Transcript Examination & Treatment of the Lower Extremity Amputee

Examination &
Treatment of the
Lower Extremity
Amputee
Pre-prosthetic PT Intervention
4-03-07
Reading Focus for
Class Discussion
O’Sullivan
 pp. 620, 622-639
 Blackboard-foot care/prevention
 **We will use Guide to PT practice for
this unit
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Introduction
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Labs for Unit 4, grading rubric for discharge
note, home exercise program will be posted
on Blackboard this week
Visit to Hanger will be scheduled for late April,
in the evening and attendance is required (in
lieu of Thursday/Friday lab)
Learning Objectives
Identify and apply major factors leading
to lower extremity amputation
 Describe and apply the levels of lower
extremity amputation and the functional
impact
 Discuss and apply PT early postoperative 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
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Case Scenario

It’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
NAGI Disablement
Model
What is the
cause/reason for Mr.
Howard’s amputation?
History of diabetes with peripheral
vascular disease (PVD) and chronic
non-healing foot ulcers
 Very mild peripheral neuropathy
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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)
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Pt. with DM who undergoes one amputation 2 to PVD
has 51% chance of 2nd operation within 10 yrs.2
Trauma
– MVA, gunshot
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Cancer
Congenital
2
Causes of Amputation
by Percent
Lusardi MM & Nielsen
CC. Orthotics and
Prosthetics in
Rehabilitation. Woburn,
MA: ButterworthHeinemann; 2000, p.
328.
Risk factors for PVD?

Lusardi MM & Nielsen CC.
Orthotics and Prosthetics in
Rehabilitation. Woburn, MA:
Butterworth-Heinemann; 2000, p.
330.
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Diabetes
Poorly managed HTN
High
cholesterol/triglycerides
Smoker
– *same as risk factors for
cardiovascular and
cerebrovascular disease
– PVD and peripheral
neuropathy (numb, cold,
paresthesia, pain) are the
major predisposing factors
for LE amputation in
individuals with DM
2
What are
Signs/Symptoms of
Vascular Insufficiency?
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Intermittent claudication
– What is this?
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Significant cramping pain, usually in the calf, that is
induced by walking or other prolonged muscle
contraction and relieved by a short period of rest
– Vascular pain (increase with LE elevation)
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Loss of one or more lower extremity pulses
– Arteriosclerosis obliterans=at least one major
arterial pulse (dorsal pedis artery at ankle,
popliteal artery at knee or femoral artery in the
groin) absent or impaired
2
Clinical signs of PVD
Lusardi MM & Nielsen CC. Orthotics and
Prosthetics in Rehabilitation. Woburn, MA:
Butterworth-Heinemann; 2000, p. 344.
Protective sensation
Must be able to perceive 5.07
Semmes-Weinstein monofilament
 Easy and inexpensive way to identify
patients at risk for foot ulceration
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2
What should primary
goal be with PVD/DM in
regards to feet?
PREVENTION!
What is the level of Mr.
Howard’s amputation?

s/p transtibial amputation of ideal
length
Levels of Amputation
What are the
levels/classification of
amputation?
Transtibial (BK) 54%
 Transfemoral (AK) 32%
 Syme/foot 3%
 Hip disarticulation 1%
 Upper extremity 8%
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4
How was Mr. Howard’s
level of amputation
selected?

Preserve as much viable tissue/select
most appropriate level
Selection of
Amputation Levels
General guidelines
 Considerations with PVD
 Considerations with trauma
 Considerations with malignant tumor
 Considerations with deformity
 Considerations with congenital limb
deficiency/deformity revision

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.

