PP06 - Week Two

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Introduction

This week we are exploring the acute care phase of the individual following amputation surgery. Many of these topics will be relevant for the entire pre-prosthetic period.

You can see the online version of the week two email here.

In the video below Aicha Benyaich from the ICRC and Rachael Lowe sum up week one and discuss the topics for this week (Note - watching this video is optional). Unfortunately the audio quality is poor due to the internet connection in Iraq.

Objectives for this week

At the end of this week you should be able to:

1. Assess an individual undergoing amputation and have an understanding of the management of their physical, psychological and social needs.
2. Identify and appropriately manage complications of amputation.
3. Identify common challenges associated with amputees post operatively and their management
   
4. Recognise and understand pain related conditions.
   

Topic 1: Assessment

The surgical removal of a limb(s) due to complications associated with disease or trauma is considered as an "acquired amputation".

To appropriately assess individuals undergoing acquired amputation you must have an understanding of the management of their physical, psychological and social needs.  This is done by performing an assessment which includes asking questions about past medical history, medication, present medical history and social history as well as performing a physical/objective assessment.

1. For an overview of the the assessment of an individual undergoing amputation read Assessment of the amputee in Physiopedia.  This information is applicable for both pre and post operative assessment.
   

Topic 2: Pre-operative physiotherapy 

In an ideal situation all individuals facing amputation surgery would have a full interdisciplinary assessment pre-operatively. In reality this is not always possible for a number of reasons, including the urgency of the surgery, patient level of consciousness, or even poor planning and communication. In this situation it is important to include this aspect of your patient management into the post-operative assessment.

A pre-operative consultation enables the physiotherapist to give appropriate advice, information and reassurance. Early assessment and planning can commence at this stage when possible and helps to prepare the patient for rehabilitation, prevent secondary complications and maximise the patient's physical outcome.

1. In the Engstrom textbookread pages 39-50 from chapter 2 which builds on last weeks knowledge and covers pre-operative therapy assessment and preparation.
2. Read the Pre-operative physiotherapy page from AustPAR to find detail of what a pre-operative assessment would ideally include.

Patient education is a very important ongoing part of your treatment plan for the individual with amputation. Take a look at this document which can be a useful pre-operative education tool for your patients.

• Questions to Ask Your Surgeon

Topic 3: Acute post-operative physiotherapy

Goals of the acute post operative phase are to prevent complications, manage the wound and stump, restore mobility and independence, manage pain and commence discharge planning.  This topic will give you knowledge and strategies to work towards these goals.

1. For an overview of acute post-surgical management take a look at this page on Physiopedia.
   
2. Also read through the AustPAR post-operative physiotherapy page which gives a good guideline for post-op management.
3. Read about immediate post surgical management and the advice that you can give to patients on pages 56-62 ICRC PGA Manual
4. If you have time you can also read chapter 4 (pages 93-118) in the Engstrom textbook which covers immediate post operative treatment.

Topic 4: Post-operative complications

Post surgical complications can create a challenge to successful rehabilitation.  This topic will give you an understanding of the complications that can be associated with amputation surgery and provide therapeutic answers to these complications.

1. This Physiopedia page Complications post amputation gives an overview of complications that can occur after amputation. 
   
2. Read about ideal stump conditions on pages 44-47 in the ICRC PGA manual for physiotherapists
   

Topic 5: Pain management

Post-amputation pain is experienced by most individuals who have undergone amputation surgery.  This topic will explore the different types of pain that amputees experience and also the strategies used to deal with the pain.

1. Read this short overview on pain management of the amputee in Physiopedia
2. If you have time, for a more in depth look at pain in different types of amputation read chapter 27 from the O&P Library on management of pain in the amputee
3. Chapter 20 (pages 528-543) in the Engstrom textbook covers pain management.
   
4. To find out more about Phantom limb pain read this page in Physiopedia (be sure to click through the link to read more about mirror therapy)
5. Optional - In this video from Peter Le Feuvre we discuss important aspects of pain management in the individual with amputation:

Key to preventing secondary pain after limb loss is preventing complications.  As Peter mentions in the video, along side early prosthetic fitting and management of musculoskeletal imbalances, patient education is key to managing pain.  Below are a variety of patient education leaflets from the Amputee Coalition that you should read and then use with your patients as appropriate:

• Introduction to managing pain
• Perioperative pain management
• Avoiding secondary pain
• Living with Residual Limb Pain
• Living with Phantom Limb Pain

Quiz

You are not assessed on this quiz, it is designed for you to test your knowledge on the topics this week.

