Transcript module i - American Academy of Orthotists & Prosthetists

POST-OPERATIVE
MANAGEMENT OF LOWER
LIMB AMPUTATIONS
Produced under a grant from the
Department of Education
through the American Academy of
Orthotists and Prosthetists and the
Prosthetics Research Study
by the Northwestern University
Prosthetics-Orthotics Center
Learning Objectives
• After completing this on-line module the
clinician should be able to:
– Identify and describe the 5 basic postoperative strategies available.
– Compare and contrast the effectiveness of
strategies to best manage their patient
populations.
– Identify and understand the minimum
standards of care required to achieve
appropriate rehabilitation.
Instruction for Use
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Table of Contents
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
IX.
X.
Literature Review
Post-operative Strategies
Comparison of Strategies
Standards of Care
Team Approach
Time frames
Wound Healing
Amputation Specific Goals
Whole Person Goals
Education and Empowerment
Case Studies
I. Literature Review
I. Literature Review:
Journal of Rehabilitation Research
and Development
– Postoperative dressing and management strategies for
transtibial amputations: A critical review
Conclusion: the literature and evidence to date is primarily
anecdotal and insufficient to support many of the claims made.
Future randomized trials on TTA dressing and management
strategies are clearly needed to collect evidence to best guide
clinicians with their decisions
Click here to read the full article
Journal of Rehabilitation Research and Development
Postoperative dressing and management strategies for
transtibial amputations: A critical review
• After reading the journal article please answer
the following self-assessment questions.
• Advance to the next slide to begin
Click here to read the full article
Review of Module I
Overall, current research on post-operative
management
a. Lacks standard definitions for endpoints to
measure success and failure
b. Compares all of the various management
strategies
c. Is consistent in measurement outcomes
d. Compares individuals w/ the same level and
etiology of amputation
Of the 10 controlled studies, which
comparison has not taken place?
a.
b.
c.
d.
Removable Rigid Cast to Soft Dressing
Thigh level Rigid IPOP to Soft Dressing
Removable Rigid Cast to any IPOP
Prefab IPOP to Soft Dressing
What fraction of transtibial amputations
occur in those with diabetes?
a.
b.
c.
d.
e.
One-third
One-quarter
One-half
Two-thirds
All
Which is not a goal of post-operative
management?
a.
b.
c.
d.
e.
Prevent knee contractures
Reduce edema
Protect the limb from external trauma
Facilitate early weight bearing
Bill as much as possible
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II. Introduction to PostOperative Amputation
Management Strategies
II. Introduction to Post-Operative
Amputation Management Strategies
• Definitions:
– Strategy- specifically refers to the postamputation dressing or device.
– Protocol- specifically refers to how the postoperative device or dressing is prescribed
and used.
Strategy
1. Soft Dressings
-Types:
• Ace wraps
• compressive stockinette
• traditional shrinker socks
• Unna paste wraps
(Semi-rigid)
• gel liners
Soft Dressings
• The soft dressing is used routinely in post-operative
management to control swelling.
If soft compressive dressings are used, proper wrapping
techniques must be taught to the staff, patient and
caregivers to reduce complications.
Instruction on the use of proper wrapping techniques
can be found at the link below.
Soft Dressings
• The use of soft dressings also may be used with
adjunctive mechanisms to obtain compression as well as
addressing knee flexion contractures.
Soft dressings can be combined with the use of simple
knee immobilizers, hinged knee immobilizers, and low
temperature thermoplastic protective shells to minimize
contracture or protect the amputation site.
Soft Dressings
• While frequently used in many patient care settings,
these devices do not directly offer a mechanism to
promote residual limb maturation.
• There is currently minimal evidence to document the
effectiveness of soft dressings.
Elastic shrinkers
• Commercially ready-made and
individually packaged is effective for
residual limb shrinkage, but lacks
protection of the residual limb from
trauma such as accidental falls or
weight-bearing exercise.
• Its use is limited by the cost and
availability in the office
Elastic shrinkers
Has limited sizes and lengths, lack of size
for obese patients with short residual
limbs or for children with amputated
limbs
May be either too tight to put on or too
loose to have enough compression
Elastic stockinette
• commercially available in rolls and in various sizes
• can be used in place of elastic bandage and stump
shrinkers
• less expensive
• easily applied onto the residual limbs or edematous
limbs
• most importantly, can achieve a desirable gradient
pressure by adding layers of various length of elastic
stockinette
Elastic
stockinette
Elastic stockinette provides pressure
more over wide areas than narrow areas
The compression pressure on the distal part (with increased tension) is
higher than on the smaller proximal area (with less tension from less
stretching of elastic stockinette)
Strategy
2.
Non-removable rigid dressings
without immediate prosthetic
attachment.
– Custom molded thigh high device made from plaster,
fiberglass, or other rigid material.
Non-removable rigid dressings without
immediate prosthetic attachment
This strategy used at the transtibial level of amputation
is usually worn for the first 1 to 2 weeks after surgery
to shape and protect the limb.
The cast extends above the knee and does not allow the
knee to bend.
