Examination & Treatment of the Lower Extremity Amputee

1. Examination & Treatment of the Lower Extremity Amputee Training the LE amputee in the use of a prosthesis 4-17-07

2. Focused reading for class discussion: • O’Sullivan • pp. 624-629 (from last week) • Physical Therapy Management pp. 660-670

3. Learning Objectives • Discuss and apply the psychological impact of an amputation. • Discuss in detail and apply the progression followed in gait training an amputee with a prosthesis. • Discuss and apply the aspects of the home program for a patient receiving a LE prosthesis (correct use, maintenance/care, exercise, skin care, sock care, etc.) • When presented with a clinical case study, analyze & interpret patient data; determine realistic goals/outcomes and develop a plan of care.

4. IMPAIRMENTS Pain Decreased strength, ROM, mobility Decreased skin integrity Decreased endurance Psychological issues FUNCTIONAL LIMITATIONS Inability to walk, work, play What are likely limitations for Mr. Howard?

5. Early Post-op care:How should Mr. Howard be taught to care for his residual limb? • Wash nightly w/mild, nondrying soap (after sutures removed); pat dry with terry cloth towel • Small amt. of lotionsoft, pliable limb more tolerant of prosthetic wear than tough, dry limb • DON’T use alcohol • Daily skin inspectionsuse mirror if necessary • Desensitization;rub, tap, massage, touch w textures • Soft tissue mobilization *Don’t forget care of sound limbsame guidelines for washing & inspecting plus don’t walk barefoot, don’t soak feet, avoid extreme temperatures/binding socks, inspect shoeswatch for skin changes: color, temperature, loss of hair, sores, etc. 6

6. What functional activities should PT concentrate on for Mr. Howard in early post-op period? • Wheelchair • post-op & pre-prosthetic period & for long distances, very short TF & double amputees often need indefinitely • Use anti-tippers or amputee axle if no prosthesis • Bed mobility • Transfers-try to use stand-pivot • Monitor vitals • May need sliding board • Balance: sit, hands and knees, tall kneeling, stand activities • Gait • Begin in parallel bars • Single limb amb. with assistive device VERY energy intensive • Outside of bars try crutches, last resort wheeled walker • All LE amputees will need an ambulation aid to use when prosthesis is off2

7. Should PT be concerned with the psychological impact of Mr. Howard’s amputation? • Absolutely! • Affects all aspect of rehab. • Often PT spends most time with pt. on team and pt. will open up to PT • Need to know what “normal” acceptance is compared to depression

8. What should PT include in Mr. Howard’s home program? • Compression bandaging • Contracture prevention • Residual limb care/remaining limb care • Strengthening-UE/LE • ROM • Balance • Functional activities • General conditioning • Provide in writing, in layman’s terms,teach pt.and family

9. Target Clinical Pathway (usually longer than this, though) • Day 0: Amputation surgery • Day 1-4: Acute hospital, pre-prosthetic PT • Day 5-21: Sub-acute rehabilitation hospital or home for wound healing and continued pre-prosthetic PT • Day 21-28: Suture/staple removal followed by casting for temporary prosthesis 7

10. Case Scenario • Mr. Howard has been at home for the past 5 weeks performing pre-prosthetic program with a home health PT. The prosthetist has fit him with his temporary prosthesis and Mr. Howard is now ready for OP daily physical therapy to work on walking.

11. What are factors that can affect Mr. Howard’s prosthetic training success? • Physical abilities (strength, ROM, endurance, skin, pain, etc.) • Cognitive abilities • Prosthetic fit • Motivation • Financial resources-insurance often determines LOS/type of prosthesis • Socio-economic circumstances-caregiver, car, living situation, etc.

