STUMP CARE, PHANTOM LIMB PAIN ,
GAIT TRAINING IN LOWER LIMB
HARSHITA YADAV
M.P.T (ORTHOPAEDICS)
AMPUTATION
• Derived from the Latin amputare.
• "to cut away", from ambi- ("about",
"around") and putare ("to prune").
• A...
 Amputation is the calculated surgical removal
of all or part of an extremity when its blood
supply is irreversibly compr...
 The reported annual incidence of LLA related
to peripheral vascular disease has ranged from
approximately 20 to 35 per 1...
 Amputation can be regarded as a treatment and not tragedy
Indications :-
1. Dead ( or dying ) limb
 Peripheral vascular...
3. Damn nuisance
Retaning the limb is more worse than having no limb at all
…. Because of :-
 Pain
 Gross malformation
...
CAUSES
o CONGENITAL ACQUIRED
- Vascular
- Trauma
- Infection
- Neoplasm
- Iatrogenic
- - Neuropthic
(Rehabilitation S Sund...
CONGENIAL ANOMALY
PERIPHERAL VASCULAR DISEASE
TRAUMA (severe tissue damage) –
traumatic amputation
MALIGNANT TUMOUR
 SCLERODERMA
DIABETES CRUSH INJURY
BURNS FROTBITE
 90 % amputation – peripheral vascular disease
 Young patient – trauma/ malignancy
 Absolute indication – irreversible ...
PRINCIPLES
GENERAL SURGICAL
PRINCIPLES PRINCIPAL
(Rehabilitation S Sunder 3rd ed.)
GENERAL PRINCIPLES
 To save as much limb as possible while
providing a residual limb that is able to
tolerate the stress ...
 Skin flaps – skin should be mobile ,
sensation intact , and without adherent
scars.
 Muscles are divided 3 to 5 cm dist...
 Several studies have suggested guidelines to help ,to decide
which limb is salvageable. Most of these studies have
conce...
 Other authors have attempted to remove subjective decision
making process.
 To predict which limbs will be salvalgeable...
( Campbell’ s operative orthopaedics , vol 1, 7th ed.)
1. MYODESIS -
o Muscles & fasciae are sutured directly to the distal
residual bone through drill holes.
o Muscles inserted...
2. MYOPLASTY –
o Procedure require surgeon to suture the opposing muscles in
the residual limb to each other & to the peri...
TYPES OF AMPUTATION
(classified according to the surgical technique or the
emergency of situation)
1.PROVISIONAL
Used when...
3. ACCORDING TO THE ANATOMICAL LEVEL
Depending on whether the amputation is through the joint or
the bone, these may be de...
LEVEL OF AMPUTATION IN
LOWER LIMB
 HEMICORPORETOMY
Amputation both lower
limbs & pelvis below
L4- L5 level
HEMIPELVECTOMY
Resection of lower half of
the p...
HIP DISARTICULATION
Amputation through hip joint ;
pelvis intact
 SHORT TRANSFEMORAL
(Above knee)
Less than 35% femoral ...
TRANSFEMORAL(above knee)
Between 35% & 60% femoral length
 LONG TRANSFEMORAL(above
knee)
More than 60% femoral length
KNEE DISARTICULATION
Amputation through the knee
joint; femur intact
SHORT TIBIAL(below knee)
Less than 20% tibial length
TRANSTIBIAL(below knee)
Between 20 -50% of tibial length
LONG TRANSTIBIAL (below
knee)
More than 50% tibial
SYME’S AMPUTATION
Ankle disarticulation with
attachment of heel pad to
distal end of tibia. Many
include removal of malle...
PARTIAL FOOT/ RAY
RESECTION
Resection of the 3rd, 4th , 5th
metatarsals and digits
TOE DISARTICULATION
Disarticulation a...
PARTIAL TOE
Excision of any part of one or more
toes
Closed amputation one in which flaps are made from the
skin and subcutaneous tissue and sutured over the end of the
bone.
...
Teale's amputation amputation with short and long
rectangular flaps
Gritti-Stokes amputation amputation of the leg through...
