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The primary responsibility of the occupational therapist in the rehabilitation program consists of

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formulation and execution of the preprosthetic program and prosthetic training.

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Preprosthetic phase

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the treatment plan involves preparing the limb for a prosthesis

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prosthetic phase

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treatment involves increasing tolerance and function with the prosthesis.

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The rehabilitation program involves

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an individualized intervention plan that helps the client with physical and psychological adjustments to function as independently as possible.

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Most amputations may result from

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1.trauma; 2.peripheral vascular disease (PVD);3. peripheral vasospastic disease; 4.chronic infection; 5.chemical, 6.thermal, or 7.electrical injury; or 8.malignant tumor.

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The major cause of lower limb amputation is

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PVD, often associated with smoking and diabetes.

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Approximately 75% of upper limb amputations in adults are caused by

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trauma.

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The surgeon attempts to preserve as much

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length as possible and to provide a residual limb that has good soft tissue coverage and vascularization.

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Preservation of limb length directly affects

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the type of prosthesis that the limb can support

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During and after surgery the primary goal is to

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form a residual limb that maintains maximal function of the remaining tissue and allows maximal use of the prosthesis.

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The open method allows

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drainage as the surgical site heals and minimizes the possibility of infection.

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The closed method

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reduces the period of hospitalization but also reduces free drainage and increases the risk of infection.

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When the surgeon reconstructs a residual limb (sometimes referred to as a stump) this is done to

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achieve optimal prosthetic fitting and function.

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Several factors and potential problems can affect the outcome of rehabilitation:

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1. Length of the residual limb, 2. skin integrity, 3.edema, 4.sensation, 5.pain, 6.time for healing, 7.infection, and 8.allergic reaction to the prosthesis.

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account for most postsurgical problem

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skin

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o Complications of Preprosthetic phase-

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1.Delay healing (earliest preprosthetic complication) results in postponed prosthetic fitting, and development of necrotic areas.

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Extensive skin grafting- if skin graft adheres to the bone

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the area may ulcerate. Daily massage decreases skin graft adherence to bone.

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o Complications of prosthetic phase-

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1.Skin breakdown (ill fitting socket or wrinkles in the prosthetic sock), 2.ulcers, 3.infected sebaceous cysts (torque forces between socket and residual limb), and 4. allergic reactions.

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o Complications of both phases-

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1.Residual limb edema. Immediately after surgery, the residual limb is normally edematous as a result of fluid that collects within the soft tissues, especially in its distal portion.

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Compression wrap-

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ping, that is, wearing a prosthetic sock or a rigid dressing, helps decrease the edema.

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Sensation-

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Residual limb hyperesthesia, neuroma, and phantom sensations are problems that interfere with functional use of the limb with or without the prosthesis

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Residual limb hyperesthesia

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- overly sensitive limb. Desensitization consists of texture stimulation, tapping, and massage.

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o Neuroma-

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small ball of nerve tissue that develops when growing axons attempt to reach the distal end of the residual limb. Most neuromas occur 1 to 2 inches (2.5 to 5 cm) proximal to the end of the residual limb and are not troublesome.

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o phantom limb

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. sensation of the limb that is no longer there. The phantom usually occurs initially immediately after surgery.

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o Phantom sensations are different from phantom limb in that they are

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detailed sensations of the limb. Individuals may describe these as cramping, squeezing, relaxed, numb, tingling, painful, moving, stuck, shooting, burning, cold, hot, or achy. Phantom sensations are described as constant or intermittent.

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Bone -

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formation of bone spurs

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· Wound Healing factors affecting would healing

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-smoking, failure of limb revascularization, severity of vascular problem, diabetes, renal disease, cardiac disease.

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Body-Powered Prostheses factors?

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The client's age, medical status, amputation level, skin coverage, skin condition, cognitive status, and desire for a prosthesis are important factors in making the decision.

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Levels of amputation and functional losses in the upper limb

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The higher the level of amputation, the greater is the functional loss of the limb. TABLE 43.1 page 1157

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Component Parts of Upper Limb Body powered prosthesis

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first five prosthetic components described in the following sections are common to all body-powered pros- theses prescribed for wrist disarticulation and higher levels.

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1. Prosthetic Sock

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A prosthetic sock of knit wool, cotton, or Orlon Lycra is worn between the prosthesis and the limb, minimizes hypertrophic scaring, absorbs perpiration, protects irritation

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2. Socket

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The socket is the fundamental component to which the remaining components are attached.

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3. Harness and Control System

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The prosthetic control system functions through the interaction of a Dacron harness and stainless-steel cable. The figure-of-eight harness is commonly used, although others are available. The harness is worn across the back and shoulders or around the chest and fastens to the socket to secure the prosthesis.

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4. Terminal Device most distal component

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functions to stabilize or hold an object. Consider age and roles. Two styles: Hook and hand.

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5. Wrist Unit connects

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the TD to the forearm socket and serves as the unit for interchange and to pronate and supinate the TD for prepositioning purposes. The wearer rotates the TD by turning it with the sound hand, by pushing the TD against an object or surface, or by stabilizing the TD between the knees and using the arm to rotate it.

