PT MANAGMENT FOR EHP

PRE- AND POST-PROSTHETIC PHYSICAL THERAPY MANAGEMENT FOR A PATIENT FOLLOWING EXTERNAL HEMIPELVECTOMY DUE TO SPINDLE-CELL SARCOMA: A CASE REPORT

A Case Report

Presented to

The Faculty of the Marieb College of Health and Human Services

Florida Gulf Coast University

In Partial Fulfillment of the Requirement for the

Degree of

Doctor of Physical Therapy

By

Jonathon Shumway, SPT

2019

PT MANAGEMENT FOR EHP

APPROVAL SHEET

This case report is submitted in partial fulfillment of the requirements for the degree of Doctor of Physical Therapy

Jonathon Shumway

Approved: April, 2019

Ellen Donald, PhD, PT Committee Chair

Mark Erickson, DScPT, MA, PT, OSC Committee Member

The final copy of this case report has been examined by the signatories, and we find that both the content and the form meet acceptable presentation standards of scholarly work in the above mentioned discipline. PT MANAGEMENT FOR EHP

ACKNOWLEDGMENTS

I would like to express my very great appreciation and gratitude to Dr. Ellen Donald and Dr.

Mark Erickson for their constructive suggestions during the planning and development of this case report. Their willingness, patience, and generosity has been very much appreciated. A special thanks, to the participating facility, therapists, and prosthetist for their time in assisting with this report.

OP REHAB FOR EHP 1

TABLE OF CONTENTS

Table of Contents 1

Abstract 2

Background and Purpose 3

Case Description 4

Patient History 4

Systems Review and Examination 5

Clinical Impression #1 9

Evaluation 9

Prognosis 10

Plan of Care 11

Clinical Impression #2 11

Intervention 11

Pre- and post-prosthetic rehabilitation 11

Patient compliance 13

Post-amputation and prosthetic complications 13

Outcomes 15

Discussion 16

References 19

Appendix A: Summary of findings from tests and measures over 40 visits 22

Appendix B: Pre-prosthetic rehabilitation 23

Appendix C: Post-prosthetic rehabilitation 24 OP REHAB FOR EHP 2

ABSTRACT

Background and Purpose . External hemipelvectomy (EHP) is a rare procedure performed as a treatment for tumors of the pelvis, which often results in extensive impairments and limitations to a patient’s functional independence. The purpose of this case report is to describe the outpatient physical therapy (PT) management for a patient with EHP due to undifferentiated spindle-cell sarcoma of the pelvis. Case Description . The patient was a

36 year-old male who underwent right EHP due to undifferentiated spindle-cell sarcoma of the pelvis. The patient attended 12 visits of pre-prosthetic and 28 visits of post-prosthetic outpatient PT. Outcomes . After 40 visits of outpatient PT the patient had significant improvements in functional mobility as assessed by the Boston AM-PAC Basic Mobility

Outpatient Short Form and was able to ambulate 430 feet with no assistive device. Discussion .

This case report provides an account of outpatient PT management and prosthetic training for a patient with EHP, including multiple challenges experienced during the rehabilitative process including post-amputation pain, prosthetic fit, and the influence of psychosocial factors and patient comorbidities.

Key Words : hemipelvectomy, outpatient, rehabilitation, physical therapy, undifferentiated spindle-cell sarcoma

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BACKGROUND AND PURPOSE

External hemipelvectomy (EHP) is a rare procedure, making up less than one percent of total lower limb amputations in the United States and Canada, 1,2 that is most commonly indicated for resection of bone and soft tissue sarcomas of the pelvis. Established criteria for performing an EHP include involvement of tumor invasion to at least two of the following structures: the lumbosacral plexus, femoral neurovascular bundle, and/or bone of the ilium, sacrum, ischium, and pubis. 3 External hemipelvectomy results in resection of the affected innominate, sacrum, and entire limb. Surgical techniques for EHP are complex, and until recent advances in anesthesia and surgical techniques, EHP procedures carried a low survival rate and high rate of complications. 4-6 It has been reported that patients with hemipelvectomy walk 50% slower and spend 125% more energy than age matched able-bodied controls. 7

Use of a prosthetic limb requires more energy and is a more difficult form of mobility compared to the use of bilateral crutches with no prosthesis, contributing to the high percentage of patients ambulating without a prosthesis.8,9 Modern prosthetic design has decreased this burden, making prosthesis use a more viable option for the individual with EHP.

