2224 West Sunset Springfield, MO 417-730-2000

Lower Extremity Amputee/Prosthetic Rehabilitation: A Team Approach

Fred Lerche PT, C.Ped Administrative Director OP Rehab. And Prosthetics and Orthotics

CoxHealth Center for Prosthetics And Orthotics

Our Clinical Model ???

Demographics of Demographics of Amputees in the United Amputees in the United

StatesStates

In 2009, there were approximately In 2009, there were approximately 1.9 million persons with 1.9 million persons with

amputations in the United States.amputations in the United States.

Each Year an additional 80,000 lose a limb as a result of an accident or disease 2009 study

2010 Study 2010 Study

• 19,000,000 people living with 19,000,000 people living with DMDM

• 4% will develop an ulcer4% will develop an ulcer• 6% will have an amputation 6% will have an amputation

• 45% mortality rate with an ulcer 45% mortality rate with an ulcer or amputation at 1 year or amputation at 1 year

2010 507 amputations done 2010 507 amputations done each day each day

WOW 85% are preventable WOW 85% are preventable

Sound Limb CareSound Limb Care

Sound Limb InspectionSound Limb Inspection Shoe recommendationsShoe recommendations

OrthoticsOrthotics Transfer Techniques to Transfer Techniques to

decrease Sheardecrease Shear Adaptive Equipment-sliding Adaptive Equipment-sliding

board????board????

CASE REPORTCASE REPORT

April 2014

CASE REPORT

February 2015

LEAP PROGRAM

CASE REPORT

REASON FOR REASON FOR AMPUTATIONAMPUTATION

Disease 70%Disease 70%

Trauma 22%Trauma 22%

Congenital 4%Congenital 4%

TumorTumor 4% 4%

STATISTICSSTATISTICS

GenderGender

Male 75%Male 75%

Female 25%Female 25%

STATISTICSSTATISTICS

Hours of Prosthetic Use Hours of Prosthetic Use per dayper day

>12 hrs 60%>12 hrs 60%

1-12 hrs 34%1-12 hrs 34%

no use at all 6%no use at all 6%

Pre-surgical VisitPre-surgical Visit

• Provide time for introductionsProvide time for introductions• Discuss level of activity over the past two yearsDiscuss level of activity over the past two years

• Support medical teamSupport medical team’’s decisionss decisions• Explore patient expectations after amputationExplore patient expectations after amputation• Explain the sequence of events from surgery Explain the sequence of events from surgery

through rehabilitation through rehabilitation • Reinforce realistic expectationsReinforce realistic expectations

• Answer any questions of the patient and familyAnswer any questions of the patient and family

Post Operative CarePost Operative Care

Goals for the Post-Op (Acute) Goals for the Post-Op (Acute) Treatment PhaseTreatment Phase

Reduce edema and promote healingReduce edema and promote healingPrevent Loss of Motion – a Prevent Loss of Motion – a MUSTMUST Increase upper and lower extremity Increase upper and lower extremity

strength- think function strength- think function Promote mobility and self carePromote mobility and self carePromote sound limb care- a Promote sound limb care- a MustMustAssist with limb loss adjustmentAssist with limb loss adjustment

PRIMARY GOAL -- HEALING WITHOUT COMPLICATIONS

Goals for the Post-Op (Acute) Goals for the Post-Op (Acute) Treatment PhaseTreatment Phase

Residual limb dressing care Residual limb dressing care PositioningPositioning Transfer skillsTransfer skills Exercise program – keep it simple for home – Exercise program – keep it simple for home –

the Essential Basic Fourthe Essential Basic Four1. Supine A/AROM alternating hip and knee flexion1. Supine A/AROM alternating hip and knee flexion

