Assessment for TF Amputee.

Introduction

Clinical assessment is performed to examine the assessment process and consider important information that should be collected during initial patient consultation. And also examine the difference between subjective and objective assessment.

Definition:
Assessment is the process of gathering information to make decisions for diagnosis and prescription.
Our diagnosis and prescription should be in light of information that we get during assessment. It is done before casting and procedure during which the careful and detailed examination of both the normal and amputated side as well as sound side is done. And use for purpose to do right diagnosis. When done for amputation above knee then it is called assessment of trans femoral amputee.
CLINICAL ASSESSMENT CONTEXT.

CLINICAL ASSESSMENT CONSIST OF TWO PARTS.
1) Subjective assessment.
2) Objective assessment.

Subjective Assessment
Personal information.
General information about patient, e.g Name, father name, gander, age etc.
• Social condition.
Finical condition, assistance available, living arrangements of patient etc.
• Medical history.
List of present condition, symptom, medication and health risk factors
• Past medical history.
List of previous illness
. Previous treatment.
Pre prosthetic treatment, crutches, old prosthesis.

Objective Assessment
• Observation.
a) Posture.
Shoulder height, pelvic level, spine condition etc.
b) Amputation.
Trans femoral amputation, Level of amputation weather it is at proximal 1/3, middle 1/3, distal 1/3.
c) Causes of Amputation.
Congenital, Traumatic, Vascular, Infection, Neoplasm, Diabetes Mellitus etc
d) Swelling.
Edema. e) Muscle bulk or wasting.

Bulky stump or atrophic stump.

. Palpation.
a) Stump condition.
Stump is good for prosthetic fitting or not, Scar is moveable or fixed, Myoplasty or Myodesis.
b) Stump complication.
Flexion contracture, Abduction contracture, fixed scar, cut

aneous horn, Neuroma , cutaneous Horn etc.

• U/L manual dexterity.

Amputation in upper limb, power of U/L (Donning & Doffing).

• Joint condition.
a) Hip joint (Sound side & effected side).
b) Knee joint (Sound side).
c) Ankle joint (Sound side).

• Spinal condition.
Deformity in spine (Lardosis, Kyphosis, scoliosis).

Muscle Grading.

We start to check muscles strength from grade 3 if muscle is weak we move to grade 2, 1, 0. If a muscle is strong we move towards grade 4 and 5.

0 no movement
1 flickering movement
2 complete range of movement without gravity
3 complete range of movement against gravity
4 complete range of movem
ent against gravity and with slight resistance
5 complete range of movement Against gravity with full resistance
Tests

Tests

1) Hip Abduction test.
• ROM: 45 deg – 50 deg.
Muscles:
a) Gluteus Medius.
b) Gluteus minimus.
c) Tensor Fascia lata.

POSITION OF PATIENT DURING TEST.

Patient will lie down on examination table in spine position if patient muscle is below grade 3 or side vise when its grade is above 3.
Place your hand on the lateral aspect of stump and ask patient to push against your hand .The force with which patient pushes will give good impression of muscle strength’s. Ask the patient to do the same movement alone .observe if range of movement is normal.
NOTE: while doing this test patient should keep pelvis in level otherwise movement will occurring at trunk as will as the hip.

2) Hip Adduction Test.
• ROM: 20 deg – 30 deg.
• Muscles:
a) Adductor Longus.
b) Adductor Brevis.
c) Adductor Magnus.
d) Gracilus.
e) Pectineus.

POSITION OF PATIENT DURING TEST.

Patient will lie down on examination table in spine position if patient muscle is below grade 3 or side vise towards amputated side when its grade is above 3.
Place your hand on the medial aspect of stump and ask patient to push against your hand .The force with which patient pushes will give good impression of muscle strength’s. Ask the patient to do the same movement alone .observe if range of movement is normal.
NOTE: while doing this test patient should keep pelvis in level otherwise movement will occurring at trunk as will as the hip.

3) Hip Flexion Test.
• ROM: 130 deg.
• Muscles:
a) Psoas Major.
b) Iliacus.

POSITION OF PATIENT DURING TEST.

Patient will lie down on examination table in spine position if patient muscle is above grade 3 or side vise when its grade is below 3.Place your hand on the anterior aspect of stump and ask patient to push against your hand .The force with which patient pushes will give good impression of muscle strength’s. Ask the patient to do the same movement alone .observe if range of movement is normal.

4) Hip Extension Test.
• ROM: 20 deg – 30 deg
• Muscles:
a) Gluteus Maximus.
b) Hamstring.

POSITION OF PATIENT DURING TEST.

Patient will lie down on examination table in prone position if patient muscle is above grade 3 or side vise when its grade is below 3.Place your hand on the posterior aspect of stump and ask patient to push against your hand .The force with which patient pushes will give good impression of muscle strength’s. Ask the patient to do the same movement alone .observe if range of movement is normal.
Note: If the patient compensates for lack of hip movement by moving the pelvis. it is strong indication of flexion contracture.

5) Thomas Test.

POSITION OF PATIENT DURING TEST.

The patient lies flat on the examination table. the sound leg is flexed and held in position by either the patient or posthetist.if the patient can keep the back and the stump in contact with the table, there is no flexion contracture in the stump. if patient is unable to bring stump down on table in this position. There is flexion contracture of the muscles of stump and degree of flexion contracture is measured by measuring the angle between the mid line of body and the mid line of the stump.
1 2 3
Note: Patient with flexion contracture must be fitted with TFP where the Socket is flexed to accommodate contracture. Other wise patient will walk with anterior pelvic tilt and excessive Lumbar Lordosis.

6) Measuring The Lateral Wall Adduction Angle.

 The amputee will have to stand between bars or other supports with pelvis in level position.
 The amputee will have to extend the stump as for as possible without anterior rotation of pelvis.
 Then move the amputee s pelvis slightly towards amputated side, so that the mid sagittal line will be about one inch medial to the heel of sound foot.
 Normally the mid sagittal line is at the same distance from both the heels, there for to get normal alignment the stump should be adducted so that if the amputated leg were back in place, the heel would be about 2.5cm from mid sagittal line.
 If the patient has an abduction contracture, it will not be possible to adduct the stump to the position just prescribed above in such case help the patient to adduct the stump as much as possible, keeping the pelvis level, and then measure the angle.

Conclusion

After performing subjective, objective assessment, muscle grading and Tests, we will get the Diagnosis. According to the diagnosis we prescribed appropriate Prosthesis for the Patient.

References

• Nizar Akhtar. Transfemoral Prosthetic Module. PIPOS. 2004.
• Aziz Ahmad. Patient Evaluation and Assessment. PIPOS. 2008
http://en.wikipedia.org/wiki/Assessments
http://www.biologyonline.org/dictionary / Subjective assessment
C. Leslie Mitchell and S. William Levy
National research council Washington 25, D.C

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