post-operative management of lower limb amputations

POST-OPERATIVE POST-OPERATIVE MANAGEMENT OF LOWER MANAGEMENT OF LOWER

LIMB AMPUTATIONSLIMB AMPUTATIONS

Produced under a grant from Produced under a grant from the Department of Education the Department of Education

through the American through the American Academy of Orthotists and Academy of Orthotists and

Prosthetists and the Prosthetists and the

Prosthetics Research StudyProsthetics Research Study

by the Northwestern by the Northwestern University Prosthetics-University Prosthetics-

Orthotics CenterOrthotics Center

Learning ObjectivesLearning Objectives

• After completing this on-line module the After completing this on-line module the clinician should be able to:clinician should be able to:

– Identify and describe the 5 basic post-Identify and describe the 5 basic post-operative strategies available.operative strategies available.

– Compare and contrast the effectiveness of Compare and contrast the effectiveness of strategies to best manage their patient strategies to best manage their patient populations.populations.

– Identify and understand the minimum Identify and understand the minimum standards of care required to achieve standards of care required to achieve appropriate rehabilitation.appropriate rehabilitation.

Instruction for UseInstruction for Use

• When you see this icon, please click your When you see this icon, please click your mouse on the icon to be linked to a mouse on the icon to be linked to a required reading.required reading.

• When you see this icon, click your mouse When you see this icon, click your mouse to be linked to recommended readings.to be linked to recommended readings.

http://www.oandp.org/jpo/library/2002_01_019.asp

http://www.ejbjs.org/cgi/content/abstract/61/5/724?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&author1=Wu&andorexactfulltext=and&searchid=1086708501846_3295&stored_search=&FIRSTINDEX=0&sortspec=relevance&resourcetype=1&journalcode=jobojos

Table of ContentsTable of ContentsI.I. Literature ReviewLiterature Review

II.II. Post-operative StrategiesPost-operative Strategies

III.III. Comparison of StrategiesComparison of Strategies

Standards of CareStandards of Care

IV. IV. Team ApproachTeam Approach

V. V. Time framesTime frames

VI.VI. Wound HealingWound Healing

VII.VII. Amputation Specific GoalsAmputation Specific Goals

VIII.VIII. Whole Person GoalsWhole Person Goals

IX.IX. Education and Education and EmpowermentEmpowerment

X.X. Case StudiesCase Studies

I.I. Literature ReviewLiterature Review

II.II. Post-operative StrategiesPost-operative Strategies

III.III. Comparison of StrategiesComparison of Strategies

Standards of CareStandards of Care

IV. IV. Team ApproachTeam Approach

V. V. Time framesTime frames


VII.VII. Amputation Specific GoalsAmputation Specific Goals

VIII.VIII. Whole Person GoalsWhole Person Goals

IX.IX. Education and Education and EmpowermentEmpowerment

X.X. Case StudiesCase Studies

I. Literature ReviewI. Literature Review

I.I. Literature Review:Literature Review:Journal of Rehabilitation Research Journal of Rehabilitation Research

and Developmentand Development – Postoperative dressing and management strategies for Postoperative dressing and management strategies for

transtibial amputations: A critical reviewtranstibial amputations: A critical review

Conclusion: the literature and evidence to date is primarily Conclusion: the literature and evidence to date is primarily anecdotal and insufficient to support many of the claims made. anecdotal and insufficient to support many of the claims made. Future randomized trials on TTA dressing and management Future randomized trials on TTA dressing and management strategies are clearly needed to collect evidence to best guide strategies are clearly needed to collect evidence to best guide clinicians with their decisionsclinicians with their decisions

Click here to read the full article

http://www.rehab.research.va.gov/jour/03/40/3/smith.html

Journal of Rehabilitation Research and DevelopmentJournal of Rehabilitation Research and Development Postoperative dressing and management strategies for Postoperative dressing and management strategies for

transtibial amputations: A critical reviewtranstibial amputations: A critical review

• After reading the journal article please answer After reading the journal article please answer the following self-assessment questions.the following self-assessment questions.

• Advance to the next slide to beginAdvance to the next slide to begin

Click here to read the full articleClick here to read the full article

Review of Module IReview of Module I

Overall, current research on post-operative Overall, current research on post-operative managementmanagement

a.a. Lacks standard definitions for endpoints to Lacks standard definitions for endpoints to measure success and failuremeasure success and failure

b.b. Compares all of the various management Compares all of the various management strategiesstrategies

c.c. Is consistent in measurement outcomesIs consistent in measurement outcomesd.d. Compares individuals w/ the same level and Compares individuals w/ the same level and

etiology of amputationetiology of amputation

a.a. Lacks standard definitions for endpoints to Lacks standard definitions for endpoints to measure success and failuremeasure success and failure

b.b. Compares all of the various management Compares all of the various management strategiesstrategies

c.c. Is consistent in measurement outcomesIs consistent in measurement outcomesd.d. Compares individuals w/ the same level and Compares individuals w/ the same level and

etiology of amputationetiology of amputation

Of the 10 controlled studies, which Of the 10 controlled studies, which comparison has not taken place? comparison has not taken place?

a.a. Removable Rigid Cast to Soft DressingRemovable Rigid Cast to Soft Dressing

b.b. Thigh level Rigid IPOP to Soft DressingThigh level Rigid IPOP to Soft Dressing

c.c. Removable Rigid Cast to any IPOPRemovable Rigid Cast to any IPOP

d.d. Prefab IPOP to Soft DressingPrefab IPOP to Soft Dressing

a.a. Removable Rigid Cast to Soft DressingRemovable Rigid Cast to Soft Dressing

b.b. Thigh level Rigid IPOP to Soft DressingThigh level Rigid IPOP to Soft Dressing

c.c. Removable Rigid Cast to any IPOPRemovable Rigid Cast to any IPOP

d.d. Prefab IPOP to Soft DressingPrefab IPOP to Soft Dressing

What fraction of transtibial amputations What fraction of transtibial amputations occur in those with diabetes?occur in those with diabetes?

a.a. One-thirdOne-third

b.b. One-quarterOne-quarter

c.c. One-halfOne-half

d.d. Two-thirdsTwo-thirds

e.e. AllAll

a.a. One-thirdOne-third

b.b. One-quarterOne-quarter

c.c. One-halfOne-half

d.d. Two-thirdsTwo-thirds

e.e. AllAll

Which is not a goal of post-operative Which is not a goal of post-operative management?management?

a.a. Prevent knee contracturesPrevent knee contractures

b.b. Reduce edemaReduce edema

c.c. Protect the limb from external traumaProtect the limb from external trauma

d.d. Facilitate early weight bearingFacilitate early weight bearing

e.e. Bill as much as possibleBill as much as possible

a.a. Prevent knee contracturesPrevent knee contractures

b.b. Reduce edemaReduce edema

c.c. Protect the limb from external traumaProtect the limb from external trauma

d.d. Facilitate early weight bearingFacilitate early weight bearing

e.e. Bill as much as possibleBill as much as possible

Continue to Next Module

Return to Table of Contents

II. Introduction to Post-II. Introduction to Post-Operative Amputation Operative Amputation Management StrategiesManagement Strategies

II. Introduction to Post-Operative II. Introduction to Post-Operative Amputation Management StrategiesAmputation Management Strategies

• Definitions:Definitions:

– Strategy- specifically refers to the post-Strategy- specifically refers to the post-amputation dressing or device.amputation dressing or device.

– Protocol- specifically refers to how the post-Protocol- specifically refers to how the post-operative device or dressing is prescribed operative device or dressing is prescribed and used.and used.

StrategyStrategy

1.1. Soft DressingsSoft Dressings-Types:-Types:

• Ace wrapsAce wraps• compressive stockinettecompressive stockinette• traditional shrinker sockstraditional shrinker socks• Unna paste wrapsUnna paste wraps

(Semi-rigid)(Semi-rigid)• gel linersgel liners

Soft DressingsSoft Dressings

• The soft dressing is used routinely in post-operative The soft dressing is used routinely in post-operative management to control swelling. management to control swelling.

If soft compressive dressings are used, proper wrapping If soft compressive dressings are used, proper wrapping techniques must be taught to the staff, patient and techniques must be taught to the staff, patient and caregivers to reduce complications.caregivers to reduce complications.

Instruction on the use of proper wrapping techniques Instruction on the use of proper wrapping techniques can be found at the link below.can be found at the link below.

http://www.oandp.com/resources/patientinfo/manuals/5.htm


• The use of soft dressings also may be used with The use of soft dressings also may be used with adjunctive mechanisms to obtain compression as well as adjunctive mechanisms to obtain compression as well as addressing knee flexion contractures.addressing knee flexion contractures.

Soft dressings can be combined with the use of simple Soft dressings can be combined with the use of simple knee immobilizers, hinged knee immobilizers, and low knee immobilizers, hinged knee immobilizers, and low temperature thermoplastic protective shells to minimize temperature thermoplastic protective shells to minimize contracture or protect the amputation site.contracture or protect the amputation site.


• While frequently used in many patient care settings, While frequently used in many patient care settings, these devices do not these devices do not directlydirectly offer a mechanism to offer a mechanism to promote residual limb maturation.promote residual limb maturation.

• There is currently minimal evidence to document the There is currently minimal evidence to document the effectiveness of soft dressings.effectiveness of soft dressings.

Elastic shrinkers

• Commercially ready-made and Commercially ready-made and individually packaged is effective for individually packaged is effective for residual limb shrinkage, but lacks residual limb shrinkage, but lacks protection of the residual limb from protection of the residual limb from trauma such as accidental falls or trauma such as accidental falls or weight-bearing exercise.weight-bearing exercise.