Due to a higher number of patients surviving EHP surgery, and advancements in prosthetics, there is a growing need for physical therapy (PT) management and prosthetic gait training in this population.

Currently, the extent of published resources describing PT management for individuals with EHP is limited. Published studies in the PT literature include case reports that describe the acute and sub-acute rehabilitation of individuals with EHP, while resources describing outpatient care for individuals with EHP are limited. The purpose of this case report is to describe the OP REHAB FOR EHP 4 outpatient pre-prosthetic and post-prosthetic PT management and outcomes for a patient following EHP due to resection of undifferentiated spindle cell sarcoma of the pelvis.

CASE DESCRIPTION

Patient History

The patient was a 36 year-old male following EHP due to spindle cell sarcoma of the pelvis.

His condition originally presented as sciatica one year prior to his amputation. A spindle cell sarcoma compressing the patient’s right sciatic nerve was identified after the patient experienced a fall, leading to a diagnosis of pathological hip fracture and high-grade primary sarcoma of the right periacetabular region with posterior extension to the sciatic nerve. The patient underwent emergency amputation in September, 2017. A right external hemipelvectomy with partial sacrectomy, including right external and common iliac artery and vein arterolysis and venolysis, with a pedicled right anterior thigh myocutaneous flap was performed. Pre- and post- operative imaging can be seen in Figure 1.

The patient attended acute, post-acute inpatient, and home health PT in the months following his amputation. He was participating in palliative care, and had monthly follow-ups with his oncologist. To date, the patient has had no recurrence of cancer. Past medical history was significant for schizoaffective schizophrenia, which was controlled by medication. The patient was referred for outpatient PT by his physician to begin progression toward use of a prosthesis six months after his amputation. At that time, he was ambulating with two standard crutches for limited community distances. His chief complaints included pain and soreness in his residuum, which he described as being in his non-existent “hip” joint, when changing positions and during crutch ambulation. He also complained of a “constant glowing hot pain” at the distal- OP REHAB FOR EHP 5 lateral aspect of his residuum. Prior to amputation, the patient was active in recreational activities including hunting, fishing, scuba diving, water skiing, and snow skiing. At the time of the initial examination, the patient was participating in any of these activities. This case report will focus on the six weeks of pre-prosthetic and one year of post-prosthetic PT management during his course of outpatient rehabilitation.

Figure 1 . Pre-operative MRI and post-operative radiograph

Systems Review and Examination

A systems review and initial examination was performed by a physical therapist six months after the patient’s amputation to initiate his outpatient care. The plan for examination included assessment of the integumentary, musculoskeletal, neuromuscular, cardiovascular, and pulmonary systems. Tests and measures chosen were related to muscle force production, muscle length, balance, endurance, joint range of motion, skin integrity, patient-reported pain, neurological function, sensory function, and functional mobility (Table 1).

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Table 1. Plan for examination History and review of Systems review Impairments to be assessed systems Integumentary Skin integrity and scar mobility Neuromuscular Neurological function, sensory function, and balance Musculoskeletal Range of motion, strength, muscle length, core stability, and functional mobility Cardiovascular/Pulmonary Ambulation endurance, circulation, and activity tolerance Other Pain, fatigue, distress, psychosocial issues (depression and schizophrenia), sedentary behavior, and obesity

During the systems review, the patient presented with normal communication, cardiovascular, pulmonary, and gastrointestinal function. The patient denied chest pain, headaches, cough, shortness of breath, nausea, vomiting, and abdominal pain. While reviewing the integumentary system, the patient denied recent changes to skin color or texture. On observation, the patient presented with a well-healed incision on his residuum with no signs of infection and moderate edema in his residuum.

