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COURSE INSTRUCTORS:

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EmpoweringAmputees.org

Overview of Upper Limb Prostheses

1

Continuing Education Series

Overview of Upper Limb Prostheses

© Hanger Clinic


Disclosure Statements

I have the following relevant relationships in the products or services described, reviewed, evaluated or compared in this

presentation.

Hanger Clinic• Our speaker is a paid employee of Hanger Clinic and

receives a salary.

Other Disclosures (if any):

• Financial

• Nonfinancial relationships (i.e. board member, association committees outside of Hanger Clinic)


Hanger Clinic’s Continuing Education Series

Spinal Orthotics

Lower LimbOrthotics

Upper LimbOrthotics

Lower LimbProsthetics

Upper Limb Prosthetics

2


Learning Outcomes

Upon completion of this presentation, the participant will be able to:

• Recall common terms associated with upper limbprosthetics.

• Describe the design of an upper limb prosthesis relative tothe user’s injury and goals.

• Discuss the basic components of an upper limb prosthesis.• Compare and contrast the prosthetic options available for

the patient with upper limb loss.• Summarize the benefits and limitations of body-powered

and myoelectric prosthetic systems.


Agenda

• Basic Prosthetic Goal

• Prosthetic Design

• Prosthetic Options

• Advancements in UpperLimb Components

• Summary

© Hanger Clinic


Basic Prosthetic Goal

Provide appropriate function and appearance

to increaseindependence with

ADLs and improve quality of life

Images © Hanger Clinic

3


New AmputeesPriorities and Challenges

• Patient/caregivereducation

• Peer support

www.amputee-coalition.orgWise, 2013.

© Amputee Coalition™

www.empoweringamputees.org



• Delineate prostheticexpectations

• Rebuildingproprioception

• Establishing securityand confidence

• Establishing goodhabits

© Hanger Clinic


41.5

76.1

31

97

58.5

23.9

68.6

3

Congenital

Cancer

Trauma

Dysvascular

0 20 40 60 80 100Per 100,000 limb-loss related hospital discharges

United States Statistics, Amputation,1988-1996

Upper Limb Lower LimbAdapted from Dillingham, Pezzin and MacKenzie, 2002.


4


• Traumatic‒ MVA‒ Farming‒ Burn

• Congenital• Tumors• Vascular• Infection

New AmputeesEtiology


Lake, 2008.Ziegler-Graham, et al., 2008.Dillingham, Pezzin and MacKenzie, 2002.


Agenda


• Prosthetic Design‒User Evaluation‒Basic components of an

Upper Limb Prosthesis

© Hanger Clinic


Prosthetic Design

The actual physical evaluation of the patient and the residual limb is a critical step in the

recommendation of the prosthesis.

Images © Hanger ClinicZenie, 2013.

5


Prosthetic DesignUser Evaluation

Special Considerations• Trauma

www.123rf.com

Zenie, 2013.



Special Considerations• Trauma• Visually more apparent

www.123rf.com

© Linda Bränvall and Martin Carlssonhttp://www.engadget.comZenie, 2013.



Special Considerations• Trauma• Visually more apparent• Expectations can differ

from reality

www.shutterstock.com

www.123rf.com

© Linda Bränvall and Martin Carlssonhttp://www.engadget.comZenie, 2013.

6



Special Considerations• Trauma• Visually more apparent• Expectations differ from

reality• Prosthesis ≠ Hand

Zenie, 2013.

www.gettyimages.com



Special Considerations• Trauma• Visually more apparent• Expectations differ from

reality• Prosthesis ≠ Hand• Culture plays a role

© www.amputee-coalition.org

Zenie, 2013.

www.gettyimages.com


• Design a device thatmost appropriately meets:‒ Activities of daily living‒ Medical needs‒ Gainful employment/

Vocational need‒ Psychological need‒ Avocational needs‒ Specific tasks


Thorough Evaluation Process


7


© Otto Bock

Basic Structure of a Prosthesis

SocketSuspensionInterface

ComponentsElbowWrist

Terminal Device

© Otto Bock


© Otto Bock


SocketSuspensionInterface

ComponentsElbowWrist

Terminal Device

© Otto Bock


Socket Interface• Extremely flexibleplastic material

• Improves socketcomfort


© Hanger Clinic

8


Agenda




© Hanger Clinic


Prosthetic Options

• No Prosthesis• Oppositional Prosthesis• Body Powered• Externally Powered• Hybrid• Activity Specific• Multiple Prostheses

Zenie, 2013.Musicus and Davis, 2014.


