OP Week 8: Post-AMP Interventions

Acute focus areas post-amputation

-pain management

-care of the residual limb

-positioning to prevent surgical site compromise

-pressure wounds and contractures

-initial mobility training.

Main concern for vascular amputations

Delayed wound healing due to vascular compromise.

Effect of post-op pain meds on PT

-May affect ability to participate in PT

-Lethargic pts will have less ability to maintain safety during mobility training

PT role before mobility training

Evaluate cognitive, autonomic, sensory, and motor function.

PT role post-op amputation

-Timing of pain meds - prep for PT

-Pt/C caregiver Ed: PLP/PLS, safety with mobility as Pts may need assistance to keep safety

-Interventions to manage pain: desensitization, guided imagery/relaxation techniques,

Interventions for phantom limb pain (PLP)

Desensitization, guided imagery, relaxation, biofeedback, and virtual reality.

manual therapy post-op may be needed to address back pain d/t

immobility and poor sitting postures

Residual and Intact Limb Care: Shaping and Edema Management

dressings, shrinkers

incision care

inspection (infection), caution with dressing changes and shearing forces, mobility

Why protect the intact limb?

to avoid detrimental affects on joints from larger amount of WB and forces on it to avoid any injury

Transfer Training > Bed to chair, w.c. to toilet

-Slide board - line/lead/tube management (most amputees will have a catheter 1-3 days post AMP complicating transfers)

-Pivot transfer

Transfer STS > Bed to Chair > AD (crutches, RW)

-Stand Pivot transfer

-Posture and Postural Control standing

Balance on intact limb

-Limb loss shifts COM over the intact limb

-Important to educate the pt on Fall Risk and how to maintain safety

Self-care task training usually falls under

OTs

Most common time for acute falls

During self-transfer between wheelchair and bed or toilet.

Acute Care Setting post-op

-Pain Management (RLP, PLP)

-Residual and Intact Limb Care

-Positioning

-Bed Mobility Training

-Transfer training

-Pt/Caregiver Ed

-D/C Planning

D/C Planning

identifying environmental barriers, continuum of care (home, OP, IP Rehab, SNF)

Residual Limb Shaping begins with

compression dressings

Ace wrap

-Inexpensive

-Good for rural area pt

-Caregivers must be taught on how to perform this

-Figure 8

Ace wrap application rule

-Applied distal to proximal in a figure-8 pattern.

-Smooth, wrinkle-free, angular turns (avoid choking), distal pressure is more than proximal pressure, proximal joint extension (

Why avoid pins in Ace wrapping?

To prevent wounds or infection; use tape instead.

Ace wrap for TT pt

-ensure knee is in extension

-applied in sitting

Ace wrap for TF pt

-ensure knee and hip are in extension

-applied in SL or supine

Ace wrap limitations

-Minimal effect on post-op edema

-No protection for bumps, shearing, fall

-Loosen with mobility > dec effectiveness > shape

-Require frequent dressing change

Ace wrap wear limit

Change every 4-6 hours; maximum 12 hours continuous wear.

Ace wrap that is Too tight

dec blood flow > , reduced incision healing, increased risk of skin breakdown

Ace wrapping independent considerations

-Impaired Vision

-Arthritis, Neuropathy > hands, wrists

-Limited trunk mobility

-Compromised postural control

What is an adductor roll?

Redundant soft tissue in the proximal thigh from transfemoral amputation.

Elasticized stockinet, sock

-Various levels of pressure > pt tolerance

-Decent amount of dexterity is required to apply them

-Inexpensive, not as durable as elastic shrinkers

Shrinkers Considerations

-Need a Sufficiently healed incision

-Difficult with limited UE strength, dexterity

-Ongoing edema > 6mo - 1yr post op when not wearing prosthesis

-TF > easier to apply and remain in place vs Ace wrap, caution adductor roll (redundant tissue)

Jobst garment

half/full pant - more consistent suspension/compression (obese pt)

Compressogrip layer gradient rule

Lower layer is longer, outer layer is shorter to push fluid proximal.

