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To appreciate the challenges encountered during each phase of rehabilitation To be able to plan and create rehab goals and the strategy for progression based on patient status and phases of rehab

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Pre-Op Immediate Post-op/Acute/Wound Healing Anywhere from 2 weeks – 8 weeks Pre-prosthetic/ Sub-acute Prosthetic

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Limited ability to understand Limited ability to follow instructions Transient cognitive changes Anesthesia Narcotics Unfamiliar environment

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WOUND HEALING EDEMA CONTROL/ RESIDUAL LIMB SHAPING ROM/ contracture prevention Strength Pain management Desensitization Functional mobility training Emotional adjustment IPOP

Independent function Mobility Self care Crutches, walker, wheelchair, IPOP Residual limb care

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Skin, wound Sensation Residual limb Pain ROM, muscle length, contractures Strength Neuro exam

ADL’s Balance Affect Expectations Motivation Endurance Social support

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Control Edema Decrease pain Decrease phantom sensations Encourage early weight bearing Improved wound healing Shape residual for future socket fit Protect limb

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Most commonly used method Not necessarily the best Elastic Ace wraps, Shrinkers Protocol Non-adherent dressing over sutures Sterile gauze + gauze roll overwrap Elastic bandage or sock for compression Delay weight bearing until fully healed Shrinkers better, but cannot be used over staples or sutures Must contain adductor roll Controversial. Eventually physician preference

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Elastic wrap Inexpensive, light weight, frequent reapplication, must contain adductor roll Figure 8 technique Can use knee immobilizer, do not tighten straps over or across suture line Shrinkers  Would need multiple sizes Provide uniform compression Contraindication of elastic wraps Infection Never under hard splint Never over wound vac or vacuum pump

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No differences have been demonstrated in: Uncomplicated healing rates Eventual prosthesis use Post Op pain Mortality Controlled studies suggest Reduced healing rates than Non-RRD Greater edema than Non-RRD More Post-op complications than PPOPs (Pneumatic IPOPs) More high level revisions than PPOPs

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Custom molded casts made in OR by surgical team Mid-thigh custom molded cast for TTA, Hip  spica  for TFA Depends on skills of OR team Protocol Non-adherent dressing over sutures Sterile pads + elastic sock Rigid cast prevents post-op edema, contractures  Problem with wound inspection Can only be done indirectly based on patient’s body temp, blood profile, patient report, etc. Bivalve the cast to remove it for short period of time.

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Contraindications: Poor/questionable blood supply Slow healer History of MRSA or other resistant infection Need for wound care Non-compliance DO NOT TAKE IT OFF If for any reason has to be taken off, wear shrinker in the mean time.

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IPOP- Immediate Post-op prosthesis Different from temporary prosthesis Add a prosthetic connector + Pylon + SACH foot Protected and limited WB: first 24 hours Toe-touch or PWB: 10-20days Maximum 20-40 pounds weight bearing total Initial prosthesis at suture removal Different reasons for recommendation Increase tissue remodeling, reduce healing time, reduce time to first prosthesis In those who cannot walk with one limb and crutch/ walker, significant risk of functional decline, deconditioning, pneumonia, atelectasis due to inactivity

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High risk in frail individuals because increases the risk of falls Well tolerated when wound has adequate blood supply Ischemic wounds only tolerate minimum stress during healing phase Though non-cosmetic but fit and function can be close to definitive prosthesis. Signs and symptoms to watch out for: Drainage through cast Sharp localized pain in the residual limb Fever Significant  pistoning  of the limb in the cast/ socket Foul smell of infection

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Ability to don and doff RRD have to be used all the time, even while sleeping. Use shrinker when RRD is not in use. Early ambulation than soft dressing Used when  Incision is in early stages of healing No infection, ecchymosis or large areas of wound dehiscence Best if distal residual limb – proximal limb circumference <= 0.5 inch Not good if large amount of drainage from wound requiring large and frequent dressing

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Protocol Protect suture line by placing 1-2 layers of gauze Prosthetic sock,  tubigrip , elasticized stockinet or shrinker is donned with additional ply sock on top to ensure snug fit. Ensure the RRD maintains a cylindrical shape Worn all the time with shrinkers in between if RRD needs to be removed.

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Semi-rigid Polyethylene High skill needed, used after removal of non-RRD Easier to clean: Improves hygiene Lighter and more durable than RRD, thus easier to use High costs especially due to repeat casting as limb shape and size changes Zinc oxide impregnated Unna bandage Bandage with Zinc Oxide, gelatin, calamine,  triglycerine Pasty and applied in OR after wound closure Easy to cut through if wound inspection needed, can be left for 5-7 d Not as stable or rigid as Polyethylene SRD or RRD

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Residual limb length (from the last intact joint) Residual length of bone and residual length of limb including soft tissue Subtract to get the residual limb length For TTA: medial joint line or tibial tuberosity For TFA: ischial tuberosity or GT Volume Serial circumferential girth measurement Landmarks as above Referral for prosthetic fit when distal – proximal <=1/4 inch TTA: tapered cylindrical, TFA: conical

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Segment Level Preserved Function Adult tibia Intact 100% Effective   walking TTA Short <35% Insufficient knee extension strength and power for prosthetic control, intolerance of weight bearing Standard 35-50% Effective control, efficient gait, comfortable pressure tolerance Long >50% Distal ant discomfort and skin irritation during sitting and swing phase due to high socket pressure Adult femur Intact 100% Effective walking ability TFA Short <35% Insufficient hip extension and abduction strength and power for stance phase control Standard 35-50% Effective control, sufficient strength, good efficiency, and fit Long >50% Long lever increases control, limit prosthetic knee choices due to limb length issues

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Strength assessment If open amputation: try but chances are you wont succeed, other things are more important Be cautious: do no harm, watch for sutures and associated wounds Functional movements MMT: reduced MA due to amputation, adjust accordingly Protocol: Isometric, AAROM, AROM: Progress as tolerated Do not add resistance unless surgeon gives clearance Single leg standing muscle strength UE ex’s, quad sets, glut sets, SLR

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Contracture prevention is a primary concern Positioning Add a roll distal to knee to keep knee extended Prone lying Supine: Problem with short residual Common contracture: TTA: Knee flexion, hip flexion Depends on stump length TFA: Hip flexion, abduction, external rotation

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Static quad ex’s Use extension board for TTA Encourage prone Align prosthesis to stretch tissues when  weight bearing.

