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Clinical Procedures in Prosthetics II

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Presentation on theme: "Clinical Procedures in Prosthetics II"— Presentation transcript:

1 Clinical Procedures in Prosthetics II
Designing a PT Management Program for Patients with Prosthesis Mark David S. Basco, PTRP Faculty Department of Physical Therapy College of Allied Medical Professions University of the Philippines Manila

2 Learning Objectives At the end of the session, you should be able to
Discuss principles behind designing a management procedure for prosthesis users in the different phases: Pre-operative Early post-operative Late post-operative Prosthetic training phase Gait Vocational

3 Learning Objectives At the end of the session, you should be able to
Discuss indications, precautions, and contraindications to prosthetic management Discuss special considerations when designing a program for children

4 Pre-operative stage Introductory Visit Assessment
Discussion of outcomes Preparation for the operation Pre-operative exercises

5 Introductory Visit Introduce self and role in the rehab team, emphasize role of patient and family Need for reassurance that amputation and rehabilitation is a positive step towards reintegration back into the community Goals and expectations Introduce team management concepts

6 Assessment Physical Conditions that may affect mobility
Functional capacity Psychological Attitude Social situation Accommodation after surgery

7 Outcomes and Prognostication
What the patient may feel or encounter post-op Complications that may arise Expected highest level of function possible given the level of amputation Use of the prosthesis is the patient’s decision Options for prosthetic devices Life with a prosthesis

8 Preparation for the operation
Show the patient around the facility where he will be in after the operation Possible prosthesis given the level Speak to other amputees Exercise program Operating room, equipment, gadgets, medications, etc Phantom sensations

9 Pre-operative Exercises
Increases tolerance to surgery Faster recovery and gain of independence in prosthesis use Mentally prepares the patient Exercise program: Strengthening Endurance training Simulation of training activities post-op Pre-operative exercises Short and frequent porgressive free exercises on sitting, standing, and supine Should focus on exercises such as: PREs to the Ues Core stability exercises Exercises on the sound leg Resisted exercises on the hip muscles particularly on the unaffected side


11 Early Post-op Stage Goals Treatment methods Early home visit Others

12 Goals Prevent the deleterious effects of immobilization and loss of a limb segment Facilitate faster wound healing Pain management Provision of needed accessories or equipment to progress patient to the next stage Prepare patient and stump for prosthetic fitting Promote early independence in ADLs Post-op Mobility should be done on day 1 Normal pt Proper wound care Prevent contractures Immediate wound closures Vascular pt Immediate mobilization 1-2 days post-op particularly pt’s with diabetes (promote circulation) Chest care Breathing exercises Managing pain, faster wound healing Pain control is ESSENTIAL

13 Treatment Methods Proper positioning Stump edema management
Active exercises Selective Stretching Donning and doffing Functional training Stump edema management ISOMS, bandage, compression Donning and doffing Volume containment devices Functional training - Going to the toilet

14 Proper Positioning Stump should be flat on the bed
Use of comfort pillow Prevent flexion contractures Sitting vs supine Advocating intermittent positioning in prone Sidelying to relieve buttocks pressure Stump should be horizontal PRESCRIBE A GOOD BED-TURNING PROGRAM!


16 Stump edema management
Elevation Exercises Bandaging Intermittent variable air pressure machines Pneumatic pylon Shrinker socks Rigid dressing Rigid dressing- plaster of paris

17 Exercises for the Stump
Done every 10 reps / hour Active contraction of the stump muscles is the best method of reducing edema For BKA Patient must imagine the performance of alternate DF/PF Through knee/AKA Patient must perform alternate hip flexion and extension as well as hip abduction Done

18 Bandaging Precaution: development of pressure necrosis
Stump bandaging can never change stump shape without the danger of interference with the local circulation A uniformly edematous stump is more readily fitted than one which has been misshapened by bandaging Allow rest period for the patient


20 Active Exercises & Stretching
Determine which muscles decreased / lost their strength and which muscles gained a mechanical advantage Determine biomechanical implications to identify appropriate exercise for the patient

21 Active exercises Start with the intact side
Applicable across all amputation levels 1st day post-op, exercises could be done on supine All techniques could be performed except push-ups if attachments are present. Be vigilant especially for patients with co-morbidities e.g. DM Contraction of distal mm of the stump

