PTY3051 Week 3: Physiotherapy management of amputees

Causes of amputation

1. Vascular (Diabetes / PVD)

2. Trauma

3. Malignancies

4. Infection

5. Congenital

Complications of diabetes

- Ulcers

- Peripheral neuropathy

- Cognitive impairments due to vascular compromise

- Retinopathy

- Renal disease

Levels of amputation

Toe: 43%

Partial toe: 29% Transtibial (below knee) amputation: 16%

Transfemoral (above knee) amputation: 12%

Through knee amputation (knee dysarticulation)

Symes amputation (ankle disarticulation)

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?

Appropriate transfers for amputees

- Slideboard, low pivot, or hoist transfers

- 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)

Pre-prosthetic physio management

- Strengthening (UL, core, remaining joints of amputated limb)

- Balance retraining

- General conditioning

- Contracture mx (+ education & pain control)

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

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

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

- Loading area (not through bony areas)

- May have single / multi axis prosthetic foot +/- dynamic responses

- Transfemoral amputations may have locked, mechanical (depending on hip E forces) or microprocessor knees

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)