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Amputee management must consider as a dynamic continuous process which begins at the time of injury or disease and continues until the patient has achieved maximum functional use of the prosthesis and is able to perform the activities of daily living and gainful employment.
Causes • Congenital – deformities in infants (1% of all causes) • Acquired • Peripheral vascular disease – arterial disease usually atherosclerosis, mostly in elderly (64%) • Trauma – RTA ,mostly in young adults (8%) • Malignancy (4%) • Metabolic – diabetes giving rise to ulcers & gangrene (21%) • Infection – bone disease (2%)
Site Amputation of the lower limb is more common (24:1) & due mainly to peripheral vascular disease. That of the upper limb is due mainly to trauma. Sex Male to female 2:1 – all amputations.
Levels of lower limb amputation • Partial toes (Excision of any part of 1 or more toes) • Toe disarticulation (Disarticulation at the MTP joint) • Partial foot ray section (Resection of a portion of up to 3 metatarsals and digits) • Transmetatarsal amputation (Amputation through the midsection of all metatarsals)
5.Lisfranc (Amputation at the tarso-metatarsal junction) 6.Chopart (Midtarsal amputation—only talus and calcaneus remain) 7. Pirogoff amputation is a vertical calcaneal amputation. 8. Boyd is a horizontal calcaneal amputation.
9. Syme’s (Ankle disarticulation with attachment of heel pad to distal end of tibia; may include removal of malleoli and distal tibial/fibular flares) 10. BK (transtibial) 11.Knee disarticulation (Amputation through the knee joint, femur intact) 12. AK (transfemoral)
13. Hip disarticulation (Amputation through hip joint, pelvis intact) 14. Hemipelvectomy (Resection of lower half of the pelvis) 15. Hemicorporectomy (Amputation of both lower limbs and pelvis below L4, 5 level)
A/K amputees are classified according to amputation level as • 0 to 9% - hip disarticulation • 10 to 33% - short A/K • 34 to 67% - medium A/K • 68 to 100% - long A/K • Unilateral A/K% = stump length × 100 sound thigh length
Goals of amputee rehabilitation • To provide substitution for the function of the severed part • To assist patients in returning to a safe, productive life • To achieve the highest level of function
Common Goals for Amputees • Transferring in and out of bed, chairs and wheelchairs • Donning and doffing an upper or lower limb prosthesis • Bathing, dressing, toileting and eating (ADLs) with or without a prosthesis • Walking over different surfaces such as stairs, ramps, curbs and uneven terrain • Getting in and out of a bathtub • Getting up off of the floor after a fall • Education regarding care of the residual limb and prosthesis
Amputee rehabilitation includes: • Balance, coordination, endurance and agility exercises • Bed mobility/transfer training • Education on use and care of the prosthesis • Education regarding residual limb care • Home exercise programs • Progression toward recreational activities • Prosthetic gait training • Resource information about support groups and recreational organizations • Stretching and strengthening exercises
Patient Care Team Includes • Surgery • Physical Medicine and Rehabilitation • Regional Anesthesia and Pain Management • Nursing • Physical Therapy • Occupational Therapy • Prosthetics and Orthotics • Vocational Rehabilitation and Employment Services • Patient • Patient's Family • Psychiatric Consultation
Optimal (or) Standard Stump Requirement I. Correct functional length that is 5-6" below the medial tibialarticular margin measured with the knee flexed 90°. - In growing children amputation should be done with the stump as long as possible. - Longer stump (>6") will not materially affect the leverage on function power, depend, not so much on the length of the bone but more on the site of insertion of the muscles i.e. Quadriceps, Hamstrings. - Long stump do not maintain their vascularity - Nutrition of skin poor, and become discolored and painful, infected, reamputation sometimes required. - Shorter stump less than 5 can be fitted with suitable suspension system.
II. The bone end should be rounded off and free from spurs. III. Surgical scar should be, non adherent and should be transversely across the end of stump or just proximal to it. IV. Skin over the scar should be freely movable, and should fit snugly without redundancy, normal tone and sensation.
V. The muscles and fascia covering the bone should be just enough to form a band of scar tissue. VI. The stump should have normal smooth and even contour and activated by well balance powerful muscles. VII. Joint proximal to the stump should have normal range of motion.
