once suture line healed (10-21 days) use shrinker wrap TT/TF
(rigid, semi-rigid, soft bandaging)
soft bandaging
Principles of ace-wrapping:
distal pressure should be ___more/less than proximal
pressure applied on _______turns (oblique/angular)
wrinkles?
metal clips?
wear ____hours a day
wash ___ don't _____
more pressure on distal
pressure applied oblique
no wrinkles!
no metal clamps!
wear 23 hours a days
what are most common contractures that can occur in transtibial amputation?
hip flexion
knee flexion
why do TT amputees get contractures?
long periods of sitting, flexion position is comfy
protective flexion withdrawal pattern associated with LE pain
muscle imbalance
loss of sensory input
what are common contractures in transfemoral amputees?
hip flexion
hip abduction
hip ER
how can you prevent contractures?
knee in extension
lie prone
HEP
AROM/PROM
post op strengthening consists of what type of contractions? and where should ROM occur?
isometric contractions
limited ROM at proximal joint
strengthening protocol
10 sec contraction
5-10 rest for 10 reps
AROM of unaffected limb on day ___
affected limb day ___
bed mobility/transfers day _____
day 1
days 1-3
day 2
as wound healing progresses include the following:
large arc of motion
active resistive exercises
isokinetics
eccentric
general plan of care for amputee
hip ext/hip abd/add, knee ext
general strengthening/ ROM of trunk/UEs
aerobic exercise
posture
skin integrity
PT ideally begins _____(before/after) pt has amputation
BEFORE
after a LE amputation PT focuses on ....?
pre-prosthetic training for functional mobility
skin care
typical socket designs for trans-tibial
patellar tendon bearing
supra-condylar suspension
total surface bearing
typical socket design for trans-femoral
ischial containment/narrow ML
quadrilateral socket/narrow AP
what does the pylon do?
connects socket to foot
components of prosthesis
based on patients function/goals
length of limb
consider weight of patient plus their lifting activities
what is the job of the suspension?
holds prosthesis on the residual limb
what are the different types of suspensions?
pin
cuff
sleeve
belts
suction
combination
what are the different types of liners/socks?
pelite inserts
sheath
socks
gel liners
post op care for residual limb (make sure to do to sound limb)
wash nightly with mild soap, pat dry with cloth
small amount of lotion/powder (no alcohol)
daily skin inspections
desensitization
soft tissue mobilization
are wheelchairs used for amputees? if so what are they used for?
Yes! used for long distances for very short TF
what is a common transfer to use?
stand and pivot
may need sliding board?
how can you work on balance?
sit, hands and knees, kneeling, stand
progression of gait in amputees
1. parallel bars
2.single limb ambulation w/ assisted device
3. outside of bars..try crutches
4. most LE amputees will need an assisted device (always exceptions)
can psychological issues arise from an amputation?
Yes!
target clinical pathway:
Day 0
amputation surgery
target clinical pathway:
day 1-4
acute hospital, pre-prosthetic PT
target clinical pathway:
day 5-21
sub-acute rehabilitation hospital or home for wound healing and continued pre-prosthetic PT
target clinical pathway:
day 21-28
suture/staple removal followed by casing for temporary prosthesis
what are some factors that can affect prosthetic training success?
physical abilities
cognition
prosthetic fit
motivation
financial resources
SES/ support system
data to be collected during eval
endurance
anthropometric characteristics
cognition
assistive devices
circulation
cranial/peripheral nerve
environmental barriers
body mechanics
gait
skin
joint integrity
motor control
muscle performance
pain
orthoses
posture
ROM
self care
sensory
work
community
how would you teach patient to don prosthesis?
sit in chair
check prosthesis
check residual limb
sheath-->socks--> gel liner
insert over residual limb (if there is one)
step into prosthesis while sitting
attach suspension
pressure tolerant areas:
patellar tendon,
medial tibial flare
supracondylar area
adductor tendon
ischial tuberosity
pressure sensitive areas:
distal fibular head
end of femur
most common sites for blisters?
bones
why do you get blisters? how do you fix it?
why? settling, pistoning, tilting, torsion
solution--lambs wool
why do you get distal edema? solution?
not good enough contact
lambs wool solves this
what should the prosthetic sock look like?
should look the same all over, no wrinkles etc
what does the loss of hair/ redness on extremities suggest?
continued pressure and reduced nourishment of tissues and skin
CALL DR ASAP!
choking is what?
throbbing pain
if limb is cold means what?
if limb is hot means what?
cold=impaired circulation
hot=infection
skin should be checked how often?
every 15 mins
if skin is red after 15 mins do what?
if skin isn't red after 15 mins do what?
