Article

Hyperbaric oxygenation accelerates prosthetic rehabilitation of lower limb amputees

Specialized Hospital for Rehabilitation and Orthopedic Prosthetics, Belgrade, Serbia.
Undersea & hyperbaric medicine: journal of the Undersea and Hyperbaric Medical Society, Inc (Impact Factor: 0.77). 05/2013; 40(3):289-97.
Source: PubMed

ABSTRACT

The purpose of the study was to assess the effects of hyperbaric oxygen (HBO2) therapy on prosthetic rehabilitation of patients with unilateral lower limb amputation. Narang's scale,the Locomotor Capabilities Index and the two-minute walk test were used to assess functional abilities of amputees on the admission and on discharge from hospital. We also kept records of some clinical parameters whose improvement enables better mobility of patients: thigh and lower leg girth, strength of amputation stump, existence of amputation stump contracture, existence of some other complications on amputation stump, blood oxygenation and pulse palpation. Our results show that hyperbaric oxygenation accelerates prosthetic rehabilitation of lower limb amputees. HBO2-treated patients were discharged from the hospital faster than the controls (hospitalized for 133.2 +/- 54.87 days vs. 158.36 +/- 53.05 days), they had improved arterial Hb saturation (97.40 +/- 3.51% vs. 94.74 +/- 3.28 %) and pulse palpability (pulse palpable in 27 vs. 18 subjects), less complications of the amputation stump (complications present in 24 vs. 30 subjects), greater healthy leg thigh girth (50.75 +/- 3.96 cm vs. 48.90 +/- 2.59 cm), stronger amputation stump (mark 3.90 +/- 0.54 vs. 3.33 +/- 0.47) and better functional abilities as measured by adapted Narang's scale (category 3.43 +/- 1.30 vs. 4.10 +/- 1.12) and locomotor capabilities index (score 38.06 +/- 10.90 vs. 33.16 +/- 8.80). These findings highlight the increasing validity of this procedure after limb amputation, which should be confirmed by further research in multicenter studies involving a larger number of respondents.

Full-text

Available from: Dusica Djordjevic, Feb 11, 2014
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UHM 2013, VOL. 40, NO. 3 – HYPERBARIC OXYGENATION HELPS AMPUTEES’ REHABILITATION
Hyperbaric oxygenation accelerates prosthetic rehabilitation
of lower limb amputees
Simanic Igor
1
, Teolovski Mirko
1
, Paspalj Dalibor
2
, Radotic Milutin
1
, Djordjevic Dusica
3
,
Zivkovic Vladimir
3
, Jakovljevic Vladimir
3
1
Specialized Hospital for Rehabilitation and Orthopedic Prosthetics, Belgrade, Serbia
2
Institute for Gerontology, Belgrade, Serbia
3
Department of Physiology, Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
CORRESPONDING AUTHOR: Vladimir Jakovljevic M.D., Ph.D.drvladakgbg@yahoo.com
Copyright © 2013 Undersea & Hyperbaric Medical Society, Inc.
______________________________________________________________________________________________
ABSTRACT
The purpose of the study was to assess the effects
of hyperbaric oxygen (HBO
2
) therapy on prosthetic
rehabilitation of patients with unilateral lower limb
amputation. Narangs scale, the Locomotor Capabilities
Index and the two-minute walk test were used to assess
functional abilities of amputees on the admission and on
discharge from hospital. We also kept records of some
clinical parameters whose improvement enables better
mobility of patients: thigh and lower leg girth, strength
of amputation stump, existence of amputation stump
contracture, existence of some other complications on
amputation stump, blood oxygenation and pulse pal-
pation. Our results show that hyperbaric oxygenation
accelerates prosthetic rehabilitation of lower limb am-
putees. HBO
2
-treated patients were discharged from
the hospital faster than the controls (hospitalized for
133.2
± 54.87 days vs. 158.36 ± 53.05 days), they had
improved arterial Hb saturation (97.40
± 3.51% vs.
94.74
± 3.28 %) and pulse palpability (pulse palpable
in 27 vs. 18 subjects), less complications of the am-
putation stump (complications present in 24 vs. 30
subjects), greater healthy leg thigh girth (50.75
± 3.96
cm vs. 48.90
± 2.59 cm), stronger amputation stump
(mark 3.90
± 0.54 vs. 3.33 ± 0.47) and better function-
al abilities as measured by adapted Narang’s scale
(category 3.43
± 1.30 vs. 4.10 ± 1.12) and locomotor
capabilities index (score 38.06
± 10.90 vs. 33.16 ±
8.80). These ndings highlight the increasing validity
of this procedure after limb amputation, which should
be conrmed by further research in multicenter studies
involving a larger number of respondents.
