Below the Knee Amputation and Physical Therapy Rehabilitation - Research Paper Example

?Below the Knee Amputation and Physical Therapy Rehabilitation Introduction Below the knee amputations are normally performed when tumors at the feetand ankles manifest. Current developments in medicines however, have brought around preoperative chemotherapy and adjuvant radiation therapy that managed to confine the growth of tumors within a certain location only. Such developments resulted to surgical procedures which allowed limb-sparing surgery in most cases (Sugarbaker et al, 2001). Limb amputation is necessary because: 1) it may threaten the life of a victim or a patient if left attached; 2) it is non-viable; 3) if the function or appearance of the limb can be improved by replacing the defective part with a prosthesis; and 4) if the patient suffers from chronic pain that has not been alleviated or treated by other forms of therapy. The last reason is generally rare because amputation may not relieve the pain that is constantly felt due to the presence of phantom pain (Duckworth, 2000a). The most common cause of amputation is ischaemia that originates from vascular diseases. When amputation is the recourse, the full cooperation of a professional prosthetist is compulsory prior to and after surgery because the residual limb must be set to have the best possible function and physical appearance which adheres to removing the pathology. If amputation is the last possible medical option to remove a tumor or growth on the lower limbs; the procedure will necessitate amputation through the joint above the pathology or if possible even higher, the outcome of which may leave the residual stump a reduced amount of ideal functionality after the procedure. Below the knee amputation is the most common because such procedures provide the remaining limb or stump greater function if the knee-joint is retained, especially in elderly individuals (Palma et al., 2009). The general considerations for amputations are as follows: 1) if the amputation is more marginal or on the borderline results in a too long stump. This will make prosthesis fitting below it quite difficult; 2) If the joints like the knees or elbows can be retained then the expected result for function retention is quite improved; 3) most lower limb amputations can be fitted with prosthesis, but when amputation is made higher than the joints prosthetic fitting becomes impossible; 4) on the other hand, prosthetic function for upper limb amputations have poor outcomes since hand functions are quite complex along with the replacement of its sensibility (Duckworth, 2000b). Etiology Amputations below the knee is necessary when the leg or foot has either been crushed in an accident or blown up with a landmine in places considered as war zones like Iraq. The severe trauma and injuries sustained by the foot or leg requires amputation since there is no other recourse to save the mangled foot or leg. The necessity to have the foot or limb amputated is to eradicate the risk of gangrene occurrence that may cost the person’s life (Kennedy, 2007). People with illness like diabetes or those who suffer from deep vein thrombosis are at risk of developing complications in the lower extremities. This includes but is not limited to: foot ulcers, infections, tumor and vascular insufficiency. Amputation of a lower extremity is recommended if complications are severe or do not improve with other forms of treatment. And since such condition affects the individual’s quality of life and the patients’ health care costs; the efficient medical management and monitoring is often applied (Gerstein et al, 2002). In cases of foot ulcers and tumor growths that stem from the abovementioned medical conditions the ulcer severity is usually classified according to the Wagner system that has a 1 to 5 grading classification. Grade 1 ulceration pertains to superficial ulcers that involve the entire thickness of the skin but not the tissues beneath. Grade 2 ulceration refers to deeper ulcers that penetrate down to the ligaments including the muscles but excludes the bones and has not yet formed any abscesses. Grade 3 ulceration signifies deep ulcers that have swellings or sores (abscesses). Grade 4 and grade 5 have localized gangrene and have extensive gangrene formation that involves the entire foot respectively. These kinds of foot complications are outcomes of poor glycaemic control or blood sugar control in diabetics; and the presence of vascular diseases in others that results to complications like neuropathy that alters foot sensation and foot functions (Fitzmaurice et al., 2002). Pathophysiology Undergoing amputation means losing a part of the body that serves in its normal overall functions due to accidents, trauma, cancer or other diseases that impairs the normal foot or leg mobility. Amputations in