Physical Therapy Management of the Patient with LE Amputation

what is NEGATIVE MOLD

is casted by a certified prosthetist to replicate the remaining limb

what is the "NEGATIVE IMPRESSION" used for

to build positive mold that will serve as the guide for prosthetic device

what is the NUMBER 1 REASON for an AMPUTATION

diabetes

what are 3 major causes of AMPUTATIONS

1. peripheral vascular disease (~51%)

2. trauma (~41%)

- MVA, severe burn/gunshots

- usually young adults + more frequently male

3. birth defects/congenital limb deficiency (~8%)

what are 4 other causes of AMPUTATION

1. tumor

2. frostbite

3. serious infection

4. neuroma (thickening of nerve tissue)

do most amputations involve the arms or legs?

legs

what are the 3 LEVELS of AMPUTATIONS

1. partial

2. trans

3. disarticulation

what does the PARTIAL LEVEL include

only for hand + foot

what does the TRANS LEVEL include

through the long bone

what does DISARTICULATION include

through joint itself

what 4 factors is the AMPUTATION LEVEL SELECTION by surgeons based on

1. tissue viability/wound healing

2. potential for function

3. prosthetic issues

4. cosmesis

what are 4 types of PARTIAL FOOT AMPUTATIONS

1. toe

2. transmetatarsal

2. lisfranc

3. chopart

what is a LISFRANC amputation

disarticulation b/w TARSALS + METATARSALS

what is a CHOPART amputation

disarticulation at MIDTARSAL JOINT leaving CALCANEOUS + TALUS

who first described ANKLE DISARTICULATION

Syme (1843)

what are 4 components of an ANKLE DISARTICULATION

1. only tibia + fibula left

2. amputation of foot at ankle

3. malleoli removed

4. calcaneal fat pad retained

what 2 bones are only left with an ANKLE DISARTICULATION

tibia + fibula

what is amputated with an ANKLE DISARTICULATION

foot at ankle

what is removed with an ANKLE DISARTICULATION

malleoli

what is retained with an ANKLE DISARTICULATION

calcaneal fat pad

what is a TRANSTIBIAL/BKA also known as

below knee amputation

what are 2 components of a TRANSTIBIAL/BKA/BELOW KNEE AMPUTATION

1. retain knee joint

2. tibia + fibula transected

what joint is retained with a TRANSTIBIAL/BKA/BELOW KNEE AMPUTATION

knee joint

what 2 bones are transected with a TRANSTIBIAL/BKA/BELOW KNEE AMPUTATION

tibia + fibula

what are 2 components of a KNEE DISARTICULATION

1. through knee joint

2. femur intact

what joint does a KNEE DISARTICULATION go through

knee joint

what bone is in intact with a KNEE DISARTICULATION

femur

what is a TRANSFEMORAL/AKA also known as

above knee amputation

what are 2 components of a TRANSFEMORAL/AKA/ABOVE KNEE AMPUTATION

1. retain hip joint

2. femur transected

what joint is retained with a TRANSFEMORAL/AKA/ABOVE KNEE AMPUTATION

hip joint

what bone is transected with a TRANSFEMORAL/AKA/ABOVE KNEE AMPUTATION

femur

what are 2 components of a HIP DISARTICULATION

1. through hip joint

2. pelvis intact

what joint does a HIP DISARTICULATION go through

hip joint

what bone is intact with a HIP DISARTICULATION

pelvis

what is a TRANSPELVIC/HEMIPELVECTOMY

is a resection of lower 1/2 of pelvis

what type of incident would result in a TRANSPELVIC/HEMIPELVECTOMY

land mine incident

what is a TRANSLUMBAR/HEMICORPORECTOMY

is an amputation of both LEs, pelvis + below L4-L5 level

what is the 4 steps of the SURGICAL PROCESS of an amputation

1. removal of nonviable bone + tissue

2. bone beveled, smooth, rounding of sharp edges

3. hemostasis, cauterization (stop bleeding)

