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23/03/2017
1
Acute Amputee Physiotherapy
Management
Kate Primett
Clinical Lead Amputee and Vascular Rehabilitation (BSc, PGc, MCSP, MBACPAR )
Royal Free London NHS Foundation Trust
27/03/2017
Content
Causes/ levels of AmputationCauses/ levels of Amputation
Amputation surgeryAmputation surgery
Pre-operative therapy Pre-operative therapy
Post operative therapy Post operative therapy
Amputee Therapy GuidelinesAmputee Therapy Guidelines
Causes of Amputation
5000-6000 major LLA/yr
70,000 in UK
5000-6000 major LLA/yr
70,000 in UK
Diabetes MellitusDiabetes Mellitus
TraumaTrauma
TumourTumour
Vascular DiseaseVascular Disease
InfectionInfection
CongenitalCongenital
(NCEPOD 2014)
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Levels of UL and LL Amputation
Amputation
Level
Lower Limb
Percentage Amputation
Level
Upper Limb
Percentage
Partial foot 1.5 Partial Hand 22
Transtibial 53 Wrist
Disarticulation
3
Knee
Disarticulation
3 Trans-radial 40
Transfemoral 41 Trans- humeral 30
Hip
Disarticulation
1 Shoulder
Disarticulation
5
Hemi
Pelvectomy
0.5
% Levels of UL and LL Amputation
www.limbless-statistics.org (2011/2012)
Myodesis
muscles are anchored to the end of the bone
Myoplasty
muscles are attached to the opposing group
Amputation Surgical Terminology
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• A Skew flap
• B Equal A-P
• C Equal M-L
• D Long Post. Flap
Surgical Closure of Trans Tibial Amputations
Physiotherapy Pre-Operative
Management
“All patients admitted electively for lower limb amputation should be seen in a pre-assessment clinic to optimise medical co-
morbidities and to plan post operative rehabilitation”.
(NCEPOD, 2014)
Pre-Operative Subjective Assessment
MDT Communication
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Pre-Op Subjective Assessment
Social Situation
Social Situation
Marital Status /
Dependants(age)
Marital Status /
Dependants(age)
POCPOC
ADL’s / PADL’sADL’s / PADL’s
HousingHousing
OccupationOccupation
Hobbies / Driver
Hobbies / Driver
Alcohol / Smoker / Drug Use
Alcohol / Smoker / Drug Use
MobilityMobility
Pre –op Subjective Assessment
Discuss stages/ expectations of Rehabilitation
• Gage what the patient is thinking - Goals
• Explain Immediate post-op rehab
• Exercise programme
• Day 1 post-op review.
• Physio gym asap
• Review discharge needs
• OT - access visit/ wheelchair referral
Pre-operative Objective Assessment
Bed mobility
Bed mobility
Joint AROMJoint
AROMMobilityMobility
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Physiotherapy Post – Operative
Management
It all begins first day Post Op – No lying
about!
“Post operative physiotherapy should commence
on the first day where possible and should
include exercise, oedema management and use
of early walking aids as appropriate.”
