Pre-Fitting Management of the Patient with a Lower Limb Amputation: Difference between revisions

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'''Original Editor '''- [[User:Liezel Wegner|Liezel Wegner]] as part of the [[WCPT Network for Amputee Rehabilitation Project]]  
'''Original Editor '''- [[User:Liezel Wegner|Liezel Wegner]] as part of the [[World Physiotherapy Network for Amputee Rehabilitation Project]]  


'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}} &nbsp;<br>  
'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}} &nbsp;<br>  
</div>  
</div>  
<br>
== Introduction  ==
== Introduction  ==


The loss of a lower limb has severe implications for a person’s mobility, and ability to perform activities of daily living <ref name="dillingham">Dillingham TD &amp;amp;amp; Pezzin LE. Rehabilitation setting and associated mortality and medical stability among persons with amputations. Archives of Physical and Medical Rehabilitation 2008; 89; 1038-1045.</ref>. This negatively impacts on their participation and integration into society <ref name="who">World Health Organisation (WHO). International classification of functioning disability and health (ICF). World Health Organisation 2001. Geneva.</ref>.The ultimate goal of rehabilitation after limb loss, is to ambulate successfully with the use of a prosthesis<ref name="lusardi">Lusardi MM, Postoperative and preprosthetic care. In Lusardi, MM, Jorge, M &amp;amp;amp; Nielsen, CC editors. Orthotics and Prosthetics in Rehabilitation, Third Edition. Missouri: Elsevier, 2013.p. 532-594.</ref> . Prosthetic rehabilitation is a complex task that ideally requires input from a transdisciplinary rehabilitation team. However, most often physiotherapists are in charge of the physical rehabilitation process <ref name="kaplan">Kaplan SL, Outcome measurement and management: First steps for the practicing clinician. Philadelphia, FA Davis Company, 2007.</ref>.  
The loss of a lower limb has severe implications for a person’s mobility, and ability to perform activities of daily living <ref name="dillingham">Dillingham TD and Pezzin LE. Rehabilitation setting and associated mortality and medical stability among persons with amputations. Archives of Physical and Medical Rehabilitation 2008; 89; 1038-1045.</ref>. This negatively impacts their participation and integration into society <ref name="who">World Health Organisation (WHO). International classification of functioning disability and health (ICF). World Health Organisation 2001. Geneva.</ref>. The ultimate goal of rehabilitation after limb loss is to ambulate successfully with the use of a prosthesis<ref name="lusardi">Lusardi MM, Postoperative and preprosthetic care. In Lusardi, MM, Jorge, M and Nielsen, CC editors. Orthotics and Prosthetics in Rehabilitation, Third Edition. Missouri: Elsevier, 2013.p. 532-594.</ref>. Prosthetic rehabilitation is a complex task that ideally requires input from an interdisciplinary rehabilitation team. However, most often physiotherapists are in charge of the physical rehabilitation process <ref name="kaplan">Kaplan SL, Outcome measurement and management: First steps for the practicing clinician. Philadelphia, FA Davis Company, 2007.</ref>.


== Overview of the rehabilitation process ==
== Overview of the Rehabilitation Process ==


The rehabilitation process of the lower limb amputee consists of nine phases <ref name="esq">Esquenazi A. Amputation rehabilitation and prosthetic restoration: from surgery to community reintegration. Disability and Rehabilitation, 2004; 26,(14/15); 831–6.</ref>&nbsp;, namely:  
The rehabilitation process of the lower limb amputee consists of nine phases<ref name="esq">Esquenazi A. Amputation rehabilitation and prosthetic restoration: from surgery to community reintegration. Disability and Rehabilitation, 2004; 26,(14/15); 831–6.</ref>&nbsp;as shown in the table below (modified from Esquenazi &amp;Meier<ref>Esquenazi A, Meier RH. Rehabilitation in limb deficiency. 4. Limb amputation.Arch Phys Med Rehabil. 1996 Mar;77(3 Suppl):S18-28.</ref>cited in Esquenazi<ref>Esquenazi A.  Amputation rehabilitation and prosthetic restoration. From surgery to community reintegration. Disabil Rehabil. 2004 Jul 22-Aug 5;26(14-15):831-6.</ref>):


*pre-operative,
{| class="wikitable" width="70%" border="1" cellpadding="1" cellspacing="1"
*amputation surgery,
*acute post-surgical,
*pre-prosthetic,
*prosthetic prescription,
*prosthetic training,
*community integration,
*vocational rehabilitation and
*follow up.
 
<br>
 
Table 1: Phases of amputee rehabilitation: Modified from Esquenazi &amp;Meier (1996) cited in Esquenazi (2004).
 
{| width="70%" border="1" cellpadding="1" cellspacing="1"
|-
|-
! scope="col" | Phase  
! scope="col" | Phase  
Line 39: Line 23:
| Length, myoplastic closure, soft tissue coverage, nerve, handling, rigid dressing
| Length, myoplastic closure, soft tissue coverage, nerve, handling, rigid dressing
|-
|-
| Acute post-surgical  
| Acute Post-surgical  
| Wound healing, pain control, proximal body motion, emotional support
| Wound healing, pain control, proximal body motion, emotional support
|-
|-
Line 52: Line 36:
|-
|-
| Community Integration  
| Community Integration  
| Resumption of roles in family and community activities. Emotional equilibrium and healthy coping strategies. Recreational activities.
| Resumption of roles in family and community activities. Emotional equilibrium and healthy coping strategies. Recreational activities
|-
|-
| Vocational Rehabilitation  
| Vocational Rehabilitation  
| Assess and plan vocational activities for future. May need further education, training or job modification.
| Assess and plan vocational activities for future. May need further education, training or job modification
|-
|-
| Follow-up  
| Follow-up  
Line 61: Line 45:
|}
|}


<br>
== Pre-prosthetic Fitting Phase  ==
 
== Acute Post-surgical Phase  ==
 
It is important to remember that earlier the onset of the rehabilitation and the greater the potential for success will be. Patient need to recieve physiotherapy treatment early to avoid complication such as joint contractures, pathological scars and depressed psychological state. The main post-surgical complications are cardio-vascular, residual limb pain and phantom sensation, oedema, contracture and wound dehiscence.&nbsp;<ref>ICRC PGA Manual pp 57</ref>
 
The goals of rehabilitation at this stage are to&nbsp;:
 
• Obtain maximum independence <br>• Prevent the oedema <br>• Maintain joint ROM<br>• Prevent amyotrophy <br>• Decrease the muscular activation delay <br>• Prevent muscular weakness<br>• Prevent bronchopneumonia<br>• Prevent pressure sore<br>• Control pain<br>• Sensory reeducation<br>• Support the client psychologically <br><br>
 
