There are times in one's life when it is necessary and appropriate to rest and stay immobile: after major surgery or trauma. There are other times when the thought of moving can be so overwhelming that staying in bed seems like a good idea. Immobility is not a great idea for anyone for any length of time. It sets into motion a whole set of medical conditions that may have major consequences to our well being. Osteoporosis, obesity, Syndrome X, deep vein thrombosis and pulmonary embolism are but a few.

OSTEOPOROSIS

Mobility allows the vector forces of gravity to have a beneficial effect on our bones increasing our total bone mass. Conversely, immobility results in a decrease in total bone mass which can cause bones to become thin and brittle. This condition, osteoporosis, may increase an individual's risk of fracture which can occur with little or no trauma. Hip and spine fractures are the most common sites causing more immobility which only further decreases bone mass. This loss of bone mass occurs slowly in younger individuals whose bones are strong and dense. Older individuals, especially post menopausal females, can experience a dramatic loss of bone mass. Medications are available which help increase bone density. However, the best defense is maintaining mobility.

OBESITY

It should come as no surprise that immobility is directly related to weight gain whether you live with limb loss or not. Researchers in the United Kingdom found that "obesity is a well known complication of amputation but more so in the patient with transfemoral and bilateral amputations."¹  In their article, Nassar et. al. states that weight was a significant factor in determining the number of repairs in lower limb prosthesis.²  Weight gain often times triggers a cascade of other metabolic conditions which may impact an individual's overall well being.

SYNDROME OR METABOLIC X

In 1988 researchers at Stanford University identified a syndrome complex, linked to obesity which includes: abdominal obesity, hypertension, insulin resistance, elevated triglycerides, and low levels of "good" cholesterol (HDL). It is felt to effect as many as 2/3 of all Americans or up to 50 million people. Syndrome X is believed to be the precursor of Type 2 diabetes where the insulin in our bodies becomes less effective in moving glucose into cells. Patients with Syndrome X will develop increased risk for coronary heart disease and peripheral vascular disease caused by the cholesterol deposits in their vessels.³

Lifestyle changes are the main intervention in the treatment of Syndrome X including weight loss and increased physical activity. These goals are all the more challenging for those living with limb loss whose options are more limited. Another component of Syndrome X is a tendency of blood to clot especially in our lower extremities where it can pool during times of immobility.⁴  The result is DVT or deep venous thrombosis, a potentially fatal condition which needs immediate medical attention once recognized.

DEEP VEIN THROMBOSIS (DVT)

DVT presents with painful swelling and often redness in the calf and lower legs. It can be easily diagnosed using Color Doppler ultrasound. Sound waves are able to "see" blood flowing through normal veins. If a clot is present, the normal flow pattern is disrupted and a "filling defect" or clot is seen on the images.

NORMAL COLOR DOPPLER ULTRASOUND

This ultrasound image demonstrates a vein (blue) and an artery (red/orange). The color is seen filling the entire structure of both vessels indicating that both artery and vein are free of clot or "filling defects."

Figure 1 obtained at http://www.wikipedia.org. kw ultrasound DVT
 

ABNORMAL VESSEL WITH A CLOT

When a clot is present in a vein or artery, it will fill in a portion of the vessel causing the blood to flow around the clot. This will appear as a filling defect on either an ultrasound or CT scan.

Figure 2 obtained at http://www.wikipedia.org kw ultrasound DVT
 

PULMONARY EMBOLUS (PE)

Once blood clots develop in the lower legs, they may become dislodged and travel through the major veins in the abdomen into the chest. Once in the lungs, the clots block the normal flow of blood through the lungs restricting their ability to oxygenate the blood. The resulting condition is called pulmonary embolism which may cause total cardiovascular collapse and oftentimes death. David Bloom, NBC reporter embedded in Iraq with the Armed Forces, died as a result of PE from a lower leg clot.⁵  This condition, if suspected, can be diagnosed by the CT Pulmonary Angiogram.

CT PULMONARY ANGIOGRAM

Newer generation CT scanners are able to see the major vessels of the heart and lungs. The image below was obtained after a contrast agent (bright white material) was given to make the blood visible to the scanner. The darker structure outlined by the contrast is a large clot (PE) within the main pulmonary artery. This is a life threatening emergency.

Figure 3 obtained in http://www.wikipedia.org. KW pulmonary embolism
 

CONCLUSION

Mobility is a necessity if we are to maintain a healthy lifestyle. Individuals living with limb loss can choose from a variety of options: crutches, walkers, traditional prosthetic device or the LegSim. Each device has its own sets of pluses and minuses. The key point to keep in mind is that mobility is an imperative if we are to maintain our independence and overall sense of well being.

KEEP MOVING:  SAFELY, COMFORTABLY AND PRUDENTLY
 

John A. Tata, MD
Medical Director
Hartford Walking Systems, Inc.

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¹ Naseer H. J. Haboubi, MBChB, MRCP; Michael Heelis, BSc; Ruth Woodruff, DIPT, MCSP; Imad Al-Khawaja, PhD, MRCP, "The effect of body weight and age on frequency of repairs in lower-limb prostheses," Journal of Rehabilitation Research and Development,Vol. 38 No. 4, July/August 2001
² Ibid. et.al.
³ American Heart Association at www.americanheart.org. keywords, "metabolic syndrome." March 8, 2007.
⁴ Ibid.
⁵ ClotCare Online Resource, "David Bloom's DVT Story: An Interview with Melanie Bloom," April 8, 2007. www.clotcare.com. Key words DVT obtained April 8, 2007

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