Assessment of the amputee

Original Editor - Julia Earle as part of the World Physiotherapy Network for Amputee Rehabilitation Project

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. 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. Either pre-or post-surgery it is of utmost importance to have a discussion with the patient about his/her short term and long term goals, as well as specific expectations and feelings they might have regarding the surgery, rehabilitation, etc.

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 the 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 the 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 problems resulting from misinformation. Usually, patients will experience a lower level of function following an amputation than previously, especially if having 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 the 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 the 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 patient's care prior to admission. Assessment is never a one-off exercise but an ongoing process. See Clinical guidelines for the pre and post operative physiotherapy management of adults with lower limb amputation .

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

Subjective 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

Medications

Especially:

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

Present Medical History

• Date of amputation or planned amputation date
• Pre-op: level and side of planned amputation
• 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
• Condition of intact limbs or contralateral amputation and prosthetic function, mobility level, ability to walk, and don/doff prosthesis
• 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
• Patient's weight
• 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 others amputees are 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. Timely referral is needed on to the appropriate specialty if required.

Pre-existing Functional Mobility

• Bed mobility, transfers, sit to stand
• Use of assistive devices like crutches or a wheelchair
• Gait or wheelchair distance/endurance
• Factors limiting mobility
• Negotiation of environmental factors like stairs, ramps, uneven terrain, curbs, crowds, obstacles, etc.

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

Objective Assessment

Physical Assessment

The physical assessment could be done pre- or post-amputation and should be tailored to the specific patient.

• Chest and respiratory assessment (as needed)
• Inspection of the residuum and remaining limbs, pressure areas, and pain
• Wound assessment
  • Wound approximation
  • Peri-wound erythema - normally after 72 hours the erythema due to surgery should not decrease, an increase might be a sign of infection
  • Wound drainage - Note any quality or quantity change. Serosanguinous drainage is normal in the healing phase and will decrease over time
  • The moistness of the area around the wound: a wet environment (like the dressing) might predispose the wound to infections, whereas a very dry wound may limit the healing process.
• Presence of scar tissue/skin grafts
• Condition of the contralateral limb/foot
• Vascular exam (when the amputation is due to a vasculopathy this exam should be done at every visit)
  • Presence and quality of distal extremity pulses
  • Colour
  • Skin temperature
• Joint integrity and range of motion 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 don and doff a prosthesis, use a manual wheelchair
• Neurological
  • Peripheral
    • Protective sensation using 10-gm Semmes-Weinstein monofilament (this represents the pressure threshold to protect the skin from ulcerations)
    • 128Hz tuning fork test for peripheral neuropathy
    • Pinprick sensation test
    • Ankle reflexes
    • Tinel's test on the residuum if a neuroma is suspected
  • Cognitive
• Activities of daily living
• Functional mobility
  • Balance in sitting and standing
  • Bed mobility
  • Ability to transfer and mobilise
  • Standing tolerance
  • Gait - assess the patient's ability to use assistive devices and their ability to climb stairs

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 the bone (prominent or not), skin perfusion, sensation, tenderness, stump shape, redundant tissue, mobility of scar and pain should all be considered.

International classification of functioning

The functional impairments affect many facets of life including but not limited to: the activity of daily living, mobility, body function and structure. The introduction of the International Classification of Functioning, Disability and Health (ICF) by the World Health Assembly in May 2001 provides a globally accepted framework and classification system to describe, assess and compare function and disability. The article Portraying the amputation of lower limbs: an approach using ICF shows how the ICF could guide a multidirectional approach during the rehabilitation of a person a with limb amputation.

Short version booklet of the International Classification of Functioning, Independence and Health

In the World Health Organisation ICF Framework, they included a specific "amputee element"

Outcome measures

In order to evaluate the lower limb amputation rehabilitation outcome, the use of measurement instruments will quantify those outcomes classified within the International classification of functioning, disability and health (ICF) category of body function or structure.

It is important to have an individualized approach (keeping the patient and their amputation level in mind) when selecting the appropriate validated outcome measure as some outcome measures may not provide specific assessment or be valuable for your patient. The selected outcome measure could then be complemented with another outcome instrument. When using outcome measures during amputee rehabilitation the therapist can show the value of the therapy to the patient, family, caregivers, and medical insurance.

