Rehabilitation of lower limb amputee


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Rehabilitation of lower limb amputee

  1. 1. Presenter:Dr.S.M.Waseem Ahmed Moderator : Dr.Biju.R
  2. 2.   The main goal of rehabilitation is to prevent any complications of immobility. Other goals include patient education, conditioning, functional training,and psychologic support.
  3. 3.      Rehabilitation prog can be divided into 1.Pre-op period 2.Post-op period which is in a.Preprosthetic stage b.Prosthetic stage 3.Community and vocational rehabilitation 4.Life long management and follow-up
  4. 4. Involves : 1. medical and physical assessment (power of crutch muscles,joint mobility,balance reactions in sitting & standing): 2. patient education, 3. Functional abilities, 4. discussion about phantom limb pain,  If possible, patient should be placed in a cardiopulmonary conditioning program.
  5. 5.       Breathing exercises to clear lung secretions Strengthening exercises for shoulder extensors & adductors elbow extensors & other crutch muscles hip extensors,abductors & Quadriceps Mobilisation for hip extension,knee flexion & extension Transfer from bed to chair & back Wheelchair mobility Stabilisation for trunk in sitting & standing
  6. 6.       Involves 1.surgical residual limb length determination, 2.closure of wound and soft-tissue coverage, 3.nerve management, 4.dressing application, and 5.limb reconstruction.
  7. 7.   The residual limb must be surgically constructed to fit the future prosthesis, maintain muscle balance, and allow it to assume the stresses necessary to meet its new function. An underlying goal of surgical management of patients’ requiring lower limb amputation is to retain the knee joint given its contribution to more efficient ambulation with a prosthesis,requiring less energy expenditure.
  8. 8.   This phase begins immediately post-operatively and continues until the patient is discharged from the acute care hospital. Goals at this stage are 1.pain control, 2.optimization of range of motion (ROM) and 3. strength of both lower and upper extremity musculature, 4.promotion of wound healing, 5.phantom limb pain/sensation management, 6.functional mobility training, prescription, and 8.continued patient education and emotional support.
  9. 9.      Phantom limb sensation is the sensation that the limb is still present. Phantom pain includes various painful sensations in the body part that is no longer present. Immediate post-operative incidence of phantom pain and phantom sensation has been reported to be 72% and 84%, respectively, while the incidence at 6 months post-operatively changes to 67% and 90%, respectively. Both phantom pain and sensation are generally localized to the distal part of the missing,limb. Persons with phantom limb pain have worse or lower health-related Quality of Life
  10. 10.  1. 2. 3. 4. 5. 6. 7. 8. 9. Based on the person's level of pain,multiple treatments may be combined. Heat application Biofeedback to reduce muscle tension Relaxation techniques Massage of the amputation area Surgery to remove scar tissue entangling a nerve Physical therapy TENS (transcutaneous electrical nerve stimulation) of the stump Neurostimulation techniques such as spinal cord stimulation or deep brain stimulation Medications, including: painrelievers, neuroleptics, anticonvulsants,antidepressants, beta-blockers, and sodium channel blockers.
  11. 11.       Other causes of pain in individuals undergoing lower limbamputation may include 1.Neuroma formation is a natural repair phenomenon that may occur when a peripheral nerve is transected. Pain occurs when the neuroma is situated at the end of the residual limb or at a pressure point in the prosthesis. Non operative : local analgesics or corticosteroids. Surgical Excision of the neuroma is the treatment of choice.
  12. 12.     2.Reflex sympathetic dystrophy,also called complex regional pain syndrome, Includes sensory, autonomic and motor symptoms that may occur in the affected extremity. The hallmark of this condition is severe, unremitting pain that is out of proportion to the injury. Early treatment with the TENS or sympathetic blocks, pharmacologic agents, and physical therapy.  3.Bursitis or tendonitis  cause aggravating residual limb pain, characterized by localized   tenderness, mild edema, slight occasional erythema of the overlying skin, increased skin temperature, and subcutaneous crepitus. If tendonitis is present, passive stretching of theinvolved tendon will cause significant pain. Intervention : cessation of provocative activities,oral NSAIDS, temporary discontinuation of the prosthesis, rigid immobilization for brief periods, compression dressings, thermal modalities, corticosteroid
  13. 13. Involves  Stump shaping and shrinking  Care of stump  Desensitisation  ROM and muscle strengthening  progressive functional mobility training without a prosthesis,  restoring locus of control of the patient  patient education and preparation for prosthetic use.
  14. 14. During initial recovery it is important to restore the individuals’ locus of control.  Generally 1. 6-8 weeks post op with soft dressings,or 2. 3-6 weeks with use of an Immediate PostOperative Prosthesis (IPOP).  Preparatory or training prosthesis may be used to promote residual limb maturation and for use during gait training.  Individuals are vulnerable to losses in strength and range of motion (contractures) during this period 
  15. 15.    Immediate post op dressing: Made of POP,rigid post op is useful as: ADV: post op edema,pain, enhances healing DISADV: expensive & special training required Semirigid dressing: Unna’s dressing,guaze with ZnO DISADV:loosen easily Soft dressing: 1.Elastic wrap(need freq reapplication) 2.Shrinkers(sock like conical garments of knitted cotton cannot be used untill primary healing occured)
  16. 16. For Transfemoral amputation: Hip extensors & abductors are needed  For Transtibial amputation: Hip extensors & abductors knee flexors & extensors are needed 
  17. 17.     Prosthetic management and training to increase wearing time and functional use. For patients with AKA and BKA using a soft dressing after amputation, a cast for a temporary socket is often fabricated 6-8 weeks postoperatively. Ambulation activities with a lower limb prosthesis often begin during weeks 10-11 after amputation. The more proximal the amputation, the more energy is demanded from the cardiovascular and pulmonary systems for prosthetic gait.
  18. 18. 1. 2. 3. 4. 5. Dynamic response feet(Seattle foot,Flex feet) SAFE foot(Stationary ankle flexible endoskeletal) Multiaxis foot Single axis foot SACH(Solid ankle cushioned heel)
  19. 19.  Structural link between prosthetic components 1.Endoskeletal 2.Exoskeletal
  20. 20. 1. 2. 3. 4. 5. 6. Polycentric knee Stance phase control knee Fluid control (Hydraulic or Pneumatic) knee Constant friction knee Variable friction knee Manual locking knee
  21. 21.     Transtibial suspension(Gel liner suspension with locking pin) Transfemoral suspension(vacuum suspension) Transfemoral sockets Transtibial sockets
  22. 22.     Posture Even weight bearing Proprioception with weight shifting Weight transfer in stance
  23. 23.     Stairs, slopes, uneven ground On/off floor Crowded environments Public transport
  24. 24. Involves 1. resumption of family and community roles, 2. addressing emotional needs 3. developing healthy coping strategies, 4. resumption of previous and adapted recreational activities. 
  25. 25.    Involves assessment and training for work activities, and assessment of further education needs or job modification On the basis of residual functional capacity, patients may be able to return to their previous line of work. In many cases patients’ may choose a different line of work,dependent on the physical demands of the job. For the successful reintegration of the amputee, return to work should take place gradually, with time and workload increasing over several weeks and clinical staff being available for counseling and consultation
  26. 26.    Includes lifelong prosthetic, functional, and medical assessment and psychological support. Patients should be seen for follow-up by one of the team members at least every 3 months for the first 18 months, with physical followup every 6 months Support groups
  27. 27.   Mercer Internet