1. 2224 West Sunset Springfield, MO 417- 730-2000 Lower Extremity Amputee/Prosthetic Rehabilitation: A Team Approach Fred Lerche PT, C.Ped Administrative Director OP Rehab. And Prosthetics and Orthotics

2. CoxHealth Center for Prosthetics And Orthotics Our Clinical Model ???

3. Demographics of Amputees in the United States In 2009, there were approximately 1.9 million persons with amputations in the United States.

4. Each Year an additional 80,000 lose a limb as a result of an accident or disease 2009 study

5. 2010 Study 19,000,000 people living with DM 19,000,000 people living with DM 4% will develop an ulcer 4% will develop an ulcer 6% will have an amputation 6% will have an amputation 45% mortality rate with an ulcer or amputation at 1 year 45% mortality rate with an ulcer or amputation at 1 year

6. 2010 507 amputations done each day WOW 85% are preventable

7. Sound Limb Care  Sound Limb Inspection  Shoe recommendations  Orthotics  Transfer Techniques to decrease Shear  Adaptive Equipment-sliding board????

8. CASE REPORT CASE REPORT

9. April 2014 CASE REPORT

10. February 2015 LEAP PROGRAM CASE REPORT

11. REASON FOR AMPUTATION Disease 70% Trauma 22% Congenital 4% Tumor 4% Tumor 4%

12. STATISTICS Gender Gender Male 75% Male 75% Female 25% Female 25%

13. STATISTICS Hours of Prosthetic Use per day Hours of Prosthetic Use per day >12 hrs 60% >12 hrs 60% 1-12 hrs 34% 1-12 hrs 34% no use at all 6% no use at all 6%

14. Pre-surgical Visit Provide time for introductions Provide time for introductions Discuss level of activity over the past two years Discuss level of activity over the past two years Support medical team’s decisions Support medical team’s decisions Explore patient expectations after amputation Explore patient expectations after amputation Explain the sequence of events from surgery through rehabilitation Explain the sequence of events from surgery through rehabilitation Reinforce realistic expectations Reinforce realistic expectations Answer any questions of the patient and family Answer any questions of the patient and family

15. Post Operative Care

16. Goals for the Post-Op (Acute) Treatment Phase Reduce edema and promote healing Reduce edema and promote healing Prevent Loss of Motion – a MUST Prevent Loss of Motion – a MUST Increase upper and lower extremity strength- think function Increase upper and lower extremity strength- think function Promote mobility and self care Promote mobility and self care Promote sound limb care- a Must Promote sound limb care- a Must Assist with limb loss adjustment Assist with limb loss adjustment PRIMARY GOAL -- HEALING WITHOUT COMPLICATIONS

17. Goals for the Post-Op (Acute) Treatment Phase Residual limb dressing care Residual limb dressing care Positioning Positioning Transfer skills Transfer skills Exercise program – keep it simple for home – the Essential Basic Four 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 Early ambulation- Very Controlled

18. PROSTHETIC CRITERIA 1. I ndependent with Bed mobility 2. I ndependent with transfers 3. I ndependent with Ambulation Douglas G. Smith MD

19. INTERDISCIPLINARY REHABILATION TEAM The Key to Successful Outcomes The Key to Successful Outcomes Fred Lerche PT, C.Ped

20. 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

21. 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

22. 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 “Too often amputation is performed without thought for biomechanical principles or preservation of muscle function.” Frank Gottschalk MD

27. Incisional line causing excessive shear and pressure

28. Case Report

29. 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

30. Must Improve Cardiovascular Status Why ??????

31. Energy Expenditure Long BKA 20% additional energy Long BKA 20% additional energy Short BKA 40% Short BKA 40% Long AKA 60% Long AKA 60% Short AKA 80% Short AKA 80% Hip Disartic 100% Hip Disartic 100% Long BKA 20% additional energy Long BKA 20% additional energy Short BKA 40% Short BKA 40% Long AKA 60% Long AKA 60% Short AKA 80% Short AKA 80% Hip Disartic 100% Hip Disartic 100% WatersWaters

32. Must Improve Functional Muscle Strength

33. Must Prevent Joint Contractures

34. Bella May

35. Do Not……Do…….. Bella May

36. Do Not……Do…….. Bella May

37. Must be able to Control the repositioned C.O.M. over the altered B.O.S.

38. Controlled Ambulation

39. Postoperative day 10 - 21 Regular dressing changes Regular dressing changes Residual limb wrapping or compression RRD ect. Residual limb wrapping or compression RRD ect. Assess Ambulation skills Assess Ambulation skills PROM and AROM to all joints PROM and AROM to all joints Initiate balance and coordination Initiate balance and coordination Increase endurance training Increase endurance training

40. Postoperative day 21-30 Sutures or staples removed at day 21 Sutures or staples removed at day 21 Aggressive ROM for knee flexion if rigid dressing was used Aggressive ROM for knee flexion if rigid dressing was used Continue residual limb compression Continue residual limb compression Begin Dynamic residual limb exercises as healing permits- hold 4 weeks if Myodesis Begin Dynamic residual limb exercises as healing permits- hold 4 weeks if Myodesis Increase endurance program Increase endurance program Progress with balance and agility training Progress with balance and agility training

41. A timeline for Patients or Treatment guidelines A timeline for Patients or Treatment guidelines Week 3 : Sutures or staples removed Week 3 : Sutures or staples removed Week 4: Shrinker and healing monitoring Week 4: Shrinker and healing monitoring Week 6-8: Cast for Diagnostic socket Week 6-8: Cast for Diagnostic socket Week 10-11: Prosthetic Gait training Week 10-11: Prosthetic Gait training

42. Pre-Prosthetic Program Stretching Stretching Strengthening Strengthening Progressive Balance, agility, and coordination Progressive Balance, agility, and coordination Stretching Stretching Strengthening Strengthening Progressive Balance, agility, and coordination Progressive Balance, agility, and coordination

43. Robert Gailey

44. ACUTE CARE AMPUTEE EXERCISES

48. STRENGTHENINGSTRENGTHENING

49. STRENGTHENINGSTRENGTHENING

50. STRENGTHENINGSTRENGTHENING

51. STRENGTHENINGSTRENGTHENING

53. Functional Progression exercises Start Long Sitting Start Long Sitting Quadruped Position Quadruped Position High kneeling High kneeling