Post-Operative and Pre-Prosthetic Assessment Flashcards
(57 cards)
1
Q
The shorter the time between ____ and ____, the better the overall outcomes.
A
- amputation
- prosthetic
2
Q
What complications can youanticipate could occur with delayed prosthetic fitting?
A
- Infection
- Uncontrolled edema
- Uncontrolled pain
- Delayed wound healing (suture)
- Improper positioning results in contractures
- Insurance (how many visits they will pay for)
3
Q
IPOP and EPOP
A
IPOP: Immediate Post-op Prosthetic
* Applied in the OR
* Prosthetist present for application
* Focus on rehabilitation over simply recovery
EPOP: Early Post-op Prosthetic
* 5-7 days post-surgical
* Prosthetist performs at bedside
* Allows for wound management
4
Q
Prosthetic Phase - Post Surgery
A
- Part 1: time between surgeryand fitting with adefinitive prosthesis oruntil the decision ismade to not fit thepatient for a prosthesis
- Part 2: Starts with the delivery of a “check (trial) socket” and progresses to the permanent prosthesis.
5
Q
Limb volume, shaping and post-operative edema management
Why does it matter?
A
- Pain control
- Promote wound healing
- Protect incision
- Prepare for prosthesis and weight bearing
6
Q
Limb volume, shaping and post-operative edema management
Options (Least to most constrictive)
A
- Soft dressings (wrap, no compression)
- Ace wraps/compressive coverings
- Semi-rigid dressing (SRD)
- Removable Rigid Dressing (RRDs)
– Very popular - Rigid cast dressing (done in OR)
– Cannot be taken off
7
Q
Rigid - Plaster Cast
A
- Must be cut off like a cast
- Holds knee in extension
- Removed when limb volume decreases or per surgeon protocol
- May afforc limited WB with distal attachment
8
Q
Rigid - Pre-fabricated polymer shell
A
- Removable to be ableto inspect wound
- Holds knee inextension
- May ormay notaccommodate distal attachment
9
Q
This is an example of
A
- Rigid Dressing
- Often used for transtibial amputations
10
Q
Rigid Dressings: Pros and Cons
A
Pros
* Excellent post-op edemacontrol (Fluid can’t come in)
* Excellent residual limb (RL)protection (Hard shell keep shape)
* Better control of phantomand post op pain
* Allow for earlier WB andprosthesis fitting
Cons
* No access to incision if it isnot removable
* More expensive – requiresprosthetist in OR or at bedside
* Training is essential forproper application andmonitoring
* Close supervision required
11
Q
Semi-Rigid Dressing (SRD)
A
- Composed of paste compounds and are applied inOR
- Dressing adheres to skin – no need for suspensionbelts
- Allows slight jointmovement
Just like an Unna boot – same materials used for post-op amputation.
12
Q
Semi-Rigid Dressing: Air Splint - Pros/Cons
A
- Put on, pumped up; immobilizes and compresses
- Similar to what would be used for fracture immobilization in an acute environment.
- Can also be used as a temporary prosthesis.
Pros:
* Allows inspectionand protection
* Comfort
Cons:
* Pressure is notuniform
* Hot , humid
* Require frequentcleaning limb and air cast
* Require frequentcleaning
13
Q
Semi-Rigid Dressings: Overall - Pros/Cons
A
Pros
* Better edema control than soft dressings
* Residual limb (RL) protection
Cons
* Needs frequent changing
* Must be applied by a professional
* No access to incision
14
Q
Soft Dressing: Elastic Wrap
A
- ACE Wrap
Pros
* Easy to apply
* Easy to incision
* Inexpensive
Cons:
* Needs frequent rewrapping (slippage)
* Risk of torniquet pressure
* May be tough to put on oneself
15
Q
Soft Dressings: Shrinker
A
- Sock-like garments of heavy rubberized cotton
Pros:
* Easy to apply
* Inexpensive
* Various sizes
* Easy to apply (slide on)
Cons:
* May or may not be used prior to suture removal
* Must change sizes as RL volume decreases
16
Q
Early Prosthetic Fitting
A
- Ideally fit RL when shrinkage is maximal
- Reality is limb will shrink regardless
- Literature strongly supports benefits of early fittingfor pain and edema control, RL protection andimproved activity levels. (8-12 weeks)
17
Q
Pros and cons of remaining non-WB early on?