It is intented that prior to any treatment, an assessment will be carried out by the physiotherapist. A functional assessment should be carried out including both uper-limb, lower-limb and trunk &nbsp;in order to evaluate the patient potential to carry out activities such as transfer, wheelchair mobility and ambulation (with or without prosthesis)&nbsp;<ref>ICRC PGA manual p. 56</ref>
 
=== 1.Treatment modalities  ===
 
Treatments modalities to prevent complications include:
 
*Breathing exercises
*AROM
*Resistance exercises
*PROM
*Desensitising techniques
*Bed mobility and transfers
*Positioning
*ADL
*Prevention of oedema
*Walking and wheelchair use
 
==== 1.1 Breathing exercises  ====
 
Deep breathing exercises and relaxation exercises)will help to increase vital capacity and decrease anxiety and prevent bronchopneumonia
 
==== 1.2 Active range of motion (AROM)  ====
 
Amputated side (from the 1st post op day unless the post surgical dressing restricts motion):<br>• First Hip flexion, ext, ADD, ABD&nbsp;<br>• Knee flexion exercises (for below-knee amptutations)
 
Amputated side (from the 3rd post op day)<br>• To reduce oedema TT amputee can imagine the performance of alternate dorsi flexion and plantar flexion.<br>• The knee disarticulation and TF amputee must perform alternate hip flexion and extension, hip ADD and ABD.<br>These active exercises must be performed at regular intervals during the day (10 repetitions per hour).<br>Bilateral activities often achieve a more vigorous contraction in the amputated side.
 
==== 1.3 Resistance exercises  ====
 
From the 1st post op day <br>• Isometric contraction of the quadriceps (TT)<br>• Isometric contraction of gluteus, ADD and hip int rot <br>• Strengthening exercises of the sound lower limb (in progression)
 
From the 3rd post-op day
 
*Resistance exercises of the upper limbs
*Resistance exercises of the torso
 
==== <br>1.4 PROM  ====
 
==== Passive extension of a TT residual limb.<ref>Engstrom - C. Van de Ven, THERAPY FOR AMPUTEES,  3ième édition, Livingstone, 1999</ref><br><br>1.5 Desensitising techniques<br>1.6 Bed mobility and transfers<br>1.7 Positioning<br>1.8 ADL<br>1.9 Prevention of edema<br>1.10 Walking and wheelchair use  ====
 
====
 
For further details on the acute post-surgical phase refer to http://www.austpar.com/portals/acute_care/post-op.php&nbsp;
 
== Pre Prosthetic Fitting Phase  ==


The PRE-PROSTHETIC rehabilitation phase of the lower limb amputee will include six components:  
The PRE-PROSTHETIC rehabilitation phase of the lower limb amputee will include six components:  


#Physiotherapist preparation  
#Physiotherapist preparation  
#&nbsp;Assessment of the amputee (see section 6 not covered in this section)  
#[[Assessment_of_the_amputee|Assessment of the amputee]] (covered on a different page)  
#Patient education  
#Patient education  
#Stump management  
#Residuum management  
#Exercise therapy  
#Exercise therapy  
#Restoring locus of control  
#Restoring locus of control  
#Referral<br>
#Referral


=== 1. Physiotherapist preparation ===
== Physiotherapist Preparation ==


As you approach an amputee, the therapist have to physically and mentally prepare for the interaction with the patient. Some questions to consider include:  
As you approach an amputee, you should physically and mentally prepare for the interaction with the patient. Some questions to consider include:  


*Who is my patient? (young / old)  
*Who is my patient? (young/old)  
*What was the cause of the amputation? (traumatic / dysvascular)  
*What was the cause of the amputation? (traumatic/dysvascular)  
*Where (what level) was the amputation performed? (implications for rehabilitation outcome)  
*Where (what level) was the amputation performed? (implications for rehabilitation outcome)  
*What is the patient’s goal? (Is the patient aware of the possibilities, are they being realistic?)  
*What is the patient’s goal? (Is the patient aware of the possibilities, are they being realistic?)  
*What prosthetic options are available for this particular patient? (self-study and preparation)<br>
*What prosthetic options are available for this particular patient? (self-study and preparation)


==== 1.1 Awareness of stages of grief process ====
=== Awareness of Stages of Grief Process ===


A young patient who suffered an amputation as result of a traumatic experience will most likely be in some stage of the grieving, and in acute post-surgical pain. An older patient who suffered a dysvascular or neuropathic limb loss, might have had some time to psychologically and physically prepare for the loss of their limb <ref name="lusardi" />. Either way, your patient might be psychologically and physically distressed when you start the rehabilitation process, so early discussion and education about the patient’s expectations and goals are essential <ref name="livingstone">Livingstone W, Van de Mortel TF, Taylor B. A path of perpetual resilience: Exploring the experience of a diabetes related amputations through grounded theory. Contemporary Nursing. 2011; 39(1):20-30.</ref>&nbsp;.  
A young patient who suffered an amputation as a result of a traumatic experience will most likely be in some stage of the grieving process and be in acute post-surgical pain. An older patient who suffered a dysvascular or neuropathic limb loss, might have had some time to psychologically and physically prepare for the loss of their limb<ref name="lusardi" />. Either way, your patient might be psychologically and physically distressed when you start the rehabilitation process, so early discussion and education about the patient’s expectations and goals are essential <ref name="livingstone">Livingstone W, Van de Mortel TF, Taylor B. A path of perpetual resilience: Exploring the experience of a diabetes related amputations through grounded theory. Contemporary Nursing. 2011; 39(1):20-30.</ref>.  


*'''''Link to full-text articles:'''''<i>&nbsp;&nbsp;</i>[http://www.amputee-coalition.org/first_step_2003/psychological-aspects-amputation.html www.amputee-coalition.org/first_step_2003/psychological-aspects-amputation.html]  
*[[Emotional and psychological reactions to amputation]]  
*'''Reaction to amputation: Recognition and treatment&nbsp;:&nbsp;'''[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2018851/pdf/i1523-5998-9-4-303.pdf www.ncbi.nlm.nih.gov/pmc/articles/PMC2018851/pdf/i1523-5998-9-4-303.pdf]  
*[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2018851/pdf/i1523-5998-9-4-303.pdf Reaction to amputation: Recognition and treatment]  
*'''Slideshow on grief amongst amputees:'''&nbsp;[http://www.slideshare.net/jrod_reggie/grieving-and-psychological-impact-on-amputees-presentation www.slideshare.net/jrod_reggie/grieving-and-psychological-impact-on-amputees-presentation]
*[http://www.slideshare.net/jrod_reggie/grieving-and-psychological-impact-on-amputees-presentation Slideshow on grief amongst amputees]


==== 1.2.Knowledge of appropriate outcome measures and assessment tools ====
=== Knowledge of Appropriate Outcome Measures and Assessment Tools ===


Be prepared with the appropriate assessment tools and outcome measures to assess your patient’s potential for prosthetic use, and not create false hope (refer to section 19 [[Outcome measures for amputees]]&nbsp;)  
Be prepared with the appropriate assessment tools and outcome measures to assess your patient’s potential for prosthetic use, and try not to create false hope ([[Outcome Measures for Patients with Lower Limb Amputations]])


==== 1.3 Knowledge of the appropriate assistive technology available ====
=== Knowledge of the Appropriate Assistive Technology Available ===


Your patient will look to you to provide early information about the possibilities for a prosthesis. Ensure that you have a basic knowledge and understanding of the prosthetic technology that is available and could be appropriate for your patient (refer to Section 9 on [[Prosthetics]]).<br>
Your patient will look to you to provide early information about the possibilities for a prosthesis. Ensure that you have a basic knowledge and understanding of the prosthetic technology that is available and could be appropriate for your patient ([[Prosthetics]]).  


