Comprehensive Evaluation

subjective information required for a prosthesis prescription

age, amputation-specific, prosthesis-specific (components they already have), PMH, motivation to ambulate with prosthesis

amputation-specific information to gather during a subjective

date of initial amputation, cause, medical management prior to, complications, planned/unplanned, coping, PTSD

when to replace a prosthesis

pt weight no longer within safety specs, no longer working, socket fit issue, worn down, change in pt activity level

signs on the prosthesis that it is time for a new one

fatigue, rust, alignment issues, fit issues

how is the socket comfort score scored

opposite of the pain rating scale (0 is not good)

function of TAPES-R

has pt rate themselves in terms of adjustment to the prosthesis, activity restrictions, and satisfaction to gauge coping

trends in prosthesis satisfaction

generally satisfied, but comfort is the leading contributor to dissatisfaction

relationship between prosthesis use and residual/phantom limb pain

no effect

medications that are important to ask about

diuretics and pain meds

how many people with amputations report using an AD

80%

environmental barriers of amputees

a lot more barriers than other general disabled pts

consequences of lack of PT following amputation

increase falls risk and decrease community integration

why is screening important in general

early detection, treatment, management

potential screens for amputees

CV, cognition, pulse, thomas test, mental health, pain, vision, fall risk

mental health screening tools

PROMIS-29 anxiety subscale, PHQ-9

cutoff score of PHQ-9 for MDD

10

consequences of greater pain extent in amputees

more activity restrictions, worse adjustment, worse prosthesis satisfaction

why is vision important to screen

important especially if the pt has DM because they need to be able to inspect their wounds

relationship between lower limb amputation and falls

2x more at risk, 40% sustain injury, 50% report a fear of falling

where do most falls occur

in the home

what activity poses the greatest risk to falling

walking (then transfers)

non-modifiable risk factors of falls

transfemoral level

modifiable risk factors of falls

residual limb issues, mechanical back/joint pain

best patient reported outcome measures to assess fall risk

houghton scale, ABC, PLUS-M

what does the houghton scale look at

prosthesis wear time and use, perceived stability

what does the PLUS-M look at

mobility of prosthetic users

performance-based outcome measures to assess falls risk

four square step test, functional reach

relationship between time since amputation and fall risk

the more time since the amputation the less concern about falling

relationship between extent of pain and fall risk

multisite pain increases the fall risk more than intensity

cluster of fall risk measures to use post-acute amputation

ABC, PLUS-M, four square step test, functional reach on the prosthetic side, multisite pain

interventions to reduce fall risk

walking distance/speed, curbs, hills, busy environments, dynamic balance, trunk stability

why are adults with limb loss at a balance disadvantage

1/5 have vestibular problem, and decreased somatosensation from amputation

why do we want to train balance while fatigued

fatigue decreases balance which increase fall risk

prosthetic knee to decrease fall risk

microprocessor knee because of the stumble recovery

rules for falling safely

don’t lock up, protect the head, aim for the meat, roll with it, don’t FOOSH

benefits of using outcome measures

motivates pts, guides clinical decisions, facilitates communication, justifies care to payers

barriers to using outcome measures

clinicians have difficulty with selection, administration, and interpretation

why are non-specific outcome measures important in pts with limb loss

you need to compare them to the general population (unmatched measures) to see if they can be a community ambulator

floor effect

measure does not register a further decrease in score (test is too hard)

ceiling effect

measure does not register a further increase (test is too easy)

tests with a ceiling effect

berg, TUG

tests that do not have a floor or ceiling effect

functional reach, 2MWT

goals of a limb loss evaluation

determine K level, determine optimal prosthetic componentry, justify need for therapy, return to higher level activities

critical joint mobility to assess in a transfemoral amputee

hip extension (anterior glide)

critical joint mobility to assess in a transtibial amputee

knee extension (anterior and ER tibiofemoral glide, superior patellofemoral)

important strength measures to get at evaluation

trunk, UE screening, overall strong/weak of LEs

why is MMT and HHD not really good to use in limb loss population

lever arm affected, residual limb pain, different weight of limb

what strength test can be used to differentiate K3 and K4 levels

5xSTS

additional tests that can be used to test strength in pts with limb loss

5xSTS, stair climbing

what does the stair climbing test assess

ascending stairs assesses power because the prosthetic device does not aid in this motion (therefore if struggling may need a power knee)

why should we give PROMs before outcome measures

so performance on outcome measures does not impact the pt reported measures

self-report measures that are best to evaluate pt progress

houghton scale, PLUS-M, ABC

drawback of houghton scale

ceiling effect

houghton scale cutoff score between K2 and K3 levels (community ambulators)

9/12

benefits of PLUS-M and ABC

no floor or ceiling effect

benefits of performance based measures

assesses pt capacity, improves pt assessment and confidence, helps fine-tune interventions

best non-specific performance-based measures to use for pts with limb loss

four square step, L test, 10WMT, 6MWT

what interventions should be done if pt has a slow four square step test

balance training

why is the L test better than the TUG

it eliminates the ceiling effect and you can do it with dual tasking

why do pts with amputations not walk at 1.2 m/s required for community ambulation

we undertrain gait speed during PT

modifiable factors that affect gait speed

cardiorespiratory fitness, thigh muscle strength, plantarflexors, hip flexion/extension ROM, prosthetic componentry

population-specific performance based measures

amputee mobility predictor (AMP), comprehensive high-level activity mobility predictor (CHAMP)

types of amputee mobility predictor tests

prosthesis/no prosthesis, unilateral/bilateral

items in the champ

single-limb stance 30 sec, edgren side step test 10 sec, t-test, illinois agility test

what is the CHAMP normally used for

service members with no matched results because they must be fit for duty

what to do for a quick eval of a pt with an amputation

ABC, four square step test, PLUS-M, L test

what to do in an extended eval of a pt with an amputation

ABC, four square step test, PLUS-M, L test, 10MWT, 6MWT