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Effective Treatment of Limb Loss

Originally posted on QLI Omaha.

Join the QLI team as they discuss their comprehensive approach to effective limb loss treatment. This informative webinar covers how to connect therapy to life, details several limb loss case studies, and provides an overview of the four phases of limb loss treatment: Acute hospitalization, pre-prosthetic training, prosthetic training, and getting back to life.

Speakers: Tim Benak, Steve Kerschke


Video Transcription


Tim Benak – 00:44

New topic for us today, effective treatment of limb loss, not a new specialty of ours, but definitely a new webinar topic for us.

Steve Kerschke – 01:01

Yeah, definitely not a new specialty, but part of the reason we did this is many of our payers were asking us to address limb loss, maybe a bit differently than what we have in the past. We definitely have a competency in place, but normally, when we see these types of individuals, they’re paired with some sort of other complex injury, like a brain injury or spinal cord injury.

We end up getting the most complex of the complex. And as a result, we started getting requests to see just limb loss. That’s been an exciting project for us, it definitely allows us to do some different things, maybe to a different speed and intensity. So that’s been really fun to see.

Limb Loss Treatment at QLI

Steve Kerschke – 02:17

When we think of treatment of limb loss, really, we tackle this, much like we tackle a lot of our folks with brain injuries, spinal cord injuries and other complex injuries. We look at this and when we stepped back to prepare, what a program might look like and put together, you know, a curriculum of sorts, we did it through a lens of a center of excellence.

We also did it from the standpoint of how do we get in touch with these individuals from the very start of their recovery journey? And how do we keep in touch with them all the way through the recovery journey, hopefully till the end.

This presentation really outlines that, what we think it does is it provides a really structured approach at every phase. And in doing so, I think it helps facilitate and coordinate things maybe a bit differently than what we’re used to seeing with these types of individuals.

I think traditionally, these individuals have really short stints of a hospital stay pretty quickly transitioned to outpatient therapy. That outpatient therapy is really driven towards massed practice and it’s driven towards maybe some less than functional goals and less than functional activities.

As a result of that, I think it leaves these folks coming up a bit short as to their progress, and really their emotional health and just satisfaction with their life after an injury like this.

That’s the lens that we looked at this through and those of you who are familiar with how we do things at QLI probably doesn’t sound much different than how we look at other things that we tackle.

It’s been really fun to try to apply that to really somewhat of a different population.

Why the QLI Process is So Effective

Just to highlight, again, you know why we feel like this is a good approach.

Minimize Costs Related to Recovery

First of all, a lot of the feedback we were getting from our payers was that, that costs of treating these individuals was rising very, very quickly, for a couple of reasons.

One, there was no methodical way to go about doing this. And there really is not always a specific decision making process when it comes to the type of prosthetic, when to get the prosthetic, as well as some of the other comorbid factors that we consider when we’re dealing with these individuals .

So, obviously keeping costs down is a nice motivator for everyone.

Streamline Clinical Decision Making and Prosthetic Device Selection

And, again, in doing so I think by streamlining the clinical decision making process and the prosthetic device selection, it does have a direct effect on the cost.

Manage the Intricacies of Complex Cases

I also think it has a direct effect on the outcome. We really want to make sure that these individuals get to a high level of recovery and the way we look at it is these individuals for the most part, can get back to a pretty baseline level of functioning as to what they were doing before their injury.

It might look a little bit different, maybe they can’t get to the exact same job that they’re going to. I don’t want to overstate that, but you can definitely get a really great recovery from these individuals just, you know, for a lot of reasons.

But that’s not to say that these cases are not complex, there’s lots of different factors that can come up, you know, when their wounds are healing, and all those factors at the very beginning are top of mind, that can be very challenging.

Teach Emotional Coping and Resilience

And then, you know, to that last point, I really think the emotional coping and resilience piece of this is something that gets overlooked, or it gets looked at late in the game.

They go through the surgery, they get their amputation, and they start to get along the process of getting their prosthetic. Then we might start to think about the psychological, the emotional recovery portion of this.

I think there’s really a better way to do that, so something to be thinking about as we move forward.

Connecting Therapy to Life

And, you know, no surprise here, everything that we’re doing is really trying to connect our therapy to the person’s life.

I think what happens a lot of times is if we look at just the therapy in a hospital, or just the therapy in an outpatient clinic, we miss all of the other real world, things that are going on, once they get back to their home or to wherever they’re going.

The other thing is, is that it’s sometimes hard to connect to those activities that we’re doing in a hospital or clinic, to something meaningful and engaging. And so, you know, looking at it from that perspective, I think really shapes the approach, and it shapes the effectiveness.

Four Phases of Limb Loss Treatment

So we break this up into four phases.

Phase 1: Acute Hospitalization

So the first phase doesn’t necessarily even pertain to QLI and our team. At this point, usually, we would be getting maybe word of this potential referral, but it starts with an acute hospitalization, and the person probably has some sort of catastrophic injury, that is going to lead to some decisions around whether or not to take it towards an amputation.