_____________________________________________________________________________________________
INTRODUCTION
Hyperbaric oxygen (HBO
2
) therapy is increasingly used
in a number of areas of medical practice. As dened by
the Undersea and Hyperbaric Medical Society, HBO
2
represents a treatment in which a patient intermittently
breathes 100% oxygen while the treatment chamber is
pressurized to a pressure greater than sea level [1]. So,
the effects of HBO
2
are based on the physiological
and biochemical effects of hyperoxia. The increment of
partial oxygen pressure in blood helps enable the body
to overcome hypoxia, energy metabolism collapse and
consequent cell death [2].
There is extensive literature suggesting the use of
HBO
2
in a range of clinical conditions [3]. A grow-
ing number of studies prove the efcacy of HBO
2
in
the treatment of chronic non-healing wounds and other
forms of severe soft tissue damage of lower limbs [4-6].
HBO
2
represents one of the most effective procedures
in treatment of “diabetic foot” i.e., ulcerations,
edema and ischemic changes that lead to necrosis
and gangrene of the foot [7-14]. It has proven to be
an effective adjunct to multidisciplinary therapies to
improve limb salvage and help reduce the patient’s
hospital stay and wound care expenses [15]. In a
prospective long-term follow-up of 38 patients with
diabetic foot ulcers, Kalani and co-workers [12] noted
that HBO
2
accelerated the rate of healing and reduced
the need for amputation.
Literature suggests that HBO
2
represents one of the
most effective procedures in the treatment of infected
wounds and prevention of amputation, but the data about
its possible positive effects on a patient’s rehabilitation
when, despite all applied therapeutic procedures,
amputation takes place, are almost non-existent. Thus,
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UHM 2013, VOL. 40, NO. 3 – HYPERBARIC OXYGENATION HELPS AMPUTEES’ REHABILITATION
I. Simanic, M. Teolovski, D. Paspalj, et al.
the aim of our work was to assess the effects of HBO
2
on a number of parameters important for the prosthetic
rehabilitation of patients with unilateral lower limb
amputation.
MATERIALS AND METHODS
The study was performed in Specialized Hospital for
Rehabilitation and Orthopedic Prosthetics (Belgrade,
Serbia), from March 2011 to December 2011. The
study population consisted of 60 patients with unilat-
eral amputation of lower limb due to diabetic gangrene,
vascular diseases or trauma. General characteristics
of the population are presented in Table 1. The study
was approved by Ethical Committee of the Hospital,
and all patients gave written informed consent.
Subjects were randomly assigned to either the ex-
perimental or the control group. The experimental
group was, besides standard prosthetic rehabilitation,
subjected to 15 one-hour HBO
2
treatments in a
multiplace chamber, where they breathed 100% oxygen
at a pressure of 1.7 atmospheres absolute (atm abs).
Standard prosthetic rehabilitation contains the
following procedures:
1) internal and orthopedic examination and prognosis
for prosthetic rehabilitation;
2) kinesitherapy treatment including: daily respiratory
exercise, immobilization and bandage for amputated
extremity (twice a day, two hours’ treatment),
postural exercise (10 minutes daily), exercise
training for upper limb musculature (15 times daily),
training for better exibility in different joints
(15 times daily), exercise training for the rest of
lower limb musculature (above the amputation
region) (15 times daily), multidisciplinary team
prescription of adequate prosthesis – (responsible
physician, physiotherapist, orthopedic technician
_____________________________________________________________________
TABLE 1. General characteristics of population
Characteristic Experimental Control Test
group group
_____________________________________________________________________
Age (X
± SD; years) 61.20±11.93 62.60±11.52 p>0.05
_____________________________________________________________________
Gender (n; male/female) 25/5 21/9 p>0.05
_____________________________________________________________________
Cause of amputation
(n; diabetic gangrene/
vascular etiology/ trauma) 19/6/5 19/9/2 /*
_____________________________________________________________________
Level of amputation
(n; transfemoral/transtibial) 17/13 16/14 p>0.05
_____________________________________________________________________
* χ
2
test could not be performed due to low number of frequencies in one subgroup (n<5)
and leader specialist in physical medicine and
rehabilitation, education for walking with rst
prosthesis (twice daily, 45 minutes in duration),
biomechanical evaluation;
3) permanent physical treatment: laser therapy
(15 treatments), magnetotherapy (20 treatments),
electrotherapy (15 treatments), thermotherapy
(periodically), electrostimulation (periodically).
HBO
2
therapy was performed for 15 days: once per
day for 60 minutes at the atmospheric pressure of 1.7
atm abs between 3 and 4 p.m. All treatments were
applied in a multipersonal chamber (“Haux”) by inhal-
ing oxygen through an oronasal mask. Oxygen saturation
in peripheral circulation was monitored continuously
and consistently maintained at around 100%. The rst
treatment was performed after the screening at Step 1
in standard prosthetic rehabilitation.