• Its use is limited by the cost and Its use is limited by the cost and availability in the officeavailability in the office

Elastic shrinkers

Has limited sizes and lengths, lack of size Has limited sizes and lengths, lack of size for obese patients with short residual for obese patients with short residual limbs or for children with amputated limbs or for children with amputated limbslimbs

May be either too tight to put on or too May be either too tight to put on or too loose to have enough compressionloose to have enough compression

http://store6.yimg.com/I/ames-walker_1792_158606

Elastic stockinette

• commercially available in rolls and in various sizescommercially available in rolls and in various sizes

• can be used in place of elastic bandage and stump can be used in place of elastic bandage and stump shrinkersshrinkers

• less expensiveless expensive

• easily applied onto the residual limbs or edematous easily applied onto the residual limbs or edematous limbslimbs

• most importantly, can achieve a desirable gradient most importantly, can achieve a desirable gradient

pressure by adding layers of various length of elastic pressure by adding layers of various length of elastic stockinettestockinette

Elastic stockinette provides pressure

more over wide areas than narrow areas

The compression pressure on the distal part (with increased tension) is higher than on the smaller proximal area (with less tension from less stretching of elastic stockinette)

Elastic stockinette

StrategyStrategy

2.2. Non-removable rigid dressings Non-removable rigid dressings without immediate prosthetic without immediate prosthetic attachment.attachment.

– Custom molded thigh high device made from plaster, Custom molded thigh high device made from plaster, fiberglass, or other rigid material.fiberglass, or other rigid material.

Non-removable rigid dressings without Non-removable rigid dressings without immediate prosthetic attachmentimmediate prosthetic attachment

This strategy used at the transtibial level of amputation This strategy used at the transtibial level of amputation is usually worn for the first 1 to 2 weeks after surgery is usually worn for the first 1 to 2 weeks after surgery to shape and protect the limb. to shape and protect the limb.

The cast extends above the knee and does not allow the The cast extends above the knee and does not allow the knee to bend. knee to bend.

At the transfemoral level of amputation a this cast may At the transfemoral level of amputation a this cast may or may not incorporate a preformed brim.or may not incorporate a preformed brim.

This strategy also may or may not use a soft or rigid This strategy also may or may not use a soft or rigid hip spica component around the waist.hip spica component around the waist.

Non-removable rigid dressings without Non-removable rigid dressings without immediate prosthetic attachmentimmediate prosthetic attachment

II.II. Introduction to Post-Operative Introduction to Post-Operative Amputation Management StrategiesAmputation Management Strategies

3.3. Non-removable rigid dressings Non-removable rigid dressings

with Immediate Post-Operative with Immediate Post-Operative Prosthesis (IPOP).Prosthesis (IPOP).

– Custom molded thigh high device made from Custom molded thigh high device made from plaster, fiberglass, or other rigid material with plaster, fiberglass, or other rigid material with pylon and foot attachment.pylon and foot attachment.

The immediate post-operativeThe immediate post-operativeprosthesis was initiated in the lateprosthesis was initiated in the late1950’s by Dr. Berlemont (France)1950’s by Dr. Berlemont (France)and Dr. Weiss (Poland).and Dr. Weiss (Poland).

The technique was furtherThe technique was furtherdeveloped in the United Statesdeveloped in the United Statesby Dr. Burgess at Prostheticsby Dr. Burgess at ProstheticsResearch Study in Seattle,Research Study in Seattle,WAWA

IPOPIPOP

General Principles:General Principles:

Supervised weight bearing of no more than 5-10 lbs of Supervised weight bearing of no more than 5-10 lbs of measured weight during the first 1-2 days post surgery.measured weight during the first 1-2 days post surgery.

No more than 20 lbs of weight bearing in the parallel No more than 20 lbs of weight bearing in the parallel bars until after the first cast change.bars until after the first cast change.

This usually occurs around 2 weeks postoperatively.This usually occurs around 2 weeks postoperatively.

IPOPIPOP


4.4. Removable Rigid Dressing Removable Rigid Dressing (RRD)(RRD)

– Removable rigid dressings made from Removable rigid dressings made from plaster, plaster, fiberglass, or other rigid material may be used with fiberglass, or other rigid material may be used with or without a prosthetic attachment.or without a prosthetic attachment.

http://www.ejbjs.org/cgi/content/abstract/61/5/724?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&author1=Wu&andorexactfulltext=and&searchid=1086708501846_3295&stored_search=&FIRSTINDEX=0&sortspec=relevance&resourcetype=1&journalcode=jobojos

The procedure was developed in 1978 and published in:

-Wu Y, Keagy RD, et al. An innovative removable rigid dressing technique for below-the-knee amputation. J Bone Joint Surg 1979;61A:724-729.

-Wu Y,Krick HJ. Removable rigid dressing for below-knee amputees. Clin Prosthet Orthot 1987;11:33-44.

1)1) Pressure sore over tibial tuberclePressure sore over tibial tubercle

2) Distal edema2) Distal edema

3) Knee contracture due to pain.3) Knee contracture due to pain.

It was developed to solve the common problems from elastic bandaging such as:

Steps of applying RRD: Steps of applying RRD:

1) apply the wound dressing as 1) apply the wound dressing as needed, needed,

2) wear proper layers of tube 2) wear proper layers of tube socks or stump socks of socks or stump socks of various lengths,various lengths,

3) apply the plaster cast; use a 3) apply the plaster cast; use a plastic sheath to reduce plastic sheath to reduce friction,friction,

4) pull the suspension stockinette 4) pull the suspension stockinette upward covering the plaster upward covering the plaster cast,cast,

5) place the supracondylar cuff 5) place the supracondylar cuff and fasten the Velcro closure,and fasten the Velcro closure,

6) pull the suspension stockinette 6) pull the suspension stockinette tight,tight,

7) fold suspension stockinette 7) fold suspension stockinette downward and anchor on the downward and anchor on the suspension cuffsuspension cuff

8) knee flexion is possible and 8) knee flexion is possible and encouraged.encouraged.


5.5. Pre-fabricated post-operative Pre-fabricated post-operative prosthetic systemsprosthetic systems

Pre-fabricated post-operative Pre-fabricated post-operative prosthetic systemsprosthetic systems

These devices provide varying degrees of protection and contracture prevention and are designed for early weight bearing.

They maintain some of the advantages of the removable rigid dressing, in that they are easily removed and replaced for wound evaluation.

Examples of Pre-fabricated Examples of Pre-fabricated systemssystems

http://www.1800flo-tech.com/

Review of Module IIReview of Module II

The use of elastic stockinette may be better The use of elastic stockinette may be better than Ace-type bandages because: than Ace-type bandages because:

a.a. It provides better protectionIt provides better protection

b.b. It is more expensiveIt is more expensive

c.c. Can apply gradient pressureCan apply gradient pressure

d.d. Eliminates contracturesEliminates contractures

a.a. It provides better protectionIt provides better protection

b.b. It is more expensiveIt is more expensive

c.c. Can apply gradient pressureCan apply gradient pressure

d.d. Eliminates contracturesEliminates contractures

The RRD allows for all of the following The RRD allows for all of the following except: except:

a.a. Inspection of the limbInspection of the limb

b.b. Protection of the limbProtection of the limb

c.c. Graded weight-bearingGraded weight-bearing

d.d. Immobilization of the kneeImmobilization of the knee

a.a. Inspection of the limbInspection of the limb

b.b. Protection of the limbProtection of the limb

c.c. Graded weight-bearingGraded weight-bearing

d.d. Immobilization of the kneeImmobilization of the knee

When using a prefabricated system for early When using a prefabricated system for early weight bearing, the patient should only weight bearing, the patient should only bear______ pounds of weight in the parallel bear______ pounds of weight in the parallel bars.bars.

a.a. 5-10 5-10

b.b. 20-4020-40

c.c. 60-8060-80

d.d. Full weight-bearing Full weight-bearing

a.a. 5-105-10

b.b. 20-4020-40

c.c. 60-8060-80

d.d. Full weight-bearingFull weight-bearing

III. Comparison of StrategiesIII. Comparison of Strategies

III.III. Comparisons of StrategiesComparisons of Strategies

• The literature identifies the lack of scientific The literature identifies the lack of scientific evidence to support the use of one strategy over evidence to support the use of one strategy over another. Analysis of 10 controlled studies another. Analysis of 10 controlled studies supported only four of the fourteen claims cited supported only four of the fourteen claims cited in uncontrolled, descriptive studies in uncontrolled, descriptive studies


• The literature supports that:The literature supports that:

– 1) Non-removable rigid dressings result in 1) Non-removable rigid dressings result in significantly accelerated rehabilitation times significantly accelerated rehabilitation times when compared to soft gauze dressings.when compared to soft gauze dressings.

– 2) Non-removable rigid dressings result in 2) Non-removable rigid dressings result in significantly less edema when compared to significantly less edema when compared to soft gauze dressing. soft gauze dressing.


• The literature supports that:The literature supports that:

– 3) Pre-fabricated post-operative prosthetic 3) Pre-fabricated post-operative prosthetic systems were found to have significantly fewer post-systems were found to have significantly fewer post-surgical complications when surgical complications when compared to soft compared to soft gauze dressings.gauze dressings.

– 4) Pre-fabricated post-operative prosthetic 4) Pre-fabricated post-operative prosthetic systems lead to fewer higher level systems lead to fewer higher level revisions compared to soft gauze revisions compared to soft gauze dressings.dressings.


• No studies directly compared pre-fabricated systems to No studies directly compared pre-fabricated systems to rigid dressings, and no studies compared all types of rigid dressings, and no studies compared all types of dressings within one study.dressings within one study.

