INTRO TO PROSTHETICS Causes of Amputation

1. Diseases
Levels of Amputation - Peripheral vascular disease, diabetes, blood
clots, osteomyelitis
LOWER EXTREMITIES - Most common cause of LE amputation
2. Injuries
Transmetatarsals ►Amputation through the
midsection of metatarsals - Vascular injury
- Most commonly the UE
Symes/Ankle ►ankle disarticulation with 3. Surgery
disarticulation attachment of the heel pad - Tumors of bones & muscles
to the distal end of tibia for
weight bearing Stages of an upper limb amputation rehabilitation program
►may include removal of Stage 1 ➜ preamputation counseling
the malleoli, distal tibia and
Stage 2 ➜ amputation surgery
fibular flares
Stage 3 ➜ acute postamputation period
Transtibial ►long below knee Stage 4 ➜ preprosthesis training
amputation(BKA) more than Stage 5 ➜ preparatory prosthesis fitting
50% of tibial length is spared Stage 6 ➜ prosthesis fitting and training
►standard BKA: 20%-50% Stage 7 ➜ reintegration into the community
of tibia is spared Stage 8 ➜ long-term follow-up
►short BKA: <20% of tibia
is spared
Chief Goals of Prosthesis fitting
Knee disarticulation ►amputation through the 1. Limb substitution
knee joint with the femur 2. Cosmesis
intact 3. Locomotion

Transfemoral ►long AKA: >60% of FACTORS AFFECTING OUTCOME OF A PROSTHETIC

femoral length spare PRESCRIPTION:
►ideal AKA: 35-60% of the
1. Decrease cardiopulmonary reserve
femoral length is spared
►Short AKA: <35% of 2. Generalized vascular disease
femoral length 3. Impaired vision
4. Generalized physical deconditioning
Hip disarticulation ►amputation through the 5. Poor stump condition
hip joint. Pelvis intact 6. Joint pathology
7. Pain
Hemipelvectomy ►resection of the lower half 8. Impaired mental status
of pelvis
9. Decrease sensation
Hemicorporectomy ►amputation of both lower
limbs and pelvis below the REHABILITATION AFTER AMPUTATION:
L4-L5 level ►To maintain function, the surgical reconstruction should
consider how the prosthesis will fit on a residual limb, including
consideration of any contractures, insensate areas, scars, graft
UPPER EXTREMITIES
sites, and length.
Wrist disarticulation ►amputation through the ►should begin as soon as possible after surgery
wrist joint ►The intensity can be increased as the patient’s condition
improves
Transradial Below elbow amputation
►accounts to 57% of all arm
►The success of rehabilitation depends on the;
amputations
1. level of amputation
Elbow disarticulation ►amputation through the 2. type of amputation,
elbow joint. 3. any premorbid or resulting impairments and disabilities
4. the patient’s overall health
Transhumeral ►above elbow amputation 5. family support
►23% of arm amputation

Shoulder disarticulation ►amputation through the

shoulder joint
THE GOAL OF REHABILITATION: PROSTHESIS:
►is to maximize the patient’s capabilities, function, and ►replacement of a body part with an artificial device
independence, and is achieved as follows; ►an artificial limb
►a replacement of all or part of the leg or arm
1. Post-amputation care to promote wound healing and stump
care, desensitization of the limb (a way to decrease the PROSTHETIST:
hypersensitivity that can often be experienced after limb ►a health care professional who designs, fabricates, and fits
amputation), reduce edema, shape the limb to fit a prosthesis, limb prosthesis
and prevention of contractures
2. Pain management for both postoperative and phantom pain NOTE:
(pain felt in the amputated area of the limb). ►in the broad sense, prosthesis include dentures, titanium
femoral heads and plastic heart valves
►Explain to the patient that phantom sensation is normal,
whereas phantom pain is abnormal and needs to be addressed
as soon as possible. COMMON TERMINOLOGIES:
►Phantom sensation results because the neural pathways 1. Myodesis:
continue to tell the brain that the limb is still there. ►direct suture of muscle or tendon to bone (via drill holes)
►With time, there is “telescoping” of the sensation of the limb.
►Touching the residual limb will help with both phantom 2. Myoplasty:
sensation and psychological adjustment to the amputation ►suturing agonist and antagonist muscles together

