Post/Pre Op and Prosthetic Management Flashcards
What are the phases of amputee rehab
- Preoperative
- Amputation surgery/dressing
- Acute post surgical
- Preprosthetic
- Prosthetic prescription/fabrication
- Prosthetic training
- Community Integration
- Vocational rehab
- Follow up
Describe preoperative management
- Medical & body condition assessment
- Patient education on surgical level discussion, functional expectations, skin hygiene, phantom limb discussion (surgical, MSK, phantom pain, or phantom sensation), & desensitization
What are some post-op possible complications
- Deep venous thrombosis (DVT)
- Pulmonary embolus (PE)
- Arrhythmias
- Congestive heart failure (CHF)
- Sepsis
- Renal failure
- Infection
- Hematoma
Assessment for hemodynamic stability post-op
- Hemoglobin: assess for anemia due to blood loss & decreased bone marrow
- Norms: 12-16 g/dL females and 14-17 g/dL males
- If <8 g/dL: sSx based approach when determining appropriateness for activity, collaborate with inter professional team (regarding possible need for/timing of transfusion prior to mobilization)
- Consultation with the inter professional team while monitoring s/s is imperative since hemoglobin levels & blood transfusions is individualized
Causes, presentation, and clinical implications of anemia in post-op
- Causes: hemorrhage, poor nutrition, neoplasia, lymphoma, lupus, sarcoidosis, renal disease, splenomegaly, sickle cell anemia, bone marrow stress, RBC destruction
- Presentation: decreased endurance, activity tolerance, pallor, tachycardia
- Implications: monitor vitals including SpO2 to predict tissue perfusion, may present with tachycardia and/or orthostatic hypotension
Causes, presentation, and clinical implications of polycythemia in post-op
- Too many red blood cells
- Causes: dehydration, COPD, CHF, burns, high altitude, congenital heart disease
- Presentation: orthostasis, pre syncope, dizzy, CHF exacerbation, seizures, TIA, MI, angina
- Implications: low <5-7 g/dL = HF or death; High >20 g/dL = clogging of capillaries
Slide 11-12
Nutrition for wound healing after surgery
- Extra protein & energy in the form of calories are needed for healing
- Vitamins & minerals especially zinc, vitamin A, C, and K, and arginine
- Check with doctor or dietitian if vitamin/mineral supplements or if an oral medical nutrition supplements is needed
Nutrition for wound healing long term
- A higher energy/calorie diet may be needed if you have lost weight & are below your ideal body weight
- If more food or calories are needed choose food low in saturated (animal) fat & low in cholesterol
- Eat a balanced diet with a wide variety of food & drink plenty of water to prevent dehydration
Association of cognitive function and post-op prosthetics
- Association b/w decreased cognitive function (memory and executive function) and failure to be successfully fitted with a prosthetic device
- Poor cognitive function is also related to: overall decreased prosthetic device use, decreased mobility & loss of independence, and increased incidence of falls
Tools for cognitive screening
- SLUMS Examination
- MOCA (montreal cognitive assessment)
- MMSE as primary cognitive measure will not detect mild deficits in cognition that influence fall risk
Describe assessment of amputation surgery/dressing management
- Residual limb length determination
- Myodesis (muscle/tendon directly to bone, excellent stabilization) or myoplastic (muscle sutured to muscle then placed over bone, preferred for patients with poor vascular health) closure
- Soft tissue coverage
- Nerve handling
- Rigid dressing application (surgeon dependent)
- Limb reconstruction
What percentage of residual length length preserved are ideal
- Transtibial residual limb: 35-50%, 5-7 inches, effective prosthetic control for safe & energy efficient gait, relatively comfortable prosthetic fit
- Transfemoral residual limb: 35-50%, 5-8.5 inches, effective prosthetic control for safe & energy efficient gait, relatively comfortable prosthetic fit
Describe pain management before surgery to long term prosthetic use
-Before surgery: assess for existing pain
- After surgery: aggressively treat residual & phantom limb pain
