Pedretti Chapter 43, Amputations and Prosthetics

Passive Prosthesis

-serve in both cosmetic and functional restoration of the hand after amputation. A passive prosthesis is static and does not have an active grasp. Often the digits can be passively positioned to assist with stabilizing, carrying, or grasping objects.

vascularized composite allotransplantation (VCA)

"transplantation of multiple tissues such as muscle, bone, nerve and skin, as a functional unit (e.g., a hand or face) from a deceased donor to a recipient with a severe injury."

ADLs that should be addressed immediately after amputation

(1) self-feeding, (2) toileting, and (3) oral hygiene

interscapular thoracic

amputation of the entire upper extremity, scapula and clavicle

transradial

amputation of radius and ulna

transhumeral

amputation through the humerus

proximal LL amputations

hemipelvectomy and hip disarticulation amputations

Residual Limb

sometimes referred to as a stump

electrically powered prosthesis controls training

-Simple opening and closing of the terminal -device is practiced in various arm positions to ensure that the electrodes maintain contact with the skin in each position. Next, the client practices opening the TD through onethird, one-half, and three-fourths of range. If a proportional control system is used, the client may also practice opening and closing quickly and slowly.

Post Surgical LL amputation care

-Skin care and positioning -elastic bandage (e.g., Ace wrap) is a common method to control edema -shrinker

what are the two phases of prosthetic therapy?

(1) prosthetic controls training and (2) use training -The goal of prosthetic controls training is to achieve smooth movement of the prosthesis with minimal delay or awkward movements with task performance. -Functional use training is designed to apply the skills learned during controls training and apply them to functional use of the prosthesis

Statistics for amputations

- 1.6 million persons live with limb loss in the United States. Projected to more than double by 2050 -185,000 persons in the United States undergo an amputation every year -Dysvascular disease and diabetes are the primary reasons for amputation of the lower limb, and trauma is the primary cause of upper limb amputation in adults -Approximately 75% of upper limb amputations are the result of trauma caused by work-related accidents, gunshot wounds, and burns.59 The ratio of upper limb to lower limb amputation is estimated to be 1 : 3.36 Limb loss as a result of trauma is increased during times of active warfare.

Activity-Specific Prosthesis

-Activity-specific prostheses are designed for a particular activity or task -often used when body-powered or electrically powered prostheses cannot perform the needed function or provide the required durability for a specific activity. -typically used for recreational or work activities, such as sports, hobbies, and tool use.

CAUSES OF LOWER LIMB AMPUTATION

-In the United States 95% of LL amputations are performed as a result of complications of peripheral vascular disease (PVD), where 25% to 50% of these cases are caused by diabetes mellitus. -Trauma is the second most common cause of amputation in the United States, but it is the leading cause in developing countries because of land mines and other environmental hazards. - malignancy in an effort to prevent it from spreading to other sites or systems in the body.

disarticulation

Amputation through the joint

Nerve management in the residual limb-traction neurectomy

important for limiting neuroma development and optimize myosite signals for myoelectric control

Separation of Controls (bilateral amputation prosthetics)

-learn to operate each prosthetic component without affecting the components on either side

Syme's amputation, or ankle disarticulation

-loss of both ankle and foot -performed in cases of trauma or infection.

Phantom Limb Pain

-experienced by 90% of individuals iwth amputations -Treatment methods for those with phantom limb pain may include analgesics, acupuncture, electrical nerve stimulation, and mirror therapy, among others. Isometric exercises of the phantom and residual limb initiated 5 to 7 days after the amputation and performed several times throughout the day may help to minimize pain.

Bilateral Amputations

-adaptive equipment should be introduced as soon as possible to increase the client's level of independence - learn to complete activities using foot skills, such as holding items between the toes in a functional pinch for dressing, eating, and reaching items -The use of an immediate or early postoperative prosthesis (IPOP or EPOP, respectively), is strongly recommended in bilateral upper extremity amputations.107 Fitting an individual with an early temporary prosthesis not only promotes immediate participation and independence in ADLs, but also may facilitate acceptance and use of the permanent prosthesis

Body Powered Prosthesis controls training

-begins with the operation of each component, starting with the TD. -The reminder "down, out, and away" may be repeated until the client develops a proprioceptive memory.

hybrid prosthesis

-combines body-powered and electrically powered components in one design. These prostheses are most commonly used with a transhumeral amputation

Evaluation

-creates baseline about client's past medical history, functional status, rehab. goals -evaluates ROM and strength, sensation in residual and intact limb, wound and skin healing, phantom limb pain, emotional adjustment

Donning and doffing prosthetic

-critical first step in training for the user -two methods: coat method and the pullover (or sweater)

