Limb Loss

How many people in the US currently live with limb loss or limb difference?

5.6 million

On average, how many Americans experience limb loss per year?

500,000

T or F: Lower limb amputations occur much more frequently than upper limb amputations

True

What lower limb amputation is the most common?

Toe amputation

What upper limb amputation is the most common?

partial hand amputation

What age population does limb loss occur the most in?

older adults, 45-65

What are the demographics associated with limb loss?

• 4x more likely to be black people

• 1.5x more likely to be Latinx people

  • More likely to be persons with lower incomes

What are the leading causes of limb loss? (rank ordered)

Diabetes (57%), infection (43%), vascular disease (40%)

True or false: A quarter of individuals who have an amputation due to vascular disease will die within 5 years

False: The statistic is half of individuals with an amputation

T or F: Of persons with diabetes who have a lower extremity amputation, up to 55% will require amputation of the second leg within 2 to 3 years.

True

Limb loss at the shoulder is called:

Shoulder disarticulation

Elbow disarticulation

limb loss through the elbow joint

Wrist disarticulation

Limb loss through the wrist joint

Transhumeral

Limb loss through the humerus

Transradial

limb loss through the forearm (both ulna and radius)

Hip disarticulation

limb loss through the hip joint

Through knee

Limb loss through the knee… lol

Transfemoral

Above the knee amputation

Transtibial

Below the knee amputation

Pediatric limb loss

acquired condition that results in the loss of a limb, usually from injury, disease, or surgery

How many pediatric limb loss cases are lower limb?

60%

How many pediatric limb loss cases are upper limb?

40%

What gender is more prominent with limb loss in pediatrics

Boys over girls 3:2 ratio

Congenital limb deficiency

when an infant is born without part of or full limb

Residual limb

remaining limb

Socket

interface connecting and containing the residual limb

Suspension

means of holding prosthesis to user

frame

rigid outer structure supporting the socket

harness

method of securing prosthesis to the body and incorporating physical control of the components

component

fingers, hand, wrist, elbow, and/or shoulder

terminal device

distal end of prosthesis, hook, hand, activity specific device, etc

transradial prosthesis

transhumeral prosthesis

1) Suspension

2) Liner

3) Socket

4) Alignment device

5) shin

6) Foot/ankle

transtibial prosthesis

transfemoral prosthesis

What are the 6 prosthetic options?

• no prosthesis

• passive prosthesis

• body-powered prosthesis

• electrically power prosthesis

• hybrid prosthesis

  • activity specific prosthesis

Passive prosthesis

Prosthetic does not move on its own

Body-powered prosthesis

controlled by body power and includes a system of cables, harness, and integrated mechanical parts

Electrically powered prosthesis

battery powered device operated by using muscle signals

hybrid prosthesis

both electric and body-powered components, usually a body-powered elbow and myoelectric hand

activity specific prosthetic

a prosthetic designed for specific activities

initial prosthesis

first prosthesis that is intended to be temporary, designed to accommodate changes in size/shape and usually has a socket insert

Definitive prosthesis

final prosthesis for a mature residual limb. Does not have a socket insert

Important considerations involved with prosthesis

Level of limb loss, the condition of residual limb, condition of contralateral limb, condition of uninvolved limbs, stage of psychosocial adjustment

Complications after amputation

infection, delayed healing, hypersensitivity, limited range of motion, neuroma, scar adherence, poorly shaped residual limb, alienation of the residual limb

Colloborative rehabilitation

The amputation must be defined to the client with physical and psychological screens taking place. The client will need to go through grief management and be education on reconstruction and prosthetic options. It is important for all members of the healthcare team to define and communicate the plan with the client.

Assessment of needs of client

Muscle strength, range of motion, gross/fine motor skills, pain and phantom sensation, hypersensitivity of residual limb, self-concept, attitude or acceptance, coping skills, ADLs/IADLs, work history, leisure interests

Assessment tools for limb loss

manual muscle testing, dynameter and pinch gauge, goniometers, prosthetic checkout forms, formal and informal assessments of ADLs/IADLs, sensory tools, dexterity measures

Limb loss specific outcome measures

psychosocial screen, patient report, patient performance

Motor problems with limb loss

loss of motion, loss of strength, loss of coordination, loss of dexterity

sensory problems with limb loss

loss of touch and tactile sensation, loss of proprioception and kinesthesia, phantom pain, phantom limb sensation