The patient had abnormal findings in the musculoskeletal system presenting with complaints of lower back pain, residuum pain with movement and with change in positions, and restrictions in movement of his unaffected lower extremity. During examination the patient’s active range of motion (AROM) was measured through use of standard goniometry as described by Norkin and White.10 The patient’s bilateral upper extremities were within normal limits (WNL). Active range of motion (AROM) measurements were WNL on the patient’s left lower extremity (LLE) other than hip external rotation (ER) and hip internal rotation (IR), OP REHAB FOR EHP 7 measured at 0-26 degrees and 0-21 degrees, respectively. Hip ER and IR were measured in supine with the hip and knee at 90 degrees of flexion. 11 Hamstring and hip flexor muscle length of the unaffected lower extremity was assessed through the passive knee extension test 12 and a modified Thomas test. 13 The patient lacked 40 degrees of knee extension on initial examination with the passive knee extension test, and demonstrated decreased iliopsoas length during the

Thomas test indicated by a flexion position of the hip joint in relation to the plinth with a neutral lumbar spine.

During a review of the neuromuscular system the patient described abnormal sensations in his residuum including hypersensitivity and a “constant glowing hot pain” in addition to having impairments in muscle force production, muscular endurance, balance, and gait. Upper and lower extremity strength was measured using standard manual muscle testing

(MMT) techniques. 14 Bilateral upper extremity strength measured 5/5 in all planes of motion.

Manual muscle testing of the patient’s left hip, knee, and ankle motions were all quantified at

5/5, with complaints of pain in the left groin and popliteal space during hip and knee MMT, respectively. Neurological function was measured by assessing deep tendon reflexes of the unaffected limb, and testing sensation along the residuum, including sensation to light touch. 15

Deep tendon reflexes were found to be WNL. Sensation testing found hypersensitive areas on the distal-lateral residuum and along his lateral trunk skin flap. Core stability and muscular endurance were assessed through the unilateral hip bridge endurance test 16 and plank static core test. 17 The patient was unable to perform a full unilateral bridge on initial evaluation and was able to hold a plank position for 30 seconds. OP REHAB FOR EHP 8

Overall pain, fatigue, and distress were assessed through use of the visual analog scale

(VAS). 18 The patient rated his average pain and fatigue at 5/10, and rated his average distress at

1/10. Patient-report of current residuum pain and right “hip” pain was assessed through use of a numeric pain rating scale (NPRS), 19 which he rated at 5/10 and 4/10, respectively. The patient’s height and weight were used to calculate body mass index (BMI), which was valued at

36.61 kg/m 2, placing the patient in the obese category. The patient also reported living a sedentary lifestyle and having little to no participation in recreational physical activity since his amputation. The patient did participate in limited community ambulation with use of bilateral crutches and no prosthesis, but reported that he experienced significant fatigue during activity.

Functional mobility was measured using the Boston Activity Measure for Post-Acute

Care (AM-PAC) Basic Mobility Outpatient Short Form,20 an 18-item self-reported measure of functional ability rating difficulty or assistance needed in tasks ranging from moving in bed to taking part in strenuous activity such as running three miles. This measure has demonstrated excellent psychometric properties, 21 and has adequate internal consistency, concurrent validity to the Barthel Index, and test-retest reliability in rehabilitation outpatients. 22

Given the rarity of EHP, limited literature exists regarding the reliability and validity of

PT tests and measures for this population. It is realistic to assume that tests and measures on the patient’s unaffected limb would be valid as no soft tissue or structural changes are expected in his unaffected limb as a direct result of the amputation. However, with the lack of muscular attachment sites and other major adaptations that have occurred due to the amputation, some of the measures are expected to be non-normal. Results of the examination can be seen in Appendix A. OP REHAB FOR EHP 9

Clinical Impression #1

The patient was a young male who underwent emergency EHP due to undifferentiated spindle-cell sarcoma. At six months post-amputation, he started outpatient physical therapy in preparation for prosthetic fitting and for post-prosthetic gait training. The patient demonstrated multiple functional limitations affecting his activity participation and social role, including limitations in ambulation, functional mobility, and self-care activities. Structural impairments caused from EHP included loss of his entire right lower extremity, loss of his right hemi-pelvis, and disruptions in the muscle, skin, and nervous tissue of his right lower extremity and trunk. Impairments resulting from the condition were identified in sensation, muscle length, lower extremity strength, and activity tolerance. The patient had significant residuum pain, phantom limb pain, low back pain, hypersensitivity, and daily fluctuations in the volume of his residuum that were expected to limit his ability to use a prosthesis in addition to limiting his activity tolerance, endurance, and functional mobility. Comorbid conditions of obesity and schizoaffective schizophrenia along with lack of financial resources and limited access to transportation were negative factors influencing the patient’s prognosis and prosthesis use.

