week 7 acquisitions

Are lower limb or upper limb amputations more common? Explain rationale as to why.

Lower limb amputations are more common – because they are related to a higher incidence of traumatic injuries such as within work related accidents and other causes.

Upper limb amputations are more related to trauma – a sudden jolt that makes it more complex

- Working with people who have this immediate transition into their life.

- Upper limb will be more male than female, and more cases are distal to the wrist

Who are members of the multidisciplinary team when providing care to a client receiving an orthoses or prostheses?

- OT, PT, Prosthetist, mental health professional, PCP, Case manager, vocational rehab, family/social

Why is communication important among the multidisciplinary team?

- Effective communication is essential for multidisciplinary collaboration and a key indicator of quality care. They are an integral component of improved health outcomes that provide specialized patient support and contribute important information regarding patients’ function, social situations, recovery goals and discharge needs.

o Can overall work together to address what is best for the client!

What is the difference between an amputation along the joint vs middle of the bone? (disarticulation vs transhumeral for example).

- Along the joint an amputation is known as a -disarticulation (ex: shoulder disarticulation, elbow disarticulation)

- Through the middle of the bone, an amputation is a -humeral joint (ex: transhumeral, transradial, transcarpal)

How is the most appropriate prosthesis decided for a patient? Why or why not

- Prosthetic Goal:

Provide appropriate appearance and function to increase independence with ADLs and improve quality of life through participation in desired activities.

o It is important to choose a prosthesis suitable for the individual’s age, level of amputation, and functional level.

- A prosthesis is chosen if it enhances independence, safety, comfort, and overall quality of life, while meeting the patient’s daily and recreational needs.

- It might not be chosen if it offers little functional benefit, is too heavy or complex for the patient ot use effectively, causes pain or skin breakdown, or if it is financially inaccessible.

Explain the process of obtaining a prosthesis and OTs role in each stage.

1. Acute care

a. Independence with most basic ADLs including environmental control

b. Initiate peer intervention

c. Refer for prosthesis consult

Explain the process of obtaining a prosthesis and OTs role in each stage.

1.         Pre-prosthetic

a.         ADL retraining incorporating residual limb

b.         Hand dominance retraining

c.         Pain management, desensitization, edema management, strengthening ROM

Explain the process of obtaining a prosthesis and OTs role in each stage.

3. Basic prosthetic training

a. Device management: don/doff cleaning, precautions, etc

b. Basic control of all functions of prosthesis

c. Incorporation of prosthesis into simple bimanual ADLs

Explain the process of obtaining a prosthesis and OTs role in each stage.

4. Intermediate prosthetic training

a. Progression of bimanual ADL complexity

b. Progressing control of prosthesis to include proportional control and pre-positioning

c. Focus on proper body mechanics and minimize compensatory movements

Explain the process of obtaining a prosthesis and OTs role in each stage.

5. Advanced prosthetic training

a. Focus is advanced bimanual ADLs

b. Increased task speed, divided attention, safety

c. Driving and work assessments

- No prosthesis:

The individual chooses not to use a prosthetic limb

- Activity specific prosthesis:

Specifically designed for a single tasks or sport (ex: swimming, cycling, playing a musical instrument) to optimize performance for that activity

o The impact that an activity specific prosthesis can have on an amputee’s overall quality of life cannot be overstated. Allows for patients to resume participation in meaningful and exciting activties.

Oppositional/passive functional:

Primarily for cosmetic purposes or to provide passive support/stabilization during activties (holding objects while the other hand works)

- Body powered:

Controlled by cables and harnesses that use the body’s own movements (ex: shoulder motion) to operate the prosthesis

-

Externally powered:

Powered by battery systems and controlled by various input devices such as switches or electrodes.

o When electrodes are used, referred to as myoelectric

- Hybrid:

Combines different types of prosthetic components into one device, usually a mix of body powered and externally powered (ex: electric motor driven).

