rods. verse plane, motions. An older option is a leather valgus The BiCAAL joint enables the clinician to adjust the or varus correction strap used with a stirrup. Valgus angle of the orthotic ankle. Tilting the uprights into dor- control requires a strap that is attached to the medial siflexion aids knee flexion and shifts the wearer’s weight part of the shoe sole; the strap buckles around the lateral forward. Tilting the uprights into plantar flexion has the upright of the AFO, exerting a laterally directed force. If opposite effect. the strap is too tight, it will be uncomfortable and if too loose, will be ineffective. Some plastic AFOs have a solid ankle that restricts all foot and ankle motions.41 Its trim lines are anterior to the Superstructure encompasses the portion of the AFO malleoli. The solid ankle AFO is streamlined and rela- proximal to the foot and ankle controls. Vertical compo- tively lightweight. A hinged plastic AFO (Figure 22-8) nents of the superstructure may be one or two metal permits a few degrees of plantar flexion, reducing the uprights, (Figure 22-9, A) whether medial, lateral, or tendency of the knee to flex in early stance; hinged ortho- bilateral. A posterior or anterior upright is plastic or ses also facilitate stair climbing.42 Both the solid-ankle carbon fiber. A plastic spiral or hemispiral upright assists AFO and the hinged AFO resist untoward mediolateral dorsiflexion in swing phase and resists inversion during and anteroposterior motion. The leather/metal equivalent stance phase. A plastic shell covers the posterior half of is an AFO with a limited-motion ankle joint. All these the leg (Figure 22-9, B). The horizontal part of the super- structure is a band that usually covers the posterior FIGURE 22-7  ​BiCAAL joint. Either a pair of springs or a pair of rods is located in the channels.

CHAPTER 22  Lower-Limb Orthoses for Older Adults 419 FIGURE 22-8  H​ inged ankle–foot orthosis. Orthotic excursion AB FIGURE 22-9  ​A, Ankle-foot orthosis with bilateral uprights, adjusted by screw placement. stirrup, and calf band is appropriate when limb volume fluctuates portion of the leg at the top of the upright(s) (see Figure significantly. B, Thermoplastic hinged ankle-foot orthosis closely 22-6). Some AFOs have an anterior band (Figure 22-10). follows the contours of the limb minimizing contact pressure. Knee–Ankle–Foot Orthoses FIGURE 22-10  ​Ankle-foot orthosis fabricated with carbon graph- Choices for shoe foundation, ankle control, and foot ite and fiberglass to provide maximum stiffness. The combination of control for KAFOs are the same as for AFOs. Most KA- a solid-ankle design and an anterior band produces a knee exten- FOs are prescribed to provide knee control in the sagittal sion force to enhance stance phase stability. plane, to prevent knee collapse, especially during early stance phase. An offset knee joint is a hinge with its axis located behind the anatomic knee axis. Consequently, when the wearer stands, the weight line passes in front of the hinge, stabilizing the individual’s knee joint. The offset knee joint does not interfere with swing-phase knee flexion or sitting ease. The drawback is that if the patient walks on a ramp, the orthotic joint may no lon- ger be stable. The most common knee control is a drop ring lock that, when engaged, ensures knee stability re- gardless of terrain. A steel ring surrounds the distal end of the thigh upright and the proximal end of the leg up- right. A spring-loaded retention button prevents the ring from dropping inadvertently; the wearer must push the ring past the button in order to lock the knee hinge. A thigh-level release is a cord attached to the ring; the cord is secured on the lateral upright with a small handle at thigh level so that the wearer can unlock the knee joint without bending. Individuals with poor balance may prefer a pawl lock with bail release (Figure 22-11). The pawl is a lever projecting from a small wheel in the lock. When the patient rotates the wheel, the pawl catches in the teeth of the lock. The bail is a spring-loaded posterior metal semicircular band connecting the medial and lateral

420 CHAPTER 22  Lower-Limb Orthoses for Older Adults FIGURE 22-11  ​Knee-ankle-foot orthosis with pawl knee lock with FIGURE 22-12  ​Swing phase lock system developed by Basko bail release and infrapatellar band. (From Hsu JD, Michael J, Fisk J: Healthcare in the Netherlands, marketed by Fillauer, Inc. Internal AAOS atlas of orthoses and assistive devices, ed 4, St Louis, 2008, mechanism of the lateral knee joint triggers locking before initial Mosby.) contact then the knee is fully extended and unlocking at the end of stance phase. A medial knee joint that further resists flexion during uprights at the level of the knee. The patient lifts the bail stance can also be used. (Courtesy Fillauer, Inc., Chattanooga, TN.) to release the lock. In its relaxed position, the bail engages the pawl lock. The bail locks the medial and (Figure 22-15) is buckled to the medial and lateral up- lateral knee joints simultaneously and offers a much rights. Although it also provides needed posteriorly di- larger surface for the patient to grasp, as compared with rected force when the wearer stands, it may need to be the small drop ring lock. Both the pawl lock and the loosened when the individual sits. drop ring lock can be used only by someone with full passive knee extension. A few KAFOs provide frontal plane control either by means of a proximal extension from the medial or lateral Individuals with knee flexion contracture require an side of a rigid plastic calf band, or by a five-strap leather adjustable orthotic knee joint to accommodate the con- knee pad (see Figure 22-15). The fifth strap is attached tracture. Both the fan joint and the serrated lock are to a broad section on the medial side for valgus correc- readily adjustable. The ratchet lock also accommodates tion, or on the lateral side for varus correction. The nar- contractures. It also stabilizes the knee hinge in interme- row portion of the strap passes behind the knee and may diate degrees of flexion, as when the wearer rises from a press into the popliteal fossa. chair or moves from standing to sitting. Superstructure of the KAFO includes thigh uprights Recently introduced stance control units (Figure 22-12) and one or two thigh bands connecting the uprights pos- provide stability during early stance phase, while allowing teriorly. A weight-relieving band is a proximal thigh a more natural movement of the knee into controlled flex- band designed to enable the wearer to support partial ion during late stance and swing phase.43-46 Some units weight on the ischial tuberosity. have a cable connecting a foot plate and the knee hinge, whereas others have a locking mechanism within the knee Hip–Knee–Ankle–Foot and hinge. The patient can select various modes, including Trunk–Hip–Knee–Ankle–Foot Orthoses stance control, full manual lock, and fully unlocked knee joint. A pair of KAFOs is connected by a pelvic band. The HKAFO restricts hip rotation and abduction and adduc- Regardless of knee hinge and locking mechanism, tion. If the hip joint(s) include a lock, the orthosis also most patients also require one or two anterior bands or restricts hip flexion and extension. Although these or- pad to resist knee collapse (Figure 22-13). The suprapa- thoses are occasionally prescribed for patients with low- tellar band (Figure 22-14) is a rigid plastic band over the level paraplegia, the orthoses are difficult to don and distal thigh; the infrapatellar band (see Figure 22-11) lies cumbersome to wear. The patient usually requires just below the knee joint. A four-strap leather knee pad

CHAPTER 22  Lower-Limb Orthoses for Older Adults 421 FIGURE 22-13  D​ iagram of the components and sagittal plane force system acting at the knee in a knee-ankle-foot orthosis. FIGURE 22-14  ​Knee–ankle–foot orthoses with suprapatellar bands. A, Anterior view. B, Lateral view. AB crutches or other assistive devices when ambulating. EVALUATING FIT AND EFFECTIVENESS HKAFOs are seldom prescribed for older adults. OF AN ORTHOSIS If a trunk orthosis is added to a pair of KAFOs, the Before the patient dons the orthosis, the clinician should resulting orthosis is a THKAFO. The orthosis controls check its construction, with particular attention to con- the paralyzed trunk and lower limbs. The wearer usually firming that the interior is smooth. Joints and locks ambulates with a swing-to or swing-through crutch gait. should move easily. Even heavier and more cumbersome than an HKAFO, the THKAFO is rarely used on a regular basis because On the sitting and standing patient, one should deter- gait is fatiguing and slow, and transferring from sitting mine whether the shoe fits properly. The shoe should be to standing is awkward. slightly longer than the longest toe and as wide as the metatarsophalangeal region. The counter should fit the

422 CHAPTER 22  Lower-Limb Orthoses for Older Adults FIGURE 22-15  F​ our- and five-strap knee pads. Foot and Ankle Disorders anatomic heel snugly. Any shoe modifications should Changes in the foot and ankle with aging are common provide the intended force. and frequently lead to pain and disability.48-54 Both a 65-year-old plumber with traumatic arthritis due to re- If the AFO has ankle hinges, the medial hinge should current ankle injuries and an 87-year-old homemaker be at the level of the distal tip of the medial malleolus with painful feet from age-related atrophy of the plantar and the lateral hinge at the corresponding level, parallel fat pads and arthritic metatarsophalangeal changes may to the floor. This placement minimizes vertical shift of achieve increased comfort and stability during ambula- the orthosis when the wearer walks.47 The calf band tion with a lower-limb orthosis.55 should lie below the head of the fibula to avoid pressure on this bony prominence and the adjacent peroneal Foot deformities can negatively affect standing bal- nerve. ance.56-58 Rational selection of shoes contributes to walking stability, decreasing the risk of falling in older Key features of the KAFO are the placement of the adults.59-63 Individuals with poor balance should wear orthotic knee joints. The medial joint should be slightly well-fitting shoes rather than slippers, which tend to above the medial tibial plateau so that the orthosis does shift on the foot during the transition from swing to not interfere with sitting. The lateral joint is at the same stance phase. Walking at home with feet clad only in height. The medial upright should not impinge on the socks invites slipping.64 Shoe soles should provide perineum. The lateral upright should end below the adequate traction and shock absorption. Overly thick greater trochanter. The top of the calf band and the bot- soles, however, obscure proprioception. High heels also tom of the distal thigh band should be equidistant to increase falls risk. Menant et al reported that a walking avoid squeezing the wearer’s leg when the individual sits. shoe with an elevated 4.5 cm square heel significantly impaired standing balance in older adults.58 Horgan When used by the walking patient, ankle restraint, et al,57 examining the effect of footwear on balance of such as that imposed by a solid ankle AFO, posterior 100 typically aging older adults (mean age of 82), con- stops, or limited motion stops, should contribute to a cluded that walking in one’s typical footwear is better more secure gait pattern without excessive interference. than walking barefoot. No particular type of shoe was With a KAFO, the knee control should not interfere un- found most advantageous. The greatest balance advan- duly with swing phase. Afterward, the orthosis should tage from wearing shoes was in those who had the poor- be removed and the patient’s skin checked to make cer- est balance. tain that no blemishes attributable to the orthosis are present. Whenever possible, one should assess the pa- Toe deformities, such as hallux valgus, hammer toes, tient’s gait with and without the orthosis to determine claw toes, and bunionette necessitate shoes with ade- whether the orthosis is beneficial. The ultimate outcome quate space to accommodate the abnormalities. The measure of orthotic effectiveness is whether the patient upper should be made of soft leather to conform to the can walk farther and faster with the orthosis as com- dorsal contour of the foot.65 pared with walking without it. Metatarsalgia usually results from persistently wear- CLINICAL APPLICATIONS ing high-heeled shoes.16,18 The heels shift body weight anteriorly onto the forefoot. Atrophy of the plantar fat Orthoses are used widely in geriatric physical therapy pad aggravates the discomfort. To the extent that the practice. Typically, the orthosis is part of the physical patient will allow, shoes with lower heels also reduce therapist’s integrated management approach. The follow- forefoot pressure. A metatarsal pad within the shoe ing section provides examples of typical situations in shifts weight posteriorly, away from the painful metatar- which a lower-limb orthosis can help older patients sophalangeal joints. A metatarsal bar on the sole com- achieve their functional mobility goals. bines the weight shift effect with reduction in painful motion. Pes planus can be addressed with a longitudinal arch support.19 The degree of orthotic firmness depends on the patient’s comfort and body weight. An obese patient requires a more rigid support. Diabetic peripheral neuropathy, if not conscientiously managed, can be a major catastrophe leading to amputa- tion. Shoes should be well fitting with resilient in- soles.66-71 Hose must also be roomy enough not to con- strict the toes. Regular foot inspection by the patient or, if vision is impaired, by a family member or health care professional, is critical to identify superficial abnormali- ties before they develop into ulcers. Because involvement