The patient’s high motivation and available family support were positive factors for successful rehabilitation.

Evaluation

Primary impairments limiting the patient’s potential prosthesis use, ability to perform functional mobility, and activities of daily living (ADLs) included impaired sensation, pain, decreased core stability, decreased endurance, decreased muscle length, and impaired balance.

These impairments were associated with his loss of anatomical structure, extended post- OP REHAB FOR EHP 10 surgical recovery, deconditioning, alterations in his center of mass, and sedentary behavior after amputation. Hypersensitivity in the residual tissues was expected to influence socket comfort and his ability to weight bear in the prosthesis. His reduced core stability needed to be addressed prior to prosthesis use, as adequate core stability and residuum muscle recruitment are required to provide control and stability to the prosthesis. The patient’s pain had a significant influence on his activity participation and was expected to influence prosthetic use and patient compliance. Considering the increased energy expenditure and oxygen consumption required for prosthetic use, the patient’s poor endurance and tolerance to activity would need to be improved for functional use of his prosthesis.

Prognosis

Bio-behavioral comorbidities including fear avoidance beliefs, depression, and schizoaffective schizophrenia were expected to negatively influence patient success. Although obesity was expected to influence the patient’s functional mobility and endurance, it has not been seen as a factor influencing successful prosthetic fitting in individuals following EHP. 23

Furthermore, the patient’s age, high motivation, family support, and etiology (tumor) of amputation put this patient at a higher likelihood of being a successful prosthetic user.

However, the high level of his amputation decreases this likelihood when compared to other levels of amputation. 23 The rehabilitation potential for this patient was determined to be good, and it was expected that the patient would be a community ambulator with use of a prosthesis with or without an assistive device (AD) after discharge from outpatient PT.

OP REHAB FOR EHP 11

Plan of Care

Due to the high complexity of the patient’s initial clinical presentation, the evaluating therapist determined that the patient would be seen three times a week for a 90-day period for

45-60 minute sessions, with assessment of progress every 10 visits. The patient was able to attend an average of one appointment per week over the course of one year, due to issues with transportation and his need to attend other health appointments. Expected outcomes and goals included independence with transfers, community ambulation with or without an AD, and independence with stair and obstacle negotiation as well as improved strength, balance, and endurance. In total, the patient attended six weeks of pre-prosthetic rehabilitation followed by one year of post-prosthetic rehabilitation.

Clinical Impression #2

Based on the examination data, the initial impression was confirmed. The patient’s impairments in strength, muscle length, core stability, balance, and endurance were expected to be improved by PT intervention. Additionally, the patient was a good candidate for successful prosthetic fitting considering his positive prognostic factors. The next plan of action was to proceed with intervention. The patient was already attending prosthetic appointments in preparation for his prosthesis. The patient’s prosthetist was consulted, and the patient was to receive his definitive prosthesis six weeks after his initial PT examination. The initial plan was to prepare the patient for prosthetic training by improving core stability, endurance, strength, balance, and flexibility. After being fit with his definitive prosthesis the patient would be reassessed. Post-prosthetic interventions included prosthetic training, transfer training, standing balance training, gait training, obstacle training, stair training, and endurance training. OP REHAB FOR EHP 12

Intervention

Pre- and post-prosthetic rehabilitation. The patient participated in a six week pre- prosthetic phase, followed by a year of post-prosthetic training. A progressive core strengthening, flexibility, lower extremity strengthening, and upper extremity strengthening program occurred in the first six weeks following initial evaluation. Interventions were progressed when the patient was able to perform all repetitions of exercises for a muscle group without fatigue. See appendix B for pre-prosthetic intervention parameters and progression.

After the patient received his definitive prosthesis, interventions included transfer training, therapeutic exercise, standing balance training, gait training, stair training, and obstacle navigation. Progression was based on patient tolerance to activity, and was heavily influenced by prosthetic componentry, changes in socket fit, changes in prosthetic alignment, patient confidence, low back pain, residuum pain, patient compliance, and psychological factors including depression and decreased motivation. Increasing stance time on prosthetic limb, equalizing step length, and controlling the prosthesis during swing phase through compensatory movement patterns involving muscles of the trunk and tissues of the residuum were all main components of the patient’s post-prosthetic rehabilitation.

