Examination

1
Examination Treatment of the Lower Extremity
Amputee

• Pre-prosthetic PT Intervention
• 4-03-07

2
Reading Focus for Class Discussion

• OSullivan
• pp. 620, 622-639
• Blackboard-foot care/prevention
• We will use Guide to PT practice for this
  unit

3
Introduction

• Labs for Unit 4, grading rubric for discharge
  note, home exercise program will be posted on
  Blackboard this week
• Visit to Hanger will be scheduled for late April,
  in the evening and attendance is required (in
  lieu of Thursday/Friday lab)

4
Learning Objectives

• Identify and apply major factors leading to lower
  extremity amputation
• Describe and apply the levels of lower extremity
  amputation and the functional impact
• Discuss and apply PT early post-operative
  examination, goals treatment of the LE amputee.
• When presented with a clinical case study,
  analyze interpret patient data determine
  realistic goals/outcomes and develop a plan of
  care

5
Case Scenario

• Its Tuesday morning, and you receive a PT order
  to evaluate and treat the following patient
• Mr. John Howard, 70 year old man who underwent a
  left lower extremity amputation Saturday afternoon

6
NAGI Disablement Model
7
What is the cause/reason for Mr. Howards
amputation?

• History of diabetes with peripheral vascular
  disease (PVD) and chronic non-healing foot ulcers
• Very mild peripheral neuropathy

8
What are the major causes for lower extremity
amputation?

• PVDperipheral vascular disease
  (arteriosclerosis)
• Associated with smoking diabetes (6-25 of pts.
  With PVD DM will need amputation)
• Pt. with DM who undergoes one amputation 2 to PVD
  has 51 chance of 2nd operation within 10 yrs.2
• Trauma
• MVA, gunshot
• Cancer
• Congenital2

9
Causes of Amputation by Percent
Lusardi MM Nielsen CC. Orthotics and
Prosthetics in Rehabilitation. Woburn, MA
Butterworth-Heinemann 2000, p. 328.
10
Risk factors for PVD?

• Diabetes
• Poorly managed HTN
• High cholesterol/triglycerides
• Smoker
• same as risk factors for cardiovascular and
  cerebrovascular disease
• PVD and peripheral neuropathy (numb, cold,
  paresthesia, pain) are the major predisposing
  factors for LE amputation in individuals with DM2

Lusardi MM Nielsen CC. Orthotics and
Prosthetics in Rehabilitation. Woburn, MA
Butterworth-Heinemann 2000, p. 330.
11
What are Signs/Symptoms of Vascular Insufficiency?

• Intermittent claudication
• What is this?
• Significant cramping pain, usually in the calf,
  that is induced by walking or other prolonged
  muscle contraction and relieved by a short period
  of rest
• Vascular pain (increase with LE elevation)
• Loss of one or more lower extremity pulses
• Arteriosclerosis obliteransat least one major
  arterial pulse (dorsal pedis artery at ankle,
  popliteal artery at knee or femoral artery in the
  groin) absent or impaired2

12
Clinical signs of PVD
Lusardi MM Nielsen CC. Orthotics and
Prosthetics in Rehabilitation. Woburn, MA
Butterworth-Heinemann 2000, p. 344.
13
Protective sensation

• Must be able to perceive 5.07 Semmes-Weinstein
  monofilament
• Easy and inexpensive way to identify patients at
  risk for foot ulceration2

14
What should primary goal be with PVD/DM in
regards to feet?

• PREVENTION!

15
What is the level of Mr. Howards amputation?

• s/p transtibial amputation of ideal length

16
Levels of Amputation
17
What are the levels/classification of amputation?

• Transtibial (BK) 54
• Transfemoral (AK) 32
• Syme/foot 3
• Hip disarticulation 1
• Upper extremity 8 4

18
How was Mr. Howards level of amputation selected?

• Preserve as much viable tissue/select most
  appropriate level

19
Selection of Amputation Levels

• General guidelines
• Considerations with PVD
• Considerations with trauma
• Considerations with malignant tumor
• Considerations with deformity
• Considerations with congenital limb
  deficiency/deformity revision

20
How does the level of amputation and age of
patient affect outcome?

• Higher the amputation, more difficult the rehab.
• Older/sicker the pt., more difficult the rehab.

