Rebecca H. Crouch, PT, DPT, MS, CCS, FAACVPR

Significant Musculoskeletal and
Neurological Impairments: Can These
Patients be Integrated into Pulmonary
Rehabilitation?
CARL FAIRBURN, PT, DPT
ASSISTANT PROFESSOR
UNIVERSITY OF THE PACIFIC
DEPARTMENT OF PHYSICAL THERAPY
STOCKTON, CALIFORNIA
KARLYN SCHILTGEN, PT, DPT, OCS
PULMONARY REHABILITATION
DUKE UNIVERSITY MEDICAL CENTER
DURHAM, NORTH CAROLINA
REBECCA H. CROUCH,PT,DPT,MS,CCS,FAACVPR
DIRECTOR OF PULMONARY REHABILITATION
DUKE UNIVERSITY MEDICAL CENTER
DURHAM, NORTH CAROLINA
Cardiopulmonary Rehabilitation
and Amputation:
Special Considerations
CARL FAIRBURN PT, DPT
ASSISTANT PROFESSOR
UNIVERSITY OF THE PACIFIC
DEPARTMENT OF PHYSICAL THERAPY
STOCKTON, CALIFORNIA
Overview
 Common mechanisms for amputation
 Lower extremity levels of amputation
 Review prosthetics and fitting
 Management and considerations
Mechanisms for Lower Extremity Amputation
 Diabetes Mellitus (DM)
 Peripheral Arterial Disease

Approximately 60% of non-traumatic LE amputations among
those >20 yrs of age occur in those with underlying DM1
 Trauma
 Infection
 Tumors
Diabetic Population in the U.S.
Centers for Disease Control and Prevention
Common Amputations in the Clinic
 Above Knee Amputation (AKA)
 Below Knee Amputation (BKA)
 Foot Amputation (various)
Prosthetics and Fitting
 Components
 Socket

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Suspension
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Protect residual limb, distribute forces
Cuffs, Sleeves, Pylon, Vacuum
Foot
Shock absorption
 Translation of energy

Management and Considerations
 Gait
 Prosthesis Fit
 Skin Integrity
 Metabolic Demand
 Phantom Limb Pain
 Phantom pain and sensation at 6 months post-operatively
reported at 67% and 90%2
 Assistive Devices
 ROM
Gait Dysfunction
 Common impairments
 Vaulting
 Lateral Whip
 Circumduction
 Excessive/Restricted Knee flexion/extension
 Excessive Plantar/Dorsiflexion
 May require subtle adjustments at foot or knee
Prosthetic Fit
 Too loose or too tight
 Shrinking or swelling of residual limb
 Add or remove thick/thin liner to accommodate changes in
limb size
 Areas of irritation
 Excessive foot inset/outset
Skin Integrity
 Inspection
 Incision
 Contralateral Lower Extremity
 Color
 Vascularity
 Erythema
 Skin Quality
 Increased Pressure
 Friction
Metabolic Demand
 02 consumption increases ~ 30% for a trans-tibial
amputee (TTA)3
 Nearly double the metabolic demand for the transfemoral amputee3


Target HR
Max HR
 Metabolic demand of service members with TTA
8.5 – 10.4%4
Assistive Devices
 Walker
 Standard Walker
 Front Wheel Walker (FWW)
 Four Wheel Walker (4WW)
 Lofstrand Crutches
 Standard Crutches
 Cane
Summary
 Heart disease is the leading cause of death in the
diabetic population
 Residual limb may shrink due to weight loss,
deconditioning, post-operative manifestations
 Change in residual limb size will alter gait
mechanics, prosthesis fit



This may further lead to increased friction, pain, and skin
breakdown
May warrant referral back to prosthetist
Gait impairments/weakness may warrant referral to PT
 Consider the increased metabolic demand
References
1.
2.
3.
4.
Centers for Disease Control and Prevention. National Diabetes Statistics Report: Estimates of
Diabetes and Its Burden in the United States, 2014. Atlanta, GA: U.S. Department of Health and
Human Services; 2014.
Casale R, Alaa L, Mallick M, Ring H. Phantom limb related phenomena and their rehabilitation after
lower limb amputation. Eur J Phys Rehabil Med. 2009;45(4):559-566.
Pomeranz B, Adler U, Shenoy N, Macaluso C, Parikh S. Prosthetics and orthotics for the older adult
with a physical disability. Clin Geriatr Med. 2006;22(2):377-394.
Schnall BL, Wolf EJ, Bell JC, Gambel J, Bensel CK. Metabolic analysis of male servicemembers with
transtibial amputations carrying military loads. Journal of Rehabilitation and Research
Development. 2012;49(4):535-543.
Cardiopulmonary
Rehabilitation and
Musculoskeletal Conditions
Karlyn Schiltgen PT, DPT, OCS
Duke University Physical Therapy
Pulmonary Rehabilitation
Orthopedic Issues
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Osteoarthritis
Total Hip/Total Knee Replacement
Total Shoulder Replacement
Low back pain
Osteoporosis
Osteoarthritis
 Worse in morning and with immobility
 Strength around arthritic joints can help with

