C l i n i c a l R e s e a r c h K n o w l e d g e a n d S k il l o f Pa t ie n t s w it h REGARD TO AMPUTATION STUMP B a n d a g i n g , p r io r t o a P r o s t h e s is A B S T R A C T : A sw ollen or p o o rly con ed stump makes it im possible f o r the p rosth etist to VISSER C p ro vid e a p a tien t who had an am putation with a prosthesis. ________________________ It is both costly, and time consuming f o r the p a tien t and the am putation team i f the p a tie n t needs to make repeated visits to the clinic. The p u rp o se o f this study is to determ ine the know ledge and skill o f p a tien ts with regard to am pu­ tation stump bandaging. Thirty-three low er limb am putees, who visited the am putation clinic, were random ly chosen to p a rticip a te in this survey. The investigation included a questionnaire and a p h ysica l evaluation by a p h ysio th e ra ­ p is t on the effectiveness o f the bandaging. Results: Only 16 (49% ) o f su bjects received information, education an d dem onstration on bandaging f o r their stump. Three o f the 16 su bjects were ju d g e d to have had effective stump bandaging. From this study it is clea r that there is a lack o f knowledge an d skills relating to bandaging am ongst am putation p a tien ts an d that this urgently needs to be rec­ tified to ensure m aximal fu n ction al outcomes. INTRODUCTION The reason why a primary amputee may be referred to the local amputation team is for cast, measurement, fitting and subsequent delivery of a prosthesis. Not every patient referred to the prosthetic rehabilitation team will be fitted with a prosthesis. The success of the rehabilita­ tion program is determined to some extent by the individual’s physical char­ acteristics of the residual limb. A well- healed, cylindrical limb with a non­ adherent scar is easier to fit than one that is conical or has redundant tissue distally or laterally (O ’Sullivan and Schmitz 1988). Prosthetists at the Pretoria Academic Hospital (PAH) are concerned about the quality of amputation stump shape and size of patients presenting at the amputation clinic for a prosthesis. At the PAH, patients attend the ampu­ tation clinic six weeks after the amputa­ tion for the first cast model in preparation for a prosthesis to be made. If oedema is still present at this stage, prosthetic fit­ ting will be delayed (Brady 1982). Control and reduction of oedema are pre­ requisites for wound healing, coning and eventual prosthetic fitting (MacLean and Fick 1994). Soft dressings remain a pop­ ular form of post-operative dressing tech­ nique for the amputee. Sustainable pres­ sures greater than 15 mm Hg have been found to decrease blood flow and sus­ tained pressures greater than 25 mm Hg have been found to be potentially harm­ ful, due to tissue ischemia as a result of direct mechanical pressure (Spiro et al 1980). Intercapillary pressure varies with dependency of the limb, therefore the ideal bandage should provide graded pressure that is maximal at the most dis­ tal point and decreases proxim ally (Isherwood et al 1975). Isherwood et al (1975) com pared pressures under amputee dressings that had been applied by skilled staff to those applied by unskilled staff. The conclusion was made that elastic bandages can be potentially dangerous when applied by unskilled individuals. Soft dressings remain popu­ lar, as they are inexpensive, readily avail­ able, quick to apply and frequent obser­ vations to the wound are possible (Browse 1974). Bandaging is an acquired skill. If applied correctly, it is an effective and econom ical stum p shrinkage tool (O ’Sullivan and Schm itz 1988). The bandaging must be done accurately, supervised continuously, and taught to the am putee (H olliday 1981). Early prothetic limb fitting not only hastens recovery of an amputation but can be cost effective and time saving (Pinzur et al 1988). Since bandaging is so vital, this study was initiated to determine the knowledge and skill of patients with regard to ampu­ tation stump bandaging, prior to fitting of a prosthesis. This study will also attempt to provide solutions for the possible lack of knowledge and skills by means o f the CORRESPONDENCE: Mrs C Visser (Lecturer University of Pretoria) B Phys T (UP) PO Box 710 Faerie Glen 0043 Tel (h) (012) 991 1953 (w) (012) 354 2023 8 SA J o u r n a l o f Physiotherapy 1998 V o l 54 No 3 Fig 1: D em onstration and education on the bandaging o f the a m p u ta tio n stum p. FIGURE 1 Demonstration and education on the bandaging of the amputation stump Subjects studied □ Demonstration and Education received ES No Education and Demonstration received 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. ) FIGURE 2 Members of the medical team who provided education and demonstration B Subjects studied □ O