Post-Surgical Amputee Care Flashcards
what is the name of Phase 1
Acute
what is the name of Phase 2
post acute/ pre-prosthetic
what is the name of Phase 3
initial prosthetic/ rehab
what is the name of Phase 4
prosthetic/ advanced rehab
what is the name of Phase 5
return to PLOF
where would a patient be located for phase 1
hospital or just transferred to rehab unit
what are the main goals for phase 1
- edema/hypersensitivity
- basic mobility
- limb care
- positioning
- wound care
what are the goals for phase 2
- edema/ hypersensitivity
- ROM/ strength deficits
- I with bed mobility, transfers, w/c mobility using AD
- education/ support services
- NOT casted/fitted with prosthetic
what are the goals of phase 3
- intermediate rehab stage
- 50-90% strength returns
- temp prosthetic
- WBing activities
- prosthetic gait training
- education about prosthetic/ residual limb care
what are the goals of phase 4
- edema/ limb sensitivity stable
- I prosthetic ambulation w/ and w/o prosthetic device
- minor difficulty with WB
- agility/endurance training
- higher level skills
- community level functional mobility
what are the goals of phase 5
- edema/limb sensitivity stable
- I with prosthetic ambulation
- minor difficulty WBing
- agility/ endurance
- higher level skills
- community level functional mobility
what are some residual limb management for phase 1
promote wound healing, control edema, improve strength/ROM, and manage pain
for phase 1 what are some wound care techniques
cover wound with gauze/sterile dressing; monitor wound and periwound; watch dressing
what kind of dressing can you use for wound care management for phase 1
soft elastic, unna dressing/air splint, semi-rigid dressings, rigid removable dressing, and immediate postoperative prosthesis
what are the pros of elastic bandages
- readily available
- inexpensive
- distal to proximal pressure gradient to control edema
- helps with limb shaping
what are the cons of elastic bandages
- restrict circulation
- manual dexterity to apply
- doesn’t protect from trauma
what is the advantage of shrinkers?
give more symmetrical pressure = provides same pressure gradient but its even
what should you avoid with bandages
no circular turns, no open areas or wrinkles
what kind of pressure should you use for bandages
distal > proximal
what are pros of shrinkers
- more effective than elastic bandages in reducing edema
- shapes limb
- symmetrical pressure
what are the cons of shrinkers
- careful with staples
- difficult to keep on TF liimb
- order new size for limb volume change
- need two
- doesn’t protect from trauma
what are the pros of unna dressings?
- lightweight
- left for several days
- applied in OR
- TF stays on better
- TT - prevents flexion contracture
what are the cons of unna dressings?
- can’t inspect wound
- itchy
- doesn’t protect from trauma
what are the pros of air splint
- easy to get on/off
- uniform compression (25)
protects from trauma - cleaned/sterilized
- aluminum frame for early ambulation
what are the cons of air splint
- cant use for TF limbs
- need manual dexterity to apply
- humid to wear
- only PWB allowed
what are the pros of silicone gel liners?
- compression for edema control
- smooth scar tissue
- learn to use it early
what are the cons of silicone gel liners?
- traps sweat
- manual dexterity needed
- can’t use with skin grafts, poor BF, necrosis, infection, and allergy
- must be cognitively aware and complaint
what are the pros of rigid dressings
- applied in OR
- healing faster
- protects against trauma
- controlling edema decreases need for pain meds
- shapes limb
what are the cons of rigid dressings
- can’t be used with infection
- can cause skin breakdown
- pain if limb swells
- paid onset of edema can cause pain after removal
what are the pros of removable rigid dressing
- can inspect the wound
- protects from trauma
- compresses wound
- can be washed
- adjustable with limb atrophy, volume reduction
what are the cons of removable rigid dressing
- patient can take it off
- pre-fabricated RRDs may need to be replaced if limb loses volume
- not designed for ambulation
what are the pros of IPOP
- detach from pylon to ensure compliance with WBing restrictions
- early ambulation possible
- limits deconditioning
- psychological benefit
- transition to prosthetic easier
what are the cons of IPOP
- patient can WB too much and open surgial wound
- can injure the sound leg
- rigid dressing cons
what are the 3 pains amputees can have
- phantom pain
- nonpainful phantom sensations
- residual limb pain
what is non-painful phantom limb sensations
feels like limb is present, can feel like limb is wrapped in cotton, feel itching,touch, pressure, and feelings of movement
what is phantom limb pain?
pain in the missing portion,
what is the prevalence of phantom limb pain?