CHAPTER 22  Lower-Limb Orthoses for Older Adults 423 of the intrinsic musculature is common in diabetes, the paretic foot from dragging during swing phase. As com- shoe upper must accommodate toe deformities, particu- pared with walking barefoot or with only shoes, patients larly hammer toes. A serious consequence of diabetic who wore AFOs achieved longer stride lengths.76 An neuropathy is Charcot neuropathic joint, often at the AFO can either assist dorsiflexion or resist plantar flex- ankle. Stabilization with an AFO is important to avoid ion.77 The posterior leaf spring AFO is a lightweight, uncontrolled ankle motion, which can lead to falls. relatively inexpensive option. Osteoarthritis A more cumbersome AFO is one with a posterior ankle stop or an AFO with dorsiflexion spring assist. Shock absorption is a major requirement for arthritic These orthoses have a stirrup foundation, adding weight patients. Shoes with resilient insoles with or without to the orthosis and inconvenience to the wearer. If the supple outsoles absorb impact shock during walking.72,73 patient has marked extensor synergy, the spring may Jannink et al measured plantar pressure and associated trigger ankle clonus. Orthoses generally enable wearers pain as 77 patients with degenerative foot disease to increase walking velocity and step length.78-81 Two of walked; custom-made orthoses reduced pain in an aver- these studies suggest that orthoses are more effective in age of 23% and plantar pressure by at least 9% across the earlier phase of stroke rehabilitation rather than all weight-bearing surfaces.73 Some individuals are more later.79,80 With hinged orthoses, a full-length foot plate comfortable wearing shoes with heel or sole wedges to improved gait.82 offset ankle or knee deformity. For example, the person with genu valgum would probably be more comfortable Functional electrical stimulation (FES) can be used with medial wedges. either as a temporary motor retraining device to enable the patient to learn foot clearance during swing phase,83-86 Knee orthoses may be worn by patients with knee OA or as a permanent means for day-to-day mobility.85-88 to reduce load on painful knee joint structures. Brouwer Electrical stimulation is delivered by either a surface or et al,74 in a systematic review of patients with knee OA, an implanted electrode over the peroneal nerve. Typi- found moderately strong evidence indicating that people cally, the patient wears around the upper leg a fabric using knee orthoses walked for a greater duration than band with an imbedded electrode. Some systems also control subjects, and that this difference was maintained include an ankle strap holding a floor reaction sensor. at 1-year follow-up. Despite the improved ambulation The clinician adjusts the stimulation that the patient duration, which has very beneficial functional implica- receives. FES eliminates components within the shoe as tions, there was no significant decrease in overall pain or well as an orthotic superstructure. When FES is com- improvement in perceived quality of life in the knee bined with body weight support, preliminary clinical orthosis group. People with grades 1 or 2 OA, mostly results are positive.89,90 A systematic review indicates medial compartment, did better, as did those younger that walking speed increased 38% when a pooled effect than age 60 years. was calculated across the eight studies in the review.86 Other investigators found that subjects who obtained Cerebrovascular Accident FES at least 5 years after stroke and who used stimula- tion for a year walked 50% faster than they did with a Orthoses can offer patients who have sustained stroke plastic or metal/leather orthosis.87 both clearance during swing phase and stance phase control and propulsion. For example, a man with exten- Peripheral Neuropathies sor synergy resulting from a stroke may have difficulty initiating stance phase with heel contact. An AFO would Some older adults have difficulty during swing phase usually give him sufficient stability to resume a more because of traumatic or diabetic peroneal neuropathy. stable gait pattern. The same person may also walk more The same orthotic options that suit individuals with safely when wearing an orthosis that counteracts the cerebrovascular accident are applicable, namely, contra- tendency of his paretic foot to drag during swing phase. lateral heel and sole elevation if paralysis is unilateral; ankle-shoe strap, and an AFO that assists dorsiflexion or The shoe closure should be one that the patient can resists plantar flexion, especially the posterior leaf spring manage with one hand. A shoe on the paretic side with AFO. AFO use results in reduced dorsiflexor activity91 a hook and pile strap that can be cinched medially is and improved balance possibly associated with addi- often indicated. tional sources of sensory cues from the orthosis,92 if shoe soles are not thick. Thick soles deteriorate balance by The simplest way to enable swing clearance is by add- blunting somatosensory cues.93 ing a ½ in. heel and sole lift to the shoe on the nonparetic foot; the lift also increases weight bearing on the paretic Spinal stenosis with or without sciatic neuropathy af- limb.75 Although the lift is unlikely to disturb pelvic bal- fects swing and stance control because of pain and, occa- ance, the patient should be monitored for any indication sionally, weakness. If reducing load through the affected of hip or back pain. A strap connecting the shoe closure lower limb by means of a cane or walker does not suffice, to the anterior part of the ankle will also prevent the then a solid-ankle AFO or an AFO with a limited-motion

424 CHAPTER 22  Lower-Limb Orthoses for Older Adults ankle joint may improve the ease of walking by restricting and effectiveness and by laboratory measurement of painful motion. oxygen consumption with and without the orthosis. Popular clinical tools that assess gait speed and/or dis- Late-Onset Poliomyelitis tance walked, such as the Timed Up and Go test98 and the 6-minute walk test99,100 are appropriate outcome as- People who contracted poliomyelitis in the first half sessment instruments. of the 20th century, before the advent of Salk and Sabin vaccines, combine age-related neuromusculoskel- Decreased energy expenditure is a major goal of etal changes with ongoing deterioration of the anterior many orthoses. In the area of stroke, studies clearly horn motor cells in the spinal cord.94,95 demonstrate that energy expenditure per distance walked exceeded the oxygen cost of able-bodied adults If the disease occurred in childhood, then the indi- by 37%.101 Subsequent research confirms that adults vidual is likely to present both leg length and foot size with stroke who wore AFOs walked with greater speed discrepancy. To determine the extent of leg length differ- and less energy per distance.5-9 Changes in the 6-minute ence, one should palpate the anterior superior iliac walk test are often used as a surrogate score for changes spines, posterior superior iliac spines, and iliac crests of in oxygen consumption. Formal exercise testing of the patient who stands on lift blocks under the shorter maximal oxygen consumption with and without an leg. When the lift causes the pelvis to reach a level posi- orthosis can be performed but may not add sufficient tion, the clinician should measure the height of the lift, clinically useful information to warrant the increased which indicates the extent of discrepancy. The lift on the effort and expense. shoe should be approximately ½ inch less than the height discrepancy to facilitate swing of the shorter leg. WORKING WITH AN ORTHOTIST Part of the shoe lift can be concealed inside the shoe. The exterior sole lift should have a rocker shape to aid in Cooperative interaction between physical therapists and stance phase transition. orthotists is likely to foster optimum rehabilitation for all patients, particularly older adults. Usually, the patient Foot size discrepancy should be managed so that each is examined first by the therapist. A focused report high- foot is well fitted. The patient has three options: (1) two lighting the patient’s musculoskeletal and neuromuscular pairs of shoes, discarding the shoes from each pair which status facilitates formulation of an optimum orthotic do not fit; (2) one pair of mismatched (split size) shoes, prescription. Ideally, the prescription will reflect consen- which offer a relatively limited range of styles; (3) a sus among the clinicians and will be acceptable to the custom-made insert for the smaller foot to fit into the patient. larger, contralateral, shoe, which entails a one-time ex- pense but enables the patient to purchase only one pair Either the physical therapist or the orthotist should of shoes whenever new shoes are desired. inform the patient regarding what to expect in the or- thotic laboratory. The patient will probably select shoes A frequent consequence of poliomyelitis is quadriceps that include features appropriate to the individual’s paralysis. An AFO with a limited-motion ankle and an needs. If a plastic or plastic/metal orthosis has been pre- anterior band will resist knee flexion.96 The band pro- scribed, the patient’s foot and leg will probably be cast vides a posteriorly directed force just below the knee. in plaster of paris. Multiple length and circumferential The alternatives, namely a KAFO with knee locks or a measurements of the involved limb will be taken regard- KAFO with stance control joints, also prevent knee col- less of whether the orthosis is to be plastic, plastic/metal, lapse. Loads on the orthosis are substantial.97 These or- or leather/metal. thoses are more difficult than AFOs for the older person to manage. Most likely, while the orthosis is being made, the therapist will engage the patient in a program of thera- An alternate sequel to chronic quadriceps paralysis peutic exercise designed to maintain or increase range of is genu recurvatum. The older adult is likely to com- joint motion, muscle strength, standing balance, and plain of pain in the back of the knee as well as knee cardiopulmonary endurance. instability. An AFO that limits plantar flexion will re- strain the leg from shifting posteriorly. The AFO may When the orthosis is finished, the therapist, together have a solid ankle or a limited-motion ankle joint. A with the orthotist and other members of the rehabilita- knee–ankle–foot orthosis (KAFO) with knee locks also tion team, will evaluate its fit and construction and the protects the knee; however, the orthosis is cumbersome, patient’s function with it. The team will question the heavy, and difficult to don. patient regarding comfort and overall satisfaction. OUTCOME ASSESSMENT For the remainder of the rehabilitation, the therapist and orthotist should maintain good communication The effectiveness of orthotic intervention can be mea- and mutual cooperation, so that any problems in fit or sured subjectively by patient satisfaction questionnaires function can be addressed promptly, minimizing the and objectively by clinical parameters of gait efficiency time that the patient does not have the orthosis. A writ- ten record of issues relating to the orthosis facilitates

CHAPTER 22  Lower-Limb Orthoses for Older Adults 425 communication. Working harmoniously, the members depending on the therapeutic goal. AFOs consist of a of the clinical team can enable the patient to achieve foundation, ankle control, and superstructure; some maximum function. patients also require foot control. KAFOs add knee control. Before the patient begins training with the or- SUMMARY thosis, the clinician should evaluate its fit, function, and construction. Orthotic management can improve acute and chronic mobility limitations, which affect many older adults. Clinical application of orthoses encompasses foot and FOs and AFOs are the most usual appliances that ad- ankle disorders, especially diabetic peripheral neuropa- dress foot deformities, spastic or flaccid ankle paralysis, thy, osteoarthritis, stroke, peripheral neuropathies, and and, occasionally knee disorders. KAFOs and higher late-onset poliomyelitis. For older people with disabili- orthoses are heavier, more difficult to don, and associ- ties, as compared with walking without an orthosis, the ated with higher energy cost during ambulation. devices are associated with faster gait at lower energy cost. Cooperative interaction among the members of the Prescription of an orthosis should be based on a thor- clinical team, especially the physical therapist and the ough examination and evaluation of the patient, taking orthotist, usually affords the patient the best opportu- into account any previous experience the individual may nity to improve function. have had with orthoses, as well as the patient’s concerns about the utility and practicality of the appliance. REFERENCES Orthoses, whether made principally of plastic, To enhance this text and add value for the reader, all carbon fiber, or metal, apply forces to the body to limit references are included on the companion Evolve site or assist motion. The shoe is an essential component of that accompanies this text book. The reader can view the all lower-limb orthoses. Many older people benefit reference source and access it online whenever possible. from wearing an extra-depth shoe with a Blucher clo- There are a total of 101 cited references and other gen- sure. The shoe may be worn with many combinations eral references for this chapter. of inserts and internal and external modifications,

