Stages of Care

8/19/2019 Stages of Care

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Stages of Care

Understanding the time frame of recovery from lower limb amputation is essential to the design and implementation

of any postoperative management strategy. Although today's health care system has placed an emphasis on speed, the

consensus committee participants agreed that placing an emphasis on shortening the time of healing and recovery

following limb loss is not necessarily the wisest path.

Regardless of the etiology, the postoperative recovery period after the amputation of a lower extremity typically is 12to 1 months and simply cannot be rushed. 1 !his 'recovery period' includes activity recovery, reintegration,

prosthetic management, and training. "ome members of the expert panel of the consensus committee felt that settingfast#paced and often unrealistic goals can lead to a sense of failure in an individual who is actually progressing

normally.

!he postoperative year#long continuum does not separate easily into $stages$. %owever, an attempt to define thestages of recovery has been made to facilitate discussion of how the goals evolve throughout the rehabilitative process.

A. Preoperative Stage

!he preoperative stage typically starts with the very difficult decision of whether to amputate. !his stage also includes

an assessment of the vascular status and decisions on attempts to improve circulation. !he difficult process of level

selection, preoperative education, emotional support, physical therapy and conditioning, nutritional support, and

pain management also all occur in this stage of care.



B. Acute Hospital Postoperative Stage

!he acute hospital postoperative stage is the time in the hospital after the amputation surgery. !his hospital timetypically ranges from & to 1 days.

C. Immediate Postacute Hospital Stage

(n general, this stage begins with hospital discharge and extends , ), or even wee*s after surgery. !his is the time of

recovery from surgery, a time of wound healing, and a time of early rehabilitation. +re uently, end points of this stageare characteri-ed as the point of wound healing and the point of being ready for prosthetic fitting. %owever, it should

be noted that healing of a residual limb is a continuous process, and the limb does not have a clear and decisive point

of $being healed.$ +urthermore, prosthetic readiness is a transition point that is difficult to standardi-e and measure.

uch of the current research comparing different postoperative management strategies attempts to use these two

elusive end points with varying results.

D. Intermediate Recovery Stage

!his is the time of transition from a postoperative strategy to the first formal prosthetic device. %istorically, this

device was called the $preparatory$ prosthesis, but with the use of higher technology earlier in the process, it is

sometimes simply called the $first prosthesis.$ !he term $preparatory$ has traditionally been lin*ed to very basic

prosthetic styles and components. !he consensus committee participants felt that the historical interpretation of

$preparatory prosthesis$ is no longer ade uate.

(t is during this stage that the most rapid changes in limb volume occur, due to the beginning of ambulation and

prosthetic use. !he immediate recovery period begins with the healing of the wound and usually extends to )months from the healing date. Although difficult to define, this stage ends with the relative stabili-ation of the

residual limb si-e, as defined by consistency of prosthetic fit for several months.

E. Transition to Stable Stage



!his period is defined as a period of relative limb stabili-ation after the fourth stage when rapid limb volume changesoccurred. Although limb volume changes are not as drastic as in this stage, the limb will continue to change to some

degree, for a period of 12 to 1 months after initial healing. %istorically, this stage was mar*ed as a transition fromthe $preparatory$ to the definitive prosthesis. /urrently, with the use of higher technology and modular systems in theprevious stage 0 Intermediate Recovery Stage , this transition is no longer defined by a change in the prosthesis,

but rather a change from a rapidly changing limb to a slower maturation of the limb. !he prosthesis will still re uire

occasional ad ustments, and visits to the prosthetist will remain relatively fre uent until after the first year ofprosthetic use. odular systems are appropriate and encouraged to enhance ease of soc*et replacement in this stage.

(n this phase the patient should move toward social reintegration and higher functional training and development as

well as becoming more empowered and independent from his or her health practitioner.

!he fitting of the definitive prosthesis may certainly occur within this time period3 however, limb stabili-ation must

occur before definitive fitting. Residual limb volume must be stable so the device can be used for an extended period

of time. !his extended period of time is typically 2#& years in adults and as long as 1 year in growing children.

4efining limb stability is very difficult. +or most patients, the period of limb stabili-ation re uires at least ) months of

prosthetic use.