• It is currently not possible to provide evidenced-based It is currently not possible to provide evidenced-based protocols, or make conclusive evidence-based protocols, or make conclusive evidence-based recommendations for the use of one strategy over recommendations for the use of one strategy over another.another.

Assessing OutcomesAssessing Outcomes

• Due to the lack of evidence based outcomes measures in the Due to the lack of evidence based outcomes measures in the area of Post-operative management, the consensus conference area of Post-operative management, the consensus conference also strongly suggested the adoption of reporting standards also strongly suggested the adoption of reporting standards for the assessment of outcomes. for the assessment of outcomes.

• These standards included:These standards included:

– Better classification systemsBetter classification systems– Improved documentation of wound healing Improved documentation of wound healing

(module VI)(module VI)– Documentation of contralateral limb statusDocumentation of contralateral limb status– Pre- and Post-amputation functional status evaluationPre- and Post-amputation functional status evaluation

Classification SystemsClassification Systems

• ““Traumatic” vs. “diabetic” amputation terminology is not Traumatic” vs. “diabetic” amputation terminology is not completecomplete

• Etiology and co-morbidities must be consideredEtiology and co-morbidities must be considered

• For example, a “diabetic” amputation may be due to:For example, a “diabetic” amputation may be due to:

– Infection, Minor trauma, Poor circulation, Chronic Infection, Minor trauma, Poor circulation, Chronic ulceration, etculceration, etc

• Systemic complications (death, myocardial infarction, deep Systemic complications (death, myocardial infarction, deep venous thrombosis, pneumonia, strong, urinary infection) venous thrombosis, pneumonia, strong, urinary infection) should also be tracked. should also be tracked.

Contralateral Limb statusContralateral Limb status

• 28-51% undergo second leg amputation within 28-51% undergo second leg amputation within 5 years of initial5 years of initial

• 39-68% mortality at 5 years following 39-68% mortality at 5 years following amputation*amputation*

• Therefore, ulceration, wounds, infection and Therefore, ulceration, wounds, infection and amputation in the contralateral limb should be amputation in the contralateral limb should be documenteddocumented

Reiber, Boyko, and Smith (1995) in Diabetes in America

Pre- and Post- amputation functional statusPre- and Post- amputation functional status

• The consensus was that pre-amputation (whenever possible) and The consensus was that pre-amputation (whenever possible) and post-amputation functional status should be documented using post-amputation functional status should be documented using standardizedstandardized general outcome tools. e.g.: general outcome tools. e.g.:

– SF-36 (Short form 36) SF-36 (Short form 36)

– MFA (Musculoskeletal Functional Assessment) MFA (Musculoskeletal Functional Assessment)

– SIP (Sickness Impact Profile)SIP (Sickness Impact Profile)

• Or tools specific to amputation and prosthetics. e.g.:Or tools specific to amputation and prosthetics. e.g.:

– AMP (Amputee Mobility Predictor)AMP (Amputee Mobility Predictor)

– PEQ (Prosthetic Evaluation Questionnaire)PEQ (Prosthetic Evaluation Questionnaire)

Review of Module IIIReview of Module III

A well-designed comparison of post-A well-designed comparison of post-operative management will operative management will

a.a. Randomize selectionRandomize selection

b.b. Define outcome measures consistentlyDefine outcome measures consistently

c.c. Better detail pain and complicationsBetter detail pain and complications

d.d. Compare all management methodsCompare all management methods

e.e. Quantify health care savingsQuantify health care savings

f.f. All of the aboveAll of the above

a.a. Randomize selectionRandomize selection

b.b. Define outcome measures consistentlyDefine outcome measures consistently

c.c. Better detail pain and complicationsBetter detail pain and complications

d.d. Compare all management methodsCompare all management methods

e.e. Quantify health care savingsQuantify health care savings

f.f. All of the aboveAll of the above

Which of the following is an unsupported claim of Which of the following is an unsupported claim of the descriptive studies?the descriptive studies?

a.a. NR Rigid dressings accelerate rehab time NR Rigid dressings accelerate rehab time compared to soft dressingscompared to soft dressings

b.b. Eventual use of a prosthesis is increased for Eventual use of a prosthesis is increased for an IPOP compared to soft dressingsan IPOP compared to soft dressings

c.c. IPOPs require fewer higher-level revisions IPOPs require fewer higher-level revisions compared to soft dressingscompared to soft dressings

d.d. NR Rigid dressings significantly reduce NR Rigid dressings significantly reduce edema compared to soft dressingsedema compared to soft dressings

*NR=Non-removable

a.a. NR Rigid dressings accelerate rehab time NR Rigid dressings accelerate rehab time compared to soft dressingscompared to soft dressings

b.b. Eventual use of a prosthesis is increased for Eventual use of a prosthesis is increased for an IPOP compared to soft dressingsan IPOP compared to soft dressings

c.c. IPOPs require fewer higher-level revisions IPOPs require fewer higher-level revisions compared to soft dressingscompared to soft dressings

d.d. NR Rigid dressings significantly reduce NR Rigid dressings significantly reduce edema compared to soft dressingsedema compared to soft dressings

Systemic complications may be considered Systemic complications may be considered perioperative if they occur within __ days of perioperative if they occur within __ days of surgery: surgery:

a.a. 55

b.b. 1010

c.c. 3030

d.d. 6060

e.e. 365365

a.a. 55

b.b. 1010

c.c. 3030

d.d. 6060

e.e. 365365

IV. Team ApproachIV. Team Approach


• The goal of the rehabilitation team is to The goal of the rehabilitation team is to work together with the patient/ client and work together with the patient/ client and family to help a person with an family to help a person with an amputation reach maximum potential.amputation reach maximum potential.

Team MembersTeam Members

Family

Patient

Surgeon

Physiatrist

Nurse

Therapy

Prosthetist

Chaplain

Case Manager

Psychologist

Social Worker

Peer Support


• Patient/ Client and FamilyPatient/ Client and Family– The patient/ client and family are considered The patient/ client and family are considered

the most important members of the the most important members of the rehabilitation team.rehabilitation team.


• SurgeonSurgeon– The surgeon performs the amputation and The surgeon performs the amputation and

provides medical care.provides medical care.

• PhysiatristPhysiatrist– A physician who is specially trained in A physician who is specially trained in

Physical Medicine and Rehabilitation Physical Medicine and Rehabilitation prescribes the individualized therapy prescribes the individualized therapy programs and coordinates the team effort of programs and coordinates the team effort of the many professionals.the many professionals.

Team MembersTeam Members• TherapyTherapy

– The various therapies provide a vital role in The various therapies provide a vital role in the rehabilitation of the patient/ client.the rehabilitation of the patient/ client.

– The various therapies include Physical The various therapies include Physical therapy, Occupational therapy, Vocational therapy, Occupational therapy, Vocational therapy, Recreational therapy, and Speech therapy, Recreational therapy, and Speech therapy.therapy.


• Physical TherapistPhysical Therapist– A therapist who designs an A therapist who designs an

individualized program to help individualized program to help restore function for patients/ restore function for patients/ clients with problems related to clients with problems related to movement, muscle strength, movement, muscle strength, exercise, and joint function.exercise, and joint function.


• The Rehabilitation NurseThe Rehabilitation Nurse– Provides 24 hour a day nursing care.Provides 24 hour a day nursing care.– The nurse implements the plan of care, The nurse implements the plan of care,

reinforces the skills learned in therapy, and reinforces the skills learned in therapy, and teaches the patient/ client and family about teaches the patient/ client and family about self care and medications.self care and medications.


• ProsthetistProsthetist– Prepares patient/ client for prosthetic carePrepares patient/ client for prosthetic care– Educates the patient/ client on prosthetic Educates the patient/ client on prosthetic

carecare– Recommends prosthetic components based Recommends prosthetic components based

on rehabilitation potentialon rehabilitation potential


• Psychiatrist/ PsychologistPsychiatrist/ Psychologist– A person who conducts cognitive (thinking A person who conducts cognitive (thinking

and learning) assessments of the patient/ and learning) assessments of the patient/ client.client.

– Helps the patient/ client and family adjust to Helps the patient/ client and family adjust to the disability.the disability.


• Social workerSocial worker– A professional counselor who acts as a A professional counselor who acts as a

liaison for the patient/ client, family and liaison for the patient/ client, family and rehabilitation team.rehabilitation team.

– The social worker helps patient/ client and The social worker helps patient/ client and families cope with their disability.families cope with their disability.

– The social worker makes arrangements for The social worker makes arrangements for assistance from community agencies.assistance from community agencies.


• ChaplainChaplain– A spiritual counselor who helps patients/ A spiritual counselor who helps patients/

clients and families during crisis periods.clients and families during crisis periods.– Serves as a liaison between the hospital and Serves as a liaison between the hospital and

place of worship. place of worship.


• Peer SupportPeer Support– A person with a similar disability who A person with a similar disability who

provides insight for the patient /clientprovides insight for the patient /client– Provides perspective of what living with a Provides perspective of what living with a

disability is like.disability is like.

Team ApproachTeam Approach

• As health care has evolved, it is more difficult As health care has evolved, it is more difficult to have the whole team meet together at the to have the whole team meet together at the same time.same time.

• The team approach is still needed to optimize The team approach is still needed to optimize recovery from limb loss, perhaps now more recovery from limb loss, perhaps now more than ever.than ever.

IV.IV. Team ApproachTeam Approach

• The “team without walls” demands increased The “team without walls” demands increased effort and attentiveness to work toward the effort and attentiveness to work toward the common goal of maximum recovery and common goal of maximum recovery and rehabilitation.rehabilitation.