ccupational Therapist M Physiotherapist S Nurses Fig 2: Members o f the medical team w ho provided education and dem onstration following: An inform ation booklet that will include: - Pre- and post-operative information to the patient. - Applicable exercises and do’s / don’ts. - Setting the criteria for obtaining a prosthesis. - Explaining the role of each member of the amputation team. - Translating this inform ation into other languages and distributing it to rural clinics. METHODS This investigation was done on the first 33 subjects who attended the amputation clinic at the PAH since the start of this study (1997/4/4). Only subjects with lower limb amputations were included in this study, while subjects who did not use the prescribed bandage for coning were excluded. R easons for am putations included the following: tumors (5), trau­ ma (11), diabetes (5), arteriosclerosis (12). Most amputation procedures were done at the PAH and referrals from other hospitals were as follows: private (3), Kalafong (4). All participants completed a consent form. Evaluations were done individually in an examination room, by the same physiotherapist. T h e s t u d y in c lu d e d th e fo llo w in g : • A questionnaire to test the patient’s know ledge and skills on amputation stump bandaging. The questionnaire was developed for this study, and pre-tested for clarity. • A physical evaluation by the same physiotherapist on the effectiveness of the bandaging. The criteria for effective stump ban­ daging included (Brady 1982): - Bandage worn for more than 20 hours a day. - Bandaging technique demonstrated by either the physiotherapist or occu­ pational therapist and practised by the patient under supervision. - The bandage washed every third day and the washing technique consisting o f a gentle pressing out with the hands. - Three bandages available at any given time. - As the main reason for bandaging is shaping the stump for a prosthesis, most tension should be on the distal part of the stump. - The physical application o f the ban­ dage included the following: - Application to start distally. - Bandage applied in a figure of eight. - The bandage to end high enough in the groin for the above-knee amputee and five fingers above the patella for the below-knee amputation. RESULTS Twenty-one males and 12 females, aged between 23 years and 78 years par­ ticipated in the study and the period of time after amputation was 6 weeks to 2 years. 1.1 Education to patients on bandag­ ing of amputation stumps. (Figure 1) O f the 33 subjects who partici­ pated in this study, only 16 (49%) received previous education and dem onstration on am putation stump bandaging. Seventeen (52%) o f the subjects had received no form of demonstra­ tion or education at all. 1.2 Members of the medical team whoprovided education to the patients. (Figure 2) Sixteen subjects who received dem onstration and education obtained their information from the following members of the team: Eight (50%) received this information from an occupational therapist, two (13%) from a phys­ iotherapist and six (38%) from a nurse. None o f the subjects received written information on FIGURE 3 Effectiveness of the bandaging 9 Suojects studied □ Bandaged > 20 hrs per day 0 Bandaged high enougn m Bandaged in a □ Bandoging stdrfed distally ■ Most pressure distally E3 aanaaged effectrveiy Fig 3.- Effectiveness o f bandaging SA J o u r n a l o f Ph ysio t h er a py 1998 V o l 54 No 3 9 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. ) amputation stump bandaging as part of their education. 1.3 Reasons for bandaging Eleven (69%) of the 16 subjects knew that the main reason for amputation stump bandaging was coning, four (25%) said that it was for pain control and 1 (6%) for cosmetic reasons. 1.4 Effectiveness of the bandaging. (Figure 3) Ten (63%) of the 16 subjects wore the bandage for the prescribed 20 out of 24 hours a day. All the subjects had more than one bandage and there was therefore no rea­ son for a subject to go without stump bandaging at any stage. Seven (44%) continued the bandaging o f the stump high enough. Twelve (75%) bandaged the stump in a figure of 8, 14 (88%) started with the bandaging distally and 10 (63%) applied the bandage with enough pressure distal­ ly- After individual analysis it was found that only 3 (9%) subjects fitted all the cri­ teria o f effective stump bandaging. 