Non-removable rigid dressings without
immediate prosthetic attachment
At the transfemoral level of amputation a this cast may
or may not incorporate a preformed brim.
This strategy also may or may not use a soft or rigid
hip spica component around the waist.
II. Introduction to Post-Operative
Amputation Management Strategies
3. Non-removable rigid dressings
with Immediate Post-Operative
Prosthesis (IPOP).
–
Custom molded thigh high device made from
plaster, fiberglass, or other rigid material with
pylon and foot attachment.
IPOP
The immediate post-operative
prosthesis was initiated in the late
1950’s by Dr. Berlemont (France)
and Dr. Weiss (Poland).
The technique was further
developed in the United States
by Dr. Burgess at Prosthetics
Research Study in Seattle,
WA
IPOP
General Principles:
Supervised weight bearing of no more than 5-10 lbs of
measured weight during the first 1-2 days post surgery.
No more than 20 lbs of weight bearing in the parallel
bars until after the first cast change.
This usually occurs around 2 weeks postoperatively.
II. Introduction to Post-Operative
Amputation Management Strategies
4.
Removable Rigid Dressing
(RRD)
– Removable rigid dressings made from
plaster,
fiberglass, or other rigid material may be used with
or without a prosthetic attachment.
The procedure was developed in 1978
and published in:
-Wu Y, Keagy RD, et al. An innovative removable rigid
dressing technique for below-the-knee amputation.
J Bone Joint Surg 1979;61A:724-729.
-Wu Y,Krick HJ. Removable rigid dressing for below-knee
amputees. Clin Prosthet Orthot 1987;11:33-44.
It was developed to solve the common
problems from elastic bandaging such as:
1) Pressure sore over tibial tubercle
2) Distal edema
3) Knee contracture due to pain.
Steps of applying RRD:
1) apply the wound dressing as
needed,
2) wear proper layers of tube
socks or stump socks of
various lengths,
3) apply the plaster cast; use a
plastic sheath to reduce
friction,
4) pull the suspension stockinette
upward covering the plaster
cast,
5) place the supracondylar cuff
and fasten the Velcro closure,
6) pull the suspension stockinette
tight,
7) fold suspension stockinette
downward and anchor on the
suspension cuff
8) knee flexion is possible and
encouraged.
II. Introduction to Post-Operative
Amputation Management Strategies
5.
Pre-fabricated post-operative
prosthetic systems
Pre-fabricated post-operative
prosthetic systems
These devices provide varying degrees of
protection and contracture prevention and are
designed for early weight bearing.
They maintain some of the advantages of the
removable rigid dressing, in that they are
easily removed and replaced for wound
evaluation.
Examples of Pre-fabricated
systems
Review of Module II
The use of elastic stockinette may be better
than Ace-type bandages because:
a.
b.
c.
d.
It provides better protection
It is more expensive
Can apply gradient pressure
Eliminates contractures
The RRD allows for all of the following
except:
a.
b.
c.
d.
Inspection of the limb
Protection of the limb
Graded weight-bearing
Immobilization of the knee
When using a prefabricated system for early
weight bearing, the patient should only
bear______ pounds of weight in the parallel
bars.
a.
b.
c.
d.
5-10
20-40
60-80
Full weight-bearing
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III. Comparison of Strategies
III. Comparisons of Strategies
• The literature identifies the lack of scientific
evidence to support the use of one strategy over
another. Analysis of 10 controlled studies
supported only four of the fourteen claims cited
in uncontrolled, descriptive studies
III. Comparisons of Strategies
• The literature supports that:
– 1) Non-removable rigid dressings result in
significantly accelerated rehabilitation times
when compared to soft gauze dressings.
– 2) Non-removable rigid dressings result in
significantly less edema when compared to soft
gauze dressing.
III. Comparisons of Strategies
• The literature supports that:
– 3) Pre-fabricated post-operative prosthetic
systems were found to have significantly fewer postsurgical complications when compared to soft gauze
dressings.
– 4) Pre-fabricated post-operative prosthetic
systems lead to fewer higher level
revisions compared to soft gauze
dressings.
III. Comparisons of Strategies
• No studies directly compared pre-fabricated systems to
rigid dressings, and no studies compared all types of
dressings within one study.
• It is currently not possible to provide evidenced-based
protocols, or make conclusive evidence-based
recommendations for the use of one strategy over
another.
Assessing Outcomes
• Due to the lack of evidence based outcomes measures in the
area of Post-operative management, the consensus conference
also strongly suggested the adoption of reporting standards
for the assessment of outcomes.
• These standards included:
– Better classification systems
– Improved documentation of wound healing
(module VI)
– Documentation of contralateral limb status
– Pre- and Post-amputation functional status evaluation
Classification Systems
• “Traumatic” vs. “diabetic” amputation terminology is not
complete
• Etiology and co-morbidities must be considered
• For example, a “diabetic” amputation may be due to:
– Infection, Minor trauma, Poor circulation, Chronic
ulceration, etc
• Systemic complications (death, myocardial infarction, deep
venous thrombosis, pneumonia, strong, urinary infection)
should also be tracked.
