Amputations Slides (Spencer et al, 2024) PDF

Amputations Presented by Nathan, Connor B, Lynden, Fynn M  What is an Amputation Amputation is surgery to remove all or part of a body appendage, usually a limb or extremity (an arm, leg, hand or foot). Types of Amputatios Upper Body Lower Body  Etiology Diabetes and oth...

Amputations Presented by Nathan, Connor B, Lynden, Fynn M  What is an Amputation Amputation is surgery to remove all or part of a body appendage, usually a limb or extremity (an arm, leg, hand or foot). Types of Amputatios Upper Body Lower Body  Etiology Diabetes and other vascular diseases such as peripheral artery disease Traumatic incidents Congenital limb deformities Cancer (such as bone cancer) The primary cause for lower limb amputations in Canada is diabetes (Imam et al., 2017, p.1)  Prevalence of Lower Limb Amputations (LLA) According to a leading study on amputation prevalence in Canada, between 2006 - 2011, 44430 amputations were done. There is little disperancy from year to year. (Imam et al., 2017, pp 1-4) The mean age for LLA was 65 years old (with 54.9% of LLA done on people ages 50-74 years old) 68.8% of people who got a LLA were male The most common type of LLA were transtibial amputations at 30.9% The highest cause of LLA was Diabetes at 65.4% 10% of Canadian LLA were done in BC *Note: Upper limb amputations are far less studied and documented to their lower prevalence compared to LLA (Essien et al., 2022) Jim Who is he? 68-year-old African American man low-income limited access to healthcare diagnosed with Type 2 diabetes peripheral artery disease peripheral neuropathy long history of smoking minimal physical activity infected ulcer surgical removal  Research Informed Timeline For the sake of our presentation, we are going to follow the story of Jim through the phase based model of rehabilitation. The phases are broken up into periods of several weeks based off research and physiotherapy guides. The linear timeline of events will show Jim’s progress and development throughout rehabilitation. Pieces of the ICF model, exercise interventions and various other physical/mental/emotional/social characteristics and factors will be addressed and considered according to when they are most prominent in the big picture. Stage 1 Right After Amputation Time Line Focus on In this Stage Goals for this Stage Medication Types of different Medication Most common Medication Jim’s Medication Types of pain  NRPS: Exercise Numerical Pain remedies Rating Scale for pain Pre-intervention: 9/10 NRPS Score While medications and pharmaceutical Post-intervention: 2/10 NRPS Score interventions may relieve pain, exercise can also be used as a remedy for pain. Based on research, the exercise prescriptions and plans for Jim “Following the physiotherapy discussed in this presentation are a factor in rehabilitation [primarily discussed in reducing pain. phase 2], the patient experienced no pain and an improvement in range of motion.” (Sheikh et al., 2016)  List of Exercises Static gluteal contraction Exercise Hip flexion and extension in side lying Hipflexor stretch Main Reasons what exercises for at this stage Hip extension in Types of Exercises prone lying Hip adduction with resistance Hip hitching Limb elevation  ICF Model Body Function / Health Condition Activates Personal Factor Body structure Bed Exercises New to having an Amputation Medication amputation Effecting body and Blood flow mind Has to come to relation Getting back into movement from the Accepting this new bed rest way of life  Decrease in Health- Related Quality of Life Onset of depression, low esteem, decreasing motivation, hopelessness and other mental factors correlated with: 1. Prosthesis use / availability 2. Perceived social support 3. Functionality levels Duration, frequency, and factors related to lower extremity prosthesis use: systematic review and meta-analysis (Paquette et al., 2024, p. 3) (Paquette et al., 2024, p. 3) (Paquette et al., 2024, p. 14)  Quality of Life Following a Lower Limb Amputation in Diabetic Patients: A Longitudinal and Multicenter Study 86 person study group Perceived social support and functionality levels have an effect on HRQoL. i) patients with Diabetes Mellitus, Type 2 (DMT2) and a Diabetic Foot Ulcer (DFU); ii) be indicated for a LLA surgery; Early, untreated anxiety symptoms can affect rehabilitation at and iii) be over 18 years old. the 