Gait training was initiated in the parallel bars and consisted of weight shifting and balance activities with use of the prosthesis. This was progressed to performance of multi- directional steps within the parallel bars, to open floor ambulation with progressively decreased use of assistive devices (ADs). The patient initially used a rolling walker for ambulation outside of the parallel bars, but progressed to use of bilateral crutches, one unilateral crutch, and then used no AD. The patient trialed bilateral Lofstrand crutches during OP REHAB FOR EHP 13 several visits, but preferred to use axillary crutches as he found them more comfortable, stable, and easier to use. Static standing balance activities were progressed to more advanced dynamic balance activities including catching/throwing activities and weighted medicine ball activities involving stepping and trunk rotations. Gait and mobility training was progressed to include stair and obstacle navigation in later visits. The patient was also educated in prosthetic componentry, prosthetic wear time, skin checks, AD use, aquatic therapy, and the benefits of weight loss and increased activity throughout rehabilitation. See appendix C for post-prosthetic rehabilitation interventions that were used with this patient.

Patient compliance. The patient averaged one PT session per week. On one occasion, the patient did not attend PT or wear his prosthesis for one month when he went on vacation.

On his return to PT, the patient had regressed in his endurance and activity tolerance, but due to a recent adjustment from his prosthetist he demonstrated improved gait mechanics. The patient also had a higher fear of falling and a higher reliance on his AD during his returning treatment session. The patient had variable compliance to his home exercise program (HEP) at times stating he was performing his exercises three times a day, and more often, stating he was not performing the exercises at all. Lastly, the patient varied on compliance to prosthesis use at home, often going days to weeks without wearing his prosthesis.

Post-amputation and prosthetic complications. Interventions were needed to address the patient’s low back pain, which included stretching and soft tissue mobilization to the patient’s right lower back and right gluteal region in addition to educating the patient to perform lumbar extension activities throughout the day. Issues with prosthetic alignment, prosthetic length, and socket fit influenced prosthetic training and patient gait mechanics. On OP REHAB FOR EHP 14 occasions where prosthetic length was inadequate, exercises were performed with use of an object such as a thin book underneath the patient’s prosthetic leg. Issues with prosthetic alignment and componentry were normally resolved within 1-2 weeks after communication was established with the patient’s prosthetist. Common issues included excessive prosthetic knee friction not allowing sufficient swing through during gait and excessive pistoning from an ill-fitting socket. The patient also had 20 pounds of intentional weight loss during the course of rehabilitation, which influenced socket fit and comfort. The patient participated in pain management, including frequent nerve blocks and the use of oxycodone and gabapentin. Pain management had variable success with this patient which may have influenced lethargy and decreased motivation seen with the patient during some sessions. In the sessions after lumbar nerve blocks, the patient stated that he experienced less phantom limb pain and was able to tolerate therapy sessions with less pain during and after PT. Initially, the patient experienced significant pain during the night after use of prosthesis which deterred him from using his prosthesis outside of PT and for which he stated he increased his use of pain management medication. Weight bearing through the prosthesis and prosthesis wear time was slowly progressed to allow residual tissues to tolerate more pressure. An occasion of an ingrown toenail in the patient’s unaffected foot was quickly resolved after being told to immediately see his podiatrist.

Throughout rehabilitation, the patient had issues with confidence in his prosthesis and preferred to hold bilateral crutches in his hands without actual use of the crutches on the ground during ambulation while using a prosthesis. The patient also preferred a more stable OP REHAB FOR EHP 15 prosthetic knee joint, with a higher resistance into knee extension which impaired the ability of the prosthetic knee to swing through during swing phase of gait.

Outcomes

After one year of outpatient PT, the patient had significant improvement in his functional mobility as assessed by Boston AM-PAC Basic Mobility Outpatient Short Form.

Cheville et al. suggested using a minimal clinically important difference (MCID) of 2 points on a t-scale score as a pragmatic MCID for patients with late-stage lung cancer, 24 who present with a similar medical complexity as the patient of this case report. Between his 20 th and 40 th visit, the patient improved from a t-scale score of 51.68 to 55.57 on the Boston AM-PAC Basic Mobility

Outpatient Short Form. Using the value of two points for a MCID compared to the patient’s improvement of 3.89 points, there was meaningful change for this patient in his functional mobility over his last 20 visits of outpatient rehabilitation.

