LE Amputation: Pre and Post-Operative Intervention

• Pre and Post-Operative Examination & Intervention for LE Amputation

Objectives

• To provide a basic understanding of pre-prosthetic management goals and components for patients after amputation.
• To recognize suitable interventions and create exercise programs based on movement element examinations post-amputation.
• To facilitate discussion on different volume containment types, including their advantages and disadvantages.
• To have general knowledge of functional mobility training, environmental concerns, and discharge planning for patients undergoing lower limb amputation rehabilitation.
• To demonstrate competence in ACE wrapping for transtibial amputation (TTA) and transfemoral amputation (TFA) with correct technique and understanding of patient education for volume containment intervention.

Goals of Pre-prosthetic Management

• Promote healing of the residual limb.
• Educate on the care of the residual limb and the intact lower extremity to prevent future amputation.
• Restore functional mobility to promote independence.
• Achieve volume control and prepare the residual limb for prosthetic use.
• Encourage pain control and desensitization.
• Discharge planning and ordering appropriate durable medical equipment (DME).
• Assess movement elements and prescribe interventions to maintain and improve ROM, strength, endurance, and balance.

Components of Pre-Prosthetic Program

• Pain management focusing on residual limb and phantom limb pain.
• Skin desensitization, inspection, and moisturizing are crucial in residual limb care, alongside skin/scar mobilization.
• Address risk for motion limitations through contracture prevention and management.
• Volume containment is vital.
• Incorporate Functional Mobility with ADL training.
• Equipment ordering is necessary.
• Prescribe motion (ROM), force (strength), control (balance/motor control), and energy (CV endurance) exercises.

Pain Management

• Addressing pain from residual limb and phantom limb

Amputation Related Pain

• Post-operative pain is acute discomfort due to surgery.
• Factors contributing to post-operative pain include edema, poor positioning, pre-operative anxiety and depression, previous pain experiences, and fear of pain.
• Early rehabilitation and pain management includes pharmacological intervention (timing of medication), positioning, TENS, volume control, and energy-based medicine.
• Patient interview questions relate to the nature/type, and description of pain, its location, intensity, impact on function, and positions that improve or worsen it.

Phantom Limb Pain (PLP)

• Phantom Limb Pain is experienced in the amputated limb.
• Treatments include pharmacological intervention, mechanical stimulation, relaxation techniques, desensitization, graded motor imagery, virtual reality, laterality training, TENS, explicit motor imagery, biofeedback, mirror therapy and compression.

Residual Limb Care

• Residual limb care includes desensitization, skin inspection, moisturizing, and skin/scar mobilization.

Skin Inspection

• Inspect skin to monitor for breakdown by visual inspection using a mirror for redness and tactile inspection for temperature or skin issues.
• Skin inspection should be done daily, before and after volume containment, and before and after prosthesis use.

Skin Care for Residual Limb

• Once the incision is healed, normal bathing can resume, though daily cleaning is necessary with mild, non-drying soap.
• Pat skin dry with a towel before donning volume containment or a prosthetic.
• Education should include guidance on proper skin care, signs of infection, awareness of dermatologic conditions, and managing increased perspiration with prosthetic wear.

Skin Desensitization

• The goal of skin desensitization it to reduce hypersensitivity of the limb.
• Methods for skin desensitization include physical touch, fabric, tapping, massage, and weight bearing.

Moisturizing Skin

• The purpose is to keep skin elastic and less prone to breakdown with daily applications of water-based, non-Vaseline, and non-scented moisturizers.

Skin and Scar Mobilization

• The purpose of skin and scar mobilization is to reduce skin adhesion that is problematic during prosthetic use.
• Perform mobilization and scar tissue release over bony prominences and scar areas such as the distal tibia, distal femur, and skin grafts.

Transverse Friction Massage

• This is a manual massage over the incision.
• When: sutures/staples are removed, incision is healed, and skin is approximated
• Where: directly over the incision line or scarred areas.

Contracture Prevention & Management

• Address muscles at risk, risk factors, & interventions.

Contracture Prevention and Management

• Contractures for TTA include knee flexion and hip flexion.
• Contractures for TFA include hip flexion, hip abduction, and hip external rotation.
• Immobilization, lack of education, muscle imbalance, tone, and pain are risk factors.

