OP Week 7

What is the goal of the rehab process after limb loss?

To restore independent functioning with or without a prosthesis.

What is included in pre-operative education for amputees?

Surgical interventions, rehab process, prosthetic options, and potential outcomes.

What factors are assessed pre-operatively for amputees?

Ambulatory status and cardiovascular condition.

What increases the risk for phantom limb pain?

Pre-operative pain.

How long is the acute post-operative phase generally?

4-7 days.

What may prolong the acute post-operative phase?

Chronic illness, multiple comorbidities, multiple traumatic injuries, delayed wound healing, and older adults.

What is important for managing pain in the residual limb?

Education on pain management and care for incision/wounds.

What can lead to delayed wound healing and prosthetic fitting?

Vascular insufficiency.

What are the risks associated with amputations due to traumatic injury?

Higher risks for infection and greater physiological and psychological challenges.

What methods can help prevent edema in the residual limb?

Rigid dressings, shrinkers, and Ace wraps.

What is the importance of maintaining near normal range of motion (ROM) in proximal joints?

It is paramount for optimal prosthetic use.

Pts in bed or sitting have a higher risk for

hip and knee flexion contractures

Weak UE or weak intact limb may not be able to use

crutches or a RW

acute post-op phase

-Educating on Pain management of the Residual limb, Phantom limb pain/sensation

-Residual Limb Care

-Residual Limb Shaping and Edema management

-ROM

-Functional Mobility

-Grieving loss of limb

What is the typical duration of the pre-prosthetic phase?

Usually 3-6 weeks.

IPOP pts may get a prosthesis in

3 weeks

Dysvascular conditions may take

8-12 weeks d/t delayed wound healing

Pre-prosthetic phase

Prepares limb for the prosthesis - shaping, desensitization, decrease edema, ROM, strengthening.

Important item in pre-prosthetic phase

Fall recovery (21% fall in acute setting, up to 58% fall in community)

prosthetic phase

treatment involves increasing tolerance and function with the prosthesis.

Prosthetic Prescription/Fabrication begins with the

Amputee Mobility Predictor Outcome measure

Amputee Mobility Predictor

- Outcome measure designed to help determine an amputee's ability to ambulate with a prosthesis

- Predictor of successful prosthetic use

- Corresponds to Medicare's functional classification system for ambulation (K - levels)

What is the role of the Amputee Mobility Predictor?

To determine the prosthetic prescription and fabrication.

What is assessed during the prosthetic fitting and training phase?

Learning to don and doff the prosthesis, care of components, and functional mobility.

What is the significance of the K level in prosthetic prescription?

It determines which type of prosthesis is indicated.

Interdisciplinary Rehab Team is most important during

acute post-op and pre-prosthetic phase where the pt has multiple needs requiring care of multiple disciplines

What are the potential risks of delayed referrals to physical therapy?

-Contractures

-CV/MSK deconditioning

-Delay prosthetic fitting & training

-Inc risk of dependency on others

-Inc risk of re-amputation

-Inc risk of institutionalization

-Inc risk of mortality

What should be included in the examination of amputees?

History, demographics, social and occupational history, functional status, pain assessment, and sensory integrity.

Exam Contents Specific to Post-AMP Population

-Pain

-Attention/cognition

-Integ

-Sensory integ

-Residual Limb Assessment

-Muscle Length tests > Contractures

-Muscle Performance (strength/endurance) and Motor Control

-Aerobic Capacity/Endurance

-Mobility, Locomotion/Balance

-Posture, Ergonomics, Body Mechanics

-Self Care, Environmental Barriers

Pain assessment > Residual limb, Phantom Limb Pain/Sensation

-Must include the level and location of pain and descriptors of pain to delineate phantom pain from phantom sensation

-What strategies to manage pain

-How does pain affect daily function

outcome measures for pain

VAS, McGill Pain Questionnaire, Brief Pain Inventory

Attention/Cognition >

Rehab planning - specific to pt's needs, Prosthetic Device use, Safety considerations

