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Lower Extremity

AMPUTATIONS

Review of Previous Lecture

You are teaching your patient about their total hip precautions (for a posterior approach) and the patient is sitting in a wheelchair. Is “Don’t turn your foot/toes inward” an appropriate instruction?

Rehab Terminology

STUMP: Residual Limb

Artificial Limb: Prosthesis

Stump sock: Sock

Stump shrinker: Shrinker

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Cause of LE amputation

The major cause of LE amputation continues to be PVD, especially when associated with smoking and diabetes.

Second leading cause is trauma (MVA or GSW)

Risk Factors

Factors that Influence Vascular Disease

Hypertension

Age

Diabetes mellitus

Infection

Poor nutrition

Cigarette smoking

Risk Factors for Amputation

Vascular disease

Malignancy/tumor

Congenital deformities

Infection

Trauma

Study #1: DM & exercise

DM commonly leads to peripheral neuropathy, which causes motor and sensory deficits, often resulting in mobility-related dysfunction, balance impairments, lower gait velocity, decreased cadence, shorter stride length, increased stance time, decreased ankle strength and mobility, postural instability & increased risk of injurious falls

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Study #1: DM & exercise

Fall-related injuries are often assumed to trigger vicious cycles b/c of their detrimental influence on physical activity.

Which treatment strategies can improve gait and balance, thereby reducing the risk of falls?

RCT = 71 subjects put into control and intervention groups. Control group received nothing

Study #1: DM & exercise

Intervention group received 60 minutes, 2X/week X 12 weeks of: stance on heels/toes, tandem stance, SLS, different kinds of walking, sit to stand, walk up/down slope, stair climbing, mini-hops, interactive game such as badminton.

Gait, balance, fear of falls, muscle strength and joint mobility were measured at baseline, after 12 weeks and 6 month f/u

Study #1: DM & exercise

Results: Significant improvements for intervention group for increased habitual walking speed, balance, performance-oriented mobility, degree of concern re: falling, hip and ankle plantarflexor strength, and hip flexion mobility.

After 6 months, all remained significant except Biodex sway index and ankle PF strength

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Study #1: DM & exercise

Specific training can improve gait speed, balance, muscle strength and joint mobility in patients with diabetes.

Allet et al (2009)

LEVELS OF AMPUTATION

Usually identified by anatomical considerations/body region

What are the gait implications?

Toe Disarticulation

Gait Implication:

The hallux affects propulsion during fast ambulation

Can use toe fillers in the shoe

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Transmetatarsal

Gait Implications:

Problems with propulsion

Problems with later part of stance phase

The knee flexes too quickly

Syme’s Amputation

Everything distal to the tib/fib is amputated

Gait Implication:

have LLD

Can stand & walk without prosthesis for short time

Below Knee - Transtibial

Gait Implications:

ambulatory

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Above Knee - Transfemoral

Gait Implications:

can be ambulatory

Hip Disarticulation

femur removed if shorter than gr. troch

ambulatory with Canadian hip disarticulation prosthesis (very energy consuming)

Hemipelvectomy

removal of LE & ½ the pelvis

can walk with Canadian hip dis. Prosthesis, but may be better off in a W/C

Hemicorporectomy

Amputation through the lumbar spine

patient in a sitting bucket

SURGICAL PROCESS

Specific length of amputation is determined by the status of the extremity at the time of amputation

Considerations:

conservation of residual limb length

wound healing

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Closure

Primary: the skin is closed after surgery

Tertiary: the surgical site is left open

If infected

May see these patients for whirlpool

Important to maintain skin traction so there will be adequate skin for later closure/coverage

Ideal Surgery

Skin flaps: are as broad as possible. The scar should be pliable, painless, and nonadherent.

