Physical Therapy For Lower Limb Amputee PDF

PHYSICAL THERAPY FOR THE LOWER LIMB AMPUTEE  DEFINITION  Amputation is the removal of limb, part or total from the body.  Disarticulation is removing the limb through a joint.  Generally the amputation of Lower Limb are more common than those of upper limb. INCIDENCE  Age...

PHYSICAL THERAPY FOR THE LOWER LIMB AMPUTEE  DEFINITION  Amputation is the removal of limb, part or total from the body.  Disarticulation is removing the limb through a joint.  Generally the amputation of Lower Limb are more common than those of upper limb. INCIDENCE  Age –  Common in 50 – 70 year  Gender –  Male – 75%  Female – 25%  Limbs –  Lower limbs 85%  Upper limbs – 15% INDICATIONS OF AMPUTATION  Trauma, Gun Shot Wounds  Malignant tumors  Nerve injuries & infection  Extreme heat & cold – burn, gangrene  Peripheral vascular insufficiency  Congenital absence of limbs or malformation  Severe infection  CAUSES OF AMPUTATION  Natural causes  Accidental causes  Ritual, Punitive & Legal Amputations  Cold steel & Gunshot causes NATURAL CAUSES OF LIMB LOSS  Congenital absence  Arterial disease  Frostbite  Ergot and other toxins  Wound infections  Diabetes mellitus  Dietary deficiencies  Tumors  Relative % of causes of LL amputation Developed world causes (%) Developing world causes (%) PVD (approx. 25-50% 85-90 Trauma 55-95 diabetes mellitus) Trauma 9 Disease 10-35 Tumor 4 Tumor 5 Congenital deficiency 3 Congenital deficiency 4 Infection 1 Infection 11-35  Relative % of causes of UL amputation Developed world causes (%) Developing world causes (%) Trauma 29 Trauma 86 Disease 30 Disease 6 Congenital deficiency 15 Congenital deficiency 6 Tumor 26 Tumor 1 TYPES OF AMPUTATION  Closed Amputation  Open Amputation (Guillotine Operation) CLOSED AMPUTATION  It is done as an elective procedure.  After amputations, the soft tissues are closed primarily over the bony stump.  E.g., above knee, below knee etc.  OPEN AMPUTATION (GUILLOTINE OPERATION)  It is done as an emergency procedure.  E.g. life threatening infections  After amputations, the wound is left open & not closed.  2 types depending upon the skin flaps:  Open amputation with inverted skin flap  Circular open amputation  PRINCIPLES OF CLOSE AMPUTATION  Tourniquets: desirable except in ischemic limbs.  Level of amputation: it is very important to fit the prosthesis.  Skin flaps: good skin coverage is important. Skin should be mobile & sensitive.  Muscle: is divided at least 5cm distal to the level of intended bone section & sutured.  PRINCIPLES OF CLOSE AMPUTATION CONT…  Methods of Muscle Suture  Myodesis – muscle is suture to bone  Myoplasty – muscle is sutured to opposite muscle group under appropriate tension.  PRINCIPLES OF CLOSE AMPUTATION CONT…  Nerves: cut proximally & allowed to retract. Large nerves are ligated before division.  Blood vessels: doubly ligated & cut. Then the tourniquet is released & hemostasis is completed.  Bone: section above level of muscle section.  Drains: removed after 48 – 72 hours.  PRINCIPLES OF CLOSE AMPUTATION  Compression dressing: Either elastic or a rigid plaster dressing fitting immediately.  Absolute bed rest with limb elevation: This is acceptable for the conventional prosthesis with adequate vascularity.  Limb fitted: Conventional prosthesis is fitted a minimum of 8 – 12 weeks after surgery. Rigid dressing with temporary pylon prosthesis maybe elected as an alternative. PRINCIPLE OF OPEN AMPUTATION  Indication:  Severe infection  Severe crush injuries  Types:  Open amputation with inverted skin flaps: it is a common choice.  Circular open amputation: wound is kept open & closed 2* by suture, skin graft or re-amputation. PRINCIPLE OF OPEN AMPUTATION CONT…  Rx following amputation:  Rigid dressing concept (Pylon): POP cast is applied to the stump over the dressing after surgery.  