10 month mark. Traumatic stress symptoms have a negatice affect on Physical Component Score whereas social The sample consisted of 73.3% male patients (n = 63), with support and functionality had positive impact on PCS a mean age of 63 years old (Pedras et al., 2019) (Pedras et al., 2019) Amputation patients should recieve psychological support from professionals in that area. Hospital Anxiety and Depression Scale Barthel Index (assessing functionality) As exercise experts, rehabilitation should be more goal- Satisfaction with Social Support Scale oriented, not only to maximize function but also to improve Short Form Health Survey (assessing mental component HRQoL. This involves clear communication with patient score and physical component score) (Pedras et al., 2019) regarding physical abilities and goals. (Pedras et al., 2019)  Stage 2: Pre-Prosthetic Training (Weeks 4 - 8) Consists of: Communication, continual goal planning and teamwork with patient Specific, tested training plans to improve muscle strength and range of motion Preparing patient for prosthesis use Improving capacity for day to day tasks Stage 2 Patient Plan  Tailored Physiotherapy Combined With Exercises for Enhanced Recovery Post-Below-Knee Amputation in a Diabetic Patient With Peripheral Artery Disease (PAD): A Case Report Focus: 59-year-old male patient who had undergone a below-knee amputation due to complications from diabetes mellitus, leading to peripheral artery disease (PAD). Time considerations: Early rehabilitation was noted to have positive effects as physiotherapy was started in the pre-prosthetic training phase. Other factors such as pain, comorbid conditions and edema management also had to be factored into the training plan. The next two slides have content taken directly from the training plan, but have been organized and modified to meet the needs of this presentation. Refer to (Sheikh et al., 2016) for more information.  Exercise Perscription Goals Intervention Proceedure Dosage To prevent 1. Range of movement hip extension in a prone. Knee extension with a rolled towel under the knee. Gentle 1 set of 10 repetitions muscle atrophy exercises (ROM) hip abduction/ adduction. Ankle ROM on the unaffected side 1. Isometric exercises: *Quadriceps sets (press the knee into the bed). *Gluteal sets To strengthen (squeeze the buttocks); 1 set of 10 repetitions 1. Strengthening exercises the muscles 2. Core strengthening: Pelvic tilts and abdominal bracing; 3. Upper limb strengthening Bed mobility 1. Rolling from supine to side lying and then to sitting; 2. Safe transfer techniques from 1. Rolling; 2. Transfers NA and transfers bed to wheelchair using assistance as needed. Balance and 1. Seated Balance Exercises; 1. Practice sitting balance with and without upper limb support; 2. Gentle weight- NA coordination 2. Weight Shifting shifting exercises while seated or standing (with support) 1. Begin standing exercises using a walker, focusing on maintaining a neutral pelvis and 1. Gait training with the knee extension. 2. Non-weight-bearing (NWB) or partial weight-bearing (PWB) gait For 10-15 minutes. Started Mobility training assistance of a walker training with walker in the second week Posture correction Exercises 1. Static back; 2. Seated forward bend; 3. Arm circles; 4. Hip crossover stretch 1 set of 10 repetitions  Other Perscriptions Goals Intervention Proceedure Dosage 1. Transcutaneous 1. Utilizes low-intensity, short-duration 1. For phantom pain, placement might be on the residual limb or around the To alleviate electrical nerve pulse width of 50-200 μs and high- stump area, depending on the pain location; 2. An ice pack wrapped in a towel pain stimulation (TENS); frequency 50-100 Hz current; 2. Kept kept around the painful area 2. Cryotherapy for 15-20 minutes for 2-3 times a day 1. Elevation; 2. Avoid 1. Keep the affected limb elevated to reduce edema; 2. Encourage lying prone to Positioning prolonged knee prevent hip and knee flexion contractures; 3. As the surgical wound is stable, and edema flexion; 3. 