1.2 - acute post-op management and pre-prosthetic training

pre-amputation

_______________ phase of amputation/prosthesis:

patients who are preparing for an amputation

pre-amputation

_______________ phase of amputation/prosthesis:

patients in the hospital outpatient clinic (ex. amputation, wound, diabetic)

pre-amputation

_______________ phase of amputation/prosthesis:

objectives - explain sequence of upcoming events, discuss expectations of provider and patient, pt ed, answer any questions

acute post-operative

_______________ phase of amputation/prosthesis:

patients in the immediate recovery from the amputation surgery

acute post-operative

_______________ phase of amputation/prosthesis:

patients in the acute care hospital

acute post-operative

_______________ phase of amputation/prosthesis:

objectives - prevent post-op medical complications, manage residual limb health, prevent loss of motion and physical deconditioning, promote basic mobility and self-care, promote sound limb care, assist with limb loss adjustment

• prevent post-op medical complications

• manage residual limb health (promote wound healing)

• prevent contractures

what are the main objectives during the acute postoperative phase

pre-prosthetic training

_______________ phase of amputation/prosthesis:

patients whose residual limb is NOT ready to be fit with a prosthetic limb

pre-prosthetic training

_______________ phase of amputation/prosthesis:

patients who are in IPR, SNF, outpatient rehab, or home

pre-prosthetic training

_______________ phase of amputation/prosthesis:

objectives - manage residual limb health, address any ROM deficits, increase UE and LE strength, progress mobility and self-care, reinforce sound limb care, assist with limb loss adjustment

• manage residual limb health (add scar management and limb shaping)

• prevent contractures

• LE strength

what are the main objectives during the pre-prosthetic training phase

prosthetic training

_______________ phase of amputation/prosthesis:

patients whose limb has healed enough to tolerate using a prosthesis

prosthetic training

_______________ phase of amputation/prosthesis:

patients in IPR, SNF, outpatient rehab, home, prosthetist clinic

prosthetic training

_______________ phase of amputation/prosthesis:

objectives - same as pre-prosthetic objectives, incorporate prosthesis use into activities, address community reintegration

lifetime care

_______________ phase of amputation/prosthesis:

any post-acute person with amputation

lifetime care

_______________ phase of amputation/prosthesis:

patients in an outpatient clinic or prosthetist clinic

lifetime care

_______________ phase of amputation/prosthesis:

objectives - maintain function and quality of life, promptly address any medical or prosthetic concerns

rigid

a _____________ dressing is a cylindrical plaster or fiberglass cast applied to residual limb immediately after surgery (in operating room)

5-7 days (or sooner: severe pain/pressure, significant loosening, or fever and oder present)

rigid dressing should be changed after _________

rigid

the advantages of ____________ dressing:

• Best for limiting the formation of post-op edema (and pain)

• Limits contracture formation

• Protects residual limb (including incision)

• Assists with desensitization, adjustment to socket weight.

• Can allow early ambulation with the attachment of a pylon and foot (described with IPOP)

• May allow earlier fitting of the definitive prosthesis

rigid

the disadvantages of _____________ dressing:

• Requires careful application by a professional

• NOT removable

  • Does NOT allow daily inspection

F (i made that up… the rigid dressing does NOT allow for daily inspection period)

T/F: the rigid dressing is made to check for pressure wounds daily

removable rigid

_______________ dressing is plaster cast or prefabricated shell worn over a soft dressing and held in place by a suspension belt or cuff

limb protectors

removable rigid dressing is also called ______________

soft

a removable rigid dressing uses ____________ dressings to fill volume as residual limb shrinks

removable rigid

______________ dressing is recommended as the first treatment of choice for a transtibial amputation

removable rigid

advantages of _____________ dressing:

• Limits the formation of post-op edema

• Provides residual limb protection

• Can help prevent contracture formation

• Promotes using socks regulate fit

• Assists with desensitization, adjustment to socket weight

• Allows daily inspection and dressing

removable rigid

disadvantages of _____________ dressing:

• Require careful application by a skilled professional

• Almost exclusively used with transtibial amputation

• Requires an external suspension system

immediate post-operative (IPOP)

the __________________ prosthesis has a rigid or removable rigid dressings designed to allow attachment of temporary components

immediate post-operative (IPOP)

the intent of the ________________ prosthesis is to facilitate ambulating with both limbs as soon as possible

T (leads to functional gains and earlier discharge)

T/F: you can mobilize with the immediate post-operative prothesis (IPOP) within the first 3 days

immediate post-operative (IPOP)

advantages of the _______________ prosthesis:

• Reduced extrinsic risks (i.e., falls etc.)

• Facilitates healing

• Promotes early fitting and training

• Reduced inpatient length of stay and cost

immediate post-operative (IPOP)

disadvantages of the _______________ prosthesis:

• hard to control WB

F (but we aren’t necessarily worried about it right now because we aren’t focused on gait)

T/F: the immediate post-operative prosthesis allows from knee flexion

soft

____________ dressing is the use of elasticized materials to provide an evenly distributed pressure gradient

soft

______________ dressing is the most used post-op dressing method

F (suture line needs to be healed)

T/F: the advantage of using a shrinker dressing is the ability to use it before the suture line heals

shrinker

____________ is used for shaping the residual limb and is the most commonly used soft dressing

soft

disadvantages of _____________ dressing:

• Poor control of edema

• Provides little protection

• Requires careful application (ace-wrap) and some manual strength/dexterity

• Can form a tourniquet

• Requires frequent reapplication throughout day because of loosening and shifting (shrinkers < ace-wrap)

soft

advantages of _____________ dressing:

• Inexpensive and can be laundered

• Lightweight and readily available

• Easily removable for limb inspection

• A variety of pressure gradients are available

• Can help with limb shaping

vascularity; sensation

the examination of acute post-op care for a prosthesis includes checking both limbs _____________ and the contralateral limb ____________

ischial tuberosity or greater trochanter → end of bone

when measuring bone length for a transfemoral amputation, measure from ______________ to _____________

medial tibial plateau → end of bone of redundant tissue

when measuring bone length for a transtibial amputation, measure from ______________ to _____________

cylindrical; better pressure distribution, conical is too pointy

what’s better, a cylindrical or conical shape of the residual limb? WHY?

8-10cm

when examining the residual limb, measure the soft tissue circumference by every __________

phantom limb

________________ sensation is perceived as originating from the amputated limb

F (can occur immediately after the amputation)

T/F: phantom limb sensation occurs 24hrs after surgery

F

T/F: phantom limb sensation can be painful

phantom pain

_______________ is a painful sensation perceived as originating from the amputated limb

sensation

which is more common:

phantom sensation or pain

1-2 years

phantom pain usually decreases within __________

T

T/F: residual limb pain is NOT phantom

• nerve

• bone

• vascular

• wound

intrinsic factors that lead to residual limb pain (4)

• cast pressure

• socket fit

extrinsic factors that lead to residual limb pain (2)

• reduce edema

  • **also for a candidate NOT using a prosthesis

• control pain

  • **also for a candidate NOT using a prosthesis

• wound (incision) healing

  • **also for a candidate NOT using a prosthesis

• protect incision during functional activity

  • **also for a candidate NOT using a prosthesis

• prevent contracture

  • **also for a candidate NOT using a prosthesis

• facilitate preparation for prosthetic placement by shaping and desensitizing limb

what are the 6 post-op residual limb management goals?

Out of the 6 goals, which are also goals for a candidate is not going to use a prosthesis?

0-5 days

what is the timeline for the inflammatory healing phase?

5-21 days

what is the timeline for the fibroblastic (proliferative) healing phase?

begins at 21 days

when does the remodeling healing phase begin?