• The team should be flexible in that different The team should be flexible in that different people share the leadership and service people share the leadership and service responsibilities of the postoperative periodresponsibilities of the postoperative period

IV.IV. Team ApproachTeam Approach

• Each member of the team has an obligation to Each member of the team has an obligation to educate, empower and allow client and/or educate, empower and allow client and/or advocate to take control and responsibilityadvocate to take control and responsibility

• ““Act like a Team”- No one health care provider Act like a Team”- No one health care provider has all the answers and everyone has specific has all the answers and everyone has specific skills and roles to assist in the pre-operative and skills and roles to assist in the pre-operative and post-operative process.post-operative process.

IV.IV. Team ApproachTeam Approach• Team members should keep an open mind and a Team members should keep an open mind and a

positive, motivating approach to optimize positive, motivating approach to optimize appropriate care.appropriate care.

• All providers have the responsibility to envision All providers have the responsibility to envision the best possible outcome and help assure that the best possible outcome and help assure that medical care, prosthetic fabrication and fitting, medical care, prosthetic fabrication and fitting, training and therapy, navigation of the funding training and therapy, navigation of the funding process and social re-integration occur.process and social re-integration occur.


• Team members should work together, Team members should work together, support or discuss each member’s treatment support or discuss each member’s treatment recommendations and communicate directly recommendations and communicate directly when disagreements exists. Communication when disagreements exists. Communication through the patient should be avoided at all through the patient should be avoided at all costs. costs.

Review of Module IVReview of Module IV

The most important member of the The most important member of the treatment team is: treatment team is:

a.a. PhysicianPhysician

b.b. ProsthetistProsthetist

c.c. Physical TherapistPhysical Therapist

d.d. Case ManagerCase Manager

e.e. Patient/ FamilyPatient/ Family

a.a. PhysicianPhysician

b.b. ProsthetistProsthetist

c.c. Physical TherapistPhysical Therapist

d.d. Case ManagerCase Manager

e.e. Patient/ FamilyPatient/ Family

In the team approach, what should be In the team approach, what should be avoided at all costs? avoided at all costs?

a.a. Team members working togetherTeam members working together

b.b. Communicating with one another Communicating with one another through the patient/clientthrough the patient/client

c.c. Discuss each members treatment Discuss each members treatment recommendationsrecommendations

d.d. Communicating with one anotherCommunicating with one another

a.a. Team members working togetherTeam members working together

b.b. Communicating with one another Communicating with one another through the patient/clientthrough the patient/client

c.c. Discuss each members treatment Discuss each members treatment recommendationsrecommendations

d.d. Communicating with one anotherCommunicating with one another

What is the obligation of each member of What is the obligation of each member of the team? the team?

a.a. Concentrate on his/her own profession and Concentrate on his/her own profession and nothing elsenothing else

b.b. Communicate to other professionals through Communicate to other professionals through the patient/clientthe patient/client

c.c. Communicate only to the familyCommunicate only to the family

d.d. Educate, empower, and allow client and or Educate, empower, and allow client and or advocate to take control and responsibilityadvocate to take control and responsibility

a.a. Concentrate on his/her own profession and Concentrate on his/her own profession and nothing elsenothing else

b.b. Communicate to other professionals through Communicate to other professionals through the patient/clientthe patient/client

c.c. Communicate only to the familyCommunicate only to the family

d.d. Educate, empower, and allow client and or Educate, empower, and allow client and or advocate to take control and responsibilityadvocate to take control and responsibility

V. Time Frame of Surgery and V. Time Frame of Surgery and RecoveryRecovery

V.V. Time Frame of Surgery Time Frame of Surgery and Recoveryand Recovery

• Following amputation (regardless of Following amputation (regardless of etiology) the post-operative recovery period etiology) the post-operative recovery period is typically 12 to 18 months and is typically 12 to 18 months and simply simply cannot be rushed!cannot be rushed!


• Stages of RecoveryStages of Recovery– Pre-Operative StagePre-Operative Stage– Acute Hospital Post-Operative StageAcute Hospital Post-Operative Stage– Immediate Post-Acute Hospital StageImmediate Post-Acute Hospital Stage– Intermediate Recovery StageIntermediate Recovery Stage– Transition to Stable StageTransition to Stable Stage


• Stages of RecoveryStages of Recovery• Pre-Operative StagePre-Operative Stage

– This stage begins with the decision to amputate, the This stage begins with the decision to amputate, the vascular assessment and decisions or attempts to vascular assessment and decisions or attempts to improve circulation. This stage also includes level improve circulation. This stage also includes level selection, pre-operative education, emotional selection, pre-operative education, emotional support, physical therapy and conditioning, support, physical therapy and conditioning, nutritional support, and pain management.nutritional support, and pain management.


• Acute Hospital Post-Operative StageAcute Hospital Post-Operative Stage

– This includes the time in the hospital This includes the time in the hospital following the amputation surgery. This following the amputation surgery. This hospital time is typically 5-14 days.hospital time is typically 5-14 days.


• Immediate Post-Acute Hospital StageImmediate Post-Acute Hospital Stage

– This stage begins at hospital discharge and can extend This stage begins at hospital discharge and can extend up to as much as 8 weeks following surgery. up to as much as 8 weeks following surgery.

– This time allows for recovery from surgery, wound This time allows for recovery from surgery, wound healing, and early rehabilitation. healing, and early rehabilitation.

– Typical end points for this stage include the point of Typical end points for this stage include the point of wound healing and the point of being ready for wound healing and the point of being ready for prosthetic fitting. prosthetic fitting.


• Immediate Post-Acute Hospital StageImmediate Post-Acute Hospital Stage

– However, wound healing is a continuous process, and However, wound healing is a continuous process, and does not have a clear end point of “being healed”. does not have a clear end point of “being healed”.

– Much of the literature attempts to use these two Much of the literature attempts to use these two elusive endpoints when comparing different post-elusive endpoints when comparing different post-operative strategies with varying results.operative strategies with varying results.


• Intermediate Recovery StageIntermediate Recovery Stage

– This is the time of transition from a post-operative This is the time of transition from a post-operative strategy to first formal prosthetic fitting. The most strategy to first formal prosthetic fitting. The most rapid changes in limb volume occur during this rapid changes in limb volume occur during this stage due to the beginning of ambulation and stage due to the beginning of ambulation and prosthetic use. prosthetic use.

– This intermediate recovery stage begins with wound This intermediate recovery stage begins with wound healing and usually extends out 4-6 months from the healing and usually extends out 4-6 months from the healing date. healing date.

• Intermediate Recovery StageIntermediate Recovery Stage

– This stage ends when relative stabilization of limb This stage ends when relative stabilization of limb size occurs, as defined by consistency of prosthetic size occurs, as defined by consistency of prosthetic fit, for several months. fit, for several months.

– The definitive prosthesis should The definitive prosthesis should notnot be fit prior to 6 be fit prior to 6 months of temporary prosthetic use months of temporary prosthetic use andand when the when the stabilization of the limb occursstabilization of the limb occurs



• Transition to Stable StageTransition to Stable Stage

– This stage includes maturation of the limb This stage includes maturation of the limb and less volume change. and less volume change.

– Patient should move toward social re-Patient should move toward social re-integration and higher functional training integration and higher functional training and development as well as becoming more and development as well as becoming more empowered and independent.empowered and independent.

Clinical ConcernsClinical Concerns

• 14 clinical concerns were identified in the 14 clinical concerns were identified in the stages of recoverystages of recovery

• Each concern will take on different levels of Each concern will take on different levels of importance at different stages of the healing importance at different stages of the healing processprocess

• There may be overlap between stages which There may be overlap between stages which may vary with individual differencesmay vary with individual differences


1. Determine amputation level1. Determine amputation level

• Important earliest, in pre-operative stageImportant earliest, in pre-operative stage

• Must include assessment of vascular status Must include assessment of vascular status and circulation to determine leveland circulation to determine level

Clinical ConcernsClinical Concerns2. Minimize systemic complications including2. Minimize systemic complications including

– Myocardial infarction (MI)Myocardial infarction (MI)

– Deep Vein Thrombosis (DVT)Deep Vein Thrombosis (DVT)

– Decubitus, etc.Decubitus, etc.