Boyd’s amputation at the ankle with removal of the talus
and fusion of tibia & calcaneous
Spontaneous amputation loss of a...
 Approximately 60,000 transtibial and transfemoral amputations
are performed each year in the United States alone.
(Gait ...
 Likely, due to the significant comorbidities of patients
undergoing amputation for ischemic disease, perioperative
morta...
POST – OPERATIVE DRESSINGS
DRESSINGS
RIGID
DRESSINGS
SEMI-RIGID
DRESSINGS
SOFT
DRESSINGS
SHRINKERS ELASTIC WRAPS
REMOVAL RIGID DRESSINGS
NON REMOVAL RIGID
DRESSINGS
SEMI-RIGID DRESSINGS
ELASTIC SOFT DRESSINGS
SHRINKERS
COMPLICATIONS
HAEMATOMA
DEHISCENCE
/WOUND
BREAKDOWN
PROBLEMS
ASSOCIATED
WITH THE
SURROUNDING
SKIN
BONE EROSION/
OSTEOMYELI...
TISSUE NECROSIS DEVELOPING
ON A STUMP WOUND CAUSING
WOUND BREAKDOWN.
EXTENSIVE TISSUE NECROSIS TO A
STUMP EXTENDING BELOW ...
A DEHISCED ABOVE-KNEE
AMPUTATION WOUND EXPOSING
THE FEMUR.
STUMP SINUS MASKING UNDERLYING
OSTEOMYELITIS.
(Wound healing co...
Classified as:
PREPROSTHETIC
1. Delayed healing
2. Skin adherence to
bone of residual limb
3. Problems in shaping
of resid...
Knee flexion contracture that
occurred from a failure to
apply postoperative rigid
dressing following transtibial
amputati...
 The phantom is the sensation of the limb that is no
longer there. The phantom, which usually occurs
initially immediatel...
 Phantom pain and sensations are defined as
perceptions ranging from slight tingling to sharp,
throbbing pain or aching t...
 Amputees can experience two different types of pain:
incisional stump pain and phantom pain.
Stump pain is localised to...
Phantom pain is a common problem, affecting
between 8% to 10% of patients and is usually
reported during the immediate po...
 The pain may be localized or diffuse; it may be
continous or intermittent & triggered by some
external stimuli.
(Physica...
 The neuromatrix is defined as a neuronal
organization that is genetically determined within
individuals and modified by ...
 The interference of normal impulse traffic to the
brain and excessive impulse discharge from
damaged neurons after amput...
 In amputees with phantom limb pain, regional
anaesthesia at the stump causes both rapid
reduction in cortical reorganisa...
Non invasive treatments such as US, icing, TENS,
or massage have been used with varying success.
Mild non-narcotic analge...
Pain relief associated with mirror therapy, may be
due to the activation of mirror neurons in the
hemisphere of the brain...
PHYSIOTHERAPEUTIC
MANAGEMENT
PRE-OPERATIVE
• ASSESSMENT
• STRENGTH TRAINING
POST-OPERATIVE
 PRE-PROSTHETIC
• ASSESSMENT...
PRE-OPERATIVE MANAGEMENT
Training involves:
• Breathing exercises
• Strengthening exercises
• Mobilization exercises
• Bed...
POST-OPERATIVE MANAGEMENT
The aims of treatment are:
• Prevention of joint contracture
• To strengthen and mobilize unaffe...
Cardiac precaution
Oedema control can be done by
following methods:
• Elevation and exercises
• Bandaging
• Shrinker soc...
Care of the Stump
– Keep the stump clean, dry, and free
from infection at all times.
– If fitted with a prosthesis, you sh...
RESUDIAL LIMB WRAPPING
Eary wrapping provides a no. of positive
benefits:
o Decrease odema & venous stasis
o Assist in sha...
Residual limb wrapping
Post-operative stump training
• Exercise
• Massage
• Pressure
• Mobilization
• Strengthening
PPAM aid for pressure
toleran...
