8: Phases of Rehab Flashcards
What are the three phases of rehabilitation?
- Pre-prosthetic phase
- Prosthetic training phases
- LTC
What are 6 key suggestions for all phases of amputation rehab?
- Pt education
- Measure pain intensity and interference with activity
- Document pain with standardized tools
- Offer multi-modal pain management
- Assess behavioral health and psychosocial functioning
- Offer peer support interventions
When is the pre-prosthetic phase?
Between surgery and prosthetic fitting
What factors influence rehab potential?
Level of amputation, prior level of functioning, motivation, comorbidities, support, cognitive, physical conditioning, smoking, compliance
How does the presence of comorbidities effect pt prognosis?
Increase mortality and negatively affect recovery
How does pre-op ambulatory status effect pt prognosis?
Non-ambulatory and homebound status is associated with inability to use a prosthesis post-op
How does age effect pt prognosis?
> 60 at the time of surgery is associated with decrease prosthetic use, increased mortality, and decreased ability to ambulate and be independent
How does the level of amputation effect pt prognosis?
Bilateral or AKA are less likely to ambulate, use prosthesis, and be independent
Describe the general rehab goals 1-2 days post-op
ROM, bed mobility, transfers, sound limb exercises, post-op dressings
Describe the general rehab goals 3-14 days post-op
Pre-prosthetic ambulation with crutches, post-op dressings
Describe the general rehab goals 2-3 weeks post-op
Staples removed, shrinker or wrap, dynamic resistive exercises, ROM and ambulation
Describe the general rehab goals 4-6 weeks post-op
Shrinker and monitor healing, prevention of complications, casting for prosthetic socket if incision healed
How long does it typically take for the incision to heal?
6 weeks
During the pre-prosthetic phases, intervention should include what two types of exercise?
Open and closed chain
What functional mobility is included in the pre-prosthetic phase of rehab?
Bed mobility, sit to stand, transfers, ambulation without prosthesis
During the pre-prosthetic phase, why is progressive resistance added?
To improve gait, mobility, strength, CV fitness, ADL performance in order to maximize function
What type of dressing is preferred when limb protection is a priority?
Rigid dressing
What should be assessed prior to setting goals and why?
Cognitive status to assess the pt’s ability and suitability for appropriate prosthetic tech
What treatment setting is recommended for the pre-prosthetic phase?
Acute inpatient
When should mobility training be initiated?
As soon as possible
What interventions are included in pre-prosthetic training?
Skin inspection, residual limb monitoring, ROM, sensation, strengthening, functional mobility, cardiopulmonary, psychosocial, preparation for prosthesis
How often doe pt’s initially have PT?
5-7x per week
What are the 10 short term goals for the first 3-5 days of acute care if a pt was independent prior to surgery?
- Independent bed mobility
- Independent transfers to wheelchair
- Independent ambulation > 100 ft with AT
- Independent or assisted stairs
- ROM WFL and strength >3/5
- Good balance in sitting and standing
- Perform initial independent HEP
- Good understanding of residual limb management
- Independent wrapping techniques
- Safety awareness
What does the acute care length of stay depend on?
Payer source, ambulation level, comorbidities, age, social support, injury characteristics
Pt’s with dysvascular amputation are likely to be discharged to where?
Nursing homes and inpatient rehab
Likelihood to discharge to nursing facility is increased with what?
Age, higher level amputation, medicare with dysvascular amputees
What type of patients are less likely to be discharged to skilled nursing facility?
Men and married patients
Where are many pt’s discharged to to progress toward PT goals and initiate prosthetic fitting?
Inpatient acute, subacute, or skilled nursing facilities
When will a pt be discharged directly home?
If they meet their short terms goals and they have an environment that is wheelchair and disability friendly to allow for better functional outcomes
How long is a typical long-term goal for a pt following an amputation?
4-6 months
What is a long term goal for a pt following an amputation?
The predicted optimal level of improvement for this pt population is to return to their previous life roles and lifestyles using a prosthetic and/or AD as appropriate
What factors will modify the pt’s prognosis and setting long term goals?
Presence of comorbidities, post-op complications, barriers to returning to previous living environment, barriers to using prosthetic
What are the dependent factors of the timing of prosthetic fitting and training?
Age, type of amputation (traumatic vs dysvascular)
When should the fitting for the first prosthesis be?
As soon as possible after wound healing
How should the choice of the prosthetic device be individualized to the patient?
Based on their functional capacity and goals with the intent to allow the highest possible level of function
Describe the ideal prosthesis in terms of energy expenditure
Prosthesis should restore function with a minimal amount of energy expenditure
How does oxygen consumption change following a transtibial amputation?
Oxygen consumption increases by 33%
How does oxygen consumption change following a transfemoral amputation?
Oxygen consumption increases by 50%
Why does the level of amputation have a direct effect of successful prosthetic rehabilitation in older patients?
Due to the increasing cardiopulmonary demands with more proximal or bilateral amputations
What equipment is preferred to initial prosthetic training?
Parallel bars
What are “stubbies”?
Short prosthetic limbs without a knee joint that are used in early prosthetic training
What are five reasons for using “stubbies” for prosthetic training?
- COM is lover to the ground
- Easier to maintain balance
- Reduce fall risk
- Requires less energy expenditure
- Improve strength
How long does the pre-prosthetic phase of rehab last?
Approximately 6 weeks
What are the main goals for pre-prosthetic rehab?
Protecting the limb, preventing contracture, developing single limb mobility skills, preparing the patient for the prosthetic phase of rehab
What is an IPOP?
Immediate post-op prosthesis to allow for immediate weight bering using a temporary device
When can the pt begin to use a shrinker?
Once the sutures are removed
When will a permanent prosthesis be manufactured?
During the prosthetic phase once modifications are made for function and comfort and the limb volume has stabilized
How often should a pt receive a new prosthesis according to medicare?
Every 5 years
What are the 5 key goals and interventions for the prosthetic training phase?
- Donning and doffing
- Hygiene
- Strengthening
- Balance and coordination
- Gait
What are the three recommendations for long term care following an amputation?
- No long term opioid therapy for chronic pain
- Return to care team 1x per year
- Continue education
Which limb is likely to develop osteoporosis following LE amputation?
The residual limb
What is the cause of osteoporosis development following amputation?
Insufficient loading
What secondary effects can the development of osteoporosis cause?
Residual limb pain and increased risk of fracture
What limb is osteoarthritis likely to be found in following amputation?
Intact limb
Why is osteoarthritis likely to develop?
Overloading of the sound limb
What is heterotrophic ossification?
Formation of extraskeletal bone in muscle and other soft tissue
What type of amputations is heterotrophic ossification more likely to develop in?
Traumatic