Prosthetic OptionsNo Prosthesis

Option should be patient driven:‒NOT because of non-coverage‒NOT because of lack of access

Reasons:‒Limited perceived functional

benefit‒Reduced sensory input‒Comfort‒Hot &/or heavy

Biddis and Chau, 2007.Johnson et al, 2014.

Miles O’Brien, © Christopher Anderson,

Magnum Photos/Getty Images

9


Prosthetic OptionsNo Prosthesis

• Referral to occupational therapist‒One-handed techniques‒Posture and ergonomics

• Yearly follow-up to ensure functionalrequirements are met

Biddis and Chau, 2007.Zenie, 2013. © www.amputee-coalition.org


Prosthetic OptionsOppositional Prosthesis

Benefits• Provides aestheticappearance

• Light weight & simple• Functions‒ Opposition‒ Holding objects‒ Restore body image

• Proprioceptivefeedback

Zenie, 2013.Musicus and Davis, 2014.Johnson et al., 2014.


Prosthetic OptionsOppositional Prosthesis

Limitations

• No active prehension

• High cost for custom

• Durability

• Patient can haveunreal expectationsfor cosmesis


Video © Hanger Clinic

10


Prosthetic OptionsBody-Powered Prosthesis

• A.k.a. ‘cable driven’

• Relies upon gross bodymovements capturedthrough a harness


Image and video © Hanger Clinic



Benefits• Moderate cost and

weight

• Durable

• Environmentallyresistant

• Proprioceptionthrough harnesssystem

© Brandon Peterson, CP, LPHanger Clinic




Limitations• Grip strength or

pinch force• Restrictive &

uncomfortable harness

• Requires musclepower & excursion

• Poor static &dynamic cosmesis



11


Level of Amputation

Prosthetic Elbow Flexion

Prosthetic Elbow Lock

TerminalDevice

Transradial Intact Intact Biscapularabduction & Humeral flexion

Transhumeral Biscapularabduction & humeral flexion

Shoulder depression & humeral abduction & extension

Biscapularabduction & humeral flexion

Adapted from: Musicus M and Davis AJ. (2014) Ch 15 Upper Extremity Prosthetic Design and Function. In: Spires MC, Kelly B and Davis AJ. Prosthetic Restoration and Rehabilitation of the Upper and Lower Extremity. Demos Medical Publishing; New York, NY. Pages 167-178.

Body Movements Needed for Prosthetic Control


Prosthetic OptionsExternally Powered Prosthesis


• A.k.a. ‘electrically’powered or ‘myoelectric’

• Powered by a battery

• Myoelectric signals

• Controlled by variousinput methods




Benefits• Stronger grip force• Moderate or no

harnessing• Minimal energy

expenditure• Least body movement

to operate• Moderate aesthetics



12



Limitations• Heavier

• More expensive

• Limited sensoryfeedback

• Extensivetherapy training




Amputation Level Muscles for MyotestingTransradial Wrist flexors and extensors:

- Flexor carpi radialis,- Flexor carpi ulnaris- Extensor carpi radialis longus

& brevis, - Extensor digitorum

Transhumeral - Biceps brachii- Triceps brachii- Deltoid

Adapted from: Miller Q, Spires MC, Davis AJ and Kelly BM. (2014) Ch 14 Upper Extremity Prosthetic Training: Use and Integration into Life. In: Spires MC, Kelly B and Davis AJ. Prosthetic Restoration and Rehabilitation of the Upper and Lower Extremity. Demos Medical Publishing; New York, NY. Pages 153-165.