3. Exercise therapies that promote improvement of muscle 3. Residual limb:

strength, range of motion, endurance, and motor skills, restore ►remaining portion of the amputated limb
activities of daily living (ADLs), and reach maximum
independence. 4. Build-up:
►area of convexity designed for areas tolerant to high
4. Determining home equipment needs (assistive devices) and pressure
coordinating outpatient rehabilitation services and community
resources 5. Relief:
►area of concavity within the socket designed for high
5. Educating the patient and family or caretakers on proper pressure bony prominence areas
skin care, proper nutrition, and home exercise program to
maintain range of motion and prevent tightness in joints and Traditional vs Newer Componentry
muscles 1. Traditionally prostheses were made in the form of
exoskeleton, usually of wood or plastic
6. Supporting the patient and the family as they learn to adjust
to the patient’s physical limitations. 2. Modern prostheses are endoskeletal
►Constructed in a tube frame fashion
7. Appropriate fitting of a prosthesis as well as training and ►Flexible foam cover is used for the outer surface
follow-up ►Elements adjustable individually and detachable

ENERGY EXPENDITURE:
►The amount of energy expended depends on a variety of
factors, including length of the stump, the patient’s health, and
the reason for the amputation.
Elements to Consider in UL Prostheses: 4. Pressure, if properly applied and evened out, can be exerted
1. The level of amputation over neurovascular structures (such as the adductor canal in
2. Cognition the case of transfemoral quadrilateral socket)
3. Expected function required of prosthesis 5. Stress to tissues will be minimized if the force is applied over
4. The job of the patient, e.g. sedentary vs. manual the widest possible area
5. Patient’s hobbies
[Link], importance can be increased if female or if the 2. TERMINAL DEVICE:
child grows up ►Functions to provide an interface between the prosthesis
7. Other considerations: finance and the external environment
♦ lower limb - foot
COMPONENTS OF UE PROSTHESIS: ♦ upper limb - hook or hand
►All prosthetic devices contain a socket and terminal device
with varying components in between. 2A. PASSIVE
2B. BODY POWERED (voluntary opening or voluntary
closing))
1. socket 2C. EXTERNALLY POWERED HOOKS & HAND
2. terminal device
3. shoulder unit ►HAS 2 FUNCTIONAL CLASSES:
4. elbow unit 2.1 PASSIVE DEVICES
5. wrist unit 2.2 PREHENSILE DEVICES
6. prosthetic control device A. Voluntary-opening devices
7. suspension device B. Voluntary-closing devices

PASSIVE COSMETIC HAND:

►have no moving parts and require no cables or batteries for
operation, they are typically extremely lightweight and reliable