15-20 minutes, 2-3 times daily begin gentle compression wrapping with an elastic bandage or shrinker to management Compression control swelling and shape the residual limb. wrapping To prevent 1. Deep breathing 1. To prevent respiratory complications, especially in patients with reduced respiratory exercises; 2. mobility; 2. Encourage the use of an incentive spirometer to improve lung 1 set of 10 repetitions complications Incentive spirometry function To promote healing of Infrared radiation For 10-15 minutes per week for the The frequency will depend on the patient's specific needs. Initially, it may be stump and therapy healing of the stump and 20 minutes in applied daily or several times a week and less frequently as healing progresses scar the fourth week for scar management management 1. Pre-prosthetic gait 1. Weight distribution and limb care; 2. Compression bandaging and massaging. Pre-prosthetic training; 2. Soft tissue mobilization NA teaching Prosthetic preparation  Results Results showed an improved strength in the affected limb for each group of muscles. (Sheikh et al., 2016)  Results Results showed an improved range of motion by nearly 2X in the affected limb for each category post intervention. (Sheikh et al., 2016)  ICF Model Development Body Structures and Functions Activities Participation Environmental Factors Body structures Difficulty / inability Some degree of muscle atrophy and impairments walking, getting out of posed difficulties to bed / bed mobility Wheelchair dependance / Limited range of motion complete tasks Jim and other daily immense assistance needed used to be capable situations requiring Decreasing motivation / mental health of balance Nearly a 2X increase in range of motion in affected limb for nearly every tested movement Access to a walker / instructions Successful Is now able to do on how to use it Increase in muscle strength in every completion of assisted walking, tested category in affected limb detailed fitness plan navigate his bed and Compression bandaging to after slow washroom maintain prepare stump for prosthesis Positive mental health shift progression appropriate posture fitting Decrease in overall pain levels Continual Safety Considerations and Limitations Imposed by Amputations on Exercise Even though our patient, Jim, has made significant progress to reduce the limitations imposed by his disability, his safety must still be considered in exercise prescription. For example, cardiovascular endurance, pain, and balance are still limiting factors in our patient’s life. Therefore, studies on harness-supported treadmill ambulation suggest that the use of a harness eases the cardiovascular burden as well as provides a safer margin for error and is a positive alternative to unsupervised treadmill exercises. (Hunter et al., 1995) (Lamberg et al., 2014) Such alternatives and safety measures should be considered by the health care provider.  Physiotherapy Intervention Physiotherapy and rehabilitation is the totality of treatments specifically designed to bring a patients overall physical and mental capacity to the maximum their body will now allow them too, minimize their dependencies, and overall improve their quality of life. Programs for patients with lower limb amputations include strengthening exercises, training walking cardio usually done with an ergometer, coordination and gait training, as well as functional activities.  Stage 3: Initial Prosthetic Training (Weeks 8-12) Focuses are Gait training, Weight Bearing, Functional Movement Implementing Mirror Therapy in this phase for treatment of Phantom Limb Pain This stage is crucial for the client to gain additional independence and incorporate their prothesis into day to day life  Stage 3: Initial Prosthetic Training (Weeks 8-12) Types of Protheses For Lower Limb Amputations Hemipelvectomy Prothesis Hip Disarticulation Prothesis Transfemoral/ Above Knee Prothesis Transtibial/Below Knee prothesis Symes Prothesis (Selvam, Sandhya, Chandrarasekaran, Rubells, & Karthikeyan, 2020) Transtibial or below-knee prothesis Strengthening Gait & Balance Training Core: Plank - 2 sets of 15 seconds Weight Shifting (Side to side, isometric holds to 30 seconds, 3 forward and backward: 5-10 times / week minutes daily to improve balance Oblique Twists: 2 sets of 15 and confidence with prothesis repetitions, 3 times / week Heel to toe walking: 5 minutes, 3 Lower Body Mini Squats: 2 sets of 10, 2 times / week, building and refining times per week for hip stability walking mechanics back Calf Raises on Non-Amputated Step-ups on Low platform: 2 sets Limb: 2 sets of 15, 3 times / of 8, 3 times / week to build week stability Functional Mobility and Mirror Therapy Endurance Mirror therapy is a rehabilitation Walking with Assistive