Contralateral Limb status
• 28-51% undergo second leg amputation within
5 years of initial
• 39-68% mortality at 5 years following
amputation*
• Therefore, ulceration, wounds, infection and
amputation in the contralateral limb should be
documented
Reiber, Boyko, and Smith (1995) in
Diabetes in America
Pre- and Post- amputation functional status
• The consensus was that pre-amputation (whenever possible) and
post-amputation functional status should be documented using
standardized general outcome tools. e.g.:
– SF-36 (Short form 36)
– MFA (Musculoskeletal Functional Assessment)
– SIP (Sickness Impact Profile)
• Or tools specific to amputation and prosthetics. e.g.:
– AMP (Amputee Mobility Predictor)
– PEQ (Prosthetic Evaluation Questionnaire)
Review of Module III
A well-designed comparison of postoperative management will
a.
b.
c.
d.
e.
f.
Randomize selection
Define outcome measures consistently
Better detail pain and complications
Compare all management methods
Quantify health care savings
All of the above
Which of the following is an unsupported claim of
the descriptive studies?
a. NR Rigid dressings accelerate rehab time
compared to soft dressings
b. Eventual use of a prosthesis is increased for
an IPOP compared to soft dressings
c. IPOPs require fewer higher-level revisions
revisions
compared to soft dressings
d. NR Rigid dressings significantly reduce
edema compared to soft dressings
*NR=Non-removable
Systemic complications may be considered
perioperative if they occur within __ days of
surgery:
a.
b.
c.
d.
e.
5
10
30
60
365
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IV. Team Approach
IV. Team Approach
• The goal of the rehabilitation team is to
work together with the patient/ client and
family to help a person with an
amputation reach maximum potential.
Team Members
Family
Social Worker
Surgeon
Psychologist
Physiatrist
Peer Support
Nurse
Case Manager
Prosthetist
Chaplain
Therapy
Patient
Team Members
• Patient/ Client and Family
– The patient/ client and family are considered
the most important members of the
rehabilitation team.
Team Members
• Surgeon
– The surgeon performs the amputation and
provides medical care.
• Physiatrist
– A physician who is specially trained in
Physical Medicine and Rehabilitation
prescribes the individualized therapy
programs and coordinates the team effort of
the many professionals.
Team Members
• Therapy
– The various therapies provide a vital role in
the rehabilitation of the patient/ client.
– The various therapies include Physical
therapy, Occupational therapy, Vocational
therapy, Recreational therapy, and Speech
therapy.
Team Members
• Physical Therapist
– A therapist who designs an
individualized program to help
restore function for patients/
clients with problems related to
movement, muscle strength,
exercise, and joint function.
Team Members
• The Rehabilitation Nurse
– Provides 24 hour a day nursing care.
– The nurse implements the plan of care,
reinforces the skills learned in therapy, and
teaches the patient/ client and family about
self care and medications.
Team Members
• Prosthetist
– Prepares patient/ client for prosthetic care
– Educates the patient/ client on prosthetic
care
– Recommends prosthetic components based
on rehabilitation potential
Team Members
• Psychiatrist/ Psychologist
– A person who conducts cognitive (thinking
and learning) assessments of the patient/
client.
– Helps the patient/ client and family adjust to
the disability.
Team Members
• Social worker
– A professional counselor who acts as a
liaison for the patient/ client, family and
rehabilitation team.
– The social worker helps patient/ client and
families cope with their disability.
– The social worker makes arrangements for
assistance from community agencies.
Team Members
• Chaplain
– A spiritual counselor who helps patients/
clients and families during crisis periods.
– Serves as a liaison between the hospital and
place of worship.
Team Members
• Peer Support
– A person with a similar disability who
provides insight for the patient /client
– Provides perspective of what living with a
disability is like.
Team Approach
• As health care has evolved, it is more difficult
to have the whole team meet together at the
same time.
• The team approach is still needed to optimize
recovery from limb loss, perhaps now more
than ever.
IV. Team Approach
• The “team without walls” demands increased
effort and attentiveness to work toward the
common goal of maximum recovery and
rehabilitation.
• The team should be flexible in that different
people share the leadership and service
responsibilities of the postoperative period
IV. Team Approach
• Each member of the team has an obligation to
educate, empower and allow client and/or
advocate to take control and responsibility
• “Act like a Team”- No one health care provider
has all the answers and everyone has specific
skills and roles to assist in the pre-operative and
post-operative process.
IV. Team Approach
• Team members should keep an open mind and a
positive, motivating approach to optimize
appropriate care.
• All providers have the responsibility to envision
the best possible outcome and help assure that
medical care, prosthetic fabrication and fitting,
training and therapy, navigation of the funding
process and social re-integration occur.
IV. Team Approach
• Team members should work together,
support or discuss each member’s treatment
recommendations and communicate directly
when disagreements exists. Communication
through the patient should be avoided at all
costs.
Review of Module IV
The most important member of the
treatment team is:
a.
b.
c.
d.
e.