23C H A P T E R Prosthetic Management for the Older Adult with Lower Limb Amputation Carol A. Miller, PT, PhD, GCS INTRODUCTION array of prosthetic feet accommodate different levels of function.2,21,22 Researchers are only beginning to illus- Among the many challenges faced by older adults, the trate the effect of these new prosthetic components on potential loss of ambulatory ability threatens inde- function.23-28 The impact of these prosthetic improve- pendence as perhaps no other functional limitation ments on long-term lower limb prosthetic use and func- can. One can only guess at the magnification of that tional ability for the older adult with amputation remains threat when ambulatory abilities are compromised by unclear. lower limb amputation. The continued advancement in general medical care, surgical technique, and the Each member of the multidisciplinary clinical team development of more sophisticated prosthetic compo- shares the responsibility for identifying key factors nents provides many options for prosthetic use fol- that affect successful prosthetic management and reha- lowing amputation that were not available just a few bilitation of older persons. The physical therapist, years ago.1,2 With these advancements, research stud- along with the entire prosthetic team, must incorpo- ies are now better able to elucidate the range of poten- rate into a prosthetic prescription a thorough under- tial functional outcomes for an older person after standing of the physiological changes associated with amputation.1,3-9 the amputation as well as the impact of comorbid con- ditions combined with normal aging-related changes As a result of improved medical diagnostic testing, to promote maximum patient satisfaction and long- surgeons are more frequently able to save the knee by term prosthetic use. In addition, knowledge about performing transtibial amputations and are also at- psychological readiness, appreciation of socioeco- tempting through-ankle (Syme’s) amputation, even with nomic factors, and awareness of third-party payer older adults with vascular disease.10,11 The benefit systems for the older adult are essential to determine of these distal amputations is decreased energy demand optimal prosthetic prescription and physical therapy of prosthetic ambulation compared to more proximal or intervention. transfemoral levels of amputation.12,13 Unfortunately, advances in surgical intervention do not always result in The overall goal of this chapter is to establish the decreased morbidity and mortality, particularly in indi- scientific basis for clinical decision making by physical viduals who undergo lower limb amputation as a result therapists regarding prosthetic management and reha- of vascular compromise.14-20 bilitation of the older adult. Further, the emphasis of this chapter is on amputation as a sequelae of disease— Although the overall concept of prosthetic design not trauma or congenital deformity—because loss of has remained relatively unchanged over the past few de- limb from disease accounts for the vast majority of am- cades, the prosthetic components being used to fashion putations among older adults.10,29 Although there are prostheses have been regularly updated to accommodate many similarities between younger and older adults in improved technology and materials. For example, contem- prosthetic fabrication, fit, alignment, and training to use porary socket fabrication emphasizes lightweight material a prosthesis, critical differences in preoperative and (carbon graphite) and endoskeletal design with gel liner postoperative physical therapy prosthetic management suspension systems to improve fit and comfort; advanced of the older adult are evident and highlighted in the knee units including sophisticated microprocessors, and an chapter.21,22,30,31 426 Copyright © 2012, 2000, 1993 by Mosby, Inc., an affiliate of Elsevier Inc.

CHAPTER 23  Prosthetic Management for the Older Adult with Lower Limb Amputation 427 AMPUTATION IN THE OLDER ADULT in African Americans10,17 and Hispanics when compared to white non-Hispanic persons, even when factors such Incidence as age, sex, and presence of diabetes are controlled for in statistical analyses.18 There are approximately 1.6 million persons living with limb loss in the United States, a number projected to An estimated 23 million people in the United States increase to 3.6 million by the year 2050.29 The annual have diagnosed or undiagnosed diabetes, with nearly incidence of amputation in an older adult population in 52% of these individuals being older than age the United States is also projected to increase from 60 years.36 This means that approximately 23% of the 28,000 to 58,000 per year by 2030.3 The major causes U.S. population older than age 60 years has diabetes.15 for all lower limb amputations include dysvascular King et al predict that the number of people in the disease, trauma, malignancy, and congenital deficiency. United States older than age 65 years with diabetes mel- Dysvascular disease is the most common cause for lower litus (DM) will increase from 13.8 million in 1995 to limb amputation in the older adult.10 nearly 22 million in 2025.37 Peripheral vascular disease (PVD) is the most common cause of lower limb amputa- Currently, the most common levels of surgical ampu- tion in older adults, particularly vascular disease associ- tation secondary to dysvascular disease are transfemo- ated with diabetes. Roughly 70% of all amputations are ral (25.8%) and transtibial (27.6%), with other lower the result of either diabetes or PVD or a combination of limb levels such as toe(s) and transmetatarsal account- both diseases.10,14,17,19,38 ing for approximately 31% and 10.5%, respectively.10,32 Other levels of amputation, such as hip disarticulation, Impact and Outcomes (Morbidity, knee disarticulation, and hemipelvectomy are much less Mortality, Costs) common for the older adult with vascular disease. Transmetatarsal amputations as a result of ischemia or No one can doubt the serious medical condition of the gangrene of the metatarsals may become a more com- individual who requires lower limb amputation. All mon surgical approach in the future11,16; however, post- domains of health are negatively impacted, including operative intervention requires the addition of an physical, social, and emotional. Dysvascular disease and orthotic filler inside the shoe but does not require pros- diabetes mellitus are both associated with increased im- thetic intervention. pairment and functional limitation among older adults, even those without amputation.15,17 Leg amputation fur- Amputation due to vascular disease (dysvascular) ac- ther affects function and productivity, and reduced qual- counts for 82% of all lower limb loss hospital dis- ity of life.39,40 A recent study found that only 25% of charges,10 which increased from 38.3 per 100,000 in transtibial amputees older than age 50 years achieved 1988 to 46.92 per 100,000 in 1996.10,29 This significant community mobility,41 whereas other studies note that increase in dysvascular amputation rate (27%) in the transfemoral amputees have an even greater level of mo- United States is in stark contrast to the decreases (ap- bility disability and increased energy expenditure than proximately half) in trauma and cancer-related amputa- transtibial amputees.42,43 tions during the same decade of study.10,29 In addition to the concern over an increasing incidence of lower limb Alarmingly, in a study on older adults with diabetes, amputation, the absolute number of older adults living the potential risk for reamputation per person occurred with lower limb amputation is expected to continue to at the rate of 26.7% at 1 year, 48.3% at 3 years, and increase well into the 21st century, based on the aging of 60.7% at 5 years, whereas major lower extremity con- the U.S. population and the increased incidence of diabe- tralateral limb loss occurred at a rate of 11.6%, 44.1%, tes and dysvascular disease.6,10,15,17,33,34 and 55.3% for 1, 3, and 5 years, respectively.44 There is also a 20% to 50% risk of losing the contralateral leg Epidemiology due to vascular disease during the 5 years after amputa- tion, which must be taken into careful consideration Risk factors associated with lower extremity amputation when considering prosthetic intervention.17 for the older adult include diabetes and poor glucose control,17 renal disease,10 peripheral vascular or periph- Reported survival rates following major lower extrem- eral arterial disease, nonhealing wounds with infection, ity amputation vary across the literature and depend neuroischemic ulcers, older age, male gender, and African upon many factors, including the primary cause for am- American or Hispanic race or ethnicity.10,14,17-19 Increas- putation. A recent study found that the 1-year mortality ing age, especially those older than 55, constitute the rate was as high as 41% in a cohort of older adults with largest proportion of individuals with disease-related lower limb amputation.20 When controlling for factors lower limb amputations.10,34,35 Men are at a higher risk such as age, sex, race, level of amputation, and severity than women for limb loss, especially for trauma-related of comorbid conditions, the 1-year survival rate postam- causes.10,34,35 Recent literature concurs that the risk of putation was greater in those who received inpatient dysvascular-related lower extremity amputation is greater rehabilitation (75%) immediately following acute hospi- talization than for those who were discharged to home

428 CHAPTER 23  Prosthetic Management for the Older Adult with Lower Limb Amputation (51%) or to a skilled nursing facility (63%). Other stud- many of these situations, the clinician may choose to ies have reported that a 2-year survival rate after lower take on an advocacy role or make a decision to refer the extremity amputation averages 50%, with most of the patient to a skilled case manager for further support. deaths attributable to cardiovascular complications.14,45 High mortality rates following amputation in persons In summary, many of the medical and sociodemo- with diabetes range from 39% to 80% at 5 years.19 Over- graphic risk factors associated with lower limb amputa- all survival rates are significantly worse for individuals tion often mitigate against providing a prosthesis to an with transfemoral amputation (50.6% and 22.5%) than older adult. The health care practitioner must recognize, transtibial amputation (74.5% and 37.8%) at 1 and however, that it is critical to understand the interplay 5 years, respectively.14 between risk factors for diseases, such as diabetes and vascular disease, and health habits that put the individu- The costs associated with prosthetic fabrication, fit- als at risk for other comorbidities. For example, the ting, and follow-up can also be substantial. A prosthesis older adult at greatest risk for amputation, reamputa- for a person with lower limb amputation can cost thou- tion, and loss of contralateral limb has a history of dia- sands of dollars, yet many insurance policies, including betes with poor glucose control17,44 and other modifiable Medicare, often only cover 80% of the total amount. In risk factors, such as a history of smoking or poor diet 1997, in an overview report on 15 persons with trau- habits that also increase the occurrence of PVD.35,48 The matic below-knee amputation, Lims noted that the mean practitioner must therefore focus on decreasing risk fac- number of prostheses per patient was 3.4 with a total tors, in order to promote successful prosthetic outcomes. prosthetic charge of $10,829 (range 5 $2558 to $15,700) It is also essential to remember that the individual’s during the first 3 years of wearing a prosthesis.46 In a goals, personal motivation, and premorbid status are medical review of 545 individuals during the first 2 years often the strongest determinants of success with a pros- postamputation, Mackenzie et al estimated the cost of thesis and that numerous studies demonstrate that many providing a lower limb prosthesis using Consumer Price older adults with transfemoral or transtibial amputa- Index with constant 2002 dollars and found that the tions do achieve functional prosthetic success.5-9,49 average total prosthetic cost was $12,885, ranging from $10,058 for below-knee prostheses to $21,199 for PROSTHETIC DESIGN above-knee prostheses.47 In another study of 935 ampu- tees, it was noted that on average, 24% of all persons Numerous advances in the design of prosthetic compo- with dysvascular amputation reported being fitted with nents have occurred over the past few decades. The in- a new prosthesis at least once per year.24 Today, the costs creased use of modern thermoplastics since the 1980s and associated with some of the newer prosthetic designs, more recently carbon graphite has resulted in the fabrica- such as a transfemoral ischial containment socket with a tion of many different types of prosthetic sockets. There microprocessor knee unit (C-leg) and dynamic response are many changes in suspension liners, knee mechanisms, foot can increase the total cost of the prosthesis to and ankle/foot designs. Generally, the use of endoskeletal greater than $40,000 (N. Kaselak CPO, personal com- components to reduce the weight of the prosthesis has munication, 2009). increased. Many companies produce components target- ing older adults. These components are typically made of Presently, many of the advances in socket design and aluminum, titanium, and other materials that allow for components are not fully covered, which can be costly lighter prostheses. In addition, computerized programs for the patient. Many older adults live on limited in- such as contoured adducted trochanteric–controlled align- come in their later years, especially older women whose ment method (CAT-CAM) and computer aided design– income after retirement is generally less than that of computer aided manufacturing (CAD-CAM) are available their male counterparts. According to Pezzin et al24 ap- to assist the prosthetist in fabrication and follow-up fit- proximately 40% of all persons with dysvascular or ting. The daily and long-term effects that these newer trauma-related amputations lived in poverty or near prosthetic modifications have on functional abilities yield poverty levels when compared to other causes for am- equivocal results,23,25,50,51 suggesting that optimal design putation. The existence of poverty, more prevalent may vary for different individuals and populations of among older persons of racial and ethnic minority amputees. A recent study demonstrated that the use and groups, may further prevent their ability to pay 20% of satisfaction with prosthetic limb devices increases among the medical bills incurred. Further, those who are under- those with shorter timing to first prosthetic fitting and insured may need other sources of income or support, with those who had better communication with the pros- such as community organizations, to subsidize pros- thetist and team.24 thetic costs. Any of these factors can create financial hardship for the older person after amputation. Thus, It is well accepted that the prosthetic team must strive the decision about which type of prosthesis, or even to achieve three essential goals in prescription, fabrica- whether to provide a prosthesis, may become quite de- tion, and training: comfort, function, and cosmesis. pendent on the older adult’s socioeconomic status. In Comfort must be addressed first and foremost, followed