Muscle Groups for Myoelectric Control


Prosthetic OptionsHybrid Prosthesis

• A single prosthesis inwhich two or moretechnologies arecombined

• Less weight than fullypowered system

• More grip strengththan a body poweredsystem

Zenie, 2013.Musicus and Davis, 2014.Johnson et al., 2014. Photo courtesy of Otto Bock

13



• Elbow: Body-Powered

• Hand: ExternallyPowered

© Troy Farnsworth, CP, FAAOPHanger Clinic



Benefits• Simultaneous control

of the elbow and terminal device

• Reduced weightcompared to all electric

Limitations• Less pinch with cable

controlled TD • Difficult to lift battery

powered TD

© Troy Farnsworth, CP, FAAOPHanger Clinic



Prosthetic OptionsActivity Specific

• A.k.a. ‘Adaptive’ or‘recreational’ prosthesis

• Prosthesis is designed fora specific activity

• An adaptation to anexisting prosthesis


© www.trsprosthetics.com

© Hanger Clinic

14


Prosthetic OptionsActivity Specific

© Hanger Clinic

images © www.n-abler.orgimages © www.trsprosthetics.com


Prosthetic OptionsMultiple Prostheses

• Limitations exist in all prosthetic approaches

• Multiple devices may be needed to addressfunctional deficits

• Multi-articulate hand/durable electric hook• Body powered device/externally powered device

© Hanger Clinic


Prosthetic OptionsMultiple Prostheses


15


Agenda




• Advancements in Upper Limb Components

• Targeted Muscle Reinnveration• Pattern Recognition• Multi-articulating Hands• Partial Hand Options

© Hanger Clinic


Images from Kuiken et al, 2009.

• ‘Reassignment’ of nerves

Targeted Muscle Reinnervation (TMR)


Pattern Recognition

• Traditional myoelectric control has limitations

‒Lack of control signals…usually just 2 electrodes‒Rely on larger muscle groups for signal‒Control muscles usually physiologically

inappropriate

Stevens, 2014.Powell and Thakor, 2013.

Traditional myoelectric system

16


Pattern Recognition

• Computer software translates muscle activityinto prosthetic movements

• Many electrodes• More complete muscleactivity picture

Processing stages of pattern recognition as defined by Scheme and Englehart, 2011.

Image from Zhou et al, 2007.


TMR & Pattern Recognition

http://www.ric.org/conditions/prosthetics‐orthotics/bionic/


• Prior to 2007‒Single motor

‒Single grip pattern

‒Pronation/supination donepassively or with electric wrist rotator

‒Rigid, solid

• Goal

Multi-articulating Hands

Image from Peerdeman et al, 2011.

© www.ottobockus.com

17


Multi-articulating Hands

Michelangelo Hand by Otto Bock

i-limb by Touch Bionics

Vincent Standard Hand and Vincent Small Hand

by Vincent Systems

bebionic Small and bebionic Medium by RSL Steeper


• Amputation levelsfrom a single fingertip to completetranscarpal loss‒Silicone Restoration‒Opposition Prosthesis‒Mechanical Systems

Partial Hand Options



• Amputation levelsfrom a single fingertip to completetranscarpal loss‒Silicone Restoration‒Opposition Prosthesis‒Mechanical Systems‒Powered Finger

Systems

Partial Hand Options


18


Agenda




• Advancements in UpperLimb Components

• Summary

© Hanger Clinic


Summary

There isn’t a single prosthetic system that meets the needs of all individuals with upper

limb loss.

Zenie, 2013.

And multiple systems may be necessary to meet the functional demands of their daily lifestyle.


Summary

• Communication

Patient

Occupational Therapist

Clinician & UL Specialist

Team

Case Manager &

Social Worker

Family, Friends&

Peer Support

Physician

19


Summary

Many factors lead to the final device selection

Security‒Physical‒Psychosocial‒Specific needs

Performance‒Activities‒Vocational‒Future needs


Questions?


Hanger Clinic’s Continuing Education Series

Spinal Orthotics

Lower LimbOrthotics

Upper Limb Orthotics

Lower Limb Prosthetics

Upper Limb Prosthetics

20


Overview Upper Limb Prostheses


Citations

• Biddiss E and Chau T. (2007) Upper-Limb Prosthetics Critical Factors in Device Abandonment. Am J Phys Med Rehabil; 86:977-987.

• Dillingham TR, Pezzin LE and MacKenzie EJ. (2002) Limb amputation and limb deficiency: epidemiology and recent trends in the United States. South Med J; 95(8):875-883.

• Johnson K, et al. (2014) Ch 16 Upper Extremity Prosthetic Sockets, Suspension Systems, andComponent Options to Fulfill Prescription Criteria. In: Spires MC, Kelly B and Davis AJ. Prosthetic Restoration and Rehabilitation of the Upper and Lower Extremity. Demos Medical Publishing; NewYork, NY. Pages 179-194.

