F I S I O T E R A P I E m a a b t ” >7 8 t Cf SIMONSENSE APPROACH TO AMPUTEE CHECK-OUT 11 J. F . N O R T H * and D. W. S T U A R T t , r:ee evaluering .van die pasient en sy kuns- , is 'n uiters belangrike deel van die aanpassings- ltdetnaa / Hgemene benadering word toegepas wat - n n r f l t T l ' ■> __ H i ' n u r t / i c / J o / f l \ 1 0 r b n ~ t H f l p |f»v ’m y t n u u n ‘“ ft L J proSrf . ' m elke pasient te pas. Die voordele verbonde V s k j- behoorlike ondersoek van die pasient voor die nan f e " at gepas word, word beklem toon. Die be- liiins'ea j j e pasient se aktiew e deelnam e om enige hoeftf ° l >n vroee stadium te ontdek, word ook be- Prob I Statistiek w ord gelewer om die getal nuwe sPre.e„.„ m et die getal ou p asiinte te vergelyk. pQSlt"'* lntroduction D e b i l i t a t i o n o f th e am putee is im proved if a clinic approach is used and both the p a tie n t and the team*k«is are carefully checked out. In m any ways the i . t - m i procedure is sim ple, b u t the n u m b er o f pros- I S c variations can be a little daunting: E ach con­ t r a r y appliance seem s, to contain a m u ltitu d e of "1 materials and a host o f indiscrim inately nam ed c o m p o n e n t s w hich cloud the device in a veneer of technical complexity. T h ere are, how ever, a num ber of ™ X r factors w hich apply to any p ro sth etic design and therefore it is possible to develop a com m onsense a p ­ proach to the checkout pro ced u re w hich w ill be applic­ able in every case. It is suggested th a t the key factors in any checkout are: donning, suspension, com fort, stability, function, cosmesis, w orkm anship and p a tie n t satisfaction. T o elaborate on these factors, a n u m b er o f questions are posed to highlight the procedure. 1. D onning Can the am putee don the prosthesis? The amputee m ust be able to don h is a p p lian ce cor­ rectly by him self and get it rig h t every tim e. T h ere is a definite technique fo r every appliance and it involves placing the stum p in a suitable p osition fo r entry into the prosthetic socket. . Below-knee appliances are n orm ally b etter donned in a seated p osition w here m ovem ent o f th e knee perm its easy entry into th e socket. D onning a below -knee pros­ thesis is a very straig h tfo rw ard technique and am putees jnd it relatively easy. 7 Above-knee appliances are b etter donned in a stand­ ing position because this places th e stum p in the optimum p osition fo r entry into the socket. T h e donning procedure is th erefo re m ore com plicated th an fo r a below-knee ap p lian ce and it is m ore tim e-consum ing and energy-taxing. With the advent o f the suction socket th e donning technique has becom e m ore intricate. T he stum p is fed into the socket using a length o f bandage w hich is wrapped a ro u n d th e stum p. T h e bandage is fed down through the suction release valve in the distal end of the socket and is pulled through to feed the stum p into the socket. T h e technique requires p ractice to achieve repeated success. 2. Suspension Is the prosthesis adequately suspended? Suspension is necessary because the forces generated * B.Sc. (H ons.) D undee, P h.D . (Strathclyde) S enior Lecturer in B ioengineering, U n iv ersity o f C ape Town, t Senior T echnician, D ep artm en t o f M edical Physics and N u clear M edicine. during the swing phase o f w alking tend to pull the ap p lian ce off th e stum p. T h ere are a n u m b er of suspen­ sion techniques av ailable and they use straps, belts, cuffs o r suction depending u p o n th e level of th e am putation. It is n o t necessary to know every individual system because they are all essentially sim ilar in th a t they^ all apply suspension forces to som e p o rtio n o f the a n a ­ tom ical structure, such as the condyles, soft tissues, o r shoulders. T h e suspension technique m ust n o t interfere w ith p ro sth etic fu n ctio n in sitting and w alking. I t also m ust be co m fortable and not cause tissue ab rasio n in use. In som e cases the suspension passes over sensitive regions, e.g. scar tissue o r hernias and great care has to be exercised. 