TRIA-MF protocol as an innovative tool in the comprehensive treatment and outcome evaluation of lower limb amputees before and after prosthesis use

Background: A structured multidisciplinary team is very important during every phase of the amputation process and a good communicative team guarantees a greater tranquility for the patient, thanks to more homogenous information, that is already discussed between the clinicians. Aim: The aim of this study was to defi ne the effi cacy and outcome value of an innovative procedure tool (TRIA-MF protocol) in the treatment of lower limb amputees before and after prosthesis use with the purpose to quantify the quality of the procedure and its economic impact on the clinical patients’ recovery. Setting: A rehabilitation institute for the treatment of neurological and orthopaedic gait disorders. Methods: 12 patients (4 women and 8 males) subjected to lower limb amputation and admitted according to the principles of inclusion criteria of the TRIA-MF protocol at the Rehabilitation Department of the Clinical Institute Città di Brescia were recruited in this study. All patients were included in an integrated and task-specifi c management protocol of the amputee, which allowed to follow the rehabilitation process from amputation to the fi nal restoration, for a period of 6 months for each patient. Patients were evaluated 5 times during the study, collecting their degree of pain (VAS), their independence profi le (Barthel Index) and the cirtometry of their amputation stump. Data on the duration of their admission to the rehabilitation unit, the inter-time between the amputation and acquisition of the temporary prosthesis, and between temporary prosthesis acquisition and the fi nal prosthesis acquisition were also reported. Results: Patients of our sample, at the end of their hospitalization, highlight a signifi cant modifi cation of the temporal data at 1 month and 6 months from their hospital discharge. A statistical signifi cant increase of the Barthel Index value was observed in all patients recruited in this study proceeding from time T0 to time T4; in the same way, a statistical signifi cant decrease of the VAS scale was observed in all patients recruited proceeding from time T0 to time T4; the cirtometry of the amputation stump (expressed in cm) showed a statistical signifi cant decrease in all patients recruited proceeding from time T0 to time T4. We haven’t observed a statistical signifi cant correlation between the duration of the rehabilitative hospitalization and our clinical data; no statistical signifi cant correlation was observed between the amputation stump cirtometry time-related modifi cation and our intertime data. Conclusion: The protocol was found to be a clear and relevant tool with the defi nition of the operational profi le for each single professional fi gure involved; it could also be considered as an optimal tool for coding the management and evaluation of the effectiveness of amputee treatment, with a related high reproducibility, sensitivity and specifi city profi le. In line with the literature, the TRIA-MF protocol has allowed us not to exceed a period of hospitalization in rehabilitation units of more than 23 days, thus showing that it is an excellent tool for optimizing the management costs of the amputee over time. Research Article TRIA-MF protocol as an innovative tool in the comprehensive treatment and outcome evaluation of lower limb amputees before and after prosthesis use Maurizio Falso1, Silvia Zani1, Eleonora Cattaneo2, Marco Zucchini3 and Franco Zucchini3 1Middle Cares Rehabilitation Unit, Fondazione Madonna del Corlo, Lonato (Bs), Italy 2Section of Neurological Rehabilitation, Clinical Institute Città di Brescia, Brescia, Italy 3Poliortopedia, Brescia, Italy *Address for Correspondence: Maurizio Falso, MD, Physical Medicine and Rehabilitation, Middle Cares Rehabilitation Unit, Fondazione Madonna del Corlo, Corso Garibaldi 3, 25017, Lonato (Bs), Italy, Tel: 349.4971729; Email: falsomaurizio@libero.it Submitted: 31 December 2018 Approved: 17 January 2019 Published: 18 January 2019 Copyright: © 2019 Falso M, et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited Abbreviations: TRIA-MF: Amputees Integrated Rehabilitative TreatmentMaurizio Falso; POP: Post-Operation; TF: Trans-Femoral; TT: TransTibial; K-level: Kode-level; A: Amputation; TP: Temporary Prosthesis; DP: Definitive Prosthesis: FKT: Physiokynesis therapy; PCC: Pearson Correlation Coefficient How to cite this article: Falso M, Zani S, Cattaneo E, Zucchini M, Zucchini F. TRIA-MF protocol as an innovative tool in the comprehensive treatment and outcome evaluation of lower limb amputees before and after prosthesis use. J Nov Physiother Rehabil. 