UE AMPUTATION- SYNCH Flashcards
Functions of the upper limb
fine manipulation
power grasp
communication
interaction with the environment
self-image
completion of most ADL
Most common cause of UE amputation
trauma
-50% of those with UE acquired amputation choose to wear prosthesis
-majority are young males
-male to female ratio 8:1
-21-64 years old make up 80%
Congenital amputation
-transverse: limb is absent across the longitudinal axis
-longitudinal: the deficiencies are along the axis of the limb but do not cross it (radial or ulnar deficiencies)
-upper limb absences are more common than lower limb by a ratio of 60:40%
acquired amputation
Traumatic: machinery, explosives, projectiles, MVA, burns, electrical and cold exposure injury
Dysvascular: necrotizing fasciitis, toxic shock, DM, etc
Malignancy of bone/joint
Questions to ask during exam/subjective
current thoughts and info regarding prosthesis (before pt has their own)
any visual or short term memory problems which may affect treatment
Signs of PTSD:
sleep pattern changes
presence of night/daymares or flashbacks
occurrence of sudden or disruptive anxiety/depression causing immobility/feeling of a loss of control
Assessment of the residual limb:
-wound
-skin/scar: adherent, flabby/firm, flap coverage, palpable neuroma
-length
-shape
-bony prominences (for suspension)
-sensation
-A/PROM: primarily proximal, including scapula
-the strength of remaining mm. noting weakness which may be related to a peripheral nerve injury
-residual pain
-phantom sensation/phantom pain
Levels of UE amputation
forequarter- loss of scapula and clavicle
shoulder disarticulation
transhumeral= above elbow (very short, short, standard, long)
elbow disarticulation
transradial - below elbow (very short, short, standard, long)
wrist disarticulation
carpal disarticulation
transmetacarpal
digital
Options for a prosthesis for the UE:
no prosthesis
a passive or oppositional prosthesis
body-powered prosthesis
externally powered prosthesis
use of a combination of each (hybrid)
task-specific prosthesis
Phases of UE amputation rehab
pre-op: acute rehab, 1-2 visits to talk about edema control, residual limb shaping and 1-handed ADLs
-team consult or while patient is in critical care (limb salvage)
-may occur before elective amputation for malignancy, brachial plexus injury, or revision of present amputation
-discuss: amputation level, collaboration between IP and OP staff, patient goals, plan for prosthetic use and strengthening
-address one-handed use and change of dominance
**often the patient and family are not ready to see or hear about the prosthesis at this time
post-op:
- in inpatient physical therapy
-grief
-one-handed ADLs
pre-prosthetic
prosthetic prescription and fabrication
prosthetic training
** need 3 months or more
Incisional pain and phantom pain management
INCISIONAL:
-generally managed by narcotic agents delivered IV or IM in the first 3-4 post-op days, TENS
PHANTOM:
-amitriptyline (Elavil)
-isometric exercise
-guided imagery/mirror therapy (Ramachandran)
Phantom sensation vs phantom pain
SENSATION
-feeling that the limb is still present or partially present
-can be helpful for prosthetic training
PAIN
-feeling or sensation of pain in the limb that was removed
-abnormal
-treated aggressively
Where is UE ROM most commonly lost following amputation?
GH and elbow joints
-can begin AROM of the residual limb as early as POD 2
-gentle isometric contractions can begin at POD 5, isotonic 7-10
What is the necessary shape of the residual limb needed for prosthetic fitting?
conical shape
-achieve this shape with ace wrapping in a figure-of-eight fashion with more pressure distally than proximally
-can also perform tubular elastic bandaging
ROM, strengthening, and hygiene
-address chest expansion with burns due to scar tissue formation
-address scapular and glenohumeral mobility and strengthening
-distal weighting with cuff weights
-residual limb to be washed daily with soap and water, patted dry
Strengthening during post-operative pre-prosthetic phase
-scapular stabilization BL
-functional strength training for core strengthening (ball)
-balance/symmetry of gait and arm swing
-strengthening of unaffected uE
-strength of remaining mm. of residual limb
-** Strengthening helps to reduce phantom limb pain
-lifting hook
Things to watch out for when using a prosthesis during strength training
-blisters, abrasions and rashes due to harnessing on a body-powered prosthesis or from hanging unsupported and then being subjected to the opposite forces with sudden suction on closed chain contact
–> swelling, dark, red discoloration and a bulbous end of the limb
Overuse of the unaffected limb- things that can be examined/ addressed
-activity analysis needs to be performed to address repetitive, forceful, or awkward ADL
-joint protection training
-energy conservation training
-can also have dental damage due to donning and doffing with teeth
Two important things to focus on to maximize an individual’s independence after an UE amputation
-interventions to adapt to one-handed ADLs
-change of hand dominance if necessary
Most important/impactful reason why individuals choose not to get an upper extremity prosthesis:
-too much time was taken before fitting–> they adapted to life without one
-easiest to accept one within the first 3 months
Something to consider with insurance
-a lot of patients opt for the myoelectric prosthesis because most third-party payers will only cover one prosthetic
Types of UE prostheses
IPOP - immediate post-operative prosthesis
-passive or oppositional
Body Powered -
-powered an controlled by gross body movements captured by a harness system through a cable
Externally Powered - myoelectric, switch controlled, touch pad controlled, servo controlled
Hybrid
Activity Specific/Recreational
Where are BUE patients often seen for rehab care?
inpatient setting (regional amputee programs)
TIRR - Texas Institute for Rehabilitation and Research
RIC - rehab institute of chicago
Order of how much training time is required for body powered prostheses
transradial (5 hours) –> transhumeral and shoulder disarticulation–> bilateral transradial –> bilateral transhumeral (20 hours)
Donning a body bowered prosthesis
“coat method”
-most often used by unilateral amputees
“pullover sweater method”
-bilateral amputees most common
Prosthetic wearing schedule:
start with <15 min at a time with frequent skin checks
if no skin problems–> increase wear time to 30 increments 3x/day
then at the end of the week –> patient wearing all day
clean res. limb and prosthetic socket with soap and water
change stump socks often
Body control Motions for Body Powered Prosthesis
OPENING THE TD
-scapular abduction and shoulder flexion
-hook opens as you move the arm forward
-elbow must be locked first
LOCKING/UNLOCK THE ELBOW UNIT
- Scapular
Depression/Extension/Abduction; this “down, back and
out” combined motion is required to lock and unlock an
elbow unit with an AE prosthesis; this is a “two-click” cycle
-elbow must be locked before the TD can be operated
ELBOW FLEXION/EXTENSION
- Accomplished using a forearm-
lift device which responds to scapular abduction and chest
expansion when the elbow is unlocked
CHEST EXPANSION
- Used for harnessing with a forequarter,
shoulder disarticulation or high AE amputee with a cross-chest strap
Manual controls training for body powered prosthesis:
Positioning of the shoulder joint:
-manually adjusted by sound hand or against an object with a friction unit
internal/external rotation
-controlled by rotation of the elbow turnable by leaning the prosthesis against an object in an internal or external rotation fashion
wrist flexion
-operate unit by pushing on the button on the forearm by sound hand or against object for BL amputee
positioning the TD in the wrist unit:
-done by passive rotation with the sound hand into pro/supination for UL
-force against another object or between the patient’s knees for BL
How is elbow lock/unlock accomplished for forequarter or shoulder disarticulation amputees?
chin nudge control button attached to the thoracic socket
Functional use training
-most difficult, prolonged stage during which acceptance of the prosthesis is determined
-pre-positioning of the TD is emphasized: aided with phantom limb sensation and mirroring sound hand
What level of amputation requires prostheses to function independently?
bilateral above the elbow amputees
Electrically powered prostheses
- Clinical use of these devices began in Europe due to government-supported healthcare and a large patient population of congenital amputees (post- thalidomide)
- The term myoelectric is often used interchangeably
with electric prosthesis - Myoelectric prosthesis uses mm. surface electricity to control the prosthetic hand function