Revolutionizing Upper Extremity Prosthetics

-established by the Defense Advanced Research Project Agency (DARPA) -create a fully functional (motor and sensory) upper limb that responds to direct neural control -advances have been made in signal control schemes, socket design, and prosthetic componentry.

transfemoral amputation, or above-knee amputation

-loss of knee and everything distal to it. -Residual limb length from an AKA typically varies from 10 to 12 inches (from the greater trochanter -transfemoral amputations can also be classified as upper, middle, or lower third, indicating the amputation distance from the ischium. -A through-the-knee (disarticulation) amputation results in loss of knee joint function but allows a high level of prosthesis control and mobility.

myosites

-myoelectric prosthesis functions by detecting electromyographic (EMG) signals produced by muscles in the residual limb. -Use of an agonist-antagonist pairing for control of the prosthesis is called two-site control. -Preference is given to distal myosites that are adequate in signal to allow the prosthetist room to position the electrodes within a well-suspended socket. -strong contraction controls one operation, a weaker contraction controls another, and relaxing the muscle turns the system off.

Residual limb hyperesthesia,

-overly sensitive limb, limits functional use and causes discomfort -requires desensitization techniques like tapping, vibration, pressure and rubbing of various textures on limb -used to prepare limb for initial socket

Five characteristics of functional training

-person's rehabilitation is individualized, and each client has a unique set of goals. - client uses tools or interacts with an object such as a cooking utensil or a piece of sports equipment -involves complex, multistep tasks that are typically bimanual in nature -involves the prosthesis of choice for the client. Training should focus on advancing and refining the control of the preferred prosthesis for functional use. -training and activity selection are meaningful to the client

Phantom limb sensations

-present because the neural system in the brain still exists, even when the input to the body is interrupted by an amputation. -Almost all individuals who have undergone amputation report this painless sensation. -has also been known to occur in persons with congenital limb absence. -The distal part of the limb is most frequently felt, although

transtibial amputation, or below-knee amputation (BKA)

-preserves knee and thus eliminates necessity for a mechanical knee joint in prosthesis. -residual limb from a BKA typically varies from 4 to 6 inches from the tibial plateau

Wearing Schedule

-reviewed during first training session - client increases the wearing time gradually to develop a tolerance and decrease the likelihood of skin breakdown. The prosthesis initially is worn 15 to 30 minutes three times a day. Each time the prosthesis is removed, the skin must be inspected for redness or irritation

preprosthetic phase

-right after amputation through to prosthetic fitting -promote wound healing an closure, pain management, ADL retraining, client and family education, preparation for prosthesis and self care

what modifications can be made for driving?

-spinner knob, or driving ring

Osseointegration

-surgical procedure in which an implanted device is fixed to the bone of the residual limb. - component of the implant protrudes from skin and anchors prosthesis directly to residual limb, eliminating need for suspension

Pattern recognition

-uses multiple electrodes to control several degrees of freedom for more complex movement

Golden Window

-fitting an individual with a prosthesis within 30 days of amputation significantly increases chances of acceptance of the prosthetic limb. -30-day period Early fitting programs have been very successful in helping the client who has had an amputation incorporate the new extremity more rapidly into his or her daily activities.

Five assessments for evaluation of UE prosthetic use:

1)Capacity for Myoelectric Control (ACMC) -measurement of electrically controlled prosthesis in the performance of bimanual tasks. Evaluates performance with the prosthesis in the areas of gripping, holding, releasing, and bimanual manipulation 2)Trinity Amputation and Prosthesis Experience Scales-Revised (TAPES-R) -self-report measure that evaluates psychosocial adjustment, activity restriction, and satisfaction with the prosthetic device 3)Orthotics and Prosthetics User Survey (OPUS) -self-report instrument that assesses for functional status, quality of life, and client satisfaction with the prosthetic devices and services. The survey is used to examine both upper and lower extremity function 4)The Southampton Hand Assessment Procedure (SHAP) - examines upper limb prosthetic use during manipulation of 8 objects and 14 ADL tasks 5)Activities Measure for Upper Limb Amputees (AM-ULA) -observational measure of activity performance for adults with upper limb amputation that evaluates task completion, speed, movement quality, skillfulness of prosthetic use, and independence

Unilateral Upper Extremity Amputation: Activities of Daily Living Assessment

comprehensive checklist of functional activities that can be used as a reference to show progression with advanced prosthetic training

Basic Maintanace Procedures

daily socket cleaning and inspection; battery charging procedures for the prosthesis; component maintenance; harness adjustment; and cable system changes and rubber band replacement

