The Continuum of Care: An Approach to Therapy for the Patient With an Amputation Dr. Lynn Geyer, DPT Covenant HealthCare Physical Medicine and Rehabilitation April 23, 2016 Neuro Symposium

Today our focus will be primarily on those people with a lower extremity amputation, but care guidelines still apply to upper extremity amputation care as well.

130,000+ amputations occur yearly in the United States Standards of care recommend that people with amputations be in contact with at least one professional from their healthcare team every 3 months for the first 18 months post amputation, and then every 6 months in order to reach their full potential Each year, more than 130,000 individuals in the US undergo the amputation of a limb. Providing these patients with a continuum of care from all those who come in contact with them is highly important. Standards of care are important… As a therapist, our contact immediate begins and should be throughout the weeks immediately post amputation and due to our more intense contact, therapists need to be knowledgable about the care and referrals and flags that need to be addressed

Here are Covenant, we offer each important healthcare area and work as a team to ensure patients do not fall between the cracks. Our goals are simple, we want all people with an amputation to return to their full potential and daily activities

It takes an amputee about 2 years to reach maximum potential use of a prosthetic limb The potential of amputees varies due to different reasons for the amputation, type of amputation, co-morbidities, and environment, but all amputees should reach a minimal level of household mobility with prosthetic limb Most should expect to reach a community level of mobility and return to vocational and community activities It takes a person with an amputation about two years to reach maximum potential use of a prosthetic limb, factors include healing time of residual limb, strengthening after amputation, getting used to the balance and mobility difference on a limb, and training for use of the limb. Just like training for a marathon, it doesn’t happen overnight. There are set backs and times of plateau where mobility and use will not change, yet will not be at previous level of function. Prosthetic limbs have the ability to change often. We will talk later on the qualifications of change in limb, but with each step of progress, the prosthetic limb should change and improve. Temporary  permanent these individuals have many challenges that affect quality of mobility and life, both pre and post amputation. Take away: NO ONE should expect to be wheelchair bound with proper care and referrals

Mobility Potential Most amputees will start in a wheelchair, but can quickly be up and moving in a walker with or without a prosthetic leg within a few weeks of amputation All amputees should be expected to reach a minimum of household ambulation and should never be expected to be wheelchair bound The more people that say this to amputees and their families, the better With proper standards of care applied and referrals made, an amputee should at least reach limited community mobility and depending on comorbidities, unlimited community ambulation should occur More on K levels and how we define potential on outcomes measures later

Prosthetic Limbs After an amputation, you should expect to receive and start using a prosthetic limb within 1-2 months, some may begin as soon as 1 week Because a limb should be received immediately, then therapy needs to begin immediately

You are never too young or old to use a prosthetic!

Who’s Who of Amputee Care Primary Care Physician – Family physician Physiatrist – Physical Medicine and Rehabilitation physician Physical Therapist – Specialist in lower extremity amputee and neurology therapy Prosthetist – Creator of prosthetic limb Case Management/Social Worker – Community resources Wound Clinic – Care of the residual limb and any other wound/skin issues Pain Clinic – Physicians who specialize in pain management Psychology – Psychologist or Psychiatrist Dietician – Specialist in food education Referrals are to assist the patient to achieve functional independence, to improve quality of life, to provide Why each area is important ***Nursing with each! Amputees are at high risk for being lost in the system without appropriate referrals as check points throughout their care. All physicians and healthcare professionals play a role in an amputee’s two-year recovery period, but if those key referrals are not in place, the patient may never reach their full potential or mobility beyond a wheelchair or walker. This limits quality of life while increasing healthcare expenses with continued health problems.

Stages of Rehabilitation Preoperative Stage Acute Stage Sub-Acute to Chronic Stage Community Integration/Stable Stage

Preoperative Stage For those patients who have a planned amputation Rehabilitation through physical therapy and/or cardiac rehabilitation Education for the surgery, prosthetic, goals for mobility Preparation for amputation involves patient education about the process and potential prognosis; preoperative rehabilitation with a physical therapist and/or cardiac rehabilitation for increased strength and range of motion (ROM) of all extremities and core; and education about future mobility and realistic goals. Rehabilitation through physical therapy and/or cardiac rehabilitation for strength and endurance to be prepared for post amputation mobility

Preoperative Stage, continued Healthcare professionals the patient should be in contact with Primary Care Physician Surgeon Prosthetic Company/Prosthetist Physical Therapist or Cardiac Rehab Unit

Acute Stage Amputation occurs Therapy in the hospital Discharge plan to home or another rehabilitation facility Post-amputation includes patient education about residual limb healing and shaping; acute/hospital PT and occupational therapy (OT) for basic mobility; activities of daily living training with durable medical equipment (DME) provided as needed; referral to physiatry (inpatient rehabilitation consult or outpatient consult if patient is able to return home post-surgery); discharge setting planned and completed; referral to prosthetist for immediate post-operative prosthesis and temporary limbs.