Short arc quadriceps
Straight Leg Raise
Ankle Pumps
Side Lying Hip Abduction - Modified
Side Lying Hip Abduction - Advanced
Prone Hip Extension
Prone Hip Extension (Sound Limb)
Prone Adductor Squeeze
Prone Knee Flexion
Push-ups
Quadruped Leg Lift
Abdominal Curl-up
Bosu Head Twists
Bosu Ball Exercises
Prosthetics
It is a replacement of
substitution of a missing or a
diseased part
Types of Prosthesis
BELOW KNEE
KNEE
DISARTICULATION ABOVE KNEE
HIP
DISARTICULATION
PROSTHETICS
LOWER EXTREMITY
Ideal prosthesis
1. Fits comfortably
2. Function well
3. Looks presentable
4. Fit as soon after the operation
Classification
Endoprosthesis- implants
used in Orthopaedic
surgery eg; austin moore
Prosthesis
Exoprosthesis-external
rep...
Temporary –
Used following amputation
till paient is fitted with
permanent prosthesis
eg;pylon
Permanent prosthesis
Lower Limb Prosthesis
Types of lower limbs prosthesis :
 Types of L.L. prostheses depend on
different stages after amputa...
DONNING
&
DOFFING
Center of gravity
Amputation,Stump care, phantom limb pain and gait training in lower limb
Amputation,Stump care, phantom limb pain and gait training in lower limb
Amputation,Stump care, phantom limb pain and gait training in lower limb
Amputation,Stump care, phantom limb pain and gait training in lower limb
Amputation,Stump care, phantom limb pain and gait training in lower limb
Amputation,Stump care, phantom limb pain and gait training in lower limb
Amputation,Stump care, phantom limb pain and gait training in lower limb
Amputation,Stump care, phantom limb pain and gait training in lower limb
Amputation,Stump care, phantom limb pain and gait training in lower limb
Amputation,Stump care, phantom limb pain and gait training in lower limb
Amputation,Stump care, phantom limb pain and gait training in lower limb
Amputation,Stump care, phantom limb pain and gait training in lower limb
Amputation,Stump care, phantom limb pain and gait training in lower limb
Amputation,Stump care, phantom limb pain and gait training in lower limb
Amputation,Stump care, phantom limb pain and gait training in lower limb
Amputation,Stump care, phantom limb pain and gait training in lower limb
Amputation,Stump care, phantom limb pain and gait training in lower limb
Amputation,Stump care, phantom limb pain and gait training in lower limb
Amputation,Stump care, phantom limb pain and gait training in lower limb
Amputation,Stump care, phantom limb pain and gait training in lower limb
Amputation,Stump care, phantom limb pain and gait training in lower limb
Upcoming SlideShare
Loading in …5
×

Amputation,Stump care, phantom limb pain and gait training in lower limb

5,242 views
4,846 views

Published on

Published in: Health & Medicine
0 Comments
16 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
5,242
On SlideShare
0
From Embeds
0
Number of Embeds
6
Actions
Shares
0
Downloads
336
Comments
0
Likes
16
Embeds 0
No embeds

No notes for slide
  • Leg Prosthesis (2 types):An exoskeletal prosthesis has a hard outer shell made primarily of plastics and laminates.An endoskeletal or modular prosthesis has the tube or pylon frame that acts as a type of “skeleton.”A soft foam cover is usually applied over the prosthesis. The foam cover is shaped to match the remaining sound limb.Arm:A myoelectric arm, in which signals from muscles in the residual limb are sent via electrodes to the prosthetic hand to open or close it, is powered by a batteryThe cheetah prosthetic which is pictured above has been riddled with controversy. Oscar Pistorius is a double below-knee amputee from South Africa who recently won the silver medal in the 400m at the South African senior athletics championships against an entirely able-bodied field. However, he may be excluded from further competing in "able-bodied" events because some feel that his artificial legs give him an unfair advantage by virtue of being longer then natural legs. Others say that his legs are a disadvantage, since unlike natural legs, they are merely akin to springs and can not generate energy like a natural leg. It is important to consider culture and ethnic origin when discussing a prosthetic with patients. When I was in Haiti it was common for prosthetics to go unused as they were not made to match the skin tone of their wearer!