Examination of the HBO
2
inuence on prosthetic
rehabilitation of amputees included monitoring clinical
parameters, assessing postoperative complications, and
evaluation of functional capabilities of amputees. The
following measurements were performed:
1. pulse palpation on art. dorsalis pedis of healthy leg;
2. pulse oximetry (measuring the oxygen saturation
of arterial blood) on a ngertip using oximeter
Oxy 5 (FIMA, Italy);
3. frequency of complications on amputation stump
(hematoma, dehiscence, infection, edema, phantom
sensations and phantom pain, etc.);
4. frequency of amputation stump contractures;
5. measurement of thigh and lower leg girth of healthy
leg (measurement was performed in the middle
of the body segment, using the measurement tape);
6. estimation of amputation stump’s muscle strength
(manual muscle test);
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UHM 2013, VOL. 40, NO. 3 – HYPERBARIC OXYGENATION HELPS AMPUTEES’ REHABILITATION
I. Simanic, M. Teolovski, D. Paspalj, et al.
7. evaluation of functional capabilities of patients using
the Narang’s scale [16,17], Locomotor Capabilities
Index test (LCI) [18] and the two-minute walk
test (2MWT) [19,20];
8. Time of prosthetic rehabilitation (from admission
to discharge).
Statistical analysis was performed using SPSS 19.
The data in tables and gures are presented as mean ±
standard deviation or as frequencies. The differences
between two independent samples were assessed using
the Mann-Whitney test, while the differences between
two dependent samples were assessed using the Wil-
coxon Signed Rank test. When data were expressed as
frequencies, an χ
2
test of independence was used. When
frequencies in 2 x 2 contingency tables were lower than
5, Fisher’s test was used. When frequencies in contin-
gency table belonged to the same subjects before and
after experimental period, McNemars test was used.
RESULTS
The results regarding clinical parameters are presented
in Table 2, while the results regarding functional
abilities are presented in Figures 1-3.
Percentage of arterial hemoglobin (Hb) saturation
was not signicantly different between experimental
and control groups on admission to hospital (p=0.152).
Both groups experienced the rise of this parameter
through time (p=0.000 for both groups), but this rise
was higher in the group of patients who received
____________________________________________________________________________________________
TABLE 2. Clinical parameters on admission and on discharge from the hospital.
Characteristic On admission Test On discharge Test
____________________________________________________________________________________________
Pulse oximetry EG 88.23±10.43 p>0.05 97.40±3.51 p<0.05
(X±SD; %) CG 92.60±4.66 94.74±3.28
____________________________________________________________________________________________
Pulse palpation of ADP EG 19/11 p>0.05 27/3 p<0.05
(n; palpable/nonpalpable) CG 18/12 18/12
____________________________________________________________________________________________
Complications of AS EG 27/3 p>0.05 24/6 p<0.05
(n; yes/no) CG 30/0 30/0
____________________________________________________________________________________________
Contractures of AS EG 11/19 p<0.05 4/26 p>0.05
(n; yes/no) CG 28/2 6/24
____________________________________________________________________________________________
Thigh girth of HL EG 50.08±4.12 p>0.05 50.75±3.96 p<0.05
(X±SD; cm) CG 48.63±2.75 48.90±2.59
____________________________________________________________________________________________
Lower leg girth of HL EG 35.91±2.52 p>0.05 36.25±2.64 p>0.05
(X±SD; cm) CG 36.80±2.15 37.03±2.31
____________________________________________________________________________________________
Muscle strength of AS EG 3.06±0.44 p>0.05 3.90±0.54 p<0.05
(X±SD; grade) CG 2.86±0.34 3.33±0.47
_____________________________________________________________________________________________
EG – experimental group; CG – control group; ADP – art. dorsalis pedis; HL – healthy leg; AS – amputation stump
HBO
2
therapy, so they had a signicantly higher per-
centage of arterial Hb saturation on discharge (p=0.009).
On admission, pulse on ADP was palpable in a
similar number of patients in both groups (p=0.791).
The frequency of ADP pulse palpability in the control
group stayed the same until discharge, but in the group
of patients treated with HBO
2
therapy ADP pulse
became palpable in eight more patients. The differ-
ence in frequency of ADP pulse palpability became
signicantly different between the experimental and
the control groups on discharge (p=0.015).
Frequency of complications on the amputation
stump was similar in both groups on admis-
sion (p=0.237), but on discharge the HBO
2
-treated
group had a signicantly lower number of patients who
suffered complications (p=0.024).
Regarding the amputation stump contractures, the
initial difference in frequencies of this phenomenon
between groups (p=0.000) disappeared after the pe-
riod of prosthetic rehabilitation (p=0.731), since in
both groups, and especially in the control group, the
frequency of contractures decreased.
The experimental and the control groups had
similar thigh girth of the healthy leg on admission
(p=0.115). Thigh girth increased in both groups during
the period of rehabilitation, but the rise was more
noticeable in the experimental (p=0.000) than in the
control group (p=0.019), so the difference between
groups became signicant on discharge (p=0.017).
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UHM 2013, VOL. 40, NO. 3 – HYPERBARIC OXYGENATION HELPS AMPUTEES’ REHABILITATION
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Regarding girth of the lower leg, although it in-
creased in both groups during the rehabilitation period
(p=0.019 for EG, p=0.020 for CG), this parameter
was not signicantly different between groups either
on admission (p=0.279) or on discharge (p=0.374).
