Week 3 (Physiotherapy Management of Amputees)

Causes of amputation

• Vascular (Diabetes / PVD)

  • diabetic foot complications

  • diabetic co-morbidities (ulcers, peripheral neuropathy, cognitive impairment, retinopathy, renal disease)

• Trauma

• Malignancies

• Infection

• Congenital

transtibial amputation (TTA)

below the knee (BKA)

transfemoral amputation (TFA)

above the knee (AKA)

through knee amputation (TKA)

at level of knee joint

symes/ankle disarticulation

at level of ankle joint

disarticulation

amputation at the level of a joint

partial foot and toe amputation

partial - can lead to further amputation

mortality associated with amputation

• increased age

• renal disease

• proximal amputations

• diabetes

• vascular disease

Pathway for amputees

- Preoperative counselling

- Major amputation & acute stay

- Pre-prosthetic training: IPR / community)

- Prosthetic prescription at MDT prosthetic clinic

- Prosthetic gait training (IPR / community)

- Lifelong follow up

Acute postoperative physio management for amputees

- Education

- Chest physio if indicated

- Bed mobility

- Teaching appropriate transfers

- Wheelchair prescription (w/ OT)

- D/c planning

- Prevent contractures

- Oedema management

- Social worker referral for counselling?

pre-prosthetic management of amputees

• strengthening (of remaining joints, hip extension important for gait, UL, core)

• balance

• general conditioning

• continuous stretching/contracture management

Appropriate transfers for amputees

- Slideboard (starting point if sitting balance and bed mobility adequate)

- low pivot (not fully standing)

- hoist transfers (if unable to slide/low pivot, be aware of sling requirements for AKAs)

- Hopping not advisable due to risk of falls, ↑ oedema, ↓ balance and risk of overuse / vascular damage to remaining limb

Wheelchair prescription considerations

- Stump rest (elevation: oedema & knee F contracture mx)

- Anti-tippers

- Wheel positions (back = harder to self-propel)

- Removable arm rests (allow for transfers)

- Pressure cushion (sores)

contracture management for TTAs

at risk of knee and hip flexion contracture

contracture management for TFAs

at risk of hip flexion and abduction contracture

why is contracture management important in amputees

• enable good prosthetic fit and easier gait re-education

• reduce joint pain

• reduce risk of skin breakdown

• pt will be unable to walk with prosthesis if contracture is too great

contracture management strategies

• education immediately post op re positioning

• no pillows under knees

• pain control

• stretching - prone lying for TFAs

oedema management (for fitting and comfort of prosthesis)

• elevation of stump

• acute: rigid removal dressing for TTAs

• inpatient rehab/at home: shrinkers (compressive socks worn over stump)

Stump care

- Desensitisation (to tolerate touch & pressure)

- Self-massage

- Skin care (marks, rashes & dryness)

- Hygiene (skin, socks & liners)

- Formation of habits

Predictors of prosthetic potential

Assessed by the Amputee Mobility Predictor (AMPPro)

- Motivation

- Cognition

- Level of amputation (higher = harder)

- Stump condition (shape, length)

- Premorbid function

- Comorbidities (diabetes, renal failure, etc.)

- Standing balance on sound limb

Basic prosthesis design (TTAs)

- Suspension option: sleeve, valve, pin lock, cuff or supracondylar suspension

- Liner between stump and socket: gel, silicone or foam petite liner

- Loading area (often through patella tendon, do not want pressure over prominent bony areas)

prosthetic feet

• Non-articulated (SACH foot); less common

• Single axis (get some dorsiflexion and plantarflexion)

• Multi axis (gives inversion/eversion as well)

• Dynamic response (carbon, act as spring, energy given back to move more freely, for community ambulators)

prosthetic prescription for TFAs

• lesser risk of skin breakdown than BKAs

• variable socket designs, most predominantly load through ischial tuberosity

• suspension options include

  • silicon liner with pin lock, lanyard or seal

  • harness/belt

prosthetic prescription for knee joints

• Vary widely with respect to function and price

• Types

  • Locked knee joint (no knee flexion)

  • Mechanical knee joint (single axis or polycentric)

    • Polycentric knees enable and safer and smoother gait pattern than a single axis knee

    • Patient needs good knee control; timing and swing (high falls risk)

  • Microprocessor knees (Expensive, becoming more accessible with NDIS)

    • Can detect what you're doing

Gait retraining for transfemoral prosthesis post prosthesis prescription

- ↑ time period of rehab due to practice needed

- ↑ falls risks

- ↑ hip power needed (especially E in stance, especially with mechanical knees)

- Hip F contracture mx

Education post prosthesis prescription

- Management of stump volume (can fluctuate initially) e.g. with socks

- Management of comorbidities (e.g. renal failure, as can influence stump volume)

- Graded use of prosthesis (from standing, to weight shifts, to walking)

- Skin pressure checks

- Prosthetic reviews (every few days / weekly initially, then monthly afterwards)