JUNIE 1976 F I S I O T E R A P I E 11 MANAGEMENT OF AMPUTEES A TEAM APPROACH by B E R N IC E K E G E L , B .Sc., P h ysio. (R and) R .P .T . S taff P h ysical T herapist U n iversity o f C h icago H osp ital and Clinics T he need for com prehensive p ro sth e tic services is ever increasing. U n fo rtu n a te ly in m an y in stitu tio n s a n in te r­ disciplinary a p p ro a c h is n o t utilized. Physicians, P h y sio ­ therapists, O c cu p a tio n a l T h era p ists, P ro sth e tists, Social W orkers a n d n u rsin g staff o p e rate as in d ividuals w ith no f o m m u n ic atio n o th e r th a n p re scrip tio n s a n d p rogress eports. T his is n o t alw ays in the best interest o f the p a tie n t and th ere fo re th e co n ce p t o f a n A m p u ta tio n Clinic is recom ­ m ended as a n a lternative. A com prehensive clinic has been in o p e ra tio n a t th e U n i­ versity o f C hicago fo r th e p a st th ree y ears, a n d c o uld p ro b a b ly be in itiated a t a ny h ospital, involving m inim al effort or expense. N o m a jo r ren o v atio n s a re necessary. T h e P hysio­ therapy G y m n a siu m is a n a p p ro p ria te p lace to h old th e clinic, as parallel b a rs a n d w alking a id s a re readily available. T he cost o f e stablishing a n d o p e ra tin g this clinic is also low. N o new em ployees need be hired to im p le m e n t th e p r o ­ gram m e, m erely re o rg a n iz a tio n o f the p resent staff w ho continue to m ain tain th e ir general case load. The A m p u ta tio n C linic a t this facility is held fo r 2£ h o u rs once a m o n th . A p p ro x im ately 10 p a tie n ts a re seen every m onth, thus each p a tie n t receives 15 m inutes o f individual a tte n tio n . O bviously, frequency o f th e clinic w o uld dep en d on p a tie n t load in e ach p a rtic u la r hospital. T he clinic is a tte n d e d by th e O rth o p a e d ic S urgeon (or C ard io v a sc u la r S urgeon w here a p plicable), th e P ro sth e tist (a p riv ate c o m p a n y in this incident), the P h y sio th e rap ist, O ccupational T h e ra p is t a n d Social W o rk er. A file o n each pa tie n t c o n ta in in g th eir h isto ry , o p e rativ e a n d progress re p o rts re levant to th e case is k e p t in th e P h y sio th e rap y d e p artm e n t. T h e P h y sio th e rap ist c o -o rd in a tin g the clinic is called u p o n to m eet a n d ev alu ate each p a tie n t before a m p u ta tio n (w herever applicable). T h e Physician a nd P h y sio th e rap ist w ork to g eth e r in th e early post-o p e rativ e phases o f re h ab ilitatio n . Physician, P ro s th e tis t a n d P hysio­ th era p ist are p re sen t d u rin g rigid dressing changes in o rd e r to exam ine the c o n d itio n o f th e residual lim b a n d to p lan a progressive w eight b earing regim e fo r th e pa tie n t. It is the responsibility o f th e P h y sio th e rap ist to assure th a t th e p a tie n t is scheduled to be seen in clinic as so o n as th e “ sh a p in g " o f th e residual lim b h as been c o m pleted. A t th e clinic the P h y sio th e rap ist presents the p a tie n t, offering a b rie f synopsis o f his h isto ry a n d p o st-o p e rativ e course, as well as the reaso n fo r th e present visit. A g ro u p discussion is th e n u n d e rta k e n with each m em ber o f th e team p a rticip a tin g in th e discussion. A decision is m a d e as to w hether th e p a tie n t is indeed a pro sth e tic c a n d id a te , a n d if so, w hich p ro sth e tic device is ind ic a te d fo r th a t p a rtic u la r p a tie n t. T he m o st a p p ro p ria te pre scrip tio n is m ad e w ith th e P h ysician using m edical discretion, th e P ro s th e tis t h a ving in p u t in to w h a t is pros- thetically a v ailable, the P h y s io th e ra p ist exp la in in g the p a tie n t’s physical abilities a n d lim ita tio n s a n d the p a tie n t expressing his o w n desires a n d e x pectations. A sta n d ard ize d p ro sth e tic p re scrip tio n fo rm (see figure 1) is filled o u t by the Physician in d u plicate. O ne copy