There’s some pre and post surgery planning, you’re probably starting to look at, you know, what is the overall rehabilitation plan look like?

Hopefully, we’re thinking pretty long term about this, and trying to understand, you know, is an extensive hospital stay going to be necessary, or can this person pretty quickly move through the hospital, to outpatient therapy. And then trying to envision even what outpatient therapy looks like and talking about things like back to work, and hopefully all of those are starting to be projected, certainly don’t have clarity of these at this point in time. Maybe too, a little too early to tell.

But I think a good collaborative interdisciplinary plan in place at this state, at this juncture is a good idea.

And then, as I alluded to, starting to consider the emotional coping and adjustment portion of this, and that might be even going as far as getting some more formal psychology impact at this point.

The person may not even be ready for this, though, too. So I think we have to take this as an individualized process. Maybe we’re starting to ask a few more questions, or at least red flagging some situations that might lead towards some challenges down the road.

I think we’re all getting a better understanding what are some premorbid factors that might contribute to this, so is there a history of mental health? Is there a history of relationship challenges, and what’s the family structure? And what’s the network of that person look like, so that we can start to understand how things might be affected from this perspective.

You know, and again, what we believe is if you tackle this early, then I think there’s a significant impact on down the road. I think the person becomes even more open to being pushed and challenged, and willing to try some things that might look a little bit different than what they had in mind.

It’s pretty obvious that having some sort of amputation is a big deal. But finding ways to work through that and make decisions about prosthetics and make decisions about back to work, can really get slowed down, if we’re not addressing this effectively.

The other thing I would say is, you know, and I mentioned a more formalized approach with a psychologist, I don’t think it always has to be a psychologist, right, it could be another clinician, and it could be a social worker. It could be anyone in the person’s network, especially if they’re not ready for that.

So we really look at this through a lens of everyone can be that emotional support, and everyone can start to guide that. But those people might need a little bit more guidance from a psychologist or someone who’s trained.

We see that the repetition of this is really important. So when it comes to learning how to deal with this, the more that we can expose them, and the more conversations that we can have, formally and informally, is something that we really strive to do.

I think it leads to some of these extra phases and how we incorporate those into the treatment.

Phase 2: Pre-prosthetic Training

Once someone has chosen to, you know, move through with a surgery, there’s definitely some pretty straightforward medical things that need to happen.

When we think about brain injury and spinal cord injury, we look at this through three different ways.

You’ve probably heard about us talking about our tri-dimensional model, and the first part of that tri-dimensional model really is just medical stability. I think that’s really front and center here in phase two.

These individuals need to be medically stable, medically taking care of the wound, the extent of the wound needs to be managed and any pain that’s associated with that, start to jump on that right away and help these individuals understand what causes pain. I think pain education is a big component to that, that we talked about.

Beyond the pain education, it is, maybe some more acute factors to help them manage their pain.

The other thing is that residual limb needs to be addressed in order to start to prepare for a prosthetic should the person need one or choose to have one. So any shrinking and shaping of the residual limb, obviously, the best way to do this is in conjunction with a prosthetist, so getting prosthetist in on this as early as possible, we feel is helpful.

Now the prosthetist factor can be challenging as you move through the center of excellence approach, because sometimes that prothetist might be local, and in our case, we’re not always local. And so collaborating with that prosthetist or getting a prosthetist team in place is something to consider, especially now.

Choosing that prothetist at this point, or at least thinking about that is going to be important too.

Making sure that we’re starting to address flexibility, strength and endurance. So we know that whether it’s an upper extremity or a lower extremity type of situation, or both, we know that these factors are going to contribute to the person’s capability of managing the prosthetic, as well as completing some functional activities with it.

And so if we can prepare them for all that, you know, even before they get it, then we can jump right into the prosthetic phase a bit more quickly.

Then the last factor is just the independence without the prosthesis. It’s definitely an adjustment.

So at this point in time, we might be looking at some adaptive devices, they may need a wheelchair of some sort, some shower accommodations, or even home accommodations, depending on if they’re going to be going home, and where the rehab’s going to happen.

So you know, OT and PT are pretty key here, and understanding that getting a good idea of what their environment looks like, is going to be really important, not only for this first phase, but it also bleeds into the additional phases.

During this phase, the way that QLI has envisioned it, is that we would use our telerehab services at this point in time. Because we have those capabilities, you know, getting a referral at this point is definitely possible.

Our telerehab team would take the lead on this back to the prosthetist involvement. We can definitely collaborate with the prosthetist whether they are local or not. We do have some local partnerships that could be helpful with that process. But really, we’re able to provide all of this through a virtual environment.

So understanding, how do we manage and address the wound? Certainly, you know, even if we were in person, we wouldn’t be managing the dressings and that sort of thing. But, we can manage and monitor what the wound is looking like. Is it healing well? Make recommendations as to consultations with physicians or nurses around those and same thing with with the residual limb, size and shape.