Outcome measure for Attention/Cognition

Outcome Measures: SLUMS (detect mild neurocog. disorder), MOCA (cog deficits), Mini-Cog (quick cog screen)

Integ measures

incision/wounds (PVD), integrity, mobility, color, temp

Circulation: pedal (dorsalis pedis, posterior tibial), popliteal, femoral pulses

sensory integ measures

protective sensation, superficial (light touch, sharp/dull, pressure, temp), proprioception

Residual Limb Assessment

-Length

-Volume and shape

actual limb length

residual tibia/femur (TT - medial joint line of knee, tib tubercle; TF - ischial tub., greater troch.)

total limb length

includes soft tissue

TT volume

start at medial tibial plateau or tibial tubercle to end of limb

TF volume

start at ischial tuberosity or greater trochanter to end of limb

TT contractures

knee/hip flexion

TF contractures

flex, abd, ER (usually occurs with abduction contracture)

TT muscle performance

knee flex/ext

TF muscle performance

hip movements

muscle performance in amputee is

Observed via observation until incision healing is cleared by physician, then MMT/dynamometry

Mobility, Locomotion/Balance assesment

AMP Mobility Predictor

What is the purpose of the AM-PAC 6 Clicks assessment?

To assess self-care and environmental barriers.

Amputees typically have catheters post-op which can lead to

UTIs

Minimally activity Amputees post-op are at risk for

DVT and pressure wounds

AMP MDC

3.5

AMP can be used with

unilat/bilat TT amputee and unilat TF amputee

AMPnoPro

-Amputee mobility predictor without the use of prosthesis

-Total score 0-43

-Eliminates Item 8 (Single limb Standing Balance)

AMPPRO

-Amputee mobility predictor with the use of prosthesis

-Total score 0-47

What is the significance of the Comprehensive High-Level Activity Mobility Predictor (CHAMP)?

-It correlates with the 6-Min Walk Test for service members with lower-limb loss.

-High level mobility

What does a higher score on the AMP indicate?

Better mobility.

AMP-B

For bilat TF or TT-TF (one LETT, one TF) amputee

Most important determinant of a good prosthetic candidate= Functional potential (safe use and benefit from prosthesis

Pre amputation ambulatory status

What is the K-Level indicating 'No Functional Use'?

The individual does not have the ability or potential to ambulate or transfer safely.

What does the K-Level Mobility classification determine?

Medicare Functional Classification Level scale

What are the PT implications for K0?

Non-ambulatory, severe limitations, focus on wheelchair mobility and caregiver training

What does K1 represent?

Household ambulator

What are the PT implications for K1?

Walks mainly inside home, needs stable/simple prosthesis, focus on safe transfers and short distances

What does K2 indicate?

Limited community ambulator

What are the PT implications for K2?

Short distances outdoors, may use assistive devices, prosthesis may include multi-axial components

What does K3 represent?

Community ambulator with variable cadence

What are the PT implications for K3?

Active person, independent community ambulation, eligible for advanced prosthetic components

What does K4 indicate?

Athletic/high-impact ambulator

What are the characteristics of a K4 ambulator?

Exhibits high impact, stress, or energy levels typical of active individuals or athletes

What are the implications of prosthetic use in amputees?

Prosthetic use contributes to performing basic IADLs and requires advanced components for high-demand mobility.

What factors are considered in the prognosis of amputees?

-Age

-Overall health (comorbidities), pre-AMPutation functional status, cognition

-Cause (elective/trauma) and Level of Amputation

-Contribution of prosthetic use to perform basic IADLs

-Resources - financial and instrumental (tools, services, support)

prognosis for amputees

-Trauma related has worse prognosis

-Elective amputation have better prognosis

Acute care Interventions for amputees

pain management, functional mobility training, residual limb care

outpatient amputee interventions

Preparing patient of prosthetic fitting and training

What is a residual limb?

Any remaining portion of a body part after amputation, also known as the stump.

