Eval, Assess, Intervention, & Transfer Techniques

FACTORS IMPACTING REHABILITATION

Comorbidities

Level of Amputation

●Cognitive Impairment

●Physical Conditioning

●Social Support

●Psychological Factors

role of PT in amputee rehab

Encouragement & education

● Positioning

● ROM, strength, sensory & balance assessment

● Residual limb care & desensitization

● Mobility & Gait (no hopping)

FUNCTIONAL BIOMECHANICS & POSTURE

Theoretical center point of human body presumed to be 2-4” below umbilicus. Dependent upon position of body & limbs.

COM

Front on & back off transfer approach is most often used for pts after

B LE Limb Loss, can be executed & practiced thru series of lateral weight shifts

Hip ROM assessment for transtibial amputation includes assessing what ROM?

extension

● assess in sidelying or Thomas Test position

Hip ROM assessment for transfemoral includes assessing extension via utilizing

sidelying or Thomas Test position

assess abduction/ adduction

*disposition to abductor tightness

strength assessment same as would in any eval, due to pain may be unable to apply resistance to surgical limb, so look at

Core strength, particularly important w/ this pop, is needed for bed mobility, transfers, & eventual gait/mvmt quality

sensation assessment of 

light touch of sound limb & surgical limb

● Test proprioception of sound & surgical limbs at most distal jt

● Be sure to assess B LE

● Consider comorbidities including DM or PA

pain assessment post op is expected. residual limb pain is pain felt in

remaining tissue. Expected sxs after surgery. Can be caused by poor prosthetic fit, bruising, rubbing

sensations felt in the part of the leg that is missing. NOT painful, may be lifelong

phantom sensation

pain felt in a portion of leg that is missing

■ Described as cramping, burning, tingling, sharp, shooting, electrical, squeezing, knifelike

■ Assess pain via 0-10 scale, FACES scale, word descriptions

phantom pain

○ Incidence of phantom pain 42.2-78.8%

for skin integrity assessment, measure girth to assess baseline for changes. Assess for skin impairments (wounds: surgical vs acquired)

○ Consider risk factors for skin breakdown. dressing type: Covered vs uncovered (pending physician orders). Education on

need for regular skin checks of both surgical & intact side. Utilization of mirror for visual assessment of difficult to visualize areas

what is method by which you control shape & edema of residual limb after amputation?

volume containment (residual limb shaping)

GOALS OF VOLUME CONTAINMENT:

Cylindrical Shape of residual limb

○ Better WBing surface

○ easiest to don prosthesis

● Reduce edema

○ Allow for prosthetic fit

○ decrease fluctuation in size of limb

METHODS OF VOLUME CONTAINMENT

Ace wrapping

● Stump shrinker

● Tubigrip

● Semi-rigid

● Rigid removable

● Rigid non-removable-IPORD

● Immediate post-op pylon-IPOP

What are advantages of ACE wrapping?

Inexpensive

○ Easily available

○ Easy to inspect wound

○ Excellent shaping & edema control

○ Easily modified to patient volume changes

What are disadvantages of ACE wrapping

Must be frequently reapplied

○ Difficult to teach to clinicians & pts

○ Requires 2 functional hands

○ Can be harmful when applied incorrectly

what are advantages of residual limb shrinker?

easy to don

○ easy to care for

○ easy to instruct pt & family

○ does not have to be re-applied

○ easy to view limb

what are disadvantages of residual limb shrinker?

not accessible outside clinics

○ expensive to replace

○ Contraindicated for sutures & sensitive skin (not used in phase 2)

○ loses effectiveness as limb shrinks

**Progress from wrapping to shrinker occurs when

sutures & staples are removed

what are some advantages of Tubigrip?

ease of application

○ easy to care for

○ easy to view limb

what are some disadvantages of Tubigrip?

not durable

○ increased cost

○ can roll & constrict

○ can cause window edema at end

○ difficult to purchase out of hospital

what is a gauze impregnated w/ calamine lotion or zinc oxide. Wrap onto residual limb w/o applying any tension tightens as it dries. This hardens into a semi-rigid cast.

Semi-Rigid Limb Shrinker: UNNA BOOT

what are some advantages of a Semi-Rigid Limb Shrinker: UNNA BOOT?

Good compression

○ Allows skin checks every 3 days

what are some disadvantages of a Semi-Rigid Limb Shrinker: UNNA BOOT?

Messy to apply

○ Can be expensive over time

○ Not easily applicable by a pt

what are some advantages of a rigid removeable?

Excellent edema control

○ easy to apply

○ skin is accessible

○ modified as limb shrinks-sock mgmt

○ Protection of residual limb against accidental trauma

what are some disadvantages of a rigid removeable?

time consuming to fabricate

○ skill to fabricate

○ donning can injure very fragile skin

○ Must closely monitor sock ply

what is a Rigid Cast above knee?

●1st cast changed 3 days

●Subsequent cast changes every 7 days, used in oncology realm

NON-REMOVABLE RIGID : IPORD

what are some advantages of a non-removable rigid: IPORD?

Best edema control

○ excellent wound protection

○ aids in contracture prevention

○ Increased pt confidence

what are some disadvantages of a non-removable rigid: IPORD?

Cannot view wound-not for disease pts

○ Skill in fabricating

○ Heavy

○ Skin breakdown as limb shrinks

what has a connector, plyon, & foot are immediately attached to cast?

● Generally there is a protocol for WBing

○ Start at 20%

○ Progress

immediate post-op pylon: IPOP

what are some advantages of an immediate post-op pylon: IPOP?

● aids in contracture prevention

● Increased pt confidence

● Allows early WBing

● reduces phantom pain & edema control

● decreased hospital stay

what are some disadvantages of an immediate post-op pylon: IPOP?

Cannot view wound

● Skill in fabricating

● Heavy

● Skin breakdown as limb shrinks

● Risk of wound irritation

pt education regarding limb volume should include factors that impact limb volume such as

Water retention, Salt intake, Fluid intake, Activity Level

Pressure changes related to use of prosthesis

Gender- females have greater volume changes

Health Factors: Dialysis, medications, Lasix, PVD

Time since amputation

pt education regarding limb volume should include prognosis

7.3% volume decrease in 1st 3 months

35% after 5-6 months

Typically stabilize after that time

Transtibial limb loses 4-10% of volume in an 8 hour day, how much occurs in 1st 2 hrs?

90%, Prosthetic use may require more ply as day progresses due to volume loss

Residual Limb Wrapping compression must be worn up to

23 hrs per day; remove for hygiene & skin check

residual limb wrapping should progress to

residual limb shrinker when sutures & staples are removed

Interventions for residual limb volume control in addition to compression

Elevation & exercises (muscle pump)