• Kuiken T, Li G, Lock B, Lipschutz R, Miller L, Stubblefield K and Englehart K. (2009) Targetedmuscle reinnervation for real-time myoelectric control of multifunction artificial arms. JAMA., 301(6):619-628.

• Lake C. (2008) The evolution of upper limb prosthetic socket design. JPO;20:85–92.• Miller Q, Spires MC, Davis AJ and Kelly BM. (2014) Ch 14 Upper Extremity Prosthetic Training:

Use and Integration into Life. In: Spires MC, Kelly B and Davis AJ. Prosthetic Restoration and Rehabilitation of the Upper and Lower Extremity. Demos Medical Publishing; New York, NY. Pages 153-165.

• Muscious M and Davis AJ. (2014) Ch 15 Upper Extremity Prosthetic Design and Function. In: Spires MC, Kelly B and Davis AJ. Prosthetic Restoration and Rehabilitation of the Upperand Lower Extremity. Demos Medical Publishing; New York, NY. Pages 167-178.

• Peerdeman B, Boere D, Witteveen H, Huis in `t Veld R, Hermens H, Stramigioli S, Rietman H,Veltink P, Misra S. (2011) Myoelectric forearm prostheses: State of the art from a user-centeredperspective. J Rehabil Res Dev;48(6): 719-38.


Citations• Powell MA and Thakor NV. (2013) A training strategy for learning pattern recognition

control for myoelectric prostheses. JPO; 25(1): 30-41.• Scheme E and Englehart K. (2011) Electrogram pattern recognition for control of

powered upper-limb prostheses: State of the art and challenges for clinical use. JRRD;48(6):643-660.

• Stevens P. (2014) Pattern recognition. O&P Edge; 13(12):38-44.• Wise M. (2013) Ch 31 Rehabilitation for Persons with Upper Extremity Amputation. In:

Lusardi MM, Jorge M and Nielsen CC (eds). Orthotics & Prosthetics in Rehabilitation, 3rd edition. Elsevier Saunders; St Louis, MO. Pages 814-829.

• Zenie JR. (2013) Ch 30 Prosthetic Options for Persons with Upper-Extremity Amputation. In: Lusardi MM, Jorge M and Nielsen CC. (Eds), Orthotics & Prosthetics in Rehabilitation, 3rd edition. Elsevier Saunders; St Louis, MO. Pages 795-813.

• Zhou P, Lowery MM, Englehart KB, Huang H, Li G, Hargrove L, Dewald JP and KuikenTA. (2007). Decoding a new neural machine interface for control of artificial limbs. J Neurophysiol; 98(5):2974-2982.

• Ziegler-Graham K, MacKenzie EJ, Ephraim PL, Travison TG and Brookmeyer R. (2008)Estimating the prevalence of limb loss in the United States: 2005-2050. Arch PhysMed Rehabil; 89(3):422-429.

PARTICIPANT WORKBOOKCOURSE NAME:

COURSE INSTRUCTORS:

To learn more about Hanger Clinic’s Continuing Education Programs, please contact:

1-877-4HANGER | HangerClinic.com

Facebook.com/HangerNews

Twitter.com/HangerNews

YouTube.com/HangerNews

EmpoweringAmputees.org

Lower Limb Prostheses, Design to Ambulation

1




Disclosure Statements

I have the following relevant relationships in the products or services described, reviewed, evaluated or compared in this presentation.

Hanger Clinic

• Our speaker is a paid employee of Hanger Clinic and receives asalary.

Other Disclosures (if any):

• Financial

• Nonfinancial relationships (i.e. board member, association committees outside of Hanger Clinic)


Hanger ClinicContinuing Education Series

Spinal Orthosis

Lower Extremity Orthotics

Upper Extremity Orthotics

Lower Extremity

Prosthetics

Upper Extremity

Prosthetics

2


Learning Outcomes

• Upon completion of this presentation, theparticipant will be able to:

• Describe general pre- and postoperative management of theindividual with a lower extremity amputation

• Describe the overall prosthetic process from amputation surgery tofitting of a definitive device

• Explain the general process of donning a transtibial or transfemoralprosthesis

• Describe general activities of physical therapy that prepare theprosthetic user for ambulation, such as: weight shifting, balancetraining, proprioception training, use of assistive devices and specialconsiderations.


