Rehabilitation for Amputation and Prosthetic Fitting after Burn Phase I

Characteristics of amputated limb which can functional well in prosthesis Pain free Well padded by soft tissue Non adherent scar Cylindrical shape Greatest bone length Normal sensation

Prosthetic Rehabilitation Following Burn Amputation

Promote Wound Healing 1-A superficial skin defect can usually be closed adequately with a Split –thickness skin graft (STSG). 2-Full –thickness defect over bony prominence is better handled with full –thickness coverage (either with local flap, pedicle flap, or free island flap). Physical therapy can enhance wound healing and reduce associated complication (such as development of hypertrophic scar) through using low level laser therapy (LLLT) (Helium neon laser therapy and or Gl-Al-Ars), with following treatment protocol;

Control Incisional and Phantom Pain Incisional Pain:- 1-It is a natural part of any surgical procedure where skin subcutaneous tissue, nerve and muscles have been cut .It usually goes away when swelling reduced and healing occurs. 2-Incisional pain should be controlled with adequate amounts of narcotic preferably given intravenously on regularly prescribed dose basis. This is usually helpful for the first three postoperative days. Subsequently oral analgesic should be adequate if there are no other sources of significant pain

Control Incisional and Phantom Pain 1-This is a pain in the missing or amputated part of the limb. It varies tremendously from person to person .It can include burning, tingling, squeezing and cramping, shocking, and shooting description. 2-Phantom pain should be explained to the patients since they occur in the early postoperative period. 3-The patient should expect that phantom pain sensation and phantom limb changes and usually diminished, and may be become long term problem. 4- Use of oral pain medication for significant phantom pain has not usually produced adequate pain reduction over period of time exceeding one week.

Control Incisional and Phantom Pain Phantom Sensation:- This is sensation or feeling in the part of the limb that has been removed. it include itching , tingling , warmth, cold, cramping , constriction , movement, and any other imaginable sensation , and all persons with limb loss experience some phantom sensation. Rresidual limb pain:- This kind of pain occurs in what is left of your natural limb after the amputation, as the residual limb always is more sensitive than other parts of body.

Maintain Joint ROM &Strength 1-Positioning is an important part of a patient's exercise program. It is done to prevent shortening of soft tissue and joint(s) contractures, that can result from ; (i) Soft tissue shortening . (Ii) Muscle imbalance. (iii) Protective withdrawal reflex. (iv) Faulty position. 3-If possible patients with an amputation should lie prone intermittently to enhance hip and knee extension, however care should be taken to avoid over stress on cardiovascular system during assuming this position. 4-The positioning program should emphasize active or active assistive ROM of the joint (s) proximal to the amputation. 5-Elevation of residual limb on a pillow can lead to the development of hip flexion contracture and so should be avoided.

Positioning Approach of Post burn Amputation Description Lying supine: make sure that hips and knees are straight, the patients should lie on a firm surface and avoid pillows under the residual limb. The legs should be held close together. Lying prone; pillow should be avoided under the hip and the hip should be kept straight, and the leg close together. The patients should lie prone or on wither side for up to 15 minutes, four times a day. This position will extended the hip and knee Side lying; the hip should be kept in a neutral position. The patient should not sleep with large pillow between the legs or under the back .Pillow in these positions enhance hip flexion and abduction. Sitting: when sitting patients should use a sliding board or other firm surface under the residual limb to promote knee extension.

Exercises 1-The exercises program is designed individually and includes ROM, exercises, isometric, isotonic, and endurance activities, and these dependent largely on (i)-Postoperative healing. (ii)-Postoperative pain (iii)-Post-surgical dressing. 2-This exercise should not produce more than mild discomfort and put less stress on suture line, otherwise stop exercises. 3-The hip extensor, abductors and knee extensor and flexors are particularly important for prosthetic ambulation.

4-Strengthening exercise for upper extremity muscles of shoulder depressor, elbow extensor, wrist extensor, and hand flexor should encouraged, with general strengthening program for trunk and abdominal muscles. 5-The program should emphasize active or active assistive ROM of the joint (s) proximal to the amputation, at 1st to 2nd day postoperative. 6- Active motion of all proximal joints through the full ROM should be obtained by 10 -14 days following amputation unless grafting procedure precludes exercising.

7-Gentle isometric exercises can be started at the 5th postoperative day. * A brief repetitive isometric exercises (BRIME), regimen is an extension of the original isometric .A patient with an imputation may use this regiment which consists of up to 20 maximum contractions. Each held for 6 second (Why?). A 20 seconds rest after each contraction is recommended (Why?). Rhythmic breathing during the contraction is recommended (Why?). * Multiple angle isometric exercises should be performed. 8- Isotonic exercises can be encouraged at 7 -10 days postoperative. 9-Program of muscle contraction and joint motion (8-10 repetition for 3sets) should be repeated several time daily (4-6 times), and once when adequately performed no need for supervision.

10-These exercises help to (i)-Reduce edema, and promote healing. (ii)-Maintain joint ROM, (iii)-Prevent contracture and correct existing contracture (iv)-Allow early mobility self care and (v)-Maintain muscle strength, and kinesthetic sense of residual and phantom limb, which can later be used in prosthetic training

Exercises for post-burn amputation Exercises Suggestion Hip Extension *Lie supine on firm matters, with towel placed under the residual limb; the residual limb is pressed firmly into the towel, raising the buttocks off the resting surface. *Bridging: lie supine with sound knee 90degrees of flexion, with foot is pushed down into the resting surface. The residual limb should be raised until both hips are of equal height. * Lie prone; lift the leg off the mat, at time with knee extended.

Hip abduction *Lie side on amputated side, with towel under the residual limb. The sound limb rested in pillow, stool in front of residual limb. The residual limb is depressed down on the towel. *Lie side on sound side, raising the residual limb, with weight around the distal tibia. *lie supine with rubber banding around the distal end of both limb, the patients pulls the residual limb away from sound limb.

*Lie prone and flex the knee against gravity. Knee Extension *Straight leg rising *Short arc quad sets *Lie Prone; the patient is prone with towel under the residual limb. the distal residual limb is pushed into the towel , and extended the knee Knee Flexion *Lie supine, with a towel under the residual limb, the patient pulls back into the towel, slightly bending the knee. *Lie prone and flex the knee against gravity.

Pre-Ambulation Exercises Program

Concurrent Activities

Parallel Bar and Ambulation Activities

(For persons with single leg amputations only): Walking with crutches (For persons with single leg amputations only): First move the crutches forward about (30 cm). Step forward with your residual limb/prosthesis. Land it between your crutches. Lift your natural limb and step to, or past the crutches.

Going up stairs: Step up with your natural limb first. Then bring your crutches and residual limb/prosthesis up. Going down stairs: Don’t hop. Move your crutches down first, then step down with your residual limb/ prosthesis. Lastly, step down with your natural limb.