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POST-OPERATIVE MANAGEMENT OF LOWER LIMB AMPUTATIONS Produced under a grant from the Department of Education through the American Academy of Orthotists and Prosthetists and the Prosthetics Research Study by the Northwestern University Prosthetics-Orthotics Center Learning Objectives • After completing this on-line module the clinician should be able to: – Identify and describe the 5 basic post- operative strategies available. – Compare and contrast the effectiveness of strategies to best manage their patient populations. – Identify and understand the minimum standards of care required to achieve appropriate rehabilitation. Instruction for Use • When you see this icon, please click your mouse on the icon to be linked to a required reading. • When you see this icon, click your mouse to be linked to recommended readings. Table of Contents I. Literature Review II. Post-operative Strategies III. Comparison of Strategies Standards of Care IV. Team Approach V. Time frames VI. Wound Healing VII. Amputation Specific Goals VIII. Whole Person Goals IX. Education and Empowerment X. Case Studies I. Literature Review I. Literature Review: Journal of Rehabilitation Research and Development – Postoperative dressing and management strategies for transtibial amputations: A critical review Conclusion: the literature and evidence to date is primarily anecdotal and insufficient to support many of the claims made. Future randomized trials on TTA dressing and management strategies are clearly needed to collect evidence to best guide clinicians with their decisions Click here to read the full article Journal of Rehabilitation Research and Development Postoperative dressing and management strategies for transtibial amputations: A critical review • After reading the journal article please answer the following self-assessment questions. • Advance to the next slide to begin Click here to read the full article Review of Module I Overall, current research on post-operative management a. Lacks standard definitions for endpoints to measure success and failure b. Compares all of the various management strategies c. Is consistent in measurement outcomes d. Compares individuals w/ the same level and etiology of amputation Of the 10 controlled studies, which comparison has not taken place? a. Removable Rigid Cast to Soft Dressing b. Thigh level Rigid IPOP to Soft Dressing c. Removable Rigid Cast to any IPOP d. Dressing Prefab IPOP to Soft Dressing What fraction of transtibial amputations occur in those with diabetes? a. One-third b. One-quarter c. One-half d. Two-thirds e. All Which is not a goal of post-operative management? a. Prevent knee contractures b. Reduce edema c. Protect the limb from external trauma d. Facilitate early weight bearing e. Bill as much as possible Continue to Next Module Return to Table of Contents II. Introduction to Post- Operative Amputation Management Strategies II. Introduction to Post-Operative Amputation Management Strategies • Definitions: – Strategy- specifically refers to the post- amputation dressing or device. – Protocol- specifically refers to how the post- operative device or dressing is prescribed and used. Strategy 1. Soft Dressings -Types: • Ace wraps • compressive stockinette • traditional shrinker socks • Unna paste wraps (Semi-rigid) • gel liners Soft Dressings • The soft dressing is used routinely in post-operative management to control swelling. If soft compressive dressings are used, proper wrapping techniques must be taught to the staff, patient and caregivers to reduce complications. Instruction on the use of proper wrapping techniques can be found at the link below. Soft Dressings • The use of soft dressings also may be used with adjunctive mechanisms to obtain compression as well as addressing knee flexion contractures. Soft dressings can be combined with the use of simple knee immobilizers, hinged knee immobilizers, and low temperature thermoplastic protective shells to minimize contracture or protect the amputation site. Soft Dressings • While frequently used in many patient care settings, these devices do not directly offer a mechanism to promote residual limb maturation. • There is currently minimal evidence to document the effectiveness of soft dressings. Elastic shrinkers • Commercially ready-made and individually packaged is effective for residual limb shrinkage, but lacks protection of the residual limb from trauma such as accidental falls or weight-bearing exercise. • Its use is limited by the cost and availability in the office Elastic shrinkers Has limited sizes and lengths, lack of size for obese patients with short residual limbs or for children with amputated limbs May be either too tight to put on or too loose to have enough compression Elastic stockinette • commercially available in rolls and in various sizes • can be used in place of elastic bandage and stump shrinkers • less expensive • easily applied onto the residual limbs or edematous limbs • most importantly, can achieve a desirable gradient pressure by adding layers of various length of elastic stockinette Elastic stockinette The compression pressure on the distal part (with increased tension) is higher than on the smaller proximal area (with less tension from less stretching of elastic stockinette) Strategy 2. Non-removable rigid dressings without immediate prosthetic attachment. – Custom molded thigh high device made from plaster, fiberglass, or other rigid material. Non-removable rigid dressings without immediate prosthetic attachment This strategy used at the transtibial level of amputation is usually worn for the first 1 to 