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Remaining body-powered prosthetic components maximize function at

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specific levels of amputation. These components are the elbow hinges for trans-radial prostheses, elbow units for trans-humeral prostheses, and shoulder units designed for shoulder prostheses

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Trans-radial Hinges-

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stabilize and align the trans-radial prosthesis on the residual limb. Distributes stress of the prosthesis on the limb

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Elbow units for Trans-Humeral Prostheses-prescribed for the person who has had an amputation through the level of the elbow or higher. The elbow unit allows--degrees of flexion

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5 to 135 degrees of elbow flexion and locks in various positions.

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Shoulder Units most shoulder units are manually operated and friction held because

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shoulder and back movements are not sufficient.

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Two shoulder unit styles that are often prescribed are the

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flexion-abduction unit and the locking shoulder joint

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Preprosthetic Program-OT coordinates program may include

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education on prosthesis options, relaxation techniques, phantom limb. Program prepares residual limb for prosthesis, facilitate adjustment for loss, and achieve independence in self-care.

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· Evaluation

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Assess medical hx, motor skills, body functions, ADLs IADL's

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· Treatment unilateral amputation:

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one-hand activity completion usually outpatient.

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Bilateral-inpatient setting-address

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functional independence

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Interventions for Body Functions

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body structures, and performance skills, Improve body image, self-image, psychosocial adjustment. Promote independent function during ADLs and IADLs.Promote wound healing. Improve desensitization of the limb.

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pain management practices.

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Promote residual limb shaping and shrinking. ,Promote proper skin hygiene. ,Promote care of insensate skin. Maintain and restore passive and active range of motion. Maintain and restore upper body strength and endurance. Improve understanding of prosthetic components and options. Recommend appropriate prosthetic components.

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Prosthetic ProgramThe prosthesis will not be as functional as a normal arm and training for the client with a unilateral amputation should stress

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that the prosthesis functions primarily as an assist or helper to the sound arm. If the prosthesis is presented in this manner, the wearer may experience less difficulty when incorporating it into daily occupations.

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In training the person with bilateral amputations to function with prostheses

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the likelihood of success with one prosthesis is high, as the wearer instantly recognizes the benefit of the prosthesis to independent function.

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The occupational therapy intervention is

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occupation-based and includes purposeful activity and preparatory methods to facilitate therapeutic goals. These include the following: 1.Promote positive body image and self-image,2.Establish successful adaptation and problem-solving skills , 3. Promote proper residual limb and prosthetic sock hygiene, 4. Promote recognition of prosthesis terminology and function ,5. Promote proper care of the prosthesis ,6. Establish a prosthesis-wearing schedule and routines 7.Promote control of the prosthesis (control training) 8. Promote use of the prosthesis in activity (use training) 9 Promote independent ADL and IADL function with the prosthesis (functional training) 10.Promote driving modifications and ability 11. Recommend a home activity program 12. Restore upper extremity muscle strength necessary for operation of the prosthesis 13. Prevent repetitive use injury of the sound arm 14. Promote vocational re-entry 15. Establish follow-up care 16. Promote social routines and community integration

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BODY IMAGE AND SELF-IMAGE

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observe body language (is client hiding prostheses?). Facilitate styling hair, apply makeup, drive, resume physical activity

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RESIDUAL LIMB AND PROSTHETIC SOCK HYGIENE

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he residual limb and armpit should be inspected, washed, and patted dry, deodorant and clean sock should be applied daily.

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CARE OF PROSTHESES Inspect prosthesis

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daily

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PROSTHESES WEARING SCHEDULE

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the client initially wears the prosthesis 15 to 30 minutes three times a day, if not problems arise, increase by 30 min each day increase number of rubber bands to terminal device to increase pinch force.

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CHECKOUT OF PROSTHESIS

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check for fit. tests performed are 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.

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TRANS-RADIAL PROSTHESIS

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With the elbow flexed at 90 degrees, the client should be able to open the TD fully. The TD is also opened near the mouth (elbow fully flexed) and again near the zipper of the trousers (elbow extended). From 70% to 100% of TD opening should be achieved in these two positions.

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TRANSHUMERAL AND SHOULDER PROSTHESIS Minimal standards for shoulder ROM with the prosthesis on are as follows:

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90-degree flexion, 30-degree extension, 90-degree abduction, and 45-degree rotation.

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DONNING AND DOFFING

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the harness and cables must not be kinked or twisted around the prosthesis before starting. Two common methods are coat and sweater methods

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CONTROL TRAINING

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Joint protection, energy conservation, and work simplification principles and techniques should be stressed during this phase of training. Each prosthetic component should be reviewed separately and understood before the components are combined into functional activities.

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A. Control Training for unilateral Trans radial Prosthesis Terminal Device Control-

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Scapula abduction and glenohumeral flexion are the motions necessary to open and close the TD

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B. Control Training for unilateral Trans radial Prosthesis Pronation and Supination-

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Stabilize elbow at 90 degrees to pronate and supinate forearm.

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C. Control Training for unilateral Trans radial Prosthesis Exchanging terminal devices-

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Exchange TD in the wrist, When the TD has been removed, another TD style may then be positioned in the wrist unit and the cable attached to it.