(NCEPOD 2014)
BACPAR guidelines
(Pre and Post Op Mgmt – 2006)
Good Communication Is Essential
The MDT
Local PhysioLocal PhysioSocial WorkerSocial WorkerPain TeamPain Team
Prosthetic PhysioProsthetic Physio
Occupational
Therapist
Occupational
Therapist
Rehab
Consultant
Rehab
Consultant
CounsellorCounsellor
ProsthetistProsthetistWheelchair
Service
Wheelchair
Service
DieticianDietician
Diabetic Foot
Clinic/ Podiatry
Diabetic Foot
Clinic/ Podiatry
Surgical TeamSurgical Team
NurseNurse
PATIENTPATIENT
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Monitor and
reduce
dressings
Monitor and
reduce
dressings
Bandages/ drain
removal 1-3 days
post – op
Bandages/ drain
removal 1-3 days
post – op
Pain ControlPain Control
Anticoagulation
levels and return
to normal
medication
Anticoagulation
levels and return
to normal
medication
Stitches
removed ~ 10 –
14 days
Stitches
removed ~ 10 –
14 days
Medical &
Nursing
Medical &
Nursing
Encourage gradual independence
on the ward eg. Transfers, washing
and toileting
Post Operative Management & MDT Roles
Acute Post Op Physiotherapy Management
ReassuranceReassurance
Respiratory
Care
Respiratory
Care
Maintaining
ROM/Posture
Maintaining
ROM/Posture
Prevent
contractures
Prevent
contractures
StrengtheningStrengthening
Oedema
Control
Oedema
Control
Improving
Mobility
Improving
Mobility
Residual limb
care
Residual limb
care
Education/Health
Promotion
Education/Health
Promotion
Falls
prevention
Falls
prevention
Wheelchair
use
Wheelchair
use
Goal settingGoal setting
Timetabling
Inpatient
Activity
Timetabling
Inpatient
Activity
Say What You See!
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AKA – Prevent
Hip flex/ abd
contracture
BKA – Maintain
full knee
extension
Assess all UL/LL joints
Adequate Analgesia
Positioning
Education Stretching
PNF/ Manual therapy
Splinting
Positioning – Prevention of Contractures
Psychological impact (immediate or delayed)
Normalising altered body image
• Residual limb handling
• Moving the residual limb
• Use of appropriate language
• Visual feedback
• Support Group/ Limbless
Association
Reassurance / Acceptance of new body image
Pain / Phantom Limb pain or Sensations
EducationEducation
Adequate Pain ReliefAdequate Pain Relief
Self Management:
Massage/Residual Limb Handling
Self Management:
Massage/Residual Limb Handling
AcupunctureAcupuncture
TENSTENSGraded Motor
ImageryGraded Motor
Imagery
Mind – Body InterventionsMind – Body Interventions
ReassuranceReassurance
ExerciseExercise
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Phantom Limb Pain Evidence• Davies, A (2013)• Case study: PLP post above elbow amputation. Benefit for use of short acupuncture
sessions
• Mortimer et al (2002), • Well-conducted qualitative study, using focus groups. Patients need accurate and
timely information about phantom limb pain, and this should be provided by individuals with appropriate knowledge and training.
• Mulvey et al. (2012)• Pilot study: 10 TTA. Tens reduced pain at rest and on mvmt when TENS sensation was
projected into the main site of pain which was either the phantom limb or stump.
• Moseley, G. (2006)• RCT. 51 PLP or CRPS randomly allocated to 2/52 GMI or to PT and function. GMI
reduced pain and disability.
• Clark et al. (2012)• Customised postal questionnaire. 102 responses. 85.6%
prevalence of PLP. No significant difference between DM and control group.
• Moura et al (2012)• Literature review. Only studies of hypnosis, imagery and
biofeedback were found. Studies on meditation, yoga and tai chi were missing. Mind-body approach to PLP is promising
Residual Limb Oedema Control
Management
Rigid Dressings
Compression socks
W/c stump boards
Active exercises
EWA
Prosthetic limb use
Elevation
Medication
Management
Rigid Dressings
Compression socks
W/c stump boards
Active exercises
EWA
Prosthetic limb use
Elevation
Medication
Bed Mobility / Transfers
Transfer Day One Post OpTransfer Day One Post Op
HoistHoist
Slide BoardSlide Board
Forward/BackwardForward/Backward
Pivot (With/Without side panel)Pivot (With/Without side panel)
On/Off FloorOn/Off Floor
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Exercises
Mobility
Assess Standing BalanceAssess Standing Balance
EWA - PPam aid/ FemurettEWA - PPam aid/ Femurett
Stair AssessmentStair Assessment
Prosthetic mobility (early mobilisation
– VanRoss – 2009)
Prosthetic mobility (early mobilisation
– VanRoss – 2009)
Wheelchair mobilityWheelchair mobility
Benefits of early walking aids
Regain Mid LineRegain Mid LineIncrease exercise
tolIncrease exercise
tol
Improve joint ROM and m/s
strength
Improve joint ROM and m/s
strength
