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

Introduction 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 post-operative 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

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

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) Pt. with DM who undergoes one amputation 2 to PVD has 51% chance of 2nd operation within 10 yrs.2 Trauma MVA, gunshot Cancer Congenital2

Causes of Amputation by Percent Lusardi MM & Nielsen CC. Orthotics and Prosthetics in Rehabilitation. Woburn, MA: Butterworth-Heinemann; 2000, p. 328.

Risk factors for PVD? 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 DM2 Lusardi MM & Nielsen CC. Orthotics and Prosthetics in Rehabilitation. Woburn, MA: Butterworth-Heinemann; 2000, p. 330.

What are Signs/Symptoms of Vascular Insufficiency? Intermittent claudication What is this? 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) 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 impaired2

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 ulceration2

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% 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 40% 41-60 35% <40 25% 72% are males 4

Who is on the Team? 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

What tests/measures should be included in Mr What tests/measures should be included in Mr. Howard’s Initial PT examination? 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.2 Guide to Physical Therapy Practice Practice pattern 4 J, 5G, 7 A, 7C/D/E1

Pre-prosthetic Examination 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 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 May, BJ. Amputation and Prosthetics: A Case Study Approach. Philadelphia: Davis; 1996, p. 79.

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

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 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

How should PT inspect Mr. Howard’s wound? 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 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 142

How can you teach Mr. Howard scar management? 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 breakdown2

What are common post-amputation sensations Mr. Howard may experience? phantom limb sensation 70% will experienceNumbness, tingling, pressure, itching, mild cramp in foot/calf 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 pain2

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? 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 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 healing2

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 prosthesis2

What options are there for edema control for Mr. Howard? 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 Lusardi MM & Nielsen CC. Orthotics and Prosthetics in Rehabilitation. Woburn, MA: Butterworth-Heinemann; 2000, p. 400. RRD

Semi-rigid dressing Lusardi MM & Nielsen CC. Orthotics and Prosthetics in Rehabilitation. Woburn, MA: Butterworth-Heinemann; 2000, p. 401.

Shrinkers Lusardi MM & Nielsen CC. Orthotics and Prosthetics in Rehabilitation. Woburn, MA: Butterworth-Heinemann; 2000, p. 405.

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 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? Hip flexion Hip abduction Hip lateral rotation

How can PT prevent contractures in Mr. Howard? 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) 2

Prevention of Contractures May, BJ. Amputation and Prosthetics: A Case Study Approach. Philadelphia: Davis; 1996, p. 87.

Strengthening For LE Amputee 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? Hip ext., hip abductors/adductors, knee ext. hip flexors, knee flexors as needed (may need to stretch these short muscles) 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?

References: 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.