How many times have you heard that physical therapy is for the legs and occupational therapy is for the arms? Or how about this one: “OT? You mean overtime?” Or my personal favorite: “Occupational therapy? I don’t need a job!”
Like O&P clinicians, the role of the occupational therapist (OT) can be misunderstood by the public. According to the 2024 Government Accountability Office’s report on Rehabilitation Services and Outcomes for Medicare Beneficiaries, 89 percent of those with lower-limb amputations received occupational therapy services compared to 97 percent who received physical therapy.1 This means more than 3,500 Medicare beneficiaries with a lower-limb amputation who received physical therapy did not receive occupational therapy. Additionally, in the same report, one healthcare representative hypothesized that some patients may not receive occupational therapy services when the primary care physician or other healthcare professionals have not worked with OTs in the past, nor understood their role. Although there is a high number of patients receiving occupational therapy after lower-limb amputations, the lack of knowledge regarding occupational therapy is potentially preventing patients from receiving beneficial treatment.
As a prosthetist, how many of your patients have you referred to an OT after a lower-limb amputation compared to those referred to an OT for an upper-limb amputation? Occupational therapy is beneficial for all patients after amputation, as it helps them work towards functional independence and to improve their overall quality of life.
What Do OTs Do?
OTs help individuals improve independence in their occupations—or the everyday activities one wants, needs, or is expected to do. An occupation could be as simple as sitting up at the edge of the bed or watching a film at a movie theater, or as complex as volunteering in the community or planning a vacation.
Many of our daily occupations are made up of activities of daily living (ADLs) and instrumental activities of daily living (IADLs). ADLs are the basic tasks we do to take care of ourselves, like eating, brushing our teeth, and getting dressed, while IADLs are the more complex activities like cooking, navigating public transportation, or caring for family members or pets.
OTs can help patients with their ADLs and IADLs by utilizing activity analysis—that is, breaking down the steps and aspects of a task. By doing this, OTs identify the performance skills needed to complete an activity, or the action steps one needs to take. For instance, for a person to cook an egg on a stove, there are several performance skills required, including reaching into the refrigerator to grab the eggs and butter, attending to the skillet to make sure the egg doesn’t burn, and coordinating flipping the egg with a spatula. OTs help individuals complete these through interventions such as ADL training, therapeutic activities, and therapeutic exercises.
OTs help patients achieve their goals through a variety of techniques, utilizing areas of a patient’s occupational profile to guide them. The occupational profile is an interview, typically a part of the initial evaluation that helps the therapist gain insight into a person’s occupational history, experiences, their everyday activities, what they like, and other factors relevant to their case. It’s a holistic picture that allows therapists to better understand their patients and helps individualize the plan of care. For example, let’s say we have a patient with bilateral lower-limb prostheses who loves cooking, especially baking cookies. An OT might challenge this patient to regain his or her balance and confidence in the kitchen by working on balance while mixing the dough or reaching for ingredients in cabinets. By engaging the patient in this way, OTs not only promote a patient’s independence with a task but also personalize the plan of care.
Once the plan of care is set, OTs use their problem-solving skills, creativity, and evidence-based practice to provide interventions for their patients to meet their goals. Additionally, like O&P professionals, OTs use outcome measures throughout the plan of care to measure patients’ progress toward their goals. Some examples of outcome measures that an OT might use with this population include the Functional Independence Measure and the Modified Barthel Index that assess ADL status, and the Patient Specific Function Scale, a self-reported measure of three activities deemed important by the patient. If your patient is working with an OT, it could be beneficial to reach out to them to discuss the patient’s progress and use the outcome measure results as a part of your medical necessity justification.
What Is the OT’s Role?
After lower-limb amputation, a transdisciplinary and holistic approach is crucial to the rehabilitation process.2 Although there is lack of specific occupational therapy interventions in the scientific literature, there is some emerging evidence that supports an OT’s role on the multidisciplinary team for those with lower-limb amputations.3 Clinical expertise suggests how occupational therapy can have a positive impact on this population. In fact, OTs can play a role in lower-limb amputation rehabilitation even before the amputation.