T (report any red or darker blood or thickened discolored drainage with odor)

T/F: clear drainage is normal for the first couple of days post amputation

tension

the ____________ theory of wound healing is that external stress can effect the strength of a wound and improve collagen organization

2 weeks; 3 weeks; 6 weeks

scar tissue mobility should begin above/below the scar for the first ________

after about __________ and once the wound is closed and there is no steri-strips you can mobilize directly over the scare after

continue scar tissue mobilization for about ___________ or until the epithelial line (lump under the skin) is gone

T (include in pt ed)

T/F: a patient can perform their own scar tissue mobilization

T (whenever they aren’t using their prosthesis)

T/F: a shrinker is often used for the rest of a person’s life

because it will put tension on the skin and the incision

why should a patient not pull the shrinker off like a sock???

24hrs a day for the rest of life

how often should a shrinker be worn

23 hours/day (removed for hygiene only)

how often should an ace wrap be worn

distal; proximal

when using ace wrap, the (proximal or distal) pressure should exceed the (proximal or distal)

4 hours

ace wrapping should be reapplied at least every ___________

F (use tape)

T/F: ace wrapping should be secured via metal clips

residual limb

________________ sensation is where the skin becomes hypersensitive to touch and pressure inhibiting dressing and prosthetic use

• light touch or tapping

• exposure to different textures

• massage

• wear prosthesis/compression bandages

what are 4 early and continual methods of desensitizing the stump

conservative and complementary

examples of a _______________ treatment approach for phantom and residual limb pain:

• Compression, use of prosthesis, desensitization techniques

• Ultrasound (heat), ice

• Massage, Vibration Therapy

• Electric Stimulation (TENS)

• Acupuncture

• Mirror Therapy

  • Note: May help prevent/lessen phantom pain (Purushothaman 2023 J Anesthesia)

• Biofeedback to reduce muscle tension

• Psychological Interventions (motor imagery and relaxation)

• Stretching, strengthening, low-impact aerobic training

medical and invasive

examples of a _______________ treatment approach for phantom and residual limb pain:

• Medication and Injections (muscle relaxers and pain meds)

• Neurostimulation (spinal cord stim, transcranial stim, deep brain)

• Surgery- Remove neuroma or structure impinging a nerve

contractures

range of motion and strength prevents _____________

gait

there is a focus on certain muscle groups within general strengthening, muscles are selected based on their impact on ___________

• hip flexion

• knee flexion

what range of motion should you focus on to prevent contracture with a transtibial

• hip flexion

• hip abduction

• hip lateral rotation

what range of motion should you focus on to prevent contracture with a transfemoral

• positioning in bed and wheelchair

• stretching

• prone lying (as tolerated)

• serial casting/bracing (in severe cases)

what are 4 contracture prevention techniques

• spinal stabilization

• core strength and control

• hip strength and control

what are the 3 total body focuses for muscle strength training with an amputee

before the amputation (ideally/if possible)

when should strength training begin for an amputee

isometrics

what kind of strength training should you start with an amputee

6-10; 5-10; 6-10

the isometric strength training recommendations are _______ sec holds followed by ________ rest for ______ reps

• muscles

  • glutes

  • hamstrings

• gait phases

  • initial contact

  • loading response

  • terminal swing

with hip extension…

• what muscles are activated?

• what phases of gait include it?

an above knee amputation doesn’t have quads to prevent knee buckling

why is hip extension so important for an above knee amputation

• muscles

  • glute med

  • glute minimus

• gait phases

  • midstance

  • terminal stance

with hip abduction…

• what muscles are activated?

• what phases of gait include it?

• muscles

  • iliopsoas

  • rectus femoris

• gait phases

  • loading response

  • midstance

  • initial/mid/terminal swing

with hip flexion…

• what muscles are activated?

• what phases of gait include it?

• muscles

  • hip ADD

• gait phases

  • initial contact

  • mid/terminal swing

with hip adduction…

• what muscles are activated?

• what phases of gait include it?

• muscles

  • lumbar extensors

  • glute max

  • hip ADD mm (if using roll)

• gait phases

  • initial contact

  • loading response

  • mid/terminal swing

with trunk extension…

• what muscles are activated?

• what phases of gait include it?