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Lower Extremity Amputation Care by Therapists - Adult - Inpatient/Ambulatory

Lower Extremity Amputation Care by Therapists - Adult - Inpatient/Ambulatory - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Rehabilitation Therapy


1
Lower Extremity Amputation Care by
Therapists – Adult –
Inpatient/Ambulatory
Clinical Practice Guideline
Note: Active Table of Contents – Click to follow link
EXECUTIVE SUMMARY ........................................................................................................... 3
SCOPE ...................................................................................................................................... 4
METHODOLOGY ...................................................................................................................... 4
DEFINITIONS: ........................................................................................................................... 5
INTRODUCTION ....................................................................................................................... 5
Phases of Recovery ............................................................................................................................ 6
RECOMMENDATIONS .............................................................................................................. 7
1. Pre-Amputation Phase .................................................................................................................... 7
2. Acute Post-Amputation Phase ........................................................................................................ 9
3. Acute Rehabilitation Phase ........................................................................................................... 13
4. Community Reintegration Phase/Return to Home ........................................................................ 17
5. Long Term Management ............................................................................................................... 21
UW HEALTH IMPLEMENTATION ............................................................................................24
Patient Resources: Health Facts for You .......................................................................................... 24
Durable Medical Equipment .............................................................................................................. 24
Assessment Tools ............................................................................................................................. 24
Community Resources ...................................................................................................................... 25
APPENDIX A. EVIDENCE GRADING SCHEME(S) .................................................................28
APPENDIX B: SAMPLE DOCUMENTATION ...........................................................................29
REFERENCES .........................................................................................................................58
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2
Content Expert(s):
Name: Sarah Smith, PT
Phone Number: (608) 263-8060
Email Address: ssmith6@uwhealth.org
Name: Sarah Jones, OT
Phone Number: (608) 263-6443
Email Address: sjones4@uwhealth.org
Contact for Changes:
Name: Lindsey Spencer, MS – Center for Clinical Knowledge Management (CCKM)
Phone Number: (608) 890-6403
Email Address: lspencer2@uwhealth.org
Workgroup Members:
Susanne Angileri, MPT – Inpatient Physical Therapist
Sandy Grady, PT – Outpatient Physical Therapist
Sarah Jones, MOT, CLT – Inpatient Occupational Therapist, Rehab Manager
Lynelle Palma, DPT, CLT – Home Health Physical Therapist, Therapy Supervisor
Deb Schuetz, COTA – Inpatient Occupational Therapy Assistant
Sarah Smith, MPT – Inpatient Physical Therapist
Janet Spaeth, OTR – Outpatient Occupational Therapist
Reviewer(s):
Jon Matsumura, MD, UWSMPH Chief of Vascular Surgery
Lee Faucher, MD, UWSMPH Department of Surgery
Amy Paulios, Certified Prosthetist, Prosthetic Laboratories
Lauren M. Dallman, MS, RN, ACNP, Division of Vascular Surgery
Dave Maiers, PT, Rehab Manager, UW Health
Committee Approvals/Dates:
Ortho Rehab Therapy Executive Council Clinical Practice Guidelines Committee (05/03/2017)
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3
Executive Summary

Guideline Overview
This clinical guideline is a guide for the rehabilitation process for adult patients after lower
extremity amputations. It was developed by Physical Therapists and Occupational Therapists at
University of Wisconsin Hospital and Clinics in collaboration with vascular surgery, the physical
medicine and rehabilitation department, and local prosthetists. An evidence based approach
was utilized in development of this standard of care.

Key Practice Recommendations – presented in order of phases of care
ξ Prevent knee and hip flexion contractures in each phase of recovery for maximal
functional outcomes and eventual prosthetic use as well as preventing skin
breakdown.1-3 (UW Health Low quality evidence, strong recommendation)
ξ Strengthen all four extremities and trunk to prevent deconditioning during recovery and
to reach highest functional outcome.1-3 (UW Health Low quality evidence, strong
recommendation)
ξ Protect residual limb and manage edema to aid healing and limb shaping, and to
facilitate pre-prosthetic care. Prevent additional skin breakdown and maintain health of
contralateral lower extremity to avoid delay in prosthesis fitting. Use of rigid removable
dressing is recommended for decreased time in wound healing, decreased time to
prosthetic, and decreased time to independent walking.4-9 (UW Health High quality
evidence, conditional recommendation)
ξ Begin planning for long-term home management immediately and continue through all
phases of care. This should be an interdisciplinary approach, and should include social
support, any environmental barriers, need for ongoing services, and durable medical
equipment. (UW Health Very low quality evidence, strong recommendation)
ξ Collaborate with team to safely progress functional mobility and engagement in self-
cares as appropriate at each phase of recovery in order to meet patient’s goals for
return to community. High level, acute inpatient rehabilitation with interdisciplinary
approach is recommended for best functional outcomes.10,11 (UW Health Low quality
evidence, strong recommendation)
ξ Address phantom limb pain and phantom limb sensation with use of mirror therapy.12-17
(UW Health High quality evidence, strong recommendation)
ξ Provide fall prevention education and implement fall prevention techniques at all phases
of care.18-20 (UW Health Low quality evidence, strong recommendation)


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4
Scope
Disease/Condition(s): Adults with lower extremity amputations

Clinical Specialty: Physical Therapy, Occupational Therapy, Physical Medicine and
Rehabilitation, Vascular, Trauma, Orthopedics, Burn

Intended Users: Physical Therapists, Physical Therapist Assistants, Occupational Therapists,
Occupational Therapy Assistants across practice environments including acute care, acute
rehabilitation, subacute rehabilitation, home health, and outpatient therapies.

Objective(s): This clinical guideline is a guide for the rehabilitation process for adult patients
after lower extremity amputations across the phases of recovery. It was developed by Physical
Therapists and Occupational Therapists at University of Wisconsin Hospital and Clinics in
collaboration with vascular surgery department, trauma surgery department, and local
prosthetists. An evidence based approach was utilized in development of this standard of care.

Target Population: Adults with lower extremity amputations

Interventions and Practices Considered:
ξ Mirror therapy
ξ Edema management
ξ Pre-prosthetic training
ξ Durable medical Equipment recommendations and procurement
ξ Home exercise program prescription
ξ Fall prevention
ξ Therapeutic exercise
ξ Mobility retraining
ξ Activities of daily living and instrumental activities of daily living retraining
ξ Self-management training

Major Outcomes Considered:
By following these recommendations, patient will have the opportunity to achieve maximal
functional outcomes in mobility, activities of daily living, work, leisure, and social participation.
Methodology
Methods Used to Collect/Select the Evidence:
Electronic database searches (e.g., PUBMED) were conducted by the guideline author(s) and
workgroup members to collect evidence for review. Expert opinion and clinical experience were
also considered during discussions of the evidence.

Methods Used to Formulate the Recommendations:
The workgroup members agreed to adopt recommendations developed by external
organizations and/or arrived at a consensus through discussion of the literature and expert
experience. All recommendations endorsed or developed by the guideline workgroup were
reviewed and approved by other stakeholders or committees (as appropriate).

Methods Used to Assess the Quality of the Evidence/Strength of the Recommendations:
Recommendations developed by external organizations maintained the evidence grade
assigned within the original source document and were adopted for use at UW Health.
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5

Internally developed recommendations, or those adopted from external sources without an
assigned evidence grade, were evaluated by the guideline workgroup using an algorithm
adapted from the Grading of Recommendations Assessment, Development and Evaluation
(GRADE) methodology (see Figure 1 in Appendix A).

Rating Scheme for the Strength of the Evidence/Recommendations:
See Appendix A for the rating scheme(s) used within this document.

Recognition of Potential Health Care Disparities: Patients who receive lower extremity
amputations have been associated with health disparity related to gender and ethnicity.21 Fall
risk with injury is also increased for women and racial minorities. Rehabilitation professionals
should insure fall prevention exercises and recommendations are provided to all patients with
lower extremity amputations and should ensure women and racial minorities receive this
education.18
Definitions:
Types of amputations included in this document:

Transmetatarsal Amputation (TMA): Foot amputation in which an incision is made through the
mid to proximal metatarsal shafts to remove the distal structures; amputation of the forefoot

Below the knee amputation (BKA) or Transtibial amputation (TTA): Removal of a portion of
the tibia, fibula and foot, but preserving the knee joint

Above the knee amputation (AKA) or Transfemoral amputation (TFA): Removal of the lower
leg, foot and knee joint, but preserving a portion of the femur
Introduction
Currently, over 1.6 million people are living after limb loss in the United States. This number is
expected to more than double by 2050.22 Causes of lower extremity amputation include vascular
deficits, trauma, or oncologic issues, with vascular conditions being the leading cause of
amputation.22 Within vascular, peripheral vascular disease and diabetes, are the main factors
leading to lower extremity amputation.23 Limb loss impacts a person’s ability to engage in
regular activities including mobility, self-cares, relationships, and productivity. Rehabilitation is
an important part of the process after amputation to provide opportunity for people to return to
fully functioning members of society.

Complications of lower extremity amputation include residual limb pain, phantom limb pain,
contractures, infection, residual limb dehiscence, hematoma, atrophy, blood clots, skin break
downs or pressure sores.23

The relationship a patient develops with a prosthetist is crucial as this relationship will impact
the rest of their life. It is important for patients to be aware of their insurance coverage and to
find prosthetists and rehabilitation professionals that are approved providers.

Limb shaping – Following surgery, a patient’s operative limb will be edematous. Depending on
healing and protocol of the patient’s surgeon, methods will be chosen to assist in controlling this
edema and shaping the limb for eventual prosthetic use. These methods may include elastic
bandages, amputee shrinker socks, tubular compression, and rigid removable dressings.
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6
Phases of Recovery

1. Pre-amputation phase: the period of time prior to the surgical procedure for an
amputation.

2. Acute post-amputation phase: the period of time from post op day #0 to approximately
10-14 days post-operative (approximately until the staples or sutures are removed)

3. Acute rehabilitation phase: the period of time focusing on improving function to return to
safe mobility and self care skills, most often before returning home. This phase most
often occurs in an inpatient rehabilitation unit or skilled nursing facility, but may also
include home health therapy. This phase may overlap with phase 2.

4. Community reintegration phase/return to home: the period of time after an amputation
when a person has returned home and is beginning to reintegrate into their previous
roles and functional tasks. A person may be receiving home health therapies or
outpatient therapies.

5. Long term management phase: the period of time when a person has achieved stable
function skills including mobility and self care skills, they have returned to previous roles
or modified their roles. Most people in this phase or no longer receiving skilled therapy
and are at a self-maintenance level of care.

Patients will progress through the phases of recovery at slightly different rates. The phases of
recovery may overlap. Lengths of the phases are also impacted by healing and rehabilitation.
Physician preferences and technique will also vary from patient to patient and with the unique
needs of each patient.

This clinical guideline reviews areas of consideration for each of the phases of recovery for
patients who encounter any rehabilitation professional. The areas of consideration include rehab
goals, precautions, pain management and pain control, mobility, self cares, exercises, medical
management, edema control, wound and skin care, positioning, medical professionals involved,
and psychological management.















