6122 - Amputation: Etiology and Prefitting Management (Done)

The top three causes of amputations is what?

1. Peripheral Vascular Disease (some would say diabetes but it's kind of a chicken and an egg situation) - most likely lower extremity. 2. Trauma - 2nd most common lower extremity amputation cause and 1st most common upper extremity amputation cause. 3. Infection.

The three most common amputations are what?

1. Toe 33% 2. Transtibial 28% 3. Transfemoral 26%

Cardiovascular endurance is important with a new amputee, and can be particularly challenging considering the likelihood of PVD and DMII. What objective test is recommended to establish a cardiovascular training baseline? What key measure correlates with a successful prosthetic outcome?

2 - minute walk test. The ability to achieve exercise intensity > 50% VO2 max.

To balance edema control, enough time to help shaping, and being soiled, a wrap should stay in place on a fresh amputation about how long?

4 - 6 hours Keep a schedule if it helps.

A standard transtibial amputation is approximately ____ inches long. Why is this standard used? A standard transfemoral amputation is approximately ____ inches long. Why is this standard used?

5 - 7 inches (Baker says 33-50% of tibia) This seems to be the best length for future prosthetic use and functional mobility. Longer or shorter have more discomfort and/or biomechanical impairments. 5 - 8.5 inches (you're safe for both around ~7 inches it seems) Same deal really.

A temporary prosthesis should be considered how soon after an amputation? When should weight bearing be encouraged?

ASAP, as soon as the wound has healed! Also as soon as the wound has healed, though it will likely take some desensitization and partial weight bearing strategies at first...

What are some medical conditions that might prevent a patient from being a candidate for a prosthetic?

Advanced cardiovascular/pulmonary disease. End-stage-renal-disease History of CVA Morbid Obesity BMI >40 Patient motivation Significant hip and knee flexion contractures already present >15 degrees.

What functional assessment can be converted into a "K" level?

Amputee Mobility Predictor. Very cool assessment. Worth taking a look: https://www.tac.vic.gov.au/files-to-move/media/upload/ampnopro.pdf

The primary cause of peripheral vascular disease is what?

Atherosclerosis. Diabetes accelerates and complicates the issue, but the condition is still technically atherosclerosis.

Positioning for a transtibial amputation should focus on?

Avoiding hip and knee flexion contractures.

Positioning for a transfemoral amputation should focus on?

Avoiding hip flexion, ER, and ABD contractures.

Steps to desensitize a residual limb include?

Begin with manually rubbing, tapping, and massaging, then try rubbing circular motions with increasingly coarse materials like cotton ball > tissues > terry cloth. Use a towel to loop around stump and apply axial pressure, then progress to PWB on a bathroom scale to track weight-bearing ability.

Review Lursadi Ch 16 on wheelchairs...

Bleh.

What are the number one and number two ways that diabetes contributes to amputations.

Chronic hyperglycemia in the blood accelerates the degradation of blood vessels and increases the risk of atherosclerotic plaque formation, which become peripheral vascular disease, the #1 cause of LE amputations. Beyond that, diabetic peripheral neuropathy leads to foot ulcers and a metabolism that is unable to heal them or prevent infection, and the limb is amputated as a result.

From a direct PT care perspective, what is one of the biggest complications of amputation surgery that if left unchecked could prevent a patient from being able to ambulate later.

Contracture.

The goal of shaping a residual limb is to get a nice ________ shape.

Cylinder. NOT a cone or a dog-ear.

During a surgery, if a nerve is not retracted, what is the potential for complication?

Development of a painful neuroma that can be a barrier to prosthetic use.

Any exercise for an amputee is good to prepare for prosthetic training, but which muscle quality is the best prognostic indicator for success?

Endurance. Keep your reps relatively high and your rest relatively short if you want them to start walking again...

Edema is still edema, so gravity dependent positions will increase it, but elevating the residual limb will encourage flexion contractures. What is a solution?

Go prone.

What muscle length is a significant concern after a transtibial amputation and effects both hip flexion and extension.

Hamstrings. (that's what her notes say... not sure what her intention was but whatever, just stretch the hamstrings out)

What ROM exercises are critical post lower extremity amputation? This means you will want your patient to spend time in _________ position on a regular basis.

Hip and knee EXTENSION. Got to avoid those flexion contractures. Prone.

