Transcript Clinical Procedures in Prosthetics II

Designing a PT Management Program
for Patients with Prosthesis
Mark David S. Basco, PTRP
Faculty
Department of Physical Therapy
College of Allied Medical Professions
University of the Philippines Manila
Learning Objectives
At the end of the session, you should be able to
 Discuss principles behind designing a management
procedure for prosthesis users in the different phases:
 Pre-operative
 Early post-operative
 Late post-operative
 Prosthetic training phase


Gait
Vocational
Learning Objectives
At the end of the session, you should be able to
 Discuss indications, precautions, and
contraindications to prosthetic management
 Discuss special considerations when designing a
program for children
Introductory Visit
Assessment
Discussion of outcomes
Preparation for the operation
Pre-operative exercises
Introductory Visit
 Introduce self and role in the rehab team, emphasize
role of patient and family
 Need for reassurance that amputation and
rehabilitation is a positive step towards reintegration
back into the community
 Goals and expectations
 Introduce team management concepts
Assessment
Physical
 Conditions that may affect mobility
 Functional capacity
Psychological
 Attitude
Social situation
 Accommodation after surgery
Outcomes and Prognostication
 What the patient may feel or encounter post-op
 Complications that may arise
 Expected highest level of function possible given the
level of amputation
 Use of the prosthesis is the patient’s decision