2 weeks after surgery to shape and protect the limb. The cast extends above the knee and does not allow the knee to bend. Non-removable rigid dressings without immediate prosthetic attachment At the transfemoral level of amputation a this cast may or may not incorporate a preformed brim. This strategy also may or may not use a soft or rigid hip spica component around the waist. II. Introduction to Post-Operative Amputation Management Strategies 3. Non-removable rigid dressings with Immediate Post-Operative Prosthesis (IPOP). – Custom molded thigh high device made from plaster, fiberglass, or other rigid material with pylon and foot attachment. IPOP The immediate post-operative prosthesis was initiated in the late 1950’s by Dr. Berlemont (France) and Dr. Weiss (Poland). The technique was further developed in the United States by Dr. Burgess at Prosthetics Research Study in Seattle, WA IPOP General Principles: Supervised weight bearing of no more than 5-10 lbs of measured weight during the first 1-2 days post surgery. No more than 20 lbs of weight bearing in the parallel bars until after the first cast change. This usually occurs around 2 weeks postoperatively. II. Introduction to Post-Operative Amputation Management Strategies 4. Removable Rigid Dressing (RRD) – Removable rigid dressings made from plaster, fiberglass, or other rigid material may be used with or without a prosthetic attachment. The procedure was developed in 1978 and published in: -Wu Y, Keagy RD, et al. An innovative removable rigid dressing technique for below-the-knee amputation. J Bone Joint Surg 1979;61A:724-729. -Wu Y,Krick HJ. Removable rigid dressing for below-knee amputees. Clin Prosthet Orthot 1987;11:33-44. It was developed to solve the common problems from elastic bandaging such as: 1) Pressure sore over tibial tubercle 2) Distal edema 3) Knee contracture due to pain. Steps of applying RRD: 1) apply the wound dressing as 5) place the supracondylar cuff needed, and fasten the Velcro closure, 2) wear proper layers of tube 6) pull the suspension stockinette socks or stump socks of tight, various lengths, 7) fold suspension stockinette 3) apply the plaster cast; use a downward and anchor on the plastic sheath to reduce suspension cuff friction, 8) knee flexion is possible and 4) pull the suspension stockinette encouraged. upward covering the plaster cast, II. Introduction to Post-Operative Amputation Management Strategies 5. Pre-fabricated post-operative prosthetic systems Pre-fabricated post-operative prosthetic systems These devices provide varying degrees of protection and contracture prevention and are designed for early weight bearing. They maintain some of the advantages of the removable rigid dressing, in that they are easily removed and replaced for wound evaluation. Examples of Pre-fabricated systems Review of Module II The use of elastic stockinette may be better than Ace-type bandages because: a. It provides better protection b. It is more expensive c. Can apply gradient pressure d. Eliminates contractures The RRD allows for all of the following except: a. Inspection of the limb b. Protection of the limb c. Graded weight-bearing d. Immobilization of the knee When using a prefabricated system for early weight bearing, the patient should only bear______ pounds of weight in the parallel bars. a. 5-10 b. 20-40 c. 60-80 d. Full weight-bearing Continue to Next Module Return to Table of Contents III. Comparison of Strategies III. Comparisons of Strategies • The literature identifies the lack of scientific evidence to support the use of one strategy over another. Analysis of 10 controlled studies supported only four of the fourteen claims cited in uncontrolled, descriptive studies III. Comparisons of Strategies • The literature supports that: – 1) Non-removable rigid dressings result in significantly accelerated rehabilitation times when compared to soft gauze dressings. – 2) Non-removable rigid dressings result in significantly less edema when compared to soft gauze dressing. III. Comparisons of Strategies • The literature supports that: – 3) Pre-fabricated post-operative prosthetic systems were found to have significantly fewer post- surgical complications when compared to soft gauze dressings. – 4) Pre-fabricated post-operative prosthetic systems lead to fewer higher level revisions compared to soft gauze dressings. III. Comparisons of Strategies • No studies directly compared pre-fabricated systems to rigid dressings, and no studies compared all types of dressings within one study. • It is currently not possible to provide evidenced-based protocols, or make conclusive evidence-based recommendations for the use of one strategy over another. Assessing Outcomes • Due to the lack of evidence based outcomes measures in the area of Post-operative management, the consensus conference also strongly suggested the adoption of reporting standards for the assessment of outcomes. • These standards included: – Better classification systems – Improved documentation of wound healing (module VI) – Documentation of contralateral limb status – Pre- and Post-amputation functional status evaluation Classification Systems • “Traumatic” vs. “diabetic” amputation terminology is not complete • Etiology and co-morbidities must be considered • For example, a “diabetic” amputation may be due to: – Infection, Minor trauma, Poor circulation, Chronic ulceration, etc • Systemic complications (death, myocardial infarction, deep venous thrombosis, pneumonia, strong, urinary infection) should also be tracked. Contralateral Limb status • 28-51% undergo second leg amputation within 5 years of initial • 39-68% mortality at 5 