general affect people in different ways depending on how they perceive themselves then and now. Having a limb removed from one’s body can be perceived by some as like losing someone they loved. Body functions will definitely be altered, which will certainly affect some aspects of the amputee’s life. Elderlies may experience hardening of arteries, while others are at risk of infection and muscle contracture. The adaption process varies from person to person, and the younger ones are able to return to most of their normal activities. Ultimately, leading a productive life after undergoing amputation depends on one’s state of mind, physical health and the sound physical therapy plan implemented by the physical therapist in close coordination with the prosthetist (Mosquera, 2011a). Description of Condition Amputations are generally classified into minor and major. Minor amputations are those that deal with the removal of a small section of the foot like a toe; while major amputations comprise of the removal of the leg, which are commonly above or below the knee joint. The Burgess technique and the Kingsley Robinson technique are often used to perform the operation. Both techniques require the use of the calf muscles to cover the shin bones, the only difference is that the Kingsley Robinson technique are “skewed in relation to the muscles” (Mosquera, 2011b). The amputation of the lower extremities, especially below the knee is most common than amputations for the upper extremities. Ideally, below the knee amputations must be done with retaining much of the functions of the lower leg in mind. The most common form of amputation below the knee requires two equivalent medial and lateral flaps that must be cut slightly longer than shorter. The residual limb must also be adequately long for better prosthesis fitting. For this reason, the chosen prosthesis must be able to bear the weight of the patient like a normal foot can. Since prosthetic stumps have standard measurements, it is generally recommended that standard leg amputations are followed (CNIS, 2007). Medical Diagnosis Therapeutic planning for patients is on a case to case basis, especially for those who need to undergo surgical amputations below the knee. Therapeutic planning comes in before and after the surgery and this includes all the medical professionals involved in the case. Planning includes problem identification and prioritization; selection of treatment regimens for each problem the case may present; and the development of an integrated monitoring plan (Tietze, 2006a). Before a treatment can be recommended specific patient problems must be known for a better evaluation of the patient’s case. This involves patient’s past medical history, physical examination, laboratory and diagnostics tests and the medication history. Once the data is gathered, the doctors/physicians as well as the nurses have a baseline of information that generally comes in handy during the treatment process. The second step is problem prioritization where the patient’s most urgent medical problem is tackled first and the least medical problems are taken cared of last. Prioritization aids the medical team to rank in proper order the patient’s total health care needs. This determines the problems, which if left untreated in proper order may seriously harm the patient in the shortest time possible. The prioritization list is established based on the clinical judgement and experience of the lead medical practitioner handling the case (Tietze, 2006b). The selection of specific therapeutic regimens for patients, including initial and alternative medication usually takes place after the problems have been identified and prioritized. The results therein lead to decisions about proper medication for the management of each identified problem. The recommendation includes particular medication regarding dosage, way of administering medicines, formulation, duration of therapy and logic. The general approach is to have a therapeutic plan for each and every problem, which are then integrated into an overall plan for a specific patient. The selection of definite treatments in the assessment of each patient problem is mostly based on the past medical history of the patient along with external factors like state-of-the-art medical equipment and cost considerations that may affect or limit the efficiency of administering medical treatment (during hospital stay) and rehabilitation – when the patient is released for home care and continuing recuperation. Monitoring drug intake specifications along with physical therapy is significant in attaining a good overall result when patients recuperate at home. It is important to consider that amputees will feel phantom limb pain from time to time so medications prescribed must be taken religiously to alleviate pain and discomfort (Tietze, 2006c). Equally