Introduction 20to 20amputation 20and 20rehabilitation 20care

8/13/2019 Introduction 20to 20amputation 20and 20rehabilitation 20care

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Introduction to amputation and rehabilitation care in U/E

Jyh-Jong Chang

Tel: 2644 Office: CS505Email:[email protected]

2007 11 16Outline

1. Introduction to Amputation2. Surgical Management for Amputation3. Post-surgical Treatment Objectives of Amputation Rehabilitation

4. Introduction to Prosthesis and its components

5. Prosthesis control and Choices


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Limb Amputation Can Be Categorized As

Congenital : present at birth

Acquired: Trauma, tumors, vascular disease or infection

Incidence : Most upper limb amputations occur as a result of trauma from

Motor vehicles and machinery accidents, gunshot wounds, electrical

burns

Majority of these are males

U/E : L/E amputation ---- 1:3

75% are peripheral vascular disease and diabetes mellitus being the

most common causes in people over 60 years of age

Level of Amputation

Forequarter : Clavicle and scapula involved

Shoulder disarticulation

Transhumeral (above-elbow amputation): Short, standard A/E


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Elbow disarticulation

Transradial (below elbow amputation ): Very short, short, long B/E

Wrist disarticulation:

Transcarpal:

Transmetacarpal amputation : Partial hand

Finger amputation:

Rehabilitation of the U/E Amputee

Stump care

Strengthening and ROM programs

Training in one hand techniques

Checkout of the prosthesis

Provision of prosthesis training

Referrals for further management


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Surgical Management for Amputation

Preserve as much tissue as possible

Blood vessels and nerves are severed

Allow to retract to reduce stump pain

Bone beveling

Smooth the rough edge and prevent spur development

Muscle

Sutured to the bones distally (myodesis)

Close or open surgical procedure

Open : Allow drainage, minimize infection

Close: Reduce the days of hospitalization, but increase infection

Special Considerations and Problems after Limb Amputation

Skins: Delay healing, skin break down, ulcers, stump corn Stump edema: Compression wrapping, rigid dressing Extensive skin graft

Skin adhesion to the bone

Daily gentle massage of the adhesive tissue is necessary

Sensory problemsLoss of sensory feedbackStump hypersensitive

Neuroma

A small ball of nerve tissue, excessive growth of axons attempting to


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reach the distal portion of the stump (2.5~5cm proximal to the end of

the residual limb)

Phantom sensation, phantom pain Bone and joint problems

Bone spurs formation and cause pain

Phantom Sensation and Phantom Pain

Most in crush injuries, in distal parts

The "neural system exists within the brain even when the body input is cut

off by amputation"

Phantom limb sensation often never subsides and is ordinarily accepted by

the patient

Pain is experienced as more intense with stress increases

Peripheral nerve irritation, abnormal sympathetic function, and

psychological factors are thought to be contributory factors

Treatment of Phantom Pain

Avoid emphasizing the issue of pain when possible

Severe pain

Analgesics have been used as well as surgery such as nerve blocks

and neurectomies

Limb rubbing and tapping, ultrasound, and transcutaneous electrical nerve

stimulation (TENS), acupuncture and biofeedback:

http://www.bfe.org/protocol/pro05eng.htm

Psychotherapy, hypnotherapy, and relaxation techniques


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Psychological reaction to amputation