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pain
May have an increase symptoms with
initiation of exercise program
Use assistive devices to off-load
Refer to PT if OA limits progress with rehab
for specific strength training
Refer to orthopedics for pain management,
surgical options if Red Flags present
Total Knee
Replacement
Total Knee Replacement
 Most joints are cemented to allow for

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
immediate weight bearing
Patients in PT for 1-3 months post-op
with ROM goals 0-90+ degrees
Excessive pain, swelling, or redness
refer back to surgeon
Very low complication rates post 3
months
Can take up to one year to feel
“normal” to patient
Total Hip Replacement
Total Hip Replacement
Total Hip Replacement
 Posterior Approach

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– No bending past 90 degrees, no crossing
at the ankles, no twisting in standing
Anterior Approach
– Limited hip motion out to side and back
Precautions present for first 6-8 weeks
depending upon surgeon
Patient should attend PT for 1-3 months
Low complication rate post 3 month time
frame
Total Shoulder vs Reverse
Total Shoulder Replacement
Total Shoulder Replacement
 Total Shoulder
– In sling for 2-6 weeks
– Limited mobility initially
 Reverse Total Shoulder
– In sling for 4-6 weeks
– No UBE for 3 months
– Likely to have limited ROM (135 deg)
 Refer to PT if symptoms limiting
progress. Patient should leave PT with
home exercise program.
Low Back Pain
 No longer “one program fits all”
 Strength of specific abdominals as well
as flexibility
 When to Refer:
– Acute onset
– Back pain that limits walking/progress
– Weakness, numbness/tingling, foot drop
Osteoporosis
 Exercise builds bone mass, slows
decline of bone loss, and maintains
muscle mass and strength
 No twisting (avoid rotational forces at
the spine)
– Limit use of arms on Nustep
 Encourage weight bearing activities and
resistance training
 Use assistive devices to prevent falls
Osteoporosis
 Ask about medical management
– Recent bone density scan
– Medications to treat
– Medications that cause bone loss
– Recent compression fractures
– Bracing
References
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Dionyssiotis Y, Skarantavos G, and Papagelopoulos P. Modern Rehabilatation
in Osteoporosis, Falls, and Fractures. Clinical Medicine Insights: Arthritis and
Musculoskeletal Disorders. 2014;7:33-40.
Varacallo M, Fox E. Osteoporosis and Its Complications. Med Clin N Am. 2014;
98:817-831.
Davis, AM, MacKay C. Osteoarthritis year in review: outcome of rehabilitation.
Osteoarthritis and Cartilage. 2013; 21: 1414-1424.
Darcy, AM, Murphy, GA, DeSanto-Madeya, S. Evaluation of Discharge
Telephone Calls Following Total Joint replacement Surgery. National
Association of Orthopedic Nurses. 2014; 33(4). 188-195.
Peter, WFH, Jansen, MJ, Hurkmans, EJ, et al. Physiotherapy in hip and knee
osteoarthritis: Development of a Practice Guideline Concerning Initial
Assessment, treatment and Evaluation. ACTA Rheumatology Port. 2011; 36:
268-281.
American Association of Orthopedic Surgery. Treatment of Knee
Osteoarthoritis. 2nd Edition.
American Association of Orthopedic Surgery. Website accessed 9/2/14 at
http://orthoinfo.aaos.org/main.cfm.
Incorporating Neurological Patients
into Pulmonary Rehabilitation
Rebecca H. Crouch,PT,DPT,MS,CCS,FAACVPR
Director of Pulmonary Rehabilitation
Duke University Medical Center
Durham, North Carolina
Neuromuscular Diseases
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Amyotrophic Lateral Sclerosis (ALS)
Muscular Dystrophy (MD)
Myasthenia Gravis
Multiple Sclerosis (MS)
Spinal Muscular Atrophy
Cerebral Vascular Accident (CVA/Stroke)
Parkinson’s
Peripheral Neuropathy
Chronic Pain
– Fibromyalgia
Neuromuscular (NMD) Disease with bulbar
involvement and glottal impairment (All of the Central
Nervous System diseases)
• Chest wall contractures
• Lung capacity restriction
• Non or partially functioning
glottis
• Poor cough strength
• Respiratory muscle
weakness
• Respiratory muscle fatigue
Respiratory Impairment
• Worsens in a linear progression with
advancing disability
• Major contributor to mortality: Aspiration
pneumonia, atelectasis, acute respiratory
insufficiency/respiratory failure
• May be present in those with minimal
signs/symptoms of dx and relatively normal
PFTs
Respiratory Impairment
• Effects both inspiratory and expiratory
muscles
• Expiratory
– Impaired cough
– Reduced secretion clearance
– Weak voice
• Inspiratory
– Dyspnea
– Exercise intolerance
– Low lung volumes
– Hypoventilation and hypercarbia/hypoxia
Other Respiratory Complications
• Sleep disturbance
– Obstructive sleep apnea (OSA)
– Alveolar hypoventilation