____________ is a key prognostic indicator for functional gait.

Hip extensor strength

What are the medicare functional "K" levels that determine how much they will spend on a patient's prosthetic? Where do they get this information from?

K0 - no ability to ambulate or transfer K1 - ability or potential ability to ambulate on level surfaces with a fixed cadence K2 - " " + low barriers K3 - " " + variable cadence K4 - " " + exceeds basic ambulation skills This information comes in part from our assessments!

When testing a (healed) amputee with MMT, keep in mind what basic principle of MMT may no longer apply?

MMT basic principle is to apply force at the most distal portion of the bone involved in the joint. However with an amputee that likely is no longer there... so bottom line, stay symmetrical when testing from side to side. Test the uninvolved side the same way as you do the amputated side.

Keep in mind, when retraining gait post-amputation, the shorter a limb is the (more/less) energy it takes to walk.

More! - kind of the opposite of what you would think...

What exercise progression should you follow post amputation surgery? There should be no _________ to a residual limb during exercise until the wound has healed!

Same as any surgery. Gentle isometrics > AROM in pain-free zones > light stretching > progress to end ranges and resisted exercises. resistance

What is a common mistake in the pre-prosthetic phase that will impede your patient's progress towards mobility and gait.

Not enough resistance in the exercises. Once those wounds have healed and the edema is under control GET AFTER IT.

Fall risk is highest during which of the phases of amputation rehabilitation?

Phase I - everything is still new and disorienting.

What the three general phases of amputation rehabilitation and their basic goals.

Phase I - post operative - incision management, healing, management of limb. Phase II - pre-prosthetic - preparing residual limb for prosthesis. Phase III - prosthetic fitting and training - gait, mobility, ADLS, work, recreation.

What are some of the reasons that an amputee has an increased risk of falling, and what phase it the highest risk?

Phase I, right after operation. BOS, COG, coordination, and movement patterns have all changed. Plus now you have drug interactions, anemia, hypotension, pain, numbness/sensory impairment. Same old stuff as any other serious surgery really.

A knee disarticulation is preferred over a transfemoral amputation for what reason, particularly in younger populations?

Preservation of the growth plate.

What are the pros and cons of the semi-rigid and rigid dressings compared to the softer ACE wrap and shrinker?

Pros - the more rigid it is, the better the edema control and more protection it gives to the stump. Cons - they are expensive, require a prescription, cannot be applied by the patient alone, and there is no access to the incision.

Transfer activities are easier to accomplish when transferring to the _________ side.

Stronger, or in this case, still attached. Just like everything else.

For an amputee, rolling in bed from one side to the other is always more difficult towards which side?

The normal limb. There is less to push off with and less momentum to swing around.

What are the pros and cons of a shrinker compared to an ACE wrap for wrapping residual limb?

The pros are a shrinker has better edema control, and is much easier to apply for the patient. The cons are a shrinker can cause shearing forces, cannot adjust with the size of the stump, and can only be used after surgical sutures are removed. It also prevents easy access to the incision site.

During rehabilitation, remember to look past the amputated limb and to train what?

The rest of the body! The patient will likely be extra deconditioned, the rest of their body probably has PVD, and now the rest of their body like their upper limbs and trunk will require more strength for mobility than ever before. Goh said "endurance exercises need to be done every day post-amputation"

During a amputees first few standing attempts after their surgery and before a prosthetic, what is a common reason for losing balance?

The tendency to spin when standing on their remaining limb.

Regularly perform the _____________ test to assess your patient for hip flexion contractures. Use the ____________ test to examine both hip and knee contractures.

Thomas Test Modified Thomas Test These not only make a good assessing tool, but could also be used for treatment...

Simply describe what is occurring in phantom-limb pain? What can we do to assist with phantom-limb pain?

Though the limb is gone, the area of the brain mapped out for it's sensation is still active and receiving misguided signals. The result is pain that feels numb, tingling, burning, cramping, shooting, etc. Desensitization strategies, motor imagery, and exercising the surrounding muscles will help re-map the parietal cortex.

What does a typical amputee patient look like?

Very likely to be male, between 50-70 y/o. They will probably have peripheral vascular disease with diabetes and be getting a piece of lower limb chopped off.

When doing exercises for a new amputee, when in doubt, do ___________ exercises!

extension