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Control Training for Unilateral Trans-Humeral Prosthesis

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Most trans-humeral prostheses operate through the use of a dual-control cable system. When tension is applied on the cable attached to the elbow unit, it locks and unlocks.

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A. Internal and External rotation-

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The person operates the turntable, first with the elbow at 90 degrees, by manually rotating the forearm medially (toward the body) or laterally (away from the body)

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B. Elbow Flexion and extension-

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protect face from flexion- therapist asks the client to flex the humerus slowly and to simultaneously abduct the scapula to accomplish elbow flexion, and to slowly extend the shoulder to achieve elbow extension.

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C. Elbow locking-

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he elbow unit operation has an audible two-click cycle. Both clicks must be heard each time the unit is locked or unlocked

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D. Terminal device control-

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he person is instructed to lock the elbow, first at 90 degrees, and to perform the motions to operate the TD. Client rotates the TD manually in the wrist unit and to exchange TDs.

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Control Training for the shoulder disarticulation prosthesis

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- learns the two-click cycle and dual-cable system of operation described previously for the trans-humeral prosthesis. The elbow turntable is also available for a shoulder prosthesis.

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Control Training for bilateral Prostheses

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- client must learn to operate each prosthetic component without affecting the components on either side. This skill is called separation of controls. Wrist flexion unit and a cable-operated wrist rotation (not used for unilateral), prescribed to improve functional independence.

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USE TRAINING-

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wearer to gain an understanding of how to pre-position the prosthesis and the objects, and how to use the environment to help pre-position them

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• use training for Pre-positioning-

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All prosthetic components must be pre-positioned in a proximal-to-distal order.

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• use training for Prehension training-

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The person first should use large, hard objects such as blocks, cans, and jars and progress to soft, then to crushable objects, such as rubber balls, sponges, paper boxes, cones, and paper cups.

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• Use training for bilateral prostheses-

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client learn separation of controls is holding an object in one prosthesis without dropping it, while completing an activity with the other prosthesis.

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FUNCTIONAL TRAINING

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Prehension training and methods to complete ADLs and IADLs, including vocational, leisure, and driving skills, are addressed in this phase.

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• fxnl training for Prehension Training- teaches the client to use all prescribed TDs in a meaningful manner

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such as using the heavy duty TD with tools and the hand to eat

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• fxnl training for Activities of Daily living

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Personal care and hygiene activities are performed first.

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• fxnl training for Adaptation and problem solving

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With guidance and practice, they can accomplish the activity with their sound arm as the dominant arm and use the prosthesis to assist

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• Work-related activities

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sit to the worksite may be necessary to make recommendations that will enable the client to return to work in a safe and efficient environment

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• Social routines and

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community integration

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• Driver Training may refer to

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adaptive driving program, OT assess predriving skills

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• Duration of training- unilateral trans-radial average is

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8 hrs 5-10 treatment sessions.

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training Unilateral transhumeral-

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12 hours,

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bilateral trans radial training

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15 hrs.

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training Bilateral trans humeral

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20.

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Electric -

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Powered Prostheses

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myoelectric prosthesis

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uses muscle surface electricity to control the prosthetic hand function. The muscle membrane generates an electric potential at the time of contraction.

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Advantages of myoelectric prosthesis

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Improved cosmesis, increased grip force (25lb), minimal/no harnessing, ability to use overhead, minimal effort needed to control, control more closely

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Disadvantages of myoelectric prosthesis

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Cost of prosthesis, frequency of maintenance and repair, fragile nature of glove necessity of frequent replacement, lack of sensory feedback, slowness in responsiveness of electric hand, increased weight.

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Candidates for Prostheses

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Before a myoelectric prosthesis is prescribed, the client should have adequate strength and the ability to contract muscles independently. A minimum muscle signal of 5 microvolts will operate the most sensitive system. The candidate with this minimum signal should be capable of developing stronger signals for longer-term use of the prosthesis. Independent contraction of each muscle is important to produce smooth and controllable prosthetic function

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Hybrid Prostheses

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combines body power with electrical power. in many cases can serve as a prosthesis that is more functional and more acceptable to the individual

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Preprosthetic therapy With an electric prosthesis

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additional treatment goals are as follows: Identify or test potential muscle sites for prosthesis control. - Locating appropriate superficial muscle sites is the most important aspect of the successful operation of a myoelectric prosthesis. EMG testing begins with the most distal portion of the remnant muscle. Improve muscle site control and strength (once identified). he goals of training at this point are to increase muscle strength and to isolate muscle contractions. As confidence and accuracy improve, visual or auditory feedback should be removed. Practicing muscle contractions without feedback teaches the client to internalize the feeling of each control movement.Obtain adequate financial sponsorship for the prosthesis and training

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Prosthetic program-client understands the functional potential and limitations of the prosthesis

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success can be more realistically achieved

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ORIENTATION AND EDUCATION

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orientation to prosthesis terminology and operation, independence in donning and doffing the prosthesis, orientation to a prosthesis-wearing schedule, and care of the residual limb and prosthesis.

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ORIENTATION TO PROSTHESIS TERMINOLOGY

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Review the battery-charging procedure with the wearer.