3. Comfort Is the prosthesis com fortable? C o m fo rt is im p o rtan t to the am putee. P o o r p rosthetic fitting w ill not produce a com fortable socket and pain can be generated in areas of the stum p. It is quite difficult to define socket com fort, as there w ill be some in itial discom fort u n til the am p u tee becom es used to the socket. I t is very im p o rtan t, therefore, to check fo r com fort a n u m b er of tim es during the procedure. T h e stum p should be exam ined carefully afte r a m b u ­ lation to detect areas o f high pressure and reddening of th e soft tissues. P ain usually occurs at the distal end o f th e stum p and at those p o in ts w here the w eight is being carried. A b u rn in g sensation is experienced by th e am putee w hen muscles are constrained too tightly by the socket an d at p o in ts w here soft tissue-rolls form at th e socket rim . D iscom fort can be caused by poor donning o f the prosthesis and this should be carefully checked o u t if the socket is very uncom fortable. Som e sockets can fit b eau tifu lly when first applied to the stum p b u t becom e un co m fo rta b le and p ainful w ith use. A n unco m fo rtab le socket w ill cause tissue break- own, g ait deviations and quite possibly rejection o f the appliance, so co m fo rt is a critical factor governing the success o f am putee reh ab ilitatio n . 4. Stability Is the prosthesis stable when w orn by th e am putee? S tab ility is th e key to p atien t safety. If the appliance is unstable the am putee will fe a r collapse and am b u la­ tion w ill be severely hindered. T h e p atient m ust have confidence in the prosthesis and its stability. T h e appliance m ust be aligned carefully and the suspension m ust not in terfere w ith the stability req u ire­ ments. In above-knee and h ip -d isarticu latio n appliances the use o f p ro sth etic joints makes alignm ent very im ­ p o rta n t and so it must be checked o u t very carefully. 5. Function Is th e prosthesis o f th e correct length? T h e length o f the prosthesis m u st be correct o r the p a tie n t’s gait will be severely ham pered. G ait deviations due to too long a prosthesis are abundant, e.g. circum ­ d u ctio n o r vaulting, so it is im p o rtan t to check the length o f the appliance. T his is best carried out in the standing p o sitio n by placing th e thum bs on the an terio r su p erio r iliac spines and checking th at they are on the sam e h o riz o n ta l level. C an the p a tie n t am bulate w ith h is prosthesis? R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 12 A m b u latio n is th e m otivating fa c to r behind the fitting o f a prosthesis. T he fu nctional requirem ents fo r g ait a re n o t n orm ally very excessive and the am putee should be able to w alk w ith the appliance. G a it de­ v iatio n s can be corrected by m odifications to the alig n ­ ment, suspension o r knee m echanism . Some g a it p ro b ­ lems can be attrib u te d to the lack o f experience o f the am putee and u n fa m ilia rity w ith the prosthesis an d these can be solved during th e train in g process. C areful atten tio n has to be given to the p ro b lem o f stum p pisto n in g (slipping up and down) w ith in the socket du rin g locom otion. P istoning can be caused by p o o r socket fitting o r inadequate suspension and, if not corrected, can lead to tissue injuries due to the rubbing action. T h e easiest m ethod o f checking piston action is to stand the am putee on his good lim b w ith the p ro s­ thesis raised clear o f the ground. If a significant gap appears betw een the socket b rim and the stum p, then the prosthesis w ill p isto n during locom otion. C an the am putee sit com fortably? T h e prosthesis should p erm it the am putee to sit com fortably. In som e cases the suspension system in te r­ feres w ith sitting and this