P&O

Question 1

Medicare covers what for patients with Diabetes?

Answer 1

Medicare covers
– DM with DM neuropathy –> yearly Podiatry evaluation
– DM –> one pair of DM specific shoes a year

Question 2

Every Physical exam of a amputee, make sure to…

Answer 2

Check the other limb! (For wounds, For decreased sensation, For subtle findings like hair loss)

9-17% of patients undergoing transtibial amputation will require contralateral amputation within 12 months

Question 3

% of patients that undergo transtibial amputation within 12 months of the contralateral amputation…

Answer 3

9-17% of patients undergoing transtibial amputation will require contralateral amputation within 12 months

Question 4

Screening tool for limb health =

Answer 4

ABI (ABI = SBP at ankle / SBP at arm)

ABI > 0.9 is good
ABI < 0.9 mild PVD,
< 0.7 mod PVD,
< 0.4 severe PVD

If not yet done, referral for vascular evaluation – arterial angiography +/- angioplasty +/- stenting

Question 5

Timeline and Goals (4) for PREPROSTHETIC phase of amputation:

Answer 5

Post-op after acute amputation
Inpatient rehabilitation admission
About 3 weeks admission

• Key concepts:
  – Surgical wound healing
  – Conditioning & strengthening for later prosthetic ambulation
  – Prevention of contractures
  – Medical care

Question 6

Common post-op wound care orders for new amputation:

Answer 6

“clean & dry, cover incision line with ABD pad to protect it, wrap with soft gauze wrap, wrap over everything with figure of 8 ACE wrap, no tape on skin.” (last part is VERY important)

Question 7

When can you use shrinkers on the new residual limb?

Answer 7

Only after sutures/staples out

Question 8

General conditioning in therapy during PREPROSTHETIC phase: (% demand)

Answer 8

Atherosclerosis likely already in place, and increased risk after amputation. Increased metabolic demand per step (1 TT, 30%, 2 TT 40%, 1 TF 70%, 2 TF 200%)

Question 9

Does energy rate change for amputees?

Answer 9

amputees walk at own self selected
slower speed, so rate of energy expenditure is same as non-amputee
– Rate = energy used / time to walk a distance

Question 10

Strengthening goals in preprosthetic phase therapy:
-UE
-LE
w/ examples

Answer 10

– Shoulder complex & triceps for UE assist with transfer & ambulation with walker. Ex) Rickshaw, resistance bands, weighted bars.

– Core, Hip girdle, gluteal muscles – all the movement of the prosthetic limb will be initiated by the remaining intact proximal muscles. Ex) Supine leg lifts, Prone leg extensions, Side lying hip abduction

Question 11

Transtibial BKA prosthesis contracture limit?

Answer 11

Transtibal BKA Prosthesis usually can only accommodate 15deg of knee flexion contracture

Question 12

Lower extremity contracture risks for AKA and BKAs:

w/ exercises to prevent them!

Answer 12

– Transtibial BKAs prone to hip flexion & knee flexion contractures
– Transfemoral AKAs prone to hip flexion & hip abduction contractures

– Ex) Prone stretching of iliopsoas & hip flexors; knee immobilizer/Flotech for passive stretching of hamstrings & keeping knee extended

Question 13

List common Amputee DME orders:

Answer 13

– Long handled mirror for self-inspection of amputation site

– Wheelchair adjustments:
* Rear axle more posterior to increase base of support to prevent tipping backwards (accounts for less anterior weight from loss of limb)
* For transtibial BKAs, knee extension board added to elevating leg rest

Question 14

Describe post-amputation (type, duration, prognosis)

What modalities work best to treat phantom limb pain? (4)

Answer 14

– General somatic pain related to surgical incision
* Usually subsides over 1-3 weeks post-op
* Analgesic medications as medically appropriate & tolerated

– Phantom limb pain
* Desensitization
* Analgesic medications
* Neuropathic pain medications
* Mirror therapy (central processing and possible cortical reorganization)

Question 15

Based on National Surgical QPI database: Perioperative morality for lower ext. amputations? What about the likelihood they had a complication within one month? (what type of comp?)