years following amputation* • Therefore, ulceration, wounds, infection and amputation in the contralateral limb should be documented Reiber, Boyko, and Smith (1995) in Diabetes in America Pre- and Post- amputation functional status • The consensus was that pre-amputation (whenever possible) and post-amputation functional status should be documented using standardized general outcome tools. e.g.: – SF-36 (Short form 36) – MFA (Musculoskeletal Functional Assessment) – SIP (Sickness Impact Profile) • Or tools specific to amputation and prosthetics. e.g.: – AMP (Amputee Mobility Predictor) – PEQ (Prosthetic Evaluation Questionnaire) Review of Module III A well-designed comparison of post- operative management will a. Randomize selection b. Define outcome measures consistently c. Better detail pain and complications d. Compare all management methods e. Quantify health care savings f. All of the above Which of the following is an unsupported claim of the descriptive studies? a. NR Rigid dressings accelerate rehab time compared to soft dressings b. Eventual use of a prosthesis is increased for an IPOP compared to soft dressings revisions c. IPOPs require fewer higher-level revisions compared to soft dressings d. NR Rigid dressings significantly reduce edema compared to soft dressings *NR=Non-removable Systemic complications may be considered perioperative if they occur within __ days of surgery: a. 5 b. 10 c. 30 d. 60 e. 365 Continue to Next Module Return to Table of Contents IV. Team Approach IV. Team Approach • The goal of the rehabilitation team is to work together with the patient/ client and family to help a person with an amputation reach maximum potential. Team Members Family Surgeon Social Worker Physiatrist Psychologist Nurse Peer Support Prosthetist Case Manager Therapy Chaplain Patient Team Members • Patient/ Client and Family – The patient/ client and family are considered the most important members of the rehabilitation team. Team Members • Surgeon – The surgeon performs the amputation and provides medical care. • Physiatrist – A physician who is specially trained in Physical Medicine and Rehabilitation prescribes the individualized therapy programs and coordinates the team effort of the many professionals. Team Members • Therapy – The various therapies provide a vital role in the rehabilitation of the patient/ client. – The various therapies include Physical therapy, Occupational therapy, Vocational therapy, Recreational therapy, and Speech therapy. Team Members • Physical Therapist – A therapist who designs an individualized program to help restore function for patients/ clients with problems related to movement, muscle strength, exercise, and joint function. Team Members • The Rehabilitation Nurse – Provides 24 hour a day nursing care. – The nurse implements the plan of care, reinforces the skills learned in therapy, and teaches the patient/ client and family about self care and medications. Team Members • Prosthetist – Prepares patient/ client for prosthetic care – Educates the patient/ client on prosthetic care – Recommends prosthetic components based on rehabilitation potential Team Members • Psychiatrist/ Psychologist – A person who conducts cognitive (thinking and learning) assessments of the patient/ client. – Helps the patient/ client and family adjust to the disability. Team Members • Social worker – A professional counselor who acts as a liaison for the patient/ client, family and rehabilitation team. – The social worker helps patient/ client and families cope with their disability. – The social worker makes arrangements for assistance from community agencies. Team Members • Chaplain – A spiritual counselor who helps patients/ clients and families during crisis periods. – Serves as a liaison between the hospital and place of worship. Team Members • Peer Support – A person with a similar disability who provides insight for the patient /client – Provides perspective of what living with a disability is like. Team Approach • As health care has evolved, it is more difficult to have the whole team meet together at the same time. • The team approach is still needed to optimize recovery from limb loss, perhaps now more than ever. IV. Team Approach • The “team without walls” demands increased effort and attentiveness to work toward the common goal of maximum recovery and rehabilitation. • The team should be flexible in that different people share the leadership and service responsibilities of the postoperative period IV. Team Approach • Each member of the team has an obligation to educate, empower and allow client and/or advocate to take control and responsibility • “Act like a Team”- No one health care provider has all the answers and everyone has specific skills and roles to assist in the pre-operative and post-operative process. IV. Team Approach • Team members should keep an open mind and a positive, motivating approach to optimize appropriate care. • All providers have the responsibility to envision the best possible outcome and help assure that medical care, prosthetic fabrication and fitting, training and therapy, navigation of the funding process and social re-integration occur. IV. Team Approach • Team members should work together, support or discuss each member’s treatment recommendations and communicate directly when disagreements exists. Communication through the patient should be avoided at all costs. Review of Module IV The most important member of the treatment team is: a. Physician b. Prosthetist c. Physical Therapist d. Case Manager e. Patient/ Family In the team approach, what should be avoided at all costs? a. Team members working together