Although not a validated outcome measure, ambulation distance has been reported in the literature for individuals with hemipelvectomy and hip disarticulation. In a paper by

Kralovec et al., successful prosthesis users with EHP or hip disarticulation were able to ambulate an average maximum distance of 158 feet with or without an assistive device between rest periods during their rehabilitation. 23 In this study, successful prosthesis use was defined as patients who used a prosthesis at least three times a week for at least one hour per day at the time of their last clinical visit or physical therapy appointment. At his 40 th visit of rehabilitation, the patient was able to ambulate 430 feet consecutively without use of an assistive device, compared to 5 feet on his 20 th visit. OP REHAB FOR EHP 16

The difficulty of controlling phantom limb pain and residual limb pain has been consistently reported in the literature for individuals with amputations. 25,26 There is limited research that suggests prosthetic use has been seen to decrease phantom pain in individuals with amputation, through the mechanism of cortical reorganization. 27 A clinically significant change of 1.8 points on the NPRS in one study of individuals with spinal cord injury or amputation has been reported. 28 From initial evaluation to visit 30, the patient’s pain increased by 1-2 points on the NPRS, possibly due to his increased activity level and issues with socket fit and comfort. Between visit 30 and 40, the pain in the patient’s residuum and R “hip” both decreased by 3 points, to 4/10 and 3/10 respectively.

By his 40 th visit, the patient reported walking in his household with his prosthesis and no

AD, wearing his prosthesis in the community with use of an AD, and stair and obstacle navigation with use of his prosthesis and AD. The patient reported being able to participate in prior recreational activities including fishing and hunting with use of his prosthesis. The patient had also participated in a scuba diving outing since starting PT.

Discussion

A lack of literature exists for pre- and post-prosthetic training for individuals with EHP.

An impairment-based treatment approach was used to plan interventions, while considering the structural implications of EHP. In this case, the patient’s functional mobility, ADLs, and endurance improved following pre- and post-prosthetic PT. The patient also returned to past recreational activities that he was not participating in prior to outpatient rehabilitation.

Multiple challenges associated with EHP have been reported in this report including difficulty in establishing prosthetic control, issues with prosthetic fit, and the substantial pain OP REHAB FOR EHP 17 associated post-amputation for this population. Application of a progressive pre-prosthetic core strengthening, upper extremity strengthening and lower extremity strengthening and flexibility program was feasible given the required core stability to use his prosthesis, the required UE strength for use of an AD, and the necessary function in the unaffected LE for eventual reciprocal gait with a prosthesis. Post-prosthetic training included elements necessary for safe functional mobility and control of the prosthesis, which included transfer training, pre-gait activities, gait training, stair training, obstacle navigation training, endurance training, and progressive dynamic balance training.

An additional challenge with this patient is that he received an extensive amount of PT, including 12 visits of pre-prosthetic rehabilitation and 28 visits of post-prosthetic rehabilitation that spanned over one year. Although not commonly seen in outpatient PT practice, the associated medical complexity, comorbidities, and continued progression of this patient’s function justified the need for this amount of PT. Between visits 20 and 30, the patient had improvements in strength, balance, activity tolerance, ambulation distance, and functional mobility. The patient improved ambulation distance without an AD from five feet on his 20 th visit to 200 feet on his 30 th visit and had a 2.02 point improvement in functional mobility based on the Boston AM-PAC Basic Mobility Outpatient Short Form. The patient improved his pain by

3 points on NPRS, progressed in ambulation distance with prosthesis and no AD 230 feet, and improved his functional mobility based on the Boston AM-PAC Basic Mobility Outpatient Short

Form by 1.87 points from his 30 th visit to his 40 th visit.

Improvements in functional mobility were seen following PT including pre- and post- prosthetic training in this individual. This case report provides a detailed account of the OP REHAB FOR EHP 18 extensive outpatient PT management and prosthetic training over a year for a patient with EHP.

Physical therapists in outpatient care can use this case study to assist in creating a plan of care for patients with high-level amputations seeking prosthetic training, and to help guide prognostic decisions for individuals with EHP. Research is needed to better understand the specific needs of this unique population of patients and to provide the best physical therapy assessment and interventions to maximize patient outcomes.