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INDEPENDENCE IN DONNING AND DOFFING THE PROSTHESIS

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Turn off before donning. A silicone-based skin lotion applied to the skin before donning the pull sock enables the person to remove the pull sock with less effort.

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PROSTHESIS-WEARING SCHEDULE

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Initially no longer than 15-30 min. if no skin problems arise, wearing period can increase by 30 min increments

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CARE OF THE RESIDUAL LIMB AND PROSTHESIS

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Appropriate care of the skin is vitally important. The residual limb should be washed daily with mild soap and lukewarm water. It should be rinsed thoroughly and dried thoroughly.

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CONTROL TRAINING

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first function to master is opening and closing of the TD. therapist will design a home program of specific patterns of terminal device action that the person performs, to offer more practice.

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USE TRAINING

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repetitive grasp and release of objects is introduced after control training. These activities are considered preparatory in that they prepare the person for functional activity.

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Simple approach grasp

answer

and release activities are practiced with ,objects of various shapes, sizes, and densities. training a client to grasp an object is mastering pressure control or the gripping force of the TD. Working on approach, grasp, and release in multiple arm positions then follows. Release is accomplished by visualizing a wrist extension contraction or a quick "hand up" or "fingers open" in the person with a trans-radial amputation

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FUNCTIONAL TRAINING The prosthesis is used as a functional assist in most

answer

bilateral activities. Therefore, most functional activities are accomplished with the uninvolved arm and hand as dominant. The therapist will review a list of bilateral ADLs with the client to determine which tasks are most important for him or her to accomplish. The therapist will focus on these purposeful and occupation-based activities during training, stressing throughout that the myoelectric TD is used as an assist and a stabilizer

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VOCATIONAL AND LEISURE ACTIVITIES

answer

As training proceeds and a sense of the person's self- acceptance and comfort with the amputation is heightened, the therapist will address the subject of return to work. Ideally, the therapist makes an on-site visit. job requirements can be discussed and then practiced in a simulated, step-by-step process during a therapy session.

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SELF MANAGEMENT INSTRUCTION

answer

information regarding a wearing sched- ule, care instructions, and additional tasks to practice should be shared with the wearer and his or her family members.

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A transfemoral or above-knee amputation (AKA)

answer

results in loss of the knee and everything distal to it.

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A through-the-knee (disarticulation) amputation does result in

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loss of knee joint function, but it allows a high level of prosthesis control and mobility.

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A transtibial or below-knee amputation (BKA) pre-

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serves the knee and thus eliminates the necessity for a mechanical knee joint in the prosthesis

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A Syme's amputation

answer

or ankle disarticulation, results in loss of both ankle and foot function and is typically performed in cases of trauma or infection.

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A transmetatarsal amputation results in

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severing the foot through the metatarsal bones, but the ankle remains intact. although amputation of the first toe impairs ambulation by preventing toe-off. loss of the small toes does not usually result in impaired ambulation.

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95% of LL amputations are performed as a result of complications of

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PVD

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Postsurgery Residual Limb Care

answer

Wrapping with an elastic bandage, is a common method to control edema after surgery.

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Lower Limb Equipment and Prostheses

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A residual limb support is basically a padded board that is placed on the seat of the wheelchair; it has an extended component on the side of the affected limb that projects forward from the seat of the chair

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Antitippers

answer

commercially available wheelchair accessories, can also be used on the back of the chair to reduce the likelihood of tipping backward during weight shifting.

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For all prostheses what improves QOL?

answer

comfort, ease of application, appearance, and function of a pros- thesis, including the client's ability to perform ADLs and IADLs with use of the affected limb, correlate significantly with the client's walking distance and with his or her perceived quality of life after an LL amputation.

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The socket is the direct connection between the

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residual limb and the prothsis

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The pylon is the structure that attaches the socket to the

answer

TD

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The TD is the

answer

prosthetic foot, which provides a stable weight-bearing surface and can itself function as a shock absorber.

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Client Factors-

answer

Structures related to movement, as well as skin and related structures, are always altered by an LL amputation.

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Performance Skills

answer

Sensory and perceptual skills may also be affected by the amputation, and a client may have had prior difficulty with these skills caused by impaired sensory function.

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Performance Patterns

answer

The client may already have useful habits, routines, rituals, and roles that can be drawn upon in therapy to facilitate his or her return to prior levels of occupational performance.

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Psychosocial Repercussions

answer

The therapist can teach the client coping skills for dealing with anxiety and depression, as well as techniques for improving postsurgical body image.

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Context and Activity Demands

answer

therapist adapt the activity demands of the client's chosen occupations to facilitate greater independence and development of proficiency.

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Additional Considerations for Elderly Clients

answer

older persons who underwent a BKA found the survival probability after BKA to be 77% at 1 year, 57% at 3 years, and 28% at 7 1 2 years

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Incidence -

answer

2 million people living with limb loss in U.S., more than 185,000 annually, ratio of arm to leg is 1:3.

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57% upper limb amputations are

answer

transradial - below elbow through the radius and ulna.

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Trauma rather than disease is

answer

primary cause (close to 75%) of upper limb amputations in adults with injury occurring primarily to males aged 15-45 in work related accidents.

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Disease is primary reason for

answer

lower limb amputations, with peripheral vascular disease and diabetes being most common in people older than 60.

