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

Also, aging with a disability research has shown the onset of additional disabling changes in body systems within 20 to 30 years from the onset of the initial disability. In the amputee, issues of overuse and biomechanical stress and strain do occur over years of altered biomechan­ics. Often, changes are seen in the extremity opposite to the amputated one and also in the more proximal body segments, which take additional stress and strain to compensate for the amputation.

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)

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

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

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

The physiatrist has been trained in the team approach to provide rehabilitative care to persons with simple and complex disabilities. The physiatrist should serve as an ally with the life care planner in determining the ideal outcome of rehabilitative care. In addition, if the physiatrist has been the care provider throughout the active rehabilitation treatment phase, they also will have insights into the psychosocial issues of the person with the disability that will enhance the life care plan. The physiatrist can also medically case manage the variety of health professionals and treatments that are necessary, especially in cases of catastrophic disability. The physiatrist is an excellent resource to provide rehabilitative care and determine equipment costs.

For the person with an amputation, the physiatrist should have the ability to provide meaning­ful information for the life care plan, especially in the following areas:

¦     Point of maximum medical improvement

¦     Life expectancy

¦     Expected functional outcomes

¦     Costs of prosthetic devices

¦     Frequency of prosthetic replacement

¦     Quantity and types of rehabilitation services and their costs

¦    Adaptive equipment needs and costs

¦    Architectural modifications for function

¦    Attendant care hours and level of service

¦     Psychosocial needs

¦    Vocational and avocational expectations and modifications

¦     Work restrictions

¦     Future medical needs

¦     Future surgical needs

If the local physiatrist is unable to provide useful life care planning information, there is a net­work of specialized physiatrists who have years of experience in working with the rehabilitation of specific areas of disability. These physiatric specialists can be located through the life care planner network. They should have extensive experience in providing health care for a person with an amputation. The physiatrist can be of great service to the life care planner in indicat­ing the appropriate level of functional outcome to be achieved and the future needs for the amputee.

The loss of a body part(s) is an emotionally traumatic experience. Yet most persons who sustain an amputation can look forward to a fulfilling life of meaningful function using contemporary pros­thetic designs. The key to successful prosthetic rehabilitation is having an understanding of the desired functional outcome and the rehabilitative process necessary for achieving that outcome. In addition, the physiatrist should provide a time framework for the achievement of the ideal outcome. The physiatrist can also outline the most cost-efficient array of rehabilitative services to achieve the desired rehabilitation goals.

To understand the rehabilitative process for a person with an amputation, it is best to consider the following phases of amputation rehabilitation. These phases, while somewhat artificial, do interweave and flow from one to the next. By knowing the phase of the amputation rehabilita­tive process, the life care planner can identify the issues to be considered in each phase and assist the amputee toward the next phase. The hallmarks of each phase can be used to determine if the amputee is successfully moving through the phases or is delayed in a phase. Being delayed in a phase of rehabilitative care can detract from the best functional or psychosocial outcome and can also add to the costs of health care.

The phases for amputation rehabilitation staging and the setting in which they are usually accomplished in today’s health systems are

OUTPATIENT

Preoperative

INPATIENT

SurgicalAcute postsurgical (some inpatient and some outpatient)

OUTPATIENT

PreprostheticProsthetic prescription and fabricationProsthetic trainingCommunity reentryVocational/avocationalFollow-up

Hallmarks of each phase have been assigned to measure the progress of the person with an ampu­tation from one phase to the next (Table 12.1). There is usually some overlap from one phase to the next, and the person may move more quickly through one phase than another (Meier, 1994). The focus throughout all these phases is on the needs and desires of the amputee. The person’s ability to adapt to an altered body image and, in some cases, an altered lifestyle is essential for achieving the idealized outcome. Paying attention to and providing service for their psychosocial well-being are paramount to successful rehabilitative outcomes.

On a few occasions, the patient is delayed in the decision for an amputation. This is an ideal time for the rehabilitation team to assess and begin a treatment plan focusing on function of the remain­ing extremities. This is also an appropriate time to practice preventive care to maintain full range of motion and strength in the proximal limb muscles of the side to be amputated and also in the intact limb. An aerobic conditioning program should be provided during this phase since this type of exer­cise will hasten the postoperative functional recovery, especially in the use of a leg or arm prosthesis.

Medical and Rehabilitation Progression of Amputation Assess body condition, patient education; discuss surgical level, postoperative rehabilitation, and prosthetic plans.Length, myoplastic closure, soft tissue coverage, nerve reconstruction handling, and rigid dressing.Wound healing, pain control, proximal body motion, and emotional support.Shaping and shrinking amputation stump, increasing muscle strength, and restoring patient locus of control.Team consensus on prosthetic prescription, and experienced prosthetic fabrication.Increase wearing of prosthesis, mobility, and ADL skills.

Resume roles in family and community activities; regain emotional equilibrium and healthy coping strategies; and pursue recreational activities.Assess and plan vocational activities for future; may need further education, training, or job modification.Provide lifelong prosthetic, functional, medical, and emotional support; and provide regular assessment of functional level and prosthetic problem solving.

