Limb Pros the Tics

8/14/2019 Limb Pros the Tics

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What is the difference between a prosthesis and an orthosis?

A prosthesis is a device or an artificial substitute designed to replace, as much aspossible, the function or appearance of a missing limb or body part. An orthosis isa device designed to supplement or augment the function of an existing limb or

body part.

A prosthesis is often also referred to as a prosthetic device. Similarly, an orthosisis often referred to as an orthotic device.

What are some of the determinants of a successful outcome withprosthetic use?

The level of motivation of the individual should be assessed. Ideally discussionsabout prosthetic use should begin preoperatively and should involve the surgeon,physiatrist, prosthetist, and patient. Foremost, a prosthesis must be comfortable

to wear, easy to don (put on) and doff (take off), light weight and durable, andcosmetically pleasing. Furthermore, a prosthesis must function well mechanicallyand have reasonably low maintenance requirements.

What should be considered when choosing a prosthesis?

What is the amputation level?

What is the expected function of the prosthesis?

What is the cognitive function of the patient?

What is the patient's vocation (desk job vs manual laborer)?

What are the patient's avocational interests (ie, hobbies)?

What is the cosmetic importance of the prosthesis? What are the patient's financial resources (eg, medical insurance, worker's

compensation)?

What are the most common reasons for a lower extremity amputation?

In contrast to upper extremity amputations, which most commonly result fromtrauma in the young male population, most lower extremity amputations occur inindividuals older than 60 years because of complications of medical disease.Diabetes and peripheral vascular disease are the leading complications ofmedical disease requiring amputation, followed by thromboembolism and

vasculitis. Trauma is the second most common cause of lower extremityamputation and typically occurs in the young male population. Tumors andcongenital malformations less commonly result in lower extremity amputation.

What are the minimal functional requirements to fit a patient with a lowerextremity prosthesis?


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The patient must demonstrate sufficient trunk control, good upper body strength,static and dynamic balance, and adequate posture in order to be functionallysuccessful with a prosthesis. Once these basic requirements are met, thenstability, ease of movement, energy efficiency, and the appearance of a naturalgait are key elements to achieve with prosthetic use.

How long does an average prosthesis last?

Minor cosmetic modifications aside, prostheses can be expected to last at least 2years with standard daily use. Children may need much more frequentmodifications or adjustments as they grow.

Determination of functional level for Medicare patients

Centers for Medicare & Medicaid Services (CMS), formerly known as HealthCare Financing Administration (HCFA), requires a determination of functional

level with certificates of medical necessity for prostheses.

Level 0: Does not have the ability or potential to ambulate or transfer safely withor without assistance and a prosthesis does not enhance his/her quality of life ormobility.

Level 1: Has the ability or potential to use a prosthesis for transfers or ambulatingon level surfaces at fixed cadence. Typical of the limited and unlimited householdambulator.

Level 2: Has the ability or potential for ambulating with the ability to traverse

environmental barriers such as curbs, stairs, or uneven surfaces. Typical of thelimited community ambulator.

Level 3: Has the ability or potential for ambulating with variable cadence. Typicalof the community ambulator who has the ability to traverse most environmentalbarriers and may have vocational, therapeutic, or exercise activity that demandsprosthetic utilization beyond simple locomotion.

Level 4: Has the ability or potential for prosthetic ambulating that exceeds basicambulating skills, exhibiting high impact, stress, or energy levels. Typical of theprosthetic demands of the child, active adult, or athlete.


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What are the most common reasons for a lower extremity amputation?

In contrast to upper extremity amputations, which most commonly result fromtrauma in the young male population, most lower extremity amputations occur inindividuals older than 60 years because of complications of medical disease.

Diabetes and peripheral vascular disease are the leading complications ofmedical disease requiring amputation, followed by thromboembolism andvasculitis. Trauma is the second most common cause of lower extremityamputation and typically occurs in the young male population. Tumors andcongenital malformations less commonly result in lower extremity amputation.

What are the minimal functional requirements to fit a patient with a lowerextremity prosthesis?

The patient must demonstrate sufficient trunk control, good upper body strength,static and dynamic balance, and adequate posture in order to be functionally

successful with a prosthesis. Once these basic requirements are met, thenstability, ease of movement, energy efficiency, and the appearance of a naturalgait are key elements to achieve with prosthetic use.

How long does an average prosthesis last?

Minor cosmetic modifications aside, prostheses can be expected to last at least 2years with standard daily use. Children may need much more frequentmodifications or adjustments as they grow.

Determination of functional level for Medicare patients

Centers for Medicare & Medicaid Services (CMS), formerly known as HealthCare Financing Administration (HCFA), requires a determination of functionallevel with certificates of medical necessity for prostheses.

Level 0: Does not have the ability or potential to ambulate or transfer safely withor without assistance and a prosthesis does not enhance his/her quality of life ormobility.

