LEC 2. Assessment of the amputee PDF

 Prosthetics & Orthotics Clinical Placement By Dr/ Ahmed Bayuomy Abo Elatta 2-Assessment of the amputee  Assessment of the amputee Assessment of a patient having an amputation should begin as early as possible, ideally preoperatively, by the whole multi-discip...

 Prosthetics & Orthotics Clinical Placement By Dr/ Ahmed Bayuomy Abo Elatta 2-Assessment of the amputee  Assessment of the amputee Assessment of a patient having an amputation should begin as early as possible, ideally preoperatively, by the whole multi-disciplinary team in order to prepare the patient, maximize the outcome. The decision to amputate should be made by this team where ever possible. This could even be before admission to hospital for the surgery. It is importance to have a discussion with the patient about short term and long term goals, as well as specific expectations and feelings regarding the surgery, rehabilitation.  Why Assess? To assess the most appropriate level of amputation for the individual, not only according to tissue viability but also the future potential mobility the patient may have. For example: Is preservation of the knee joint serious? Usually, this would be the ideal in order to maximize function but, if it is fixed in flexion and distally likely to be a pressure area if the patient is (not mobile) maybe this is not the case. On other hand, it may still worth preserving if the other limb is also likely to require amputation in the near future at a higher level and the use of a trans-tibial prosthesis on the first side would facilitate independent transfers, safety in sitting. Also if the same limb also require amputation in the near future at a higher level. To prepare and inform the patient and their family/carers for the surgery, hospital stay and rehabilitation. To discuss the level of mobility whether this is likely to be using a wheelchair or prosthesis depending on the findings of assessment. It is important to be open and realistic from the start in order to facilitate adjustment to their new situation and to minimize problems resulting from misinformation.  To optimise pain relief pre-op and post-op. Discuss pain relief and possible phantom limb sensation and pain post-op. To refer to other members of the team as required such as Occupational Therapist, Psychologist or Counsellor, Podiatrists, Prosthetic service, Dietician. To begin discharge planning - whether the patient will be able to return home or will need rehousing or adaptations to be made, a care package or admission to a residential or nursing home. To plan pre and postoperative physiotherapy intervention through the setting of realistic goals with the patient. Assessment is never a one-off exercise but an ongoing process.  The elements of assessment: A- Subjective Assessment 1- Past Medical History Diabetes and its complications: such as neuropathy (U.L& L.limbs), retinopathy, poor glycaemic control and condition of the sound limb. Cardiac history/exercise tolerance. Renal function/dialysis potentially resulting in fluctuating stump volume. Respiratory function/exercise tolerance/shortness of breath on exercise. Previous stroke and any residual effects. Previous trauma and associated surgery.  Previous joint surgery. Previous vascular investigations such as doppler, angiography, CT or MRA e.g. video of MRA showing occlusion and collateral circulation Allergies: may affect treatment (especially dressings), therapy and prosthetic materials used Medications Especially: Diabetic control Antihypertensive Antiplatelets 2- Present Medical History Date of amputation or planned amputation date. Pre-op: level and side of planned amputation Reason for amputation: Peripheral arterial disease, trauma, tumour, congenital deformity Associated medical problems: ulcers, fractures, soft tissue injuries History of deterioration of limb: acute or chronic Skin condition, sensation. Condition of intact limbs and prosthetic function, mobility level, ability to walk, and don/doff prosthesis. Current functional ability: self-care, mobility (use of aids, distance, reasons for limitations), activities of daily living Pain Cognitive ability  Vision and hearing ability Patient's weight Patients expectations of planned surgery: Psychological and emotional state: During rehabilitation, the advice and support given by the team, family and others amputees are very helpful, we need to be aware of possible responses that may be of concern such as denial, withdrawal, suppression, regression and displacement. Timely referral is needed on to the appropriate specialty if required. Pre-existing Functional Mobility Bed mobility, transfers, sit to stand. Use of assistive devices like crutches or a wheelchair. Gait or wheelchair distance/endurance. Factors limiting mobility. Environmental factors like stairs, ramps, uneven terrain, curbs, crowds, obstacles. 3- Social History Housing: Type of property, access internally and externally, previous adaptations, layout, position of bathroom facilities and bedroom Occupation: Type of work, mobility required, wheelchair accessibility, travel to and from, retraining necessary. Hobbies and interests: Sedentary, social and more active including sports Driving: manual or automatic. Existing wheelchair use, duration, for what purpose  B- Objective Assessment Physical Assessment The physical assessment could be done pre- or post-amputation and should be tailored to the specific patient. Inspection of the remaining limbs, pressure areas, and pain sites. Wound assessment Wound approximation Peri-wound erythema - normally after 72 hours the erythema due to surgery should not decrease, an increase might be a sign of infection Wound drainage - Note any quality or quantity change. drainage is normal in the healing phase and will decrease over time The moistness of the area around the wound: a wet environment (like the dressing) might predispose the wound to infections, whereas a very dry wound may limit the healing process. Presence of scar tissue/skin grafts. Condition of the contralateral limb/foot.  