=== 2. Assessment of the amputee&nbsp;<br> ===
== Assessment of the Amputee ==


In order to formulate an appropriate patient-centred prosthetic rehabilitation plan for any amputee, the patient needs to be adequately assessed. Refer&nbsp;[[Assessment of the amputee]]  
In order to formulate an appropriate patient-centred prosthetic rehabilitation plan for any amputee, the patient needs to be adequately assessed. Refer to&nbsp;[[Assessment of the amputee]]  


=== 3.Patient education<br> ===
== Patient Education ==


==== 3.1 Rehabilitation process ====
=== Rehabilitation Process ===


Patient education should commence with a discussion regarding the rehabilitation process, and patient-centred goal setting <ref name="lusardi" />.The patient should be educated with regards to his potential options for assistive and prosthetic devices <ref name="gaily">Gaily RS, Clark CR.Physical therapy management of adult lower-limb amputees. In: Michael, JW editor. Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles. Rosemont, IL, American Academy of Orthopedic Surgeons,1992. http://www.oandplibrary.org/alp/(accessed 8 February 2015).</ref>.  
Patient education should commence with a discussion regarding the rehabilitation process, and patient-centred goal setting<ref name="lusardi" />. The patient should be educated with regards to their potential options for assistive and prosthetic devices <ref name="gaily">Gaily RS, Clark CR.Physical therapy management of adult lower-limb amputees. In: Michael, JW editor. Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles. Rosemont, IL, American Academy of Orthopedic Surgeons,1992. http://www.oandplibrary.org/alp/(accessed 8 February 2015).</ref>.


==== 3.2 Pain management  ====
=== [[Pain Management of the Amputee|Pain Management]]===


Managing the patient’s expectations with regards to the acute post-surgical pain they will potentially experience during the rehabilitation process will enhance patient cooperation and improve the rehabilitation outcome <ref name="lusardi" />&nbsp;<ref name="gaily" />&nbsp;.  
Managing the patient’s expectations with regards to the acute post-surgical pain they will potentially experience during the rehabilitation process will enhance patient cooperation and improve the rehabilitation outcome <ref name="lusardi" />&nbsp;<ref name="gaily" />.  


==== 3.3 Prevention of complications  ====
=== [[Complications post amputation|Prevention of Complications]] ===


Education on limb care of both the residual and sound limbs are vital in preventing further complications, and the possibility of re-amputaiton <ref name="gaily" />&nbsp;. Patients should be educated on diabetic foot care and advised to visually inspect the sound limb daily for any signs of redness <ref name="gaily" />.  
Education on limb care of both the residual and sound limbs are vital in preventing further complications, and the possibility of re-amputation<ref name="gaily" />. Patients should be educated on diabetic foot care and advised to visually inspect the sound limb daily for any signs of redness<ref name="gaily" />.


==== 3.4 Carer education ====
=== Carer Education ===


The primary caregiver of the amputee should be involved from an early stage of the rehabilitation process and educated on all the rehabilitation techniques that is taught to the patient in order to improve patient compliance on discharge <ref name="gaily" />.  
The primary caregiver of the amputee should be involved from an early stage of the rehabilitation process and educated on all the rehabilitation techniques that are taught to the patient in order to improve patient compliance on discharge<ref name="gaily" />.


=== 4. Stump management<br> ===
== Residuum (Stump) Management  ==
The following list of factors may directly influence the success of rehabilitation with a prosthesis, and should be evaluated and addressed during rehabilitation: the wound, oedema, scar from the incision, skin condition, length and shape of the residuum, tenderness, contracture of the proximal joint, the distal bone, dog ears, additional (redundant) tissue, other scars/factors<ref>O'Keeffe B, Rout S. [https://www.thieme-connect.com/products/ejournals/html/10.1055/s-0039-1687919 Prosthetic Rehabilitation in the Lower Limb]. Indian Journal of Plastic Surgery. 2019 Jan;52(01):134-43.</ref>.


==== 4.1 Oedema control (shrinking) ====
=== Desensitisation of the Residuum, Scar Massage and Skin Care ===


