Week 7 Flashcards
1
Q
What is the role of the physical therapist in the rehabilitation of lower extremity amputees?
A
Maximize level of functional ability possible
2
Q
What are the characteristics of the role of the PT in the rehab of the LE amputee?
A
- 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.
3
Q
What are the primary phases of rehabilitation for lower extremity amputees?
A
- Post-surgical Management
- Pre prosthetic Management
- Prosthetic Management
4
Q
What defines the post-surgical management phase?
A
Time between the performance of amputation surgery and discharge from the hospital.
5
Q
What are the goals of the post- surgical management phase?
A
- Promote healing residual limb
- Protect intact limbs
- Maximize functional independence Prevent motion loss
- Educate in the process of prosthetic rehabilitation
- Facilitate psychological adjustment
6
Q
Which elements are key in the post-surgical assessment?
A
- General systems review
- Post-surgical status
- Pain
- Functional status
- Range of motion
7
Q
What are the characteristics of the post-surgical status that is key in the post-surgical assessment?
A
- Cardial
- Vascular
- Respiratory
- Metabolic (esp relating to blood sugar control)
- Infection status
8
Q
What are the characteristics of the pain that is key in the post-surgical assessment?
A
- Incisional
- Neuropathic
- Experience of pain in other body region that could affect functionability.
9
Q
What are the characteristics of the functional status that is key in the post-surgical assessment?
A
- 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.
10
Q
What are the characteristics of the ROM that is key in the post-surgical assessment?
A
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.
11
Q
What criteria are used in selecting dressings during this phase?
A
- Level of amputation
- Surgical technique
- Healing requirements
- Patient compliance
- Surgeon preference
12
Q
What are the effects of a dressing for surgery?
A
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.
13
Q
What are the pros that soft dressings offers during the post-surgical management phase?
A
- Easy to apply
- Inexpensive
- Easy access to incision
14
Q
What are the cons that soft dressings offers during the post-surgical management phase?
A
- Little edema control
- Minimal protection
- Requires frequent rewrapping
15
Q
What are the pros that shrinkers offers during the post-surgical management phase?
A
- Easy to apply
* Inexpensive
16
Q
What are the cons that shrinkers offers during the post-surgical management phase?
A
- Not used until sutures are removed
* Requires changing as residual limb shrinks in size
17
Q
What are the pros that semi-rigid dressings offers during the post-surgical management phase?
A
- Better edema control than soft dressing
* Improved protection
18
Q
What are the cons that semi-rigid dressings offers during the post-surgical management phase?
A
- Needs frequent changing
- Cannot be applied by patient
- No access to incision
19
Q
What are the pros that immediate post-op prosthesis (IPOP) offers during the post-surgical management phase?
A
- Excellent edema control
- Excellent protection
- Pain control
- Early weight bearing
20
Q
What are the cons that immediate post-op prosthesis (IPOP) offers during the post-surgical management phase?
A
- No access to incision
- More expensive than other dressings
- Requires proper training for use
21
Q
What kind of patient is an immediate post-op prosthesis (IPOP) ideal for?
A
Ideal for patients possessing the physical capacity and
healing potential required for their use.
22
Q
What are the outcomes associated with the rigid dressing post surgery?
A
- Accelerated rehabilitation times
* Reduced edema
23
Q
What are the outcomes associated with the immediate post-op prosthesis (IPOP) post surgery?
A
- Fewer post-surgical complications
* Fewer higher-level revisions of surgeries
24
Q
Why is sound side limb care crucial in post-surgical management?
A
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.
25
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
```
26
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.
27
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.
28
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.
29
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.
30
Which psychosocial considerations are key in the post-surgical phase?
- Medical Status
- Body Image
- Reaction to Grief and Loss
- Affective Responses
31
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
32
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.
33
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.
34
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
35
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
36
Which elements of residual limb care are crucial during pre-prosthetic management?
* Healing of incision complete
| * Resolution of postoperative edema
37
____ 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.
38
When is the residual limb fully healed and prepped for the considerable and varied pressure during the prosthetic walking?
8 to 12 weeks.
39
What is the most effective method of prepping the limb for prosthetic fitting?
Rigid dressing.
40
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.
41
Using elastic wraps or shrinkers to reduce edema is a ___
Using elastic wraps or shrinkers to reduce edema is a *slow process.*
42
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.
43
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.
44
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.
45
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.
46
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.