Shock, self-pity, suicidal impulses

Fear for the future, anger, grief

Depression

Personality of the person determines the severity and duration of the

reactions to amputation

Post-surgical Treatment Objectives

Emotional supports, facilitate psychological adjustments

Instruct limb hygiene, wound healing care

Control edema and shaping of the stump

Elastic bandage, elastic shrinker

Removable rigid dressing

Immediate postoperative prosthesis

Early postoperative prosthesis

Desensitize the residual limb

Percussion or weight bearing

Tapping and rubbing, applying a vibrator

Wrapping

Massage is useful as a desensitizing technique

but is primarily used to prevent or release

adhesions and soften scar tissue

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Maintain and regain ROM

Strengthening of all remaining muscles

Increase one hand skill, independence in ADL

Discuss the prosthetic choice

Demonstrate the prostheses to help the patient establish realistic

expectations

Arrange a meeting with the patient and former patient with a similar

level of amputation

Choosing a myoelectrically controlled prosthesis

Conduct muscle site testing

Provide visual and auditory feedback for muscle reeducation training

Train the patient to control the intensity of the muscle contractions

and relaxation, and help him to isolate the contractions of different

muscle groups

Early Postsurgical Fitting of U/E Amputees

Within the first 30 days postsurgery

Strong recommend for bilateral amputation

Decrease rejection rate of U/E prosthetics

Encourage early use of bilateral activities with prosthesis

Control edema and accelerate stump shaping

Prevent or reduce phantom pain


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Early prosthetic training

Better psychological adaptation

Higher rates of return to work

Factors of Prescribing the Prosthesis

Patient's preferences for cosmesis and function

Life activities at work, home, and school

Physical attributes of the residual limb

Length of limb, ROM, strength, and skin integrity

Financial coverage for the prosthesis

Third-party payment

Patient's motivation and attitude

Patient's cognitive abilities to learn and grasp concepts of prosthetic

component controls


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U/E Amputation and Prosthetics (I)

Jyh-Jong Chang

Prosthetics Components (From Distal to Proximal)

Terminal devices (TD) : To grasp and hold the objects

Active prehensors: Hook and hand

Passive terminal devices: Hook and hand

Wrist units

Forearm component or sockets

Elbow units or hinges

Upper arm component or sockets

Shoulder units or hinges


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Prosthetic Control Choices

Body powered (BP)

Elbow and terminal device components are activated through body

motion (scapular and shoulder movement)

Harness and control cable for BE and AE

Externally powered


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Electrical motor: myoelectric and microswitch

The elbow and/or TD can be externally powered

Hybrid systems:a combination of body powered and electricallypowered controls

Passive, cosmetic: no active motion

Terminal Devices:Substitute for the

patients amputated hand

Hand : Thumb positioning, 2nd, 3rd

fingers move

Cosmetic hand

Functional hand

Electric hand

Hook

Voluntary opening

Voluntary closing

Hook is lighter and more functional than hand

Hand are cosmetic use and too large for prehension


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VO and VC Terminal Devices (Hand and Hook)

VC type

Pinch force is determinated by the patient

Pinch force is more precisely controlled

Better proprioceptive feedback

VO type

Maximal pull force to open TD and force is determinate by the rubber

bands (lb./band)

More cosmetic than VC type

Cosmetic Gloves

All prosthetic hands have rubberized coverings

Available in a variety of colors and sizes

These gloves cover mechanical, passive, and electric hands

Passive Cosmetic Hands

For some patients the hand not only is a functional tool but also possesses

expressive beauty

Patients will choose a passive cosmetic prosthesis when aesthetics is of

prime importance

Unilateral amputations, high-level amputations, or partial hand

amputations always make this choice

Available to replace a single digit or a total arm


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The Final Choices: Hooks or Hands ?

The hook is more functional as:Small items can be grasped with precision

Patient can view the items more easily while using a hook

Providing sensory feedbackIt weighs and costs less than the hand

It is more reliable and requires less maintenance than the hand

It can fit in close quarters

Many people prefer the Handwith cosmetically more appealing

TDs are chosen as mechanical hands especially in B/E amputation

Easily activated, greater pinch force, do not require aharness(external power)

Individual with bilateral amputations

The body powered hooks continue to be preferred

Some individuals will choose a different TD for each limb

A body powered hook for one side and a myoelectrically poweredhand for the contralateral side


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References:

1. Mary Vining Radomski, Catherine A. Trombly Latham. Occupational Therapy for physicalDysfunction. 6

thEd. Lippintcott Williams & Wilkins. 2007.

2. Lorraine Williams Pedretti, Mary Beth Early. Occupational TherapyPractice Skills forPhysical Dysfunction. 5

thEd. Mosby 2001

Documents

Introduction 20to 20amputation 20and 20rehabilitation 20care