Occupational Therapy For Lower Limb Amputation Rehabilitation Lauren Hawkins, OTS & Jennifer Tom, OTS Touro University Nevada

Purpose Outline the role occupational therapy in lower extremity amputation care Provide evidence-based occupational therapy practice Discuss protocol for mirror therapy to reduce phantom limb pain Kalapatapu, V. (2014). Lower extremity amputation. Retrieved from http://www.uptodate.com/contents/lower-extremity-amputation College of Occupational Therapy. (2011). Occupational therapy with people who have had lower limb amputations. Great Britain: Lavenham Press

Causes Dysvascular Trauma Cancer-related Congenital (Center for Orthotic & Prosthetic Care, N.D.)

Statistics More than 500 Americans lose a limb daily An estimated 1.9 million people living with limb loss in the United states Annually, the immediate health care costs of limb amputations-not including costs for prosthetic devices or rehabilitation costs, total more than $8.3 billion (CDC, 2015)

Evidenced-Based Research College of Occupational Therapists Specialist Section –Trauma and Orthopaedics is a subsidiary of the British Association of Occupational Therapists 29 critically appraised papers Articles are assigned An evidence score V-I (Low-high) A quality score 0-10 (Low-high) (College of Occupational Therapists, 2011) Level of evidence Systematic review of all relevant RCT At least one properly designed RCT III-1. Pseudo-RCT III-2. Comparative studies III-3. Comparative studies with historical control IV. Case series, Post/pre test V. Surveys, correlation studies, reliability and validity studies, case studies and focus groups Quality: High quality at least 7/10 Medium quality 4-6/10 Poor quality 3/10 or less An evidence score V-I (Low-high) >26 level V , 1 level IV, 1 level III-3, 1 level III-2 A quality score 0-10 (Low-high) >5 high quality, 19 medium quality, 5 poor quality

Areas of OT Interventions Functional rehabilitation Environment Psychology Prosthetic use Assessment tools and outcome measures Cognition Work Leisure and recreation (College of Occupational Therapists, 2011)

Functional Rehabilitation In regards to OT for functional rehabilitation we need to work closely with PTs to meet milestones especially in regards to mobility (College of Occupational Therapists, 2011)

Environment (College of Occupational Therapists, 2011) Consider age of the individual when recommending w/c versus prosthetics (College of Occupational Therapists, 2011)

Psychology (College of Occupational Therapists, 2011) Consider the individual’s self-concept, psychosocial factors such as depression and anxiety, phantom pain Numerous assessments that can be utilized in order to assess things such as coping and body image (College of Occupational Therapists, 2011)

Prosthetic Use (College of Occupational Therapists, 2011) Consider the following -level of amputation, condition of residual limb and prognosis -co-morbidities -cognition -pre-amputation lifestyle and roles Common reason for not wearing prosthesis: cosmetic problems, or discomfort at follow up Meuleembelt et all (2006) systematic review of literature of skin disorder and conclude that it is a prevalence in residual limb, thus, skin, checks are important (College of Occupational Therapists, 2011)

Assessment Tools and Outcome Measures Purpose: appraise and monitor service effectiveness -assess rehabilitation needs -set client-centered goals -evaluate outcomes -determine whether goals have been achieved Outcome measures should have validity and reliability and responsiveness to change Amputee Activity Score (AAS): -ability to don or doff prosthesis -hours per day wearing prosthesis -use of walking aids -amount of walking -type of house -ability to climb stairs (College of Occupational Therapists, 2011)

Assessment Tools Cont. (College of Occupational Therapists, 2011)

Cognition (College of Occupational Therapists, 2011) 1. Sansam et all (2009) found that cognitive impairment is a predictor of poor prosthetic use following lower limb amputation 2. Kendrick Object Learning Test (KOLT) >assesses older people’s cognitive abilities through immediate recall of visual and auditory information, assessing speed of processing and recording information >Larner et all (2003) found that KOLT correctly predicted whether people with lower limb amputation will use a prosthesis during the inpatient rehab programme 3. CAPE >measures the degree of cognitive and behavioural impairment through orientation, mental abilities, psychomotor performance tests and behavior rating scale e >can be used to help facilitate wheethere the prostheesis should be prescribed (College of Occupational Therapists, 2011)