21
Age of Amputees

• gt 61 40
• 41-60 35
• lt40 25
• 72 are males 4

22
Who is on the Team?

• Pt.
• Dr.
• PT
• Prosthetist
• OT
• Social worker/case manager
• Dietician, nursing, etc.
• Vocational Rehab

23
Responsibilities of the Team

• Evaluate pt.
• Initial training in prep. for prosthesis
• Prescription of prosthesis (if appropriate)
• Fabrication of prosthesis
• Delivery of prosthesis
• Evaluate fit of prosthesis
• Train in use, care of prosthesis
• Follow-up eval. For problems, possible changes,
  needs of pt.
• Maintenance/replacement of prosthesis

24
What tests/measures should be included in Mr.
Howards Initial PT examination?

• Ideally Mr. Howard would have had a referral to
  PT BEFORE his amputation
• Definitive strength assessment of joint just
  proximal to amputation can consist of only
  active, nonresisted antigravity motion until
  adequate healing of surgical site
• i.e. will only be able to assess knee flexion and
  extension to fair muscle grade TF will only be
  able to assess hip to fair muscle grade
• When incision healed cleared by Dr., remember
  that lever arm reduced MMT grades could be
  inflated
• Do not apply pressure for MMT through
  dressing?must be able to visualize suture line
  during 1st several weeks of preprosthetic prog.2
• Guide to Physical Therapy Practice
• Practice pattern 4 J, 5G, 7 A, 7C/D/E1

25
Pre-prosthetic Examination

• May, BJ. Amputation and Prosthetics A Case Study
  Approach. Philadelphia Davis 1996, p. 73.

26
Exam
Seymour, R. Prosthetics and Orthotics Lower
Limb and Spinal. Philadelphia Lippincott,
Williams and Wilkins 2002, p. 37.
27
How can PT record measurements for Mr. Howards
residual limb?

• Actual length
• Total length including soft tissue
• Measurements taken from easily ID bony landmark
  to the palpated end of the long bone, to the
  incision line, or to the end of soft tissue
• Medial joint line or tibial tubercle
• TF start measurement at at ischial tuberosity or
  greater trochanter
• Document which landmark you used!
• TT 5-6 inches ideal TT less than 3 inches
  problematic for prosthetic control and skin
  integrity
• Circumferencemedial tibial plateau or tibial
  tubercle and at equally spaced points to end of
  limb TFbegin at ischial tuberosity or greater
  trochanter?clearly document interval between
  measurements
• Prosthesis often made when distal limb circprox
  limb circ (lt1/4 inch difference) 2

28
Poor Residual Limb Healing

• May, BJ. Amputation and Prosthetics A Case Study
  Approach. Philadelphia Davis 1996, p. 79.

29
What are likely limitations for Mr. Howard?

• IMPAIRMENTS
• Pain
• Decreased strength, ROM, mobility
• Decreased skin integrity
• Decreased endurance
• Psychological issues

• FUNCTIONAL LIMITATIONS
• Inability to walk, work, play

30
What should be included in the early post-op care
for Mr. Howard?

• ROM, positioning, skin care, edema control,
  isometrics, strengthening of UEs/residual and
  remaining limb,pt. education, bed mobility,
  transfers, balance, etc.

