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Stages of Care
Clinical Concerns
The expert panel for this consensus committee identified fourteen clinical concerns in the stages of recovery .
1. Determination of Amputation Level
2. Minimize sy stemic complications
3. Prevent contractures
4. Bed mobility and transfers
5. Pain management
6. Protect amputated limb from trauma
7. Fall prevention
8. Emotional care/education
9. Manage and teach about wound healing
10. Promote residual limb muscle activity
11. Early ambulation
12. Advanced ambulation
13. Control limb volume changes
14. Trunk and body motor control and stability
Each concern will take on a different level of importance at different stages of the healing process. Since the goals of care change at each
stage of rehabilitation, a table of clinical concerns and treatment goals was established by the consensus committee for each stage.
(Table 1) There may be overlap between stages which may vary with individual differences.
Table 1. Changing clinical concerns during the stages of recovery after a lower limb amputation
These clinical concerns and treatment goals may be used by clinicians for development of treatment protocols and guidelines within
their communities. Each goal of the table is ranked in relative importance with regard to the level of clinical concern at each stage of
rehabilitation. For example, the determination of amputation level is of concern at the preoperative stage however, it is usually of
little concern after the surgery . Conversely , emotional care is of high clinical concern through most of the rehabilitation process, with
a slight drop off in the intermediate recovery stage and with a renewed concern at around 1 y ear after the amputation.
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a slight drop off in the intermediate recovery stage and with a renewed concern at around 1 y ear after the amputation.
Although progression through these phases is largely individual, the time needed to progress is reported consistently between 12 and
18 months. It is during this extended time that many individuals still have significant changes in limb volume that must be
considered and managed. During this 12 to 18 month period, social reintegration, life planning, and goal setting all progress as well.
For pediatric amputees, the stages of recovery and the clinical concerns are modified to take into account the developmental milestones
of the growing child. Finally , in the later portions of the process come the mastery of prosthetic use and a desired range of activities.
Physical Therapy and Prosthetic Management
Although the role of all team members is to assess, educate, and motivate the patient, the role of two particular members of the team,
the phy sical therapist and the prosthetist, during this long period is often underestimated.
Physical therapy treatment continues throughout this entire period with specific
rehabilitation protocols designed to meet the specific needs of each amputee. Continual
reevaluation and updating of the amputee's program is essential to ensure that each patient
reaches his or her maximal activity level with a prosthesis.
Although the patient must be an active participant in his or her rehabilitative care, the
treatment guidelines and specific exercises are the therapist's responsibility and an integral
component of the continuum of care for the first 12 to 18 months.
Initial prosthetic management after amputation requires strategies different from those used during the period after
residual limb stabilization.
During the initial time frame, the prosthetist is "chasing a moving target," as the residual limb
changes dramatically in volume and shape. - Therefore, the definitive prosthesis should not be
prescribed or fit until the limb has begun to stabilize and the "moving target" has slowed
considerably .
Stabilization is difficult to define and needs to be further researched. However, when a patient has
used a prosthesis full time for a period of at least 6 months and when the limb volume has stabilized
to a point that socket fit remains relatively consistent for at least 2 to 3 weeks, a definitive prosthesis
may be indicated.
Intermediate prosthetic management concentrates on edema reduction and to define limb stabilization.
Additional studies need to be done to determine the most appropriate technique to achieve this stabilization.
Little literature is available that attempts to define when adjustment of the current socket may meet the needs of the
patient versus when socket replacement is required. Clearly , research is needed in this area.
Finally , it should be noted that a patient may return to work during this rehabilitative period, not just at the end of the process.
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Stages of Care
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