47
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.
48
What is one of the deterrence to functional prosthetic rehabilitation?
Contracture of the hip and knee.
49
In what motions is full ROM necessary for a trans- tibular amputation?
With the trans-tibular amputation, full range of motion in the hips and knees, particularly in the extension are necessary.
50
In what motions is full ROM necessary for a trans- femoral amputation?
The patient with a trans-femoral amputation needs full range of motion in the hip particularly in extension and abduction.
51
Mild contractures of hip and knee flexion may respond to ___
Manual mobilization with hand contacts appropriately adjusted based upon specific activities of the residual limb and active exercises
52
What can be done to manage severe contractures?
It is almost impossible to reduce severe contractions by manual stretching, especially in flexion. In such cases, lower load, longer duration and/or facilitated stretching technique may be useful.
53
If the patient is being equipped with the prosthesis, it may be useful to perform ____ exercises with the prosthesis on in order to improve leverages for stretching.
If the patient is being equipped with the prosthesis, it may be useful to perform *flexible* exercises with the prosthesis on in order to improve leverages for stretching.
54
____, continues to be the best treatment for contractures.
*Prevention*, continues to be the best treatment for contractures.
55
Which other modes of exercise are beneficial in the preprosthetic management? phase?
- Includes strengthening, balance and coordination activities.
- The type of post-surgical dressing, the degree
of the pain and healing of the incision will determine when resistive exercises involving the extremities can be started.
- The hip extensors and abductors, knee extensors and flexors are particularly
important for prosthetic ambulation. Studies have shown a correlation between the strengths of these key muscle groups and the ability to use a prosthesis effectively.
- A general strengthening program that includes the trunk and all extremities as often indicated, particularly for the older person.
- Specific training of the spinal and abdominal muscles may be beneficial as it is being demonstrated the trunk control training may possibly influence gait parameters in amputees.
56
Where does balance training fit into this phase?
Balance is a key element to effective mobility and an area too often overlooked. Although individuals with unilateral amputations usually do not have a problem with sitting down, it is important for the individual to develop a good standing balance in the remaining limb. While care must be taken to protect the sound limb from injury, particularly in patients with vascular diseases, balance exercise with and without shoes as well as with eyes opened and closed are inevitable part of the program.
57
How can weight bearing through the residual limb be performed without a prosthesis?
This can be performed with the patient kneeling on the cushion in a chair of the appropriate height and shifting his/her weight on and off the amputated side.
58
What are the characteristics of gait training to be included in the pre-prosthetic phase?
Gait training can start early in a person with a unilateral low extremity amputation can become quite independent using a step three gait pattern crutches. The individual who can ambulate with crutches will develop a greater degree of general fitness than the person who spends most of their time in a wheel chair. Crutch walking is good preparation for prosthetic ambulation, and the person who can learn to use crutches generally will not have difficulties learning to use prosthesis.
However, the individual who cannot learn to walk with crutches independently may still become a very functional prosthetic user. All individuals with an amputation need to learn some form of mobility with either prosthesis for use at night, or when the prosthesis is not worn for some reason.
59
What are some of the reasons that older people have problems with crutch walking?
Some are afraid, some lack the necessary balance and coordination and others lack endurance.
60
What are some of the advantages and disadvantages of walking with a walker post surgery?
- Walking with a walker is physiologically and psychologically more beneficial than sitting in a wheelchair, but it should be used only if the person cannot learn to walk with a crutch.
- A walker is sturdier than crutches but cannot be used in stairs or curbs.
- It is sometimes difficult for the person who's used a walker following the amputation to switch to crutches or cane when fitted with the prosthesis. - The gait pattern used with the walker is not appropriate with the prosthesis and should not be USED IN ANY PART OF PROSTHESIS TRAINING.
- A walker encourages a step 2 gait pattern whereas an efficient prosthetic use requires a step 3 gait pattern
61
How can endurance training be incorporated in preprosthetic management?
Cardiovascular endurance is necessary for effective prosthetic ambulation, particularly the trans-femural level. Specific attentions to improving the cardiovascular fitness should be incorporated into the rehabilitation programme and remain as part of the amputee's general fitness programme in the pre-prosthetic phase. The upper body ergometer (UBE) can be introduced and safely performed by most people. Once balance and strength returns, lower body ergometry may be performed but first only the sound limp progressing to use of the prosthetic limb as appropriate.