Age of Amputees
> 61
 41-60
 <40
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40%
35%
25%
– 72% are males
4
Who is on the Team?
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Pt.
Dr.
PT
Prosthetist
OT
Social worker/case manager
Dietician, nursing, etc.
Vocational Rehab
Responsibilities of the
Team
Evaluate pt.
 Initial training in prep. for prosthesis
 Prescription of prosthesis (if appropriate)
 Fabrication of prosthesis
 Delivery of prosthesis
 Evaluate fit of prosthesis
 Train in use, care of prosthesis
 Follow-up eval. For problems, possible
changes, needs of pt.
 Maintenance/replacement of prosthesis
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What tests/measures should be included in
Mr. Howard’s Initial PT examination?
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Ideally Mr. Howard would have had a referral to PT
BEFORE his amputation
Definitive strength assessment of joint just proximal to
amputation can consist of only active, nonresisted
antigravity motion until adequate healing of surgical site
– i.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 grade
When incision healed & cleared by Dr., remember that
lever arm reduced & MMT grades could be inflated
– Do not apply pressure for MMT through
dressingmust be able to visualize suture line
during 1st several weeks of preprosthetic prog.
Guide to Physical Therapy Practice
– Practice pattern 4 J, 5G, 7 A, 7C/D/E
2
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1
Pre-prosthetic Examination
1.
May, BJ. Amputation and
Prosthetics: A Case Study
Approach. Philadelphia:
Davis; 1996, p. 73.
Exam
Seymour, R. Prosthetics and
Orthotics: Lower Limb and
Spinal. Philadelphia: Lippincott,
Williams and Wilkins; 2002, p.
37.
How can PT record measurements
for
Mr.
Howard’s
residual
limb?
 Actual length

Total length including soft tissue
– Measurements taken from easily ID bony landmark to the
palpated end of the long bone, to the incision line, or to the
end of soft tissue
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Medial joint line or tibial tubercle
TF start measurement at at ischial tuberosity or greater trochanter
Document which landmark you used!
TT 5-6 inches ideal; TT less than 3 inches problematic for prosthetic
control and skin integrity
Circumference:medial tibial plateau or tibial tubercle
and at equally spaced points to end of limb; TF=begin
at ischial tuberosity or greater trochanterclearly
document interval between measurements
– Prosthesis often made when distal limb circ=prox limb circ
(<1/4 inch difference)
2
Poor Residual Limb
Healing
1.
May, BJ. Amputation and
Prosthetics: A Case Study
Approach. Philadelphia: Davis;
1996, p. 79.
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
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.
What are PT’s primary
goals/outcomes for Mr. Howard’s
immediate post-operative period?
Ensure optimal wound healing
 Early preparation of the limb for
prosthetic fitting
 Maintain, increase mobility
 Improve endurance
 Care of remaining limb
 Maintain/increase ROM and strength
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How should PT inspect
Mr. Howard’s wound?
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Monitor residual limb for shape, incision
healing/closure, length, sensory integrity,
volume, tissue integrity, color temp., pain
Easy to do with dressing change
– Record quantity/quality of drainage
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Normal for clear drainage first couple daysshould
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 14
2
How can you teach Mr.
Howard scar management?
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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 itself
Why is scar mobilization important?
– Tissues must be able to glideadherence
promotes shearing forces which lead to skin
breakdown
2
What are common postamputation sensations Mr.
Howard may experience?
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phantom limb sensation
– 70% will experienceNumbness, tingling, pressure,
itching, mild cramp in foot/calf
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phantom limb pain
– Shooting limb pain, severe cramping, severe
burning in amputated foot/limbNOT
psychological!
– higher amputationgreater liklihood
– Evidence if pt. had significant dysvascular limb
pain a surgery are more likely to have phantom
limb pain
2
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
What are some strategies for
treatment of phantom limb pain?
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Patient education before surgery
– Alert pt. to issues of safetywake up in middle of
night p recent amputation and fall when attempt to
stand and walk thinking both limbs are intact
Careful inspection of limb to r/o neuroma or infected
wound
Compression, use of prosthesis, desensitization
techniques, heat
Medications, steroid injection, nerve block,
relaxation/hypnosisvaried effectiveness2
PT management of
Pain
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Time pain meds. So that pain control in
optimal during PT activities
Pt. ed. on imagery & relaxation methods
TENS: wound healing and phantom pain
US, cold therapy, massage
Wear prosthesis/compression bandages
– Varying effectiveness
– Pain management MUST NOT interfere with
wound healing
2
Why is compression
bandaging important for
ALL amputees?
Reduce edema
 Controls pain
 Enhances wound healing
 Protects incision during functional activity
 Facilitate preparation for prosthetic
placement by shaping and desensitizing
limb
*1st 4 are required even if pt. not a
candidate for prosthesis
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2
What options are there for
edema control for Mr. Howard?
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Compression bandaging
– Rigid
 Rigid applied by surgeon in OR, removed 3-4 day, can then put new
c IPOP-allows limited TTWB in 2-3 days-prosthetist
 Best for controlling edema and pain
 Not good for pt. c significant risk for infection because wound status
not easily visualized unless removeable (RRD)-PT
– Semi-rigid
 Prosthetist takes negative mold in OR or p rigid removed 3 day
 Polyethlene light weight,easy to clean,more durable than plaster
 Unna paste=zinc oxide,glycerin,calamine & gelatindries 24 h; Can
be left on for 5-7 days
 Air bag
– Soft bandaging=ace bandage, compressogrip
 Once suture line healed (10-21 days), use shrinker TT/TF, Jobst for
TF 2
Lusardi MM & Nielsen CC. Orthotics
and Prosthetics in Rehabilitation.
Woburn, MA: ButterworthHeinemann; 2000, p. 400.
RRD
Semi-rigid dressing
Lusardi MM & Nielsen
CC. Orthotics and
Prosthetics in
Rehabilitation.
Woburn, MA:
ButterworthHeinemann; 2000, p.
401.
Shrinkers
Lusardi MM & Nielsen CC.
Orthotics and Prosthetics in
Rehabilitation. Woburn, MA:
Butterworth-Heinemann;
2000, p. 405.
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Principles of
Ace-wrapping
Distal pressure should exceed proximal
Pressure applied on oblique turns only
Should be reapplied at least every 4 hours
No wrinkles
Don’t use metal clips—tape down
No aching, burning or numbness—remove
Wear 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
What are the most
common contractures to
prevent in Mr. Howard?

