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Overcoming Challenges in Treatment of Patients With Obesity, Diabetes

Rates of obesity and diabetes are increasing in health care. The CDC reported an obesity prevalence of 37.9% among U.S. adults in 2014, and reported nearly one of every 11 Americans has diabetes.

Obesity prevalence rose almost 8% since 2000, the CDC found, and if current trends continue, the group estimates one in three U.S. adults could have diabetes by 2050. This poses a unique challenge for the O&P profession.

Staggering numbers

According to the American Diabetes Association, in 2010, about 73,000 non-traumatic lower limb amputations were performed on adults aged 20 years or older with diabetes.

“The numbers are staggering,” Jacob Townsend, CPO, of Ability Prosthetics and Orthotics in Asheville, N.C., told O&P News. “Unfortunately, the market is growing and that is something we need to deal with.”

Thomas Martin, MS, CPO, BOCO, at Ability Prosthetics and Orthotics in Hanover, Pa., said patients with diabetes and obesity are the largest population of amputees treated at his facility, and Jon Shreter, CPO, prosthetic manager at Synergy Orthopedics and executive director of the Prosthetic and Orthotic Management Associates Corporation (POMAC), said nearly 80% his practice is made up of patients with diabetes.

However, Shreter foresees the number of amputations decreasing. “I have seen an uptick in the [number] of people who are eligible for coverage thanks to Medicare coverage of diabetic shoes and inserts,” he said. “Patients’ limbs are being saved longer and they do not need amputation as often as they used to.”

But there are still challenges, sources said, most specifically in achieving volume management, as these patients often experience volume fluctuation of their limbs. “We can take a scan or a mold of a patient’s limb,” Shreter said, “and they come in 3 [days] or 4 days after the cast is done and they have a change in size.”

Image: ©Shutterstock

©Shutterstock

Comorbidities also can contribute to volume fluctuation, according to Martin. “The goal is to get these patients up and moving as quickly as possible,” he said. “Patients with obesity usually have other factors, such as edema [and] delayed healing, where you may be following them a lot longer prior to fitting a prosthesis.”

Patients with edema often experience rapid reduction of the limb after putting on a prosthesis. “They may need to sit down and have someone help them put on more volume management socks to prevent skin breakdown,” Martin said.

Patients also can experience neuropathy and experience rapid limb reduction in the prosthesis, but may not be able to detect it. This could lead to irritation or a skin breakdown, “set [patients] back and lead to further risk and infection,” according to Martin.

Kate Allyn, L/CPO, FAAOP, a research prosthetist in the Department of Bioengineering at University of Washington in Seattle, said a reduction in residual limb fluid volume can cause the prosthesis to become loose on the residual limb while the person walks or runs.

“A loose socket can injure soft tissues and cause the user to be unstable and fall down,” she said. “An increase in residual limb fluid volume restricts the blood flow and makes the socket feel tight and painful, possibly injuring limb tissues.”

Financial barriers

Jon Shreter, CPO
Jon Shreter

In addition to the challenges of working with patients with obesity or diabetes, practitioners may also face financial impacts, as these patients are limited in which prostheses they can wear and reimbursement is often lower because of the number of follow-up appointments.

“Insurance plans are setting limits on the amount of money they will pay for a prosthesis,” Shreter said. “That is a challenge, and some insurance companies have a limit on what types of prostheses a patient can get.”

In handling the issues with reimbursement, Townsend said it will require companies to be secure in their profit with “how they treat patients and how they handle the general workload.”

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“Some of the obese population also cannot come into the office and we may actually have to go see them, [which could limit the number of patients being seen in the clinic],” Martin said.

However, persistence and documentation are the best strategies for resolving issues with reimbursement, according to Shreter. He said documentation with the physician and physical therapy facility is also important to include in submitting claims for approval.

Prompt care and collaboration

Regarding medical care, the most important strategy in treating patients is collaboration and prompt care to minimize the chance of a change in condition, Shreter added.

When treating patients with diabetes or obesity, Martin and colleagues often employ a team approach that involves family members or a caregiver. In addition to educating family or caregivers on how to put on the prosthesis, they also educate family members on what to look for and how to prevent irritation or other issues.

Multiple physical therapists are often on hand for initial fittings of patients with obesity to help them get to parallel bars or a walker, Martin said. “You will have multiple therapists, and you will have the prosthetist there to make sure the height and alignment are correct,” he said. “It takes a whole team in some of these cases to be able to properly fit the patient and have them walking with a prosthesis, especially the first time.”

Often, obese patients have family members help to fit the prosthesis as well. “Many of them are unable to independently put the prosthesis on, but once it is on, they are able to get up and walk, usually with a walker or an ambulatory aid,” Martin said.

Thomas Martin, MS, CPO, BOCO
Thomas Martin

After the initial fitting, obese patients often have multiple follow-up appointments with the practitioners. “We need to stay on top of it to make sure the patients are doing everything properly, but a lot of times, [they also] have large changes in their limb where they may go through a few sockets in a short period of time because of edema and because they are not usually walking for quite a bit of time,” Martin said. “Once they get up and start walking again, they can change rapidly.”