22 Selective Stretching BKA AKA Obtain neutral hip alignment
Knee must rest in full extension immediately post-op AKA Major concern is development of hip flexion and abduction contractures Obtain neutral hip alignment Gradually altering hip position

23 Special considerations in exercise prescription
AGE Gender Other medical conditions

24 Early Home Visit Meet the family Prepare the family
Goal should be independance of the patient once he/she goes back home

25 Others Weekly team meeting Early walking aid prescription
Pneumatic devices on the sockets Vacuum techniques Laminated plastic sockets Local varieties Group therapy Let the patient see other patients who were amputated

26 Late post-operative phase
Usually takes less than a month

27 Goals Promote wound closure Stabilize the stump Decrease edema
Start prosthesis measurement

28 Exercises for the following groups of muscles
Hip Extensors Hip Flexors Hip Abductors Hip Adductors Knee Extensors Knee Flexors Trunk strengthening exercises

29 Exercises for the following groups of muscles
Hip Extensors

30 Exercises for the following groups of muscles
Hip Flexors

31 Exercises for the following groups of muscles
Hip Abductors

32 Exercises for the following groups of muscles
Hip Adductors

33 Exercises for the following groups of muscles
Knee extensors

34 Exercises for the following groups of muscles
Trunk strengthening

35 Special considerations during exercise prescrtiption
Incorporate play therapy especially for your pediatric patients Make sure that activities that you plan to do are developmentally appropriate for your patient

36 Donning and Doffing Patients are encouraged to dress independently as much as possible According to Engstrom (1993) If the patient is unable to put the underpants independently, it is very unlikely that the indpendent application of the prosthesis is possible

37 Transfers Initial requirements
Alertness and the ability to comprehend instructions It is possible to do transfers while the drip / catheter is in situ (PRECAUTION) A suitable wheelchair should have been loaned pre-operatively and must be self-propelling

38 Transfers Independence for all transfers on all level surfaces should be the goal Therapist should try to make all transfer surfaces level

39 Transfers

40 Transfers

41 Basic mobility skills Independence in sit-to-supine, supine-to-sit, and rolling for all LE amputees What happens when the amputation of the LE is high? Tendency to fall Good core muscle strength is needed

42 Prosthetic referral Upon complete wound healing and stump stability
Upon gaining independence in ADL’s

43 What if bilateral AKA? Possible non-walker
Activities are: bed mobility training, arm exercises, balance re-education, transfers, wheelchair maneuvers Wheelchair concerns...

44 Prosthetic Training Phase
Training Program Design Pre-ambulation training Gait training Falls training Functional training Environmental considerations Specialized prosthetic training

45 Training Program Design
Principles of exxercise prescription Should be done daily and runn the whole day Family / caregiver involvement Use of different appliances / attachments Donning and doffing of the prosthesis

46 Training Program Design
Principles of exxercise prescription Should be done daily and runn the whole day Family / caregiver involvement Use of different appliances / attachments Donning and doffing of the prosthesis

47 Pre-ambulation Training
Sit-to-stand Balance re-education Weight transfer on to the prosthetic leg Considerations for progressions

48 Pre-ambulation Training

49 Gait Training Weight bearing on the prosthetic leg is advocated
Done on various types of surfaces Protection of the stump

50 Gait Training Gait Pattern; Indoor then outdoor mobility
2-point vs 3 point Indoor then outdoor mobility

51 Functional Training

52 Environmental Modifications
For grasping Toilet seat raise, grab bars, bed blocks Velcro and snaps vs zippers and buttons Ramps Others Doors Knobs Switches

53 Other considerations Disablement resettlement Driving

54 After Discharge Out-patient services Follow-up visits
Maintenance of prosthesis

55 Specialized prosthetic training
Vocational training Athletics Recreational activities

56 Specialized prosthetic training

57 Specialized prosthetic training

58 Specialized prosthetic training

59 References Mariano, LMMJr. (2007). PT150 Archives. UP-CAMP
Meyers, R.S. (1995). Saunders manual of physical therapy parctice. Philadelphia: W.B. Saunders. (2004). A manual for the rehabilitation of people with limb amputation . World Health Organization.

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