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1. Examination & Treatment of the Lower Extremity Amputee Pre-prosthetic PT Intervention

2. Learning Objectives Identify and apply major factors leading to lower extremity amputation Describe and apply the levels of lower extremity amputation and the functional impact Discuss and apply PT early post-operative examination, goals & treatment of the LE amputee. When presented with a clinical case study, analyze & interpret patient data; determine realistic goals/outcomes and develop a plan of care

3. What are the major causes for lower extremity amputation?

4. Causes of Amputation by Percent Lusardi MM & Nielsen CC. Orthotics and Prosthetics in Rehabilitation. Woburn, MA: Butterworth-Heinemann; 2000, p. 328.

5. Amputation and PVD • Associated with smoking & diabetes • 6-25% of pts. With PVD & DM will need amputation • Pt. with DM who undergoes one amputation secondary to PVD has 51% chance of 2nd operation within 10 yrs.2

6. Risk factors for PVD *same as risk factors for cardiovascular and cerebral-vascular disease

7. Diabetic Disaster (numb, cold, paresthesia, pain)

8. Does a physical therapist have a role in identification of risk factors for disease? • Yes • No Optimize patient outcomes through physical therapy intervention!!!!!!!!!!!

9. Signs/Symptoms of Vascular Insufficiency • Intermittent claudication • What is this? • Significant cramping pain, usually in the calf, that is induced by walking or other prolonged muscle contraction and relieved by a short period of rest – ischemic response • Vascular pain (increase with LE elevation)

10. Signs/Symptoms of Vascular Insufficiency Loss of one or more lower extremity pulses Arteriosclerosis obliterans - at least one major arterial pulse absent or impaired2

11. Which of the following pulses would you check if suspicious of LE PVD? • A. dorsalis pedis • B. brachial pulse • C. popliteal pulse • D. femoral artery pulse • E. all of the above

12. Clinical signs of PVD Lusardi MM & Nielsen CC. Orthotics and Prosthetics in Rehabilitation. Woburn, MA: Butterworth-Heinemann; 2000, p. 344.

13. Protective sensation Must be able to perceive 5.07 Semmes-Weinstein monofilament Easy and inexpensive way to identify patients at risk for foot ulceration2

14. What should primary goal be with PVD/DM in regards to feet? PREVENTION!

15. Levels/classification of amputation

16. Levels of Amputation

17. Determining Level of Amputation Preserve as much viable tissue as possible/select most appropriate level

18. Selection of Amputation Levels General guidelines Considerations with PVD Considerations with trauma Considerations with malignant tumor Considerations with deformity Considerations with congenital limb deficiency/deformity revision

19. What factors might influence outcomes following an amputation? • Age • Level of Amputation • General health of patient • All of the above

20. Impact of level of amputation and age of patient on outcome: Must examine the patient carefully to determine their potential

21. Age of Amputees 25% 40% 35% 72% are males 4

22. Who is on the Team? • Pt. • Dr. • PT • Prosthetist • OT • Social worker/case manager • Dietician • Nursing • Vocational Rehab

23. Responsibilities of the Team Evaluate pt. Initial training in prep. for prosthesis Prescription of prosthesis (if appropriate) Fabrication of prosthesis Delivery of prosthesis Evaluate fit of prosthesis Train in use, care of prosthesis Follow-up eval. for problems, possible changes, needs of pt. Maintenance/replacement of prosthesis

24. Guide to Physical Therapy Practice • Practice patterns • 4 J – Impaired Motor Function, Muscle Performance, Range of Motion, Gait, Locomotion, and Balance Associated with Amputation • 5G – Impaired Motor Function and Sensory Integrity Associated with Acute or Chronic Polyneuropathies • 7 A – Primary Prevention/Risk Reduction for Integumentary Disorders • 7C/D/E1 - Impaired Integumentary Integrity Associated with partial thickness/full-thickness skin involvement or extending into fascia, muscle, bone and scar formation

25. What tests/measures should be included in Initial PT examination post amputation? • A. ROM • B. Cognitive Function • C. Balance • D. Muscle Strength • E. Sensation • F. Pulses • G. Integumentary Exam • H. Functional Status • I. Residual Limb Length and Shape Ideally would have had a referral to PT BEFORE the amputation

26. Pre-prosthetic Examination Template • General Medical Exam/history/other co-morbidities/medications • Skin condition – scars, lesions, sensation, moisture • Residual limb length/shape – circumferences, conical, cylindrical, bulbous • Vascular status – pulses, color, temperature. Edema, trophic changes, capillary refill • Pain • ROM • Muscle Strength • Cognitive Status/Emotional Status • Functional Status – mobility, transfers, balance • Home Situation • Patient Goals