CHAPTER 23  Prosthetic Management for the Older Adult with Lower Limb Amputation 429 by function and then cosmesis. The prosthesis must pro- pendence in the use and management of the prosthesis, vide comfortable containment of the residual limb tissue and should be as simple as possible, with components during the stance phase of gait and provide an effective targeted for the potential functional level deemed most means of transferring the amputee’s weight through the appropriate for the individual patient. The prosthesis pelvis and residual limb to the floor.52 should be fitted and aligned to maximize stability. A general rule regarding prosthetic prescription for the The obvious impact of amputation on function and older adult is that the prosthesis should be lightweight, gait of a person with a lower limb prosthesis is easily comfortable, safe, securely suspended, and easy to put attributable to the substitution of prosthetic parts for the on and take off.63 Table 23-1 summarizes the functional normal skeletal segments and joints.53 Prosthetic factors levels that commonly guide prosthetic prescription. such as fit and alignment, the type of knee unit, and foot Examples of the more commonly prescribed lower component have been demonstrated to influence gait limb prosthetic components are shown in Figures 23-1 parameters.13,52,54-56 The fit, alignment, and adjustment to 23-3 and are also listed in Table 23-1.64 of the prosthesis must provide maximal restoration of function to the amputee with minimal gait deviation, in The socket is the most important component of the both the stance and swing phase of a walking cycle.52-54,57 prosthesis because it requires intimate fit with the resid- ual limb. Thus, socket fabrication and design may be During normal gait, lower limb stance and swing more dependent on the comfort of the patient and the phases occur as the result of precisely timed control of skill of the prosthetist. For example, the transtibial joint motion and muscle action. The lower limbs easily socket is usually patella-bearing, but may require higher adapt to changes in walking terrain and naturally ac- walls for stability. Ischial containment sockets with flex- commodate for obstacles, in which case, energy conser- ible features are becoming more common for the trans- vation is optimal. Lower limb amputation causes a loss femoral amputee rather than the rigid quadrilateral de- of limb length; normal joint mobility; muscular control, sign. Although suction is the preferred method for and local proprioception, especially altering the precise suspension for achieving intimate fit, this is often diffi- awareness of foot contact on the floor.58 Even with the cult for the older adult amputee with conventional don- many advances made with prosthetic components, the ning techniques.33 Prosthetic donning with atmospheric prosthesis at best can only imitate, but certainly cannot suction requires the individual to stand and balance pri- replicate, normal gait patterns. Thus, to date, the opti- marily on the sound limb, while bending downward to mal prosthetic design regardless of the individual’s age pull the parachute sock through a small suction valve remains elusive. Because of the complexity of issues that located on the lower end of the socket. Many older surround the older adult whose health status necessitates adults may not be able to tolerate the amount of forward an amputation, these seemingly simple primary goals of bend necessary, nor have sufficient hand strength to cor- providing optimal comfort, function, and cosmesis con- rectly don this type of suspension. Alternative types of tinue to present the medical team with challenging clini- liners and suspension systems, such as the “3-S pin sys- cal problems. tem” (Figure 23-4) or roll-on gel liner (Figure 23-5) may be easier for an older person because the liner and sleeve Components of the Prosthesis systems can be initially donned in sitting and then the individual can stand with bilateral upper extremity sup- Comprehensive texts21,22,46,59-61 and recent articles re- port to safely secure the prosthesis. garding specific prosthetic components and prosthetic training2,62 for diverse patient populations have been With the transfemoral prosthesis, the knee joint well documented and is beyond the scope of this chapter. should be reliable, stable, and simple to use. Newer knee To ensure that the patient can properly and safely use joints that combine the features of weight-activated the prosthesis, the clinician must understand how the stance as well as polycentric and pneumatic control pro- various sockets and components function. Different vide greater stability in stance phase.2,33 Microprocessor approaches to functional training are often dictated knee units, such as Otto Bock’s C-leg (see Figure 23-3), by the limits or advantages of the components used. have been reported to decrease the risk of falling and Consultation and discussion with a prosthetist is increase confidence of walking.26,28 The prosthetic foot extremely helpful to develop further appreciation of should also be lightweight for an older adult. Again, all the various types of components most suitable to the components should be considered durable, stable, sim- older adult patient. Sequences for donning and doffing ple, and cost-effective.65 and the progression of functional training with the pros- thesis are quite similar for the older adult and a younger Insurance Guidelines for Prosthetics person. Insurance reimbursement guidelines for prosthetics are Most prosthetic adaptations are based on collabora- usually found with the rules that cover durable medical tive decision making between the patient and the clinic equipment. Insurance limitations or specific guidelines team. The prosthetic prescription should maximize inde-

430 CHAPTER 23  Prosthetic Management for the Older Adult with Lower Limb Amputation TA B L E 2 3 - 1 Potential Functional Levels for Prosthesis Use and Commonly Prescribed Prostheses for the Older Adult Functional Level K0: Does not have the ability or potential to ambulate or transfer safely with or without assistance, and a prosthesis Functional Level K1: does not enhance their quality of life or mobility Functional Level K2: No prosthesis is prescribed Functional Level K3: Amputee Mobility Predictor Score (AMPnoPRO) less than 9.67 Functional Level K4: Has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed cadence; typical of the limited and unlimited household ambulator Suspension: Hip control with pelvic belt, Silesian belt, gel locking liner or lanyard for transfemoral; supracondylar or patella tendon bearing with gel locking liner or nonlocking “cushion” gel liner with suspension sleeve for transtibial; suction considered on a case-by-case basis (i.e., an experienced wearer who has always worn suction) Socket: Ischial containment for transfemoral; patella tendon bearing total contact for transtibial Socket Inserts/Liner/Sleeve: Locking or cushion gel liners (two per prosthesis) Knee: Single axis, constant friction, stance phase lock, manual locking or polycentric Ankle/Foot: SACH or single axis ankle/foot Amputee Mobility Predictor Score (AMPnoPRO) greater than 9.67 and (AMPPRO) average score of 25.0 Has the ability or potential for ambulation with the ability to traverse low-level environmental barriers, such as curbs, stairs, or uneven surfaces; typical of the limited community ambulator Suspension: Same as for K1, suction considered Socketa and Knee: Same as for K1 Ankle/Foot: Flexible-keel foot or multiaxial foot, axial rotation unit, dynamic prosthetic pylon Amputee Mobility Predictor Score (AMPnoPRO) greater than 25.28 and (AMPPRO) average score of 34.65 Has the ability or potential for ambulation with variable cadence; typical of the community ambulator who has the ability to traverse most environmental barriers and may have vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion Amputee Mobility Predictor Score (AMPnoPRO) greater than 31.36 and (AMPPRO) average score of 40.5 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 Suspension: Same as K1 and K2, suction optional Socket: Same as for K1 and K2 Knee: Fluid, pneumatic, or computerized knee Ankle/Foot: Flex foot or flex-walk system, energy-storing foot, multiaxial ankle/foot, dynamic response, shank/foot system with vertical loading pylon Amputee Mobility Predictor Score (AMPnoPRO) greater than 38.49 and (AMPPRO) average score of 44.67 aSuction socket designs, such as the narrow medial lateral, CAT-CAM or CAD-CAM, ischial containment, flexible brim, etc. Note: The AMPPRO and AMPnoPRO assess functional potential for unilateral amputee subjects with and without the prosthesis; bilateral amputees are tested with AMPPRO only. The total range for AMPPRO scores is 0 to 42 points. Total range for AMPnoPRO is 38 points. If using an assistive device, the subjects’ potential total score possibilities increase by 5 points (to 43 and 47 points for the AMPnoPRO and AMPPRO, respectively). SACH, single axis cushion heel (Adapted from the Region C DMERC DMEPOS supplier manual, Spring 2005.) for prosthetic socket design are not as restricting as those was updated in 2005 and is a detailed supplier manual for component parts. Established insurance guidelines for prosthetics and orthotics, whereby the four durable can often affect the patient’s, the prosthetist’s, and other medical equipment regional carriers (DMERCs) follow clinic team members’ decisions before a prosthesis is the same policies for prosthetic prescription64; however, prescribed. As health care changes, with the possibility coverage and reimbursement for similar items may vary of increased managed care for all older adults, the clini- by region. The Centers for Medicare and Medicaid Ser- cal team will need to consider the particulars of the indi- vices (CMS), which administers the Medicare program, vidual’s health insurance benefits before prescribing approved these policies as an established set of guide- the prosthesis. Third-party payers typically require a lines that describe the type of lower limb prosthesis that physician’s prescription as a part of the reimbursement may be covered based on the person’s “potential” func- process.30,66 tional level. Functional level, defined by Medicare, is a measurement of the capacity and potential of the In the early 1990s, four regional medical directors patient to accomplish their expected postrehabilitation for prosthetics, orthotics, and supplies collaborated daily function.64 Originally, the guidelines did not with Medicare to develop criteria and coverage policies include the word potential. This term was added to for prosthetic prescriptions. The most recent document