Prior to amputation, it is recommended that an OT evaluates a patient’s ability to complete ADLs and IADLs, which can be used to establish a patient’s functional level prior to surgery and can help determine goals and expectations post-surgery.2 Additionally, OTs can create a home exercise program for the individual to maximize strength and balance prior to surgery. An example from the literature describes how a pre-amputation ADL intervention amongst 52 participants focused on dressing, showering, grooming, bed-chair transfers, feeding, and toileting helped improve their Barthel Index scores post-intervention.4
After lower-limb amputation, OTs play a large part in inpatient rehabilitation, prior to receipt of the prosthesis. The OT helps patients complete their ADLs and IADLs to their highest level of independence by ensuring they can complete these essential tasks at their current level of mobility. This includes transfer training, positioning for dressing, and teaching modification of activities to promote independence.
Much like PTs, OTs can also help with management of the residual limb. First, they ensure the patient has the proper hand strength and dexterity to use a shrinker. They can then educate the patient on use of the shrinker or wrap to help prepare the limb for prosthesis use. Second, they teach desensitization of the lower limb through massage, light tapping, and use of different textured materials to decrease sensitivity, prepare the limb for prosthesis wear, and decrease pain. The OT might provide adaptive tools to the patient to complete desensitization if the patient can’t reach his or her limb. Third, they train the patient to use a long-handled mirror to inspect the residual limb for any skin redness or any other skin abnormalities. Finally, they educate the patient on protecting the residual limb with a removable rigid dressing for increased safety.
Aside from residual limb management, OTs assist with proper wheelchair use. The OT will help position the patient in the chair safely, with use of a residual limb support to prevent contractures, a solid seat insert to improve weight distribution, anti-tippers on the chair to increase safety, and the proper wheelchair cushion for comfort and pressure relief. They also educate and assist the patient in learning to navigate with the wheelchair, including going up and down ramps, positioning the wheelchair to transfer from the wheelchair to the bed/chair/toilet, maneuvering in small spaces, using the brakes, and shifting for pressure relief in the wheelchair.
Further, if home modifications are not completed prior to the amputation, these skills are crucial in the transition from the rehabilitation facility to returning home. OTs can complete home evaluations to determine if patients can maneuver their wheelchairs and devices safely through doorways and within their homes. They will recommend durable medical equipment such as a transfer bench for the bathtub or a grab bar by the toilet and may suggest rearranging furniture for improved access.
After prosthesis receipt, OTs train their patients on ADLs and IADLs with the use of the prosthesis. The OT will have patients practice dressing, including donning and doffing the prosthesis, liner, and socks. Patients will also practice transfer training to a variety of surfaces with their prostheses. When patients have mastered these skills, they will further enhance their performance skills pertinent to important tasks to facilitate their highest level of independence. For example, for a mother of a toddler, this may include practicing the motor skills of reaching, squatting, and lifting to pick up her child while using her prosthesis.
These skills are especially important, as falls are common for people with lower-limb amputations with as many as 50 percent of lower-limb prosthesis users experiencing a fall at least once per year.5,6 OTs help their patients prevent falls through home modifications, environmental modifications, ADL and IADL training, and education. For example, if a patient demonstrates difficulty getting out of bed, OTs may recommend environmental modifications such as a grab bar by the bed or bed rails, a no-slip mat by the bedside, or a higher bed to improve ease with transfers. They would also make sure the person can safely put on his or her prosthesis and work on transfer strategies to ensure safety. The therapist can also reinforce all measures with reminders such as a visual sign and educating family members as necessary.