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7
Recommendations

1. Pre-Amputation Phase
the period of time prior to the surgical procedure for an amputation
At this stage, education and counseling are the primary goals. Patients are often in
physical as well as emotional pain as they adjust to the idea of amputation. Developing
rapport, providing emotional support, and answering any questions they may have will
assist in the post-operative phase as the patient and family will already be familiar with
you as a therapist, and have some idea of what to expect from the process.
Considerations
Rehab Goals
Goals may include:
ξ Education, what to expect (e.g., length of limb,
length of time it may take to get to prosthetic,
disposition options and role of physical therapy
[PT] and occupational therapy [OT] services)
ξ Discussion of home modification
ξ Pre-operative mobility assessment
Precautions Fall risk Weight bearing status dependent on physician orders
Pain Control/Management Variable per patient, managed by physician.
Mobility
Recommend bringing a comfortable, supportive shoe for
the non-operative foot to allow for mobility post-
operatively. The patient may need an assistive device to
perform mobility.
Self Cares
Maintain level of functioning. May need adaptive
equipment to perform self cares.
Education in foot care
Exercises Maintain range of motion (ROM) and strength in all
extremities.
Medical Management
Considerations
Management per medical/surgical team.
Considerations for therapists may include:
ξ wound care
ξ pain management
Clinic/nursing staff may issue educational materials on
what to expect. (Below and Above Knee HFFY 7105,
HFFY 4887) (Transmetatarsal HFFY 4892)
Edema Control
If edema present and Ankle Brachial Index (ABI) is less
than 0.5 then NO compression is recommended for lower
extremity.
If ABI is 0.8-0.5, then approval for compression from the
Vascular Medicine provider is needed.
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8
1. Pre-Amputation Phase
the period of time prior to the surgical procedure for an amputation
Wound/skin care Per physician or wound/skin team. May have wound vac.
Positioning Keep affected extremity elevated. Maintain ROM. Position
per comfort or physician (MD) order.
Equipment Potential needs include: shower chair, wall mounted grab
bars, walker, cane, wheelchair, crutches.
Prosthetics Education on role of prosthetists. Consider options for
prosthetists. Investigate insurance coverage.
Medical Professionals
that may be involved at this
phase
Vascular, Burn, or Orthopedic surgeon, Physical Medicine
and Rehabilitation (PMR) physician, home health
services, wound nursing, PT, dietician
Psychological Management
Provide education on rehabilitative process, functional
outcomes, and an initial introduction to prosthetic process.
Consider a health psychology referral if needed.
Therapy Assessment
Options
Timed Up and Go (TUG)
Sensory assessment with Semmes-Weinstein
monofilaments. Use 10g monofilament to assess the
intact foot for protective sensation, and if not present, to
educate the patient about risks and coordinate protective
footwear prescription
Ankle Brachial Index (ABI)
Bilateral Amputees
If the patient has had a prior amputation on the opposite
limb, ask the patient if they use a prosthetic. Recommend
bringing any appropriate equipment they already own
(e.g., shrinker socks, prosthetic, wheelchair) to the
hospital. Educate on the importance of good edema
control for the non-surgical limb, so that their prosthetic
will still have proper fit once cleared for mobility. If the
patient no longer has a shrinker sock, the patient may
wear their roll-on gel liner for edema control. Ask the
patient for their prosthetist’s contact information, and ask if
they can be contacted if needed for pre-prosthetic limb
care.
Immediate Intra-Operative
Prosthesis (IPOP)
Assess upper extremity strength to ensure that the patient
will be able to support weight in ambulation due to weight-
bearing restrictions.
Consider social support, and if the patient’s rehabilitation
facility and home will be close to a prosthetist to be able to
maintain IPOP

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9
2. Acute Post-Amputation Phase
the period of time from post op day #0 to approximately 10-14 days post-operative

Patients will be at varying levels of mobility and acceptance post-operatively. Goals at
this phase include progressing functional mobility, providing education, and facilitation to
next level of care. The therapist’s role in recovery for a new amputee is very important.
In the acute care setting, we have a great opportunity to start them on a path to
acceptance and independence.
Considerations
Rehab Goals
Goals may include:
ξ Initiate upper extremity (UE) and lower extremity
(LE) home exercise programs (HEP).
ξ Patient will perform bed mobility with stand-by
assistance.
ξ Patient will maintain seated balance at edge of bed
while performing activities of daily living (ADLs)
ξ Patient will perform bed to chair and commode
transfers with assist. Use of walker, gait belt,
seated slideboard as needed.
ξ Progress to ambulation with appropriate assistive
device and use of gait belt.
ξ Patient will propel wheelchair 150 feet with bilateral
upper extremities, demonstrate good use of brakes,
with stand-by assist and verbal cues.
ξ Patient will verbalize understanding of limb
protection and use of compression, rigid removable
dressings, and knee immobilizers as applicable
ξ Patient will demonstrate non-pharmacological pain
relief techniques such as gentle skin desensitization
and mirror therapy.
ξ Assist patient and family in progressing to most
appropriate next level of care with ongoing therapies
after hospital discharge.
Precautions
Fall risk
Fall prevention strategies: bed in lowest position, bed
alarm, chair alarm, consistent rounding for toileting, pain,
possession checks
Knee immobilizer for BKA
Heel weight bearing shoe for TMA
Non weight bearing (NWB) post op BKA and AKA, heel
weight bearing for TMA
Pain Control/Management
Nerve blocks, managed by physician
Oral medications, managed by physician
Gentle residual limb massage (tapping/rubbing through soft
dressing) may be completed. Educate the patient on hand
hygiene prior to limb massage with healing incision.
Assess for phantom pain or sensation:
ξ Utilize mirror therapy13,14 (HFFY 7540)
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10
2. Acute Post-Amputation Phase
the period of time from post op day #0 to approximately 10-14 days post-operative
ξ Current best evidence shows that mirror therapy for
15 minutes for at least 4 weeks has statistically
significant reduction in phantom limb pain12.
ξ Notify physician for possible consideration of
medication management.
Cryotherapy or superficial thermal modalities if appropriate
(consider sensation and vascularization prior to initiating).
Mobility
Seated balance
Transfers based on assessed ability (seated slideboard
versus stand pivot, use of mechanical lift if unable to safely
perform manual transfer)
Wheelchair
Short distance ambulation if appropriate/cleared by PT
In more advanced patients, may assess stairs
Self Cares
Begin edge of bed ADLs
Progress to commode transfers
Education in foot care
Exercises
Upper Extremity (UE) Exercises: focus on initiating UE
exercises to prevent hospital deconditioning, begin
exercises to support pressure relief and increased use of
UEs during functional mobility.
Supine LE Exercises: progress (pending tolerance) to
positioning, dressings, nerve blocks, and lines. May
remove knee immobilizer for exercises
Medical Management
Considerations
Management per medical/surgical team. Considerations for
therapists may include:
ξ Post-operative dressings
ξ IVs, lines and drains
ξ Foley catheter
ξ Oxygen
ξ Nerve block
ξ Pain management
ξ Suture removal per surgeon
ξ Consider blood sugar levels if applicable
Edema Control
Post-operative dressing
Elastic wrap (see HFFY 4409) or tubular compression
garment with MD order.
Shrinker sock with MD order. Use sock donner for comfort
and to prevent shearing (HFFY 7679).
Peri-operative casting to residual limb (dependent on
surgeon orders)
Wound/skin care
Suture care per primary medical provider
Peri-operative casting to residual limb (dependent on
surgeon orders).
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11
2. Acute Post-Amputation Phase
the period of time from post op day #0 to approximately 10-14 days post-operative
Positioning
For patients with BKA, keep knee in extension with
immobilizer. Check appropriate fit to be sure straps do not
cause pressure on patella.
For patients with BKA and AKA, avoid keeping limb on a
pillow at all times to prevent hip flexion contracture.
Patients should get out of bed 2-3 times per day.
Pressure relief techniques with frequent position changes
are suggested to maintain skin integrity (HFFY 7616).
Equipment (for in hospital
use, possibly for home if
discharging directly home)
From Central Supply (CS):
Order bedside commode or drop arm commode
Walker or crutches
Possibly cane for TMA
Wheelchair: consider residual limb support, anti-tippers,
possible need for lightweight or high-strength lightweight
chair
Seated slideboard
Heel weight bearing shoe for TMA
Knee immobilizer (usually placed in OR post op), should be
checked post-operatively for proper fit.
If the patient is discharging directly home, then coordinate
equipment with Case Manager.
Prosthetics
If ordered, PT or local prosthetist may fabricate a Rigid
Removable Dressing for patients with BKA post-op day 3-5
for protection and limb shaping. (HFFY 6592) Rigid
Removable Dressings (RRD) are associated with reduced
time to wound healing, initial prosthetic casting, and
independent walking.5,6 They have also been shown to
have comparable results to conventional non-removable
post-op casting.4
Shrinker sock should be applied for patients with BKA post-
op day 3-5 for edema management and limb shaping.
Discussion with prosthetist should be offered to the patient
and facilitated if appropriate. Provide the patient with
information on local prosthetic services.
If the surgeon orders intra-operative prosthetic, close
collaboration between therapy and prosthetist is required.
Medical Professionals that
may be involved at this
phase
Surgeon, anesthesiologist, PMR physician, Nurse
Practitioner (NP), registered nurse (RN), nursing assistant
(NA), PT, OT, social worker (SW) or case manager (CM),
health psychologist, prosthetist, dietician
Psychological
Management
Be sensitive to language. Many patients find use of the
word “stump” to be disheartening and offensive. Suggested
alternatives are “residual limb” or “surgical leg”.
Assess/acknowledge the patient’s readiness to view and
touch residual limb prior to initiating exercise or self cares.
Consult health psychology if patient amenable and
appropriate.
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12
2. Acute Post-Amputation Phase
the period of time from post op day #0 to approximately 10-14 days post-operative
Therapy Assessment
Options
Range of motion for upper extremities and lower extremities
Manual muscle test for upper extremities and lower
extremities
ADL assessment
Mobility assessment
Pain – phantom and/or surgical
Sensation – upper and lower extremity
Edema
Skin integrity – observation of incision and residual limb,
observation of non-surgical limb
Cognition and learning assessment
Activity tolerance
Social history, determining home environmental supports
and barriers, societal roles3
Bilateral Amputees
Check skin integrity of both limbs.
Post-surgically, edema in non-surgical limb will often be a
barrier to prosthetic use, so good edema control is
important throughout hospital stay.
While bilateral amputees are unable to utilize mirror
therapy, recent evidence supports patient observation of
the therapist’s limbs moving while attempting the
movements in their phantom limbs as it may significantly
reduce phantom pain in bilateral amputees.16
Seated balance at edge of bed will be a more challenging
consideration for a bilateral amputee compared with a
unilateral amputee due to loss of stabilizing limb.
Patients with bilateral above-knee amputations may
consider direct anterior or posterior scooting transfers (as
opposed to lateral).
Immediate Intra-Operative
Prosthesis (IPOP)
In most cases, patients will be Touch Down Weight-Bearing
on their surgical limb.
Cast should be supported during exercise program and
transitional movements to prevent pressure/chafing on a
fresh incision. If possible and therapist feels comfortable,
the foot piece may be removed to decrease weight of
device during exercises.
Have close contact with the prosthetist, post contact
information in the patient’s room, so all staff may call with
any questions, concerns, or in case of sudden need to
remove cast.
While the elastic support can be loosened at rest, it should
be tightened before any mobility or ambulation is
attempted. It should be snug, to prevent any pistoning of
the limb inside the cast.