12. What will the PT examination of Mr. Howard look like? • Guide to PT practice • Prosthetic checkout • Static assessment • Stand in parallel bars • sit • Dynamic assessment

13. Evaluation Data to Collect • Aerobic Capacity and Endurance • Anthropometric Characteristics • Arousal, Cognition, and Attention • Assistive/Adaptive Devices • Circulation (Arterial, Venous, and Lymphatic) • Cranial and Peripheral Nerve Integrity • Environmental Barriers • Body Mechanics

14. Evaluation Continued • Gait, other Locomotion, and Balance • Integumentary Integrity • Joint Integrity and Mobility • Motor Control and Motor Learning • Muscle Performance • Orthoses, and/or protective/supportive devices • Pain – Location and Intensity

15. Evaluation Continued • Posture • Prosthetic Requirements • Range of Motion (include muscle length) • Self-Care and Home Management • Sensory Integrity • Work (job/school/play) • Community Integration/reintegration

16. Mr. Howard’s PT Diagnosis • Impaired Motor Function, Muscle Performance, Range of Motion, Gait, Locomotion, and Balance Associated With Amputation • Practice Pattern: Musculoskeletal, 4J 1

17. What are likely PT goals for Mr. Howard? Pair & Share • Remember: • Audience • Behavior • Condition • Degree

18. What is the likely plan of care for Mr. Howard? • Teach donning/doffing prosthesis • Continue evaluation of skin/teach pt. care • Check fit of prosthesis • Teach transfers • Begin gait training • Continue strengthening/ROM/balance, etc.

19. How would you teach Mr. Howard to don his prosthesis? • Have sit in firm chair with arms • Identify and check prosthesis • Inspect condition of residual and remaining limb • Place sheath then prosthetic socks over residual limbmake sure there are no wrinkles • Place insert over residual limb (if pt. has one) • “step” into prosthesis while sitting • Attach suspension • Reverse to doff, and check skin 4

20. What skin problems should PT look for with Mr. Howard’s use of LE prosthesis? • Abrasion/blisters (poor distal contact) • Most common sites: bony • Why? Settling, pistoning, tilting, torsion • Solutions: lamb’s wool • Distal edema • Why? Not good contact • Solutions: add lamb’s wool

21. Residual limb condition: • Prosthetic sock pattern-pinpoints high pressure area, shows whether limb has total contact with prosthesis (should look the same all over) • Loss of hair/skin condition-indicates continued pressure and reduced nourishment of tissues and skinsee Dr. ASAP • Sensation: throbbing pain indicates choking (ace wrapped improperly); temperature: cold=impaired circulation, hot=infection possiblecall Dr. • Skin-check every 15 minutes of prosthetic wear • Texture • Appearance • Color • Condition • Reddened areas should disappear in 15 minutes. If red area noted, leave shrinkers off and prosthesis off. If red area gone within 15 minutes, reapply prosthesis. If red area not gone in 15 minutes, inform prosthetist. • No red areas, maintain wear schedule of 15 minutes on with activity, check skin and continue as appropriate. Shrinkage devices should be applied when prosthesis is removed. 3

22. Weight-shift activities • Primary goal is to get weight shift onto prosthetic side normalize gait • Pt. stands in parallel bars with an open hand, use of full-length mirror helpful, feet approximately 4 inches apart • Shift weight side to side • Shift weight forward and back • Shift weight diagonally • Progress to doing activity with one hand (opposite prosthesis, then same side as prosthesis), then to no hands, if possible 3

23. Stepping activities • Stand in parallel bars, feet 4 inches apart, both hand on bars, can progress to one, then no hands • Pt. steps forward, back with sound limb • Pt. steps forward, back with prosthetic limb *focus on forward rotation of pelvis, weight-shift, flexing prosthetic knee at pre-swing for Mr. Howard (foot placement for TF) • Can also do side stepping 3

24. Stool stepping • Use 8 inch stool, pt. stands in parallel bars, stool in front of sound limb, both hands on bars • Step onto stool slowly with sound limb, then back off • Mr. Howard can also practice stepping up with prosthesis, but this is not recommended with a TF because requires hip hike/circumduction to get foot off step which is undesirable and is a pattern to be avoided *emphasize control of hip and knee of prosthetic side *progress activity by removing one hand, then if possible, two 3