27. MMT Definitive strength assessment of joint just proximal to amputation can consist of only active, non-resisted antigravity motion until adequate healing of surgical site • i.e. TT will only be able to assess knee flexion and extension to fair muscle grade; TF will only be able to assess hip to fair muscle grade

28. Manual Muscle Testing When incision healed & cleared by Dr., remember that lever arm reduced & MMT grades could be inflated Do not apply pressure for MMT through dressingmust be able to visualize suture line during 1st several weeks of pre-prosthetic prog.2

29. PT measurements for residual limb: Total length including soft tissue • TT - Medial joint line or tibial tubercle • TF - ischial tuberosity or greater trochanter • Document which landmark you used!

30. PT measurements for residual limb: TT 5-6 inches ideal TT less than 3 inches problematic for prosthetic control and skin integrity TF 4-5” above knee ??

31. PT measurements for residual limb: • Circumference: • medial tibial plateau or tibial tubercle and at equally spaced points to end of limb; • TF: begin at ischial tuberosity or greater trochanterclearly document interval between measurements • Prosthesis often made when distal limb circ=prox limb circ (<1/4 inch difference) 2

32. Poor Residual Limb Healing • May, BJ. Amputation and Prosthetics: A Case Study Approach. Philadelphia: Davis; 1996, p. 79.

33. Possible Impairments or Limitations for Amputee IMPAIRMENTS Pain Decreased strength, ROM, mobility Decreased skin integrity Decreased endurance Psychological issues Decreased balance Decreased coordination/proprioception Functional limitations Inability to walk, work or play

34. Early post-op care

35. PT’s primary goals/outcomes for immediate post-operative period:

36. Wound Inspection:

37. Wound Inspection: Easy to do with dressing change Record quantity/quality of drainage Normal for clear drainage first couple daysshould decrease over time; report red or darker blood or thickening discolored drainage with odor to Dr. Traumatic (nondysvascular) pt. often ready to be casted for training prosthesis day 10, others day 142

38. Scar management: Once primary healing established, teach pt. scar massage above & below incision (not across) Once wound well-closed, and no steri-strips, can begin gently to mobilize scar itself Why is scar mobilization important? Tissues must be able to glideadherence promotes shearing forces which lead to skin breakdown2

39. Post-Amputation Sensations:

40. Explanation for phantom sensations All nerves that once had branches to LE are still present, but end at a new place. It takes time for the brain to learn this fact. Also, these nerves may be very sensitive from the amputation surgery as they are pulled and then severed and allowed to retract. 4

41. Strategies for treatment of phantom limb pain: Patient education before surgery Alert pt. to issues of safetywake up in middle of night after recent amputation and fall when attempt to stand and walk thinking both limbs are intact Careful inspection of limb to r/o neuroma or infected wound Compression, use of prosthesis, desensitization techniques, heat Medications, steroid injection, nerve block, relaxation/hypnosisvaried effectiveness2

42. PT management of Pain

43. Compression bandaging: important for ALL amputees *1st 4 are required even if pt. not a candidate for prosthesis2

44. Edema Control Measures: Compression bandaging

45. Rigid Removable Dressing Lusardi MM & Nielsen CC. Orthotics and Prosthetics in Rehabilitation. Woburn, MA: Butterworth-Heinemann; 2000, p. 400.

46. Semi-rigid dressing Lusardi MM & Nielsen CC. Orthotics and Prosthetics in Rehabilitation. Woburn, MA: Butterworth-Heinemann; 2000, p. 401.

47. Shrinkers Lusardi MM & Nielsen CC. Orthotics and Prosthetics in Rehabilitation. Woburn, MA: Butterworth-Heinemann; 2000, p. 405.

48. Principles of Ace-wrapping Distal pressure should exceed proximal Pressure applied on oblique turns only Should be reapplied at least every 2-4 hours No wrinkles Don’t use metal clips—tape down No aching, burning or numbness—remove Wear 23 hours a day (remove for hygiene only) Wash daily, squeeze, don’t wring and air dry (need 2 sets) Continue use until pt. has definitive prosthesis & pt. can leave stump unwrapped overnight and don prosthesis without difficulty in the morning 6

49. What joint issues will you be concerned about in your new amputee patient? • Joint contractures • Joint pain • Joint instability

50. Most common contractures Transtibial Hip flexion Knee flexion Why? Long periods sitting in w/c, bedposition of comfort is one of flexion Protective flexion withdrawal pattern associated with LE pain Muscle imbalances Loss of sensory input from foot in WBing2