Level 1: Has the ability or potential to use a prosthesis for transfers or ambulatingon level surfaces at fixed cadence. Typical of the limited and unlimited household

ambulator.

Level 2: Has the ability or potential for ambulating with the ability to traverseenvironmental barriers such as curbs, stairs, or uneven surfaces. Typical of thelimited community ambulator.

Level 3: Has the ability or potential for ambulating with variable cadence. Typicalof the community ambulator who has the ability to traverse most environmental


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barriers and may have vocational, therapeutic, or exercise activity that demandsprosthetic utilization beyond simple locomotion.

Level 4: Has the ability or potential for prosthetic ambulating that exceeds basicambulating skills, exhibiting high impact, stress, or energy levels. Typical of the

prosthetic demands of the child, active adult, or athlete.

Preamputation

Since most lower extremity amputations are the result of disease and are tosome extent preplanned, the rehabilitation team often is able to meet with thepatient prior to surgery. During this time, an assessment of the patient'spostoperative needs and desires can be made, and range of motion (ROM)exercises, strengthening, and activities of daily living (ADL) training can beinitiated. The rehabilitation team typically consists of a physiatrist (a physicianwho specializes in physical medicine and rehabilitation), an occupational

therapist, a physical therapist, a prosthetist, a recreational therapist, and a casemanager/social worker.

Surgical procedure

During the amputation surgery, several actions can be taken to maximize thefunction of the residual limb. These actions include 1) beveling the bone end, 2)sharply transecting the nerve to decrease the likelihood of neuroma formation,and 3) positioning the wound edges to avoid bony prominences at the far distalend of the residual limb.

Acute postsurgery

The major issues in this phase are adequate wound healing; pain management;and physical and occupational therapy to train the patient to perform ADL,mobility, ROM, and strength. During this time, initiate a program to prepare theresidual limb for the prosthesis. A skin desensitization program consists of (1)gentle tapping on the distal portion of residual limb to mature the site, (2)massage to prevent excessive scar formation, and (3) edema control with acewraps or a residual limb (stump) shrinker.

Prosthetic fitting and testing

When the suture line has completely healed, fitting for the prosthesis can begin.The prosthesis must be individually fitted to the patient.

Prostheses are described at this stage as either preparatory or definitive. Thepreparatory prosthesis is fitted while the residual limb is still remolding. Thisallows the patient to commence the rehabilitation program of donning anddoffing, transfer training, building wear tolerance, obtaining balance and


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ambulating with the prosthesis several weeks earlier in the process. Apreparatory prosthesis often allows a better fit in the final prosthesis as thepreparatory socket can be used to mold the residual limb into the desired shape.

Sometimes a preparatory prosthesis is not feasible because of financial

considerations. In this case, the patient can only be fitted for the definitive (final)prosthesis. If the patient is being fitted for a final prosthesis without ever having apreparatory prosthesis, delay fitting for the socket until the residual limb is fullymature (usually 34 mo) or until general stabilization occurs in the patient'sweight and stump circumference

Initially, teach the patient the basics of prosthetics care, including how to don anddoff the prosthesis, how to inspect the residual limb for signs of skin breakdown(should be completed daily), and how to perform safe transfers (moving from oneposition or surface to another). Then, shift emphasis to weight bearing with theprosthesis. Finally, address ambulation on level surfaces with a walker or other

assistive device. Once the patient has mastered these skills, begin training onstairs, uneven surfaces, and ramps/inclines. The end goal is for the patient tosafely ambulate on all usual surfaces without adaptive equipment. Weightbearing

An individual with a lower extremity amputation must bear full body weight on softtissues not designed for that function. The socket must be designed such thatthese forces are distributed as much as possible and as evenly as possible overpressure-tolerant areas. These include the patellar tendon, the pretibial muscles,the residual posterior muscles, the medial flare of the tibia, and the lateral fibula.The presence of ongoing pain, skin breakdown, change in the ability to don and

doff the prosthesis, and change in the number of sock plies indicates that theprosthesis needs to be modified. Erythema normally appears within a fewminutes after removing the prosthesis and should fade quickly. Erythema that ispresent upon removing the prosthesis or that does not completely resolve within20 minutes is particularly worrisome.

Phantom pain versus phantom sensation versus postoperative pain

In addition to the usual postoperative pain, most individuals with amputationexperience phantom sensation. Phantom sensation is the perceived sense thatthe amputated limb or part of it is still present. Phantom sensation is not painful,

and the patient usually just needs to be reassured that this sensation is verycommon and that they are not crazy. The phenomenon of telescoping canaccompany phantom sensation. This is the sensation that the amputated limbhas shrunk (eg, the toes are at the ankle, the foot is at the knee). Telescoping isnormal and usually fades without sequelae.

