Lower Extremity Amputation: Pre/Post-Op Care

• The presentation discusses pre- and post-operative examination and intervention for lower extremity (LE) amputation.

Objectives

• Students gain a basic understanding of pre-prosthetic management goals and components for post-amputation patients.
• Students learn to identify appropriate interventions and create exercise programs based on post-amputation movement examination.
• Students explore different volume containment types, considering their advantages and disadvantages.
• Students learn about functional mobility training, environmental concerns, discharge planning in lower limb amputation rehabilitation.
• Students demonstrate correct ACE wrapping technique for transtibial amputation (TTA) and transfemoral amputation (TFA), capable of educating patients on volume containment.

Goals of Pre-prosthetic Management

• Promote residual limb healing and provide education on its care as well as 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.
• Promote pain control and desensitization.
• Facilitate discharge planning and order appropriate durable medical equipment (DME).
• Assess movement elements and prescribe interventions to maintain/improve ROM, strength, endurance, and balance.

Components of Pre-Prosthetic Program

• Pain Management addresses residual limb and phantom limb pain.
• Residual Limb Care includes skin desensitization, skin inspection, moisturizing, and skin/scar mobilization.
• Managing Risk for Motion Limitations involves contracture prevention and management.
• Volume Containment helps in shaping the residual limb.
• Functional Mobility and Activities of Daily Living (ADL) training are essential.
• Equipment Ordering ensures necessary assistive devices.
• Exercise Prescription focuses on motion (ROM), force (strength), control (balance, motor control), and energy (CV endurance).

Amputation Related Pain

• Post-operative pain involves managing acute discomfort following surgery.
• Factors contributing to post-operative pain include edema, poor positioning, preoperative anxiety/depression, previous pain experiences, and fear of pain.
• Treatment addresses pharmacological intervention (timing of medication), positioning, TENS, volume control, and energy-based medicine.
• Early rehabilitation plus pain management is key.
• Patient Interview Questions explore the nature/type, description, location, and intensity of pain, its impact on function, and positions that improve or worsen the pain.

Phantom Limb Pain (PLP)

• PLP refers to pain experienced in the amputated limb.
• Treatments include pharmacological intervention, mechanical stimulation, graded motor imagery, relaxation techniques, laterality training, desensitization, explicit motor imagery, virtual reality, mirror therapy, TENS, biofeedback and compression.

Residual Limb Care

• Elements of residual limb care include skin desensitization, skin inspection, moisturizing, and skin/scar mobilization.

Skin Inspection

• The purpose is to monitor the skin for breakdown.
• Redness might be observed during visual inspection with a mirror.
• Tactile inspection identifies Temperature changes or skin issues.
• Skin Inspection: Daily, before and after volume containment, and before and after prosthesis use.

Skin Care for Residual Limb

• Once the incision has healed, normal bathing can resume.
• Daily cleaning of the leg is necessary using mild, non-drying soap and patting dry with a towel before donning volume containment or a prosthetic.
• Education includes appropriate skin care strategies and recognizing signs of infection and dermatologic conditions.
• Increased Perspiration is expected with prosthetic wear

Skin Desensitization

• The goal is to reduce hypersensitivity of the limb using physical touch, fabric, tapping, massage, or weight-bearing exercises

Moisturizing Skin

• Moisturizing skin increases elasticity and decreases the likelihood of breakdown and should be done daily.
• Use Water-based, Non-Vaseline, Non-Scented moisturizers.

Skin and Scar Mobilization

• The Purpose is to reduce skin adhesion that are problematic during prosthetic use.
• Adhesion occurs over bony prominences and scar areas—distal tibia, distal femur, and skin grafts.

Transverse Friction Massage

• Use manual massage over the incision, when sutures/staples have been removed, the incision is healed, and the skin is approximated.
• Massage directly over the incision line or scarred areas.

Contracture Prevention and Management

• This involves identifying muscles at risk, risk factors, and interventions.

Contractures

• TTA Specific: Knee and hip flexion.
• TFA Specific: hip flexion, hip abduction, and hip external rotation.
• Risk Factors include immobilization, lack of education, muscle imbalance, tone, and pain.

Contracture Management Assessment

• Assess muscle length/flexibility, PROM/AROM, and soft tissue mobility.

Interventions for Contracture Management

• Education is key.
• Positioning Provide AROM & PROM Exercises, Manual Therapy, Prolonged stretching, PNF, Joint & Soft tissue Mobilization.

Environment Education: Sitting

• The limb has to be elevated with the knee in the extended position.
• Use a universal residual limb support or elevating leg rest as needed to achieve extended knee position.

Environment Education: Supine & Prone Lying

• Correct supine position is without pillows.
• Correct Prone position is with a towel roll under the thigh
• Positioning Alone is not effective to gain range
• It’s key to initiate a Prone lying program ASAP which includes HEP.