Groups had similar muscle strength of the amputation
stump on admission (p=0.061), but although it signi-
cantly increased in both groups during the rehabilitation
period (p=0.000 for both groups), this rise was more
noticeable in the experimental group, who on discharge
had a signicantly stronger amputation stump (p=0.000).
In the beginning, groups were similarly categorized
according to an adapted Narang’s scale (p=0.394).
After the experimental period, both groups improved
(were classied as lower category), but the improve-
ment was bigger in the group of patients who received
HBO
2
treatment (p=0.000 for both groups). Thus, the
experimental group was classied as a lower category
of the adapted Narang’s scale on discharge (p=0.038).
Regarding LCI score, the results followed the
same trend as for the Narang’s scale. There was no
signicant difference between groups on admission
(p=0.376): Both groups experienced improvement during
the experimental period (p=0.000 for both groups),
and on discharge the HBO
2
group achieved better
results than the control group (p=0.048).
Although both groups increased their walking
speed and stride length over time (p=0.000 for both
groups), there was no statistically signicant difference
in results achieved on the two-minute walking test
between the experimental and the control groups either
on admission (p=0.297) or on discharge (p=0.081).
Regarding the total time of prosthetic rehabilitation,
the HBO
2
-treated group of patients needed less time
to complete the hospital’s rehabilitation tasks and get
discharged (p=0.047).
DISCUSSION
Hyperbaric oxygen treatment has been recommended
and used for a wide range of medical conditions,
with a varying evidence base [3]. HBO
2
has been
described as “a therapy in search of diseases” [3],
since its use in many clinical conditions has not yet
been elucidated. Its use in treatment of conditions that
may induce amputation is widespread, but its benets
on the rehabilitation of patients after amputation have
been rarely investigated. Thus, the aim of our research
was to assess the effects of HBO
2
therapy on the
prosthetic rehabilitation of unilateral leg amputees.
Rehabilitation of an individual with lower limb am-
putation is a very complex and long-term process that
requires a multidisciplinary approach and involvement
of many specialists from different areas in order to
achieve the maximal physical, psychosocial and pro-
fessional capability of an amputee, i.e., enable his/her
reintegration into society and improve quality of life.
The key to independence for members of this group is
their walking ability and their ability to move in and
around their homes [21]. Mobility is a basic physical
need and its best possible restoration represents an
important goal of rehabilitation programs following
amputation of lower limbs, and particularly of
prosthetic trials [22,23].
In order to assess the effects of HBO
2
on amputees’
prosthetic rehabilitation we evaluated their functional
abilities using widely accepted tests and scales, such as
the Narang’s scale, the Locomotor Capabilities Index
and the two-minute walk test [16-20]. We also kept
records of some clinical parameters whose improve-
ment enables better mobility of patients: thigh and
lower leg girth, strength of amputation stump, the
existence of amputation stump contracture, the
existence of some other complications on amputation
stump, blood oxygenation and pulse palpation. The
results of our study show an evident positive inuence
of HBO
2
therapy on rehabilitation of amputees.
Peripheral vascular disease accounts for more than
90% of all amputations, and more than half occur in
people diagnosed with diabetes [24]. Since most ampu-
tations take place due to vascular etiology, we explored
patients’ oxygen saturation of blood and peripheral
vascularization through ADP pulse palpation. On
admission to hospital, ADP pulse was palpable in 19
out of 30 patients from the experimental i.e., HBO
2
group, and in 18 out of 30 controls. Since there was
no change in frequency of ADP pulse palpability in
the control group after the experimental period, while
ADP pulse became palpable in eight patients treated
with HBO
2
therapy, we can assume that HBO
2
signi-
cantly affected peripheral vascularization of our
patients. Regarding hemoglobin saturation of arterial
blood, both groups had a very low percentage of
saturation on admission (the experimental group:
88.23 ± 10.43%, control group 92.60 ± 4.66%). Blood
oxygenation signicantly increased with time in both
groups, but this increase was more noticeable in the
patients treated with HBO
2
, who on discharge had not
only signicantly higher blood oxygenation compared
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UHM 2013, VOL. 40, NO. 3 – HYPERBARIC OXYGENATION HELPS AMPUTEES’ REHABILITATION
I. Simanic, M. Teo lovski, D. Paspalj, et al.
FIGURE 1. Category according to adapted Narang’s scale on
admission and on discharge from hospital in patients who
received HBO
2
treatment and the control group (experimental
group: a – p<0.01: signifi cantly lower than on admission;
control group: b – p<0.01: signifi cantly lower than on
admission, c – p>0.05: signifi cantly higher than average
category of the experimental group on discharge).
FIGURE 2. Score on Locomotor Capabilities Index test on
admission and on discharge from hospital in patients who
received HBO
2
treatment and the control group (experimental
group: a – p<0.01: signifi cantly higher than on admission;
control group: b – p<0.01: signifi cantly higher than on
admission; c – p>0.05: signifi cantly lower than average
score of the experimental group on discharge).
