A statewide amputee rehabilitation programme
B. J. May *
Patients are referred to the amputee clinic at the Medical College of Georgia from all areas of the State of Georgia. Most referrals are made a considerable time after amputation and most patients live from 50 to 250 miles from the amputee clinic. A special programme was designed to alleviate some of the problems incurred by the distance and the delayed referral. Physical therapists, prosthetists, social workers, the vocational counsellor and the orthopaedic surgeon co-operate to provide maximum care on the day of the amputee clinic. The co-operative efforts of all members of the team and the ability to plan ahead for optimum rehabilitation maximize the use of patients' time and his rehabilitation level.
The team approach to the management of the amputee is generally accepted as the optimum approach. It is also recognized that, ideally, the amputee should be referred to the rehabilitation team even prior to surgery. During this period the patient can be prepared both physically and psychologically for the adjustments he will have to make. If pre-surgery referral is not possible then postsurgical management should be initiated as soon after surgery as possible whether the patient was fitted with a rigid dressing or not. Early initiation of restorative programmes increases the likelihood that the patient will become a functional prosthetic wearer. This is particularly true among the elderly who require comprehensive therapeutic programmes to overcome the general debility which often occurs after a long period of incapacitating circulatory problems.
Unfortunately, situational factors such as time and distance often interfere with the ideal rehabilitation programme. A creative approach to prosthetic management may limit the negative influence of such factors and provide the patient with the best available rehabilitation programme. Such a programme was developed at the Eugene Talmadge Memorial Hospital of the Medical College of Georgia in Augusta, Georgia. The hospital is the teaching hospital of the Medical College of Georgia and the referral hospital for the State of Georgia.
Patients are referred to the amputee clinic in Augusta from all over the state, sometimes as far as three hundred miles. Some but not all have been amputated at the Medical College of Georgia. In some instances referral may be soon after surgery but often referral is delayed for many months. Both adults and children are seen in the clinic but the majority of patients are elderly because the leading cause of amputation is vascular disease. The majority of patients present multiple physical and social problems.
Amputee clinic is held on a bimonthly basis and the prosthetic rehabilitation team includes the clinic chief who is an orthopaedic surgeon, physical therapists, prosthetists from two local prosthetic facilities, occupational therapists, social workers, and a vocational counsellor. Also available on a call basis are a dietician and a nurse from the peripheral vascular disease service.
The major problems faced in rendering optimum service include:
The delay in patient referral from private physicians throughout the state. Patients are frequently not referred for many months after surgery.
The distance the patient lives from the clinic. The majority of the patients live in rural areas from fifty to two hundred and fifty miles from the hospital. Most are in the lower socio-economic strata and must depend on others for transportation to and from the hospital.
The lack of a local in-patient rehabilitation facility where patients can stay during their rehabilitation programme. Insurance and other third party payers usually will not finance hospitalization for rehabilitation care and most of our patients cannot afford to stay in a hotel or motel while undergoing prosthetic care.
The programme that was developed to try and alleviate some of these problems is designed to maximize the patient's time at the hospital. It requires the co-operation of all members of the prosthetic team and the ability to plan ahead. The physical therapy department co-ordinates the activities of the team to enhance effectiveness.
Amputee clinics are held in the afternoon and all patients scheduled to be seen that day are requested to report first thing in the morning to the screening evaluation clinic held by the physical and occupational therapists. All patients scheduled for the afternoon clinic are first seen in the morning clinic.
New patients on initial referral undergo complete evaluation to determine current physical and socio-economic status and needs. The physical therapy evaluation includes determination of muscle strength, range of motion, stump circumference, self-care capabilities, home situation and general condition. If the patient is diabetic a dietician is called to review his diet.
The social worker is contacted to help in determining financial status and to make plans for payment of prosthetic device, continued therapy and prosthetic training. The social worker will also assist the patient in obtaining appliances such as wheelchairs or meeting other social needs. If the patient is of an appropriate age the vocational counsellor may also be called that morning for an initial interview. The vocational counsellor provides liaison for clients of counsellors in remote areas and makes referrals to counsellors in the patient's home county. The social worker and vocational counsellor work closely together to help the patient meet his socio-economic needs.
