PT Management of Amputations Throughout the Continuum Flashcards
what is the primary cause of amputation?
PVD (peripheral vascular disease) of the LE particularly due to DM
what is the second leading cause of amputation?
trauma (MVA, machines, gunshots)
t/f: adults with DM are 10x more likely to have an amputation that someone without DM
true
PVD is most prevalent in what people?
males
those over 75 yo
African Americans
many amputations are preceded by what?
foot ulcers
are amputations more common in the UEs or LEs?
LEs
what are the levels of amputation in the LEs?
hemipelvectomy
hip disarticulation
transfemoral
knee disarticulation
trans tibial
ankle disarticulation
Syme’s (type of foot amp)
partial foot (CHopart, Lisfranc, transmatatarsal)
what are the levels of UE amputations?
forequarter
shoulder disarticulation
transhumeral
elbow disarticulation
transradial
wrist/hand disarticulation
partial hand (transcarpal/transmetacarpal)
t/f: in post-traumatic amputation, the surgeon will attempt to maintain the greatest bone length and save all possible joints
true
why is it important that surgeons try to maintain as much of the limb as possible?
bc have a greater limb length will decrease the metabolic cost of ambulation and lead to greater fxnal px
t/f: amputation d/t vascular disease is generally performed partial foot (transmetatarsal), transtibial, transfemoral
true
what are the types of skin flaps that may be used in amputation?
equal length flaps
posterior flaps
what type of skin flap involves a scar right on the distal tip of the residual limb?
equal length flaps
what type of skin flap involved taking the skin from the posterior aspect of the limb and wrapping is around so we see the incision on the anterior aspect of the residual limb surface?
posterior flaps
why are posterior flaps preferred to equal length flaps in amputation?
bc the posterior aspect of limbs often have better blood circulation to the area which promotes good healing
t/f: skin flaps in amputation are intended to be as BROAD as possible
true
scars should be…
pliable, painless, and non-adherent
what is the incision?
where the two ends of skin come together
what is the residual limb?
what’s left of the limb after the amputation
what things must we consider about the residual limb?
length
uncomplicated wound healing
creation of a pain-free limb
swelling of the residual limb
why is it important to understand where muscles were stabilized in an amputation?
bc it contributes to muscle fxn and resting postures
why must we stabilize major muscles that are cut during surgery?
to promote max muscle tension and fxn
how is muscle stabilization achieved post amputation?
myofascial closure (ms to fascia)
myoplasty (ms to ms closure)
myodesis/tenodesis
what are neuromas?
collections of nerve cell endings
t/f: neuromas must be well surrounded by soft tissue
true
t/f: nerves are cut cleanly to allow for retraction
true
if neuromas are bundled too much, what does it cause?
pain
what is involved in managing neuromas?
desensitization
what are the concerns for post surgical healing?
infection
smoking
vascular health
renal fxn
cardiac healing
what can PT do to influence healing post amputation?
proper bed mobility with proper utilization of the residual limb
pressure relief of new surgical site
early mobilization
edema management (critical and related to prosthetic fitting)
what are the goals of post surgical phase of amputation?
residual limb wound healing, pain management, and edema control
ROM and strength of UEs and LEs (residual and intact)
residual limb protection
sitting and standing balance
independence with transfers and bed mobility
proper sitting and bed positioning
education of process of prosthetic care
what are the goals for the preprostehtic phase of amputation?
independence with residual limb care (edema, skin care, desensitization, positioning)
independence with mobility, transfers, and fxnal activities
performance of HEP with good form
general CV conditioning for prosthetic use
what may be involved in independence with mobility, transfers, and fxnal activities in the preprosthetic phase?
IPOP
ambulation on various surfaces
car, floor, and bathroom transfers
what is IPOP?
immediate post-op prosthesis
t/f: HEP should include ROM and resisted exercises of just the residual limb in the preprosthetic phase
false, it should include the residual limb and unamputated limb and the UEs
what is involved in the post-surgical examination?
medical record review
physical exam
systems review
pain
MSK
balance
fxnal status
what is involved in the medical record review in the post-surgical examination?
