1. Amputations

2. Objectives
Demonstrate and instruct proper body mechanics for assisted transfers, bed mobility, and functional activities within the POC
Identify safety issues while utilizing compression garments as a modality
Demonstrate competency while following proper safety protocols and patient protection with application of compression garment or limb wrapping

3. Objectives
Discuss and demonstrate appropriate functional treatment techniques for above knee and below knee amputees, within the plan of care established by a PT
Discuss and demonstrate appropriate functional training treatment techniques of an amputee, including use of assistive or adaptive equipment and devices
Document the safety, status, and progression of patients while engaged in gait, locomotion, balance, wheelchair management and wheelchair mobility, within the POC established by a PT during patient-simulated scenarios

4. Objectives
Differentiate between typical and atypical changes in skin condition while utilizing orthotics, splints, or assistive devices
Describe the role of the physical therapist assistant in the instruction and management of orthotics, prosthetics, or assistive devices
Differentiate between above joint and below joint prostheses for UEs and Les
Design an exercise program based on level of amputation

5. Objectives
Demonstrate safety techniques and progression of amputee patients during gait, mobility, balance, wheelchair training
Document findings regarding functional status and any physical barriers, in collaboration with supervising PT, in preparation for discharge
Instruct patients and/or caregivers on pressure relief techniques and their importance

6. What is an Amputation? What are Common Types?
Transhumeral
Transradial
Transtibial
Transfemoral

7. Amputations Refer to Audio Lecture
Pediatric and UE limb amputations

8. Discussion
Give examples of congenital and acquired pediatric amputations
What might be some unique challenges experienced while treating a pediatric client?
What is a terminal device?
Which UE prosthesis is the easiest to use and care for?
What are the pros and cons of a myoelectric device?
What specific exercises might you focus on when training for using a body powered unit?

9. 2 Causes for Pediatric Amputations
1) Congenital limb deficiencies
2) Acquired limb deficiencies

10. 1. Congenital Limb Deficiencies
Occur in-utero
All or part of the bone fails to develop
Amelia: Entire bone or segment is missing
Hemimelias: all or part of bone is missing longitudinally
Phocomelia: absence of proximal segment of the limb.

11. Amniotic band syndrome (ABS)
Common cause of congenital amputations
Believed to occur secondary to fetus getting entangled in ruptured amniotic bands.
ABS typically sporadic, not hereditary.
No risk of familial recurrence.

12. 2. Acquired Limb Deficiencies
May occur secondary to: trauma, vascular disease, tumors, infections, or burns.
Twice as many amputations from trauma vs disease.
May involve partial or complete removal of limb.

13. Interventions Surgery: Therapeutic: Shape and desensitize limb
Plan program of exercise and strengthening
Improve endurance
Improve prosthetic tolerance (if applicable).
Family support should be established
Special attention should be paid to range of motion, skin condition, shape and strength of residual limb.
Issues of Phantom Pain and limb hypersensitivity may need to be addressed as well.

14. Interventions Surgery Therapeutic Limb preparation Exercise
Functional training for age level
Prosthetic training
Education

15. General Rules for Intervention for Pediatrics
Prosthetics:
For upper extremities prosthetic wear can occur as early as 3 months. Allowing child to develop age appropriate skills.
Components should match child’s development as he or she grows.

16. UE Amputation

17. Adult and Adolescent Upper Extremity Amputation
Main cause of amputation for young adults and adolescents is trauma.
Can occur anywhere along the upper extremity
Two of the most common
Transhumeral
Transradial

18. Upper Extremity Amputation
Amputation Sites
Three Levels Transhumeral:
1) Very short above elbow
2) Standard above elbow
3) Long above elbow
Three Levels Transradial:
1) Very short below elbow
2) Short below elbow
3) Long below elbow

19. Adult Upper Extremity Amputation: Post Surgical Phase
Residual Limb Care Residual limb wrapping for shaping Skin Desensitization and Preparation for prosthesis

20. Adult Upper Extremity Amputation: PT Interventions
Strengthening
ROM
Functional Training
Control training (utilization of prosthesis)
ADLs
Task specific training
Donning/ doffing
Integration of device into daily life

21. Upper Extremity Amputation: Basic Components
Socket
Suspension
Control –cable system
Terminal device
In accordance with amputation level; interposing joints components are available as needed.