Clinical Concerns

!he expert panel for this consensus committee identified fourteen clinical concerns in the stages of recovery.

1.Determination of Amputation Level

2.Minimize systemic complications

3.Prevent contractures

4.Bed mobility and transfers



.Pain mana!ement

".Protect amputated limb from trauma

#.$all prevention

%.&motional care'education

(.Mana!e and teac) about *ound )ealin!

1+. Promote residual limb muscle activity

11. &arly ambulation

12. Advanced ambulation

13. ,ontrol limb volume c)an!es

14. -run and body motor control and stability

5ach concern will ta*e on a different level of importance at different stages of the healing process. "ince the goals of

care change at each stage of rehabilitation, a table of clinical concerns and treatment goals was established by theconsensus committee for each stage. 0 Table 1) !here may be overlap between stages which may vary with individual

differences.

-able 1. ,)an!in! clinical concerns durin! t)e sta!es of recovery after a



lo*er limb amputation

!hese clinical concerns and treatment goals may be used by clinicians for development of treatment protocols and

guidelines within their communities. 5ach goal of the table is ran*ed in relative importance with regard to the level of

clinical concern at each stage of rehabilitation. +or example, the determination of amputation level is of concern at

the preoperative stage however, it is usually of little concern after the surgery. /onversely, emotional care is of high

clinical concern through most of the rehabilitation process, with a slight drop off in the intermediate recovery stage

and with a renewed concern at around 1 year after the amputation.

Although progression through these phases is largely individual, the time needed to progress is reported consistently

between 12 and 1 months. (t is during this extended time that many individuals still have significant changes in limb

volume that must be considered and managed. 4uring this 12 to 1 month period, social reintegration, life planning,

and goal setting all progress as well. +or pediatric amputees, the stages of recovery and the clinical concerns are

modified to ta*e into account the developmental milestones of the growing child. +inally, in the later portions of the

process come the mastery of prosthetic use and a desired range of activities.

Physical Therapy and Prosthetic Management

Although the role of all team members is to assess, educate, and motivate the patient, the role of two particular

members of the team, the physical therapist and the prosthetist, during this long period is often underestimated.

• Physical therapy treatment continues t)rou!)out t)is entire period *it) speci/c

re)abilitation protocols desi!ned to meet t)e speci/c needs of eac) amputee. ,ontinualreevaluation and updatin! of t)e amputee0s pro!ram is essential to ensure t)at eac) patientreac)es )is or )er ma imal activity level *it) a prost)esis.

o Alt)ou!) t)e patient must be an active participant in )is or )er re)abilitative care t)e

treatment !uidelines and speci/c e ercises are t)e t)erapist0s responsibility and an inte!ralcomponent of t)e continuum of care for t)e /rst 12 to 1% mont)s.

• Initial prosthetic management after amputation re uires strate!ies di erent from t)ose

used durin! t)e period after residual limb stabilization.



o Durin! t)e initial time frame t)e prost)etist is 5c)asin! a movin! tar!et 5 as t)e

residual limb c)an!es dramatically in volume and s)ape. 6 -)erefore t)e de/nitive prost)esiss)ould not be prescribed or /t until t)e limb )as be!un to stabilize and t)e 5movin! tar!et5 )asslo*ed considerably.

o 7tabilization is di8cult to de/ne and needs to be furt)er researc)ed. 9o*ever *)en a

patient )as used a prost)esis full time for a period of at least " mont)s and *)en t)e limbvolume )as stabilized to a point t)at soc et /t remains relatively consistent for at least 2 to 3*ee s a de/nitive prost)esis may be indicated.

• Intermediate prosthetic management concentrates on edema reduction and to de/ne limbstabilization.

o Additional studies need to be done to determine t)e most appropriate tec)ni ue to

ac)ieve t)is stabilization.o Little literature is available t)at attempts to de/ne *)en ad:ustment of t)e current

soc et may meet t)e needs of t)e patient versus *)en soc et replacement is re uired. ,learlyresearc) is needed in t)is area.

+inally, it should be noted that a patient may return to wor* during this rehabilitative period, not ust at the end of

the process.

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Stages of Care