Benefits of Removable Rigid Dressings (RRD)

-Reduce Edema - lessen pain

-Decreases healing time

-Better contouring

-Limb protection

-Stay in place vs soft dressings

-Ease of don/doff which can improve pt indep.

-Prevent knee contracture in (TT) amputees

-Improve Readiness for prosthetic fitting

Positioning is used to prevent

*Contractures

*Pressure wounds

Positioning goal for Transtibial (TT) amputees

Prevent hip and knee flexion contractures.

Pillow placement for sitting/supine TT

Under the distal residual limb; avoid under thigh/knee.

TF positioning in Bed, w.c., chair

avoid excess hip flexion angle and abduction and ER

Why are Transfemoral (TF) pts prone to abduction and ER contractures?

Loss of the adductor counterforce.

TT positioning in supine

pillow /towel under distal residual limb, minimize knee flexion

TF supine positioning

minimal pillow /towel under residual limb for comfort.

Amputee prone positioning

-TT & TF - pillow/towel under thigh > hip ext

-TT - add weight to distal residual limb - knee ext

Tummy time daily goal

30 minutes daily to improve hip extension and glute strength.

Postural Control

Ability to keep the body stable and properly oriented using sensory input, motor responses, and cognitive processing > essential for balance, movement, and functional independence.

Which amputee type has more difficulty with sitting balance

Bilat LE amputation

Amputees may have difficulty with

sitting balance, transfers, single limb ambulation, w.c. locomotion

Center of Mass (COM) shift after limb loss

Shifts slightly upward and toward the intact limb.

Bed mobility and sitting postural control in amputees

-Caution shearing

-Log roll should be done toward intact limb

-Bridge on intact limb

-Sitting reactive postural control interventions

Perturbations

Log roll should be done toward

intact limb

Wheelchair tipping hazard

Reaching backward shifts the COM beyond the wheel axis because the COM shifts post. and laterally toward intact limb

Log roll direction post-amputation

Roll toward the intact limb side.

Supine Core/Postural Muscle Strengthening

-Lat. Thoracic breathing - neutral spine

-Bridging

sitting Core/Postural Muscle Strengthening

-Lat. Thor. Breathing with core corseting on exhale

-Weight shift

-Reaching

Quadruped Core/Postural Muscle Strengthening

-Weight shift > graded inc pressure on residual limb

-Unilat UE/LE lift off

-Bird dog

Tall kneeling Core/Postural Muscle Strengthening

Weight shift

Reaching

Throwing/catching ball

Which limb should lead initially with slide board and transfer training

residual limb leading initially

Gait and Locomotion for amputees

Short distances > acute care setting

Long distances > post acute care

W.C. > locomotion

Crutches > bilat axillary, Lofstrand

Single limb ambulation with an AD requires more Energy than walking with a

prosthesis

Three primary concerns for pre-prosthetic exercise

ROM is priority, modified closed-chain exercises, and gait-specific prescription.

Rigid compression

Works well but require constant follow up

Shrinker types

-Compressy grip is the most common

-True form: thicker and provides more compression

-Juzo: lightweight and soft

Donning the shrinker:

roll it back—>pull up thigh

Roll all the way up to prevent a tissue damn

If no ring to close the shrinker: turn it and fold up again

Lower layer is longer and the outer layer is shorter to push fluid back towards the heart using compression gradient

Incision line management

Questions

How well is it going to heal

Is it mobile

Does it have good tensile strength

solid scar should from around

21 day mark

Scar management

-Move thumbs together over the outside of the scar

-Once after 3 weeks we can mobilize the the scar more by creating shear forces across

invagination

wound has scarred to tissue underneath

Should mobilize scars for at least

6 weeks post op

Care of contralateral limb

Pts heel may get stasis ulcers from increased WB; Ensure the heel is floated on pillows to protect it

Learning how to roll to the sound side

Hip flexion with the residual limb then back into extension

Builds mobility: focus should be on extension

Should be done every hour

Glute motor activation exercise

-Press residual limb down into a towel roll to activate glutes.