Soft dressing concept: The stump is dressed with the sterile dressing & elastocrepe bandage applied over it. 17  COMPLICATION OF AMPUTATION  Hematomas  Phantom sensation  Infections  Hyperesthesia of stump  Necrosis  Stump edema  Contractures  Bone overgrowth  Neuromas  Causalgia  Stump pain  AMPUTATION - COMPLICATIONS  Phantom Limbs –  Some amputees experience the phenomenon of Phantom Limbs; they feel body parts that are no longer there.  Limbs can itch, ache, & feel as if they are moving.  Scientists believe it has to do with neural map that sends information to the brain about limbs regardless of their existence.  AMPUTATION – COMPLICATIONS CONT…  In many cases, the phantom limb aids in adaptation to a prosthesis, as it permits the person to experience proprioception of the prosthetic limb. Dr.PR Khuman,MPT(Ortho & Sport) 20  AMPUTATION – COMPLICATIONS CONT…  Painful adhesive scar formation  An adherent painful scar over the surgical incision poses a problem in process of rehab.  It may obstacle in fitting prosthesis.  Early mobilization of the painful scar is recommended with other therapeutic modalities.  AMPUTATION – COMPLICATIONS CONT…  New bone formation at the amputation sites  It has been reported that new bone formation 5 weeks after electrical burn.  The stump should be closely watch for any sing & symptoms like – tenderness, warmth & swelling (Helm & Walker, 1987)  Such symptoms delayed fitting final prosthesis.  AMPUTATION – COMPLICATIONS CONT…  Flexion Deformity  Deformity complicates the process of prosthetic fitting & ambulation.  AMPUTATION – COMPLICATIONS CONT…  Hyperesthesia of the stump:  This is another annoying symptom that is difficult to control.  Re-amputation results only in reproducing the symptom at a higher level. REASONS FOR AMPUTATION  Circulatory disorders  Diabetic foot infection or gangrene (the most common reason for non-traumatic amputation)  Sepsis with peripheral necrosis REASONS FOR AMPUTATION CONT…  Neoplasm  Cancerous bone or soft tissue tumors  e.g. osteosarcoma, osteochondroma, fibrosarcoma, epithelioid sarcoma, ewing's sarcoma, synovial sarcoma, sacrococcygeal teratoma  Melanoma REASONS FOR AMPUTATION CONT…  Trauma  Severe limb injuries in which the limb cannot be spared or attempts to spare the limb have failed  Traumatic amputation (Amputation occurs usually at scene of accident, where the limb is partially or wholly severed).  Amputation in utero (Amniotic band) REASONS FOR AMPUTATION CONT…  Infection  Bone infection (osteomyelitis)  AMPUTATION LEVEL NOMENCLATURE Old Terminology Current Terminology Partial hand Partial hand Wrist disarticul ation Wrist disarticulation Below elbow Transradial Elbow disarticulation Elbow disarticulation Above elbow Transhumeral Shoulder disarticulation Shoulder disarticulation Forequarter Forequarter Partial foot Partial foot Syme’s Ankle disarticulation Below knee Transtibial Knee disarticulation Knee disarticulation Above knee Transfemoral Hip disarticulation Hip disarticualation Hemipelvectomy Transpelvic  Levels of Amputation Partial toe Excision of any part of one or more toes Toe disarticulation Disarticulation at the MTP joint Partial foot/ ray resection Resection of 3rd-5th metatarsal & digit Transmetatarsal Amputation through the midsection of all metatarsals Syme’s Ankle disarticulation with attachment of heel pad to distal of tibia Long transtibial (Below knee) More than 50% tibial length Short transtibial (Below Knee) Between 20% and 50% of tibial length Knee disarticulation Through knee joint Long transfemoral ( Above knee) More than 60% femoral length Transfemoral (above knee) Between 35% and 60% femoral length Short transfemoral (Above Knee) Less than 35% femoral length Hip disarticulation Amputation through hip joint, pelvis intact Hemipelvectomy Resection of lower half of the pelvis Hemicorporectomy/ Translumbar Amputation both lower limb & pelvis below L4-L5 level  Level of Amputation (%) Developing Developing Level world world ❖ Lower limb – ❑ Trans-tibial (including foot) 29-62 49-71 ❑ Trans-femoral (including knee disarticulation) 33-49 26-40 ❖ Upper limb – ❑ Trans-radial (including wrist disarticulation) 32-66 21-33 ❑ Trans-humeral (including elbow disarticulation) 14-26 25-36 PRINCIPLE CONSIDERATION TO AMPUTATE  Preservation of life  Improvement of general health  Restoration of function  Reduction of pain REHABILITATION OF LL AMPUTATION  Pre operative period  Post operative period  Pre-prosthetic stage  Prosthetic stage Pre - Operative period PRE OPERATIVE PERIOD  Assessment  Physical  Social  Psychological  Training  Re-assurance  PRE OPERATIVE ASSESSMENT  Assessment of –  The affected limb  The unaffected limb &  The patient as a whole is conducted thoroughly.  Assessment of physical, social & psychological status of the patient should be made.  PHYSICAL ASSESSMENT  Muscle strength of UL, trunk & LL apart from the affected limb before level of amputation.  Joint mobility, particularly proximal to the amputation level.  Respiratory function  Balance reaction in sitting & standing  Functional ability  Vision & hearing status  SOCIAL ASSESSMENT INCLUDES  Family & friends supports  Living accommodation –  Stairs, ramps, rails, width of door, wheelchair accessibility  Proximity of shops  PSYCHOLOGICAL ASSESSMENT  Patients psychological approach to amputation.  Motivation to walk.  Other psychological problems. Pre Operative Training  BASIC AIMS  To prevent post operative complication  To reduce the cost of rehabilitation  To reduce the period of rehabilitation TRAINING PROGRAM INCLUDES  To prevention of thrombosis:  Maintaining circulation through movt of the other good limb.  To prevent the chest complication:  Deep breathing, coughing & postural drainage  To relieve pressure:  Pressure mobility of all the joints  More emphasis is given to susceptible joints. TRAINING PROGRAM CONT…  To improve mobility:  Mobility ex for trunk, pelvic or shoulder girdle  Mobility ex to compensate for the deficiencies & restriction due to prosthesis.  Teach the technique to be adapted for mobility & limb positioning in bed. TRAINING PROGRAM CONT…  To educate the patient:  Educate the techniques of transfers, monitoring wheelchair, single limb standing & balancing.  Explain important aspect of balance, equilibrium, standing & walking techniques.  Educate to detect the possible complications like – soft tissue tightness, pressure point, expected degree of pain & phantom pain. REASSURANCE  Psychological reassurance play an important roll in recovery  Reassurance with all possible encouragement  Practical demonstration by who has undergone similar surgery.  Post Operative Period (pre prosthetic stage)  AIMS OF RX To prevent post operative complication To prevent deformities To control stump edema To maintain strength of whole body & increase strength of muscle controlling the stump To maintain general mobility To improve balance & transfer To re-educate walking To address Phantom Pain To restore functional independence  PREVENTION OF POST OPERATIVE COMPLICATION  Breathing ex to prevent respiratory complications.  Brisk ankle & foot ex for unaffected leg to prevent circulatory complications.  This exs are given form 1st day onward until patient ambulate.  PREVENTION OF DEFORMITIES  Positioning in bed:  Stump should be parallel to the unaffected leg without resting on pillow.  Patient should lie as flat as possible & progress to prone lying when drains are out.  Pt with cardiac & respiratory problems may discomfort in prone lying, brought to supine.  Prolong sitting on soft mattress can predispose to development of hip flexion deformity. PREVENTION OF DEFORMITIES CONT…  Exercise to counteract the deformity:  Strong isometric quadriceps ex – BKA  Hip extensor & add isometric ex – high AKA  Hip extensor & abd isometric ex – low AKA  Progression is made to free active & resisted stump ex.  Stump board – in BKA – stump should be rest on board when sitting in wheelchair.  Prolong sitting with knee flex should be avoided. TO CONTROL THE STUMP EDEMA CONT…  Stump compression socks or bandaging:  Elastic stump compression socks ( Juzo Socks) methods reduce edema & conditioning the stump.  