Evaluation And Treatment Of Adults With Lower Extremity .

Evaluation and Treatmentof Adults withLower Extremity Amputation:A Clinical Practice Guidelinefor Therapists

Introduction Sarah Smith, MPT– Advanced Clinician, Inpatient MedSurg at University Hospital Sarah Jones, MOT, CLT– Rehab Manager of Inpatient OT at University Hospital Susanne Angileri, MPT– Clinician, Acute Rehab at UW Health– Clinician, Inpatient MedSurg at University Hospital Sandy Grady, PT– Advanced Clinician, Outpatient Middleton Neuro/Rehab Clinic atUW Health– Prosthetic Clinic

Course Objectives Participants will have an understanding of the keypractice recommendations from the UW HealthRehab Lower Extremity Amputations ClinicalPractice Guideline for Therapists. Participants will have an understanding of rehabgoals and key interventions at each phase of carefor adults with LE amputations. Participants will have an understanding ofresources for patients and clinicians.

Course Objectives Participants will have an understanding ofthe assessment tools appropriate for useat each phase of care. Participants will have an understanding ofDurable Medical Equipmentrecommendations at each phase of careand how to assist with procurement.

Key Recommendations Included throughout presentation Highlight best practice in the phases ofrecovery

Understanding UW Health

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Introduction This clinical guideline is a guide for the rehabilitationprocess for adult patients after lower extremityamputations across the phases of recovery. It wasdeveloped by Physical Therapists and OccupationalTherapists at University of Wisconsin Hospital andClinics in collaboration with vascular surgery, thephysical medicine and rehabilitation department, andlocal prosthetists. An evidence based approach wasutilized in development of this standard of care.

Clinical Practice Guideline The Center for Clinical Knowledge Management(CCKM) is responsible for interdisciplinaryguidelines which include various types ofinterventions (e.g., pharmacological and nonpharmacological recommendations). Theseguidelines often describe care for an entirepopulation and/or cross care settings and clinicaldisciplines. https://uconnect.wisc.edu/clinical/cckmtools/cpg/

GRADE algorithm

Introduction Currently, over 2 million people are living afterlimb loss in the United States.– e-center/limbloss-statistics/index.html This number is expected to more than double by2050. (Zielgler-Graham, et al 2008). Causes of lower extremity amputation includevascular deficits, trauma, or oncologic issues,with vascular conditions being the leading causeof amputation (Ziegler-Graham, et al 2008).

Introduction Limb loss impacts a person’s ability toengage in regular activities includingmobility, self-cares, relationships, andproductivity. Rehabilitation is an important part ofthe process after amputation to provideopportunity for people to return to fullyfunctioning members of society.

Health Disparity Fall risk with injury is increased for womenand racial minorities. Rehabilitation professionals should ensurefall prevention exercises andrecommendations are provided to allpatients with lower extremity amputations Rehab Professionals should ensurewomen and racial minorities receive thiseducation (Wong, et al, 2016)

Phases of RecoveryLong TermManagementCommunity Reintegration PhaseAcute RehabilitationPhaseAcute Post-AmputationPhasePre-Amputation Phase

Pre-Amputation Phase The period of time prior to the surgicalprocedure for an amputation. Can be in the clinic, or a pre-operativeconsult in the hospital At this stage, education, counseling, andpre-operative mobility assessment are theprimary objective

Precautions Generally not limited by any weightbearing restriction May have nerve block (usually placed 1day prior to OR) Falls risk

Rehab Goals Education on what to expect– Estimated length of limb– Length of time it may take to get toprosthetic– Disposition options and role of PT andOT Discussion of home modifications

Rehab Goals Pre-operative mobility assessment Recommend bringing in comfortableclothing and supportive shoe for nonoperative foot

Mobility/Assessment Tools Bed mobility, transfers Could consider single leg stance Could consider Timed Up and Go– (Cutoff score for community dwellingadults: 13.5. For LE Amputees: 19) Sensory testing on sound limb

Mobility/Assessment Tools Any mobility and assessment at this pointmay be limited by pain and emotionalconsiderations

Patient Education Issue copy of First Step magazine– Published by Amputee Coalition of America Begin discussion on home modifications.Can issue information on ramp specs ifappropriate.– 12 inches of run for every 1 inch of rise Acknowledge the patient’s grief atimpending loss of limb

Considerations for Patients withBilateral Amputations If the patient has an amputation on thenon-surgical limb, ask the patient if theyuse a prosthesis and if it can be brought tothe hospital. Ask them to bring their shrinker sock andwear it post-op, or wear their roll on gelliner to manage edema, so that prosthesiswill maintain good fit

Acute Post Amputation Phase The period of time from post op day #0 toapproximately 10-14 days post-operative Typical Hospital length of stay is 3-5 dayspost operatively PT/OT consults are in for POD #1 Health Psych is also included in the orderset for all new amputees

Precautions Sciatic and Femoral Nerve Blocks IV, may have foley, will usually discontinueday 1 Surgical dressing (ACE wrap) and kneeimmobilizer (20 inch most oftenappropriate) Occasionally a cast; stays on 3-5 days

Knee Immobilizer To protect, and preventknee flexion contracture Adjust to fit No straps over patella!

High Falls Risk All patients with lower extremityamputations are at risk of falls. A fall can lead to further surgery,prolonged time to prosthetic limb, andprogression to higher level of amputation.

