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MODULE Amputation

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MODULE Amputation Powered By Docstoc
					   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
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        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
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Module




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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
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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
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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
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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
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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




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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




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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




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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




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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.