Examination & Treatment of the Lower Extremity Amputee Training the LE amputee in the use of a prosthesis 4-17-07 Focused reading for class discussion: O’Sullivan pp. 624-629 (from last week) Physical Therapy Management pp. 660670 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. What are likely limitations for Mr. Howard? IMPAIRMENTS FUNCTIONAL LIMITATIONS Pain Inability to walk, work, play Decreased strength, ROM, mobility Decreased skin integrity Decreased endurance Psychological issues 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 lotionsoft, pliable limb more tolerant of prosthetic wear than tough, dry limb DON’T use alcohol Daily skin inspectionsuse mirror if necessary Desensitization;rub, tap, massage, touch w textures Soft tissue mobilization *Don’t forget care of sound limbsame guidelines for washing & inspecting plus don’t walk barefoot, don’t soak feet, avoid extreme temperatures/binding socks, inspect shoeswatch for skin changes: color, temperature, loss of hair, sores, etc. 6 What functional activities should PT concentrate on for Mr. Howard in early post-op period? Wheelchair Bed mobility Transfers-try to use stand-pivot 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 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 off 2 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 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 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 preprosthetic PT Day 21-28: Suture/staple removal followed by casting for temporary prosthesis 7 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. 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. 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 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 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 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 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 What are likely PT goals for Mr. Howard? Pair & Share Remember: Audience Behavior Condition Degree 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. 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 limbmake 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 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 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 skinsee Dr. ASAP Sensation: throbbing pain indicates choking (ace wrapped improperly); temperature: cold=impaired circulation, hot=infection possiblecall 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 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 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 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 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 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 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 What new information should be included in Mr. Howard’s HEP now that he has a prosthesis? Don/doff Wear Schedule Care for prosthesis 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 functiondo not oil or grease any parts Do not make any adjustments yourself Keep away from heat 4 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 potentialfails 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 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 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 shrinkage 5 Energy Expenditure 5 % Functional Recovery % Increased Energy Requirement Transmetatarsal > 95% ~ 0% Transtibial 70-75% 20-40% Transfemoral 20-40% 50-80% *Up to 300 % increased energy expenditure for bilateral transfemoral amputee 6 Medicare Functional Levels Level 0-Pt. is non-ambulatory Level 1-Transfers or limited household ambulator Sach/single axis foot Manual knee lock, stance control Level 2-Limited community ambulator Medicare won’t pay for prosthesis 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 Timeline Seymour, R. Prosthetics and Orthotics: Lower Limb and Spinal. Philadelphia: Lippincott, Williams and Wilkins; 2002, p. 163. 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 References: 1. 2. 3. 4. 5. 6. 7. 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.