Contracture Prevention and Management: Assessment

• Assess muscle length/flexibility to see what tests need to be done, PROM/AROM to observe what joints are invovled and soft tissue mobility for any ideal treatment.

Contracture Prevention and Management: Interventions

• The interventions include education, positioning, AROM & PROM exercises, Manual therapy, prolonged stretching, PNF and Joint & Soft tissue Mobilization.

Environment Education: Sitting

• The correct position includes elevating the limb with knee in the extended position, and using a universal residual limb support or elevating leg rest.

Environment Education: Supine & Prone Lying

• The correct Supine position is without pillows and use of the prone position.
• Initiate a Prone lying program ASAP including HEP and advance with a towel roll under the thigh.

Exercise/Stretching for Contracture Prevention

• Select a method based on the patients tolerance.
• Static Stretching & prolonged positioning, and PNF.
• Emphasize muscles at risk for contracture.

Contracture Prevention and Management: Mobilization

• Mobilization consists of Joint Mobilization and Soft tissue mobilization/Myofascial Release

Volume Containment

• Review purposes, types, techniques, advantages, and disadvantages

Volume Containment

• Purposes are to promote optimal shape, desensitize the residual limb to prepare for a prosthesis, manage edema, manage post-operative pain, enhance wound healing, and protect the incision.

Goals of Volume Containment

• Cylindrical shape is the goal of the residual limb because it allows for a better weight bearing surface and make it easier to don the prosthesis.
• Reduce edema to allow for better prosthetic fit and to decrease fluctuation in the size of the limb.

Considerations for what method should be used

• Consider etiology, amputation level, skin presentation & tolerance and the functional status when determining the volume containment method.
• Other considerations the surgeon's preference, the facility protocols, the stage of rehabilitation and their ability to don/doff volume containment.

Methods of Volume Containment

• Possible methods of volume containment include Soft Dressing/Compression wrapping, Stump shrinker, Tubigrip, Semi-rigid, Rigid removable, Rigid non-removable-IPORD and Immediate post-op pylon-IPOP.

Ace Wrapping

• Ace Wrapping indications are for soft post-operative compression and using with dressing
• Advantages: Inexpensive, easily available, easy to inspect the wound, promotes a cylindrical shape, and can be easily modified for patient volume changes.
• Disadvantages: Limited control of post-op edema, must be frequently reapplied every 4-6 hours, is difficult to teach to clinicians and patients and requires 2 functional hands, can be harmful if applied incorrectly

Ace Wrap Technique-TTA

• All wraps should be on a diagonal.
• No circumferential wraps to be made.
• Avoid wrinkles.
• Avoid open areas.
• Most will require 2 ace wraps.
• Wrap to above the knee.
• Becareful applying pressure over the tibial crest

Ace Wrapping Technique-TFA

• All wraps should be on a diagonal.
• No circumferential wraps to be made.
• Avoid wrinkles.
• Avoid open areas.
• Most will require 2-3 ace wraps.

Ace Wrapping Techniques- TFA

• Wrap to the groin area.
• Enclose all the groin tissue.
• Avoid creating an adductor roll.

Shrinkers

• Shrinkers indications are for when the incision is healed and used for compression when the prosthetic is doffed.
• Advantages: effective edema control, easy to don, easy to care for, easy to instruct patient and family, does not have to be re-applied, and easy to view the limb.
• Disadvantages: Physician Prescribed, administered by prosthetist, is expensive to replace, contraindicated for sutures and sensitive skin, loses effectiveness as the limb shrinks and there is no relief for bony or pressure sensitive areas.

Shrinker Donning Technique

• For TTA: Have Good distal contact and set Seam side to side
• For TFA: set Seam front to back, make sure it covers the groin area with a Lateral side pane.

Tubi-grip

• Tubi-grip indications are for post operative care or once the incision has been healed. used frequently with UE, soft dressing alternative for Pressure sensitive skin or poor dexterity
• Advantages: are that it is easy to apply, easy to care for and easy to view the limb
• Disadvantages: they are not durable, have increased cost, can roll and constrict, can cause window edema at the end, is difficult to purchase out of ospital, and require a smaller size as volume decreases.

Tubigrip Donning

• Place 3/4 of tubigrip on residual limb, then Twist the end and Pull the remaining back over the first layer.