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As of January 2012

answer

over 1,400 military service members have sustained limb loss as a result of wars, with over 200 sustaining UE amputation.

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Forequarter

answer

- amp amputation of the arm, scapula, and clavicle.

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Transhumeral

answer

(AE -above elbow) - an amputation through the humerus

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Transradial

answer

(BE -below elbow) - amputation through radius and ulna

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Higher amputation

answer

more difficult it will be to use a prosthesis because fewer joints and muscles are available to control prosthesis and weight is greater.

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Preprosthetic therapy program occurs

answer

from post surgical period until patient receives a temporary (test) or permanent prosthesis.

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Postoperative care addresses

answer

wound care, maintenance of skin integrity, joint mobility, reduction of edema, prevention of scarring, and control of pain.

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Phantom limb sensation -

answer

sensation in missing limb. Cause is unknown. Most common in adults with traumatic amputations. Strongest in UE and felt more vividly in hand and fingers.

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Telescoping -

answer

distal portions of phantom limb have moved closer to the site of the amputation. Phantom limb often remains and client learns to accept, may view as annoyance if sensation is mild burning or tingling.

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Phantom limb pain -

answer

can be intense burning or cramping or shooting pain.

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At least 90% of people with limb loss experience

answer

phantom limb pain.

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CNS changes and PNS damage are thought to cause

answer

phantom limb pain and psychological factors may trigger. Pain increases with stress. Therapist is advised to avoid emphasizing pain when possible. Tx - analgesics and surgery, such as nerve blocks and neuroctomies.

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In rehab setting TX for phantom limb - limb percussion

answer

ultrasound, TENS, acupuncture, psychotherapy, hypnotherapy, relaxation techniques.

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Mirror therapy

answer

- mirror placed at midline and against patient's chest or groin depending on level of amputation, residual limb is placed behind the mirror and intact limb is placed in front of mirror so patient can observe the reflections of the intact limb in mirror. Mirror should be close enough to obstruct view of residual limb. The patient is instructed to place intact limb in position that residual limb feels and patient should move phantom limb through motions that do not elicit pain in phantom or residual limb. Typically fatigue easily so may only perform 8-12 min. but should be encouraged to work up to 15-20 min. daily over a 4 week period as part of home program.

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Psychological aspects of limb loss -

answer

affects competence and satisfaction in life roles. Early response is shock and disbelief, when both UE amputated may feeling of helplessness.

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Depression rates higher in amputees than general population for

answer

up to 2 yrs.

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Anxiety rates

answer

also higher but readjusted after 1 year.

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Therapist should encourage

answer

open discussion, develop trust and work with treatment team. Give patient information, explain therapy and establish realistic goals. Introduce patient to a peer visor who has similar amputation to facilitate discussion on stages of recovery. Provide patient with referenced material, topics on coping, adjusting to amputation, ADLs. Communicate with the psychologist, counselor or other team members.

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Preprosthetic program guidelines

answer

1.Provide emotional support - establish supportive, trusting relationship with patient and family 2. Instruct limb hygiene and expedite wound healing - instruct patient to wash limb daily with mild soap and dry it thoroughly, provide basic wound care such as cleansing or debridement, use creams to massage at scar line to decrease scar adhesions. 3.Minimize limb shrinkage and limb shaping - goal is to shrink and shape residual limb so it is tapered at the distal end for optimal prosthetic fit. 4. Interventions include: elastic bandage - patient is taught to wrap the limb in a figure of eight pattern independently or caregiver. Residual limb must be wrapped in figure of eight diagonal configuration, with most pressure applied at the end of the limb. (NEVER is a circular manner, this causes a tourniquet effect and restrict circulation). Wrapped in distal to proximal direction and worn continuously and reapplied immediately if loosen. (patient is advised to remove bandage 2-3x daily to examine for redness) clean bandage every 2 days - wash with mild soap and air dry.

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Elastic shrinker -

answer

if shrinker loosens, a small shrinker size will be needed. Shrinkers should be worn when not wearing prosthesis and while sleeping in order to maintain residual limb shaping and size.

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Early postoperative prosthesis -

answer

strongly recommended for bilateral UE amputations to reduce dependency for self-care.

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Temporary prosthesis may facilitate

answer

acceptable and use of permanent prosthesis.

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Early in phase -

answer

important to educate client and family on wear time/schedule of prosthesis. Wear time is gradual after initial fitting. Wear 15-30 min. then check for skin integrity. Daily wear time will incr gradually as tolerance and skin integrity improves.

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Desensitize residual limb

answer

- necessary to tolerate touch and pressure in preparation for fitting the socket. Goal can be met through: Residual limb wrapping or wearing of a shrinker. Percussion ,(tapping, rubbing and vibration) over residual limb

question

Massage to prevent or release adhesions and soften scar tissue .If not contraindications

answer

patient may bear weight on end of limb against various surfaces.

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Maintain or incr ROM and strength of limb

answer

- physical conditioning program is instituted to increase or maintain ROM of all joints proximal to amputation. incr muscle strength of residual limb and shoulder area are important to address. Core strengthening will promote postural control, balance and endurance and prevent asymmetry. Mobilization of limb will also incr circulation and reduce edema. Encourage client with unilateral limb loss to incorporate the residual limb into bilateral tasks. Patient education on risks of overuse of contralateral limb - such as biomechanical overuse syndrome, learned nonuse of amputated side, and reduction of cortical representation of amputated part.