But more specifically, with the flexibility, strength and endurance, as well as the independence, we put together programs for this, we work with the individual in their environment, again, because that makes it more functional, and we allow them to manage all of this, usually from the comfort of their own home.

But they’re also likely going into the community. And so when they go into the community, you know, we would be right with them there to do to the virtual nature of things.

So, we really bookend as you’ll see, when we get into phases three, and four, we really bookend our program in phase two and phase four with telerehab.

Phase 3: Prosthetic Training

As we get to this next phase here, this is where it could mean an actual visit to our campus.

You know, I think this is probably the most polarizing part of it, we always get the discussion to me, and I always deal with this, even on the brain injury and spinal cord injury side for individuals who don’t live in Omaha, or in the immediate Midwest, it’s pretty common to get the question of why would I go to Omaha.

I think in some cases, we’re still probably dealing with that with this population, because traditionally, this population stays local. And the mindset has been, well, you know, I have a physician, local, I have a process local, and I have a therapist local.

Those three, and and the rest of the medical team may have a ton of experience in limb loss, which is great. More than likely, they don’t have a lot. And so in those cases, you know that could mean a trip to Omaha.

Tim Benak – 17:09

One, I think it’s important to Steve to talk about, they may have a lot of expertise in limb loss, but bouncing back to your emotional support side. When it’s all in the one area. It’s all being done at the same time. We’ve just seen better outcomes.

Steve Kerschke – 17:22

Yeah, I mean, I think the skillful implementation of it in an interdisciplinary model is something that gets missed. I think that’s a really good point.

I think traditionally, it’s PT, handling the strength and the flexibility and all that sort of thing, you have your OT, managing the functional aspect and accessing the community, you have the physician and the prosthetist, maybe working on that residual limb.

But maybe they’re not even all talking to each other. Then the psychologist is kind of off in the corner doing whatever he or she is doing.

I think that’s a big miss, in my opinion. Because what we find and how we usually approach even phase two, is that our clinicians can collaborate. They’re all in the same building for one. But even if they weren’t, they would be pretty collaborative. And talking about well, okay, how is this affecting that and making sure that the right hand knows what the left hand is doing.

That allows us to continue to address and manage things that are already present, but maybe things that are popping up along the way. I think that’s a really good point, and I think it takes it to another level when you think of phase three, right?

A lot of times people come to QLI for a comprehensive program, which I think that’s great, but in this case, I think I’ve added the word intensity too. The reason we set intensity is we’ve envisioned this as a day program, and so individuals would come to QLI for a day program, granted, they would have to stay somewhere, probably.

But the intensity that we can provide during that day program hopefully limits the time that they need to stay here in Omaha and that we can get them back home as quickly as possible.

So usually, we envision this as really like a two to four weeks stay. It could happen in a couple of intervals, too, though, because a lot of times these individuals are working through the prosthetic choice and choosing that prosthetic can be a multi level process.

Sometimes, you know, they might be here we get them set with that initial introductory prosthetic, they go home for a period of time, and then they may need to come back to get that updated. Or as you’ll see in phase four, we could maybe collaborate with a local provider at that point in time.

And so this isn’t like a strict linear process. I think it definitely has the opportunity to bounce back and forth between phases three and four. But it allows us to provide a really intense hands on experience and then it starts to make it really functional too.

All the things that we traditionally do on the brain injury and spinal cord injury side of getting folks into the community and starting to envision, you know, what a life beyond the actual injury looks like, that is all applied to these individuals through the day program.

We start to establish partnerships with the prosthetist, we’re achieving optimal function. But really, we’re starting to envision what this person’s life is going to look like, from a hopeful perspective, helping them see that their life can be something gainful, and worth living again. And then, you know, identifying that sense of purpose.

For many folks, that’s, how do I be a father, potentially, in this type of situation? Or how do I go back to work? How do I access maybe my leisure activities, so that could be adaptive sports, you know, running, fishing, cycling, all of those things, right, they come with some new challenges, and some adaptations that might be necessary.

We’re starting to investigate and put a few things in place during this time.

Phase 4: Getting Back to Life

I’ve alluded to phase four, which again, if you remember back to the book end comment, this again, pulls in telerehab, and so we’re able to collaborate with the clinicians that the individual worked with on campus, and then provide the access to the expertise, once they leave and go back into their community.

Many of our individuals are coming from outside of Omaha or even Nebraska, and making sure that we can support them once they leave. It provides access, and then that second bullet there, it provides a level of continuity for them. So hopefully, we’ve collaborated with the prosthetist whether it’s either local or local to Omaha or local to where they’re going back to.

And then we’ve also established some sort of routine that might be going on once they get back so made contact with their work, collaborated with their family and friends and, and helped to put in some routines that would, would transfer.

I think the third bullet is almost the most important bullet, probably no surprise, by the end of this, you’re going to be tired of me harping on it, but this idea of therapy happening in the real world, is really important.