Amputation surgery should proceed as a reconstructive surgery that will provide a residual limb with the best function, whether or not a prosthesis is likely to be prescribed. A reconstructive phi­losophy of amputation is best accomplished by a surgeon who has performed a number of amputa­tions and understands contemporary prosthetic options and ideal functional outcomes.

In some cases, further reconstructive surgery for the residual limb will be necessary in order to achieve the best prosthetic function and the ideal outcomes following prosthetic fitting. This type of surgery may include both plastic and orthopedic surgery in order to improve the bony elements of the residual limb or surgery to enhance the quality of soft tissue coverage. The costs of this surgical reconstruction would need to be included in the life care plan.

This is a time for wound healing and pain control. Usually there is wound care necessary until the sutures are removed. The rehabilitation focus is on the remaining limbs and instructing the
amputee in preventive exercise for the amputated limb and the intact limbs. Psychosocial support is essential during this period of loss for the individual.

This period is usually accomplished on an outpatient basis. Once the sutures are removed, atten­tion is paid to shaping and shrinking the residual limb in preparation for prosthetic casting. This is a good time to educate the amputee and the family regarding the prosthetic options available, and to develop and review the rehabilitation plan, if it has not previously been accomplished. At this time, careful therapeutic attention should be paid to aerobic conditioning and strength training. Emotional stresses should be anticipated that surround change in body image, function, family roles, and income. Empowering amputees to view themselves as healthy individuals and regaining the locus of control in their life are important components of this phase.

At this phase, the team, including the amputee, should decide on a prosthetic prescription that best meets the person’s needs and desires (Meier, 1995). More and more, the prosthetic prescrip­tion is also dependent on what a third-party payer will sponsor. It is preferable that a prosthetist who is frequently experienced in fitting the specific level of amputation be used to fabricate the prosthesis. The time framework from prosthetic casting until final fitting of the prosthesis should be presented to the amputee and the rehabilitation team for planning purposes.

In this author’s experience, prosthetic prescription is often determined by the prosthetist with little input from other team members, including the patient. There is a great new array of prosthetic components with sophisticated technology continuing to be brought to the market. However, this newer technology is usually more expensive than preexisting components with little to no research to demonstrate when it is most appropriate to use them. In addition, there is meager research to indicate whether it is cost-effective or efficacious to utilize in the prosthetic prescription.

As a general rule, the lower-limb amputee should be fitted within 8 weeks of amputation and the arm amputee fitted within 4 to 6 weeks of amputation surgery. If the upper-limb amputee is delayed in fitting, the chances of using a prosthesis for bimanual activities decreases significantly. They become accustomed to performing activities in a one-handed manner and, therefore, do not find the prosthesis to be of much assistance in performing their daily activities.

This phase is most often accomplished in an outpatient therapy setting with therapists who have trained many amputees with similar levels of amputation and similar types of prosthetic com­ponents. It is important that the therapist have worked with the types of prosthetic components included in the prosthesis. Today’s prosthetic technology is changing so quickly that it is impor­tant that the treating therapist keep abreast of the latest componentry and understand the bio­mechanics of each component. This phase should continue until the expected level of functional outcome has been achieved. The length of treatment time will vary depending on the level of amputation, the amputee’s health, level of function prior to the amputation, associated injuries, and medical problems. The rehabilitation team should proceed with gradual prosthetic wearing and functional training with the goal of achieving the idealized functional outcomes listed in Tables 12.2, 12.3, and 12.4. The rehabilitation treatment plan should focus on the level of func­tion necessary for community reintegration and for vocational and avocational outcomes.

It should be noted that some amputees choose to not wear a prosthesis and function quite well. Many of these non-prosthetic-wearing amputees develop a meaningful quality of life that suits them. A prosthesis may not always be appropriate to include in a life care plan.

Persons with the amputations should begin to resume their roles in the family and the community as quickly as possible following the amputation. Prosthetic training can assist with community reintegration by restoring meaningful function. A psychologist or social worker should assist the amputee in developing productive social interactions with family, friends, peers, and other persons in the community. This reintegration demonstrates a positive emotional adaptive process from the amputee with the motivation to achieve an optimal quality of life. There are some amputees who, for whatever their individual reasons, have not developed a positive emotional adjustment and do not relate a positive quality of life. This maladaptation is more frequently seen in persons who have chronic pain that has not been adequately addressed or who have been depressed or anxious without appropriate counseling.

 Functional Expectations for the Below-Knee Amputee Wears the prosthesis during all waking hoursWalks on level and uneven surfacesCan fall safely and arise from the floorCan hop without the prosthesisParticipates in avocational interestsHas returned to same or modified workPerforms aerobic conditioning exercise (if cardiovascular system permits)Knows how to inspect skin of the amputated and nonamputated legs and footKnows how to change stump socks to accommodate for soft tissue changesKnows how to buy a correctly fitting shoe for the remaining footUnderstands the necessity of follow-up