Life Care Planning for the Amputee – Case study (III)

Life Care Planning  for the Amputee – Amputation Rehabilitation (I)

Life Care Planning  for the Amputee – Prosthetic Prescription (II)

Mr. M. was a 57-year-old male at the time of his motorcycle accident in 2001, when he sustained multiple injuries to his body. He was air-lifted to a trauma unit, where he was stabilized and intubated. It was decided that his left leg was not viable, and a left mid-length above-knee amputation was performed. This incision healed without incident, and the scar has matured well. He was unconscious for a period of 1 week and was determined to have a closed head injury that cleared slowly. Since the injury, the apparent sequelae from the head injury are mild short-term memory deficit and quick change of mood and temper. He also sustained a fractured larynx and had to be intubated for a prolonged period of time. When the tube was removed, he continued to have a hoarse voice with vocal cord paralysis on one side. Since the amputation, he has received a well-fitted prosthetic leg and taught himself to walk using the prosthesis. He has little time for health professionals and always seems to know what is best for his care needs. He now lives independently in a two-story home. He has intermittent pain in the residual leg and also phantom pain. The pain is exacerbated with weather changes that occur frequently where he lives in the Pacific Northwest.

He wants to return to riding motorcycles and remain in his current two-story home. He is currently divorced but has an adult son who checks on his well-being a couple of times a week. He feels that his home would better suit his needs if an elevator were installed since negotiating steps is a hassle even though he can climb them independently and safely.

He has no intention of returning to work with his multiple disabilities following the motor­cycle accident. However, before his accident, he worked doing outdoor construction, and the employer and the insurance carrier would like him to pursue some type of gainful employment.

NAME: Sample DOB:

DOI:

AGE:

REPORT DATE:

Routine Future Medical Care—Physician Only

Otolaryngology (per Dr. XYZ at U. WA Med Ctr.)Reconstructive surgery of the trachea and larynx with a temporary tracheostomy.$30,000 total for staged proceduresMonitor prosthetic function, evaluate right foot and proper footwear.Orthopedic Surgery (R. Meier, MD)Evaluate low back pain that is expected to begin at age 65 years related to abnormal gait associated with prosthetic walking.$350 per year beginning at age 65 yearsAt least every 5 years once back pain has begun, expected age 65$1,300-$1,500 (avg.) every 5 years beginning at age 65 yearsTo monitor diabetes and its associated complications.Projected Evaluations—Nonphysician (include all allied health evaluations)

See next section, “Projected Therapeutic Modalities.”Projected Therapeutic Modalities

Physical therapy to upgrade prosthetic skills as new components are used (R. Meier, MD)Every 4 years for four sessionsMotorcycle for recreation (R. Meier, MD, and Adaptive Automotive)Cost of modification related to amputationHealth and Strength Maintenance (Leisure Time Activities)

Aerobic conditioning program for the remainder of his life (R. Meier, MD)Annual membership for club or every 5 years for exercise equipmentRange $500-$1800/year for YMCA, health club, or home exercise equipmentACA membership with InMotion magazine subscription (R. Meier, MD)The client requires some architectural changes to his existing home that include replacing the banister to the second floor so he can grasp it for safety reasons when going up and down the flight of stairs, the countertop in his bathroom should be raised about 6 inches to provide better standing posture, a ramp should be permanently installed from the garage into the kitchen, the master bathroom should have an elevated commode installed with side rails, fire alarm, and smoke detectors installed, and shower rails/grab bars in bathroom. All of these items should cost $5000.

When the client reaches approximately 70 years of age, he will require further architectural changes to his existing home in order for him to function using both floors of his home. The following figures were provided by Goldwal Construction in Vancouver, WA:

Kitchen $35,781 Bath $25,558

Interior doorway modifications $5725

Exterior doorway and ramping modifications $15,335

Stair glide for access to the second floor of the existing home $8500

Deferred to vocational expert.Future Medical Care, Surgical Intervention, Aggressive Treatment

Revision of current above-knee amputation stump (R. Meier, MD)Surgeon: $3000 Hospital: $17,000 Anesthesiology: $630 Total: $20,630(Continued) See also

otolaryngologist for larynx surgery

Potential Complications

Potential complications are included for information only.

No frequency or duration of complications is available.