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The importance of maintaining ROM and strength may be the difference in a functional ambulator and a   non-ambulator. Heart rate should not exceed   75% of MHR for patients   age. If pre-existing cardiac disease   is present, do not exceed 20 BPM over the resting   baseline.

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Pain can be due to multiple factors Surgical pain Phantom sensation and pain Residual limb Phantom sensation: affects 54% – 99% of new amputation Sense of numbness, tingling, tickling or pressure in the missing limb, cold, wet Some complain of itchy toes or muscle cramps in calf and foot Kinesthetic: posture, length, volume Kinetic: willed, spontaneous movements Exteroceptive: touch, pressure, temperature

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Phantom pain: affects 46% - 63% of new amputation Shooting pain, severe cramping, or a distressing burning that may be localized in the amputated foot or whole missing limb.  Less than 15% people will rate it as constant or severe.  Usually stabilizes after 6 months. More common in longstanding  dysvascular  state or severe traumatic injury. Rule out neuroma Variety of medication: low efficacy Careful: Falls because of sensations from missing limb

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Relieve pain by Using prosthesis Stroking the stump Using heat Distraction Exercise Provoke pain Stress Cold Local irritant like cysts

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Prosthetic Improper fit Neurogenic N euroma Sympathetic RSD Referred R adiculopathy

Soft tissue pain B ursitis, tendonitis , ligamentous Joint pain A rthritis Bone pain Exostosis,  Residual limb  ∆ ’s Changes with age Atrophy,    fat.

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Mobility and Balance Re-learn balance in sitting, standing and TRANSITIONING Learning crutch and walker use Functional mobility training, ADL’s, Endurance ASAP With all ages Education Immediate, support groups, families

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Post-operative Prosthesis Fit either in OR or w/I the first week of amputation Utilized only the first few weeks after amputation Not received by all

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Dacron webbing waist belt Elastic anterior strap 3-prong buckle Fork strap on socket May be modified with velcro and/or loops for  patients with limited hand  function.

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SACH Wood keel Cushion heel Not contoured for shoe May progress to  contoured SACH foot.

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Wound healing has occurred, sutures are more or less out CP will make a cast for an initial prosthesis Initial prosthesis Socket shape and size can and will change Socket function not as much Opportunity for individual to learn tasks and skills, gait training Edema control and limb shaping continues

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Residual limb care Contralateral limb care Mobile, non adherent scars and supple skin Strengthening Endurance ROM Balance and mobility Psychologist, MSW, support groups

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Remember: Fair+ strength is minimal for prosthetic ambulation Ability to balance dynamically on single leg is essential for ambulation

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Proximal muscle strength critical in ensuring efficient prosthetic use Watch for muscle atrophy both proximally and distally Distal muscle atrophy may cause change of stump shape and socket fit May continue for more than a year Endurance Energy consumption increases with short residual limb The more joints and muscles lost, the greater the energy cost and greater the disability

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Energy expenditure: Increases 25% for TTA Increases 40% for bilateral TTA Increases 65% for TFA Increases 59% for bilateral axillary crutches without a prosthesis: faster ambulation Increases 9% for wheelchair Increased metabolic cost, decreased surface area, circulation adjustments affect temperature control

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Balance Single leg as well as  b/l  balance tasks Single leg standing: pay attention to?? Single leg standing with perturbations: push, catching a ball, throwing Maintaining balance while doing UE activities Bosu ,  theraballs  with single and double leg support CAREFUL For athletes, more demanding activities and tests can be used

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Gait training: With and without prosthesis Starts in a parallel bar Pay attention to posture and weight bearing Limited by the device Training should include getting up from floor in case of a fall or just to increase independence in tasks Obstacle crossing, side stepping, dynamic difficult tasks like stairs and ramps

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Use shrinker when not wearing prosthesis Wear prosthesis as much as tolerated but build gradually Pressure from socket helps in edema control Desensitization of stump essential for any pressure tolerance to take hold Understand prosthetic socks and their usage Limb volume will change early on  Limb volume will change as the day progresses

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Daily hygiene Mild  antibacterial soap Check water temp with elbow: lukewarm Wash at night Pat dry, don’t rub, clean skin folds, complete rinse Clean socks every day Hand mirror for stump inspection No home remedies, home surgery Avoid excessive lotion, but do not keep skin dry Avoid shaving

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Dull pain: Pressure on muscle  belly, cut bone, deep  nerve Sharp pain: Pressure on  superficial nerve Throbbing pain Choking Blisters

Hot: Infection Cold:	Circulation Others: Adherent Scar: Distal tibia Edema Acute Chronic Cysts

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Can be biggest roadblocks Depression is common Some patients may be relieved but still depressed Some may grieve and will be depressed Support system and community resources essential Patient’s ability to work independently and also where and how they used to work important Does not mean it is always possible

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More of the same Requires a CP role more than PT Some patients may benefit and/ or need more PT during this phase Patient who are going to be very active/ athletic and those who will have co-morbidities Focus on strengthening, balance, gait training and posture

Management

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