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PHT 2704 Final Exam Study Guide
ETIOLOGY of Amputations - ANSWER o PVD o TRAUMA o MALIGNANCY o CONGENITAL DEFICIENCY o Ethnicity: increased rate of amputations among african-americans with PVD PVD-Peripheral Vascular Disease - ANSWER - compromised blood flow, accounts for 75% of amputations; Surgical procedures (Bypass) attempt to provide re-vascularization Levels of Amputations - ANSWER o 53% are transtibial (below Knee) amputees o 33% are transfemoral (above knee) amputees o The higher the level of the amputation the more difficult ambulation becomes Partial Toe Toe Disarticulation partial foot/ray resection transmetatarsal Ankle Disarticulation (Syme's) Long Transtibial (Below Knee) Transtibial (Below Knee) Short Transtibial (below knee) Knee Disarticulation Long transfemoral (above knee) Transfemoral (above knee) Short Transfemoral (above knee) Hip disarticulation Hemipelvectomy Hemicorpectomy
Partial Toe- - ANSWER excision of any part of one or more toes Toe Disarticulation- - ANSWER Disarticulation at the metatarsal phalangeal joint partial foot/ray resection- - ANSWER resection of the 3rd, 4th, 5th metatarsals and digits transmetatarsal- - ANSWER amputations through the midsection of all metatarsals Ankle Disarticulation (Syme's) - ANSWER • ankle disarticulation with attachment of heel pad to distal end of tibia; may include removal of malleoli and distal tibial/fibular flares
**- Plantar flap used from bottom of foot to create weight bearing residual limb
- will have a leg discrepancy
- heel pad is attached to the distal end of the tibia.** Long Transtibial (Below Knee) - ANSWER more than 50% of tibial length Transtibial (Below Knee)- - ANSWER between 20% and 50% of tibial length Short Transtibial (below knee)- - ANSWER less than 20% of tibial length Knee Disarticulation- - **ANSWER • amputation through the knee joint; femur intact
- With younger population the growth plates are taken into consideration** Long transfemoral (above knee) - ANSWER -more than 60% of femoral length Transfemoral (above knee) - ANSWER - between 35%-60% of femoral length Short Transfemoral (above knee) - ANSWER - less than 35% of femoral length Hip disarticulation - ANSWER - amputation through hip joint; pelvis intact Hemipelvectomy - ANSWER - resection of lower half of the pelvis hemicorpectomy- - ANSWER amputation both lower limbs and pelvis below L4-L5 level Different Procedures - ANSWER o Myoplasty- o Myodesis- o Myofascial closure- o Tenodesis- Myoplasty- - ANSWER muscle to muscle closure Myodesis - ANSWER muscle attached to bone Myofascial closure- - ANSWER muscle to fascia
May be called Unna boot Impregnated/medicated gauze that hardens as it gets dry Disadvantage -couple of days without inspecting wounds Elastic/Soft Bandages - ANSWER Advantage
- inexpensive -lightweight Disadvantage -requires skill for application -frequent reapplication/falls off -Not very effective for edema control Shrinkers - ANSWER Type of Elastic/soft bandage Advantage - most effective compression Disadvantage **- incision must be healed
- Sutures + staples must be removed
- Difficult application
- Must be 100% healed** Phantom sensation - ANSWER o Brain registers an awareness of amputated limb o Experienced by majority of individuals post amputation o Pt feels the limb that is no longer there; pt may report tingling, burning, itching, pressure, numbness Phantom Pain - ANSWER o Brain registers pain in the amputated limb o 80% of pts may experience this o Not the same as the phantom sensation o Pt may report cramping, squeezing, shooting and/or burning pain
o May be localized or diffused Residual Pain - ANSWER o Physical pain in the residual limb o Severe pain post op; need to work around pain meds o Ensure pain control to increase pt's performance Residual limb care - ANSWER o Involve pt; make him responsible o Importance of edema control: ace wrapping, shrinker use o Positioning of the residual limb; goal is to avoid contractures o Remember that flexion is a protective withdrawal reflex o Skin care of the residual limb o Encourage pt to handle residual limb o Educate pt on wrapping/bandaging o Involve caregivers and educate as needed o Pt education r.e. home remedies
Positioning Guidelines for the Trasfemoral Amputee DO'S - ANSWER o Keep hip straight when walking without prosthesis o Keep hip straight when lying on back in bed; NO PILLOWS o Lie on stomach at least 1/2 hour daily o Avoid prolonged sitting
Transfemoral Amputee Positions to Avoid - ANSWER o Hip flexion o Hip ABDuction o Hip external rotation o NEED EXTENSION AND ADDUCTION
Transtibial Amputee Positions to Avoid - ANSWER o Hip flexion; no pillows under the leg which will allow knee flexion o Hip ABDuction
Syme's Prostheses - ANSWER o Used with an ankle disarticulation amputation o With this prosthesis there is no need for straps or a harness - a plastic liner is used to aid in suspension