- Pre-prosthetic rehabilitation:

o Everything that happens before a prosthesis is delivered

o May run concurrent with prosthetic rehabilitation

o Goals:

 Prepare limb for wear and use of prosthesis

 Prepare limb for function without prosthesis

 Provide skills to patient for independence when they are not using a prosthesis

o Acute care:

 May be in the hospital or outpatient

 Initial surgery through two weeks (depending on complexity of case)

 Goals:

• Simple ADL: self-care, feeding, toileting, bathing, and balance

• Self-management of edema and wounds

• Peer intervention

o Psychosocial component

 Thinking about the grieving process and providing the necessary supports

 Asking mental health questions, including participation barriers

 Using registration for peer visits as treatment modality

o ADL/Function component:

 Goal is independence with ADLs using:

• Modified technique using a “One Plus” style (one hand + residual limb)

• Body English

• Adapative equipment

 Progress from very basic ADLs to more complex

• Dressing in loose clothes builds up to dressing in a suit

• Making microwave meal builds up to full meal prep

 Intervention:

• Have a few pieces of AE for patient to try in clinic

• Prosthosis

• Use videos or visual for the task

• Incorporate residual limb in appropriate tasks

• Provie written HP (home program) with times and task

o Home program is as important as when to do the home program

physical component:

 Body:

• AROM, strengthening, symmetry

• Pain

• Desensitization/scar massage

• Edema control/limb shaping

- Prosthetic therapy:

o Goals:

 Integration of prosthesis into life

 Full use of features

 Bimanual usage

o Current literature has it divided into three stages:

 Basic control training

 Intermediate/gaining controls training

 Advanced/bimanual skills training

o Current literature also says not to progress to the next stages until previous is mastered

Why are donning and doffing a prosthetic important? Especially for a bilateral UE amputee?

- Donning (putting on) and doffing (taking off) ensure the prosthetic device is worn correctly for comfort, proper alignment, and full function. While also preventing skin breakdown and injury

o Donning/Doffing

 Commonly skipped over

 Don it 2-3 times in therapy

 At home 3-5 times

 Needs to be a fluid and natural motion

o Establish a wear schedule:

 Start 30 minutes three times a day and increase as tolerated

o Basic care and maintenance:

 Cleaning daily (damp cloth, alcohol)

 When appropriate:

• Charging

• Removal/changing components

- Especially for a bilateral UE amputee:

o Because they have no “natural hands” to assist with the process, especially when using their prosthesis outside of therapy

 Without properly learning this may lead to struggles with daily independence, hygiene, or prosthesis maintenance.

How are OTs involved in Lower Limb prosthetic?

- OTs will address:

o Pre-prosthetic training:

 Residual limb care

 Edema reduction/wrapping

 Safety/balance

 ADL participation

o Prosthetic training

 Device management-care and cleaning

 Donning and doffing

 Integration into ADLs and IADLs (childcare, going ot the park, walking dog)

 Balance during ADL

- Psychosocial Impacts of Amputations

o Losing a limb can be emotionally distressing, akin to losing a loved one.

o Common reactions:

 Distress, anger projection, insecurity, and difficulty adjusting socially.

- Why Psychosocial Considerations Matter:

o Psychosocial distress can hinder recovery, affecting self-efficacy and quality of life.

o Addressing emotional well-being is as important as physical rehabilitation.

Why is the psychosocial/grieving process important when working in orthoses and prostheses?

- Because losing a limb and adaptation to a significant change affects more than physical ability. It has an impact on identity, self-image, independence, relationships, and emotional-well-being.

o Losing a limb can be emotionally distressing, akin to losing a loved one.

o Basic control prosthetic training:

 Uses repetitive drills and task to build motor control patterns

• Stacking cones

• Repetitive ADL components

 Progress to alternating components

• Mirroring activities

• Grasp item then flip to stack

 ADL integration

• Holding vegetable in position to cut

• Holding containers in position to open

• Donning shirt with px on

• Holding static items of DL like toothbrush, pill bottle or glass while pouring

o Intermediate/gaining controls training:

 Proportional control-goal is to no apply too much pressure to items

• Start with harder items and progress to softer

• Gripping different resistances of sponges

• Plastic cups, then Styrofoam cups, then thin paper cups

• Different foods

 Partial arc control of components

• Rotating wrist part way

• Opening hand only as wide as needed

• Positioning elbow to the right level

 ADL integration:

• Hold vegetables of different consistencies for cutting

• Hold containers of different hardness: plastic cup, Styrofoam cup, thin paper cups

• Simulated shopping: positioning px for pushing cart, supporting bag, managing wallet

• Positioning px at different heights: standing at counter, sitting at table

o Advanced/bimanual skills training:

 Goals:

• Incorporate into ADLs

• Full time wearing

 Have patient perform task analysis

• What is the best way to do a task?