Passive Terminal Devices

►The most commonly prescribed passive terminal device is
the passive hand .
►custom-sculpted hand and emphasizes the functions of
static grasp and social acceptance offered by these devices.
►A much less expensive production hand is also available.
1. SOCKETS: ►The production passive hand is created from a donor mold
►are custom-molded to the residual limb that is similar to (but not identical to) the missing appendage
►total contact is desired with the load distributed to all the and offers acceptable cosmesis to some patients
tissues
►assists in circulation COMMONLY USED UPPER LIMB PROSTHESIS:
►and provides maximal sensory feedback 2A. PASSIVE
2B. BODY POWERED (voluntary opening or voluntary
FUNCTIONS OF RESIDUAL SOCKET: closing):
1. Contain the residual tissues. ►cable controlled
2. Provide a means to suspend the prosthetic limb. 2C. MYOELECTRIC/EXTERNALLY POWERED HOOKS &
3. Transfer forces from the prosthesis to the residual limb. HAND
►Electrically controlled device
[Box 13-5] Key Functions of Prosthetic Socket
● Comfortable residual limb-prosthesis interface 2B. BODY POWERED (voluntary opening or voluntary
● Efficient energy transference to the prosthesis closing):
● Secure suspension of the prosthesis ►Body-powered prostheses (cables) usually are of moderate
● Adequate cosmesis cost and weight.
● ►They are the most durable prostheses and have higher
Biomechanical Principles of Socket (According to Hall) sensory feedback.
1. Proper contour and pressure relief for functioning muscles, ►However, a body-powered prosthesis is more often less
allowance for dynamic changing contours cosmetically pleasing than a myoelectrically controlled type is,
2. Application of stabilization forces to locations where no and it requires more gross limb movement.
functioning muscles exist
3. Functioning muscles need be stretched to slightly greater
than length at rest to generate maximum power
 VOLUNTARY OPENING HOOK/TERMINAL DEVICE:
►operates quickly with a minimum of control motions
►preferred by most amputees
►functional
►OPEN by tension on control cable
►CLOSE by rubber bands/spring

VOLUNTARY CLOSING TERMINAL DEVICE:

►require that the patient close the device by 'pulling' the cable
with the harness system to grasp an object.
►To release, the patient releases the pull on the harness, and
a spring in the terminal device opens it.
►The maximum prehensile force possible is determined by the
strength of the individual
►One major disadvantage of this system is that prolonged
prehension requires constant pull on the harness, but it might
allow improved speed of motion.
►The human hand normally does not reach out to grasp an
TERMINAL DEVICE: object in the closed position, but rather uses the semi-open
Functional activities of the hands: position to facilitate the interaction with the environment.
1. Non-prehensile activities ►This is why a VC device is said to be more physiological
2. Prehensile activities:
2.1 precision VOLUNTARY CLOSING HOOK/TERMINAL DEVICE
2.2 power grips ►provides a degree of graded prehension
►usually has a four-cycle action
1. Non-prehensile activities 1. pulling the control cable closes the hook partially or fully
►include touching, feeling, pressing down with the fingers, 2. releasing the control cable tension causes the hook to
tapping, vibrating the cord of a musical instrument, and lifting lock in the attained position
or pushing with the hand 3. slightly stronger pull unlocks the hook
4. release of the pulling force allows the hook to spring
2. Prehensile activities: open
►three jaw chuck: involves grips with the thumb, index and ►functional
middle finger ►APRL hook was developed by the Army Prosthetics
►a lateral or key grip: involves contact of the pulp of the Research Laboratory after World War II
thumb with the lateral aspect of the corresponding finger.

2.2 Power grips:

►Power grip predominantly involves the ulnar aspect of the EXTERNALLY POWERED DEVICE:
hand, with less involvement of the ring and little fingers. ►electrically powered device
►Externally powered devices can have digital (on or off) or
A. HOOK POWER GRIP: proportional (stronger signal equals faster action) control
►involves flexion of both interphalangeal joints and minimal systems.
participation of the MCP joint. ►More recently, a slip control system was introduced by the
►is used in carrying a briefcase. Otto Bock Company to improve hand grip and increase speed
of motion
B. SPHERICAL GRIP: ►The device has a sensor that maintains a constant pressure
►The spherical grip is very much like the power grip but with on an object to prevent slippage.
minimal flexion of the fingers, which are abducted and rotated; ►If the sensor perceives that the object is slipping, it
the thumb is used to stabilize the object and to provide automatically slightly increases the pressure on the object
counter- pressure
Key Difference Between Body-Powered and Myoelectric
VOLUNTARY OPENING TERMINAL DEVICE: Prostheses:
►The voluntary opening device is maintained in the closed ►Myoelectric prostheses work by detecting the EMG activity of
position by rubber bands or tension springs. the contracting muscles of the residual limb
►The number of springs or rubber bands predetermines the ►Body-powered prostheses work by mechanical links and
maximum prehensile force possible. cable powered by the motion effected by the intact proximal
►To control the amount of prehensile force, the patient must musculature of the amputee (e.g. scapula muscle in the UL
generate an opening force all the time amputee)
Pros and Cons of Body-Powered Prostheses PROSTHETIC WRIST:
1. Moderate cost and weight ►The type of prosthetic wrist (Box 13-3) most commonly used
2. Durable allows passive pronation and supination
3. Higher sensory feedback
4. Less cosmetic than myoelectric prosthesis
5. Need more gross limb motion to activate