- Before prosthetic: determine etiology of pain & treat appropriately; if no specific cause identified treat with non-narcotic medications & other non-pharmacological, physical, psychological, & mechanical modalities
- During prosthetic training: extension of “before prosthetic” phase
- Long term: assess and treat associated MSK pain that may develop over time
Describe the McGill Pain Questionnaire (MPQ)
- Users mark words that best describe their pain across the following domains: sensory, affective, evaluative, & miscellaneous
Slide 23-25
Pain between the end of the residual limb & the next proximal joint is likely
- Residual limb pain
Pain distal to the end of the residual limb could be ___________________ & ________________
- Phantom pain
- Phantom sensation
Describe mirror therapy for pain management
- Commonly used for chronic post-op pain but no robust proof of efficacy has yet been provided
- There is currently inadequate evidence to recommend it as a first intention treatment
- The evidence for use of mirror therapy is more supported for management of phantom limb pain following upper extremity limb loss
Describe prosthetic fitting & phantom limb pain (PLP)
- Positioning of a prosthetic limb creates new sensory stimuli & this is a Tx for PLP that could be more oriented towards restoring function
- Early fitting of a prosthesis by rigid socket contact has long been known to favor the healing of the residual limb, to prevent venous thrombosis, & to play a part in pain control via a better realization of the amputation
To help desensitize your residual limb do the following
- Perform desensitization when you are not wearing your compression garment (shrinker, elastic wrap)
- Perform desensitization for 2-3 min 2x/day, it may be easiest to do during bathing time
- Start with a cotton ball & gently rub the skin of your residual limb using a circular motion
- When you are able to tolerate it progress to a rougher material such as a paper towel
- Try to advance to a Terry cloth towel or shower sponge
Desensitization techniques
- Massage: at least 5 min 3-4x/day, can be done more often if it helps you in reducing phantom limb pain
- Tapping: tap residual limb with fingertips being careful not to tap with fingernails, perform for 1-2 min 3-4x/day, it can be done more often if it helps you in reducing phantom limb pain
Components of acute post surgical rehab
- Wound healing
- Pain control
- Proximal body motion
- Emotional support
- Phantom limb discussion
Describe scar/incision line management
- Important to mobilize the scar once wound healing is complete
-Prime time to attempt to mobilize & prevent adhesions tot he underlying tissue is when the scar is not yet mature - Pressure is applied above & below the incision line mobilizing the incision
- Olive oil, cocoa butter, & vitamin E cream can facilitate massage & prevent dryness
- Once the prosthetic wearing is initiated an adherence along the suture line could result in skin breakdown delaying ambulation
Components of pre-prosthetic phase
- Residual limb protection/shaping/shrinking
- Increasing muscle strength
- Improving ROM
- Restoring patient’s sense of control
Effective post-operative dressing management should maintain the integrity of the residual limb and should:
- Protect the residual limb
- Control & reduce edema
- Facilitate primary wound closure
- Maintain extension ROM
- Facilitate advancement to prosthetic fitting
- Rigid or semi-rigid protective devices that cross the knee joint can consistently accomplish the aforementioned goals, when properly applied
Describe edema management and compression
- The consistent wearing of shrinkers whenever the prosthesis is not in place is often necessary for edema control during the first year after the amputation. Seasoned prosthetic wearers may still require the use of a shrinker to maintain prosthetic fit secondary to fluctuations in circumference such as in the end-stage renal disease (ESRD) patient or those with other medical conditions such as CHF. Prosthetic wearers sometimes choose to wear a liner instead of a shrinker to maintain the circumference needed for donning the prosthesis.