One of the main acute post-operative factors affecting the time to prosthetic fitting and the speed of rehabilitation, is the wound healing of the stump, especially in the vulnerable vascular compromised population <ref name="johannesson">Johannesson A, Larsson G, Oberg,T &amp;amp;amp;amp;amp;amp;amp; Atroshi, I. Comparison of vacuum-formed removable rigid dressing with conventional rigid dressing after transtibial amputation. Acta Orthopeadica 2008;79(3); 361-369</ref>. Oedema in the residual limb is also a common complications after LLA surgery <ref name="bryant">Bryant G. Stump Care. The American Journal of Nursing 2001; 101(2); 67-71</ref>. Controlling the amount of oedema post-surgically is vital for promoting wound-healing, pain control, protecting the incision during rehabilitation and assisting in shaping the stump for prosthetic fitting <ref name="lusardi" />. Traditionally soft dressings or non-adhesive elastic bandages are used to prevent oedema of the stump post-surgically, but no evidence supports the use of these bandages <ref name="nawijn">Nawijn SE, Van der Linde H, Emmelot CH, Hofstad CJ. Stump management after transtibial amputation: a systematic review. Prosthetics and Orthotics International 2005; 29(1); 13-26.</ref>&nbsp;<ref name="smith">Smith DG, McFarland LV, Sangeorzan BJ, Reiber GE, Czerniecki JM. Postoperative dressing and management strategies for transtibial amputations: A critical review. Journal of Rehabilitation Research Development 2003; 40; 213-224.</ref>. The use of immediate post-surgical rigid or semi-rigid dressings to prevent acute oedema have increased in popularity in the developed world, and is well supported by evidence in the literature <ref name="lusardi" />&nbsp;<ref name="nawijn" />. Some of the reported benefits of the rigid dressing include promotion of wound healing, shaping of the stump, pain management, protection against trauma during falls, stump volume control and increased speed of prosthetic fitting <ref name="lusardi" />&nbsp;<ref name="nawijn" />&nbsp;. The conventional method of application of rigid dressings is a plaster cast rigid dressing that is usually applied in theatre under anaesthesia. This method has proven to be effective, but often surgeons choose not to opt for this method of rigid dressing since it is time-consuming, and requires some skill to apply <ref name="johannesson2">Johannesson A, Larsson G, Ramstrand N, Lauge-Pedersen H, Wagner P. &amp;amp;amp;amp;amp;amp;amp;Atroshi I. Outcomes of a standardized surgical and rehabilitation program in trans-tibial amputation for peripheral vascular disease: A 10 year prospective cohort study. The American Journal of Physical Medicine and Rehabilitation / Association of Academic Physiatrists 2010; 89(4); 293-303.</ref>.Another disadvantage of this technique is that the wound cannot be inspected for 5-7 days post surgically. An alternative vacuum-formed removable rigid dressing has proven to be as effective as the conventional rigid dressing in a randomized controlled trial, and is an useful alternative to the plaster casting method <ref name="johannesson" />. The advantages of this vacuum-formed rigid dressing include the ease of application, and ease of access for wound inspection <ref name="johannesson" />.
Management of the surgical scar is also important when preparing the residual limb for prosthetic fitting. A scar that is hypersensitive or uneven can make weight-bearing on the residuum very painful or impossible. Once the surgical wound on the residual limb is adequately healed, the therapist should initiate a regime of desensitisation of the residuum in order to prepare the residuum for weight-bearing on a prosthesis and scar massage to prevent adhesions of the scar to bony prominences <ref name="lusardi" />&nbsp;<ref name="gaily" />&nbsp;and teach the patient how to perform it themselves. <br>  


<br>  
<div class="row">
  <div class="col-md-4"> {{#ev:youtube|AqmKhuT-mWw|200}} <div class="text-right"><ref>AmputeeOT: Massage, Scar Mobilization, Desensitization, and End-Bearing Exercises for New Amputees. Jan 2014. Available from: https://youtu.be/AqmKhuT-mWw</ref></div></div>
  <div class="col-md-4">{{#ev:youtube|15gsqIrz8Ps|200}} <div class="text-right"><ref>Ottobock. Skin care after amputation. Jan 2019. Available from: https://youtu.be/15gsqIrz8Ps</ref></div></div>
<div class="col-md-4">{{#ev:youtube|-IMV8j21kLw|200}} <div class="text-right"><ref>Ottobock. Scar care & scar mobilisation after amputation. Available from: https://youtu.be/-IMV8j21kLw</ref></div></div>
</div>


*&nbsp;'''Video of Ossur semi-rigid dressing immediately post operatively'''
=== Shaping of the Residuum (bandaging)  ===


{{#ev:youtube|d_C9wbW7sLI}}
[[Image:Bulbous stump.jpg|right]]See [[Acute post-surgical management of the amputee]] to read more about post-op dressings. 


*'''&nbsp;Iceross post op liner for compression post operatively'''
Shaping or coning of the residuum is a vital part of pre-prosthetic rehabilitation <ref name="lusardi" />&nbsp;<ref name="esq" />&nbsp;<ref name="gaily" />. A residuum that is poorly shaped or bulbous in shape (distal circumference measured 5cm proximal to the end of the residuum is larger than the proximal circumference) cannot be fitted with a prosthesis, or greatly complicates prosthetic fitting (see figure below).


{{#ev:youtube|Yq-61P7kWbo}}
residuum bandaging or coning is essential in shaping the residuum. See the videos and diagrams below on how to perform residuum bandaging for a transtibial and transfemoral amputee.


==== 4.2 Wound healing<br>  ====
====Transtibial residuum Bandaging:====
{| width="100%" border="0" align="center" cellpadding="1" cellspacing="1"
|-
| width="40%" | {{#ev:youtube|FM5e099p5eQ}}{{#ev:youtube|yUizOiWBvs8}}
| [[Image:Transtibial bandaging.png|right|400px]]
|}


Wound healing is always a cause of concern, but especially in the dysvascular population. Adequately controlling oedema of the stump can assist with healing, but some evidence also supports the use of low intensity laser in order to facilitate and speed up wound healing in diabetic patients <ref name="johannesson" />. However the exact dosages for optimal effect has not yet been established.<br>
====Transfemoral residuum Bandaging:====
 
{| width="100%" border="0" align="center" cellpadding="1" cellspacing="1"
'''Free full text article''': Effects of low-level laser therapy on the progress of wound healing in humans: the contribution of in vitro and in vivo experimental studies -&nbsp;[http://www.scielo.br/pdf/jvb/v6n3/v6n3a09 www.scielo.br/pdf/jvb/v6n3/v6n3a09]&nbsp;<ref name="rocha">Rocha AM, Vieira, BJ, de Andrade, LCF , Aarestrup, FM, 2008, Effects of low-level laser therapy on the progress of wound healing in humans: the contribution of in vitro and in vivo experimental studies. http://www.scielo.br/pdf/jvb/v6n3/v6n3a09 (accessed 12 February 2015).</ref>&nbsp;
|-
 
| width="40%" | {{#ev:youtube|X9fbOpvZbQo}} {{#ev:youtube|PHO2cH1BoNs}}
==== 4.3 Pain management  ====
| [[Image:Transfemoral bandaging 2.jpg|right|400px]]
 
|}
Pain is a very common physiological stressor that occurs during the acute postoperative period and affects the patient’s ability to learn new skills <ref name="lusardi" />&nbsp;. Adequately controlling the new amputee’s levels of pain greatly facilitates their early rehabilitation <ref name="lusardi" />&nbsp;. Physiotherapists should take this into consideration, and treat patients shortly after receiving their pain medication. Controlling oedema in the residual limb through positioning also assists in relieving acute postoperative pain <ref name="lusardi" />. Various physiotherapy interventions are used for the management of phantom limb pain, but very few of these have been studied to prove their efficacy in the research literature <ref name="mulvey">Mulvey MR, Radford HE, Fawkner HJ, Hirst L, Neumann V, Johnson MI. Transcutaneous electrical nerve stimulation for phantom pain and stump pain in adult amputees. Pain Practice. 2013; 13(4):289-96. fckLRdoi: 10.1111/j.1533-2500.2012.00593.x</ref>.One of the few physiotherapy modalities that has been proven to be effective for the management of residual phantom limb pain, is a 60 minute application of Transcutaneous Electrical Nerve Stimulation (TENS) <ref name="bryant" />.<br>See recent full-text article on the management of phantom pain <br>