A
- Pros: skin protection, incision protection, healing time, controlling RL volume, pain management, desensitization
- Cons: delayed ambulation patterning/practice, possible delay in strengthening and balance training, pain management, edema control
18
Q
Discharge Options - Post Surgical
A
Inpatient rehab: patient must be able to tolerate 3 hours of therapy/day (PT, OT, SLP combined)
Home health care: patient must be able to get into home, but be homebound
Outpatient: patient must be able to get into/out of home without significant burden
SNF/sub-acute stay: patient unable to return home but needs a slower therapy progression
19
Q
Early Post-Operative Therapy (Pre-Prosthetic) Goals
A
- Promote RL wound healing
- Residual limb pain management and control
- Phantom limb pain/sensation management
- Optimize ROM of B LE and UE without impairing RL healing
- Optimize strength of B LE and UE without impairing RL healing
- Protect remaining limb
- Demonstrate functional sitting and standing balance
- Perform independent transfers and bed mobility
- Ambulate with appropriate assistive device
- Demonstrate proper sitting and bed positioning
- Begin psychological adjustment
- Understand the process of prosthetic rehabilitation
20
Q
Variables Impacting Progress
A
- Type of amputation
- Etiology of amputation (Traumatic, PVD, etc.)
- Co-morbidities
- Pt’s ability tocontribute information
- Pain
- Infection
- Post-surgicaldressing
- Psychological status (Mental adjustment after loss of limb)
21
Q
How to perform exam for someone with amputation?
A
- Subjective
- Systems Review
- Objective
22
Q
Priorities of the Acute Care Exam
A
- Pain management (PCA button, oral medication, when last taken)
- Grieving and psychological adjustment
- Wound care /sutureline healing
- Limb volume control
- Mobility training
- Readiness for singlelimb ambulation
23
Q
Post-Surgical Exam Guide
A
- Systems review/ Medical record review
- Post-op status (medically how are they?)
- Pain
- Vascularity/ conditionof the wound
- Functional status
– bed mobility
– transfers
– Balance - Gross ROM
– Sound extremity
– Amputated extremity
– UEs - Gross functional muscle performance (strength)
24
Q
Phantom Pain
A
- 70-80% incidence (Normal anticipated outcome; pre-op education)
- Pain experience varies
- Etiology poorly understood
- 33% extremely bothered by phantom pain post-amputation regardless of time
25
What is the shape of a TTA and TFA?
* Transtibial (TTA) tapered cylindrical shape
* Transfemoral (TFA) conical shape
26
Wound Integrity and Healing of Residual Limb
* Initial exam of incision
* Drainage
* Wound closure
-- Risk of dehiscence
-- Delayed prosthetic fitting
-- Impact of co-morbidities?
27
Considerations for Sound Limb
* Biomechanical stress of sinlge limb mobility
* Effect of co-morbidities (at risk for wounds?)
28
How do you perform early strength testing?