4. nerves cut under tension to retract into soft tissue

what is MYOFASCIAL

muscle to fascia

- minimal stabilization

what type of STABILIZATION is associated with MYOFASCIAL

minimal stabilization

what is MYOPLASTY

muscle to muscle

what is MYODESIS

muscle to bone

- good stabilization

what type of STABILIZATION is associated with MYODESIS

good stabilization

what are 3 ways of TENODESIS

1. muscle to tendon

OR

2. tendon to tendon

OR

3. tendon to bone

what is TENODESIS

is the distal attachment of severed tendon

what is the BEST METHOD of STABILIZING MUSCLE

tenodesis

when is TENODESIS usually done

only with disarticulation

what is a SKIN/TISSUE FLAP

is the soft tissue covering the end of bone

- where tissue came from

what are 3 types of SKIN/TISSUE FLAPS

1. anterior flap

2. posterior flap

3. equal length (fish-mouth)

what type of INCISION is associated with an ANTERIOR SKIN FLAP

posterior incision

what type of INCISION is associated with an POSTERIOR SKIN FLAP

anterior incision

what type of INCISION is associated with an EQUAL LENGTH (fish-mouth) SKIN FLAP

distal end incision

what are 2 types of *CLOSURE8

1. primary intention

2. secondary intention

is a primary intention CLOSED SURGICALLY/LEFT OPEN to HEAL

closed surgically

is a secondary intention CLOSED SURGICALLY/LEFT OPEN to HEAL

left open to heal

what are the 4 steps involved in the SURGICAL PROCESS of a TRANSTIBIAL AMPUTATION

1. long posterior flap from gastrocnemius + soleus muscles

2. surgeon bevels + contours flap for a smooth (not sharp) distal end

3. after myoplasty soft tissues are approximated

4. final suture is over the anterior part of distal limb

what is a PRINCIPLE for a TRANSTIBIAL AMPUTATION

bone bridging

what is BONE BRIDGING

- popularized by: surgeon ERTL

- osteomyoplastic amputation surgery using a bone graft that bridges tibia + fibula to create bony bridge

- in theory: accomplishes better weight bearing surface, prevents scissoring of tibia + fibula and closes medullary canal

- has not been proven better

who was BONE BRIDGING popularized by

surgeon ERTL

what does BONE BRIDGING involve

using a bone graft that bridges tibia + fibula to create bony bridge

in theory, what does BONE BRIDGING accomplish

better weight bearing surface

in theory, what does BONE BRIDGING prevent

scissoring of tibia + fibula

in theory, what does BONE BRIDGING close

medullary canal

what are the 17 members that are apart of the AMPUTATION REHABILITATION TEAM

1. family physician

2. surgeon

3. other MDs

4. physiatrist

5. nurse/nursing staff

6. PT/PTA

7. OT/OTA

8. prosthetist/orthotist

9. psychologist

10. social service workers

11. case manage

12. recreational therapist

13. speech therapist

14. vocational counselor

15. family member(s)

16. mentor/peer visitor

17. housekeeping staff

what type of model does an AMPUTATION REHABILITATION TEAM follow

patient focused team model

what are 7 components that the OPTIMUM AMPUTEE REHABILITATION consists of

1. pre-amputation care

2. IPOP/RRD stage

3. pre-prosthetic care

4. preparatory stage

5. gait + prosthetic training

6. definitive stage

7. follow-up care

what is the entire timeline length of rehabilitation for PATIENTS w/ LE AMPUTATION

0 wks-1 year

what occurs during week 0 of LE AMPUTATION REHAB

apply post-operative protector

what stages are included prior to week 0 of LE AMPUTATION REHAB

pre-prosthetic training period from pre-surgery to temporary device

what 2 events are included during week 0-week 4 of LE AMPUTATION REHAB

1. sutures removed

2. limb shaping

what 2 events take place during week 4-week 8 of LE AMPUTATION REHAB

1. incision fully healed

2. cast for prosthesis

what are 2 events that take place from week 4 - week 12 of LE AMPUTATION REHAB

1. temporary prosthesis

2. begin prosthetic gait training

what are 2 events that take place from 4 months - 6 months of *LE AMPUTATION REHAB