*&nbsp;Know Pain Know Gain: proposing a treatment approach for phantom limb pain&nbsp;:&nbsp;[http://jramc.bmj.com/content/160/1/16.full.pdf+html jramc.bmj.com/content/160/1/16.full.pdf+html]
====Post-op Silicone Liner<ref>Johannesson A, Larsson GU, Öberg T. From major amputation to prosthetic outcome: a prospective study of 190 patients in a defined population. Prosthetics and orthotics international. 2004 Jan 1;28(1):9-21. Available at: https://www.researchgate.net/publication/8534355_From_major_amputation_to_prosthetic_outcome_A_prospective_study_of_190_patients_in_a_defined_population[Accessed 11 Oct 2017]</ref> ====
* it is applied after the Removable Rigid Dressing is taken off
* the same level of compression is applied to the residuum even if different people apply it
* it decreases oedema and shapes the residuum for prosthetic fitting
* helps with pain relief
* fast track the rehabilitation process
* It can be sterilised
* the liner size is prescribed according to the circumference of the residuum and can be changed when oedema decreases
* Disadvantages are: the cost involved, as the oedema goes down another size silicone liner needs to be applied, not readily available


==== 4.4 Desensitisation of the stump and scar massage  ====
== Exercise Therapy  ==


Management of the surgical scar is also important when preparing the residual limb for prosthetic fitting. A scar that is hypersensitive or uneven can make weight-bearing on the stump very painful or impossible. Once the surgical wound on the residual limb is adequately healed, the therapist should initiate a regime of desensitisation of the stump in order to prepare the stump for weight bearing on a prosthesis and scar massage to prevent adhesions of the scar to bony prominences <ref name="lusardi" />&nbsp;<ref name="gaily" />&nbsp;and teach the patient how to perform it themselves. <br>
Exercise forms a large component of pre-prosthetic rehabilitation. The different elements of a pre-prosthetic exercise programme that should be included and tailored to the needs of the individual patient are listed below <ref name="gaily" />.  


*See the video below, for techniques that can be used&nbsp;:
=== Basic Training and Skills ===
 
{{#ev:youtube|AqmKhuT-mWw}}
 
==== 4.5 Shaping of the stump (rigid dressings / bandaging)  ====
 
Shaping or coning of the stump is a vital part of pre-prosthetic rehabilitation <ref name="lusardi" />&nbsp;<ref name="esq" />&nbsp;<ref name="gaily" />&nbsp;. A stump that is poorly shaped or bulbous in shape (distal circumference measured 5cm proximal to the end of the stump is larger than the proximal circumference) cannot be fitted with a prosthesis, or greatly complicates prosthetic fitting (see figure below).
 
[[Image:Bulbous stump.jpg|center]]
 
Stump bandaging or coning is essential in shaping the stump. See the videos and diagrams below on how to perform stump bandaging for a transtibial and transfemoral amputee.
 
'''Transtibial stump bandaging:''' {{#ev:youtube|FM5e099p5eQ}}
 
<br>
 
[[Image:Transtibial bandaging.png|center]]
 
<br>
 
<br> '''Transfemoral stump bandaging:'''<br> {{#ev:youtube|X9fbOpvZbQo }}
 
<br>
 
[[Image:Transfemoral bandaging 2.jpg|center]]
 
<br>
 
<br> &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;
 
=== 5. Exercise therapy <br>  ===
 
Exercise forms a large component of pre-prosthetic rehabilitation. The different elements of a pre-prosthetic exercise programme that should be included and tailored to the needs of the individual patient will be listed below <ref name="gaily" />. For more reading on how to execute any of these activities please refer to: Physical therapy management of adult lower limb amputees online at: [http://www.oandplibrary.org/alp/chap23-01.asp www.oandplibrary.org/alp/chap23-01.asp]
 
==== 5.1 Basic training and skills<br> ====


*Strengthening  
*Strengthening  
Line 253: Line 166:
*Ambulation With Assistive Devices
*Ambulation With Assistive Devices


==== 5.2 Pre-gait Training  ====
=== Pre-gait Training  ===


*Balance and Coordination  
*Balance and Coordination
**Single limb balance<ref name=":0">International Committee of the Red Cross (ICRC), ICRC physiotherapy reference manual: prothetic gait analysis, 2014  Prosthetic gait analysis, a course manual for physiotherapists, ICRC, 2014. Available from: https://members.physio-pedia.com/open-ebooks/prosthetic-gait-analysis-for-physiotherapists/view.php?start=44 [Accessed 27 Dec 2017]</ref>
**Seated balance on Bosu or therapy ball<ref name=":0" />
**Balance training while transitioning from lying, sitting, or standing<ref name=":0" />
**Training should occur in a safe environment like between parallel bars<ref name=":0" />
*Orientation to the Center of Gravity and Base of Support  
*Orientation to the Center of Gravity and Base of Support  
*Single-Limb Standing
*Gait-Training Skills  
*Gait-Training Skills  
*Sound Limb and Prosthetic Limb Training  
*Sound Limb and Prosthetic Limb Training  
*Pelvic Motions  
*Pelvic Motions  
*Variations<br>
*Variations
*Immediate post-op prosthesis
**Balance standing on 2 limbs
**Pelvic motions
**Gait training
**Sit to stand


==== 5.3 Advanced Gait-Training Activities<br>  ====
=== Exercise Videos ===


*Stairs
{| width="100%" border="0" align="center" cellpadding="1" cellspacing="1"
*Step By Step
|-
*Transfemoral Amputees: Step Over Step
| {{#ev:youtube|R7AVSUdE_1U}}
*Transtibial Amputees: Step Over Step
| {{#ev:youtube|vg-gBhf1wkk}}
*Crutches
|-
*Curbs
| Strengthening of residual limb with and without thera-band
*Uneven Surfaces
| Transfemoral amputation BOSU ball balance retraining
*Ramps and Hills
|}
*Sidestepping
Follow these links to YouTube playlists with exercise videos:
*Backward Walking
* [https://www.youtube.com/playlist?list=PLdikOjAAweeJNxsPB_tj6eMVnXqxDL_Js Below knee amputee exercise video collection]
*Multidirectional Turns
* [https://www.youtube.com/playlist?list=PLdikOjAAweeK4GeAig6VdGZPnYKbkJURj Above knee amputee exercise video collection]
*Tandem Walking
* [https://www.youtube.com/watch?v=Tb6oDJ39QUs&list=PLdikOjAAweeLKX3Sohk23Vdiaj4gdBFXe Bilateral leg amputee exercise video collection]
*Braiding
*Single-Limb Squatting
*Falling
*Floor to Standing
*Running Skills
*Recreational Activities
 
Another useful WHO resource with suggestions and figures for upper limb and lower limb amputation stretches and exercises is the:<br>
 
