L8 Amputee Rehab Flashcards
Poor or incomplete donning may result in
- proximal soft tissue folding over socket
- gap of ≥1cm between distal limb and base of socket
- residual air expulsion w/movement
- pain
- prosthesis feeling too tall or unstable
- Unusual rotation of knee and foot
- risk to skin integrity
Sitting socket fit, TT
assess with knees flexed to 90° and foot flat
RL tends to move up a little when person sits. Knee may be extended if there is pressure on knee or RL. Also check for pressure on hamstrings
Sitting socket fit, TF
socket is securely fit on RL
length of shin/thigh correspond to shin/thigh length on intact limb
client can sit comfortably
can lean forward and reach shoes
Standing alignment, TT & TF
no pain with WB
knee stability
equal leg. length
WB should be equal between legs
shoes level on floor
pressure on pubic ramus or adductor roll
Suspension Check
have pt lift weight off of prosthesis and check for excessive movement
there should be no movement with suction or shuttlelock suspension, movement causes skin breakdown
Sleeve suspension
should have direct contact with skin for at least 2” above any socks or liners
Total Contact
limb is seated well in the socket while also not bottoming out
Powder Test
place a small amount of baby powder or cornstarch on sides and bottom of socket
don the prosthesis, stand/walk short distance
Powder on bottom or sides of socket
indicates loss of total contact fit
Minimal powder at bottom of socket
total contact fit
Ball of Clay Test
identifies if the residual limb is seated within socket
place little ball of clay at end o socket. have client WB
clay should be compressed into flat disk, indicating proper pressure on distal end
Clay ball is smashed or thin
indicates too much pressure on distal end of limb
Clay ball is not deformed
indicates that limb is not descending far enough into the socket for proper support
K Levels
as a means to quantify need and potential benefit of prosthetic devices for patients after lower limb amputations
guide prosthetists on component reimbursement
based on functional ability, potential ability to function, needs of pt
K-0 Level
pt does not have ability or potential to ambulate or transfer safely w/out assistance and a prosthesis does not enhance QOL or mobility
no eligible for prosthesis
K-1 Level
pt can do transfers, ambulate on level surfaces, fixed cadence, limited household ambulator
eligible for single axis, constant friction, SACH
K-2 Level
for tranverse low level barriers, like curbs, limited community ambulator
eligible for polycentric, constant friction, flexible keel foot, multi axial
K-3 Level
for variable cadence ambulator, unlimited community, traverse most environmental barriers, beyond simple locomotion
eligible for hydraulic pneumatic, microprocessor, variable friction, energy storing, dynamic response, multi-axial
K-4 Level
exceeds basic ambulation, exhibits high impact, typical for child/athlete/active adult
eligible for any system
10 meter walk test K-levels
K1 = .17m/s
K2 = .38m/s
K3 = .63m/s
K4 = 1.06 m/s
Amputee Mobility Predictor
used with LE amputees and assess functional mobility
can be performed with or without prosthesis
3.4 MDC
not recommended for pts with bilateral amputation at levels higher than transtarsal foot amputation
AMnoPRO scores and K Levels
K0 = ≤ 8
K1 = 9-20
K2 = 21-28
K3 = 29-36
K4 = ≥ 37
AMPPRO scores and K levels
K0 = N/A
K1 = 15-26
K2 = 27-36
K3 = 37-42
K4 = ≥ 43
Assistive Device Selection on AMP
0 = unable to leave bed
1 = w/c or parallel bars
2 = walker
3 = crutches
4 = cane
5 = none
L Test
Modified TUG Test
Can use AD, done at comfortable walking speed
has patient walk to first line, turn 90°, walk to second line, turn 180°, and return to chair
CHAMP
4 item test that measures high level mobility in people with lower limb loss
involves SLS, edgren side step, agility test, T-test
designed to quantify functional capabilities, measure change in function and help determine readiness to return to high level activity
used mainly in military treatment facilities
Illinois Agility Test
lying prone on floor behind starting line with arms at their side
patient will rise to their feet and move as quickly as possible and complete 10 meters forward and back. Weaving around 4 cones. Forward and back 10 m
Prosthesis Eval Questionnaire
asks about the prosthesis, pain, social/emotional aspects, ability to move, satisfaction, ADLs
Houghton Scale