Work (College of Occupational Therapists, 2011) Schoppen et all (2001b) found that people who had to stop work as a result of their amputation showed a worse health experience than those people with an amputation who continued working Factors preventing/delaying return to work >problems related to the stump (Bruins et all 2003) >wearing comfort of the prosthesis (Schoppen et all 2001a) >educational level (Schoppen et all 2001a) >age at the time of amputation (Schoppen et all 2001a) >co-morbidity (Schoppene et all 2002) >workplace modifications (Schoppen et all 2001b, Bruins et all 2003) (College of Occupational Therapists, 2011)

Leisure and Recreation Constraints on participate in leisure activities for people with lower limb amputations were lack of accessibility, material considerations, functional abilities, affective constraints, social constraints (Couture et all 2009). Benefits of leisure activities >natural opportunities for social interaction and friendship, and provide a sense of identity and social inclusion (Lloyd ete all 2000, Pegg and Moxham 2000, Taylor 2003) >reduce psychological distress (Waters and Moore 2002) >protect against and enable individuals to manage stress (Iwasaki 2001, Kleiber et all 2002). >increase self-esteem and confidence (Baxter et al 1995, Passmore and French 2000) >enhance physical health (Cassidy 1996) 3. Consider the Pt.’s age as older individuals may prefer solitary leisure (College of Occupational Therapists, 2011)

Areas of OT Intervention Con’t Prevention of contractures at hip and knee Edema reduction Fall prevention Trunk stability Assist with other deficits/comorbidities

Care of the Remaining Limb Skin inspection to avoid skin breakdown and infections Do not cut on corns or calluses Have a podiatrist cut your nails Avoid walking barefoot Do not wear socks that have holes, change socks daily Break in new shoes slowly Wear only well-fitting shoes (Hall, 2009) Lauren Starts

Foot Care for People with Diabetes Check feet daily Wash feet daily Keep skin soft and smooth Smooth corns and calluses Trim toenails regularly Wear shoes and socks Keep blood flowing to the feet (National Institute of Health, 2014) Steri Shoe. (2014). Retrieved from http://www.sterishoe.com/foot-care-blog/diabetes/smart-tools-improve-diabetic-foot-outcomes/

Care for the Residual Limb Wash residual limb regularly Inspect residual limb daily and can be completed using a long-handled mirror Skin desensitization Do not shave residual limb Do not soak residual for prolonged time to prevent swelling (Hall, 2009) Wash residual limb every evening with lukewarm water and mild soap. Evening bathing is recommended beceause bathing may cause residual limb to swell and may affect prosthesis fitting (Hall, 2009). Inspect limb for signs of infections --Signs of infection: >warm, red and tender skin >discharge of fluid or pus >increasing swelling (http://www.nhs.uk/Conditions/Amputation/Pages/Recovery.aspx >https://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000014.htm Your stump looks redder or there are red streaks on your skin going up your leg Your skin feels warmer to touch There is swelling or bulging around the wound There is new drainage or bleeding from the wound There are new openings in the wound, or the skin around the wound is pulling away Your temperature is above 101.5 °F more than once Your skin around the stump or wound is dark or it is turning black Your pain is worse and your pain medicines are not controlling it Your wound has gotten larger A foul smell is coming from the wound Skin desensitization -gently massage residual limb daily helps decrease sensitivity and increase pressure tolerance (Hall, 2009) -steps: >gently tapping skin with face cloth >using compression bandages to help reduce swelling and prevent fluid buildup -rubbing and pulling the skin around bone to prevent excessive scarring (http://www.nhs.uk/Conditions/Amputation/Pages/Recovery.aspx) https://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000014.htm