Vascular exam (when the amputation is due to a vasculopathy this exam should be done at every visit)  Presence and quality of distal extremity pulses  Colour  Skin temperature Joint integrity and ROM and presence of contractures. Muscle power as well as trunk – especially core stability Hand function – will they be able to don and doff a prosthesis, use a manual wheelchair Neurological  Peripheral  Ankle reflexes  Tinel's test on the residuum if a neuroma is suspected. Stump assessment also should be done: This will have an impact on the prosthetic rehabilitation potential for the patient. Wound condition, oedema, stump length, cut end of the bone (prominent or not), sensation, tenderness, stump shape,, mobility of scar and pain should all be considered. Activities of daily living (Functional mobility) o Balance in sitting and standing o Bed mobility o Ability to transfer and mobilize o Standing tolerance o Gait - assess the patient's ability to use assistive devices and their ability to climb stairs. Video 1 - Patient evaluation  International classification of functioning The functional impairments affect many facets of life including: the ADL, mobility, body function and structure. The introduction of the International Classification of Functioning, Disability and Health (ICF) by the World Health Assembly provides a globally accepted framework and classification system to describe, assess and compare function and disability. The ICF could guide a multidirectional approach during the rehabilitation of a person a with limb amputation. In the World Health Organisation ICF Framework, they included a specific "amputee element"  Outcome measures In order to evaluate the lower limb amputation rehabilitation outcome. It is important to have an individualized approach (keeping the patient and their amputation level in mind) when selecting the appropriate outcome measure as some outcome measures may not provide specific assessment or be valuable for your patient. The selected outcome measure could then be complemented with another outcome instrument. Outcome measures not only help clinicians to determine the effectiveness of an intervention but they can also detect the cause of the problem and in some cases provide solutions and therapeutic interventions.  Example outcome measures: 1) The Amputee Mobility Predictor (AmpPro/AmpNoPro): is an instrument to Assess determinants of the Lower-Limb Amputee's Ability to Ambulate and measure function post-rehabilitation. It was developed to provide a more objective approach to rating amputees under the various "K Classifications". The test can be performed with or without the prosthesis. 2) Prosthesis evaluation questionnaire is a 82-item questionnaire developed to assess prosthetic function, mobility, psychosocial aspects, and well-being 3) Locomotor capability index questionnaire: The LCI assesses a lower limb ampute's capability to perform 14 different locomotor activities with a prosthesis. 4) The Trinity Amputation and Prosthesis Experience Scale (TAPES): is to examine psychosocial issues related to adjustment to a prosthetic, specific demands of wearing a prosthesis and potential sources of maladjustment. 5) The Barthel scale or Barthel ADL index is an ordinal scale used to measure performance in activities of daily living (ADL). 6) Prosthetic Profile of the Amputee (PPA) measures the function of adult unilateral lower l. amputees, factors related to prosthetic use after discharge from hospital. 7) Timed up and go test, 6 min walking test.  Assessment for suitability for a prosthesis Many trans-tibial amputees will be able to use a prosthesis, even if it is only for transfers or to help with sitting balance or even for cosmetic reasons but a trans- femoral limb is very different so careful assessment is required as to whether the patient will be able to benefit from a prosthesis, particularly at this level.  Differences between trans-tibial and trans- femoral prosthetic use Trans-tibial prosthesis Trans-femoral prosthesis Can be donned in sitting Ideally donned in standing so requires balance and use of both hands Can be used to aid sit to stand Does not help the patient to stand up Aids sitting balance and transfers Can make transfers more difficult Lower energy expenditure in gait Higher energy consumption in gait compared with trans-femoral level. compared with trans-tibial level Lower risk of falling Higher risk of falling Usually comfortable to sit in uncomfortable if sitting for a prolonged period due to high level of socket anteriorly Can be used purely cosmetically  Most important parameters to take in consideration for prosthetic fitting: 1. Does the person with an amputation want to walk? 2. Will it be possible for the person with an amputation to walk? per e.g.: A hip flexion contracture of 15 degrees or more makes fitting a prosthesis difficult. 3. Where will the person with an amputation walk? 4. Will prosthetic rehabilitation improve the person with an amputation's quality of life? After the assessment, the team will base the decision as to whether or not to supply a prosthesis on the balance of successful outcome when considering the different parameters such as the pathology, level of amputation, length and condition of the stump, the environment and individual wishes. If patients are unable to achieve the following they are unsuitable for prosthetic rehabilitation: Transfer independently from a seat to bed/chair/toilet and back using a standing pivot transfer. Push up from sitting in a wheelchair to standing independently in parallel bars. Have independent standing balance within parallel bars (patients may need to be able to stand for up to 5 minutes for prosthetic casting). Cognitively unimpaired i.e. be able to follow instructions. With the aid of an early Walking Aid mobilise within the parallel bars. The patient should be able to achieve 6-10 lengths, repeatedly, throughout a treatment session on a regular basis during their initial phase of rehabilitation. The following areas would impact prosthetic rehabilitation : Poor Muscle strength. Poor hand dexterity, with the patient unable to manage velcro fastenings, straps or knee locking mechanisms. Patient unable to wash and dress independently. Other pathologies e.g. CVA, R.A, O.A, Respiratory problems. Poor motivation, social support, home environment.