"By incorporating outcome measures in daily practice clinicians can have the ability to evaluate the various aspects of clinical care such as level of confidence with the prosthesis, socket comfort, functional level and quality of life with the prosthesis. Outcome measures not only help clinicians to determine the effectiveness of an intervention but they can also detect the cause of the problem and in some cases provide directions on potential solutions and therapeutic interventions."

Example outcome measures:

• Activities-specific Balance confidence scale- UK (ABC-UK); The ABC -UK is a self-report, quality of life outcome measure, relating balance confidence to functional activities.
  
• The Amputee Mobility Predictor (AmpPro/AmpNoPro): is an instrument to Assess determinants of the Lower-Limb Amputee's Ability to Ambulate and measure function post-rehabilitation. It was developed to provide a more objective approach to rating amputees under the various "K Classifications". The test can be performed with or without the prosthesis. The AmpPro form & instructions can be viewed here AmpNoPro (In Appendix 2 for instructions).
• Prosthesis evaluation questionnaire used to describe the perception of difficulty in performing prosthetic function and mobility. The PEQ is a self-report, 82-item questionnaire developed to assess prosthetic function, mobility, psychosocial aspects, and well-being
  
• Locomotor capability index questionnaire: the LCI is a self-report outcome measure that forms part of the Prosthetic Profile of the Amputee questionnaire. The LCI assesses a lower limb amputee's perceived capability to perform 14 different locomotor activities with a prosthesis.
• The Trinity Amputation and Prosthesis Experience Scale (TAPES): is to examine psychosocial issues related to adjustment to a prosthetic, specific demands of wearing a prosthesis and potential sources of maladjustment.
  

• The Barthel scale or Barthel ADL index is an ordinal scale used to measure performance in activities of daily living (ADL). Each performance item is rated on this scale with a given number of points assigned to each level or ranking.
  
• The Prosthetic Profile of the Amputee (PPA) measures the function of adult unilateral lower limb amputees (prosthetic users and nonusers) in terms of predisposing, enabling, and facilitating factors related to prosthetic use after discharge from the hospital.
  
• Additional outcomes measures; Timed up and go test, L test, 2 min walking test, 6 min walking test.
  

Related resources

• Read a detailed resource on Outcome Measures for Patients with Lower Limb Amputations 
• Condie et al (2006) conducted a literature review of Lower Limb Prosthetic Outcome Measures   
• You can find a summary of most of the outcomes measures in the BACPAR toolbox_version_outcomes measures
• Outcomes measures relating to amputee gait from AustPAR
• Clinical Outcome Measures for Rehabilitation of Amputees – A Review. Agrawal V. Phys Med Rehabil Int. 2016; 3(2): 1080.

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 the patient to stand up
Aids sitting balance and transfers	Can make transfers more difficult
Lower energy expenditure in gait compared with trans-femoral level	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 a prolonged period due to high level of socket anteriorly
Can be used purely cosmetically

 

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

Most important parameters to take in consideration for prosthetic fitting:

1. Does the person with an amputation want to walk?

2. Will it be possible for the person with an amputation to walk?  per e.g.: A hip flexion contracture of 15 degrees or more makes fitting a prosthesis difficult.

3. Where will the person with an amputation walk?

4. Will prosthetic rehabilitation improve the person with an amputation's quality of life?

After the assessment, the team will base the decision as to whether or not to supply a prosthesis on the balance of successful outcome when considering the different parameters such as the pathology, level of amputation, length and condition of the stump, the environment and individual wishes.

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

• Transfer independently from a seat to bed/chair/toilet and back using a standing pivot transfer.
• Push up from sitting in a 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).
• 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 prosthetic rehabilitation :

• Muscle strength scale 4 (Oxford) in all 4 limbs
• Poor hand dexterity, with the patient unable to manage velcro fastenings, straps or knee locking mechanisms
• Patient unable to wash and dress independently
• 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

Resources

• Sample form used in one ICRC PRC setting; 2014 06 21 KAB PT Assessment Form- GENERAL
• Sample form NHS in appendix 2  Amputee_Rehabilitation_Guideline_for_Physios
• Outcome Measures for Patients with Lower Limb Amputations
• Acute Care. Pre-operative physiotherapy. AustPAR. Australian Physiotherapists in Amputee Rehabilitation.
• Portraying the amputation of lower limbs: an approach using ICF. Gonçalves Junior E, Knabben RJ, Luz SC. Fisioterapia em Movimento. 2017 Mar;30(1):97-106.