Physiotherapy management

Transcription

1 Physiotherapy management

2 Pre-operative Focus is on the objective assessment looking at ROM and muscle power. Using assessment findings, knowledge of prosthetic componentry and gait patterns, provide a clinically reasoned recommended level of amputation to the consultant. Provide patient with appropriate exercises to aid post-amputation mobility.

3 Pre Surgery Teach post amputation exercises..prone lying, limb abduction, hip extension, static quads contraction Do s and Don ts contracture prevention Educate patient about phantom pain and the difference between stump and phantom pain Inform about the bandaging routine and why Fit the patient with mobility aids (axillary crutches usually the best), train him to use them, including negotiating stairs safely Be careful when talking about prosthetic options not all patients qualify, do not raise expectations But if appropriate, educate patient about their likely prosthetic option and functional capacity post amputation

4 Pre Surgery cont. Family members likely to be present and have views about amputation Try to educate them, the patient, not the family should make the decision Describe the likely functional activity level post amputation Check on home and social situation wheelchair / crutches access and former occupation If patient a smoker explain the risks and teach DB&C. (Surgeon will reinforce healing consequences of smoking.)

5 Post Surgery Day 1 Check on pain level, patient will be heavily medicated. Start static exercises, then active hip abd / add, flex / ext with PT supporting and guiding the stump. Hip extension in side lying if prone lying too painful (depends on wound location and bandaging). Position of stump in bed minimize stump / hip flexion, remove pillows if placed under stump For TT a knee extension slab may be ordered by surgeon If patient alert commence moving in the bed, S to S rolling, bridging, abduction of stump If patient alert and vital signs good you can assist patient to sit over the edge of the bed (SOOB).

6 Day 2 time to mobilise Stump exercises in bed with PT guidance. Stronger bridging exercise. SOOB. If no dizziness after 2 mins you can try a supported stand on sound limb, beside the bed in walking frame or crutches. PT must monitor patient closely and be positioned to support patient if they faint (anaesthetic and pain medications can cause nausea and hypotension, do not walk the patient if drowsy, dizzy or nauseated) Commence stump exercises in standing if patient condition allows. Gentle walking in high frame, or on crutches depending on age, strength and medical status. Important to mobilise early, if possible, to prevent muscle wasting and respiratory complications. Close monitoring by PT to prevent patient falling. Patient to mobilise generally in a wheelchair with knee extension board (or crutch) under the TT stump to prevent constant knee flexion

7 Day 3 to Discharge Patient should be mobilizing on crutches (or in wheelchair if crutches not possible due to complications, age, weight etc). If slow on crutches assist to walk daily in a walking frame Patient should lie prone 30 mins twice daily to prevent iliopsoas tightening Stump should be bandaged and positioned in the neutral position, not in flexion or abduction Patient to do stump exercises, at least twice daily Day 7 10 stitches removed and compressive stump bandaging should begin

8 Pain Differentiate between stump and phantom pain Inform Dr. if phantom pain present (different medications helpful) Stump pain will subside over first week, tenderness over the scar area will continue for some weeks Scar desensitization program may begin after suture removal (5 mins daily gentle massage with soft substance (cotton wool then gauze, then progress to rougher material), then 5 mins gentle tapping over distal end of stump with fingers, the process can take several weeks

9 Compressive Bandaging Commences post surgery, usually after suture removal. Should continue until fitting of the prosthesis. Patient should learn to do himself before discharge. Otherwise the carer should be trained. Surgeon and Nursing staff will monitor wound healing in hospital. PT to monitor any wound changes during Rehabilitation. Be aware of suture location and prevent pressure on or stretching of the suture line with the early post op exercises Stump volume can take 4 6 months to stabilize Stump socks may replace bandages in some countries

10 Why Bandage.? Helps shape the stump for prosthesis Decreases oedema (to test for oedema press your finger tip against the swelling for 1 min. Remove finger, if dimple remains = oedema). Increases distal circulation (by decreasing venous stasis) Provides skin protection In some cases a rigid bandage or POP caste may be applied post surgery for several weeks

11 Bandaging TT 11

12 Bandaging TF 12

13 Immediate post-operative prosthetic fitting It can be done especially for children The main aims are: Control of pain. Prevention of edema. Prevention of infection. Prevention of deformity/ stiffness. Prevention of DVT. Improving muscle power. Psychological confidence.