31
What are PTs primary goals/outcomes for Mr.
Howards immediate post-operative period?

• Ensure optimal wound healing
• Early preparation of the limb for prosthetic
  fitting
• Maintain, increase mobility
• Improve endurance
• Care of remaining limb
• Maintain/increase ROM and strength

32
How should PT inspect Mr. Howards wound?

• Monitor residual limb for shape, incision
  healing/closure, length, sensory integrity,
  volume, tissue integrity, color temp., pain
• Easy to do with dressing change
• Record quantity/quality of drainage
• Normal for clear drainage first couple
  days?should decrease over time report red or
  darker blood or thickening discolored drainage
  with odor to Dr.
• Traumatic (nondysvascular) pt. often ready to be
  casted for training prosthesis day 10, others day
  142

33
How can you teach Mr. Howard scar management?

• Once primary healing established, teach pt.scar
  massage above below incision (not across)
• Once wound well-closed, and no steri-strips, can
  begin gently to mobilize scar itself
• Why is scar mobilization important?
• Tissues must be able to glide?adherence promotes
  shearing forces which lead to skin breakdown2

34
What are common post-amputation sensations Mr.
Howard may experience?

• phantom limb sensation
• 70 will experienceNumbness, tingling, pressure,
  itching, mild cramp in foot/calf
• phantom limb pain
• Shooting limb pain, severe cramping, severe
  burning in amputated foot/limb?NOT psychological!
• higher amputation?greater liklihood
• Evidence if pt. had significant dysvascular limb
  pain a surgery are more likely to have phantom
  limb pain2

35
How would you explain phantom limb pain to Mr.
Howard?

• All nerves that once had branches to LE are still
  present, but end at a new place. It takes time
  for the brain to learn this fact. Also, these
  nerves may be very sensitive from the amputation
  surgery as they are pulled and then severed and
  allowed to retract. 4

36
What are some strategies for treatment of phantom
limb pain?

• Patient education before surgery
• Alert pt. to issues of safety?wake up in middle
  of night p recent amputation and fall when
  attempt to stand and walk thinking both limbs are
  intact
• Careful inspection of limb to r/o neuroma or
  infected wound
• Compression, use of prosthesis, desensitization
  techniques, heat
• Medications, steroid injection, nerve block,
  relaxation/hypnosis?varied effectiveness2

37
PT management of Pain

• Time pain meds. So that pain control in optimal
  during PT activities
• Pt. ed. on imagery relaxation methods
• TENS wound healing and phantom pain
• US, cold therapy, massage
• Wear prosthesis/compression bandages
• Varying effectiveness
• Pain management MUST NOT interfere with wound
  healing2

38
Why is compression bandaging important for ALL
amputees?

• Reduce edema
• Controls pain
• Enhances wound healing
• Protects incision during functional activity
• Facilitate preparation for prosthetic placement
  by shaping and desensitizing limb
• 1st 4 are required even if pt. not a candidate
  for prosthesis2

39
What options are there for edema control for Mr.
Howard?

• Compression bandaging
• Rigid
• Rigid applied by surgeon in OR, removed 3-4 day,
  can then put new c IPOP-allows limited TTWB in
  2-3 days-prosthetist
• Best for controlling edema and pain
• Not good for pt. c significant risk for infection
  because wound status not easily visualized unless
  removeable (RRD)-PT
• Semi-rigid
• Prosthetist takes negative mold in OR or p rigid
  removed 3 day
• Polyethlene light weight,easy to clean,more
  durable than plaster
• Unna pastezinc oxide,glycerin,calamine
  gelatin?dries 24 h Can be left on for 5-7 days
• Air bag
• Soft bandagingace bandage, compressogrip
• Once suture line healed (10-21 days), use
  shrinker TT/TF, Jobst for TF 2

40
RRD
Lusardi MM Nielsen CC. Orthotics and
Prosthetics in Rehabilitation. Woburn, MA
Butterworth-Heinemann 2000, p. 400.
41
Semi-rigid dressing
Lusardi MM Nielsen CC. Orthotics and
Prosthetics in Rehabilitation. Woburn, MA
Butterworth-Heinemann 2000, p. 401.
42
Shrinkers
Lusardi MM Nielsen CC. Orthotics and
Prosthetics in Rehabilitation. Woburn, MA
Butterworth-Heinemann 2000, p. 405.
43
Principles of Ace-wrapping

