Presentation on theme: "Examination & Treatment of the Lower Extremity Amputee"— Presentation transcript:
1 Examination & Treatment of the Lower Extremity Amputee Pre-prosthetic PT Intervention
2 Reading Focus for Class Discussion O’Sullivanpp. 620,Blackboard-foot care/prevention**We will use Guide to PT practice for this unit
3 IntroductionLabs for Unit 4, grading rubric for discharge note, home exercise program will be posted on Blackboard this weekVisit to Hanger will be scheduled for late April, in the evening and attendance is required (in lieu of Thursday/Friday lab)
4 Learning ObjectivesIdentify and apply major factors leading to lower extremity amputationDescribe and apply the levels of lower extremity amputation and the functional impactDiscuss and apply PT early post-operative examination, goals & treatment of the LE amputee.When presented with a clinical case study, analyze & interpret patient data; determine realistic goals/outcomes and develop a plan of care
5 Case ScenarioIt’s Tuesday morning, and you receive a PT order to evaluate and treat the following patient:Mr. John Howard, 70 year old man who underwent a left lower extremity amputation Saturday afternoon
7 What is the cause/reason for Mr. Howard’s amputation? History of diabetes with peripheral vascular disease (PVD) and chronic non-healing foot ulcersVery mild peripheral neuropathy
8 What are the major causes for lower extremity amputation? PVD=peripheral vascular disease (arteriosclerosis)Associated with smoking & diabetes (6-25% of pts. With PVD & DM will need amputation)Pt. with DM who undergoes one amputation 2 to PVD has 51% chance of 2nd operation within 10 yrs.2TraumaMVA, gunshotCancerCongenital2
9 Causes of Amputation by Percent Lusardi MM & Nielsen CC. Orthotics and Prosthetics in Rehabilitation. Woburn, MA: Butterworth-Heinemann; 2000, p. 328.
10 Risk factors for PVD? Diabetes Poorly managed HTN High cholesterol/triglyceridesSmoker*same as risk factors for cardiovascular and cerebrovascular diseasePVD and peripheral neuropathy (numb, cold, paresthesia, pain) are the major predisposing factors for LE amputation in individuals with DM2Lusardi MM & Nielsen CC. Orthotics and Prosthetics in Rehabilitation. Woburn, MA: Butterworth-Heinemann; 2000, p. 330.
11 What are Signs/Symptoms of Vascular Insufficiency? Intermittent claudicationWhat is this?Significant cramping pain, usually in the calf, that is induced by walking or other prolonged muscle contraction and relieved by a short period of restVascular pain (increase with LE elevation)Loss of one or more lower extremity pulsesArteriosclerosis obliterans=at least one major arterial pulse (dorsal pedis artery at ankle, popliteal artery at knee or femoral artery in the groin) absent or impaired2
12 Clinical signs of PVDLusardi MM & Nielsen CC. Orthotics and Prosthetics in Rehabilitation. Woburn, MA: Butterworth-Heinemann; 2000, p. 344.
13 Protective sensationMust be able to perceive 5.07 Semmes-Weinstein monofilamentEasy and inexpensive way to identify patients at risk for foot ulceration2
14 What should primary goal be with PVD/DM in regards to feet? PREVENTION!
15 What is the level of Mr. Howard’s amputation? s/p transtibial amputation of ideal length
17 What are the levels/classification of amputation? Transtibial (BK) 54%Transfemoral (AK) 32%Syme/foot 3%Hip disarticulation 1%Upper extremity 8% 4
18 How was Mr. Howard’s level of amputation selected? Preserve as much viable tissue/select most appropriate level
19 Selection of Amputation Levels General guidelinesConsiderations with PVDConsiderations with traumaConsiderations with malignant tumorConsiderations with deformityConsiderations with congenital limb deficiency/deformity revision
20 How does the level of amputation and age of patient affect outcome? Higher the amputation, more difficult the rehab.Older/sicker the pt., more difficult the rehab.
22 Who is on the Team? Pt. Dr. PT Prosthetist OT Social worker/case managerDietician, nursing, etc.Vocational Rehab
23 Responsibilities of the Team Evaluate pt.Initial training in prep. for prosthesisPrescription of prosthesis (if appropriate)Fabrication of prosthesisDelivery of prosthesisEvaluate fit of prosthesisTrain in use, care of prosthesisFollow-up eval. For problems, possible changes, needs of pt.Maintenance/replacement of prosthesis
24 What tests/measures should be included in Mr What tests/measures should be included in Mr. Howard’s Initial PT examination?Ideally Mr. Howard would have had a referral to PT BEFORE his amputationDefinitive strength assessment of joint just proximal to amputation can consist of only active, nonresisted antigravity motion until adequate healing of surgical sitei.e. will only be able to assess knee flexion and extension to fair muscle grade; TF will only be able to assess hip to fair muscle gradeWhen incision healed & cleared by Dr., remember that lever arm reduced & MMT grades could be inflatedDo not apply pressure for MMT through dressingmust be able to visualize suture line during 1st several weeks of preprosthetic prog.2Guide to Physical Therapy PracticePractice pattern 4 J, 5G, 7 A, 7C/D/E1
25 Pre-prosthetic Examination May, BJ. Amputation and Prosthetics: A Case Study Approach. Philadelphia: Davis; 1996, p. 73.