World Health Organization, United States Department of Defense, MossRehab Amputee Rehabilitation Program, MossRehab Hospital, USA. The Rehabilitation of People with Amputations 2004 .This can be accessed online at:&nbsp;[http://www.posna.org/news/amputations.pdf www.posna.org/news/amputations.pdf]<br>
 
'''Other online resources:'''
 
*Exercise tick-sheet for transtibial amputation strengthening exercises&nbsp;:&nbsp;[https://patienteducation.osumc.edu/Documents/strengthening-bka.pdf patienteducation.osumc.edu/Documents/strengthening-bka.pdf]<br>
 
*Strengthening of residual limb: with and without thera-band&nbsp;:
 
{{#ev:youtube|R7AVSUdE_1U}}
 
*Transfemoral amputation BOSU ball balance retraining:
 
{{#ev:youtube|vg-gBhf1wkk}}&nbsp;<br>


=== 6.Restoring locus of control<br> ===
== Restoring locus of control  ==


==== 6.1 Mobility with an assistive device/ wheelchair  ====
=== Mobility with an assistive device/ wheelchair  ===


Early post-operative mobilisation is imperative to prevent deconditioning after amputation surgery. Ideally patients would be mobilised with an assistive device such as a walking frame or elbow crutches, but often this is quite challenging in patients with co-morbid diseases. The use of a pneumaticcompression splint prosthesis is advised for patients with limited physical function and mobility <ref name="lusardi" />. This type of inflatable splint fits around the residual limb without putting pressure on the wound, and can be used to facilitate early mobilisation, and to assess the potential for prosthetic rehabilitation <ref name="lusardi" />&nbsp;. Another alternative for early mobilisation in high-risk patients is the application of an immediate postoperative prosthesis (IPOP) <ref name="lusardi" />. The non-removable rigid dressing used for an IPOP is applied by a Prosthetist in the theatre, and is shaped around the residual limb for patellar-tendon weight bearing to avoid pressure on the wound during early mobilisation <ref name="lusardi" />&nbsp;.<br>Patients will have to be assessed in order to determine which assistive device is most appropriate for early mobilisation, and then taught how to mobilise safely with these devices. <br>See this video below on how amputees can safely accommodate stairs with the use of crutches. <br>Using crutches to ascend stairs:
Early post-operative mobilisation is imperative to prevent deconditioning after amputation surgery. Ideally, patients would be mobilised with an assistive device such as a walking frame or elbow crutches, but often this is quite challenging in patients with co-morbid diseases. The use of a pneumatic compression splint prosthesis is advised for patients with limited physical function and mobility <ref name="lusardi" />. This type of inflatable splint fits around the residual limb without putting pressure on the wound, and can be used to facilitate early mobilisation, and to assess the potential for prosthetic rehabilitation <ref name="lusardi" />. Another alternative for early mobilisation in high-risk patients is the application of an immediate postoperative prosthesis (IPOP) <ref name="lusardi" />. The non-removable rigid dressing used for an IPOP is applied by a Prosthetist in the theatre, and is shaped around the residual limb for patellar-tendon weight bearing to avoid pressure on the wound during early mobilisation <ref name="lusardi" />. &nbsp;Patients will have to be assessed in order to determine which assistive device is most appropriate for early mobilisation, and then taught how to mobilise safely with these devices.  


{{#ev:youtube|lugS_AmY2BU}}
Mobilising with crutches:
* Using [https://www.saintlukeshealthsystem.org/health-library/using-crutches-after-lower-limb-amputation elbow crutches] with an amputation
* Using [https://patienteducation.osumc.edu/Documents/crutches-amp.pdf axillary crutches] with an amputation
* Alternatives: [http://iwalk-free.com/amputee-testimonials/ Hands-free crutches]
<br>See this video below on how amputees can safely accommodate stairs with the use of crutches


<br>  
<div class="row">
  <div class="col-md-6"> {{#ev:youtube|lugS_AmY2BU|250}} <div class="text-right"><ref>AmputeeOT: Using crutches etc to get around after amputation . Available from: https://www.youtube.com/watch?v=lugS_AmY2BU&t=86s[last accessed 16/12/17]</ref></div></div>
  <div class="col-md-6">{{#ev:youtube|9voyLE_9IMU|250}} <div class="text-right"><ref>IPOP Immediate Postoperative Prosthesis. Available from: https://youtu.be/9voyLE_9IMU[last accessed 16/12/17]</ref></div></div>
</div>


==== 6.2 Transfers  ====
=== Transfers  ===


An important step in the rehabilitation process is regaining functional independence. The amputee should be taught how to safely and if possible independently transfer themselves between the following surfaces especially in the case of a double lower limb amputee, or a frail person.  
An important step in the rehabilitation process is regaining functional independence. The amputee should be taught how to safely and if possible independently transfer themselves between the following surfaces especially in the case of a double lower limb amputee, or a frail person.  
Line 317: Line 223:
*Bed to wheelchair  
*Bed to wheelchair  
*Wheelchair to bed  
*Wheelchair to bed  
*Wheelchair to floor – if patient has the muscle power to perform this  
*Wheelchair to floor – if the patient has the muscle power to perform this  
*Floor to wheelchair– if patient has the muscle power to perform this  
*Floor to wheelchair – if the patient has the muscle power to perform this  
*Wheelchair to toilet  
*Wheelchair to toilet  
*Wheelchair to shower / bath  
*Wheelchair to shower/bath  
*Wheelchair to car  
*Wheelchair to car  
*Car to wheelchair
*Car to wheelchair


See the videos below on some transfers involving double lower limb amputees.<br>
See the videos below on transfers involving lower limb amputees.  
 
'''Double amputee, wheelchair to couch transfer''': &nbsp;
 
{{#ev:youtube|Oz8nqPsIqQY}}
 
<br> '''Double amputee, wheelchair to floor, and floor to wheelchair: '''<br>{{#ev:youtube|VOEBafD9mow}} {{#ev:youtube|1l5447Hhfxc}}
 
<br> '''Safe showers:'''
 
{{#ev:youtube|16qdl_25xmQ}}
 
<br> '''Double amputee, transfer in and out of a car:''' <br> {{#ev:youtube|AyqJqt2Ok_c}}


<br>  
<div class="row">
  <div class="col-md-6"> {{#ev:youtube|1l5447Hhfxc|250}} <div class="text-right"><ref>Double amputee transferring from wheelchair to floor . Available from: https://www.youtube.com/watch?v=1l5447Hhfxc[last accessed 16/12/17]</ref></div></div>
  <div class="col-md-6">{{#ev:youtube|16qdl_25xmQ|250}} <div class="text-right"><ref>AmputeeOT: Safe Showers and Baths for Amputees . Available from: https://www.youtube.com/watch?v=16qdl_25xmQ[last accessed 16/12/17]</ref></div></div>
</div>