-uses reciprocal inhibition to inhibit the hip flexors to prevent contracture

Adductor motor activation exercise

-Squeeze a towel roll between the legs to inhibit abductors.

-Reciprocally inhibits the abduction moment and strengthens the adductors

Basic level exercises

Dosage

10-15 reps for 5s holds

Progression of glute activation

lift the C/L limb and hold it in the air while holding the hips up with the residual limb

Adductor progressions

-Basic: Towel on a stool placed in between the legs with the residual limb on top of the stool: place the residual limb in mid-stance and have them push down onto the stool while lifting the pelvis and bodyweight up with a 5s hold

-Advanced progression: add more body weight by lifting the bottom leg up as well

Hip flexor exercise in prone

Pt in prone with the foam roller underneath the residual limb: pt will press down into the towel roll to lift the body weight up and then on release ensure to stretch the hip flexors

Hip abductor exercise for amputees

Put the residual limb into hip extension with a towel roll underneath the residual limb: Press down into the towel to raise the hips off the mat

Core control exercise for amputees

SL bridging

Single leg bridge progression

Bridge on intact side, rotate residual limb anteriorly, then posteriorly.

TT active ROM in sidelying

Flex hip and knee, then extend hip and knee.

TT exercise for both glutes and quads

With a Soft towel above incision line: tighten quads and glutes to feel activation

TT adductors exercise

squeeze the towel+turn knees in and pull towel into mat to work the adductors, IRs and extensors

Closest position to erect standing by placing hips into full extension

Prone

TT exercise in prone for both glutes and paraspinals

Squeeze towel roll and then lift trying to lift the roll off the mat

BL amputation supine exercise to Activate the glutes and relax the hip flexors

-press down into roller and lift hips into the air

-Progression: lift the opposite leg into the air and try to lift both hips into the air

BL amputee exercise for adductors

Squeeze the towel roll between the legs, and press it down into the mat: activates the erector spine, and glutes

BL amputee abductor exercise

Place top residual limb onto a stool in front of the pt

Place a towel roll under the bottom residual limb in extension

Pt will push down and create power to lift the body up

TT ace wrapping factors

Want distal compression, no wrinkles, and no skin showing

Ensure to go above patella to ensure the wrap stays on

Ace wrap for transtibial

Lateral patellar border→medial and into calf crease→lateral distal limb →upper medial crease→medial distal limb→figure 8 method

areas to avoid with TF ace wrapping

the groin and buttock areas for toileting purposes

TF ACE wrapping steps

1st wrap: Start in inguinal area and wrap around lateral distal limb→up medial distal limb→wrap laterally around the posterior pelvis and back to the front→medial distal end back towards pelvis→tape first wrap on posterior pelvis

2nd wrap: Start in inguinal area and wrap around lateral distal limb→up medial distal limb and catch adductor tissue→wrap laterally around the posterior pelvis and back to the front→ and wrap laterally then secure medially

massage duration for suture hypersensitivity

Done for 5 mins, 3-4x daily

Tapping duration for suture hypersensitivity

Tap for 1-2 minutes, 3-4 times daily.

cotton ball and eventually rougher materials used to rub on the limb duration for suture hypersensitivity

2-3 mins 2x daily

End bearing exercises

increase amount of weight the residual limb can tolerate at the end of the residual limb

Timeline for end-bearing exercises

At least 4 weeks post-op for ERTL; 6 weeks for regular.

Towel end bearing exercise

Fold towel and pull up bottom of the limb for 5s then releases slowly

25 reps for 5s holds then switch angles

End-bearing scale progression goal

Tolerate 40% of body weight on the residual limb.

Pressure relief in wheelchair

Push through armrests or lean forward to relieve ischial tuberosities.

Slideboard transfer safety

Lift up and over the board; do not slide.

Sliding can cause

shear forces against soft tissue and compromise blood supply in that area

Slide board steps

position the residual limb closest to the boards→WC brakes→remove armrest and footplate closest to the board→lean towards intact side to slide board under→ensure pt doesnt put hands under the board