• Distal pressure should exceed proximal
• Pressure applied on oblique turns only
• Should be reapplied at least every 4 hours
• No wrinkles
• Dont use metal clipstape down
• No aching, burning or numbnessremove
• Wear 23 hours a day (remove for hygiene only)
• Wash daily, squeeze, dont wring and air dry
  (need 2 sets)
• Continue use until pt. has definitive prosthesis
  pt. can leave stump unwrapped overnight and don
  prosthesis without difficulty in the morning 6

44
What are the most common contractures to prevent
in Mr. Howard?

• Transtibial
• Hip flexion
• Knee flexion
• Why?
• Long periods sitting in w/c, bed?position of
  comfort is one of flexion
• Protective flexion withdrawal pattern associated
  with LE pain
• Muscle imbalances
• Loss of sensory input from foot in WBing 2

45
What contractures are common in a transfemoral
amputee?

• Transfemoral
• Hip flexion
• Hip abduction
• Hip lateral rotation

46
How can PT prevent contractures in Mr. Howard?

• Maintain knee in ext
• Bed?avoid use of pillows under residual limb
• W/C?sliding board, elevating amputee hanger
  avoid long periods of sitting
• Lie prone
• PNF w/CR ,HMP/US, manual stretching, AROM/PROM
• HEP (IP OP) 2

47
Prevention of Contractures
May, BJ. Amputation and Prosthetics A Case Study
Approach. Philadelphia Davis 1996, p. 87.

48
Strengthening For LE Amputee

• Maximization of overall UE/LE/TRUNK strength and
  muscular endurance for safe, energy-efficient
  prosthetic gait, helps prevent contractures,
  maintains mobility
• Post-operative muscle strengthening consists of
  isometric contractions within a limited ROM at
  joint proximal to amputation to minimize stress
  across incision
• Watch breathing?no valsalva!
• Recommend 10 second cx, followed by 5-10 seconds
  rest for 10 reps.\
• AROM of unaffected limbs day 1, affected-limb day
  1-3 bed mobility/transfers day 2
• As wound healing progresses, include large arcs
  of motion, active resistive exercise,
  isokinetics, eccentric, etc. 6

49
What should PT POC include for Mr. Howard?

• Hip ext., hip abductors/adductors, knee ext.
• hip flexors, knee flexors as needed (may need to
  stretch these short muscles)
• General strengthening/ROM of trunk and UEs
  important (esp. back ext. and abdominals,
  shoulder depressors and elbow ext.)
• Aerobic ex. to increase endurance
• mobility
• Posture-COG shifted up, back and toward remaining
  extremity
• Skin integrity?prep residual limb/care remaining
• Balance 2

50
TT Exercises
May, BJ. Amputation and Prosthetics A Case Study
Approach. Philadelphia Davis 1996, p. 88.
51
TF Exercises
May, BJ. Amputation and Prosthetics A Case Study
Approach. Philadelphia Davis 1996, p. 89.
52
Key Points

• PT will ideally begin BEFORE pt. has amputation
• After a LE amputation, PT focus on pre-prosthetic
  training for functional mobility, residual AND
  remaining limb skin care
• Questions?

53
References

• American Physical Therapy Association. Guide to
  Physical Therapy Practice. 2nd ed. Alexandria,
  Va American Physical Therapy Association 2001.
• May, BJ. Amputation and Prosthetics A Case Study
  Approach. Philadelphia Davis 1996.
• Northwestern University Prosthetics Training
  Handouts, 2003.
• OSullivan SB Schmitz TJ. Physical
  Rehabilitation Assessment and Treatment.
  4thed. Philadelphia Davis 2001.
• Seymour, R. Prosthetics and Orthotics Lower
  Limb and Spinal. Philadelphia Lippincott,
  Williams and Wilkins 2002.