ClinKinesExam4

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ClinKinesExam4
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2011-04-25 21:05:41
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  1. What are the major causes for LE amputation?
    PVD

    Trauma

    Cancer

    Congenital
  2. Risk factors for PVD?
    diabetes

    poorly managed hypertension

    high cholesterol/triglycerides

    smoking
  3. Causes of amputation by %
    disease 70%

    congenital 2%

    trauma 23%

    cancer 4%
  4. What is intermittent claudication?
    cramping pain, especially in the calf

    induced by walking or other prolonges muscle contraction

    relieved by short period of rest
  5. does vascular pain (increase/decrease) with LE elevation?
    increases
  6. What is arteriosclerosis obliterans
    @ least 1 major arterial pulse (dorsalis pedis, poplieal artery, femory artery) absent or impaired
  7. Clinical signs of PVD (10)
    • 1. absent pulses
    • 2. cold feet
    • 3. dependent rubor
    • 4. shiny skin
    • 5. intermittent claudication
    • 6. loss of hair on leg and foot
    • 7. atrophy of subcutaneous fat
    • 8. rest pain relieved with dependency
    • 9. delayed capillary filling time
    • 10. ischemic lesions
  8. how long does it take for capillary filling time? UE vs LE
    UE--2-3 secs

    LE-3-4 secs
  9. what is the number of the Semmes-Weinstein monofilament protective sensation?
    5.07
  10. what should be the primary goal of people with PVD/DM in regards to feet?
    PREVENTION!!!!
  11. what is the ideal length of a transtibial amputation?
    5-7 inches
  12. What is the level/classification of amputation in transtibial?
    54%
  13. What is the level/classification of amputation of transfemoral?
    32%
  14. what is the level/classification of syme/foot?
    3%
  15. what is the level/classification of amputation of hip disarticulation?
    1%
  16. What is the level/classification of amputation of UE?
    8%
  17. selection of amputation level? consideration with.....?
    PVD, trauma, malignant tumor, deformity, congenital limb deficiency
  18. higher the amputation ______difficult the rehab (more/less)

    older/sicker the pt. _______difficult the rehab (more/less)
    more

    more
  19. name the age and % of amputees
    > 61 yrs 40%

    41-60 yrs 35%

    < 40 yrs 25%
  20. are amputations more common in men or women?
    men (72%)
  21. tests to do initially when seeing an amputee
    strength test of joint just PROXIMAL to amputation can consist of only ACTIVE, non-resisted antigravity motion until suture heals
  22. once cleared by a physician how is MMT different in amputee vs healthy person
    lever arm is reduced to MMT grades could be inflated
  23. how to you measure the residual limb?
    find a bony landmark and measure to the end of the soft tissue
  24. how do you measure circumference?
    medial tibial plateau or tibial tubercle and at eqaully spaced points to end of lib

    transfemoral-begin at ischial tuberosity or greater trochanter--measure inbetween intervals
  25. what are some likely impairments in amputees? decreased.....
    • -strength, ROM, endurance
    • -skin integrity
    • -mobility
    • -psychological issues
    • -balance
    • -coordination/proprioception
  26. what are some functional limitations in amputees?
    inability to walk, work, play
  27. what are some aspects to include in the early post-op care?
    • ROM
    • positioning
    • skin care
    • edema control
    • isometrics
    • strengthening of UE and residual/sound limb
    • pt education
    • bed mobility
    • transfers
    • balance
  28. primary goals/outcomes post-op?
    • wound healing
    • prep of limb for prosthesis fit
    • increase mobility
    • improve endurance
    • care of sound limb
    • increase ROM/strength
  29. how should you inspect the wound?
    shape, incision, healing/closure, length, sensory integrity, volume, tissue integrity, color, temp, pain
  30. is it normal for drainage to occur from the residual limb? when does it become a problem?
    Yes, its normal

    if it becomes red or darker blood or thickening discharge call a doctor
  31. where do you do scar massage?
    above and below, not across
  32. what is phantom limb sensation?
    numbness, tingling, presure, itching, mild cramp in foot/calf

    70% will experience this
  33. what is phantom limb pain?
    shooting pain, severe cramping, severe burning

    higher the amputation greater the liklihood
  34. how do you explain to your patient phanton limb pain?
    nerves that once had branches to the LE are still present but have ended up at a new place and this takes the brain a while to adjust
  35. treatment of phantom limb pain
    patient education

