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Special Topics

Amputations II

QuestionAnswer
Team Effort: Patient -Include in all rehab plans -Disbelief...Anger...Bitterness...Denial...Acceptance= stages of grief -Varying attitudes towards prosthetics
Team Effort: Physician -Mostly vascular surgeons with varying knowledge of prosthetic rehab -Orthopedics and psychiatrists tend to be more knowledgeable of rehab
Team Effort: Nursing -Most of education and wound care
Team Effort: Therapists -PT makes prosthetic recommendations -Co-treatments common with OT and PT
Team Effort: Dietician -Consult to aid in healing
Team Effort: Prosthetist -Fabricates/ modifies prosthetic -Most of education and training now
Team Effort: Social worker -Counseling/ vocational rehab
Team Effort: Psychologist -Serve emotional needs
Phantom limb -Sensation that the limb is still there -Occurs initially after surgery -Tingling, burning, itching, pressure, or numbness- -Distal part is most frequently “felt” -Responsive to bandaging or rigid dressings -Usually improves with time
Phantom pain (different than sensation) -Occurs in 80% of amputees -Described as cramping, squeezing, shooting or burning pain -May be localized or diffuse -Can be continuous or intermittent -Can be triggered by external stimuli -Usually improves with time
Phantom pain cont... -RL should be examined for neuromas and trigger points -Wearing a prosthesis may help; Why? -Non-narcotic analgesics have been of limited value
Phantom limb and pain treatment -Good evidence- Anti-convulsents, opioids, anti-depressants, anti-epileptic, manual therapies -Insufficient evidence- TENS, sympathectomies, spinal cord stimulation -Others- no systematic reviews in Cochrane Library
Phantom limb and pain treatment cont... -Manual therapy- progress from: -Soft to rough textures -Light to heavier pressures
Rehab phases -Pre-prosthetic or Post-surgical phase: -Promote function without prosthetic -Prepare for prosthetic as needed -Prosthetic phase
Pre-prosthetic or post-surgical phase -Skin care -Bandaging -Positioning -Exercise -Bed mobility -Basic transfer training -Gait training
Skin care -Education of skin care: -Pay attention to skin folds; keep dry -RL washed daily with mild soap; early handling promotes acceptance; desensitization -Man ther/ther ex to avoid excess scar tissue -No creams, etc should be put on without MD approval
Bandaging -Family may help initially -Encourage joint extension -Smooth/wrinkle free -Avoid unevenness with: -Adductor rolls -Dog ears -Tourniquet Effect -Greater pressure distally -Shrinkers
Shrinkers -Not used until incision is healed -Rolled NOT pulled
Positioning for BKA -Avoid prolonged: hip IR and knee flexion
Positioning for AKA -Avoid prolonged: hip flexion and abduction
Positioning in general -Limit prolonged sitting -Assume prone position daily
Exercise for amputations -ROM: -Manual techniques -STM/JM -PROM- with/without PNF motions -Self stretching -Strengthening: -Focus on UE/LE anti-gravity muscle groups -Focus on all groups of RL
Transfer training -Protect RL- don’t push or slide on bed/chair -Sliding board/pivot transfers for AKA/BKA -Forward/backward transfer for AKA, especially with bilateral RLs
Wheelchair Mobility -Required for bilateral amputees -Special cushion -Amputee chairs: -Offset wheels for balance or anti-tip device -No leg rests -RL rest for BKA -Place a sliding board under your residual limb while sitting in W/C
Pre-prosthetic gait -Standing balance -Ambulation: parallel bars -Assistive device
Prosthesis -PT must determine potential first -Temporary ones are often used initially
Prosthetic phase -Skin & Prosthetic care -Don/Doff prosthesis -Exercise -Transfers -Ambulation with prosthesis
Skin care -Only put dry RL into socket -Examine RL for signs of chafing, blisters, or bruising- use mirror
Prosthetic care -Wash socket regularly -Tighten and clean all parts -Oil leather parts
Donning/ doffing of prosthesis -Usually done in lying/ sitting -Exact sequence depends on type
Exercises -Greater focus on standing and functional activities -UE and trunk activities as well due to greater dependence on these areas
Basic transfer -(sit to stand) with and without prosthesis
Advanced tansfer -(floor/car/tub/etc) utilizing various positions with and without prosthesis
Advanced activities and gait training -Verbal feedback -Physical contact/ tapping -Mirror/video give visual feedback -Parallel bars: press down w/ UEs, don't pull to mimic gait -Emphasize knee control in opened & closed chain activity -Control swing momentum & controlling foot placement
AKAs -Using hip flexion to bend the knee -Using hip extension to stabilize the knee -Keeping good leg forward increases knee stabilization in prosthetic leg
Advanced activities and gait training -2 feet to one -2 hand support to none -Frontal plane then to sagittal plane -Predictable to unpredicatable enviroments
Advanced activities and gait training cont... -Balance and weight shifting- away and then toward prosthetic -Reaching outside of BOS: -Over sound then prosthetic side -Two to one hand -Vary heights -How to fall -Side stepping -Braiding -Gait cycle components to full gait cycle
Advanced activities and gait training cont... -Sound leg step forward/backward -Sound leg step through -Prosthetic leg step forward/backward -Prosthetic leg step through -Walking: level to uneven surfaces, inclined surfaces, stepped surfaces -Ramps and stairs: up w/ good, down w/ bad
Advanced activities and gait training cont... -Walking around furniture -Picking things up off floor -Lifting techniques & carrying techniques -Busy hallway -Obstacle course for endurance & control -Exercise videos i.e. www.veho.com -Running, sports
Extras -Swimming- fixed ankle PF -Driving -Artificial intelligence
Created by: alovedaytn