FIGURE 3. The distance that patients from the experimental
and control groups covered by walking for two minutes on
admission and on discharge from hospital (experimental group:
a – p<0.01: signifi cantly higher than on admission; control
group: b – p<0.01: signifi cantly higher than on admission).
n on admission
on discharge
n on admission
on discharge
n on admission
on discharge
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I. Simanic, M. Teolovski, D. Paspalj, et al.
with the control group (97.40
± 3.51% vs. 94.74 ± 3.28%),
but also entered the levels of blood oxygenation of
a healthy person (95 - 99%). These effects of HBO
2
therapy were expected, and although they represent a
temporary change, they certainly positively affected
early rehabilitation of our patients and helped with
improvement of other parameters important for the
prosthetic rehabilitation.
Complications on the amputation stump, such as
hematoma, dehiscence, infection, edema, joint contrac-
tures, etc., are very frequent phenomena in the early
rehabilitation period of amputees [25]. Almost all of
our patients (57 out of 60) experienced on average two
to three complications when admitted to hospital. On
discharge, three patients treated with HBO
2
were free
of any amputation stump complication, which may be
partially attributed to the effects of HBO
2
therapy on
the above-mentioned peripheral vascularization and
blood oxygenation.
Joint contractures usually occur between the time of
amputation and prosthetic tting. The lower limb ampu-
tee is at increased risk for developing joint contractures
secondary to immobilization, poor positioning, pain
and changes in agonist-antagonist muscle balance [25].
Additionally, the risk of contracture is increased in the
presence of other complications, such as edema, ischemia,
bleeding, accid paralysis, spasticity, etc. [26]. Con-
tracture can prohibit prosthetic tting, affect step
length, and place abnormal forces on joints and in-
crease energy expenditure during ambulation [27].
On admission, 40 out of 60 patients experienced
joint contracture, and they were particularly frequent
in the control group (28 out of 30 controls had con-
tracture of the amputation stump). This problem was
successfully solved by a proper exercise program
i.e., an active and passive range-of-motion program
with terminal stretch so on discharge, only four
HBO
2
-treated patients and six controls still had AS
contracture.
As previously mentioned, the goal of rehabilitation
programs following the amputation of lower limbs is
improvement of the mobility of amputees. A multitude
of measurement scales and questionnaires are available,
each differing in methods and measuring range [22].
Measuring mobility by a scale has been shown to have
limitations; all measure only a number of aspects of
mobility. Thus we included three mobility tests in our
research: the adapted Narang’s scale [16,17], the Loco-
motor Capabilities Index [18] and the two-minute walk
test [19, 20].
The Narang’s scale [16], adapted by Pohjolainen [17],
ranks patients into 7 categories based on their ability
to ambulate. “Ambulating with prosthesis but without
other walking aids” represents the rst class, while
“non-ambulatory except in a wheelchair” patients are
classied as the seventh class. On admission, our
patients belonged mostly to the seventh or sixth class
(“non-ambulatory except in a wheelchair” or “walking
with aids, but without prosthesis,” respectively).
After the experimental period, patients from both
groups signicantly improved their ability to move
and use a prosthesis. However, on discharge, patients
treated with HBO
2
were classied as lower grade (more
mobile) than the controls. Median and average class
in HBO
2
-treated patients was third (“independent in-
doors, ambulating with a prosthesis and one crutch,
but requiring two crutches outdoors and occasionally
a wheelchair”), while the median class in controls
was fth (“walking indoors only short distances,
ambulating mostly with a wheelchair”). On average,
however, they reached the fourth class of
Pohjolainen’s categorization (“walking indoors with a
prosthesis and two crutches or a walker, but requiring
a wheelchair for outdoor activities”).
The Locomotor Capabilities Index represents one
of the most comprehensive and most valuable tests for
evaluation of functional abilities of amputees. Follow-up
studies of lower limb amputees, interviewed six months
to ve years after rehabilitation, provided evidence of
test-retest reliability [28,29], internal consistency [30]
and construct validity [28,29,31] of the LCI. These
ndings suggest that the LCI is able to evaluate and
detect changes in the global locomotor ability of lower
leg amputees with the prosthesis both during prosthetic
training and in follow-up studies [18].
Mobility improvement enables functional inde-
pendence of lower limb amputees in all activities of
personal care and daily living, and enhances their
quality of life [23,32]. In our research, both the experi-
mental and control groups achieved not signicantly
different LCI scores on admission to hospital. Just like
the Narang’s test, the LCI test also showed that both
groups signicantly improved their functional abilities
during the experimental period, and proved that HBO
2
-
treated patients experienced more noticeable mobility
improvement. Thus, on discharge, HBO
2
-treated patients
scored higher on the LCI test compared with controls.