4 item instrument that assesses prosthetic use in people with LE amputations. Self report of perception of use and functional outcomes
asks if they wear prosthesis, use of walking, going outside, feelings of instability
Scoring of houghton scale
Score ≥ 9 independent community
Score 6-8 household and limited community
Score ≤ 5 limited household
Locomotor Capabilities Index
self report instrument for assessing locomotor abilities essential for basic and advanced ADLs of people with LE amputations
max score of 56 from 14 Qs
Trinity Amputation and Prosthesis Experience Scales
designed to examine the pyschosocial process involved in adjusting to using a prosthesis
four sections of activity restriction, psychosocial adjustment, satisfaction w/prosthesis, factors influencing health
Goal setting for amputees is based on
current/expected functional level
outcome measures
patient goals
goals related to prosthetic management
Gel Liners
fits directly over skin of RL
avoid pulling on top, roll it up from distal
no space distally between end of limb and end of liner
Residual Limb Socks
used to modify fit between socket and shrinking residual limb
proper use of socks enhances RL WB in pressure tolerant areas, decreases skin breakdown, increases comfort
as RL shrinks, more socks are added
Sock ply
sock thickness
Once an individual needs ______, the socket needs to be replaced
10-15 plys
sock ply can vary daily
Too few socks
residual limb descends too far into socket
pistoning
Pistoning
prosthesis slips downward when unweighted during swing phase and pushed upward during stance
Too many socks
may be difficult to put on
fits too tightly
feels slightly longer
checking Shuttlelock/pin for adequate suspension
pin should further depress into ring mechanism 3 to 6 clicks
more than 10 clicks means more socks are needed
fewer clicks than 3 suggest need for less socks
Groin discomfort may indicate
need to apply more prosthetic socks
Wearing Schedule
break is prescribed for first few weeks of wear
1 hour a day, 1/2 of that time should be walking
skin should be inspected every 30 min or after walking
Add 1 hour a day if no skin breakdown, and can increase time to check skin to 45 min-60 min
What forces are primary causes of skin breakdown?
pressure
friction
shear
Normal reactive hyperemia
blanchable redness over WB areas that returns to normal skin color within 10 min
Abnormal hyperemia
persistent redness or redness that does not blanch on firm palpation
Pressure tolerant areas showing signs of excessive pressure
suggest that the duration or amount of WB may need to be decreased
Pressure sensitive areas showing signs of too much pressure
suggests that socket fit or alignment needs to be adjusted
Most common causes of new discomfort
residual limb volume changes
shoes with different heel heights
changes in activity level
Systematic troubleshooting process
location and pattern of pain
prosthetic fit that may cause S/S
pt related factors that may cause S/S
Limb descends too far into socket, TT
indicators:
inferior patella pain
fibular head pressure/redness
pressure of ant distal tibia or distal RL
inability to fully flex knee
+ ball of clay
feeling of looseness
pistoning
How can you fix limb descends too far into socket, TT
add additional sock ply
Limb not fitting far enough into socket, TT
indicators:
proximal ant tibial shaft pain
distal discoloration
distal end pain
pain at fibular head
significant pistoning
difficulty controlling prosthesis
increased ML movement in socket
+ ball of clay
How can you fix limb not fitting far enough into socket, TT
remove sock ply
Prosthesis Rotates on Residual Limb, TT
indicators:
foot points into toe out/toe in
fibular head pain
general discomfort
How to solve prosthesis rotates on residual limb, TT
re-don prosthesis w/patella centered
add or subtract sock ply
Pistoning indcators
pain at distal patella
loose feeling in prosthesis
inability to fully flex knee
pain on ant distal tibia
lack of control of prosthesis
Solutions for Pistoning
replacing suspension system
adding or removing sock ply
TF Too many socks
lose total contact with distal end
prosthesis feels too long
difficulty clearing toe
TF Too few socks
increases distal end pressure
discomfort in perineum
Shoe with lower heel height
excessive knee stability in stance
Shoe with higher heel
compromises alignment stability of knee and places greater demand on pt for muscular control of knee position during stance
