inMotion Magazine

Living the Dream 37 standards. Sometimes your healthcare team can learn something from you . First, let’s go over a few definitions. A physiatrist is a physician who specializes in rehabilitation. These physicians are great choices to lead an amputation healthcare team. These teams usually include your physiatrist, physical therapist, occupational therapist and prosthetist. The team can also include your surgeon, dieticians, nurses, pharmacists and others who bring important knowledge and skills to your care. What is a clinical practice guideline? Congress established the VA and DOD Evidence- Based Practice Work Group in 2004. Its mission is to advise leaders on how to improve healthcare through taking the best scientific evidence and writing guidelines. This process helps improve healthcare by shifting guidance to clinicians away from expert opinion to research-based scientific evidence. The guidance, known as clinical practice guidelines (CPGs), is updated every 10 years. The VA and DOD first published a CPG for the Rehabilitation of Lower- Limb Amputation (LLA) in 2007. Since 2007, research has thrown more light on the complex nature of LLA. The 2017 CPG (Rehabilitation of Individuals with Lower‑Limb Amputation) reflects these scientific advancements and creates a revised guideline for clinicians. How is the CPG scientific evidence assessed and graded? Expert panels of medical specialists develop CPGs by reviewing and grading all the scientific evidence from the last 10 years. Experts grade the quality and strength of all the evidence. Note: Good quality evidence in one study may not give enough scientific support for experts to feel confident enough to change longstanding clinical practices. The final CPG has 18 recommendations. Of these, 14 are Suggestions based on weak evidence or confidence; four are Recommendations with strong evidence and confidence. Usually, studies have to be large, repeated and specific to amputees before experts can create strong Recommendations. Although the scientific evidence has come a long way in the last 18 years, it is still far from complete. Why should I care? The updated LLA CPG helps your healthcare team assist you through all phases of your amputation care. This includes perioperative care (before and after surgery), training without a prosthesis, training after you get a prosthesis, and lifelong care. For lifelong care, the CPG sets a standard of an annual checkup by your entire healthcare team. When was your last checkup by your team? You need to understand the guidelines so you can fully participate in your care, goal-setting and decision-making. Variations from the CPG may occur when your care team considers your individual needs, available resources and local limitations. Your knowledge will help you to understand why variations occur. What are the 18 CPG Recommendations? When you visit the VA/ DOD website (www. healthquality.va.gov/ guidelines/Rehab/amp) , you will find a patient summary sheet for this CPG. This sheet contains great information for you, your family and your caregivers, but omits the CPG’s 18 recommendations. Here they are, with Suggestions and Recommendations in bold. 1. We Suggest educating you through all phases of amputation rehabilitation. 2. We Suggest assessing your mental well‑being at every phase of rehabilitation. 3. We Suggest measuring intensity of your pain. This includes measuring its interference with your daily function. 4. We Suggest individualizing your pain management. This includes transitioning away from opioids. 5. We Recommend considering your birth sex or gender identity in developing your personal treatment plan. 6. We Suggest offering you peer support as early as possible and throughout rehabilitation (DOD and VA use the Amputee Coalition’s Peer Visitor Program). 7. We Suggest including you in decision-making on rehabilitation goals, outcomes and discussions on residual limb length and amputation level. 8. There is not enough evidence to make any recommendation on types of surgery. 9. We Suggest using rigid or semi-rigid dressings as soon as possible after transtibial amputation. 10. We Suggest assessing your cognitive ability in deciding on an appropriate prosthesis. 11. We Suggest giving you rehabilitation as well as durable medical equipment (wheelchairs, grab bars, shower chairs) and assistive technology before discharge. 12. We Suggest considering discharge to an acute inpatient rehabilitation program when suitable.