=== 7.Referral<br> ===
== Referral  ==


The physiotherapist should always remember that even though they might often manage the rehabilitation process of an amputee <ref name="esq" />&nbsp;, pre-prosthetic rehabilitation is a multidisciplinary task <ref name="lusardi" />&nbsp;<ref name="esq" />&nbsp;, and physiotherapists should not operate in isolation of other health care professionals. Some of the health care professionals and other resources that should form part of the MDT and could be referred to are listed below&nbsp;<ref name="lusardi" />&nbsp;<ref name="esq" />&nbsp;  
The physiotherapist should always remember that even though they might often manage the rehabilitation process of an amputee <ref name="esq" />, pre-prosthetic rehabilitation is a multidisciplinary task <ref name="lusardi" />&nbsp;<ref name="esq" />, and physiotherapists should not operate in isolation of other health care professionals. Some of the health care professionals and other resources that should form part of the MDT and could be referred to are listed below.<ref name="lusardi" />&nbsp;<ref name="esq" />&nbsp;  


*Psychologist - counselling  
*Psychologist - counselling  
Line 349: Line 246:
*Physician –medical management of phantom pain  
*Physician –medical management of phantom pain  
*Prosthetist – prosthetic prescription and management  
*Prosthetist – prosthetic prescription and management  
*Occupational therapist – assessment and adaptation of home environment  
*Occupational therapist – assessment and adaptation of the home environment  
*Social services – potential disability grant / financial support  
*Social services – potential disability grant / financial support  
*Local of national amputation support group or disabled persons organisation for peer support<br><br>
*Local or national amputation support group or disabled persons organisation for peer support


== Useful resources  ==
== Useful resources  ==


*Digital resources:&nbsp;[http://www.oandplibrary.org/ www.oandplibrary.org/]  
*[http://www.oandplibrary.org/alp/chap23-01.asp Physical therapy management of adult lower limb amputees]
*VA/DoD clinical practice guideline for rehabilitation of lower limb amputation&nbsp;:&nbsp;[http://www.healthquality.va.gov/amputation/amp_sum_508.pdf www.healthquality.va.gov/amputation/amp_sum_508.pdf]&nbsp;<br>
*[http://www.posna.org/news/amputations.pdf The Rehabilitation of People with Amputations]
*[http://www.healthquality.va.gov/amputation/amp_sum_508.pdf VA/DoD clinical practice guideline for rehabilitation of lower limb amputation]
*[http://patienteducation.osumc.edu/Documents/strengthening-bka.pdf Exercise tick-sheet for transtibial amputation strengthening exercises]
*[http://www.amputee-coalition.org/resources/after-amputation-surgery/ Care of Your Wounds After Amputation Surgery - Amputee Coalition]
*YouTube presentation: [https://youtu.be/EscSym94M70 Transfemoral Strength and Balance Exercises]
*[https://opedge.com/Articles/ViewArticle/2005-04_01 Focus on IPOPs, EPOPs: Does Early Mobility Benefit Amputees?]
*[https://www.healio.com/orthotics-prosthetics/prosthetics/news/online/%7B6255c29d-5c26-4de6-9565-4ba3f367cb3e%7D/improving-outcomes-with-immediate-postoperative-prostheses Improving Outcomes With Immediate Postoperative Prostheses]
*[https://www.amputee-coalition.org/resources/post-op-prostheses-benefits/ Post-Op Prostheses offer Benefits After Amputation Surgery]
*[http://iwalk-free.com/injury-resource-center/below-knee-amputation/ Below Knee Amputation – Surgery, Recovery and Maintaining Mobility]


== References<br> ==
== References  ==


<references />  
<references />  


[[Category:Amputees]] [[Category:WCPT_Amputee_Project]]
[[Category:Amputees]]  
[[Category:World Physiotherapy Amputee Project]]
[[Category:Occupational Health]]
[[Category:Course Pages]]

Latest revision as of 12:54, 1 March 2022

Original Editor - Liezel Wegner as part of the World Physiotherapy Network for Amputee Rehabilitation Project

Top Contributors - Sheik Abdul Khadir, Admin, Leslie Angama, Tarina van der Stockt, Lucy Aird, Kim Jackson, Tony Lowe, Simisola Ajeyalemi and Amrita Patro  

Introduction[edit | edit source]

The loss of a lower limb has severe implications for a person’s mobility, and ability to perform activities of daily living [1]. This negatively impacts their participation and integration into society [2]. The ultimate goal of rehabilitation after limb loss is to ambulate successfully with the use of a prosthesis[3]. Prosthetic rehabilitation is a complex task that ideally requires input from an interdisciplinary rehabilitation team. However, most often physiotherapists are in charge of the physical rehabilitation process [4].

Overview of the Rehabilitation Process[edit | edit source]

The rehabilitation process of the lower limb amputee consists of nine phases[5] as shown in the table below (modified from Esquenazi &Meier[6]cited in Esquenazi[7]):

Phase Hallmark
Pre-operative Assess body condition, patient education, surgical level discussion, postoperative prosthetic plans
Amputation Surgery/Reconstruction Length, myoplastic closure, soft tissue coverage, nerve, handling, rigid dressing
Acute Post-surgical Wound healing, pain control, proximal body motion, emotional support
Pre-prosthetic Shaping, shrinking, increase muscle strength, restore patient locus of control
Prosthetic Prescription Team consensus on prosthetic prescription and fabrication
Prosthetic Training Increase prosthetic wearing and functional utilization
Community Integration Resumption of roles in family and community activities. Emotional equilibrium and healthy coping strategies. Recreational activities
Vocational Rehabilitation Assess and plan vocational activities for future. May need further education, training or job modification
Follow-up Life-long prosthetic, functional, medical assessment and emotional support

Pre-prosthetic Fitting Phase[edit | edit source]

The PRE-PROSTHETIC rehabilitation phase of the lower limb amputee will include six components:

  1. Physiotherapist preparation
  2. Assessment of the amputee (covered on a different page)
  3. Patient education
  4. Residuum management
  5. Exercise therapy
  6. Restoring locus of control
  7. Referral

Physiotherapist Preparation[edit | edit source]

As you approach an amputee, you should physically and mentally prepare for the interaction with the patient. Some questions to consider include:

  • Who is my patient? (young/old)
  • What was the cause of the amputation? (traumatic/dysvascular)
  • Where (what level) was the amputation performed? (implications for rehabilitation outcome)
  • What is the patient’s goal? (Is the patient aware of the possibilities, are they being realistic?)
  • What prosthetic options are available for this particular patient? (self-study and preparation)

Awareness of Stages of Grief Process[edit | edit source]

A young patient who suffered an amputation as a result of a traumatic experience will most likely be in some stage of the grieving process and be in acute post-surgical pain. An older patient who suffered a dysvascular or neuropathic limb loss, might have had some time to psychologically and physically prepare for the loss of their limb[3]. Either way, your patient might be psychologically and physically distressed when you start the rehabilitation process, so early discussion and education about the patient’s expectations and goals are essential [8].