b. Communicating with one another through the patient/client c. Discuss each members treatment recommendations d. Communicating with one another What is the obligation of each member of the team? a. Concentrate on his/her own profession and nothing else b. Communicate to other professionals through the patient/client c. Communicate only to the family empower, allow d. Educate, empower, and allow client and or advocate to take control and responsibility Continue to Next Module Return to Table of Contents V. Time Frame of Surgery and Recovery V. Time Frame of Surgery and Recovery • Following amputation (regardless of etiology) the post-operative recovery period is typically 12 to 18 months and simply cannot be rushed! V. Time Frame of Surgery and Recovery • Stages of Recovery – Pre-Operative Stage – Acute Hospital Post-Operative Stage – Immediate Post-Acute Hospital Stage – Intermediate Recovery Stage – Transition to Stable Stage V. Time Frame of Surgery and Recovery • Stages of Recovery • Pre-Operative Stage – This stage begins with the decision to amputate, the vascular assessment and decisions or attempts to improve circulation. This stage also includes level selection, pre-operative education, emotional support, physical therapy and conditioning, nutritional support, and pain management. V. Time Frame of Surgery and Recovery • Acute Hospital Post-Operative Stage – This includes the time in the hospital following the amputation surgery. This hospital time is typically 5-14 days. V. Time Frame of Surgery and Recovery • Immediate Post-Acute Hospital Stage – This stage begins at hospital discharge and can extend up to as much as 8 weeks following surgery. – This time allows for recovery from surgery, wound healing, and early rehabilitation. – Typical end points for this stage include the point of wound healing and the point of being ready for prosthetic fitting. V. Time Frame of Surgery and Recovery • Immediate Post-Acute Hospital Stage – However, wound healing is a continuous process, and does not have a clear end point of “being healed”. – Much of the literature attempts to use these two elusive endpoints when comparing different post- operative strategies with varying results. V. Time Frame of Surgery and Recovery • Intermediate Recovery Stage – This is the time of transition from a post-operative strategy to first formal prosthetic fitting. The most rapid changes in limb volume occur during this stage due to the beginning of ambulation and prosthetic use. – This intermediate recovery stage begins with wound healing and usually extends out 4-6 months from the healing date. V. Time Frame of Surgery and Recovery • Intermediate Recovery Stage – This stage ends when relative stabilization of limb size occurs, as defined by consistency of prosthetic fit, for several months. – The definitive prosthesis should not be fit prior to 6 months of temporary prosthetic use and when the stabilization of the limb occurs V. Time Frame of Surgery and Recovery • Transition to Stable Stage – This stage includes maturation of the limb and less volume change. – Patient should move toward social re- integration and higher functional training and development as well as becoming more empowered and independent. Clinical Concerns • 14 clinical concerns were identified in the stages of recovery • Each concern will take on different levels of importance at different stages of the healing process • There may be overlap between stages which may vary with individual differences Clinical Concerns 1. Determine amputation level • Important earliest, in pre-operative stage • Must include assessment of vascular status and circulation to determine level Clinical Concerns 2. Minimize systemic complications including – Myocardial infarction (MI) – Deep Vein Thrombosis (DVT) – Decubitus, etc. • Risk must be assessed pre-operative • High level of concern during acute hospital post-operative stage • Moderate concern during initial healing (post- acute hospital stage) Clinical Concerns 3. Prevent contractures • Contractures should be addressed and treated pre-operatively, if possible • Highest concern during acute hospital stage – Isometric quad sets at day 2 • Continue at high risk during immediate post- acute stage • Reduce to moderate concern for intermediate recovery • Low concern during transition to stable Clinical Concerns 4. Bed mobility and transfers • High concern during acute and immediate post-acute stages • Should reduce in level of concern as prosthesis use is begun Clinical Concerns 5. Pain management • High during most of the rehab process • Pain pre-operatively should be addressed. Unresolved pre-op pain may lead to increased risk of phantom pain post-operatively • Typically pain reduces as limb heals and prosthesis use is begun • Concern may shift from acute pain management to identification and treatment of chronic pain issues in stages 4 and 5 Clinical Concerns 6. Protect amputated limb from trauma • Highest immediately after surgery during acute hospital stay • Still important during immediate post-acute stage as patient begins to transfer • Post-operative management strategies that address this concern include: – Non-removable rigid dressings – Removable rigid dressings – Prefabricated IPOPs • Post-operative management strategies that DO NOT address this concern include: – Soft dressings Clinical Concerns 7. Fall prevention • Moderate concern during pre-op phase • High concern during acute and immediate post-acute stage since falls may traumatize limb • Moderate concern during intermediate recovery as patient learns to walk with first prosthesis • Lower concern during final transition to