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15 Stump Hygiene Cannot be overemphasized with patient Wash stump with soap and water daily (preferably at night) Ensure bandages are clean and dry Check skin condition daily The smallest wound / infection can be a big problem and delay wearing a prosthesis Keep stump dry, change bandages more often than daily if required

16 Psychology Patient may be depressed, think their previous life is over, tendency to hide from the world Immediately post surgery may refuse to look at or touch the stump. PT s job to address this. Then to keep them busy with exercises and focused on their training program, looking ahead Good to bring them to Rehab setting ASAP to meet and observe other amputees Use the wheelchair / crutches to re-engage with outside world. Educate carers to support the patient but also encourage independence.

17 Discharge Home Program Stump massage twice daily (5 mins per session) 2 X daily prone lying (30 mins) Stump exercises Hip / stump extension (prone), stump abduction (prone or sidelying) Knee extension (TT) in supine or sitting, 3 X 10 reps then build to a full straight leg raise Bridging on the stump (supported by firm cushion or towell) Upper limb strengthening (push up, arm or wheelchair lift, hand weights (biceps / triceps / shoulder girdle), trunk / abdominal strengthening Independent with transfers and toileting, if possible Mobilising on crutches +++, safely and on all terrain

18 Challenging Home Environment Refugees or vulnerable persons returning to refugee camp like conditions must be proficient on crutches or be given a wheelchair. Camps are placed on uneven, muddy (even flooded) ground, with few safe walking tracks, latrines located a long distance from tent, no supports in place in the latrine area Emphasize the importance of the daily stump wash with soap and water, and good drying. Stump bandages need to be cleaned regularly also. Exercises can all be done on simple mat on dry ground. Encourage patient to exercise and strengthen +++

19 POSITIONING ADVICE TO PATIENT

20 POSITIONING

21 POSITIONING To roll prone the client must turn towards the sound side, the PT ensuring that the stump is lowered gently. At first the client lies prone for 10 min only. The amputee should then build up to lying prone for 30 min 3 times a day.

22 POSITIONING

23 TRANSFERS / bed-chair Transfer method n 1: standing pivot transfer (patient must participate as much as possible).

24 TRANSFERS / bed-chair Transfer method n 2: backwards forwards transfer

25 TRANSFERS / bed-chair Transfer method n 3: sliding board transfer

26 Falls Prevention Transfers: Floor to Chair Good transfer technique (don t rush) Carers who are trained by the PT Sliding board helpful for TF or bilateral amputees Identify high fall risk patients and adjust their mobility program, aides and carer instructions accordingly

27 Whilst at Home Minimum 3 months required from amputation to prosthetic screening appointment, in best case scenario. Allow more time for complex cases (infections, other injuries, systemic disease) Patient should continue Home Program (2 hours work per day) in the meantime. Very important patient is mobilizing throughout day and not remaining in wheelchair or bed. Body deconditioning a major limitation for prosthetic use and outcomes

28 Preparing the stump for weight bearing After 3 months Push the end of the stump in the cushion of a chair. Push for 5 seconds and release the pressure. Repeat the procedure 20 times and several times a day.

29 Screening : Ready for a Prosthesis? No hip flexion contracture present (or at least <10 degrees) Stump volume is stable Muscle strength 4 5 (preferably 5) Balance good, able to stand on sound leg for 1 min Able to walk with mobility aid for 10 mins Energy requirements: TT - > 60 %, TF - > 120 %, Hip Disart - > 200 %

30 If not ready then more physiotherapy! Stump bandaging Intensive exercise and stretching (also passive) Intensive balance work Intensive upper limb work NB: All bilateral amputees should be issued with a wheelchair Some unilateral amputees will also need one, but guard against wheelchair dependence

31 Fitting Considerations Patient Age - the energy cost of a prosthesis may be too high for a patient over 50 in poor health Health diabetes and vascular disease may be too advanced to manage the energy and balance requirement Post op morbidity of amputation patients over 65 very high (especially with diabetes and PVD) Weight of prosthesis the lighter the prosthesis the lower the energy cost (ICRC components are light) Note: energy cost of using crutches is higher than that of a TF amputation