Three Phases of Amputee management 1. Pre Prosthetic phase 2. Prosthetic phase 3. Post Prosthetic phase 1. Pre Prosthetic Phase • Soon after surgery • When the stump is ready for fitting • Evaluation & attention of physical characteristic of patient and stump.
Attention of patient • Improve general medical and surgical condition • Maintain general body mechanics and posture • Maintain or improve status of remaining ability and balancing on the sound leg Attention to stump • Conditioning • Shaping • Shrinking • Maintaining full range of motion in the proximal joints. • Development of muscle strength.
Crutch Walking & Training • Important for amputee patient • Must achieve safe, stable and secure crutch • Walking gait with the remaining leg. • Develop strength for crutch walking muscles • Suitable method i.e. Swing to, Swing through gait.
Four Periods in Pre Prosthetic Phase 1. Recovery Period 2. Bed Rest Period 3. Pre ambulatory Period 4. Gymnasium Period
1. Recovery Period • Following 3 days after surgery • Bed positioning to maintain correct body posture • General Body conditioning • Stump Care and stump positioning
2. Bed Rest Period • 4 days after surgery to removal of stitches • General body conditioning exercise • Stump exercise • Responsibility of nurse, P-T. (Physiotherapist) • Patient co-operation and willing to perform exercise is important. • Rate of progression must be suited to the individual patient. • Exercise should not prescribe that the patient cannot easily performed. • Exercise should be easily performed and progressively increased to more strenuous and difficult exercise to achieved the desire goal.
(a) General body exercises • Exercise to good limb and general body • To prevent or correct abnormal posture and the injurious effects of bed rest Exercises to good limb and body Day - 1 Active ROM exercises to all joint of upper extremities, 10 times/section, at least twice a day, 7 days per week. Day - 2&3 SLR to good leg first active assistively and then gradually actively, hold 5 counts after each SLR, repeat 10 times, twice a day, 7 days per week. Active hip abduction exercises to good leg
Day – 4 Active exercises to strengthen anterior abdominal muscles – with knee flexed and foot flat on bed, actively contract the gluteal muscles and then abdominal muscles to tilt the pelvis posteriorly and flatten the lumbar spine, raise the head, shoulders and arms until hands are about 6 inches above knee, hold 5 counts, return to starting position and then relax, repeat 10 times, twice a day, 7 days per week.
Day 5&6 Active exercises to strengthen oblique abdominal muscles – supine with hips and knees straight, rotate the upper trunk towards opposite side as far as possible, keeping the pelvis and L/E on the same side , as far as possible, repeat 10 times, twice a day, 7 days per week.
Day - 6&7 • Active exercises to stretch hip flexors • Active exercises to strengthen hip extensors of good side • Active exercises to strengthen elbow extensor muscles • Active exercises to strengthen shoulder girdle depressor
(b) Stump exercises • As soon as the pain has subside or the good leg can actively perform SLR efficiently, mobilization of the stump may be considered. • Purpose of stump exercises are – • To develop coordination ,strength and endurance of the muscles • To prevent disuse atrophy • To correct contractures which may have developed • To improve circulation • To relief pain and sensitivity
Following specific stump exercises should be prescribed: Hip disarticulation amputee • Function of joint is lost, prosthesis must be activated by movements of pelvis and trunk • Active exercises to stretch lumbar muscles • Active and manual exercises to strengthen abdominal muscles A/K amputee • Exercises for H/D amputee • Active exercises to strengthen hip adductor • Active exercises to strengthen hip abductor • Active exercises to strengthen hip extensor • Stretching of hip flexor
B/K amputee • Efficient use and control of B/K prosthesis depend on normal motion at hip especially extension, upon normal knee extensor and flexor muscles • Prevention of knee flexion contracture by correct bed positioning and by early active exercises including quadriceps settings is to be stressed • Strengthening exercises for hamstring and quadriceps should be started as early as possible • If knee contraction contracture develops, vigorous treatment is essential by weight stretching • exercises same as for A/K
3.Pre Ambulatory Period • Begin as soon as stump is painless • Patient is permitted to sit on bed and stand by the side of bed. • May be even before sutures are removed • Balancing exercise ie, sitting, standing • Hopping • Crutch Walking
4.Gymnasium Period • Begins as soon as the patient is able to walk safely with crutches, with or without healed stump after removal of suture, carried out in Gymnasium. • More vigorous general body conditioning exercise and stump exercise • Contracture stretch if present – weight stretching of tight hip flexors and abductors • Progressive resistive exercise (PRE) • Stump bandaging for shrinkage and shaping if stump healed