Answer 15

National Surgical Quality Improvement Program database:

• 30 day perioperative mortality
  –13%, for transfemoral AKA
  – 6.5% for transtibial BKA
• 34% of of transtibial BKAs had a 30 day perioperative complication
  – Most commonly = return to operating room for revision (15%) – Amputation site wound infection (9%)

Question 16

Likelihood of thromboembolic disease in those with LE amputations NOT on anticoagulation?

Answer 16

• 38% incidence of DVT after transfemoral AKA
• 21% incidence of DVT after transtibial BKA

Question 17

You begin a prosthetic evaluation after when?

What is the time course of this process beginning/duration itself?

Answer 17

Patient completes inpatient recovery phase + already done their post-op discharge follow up with their surgeon.

– every patient will take their own time for wound healing &
limb shaping
– every insurance will take their own time to approve/deny
prosthesis
– every patient & prosthetist will take their own time to fabricate & adjust prosthesis prior to prosthetic training

Question 18

After surgeon has taken sutures and staples out, what do you continually do at each visit before even considering a prosthetic/during the process?

Answer 18

Skin eval! (don’t forget the other side)

– Scabs associated with surgical incision
– Day-to-day cuts & scratches

Shrinker garments worn more or less all day & night to address residual limb edema & promote ideal limb shaping

Question 19

Ideal limb shape for UE and LE amputations:

Answer 19

A conical shape is preferred for the transhumeral amputation and a screwdriver shape for the transradial amputation. The latter preserves maximum use of residual rotation

– Transtibial BKA = cylindrical shape
– Transfemoral AKA = conical shape

(Shrinker garments worn more or less all day & night to address residual limb edema & promote ideal limb shaping)

Question 20

Fabrication of the prosthetic involves:

What are common post-production modifications/adjustments?

Answer 20

Fabrication of socket & combining of components into a prosthesis
– Plaster casting of residual limb to use as a mold for socket creation (most common and cheaper, but dependent on the skills of the prosthetist)
– New technology: 3D scanning of residual limb ($$$)

Even after fabrication, still probably going to need some adjustments
– Ex) Cut out some pressure relief of socket; Resize endoskeleton pylon for proper height

Question 21

Prosthetic training begins when and how is it organized?

Answer 21

After outpatient re-evaluations & “final” fitting of initial temporary prosthesis

• Therapy course specifically to practice and become independent with prosthetic management
• Inpatient rehabilitation admission (if authorized), about 2 weeks
• Or if inpatient admission not authorized, formal outpatient therapy

During this process, make sure to Reinforce all the amputee health maintenance concepts:
-thorough residual limb skin evaluations
-prevention of contracture, etc.

Question 22

Initial prosthetic wear/use time instructions:

Red flags to look out for:

Answer 22

– Start low & build up gradually
– Can start as little as 15 min wear time intervals

– EVERYTIME prosthesis is taken off, skin must be inspected

• BAD: erythema that does not go away even after a few minutes of the prosthesis being off; ecchymosis; skin breakdown/abrasions; etc

Question 23

Two major skin complications that can be a result of poorly fitting prosthesis

Answer 23

CHOKE SYNDROME
* Venous obstruction from socket that is too tight proximally
* Red, indurated skin that does not improve long after prosthesis is removed

VERRUCOUS HYPERPLASIA
* Wart-like overgrowth of thickened skin
* Fissuring & ulceration adds to infection risk
* Chronic proximal constriction

Question 24

Examples of independence of prosthetic management when used: Donning, Doffing, Maintenance, and Managing socks

Answer 24

Donning:
-Enough clicks for pin & shuttle lock suspension (at least 5) without struggling to get them all (too tight)?
-At the same time, not too many clicks (too fast or too loose)

Doffing:
-Finding the release button for shuttle lock suspension to release it

Maintenance:
-Higher end components need this (charging microprocessor)

Socks:
-Adding or subtracting # of ply of socks over course of day to ensure fit.

Question 25

Examples of exercises/targets you should be addressing in prosthetic training:

Answer 25

• In Therapy:
  – Sit-to-stand transfers
  – Upright static standing balance
  – Weight shifting side to side, increasing tolerance to full body weight bearing on just prosthesis
  – Ambulation with assistive device as needed
• Step-to gait pattern & progress to reciprocal gait as tolerated
• Remember there is NO sensory feedback from prosthetic leg. Have to learn the feeling of trusting full weight bearing on the prosthesis.