22. UE prosthetics Many varieties: Appearance Weight Cost Function
Terminal device (TD)

23. Upper Extremity Amputation: Types of Prosthetics
Cosmetic
Body Powered
Myoelectric (Battery Powered)
Hybrid

24. Cosmetic UE Device Lightest in weight Least functional
Provides simple aid in balancing and carrying
Simple to use
Easy to maintain
Passive functional

25. Cosmetic Device

26. Body Powered UE Device Most durable
Operated by a harness system, controlled by specific body movements
Medium weight
Least satisfactory appearance
Conventional device

27. Body Powered Device

28. Myoelectric UE Device Heaviest Powered by a battery system
Controlled by EMG signals generated during muscle contractions
Reduced harness system
Grip force up to lbs
Cosmetically appealing

29. Myoelectric Device

30. Hybrid UE Device Combines the use of body power and external power
Two types:
Excursion to elbow/Battery powered Terminal Device –body power controls elbow, battery controls TD (stronger TD pinch)
Excursion to TD/Battery powered elbow –battery controls elbow, body power controls pinch (weaker TD pinch)

31. Recreational or Adaptive UE Device
Customized for a specific function or recreational activity
Available for activities such as skiing, golf, fishing, construction work, shooting pool, playing guitar and more

32. Upper Extremity Amputation: Adaptations
Adaptive Equipment
Board with nails for stability of objects when cutting and peeling
Self-wringing mop
Adaptive Technique
Use of scissors to open plastic bag
When making bed don’t tuck sheets in.

33. LE Amputations

34. 4 Common Causes of Amputation:
PVD
2/3 of all amp. in US are due to complications from diabetes
Trauma
Seen in mainly in younger adults and adolescents
Tumor
a distant second to trauma for amputations
Congenital
58.5 % of upper limb extremity amputations from to 1996 were congenital

35. Case Study: George
What risk factors contributed to George’s amputation?

36. Lower Extremity Amputations
Transtibial and Transfemoral:
Either can occur unilaterally or bilaterally
Transtibial amputees are promising for successful, functional prosthetic use.
Those with B transfemoral amputations can become functional ambulators (if good balance), aided by computer components
Prior level of function?!?

37. Postoperative Phases
1) Postsurgical Phase
2) Prosthetic Phase

38. Soft vs. Semi-rigid vs. Rigid

39. PT Examination History Systems Review Skin Residual Limb Length
Residual Limb Shape
Emotional Status
Vascularity
Range of Motion
Muscle Strength
Neurological
Functional Status

40. Functional Treatment Techniques
Residual Limb Care
Limb Wrapping
Positioning
Management of Contractures
Therapeutic Exercise
Transfer Training
Balance
Ambulation
Wheelchair Management

41. Case Study: George
What is involved in residual limb care, and why is it so important?
What is desensitization and how can a PTA employ these techniques in treatment?

42. 1. Residual limb care Proper skin care and hygiene
Patient educated to keep clean and dry
Avoid cuts, abrasions, and other skin irritants
Educate on pressure relief
Patient educated to self inspect limb
Visually
Use of a mirror
Consider decreased sensation
Consider impaired vascularity

43. Residual limb care
Bathe normally once incision healed; sutures removed
Night bathing is encouraged
limb becomes a little edematous afterward
Dermatological conditions may be contraindications against limb wrapping
Eczema, psoriasis, dermatitis

44. Desensitization Neuroma – pain and hypersensitivity Phantom Sensation
Phantom Pain
Massage, pressure, various textures, lotions, massage with washcloth, etc.
Mirror therapy
Psychological considerations

45. Case Study: George Why is limb shaping important?
What are the pros and cons of using a shrinker versus an elastic wrap for limb shaping?
When should they be used? How long should they be worn throughout the day?

46. 2. Limb Wrapping Two types of compression wraps: A) Shrinkers
B) Elastic wrap
Used to help reduce size of residual limb for those not fit with rigid, removable rigid dressing or temporary prosthesis
rehabilitation-program/educational-videos

47. A. Shrinkers Pros- Cons- Easier to apply
Option for pt who is unable to properly wrap limb
Cons-
Cost
Need to purchase smaller sizes as limb size decrease
Not able to be used until the incision is healed and sutures are removed.

48. Shrinkers: cont Precautions- Transtibial residual limb-
Avoid rolling of edges or slipping of shrinker-could cause tourniquet around proximal limb.
Transtibial residual limb-
Self suspending (patient with heavy thighs may require additional suspension).
Transfemoral residual limb-
May incorporate hip spica. Good suspension for most patients(Not adequate for obese).

49. B. Elastic Wrap Pros- Cons –
May be applied over post surgical dressing
Patient or family member can be instructed in wrapping as soon as wound care is no longer necessary
Cons –
Need frequent wrapping
Manual coordination/dexterity needed

50. Elastic Wrap: con’t Precautions-
Avoid any wrinkles or folds
Avoid adductor roll
Wrapping may be done by pt, family, PT/PTA, nurse
Allows easy access for therapist and family member

51. Elastic Wrap: con’t Transtibial – Transfemoral-
Wrap while pt in sitting
Transfemoral-
Wrap with pt in sidelying (standing if good balance)
Sitting is not recommended

52. Case Study: George
What is the importance of positioning following an amputation?
Which muscles are at risk for shortening and developing contractures?
Which muscles should be stretched?
Which muscles should be strengthened?
Why?