Tobacco use
Chronic conditions
Type/level amputation
Residual limb status: healing, infection, dressing
Social hx/PLOF
OOB status/orders
why is it important to ask about tobacco use in the post surgical examination medical review?
bc it can slow healing
what is involved in the physical exam in the postsurgical examination?
Observation of residual limb position, dressings
Mental status
Affect
what is involved in the systems review of the postsurgical examination?
CV
VS
Pulm
Resp
Integ (of entire body)
neuromuscular
what is involved in the pain assessment of the postop examination?
Residual limb pain
Incision pain (pay attention to pliability of the scar and mobility of the skin)
Phantom limb pain
what is involved in the MSK assessment in the post-op examination?
ROM of residual limb and intact extremities
Gross fxnal performance of intact extremities
what is involved in the balance assessment in the post-op examination?
sitting
standing
reactive balance
what is involved in the functional status assessment in the post-op examination?
bed mobility
transfers
sitting
standing
ambulation with AD
safety
what are the post-surgical interventions?
positioning
fxnal training
balance training
pt education
caregiver education
ambulation and gait training
residual limb care
what is involved in position post-surgical?
avoidance of contractures of the residual limb
preparing for adequate ROM for prosthetic use
prolong positioning strategies
what is a common TTA contracture we need to avoid with our positioning interventions?
knee flexion contracture
what are common TFA contractures we need to avoid with our positioning interventions?
hip flexion and abduction contractures
t/f: it is much easier to avoid contractures than to have to reverse them once they occur
true
t/f: we should support the residual limb by putting a pillow under it
FALSE, no pillows should go under the knee
what is an good way to avoid a flexion contracture of the knee and promote extension?
prone positioning
what is involved in fxnal training post-surgical?
independence with bed mobility
transfer training with safety awareness
t/f: pts post amputation are learning new motor patterns due to a new weight distribution
true
what is involved in balance training post-surgical?
Unsupported sitting balance (TFA)
Sitting balance (BL amputations)
Standing balance on intact extremity using an AD or IPOP as needed
Compliant surfaces if appropriate
what is involved in pt ed post surgical?
rehab of amputation and prosthetics
safety awareness
caregiver ed
what is involved ambulation and gait training post surgical?
utilization of appropriate devices
we, often use RW with ambulation/gait training, but this tends to promote an abnormal gait patterns, so what is a better option for promoting normalized gait?
crutches
if using an IPOP, what AD should be used?
crutches
what is involved in residual limb care in the postsurgical phase?
volume containment/edema management
monitor incision and healing status
gentle, pain-free mobility
resistive exercises are CONTRAINDICATED at this time
care of remaining limb (circulation)
t/f: the limb needs to be reshaped after surgery due to swelling
true
what shape are we striving to achieve with limb reshaping for optimal fit in a prosthesis?
conical shape
t/f: we still need to manage edema after prosthetic fitting
true
how do we reshape the residual limb?
With soft, semi-rigid, rigid dressings or a temporary immediate post op prosthesis (IPOP), soft dressings (ace wrapping figure 8, or “shrinker”)
soft dressings/elastic wraps are most commonly interacted with by PTs in what setting?
in the acute care environment
t/f: we want even tension/pressure throughout the wraps
true
what is the limb shape immediately post op?
bulbous
what are the goal shapes when reshaping the limb? what is the most ideal shape?
conical and cylindrical and the goal shapes with cylindrical being the most ideal
what is the healing timelines post-op?
4-8 weeks typically depending on the pt and their hx
what are the goals of post-op care?
PROTECT
shape
rehab
what is involved in the preprosthetic phase examination?
medical record review
physical exam
system review
pain
MSK
balance residual limb
fxnal status
what is involved in the medical record review preprosthetic examination?
