Major limb amputation and the relevance of osteopathic manipulative medicine in management

Zachary Comeaux, DO, West Virginia School of Osteopathic Medicine, 400 N. Lee St., Lewisberg, WV 24901.

E-mail address: zcomeaux@osteo.wvsom.edu.

KEYWORDS:

Amputation; Osteopathic manipulation; Phantom limb

Major limb amputation, traumatically or nontraumatically induced, is a major life-changing event, often precipitating chronic pain, dysfunction, and altered self-image. This article explores the relevance of osteopathic manipulative treatment in management of the patient with major limb amputation, using the lower limb as an example and focusing primarily on issues related to gait and psychological independence.

© 2012 Elsevier Inc. All rights reserved.

Corresponding author: Zachary Comeaux, DO, West Virginia School of Osteopathic Medicine, 400 N. Lee St., Lewisberg, WV 24901.

E-mail address: zcomeaux@osteo.wvsom.edu.

icant contributing factor in ongoing patient management in this context.

‌Gait-critical structure and function changes with amputation

1877-573X/$ -see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.osfp.2011.08.001

symmetry maintained in dynamic balance. The authors of this article suggest that unimpaired upper and lower extrem- ities, as well as a flexible spine and distensible connective tissue matrix, contribute to efficient gait by channeling much of the kinetic energy of each cycle as potential energy for the next stride. The radial arrangement of muscle fibers around the hub of the L3 area mirrors this aspect of func- tion. This efficiency is based on an intact body and the reciprocal contribution of paired limbs. Major limb ampu- tation, upper or lower, significantly compromises symmetric balance and therefore effective, rhythmic, and energy-effi- cient gait.

The removal of the distal attachment of the thigh mus- culature caused by above-knee amputations (AKAs) alters limb movement (most notably on the side of the prosthetic limb) during the swing phase of gait. As such, it represents a “somatic dysfunction.” Chronic somatic dysfunction quite frequently leads to compensation elsewhere. Secondary muscles, including the iliacus, psoas, and quadrates lumbo- rum, assume more of an active role in limb displacement, replacing natural recoil and coordinated swing. The hyper- tonia associated with relative overuse of these muscles may create compensatory spinal dysfunctions at their proximal lumbar attachments. These in turn can lead to further com- pensation or decompensation at the lumbosacral junction, or at the contralateral sacroiliac joint, among other tissues, because of asymmetric loading and wear.

‌Role of the upper extremity

The upper extremity’s participation in gait as arm swing, along with torsion of the thorax, is another major element of energy conservation between gait cycles. The literature cited above on efficiency of crutch use supports this. Upper limb amputation, in a fashion similar to lower limb ampu- tation, can alter gait rhythm in this way, also contributing to asymmetric gait. However, the fact that the upper extremity is not involved in weight-bearing diminishes its role in force transfer. As a result, upper limb loss leads to less intense secondary complications.

However, upper limb function becomes more critical in the lower limb amputee who elects to use crutches rather than rely on a leg prosthesis. This situation results in weight-bearing being transferred to the shoulder joints as well as a different force distribution (traction versus com- pression) to the lumbar spine and pelvis during the swing phase. Accelerated osteoarthritic changes may occur, espe- cially in the glenohumeral joints.

‌Role of OMT

‌A case

Charles is a 48-year-old above-knee amputee, the surgery

12 years ago resulting from a gunshot wound acquired during a dispute among peers. He presented new to a family medicine practice for continuation of narcotic pain medica- tion. He complained of limited stump pain that tended to worsen with bad weather. However, his more salient com- plaints were low back pain and phantom limb pain, the latter occurring episodically, beginning as a severe stabbing sen- sation on this absent foot and progressing up to the stump. His low back pain was an ache from his mid to low back. The patient admitted to narcotic habituation and that a refill was the main reason for making the appointment.

Musculoskeletal examination revealed right upper thigh amputation, with the hip and sacroiliac joint remaining intact. Tissue texture change at the thoracolumbar junction with T12 flexed, rotated, and side-bent left corresponded to a positive right iliopsoas tender point anteriorly (origin and insertion). L5 was extended, side-bent, and rotated left. The sacrum demonstrated findings consistent with left-on-left

rotation with a compensatory posterior rotation of the in- nominate bone.