is k e p t by th e P ro sth e tist, a n d o ne copy k e p t in the p a tie n t’s file. I f this p ro c ed u re is used, u n n e :e ss a ry tim e co n su m in g te le p h o n e calls o r letters a re e lim inated. T h e Social W o rk e r th e n discusses w hatever social a n d financial a rra n g e m e n ts th a t a re a p p ro p ri­ ate. A p p o in tm e n ts a re th e n m ade fo r the p a tie n t to go to the p ro sth e tic c o m p a n y fo r c asting a n d fitting. U sin g this p ro to co l the p rosthesis is c o m plete w ithin 1 to 6 weeks de p ending u p o n w ork lo a d a n d com plexity o f th e device. A s so o n as th e p rosthesis has been fa b ric a te d it is sent to the P h y sio th e ra p y d e p a rtm e n t — never ever directly to the pa tie n t, o r via th e p a tie n t. G a it train in g is th en initiated, p referably daily, b ut usually th ree tim es per w eek. O c ca sio n ­ ally, if tra n s p o rta tio n o r o th e r difficulties arise, tra in in g m ay be pe rfo rm e d o n a n in p a tie n t basis. T he P h y sio th e rap ist does b o th a n initial a n d final ch ec k o u t o f the pro sth esis (a s ta n d ­ a rd iz ed fo rm is used as sh o w n in figure 2). A ny m in o r changes o r co rre c tio n s necessary a re discussed w ith th e P ro s th e tis t a n d com p le te d befo re fu rth e r tra in in g is c om m enced, so as to p revent p o o r g ait p a tte rn s d ue to a n in ad e q u ate ly aligned prosthesis. P e rio d o f tra in in g re q u ire d is highly variable. Sixty e ight p a tie n ts w ere tra in e d a t th e U n iversity o f C h icago in the p a st th ree years. T ra in in g tim e v aried fro m 2 weeks to 7 m o n th s w ith a m ean o f 1,9 m o n th s. T w o m o n th s on the average w as re q u ire d to pro sth e tic ally tra in a below knee am p u te e, a n d th ree m o n th s fo r a n a b o v e k n e e am p u te e. T his in fo rm a tio n is based o n a frequency o f tre a tm e n t averaging a t tw ice a week. W h en the P h y s io th e ra p ist believes th e p a tie n t has o b ta in e d o p tim a l physical benefits fro m tra in in g she refers him back to the a m p u ta tio n clinic. A g ro u p ch ec k o u t is then d o n e by Physician, P ro s th e tis t a n d P h y sio th e rap ist o r O c cu p a tio n a l T h era p ist. T h e p a tie n t is e v alu ate d fo r c o m fo rt, fit, a lignm ent, fu n c tio n a n d cosm esis. H e is ask e d to d e m o n s tra te his skill in h a n d lin g a n d using th e p rosthesis. I f b o th th e team a n d the p a tie n t a re satisfied, th e p a tie n t is tem p o ra rily discharged. T his is n o t th e end. R esidual lim bs c hange, prostheses w ear o u t, a n d vascular changes o ccur in o th e r extrem ities. R e g u la r checkups have to be offered to these pa tie n ts. T he jre q u e n c y o f rechecks will d e p en d o n age, re a so n fo r a m p u ta ­ tion, activity level a n d reliability o f th e p a tie n t. In this clinic, vascular p a tie n ts a re seen a t th ree m o n th ly intervals. Ju venile am p u te es a re a lso scheduled extrem ely freq u e n tly so as to observe carefully fo r g row th a n d b ony ov e rg ro w th , a c o m m o n p ro b lem in g row ing stu m p s. P a tie n ts w ho have h a d th e a m p u ta tio n fo r n eoplasm o r tra u m a seldom need to be seen m ore th a n once a y e a r in th e a m p u ta tio n clinic p e r se. W h atev e r th e p ro b lem , each p a tie n t sh o u ld be given a c ard w ith th e tele p h o n e n u m b ers of all th e a p p ro p ria te p rofessional pe rso n n el so th a t h e m ig h t c o n su lt them a t a ny tim e deem ed necessary. T he Social W o rk e r o r V oc atio n al C o u n se lo r m ay c o n tin u e to have c o n ta c t w ith th e p a tie n t to assure sm o o th tra n s itio n to his new life s itu a tio n o r a d a p ta tio n to a c h anging la b o u r m ark e t. K e rstein a n d associates (1974) re p o rte d th a t a m edium o f 5\ m o n th s tra n s p ire d betw een tim e o f a m p u ta tio n a n d final discharge fro m P h y sio th e rap y . T his is a long tim e, especially w hen o n e co n sid ers th a t th e m ajo rity o f p atien ts are in th e o lder age g ro u p anyw ay. C o n tin u e d e m phasis a n d effort sh o u ld be afforded a im ing a t re d u cin g th e length o f tim e involved. A g re at deal o f tim e is usually lost d u e to lac k o f o rg a n iz a tio n o n th e p a r t o f th e sta ff involved ra th e r th a n m edical p ro b lem s in h ere n t in the p a tie n t. T his tim e 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. ) 1 2 P H Y S I O T H E R A P Y JUNE, 1976 p e rio d c o uld be su b sta n tia lly red u ced by h a v in g a n efficient a n d freq u e n tly ru n clinic caterin g to th e needs o f these patients. By keeping a c c u ra te records, a n d follow ing p a tie n ts up on a re g u la r basis, one is a fforded a n excellent o p p o rtu n ity fo r clinical a n d sta tistica l research, so m e th in g so sorely lacking in m an y sp h eres o f re h ab ilitatio n . L a s t b u t n o t least th e clinic situ a tio n offers a n ideal s itu a tio n fo r inte rd isc ip lin ary teaching. I t offers a learning e xperience fo r m edical, p h y sio th era p y , o c cu p a tio n a l th era p y a n d social w o rk stu d e n ts. B oth th e ra p is t a n d physician are offered th e o p p o rtu n ity o f learn in g as m uch a b o u t p ro s­ thetics as th ey desire, a topic usually skim m ed over a t the u n d e rg ra d u a te level. Figure 1: Below Knee Amputee Prosthetic Prescription. N a m e : Sex: H e ig h t: D a te : C o n s tru c tio n : E x o sk e le ta l: E n d o sk e le tal M o d u la r: S o c k e t: P .T .B . w ith Soft L e a th e r L iner. P.T .B . H a r d Socket. P .T .B . H a r d w ith Soft E nd. P.T .B . A ir C ushion. P lug F it. P.T .S. A ge: Side o f A m p u ta tio n : W e ig h t: O c c u p a tio n : Figure 2: Checkout o f Below Knee Prosthesis. A d a p ted fro m form s used a t N o rth w e ste rn U niversity C hicago a n d U n iversity o f C alifo rn ia, L os Angeles. N a m e o f P a t ie n t : D a te o f In itia l C h e c k o u t: D a te o f F in a l C h e c k o u t: 1. Is the p rosthesis as p re sc rib e d ? A re any changes justified. C heck W ith P atient Standing In Parallel Bars, 2 . Is the pelvis level w hen th e a m p u te e b ears weight equally on b o th feet? 3. Is the p a tie n t c o m fo rtab le ? 4. Is the socket c o m fo rta b le in th e d istal a n te rio r a re a of the tib ia ? (P ressure fo r a n te rio r knee sta b ility is exerted here but it sh o u ld n o t be u ncom fortable). 5. Is the socket c o m fo rta b le over the e n d o f th e fib u la ? 6 . Is the knee stable on w eight be arin g ? 7. D oes th e sole o f the shoe m ain tain even c o n ta c t withf th e flo o r? " 8 . A re tissue rolls a ro u n d the trim line o f the socket a nd the cuff suspension m inim al ? 9. D oes the a n te rio r trim line extend to th e m iddle o f the p a te lla ? (unless P.T .S.). 10. D o es the insert extend a b o v e the trim line o f the so c k e t? 11. Is there g a pping a t the b rim o f the so c k e t? 12. Is the stu m p in c o n ta c t with the distal e n d o f th e so c k e t? (Test w ith a ball o f clay o r pow der). 13. D o e s the suspension system m ain tain it’s p ro p e r p o sitio n as the fo o t is elevated off the flo o r? Socket M a te r ia l: Plastic. W ood. S u s p e n s io n : Cuff. S u p ra c o n d y la r, su p ra p ate lla r. S u p ra c o n d y la r w ith rem o v a b le wedge. T h ig h lacer. W aist Belt. A n k le /fo o t: Sach. Single axis. D o u b le Axis. H eel: Soft. M edium . H a rd . Special A lignm ent P ro b le m s: S tu m p Socks: N u m b e r. Ply. W ool. C o tto n . O ther. R e m a r k s : P ro sth e tic Facility. ...................................................................... M .D . K ey: P .T .B . = Patella T en d o n B earing. P .T .S . = P a tella T en d o n S upracondylar. Sach. = Solid A nkle C u sh io n Heel. C heck W ith the Patient Sitting. 