Early amputation rehab and medical management Dr. del toro part 2

The Three E's

Patient education

Patient evaluation

Managing expectations - "give hope yet be realistic"

Referring surgeons

Vascular

Orthopedics

Trauma

Transplant

History and physical exam

Co-morbidities: CAD, DM, Stroke, OA/RA, PVD

Neurologic or MSK deficits: hemiparesis, arthritis, contractures

Mood disorder - Depression

Cognitive impairment = major obstacle to gait training

Functional evaluation

Mobility and safety: assistive device used pre-op, recent falls, barriers

Self-cares

Vocational status

Recreational activities

Patient education

"when will I get my artificial leg?"

"What will it look like?"

"Will my insurance pay for the prosthetic leg?"

Determining level of amputation

Assist surgeon in determining optimal level

Severe foot trauma - midfoot vs transtibial

PVD with no vascular reconstruction options - TTA vs TFA

Length vs soft tissue coverage

Premorbid functional status and future prosthetic prognosis

Relative contraindications for prosthetics

Significant cognitive impairment - ability to do new learning

severe cardiac dysfunction

severe hip or knee contractures

Psychological issues

Preoperative counseling = outline amputee and prosthetic rehab plan

Various emotional reaction = sadness, shock, fear, anxiety, helpless, determination, relief, inspiration

Goals of Post-Op residual limb care

Control edema

promote wound healing = optimize BS control, treat anemia, maximize nutrition, reduce swelling, antibiotics

Protect residual limb

Pain control

Shaping residual limb: cylindrical

Preparation for early ambulation

Post op dressing

Immediate post-surgical rigid dressing

Elastic (ACE) wrap

Rigid removable dressing

Soft removable cast - custom made (by PT or OT), combines posterior splint with RRD

Elastic stump shrinker

Residual limb pain

Painful sensation in residual limb (incisional pain, surgical pain or stump pain)

Qualities: sharp, stabbing, knife-like, dull, aching, throbbing, pressure

May include proximal RLP = muscle spasms or cramps

Phantom limb sensation

any pain-free awareness of the amputated limb

Qualities: touch, wetness, tingling, cold, pressure, warmth, itching

Treat with patient education, reassurance, not medications

Phantom limb pain

Painful sensation (as defined by pt) in any part of the amputated limb

Qualities: burning, cramping, stabbing, tingling, sharp, shooting, throbbing

Treat: patient education (it interferes with daily activities, impedes prosthetic usage/gait training) Physical, pharmacologic, interventional procedures, psychological, surgical

Pain control for residual limb

Peripheral nerve blocks, opioids, control edema, prophylactic treatment

Desensitization techniques

Taper opioids and transition to weaker analgesics

Causes of phantom limb pain

Central

Spinal cord

peripheral

Physical PLP modality

usually provides temporary relief and likely mediated by gate control theory

- desensitization

- TENS

- Acupuncture

- Vibration

- Ultrasound

Pharmacological intervention PLP

Neuromodulators

Gabapentin - Ca channel blocker

Pregabalin - Neuropathic pain agent

Tramadol - pain reliever

Amitriptyline - anti-ACh

Baclofen - muscle relaxant

Psychological intervention PLP

CBT, biofeedback, relaxation therapy, hypnosis, mirror, mental imagery, peer advisors, support groups

Rehab timeline to prosthetic

P/O days to week in hospital

Acute rehab - IPR or SAR (2-6 weeks)

Follow up surgery clinic incision check (2-8 weeks, ortho or vascular)

Follow up with physiatrist and referred to prosthetist (1-3 months)

Fabrication = 2 months

Out patient PT gait training (2-6 months)

Targeted muscle reinnervation

nerves are connected to motor branch within a muscle

Regenerative peripheral nerve interface

Free nerve ending is wrapped in a muscle and sutured up - fibers grow into the muscle

Osseointegration

Implantation is drilled into the bone itself allowing for easier donning/doffing