Sample Documentation can be found in Appendix B, or click links below:
Sample Acute Post-Amputation Phase Physical Therapy Evaluation
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13
Sample Acute Post-Amputation Phase Occupational Therapy Evaluation
Sample Acute Post-Amputation Phase Physical Therapy Progress Note/Rigid Removable Dressing
Documentation
Sample Letter of Medical Necessity for Wheelchair
Sample Occupational Therapy Home Access Questionnaire
3. Acute Rehabilitation Phase
the period of time focusing on improving function to return to safe mobility and self care skills,
most often before returning home. This phase most often occurs in an inpatient rehabilitation unit
or skilled nursing facility, but may also include home health therapy. This phase may overlap with
phase 2.
Acknowledging the loss of a limb and preparing for needed adaptation are key concepts
in this phase of recovery. Interdisciplinary team approach is utilized to address patient
needs comprehensively.
Considerations
Rehab Goals
Goals may include:
ξ Modified Independent with ADLs
ξ Modified independent with transfers and bed
mobility
ξ Independent with home exercise program
ξ Independent with residual limb care including daily
skin checks
ξ Modified Independent with wheelchair mobility x
500- 1000 feet, including thresholds, ramps and
accessing hallways and bathrooms.
ξ Independent with car transfers, including
management of all assistive devices.
ξ Independent with floor transfers or be able to direct
caregivers in proper technique.
ξ Modified independence with IADLS with use of
adaptive equipment/techniques, including light
meal preparation, home management
ξ Family training as needed to assist with all of the
above if independence is not achieved
Precautions
High fall risk
Fall prevention strategies: bed in lowest position, bed
alarm, chair alarm, consistent rounding for toileting, pain,
possession checks.
May be non weight-bearing on surgical limb.
May wear post-op shoe for TMA, or a knee immobilizer for
BKA patients.
Pain Control/Management
Desensitization strategies
Mirror Therapy for phantom pain or sensations is
recommended.13,14 (HFFY 7540)Current best evidence
shows that mirror therapy for 15 minutes for at least 4
weeks has statistically significant reduction in phantom
limb pain.12
Compression socks, require MD order. Use of sock
donner is recommended for comfort and to prevent
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14
3. Acute Rehabilitation Phase
the period of time focusing on improving function to return to safe mobility and self care skills,
most often before returning home. This phase most often occurs in an inpatient rehabilitation unit
or skilled nursing facility, but may also include home health therapy. This phase may overlap with
phase 2.
shearing (HFFY 7679)
Oral medications, managed by physician
Cryotherapy or superficial thermal modalities if
appropriate (consider sensation and vascularization prior
to initiating).
Back pain prevention.24
Mobility
May use a walker, crutches and/or wheelchair.
Should work on transfers to varying surfaces with
assistive devices if needed.
Should practice standing and progress to gait if able.
Wheelchair skills training as fall prevention strategy.25
Self Cares
May use adaptive equipment to assist with dressing,
showering and toileting
Self care may be performed at edge of bed or in a
wheelchair
Provide education in foot care
Educate patient in compensatory strategies for absent or
diminished sensation.
Exercises
Bilateral UE’s in all major muscle groups
Trunk strengthening
Bilateral LE strengthening especially hip, glutes and knee
musculature
Prone Bilateral LE strengthening and stretching
Back pain prevention exercises – core strengthening
Medical Management
Considerations
Management per medical/surgical team. Considerations
for therapists may include:
ξ Bladder management as needed, if Foley not
discharged yet.
ξ Bowel management if needed.
Edema Control
Rigid Removable Dressing- see below, under Prosthetics
Elastic wrap (see HFFY 4409) or tubular compression
garment with MD order
Shrinker sock with MD order. Use sock donner for comfort
and to prevent shearing (HFFY 7679)
Wound/skin care
Have quality footwear for sound limb. Use 10g
monofilament to assess the intact foot for protective
sensation, and if not present, educate the patient about
risks and coordinate protective footwear prescription.
The therapist should have good awareness of residual
limb dressing changes.
Begin educating patient on residual limb care
Instruct patient in daily skin inspection for both lower
extremities with use of mirror.
Provide education on wound healing properties of RRD.6
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15
3. Acute Rehabilitation Phase
the period of time focusing on improving function to return to safe mobility and self care skills,
most often before returning home. This phase most often occurs in an inpatient rehabilitation unit
or skilled nursing facility, but may also include home health therapy. This phase may overlap with
phase 2.
Staples should be removed 10-14 days post operatively
when cleared by surgeon.
Positioning
No pillows should be used under the knee for BKA
patients.
Encourage prone positioning to avoid hip and knee
contractures and back pain prevention.
Provide instruction in pressure relief for wheelchair users
(HFFY 7616).
Equipment
For use during admission, then definitive
recommendations for DME at discharge may include:
Wheelchair: consider residual limb support, anti-tippers,
possible need for lightweight or high-strength lightweight
chair. Postural support may be necessary, especially for
bilateral amputees.
Pressure relieving cushion
Appropriate assistive device i.e. standard vs front wheeled
walker, axillary crutches, seated slideboard
Bathroom equipment i.e. commode, transfer tub bench
Patients benefit from consultation with DME vendors for
best fit of wheelchair, cushion at discharge (see vendor
list in appendix).
Wheelchair gloves
Elastic shoelaces
Prosthetics
Patient should receive information of a local prosthetist in
the area to have future follow-up. The
local Madison, WI prosthetist may perform a meet and
greet to hand out general amputee information.
Refer the patient to their local Amputee Clinic.
If ordered, PT or local prosthetist may fabricate a Rigid
Removable Dressing (RRD) for patients with BKA post-op
day 3-5 for protection and limb shaping. (HFFY 6592)
Rigid Removable Dressings are associated with reduced
time to wound healing, initial prosthetic casting, and
independent walking.6 They have also been shown to
have comparable results to conventional non-removable
post-op casting.4
Medical Professionals that
may be involved at this
phase
PMR physician, PT, OT, prosthetist, health psychology,
case manager, social worker, rehab nurse
Psychological Management
A health psychology consult can be considered for coping
with limb loss.
Considerations of changing social and family roles.
Be sensitive to language. Many patients find use of the
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16
3. Acute Rehabilitation Phase
the period of time focusing on improving function to return to safe mobility and self care skills,
most often before returning home. This phase most often occurs in an inpatient rehabilitation unit
or skilled nursing facility, but may also include home health therapy. This phase may overlap with
phase 2.
word “stump” to be disheartening and offensive.
If interested in peer mentor, the patient should be
responsible to contact Amputee Coalition of America, see
list of community resources for information. Your
prosthetist may also be able to assist the patient in setting
up peer mentoring.
Discussing sexuality and implication after an amputation is
important.26,27
Therapy Assessment
Options
2 minute walk test
6 minute walk test
Amputee Mobility Predictor (AMP)
Berg Balance Scale
Borg Rating of Perceived Exertion Scale
Four Step Square Test
Functional Gait Assessment
Functional Reach Test
Sensory assessment with Semmes-Weinstein
monofilaments , on sound limb
Single limb stance (SLS)
Timed up and go (TUG)
Timed up and go dual task (TUGDT)
Bilateral Amputees
May need a wheelchair re-assessment, could benefit from
more stable cushion and/or postural support, anti-tippers if
not already present. Consider need for lightweight or high
strength lightweight chair, or possibly power wheelchair.
Seated balance may be an increased concern during
ADL’s due to loss of a stabilizing limb during reaching
activities.
Patients with bilateral above-knee amputations may
consider direct anterior or posterior scooting transfers (as
opposed to lateral).
Immediate Intra-Operative
Prosthesis (IPOP)
In most cases, patients will be touch down weight-bearing
on their surgical limb.
Cast should be supported during exercise program and
transitional movements to prevent pressure/chafing on a
fresh incision. If possible and therapist feels comfortable,
the foot piece may be removed to decrease weight of
device during exercises.
Have close contact with the prosthetist, post contact
information in the patient’s room so all staff may call with
any questions, concerns, or in case of sudden need to
remove cast.
While the elastic support can be loosened at rest, it should
be tightened before any mobility or ambulation is
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3. Acute Rehabilitation Phase
the period of time focusing on improving function to return to safe mobility and self care skills,
most often before returning home. This phase most often occurs in an inpatient rehabilitation unit
or skilled nursing facility, but may also include home health therapy. This phase may overlap with
phase 2.
attempted. It should be snug, to prevent any pistoning of
the limb inside the cast.

Sample Documentation can be found in Appendix B, or click links below:
Sample Letter of Medical Necessity for Wheelchair
Sample Acute Rehabilitation Phase Occupational Therapy Initial Evaluation
Sample Acute Rehabilitation Phase Occupational Therapy Discharge Summary
Sample Occupational Therapy Home Access Questionnaire

4. Community Reintegration Phase/Return to Home
the period of time after an amputation when a person has returned home and is beginning to
reintegrate into their previous roles and functional tasks. A person may be receiving home health
therapies or outpatient therapies.

Goals at this phase include progressing functional mobility, providing education, and
transition to prosthetic use as appropriate. In the home health or outpatient setting,
therapy can engage the multidisciplinary team to provide support and engage family to
assist with adjusting to the new norm.
Considerations
Rehab Goals
Goals may include:
ξ Independent donning and doffing of prosthetic
components
ξ Independent assessment of fit of prosthesis with
management of fit with use of amputee ply socks
ξ Achieve normal scar mobility
ξ Achieve the ability to independently attain equal
weight bearing left and right in static stand.
ξ Achieve equal lateral and anterior/posterior weight
shifting performance bilaterally, and learn to use
proprioceptive input of the limb against the socket
interface to better control the prosthesis.
ξ Independent floor to upright transfers
ξ Establish wearing schedule of prosthesis (initial
goal of 1-6 hours, long term goal 6-12 hours)
ξ Establish progressive walking with prosthesis
schedule (initial goal 1-3 hours, long term goal of
8-12 hours)
ξ Stepping over obstacles, stepping sideways,
stepping backwards if allowed (patients with AKA
not allowed unless in Genium knee due to forefoot
loading resulting in loss of knee control)
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4. Community Reintegration Phase/Return to Home
the period of time after an amputation when a person has returned home and is beginning to
reintegrate into their previous roles and functional tasks. A person may be receiving home health
therapies or outpatient therapies.
ξ Patient will tolerate household distances (100 feet)
on indoor or level outdoor surfaces with
appropriate gait device and prosthesis in place
ξ Progress to ambulation without use of gait device if
safe with minimal gait deficits
ξ Safely ascend/descend 12 stairs with use of gait
device utilizing step-on or step-over-step as
appropriate (AKA’s: C Leg can perform step-over-
step descending, step-on for ascending. Genium
knee can perform step-over-step
ascending/descending)
ξ Safely ascend/descend a standard curb with gait
device as needed.
ξ Initiate gait training on grass, gravel, stones or
other uneven terrain.
ξ Safely ascend/descend coded ramp with gait
device as needed.
ξ Walk with prosthesis and gait device at varying
speeds
ξ Improve aerobic capacity as indicated by reduced
perceived rate of exertion during the 2 or 6 minute
walk test
ξ Maximize independence of functional mobility with
and without prosthesis
ξ Achieve independence with car transfers with
prosthesis, including management of all assistive
devices.
ξ Normalize gait pattern: eliminate/reduce
asymmetry, achieve a base of support of 2-4
inches, eyes looking a minimum of 5 feet in front,
achieve trunk rotation and arm swing.
ξ If not progressing to prosthetic, achieve
independence with wheelchair skills, such as
ramps, curbs, and community distances.
Precautions Ongoing falls risk Closely monitor skin tolerance and maintain intact skin
Pain Control/Management
Use of scar mobilization
Use of compression
Use of medication, managed by physician
Desensitization of residual limb
Mirror therapy can continue independently at home to
reduce phantom pain symptoms as needed13,17 (HFFY
7540)
Current best evidence shows that mirror therapy for 15
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19
4. Community Reintegration Phase/Return to Home
the period of time after an amputation when a person has returned home and is beginning to
reintegrate into their previous roles and functional tasks. A person may be receiving home health
therapies or outpatient therapies.
minutes for at least 4 weeks has statistically significant
reduction in phantom limb pain.12

Mobility
Ambulate with normal gait pattern (see Rehab Goals
above)
Independent ambulation within the home with or without
assistive device and prosthesis
Independent ambulation over outdoor terrain with or
without assistive device and prosthesis
Education on safe falling techniques and floor to upright
transfers with environmental objects for assist.
Self Cares
Independent use of prosthesis with static standing
activities with performance of personal cares.
Provide education in foot care
Provide education on importance of not shaving residual
limb to prevent skin injury and ingrown hairs.
Provide education on how to prevent further limb loss
(HFFY 7104)
Provide education on return to sexual activity (HFFY
7108) and considerations for driving28
Exercises
Perform appropriate stretching and strengthening for
lower extremities and core.
Use balance activities static and dynamic, with eyes open
and eyes closed, on various surfaces.
Have the patient perform endurance activities, including
distance walking/treadmill.
Medical Professionals that
may be involved at this
phase
Ongoing pain management needs, skin issues and
concerns, prosthetic/equipment assessment and
prescriptions, coordination of therapy services
Edema Control Use of RRD, residual limb shrinker or roll on gel liner
(HFFY 6592)
Wound/skin care
Closely monitor skin pre and post use of the prosthesis,
visually and tactilely. Educate patient on performing
regular skin inspections independently.
Provide education on need for careful and through rinsing
of all prosthetic components after use of cleaning products
to prevent skin irritation.
Recommend performance of scar mobilization, minimum
of two times per day.
Semmes-Weinstein Monofilament test: Use 10g
monofilament to assess the intact foot for protective
sensation, and if not present, to educate the patient about
risks and coordinate protective footwear prescription
Achieve normal skin and scar mobility.
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20
4. Community Reintegration Phase/Return to Home
the period of time after an amputation when a person has returned home and is beginning to
reintegrate into their previous roles and functional tasks. A person may be receiving home health
therapies or outpatient therapies.
Continue use of RRD when not wearing prosthesis.
Positioning
Instruction in prone lying for 5-10 minutes 1-2 times per
day for both AKA and BKAs, especially for the more
sedentary patients.
Provide instruction in pressure relief for wheelchair users
(HFFY 7616)
Equipment
Most appropriate gaiting device – front wheeled walker,
four wheeled walker, forearm crutches, axillary crutches,
canes, walking sticks.
Ongoing use of the wheelchair as needed.
Prosthetics
Monitor shape of limb.
Monitor circumferential measurements.
Document all prosthetic components (contact prosthetist
as needed to obtain this information).
Maintain contact with prosthetists regarding appropriate
times to return for reassessment and adjustments to
prosthesis as limb matures.
Medical Professionals
Physical Therapist
Maintain contact with prosthetist
Continue Rehab MD appointments as needed
Prosthetic Clinic intervention with Physical Medicine and
Rehabilitation team (first Friday morning of every month at
UW Rehab Clinic, Middleton)
Health Psychology intervention as indicated.
Occupational Therapy intervention as indicated.
Vocational Rehabilitation/Division of Vocational Rehab as
needed for return to school or work.
Psychological Management
Aesthetics of the prosthetic.
Empower the patient to self-advocate for their needs and
ongoing prosthetic management, including comfort, fit,
and personal activity goals.
Encourage discussing sexuality with a healthcare
professional.26,27
Therapy Assessment
Options
2 minute walk test
6 minute walk test
Amputee Mobility Predictor (AMP)
Berg Balance Scale
Borg Rating of Perceived Exertion Scale
Four Step Square Test
Functional Gait Assessment
Functional Reach Test
Sensory assessment with Semmes-Weinstein
monofilaments , on sound limb
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21
4. Community Reintegration Phase/Return to Home
the period of time after an amputation when a person has returned home and is beginning to
reintegrate into their previous roles and functional tasks. A person may be receiving home health
therapies or outpatient therapies.
Single limb stance (SLS)
Timed up and go (TUG)
Timed up and go dual task (TUGDT)
Bilateral Amputees
Maintain upper body and core strength and activity
tolerance in order to maximize function with two
prosthetics or from a wheelchair level.
Ambulating with two prosthetics requires increased energy
cost.


