Introduction to amputation and rehabilitation care in U/E

Jyh-Jong Chang Tel: 2644 Office: CS505

Email:jjchang@kmu.edu.tw 2007 11 16 Outline 1. Introduction to Amputation 2. Surgical Management for Amputation 3. Post-surgical Treatment Objectives of Amputation Rehabilitation 4. Introduction to Prosthesis and its components 5. Prosthesis control and Choices

Limb Amputation Can Be Categorized As

Congenital : present at birth Acquired: Trauma, tumors, vascular disease or infection Incidence : Most upper limb amputations occur as a result of trauma from
Motor vehicles and machinery accidents, gunshot wounds, electrical

burns
Majority of these are males

U/E : L/E amputation ---- 1:3

75% are peripheral vascular disease and diabetes mellitus being the
most common causes in people over 60 years of age

Level of Amputation

Forequarter : Clavicle and scapula involved

Shoulder disarticulation Transhumeral (above-elbow amputation): Short, standard A/E

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Elbow disarticulation Transradial (below elbow amputation ): Very short, short, long B/E Wrist disarticulation:
Transcarpal: Transmetacarpal amputation : Partial hand Finger amputation:

Rehabilitation of the U/E Amputee

Stump care Strengthening and ROM programs Training in one hand techniques

Checkout of the prosthesis Provision of prosthesis training Referrals for further management

Surgical Management for Amputation

Preserve as much tissue as possible Blood vessels and nerves are severed Allow to retract to reduce stump pain

Bone beveling

Smooth the rough edge and prevent spur development

Muscle Sutured to the bones distally
Close or open surgical procedure Open : Allow drainage, minimize infection Close: Reduce the days of hospitalization, but increase infection
(myodesis)

Special Considerations and Problems after Limb Amputation

Skins: Delay healing, skin break down, ulcers, stump corn Stump edema: Compression wrapping, rigid dressing Extensive skin graft

Skin adhesion to the bone Daily gentle massage of the adhesive tissue is necessary
Sensory problems

Loss of sensory feedback Stump hypersensitive

Neuroma
A small ball of nerve tissue, excessive growth of axons attempting to
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reach the distal portion of the stump (2.5~5cm proximal to the end of the residual limb)

Phantom sensation, phantom pain

Bone and joint problems Bone spurs formation and cause pain

Phantom Sensation and Phantom Pain

Most in crush injuries, in distal parts The "neural system exists within the brain even when the body input is cut
off by amputation"

Phantom limb sensation often never subsides and is ordinarily accepted by

the patient

Pain is experienced as more intense with stress increases Peripheral nerve irritation, abnormal sympathetic function, and
psychological factors are thought to be contributory factors

Treatment of Phantom Pain

Avoid emphasizing the issue of pain when possible Severe pain

Analgesics have been used as well as surgery such as nerve blocks and neurectomies

Limb rubbing and tapping, ultrasound, and transcutaneous electrical nerve

stimulation (TENS), acupuncture and biofeedback:
http://www.bfe.org/protocol/pro05eng.htm

Psychotherapy, hypnotherapy, and relaxation techniques

Psychological reaction to amputation

Shock, self-pity, suicidal impulses Fear for the future, anger, grief Depression Personality of the person determines the severity and duration of the
reactions to amputation

Post-surgical Treatment Objectives

Emotional supports, facilitate psychological adjustments Instruct limb hygiene, wound healing care Control edema and shaping of the stump

Elastic bandage, elastic shrinker Removable rigid dressing Immediate postoperative prosthesis Early postoperative prosthesis
Desensitize the residual limb

Percussion or weight bearing Tapping and rubbing, applying a vibrator Wrapping

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Massage is useful as a desensitizing technique

but is primarily used to prevent or release adhesions and soften scar tissue

Maintain and regain ROM Strengthening of all remaining muscles Increase one hand skill, independence in ADL Discuss the prosthetic choice

Demonstrate the prostheses to help the patient establish realistic

expectations

Arrange a meeting with the patient and former patient with a similar
level of amputation

Choosing a myoelectrically controlled prosthesis

Conduct muscle site testing Provide visual and auditory feedback for muscle reeducation training

Train the patient to control the intensity of the muscle contractions

and relaxation, and help him to isolate the contractions of different muscle groups

Early Postsurgical Fitting of U/E Amputees

Within the first 30 days postsurgery Strong recommend for bilateral amputation Decrease rejection rate of U/E prosthetics Encourage early use of bilateral activities with prosthesis Control edema and accelerate stump shaping Prevent or reduce phantom pain

Early prosthetic training Better psychological adaptation Higher rates of return to work

Factors of Prescribing the Prosthesis

Patient's preferences for cosmesis and function Life activities at work, home, and school Physical attributes of the residual limb

Length of limb, ROM, strength, and skin integrity

Financial coverage for the prosthesis

Third-party payment

Patient's motivation and attitude Patient's cognitive abilities to learn and grasp concepts of prosthetic
component controls

U/E Amputation and Prosthetics (I)

Jyh-Jong Chang

Prosthetics Components (From Distal to Proximal)

Terminal devices (TD) : To grasp and hold the objects

Active prehensors: Hook and hand Passive terminal devices: Hook and hand
Wrist units Forearm component or sockets Elbow units or hinges Upper arm component or sockets Shoulder units or hinges

Prosthetic Control Choices

Body powered (BP)

Elbow and terminal device components are activated through body

motion (scapular and shoulder movement)

Harness and control cable for BE and AE

Externally powered

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Electrical motor: myoelectric and microswitch The elbow and/or TD can be externally powered
Hybrid systems: a combination of body powered and electrically powered controls

Passive, cosmetic: no active motion

Terminal Devices: Substitute for the patients amputated hand

Hand : Thumb positioning, 2nd, 3rd

fingers move

Cosmetic hand Functional hand Electric hand

Hook

Voluntary opening Voluntary closing

Hook is lighter and more functional than hand Hand are cosmetic use and too large for prehension

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VO and VC Terminal Devices (Hand and Hook)

VC type

Pinch force is determinated by the patient Pinch force is more precisely controlled Better proprioceptive feedback
VO type

Maximal pull force to open TD and force is determinate by the rubber

bands (lb./band)

More cosmetic than VC type

Cosmetic Gloves

All prosthetic hands have rubberized coverings

Available in a variety of colors and sizes

These gloves cover mechanical, passive, and electric hands

Passive Cosmetic Hands

For some patients the hand not only is a functional tool but also possesses
expressive beauty

Patients will choose a passive cosmetic prosthesis when aesthetics is of

prime importance

Unilateral amputations, high-level amputations, or partial hand

amputations always make this choice

Available to replace a single digit or a total arm

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The Final Choices: Hooks or Hands ?

The hook is more functional as:

Small items can be grasped with precision Patient can view the items more easily while using a hook Providing sensory feedback It weighs and costs less than the hand It is more reliable and requires less maintenance than the hand It can fit in close quarters
Many people prefer the Hand with cosmetically more appealing TDs are chosen as mechanical hands especially in B/E amputation
Easily activated, greater pinch force, do not require a harness(external power)

Individual with bilateral amputations

The body powered hooks continue to be preferred

Some individuals will choose a different TD for each limb

A body powered hook for one side and a myoelectrically powered hand for the contralateral side

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References:
1. Mary Vining Radomski, Catherine A. Trombly Latham. Occupational Therapy for physical Dysfunction. 6th Ed. Lippintcott Williams & Wilkins. 2007. 2. Lorraine Williams Pedretti, Mary Beth Early. Occupational TherapyPractice Skills for Physical Dysfunction. 5th Ed. Mosby 2001