Physician
Prosthetist
Physical Therapist
Case Manager
Patient/ Family
In the team approach, what should be
avoided at all costs?
a. Team members working together
b. Communicating with one another
through the patient/client
c. Discuss each members treatment
recommendations
d. Communicating with one another
What is the obligation of each member of
the team?
a. Concentrate on his/her own profession and
nothing else
b. Communicate to other professionals through
the patient/client
c. Communicate only to the family
d. Educate, empower, and allow client and or
advocate to take control and responsibility
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V. Time Frame of Surgery and
Recovery
V. Time Frame of Surgery
and Recovery
• Following amputation (regardless of
etiology) the post-operative recovery period
is typically 12 to 18 months and simply
cannot be rushed!
V. Time Frame of Surgery
and Recovery
• Stages of Recovery
–
–
–
–
–
Pre-Operative Stage
Acute Hospital Post-Operative Stage
Immediate Post-Acute Hospital Stage
Intermediate Recovery Stage
Transition to Stable Stage
V. Time Frame of Surgery
and Recovery
• Stages of Recovery
• Pre-Operative Stage
– This stage begins with the decision to amputate, the
vascular assessment and decisions or attempts to
improve circulation. This stage also includes level
selection, pre-operative education, emotional
support, physical therapy and conditioning,
nutritional support, and pain management.
V. Time Frame of Surgery
and Recovery
• Acute Hospital Post-Operative Stage
– This includes the time in the hospital
following the amputation surgery. This
hospital time is typically 5-14 days.
V. Time Frame of Surgery
and Recovery
• Immediate Post-Acute Hospital Stage
– This stage begins at hospital discharge and can extend
up to as much as 8 weeks following surgery.
– This time allows for recovery from surgery, wound
healing, and early rehabilitation.
– Typical end points for this stage include the point of
wound healing and the point of being ready for
prosthetic fitting.
V. Time Frame of Surgery
and Recovery
• Immediate Post-Acute Hospital Stage
– However, wound healing is a continuous process, and
does not have a clear end point of “being healed”.
– Much of the literature attempts to use these two
elusive endpoints when comparing different postoperative strategies with varying results.
V. Time Frame of Surgery
and Recovery
• Intermediate Recovery Stage
– This is the time of transition from a post-operative
strategy to first formal prosthetic fitting. The most
rapid changes in limb volume occur during this
stage due to the beginning of ambulation and
prosthetic use.
– This intermediate recovery stage begins with wound
healing and usually extends out 4-6 months from the
healing date.
V. Time Frame of Surgery
and Recovery
• Intermediate Recovery Stage
– This stage ends when relative stabilization of limb
size occurs, as defined by consistency of prosthetic
fit, for several months.
– The definitive prosthesis should not be fit prior to 6
months of temporary prosthetic use and when the
stabilization of the limb occurs
V. Time Frame of Surgery
and Recovery
• Transition to Stable Stage
– This stage includes maturation of the limb
and less volume change.
– Patient should move toward social reintegration and higher functional training
and development as well as becoming more
empowered and independent.
Clinical Concerns
• 14 clinical concerns were identified in the
stages of recovery
• Each concern will take on different levels of
importance at different stages of the healing
process
• There may be overlap between stages which
may vary with individual differences
Clinical Concerns
1. Determine amputation level
•
Important earliest, in pre-operative stage
•
Must include assessment of vascular status
and circulation to determine level
Clinical Concerns
2. Minimize systemic complications including
– Myocardial infarction (MI)
– Deep Vein Thrombosis (DVT)
– Decubitus, etc.
•
Risk must be assessed pre-operative
•
High level of concern during acute hospital
post-operative stage
•
Moderate concern during initial healing (postacute hospital stage)
Clinical Concerns
3. Prevent contractures
•
Contractures should be addressed and treated
pre-operatively, if possible
•
Highest concern during acute hospital stage
– Isometric quad sets at day 2
•
Continue at high risk during immediate postacute stage
•
Reduce to moderate concern for intermediate
recovery
•
Low concern during transition to stable
Clinical Concerns
4. Bed mobility and transfers
•
High concern during acute and immediate
post-acute stages
•
Should reduce in level of concern as prosthesis
use is begun
Clinical Concerns
5. Pain management
•
High during most of the rehab process
•
Pain pre-operatively should be addressed.
