Hi, I'm David Lawrence and in this video I'm going to talk to you about prosthetic wearing
schedules and preparing for both the residual limb, that will utilize the prosthesis as
well as the opposite limb.
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Now we're going to talk about wearing schedules with the prosthetic.
Every patient wants to get that prosthetic, put it on, and if it's not uncomfortable they
want to get up and they want to walk and they want to leave it on and just wear it all day
long.
That's a very bad idea.
We have to be very careful.
It is important to remember if you look at the tissue on the middle of your shin or the
middle of your thigh, it's not like the tissue on the bottom of your foot.
So it has to have time to adapt and become capable of absorbing the pressures and shear
tension that's going to be on the skin.
We want to give the body time to develop a tolerance and a tensile strength to be able
to absorb the energy that's going to come through the prosthetic device, or the weight,
or the pressure.
So, really important, the skin is different and the wearing schedule has got to be something
that you closely adhere to, especially with your diabetic patients.
Diabetic patients who have sensory neuropathy issues and don't have good feeling can often
times go into a prosthetic device and say, "Well, it feels great."
and not realize that they cause a lot of damage until its already done.
When people ask me can I be more aggressive with above-the-knee or below-the-knee patients
as far as the wearing schedule.
Honestly, you can be much more aggressive with the above-the-knee.
Sometimes that sounds funny but you got to remember that most below-the-knee amputees
can damage themselves before they hurt.
In other words that pressure right at the bottom of the residual limb here in the socket
may not have good sensation of before they have actually done skin damage or worse.
On the above knee amputation what you're going to have is pressure high up into the groin
if you get too far in the socket or the place where the socket's not fitting.
And even high up in the groin in a diabetic patient there's usually pretty good sensations.
So, they'll usually feel the pain and pressure before they can really hurt themselves where
on a below-the-knee it's the opposite.
You must educate your patient to take the time and inspect the limb and look at things
and don't trust what you feel.
So, what kind of wearing schedule do I use?
I love the 2-2-20 system.
It's a system I've used for years and it really works well with most patients.
That means wear the prosthetic for 2 hours on, and then take it off for 2 hours, and
no more than 20 minutes of weight bearing time per hour.
You don't want to put it on and walk around for two hours.
Five minutes here, five minutes there for up to 20 minutes per hour.
Remember there's benefit to having the prosthetic device on even if you're not up and moving.
Just simply having it on is helping your brain reconnect with the ground and feel that there
is something down there that I'm going to be working with.
As we're remapping the brain it's important to have that information for your brain to
work with and feel comfortable with.
The system is: 2 hours on, at the end of the 2 hours you want to take everything off, the
socket, the liner, the sleeve, everything.
Closely inspect the skin, if you have good vision then that's really helpful, but if
not you may need someone to help you.
Use a mirror.
Sit in a wheelchair and roll up to mirror, use a hand mirror to look all around the residual
limb to look for any spots of irritation.
Many times there's going to be some pink areas on the skin.
That's normal because there's pressure.
As soon as you look, as long as there's no areas of drainage, there's some pink spots,
you want to immediately put your shrinker back on.
And by immediately, I mean right away, not in five or ten minutes because there's going
to be rebound swelling that's going to occur as you come off of the prosthetic use from
the pressure that you were on.
So, put the shrinker on immediately, leave it on for two hours.
At the end of two hours, take it off.
If all the pink areas are gone and it looks back to where it was, you're ready to put
the prosthetic back on again.
If something looks worse, more irritation, more red, you want to leave the prosthetic
off until you talk to your therapist, your doctor, or your practitioner.
But in most cases you'll find you can put it back on and then build that schedule.
How do you build the schedule?
I usually add an hour of on-time every two to three days based on how someone's doing.
So let them go to three hours on and two off, four hours on two off.
Once you get to there, you can really go to five and one.
And then patients most likely within a two to three week period can be up to wearing the device
all day.
So with prosthetic fitting and a wearing schedule, one of the things that's very important to
not forget about is the contralateral limb.
Often times the patient's contralateral limb, especially if they have vascular disease or
are an older patient, has more potential compromise than the residual limb.
As the surgeon got the amputation at a good level, they're more likely to have an amputation
on the contralateral limb if it isn't cared for correctly.
And that means you have to monitor it closely as you go through the wearing schedule and
they're getting up on the prosthetic, closely keeping an eye on skin inspection all the
way down through for marks, irritations, swelling around the ankle, things in which you can
use a compression sock for or TED hose.
Those types of things, but the other aspects of things, how can I help that foot out because
honestly the foot on that side I like to say to patients, it sounds a little corny: You
want to think of your remaining foot as it's made of gold.