If there is time during the morning session the patient will be taught proper stump bandaging, conditioning exercises and whatever transfer or ambulatory activities may be necessary. Depending on the patient's status, a determination is made if further therapy is indicated to maximize self-care at home. If daily pre-prosthetic treatment is indicated then the social worker may help the patient make arrangements for transportation to and from the department each day or for temporary living accommodation in Augusta. Sometimes the patient can be referred for pre-prosthetic treatment to a clinic or hospital closer to his home. The social worker and physical therapist work together with the patient to make that decision.
When the patient is seen by the total clinic team in the afternoon the physician has the benefit of the evaluation and a tentative rehabilitation plan. The physician reviews the data and makes final recommendations. If the patient is ready for prosthetic fitting, or if a temporary prostheses is prescribed, the initial measurements can be taken later that day at the prosthetic facility.
Prosthetists from the two facilities in Augusta work very closely and in co-operation with the rest of the team. All new limbs are checked out on the alignment instrument and the patient goes through the initial stages of gait training before the limb is finished. The prosthetist usually schedules the final fitting on a clinic day; he then sends the patient to the therapist for check-out that same morning. The open exchange of information and mutual respect between the prosthetists and the physical and occupational therapists make for co-operative activities and effective patient management. Both prosthetic facilities are within two blocks of the hospital so that, if a problem develops during the check-out, the therapist can contact the prosthetist and necessary adjustments can be made. The physical and occupational therapists involved in the prosthetic rehabilitation programme are competent to make minor alignment adjustments themselves.
The initial check-out for a new lower limb amputee is done only to determine if the socket fit is adequate to initiate gait training. The check-out is completed and final alignment is determined when the amputee has developed an adequate gait.
As soon as a prosthesis is prescribed, the social worker begins to help the patient plan for living accommodation during gait training. If the patient lives within commuting distance only transportation arrangements need to be made. If the patient lives too far to commute, then the social worker tries to find a boarding house in the community where the patient can live during gait training. While there is one boarding house in the immediate vicinity, the patient must be independent in self-care to stay there. Sometimes a relative or friend can be found in the community but the problem of finding appropriate temporary living accommodation for our patients remains as one of the most persistent problems. Once the patient has been situated in the boarding house, the University's Public Safety department will provide transportation to and from the hospital and the prosthetic shop.
Prosthetic problems that arise during gait training are quickly resolved between the therapist and prosthetist. The ready availability of the clinic chief for more major problems also enhances the total programme. Once the patient has attained a satisfactory prosthetic function, he is again checked by the clinic team and the limb is finished.
During the time it takes to finish the limb the patient returns to his home. He comes back for the next clinic and may again undergo a few days of training to make sure he has retained his skill in the use of the appliance. Following initial discharge from the treatment the patient is expected to return for his first recheck in four to eight weeks. He is maintained on a regular review programme until the stump has stabilized.
No patient is ever discharged from the clinic. Once the stump has stabilized he is placed on a yearly re-evaluation. When the patient returns he undergoes a complete evaluation to determine his general condition, his physical status, his level of prosthetic adjustment and use and the condition of the prosthesis. Necessary prosthetic adjustments and repairs are made during this visit to the extent possible. Minor prosthetic repairs can be made in the morning prior to the afternoon clinic if payment is not a problem. Close co-operation between all members of the prosthetic team makes this possible.
Prior to the onset of the programme the clinic chief, physical therapists and prosthetists reviewed the types of problems that could be handled directly between physical and occupational therapists and prosthetists without first being evaluated by the physician. Routine repairs and upkeep fall into this category but if there is a question about the best course of action or if a new socket is indicated then the decision is delayed until the patient has been seen by the total team in the afternoon. The ability to tighten joints, replace worn leather, replace broken straps or broken feet without waiting for the afternoon clinic has greatly enhanced the use of the patient's time. Sometimes the social worker or the vocational counsellor will assist with a financial problem to further expedite repairs or maintenance of appliances.
This has been a brief description of a system that was devised to improve the quality and quantity of patient services and limit the number of trips a patient has to make to and from the prosthetic clinic. While it is not ideal and there are still problems to be resolved, the system does maximize the patient's time in Augusta through the co-operative efforts of all members of the team. The system is based on mutual respect, the ability of each health professional to work with other health care providers in the patient's best interest, the ability of one service to function as co-ordinator and of the other services to accept that role, and the ability to plan ahead and anticipate needs. The system worked so well in one hospital that it has been initiated in another hospital serviced by the clinic chief.