Agenda

• Patient Evaluation Techniques

• Casting and Prosthetic Design

• Functional Levels

• Component Selection

• Suspension Methods and Selection

• Fitting and Initial Gait Training

• Alignment Evaluation, SpecialConsiderations and Gait Deviations

Stages of Amputee Rehabilitation

• Pre-amputation care

• Pre-prosthetic care

• IPOCare Stage

• Preparatory stage

• Gait and prosthetic training

• Definitive stage

• Follow-up care

3


General Rehabilitation Timeline: Patients with Lower Extremity Amputation

Receive permanent prosthesisPre-prosthetic

training period from

presurgery to temporary

device

Sutures removed;

limb shaping

Temporary prosthesis; Begin

prosthetic gait training

Apply post-operative protector

Incision fully healed; Cast for

prosthesis

Ongoing therapy and prosthetic adjustments

1 year6 mons.12 wks8 wks4 wks0 wks 4 mons. 5 mons.

**Individual experiences will vary. Slow healers have a different timeline

Adapted from www.gettingbacktolife.com






device

Sutures removed;

limb shaping



Apply post-

operative protector Incision fully

healed; Cast for prosthesis





Pre-Amputation Counseling

• Establish rapport

• Educate the patient and family

• Reduce anxiety

• Set realistic goals

• Peer Support

• 92% of patients indicated apeer visit substantiallyimproved their outlook.

*Rogers et al 1977, May CH and McPhee MC 1979, Fisher RF 1998, Jacobson J 1998, Fitzgerald DM 2000, Williams RM 2004, Marzen-Groller K and Bartman K 2005

4

Benefits of Peer Support

• Improvement in the quality ofcare and life for the newamputee

• More successful rehabilitationoutcomes

• Improved ability to cope withdepression, fear, and feelings ofhelplessness often associatedwith amputation

*Rogers et al 1977, May CH and McPhee MC 1979, Fisher RF 1998, Jacobson J 1998, Fitzgerald DM 2000, Williams RM 2004, Marzen-Groller K and Bartman K 2005

www.amputee-coaliotion.org

Benefits of Peer Support

• Faster acceptance of aprosthesis and return to ADLs

• Fosters social interaction andparticipation in activities

• Peer support has a greaterimpact than education alone forthe preoperative amputeepatient

• Peer support is beneficial toboth patient and familymembers

*Rogers et al 1977, May CH and McPhee MC 1979, Fisher RF 1998, Jacobson J 1998, Fitzgerald DM 2000,

Williams RM 2004, Marzen-Groller K and Bartman K 2005

• Fit immediately after amputation

• Eliminates contracture potential

• Reduces time to fitting of preparatoryprosthesis by 40%

• Restricted use on vascular or diabeticpatient due to skin abrasion andinability to monitor the residual limb

IPOCareImmediate Post-Operative Care

*Sumpio B 2013, Gooday H 2004, Taylor L 2008, Hidayati E 2013

http://www.amputee-coalition.org/

http://www.amputee-coalition.org/

5


*Yu JC et al 2010, Gooday et al 2004, Pauley et al 2006

• 20% of lower extremity amputeesexperience a fall in the hospital

• 3% of all LE amputees experience afall significant enough to requirerevision surgery

• 47% of those revision surgeries resultin a higher level amputation

• Revision surgery due to a fall isreduced through the use of aRemovable Rigid Dressing

• Hospital is responsible for falls costsfor Medicare patients www.amputee-coalition.org


• Reduce the acute length of stayby 45%

• Reduce edema and pain

• Significantly quicker healingtime when rigid dressing is usedas compared with soft dressing

* Sumpio et al 2013, Gooday et al 2004, Taylor et al

2008, Hidayati et al 2013

Edema Control

• Figure of 8 compressionbandage

• Easy to apply

• Poor compliance

• Shrinker sock

• Maintains appropriateconsistent gradientcompression

• Requires dexterity and somehand strength to apply

© www.juzo.com

http://www.google.com/url?url=http://www.o-pspecialists.com/whattoexpect/precare.html&rct=j&frm=1&q=&esrc=s&sa=U&ved=0ahUKEwj23KGt_d7LAhWFBSwKHQT9DHAQwW4IGjAC&usg=AFQjCNHBhX-PloGfhSsMb2QWH9NXwPD0oA

http://www.google.com/url?url=http://www.o-pspecialists.com/whattoexpect/precare.html&rct=j&frm=1&q=&esrc=s&sa=U&ved=0ahUKEwj23KGt_d7LAhWFBSwKHQT9DHAQwW4IGjAC&usg=AFQjCNHBhX-PloGfhSsMb2QWH9NXwPD0oA