  • Amputation,Stump care, phantom limb pain and gait training in lower limb

    1. 1. STUMP CARE, PHANTOM LIMB PAIN , GAIT TRAINING IN LOWER LIMB HARSHITA YADAV M.P.T (ORTHOPAEDICS)
    2. 2. AMPUTATION • Derived from the Latin amputare. • "to cut away", from ambi- ("about", "around") and putare ("to prune"). • Amputation is the complete removal of an injured or deformed body part. • The English word "amputation" was first applied to surgery in the 17th century.
    3. 3.  Amputation is the calculated surgical removal of all or part of an extremity when its blood supply is irreversibly compromised by disease or severe injury. (Medical Disability guidelines)  The national center for Health Statistics estimated that more than 300,000 patients with amputations live in the US. DEFINATION INCIDENCE ( Campbell’ s operative orthopaedics , vol 1, 7th ed.)
    4. 4.  The reported annual incidence of LLA related to peripheral vascular disease has ranged from approximately 20 to 35 per 100,000 inhabitants.  It has been reported that one in four diabetic individuals develops peripheral vascular disease that, when severe, may require amputation . (Incidence of Lower-Limb Amputation in the Diabetic and Nondiabetic General Population; Diabetes Care 32:275–280, 2009)
    5. 5.  Amputation can be regarded as a treatment and not tragedy Indications :- 1. Dead ( or dying ) limb  Peripheral vascular disease ( 90% )  Sever trauma  Burns  Frostbite 2. Dangerous limb  Malignant tumors  Lethal sepsis  Crush injury leading to Crush syndrome
    6. 6. 3. Damn nuisance Retaning the limb is more worse than having no limb at all …. Because of :-  Pain  Gross malformation  Recurrent sepsis  Sever loss of function
    7. 7. CAUSES o CONGENITAL ACQUIRED - Vascular - Trauma - Infection - Neoplasm - Iatrogenic - - Neuropthic (Rehabilitation S Sunder 3rd ed.)
    8. 8. CONGENIAL ANOMALY
    9. 9. PERIPHERAL VASCULAR DISEASE
    10. 10. TRAUMA (severe tissue damage) – traumatic amputation
    11. 11. MALIGNANT TUMOUR
    12. 12.  SCLERODERMA
    13. 13. DIABETES CRUSH INJURY
    14. 14. BURNS FROTBITE
    15. 15.  90 % amputation – peripheral vascular disease  Young patient – trauma/ malignancy  Absolute indication – irreversible ischaemia: disease or trauma ( Campbell’ s operative orthopaedics , vol 1, 7th ed.)  70% of lower-extremity amputations result from complications associated with diabetes mellitus and peripheral vascular occlusive disease.  Peripheral vascular compromise, resulting from diabetes mellitus, leads to multiple health problems, including poor ability to heal wounds, infections, ischemia and neuropathy .Due to these factors, people who have diabetes are 15 times more likely to have an amputation. (The Influence of Lower-Extremity Muscle Force on Gait Characteristics in Individuals With Below-Knee Amputations Secondary to Vascular Disease , APTA ; Vol – 76 )
    16. 16. PRINCIPLES GENERAL SURGICAL PRINCIPLES PRINCIPAL (Rehabilitation S Sunder 3rd ed.)
    17. 17. GENERAL PRINCIPLES  To save as much limb as possible while providing a residual limb that is able to tolerate the stress of the prosthesis and return to mobility . SURGICAL PRINCIPLES  The use of tourniquet is advised to obtain a bloodless field – except in ischemic conditions.  Level of amputation – effort should be made to preserve all possible limb length, keeping in mind the prosthesis to be fit. (Rehabilitation S Sunder 3rd ed.)
    18. 18.  Skin flaps – skin should be mobile , sensation intact , and without adherent scars.  Muscles are divided 3 to 5 cm distal to the level of bone resection.  Nerves are gently pulled and cut cleanly so that they retract well proximal to the bone level. This reduces complication of neuroma. (Rehabilitation S Sunder 3rd ed.)
