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AMPUTATIONS

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~LE amputations 3x more often than UE amputations

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TYPES OF AMPUTATIONS

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Congenital Traumatic Surgically

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UE amputation

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Most common cause is trauma

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LE amputation

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Most common cause is vascular disease

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Goal of Surgical Amputation

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Residual limb that is pain free & functional

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POST-OT & PRE-PROSTHETIC PHASE

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Signs & Symptoms: Pain Skin complications Edema of residual limb Bone spurs Neuroma on distal end of residual limb Phantom limb Phantom sensation

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SKIN COMPLICATIONS IN POST-OP PHASE

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delayed healing, necrosis, skin graft adherence to bone

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PHANTOM LIMB

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sensation that missing limb is still there usually not painful may remain for duration of person's life

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PHANTOM SENSATION

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sensation appears to occur in missing limb can be of any type cramping, relaxed, numb, cold, burning

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Neuroma

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neuroma a tumor or new growth largely made up of nerve cells and nerve fibers, can occur post-amputation

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PROSTHETIC PHASE

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Signs & Symptoms: -skin ulcers from ill fitting prosthesis socket/wrinkles in prosthetic sock -sebaceous cysts from torque of prosthetic socket -edema from ill fitting socket or too-tight prosthetic sock -sensory changes

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SENSORY CHANGES IN PROSTHETIC PHASE

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-loss of sensory information resulting from missing limb -residual limb hyperesthesia (over-sensitivity) -areas of absent/impaired sensation -phantom limb/phantom sensation

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DIAGNOSIS

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The level of limb amputation is identified by which joint or long bone has been amputated through

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ABOVE THE KNEE AMPUTATION

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transfemoral

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BELOW THE KNEE AMPUTATION

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transtibial

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BELOW THE ANKLE AMPUTATION

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transmetatarsal

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ABOVE THE ELBOW AMPUTATION

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transhumeral

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BELOW THE ELBOW AMPUTATION

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transradial

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BELOW THE WRIST AMPUTATION

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transmetacarpal

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Memory Note

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Trans=across (like trans continental railroad which cuts across the continent) + name of bone that is cut/amputated through transfemoral = cut across the femur= above the knee amputation

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DISARTICULATION

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Across a joint such as hip, wrist, elbow, or shoulder

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ANKLE DISARTICULATION

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Symes Amputation

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PRE-PROSTHETIC TRAINING

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from post-surgery until client recieves permanent prosthesis

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GOALS OF PRE-PROSTHETIC TRAINING

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--coping with psychological aspects of limb loss: changed body scheme, reduced self-esteem/self-efficacy, shock, disbelief, anger, grief, guilt, denial, hopelessness, depression --optimize wound healing --maximize residual limb shrinkage & shaping to achieve tapered distal end (optimal shape for prosthetic socket) --desensitize residual limb --maintain or increase ROM & strength --facilitate independence in ADLs --explore prosthetic options

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PROSTHETIC TRAINING

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Occurs after client receives permanent prosthesis

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GOALS OF PROSTHETIC TRAINING

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--ct will independently don/doff prosthesis --ct will independently care for the prosthesis --ct will increase wearing time to full day --ct will learn to independently use prosthesis

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INTERDISCIPLINARY TEAM MANAGMENT

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--prosthetist collaborates with client & OT to identify prosthetic options appropriate to client's goals --prosthetist constructs & ensures proper fit of prosthesis --PT primarily responsible for LE amputation training & prosthetic development to maximize ambulatory skills

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OT EVALUATION

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Clients with UE amputations: more limitations in tasks with manipulation of objects Clients with LE amputations: more limitations in mobility & ADLs related to mobility, e.g. toileting

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EVALUATION OF SELF-CARE

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evaluate self-care activities both with & without prosthesis

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EVALUATION OF CLIENT FACTORS

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--any changes in sensation in residual limb, including hypersensitivity & sensation loss --presence/severity of phantom sensation --pain --experiences of self, including body image, self-concept/self-esteem --strength, flexibility, endurance of residual limb in preparation for wearing prosthesis --full body strength, flexibility, endurance --skin integrity

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PERFORMANCE SKILLS

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Assess performance skills related to motor skills of uninvolved hand in preparation for training in one-handed techniques, and in use of prosthesis when it is worn

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FUNCTIONAL MOBILITY & BALANCE

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May be impaired in LE amputations

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VOCATIONAL/RECREATIONAL INTERESTS

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Should be evaluated

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DRIVING EVALUATION

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Should be performed

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ENVIRONMENTAL ANALYSIS

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Complete for community, home, school, & work

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INTERVENTIONS: PRE-PROSTHETIC

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--train in limb hygiene --wound healing, including whirlpool & massage --limb shrinkage & shaping --desensitization of residual limb --maintenance of/or increasing flexibility/strength of residual limb --maintenance of/or increasing flexibility/strength of remaining limbs --wheelchair seating

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INTERVENTION: LIMB SHRINKAGE & SHAPING

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--train client to wrap residual limb in elastic bandage to reduce edema & develop tapered shape --elastic shrinker or removable rigid dressing can be used if client is unable to perform proper wrapping techniques

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INTERVENTION: DESENSITIZATION RESIDUAL LIMB

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--weight bearing through residual limb on variety of surfaces --massage, tapping & rubbing

