PP06 - Week Three
- 1 Introduction
- 2 Topic 1: Pre-fitting rehabilitation phase
- 3 Topic 2: Pre-prosthetic exercise therapy
- 4 Topic 3: Psychology and amputation
- 5 Topic 4: Patient education
- 6 Topic 5: Risk assessment:
- 7 Topic 6: Equipment:
- 8 Quiz
- 9 Case Study
- 10 Discussion
- 11 Optional: Explore other resources
This week we are going to look in more detail at how to manage a patient with an amputation during the pre-fitting phase; this is after the acute post-surgical phase until the moment the patient is ready to be fitted with a prosthesis. You will also see how to perform a risk assessment and what type of equipment, including wheelchairs, mobility aids and prostheses, can be used and prescribed, including their application and also their advantages and disadvantages.
In the video below Leslie Muller from the ICRC and Rachael Lowe introduce the topics of the week (Note - watching this video is optional).
Objectives for this week
At the end of this week you should:
- Have a good knowledge of pre-fitting physiotherapy management techniques, including bed mobility and transfers, stump management, musculoskeletal considerations and patient education.
- Understand and discuss some of the issues relating to loss and bereavement in relation to limb loss.
- Recognise/understand the importance of carrying out a risk assessment and the inherent risk in the provision and use of specialist equipment.
- Identify and describe the different types of commonly used equipment for the rehabilitation of lower-limb amputees and discuss their application, advantages and disadvantages, indications and contraindications.
Topic 1: Pre-fitting rehabilitation phase
The aim of this topic is to give you an overview of how to appropriately manage an individual with amputation prior to their prosthetic fitting after the acute post-surgical period. Pre-prosthetic-fitting treatments aim to improve the general condition and function of the patient and prepare the stump for prosthetic fitting. You should know about transfers and functional tasks, exercises (strengthening and stretching), bandaging and scar management:
- This Physiopedia page gives an overview of Pre-Fitting Management of the Patient with a Lower Limb Amputation
- Read about special considerations for the pre-fitting phase in the ICRC PGA Manual-pages 55-64
This short interview with Saeda Baraawi from the ICRC centre in Gaza discusses important aspects of pre-fitting management and criteria to aim for when sending patients for casting:
Topic 2: Pre-prosthetic exercise therapy
Below are some links to books that demonstrate many exercises that you may wish to use. You may not have time to read all these books now but having a browse through them will give you some ideas. If you would like your own copy of the Gailey books or the Engstrom book to refer to at a later date you can download the pdfs from the links at the bottom of the page.
- Have a read through Chapter 5 in Engstrom (pages 120-149) Exercise programme and pre-prosthetic activities of daily living
- Get some ideas for strengthening and stretching exercises from pages 10-38 of the Limbs International Manual
- Have a browse through the Gailey book titled Stretching and Strengthening for Lower Limb Amputees.
- To get some ideas for balance, agility and co-ordination exercises take a look through pages 9-26 of the Gailey book Balance Agility, Coordination and Endurance.
Topic 3: Psychology and amputation
It is very important to understand and have special consideration for the psychological impact of limb loss:
- Read Engstrom textbook Chapter 3 (pages pp. 68-92) Psychological impact of amputation
- Read this article titled The Psychological Aspects of Amputation that goes into the grieving process in more detail.
- Read the WHO textbook Chapter 2.3 (pages 19-21) Psychological adjustment
Topic 4: Patient education
Patient education is important through all stages of the rehabilitation for individuals with limb loss, at this stage you might wish to consider and/or use the following resources:
- AustPar provide two useful patient education leaflets for Care of your stump and skin and Care of your stump socks, bandages and shrinkers
- On page 60-62 of the ICRC Manual there some general advice for individuals with amputation, it contains a couple of pages that can be printed out for your clients.
- The amputee coalition provdes a couple of useful leaflets for your clients at this stage: Care of Your Wounds and Getting the Most Out of Physical Therapy.
Topic 5: Risk assessment:
The aim of this topic is to briefly mention risk assessment. Walking equipment should improve mobility. Nevertheless if inappropriate walking equipment is used, incorrect techniques are adopted, or if the equipment is not suitable for a particular environment, independence and safety will be compromised. It is therefore essential to carry out a risk assessment to insure the equipment is safe and suited to the patient's needs and will not increase the risk of falls.
- Take a look at the guidelines for the prevention of falls in lower limb amputees from BACPAR
- Have a read through this presentation of a literature review of falls in the amputee population
- A number of assessment tools are readily available to identify adults’ fall risk factors.
- Here is an example of a falls risk assessment and management plan
Risk assessment can be quite different depending on your country and working environment. Please investigate and comply with your local rules and regulations.
Topic 6: Equipment:
The aim of this topic is to review a range of equipment such as wheelchairs, manual handling equipment and walking aids (prostheses will be covered next week!).
- Read the Physiopedia page Equipment for individuals with limb deficiency
- Read chapter 6 in the Engstrom textbook (pages 150-185) Wheelchair Use and early walking aids
- To know how to adjust and use mobility aids read chapter 5.2 (pages 96-100) in the WHO textbook
- Read the chapterWalking with assistive device (pages 58-90) from the Limbs International Manual to see how to use walking aids in idividuals with amputation
You are not assessed on this quiz, it is designed for you to test your knowledge on the topics this week.
Watch this video:
Find out more about Farzana (alternative text document if you can't watch the video)
Go to the Discussion Forum and add responses for the three discussion activities below. Please post your discussions as a comment in the relevant discussion thread that will be set up for you.
- What criteria do you use in your specific context/setting to decide that a patient is ready to be fitted with a prosthesis?
- What type of risk assessment do you use in your own context/setting? Post your risk assessment protocols.
- With reference to the case study video, what role does Farzana's own prosthesis play in her own grieving process? For a new amputee patient what psychological impact is there when they receive their prosthesis from a specialist, like Farzana, who has a disability herself?
Optional: Explore other resources
The following resources are optional for you to read/ but will further expand your knowledge on this week's topics:
- Pre-prosthetic checklist and stump measures
- This is an example of an exercise programme that you can give to your patients
- This article (2010) describes the incidence and risk factors of falling in the postoperative lower limb amputee while on the surgical ward.
- In the WHO Guidelines on the provision of manual wheelchairs in less-resourced settings read pages 21-30 on benefits and type of wheechairs and pages 41-56 on the advantages and disadvantages of different wheelchair designs.
- Wheelchair Service Training Package - Basic level
- Wheelchair Service Training Package – Intermediate Level
- How to Use Crutches, Canes, and Walkers
The Rehabilitation Series for Lower Extremity Amputees
Free access to these three text books has kindly been provided by Robert and Ann Gailey for the duration of the course:
Alternatively you might be interested in having your own copy of the books.
Additionally you might be interested to purchase the complementary DVDs direct from Robert and Ann Gailey.
Prosthetic Gait Analysis for Physiotherapists
This is the course textbook from ICRC which will be available to all participants of the course.
Alternatively you might be interested in having your own copy of the book.
Therapy for Amputees
This course textbook has kindly been provided by Elsevier and will be available to all participants of the course for FREE for the duration of the course. Please bear in mind that this book is fairly old so use it critically in addition to all the other resources that we will point you at.
Alternatively you might be interested in having your own copy of the book.
Buy with 20% discount from your local online Elsevier store (not available in all regions)