Danielle MeltonFor patients who face amputations, the road to recovery is a long one, filled with physical, emotional and social challenges. For those like Yvonne Thiem-Hester, who undergo multiple-limb amputations, the impact of limb loss is magnified. Thiem-Hester is among the large population of multiple-limb amputees to benefit from the close collaboration of Danielle Melton, MD, director of the Limb-loss and Orthotics and Prosthetics Program at TIRR Memorial Hermann, and P. Jacob Joseph, MD, director of medical affairs and services at the rehabilitation hospital. The Limb-loss Program’s clinical treatment team is internationally recognized, particularly for its work with patients with upper-limb and multiple amputations.

Following a laparoscopic hysterectomy at a community hospital, Thiem-Hester developed sepsis. She was transferred to TIRR Memorial Hermann after four weeks in acute care, eight days of which she spent on a ventilator. The medications she was given to help circulate blood through her vital organs constricted the vessels in her limbs, restricting blood flow and leaving the 58-year-old with dry gangrene of the hands and feet.

“Usually when we see patients in inpatient rehabilitation, they’ve just been discharged from acute care,” says Dr. Joseph, vice chair of clinical operations and a clinical assistant professor in the department of Physical Medicine and Rehabilitation at McGovern Medical School at UTHealth. “They have new amputations, or in Yvonne’s case, necrotic extremities, and still have ongoing medical issues. We work on getting them as medically stable as possible to maximize participation in therapy. Yvonne was stable with dry gangrene of her hands and feet, but eventually would require amputations. We spent time getting her psychologically prepared. After surviving sepsis, she viewed amputation as a step backward. We helped her understand that amputation would allow improved function and independence in the long run.”

Jacob JosephWhile Dr. Joseph guided Thiem-Hester’s inpatient care, Dr. Melton came in as a consultant to work with the rehabilitation team. “We all work really well together as a team focused on pre-prosthetic management, the psychological aspects of limb loss and wound care,” she says. “In the case of Mrs. Hester, I spoke with her and her husband about what it would be like to have an amputation. For all our patients with limb loss, we screen for depression, anxiety and sleep disorders up front, and talk about how limb loss may affect the family. Depending on the needs of the patient, we may involve key psychologists to assist them with techniques for coping with limb loss. Our goal is to help patients move beyond the life-changing event to a place where they can feel productive and functional again. By working together, we can make good things happen for them.”

While Thiem-Hester was coming to terms with the idea of amputation, her rehabilitation team was training her husband to help with her care. “I was especially weak on my right side,” she says. “I couldn’t dress myself and had a physical therapist to help with my lower body and an occupational therapist to help with my upper extremities. I was very impressed with everything at TIRR. Dr. Joseph always had a smile on his face, and all the nurses and therapists were great. When I saw people with other problems, I didn’t feel so lonely. Everybody was so nice and very cool, not just with me but with all the patients. But when Dr. Melton came in to see me during my first phase of rehab, I wasn’t ready to talk about getting anything amputated.”

Thiem-Hester completed her first stay at TIRR Memorial Hermann in September 2016 and was discharged home. With the support of her husband, Mark Hester, she decided to move forward with amputation and chose David Netscher, MD, a specialist in plastic and hand surgery, as her surgeon. Dr. Melton consulted with him about the appropriate level of amputation to optimize function.

Thiem-Hester had hand amputations in October 2016, and a right below-the-knee amputation in November 2016. In January 2017, she had a partial foot amputation. Dr. Netscher was able to save her ankle. After healing, she was ready to begin the next phase of rehabilitation – team collaboration with a prosthetist to determine the types of prostheses best for her, followed by an intensive training program to ensure optimal fit and function.

She chose myoelectric hand prostheses and learned how to use them during her second phase of inpatient therapy in January 2017. “Once I got home and tried to use them, I had difficulty with certain things, like vacuuming,” she says. “It would slide out of my hands. You can do more intricate things with the body-powered hooks, so my husband and I decided we wanted the mechanical ones. All the guys I see say they can do everything with the hooks.”

“A prosthesis is always a work in progress, and we’ll be managing Yvonne, like all the people we see, through this ongoing lifelong process,” says Dr. Melton. “She learns very quickly and has a really supportive husband. He was super involved from the very beginning, which has helped her be so successful. She was very dependent on him initially and is super independent now.”

Thiem-Hester sees Dr. Melton twice a week at her Limb-loss Clinic at TIRR Memorial Hermann Outpatient Rehabilitation West University, where she works with a multidisciplinary team to improve her ability to function with her prostheses. She’s now learning to walk with her right partial foot and left below-knee prostheses.

“Dr. Melton sees where you’re at functionally and meets you there,” she says. “The last year has been a struggle but all the support I had helped me move forward instead of wallowing. Having good people at your side makes it a whole lot easier.”

Standardizing Care for Limb-loss Patients

Most people who undergo amputation get the majority of their rehabilitation in the outpatient setting and prefer to go to a facility close to home. With funding from a TIRR Innovation Award, principal investigator Kristin Reeves, MS, PT, and her mentor Danielle Melton, MD, are establishing clinical practice guidelines for lower-limb amputees that will ensure consistent rehabilitative care at the six TIRR Memorial Hermann Outpatient Rehabilitation locations across the Greater Houston area.

“Amputation affects body functions and structure, and can result in a variety of psychological and physical deficits,” says Reeves, coordinator of Outpatient Medical Clinic Amputee Services. “Lower-limb amputation can affect gait and balance and also can result in impaired motor function and mobility strength. Physical therapy has an important role in restoring function and preparing patients for success in using a lower-limb prosthesis. Early mobility has been shown to improve functional outcomes, foster independence, decrease mortality rates and reduce acute care length of stay for patients.”

Reeves meets with therapists at TIRR’s outpatient facilities quarterly to ensure that they are well trained in amputee care, covering a range of issues such as gait training, outcome measures, support groups and education needs.

“Our goal is to maximize outcomes for limb-loss therapy in our patients with lower-extremity amputations,” says Dr. Melton, director of the Limb-loss and Orthotics and Prosthetics Program at TIRR Memorial Hermann and a clinical associate professor of orthopedics at UTHealth who specializes in the care of people with amputations. “The use of clinical practice guidelines has been shown to improve functional outcomes measures with statistical significance in other diagnoses, such as spinal cord injuries. With the study, we hope to eliminate variability of practice and create consensus on what outcome indicates successful lower-limb rehabilitation and what measures should be used to assess the selected outcome.”

Other members of the research team are UTHealth research scientist M’hod Bakhit, MD, research associate James Chang, PT, PhD, and medical assistant Kacee Pavelka. For more information, contact Reeves at kristen.reeves@memorialhermann.org.

Winter 2018 Edition