Reduce stump volumeReduce stump volume PsychologicalPsychologicalAssess
prosthetic suitability
Assess prosthetic suitability
Skin Preparation
Skin Preparation
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PPAM Aid – Adv/ DisadvAdvantages
Easy to use
Quick to donn
Cheap
De-sensitises stump
Reduces volume
Advantages
Easy to use
Quick to donn
Cheap
De-sensitises stump
Reduces volume
Disadvantages
Poor aesthetics
Heavy
No free knee mode
Limited length options
Non-durable
Disadvantages
Poor aesthetics
Heavy
No free knee mode
Limited length options
Non-durable
Femurett – Adv/ Disadv
Advantages
Very adjustable
Free+ fixed knee mode
IT weight bearing
Variable socket sizes
Advantages
Very adjustable
Free+ fixed knee mode
IT weight bearing
Variable socket sizes
Disadvantages
Poor aesthetics
TFA only
Timely and fiddly
Expensive
Disadvantages
Poor aesthetics
TFA only
Timely and fiddly
Expensive
GAS goalsGAS goals
SIGAMSIGAM
AmpnoProAmpnoPro
Outcome Measures
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Falls Prevention
MDT ApproachMDT Approach
Environmental ModificationsEnvironmental Modifications
ExerciseExercise
Medication Review/ MgmtMedication Review/ Mgmt
Gait training / walking aids provisionGait training / walking aids provision
EducationEducation
Appropriate socket fitAppropriate socket fit
Say What You See!
23-Mar-17
Falls Guidelines
http://bacpar.csp.org.uk/publications/guidance-
falls-prevention-lower-limb-amputees
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After 1-5 years, 26-53% of the dysvascularamputee population requires a second
amputation
Care of the remaining limb guidelines
(Izumi et al. (2006)
23-Mar-17
Residual Limb Care
http://bacpar.csp.org.uk/publications/risks-contra-lateral-
foot-unilateral-lower-limb-amputees-guideline
23-Mar-17
Residual Limb Care
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Health Promotion
Guidelines• Rehabilitation process should have an educational
element that empowers the patient and carers to take an active role in their present and future management (BACPAR, 2006)
On-going service referrals- Wellness Centre- Alcohol/ Drug liaison - Smoking Cessation- Dietician/ Nutritionalist- Diabetic Team- Podiatry- Therapy - Exercise promotion/ programmes- Community Active Health Schemes
Occupational Therapy
Assess the patient
Physical ability
Cognition, memory
Assess the patient
Physical ability
Cognition, memory
Assess home environment
For wheelchair
For prosthesis
Assess home environment
For wheelchair
For prosthesis
Equipment provisionEquipment provision
Discharge Planning
Inpatient rehab – generic or amputeeInpatient rehab – generic or amputee
RepatriationRepatriation
ICT or Community therapyICT or Community therapy
DSc Referral + OPD PTDSc Referral + OPD PT
Social services OTSocial services OT
OT report for re-housingOT report for re-housing
ReferralsReferrals
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Clinical guidelines for the pre and post operative Physiotherapy management
of adults with lower limb amputation
(BACPAR - 2006)
Evidence based Clinical Guidelines for Physiotherapy management of Adults
with Lower Limb Prostheses
(BACPAR - 2006)
Lower Limb Amputation: working together. A review of the care received by
patients who underwent major lower limb amputation due to vascular disease
or diabetes
(NCEPOD 2014)
Guidance for the multi disciplinary team on the management of post operative
residuum oedema in lower limb amputees
(BACPAR, 2012)
Amputee Rehabilitation Guidelines
Blundell, R., Bow, D., Donald, J., Drury, S. and Hurst, L. (2007) Guidelines for the prevention of falls in Lower limb amputees.BACPAR. Available from: http://www.csp.org.uk/sites/files/csp/Amputee%20guidline1.pdf [accessed on 29th March 2016]
Brett, F., Burton. C., Brown. M., Clark, K., Duguid, M., Randell. And Thomas. D. (2012) Risks to the contra-lateral foot of unilateral lower limb amputees: A therapists guide to identification and management. BACPAR. Available from: http://www.csp.org.uk/sites/files/csp/secure/ka-final_contra_foot_guideline.pdf [accessed on 29th March 2016]
Broomhead, P., Dawes, D., Hancock, A., Unia, P., Blundell, A. and Davies, V. (2006) Clinical guidelines for the pre and post operative physiotherapy management of adults with lower limb amputation. London: Chartered Society of Physiotherapy [NB: review of guidelines currently underway]
Broomhead, P., Clark, K., Dawes, D., Hale, C., Lambert, A., Quinlivan, D., Randell, T., Shepherd,R. and Withpetersen, J. (2012) Evidence Based Clinical Guidelines for the Managements of Adults with Lower Limb Prostheses. 2nd Edition. Chartered Society of Physiotherapy: London.
