Pre-operative Amputee PT Assessment

Question 1

Diabetes and amputations

Answer 1

it takes a while for diabetes to get so bad that they need a limb removed, therefore once the limb is removed they have a higher chance of dying within 1-3 years

Question 2

Ratio of Lower limb : upper limb amputations

Answer 2

4:1 due to infection

Question 3

Upper limb amputations are mostly caused by:

Answer 3

trauma

Question 4

Statistics of amputations

Answer 4

prevalence is equal with sex and race, cancer is associated with LE, only 1/3 of limb loss was in the UE, all age groups the risk of dysfunctional vascular related amputations was highest among males and individuals who are African American

Question 5

MC cause of amputations in non-industrialized countries?

Answer 5

trauma

Question 6

In the US 82% of all LE amputations are caused by? What are other causes?

Answer 6

PVD, DM or chronic venous insufficiency. Other causes are trauma (16.4%), cancer and malignancies (0.9%), and congenital deficiencies (0.8%).

Question 7

Risk of amputation increases with:

Answer 7

age, regardless of etiology, sex, and race

Question 8

Leading causes of trauma-related amputations are due to:

Answer 8

machinery (40.1%), powered tools and appliances (27.8%), firearms (8.5%), and MVA (8%)

Question 9

How often do vascular amputees use their prosthesis?

Answer 9

Vascular amputees don’t tend to use their prosthesis, prosthesis use drops from 85-31% in 5 years. Only 26% of major LE amputees walk outdoors after 2 years.

Question 10

How often do Syme amputation (ankle disarticulation) patients use their prosthesis?

Answer 10

Cumulative ambulatory rate at 1, 2, & 5 years has been reported to be 92%, 80%, and 80% respectively.

Question 11

Prosthesis practice pattern:

Answer 11

4J: Impaired gait, locomotion, and balance and impaired motor function secondary to LE amputation

Question 12

Causative Factors of Amputations

Answer 12

peripheral arterial disease, DM, gangrene (various causes e.g. due to the complication of a plaster cast), trauma (crushing, frost bite, burns), congenital deformities, chronic osteomyelitis, malignant tumor

Question 13

Risk factors of amputations:

Answer 13

age, cardiovascular disease, respiratory disease & smoking, GI (malnutrition, jaundice & adhesions), rehal dysfunction, hematological disorders, obesity, drugs, diabetes

Question 14

Complications of diabetes that contribute to the increased risk of foot infection include:

Answer 14

neuropathy, sensory, autonomic, motor, PVD, immuno-compromise

Question 15

High risk characteristics for developing food infections

Answer 15

Duration of diabetes more than 10 years, age >40, history of smoking, decreased peripheral pulses, decreased sensation, hx of previous foot ulcers or amputation

Question 16

Proper foot care for diabetics:

Answer 16

Check your sound foot and residual limb for sores, cuts, blisters or other problems every day. Check your shoes for pebbles and foreign objects. Wash your foot in warm, non hot, water, dry it well, especially between the toes. Trim toenails straight across. Protect your foot from extreme hot or cold, if you are cold at night, wear socks. Never use heating pads or hot water to warm your foot. Never go barefoot. Wear slippers or socks inside the house. Always wear your prosthesis or use a mobility aid. Hopping on your sound foot can lead to injury from overuse or by stubbing your toes or falling.

Question 17

Types of LE Extremity Amputation

Answer 17

Types of Lower Extremity Amputation

1. Toe Amputation
2. Transphalangeal Amputation (Toe Disarticulation)
3. Transmetatarsal Amputation (TMA)
4. Lisfranc Amputation (tarsometatarsal joint)
5. Chopart Amputation (talonavicular and calcaneocuboid joints)
6. Syme Amputation (Ankle disarticulation in which the heel pad is kept for good weight-bearing)
7. Transtibial Amputation (BKA)
8. Knee Disarticulation (Through-Knee Amputation or TKA)
9. Supracondylar Amputation
10. Transfemoral Amputation (AKA)
11. Hip Disarticulation
12. Hemipelvectomy

Question 18

Stages of Amputee Rehabilitation

Answer 18

9 periods of evaluation & intervention (each with its particular set of treatment goals). Communicate with interdisciplinary team, the patient, and family.

Question 19

1st stage of amputation

Answer 19

Preoperative: involves medical and physical assessment, patient education, functional prognosis, strengthening, discussion about phantom limb pain, realistic short and long term goals. If possible, patient should be placed in a cardiopulmonary conditioning program. Optimal rehab care of the amputation begins, if feasible, prior to the amputation.

Question 20

2nd Stage of Amputation

Answer 20

Amputation/Surgery/Dressing: Involves surgical residual limb length determination, closure of wound and soft-tissue coverage, nerve management, dressing application, and limb reconstruction.