Skin flaps: skin shouldn’t be too tight or loose

Edges of suture lining should be smooth

Nerve should be protected well

Rounded, well beveled end of bone

Muscles attachment

HEALING PROCESS

Factors that may affect wound healing

Post-op infection

Smoking is a major deterrent to wound healing

Other factors

severity of vascular problems

diabetes

renal disease

cardiac disease

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Post-operative Dressings

It is important for some sort of edema control to be used post operatively because excessive edema in the residual limb can compromise healing and cause pain

Post-Op Dressings

Rigid dressing * Greatly limits post-op edema * Can attach a pylon for early ambulation (Plaster of Paris

socket in the configuration of definitive prosthesis) * Requires close supervision during the early healing stage * Does not allow for daily wound inspection

Semi-rigid dressing * Applied in OR or recovery room * Adheres to skin * Allows slight joint movement * Made of compounds: zinc oxide, gelatin, glycerin & calamine

Soft dressing * Inexpensive * Lightweight * Most commonly seen in acute care setting * Two types: Elastic wrap and shrinkers

Rigid Post-Op Dressing

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Rigid Post-Op Dressing

Semi-Rigid Post-Op Dressings

Soft Post-Op Dressings

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PT ASSESSMENT

ROM

Strength

Sensation

Skin assessment

Balance

Endurance

Mobility skills

PT ASSESSMENT

Residual limb assessment

Color

Shape

Pulses

Edema (circumferential measurements)

Length

Skin condition

Sensation

Joint proprioception

PT ASSESSMENT

Pain

Phantom limb sensation: sensation of the

limb that is no longer there. NORMAL to

occur

Phantom limb pain: cramping, burning,

shooting pain perceived “in” the amputated

limb.

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Phantom Limb Sensation

Phantom Limb Sensation: This is any sensation of the missing limb except pain. Sensations include pins and needles, tingling and prickling. Awareness of movement and positional orientation of the limb are widely reported. (Casale et al

2009, Chapman 2010)

Residual Limb Pain

Residual Limb (RL) pain is pain experienced in the residual portion of the limb (Prantl et al 2006)

Causes of RL pain may include neuromas – scarred nerve endings or nodules that may cause abnormal ectopic firing of nerves (Bloomquist, 2001) as well as bony spurs in the residual stump, localized skin disease and infection (Prantl et al 2006)

Phantom Limb Pain

Often the temperature in the residual limb is lower, which is correlated to the burning sensation that may be experiences as part of phantom pain (Schug 2008)

Muscle tension in the residual limb can increase the cramping associated with phantom pain (Chapman, 2010)

Risk factors proposed for the development of phantom limb pain include the severity of pre-amputation pain and post-operative pain (Nikolajsen and Jenson 2001), older age (Schug 2008), and catastrophising and passive coping styles (Richardson et al 2007)

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Phantom Limb Pain continued

Catastrophising refers to a coping style characterized by excessively negative thoughts and emotions in relation to pain (Vase et al 2010)

REHABILITATION GOALS

Short Term Goals Edema reduction

Prevent contractures

Regain strength in both LE

Independence in basic residual limb exercises, positioning, bandaging, & care

Learn proper care of remaining extremity

Promote as high a level of independent function as possible (bed mobility, transfers, self care, supervised or independent mobility with walker or crutches)

Decrease hypersensitivity

REHABILITATION GOALS

Long Term Goal

To help the patient regain the pre-surgical level of function

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Rehab Interventions

Residual Limb Care

Residual Limb Wrapping

Pain Management

Positioning

Exercise

Mobility

Temporary Prostheses

Patient Education

Nonprosthetic Management

Residual Limb Care

Edema Control

limb wrapping

shrinkers

Proper hygiene and skin care

Clean & dry

Scar massage (TFM)

Visual inspection

Early handling by the patient

RESIDUAL LIMB WRAPPING

Never wrap in a circular, tourniquet fashion which creates a bulbous end and compromises healing

Effective wrapping should: be smooth and wrinkle free

emphasize angular turns

provide pressure distally

encourage proximal joint extension

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Residual Limb Wrapping

Residual Limb WRAPPING

1. Apply firm, even pressure to decrease post-

op edema

2. Residual limb should be completely covered

3. Semicircular turns are made posteriorly to

align the wrap to cross anteriorly in an

angular line

4. Cross wraps by 1/2”

5. Use tape/Velcro to secure. NEVER clips

Pain Management

Chan et al (2007) demonstrated that mirror therapy reduced phantom limb pain in patients who had undergone lower limb amputation.