Bouch, E., Burns, K., Geer, E., Fuller, M. and Rose, A. (2012) Guidance for the multi disciplinary team on the management of post operative residuum oedema in lower limb amputees. London: Chartered Society of Physiotherapy
Hale, C., Shepherd, R., McBrearty, J. and Fletcher-Cook, P. (2008) Amputee Rehabiliation: A guideline for the education of undergraduate physiotherapy students. BACPAR. Available from: http://www.csp.org.uk/sites/files/csp/BACPAR%20student%20guidelines%20082.pdf [accessed on 29th March 2016]
Lower Limb Amputation: working together. A review of the care received by patients who underwent major lower limb amputation due to vascular disease or diabetes. Available from: http://www.ncepod.org.uk/2014report2/downloads/WorkingTogetherFullReport.pdf [accessed on 2nd March 2016]
Occupational therapy with people who have had lower limb amputations. Evidence-based guidelines (2011) http://www.cot.co.uk/sites/default/files/publications/public/Lower-Limb-Guidelines[1].pdf [accessed on 29th March 2016]
Ortho Europe. Introducing PPam Aid the pneutmatic post-amputation mobility aid. Hampshire: Ortho Europe. Available from: http://www.ortho-europe.com/products/PPAM/ppam-aid-brochure-2010.pdf [accessed on 29th March 2016]
MDT Guidelines References
1. Moxey PW, Gogalniceanu P, Hinchliffe RJ, Loftus IM, Jones KJ, Thompson MM, et al. Lower
extremity amputations--a review of global variability in incidence. Diabetic medicine : a journal of
the British Diabetic Association. 2011;28(10):1144-53.
2. Scott MH, Patel R and Hebenton J. A Survey of the Lower Limb Amputee Population in
Scotland, 2012. Scottish Physiotherapy Amputee Research Group, Glasgow. 2015
3. Papazafiropoulou A, Tentolouris N, Soldatos RP, Liapis CD, Dounis E, Kostakis AG, et al.
Mortality in diabetic and nondiabetic patients after amputations performed from 1996 to 2005 in a
tertiary hospital population: a 3-year follow-up study. Journal of diabetes and its complications.
2009;23(1):7-11.
4. Coffey L, Gallagher P, Horgan O, Desmond D, MacLachlan M. Psychosocial adjustment to
diabetes-related lower limb amputation. Diabetic medicine : a journal of the British Diabetic
Association. 2009;26(10):1063-7.
5. Ostler C, Ellis-Hill C, Donovan-Hall M. Expectations of rehabilitation following lower limb
amputation: a qualitative study. Disability and rehabilitation. 2014;36(14):1169-75.
6. Moxey PW, Hofman D, Hinchliffe RJ, Jones K, Thompson MM, Holt PJ. Epidemiological study
of lower limb amputation in England between 2003 and 2008. The British journal of surgery.
2010;97(9):1348-53.