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APPENDIX A: Summary of findings from tests and measures over 40 visits

Appendix A . Summary of findings from tests and measures over 40 visits Impairments Tests and Measures Relevant findings on initial Visits 10 and 12* Visit 20 Visit 30 Visit 40 evaluation Pain, fatigue, and Pain VAS (average) 5/10 distress Fatigue VAS (average) 5/10 Distress VAS (average) 1/10 Residual limb pain 5/10 5/10 6/10 7/10 4/10 NPRS (current) R “hip” pain NPRS 4/10 5/10 6/10 6/10 3/10 (current) Circulation Blood pressure 122/64 mmHg 135/77 mmHg Pulse 67 bpm 92 bpm Neurological DTRs 2+ on all LLE reflexes function Sensory function Sensation to light Grade 2 10 on lateral trunk Patient had touch and distal-lateral residuum. decreased The patient is unable to sensitivity and tolerate right side lying was able to tolerate right side lying Skin integrity and Observation and Incision well healed with no scar mobility palpation signs of infection and good scar mobility Range of motion Goniometry WNL for BUE and LLE motions except for LLE hip IR (26 °) and LLE hip ER (20 °) Strength MMT (0 -5) 5/5 in BUE and LLE with c/o 5/5 in pain in the left popliteal LLE, fossa during knee flexion pain and pain in the left groin free with hip flexion and adduction Muscle length Passive knee extension + ( -40 °) with c/o pain in + ( -30 °), pain test (hamstring) popliteal fossa free Thomas test (hip flexor) + for decreased iliopsoas + for decreased length iliopsoas length Core stability and Unilateral hip bridge Unable to perform 45 sec endurance endurance test Plank static core test 30 seconds 60 sec Balance Single limb stance time < 1 sec* 3 sec on prosthetic limb Activity tolerance Time to fatigue during 5 min* 25 min standing activity Ambulation Distance ambulated 100 ft 320 ft endurance (with with AD prosthesis) Distance ambulated 5 ft 200 ft 430 ft without AD Functional mobility Boston AM -PAC basic 51.68 53.70 55.57 mobility outpatient short form (t-scale score) *These measures were taken during the 12 th visit, after the patient received his prosthesis. VAS=visual analog scale, NPS=numeric pain scale, R=right, mmHg=millimeter of mercury, bpm=beats per minute, UMN/LMN=upper motor neuron/lower motor neuron, DTRs=deep tendon reflexes, WNL=within normal limits, BUE=bilateral upper extremities, LLE=left lower extremity, IR=internal rotation, ER=external rotation, MMT=manual muscle testing, c/o=complaints of, AD= assistive device, AM-PAC=activity measure for post-acute care OP REHAB FOR EHP 23

APPENDIX B: Pre-prosthetic rehabilitation

Appendix B . Pre -prosthetic rehabilitation Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Core stability exercises Abdominal crunches BW 1 X 20 BW 1 X 20 BW 1 X 20 BW 1 X 20 BW 1 X 20 BW 1 X 20 Bilateral oblique crunches BW 1 X 10 BW 1 X 10 Oblique sit -up reaching BW 1 X 10 BW 1 X 10 BW 1 X 20 BW 1 X 20 elbow to knee Forearm plank on left knee 1 x 30 sec ea 1 x 60 sec ea 1 x 60 sec ea 1 x 60 sec 1 x 60 sec 1 x 60 sec ea and on toes ea ea Seated trunk rotation 6 # med ball 1 x 6 # med ball 1 x 8 # med ball 2 x 15 ea direction 15 ea direction 10 ea direction Diagonal sit ups 6 # med ball 2 x 6 # med ball 2 x 5 5 Side crunches with med ball 6 # med ball 2 x 8 # med ball 2 x 10 10 3 sec hold Cable upper trunk rotation 10 # 1 x 10 10 # 1 x 10 Single leg bridge, L foot on 2 x 10 2 x 10 3 x 30 sec 3 x 45 sec stability ball TA activation with 3 sec hold 1 x 10 1 x 10 1 x 10 TA activation with LLE 2 x 5 2 x 10 2 x 10 marching Upper extremity exercises Prone shoulder horizontal 3 # 1 x 20 3 # 1 x 20 abduction Prone shoulder extension 3 # 1 x 20 3 # 1 x 20 Prone Ws BW 1 x 20 3# 1 x 20 Seated t -band rhythmic Green t -band Green t -band Green t -band 2 stabilization (arms at 45 seconds 45 seconds x 30 sec 90 °shoulder flexion) Triceps dips and extension BW 1 x 10 BW 1 x 10 50 # 1 x 10 50 # 1 x 10 (seated) (seated) (machine) (machine)