Sample Documentation can be found in Appendix B, or click links below:
Sample Outpatient Physical Therapy Evaluation Note



5. Long Term Management
The period of time when a person has achieved stable function skills including mobility and self
care skills, they have returned to previous roles or modified their roles. Most people in this phase
are no longer receiving skilled therapy and are at a self-maintenance level of care.
Goals at this phase include training in advanced prosthetic use and wheelchair
modification and skills. Patients are encouraged to maintain contact with their
interdisciplinary team as needed to address and ongoing or new concerns.
Considerations
Rehab Goals
Goals may include:
ξ Return to social roles within family and community
ξ Patient takes responsibility for own health care
ξ Independent ambulation within home, with or
without use of gait device
ξ Ambulation for community distances (1,000 ft) as
tolerated, with or without use of gait device
ξ Independent with advanced prosthetic skills such
as multi-directional turns, quick starting and
stopping, braiding, tandem walking, etc.)
ξ Independent wheelchair skills for community
distances as needed, such as ramps, curbs
Precautions Increased falls risk continues Skin issues can continue to present
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5. Long Term Management
The period of time when a person has achieved stable function skills including mobility and self
care skills, they have returned to previous roles or modified their roles. Most people in this phase
are no longer receiving skilled therapy and are at a self-maintenance level of care.
Pain Control/Management
Use of medication as needed, managed by physician.
Continue use of compression as needed.
Address back pain, which is common 6 months post-
amputation.24
Mirror therapy can continue independently at home to
reduce phantom pain symptoms as needed13,17 (HFFY
7540)
Current best evidence shows that mirror therapy for 15
minutes for at least 4 weeks has statistically significant
reduction in phantom limb pain.12
Mobility
Independent performance of basic mobility skills
Independent performance of floor to and from upright
without use of an environmental object for support.
Self Cares
Self-assessment on a daily basis of skin condition,
bilaterally if there are vascular issues.
Provide education on how to prevent further limb loss
(HFFY 7104)
Use mirror, magnified if needed.
Discuss return to sexual activity (HFFY 7108)and driving
considerations28
Exercises
Ensure ongoing stretching/flexibility and strengthening.
Core strengthening of pelvis, trunk and shoulder girdle
muscles is recommended.
Encourage ongoing upright balance exercises and
Ongoing cardiovascular activities
Medical Management
Continue with primary care physician. Follow up with PMR
or surgical team as recommended.
Prosthetic Clinic intervention with Physical Medicine and
Rehabilitation if indicated for new prosthetic, components,
pain, or skin concerns (first Friday morning of every month
at UW Rehab Clinic, Middleton)
If patient is hospitalized for unrelated medical or surgical
concerns, it is important to address edema control during
inpatient hospitalizations to ensure their prosthetic will
continue to have a proper fit.
Edema Control
Limb volume changes may continue as well as ongoing
reshaping of the limb.
Use of prosthesis is likely to control edema.
Assess the need for ongoing use of the RRD or residual
limb shrinker when the patient is not using the prosthesis.
Consider use of shrinker sock or roll-on gel liner if the
patient is having any surgical procedure, as any surgery
may cause systemic edema including in the residual limb.
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5. Long Term Management
The period of time when a person has achieved stable function skills including mobility and self
care skills, they have returned to previous roles or modified their roles. Most people in this phase
are no longer receiving skilled therapy and are at a self-maintenance level of care.
Wound/skin care
Maturation of the suture line
Achievement of normal skin/scar mobility
Contralateral lower limb preservation
Positioning Ongoing prone positioning 1 to 2 times per day for 5-10 minutes.
Equipment
Appropriate ambulatory assistive device or wheelchair.
Device may vary depending on the types of surfaces and
longer distances, such as indoor or outdoor surfaces,
shopping malls, parking lots, and may vary based on
weather conditions.
Prosthetics
Likely transition from preparatory to definitive prosthesis
Attend to weight changes as a 10# change would prompt
a return to the Prosthetist.
Regular and ongoing check-up appointments are
necessary to maintain proper fit and functionality of
prosthesis.
Weight change of 10 pounds or more likely will prompt
new fitting.
Medical Professionals that
may be involved at this
phase
Continue to follow with the Prosthetist for adjustments.
Vocational Rehabilitation may be considered,
PMR physician, nursing, PT, OT, Social Work, Health
Psychology

Psychological Management
Health Psychology intervention, peer mentoring, and
social support including family, friends, co-workers may all
be considered.
Therapy Assessment
Options
Initial OP Physical therapy intervention likely completed.
Patient may return to therapy with a new consult (if no
direct access) if new problems present, to progress skills
as strength improves to allow for new functional goals, or
if the patient becomes more tolerant of prosthetic use.
Bilateral Amputees Maintain upper body and core strength and activity
tolerance in order to maximize function with two
prosthetics or from a wheelchair level.
Ambulating with two prosthetics requires increased energy
cost.




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24
UW Health Implementation
Potential Benefits:
Improved consistency of care between clinicians across practice areas to improve functional
outcomes of adults with lower extremity amputation.

Potential Harms:
ξ Risk of skin breakdown may be associated with rigid dressings if improperly used or skin
checks not performed regularly.
ξ Delay in prosthetic fitting and use or potential to not attain prosthetic fitting.

To mitigate harms of implementation, Home Exercise Programs should be reviewed and
customized as appropriate for each patient, and Clinical judgment should always be used by
the issuing therapist.

Pertinent UW Health Policies & Procedures
1. None identified
Patient Resources: Health Facts for You
1. HFFY #7105- Above and Below Knee Amputations Complications and Management
2. HFFY #4892- Transmetatarsal Amputation (TMA)
3. HFFY #4409- Ace Wrapping Lower Extremity (Leg) Stump
4. HFFY #6592- Instructions for Wearing a Limb Protector
5. HFFY #4887- Below and Above the Knee Amputations: What You Need to Know about
Limb Loss
6. HFFY #7108- Sexuality – Life after Limb Loss
7. HFFY #7540- Mirror Therapy – Patient and Family Information
8. HFFY #6615- Preventing Pressure Ulcers
9. HFFY #7106- Above and Below Knee Amputations Why Do Amputations Occur
10. HFFY #7616 https://www.uwhealth.org/healthfacts/wound-skin/7616.html
11. HFFY #7679- Using an Amputee Sock Donner
12. HFFY #5878- Neuropathic Pain
13. HFFY #7104- Above and Below Knee Amputations: Preventing Further Limb Loss for Non-
Traumatic Lower Extremity Amputations (LEA)
14. HFFY #6626 Home Safety – Preventing Falls
15. HFFY #7616 Pressure Ulcer/Bed Sore/Decubitus Ulcer Relief

Staff Resources: Companion Documents
Durable Medical Equipment

Local Supplier Contact Information: Click here for internal UW Health document

For users external to UW Health, please contact the patient’s insurance company to confirm
coverage and preferred providers.
Assessment Tools
Click links for external websites, including references for these assessment tools
ξ 2 minute walk test
ξ 6 minute walk test
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25
ξ ABI
o ABI Worksheet
ξ Amputee Mobility Predictor (AMP)
ξ Berg Balance Scale
ξ Borg Rating of Perceived Exertion Scale
ξ Dynamic Gait Index
ξ Four Step Square Test
ξ Functional Gait Assessment
ξ Functional Independence Measure (FIM)
ξ Functional Reach Test
ξ Sensory assessment with Semmes-Weinstein monofilaments , on sound limb
ξ Single limb stance (SLS)
ξ Timed up and go (TUG)29
ξ Timed up and go dual task (TUGDT)
ξ Consider language of K levels in documentation to assist the prosthetist with determining
patients K level.
o K levels, categories defined by Medicare as anticipated functional status
o K0: Prosthesis does not enhance quality of life, no ability to transfer or ambulate
with prosthesis.
o K1: Has potential to use prosthesis for transfers and ambulation on level
surfaces; household ambulatory
o K2: Ambulates on uneven surfaces and can negotiate environmental barriers;
limited community ambulatory
o K3: Ambulates with variable cadence; has vocational, therapeutic or exercise
activity beyond simple locomotion.
o K4: Exceeds basic ambulation skills, exhibits high impact, stress, energy levels;
active adults, children and athletes.

Community Resources

Prosthetic Clinic: The Prosthetic Clinic is a multidisciplinary clinic that addresses the needs of
patients who have undergone amputation.

Our staff sees patients with amputations at all levels of the upper and lower extremities. Our
evaluation process includes a physician, prosthetist and physical therapist, and we also have
nurses with expertise in skin and wound care available.

Services
ξ Thorough evaluation of all patients, with input from physicians, prosthetists and physical
therapists
ξ Development of a management plan that allows for maximum patient independence and
mobility

UW Health Prosthetic Clinic: (608) 263-6540
http://www.uwhealth.org/physical-therapy-occupational-therapy-speech-
therapy/prosthetics/11379

Websites:
ξ Amputee Coalition of America: http://www.amputee-coalition.org/
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ξ American Orthotic Prosthetic Association www.aopanet.org
ξ Video on Mirror Therapy at Walter Reed:
http://www.youtube.com/watch?v=YL_6OMPywnQ
ξ American Board for Certification in Orthotics, Prosthetics, and Pedorthotists:
http://www.abcop.org/Pages/default.aspx

Support Groups:
Peer counseling http://www.amputee-coalition.org/

American Amputee Foundation, Inc. (AAF)
PO Box 250218
Hillcrest Station
Little Rock, Arkansas, USA 72225
501.666.2523
 Provides various forms of peer support, new amputee packet, & information and
referrals to other resources and providers.
Amputation Resource Foundation of America, Inc.
 http://www.amputeeresource.org/
 Their mission: To disseminate timely and useful information, to perform charitable
services, and to conduct research to enhance productivity and quality of life for
amputees in America.
Amputee Coalition of America
(Local chapter associated with UnityPoint Meriter Hospital)
202 S Park Street
Madison, WI
Contact: Barb Tomas at 608.267.6000(W) or 608.249.8565(H)
ξ http://www.amputee-coalition.org/
ξ The Amputee Coalition of America (ACA) is a national, non-profit amputee consumer
educational organization representing people who have experienced amputation or are
born with limb differences.
ξ Offer peer visitors at hospitals or homes in the Madison area, or over the phone
conversations.
National Amputation Foundation [NAF]
73 Church Street
Malverne, New York, USA, 11565
516.887.3600
 http://www.nationalamputation.org/
 NAF is comprised of amputee volunteers who offer their support to fellow amputees and
their families, and provide the patient with the opportunity to relate to another person
who has been through a similar experience. NAF supports the new amputee in returning
to as normal a life as possible within the sphere of his or her potential.
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ξ NAF publishes a monthly newsletter, A M P that is included in membership fees of
$25.00 dollars a year. There are pamphlets available and they sponsor an "Amp to Amp"
program where an AMP member who has returned to a normal life will visit a new
amputee.

Unlimited Potential/Rehab Institute of Chicago
345 E Superior Street
Chicago, IL
Contact: 312.238.1160
ξ Meets the 3rd Sat of the month from 10am - 12pm

Wisconsin Amputee Support Group
DePere, WI
Contact: John Dederich at 920.336.7063 (VM)


Guide to Physical Therapy Practice

Practice Pattern: 4 J Impaired Gait, Locomotion, and Balance; Impaired Motor Function
secondary to lower extremity amputation

Guideline Metrics
Intradepartmental Chart Reviews, Clinical Case Presentations, Percentages of patients with
lower extremity amputations discharged to Inpatient Rehabilitation.

Implementation Plan/Clinical Tools
1. Guideline will be posted on uConnect in a dedicated location for Clinical Practice Guidelines.
2. Release of the guideline will be advertised in the Physician/APP Briefing newsletter.
3. Content and hyperlinks within clinical tools, documents, or Health Link related to the
guideline recommendations (such as the following) will be reviewed for consistency and
modified as appropriate.

SmartTexts
Rehab IP PT Medsurg Eval Amputee

Disclaimer
Clinical practice guidelines assist clinicians by providing a framework for the evaluation and
treatment of patients. This guideline outlines the preferred approach for most patients. It is not
intended to replace a clinician’s judgment or to establish a protocol for all patients. It is
understood that some patients will not fit the clinical condition contemplated by a guideline and
that a guideline will rarely establish the only appropriate approach to a problem.

