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Rehabilitation for Amputation an

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Rehabilitation for Amputation an Powered By Docstoc
					  Rehabilitation for
   Amputation and
Prosthetic Fitting after
         Burn
       Phase I
  Characteristics of amputated limb
which can functional well in prosthesis
 Pain free
 Well padded by soft tissue
 Non adherent scar
 Cylindrical shape
 Greatest bone length
 Normal sensation
 Prosthetic Rehabilitation Following
          Burn Amputation
Phases of Rehabilitation

                     Acute Post Surgical Phase

                       Pre- Prosthetic Phase

                 Prosthetic Prescription and Fabrication
                                  Phase

                       Prosthetic Training Phase

                     Functional & follow up Phase
                  Time:
        Amputation Surgery to Suture
                 Removal


Goals

                              Promote wound healing

                                 Control incisional and
                                    phantom pain

                                Maintain joint(s) ROM

                            Promote positive nitrogen
                                    balance

                                  Mobilize entire body
               Promote Wound Healing

1-A superficial skin defect can usually be closed adequately
with a Split –thickness skin graft (STSG).
2-Full –thickness defect over bony prominence is better
handled with full –thickness coverage (either with local
flap, pedicle flap, or free island flap).

Physical therapy can enhance wound healing and reduce
associated complication (such as development of
hypertrophic scar) through using low level laser therapy
(LLLT) (Helium neon laser therapy and or Gl-Al-Ars), with
following treatment protocol;
      Control Incisional and Phantom
                   Pain
   Incisional Pain:-
 1-It is a natural part of any surgical procedure
  where skin subcutaneous tissue, nerve and
  muscles have been cut .It usually goes away
  when swelling reduced and healing occurs.
 2-Incisional pain should be controlled with
  adequate amounts of narcotic preferably given
  intravenously on regularly prescribed dose basis.
  This is usually helpful for the first three
  postoperative days. Subsequently oral analgesic
  should be adequate if there are no other sources
  of significant pain
       Control Incisional and Phantom
                    Pain
   Phantom Pain:-
   1-This is a pain in the missing or amputated part of the
    limb. It varies tremendously from person to person .It
    can include burning, tingling, squeezing and cramping,
    shocking, and shooting description.
   2-Phantom pain should be explained to the patients
    since they occur in the early postoperative period.
   3-The patient should expect that phantom pain
    sensation and phantom limb changes and usually
    diminished, and may be become long term problem.
   4- Use of oral pain medication for significant phantom
    pain has not usually produced adequate pain reduction
    over period of time exceeding one week.
       Control Incisional and Phantom
                    Pain
   Phantom Sensation:-
        This is sensation or feeling in the part of the
    limb that has been removed. it include itching ,
    tingling , warmth, cold, cramping , constriction ,
    movement, and any other imaginable sensation ,
    and all persons with limb loss experience some
    phantom sensation.
   Rresidual limb pain:-
       This kind of pain occurs in what is left of
    your natural limb after the amputation, as the
    residual limb always is more sensitive than other
    parts of body.
                Maintain Joint ROM &Strength


   1-Positioning is an important part of a patient's exercise program. It
    is done to prevent shortening of soft tissue and joint(s)
    contractures, that can result from ;
   (i) Soft tissue shortening .
   (Ii) Muscle imbalance.
   (iii) Protective withdrawal reflex.
   (iv) Faulty position.
   3-If possible patients with an amputation should lie prone
    intermittently to enhance hip and knee extension, however care
    should be taken to avoid over stress on cardiovascular system
    during assuming this position.
   4-The positioning program should emphasize active or active
    assistive ROM of the joint (s) proximal to the amputation.
   5-Elevation of residual limb on a pillow can lead to the development
    of hip flexion contracture and so should be avoided.
                   Description
Lying supine: make sure that hips and knees are
straight, the patients should lie on a firm surface
and avoid pillows under the residual limb. The legs
should be held close together.




Lying prone; pillow should be avoided under the
hip and the hip should be kept straight, and the leg
close together. The patients should lie prone or on
wither side for up to 15 minutes, four times a day.
This position will extended the hip and knee



Side lying; the hip should be kept in a neutral position. The patient should not sleep with large pillow between the legs or
under the back .Pillow in these positions enhance hip flexion and abduction.


