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Designing a PT Management Program for Patients with Prosthesis Mark David S. Basco, PTRP Faculty Department of Physical Therapy College of Allied Medical Professions University of the Philippines Manila Learning Objectives At the end of the session, you should be able to Discuss principles behind designing a management procedure for prosthesis users in the different phases: Pre-operative Early post-operative Late post-operative Prosthetic training phase Gait Vocational Learning Objectives At the end of the session, you should be able to Discuss indications, precautions, and contraindications to prosthetic management Discuss special considerations when designing a program for children Introductory Visit Assessment Discussion of outcomes Preparation for the operation Pre-operative exercises Introductory Visit Introduce self and role in the rehab team, emphasize role of patient and family Need for reassurance that amputation and rehabilitation is a positive step towards reintegration back into the community Goals and expectations Introduce team management concepts Assessment Physical Conditions that may affect mobility Functional capacity Psychological Attitude Social situation Accommodation after surgery Outcomes and Prognostication What the patient may feel or encounter post-op Complications that may arise Expected highest level of function possible given the level of amputation Use of the prosthesis is the patient’s decision Options for prosthetic devices Life with a prosthesis Preparation for the operation Show the patient around the facility where he will be in after the operation Possible prosthesis given the level Speak to other amputees Exercise program Operating room, equipment, gadgets, medications, etc Phantom sensations Pre-operative Exercises Increases tolerance to surgery Faster recovery and gain of independence in prosthesis use Mentally prepares the patient Exercise program: Strengthening Endurance training Simulation of training activities post-op Goals Treatment methods Early home visit Others Goals Prevent the deleterious effects of immobilization and loss of a limb segment Facilitate faster wound healing Pain management Provision of needed accessories or equipment to progress patient to the next stage Prepare patient and stump for prosthetic fitting Promote early independence in ADLs Treatment Methods Proper positioning Stump edema management Active exercises Selective Stretching Donning and doffing Functional training Proper Positioning Stump should be flat on the bed Use of comfort pillow Prevent flexion contractures - Sitting vs supine Advocating intermittent positioning in prone Sidelying to relieve buttocks pressure Stump edema management Elevation Exercises Bandaging Intermittent variable air pressure machines Pneumatic pylon Shrinker socks Rigid dressing Exercises for the Stump Done every 10 reps / hour Active contraction of the stump muscles is the best method of reducing edema For BKA Patient must imagine the performance of alternate DF/PF Through knee/AKA Patient must perform alternate hip flexion and extension as well as hip abduction Bandaging Precaution: development of pressure necrosis Stump bandaging can never change stump shape without the danger of interference with the local circulation A uniformly edematous stump is more readily fitted than one which has been misshapened by bandaging Active Exercises & Stretching Determine which muscles decreased / lost their strength and which muscles gained a mechanical advantage Determine biomechanical implications to identify appropriate exercise for the patient Active exercises Start with the intact side Applicable across all amputation levels 1st day post-op, exercises could be done on supine All techniques could be performed except push-ups if attachments are present. Be vigilant especially for patients with co-morbidities e.g. DM Selective Stretching BKA Knee must rest in full extension immediately post-op AKA Major concern is development of hip flexion and abduction contractures Obtain neutral hip alignment Gradually altering hip position Special considerations in exercise prescription AGE Gender Other medical conditions Early Home Visit Others Weekly team meeting Early walking aid prescription Pneumatic devices on the sockets Vacuum techniques Laminated plastic sockets Local varieties Group therapy Goals Promote wound closure Stabilize the stump Decrease edema Start prosthesis measurement Exercises for the following groups of muscles Hip Extensors Hip Flexors Hip Abductors Hip Adductors Knee Extensors Knee Flexors Trunk strengthening exercises Exercises for the following groups of muscles Hip Extensors Exercises for the following groups of muscles Hip Flexors Exercises for the following groups of muscles Hip Abductors Exercises for the following groups of muscles Hip Adductors Exercises for the following groups of muscles Knee extensors Exercises for the following groups of muscles Trunk strengthening Special considerations during exercise prescrtiption Incorporate play therapy especially for your pediatric patients Make sure that activities that you plan to do are developmentally appropriate for your patient Donning and Doffing Patients are encouraged to dress independently as much as possible According to Engstrom (1993) If the patient is unable to put the underpants independently, it is very unlikely that the indpendent application of the prosthesis is possible Transfers Initial requirements Alertness and the ability to comprehend instructions It is possible to do transfers while the drip / catheter is in situ (PRECAUTION) A suitable wheelchair should have been loaned preoperatively and must be self-propelling Transfers Independence for all transfers on all level surfaces should be the goal Therapist should try to make all transfer surfaces level Transfers Transfers Basic mobility skills Independence in sit-to-supine, supine-to-sit, and rolling for all LE amputees What happens when the amputation of the LE is high? Tendency to fall Good core muscle strength is needed Prosthetic referral Upon complete wound healing and stump stability Upon gaining independence in ADL’s What if bilateral AKA? Possible non-walker Activities are: bed mobility training, arm exercises, balance re-education, transfers, wheelchair maneuvers Wheelchair concerns... Training Program Design Pre-ambulation training Gait training Falls training Functional training Environmental considerations Specialized prosthetic training Training Program Design Principles of exxercise prescription Should be done daily and runn the whole day Family / caregiver involvement Use of different appliances / attachments Donning and doffing of the prosthesis Training Program Design Principles of exxercise prescription Should be done daily and runn the whole day Family / caregiver involvement Use of different appliances / attachments Donning and doffing of the prosthesis Pre-ambulation Training Sit-to-stand Balance re-education Weight transfer on to the prosthetic leg Considerations for progressions Pre-ambulation Training Gait Training Weight bearing on the prosthetic leg is advocated Done on various types of surfaces Protection of the stump Gait Training Gait Pattern; 2-point vs 3 point Indoor then outdoor mobility Functional Training Environmental Modifications For grasping Toilet seat raise, grab bars, bed blocks Velcro and snaps vs zippers and buttons Ramps Others Doors Knobs Switches Other considerations Disablement resettlement Driving After Discharge Out-patient services Follow-up visits Maintenance of prosthesis Specialized prosthetic training Vocational training Athletics Recreational activities Specialized prosthetic training Specialized prosthetic training Specialized prosthetic training References Mariano, LMMJr. (2007). PT150 Archives. UP-CAMP Meyers, R.S. (1995). Saunders manual of physical therapy parctice. Philadelphia: W.B. Saunders. (2004). A manual for the rehabilitation of people with limb amputation . World Health Organization.
