Mobility & Wound Healing a2er Trauma6c Amputa6on. David Jones PT, CWS Duke University Medical Center Department of Physical and Occupa6onal Therapy

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1 Mobility & Wound Healing a2er Trauma6c Amputa6on David Jones PT, CWS Duke University Medical Center Department of Physical and Occupa6onal Therapy

2 Objec6ves Discuss the physical therapist s role during acute care of pa6ents of trauma6c limb loss Elaborate on rehab to improve the pa6ent s strength, mobility, and overall func6oning. Describe residual limb wound care and poten6al healing complica6ons Explain biofilm and its impact on healing State the ra6onale and importance for wound debridement Review two pa6ents with trauma6c amputa6ons where PT Wound Care was involved

3 Acute Care Physical Therapy for the Trauma6c Amputee Educa6on Posi6oning Balance Re- Educa6on Safety Awareness and Fall Preven6on Exercise Mobility Wound Care Issues

4 Trea6ng the Whole Pa6ent Tremendous amount of stress associated with trauma6c amputa6on Frequently limited from other injuries Remember pa6ents grieving from the loss of their limb, a change in body image, and the impact it will have on their future O2en feelings of helplessness or dependency Much of the therapist s role is to restore control back to the pa6ent

5 Educa6on An investment in knowledge pays the best interest Benjamin Franklin Educate early with emphasis on mobility, strengthening, maintaining ROM, and pt s current and future poten6al If PT is not involved in the pt s care, please consult for pre- op assessment, educa6on, and prehab

6 Posi6oning Contractures (tendon shortening) may develop due to improper posi6oning in bed or prolonged flexed postures Trans- 6bial amputee: at risk for contractures of hip and knee flexors (Esquenazi A, DiGiacomo R 2001) Trans- femoral amputee: at risk for contractures of the hip flexors, abductors, and external rotators (Esquenazi A, DiGiacomo R 2001) Proper posi6oning prevents contractures

7 Posi6oning Encourage bouts of minutes lying supine When possible, prone for a prolonged stretch of pt s hip and knee flexors Once 48 hours post- op, limit eleva6on of residual limb on pillows If knee immobilizer used, always cut out the patella region to avoid skin damage

8 Posi6oning Image courtesy of the Digital Resource Founda6on for the Ortho6cs and Prosthe6cs Community

9 Balance There can be up to an 18.7% loss in body weight for an en6re leg (Na6onal Amputee Centre) This causes the center of gravity to shi2 up, back and toward the remaining limb During acute phase, pa6ents are taught to lean over their sound limb Later, a2er a prosthesis weight is encouraged through the residual limb to restore proper center of gravity

10 Safety Awareness and Fall Preven6on One in five persons with lower limb amputa6on experience a fall during inpa6ent rehabilita6on, with 18% sustaining an injury (Pauley T, Devlin M, Heslin K 2006) Other fall risk factors: age >71 years, extended inpa6ent rehab or hospital stay (>3 weeks), four or more significant comorbidi6es, cogni6ve impairment, and use of benzodiazepines or opiates (Pauley T, Devlin M, Heslin K 2006) Consider rigid removable dressing for limb protec6on

11 Exercise Four areas of focus: flexibility, muscle strengthening, cardiovascular training, and balance (contr/exer ref) Stretching: sustained passive to maintain ROM Isometrics: quad sets and glut sets Supine hip/knee flexion, hip abd/adduc6on, hip internal/external rota6on Progress to sidelying abduc6on, bridging, and eventual seated push- ups (dips) using arms

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13 Exercise Theraband exercises: focus on upper extremi6es esp. triceps and lalsimus Balance: core strengthening & ac6vi6es to challenge the pt. in silng (reaching ac6vi6es) Core leads to significant improvements in balance and single- limb stability W/C mobility or upper bike ergometer

14 Mobility Early mobility has been shown to improve func6onal outcomes, foster independence, decrease mortality rates, and reduce acute care length of stay for the person a2er LE amputa6on (Marzen- Groller KD, Tremblay SM, Kaszuba J, et al 2008) Mul6ple nega6ves with immobility including atrophy and bone loss (Muller EA. 1970; Uhtoff HK, Jaworski, ZF. 1978)

15 Mobility Progression Edge of bed Standing EOB then pivot out of bed as able Sliding Board Transfers Anterior- Posterior Transfer Technique pt assumes long silng posi6on and backs to chair or w/c locked perpendicular to bed Wheelchair Skills Gait as pa6ent able

16 Anterior- Posterior Transfer Image courtesy of the Digital Resource Founda6on for the Ortho6cs and Prosthe6cs Community

17 Anterior- Posterior Transfer

18 Wound Care Considera6ons Frequently inspect the pt s incision Should expect incisional drainage Important to protect intact skin from breakdown from macera6on Consider use of silicone barrier spray as moisture barrier Also there are numerous hydrophilic foams Important to reduce limb edema reduc6on (shrinker sock) Edema reduc6on enhances incisional healing, reduces pain, reduces phantom sensa6on, and prepares the limb for a prosthesis by shaping and desen6za6on (Hess C 2005; Scanlon E 2004)

19 When the incision doesn t heal? It s important to understand there is a difference between acute and chronic wound healing Chronic wounds do not undergo healing in an orderly process (Kane DP, 2007; Cook H, Davies KJ, Harding KG et al 2000) Pathology in chronic wounds: higher levels of inflammatory cytokines and proteases (protein ea6ng enzymes) and lower level of growth factors (Schultz, Gregory PhD, Sibbald, Gary R MD March 2003; Gardner SE, Frantz RA, Troia C, et al 2001)

20 Acute Wound Vs. Chronic Wound Wound bed preparation: a systematic approach to wound management. Wound Repair and Regeneration. pages S1-S28, 26 MAR 2003 DOI: /j X.11.s2.1.x