2. Supine A/AROM hip abd and add2. Supine A/AROM hip abd and add

3. Side lying AROM hip flexion and extension3. Side lying AROM hip flexion and extension

4. Sitting AROM knee flexion and extension 4. Sitting AROM knee flexion and extension

Early ambulation- Very Controlled Early ambulation- Very Controlled

PROSTHETIC CRITERIAPROSTHETIC CRITERIA

1.1. Independent with Bed Independent with Bed mobilitymobility

2.2. Independent with transfersIndependent with transfers

3.3. Independent with AmbulationIndependent with AmbulationDouglas G. Smith MDDouglas G. Smith MD

INTERDISCIPLINARY INTERDISCIPLINARY REHABILATION REHABILATION

TEAMTEAM

The Key to Successful OutcomesThe Key to Successful Outcomes

Fred Lerche PT, C.Ped Fred Lerche PT, C.Ped

AMPUTEE REHABILITATIONAMPUTEE REHABILITATION A TEAM APPROACH A TEAM APPROACH

AMPUTEE REHABILITATIONAMPUTEE REHABILITATION A TEAM APPROACH A TEAM APPROACH

Team MembersTeam Members

PhysicianPhysician

Physical TherapistPhysical Therapist

Occupational TherapistOccupational Therapist

Orthotist/ProsthetistOrthotist/Prosthetist

PsychologistPsychologist

Social worker/Case managementSocial worker/Case management

NutritionistNutritionist

Support VolunteersSupport Volunteers

FamilyFamily

NursingNursing

PatientPatient

POSSIBLE REASONS FOR FAILURE OF AN AMPUTEE PROGRAMPOSSIBLE REASONS FOR FAILURE OF AN AMPUTEE PROGRAM

h Too little early education pre-and post Too little early education pre-and post prosthesis. Education is important both to prosthesis. Education is important both to patient and family.patient and family.

h Amputee has an overly optimistic attitude.Amputee has an overly optimistic attitude.h Prosthetist and physical therapist must be Prosthetist and physical therapist must be

honest with patient.honest with patient.h Let patient know artificial limb will never be as Let patient know artificial limb will never be as

good as anatomical limb.good as anatomical limb.h Involving patient, family and rehab as much as Involving patient, family and rehab as much as

possible is a great asset. possible is a great asset. Robert S. GaileyRobert S. Gailey PhD, PTPhD, PT

Amputation is the first step in Amputation is the first step in the Rehabilitation processthe Rehabilitation process

Amputation is the first step in Amputation is the first step in the Rehabilitation processthe Rehabilitation process

““Too often amputation is performed Too often amputation is performed without thought for biomechanical without thought for biomechanical principles or preservation of muscle principles or preservation of muscle

function.function.”” Frank Gottschalk MDFrank Gottschalk MD

Incisional line causing excessive Incisional line causing excessive shear and pressureshear and pressure

Case Report

In My opinion, the key to a In My opinion, the key to a successful Amputee successful Amputee

Rehabilitation Program and Rehabilitation Program and Positive Outcomes is a Positive Outcomes is a Functional Progressive Functional Progressive

Pre-Prosthetic ProgramPre-Prosthetic Program

In My opinion, the key to a In My opinion, the key to a successful Amputee successful Amputee

Rehabilitation Program and Rehabilitation Program and Positive Outcomes is a Positive Outcomes is a Functional Progressive Functional Progressive

Pre-Prosthetic ProgramPre-Prosthetic Program Fred Lerche PT C.Ped

Must Improve Must Improve Cardiovascular Cardiovascular

StatusStatus

Why ??????

Energy ExpenditureEnergy Expenditure Energy ExpenditureEnergy Expenditure

Long BKA 20% additional energyLong BKA 20% additional energyShort BKA 40%Short BKA 40%Long AKA 60%Long AKA 60%Short AKA 80%Short AKA 80%Hip Disartic 100% Hip Disartic 100%

Long BKA 20% additional energyLong BKA 20% additional energyShort BKA 40%Short BKA 40%Long AKA 60%Long AKA 60%Short AKA 80%Short AKA 80%Hip Disartic 100% Hip Disartic 100%

Waters

Must Improve Must Improve Functional Muscle Functional Muscle

StrengthStrength

Must Prevent Must Prevent Joint Joint

ContracturesContractures

Bella May

Do Not…… Do……..