Tobacco use
Chronic conditions
Type/level amputation
Residual limb status (healing, infection, dressing)
Social hx/PLOF
OOB status/order (of utmost importance here)
what is involved in the physical exam of the preprosthetic examination?
Observation of residual limb position and dressings
Mental status
Affect
what is involved in the systems review of the preprothesis examination?
VS
CV
Resp
Integ (skin integ, wounds, scars) -very important here
Neuromuscular (sensation)
what is involved in the pain assessment in the preprosthetic examination?
residual limb pain
incision pain
phantom limb pain
what is involved in the MSK assessment of the preprosthetic examination?
ROM of residual limb and intact extremities
Gross fxnal performance of intact extremities
what is involved in the balance assessment of the preprosthetic examination?
Sitting
Standing
Reactive balance
what is involved in the residual limb assessment of the preprosthetic examination?
Length
Soft tissue length
Shape (cylindrical/abnormalities)
Incision
Skin condition
what is involved in the fxnal status assessment of the preprosthetic examination?
Bed mobility
Transfers
Sitting
Standing
Ambulation with AD
Safety
what is involved in residual limb care intervention?
Edema management/volume control (important for pt to learn to do independently)
Bandages and wrapping generally worn 23 hrs/day (all day except bathing)
how should wrapping be applied to the residual limb?
Smooth, even pressure, wrinkle free, cylindrical
how often should the limb be re-wrapped?
every 4 hours
why should the limb be re-wrapped every 4 hours?
to maintain good tension
exercise should be prescribed to what limbs?
all limbs, residual and in tact, upper and lower
the start of exercise prescription post amputation depends on what?
the residual limb healing
t/f: the goal of our exercise prescriptions is to have the pts be able to do them independently
true
what positions are exercises generally performed in?
supine, prone, and SL
LE exercises should be inclusive of what?
hip extensors and abductors
core stabilizers
knee extensors (TTA)
what is linked to negative success of prosthetic rehab and social activity?
poor balance and FOF
pts need good standing balance on the _____ limb
intact
t/f: if appropriate, we should introduce compliant surfaces, UE movt, and distracting/multitasking activities to our balance interventions
true
what is involved in mobilization and early gait training?
Early WBing on residual limb
Early gait training with crutches in 3-point gait pattern
Weight-shifting/pre-gait activities (toe taps, dynamic standing balance)
Generally, try to avoid walker use unless necessary bc it promotes abnormal gait patterns
what is involved in protecting the residual limb in the acute and subacute healing phases?
preventative positioning
fall prevention
limb/skin care
what is involved in rehabbing the residual limb?
positioning for protection
ROM
stretching
desensitization
phantom limb sensation/pain management
what stretching/ROM exercises should we prescribe at the hip to prevent contractures?
hip flexion, extension, adb, add, IR, and ER
what stretching/ROM exercises should we prescribe at the knee to prevent contractures?
knee flexion and extension
what are the goals of ROM and flexibility in treatment?
avoid contractures
maintain optimal length-tension
prepare for prosthesis
get complete hip/knee ROM
what is the best intervention for contractures?
PREVENTION
what are the cardiopulmonary implications s/p amputation?
Greater HR response
Greater cardiac workload
t/f: pts post amputation utilize energy at a higher rate s/p amputation
true
t/f: amputation, ADs, and prosthetics have no effect on metabolic cost of walking
false, they increase the metabolic cost
what is the % increase in metabolic cost of walking with a partial foot amputation?
> 15%
what is the % increase in metabolic cost of walking with a TTA amputation?
> 25%
what is the % increase in metabolic cost of walking with a vascular TTA amputation?
> 40%
what is the % increase in metabolic cost of walking with a TFA amputation?
> 68%
what is the % increase in metabolic cost of walking with a vascular TFA amputation?
100%
what percent of amputees suffer from PLP at an intensity of 5/10 VAS?