14. Is the a m p u te e co m fo rtab le while sitting w ith the sole of the shoe flat on th e flo o r? 15. Is there a d eq u a te flaring o f the p o ste rio r trim line to acc o m m o d a te th e ham strin g tendons ? 16. W ith the sole o f th e shoe flat on the flo o r is the a n te rio r gap o f the socket m inim al ? (Less th a n inch is accept­ able). 17. C an the p a tie n t flex knee to 90 degrees? 18. Is the residual lim b forced o u t o f the socket excessively? 19. A re th e c o lo u r a n d c o n to u r o f th e prosthesis sim ilar to th e sound leg? C heck W ith the P atient W alking. 20. Is gait satisfactory ? I f unsatisfactory, w hich o f the follow ing d e v ia tio u s '- exist? (a) Heel Strike: In stab ility o f the knee. K nee extension. E xaggerated knee flexion. (b) M id -S ta n ce : L ateral bending o f trunk. W ide base. Shoe n o t flat on floor. Excessive lateral pressure over fibula head. U n e q u al weight bearing time. L ateral gapping a t socket brim . M edial gapping a t socket brim. (c) P u sh -O ff: Pelvic rise o r “ hill clim bing” . Pelvic drop-off. (d) Swing P h a s e : Excessive p iston action. Excessive knee flexion. V aulting on sou n d side. C ircum duction. E rra tic line o f fo o t swing. U n e q u al step length. 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. ) A dvanced A c tiv itie s . 21 D oes the a m p u te e a scend inclines sa tisfac to rily ? 22 D oes the a m p u te e descend inclines sa tisfac to rily ? 23 D oes the a m p u te e ascend a n d descend stairs safely? (with a n d w ith o u t rails). C an the a m p u te e w alk on uneven g ro u n d ? 25 C an the a m p u te e get in a n d o u t o f a c a r ? Check with the P rosthesis off. 26. A re th ere sock im pressions o ver th e e n tire stu m p ? 27. Is the skin free o f a b ra sio n s o r b listers? 28 A re the weight bearing a reas on th e skin o f the residual lim b free o f p a in a n d disc o m fo rt ? R ecom m endation s. jUNIE 1976 F I S I O T Post Registration Courses POST G R A D U A T E COURSE U N IV E R SIT Y O F C A PE TOW N, D E P A R T M E N T O F P H Y S IO T H E R A P Y AND T H E C E N T R E O F E X T R A -M U R A L STUDIES R A P I E 13 R E F E R E N C E S 1. A lexander, A . G ., Im m ediate P ostsurgical P rosthetic Fitting, the R o le o f the P hysical Therapist. Jo u rn a l o f the A m erican Physical T h e ra p y A sso c ia tio n , V ol. 51: 2, Feb. 1971. 2. Burgess, E. M ., A lexander, A. G ., The E xpanding R ole o f the P hysical Therapist on the A m p u tee Rehabilitation Team. Physical T h e ra p y , V ol. 53: 2, F e b . 1973. 3. C h a p m a n , C. E ., P a lm e r, H . F ., Bell, D . M ., Follow up study on a Group o f Older P atients. J o u rn a l o f the A m erican M edical A sso c ia tio n , Vol. 170: 1396-1402, July 18, 1959. 4. K erstein, M . D ., Z im m er, H ., D u g d a le , F . E ., L erner, E., A m putation o f the Low er E x tre m ity , a S tu d y o f 194 cases. A rch, Phys. M ed. R e h ab il. Vol. 55, O c to b er, 1974. 5. S tern, M ., P a y to n , O. D ., E stablishing a P rosthetic Clinic in an A cu te Care Facility. H o s p ita l T opics, J a n u a ry , 1970' Books Received P H Y S IO T H E R A P Y I N P A E D IA T R IC P R A C T IC E , by S c ru tto n & G ilb e rts o n (1975). P ric e: R 20,55 p lu s 25c delivery. P O S T U R A L V A R IA T IO N S I N C H IL D H O O D , by C . A s h e r (1975). P ric e: R 12,75 p lu s 15c d e livery. B o th th e a b o v e b o o k s a re in c lu d e d in th e P o s t­ g ra d u a te P a e d ia tric Series a n d a re o b ta in a b le fro m B u tte rw o rth & C o . (S.A.) (P ty ) L td ., P .O . B ox 792, D u rb a n 4000. “ Modern Approaches to the Physiotherapeutic Treatment in the Latter Stages of Brain Injury” JU L Y 12th to 16th, 1976 Guest Lecturers: M RS. Bi. G O F F Exponent of R ood Techniques PRO FESSO R J. C. D E VILL1ERS Neuro Surgeon Course m aximum: 24 members. Registration fee (full course): R30,00. Individual Lectures available to doctors and other interested persons: R4,00 per session. U.C.T. Accom modation available: R10,00 per day. 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. )