Amputee Final Review Flashcards
Why is myodesis ideal?
o Greater muscle balance, function and force generation
What would a failed myodesis for a TFA look like?
See lateral positioning due to adductor magnus not being attached
TFA Post Surgical Precautions
- No active ADD strengthening exercises x 4 weeks
- No active ABD strengthening exercises x 2 weeks
- No forward flexion x 2 weeks s/p myodesis to protect distal HS attachment
- Bridging in supine is authorized
TTA Post Surgical Precautions
- No aggressive hamstring stretching in the first few weeks if myodesis is tenuous (if preserving length, but large soft tissue injury to the area)
Knee disarticulation Precautions
- SLR without weight x 2 weeks s/p surgery, no restriction thereafter
- No restrictions with ABD or ADD
What is the relationship between cardiovascular disease in amputees? How does this apply to treatment planning and rehab progression?
What is the relationship between low back pain in amputees?
- LBP is higher in these patients
- B LE Amputees: Loss of distal attachment on one or more limbs affects degree of lumbar lordosis secondary to loss of static pelvis stabilizers
What is the relationship between lumbopelvic stability (core strength) and amputee rehab?
- The more length of leg taken away, the more important core stability is
- COM will shift with amputation up and away from side of amputation
- If bilateral amputation, shifts up.
What strategies or tips would you use to teach a patient with an amputation (or their caregiver) to get from the floor to their wheelchair?
- Use gym mats to make the task easier by stacking it up
- As they are able to do it, slowly remove layers of padding.
What challenges should be considered by individuals with amputation or who use a prosthesis relative to home environment and bathroom accommodations?
- Ability to maneuver wheelchair – need lots of space; need a door that swings out.
What strategies or tips could be used to optimize energy conservation across the day for individuals with amputations, especially those engaging in therapies?
- Morning bathing can be exhausting (AM bathing may increase limb volume)
- Timing of ADLs in relation to rehabilitation time
- Effects of transportations and ADLs prior to start of rehabilitation and how that effects performance
What considerations and strategies are involved with progressing WB in amputees while preventing unwanted complications?
- Gradual increase in socket; initially 15-20 minutes
- Consider tilt table, total gym, assistive devices to limit weight bearing
- Check alignment and equal weight distribution
- Frequent Skin Checks
What types of amputations are end bearing (i.e. weight is taken through bone) vs. non end bearing?
End Weight Bearing
* Knee Disarticulation
* Ankle Disarticulation
* Hip Disarticulation
Non end weight bearing
* TTA
* TFA
What verbal cues would you say to a TFA or knee disarticulation to help stabilize knee during heel strike and mid-stance?
- “Push back into the socket”
- Activate hamstrings and glutes
- Stabilizes the knee joint in full extension
What rehab techniques can be used to promote prosthetic toe loading and knee activation?
- “Toe Load”
- Verbal and manual cues (at ASIS) for the patient to shift weight onto the prosthetic limb to drive forward the pelvis, rolling over the toe/forefoot of the prosthetic foot in terminal stance
- Microprocessor knee requires approximately 60% of patients weight when to trigger knee flexion.
If a patient is not able to successfully achieve toe load, what happens?
- Toe drag the first time
- Thereafter, patient will begin circumducting leg
What happens if your patient fails to stabilize the prosthetic knee joint in standing or early stance?
They will fall
Advanced Rehab Strength Exercises
- Step Ups
- Lunges
- Heel Stabs
Advanced Walking Exercises
- Banded ressited walking (Focuses hip extension)
- Stairmaster
Advanced Proprioception/Agility Exercises
- Side stepping to shuffling side
- Step vs hop on/off a plyobox
- Add a medicine ball while doing carioca pattern
- Reaching to the floor. Lifting a load, drag a bolster
What unique considerations/ rehab techniques are required for B amputees, especially B TFA?
- Stubbies
- Training for B TFA – early and long term tool
- Turn the feet backwards initially to help with balance
- Shorter height = easier balance
Rank the energy expenditure to for prosthetic use from highest to lowest: Symes, hip disarticulation, unilateral TTA, BTTA, and unilateral TFA
High
* Hip disarticulation
* Unilateral TFA
* B TTA
* Unilateral TFA
* Symes
Low
Articulate issues that the user (and PT) can change and issues that must be corrected at a prosthetic level with the help of a prosthetist
User Level (PT)
* Strength
* ROM
* Motor control patterns
* Gait training program
* Practice
Prosthetic Level
* Socket
* Ply in socket
* Alignment of components
* Suspension System
* Category of components (Prosthetic feet based on pt’s weight)
When are scenarios for plantarflexion and dorsiflexion for TTA?
Need more Plantarflexion
* Cue: Extended Knee
Need more Dorsiflexion
* Cue: Flexed Knee
Explain the relationship between TTA socket adduction/abduction and knee varus/valgus
ADDuction socket
* Knee varus
ABDuction socket
* Knee valgus
Understand the effect of flexing or extending a TFA socket. How can a hip flexion contraction be compensated for?
- Flexed hip: flex knee
- Flex knee: Flexing TFA socket
- Extend knee: Extending TFA socket
What clinical condition may requires increased socket flexion?
Hip Flexion Contracture
The tendency is for an amputee to take a longer step on their ____ limb and a ____ step on their sound limb. Why?
- Prosthetic
- Sound
- Due to a large step with prosthetic leaves them off balance or nervous resulting in them bringing through the sound to be shorter because they want to get off the limb faster. Longer swing on the prosthetic leg.