can be a problem . Some prostheses slip off th e stum p a little on sitting and have to be adjusted w hen th e am putee stands up. T h is is very com m on in the suction socket designs and the p atien t has to reap p ly suction w hen he gets up. T h is is carried o u t by pressing the stum p firm ly into the socket and forcing trap p ed a ir o u t o f th e release valve situ ated on the distal section o f the socket. A ra th e r nasty rasping sound is generally heard when the p atien t reapplies suction by this method. I t is also w orth checking w hether the p atien t can kneel w ith his device in place, as som e occupations such as those of m otor mechanic, joiner, o r p lum ber require this. 6. Cosmesis Is the ap p earan ce o f the prosthesis satisfactory? Cosmesis is im p o rta n t to every am putee and this aspect should n o t be u nderrated. A good appearance is essential to the p atien t because he has to w ear the appliance in everyday activities. If the prosthesis looks bad, it w ill affect his m o tiv atio n to use it effectively. C o n tem p o rary appliances can now provide an ex­ cellent level o f cosm etic re sto ra tio n because they use soft fo am sections and nylon skin-coloured coverings. If the device looks good to the p atien t his determ in a­ tio n to use th e prosthesis will increase, 'a n d this will help in th e train in g program m e. G o o d cosmesis adds little m ore to the total price and helps ensure a lower rejection rate. 7. Workmanship Is the prosthesis well m ade and is it reliable? W o rk m an sh ip and reliab ility are m a jo r factors in the success o f any appliance. T h e prosthesis has to be able to stand up to the w ear-andrtear o f daily activities, and it m ust m a in ta in its reliability. T h e appliance should o p erate sm oothly and th ere should be no excessive noise, rattles o r slackness a b o u t the device. Suspension straps have to be firm ly secured, and the socket m ust be very sm ooth inside. T h e cosm etic coverings m ust n o t hinder th e o p e ra tio n o f the prosthesis by jam m ing into the jo in t m echanism s. 8. Patient Satisfaction Is the p a tie n t satisfied w ith' the prosthesis? T his is o f course th e m ost im p o rta n t question in any checkout procedure. T h e p a tie n t m ust be satisfied w ith the ap p lian ce and the com fort, suspension, fu n c­ tion, stability, and cosmesis m ust fulfil his need F u tu re problem s o f rejectio n o f an appliance Ca usually be traced to the fa ilu re to satisfy th e p atient’11 needs in the early stages o f reh ab ilitatio n . It is im porS ta n t to w in the confidence of th e p a tie n t so th a t h feels free to present his views a b o u t the appliance w is all too' easy fo r the am putee to accept a poorlv fitting appliance because he feels obliged to accept it com e w h at may. T h ere w ill also certainly be som e discom fort with any prosthesis at in itial fitting and it m ust be explained th a t this is a n o rm al reaction to the device in the early stages. As the p a tie n t becomes m ore accustomed to th e prosthesis he w ill have less problem s in usins it effectively. It is essential to build up the p a tie n t’s confidence in his appliance and any questions a b o u t the device have to be answ ered adequately. T h ere is noth in g to hide fro m the p atien t and the lim itatio n s o f the prosthesis should be p o in ted o u t clearly. I t is easy to give the im pression th a t the prosthesis will p erm it the p atien t to do everything th a t he did p rio r to his am p u tatio n a n d this is n o t good practice. T h ere are problem s in u sin J any prosthesis and the p a tie n t m ust be m ade aw are th a t only a determ ined effort w ill achieve a successful con­ clusion to the reh a b ilita tio n process. 