• Risk must be assessed pre-operativeRisk must be assessed pre-operative

• High level of concern during acute hospital High level of concern during acute hospital post-operative stagepost-operative stage

• Moderate concern during initial healing (post-Moderate concern during initial healing (post-acute hospital stage)acute hospital stage)

Clinical ConcernsClinical Concerns3. Prevent contractures3. Prevent contractures

• Contractures should be addressed and treated Contractures should be addressed and treated pre-operatively, if possiblepre-operatively, if possible

• Highest concern during acute hospital stageHighest concern during acute hospital stage

– Isometric quad sets at day 2Isometric quad sets at day 2

• Continue at high risk during immediate post-Continue at high risk during immediate post-acute stageacute stage

• Reduce to moderate concern for intermediate Reduce to moderate concern for intermediate recoveryrecovery

• Low concern during transition to stableLow concern during transition to stable


4. Bed mobility and transfers4. Bed mobility and transfers

• High concern during acute and immediate High concern during acute and immediate post-acute stagespost-acute stages

• Should reduce in level of concern as prosthesis Should reduce in level of concern as prosthesis use is begunuse is begun


5. Pain management5. Pain management

• High during most of the rehab processHigh during most of the rehab process

• Pain pre-operatively should be addressed. Pain pre-operatively should be addressed. Unresolved pre-op pain may lead to increased risk of Unresolved pre-op pain may lead to increased risk of phantom pain post-operativelyphantom pain post-operatively

• Typically pain reduces as limb heals and prosthesis Typically pain reduces as limb heals and prosthesis use is begunuse is begun

• Concern may shift from acute pain management to Concern may shift from acute pain management to identification and treatment of chronic pain issues in identification and treatment of chronic pain issues in stages 4 and 5stages 4 and 5

Clinical ConcernsClinical Concerns6. Protect amputated limb from trauma6. Protect amputated limb from trauma

• Highest immediately after surgery during acute hospital stayHighest immediately after surgery during acute hospital stay

• Still important during immediate post-acute stage as patient begins Still important during immediate post-acute stage as patient begins to transferto transfer

• Post-operative management strategies that address this concern Post-operative management strategies that address this concern include:include:

– Non-removable rigid dressingsNon-removable rigid dressings

– Removable rigid dressingsRemovable rigid dressings

– Prefabricated IPOPsPrefabricated IPOPs

• Post-operative management strategies that DO NOT address this Post-operative management strategies that DO NOT address this concern include:concern include:

– Soft dressingsSoft dressings


7. Fall prevention7. Fall prevention

• Moderate concern during pre-op phaseModerate concern during pre-op phase

• High concern during acute and immediate High concern during acute and immediate post-acute stage since falls may traumatize post-acute stage since falls may traumatize limblimb

• Moderate concern during intermediate Moderate concern during intermediate recovery as patient learns to walk with first recovery as patient learns to walk with first prosthesisprosthesis

• Lower concern during final transition to Lower concern during final transition to stablestable


8. Emotional care/education8. Emotional care/education

• High level of concern throughout High level of concern throughout rehabilitation processrehabilitation process

• During earlier rehabilitation, concerns will be During earlier rehabilitation, concerns will be immediate, regarding amputation and healing immediate, regarding amputation and healing processprocess

• Later concerns may center around realization Later concerns may center around realization of limitations and work and family issuesof limitations and work and family issues


9. Manage and teach about wound healing9. Manage and teach about wound healing

• The highest concern of the acute hospital The highest concern of the acute hospital stagestage

• As wounds heal, concern will decreaseAs wounds heal, concern will decrease

• However, patient should be informed and However, patient should be informed and educated to inspect residual limb daily and educated to inspect residual limb daily and learn proper care and hygiene of limb as learn proper care and hygiene of limb as prosthesis use is begunprosthesis use is begun


10. Promote residual limb muscle activity10. Promote residual limb muscle activity

• Begins immediately after surgeryBegins immediately after surgery

– In-patient therapy may include passive range of In-patient therapy may include passive range of motion techniquesmotion techniques

• High during post-acute stage and High during post-acute stage and intermediate recovery stageintermediate recovery stage

• Maintain activity during transition to stableMaintain activity during transition to stable


11. Early ambulation11. Early ambulation

• During acute hospital stage, this will be During acute hospital stage, this will be secondary to bed mobility, transfers secondary to bed mobility, transfers and toilet activitiesand toilet activities

• Early ambulation may be with Early ambulation may be with walkers/crutches and no prosthesis walkers/crutches and no prosthesis during immediate post-acute stageduring immediate post-acute stage

• Initial fitting of a prosthesis and early Initial fitting of a prosthesis and early gait training important during gait training important during intermediate recovery stageintermediate recovery stage


12. Advanced ambulation12. Advanced ambulation

• Therapy for advanced Therapy for advanced ambulation techniques may be ambulation techniques may be prescribed during the transition prescribed during the transition to stable stage when a definitive to stable stage when a definitive prosthesis, with potentially prosthesis, with potentially more advanced components, is more advanced components, is fitfit

Clinical ConcernsClinical Concerns13. Control limb volume changes13. Control limb volume changes

• High during immediate post-acute stage as High during immediate post-acute stage as edema and swelling from surgical trauma edema and swelling from surgical trauma reducesreduces

• High during intermediate recovery stageHigh during intermediate recovery stage

– Significant volume changes expected to occurSignificant volume changes expected to occur

– Prosthesis fit and function must be accommodatedProsthesis fit and function must be accommodated

• Still of high during transition to stable stage, Still of high during transition to stable stage, though at slower ratethough at slower rate

– Should stabilize for at least 2-3 weeks prior to Should stabilize for at least 2-3 weeks prior to fitting of definitive devicefitting of definitive device


14. Trunk and body motor control and stability14. Trunk and body motor control and stability

• Balance and stability are important throughout Balance and stability are important throughout rehabilitation processrehabilitation process

• It is an especially high concern as patient It is an especially high concern as patient begins therapy to learn independence in begins therapy to learn independence in transfers transfers

• Continues in importance as patient develops Continues in importance as patient develops strength and balance for initial prosthetic gait strength and balance for initial prosthetic gait trainingtraining

Review of Module VReview of Module V

What is the primary clinical concern during the What is the primary clinical concern during the acute hospital post-operative stage?acute hospital post-operative stage?

a.a. Trunk and body motor controlTrunk and body motor control

b.b. Control limb volume changesControl limb volume changes

c.c. Fall preventionFall prevention

d.d. Manage and teach about wound healing Manage and teach about wound healing

a.a. Trunk and body motor controlTrunk and body motor control

b.b. Control limb volume changesControl limb volume changes

c.c. Fall preventionFall prevention

d.d. Manage and teach about wound healingManage and teach about wound healing

Limb stabilization typically takes at least ___ of Limb stabilization typically takes at least ___ of prosthetic use to achieve prosthetic use to achieve

a.a. 3 months3 months

b.b. 6 months6 months

c.c. 12 months12 months

a.a. 3 months3 months

b.b. 6 months6 months

c.c. 12 months12 months

Physical therapy treatment occursPhysical therapy treatment occurs

a.a. Early in the rehab process and again at Early in the rehab process and again at the endthe end

b.b. Only at the end of the rehab processOnly at the end of the rehab process

c.c. Only at the beginning of the rehab Only at the beginning of the rehab processprocess

d.d. Throughout the rehab processThroughout the rehab process

a.a. Early in the rehab process and again at Early in the rehab process and again at the endthe end

b.b. Only at the end of the rehab processOnly at the end of the rehab process

c.c. Only at the beginning of the rehab Only at the beginning of the rehab processprocess

d.d. Throughout the rehab processThroughout the rehab process

VI. Wound HealingVI. Wound Healing


SKIN ANATOMY

The skin is an ever-changing organ that contains many The skin is an ever-changing organ that contains many specialized cells and structures. specialized cells and structures.

The skin functions as a protective barrier that interfaces The skin functions as a protective barrier that interfaces with a sometimes-hostile environment. It is also very with a sometimes-hostile environment. It is also very involved in maintaining the proper temperature for the involved in maintaining the proper temperature for the body to function well. body to function well.


SKIN ANATOMY

It gathers sensory information from the environment, It gathers sensory information from the environment, and plays an active role in the immune system and plays an active role in the immune system protecting us from disease. protecting us from disease.

Understanding how the skin can function in these many Understanding how the skin can function in these many ways starts with understanding the structure of the 3 ways starts with understanding the structure of the 3 layers of skin - the epidermis, dermis, and subcutaneous layers of skin - the epidermis, dermis, and subcutaneous tissue. tissue.

SKIN ANATOMYSKIN ANATOMY

• EpidermisEpidermis

The epidermis is the most superficial layer of The epidermis is the most superficial layer of the skin and provides the first barrier of the skin and provides the first barrier of protection from the invasion of foreign protection from the invasion of foreign substances into the body.substances into the body.


• DermisDermis

The dermis assumes the important functions of The dermis assumes the important functions of thermoregulation and supports the vascular network to thermoregulation and supports the vascular network to supply the avascular epidermis with nutrients. supply the avascular epidermis with nutrients.

The dermis contains mostly fibroblasts which are The dermis contains mostly fibroblasts which are responsible for secreting collagen, elastin and ground responsible for secreting collagen, elastin and ground substance that give the support and elasticity of the substance that give the support and elasticity of the skin. Also present are immune cells that are involved in skin. Also present are immune cells that are involved in defense against foreign invaders passing through the defense against foreign invaders passing through the epidermis. epidermis.

Wound HealingWound Healing

The healing of a wound to the skin is a fairly typical mixture of regeneration and replacement.

The more regeneration that can occur, the less scaring will be left behind after wound healing.


• Many amputations do not heal in ideal primary Many amputations do not heal in ideal primary fashion.fashion.

• Small areas of the wound may require Small areas of the wound may require secondary healing and possible wound caresecondary healing and possible wound care

• Revision surgery is frequently required in Revision surgery is frequently required in vascular amputations.vascular amputations.


• Wound healing problems are most often Wound healing problems are most often related to:related to:– Type of injuryType of injury– DiseaseDisease– VascularityVascularity– Tobacco useTobacco use– The nature of amputation itselfThe nature of amputation itself


• Skin and wound problems are rarely Skin and wound problems are rarely “caused” by a single factor.“caused” by a single factor.

• In many individuals, wound problems are In many individuals, wound problems are simply not preventable.simply not preventable.


• The healing of an amputated limb should The healing of an amputated limb should be viewed as a continuous processbe viewed as a continuous process

• There is no clear and decisive point of There is no clear and decisive point of “completed healing”.“completed healing”.


• Using the outcome of “time to heal” is not Using the outcome of “time to heal” is not a precise measurement.a precise measurement.

• Documenting healing continues to be Documenting healing continues to be important for patient care and research.important for patient care and research.


