Rehabilitation with Prostheses

Intro & Pre-Prosthetic Care - Goals & Groundwork

• Primary Goals: Restore function, mobility, independence, cosmesis, and improve Quality of Life (QoL).
• Patient Assessment (Holistic):
  • Medical: Comorbidities, stump condition (vascularity, skin).
  • Psychological: Motivation, realistic expectations, body image.
  • Social: Support system, vocational needs, home environment.
• Pre-Prosthetic Management (Stump Focused):
  • Stump Care:
    • Hygiene, skin inspection, wound healing.
    • Edema control: Elastic bandaging (figure-of-8), shrinker socks.
    • Stump shaping & maturation: Aim for conical/cylindrical shape.
    • Desensitization: Tapping, massage, friction.
  • Exercises:
    • Prevent contractures (esp. hip/knee flexion).
    • Strengthen residual limb, core, trunk, upper limbs.
    • Maintain/improve Range of Motion (ROM) of proximal joints.
  • Manage phantom limb sensation/pain.

⭐ Optimal stump length for Below-Knee Amputation (BKA) is 12.5-17.5 cm (Transtibial) from medial tibial plateau for best prosthetic fit and function.

Prosthetic Prescription - Fit For Function

• Prescription: Individualized, considering:
  • Amputation: Level, residual limb (length, shape, skin, power).
  • Patient: K-level (functional potential), goals, comorbidities, motivation.
• Component Selection:
  • Socket: Critical for fit (e.g., PTB, TSB, Ischial Containment).
  • Suspension: For secure attachment (e.g., Suction, Pin/Lock, VASS).
  • Knee/Ankle Units: Based on K-level (e.g., single-axis, multi-axis, microprocessor).
  • Terminal Device: Foot (SACH, dynamic response) or hand/hook.
• Checkout & Verification: Ensures optimal fit and function.

> ⭐ Proper socket fit (total contact, specific pressure distribution) is paramount for prosthetic success and user comfort.

Lower Limb Training - Steps to Strides

• Objective: Achieve safe, symmetrical, energy-efficient gait for functional independence.
• Core Principles: Early mobilization, progressive weight-bearing, balance (static & dynamic), proprioceptive training.
• Gait Training Sequence:

• Essential Skills:
  • Prosthesis donning/doffing, stump hygiene.
  • Transfers: Sit-to-stand, bed, chair, floor.
  • Fall prevention & "up from floor" techniques.

⭐ Energy expenditure with a transtibial prosthesis is typically 10-30% higher than normal; transfemoral can be 40-70% higher, impacting endurance.

Upper Limb Training - Grasping Independence

• Goal: Achieve functional independence in Activities of Daily Living (ADLs) with the prosthesis.
• Training Phases:
  • Controls Training: Mastering operation of terminal device (TD), wrist, elbow (if applicable). Body-powered (cable tension) or myoelectric (EMG signals).
  • Use Training: Repetitive drills for grasp, release, positioning. Focus on smooth, coordinated movements.
  • Functional Training: Integrating prosthesis into ADLs (e.g., eating, dressing, writing).
• Grasp Patterns: Practice tripod, lateral (key), cylindrical, spherical, hook grasps with varied objects.

⭐ Phantom limb sensation/pain can significantly impact training; early management is crucial for prosthetic acceptance and functional use.

Complications & Outcomes - Bumps & Beyond

• Stump Issues:
  • Skin: Dermatitis, ulcers, infection, verrucous hyperplasia, epidermoid cysts.
  • Pain: Residual Limb Pain (RLP) - neuroma, spurs; Phantom Limb Pain (PLP).
• Prosthetic Problems: Socket misfit (pistoning, bell-clapping), alignment issues, component wear/failure.
• Systemic: ↑Energy expenditure, contralateral joint OA, psychological impact.
• Management: Hygiene, socket adjustments, pain meds (gabapentin for PLP), therapy.
• Outcomes: Measured by Amputee Mobility Predictor (AMP), Timed Up and Go (TUG), 6-Minute Walk Test (6MWT); patient satisfaction (TAPES).

  ⭐ Verrucous hyperplasia at stump end often due to distal negative pressure/poor fit.

High‑Yield Points - ⚡ Biggest Takeaways

• Early mobilization and comprehensive pre-prosthetic training are vital for successful outcomes.
• Phantom limb pain requires multimodal management: pharmacotherapy, mirror therapy, TENS.
• Meticulous stump care (hygiene, desensitization, shaping) prevents infection and skin issues.
• Progressive gait training focuses on balance, symmetrical weight-bearing, and efficient ambulation.
• Correct socket fit is paramount; poor fit causes pain and prosthetic rejection.
• Energy expenditure is notably ↑, particularly for transfemoral amputations.
• Psychosocial support is crucial for addressing body image concerns and depression.