stable Clinical Concerns 8. Emotional care/education • High level of concern throughout rehabilitation process • During earlier rehabilitation, concerns will be immediate, regarding amputation and healing process • Later concerns may center around realization of limitations and work and family issues Clinical Concerns 9. Manage and teach about wound healing • The highest concern of the acute hospital stage • As wounds heal, concern will decrease • However, patient should be informed and educated to inspect residual limb daily and learn proper care and hygiene of limb as prosthesis use is begun Clinical Concerns 10. Promote residual limb muscle activity • Begins immediately after surgery – In-patient therapy may include passive range of motion techniques • High during post-acute stage and intermediate recovery stage • Maintain activity during transition to stable Clinical Concerns 11. Early ambulation • During acute hospital stage, this will be secondary to bed mobility, transfers and toilet activities • Early ambulation may be with walkers/crutches and no prosthesis during immediate post-acute stage • Initial fitting of a prosthesis and early gait training important during intermediate recovery stage Clinical Concerns 12. Advanced ambulation • Therapy for advanced ambulation techniques may be prescribed during the transition to stable stage when a definitive prosthesis, with potentially more advanced components, is fit Clinical Concerns 13. Control limb volume changes • High during immediate post-acute stage as edema and swelling from surgical trauma reduces • High during intermediate recovery stage – Significant volume changes expected to occur – Prosthesis fit and function must be accommodated • Still of high during transition to stable stage, though at slower rate – Should stabilize for at least 2-3 weeks prior to fitting of definitive device Clinical Concerns 14. Trunk and body motor control and stability • Balance and stability are important throughout rehabilitation process • It is an especially high concern as patient begins therapy to learn independence in transfers • Continues in importance as patient develops strength and balance for initial prosthetic gait training Review of Module V What is the primary clinical concern during the acute hospital post-operative stage? a. control Trunk and body motor control b. Control limb volume changes c. Fall prevention d. Manage and teach about wound healing Limb stabilization typically takes at least ___ of prosthetic use to achieve a. 3 months b. 6 months c. 12 months Physical therapy treatment occurs a. Early in the rehab process and again at the end b. Only at the end of the rehab process c. Only at the beginning of the rehab process d. Throughout the rehab process Continue to Next Module Return to Table of Contents VI. Wound Healing VI. Wound Healing SKIN ANATOMY The skin is an ever-changing organ that contains many specialized cells and structures. The skin functions as a protective barrier that interfaces with a sometimes-hostile environment. It is also very involved in maintaining the proper temperature for the body to function well. VI. Wound Healing SKIN ANATOMY It gathers sensory information from the environment, and plays an active role in the immune system protecting us from disease. Understanding how the skin can function in these many ways starts with understanding the structure of the 3 layers of skin - the epidermis, dermis, and subcutaneous tissue. SKIN ANATOMY • Epidermis The epidermis is the most superficial layer of the skin and provides the first barrier of protection from the invasion of foreign substances into the body. SKIN ANATOMY • Dermis The dermis assumes the important functions of thermoregulation and supports the vascular network to supply the avascular epidermis with nutrients. The dermis contains mostly fibroblasts which are responsible for secreting collagen, elastin and ground substance that give the support and elasticity of the skin. Also present are immune cells that are involved in defense against foreign invaders passing through the epidermis. SKIN ANATOMY Wound Healing The healing of a wound to the skin is a fairly typical mixture of regeneration and replacement. The more regeneration that can occur, the less scaring will be left behind after wound healing. Wound Healing • Many amputations do not heal in ideal primary fashion. • Small areas of the wound may require secondary healing and possible wound care • Revision surgery is frequently required in vascular amputations. Wound Healing • Wound healing problems are most often related to: – Type of injury – Disease – Vascularity – Tobacco use – The nature of amputation itself Wound Healing • Skin and wound problems are rarely “caused” by a single factor. • In many individuals, wound problems are simply not preventable. Wound Healing • The healing of an amputated limb should be viewed as a continuous process • There is no clear and decisive point of “completed healing”. Wound Healing • Using the outcome of “time to heal” is not a precise measurement. • Documenting healing continues to be important for patient care and research. Wound Healing • Subjective interpretations associated with determining healing time include: – Completion of epitheliazation – Interpretation of small open areas – Individual bias – Timing of the return to clinic visits – “Research savvy” of the rehabilitation team Wound Healing • Future studies need to clearly define how the “time to heal” has been determined. • “Time to heal” may always be difficult to standardize and to measure. • It cannot be determined accurately from a simple retrospective review of a clinical