What does that mean to you?
Gold is very valuable, you want it, but it's not a very strong metal.
You're not going to build a building out of it.
You have to really care for it and treat it accordingly.
So, a couple of things that really help: Many times when a patient is on that... walking
on the prosthetic side the other limb many times can have plantar fasciitis issues or
arch issues, rolling into pronation or rolling into supination.
So, many times an insert in the shoe can be very helpful to give them some arch support,
give them some comfort, maybe its diabetic foam on top as well to really protect that residual
limb on the other side and give it the best support you can inside the shoe.
It's also not uncommon for patients to have on the other side, maybe have had a trans-metatarsal
amputation or have had a big toe removed.
So, they've got an amputation on the left and on the right side they don't have their
great toe.
That's very difficult to balance and get started and get enough push-off and enough support when
you're walking.
So carbon insert plates are paper thin but they do a really nice job to put them underneath
of some sort of insert, like this, to protect the foot.
And at the same time, give energy back where that toe is missing or all the toes are missing.
Really important component to protect that foot.
The other issue that's important, and maybe this is for a little bit higher level patients.
We have a lot of young people who don't have diabetic issues or they're getting back to
playing sports on a prosthetic.
And it's really important to think about the fact that if you sprain your ankle on your
right side when you're wearing a left prosthetic that is incredibly disabling.
You may be wheelchair bound, even if you're an 18 year old individual because you've got
a prosthetic above the knee on one side and a bad ankle sprain on the other.
So, simple ankle braces that are out there, I really like the Active Ankle.
It's really made for more of the volleyball / tennis player level, so it's not a heavy
lace-up type device.
But the lace-up devices can work well if you need that kind of stabilization.
But you really want to be looking at the contralateral limb as what can I do to be sure that it stays
in the best condition possible so as that person masters their work with a prosthetic
device, they maintain the highest level of function.
Our next topic is topical agents, both on the residual limb and the contralateral limb.
Let's start with the residual limb first.
With the residual limb, the things you might want to use is lotion.
Patients feel that the skin is dry and they want to put lotion on their leg.
I always suggest they put very very little and always put it on at nighttime and make
sure its dried out completely before you put the prosthetic on.
You never want to put lotion on and pull on a sleeve, liner, socket over top of that lotion
or a wet skin situation, you can set up dermatitis and other problems.
So you want to make sure that if you do put lotion on it's at nighttime, not before you're
going to be putting the prosthetic on.
The other issue is antiperspirant, it could be an area where it's hot, it's humid...
There's going to be a lot of sweating that can occur.
With that sweating you can begin to have pistoning or slipping of the prosthetic socket.
So, antiperspirant that is made for prosthetic wearers is out there and it works very well.
The key with it though is to really tend to use it at nighttime.
Say if you take a shower in the evening, then put on antiperspirant, sleep.
It'll be well into the skin and dry in the morning when you put your prosthetic on.
It is much better to do that than to put your antiperspirant on and be wet when you put
it into the socket.
You'll give time for it to completely dry out before you go into the socket.
Much healthier, much safer for the residual limb and for the tissue.
The other issue is the contralateral limb.
With the contralateral limb you have the issues of usually dryness in the skin and a lot of
people want to and should use skin lotion.
So if you're going to put lotion on that limb you want to make sure you massage the lotion
in good, all the way to down to get the ashy-ness off the skin and so there's no scaly-ness.
But you want to keep the lotion away from the toes and away from any wound areas.
You want to stay at least a half inch above the base of the toes, never in between the
toes where you can get a fungal infection, and you want to keep away at least a half
inch to an inch away from any wound area with any drainage.
Massage the area, that's good for circulation.
Get the ashy-ness off, but don't use more lotion than you need.
The last issue on that is then sunscreen.
Alright, sunscreen works really well.
A couple of things are important, both for your total body issues on the beach.
But, remember if you're out someplace and take the prosthetic off to get sun that tissue
on the residual limb is very blanched out, very white-skinned, does not have much sun
protection whatsoever.
So you can get a bad burn very quickly.
So you want to use good sunscreen over the residual limb.
Make sure you're well covered, or cover your residual limb with a towel, but don't leave
it exposed without good sunscreen because that burn will make it very difficult, if
not impossible to use your prosthetic limb in the future.
In the near future.
Thanks for watching and we hope that you found this information helpful.
This video is part of a series on prosthetic rehabilitation, ranging from managing the
residual limb after amputation and progressing to running with a prosthesis.
We encourage you to view our other videos in this series and to share them as well.
You can find them on our YouTube channel at YouTube.com/MissionGait.
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