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Lower Extremity Amputee/Prosthetic Rehabilitation: A Team Approach Fred Lerche PT, C.Ped Administrative Director OP Rehab. And Prosthetics and Orthotics 2224 West Sunset Springfield, MO 730-2000 417- CoxHealth Center for Prosthetics And Orthotics Our Clinical Model ??? Demographics of Amputees in the United States In 2009, there were approximately 1.9 million persons with 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 19,000,000 people living with DM • • • • 4% will develop an ulcer 6% will have an amputation 45% mortality rate with an ulcer or amputation at 1 year 2010 507 amputations done each day WOW 85% are preventable Sound Limb Care Sound Limb Inspection Shoe recommendations Orthotics Transfer Techniques to decrease Shear Adaptive Equipment-sliding board???? CASE REPORT April 2014 CASE REPORT February 2015 CASE REPORT LEAP PROGRAM REASON FOR AMPUTATION Disease Trauma Congenital Tumor 70% 22% 4% 4% STATISTICS Gender Male 75% Female 25% STATISTICS Hours of Prosthetic Use per day >12 hrs 60% 1-12 hrs 34% no use at all 6% Pre-surgical Visit Provide time for introductions Discuss level of activity over the past two years • Support medical team’s decisions Explore patient expectations after amputation Explain the sequence of events from surgery through rehabilitation • Reinforce realistic expectations Answer any questions of the patient and family • • • • • Post Operative Care Goals for the Post-Op (Acute) Treatment Phase PRIMARY GOAL -- HEALING WITHOUT COMPLICATIONS Reduce edema and promote healing Prevent Loss of Motion – a MUST Increase upper and lower extremity strength- think function Promote mobility and self care Promote sound limb care- a Must Assist with limb loss adjustment Goals for the Post-Op (Acute) Treatment Phase Residual limb dressing care Positioning Transfer skills Exercise program – keep it simple for home – the Essential Basic Four 1. Supine A/AROM alternating hip and knee flexion 2. Supine A/AROM hip abd and add 3. Side lying AROM hip flexion and extension 4. Sitting AROM knee flexion and extension Early ambulation- Very Controlled PROSTHETIC CRITERIA 1. 2. 3. Independent with Bed mobility Independent with transfers Independent with Ambulation Douglas G. Smith MD INTERDISCIPLINARY REHABILATION TEAM The Key to Successful Outcomes Fred Lerche PT, C.Ped AMPUTEE REHABILITATION A TEAM APPROACH Team Members Physician Physical Therapist Occupational Therapist Orthotist/Prosthetist Psychologist Social worker/Case management Nutritionist Support Volunteers Family Nursing Patient POSSIBLE REASONS FOR FAILURE OF AN AMPUTEE PROGRAM Too little early education pre-and post prosthesis. Education is important both to patient and family. Amputee has an overly optimistic attitude. Prosthetist and physical therapist must be honest with patient. Let patient know artificial limb will never be as good as anatomical limb. Involving patient, family and rehab as much as possible is a great asset. Robert S. Gailey PhD, PT Amputation is the first step in the Rehabilitation process “Too often amputation is performed without thought for biomechanical principles or preservation of muscle function.” Frank Gottschalk MD Incisional line causing excessive shear and pressure Case Report In My opinion, the key to a successful Amputee Rehabilitation Program and Positive Outcomes is a Functional Progressive Pre-Prosthetic Program Fred Lerche PT C.Ped Must Improve Cardiovascular Status Why ?????? Energy Expenditure Long BKA 20% additional energy Short BKA 40% Long AKA 60% Short AKA 80% Hip Disartic 100% W Must Improve Functional Muscle Strength Must Prevent Joint Contractures Bella May Do Not…… Do…….. Bella May Do Not…… Do…….. Bella May Must be able to Control the repositioned C.O.M. over the altered B.O.S. Controlled Ambulation Postoperative day 10 - 21 Regular dressing changes Residual limb wrapping or compression RRD ect. Assess Ambulation skills PROM and AROM to all joints Initiate balance and coordination Increase endurance training Postoperative day 21-30 Sutures or staples removed at day 21 Aggressive ROM for knee flexion if rigid dressing was used Continue residual limb compression Begin Dynamic residual limb exercises as healing permits- hold 4 weeks if Myodesis Increase endurance program Progress with balance and agility training A timeline for Patients or Treatment guidelines Week 3 : Sutures or staples removed Week 4: Shrinker and healing monitoring Week 6-8: Cast for Diagnostic socket Week 10-11: Prosthetic Gait training Pre-Prosthetic Program Stretching Strengthening Progressive coordination Balance, agility, and Robert Gailey ACUTE CARE AMPUTEE EXERCISES ACUTE CARE AMPUTEE EXERCISES ACUTE CARE AMPUTEE EXERCISES ACUTE CARE AMPUTEE EXERCISES STRENGTHENING STRENGTHENING STRENGTHENING STRENGTHENING Functional Progression exercises Start Long Sitting Quadruped Position High kneeling