- Published on Thursday, 05 December 2013 16:39
- Written by Ann Dennison
In a recent blog, we discussed how injuries in people with diabetes can lead to complications such as amputation, so we thought it would be a good idea to provide some information on amputations. According to the Amputee Coalition of America, there are more than 2 million people in the United States living with limb loss, and another 500 people lose a limb each day.
The most common cause of amputation is poor circulation or peripheral arterial disease (PAD), usually due to diabetes or atherosclerosis (plaque buildup in the arteries). PAD frequently occurs in individuals between 50 and 75 years old. More than half of all amputations occurring in the USA are in people diagnosed with diabetes. Various studies have shown that 28-51% of amputees with diabetes will undergo a second amputation within 5 years. In a 2011 study published in Diabetes Care, researchers found that males with diabetes, who were heavy smokers, with high blood pressure and diabetic eye disease, and had less blood glucose control, were more likely to have lower limb amputations. If you are diabetic, controlling your blood glucose and blood pressure and not smoking can reduce your risks of amputation.
Other causes of amputation are trauma and cancer. Trauma is the major cause of amputation in younger people. Large numbers of amputations have occurred as a result of the wars in Iraq and Afghanistan. Between 2000 and 2011, there were over 6000 traumatic amputations in US service members. Many of the combat related amputations involve more than one limb. Amputations due to cancer make up less than 2% of all amputations.
Amputations can occur in the arms or legs and are described by the level at which the limb is removed. For example, loss of a leg somewhere between the ankle and the knee would be described as a below knee or transtibial amputation. Amputations occurring through a joint are called disarticulations.
Rehabilitation for amputations begins very soon after surgery. Tight fitting garments or sometimes casts are used to assist with control of swelling and residual limb shaping. For lower limb amputations, upper body strengthening is important, especially if the individual will need to use a walker or crutches before being fitted for prosthesis (artificial limb). The amputee’s prosthetist, physical and occupational therapists, and physician should work closely together to achieve the best function possible for the individual. Often psychological counseling or support groups such as the Amputee Support Team of Central Pennsylvania (www.astamputees.com) can be very beneficial to those individuals about to undergo an amputation or who have just had an amputation. There are many other support groups throughout the United States which can be found at www.amputee-coalition.org.
There are a great variety of prosthetic arms and legs available and there is not one “best prosthesis” for a given type of amputation. Prosthetic prescription and fitting are very individualized and most likely will be changed during the course of an individual’s life due to technological advancements, changes in the individual’s size or functional ability. Prostheses have come a long way from the “wooden leg” of the Civil War era to the advanced myoelectric, “bionic” and osseointegrated (attached to the residual limb by the bone rather than suspended from it by one of several methods) prostheses of today. There are also specialized prostheses for different activities such as running.
Physical therapy for individuals with lower limb amputations consists of overall conditioning, strengthening and flexibility of both lower limbs, as well as gait (walking) and balance training. For upper limb amputations, strengthening and flexibility of both arms is important as well as mobility and strength of the muscles around the shoulder blades. Use of myoelectric prostheses requires special training in use of residual muscles to make the hand of the prosthesis function optimally.
If you have any questions about this topic or any other physical therapy topics, please feel free to leave any questions, comments or suggestions. Thank you for reading and stay active.
Sahakyan K et al. The 25-year cumulative incidence of lower extremity amputations in people with type 1 diabetes. Diabetes Care. 34:649-51, 2011.
Rieber GE et al. Lower Extremity Foot Ulcers and Amputations in Diabetes found at http://www.diabetes.niddk.nih.gov/dm/pubs/america/pdf/chapter18.pdf
Injury and Diabetes
- Published on Wednesday, 20 November 2013 12:05
- Written by Kateri Kane
Recently my grandmother suffered a fall in her home resulting in a gash on her leg and hospitalization. When I heard the news, several things ran through my head. I was concerned about what may have caused the fall, whether she broke a hip, if she hit her head, etc. All of the concerns that I expressed were important ones, but there was one that entered my mind first. My primary concern was infection. My grandmother has diabetes, and with that, injuries are more concerning.
My grandmother’s poor balance was no doubt a primary factor in her fall, but we have already covered the topic of balance in relation to falls in a previous blog so that will not be todays focus. Diabetes was also discussed in a prior blog around this time last year; however, our previous blog addressed some of the basics about diabetes and the effect that exercise can have on this condition. Todays entry is geared toward understanding the increased risk that individuals with diabetes face when they get injured. Diabetes has been known to increase ones risk of fall injury related hospitalization. This increased hospitalization statistic is partly due to increased balance deficits in relation to decreased sensation in the feet, but also due to the nature of wound healing in this population. Wound healing is significantly slowed in individuals with diabetes. There are several factors that play a roll in the nature of wound healing for someone with this condition. These factors include: blood glucose (sugar) levels, poor circulation, diabetic neuropathy, immune system deficiency, and infection.
