Rehabilitation of the older lower limb amputee: a brief review.

OBJECTIVE: To review outcomes, over the last 25 to 30 years, of prosthetic rehabilitation in the older patient with a major lower limb amputation. DESIGN: Literature review of articles and reports about lower limb amputation, using key words elderly amputee rehabilitation, and lower limb amputation, through a computerized Medline Search. CONCLUSIONS: Age alone should not determine prosthetic rehabilitation. Comorbidities and general health are important determinants. The more proximal the amputation, the more energy is demanded from the cardiovascular and pulmonary systems for prosthetic gait. Changes in surgical technique and revascularization procedures have allowed preservation of the knee, which decreases energy demands and allows more older patients a chance to undergo rehabilitation for ambulation. Although the ratio of below knee (transtibial) amputations to above knee (transfemoral) amputations has increased, overall postsurgical mortality (10-30%), long term survival (40-50%@2 years, 30-40%@5 years), and risk of loss of the contralateral leg (15-20%@2 years) has not changed significantly since the 1960s. Despite the lack of improvement in survival as a result of the systemic vascular disease, the older patient can benefit from rehabilitation efforts with goals of prosthetic ambulation or simply cosmesis. The shortened longevity emphasizes the need for timely rehabilitation to enhance the quality of the remaining years. The geriatrician can add to the presurgical care and preprosthetic phase of rehabilitation by attention to the problems common to the older patient, i.e., multiple comorbidities, polypharmacy, immobility, and depression. Postoperatively, early mobilization is crucial to avoid the deleterious effects of immobility in the older person. Further investigations into the psychosocial issues and cost benefits of limb loss and prosthetic rehabilitation are needed. In addition, comparison of the various rehabilitation protocols and the impact of cardiac resting before rehabilitation are needed.

Effect of a single dose of diazepam on balance measures in older people.

OBJECTIVE: This study examines the effect of a single dose of diazepam on a spectrum of balance measures in healthy older subjects. The measures include static (postural sway), dynamic (anterior tibialis muscle activation latency), and a complex self-initiated task of balance (functional reach) in addition to neuropsychological tests of attention. DESIGN: A double-blind, two-period, cross-over trial. SETTING: The community surrounding a university hospital. PARTICIPANTS: Community-dwelling, nonsmoking volunteers 65 years of age and older. MEASUREMENTS: Measures included response to unexpected perturbation (platform/EMG muscle latency), self-initiated perturbation (functional reach), and a static measure of balance (postural sway). Neurocognitive tests (digital symbol substitution test, card sorting) were included to document the cognitive effect. RESULTS: Twelve nonsmoking healthy subjects (average age = 70.4 years (66-76 years)) participated. The anterior tibalis muscle latency increased in response to a sudden perturbation with diazepam compared with placebo (TA latency 149 ms vs 142 ms, P < .001). Neurocognitive tests were adversely affected for 90 minutes after diazepam administration compared with placebo (P < .05). Other measures did not demonstrate significant effect of diazepam. CONCLUSIONS: This is among the first reports showing that benzodiazepines affect neuromuscular processing related to balance control. Increased muscle latency to sudden perturbations may represent an effect of diazepam upon the oligosynaptic spinal reflex distinct from the sedation. Surface electromyography may be a valuable noninvasive tool for future studies of drug effect on balance and falls risk among older people.

Exercise to improve spinal flexibility and function for people with Parkinson's disease: a randomized, controlled trial.

OBJECTIVES: The effectiveness of an exercise intervention for people in early and midstage Parkinson's disease (stages 2 and 3 of Hoehn and Yahr) in improving spinal flexibility and physical performance in a sample of community-dwelling older people is described. DESIGN AND SETTING: Fifty-one men and women, aged 55-84 years, identified through advertisement, local support groups, and local neurologists were enrolled into a randomized, controlled trial. Subjects were assigned randomly to an intervention or a usual care arm (i.e., no specific exercise). Of the original 51 participants, 46 completed the randomized, controlled trial. Participants in the exercise arm (n = 23) received individual instruction three times per week for 10 weeks. Participants in the usual care arm (n = 23) were "wait listed" for intervention. MEASUREMENTS: Changes over 10 weeks in spinal flexibility (i.e., functional axial rotation) and physical performance (i.e., functional reach, timed supine to stand) were the primary outcome measures. RESULTS: MANOVA conducted for the three primary outcome variables demonstrated significant differences (P < or = .05) between the two groups. Further analysis using ANOVA demonstrated significant differences between groups in functional axial rotation and functional reach for the intervention compared with the control group. There was no significant difference in supine to sit time. CONCLUSION: Study results demonstrate that improvements in axial mobility and physical performance can be achieved with a 10-week exercise program for people in the early and midstages of PD.

Quality of life and Parkinson's disease.

BACKGROUND: People with Parkinson's disease (PD) have a progressive loss of function eventually leading to severe disability. Although PD would be expected to have a profound impact on an individual's psychosocial health, there is relatively limited research on its psychosocial effect. The purposes of this study were (a) to examine the relationships between physical disability, depression, and control beliefs and quality of life in people with PD and (b) to characterize how these psychosocial variables differ by stage of disease. METHODS: Eighty-six individuals from five stages based on clinical disability, ages 51-87, were interviewed. Established instruments were used to measure physical disability, depression, and control beliefs. Quality of life (QOL) was rated on a 5-point Likert scale. RESULTS: A multivariable regression model including physical disability, stage of disease, depression, mastery, and health locus of control predicted QOL (R2 = 0.48), with mastery as the only significant predictor (p = .0001). There were significant differences by PD stage for all variables (p < .05). CONCLUSIONS: Mastery predicted quality of life in individuals with PD even when depression and physical disability were included in the model. Differences in psychosocial variables by stage of PD suggest that the psychosocial profile of PD patients may change as the disease progresses.

