“REHABBING” AMPUTEES: Caught between AROC and a hard place? Craig Evans Physiotherapist Rankin Park Limb Centre

Is anyone else finding it harder? Are patients : More unwell? More comorbities? Older? Less motivated? Lower socioeconomic groups? More challenging accommodation? MORE COMPLEX?

DATA?…. AROC!

Data Collection The AROC data collection compares our Data with similar units and national data The CORE report should be considered in conjunction with relevant Impairment Specific reports and the Target Outcomes report for your facility The AROC database is only as good as the quality and completeness of the data that are submitted to it. There are 3 reports the core report etc

Results summarised Admission: RPC has increased complexity of patients Increased comorbidities Increased patients with carer and support Decreased admission FIM’s Inpatient: Increased LOS ( Due to external service issues ) Decreased complications ( RPC good nursing care ) Discharge: Lower FIM scores Increased FIM change Increased services at home but increased discharge to home Overall as compared to our national benchmarks: We have a lower admission and discharge FIM score and longer LOS than the benchmarks but we are getting more of our patients home with increased services and carers other than Residential placement.

Improving data collection over time…

Episodes of care at RPC

FIM change over 10 + years

Average Age change over the years

More FIM data…

Overall admissions

Comorbidities…

So why are our patients “less rehabbable”? Cognition; Motivation; potential; support

So why are our patients “less rehabbable”? More complex patients - definitely Better pre-amputation interventions Reduced “Life reserve” Economics: Public vs private Private insurance – socioeconomics issue reduced “Rural” – lower SE groups Motivation?

Better Interventions & “Life Reserve” Life span Birth to death Living with comorbidity E.G diabetes. Requiring medical management of a condition. “Life Reserve” The time frame from hospitalization due to comorbidity including rehab til mortality

Better Interventions & “Life Reserve” Life span Birth to death Living with comorbidity Improvements in interventions increase the time frame of relative wellness prior to requirement for rehab “Life Reserve” Less life reserve due to age and “managed” comorbidities. By the time they reach here their potential for rehab is reduced.

What makes a good rehab candidate? Cognition; Motivation; potential; support

What makes a good rehab candidate? Motivation Potential – physical, cognitive Support “House, nous and spouse”

What then should be our expectations? How good should our patients get? Walking ADLs Home Predictors of outcome?

Predictors of function: Taylor et al 2005 Pre-op factors ?= post-op function / mortality With view to performing palliative AKA vs functional BKA >= 70 y.o – 3x or more chance of death, non-ambulatory, non-prosthetic user, functionally dependent within 1 year Other pre op predictive factors – nonambulatory / transfers only; dementia; coronary artery disease; ESRD

Predictors of function : Schoppen et al (2003) Best predictors: Age at amputation important for general functioning. Standing balance on the unaffected limb at 2 weeks post amputation – significant predictor of all functional outcome parameters Memory +/- mood/cognitive ability Comorbidity (DM and other but not cardiopulmonary disease) No social predictors were significant

Predictors of function: Gailey et al, 2002 AMPPRO / AMPnoPRO (Gailey et al, 2002) – more a functional test than a predictor.

Predictors of function : Whyte And Carroll (2004) Patients with phantom pain (questionnaire, 62% response rate, 315 subjects) Catastrophizing can account for 11% overall level of disability

Predictors of prosthetic non-use: Roffman et al (2014)

What does all this mean for us? Patients are getting more complex, not necessarily older. There are predictors of function to use as a guide. (Need to be more objective? ABF) “Rehabbing” the pre-amputees – vascular rehab?

References: AROC Reports --- John Hunter Hospital (Rankin Park Unit) 2003-2015 Gailey RS, Roach KE, Applegate EB, Cho B, Cunniffe B, Licht S, Maguire M, Nash MS. (2002). “The Amputee Mobility Predictor: an instrument to assess determinants of the lower-limb amputee ability to ambulate.” Arch Phys Med Rehabil 2002;83:613-27. Schoppen T, Boonstra A, Groothoff JW, de Vries J, Go¨eken LN, Eisma WH. (2003) “Physical, mental, and social predictors of functional outcome in unilateral lower-limb amputees.” Arch Phys Med Rehabil 2003;84:803-11. Whyte and Carroll (2004). “The relationship between catastrophizing and disability in amputees experiencing phantom pain.” Disability & Rehabilitation 26(11):649-54. Taylor SM et al (2005). “Pre-operative clinical factors predict post-operative functional outcomes after major lower limb amputation: An analysis of 553 consecutive patients” Journal of Vascular Surgery 2005; 42: 227-235 Roffman CE, Buchanan J, Allison GT (2014) “Predictors of non-use of prostheses by people with lower limb amputation after discharge from rehabilitation: development and validation of clinical prediction rules.” Journal of Physiotherapy 60: 224–231

Acknowledgements CNC/CNS at RPC – Merridie Rees, Helen Baines and Judith Dunne Tara and Jackie from AROC