Transtibial Prosthesis - ANSWER o Socket o Shank o Foot
Purpose of Foot Ankle Assembly - ANSWER BOS Shock Absorption Normalizes appearance Allows for toe off
2 Types of Foot-Ankle Assemblies - ANSWER Non-articulated: No joint or movement at "ankle"
- SACH:
- SAFE:
- Energy Storing/releasing or Dynamic response Foot: Articulated- MOVES to form to uneven surface o Single Axis o Multiple Axis
SACH: - ANSWER o solid ankle cushion heel o Most popular, light & durable o A keel is the skeleton of heel- wooden or metal o Has compression in heel for shock absorption o Soft heel compresses with weight bearing o Different densities available
SAFE: - ANSWER o stationary attachment flexible endoskeleton o Flexible keel o Adapts slightly to surface
Energy Storing/releasing or Dynamic response Foot: - ANSWER o aka dynamic response o Shock absorption at heel strike o Energy transferred through foot o Spring action at toe off
Single Axis - ANSWER Has bumper in front & back ALLOWS for DF/PF Most common
Multiple Axis - ANSWER Bumper rests on curved surface Ideal for uneven surfaces Heavy Expensive ALLOWS for DF/PF, INV/EVR, Rotation
Shank - ANSWER AKA the PYLON The connection between the foot and the socket Substitute for the human leg 2 Types of Shanks:
- Endoskeletal (modular) o Foam cover over pylon - Exoskeletal (crustacean)
o Belly of gastrocnemius o Patellar tendon o Proximo-medial tibia (pes anserinus) o Tibial and fibular shafts
TRANSTIBIAL socket alignment - ANSWER o Slight flexion Enhances loading on the patellar tendon Prevents genu recurvatum (knee hyperextension) Resists tendency of the amputated limb to slide too deeply into the socket Facilitates quad contraction o Slight lateral tilt to reduce loading on the fibular head
Socket Lining - ANSWER o Lined: foam, cotton/wool socks, synthetic fabric socks, silicone sheet o Unlined socket
SUSPENSION: - ANSWER o holding the socket in place o The mechanism that ensures the prosthesis to remain anchored to the residual limb
Types of Transtibial Suspensions: - ANSWER o Cuffs: supracondylar, fork strap, waist band o Sleeves o Distal attachment (silicone sheet with a distal metal pin) o Osseo-integration(NOT DONE IN US- COULD CAUSE INFECTION) o Socket itself may have supracondylar brim and suprapatellar suspension o Thigh corset
TRANSFEMORAL PROSTHESIS - ANSWER o FOOT, ANKLE,ASSEMBLY and SHANK
same as transtibial prosthesis o Knee Assembly/ Knee units
Knee Assembly/ Knee units - ANSWER MECHANICAL: Axis system COMPUTARIZED
MECHANICAL: Axis system - ANSWER • single o reliable, durable, light weight simple, inexpensive; basic hinge joining the thigh and the shank
- multi -axis (polycentric) o 2-4 pivoting bars joining the thigh and the shank o HYDRAULIC KNEE -OIL o PNEUMATIC KNEE -- AIR
COMPUTARIZED - ANSWER • Intelligent Knee - C leg: Computer program- accommodates to speed of pt
Types of Brakes/Knee locking systems - ANSWER Weight Activated- depends on position- prevents locking from 25-0 range Hydraulic- brake activated at heel strike, remains on through stance phase Manual- once locked, stays locked Computerized
Sockets for the Transfemoral Amputee - ANSWER Emphasizes loading on pressure-tolerant structures: gluteal muscles, sides of thigh, distal end of the amputated limb to a lesser extend Avoids pressure in the pubic symphysis and perineum -Quadrilateral -Ischial Containment Socket
SUCTION SUSPENSION - ANSWER Suction will be caused by the pressure difference between the inside and outside of the socket One-way air release valve utilized
TOTAL SUCTION - ANSWER o Total/snug contact of socket and residual limb o No socks/sheaths or liners are utilized o Pt may use powder or lotion to assist application o One way valve utilized (air is expelled from the socket -through the valve-- as the residual limb is inserted creating a vacuum -negative pressure; also the skin around the brim of the socket creates a seal)
PARTIAL SUCTION - ANSWER o Socket is looser o Pt uses socks to achieve a snug fit o May need a waist band (Silesian band) o Used with pt with short residual limbs or pts with hypersensitive skin
NO SUCTION - ANSWER o Uses socks and pelvic band o Also needs suspension sleeve over socket
SOCKS, SHEATHS AND LINERS - ANSWER Socks used by all pts except with total suction Socks are made of different fabric materials and thickness (called ply) Sheaths can be silicone, urethane, neoprene (Tes belt: total elastic suspension) If Pt is requiring 15 ply or more is time to readjust the socket
Quad Socket Fit - ANSWER Ischial Tuberosity rests on posterior shelf o 1/2" posterior to inner edge o 1" lateral to medial inner edge
Add. Long. Tend. Rests in anterior/medial corner of socket. Greater Trochanter should be in contact with lateral side of socket