Exercise/Stretching for Contracture Prevention with ROM Impairments

• Static Stretching & prolonged positioning and PNF are interventions.
• Muscles at risk for contracture are emphasized.

Contracture Prevention and Management Mobilization

• Joint Mobilization and Soft tissue mobilization/ Myofascial Release may be utilized.

Volume Containment

• Understanding the different types, techniques, advantages, and disadvantages.
• The Purpose is to promote optimal shape, desensitize the residual limb for prosthetic use, manage edema and post-op pain, enhance wound healing, and protect the incision.
• Cylindrical Shape of the residual limb promotes a better weight-bearing surface and eases prosthesis donning.

Volume Containment Goals

• Reduce Edema in order to allow a better prosthetic fit, and Decrease fluctuation in the size of the limb.
• Considerations are etiology, amputation level, skin presentation & tolerance, functional status, surgeon preference, facility protocols, rehabilitation stage, and the ability to don/doff.
• Methods include soft dressing/compression wrapping, stump shrinker, tubigrip, semi-rigid, rigid removable, rigid non-removable-IPORD, and immediate post-op pylon-IPOP.

Ace Wrapping:

• Indications are soft post-operative compression; can be used with dressing.
• Advantages are that it’s inexpensive, easily available, allows wound inspections, promotes a cylindrical shape, and is easily modified to accommodate volume changes.
• Disadvantages are limited edema control, frequent reapplication (every 4-6 hours) difficulty to teach, requirement of 2 functional hands, and potential for harmful application.

Ace Wrap Technique-TTA

• All wraps on a diagonal with no circumferential wraps, while avoiding wrinkles and open areas.
• Most TTA wraps will require 2 ace wraps.

Ace Wrapping Technique

• Wrap to above the knee and be careful while applying pressure over tibial crest.

Ace Wrapping Technique-TFA

• All wraps on a diagonal with no circumferential wraps, while avoiding wrinkles and open areas.
• Most TFA wraps will require 2-3 ace wraps.

Ace Wrapping Techniques-TFA

• Wrap to the groin area and enclose all groin tissue to avoid creating an adductor roll.

Shrinkers

• Indications: Apply when the incision is healed and use for compression when prosthetic doffed.
• Advantages are effective edema control, ease of donning, care, instructing, and viewing the limb; does not have to be re-applied.
• Disadvantages are the need for a physician's prescription and prosthetist administration, expense, contraindication for sutures/sensitive skin, loss of effectiveness with limb shrinking, and lack of relief for bony or pressure-sensitive areas.

Shrinker Donning Technique

• TTA: Good distal contact with seam side to side.
• TFA: Seam front to back; make sure it covers the groin area and is on the lateral side pane.

Tubi-grip

• Indications: post operative or incision healed; frequently used with UE, Soft dressing alternative for pressure sensitive skin or poor dexterity
• Advantages: ease of application, easy to care for, easy to view the limb
• Disadvantages: not durable, increased cost, can roll and constrict, can cause window edema at end, difficult to purchase out of hospital, Need smaller size as volume decreases

Tubigrip Donning

• Place 3/4 of tubigrip on residual limb, twist the end, Pull remaining back over first layer

Semi-Rigid Dressing: Unna’s Boot

• Gauze is impregnated with calamine lotion or zinc oxide, then wrap onto residual limb without applying any tension and Tightened as it dries.
• Indications include management of chronic venous stasis wounds, facilitation of healing post op, and use during prosthetic training for edema control.
• Semi-rigid: Unna’s Boot: Advantages include Good edema control, Faciliates healing, Good compression and can be left on for up to 5 to 7 days. Disadvantages: Messy to apply, Can be expensive over time, Not easily applicable by a patient.
• Removable Rigid Dressing: Removable cast placed over dressing, indications are can be applied in OR post amputation or later by a PT/Prosthetist/Surgeon, transtibial level and no signs of infection/poor healing.
• Rigid Removable: Advantages: Excellent edema control, Easily donned/doffed, skin is accessible, modified as limb shrinks with sock management, Protection of the residual limb againstr accidental trauma
• Disadvantages: Time consuming to fabricate skill to fabricate , donning can injure very fragile skin, Must closely monitor sock ply Removable Rigid Dressing, slide in socks before
• Non-Removable Rigid Dressings (non-RRD): Surgeon applies rigid cast in the OR, The first cast is changed 2-5 days with subsequent cast changed between 5-21 days dependent on protocol
• Non-removable Rigid Dressing (Non-RRD) Aims to provide Edema Control,Limb Protection and Reduce knee flexion contracture
• Non-removable Rigid Dressing (Non-RRD) Advantages: Excellent edema control, Wound protection, aids in contracture prevention and Increased patient confidence Disadvantages: Cannot view the wound-not for disease patients, Skill in fabricating, Heavy and Skin breakdown as limb shrinks
• Immediate Post-Op Pylon: IPOP provides Non-RRD with a patellar tendon bearing socket & foot. Also generally there is a protocol for weight bearing in post operative stage
• Immediate post-op pylon Advantages include a Same as non-RRD, Allows early weight bearing, reduces phantom pain and decreased hospital stay , While disadvantages are the same as non-RRD, Risk of wound, irritation and Inappropriate for those who can not maintain WB-ing precautions