Acute Stage, continued Healthcare professionals the patient should be in contact with Surgeon PT and OT Physiatrist Prosthetist Case Manager Social Worker Dietician

Sub-Acute to Chronic Stage Time frame: Patient discharges from the hospital throughout outpatient therapy needs Therapy setting ideally at discharge from the hospital would be an inpatient rehabilitation unit, can also be a skilled nursing rehabilitation unit Discharge could also be to home with home therapy or home with outpatient therapy Receive a prosthetic limb and begin to use When the residual limb is healed enough, activities include weight-bearing exercises through PT; creation of a prosthetic wear and use schedule; prosthetist follow-ups on limb needs; and management of nutrition and comorbidities

Sub-Acute to Chronic Stage, continued Healthcare professionals the patient should be in contact with Surgeon Physical and Occupational Therapists Physiatrist Prosthetist Case Manager/Social Worker Psychology Dietician if diet needs monitored or changed Wound Center Surgeon Physical and Occupational Therapists Physiatrist Case Manager/Social Worker Psychology Dietician if diet needs monitored or changed Wound Center

Sub-Acute to Chronic Stage, continued Prosthetic During this time, the prosthetic limb will begin with a temporary/preparatory limb Over time the prosthetic limb will be upgraded to an improved temporary and eventually a permeant limb Many factors involved with decisions in prosthetic available

Community Integration/Stable Stage Return to work, recreational activities May still be completing outpatient therapy with physical therapy or may be only completing a home exercise or gym program Community programs available to assist with maintaining progress and continuing to make progress Final Stage: When a definitive prosthetic limb is provided, activities include a return to recreational activities; community programming to break through plateau periods away from therapy (e.g., the Covenant HealthCare Step Up! Amputee Program or other local programming for mobility); peer support and education; physiatry follow-ups with therapies being re-consulted as appropriate; and vocational rehabilitation as relevant. Very important to maintain and gain during those two years

Community Integration/Stable Stage, continued Healthcare professionals the patient should be in contact with Physical Therapists, as needed Physiatrist Community Programming Prosthetist, as needed

Amputee Mobility Predictor Testing tool, going through the test

K Levels Medicare Functional Classification Level for LE amputations 5 level system categorizes the mobility potential and abilities of a person at time of testing Defines reimbursement and availability for a prosthetic prescription Measured by use of the Amputee Mobility Predictor Test K Levels can be used to judge progress throughout an episode of care and to update a prosthetic limb to include more technology and improved components Medicare Functional Classification Level, otherwise known as K Levels Standard for all Each level allows for a more complex prosthetic limb

K Levels K Level 0: Cannot use a prosthetic, nor transfer and walk K Level 1: Household Ambulator K Level 2: Limited Community Ambulator K Level 3: Community Ambulator K Level 4: Advanced Ambulator 0: does not ambulate or transfer safely with or without assistance, and a prosthesis does not enhance quality of life or mobility. Not eligible for a prosthetic 1: can household amb on level surfaces 2. Can community walk on level surfaces and low changing surfaces such as stairs and ramps 3 can amb all over the community and in home, may be working, completing community events, gym, etc 4 HIGH level mobility, could be a very active person or athlete Many Covenant PMR patients reach this level as active adult and children Medicare Functional Classification Level, otherwise known as K Levels, was introduced. This five-level coding system categorizes the mobility potential and abilities of a person with a lower limb amputation, as well as what is reimbursable for a prosthetic prescription. Each level allows for a more complex prosthetic limb. K Levels are measured by use of the Amputee Mobility Predictor testing tool using various sitting and standing balance, mobility, somatosensory and vestibular objectives. K Levels include scores for a person with and without use of a prosthetic limb. K Levels can be used to judge progress throughout an episode of care, and to update a prosthetic limb to include more technology and improved components

K Level 1 “Household Ambulator” Ability or potential to use a prosthetic Transfers Ambulation on level surfaces at fixed cadence

K Level 0-1 Evaluation Treatment Residual Limb and wound assessment Shrinker, Liner, Socket use Mobility Strength, ROM, flexibility Treatment Prosthetic management Sock ply education Wear schedule Pain management Residual limb care Begin exercise program with prosthetic donned/doffed Not all amputees start here

K Level 2 Minimal change in speed “Limited Community Ambulator” Has ability or potential for ambulation over low level environmental barriers Curbs Stairs Uneven surfaces Minimal change in speed

K Level 2 Treatment Mobility training should start at two wheeled walker and progress to quad cane to single point cane Indoor Ambulation Treadmill training at slight incline Outdoor Ambulation Progressive exercise program Balance program Fall training

K Level 3 “Unlimited Community Ambulator” Ambulate most environmental barriers Demands of prosthetic use beyond simple locomotion Ambulates at various speeds

K Level 3 Mobility training should be progressing towards no assistive device Treadmill training with more incline Outdoor Ambulation Balance and weight shifting exercises

K Level 4 High Level Exceeds basic ambulation skills High impact, stress, and energy levels

K Level 4 Jumping Running High level balance, sports Gym progression Progression towards the CHAMP testing tool

Goals Goals for a person with an amputation should include the person becoming as independent as possible, maximizing mobility, and improving quality of life With standards of care applied and many referrals made to help the person progress, these goals should be attained This means, full functioning with BADLs, household ambulation

Covenant HealthCare References Covenant HealthCare Physiatrists Dr. Babu Nahata (director) Dr. Thomas Raymond Covenant HealthCare Physical Medicine and Rehabilitation Amputee Specialists Michigan Outpatient PMR at the 515 N. Michigan Campus (989) 583-2752 Physical Therapy, Occupational Therapy, and Speech Therapy Post Acute/Hospital Rehabilitation at the Michigan Campus Covenant Transitional Care Unit Covenant Inpatient Rehabilitation Step Up! Amputee Mobility Clinic 2nd Thursday of the month during specified months Free Clinic for anyone with or who wants to know more about amputee mobility

Questions?