53. 3. Positioning Improper positioning can result in contractures.
Need for full hip extension
EDUCATE! To prepare for prosthetic ambulation in the future

54. Positioning: Con’t Precautions-
any type of amputation: avoid elevating residual limb on pillow
leads to hip flexion contracture.
Transtibial-Full range of motion in hips and knees especially in extension.
Transfemoral-Full range of motion in extension and adduction of the hip.

55. 4. Management of Contractures
Reasons for occurrence:
1) Muscle imbalance or tight fascia
2) Protective withdrawal
3) Loss of plantar stimulation in extension.
4) FAULTY POSITIONING!
Treatment:
Stretching techniques
Positioning for prolonged muscle lengthening

56. Management of Contractures: con’t
Transtibial
Patellar tendon bearing prosthesis aligned to put the hamstrings in a stretch position (if PT and physician, and then prosthetist in agreement with suggestion).
Transfemoral
contractures occur more frequently with this type of amputation (unilateral and bilateral)

57. Case Study: George Design an exercise program for George
Write a SOAP note of your treatment session today.

58. 5. Therapeutic Exercises
Mat exercises-as applicable
Rolling, Prone on Elbows, Prone on Hands, Supine on Elbows, Pull-ups, Sitting (long and short).Quadruped position, Kneeling position, transfers.
Preparatory exercises for Locomotor training- as applicable.
Bridging, Pelvic Elevation, Quadruped position, Sitting, Sit-to-stand, Modified Plantigrade, Standing, Parallel bar progression.

59. Therapeutic Exercises: con’t
The start of any resistive exercises for the involved extremity depends on three things:
1) Post surgical dressing
2) Degree of post operative pain
3) Healing stage of the incision

60. Therapeutic Exercises: con’t
Strengthening
emphasize muscles that are key to effective use of the prosthetic device (hip extensors, abductors, knee flexors and extensors) (See fig )
Upper extremity and shoulder girdle strengthening can help prepare for crutch walking and lifting body in ambulation.
Certain exercises such as isometrics may be contraindicated for some patients’ with secondary cardiovascular issues.

61. 6. Transfer Training/Bed Mobility (without prosthetic)
Need to address bed mobility without the prosthetic
Scooting (without using heels to push up)
Supine to sit gets them sitting EOB
Sit to stands –
must get used to WB on one side
progress from AD to I
Patient should be cautioned to: Protect the limb from trauma, (Don’t push on or slide limb against chair or bed)

62. Case Study: George
How does a LE amputation affect sitting balance?

63. 7. Balance and Coordination
Sitting Balance
Must work on balance sitting EOB especially for transfemoral (no hamstings for balance)
Standing Balance
Must get used to WB on one side
Progress from AD to I

64. Case Study: George
When should ambulation be initiated following an amputation?
Why?
Which type of assistive device is preferred and why?
Would you recommend a w/c for George? Why?

65. 8. Ambulation (without prosthesis)
Crutch training is preferred if safe
Easier transition to gait with prosthesis
Use of a walker only if crutches are not safe
Limitations in community ambulation
Limitations of swing to gait pattern
Cardiovascular benefits of ambulation
Need for ongoing ability to ambulate without prosthesis

66. 9. Wheelchair management
Bilateral amputees will need to have a w/c as a resource
Transfemoral amputees
May need w/c for certain activities
Consider anti-tip bars for w/c to compensate for lack of LE weight

67. Wheelchair management: con’t
parts of w/c (brakes, foot rest management)
Propulsion, curbs, and ramps
Transfers in/out and floor/sitting

68. Temporary Prosthesis
Basic socket and pylon to allow for early ambulation on two legs
May be in the form of “Stubbies”

69. Temporary Prosthesis Fitted when the wound is healed
Pros of Temporary Prosthesis-
More effective than elastic wrap to shrink limb.
Allows for early ambulation with BLEs
can help to evaluate patient’s rehab potential.
Can use to return to a more active life.
Those who cannot afford a definitive prosthesis, can use temporary one for ambulation.

70. Temporary Prothesis: con’t
Cons of Temporary Prosthesis-
Special training is required to fabricate temporary socket.
Usually fabricated by prosthetist, BUT CAN BE MADE BY SKILLED PT OR PHYSICIAN
Need for ongoing skin care checks and limb care as size of residual limb changes

71. Gait with walker (AKA) http://www.youtube.com/watch?v=DA4JnV0 WExE
Assess gait pattern

72. Prosthetic Gait Training Lab
Sit to stand
Floor to stand
Steps, ramps and curbs
Limb wrapping

73. Amy Purdy http://www.youtube.com/watch?v=vP_QZHGr wXo
1:40 – 2:52 dance
0:20 – 1:30 practice

74. Prosthetics

75. Review Terms Shank Pylon Socket Suspension system Liner Shrinker Sock
Elastic wrap

76. Contraindications Significant Depression Significant Dementia
Significant cardiopulmonary disease
Bilateral amputees who are unable to transfer independently, or don pants independently
Why?