chart Wound Healing • It is recommended that wound healing be documented as a type of wound healing for clinical and research purposes. • The categories are defined in the following slides. Categories of Wound Healing Primary -heals without open areas, infection or wound complications Categories of Wound Healing Secondary -small open areas that can be managed, and ultimately heal with dressing strategies and wound care. Further surgery is not required. This may occasionally be intended with some portion of the amputation left open. Categories of Wound Healing • Requires minor revision – skin and subcutaneous tissue. (No muscle or bone involvement) Categories of Wound Healing • Requires major revision – but heals at initial amputation “level” (Example: mid-transtibial level revised to shorter transtibial level) Categories of Wound Healing • Requires revision to a higher level – (Example: a transtibial amputation that must be revised to either a knee disarticulation or transfemoral amputation) Wounds and Weight Bearing • The presence of an open wound or the presence of sutures does not necessarily preclude weight-bearing. • In many circumstances, institution of or continuation of activity can be helpful to control edema and facilitate healing. Review of Module VI Wound healing problems are related to all of the following EXCEPT: a. Type of injury • Disease • Vascularity • Musculature The phrase “Time to heal” a. Is easy to measure b. Can be determine from chart notes c. Is not a precise measurement d. Is not useful in research Continuing activity in the presence of a wound: a. Is often encouraged to facilitate healing b. Is not encouraged during the rehabilitation process c. Will lead to revision d. Will delay healing Continue to Next Module Return to Table of Contents VII. Amputation Specific Goals Amputation Specific Goals Amputation Specific Goals • Prevention of • Emotional care contractures • Promote limb activity • Reduce post-surgical edema • Establish trunk stability • Improve bed mobility • Begin ambulation • Pain management • Accommodate limb • Protection of limb from volume changes trauma • Achieve distal end • Prevention of falls loading Prevention of contractures • Is necessary at both the hip and knee • Active strategies such as bed positioning, prone activities are well documented along with stretching techniques used by physical therapy Prevention of contractures • Several passive strategies such as knee immobilizers and rigid dressings attempt to address the goal of knee flexion contracture • Literature is unavailable to support any one passive strategy • Passive strategies to prevent hip flexion contractures have yet to be proposed Reduce post-surgical edema • Use of compressive strategies is important following any amputation. • If soft compressive dressings are used, proper wrapping techniques must be taught to the staff, patient and caregivers to reduce complications. Improve mobility • Bed mobility, transfers (bed, toilet), and activities of daily living (ADL”S) must be taught early in the post-amputation period • This encourages independence, strength, and reduces the fear of falling • Physical and Occupational therapy are essential to this process • The addition of a pylon and foot may make bed mobility more difficult Pain management • Pain and contractures may be associated although no scientific evidence supports this claim • Pain must be controlled throughout in order to facilitate mobility and eventual prosthetic use • Careful evaluation will help determine the appropriate treatment modality Pain Management • It is important to vary pain management strategies such as, medicine or manual desensitization based on: time from surgery, type of post operative dressing, and the cause of amputation • Desensitization is believed to reduce pain in the residual limb and may help the amputee adjust to their new body image which includes limb loss • Literature is lacking with any one approach Protection of limb from trauma • Evidence suggests the use of rigid dressings (custom or prefabricated) provide better limb protection than soft dressings • Examples of limb protection systems can be found in the links below. Prevention of Falls • Fall prevention is an essential part of rehabilitation • Complications secondary to falls may result in increased healing time, further surgical intervention, other injuries, and increased hospitalization Prevention of falls • “Limb loss reminders”, i.e. placing a chair next to the bed as a reminder to be careful, may reduce falls, but further studies are needed • Strength and balance training can reduce the number of falls Emotional care • Treatment must be highly individualized and does not appear to be related to post-operative limb management strategy • Documented options include supportive encouragement, educational literature, psychological counseling, peer counseling, amputee support groups, and chaplainry. Emotional care • The risk of depression in amputees is high • When necessary, pharmacological intervention and/or psychiatric referral should be considered Promote limb activity • Promotion of residual limb activity (desensitization, muscle contraction, and endurance development) is an important strategy • It may be instituted at various times based on post operative strategy, surgical procedure, and cause of amputation but conventional wisdom says that the earlier the intervention the better Promote limb activity • Exercise to improve gluteus (medius and maximus) and quadriceps strength may begin as early as day 1 • Exercises to promote muscle action within the residual limb depend on pain tolerance, surgical