So at the end of this, we do have a couple of case studies, and there’s a couple videos. What we know is that that real world training provides a clear picture of the challenges and it allows us to really tackle those in the settings that they’re going to be in.

Then this convenience factor, I think, I’ve been amazed at how many people just enjoy being able to click on their iPad or phone and be able to have almost on demand access to our clinicians.

I think, in this time of COVID, I mean, there’s certainly a safety factor to consider and I don’t know how long that will last. You got to think though, that it’ll start to shape some folks behavior long term.

So, I think we’re really thankful that we’re in the telerehab game way before COVID came about. And so we didn’t have to play catch up during the COVID process and figure out how to implement this therapy that is really complex.

It’s been really nice to be able to respond in this way, but also, it’s going to be interesting to see what happens, and hopefully once things kind of died down in this in this realm.

And then we see just the motivation factor of our clients to be really high. A, because it’s convenient, B, because it’s meaningful, and it’s tied to their world.

So all of those factors, I think lead to really great outcomes.

Limb Loss Case Studies

Okay, so just a couple case studies, so we have two case studies here.

Limb Loss Case Study 1

This first one is with Yhoni, I’m gonna try to refer to it in phases. So you’ll see here that Yhoni participated in phases three and four of our program, so you’ll see that there at the bottom.

That meant that he actually came to QLI stayed at QLI for our day program. We worked with him while he was here, and then he transitioned back into his own community after he left and we’re still currently doing telerehab with him.

Quick background on his diagnosis and situation, he had a right hand amputation through the proximal failings of the thumb metacarpal necks of the fingers two, three and four. He also had a shoulder injury that associated with this.

Yhoni worked at a butcher plant and he was working around, you know, his butcher device, and as he was working the glove that he was wearing, actually got caught and then he incurred the injury from there and associated rotator cuff injury as well. So that’s how he got it.

He’s 24 years old, so he’s a young guy, really loves the outdoors, loves to skateboard, loves to go to concerts and play, Xbox. Actually, Xbox and video games was a huge thing for him.

After, you know, his amputation, accessing video games is really huge and something that was missing.

The other thing is he was a father of two young kids.

And so really, when we did the intake with Yhoni, one of the things that he said was that his identity was totally stripped from him.

This really isn’t an uncommon statement from many of our folks. A lot of times they’re identity is really tied to their work, or tied to their role as a parent, and tied to their role, and how they’re seen socially with their friends and some of the leisure things that they can do.

That was a really big deal to Yhoni, and up to coming to QLI had been working with the prosthetist that was two to three hours away from his home, so didn’t really have access to that person consistently.

His support system wasn’t all that great. He also had a pretty substantial history of some mental health and so the emotional factor was really big, too. His case manager reached out and asked if we could be helpful.

The other thing to think about here is at the point when he was coming to our day program, they were in the process of determining whether or not his current body powered prosthetic was a good fit for him. Like A, was it the right prosthetic? And B, did it actually fit his residual limb?

Well, there were some discussions about going to a more expensive electronic unit and so part of him coming to us was to help understand A, does the prosthetic fit his residual limb, the way it should? And B does he need a more intricate unit. That was kind of what the team was tasked with while he was here.

And so, you know, the way we tackled this was collaboration with the local prosthetist happened even before he came to QLI. So that meant phone calls with our clinicians, we actually pulled in our prosthetist locally, and we did several conference calls to make sure that we had a good idea of what that would look like.

I’ll be honest, and this is probably more of a challenge that I expected, but the ego of the prosthetist that was local was extremely high, and I think he was immediately kind of on guard with like, Who are you? What are you doing? And, you know, why is he leaving my care.

So I think we had to work really hard of gaining the trust of him, and helping him understand like, our position where we’re coming from, also that we were there to support him and we actually had a lot more information than he had.

That process was really interesting. And I think our team did a really good job of that.

Then as I mentioned, the evaluation for the need for an additional device, what we actually found while he was here, because we put him through and evaluated everything in a functional way. Yhoni actually didn’t need a more intricate device, he actually ended up doing more without his device, because he was way more functional.

It was this emotional tie to well, A, I don’t want this device to begin with, but this device appears to make me look more normal and have more function.

But that actually wasn’t the case at the end. And so things like eating, he still had some function to be able to do that things like dressing and even some work related tasks he was able to do without his prosthetic device.

But then we were able to say, Okay, here’s a handful of things, if not more, that your device would actually be a great use for and made some recommendations on there, we’re able to get the fit to a point that was comfortable to him, and then establish a more consistent wearing schedule.

What we found is his self report, when he came was he was wearing his device quite a bit. Once we actually saw him in person, there is a big gap with that. And he actually wasn’t wearing it at all, he’s only wearing it a couple hours a day.

We were able to make some recommendations as to the wearing schedule, and if he would have needed a more intricate device, we would want to make some recommendations on whether or not his behavior around wearing the actual device lended to him being compliant with wearing a more expensive device.