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Appendix A. Evidence Grading Scheme(s)

Figure 1. GRADE Methodology adapted by UW Health


GRADE Ranking of Evidence
High We are confident that the effect in the study reflects the actual effect.
Moderate We are quite confident that the effect in the study is close to the true effect, but it
is also possible it is substantially different.
Low The true effect may differ significantly from the estimate.
Very Low The true effect is likely to be substantially different from the estimated effect.

GRADE Ratings for Recommendations For or Against Practice
Strong The net benefit of the treatment is clear, patient values and circumstances
are unlikely to affect the decision.
Weak/conditional
Recommendation may be conditional upon patient values and
preferences, the resources available, or the setting in which the
intervention will be implemented.


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29
Appendix B: Sample Documentation

Sample: Acute Post-Amputation Phase Physical Therapy Evaluation

Physical Therapy Initial Evaluation
Medical Surgical Service

Patient: Test Patient MRN#: 1234567
Unit: D4/5 Rm:D4/566

Treatment Completion Time(s): 3:50 PM
PT Treatment
Minutes of Physical Therapy Time : 60

Evaluation/Treatment performed: Initial Evaluation, including chart review and
documentation, for 60 minutes

Consult received for Test Patient for Evaluation and Treatment for Therapy Diagnosis Below,
Mobility/ADL training and s/p left foot amputation.

Precautions and Contraindications:
Observations/Precautions
Isolation Precautions: Enhanced Isolation Precautions
Fall Risk Factors: Strength impairments (new BKA)
Left Lower Extremity Weight Bearing Status: Non-weight bearing (guillotine BKA)
Right Lower Extremity Weight Bearing Status: As tolerated

Current Hospitalization:
Referring Provider: Johnson
Date of Referral: 3/09/2013
Patient Active Problem List:
Diabetes mellitus type II [250.00]
Hyperlipidemia [272.4]
Hypothyroidism [244.9]
CAD (coronary artery disease) [414.00]
Pulmonary nodule [793.11]
Chronic foot ulcer [707.14]
Weakness of right leg [729.89]
Polyneuropathy in diabetes [250.60, 357.2]
Hypertension [401.9]

Medical Diagnosis: gangrene of left foot, s/p BKA

History of Present Illness: Test Patient is a 53 year old female admitted on 3/12/2014 with a
13-year-history of DM type 2 controlled by insulin who presents with a one week history of an
"infected" foot. Per the patient, she had a "callus" on the bottom of her left forefoot for several
months that had not been bothering her until a few weeks ago when it "cracked" and began to
bleed. At that time she began to see a podiatrist who attempted to treat the callus. It continued
to worsen, however, and about a week ago she noticed that it became "infected" with increased
redness and pain with ambulation. She admits to chills and nausea/vomiting during this time,
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30
but is not sure if this is related to her foot. She endorses difficulty keeping food down over the
last couple of weeks.

Pt is now s/p below knee amputation.


Past Medical/Surgical History:
has a past medical history of Diabetes mellitus Hypothyroid; essential hypertension
hyperlipidemia; Obesity; Unspecified sleep apnea; Osteoarthritis; Cellulitis; and Foot abscess,
right., has past surgical history that includes tonsil and adenoidectomy

Subjective: Patient is agreeable to participation in the therapy session. Pt reports she is
actually okay with this happening, that she has had difficulty with this foot/leg for a long time, but
that she is nervous about moving on one leg. Reports some weakness in her right hip following
a fall some time ago. "I had some Physical Therapy for it, they say I walk a little funny." "I
really, really want to get in to the rehab here."
Patient participation is not impaired by pain.
Pain Assessment
Pain Present: No (nerve blocks in place)

Social History/Prior Level of Function:
Home Situation
Lives with: Alone (but says a sister can come stay with her if needed)
What is your occupation?: clerical work
Permanent Residence: House, single story
Housing Accessibility: Ramp
Assistive Gait Device : None

Objective:
Observation of Patient / Vital Signs: Patient is in bed with PICC line, Foley catheter and
sciatic and femoral nerve blocks in place. Patient's medical condition is appropriate for Physical
Therapy intervention at this time.
Height: 175.3 cm (5' 9") Actual Weight: 122.925 kg (271 lb)

Cognition and Interaction: Pt is alert and oriented x 4.

Musculoskeletal Exam Lower Extremities:
Right LE: pt able to achieve 0º ankle position but only with overpressure. Knee and hip range of
motion within functional limits.
Strength: R Hip Flexion: 3+/5, R Knee Extension: 4/5, R Ankle Dorsiflexion: 5/5

Left LE: L knee extension: able to achieve 0º via quad set. L knee flexion: 30º in supine.
Observation of residual limb: incision clean and well approximated, bulbous shape, edematous.

Sensory Examination: intact to light touch right LE, not fully assessed L LE today secondary to
dressings. No complaints of phantom pain or sensations at this time.

Functional Mobility:
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Bed Mobility
Bed Mobility: Requires assistance for bed mobility
Supine to Sit: Stand-by assistance (with head of bed elevated)
Sit to Supine: Minimal assistance

Sit to stand: Pt unable to achieve full stand. Able to perform 3 seated boosts (lifting ~1-2 inches
off the bed) with min A and right knee blocked.


Treatment Activities: evaluation as above. Discussion of role of Physical Therapy, education on
rehab and answered questions on prosthetics use. Issued home exercise program including
right ankle pumps, bilateral quad sets, gluteal sets, bilateral knee flexion, single-leg bridging, hip
abduction in side-lying and hip extension in side-lying.



Clinical Impression: Pt is a 53 year old year old female presenting with gait and mobility
deficits s/p left below knee amputation. Pt was independent prior to admission, is very
motivated to participate with therapies, and has an accessible home. She has good potential to
progress to community ambulation with variable cadence. Anticipate she will be a good
candidate for acute inpatient rehab. Will attempt seated slideboard transfer at next session
given patient's good ability to boost, but difficulty achieving full stand.

Therapy Diagnosis: MUSCULOSKELETAL: Impaired motor function, muscle performance,
ROM, gait, locomotion and balance associated with amputation

Recommended Disposition: Acute rehabilitation candidate due to:
Ability to participate: Based on progress demonstrated in therapy sessions, anticipate patient
will be able to participate in 3 hours of daily therapy.
Willingness to participate: Patient is motivated to participate.
Environmental concerns: Patient has no environmental barriers, will likely have support
available if needed at discharge.



Patient’s potential for functional improvement is good. Factors favorable to functional recovery
include high motivation level. Factors which may impede functional recovery include past
medical history/co-morbidities as listed above in active problem list. Patient required and
benefited from skilled hands on and/or verbal instruction throughout the session. She requires
ongoing skilled Physical Therapy services, which may be delegated to a PTA, in order to regain
function and achieve the goals listed below.


Long Term Goals to be achieved by discharge from acute inpatient hospitalization:
1) Pt. supine to/from sit with stand-by assist.
2) Pt. transfers with mod A, use of seated slideboard as needed.
3) Pt. ambulates 10 feet with front wheeled walker or parallel bars, mod A.
4) Pt will propel manual wheelchair 50 feet with B UE's, stand-by assist.
5) Pt will consistently perform home exercise program independently.

Plan:5-6x/week
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Physical Therapy Interventions:, Therapeutic Activities, Therapeutic Exercise, Gait Training,
Wheelchair management, Education and Training for Patient Self Management,
Orthotics/Prosthetics Management and Training and Rigid Removable Dressing if ordered by
physician
Patient had input and is in agreement with goals and treatment plan.

Information provided by: Cindy Smith PT #4321, 3/13/2014 ,3:50 PM



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Sample Post-Amputation Phase Occupational Therapy Evaluation:

Occupational Therapy Initial Evaluation
Medical Surgical Service

Patient: Patient A MRN#: 0012345
Unit: D4/5
Patient Class: Inpatient

Time of Treatment: ___
Minutes of Occupational Therapy: ____

Consult received for Patient A for Evaluation and Treatment and Mobility/ADL training.Patient A
is a 53 year old female admitted on ____ (date).

Precautions and Contraindications:
Observations/Precautions
Precautions: Precautions identified
Fall Risk Factors: Balance impairments (new BKA)
High Fall Risk per nursing assessment

Current Hospitalization:
Referring Provider: Dr. Lowerextremity
Date of Referral: ____ (date)

Medical Diagnosis: Left below-knee amputation

History of Present Illness: Patient A is a 53 year old female now status post left below-knee
amputation on ____ (date).

Past Medical/Surgical History:

Subjective: Patient is agreeable to participation in the therapy session.
RN cleared patient for participation in therapy.. Patient's medical condition is appropriate for
Occupational Therapy intervention at this time.
Patient participation is not impaired by pain.
Pain Assessment
Pain Present: Yes
Current Pain Location: left residual limb
Pain Severity: 2/10
Pain Scale Used: Numeric Rating Scale (0-10)

Social History/Prior Level of Function:
Home Situation
Lives with: Spouse
Prior Level of Function: Requires some assistance from family
Prior Assistance Required: IADLs;Driving
What is your occupation?: retire
Permanent Residence: House, single story
Housing Accessibility: Stairs to entrance
Number of Levels in Dwelling: Multiple levels, can live on main level
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Number of Steps to Enter Home: 4
Rails to Enter: 1
Number of Stairs between Levels: (flight to basement with rail)
Location of Toilet: Main level
Location of Tub/Shower: Tub/shower on main level
Location of Laundry: Not on main level

Objective:
Observation of Patient / Vital Signs: Patient is in bed with peripheral IV and 2 left lower
extremities nerve blocks in place.
Skin Integrity: Impairment observed
LLE Skin Impairment: Edema
Cognition and Interaction
Level of Consciousness: Alert
Orientation Level: Oriented X4
Affect: Appropriate to circumstances
Attention: Attends to directions
Memory: No deficits noted
Follow Commands: All commands and directions followed without difficulty

Basic ADL and Instrumental ADL:
Basic ADL Skills
Method of ADL Assessment: Observation
Eating (includes set-up of food items): Complete Independence
Grooming - Level of assistance for retrieving items and grooming : Supervision/Setup
Lower body dressing (includes retrieving items) : Maximal (patient performs 25%-49% of task)
(from edge of bed)
Toileting (clothing management and hygiene): Maximal (patient performs 25%-49% of task)
Toilet transfer: Moderate (patient performs 50-74% of task)
Toilet transfer - Devices or equipment used : commode
Functional Mobility: Moderate assistance

Musculoskeletal Examination:
Active ROM Upper Extremities
AROM Left UE: Within Functional Limits
AROM Right UE: Within Functional Limits
Strength Upper Extremities
Overall Strength Left UE: 4/5 overall
Overall Strength Right UE: 4/5 overall

Sensory/Oculomotor Examination:
Patient wears glasses. Able to read clock and menu in room. No complaints of visual changes.
Sensory Assessment
GENERALIZED SENSATION: Impairment identified
LUE Sensation Impairment: (diminished sensation due to diabetic neuropathy)
RUE Sensation Impairment: (diminished sensation due to diabetic neuropathy)

Functional Mobility:
Bed Mobility
Bed Mobility: Requires assistance for bed mobility
Rolling to left: Minimal assistance
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Supine to Sit: Moderate assistance
Transfers
Sit to Stand: Moderate assistance
Stand to Sit: Minimal assistance
Stand Pivot Transfer: Moderate assistance
Device Used - standing transfer: Walker
Toilet Transfers: Moderate assistance
Device Used - toilet transfer: Drop arm commode

Treatment Activities: OT eval, pt educated in role of OT and plan of care, ADL, from edge of
bed, patient educated in initial upper extremities home exercise program including shoulder
flexion/overhead press, shoulder forward press, shoulder abduction, and wheelchair push ups.
Recommend use of water bottle in room for resistance with shoulder exercises.

Clinical Impression: Patient is a 53 year old female admitted status post left below-knee
amputation on ____ (date). Patient currently presents with ADL, IADL, and functional mobility
deficits post op. Patient with slight weakness in bilateral upper extremities, will need improved
upper extremity strength for safety and improved independence with ADLs and functional
mobility. Began ADL retraining today and instruction in initial upper extremity home exercise
program. Patient will benefit from inpatient rehab at discharge from acute care to maximize
level of independence prior to discharge to home.

Therapy Diagnosis: Deconditioned, Impaired ADL and IADL and Impaired Functional Mobility
Recommended Discharge Disposition: Acute rehabilitation facility due to Ability to participate:
Based on progress demonstrated in therapy sessions, anticipate patient will be able to
participate in 3 hours of daily therapy.
Willingness to participate: Patient is motivated to participate.
Environmental concerns: Patient has environmental barriers but does have good social
support available at discharge.