• Subjective interpretations associated Subjective interpretations associated with determining healing time include:with determining healing time include:– Completion of epitheliazationCompletion of epitheliazation– Interpretation of small open areasInterpretation of small open areas– Individual biasIndividual bias– Timing of the return to clinic visitsTiming of the return to clinic visits– ““Research savvy” of the rehabilitation teamResearch savvy” of the rehabilitation team


• Future studies need to clearly define how Future studies need to clearly define how the “time to heal” has been determined.the “time to heal” has been determined.

• ““Time to heal” may always be difficult to Time to heal” may always be difficult to standardize and to measure.standardize and to measure.

• It It cannotcannot be determined accurately from a be determined accurately from a simple retrospective review of a clinical simple retrospective review of a clinical chartchart


• It is recommended that wound healing be It is recommended that wound healing be documented as a type of wound healing documented as a type of wound healing for clinical and research purposes.for clinical and research purposes.

• The categories are defined in the The categories are defined in the following slides.following slides.

Categories of Wound HealingCategories of Wound Healing

PrimaryPrimary

-heals without open areas, -heals without open areas, infection or wound infection or wound complicationscomplications


SecondarySecondary

--small open areas that can be small open areas that can be managed, and ultimately heal with managed, and ultimately heal with dressing strategies and wound care. dressing strategies and wound care. Further surgery is not required. Further surgery is not required. This may occasionally be intended This may occasionally be intended with some portion of the with some portion of the amputation left open.amputation left open.


• Requires minor revisionRequires minor revision

– skin and subcutaneous tissue. skin and subcutaneous tissue.

(No muscle or bone involvement)(No muscle or bone involvement)

• Requires major revisionRequires major revision– but heals at initial amputation “level” but heals at initial amputation “level”

(Example: mid-transtibial level revised (Example: mid-transtibial level revised to shorter transtibial level)to shorter transtibial level)


• Requires revision to a higher levelRequires revision to a higher level

– (Example: a transtibial (Example: a transtibial amputation that must be revised to amputation that must be revised to either a knee disarticulation or either a knee disarticulation or transfemoral amputation)transfemoral amputation)


Wounds and Weight BearingWounds and Weight Bearing

• The presence of an open wound or the The presence of an open wound or the presence of sutures does not necessarily presence of sutures does not necessarily preclude weight-bearing. preclude weight-bearing.

• In many circumstances, institution of or In many circumstances, institution of or continuation of activity can be helpful to continuation of activity can be helpful to control edema and facilitate healing. control edema and facilitate healing.

Review of Module VI Review of Module VI

Wound healing problems are related to all of the Wound healing problems are related to all of the following EXCEPT: following EXCEPT:

a.a. Type of injuryType of injury• DiseaseDisease• VascularityVascularity• MusculatureMusculature

a.a. Type of injuryType of injury• DiseaseDisease• VascularityVascularity• MusculatureMusculature

The phrase “Time to heal”The phrase “Time to heal”

a.a. Is easy to measureIs easy to measure

b.b. Can be determine from chart notesCan be determine from chart notes

c.c. Is Is notnot a precise measurement a precise measurement

d.d. Is not useful in researchIs not useful in research

a.a. Is easy to measureIs easy to measure

b.b. Can be determine from chart notesCan be determine from chart notes

c.c. Is Is notnot a precise measurement a precise measurement

d.d. Is not useful in researchIs not useful in research

Continuing activity in the presence of a Continuing activity in the presence of a wound: wound:

a.a. Is often encouraged to facilitate healingIs often encouraged to facilitate healing

b.b. Is Is notnot encouraged during the encouraged during the rehabilitation processrehabilitation process

c.c. Will lead to revisionWill lead to revision

d.d. Will delay healingWill delay healing

a.a. Is often encouraged to facilitate healingIs often encouraged to facilitate healing

b.b. Is Is notnot encouraged during the encouraged during the rehabilitation processrehabilitation process

c.c. Will lead to revisionWill lead to revision

d.d. Will delay healingWill delay healing

VII. Amputation Specific VII. Amputation Specific GoalsGoals

Amputation Specific GoalsAmputation Specific Goals

Amputation Specific GoalsAmputation Specific Goals

• Prevention of Prevention of contracturescontractures

• Reduce post-surgical Reduce post-surgical edemaedema

• Improve bed mobilityImprove bed mobility• Pain managementPain management• Protection of limb from Protection of limb from

traumatrauma• Prevention of fallsPrevention of falls

• Emotional careEmotional care• Promote limb activityPromote limb activity• Establish trunk stabilityEstablish trunk stability• Begin ambulationBegin ambulation• Accommodate limb Accommodate limb

volume changesvolume changes• Achieve distal end Achieve distal end

loadingloading

Prevention of contracturesPrevention of contractures

• Is necessary at both the hip and kneeIs necessary at both the hip and knee

• Active strategies such as bed positioning, Active strategies such as bed positioning, prone activities are well documented prone activities are well documented along with stretching techniques used by along with stretching techniques used by physical therapyphysical therapy

Prevention of contracturesPrevention of contractures

• Several passive strategies such as knee Several passive strategies such as knee immobilizers and rigid dressings attempt to immobilizers and rigid dressings attempt to address the goal of knee flexion contractureaddress the goal of knee flexion contracture

• Literature is unavailable to support any one Literature is unavailable to support any one passive strategypassive strategy

• Passive strategies to prevent hip flexion Passive strategies to prevent hip flexion contractures have yet to be proposedcontractures have yet to be proposed

Reduce post-surgical edemaReduce post-surgical edema

• Use of compressive strategies is Use of compressive strategies is important following any amputation. important following any amputation.

• If soft compressive dressings are used, If soft compressive dressings are used, proper wrapping techniques must be proper wrapping techniques must be taught to the staff, patient and caregivers taught to the staff, patient and caregivers to reduce complications.to reduce complications.

Improve mobilityImprove mobility• Bed mobility, transfers (bed, toilet), and Bed mobility, transfers (bed, toilet), and

activities of daily living (ADL”S) must be activities of daily living (ADL”S) must be taught early in the post-amputation periodtaught early in the post-amputation period

• This encourages independence, strength, and This encourages independence, strength, and reduces the fear of fallingreduces the fear of falling

• Physical and Occupational therapy are Physical and Occupational therapy are essential to this processessential to this process

• The addition of a pylon and foot may make The addition of a pylon and foot may make bed mobility more difficultbed mobility more difficult

Pain managementPain management

• Pain and contractures may be associated Pain and contractures may be associated although no scientific evidence supports although no scientific evidence supports this claimthis claim

• Pain must be controlled throughout in Pain must be controlled throughout in order to facilitate mobility and eventual order to facilitate mobility and eventual prosthetic useprosthetic use

• Careful evaluation will help determine the Careful evaluation will help determine the appropriate treatment modalityappropriate treatment modality

Pain ManagementPain Management• It is important to vary pain management It is important to vary pain management

strategies such as, medicine or manual strategies such as, medicine or manual desensitization based on: time from surgery, type desensitization based on: time from surgery, type of post operative dressing, and the cause of of post operative dressing, and the cause of amputationamputation

• Desensitization is believed to reduce pain in the Desensitization is believed to reduce pain in the residual limb and may help the amputee adjust to residual limb and may help the amputee adjust to their new body image which includes limb losstheir new body image which includes limb loss

• Literature is lacking with any one approachLiterature is lacking with any one approach

Protection of limb from traumaProtection of limb from trauma

• Evidence suggests the use of rigid dressings Evidence suggests the use of rigid dressings (custom or prefabricated) provide better limb (custom or prefabricated) provide better limb protection than soft dressingsprotection than soft dressings

• Examples of limb protection systems can be Examples of limb protection systems can be found in the links below.found in the links below.

Prevention of FallsPrevention of Falls

• Fall prevention is an essential part of Fall prevention is an essential part of rehabilitationrehabilitation

• Complications secondary to falls may Complications secondary to falls may result in increased healing time, further result in increased healing time, further surgical intervention, other injuries, and surgical intervention, other injuries, and increased hospitalizationincreased hospitalization

Prevention of fallsPrevention of falls

• ““Limb loss reminders”, i.e. placing a chair Limb loss reminders”, i.e. placing a chair next to the bed as a reminder to be careful, next to the bed as a reminder to be careful, may reduce falls, but further studies are may reduce falls, but further studies are neededneeded

• Strength and balance training can reduce the Strength and balance training can reduce the number of fallsnumber of falls

Emotional careEmotional care• Treatment must be highly individualized and Treatment must be highly individualized and

does not appear to be related to post-operative does not appear to be related to post-operative limb management strategylimb management strategy

• Documented options include supportive Documented options include supportive encouragement, educational literature, encouragement, educational literature, psychological counseling, peer counseling, psychological counseling, peer counseling, amputee support groups, and chaplainry. amputee support groups, and chaplainry.