CHAPTER 23  Prosthetic Management for the Older Adult with Lower Limb Amputation 431 FIGURE 23-3  K​ 3/4 Level: Ischial containment/flexible suction socket with neoprene secondary suspension, microprocessor knee unit (C-leg), and dynamic response foot. FIGURE 23-1  ​K2 Level: Ischial containment/flexible socket with gel liner lanyard suspension, weight activated stance control knee, and multiaxial foot. FIGURE 23-4  ​A suspension sleeve with a pin attachment on its end can be rolled onto the residual limb, requiring less fine motor hand function. FIGURE 23-2  ​K3 Level: Ischial containment/flexible socket with allow the clinical team greater decision-making auton- omy in determining the likelihood of prosthetic success. lock-in liner, hydraulic knee unit, and dynamic response foot. Lower limb amputation potential functional levels from the Region C DMERC Supplier Manual for prosthetics is displayed in Table 23-1.64 Presently, the guidelines state that the determination of potential functional ability is based on the reason- able expectations of the prosthetist and the ordering physician that consider factors including but not lim- ited to: the patient’s past history (including prior pros- thetic use if applicable); the patient’s current condition, including the status of the residual limb and the nature of other medical problems; and the patient’s desire to ambulate.62,64

432 CHAPTER 23  Prosthetic Management for the Older Adult with Lower Limb Amputation FIGURE 23-5  G​ el liners. Top (L), seal or lock-in; top (R), pin and the physical therapist ultimately creates a very effec- tive means of caring for the patient. system; bottom (L), Velcro lanyard (KISS); bottom (R), “latch-in” lanyard. Once the prosthesis is fabricated and fit to the patient, the physical therapist bears substantial respon- PROSTHETIC CLINIC TEAM sibility for assisting the patient with adjustment to and acceptance of the device, along with continual assess- Composition, Roles, and Benefits ment of fit and function, during all of the patient’s ac- tivities of daily living. Finally, the physical therapist Typically, for individuals with lower limb amputation, must maintain open lines of communication with the the clinic team will include the patient, a physician prosthetist so that modifications can be made based on (usually a physiatrist), a prosthetist, and a physical the patient’s physical performance and the fit and align- therapist. Each one of these members of the prosthetic ment of the prosthesis. clinic team contributes an important perspective. Other medical and rehabilitation specialists, such as the case It is unfortunate that clinical teams may not be readily manager, nurse, and psychologist, may be added to the available to every patient with prosthetic requirements; team as needed to assist the older person to achieve this may especially affect persons residing in long-term optimal recovery after amputation. Unfortunately, the care, assisted care facilities, and at home. Quite often for patient’s role as a member of the team is often over- persons with amputation who reside in long-term-care looked by the practitioners on the clinical team. Patient facilities, the therapist initially learns of problems, such and family involvement are extremely important, and as changes in the person’s ability to wear and use the these members of the team should be present at each prosthesis safely and effectively, from the nursing staff or meeting whenever possible. family members or from an annual screening process. By this time, problems such as improper fit and decreased The physical therapist should provide the team with a patient satisfaction may have resulted in a decline in thorough examination and evaluation of the patient be- functional abilities.20 In settings where a clinic team is fore the prosthetic prescription. Further, the physical not readily available, the physical therapist may need to therapist must play a collaborative role with the team in take the initiative to assist the patient and family in lo- discussing the functional activity level and mobility cating the originally prescribing prosthetist or consider potential64 for the patient related to prosthetic prescrip- outreaching for a nearby prosthetist willing to assist in tion. The initial part of the prescription process should patient consultation. involve all team members, including the patient. The prosthetist has particular expertise in the fabrication and For the person living in the community, dissatisfac- alignment of the prosthesis. Further, the prosthetist will tion with fit and function often arises when the patient bring to the attention of the team knowledge of the most obtains multiple prostheses from different prosthetists recent advances in components appropriate to the older without adequate examination from rehabilitation ex- adult. Continual consultation between the prosthetist perts or clinic teams.20,24 Further, Lims demonstrated a reduction of about 20 days in inpatient hospital stay, a fivefold increase in percentage of patients discharged with prosthesis, and a threefold increase in the effective- ness of long-term rehabilitation over a 5-year period among patients who received team care compared with persons treated in environments without a clinical team approach.46 Transdisciplinary teams functioning in a coordinated effort offer a sound way to identify and re- solve the complex problems that accompany amputa- tions, especially among the very young and very old.2,21,67 EXAMINATION CONSIDERATIONS RELEVANT TO PHYSIOLOGICAL CHANGES OF AGING, PROSTHETIC PRESCRIPTION, PROSTHETIC USE, AND REHABILITATION The physical therapy examination should include a thor- ough history and systems review and objective tests and measures, with an overall emphasis on the patient’s previ- ous functional abilities, social responsibilities, and goals for the future (Box 23-1). The clinician is best able to identify goals and formulate a plan of care for successful

CHAPTER 23  Prosthetic Management for the Older Adult with Lower Limb Amputation 433 B O X 2 3 - 1 Physical Therapist Examination prosthetic use by considering a detailed list of clinical for Prosthetic Determination concerns: cognitive dysfunction that interferes with training, advanced neurologic disorders, cardiopulmo- I.  Patient History nary conditions severe enough to impose limitations on Medical diagnosis effort, ulcers or infections with compromised circula- Past medical/surgical history tion, and irreducible and pronounced knee flexion Prior functional abilities contractures in below-knee candidates and hip flexion Patient’s goals contractures in above-knee candidates. These factors continue to be identified as essential in the clinical deci- Systems Review sion-making process for determining an individual’s Cardiopulmonary prosthetic potential.21,22,68 Musculoskeletal Neuromuscular Age alone does not predict older adults’ ability to suc- Integumentary cessfully use a prosthesis. However, age is a risk factor Cognitive/Emotional/Education for increased mortality and less-than-optimal functional Other Systems (i.e., endocrine, gastrointestinal) outcomes.3,6 Older age has a well-established association with increased likelihood of above-knee amputation, Tests and Measures greater incidence of bilateral limb loss, lengthened time Pain: (type) residual limb pain, phantom sensation, or phantom pain necessary for successful rehabilitation, and increased Range of motion number of comorbid health problems.3,6,44 Individuals Muscle performance with amputation who have multiple comorbidities, espe- Neuromotor development/Control of movement and coordination: cially diabetes and peripheral vascular disease, are at the Integumentary integrity (involved and uninvolved side) highest risk for mortality and have the least success with Sensory integrity rehabilitation.6,14,19,20 Finally, psychosocial factors, such Anthropometric characteristics of residuum: as diminished body image,69 level of emotional readi- Vascular integrity ness,70 or the presence of depression and issues related to Functional mobility, locomotion, and balance quality of life4,71 may hinder prosthetic success in the older adult with lower limb amputation and should be Ambulation Device Assistance addressed. Distance Cognition Footwear History, Systems Review, and Tests Evaluation/Physical Therapist Diagnosis and Measures Plan for Prosthetic Prescription The initial history and interview should address all es- II.  Clinic Visits Examination sential elements of physical therapy practice,72 including Device such items as general demographic information, family Patient self-report and social data, financial concerns, preamputation abili- Gait deviations ties, and prosthetic goals. The interview also needs to be Problem areas (include the prosthetic or patient problem and directed toward the primary cause or causes for the lower limb amputation. For example, questions that source) specifically address the presence or absence of diseases Fit (document adjustments needed) such as diabetes or dysvascular disease, and lifestyle Patient/Family instruction (includes wearing time, skin inspection, habits (i.e., smoking) associated with increased risk for lower limb amputation will provide critical information gait, don/doff of device, exercise, other) for directing physical therapy care. Further, knowledge Footwear (includes shoe/sneaker—modifications needed): of an individual’s preamputation functional ability will Plan for follow-up also assist the physical therapist in guiding the examina- tion and for determining a comprehensive plan of care prosthetic rehabilitation by completing a comprehensive that addresses patient and family goals. examination and applying sound knowledge of the influ- ences of the cardiovascular, musculoskeletal, neuromus- Cardiovascular and Endocrine Systems cular, integumentary, cognitive, and endocrine systems to evaluation of these data. Physiological changes in each of In the older adult with amputation, dysvascular disease these systems can affect prosthetic fit and function; there- is most commonly associated with complications from fore, the examination information will be presented using long-standing diabetes, such as peripheral neuropathy, a body systems–based approach. In this way, the thera- nephropathy, and vascular conditions, particularly pe- pist can organize multiple aspects of examination in rela- ripheral arterial disease. Therefore, for the purpose of tion to the influence that each body system has on pros- comprehensive examination of the older adult with thetic care for the older adult. The physical therapist must also be prepared to in- clude in the examination pertinent questions and se- lected tests to assist the clinician in determining whether prosthetic use is feasible. In 1985, Steinberg49 recom- mended careful selection of patients appropriate for

434 CHAPTER 23  Prosthetic Management for the Older Adult with Lower Limb Amputation lower limb amputation, the cardiovascular and endo- response to activity in persons with nonvascular amputa- crine systems will be presented together. tion.12,43,55,77 Clinicians must also take into consideration that many older adults with vascular or diabetes-related Complications with diabetes, in relation to manage- amputation, particularly those with transfemoral amputa- ment of the older adult with amputation, more com- tion, cannot walk for a total of 6 minutes until much monly occur when blood glucose levels are consistently later in the rehabilitation process, and many others elevated over time.14,15,17 For the older individual with are never able to achieve this goal. For the older person diabetes, it is important to ask the patient to monitor with amputation who is able to complete a walk test, and report glucose levels at each and every physical cadence and velocity are likely to be very slow to reduce the therapy session. The need for consultation and referral significantly increased cardiovascular stress of ambulation to the patient’s primary medical physician or endocri- with a prosthesis. In light of this, the results of the 6-minute nologist is not uncommon while a patient is recovering walk test have to be interpreted cautiously. Monitoring from lower limb loss, as the amount of physiological vital signs during arm ergometry exercise or with single- stress placed on the body following major surgery such lower-limb bicycling78 may initially offer the clinician as lower limb amputation may make it difficult to ini- an alternative for assessing cardiopulmonary integrity in tially control blood glucose levels.73 these patients. Microvascular, or small blood vessel, complications Interestingly, steady-state or resting energy costs for the evident in retinopathy, nephropathy, and peripheral neu- older persons with amputation compared with a healthy ropathy are discussed under neuromuscular consider- adult of similar age are not significantly different.12,43,76 ations later in this chapter. Macrovascular, or large As discussed, when compared with normal gait, persons blood vessel, complications of diabetes include athero- using a lower limb prosthesis will demonstrate much sclerotic narrowing of blood vessels, which contributes slower walking velocity and cadence, with speed decreas- to coronary artery disease, peripheral arterial disease, ing as level of amputation becomes more proximal. In myocardial infarction, as well as cerebral vascular dis- effect, the person with a lower limb amputation seemingly ease and stroke.17,61,74 A significant implication of micro- slows down to reduce the stress on his or her cardiovas- and macrovascular disease is that the person with lower cular system. Thus, when only the amount of oxygen limb amputation and diabetes will have many more con- utilization is compared between a healthy individual and founding risk factors that could increase demands on the one using a prosthetic limb, and time or distance is ig- cardiovascular system. Consequently, the medical condi- nored, the oxygen utilization per meter can be essentially tions of these persons require careful monitoring by all the same between the two individuals. members of the medical team to prevent undue stress to the cardiovascular system. Prosthetic factors must also be considered during ex- amination as energy requirements for using a lower limb The systems review and initial examination should prosthesis have been a major concern for decades. In also include careful monitoring of all vital signs, particu- earlier years, prostheses were not prescribed for the larly heart rate (HR) monitoring during all activities in older adult because of the extensive demands on the the clinic. One of the best indicators of cardiovascular cardiovascular system. In the past 2 decades, prosthetics functional capacity is obtained through the measure- have increasingly moved toward lighter endoskeletal ment of the maximal oxygen uptake, or V•  o2max. components, especially for the older adult. Newer com- Healthy older individuals in the 6th decade of life use ponents, such as hydraulic knee units,25,28 microproces- 41% of their maximum aerobic capacity during walk- sor knee units,55 and dynamic-response prosthetic feet ing.43,75 Malatesta et al76 confirmed these findings and have shown improvements in energy consumption over further demonstrated that during all speeds of walking, early design components, even in individuals with dys- V•  o2 max was significantly greater in 80- and 65-year-old vascular amputations.12,13,27 Lighter-weight prostheses, adults, when compared to 25-year-olds, at approxi- specially fabricated for the older adult ambulator, have mately 22% and 13%, respectively. Many studies have been marketed by many different manufacturers; how- indicated that the energy costs of using a prosthesis are ever, the effect of these lighter components on reducing substantially increased over normal bipedal locomotion, stress to the cardiovascular system remains to be fully with estimates ranging from 40% to 60% with unilat- studied. eral transtibial amputation, 60% to 100% with bilateral transtibial amputation, 90% to 120% with unilateral Foremost for the clinician, knowledge of energy cost transfemoral amputation, and more than 200% with and oxygen utilization requirements is necessary to for- bilateral transfemoral amputation.6,43,55 mulate an intervention with the appropriate exercise frequency, duration, and intensity. Careful attention Most clinicians do not have access to equipment that should be paid to appropriate intensity of cardiovascular measures V•  o2max; however, there is increasing evidence for exercise before, as well as during, gait training. Allowing use of cardiovascular tests, such as the 6-minute or 2-minute the person with amputation a longer period of time to walk in individuals with amputation. The 6-minute perform a task and encouragement of slower or more walk test has been used by physical therapists to assess comfortable speeds for gait also may prove helpful. the quality and integrity of a person’s cardiopulmonary