Bella May

Do Not…… Do……..

Bella May

Must be able to Must be able to Control the Control the

repositioned C.O.M. repositioned C.O.M. over the altered B.O.S.over the altered B.O.S.

Controlled AmbulationControlled Ambulation

Postoperative day 10 - 21Postoperative day 10 - 21

Regular dressing changesRegular dressing changesResidual limb wrapping or compression Residual limb wrapping or compression

RRD ect.RRD ect.Assess Ambulation skillsAssess Ambulation skillsPROM and AROM to all jointsPROM and AROM to all joints Initiate balance and coordinationInitiate balance and coordination Increase endurance trainingIncrease endurance training

Postoperative day 21-30Postoperative day 21-30

Sutures or staples removed at day 21Sutures or staples removed at day 21Aggressive ROM for knee flexion if rigid Aggressive ROM for knee flexion if rigid

dressing was useddressing was usedContinue residual limb compressionContinue residual limb compressionBegin Dynamic residual limb exercises as Begin Dynamic residual limb exercises as

healing permits- healing permits- hold 4 weeks if Myodesishold 4 weeks if Myodesis Increase endurance programIncrease endurance programProgress with balance and agility trainingProgress with balance and agility training

A timeline for Patients or A timeline for Patients or Treatment guidelinesTreatment guidelines

Week 3 : Sutures or staples removedWeek 3 : Sutures or staples removedWeek 4: Shrinker and healing Week 4: Shrinker and healing

monitoringmonitoringWeek 6-8: Cast for Diagnostic socketWeek 6-8: Cast for Diagnostic socketWeek 10-11: Prosthetic Gait training Week 10-11: Prosthetic Gait training

Pre-Prosthetic ProgramPre-Prosthetic ProgramPre-Prosthetic ProgramPre-Prosthetic Program

StretchingStretchingStrengtheningStrengtheningProgressive Balance, agility, and Progressive Balance, agility, and

coordinationcoordination

StretchingStretchingStrengtheningStrengtheningProgressive Balance, agility, and Progressive Balance, agility, and

coordinationcoordination

Robert GaileyRobert Gailey

ACUTE CARE AMPUTEE ACUTE CARE AMPUTEE EXERCISESEXERCISES

ACUTE CARE AMPUTEE ACUTE CARE AMPUTEE EXERCISESEXERCISES

ACUTE CARE AMPUTEE ACUTE CARE AMPUTEE EXERCISESEXERCISES

ACUTE CARE AMPUTEE ACUTE CARE AMPUTEE EXERCISESEXERCISES

ACUTE CARE AMPUTEE ACUTE CARE AMPUTEE EXERCISESEXERCISES

ACUTE CARE AMPUTEE ACUTE CARE AMPUTEE EXERCISESEXERCISES

ACUTE CARE AMPUTEE ACUTE CARE AMPUTEE EXERCISESEXERCISES

ACUTE CARE AMPUTEE ACUTE CARE AMPUTEE EXERCISESEXERCISES

STRENGTHENINGSTRENGTHENINGSTRENGTHENINGSTRENGTHENING

STRENGTHENINGSTRENGTHENINGSTRENGTHENINGSTRENGTHENING

STRENGTHENINGSTRENGTHENINGSTRENGTHENINGSTRENGTHENING

STRENGTHENINGSTRENGTHENINGSTRENGTHENINGSTRENGTHENING

Functional Progression Functional Progression exercisesexercises

Functional Progression Functional Progression exercisesexercises

Start Long SittingStart Long SittingQuadruped PositionQuadruped PositionHigh kneelingHigh kneeling