if yes--leave shrinker and prosthestic off. if gone after 15 mins put back on, if still red after 15mins call prosthetist
if no--put back on
pressure on the inferior pole of the patella suggests what?
solution?
going down into the prosthesis too far--weight change
add socks
pressure on tibial tuberosity suggests what?
solution?
not going down far enough--swelling, weight change
decrease number of socks
movement between skin and the socket, excessive drop of socket away from residual limb in swing is....?
pistoning
suggest problem with suspension
weight shift in prosthesis helps for what?
normalizes gait
how do you progress patients in weight shift activities?
start in parallel bars-both hands. weight shift forward,backward, side to side, diagonal
progress to all those with 1 hand holding on
then no hands
during stepping activities the focus is on....?
rotation of pelvis, weight shift flexing prosthetic knee at pre-swing
step forward/backward with sound limb
step forward/backward with residual limb
stool stepping
in parallel bars, with both hands step up with sound limb
then practice stepping up with prosthesis
emphasize hip and knee control on residual side
progress by removing 1 hand then 2
is stool stepping recommended for TF amputees?
No! requires hip circumduction/hike to get foot off step with is undesirable and should be avoided
stride stepping
start 4 in apart in parallel bars
alternate starting with sound and residual, progress to 2, then 3 then so on
when can you progress patient outside of parallel bars?
shift weigh A/P, R/L without deviations
forward with sound and put weight on residual
step forward with residual doing hip rotation not trunk rotation
advanced activities to teach should include?
transfers
curbs/stairs
inclines
uneven terrain
picking up dropped objects
clearing obstacles/barriers
falling and rising
sitting/kneeling
running, single leg stance
how do you know when its time to discharge or discontinue a patient?
when they can do all functional skills, gait on all surfaces, get up from fall, care of skin/prosthesis
usually determined by insurance companies
ending PT secondary to pt reached anticipated outcomes/goals =?
discharge
ending PT secondary to pt request, unable to continue due to insurance, no longer progresses =?
discontinue
when do patients need socket revision?
after a year of wear to accomodate shrinkage
technology improves and patients need new foot or knee
level of function
transmetatarsal recovery and energy requirement
95% recovery
0% increases energy
transtibial recovery and energy
70-75% recovery
20-40% increased energy
transfemoral recovery and energy
20-40% recovery
50-80% increase energy
if you have a bilateral transfemoral prosthesis how much % is energy increased?
300%
Medicare Level 0
non-ambulatory
medicare wont pay for prosthesis
Medicare Level 1
transfers or limited household ambulator
sach/single axis foot
manual knee lock, stance control
Medicare Level 2
limited community ambulator
multi-axis foot
polycentric, pneumatic knee
Medicare Level 3
unlimited community ambulator
Medicare Level 4
high energy activities
level 3/4: energy storing feet and hydraulic/microprocessor knee
transtibial prosthetic rehab
4-6 weeks OP PT/day pt
transfemoral prosthetic rehab
6-12 weeks OP PT/day pt
temporary prosthesis 4-5 weeks after amputation
permenant prosthesis 3-6 months post op
re-eval anually
replace prosthesis every 4-5 years
From Teresa's review:
Identify four possible forms of
compression bandaging commonly used after amputation.
1. ace bandage
2. shrinker socks
3. rigid removable dressing
4. semi-rigid dressing
From Teresa's review:
What Medicare functional level is
transfers or limited household ambulator?
level 1
From Teresa's review:
What is the significance of these
Medicare functional levels?
these levels guide decisions about type of prosthesis and componentry based on patients functional level
From Teresa's review:
What are the purposes of compression
bandaging for the amputee?
-reduce edema
-control pain
-enhance wound healing
-protection of incision
-faciliate limb shaping for prosthesis
From Teresa's review:
what contractures are common in patients with transtibial amputations?
knee flexion, hip flexion
From Terea's review:
How do you prevent contractures in transtibial amputee patients?
-amputee board in w/c
-exercises
-avoid use of pillows
-prone lying
-education
From Terea's review:
what contractures are common in a patient with a transfermoral amputation?
hip flexion, hip abduction, hip ER
From Teresa's review:
Discuss scar management for your patient
-scar massage above and below incision
-appropriate to being once healing has occurred
-avoid adherence along incision which can increase shearing and can cause breakdown and pain
From Teresa's review:
Difference between phantom limb pain vs phantom limb sensation
phantom limb sensation:
-feeling that limb is cramped, itching, numbness 70% will experience this
phantom limb pain:
shooting pain, severe cramping, burning in limb
From Teresa's review:
What is the most common cause of amputation?
PVD
From Teresa's review:
identify at least 3 factors that influence a patients outcome in prothestic training