    19. 19.  Several studies have suggested guidelines to help ,to decide which limb is salvageable. Most of these studies have concentrated on severe injuries of the lower extremity.  Most authors would agree with Lange’s absolute indications for amputations of type3-C open tibial #, which include complete distruption of the tibial nerve or a crush injury with warm ischemia ,time of more than 6 hrs.  Lange’s relative indications for primary amputation include: * Severe associated injuries * Severe ipsilateral foot injuries *Anticipated protracted course to obtain soft- tissue coverage and tibial reconstruction DESIGN MAKING FOR THE SALVAGEABLE LIMB
    20. 20.  Other authors have attempted to remove subjective decision making process.  To predict which limbs will be salvalgeable, available scoring systems include : • the predictive salvage index, • the limb injury score, • the limb salvage index, • the mangled extremity syndrome index, and • the mangled extremity severity score.  Of these , it was found that the mangled extremity severity score was to be most useful. ( Campbell’ s operative orthopaedics , vol 1, 7th ed.)
    21. 21. ( Campbell’ s operative orthopaedics , vol 1, 7th ed.)
    22. 22. 1. MYODESIS - o Muscles & fasciae are sutured directly to the distal residual bone through drill holes. o Muscles inserted function better , resulting in good prosthetic control. o Procedure compromises blood supply to the muscles & hence is contraindicated in patients with severe peripheral vascular disease. o Sometimes myodesis fails even with best care. (Rehabilitation S Sunder 3rd ed.) SURGICAL PROCEDURE
    23. 23. 2. MYOPLASTY – o Procedure require surgeon to suture the opposing muscles in the residual limb to each other & to the periosteum or to the distal end of the cut bone. o Muscles must be stretched enough so that they control the residual limb. o Muscles sutured to each other provide distal soft-tissue padding over the residual bone. o Sometimes a painful bursa develops between the soft tissues & underlying bone and some of these bursa can become infected & painful. 3. OSTEOMYODESIS – o Similar to myodesis but the periosteum is stripped. This enables bone growth in that area. (Rehabilitation S Sunder 3rd ed.)
    24. 24. TYPES OF AMPUTATION (classified according to the surgical technique or the emergency of situation) 1.PROVISIONAL Used when primary healing is unlikely or delayed because of infection, ischemia, or inadequate wound debridement. It is done as an emergency procedure , to save the life of the patient. 2. DEFINITIVE Used after provisional amputation as an elective surgery. In this, level is well- defined & thought out, with the ultimate prosthesis kept in mind. (Rehabilitation S Sunder 3rd ed.)
    25. 25. 3. ACCORDING TO THE ANATOMICAL LEVEL Depending on whether the amputation is through the joint or the bone, these may be defined as:  Disarticulation: amputation through joint  Through the shaft of a long bone (Rehabilitation S Sunder 3rd ed.)
    26. 26. LEVEL OF AMPUTATION IN LOWER LIMB
    27. 27.  HEMICORPORETOMY Amputation both lower limbs & pelvis below L4- L5 level HEMIPELVECTOMY Resection of lower half of the pelvis (Physical rehabilitation;Susan B O’ Sullivan; 5th )
    28. 28. HIP DISARTICULATION Amputation through hip joint ; pelvis intact  SHORT TRANSFEMORAL (Above knee) Less than 35% femoral length (Physical rehabilitation; Susan B O’ Sullivan; 5th )
    29. 29. TRANSFEMORAL(above knee) Between 35% & 60% femoral length  LONG TRANSFEMORAL(above knee) More than 60% femoral length
    30. 30. KNEE DISARTICULATION Amputation through the knee joint; femur intact SHORT TIBIAL(below knee) Less than 20% tibial length
    31. 31. TRANSTIBIAL(below knee) Between 20 -50% of tibial length LONG TRANSTIBIAL (below knee) More than 50% tibial
    32. 32. SYME’S AMPUTATION Ankle disarticulation with attachment of heel pad to distal end of tibia. Many include removal of malleoli & distal tibia/ fibular flares TRANSMETATARSAL Amputation through mid section of all metatarsals
    33. 33. PARTIAL FOOT/ RAY RESECTION Resection of the 3rd, 4th , 5th metatarsals and digits TOE DISARTICULATION Disarticulation at the metatarsal phalangeal joint .
