Physical Therapy Management of the Patient with LE Amputation

negative mold

casted by a certified prosthetist to replicate the remaining limb; this impression of the body part will later be used to build positive mold that will serve as the guide for the prosthetic device

Job outlook for orthotists and prosthetists projected to grow ___% by 2028, much faster than other occupations.

20%

How many new amputees per year?

185,000

___% of all amputations occur due to disease.

74%

____% of all amputations occur due to injury.

23%

What percentage of amputations are below the knee?

54%

What percentage of amputations are above the knee?

37%

What percentage of amputations involve the arm?

7%

What percentage of amputations occur due to birth defects?

8%

What is the number one reason for an amputation?

peripheral vascular disease

What percentage of amputations are caused by peripheral vascular disease?

51%

What is the second-most reason for amputations?

trauma

What percentage of amputations are due to trauma?

41%

What is the third-most cause of amputations?

birth defects/congenital disease

1 in ___ people have diabetes.

10

More than 1 in ___ adults have prediabetes.

3

Risk of death for adults with diabetes is ___% higher than those without diabetes.

60%

The number of amputations caused by diabetes increased by ___% from 1988 to 2009.

24%

Diabetics represent ___% of total healthcare costs, but they represent only ___% of the total population.

19%, 4.2%

This age group of persons living with limb loss has a frequency of 70,000.

a. <18 years

b. 18-44 years

c. 45-64 years

d. 65-74 years

e. 75+ years

a

This age group of persons living with limb loss has a frequency of 293,000.

a. <18 years

b. 18-44 years

c. 45-64 years

d. 65-74 years

e. 75+ years

b

This age group of persons living with limb loss has a frequency of 305,000.

a. <18 years

b. 18-44 years

c. 45-64 years

d. 65-74 years

e. 75+ years

c

This age group of persons living with limb loss has a frequency of 395,000.

a. <18 years

b. 18-44 years

c. 45-64 years

d. 65-74 years

e. 75+ years

d

This age group of persons living with limb loss has a frequency of 223,000.

a. <18 years

b. 18-44 years

c. 45-64 years

d. 65-74 years

e. 75+ years

e

There are more MALES/FEMALES living with limb loss.

males

There are more WHITE/AFRICAN Americans living with limb loss.

white

What is the leading cause of death in older adults?

falls

partial

levels of amputation nomenclature; only for hand and foot

trans

levels of amputation nomenclature; through the long bone

disarticulation

levels of amputation nomenclature; through the joint itself

What are the four things that surgeons base their amputation level selection on?

tissue viability (wound healing), potential for function, prosthetic issues, cosmesis

partial foot

levels of LE amputations; toe, transmetatarsal, Lisfranc, Chopart

ankle disarticulation

levels of LE amputations; first described by Syme in 1843; only tibia and fibula left, amputation of foot at ankle, malleoli removed, calcaneal fat pad retained

Chopart

disarticulation at midtarsal joint leaving calcaneus and talus

Lisfranc

between tarsals and metatarsals

transtibial (BKA)

levels of LE amputations; known as below the knee; retain knee joint, tibia and fibula transected

knee disarticulation

levels of LE amputations; through knee joint, femur in tact

transfemoral (AKA)

levels of LE amputations; also known as above the knee; retain hip joint, femur transected

hip disarticulation

levels of LE amputations; through hip joint, pelvis in tact

transpelvic/hemipelvectomy

levels of LE amputations; resection of lower 1/2 of pelvis; ex: land mine incident

translumbar/hemicorporectomy

levels of LE amputations; amputation of both LE's, pelvis and below L4-L5 level

myofascial

muscle stabilization; muscle to fascia, minimal stabilization

myoplasty

muscle stabilization; muscle to muscle; ex: transfemoral pulls hamstrings and quadriceps

myodesis

muscle stabilization; muscle to bone; good stabilization

tenodesis

muscle stabilization; muscle to tendon OR tendon to tendon OR tendon to bone; distal attachment of severed tendon and best method of stabilizing muscle; ex: usually only done with disarticulation

skin flap

soft tissue covering end of the bone where the tissue came from

anterior flap

surgical process; posterior incision

posterior flap

surgical process; anterior incision

fish mouth (equal length)

surgical process; incision distal end

closure

the primary intension of surgery

bone bridging (Ertl Procedure)

popularized by surgeon ERTL; osteomyoplastic amputation surgery using a bone graft that bridges tibia and fibula to create bony bridge; in theory, it accomplishes better weight bearing surface, prevents scissoring of tibia and fibula, and closes medullary canal

A modification of the ERTL procedure uses the TIBIA/FIBULA as a bridge.

fibula

In a pre-amputation home program, it is important to maximize LE ROM, specifically in ____ and ____ extension.

hip, knee

For a transfemoral patient, it is important to strengthen what two muscles?

gluteus maximus, gluteus medius

For a transtibial patient, it is important to strengthen what three muscles?

quadriceps, hamstrings, gluteus maximus

What other muscle group outside of the LE is important to strengthen for both transfemoral and transtibial patients?

abdominals

What is the most important exercise for patients with LE amputation?

bridging

Ambulation with a prosthetic will demand ___-___% increase in energy expenditure.