CHAPTER 23  Prosthetic Management for the Older Adult with Lower Limb Amputation 435 Musculoskeletal System FIGURE 23-6  ​Shrinkers. (Left to right) transtibial and transfemoral. With each ensuing decade of life past the middle years of muscles, previous impairment, or long-standing poor comes an increased likelihood of postural changes , even postural habits. Hip flexion, abduction, and external rota- in the absence of disease.79 Although the precise etiology tion contractures may occur in a patient after transfemo- of these changes is unknown, most often postural change ral amputations, with hip flexion being the most common is associated with inactivity and decreased mobility, in this patient group. Hip flexion, abduction, external which has been shown to improve with exercise and rotation, and, most commonly, knee flexion contractures adapted physical activity.79,80 The most common types of may develop as a result of transtibial amputations. postural changes in the lower limb joints of older adults are increased flexion at the hips and knees and loss of Generally, knee flexion contractures of no more than dorsiflexion at the ankle. In addition, physiological 10 to 15 degrees for below-knee amputations and hip changes that occur with aging of the musculoskeletal flexion contractures of no more than 15 to 20 degrees system, such as decreased connective tissue extensibility, for above-knee amputations can be readily accommo- decreased muscle strength, and muscle imbalance further dated for in the fabrication and fit of the prosthetic promote these postural problems and may limit the ef- device. Although persons with contractures greater than fectiveness of the physical therapist’s intervention. De- these can be fitted with prostheses, gait patterns may pending on the surgical technique employed, removal of become more significantly altered with increased defor- the lower limb will create extensive changes in bony mity. Contractures greater than those identified above alignment and muscle attachment, which in turn will may also inhibit safe ambulation and diminish an indi- further affect posture and postural control in sitting and vidual’s ability to maintain safe static and dynamic in standing. postures. The musculoskeletal systems review and examination To promote the ability to transfer and provide accept- should include pertinent testing of range of motion and able cosmesis, a prosthetist is often able to modify the lower limb muscle length, strength testing of the trunk prosthesis for a person with transtibial amputation and and extremities, and posture in both sitting and standing accommodate knee flexion contractures as great as 35 to with and without the prosthesis. Extremity and trunk 40 degrees. In addition, even in the presence of these strength, collected through standard manual muscle test- more significant contractures, some patients have been ing, will be essential for determining the patient’s needs able to successfully ambulate with a modified prosthesis for assistive devices in both the pre and prosthetic gait and an assistive device. Therefore, impaired muscle phases of recovery. Postural examination, especially in length or soft tissue extensibility should not necessarily standing, is important to record and relate to dynamic deter the patient or clinician from pursuing a prosthetic gait control and function. Range of motion, muscle fit. Other modifications in prosthetic design, such as the length and strength for major lower extremity move- “bent knee” prosthesis, have been used in the presence ments should also be assessed. of extreme knee flexion contractures, sometimes as large as 70 to 90 degrees. However, poor cosmesis is often a Girth measures for the residual limb should also be problem in these cases and may discourage long-term recorded at the distal end and approximately every 2 use of the prosthesis. A walker can also be adapted by in. up toward the knee for the transtibial level or adding a weight-bearing surface (seat) that allows the greater trochanter for a transfemoral level. These mea- individual with a transtibial amputation and significant surements will assist in determining the size for a shrinker (Figure 23-6), an elastic sock-like garment used instead of an ace wrap for control of edema and for shaping the residual limb. A shrinker is generally prescribed once the stitches or staples are removed and will be fitted by the prosthetist. Girth measures should be taken regularly, as limb volume must be relatively stable prior to considering initial prosthetic fitting. Re- ferral to the prosthetist is warranted if the shrinker becomes too loose or too tight as a result of volume change. A properly fit shrinker is essential to effectively control residual limb edema and shape. Lower limb joint contractures can negatively affect functional outcomes, influence prosthetic fit, alter pos- tural alignment in stance, and contribute to poor gait patterns. Contractures can even prevent ambulation and use of a prosthesis. Most contractures are the result of muscle imbalance, especially after the surgical division

436 CHAPTER 23  Prosthetic Management for the Older Adult with Lower Limb Amputation knee, and possibly hip, flexion contracture a means to The most difficult type of pain to ameliorate with ambulate without the prosthesis.81 prosthetic intervention is phantom sensation of pain, a perception of pain in the missing limb that is usually For the person with transfemoral amputation, it can be reported as severe, constant burning, cramping, and quite difficult, if not impossible, for the prosthesis to accom- sharp in nature. The exact mechanism of phantom limb modate a hip flexion contracture greater than 25 degrees pain remains unclear; however, it is thought to involve and allow for safe ambulation without the use of an assis- disruption in peripheral, spinal, and central nervous sys- tive device. Stability during the gait cycle can be significantly tem processes.82 Traditional theory suggests that gener- compromised, resulting in decreased safety and increased ated impulses from the affected limb are sent through risk for falls. With significant contractures at the hip, a pros- peripheral and spinal nerves to the thalamus in the so- thesis is not generally provided, even to assist with transfers. matosensory areas of the brain, causing abnormal sensa- If requested by the patient, a prosthesis may be provided to tion.62,82 Phantom limb pain following amputation is improve cosmesis. also thought to be the result of abnormal reorganization of the central neuromatrix, which holds past sensory Prevention of these deformities from the outset is the experience in the brain for each body part.82 Biopsycho- best intervention and should be emphasized throughout social factors such as depressive symptoms, pain coping the rehabilitation process. Along with patient education, mechanisms, cognitive beliefs, and social environmental early postoperative management should include stretch- factors such as social support are also related to long- ing and strengthening the remaining lower limb joints term adjustment to phantom pain.83 There are no known and muscles as well as proper positioning to reduce the prosthetic adaptations that address phantom pain; how- chances of developing contractures. ever, physical therapy interventions, such as transcutane- ous electrical stimulation (TENS), ultrasound, ice, and Neuromuscular System mirror-box therapy have been documented to reduce phantom pain.1,2,6,21,84 In a systematic review of literature, van Velzen et al81 found that among many physical capacity factors affecting Peripheral neuropathy, a diabetic complication that function in amputees, there was especially strong evidence ensues over longer periods of time, may also contribute relating balance to walking ability in those persons using to atrophy of the intrinsic musculature of the hands and lower limb prosthetics. With this in mind, a comprehensive feet. Depending on the severity, intrinsic muscle wasting neuromuscular systems review and tests should include the in the hands can affect grasp and may prevent indepen- measurement of sensation, motor control, coordination, dent donning and doffing of the prosthesis without tone, balance, and locomotion ability, including gait. modification. Hand function, especially grasp, should be tested and documented as a part of the physical thera- Peripheral neuropathies may result from microvascu- pist’s initial examination. Finally, retinopathy, which is lar changes seen with peripheral vascular disease (PVD) often present with microvascular disease, and other but can also be attributed to diabetes alone. Altered sen- aging-associated visual problems such as cataracts and sation in the distal parts of the extremities, especially the glaucoma, can greatly affect vision and may impede in- hands and feet, is noted in the presence of PVD and in dependence in prosthetic donning and doffing without clinical diabetic neuropathy.74 Any areas on the body modification. with diminished sensation, especially due to diabetes or PVD, can potentially increase a patient’s risk of develop- Prosthetists often are able to make different types of ing bruises, ulcers, and other skin problems. In the long prosthetic modifications to accommodate decreased term, this patient may experience additional detrimental hand function and impaired vision. Simple modifications consequences, including further loss of limb or loss of can be made to partially accommodate decreased hand the contralateral limb. Prosthetic fit and comfort can be dexterity. Today, the most commonly prescribed suspen- particularly difficult if sensory feedback in the residual sion systems utilize either a roll-on gel liner with pin limb is affected. suspension, or “lock in liner,” or a liner with a lanyard system (see Figures 23-4 and 23-5).59 These newer types The examination should also include a thorough as- of suspension sleeves can be easily rolled onto the re- sessment of pain, to help distinguish the type experi- sidual limb using the heel of the hand, thus requiring less enced by the patient and relate the symptoms to the fine-motor hand function. In the pin system, the sleeve is cause of pain.1,2,6 For example, pain following amputa- simply inserted into the prosthesis until audible clicks tion may be associated with the surgical procedure itself, are heard for safe attachment of the prosthesis; a gentle which is referred to as residual limb pain. Other sensory push on the locking mechanism easily releases the sleeve. perceptions of pain or phantom sensation may be ex- With the lanyard system, once the sleeve is on, the Velcro pressed as a tingling or numbness in the removed part of strap is pulled through the socket and secured or re- the limb. Phantom sensations are often intermittent and leased to attain adequate suspension. The newer types of respond well to gentle tapping or rubbing as well as limb suspension systems may also be easier for an older adult wrapping (ace wrap or shrinker) and consistent daily use of the prosthesis.

