Post-Operative and Pre-Prosthetic Assessment Flashcards
The shorter the time between ____ and ____, the better the overall outcomes.
- amputation
- prosthetic
What complications can youanticipate could occur with delayed prosthetic fitting?
- Infection
- Uncontrolled edema
- Uncontrolled pain
- Delayed wound healing (suture)
- Improper positioning results in contractures
- Insurance (how many visits they will pay for)
IPOP and EPOP
IPOP: Immediate Post-op Prosthetic
* Applied in the OR
* Prosthetist present for application
* Focus on rehabilitation over simply recovery
EPOP: Early Post-op Prosthetic
* 5-7 days post-surgical
* Prosthetist performs at bedside
* Allows for wound management
Prosthetic Phase - Post Surgery
- Part 1: time between surgeryand fitting with adefinitive prosthesis oruntil the decision ismade to not fit thepatient for a prosthesis
- Part 2: Starts with the delivery of a “check (trial) socket” and progresses to the permanent prosthesis.
Limb volume, shaping and post-operative edema management
Why does it matter?
- Pain control
- Promote wound healing
- Protect incision
- Prepare for prosthesis and weight bearing
Limb volume, shaping and post-operative edema management
Options (Least to most constrictive)
- Soft dressings (wrap, no compression)
- Ace wraps/compressive coverings
- Semi-rigid dressing (SRD)
- Removable Rigid Dressing (RRDs)
– Very popular - Rigid cast dressing (done in OR)
– Cannot be taken off
Rigid - Plaster Cast
- Must be cut off like a cast
- Holds knee in extension
- Removed when limb volume decreases or per surgeon protocol
- May afforc limited WB with distal attachment
Rigid - Pre-fabricated polymer shell
- Removable to be ableto inspect wound
- Holds knee inextension
- May ormay notaccommodate distal attachment
This is an example of
- Rigid Dressing
- Often used for transtibial amputations
Rigid Dressings: Pros and Cons
Pros
* Excellent post-op edemacontrol (Fluid can’t come in)
* Excellent residual limb (RL)protection (Hard shell keep shape)
* Better control of phantomand post op pain
* Allow for earlier WB andprosthesis fitting
Cons
* No access to incision if it isnot removable
* More expensive – requiresprosthetist in OR or at bedside
* Training is essential forproper application andmonitoring
* Close supervision required
Semi-Rigid Dressing (SRD)
- Composed of paste compounds and are applied inOR
- Dressing adheres to skin – no need for suspensionbelts
- Allows slight jointmovement
Just like an Unna boot – same materials used for post-op amputation.
Semi-Rigid Dressing: Air Splint - Pros/Cons
- Put on, pumped up; immobilizes and compresses
- Similar to what would be used for fracture immobilization in an acute environment.
- Can also be used as a temporary prosthesis.
Pros:
* Allows inspectionand protection
* Comfort
Cons:
* Pressure is notuniform
* Hot , humid
* Require frequentcleaning limb and air cast
* Require frequentcleaning
Semi-Rigid Dressings: Overall - Pros/Cons
Pros
* Better edema control than soft dressings
* Residual limb (RL) protection
Cons
* Needs frequent changing
* Must be applied by a professional
* No access to incision
Soft Dressing: Elastic Wrap
- ACE Wrap
Pros
* Easy to apply
* Easy to incision
* Inexpensive
Cons:
* Needs frequent rewrapping (slippage)
* Risk of torniquet pressure
* May be tough to put on oneself
Soft Dressings: Shrinker
- Sock-like garments of heavy rubberized cotton
Pros:
* Easy to apply
* Inexpensive
* Various sizes
* Easy to apply (slide on)
Cons:
* May or may not be used prior to suture removal
* Must change sizes as RL volume decreases
Early Prosthetic Fitting
- Ideally fit RL when shrinkage is maximal
- Reality is limb will shrink regardless
- Literature strongly supports benefits of early fittingfor pain and edema control, RL protection andimproved activity levels. (8-12 weeks)
Pros and cons of remaining non-WB early on?
- Pros: skin protection, incision protection, healing time, controlling RL volume, pain management, desensitization
- Cons: delayed ambulation patterning/practice, possible delay in strengthening and balance training, pain management, edema control
Discharge Options - Post Surgical
Inpatient rehab: patient must be able to tolerate 3 hours of therapy/day (PT, OT, SLP combined)
Home health care: patient must be able to get into home, but be homebound
Outpatient: patient must be able to get into/out of home without significant burden
SNF/sub-acute stay: patient unable to return home but needs a slower therapy progression
Early Post-Operative Therapy (Pre-Prosthetic) Goals
- Promote RL wound healing
- Residual limb pain management and control
- Phantom limb pain/sensation management
- Optimize ROM of B LE and UE without impairing RL healing
- Optimize strength of B LE and UE without impairing RL healing
- Protect remaining limb
- Demonstrate functional sitting and standing balance
- Perform independent transfers and bed mobility
- Ambulate with appropriate assistive device
- Demonstrate proper sitting and bed positioning
- Begin psychological adjustment
- Understand the process of prosthetic rehabilitation
Variables Impacting Progress
- Type of amputation
- Etiology of amputation (Traumatic, PVD, etc.)