32 Pre-prosthetic rehabilitation???

33 Purpose of pre- prosthetic rehabilitation Physical and psychological recovery from the surgical intervention. Preparation of the body for the prosthesis. Mental preparation for a life with a prosthesis. 33

34 Aim of physiotherapy Reduce swelling. Prevent contractures. Manage pain, decreasing residual limb pain (also known as phantom pain ). Prepare people with amputations for the use of a prosthesis. 34

35 3) Pre- prosthetic training Loss of part of the body causes a change in the position of centre of gravity. Balance is disrupted and it takes time and effort to regain good control. Pre-prosthetic training influence the recovery of adequate coordination. Prepares for prosthetic rehabilitation. 35

36 3) Pre- prosthetic training Strengthening exercises ROM exercises Stretching exercises, Balance and coordination, Functional activities. 36

37 Strengthening exercises Strengthening exercises are important to enable people with amputations to get the skills needed for transfer, functional skills and ambulation. The type of strengthening exercise depend on individual muscular strength and endurance, the level of independence, access to equipment, time constraints, safety. The most usual techniques employed are: isometric strengthening; manual resistance strengthening; and concentric strengthening. The exercises should focus on the muscles of the amputated leg, the sound leg, the upper extremities and the muscles of the trunk. 37

38 Range of motion and stretching exercises Must be specific and target the adequate muscles. Movements should be slow, soft and held over time. Manual stretching passive joint mobilization passive or self-stretching contract-relax stretching 38

39 Balance Use a variety of exercises in lying, sitting and standing positions. It is important for patients to exercise in a safe environment and avoid falling (parallel bars, hand control, soft mattress). 39

40 Functional activities The greater the degree of mobility and activity gained by persons with amputations without a prosthesis, the greater the functional result with the prosthesis will likely be. Rehabilitation should also consist of a well-defined home program of exercises and exposure to activities of daily life within their usual context. 40

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51 Prosthetic prescription Physiotherapist may be needed to assist in the cast appointment, to ensure a neutral alignment of the pelvis is obtained. Physiotherapy provides intervention on mobility guidance, static balance and weight bearing

52 Basically we can make 3 groups: Ready for fitting Preparation required for fitting Can not be fitted

53 Category one Yes, service user is ready for fitting: No oedema, No contracture, Free scar, No wound, No muscle weakness, General condition is good. 53

54 Category two Yes, service user is ready for fitting but pre fitting therapy is needed: Oedema, Contracture, Adherent scar, Wound, Bad hygiene, Neuroma, Bone spur, Muscle weakness. 54

55 Category three Prosthesis is technically not possible Service user is not in condition to be fitted Service user is not willing to be fitted

56 Prosthetic Training The physiotherapist takes a lead role at this stage. Beginning with educating the patient about donning and doffing the prosthesis, skin integrity and weight bearing areas on their residuum. A gait rehabilitation programme can then commence.

57 The first fitting process A continuous process of interaction between the patient, the prosthetist and the physiotherapist. Evaluations are made throughout this process to prevent, detect and correct unfavorable outcomes that might have developed (socket design/alignment). 57

58 The aim of the first fitting To reduce to a minimum the gait deviations seen as a result of the prosthetic construction (socket design/bench alignment). 58

59 The role of the physiotherapist Explain the aim and the outline of the fitting process to the person with an amputation Re-examine the person Re-examine the stump Check the prosthesis prescription Inspect the prosthesis 59

60 Fitting a prosthesis 1) Prescription and design 2) Footwear 3) Bench alignment 4) Static alignment, sitting and standing 5) Doffing- removing the prosthesis 60

61 Prosthetic training Orientation of Centre of Gravity and Weight Bearing on the Prosthesis Lateral weight shifting Forward and back weight shifting High stepping Balance board Throwing and catching Obstacle stepping Single leg standing Gait Re-Education

62 Prosthetic training Backward walking Multidirectional changes Tandem walking Stairs Slopes/hills Weight carrying Uneven surfaces Cycling Treadmill Trampoline

63 Discharge Management The physiotherapist should ensure that they include education for ongoing management, strategies for coping and training for resumption of functional activities.

64 Follow up The consultant and/or prosthetist may ask for physiotherapy input. For example if the patient is having a change of prescription, their goals have changed, their mobility has decreased/increased. The physiotherapist may be required to re-commence a gait rehabilitation programme with the patient or advice only may be required

65 Thank you