CHAPTER 23  Prosthetic Management for the Older Adult with Lower Limb Amputation 437 with visual impairment. A few factors that may deter the functional tests until much later in the rehabilitation use of the gel liner system include increased difficulty in process; furthermore, it must be recognized that many prosthetic fit, need to still use socks over the sleeve in the older adults will not be able to complete them at all. event of limb shrinkage during the day, increased fabri- cation costs, and a potential development of skin aller- Integumentary System gies from the liner material. In essence, the only skin surface on the human body Intrinsic muscle atrophy in the unaffected lower ex- designed to tolerate weight bearing is the plantar surface tremity can also influence lower limb alignment and the of the foot. By virtue of the design of lower limb pros- joint integrity and soft tissue structure of the remaining theses, one must consider the impact of weight-bearing foot, resulting in greater risk of damage due to trauma. forces on the skin and soft tissue of the residual limb. Consultation with an orthotist is recommended in these Examination of and the promotion of healthy skin integ- cases to provide orthoses or other types of accommoda- rity is critical because wearing a prosthesis requires an tive footwear that may reduce trauma and, if possible, intimate fit between the socket and the person’s residual delay further excess strain on the muscles of the unaf- limb. An essential part of clinical examination and man- fected lower limb. agement of the patient with lower limb amputation re- quires careful monitoring of the patient’s skin condition The result of limb dysfunction secondary to cerebro- before, after, and throughout prosthetic training. Teach- vascular accident (CVA), another commonly occurring ing compensatory techniques, such as using a handheld condition in older adults with macrovascular disease, mirror to clearly see the entire residual limb along with may affect the person’s ability to control the prosthesis if careful monitoring of skin condition will reduce the risk worn on the involved side. Changes in muscle tone, loss of skin damage to all areas affected by sensory loss. of range of motion, weakness, and decreased coordina- tion associated with CVA can also have effects on the Aging-related skin changes occur and are influenced contralateral extremities and must be carefully exam- to varying extents by gender, race, and health conditions. ined. The ability to perform coordinated tasks in a spe- Much more research is needed to accurately delineate cific sequence is essential for prosthetic donning and the impact of integumentary changes on prosthetic use doffing as well as functional performance. Few, if any, by older adults. Some aging-related changes in skin that prosthetic modifications can accommodate for these likely affect skin tolerance for prosthetic use include at- types of problems. Unfortunately, when the impairments rophy and fragility of the dermis, decreased solubility and functional limitations are substantial as a result of a and stiffness of collagen, decreased elasticity, reduced CVA, the patient is typically not considered a strong viscosity, less eccrine and apocrine sweat, and regression candidate for safe prosthetic use. and disorganization of small vessels.90 The skin’s ability to resist shearing forces is especially compromised with In the past decade, there have been an increasing aging. Clinically, this is often seen as skin tears, which number of tests implemented to measure motor control, can easily occur at any interface between the residual balance, and gait in individuals with amputation, across limb and the prosthesis.91 Persons with diabetes or PVD multiple age groups, levels of amputation, and those are particularly vulnerable to decreased sweat gland with amputation related to nonvascular and vascular function, decreased tolerance to shear forces, and de- disease.77,85-89 The Timed “Up & Go” (TUG) test,89 Ac- creased skin structural stability secondary to a compro- tivities Specific Balance Scale (ABC),87,88 the L Test of mised microcirculation. Functional Mobility,85 and the Amputee Mobility Pre- dictor86 (AMP with or without prosthesis) have been It is also important to consider the problem of de- shown to be reliable and valid instruments for assessing creased sweat gland function because the gel liners and balance and gait function in older adults with amputa- socks worn within a prosthesis can be extremely warm tion. The Amputee Mobility Predictor (AMP)86 is spe- and often hot. Alteration in perspiration within the cifically designed to assess balance, transfer ability, and socket can result in skin conditions such as folliculitis gait ability in the individual with amputation. The AMP (inflammation of the hair follicle) that may result in pain is unique in that the instrument can be implemented with and discomfort. If this condition persists, prosthetic use or without the prosthesis and effectively predicts the must often be temporarily discontinued, which has Medicare guidelines for functional classification level significant impact on the person’s functional abilities. (see Table 23-1), based upon scores achieved on the in- Patient education regarding personal and prosthetic strument.77,86 Therefore, this instrument can be effec- hygiene and consultation with the prosthetic team are tively used to assist the clinical team in determining the encouraged. prosthetic components needed to match the functional ability of the patient. To understand the appropriate timing to schedule prosthetic fitting and initiate safe progression of pros- As already noted with more advanced cardiovascular thetic use, the clinician needs to be aware of normal testing for older adults with amputation, many individu- wound healing for the older adult, including wounds als may not be able to perform these neuromuscular

438 CHAPTER 23  Prosthetic Management for the Older Adult with Lower Limb Amputation that occur through surgical intervention. Wound healing over the skin to create a more intimate fit within the is age dependent92 but does follow the classical inflam- nonsuction socket. Today, synthetic gel liners made of matory, proliferative, and remodeling phases often at a silicone are much more commonly prescribed, and if delayed or slowed rate in the older adult.93,94 PVD and necessary, socks can be worn over the liner to achieve a diabetes can delay healing time for surgical wounds. The snug fit within the socket if there are changes in limb tensile strength of healing wounds as defined by the force volume secondary to edema.21,51,59 The gel liners, such as required to disrupt wounds is decreased in persons older alpha liners, Silipos sleeves, among many others provide than 70 years.33,95 The distal end of the limb, especially cushioning to the residual limb within the socket, may be along the scar line, is most vulnerable to damage. helpful in reducing shear on the residual limb and pro- Wound dehiscence can occur if fit is improper or if exces- viding more uniform pressure. In turn, hopefully, im- sive stress is placed on the incision site, particularly proved comfort is achieved, especially for the older per- when wearing the prosthesis in the early phases of post- son with fragile skin. surgical rehabilitation. Edema reduction or control of volume of the residual limb may be difficult because of One concern is that the materials used in the newer the presence of circulatory disease. Volume changes in liners or socket fabrication materials may cause allergic the residual limb affect its shape and size, ultimately in- reactions in the form of a rash or dry irritated skin25; fluencing the type and timing of initial and final pros- therefore, skin condition must be monitored carefully. thetic fit. As with other prosthetic modifications, research regard- ing the effectiveness for preventing skin breakdown and Considering the skin changes and longer time for improving comfort and function in the older amputee is wound healing in older adults, particularly those with clearly needed. vascular disease, the therapist must be certain that the wound is completely healed before initiating training Finally, it is important to examine the skin integrity of with the prosthesis. Depending on scar healing, pros- the contralateral limb as we are reminded that the risk thetic fitting can possibly occur as early as 3 to 4 weeks for loss of the contralateral limb or need for higher levels post transfemoral amputation, and 5 to 6 weeks post of amputation is great in older adults with dysvascular transtibial amputation; however, the average time to disease. Changes in the quality of lower limb pulses prosthesis fitting is generally longer. Lilja and Oberg, (weak, normal, strong/bounding) when compared to the using residual laser scanning to assess limb volume same vessel on the sound limb; presence of edema; and changes with 11 older patients with dysvascular amputa- any alterations in the amount of hair, color, and degree tions, concluded that 3 months postsurgery was a safe of warmth should be documented. Padding areas of the approximate of average time for fitting a transtibial prosthesis, such as over any rivets used for suspension prosthesis.96 In a recent study of 1538 adults, ages 18 to mechanisms or over prominent areas of the socket wall 84 years, Pezzin et al24 reported that, although the aver- or ankle/foot components, may be needed to reduce the age time from surgery to initial prosthetic fitting varied risk of tearing skin on the uninvolved limb. somewhat by etiology of the lower limb amputation, the average time from surgery to initial fit was between 5 Cognitive System and 6 months. Early or immediate postoperative fitting is sometimes attempted but is not commonly recom- Although intellectual ability is normally maintained well mended for the older adult because of the nature of into the mid-70s or later, other aspects of cognitive func- amputations. tion, including the speed of memory processes and ab- stract thinking, decline with age.99,100 Cognitive changes, The most commonly prescribed prosthetic sockets are if present, can have significant implications for an older made of rigid materials that do not readily yield under individual’s ability to incorporate new skills in motor forces during activities such as gait. Pressure and stabil- behaviors to replace lost abilities.33,100 Chapter 8 pro- ity requirements are in opposition within the prosthesis, vides a detailed summary of mental and affective tools to where a rigid support is required for stabilization during assess cognitive function in older adults. Memory, atten- weight bearing, but a soft support is important to reduce tion, concentration, and organizational skills are neces- pressure on soft tissue and enhance proprioception.97 sary for effective use and maintenance of a prosthetic The material of the socket and the alignment of the pros- limb.101,102 thesis have been shown to increase the shear forces and pressure on the residual limb within a socket.57,98 Flexi- If cognitive changes are present, all members of the ble sockets are now more commonly prescribed for the health care team, and especially the physical therapist, older adult. However, although this socket design is must actively become involved in consistent, ongoing more expensive and complex to fit, its increased flexibil- education. Repetition of tasks may prove helpful for the ity reduces shear forces on the skin, making it more patient and family to learn new tasks such as donning comfortable.21,51,59 and doffing of the prosthesis. Even patients with mini- mal to moderate cognitive impairments have learned to In the past, residual limb socks or liners, made of use a prosthesis with consistent repetition in a structured materials such as cotton and wool, were worn directly environment.

CHAPTER 23  Prosthetic Management for the Older Adult with Lower Limb Amputation 439 ESTABLISHING A PHYSICAL THERAPY Psychosocial Implications and DIAGNOSIS, PROGNOSIS, AND PLAN Rehabilitation OF CARE TO GUIDE PHYSICAL THERAPY REHABILITATION Psychosocial issues relevant to successful prosthetic management warrant careful consideration of an indi- Lower limb amputation as the result of disease is associ- vidual’s readiness, cognitive status, and extent of depres- ated with multisystem failure that will require compre- sion, if present.71 In some cases, the influence of the in- hensive multidisciplinary intervention. Further, for older volvement of significant others or family is a key adults, lower limb amputation may be just one of many determinant of successful prosthetic use. The cost of losses across many aspects of their life. The individual obtaining and learning to use the prosthesis may pose a may be experiencing role loss due to a loss of work or significant financial burden to the patient and family and ability to participate in other meaningful activity, finan- therefore must be considered. cial stresses as a result of retirement, increasing depen- dence from the physical challenges of the amputation Most importantly, the patient must have a desire to combined with aging and comorbid health conditions. use the prosthesis. The loss of a limb is almost always The inability to deal with all of the biological, social, considered initially devastating by the individual, and and functional losses due to amputation may potentially this perception exists regardless of age. A person’s evalu- lead the individual toward despair, depression, and with- ation of his or her body image can both positively and drawal from society.71 negatively influence self-esteem, anxiety, and depres- sion.69,71,103 Specific education about the advantages and In regard to diagnosis, the very nature of a major disadvantages of using a prosthesis for cosmesis, func- surgical amputation will significantly affect most, if not tional activities, and ambulation may assist the patient all, of the primary body systems considered in the phys- and others involved to understand the scope and limita- ical therapy examination, but will most directly affect tions of the rehabilitation outcomes expected for that the musculoskeletal, integumentary, and neuromuscular individual. Support groups, peer visitors, or volunteers systems. Considering the primary cause for amputation who can demonstrate different prosthetic components in the older adult, dysvascular disease, the therapist will and their level of success are sometimes psychologically often need to consider secondary diagnoses related to beneficial to the patient who is preparing to use a pros- cardiovascular disease and endocrine system compro- thesis. Because psychological readiness is so extremely mise, specifically diabetes-associated impairments. Using important to outcome, the patient may require psycho- the Guide to Physical Therapist Practice,72 most indi- logical intervention before or concomitant with the viduals with a primary diagnosis of lower extremity physical therapist’s intervention. amputation will fall under “Pattern 4J: Impaired Motor Function, Muscle Performance, Range of Motion, Gait Rehabilitation professionals need to be aware of their Locomotion, and Balance Associated With Amputa- own biases against older adults, particularly older adults tion.” If the patient also has significant dysvascular dis- with disabilities and chronic conditions who may be ease, then a second pattern may be used, such as “Pat- noncompliant or depressed. Rybarczyk et al,104 in a tern 6D: Impaired Aerobic Capacity/Endurance well-devised study of nearly 1000 rehabilitation profes- Associated With Cardiovascular Pump Dysfunction or sionals, found that perceptions of the “ideal” younger Failure.” Considering the significant intimacy of pros- patient and “ideal” older patient with an amputation thetic wearing on the integumentary system, a third pat- were quite similar. However, if the same generic patients tern may also be required: “Pattern 7A: Primary Preven- were identified as depressed or noncompliant, then the tion/Risk Reduction for Integumentary Disorders.” rehabilitation professional had a more negative reaction to the older patient and deemed the older patient less Factors Relevant to Prognosis “worthy” of rehabilitation than the identically described younger patient. In order to effectively implement a plan of care, the physical therapist will need to comprehensively consider Prosthetic Factors Influencing Prognosis all essential findings from the examination as it relates to and Rehabilitation the potential for recovery. These findings should collec- tively reveal a patient’s sense of health and well-being It is important to remember that many studies show across multiple domains, including physical, psychologi- that a high percentage of older adults discard their pros- cal, and social health. Awareness of epidemiologic data thesis within months or the first year of training.6,40 regarding morbidity and mortality along with sound Rehabilitation after the loss of the second limb is more knowledge of prosthetic requirements for function must likely to be successful if rehabilitative efforts were suc- also be taken into account in order to successfully pre- cessfully undertaken after the loss of the first limb.23 dict functional potential and recovery for the older adult Intensive rehabilitation efforts by an interdisciplinary with lower limb amputation. team have shown positive outcomes for use of a pros- thesis and functional success,31,46 particularly intensive