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For amputation of dominant limb

answer

change of dominance activities, such as handwriting, must receive special attention. Therapist can provide tips for one-handed techniques or recommend adaptive equipment.

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Bilateral amputation

answer

- establishing some level of independence is essential for bilateral UE amputations, must be addressed promptly to lessen feelings of dependency and frustration.

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Universal cuff

answer

- useful for holding utensil or toothbrush (if patient has enough length in one of the residual limbs). Inserting a small pencil into universal cuff with eraser end downward can be used to operate cell phones, telephones, text messages. Smartphone - a stylus with thermoplastic, silicon, elastic or neoprene tip can be fabricated to be mounted on residual limb.

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Choosing prosthesis Consider these factors:

answer

Residual limb: length, ROM, skin integrity, strength,Preference for cosmesis and function,Hand dominance,Prior level of function and activity levels,Activities at work, home, school, community and recreational interests.Patient goals, motivation, and attitude.Financial coverage: health care insurance, ability to pay privately, and alternative funding sources.Cognitive abilities to learn to use various components

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Prosthetic systems-

answer

Most common UE prosthetic options available are body powered (BP), externally powered, hybrid, activity-specific, and passive prosthesis.

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BP system -

answer

uses motions from body, proximal to amputation, operate a TD (terminal device).

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Tension is produced from

answer

contralateral limb and the scapulohumeral motions are transferred to a TD through a cable.

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Externally powered

answer

- uses power external to body for operation. More commonly known as myoelectric systems - require electrical signals produced from muscle contraction to operate powered elbow and electric TDs.

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Hybrid

answer

- combo of BP and externally powered - often includes BP elbow and myoelectrical TD. For patients with elbow disarticulation or transhumeral amputations.

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Activity-specific -

answer

designed for specific function or activity.

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Passive prosthesis

answer

-endoskeletal, contoured to shape of the arm and covered with foam. Lightweight, contains an internal pylon shaft, designed with natural arm and hand characteristics. No functional component.

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Each option has a specific socket design for each level of amputation

answer

as well as harnessing and suspension options, available TDs

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Transradial amputation

answer

- The residual limb is encased in the socket of the prosthesis with total contact.

question

A standard forearm socket encases

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the full length of the residual forearm but can be modifed to allow for more active pronation and supination if the patient has a long residual limb as well as for more elbow flexion and extension.

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supracondylar socket (modifed Muenster)

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is a frequent choice for the short transradial limb; the proximal brim grips the humeral lateral and medial epicondyles and the posterior olecranon

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Transhumeral Amputation

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-The conventional socket edge is generally just near or above the acromion, depending on residual limb length. If rotational stability is of concern there are other variations to socket design that the prosthetist may consider.

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Shoulder Disarticulation and Forequarter Amputation.

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Most socket designs at this level consist of a plastic laminated shoulder cap or frame socket with carbon fiber reinforcements. Another choice is an endoskeletal passive arm that is lightweight and contains an internal pylon shaft.

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Harness and other control system options

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The harness serves two purposes: (1) to suspend, or hold, the prosthesis firmly on the residual limb and (2) to allow for force (through body motions) to be transmitted to the control cable on a BP or hybrid system.

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Wrist Units.

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The wrist rotation unit provides a means to attach the TD to the forearm. It also provides an important function: the TD can be rotated to positions of supination, pronation, or midposition before engaging in an activity.

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Wrist flexion units provide the user with the ability to manually flex at the wrist often at

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neutral, 30°flexion, or 50° flexion. Wrist flexion units are indispensable for the person with bilateral amputations because of their usefulness in reaching the midline for toileting, dressing, and eating.

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Two kinds of elbow units are available for the BP transhumeral prosthesis:

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(1) an internal elbow locking unit for a standard or short transhumeral amputation and (2) an external elbow locking unit for a long transhumeral or elbow disarticulation amputation.

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For an above-elbow externally powered prosthesis

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the elbow is controlled by electromechanical switches or by myoelectric control.

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Body powered terminal device prehensors

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TD prehensors for a BP prosthesis can be classifed as operating by a voluntary opening (VO) mechanism or voluntary closing (VC) mechanism.

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Voluntary Opening Terminal Devices.

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The VO hook is widely used and can vary in size. Hooks are made of aluminum, titanium, or stainless steel; some have rubber-lined fingers. The lining provides a firm grip and prevents slippage. Many available hooks can withstand the rigors of heavy mechanical activity and are able to facilitate holding tools in activities. The VO mechanical hands operate similarly to the VO hooks except that, in the hand, the thumb and first two fingers open when the cable is pulled. These fingers oppose in a three-point prehension pattern.Voluntary Closing Terminal Devices. A VC TD has strong variable prehension and is controlled by the amount of force the individual can exert. It is possible that a grasp of more than 30 pounds can be attained. This TD may be appealing for individuals who are active in sports, heavy physical work, or recreational activities. A VC mechanical hand has a thumb that can be manually adjusted and locked in two positions to achieve a 1.5- or 3-inch opening.

