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Amputees (Healthcare team (Nurse, Doctor, Occupational therapist,…
Amputees
Healthcare team
Nurse
Doctor
Occupational therapist
Podiatrist/bootmaker
Psychologist
Diabetic Educator
Physiotherapist
Prosthetist
Social worker
Levels of lower limb amputations
5% Bilateral transtibial
3% unilateral trans-femoral or knee disarticulation with unilateral transtibial amputation
63% unilateral trans-tibial
2% bilateral transfemoral
27% Unilateral transfemoral amputation or knee disarticulation
Causes of Lower limb amputation
Vascular Am
putee
s 80%
Diabetes
Smoking
Artirtis
Venous insufficiency
Chronic Infection 5-10%
Often coincides with diabetes or trauma
Traumatic amputee 5-10%
Road Trauma
Sporting injury
Work related injury
Malignancy 2-5%
Primary Tumor
Secondary Malignant melanoma
Congenital Limb Deficiency 1-2%
Rural Pathways
Most amputees will complete rehab in metro or regional center and return home with interim prosthesis
If a patient returns to district with an amputation and has not undergone rehab - refer to metro or regional hospital for urgent clinic review
If established amputee with interim and needs definitive - refer to nearest amputee clinic
If the patient is an amputee with a definitive prosthesis issue - refer to prosthetic provider in first instance, and provider can determine further need for referral
Rehabilitation
Stump Care
wound healing and preparation for prosthesis: stump shape, odemea control, skin and scar care, protection
Stump shape: Very important for long term prosthesis fit. Influenced by: surgical approaches, scar and oedema
Types of stump shapes: Bulbous, dog eared, cylindrical, conical - most ideal for prosthetic fit
Oedema Control: Elevation -WC stump support, avoid dependence of stump. Stump protection - RRD. Stump pressure support/shaping: stump shrinkers, bandaging, gel liners
Protections RRD: High % of patients fall in first few weeks due to effects of pain, medication and impaired body schema. Rigid removable dressing (RRD) - ideally applied in theater, manufactured differently depending on institution.
RRD: Prevents build up of post op oedema, protect stump from trauma, provide closed environment for healing, minimize dressing changes, minimize movement at wound edges, protect from exposure of infections, reduces pain via support, prevent knee flexion contracture.
Oedema Control: Stump shrinkers: Reduce oedema, stable constant volume, shape. Applied once sutures/ staples are removed. Graduated increase in time worn (20min-> 24hr)
Stump bandaging: goal is firm graduated pressure. Risk: shear pressure on skin, decreased circulation, potential for wound breakdown. Apply with caution
Gel Liner: Goal is firm graduated pressure, very useful in selected populations. Risk: skin maceration, allergic reaction, inadequate volume control.
Compression precaution and contraindications: Severe stump/wound pain. Necrotic or infected wound. Very oozy wound. Severely compromised circulation
Emotional Supports
Grief and loss, honest and realistic, support groups, social worker or psych, ongoing goal setting, patient centered care.
Functional activities
Bed mobility. sitting Balance. TFs: Seated - slide boards, stand pivot, bed <-> WC, walking aids, car TFs, Floor TFs. Standing Balance: Altered centre of gravity, high falls risk
Non-prosthetic options - crutches, hopper, rollator, WC, nil aids.
Hopping considerations: some methods unsafe, risk falls, dependent on oedema, claudication of remaining limb, high energy consumption, upper limb oveuse injuries.
Pre-Prosthetic training
Cardiovascular fitness: High energy consumption
Strength: Weight bearing/balance, core musculature, increased reliance of UL
Maintain/increase ROM: specify hip flexors and hamstrings
Specific strengthening of stump control: resistance training - closed>open chain. Hip extension and abd/adductors, knee extensors.
Amputation Levels
Upper Extremity
Shoulder Disarticulation
Elbow Disarticualtion
Wrist Disarticulation
Transhumeral
Transradial
Lower Extremity
Hip Disarticualtion
Through knee
Transfemoral
Transtibial
Foot
Symes
Chopart
LisFranc
Transmetatarsal
Pathways
Amputation
Acute management on surg ward
Home or residential care
Day Rehab service and amputee clinic
Rehab unit
Pre-op managment
Decision to operate
Drive by necessary - Life saving - extent of disease, PVD/Cancer, trauma
Elective (Seeking functional improvement) - Post trauma/ surgical, congenital, body dysmorphic disorder
Physiotherapy Role
Assessment
Conducted as pre-amputation consult with MDT
Establish baseline of general health, strength, ROM and function
Management/treatment plan to maintain/increase
Mobility, ROM, strength, Balance, Cardio fitness
Consider DC accomodation and eequipment required
TF practice/ functional ADLs,
Introduce WC, alternate method of mobility
Family carer interactions
Psychological impacts
Referals to other members of MDT
Acute Care
Assessment
History of presenting condition - Why, When, finalised?, Post OP considerations
PMHx - Diabeties, incontinence, atherosclerosis, concurrent infection, respiratory diseases, psychiatric conditions, visual impairment, balance impairment, skin issues, peripheral neuropathy, kidney disease, heat disease, stroke, dementia
SHx: Level of family support, function prior, home environment, occupation and leisure activities
Emotional/psychological state: Reasction to amputation, insight and expectations/ goals and reality, general cognitive function, learning capactiy
Physical status: joint ROM/ muscle length ?contracture, muscle strength, mobility, balance, upper limb dexterity/function
Remaining limb: skin condition, sensation, circulation, wounds, toenails, foot shape prior, footwear
Amputated limb: Length/shape/drains/dressings, stump condition - skin/scars/others, wound healing,oedema, pain, phantom sensation/pain, sensation and sensitivity
Treatment
Usual post surgucal acute care - Chest care, early mobilisation - with caution to walking and standing.
Dont always assume patient is prosthetic candidate
Amputation stump care: oedema control, promote wound healing, stump protection, pain managment
Education, joint ROM, strength, mobility progression, DC planning, post DC followup