Semi-Rigid Dressing: Donning Unna's Boot

• The gauze is impregnated with calamine lotion or zinc oxide.
• Wrap onto residual limb without applying any tension.
• Tightens as it dries.

Semi-Rigid Dressing: Unna's Boot

• Indications: used to manage chronic venous stasis wounds, Facilitate healing post op, and can be used during prosthetic training for edema control.
• Advantages: Provides good edema control, Facilitates healing, Provides Good compression and Can be left on for up to 5 to 7 days.
• Disadvantages: Messy to apply, Can be expensive over time and Is not easily applicable by a patient.

Removable Rigid Dressing

• The dressing indicated can be applied in OR post amputation or later by a PT/Prosthetist/Surgeon for Trans-tibial level amputations where there are no signs of infection and poor healing.
• Advantages: Excellent edema control, Easily donned/doffed, Skin is accessible, Modified as limb shrinks with sock management and it Provides Protection of the residual limb against accidental trauma.
• Disadvantages: Time consuming to fabricate, requires skill to fabricate, donning can injure very fragile skin and it is important to closely monitor sock ply.
• When donning: Place on prosthetic socks over dressing as needed, Slide on removable cast, Apply suspension and apply Continuous wear

Non-Removable Rigid Dressings (non-RRD)

• A Rigid cast is applied by the surgeon in the OR, the first cast changed 2-5 days later, and subsequent casts are changed between 5-21 days dependent on protocol.
• Goals: To provide Edema Control, Limb Protection and Reduce knee flexion contracture
• Advantages: Excellent edema control, Wound protection, aides in contracture prevention, and Increased patient confidence
• Disadvantages: Cannot view the wound-not for disease patients, requires skill in fabricating, heavy and it can cause skin breakdown as limb shrinks.

Immediate Post-Op Pylon: IPOP

• Non-RRD with a patellar tendon bearing socket & foot
• Generally there is a protocol for weight bearing in post operative stage
• Advantages: Same as non-RRD, Allows early weight bearing, reduces phantom pain and the patient will have a decreased hospital stay.
• Disadvantages: Same as non-RRD, there is a Risk of wound irritation, and is Inappropriate for those who can not maintain WB-ing precautions.

Pneumatic Compression

• An air splint is Utilized to initiate early mobilization for individuals unable to hop on one limb
• Indications: post op or pre-prosthetic stage, and has Advantages: Inexpensive, easily donned/doffed, assesses prosthetic rehab potential
• Disadvantages: can only be used up to 20-30mins at a time, difficult to control amount of WB-ing

Functional Mobility Training & Intact Foot Protection

• Provide education for DME ordering, ADL training, and diabetic foot assessment/management

Pre-Prosthetic Functional Mobility

• To achieve Safe mobility without a prosthesis, with Protection of the intact limb is a key component
• Prognosis: 30 days post op: 9-10% mortality
  • Mortality Rates:
    • 1 year: 48%
  • Survival rates following LEA:
    • 5 years: 35%
  • Rate of New Amputation
    • 3-5 Years: 56%

Pre-Prosthetic Functional Mobility & Foot Protection

• Every 30 seconds, a limb is lost to Diabetes Mellitus (DM).
• 84% of all non-traumatic amputations with a history of DM are preceded by a foot ulcer.
• 78% of foot ulceration & Lower extremity amputation (LEA)can be prevented with early identification & management.

Skin Care Intact Limb

• The patients Foot should be protected at all times during weight bearing with appropriate shoe wear.
• Limit Mobility to avoid too much hopping with proper Education.

Diabetic Foot Exam

• Assessment includes:
  • Vascular: includes pulses and ABI levels.
• Sensory: includes protective sensation, vibratory sensation, and pinprick.
  • Musculoskeletal: Includes ROM, deformity and muscle wasting.
  • Dermatologic: Check for ulcers and signs of infection.
  • Autonomic: Includes checks for hair and nail growth and the overall skin integrity.
  • Shoe wear and fit is also necessary.