Patients attempt to perform movements of the phantom limb while viewing the reflected image of the movement of the intact limb.

http://www.youtube.com/watch?v=YL_6OMPywnQ

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Pain Management continued

MacIver et al (2008) used a mental imagery technique with a group of 13 people with upper limb amputation. The participants had 6 weeks of intensive training in mental imagery, which included a “body scan” exercise and imagined movement and sensation in the phantom limb. They showed changes in cortical reorganization using functional MRI with a corresponding reduction in some aspects of phantom limb pain.

Pain Management continued

Transcutaneous electrical nerve stimulation may also be considered to relieve pain.

However, current evidence in conflicting and a recent Cochrane review found no studies met the eligibility criteria for inclusion in the review and recommended that a large multicenter RCT is needed (Mulvey et al 2010)

POSITIONING

Major goal is to prevent post-op contractures

BKA: must prevent hip & knee flexion contractures; full extension necessary for proper prosthetic use

AKA: must prevent hip flexion, abd, & ER contractures; full hip extension crucial for prosthetic function (prone lying)

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EXERCISE

The exercise program needs to be individualized & should include strengthening, balance (in sit & stand), coordination, & function

Depends on the patient’s pre-op status

Need to focus on trunk and upper body for ambulation

Early mobility is essential

resumption of independent activities (self-care, bed mobility, transfers)

Strengthening

BKA:

Strengthen the Quads!!

Active patients – strengthen Hamstring too

Strengthen proximal muscles around the pelvis (glut med)

AKA:

Strengthen the hip extensors!!

Strengthen glut med

Exercise

Specific exercises for both BKA & AKA will be reviewed and practiced in Lab

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Decreasing Hypersensitivity

Don’t confuse it with a neuroma or phantom limb pain

How to decrease hypersensitivity?

TENS

Massage

Slapping the residual limb

Using various materials

MOBILITY

Gait training can begin early on in rehab using a swing through 3 point gait pattern and crutches.

Will improve general fitness (CV & muscular endurance)

All individuals with an amputation need to learn some form of mobility without a prosthesis for use at night or when the prosthesis is not worn for some other reason.

TEMPORARY PROSTHESIS

A temporary prosthesis can be fitted as soon as the wound has healed

Advantages to using a temp prosthesis: Allows for early bipedal ambulation

May allow patients to return to full active

daily life

Some patients can return to work

Positive motivating factor

Shrinks the residual limb more effectively

than wrapping

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PATIENT EDUCATION

As with all pts, education is crucial. With these patients, it is essential that they are instructed in:

care of the residual limb

proper care of the uninvolved extremity

positioning

exercises

diet

Patient Education cont…

Skin Inspection:

Foot Care:

Foot Wear:

May, 2002

Bilateral Amputation

The post surgical program is similar to the one for unilateral amputation, except ambulation

These patients will need a wheelchair on a permanent basis

Mat activities to regain a sense of body position & balance

Functional mobility stresses independence in bed mobility, transfers & W/C use

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Bilateral Amputation

These patients spend a considerable amount of time sitting

Stubbies: shortened prosthesis (no knee joint, modified rocker bottoms to prevent falling backwards)

http://www.youtube.c

om/watch?v=sW9-

akxea_U&feature=rel

ated

NONPROSTHETIC

MANAGEMENT

There are some patients who, for any number of reasons, are not fitted with a prosthesis (and will not be fitted in the future)

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Study #1

21 participants with lower limb amputations who were ambulatory with prostheses and 20 age-matched healthy individuals as the control group.