• Pulmonary hypertension
• Cor pulmonale
Treatments That May Help With CNS
Impairment
• Intermittent Positive Pressure Breathing (IPPB)
• One-way valve (Max Insufflatory Capacity)/Airstacking
• Non-invasive positive pressure ventilation
(Continuous Positive Airway Pressure—CPAP)
Cardiopulmonary Characteristics of
Stroke Patients
• Asymmetry of chest wall movement—especially
on side of paralysis
• Chest wall structural abnormalities
• Respiratory muscle weakness
• Decreased cardiovascular stamina and endurance
due to movement impairment and inefficiency
• Risk of aspiration due to impaired swallowing
mechanism
How Can PR Help Stroke Patients?
• Breathing Re-training
• Inspiratory/Expiratory muscle training—based
on PImax and PEmax
• Improve breathing mechanics (movement of
rib cage)
• Increase muscle strength
• Cardiopulmonary exercise: help respiratory
muscle strength, stamina, movement
efficiency
• Strengthens swallowing mechanism
Parkinson’s Disease
• Degenerative disorder of
the Central Nervous
System
• Symptoms: Tremor in
hands, arms, legs, jaw,
face; rigidity of
limbs/trunk; bradykinesia;
postural instability;
impaired balance and
coordination; difficulty
swallowing, chewing,
speaking
• Treatment: Medication
(levodopa) to replenish
dopamine; exercise;
ambulatory safety
Breathing and Parkinson's
• Obstructive Lung Disease
– Reduction of air flow, increased respiratory
resistance, FRC, RV
– Due to rigidity of upper airway structures?
– Due to rigidity and tremor of upper airway
musculature?
• Restrictive Lung Disease
– Chest wall stiffness
– Low lung volumes
Peripheral Neuropathy
• Common rehabilitation problem
• Due to:
– Diabetes: most common, increasing
with age and disease duration,
present in 50% > 60 yo
– Renal disease
– Neurotoxic chemotherapeutic
agents
– Acute/chronic inflammatory
demyelinating dx
– Hereditary (Charcot-Marie-Tooth)
– Idiopathic
• Rarely curable, but manageable
Peripheral Neuropathies
Treatment Goals
• Maximize function
• Prolong ability to
independently mobilize
• Prevent deformity
• Improve QOL
• Strengthen muscles
• Safe mobility
• Avoid over-fatigue of
affected muscles
Rehab Considerations
• Ankle Foot Orthosis (AFO—
foot brace)
• Ambulatory assistive device
(cane, rollator)
• Generalized exercise rather
than intensive exercise of
affected muscles
• Supportive shoes
• Group exercise
Chronic Pain---Fibromyalgia
• A chronic disorder that causes
widespread muscle
pain/sleep
disturbance/fatigue/inability
to think clearly-- ACR(2010)
• Unknown etiology
• Dx between 25-60 yo
• 80-90% women
• Associated with family
hx/Rheumatoid
Arthritis/Lupus/Ankylosing
spondylitis
Fibromyalgia and Breathing
• Associated with hyperventilation
and back pain---pain response?
• 50% reported dyspnea even
though volumes were normal--chest wall pain?
• Dyspnea due to brain stem
abnormalities—low blood flow?
• Thyroid hormone regulation--nerve signal impairment to
diaphragm
• National Fibromyalgia Association
• Journal of Musculoskeletal Pain
2001
• Journal of Internal Medicine 1989
and Arthritis and Rheumatism
2000
• www.fibromyalgia-Symptoms.org
Can Cardiopulmonary Rehabilitation
Help Patients With Musculoskeletal
and Neuromuscular Impairments?
• YES!
• With a few accommodations these patients
can successfully participate. They need the
exercise and education just as much as
others…..probably more!
References
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Ugalde V, Walsh S, Abresch R, et al. Respiratory abdominal muscle
recruitment and chest wall motion in myotonic muscular dystrophy. J Appl
Physiol . 91:395-407, 2001.
Seo K, Lee H, Kim H. The effects of combination of inspiratory diaphragm
exercise and expiratory pursed-lip breathing exercise on pulmonary functions
of stroke patients. J Phys Ther Sci. 25(3), 2013.
Bach J, Mahajan K, Lipa B, et al. Lung insufflation capacity in neuromuscular
disease. Am J Phys Med Rehabil. 87(9), 2008.
Vercueil L, Linard J, Wuyam B, et al. Breathing pattern in patients with
Parkinson’s disease. Respiration Physiology . 118; 163-172, 1999.
Canning C, Alison J, Allen N, et al. Parkinson’s Disease: An investigation of
exercise capacity, respiratory function, and gait. Arch Phys Med Rehabil.
78:199-207:1997.
Krsnich-Shriwise S. Fibromyalgia syndrome: An overview. Phys Ther. 77:6875;1997.
Handelsman H. Intermittent positive pressure breathing (IPPB) therapy.
Health Technol Assess Rep. 1;1-9:1991. www.ncbi.nlm.nih.gov/
Carter G. Rehabilitation management of peripheral neuropathy. Seminars In
Neurology. 25(2); 2006.
Smith M, Mulligan N. Peripheral neuropathies and exercise. Topics in Geriatric
Rehabilitation. 30(2); 131-147:2014.

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