* Active, NON-resistive ROM at the joint proximal to amputation ONLY until wound is closed to protect myodesis
* If they can perform full active ROM (3/5 MMT)
29
Early Post-Operative POC: Goals
* Healing of RL
* Protection of uninvolved limb (i.e. dysvascular co-morbidities)
* Independent in transfers, bed and W/C mobility
* Demonstrate proper positioning
* Begin psychological adjustment
* Education regarding prosthetic rehab
30
Early Post-Operative POC: Interventions
* Phantom pain control
* Positioning
* Residual limb care/ bandaging
* Care of uninvolved limb
* Functional training
* Balance training
* Mobility with assistive device (ambulation & gait training)
* Postural control (core training)
* Education on amputation and prosthetics
31
____ related amputations are 1.5x more likely to have phantom limb pain
* Trauma
* 80% reported PLP regardless of time since amputation
* UE most common
32
Treatments for Phantom Limb Pain
* Pharmalogical (Gabapentin; short term pain relief)
* Non Pharmalogical
-- TENS
-- Dry Needling
-- Massage
-- Mirror Therapy/Virtual Reality
33
How does mirror therapy/virtual reality help with PLP? How do they work?
* Both: Target neuroplastic mechanisms to restore neural representation of the missing limb through motor imagery.
* MT: Patient observes movements executed by their intact limb, viewed in a mirror or a virtual environment, and then couple the observed movement with movement of the phantom limb.
* VR: Augmented virtual reality allows images to be created from myoelectric signals from the RL, and therefore can be used for patients with bilateral amputations.
34
What motions are essential to:
Transtibial amputation?
Transfemoral amputation?
Partial foot amputation?
Depends on the functional task!
For walking degrees needed
Hip Extension: 10, F: 30
Knee Extension: 5-10 in flexion
Knee Flexion: 40
Plantarflexion:
Dorsiflexion: 10
Sit to stand
Knee flexion: 100
35
What are the predictable contracture patterns for:
Transtibial amputation?
Transfemoral amputation
Partial foot amputation?
Transtibial:
* Knee flexion
* Hip Flexion
Transfemoral: (Due to how IR/Adductor muscles are cut)
* Hip flexion
* Hip ER
* Hip Abduction
-- **Need to teach neutral leg position when sitting**
36
Optimal Transitbial positions
37
Optimal Transfemoral Positions
* Same as transtibial positions for seated, supine and prone.
* Emphasize neutral LE positioning, especially in supine and seated positions.
* Avoid position with hip flexion and abduction (cushion under the stump for example).
38
Residual Limb Care
* PROTECTION!
-- Sutures gradually and sequentially removed
-- Primary focus: Teach the patient how to protect the RL while moving in bed, coming to sitting and transferring.
-- Patients should not put pressure on the limb or drag it on the bed: AVOID STRESS ON INCISION!
* Cleansing and drying
* Gentle AROM /no resistance!
* Tissue and scar mobilization – only after sutures are removed
* Inspection & patient education!
39
Residual Limb Care: Edema Control
If RL is in rigid dressing or removable rigid dressing, limb wrapping is not needed at that time.
-- Educate on limb wrapping in a later phase of healing.
If RL is in a soft dressing, limb wrapping is necessary
-- Educate on wrapping
-- Educate on application of shrinker
40
Things to remeber with limb wrapping
* No wrinkles!
* No tourniquet! (Figure 8 wrap).
* No clips! (Use tape, Velcro or pins to fasten).
* Proximal joint extension.
* Special accommodations for elderly. (skin more fragile, circulation may be more compromised, may be more diffcult to apply)
41
Limb wrapping should be performed...
every 4 hours!
* All skin of the RL should be covered
* The shape of the RL should be cylindrical
42
How are shrinkers applied?
* Transtibial: Rolled onto the RL to midthigh, designed to be self-suspending
* Transfemoral: Utilize a hip spica (encircle the pelvis)
* Proper suspension is key!
-- Any rolling of the edges or slipping can create a tourniquet
* Easier to apply than ACE wraps
* More expensive; need to be replaced as limb volume decreases
43
How to treat contractures
* Prevent prolonged positions (Except prone)
* Place them in prolonged prone position
* PNF
* Soft Tissue
* Joint Mobilizations
44
Care of Uninvolved Limb
Examination should include:
* Skin
* Presence of pulses
* Sensation
* Temperature
* Edema
* Pain on exercise or at rest
* Presence of wounds/ulcerations/abnormalities
ROM & Strength status
Deformities or other orthopedic problems
I.e. arthritis , previous replacement (knee, hip, etc)
WB Status
**Prevent contractures on the sound limb**
45
Functional Mobility: What is important and why?