Over time when fitness level improves, other equipments may be used such as treadmills,
stair climbing machines and rowing machines.
62
How relevant is patient education in this preprosthetic management phase?
Patients' education is an integral part of an ongoing rehabilitation process. Information and the care for the residual limb, proper care of the uninvolved extremity, positioning, exercises and diet (if the patient has diabetes or is overweight) are necessary for the patient to be a full participant of the rehabilitation program. Discussions can also be held regarding patients' goals projected activity levels, funding the prosthetic components. If the patient underwent the amputation due to vascular problems, the education program should include information on proper footwear.
63
What are the factors in determining if a patient is a candidate for a prosthesis?
* Patient desires
* Physical capabilities
* Financial resources
* Age
* Weight
* Comorbidities
* Amputation level
* Unilateral or bilateral amputation
64
What are some of the characteristics of individuals and the different prostheses that they might have?
- Most older individuals with bilateral trans-femural amputations have considerable difficulty learning to use prosthesis.
- Patients with one trans- femural and one trans-tibular amputation generally can learn to use two prosthesis if the first amputation was at the trans-femural level.
- And if the person successfully uses the trans-femural prosthesis before losing the other leg.
65
What are some of the things that may impede successful prosthetic ambulation?
Severe hip flexion contraction, obesity, weakness/paralysis of hip musculature and poor balance and coordination.
66
What are the things that will help in determining potential for prosthetic ambulation?
The person's level of activity and participation in post-surgical and pre-prosthesis program
67
___ individuals are generally good candidates for prosthetic fitting regardless the level of amputation
*Young, agile* individuals are generally good candidates for prosthetic fitting regardless the level of amputation
68
What defines the prosthetic management phase?
This involves the time from the fitting with the definitive prosthesis, to attaining fully functional ambulation and beyond depending upon the desire and capabilities of the patient.
69
What are the goals of the prosthetic management phase?
- Attain smooth, energy efficient gait
- Allow the individual to perform ADLs
- Maximize participation in employment activities
- Facilitate participation in desired recreational activities
70
What are the key elements of assessment in the prosthetic management phase?
- History
- Systems Review
- Skin (imp)
- Residual Limb
- Vascularity
- Range of Motion
- Muscle strength
- Neurological
- Functional status (imp)
- Pain (imp)
- Emotional status
71
Which program elements are key in the continued rehabilitation of the lower extremity amputee?
- Donning
- ROM/Flexibility Training
- Strength Training
- Cardiovascular Training
- Balance and Coordination training
- Gait Training
- Functional Training
- Advanced Training
- Activity specific training
72
How is donning a prosthesis approached?
- Patients with trans-tibular amputation often don the prosthesis while seated after having applied the correct number and sequence of socks or sheet. Then in most instances, the individual simply insert the residual limb in the socket. However, final tightening of laces and straps if present should be done in the standing position to ensure the limb is lodged suitably in the socket.
- Those with trans-femural amputations also can begin the donning process while seated but most prefer to stand while pulling the socket or aid if utilized out through the valve hole. By leaning forward, the body's weight line will prevent the prosthetic knee from fitting abnormally. The patient often extends the sound hip and kneed while tugging downward on the donning aid till it slips out from the prosthesis. Finally, the patient inserts the valve once the residual limb is firmly seated within the socket. Regardless of the type of system used to secure the socket, correct orientation of the thigh within the socket is crucial for proper fit.
73
Do range of motion and flexibility activities continue to be a part of rehabilitation in the prosthetic management phase?
ROM and/or flexibility activities may continue to be part of rehabilitation in the prosthetic phase especially as the amputee looks towards a higher level of functionality
74
Where does continued strength training continue to fit into the rehabilitation program in the prosthetic management phase?
Strength training is likely to continue to play an integral part of the rehabilitation program. Although many strengthening activities can do overlap with function
75
Should cardiovascular training continue in the prosthetic management phase?
Cardiovascular training should continue in this phase, not only for the general health benefit provided, as cvd fitness remains special and important to the lower extremity. amputee, as prosthetic gait is significantly more metabolically demanding than normal gait on sound limbs.
76
How can balance and coordination be developed in the prosthetic management phase?
- Focus trainings initially on balance and integration of prosthesis. If the patient can learn to balance on and off the prosthesis smoothly, they feel a sense of control and integration with the prosthesis, he/she will progress with less therapy than if started walking before the necessary balance was developed.