Patient A required and benefited from skilled hands on and/or verbal instruction throughout the
session. The patient requires ongoing skilled Occupational Therapy services, which may be
delegated to an OTA, in order to regain function and achieve the goals listed below. Patient’s
potential for functional improvement is good. Factors favorable to functional recovery include
high motivation level and good social support. Factors which may impede functional recovery:
past medical history/co-morbidities as listed above in active problem list.

Goals: To be achieved within one week from date of evaluation.
1. Patient to demonstrate ability to complete UB dressing/bathing with supervision/setup.
2. Patient to demonstrate ability to complete LB dressing/bathing with minimal assistance.
3. Patient to demonstrate ability to sit edge of bed for ADL tasks with supervision/setup for 20
minutes.
4. Patient will demonstrate independence with upper extremity home exercise program to
increase independence with activities of daily living.
5. Patient to complete toileting including transfer to bedside commode with minimal assistance.


Plan: 4-5 days per week.
Occupational Therapy Interventions:
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Community/Work Re-integration Training
Self-care/Home Management Training
Therapeutic Activities
Therapeutic Exercise
Patient had input and is in agreement with goals and treatment plan.

Submitted by: Cindy Jones, MOT, CLT Pager 1234- 10/27/2014 - 11:29 AM




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37
Sample Acute Post-Amputation Phase Physical Therapy Progress Note/Rigid Dressing
Fabrication Documentation

Physical Therapy Progress Note
Medical Surgical Service

Patient: Test Patient MRN#:1234567
Unit: D4/5 Rm: D4/562

Treatment Completion Time: 11:29 AM
Minutes of Physical Therapy Time : 58

Precautions and Contraindications:
High Fall Risk per nursing assessment

Medical Diagnosis: s/p left below knee amputation

Subjective: Patient is agreeable to participation in the therapy session.
Patient participation is not impaired by pain, though did state some phantom pain experienced
earlier this morning.


Objective: Pt is in bed with peripheral IV and dressings in place.

Ace Wrap and dressings removed.

Observation of limb: Incision clean and well-approximated, very minimal serosanguinous
drainage noted at medial border of incision. Bulbous shape, edematous.

Telfa dressing applied, Shrinker sock, size 5x24, applied with use of amputee sock donner.

Rigid Removable Dressing (RRD) fabricated and applied.

Treatment Activities: Fabrication and application of RRD as above. Pt and nursing staff
educated on donning/doffing RRD and shrinker sock. Written instructions about removing RRD
at night to sleep, and checking skin every 4 hours for first 48 hours issued to nursing staff.
Additional limb socks and suspension sock issued to patient.



Assessment: Tolerated well. Anticipate discharge to acute rehabilitation for ongoing
therapies, with follow-up with prosthetist for further pre-prosthetic limb care. May benefit
from trial of mirror therapy to address phantom pain.

Recommended Disposition: Acute Rehabilitation with ongoing Physical Therapy




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Plan: Patient would benefit from continued skilled therapy services 5-6x/week with focus on LE
strengthening, pre-prosthetic limb care, and progression of functional mobility while patient
remains in acute care.

Information provided by: Cindy Smith PT #4321, 10/27/2014 ,11:34 AM




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Sample Acute Rehabilitation Phase Occupational Therapy Initial Evaluation
Occupational Therapy Initial Evaluation
Acute Inpatient Rehabilitation

Patient: Joe Patient MRN#: 1234567
Unit: B4/4

Treatment Completion Time(s): 830, 1300
Minutes of Occupational Therapy Time: 60, 30
Scheduled Minutes of Therapy: 30, 30

Evaluation/Treatment Performed: Initial Evaluation, including chart review and documentation,
for 60 minutes
Other Billed Treatment Interventions including: Occupational Therapy Interventions:
Self-care/Home Management Training for 15 minutes. Transfer train to bedside commode at
height of 22". Patient transfers with contact guard assist from 22" and minimal assist from height
of ~20" from wheelchair. Some difficulty with lower surface.
Therapeutic Exercise performed for 15 minutes. Patient performs arm bike for >10 minutes at
level of 4. He is able to push wheelchair room to/from clinic independently.
Patient issued home access form. Initiated recommendations for durable medical equipment
discussed

Consult received for Joe Patient for Home Safety Evaluation, Mobility/ADL training and
ROM/Strengthening/Endurance.

Precautions and Contraindications:
Observations/Precautions
Precautions: Precautions identified
Fall Risk Factors: Strength impairments; Balance impairments
Lower Extremity Orthopedic/WB Precautions: Weight bearing or other precautions
Left Lower Extremity Weight Bearing Status: Non-weight bearing
Right Lower Extremity Weight Bearing Status: As tolerated
Left Upper Extremity Weight Bearing Status: As tolerated
Right Upper Extremity Weight Bearing Status: As tolerated
High Fall Risk per nursing assessment

Current Hospitalization:
Referring Provider: , MD
Date of Referral: 00/00/0000

Medical Diagnosis: Left below knee amputation

History of Present Illness: The following is a summary of the patient's history obtained via
chart review: Joe Patient is a ** yo male who underwent left below knee amputation. He has
been recovering well post op and his pain is controlled with his current pain regimen. Prior to
surgical procedure, he has been on disability. He was admitted to inpatient rehabilitation.

Patient Active Problem List:
Elevated blood pressure reading without diagnosis of hypertension [796.2]
Dyslipidemia (high LDL; low HDL) [272.4]
GERD (gastroesophageal reflux disease) [530.81]
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Debility [799.3]
Impaired mobility and ADLs [799.89]
DVT prophylaxis [V58.61]
Constipation [564.00]
Obesity [278.00]


Past Medical/Surgical History:
has a past medical history of Metatarsal fracture; Hypertension; and Hypercholesteremia

Subjective: Patient is agreeable to participation in the therapy session.
Patient participation is not impaired by pain. Pain Assessment
Pain Present: Yes
Current Pain Location: LLE (incision and occasional phantom pain)
Pain Severity: (1-2/10)
Pain Scale Used: Numeric Rating Scale (0-10)

Social History/Prior Level of Function:
Home Situation
Lives with: Parent/parents
Prior Level of Function: Requires some assistance from family
Prior Assistance Required: Home management; IADLs; Meal preparation; Shopping (Patient
assists with stove top cooking)
Have you had any falls in the last year?: Yes
Describe: "just walking"
How many times have you fallen in the past 6 months?: 2 or more
Were you injured as a result?: No
Have you limited what you do because you are afraid of falling?: Yes
What is your occupation?: disabled
Permanent Residence: House, multiple story
Housing Accessibility: Stairs to entrance; Stairs between floors
Number of Levels in Dwelling: Multiple levels
Number of Steps to Enter Home: 12
Rails to Enter: 2
Number of Stairs between Levels: 6
Rails Between Levels: 1
Location of Toilet: Main level
Location of Tub/Shower: Tub/shower on main level
Location of Laundry: Not on main level
Assistive Gait Device (prior to admission): None
ADL Equipment (prior to admission): Transfer tub bench; Hand held shower hose; Wall mounted
grab bar(s) for tub/shower; Non-skid tub mat for tub/shower; Reacher

Objective: Patient's medical condition is appropriate for Occupational Therapy intervention at
this time.

Cognitive-Perceptual Examination:
Cognition and Interaction
Level of Consciousness: Alert
Orientation Level: Oriented X4
Affect: Appropriate to circumstances
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Basic ADL and Instrumental ADL:
Basic ADL Skills
Method of ADL Assessment: Observation
Eating (includes set-up of food items): Modified Independence
Grooming - Level of assistance for retrieving items and grooming : Minimal/Contact guard assist
(patient performs 75-99% of task) (standing at sink)
Grooming - Tasks performed: wash and dry hands; wash and dry face; brush teeth/dentures;
apply deodorant
Grooming - Devices or equipment used: none
Upper body dressing (includes retrieving items): Minimal/Contact guard assist (patient performs
75-99% of task) (for retrieval of clothing)
Upper body dressing - Garments donned/doffed: pullover shirt
Lower body dressing (includes retrieving items): Minimal/Contact guard assist (patient performs
75-99% of task) (for retrieval, Max A with sock and shoe)
Lower body dressing - Garments donned/doffed: elastic waist pants/shorts; underwear (not a
disposable brief); sock(s);lace-up shoe(s)
Upper and lower body dressing - Devices or equipment used: reacher
Toileting (clothing management and hygiene): Minimal/Contact guard assist (patient performs
75-99% of task)
Toileting - Devices or equipment used: grab bar(s); assistive gait device; toilet safety frame
Toilet transfer: Minimal/Contact guard assist (patient performs 75-99% of task)
Toilet transfer - Type of transfer: stand-pivot
Toilet transfer - Devices or equipment used: toilet safety frame
Assistive Gait Device: Walker, 4 wheeled; Gait Belt

Functional Mobility and Balance:
Balance: Some imbalance in standing on right lower extremity with one-hand support

Musculoskeletal Examination:
Upper Extremity Range of Motion:
LEFT Upper Extremity: Active ROM: Within Normal Limits
RIGHT Upper Extremity: Active ROM: Within Normal Limits

Upper Extremity Strength:
LEFT Upper Extremity: 5/5
RIGHT Upper Extremity: 5/5

Neuromotor Examination:
Motor Tone and Spasticity
Motor Tone (General): No deficits observed
Movement Quality
Upper Extremity Movement Quality: No deficits observed

Visual Examination:
Vision Assessment
Subjective Report: No report of blurred vision, double vision or dizziness

Sensory Examination:
Sensory Assessment
GENERALIZED SENSATION: Intact light touch, pin prick, temperature (upper extremities)
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Selected OT Assessments: initial evaluation, role of OT discussed, initiated bathroom
equipment assessment and issue of home access form

Clinical Impression: Joe Patient is a ** year old male admitted for left below knee amputation.
Patient currently presents with low activity tolerance, incision and phantom pain and decreased
standing balance/tolerance due to recent amputation. Patient lives with his parents in a multi-
level home with multiple steps to enter and to the main level. Patient will be required to
negotiate stairs for safe discharge home. This environmental obstacle may be a barrier to his
discharge plan. Patient states that his father has already purchased many of the bathroom
equipment recommendations. Plan to address further with patient/family that obtained items are
most appropriate for the patient. Patient will benefit from skilled OT services for increased
activity tolerance, increased standing balance and tolerance, increased independence and
safety with self-cares, IADLS and functional transfers.

Patient’s potential for functional improvement is good. Factors favorable to functional recovery
include high motivation level, good social support, prior level of function, age and agreeable to
treatment. Factors which may impede functional recovery: past medical history/co-morbidities
as listed above in active problem list and environmental barriers. Joe Patient required and
benefited from skilled hands on and/or verbal instruction throughout the session. He requires
ongoing skilled Occupational Therapy services, which may be delegated to an OTA, in order to
regain function and achieve the goals listed below. Patient will benefit from interdisciplinary
services to maximize independence and facilitate a safe discharge plan.

It is anticipated that he will require a length of stay of 10-14 days pending the team discussion.

Therapy Diagnosis: Deconditioned, Impaired ADL and IADL, Impaired Functional Mobility and
Weakness
Expected Disposition: Home (with parents) with Home exercise program

Goals:
Short Term Goals to be achieved within one week
ADL/DME GOALS:
The patient will complete grooming while standing at sink with supervision/set up
The patient will complete dressing and toileting with stand by assistance
The patient will complete toileting and toilet transfers with stand by assistance
The patient will complete bathing with minimal assistance
Upper Extremity/Physical Goals:
The patient will tolerate standing while performing one-handed activities for up to 10 minutes at
a time with stand by assistance
The patient will tolerate upper extremity exercises for up to 20-30 minutes

Long Term Goals to be achieved by discharge from acute inpatient rehabilitation:
ADL/DME GOALS:
The patient will complete eating, grooming and upper body dressing with modified
independence, using adaptive equipment as needed.
The patient will complete lower body dressing and toileting with modified independence, using
adaptive equipment as needed.
The patient will perform toilet transfers with modified independence, using adaptive equipment
as needed.
The patient will perform bathing and tub/shower transfers with supervision, set up or cues.
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The patient/caregiver will demonstrate good understanding of home modifications and/or
durable medical equipment recommended for home, in order to optimize independence and
safety in self-care.
The patient will perform light household management tasks with supervision, set up or cues.
The patient will perform heavy household management tasks with maximum assistance.
The patient will perform meal preparation involving hot food and sharps with supervision, set up
or cues.
UPPER EXTREMITY/PHYSICAL GOALS:
The patient/family will demonstrate follow through of home exercise program.
The patient will demonstrate incorporation of work simplification and/or energy conservation
strategies during ADL/IADL activities.

Plan: Patient will require Occupational Therapy services through the length of inpatient stay.
Patient will be seen for 90 minutes of therapy 5 out of 7 days
Occupational Therapy Interventions:
Self-care/Home Management Training
Therapeutic Activities
Therapeutic Exercise
Wheelchair Management

Patient had input and is in agreement with goals and treatment plan.