Low back pain at age 65 years. See prior recommendations for orthopedic surgeon visits and MRI evaluations.Degenerative changes in the right hip, foot, and ankle from more than usual stress and strain imposed on the remaining foot due to the amputation of the opposite leg that also is compounded by having diabetes and its long-term consequences.Musculoskeletal problems including altered gait, back problems, and back pain related to abnormal gait, osteoarthritis, neuromas, heterotopic ossification, myositis ossificans, or bone spurs on stump, all of which may become significant and require additional diagnostic tests, treatment, or more surgery than projected. At risk for overuse syndrome of upper extremities (shoulders and wrists) related to crutch use and manual wheelchair propulsion over time that may require additional diagnostic tests for upper extremities (EMGs, nerve conduction tests, X-rays, etc.) or splints and/or other treatment if complications occur.Psychological problems related to adjustment to disability including self-esteem, self-image, self-confidence, difficulty with relationships, reduced functional abilities, adjustment to permanency of disability, depression, etc.Increased risk for falls and reinjury due to impaired physical/mobility skills and increased fatigue associated with AK prosthesis use.• Weight changes including significant gain, loss, stump shrinkage, or atrophy, which affect prosthesis fit and require more frequent replacements or adjustments than expected.More extensive or expensive medical care and equipment than expected due to expected reduced function and physical decline as one ages. Failure to maintain prosthesis or do proper skin care can result in increased prosthesis maintenance costs or more frequent replacement than expected. Stability and durability of prosthesis also can affect functional abilities and long-term outcomes. Additionally, pain may increase as one ages due to prolonged prosthesis use such that daily prescription of nonsteroidal anti-inflammatory medications may be needed.Skin breakdown on stump due to prosthesis use may result in additional treatment or surgery.Excessive sweating that affects fit of prosthesis, requiring medical treatment and possible medication.• Vascular compromise or other vascular or circulatory issues related to AK amputation.

The physiatrist should play a valuable role in assisting in the development of the life care plan for the person who has sustained an amputation. An emphasis should be placed on the amputee achieving the ideal level of function with an appropriate rehabilitation program. Just providing a prosthesis is not the same as providing an integrated rehabilitation program that includes a pros­thesis. The emphasis should be placed on the needs and desires of the person with amputation. Measuring the functional outcome, the success of community reintegration, and the individual’s emotional adaptation to the changes are important in developing an accurate life care plan. The physiatrist should serve as an invaluable collaborator with the life care planner in order to develop the most accurate and comprehensive life care plan.

References

Davis, R. (1993). Phantom sensation, phantom pain and stump pain. Archives of Physical Medicine Rehabilitation, 74, 79—84.

Esquenazi, A., Leonard, J. A., & Meier, R. H. (1989). Prosthetics. Archives of Physical Medicine Rehabilitation, 70, 207.

Esquenazi, A., & Torres, M. M. (1991). In L. W. Friedmann (Ed.), Physical Medicine and Rehabilitation Clinics of North America. Philadelphia: W. B. Saunders.

Friedmann, L. (1981). Amputation. In W. Stolov and M. Clowers (Eds.), Handbook of Severe Disability.

Washington, DC: U. S. Department of Education, Rehabilitation Services Administration.

Leonard, J. A., & Meier, R. H. (1993). Upper and lower extremity prosthetics. In J. A. DeLisa (Ed.), Rehabilitation Medicine: Principles and Practices. Philadelphia: J. B. Lippincott.

Meier, R. H. (1994). Upper limb amputee rehabilitation. In A. Esquenazi (Ed.), Prosthetics: State of the Art Reviews. Philadelphia: Hanley & Belfus.

Meier, R. H. (1995). Rehabilitation of the person with an amputation. In R. B. Rutherford (Ed.), Vascular Surgery. Philadelphia: W. B. Saunders.

Meier, R. H. (1996). Upper limb prosthetics: Design, prescription and application. In C. A. Peimer (Ed.), Surgery of the Hand and Upper Extremity. New York: McGraw-Hill.

Meier, R. H., & Atkins, D. J. (2004). Functional Restoration of Adults and Children with Upper Extremity Amputation. New York: Demos Medical Publishing.

Moore, W. S., & Malone, J. M. (Eds.). (1989). Lower Extremity Amputation. Philadelphia: W. B. Saunders. Sears, H. H. (1991). Approaches to prescription of body-powered and myoelectric prosthetics. In L. W. Friedmann (Ed.), Prosthetics: Physical Medicine and Rehabilitation Clinics of North America. Philadelphia: W. B. Saunders.

Sherman, R. A., Sherman, C. J., & Gail, N. A. (1980). Survey of current phantom limb treatment in the United States. Pain, 8, 85—99.

Weed, R., & Sluis, A. (1990). Life Care Plans for the Amputee: A Step by Step Guide. Boca Raton, FL: CRC Press.

Life Care Planning  for the Amputee – Amputation Rehabilitation (I)

Life Care Planning  for the Amputee – Prosthetic Prescription (II)