6

Contracture Control

• Contracture has significantnegative impact on rehabilitationtime and outcomes

• Maintain regular exerciseprogram on major muscle groups

• Encourage proper positioning atrest

© O&P in Rehab






device

Sutures removed;

limb shaping




Incision fully healed; Cast

for prosthesis






Structural Goals of a Prosthesis

*Smith DG et al 2004

• Replace structural support toskeletal system

• Transfer support forces throughthe residual soft tissue to thefemur

• Stabilize the femur into the hipin a natural position for postureand force.

7

Prosthetic Design: Developing A Compliant Prescription

A detailed prescription (written only)**

• Diagnosis Code (ICD10)• Patient’s Name• Physician’s Name, Signature and

Date• Base Procedure Code (ie: TT

Prosthesis)• Add on Codes (ie: suction, total

contact, test socket, etc.) ***• Modifiers (RT, LT, Functional Level)**This is needed prior to provision of the device

***A detailed prescription may have >15 codes- your prosthetist will work with you in identifying the correct procedure codes for the detailed prescription

A dispensing order (verbal or written)*

• General description of the item• Name of the patient• Start date of the order• Physician’s signature and date• *This is needed to get started

Prosthetic Design: Developing A Compliant Prescription

ICD10 Diagnosis Codes

• Partial Foot (Z89.43X)

• Symes (Z89.44X)

• Transtibial (Z89.51X)

• Knee Disarticulation (Z89.52X)

• Transfemoral (Z89.61X)

• Hip Disarticulation (Z89.62X)

• X =

• 1 if Right

• 2 if Left

• 3 if NOS

Functional Level Assessment

• K0: No ability or potential to ambulate or transfer safely with our without a prosthesis and a prosthesis will not enhance quality of life or mobility.

• K1: Ability or potential to transfer or ambulate on level surface at fixed cadence

• K2: Ability or potential for ambulation with ability to traverse low level barriers

• K3: Ability or potential to ambulate with variable cadence; perform activities beyond simple locomotion

• K4: Ability or potential for activities including high impact,stress or energy levels

Pre-Prosthetic Evaluation

• Stretching/strengtheningexercises

• Residual limb wrapping/shrinker

• Transfer training

• Gait training with assistivedevices

• Skin/scar mobilization

• Desensitization

• Residual limb protectors

8

Evaluation, Casting & Measuring

• Formulate design of prosthesis

• Create relationship with patient

• Establishing rehab pathway

• Set “outcome” target

CadCam Imaging

• Computerized image of residuallimb

• Modifications and socketadjustments performed oncomputer

• Digital image created andstored in database

• Data transferred to computercarver to produce socket toexact specifications

Preparatory Prosthesis

• Fit as soon as suture line has healed

• Typically 4-8 weeks post-op

• Reduces edema

• Adjustable socket & interface

• Adjustable/interchangeable components

• Accelerated delivery

• Lacking complete cosmetic finish

• Second socket required with extremeedema and rapid/excessive limbreduction

9

Check Socket

• Clear diagnostic socket allowsfor visual inspection of pressureand relief areas of the socketdesign

• Necessary modifications andadjustments will be made tocreate the prosthetic socket

Alignment: Bench

• Socket and components set in“Bench Alignment”

• Bench alignment determines thepreliminary relationship betweenthe socket and components (foot,knee, etc.)

• All components capable ofadjustment and modification foroptimum fit

*Lusardi M 2000

Alignment: Static

• Stationary alignment toestablish:

• Height

• Foot rotation

• Socket position

• Flexion/extension

• Ab/adduction

• AP position

• ML position

10

Alignment: Dynamic

• Allows for minute adjustments tothe prosthesis

• Customizes alignment ofprosthesis to the patients’ needsand requirements

• Ensures maximum activity andstability resulting in achieving thehighest possible outcome

BK Donning: Suction Suspension

• Ensure sock count is correct

• Apply in correct order i.e.:

• Liner

• Sock

• Socket

• Sleeve

• Positioning and posture areimperative

• Practice, practice, practice

AK Donning: Suction Suspension

• Suction socket

• Highest degree of fit, suspension& security

• Highest degree of difficulty todon

• Sock or Liner fit…apply in correctorder

• Liner

• Sock

• Socket

• Positioning and posture areimperative

11






device

Sutures removed;

limb shaping

Temporary prosthesis;

Begin prosthetic gait

training



prosthesis





Initial Gait Training: Weight Shift

• Socket fit and “basic” alignmentare key

• Establishes foundation for gaitpattern

• Introduces residual limb topressures and weight bearing.