Submitted by: Sue Smith , OT



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44

Sample Acute Rehabilitation Occupational Therapy Discharge Summary
Occupational Therapy Completion Note
Acute Inpatient Rehabilitation

Patient: Joe Patient MRN#: 12345678
Unit: B4/4 Rm: B4/416

Precautions and Contraindications:
High Fall Risk per nursing assessment

Rehab Admission Date: 00/00/0000
Rehab Discharge Date: 00/00/0000

Past Medical History: history of Metatarsal fracture; Hypertension; and Hypercholesteremia.,

Current Hospitalization: Patient Active Problem List:
Elevated blood pressure reading without diagnosis of hypertension [796.2]
Dyslipidemia (high LDL; low HDL) [272.4]
GERD (gastroesophageal reflux disease) [530.81]
Debility [799.3]
Impaired mobility and ADLs [799.89]
DVT prophylaxis [V58.61]
Constipation [564.00]
Obesity [278.00]
Skin sore [709.9]
Phantom limb pain [353.6]
Phantom pain [353.6]

Basic ADL Status at Discharge:
Feeding: Modified Independence
Oral Facial Hygiene/Grooming: Modified Independence
Grooming - Tasks performed : brush or comb hair; apply deodorant
Grooming - Devices or equipment used: none
Upper Body Dressing: Modified Independence
Upper body dressing - Garments donned/doffed : pullover shirt
Lower Body Dressing: Modified Independence
Lower body dressing - Garments donned/doffed: elastic waist pants/shorts; underwear (not a
disposable brief);sock(s);lace-up shoe(s)
Upper and lower body dressing - Devices or equipment used: none
Toileting: Modified Independence
Toileting - Devices or equipment used: grab bar(s);assistive gait device; toilet safety frame
Toilet Transfer: Modified Independence
Toilet transfer - Type of transfer: stand-pivot
Toilet transfer - Devices or equipment used : grab bar(s);assistive gait device; toilet safety frame
Bathing: Supervision/Setup
Bathing - Location performed: shower
Hygiene: CHG (Hibiclens) bath during therapy session
Bathing - Body parts washed/dried: entire body
Bathing - Devices or equipment used: long handled sponge; handheld showerhead; grab bar (s)
Tub/Shower Transfer: Supervision/Setup
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Tub/shower transfer - Type of transfer: shower transfer; actual - wet; stand-pivot
Tub/shower transfer - Devices or equipment used: grab bar(s); other (commode chair in shower)
Functional Mobility During ADL: Supervision/set up
Assistive Gait Device : Walker, front wheeled

Instrumental ADL Status at Discharge:
Instrumental ADL
IADL Skills: Assessed
Emergency Communication: Patient is independent in telephone use to request
assistance/call 911
Financial Management: Patient is independent with basic money management (completing
simple money transaction, making change etc.)
Medication Management: Patient is modified independent managing medications
Home Management: Requires supervision with light household management tasks (dusting,
folding laundry, washing dishes, etc)
Meal Preparation: Requires supervision for hot meal preparation or handling knives/sharp tools
from wheelchair level. Limited tolerance to time up in standing with use of walker and assist to
transport items if using walker.
Shopping: Requires supervision for shopping tasks, including ambulation or wheelchair
propulsion in store, dynamic balance to retrieve items, proper selection of items and payment)
Driving: A driver readiness screen/evaluation is recommended before patient returns to driving
Supervision in the home: Patient may be left alone, with structure and caregiver check-ins by
phone or in person
Supervision in the community: Patient requires close supervision at all times while in the
community


Upper Body Physical Status at Discharge:
Upper Extremity Range of Motion:
LEFT Upper Extremity: Active ROM: {Within Normal Limits (HEP handout provided)
RIGHT Upper Extremity: Active ROM: {Within Normal Limits (HEP handout provided)

Upper Extremity Strength:
LEFT Upper Extremity: 5/5
RIGHT Upper Extremity: 5/5

Upper Extremity Range of Motion:
LEFT Upper Extremity: Active ROM: WFL overall
RIGHT Upper Extremity: Active ROM: WFL overall

Upper Extremity Strength:
LEFT Upper Extremity: WFL overall
RIGHT Upper Extremity: WFL overall


Cognitive Status at Discharge: Within normal limits

Vision/Visual Perception at Discharge: No blurred or double vision


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Clinical Impression/Recommendations: Joe Patient is a ** year old male admitted to the
acute rehabilitation unit following left below knee amputation. Joe Patient has demonstrated the
ability to perform all household mobility tasks required to access his home safely and
appropriately with use of a bariatric front wheeled walker. He will require a family member or
friend to be present whenever negotiating the stairs, as they will have to carry the front wheeled
walker up/down the stairs for him as he bumps up/down the stairs. He has met all of his long
term goals and has displayed great motivation throughout treatment sessions. All recommended
durable medical equipment has been purchased and obtained. Joe Patient is being discharged
with a home exercise program to complete daily. Pt has great family support and is highly
motivated. He has great support and it is anticipated he will continue to increase his
independence with strength and speed for self-cares and IADL's.

Long Term Goals: ADL/DME GOALS:
The patient will complete eating, grooming and upper body dressing with modified
independence, using adaptive equipment as needed. met
The patient will complete lower body dressing and toileting with modified independence, using
adaptive equipment as needed. met
The patient will perform toilet transfers with modified independence, using adaptive equipment
as needed. met
The patient will perform bathing and tub/shower transfers with supervision, set up or cues. met
The patient/caregiver will demonstrate good understanding of home modifications and/or
durable medical equipment recommended for home, in order to optimize independence and
safety in self-care. Met
The patient will perform light household management tasks with supervision, set up or cues.
met
The patient will perform heavy household management tasks with maximum assistance. Met
The patient will perform meal preparation involving hot food and sharps with supervision, set up
or cues. Met from wheelchair level.
UPPER EXTREMITY/PHYSICAL GOALS:
The patient/family will demonstrate follow through of home exercise program. Met
The patient will demonstrate incorporation of work simplification and/or energy conservation
strategies during ADL/IADL activities. Met

Reason for Completion of Occupational Therapy: Discharged from facility, patient had been
progressing toward goals.
Patient and Family/Caregiver Education: Handouts/resources were provided to patient.

Discharge disposition: Home with Home exercise program

Submitted by: Susie Smith OT

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Occupational Therapy Rehabilitation Department
Home Access Questionnaire

Patient’s Name: _____________________________ Date:_____________
Therapist’s Name: _______________________________
Therapist Phone #:_______________________________

HOME ASSESSMENT:
The information below is being requested about your home so that we may adequately plan for
your discharge. This will allow us to recommend assistive equipment if necessary and offer
suggestions for any possible home modifications to increase your safety.

Types of Living Situation
Ranch Style ___ Condo____ Apartment ___
Two-story ____ Multilevel ___
Entrance
How many steps into the entrance _____ Width of this entrance ____
What is height of each step_____ Are hand rails installed______
If home is multilevel please state number of steps to areas used ________

Bedroom
Is there a bedroom on the main level yes_____ no_____ Width of entrance _____
What is the height of bed, floor to top of mattress_________

Bathroom
Is there a bathroom on the main level yes_____ no______
Full Bath ___ ½ Bath ___
Door Width _____
Overall length x width of bathroom ____________

Sink: Height _____
Is there clearance beneath the sink? yes_____ no_____
Toilet: Height _____
Are there safety rails present yes_____ no_____
Tub: Is it a combination tub/shower____ tub_____ shower_____
Are there grab bars installed yes_____ no_____
Fiberglass____ tile enclosure_____
Shower curtain_____ doors_____
If you have shower doors what is the width of the opening _____
What is the height of the side of the tub ___________
If a shower stall what is the height of shower lip _____
What is the size of shower floor ______

Do you have access to a raised toilet seat______ bath bench_____ commode______



Would you like information on ramp specifications? _______



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Occupational Therapy Rehabilitation Department
Home Access Questionnaire

BATHROOM LAYOUT
Please draw the layout of your bathroom using the diagram available.

Bathroom 1 Bathroom 2



Key



Toilet Shower



Bathtub


Sink Door
NOTES:





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49
Sample Letter of Medical Necessity for Wheelchair

CERTIFICATE OF MEDICAL NECESSITY/VENDOR EQUIPMENT PRESCRIPTION

Patient: Test Patient
Date of Birth: 3/30/1954
Medical Record Number: 2935710
Wt Readings from Last 1 Encounters:
02/24/14 82.237 kg (181 lb 4.8 oz)

Ht Readings from Last 1 Encounters:
02/17/14 1.676 m (5' 6")

Diagnosis: Foot infection [686.9] s/p right below-knee amputation

History of Present Illness: The following information was obtained from the medical record:
Patient is a ** year old male Post OP Day #8, S/P R ankle guillotine amputation, now POD#5
s/p definitive BKA right leg for a right plantar abscess and streaking cellulitis. Pt with history of
left BKA.

Past Medical/Surgical History: Patient has a past medical history of Diabetes mellitus, type 2;
Diabetic retinopathy; Renal failure; Peritoneal dialysis; Hypertension; Cataract; Diabetic
neuropathy; Diabetic nephropathy; Hyperkalemia; deceased donor kidney transplant; Diabetic
foot; Steroid long-term use; PDR (proliferative diabetic retinopathy); Osteoporosis; Status post
amputation of leg; Diabetic Foot - RLE; and Atherosclerosis of extremity artery with intermittent
claudication. He also has no past medical history of History of anesthesia complications or
Family history of anesthesia complication., has past surgical history that includes unlisted
procedure femur/knee; eye service or procedure; OR - Peritoneal Catheter Placement; renal
transplant; Stent Removal; amputation; below knee amputation left; cataract removal; and
amputation.

Social History: Pt lives with his wife in a home with all needs on main level. Pt has 1 step to
enter (over threshold). Pt has a walk-in shower with seat. Pt has a left prosthetic (and recently
ordered a new one through Prosthetics Labs). Pt has a front wheeled walker, and "an old, hand-
me-down" manual wheelchair

Objective-
Cognition and Interaction: Pt is alert and oriented x 4.

Musculoskeletal Exam Upper Extremities: WFL B UE's

Musculoskeletal Exam Lower Extremities: B BKA, WFL at hips and knees.

Functional Mobility:
Supine to sit: independent
Sit to stand: modified independent with left prosthetic and front wheeled walker
Stand Pivot Transfer: modified independent with left prosthetic and front wheeled walker
Ambulation: Pt requires contact-guard assist to safely ambulate 150 feet with front wheeled
walker hopping on left prosthetic. Fatigue during ambulation, requiring several rest breaks.

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Recommended Equipment:
High Strength Lightweight Wheelchair, 18x16:
Patient is unable to ambulate to accomplish his mobility related ADL's. He does not have the
ability to stand to accomplish these activities. He is unable to use any ambulatory assistive
device to accomplish these activities. He is able to use a high strength lightweight manual
wheelchair sufficiently to accomplish these types of tasks while in a seated position. A standard
wheelchair and lightweight wheelchair cannot be used for these activities because they are not
adjustable enough to accommodate his needs and are too heavy. The weight of the chair
combined with his body weight exceeds his ability to propel himself on a daily basis without
limiting his independence and increasing his risk for overuse injuries to his shoulders as he will
be using the chair for several hours each day. He requires a lower seat to floor height and the
seat will need to be sloped to promote upright posture. These accommodations cannot be made
in a less adjustable chair. A high strength lightweight wheelchair will enable patient to be able to
better accomplish his mobility related ADL's.

Adjustable Tension Upholstery:
This back upholstery can be adjusted to provide correct postural support for patient while seated
in the manual wheelchair. This back is adjusted with 1 inch Velcro tension straps inside the
upholstery. This will allow tension to be applied in the lumbar area to provide support for
corrected posture in sitting. The remaining straps can be adjusted to a looser setting to
accommodate the shape of the trunk. This item is required because standard upholstery will not
provide enough support for his low back or enough postural support to prevent low back pain
and sliding out of the chair. Patient requires additional support while seated. The adjustable
tension upholstery is the least costly alternative and adds the least amount of weight to the
wheelchair.

Adjustable Height Desk Armrests:
The height adjustable feature is necessary to accommodate and support his upper arm and
shoulder to improve spinal alignment and prevent trunk flexion caused by the weight of his arm
and shoulder girdle. The height adjustable feature is also necessary for approximation to table
tops and work surfaces. Standard height armrests are not able to be adjusted to accommodate
patient.

Right Residual Limb Support:
Patient has a below knee amputation. This device provides a surface to support his residual
limb. This device will protect and elevate the limb in knee extension preventing hamstring
tightness and dependent edema. He will be less likely to develop contractures and swelling of
his residual limb with this passive support.