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Electrically Powered Terminal Device Prehensors

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The electrically powered prehensors are heavier (approx-imately 1 pound) but provide stronger pinch force (approximately 20-40 pounds) than the BP TDs.These devices are activated through myoelectric or switch control. The two speed systems are (1) digital control (constant speed), in which muscle contractions cause opening and closing at a given speed; and (2) proportional control (variable speed), in which the speed and pinch force increase in proportion to the intensity of muscle contraction.

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Electric hands -

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Sensorhand Speed by Ottobock has a motor in hand mechanism that drives thumb and first two fingers as a unit to provide palmar (three-point) prehension. Ultimate goal of these devices is to have individual articulating digits to include an opposable thumb and multiple grips, pinch, and grasp patterns.

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Electric hooks -

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Ottobock electric Griefer TD is available in one size, and its two "fingers" move symmetrically in opposition of one another for precision pinch. May be chosen when activity requires prehension force up to 40 pounds.

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Myoelectric control and terminal devices

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- numerous options available and each has advantages and disadvanges. Up to user to decide which TD is most useful and functional.

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Myoelectric site testing and training-

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muscle site testing is necessary for patients choosing a myoelectric prosthesis. Results in choosing optimal location for control site. Goal is to find site where patient can hold steady contraction for 1-2 seconds and relax for that time. Agonist and antagonist are chosen. During testing/training - electrodes are strapped to residual limb or encased in a test socket. Myotester is used to provide feedback.

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Cosmetic gloves

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- prosthetic hands will have rubberized covering or gloves - variety of colors and sizes. Stock production glove is one covering available. Polyvinyl chloride (PVC) least expensive but susceptible to staining. Silicone covering is more expensive than PVC, details such as veins, withstand extreme temps and do not stain as easily as PVC. Custom-sculpted and painted silicone gloves - aka anatomical cover - attempts to replicate individual's remaining hand. Remaining hand is cast in silicone, then reversed. Cosmetic restoration; more costly than stock production gloves.

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Bilateral UD prosthesis considerations

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- no ideal set up for all individuals with bilateral UE amputations - listen to patient and their needs and goals and consult with other team members. In the end, patient will select system best for them.

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Prosthetic training program Initial stage

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- covered in 1-2 therapy sessions

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Prosthetic training program Evaluation of prosthesis

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- therapist evaluates prosthesis before training.

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Prosthetic training program Eval is to determine:

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1- compliance with the prescription, 2 - comfort of fit of socket and harness, 3 - satisfactory operation of all components and 4 - appearance of prosthesis and its parts.

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First therapy session - unilateral amputations

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attend therapy on outpatient several days a week. Initial goal is to minimize negative experiences in order to facilitate future acceptance and use of prosthesis. Other topics on first visit include: donning and removing prosthesis, wearing schedule, hygienic care of residual limb.

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Donning and removing prosthesis

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- donning and doffing of full prosthetic system - residual limb sock, prosthetic donning liner, alcohol-based lubricant gels or powder, prosthetic socket, and harnessing.

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Methods for donning/doffing BP prosthesis

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- coat method and pullover method

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Coat method

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-residual limb is inserted into socket, which is held in place with the intact hand, with the harness and axilla loop dangling behind the back. Intact arm reaches behind and slips into the axilla loops; a forward shrug of shoulders positions the prosthesis in place.

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Pullover method

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- patient places prosthesis in front of him and intact arm is placed through the axilla loop while residual limb is placed into the socket. Both limbs are raised to lift the prosthesis and harness over the head as the harness falls into place.

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Wearing time -

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patient must increase wearing time gradually to develop tolerance to socket and harness. Initial time may be 2-3x of 15-30 min sessions spread out over day. Each time prosthesis is removed, residual limb must be examined for excessive redness or irritation. (redness that does not disappear after 20 min. should be reported to prosthesist for adjustment). Wearing time can be increased in 30 min. increments until worn all day.

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Limb hygiene

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- residual limb is enclosed in a rigid socket where excessive perspiration can macerate the skin. Instruct patient to inspect residual limb each time prosthesis is removed and wash residual limb with mild soap and lukewarm water and pat dry.

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Treatment Guidelines for Initial Stage of Prosthetic Training

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? Evaluate to determine roles, tasks, and activity needs and preferences.? Evaluate the prosthesis. ? Explain program goals to the patient.? Describe the functions of each component; give the patient an illustration of the prosthesis with components labeled.? Teach the patient to don and doff the prosthesis.

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Operational prosthetic knowledge

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: componentry and maintenance

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Componentry knowledge-

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patient must obtain and demonstrate knowledge of prosthesis componentry terminology and a general understanding of proper prosthetic maintenance. Basic common terminologies include but is not limited to (1) socket and harness design; (2) component identification, operation, and care; (3) types of TDs; (4) type of control system used; and (5) basic prosthesis mechanics. The goal is for the patient to be able to articulate problems to the prosthetist and therapist using correct terminology if the prosthesis malfunctions.