60-85%
adults > children > congenital amputees
when is the common onset of phantom limb pain?
1 week post op
what exacerbates the phantom limb pain?
stress
what causes phantom limb pain?
peripheral and central changes
what are some peripheral changes that cause phantom limb pain?
structure changes in neurons, ectopic impulses, ephaptic transmission, sympathetic-afferent coupling, down or up regulation of transmitters, alterations in channels and transduction molecules, and selective loss of unmyelinated fibers
terminal swelling and regenerative sprouting of injured axon end creates a _________ which has ______ __________ which causes ____________ ___________ _________.
neuroma; ectopic charge; abnormal afferent input
what also has ectopic discharges?
DRG
DRG plus neuroma discharges create what?
barrage of afferent input
what can also contribute to a “barrage” of afferent input?
sympathetic sprouting (adrenergic blockers sometimes help)
what are some central changes that cause phantom limb pain?
unmasking, sprouting, general disinhibition, map remoderling, loss of neurons, denervation, and alterations in neuronal and glial activity
after UE amputation, there is what?
massive cortical reorganization
because of the reorganization after UE amputation, what is a result?
touch, cold, warmth, vibration that is applied to face refers to phantom sensation in the hand
why does the hand get phantom sensation when something is applied to the face?
brain perceives sensations as originating from the missing hand
the greater the phantom limb pain, _______.
the greater the sensory cortical reorganization
“cells that fire together, ____ ____________”
wire together - nerves for touch, pain, temp are close to each other and can “rewire”
what is phantom limb pain treated with?
medications, rehabilitation, and occasionally surgery
what is residual limb pain related to? will it go away?
surgical procedure (trauma), yes, it will go away
what are some residual limb pain causes?
neuroma, bone spurs, MS pain from overuse, prosthesis, referred LBP
what is part of the initial rehab?
positioning, functional mobility, W/C considerations, and psych
For initial rehab, what should you focus on relating to ROM
- positioning - hip and knee extension, hip adduction
- immobilization to maintain ROM (air splint, rigid dressing)
- Manual Therapy - at incision site for scar management
For initial rehab, what should you focus on relating to strength?
isometrics, AROM, resistance, closed chain activities
For initial rehab, what should you focus on relating to functional mobility?
transfers - sliding board, AD
bed mobility - new awareness of body parameters, core strength issues
what are some w/c considerations?
cushions (ROHO), want max push efficiency, change in COG (anti-tippers needed)
when developing interventions, what should you think about?
- impairments CANT be ignored
- meaningful to the patient
- relevant to pt in their specific life environment
How do you establish a foundation for success
setting goals, listen to your patient, provide them info about how to be an amputee
what are some considerations to think about when wrapping the residual limb?
no circular turns, distal > proximal, and no open areas/wrinkles
what should be included in patient education during the postacute/ pre-prosthetic phase?
- residual limb care
- use of shrinker
- HEP
- emphasis on rehab process
what are some considerations for residual limb management?
- volume stabilization
- shaping the limb
- desensitization of phantom and residual limb pain
What should you do for edema management?
education, volume reduction with limb wrapping/shrinker, and diet
what should you do if the patient has soft tissue restrictions?
manual therapy - ST mobilization, self massage, general desensitization techniques
how would you address ROM limitations
- stretching - prone position, thomas stretch
2. positioning device - posterior shell or leg board
How would you address strength deficits and motor control issues?
strengthen - LE, core, UE
what do you do about motor control?
coordination and agility
what do you do about decreased balance
sitting and standing balance,
why is SLS important
important for stance phase during walking
what are terms for body awareness?
proprioception and kinesthesia
what are some considerations for mobility?
w/c
walker - energy expenditure and UE wear and tear
what should initial prosthetic wear schedule be based on?
skin integrity, cognition, and patient safety