‌Continuing need

In addition to the secondary preventive benefits related to the physical need to amputate, amputation represents an unpredicted stressor. Altered functional capacity and social function add another level of adaptive stress. Either of these can readily lead to anxiety or depression. Permanency leads to fatalism. If the inciting cause were traumatic, as in com- bat, the patient may additionally have to deal with posttrau- matic stress disorder.

‌The elusive phantom limb differential mechanisms

Numerous pain syndromes have been described in the lit- erature in relation to amputated limbs, usually initiating the primary discrimination among phantom limb pain, phantom limb sensation, and stump pain. Diagnosis may also be confounded by the continuum in which these processes manifest. The hallmark difference between stump pain and phantom limb pain or sensation is the presence of peripheral nervous tissue transmitting the pain signals. Intrinsic stump pathology such as scarring and neuroma formation may complicate existing phantom limb pain. Phantom limb sen- sation describes a patient who has undergone amputation

Whether a peripheral or central mechanism is responsi- ble, phantom sensations may be attenuated by feelings of well-being after OMT. In addition, the structural basis of osteopathic diagnosis and treatment can lead to a shift of attitude and attention from fatalism to empowerment, espe- cially when combined with appropriate home exercise to enhance the intent of the manipulation. This has been the case in the ongoing management of the case cited above.

‌Conclusion

Despite the trend toward evidence-based preference in prac- tice, compassionate treatment of a number of conditions remains a medical responsibility. Rational use of osteo- pathic manipulation in a case-specific context appears to have a place. Treatment is based on common fundamental principles, but in the amputee, correcting for compensations and decompensations after structurally altered gait is a start- ing point. Attitude is an additional dimension of function targeted in OMT. The authors recognize the absence of supportive outcome studies but hopes this article will stim- ulate interest in this area.

‌References

1. ‌Ziegler-Graham K, MacKenzie E, Ephraim P, et al: Estimating the prevalence of limb loss in the United States: 2005 to 2050. Arch Phys Med Rehabil 89:422-429, 2008‌

2. ‌Reiber G, Boyko E, Smith D: Lower extremity foot ulcers and ampu- tations in diabetics. In: Harris M, Cowie C, Stern M, et al, editors. Diabetes in America, 2nd ed. Bethesda, MD: National Institutes of Health, 2002 (Pub No 95-1468)‌

3. Laughlin G, Helak J: Phantom limb pain. J Osteopath 65:23-24, 1958

4. ‌Waters R, Perry J, Antonelli D, et al: Energy cost of walking of amputees: the influence of level of amputation J Bone Joint Surg Am 58:42-46, 1976

5. ‌Thys H, Willems P, Saels P: Comments on energy cost, mechanical work and muscular efficiency in swing-through gait with elbow crutches. Biomechanics 29:1473-1482, 1996

6. ‌Vleeming A, Pool-Goudzwaard A, Stoeckart R, et al: The posterior layer of the thoracolumbar fascia: its function in load transfer from the spine to legs. Spine 20:753-758, 1995

7. Myers T: Anatomy Trains: Myofascial Meridians for Manual and Movement Therapists. Philadelphia: Churchill-Livingstone, 2009

   
   

8. ‌van der Wal J: The architecture of the connective tissue in the mus- culoskeletal system as to proprioception in the locomotor apparatus. Int J Ther Massage Bodywork 2:9-23, 2009‌

9. ‌Glover J: Glossary of osteopathic terminology. In: Chila A. Founda- tions of Osteopathic Medicine, 3rd ed. Philadelphia: Lippincott Wil- liams & Wilkins, 2011, p 1106

10. Beatty D, Steele KM, Comeaux Z, et al: Pocket Manual of OMT: Osteopathic Manipulative Treatment for Physicians. Philadelphia: Lippincott Williams & Wilkins, 2010, pp 71, 146, 159

11. ‌Nelson K: The manipulative prescription. In: Nelson K, Glonek T. Somatic Dysfunction in Osteopathic Family Medicine. Baltimore, MD: Lippincott Williams & Wilkins, 2007, p 34‌

12. ‌Comeaux Z: Robert Fulford DO and the Philosopher Physician. Se- attle, WA: Eastland Press, 2002

13. Pucher I, Kickinger W, Frischenschlager O: Coping with amputation and phantom limb pain. J Psychosom Res 46:379-383, 1999

14. Blakesle S, Ramachandran V: Phantoms in the Brain: Probing the Mysteries of the Human Mind. New York, Harper Collins, 1998