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INTERVENTION: MAINTENANCE OF RESIDUAL LE LIMB

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--maintain or increase ROM & strength of residual limb to prevent flexion contractures of knees & hip in LE amputations

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INTERVENTION: MAINTENANCE OF REMAINING LIMBS

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--maintain or increase ROM & strength of remaining limbs --clients with LE amputations need to strengthen upper body to use wheelchair & mobility aids --clients with LE amputations need to strengthen remaining LE to increase weight bearing ability

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INTERVENTION: WHEELCHAIR SEATING

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--clients with LE amputation need residual limb support --large rear wheels should be placed further back to counterbalance missing limbs --wheelchair should have anti-tippers

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DON'TS OF POSITIONING

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DO NOT let residual limb hang off edge of bed DO NOT place pillow under thigh or knee when client is supine DO NOT place pillow under low back DO NOT allow client to lie with knee flexed DO NOT allow patient to cross legs

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DOS OF POSITIONING

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DO keep hips in neutral rotation DO extend the knee DO minimize sitting time with knee flexed

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TRANSFEMORAL AMPUTATION

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At risk for hip contracture OT must teach client to counter typical positions of comfort: hip flexion, abduction, external rotattion

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TRANSTIBIAL AMPUTATION

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At risk for knee contracture & hip contracture OT must teach client to counter typical positions of hip comfort, same as for transfemoral amputation OT must teach client to prevent knee flexion contractures by positioning knee in extension as much as possible, when in w/c, bed, seated in chairs, use of amputation board to support knee in flexion while seated in w/c

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PROSTHETIC PRESCRIPTION

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Key Considerations: --length, strength, flexibility of residual limb --skin integrity of residual limb --patient preference for cosmesis (appearance) & function --hand dominance --typical activities to be performed with prosthesis (home, work, leisure) --motivation & attitude --financial coverage --cognitive ability

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PROSTHESIS COMPONENTS: TERMINAL DEVICE

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Lower Limb Amputation: foot Upper Limb Amputation: hand

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PROSTHESIS COMPONENTS: PASSIVE TERMINAL DEVICE

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--realistic, non-functional hand worn for cosmesis

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PROSTHESIS COMPONENTS: ACTIVE TERMINAL DEVICE

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1. body-powered 2. externally-powered: via electrical connection or electromyogrraphic (EMG) signals 3. hybrid-powered: can be hook or realistic looking hand that assists with functional activities

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PROSTHESIS COMPONENTS: HOOK

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--more functional than hand --greater precision --greater visibility of object grasped --less weight --lower cost --more reliable --ability to fit into small spaces

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PROSTHESIS COMPONENTS: MYOELECTRIC DEVICES

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--clients using myoelectric device must have 2 superficial muscle sites that can fit within prosthesis socket with sufficient electromyographic signals to power the hand

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PROSTHESIS COMPONENTS: SOCKET

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--attached prosthesis to residual limb

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PROSTHESIS POSITIONING COMPONENETS

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--can include wrist, elbow, shoulder, knee, & ankle devices --may have locking system activated by user

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HARNESS & SUSPENSION SYSTEM

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--holds prosthesis on residual limb

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UPPER LIMB PROSTHESIS

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--In upper limb prostheses, a control system is combined with the harness to transmit body forces to control the cable that operates the terminal device

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LOWER LIMB PROSTHESIS

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--In lower limb prostheses, a pylon is used to connect the terminal device to the socket

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PROSTHETIC SOCK/GEL LINER

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--protects residual limb/improves fit of the socket

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POST-PROSTHETIC INTERVENTIONS

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--education about prosthesis --training to don/doff prosthesis --myoelectrically controlled prosthesis: train pt. in alignment of electrodes to obtain good electrode/muscle contact

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INTERVENTION: PROSTHETIC WEARING SCHEDULE

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1. initial wearing time 15-30 min 2. prosthesis removed after 15-30 minutes to check stump for reddened areas 3. if no reddened areas appear after 20 minutes, wearing time increased in 15-30 min increments until pt. wears prosthesis for a full day 4. Any reddened areas that do not disappear after approx 20 min should be reported to prosthetist so that device can be adjusted

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INTERVENTION: LIMB HYGIENE

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1. daily cleansing 2. inspection of stump for reddened areas, especially insensate areas

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CARE OF PROSTHESIS:

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1. clean interior with mild soap & water 2. clean hook or cosmetic hand with soap & water 3. myoelectrically controlled prosthesis: teach ct. to change batteries

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UPPER LIMB PROSTHESIS TRAINING

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1. PROSTHESIS CONTROL TRAINING: operation of each component of upper limb prosthesis 2. PREPOSITIONING TRAINING: identification of optimal position of each positioning unit (e.g., wrist, elbow) to perform an activity or grasp object 3. PREHENSION TRAINING: terminal device control during grasp activities 4. FUNCTIONAL TRAINING: control & use of prosthesis during functional activities a. incorporation of the terminal device as functional assist b. focus on problem solving approach

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INTERVENTION: GENERAL

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1. provide adaptive equipment as needed 2. develop skills needed to perform ADLs & IADL s 3. for ct. with LE amputation, train in functional mobility: transfers, bed mobility, W/C mobility 4. training in performing vocational & leisure activities; job site analysis/intervention 5. home evaluation/intervention as needed 6. emotional/psychosocial support

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