Wednesday, November 18, 2009

Preventing Phantom Limb Pain with Immediate Post-Operative Prostheses (IPOP) Procedure

Though the Immediate Post-Operative Prostheses (IPOP) Procedure offers the highest rate of healing of any of the post operative modality treatments for lower limb amputation, it is not widely in use.

The primary reasons for its modest use include the fact that the process itself is slightly more time consuming in the O.R.(approx. 20 min); requires more monitoring of the wound itself; possible payment issues for the prosthetist for the procedure, including the frequency of subsequent visits and lack of familiarity with the treatment itself.   Many surgeons performing the amputation are not trained in IPOP principles nor have knowledge of the benefits in the rehabilitation aspect.  Many do not have a working relationship with a prosthetist who will be performing this procedure in the O.R. immediately after they are finished.  And, the prosthetist needs to be available for this critical time period to apply the rigid dressing & the associated components.

These, and any other objections, are greatly offset by the benefits to the patient/client, when used immediately after lower limb amputation:

Accelerates recovery – Early use of a prosthesis often results in shorter hospital stays and a faster transition to a temporary prosthesis as patients begin to develop a tolerance to weight bearing.

Controls swelling – In applying gentle pressure to the patient’s residual limb, an IPOP will minimize swelling. This helps the healing process, shaping the limb, making the final custom-made prosthesis easier to fit and in a more timely manner.

Reduces pain – In controlling the swelling, pain is often reduced. This reduces the use of drugs, decreasing costs and may even eliminate drug dependency.  Research also indicates that early prosthetic use made possible with the IPOP Procedure, may reduce (or eliminate) the occurrence and severity of phantom limb pain and sensations.

Protection and Safety – Especially in patients who are in a weakened condition, elderly or have other medical considerations, IPOP practice shows a dramatic reduction in the number of falls and can help prevent additional injury to the wound.

Prevents knee flexion contractures and loss of muscle strength – By allowing amputees to stand almost in very short order and to gradually begin using their legs, an IPOP can significantly improve rehabilitation – again, reducing hospital stays & costs.

Greater stability - An IPOP, which is a rigid locked knee above a "weightless" prosthesis, gives the patient more stability than prior to the surgery, when they undoubtedly had a painful or weak leg.  It is usual practice to mobilize patients within 24 hours post-surgically.  At a minimum to have the patient stand and transfer to the toilet or wheelchair using a limb. The importance of minimal ambulation in therapy from the second day onwards cannot be emphasized enough. The minor risk of harm involved with minimal weight bearing and the brief stance phase on the amputated leg is outweighed by all the general advantages to the patient for ultimate survival.

Psychological benefits – Patients learn immediately what it feels like to wear a prosthesis and thereby can focus more on their rehabilitation than on their missing limb. This is usually very positive as long as it does not delay the process of accepting the loss of their limb. Having an IPOP can help them return to their homes, or workplaces, sooner especially if wheelchair accessibility is a problem.  The new amputee generally has a more positive outlook on their future.

The risks and side effects of an IPOP also need to be considered. Not every patient is an ideal candidate for an IPOP. It should be a decision reached by the patient, the physician(s) and any others in the rehab team to determine if the benefits outweigh the risks.

Side effects can be avoided or minimized with attentive care by a well-trained rehab team. Damage to the wound can occur from excessive weight bearing too soon after amputation. To use an IPOP correctly, the patient must be able to limit the amount of weight he or she applies to it.

Pre-existing disease issues can complicate matters – diabetes and other circulatory problems should be taken into consideration along with general health, age and strength factors.  Although rare, in some cases a patient may develop an infection or non-healing surgical wounds. In this situation, the use of the IPOP is discontinued while the problem is being addressed.  It can be reinstituted at the soonest appropriate time after the ‘problem’ has been eliminated or determined.  Sometimes a slight elevation in temperature has worried hospital staff to the point that the IPOP is removed - only to find out that the wound was perfectly fine.  The IPOP/rigid dressing then has to be re-done.

Other issues would include cognitive dysfunction and delirium, poor nutrition and the presence of a stroke.  They sould be strongly taken in to consideration in the determination to use or not use an IPOP.  .