2. Prosthetic Phase • Prosthetic Prescription • Fabrication • Fitting • Check out.
Prosthetic clinic procedures Prosthetic phase and post prosthetic phases are carried out a/c to prosthetic clinic procedure • Pre prescription examination • Pre prosthetic training • Prosthetic prescription • Fabrication • Initial check out • Post prosthetic training • Final check out • Vocational training • Job placement
MO presents the case to clinic, such information as: • Age, address • Education level • Premorbid vocation and avocation • Future plan for employment • Characteristics and biomechanics of stump If amputee is ready for prosthesis: • Type of the socket • Knee joint • Suspension system • Foot and footwear • Alignment system that will be employed
Pre Prescription Examination • Amputee intake formwhich consists of informationconcerning the patient and examination • Demorgraphic record of individual • Education • Occupation- previous, recent, nature of job i.e.,sedentary, manual, hard labor, fisherman, etc. • Social - Marital status, - Head of the family, family members - Supporter - Condition of the house - Hobby • Economic status • Medical conditions - General medical conditions - Congenital, trauma, diseases etc. • Physical conditions - Biomechanics entity of the stump - Condition of the sound limb
Prosthetic fabrication – completed by the prosthetist and his technicians • Initial check out – is accomplished before the device is delivered to the patient and the initiation of post-prosthetic training, sometimes performed with the appliance with the unfinished state, so the minor improvements may be introduced at minimum cost. • Should be checked with standing, sitting and walking, check the stump after prosthesis off whether free from abrasions, discolorations.
Initial Check Out • Systemic examination of the patient with the prosthesis as biomechanical entity • Accomplished before the prosthesis is delivered • Performed with the appliance in unfinished stage • To provide the assurance that the prescription prescribed by the clinic has developed precisely • To evaluate the biomechanical adequacy of prosthetic device against set standards of quality, efficiency & design • Correction can be introduced before development of undesirable physical or psychological reaction
Post prosthetic Phase • Training to use prosthesis effectively • Don and Doff • Training of gait on various levels & occasions • Stair Climbing • Care of the stump and prosthesis. • Pre prosthetic Phase and Post prosthetic phase are carried out according to Prosthetic Clinic Procedures.
Gait training Gait training should be carried out in front of a full-length mirror to enable the patient to observe & correct any fault. • Walking sideways & backwards • Walking on different surfaces, carpets, tiles, grass, rough ground. • Standing up & sitting down in a chair. • Ascending stairs (unaffected leg first) & descending stairs (prosthesis first)
e. Ascending a slope (long stride with unaffected leg, short stride with prosthesis) & descending slope (strides reversed). f. Getting up from the floor – roll over to unaffected side, extend prosthesis, push up on unaffected leg with hands on chair or stick. g. Picking up objects from floor. h. Clearing obstacles.
Stump • Inspect for redness after 15 minute • Check for abrasion, edema • Wash stump properly and keep dry Prosthesis • Clean both inside and outside after end of the day • Stand at airy area • Machine oil should be put once a month to the joint • Stump socks should be washed properly • Leather parts should be polished with wax
Post Prosthetic Training • When the prosthesis is found to be satisfactory • Delivery to the patient • Referred to Physiotherapist for appropriate prosthetic training schedule • Length, type and intensity of training depend upon the nature of the disability and the characteristic of the patient • When satisfied, it is ready for Final Check Out
Final Check Out • Biomechanical adequacy of the prosthesis is reviewed • Extent and effectiveness of the patient use of prosthesis is evaluated as well as the patient’s physical and psychological status • Discharge summary, received from the MO • Vocational training
Follow Up • Maximal prosthetic function is obtained only when the patient is called in for follow up examination. • One visit every six month or on graduated schedule for periodic adjustment.