References
23/03/2017
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References
7. Mayor S. Less than half of people undergoing leg amputation get good care, inquiry warns.
BMJ (Clinical research ed). 2014;349:g6757.
8. Clark, R., Bowling, F., Jepson, F., and Rajbhandari, S. (2013) Phantom Limb Pain after amputation in diabetic patients does not differ from that after amputation in non diabetic patients. Pain, 154, pp. 729-732
9. Davies, A . (2013) Acupuncture treatment of Phantom Limb Pain and Phantom Limb Sensation in a primary care setting. Acupunct Med. 31, pp. 101-104
10. Mortimer, C. et al. (2002) Patient information on Phantom Limb Pain: a focus group study of patient experiences, perceptions and opinions. Health Educ Res. 17 (3) pp. 291-304.
11. Moura, V. L., Faurot, K., Gaylord, S., Mann, J., Still, M., Lynch, C., and Lee, MY (2012) Mind- body Interventions for Treatment of Phantom Limb Pain in Persons with Amputation
12. Mulvey, M., Radford, H., Fawkner, H., Hirst, L., Neumann, V and Johnson, M. (2012) Tanscutaneous Electrical Nerve Stimulation for Phantom Pain and Stump Pain in Adult Amputees. Pain Practise, 13, (4), pp.289-296.
13. VanRoss, E., Johnson, S., and Abbott, C. (2009) Effects of early mobilisation on unhealed dysvascular transtibial amputation stumps: A Clinical Trial. Arch Phys Med Rehab. 90, pp.610-617
Early Prosthetic Physiotherapy
ManagementKate Primett
Clinical Lead Amputee and Vascular Rehabilitation (BSc, PGc, MCSP, MBACPAR )
Royal Free London NHS Foundation Trust
27/03/2017
Prosthetic suitabilityProsthetic suitability
Prosthetic terminologyProsthetic terminology
Prosthetic suspensionProsthetic suspension
Socket designSocket design
Aims of prosthetic rehabilitationAims of prosthetic rehabilitation
Normal gaitNormal gait
Prosthetic gait training Prosthetic gait training
ContentsContents
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Not Suitable
Cognitive impairment
Hip contracture > 20 TFA
Knee contracture > 30 TT
Large open wound
Patient does not want one
Unable to sit – stand Ind.
Unable to stand for > 5 minsin bars – TFA only
Not used EWA
Medically unstable
Oedematous stump
Suitable
Wound healed
No contractures
Sit – stand Indep
Indep. Transfers
Medically stable
Has successfully used
EWA
Understanding of
prosthesis
When are patients ready for a prosthesis?When are patients ready for a prosthesis?
Proximal part of the prosthesis. Has direct contact with the residual limb
Used for TT prostheses to protect the skin. Made
from a variety of materials including polyurethane and silicone
The hardwear eg. the knee, foot and tibial tubes
Prosthetic TerminologyProsthetic Terminology
Socket
Liner
Componentry
Transtibial Prosthetic FittingTranstibial Prosthetic Fitting
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• Several techniques used to
capture the residual limb:
• POP casting
1. Hand casting
2. Pressure casting
3. Vacuum casting
• Scanning using Tracer Cad
Making a ProsthesisMaking a Prosthesis
Tolerant Areas
Patella tendon
Popliteal fossa
Para-tibial areas
Distal post aspect of stump
Pressure Relieving Areas
Patella
Tibial shaft, tibial tubercle
and cut end of tibia
Fibula head
Pressure Areas for TTAPressure Areas for TTA
Transtibial socket suspensionTranstibial socket suspension
How does the prosthesis stay on?
• Cuff strap
• Supracondylar
• Elastic rubber/gel/silicone
or suction sleeve
• Seal in liner
• Pin Lock system
• Belts
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Transfemoral ProstheticsTransfemoral Prosthetics
Ischial tuberosity weight bearing Ischial tuberosity weight bearing
Ischial containmentIschial containment
QuadrilateralQuadrilateral
TF and Knee Disarticulation Socket DesignTF and Knee Disarticulation Socket Design
How the prosthesis stays on?
