Clinical Procedures in Prosthetics II

1. Clinical Procedures in Prosthetics II Designing a PT Management Program for Patients with Prosthesis Mark David S. Basco, PTRP Faculty Department of Physical Therapy College of Allied Medical Professions University of the Philippines Manila

2. Learning Objectives At the end of the session, you should be able to • Discuss principles behind designing a management procedure for prosthesis users in the different phases: • Pre-operative • Early post-operative • Late post-operative • Prosthetic training phase • Gait • Vocational

3. Learning Objectives At the end of the session, you should be able to • Discuss indications, precautions, and contraindications to prosthetic management • Discuss special considerations when designing a program for children

4. Pre-operative stage Introductory Visit Assessment Discussion of outcomes Preparation for the operation Pre-operative exercises

5. Introductory Visit • Introduce self and role in the rehab team, emphasize role of patient and family • Need for reassurance that amputation and rehabilitation is a positive step towards reintegration back into the community • Goals and expectations • Introduce team management concepts

6. Assessment Physical • Conditions that may affect mobility • Functional capacity Psychological • Attitude Social situation • Accommodation after surgery

7. Outcomes and Prognostication • What the patient may feel or encounter post-op • Complications that may arise • Expected highest level of function possible given the level of amputation • Use of the prosthesis is the patient’s decision • Options for prosthetic devices • Life with a prosthesis

8. Preparation for the operation • Show the patient around the facility where he will be in after the operation • Possible prosthesis given the level • Speak to other amputees • Exercise program • Operating room, equipment, gadgets, medications, etc • Phantom sensations

9. Pre-operative Exercises • Increases tolerance to surgery • Faster recovery and gain of independence in prosthesis use • Mentally prepares the patient • Exercise program: • Strengthening • Endurance training • Simulation of training activities post-op

11. Early Post-op Stage Goals Treatment methods Early home visit Others

12. Goals • Prevent the deleterious effects of immobilization and loss of a limb segment • Facilitate faster wound healing • Pain management • Provision of needed accessories or equipment to progress patient to the next stage • Prepare patient and stump for prosthetic fitting • Promote early independence in ADLs

13. Treatment Methods • Proper positioning • Stump edema management • Active exercises • Selective Stretching • Donning and doffing • Functional training

14. Proper Positioning • Stump should be flat on the bed • Use of comfort pillow • Prevent flexion contractures • Sitting vs supine • Advocating intermittent positioning in prone • Sidelying to relieve buttocks pressure

16. Stump edema management • Elevation • Exercises • Bandaging • Intermittent variable air pressure machines • Pneumatic pylon • Shrinker socks • Rigid dressing

17. Exercises for the Stump • Done every 10 reps / hour • Active contraction of the stump muscles is the best method of reducing edema For BKA • Patient must imagine the performance of alternate DF/PF Through knee/AKA • Patient must perform alternate hip flexion and extension as well as hip abduction

18. Bandaging • Precaution: development of pressure necrosis • Stump bandaging can never change stump shape without the danger of interference with the local circulation • A uniformly edematous stump is more readily fitted than one which has been misshapened by bandaging

20. Active Exercises & Stretching • Determine which muscles decreased / lost their strength and which muscles gained a mechanical advantage • Determine biomechanical implications to identify appropriate exercise for the patient

21. Active exercises • Start with the intact side • Applicable across all amputation levels • 1st day post-op, exercises could be done on supine • All techniques could be performed except push-ups if attachments are present. • Be vigilant especially for patients with co-morbidities e.g. DM

22. Selective Stretching • BKA • Knee must rest in full extension immediately post-op • AKA • Major concern is development of hip flexion and abduction contractures • Obtain neutral hip alignment • Gradually altering hip position

23. Special considerations in exercise prescription • AGE • Gender • Other medical conditions

24. Early Home Visit

25. Others • Weekly team meeting • Early walking aid prescription • Pneumatic devices on the sockets • Vacuum techniques • Laminated plastic sockets • Local varieties • Group therapy

26. Late post-operative phase

27. Goals • Promote wound closure • Stabilize the stump • Decrease edema • Start prosthesis measurement

28. Exercises for the following groups of muscles • Hip Extensors • Hip Flexors • Hip Abductors • Hip Adductors • Knee Extensors • Knee Flexors • Trunk strengthening exercises

29. Exercises for the following groups of muscles • Hip Extensors

30. Exercises for the following groups of muscles • Hip Flexors

31. Exercises for the following groups of muscles • Hip Abductors

32. Exercises for the following groups of muscles • Hip Adductors

33. Exercises for the following groups of muscles • Knee extensors

34. Exercises for the following groups of muscles • Trunk strengthening

35. Special considerations during exercise prescrtiption • Incorporate play therapy especially for your pediatric patients • Make sure that activities that you plan to do are developmentally appropriate for your patient

36. Donning and Doffing • Patients are encouraged to dress independently as much as possible According to Engstrom (1993) • If the patient is unable to put the underpants independently, it is very unlikely that the indpendent application of the prosthesis is possible

37. Transfers • Initial requirements • Alertness and the ability to comprehend instructions • It is possible to do transfers while the drip / catheter is in situ (PRECAUTION) • A suitable wheelchair should have been loaned pre-operatively and must be self-propelling

38. Transfers • Independence for all transfers on all level surfaces should be the goal • Therapist should try to make all transfer surfaces level

39. Transfers

40. Transfers

41. Basic mobility skills • Independence in sit-to-supine, supine-to-sit, and rolling for all LE amputees • What happens when the amputation of the LE is high? • Tendency to fall • Good core muscle strength is needed

42. Prosthetic referral • Upon complete wound healing and stump stability • Upon gaining independence in ADL’s

43. What if bilateral AKA? • Possible non-walker • Activities are: bed mobility training, arm exercises, balance re-education, transfers, wheelchair maneuvers • Wheelchair concerns...

44. Prosthetic Training Phase Training Program Design Pre-ambulation training Gait training Falls training Functional training Environmental considerations Specialized prosthetic training

45. Training Program Design • Principles of exxercise prescription • Should be done daily and runn the whole day • Family / caregiver involvement • Use of different appliances / attachments • Donning and doffing of the prosthesis

46. Training Program Design • Principles of exxercise prescription • Should be done daily and runn the whole day • Family / caregiver involvement • Use of different appliances / attachments • Donning and doffing of the prosthesis

47. Pre-ambulation Training • Sit-to-stand • Balance re-education • Weight transfer on to the prosthetic leg • Considerations for progressions

48. Pre-ambulation Training

49. Gait Training • Weight bearing on the prosthetic leg is advocated • Done on various types of surfaces • Protection of the stump

50. Gait Training • Gait Pattern; • 2-point vs 3 point • Indoor then outdoor mobility