Unresolved pre-op pain may lead to increased risk of
phantom pain post-operatively
•
Typically pain reduces as limb heals and prosthesis
use is begun
•
Concern may shift from acute pain management to
identification and treatment of chronic pain issues in
stages 4 and 5
Clinical Concerns
6. Protect amputated limb from trauma
•
Highest immediately after surgery during acute
hospital stay
•
Still important during immediate post-acute stage as
patient begins to transfer
•
Post-operative management strategies that address
this concern include:
–
–
–
•
Non-removable rigid dressings
Removable rigid dressings
Prefabricated IPOPs
Post-operative management strategies that DO NOT
address this concern include:
–
Soft dressings
Clinical Concerns
7. Fall prevention
•
Moderate concern during pre-op phase
•
High concern during acute and immediate
post-acute stage since falls may traumatize
limb
•
Moderate concern during intermediate
recovery as patient learns to walk with first
prosthesis
•
Lower concern during final transition to
stable
Clinical Concerns
8. Emotional care/education
•
High level of concern throughout
rehabilitation process
•
During earlier rehabilitation, concerns will be
immediate, regarding amputation and healing
process
•
Later concerns may center around realization
of limitations and work and family issues
Clinical Concerns
9. Manage and teach about wound healing
•
The highest concern of the acute hospital
stage
•
As wounds heal, concern will decrease
•
However, patient should be informed and
educated to inspect residual limb daily and
learn proper care and hygiene of limb as
prosthesis use is begun
Clinical Concerns
10. Promote residual limb muscle activity
•
Begins immediately after surgery
– In-patient therapy may include passive range of
motion techniques
•
High during post-acute stage and
intermediate recovery stage
•
Maintain activity during transition to stable
Clinical Concerns
11. Early ambulation
•
During acute hospital stage, this will be
secondary to bed mobility, transfers
and toilet activities
•
Early ambulation may be with
walkers/crutches and no prosthesis
during immediate post-acute stage
•
Initial fitting of a prosthesis and early
gait training important during
intermediate recovery stage
Clinical Concerns
12. Advanced ambulation
•
Therapy for advanced
ambulation techniques may be
prescribed during the transition
to stable stage when a definitive
prosthesis, with potentially
more advanced components, is
fit
Clinical Concerns
13. Control limb volume changes
•
High during immediate post-acute stage as
edema and swelling from surgical trauma
reduces
•
High during intermediate recovery stage
– Significant volume changes expected to occur
– Prosthesis fit and function must be accommodated
•
Still of high during transition to stable stage,
though at slower rate
– Should stabilize for at least 2-3 weeks prior to
fitting of definitive device
Clinical Concerns
14. Trunk and body motor control and stability
•
Balance and stability are important throughout
rehabilitation process
•
It is an especially high concern as patient
begins therapy to learn independence in
transfers
•
Continues in importance as patient develops
strength and balance for initial prosthetic gait
training
Review of Module V
What is the primary clinical concern during the
acute hospital post-operative stage?
a.
b.
c.
d.
Trunk and body motor control
control
Control limb volume changes
Fall prevention
Manage and teach about wound healing
Limb stabilization typically takes at least ___ of
prosthetic use to achieve
a. 3 months
b. 6 months
c. 12 months
Physical therapy treatment occurs
a. Early in the rehab process and again at
the end
b. Only at the end of the rehab process
c. Only at the beginning of the rehab
process
d. Throughout the rehab process
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VI. Wound Healing
VI. Wound Healing
SKIN ANATOMY
The skin is an ever-changing organ that contains many
specialized cells and structures.
The skin functions as a protective barrier that interfaces
with a sometimes-hostile environment. It is also very
involved in maintaining the proper temperature for the
body to function well.
VI. Wound Healing
SKIN ANATOMY
It gathers sensory information from the environment,
and plays an active role in the immune system
protecting us from disease.
Understanding how the skin can function in these many
ways starts with understanding the structure of the 3
layers of skin - the epidermis, dermis, and subcutaneous
tissue.
SKIN ANATOMY
• Epidermis
The epidermis is the most superficial layer of
the skin and provides the first barrier of
protection from the invasion of foreign
substances into the body.
SKIN ANATOMY
• Dermis
The dermis assumes the important functions of
thermoregulation and supports the vascular network to
supply the avascular epidermis with nutrients.
The dermis contains mostly fibroblasts which are
responsible for secreting collagen, elastin and ground
substance that give the support and elasticity of the
skin. Also present are immune cells that are involved in
defense against foreign invaders passing through the
epidermis.
SKIN ANATOMY
Wound Healing
The healing of a wound to the skin is
a fairly typical mixture of
regeneration and replacement.
The more regeneration that can
occur, the less scaring will be left
behind after wound healing.
Wound Healing
• Many amputations do not heal in ideal primary
fashion.
• Small areas of the wound may require
secondary healing and possible wound care
• Revision surgery is frequently required in
vascular amputations.
Wound Healing
• Wound healing problems are most often
related to:
– Type of injury
– Disease
– Vascularity
– Tobacco use
– The nature of amputation itself
Wound Healing
• Skin and wound problems are rarely
“caused” by a single factor.
• In many individuals, wound problems are
simply not preventable.
Wound Healing
• The healing of an amputated limb should
be viewed as a continuous process
• There is no clear and decisive point of
“completed healing”.
Wound Healing
• Using the outcome of “time to heal” is not
a precise measurement.
• Documenting healing continues to be
important for patient care and research.
Wound Healing
• Subjective interpretations associated with
determining healing time include:
–
–
–
–
–
Completion of epitheliazation
Interpretation of small open areas
Individual bias
Timing of the return to clinic visits
“Research savvy” of the rehabilitation team
Wound Healing
• Future studies need to clearly define how
the “time to heal” has been determined.
• “Time to heal” may always be difficult to
standardize and to measure.
• It cannot be determined accurately from a
simple retrospective review of a clinical
chart
Wound Healing
• It is recommended that wound healing be
documented as a type of wound healing
for clinical and research purposes.