Postural stability and balance were studied using computerized dynamic posturography

Study #1

Results:

1. equilibrium scores were significantly reduced in persons with amputations as compared to those without

2. equilibrium scores were significantly reduced in persons with amputations due to vascular problems as compared to persons with amputations due to trauma

3. no significant differences were found in equilibrium scores between BKA & AKA

Study #1

Mohieldin A, Chidambaram A, Sabapathivinayagam, R, et al. Quantitative Assessment of Postural Stability and Balance Between Persons with Lower Limb Amputation and Normal Subjects by using Dynamic Posturography. Macedonian Journal of Medical Sciences. 2010; Jun 15; 3(2): 138-143.

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Review of Today’s Lecture

Amputee-coalition.org

Looking Ahead

Prosthetics

Review

You are instructing a patient in w/c mobility. To have them turn to their right, which wheel of the w/c should be held still and stabilized?

A. Right

B. Left

C. Both

D. Neither

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References

Allet L, Armand, S, et al (2009) The Gait and Balance of Patients with Diabetes can be Improved: A Randomized Controlled Trial. Diabetologia 53: 458-466.

Bloomquist T (2001) Amputation and phantom limb pain: a pain-prevention model. Journal of the American Association of Nurse Anesthetists. 69, 3, 211-217.

Casale R, Alaa L, Mallick M, Ring H (2009) Phantom limb related phenomena and their rehabilitation after lower limb amputation. European Journal of Physical Rehabilitation Medicine. 45, 4, 559-566.

Chan BL, Witt R, Charrow AP et al (2007) Mirror therapy for phantom limb pain. New England Journal of Medicine. 357, 21, 2206-2207.

Chapman S. Pain Management in Patients Following Limb Amputation. Nursing Standard. 2010; 25(19):35-40.

References Continued

MacIver K, Lloyd DM, Kelly S, Roberts N, Nurmikko T (2008) Phantom limb pain, cortical reorganization and the therapeutic effect of mental imagery. Brain. 131, Pt 8, 2181-2191.

May, B.M., (2002), Amputations & Prosthetics: A Case Study Approach, 2nd Ed., F.A. Davis Company: Philadelphia.

References Continued

Mohieldin A, Chidambaram A, Sabapathivinayagam, R, et al. Quantitative Assessment of Postural Stability and Balance Between Persons with Lower Limb Amputation and Normal Subjects by using Dynamic Posturography. Macedonian Journal of Medical Sciences. 2010; Jun 15; 3(2): 138-143.

Mulvey MR, Bagnall AM, Johnson MI, Marchant PR (2010) Transcutaneous electrical nerve stimulation (TENS) for phantom pain and stump pain following amputation in adults. Cochrane Database of Systematic Reviews. Issue 5.

Nikolajsen L, Ilkjaer S, Christensen JH, Krøner K, Jensen TS (1997) Randomised trial of epidural bupivicaine and morphine in prevention of stump and phantom pain in lower-limb amputation.

The Lancet. 350, 9088, 1353-1357.

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References continued

O’Sullivan, S.B. & Schmitz, T.J., (2000), Physical Rehabilitation, 4th Ed., F.A. Davis Company: Philadelphia.

Prantl L, Schreml S, Heine N, Eisenmann-Klein M, Angele P (2006) Surgical treatment of chronic phantom limb sensation and limb pain after lower limb amputation. A randomized clinical trial. Plastic and Reconstructive Surgery. 118, 7, 1562-1572.

Richardson C, Glenn S, Horgan M, Nurmikko T (2007) A prospective study of factors associated with the presence of phantom limb pain six months after major lower limb amputation in patients with peripheral vascular disease. Journal of Pain. 8, 10, 793-801.

References continued

Schug S (2008) Acute neuropathic pain:

amputations. Acute Pain. 10, 3-4, 189-190.

Vase L, Nikolajsen L, Christensen B et al (2010) Cognitiveemotional sensitization contributes to wind-up like pain in phantom limb pain patients. Pain. doi: 10.1016/j.pain.2010.10.013.