So I think for the insurance company, they got a lot of information from this, it saved them some money on the device, but also, Yhoni was actually more functional in the way that we did this.

We were able to really help the insurance company in that way. But I think more importantly, help Yhoni work through the emotional factors at QLI transition this back to his home.

So right now, just to kind of round the story out, he’s living home independently, you know, able to do some parenting and some of those activities with his kid. He’s back to gaming, because we were able to find some ways to address that.

And then he’s working with our OT, to continue working on the function of his residual limb, as well as working with her to identify a volunteer job to go back to because I think that was the thing that before he came, he didn’t have that sense of purpose. He was used to working and his identity was tied to his job. So we’ve been working and trying to identify a way for him to do that.

He’s now driving, he wasn’t driving before. So his world is just really opened up in many ways.

The other thing that we that we addressed was just pain management, he had some sensitivity in his upper extremity, some shoulder, just comfort, that sort of thing. So that was all part of it. Then just general strength and endurance. As I had mentioned already, just the purposeful activities and the employment there too.

Tim Benak – 31:07

I’m here with a few questions that came in. There was somebody that asked, you just answered this. But assuming your discussion on prosthetics is specific to lower limb prosthetics? Obviously, that’s not I think there was just a clarification on that. And then does our center of excellence in Omaha have a full staff of prosthetists OTs, PTs, an MD and psychological health?

Steve Kerschke – 31:31

Yes to all the above except for the prosthetist. We have two local prosthetists that we have a great deal of experience with good relationships with, they do come to our campus, they also have offices if we need to use them, and they’re within just five minutes of our facility.

While they’re not employed by QLI, very good partners of QLI, they also do make trips, when they do come to campus, they’re able to work right alongside our clinicians, which we see a ton of value in.

So whether it’s an upper or lower extremity situation, having that prosthetist there to make adjustments to the fit, you know, right in the therapy setting is important, and then be able to trial that and have them walk or have them use the device, tweak it a little bit more.

So it’s more real time that way. So we find a lot of value, and it’s pretty highly collaborative.

Beyond that, though, our physician, we do have a medical director that oversees our program, but he’s actually more of a partner in the program, it’s not very hierarchical, like, maybe you’ve seen some other programs.

I think he would say, he gets the best of both worlds, right, he gets to practice medicine, which he loves to do, and he definitely brings a lot of value.

But I think his impact is even greater, because he works alongside the clinicians too. Let’s just say we need to make a med adjustment, or, you know, he’s trying to understand the mechanism of pain, he’ll come to a therapy session and work right alongside our clinicians in the same fashion that the prosthetist does.

He gets a lot of information from our clinicians and the clinicians are funneling all of that dialogue up to him. I think the decision making actually is really superior because of that.

Tim Benak – 33:21

Some questions pertaining to this exact case here. So how long post injury did Yhoni come to us?

Steve Kerschke – 33:28

I think it was two to three years post injury, and I apologize, I don’t have right off the top of my head.

But he had been home for a good while, the residual limb was fully healed. So he was definitely more in the routine of dealing with his situation.

I think because of his isolation at home, because of his lack of resources, I don’t think he had really moved through the actual recovery process.

Honestly, he still is moving through the recovery process. I don’t want to make it sound like because he came here, he’s totally good to go.

That’s why we still have the telerehab in place. Yeah, he was definitely more into the recovery than some of our folks.

Tim Benak – 34:25

Okay. And then did he lose his hand completely in the accident? Was there any surgery like certain body parts, so surgically removed post accident and would the plan be significantly different if accident caused a total amputation?

Steve Kerschke – 34:40

Yeah, so back to his diagnosis. If you think about his hand, fingers, two, three, and four, were basically amputated.

He had like his use of his palm. He had a little bit of his thumb leftover and so he could do like In almost an opposition grasp.

And so that was really why our clinicians were able to get a bit more function because he was able to pick up things. We worked on some fine motor stuff with him.

As a result, the device that he was using really only allowed almost like a tenodesis grasp. It just wasn’t super functional for some fine motor things, and it was just a bit cumbersome to use.

But again, I think what was the biggest impact is that we helped Yhoni work through the emotional factor of like, I don’t need that device, I can still be really functional with my hand the way that it actually sits today. I think some people just, they need a little bit of re-calibration along those lines.

Tim Benak – 35:47

I think what’s interesting, too, is that’s years post. I think that’s the importance of, you know, I wanted to touch on this, I’ll touch on it now. But just like the ego of maybe a local prosthetist and saying, No, I think the recommendation is just to give him a more expensive device. Yeah, newer device.

Really, you peel back the layers and you sit down, you fully understand his complete situation. And say, well, no, there’s other things that may lead to him being more successful and motivated then just a new fancy device.

Steve Kerschke – 36:14

Yeah. Totally agree. If the amputation was more severe, I think that it would have looked at differently, because we would have had to figure out how does he use the device more effectively, and does he need multiple devices?