Transtibial
– Hip flexion
– Knee flexion
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Why?
– Long periods sitting in w/c, bedposition of
comfort is one of flexion
– Protective flexion withdrawal pattern associated
with LE pain
– Muscle imbalances
– Loss of sensory input from foot in WBing
2
What contractures are
common in a
transfemoral amputee?

Transfemoral
– Hip flexion
– Hip abduction
– Hip lateral rotation
How can PT prevent
contractures in Mr.
Howard?
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Maintain knee in ext
– Bedavoid use of pillows under residual
limb
– W/Csliding board, elevating amputee
hanger; avoid long periods of sitting
Lie prone
 PNF w/CR ,HMP/US, manual
stretching, AROM/PROM
 HEP (IP & OP)
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2
Prevention of
Contractures
May, BJ. Amputation
and Prosthetics: A
Case Study
Approach.
Philadelphia: Davis;
1996, p. 87.
Strengthening For LE
Amputee
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Maximization of overall UE/LE/TRUNK strength and
muscular endurance for safe, energy-efficient prosthetic
gait, helps prevent contractures, maintains mobility
Post-operative muscle strengthening consists of isometric
contractions within a limited ROM at joint proximal to
amputation to minimize stress across incision
– Watch breathingno 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 2
As wound healing progresses, include large arcs of
motion, active resistive exercise, isokinetics, eccentric, etc.
6
What should PT POC
include for Mr. Howard?
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Hip ext., hip abductors/adductors, knee ext.
– hip flexors, knee flexors as needed (may need to stretch
these short muscles)
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General strengthening/ROM of trunk and UE’s
important (esp. back ext. and abdominals, shoulder
depressors and elbow ext.)
Aerobic ex. to increase endurance
mobility
Posture-COG shifted up, back and toward
remaining extremity
Skin integrityprep residual limb/care remaining
Balance
2
TT Exercises
May, BJ.
Amputation and
Prosthetics: A
Case Study
Approach.
Philadelphia:
Davis; 1996, p.
88.
TF Exercises
May, BJ. Amputation
and Prosthetics: A Case
Study Approach.
Philadelphia: Davis;
1996, p. 89.
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 care
 Questions?
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References:
1.
2.
3.
5.
6.
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.