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| Year : 2001 | Volume
: 49
| Issue : 1 | Page : 84-6 |
Multiple vasculogenic disabilities : a challenge in rehabilitation.
Handa G, Singh U
Department of Physical Medicine and Rehabilitation, All India Institute of Medical Sciences, New Delhi-29, India.
Correspondence Address:
Department of Physical Medicine and Rehabilitation, All India Institute of Medical Sciences, New Delhi-29, India.
A 37 year old male presented with left hemiplegia, left below knee amputation, right partial foot amputation and claudication pain. The limitations in the rehabilitation management in such a high-risk patient are multiplied. The appreciable benefits from supervised rehabilitation and judicious goal setting can help in improving the functional status and retard the disease progression in such patients. This study highlights that coexisting cerebrovascular, coronary and peripheral vascular diseases can pose a real challenge and can result in multiple disabilities.
How to cite this article:
Handa G, Singh U. Multiple vasculogenic disabilities : a challenge in rehabilitation. Neurol India 2001;49:84 |
Vascular disorders can manifest in cerebral, coronary or peripheral circulation. Their association with each other is well documented in the literature.[1],[2],[3] Atherosclerosis and its common aetiologies are known causes of the coexisting vascular diseases. Each of the above can result in significant morbidity, mortality and disability. This case report highlights the fact that the multiple disabilities resulting from the common vascular aetiology can have a compounding effect on the already compromised circulation and a very realistic goal setting is required for the rehabilitation. The dual disability of hemiplegia and amputation itself is known to have a poor ambulation potential.[4]
A 37 year old male farmer came with left hemiplegia due to right middle cerebral artery (MCA) territory infarct for the last two years, left transtibial amputation for the last one year and first, second and third ray amputation of the right foot of eight months duration. Coronary artery disease was diagnosed 10 years back although he was asymptomatic at present and was in NYHA class II as per the cardiac status. He was chronic alcoholic and smoker. At presentation, he was wheelchair dependent for mobility and partially dependent for self-care. Spasticity (grade 3) was present in the left upper and lower limbs with poor left-hand function and poor trunk balance. Knee flexion contracture of 30o was present on the hemiplegic side. Lipid profile and sugar were within normal range. ECG findings were suggestive of old inferior wall infarct. Duplex scan of the limb vessels revealed reduced flow in the right femoral artery and very feeble flow in right poplitial artery, suggestive of severe arterial disease. Fundus findings also showed extensive arteriosclerosis. X-ray of the knee joint showed marked osteoporosis in the bones. It was observed that the patient had reduced endurance and motivation levels.
The patient had undergone various surgeries in the past two years. Embolectomy of left femoral artery and debridement of the gangrenous left toe, left below knee amputation, right great toe amputation followed by second and third ray amputation, had been performed. All these surgeries were performed in 3-4 months intervals, in the past two years. Dietary modification for weight reduction with adequate calories and low fat was advised. General conditioning and endurance building exercise and progressive mobilisation along with exercises to reduce spasticity and improve movement control, helped in achieving a satisfactory baseline level for further rehabilitation interventions. Gradual stretching of the knee flexion contracture using a corrective splint helped in reducing the contracture by 15o. The residual contracture was accommodated in the patellar tendon bearing (PTB) prosthesis. Knee contracture got further reduced after the patient started bearing weight on the affected side [Figure - 1]. He was given gait training with crutches. It was observed that after gradual mobilisation, the spasticity got reduced to grade 2; hence no medications were needed to control the same. He continued with his medications, which included antiplatelet drugs, calcium channel blocking drugs and vitamin B complex. The claudication pain in the other extremity, reduced cardiac function, inadequate movement control of the prosthesis due to spasticity on same side and improper base of support on the other side due to partial foot amputation, limited any further inputs for rehabilitation. He was given gait training with left PTB prosthesis, right shoe with filler and elbow crutches. This resulted in improvement in patient's motivation and social interaction. He was discharged after the optimal level of rehabilitation was achieved. The patient could not resume farming and was doing only supervisory activities in the field. At the time of last followup, he preferred wheelchair for community ambulation and used prosthesis for occasional and indoor use only. There was no further progression of the disease process clinically even after 2 years of follow-up and his sense of well being and social interactions had improved markedly. Prevention of progression of the disease and disability forms the mainstay of the management.
Although the morbidity and mortality risk in the patients with vascular disorders is well known, little is published on the aspect of rehabilitation of the patients with disabilities resulting from multiple vascular disorders. Connel and Gnatz[4] reviewed the rehabilitation outcomes of 46 patients with the dual disability of hemiplegia and amputation resulting from vascular disorders. The mean age of the patients was 63 years (range 49-84 years). Forty one (89%) could participate in a trial of physical therapy, while 25 (54%) were in a comprehensive rehabilitation programme. Seventeen (37%) were fitted with a prosthesis, and 12 (26%) became independent ambulators. Eighteen (39%) patients achieved independence in their activities of daily living (ADL). In a retrospective study on 52 patients, Altener et al[5] reported that factors such as ipsilateral below knee amputation preceding hemiplegia, a good-to-fair neuromuscular status, and an intact mental status have been associated with better functional results. Although producing higher fitting rates, none of these factors had been found in their study to be associated with statistically higher levels of ambulatory function.
A good-to-fair neuromuscular status seemed to be the prime requisite for good ambulatin with a prosthesis in a patient with the double disability of amputation and hemiplegia. [Table I] summarises the different factors affecting the rehabilitation and the solutions to overcome them. The compromised coronary cirulation and cardiac output, compromised peripheral circulation in the remaining lower extremity, amputation with contracture at the proximal joint, amputation of the other foot with limb pain, spasticity, poor trunk control and hand function, obesity, lack of motivation and reduced endurance levels for exercise were the negative prognostic factors affecting rehabilitation in this case.[4],[7] Considering the risk factors, aggressive surgical interventions were deferred and emphasis was put on conservative modes of rehabilitation.[8]
Preventive aspects of vascular medicine are the need of the hour especially in the high risk pateints where multiple vascular disorders are likely to manifest.[9] Effective preventive medical management of the patients with even one type of vascular disorders should be made a part of routine management. The rehabilitation helps in reducing the progression of the disease and limiting the secondary disabilities. The multifocal nature of the disease process and the vulnerability of the already compromised circulation can lead to multiple disabilities and can limit the rehabilitation inputs. Improvement in the functional level and prevention of disease progression helps in improving the quality of life of an otherwise dismal picture of a vascular disease patient.
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| 4. | OConnell PG, Gnatz S : Hemiplegia and amputation : rehabilitation in the dual disability. Arch Phys Med Rehabil 1989; 70 : 451-454. |
| 5. | Altner PC, Rockley P, Kirby K : Hemiplegia and lower extremity amputation : double disability. Arch Phys Med Rehabil 1987; 68 : 378-379. |
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| 8. | Kaul TK, Fields BL, Wyatt DA et al : Surgical management in patients with coexistent coronary and cerebrovascular disease. Long-term results. Chest 1994; 106 : 1349-1357. |
| 9. | Criqui MH, Langer RD, Fronek A et al : Coronary disease and stroke in patients with large-vessel peripheral arterial disease. Drugs 1991; 42 : 16-21. |
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