1. ongoing therapy

2. prosthetic adjustments

what are takes place from 6 months - 1 year of *LE AMPUTATION REHAB

receive permanent prosthesis

what are 6 components included in PRE-AMPUTATION COUNSELING

1. establish rapport

2. educate patient

3. reduce anxiety

4. set realistic goals

5. provide peer support contacts

6. provide initial home exercise

what are 16 components included in PATIENT EDUCATION for AMPUTATIONS

1. role of PT

2. stage of recovery + treatment plan

3. care of residual limb + uninvolved extremity

4. LE cleanliness, proper foot care + proper shoe fitting

5. positioning

6. pain

7. methods of edema control

8. benefits of exercise + HEP

9. diet

10. discussion of disease process as applies to patient (DM, PVD, etc)

11. changes in skin color/temperature

12. functional mobility (bed mobility, transfers)

13. wheelchair use, gait training, stair training

14. equipment needs + training on use

15. prosthetic use

16. family training

what are the 3 major guidelines of a PRE-AMPUTATION HOME EXERCISE PROGRAM

1. maximize LE ROM (hip extension + knee extension)

2. provide basic strengthening exercises in supine/sitting with progression to standing exercises

3. provide safe cardiovascular exercise

for TRANSFEMORAL PATIENTS, what 2 HIP ROMs should be strengthened

1. hip extension

2. hip abduction

for TRANSFEMORAL PATIENTS, what MAJOR MUSCLE is strengthened with HIP EXTENSION

gluteus maximus

for TRANSFEMORAL PATIENTS, what MAJOR MUSCLE is strengthened with HIP ABDUCTION

gluteus medius

for TRANSTIBIAL PATIENTS, what 3 LE ROMs should be strengthened

1. knee extension

2. knee flexion

3. hip extension

for TRANSTIBIAL PATIENTS, what MAJOR MUSCLE is strengthened with KNEE EXTENSION

quads

for TRANSTIBIAL PATIENTS, what MAJOR MUSCLE is strengthened with KNEE FLEXION

hamstrings

for TRANSTIBIAL PATIENTS, what MAJOR MUSCLE is strengthened with HIP EXTENSION

gluteus maximus

for both a TRANSFEMORAL + TRANSTIBIAL AMPUTATION PATIENTS, what should be strengthened to HELP LBP

abdominals

what is the MOST IMPORTANT EXERCISE for amputation patients

bridging exercise (regular/modified)

what ENERGY EXPENDITURE PERCENTAGE does ambulation w/ prosthetic demand*

50-75% increase in energy expenditure

what are the 9 components involved in an AMPUTATION REHABILITATION TREATMENT PLAN

1. postoperative pain management

- massage + tapping

- desensitization

2. scar mobilization

3. emotional well being

4. functional mobility

5. gait training

6. exercise program

- strengthening

- stretching

- balance

7. weekly follow-up

8. patient/family education

9. contraction prevention

what are the 6 stages of AMPUTATION REHAB

1. pre-operative

2. acute hospital post-operative

3. immediate post acute

4. immediate recovery stage

5. transition to stable stage

6. stable

what is the length of the ACUTE HOSPITAL POST-OPERATIVE STAGE

usually 4-6 days

when does the IMMEDIATE POST ACUTE STAGE begin

hospital discharge

how many weeks post surgery does the IMMEDIATE POST ACUTE STAGE extend through

extends 4-8 weeks post surgery

what is the length of the IMMEDIATE RECOVERY STAGE

from healing of wound to "preparatory"/first prosthesis

what is included in the TRANSITION to STABLE STAGE

transitioning from preparatory to definitive prosthesis + moving toward higher functioning

what does the STABLE STAGE consist of

limb volume level stable + definitive fitting

what is the required time needed to progress through each amputation rehab stage

12-18 months

what occurs during stage of amputation rehab

significant residual limb volume changes

what are 5 COMPLICATIONS following amputation surgery

1. pneumonia

2. DVT

3. MI

4. skin breakdown

5. contractures

what is the goal of physical therapy regarding amputation

help to prevent complications from surgery + decreased mobility

(get patient moving)

where are 3 SITES where SKIN BREAKDOWN may occur at

1. bony prominences (patella tendon + tibial flare)

2. adherent scar tissue

3. areas of high friction