Clinical Decision Making

Haneul Lee, DSc, PT

9Lecture 9Clinical Decision Making

in Prosthetic and Orthotic Training

Necessitates effective collaboration between themedical doctor and PT.

PTs may be called upon to provide orthotic andprosthetic training.

PTs will make clinical decisions in the training ofpatients with orthotic and prosthetic devices.

Even before the patient receives these devices

Goals for patients awaiting orthotics Functional activates – gait training Improving ROM and strength

Goals for patients awaiting prosthetics Wound management Shaping of the residual limb Contracture prevention Improving ROM, strength, and functional activities

Goals for patients after receiving orthotic or prosthetic Advanced to functional activities

▪ Donning and doffing the device▪ A이 training▪ Ameliorating gait deviations

Goals for patients with amputations will not only depend on the phase of recovery, but also on the patient’s age, diagnosis, past medical history, functional abilities, and personal goals.

For example, (2 patients)

A 21-year-old patient who has undergone a traumatic amputation

A 75-year-old patient who has had an amputation secondary to peripheral vascular disease (PVD).

Each patient will receive a very different prosthetic device

Both patients will need a plan of care that involves strengthening and

functional triaging with their new device.

Transmetatarsal amputation Ankle disarticulation (Syme's) Transtibial amputation: below-knee (BK) amputation Knee disarticulation Transfemoral amputation: above-knee (AK) amputation Hip disarticulation Hemipelvectomy Hemicorporectomy Transradial amputation: below-elbow (BE) amputation Elbow disarticulation Transhumeral amputation: above-elbow (AE) amputation Shoulder disarticulation

Ankle-Foot-Orthosis (AFO) Knee-Ankle-Foot-Orthosis (KAFO) HKAFO

Foot orthosis (FO)

Shoes

Corset

Lumbosacral orthosis (LSO) Thoracolumbosacral orthosis (TLSO)

Cervicalorthosis (CO)

Passive (static) positioning devices -cock-up splint

Passive (static) positioningairplane splint

Dynamic devices - Wrist-driven prehension orthosis

No matter which type of orthotic or prosthetic device the patientreceives, goals usually address

Donning/doffing the device

Caring for the deceive

Maintaining skin integrity

Patient education

Under staining proper use

Understanding care of the device

Skin care

Psychological issue throughout recovery

Struggling with feelings of grief over the loss of the limb

Depressed and appear unmotivated during treatment

Having hard time accepting the reality of the amputation andbe too fearful to even look at the residual limb

Expressing anxiety about the recovery

Developing phantom limb pain

In the early phases

ROM : Ability to use prosthetic or orthotic devices

Strength : Type of the device

Edema : Fit of the device

Pain : Wear the device

When providing orthotic and prosthetic

Skin condition : skin breakdown retards rehabilitation

Skin integrity assessment begins at the initial evaluation and continuesthroughout the rehab process.

• Excessive or protracted redness• Skin breakdown• Edema monitoring

• Suspension• Excessive rotation• Excessive pistoning• Pain complaint• Edema monitoring

• Medial / Lateral whip• Circumduction• Hip hike

Integument

Gait deviations

Proper fit

Steven B. Skinner, Christina McVey, Clinical making decision for physical therapy assistant, p.146

Pre-wear skin assessment

Molded areas match up with properanatomical landmarks

Appropriate placement of orthotic in shoe

Patient comfort

Post-wear skin assessment

Steven B. Skinner, Christina McVey, Clinical making decision for physical therapy assistant, p.147

Scenario

Your patient has a left transfemoral prosthetic device. When the patient ambulates you notice that he circumducts his left lower extremity.

1. During what phase of gait would you expect to see the circumduction? 2. What might be one possible cause?

http://www.amputee-coalition.org/inmotion/jul_aug_04/transfemoral-03.jpg

Question?Thank

you

1. Clinical Decision Making for the physical therapist assistance, Steven B. Skinner, Jones and Bartlett Publishers

2. National Physical Therapy Examination,O’sulivan