LE EXAMINATION OF AMPUTEE Flashcards
Common causes of LE amputation
infection, gangrene, trauma, congenital, necrosis, necrotizing fasciitis, cellulitis, PAD, frostbite, tumor (osteosarcoma), complications from DM
Pre-prosthetic phase of treatment
weeks 2-12
-in home health or SNF
-want to help the individual to be safe at the wheelchair level
Post-operative phase timeline and care
weeks 1-3
-acute care, SAR, acute rehab
-functional mobility and wound assessment
Prosthetic training phase of treatment
weeks 12-16
outpatient or acute rehab
Long term follow phase of treatment
3 months and beyond
outpatient
What types of pain may you ask about in a subjective evaluation of pain?
phantom limb sensation
phantom limb pain
residual limb pain
referred pain - neuroma or heterotopic ossification
MSK pain - back pain is common
What is a very important area to inquire about in a subjective eval post-amputation?
psychosocial factors
-grief assessment
-coping strategies
-QOL
-dep/anxiety
-PTSD
-self-perception of body or self defense
-housing instability
-consider home and social environment
Areas of subjective evaluation post-op
-systems review
-cognition
-pain
-psychosocial
-home and social environment
-prior level of function: ex: occupation, driving
-GOALS
-patient preferences and values
Components of physical evaluation
-vitals
-observation
-vision/vestibular/hearing
-skin
-residual limb assessment
-contralateral limb inspection
-sensation
-ROM
-strength
-functional mobility
-gait
-outcome measure assessment
Assessment of residual limb
-level
-type
-overall observation: shape and swelling
-incision: sutures, staples, eschar, slough, drainage, dehiscence
-scar mobility and invagination
Sensation assessment on the residual limb
BLUE BLE dermatomes
light touch
sharp/protective sensation
Coordination assessment
hand function and dexterity
donning and doffing ability
ROM assessment
-hip and knee ROM
-lumbar/pelvic mobility
–> have the hamstrings impacted pelvic and lumbar positioning and pain?
-development of contractures
-contralateral ROM
Strength assessment
-the affected limb may be limited by post-surgical pain
-assess upper extremity strength!
KEY CONSIDERATIONS
-hip abduction and adduction
-gluteus activation
-quad activation
Components of functional evaluation
Functional mobility
-bed mobility
-transfers
-W/C mobility
Gait
Stairs
-hopping vs bumping
Balance
-static and dynamic
Cardio/endurance
-functional tolerance to intervention
Patient-reported outcome measures
PSFS
GAS - goal attainment scale
ABC - Activities of Balance Confidence Scale
PLUS-M (prosthetic limb users survey of mobility)
Performance outcome measures
Functional mobility
-amputee mobility predictor, AMP-B, 5TSTS, 30sec STS
Gait
-10MWT
-TUG
Balance
-SL balance, AMP, TUG
Endurance
-2MWT, 6MWT
Higher level
-CHAMP, FGA, DGI
Goals for pre-prosthetic management
-patient education on amputation and rehab
-CV endurance
-residual limb management
–positioning and contracture
–residual limb care and protection
–strength and ROM
–compliance
-balance training
-transfer training
-mobility training
–single limb ambulation
–w/c mobility
Residual limb management/assessment
-what is the level of the residual limb?
PAIN MANAGEMENT
-scar tissue massage
–> approximate tissue and move it around, prevent invagination
-desensitization
–> diff pressures, diff temperatures, diff textures
-mirror therapy
–> reflect the sound side
–> AROM and take adv. of mirror neurons
-compression
OTHER:
-positioning, edema management
-compression for shrinking and shaping
–> ACE, cast, shrinker sock (whenever not wearing prosthetic)
-incision and wound management
-compliance with wear schedule and residual limb management
-proprioception/joint position
Clinical indications for prosthetic candidacy
- sufficient strength and independence for functional mobility
- sufficient ROM
- K level predicted by Amputee Mobility Predictor
-household vs community - Physician clearance for progressive weight-bearing
-incision healed
-compliance with wear schedule - well-fitting socket with correct alignment
Blistering/things to look out for with prosthetic use:
-ring on the bottom of limb–> pistoning
-blanching that does not go back to pink in 5-10 min
-dark pink color of skin–> bad
Evaluation components
-residual limb management
-prosthetic use and compliance
–> wear schedule, donning/doffing liners, socks, socket, suspension
–compliance with shrinker use
-fit and alignment of prosthetic
-skin inspection and tolerance
-functional mobility
–level of support
–AD use
–history of falls
Possible causes of gait deviations seen on assessment
range of motion requirement
torque demand
muscle action
functional significance
Goals for prosthetic training
-patient engagement and compliance
-independence/safety with residual limb management and functional mobility
-sufficient strength, ROM, and endurance for functional activities
-full-weight acceptance on new prosthesis
–> Symmetrical and appropriate gait mechanics
-safety with balance, transfers, gait, stairs
-assistive device progression
-Ability to adapt to enviro demands while walking
-return to PLOF and recreational/vocational activities
3 most common causes of amputation
1.) vascular disease
2.) trauma
3.) cancer
97% of all amputations are LE amputations
African Amercians are up to 4x more likely to have an amputation than white Americans
Amputation timeline and presentation
pre-op
acute/post-op: weeks 1-3
pre-prosthetic: week 3-12 post-op
-home health/SNF
-shaping and compression of limb
-protection of residual limb at this time (hard cast)
prosthetic and gait training/OP: week 6-8 to 16
long term f/u: 3-6 mo follow-up/ annually for life in the VA
CV, integumentary screen, and other screening post-op
CV
-look at all pulses
Integumentary
-hair growth
-swelling
-irritation from socket
-look at scar
-teach family how to check skin
OTHER
-psychosocial concerns/depression
Interventions for phantom limb pain
-Compression at night
-Gabapentin
-targeted muscle re-innervation:
Types of pain following amputation
phantom limb sensation (upwards of 100% of amputees experience)
phantom limb pain
-ex: inability to empty bowel and bladder can increase PLP because bladder and bowels right next to LE on somatosensory cortex (homunculus)
residual limb pain
-neuromas, bone spur
back pain/referral (S1, L4, L5)
What are dysvascular amputees more at risk for?
psychosocial considerations such as depression, anxiety, grief
What is targeted muscle re-innervation?
Targeted muscle reinnervation (TMR) is essentially a way to give nerves affected by an amputation procedure something to do. When they’re rerouted into muscle as motor nerves, they’re less likely to send pain signals to the brain while they are attempting to regenerate properly.
ROM assessment
hip and knee ROM–> risk of contracture
ROM needed for gait and functional mobility
-60 knee flexion for gait
-110 knee flexion for stairs
-about 10-degrees hip extension for walking
pelvic mobility
lumbar mobility
contralateral ROM
What muscle is key in both the sound and residual limb to help prevent an individual from falling?
hip extensor strength
*UE strength needed for use of an AD
Sensation testing on residual and sound limb
light touch
sharp
** protect yourself by wearing shoes around the house/or socks due to lack of sensation
Why is it important to do an ortho exam for the sound limb?
predisposed to overuse and OA of sound limb