- Although the individual with the trans-femural prosthesis may be expected to encounter more difficulty controlling the mechanical knee compared to those with two anatomical knees, all must learn to balance the amputated knee, placing the sound foot ahead of the prosthesis makes the prosthetic knee more stable.
- Patients should be instructed to weight shift those symmetrical and stride position and in stepping movement. Stepping on a low stool or step platform with the sound foot obliges the patient to shift weight on the prosthesis and increases stance phase duration on the prosthesis. Static erect balance re-introduces upright posture. The patient should strive for level pelvis to shoulders, vertical trunk without excessive lordosis and equal weight bearing.
- The PT stands near the prosthesis, to encourage the patient to shift his/her weight on to it.
- Dynamic exercising improves medio-lateral, sagittal and rotatory control.
- The patient learns that the hip flexion causes the knee to bend and hip extension stabilizes the knee during this phase.
77
What factors are essential for efficient prosthetic gait?
* Accept the weight of the body on each leg
* Balance on one foot in single-limb support
* Advance each limb forward and prepare for the next step
* Adapt to environmental demands
78
How should gait training be approached in the prosthetic management phase?
- Patients tend to place greater load and exert more propulsive force on the intact side, so gait training should emphasize
symmetrical performance.
- Either a cane or a pair of arm crutches is an appropriate aid for a client who is unable to achieve a safe gait without unnecessary fatigue.
- Ordinarily the cane is
used in contralateral side to enhance frontal plane balance. - If bilateral assistance is required, a pair of arm crutches is preferable to two canes.
- The crutches remain clasped around the forearm when the user opens the door.
- Axillary crutches tempt the user to lean on the axillary bars risking impingement of the radial nerves, they are are also
inconvenient in climbing stairs. - Although not ideal for a symmetrical gait pattern, a normal walker provides maximal stability which is particularly useful for patients with generalized weakness. The walker should be adjusted so the user does not lean too far forward.
- Patients with trans-tibular amputation walk faster with a two wheel walker as compared to four footed walker.
79
What elements of functional training are key in prosthetic management?
- Advanced training
- Stairs, ramps, and curbs
- Transfers
- Fall management
- Activity/sport specific
80
Should a patient always rly on instructions from their PT in every new situation?
Generally, the patient should have the opportunity to analyze each new situation and arrive with the solution to the problem rather than depending on the directions from the therapist. The learned practice are critical in decision making in absorbing other prosthesis wearers as well as from professional instruction.
81
What is included in the training programme for vigorous individuals?
Stair climbing, negotiating ramps, retrieving objects from the floor, kneeling, sitting on the floor, running, driving a car,
and engaging in sports
82
What is the difference between walking and other functional task when in rehab for a prosthesis?
Walking implies symmetrical usage but the other activities are done asymmetrically with great reliance on the strength, agility and central control of the sound limb.
83
How does training in fall management fit into the prosthetic management phase?
During falling, the amputee must first discard any assisted device to prevent injury. Amputees should land on their hands with their elbows slightly flexed to dampen the fall and decrease the possibility of injury. As the elbows flex, the amputee should roll to one side, further decreasing the impact of the fall.
84
What types of transfer training are crucial in the prosthetic management phase?
- Initially, the patient can park the chair at the parallel bars or at a plinf. After locking the wheelchair and raising the footrest, the patient should sit forward and transfer weight to the intact leg then push down on the armrest. The individual will find a place with the sound foot close to the chair enables rising by extending the knee and the hip on the sound side. Sitting is accomplished by placing the sound side close to the chair and lowering oneself by controlled knee and hip flexion on the sound side. For both standing and sitting, the beginner should have the advantage of a chair with an armrest that enables using the hands to control and access trunk movement. Later, the person should practice sitting and deeper postures for low chairs as well as benches, the toilet and other seats that do not have armrests.
85
What are the characteristics of training for transfers in and out of an automobile?
To enter the right or passenger side of an automobile, the prosthetic wearer faces towards the front of the car. The person with a right prosthesis places the right hand on the door post, with the left hand on the back of the front seat. Then swings the left leg into the car, slides on to the car seat and finally places the prosthesis in the car.
The individual with a left prosthesis may find sitting sideways with both feet out of the car door the easiest. The patient then leans on the seat while swinging in the prosthesis into the car then puts the intact right foot inside the car. The opposite procedure can be utilized for transferring to the left or driver's side of an automobile. Although presence of the steering wheel will need to be accounted for as well.