Device: technique where a mirror is Starting with 5 minutes of walking placed between the patients legs to create a reflection of the with the goal of building 2-3 present leg, tricking the brain into minutes extra weekly believing that movement Stair Climbing Practice: When occurred without pain. (HPRC, 2016). comfortable, start with step ups Used in treating Phantom Limb with assistance 2 times / week Pain Affects 50 - 85% of patients following amputation (Timms & Carus, 2015)  What is Phantom Limb Pain? Phantom Limb Pain is a “painful sensation in a portion of the body that has been amputated.” (Physiopedia, 2016) Usually described as a crushing, burning, tingling, or shooting pain Risk factors can be pain and psychological distress.  Mirror Therapy & Phantom Limb Pain 01 02 03 04 Shown to increase Mirror therapy gives a low While mirror therapy is Significant relief of cost way to reduce extremely beneficial, phantom limb and cortical and spinal Phantom Limb Pain there has been a lack of increased motor control motor excitability (Physiopedia, 2022) understanding of was displayed in the mechanisms and case study. guidelines for treatment (MacLachlan, Mcdonald, protocol. & Waloch, 2004, pg. 904)  Health Condition Amputation Body Functions & Structures Activity Participation Now able to walk without a Prothesis being implemented Difficulty adapting to the walker, and training to gain more Muscle loss in surrounding prothesis independence in life with a muscles Limited mobility and challenges prothesis with day to day tasks Environmental Factors Personal Factors Jim's ability to fully buy into the training Getting the new transtibial prothesis, and and rehabilitation program getting comfortable using it Possible fear of trying to reintegrate certain Support from surrounding family & friends activities  Stage 4: Advanced Mobility and Community Reintegration Weeks 17+ Goals: Achieve independence in daily tasks, enhance community participation, and continue long-term health management  Advanced Gait Training: Lifestyle Adjustments: Obstacle Course: 10 minutes, 2 times per Diabetes and PAD Management: Ongoing education on diet and glucose control, along with regular vascular check- week, to practice manoeuvring around ups to monitor PAD progression. different obstacles. Community Support: Joining an amputee support group to Walking on Uneven Surfaces: 5–10 minutes, build social connections, share experiences, and reinforce 3 times per week, if safe, to improve stability. long-term motivation. Advanced Rehabilitation Strength Training: Cardiovascular and Endurance: Core and Lower Body: Single-leg Balance on Prosthetic Leg: Start with 10- Stationary Cycling: Start with 10–15 minutes, 3 second holds, increase to 30 seconds as tolerated, 3 times per week, gradually increasing duration and times per week. resistance. Lunges (if safe, modified): 2 sets of 10, 3 times per week. Swimming or Aquatic Therapy: 15–20 minutes, 3 Upper Body: times per week for low-impact cardiovascular Resistance Band Rows: 2 sets of 15, 3 times per week. conditioning. Weighted Arm Exercises: (bicep curls, tricep extensions) 2 sets of 10–12 reps, 3 times per week.  ICF Model Development Body Structures and Functions Activities Participation Environmental Factors Can independently perform daily tasks Actively participates in Requires occasional assistance Muscle atrophy has significantly with minimal or no community events and from family members for improved difficulty, feels confident navigating complex tasks. public spaces. Noticeable muscle growth and strength Able to walk independently on both Attends social gatherings Mostly independent with gains in the affected limb and even and uneven and actively engages in mobility aids, like a cane or surrounding muscles. support groups. surfaces with walker, for support. prosthetic. Fully integrated back Full range of motion in the affected leg into social settings. Fully independent in mobility Completes advanced Confident and with the prosthetic. Nearly complete restoration of strength mobility tasks. independent in a variety and stability in the core and upper body of environments. Has access to community Can perform adaptive programs and resources for Significant improvement in mental health sports or activities. Actively participates in adaptive sports and social with motivation levels recreational activities support networks. and adaptive sports.  