Have a go at the quiz for week two

Case Study

Watch this video:

Find out more about Tahir (alternative text document if you can't watch the video)

Discussion

Go to the Discussion Forum and add responses for the three discussion activities below. Please post your discussions as a comment in the relevant discussion thread that will be set up for you.

1. Should we use the ICF as a clinical tool for lower limb amputees? What are the advantages and disadvantages?
   • Go directly to this discussion
2. What are the most common post surgery complications that you meet in your working environment? What are the techniques used to address these complications in your setting?
   • Go directly to this discussion
3. In relation to the case study in the video of Tahir what is the most important assessment parameter to take and how it will influence his follow up? What outcome measure might you propose for assessing his function?
   • Go directly to this discussion

Optional: Explore other resources

The following resources are optional for you to read/view but will further expand your knowledge on this week's topics:

• Gailey et al. The amputee mobility predictor: an instrument to assess determinants of the lower-limb amputee's ability to ambulate. 2002. Arch Phys Med Rehab, 83:613-627
• Raya, M.A. et al. Amputee Mobility Predictor-Bilateral: A performance-based measure of mobility for people with bilateral lower-limb loss. Journal of Rehabilitation Research & Development. 2013. 50(7):843 — 854
• Diabetic foot/stump assessment
• Read more about wound healing
• Pain management (AustPAR)
• Pain Management - Post Amputation Pain (1998). Amputee Coalition of America, inMotion, 8, 2.
• Walsh, NE (2005). Pain Management for the Lower-Limb Amputee. Journal of Orthotics & Prosthetics.
  
• How to use Mirror Box Therapy with David Butler. www.youtube.com/watch?v=hMBA15Hu35M

If you can get hold of these articles you may find them useful:

• Jensen TS, Krebs B, Nielson J, et.al: Phantom Limb, Phantom Pain, and Stump Pain in Amputees During the First Months Following Limb Amputation. Pain 1983, 17:243- 256.
• Jensen TS, Krebs B, Nielson J, Rasmussen P: Immediate and Long Term Phantom Pain in Amputees: Incidence - Clinical Characteristics in Relationship to Pre-amputation Pain. Pain 1985, 21:256-78.
• Nikolajsen L, Jensen TS. Phantom Limb Pain. British Journal of Anaesthesia 2001, 87:107-116, 2001.
  Kalauokalani DAK, Loeser JD: Phantom Limb Pain. In: Crombie IK: Epidemiology of Pain. IASP Press: Seattle. pp.143-53, 1999.
• Nikolajsen L, Hansen CL, Nielsen J, et. al: The Effect of Ketamine on Phantom Limb Pain: a Central Neuropathic Disorder Maintained by Peripheral Input. Pain 1996, 67:69- 77.
• Ramachandran VS, Rogers-Ramachandran D: Synaesthesia in Phantom Limbs included with Mirrors. Biological Sciences 1996, 263:377-86.
• Dworkin RH, Backonja M, Rowbotham MC, et.al: Advances in Neuropathic Pain: Diagnosis, Mechanisms, and Treatment Recommendations. Arch Neurol 2003, 60: 1524-34.
• Flor H: Phantom Limb Pain: Characteristics, Causes, and Treatment. Lancet Neurology 2002, 1:182-189.
• Sherman RA: Postamputation Pain. In: Jensen TS, Wilson PR, Rice ASC (eds.): Clinical Pain Management: Chronic Pain. Arnold Press: London. pp. 239-49, 2003.
  

Prosthetic Gait Analysis for Physiotherapists This is the course textbook from ICRC which will be available to all participants of the course. Access the book here Alternatively you might be interested in having your own copy of the book. Download your own FREE copy here

Therapy for Amputees This course textbook has kindly been provided by Elsevier and will be available to all participants of the course for FREE for the duration of the course. Please bear in mind that this book is fairly old so use it critically in addition to all the other resources that we will point you at. Access the book here Alternatively you might be interested in having your own copy of the book. Buy with 20% discount from your local online Elsevier store (not available in all regions) Buy PDF version for £4.99 direct from Physiopedia