Prosthesis and Socks Prosthesis and socks should be cleaned and dried Wear new socks daily Inspect residual limb with a mirror for signs of irritation/infection Don sock prior to prosthesis to protect skin from sores and injury with seams facing out Ensure socks fit without folds or wrinkle as this can irritate the skin (Hall, 2009)

Management of Phantom Pain Phantom limb pain: Painful sensation that is perceived in a body part that no longer exists Exercise limb to increase circulation Distraction, change position Soak in warm bath or shower massage on residual limb Massage gently to increase circulation Keep a diary of pain to help identity recurring causes Relaxation techniques (Hall, 2009)

Mirror Therapy for Phantom Limb >90% experience phantom limb Experimental groups: Mirror group, covered mirror, visual imagery Sample size: 18/22 completed the study Results: After 4 weeks of therapy, findings indicated mirror therapy reduced phantom limb pain in patients with lower limb amputation Mirror therapy video: https://www.youtube.com/watch?v=HMIparaWrUo (5:44) (Chan, B., Witt, R., Charrow, A., Howard, R., Pasquina, P., Heilman, K., &Tsao, J, 2007)

Protocol for Mirror Therapy Condition of limb: normal and pain-free ROM No visual impairments Normal cognition level Remove all jewelry and cover tattoos or scars Sitting tolerance WFL Complete daily for at least 10 mins Some patients are unable to tolerate the image of having two intact limbs May sweat, become dizzy or emotional Have patient focus on another point in the room, the intact limb or stop the session all together Removing jewelry/covering tattoos helps facilitate the vividness of the mirror illusion (Rothgangel, Braun, Witte, Beurskens, & Smeets, 2015)

Protocol for Mirror Therapy Sit without prosthesis with mirror in between legs at patient’s midline in a comfortable and supported position Start with simple motor or sensory exercises Increase difficulty as sessions continue Aim for high repetitions (at least 15) Try to include patient’s hobbies or interests in sessions Prepare patient at end of session to view the amputated limb (Rothgangel et al., 2015)

Examples of Interventions (Rothgangel et al., 2015)

April is Limb Loss Awareness Month CDC supports and provides funding for Amputee Coalition National Limb Loss Resource Center (http://www.amputee-coalition.org/limb-loss-resource-center/) In 2013, the Amputee Coalition launched Show Your Metal with the goal of showing that amputees are resilient by encouraging amputees to display their strength of character by showing their metal, such as prosthetic devices or wheelchairs (CDC, 2015)

References CDC (Apr. 20, 2015). Limb loss awareness. Retrieved from http://www.cdc.gov/ncbddd/disabilityandhealth/features/limb-loss-awareness.html Center for Orthotic & Prosthetic Care. (N.D.). Amputation statistics. Retrieved from http://www.centeropcare.com/Portals/COPC/Amputation%20Statistics.pdf Chan, B., Witt, R., Charrow, A., Howard, R., Pasquina, P., Heilman, K., &Tsao, J. ( 2007). Mirror therapy for phantom llimb pain. The New England Journal of Medicine, 357, 2206-2207. doi: 10.1056/NEJMc071927 College of Occupational Therapists. (2011). Occupational therapy with people who have had lower limb amputations. Retrieved from https://www.cot.co.uk/publication/z-listing/occupational-therapy-people-who-have-had-lower-limb-amputations-evidence-bas-0

References cont. Hall, C. (2009). Occupational therapy toolkit. Timonium. MD. National Institute of Health. (2014). Diabetic Foot. Retrieved from https://www.nlm.nih.gov/medlineplus/diabeticfoot.html NCBDE. (n.d.). Eligibility requirements. Retrieved from http://www.ncbde.org/certification_info/eligibility-requirements Rothgangel, S. A., Braun, S. M., Witte, L. D., Beurskens, A. J., & Smeets, R. J. (2015). Practical protocol mirror therapy phantom limb pain. Retrieved from https://www.researchgate.net/publication/275038036_Practical_protocol_mirror_therapy_phantom_limb_pain