Sitting: when sitting patients should use a sliding
board or other firm surface under the residual limb
to promote knee extension.
                       Exercises

 1-The exercises program is designed individually and
  includes ROM, exercises, isometric, isotonic, and
  endurance activities, and these dependent largely on
     (i)-Postoperative healing.
     (ii)-Postoperative pain
     (iii)-Post-surgical dressing.
 2-This exercise should not produce more than mild
  discomfort and put less stress on suture line,
  otherwise stop exercises.
 3-The hip extensor, abductors and knee extensor and
  flexors are particularly important for prosthetic
  ambulation.
 4-Strengthening exercise for upper extremity muscles
  of shoulder depressor, elbow extensor, wrist extensor,
  and hand flexor should encouraged, with general
  strengthening program for trunk and abdominal
  muscles.
 5-The program should emphasize active or active
  assistive ROM of the joint (s) proximal to the
  amputation, at 1st to 2nd day postoperative.
 6- Active motion of all proximal joints through the full
  ROM should be obtained by 10 -14 days following
  amputation unless grafting procedure precludes
  exercising.
 7-Gentle isometric exercises can be started at the 5th
  postoperative day.
   * A brief repetitive isometric exercises (BRIME), regimen is
  an extension of the original isometric .A patient with an
  imputation may use this regiment which consists of up to 20
  maximum contractions.
 Each held for 6 second (Why?).
 A 20 seconds rest after each contraction is recommended
  (Why?).
 Rhythmic breathing during the contraction is recommended
  (Why?).
   * Multiple angle isometric exercises should be performed.
 8- Isotonic exercises can be encouraged at 7 -10 days
  postoperative.
 9-Program of muscle contraction and joint motion (8-10
  repetition for 3sets) should be repeated several time daily (4-6
  times), and once when adequately performed no need for
  supervision.
 10-These exercises help to
 (i)-Reduce edema, and promote healing.
 (ii)-Maintain joint ROM,
 (iii)-Prevent contracture and correct existing
  contracture
 (iv)-Allow early mobility self care and
 (v)-Maintain muscle strength, and kinesthetic
  sense of residual and phantom limb, which can
  later be used in prosthetic training
                       Exercises for post-burn amputation



Exercises Suggestion
Hip Extension
*Lie supine on firm matters,
with towel placed under the
residual limb; the residual
limb is pressed firmly into
the towel, raising the
buttocks off the resting
surface.
*Bridging: lie supine with
sound knee 90degrees of
flexion, with foot is pushed
down into the resting
surface. The residual limb
should be raised until both
hips are of equal height.
* Lie prone; lift the leg off
the mat, at time with knee
extended.
                                       Hip abduction
*Lie side on amputated side, with towel under the residual limb. The sound limb rested
  in pillow, stool in front of residual limb. The residual limb is depressed down on the
                                             towel.
 *Lie side on sound side, raising the residual limb, with weight around the distal tibia.
 *lie supine with rubber banding around the distal end of both limb, the patients pulls
                          the residual limb away from sound limb.
Knee Extension
 *Straight leg rising
  *Short arc quad sets
  *Lie Prone; the patient is prone
with towel under the residual limb.
the distal residual limb is pushed
into the towel , and extended the
knee




Knee Flexion
 *Lie supine, with a towel under
the residual limb, the patient
pulls back into the towel, slightly
bending the knee.
  *Lie prone and flex the knee
against gravity.
Pre-Ambulation Exercises Program
           Concurrent Activities




               Strengthening




               Coordination

Transfer                           Wheelchair
                                   Walking aid
Training
     Parallel Bar and Ambulation Activities




                      Standing
                       Balance        Anterior
    Turning
                                      Posterior
       &
                                       Weight
   Returning       Parallel             Shift
                     Bar
Stepping           Activitie                  Lateral
 Forward              s                       Weight
Backward                                       Shift

           Standing               Hip
           Push up               Hiking
          Walking with crutches
  (For persons with single leg amputations
                   only):

First move the crutches forward about (30 cm).
         Step forward with your residual
limb/prosthesis. Land it between your crutches.
  Lift your natural limb and step to, or past the
                     crutches.
               Going up stairs:

Step up with your natural limb first. Then bring
 your crutches and residual limb/prosthesis up.




              Going down stairs:

Don’t hop. Move your crutches down first, then
step down with your residual limb/ prosthesis.
   Lastly, step down with your natural limb.

				
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