Week 7 Flashcards
What is the role of the physical therapist in the rehabilitation of lower extremity amputees?
Maximize level of functional ability possible
What are the characteristics of the role of the PT in the rehab of the LE amputee?
- Amputee must be physically prepared about prosthetic gait training even before being fitted with it.
- He must learn how to use and care for the prosthesis. Prosthetic gait training can be the most frustrating and rewarding phase for all involved. He must be re-educated on the bio-mech of gaits while learning how to use the prosthesis.
- The therapist should introduce the amputee to high level of activities beyond learning to walk. The
amputee might not be able to engage in sports and recreational activities immediately, however, that is
the ultimate goal in most part of the population.
What are the primary phases of rehabilitation for lower extremity amputees?
- Post-surgical Management
- Pre prosthetic Management
- Prosthetic Management
What defines the post-surgical management phase?
Time between the performance of amputation surgery and discharge from the hospital.
What are the goals of the post- surgical management phase?
- Promote healing residual limb
- Protect intact limbs
- Maximize functional independence Prevent motion loss
- Educate in the process of prosthetic rehabilitation
- Facilitate psychological adjustment
Which elements are key in the post-surgical assessment?
- General systems review
- Post-surgical status
- Pain
- Functional status
- Range of motion
What are the characteristics of the post-surgical status that is key in the post-surgical assessment?
- Cardial
- Vascular
- Respiratory
- Metabolic (esp relating to blood sugar control)
- Infection status
What are the characteristics of the pain that is key in the post-surgical assessment?
- Incisional
- Neuropathic
- Experience of pain in other body region that could affect functionability.
What are the characteristics of the functional status that is key in the post-surgical assessment?
- Bed mobility
- Transfer; -sitting and standing
- Assessment of certain functionability may be deferred till when adjudged appropriate depending upon the surgeon’s discretion and patient’s status.
What are the characteristics of the ROM that is key in the post-surgical assessment?
Growth range testing between lower and upper extremities. Care should be taken on this assessment with excess support on active motion only initially with the avoidance of knee fracture and extension following trans-tibia amputation. As well as the avoidance of rigorous hip abduction following trans-femural amputation.
What criteria are used in selecting dressings during this phase?
- Level of amputation
- Surgical technique
- Healing requirements
- Patient compliance
- Surgeon preference
What are the effects of a dressing for surgery?
Dressings are for protection of the surgical site, may aid in reducing edema and may help in shaping the residual limb. The selection of the type of dressing used in this phase depends on the level of amputation, the surgical technique used, the healing requirement, especially if burns and tissue grafts are involved.
What are the pros that soft dressings offers during the post-surgical management phase?
- Easy to apply
- Inexpensive
- Easy access to incision
What are the cons that soft dressings offers during the post-surgical management phase?
- Little edema control
- Minimal protection
- Requires frequent rewrapping
What are the pros that shrinkers offers during the post-surgical management phase?
- Easy to apply
* Inexpensive
What are the cons that shrinkers offers during the post-surgical management phase?
- Not used until sutures are removed
* Requires changing as residual limb shrinks in size
What are the pros that semi-rigid dressings offers during the post-surgical management phase?
- Better edema control than soft dressing
* Improved protection
What are the cons that semi-rigid dressings offers during the post-surgical management phase?
- Needs frequent changing
- Cannot be applied by patient
- No access to incision
What are the pros that immediate post-op prosthesis (IPOP) offers during the post-surgical management phase?
- Excellent edema control
- Excellent protection
- Pain control
- Early weight bearing
What are the cons that immediate post-op prosthesis (IPOP) offers during the post-surgical management phase?
- No access to incision
- More expensive than other dressings
- Requires proper training for use
What kind of patient is an immediate post-op prosthesis (IPOP) ideal for?
Ideal for patients possessing the physical capacity and
healing potential required for their use.
What are the outcomes associated with the rigid dressing post surgery?