important is the assessment of the patient’s state of mind or mental status. Proper evaluation must be performed with regards to the cognitive level of the patient prior to surgical amputation because this will be the source that would show if the patient is capable of taking proper care of himself or herself after the amputation. Recovery after amputation requires a lot of hard work since the patient is required to perform activities for himself/herself like the donning and taking off of the stump sock; achieving good bed mobility; doing proper skin care; learning and integrating safe ambulation and other forms of activities needed for daily living. When the patient has achieved most of these right after the amputation, he or she will be further inspired to do or try other complex activities, probably even going back to having an active lifestyle despite having lost a limb (Gailey et al., n.d. a). Medical Treatment When all other forms of medical treatment like chemotherapy fail to improve the condition of one’s leg or feet, the last alternative is to undergo surgical amputation. This is likewise the case for traumatic amputations that require immediate decision making to salvage the body part and prevent further complications like hemorrhage or sepsis. Normally surgical amputation is planned carefully in contrast to traumatic amputations. But the basic concern in both situations is how to prevent secondary complications that may endanger the life of the patient. After surgery, the normal process would be to induce appropriate medications that would help the patient overcome pain; and the immediate start of rehabilitation through physical therapy so lost sensations and mobility are recovered within the shortest span of time (MDGuidelines, n.d.). Relevance to Physical Therapy Practice When the patient who had below the knee amputation is released or discharged from the hospital, the normal course would be to begin physical therapy rehabilitation. Physical therapy is the art and science on the treatment of the neuro-musculo skeletal system of the human body by using light, electricity, heat, sound, water, therapeutic exercise and massage. The rehabilitation process for the post-amputee patient is essential in order to: 1) achieve relief from pain; 2) increase blood and fluid circulation; 3) to correct and prevent further disabilities; 4) for the maximum return of strength, mobility and coordination; and 5) to teach the patient whatever capacities he/she possesses to fully realize his/her potentials for daily living. However, prior to the actual application of physical therapy treatments, the physical therapist in coordination with the patient’s doctor or physician must evaluate or do the following tests so that a rehabilitation plan can be drawn up: a) muscle test; b) measurement of ROM (range of motion); c) measurement of leg-length and circumference of mid-thigh; d) electro diagnosis test (E.D.C.); and e) electromyography test (Boggild et al., 2002). The primary health provider or doctor (surgeon) must encourage the patient to move after a couple of days once surgery is over. The reason behind this is that it will prevent muscle atrophy from happening when the body is at rest for a length of time. It will likewise aid in the improved circulation of body fluids and strengthen the joints and muscles. Encouraging the patient to move as early as possible will help in the development of lost self-confidence to perform standard daily living activities that will continuously propel him/her to try and achieve independence during the rehabilitation phase (Gailey et al., n.d. b). It is also vital in relation to physical therapy (rehabilitation) that patients are properly educated about their condition and what they must do in order to maintain physical fitness. The following are recommendations from Amin (2000) on the basic instructions which the medical team must do: 1. Provide client teaching about effective pain management techniques, signs and symptoms; to report redness, elevated temperature, unusual foul smelling drainage, abrasions and other signs of skin breakdown. 2. Teach client how to care for residual limb by washing it daily with warm water and bacteriostatic soap. This must be followed by rinsing and to thoroughly dry by gently patting the stump end. The wound must be exposed to air daily for at least twenty minutes (20 minutes). 3. The patient must avoid using lotions, alcohol, powder or oils unless prescribed by the healthcare provider because this might irritate the skin around the wound, which may lead to skin breakdown. 4. Limb sock must be changed daily and must be washed properly. Socks in poor condition must be discarded. 5. Patient must regularly perform upper extremity active range of motion (AROM) on a daily basis. 6. Patient must lay prone for thirty minutes 3 to 4 times a day (if patient is able and if it is a part of standard care). 