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Clinical Procedures in Prosthetics II. Designing a PT Management Program for Patients with Prosthesis. Mark David S. Basco, PTRP Faculty Department of Physical Therapy College of Allied Medical Professions University of the Philippines Manila. Learning Objectives. - PowerPoint PPT Presentation
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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.