1. 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

2. 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.

3. 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

4. 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

5. 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

6. 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

7. 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

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

9. 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.

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

11. 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

12. 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

13. 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.

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

15. 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

16. 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

17. 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

18. 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

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

20. Amputee Mobility Predictor
Testing tool, going through the test

21. 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

22. 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

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

24. 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

25. 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

26. 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

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

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

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

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

31. 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

32. 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)
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

33. Questions?