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Care of prosthesis -

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mild soap and warm water for daily cleaning of interior of socket to remove any residues of powders, lubricants and perspiration. Rubbing alcohol every several weeks. No added fragrance in lotions, hand sanitizer. Regardless of the type of prosthesis, basic prosthetic maintenance procedures that the patient is expected to be-come proficient with include (1) socket daily maintenance (i.e., daily cleaning and socket inspection), (2) routine battery charging procedures appropriate for the prosthesis, (3) component maintenance (i.e., routine cleaning and lubrication), (4) harness adjustment, and (5) rubber band replacement and cable system changes for BP prosthesis

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Intermediate stage -

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2 phases - prosthetic controls training and prosthetic functional use training.

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Prosthetic controls training -

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therapy for BP controls training begins with teaching the operation of each control, beginning with the TD. The therapist guides the patient to practice repetitive activation of each component.

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Transradial

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have single control system that activates the TD by cable pull. Patients activate TD through humeral flexion and scapular abduction (protraction).

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Transhumeral prostheses

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have dual control system for TD and elbow. Motions required to lock and unlock elbow are combination of scapular depression and humeral extension and abduction.

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Chest expansion can be useful for patients with

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higher level amputations or nerve involvemnent.

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Myoelectric tester -

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isolate muscle contraction and increase muscle strength. For transhumeral amputations - common choices are biceps and triceps.

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Therapy program begins with

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eval of prosthesis, emphasis on control system.

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Other factors to be addressed with externally powered prosthesis:

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Are electrodes aligned along direction of muscle fiber and placed over site offering the best muscle control potential? Is there good contact between electrodes and skin? Can patient open and close hand in various planes? If there is an internal battery, can the patient manage the battery charging strategy?If there is an external battery, can the patient remove and replace with ease?

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Practice in control drills

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- patterns of reach, grasp, and release objects that vary in weight, size, texture. Sequence is from large, hard objects to smaller, softer and more fragile. Initially on the table then various locations in the room.

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Functional envelope

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- refers to the area of space in which the patient can operate the upper limb prosthesis. Therapist instructs patient to perform motion patterns in ,different planes away from midline through the functional envelope.

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Prosthetic functional use training

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Spontaneous, automatic skillful prosthetic use is a goal for functional use training. Another is completion of activities within a reasonable length of time while using minimal extraneous movement and energy expenditure.

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A person with a unilateral amputation can be expected to use the prosthesis primarily for

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sustained holding or for stabilization

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Bilateral amputation - The therapist is advised to encourage

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foot use when patients show potential and are agile. Persons who have developed this ability at an early age have a high degree of independence.

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Final Stage of prosthetic training

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- iADL

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Discharge planning should include exploration of

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vocational and recreational interests, driving, use of public transportation, community reintegration, and adaptive sports. Visits to community, home, school, work are strongly advised. Amputee peer support groups.

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Driving - adaptive equipment

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- spinner knob; left foot accelerator bar and pedal, hand controls instead of pedals.

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Upper Limb Prosthetic Outcome Measure (ULPOM)

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- traditional dexterity assessments (Pegboard, box and blocks) do not provide meaningful data for amputation. There are five assessments worthy of consideration.

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Partial hand amputations

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ProDigits provide myoelectic control for partial hand amputations, specifically those with transmetacarpal level amputations. Each ProDigit is a self-contained finger that is individually powered through remote electrodes called force-sensitive resistors, more commonly known as FSRs.These devices provide fine motor pinch, touch, grasp, and pointing

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Lower limb amputations -Primary reason for LE amputation is

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disease.

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Requires collaboration between physical therapist and occupational therapist. PT responsible for

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limb wrapping, core and lower limb strengthening exercises, ROM, preprosthetic, and gait training.

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Both OT and PT -

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focus on ADL, patient and family education on wound care, limb wrapping, bed mobility, transfers, basic wheelchair propulsion. Safety.

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OT

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- self-maintenance skills - kitchen tasks, housecleaning, bed making, home/community visits, balance, posture, equal weight bearing. Fall recovery. OT may recommend home modifications and equipment - transfer tub bench or shower chair, safety arm rails around toilet.

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Medical team will clear patient to start wearing

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shrinker prior to receiving prosthesis. Education on shrinker - donning techniques, care, no wrinkles, seams should not be over bony areas or scar, inspect skin everyday.

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Energy conservation methods - percentage increase in energy costs for prosthetic ambulation is

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9%-28% for unilateral transtibial, 40%-60% for unilateral transfemoral, 41%-100% bilateral transtibial and 280% for bilateral transfemoral amputations.

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Multiple limb loss

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The rehabilitation team and patient must discuss initial mobility options such as ambulating with or without wearing a upper limb prosthesis use of an electric wheelchair versus a manual wheelchair for mobility, and the direct effects mobility choices have on areas such as home modifications and vehicle selection.

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General considerations that will influence rehabilitation for this subset of the amputee population include (1) increased body temperature secondary to reduced body surface area; (2) increased risk of joint contractures

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weight gain, deconditioning, and bone resorption as a result of immobility; (3) unique pain management needs given architectural changes to the musculoskeletal system; (4) psychosocial issues, such as the importance of body image acceptance and return to work; and (5) likely ongoing medical risks, such as cardiovascular disease, metabolic dysfunction, musculoskeletal pain, and arthritis

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