25. Stride • Stand in parallel bars, feet 4 inches apart, both hands on bars, can progress to one, then no hands • Alternate which leg begins stride • Progress to two strides, then three, etc. *can progress outside parallel bars when: -pt. is able to shift weight A/P, R/L without deviations -pt. is able to step forward with sound limb and shift weight adequately onto prosthesis without deviations -pt. is able to step forward with prosthetic limb, using rotation then hip flexors, rather than trunk -Pt. is able to walk length of parallel bars with flat hands and minimal deviations 3

26. What might Mr. Howard’s assistive device progression look like? • Gait training in parallel bars • Gait training with suspension harness • Axillary crutches-risk radial nerve impingement/ Forearm crutches • Walker-only if can’t use crutches • Cane

27. Advanced activities should include: • Transfers to various chairs/car/toilet • Curbs/stairs • Inclines • Uneven terrain • Picking up dropped object • Clearing obstacles/barriers • Falling and rising • Sitting/kneeling to floor and rising • Running, single leg stance, dynamic balance 3

28. What new information should be included in Mr. Howard’s HEP now that he has a prosthesis? • Don/doff • Wear Schedule • Care for prosthesis

29. How should Mr. Howard care for his prosthesis? • Wash socket daily with a damp cloth dipped in mild sudsy water • Rinse cloth, wring dry, and wipe socket again • Clean valve in a suction socket with a small brush • Check joints/locks regularly for wear/proper functiondo not oil or grease any parts • Do not make any adjustments yourself • Keep away from heat 4

30. When will PT discharge/ discontinue Mr. Howard from PT? • Ideally when he can do all functional skills, gait on all surfaces, fall/get up, care of skin/prosthesis, etc. • Without pain, huge energy cost or abnormal gait • When pt. has reached maximum potentialfails to progress • Often determined by insurance coverage • Ideally Mr. Howard will be wearing prosthesis for 3-4 hours a day, good knowledge of skin care and prosthetic management, proficiency with prosthetic skills • Transfemoral amputee may only wear prosthesis for 30-60 minutes at discharge 4

31. Discharge/discontinue PT • Guide to PT Practice p. 311 • Discharge=ending PT secondary to pt. reached anticipated goals/outcomes • Discontinuation=ending PT secondary to: • Patient request/preference • Unable to continue secondary to insurance, lack of finances, no transportation, medical complications, etc. • Pt. no longer benefits (i.e. no progress) 1

32. When will Mr. Howard most likely require a socket revision? • Most new wearers need a major socket revision/new socket within a year to accommodate shrinkage5

33. Energy Expenditure5 *Up to 300 % increased energy expenditure for bilateral transfemoral amputee6

34. Medicare Functional Levels • Level 0-Pt. is non-ambulatory • Medicare won’t pay for prosthesis • Level 1-Transfers or limited household ambulator • Sach/single axis foot • Manual knee lock, stance control • Level 2-Limited community ambulator • Multi-axis foot • Polycentric, pneumatic knee • Level 3-Unlimited community ambulator • Level 4-High energy activities • Level ¾: energy storing feet and hydraulic/microprocessor knee7

35. Timeline Seymour, R. Prosthetics and Orthotics: Lower Limb and Spinal. Philadelphia: Lippincott, Williams and Wilkins; 2002, p. 163.

36. Prosthetic Rehabilitation • Transtibial: 4-6 weeks outpatient PT/day pt. • Transfemoral: 6-12 weeks outpatient PT/day pt. • Temporary prosthesis 4-5 weeks after amputation • Provide permanent prosthesis 3-6 months post-op • Annual re-evaluation of fit and function • Replacement prosthesis every 4-5 years 7

37. References: • American Physical Therapy Association. Guide to Physical Therapy Practice. 2nd ed. Alexandria, Va: American Physical Therapy Association; 2001. • Lusardi MM & Nielsen CC. Orthotics and Prosthetics in Rehabilitation. Woburn, MA: Butterworth-Heinemann; 2000. • 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 Orhtotics: Lower Limb and Spinal. Philadelphia: Lippincott, Williams and Wilkins; 2002. • University of Missouri-Columbia Department of Physical Medicine and Rehabilitation Handouts. Lower Limb Prosthetics; 2005.