I think that’s always a big question. As to, you know, a lot of the feedback we get is those mechanical, pretty basic devices are actually more functional for people. Those newer myoelectric devices are, A, it’s technology. So it’s new and shiny and fancy, and it looks cool. There’s definitely some benefit to it, but they aren’t the most durable, they’re definitely more expensive. Functionality wise, they’re not all that versatile.

So, you know, I think we would have had to work through some of those decisions a bit more if he was more appropriate for something like that or if it was just more of a severe, let’s say, above wrist or above elbow type of situation.

Limb Loss Case Study 2

Steve Kerschke – 37:24

I should probably put the therapy approach at the very top because it seems almost easier to talk about that way, but this gentleman Lane actually has only participated in our telerehab program.

I think that’s another thing to mention, is you don’t have to go through our inpatient program in order to access telerehab. These processes aren’t linear in nature. So you could again bounce back from one or the other, or someone could just decide to go through that stage two pre prosthetic phase with our telerehab program, and do the rest of their therapy locally.

So I guess as you guys might be thinking about how to make decisions on referrals, if that would be the case, we can be pretty flexible with that and really just want to jump in and be helpful to the best of our ability and at whatever phase makes sense.

This this gentleman happened to be in phase four. He actually is pretty complex. He had a left upper extremity amputation, and a left above knee amputation. And then on top of that he had a right meeting and a nerve palsy. That happened as a result of an electrical fire at work.

And so again, this gentleman is extremely young, lives at home with his wife, but came to us actually due to COVID because he was confined to his home.

Prior to getting to us, he was participating in more traditional therapies OT and PT at a clinic. As I was talking to our OT about this particular situation, one of the things that really stuck out to me is that, you know, he reported doing a lot of mass practice type of activities. So using the body powered and the myoelectric prosthesis, you see there.

Using those two prosthetics, he was doing things like fine motor and grasp and things like that with the goal of some functional activities.

But what they were finding was it didn’t translate. He ended up being frustrated because he would be doing these A, it didn’t translate and he couldn’t really connect why he was doing that. It’s really interesting once you are working with an individual and you’re having them do an activity and then as a clinician, you see on their face that they have no clue why they’re doing the activity.

It happened to me the other day. It wasn’t am amputee, I wasn’t working with someone with limb loss. But, you know, we did the activity I was working on standing and reaching, and he looked at me and said, I don’t understand why I’m doing this.

It was really good feedback for me to say, well, everything that we’re doing, I have to make sure that they know exactly why. For this gentleman that was missing. That’s been a really big gap that we’ve been able to fill.

His therapy goals, you know, he wants to be independent with the completion of his ADLs. And specifically taking on and off his socks and jeans. He wants to complete some simple meal prep. The left prosthetic liner, you’ll see a video on this, in addition to the jeans, but that’s been a really big challenge for him, and trying to figure out how to do that, as well as some house chores and mowing the lawn.

The other thing that’s happened is he came to us without any involvement from a psychologist. This has actually been a referral that we’ve sent to a psychologist local to telerehab psychologists associated with QLI, because he was just getting really frustrated and having a hard time envisioning what life was going to look like as he’s in the middle of all this kind of stuff that he’s dealing with.

That was something that came out of working with him, getting to know him and understanding really what he needed to be successful.

These are the therapy goals.

What we’re going to do is show you two videos, and I apologize, the video quality isn’t isn’t terrific. Some of them are depending on, it got blown up, and as we were putting this together, we just tried to get a couple of good videos that made a little bit of sense, there’s no sound.

So I’ll talk you through what’s going on.

But this first video, he’s standing and you can see he’s got a mechanical prosthetic on that left side. Mel is working with him. You don’t see Mel, but this is a virtual session, so Mel can actually see what he’s doing.

You guys are actually from the perspective of Mel, and she’s working with him on strategies to take and put the button in and out of his jeans.

Now granted, we’re missing some specificity with this from a learning perspective, because the better way to do this would be, you know, actually on his body. But he’s not quite ready for that, so Mel was working through, and you can see it cut out to her.

She’s giving him some cues and some directions, it’s going to cut back into it here as well. She’s giving him some verbal cues and some strategies to work through this.

The next step will be, you know, to actually put them on and try it while he’s standing or while he’s sitting or however, they’re going to do this next.

So, you know, the clinicians have gotten really good at providing verbal cues. Mel is actually really good at doing some therapies right alongside them.

It’s pretty common that she’ll go down into the kitchen here at QLI, and cook with them. They’ll be cooking in their kitchen, she’ll be cooking in our kitchen, and she can demonstrate and show them what’s going on, and what she wants them to do. From maybe a strategy standpoint, from a sequencing standpoint, that sort of thing.

Our clinicians have gotten really creative for a couple reasons. One, it’s more engaging for the client and but it’s also more engaging for our clinicians. Our clinicians are just not built to be sitting in front of a screen. We’re really encouraging them to find ways to engage themselves in some of this therapy. That’s been really cool to see them do that.