Question 21

3rd stage of Amputation

Answer 21

Acute Post-Surgical: This phase begins immediately post-operatively and continues until the patient is discharged from the acute care hospital. Goals at this stage are pain control, optimization of ROM and strength.

Question 22

Stage 4 of amputation

Answer 22

Pre-prosthetic: involves residual limb shaping, stunp shrinking, skin care, increasing ROM and m. strengthening, cardiovascular training, progressive functional mobility training w/o a prosthesis

Question 23

Stage 5 of amputation

Answer 23

Prosthetic prescription/fabricaiton: involves team consensus on prosthetic prescription to satisfy the needs, desires and abilities of the patient.

Question 24

Stage 6 of amputation

Answer 24

Prosthetic training: prosthetic managment and training to increase wearing time and functional use.

Question 25

Stage 7 of amputation

Answer 25

Community Integration: Involves resumption of family and community roles, addressing emotional needs and developing health coping strategies, and resumption of previous and adapted recreational activities.

Question 26

Stage 8 of amputation

Answer 26

Vocational Rehabilitation: Involves assessment and training for work activities, and assessment of further education needs or job modification.

Question 27

Stage 9 of amputation

Answer 27

Follow-up: Includes lifelong prosthetic, function, and medical assessment and psychological support.

Question 28

Pre-operative history:

Answer 28

History, concurrent medical problems [ CVS (MI), RS, Smoking, BP, DM, Bleeding diathesis, CVA. Drugs, allergies, and alcohol, reactions to anesthesia, nutritional status, current meds, PMH, Family Hx., Social Hx., occupational Hx. (esp, living situation), systems review.

Question 29

Psycological Support Preparation

Answer 29

Emotional reaction to amputation, circumstances surrounding amputation (i.e. traumatic versus surgical), occupational and socail rehabilitation

Question 30

Integumentary circumferential measurements: What constitutes the presence of pitting edema? What are the scores?

Answer 30

Presence of pitting edema (0-4+). 0=non pitting. 1+= barely perceptible. 2+= skin rebounds <15sec. 3+= skin rebounds 15-13 sec. 4+= skin rebounds >15sec. If there is a s/s of infection, culture required.

Question 31

Pre-operative Examination Measurements

Answer 31

Edema measurements. Measurements taken to reduce pain must also be documented in every visit. Consider self-report measures such as the McGill Pain Questionnaire (MPQ). Balance: static/dynamic sitting and standing assessment. ROM of all limbs. Neuromuscular and functional status of all extremities (light touch, proprioception, semmes-weinstein monofilaments, MMT or gross measurement of LE and UE m. is assessed and documented, head/trunk control). Functional ability and condition of all limbs and the person in general**. Posture/Positioning including resting position of limbs (neutral or rotated). Vital signs (HR, BP, RR, SpO2) at rest, during, and post-activity). **Pulmonary**: auscultation, breating pattern, cough quality, managment of secretions. **Cardiac**: EKG, auscultation (rate/rhythm). **Vascular examination.

Question 32

Vascular examination includes:

Answer 32

Pulses of residual and opposite LE (femoral, tibial, dorsalis pedis, and posterior tibial); 0=absent, D=doppler, 1+= normal, 2= increased. Capillary refill (normal <3 seconds). Doppler ultrasound. Temperature (normal, increased temp, cool).

Question 33

Outcome Measurement tool uses:

Answer 33

They are useful to objectively measure various aspects of physical and phychologial functioning, and to track changes over time. Choose one that is appropriate for the specific stages of amputees’ rehabilitation course. LE amputee specific outcome measure appropriate for use in the inpatient acute care setting is the Amputee Mobility Predictor.

Question 34

What is the Amputee Mobility Predictor (AMP)

Answer 34

The total score range for the AMP is 0-24 points. When used with subjects without a prosthesis, the highest possible score is 38 points because item 8 (single-limb standing) is eiminated, as standing on the prosthetic slide is impossible. By using an assistive device, the subjects’ potential total score possibilities increase by 5 points (to 43 and 47 points), depending on the type of assistive device used during testing.

Question 35

What is the Medicare Functional Classification System (MFCL)

Answer 35

5 level functional classification system which uses code modifiers (K0, K1, K2, K3, K4) to describe the functional abilities of persons who have undergoing lower-limb amputation, and to justify the medical necessity of certain prosthetic components.

Question 36

Name Some Outpatient Outcome Measurement Tools:

Answer 36

Functional Independence Measure
Office of Population Censuses and Surveys Scale (OPCS)
Amputee Activity Score (AAS)
Get up and Go Test
6-minute Walk Test
Barthel Index
Trinity Amputation and Prosthetic Experience Scale
Locomotor Capabilities Index (LCI)
Medical Outcomes Study 36-Item Short Form Health Survey
Prosthesis Evaluation Questionnaire (PEQ)
Questionnaire for Persons with Transfemoral Amputation
Sickness Impact Profile
Amputee Body Image Scale: Developed to specifically address body image with persons with lower extremity amputation, both with and without prosthesis

Question 37

What are some potential body function changes:

Answer 37

Muscle performance (including strength, power, and endurance), ROM (including m. length), aerobic capacity and endurance, pain, posture, sensory integrity, gait, locomotion, balance, and knowledge of exercise program/ACE wrapping techniques. These impairments will result in decreased independence with bed mobility, transfers, ambulation, functional activities, B/IADL, and may negatively impact quality of life.