Slide 38
What can poor shaping of the residual limb lead to
- “Dog Ears” (flattened with the sides protruding)
- “Bulbous” residual limb (very rounded and ball like shape)
Do the following for contracture prevention pre-prosthetic
- Elevate your residual limb on a well padded board when sitting in a wheelchair (below knee)
- When you sleep on your back try to keep your legs stretched out flat (below/above knee)
- Try to lie flat on your stomach for 15-20 min several times a day is approved by your doctor (above knee)
What to not do for contracture prevention pre-prosthetic
- DON’T sit/lie with your knee bent in a chair or on the side of the bed for prolonged periods of time (below knee)
- DON’T place a pillow under your knee while you are sitting or lying down (below knee)
- DON’T put weight or pressure on the end of your residual limb (below knee)
- DON’T sit in the bed for long periods of time (above knee)
- DON’T lie in the bed with a pillow under the residual limb (above knee)
- DON’T lie on your back pushing the residual limb out to the side/spreading the residual limb (above knee)
Assessment of ROM post-op
- Any contracture can prolong the time to prosthetic fit or even result in the inability to fit a patient with prosthetics
- The most frequently seen contracture for the transtibial (TT) amputee is a knee flexion contracture which can be prevented by donning a knee immobilizer immediately post-op or intra-operatively
- The most frequently seen contracture for the transfemoral amputee is a hip flexion & hip abduction contracture
Slide 45**
During the early post-operative period, the clinician must consider several factors that may influence the timing, frequency, and intensity of mobility training. These factors include:
- Overall medical stability
- Hemodynamic stability
- Residual limb healing status
- Pain management
- Mental status
- Fall risk
Benefits of early mobilization
- Facilitating early mobilization
- Gait re-education
- Accelerated stump healing
- Reduced complications
- Facilitation of early definitive prosthetic fitting
- Psychological benefit from early prosthetic device fitting
Potential disadvantages of early mobilization
- Risk of skin breakdown of the residual limb
- Increased residual limb pain
- Increased risk of falls
Therapeutic exercise recommendations for post-op amputation
- Recommend instituting rehab training interventions using both open & closed chain exercises & progressive resistance to improve gait, mobility, strength, cardiovascular fitness & activities of daily living performance in order to maximize function
Phase 1 therapeutic interventions for lower limb amputations
- Prone hip extension: keep both legs straight, lift residual limb, hold for 5 secs, repeat 30 times 1-2x/day
- Hip flexor stretch in prone: slowly prop yourself up on elbows, hold for 10+ sec, repeat 3-5 times 1-2x/day
- Hip ABD in sidelying: lift residual limb toward ceiling, hold for 5 sec, repeat 30 times 1-2x/day
- Bridging: place rolled up towel under residual limb, push down through both legs, hold for 5 sec, repeat 30 times 1-2x/day
- Prone knee flexion: hold 5 sec, repeat 30 times 1-2x/day
- Quad sets: hold 5 sec, repeat 30 times 1-2x/day
Slides 54-55
Describe UE pre-prosthetic phase
- Must strengthen muscles that control shoulder flexion, scapular protraction, retraction, & depression to operate a body-powered or hybrid prosthesis
- Opening/closing of the hand is often controlled through shoulder & scapular movements
- Scapular protraction or retraction combined with shoulder flexion of the residual limb, produces tension on the control cable and activates the terminal device (older models).
What muscles are used to stabilize the glenohumeral & scapulothoracic joints
- Trapezius
- Serratus anterior
- Rotator cuff
- Deltoids
Describe fall prevention management
- Practice floor recovery
- Educate patients regarding risk for falls & to have a plan for how to call for help
Functional ADLs should include:
- Transfers, practiced with and w/o a prosthesis
- Including sit to stand, bed to chair, chair to toilet and tub, into & out of a vehicle, & on and off the floor
Self-care training should include:
- Dressing
- Feeding
- Grooming
- Bathing
- Toileting
- All of the above with and w/o a prosthesis
Describe the prosthetic prescription/fabrication phase of amputee rehab
- Team approach for prosthetic prescription
Describe the prosthetic training phase of amputee rehab
- Prosthetic management & training to increase wearing time & functional use
Describe the community integration phase of amputee rehab
- Resumption of family & community roles
- Regaining emotional equilibrium/developing healthy coping strategies
- Recreational activities
Describe the follow-up phase of amputee rehab
- Lifelong prosthetic, functional, and medical assessment
- Emotional support