Walk tests are quantitative measures of speed and
distance that provide information about functional
exercise capacity. An informal unpublished Canadian
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survey of amputee programs in 1998 reported the two-
minute walk test as the second most commonly used
outcome measure [20]. The primary outcome of interest
is distance walked, but velocity can also be calculated.
The 2MWT also showed that our patients from both
groups experienced improvement of mobility during
the experimental period, but, unlike the results of the
adapted Narang’s scale and the LCI test, there was
no statistically signicant difference between the
experimental and the control groups on discharge
(89.36
± 34.34m vs. 72.53 ± 21.80m). This was due to
great variations of results achieved on this test (note
the SD in the previous seentence).
Brooks et al. has shown that this test is responsive
to change with rehabilitation and that it correlates
with measures of physical function and prosthetic use
in this population [19], but big variations in results
achieved on this test even in the same population two
days in a row (on the rst day subjects performed 2MWT
twice and achieved similar results of 50 meters, while
on the day after they passed about 120 meters, again
in both attempts) [20] question the role of learning,
motivation and training in improvements observed.
Better results on tests of functional abilities achieved
by patients treated with HBO
2
compared with patients
from the control group may be due in part to a higher
muscle mass of healthy leg and stronger amputation
stump muscles. Namely, groups had similar healthy leg
thigh and lower leg girth and strength of amputation
stump on admission, but during the experimental period
the HBO
2
group experienced higher gains in healthy
leg thigh girth and amputation stump muscle strength,
which enabled their improved mobility, not only in
rectilinear movement, but also in a number of transfers
and other movements that amputees have to perform
during everyday activities (get up from the oor, pick up
an object from the oor, walk outside on uneven ground,
step up/down a sidewalk curb, go up/down the stairs
with a hand-rail, walk while carrying an object etc.).
The nal parameter that persuades us about the
positive effects of HBO
2
therapy on the prosthetic
rehabilitation of lower limb amputees is the time of
prosthetic rehabilitation i.e., the time from admission
to hospital until discharge from hospital. Subjects
treated with HBO
2
needed signicantly less time from
admission to nishing prosthesis and getting discharged
compared to patients who were not on HBO
2
therapy.
As already emphasized, there are a very low num-
ber of studies in whose light we could discuss our re-
sults. One of the available studies is a case report of a
67-year-old aboriginal woman with severe chronic
obstructive pulmonary disease (COPD) and hyper-
capnic respiratory failure who underwent right trans-
tibial amputation for severe foot gangrene [24]. Patients
with severe COPD are rarely offered limb prostheses,
as many of these patients are limited by their ventila-
tory status and unlikely to achieve the high energy ex-
penditure required for successful prosthetic ambulation
[24]. This study showed that a rehabilitation program
enriched with oxygen supplementation improved her
strength, endurance and stump contracture, and she
was able to walk for short distances with a prosthesis.
The limitations of that study are surely low number
of subjects and no control group, but it is obvious
that its results are in consistent with ours.
Research on animal models also support the use
of HBO
2
in the treatment of amputated limbs [33].
Namely, it was shown that HBO
2
treatment (100% O
2
,
2.9 atm abs, 24°C, for 240 minutes) may encourage
preservation of metabolic processes and delay the
progression of metabolic acidosis in this amputated
limb model. This is further supporting evidence for
the tissue-preserving effect of oxygen when delivered
in hyperbaric conditions.
On the other hand, a retrospective study by Zgonis
et al. [15] showed that there was no signicant differ-
ence in the number of HBO
2
treatments received by
patients with a successful vs. a failed partial foot
amputation, although a trend was present. Patients with
a successful post-surgical outcome tended to have a
greater number of HBO
2
treatments than patients who
had a failed surgical outcome. The lack of a signi-
cant relationship between HBO
2
treatment and healing
outcome was in agreement with Ciaravino et al. [34],
who noted that an average of 30 HBO
2
sessions had
no effect on improving the outcome of their patients
with non-healing amputations and other lower
extremity wounds. But it should be noted that in that
study, only 13 out of 54 patients were amputees: Others
were subjected to HBO
2
therapy in order to heal dia-
betic ulcerations, ulcerations due to arterial insuf-
ciency or gangrene lesions. However, at present,
because of the limited data available from studies
using a blinded, randomized design, a denitive state-
ment regarding the effect of HBO
2
on healing in
patients post-amputation cannot be made [34,35].
In summary, the results of our study point out to the
usefulness of HBO
2
therapy in prosthetic rehabilitation
of lower limb amputees. HBO
2
is a relatively safe, non-
invasive means of improving healing by enhancing
Page 7
296
UHM 2013, VOL. 40, NO. 3 – HYPERBARIC OXYGENATION HELPS AMPUTEES’ REHABILITATION
I. Simanic, M. Teolovski, D. Paspalj, et al.
oxygenation, decreasing edema, and modifying healing
and immune responses. Although it is expensive, not
universally available, and not without risks, limb
preservation and speedier healing make this a cost-
effective method of wound care, but further research
is needed to establish its efcacy and safety in other
conditions, such as after amputation.