And so this next video, you’re going to see he’s trying to put on his sock liner, and he does have his left prosthetic on and actually we’re just talking about this one in the office yesterday.

I think what Mel’s probably going to do is have him try this without his prosthetic on because he’s having a hard time you’ll see he’s having a hard time gripping the prosthetic or gripping the liner with his hook.

So Mel, again is talking him through helping him work on some strategies and that sort of thing. But again, this will probably be progressed the next time that they work together, just because he’s getting pretty frustrated with this.

You can see you can kind of get started but there’s no grip on that left hand side with the hook so what we think we’re going to probably do is he’ll have a little bit more grip with just his skin. T

he thing that impacts this is he’s got some sensitivity too, and so he’s got a little bit of pain and discomfort. So we’re having to figure out the best way to do that.

But really, the impact for Lane is that you know honestly he can do this on his own right now his wife’s having to help them and so this independence factor is really huge.

The other thing that I’ll mention on the functionality of the therapy is that Mel and Lane are actually going to work on mowing the lawn.

And so this wasn’t something that they even had considered at an outpatient clinic. A, if they had considered it, there’s really no way that they could have practiced it probably. But B, you know, all of those fine motor things that they were doing, wouldn’t have translated to this, because being able to position the mower, depending on the type of mower, you’d have to pull the cord of the mower, right, if you think about and envision all the things that it takes step wise to do that, and then you take someone with a lower extremity amputation, and then bilateral upper extremity involvement, and how does that all play out? That becomes a really complex task.

That’s something that we’re able to see and a small example of all the things that we start to address once we see them in their environment.

We talked to Lane and say, like, what are the things that would bring you most value, and you find most meaningful? I’ll tell you, I wouldn’t want to be mowing the lawn, probably because I hate mowing the lawn. I suppose if it was taken away from me, I might feel a little bit differently about it. So it’s pretty interesting to hear them talk about the things that they miss.

It’s a really engaging thing for many of our individuals, and I think, probably, if I was in their position too, anything that gave me a sense of purpose and feeling like I could accomplish something. That’s a pretty cool feeling. So it is really cool to watch them.


Tim Benak – 47:15

So as an insurer, we often see these cases to deal with for the remainder of the injured workers life. For Lane, what would you anticipate long term? Are there typical problems, these individuals experience? Is there an average lifespan for a prosthetic device? As the person ages would another visit to say Omaha to QLI or to a facility to talk about life changes be prudent?

For Lane, what would you anticipate long term? As the person ages would another visit to say Omaha to QLI or to a facility to talk about life changes be prudent?

Steve Kerschke – 47:48

I do believe that well, this probably goes philosophically for how we look at things at QLI. We believe that learning, regardless of your injury, brain injury, spinal cord, injury, amputee, whatever the case may be, that learning happens for a long period of time and doesn’t stop as long as you provide an environment and challenges in order to facilitate that.

Obviously, as people move through, and they age, as they learn, and grow and start to, you know, I think accommodate to their new identity of having an amputation, that I think their capabilities grow, their willingness to try things grows.

But again, the aging factor right there, their abilities might actually decline. They may need different accommodation.

I really believe in this goes back to what I said earlier that this is not a linear process, this isn’t you go through phase 123, and four, and then you’re done and graduate, I believe that you probably go through phases one and two, and then three, and four, you could bounce back between those indefinitely.

I think if you go into this with a finite attitude, I think you’re probably going to end up with some bigger challenges.

To be honest, with our telerehab program, what we’ve seen is we have lots of our payers saying like, hey, this has been really great, but can you stay on board with them just once a month for 30 minutes to check in and be proactive about this. I think that’s really insightful decision to make.

It requires a lot of trust, I think in an organization to say like, Hey, we don’t think that you’re going to take advantage of this, but it does allow us to check in and make some recommendations and just keep people going, rather than maybe depending on a boot camp or something like that.

And again, that might still be important and something that’s needed, but I think a proactive approach with this. As far as like the length of time, we’ll have good my memories here.

Is there an average lifespan for a prosthetic device?

The length of time for prosthetics, I think depends on the type of prosthetic, those really extensive and intricate mile electric ones.

What we’ve heard is they have a lifespan of two to five years. I think it depends on how well they’re taking care of. It depends on what they’re using them for. It depends on a lot of factors.

As far as those mechanical ones, they’re pretty durable. So the fit probably is the one that that might change, right, you might have someone lose some circumferential girth of that, that residual limb. So that might require a socket change of some sort. Same with the lower extremity ones. So socket changes.

But you know, I think that three to five years is probably a safe bet. But knowing how people use them, and what they do with them, definitely affects that.

Are there long term considerations with prostetics?

Tim Benak – 50:43

You talked about what they should anticipate long term in your first answer. Any typical problems? So like, is there anything that could come from the use of a prosthetic?