2019; 3: 001-024. https://doi.org/10.29328/journal.jnpr.1001024 TRIA-MF protocol as an innovative tool in the comprehensive treatment and outcome evaluation of lower limb amputees before and after prosthesis use Published: January 18, 2019 002 Introduction Amputation is a surgical technique, which has always been used in history. The word “amputation” is used for the irst time by Seneca in the 1st century A.D. This word refers to an agricultural kind of terminology; infact it means “cut off all around”, from the Greek form “amphi” (around/on both sides) and from the Latin form “putare” (cut off/trim) [1]. A person needs an amputation for different causes, but in the occidental countries we can recognize six main causes: a. systemic diseases like peripheral obliterative arteriopathy (3-5% in people between 50/60 years of age, and 20% in people over-75) and diabetic vasculopathy; b. infections; c. traumas; d. tuberculosis; e. malign tumors; f. lower limb gangrenes [2]. In the last 18 years, in Italy there were 4877 arteriopathic patients who needed a lower limb amputation, as a consequence of their illness. 66% of them were major amputations, of which 73% trans-femoral amputees while only 34% were partial foot or toe amputations. During the same year in Italy there were a total number of 13.181 amputations both lower and upper limb, and a total of 5.359 elderly people amputations. Male elderly people have a prevalence of 93.5% every 100.000 inhabitants, almost twice as much as female population, with a prevalence of 55.9% every 100.000 inhabitants. The main period of italian hospitalization for any lower limb amputation is about 20 days, and 23 days for major amputations [3]. In Europe diabetic management costs are various: from 1.305 €/year in Spain, to 3.576 €/year in Germany. In Italy the main cost is about 2.990 €/year, for a national expenditure of 5 billion euros every year [4-6]. 60% of this expenditure is caused by in-hospital care, other for ambulatorial cares and drugs. In 2009, 105.000 recovery for diabetes were needed, for an in-hospital period of 9 days. Amputation is a major surgical intervention, that has an enormous, both physical and psychological, impact on the patient’s life. Amputation can generate different emotions. Some of them can be useful and constructive, like relief, hope or euphoria. Other are very negative, such as rage, sadness, rejection, anxiety distress, uncertain, vulnerability and feeling of mutilation. All these feelings are very common for every disabling illness, but they are stronger for amputees. Amputation determinates an enormous alteration between body image and the true body, an unbearable loss. Even if a little percentage of all amputees become chronically depressed, it is very important to early treat any psychological dif iculties, because they can negatively affect the rehabilitation process [7-10]. The main goals during the immediate postoperative phase relate to wound healing, pain control, forming of the amputation stump and early mobilization. A correct stump management starts after the operation and it’s the main goal during the irst two weeks before the provisory prosthesis use. Stump management concerns wound healing, edema reduction and contracture prevention. These early interventions are essential for a correct and functional prosthesis use. In this process it is necessary to correctly educate the patient to a correct stump care. After the amputation the stump presents an edema. This is caused by a vascular and lymphatic alteration, due to the surgical operation. In trans-tibial amputations, edema can negatively affect wound healing, because of an increased pressure in the stump that can increase tension on the suture, with rare skin necrosis [7,11-13]. When the drainage is removed, it’s important to start the process of edema reduction. More recent soft silicon liner are used for postoperative edema reduction. These liners produce a uniform compression that shapes the stump, avoiding pear-shaping or not coniform or cylindrical shapes. A structured multidisciplinary team is very important during every phase of the amputation process. The guidelines suggest that this team should be composed by the surgeon, the rehabilitation physician, the anesthesiologist, the nurses, the physiotherapist and, if possible, the orthotic technician or the prosthetist. Depending to the circumstances the occupational therapist, the healthcare psychologist, the activity coordinator, the social worker, the dietician, the pastoral cares can be involved too. A good communicative team guarantees a greater tranquility for the patient, thanks to more homogenous information, that is already discussed between the clinicians. Every change in the treatment must be explained and discussed with the patient, in order to reach the objectives better suiting the patient’s future needs [14-17]. TRIA-MF protocol as an innovative tool in the comprehensive treatment and outcome evaluation of lower limb amputees before and after prosthesis use Published: January 18, 2019 003 The aim of this study was to de ine the ef icacy and outcome value of an innovative procedure tool (TRIA-MF protocol) in the treatment of l