1
Q
incidence of amputations
A
1:200
* 1.9 million amputees in US - expected to double by 2050
* vascular disease 54% - includes diabetes and peripheral arterial disease
* trauma 45%
* cancer < 2%
* 97% of all amputation are LE
* 130,000-180,000 LE amputations annual
* Black Americans are 4x more likely to have amputation than white Americans
2
Q
LE amputation levels
A
transmetatarsal amputees often get further amputations further up
3
Q
amputee timeline and presentation
A
- pre-operative: what is their function, work on ROM/strength/CV if non-emergent
- acute/post-operative: weeks 1-3, subacute/SNF, wound care, incision healing, mobility
- pre-prosthetic: weeks 3-12 post-op, home health/SNF, protection and shaping residual limb, balance and pain control, home mobility
- prosthetic and gait training/OP: weeks 6-8 to 16, fitting and components
- long term f/u: 3-6 months/annually for VA
3
Q
amputee timeline and presentation
A
- pre-operative: what is their function, work on ROM/strength/CV if non-emergent
- acute/post-operative: weeks 1-3, subacute/SNF, wound care, incision healing, mobility
- pre-prosthetic: weeks 3-12 post-op, home health/SNF, protection and shaping residual limb, balance and pain control, home mobility
- prosthetic and gait training/OP: weeks 6-8 to 16, fitting and components
- long term f/u: 3-6 months/annually for VA
4
Q
systems review for amputations
A
- MSK: ROM, strength, deformity
- NM: balance, coordination, MCML
- CV: pulses, check reamining/sound limb
- integumentary: skin quality on sound limb, skin under socket
- nervous: sensation
- other: depression screening
5
Q
pain in amputees
A
- phantom limb sensation (PLS): not pain, up to 100% of patients
- phantom limb pain (PLP): UE > LE, F > M, cortical theory (filling void of missing cortical info), use gabapentin and compression and night, 60-80%
- residual limb pain (RLP): neuromas/bone spur, OA, incisions
- back pain/referral: up to 71% of amputees
neuroma: thickening of nerve, has to be burried
6
Q
psychosocial considerations with amputees
A
- decrease in QoL: F > M
- depression: 20-45% amputees, dysvascular > traumatic (heal better, not as deconditioned)
- anxiety
- self-consciousness
- grief
- support groups, peer visitation, family
- wrok/return-to-work
7
Q
subjective amputee assessment
A
- MOI
- revisions
- previous prosthetics
- navigation/ambulation
- work
- ADLs
- tobacco/ETOH use
8
Q
residual limb assessment
A
- level: right length
- shape: bony prominences, length, contour/cylinder (trans-tib), trans-femoral are conical
- skin condition: quality, wounds, color, red flags, drainage
- swelling/edema: including circumferential measurements
- incision/scar: quality, restrictions, invagination
- proprioception/joint position
- sound limb - same concerns
9
Q
ROM for amputees
A
- hip and knee ROM
- ROM required for gait (knee needs 60 degrees flexion for walking, 110 for steps)
- ROM required for functional mobility
- pelvic mobility
- lumbar mobility
- contralateral ROM
prone lying in pre-prosthetic to avoid hip flexion contracture
10
Q
strength for amputees
A
- strength requirements for gait and function mobility/transfers (4/5 for standing)
- sound limb: needs to stand alone for STS transfers
- hip abductor/adductor strength
- lever arm/length
- UE strength if using AD
11
Q
sensation for amputees
A
- light touch
- sharp - monofilament testing
- protective - wear shoes in home
- sound limb
12
Q
gait and functional assessment in amputees
A
- functional mobility/function: AMPpro/NoPRO, PSFS, socket comfort score
- gait assessment/AD: 10m and 2m walk test, TUG, video analysis
- balance - static and dynamic: ABC, AMPpro, TUG, FR
- CV/endurance: 2 minute or 6 minute walk tests
- K level: determinant of function/potential function and componentry
13
Q
goals for amputees
A
- dependent on prognosis
- return to previous activity in 4-6 months
- short term goals: wound care
- long term goals: sound limb care, hobbies
14
Q
pre-prosthetic strengthening
A
- supine HS stretches
- prone propping
- seated quad sets, knee extension
- functional mobility: transfers, wheelchair/bathroom mobility
15
Q
pre-prosthetic functional mobility goals
A
- transfers: independence with transfers between WC, bed, chairs
- WC mobility: independent form a WC level
- bathroom: transfers from WC <> commode
- limited household ambulation: modified independent for 50 feet with LRAD