The Research Weight bearing and walking training were shown to contribute greatly to improved functional performance (Ulger,Sahan, Celik, 2018, pg 821) For those with prothesis, dynamic activities independent of the upper limbs aid in reactive balance will help to prepare the prothesis for unstable condition. (Ulger,Sahan, Celik, 2018, pg 831) Physiotherapy rehab plans showed restored strength, increased ROM, and improved function of surrounding systems. (Gakiwad, Shukla, Dobhal, 2023, pg. 5) Thank you very much!  References Barnes, J. A., Eid, M. A., Creager, M. A., & Goodney, P. P. (2020). Epidemiology and Risk of Amputation in Patients With Diabetes Mellitus and Peripheral Artery Disease. Arteriosclerosis, Thrombosis, and Vascular Biology, 40(8). https://doi.org/10.1161/atvbaha.120.314595 Bradfordhospitals.nhs.uk, 2024, www.bradfordhospitals.nhs.uk/wp-content/uploads/2022/07/179682-WYVAS-LEG-AMPUTATION-Booklet.pdfr. Accessed 14 Nov. 2024 Modest, J., Raducha, J., Testa, E., & Eberson, C. (2020). Management of Post-Amputation Pain. http://rimed.org/rimedicaljournal/2020/05/2020-05-19-pain-mo. Essien, S. K., Kopriva, D., Linassi, A. G., & Zucker-Levin, A. (2022). Trends of limb amputation considering type, level, sex and age in Saskatchewan, Canada 2006–2019: an in-depth assessment. Archives of Public Health, 80(1). https://doi.org/10.1186/s13690-021-00759-1 Gaikwad, P. R., Shukla, M. P., & Dobhal, S. P. (2023). Physiotherapy rehabilitation in bilateral lower limbs amputations following dry gangrene: A case report. The Internet Journal of Allied Health Sciences and Practice. https://doi.org/10.46743/1540-580x/2023.2397 Hunter, Diana, et al. “Energy Expenditure of Below-Knee Amputees during Harness-Supported Treadmill Ambulation.” Journal of Orthopaedic & Sports Physical Therapy, vol. 21, no. 5, May 1995, pp. 268–276, https://doi.org/10.2519/jospt.1995.21.5.268. Imam, B., Miller, W. C., Finlayson, H. C., Eng, J. J., & Jarus, T. (2017). Incidence of lower limb amputation in Canada. Canadian Journal of Public Health, 108(4), 374–380. https://doi.org/10.17269/cjph.108.6093 Lamberg, Eric M., et al. “Harness-Supported versus Conventional Treadmill Training for People with Lower-Limb Amputation.” JPO Journal of Prosthetics and Orthotics, vol. 26, no. 2, Apr. 2014, pp. 93–98, https://doi.org/10.1097/jpo.0000000000000025. Accessed 21 Feb. 2022. MacLachlan, M., McDonald, D., & Waloch, J. (2004). Mirror treatment of lower limb phantom pain: A case study. Disability and Rehabilitation, 26(14–15), 901–904. https://doi.org/10.1080/09638280410001708913 Merck Manual. (n.d.). Rehabilitation after limb amputation. Merck Manual Consumer Version. Retrieved November 12, 2024, from https://www.merckmanuals.com/home/fundamentals/rehabilitation/rehabilitation-after-limb-amputation Mirror therapy for Phantom Limb pain. HPRC. (2016). https://www.hprc-online.org/total-force-fitness/pain-management/mirror-therapy-phantom-limb-pain Mirror Therapy. (2022, December 16). Physiopedia,. Retrieved 00:55, November 14, 2024 from  References Cont’d Paquette, R., M. Jason Highsmith, Carnaby, G., Reistetter, T., Phillips, S., & Hill, O. T. (2023). Duration, frequency, and factors related to lower extremity prosthesis use: systematic review and meta-analysis. Disability and Rehabilitation, 1–19. https://doi.org/10.1080/09638288.2023.2276838 Pedras, S., Vilhena, E., Carvalho, R., & Pereira, M. G. (2019). Quality of Life Following a Lower Limb Amputation in Diabetic Patients: A Longitudinal and Multicenter Study. Psychiatry, 83(1), 1–11. https://doi.org/10.1080/00332747.2019.1672438 Senthil Selvam, P., Sandhiya, M., Chandrasekaran, K., Hepzibah Rubella, D., & Karthikeyan, S. (2021). Prosthetics for Lower Limb Amputation. IntechOpen. doi: 10.5772/intechopen.95593 Timms, J., & Carus, C. (2015). Mirror therapy for the alleviation of phantom limb pain following amputation: A literature review. International Journal of Therapy and Rehabilitation, 22(3), 135–145. https://doi.org/10.12968/ijtr.2015.22.3.135 Sheikh, S. F., Kariya, G., & Dafe, T. (2024). Tailored Physiotherapy Combined With Egoscue Exercises for Enhanced Recovery Post-Below-Knee Amputation in a Diabetic Patient With Peripheral Artery Disease (PAD): A Case Report. Cureus. https://doi.org/10.7759/cureus.69781 Physiopedia. (n.d.). Prosthetic rehabilitation. 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