Designing a PT Management Program for Patients with Prosthesis

Mark David S. Basco, PTRPFacultyDepartment of Physical TherapyCollege of Allied Medical ProfessionsUniversity of the Philippines Manila

Learning ObjectivesAt the end of the session, you should be able toDiscuss principles behind designing a

management procedure for prosthesis users in the different phases:Pre-operativeEarly post-operativeLate post-operativeProsthetic training phase

Gait Vocational

Learning ObjectivesAt the end of the session, you should be able toDiscuss indications, precautions, and

contraindications to prosthetic managementDiscuss special considerations when

designing a program for children

Introductory VisitAssessmentDiscussion of outcomesPreparation for the operationPre-operative exercises

Introductory VisitIntroduce self and role in the rehab team,

emphasize role of patient and familyNeed for reassurance that amputation and

rehabilitation is a positive step towards reintegration back into the community

Goals and expectationsIntroduce team management concepts

AssessmentPhysicalConditions that may affect mobilityFunctional capacityPsychologicalAttitudeSocial situationAccommodation after surgery

Outcomes and PrognosticationWhat the patient may feel or encounter post-

opComplications that may ariseExpected highest level of function possible

given the level of amputationUse of the prosthesis is the patient’s decision

Options for prosthetic devices Life with a prosthesis

Preparation for the operationShow the patient around the facility where he

will be in after the operationPossible prosthesis given the level Speak to other amputeesExercise program Operating room, equipment, gadgets,

medications, etcPhantom sensations

Pre-operative ExercisesIncreases tolerance to surgeryFaster recovery and gain of independence in

prosthesis useMentally prepares the patientExercise program:

StrengtheningEndurance trainingSimulation of training activities post-op

GoalsTreatment methodsEarly home visitOthers

GoalsPrevent the deleterious effects of

immobilization and loss of a limb segmentFacilitate faster wound healingPain managementProvision of needed accessories or equipment

to progress patient to the next stagePrepare patient and stump for prosthetic

fittingPromote early independence in ADLs

Treatment MethodsProper positioningStump edema managementActive exercisesSelective StretchingDonning and doffingFunctional training

Proper PositioningStump should be flat on the bedUse of comfort pillowPrevent flexion contractures- Sitting vs supineAdvocating intermittent positioning in proneSidelying to relieve buttocks pressure

Stump edema managementElevationExercisesBandagingIntermittent variable air pressure machinesPneumatic pylonShrinker socksRigid dressing

Exercises for the StumpDone every 10 reps / hourActive contraction of the stump muscles is

the best method of reducing edemaFor BKAPatient must imagine the performance of

alternate DF/PFThrough knee/AKAPatient must perform alternate hip flexion

and extension as well as hip abduction

BandagingPrecaution: development of pressure necrosisStump bandaging can never change stump

shape without the danger of interference with the local circulation

A uniformly edematous stump is more readily fitted than one which has been misshapened by bandaging

Active Exercises & StretchingDetermine which muscles decreased / lost

their strength and which muscles gained a mechanical advantage

Determine biomechanical implications to identify appropriate exercise for the patient

Active exercisesStart with the intact sideApplicable across all amputation levels1st day post-op, exercises could be done on

supineAll techniques could be performed except

push-ups if attachments are present.Be vigilant especially for patients with co-

morbidities e.g. DM

Selective StretchingBKA

Knee must rest in full extension immediately post-op

AKA Major concern is development of hip flexion

and abduction contracturesObtain neutral hip alignment

Gradually altering hip position

Special considerations in exercise prescriptionAGEGenderOther medical conditions

Early Home Visit

OthersWeekly team meetingEarly walking aid prescription

Pneumatic devices on the socketsVacuum techniquesLaminated plastic socketsLocal varieties

Group therapy

GoalsPromote wound closureStabilize the stumpDecrease edemaStart prosthesis measurement

Exercises for the following groups of musclesHip ExtensorsHip FlexorsHip AbductorsHip AdductorsKnee ExtensorsKnee FlexorsTrunk strengthening exercises

Exercises for the following groups of musclesHip Extensors

Exercises for the following groups of musclesHip Flexors

Exercises for the following groups of musclesHip Abductors

Exercises for the following groups of musclesHip Adductors

Exercises for the following groups of musclesKnee extensors

Exercises for the following groups of musclesTrunk strengthening

Special considerations during exercise prescrtiptionIncorporate play therapy especially for your

pediatric patientsMake sure that activities that you plan to do

are developmentally appropriate for your patient

Donning and DoffingPatients are encouraged to dress

independently as much as possibleAccording to Engstrom (1993)If the patient is unable to put the underpants

independently, it is very unlikely that the indpendent application of the prosthesis is possible

TransfersInitial requirements

Alertness and the ability to comprehend instructions

It is possible to do transfers while the drip / catheter is in situ (PRECAUTION)

A suitable wheelchair should have been loaned pre-operatively and must be self-propelling

TransfersIndependence for all transfers on all level

surfaces should be the goalTherapist should try to make all transfer

surfaces level

Transfers

Transfers

Basic mobility skillsIndependence in sit-to-supine, supine-to-sit,

and rolling for all LE amputeesWhat happens when the amputation of the LE

is high?Tendency to fallGood core muscle strength is needed

Prosthetic referralUpon complete wound healing and stump

stability Upon gaining independence in ADL’s

What if bilateral AKA?Possible non-walkerActivities are: bed mobility training, arm

exercises, balance re-education, transfers, wheelchair maneuvers

Wheelchair concerns...

Training Program DesignPre-ambulation trainingGait trainingFalls trainingFunctional trainingEnvironmental considerationsSpecialized prosthetic training

Training Program DesignPrinciples of exxercise prescriptionShould be done daily and runn the whole dayFamily / caregiver involvementUse of different appliances / attachmentsDonning and doffing of the prosthesis

Training Program DesignPrinciples of exxercise prescriptionShould be done daily and runn the whole dayFamily / caregiver involvementUse of different appliances / attachmentsDonning and doffing of the prosthesis

Pre-ambulation TrainingSit-to-standBalance re-educationWeight transfer on to the prosthetic

legConsiderations for progressions

Pre-ambulation Training

Gait TrainingWeight bearing on the prosthetic leg is

advocatedDone on various types of surfacesProtection of the stump

Gait TrainingGait Pattern;

2-point vs 3 pointIndoor then outdoor mobility

Functional Training

Environmental ModificationsFor graspingToilet seat raise, grab bars, bed blocksVelcro and snaps vs zippers and buttonsRampsOthers

DoorsKnobsSwitches

Other considerationsDisablement resettlementDriving

After DischargeOut-patient servicesFollow-up visitsMaintenance of

prosthesis

Specialized prosthetic trainingVocational trainingAthleticsRecreational activities

Specialized prosthetic training

Specialized prosthetic training

Specialized prosthetic training

ReferencesMariano, LMMJr. (2007). PT150 Archives.

UP-CAMPMeyers, R.S. (1995). Saunders manual of

physical therapy parctice. Philadelphia: W.B. Saunders.

(2004). A manual for the rehabilitation of people with limb amputation . World Health Organization.