26 ExamSeymour, R. Prosthetics and Orthotics: Lower Limb and Spinal. Philadelphia: Lippincott, Williams and Wilkins; 2002, p. 37.
27 How can PT record measurements for Mr. Howard’s residual limb? Actual lengthTotal length including soft tissueMeasurements taken from easily ID bony landmark to the palpated end of the long bone, to the incision line, or to the end of soft tissueMedial joint line or tibial tubercleTF start measurement at at ischial tuberosity or greater trochanterDocument which landmark you used!TT 5-6 inches ideal; TT less than 3 inches problematic for prosthetic control and skin integrityCircumference:medial tibial plateau or tibial tubercle and at equally spaced points to end of limb; TF=begin at ischial tuberosity or greater trochanterclearly document interval between measurementsProsthesis often made when distal limb circ=prox limb circ (<1/4 inch difference) 2
28 Poor Residual Limb Healing May, BJ. Amputation and Prosthetics: A Case Study Approach. Philadelphia: Davis; 1996, p. 79.
29 What are likely limitations for Mr. Howard? IMPAIRMENTSPainDecreased strength, ROM, mobilityDecreased skin integrityDecreased endurancePsychological issuesFUNCTIONAL LIMITATIONSInability to walk, work, play
30 What should be included in the early post-op care for Mr. Howard? ROM, positioning, skin care, edema control, isometrics, strengthening of UE’s/residual and remaining limb,pt. education, bed mobility, transfers, balance, etc.
31 What are PT’s primary goals/outcomes for Mr What are PT’s primary goals/outcomes for Mr. Howard’s immediate post-operative period?Ensure optimal wound healingEarly preparation of the limb for prosthetic fittingMaintain, increase mobilityImprove enduranceCare of remaining limbMaintain/increase ROM and strength
32 How should PT inspect Mr. Howard’s wound? Monitor residual limb for shape, incision healing/closure, length, sensory integrity, volume, tissue integrity, color temp., painEasy to do with dressing changeRecord quantity/quality of drainageNormal for clear drainage first couple daysshould decrease over time; report red or darker blood or thickening discolored drainage with odor to Dr.Traumatic (nondysvascular) pt. often ready to be casted for training prosthesis day 10, others day 142
33 How can you teach Mr. Howard scar management? Once primary healing established, teach pt.scar massage above & below incision (not across)Once wound well-closed, and no steri-strips, can begin gently to mobilize scar itselfWhy is scar mobilization important?Tissues must be able to glideadherence promotes shearing forces which lead to skin breakdown2
34 What are common post-amputation sensations Mr. Howard may experience? phantom limb sensation70% will experienceNumbness, tingling, pressure, itching, mild cramp in foot/calfphantom limb painShooting limb pain, severe cramping, severe burning in amputated foot/limbNOT psychological!higher amputationgreater liklihoodEvidence if pt. had significant dysvascular limb pain a surgery are more likely to have phantom limb pain2
35 How would you explain phantom limb pain to Mr. Howard? All nerves that once had branches to LE are still present, but end at a new place. It takes time for the brain to learn this fact. Also, these nerves may be very sensitive from the amputation surgery as they are pulled and then severed and allowed to retract. 4
36 What are some strategies for treatment of phantom limb pain? Patient education before surgeryAlert pt. to issues of safetywake up in middle of night p recent amputation and fall when attempt to stand and walk thinking both limbs are intactCareful inspection of limb to r/o neuroma or infected woundCompression, use of prosthesis, desensitization techniques, heatMedications, steroid injection, nerve block, relaxation/hypnosisvaried effectiveness2
37 PT management of PainTime pain meds. So that pain control in optimal during PT activitiesPt. ed. on imagery & relaxation methodsTENS: wound healing and phantom painUS, cold therapy, massageWear prosthesis/compression bandagesVarying effectivenessPain management MUST NOT interfere with wound healing2
38 Why is compression bandaging important for ALL amputees? Reduce edemaControls painEnhances wound healingProtects incision during functional activityFacilitate preparation for prosthetic placement by shaping and desensitizing limb*1st 4 are required even if pt. not a candidate for prosthesis2
39 What options are there for edema control for Mr. Howard? Compression bandagingRigidRigid applied by surgeon in OR, removed 3-4 day, can then put new c IPOP-allows limited TTWB in 2-3 days-prosthetistBest for controlling edema and painNot good for pt. c significant risk for infection because wound status not easily visualized unless removeable (RRD)-PTSemi-rigidProsthetist takes negative mold in OR or p rigid removed 3 dayPolyethlene light weight,easy to clean,more durable than plasterUnna paste=zinc oxide,glycerin,calamine & gelatindries 24 h; Can be left on for 5-7 daysAir bagSoft bandaging=ace bandage, compressogripOnce suture line healed (10-21 days), use shrinker TT/TF, Jobst for TF 2
40 Lusardi MM & Nielsen CC. Orthotics and Prosthetics in Rehabilitation Lusardi MM & Nielsen CC. Orthotics and Prosthetics in Rehabilitation. Woburn, MA: Butterworth-Heinemann; 2000, p. 400.RRD
41 Semi-rigid dressingLusardi MM & Nielsen CC. Orthotics and Prosthetics in Rehabilitation. Woburn, MA: Butterworth-Heinemann; 2000, p. 401.
