Physical Therapy as an Adjunct in O&P Care

I have been a practicing physical therapy assistant (PTA) for 17 years and recently started working in an outpatient clinic that awakened a passion to help the limb-loss community rebuild their lives and provided me with insight into the role physical therapists (PTs) and PTAs can play alongside prosthetists. Previously, I worked at a rural hospital with inpatient care, a nursing home, and an outpatient physical therapy clinic. In the outpatient and inpatient areas, I practiced wound care, which was typically a result of complications from diabetic ulcers, and occasional toe and ankle amputations. In the nursing home setting, I honed skills and techniques to help the elderly obtain and maintain more neutral postures and efficient gait patterns for endurance and safety. These treatment opportunities carried over to my current work, especially in working with patients with lower-limb loss in learning to use their prostheses. Prior to this role I had a limited understanding of the nuances of lower-limb prostheses and the occurrences that lead to limb loss. Treating patients at my current clinic has also presented the opportunity to work in the same building as the prosthetist/orthotist for most of the patients. The alliance with the neighboring O&P team, including the technicians and staff, led to an opportunity to shadow the clinician, which has increased my knowledge of various O&P protocols. I observed patients having modifications to their prostheses, participating in ongoing physical therapy, and gaining proficiency in their daily routines following rehabilitation. I was fortunate during one encounter to assist a technician and local orthotist with a KAFO modification, stabilizing the brace and freeing the technician’s hands for necessary adjustments. While I had moderate exposure to patients using AFOs following a stroke, my broader caseload added to my interest in appropriate times for the use of an AFO for foot drop or other limited functional ankle use. For patients with limb loss, physical therapy rehabilitation can be a catalyst for a return to functional living and independence. Initially there are three crucial measures for returning to optimal function: closure and healing of suture sites, residual limb edema management, and hip alignment. After amputation, PTs and PTAs can begin rehabilitation early in the process, usually in the hospital. They can change bandages and dress wounds, document progression of restorative measures, and help mitigate residual limb swelling with compression wrapping and soft tissue massage as needed. Another component to patients’ successful return to ambulation is reducing hip flexion after surgery. In many cases, patients enter outpatient physical therapy with limited hip flexion range of motion, leading to excessive trunk flexion and lower back pain. In the hospital, during home health, and throughout outpatient rehabilitation, therapists can remind patients of the importance of lying in a prone position for improving this range. Emphasizing initial strength and flexibility for prosthetic limb use can be addressed in the hospital but may be more suitable in the patient’s home. Home health therapists can be instrumental in reestablishing essential muscle activation based on the level of amputation. For someone with a transtibial amputation, the quadriceps are crucial for knee extension in proper stance phase as are the hamstrings for knee flexion in swing phase. For a patient with a transfemoral amputation, the glute muscle complex as well as the hip abductors and adductors play an important role for stability through the prosthetic knee component and pylon. Therapists can continue monitoring the wound and swelling to prepare for an efficient initial socket fitting. The physical therapy outpatient setting is a crucial stage in post-amputation rehabilitation, and pairing this with the prosthetist’s involvement, especially in the same location as the rehab, can maximize its impact. One benefit includes communication between therapists and prosthetists for potential adjustments to the prothesis or progression in therapy. In this setting, if the prosthetist deems it necessary, a therapist can assist with range of motion and manual muscle testing of limbs for prosthetic socket fitting. Additionally, therapists can relay other patient concerns, such as pain, soreness, and potential wounds affecting the residual limb—sometimes on the same day as a visit with the prosthetist. In addition to being fitted with a prosthesis, a patient can gain significantly more functional control and independence with outpatient physical therapy. The patient will learn proper gait mechanics, which is necessary for proper use of a prosthesis, gain balance and stability for daily activities in standing, getting in and out of a chair, and negotiating stairs and various surfaces. Physical therapy can help progress a patient’s independence from a walker to a cane and, potentially, no form of assistive device. Patients receiving therapy in outpatient care may be the only time between physician and prosthetist visits that they have their residual or nonaffected limbs inspected. These inspections by a therapist can catch skin infections and other conditions early that otherwise may lead to tissue damage, hospitalization, and further amputation. Advocacy and support outside of the clinic are other ways we can work together to support patients. The more I began working with the limb-loss community, the more I noticed requests for increased external support aside from family and friends. Many of my patients expressed hope for a local peer support group and activities for them to attend together, which spurred me to become involved in advocacy and support. Last April during Limb Loss and Limb Difference Awareness Month I collaborated with a local minor league baseball team for an Amputee Awareness night. Along with a former patient and an employee of a local O&P practice, we provided information, and the baseball club displayed the message about Limb Loss and Limb Difference Month on the jumbotron for over 4,000 fans to view. Advocacy can help foster a sense of community, shared understanding, and connection between patient and provider. In addition to the local baseball game awareness night, I recently had the opportunity to represent the medical field as an attendee in a virtual support group for the limb-loss community. Taking part in this group made me more aware of difficulties those with disabilities face in the public spectrum, such as malfunctioning handicapped door access, lack of wheelchair ramps, and poor directions to handicapped parking spots. The individuals who mentioned these disparities also voiced their concerns to the company or local lawmakers. As therapists, prosthetists, and orthotists, we can use our professional knowledge in health sciences and medical and rehabilitation engineering to help make changes for improved access through advocacy and legislation changes. One of the biggest contributions to advancing our patients toward their independence is growing our knowledge base as practitioners. As with most healthcare providers, therapists and O&P professionals are required to maintain their credentials through continuing education. The outpatient clinic I work in and the O&P team arranged an in-clinic continuing education course with a prosthetics manufacturer, which provided valuable insight for therapists, including how certain components improve the patients’ swing phase and sitting techniques for improved user control. The course instructor also provided new ways to increase patients’ awareness of their prostheses through ground contact, improvement in weight shifting to the residual limb, activities/exercises to perform, and other valuable treatment suggestions. Continuing to learn and collaborate with other professionals outside of our practice realm can often have the most influence and impact on the individuals we treat. Teamwork makes the dream work. John Cooper, PTA, Human Performance and Rehabilitation Centers, Georgia, has 17 years of experience in patient care and enjoys being an advocate for amputees and collaborating with O&P professionals.

Physical Therapy as an Adjunct in O&P Care

Let’s Get Functional: Occupational Therapy’s Role in Lower-Limb Rehabilitation

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Orthotic and Prosthetic Technician

Certified Prosthetist/Orthotist (CPO), Certified Orthotist (CO)

Certified Prosthetist Orthotist (CPO and/or Board Eligible Clinician)

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Let’s Get Functional: Occupational Therapy’s Role in Lower-Limb Rehabilitation

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Orthotic and Prosthetic Technician

Certified Prosthetist/Orthotist (CPO), Certified Orthotist (CO)

Certified Prosthetist Orthotist (CPO and/or Board Eligible Clinician)

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