Pneumatic Compression

• Pneumatic Compression Utilizes an air splint to initiate early mobilization for individuals unable to hop on one limb
• Indications: post op or pre-prosthetic stage
• Disadvantages: can only be used up to 20 30mins at a time, difficult to control amount of WB-ing,
• Advantages: inexpensive, easily donned/doffed, assesses prosthetic rehab potential Functional Mobility Training & Intact Foot
• It involves Protection DME ORDERING, ADL TRAINING, & DIABETIC FOOT ASSESSMENT/MANAGEMENT
• Pre-Prosthetic Functional, Mobility aims for Safe mobility without a prosthesis and gives Protection of the intact limb is a key component Prognosis- (30 days post op)Mortality- 9-10 percent or
• 1year48 percent Survival Rate- 5 years : 35 percent Rate of new- 3-5 years: 56 percent
• Pre-Prosthetic Functional Mobility & Foot Protection: Every 30sec, a limb is lost to Diabetes Mellitus (DM), 84% of all non-traumatic amputations with h/o DM are preceded by a foot ulcer and 78% of foot ulceration & LEA can be prevented with early identification & management
• Skin Care Intact Limb: Shoes that Provide Foot protection is key, as is Mobility and Education Assessment includes:Vascular: pulses, ABI, Sensory: protective sensation, vibratorysensation, pinprick, Musculoskeletal: ROM, deformity, ms.wasting,Dermatologic: ulcers, signs of infection,Autonomic: hair, nails, skin integrity, Shoe wear and fit
• Functional Mobility Goals, following Amputation: Deficits impact Function & Participation, Assessment of Mobility Tasks, Amount of assist needed and Efficiency & time for tasks
• Furthermore, Symptoms: fear of falling, pain, fatigue, confidence, Environment: gym v. hospital room v. home, Personal: motivation, fear of falling, comorbidities and Family & Community Support
• PPre-Prosthetic Functional Mobility Goals involves, Bed mobility: supine ßà prone, Transfers, Ambulation,Stair negotiation and DME Ordering & Management
• Equipment Ordering also Includes, 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 and Universal residual limb supports
• Also important is that Floor to seat height considerations,W/C propulsion, sit ßà stand transfer, height of other surfaces (bed, commode) and W/C propulsion over various surfaces indoors & community
• Pre-Prosthetic Exercise Prescription & Program-INTERVENTIONS TO ADDRESS MOTION, CONTROL, ENERGY, & FORCE DEFICITS
• Exercise Prescription provides focus on Motion Interventions to address Lower Extremity common contractures;TTA: knee flexion, hip flexion and TFA: hip flexion, hip abduction, external rotation
• Also important to Select interventions based on patient tolerance & personal factors and provide the ROM needed for normal gait (Hip, knee and ankle)
• Exercise Prescription LE provides for LE Strengthening; what is the goal and to strengthen TFA: hip extensors, flexors, abductors, and adductors to TTA: knee extensors and hip extensors .
• Exercise Prescription for Force: UE Strengthening emphasizes Should is essential to achieve independence with a Bed mobility, Transfers, Wheelchair propulsion and Ambulation with assistive device
• Interventions for Force: UE Strengthening focus Emphasis: shoulder stabilizers, adductors, depressors, and elbow extensors Force Exercise Prescription Provides, Core Strengthening which Includes Stabilization trunk stability essential for Prosthetic control,Sitting posture,Standing posture and Reduction of stress to spine that can lead to LBP
• Exercise Prescription provides, Balance for Falls, Problems post-amputation:Change in center of gravityImpact on balance reactions and Loss of sensory feedback .Focus should be 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 AmbulationIncreases with level, # of amputations, & causes (Ettema et al.) Vascular TFA: >102%, Nonvascular TFA: >41%, Vascular TTA: >36% and Nonvascular TTA: >12%
• Also understand the, Considerations including Cardiovascular ResponseBlood Sugars Pre and Post Exercise, Comorbidities and Hospital Stay/Inactivity/Bed rest
• It’s recommended 150mins of exercise per week. Also consider Outcome measures for endurance as well as Physical conditioning is a predictor of prosthetic use What are your resources? Patient education with both Written & Pictorial Education aids in providing a great group education, Treatment education ,time, Family Instruction and Booklets. Topics for Focus include Positioning/Contracture and Volume Containment, Pain Management as well as RL & Foot Care