• RPB (Rigid Pelvic Band)• Silesian RSS (Roehampton soft
suspension)• TES (Total Elastic Suspension) belt• Skin fit suction• Liner – Seal-in or pin lock• Self suspending
Transfemoral socket suspensionTransfemoral socket suspension
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Knees UnitsKnees Units
Locking –SAKL, HOKLLocking –
SAKL, HOKL
Uniaxial–safety
Uniaxial–safety
PolycentricPolycentric
Transfemoral Prosthetic ComponentryTransfemoral Prosthetic Componentry
Teach safe &correct donning & doffing until independentTeach safe &correct donning & doffing until independent
Close monitoring of skin / woundsClose monitoring of skin / wounds
Liaise with prosthetist re socket fitLiaise with prosthetist re socket fit
Set functional goals with patientsSet functional goals with patients
Progress mobility using prosthesisProgress mobility using prosthesis
Increase time prosthesis wornIncrease time prosthesis worn
Teach on / off floor with and without prosthesis onTeach on / off floor with and without prosthesis on
Teach stump hygieneTeach stump hygiene
Aims of prosthetic PhysiotherapyAims of prosthetic Physiotherapy
23-Mar-17
NO PULLING UP
NO SWIVELLING
NO HOPPING
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•A series of rhythmical, alternating movements of the trunk and limbs which result in the forward progression of the centre of gravity
•A series of controlled falls
DEFINED AS;DEFINED AS;
Normal GaitNormal Gait
Normal Gait Cycle
Pelvic rotationPelvic rotation Pelvic tiltingPelvic tiltingKnee
flexion/ExtensionKnee
flexion/Extension
Hip flexion/extension
Hip flexion/extension
Foot/Ankle mechanismFoot/Ankle mechanism
Lateral displacement of
the body
Lateral displacement of
the body
Minor: Neck and upper limb movement
Minor: Neck and upper limb movement
Determinants of Normal GaitDeterminants of Normal Gait
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Be aware of
normal gait patterns
Be aware of
normal gait patterns
Two vantage
points: Sagittal and Coronal
Two vantage
points: Sagittal and Coronal
Consider muscle
length and strength, joint
ROM, balance
and CV fitness
Consider muscle
length and strength, joint
ROM, balance
and CV fitness
Consideration
of symmetry
Consideration
of symmetry
Observe sitting,
standing, mobility and the
transition between each of
these
Observe sitting,
standing, mobility and the
transition between each of
these
Consider
prosthesis, patient biomechanics and
psychology
Consider
prosthesis, patient biomechanics and
psychology
Start at the base
of support and work up
towards head
Start at the base
of support and work up
towards head
Assessing GaitAssessing Gait
General condition
(pain, ex tol)
General condition
(pain, ex tol)
Shape, length, size of
residual limb
Shape, length, size of
residual limb
The prosthesis. Prosthesis Vs. Person
The prosthesis. Prosthesis Vs. Person
Inadequate re-educationInadequate
re-education
Psychological factors
Psychological factors
Bad habitBad habit
Compensatory patterns
Compensatory patterns
Amputee Gait ConsiderationsAmputee Gait Considerations
Say What You See!