TT Gait Deviations
- Giving Way/Excessive Knee Flexion
- Insufficient Knee Flexion
- Short Stepping (decreased stance time/stride length)
TFA Gait Deviations
- Asymmetric (Short) Prosthetic Step
- Lateral trunk bending/lean
- Toe Drags/poor clearance
- Circumduction
- Medial, lateral whips
- General Techniques
How is prosthetic putty used to assess socket fit?
Prosthetic Putty – “My limb doesn’t feel right”
* Place putty at the bottom of the persons limb
* Have them place the limb in the socket as they normally would
* Take it out and access it:
– Round: Not going far enough
– Completely flat: Too far
How can you salvage a treatment session when a patient cannot fit into their prosthesis?
Consider alternative treatments that limit walking:
* Standing balance
* Standing strengthening
* Cardio: upper body extremities
* Standing Core
What is Bottoming Out
Pressure at the distal end
Sx:
* Bruising
* Pain
What is hammocking?
Not fully in socket
Sx
* Hickey effect
* Redness
* Hyperplasia or thickness of skin on the distal RL
When would a PT NOT proceed with treatment (show stoppers?)
- Unexplained clicking or noise in the prosthetic
- Wounds that worsen with prosthetic wear
- Bruising at distal end residual limb from bottoming out
- Development of local erythema over a bony prominence that is not improves with socks, reducing friction
- Residual limb pain that isn’t improved with proper socket fit
What are the prerequisites to amputee running?
- Consistent Quadriceps (TT) or gluteus (TF) control over community distances in free swing (for TF amputte)
- 10 unilateral step ups to an 18” step or at level 10 on total gym on prosthetic side
- No socket fit or wound healing issues
- Pain free activity
- Compliant with rehabilitation program
- Dexascan (Bone Density Recommended; TFs often have osteopenia)
- Ensure sound limb is strong and able to take loads (TT will have higher loads on sound leg)
What are the contraindications to amputee running?
- Pain with walking
- Wound Issues
- Pressure Issues with Walking
Suture Removal occurs over ____. Why?
the course of days or even weeks
Perform to:
* Maintain caution with the incision
* Allow appropriate wound healing
When does delayed primary closure occur?
- When a traumatic amputation involves a dirty wound
- Need multiple surgeries to clean it
K0
- The patient does not have the ability or potential to ambulate or transfer safely with or without assistance
- A prosthesis does not enhance their quality of life or mobility
- This level does not warrant a prescription for a prosthesis.
K1
- The patient has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed cadence (up to 10 steps) or standing
- This is typical of a household ambulator or a person who only walks about in their own home.
K2
- The patient has the ability or potential for ambulation with the ability to traverse low-level environmental barriers such as curbs, stairs or uneven surfaces (grass)
- This is typical of the limited community ambulator
K3
- The patient has the ability or potential for ambulation with variable cadence
- Typically, a community ambulator who also has the ability to traverse most environmental barriers and may have vocational, therapeutic or exercise activity that demands prosthetic use beyond simple locomotion.
K4
- The patient has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills
- Exhibiting high impact, stress or energy levels
- This is typical of the prosthetic demands of the child, active adult or athlete.
How many functional K-levels are there?
5
Order of Donning the Prosthetic
- Prosthetic sheath (if using one)
- Roll on gel liner
- Sock ply (as needed)
- Polyethylene liner (firmer material)
- Prosthetic
TTA: Pressure Tolerant vs Pressure Sensitive Areas
Pressure Tolerant
* Patellar Tendon
* Quadriceps Tendon
* Soft Tissue
Pressure Sensitive (Bony Prominences)
* Patella
* Fibular Head
* Anterior of Tibia
* End of shaft of fibula or tibia
* Condyles
* Tibial Tuberosity
TFA: Pressure Sensitive Areas
- End of leg
- Ischial Tuberosity
TTA ADDucted Socket creates:
Knee Varus
TTA ABDucted Socket creates:
Knee Valgus
TTA Flexed Socket creates:
Knee Flexion
Extended socket creates:
Extension
All in relationship to the distal end of the socket
Your patient is coming in with a knee varus position, how do you correct this?
- Need to ABDuct it to correct it
- Must be the opposite
TFA Socket Changes: Flexion
- Flexed Socket due to hip flexion contracture
How does a flexed TFA socket influence step length?
- Shorten step length due to lack of full extension
- Longer initial step forward into flexion position
What problem does increased socket flexion cause at the knee?
- Decreased full knee extension in stance phase of gait
- Need an adjustment at the knee to avoid toe-load in stance position (done by prosthetist)
Ways to help reduce limb volume: short term and active swelling
Short Term:
* ACE wrap
* Consider going to a previous shrinker size
* DO NOT force the prosthetic on!
Active Swelling:
* ACE wrapping the limb (generally over the liner if they are able to get it on
* Exercise to try to get fluid out of the limb
– Isometrics
– UBE or bike
Important Factors for Tolerating PT
Pain
* Pain needs to be controlled FIRST before you move on to significant functional training (especially in early rehab)
Energy Conservation
* Timing of ADLs in relation to rehab time
* Consider bathing PM vs. AM to improve energy during therapy
Getting to sessions
* How difficult is it to get to PT
* How much assist do they need
* Have they mastered the functional mobility needed to get to PT appointments?
When to Refer Back to Prosthetist
- Bell-clapping” in the socket (Limb is going back and forth inside prosthetic; feel unsteady do to movement)
- When the prosthetic putty “pancakes” in the socket
- When the prosthetic putty remains intake, even with adjustments made by therapist
- When there is pain (not phantom limb) with ambulation/weight bearing, even with adjustments made by therapist
- When there is noise or clicking in the prosthetic with ambulation
What K level matches with which knee type?
- K1 = Mechanical (SACH foot)
- K2 = Mechanical, sometimes microprocessor
- K3 = Microprocessor