• The categories are defined in the
following slides.
Categories of Wound Healing
Primary
-heals without open areas,
infection or wound
complications
Categories of Wound Healing
Secondary
-small open areas that can be
managed, and ultimately heal with
dressing strategies and wound care.
Further surgery is not required.
This may occasionally be intended
with some portion of the
amputation left open.
Categories of Wound Healing
• Requires minor revision
– skin and subcutaneous tissue.
(No muscle or bone involvement)
Categories of Wound Healing
• Requires major revision
– but heals at initial amputation “level”
(Example: mid-transtibial level revised
to shorter transtibial level)
Categories of Wound Healing
• Requires revision to a higher level
– (Example: a transtibial amputation
that must be revised to either a knee
disarticulation or transfemoral
amputation)
Wounds and Weight Bearing
• The presence of an open wound or the
presence of sutures does not necessarily
preclude weight-bearing.
• In many circumstances, institution of or
continuation of activity can be helpful to
control edema and facilitate healing.
Review of Module VI
Wound healing problems are related to all of the
following EXCEPT:
a.
•
•
•
Type of injury
Disease
Vascularity
Musculature
The phrase “Time to heal”
a.
b.
c.
d.
Is easy to measure
Can be determine from chart notes
Is not a precise measurement
Is not useful in research
Continuing activity in the presence of a
wound:
a. Is often encouraged to facilitate healing
b. Is not encouraged during the
rehabilitation process
c. Will lead to revision
d. Will delay healing
Continue to Next
Module
Return to Table
of Contents
VII. Amputation Specific
Goals
Amputation Specific Goals
Amputation Specific Goals
• Prevention of
contractures
• Reduce post-surgical
edema
• Improve bed mobility
• Pain management
• Protection of limb from
trauma
• Prevention of falls
•
•
•
•
•
Emotional care
Promote limb activity
Establish trunk stability
Begin ambulation
Accommodate limb
volume changes
• Achieve distal end
loading
Prevention of contractures
• Is necessary at both the hip and knee
• Active strategies such as bed positioning,
prone activities are well documented
along with stretching techniques used by
physical therapy
Prevention of contractures
• Several passive strategies such as knee
immobilizers and rigid dressings attempt to
address the goal of knee flexion contracture
• Literature is unavailable to support any one
passive strategy
• Passive strategies to prevent hip flexion
contractures have yet to be proposed
Reduce post-surgical edema
• Use of compressive strategies is
important following any amputation.
• If soft compressive dressings are used,
proper wrapping techniques must be
taught to the staff, patient and caregivers
to reduce complications.
Improve mobility
• Bed mobility, transfers (bed, toilet), and
activities of daily living (ADL”S) must be
taught early in the post-amputation period
• This encourages independence, strength, and
reduces the fear of falling
• Physical and Occupational therapy are
essential to this process
• The addition of a pylon and foot may make
bed mobility more difficult
Pain management
• Pain and contractures may be associated
although no scientific evidence supports
this claim
• Pain must be controlled throughout in
order to facilitate mobility and eventual
prosthetic use
• Careful evaluation will help determine the
appropriate treatment modality
Pain Management
• It is important to vary pain management
strategies such as, medicine or manual
desensitization based on: time from surgery, type
of post operative dressing, and the cause of
amputation
• Desensitization is believed to reduce pain in the
residual limb and may help the amputee adjust to
their new body image which includes limb loss
• Literature is lacking with any one approach
Protection of limb from trauma
• Evidence suggests the use of rigid dressings
(custom or prefabricated) provide better limb
protection than soft dressings
• Examples of limb protection systems can be
found in the links below.
Prevention of Falls
• Fall prevention is an essential part of
rehabilitation
• Complications secondary to falls may
result in increased healing time, further
surgical intervention, other injuries, and
increased hospitalization
Prevention of falls
• “Limb loss reminders”, i.e. placing a chair
next to the bed as a reminder to be careful,
may reduce falls, but further studies are
needed
• Strength and balance training can reduce the
number of falls
Emotional care
• Treatment must be highly individualized and
does not appear to be related to post-operative
limb management strategy
• Documented options include supportive
encouragement, educational literature,
psychological counseling, peer counseling,
amputee support groups, and chaplainry.