86
What are the characteristics of amputees be trained to overcome stairs, ramps and curbs for a trans tibial prosthesis?
Individuals wearing trans-tibular prosthesis generally have little difficulty mastering steps and ramps once they have achieved good balance in prosthetic control. Going up step over step requires good quadriceps strength and a medium to long residual limb.
- Some gait adaptation may be needed for steep ramp or hills depending on the type of the prosthetic foot.
- The greater the limitation of in flexion, the harder it is to go up steep hills or above a step.
- Many individuals take a long step with the prosthesis and the shortest steps with the un-amputated foot.
- Going down a steep hill requires good quadriceps strength and prosthetic control but is accomplished by most individuals.
87
What are the characteristics of amputees be trained to overcome stairs, ramps and curbs for a trans femoral prosthesis?
The technique for going up and down stairs and ramps will vary for an individual wearing a trans-femural prosthesis depending on the type of knee component.
- Generally, the person climbs the stairs one step at a time leading with the unamputated leg. Individuals fitted with the stance phase knee control system will have to go down stairs one at a time leading with the prosthesis. All others have the potential of going down step over step, although it requires considerable balance. It is necessary for the individual to place the prosthesic heel only on the step to create a flexion moment in the knee as weight is brought forward, thereby allowing the knee to flex in the person bringing the un-amputated leg to the lower step. Once good balance, prosthetic control and gait have been achieved, most individual will develop their own method of doing each of these activities. Curbs present a slightly different problem from stairs 'cos there's no handrail. The technique for navigating them are basically the same however. For steep stairs, ramps or curbs, the individual may climb diagonally with side steps, with the prosthesis kept on the downhill side.
88
How can and should gait and functional training be advanced?
- Changing the environment.
- Walking around furniture, through narrow doorway, on rugs and around obstacles is
- Placing obstacles on the floor to step around or over, walking in a busy hallway of the treatment center, picking something up from the floor and carrying an object while walking - During advanced training, the patient is taught to get up and down from chairs of different heights.
- Obstacle courses can be created using a combination of chairs, single steps, cones and blocks to walk around as well as different surfaces.
89
How far can we progress our interventions with lower extremity amputees?
Activity specific training (horse back riding is a superb activity to foster strong control and perfect balance, the hiker should pack extra amputation socks or sheets to protect the
skin. Also, a well-fitting
comfortable hiking
boot is essential.)
- Other activities generally performed without the
prosthesis such as swimming, skiing or soccer.
- For sports that involve running, an energy storing and releasing foot is the most suitable.
- Patients with trans-tibular amputations usually run with reasonably symmetrical step links although they will favour the sound limb which has a greater propulsive ability.
- Those with the trans-femural amputation will derive most of the propulsive force from the sound limb and use the prosthesis as a momentary prop.
90
What is the desired outcome of interventions in patients with a prosthesis?
The desired outcome is to maximize functional capacity and quality of life.
91
What is associated with the experience of a phantom limb?
* Phantom limb awareness
* Phantom limb sensations
* Phantom limb pain
92
What does a phantom limb involve?
A phantom limb involves sensory experiences perceived in the limb that's no longer present. This can range from phantom limb awareness, to phantom limb sensation and phantom limb pain.
93
What is phantom limb awareness?
A global feeling that a missing limb is still present
94
What is phantom limb sensation?
Specific sensory and kinetic sensations often characterised as tingling, itching, pressure, position, shape, movement, warmth or cold)
95
What is phantom limb pain?
Pain perceived in a limb that is no longer present
96
How is phantom limb pain classified?
As a neuropathic pain syndrome characterized by pain in the amputated limb or pain that follows partial or complete de-affrontation
97
How is phantom limb pain common described?
It is commonly described as stabbing, throbbing, burning or cramping. It can vary from being brief, intermittent and relatively minor to constant and
excruciating which tends to be more severe in what will be the distal portions of the amputated limb.
98
What are the other types of pain an amputee commonly experiences?
- Residual limb pain
| - Pain in other body regions
99
What causes phantom limb pain?
• Peripheral nervous system
• Central nervous system
- Spinal mechanisms
- Supraspinal mechanisms
100
What peripheral mechanisms
| contribute to phantom limb pain?