Pros and Cons of Myoelectric Prosthesis

1. Expensive
2. Heavy and need maintenance
3. More cosmetic
4. Less sensory feedback
5. Works by transmission of electrical activity (that the surface
electrodes receive from the residual limb muscles) to the
electric motor

Types of Myoelectric Units

1. One site, two functions:
►e.g. one electrode for flexion and extension
►Patient uses muscle contraction of different strengths to
differentiate between flexion and extension.
►Example: stronger contraction to open the device, etc.
2. Two sites, two functions:
►e.g. separate electrodes for flexion and extension

TERMINAL DEVICE:
1. Passive
2. Active Spring assisted rotation:
►is available for the bilat. amputee
1. Passive Terminal Devices
Advantages SELECTIVE LOADING:
►Cosmesis ►pressure tolerant areas are built up to increase loading (i.e.,
►New materials can be made to closely resemble the buildups for tendon-bearing areas)
natural hand ►while pressure sensitive areas are relieved to decrease
Disadvantages loading (i.e., reliefs for bony prominences, nerves, tendons).
►Expensive
►Less functional TYPES:
►A socket made of hard plastic, with a soft polyethylene foam
2. Active Terminal Devices liner is the most common type
Advantages ►removable liners aid in ease of prosthetic donning and
►More functional adjustment
►Can be myoelectric or hooked prosthetic hand with cables
Disadvantages Flexible sockets:
►Less cosmetic ►are made of soft, pliable thermoplastic material within a rigid
frame
►Active terminal devices usually are more functional than ►used for most AK sockets because of better suspension
cosmetic;
►however, in the near future, active devices that are equally SOCKS:
cosmetic and functional may be available. (a) Used in every suspension system except suction.
(b) Provide a soft interface between the residual limb and the
►Active devices can be broken down into 2 main categories: socket; minimize shear forces between socket and skin.
1. Hook terminal devices (c) Changing sock thickness or adding more socks can assist
2. Prosthetic hands. in accommodating to changes in volume of residual limb,
►There are designs of both of these terminal device groups prevent pistoning
available to operate with cable or externally powered d) Excessive thickness of socks (greater than 15 ply) can alter
prostheses. fit and weight bearing of the socket
 D. Physical Therapy Intervention:
►Ideally the physical therapist functions as a member of the
prosthetic clinic team that includes physician, prosthetist and
therapists

Preprosthetic management:
Preprescription examination.
(1) Skin:
►inspect incision for healing; scar tissue; other lesions

