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KIN 545 Amputations

Graduate presintation

Eric Gerard

on 19 February 2013

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Transcript of KIN 545 Amputations

Amputations Disease Etiology Epidemiology Conventional medical treatment Nutrition and exercise as complementary therapies Diabetes Trauma Related Cancer Related Congenital Related Prevention Facts:
1.7 million living with limb loss from diabetes
due to vascular disease.

Lower limb amputations account for 97%
these are further broken down into above the knee (25.8%), below the knee (27.6%), and others involving numberous levels 42.8%. Primarily known as Dysvascular amputation Dysvascularisation is mainly caused by diabetes via artherosclerosis leading to blood vessel occlsion. Facts:
Males are at a significantly higher risk than females.
Rate of incidence progressively increases at 85 and older
Upper limb amputation 68.6%
Lower limb amputation 31% War, home improvement, accidents. Facts:
More common in lower limbs, both above and below the knee.
Account for 36% cancer related amputations. Newborns -
upper limb amputations 58.5% lower limb amputations 41.5% Conclusions:
Limited or poor circulation, in particular the lower extremities, is a main cause of all amputations.

Patients often experience peripheral neuropathy leading to trophic ulcers and subsequent gangrene and osteomyelitis.

Treatment of sepsis via vasoconstriction medication may at time lead to vessel occlusion and subsequent necrosis due to nutrient loss.

Along with the physical loss of limb, the patient is likely to have psychological issues associated with loss (limb, ability, social status, seen as "broken", depression)

secondary conditions, like ulcers, can result from loss of mobility or loss of sensation.

Suffering from Diabetes Mellitus is a big contributing factor for amputations.

Due to the lower immune response, the lower limb is susceptible to developing sores and ulcers that become infected. Congenital limb deficiencies are classified as the absence or hyoplasia of a long bone and/or digits. Most common cause of limb deficiencies were due to vascular disruptions (amniotic band-related limb deficiency). Trophic ulcer:
from "imperfect" nutrition-
a lesion of cutaneous leishmaniasis
Leishmaniasis is a parasitic disease that is found in parts of the tropics, subtropics, and southern Europe, classified as neglected tropical disease (NTD).
A.K.A skin sores Facts:
Dysvascular amputations are nearly 8 times greater than trauma related amputations. Those suffering from diabetes mellitus are present in half of these cases. Those suffering from diabetes mellitus are 10times more like to have an amputation. Risk factors-
Prolonged duration of diabetic disease, prolonged hyperglycemia, and neuropathy. Development of neuropathy has been attributed to the polyol pathway (A.K.A. sorbitol aldose reductace pathway ) with sorbitol accumulation in Schwann cells during periods of hyperglycemia, damaging to the nerve fibers. Neuropathy affects vasodilation leading to inflammation; affect both sensory and motor neurons. •Proper medication to attenuate risk factors
•Insulin for diabetics and –statin drugs for hypertensive patients
•Immediate lifestyle changes reflecting major problems, nutrition and exercise being stressed
•Ischemic necrosis
•Inflammatory destruction
•Treatment includes proper foot care
o Clean dry socks
o Reduce friction
o Bed rest and decrease weight bearing
•Wound cleansing is stressed to prevent infection and further necrosis Ulcers and Tissue Damage Acute rehabilitation •Stress placed on passive and active ROM in uninvolved joints first (active) and involved joints (passive and active) starting the third day post-op
•Early focuses on transferring and sitting
•Basic ambulation with walkers and other assistive devices
•Gait training beginning around the 10th week post-op Phantom Symptoms •Phantom sensation: non-painful representations of volume, weight, and ROM
o Kinesthetic
o Kinetic
o Extroceptive
•Phantom pain: pain experienced below the residual limb
o Triggered by emotional stress, exposure to cold, direct irritants to the stump
o Relieved by using the prosthesis, stroking the stump, heat
o Antidepressants are commonly used to treat phantom symptoms Additional Treatments for Phantom Pain
•Analgesics (not OTC)
o Clonidine patch
o Calcitonin
•Psychological intervention
o Hypnotherapy
o Cognitive therapies Issues • If it is an above the knee amputation, a large amount of the hip adductors have been severed
• Joint contracture is important to avoid so there are no complications, especially during gait training
o Knee flexion BTK
o Hip flexion ATK
• ROM must be worked on constantly, so education should be stressed Long-term Therapy and Gait Training • When making initial contact, base of support needs to be optimal
o Increase BOS by shortening prosthesis, externally rotating foot if necessary
o The width of the BOS determines the amount of shift in the COG
• Adductor strengthening in the residual limb
• Hip stabilization exercises will prevent horizontal dip
o Compensatory trunk leaning will result in an increase in energy cost
o For TFAs, this goes back to loss of structures
• Lordosis is common in TFAs due to anterior pelvic rotation (no knee flexion response) Education and Follow-up •Educate about necessary precautions and upkeep
•Place emphasis on home programs (ROM, etc.)
•Any psychological changes should be kept track of Life style changes •Exercise frequently to exacerbate stress of the prosthetic
•Proper health to prevent further complications and risk of further amputation being necessary Emotional/ psychological issues Processes Leading to Lower Extremity Amputation • Peripheral Vascular Disease (PVD)-
– Decreased circulation in the distal lower limb inhibits healing & immune response.
• Foot trauma produces wound that does not heal
• Infection may spread to bone
- Most common "subgroups" of PVD:
1. Diabetic Complications
2. Arteriosclerosis
3. Thromboembolism
• 60-70% of amputations attributed to vascular disease
– 30% have contralateral limb involvement within 4yrs
– 25% will die within 4yrs of amputation Sorbitol accumulation is unused glucose that enters the pathway that can’t cross cell membrane and when it accumulates cause osmotic stress on cells by drawing water in to insulin independent tissues. Emotional Distress

Emotions experienced by the amputee may not only be due to the physical loss of a limb,

Effects ones career, family life and socialization.

May have higher rates of depression

Clinical depression in amputees ranges from 18-35 %, but thankfully it goes away over time.

Some symptoms of depression
sadness, irritability, difficulty sleeping, social withdrawal or isolation, decreased or increased eating, abuse of alcohol or drugs New psychological issues emerge in the later stages of rehabilitation after amputation.
Patients attempt to adjust independently to everyday life after the initial medical and prosthetic interventions.
o Appropriate time to target counseling to optimize coping strategies There is a 50% risk of a second amputation in 2 years and the risk of death is 50 – 70% in 5 years. Most amputees require multiple prosthetics over their lifetime.

30% of those suffering from devascular amputation will have impairment in the contralateral limb within 4 years

¼ of all amputees die within 4 years of limb amputation

Prevent complications early on with proper lifestyle changes

Proper care of the amputation is necessary

ROM becomes a primary concern during rehabilitation

Prevent compensation during training

Strengthen all muscles that have become anatomically restricted

Track behavior to assess psychological well-being

Neuropathy can be attributed to the Sorbitol pathway affecting vasodilation and inflammation in which both sensory and motor neurons are affected. •Psychological stress and uncertainty with future career, family life and socializing

•Some signs and symptoms of depression
o Sadness
o Iritibility
o social isolation
o trouble sleeping
o alcohol or drug abuse

•New psychological issues usually emerge in later stages of rehab when the patient is soon to return to ADLs independently.
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