Emotional care
• The risk of depression in amputees is high
• When necessary, pharmacological
intervention and/or psychiatric referral
should be considered
Promote limb activity
• Promotion of residual limb activity (desensitization,
muscle contraction, and endurance development) is
an important strategy
• It may be instituted at various times based on post
operative strategy, surgical procedure, and cause of
amputation but conventional wisdom says that the
earlier the intervention the better
Promote limb activity
• Exercise to improve gluteus (medius and
maximus) and quadriceps strength may
begin as early as day 1
• Exercises to promote muscle action
within the residual limb depend on pain
tolerance, surgical procedure and healing
response
Promote limb activity
• Muscle contraction within the residual limb
may help with pain control, muscle reeducation, improve muscle mass, edema
control, and kinesthetic feedback
• The timing for beginning of muscle activity
within the residual limb needs to be further
evaluated
Establish trunk stability
• Trunk stability should be established as early as
possible through core strengthening exercises
• Trunk stability will assist with mobility activities,
provide the foundation for prosthetic control, sitting
posture, and can reduce the stresses to the spine that
cause low back pain and body motor control and
stability problems
Establish trunk stability
• Trunk stability may improve body
posture and readiness for gait training
• Trunk stability may decrease commonly
seen gait deviations
• Improved motor control should decrease
the energy expenditure of walking with a
prosthesis
Ambulation
• Ambulation is described as non-pedal (wheelchair
ambulation), uni-pedal (remaining limb with
assistive device) or bi-pedal (using a prosthetic
pylon) with or without assistive device
• Improvements in strength, mobility, balance, and
endurance have been shown to decrease the
potential for co-morbidities (Pulmonary embolism,
myocardial infarction etc.)
Accommodate limb volume
changes
• Critical to comfortable prosthetic use
• During this stage the limb volume is
fluctuating wildly and may be difficult to
manage
• Control of limb volume changes during
this stage is a function of the preparatory
prosthesis
Accommodate limb volume
changes
• Strategies for limb volume control
include the use of liners, socks, pads,
adjustable sockets, temporary sockets or
ambulatory check sockets
• When the patient is not wearing a
prosthesis, wrapping and/or compression
are critical to help control limb volume
changes
Achieve distal end loading
• Distal end loading, desensitization, and residual
limb weight bearing may assist with pain
control, tolerance of a prosthesis, and reduction
of adhesions
• This may begin with towel pulling on the distal
end of the residual limb or using a rigid design
and allow for pressure over the entire limb
Review of Module VII
If soft compression dressings are used, proper
wrapping techniques should be taught to
which of the following
a.
b.
c.
d.
Patient/client
Caregiver
Staff
All of the above
Which of the following does not protect the
limb from trauma
a.
b.
c.
d.
RRD
Ace (Elastic) wrap
Flo-tector
PAL guard
guard
Strategies for limb volume control include
all of the following except
a.
b.
c.
d.
Socks
Liners or pads
Adjustable sockets
Nylon sheath
Continue to Next
Module
Return to Table
of Contents
VIII. The Whole Person
The Whole Person
• Goals
– The consensus conference identified six
“whole person” goals of care for anyone
undergoing lower limb amputation.
– These goals are not directly related to the
surgical amputation but are intended to
prevent co-morbidity and to improve overall
health and mobility.
Six Goals
• Musculo-skeletal reconditioning and
cardiovascular training
• Contralateral lower limb preservation
• Emotional care, peer support and education
• Minimize systemic complications
• Social reintegration
• Setting realistic expectations and functional
outcome goals
The consensus conference stated that while all
goals are important, focus should be attempted
to address emotional care, social reintegration,
and setting realistic functional goals.
Review of Module VIII
All of the following would be
considered “whole person” goals in the
rehabilitation of the patient EXCEPT:
A.
B.
C.
D.
Social reintegration
Emotional care
Cardiovascular training
Marriage counseling
Whole person rehabilitation goals are
intended to:
A.
B.
C.
D.
Provide reimbursement
Prevent mobility
Preserve resources
Prevent co-morbidities
The consensus conference identified three “whole
person” goals as critical in the rehabilitation of the
patient with an amputation. These three are:
A. Social reintegration, emotional care and
musculoskeletal development
B. Social reintegration, emotional care and
minimize complications
C. Social reintegration, emotional care and
setting realistic goals
D. Social reintegration, emotional care and
care of contralateral limb
Continue to Next
Module
Return to Table
of Contents
IX. Education and
Empowerment
Education & Empowerment
•
•
•
•
Improve understanding of the surgical treatment
Improve understanding of the recovery time frame
Improve understanding of emotional adaptations
Improve understanding of prosthetic plan and
treatment
• Peer support and consumer groups
• Assist in navigation through marketing, hype and
realities
There is nothing that man fears
more than the touch of the
unknown
Elias Canetti (b. 1905)
The Columbia World of Quotations. 1996
Communication is Key
• The patient should be encouraged to ask
questions and research on his/her own
• The amputee should learn to be an informed
consumer of marketing material
• Education should begin as soon as possible
Surgical Treatment and Recovery
• Communication with surgeon
– May allow opportunity for pre-surgical
consult
– Surprise factor for patient can be reduce
– Vital when using post-operative prosthetic
systems
Surgical Treatment
• Medical team should explain:
–
–
–
–
–
Types of anesthesia