Bandaging is controversial method of controlling stump edema particularly in vascular patient.  Pressure should be firm, even & decreasing pressure proximally.  TO CONTROL THE STUMP EDEMA CONT…  Stump compression socks or bandaging:  Diagonal oblique & spiral turn should be used rather than circular turns to prevent tourniquet effect.  Bandage size:  Upper limb – 4”  Lower limb – 6”/8”  Above knee – 6”  Below knee – 4” 52 STUMP COMPRESSION SOCKS OR BANDAGING:  Above knee (AK) bandaging:  It should extend up to groin to prevent follicle infection due to friction with socket of prosthesis.  It should bandage with hip in extension & adduction.  Below knee (BK) bandaging:  Stump should bandage with knee in slight flexion.  Above knee Below knee 27-Jul-13 Dr.PR Khuman,MPT(Ortho & Sport) 54 MAINTAIN BODY STRENGTH & STRENGTHEN MUSCLE CONTROLLING STUMP  Strengthening muscles are:  Shoulder – extensors, Adductors,  Elbow – extensors by working against weight or springs attached to bed.  Examples are:  Grasp stretch lying (shoulder extension & adduction)  Grasp lying (elbow flexion)  Sitting push up  Strengthening of crutch muscle is very important  EXERCISE FOR UNAFFECTED SIDE  Lying:  Static quadriceps  Static gluteal  Straight leg raising (SLR)  Alternate hip & knee bending & stretching  STUMP EXERCISE  Begins when the drains are out  Gradually progressed from static to free active then resisted ex (PRE)  In BKA progress to strengthening against resistance.  In AKA prone lying leg lifting against resistance  E.g. manual resistance, weighted pulley, spring, theratube, theraband etc. MAINTAIN GOOD MOBILITY  Exercisewhich moves the shoulder in all direction will maintain shoulder mobility  Trunk movts in lying & sitting will improve trunk mobility IMPROVE BALANCE & TRANSFERS  Balance training  In sitting position by encouraging balance reaction, tapping, perturbation & trunk stabilization  Training of transfer techniques  Wheelchair to bed  Bed to wheelchair  Wheelchair to toilet etc  WALKING RE-EDUCATION  Partial weight bearing in parallel bar using pneumatic post amputation mobility aid (PPAM) 5 – 10 day post operatively  Patient should wear normal dress & a good walking shoe on unaffected side.  Initially preferred training in stable surface & progress to unstable surface. E.g. Walking in mud 60  PNEUMATIC POST AMPUTATION MOBILITY AID (PPAM)  It is a partial weight bearing early walking aid that must only used under clinical supervision in the therapy facility, not for ward or home use.  It can use from 5 -7 day postoperatively while the suture are still in the wound.  PPAM AID ADVANTAGES  Great psychological boost gained by walking soon after amputation.  Reduction of oedema by pressure in bag.  Postural reaction are re-educated by encouraging partial weight bearing.  Preparation of the residual limb for hard socket of a prosthesis.  This may help in reducing phantom sensation.  PPAM AID DISADVANTAGES  If a fixed flexion contracture is present, the residual limb is more liable to break down.  If the amputee is very heavy or heavy footed gait, excessive pistoning may occur & there will be insufficient support.  Amputees used a stiff knee gait pattern, which is unnatural for those with the trans-tibial level.  The inflation pressure may greater than the arterial pressure in the residual limb. WALKING WITHOUT A PROSTHESIS  Using firm compression socks or bandage the gait training can be done in parallel bar  Progress to – a frame or crutch depending on stability.  Crutch user found less adaptation time to use a prosthesis  Normal alignment of pelvis & reciprocal movt of stump should maintain.  PRINCIPLE OF BANDAGING OF STUMP  Pressure of bandage should be  Moderately firm  Evenly distributed  Decreasing proximally  Extra pressure over the corners – conical shape  Pattern of bandage:  Diagonal, oblique or spiral  Not circular