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Weight transfer onto prosthesis –hip stability
Weight transfer onto prosthesis –hip stability
Equal stride length
Equal stride length
Rhythmical gait patternRhythmical gait pattern
Minimiseaccessory
m/s
Minimiseaccessory
m/s
Gait re-education (Transtibial)Gait re-education (Transtibial)
Walking indoors
Turning, twisting, carpet, stepping over
Mobilizing Outdoors
PavementsSlopesCurbsGrass
As above with frame, crutches and sticks
Impact loading and running for the more active patient
Single Leg Standing Exercises
- Ball rolling
- Step ups
- Trampette
- Hurdles
Dynamic Exercises
- Directional/ speed change
- Fuctional Tasks
- CV exercise training
Transtibial Gait Re-education ExercisesTranstibial Gait Re-education Exercises
Donning –sitting or standing
Donning –sitting or standing
Sit – standSit – stand
Weight transfer onto
prosthesis
Weight transfer onto
prosthesis
Swing through - ? Knee type
Swing through - ? Knee type
Transfemoral RehabilitationTransfemoral Rehabilitation
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Functional Activities Functional Activities
Return to HobbiesReturn to Hobbies
Return to Functional ADL’sReturn to Functional ADL’s
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Musculo –skeletal
Musculo –skeletal
Neurological -Normal
Movement
Neurological -Normal
MovementRespiratoryRespiratory
OrthopaedicOrthopaedic PsychologyPsychologyCommunication with other MDT
members
Communication with other MDT
members
Pathology/ Anatomy
Pathology/ Anatomy
Use your other core Physiotherapy skillsUse your other core Physiotherapy skills
There are a number of outcome measures validated for amputee rehab : There are a number of outcome measures validated for amputee rehab :
Activities-specific Balance Confidence Scale-UK Activities-specific Balance Confidence Scale-UK
Amputee Mobility Predictor Amputee Mobility Predictor
Houghton Scale Houghton Scale
Locomotor Capabilities Index-5 Locomotor Capabilities Index-5
Trinity Amputation and Prosthesis Experiences Scales Timed Up and Go Trinity Amputation and Prosthesis Experiences Scales Timed Up and Go
L-Test 28 Timed walk tests L-Test 28 Timed walk tests
Berg Balance ScaleBerg Balance Scale
BACPAR Toolbox of Outcome Measures. Version 2 (2014)BACPAR Toolbox of Outcome Measures. Version 2 (2014)
Outcome measuresOutcome measures
Broomhead, P., Clark, K., Dawes, D., Hale, C., Lambert, A., Quinlivan, D., Randell, T., Shepherd,R. and Withpetersen, J. (2012) Evidence Based Clinical Guidelines for the Managements of Adults with Lower Limb Prostheses. 2nd Edition. Chartered Society of Physiotherapy: London.
MJ Cole et al. (2014) BACPAR outcome measure toolbox version 2. Available from: file:///V:/GoogleChromeDownloads/toolbox_version_2.pdf [accessed on 29th March 2016]
Undergraduate physiotherapy students. BACPAR. Available from: http://www.csp.org.uk/sites/files/csp/BACPAR%20student%20guidelines%20082.pdf [accessed on 19th November 2013]
Prosthetic rehabilitation GuidelinesProsthetic rehabilitation Guidelines
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• Perry et al. (1992) Gait analysis: normal and pathological function. 2nd Edition
• Jeans et al (2011) Effect of amputation level on energy expenditure during
overground walking by children with an amputation. J Bone Joint Surg Am, Jan 5;
93 (1), pp 49-56.
• http://www.physio-pedia.com/Gait_Cycle
• Saunders, M, Inman, V, and Eberhart, H (1953) The major determinants in normal
and pathological gait. The Journal of Bone and Joint Surgery. 35, p. 543 – 558.
• Lord, S, Halligan, P, Wade, T (1998) Visual Gait Analysis: The Development of a
clinical assessment and scale. Clinical Rehabilitation. 12: 107 – 109.
• Engstrom, B and Van de Ven, C (2005) Therapy for amputees. 3rd edition. Churchill
Livingstone: London.
• Trew, M and Everett, T (1997) Human Movement. An introductory text. 3rd Edition.
Churchill Livingstone: London.
• Palastanga, N, Field, D and Soames, R (1998). Anatomy & Human Movement.
Structure and function. 3rd Edition. Butterworth-Heinemann: Oxford.
• http://plexuspandr.co.uk/uncategorized/gait-a-simple-break-down/
• VanRoss, E., Johnson, S., and Abbott, C. (2009) Effects of early mobilisation
on unhealed dysvascular transtibial amputation stumps: A Clinical Trial.
Arch Phys Med Rehab. 90, pp.610-617
ReferencesReferences
Any Questions?
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