• Does the terminal device need to be opened and closed?

 Have them talk through the task with you and discuss proper use of prosthesis in task

 Provide regular feedback and keep expectations real

 Challenge skills previously worked on by adding more dynamic components

• Holding up a cup while walking without dropping it

• Use keys to open a door while holding a bag

 Progress from very basic ADLs to more complex

• Dressing in loose clothes to dressing in a suit

• Making microwave meal to full meal prep

 Expand task components

• Holding fork-cutting food-carrying plate-serving plate-obtaining plate

• Folding towels-folding all clothes-in/out of storage-management of washing machine

Is a prosthetic silicon hand or a hook terminal device more functional? Why?

-

The hook terminal device is more functional

o   It is lightweight, durable, easy to control, and often better for works tasks, tool use, and daily activities requiring dexterity.

What role does neuromuscular re-education have in the prosthetic training process? How does it relate to the homunculus?

- Neuromuscular re-education helps to retrain the communication pathways between the brain and muscles ot help regain motor control.

- The homunculus is like a map in the brain that shows which parts of the brain control which parts of the body. When a limb is lost, the brain’s “map” for that limb changes—this is called cortical reorganization. Neuromuscular re-education helps “retrain” the brain by working the muscles in the remaining limb, so the brain can update its map and learn to use the prosthesis in a smooth, natural way.

What is a GivMohr Sling?

- A dynamic positioning device designed to reduce shoulder subluxation and support the flaccid upper extremity in a functional position during activities in standing and ambulation

- Ideal for neurological diagnoses including:

o Stroke/CVA

o ALS

o Traumatic Brain Injury

o Brachial Plexus injury

o Central Cord syndrome

benefits of a GivMohr Sling?

o Reduces shoulder subluxation

o Reduces shoulder pain

o Supports the arm in a functional position

o Increases balance

o Improves gait

o Protects the flaccid arm/shoulder

o Easy application by user

o Improves ability to do ADLs/IADLs

Identify the 3 phases of rehabilitation when working with clients who have experienced an amputation and give a brief overview.

1. Pre-surgery and post-surgery phase:

a. When possible, an OT should see a patient before surgery to establish a baseline for future rehabilitation. The OT should assess their health, daily activities, and teach one-handed techniques. After surgery, the OT helps manage pain, maintain joint movement, and starts gentle exercises to prepare for prosthetic use.

Identify the 3 phases of rehabilitation when working with clients who have experienced an amputation and give a brief overview.

2. Pre-prosthetic therapy:

a.         About 2-3 weeks after surgery, therapy focuses on shaping and strengthening the residual limb, reducing sensitivity and keeping joints flexible. The OT works with a prosthetist to prepare the limb and introduce adaptive skills like one-handed techniques and equipment. For special surgeries (like targeted muscle reinnervation), exercises to control myoelectric prostheses begin once healed.

Identify the 3 phases of rehabilitation when working with clients who have experienced an amputation and give a brief overview.

3. Prosthetic training:

Starting 1–2 months after surgery, training teaches the patient how to put on, take off, care for, and control the prosthesis. Training begins with simple controls, practicing movements repeatedly, then moves to using the prosthesis in daily activities. Myoelectric prostheses often need more time and practice, especially for higher-level or bilateral amputations.

Should sensation be measured on a residual limb? Why or why not.

- Yes, sensation should be measured on a residual limb.

o Help to manage post amputation pain and sensation: including residual limb pain, phantom limb pain, and phantom limb sensation

 Treatment for phantom limb sensation specifically focuses on building awareness to reduce the risk of falls and developing compensatory strategies

o Patients with vascular disorders, a common cause of lower limb amputations, may experience sensation deficits. These deficits can increase the risk of skin integrity issues, such as ulcers, and can pose a long-term risk of additional amputations.

o OT interventions often involve sensory focused treatments for residual limb

In the acute phase when teaching residual limb wrapping, what is important to avoid? (we reviewed this in conditions).

- Wrapping the bandage too tightly and in circles around the limb, as this can create a tourniquet effect which can restrict blood flow and potentially damage nerves or tissues

- Avoid the bandage forming creases or wrinkles against the skin which can lead to pressure points, skin breakdown, and infections

- The wrap should be snug but not painful