    34. 34. PARTIAL TOE Excision of any part of one or more toes
    35. 35. Closed amputation one in which flaps are made from the skin and subcutaneous tissue and sutured over the end of the bone. Amputation in contiguity amputation at a joint. Amputation in continuity amputation of a limb elsewhere than at a joint. Double-flap amputation one in which two flaps are formed. Elliptic amputation one in which the cut has an elliptical outline.
    36. 36. Teale's amputation amputation with short and long rectangular flaps Gritti-Stokes amputation amputation of the leg through the knee, using an oval anterior flap. Guillotine amputation one performed rapidly by a circular sweep of the knife and a cut of the saw, the entire cross-section being left open for dressing. Racket amputation one in which there is a single longitudinal incision continuous below with a spiral incision on either side of the limb.
    37. 37. Boyd’s amputation at the ankle with removal of the talus and fusion of tibia & calcaneous Spontaneous amputation loss of a part without surgical intervention, as in diabetes mellitus. Subperiosteal amputation one in which the cut end of the bone is covered by periosteal flaps. Chopart's amputation amputation of the foot by a midtarsal disarticulation. Lisfranc's amputation amputation of the foot between the metatarsus and tarsus.
    38. 38.  Approximately 60,000 transtibial and transfemoral amputations are performed each year in the United States alone. (Gait Training With Virtual Reality–Based Real-Time Feedback:Improving Gait Performance Following Transfemoral Amputation; September 2011; Volume 91 Number 9 Physical Therapy) Multiple studies, have documented the increased rehabilitation rate in BKA vs AKA patients, with more than 65% of BKA patients ambulating with prosthesis. In contrast, less than one third of AKA patients are likely to rehabilitate with the use of a prosthesis. (Major Lower Extremity Amputation; Arch Surg. 2004;139:395-399)
    39. 39.  Likely, due to the significant comorbidities of patients undergoing amputation for ischemic disease, perioperative mortality rates range from 0.9% to 14.1% for BKA patients and are significantly worse for AKA patients at 2.8% to 35%. (Major Lower Extremity Amputation; Arch Surg. 2004;139:395-399)
    40. 40. POST – OPERATIVE DRESSINGS DRESSINGS RIGID DRESSINGS SEMI-RIGID DRESSINGS SOFT DRESSINGS SHRINKERS ELASTIC WRAPS
    41. 41. REMOVAL RIGID DRESSINGS NON REMOVAL RIGID DRESSINGS
    42. 42. SEMI-RIGID DRESSINGS ELASTIC SOFT DRESSINGS SHRINKERS
    43. 43. COMPLICATIONS HAEMATOMA DEHISCENCE /WOUND BREAKDOWN PROBLEMS ASSOCIATED WITH THE SURROUNDING SKIN BONE EROSION/ OSTEOMYELITIS INFECTION TISSUE NECROSIS STUMP OEDEMA . PAIN (Wound healing complications associated with lower limb amputation 29-Sep-2006 15:28:16 BST)
    44. 44. TISSUE NECROSIS DEVELOPING ON A STUMP WOUND CAUSING WOUND BREAKDOWN. EXTENSIVE TISSUE NECROSIS TO A STUMP EXTENDING BELOW THE SUTURE LINE CHARACTERISED BY DISCOLORED, CYANOSED BLISTERING CONTACT DERMATITIS TO THE DISTAL END OF A STUMP CAUSED BY THE APPLICATION OF TAPE. (Wound healing complications associated with lower limb amputation 29-Sep-2006 15:28:16 BST)
    45. 45. A DEHISCED ABOVE-KNEE AMPUTATION WOUND EXPOSING THE FEMUR. STUMP SINUS MASKING UNDERLYING OSTEOMYELITIS. (Wound healing complications associated with lower limb amputation 29- Sep-2006 15:28:16 BST)
    46. 46. Classified as: PREPROSTHETIC 1. Delayed healing 2. Skin adherence to bone of residual limb 3. Problems in shaping of residual limb 4. Contractures 5. Chronic wound sinus POSTPROSTHETIC 1. Painful residual limb 2. Adherence of skin to bone 3. Insensitive skin 4. Poor Fit 5. Boney overgrowth in children 6. Degenerative arthritis 7. Fractures (Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles)
    47. 47. Knee flexion contracture that occurred from a failure to apply postoperative rigid dressing following transtibial amputation. Appositional overgrowth of the humerus in an adolescent transhumeral amputee. (Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles)