Emotional careEmotional care

• The risk of depression in amputees is highThe risk of depression in amputees is high

• When necessary, pharmacological When necessary, pharmacological intervention and/or psychiatric referral intervention and/or psychiatric referral should be consideredshould be considered

Promote limb activityPromote limb activity

• Promotion of residual limb activity (desensitization, Promotion of residual limb activity (desensitization, muscle contraction, and endurance development) is muscle contraction, and endurance development) is an important strategyan important strategy

• It may be instituted at various times based on post It may be instituted at various times based on post operative strategy, surgical procedure, and cause of operative strategy, surgical procedure, and cause of amputation but conventional wisdom says that the amputation but conventional wisdom says that the earlier the intervention the betterearlier the intervention the better


• Exercise to improve gluteus (medius and Exercise to improve gluteus (medius and maximus) and quadriceps strength may maximus) and quadriceps strength may begin as early as day 1begin as early as day 1

• Exercises to promote muscle action Exercises to promote muscle action within the residual limb depend on pain within the residual limb depend on pain tolerance, surgical procedure and healing tolerance, surgical procedure and healing responseresponse


• Muscle contraction within the residual limb Muscle contraction within the residual limb may help with pain control, muscle re-may help with pain control, muscle re-education, improve muscle mass, edema education, improve muscle mass, edema control, and kinesthetic feedbackcontrol, and kinesthetic feedback

• The timing for beginning of muscle activity The timing for beginning of muscle activity within the residual limb needs to be further within the residual limb needs to be further evaluatedevaluated

Establish trunk stabilityEstablish trunk stability

• Trunk stability should be established as early as Trunk stability should be established as early as possible through core strengthening exercisespossible through core strengthening exercises

• Trunk stability will assist with mobility activities, Trunk stability will assist with mobility activities, provide the foundation for prosthetic control, sitting provide the foundation for prosthetic control, sitting posture, and can reduce the stresses to the spine that posture, and can reduce the stresses to the spine that cause low back pain and body motor control and cause low back pain and body motor control and stability problemsstability problems

Establish trunk stabilityEstablish trunk stability

• Trunk stability may improve body Trunk stability may improve body posture and readiness for gait trainingposture and readiness for gait training

• Trunk stability may decrease commonly Trunk stability may decrease commonly seen gait deviationsseen gait deviations

• Improved motor control should decrease Improved motor control should decrease the energy expenditure of walking with a the energy expenditure of walking with a prosthesis prosthesis

AmbulationAmbulation• Ambulation is described as non-pedal (wheelchair Ambulation is described as non-pedal (wheelchair

ambulation), uni-pedal (remaining limb with ambulation), uni-pedal (remaining limb with assistive device) or bi-pedal (using a prosthetic assistive device) or bi-pedal (using a prosthetic pylon) with or without assistive devicepylon) with or without assistive device

• Improvements in strength, mobility, balance, and Improvements in strength, mobility, balance, and endurance have been shown to decrease the endurance have been shown to decrease the potential for co-morbidities (Pulmonary embolism, potential for co-morbidities (Pulmonary embolism, myocardial infarction etc.)myocardial infarction etc.)

Accommodate limb volume Accommodate limb volume changeschanges

• Critical to comfortable prosthetic useCritical to comfortable prosthetic use

• During this stage the limb volume is During this stage the limb volume is fluctuating wildly and may be difficult to fluctuating wildly and may be difficult to managemanage

• Control of limb volume changes during Control of limb volume changes during this stage is a function of the preparatory this stage is a function of the preparatory prosthesisprosthesis

Accommodate limb volume Accommodate limb volume changeschanges

• Strategies for limb volume control Strategies for limb volume control include the use of liners, socks, pads, include the use of liners, socks, pads, adjustable sockets, temporary sockets or adjustable sockets, temporary sockets or ambulatory check socketsambulatory check sockets

• When the patient is not wearing a When the patient is not wearing a prosthesis, wrapping and/or compression prosthesis, wrapping and/or compression are critical to help control limb volume are critical to help control limb volume changeschanges

Achieve distal end loadingAchieve distal end loading• Distal end loading, desensitization, and residual Distal end loading, desensitization, and residual

limb weight bearing may assist with pain limb weight bearing may assist with pain control, tolerance of a prosthesis, and reduction control, tolerance of a prosthesis, and reduction of adhesionsof adhesions

• This may begin with towel pulling on the distal This may begin with towel pulling on the distal end of the residual limb or using a rigid design end of the residual limb or using a rigid design and allow for pressure over the entire limband allow for pressure over the entire limb

Review of Module VIIReview of Module VII

If soft compression dressings are used, If soft compression dressings are used, proper wrapping techniques should be taught proper wrapping techniques should be taught to which of the following to which of the following

a.a. Patient/clientPatient/client

b.b. CaregiverCaregiver

c.c. StaffStaff

d.d. All of the aboveAll of the above

a.a. Patient/clientPatient/client

b.b. CaregiverCaregiver

c.c. StaffStaff

d.d. All of the aboveAll of the above

Which of the following does not protect the Which of the following does not protect the limb from trauma limb from trauma

a.a. RRDRRD

b.b. Ace (Elastic) wrapAce (Elastic) wrap

c.c. Flo-tectorFlo-tector

d.d. PAL guardPAL guard

a.a. RRDRRD

b.b. Ace (Elastic) wrapAce (Elastic) wrap

c.c. Flo-tectorFlo-tector

d.d. PAL guardPAL guard

Strategies for limb volume control include Strategies for limb volume control include all of the following except all of the following except

a.a. Socks Socks

b.b. Liners or padsLiners or pads

c.c. Adjustable socketsAdjustable sockets

d.d. Nylon sheathNylon sheath

a.a. Socks Socks

b.b. Liners or padsLiners or pads

c.c. Adjustable socketsAdjustable sockets

d.d. Nylon sheathNylon sheath

VIII. The Whole PersonVIII. The Whole Person

• GoalsGoals– The consensus conference identified six The consensus conference identified six

“whole person” goals of care for anyone “whole person” goals of care for anyone undergoing lower limb amputation.undergoing lower limb amputation.

– These goals are not directly related to the These goals are not directly related to the surgical amputation but are intended to surgical amputation but are intended to prevent co-morbidity and to improve overall prevent co-morbidity and to improve overall health and mobility. health and mobility.

The Whole PersonThe Whole Person

Six GoalsSix Goals

• Musculo-skeletal reconditioning and Musculo-skeletal reconditioning and cardiovascular trainingcardiovascular training

• Contralateral lower limb preservationContralateral lower limb preservation• Emotional care, peer support and educationEmotional care, peer support and education• Minimize systemic complicationsMinimize systemic complications• Social reintegrationSocial reintegration• Setting realistic expectations and functional Setting realistic expectations and functional

outcome goalsoutcome goals

The consensus conference stated that while all The consensus conference stated that while all goals are important, focus should be attempted goals are important, focus should be attempted to address to address emotional careemotional care, , social reintegrationsocial reintegration, , and and setting realistic functional goalssetting realistic functional goals..

Review of Module VIIIReview of Module VIII

All of the following would beAll of the following would beconsidered “whole person” goals in theconsidered “whole person” goals in therehabilitation of the patient EXCEPT:rehabilitation of the patient EXCEPT:

A.A. Social reintegrationSocial reintegration

B.B. Emotional careEmotional care

C.C. Cardiovascular trainingCardiovascular training

D.D. Marriage counselingMarriage counseling

A.A. Social reintegrationSocial reintegration

B.B. Emotional careEmotional care

C.C. Cardiovascular trainingCardiovascular training

D.D. Marriage counselingMarriage counseling

Whole person rehabilitation goals are Whole person rehabilitation goals are intended to:intended to:

A.A. Provide reimbursementProvide reimbursement

B.B. Prevent mobilityPrevent mobility

C.C. Preserve resourcesPreserve resources

D.D. Prevent co-morbiditiesPrevent co-morbidities

A.A. Provide reimbursementProvide reimbursement

B.B. Prevent mobilityPrevent mobility

C.C. Preserve resourcesPreserve resources

D.D. Prevent co-morbiditiesPrevent co-morbidities

The consensus conference identified three The consensus conference identified three “whole person” goals as critical in the rehabilitation of “whole person” goals as critical in the rehabilitation of the patient with an amputation. These three are:the patient with an amputation. These three are:

A.A. Social reintegration, emotional care and Social reintegration, emotional care and musculoskeletal developmentmusculoskeletal development

B.B. Social reintegration, emotional care and Social reintegration, emotional care and minimize complicationsminimize complications

C.C. Social reintegration, emotional care and Social reintegration, emotional care and setting realistic goalssetting realistic goals

D.D. Social reintegration, emotional care and Social reintegration, emotional care and care of contralateral limbcare of contralateral limb

A.A. Social reintegration, emotional care and Social reintegration, emotional care and musculoskeletal developmentmusculoskeletal development

B.B. Social reintegration, emotional care and Social reintegration, emotional care and minimize complicationsminimize complications

C.C. Social reintegration, emotional care and Social reintegration, emotional care and setting realistic goalssetting realistic goals

D.D. Social reintegration, emotional care and Social reintegration, emotional care and care of contralateral limbcare of contralateral limb

IX. Education and IX. Education and EmpowermentEmpowerment

Education & EmpowermentEducation & Empowerment• Improve understanding of the surgical treatmentImprove understanding of the surgical treatment

• Improve understanding of the recovery time frameImprove understanding of the recovery time frame

• Improve understanding of emotional adaptationsImprove understanding of emotional adaptations

• Improve understanding of prosthetic plan and Improve understanding of prosthetic plan and treatmenttreatment

• Peer support and consumer groupsPeer support and consumer groups

• Assist in navigation through marketing, hype and Assist in navigation through marketing, hype and realitiesrealities

There is nothing that man fears There is nothing that man fears more than the touch of the more than the touch of the

unknownunknown

Elias Canetti (b. 1905)Elias Canetti (b. 1905)The Columbia World of Quotations. 1996The Columbia World of Quotations. 1996

Communication is KeyCommunication is Key

• The patient should be encouraged to ask The patient should be encouraged to ask questions and research on his/her ownquestions and research on his/her own

• The amputee should learn to be an informed The amputee should learn to be an informed consumer of marketing materialconsumer of marketing material

• Education should begin as soon as possibleEducation should begin as soon as possible

Surgical Treatment and RecoverySurgical Treatment and Recovery

• Communication with surgeonCommunication with surgeon

– May allow opportunity for pre-surgical May allow opportunity for pre-surgical consultconsult