Options for prosthetic devices
Life with a prosthesis
Preparation for the operation
 Show the patient around the facility where he will be
in after the operation
 Possible prosthesis given the level
 Speak to other amputees
 Exercise program
 Operating room, equipment, gadgets, medications, etc
 Phantom sensations
Pre-operative Exercises
 Increases tolerance to surgery
 Faster recovery and gain of independence in prosthesis
use
 Mentally prepares the patient
 Exercise program:
 Strengthening
 Endurance training
 Simulation of training activities post-op
Goals
Treatment methods
Early home visit
Others
Goals
 Prevent the deleterious effects of immobilization and
loss of a limb segment
 Facilitate faster wound healing
 Pain management
 Provision of needed accessories or equipment to
progress patient to the next stage
 Prepare patient and stump for prosthetic fitting
 Promote early independence in ADLs
Treatment Methods
 Proper positioning
 Stump edema management
 Active exercises
 Selective Stretching
 Donning and doffing
 Functional training
Proper Positioning
 Stump should be flat on the bed
 Use of comfort pillow
 Prevent flexion contractures
- Sitting vs supine
 Advocating intermittent positioning in prone
 Sidelying to relieve buttocks pressure
Stump edema management
 Elevation
 Exercises
 Bandaging
 Intermittent variable air pressure machines
 Pneumatic pylon
 Shrinker socks
 Rigid dressing
Exercises for the Stump
 Done every 10 reps / hour
 Active contraction of the stump muscles is the best
method of reducing edema
For BKA
 Patient must imagine the performance of alternate
DF/PF
Through knee/AKA
 Patient must perform alternate hip flexion and
extension as well as hip abduction
Bandaging
 Precaution: development of pressure necrosis
 Stump bandaging can never change stump shape
without the danger of interference with the local
circulation
 A uniformly edematous stump is more readily fitted
than one which has been misshapened by bandaging
Active Exercises & Stretching
 Determine which muscles decreased / lost their
strength and which muscles gained a mechanical
advantage
 Determine biomechanical implications to identify
appropriate exercise for the patient
Active exercises
 Start with the intact side
 Applicable across all amputation levels
 1st day post-op, exercises could be done on supine
 All techniques could be performed except push-ups if
attachments are present.
 Be vigilant especially for patients with co-morbidities
e.g. DM
Selective Stretching
 BKA
 Knee must rest in full extension immediately post-op
 AKA
 Major concern is development of hip flexion and
abduction contractures
 Obtain neutral hip alignment
 Gradually altering hip position
Special considerations in exercise
prescription
 AGE
 Gender
 Other medical conditions
Early Home Visit
Others
 Weekly team meeting
 Early walking aid prescription
 Pneumatic devices on the sockets
 Vacuum techniques
 Laminated plastic sockets
 Local varieties
 Group therapy
Goals
 Promote wound closure
 Stabilize the stump
 Decrease edema
 Start prosthesis measurement
Exercises for the following groups
of muscles
 Hip Extensors
 Hip Flexors
 Hip Abductors
 Hip Adductors
 Knee Extensors
 Knee Flexors
 Trunk strengthening exercises
Exercises for the following groups
of muscles
 Hip Extensors
Exercises for the following groups
of muscles
 Hip Flexors
Exercises for the following groups
of muscles
 Hip Abductors
Exercises for the following groups
of muscles
 Hip Adductors
Exercises for the following groups
of muscles
 Knee extensors
Exercises for the following groups
of muscles
 Trunk strengthening
Special considerations during
exercise prescrtiption
 Incorporate play therapy especially for your pediatric
patients
 Make sure that activities that you plan to do are
developmentally appropriate for your patient
Donning and Doffing
 Patients are encouraged to dress independently as
much as possible
According to Engstrom (1993)
 If the patient is unable to put the underpants
independently, it is very unlikely that the indpendent
application of the prosthesis is possible
Transfers
 Initial requirements
 Alertness and the ability to comprehend instructions
 It is possible to do transfers while the drip / catheter is
in situ (PRECAUTION)
 A suitable wheelchair should have been loaned preoperatively and must be self-propelling
Transfers
 Independence for all transfers on all level surfaces
should be the goal
 Therapist should try to make all transfer surfaces level
Transfers
Transfers
Basic mobility skills
 Independence in sit-to-supine, supine-to-sit, and
rolling for all LE amputees
 What happens when the amputation of the LE is high?
 Tendency to fall
 Good core muscle strength is needed
Prosthetic referral
 Upon complete wound healing and stump stability
 Upon gaining independence in ADL’s
What if bilateral AKA?
 Possible non-walker
 Activities are: bed mobility training, arm exercises,
balance re-education, transfers, wheelchair maneuvers
 Wheelchair concerns...
Training Program Design
Pre-ambulation training
Gait training
Falls training
Functional training
Environmental considerations
Specialized prosthetic training
Training Program Design
 Principles of exxercise prescription
 Should be done daily and runn the whole day
 Family / caregiver involvement
 Use of different appliances / attachments
 Donning and doffing of the prosthesis
Training Program Design
 Principles of exxercise prescription
 Should be done daily and runn the whole day
 Family / caregiver involvement
 Use of different appliances / attachments
 Donning and doffing of the prosthesis
Pre-ambulation Training
 Sit-to-stand
 Balance re-education
 Weight transfer on to the prosthetic leg
 Considerations for progressions
Pre-ambulation Training
Gait Training
 Weight bearing on the prosthetic leg is advocated
 Done on various types of surfaces
 Protection of the stump
Gait Training
 Gait Pattern;
 2-point vs 3 point
 Indoor then outdoor mobility
Functional Training
Environmental Modifications
 For grasping
 Toilet seat raise, grab bars, bed blocks
 Velcro and snaps vs zippers and buttons
 Ramps
 Others
 Doors
 Knobs
 Switches
Other considerations
 Disablement resettlement
 Driving
After Discharge
 Out-patient services
 Follow-up visits
 Maintenance of prosthesis
Specialized prosthetic training
 Vocational training
 Athletics
 Recreational activities
Specialized prosthetic training
Specialized prosthetic training
Specialized prosthetic training
References
 Mariano, LMMJr. (2007). PT150 Archives. UP-CAMP
 Meyers, R.S. (1995). Saunders manual of physical
therapy parctice. Philadelphia: W.B. Saunders.
 (2004). A manual for the rehabilitation of people with
limb amputation . World Health Organization.