Seated shoulder horizontal 35 # 2 x 10 35 # 2 x 10 abduction Seated pull downs 110 # 2 x 10 110 # 2 x 110# 2 x 110 # 2 x 10 10 10 Seated rows (narrow grip) 90 # 2 x 10 90 # 2 x 10 90 # 2 x 10 95 # 2 x 10 Seated rows (wide grip) 90 # 2 x 10 90 # 2 x 10 90 # 2 x 10 110 # 2 x 10 Stretches Manual hip flexor stretch 3 x 30 sec 3 x 30 sec 3 x 30 sec 3 x 30 sec 3 x 30 sec 3 x 30 sec (prone) Manual hamstring stretch 3 x 30 sec 3 x 30 sec 3 x 30 sec 3 x 30 sec 3 x 30 sec 3 x 30 sec (supine) Supine hamstring stretch 3 x 30 sec 3 x 30 sec 3 x 30 sec with strap BW=body weight, ea=each, #=pounds, med ball=medicine ball, TA=transversus abdominus, L=left, LLE=left lower extremity, t-band=theraband

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APPENDIX C: Post-prosthetic rehabilitation

Appendix C . Post -prosthetic rehabilitation Interventions Complications Improvements Co - Pt education treatments Visit Transfer training Decreased Pain Skin care, skin 12* Standing weight shifts sensitivity on management. checks, safety SLS stump/flap, able during activity, Static/dynamic balance in // bars to tolerate lying prosthetic Preparations for gait in // bars on side. componentry and prosthesis wear time.

HEP for standing balance. Visit Sit -stands Pt c/o LBP, Pt able to Pt saw CPO for Re -educated in 20 Stair negotiation with crutches assessed to ambulate 220 ft prosthetic HEP, pt was // bars exercises have R QL and with crutches. adjustments. not compliant - FW/BW weight shifts R Gluteal with HEP at - SLS (10 x 1 second) tightness. Pt walking in STM, MFR, ball visit 20. - Static/dynamic balance activities home with release to R QL - Gait training Patient had an prosthesis and and R glutes. Pt told to • Side stepping ingrown no crutches increase • FW/BW stepping toenail, was (limited standing time, Gait training told to distances). prosthesis use - With walker x 25 minutes immediately time, and was Trial lofstrand crutches see podiatrist. Pt able to re-educated ambulate 8-10 on safety. laps in // bars with no AD. Visit + Progression of dynamic balance activities and standing Pt weight loss, Pt walks at Lumbar nerve Updated HEP , 30 strengthening exercises prosthetic fit, home but tires block. pt educated - Rows, shoulder extension, standing presses uneven leg quickly. on potential alternating/bilateral 35# 2x10 ea length. Pt had recent issues with - Standing ball toss Pt able to adjustment prosthetic - Trunk rotation with 8# med ball ambulate 320 ft from CPO and length. - Diagonals with 8# med ball before rest with felt that he - Ball toss to rebounder (CGA) crutches. 200 ft was able to + Gait training with no AD without use of walk better + Stair negotiation (step-to pattern with hand rails) crutches. after - Focus on C-Leg eccentric lowering adjustment.

Visit + Progression of dynamic balance activities Socket Improved Review of gait 40 - Cable column push/pull, together/alternating LE discomfort and distance mechanics and 85# pain limited ambulated to AD use, - Obstacle navigation mobility. 430 ft updated HEP. consecutively Issues with without use of prosthetic AD. knee not allowing swing through (too much tension). *Patient received definitive prosthesis before the 12 th visit. // bars=parallel bars, +=added, SLS=single limb stance, pt=patient, LBP=low back pain, +=added, FW/BW=forward and backwards, ft=feet, #=pounds, LE=lower extremity, AD=assistive device, STM=soft tissue mobilization, MFR=myofascial release, R=right, QL=quadratus lumborum, c/o=complained of, HEP=home exercise program