Ischial Containment Socket Fit - ANSWER Ischial tuberosity rests within socket Add. Long. Tend. Rests in adductor groove of socket Greater Trochanter should be in contact with lateral side of socket
Gait Deviation can cause - ANSWER o Lack of Safety o Energy Expenditure o Inefficient/ Fatigue +Stress
3 Main Gait Deviations - ANSWER Lateral Displacement of Prosthetic Leg Excessive Trunk Shifting
- Prosthesis too short or medial wall too high and pinching skin Prosthetic Knee Problems (transfemoral Population)
Lateral Displacement of Prosthetic Leg - ANSWER • Lateral hip tilt o glute medius of opposite side= weak
- Abduction of leg= circumduction o Knee not flexing in prosthesis or too long o Weak hip flexors - Wide gait o pinching w/ medial aspect of prosthetic or to long - too much fluid will bend more at the knee
Neuromuscular Maturation - ANSWER o Measured by developmental milestones reached from birth to the adult age; key activities
- Can take months to years
Theories of how to achieve movement - ANSWER • Hierarchical theory
**- REFLEX MODEL
- Systems or task oriented Model**
Hierarchical theory - ANSWER (H.Jackson 1932) o TOP-DOWN progression: each successive, anatomical higher level will exert control over the levels below it
- Highest level: cortex Middle level: basal ganglia, brainstem, cerebellum Lowest level: spinal cord o Consider damage to the higher levels (cortex) there will be no inhibition re-emergence of primitive reflexive movements.
REFLEX MODEL - ANSWER o Sherrington 1900's o Stimulus is applied o Movement occurs without conscious thought o Sensory system must be intact
Systems or task oriented Model - ANSWER o (Bernstein 1932) o Views motor control as a result of an interactions /cooperative actions of many systems o It is task oriented o Considers both internal/external factors o Closed vs. Open loop models
Closed Loop Systems or task oriented Model - ANSWER CLOSED
**- Employs feedback
- Uses ERROR as reference for correctness
- Utilized when learning a new skill
- Examples: walking, stair climbing**
Open Loop Systems or task oriented Model - ANSWER OPEN
**- Motor programs that are run off without feedback or error detection
- Movement is the result of an established motor program
- Examples: riding a bike, playing piano**
How do we measure motor learning? - ANSWER 1. Performance
- Retention
- Ability to generalize
- Contextual change
Performance - ANSWER how well is the patient doing the task
Retention - ANSWER • how well are they retaining that knowledge
- able to carry over the tasks
Ability to generalize - ANSWER apply the skill to real life situation
Contextual change - ANSWER changing of the surfaces like walking on grass instead of solid floor
3 Phases of Motor Learning - ANSWER o COGNITIVE: understanding what to do o ASSOCIATIVE: how to do it
SYNERGISTIC PATTERNS - ANSWER o UE - flexor synergy more common o LE - extensor synergy more common o Isolation of individual muscle action may not be possible when the patient is demonstrating TRUE synergies o Decrease or increase in tone will determine your approach in terms of neurorehabilitation
Rehab during the early stages - ANSWER o ROM including uninvolved extremities o Positioning (out of predictable synergistic patterns); o static balance training o Mobilize (bed mobility, transfers, w/c mob) o Promote awareness of involved extremities o Proximal then distal o Pre-gait activities as able o Family/caregiver training
Rehabilitation during the Middle stage of recovery - ANSWER o Continuation and progression towards LTGs o Continue mobility o Facilitation/inhibitory techniques o Cont. balance training o Stability and controlled mobility o Family/caregiver training
Rehabilitation during late recovery-advanced stage - ANSWER o Refinement of volitional control o Improvement of speed/timing/coordination o Encourage reciprocal movements o Skill development
o Cont. to refine gait/all functional mobility tasks
Developmental Sequence - ANSWER o Patterns of movement demonstrated from birth o Normal maturation of the CNS o Neuromuscular control develops as we mature o These patterns are progressive o They progress form simple to complex movements and postures o Ability to master a posture, maintain it and progress to a more complex one
Key postures and Sequence of Development - ANSWER o Supine o Prone o Prone on elbows o Prone on hands o Quadruped/all fours; kneeling, half kneeling o Semi-squat o Modified Plantigrade/Stand o Walk
Goal of the Developmental Sequence - ANSWER o to promote achievement of higher level of functional mobility o Following the developmental sequence, the patient is likely to recover the motor skills lost in the manner that they first occurred o During neurorehabilitation your goal is to retrain that injured CNS - re-establishing NEW pathways/ connections
motor control progression as follows - ANSWER o Cephalocaudal- head to feet o Proximal to distal o Gross motor to fine motor