- stairs: single limb hopping or bumping using LRAD and railings
16
Q
pre-prosthetic residual limb management
A
- compression for shrinking and shaping: ACE wrapping, rigid removal dressing (cast), Shrinker sock
- incision/wound management: skin checks for dehiscence, changes, signs of infection, proper healing, dressing
- collaborate with prosthetist
17
Q
pre-prosthetic residual limb pain management
A
- pharmaceutical vs non
- phantom limb sensation/pain: mirror therapy, desensitization techniques (texture, touch, pressure), visual imagery
- residual limb pain: movement and positioning, compression, habituation and desensitzation
18
Q
post-amputation/pre-prosthetic mobility training
A
- strength training
- functional mobility
- residual limb management
19
Q
prosthetic training phase
A
- residual limb managment
- prosthesis management
- pre-gait training
- strength and balance training
- functional mobility
20
Q
clinical indications for gait training with prosthesis
A
- suffieicnt strength and independence for functional mobility
- sufficient ROM
- K3 (household) or K4 (community) predicted by Amputee Mobility Predictor
- physician clearance for progressive weight bearing - incision is completely healed, compliance with wear schedule
- well fitting socket with correct alignment
21
Q
progression of gait training activities - amputees
A
- steps in bars
- turn and pivoting: don’t pivot on prosthetic - aggravates stump skin
- resisted gait
- variable cadence
- stepping over obstacles
- lateral and retro-ambulation
- reactive stepping
22
Q
progression of support - amputees
A
- parallel bars
- front wheeled walker
- bilateral forearm walker
- bilateral forearm crutches
- unilateral forearm crutch
- cane
- no AD
23
Q
training common deviations and treatment
A
- trendelenburg, pelvic stability: lateral walking, hip strengthening
- decreased prosthetic stance time: part practice stance phase, pre-gait
- poor initiation of gait with pelvis: resisted gait
- poor weight shift: scales for visual and tactile feedback on weight acceptance, step ups
24
walking with a mechanical knee -- TFA
* strong extension of glutes/HS are needed to control knee
* lateral tilt of trunk is often substituted for correct trunk/pelvic rotation and knee flexion
* often uneven stride length and rhythm
* adaptive techniques are often used for descending stairs, ramps, hills
25
benefits of a microprocessor knee (MPK)
* stumble recovery - prevent falls
* ability to ride the knee down stairs, ramps, rough terrain
* stability on uneven surfaces
* controlled sitting and kneeling movements are possible
* less user concentration on the prosthetsis
* energy efficient gait with greater symmetry
| ability to place weight on knee as it is bending (ride resistance)
26
MPK gait training progression
* parallel bars activities - learning to trust the knee
* practice riding the knee in standing
* step length practice
* weight shift/timing to activate knee - loading the toe, smooth rhythm, equal sound for heel strike
* later: out of parallel bars, facilitate shoulder rotation, speed changes, flat treadmill
* advanced skills: stand to sit, stairs, reverse incline on treadmill, ramps
27
criteria for taking the leg home - 2-8 visits depending on progress
* don/doff prosthesis independently and correctly without cuing
* sit to stand performed independently with use of AD
* able to stand 2 minutes independently with use of AD - socket tolerance
* able to ambulate for 100 feet with least restrictive AD on surface compliant with home flooring
* negotiates a single step with the least restrictive AD independently
* able to negotiate stairs independently (if stairs at home)
28
osseointegration
* bone anchored prosthesis (BAP)
* anchoring of a surgical implant by the growth of bone around it without fibrous tissue formation at the interface
* initially dental implant
29
OI rehab vs socket rehab
* change in expectations
* myodesis (muscle to bone) vs myoplasty (muscle to muscle)
* contractures
* improved biomechanics - glute med function, closed chain, proprioceptive feedback
| short residual - good OI candidates
30
screw fit (OPRA) OI
* 2 stage surgery
* stage 1 - 4-6 months rest
* stage 2 - 3 weeks rest
* long
* FDA approved protocol
31
press fit OI
* 2 stage surgery
* stage 1 - 6 weeks rest
* stage 2 - 2 days rest
* faster
movement science II
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