Question 38

According to the practice pattern 4J (impaired gait, locomotion & balance, and impaired motor function secondary to LE amputation). According to this practice pattern, the expected # of visits in an episode of care is what?

Answer 38

15-45

Question 39

What is the goal after a LE amputation? What type of approach does this require?

Answer 39

Aim is to bring the person to an optimum of physical, mental, emotional, social, vocational, and economic efficiency. This requires a multidisciplinary approach.

Question 40

What is the primary goals of impatient PT while in the acute care setting?

Answer 40

pain control, optimizing ROM & strength of both lower and upper extremity musculature, promotion of wound healing, early mobilization & maximization of functional independence, and to develop the skills necessary to progress towards prior level of activity and social participation as appropriate

Question 41

What are some examples of some STG to be achieved in 3-5 days in patients who were idependent propr to acute care hospital admission?

Answer 41

Patient will demonstrate independence w/ bed mobility. Patients will demonstrate independence with transfers to wheelchair with least restrictive assistive device. Patients will demonstrate independence with ambulation >/= 100 ft w/ least restrictive assistive device. Patients will demonstrate independence or assisted w/ stairs as necessary.Patients will demonstrate ROM WFL and strength > 3/5 throughout affected and nonaffected limb, as appropriate. Patients will demonstrate good balance in sitting and/or standing with device. Patients will perform an initial independent exercise program. Patient/family will demonstrate good understanding of residual limb management, edema control, and frequent skin inspection/skin care. Patient/family will demonstrate good understanding of residual limb management, edema control, and frequent skin inspection/skin care. Patient/family will demonstrate independence with wrapping techniques (or with family assist). Patient will demonstrate good safety awareness with all functional mobility.

Question 42

The long term goals (4-6 months) are concentrated on what aspects?

Answer 42

Return to their previous lifestyle using a prosthetic and/or assistive devices and adaptive equipment, as appropriate.

Question 43

When documenting the therapist should be aware of and document factors that may negatively or positively affect the person’s prognosis. What are some factors that could negativley affect the LE amputee?

Answer 43

Presence of co-morbities, such as ESRD and coronary. CAD, which may increase mortality and affect recovery. Pre-operative ambulatory status, as non-ambulatory and homebound status is associated with inability to use a prosthesis post-operatively.

Question 44

Exercise programs for the LE amputee should focus on what 4 main components?

Answer 44

Flexibility, muscular strength, cardiovascular training, balance

Question 45

Flexibility or stretching exercise to help prevent muscle shortening and joint contractures should be performed in a slow, controlled manner and held for at least ___seconds.

Answer 45

20

Question 46

What types of strengthening exercises are used for amputees?

Answer 46

isometric, isotonic, PNF and isokinetic activities

Question 47

For the unilateral LE amputee, the non affected limb becomes the _____ limb.

Answer 47

sole support

Question 48

The stance-phase stability requires adequate strength of what 4 muscle groups?

Answer 48

hip extensors, hip abductors, knee extensors, and plantar flexors

Question 49

The swing-phase of limb advancement and clearance requires adequate strength of what muscle groups?

Answer 49

hip flexors and ankle strength

Question 50

Sitting balance, bed mobility and transfers are facilitated by what?

Answer 50

strong, flexible back and abdominal flexors, rotators, and extensors and hip extensors

Question 51

What is important in supporting the body during transfers and during the use of assistive devices?

Answer 51

shoulder stabilizers, adductors and depressors, elbow extensors, wrist stabilizers, and grip strength

Question 52

What types of mobility practice can a patient do pre-prosthetic phase?

Answer 52

wheelchair mobility, sliding board, & UE ergometry

Question 53

Name 3 pain management strategies:

Answer 53

biofeedback, relaxation and breating techniques, cryotherapy. Mechanical stimulations such as stump massage, percussions, and vibratory stimulations. US, superficial heat and cryotherapy have been reported to have some success in short-term pain relief. Eye movement desensitization and reprocessing, in which a series of rapid and rhythmic eye movements are induced by the therapist.

Question 54

What PT tx. is used to treat phantom limb pain?

Answer 54

E-stim such as auricular electrical stimulation, transcutaneous electrical nerve stimulation or TENS, spinal cord simulation, and motor cortex stimulation have been used with variable results. TENS has been demonstrated to have about 50% success rate in the tx. of phantom pain. Mirror box therapy, pain relif is hypothesized to be due to cortical restructuring.