Amputation (Amputation (Balance and strength (Balance is an important…
Aetiology plays a role in the amount of energy expended in amputee. (Younger amputees are likely to experience traumatic injury. Likely to perform better than dyvascular patients due to fitness
Energy expenditure requirements increase dependent on level of amputation
Bilat amputees have highest energy requirements
Preservation on knee means near normal lifestyle with limited limitations
Hip disatriculation amputation produces a residual limb with an excellent weight bearing characteristic. Lack of femoral shift - poor mediolateral trunk stability and noted gait deviations
Hemipelectomy amputee also lost WB surface of ishial tuberosity. Can be uncomfortable. Common to reject prosthesis due to weight and energy expenditure
Stump condition and contracture
Before prosthesis can be fit, stump must be fully healed
Decreased time can mean reduced deconditioning for patient and improved cardio towards prosthetic rehab
Knee flexion contractures make it hard to fit and align trans-tibial prostheses, as does hip flexion and abduction for trans-femoral amputee
Longer length stumps are generally better for mechanical advantage when operating prosthesis
Cognition should be weighed as a heavy impacting factor on prosthetic candidacy
Patients need to have the ability to monitor limb condition, don/doff prosthesis, allow volume changes, skin condition and ability for new learning
Social support may be necessary to use prosthesis
Memory as independent predictor of successful learning to don/doff is a 70% current predictor f cases
Increased mass comes per-disposed cardiovasucalr issues and orthopedic issues
All prosthetic have a safe working load limit
Bariatric = increased cost
Prosthetic options rely on stabilising the tissue of the residuum to improve fit. More difficult to do with overweight patients
Amputees will reduce their walking velocity to make O2 rate close to normal
Decreased fitness requires higher portion of aerobic capacity
Recognition that the patient has the autonomy to decline the prosthesis
Influence of the family memebers
Patients choice to not use is mediated by: Can be productive in terms of support for the patient and advocacy, can put undue pressure on the patient to achieve/persist with prosthetic, most prominent influence is a child amputee
Clinicians management of the patients expectations
Patients knowledge of their anticipated outcome is essential to maximize involvement in decision making process.
Patients will common have unrealistially high expectations about what prosthesis can do for them
Celebrity amputees give false expectation due to hype
Patient directed goals
Consider functional participatory goals and how you will achieve these as they impove
If personal expectation exists for a prosthesis this should be explored
Balance and strength
Balance is an important aspect of prosthetic consideration - loss of ankle strategy, hip or knee post amputation
During prosthetic gait there is long stance phase requiring increased balance
If patients can stand unsupported (or one hand on a desk) prior to being fitted for a prosthesis they're more likely to be more successful.
Impacts significantly on ability to don/doff indep.
Strength of residuum is important due to altered biomechanics
Lost soleus, gastrocs functional capacity to assist in controlling stance and lost push off and ankle full ROMs
Results in increased power generation from quads, hips extensors and abductors to control swing and stance phase
Poor strength in a transfemoral amputee is liekly to limit ability to control prosthesis
Environment and personal factors
Suggestions older age rehab will be unlikely, studies suggest should not be excluded due to age
Most recent literature suggest not a factor - rather decisions for candidacy
PHx Concerns: Hearing loss, Poor cardio, reduced balance, fragile skin
Psychiatric conditions: Schizophrenia, Affective disorders, anxiety, personality disorders
Medications side effects: Extrapyramidal side effects, drowsiness
Balance: Donning and Doffing , successful mobility
Eyesight problems: Donning an doffing, monitoring of skin, Feedback mechanism for mobility in place of limb proprioception and sensation
Skin condition: Cannot wear a prosthesis if wound on residuum, affects the prosthesis will be made from socket choice, consider the intact limb "at risk"
Wounds Healing: Longer time from amputation to prosthetic fitting, longer time for rehabilitation process, higher risk of infections
Peripheral Neuropathy: Affecting ULs - need good hand function and dexterity to don/doff a prosthesis, affecting sensation in the residuum (decreased awareness to pressure and increase risk of wound, affecting sensation, motor function and structural integrity in the remaining limb.
Fluid Fluctuations: Affects the volume of the residuum - affects fitting prosthesis
Incontinence: Especially of concern of knee disarticulation amputation, maintenance of hygiene in socket, donning and doffing prosthesis toileting, skin integrity around groin and ischial tuberosities.