    48. 48.  The phantom is the sensation of the limb that is no longer there. The phantom, which usually occurs initially immediately after surgery, is often described as a tingling, burning, itching or pressure, sensation, sometimes a numbness.  Phantom sensation may be painless although, most people find it uncomfortable & often report it as pain; it usually does not interfere with prosthetic rehabilitation. (Physical rehabilitation;Susan B O’ Sullivan; 5th ) PHANTOM LIMB PAIN
    49. 49.  Phantom pain and sensations are defined as perceptions ranging from slight tingling to sharp, throbbing pain or aching that patients perceive relating to an extremity or an organ that is physically no longer a part of the body. • It has been reported in various trials that the estimated prevalence of phantom pain varies from 49% to 83%. (A Retrospective Trial Comparing the Effects ofDifferent Anesthetic Techniques on Phantom Pain After Lower Limb Amputation; 2011 Elsevier HS Journals)
    50. 50.  Amputees can experience two different types of pain: incisional stump pain and phantom pain. Stump pain is localised to the area immediately around the stump and the amputation scar and is described by patients as 'pressing', 'throbbing', 'burning' and 'squeezing' (Wound healing complications associated with lower limb amputation 29-Sep-2006 15:28:16 BST)
    51. 51. Phantom pain is a common problem, affecting between 8% to 10% of patients and is usually reported during the immediate postoperative period but can persist for up to two years. In some cases, phantom pain can be a lifelong experience.  It is literally pain experienced in the limb that has been amputated, and is often described as a crushing, tearing pain. (Wound healing complications associated with lower limb amputation 29-Sep- 2006 15:28:16 BST)
    52. 52.  The pain may be localized or diffuse; it may be continous or intermittent & triggered by some external stimuli. (Physical rehabilitation;Susan B O’ Sullivan; 5th )
    53. 53.  The neuromatrix is defined as a neuronal organization that is genetically determined within individuals and modified by sensory experiences. According to this theory, abnormal impulses that reach the neuromatrix after an extremity amputation change the neuromatrix pattern, and this causes conversion of normal input to pain sensations, in other words, causes phantom pain. (A Retrospective Trial Comparing the Effects ofDifferent Anesthetic Techniques on Phantom Pain After Lower Limb Amputation; 2011 Elsevier HS Journals)
    54. 54.  The interference of normal impulse traffic to the brain and excessive impulse discharge from damaged neurons after amputation are believed to be responsible for occurrence of phantom pain. Additionally, somatosensory pain memory can awaken after amputation, thus leading to phantom pain. (A Retrospective Trial Comparing the Effects ofDifferent Anesthetic Techniques on Phantom Pain After Lower Limb Amputation; 2011 Elsevier HS Journals)
    55. 55.  In amputees with phantom limb pain, regional anaesthesia at the stump causes both rapid reduction in cortical reorganisation & elimination of phantom limb pain, although phantom limb pain returns as anaesthesia subsides. (Is sucessful rehabilitation of complex regional pain syndrome due to sustained attention to the affected limb? A randomised clinical trail; G. Lorimer Mosely* ;pain;2004;11,024)
    56. 56. Non invasive treatments such as US, icing, TENS, or massage have been used with varying success. Mild non-narcotic analgesics have been of limited value; biofeedback, guided imagery, psychotherapy, nerve blocks, & dorsal rhyzotomies have been used with inconsistent results. (Physical rehabilitation;Susan B O’ Sullivan; 5th ) MANAGEMENT FOR PHANTOM LIMB PAIN
