the development of flexion contracture Contractures Some

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PT for Patients with Lower Limb Amputation

• Yu Nan-Ying
• 2005/12/26

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Introduction

• The major cause of lower extremity amputation is
  peripheral vascular disease (PVD), particularly
  when associated with smoking and diabetes
• The second leading cause of amputation is trauma,
  usually from motor vehicle accidents or gunshot
• The incidence of amputation from osteogenic
  sarcoma has been reduced by better limb salvage

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Surgical Process

• Basic principles
• Skin flaps are as broad as possible and the scar
  should be pliable, painless, and nonadherent.
• For most transfemoral and nondysvascular
  transtibial amputations, equal length anterior
  and posterior flaps are used, placing the scar at
  the distal end
• Long posterior flaps are often used in
  dysvascular transtibial amputations

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Basic Principles
Surgical Process

• Muscle stabilization may be achieved by
  myofascial closure, myoplasty, myodesis, or
  tenodesis
• Severed peripheral nerves form neuromas (a
  collection of nerve ends) in the residual limb
• The neuroma must be well surrounded by soft tissue

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Basic Principles
Surgical Process

• Hemostasis is achieved ligating major veins and
  arteries
• Cauterization is used only for small bleeders
• Bones are sectioned at a length to allow wound
  closure without excessive redundant tissue at the
  end of residual limb and without placing the
  incision under greater tension

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Healing Process

• The surgeons goal is to amputate at the lowest
  possible level compatible with healing
• Factors that may affect healing include
  infection, cigarette smoking, the severity of
  vascular problems, diabetes, renal disease, and
  other physiological problems such as cardiac
  disease

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The Major Outcomes of the Postsurgical Period

• 1. Promote as high a level of independent
  function as possible
• 2. Guide the development of necessary physical
  and emotional level for eventual prosthetic
  rehabilitation
• 3. Independence in mobility and self-care
• 4. Independence in bed mobility and basic
  transfers
• 5. Supervised or independent mobility with
  crutches or walker
• 6. Demonstrate knowledge of proper residual limb
  positioning, bandaging, and care

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The Major Outcomes of the Postsurgical Program

• 1. Reduce postoperativ edema and promote healing
  of the residual limb
• 2. Prevent contractures and other complications
• 3. Maintain or regain strength in the affected
  lower limb
• 4. Maintain or increase strength in the remaining
  extremeties
• 5. Assist with adjustment to the loss of a body
  part
• 6. Demonstrate knowledge of basic residual limb
  exercise
• 7. Learn proper care of the remaining extremity
• 8. Determine the feasibility of prosthetic fitting

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Postoperative Dressing

• Rigid dressing
• An attachment incorporated at the distal end of
  the dressing allows the later addition of foot
  and pylon allowing limited weight-bearing
  ambulation within a few days or a week of surgery
  (immediate postoperative prosthesis)

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The Advantage of Rigid Dressing

• Limits the development of postoperative edema
• Allows for early ambulation
• Allows for early fitting of the permanent
  prosthesis by reducing the length of time needed
  for shrinking the residual limb
• Configured to each individual residual limb

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The Major Disadvantage of Rigid Dressing

• Requires careful application by an individual
  knowledgeable about prosthetic principles
• Requires close supervision during the healing
  stage
• Does not allow for daily wound inspection and
  dressing changes

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Semirigid Dressing

• It provides better control of edema than the soft
  dressing (Unnas dressing, air splinting, and
  controlled environmental treatment .)
• The air splint is a plastic double wall bag that
  is pumped to the desired level of rigidity
• It allows improved wound inspection
• The constant pressure does not intimately
• conform to the shape of residual limb

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Soft Dressing

• Advantages
• 1. Relatively inexpensive
• 2. Light weight and readily available
• 3. Able to be laundered

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Soft Dressing

• Disadvantages
• 1. Relatively poor control of edema
• 2. The elastic wrap requires skill in proper
  application
• 3. The elastic wrap needs frequent
  reapplication
• 4. Either can slip and form a tourniquet
• 5. New shrinkers must be purchased as the
  residual limb gets markedly smaller
• 6. Shrinker cannot be used until the sutures
  have been removed and primary healing has occurred

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Soft Dressing

• Elastic Wrap
• The elastic wrap may be applied over the
  postsurgical dressing if care is taken to ensure
  proper compression
• A dressing is applied to the incision followed
  by some form of gauze pad, then the compression
  wrap.
• Shrinkers
• Socklike garments knitted of heavy rubber
  reinforced cotton they are conical in shape and
  come in a variety of sizes.

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Examination

• Range of motion (if the dressing allows)
• Muscle strength (MMT of the involved lower
  extremity must wait until most healing has
  occurred)
• Residual limb (length, circumference, and shape,
  skin condition, sensation, and joint
  proprioception ..)
• Note Exact landmarks should be carefully
  noted in length and circumference measurement

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Examination

• The phantom limb
• Phantom is the sensation of the limb that is no
  longer there
• is often described as a tingling, pressure
  sensation, sometimes a numbness
• The phantom pain
• A cramping, squeezing sensation, or a shooting or
  a burning pain
• May be localized or diffuse continuous or
  intermittent and triggered by some external
  stimuli
• It may diminish over time or may become a
  permanent and often disabling condition

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Examination
The Phantom Pain

• The patients are usually told to view the phantom
  as a part of themselves
• Sometimes, wearing a prosthesis will ease the
  phantom pain
• Ultrasound, icing, TENS, or massage have been
  used with varying success
• Chordotomies, rhizotomies, and peripheral
  neurectomies have been tried with limited success