General Use Seat Cushion:
This basic foam curve cushion is required to alleviate pressure on patient's seated surface. He
sits for periods greater than 2 hours in his wheelchair which puts his at risk for skin breakdown
and discomfort while sitting in his chair.

Anti-Tippers:
Anti-tippers are required to prevent the wheelchair from tipping over backwards. This is
especially needed with ascending ramps, due to uncontrolled extensor tone, due to behavior
issues, due to uncontrolled sit to/from stand and due to the weight of the oxygen tank mounted
to the rear of the wheelchair.


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51
Equipment Justification: Patient has a mobility limitation that significantly impairs his ability to
participate in mobility-related activities of daily living (MRADLs). Patient would be unable to
independently prepare meals or transport them to the table in order to eat independently, would
be unable to stand and reach into closet for clothing in order to dress independently, and would
be unable to safely access the bathroom for independent toileting and bathing. Patient is
unable to safely ambulate without assistance of one due to his diagnosis of right below-knee
amputation, with history of left below-knee amputation. Patient's mobility limitations are not
resolved by the use of an appropriately fitted cane or walker. His home is accessible and has
adequate maneuvering space and access between rooms to use the recommended equipment.

Without the requested equipment he would be unable to accomplish the MRADL entirely, would
be at heightened risk of morbidity or mortality from attempting to perform the MRADL, or would
be unable to complete the MRADL within a reasonable time frame.


DURATION OF NEED FOR EQUIPMENT: Indefinite

This equipment is medically necessary to provide the greatest degree of safety and
independence in the home and community settings. If further clarification is desired, please do
not hesitate to call (608) 263-8060. Thank you for your attention to fund this medically
necessary equipment.

Cindy M Smith, PT - 2/24/2014 - 8:35 AM

Dr. John Johnson, MD
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52
Sample Outpatient Physical Therapy Evaluation Note

MIDDLETON REHAB NEURO
6630 University Ave
Middleton, WI 53562
Phone 608-263-8412
Patient M, A L
SEX: F
UWH#: 123456
DOB: 01/01/1980
DATE OF SERVICE: 07/01/2016
INITIAL PHYSICAL THERAPY EVALUATION
MEDICAL DIAGNOSIS: Left above-knee amputation performed on April 01, 2016, by Dr.
Vascular.
PHYSICAL THERAPY DIAGNOSES: Difficulty in walking and muscular weakness.
REFERRING PHYSICIAN: Dr. Rehab
REASON FOR REFERRAL: The patient is to be seen to progress towards prosthetic
ambulation as her wound heals.
TIME OF EVALUATION: The patient was seen for 60 minutes of evaluation.
SUBJECTIVE: The patient arrived in her manual wheelchair with her roommate who provided
transportation and assist with management of her manual wheelchair in and out of the vehicle.
She relates that currently she is rarely at home alone during the day or night.
The patient was able to independently self-propel the manual wheelchair from the waiting room
into the physical therapy gym primarily using her BUE.
HISTORY:
History of present condition: The following information was obtained through the medical record.
Patient is a 42-year-old female with a remote history of lymphoma. She presented with upper
respiratory symptoms, septic shock and then developed acute respiratory failure secondary to
MSSA and influenza B pneumonia.
Hospital course was complicated by Pseudomonas following a trach placement, left lower
extremity ischemia requiring an above-knee amputation on 04-01-16, onset of atrial fib and
cardiomyopathy likely secondary to sepsis, severe hypoxia treated with ECMO and AKI and
ATN requiring hemodialysis.
PAST MEDICAL/SURGICAL HISTORY: The patient has a remote history of lymphoma and a
history of migraines.
No past surgical history is on file.
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PAST TREATMENTS: The patient was followed by Physical and Occupational Therapy while
hospitalized.
PATIENT CONCERNS/GOALS: The patient reports her primary concerns currently include her
nerve type pain along the lateral aspect of the left lower extremity and at times in the lower
aspect of her buttocks, decreased strength, slow wound healing of the left residual limb and
general deconditioning.
The patient reports that her goals include using a prosthesis appropriately, learning to walk
efficiently with a reasonable gait pattern, navigating varying terrains, as well as negotiating
stairs.
SOCIAL HISTORY: The patient resides with her roommate in a multiple level condo with 2
steps to enter the home without railings and 14 stairs between levels with one railing.
WORK STATUS: The patient reports that she works for a nonprofit agency in the media and
relations department. She states some travel will be required with this newly developed position
but that would not be expected for a few months. She states that she is able to do a fair amount
of computer work from home. The patient reports that her roommate’s position requires travel
on a frequent basis.
PRIOR FUNCTIONAL LEVEL: The patient was independent in performance of all activities of
daily living, as well as her MRADLs, worked a full-time schedule and traveled frequently.
FUNCTIONAL ACTIVITIES:
Bed mobility: The patient demonstrates slightly slowed performance of basic bed mobility skills
that included sitting to and from supine, alternate side lying, assuming a prone position and
scooting in sitting and supine.
Transfers: The patient is able to perform sit to stand with use of her bilateral upper extremities
for push off and the right lower extremity. The patient once in standing is able to transfer to the
left or right with preference to use her upper extremities for support to improve ease and safety.
Balance: The patient reports that she has not had any falls since her discharge to home.
Patient demonstrates intact sitting balance tolerating shifting of weight in all directions. With
standing the patient requires at least single UE support.
Gait: The patient is currently using a front-wheeled walker for ambulation. She is able to
ambulate short indoor and outdoor distances tolerating at least 100 feet. With stairs the patient
is ascending using an axillary crutch and one railing. To descend the stairs, she currently is
performing this in a seated position ‘bumping’ down the stairs, as she has concerns with her
ability to negotiate steps safely and securely.
IMPAIRMENTS:
Strength:
Muscle action RLE LLE
Hip flexion 4 + 3+
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54
Hip abduction 4- 3+
Hip extension 4- 3+
Knee extension 5 NA
Knee flexion 4+ NA
Ankle dorsiflexion 4+ NA
Ankle plantarflexion 4 NA
Range of motion: The patient demonstrates full active range of motion at the hips and right knee
in all planes.
Skin: All sutures/staples have been removed. Good approximation of the suture line is noted
except where the wound presents. The open area demonstrates on the suture line slightly
lateral to midline. She is currently packing this as instructed by Vascular Surgery. She also
demonstrates a small amount of fairly clear exudate at midpoint of the distal end of the left limb.
She covers both of these area with a gauze bandage. Residual limb presents with good color.
Skin is warm. Several small patches of dried and flaky skin present on the distal aspect of the
left limb.
Scar mobility minimally diminished.
Limb presents moderately long in length and is cylindrical in shape
Edema: Firmness to palpation noted in the distal one third of the residual limb.
Endurance: The patient reports that she is aware that her tolerance to activity is quite limited at
this time related to her recent illness. She is working to increase her tolerance to activity, but
finds this to be progressing quite slowly.
Cognition: The patient was able to remain on task and asked and answered questions
appropriately. It appears her long-and short-term memory are intact.
Wheelchair propulsion: The patient is easily able to propel her manual wheelchair over indoor
level surfaces both on our tile as well as on the thin carpeting. The patient states she has no
issues at home, with use of the wheelchair. She does report that for longer distances propelling
the wheelchair is quite fatiguing and occasionally requests assistance.
Pain: The patient is reporting ongoing pain in the left residual limb. The pain is primarily located
on the lateral aspect of the residual limb. She feels that pain is at its lowest point in the morning
approaching but not at a 0-1/10. The pain does increase up to a 5 to 6/10 level at times. She
reports that she is not certain that the current medication is helping with her pain but is taking
this as instructed.
EQUIPMENT: The patient has a Patriot manual wheelchair and a Comfort Company basic seat
cushion. She has received this with assistance through National Seating and Mobility. The
patient has a front-wheeled walker and axillary crutches at home as well.
Home Exercise Program: The patient reports that she has misplaced the exercise program
issued to her while an inpatient on rehab. She performs the exercises that she remembers
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which includes hip abduction in side lying, lying prone performing hip extension, and use of
weights for strengthening of her bilateral upper extremities.
The patient was trained in 3 new exercises and these include supine bridging with use of the
right foot for weightbearing and use of the left residual limb up to parallel with the right. Once in
the up position, the patient is to rotate the left pelvis upwards towards the ceiling without losing
alignment of the right lower extremity to encourage pelvis protraction. The other exercises
include standing strengthening of the hip abductors and extensors on the left with use of the
TheraBand for resistance. Currently, she cannot perform this exercise on the right, as she does
not yet have a prosthesis to allow static standing.
Patient Instructions: The patient is encouraged to perform her home exercise program: 1 to 2
times per day and utilize the wheelchair for propelling within her tolerance as well as walking
with use of the front-wheeled walker to build endurance and strength. Patient is to handle her
residual limb with clean hands to provide desensitization. She is to closely monitor her skin and
care for it as instructed including the open area. The small areas of dried skin should be treated
with small amount of lotion rubbed into a washcloth that is used to gently scuff off the dried skin
avoiding any of the open areas. She is to cease use of lotion once the health of the skin is
normal. She is to continue use of the stump shrinker 23 out of 24 hours/day until she is ready to
transition to a gel sleeve.
CLINICAL OBSERVATION: The patient demonstrates signs and symptoms consistent with a
left above knee amputation with an ongoing, non-healing wound on the left lateral aspect of the
suture line, as well as some drainage at the distal end of the left lower extremity. She is followed
by Vascular Surgery regarding these aspects. The patient continues to demonstrate some
significant decrease in her LE muscle strength that will impact her use of the prosthesis for
gaiting. The patient has nerve type pain on the left lateral aspect of the left lower extremity that
may interfere with her ability to tolerate use of a prosthesis. Her tolerance to activity is
compromised. She is scheduled in Prosthetic clinic on 7-6-16 and will discuss this pain with Dr.
Rehabilitation.
A delay in fitting and use of a prosthesis is anticipated related to the open wounds.
The nerve pain is concerning and will likely be addressed by Dr. Rehabilitation in clinic.
Based on the patient's diagnosis and potential progress modifiers, treatment with a customized
home exercise program in Physical Therapy is appropriate at this time.
The patient demonstrates a willingness to actively participate in her rehabilitation and
demonstrates a good understanding of her role.
GOALS:
1. The patient's home exercise program will be reviewed and revised as appropriate to facilitate
improvement in strength, balance and endurance in preparation for prosthetic use for gaiting.
2. The patient will correctly and consistently perform her home exercise program on a 1 to 2
time per day basis using the written/pictorial instructions.
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3. The patient will continue to ambulate short distances with use of the front-wheeled walker or
axillary crutches to assist with building endurance.
4. Patient is to continue to self-propel the manual wheelchair to work on upper extremity
strengthening and improving endurance.
5. The patient will demonstrate an improvement in left hip extension and abduction by one-half
to 1 grade using the manual muscle test to allow improved ambulation performance with the
prosthesis.
6. The residual limb skin will demonstrate good hydration to ensure tolerance to use of a
prosthesis with use of lotion only as instructed.
7. The surgical suture line will demonstrate complete healing to ensure tolerance to use of the
prosthesis.
8. The patient’s surgical suture line will demonstrate normal skin mobility to better ensure
tolerance to use of the prosthesis.
9. The patient will ‘handle’ the residual limb with clean hands at least twice daily to desensitize
the limb in preparation for prosthetic use to ensure tolerance to use of the prosthesis.
Additional goals will be developed as further testing is completed and she once she receives her
roll-on sleeve and prosthetic socket.
ADDITIONAL TESTING: Once the prosthesis is in use testing will likely include the Timed Get
Up and Go test, 2 or 6-minute Walk Test, Functional Reach Test, 10 m Walk Test, Dynamic
Gait index or Functional Gait Assessment, Berg Balance Scale score are likely to establish
baseline and allow comparison of performance and assess progression with use of the
prosthesis. Use of the Sensory Organization Test may be utilized as well as videoing of gaiting.
TREATMENT STRATEGIES: The primary strategy will be use of prosthetic training, though
today evaluation was performed and treatment strategies will be dependent on her wound
status. Treatment with physical performance testing, therapeutic exercise, therapeutic activity,
manual therapy, and gait training may be possible.
Contextual factors: The following factors that may influence her rehabilitation include:
Positive factors include motivational levels, social support, and prior level of function.
The negative factors would include her wound and ongoing left residual limb pain.
PLAN: The patient will be seen in approximately 3 weeks to modify and upgrade her home
exercise program. We will then make decisions as to her return to therapy date depending on
how her wound is healing and when she might be able to utilize a prosthesis. The home
exercise program needs to be upgraded, but she is able to perform the current exercises
independently at home without physical therapy intervention.
The findings, goals, and treatment plan were discussed with the patient, and her father was
present as well. They agreed to the above.
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Submitted by: Cindy Johnson, PT

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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
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