- Co-morbidities
- Pt’s ability tocontribute information
- Pain
- Infection
- Post-surgicaldressing
- Psychological status (Mental adjustment after loss of limb)
How to perform exam for someone with amputation?
- Subjective
- Systems Review
- Objective
Priorities of the Acute Care Exam
- Pain management (PCA button, oral medication, when last taken)
- Grieving and psychological adjustment
- Wound care /sutureline healing
- Limb volume control
- Mobility training
- Readiness for singlelimb ambulation
Post-Surgical Exam Guide
- Systems review/ Medical record review
- Post-op status (medically how are they?)
- Pain
- Vascularity/ conditionof the wound
- Functional status
– bed mobility
– transfers
– Balance - Gross ROM
– Sound extremity
– Amputated extremity
– UEs - Gross functional muscle performance (strength)
Phantom Pain
- 70-80% incidence (Normal anticipated outcome; pre-op education)
- Pain experience varies
- Etiology poorly understood
- 33% extremely bothered by phantom pain post-amputation regardless of time
What is the shape of a TTA and TFA?
- Transtibial(TTA)tapered cylindricalshape
- Transfemoral(TFA)conical shape
Wound Integrity and Healing ofResidual Limb
- Initial exam of incision
- Drainage
- Wound closure
– Risk of dehiscence
– Delayed prostheticfitting
– Impact of co-morbidities?
Considerations for Sound Limb
- Biomechanical stress of sinlge limb mobility
- Effect of co-morbidities (at risk for wounds?)
How do you perform early strength testing?
- Active, NON-resistive ROM at the joint proximal to amputation ONLY until wound is closed to protect myodesis
- If they can perform full active ROM (3/5 MMT)
Early Post-Operative POC: Goals
- Healing of RL
- Protection of uninvolved limb(i.e. dysvascular co-morbidities)
- Independent in transfers, bed and W/Cmobility
- Demonstrate properpositioning
- Begin psychologicaladjustment
- Education regardingprosthetic rehab
Early Post-Operative POC: Interventions
- Phantom pain control
- Positioning
- Residual limb care/ bandaging
- Care of uninvolved limb
- Functional training
- Balance training
- Mobility with assistive device (ambulation & gait training)
- Postural control (core training)
- Education on amputation andprosthetics
____ related amputations are 1.5x more likely to have phantom limb pain
- Trauma
- 80% reported PLP regardless of time since amputation
- UE most common
Treatments for Phantom Limb Pain
- Pharmalogical (Gabapentin; short term pain relief)
- Non Pharmalogical
– TENS
– Dry Needling
– Massage
– Mirror Therapy/Virtual Reality
How does mirror therapy/virtual reality help with PLP? How do they work?
- Both: Target neuroplastic mechanisms to restore neural representation of the missing limb through motor imagery.
- MT: Patient observes movements executed by their intact limb, viewed in a mirror or a virtual environment, and then couple the observed movement with movement of the phantom limb.
- VR: Augmented virtual reality allowsimages to be created from myoelectric signals from the RL, and therefore can be used for patients with bilateral amputations.
What motions are essential to:
Transtibial amputation?
Transfemoral amputation?
Partial foot amputation?
Depends on the functional task!
For walking degrees needed
Hip Extension: 10, F: 30
Knee Extension: 5-10 in flexion
Knee Flexion: 40
Plantarflexion:
Dorsiflexion: 10
Sit to stand
Knee flexion: 100
What are the predictable contracture patterns for:
Transtibial amputation?
Transfemoral amputation
Partial foot amputation?
Transtibial:
* Knee flexion
* Hip Flexion
Transfemoral: (Due to how IR/Adductor muscles are cut)
* Hip flexion
* Hip ER
* Hip Abduction
– Need to teach neutral leg position when sitting
Optimal Transitbial positions
Optimal Transfemoral Positions
- Same as transtibial positions for seated, supine and prone.
- Emphasizeneutral LE positioning, especially in supine and seated positions.
- Avoid position with hip flexion and abduction (cushion under the stump for example).
Residual Limb Care
- PROTECTION!
– Sutures gradually and sequentially removed
– Primary focus: Teach the patient how to protect the RL while moving in bed, coming to sitting and transferring.
– Patients should not put pressure on the limb or drag it on the bed: AVOID STRESS ON INCISION! - Cleansing anddrying
- Gentle AROM /noresistance!
- Tissue and scar mobilization –only after sutures areremoved
- Inspection & patient education!
Residual Limb Care: Edema Control
If RL is in rigid dressing or removable rigid dressing, limb wrapping is not needed at that time.
– Educate on limb wrapping in a later phase of healing.
If RL is in a soft dressing, limb wrapping is necessary
– Educate on wrapping
– Educate on application of shrinker
Things to remeber with limb wrapping
- Nowrinkles!