2. Residual limb:
(a) Circumference measurements:
►check for edema
(b) Length:
►bone, soft tissue length.
(c) Shape:
►should be cylindrical or conical; check for abnormalities
►i.e., bulbous end, dog ears, adductor roll
COSMETIC HAND:
►simply a hand constructed of rigid or semi-rigid material and 3. Check vascular status of sound limb, residual limb:
covered by a cosmetic glove ►pulse , color, temperature, trophic changes, pain/intermittent
►non-functional claudication.
MYOELECTRIC HAND:
►motor-driven terminal devices 4. ROM: active and passive:
►examine for contractures that might interfere with prosthetic
UPPER LIMB PROSTHETIC DEVICES/ULPs: prescription,
1. Below-elbow (BE) prosthesis: ► e.g., hip and knee flexion contractures
►contains a terminal device (TD), wrist and forearm socket,
harness system. 5. Sensation.
(a) Proprioception, visual, vestibular function, contributions to
2. Above-elbow (AE) prosthesis: balance:
►contains a terminal device (TD), wrist and forearm socket, ►loss of proprioception in the amputated limb will necessitate
harness system, contains an elbow, and arm socket. a compensatory shift to the other senses for balance control
(b) Phantom limb sensation:
3. Conventional system: ►a feeling of pressure or paresthesia as if corning from the
►power for voluntary opening of the TD (hook or hand) is amputated limb.
transmitted by a cable from a figure-of-eight shoulder harness ►Sensations are normal, not painful; may last for the lifetime
to the TD; of the individual.
►rubber bands are used for closure and prehensile strength; (c) Phantom pain:
forearm rotation is done by manual prepositioning of the TD ►an intense burning or cramping pain; disabling, frequently
interferes with rehabilitation.
3.1 BE prosthesis:
►bilateral scapular abduction or ipsilateral flexion of the 6. Strength:
humerus are used to pull on the cable and force opening of the ►strength of residual limb as tolerated; strength of the sound
hook limb, trunk, upper extremities needed for function

3.2 AE prosthesis (dual control system): 7. Functional status:

►the same motions can be used to flex the elbow in the AE (a) Functional mobility skills:
prosthesis; when the elbow locks (by scapular depression and ►bed mobility, transfers, wheelchair use.
humeral extension), the forces are then transmitted to operate (b) Activities of daily living:
the TD. ►basic, instrumental (use of telephone, shopping, etc.).

4. Externally powered system: 8. Cardiopulmonary function, endurance.

►microswitches (EMG myoelectric devices) are activated by (a) The shorter the amputation limb, the greater the energy
the same motions as conventional power systems; small demands
electric motors (battery powered) are activated to operate the ► i.e., oxygen consumption is increased 65% over normal
TD. walking in the patient with transfemoral amputation;
a. Improves ease of function, prehensile strength. ►similar to fast walking in normal for the patient with transtibial
b. Adds weight, increased maintenance, cost. amputation
(b) Functional capacity further limited by: concomitant diseases
(e.g. cardiovascular disease, diabetes ), individual fitness level, (9) Functional mobility training
pain

9. Neurologic factors.
(a) Cognitive function
(b) Check for neuropathy.
(c) Check for neuroma:
►an abnormal growth of nerve cells occurring in the residual
limb after amputation.

10. Psychosocial factors:

►motivation, adjustment and acceptance, availability of
support systems

Preprosthetic training: goals and interventions.

(1) Ideally begins pre-operatively and continues
post-operatively.
(2) Facilitate psychological acceptance.
(3) Post-operative dressings:
►applied to the residual limb; helps to limit edema, accelerate
healing, reduce post- operative pain, shape the residual limb.

(3a) Elastic wraps:

►flexible, soft bandaging, inexpensive; requires frequent
reapplication, with pressure greatest distal to proximal;
►if wraps are allowed to loosen, may have problems with
edema control;
►avoid circular wrapping which produces a tourniquet effect

(3b) Stump shrinkers:

►flexible, soft, inexpensive, readily available in different sizes

(3c) Semirigid dressings:

►Unna paste dressing (zinc oxide, gelatin, glycerin and
calamine); applied in the operating room.

(4d) Rigid dressings:

►plaster of Paris dressing; applied in the operating room; a
component of immediate postoperative fitting;
►allows for edema reduction and early ambulation with a
temporary prosthesis (pylon and foot).
►Good for patients who are young, and who are good
candidates for a permanent prosthesis.

(4) Desensitizing activities:

►pressure, rubbing, stroking, bandaging of the residual limb.

(5) Hygiene:
►inspection and care of the residuallimb.

(6) Positioning for prevention of contracture

(7) Flexibility exercises.

(a) Full AROM and PROM, active stretching especially in UE
extension and abduction.
(b) Flexibility of sound limb and trunk

(8) Strengthening:
►utilize a general strengthening exercise program