1.5 Handling of the bandage. Only 5 (31%) of the 16 subjects knew how to wash the bandage correctly. To wash the bandage correctly is vital to the life span of these particular bandages, used for coning. It is interesting to note that 2 out of the 16 subjects who had their amputations for just over 1 year still had fairly good know ledge and skill on am putation stump bandaging. Patients seemed to remember all aspects of this traumatic procedure, vividly. O f further interest was the fact that more than half o f the subjects referred from hospitals other than the PAH did not receive any form o f education and demonstration. It was alarming that seven out o f 33 subjects did not receive any form o f exer­ cise and that two of these patients had to be sent back home with a flexion con­ tracture of the hip. DISCUSSION From this study it is clear that there is a lack o f knowledge and skill relating to bandaging amongst amputation patients and that this urgently needs to be recti­ fied to ensure maximal functional out­ comes (Esquenazi and Meier 1996). This can be achieved by involvement o f all the members o f the medical team in provid­ ing consistent education to the patient (Esquenazi and Meier 1996). Detailed instructions to the patient, followed by repetition and re-evaluation need to be emphasised. Individualising the educa­ tion process with emphasis on reasons for bandaging need to be adressed (Andrews 1996). Ozyalcin and Sesli (1989) supports the findings from this survey. He stated that the problems encountered in developing countries are inadequate fitting of pros­ thesis and the lack of proper rehabilita­ tion. CONCLUSION Physiotherapy is a vital part of the rehabilitation of amputees, which include assessm ent, post-operative exercises, transfers, bandaging techniques, educa­ tion and gait training (Andrews 1996). Stump and leg self-care procedures should be taught and reinforced through­ out the rehabilitation period. Automatic integration o f these routines into the am putee’s adapted life-style only occurs after frequent and consistent repetition. Patients often have difficulty in compre­ hending and retaining information and instructions in the early stages o f rehabil­ itation. However, simple written instruc­ tions can be provided to help ensure con­ tinued follow-up at home. REFERENCES Andrews KL 1996 Rehabilitation in limb deficiency. The ge ria tric am putee. Arch Phys M ed Rehabil 77:S -14-S -17.2. Brady W M 1982 Post-operative management o f low er extremity amputees using Tubular Elastic Com pression bandaging. O rthotics a n d P rosthetics 6:8-10. B row se N L 1974 Amputation o f the lower limb. N u rsin g M irro r June:63-65 Esquenazi A, M eier RH 1996 Rehabilitation in limb deficiency. Limb amputation. A rch P h ys M e d R eh a b il 7 7 :S -18-S-28. H olliday PJ 1981 Non-prosthetic care. In JP Kostuik and R G illespie, eds. A m p u ta tio n surgery a n d rehabilitation: The Toronto experience. N ew York: Churchill Livingstone. 238-242. Isherwood PA, Robertson JC, R ossi A 1975 Pressure measurements beneath below -knee amputation stump bandages: elastic bandag­ ing, the Puddifoot dressing and a pneumatic bandaging technique compared. B r J Surg 62:982-986. M acLean N , Fick GH 1994 The effect o f semi-rigid dressings on below -kn ee amputa­ tions. P h ys T her 74:668-673. O ’Sullivan SB, Schmitz TJ 1988 P h ysic a l rehabilitation: A sse ss m e n t a n d treatm ent. 2ed. FA David Company. Philidelphia :385- 405. O zyalcin H, Sesli E 1989 Temporary pros­ thetic fitting o f below -knee amputation. Prosthetic and Orthotic Int. 13(2):86-9. Pinzur M S, Littoy F, Osterman H, Wafer D 1988 Early post-surgical prosthetic limb fit­ ting in dysvascular below -knee amputees with a pre-fabricated tempory limb. O rthopeadics. 11(7): 1051-3. Spiro M, Roberts VC, Richarson JB 1980 The effect o f externally applied pressure loads upon blood supply to the skin. B r M e d J 1:719-723. QUESTIONNAIRE (SUMMARISED) 1. How many hours (out of 24) do you wear the bandage? betw een 0-8/betw een 8-12/m ore than 20 2. W as the bandaging technique shown to you? no yes 3. Did you practice the bandaging under supervision? yes no 4. How often do you wash the bandage? every day every second day every third day once a w eek 5. Did you receive any written infor­ mation on the bandaging technique? no yes 6. W ho demonstrated the bandag­ ing technique to you? physiotherapist occupational therapist nurse other 7. Do you have more than one bandage? no yes (how many?) 8.How do you wash the bandage? like washing clothes pressing it out with your hands use washing machine 9. W hat do you think is the main reason for bandaging? for pain looks better shaping the stump for a prosthesis keeping the stump warm other 10. Where must the most tension be after bandaging? on the upper end o f the stump on the low er end o f the stump equally distributed Physical Evaluation 1. D id the subject start distally with the application o f the bandage? 2. Is the bandage applied in a figure o f 8? 3. D oes the bandage end high enough? 10 SA J o u r n a l o f Ph y sio t h er a py 1998 V o l 54 No 3 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. )