Risk Assessment

• Risk category of 0: No LOPS, no PAD, no deformity requires Patient education including advice on appropriate footwear and will need Suggested follow-up Annually (by generalist and/or specialist)
• Risk category of 1: LOPS ± deformity is where its important to consider prescriptive or accommodative footwear, and consider prophylactic surgery if deformity is not able to be safely accommodated in shoes. Continue patient education and will need a Suggested follow-up Every 3-6 months (by generalist or specialist)
• Risk category of 2: PAD ± LOPS requires you to Consider prescriptive or accommodative footwear and Consider vascular consultation for combined follow-up and will need a Suggested follow-up Every 2-3 months (by specialist)
• Risk category of 3: A History of ulcer or amputation is where you follow the same guidelines as category 1, Consider vascular consultation for

Functional Mobility Goals following Amputation

• Deficits impact Function & Participation
• Assessment of Mobility Tasks is needed to determine the
  • Amount of assist needed?
  • Efficiency & time for tasks and to monitor for Symptoms such as fear of falling, pain, fatigue and to build their confidence.
  • Monitor the Environment while in the gym v. hospital room or at home.
  • Personal Considerations such as to encourage motivation, lower the fear of falling and deal with all comorbidities.
• Maintain a strong Family & Community Support network.

Pre-Prosthetic Functional Mobility Goals

• Bed mobility: supine ←→ prone
• Transfers:
  • Front on /back off
  • Floor ←→ chair
  • W/C ←→ step
• Ambulation
  • Limited hopping and twisting
  • Appropriate shoe wear at all times
• Stair negotiation
  • Bumping on buttocks for LE protection
• DME Ordering & Management

Equipment Ordering

• Wheelchair considerations: - W/C is necessary during post OP & pre-prosthetic stage
• Alteration in COM impacts w/c safety -COM shifts where post LE amputation?
• Rear anti-tippers are important for safety
• Universal residual limb supports
• Floor to seat height considerations - W/C propulsion, sit ←→ stand transfer, height of other surfaces (bed, commode)
• W/C propulsion over various surfaces indoors & community

Pre-Prosthetic Exercise Prescription & Program

• Interventions need to Address Motion, Control, Energy, & Force Deficits

Exercise Prescription: Motion Interventions

• Most common contractures located in the Lower Extremity with TTA (knee flexion, hip flexion) and TFA (hip flexion, hip abduction, external rotation)
• Select interventions based on patient tolerance & personal factors
• What ROM is needed for normal gait?
  • Hip
  • Knee
  • Ankle

Exercise Prescription LE Strengthening

• What is the goal?
• Most critical groups to strengthen include TFA (hip extensors, flexors, abductors, and adductors) and TTA (knee extensors and hip extensors).

Exercise Prescription for Force: UE Strengthening

• Upper Extremity Strengthening Is Essential to achieve independence with
  • Bed mobility
  • Transfers
  • Wheelchair propulsion
  • Ambulation with assistive device

Interventions for Force: UE Strengthening

• Emphasis: shoulder stabilizers, adductors, depressors, and elbow extensors

Force Exercise Prescription: Core Strengthening

• Trunk stability essential for: -Prosthetic control -Sitting posture
• Standing posture -Reduction of stress to spine that can lead to LBP

Exercise Prescription: Balance

• Falls: It has been shown that 50% of prosthetic uses report x1 fall/year; 39% with recurrent falls
• Problems post-amputation:
  • Change in center of gravity requires there to be some
  • Control of COM over altered BOS as this will
  • Impact on balance reactions and limit the their
  • Loss of sensory feedback
• Focus on both seated and standing balance for independent ADL's and mobility
• What test & measures for balance assessment?

Energy Intervention: Endurance

• Metabolic Cost of Prosthetic Ambulation along with Increases with level, # of amputations, & causes (Ettema et al.)
  • Vascular TFA: >102%
  • Nonvascular TFA: >41%
  • Vascular TTA: >36%
  • Nonvascular TTA: >12%
• What type of interventions improve CV endurance?

Energy Intervention: Endurance

• Considerations?
  • Cardiovascular Response
  • Blood Sugars Pre and Post Exercise
  • Co-morbidities
  • Hospital Stay/Inactivity/Bed rest
• Recommendations: 150mins of exercise per week
• Outcome measures for endurance
• Physical conditioning is a predictor of prosthetic use

Resources for Patient education

• Group education
• Treatment education time
• Family Instruction
• Booklets

Resources for Written & Pictorial Education

-Positioning/Contracture Prevention

• Volume Containment
• Pain Management
• RL & Foot Care