- Ectopic discharge from neuroma in residual limb,
- Ectopic discharge from dorsal root ganglion
- Maintenance by sympathetic
nervous system
- Peripheral influence on central
reorganization
101
How does Ectopic discharge from neuroma in residual limb, contribute to phantom limb pain?
As such formation show increased rates of spontaneous activity from the cut or injured C-fibers and demyelinated A-fibers. Thermal, chemical or mechanical stimulus can further the rate of discharge. (does not fully explain PLP)
102
How does maintenance by sympathetic nervous system, contribute to phantom limb pain?
- Reduced near surface blood flow to the residual limb has been implicated to predictive physiological correlate of burning PLP
- Changes in surface electromyographic representations of muscle tension in the residual limb, has been shown to precede changes in phantom limb pain described as cramping and squeezing by up to a few secs
103
How does peripheral influence on central reorganization contribute to phantom limb pain?
It indicates the peripheral and central factors are likely to interact in creating the experience of phantom limb pain
104
What spinal mechanisms
| contribute to phantom limb pain?
- Hyperexcitability in the spinal cord
- Neuropeptide expression
- Disinhibition due to loss of input related to deafferentation within the spinal cord, with a reduction of inhibitory neurotransmitter activity and a down regulation of opiod receptors, and up regulated in the injured tissue
- Unmasking of previously masked connections
- Sprouting of new connections
105
What supraspinal mechanisms
| contribute to phantom limb pain?
```
Cortical reorganization
• Somatosensory cortex
• Motor cortex
Subcortical reorganization
• Brain stem
• Thalamus
```
106
What are some factors that influence experience of phantom limb pain?
* Severity and longevity of Pre- and postoperative pain may influence occurrence, may lead to cortical pain memories and sensitization
* More frequent in adolescents and adults undergoing amputation as compared to young children. Nearly non-existent in congenital disease amputations
* Unclear relationship with regard to mechanism of amputation
* May be provoked or worsened by physical or psychological factors
107
What role do psychological factors play in phantom limb pain?
```
• Not causal
• May contribute to course and
severity
• Coping strategies related to
functional interference
• Psychological variables and
support prior to amputation
may influence pain experience
```
108
How is phantom limb pain
| treated?
```
MEDICAL
• SURGICAL
• PHARMACOLOGIC
PSYCHOLOGICAL
• COUNSELING
• BIOFEEDBACK
ACUPUNCTURE
TENS
```
109
How does sprouting of new connections in the spinal cord contribute to phantom limb pain?
The degeneration of C-fiber terminals following peripheral nerve injury associated with amputation may induce sprouting of A-fiber terminals into areas of the spinal cord where they usually aren't, which might then be interpreted as noxious
110
How does neuropeptide expression in the spinal cord contribute to phantom limb pain?
Changes in the expression of neuropeptide such as substance P that are normally expressed by A and C fibers, begin to be expressed by non-nociceptor A fibers, which then creates hyperexcitability within the spinal cord that is usually interpreted as noxious input
111
What is the primary reason for amputation in western countries?
Chronic vascular disease
112
What are the treatments that target specific brain functions in graded motor imagery?
- Left/Right Discrimination (1st step)
- Explicit Motor Imagery (imagined movements, 2nd step)
- Mirror Therapy (3rd step)
113
What is involved with Left/Right
| Discrimination activities?
Involves the process of identifying one side of the body as distinct from the other or if a part of the body is rotated from the L to R in association with pain.
114
What are the effects of Left/Right
| Discrimination activities?
- Engages activity in the premotor cortex, while disengaging the primary motor cortex.
- Dissociates movement and pain, which may make them less threatening
115
What is involved with Explicit Motor Imagery?
Patient imagines themselves moving, and activates the primary motor cortex. More likely to elicit pain
116
What are the effects of Explicit Motor Imagery?
- Improve motor performance
- Facilitate recovery of motor function
- Modulate pain
- Improve psychological function in disordered states
117
How can the perceived threat level of explicit Motor Imagery be progressed?
- Altering the demands of the movement being imagined
- The environmental demands
- Emotional cues
118
What is involved with Mirror Therapy?
The use of strategically placed mirrors to produce a reflection of the intact limb, in order to trick the brain into thinking the amputated limb is present
119
What are the effects of Mirror Therapy?
Leads to increased activation of the motor cortex and the region of the brain dedicated to the amputated limb
120
How can the Mirror Therapy be progressed?
- Altering the movement performed by the intact limb
- The environmental factors
- Emotional cues
