Physiotherapy

Class 2013

Geriatrics: Amputation
Battarjee Co!ege for Medical Sciences & Technology
Physical Therapy & Rehabilitation
(2012-2013) 4th year, 2nd Semester

Presented by: Maryam BinSiddiq - Muneera al-jehefi Raneem Mehdar - Rawan Al-Tamimi.

Contents
Definitions
Levels
Incidence
Indications
Complication
Prothesis
Goals of rehabilitation
Rehabilitation

Definitions
Amputation is the removal of
a body extremity bytrauma,
prolonged constriction,
orsurgery.
Amputee is the person who
had undergo amputation.
Residual limb is the portion of
the limb remaining fo!owing
the amputation (stump).

Upper limb levels of amputation

Shoulder disarticulation
Trans-humeral
Elbow disarticulation
Trans-radial
Wrist disarticulation
Trans-carpal
Finger amputation

Lower limb levels of amputation

Hip disarticulation
Trans-femoral {Above knee}
Knee disarticulation
Trans-tibial {Below knee}
Foot disarticulation
Partial foot
The most common are transtibial [mid-calf] & transfemoral [mid-thigh].

The most common are trans-tibial [below

knee] & trans-femoral [above knee].

Incidence
Age
It is common in 50 - 75 years of age
Traumatic amputation is common in young age
Sex
Approximately 75% male
25% female
Limb
Approximately 85% - lower limb
15% -- upper limb

Incidence

Indications

PERIPHERAL VASCULAR DISEASE

Lower limbs: 60 - 70 % of amputations
Upper limbs: 6 % of amputations
The most common diseases causing amputation in elderly
patient are DM and arterial sclerosis.
In these cases the blood supply to the limb wi! be inadequate
that leads to tissue necrosis or dry gangrene.
This cause of amputation is most common in elderly.

PERIPHERAL VASCULAR DISEASE

amputation in diabetic
patients are due to
gangrene as the blood
supply becomes
insucient

Traumatic Amputation
Though traumatic amputation is more common in younger
age group, but sti! it happens to older patient
The only absolute indication for primary amputation is an
irreparable vascular injury in an ischemic limb.
E.g.
Automobile accidents
Machinery accidents
Firearm
Freezing
Electrical burn

Post-surgery

An old vietnamese, working in a wood

factory presented with a!eged industrial
injury. His le0 hand got stuck in a wood
cutting machine, while working. Posttrauma, no LOC, no nausea & vomiting,
no headache. But c/o le0 hand bleeding
with severe pain and deformity. O/E,
the le0 hand was tota!y crushed. 1st
and 2nd finger tota!y gone and not
viable. 3rd to 5th fingers viability
questionable. In the surgery. Fortunately,
his 3rd to 5th fingers were viable.

Pre-surgery

Traumatic Amputation

Complications
Non-healing of the amputation site resulting in the need for a higher
level of amputation
Decreased range of motion in the above joint
Wound breakdown
Infection
Swe!ing of the stump
Bleeding
Phantom pain : feeling pain in amputated limb area
Phantom sensation: feeling amputated limb is sti! there
Blood clots
Reaction to anesthesia

Factors increase the risk for

complications
Poor blood flow
Diabetes
Infection
Prolonged immobilization
Heart disease
Smoking or lung disease
Blood clotting disorders

Prosthesis

Prosthesis is an artificial replacement for any or a! parts

of the lower or upper extremities, it is a device that is
designed to replace, as much as possible, the function or
appearance of a missing limb or body part.

Goals of Postoperative Management &

Rehabilitation
Prompt, uncomplicated wound healing
Control of edema
Control of Postoperative pain
Prevention of joint contractures
Rapid rehabilitation

Rehabilitation
Post Surgical phase :
Rigid dressing: decreases edema, decreases post operative pain,
protect limb 3om trauma, early mobilization.
Promote Wound Healing: Physical therapy can enhance
wound healing and reduce associated complication (such as
development of hypertrophic scar) through using low level
laser therapy (LLLT), UV, US, etc.

Rehabilitation
Post Surgical phase :
Control incisional Pain:
1. It is a natural part of any surgical procedure where skin
subcutaneous tissue, nerve and muscles have been cut .It
usua!y goes away when swe!ing reduced and healing
occurs.
2. Contro!ed with adequate amounts of narcotic preferably
given intravenously for the first three postoperative days.

Rehabilitation
Post Surgical phase :
Control phantom Pain:
1. This is a pain in the missing or amputated part of the limb. It can
include burning, tingling, squeezing and cramping, shocking, and
shooting.
2. The patient should expect that phantom pain sensation and
phantom limb may be become long term problem.
3. Use of oral pain medication for significant phantom pain.
4. Massage , cold packs, and neuromuscular stimulation ,TENS
( trans cutaneous electric nerve stimulation.
5. Preoperative analgesia can prevent or decrease the later incidence
of phantom pain.

Rehabilitation
Post Surgical phase :
Control phantom sensation: is the feeling that a! or part of
the amputated limb is sti! present; diminishes over time,
telescoping.
Residual limb pain: This kind of pain occurs in residual part
of the limb a0er the amputation, as the residual limb always
is more sensitive than other parts of body

Desensitization activities may include;

Massage, Rubbing and tapping

Stump Shrinking & Shaping

Elastic bandage
Intermittent positive
pressure compression.
Air Splint.

Stump shrinker
Use of preparatory
(temporary) prosthesis.

Care of the Stump

Keep the stump clean, dry, & 3ee
3om infection at a! times.
If fitted with a prosthesis, it should
be removed before going to sleep.
Inspect and wash the stump with
mild soap and warm water every
night, then dry thoroughly.
The prosthesis is not used until the
skin has healed.
The stump sock should be changed
daily, and the inside of the socket
may be cleaned with mild soap.

Positioning
Positioning is an important
part of a patient's exercise
program. It is done to prevent
shortening of so0 tissue and
joint(s) contractures, that can
result 3om :
1. Muscle imbalance.
2. Protective withdrawal
reflex.
3. Faulty position.

Positioning
The positioning program should emphasize active or
active assistive ROM of the joint(s) proximal to the
amputation.
Elevation of residual limb on a pi!ow can lead to the
development of hip flexion contracture and so should be
avoided .(elevate the lower bed)

Exercise Program
During exercises; Stability & safety come first
Rest should be taken between exercises.
1. The exercises program is designed individua!y and includes
ROM, isometric, isotonic exercises and endurance activities, and
these depend largely on
i. Postoperative healing.
ii. Postoperative pain
iii.Post-surgical dressing

Exercise Program
2. Strengthening exercise for upper extremity muscles of shoulder
depressor, elbow extensor, wrist extensor, hand flexor, trunk,
abdominal and sound limb muscles.
3. Gentle isometric exercises can be started at the 5th
postoperative day. (Multiple angle isometric exercises should be
performed).
4. Isotonic exercises can be encouraged at 7 -10 days postoperative.

Exercise Program
5. Active motion of a! proximal joints through the fu! ROM
should be obtained by 10 -14 days fo!owing amputation unless
gra0ing hasn't healed yet.
6. Program of muscle contraction and joint motion (8-10
repetition for 3 sets) should be repeated several time daily
(3-4times).

Stairs
Going upstairs: Step up with
natural limb first. Then
bring crutches and prosthesis
up.
Going downstairs: Dont
hop. Move crutches down
first, then step down with
prosthesis. Lastly, step down
with natural limb.

Exercise Program

Exercise Program

Exercise Program

Exercise Program

Exercise Program

~ Thank You ~