Phantom pain is the sensation of pain originating in the amputated part. Phantompain may or may not be dermatomal in nature. Individuals describe a burning,


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stinging, or cramping pain, or they describe the feeling that the missing body partis positioned awkwardly or painfully. The pain usually is most intense right afterthe amputation and resolves with time, although some patients can stillexperience phantom pain years after the amputation. The pain is usually worseat night, after the extremity has been in a dependent position, and can be

worsened by anxiety and stress. Unlike postsurgical pain, which responds well toopioids such as Percocet or Lortab, phantom pain is best treated with low dosesof tricyclic antidepressants (eg, Amitriptyline 10 mg PO qhs) or anticonvulsants(eg, Neurontin 300 mg PO qhs).

Choke syndrome

When the proximal part of the socket has too snug a fit on the residual limb,venous outflow can be obstructed. When this is combined with an empty spacemore distally in the socket, swelling can occur until that empty space is filled. Inan acute choke situation, the skin is red and indurated and may have an orange-

peel appearance with prominent skin pores. If the constriction is not resolved,then chronic skin changes with hemosiderin deposits and venous stasis ulcerscan develop.

Dermatologic problems

Common skin management issues include contact dermatitis, sebaceous cysts,scar management, and excessive sweating. The liner, socks, and suspensionmechanism are the usual culprits for contact dermatitis. The socket is a lesslikely cause. Treatment is identification and removal of the offending item andsymptomatic treatment with topical Benadryl or cortisone creams. Cysts and

sweating can be a sign of excessive shear forces and components that areimproperly fitted. Scar management is focused on massaging and lubricating thescar to obtain a well-healed result without dog ears or adhesions.

The increase in energy requirements can be the limiting factor in ambulation. Anindividual who has a lower extremity amputation and requires a walker orcrutches to ambulate uses 65% more energy than someone with a normal gait.Increased levels of energy consumption (percentage above normal) byamputation level are as follows:

Below knee unilateral amputation - 10-20%

Below knee bilateral amputation - 20-40% Above knee unilateral amputation - 60-70%

Above knee bilateral amputation - >200%

Energy consumption is actually less with a BKA than ambulating with crutches.However, ambulating with an AKA requires more energy, which makes thecardiopulmonary status of the patient more significant.


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Caption: Picture 1. Lower limb prosthetics. Below knee endoskeletal prosthesis withpatellar tendon bearing socket with Pelite liner, supracondylar cuff strap suspension,SACH foot (anterior view).

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Caption: Picture 2. Lower limb prosthetics. Below knee endoskeletal prosthesis with

patellar tendon bearing socket with Pelite liner, supracondylar cuff strap suspension,SACH foot (oblique view).



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Caption: Picture 3. Lower limb prosthetics. Below knee endoskeletal prosthesis withpatellar tendon bearing socket with Pelite liner, supracondylar cuff strap suspension,SACH foot (lateral view).



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Caption: Picture 4. Lower limb prosthetics. Left above knee prosthesis with ischial
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containment socket, TES (total elastic suspension) belt, single axis knee withextension assist, endoskeletal components, energy storing foot (anterior view).



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Caption: Picture 5. Lower limb prosthetics. Left above knee prosthesis with ischialcontainment socket, TES (total elastic suspension) belt, single axis knee with

extension assist, endoskeletal components, energy storing foot (lateral view withflexed knee).



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Caption: Picture 6. Lower limb prosthetics. Left above knee prosthesis withquadrilateral socket, hip joint and pelvic band suspension, endoskeletal componentswith cosmetic foam cover and hose, single axis knee, energy storing foot (close-upof socket and suspension system).


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Caption: Picture 7. Lower limb prosthetics. Silicone gel locking liner (front view).



Picture Type: PhotoCaption: Picture 8. Lower limb prosthetics. Silicone gel locking liner (posterior viewwith turned down cuff to expose inner surface).



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Caption: Picture 9. Lower limb prosthetics. Silicone gel locking liner on below kneeprosthesis model (lateral view - bulge would be patient's patella).



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Caption: Picture 10. Lower limb prosthetics. Left to Right: SACH (single axiscomposite heel) foot, Seattle light foot (energy storing foot with Delrin keel), CarbonCopy II (energy storing foot with carbon keel).
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Caption: Picture 11. Lower limb prosthetics. Seattle Light Foot (energy storing footwith Delrin keel). Note space between 1st and 2nd toe, which allows patient to weartoe strap sandals.



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Colwell MO, Spires MC: Lower extremity prosthesis and rehabilitation. In:

Grabois M, ed. Physical Medicine and Rehabilitation: The CompleteApproach. 2000: 583-607.

Glennon TP, Smith BS: Amputations. In: Garrison SJ, ed. Handbook of

Physical Medicine and Rehabilitation Basics. 1995: 34-60. Leonard JA Jr, Meier RH III: Upper and lower extremity prosthetics. In:

DeLisa JA, ed. Rehabilitation Medicine: Principles and Practice. 1998:669-696.

Tan JC: Prostheses. In: Practical Manual of Physical Medicine and

Rehabilitation. 1998: 229-259.
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Limb Pros the Tics

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