Steve Kerschke – 50:59

I think skin is always something to think about, right? So again, as someone ages or as someone grows in their ability, or has a different level of activity, be it more activity or less activity, I think how the fit of the socket, and what the skin health looks like, is something to keep an eye on.

And so that’s always, I think, a moving target.

I think, again, back to the aging, I think strength and flexibility are huge with these individuals. If we can maintain that I think their function stays high, I think it helps with some of the skin issues. Just overall activity level, what we know is that when people are active, they’re more healthy physically, and they’re more healthy emotionally.

And so if we can find ways to keep them engaged in purposeful activity that is meaningful and engaging, that I think the overall outcome is better.

So again, I’ve repeated that probably 100 times. But we know that if we tie all these physical goals to something that’s of purpose, that there’s a really great outcome.

That’s not any different than what it is for you and I today, right? If you think about how we’re dealing with just the COVID, restrictions and constraints, we’re probably all dealing with those in a different way.

But, we’re all going back to something that we find purpose in to give us hope and optimism on what’s going to be on the other side of this.

And so be it a limb loss situation a brain injury or spinal cord injury, or put ourselves in whatever situation you want, such as COVID. Like we all have that in common. I think that is something that I find a really interesting, because we’re really no different in that way. But B, something that is a big job for all of our clinicians and for our teams to make sure that we tie it to something bigger than just walking or just being able to put our pants on or just being able to put the liner of our prosthetic on.

How do methods of care differ when treating a lower limb versus an upper limb?

Tim Benak – 53:00

Very important to differentiate between the treatment and care of upper limb prosthetics and lower limb prosthetics. Can you comment on our methods of care when treating a lower limb versus an upper limb?

Steve Kerschke – 53:45

Admittedly, there’s definitely a difference between the two. And, there’s a difference whether it’s like let’s just say lower extremity, if it’s above knee or below knee above knee are way more complex than below knee.

Same with upper extremity, where the amputation takes place, definitely has an impact on how we address it and the complexity of it.

We definitely see them as different I guess maybe in how they’re the same we don’t split we don’t say a person with an upper extremity amputation only sees OT and a person with a lower extremity amputation only sees PT. Our PTs and OTs are very collaborative, and they work on both of those.

Maybe that doesn’t answer the question but to me what’s different is that the OT has to understand can this person stand and the mechanics of, of alignment and that sort of thing of the lower extremity, just like the PT has to understand what’s the strength of the shoulder girdle and all that with the upper extremity.

Tim Benak – 54:47

Is that’s something to differentiate us from maybe an outpatient setting?

Steve Kerschke – 54:50

I mean, I think if you go to an outpatient setting and you have somebody with an upper extremity amputation, they’re likely going to go to an OT, a certified hand therapist or something like that.

Then the lower extremity is going to go to a PT.

So again, I’m probably missing the question behind the question on this. So that’s the best I can answer with the contacts that I have.

How Does Billing Work?

Tim Benak – 55:08

Okay. Can you talk a little bit about billing? So how does billing work with all these services and clinicians?

Steve Kerschke – 55:16

So on the day program, it’s billed if you’re familiar with QLI it’s billed on a per diem. So you show up for your day program, we charge you X amount per day, and all of the therapies, all the awesome stuff that happens while they’re here is included. There’s really no need to worry about like, hey, am I going to get nickeled and dimed for an off campus trip or an extra therapy session or something like that?

On the telerehab side, it’s really billed on a fee for service. Up to this point, we had really only one CPT code that we were billing. But as telemedicine and telerehab is becoming more of a focus, we’re getting pushed to transition to more of a traditional CPT code type of situation, which we’ve responded to.

It’s billed, just like you would see at an outpatient clinic that just happens to happen virtually over FaceTime, or it’s not FaceTime, but we do it through zoom. So it just happens virtually.

What age ranges have we seen?

Can you talk about the age range that we’ve seen someone just made a comment about the case studies being younger? Yeah. What are we seeing?

Steve Kerschke – 57:44

Yeah, good question. The age range has really varied obviously, these these guys are on the younger side. It varies from it’s a similar age range is what we have for our QLI program. So roughly 18 to 65. So definitely a middle aged individual, on average you know, low 40s, upper 30s.

I apologize, it probably gives a different impression just because I chose a couple of situations that were two young guys.

So I can think of a guy right now who’s in our telerehab program. This is actually a cool story. So he’s in his 60s, but he’s an event promoter, he has a bilateral lower extremity amputation.

The reason we’re doing telerehab is that he travels around the country and has to like set up all of the music venues. And he was having a hard time, like behind the stage because it was dark, and there’s cords and he was having to step over all this stuff. He wasn’t able to get the therapy because he traveled so much.

The telerehab was a really great option because it was mobile and convenient for him. But again, we can see what the environment looked like on the job and help make recommendations about what to do with cords or, or lighting or whatever the case may be.

So he’s on the older age spectrum, but also just a really cool and pretty interesting situation. The other thing is just emotionally he has two kids and was really struggling with that. So our psychologist was kind of on the road with him too.