Longitudinal evaluation of economic and physical impact of Parkinson's disease.

The cost of parkinsonism and Parkinson's disease (PD) is largely unknown although clinical experience suggests that the impact of this disease is substantial. Longitudinal data is presented for health status, disease symptoms, functional status, and financial costs for 70 participants with PD or parkinsonism. The sample was dichotomized into those rating their health as excellent, good, or very good ('good health') and those rating their health as fair or poor ('poor health'). The 'poor health' group were significantly more disabled at baseline. Symptoms increased between year 1 and 3 with greatest increases in fatigue, pain, and depression for the 'good health' group. At year 1, total direct cost/capita was about dollars 5000/year for both groups; indirect costs were dollars 5000 for the 'good health' group and dollars 15,000/year for the 'poor health' group. By year 3, total expenditures increased over 25% for the 'good health' group and nearly doubled for the 'poor health' group, while percent costs that were compensated declined for groups. Out of pocket, expenses were as high as dollars 3000/year for the 'poor health' group by year 3. Through analysis of the broad impact of PD, including non-neurological symptoms and economic ramifications, it is possible to better appreciate the impact of this chronic condition on overall quality of life.

Pharmacological and nonpharmacological interventions in the treatment of Parkinson's disease.

Parkinson's disease is a neurodegenerative disorder of older persons that eventually leads to disability. It is characterized by tremor, rigidity, bradykinesia, and postural instability. Progressive stages can be identified, each with unique problems. The optimal management of Parkinson's disease requires multiple professionals to address the needs of the patients as well as those of the caregivers. In addition to pharmacologic management, patients with Parkinson's disease can benefit from physical intervention and psychological support. This article summarizes strategies incorporating the multiple disciplines for each stage of the disease. [Cutson TM, Laub KC, Schenkman M. Pharmacological and nonpharmacological interventions in the treatment of Parkinson's disease.

Reliability of impairment and physical performance measures for persons with Parkinson's disease.

BACKGROUND AND PURPOSE: Parkinson's disease (PD) is characterized by rigidity, postural instability, bradykinesia, and tremor, as well as other musculoskeletal impairments and functional limitations. The purpose of this investigation was to determine the reliability and stability of measures of impairments and physical performance for people in the early and middle stages of PD, Subjects. Thirteen men and 2 women in Hoehn and Yahr stages 2 and 3 of PD participated. Their mean age was 74.5 years (SD = 5.7, range = 64-84). METHODS: Thirteen impairment-level variables and 8 physical performance variables were measured. Measurements were taken on two consecutive days and again a week later on the corresponding two consecutive days. Reliability and stability were assessed using analysis of variance and intraclass correlation coefficients (ICCs). RESULTS: Test-retest reliability (ICCs) of variables ranged from .69 (hamstring muscle length) to .97 (lumbar flexion). Intraclass correlation coefficients were .85 or greater for 10 of the variables. CONCLUSIONS AND DISCUSSION: The results suggest that in the early and middle stages of PD, many of the measures of impairment and physical performance are relatively stable.

Management of cancer pain.

Primary care clinicians treat patients with cancer and cancer pain. It is essential that physicians know how to effectively manage pain including assessment and pharmacologic and nonpharmacologic treatment modalities. Barriers to adequate assessment of pain must be recognized and overcome. Pharmacologic regimens are based on the World Health Organization's "ladder of analgesia," beginning with nonopioid medications and adding the opioid narcotics and adjuvant medications as necessary. Inclusion of nonpharmacologic treatments, physical and psychological are important for effective management.

Falls in the elderly.

Falls in the elderly are a common problem with potentially serious consequences. Elderly persons who fall may incur physical injuries that result in hospitalization or even institutionalization. Fear of falling may cause the elderly to restrict their activities and become socially isolated. A fall is usually the result of a combination of factors involving the patient and the environment. A patient's risk of falls may be assessed on the basis of a complete history, including a drug review and an evaluation of the patient's environment, as well as a thorough physical examination with emphasis on neurologic components and functional performance. Correction or adjustment of even a few of these risk factors may allow the elderly patient to avoid falls.

Managing menopause.

Many women will spend one third of their lifetime after menopause. A growing number of options are available for the treatment of menopausal symptoms like vasomotor instability and vaginal atrophy, as well as the long-term health risks such as cardiovascular disease and osteoporosis that are associated with menopause. Currently, hormone replacement therapy (estrogen with or without progestin) is the primary treatment for the symptoms and long-term risks associated with menopause. However, recent evidence calls into question the protective effect of estrogen on cardiovascular disease risk. The association of risk for breast cancer with estrogen replacement therapy also has not been fully clarified. In addition, many women cannot or choose not to take hormones. For treatment of osteoporosis and heart disease, pharmacologic choices include antiresorptive agents such as bisphosphonates and calcitonin, and estrogens or selective estrogen receptor modulators such as raloxifene. In addition, complementary options that include vitamins, herbal treatments, exercise and other lifestyle adaptations are gaining increased interest. The growing number of choices and questions in this area emphasizes the need to individualize a treatment plan for each woman to meet her specific needs.