7. Patient must avoid elevating or sitting with residual limb on pillows to prevent the occurrence of flexion contractures. 8. Inform patient that the pain may persist in the amputated extremity and that this is normal and real. The discomforts will be treated with analgesics and other interventions. When the patient is already able he or she must be taught ambulatory techniques using the prosthesis or any other mechanism to help in moving around. It is better to begin the regimen and instruction with the minor details first. This includes proper use of prosthetics and prosthetics exercise that will lead to further strengthening and proper range of motion. This is to be followed by achieving correct bed mobility so lying down and getting up from the bed will not hamper the patient from accomplishing other activities. Once bed mobility has been efficiently achieved, transferring from the bed to a chair or wheel chair must be learned. This is where the patient must learn the technique of doing proper pivoting and knowing where to position the good side. Learning how to stand without support must be accomplished by balancing the body’s center of gravity over the side of the good limb. This technique will eventually be not required once the prosthesis is at hand; but being able to stand alone and do basic transfers from the bed to the chair and back again boosts self-confidence when there is already a necessity to graduate to more complex ambulatory techniques. The efficiency of the rehabilitation stage considerably depends on the medications prescribed for the patient since pain will always be present. So being able to control the pain will make things more bearable and easier. The patient’s willingness to undergo the required therapy is subject to how mentally and emotionally ready they are to turn their life around after their ordeal with surgery (Gailey et al., n.d. c). References Amin, C. (2000). Amputation. Underground Clinical Vignettes: Anatomy Classic Clinical Cases for USMLE: Step 1 Review. ISBN 1-890061-19-0. Boggild, M. and Ford, H. (July 2002). What are the Effects of Interventions Aimed at Reducing Relapse Rates and Disability?: Neurological Disorders (Abstract). Clinical Evidence Concise, 274-276.CNIS. (24 September 2007). Amputation. Retrieved from http://ps.cnis.ca/wiki/index.php/56._Amputation Duckworth, T. (2000a). Orthopaedics and Fractures. [Lecture Notes]. Department of Orthopaedic Surgery, University of Sheffield, South Yorkshire, England. Duckworth, T. (2000b). Orthopaedics and Fractures. [Lecture Notes]. Department of Orthopaedic Surgery, University of Sheffield, South Yorkshire, England. Gailey, Jr. R. S., Clark, C.R. (n.d. a). Physical Therapy Management of Adult Lower-Limb Amputees. Retrieved from http://www.oandplibrary.org/alp/chap23-01.asp Gailey, Jr. R. S., Clark, C.R. (n.d. b). Physical Therapy Management of Adult Lower-Limb Amputees. Retrieved from http://www.oandplibrary.org/alp/chap23-01.asp Gailey, Jr. R. S., Clark, C.R. (n.d. c). Physical Therapy Management of Adult Lower-Limb Amputees. Retrieved from http://www.oandplibrary.org/alp/chap23-01.asp Fitzmaurice, D., Hobbs, R. FD., McManus, R. (March 2002). What are the Effects of Treatments for Proximal Deep Vein Thrombosis?: Cardiovascular Disorders (Abstract). Clinical Evidence Concise, 35-37. Gerstein, H. and Hunt, D. ( May 2002). What are the Effects of Preventive Interventions? Foot Ulcers and Amputations in Diabetes [Brochure]. Sugarbaker, P., Bickels, J., Malawer, M. (22 February 2001). Below-knee Amputation: Chapter 23. Retrieved from http://www.sarcoma.org/publications/mcs/ch23.pdf Kennedy, M.S. (2007). Nursing with the TQ Surgical in Iraq: The Work of NAVY Nurses at Camp Tagaddum. American Journal of Nursing (AJN) Vol.107, No. 6, 128. MDGuidelines. (n.d.). Amputation (Traumatic) Lower Extremity. Retrieved from http://www.mdguidelines.com/amputation-traumatic-lower-extremity Mosquera, D. (12 October 2011a). Amputation and Amputation Surgery. Retrieved from http://www.vascular.co.nz/Amputation%20surgery.htm Mosquera, D. (12 October 2011b). Amputation and Amputation Surgery. Retrieved from http://www.vascular.co.nz/Amputation%20surgery.htm Palma, G. N. and Oseda, A.D. (2009). Common Surgical Incisions. G&A Notes, Clinical Pocket Guide. University General Hospital, TX. Tietze, K. J. (2006a). Clinical Skills for Pharmacists: A Patient Focused Approach. MA Thesis, Philadelphia college of Pharmacy and Science, Philadelphia, Pennsylvania. Tietze, K. J. (2006b). Clinical Skills for Pharmacists: A Patient Focused Approach. MA Thesis, Philadelphia college of Pharmacy and Science, Philadelphia, Pennsylvania. Tietze, K. J. (2006c). Clinical Skills for Pharmacists: A Patient Focused Approach. MA Thesis, Philadelphia college of Pharmacy and Science, Philadelphia, Pennsylvania. Read More