42 ShrinkersLusardi MM & Nielsen CC. Orthotics and Prosthetics in Rehabilitation. Woburn, MA: Butterworth-Heinemann; 2000, p. 405.
43 Principles of Ace-wrapping Distal pressure should exceed proximalPressure applied on oblique turns onlyShould be reapplied at least every 4 hoursNo wrinklesDon’t use metal clips—tape downNo aching, burning or numbness—removeWear 23 hours a day (remove for hygiene only)Wash daily, squeeze, don’t wring and air dry (need 2 sets)Continue use until pt. has definitive prosthesis & pt. can leave stump unwrapped overnight and don prosthesis without difficulty in the morning 6
44 What are the most common contractures to prevent in Mr. Howard? TranstibialHip flexionKnee flexionWhy?Long periods sitting in w/c, bedposition of comfort is one of flexionProtective flexion withdrawal pattern associated with LE painMuscle imbalancesLoss of sensory input from foot in WBing 2
45 What contractures are common in a transfemoral amputee? Hip flexionHip abductionHip lateral rotation
46 How can PT prevent contractures in Mr. Howard? Maintain knee in extBedavoid use of pillows under residual limbW/Csliding board, elevating amputee hanger; avoid long periods of sittingLie pronePNF w/CR ,HMP/US, manual stretching, AROM/PROMHEP (IP & OP) 2
47 Prevention of Contractures May, BJ. Amputation and Prosthetics: A Case Study Approach. Philadelphia: Davis; 1996, p. 87.
48 Strengthening For LE Amputee Maximization of overall UE/LE/TRUNK strength and muscular endurance for safe, energy-efficient prosthetic gait, helps prevent contractures, maintains mobilityPost-operative muscle strengthening consists of isometric contractions within a limited ROM at joint proximal to amputation to minimize stress across incisionWatch breathingno valsalva!Recommend 10 second cx, followed by 5-10 seconds rest for 10 reps.\AROM of unaffected limbs day 1, affected-limb day 1-3; bed mobility/transfers day 2As wound healing progresses, include large arcs of motion, active resistive exercise, isokinetics, eccentric, etc. 6
49 What should PT POC include for Mr. Howard? Hip ext., hip abductors/adductors, knee ext.hip flexors, knee flexors as needed (may need to stretch these short muscles)General strengthening/ROM of trunk and UE’s important (esp. back ext. and abdominals, shoulder depressors and elbow ext.)Aerobic ex. to increase endurancemobilityPosture-COG shifted up, back and toward remaining extremitySkin integrityprep residual limb/care remainingBalance 2
50 TT ExercisesMay, BJ. Amputation and Prosthetics: A Case Study Approach. Philadelphia: Davis; 1996, p. 88.
51 TF ExercisesMay, BJ. Amputation and Prosthetics: A Case Study Approach. Philadelphia: Davis; 1996, p. 89.
52 Key Points PT will ideally begin BEFORE pt. has amputation After a LE amputation, PT focus on pre-prosthetic training for functional mobility, residual AND remaining limb skin careQuestions?
53 References:American Physical Therapy Association. Guide to Physical Therapy Practice. 2nd ed. Alexandria, Va: American Physical Therapy Association; 2001.May, BJ. Amputation and Prosthetics: A Case Study Approach. Philadelphia: Davis; 1996.Northwestern University Prosthetics Training Handouts, 2003.O’Sullivan SB & Schmitz TJ. Physical Rehabilitation: Assessment and Treatment. 4thed. Philadelphia: Davis; 2001.Seymour, R. Prosthetics and Orthotics: Lower Limb and Spinal. Philadelphia: Lippincott, Williams and Wilkins; 2002.