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Examination
Other Data

• The vascular status of uninvolved lower extremity
  is determined and its condition noted
• Data gathered include condition of the skin,
  presence of pulses, sensation, temperature,
  edema, pain on exercise or at rest, presence of
  wound, ulceration, or other abnormalities
• ADL and functional mobility skill
• The persons apparent emotional status and degree
  of adjustment are noted

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Emotional Adjustment

• Psychological support
• The elderly
• As with other physically challenged
  individuals, those with amputations need to be
  accepted and intergrated into the community
  because of their abilities not their disabilities

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Interventions

• Residual limb care
• Individuals not fitted with a rigid dressing or a
  temporary prosthesis use elastic wrap or
  shrinkers to reduce the size of the residual limb
  
• An intermittent compression unit can be used to
  reduce edema
• Proper hygiene and skin care are important
• Patients can learn to properly perform a gentle
  friction massage to mobilize the scar and help
  decrease hypersensitivity of the residual limb
• The patient is taught to inspect the residual
  limb with a mirror each night to make sure there
  are no sores or impending problems

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Interventions

• Residual limb care
• Individuals not fitted with a rigid dressing or a
  temporary prosthesis use elastic wrap or
  shrinkers to reduce the size of the residual limb
  
• An intermittent compression unit can be used to
  reduce edema
• Proper hygiene and skin care are important
• Patients can learn to properly perform a gentle
  friction massage to mobilize the scar and help
  decrease hypersensitivity of the residual limb
• The patient is taught to inspect the residual
  limb with a mirror each night to make sure there
  are no sores or impending problems

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Residual Limb Wrapping

• The transtibial bandage
• Two 4-inch elastic bandages
• The first bandage is started at either the
  medial or lateral tibial condyle and brought
  diagonally over the anterior surface of the limb
  to the distal end
• It may be brought across the front of the
  residual limb in an X design

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Residual Limb Wrapping

• The transfemoral bandage
• Two 6-inch and one 4-inch elastic bandages
• The first bandage is started in the groin and
  brought diagonally over the anterior surface to
  the distal lateral corner, around the end of
  residual limb, and diagonally up the posterior
  side to the iliac crest and around the hip in a
  spica

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Positioning

• With the transtibial amputation, full range of
  motion in the hips and knee, particularly in
  extension is needed
• While sitting, the patient can keep the knee
  extended by using a posterior splint or a board
  attached to the wheelchair
• The patient with the transfemoral amputation
  needs full range of motion in the hip,
  particularly in extension and adduction
• Prolong sitting is to be avoided
• Elevation of the residual limb on a pillow can
  lead to the development of flexion contracture

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Contractures

• Some individuals will present with hip or knee
  flexion contracture
• Facilitated stretching techniques (PNF) are more
  effective than passive stretching
• Hold-relax, hold-relax active contraction that
  utilizes resisted contraction of antagonist
  muscles may increase range of motion
• Fit the patient with a Patellar-tendon-bearing
  (PTB) prosthesis aligned in a manner that places
  the hamstrings on stretch with each step

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Exercises

• The postsurgical dressing, degree of
  postoperative pain, and healing of the incision
  will determine when resistive exercises for the
  involved extremity can be started
• The hip extensors and abductors, and knee
  extensors and flexors are particularly important
  for prosthetic ambulation
• Sitting and standing balance activities are a
  useful part of the early postsurgical program
• Shoulder depression and elbow extension are
  necessary for crutch ambulation

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Mobility

• Walking is an excelent exercise and necessary for
  independence in daily life
• Gait training can start early in the
  postoperative phase (usually three-point gait
  pattern crutches)
• Walker is used only if the person cannot learn to
  walk with crutches
• A reciprocal walker is not safe during the
  postsurgical period when the patient is using a
  three-point gait pattern

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Temporary Prostheses

• Advantages in using a temporary prosthesis
• 1. It shrinks the residual limb more
  effectively than the elastic
• 2. It allows early bipedal ambulation
• 3. Many elderly people can walk safely with a
  temporary prosthesis and a cane who otherwise
  would not be ambulatory during the postsurgical
  period
• 4. Some individual can return to work
• 5. It provides a means of evaluating the
  rehabilitation potential of individuals with a
  questionable prognosis

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Temporary Prostheses

• Advantages in using a temporary prosthesis
• 6. It is a positive motivating factor
  providing a replacement for the missing part of
  the body
• 7.It reduces the need for a complex exercise
  program because many people can return to full
  active daily life
• 8. It can be used by individuals who may have
  difficulty obtaining payment for a definitive
  prosthesis

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Patient Education

• 1. A discussion of the disease process, the
  physiological effects of the symptoms, and
  life-style changes to reduce risk factors
• 2. Information on the benefits of exercises,
  lower extremity cleanliness, proper foot care,
  and proper shoe fitting
• 3. Methods of edema control
• 4. The use of exercise to improve circulatory
  status

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Bilateral Amputation

• The postsurgical program for the person with
  bilateral lower extremity amputation is similar
  to the program developed for unilateral
  amputation
• All individuals with bilateral amputations need a
  wheelchair on a permanent basis
• The postsurgical program includes mat activities
  designed to help the person regain a sense of
  body position and balance, upper extremity and
  residual limb strengthening exercise, and regular
  range of motion exercises

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Bilateral Amputation

• If possible, or at least spend some time in the
  prone position each day range of motion exercises
  
• The person with bilateral trasfemoral amputation
  can be fitted with shortened prosthesis called
  stubbies
• Stubby prostheses have regular sockets, no
  articulated knee joints or shank, and modified
  rocker bottoms turned backward to prevent the
  person from falling backward

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