Lec2 - Amputee Care

• CLAUDICATION:

  • AN EARLY PRESENTING FEATURE THAT REFERS PTS TO GP
  • Claudication of the feet refers to pain, cramping, or discomfort in the legs or feet that occurs during physical activity (like walking) and improves with rest
  • It is usually caused by poor blood flow due to peripheral artery disease (PAD), a condition where arteries supplying the legs become narrowed or blocked due to atherosclerosis (plaque buildup)
• GP RECOMMENDS EARLY CONSERVATIVE MANAGEMENT FOR CLAUDICATION:

  • Lifestyle changes
  • Reducing cholesterol
  • Stopping smoking
  • Warfarin/blood thinners
  • Reduction of Blood Pressure
  • Walking Advice
  • 30 minutes 3 times a week has been shown to improve claudication
  • Ex will increase distance walked before pain starts and further increases distance walked before unbearable pain
• VASCULAR SURGERY TO REVASCULARISE THE LEG:

  • a procedure used to restore blood flow to the legs when arteries are narrowed or blocked due to peripheral artery disease (PAD) or other vascular conditions
  • The goal is to improve circulation, relieve symptoms like claudication (pain while walking), heal wounds, and prevent complications like gangrene and amputation
  • examples:
  • angiogram, angioplasty, stenting
  • endarterectomy
  • femoral popliteal bypass
• FASCIOTOMY TO RELEASE PRESSURE:

  • Compartment syndrome due to hyper-perfusion and pressure = loss of foot/ankle movement
• FOOT WEAR FROM ORTHOTICS:

  • DIABETIC SHOES
  • Globoped shoe – off loads heel and TA
  • Hexagon removable sole to relieve pressure
  • PODUS BOOT - NWB/night resting
  • OFF LOADING SHOE (toe relieving) - Very similar shoe for heel off loading too
  • DRESSING SHOE - post op for swollen feet
• ROLE OF POST OP PHYSIOTHERAPY

  • Maximise independence
  • FROM/Power
  • Reduce swelling
  • Provide walking aids and footwear
  • Motivational approach (with analgesia)
  • Plan D/C
• Symptoms:

  • ischaemia
  • dry gangrene
  • osteomyelitis
  • wet and gas gangrene
• CONSENT FOR AMPUTATION AND THE PRE OP MEETING

  • We knew
  • frailty and level of function and social set up
  • physical strength and Joint range
  • relevant PMH
  • We discussed
  • Realistic outcomes (wheelchair for 2-3 months before prosthetic assessment is feasible)
  • Prosthesis not guaranteed
  • level of amputation
  • Start planning for access visits fir safe D/C
  • Clear message that the NHS cannot manage housing/likely for microenvironment
• BLART SCORES:

  
• POST OP - THE ANTICIPATED PAIN:

  • Phantom pain and sensations
  • Soft tissue pain
  • Massive relief from ischaemic limb
  • Dependent Oedema
  • Anxiety increases pain
  • Epidural
  • Nerve blocks
• HOW TO MANAGE THE PHANTOM LIMB PAIN:

  • Graded motor imagery
  • Thinking exercises to trick the brain that leg is still there
  • Recreate afferent signals
  • Massage, desensitisation, elevation
  • Medication (amitriptyline, gabapentin)
  • Educate this is normal
  • Prosthetic rehab
• 1ST DAY POST OP STUMP CARE:

  • Avoid contractures and gain controlled movements.
  • Reassure, adaptation and acceptence.
  • Active/assisted ex.
  • Be mindful of the empty space of the absent limb.
  • Elevation, no pillows
• • All exercises use the ‘walking muscles’; unless these are done the patient gets muscle and joint instability and they will not walk well with a prosthesis

  
• ENCOUNTERED PROBLEMS post op:

  • Poor healing wound
  • Distal swelling
  • Pain ++++
• FUNCTIONAL ACTIVITY 1st DAY POST OP:

  • Bed mobility (bridging, hip hitching, rolling leading with pelvis not pulling with arms)
  • Lying to sitting (on “good” side, use arms)
  • Sit balance (backward leaning, altered balance and levers)
  • Sideways transfer (up and down bed, lift not drag)
  • Slide/Lift transfer to a chair
  • Pivot transfer to a chair (up over arm rest)
  • Sit to stand (hands on bed bottom lift, progress to frame, not stand hoist)
  • Stand balancing
• THINK SAFETY…… WHAT IS COGNITION LIKE? CAN THE PATIENT LEARN NEW SKILLS?