Acknowledgement
This work was partially nanced by junior project 09/11,
Faculty of Medical Sciences, Kragujevac, Serbia.
No conicts exist with this submission. n
_____________________________________________________________________________________________________
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Page 9
  • Source
    [Show abstract] [Hide abstract] ABSTRACT: Hyperbaric oxygen therapy (HBO) could be described as a short-term, high-dose oxygen inhalation and diffusion therapy, delivered systemically through airways and blood, achieved by having the patient breathing concentrated oxygen at a pressure higher than 1 absolute atmosphere. In clinical practice, monoplace or multiplace hyperbaric chambers are used to achieve this. Treatment is usually given as daily 90- to 120-min-long HBO sessions at pressures between 2.0 and 2.5 absolute atmosphere, aiming for 30–40 treatment sessions. The use of HBO as treatment of diabetic foot ulcers has been founded on weak scientific ground, although the outcomes from previous studies are in concert with the conclusions from preclinical studies and supports the theoretical framework of HBO reversing hypoxia-induced pathology. Two well-designed randomized double-blind trials have put HBO on firmer ground and may justify adjunctive HBO treatment to a selected group of patients with nonhealing diabetic foot ulcers. Some health economic studies suggest potential cost effectiveness, but these studies are limited by deficient primary clinical data and should be interpreted with caution. Several issues remain to be addressed, such as developing robust criteria to improve treatment protocols, determining which patients are likely to benefit, and when to start and stop treatment. Copyright
    Full-text · Article · Feb 2012 · Diabetes/Metabolism Research and Reviews
  • Source
    [Show abstract] [Hide abstract] ABSTRACT: The cause of diabetic foot ulcers is multifactorial, e.g., neuropathy and angiopathy, leading to functional disturbances in the macrocirculation and skin microcirculation. Adequate tissue oxygen tension is an essential factor in infection control and wound healing. Hyperbaric oxygen (HBO) therapy, daily sessions of oxygen breathing at 2.5-bar increased pressure in a hyperbaric chamber, has beneficial actions on wound healing including antimicrobial action, prevention of edema and stimulation of fibroblasts. The aim of the present study was to investigate the long-term effect of HBO in treatment of diabetic foot ulcers. Thirty-eight diabetic patients (30 males) with chronic foot ulcers were investigated in a prospective study. The mean age was 60+/-13 years and the mean diabetes duration 27+/-14 years. All patients were evaluated with measurements of transcutaneous oxygen tension (tcPO(2)), peripheral blood pressure, and HbA(1c). All patients had a basal tcPO(2) value lower than 40 mmHg, which increased to >/=100 mmHg, or at least three times the basic value, during inhalation of pure oxygen. Seventeen patients underwent 40-60 sessions of HBO therapy, while 21 patients were treated conventionally. The follow-up time was 3 years. 76% of the patients treated with HBO (Group A) had healed with intact skin at a follow-up time of 3 years. The corresponding value for patients treated conventionally (Group B) was 48%. Seven patients (33%) in Group B compared to two patients (12%) in Group A went to amputation. Peripheral blood pressure, HbA(1c), diabetes duration, and basal values of tcPO(2) were similar in both groups. Adjunctive HBO therapy can be valuable for treating selected cases of hypoxic diabetic foot ulcers. It seems to accelerate the rate of healing, reduce the need for amputation, and increase the number of wounds that are completely healed on long-term follow-up. Additional studies are needed to further define the role of HBO, as part of a multidisciplinary program, to preserve a functional extremity, and reduce the short- and long-term costs of amputation and disability.
    Full-text · Article · Mar 2002 · Journal of Diabetes and its Complications
  • [Show abstract] [Hide abstract] ABSTRACT: Common causes for non-healing of diabetic foot ulcers are infection and/or ischaemia. Diabetic patients are compromised hosts as far as wound healing is concerned. Diabetes mellitus is associated with a defective cellular and humoral immunity. In particular, decreased chemotaxis, decreased phagocytosis, impaired bacterial killing and abnormal lymphocytic function have been observed, resulting in a reduced inflammatory reaction and defective wound healing. The potential benefits of hyperbaric oxygen therapy (HBO) in diabetic patients with a foot ulcer are discussed. Oxygen plays an important role in the physiology of wound healing. HBO can raise tissue oxygen tensions to levels where wound healing can be expected. Hyperbaric oxygen increases also the killing ability of leucocytes, is lethal for certain anaerobic bacteria and inhibits toxin formation in other anaerobes. Multiple anecdotal reports and retrospective studies in HBO therapy in diabetic patients suggest that HBO can be an effective adjunct in the management of diabetic wounds. Prospective studies also show the beneficial effects of HBO. Because most published studies suffer from methodological problems, there is an urgent need for a collaborative, international, randomised prospective clinical trial for the application of HBO in diabetic foot lesions, as part of a multidisciplinary treatment approach, before we can recommend HBO as standard therapy in patients with foot ulcers.