What is phantom limb sensation?

A general feeling that an amputated or missing body part is still attached and functioning.

Cortical reorganization with amputation

When an amputation occurs we still have areas in the brain devoted to bringing in information

Overtime the brain changes those segments because they are no longer needed and devotes those resources to the surrounding areas

RESIDUAL LIMB PAIN

Pain of remaining body part from a specific anatomic structure that can be identified.

Can be somatic/surgical or hypersensitive

causes of concern in residual limb pain

-Formation of heterotrophic ossification

-Infection

-Neuroma

-Prosthetic-related pain

Neuroma

Severed neurons create a tangled, bulb-like mass of nerve endings at the end of the residual limb causing pain

RESIDUAL LIMB PAIN: MANAGEMENT

-Desensitization techniques: used to prevent hypersensitivity by touching the remaining body segments to create habituation

-Gently tap with fingers

-Massage with lotion

-Touch with fabric (soft-->rough)

-Rolling small ball in circles

-Shrinker

RESIDUAL LIMB PAIN: MEDICAL MANAGEMENT

-Injection of local anesthetic

-Surgical removal of neuroma

Targeted muscle reinnervation

Sever the neuroma and wrap the nerve ending in a muscle graft

PHANTOM LIMB SENSATIONS

Sensations the amputee feels distal to surgical incision of the residual limb

symptoms of phantom limb sensations

-"Hot, cold,itching,numbness,tingling, tickling, pressure"

-Residual limb is Feeling normal in character

-Held in a particular position

-Telescoping pain

Telescoping pain

-Feels distal segment of the missing limb without feeling the middle segment

-Overtime the middle and upper segments of the missing limb feel as if they are getting shorter or go missing until the distal segment is on the end of the residual limb

benefit of phantom limb sensation

promote proprioceptive feedback for prosthetic management

concerns for phantom limb sensations

someone may wake up and forget their phantom limb has been amputated and try to stand on the missing limb

What is phantom limb pain?

Pain that is perceived in the area of the amputated limb, often described as shooting, stabbing, or cramping.

What are the medical management options for phantom limb pain?

Pharmacological treatments like analgesics and opioids, and non-pharmacological methods like deep brain stimulation.

Phantom limb pain typically is

Episodic in nature and transient

most with phantom limb pain experience

Mild/moderate discomfort that does not interfere with usual activity

phantom limb pain typically reduces in frequency and duration in

first 6 months

PHANTOM LIMB PAIN Usually improves as

healing progresses, edema is reduced, and mobility restored

causes of phantom limb pain

-Leading theory suggests maladaptive neuroplasticity

-More common in those with vascular and infection causes for amputation

PHANTOM LIMB PAIN: MEDICAL MANAGEMENT

Pharmacological

-Usual analgesics: Acetaminophen, NSAIDs

-Opioids: Morphine, Ketamine

-Gabapentin

PHANTOM LIMB PAIN: MEDICAL MANAGEMENT

Nonpharmacological Invasive

-Deep brain stimulation

-Spinal cord or dorsal root ganglion stimulation

-Prophylactic regenerative peripheral nerve interfaces to eliminate nerve pain

PHANTOM LIMB PAIN: MEDICAL MANAGEMENT

Nonpharmacological nonInvasive

-Transcranial direct current stimulation of the motor cortex

-Transcutaneous electric nerve stimulation

-Acupuncture

-Hypnosis

-Biofeedback

-Heat and cold modalities

-Firm pressure applied to residual limb

-Massage, compression, prosthetic socket

What is mirror therapy?

A technique where a mirror is used to create a visual illusion of movement in the amputated limb to alleviate phantom pain.

goals of mirror therapy and vR

-restore neural representation of the missing limb through motor imagery

-Correct the mismatch between sensory and visual input through cortical reorganization

Graded motor imagery steps

-Step 1:Orientation to limb laterality

-Step 2:Imagine moving the limb through a series of exercises

-Step 3:Mirror therapy