Assessment of the amputee

Original Editor - Julia Earle

Top Contributors - Aicha Benyaich, Tony Lowe, Admin, Tarina van der Stockt, Lucy Aird, Kim Jackson, Simisola Ajeyalemi, Rachael Lowe, Andeela Hafeez, Richard Benes and Olajumoke Ogunleye  

Assessment

Assessment of a patient having an amputation should begin as early as possible, ideally preoperatively, by the whole multi-disciplinary team in order to prepare the patient, maximise the potential outcome of the procedure both surgically and functionally. In fact the decision to amputate should be made by this team where ever possible (1, 2). This could even be before admission to hospital for the surgery, especially important if there are issues associated with wheelchair accessibility to / within the home and likely support required.

Why Assess?

• To assess the most appropriate level of amputation for the individual, not only according to tissue viability but also the likely future potential mobility the patient may have. For example: Is preservation of the knee joint paramount? Usually this would be the ideal in order to maximise function and future mobility potential but, if it is fixed in flexion and distally likely to be a pressure area if patient is not mobile maybe this is not the case. On the other hand it may still be worth preserving if the contralateral limb is also likely to require amputation in the near future at a higher level and the use of a trans-tibial prosthesis on the first side would facilitate independent transfers and safety in sitting.
• To prepare and inform the patient and their family / carers for the surgery, hospital stay and rehabilitation. Leaflets are available such as those produced by the Circulation Foundation on many areas such as peripheral vascular disease, intermittent claudication, angioplasty and stenting, bypass surgery and amputation to support local information.

• To discuss realistic potential level of mobility with patient, family and carers, whether this is likely to be using a wheelchair or prosthesis depending on the findings of the assessment. It is important to be open and realistic from the start in order to facilitate adjustment to their new situation and to minimise the problems resulting from miss information. Usually patients will experience a lower level of function following an amputation than previously, especially if at a higher level of amputation such as trans-femoral.
• To order appropriate wheelchair and stump board if needed so it is available as soon as possible.
• To optimise pain relief pre op and post op. Discuss pain relief and possible phantom limb sensation and pain post op.
• To refer to other members of the team as required such as Occupational Therapist, Psychologist or Counsellor, Podiatrists, Prosthetic service, Dietician, Specialist nurses such as Tissue viability or District nursing, Wheelchair services, Social services and other medical specialities such as Diabetology, Psychiatry, Elderly care, Neurology or Rehabilitation medicine.
• To offer support from other amputees if appropriate either locally or through national organisations such as The Limbless Association in UK and The Amputee Coalition in America or online support networks.
• To begin discharge planning - whether the patient will be able to return home or will need rehousing or adaptations to be made, a care package or admission to a residential or nursing home.
• To plan pre and postoperative physiotherapy intervention through setting of realistic goals with the patient.

Information can be gained from many sources as well as the medical and nursing notes, patients, carers and those involved in the patients care prior to admission. Assessment is never a one off exercise but an ongoing process. insert link to pre and post op guidelines – see references

The following may be an example of the elements of assessment:

Past Medical History

• Diabetes and its associated complications: particularly those that may affect the patient’s functional ability and potential for prosthetic limb use such as neuropathy (upper and lower limbs), retinopathy, poor glycaemic control and condition of the contralateral limb
• Cardiac history / exercise tolerance
• Renal function / dialysis potentially resulting in fluctuating stump volume
• Respiratory function / exercise tolerance / shortness of breath on exercise
• Previous Stroke and any residual effects
• Previous trauma and associated surgery
• Arthritis and associated limited range of movement, pain or weakness
• Previous joint surgery
• Previous vascular investigations such as doppler, angiography, CT or MRA (e.g. video of MRA showing occlusion and collateral circulation)
  

• Previous vascular interventions such as angioplasty, thrombolysis, aneurysm repair and bypass surgery
• Allergies: may affect treatment (especially dressings), therapy and prosthetic materials used

Medication, especially:

• Diabetic control
• Statins
• Antihypertensives
• Antiplatelets
• Vasoactive drug treatment such as Naftidrofuryl oxalate – recommended by NICE for treatment of leg pain triggered by exercise (intermittent claudication) in people with PAD. 
• Analgesia, type and duration

Present Medical History:

• Reason for amputation: Peripheral arterial disease, trauma, tumour, congenital deformity
• Associated medical problems: ulcers, fractures, soft tissue injuries
• History of deterioration of limb: acute or chronic
• Skin condition, perfusion, sensation, rest pain
• Current functional ability: self-care, mobility (use of aids, distance, reasons for limitations), activities of daily living
• Smoking history
• Pain
• Cognitive ability
• Claudication history
• Vision and hearing ability

Social History:

• Cohabitants / dependents: age, health, ability to assist / care / support the patient or is the patient a carer?
• Housing: Type of property, ownership, access internally and externally, previous adaptations, layout, position of bathroom facilities and bedroom
• Occupation: Type of work, mobility required, wheelchair accessibility, travel to and fro, pressure to return, adaptations required, retraining necessary
• Hobbies and interests: Sedentary, social and more active including sports
• Driving: manual or automatic, type of vehicle
• Current social services support / support from family and friends
• Existing wheelchair use, duration, for what purpose

Physical assessment:

• Joint integrity and presence of contractures, especially of flexors of hip and knee joints
• Muscle power and range of movement of upper and lower limbs as well as trunk – especially core stability
• Hand function – will they be able to donn and doff a prosthesis, use a manual wheelchair
• Balance in sitting and standing
• Ability to transfer and mobilise
• Standing tolerance
• Presence of scar tissue / skin grafts
• Use of compression therapy and PPAM aid (see oedema guidance)
• Condition of the contralateral limb / foot (see guidelines)
• Patients expectations of planned surgery: For some it will be an elective amputation following a prolonged disability or period of treatment, for others it may be an acute episode resulting in an emergency amputation. Patients expectations may be well informed and realistic but not always. Sometimes they can be over optimistic as to the ease and speed of prosthetic rehabilitation, lack of discomfort, future mobility levels but equally they can sometimes be overly pessimistic and realistic plans and goal setting is essential.
• Psychological and emotional state: During rehabilitation the advice and support given by the team, family and other amputees is very helpful and means that they may not require specialist counselling but some patients do require additional support. Every patient’s response to their amputation will be unique. Their coping strategies or reactions may well change over their rehabilitation period and beyond and as therapists we need to be aware of possible responses that may be of concern such as denial, withdrawal, suppression, regression, projection and displacement (3). Timely referral is needed on to the appropriate speciality if required.

Postoperatively the assessment should also include information about the quality of the residual limb (stump) as this will have an impact on the prosthetic rehabilitation potential for the patient. Wound condition, oedema, stump length, cut end of bone (prominent or not), skin perfusion, sensation, tenderness, stump shape, redundant tissue, mobility of scar and pain should all be considered (5).

Assessment for suitability for a prosthesis

Many trans-tibial amputees will be able to use a prosthesis, even if it is only for transfers or to help with sitting balance or even for cosmetic reasons but a trans-femoral limb is very different so careful assessment is required as to whether the patient will be able to benefit from a prosthesis, particularly at this level.

Differences between trans-tibial and trans-femoral prosthetic use

Trans-tibial prosthesis Trans-femoral prosthesis Can be donned in sitting Ideally donned in standing therefore requires balance and frequently use of both hands Can be used to aid sit to stand Does not help patient to stand up Aids sitting balance and transfers Can make transfers more difficult Lower energy expenditure in gait compared with trans-femoral level (6) Higher energy consumption in gait compared with trans-tibial level Lower risk of falling Higher risk of falling Usually comfortable to sit in Tendency to be uncomfortable if sitting for prolonged periods due to high level of socket anteriorly Can be used purely cosmetically If to be used cosmetically different type of limb usually manufactured

Borderline criteria for trans-femoral prosthetic use initiated by the South Thames Regional BACPAR group and further developed by Roehampton which may be helpful:

If patients are unable to achieve the following they are unsuitable for prosthetic rehabilitation:

• Be completely independent in using their wheelchair indoors and understand the importance of safe wheelchair drill e.g. brakes on, positioning of chair, removal of stump boards and footplates etc.
• Transfer independently from wheelchair to bed/chair/toilet and back using a standing pivot transfer.
• Push up from sitting in wheelchair to standing independently in parallel bars.
• Have independent standing balance within parallel bars (patients may need to be able to stand for up to 5 minutes for prosthetic casting).
• Hip flexion contracture under 25º.
• Cognitively unimpaired i.e. be able to follow instructions, process new information and remember it over a period of time. (A CAPE assessment can be organised if needed).
• With the aid of an early Walking Aid (such as a PPAM aid or Femurette) mobilise within the parallel bars. The patient should be able to achieve 6-10 lengths, repeatedly, throughout a treatment session on a regular basis during their initial phase of rehabilitation.

The following areas would cause concern and would impact on prosthetic rehabilitation :

• Muscle strength under MRC scale 4 in all 4 limbs
• Poor hand dexterity, with patient unable to manage velcro fastenings, straps or knee locking mechanisms
• Patient unable to wash and dress themselves independently
• Hips or remaining knee with flexion contractures over 25º
• Other pathologies e.g. CVA, R.A, O.A, Respiratory problems, poor Cardiovascular state
• Poor motivation
• Issues of concern around social support and home environment