    No preview · Article · Sep 2000 · Diabetes/Metabolism Research and Reviews
  • [Show abstract] [Hide abstract] ABSTRACT: Diabetic foot ulcers are still extremely difficult to heal. Therefore, therapeutic options to improve healing rates are continuously being explored. Hyperbaric oxygen (HBO) has been used in addition to standard treatment of the diabetic foot for more than 20 years. Evidence suggests that HBO reduces amputation rates and increases the likelihood of healing in infected diabetic foot ulcers, in association with improved tissue oxygenation, resulting in better quality of life. Nonetheless, HBO represents an expensive modality, which is only available in few centers. Moreover, adverse events necessitate a closer investigation of its safety. Finally, it is not entirely clear which patients stand to benefit from HBO and how these should be selected. In conclusion, HBO appears promising, but more experience is needed before its broad implementation in the routine care of the diabetic foot.
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  • [Show abstract] [Hide abstract] ABSTRACT: To assess the reliability, validity, and responsiveness of both the standard and revised Locomotor Capabilities Index (LCI) in people with lower-limb amputation who undergo prosthetic training. Reliability and validity study. Two freestanding rehabilitation centers. Fifty inpatients with a recent unilateral lower-limb amputation. Not applicable. Main outcome measures The standard LCI and a new version with a 5-level ordinal scale (LCI-5) were tested for internal consistency, test-retest reliability, ceiling effect, and effect size. The construct validity of both versions was analyzed by correlation with the Rivermead Mobility Index, a timed walking test, and the FIM instrument. The Cronbach alpha of both LCI versions was.95. The item-to-total correlations (Spearman rho) ranged from.50 to.87 (P<.0001 for all). The percent agreement and kappa values for the item scores ranged, respectively, from 78.4% to 100% and.58 to 1.00 in the LCI, and from 75.7% to 97.3% and.54 to.96 in the LCI-5. The intraclass correlation coefficient (model 2,1) for the total scores was.98 for both versions; the Bland-Altman plot revealed no systematic trend for either version. Both the LCI and LCI-5 correlated with all criterion measures (rho range,.61-.76), with the LCI-5 showing a larger effect size during the rehabilitation period and a lower ceiling effect. Patients with transtibial amputation were more independent in performing activities than were those with transfemoral amputation; their locomotor capability negatively correlated with age. Both the LCI and LCI-5 captured the global locomotor ability of people with lower-limb amputation during prosthetic training. The new LCI-5 presents similar and sometimes better psychometric properties than the standard LCI.
    No preview · Article · Jun 2004 · Archives of Physical Medicine and Rehabilitation
  • Source
    [Show abstract] [Hide abstract] ABSTRACT: Chronic wounds, defined as those wounds which fail to proceed through an orderly process to produce anatomic and functional integrity, are a significant socioeconomic problem. A wound may fail to heal for a variety of reasons including the use of corticosteroids, formation of squamous cell carcinoma, persistent infection, unrelieved pressure, and underlying hypoxia within the wound bed. Hypoxia appears to inhibit the wound healing process by blocking fibroblast proliferation, collagen production, and capillary angiogenesis and to increase the risk of infection. Hyperbaric oxygen therapy (HBOT) has been shown to aid the healing of ulcerated wounds and demonstrated to reduce the risk of amputation in diabetic patients. However, the causal reasons for the response of the underlying biological processes of wound repair to HBOT, such as the up-regulation of angiogenesis and collagen synthesis are unclear and, consequently, current protocols remain empirical. Here we review chronic wound healing and the use of hyperbaric oxygen as an adjunctive treatment for nonhealing wounds. Databases including PubMed, ScienceDirect, Blackwell Synergy, and The Cochrane Library were searched for relevant phrases including HBOT, HBO/HBOT, wound healing, and chronic/nonhealing wounds/ulcers.
    Full-text · Article · May 2008 · Wound Repair and Regeneration
  • Source
    [Show abstract] [Hide abstract] ABSTRACT: A systematic literature review to compare mobility scales used for lower limb amputees. A literature search was carried out by computerized search of biomedical literature including Medline and Embase. The studies included were published between 1978 and 1998 and including the following keywords: amputation, artificial limbs, prosthesis, lower limb, activities of daily living, mobility. Thirty-five studies were identified; 19 had a measurement of separate levels of mobility comparable to each other. Sixteen studies used ordinal and ratio scales without separate levels of mobility. The widest range of measurement found was the scale from 'walking with prosthesis without a walking aid' to 'totally confined to bed'. The Stanmore Harold Wood mobility scale was published most frequently. None of the 35 studies presented give a continuous measurement of mobility. A multitude of measurement scales and questionnaires are available for differ in methods and measuring range. Measuring mobility by a scale has been shown to have limitations. Several authors did extensive research but they all measure only a number of aspects of mobility. Consensus about the measurement of mobility of lower limb amputees is not available in the recent literature.
    Full-text · Article · Mar 2001 · Clinical Rehabilitation
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