- No tourniquet! (Figure 8wrap).
- No clips! (Use tape, Velcro orpins tofasten).
- Proximal jointextension.
- Special accommodations forelderly. (skin more fragile, circulation may be more compromised, may be more diffcult to apply)
Limb wrapping should be performed…
every 4 hours!
- All skin of the RL should be covered
- The shape of the RL should be cylindrical
How are shrinkers applied?
- Transtibial: Rolled onto the RL to midthigh, designed to be self-suspending
- Transfemoral: Utilize a hip spica (encircle the pelvis)
- Proper suspension is key!
– Any rolling of the edges or slipping can create a tourniquet - Easier to apply than ACE wraps
- More expensive; need to be replaced as limb volume decreases
How to treat contractures
- Prevent prolonged positions (Except prone)
- Place them in prolonged prone position
- PNF
- Soft Tissue
- Joint Mobilizations
Care of Uninvolved Limb
Examination should include:
* Skin
* Presence of pulses
* Sensation
* Temperature
* Edema
* Pain on exercise or at rest
* Presence of wounds/ulcerations/abnormalities
ROM & Strength status
Deformities or other orthopedic problems
I.e. arthritis, previous replacement (knee, hip, etc)
WB Status
Prevent contractures on the sound limb
Functional Mobility: What is important and why?
- COM redistributes upon amputation
Skills needed for preparation for prosthetic:
* Bed mobility (shift, scoot, roll, sit up, bridge)
* Transfers: (slide board, squat and stand pivot)
* Wheelchair mobility (through doorways, turning, getting back in, curbs)
* Balance skills (Seated, SL)
* Pre-gait training (adequate strength and motion to get them ready for gait)
* Gait training with appropriate AD (w/o and w/IPOP/EPOP)
Adaptive equipment for bed mobility and transfers
Adaptive equipment:
Supine<>sit
* Leg lifter
* Sliding board
* Grab bars on bed
Sit<>stand; bed<>chair
* Walker vs. Crutches
* Slideboard
Transfer Options:
* Slideboard transfer
* Stand-pivot transfer
* Squat-pivot transfer
* Front sliding transfer (for bilateral amputation)
Transfers should occur from ____ levels
different
What is a precaution with bed mobility and transfers?
- Hemodynamics (Need to ask for dizziness and take vitals pre/post)
- Increased incidence of AAA and MI post-amputation
Sitting Pressure Relief Training
- Look to eliminate high pressure areas
- Every 15 minutes need to pressure relief for 30 seconds
– Lean to side, lift up and hold or lean back
How do wheelchairs need to be adapted for amputees?
- Clients with high or double amputations do not have the weight of their leg(s) to stop their wheelchair from tipping backwards
- To improve the user’s balance in the wheelchair and reduce the risk of tipping, position the rear wheel axle in the ‘safe’ position (behind the patient’s shoulders).
- For some users, as they gain confidence and experience, it may be possible to review the wheelchair set up and move the rear wheel axle position to a more active position.
ALL levels of amputation, ____ is critical in assuming a balanced upright posture without compensations that may lead to gait asymmetries and back pain.
full hip extension (30 degrees)
For TTA, full range of motion in ____, most noted into extension,is needed.
hip and knee
Strengthening Exercises - TTA
Exercises should be given for involved limb, uninvolved limb, UE’s, and trunk/core.
Bed exercises for TTA:
* Quad set
* Hip extension with knee extended
* SLR
* Hip/knee extension with contralateral KTC
* Hip abduction against resistance
* Hip extension against towel roll (“bridging”)
Strengthening Exercises - TFA
Consider the importance of hip extension and abduction strength for TTA and TFA in regard to ambulation.
Bed exercises for TFA:
* Glute sets
* Hip abduction supine against resistance
* Hip abduction side-lying active and against resistance
* Hip extension prone
* Hip extension against a towel roll (“bridging”)
How does postural control change with amputation?
- Shifts upward and toward the uninvolved (remaining) limb
- The longer the limb, the less the shift
- If bilateral, COM only shifts up
Balance and Postural Control Exercises
- Seated on Foam Pad
- Seated balance on physioball
- Seated balance on physioball with UE movement
- Single limb balance w/UE support
- Variable surfaces
- UE challenge
- Single limb balance w/o UE support
- Variable surfaces
- UE challenge
Weight bearing through RL
* TTA only
* Standing with chair
* Kneeling on mat
* Add weight shifting forward-backward
Core Stabilization Training
Core stability training is critical in amputees where balance becomes compromised, resulting in diminished limb power outputs.
The higher the amputation, the more they need core stabilization.
Consider:
* Core training as a component of postural control
* Core training as a functional component
* Core training related to patient goals (I.e. return to sport)
Examples of core exercises:
* Crunch/sit-up-based activities (w/ or w/o resistance)
* Quadruped activities
* Use of compliant surface (in any position)
* Prolonged stabilization (i.e. plank)