    57. 57. Pain relief associated with mirror therapy, may be due to the activation of mirror neurons in the hemisphere of the brain that is contralateral to the amputated limb. These neurons fire, when a person either performs an action or observes another person performing an action. Therefore , mirror therapy may be helpful in alleviating phantom pain in an amputated lower limb. (Mirror Therapy for Phantom Limb Pain; E NGL J MED; 357;21;2007)
    58. 58. PHYSIOTHERAPEUTIC MANAGEMENT PRE-OPERATIVE • ASSESSMENT • STRENGTH TRAINING POST-OPERATIVE  PRE-PROSTHETIC • ASSESSMENT • STUMP STRENGTHENING • STUMP TRAINING FOR PROSTHESIS POST-PROSTHETIC • GAIT TRAINING • STUMP HANDLING
    59. 59. PRE-OPERATIVE MANAGEMENT Training involves: • Breathing exercises • Strengthening exercises • Mobilization exercises • Bed mobility • Transfers • Stabilization exercises • Wheelchair training Strengthening exercises Bed mobility and transfers Wheelchair training
    60. 60. POST-OPERATIVE MANAGEMENT The aims of treatment are: • Prevention of joint contracture • To strengthen and mobilize unaffected leg • To strengthen and co-ordinate the muscles controlling the stump • To strengthen and mobilize the trunk and retrain balance • To teach the patient to regain independence in functional activities • To control oedema of the stump and commence early ambulation • Re-education of sensation in healed stump • Successful discharge into community
    61. 61. Cardiac precaution Oedema control can be done by following methods: • Elevation and exercises • Bandaging • Shrinker socks • Rigid dressing • Intermittent pressure machines • PPAM aid: pneumatic post amputation mobility aid
    62. 62. Care of the Stump – Keep the stump clean, dry, and free from infection at all times. – If fitted with a prosthesis, you should remove it before going to sleep. – Inspect and wash the stump with mild soap and warm water every night, then dry thoroughly and apply talcum powder. – Do not use the prosthesis until the skin has healed. – The stump sock should be changed daily, and the inside of the socket may be cleaned with mild soap.
    63. 63. RESUDIAL LIMB WRAPPING Eary wrapping provides a no. of positive benefits: o Decrease odema & venous stasis o Assist in shaping oHelp in counteract contracture oProvide skin protection oReduce redundant tissue problems o Reduce phantom limb sensation and discomfort oDesensitize the residual limb with local pain
    64. 64. Residual limb wrapping
    65. 65. Post-operative stump training • Exercise • Massage • Pressure • Mobilization • Strengthening PPAM aid for pressure tolerance training
    66. 66. Short arc quadriceps
    67. 67. Straight Leg Raise
    68. 68. Ankle Pumps
    69. 69. Side Lying Hip Abduction - Modified
    70. 70. Side Lying Hip Abduction - Advanced
    71. 71. Prone Hip Extension
    72. 72. Prone Hip Extension (Sound Limb)
    73. 73. Prone Adductor Squeeze
    74. 74. Prone Knee Flexion
    75. 75. Push-ups
    76. 76. Quadruped Leg Lift
    77. 77. Abdominal Curl-up
    78. 78. Bosu Head Twists
    79. 79. Bosu Ball Exercises
    80. 80. Prosthetics It is a replacement of substitution of a missing or a diseased part
    81. 81. Types of Prosthesis BELOW KNEE KNEE DISARTICULATION ABOVE KNEE HIP DISARTICULATION PROSTHETICS LOWER EXTREMITY
    82. 82. Ideal prosthesis 1. Fits comfortably 2. Function well 3. Looks presentable 4. Fit as soon after the operation
    83. 83. Classification Endoprosthesis- implants used in Orthopaedic surgery eg; austin moore Prosthesis Exoprosthesis-external replacement for a lost part of the limb
    84. 84. Temporary – Used following amputation till paient is fitted with permanent prosthesis eg;pylon Permanent prosthesis
    85. 85. Lower Limb Prosthesis Types of lower limbs prosthesis :  Types of L.L. prostheses depend on different stages after amputation.  There are three types: - Immediate post- operative prosthesis - Temporary prosthesis - Definitive prosthesis
    86. 86. DONNING & DOFFING
    87. 87. Center of gravity

    ×