Stroke: Weakness of residuum limb, decreased cognition
Infection: Slow healing - increase pre prosthetic and during prosthetic training, increased deconditioning, increased metabolic demands, delirium associated cognitive issues.
Mental Health concerns: Side effects from drugs affect balance, BP, and mobility. Decreased motivation/confidence/willingness to participate. Could of been cause of amputation in first place.
Coping with Psychological adjustment
Amputees may experience anxiety, anger, depression, shock, denial, ambivalence, hopelessness, helplessness, numbeness and disconnection
Decreased ability to concentrate and decreased motivation to perform prosthetic rehabilitation
Patients who are given prosthesis in time of grief are less likely to be successful
Willingness to Persevere
Heavily linked to motivation and ability to cope with amputation
If patient does not have the willingness to persevere with the training they are not an ideal prosthetic candidate
Some patients prosthetic rehab can take months to years- may have to attend outpatient rehab 5x/week
Interim Prosthesis (initial ~12-18 months: Funded by QLD GOV, Usually public service provision
Definitive prosthesis (>12-18 months): Usually private, funded by QLD Artificial Limb Service or NDIS - if meets requirements.
Exceptions usually provided be private sector: Compensable clients will get limbs funded through insurance, DVA funded through DVA, WorkCover funding.
Does the prosthetic fit?
Is the alignment correct
What are the components of this limb, how do they function?
What are the patient risks?
Minimize skin damage - moisturiser, massage, oedema control, maintain socket fit, liners and socks, optimal alignment, cease wear in the presence of skin breakdown
When donning and doffing - patient must self check, understand prosthesis mechanics, learn to don/doff correctly, understand what is a good fit, ensure suspension is adequate, maintain hygiene
Gait as normal as possible
Security, parallel bars, SPS
Swing speed and momentum
Muscle actions of operated limb
WB, weight shift, stepping and balance
Stairs, slopes, obstacles
High level balance,agility/running, grass, carpet and rough surfaces
Sport, dance, workout, in a crowd
Dynamic core exercises.
6 Minute WT
4 Minute WT
4 Spquare step test
New pressures to adjust to
Is this more pressure than expected?
Is it excessive?
Is it a fit, alingment or patient related actions?
Understand the impact of adding to or removing from the socket/liner in terms of socks.packing/padding
Activities and participation
Pre-Hab level of Mobility
Pre-amputation mobility status is high predictor of walking ability post amputation
Dependency for self-care prior to amputation is an independent negative predictor of walking ability up to 18 years post surg.
For patients who were bed bound or at wheelchair level prior to their amputation a prosthesis is unlikely to add benefit for mobility goals or TFs
Transfemoral/transtibial amputee who had poor mobility prior to hospital admission - being safe to TF and self propel a WC might be more effective than the use of a prosthesis
Amputee Mobility Predictor - Assessment tool - AMPAT or AMPRO
Administered by PT
Can be done with or without prosthesis
Impact and shock
Muscle force transfer
Remaining joint function
Patella tendon bearing, total surface bearing.
Hard socket, socks, Petite liners (accomodates unusual stump shapes, allows loading/unloading of areas. Gel liner.
Thigh lacer, supracondylar, sleeve with active valve, pin lock, strap
Suction - hard socket, total elastic suspension, silicone suction, pelvic band
Quadrilateral socket - provides weight bearing ischial seat. Disadvantage - Ischium sitting on the back shelf move out to the side resulting in WBOS
Ischial Containment - Allows more natural muscle function and femoral adduction angle. Disadvantage - Uncomfortable in the perineum
Locked knee, constant friction system, polycentric knees, fluid control mechanism, microprocessor controlled
Rigid Ankle Feet - offer increased stability but not terrain adaptability or energy return
Mobile Axis Feet - Adaptive to uneven terrain, less stable, require more frequent maintenance
Energy Storage and return - Made predominantly of carbon, foot flexes with weight bearing and springs back a toe off, adaptive to different terrain
Microprocessor feet - Automatically adapts to terrain, slopes and speed.
Patient centered care
New amputees shrink very quickly
Other facotrs such as weight loss, weather, dialysis and lymphodema can impact volume
A firm socket fit must be maintained
New method of direct attachment of external prosthesis to the skeleton via internal titanium for UL and LL amputees
Disadvantages - Not primary treatment, cost>$150000 (not covered by healthcare, 2 stage op, stoma.
Advantages - no socket, improved proprioception, freedom of mobility, easy attachment and fit
Transtibial Gait deviations