procedure and healing response Promote limb activity • Muscle contraction within the residual limb may help with pain control, muscle re- education, improve muscle mass, edema control, and kinesthetic feedback • The timing for beginning of muscle activity within the residual limb needs to be further evaluated Establish trunk stability • Trunk stability should be established as early as possible through core strengthening exercises • Trunk stability will assist with mobility activities, provide the foundation for prosthetic control, sitting posture, and can reduce the stresses to the spine that cause low back pain and body motor control and stability problems Establish trunk stability • Trunk stability may improve body posture and readiness for gait training • Trunk stability may decrease commonly seen gait deviations • Improved motor control should decrease the energy expenditure of walking with a prosthesis Ambulation • Ambulation is described as non-pedal (wheelchair ambulation), uni-pedal (remaining limb with assistive device) or bi-pedal (using a prosthetic pylon) with or without assistive device • Improvements in strength, mobility, balance, and endurance have been shown to decrease the potential for co-morbidities (Pulmonary embolism, myocardial infarction etc.) Accommodate limb volume changes • Critical to comfortable prosthetic use • During this stage the limb volume is fluctuating wildly and may be difficult to manage • Control of limb volume changes during this stage is a function of the preparatory prosthesis Accommodate limb volume changes • Strategies for limb volume control include the use of liners, socks, pads, adjustable sockets, temporary sockets or ambulatory check sockets • When the patient is not wearing a prosthesis, wrapping and/or compression are critical to help control limb volume changes Achieve distal end loading • Distal end loading, desensitization, and residual limb weight bearing may assist with pain control, tolerance of a prosthesis, and reduction of adhesions • This may begin with towel pulling on the distal end of the residual limb or using a rigid design and allow for pressure over the entire limb Review of Module VII If soft compression dressings are used, proper wrapping techniques should be taught to which of the following a. Patient/client b. Caregiver c. Staff d. All of the above Which of the following does not protect the limb from trauma a. RRD b. Ace (Elastic) wrap c. Flo-tector d. guard PAL guard Strategies for limb volume control include all of the following except a. Socks b. Liners or pads c. Adjustable sockets d. Nylon sheath Continue to Next Module Return to Table of Contents VIII. The Whole Person The Whole Person • Goals – The consensus conference identified six “whole person” goals of care for anyone undergoing lower limb amputation. – These goals are not directly related to the surgical amputation but are intended to prevent co-morbidity and to improve overall health and mobility. Six Goals • Musculo-skeletal reconditioning and cardiovascular training • Contralateral lower limb preservation • Emotional care, peer support and education • Minimize systemic complications • Social reintegration • Setting realistic expectations and functional outcome goals The consensus conference stated that while all goals are important, focus should be attempted to address emotional care, social reintegration, and setting realistic functional goals. Review of Module VIII All of the following would be considered “whole person” goals in the rehabilitation of the patient EXCEPT: A. Social reintegration B. Emotional care C. Cardiovascular training D. Marriage counseling Whole person rehabilitation goals are intended to: A. Provide reimbursement B. Prevent mobility C. Preserve resources D. Prevent co-morbidities The consensus conference identified three “whole person” goals as critical in the rehabilitation of the patient with an amputation. These three are: A. Social reintegration, emotional care and musculoskeletal development B. Social reintegration, emotional care and minimize complications C. Social reintegration, emotional care and setting realistic goals D. Social reintegration, emotional care and care of contralateral limb Continue to Next Module Return to Table of Contents IX. Education and Empowerment Education & Empowerment • Improve understanding of the surgical treatment • Improve understanding of the recovery time frame • Improve understanding of emotional adaptations • Improve understanding of prosthetic plan and treatment • Peer support and consumer groups • Assist in navigation through marketing, hype and realities There is nothing that man fears more than the touch of the unknown Elias Canetti (b. 1905) The Columbia World of Quotations. 1996 Communication is Key • The patient should be encouraged to ask questions and research on his/her own • The amputee should learn to be an informed consumer of marketing material • Education should begin as soon as possible Surgical Treatment and Recovery • Communication with surgeon – May allow opportunity for pre-surgical consult – Surprise factor for patient can be reduce – Vital when using post-operative prosthetic systems Surgical Treatment • Medical team should explain: – Types of anesthesia – Surgical techniques – Possibility of phantom limb sensation/pain – Pain control – Possible complications Important issues that Patient and Family should understand • Time frame of recovery – Including all aspects of postoperative process – Must have realistic time frames to help avoid unrealistic goals – Usual expectation of 12 to 18 months • Emotional adaptation – Will be different for