440 CHAPTER 23  Prosthetic Management for the Older Adult with Lower Limb Amputation inpatient rehabilitation.6,31,40,46 Inpatient rehabilitation telephone or other means to allow constant dialogue has been demonstrated more effective than care at home between physician, prosthetist, and therapists. Further, alone.20 Finally, based on what has been reported in the each member of the team and those members of the pa- literature, the physical therapist must remember that tient’s immediate family affected by the limb loss need to successful use of a prosthesis is multifactorial, with independently examine and evaluate the patient to better complex and imprecise predictors of success.40,105 determine appropriate management so that the patient achieves an optimal functional level, which attends to his With increasing frequency, persons postamputation or her quality-of-life needs.66 are being discharged to home directly from acute care. Home health services provide follow-up care, with or Plan of Care without physical therapy involvement, until wound heal- ing is complete and the patient is ready for prosthetic Physical therapy intervention for the older adult with fitting. For the person with lower limb amputation, this lower extremity amputation is very well described in may mean discharge from home health rehabilitation textbooks, videos, and related literature.12,21,22,60,68,86,106,107 services before prosthetic limb fitting. Under optimal Comprehensive physical therapy rehabilitation generally circumstances, the person has achieved independence in includes planning progressive interventions that address wheelchair management and mobility and independence the postsurgical or preprosthetic and the prosthetic phase in basic activities of daily living at a wheelchair level for recovery. The preprosthetic phase intervention should before this discharge.33 In addition, with home care or focus on promoting increased strength, preventing loss of inpatient services, the added time during wound healing range of motion while emphasizing hip and knee exten- phase allows time for the patient and the rehabilitation sion to avoid contracture. Cardiovascular training, with team to focus on the preprosthetic program, which can appropriate vital sign monitoring, is essential during all afford the best opportunity to formulate realistic treat- stages of recovery and can initially be easily performed ment goals.60 The overall costs of rehabilitation for the using arm ergometry. Although there are few studies in- older adult, however, may also be increased if the patient vestigating the effect of aerobic training on function in needs an extended period of home care or outpatient older adults with lower limb amputation,108 single-limb services to function successfully after amputation. As bicycling has been shown to improve endurance and an- stated earlier, older adults with amputation who receive aerobic threshold in individuals with lower limb amputa- inpatient rehabilitation immediately following acute tion.78 Trunk or core strengthening, as well as balance hospitalization have better outcomes than patients who activities performed in sitting and in single-limb stance go home or are discharged to a nursing care facility, even are critical in preparation for prosthetic gait, especially after controlling for all likely confounding factors influ- for the patient with transfemoral amputation. encing outcomes.20 The prosthetic phase of gait training for the older Delay in prosthetic fitting may make prosthetic train- adult is also well described.21,22,68,109 Initial sessions ing at a later date more difficult. Less frequent physical should focus on education regarding prosthetic manage- therapy sessions lead to more gait deviations and may ment, donning and doffing techniques, and skin inspec- ultimately require both an increased frequency of treat- tion. Gait training will begin most often in parallel bars ment and longer episodes of physical therapy care. Psy- and emphasize standing balance activities and progres- chological readiness and motivation can also be ad- sion of the prosthetic limb. Balance activities in standing versely affected by delay in fitting.70 Some patients should progress from static tasks to dynamic reaching. become so proficient in functioning with a wheelchair that they become less enthusiastic about the effort Patient education is an essential tool for prosthetic needed to learn to be proficient in ambulating with the training. One effective tool that a physical therapist may prosthesis and express a higher fear of falling with use of use is an educational questionnaire that addresses all a prosthesis.6,31,40,46 Regardless of the setting for early aspects of residual limb care and prosthetic management intervention, once the wound is healed, successful pros- (Box 23-2). The educational program is tailored to the thetic use will be enhanced by coordinated rehabilitation cognitive, visual, and auditory level of the patient. The team efforts. questions can be asked frequently, to ensure safety with limb care once the patient is independent of therapy. Finally, there is no doubt that in the initial phases of Home programs on videotape or with pictures can be prosthetic use, more frequent prosthetic revisions and helpful for those who have difficulty with written items. patient and family training are necessary to ensure safe use and prevent complications of skin breakdown. Sys- If possible, the physical therapist will also want to tematic methods of examining the person with amputa- promote cardiovascular endurance through gait training tion and his or her prosthesis not only determine with the use of a rolling walker or any other mobility whether the goals of comfort, function, and cosmesis dsietyvicgeresaotetrhathtatnhe5p0a%tieVn· ot 2camnaaxc.1h0i8evTehaisntyexpeerocifseacintitveinty- have been met but also serve as a basis to correct prob- and level of intensity has been shown to optimize pros- lems.21,59,68 In the home arena, the members of the team thetic use and success in the older adult.108 Progressive may simply need to communicate more frequently by

CHAPTER 23  Prosthetic Management for the Older Adult with Lower Limb Amputation 441 B O X 2 3 - 2 Educational Questionnaire Predictor86 (AMP with or without prosthesis) were pre- for Independent Prosthetic Use viously described throughout this chapter. In addition, there are a few excellent review articles summarizing the Prosthetic Socket and Liner Management use of multiple outcome-based tools for patients with Where should your leg feel the pressure in the socket? amputation, which includes assessment of the psycho- What does the gel liner do? metric properties of the various instruments.77,110 What is the difference between the liner and the socks? How often should you clean the socket? How often and how do you Although there is an increasing number of perfor- mance-based rehabilitation measures being used to care for the gel liner/socks? assess functional outcomes in the older adult popula- tion,77,85,86,88,89,110 the ability to predict long-term out- Sock Management comes for older adults with amputation remains lim- Name the different types of socks (thickness: number of plies) and ited.8,77 To date, only one instrument, the Amputee Mobility Predictor, provides sufficient prediction to be how many you should wear? used to assess functional prosthetic potential under the What is the proper way to put on your socks? Medicare guidelines.86 Yet, prosthetic use following How should you wash and dry the socks? amputation is not the only sound measure of func- What do you do when your leg feels loose in the socket? tional ability following lower limb loss; therefore, What do you do when your leg feels tight in the socket? wheelchair mobility and function related to quality of Why is it important to always carry extra socks with you when life in older adults with lower limb amputation also warrant investigation. wearing your artificial leg? What has been gleaned, to date, from the results of Skin Care outcome-based studies is that older adults with amputa- What is the importance of checking your skin regularly? tion have marked physical limitations,7,81 psychosocial How long should areas of redness last on your skin? difficulties,71,103 and diminished quality of life when What do you do when you have an area of skin breakdown? compared to healthy adults of similar age.39 Using the Sickness Impact Profile, Peters et al9 further found gait training that addresses all aspects of household am- that older individuals with amputation and diabetes bulation and community ambulation on curbs, ramps, compared with age-matched individuals with diabetes and uneven surfaces is appropriate for older adults with alone had lower physical dimension scores but scored amputation. similarly in the psychosocial dimensions. From a posi- tive perspective, other studies reveal that at least 50% In certain cases, a patient may be referred to physical of older adult with amputation are able to return to therapy because the individual is having difficulty with community mobility, including driving.5 Fear of falling an existing prosthesis and might report a decline in func- is increased and balance confidence among older adults tional ability. The physical therapist should examine the with amputation is also reduced when compared to age- patient to first determine whether or not prosthetic fac- matched adults.85,87,88 Psychosocial adjustment and mo- tors are contributing to the patient’s concerns, and if so tivation, which is often measured by assessing extent of refer to the prosthetist. Once all prosthetic adjustments depression or examining satisfaction with life with and are made, functional prosthetic training will generally without the prosthesis, is also significantly affected by follow the same sequence of activities outlined earlier, amputation.70,71 Finally, reported outcomes from stud- progressing from easy to advanced prosthetic activity as ies using the Medical Outcomes Survey: SF-36 further tolerated. In addition, all education, exercise, and gait reveal that older adults with amputation, especially as activities must specifically address the impairments and the result of disease, have markedly reduced perceptions functional limitations noted during the physical therapy regarding quality of life.110,111 examination. Although amputation often occurs in the late stages OUTCOME MEASURES AND of serious illnesses that preclude return to work and ASSESSMENT former community activities, there are many older adults who do return to these activities following extensive re- Tools Used to Assess Overall Outcome habilitation.5,24 Clearly, the significant impact that lower of Prosthetic Rehabilitation limb amputation has on all aspects of health in the older adult makes any one measurement insufficient for deter- In the past and even today, measuring morbidity and mining outcomes. Perhaps the greater challenge in un- mortality rates is considered most influential in evaluat- derstanding health outcomes for the older adult with ing health outcomes for the older adult with amputation, amputation is in trying to determine which factors especially when the amputation is the result of dis- should be measured. In an extensive systematic review of ease.7,10,14,15,19,39,44,45 Many of the outcome measures literature of 25 different prosthetic outcome measures being used in rehabilitation today for individuals with from 1995 to 2005, Condie et al110 explored generic amputation such as The Timed “Up & Go” (TUG) test,89 Activities Specific Balance Scale (ABC),87,88 the L Test of Functional Mobility,85 and the Amputee Mobility