77. Case Study: George
How are the shrinker, liner and sock used, and for what purpose?
How often should George be wearing his shrinker, now that he has a prosthesis?
Pros and cons of walker vs. crutches for George
How can you verbally instruct George to improve his ability to lock the knee for loading?

78. Transtibial and Syme’s Amputation
Require socket and ankle/foot component
Transtibial also requires a suspension system and the shank
Syme’s amputation allows for weight bearing directly through the distal end of the tibia, cushioned by the fat pad

79. Syme’s Amputation

80. Case Study: George
What are the possible choices for a foot for George, based on his PLF?

81. Prosthetic Feet - Nonarticulated
SACH (solid ankle cushion heel)
SAFE (stationary attachment flexible endoskeleton) – more M-L motion at hindfoot
Carbon Copy II – energy storing/releasing
Seattle Foot – energy storing/releasing
Flex-Foot and Springlite foot – band of carbon fiber acting as a leaf spring for more energy for running and sports

82. SACH

83. Energy Storing Feet

84. Flex Feet

85. Articulated Feet Single-Axis feet – PF, DF, and toe break
Multiple-Axis feet – movement in all planes

86. Single Axis Feet

87. Multi-Axis Feet

88. Shank
Exoskeletal – rigid material, shaped to simulate the anatomical leg
Endoskeletal – often a central aluminum pylon

89. Exoskeleton

90. Endoskeleton

91. Sockets Made to disperse contact and load throughout the residual limb
Assists in venous return
Provides tactile feedback
Reliefs over bony prominences

92. Patellar Tendon Bearing Socket
Patellar-tendon-bearing: prominent indentation over the patellar tendon

93. Knee Unit Components Axis System: single axis or polycentric linkage
Friction Mechanisms: constant friction or variable friction
Extension Aid: elastic webbing on anterior knee or internal extension aid
Stabilizers: alignment, manual lock, friction brake

94. Axis system
Single axis or polycentric linkage

95. Friction Knee
constant friction or variable friction

96. Extension aid
elastic webbing on anterior knee or internal extension aid

97. Multiple knees

98. Case Study: George What are the two most common transfemoral sockets?
What is the difference between them?
Why was it important for the PT to check George’s skin before and after treatment?

99. Transfemoral Sockets Total contact Distributes load Reduces pressure
Assist venous return
Prevents distal edema
Enhances sensory feedback
Flexible plastic allows for feedback from external objects (chairs)
Socket also needed for knee disarticulations

100. Transfemoral sockets

101. Quadrilateral Socket Quad socket
Emphasizes loading on gluteal muscles, sides of the thigh, ischial tuberosity

102. Ischial Containment Socket
Narrow M-L
Medial and lateral width is more narrow
Walls cover the ischial tuberosity, weight bearing on the sides and bottom of the limb

103. Problems with fit of socket
Too big
Too small
Too tight
Too loose
Rotation/twisting
Implications for skin breakdown due to pressure and/or shearing

104. http://www.youtube.com/watch?v=CDsNZJT Ww0w Hugh Herr….
his story
fitting
propulsion
bioelectrics
gait on incline
dance
Hugh Herr is building the next generation of bionic limbs, robotic prosthetics inspired by nature's own designs. Herr lost both legs in a climbing accident 30 years ago; now, as the head of the MIT Media Lab's Biomechatronics group, he shows his incredible technology in a talk that's both technical and deeply personal — with the help of ballroom dancer Adrianne Haslet-Davis, who lost her left leg in the 2013 Boston Marathon bombing, and performs again for the first time on the TED stage.

105. Case Study: George What gait deviation is George describing?
What are the possible causes?
What gait deviations might occur if hip extension ROM continues to be limited?

106. Gait Deviations
See videos posted on Blackboard, and chart on handouts.

107. References http://encarta.msn.com/dictionary_/amputation.html
Timothy R. Dillingham, MD, et al, “Limb Amputation and Limb Deficiency: Epidemiology and Recent Trends in the United States,” Southern Medical Journal 95 (2002):
O’shea, R. K. (2009). Pediatrics for the physical therapist assistant. St. louis: Elsevier. Inc.
pp.160
physical+therapy+for+upper+extremity+amputations&source
O’Sullivan, S.B. , Schmitz, T. (2007). Physical rehabilitation 5th edition. Philadelphia, PA: F.A.Davis company pp