Incidence and Risk Factors of Falling in thePostop LE amputee While on the Surgical Ward Retrospective cohort study of 3 acute carehospitals, 370 patients 16.5% fell at least once 60.7% of those who fell sustained injuries Falls group had significantly longer lengthof stay– (Yu et al, 2010)

Health Disparity related to Falls(Wong, et al 2010) Fall risk with injury is increased for womenand racial minorities. Fall prevention exercises andrecommendations should be provided toall patients with lower extremityamputations Rehab therapists should ensure womenand racial minorities receive this education

Assessment Tools Range of motion for upper extremities and lower extremitiesManual muscle test for upper extremities and lower extremitiesADL assessmentMobility assessmentPain – phantom and/or surgicalSensation – upper and lower extremityEdemaSkin integrity – observation of incision and residual limb, observationof non-surgical limb Cognition and learning assessment Activity tolerance AM-PAC

Rehab Goals- PT Initiate lower extremity home exerciseprogram Patient will perform bed mobility withstand-by assistance. Patient will perform bed to chair transferswith assist. Use of walker, gait belt,seated slideboard as needed.

Rehab Goals -PT Progress to ambulation with appropriateassistive device and use of gait belt Patient will propel wheelchair 150 feet withbilateral upper extremities, demonstrategood use of brakes, with stand-by assistand verbal cues

Rehab Goals - PT Patient will verbalize understanding of limbprotection and use of compression, rigidremovable dressings, and kneeimmobilizers as applicable Patient will demonstrate nonpharmacological pain relief techniquessuch as gentle skin desensitization andmirror therapy.

Rehab Goals - OT Initiate upper extremity home exerciseprogram Patient will maintain seated balance atedge of bed while performing activities ofdaily living (ADLs) Patient will perform commode transferswith assist. Use of walker, gait belt,seated slideboard as needed.

Rehab Goals – PT/OT Assist patient and family in progressing tomost appropriate next level of care withongoing therapies after hospital discharge.

Guillotine Amputation Usually in the setting of gas gangrene– bacterial infection creates gas in gangrenoustissues; medical emergency, can be fatal Amputation is performed without closure,to allow wound to drain; often Syme’s level

Therapy Considerations: Guillotine Pt’s are often cleared to dangle or pivot.We do not remove knee immobilizer. Minimize time spent with limb dependent,if bleeding observed, notify RN Back to OR for closure/completion BKAusually after 1-3 days.– Helpful to talk to patients about limb length

Mobility Bed Mobility Dangle Seated balance– Remember base of support and center ofgravity has shifted– Don’t leave a new amputee at edge of bedalone

Mobility If seated balance is good, will attempt sitto stand on POD 1 If attempt unsuccessful, will considerslideboard transfer for POD 2

Stand Pivot Easier towards the sound leg. FWW for first attempt (crutches requiremore coordination, balance, difficult withlines) May need to rearrange the room. Includenursing in recommendations!

Sara Plus If a patient is really fearful ofstanding, get to edge of bedand lock in the Sara Plus lift Raise to a comfortableheight in seated position,then stop moving it and letpatient practice puttingweight on leg while feelingthey are in a safe positionand won’t fall

Slideboard Wheelchair with removable arm Slideboards can be found on D4/5 or in H6/2equipment storage. Hospital wheelchairs do have a barrier in thenon-removable leg rests Place slideboard under themiddle 1/3 of patient’s thigh Towards sound limb is easier,good for a first attempt

Slideboard Transfer Head leaning away from hips Straightforward vs over the patient’sshoulder technique Block knee to prevent sliding forward

Self Cares Initiate lower body bathing and dressing– Consider readiness to look at and handle limb Seated balance is key– Consider what surface and position is mostappropriate and safe– If in bariatric bed, try to obtain alternativemattress

Self Cares Bariatric Drop ArmCommode ideal forinpatient, regardless ofsize Flat surface allows forlateral weight shiftingand sliding transfers

Wheelchair Basic skills– BRAKES– Teaching patient and staff about the swingaway legs (unfortunately attached)– Can use slideboard on calf rest of elevatingleg rest for makeshift limb rest DME for home– Letter of Medical Necessity, vendors, etc. willbe covered in Acute Rehab phase

Key Practice Recommendation Prevent knee and hip flexion contracturesin each phase of recovery for maximalfunctional outcomes and eventualprosthetic use as well as preventing skinbreakdown. (Karacoloff 1992) (O’Sullivan2007) (Klarich 2014)(UW Health: Low quality evidence ,strong recommendation)

Key Practice RecommendationTo prevent contractures, focus on: Positioning Use of a knee immobilizer Education HEP

Lower Extremity Exercises - BKA Prevention of kneeflexion contracture Possible quad lagassociated withnerve block Supine vs Sidelying Single Leg Bridge

Key Practice Recommendations Strengthen all four extremities and trunkto prevent deconditioning during recoveryand to reach highest functional outcome.(Karacoloff 1992) (O’Sullivan 1994)(Klarich 2014)(UW Health: Low quality evidence ,strong recommendation)

Upper Extremity Exercises Increase UEendurance Prevent hospitaldeconditioning Preparation forincreased UE use Pressure Relief UE Assessment is keyto function andmobility