80%
is treatment of PLP pharmacologic or non-pharmacologic?
both
what are the non-pharmacologic treatments for PLP?
deep brain stim, SC/dorsal root stim, TCDS, TENS, acupuncture, hypnosis, mirror therapy, VR (neuroplastic change effect for neural representation)
what are the non-pharmacologic PT treatments for PLP?
mirror therapy, VR (neuroplastic change effect for neural representation)
what is the goal of desensitization?
to eliminate/minimize the physical or psychological responses to stimulation
in the healing phase, what things can we do for desensitization?
Gentle massage
Light tapping
Vibration
Constant pressure
Application of various fabrics to the sensitive area
how long should desensitization be done in the healing phase?
minimum of 2-3x/day for at least 5 minutes
after the residual limb has completely healed, what can be done for desensitization? why?
active massage therapy/deep friction massage is recommended to prevent skin adhesion and to increase tolerance to the pressure associated with contact bw the stump and socket in the prosthetic phase
what is involved in phantom limb management?
analgesics
desensitization
mirror therapy
repetitive transcranial magnetic stimulation
imaginary phantom limb exercises
VR
what is the purpose of mirror therapy for phantom limb management?
modulation of cortical excitability/cortical map
reducing pain/sensations
how do we perform mirror therapy?
have the pt perform an action with their intact limb while looking at the reflection of it in the mirror to create the illusion that the amputated body moves w/o pain
what factors strongly predict prosthetic candidacy?
amputation at a lower level
younger age
physical fitness
no/few comorbidities
what are factors that moderately predict good candidacy for prosthetics?
good cognition, mood, SLS>10s, and good pre-amputation living situation
how do we determine the K level?
interview
fxnal outcomes measures
using current abilities and restrictions
what is the K-level?
the prediction of someone’s prosthetic use post amputation
what is a K0 fxnal level?
non users
what is a K1 fxnal level?
short ambulation
what is a K2 fxnal level?
single cadence, limited community ambulation
what is a K3 fxnal level?
variable cadence, unlimited community ambulation
what is a K4 fxnal level?
high activity
why are K-levels important?
insurance looks to these classifications to determine medical necessity of a prosthesis and its components
(ie. not going to cover running blades for someone we’ve determined to be a K1 user)
what is the most important factor in determining prosthetic potential?
PLOF
what are the predictive/prognostic factors for determining prosthetic potential?
PLOF prior to amputation
hip strength and balance
rehab at a comprehensive inpatient rehab facility
time to get a fitting for prosthesis
hip strength and balance are predictive of what?
fxnal ambulation
those that receive amputation care where have better likelihood of higher mobility?
at a comprehensive inpatient rehab facility
t/f: the longer the delay in fitting prosthesis, the lower the rehab potential
true
what is the mobility assessment tool used for amputation?
Amputee mobility predictor assessment tool (AMPnoPRO or AMPRO)
a score of what indicates K1 with the AMnoPRO?
9.7+/-9.5
a score of what indicates K2 with the AMnoPRO
25.3+/-7.3
a score of what indicates K3 with the AMnoPRO
31.4+/-7.4
a score of what indicates K4 with the AMnoPRO?
38.5+/-3.0
a score of what indicates K0 with the AMPRO?
0-8
a score of what indicates K1 with the AMPRO?
25+/-7.4
a score of what indicates K2 with the AMPRO?
34.7+/-6.5
a score of what indicates K3 with the AMPRO?
40.5+/-3.9
a score of what indicates K4 with the AMPRO?
44.7+/-1.8
t/f: chatting during the administration of the AMPnoPRO and AMPRO should be limited
true
how long does shrinking/shaping take?
2-4 weeks
when is preparatory care done?
6-12 months out
what is involved in preparatory care?
trial prosthesis
when is definitive care done?
3-5 yrs out or as medically necessary
what is involved in definitive care?
prescription of their “lifelong” prosthetic unless replacements are medically necessary