Lets start with blood glucose levels and poor circulation. When blood sugar levels are elevated, the arteries stiffen resulting in atherosclerosis (hardening of the arteries). This process decreases circulation which in turn makes wound healing take even longer. The natural healing process requires oxygen and nutrients to be transported via red blood cells to the wound area, but when blood glucose level are high the function of the red blood cells is decreased. When the red blood cell circulation is impaired, white blood cells that fight infection also become less effective. This lack of circulation not only prolongs healing, but it can be a primary cause for a wound to develop.
Diabetic neuropathy is a condition that develops when the nerves become damaged due to uncontrolled blood sugar levels. This occurs most often in the feet. Once the nerves are damaged, they can no longer feel the sense of touch normally. This means that, if a person has a wound on his/her foot, they may not be able to feel that it is present or if a wound is getting worse. Visual examination is then the only means of monitoring the skin for injury or monitoring a wound for further progression.
The immune system does not function properly in the presence of diabetes due to the fact that high blood glucose levels make immune cells (certain enzymes and hormones) less effective in their functioning. As a result of a weakened immune system, infection becomes more likely. Infection slows healing time and, if left untreated, can result in gangrene, sepsis, or a bone infection. Each of these complications can lead to amputation which is why diabetes is the leading cause of limb amputation in the United States.
The best means of managing this condition and improving wound healing are as follows:
- Eat a healthy diet
- Be aware of your body including regular skin checks
- Keeping pressure off of a wound while it heals
- Exercise regularly to decreased chronic inflammation and improve circulation
- Stop smoking or performing any other action that impairs circulation.
If you have any questions on this topic or any others in which you are interested, feel free to leave any questions, comments, or suggestions. Thank you for reading and stay active.
Labral Tears and Hip Scopes
- Published on Wednesday, 06 November 2013 12:21
- Written by Kateri Kane
Football season is underway and everyone loves cheering for their favorite team. One thing that fans never want to see, however, is one of the star athletes getting injured. There are many different types of injuries that occur during football, but one in particular that can cause a prolonged loss of playing time is a hip labral tear.
The hip is a ball and socket joint made up of the head of the femur as the ball and the acetabulum of the pelvis as the socket. The labrum is a fibrocartilaginous structure that outlines the socket in order to provide stability and create a deeper socket for the ball of the femur. The labrum of the hip serves as shock absorption, joint lubrication, pressure distribution, and aids in stabilization. Damage to the labrum often occurs due to trauma, femoroacetabular impingement (FAI), capsular laxity or hip hypermobility, dysplasia, or degeneration. FAI is a disorder where bone spurs grow around either the socket or the head of the femur causing damage to the labrum. Dysplasia refers to a disorder where the socket is abnormally shallow thus increasing the likelihood of a tear along the labrum. No matter the cause, a labral tear can be a very painful injury.
Common symptoms associated with a labral tear include hip pain (typically along the front or groin region but less commonly in the buttock region), clicking, locking or catching, “giving way”, and slight hip range of motion limitations (primarily in rotation). Due to common misdiagnosis, symptoms can last years prior to being recognized as a labral tear. Common imaging techniques do not detect hip labral tears well which is why arthroscopy (commonly known as a “scope”) is the gold standard for diagnosing a tear. This procedure is ever more frequently being used for treating a tear of the labrum as well.
Hip arthroscopy or a hip scope can be used for several different conditions including FAI, dysplasia, cartilage injuries, loose bodies in/around the joint, tendonitis or tendon tears, synovitis, hip joint infection, and of course labral tears. An arthroscopy is minimally invasive which allows surgery to be performed by making only small incisions in the body. Through these incisions a miniature camera and specialized instruments are utilized to perform the surgery. Depending on the nature of the labral tear, a surgeon may opt to either remove damaged tissue or actually repair the labrum. Hip arthroscopies are different from those of the shoulder and knee due to the fact that the hip joint sits deeper beneath muscle and has a tight vacuum seal to hold the joint in place. This is why traction (pulling along the leg) is utilized for the hip joint during surgery to create enough room for the surgical instruments to move within the tight joint space. An athlete typically can return to play 4-6 months after surgery with the help of physical therapy. Physical therapy can be utilized prior to surgery as a non-invasive form of treatment, as well, in order to address deficits and correct mechanics that may be increasing stress along the labrum. However, if pain persists for greater than 12 weeks despite therapy or the hip is locking, a hip scope may likely be recommended.
Sports injuries can be devastating for both players and fans, but recovery is possible with the right tools. I hope this information helped shed some light on one particular area of sport injury. If you have any questions on this topic or any others in which you are interested, feel free to leave any questions, comments, or suggestions. Thank you for reading and stay active.