* COM redistributes upon amputation
Skills needed for preparation for prosthetic:
* Bed mobility (shift, scoot, roll, sit up, bridge)
* Transfers: (slide board, squat and stand pivot)
* Wheelchair mobility (through doorways, turning, getting back in, curbs)
* Balance skills (Seated, SL)
* Pre-gait training (adequate strength and motion to get them ready for gait)
* Gait training with appropriate AD (w/o and w/IPOP/EPOP)
46
Adaptive equipment for bed mobility and transfers
Adaptive equipment:
Supine<>sit
* Leg lifter
* Sliding board
* Grab bars on bed
Sit<>stand; bed<>chair
* Walker vs. Crutches
* Slideboard
Transfer Options:
* Slideboard transfer
* Stand-pivot transfer
* Squat-pivot transfer
* Front sliding transfer (for bilateral amputation)
47
Transfers should occur from ____ levels
different
48
What is a precaution with bed mobility and transfers?
* Hemodynamics (Need to ask for dizziness and take vitals pre/post)
* Increased incidence of AAA and MI post-amputation
49
Sitting Pressure Relief Training
* Look to eliminate high pressure areas
* Every 15 minutes need to pressure relief for 30 seconds
-- Lean to side, lift up and hold or lean back
50
How do wheelchairs need to be adapted for amputees?
* Clients with **high or double amputations do not have the weight of their leg(s) to stop their wheelchair from tipping backwards**
* To improve the user’s balance in the wheelchair and reduce the risk of tipping, **position the rear wheel axle in the ‘safe’ position (behind the patient's shoulders).**
* For some users, as they gain confidence and experience, it may be possible to review the wheelchair set up and move the rear wheel axle position to a more active position.
51
ALL levels of amputation, ____ is critical in assuming a balanced upright posture without compensations that may lead to gait asymmetries and back pain.
full hip extension (30 degrees)
52
For TTA, full range of motion in ____, most noted into extension, is needed.
hip and knee
53
Strengthening Exercises - TTA
Exercises should be given for involved limb, uninvolved limb, UE's, and trunk/core.
Bed exercises for TTA:
* Quad set
* Hip extension with knee extended
* SLR
* Hip/knee extension with contralateral KTC
* Hip abduction against resistance
* Hip extension against towel roll ("bridging")
54
Strengthening Exercises - TFA
Consider the importance of hip extension and abduction strength for TTA and TFA in regard to ambulation.
Bed exercises for TFA:
* Glute sets
* Hip abduction supine against resistance
* Hip abduction side-lying active and against resistance
* Hip extension prone
* Hip extension against a towel roll ("bridging")
55
How does postural control change with amputation?
* Shifts upward and toward the uninvolved (remaining) limb
* The longer the limb, the less the shift
* If bilateral, COM only shifts up
56
Balance and Postural Control Exercises
* Seated on Foam Pad
* Seated balance on physioball
* Seated balance on physioball with UE movement
* Single limb balance w/UE support
* Variable surfaces
* UE challenge
* Single limb balance w/o UE support
* Variable surfaces
* UE challenge
Weight bearing through RL
* TTA only
* Standing with chair
* Kneeling on mat
* Add weight shifting forward-backward
57
Core Stabilization Training
Core stability training is critical in amputees where balance becomes compromised, resulting in diminished limb power outputs.
**The higher the amputation, the more they need core stabilization.**
Consider:
* Core training as a component of postural control
* Core training as a functional component
* Core training related to patient goals (I.e. return to sport)
Examples of core exercises:
* Crunch/sit-up-based activities (w/ or w/o resistance)
* Quadruped activities
* Use of compliant surface (in any position)
* Prolonged stabilization (i.e. plank)