  • Brakes on
  • Foot plates away
  • Side arm rest down
  • Slide board to bridge gap in between bed and chair
  • Nonslip footwear
  • Glasses
  • Balance
• IN THE GYM

  • Maximise balance and function
  • Cardiovascular work
  • Avoid trauma
  • Carer/family involvement.
  • Facing the world, adapting, accepting, ownership
  • Structure to day
  • Hopping - Only if good balance,
  • normal sensation and safe
• PSYCHOLOGICAL PROBLEMS AFTER AMPUTATION examples:

  • Charlie
  • Delighted
  • Highs and Lows
  • Depressed and tearful
  • Blaming
  • Poor engagement
  • Overbearing friends.
  • Counselling allowed acceptance
  • Low mood and scared as discharge approaches
  • David
  • Depressed/bereaved of the life he knew
  • Arrogant/angry/blaming & not co-operative
  • ‘right as rain’ yet attention seeking when on phone to son
  • Crying ++ when alone
  • Regretting surgery
  • Avoiding issues and reality to go home
  • Apologetic
  • Engaging but very unrealistic
• OT ACCESS VISIT TO BOTH HOMES ON 3RD DAY

  • What obstacles to the wheelchair?
  • Threshold steps and doorways
  • Furniture and turning spaces
• DAVID BECAME INDEPENDENT ON THE WARD BY 5TH DAY:

  • Independent with Physiotherapy exercises and personal care
  • Transferring alone in bathroom
  • Going off the ward to the café
  • Asking to go home
  • Problem solving himself
  • But had to wait 7-10days until wound stable and healing
• DAVID’S DISCHARGE HOME VISIT 10TH DAY

  • Ambulance crew to carry upstairs
  • OT AX and David seen to manage safely at home
  • Package of care set up to assist
  • Therapy team back to hospital and David left at home.
  • OT follow up phone call next day
• Basic Amputee Mobility Score (BAMS)

  
• OUTPATIENT FOLLOW UP THE PRE-PROSTHETIC REHAB PHASE

  • Around 7 - 10 days post op and when stump is healed
  • Be aware of the psychological lows of new disability and isolation.
  • Patients become dependent on Physiotherapists
• PREDICTIVE FACTORS FOR SUCCESSFUL LIMB USER WITH ABOVE KNEE AMPUTATION:

  • Under 60 yrs
  • Mobilise 1 km in community 1 yr before
  • No contractures at hip
  • 5 secs indep standing balance in bars no hands
  • Transfer up and over arm rest of chair
  • Stand and balance indep with PPAM aid or femurett and walk 10m + with frame or crutches
  • A wheelchair can offer an indep lifestyle
• GOAL SETTING CAN BE A DIFFICULT CONVERSATION

  • What does patient want - not the family
  • A wheelchair offers safer and equal freedom
  • Acceptance that the amputation was a lifesaving procedure and the need to adapt
  • Only if prosthesis is appropriate, then refer to LFC
  • Not every person gets a limb
• STUMP MASSAGE, TAPPING AND DESENSITISATION

  • To be able to tolerate the stresses from the socket
  • Will increase afferent stimuli
• JUZO

  • 7 - 10 day
  • Stump needs to be carrot shaped
  • David takes off at night
  • Charlie can wear continuous

  
• BALANCE WORK FOR PROPRIOCEPTION

  • USE IT OR LOSE IT

  
• FEMURET:

  • Socket S =38-46cm; M =44-54; L =52-60cm
  • R or L , adjustable thigh and sh straps, fixed SACH foot and shin components.
  • < 105kg
  • Fixed or free knee
  • Parallel bars and walking aids

  
• PPAM AID:

  • pneumatic post amputation mobility aid

  
• OUTCOME MEASURES TO USE FOR PROSTHETIC ASSESSMENT

  • 10 m walk test
  • ROM/Power
  • Stump sensitivity
  • Timed standing balance on remaining leg
  • Standing tolerance of > 10 minutes
  • Indep with EWA out of bars with frame or crutches 20 - 30 mins
• PROSTHETIC CENTRE APPOINTMENTS

  • 8/52 - Physiotherapy assessment to ensure achieving all expected outcomes
  • 10/52 - rehab consultant assessment with decision regarding type of prosthetic prescription and casting
  • 13/52 – primary fitting and first gait training
  • 17/52 – review of prosthesis
  • Then every 3/6 months review
  • At 1yr – re-assessment – does the prosthesis meet the patients needs/lifestyle
• INCREASED ENERGY EXPENDITURE REQUIRED FOR

  PROSTHETIC WALKING

  • BKA = 25 - 40%
  • AKA = > 65%
  • BILAT BKA > 150%
  • BILAT AKA > 200%
• UNDERSTANDING THE PROSTHESIS

  
• INSTRUCTING DONNING AND DOFFING

  • Footwear (same shoes, lace up, velcro).
  • Type and number of socks (thin, thick, silipose, anti sweating)
  • Limb orientation (avoid rotation).
  • Juzo before and after to control volume changes
• AVOID DAMAGING THE SKIN

  • Check socket fit before, during and after sessions
  • Change sock layers for comfort.
  • Clean and moisturise the skin.
  • Wear limb for increasing time as you would new shoe
• INITIAL PROSTHETIC WALKING IN THE BARS IS UNSTEADY

  • no proprioception
  • No calf so no push off
  • No quads
  • Increased effort of mob
• • SUCCESSFUL WALKING IS DEPENDENT ON WB THROUGH THE PROSTHETIC FOOT
• ONE LEG DOES NOT SUIT ALL ACTIVITIES

  • Walking leg
  • Running leg
  • Water leg
  • Cosmesis
• MANAGING FALLS RISK

  • In hospital
  • Always have a hoist and sling nearby
  • Practice on and off the floor
  • At home
  • Telecare personal alarm/phone
  • Blankets and pillows
  • 999