Patient education

Educating patients is paramount, sources said. “It all comes back to whether we are doing our job of educating patients and trying as much as we can to treat the whole patient, not just the amputation,” Townsend said. “Education is an important part of our job and every medical professional’s job.”

Jacob Townsend, CPO
Jacob Townsend

Because many of these patients are elderly or have auditory and visual deficits, it takes more time to explain the treatment protocols and to explain to patients how to manage their prosthetic wear, according to Shreter.

Townsend stressed that if a person’s diabetes is so severe it has led to amputation, the person often has multiple comorbidities that should be taken into account. “It is important that we, as clinicians, educate this population to both help and encourage them maintain their overall level of health,” Townsend said.

“We want to make sure that the patient is successful,” Martin added. “We need to make sure they are taking the prosthesis on and off properly, that volume management is being accounted for. We need to make sure the patient knows what to look for and their family or caregiver knows what to look for.

“If you give the patient enough information, many take it seriously. Once they get their prosthesis, they do not want it taken away, so they are going to do everything they can to make sure they are successful.”

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Keeping the patient moving is also important, Javier La Fontaine, DPM, MS, professor in the Department of Plastic Surgery at UT Southwestern Medical Center, told O&P News. “Data have shown that people who have a higher amputation — either above-the-knee amputation or below-the-knee amputation — gain weight after the amputation,” he said. “Gaining weight will lead to other complications as well, such as hypertension and high cholesterol. Keeping the people moving is significant.”

Practitioners at Ability Prosthetics and Orthotics also employ a systematic approach to measure outcomes for each patient. “It provides us with justification when advocating for the patient to their insurance company as to why a patient requires a specific prosthesis,” Townsend said. “It also gives us a better snapshot of what the patient can and cannot do, and lets us track their progress.”

Javier La Fontaine, DPM, MS
Javier La Fontaine

Patients also can view their progress to see if they are improving, which can often help them to realize they need to walk or exercise more, Townsend said.

Advances in technology

Ability Prosthetics and Orthotics has recently partnered with Allyn and colleagues at the University of Washington to monitor patients’ residual limb fluid volume fluctuation. “As a clinical site, we are helping to set up monitoring of fluid fluctuation throughout the day for different patient populations,” Martin said.

Allyn is conducting a Department of Defense project with the objective of making prosthetic limbs more comfortable for amputees. “We are not targeting specifically diabetic and obese patients, but all transtibial amputees using prosthetics,” she said. “We understand this population will benefit a great deal from this technology, however.”

New diagnostic system

Researchers are introducing a new diagnostic system into amputee patient care. They use a small portable instrument to measure where, when and by how much limb fluid volume changes.

They initially developed the technology in their laboratory and are now contacting practitioners across the United States, such as those at Ability, to present their research, demonstrate their bioimpedance analysis and explain how the practitioners can use the data collection to improve prosthetic socket fit. Ultimately, the researchers are trying to apply the technology to practice for clinical diagnosis and treatment of volume problems.

“This application represents an important advancement from our previous effort and is necessary to ensure the developed technology can be effectively integrated into clinical care,” Allyn said.

She and colleagues will first conduct testing with prosthetic users to establish how well different volume management solutions work and how these relate to data measured by the system. “That insight will help us to determine how best to use the technology in clinical care,” she said. “We will then ask practitioners to test the system in their clinics to determine if it is a useful tool for prosthetic fitting and if it reduces the total time required to achieve a successful prosthetic fit. Results will provide us with valuable information about what clinical interventions work best and which prosthesis users are likely to benefit from each.”

Increase in patients

Other practices are also preparing new technology and procedures for a potential increase in patients.

Townsend said his practice is creating a viable system of procedures that allows it to “determine the most appropriate course of action and treatment for each patient and ensure each patient receives the appropriate care.”

O&P business facilities also can be set up to accommodate patients with obesity and diabetes. For example, all Ability offices have extra-wide hallways, doors that can accommodate bariatric wheelchairs and parallel bars secured to the floor to avoid shifting or sliding when a patient in the prosthetic lab uses the bars to stand.

“We even do something as small as keeping lollipops in our office,” Martin said. “Many people think it is for the pediatric patients, but we also have them for the patients with diabetes if they have low blood sugar and need something.”

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Practices can also utilize emerging technology to assist in treatment of patients. For example, a BMI calculator available on the Amputee Coalition website that allows amputees to enter their limb deficiency and more accurately calculate their BMI.

New socket pressure technology is helping to ensure that patients do not have too much pressure at the end of the limb, which is what leads to skin breakdown, according to Martin. Manufacturers are also constantly creating new products to accommodate higher weight ratings for the components, he said.

Preventive care

With these advances in technology and the better preventive care now available, Shreter pointed out that although obesity rates may increase, the rates of amputation may not.

La Fontaine agreed. “There are some data that show obese people may be protective to diabetes complications because [clinicians] may be more aggressive in treating them compared with someone who is not overweight,” he said. “Prevention is going to be the answer.”

“Just because obesity is going up does not necessarily mean there is going to be an increase in amputations,” Shreter added. “Especially with insulin pumps and education of patients and better footwear, the amount of amputations, I think, will decrease.” – by Tina DiMarcantonio

Disclosures: Allyn, LaFontaine, Martin, Shreter and Townsend report no relevant financial disclosures.

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