1. 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

2. 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

3. 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

4. Pre-operative stage Introductory Visit Assessment
Discussion of outcomes
Preparation for the operation
Pre-operative exercises

5. 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

6. Assessment Physical Conditions that may affect mobility
Functional capacity
Psychological
Attitude
Social situation
Accommodation after surgery

7. 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

8. 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

9. 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
Pre-operative exercises
Short and frequent porgressive free exercises on sitting, standing, and supine
Should focus on exercises such as:
PREs to the Ues
Core stability exercises
Exercises on the sound leg
Resisted exercises on the hip muscles particularly on the unaffected side

11. Early Post-op Stage
Goals
Treatment methods
Early home visit
Others

12. 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
Post-op
Mobility should be done on day 1
Normal pt
Proper wound care
Prevent contractures
Immediate wound closures
Vascular pt
Immediate mobilization 1-2 days post-op particularly pt’s with diabetes (promote circulation)
Chest care
Breathing exercises
Managing pain, faster wound healing
Pain control is ESSENTIAL

13. Treatment Methods Proper positioning Stump edema management
Active exercises
Selective Stretching
Donning and doffing
Functional training
Stump edema management
ISOMS, bandage, compression
Donning and doffing
Volume containment devices
Functional training
- Going to the toilet

14. 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 should be horizontal
PRESCRIBE A GOOD BED-TURNING PROGRAM!

16. Stump edema management
Elevation
Exercises
Bandaging
Intermittent variable air pressure machines
Pneumatic pylon
Shrinker socks
Rigid dressing
Rigid dressing- plaster of paris

17. 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
Done

18. 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
Allow rest period for the patient

20. 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

21. 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
Contraction of distal mm of the stump

22. Selective Stretching BKA AKA Obtain neutral hip alignment
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

23. Special considerations in exercise prescription
AGE
Gender
Other medical conditions

24. Early Home Visit Meet the family Prepare the family
Goal should be independance of the patient once he/she goes back home

25. Others Weekly team meeting Early walking aid prescription
Pneumatic devices on the sockets
Vacuum techniques
Laminated plastic sockets
Local varieties
Group therapy
Let the patient see other patients who were amputated

26. Late post-operative phase
Usually takes less than a month

27. Goals Promote wound closure Stabilize the stump Decrease edema
Start prosthesis measurement

28. Exercises for the following groups of muscles
Hip Extensors
Hip Flexors
Hip Abductors
Hip Adductors
Knee Extensors
Knee Flexors
Trunk strengthening exercises

29. Exercises for the following groups of muscles
Hip Extensors

30. Exercises for the following groups of muscles
Hip Flexors

31. Exercises for the following groups of muscles
Hip Abductors

32. Exercises for the following groups of muscles
Hip Adductors

33. Exercises for the following groups of muscles
Knee extensors

34. Exercises for the following groups of muscles
Trunk strengthening

35. 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

36. 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

37. 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 pre-operatively and must be self-propelling

38. Transfers
Independence for all transfers on all level surfaces should be the goal
Therapist should try to make all transfer surfaces level

39. Transfers

40. Transfers

41. 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

42. Prosthetic referral Upon complete wound healing and stump stability
Upon gaining independence in ADL’s

43. What if bilateral AKA? Possible non-walker
Activities are: bed mobility training, arm exercises, balance re-education, transfers, wheelchair maneuvers
Wheelchair concerns...

44. Prosthetic Training Phase
Training Program Design
Pre-ambulation training
Gait training
Falls training
Functional training
Environmental considerations
Specialized prosthetic training

45. 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

46. 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

47. Pre-ambulation Training
Sit-to-stand
Balance re-education
Weight transfer on to the prosthetic leg
Considerations for progressions

48. Pre-ambulation Training

49. Gait Training Weight bearing on the prosthetic leg is advocated
Done on various types of surfaces
Protection of the stump

50. Gait Training Gait Pattern; Indoor then outdoor mobility
2-point vs 3 point
Indoor then outdoor mobility

51. Functional Training

52. Environmental Modifications
For grasping
Toilet seat raise, grab bars, bed blocks
Velcro and snaps vs zippers and buttons
Ramps
Others
Doors
Knobs
Switches

53. Other considerations
Disablement resettlement
Driving

54. After Discharge Out-patient services Follow-up visits
Maintenance of prosthesis

55. Specialized prosthetic training
Vocational training
Athletics
Recreational activities

56. Specialized prosthetic training

57. Specialized prosthetic training

58. Specialized prosthetic training

59. 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.