1. Clinical Procedures in Prosthetics 3: Techniques and Strategies 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: Identify common prosthetic problems encountered in the clinics Provide techniques and strategies for patients who underwent amputation in the different phases of prosthetic management ▫Pre-operative phase ▫Early Post-operative phase ▫Late Post-operative phase ▫Prosthetic phase  Gait training  Vocational training

3. Problem Identification PIPs NPIPs Existing Anticipated Impairments, Activity limitations, Participation Restrictions Therapy problem list

4. ANXIETY Physical Readiness of the patient for the Procedure Ward Instructions

5. PROGRAM Aimed at mobilizing all joints and stimulate circulation Cardiovascular fitness Exercises prior to the operation Assistive device training Wound care training Bandaging training Exercises

7. Plan Proper positioning Stump edema management ▫Elevation/Bandaging/dressing Exercises for the stump Selective stretching Phantom limb sensation / pain Gait training with assistive device Pre-ambu with temporary prosthesis

8. Plan 1-3 days post-op: Breathing exercises 4: AAROM of the stump (adduction and extension); AROM of the sound leg/arms/trunk; Weight-bearing on the stump 6: Free active exercises, counter-flexion bias/proper positioning Sitting push-ups

9. Plan Counter-acting flexion ▫PRONE for approx 30 mins ▫Fracture boards ▫Stretching program Pre-ambulation activities ▫STS, other transfers ▫Activities in standing, weight shift, stepping

10. Precautions for the residual limb Avoid wound dehiscence Protect residual limb from trauma Avoid friction – sliding, pushing

12. Guidelines Stress to suture lines: wait for 2-3 weeks Mild range exercises, ISOMS can begin during the early post-op phase Master isomes – gentle concentric Introduce theraband and progressive resistance

13. Progression Approx 2 weeks post-op, once surgical wound is closed, pt may be brought to the gym area for more vigorous exercises ▫Week 1: Progressive exercises for the stump ▫Week 2: Increase resistance; prevent boredom

14. Plan Exercises for the important muscles of the stump needed for gait Donning and doffing Transfers

15. Consider Ischial weight bearing training ▫Bouncing ▫Seats without cushions Important muscles for gait ▫Stance  Hip Abd and EXTensors ▫Swing  Hip FLEXors

17. Pre-gait training phase Initial balance training Weight shifting exercises ▫Side to side ▫Forward / Backward ▫Diagonal weight shifting ▫Stool stepping

18. Gait training protocol Sound limb stepping partial WB Prosthetic limb stepping partial WB Prosthetic limb stepping WB Sound limb stepping WB Stride length and Prosthetic control Sidestepping Resistive gait training Trunk rotation and Arm swing Unassisted ambulation

19. Advanced balance training skills Toe and heel pivoting 90 degree balance recovery Squatting limb balance Tandem walking Braiding Turning to the sound side Turning to the prosthetic side

20. PLAN Ambulation training ▫Inside parallel bars ▫With assistive device ▫Stairs, ramps Other ▫Getting in and out of the car ▫Falls training Fitness / wellness program ▫Cycle ergo / Treadmill / Stepper