each individual Important issues that Patient and Family should understand • Prosthetic plan – Role of the prosthetist – What a prosthesis is – How it is funded – Expectations to have of a prosthesis: • e.g. not the cure • Other adaptive equipment for mobility that may be needed • Fitting and adjustments required, especially early in rehab process Important issues that Patient and Family should understand • Peer Support and Consumer groups – Including educational materials – Peer visitation – National support networks • Marketing – Hype vs. reality – Help to become an educated consumer Available Educational Resources • Brochures and Pamphlets • Internet • Local Support Groups • National Support Groups Examples of Available Brochures • A Manual for Below-Knee (Trans-Tibial) Amputees • A Manual for Above-Knee (Trans-Femoral) Amputees, A. L. Muilenburg & A. B. Wilson, Jr. (1996) • Patient Care Booklet for Below-Knee Amputees, Jack Uellendahl (1998) • Below- Knee Amputation: A Guide for Rehabilitation • Above- Knee Amputation: A Guide for Rehabilitation, T.Kuiken, M.Edwards, & N. Miceli (2002) Many of these, and more, are also available through the ACA and the Academy. Click here for a links to more items Internet • Manufacturers websites – Be willing to discuss options that your patient/client may see on the internet – Understand the pros and cons of each device and how to explain them to a consumer • OandP.com Support Groups • Find out if there are support groups in the area • National Support Groups, including the Amputee Coalition of American, can also be an excellent reference Recreational Activities • Recreational activities/groups can also be a support system • Not just for Paralympic level individuals • Special organizations exist for: – Golf – Cycling – Scuba Review of Module IX A new, active male transtibial amputee, 35-years-old and 350#, arrives in your office with an advertisement for a Dycor foot that says how flexible, light-weight and comfortable it is. You should…? a. Order the foot, since that is what they want b. Explain that this foot is for geriatric patients c. Explain that this foot is not designed for the individual’s weight and activity level A new amputee expresses concern to you that they are the only person they know with an amputation, they are never going to return to an active lifestyle and they don’t know how to handle it. What are three things you could do? a. Offer to introduce them to another amputee for peer counseling b. Express your concerns to the referring primary physician so that psychological counseling can be prescribed if indicated c. Give them reading materials that you have and let them know about the ACA List at least five things that may affect emotional adaptation to an amputation a. Culture b. Family history c. Religious preference d. Age e. Education f. Social support g. Financial background Continue to Next Module Return to Table of Contents X. Case Studies Case Study 1 • 65 y/o male, BKA 2° PVD • Prosthetist applied custom thigh-high plaster rigid dressing immediately post-surgery • Soon after awaking, pt c/o pain 10/10 • Pt instructed pain was normal and pain medication was increased. Pain still present during course of treatment. • Rigid dressing removed after 8 days • Result: Dressing removed, infection present. Limb revision to AKA required. What about this case would be a concern • How long the rigid dressing was left on • The patient’s pain concerns were dismissed • Protocol for application of rigid dressing may not have been followed (tightness of wrap, padding, drainage, etc) • Non-removable dressing did not allow inspection of wound, and dressing not removed when chance of infection was presented What should have been done? • Pain management should have been addressed • Rigid dressing should have been removed when pain did not abate. • Communication with patient should have been better. Case Study 2 • 25y/o male, BKA 2° traumatic motorcycle accident. • Pt also suffered mild head injury during injury. • Pt fit with soft dressing and compression sock. • 2 days post-surgery, while alone in the room, pt is determined to use toilet independently. • Pt falls, breaks open sutures, and requires minor soft tissue revision to re-close wound. What about this case would be a concern • Which post-operative strategy was used? • Failure to evaluate fully cognitive ability of patient. • Did practitioner educate patient/family/care- givers of procedures. What should have been done? • A post-operative strategy which provided limb protection. • Complete evaluation of patient’s head injury and cognitive level. References • M. Bergner, R.A. Bobbit, W.B. Carter and S.B. Gilson , The sickness impact profile: development and final revision of a health state measurement. Med. Care 46 (1981), pp. 787–805. • J.E. Ware and C.D. Sherbourne , A 36-item short-form health survey (SF-36): conceptual framework and item selection. Med. Care 30 (1992), pp. 473–483. • The Amputee Mobility Predictor: An instrument to assess determinants of the lower-limb amputee''s ability to ambulate. Archives of Physical Medicine and Rehabilitation, Volume 83, Issue 5, Pages 613 - 627 R. Gailey. • Martin, D. P.; Engelberg, R.; Agel, J.; Snapp, D.; and Swiontkowski, M. F.: Development of a musculoskeletal extremity health status instrument: the Musculoskeletal Function Assessment Instrument. J. Orthop. Res., 14: 173-181, 1996 http://www.oandp.com/resources/patientinfo/manuals/5.htm Examination • Please go to the course examination section. • After completing the examination, please complete the course evaluation.
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