Rehabilitation of lower limb amputee

Rehabilitationof the

Lower Limb AmputeePresenter:Dr.S.M.Waseem Ahmed

Moderator : Dr.Biju.R

The main goal of rehabilitation is to prevent any complications of immobility.

Other goals include patient education, conditioning, functional training,and psychologic support.

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

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.

Pre-operative period

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

Exercise management

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.

Amputation Surgery/Dressing

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.

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, 7.equipment prescription, and 8.continued patient education and emotional support.

Acute Post-Surgical

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

Phantom Limb Pain and Sensation:

Based on the person's level of pain,multiple treatments may be combined.

1. Heat application2. Biofeedback to reduce muscle tension3. Relaxation techniques4. Massage of the amputation area5. Surgery to remove scar tissue entangling a nerve6. Physical therapy7. TENS (transcutaneous electrical nerve stimulation) of the

stump8. Neurostimulation techniques such as spinal cord stimulation

or deep brain stimulation9. Medications, including: pain-relievers, neuroleptics,

anticonvulsants,antidepressants, beta-blockers, and sodium channel blockers.

Phantom limb pain treatment

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.

Pain Complications

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

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.

Pre- prosthetic Rehab

During initial recovery it is important to restore the individuals’ locus of control.

Generally 1. 6-8 weeks post op with soft dressings,or2. 3-6 weeks with use of an Immediate Post-

Operative 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

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)

For Transfemoral amputation: Hip extensors & abductors are needed

For Transtibial amputation: Hip extensors & abductors knee flexors & extensors are needed

Muscle strength

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.

Prosthetic Training

Parts in lower limb prosthetic

1. Dynamic response feet(Seattle foot,Flex feet)

2. SAFE foot(Stationary ankle flexible endoskeletal)

3. Multiaxis foot4. Single axis foot5. SACH(Solid ankle cushioned heel)

PROSTHETIC FEET

Structural link between prosthetic components

1.Endoskeletal 2.Exoskeletal

PROSTHETIC SHANKS

1. Polycentric knee2. Stance phase control knee3. Fluid control (Hydraulic or Pneumatic)

knee4. Constant friction knee5. Variable friction knee6. Manual locking knee

PROSTHETIC KNEES

Transtibial suspension(Gel liner suspension with locking pin)

Transfemoral suspension(vacuum suspension)

Transfemoral sockets Transtibial sockets

SUSPENSION SYSTEMS

Posture Even weight bearing Proprioception with weight shifting Weight transfer in stance

Gait Training

Stairs, slopes, uneven ground On/off floor Crowded environments Public transport

Advanced Gait Training

Involves1. resumption of family and community roles,2. addressing emotional needs3. developing healthy coping strategies,4. resumption of previous and adapted

recreational activities.

Community Integration

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

Vocational Rehabilitation

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 follow-up every 6 months

Support groups

Follow-Up

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References :

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