9. Stump Care T h ere are problem s in using a prosthesis in daily activities and both the stum p and the prosthesis take a fa ir degree o f pun ish m en t in periods of constant use. L ike any system involving m oving parts, w ear-and-tear occurs in use. E a rly m aintenance can prevent problems and m ake the prosthesis m ore acceptable to the amputee. T h e volum e o f the stum p w ill n o t rem ain constant in daily use o f th e appliance. T hough it can fit really well w hen in itially donned the stum p increases in volum e as the day proceeds, and can becom e uncom fortable. This is a fairly n orm al result o f extensive p ro sth etic use and it is one o f the problem s in using an appliance. One facto r w hich directly affects the stum p-socket re­ latio n sh ip is the change in body w eight o f the amputee. Changes in w eight w ill a lte r stum p volum e and it will n o t be possible to retain a good fit in th e prosthetic socket. T h e am putee m ust avoid p u ttin g on excessive w eight as this w ill lead to a n unco m fo rtab le socket fit. In a lo t o f cases, stum p socks are used betw een the socket and the skin surface. G o o d socks are required and they m ust be w ashed regularly to keep them cleaiM R eplacem ent m ust be. m ade w hen sock w ear become* irrep arab le. F ilth y ragged stum p socks can only lead to future tissue problem s, and sock replacem ent and cleaning should be em phasised. T h e stum p should be w ashed carefully a t least once a day to rem ove dead tissue m aterials and sw eat secre­ tions. W hen w ashing w ith a little d isin fectan t and hot w ater the tissues can be inspected fo r skin discoloura- tions, abrasions, grazing, and rough areas. U lcers should be treated by a physician at the earliest o pportunity. It is possible to have an am putee literally w alk the stump to a condition o f severe u lceration w ith o u t considering th a t m edical treatm en t is necessary. M any am putees find th a t applying some talcum pow der to the stum p before donning the prosthesis is useful. H ow ever, too much pow der can have an adverse effect by im pairing sweating. 10. Maintenance o f Prosthesis T he appliance should be exam ined regularly to see th a t it is in good condition. C areful attention, m ust be given to the socket to check fo r surface discontinuities w hich w ill lead to stum p problem s. M a jo r discontinuities M ARCH 1978P H Y S I O T H E R A P Y R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) l ke m aterial folds, cracks and rivet failu re s require ttention by the o rth o p a e d ic w orkshops. * The joints, fo o t m echanism and suspension straps hould be free o f slackness and noisy o p eratio n and all rivets should be secure. On contem porary, m o d u lar nnliances there is generally som e fo rm o f cosm etic overing. A b rasio n and tearin g o f the nylon covering c fairly com m on especially w here it passes over p ro s­ thetic joints. Severe d eterio ratio n of the cosm etic cover Hould be rep o rted to the w orkshop. O n m any below- ? nee appliances soft cushion liners are used as an interface m aterial betw een the stum p and the socket. In general, two m aterials are used to m ake th e soft liner, i.e. leather and plastic. W ith constant use the liner' becomes discoloured an d can develop a pungent odour. L eath er liners can n o t be w ashed because o f the inherent qualities o f th e m aterial; how ever, the plastic liner can be cleaned. P lastic liners are m ade fro m a closed-cell m aterial (Pe L ite) w hich is snow y w hite in colour. Pe L ite can be w ashed w ith h o t soapy w ater to remove d iscolouration s and odours and the liners fo rm ally come u p like new. I The am putee should n o t adjust the prosthesis by taking the com ponents a p art, as the alignm ent will be lost. If the alignm ent is incorrect, the appliance can become very unstable in use. In som e cases the p atien t is expected to ad ju st the w heel tightening m echanism of his p rosthetic knee jo in t b u t he should be given instruc­ tion in this before being allow ed to m ake any alterations. MAART 1978 13 Concluding Remarks T h e am putee clinic a t G ro o te Schuur H o sp