- Accelerated rehabilitation times
* Reduced edema
What are the outcomes associated with the immediate post-op prosthesis (IPOP) post surgery?
- Fewer post-surgical complications
* Fewer higher-level revisions of surgeries
Why is sound side limb care crucial in post-surgical management?
As majority of individuals undergoing amputation do so as a result of poor circulation, it’s important to evaluate the status of the remaining extremities and teach the patient and family proper care including appropriate footwear/work.
Why is positioning crucial in post-surgical management?
- For patients following either trans-tibula or trans-femural it is critical to prevent hip fracture contractions as the patient should be encouraged to spend some time in the prone position for as long as possible. - Prolonged sitting isn't recommended. - In the early days, the patient will want to avoid side-lying on the amputated side and the residual limb should be kept in extension both at the hip and knee
How balance and transfers addressed in post-surgical management?
- Sitting down is usually not a problem for patients with unilateral amputation but must be a part innovation program for individuals of bilateral amputation.
- Sitting down and exercises on the remaining extremities can be quite beneficial in helping the individual regain the sense of his/her own body space.
- The better the amputee can balance on his/her remaining extremities, the more likely he/she will be able to use crutches and lead a more active life during the period of the prosthetic.
- A variety of balancing exercises may be used including balancing on a compliant surface.
- In the early post surgical period, the person should stand and transfer leading with the un-amputated limb to protect the residual limb from possible injury against the chair or bed.
How is ambulation initiated in the post-surgical phase?
- Crutches is much more beneficial than walkers, because it teaches the patient safe and independent mobility.
- While there is more stability in a walker, there’s greater flexibility in carrying out activities in the daily living on crutches. The added bounce needed for crutches will also serve the individual well when it’s also time for prosthetic fitting. If the patient has been fitted with an IPOP or rigid dressing and has good control of weight bearing, the PT might decide to add a parlan and foot to the assembly making weight bearing gait possible.
- The remaining foot needs to be protected from any injury or sore as hospital provided slippers or any slippers do not offer any protection. This may be time to consider fitting the patient with an adaptive shoe to prevent trauma to the foot.
What is critical to do when teaching mobility to a patient with diabetes or vascular compromise post amputation?
When teaching mobility to someone with diabetes or vascular compromise, it’s critical that the patient wears a shoe on the remaining foot.
Which elements of patient education are crucial in the post- surgical phase?
- The PT needs to continually involves the patient and caregivers, answering questions and providing information at the level that is commensurate to the capability of the individuals. - The goal is to have the patient and the caregivers assume responsibilty for care, understand the need for continued care and become active participant in the rehabilitation program.
- A home program needs to be developed and the patient encouraged to be as mobile as possible, the HEP will be limited till healing has occurred, so the importance of continuity of physical therapy care is emphasised.
- It has been demonstrated that those who receive intensive in-patient rehabilitation services have significantly better outcome than those who do not.
Which psychosocial considerations are key in the post-surgical phase?
- Medical Status
- Body Image
- Reaction to Grief and Loss
- Affective Responses
What are the factors influencing psychosocial adaptation in the post-surgical phase?
- Age
- Medical Status
- Body Image
- Affective Responses
- Interpersonal Factors
- Coping Style
- Roles in society
How can a physical therapist assist with the psychological adjustment in the post-surgical phase?
- Listen
- Educate
- Empathize
- Acting when needed which can include soliciting the services of a mental health professional.
What defines preprosthetic management phase?
Simply the time between the discharge from the acute care hospital and fitting with the definitive prosthesis: Or the decision not to fit the patient with an artificial limb. Regrettably, this process lasts too long, does not include regular program of physical therapy, and often results in poor outcomes.
What are the goals of the pre-prosthetic management phase?
- Independent in residual limb care, including bandaging/shrinker app, skin care & positioning.
- Independent in mobility, transfers, and functional activities, including partial weight
- Demonstrate home exercise program accurately, including a range of motion, graduating to a resistive exercises for all part of residual extremities as well as a range of motion and strengthening exercises for the sound lower extremities needed.
- Care of the remaining lower extremity if amputated for vascular reasons
Which elements are key in the pre-prosthetic assessment?
- History
- Systems Review
- Skin
- Residual Limb
- Vascularity
- Range of Motion
- Muscle strength
- Neurological
- Functional status
- Emotional status
Which elements of residual limb care are crucial during pre-prosthetic management?
- Healing of incision complete
* Resolution of postoperative edema
____ in residual limb may be difficult to control in individuals with diabetes, particularly if they have renal involvement.
Edema in residual limb may be difficult to control in individuals with diabetes, particularly if they have renal involvement.
When is the residual limb fully healed and prepped for the considerable and varied pressure during the prosthetic walking?
8 to 12 weeks.
What is the most effective method of prepping the limb for prosthetic fitting?
Rigid dressing.
What may individuals not fitted with the rigid dressing use to prep for prosthetic fitting?
Elastic wraps or shrinkers to reduce the size of the residual limb.
Using elastic wraps or shrinkers to reduce edema is a ___
Using elastic wraps or shrinkers to reduce edema is a slow process.
What happens when the residual limb is wrapped in a circular manner?
The residual limb wrapped in a circular manner may create a tourniquet which may compromise healing and foster the development of bulbous end.
What are the characteristics of an effective bandage?
An effective bandage is smooth and wrinkle free, emphasizes angular turns provides pressure and encourages proximal joint extension. The ends of bandages are fastened with tapes or safety pins rather than clips. The system of wrapping that uses mostly angular or figure 8 turns is being developed particularly to meet the needs of older patients.
What are the characteristics fo the position a patient must be in when wrapping their residual limb, depending on the type it is?
While the trans-tibular limb can be conveniently wrapped while sitting, it is difficult to wrap for the trans-femural limb while sitting. The patients balance themselves in the standing position while wrapping.
How do residual limb shrinkers compare to wrapping?
- Shrinkers are easier to apply than bandages and may be a better alternative, particularly trans-femural residual limb.
- Shrinkers are more expensive to use than elastic wrap and the initial cost is greater. Then new shrinkers in smaller sizes must be purchased as the limb volume decreases. However, shrinkers are a viable option for individuals who are not able to properly wrap the residual limb. - Shrinkers may not be used until the incision has healed and the sutures have been removed.
- Sutures can get caught in the shrinker’s mesh and a distal distraction forces that accompany donning may cause wound splitting termed: “The essence’
- In a small study involving individuals with top bandaging techniques, it was found that residual limb wrapping was slightly more effective at reducing edema among individuals with trans-tibial amputations.
What elements of skin care are essential in preprosthetic management?
The residual limb is treated like any other part of the body in terms of proper care and hygiene. It is kept clean and dry. Individuals with dry skin may use a good skin lotion and care must be taken to avoid abrasion, cuts and problems. The patient is taught to inspect the residual limb with a mirror each night, to make sure there are no sores or impending problems, especially in areas not readily visible. If the person has diminished sensation, careful inspection is very important. Because the residual limb tends to be more edematous after bathing as a reaction to warm water, nightly bathing is recommended, particularly when the prosthesis has been fitted. The elastic bandage, elastic shrinker or removable strip rigid dressing is re-applied after bathing. If the person has been fitted with a prosthesis, the rigid residual limb is wrapped at night and anytime the prosthesis is not worn until it is fully matured. In other words, the residual limb does not develop edema when not wearing the prosthesis. Although the skin does need to adjust to the pressures of wearing artificial limb, there is no indication that toughening techniques are beneficial. Research indicates that soft pliable skin is better suited to cope with the stress than tough dry skin.
How critical is achieving and maintaining full range of motion in the residual limb?
- For all levels of amputation, full range of motion in the hip extension is critical in allowing the individual to assume a balanced posture.
What is one of the deterrence to functional prosthetic rehabilitation?
Contracture of the hip and knee.