Wound Healing and Limb Shaping

Figure-eight limb wrapping with an elastic bandage is performed for distal to proximal compression and shaping of the residual limb. The limb must never be wrapped in a circular manner because this restricts circulation and causes a tourniquet effect. Once the wound has stopped draining and clearance has been obtained from a physician, progression to use of an elastic shrinker or a compression garment can be initiated

Use Training

Goals: -important because this involves moving the prosthetic units in their optimal position to grasp an object or perform given activity in most efficient manner, thereby avoiding awkward body movements used to compensate for poor pre-positioning. -mastering pressure control Method: -control drills in patterns of reach, grasp, and release of objects of various sizes, weights, densities, and shapes. -Sequence (and progression) typically is from large, hard objects to smaller, softer ones. These objects should be placed in positions that require elbow and TD pre-positioning

Walkers

Most patients use walkers during initial phases of rehab. -four-footed standard -two-wheeled rolling

initial rehabilition

Of utmost importance is the maintenance of ROM and strength to the shoulder flexors, abductors, and rotators, as well as the scapular protractors and retractors, because limitations in these motions may result in an increased risk of rejection of the prosthesis

electric hand

Preserves the anthropomorphic nature of the human hand. The belief is that our environment is made up of objects designed to be handled by the human hand. Therefore, it would follow that a device designed with the same qualities as the human hand would offer the most function

Targeted muscle reinnervation (TMR)

Surgical technique used to increase the number of myosites (control signals) available for use, thereby increasing the potential for improved prosthetic function. -"target" muscle so that the myosites physiologically correlate with the prosthetic movements -response in which sensory nerves from the residual limb can be directed to the chest, resulting in perceived touch of the phantom limb. -Neuroma management and pain

functional envelope

area of space in which the client can operate the prosthesis

five mosts common types of UE prosthetic systems

body-powered, electrically powered, hybrid, activity-specific, and passive prostheses.

Evaluation of the Prosthesis

checked for: prescription's requirements, functions efficiently -mechanically sound -fit and function against specific mechanical standards tests performed: comparative ROM with the prosthesis on and off; control system function and efficiency; TD opening in various arm positions; amount of socket slippage on the residual limb under various degrees of load or tension; compression fit and comfort; and force required to flex the forearm or open/close the TD.

body-powered prosthesis

driven and controlled by gross body movements - must be able to perform one of the following movements to control this prosthesis: (1) glenohumeral flexion, (2) scapular abduction or adduction, (3) shoulder depression or elevation, (4) chest expansion, or (5) elbow flexion.

Electrically Powered Prosthesis

electrically powered prosthesis, also known as a myoelectric prosthesis (mentioned earlier), uses muscle surface electricity to control the operations of the terminal device. The muscle generates an electric potential at the time of contraction

goal of myosite testing

identify two muscle sites that would fit appropriately within the socket with the greatest microvolt difference between them myotester can be used to train the muscles with both visual and auditory feedback

telescoping

individual may feel that the distal portion of the phantom hand has retracted closer to the end of the residual limb

Body Symmetry and proper trunk alignment

limits the possibility of cumulative trauma or overuse injuries of the upper limbs, neck, or back

residual limb support

padded board that is placed on the seat of the wheelchair, helps facilitate extension of knee in order to prevent edema and contracture -wheels in chair are moved back, in order to accomodate change in weight distrubution

hand dominance

prosthesis has limited fine motor prehension and dexterity, it is important to transfer hand dominance in handwriting to maintain independence with written communication.121 Clients learn and adapt quickly to limb loss and often begin to perform ADLs on their own with the nondominant hand.

What are the components to body powered prostheses?

prosthetic sock, socket, harness and control system, terminal device, and wrist unit

How are amputations of upper extremities described?

referred to by their relationship to the elbow joint: above elbow (AE) and below elbow (BE).

Residual limb hygiene

residual limb can sweat, since it is in the socket -instructed to wash end of limb daily, use antiperspirants, socks or liners

neuroma

small ball of nerve tissue that develops when growing axons attempt to reach the distal end of the residual limb

main components of an LL prosthesis

socket, a sock or gel liner, a suspension system, a pylon, and a terminal device

pylon

structure that attaches the socket to the TD -Vertical shock pylons function as shock absorbers for LL prostheses.

Myodesis, myoplasty, and myofascial closur

surgical techniques used to stabilize muscle and tendons of residual limb and provide adequate soft tissue padding to distal end of bone

myoelectric sensors (IMES)

surgically implanted into various muscles in the residual limb. - improve accuracy of signal reception, provide intuitive control, and enhance simultaneous control of multiple degrees of freedom of the prosthetic hand

Electrically Powered Components

terminal device and the wrist unit

the longer the residual limb________.

the greater the functional outcome

Acquired Amputation

the loss of part or all of an extremity as the direct result of trauma/disease or by surgery