Amputations

Question 1

Amputations can result from several causes including…

Answer 1

-Trauma
-Vascular disease
-Tumors
-Infection
-Congenital limb deficiencies that present as missing or partially developed limbs

Question 2

Incidence of Amputations

Answer 2

-2 million people living with limb loss in US
-Anually, more than 185,000 people in US have amputations
-Ratio of arm: leg = 1:3
-57% of UE amputations are transracial
-Trauma is cause of 75% UE
-Most often occurs in males ages 15-45 in work related accidents
Also result from gunshot wounds/electrical burns
-Disease is cause of most LE
-Diabetes and peripheral vascular disease most common for LE in older adults >60

Question 3

When amputation is necessary, the surgeons goal is to….

Answer 3

Preserve as much limb length as possible and retain healthy skin, soft tissue, blood supply, sensation, muscles, bones, and joints
-A residual limb that is pain free and functional is the final surgical goal

Question 4

Forequarter Amputation

Answer 4

-Describes amputation of the arm, scapula, and clavicle

Question 5

Transhumeral Amputation

Answer 5

Amputation through the humerus

Question 6

Transradial Amputation

Answer 6

Amputation through the radius and ulna

Question 7

The higher the UE amputation…

Answer 7

The more difficult I will be to use a prosthesis because fewer joints and muscles are available to control the prosthesis
-Also, the weight of the prosthesis is greater, and more complex systems are needed for active control

Question 8

Amputations at Joints

Answer 8

-Shoulder disarticulation
-Elbow disarticulation
-Wrist disarticulation

Question 9

Members of the professional team for amputations

Answer 9

-Physician
-Prosthetist
-OT
-PT
-Client
-Social worker, Psychologist, and vocational counselor should be consulted as needed

Question 10

Preprosthetic Therapy Program

Answer 10

Occurs from the post surgical period until the patient receives a temporary (test) or permanent prosthesis
-Preparatory time for both physical and emotional healing

Question 11

Postoperative Care

Answer 11

Required immediately after surgery, addresses wound care, maintenance of skin integrity, joint mobility, reduction of edema, prevention of scarring, and control of pain

Question 12

Phantom Limb Sensation

Answer 12

-Common among individuals with limb loss and OT should make them aware of this possibility
-Most common in individuals with traumatic amputations, (also aphasics, persons with congenital limb absence)
-This occurs since the neural system exists within the brain even when body input is cut off by amputation
-Felt strongest with UE, specifically hand and fingers
-Often remains and the patient has to accept it
-May be annoying or support learning myoelectric control for externally powered prostheses

Question 13

“Telescoping” (phantom limb sensation)

Answer 13

With time, the patient may feel that the distal portions of the phantom limb have moved closer to the site of the amputation

Question 14

Phantom Limb Pain

Answer 14

-Even less clearly understood and its cause and management are controversial
-Pain can be felt as extremely intense burning or cramping sensations or shooting pain in the residual limb
-Most common with traumatic amputations
-At least 90% of individuals with limb loss experience
-CNS changes and PNS damage are thought to cause whereas psychological factors can trigger
-Pain increases with stress

Question 15

Treatment for Phantom Limb Pain

Answer 15

-Analgesics and surgery such as nerve blocks and neurectomies
-In rehab, limb percussion, ultrasound, TENS
-Acupuncture, psychotherapy, hypnotherapy, and relaxation techniques have also been used
-Mirror therapy

Question 16

Mirror Therapy for Phantom Limb Pain

Answer 16

-Widely accepted as standard therapy for limb amputation
-Involves mirror placed at midline against the patients chest or groin depending on the level of amputation being addressed
-Residual limb placed behind the mirror and intact limb placed in front of the mirror so that the patient observes the reflection of the intact limb
-Mirror should be close enough to the body to obstruct the view of the residual limb
-Patient focuses on intact limb in mirror while putting it in position that residual limb feels it is in
-Attempts to move both limbs through capable motions
-Should be conducted in quiet low distraction environment

Question 17

How often should mirror therapy be performed?

Answer 17

-Initially 8-12 minutes due to fatigue
-Should work up to 15-20 min sessions daily over 4 week period as part of home program
-Encouraged to perform daily as needed and when disruptive to daily activity and sleep
-Daily use of a visual analogue scale and tracking of number and duration of phantom pain episodes are recommended to determine if mirror therapy is beneficial

Question 18

Self Maintenance

Answer 18

Family and Home

Question 19

Self-Enhancement

Answer 19

Leisure and community activity engagement

Question 20

Self-Advancement

Answer 20

Work or student

Question 20

Self-Advancement

Answer 20

Work or student

Question 21

What should the OT do to support negative psychological feelings after amputation?

Answer 21

They should encourage open discussion, develop a relationship based on trust and respect, and work with other treatment team members to facilitate the patients psychological adjustment and reintegration into previous roles
-Give info and explain therapy process
-Introduce to individual who has also had an amputation
-Provide reference material

Question 22

Preprosthetic Program Guidlines

Answer 22

Provide emotional support, ensure max limb shrinkage and shaping, desnsitizing residual limb, maintain ROM and strength, facilitate independence in ADL, and change of dominance

Question 23

How often should limb be cleaned during preprosthetic program?

Answer 23

Daily with mild soap and water (after clearance)
-Provide basic wound care (cleaning/debridement)
-Use creams to massage the scar line to decrease scar adhesions

Question 24

What is the goal for limb shrinkage and shaping

Answer 24

Should be tapered at the distal end to allow for optimal prosthetic fit
-Elastic bandage
-Elastic Shrinker
-Early Post-Op Prosthesis

Question 25

Elastic Bandage

Answer 25

Taught to wrap the limb in a figure 8 pattern and is expected to do so independently unless physically or cognitively unable
-Most pressure should be applied at the end of the limb
-Must conform firmly to the limb and be wrapped in a distal to proximal direction
-Reapplied immediately if loosened
-Advised to remove 2-3x/d to check for redness or excessive pressure
-Clean bandage applied every 2 days

Question 26

Elastic Shrinker

Answer 26

aka sock
-If losers, a smaller size will be needed
-Should be worn when not wearing prosthesis and while sleeping to maintain limb shaping and size

Question 27

Early Post-op Prosthesis

Answer 27

Strongly recommended for bilateral UE amputations to reduce dependency for self-care activities
-May facilitate acceptance and use of permanent prosthesis

Question 27

Early Post-op Prosthesis

Answer 27

Strongly recommended for bilateral UE amputations to reduce dependency for self-care activities
-May facilitate acceptance and use of permanent prosthesis

Question 28

Prosthesis wear schedule

Answer 28

Early phase it is important to educate patient and family on wear time and schedule
-Wear time is a gradual process after initial fitting
-Imp to limit to 15-30 min and remove to check for skin integrity
-Gradually, wear time increases as tolerance and skin integrity improves

Question 29

Desensitize the Residual Limb

Answer 29

-Residual limb wrapping or wearing a shrinker
-Percussion (tapping, rubbing and vibration)
-Massafe to prevent or release adhesions and soften scar tissue
-If not contraindicated, may bear weigh on end of limb

Question 30

Body-powered Prosthesis

Answer 30

Uses motion from the body, proximal to amputation to operate
-Tension is produced from the contralateral limb and the scapulohumeral motions are transferred to a Td through a cable

Question 31

Externally Powered Prosthesis

Answer 31

-Uses power to operate

Question 32

Hybrid Prosthesis