Question 26

Outpatient follow up schedule for initial/temporary prosthesis:

Answer 26

Monthly, with lots of use of socks because this will help adjust limb shape and also protect the socket of the prosthetic.

Prosthetic socket is rigid in this phase so expect some limb shape changes that have to be monitored.

Question 27

Major difference in what you can do with the Permanent prosthesis compared to the Initial one?

Follow up frequency with permanent prosthesis?

Answer 27

More complex devices, cosmetic pieces can be added here now too (skin cover over endoskeleton pylon)

When things set with permanent prosthesis, wean down to follow up every few months and then yearly.

Question 28

What to assess at yearly evaluations with permanent prosthetic:

Answer 28

– Rx of DME with short lifespans, like socks and gel liners

– Evaluation of prosthesis to see if any components need repair/replacement

– Residual limb skin evaluation (ex. scar mobilization)

– Post-amputee pain

– Screening intact limb for signs of trouble

Question 29

Scar mobilization definition, treatment mechanism and why it matters:

Answer 29

Adherent connections between surface surgical scar and underlying soft tissues can source of post-amputee pain (easy to treat).

Mechanism: deep friction massage is performed vertically around the scar line.

Scar mobilization can keep the skin flexible and pliable, and make your prosthesis easier to wear.

Question 30

Driving points with amputees:
-Handicapped sign?
-Right foot BKA/AKA adjustments?

Answer 30

-Permanent loss of limb due to amputation is a qualifying reason for permanent handicapped parking on NJ application

-Right lower extremity amputation – left sided accelerator modification (You CANNOT drive with your prosthetic side because NO SENSORY feedback from prosthetic foot)

Question 31

Requirements before returning to work with a new prosthetic:

Answer 31

– Shouldn’t go back to work until fully independent with prosthetic management
– Probably shouldn’t go back to work until prosthetic wear time is up to hours
– Accommodation: periodic rest breaks for prosthetic adjustment, sock addition / subtraction, skin check

Question 32

Describe K levels

Answer 32

Question 33

Describe the Transfemoral (Endoskeletal) socket

Answer 33

Ischial containment&raquo_space;> Quadrilateral

Question 34

Transfemoral (endoskeletal) Suspension options

Answer 34

Suspension: Gel liner with pin and lock, Suction, KIS

(belts suck, avoid them)

Question 35

Transfemoral (endoskeletal) knee options

Answer 35

Knee Unit: Manual locking, constant friction, Weight activated stance* (low level), Multi-bar Polycentric, Fluid control (oil > air), Microprocessor.

Question 36

Knee of choice for knee disarticulations:

Answer 36

Multi-bar polycentric

Question 37

Transfemoral (endoskeletal) Ankle+Foot options

Answer 37

Ankle Unit: SACH, Flexible heel (low level and great for obese patients - simple and can bear weight), Single Axis, Multi Axis (uneven surfaces), Energy-Storing* — NOTE: Axis (2) and energy storing are foot AND ankle

Question 38

Transtibial (endoskeletal) Socket options

Answer 38

PTB-SC, Total surface bearing*

Total surface/contact is newer and more widely used now

Question 39

Transtibial (endoskeletal) Suspension options

Answer 39

Gel liner with pin and lock, Vacuum active and passive, sleeve, supracondylar suspension

Question 40

Transtibial (endoskeletal) Ankle/Foot unit options

Answer 40

SACH, Flexible Keel foot, Single Axis, Multi-Axis foot, Multi-Axial Energy Storing foot, Microprocessor unit* (usually ok to start with these even with initial if higher K level)

Question 41

Upper extremity socket and suspension options:

Answer 41

Socket: Double-walled socket* (Meunster only for short TR)

Suspension: Figure-8*, Figure-9 (Only for a Meunster), Shoulder saddle

Question 42

Upper extremity power system options:

Answer 42

Body powered* (cable controlled requiring the movements to activate), Myoelectric, Hybrid

Question 43

Upper extremity joint(s) options:

Answer 43

Elbow unit for TH (Internal* or External)

Wrist unit (Friction or Locking*)

Question 44

Upper extremity Terminal Device options:

Answer 44

Hook, Hand (3-jaw-chuck) — Voluntary opening* or closing.