50-75%

stages; acute hospital post-operative care for __-__ days.

4-6

stages; immediate post acute begins with hospital discharge and extends __-__ weeks

4-8

immediate recovery

stages; starts from healing of wound to "preparatory" or first prosthesis

transition to stable

stages; transitioning from preparatory to definitive prosthesis and moving toward higher functioning

stable

stages; limb volume level stable and definitive fitting

The time needed to progress through the stages of rehabilitation after an amputation is usually about __-__ months.

12-18

List five complications from surgery that PT can help prevent?

pneumonia, DVT, MI, skin breakdown, contractures

treatment plan; massage and tapping (duration, times per day)

2-5 minutes, 3-4

treatment plan; desensitization (duration, times per day)

2-5 minutes, 1-2

treatment plan; scar mobilization (duration, times per day)

1-2 minutes, 1

emotional support

post-op and pre-prosthetic interventions; recognize each person is unique in adaptation to adjustment; may need referral to a social worker, psychologist, peer visit with another person with amputation; support group

soft

post-op dressings; least compression; frequent reapplication; wrapping skill necessary; easy access to wound; inexpensive and lightweight; readily available; example = ACE wrap, shrinkers

How often do ACE wraps have to be reapplied?

4 hours

semi-rigid

post-op dressings; better control of edema than soft dressing; can loosen; hot, humid, bulky, heavy; wound access limited; skill to apply; example = Unna's dressing, air splint

rigid

post-op dressings; most compression and best edema control; example = plaster of Paris socket but not adjustable or removable IPOP but has many disadvantages

What is the goal of patient positioning?

prevent hip and knee flexion contractures

recommendation for lying flat in bed to prevent contractures? (duration, times per day)

3 minutes, 1

initial balance

pre-gait training program; goal is to maintain midline trunk orientation, use mirror, Balance Master or Wii Fit

weight shifting

pre-gait training program; goal = hips and shoulders should move symmetrically

stool stepping

advanced stance control activities; emphasize control of hip and knee of prosthetic side and smooth weight shift to prosthesis

proprioception training

teaches where the foot is in space; start walking rails, proceed to holding onto a chair, graduate to free standing

pre-gait

initial balance training, weight shifting exercises, sound limb stepping, prosthetic limb stepping are considered PRE/POST-GAIT training.

T/F: Patient can progress outside of parallel bars if they are able to shift weight A/P, R/L without deviations.

true

T/F: Patient can progress outside of parallel bars if they are able to step backward with sound limb and shift weight adequately onto prosthesis without deviations.

false

T/F: Patient can progress outside of parallel bars if they are able to step forward with prosthetic limb using trunk deviations rather than rotation of hip flexors.

false

T/F: Patient can progress outside of parallel bars if they are able to walk length of parallel bars with flat hands on bars without deviations.

true

sound/prosthetic limb stepping

pre-gait training program; therapist observes forward pelvic rotation, knee flexion, ankle movement, stride length and foot placement

resisted gait training

gait training; PT observes pelvic rotation, hip/knee flexion, BOS, lateral trunk leaning, stance time, stride length,

resisted trunk rotation

fine tuning gait training; PT observes gait biomechanics, trunk rotation is occurring, avoid lateral trunk lean

unassisted ambulation

gait training; PT observes trunk rotation, lateral trunk lean, pelvic rotation, pelvis dip, hip/knee flexion, prosthetic stance time, BOS, stride length, speed of sound limb

immediate post-operative prosthesis (IPOP)

eliminates contracture potential, reduces time to fitting of preparatory prosthesis, restricted use on vascular or diabetic patient due to skin abrasion and inability to monitor the residual limb; example of a rigid dressing

ampushield RRD

rigid removable dressing; can accomplish goals = protection, compression, contracture prevention, reduce pain

Up to ___% of new amputees fall prior to receiving prosthesis resulting in prolonged wound healing, revision surgeries, higher level amputations with reduced mobility potential.

75%

surgical

type of pain; pain from the surgery itself treat as with any post-op pain; local, diminishes over time, residual limb massage

exostosis

overgrowth of cartilaginous tissue on a bone; seen at the cut end of a bone; may occur at area of retracted muscle; causes painful areas unable to tolerate any contact; may require removal for successful prosthetic use

neuroma

type of pain; neuropathic pain originating from severed peripheral nerves; focal point/palpable mass where pain can be reproduced especially if close to bone

phantom

type of pain; pain in a limb that has been amputated; may originate from cerebellum; incidence varies from 10-85% (persistent 10-15%); higher incidence in those with significant pre-operative pain; dull, aching, stabbing, knife-like, sharp, squeezing, shooting, burning, cramping, pre-op

phantom limb

non-painful sensations of limb that is no longer there; feeling in the part of the body that is missing; 90% of patients report this; due to cortical sensory illusions

What is the ideal shape of a residual limb?

cylindrical

K0

K Scale of Functional levels; no potential for use of prosthesis

K1

K Scale of Functional levels; potential for use of prosthesis for transfers or limited ambulation at fixed speed on level surfaces

K2

K Scale of Functional levels; potential to ambulate on low level environmental barriers: limited community ambulator