There is a direct correlation between socket fit, alignment

and gait pattern.

Initial Gait Training: Balance Training

• Teaches muscular control insocket

• Enhances balance

• Improves confidence

• Strengthens sound side

• Start in the walking rails,proceed to holding onto a chair,graduate to free standing

12

Initial Gait Training: Proprioception Training

• Teaches “where the foot is inspace”

• Start in the walking rails,proceed to holding onto a chair,graduate to free standing

1

2

3 4

5 6

Initial Gait Training: Assistive Devices

• Wheelchair

• Walker

• Two canes/Forearm crutches

• One cane

• Two crutches

• One crutch






device

Sutures removed;

limb shaping





prosthesis





13

Definitive Prosthesis

• Fit once limb has stabilizedshape and size

• Two basic styles/designs

• Exoskeletal

• Endoskeltal

• Typically last 3-5 years

Replacement Socket

• Utilized when components are ingood condition but socket fit hasbeen lost

• Most common with Endoskeletalprosthesis

Special Considerations: Energy Expenditure

Level of Amputation Increased Energy

(Traumatic) (Above Normal)**

• Transtibial (TT) 20-25% (Short-40%)

(Long-10%)

• Bilateral TT 41% (Gonzalez-1974)

• TF 60-70% (Traugh-1975)

• TF + TT 118% (Traugh-1975)

• TF + TF 260% (Huang 1979)

**Energy expenditure determined by O2 Consumption

*Smith et al 2004, Gonzales et al 1974, Traugh et al 1975, Huang et al 1974

http://www.nmdog.org/wp-content/uploads/2015/02/Cub-wprosthetics1.jpg

http://www.nmdog.org/wp-content/uploads/2015/02/Cub-wprosthetics1.jpg

http://www.google.com/url?url=http://www.hangerclinic.com/limb-loss/adult-lower-extremity/adv-tech/Pages/C-Leg-Microprocessor-Knees.aspx&rct=j&frm=1&q=&esrc=s&sa=U&ved=0ahUKEwiCkJLmhd_LAhWE_SwKHVPmDm0QwW4IKjAK&usg=AFQjCNFLqnvGbJNzj0GJDjRRyBpWl1iORg

http://www.google.com/url?url=http://www.hangerclinic.com/limb-loss/adult-lower-extremity/adv-tech/Pages/C-Leg-Microprocessor-Knees.aspx&rct=j&frm=1&q=&esrc=s&sa=U&ved=0ahUKEwiCkJLmhd_LAhWE_SwKHVPmDm0QwW4IKjAK&usg=AFQjCNFLqnvGbJNzj0GJDjRRyBpWl1iORg

http://www.google.com/url?url=http://kut.org/post/austin-boston-artificial-limb-company-help-marathon-bombing-victims-run-again&rct=j&frm=1&q=&esrc=s&sa=U&ved=0ahUKEwjrlcGIht_LAhUKGCwKHbgvDfEQwW4IPDAT&usg=AFQjCNEHY_nLntcQJZJJpQr1kIE3uBu5Uw

http://www.google.com/url?url=http://kut.org/post/austin-boston-artificial-limb-company-help-marathon-bombing-victims-run-again&rct=j&frm=1&q=&esrc=s&sa=U&ved=0ahUKEwjrlcGIht_LAhUKGCwKHbgvDfEQwW4IPDAT&usg=AFQjCNEHY_nLntcQJZJJpQr1kIE3uBu5Uw

14

Special Considerations: Gait Speed

• Chosen Walking Speed declines at each higher amputation level for both traumatic and vascular amputee groups

Transtibial (TT) (71 m/min)

Knee disarticulation (61 m/min)

Transfemoral (TF) (52 m/min)

