2224 west sunset springfield, mo 417- 730-2000 lower extremity amputee/prosthetic rehabilitation: a...
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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
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CoxHealth Center for Prosthetics And Orthotics
Our Clinical Model ???
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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.
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Each Year an additional 80,000 lose a limb as a result of an accident or disease 2009 study
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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
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2010 507 amputations done 2010 507 amputations done each day each day
WOW 85% are preventable WOW 85% are preventable
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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????
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CASE REPORTCASE REPORT
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April 2014
CASE REPORT
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February 2015
LEAP PROGRAM
CASE REPORT
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REASON FOR REASON FOR AMPUTATIONAMPUTATION
Disease 70%Disease 70%
Trauma 22%Trauma 22%
Congenital 4%Congenital 4%
TumorTumor 4% 4%
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STATISTICSSTATISTICS
GenderGender
Male 75%Male 75%
Female 25%Female 25%
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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%
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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
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Post Operative CarePost Operative Care
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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
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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
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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
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INTERDISCIPLINARY INTERDISCIPLINARY REHABILATION REHABILATION
TEAMTEAM
The Key to Successful OutcomesThe Key to Successful Outcomes
Fred Lerche PT, C.Ped Fred Lerche PT, C.Ped
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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
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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
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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
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Incisional line causing excessive Incisional line causing excessive shear and pressureshear and pressure
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Case Report
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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
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Must Improve Must Improve Cardiovascular Cardiovascular
StatusStatus
Why ??????
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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
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Must Improve Must Improve Functional Muscle Functional Muscle
StrengthStrength
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Must Prevent Must Prevent Joint Joint
ContracturesContractures
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Bella May
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Do Not…… Do……..
Bella May
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Do Not…… Do……..
Bella May
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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.
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Controlled AmbulationControlled Ambulation
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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
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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
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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
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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
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Robert GaileyRobert Gailey
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ACUTE CARE AMPUTEE ACUTE CARE AMPUTEE EXERCISESEXERCISES
ACUTE CARE AMPUTEE ACUTE CARE AMPUTEE EXERCISESEXERCISES
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ACUTE CARE AMPUTEE ACUTE CARE AMPUTEE EXERCISESEXERCISES
ACUTE CARE AMPUTEE ACUTE CARE AMPUTEE EXERCISESEXERCISES
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ACUTE CARE AMPUTEE ACUTE CARE AMPUTEE EXERCISESEXERCISES
ACUTE CARE AMPUTEE ACUTE CARE AMPUTEE EXERCISESEXERCISES
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ACUTE CARE AMPUTEE ACUTE CARE AMPUTEE EXERCISESEXERCISES
ACUTE CARE AMPUTEE ACUTE CARE AMPUTEE EXERCISESEXERCISES
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STRENGTHENINGSTRENGTHENINGSTRENGTHENINGSTRENGTHENING
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STRENGTHENINGSTRENGTHENINGSTRENGTHENINGSTRENGTHENING
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STRENGTHENINGSTRENGTHENINGSTRENGTHENINGSTRENGTHENING
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STRENGTHENINGSTRENGTHENINGSTRENGTHENINGSTRENGTHENING
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Functional Progression Functional Progression exercisesexercises
Functional Progression Functional Progression exercisesexercises
Start Long SittingStart Long SittingQuadruped PositionQuadruped PositionHigh kneelingHigh kneeling
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