Phantom limb sensation

perception of the presence of amputated limb, not clearly understood, most common in traumatic amputations, strongest in upper limb amputations, long-term

Phantom limb pain

Not clearly understood, the causation and management are controversial. Intense burning, cramping, or shooting pains are described and usually increase stress. Most common in traumatic amputations

Cognitive problems with limb loss

problem-solving may be difficult initially

Intrapersonal problems with limb loss

frustration, loss of self-worth, anger, and/or depression

Interpersonal problems with limb loss

avoidance of social situations, loss of self-confidence

self-care, work, and leisure problems with limb loss

loss of dominant extremity, loss of bimanual skills, need for modifications, need for assisted self-care, need to obtain other employment, unable to engage in chosen leisure routines

OT Treatment areas with limb loss

orientation to rehabilitation process, maximize ADLs, early mobilization, promote uncomplicated wound healing, proper shaping of the residual limb, desensitize sensitive tissues, introduce prosthetic options, coping with the psychological effect of loss

Four phases of rehabilitation

1) perioperative

2) pre-prosthetic

3) prosthetic training

4) advance training and lifelong care

Perioperative phase

patient education, physical interventions, pain management, functional assessment, psychological support

Patient education in perioperative phase

overuse syndromes, musculoskeletal imbalance, one-handed strategies, adaptive equipment, hand dominance retraining, prosthetic education, work simplification and energy conservation

physical interventions in perioperative phase

wound care, scar management, edema control, desensitization, ROM, strengthening, activity tolerance, increase independence, explore coping mechanisms, prosthetic options and devices

Motor interventions for limb loss

therapeutic exercises, positioning, wound care and dressing, limb shaping, don/doff prosthesis, prosthetic operation, bimanual training, posture

sensory interventions for limb loss

pain management, compensation, desensitization

wound care and scar management

protect wounds and areas of skin coverage, edema control, compression dressings or garments, massage (distal to proximal)

Range of motion in limb loss

To proximal uninvolved joints, then to residual joint around level of amputation. Monitor and correct poorly executed substitutions, orthotic devices may be used

Pain management with limb loss

medications, modalities, graded motor imagery, alternative treatments, compression wraps and silicon insert, TENS

Desensitization for pain management

gentle tapping, massage, skin/scar mobilization, lubrication

T or F: The OT should avoid emphasizing pain with a client who experiences phantom limb pain

True

What are medical interventions for phantom limb pain?

analgesics, nerve blocks, neurectomies

What are rehabilitation methods for phantom limn pain?

mirror therapy, thermal modalities, limb percussion, ultrasound, acupuncture, psychotherapy, hypnotherapy, and relaxation techniques

Functional assessment with limb loss

assess home tasks and environment, work duties, community mobility and integration, recreational interests

What psychological symptoms might a client experience from limb loss?

PTSD, anxiety, depression, grief, fear, substance abuse, and diminished quality of life

Intrapersonal interventions for limb loss

adjust to disability, learning new ways of task completion

Interpersonal interventions for limb loss

social engagement, support group attendence

Pre-prosthetic phase

wound closure, scar control, ongoing education, ongoing physical interventions, continued psychological support, myoelectric site testing and training, prosthetic options

Shaping residual upper limb

Shaping residual lower limb

Prosthetic training

comprehensive and accelerated fitting process, prosthetic education, basic skills, ADLs

Prescribing the prosthesis

look residual limb factors, and ask client for preference on cosmetics and function. Know the client’s occupational needs and their attitude. Their financial situation also needs to be considered

When should an upper limb prosthetic be fitted?

Within one month of limb loss

Ideal pediatric timeline for congenital limb absence

• 6 months → evaluation and passive device

• 18 months → electrically powered options

• 3 years → activity specific or body powered

Prosthetic education

proper terminology and operation of prosthetic. Client should know the control strategy, device limitations, and precautions. Appropriate care of device should be considered

Basic skills and ADLs with prosthetic

donning/doffing, wear schedule, control training, repetitive drills, functional training

Advanced training phase

IADL engagement, leisure skills, social engagement, return to work, routine follow up every 6 months, continuing education, lifelong care

Discharge readiness with limb loss

The client will have normal muscle strength and proficiency in care of residual limb. The client will have knowledge of prosthetic function and will independently don/doff device. The client can operate the prosthetic and use it safely. The client will have improved self-care skills and home management. Participation in work and leisure.