    inspection for neuromas

    compression

    medications
  36. PT management of pain
    time pain meds with treatment

    pt education on relaxation

    TENS/ US/ Cold, massage

    wear prosthesis/compression bandages
  37. why are compression bandages important?
    • -reduce edema
    • -controls pain
    • -enhance wound healing
    • -protects incision
    • -shapes and desensitizes limb
  38. applied by surgeon, removed 3-4 days, replaced with IPOP allows TTWB in 2-3 days
    (rigid, semi-rigid, soft bandaging)
    rigid
  39. best for edema control
    (rigid, semi-rigid, soft bandaging)
    rigid
  40. not good for pt with risk of infection because can't see skin underneath
    (rigid, semi-rigid, soft bandaging)
    rigid
  41. prosthetist takes negative mold in OR or after rigid removed 3 days
    (rigid, semi-rigid, soft bandaging)
    semi-rigid
  42. polyethylene light weight, easy to clean, more durable than plaster
    (rigid, semi-rigid, soft bandaging)
    semi-rigid
  43. unna paste-zinc oxide , glycerin, calamine and gelatin-dries in 24 hours can be left on for 5-7 days
    (rigid, semi-rigid, soft bandaging)
    semi-rigid
  44. ace bandage, compresso-grip
    (rigid, semi-rigid, soft bandaging)
    soft bandaging
  45. once suture line healed (10-21 days) use shrinker wrap TT/TF
    (rigid, semi-rigid, soft bandaging)
    soft bandaging
  46. Principles of ace-wrapping:
    distal pressure should be ___more/less than proximal
    pressure applied on _______turns (oblique/angular)
    wrinkles?
    metal clips?
    wear ____hours a day
    wash ___ don't _____
    more pressure on distal

    pressure applied oblique

    no wrinkles!

    no metal clamps!

    wear 23 hours a days
  47. what are most common contractures that can occur in transtibial amputation?
    hip flexion

    knee flexion
  48. why do TT amputees get contractures?
    long periods of sitting, flexion position is comfy

    protective flexion withdrawal pattern associated with LE pain

    muscle imbalance

    loss of sensory input
  49. what are common contractures in transfemoral amputees?
    hip flexion

    hip abduction

    hip ER
  50. how can you prevent contractures?
    knee in extension

    lie prone

    HEP

    AROM/PROM
  51. post op strengthening consists of what type of contractions? and where should ROM occur?
    isometric contractions

    limited ROM at proximal joint
  52. strengthening protocol
    10 sec contraction

    5-10 rest for 10 reps
  53. AROM of unaffected limb on day ___

    affected limb day ___

    bed mobility/transfers day _____
    day 1

    days 1-3

    day 2
  54. as wound healing progresses include the following:
    large arc of motion

    active resistive exercises

    isokinetics

    eccentric
  55. general plan of care for amputee
    hip ext/hip abd/add, knee ext

    general strengthening/ ROM of trunk/UEs

    aerobic exercise

    posture

    skin integrity
  56. PT ideally begins _____(before/after) pt has amputation
    BEFORE
  57. after a LE amputation PT focuses on ....?
    pre-prosthetic training for functional mobility

    skin care
  58. typical socket designs for trans-tibial
    patellar tendon bearing

    supra-condylar suspension

    total surface bearing
  59. typical socket design for trans-femoral
    ischial containment/narrow ML

    quadrilateral socket/narrow AP
  60. what does the pylon do?
    connects socket to foot
  61. components of prosthesis
    based on patients function/goals

    length of limb

    consider weight of patient plus their lifting activities
  62. what is the job of the suspension?
    holds prosthesis on the residual limb
  63. what are the different types of suspensions?
    • pin
    • cuff
    • sleeve
    • belts
    • suction
    • combination
  64. what are the different types of liners/socks?
    • pelite inserts
    • sheath
    • socks
    • gel liners
  65. post op care for residual limb (make sure to do to sound limb)
    wash nightly with mild soap, pat dry with cloth

    small amount of lotion/powder (no alcohol)

    daily skin inspections

    desensitization

    soft tissue mobilization
  66. are wheelchairs used for amputees? if so what are they used for?
    Yes! used for long distances for very short TF
  67. what is a common transfer to use?
    stand and pivot

    may need sliding board?
  68. how can you work on balance?
    sit, hands and knees, kneeling, stand
  69. progression of gait in amputees
    • 1. parallel bars
    • 2.single limb ambulation w/ assisted device
    • 3. outside of bars..try crutches
    • 4. most LE amputees will need an assisted device (always exceptions)
  70. can psychological issues arise from an amputation?
    Yes!
  71. target clinical pathway:
    Day 0
    amputation surgery
  72. target clinical pathway:
    day 1-4
    acute hospital, pre-prosthetic PT
  73. target clinical pathway:
    day 5-21
    sub-acute rehabilitation hospital or home for wound healing and continued pre-prosthetic PT
  74. target clinical pathway:
    day 21-28
    suture/staple removal followed by casing for temporary prosthesis
  75. what are some factors that can affect prosthetic training success?
    • physical abilities
    • cognition
    • prosthetic fit
    • motivation
    • financial resources
    • SES/ support system
  76. data to be collected during eval
    • endurance
    • anthropometric characteristics
    • cognition
    • assistive devices
    • circulation
    • cranial/peripheral nerve
    • environmental barriers
    • body mechanics
    • gait
    • skin
    • joint integrity
    • motor control
    • muscle performance
    • pain
    • orthoses
    • posture
    • ROM
    • self care
    • sensory
    • work
    • community
  77. how would you teach patient to don prosthesis?
    • sit in chair
    • check prosthesis
    • check residual limb
    • sheath-->socks--> gel liner
    • insert over residual limb (if there is one)
    • step into prosthesis while sitting
    • attach suspension
  78. pressure tolerant areas:
    patellar tendon,