ital saw a total o f 1 594 patients during 1975- 1976, and 359 q f these w ere new am putees. T he rest were eith er referrals fro m day hospitals o r they attended o f th e ir ow n v o li­ tion. In the m ain these p atien ts attended because o f stum p p ain a n d /o r m echanical problem s w ith the appliance. A large p ro p o rtio n o f the problem s exam ined could have been avoided by careful exam ination a t the checkout and by an effective tra in in g regime. E a rly diagnosis o f stum p, g a it and p ro sth etic problem s is essential an d it is a key role fo r the physiotherapist. I f reh a b ilita tio n is going to be carried o u t, then it must be done correctly and th is m eans th a t th e checkout and train in g procedures cannot be neglected. W e have to reduce the n u m b er o f patients a t the clinic sessions so th a t m ore tim e can be allocated to those patients who need detailed evaluation. T his can only be done by im proving th e present reh ab ilitatio n process so th at few er p atien ts are referred. Acknowledgements T h e au th o rs w ish to th an k the m em bers of the am putee clinic team in G ro o te Schuur H o sp ital w here this study was carried out. References M urdoch, G . (1970). P ro sth etic O rth o tic Practice. L ondon, Ed. A rnold Ltd. F I S I O T E R A P I E FIRST W ORLD CONGRESS OF T H E COUNCIL FO R EXCEPTIO NAL C H ILD REN The F irst W orld C ongress of the C ouncil fo r E x ­ ceptional C hildren w ill be held at the U n iv ersity o f Stirling, Scotland, fro m June 25th to July 1st 1978. The Congress hopes to exam ine all aspects o f special education fo r the handicapped child, to ap p raise and perhaps challenge existing ideas and to evaluate a lte r­ natives fo r the future. H a lf of each day w ill be devoted to in tern atio n al panels on different key sub­ jects w hilst in th e afternoons p a rtic ip a n ts w ill be allocated to one o f up to fifty sem inar g ro u p m eetings according to th e ir previously determ ined specific fields of interest. \ F ull details are available fro m C E C W orld Congress, y920 A ssociation D rive, R esto n V A 22091, U.S.A. C on­ gress fees are 195,00 U.S. dollars. PO ST -G R A D U A T E COURSE — M A N IPU LA T IO N O F THE SPIN E T h e above course w ill n o t be conducted by the A u stralian P hysiotherapy A ssociation in A delaide in 1978 o r 1979, b u t it m ay be resum ed in 1980. F O R E IG N JOURNALS Jo u rn als o f m ost m em ber associations o f W .C.P.T. are received by the E d ito r. T hese are av ailab le upo n request. OORSESE TYD SK R IFTE T y d sk rifte van m eeste lede-verenigings van W .C.P.T. w ord d eu r die R ed ak trise ontvang. H ulle is op versoek beskikbaar. NOTICE T he follow ing G o v ern m en t G azettes contain im p o r­ tant notices fo r Physiotherapists. T hese a re o b tain ab le from the G o v ern m en t P rin te rs at 20c a copy. No. 5349 o f 3 D ecem ber 1976: T h e P rofessional B oard fo r P h ysiotherapy; R ules fo r the R eg istratio n o f P hysiotherapists; C onditions un d er w hich P hysio­ therapists m ay practice; T h e scope o f P hysiotherapy. No. 5741 o f 16 S eptem ber 1977: A cts o f O m issions in respect o f w hich discip lin ary steps m ay be taken; R eg istratio n o f P hysiotherapy students. No. 5765 o f 7 O ctober 1977: T ariff of fees. K E N NISG EW IN G S D ie volgende Staatskoerante bevat belangrike kennis- gewings v ir F isio terap eu te. D is b eskikbaar van die S taatsdrukkers teen 20 sent p e r kopie. N o. 5349 van 3 D esem ber 1976: D ie B eroepsraad vir F isio te ra p ie ; Reels betreffende die R egistrasie van F isio terap eu te; V oorw aardes w aarop F isio terap eu te hulle beroep mag beoefen; D ie O m vang van F is io ­ terapie. N o. 5741 van 16 S eptem ber 1977: H andelinge o f V er- suim e ten opsigte w aarvan tugstappe gedoen kan w ord; R egistrasie van studente in F isio terap ie. N o. 5765 van 7 O ktober 1977: G eldetarief. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )