Clinical Procedures in Prosthetics 3: Techniques and Strategies

1. Clinical Procedures in Prosthetics 3:Techniques and Strategies 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: • Identify common prosthetic problems encountered in the clinics • Provide techniques and strategies for patients who underwent amputation in the different phases of prosthetic management • Pre-operative phase • Early Post-operative phase • Late Post-operative phase • Prosthetic phase • Gait training • Vocational training

3. Problem Identification • PIPs • NPIPs • Existing • Anticipated • Impairments, Activity limitations, Participation Restrictions • Therapy problem list

4. Pre-operative Phase ANXIETY Physical Readiness of the patient for the Procedure Ward Instructions

5. PROGRAM Aimed at mobilizing all joints and stimulate circulation • Cardiovascular fitness • Exercises prior to the operation • Assistive device training • Wound care training • Bandaging training • Exercises

6. Early Post-operative phase

7. Plan • Proper positioning • Stump edema management • Elevation/Bandaging/dressing • Exercises for the stump • Selective stretching • Phantom limb sensation / pain • Gait training with assistive device • Pre-ambu with temporary prosthesis

8. Plan • 1-3 days post-op: Breathing exercises • 4: AAROM of the stump (adduction and extension); AROM of the sound leg/arms/trunk; Weight-bearing on the stump • 6: Free active exercises, counter-flexion bias/proper positioning • Sitting push-ups

9. Plan • Counter-acting flexion • PRONE for approx 30 mins • Fracture boards • Stretching program • Pre-ambulation activities • STS, other transfers • Activities in standing, weight shift, stepping

10. Precautions for the residual limb • Avoid wound dehiscence • Protect residual limb from trauma • Avoid friction – sliding, pushing

11. Late Post-operative phase

12. Guidelines • Stress to suture lines: wait for 2-3 weeks • Mild range exercises, ISOMS can begin during the early post-op phase • Master isomes – gentle concentric • Introduce theraband and progressive resistance

13. Progression • Approx 2 weeks post-op, once surgical wound is closed, pt may be brought to the gym area for more vigorous exercises • Week 1: Progressive exercises for the stump • Week 2: Increase resistance; prevent boredom

14. Plan • Exercises for the important muscles of the stump needed for gait • Donning and doffing • Transfers

15. Consider • Ischial weight bearing training • Bouncing • Seats without cushions • Important muscles for gait • Stance • Hip Abd and EXTensors • Swing • Hip FLEXors

16. Prosthetic Training phase

17. Pre-gait training phase • Initial balance training • Weight shifting exercises • Side to side • Forward / Backward • Diagonal weight shifting • Stool stepping

18. Gait training protocol • Sound limb stepping partial WB • Prosthetic limb stepping partial WB • Prosthetic limb stepping WB • Sound limb stepping WB • Stride length and Prosthetic control • Sidestepping • Resistive gait training • Trunk rotation and Arm swing • Unassisted ambulation

19. Advanced balance training skills • Toe and heel pivoting • 90 degree balance recovery • Squatting limb balance • Tandem walking • Braiding • Turning to the sound side • Turning to the prosthetic side

20. PLAN • Ambulation training • Inside parallel bars • With assistive device • Stairs, ramps • Other • Getting in and out of the car • Falls training • Fitness / wellness program • Cycle ergo / Treadmill / Stepper