    medial tibial flare

    supracondylar area

    adductor tendon

    ischial tuberosity
  79. pressure sensitive areas:
    distal fibular head

    end of femur
  80. most common sites for blisters?
    bones
  81. why do you get blisters? how do you fix it?
    why? settling, pistoning, tilting, torsion

    solution--lambs wool
  82. why do you get distal edema? solution?
    not good enough contact


    lambs wool solves this
  83. what should the prosthetic sock look like?
    should look the same all over, no wrinkles etc
  84. what does the loss of hair/ redness on extremities suggest?
    continued pressure and reduced nourishment of tissues and skin

    CALL DR ASAP!
  85. choking is what?
    throbbing pain
  86. if limb is cold means what?

    if limb is hot means what?
    cold=impaired circulation

    hot=infection
  87. skin should be checked how often?
    every 15 mins
  88. if skin is red after 15 mins do what?

    if skin isn't red after 15 mins do what?
    if yes--leave shrinker and prosthestic off. if gone after 15 mins put back on, if still red after 15mins call prosthetist

    if no--put back on
  89. pressure on the inferior pole of the patella suggests what?

    solution?
    going down into the prosthesis too far--weight change

    add socks
  90. pressure on tibial tuberosity suggests what?

    solution?
    not going down far enough--swelling, weight change

    decrease number of socks
  91. movement between skin and the socket, excessive drop of socket away from residual limb in swing is....?
    pistoning

    suggest problem with suspension
  92. weight shift in prosthesis helps for what?
    normalizes gait
  93. how do you progress patients in weight shift activities?
    start in parallel bars-both hands. weight shift forward,backward, side to side, diagonal

    progress to all those with 1 hand holding on

    then no hands
  94. during stepping activities the focus is on....?
    rotation of pelvis, weight shift flexing prosthetic knee at pre-swing

    step forward/backward with sound limb

    step forward/backward with residual limb
  95. stool stepping
    in parallel bars, with both hands step up with sound limb

    then practice stepping up with prosthesis

    emphasize hip and knee control on residual side

    progress by removing 1 hand then 2
  96. is stool stepping recommended for TF amputees?
    No! requires hip circumduction/hike to get foot off step with is undesirable and should be avoided
  97. stride stepping
    start 4 in apart in parallel bars

    alternate starting with sound and residual, progress to 2, then 3 then so on
  98. when can you progress patient outside of parallel bars?
    shift weigh A/P, R/L without deviations

    forward with sound and put weight on residual

    step forward with residual doing hip rotation not trunk rotation
  99. advanced activities to teach should include?
    • transfers
    • curbs/stairs
    • inclines
    • uneven terrain
    • picking up dropped objects
    • clearing obstacles/barriers
    • falling and rising
    • sitting/kneeling
    • running, single leg stance
  100. how do you know when its time to discharge or discontinue a patient?
    when they can do all functional skills, gait on all surfaces, get up from fall, care of skin/prosthesis

    usually determined by insurance companies
  101. ending PT secondary to pt reached anticipated outcomes/goals =?
    discharge
  102. ending PT secondary to pt request, unable to continue due to insurance, no longer progresses =?
    discontinue
  103. when do patients need socket revision?
    after a year of wear to accomodate shrinkage

    technology improves and patients need new foot or knee

    level of function
  104. transmetatarsal recovery and energy requirement
    95% recovery

    0% increases energy
  105. transtibial recovery and energy
    70-75% recovery

    20-40% increased energy
  106. transfemoral recovery and energy
    20-40% recovery

    50-80% increase energy
  107. if you have a bilateral transfemoral prosthesis how much % is energy increased?
    300%
  108. Medicare Level 0
    non-ambulatory

    medicare wont pay for prosthesis
  109. Medicare Level 1
    transfers or limited household ambulator

    sach/single axis foot

    manual knee lock, stance control
  110. Medicare Level 2
    limited community ambulator

    multi-axis foot

    polycentric, pneumatic knee
  111. Medicare Level 3
    unlimited community ambulator
  112. Medicare Level 4
    high energy activities

    level 3/4: energy storing feet and hydraulic/microprocessor knee
  113. transtibial prosthetic rehab
    4-6 weeks OP PT/day pt
  114. transfemoral prosthetic rehab
    6-12 weeks OP PT/day pt

    temporary prosthesis 4-5 weeks after amputation

    permenant prosthesis 3-6 months post op

    re-eval anually

    replace prosthesis every 4-5 years
  115. From Teresa's review:

    Identify four possible forms of
    compression bandaging commonly used after amputation.
    • 1. ace bandage
    • 2. shrinker socks
    • 3. rigid removable dressing
    • 4. semi-rigid dressing
  116. From Teresa's review:

    What Medicare functional level is
    transfers or limited household ambulator?
    level 1
  117. From Teresa's review:


    What is the significance of these
    Medicare functional levels?
    these levels guide decisions about type of prosthesis and componentry based on patients functional level
  118. From Teresa's review:

    What are the purposes of compression
    bandaging for the amputee?
    • -reduce edema
    • -control pain
    • -enhance wound healing
    • -protection of incision
    • -faciliate limb shaping for prosthesis
  119. From Teresa's review:

    what contractures are common in patients with transtibial amputations?
    knee flexion, hip flexion
  120. From Terea's review:

    How do you prevent contractures in transtibial amputee patients?
    • -amputee board in w/c
    • -exercises
    • -avoid use of pillows
    • -prone lying
    • -education
  121. From Terea's review:

    what contractures are common in a patient with a transfermoral amputation?
    hip flexion, hip abduction, hip ER
  122. From Teresa's review:

    Discuss scar management for your patient
    • -scar massage above and below incision
    • -appropriate to being once healing has occurred
    • -avoid adherence along incision which can increase shearing and can cause breakdown and pain
  123. From Teresa's review:

    Difference between phantom limb pain vs phantom limb sensation
    • phantom limb sensation:
    • -feeling that limb is cramped, itching, numbness 70% will experience this

    • phantom limb pain:
    • shooting pain, severe cramping, burning in limb
  124. From Teresa's review:

    What is the most common cause of amputation?
    PVD
  125. From Teresa's review:

    identify at least 3 factors that influence a patients outcome in prothestic training
    Physical abilities (strength, ROM, endurance, skin, pain, etc.)

    Cognitive abilities

    Prosthetic fit

    Motivation

    Financial resources-insurance often determines LOS/type of prosthesis

    Socio-economic circumstances-caregiver, car, living situation, etc.
  126. From Teresa's reveiw:

    What functional level describes a patient
    with unlimited community ambulation ability without high energy activity?
    level 3
  127. From Teresa's review:

    Would a medicare level 3 qualify for a C leg microprocessor knee?
    Yeah possibly!
  128. From Teresa's review:

    Application of ground force reaction
    vectors applies to prosthetic alignment and can create gait deviations. True/False
    True
  129. From Teresa's review:

    Ankle PF in a transtibial amputation creates what kind of moment at the knee?
    Extension
  130. From Teresa's review:

    Identify two shortcomings with ace wrapping for compression.
    • -need good dexterity and cognitive function
    • -needs to be rewrapped frequently
    • -can create choking if not wrapped properly
    • -needs to be worn 23-24 hours
    • -requires good technique for appropriate compression
  131. From Teresa's review:

    What bony landmark might serve as a good
    reference point for measurement of a residual limb length in a transfemoral amputee?
    -greater trochanter

    -ischial tuberosity
  132. From Terea's review:

    What bony landmark might serve as a good
    reference point for measurement of a residual limb length in a transtibial
    amputee?
    -tibial tuberosity

    -joint line
  133. From Teresa's review:

    What is the approximate increase in
    energy expenditure for a transfemoral amputee?
    50-80%
  134. From Teresa's review:

    How is that changed for a bilateral transfemoral amputee?
    increases by 300%
  135. From Teresa's review:

    Your patient had a recent transtibial
    amputation. Discuss education about skin
    checks for this
    • Check every 15 minutes of prosthetic wear
    • for edema, redness, blisters, abrasions, etc.

    If redness persists greater than 15 minutes, leave prosthesis off, contact prosthetist.

    • Look for uniform sock lines after prosthetic
    • wear.

    Monitor status of the sound limb also – pulses, skin color and temperature and sensation.
  136. From Terea's review:

    What is protective sensation with
    monofilaments?
    • 5.07 Semmes-Weinstein monofilaments on
    • the plantar surface of the foot
  137. From Teresa's review:

    Can you complete a full MMT test day 3
    following amputation?
    No

    • Need to wait for incision to heal and
    • then can apply pressure. Remember the
    • lever arms have changed and MMT scores will be effected.
  138. From Teresa's review:

    Describe the components of a PT plan of
    care for a new amputee with the first prosthesis.
    • -gait- especially weight shifting
    • -transfers
    • -strengthening
    • -ROM/stretching
    • -balance
    • -don/doff
    • -skin care

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