Surgical techniques
Possibility of phantom limb sensation/pain
Pain control
Possible complications
Important issues that Patient
and Family should understand
• Time frame of recovery
– Including all aspects of postoperative process
– Must have realistic time frames to help avoid
unrealistic goals
– Usual expectation of 12 to 18 months
• Emotional adaptation
– Will be different for each individual
Important issues that Patient and
Family should understand
• Prosthetic plan
–
–
–
–
Role of the prosthetist
What a prosthesis is
How it is funded
Expectations to have of a prosthesis:
• e.g. not the cure
• Other adaptive equipment for mobility that may
be needed
• Fitting and adjustments required, especially
early in rehab process
Important issues that Patient
and Family should understand
• Peer Support and Consumer groups
– Including educational materials
– Peer visitation
– National support networks
• Marketing
– Hype vs. reality
– Help to become an educated consumer
Available Educational Resources
•
•
•
•
Brochures and Pamphlets
Internet
Local Support Groups
National Support Groups
Examples of Available Brochures
• A Manual for Below-Knee (Trans-Tibial) Amputees
• A Manual for Above-Knee (Trans-Femoral) Amputees,
A. L. Muilenburg & A. B. Wilson, Jr. (1996)
• Patient Care Booklet for Below-Knee Amputees, Jack
Uellendahl (1998)
• Below- Knee Amputation: A Guide for Rehabilitation
• Above- Knee Amputation: A Guide for Rehabilitation,
T.Kuiken, M.Edwards, & N. Miceli (2002)
Many of these, and more, are also available through the
ACA and the Academy. Click here for a links to more items
Internet
• Manufacturers websites
– Be willing to discuss options that your
patient/client may see on the internet
– Understand the pros and cons of each device
and how to explain them to a consumer
• OandP.com
Support Groups
• Find out if there are support groups in
the area
• National Support Groups, including the
Amputee Coalition of American, can also
be an excellent reference
Recreational Activities
• Recreational activities/groups can also be a
support system
• Not just for Paralympic level individuals
• Special organizations exist for:
– Golf
– Cycling
– Scuba
Review of Module IX
A new, active male transtibial amputee, 35-years-old and
350#, arrives in your office with an advertisement for a
Dycor foot that says how flexible, light-weight and
comfortable it is.
You should…?
a. Order the foot, since that is what they want
b. Explain that this foot is for geriatric patients
c. Explain that this foot is not designed for the
individual’s weight and activity level
A new amputee expresses concern to you that they are the only
person they know with an amputation, they are never going to
return to an active lifestyle and they don’t know how to handle it.
What are three things you could do?
a. Offer to introduce them to another amputee
for peer counseling
b. Express your concerns to the referring
primary physician so that psychological
counseling can be prescribed if indicated
c. Give them reading materials that you have
and let them know about the ACA
List at least five things that may affect
emotional adaptation to an amputation
a.
b.
c.
d.
e.
f.
g.
Culture
Family history
Religious preference
Age
Education
Social support
Financial background
Continue to Next
Module
Return to Table
of Contents
X. Case Studies
Case Study 1
• 65 y/o male, BKA 2° PVD
• Prosthetist applied custom thigh-high plaster rigid
dressing immediately post-surgery
• Soon after awaking, pt c/o pain 10/10
• Pt instructed pain was normal and pain medication was
increased. Pain still present during course of
treatment.
• Rigid dressing removed after 8 days
• Result: Dressing removed, infection present. Limb
revision to AKA required.
What about this case would be a
concern
• How long the rigid dressing was left on
• The patient’s pain concerns were dismissed
• Protocol for application of rigid dressing may not
have been followed (tightness of wrap, padding,
drainage, etc)
• Non-removable dressing did not allow inspection
of wound, and dressing not removed when chance
of infection was presented
What should have been done?
• Pain management should have been addressed
• Rigid dressing should have been removed when
pain did not abate.
• Communication with patient should have been
better.
Case Study 2
•
•
•
•
25y/o male, BKA 2° traumatic motorcycle accident.
Pt also suffered mild head injury during injury.
Pt fit with soft dressing and compression sock.
2 days post-surgery, while alone in the room, pt is
determined to use toilet independently.
• Pt falls, breaks open sutures, and requires minor soft
tissue revision to re-close wound.
What about this case would be a
concern
• Which post-operative strategy was used?
• Failure to evaluate fully cognitive ability of
patient.
• Did practitioner educate patient/family/caregivers of procedures.
What should have been done?
• A post-operative strategy which provided
limb protection.
• Complete evaluation of patient’s head
injury and cognitive level.
References
•
•
•
•
M. Bergner, R.A. Bobbit, W.B. Carter and S.B. Gilson , The sickness
impact profile: development and final revision of a health state
measurement. Med. Care 46 (1981), pp. 787–805.
J.E. Ware and C.D. Sherbourne , A 36-item short-form health survey
(SF-36): conceptual framework and item selection. Med. Care 30 (1992),
pp. 473–483.
The Amputee Mobility Predictor: An instrument to assess determinants
of the lower-limb amputee''s ability to ambulate.
Archives of Physical Medicine and
Rehabilitation, Volume 83, Issue 5, Pages 613 - 627
R. Gailey.
Martin, D. P.; Engelberg, R.; Agel, J.; Snapp, D.; and Swiontkowski, M.
F.: Development of a musculoskeletal extremity health status
instrument: the Musculoskeletal Function Assessment Instrument. J.
Orthop. Res., 14: 173-181, 1996
http://www.oandp.com/resources/patientinfo/manuals/5.htm
Examination
• Please go to the course examination
section.
• After completing the examination, please
complete the course evaluation.