– Surprise factor for patient can be reduceSurprise factor for patient can be reduce– Vital when using post-operative prosthetic Vital when using post-operative prosthetic

systems systems

Surgical TreatmentSurgical Treatment

• Medical team should explain:Medical team should explain:– Types of anesthesiaTypes of anesthesia– Surgical techniquesSurgical techniques– Possibility of phantom limb sensation/painPossibility of phantom limb sensation/pain– Pain controlPain control– Possible complicationsPossible complications

Important issues that Patient Important issues that Patient and Family should understandand Family should understand

• Time frame of recoveryTime frame of recovery

– Including all aspects of postoperative processIncluding all aspects of postoperative process

– Must have realistic time frames to help avoid Must have realistic time frames to help avoid unrealistic goalsunrealistic goals

– Usual expectation of 12 to 18 monthsUsual expectation of 12 to 18 months

• Emotional adaptationEmotional adaptation

– Will be different for each individualWill be different for each individual

Important issues that Patient and Important issues that Patient and Family should understandFamily should understand

• Prosthetic planProsthetic plan– Role of the prosthetistRole of the prosthetist– What a prosthesis isWhat a prosthesis is– How it is fundedHow it is funded– Expectations to have of a prosthesis:Expectations to have of a prosthesis:

• e.g. not the curee.g. not the cure• Other adaptive equipment for mobility that may Other adaptive equipment for mobility that may

be neededbe needed• Fitting and adjustments required, especially Fitting and adjustments required, especially

early in rehab processearly in rehab process

Important issues that Patient Important issues that Patient and Family should understandand Family should understand

• Peer Support and Consumer groupsPeer Support and Consumer groups– Including educational materialsIncluding educational materials– Peer visitationPeer visitation– National support networksNational support networks

• MarketingMarketing– Hype vs. realityHype vs. reality– Help to become an educated consumerHelp to become an educated consumer

Available Educational ResourcesAvailable Educational Resources

• Brochures and PamphletsBrochures and Pamphlets

• InternetInternet

• Local Support GroupsLocal Support Groups

• National Support GroupsNational Support Groups

Examples of Available BrochuresExamples of Available Brochures

• A Manual for Below-Knee (Trans-Tibial) Amputees• A Manual for Above-Knee (Trans-Femoral) Amputees,

A. L. Muilenburg & A. B. Wilson, Jr. (1996)

• Patient Care Booklet for Below-Knee Amputees, Jack Uellendahl (1998)

• Below- Knee Amputation: A Guide for Rehabilitation• Above- Knee Amputation: A Guide for Rehabilitation,

T.Kuiken, M.Edwards, & N. Miceli (2002)

Many of these, and more, are also available through the ACA and the Academy. Click here for a links to more items

InternetInternet

• Manufacturers websitesManufacturers websites– Be willing to discuss options that your Be willing to discuss options that your

patient/client may see on the internetpatient/client may see on the internet– Understand the pros and cons of each device Understand the pros and cons of each device

and how to explain them to a consumerand how to explain them to a consumer

• OandP.comOandP.com

Support GroupsSupport Groups

• Find out if there are support groups in Find out if there are support groups in the areathe area

• National Support Groups, including the National Support Groups, including the Amputee Coalition of American, can also Amputee Coalition of American, can also be an excellent referencebe an excellent reference

Recreational ActivitiesRecreational Activities

• Recreational activities/groups can also be a Recreational activities/groups can also be a support system support system

• Not just for Paralympic level individualsNot just for Paralympic level individuals

• Special organizations exist for:Special organizations exist for:– Golf Golf

– CyclingCycling

– ScubaScuba

Review of Module IXReview of Module IX

A new, active male transtibial amputee, 35-years-old and A new, active male transtibial amputee, 35-years-old and 350#, arrives in your office with an advertisement for a 350#, arrives in your office with an advertisement for a Dycor foot that says how flexible, light-weight and Dycor foot that says how flexible, light-weight and comfortable it is. comfortable it is. You should…?You should…?

a.a. Order the foot, since that is what they wantOrder the foot, since that is what they want

b.b. Explain that this foot is for geriatric patientsExplain that this foot is for geriatric patients

c.c. Explain that this foot is not designed for the Explain that this foot is not designed for the individual’s weight and activity levelindividual’s weight and activity level

a.a. Order the foot, since that is what they wantOrder the foot, since that is what they want

b.b. Explain that this foot is for geriatric patientsExplain that this foot is for geriatric patients

c.c. Explain that this foot is not designed for the Explain that this foot is not designed for the individual’s weight and activity levelindividual’s weight and activity level

A new amputee expresses concern to you that they are the only A new amputee expresses concern to you that they are the only person they know with an amputation, they are never going to person they know with an amputation, they are never going to return to an active lifestyle and they don’t know how to handle it. return to an active lifestyle and they don’t know how to handle it. What are three things you could do? What are three things you could do?

a.a. Offer to introduce them to another amputee Offer to introduce them to another amputee for peer counselingfor peer counseling

b.b. Express your concerns to the referring Express your concerns to the referring primary physician so that psychological primary physician so that psychological counseling can be prescribed if indicatedcounseling can be prescribed if indicated

c.c. Give them reading materials that you have Give them reading materials that you have and let them know about the ACAand let them know about the ACA

List at least five things that may affect List at least five things that may affect emotional adaptation to an amputation emotional adaptation to an amputation

a.a. CultureCulture

b.b. Family historyFamily history

c.c. Religious preferenceReligious preference

d.d. AgeAge

e.e. EducationEducation

f.f. Social supportSocial support

g.g. Financial backgroundFinancial background

X. Case StudiesX. Case Studies

Case Study 1Case Study 1

• 65 y/o male, BKA 2° PVD65 y/o male, BKA 2° PVD

• Prosthetist applied custom thigh-high plaster rigid Prosthetist applied custom thigh-high plaster rigid dressing immediately post-surgerydressing immediately post-surgery

• Soon after awaking, pt c/o pain 10/10Soon after awaking, pt c/o pain 10/10

• Pt instructed pain was normal and pain medication was Pt instructed pain was normal and pain medication was increased. Pain still present during course of increased. Pain still present during course of treatment.treatment.

• Rigid dressing removed after 8 daysRigid dressing removed after 8 days

• Result: Dressing removed, infection present. Limb Result: Dressing removed, infection present. Limb revision to AKA required.revision to AKA required.

What about this case would be a What about this case would be a concernconcern

• How long the rigid dressing was left onHow long the rigid dressing was left on

• The patient’s pain concerns were dismissedThe patient’s pain concerns were dismissed

• Protocol for application of rigid dressing may not Protocol for application of rigid dressing may not have been followed (tightness of wrap, padding, have been followed (tightness of wrap, padding, drainage, etc)drainage, etc)

• Non-removable dressing did not allow inspection Non-removable dressing did not allow inspection of wound, and dressing not removed when chance of wound, and dressing not removed when chance of infection was presentedof infection was presented

What should have been done?What should have been done?

• Pain management should have been addressedPain management should have been addressed• Rigid dressing should have been removed when Rigid dressing should have been removed when

pain did not abate.pain did not abate.• Communication with patient should have been Communication with patient should have been

better.better.

Case Study 2Case Study 2

• 25y/o male, BKA 2° traumatic motorcycle accident.25y/o male, BKA 2° traumatic motorcycle accident.

• Pt also suffered mild head injury during injury.Pt also suffered mild head injury during injury.

• Pt fit with soft dressing and compression sock.Pt fit with soft dressing and compression sock.

• 2 days post-surgery, while alone in the room, pt is 2 days post-surgery, while alone in the room, pt is determined to use toilet independently. determined to use toilet independently.

• Pt falls, breaks open sutures, and requires minor soft Pt falls, breaks open sutures, and requires minor soft tissue revision to re-close wound.tissue revision to re-close wound.

• Which post-operative strategy was used?Which post-operative strategy was used?

• Failure to evaluate fully cognitive ability of Failure to evaluate fully cognitive ability of patient.patient.

• Did practitioner educate patient/family/care-Did practitioner educate patient/family/care-givers of procedures.givers of procedures.

What about this case would be a What about this case would be a concernconcern

What should have been done?What should have been done?

• A post-operative strategy which provided A post-operative strategy which provided limb protection.limb protection.

• Complete evaluation of patient’s head Complete evaluation of patient’s head injury and cognitive level.injury and cognitive level.

ReferencesReferences

• M. Bergner, R.A. Bobbit, W.B. Carter and S.B. Gilson , The sickness impact profile: development and final revision of a health state measurement. Med. Care 46 (1981), pp. 787–805.

• J.E. Ware and C.D. Sherbourne , A 36-item short-form health survey (SF-36): conceptual framework and item selection. Med. Care 30 (1992), pp. 473–483.

• The Amputee Mobility Predictor: An instrument to assess determinants of the lower-limb amputee''s ability to ambulate. Archives of Physical Medicine and Rehabilitation, Volume 83, Issue 5, Pages 613 - 627 R. Gailey.

• Martin, D. P.; Engelberg, R.; Agel, J.; Snapp, D.; and Swiontkowski, M. F.: Development of a musculoskeletal extremity health status instrument: the Musculoskeletal Function Assessment Instrument. J. Orthop. Res., 14: 173-181, 1996http://www.oandp.com/resources/patientinfo/manuals/5.htm

ExaminationExamination

• Please go to the course examination Please go to the course examination section.section.

• After completing the examination, please After completing the examination, please complete the course evaluation.complete the course evaluation.

post-operative management of lower limb amputations

Documents

literature review slide

postoperative strategies

etiology of amputation

effectiveness of strategies

review of module

journal article

required reading

critical review conclusion