Hip Disarticulation (47 m/min)

• The increased energy cost over baseline of walking with a comfortably fitting prosthesis without an assistive device is less than expended when walking without a prosthesis using a walker or crutches

*Smith et al 2004, Waters et al 1976

Special Considerations: Gait Deviations

• Identify the specific deviation

• Isolate muscle groups toexercise

• Focus on the solution

• Practice, practice, practice

Special Considerations: Advanced Gait

• Learn the basics first

• All gait deviations will besignificantly exaggerated whenrunning

15

Special Considerations: Advanced Gait

• Learn the basics first

• All gait deviations will besignificantly exaggerated whenrunning

Prosthetic Goals

• Provide appropriatefunctionalityto meet each individual’s goals& abilities

• Deliver technology and qualitycare to ensure the prosthesisenables the patient to reachtheir full potential

Maximizing Prosthetic Rehab

• Early intervention

• Multi-disciplinary approach

• Improves functional outcomes

• Reduces rehabilitation time

• Education

• Clear and concise expectationsreduces stress and anxiety

• Therapy

• Pre- and post-surgery will improvefunction and reduce overallrehabilitation time

16


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Citations

Rogers J et al. The use of groups in the rehabilitation of amputees. Int J Psych Med. 1977-1978;8(3):243-55.

May CH, McPhee MC, Pritchard DJ. An amputee visitor program as an adjunct to rehabilitation of the lower limb amputee. Mayo Clinic Proc. 1979 Dec;54[12]:774-8.

Fisher RF. Amputee visitor program. Physiotherapy Canada November/December 1997; Vol39,No.6

Jacobson J. Nursing’s role with amputee support groups. J Vas Nurs. 1998;16[2]31-4.

Fitzgerald DM. Peer visitation for the preoperative amputee patient. J Vas Nurs. 2000;18:41-6.

Williams RM et al. A two-year longitudinal study of social support following amputation. DisabilRehabil. 2004;26[14-15]:862-874.

Marzen-Groller K, Bartman K. Building a successful support group for post amputation patients. J Vas Nurs. 2005;23:42-45.

Atlas of Amputations and Limb Deficiencies: Surgical, Prosthetic, and Rehabilitation Principles, ed 3 Smith DG, Michael JW, Bowker JH, eds. Rosemont, IL 60018, American Academy of OrthopaedicSurgeons,2004, Pages 541-555.


Citations

Sumpio B, Shine S, Mahler D, Sumpio B. A comparison of immediate postoperative rigid and soft dressings for below-knee amputations. Ann Vasc Surg 2013;27:774-780.

Taylor, L, Cavenett, S, Stephien, J, Crotty, M. Removable rigid dressing: A retrospective case-note audit to determinte the validity of post-amputation application. Prosthetics and Orthotics International, 32[2]:223-230, June 2008.

Hidayati, E, Ilyas E, Murdana I, Tarigon T, Werdhani R. Efficacy of removable rigid dresing after transtibial amputation in diabetes mellitus patients. Med J Indones. 2013; 22:16-21.

Yu JC, Lam K, Nettel-Aguirre A, Donald M, Dukelow S. Incidence and risk factors of falling in the postoperative lower limb amputee while on the surgical ward. PMR 2010 Oct;2[10]:926-34. Doi:10.1016/j.pmrj.2010.06.005.

Goodday H, Hunter J. Preventing falls and stump injuries in lower limb amputees during inpatient rehabilitation. Clinical Rehabilitation 2004; 18:379/390.

Pauley T, Devlin M, Heslin K. Falls sustained during inpatient rehabilitation after lower limb amputation: Prevalence and predictors.Am J Phys Med Rehabill 2006;85:521-532.

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Citations

Lusardi M. (2000) Ch 25 Transtibial Prosthetics. In: Lusardi MM and Nielsen CC. Orthotics and Prosthetics in Rehabilitation, 2nd edition. Butterworth-Heinemann; Woburn, MA. Pages 451-452.

Gonzales EG, Corcoran PJ, Reyes RL: Energy expenditure in below-knee amputees: correlation with stump length. Arch Phys Med Rehabil 1974; 55:111-119.

Traugh GH, Corcoran PJ, Reyes RL: Energy expenditure of amputation in patients with above-knee amputations. Arch Phys Med Rehabil 1975; 56:67-71.

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