Throughout the entire rehabilitation process, OTs utilize their mental health training to support individuals with amputations. OTs help their patients adjust to limb loss by addressing changes in identity and daily roles. They also support the transition to using a prosthesis through goal setting, routine development, and stress management techniques. Additionally, OTs address depression, anxiety, and body image concerns and refer their patients to other healthcare providers when necessary. For their patients, especially those with cognitive impairments, OTs incorporate cognitive training into rehabilitation. This could include anything from helping patients develop a routine and strategies to don their prostheses correctly, to practicing problem-solving during daily tasks to reduce the risk of falls and injury in the home. These mental health and cognitive interventions combined with our holistic rehabilitation training make OTs uniquely qualified to address the needs of individuals who have had an amputation.
Now that you may have a better understanding of the OT’s role in rehabilitation of patients with lower-limb amputations, you may be wondering, how does it differ from the PT’s role? While PTs generally focus more on overall mobility, OTs concentrate on improving independence with daily activities. For example, patients with bilateral transfemoral amputations may initially work on their sitting balance at the edge of bed with PTs to improve their core strength. With OTs, those patients might do dressing activities to improve dynamic balance while seated at the edge of the bed. This demonstrates the overlap between the two disciplines and explains why occupational therapy services are important by focusing on the purpose behind the activity. OTs aren’t instructing their patients on strengthening or balance exercises for the sake of improving strength and balance, they are working on skills necessary to improve ADL and IADL performance. Both PTs and OTs play an important role in the therapy of patients with lower-limb amputations and complement each other in the rehabilitation process.
How Can Prosthetists Help Advocate for OTs?
As a part of the rehabilitation team, prosthetists and OTs can work together to ensure their patients are provided with optimal care.
Advocating for and understanding the full scope of each member of the multidisciplinary team is of utmost importance. Similarly to how an OT might advocate for a patient to reach out to their prosthetist due to an ill-fitting prosthesis, a prosthetist might recommend a person seek occupational therapy if he or she notices a patient having trouble with getting dressed after a fitting, poor wheelchair positioning, or increased assistance required for donning or doffing the device due to coordination or strength limitations. Additionally, if the patient reports having difficulty with self-care tasks with use of the prosthesis, an OT referral may be warranted.
Consistency with education across all disciplines is crucial. Just as an OT reiterates prosthetic education, such as adjusting sock ply and donning/doffing a prosthesis in the correct manner, a prosthetist should reinforce occupational therapy–related education and safety.
OTs hold an important role in lower-limb prosthetic rehabilitation. OTs, prosthetists, and other members of the rehabilitation team benefit from interdisciplinary communication, advocacy, and education to be more well-rounded providers. Even more importantly, patients benefit from more holistic and comprehensive care.
Kristin E. Nalivaika, OTD, OTR/L, is a research associate and an occupational therapist who is a member of the Hanger Institute for Clinical Research and Education. She can be contacted at knalivaika@hanger.com.
References
- United States Government Accountability Office. 2024. Limb Loss Rehabilitation Services and Outcomes for Medicare Beneficiaries.
- Department of Veterans Affairs and Department of Defense. 2017. VA/DoD Clinical Practice Guideline for Rehabilitation of Individuals with Lower Limb Amputation. U.S. Department of Veterans Affairs.
- De-Rosende Celeiro, I., L. Simón Sanjuán, and S. Santos-del-Riego. 2017. Activities of daily living in people with lower-limb amputation: Outcomes of an intervention to reduce dependence in pre-prosthetic phase. Disability and Rehabilitation 39(18):1799–806.
- Dorsey, J., and M. Bradshaw. 2017. Effectiveness of occupational therapy interventions for lower-extremity musculoskeletal disorders: A systematic review. American Journal of Occupational Therapy 71(1):1–11.
- Hunter, S. W., F. Batchelor, K. D. Hill, A.-M. Hill, S. Mackintosh, and M. Payne. 2017. Risk factors for falls in people with a lower-limb amputation: A systematic review. PM&R: The Journal of Injury, Function, and Rehabilitation 9(2): 170–80.
- Kim, J., M. J. Major, B. Hafner, and A. Sawers. 2019. Frequency and circumstances of falls reported by ambulatory unilateral lower-limb prosthesis users: A secondary analysis. PM&R: The Journal of Injury, Function, and Rehabilitation 11(4):344–53.