Knowledge of Appropriate Outcome Measures and Assessment Tools[edit | edit source]

Be prepared with the appropriate assessment tools and outcome measures to assess your patient’s potential for prosthetic use, and try not to create false hope (Outcome Measures for Patients with Lower Limb Amputations)

Knowledge of the Appropriate Assistive Technology Available[edit | edit source]

Your patient will look to you to provide early information about the possibilities for a prosthesis. Ensure that you have a basic knowledge and understanding of the prosthetic technology that is available and could be appropriate for your patient (Prosthetics).

Assessment of the Amputee[edit | edit source]

In order to formulate an appropriate patient-centred prosthetic rehabilitation plan for any amputee, the patient needs to be adequately assessed. Refer to Assessment of the amputee

Patient Education[edit | edit source]

Rehabilitation Process[edit | edit source]

Patient education should commence with a discussion regarding the rehabilitation process, and patient-centred goal setting[3]. The patient should be educated with regards to their potential options for assistive and prosthetic devices [9].

Pain Management[edit | edit source]

Managing the patient’s expectations with regards to the acute post-surgical pain they will potentially experience during the rehabilitation process will enhance patient cooperation and improve the rehabilitation outcome [3] [9].

Prevention of Complications[edit | edit source]

Education on limb care of both the residual and sound limbs are vital in preventing further complications, and the possibility of re-amputation[9]. Patients should be educated on diabetic foot care and advised to visually inspect the sound limb daily for any signs of redness[9].

Carer Education[edit | edit source]

The primary caregiver of the amputee should be involved from an early stage of the rehabilitation process and educated on all the rehabilitation techniques that are taught to the patient in order to improve patient compliance on discharge[9].

Residuum (Stump) Management[edit | edit source]

The following list of factors may directly influence the success of rehabilitation with a prosthesis, and should be evaluated and addressed during rehabilitation: the wound, oedema, scar from the incision, skin condition, length and shape of the residuum, tenderness, contracture of the proximal joint, the distal bone, dog ears, additional (redundant) tissue, other scars/factors[10].

Desensitisation of the Residuum, Scar Massage and Skin Care[edit | edit source]

Management of the surgical scar is also important when preparing the residual limb for prosthetic fitting. A scar that is hypersensitive or uneven can make weight-bearing on the residuum very painful or impossible. Once the surgical wound on the residual limb is adequately healed, the therapist should initiate a regime of desensitisation of the residuum in order to prepare the residuum for weight-bearing on a prosthesis and scar massage to prevent adhesions of the scar to bony prominences [3] [9] and teach the patient how to perform it themselves.

[11]
[12]
[13]

Shaping of the Residuum (bandaging)[edit | edit source]

Bulbous stump.jpg

See Acute post-surgical management of the amputee to read more about post-op dressings.

Shaping or coning of the residuum is a vital part of pre-prosthetic rehabilitation [3] [5] [9]. A residuum that is poorly shaped or bulbous in shape (distal circumference measured 5cm proximal to the end of the residuum is larger than the proximal circumference) cannot be fitted with a prosthesis, or greatly complicates prosthetic fitting (see figure below).

residuum bandaging or coning is essential in shaping the residuum. See the videos and diagrams below on how to perform residuum bandaging for a transtibial and transfemoral amputee.

Transtibial residuum Bandaging:[edit | edit source]
Transtibial bandaging.png

Transfemoral residuum Bandaging:[edit | edit source]
Transfemoral bandaging 2.jpg

Post-op Silicone Liner[14][edit | edit source]

  • it is applied after the Removable Rigid Dressing is taken off
  • the same level of compression is applied to the residuum even if different people apply it
  • it decreases oedema and shapes the residuum for prosthetic fitting
  • helps with pain relief
  • fast track the rehabilitation process
  • It can be sterilised
  • the liner size is prescribed according to the circumference of the residuum and can be changed when oedema decreases
  • Disadvantages are: the cost involved, as the oedema goes down another size silicone liner needs to be applied, not readily available

Exercise Therapy[edit | edit source]

Exercise forms a large component of pre-prosthetic rehabilitation. The different elements of a pre-prosthetic exercise programme that should be included and tailored to the needs of the individual patient are listed below [9].

Basic Training and Skills[edit | edit source]

  • Strengthening
  • Range of Motion
  • Functional Activities
  • General Conditioning
  • Bed Mobility
  • Transfers
  • Wheelchair Propulsion
  • Unsupported Standing Balance
  • Ambulation With Assistive Devices

Pre-gait Training[edit | edit source]

  • Balance and Coordination
    • Single limb balance[15]
    • Seated balance on Bosu or therapy ball[15]
    • Balance training while transitioning from lying, sitting, or standing[15]
    • Training should occur in a safe environment like between parallel bars[15]
  • Orientation to the Center of Gravity and Base of Support
  • Gait-Training Skills
  • Sound Limb and Prosthetic Limb Training
  • Pelvic Motions
  • Variations
  • Immediate post-op prosthesis
    • Balance standing on 2 limbs
    • Pelvic motions
    • Gait training
    • Sit to stand

Exercise Videos[edit | edit source]
Strengthening of residual limb with and without thera-band Transfemoral amputation BOSU ball balance retraining

Follow these links to YouTube playlists with exercise videos:

Restoring locus of control[edit | edit source]

Mobility with an assistive device/ wheelchair[edit | edit source]

Early post-operative mobilisation is imperative to prevent deconditioning after amputation surgery. Ideally, patients would be mobilised with an assistive device such as a walking frame or elbow crutches, but often this is quite challenging in patients with co-morbid diseases. The use of a pneumatic compression splint prosthesis is advised for patients with limited physical function and mobility [3]. This type of inflatable splint fits around the residual limb without putting pressure on the wound, and can be used to facilitate early mobilisation, and to assess the potential for prosthetic rehabilitation [3]. Another alternative for early mobilisation in high-risk patients is the application of an immediate postoperative prosthesis (IPOP) [3]. The non-removable rigid dressing used for an IPOP is applied by a Prosthetist in the theatre, and is shaped around the residual limb for patellar-tendon weight bearing to avoid pressure on the wound during early mobilisation [3].  Patients will have to be assessed in order to determine which assistive device is most appropriate for early mobilisation, and then taught how to mobilise safely with these devices.

Mobilising with crutches:


See this video below on how amputees can safely accommodate stairs with the use of crutches

[16]
[17]

Transfers[edit | edit source]

An important step in the rehabilitation process is regaining functional independence. The amputee should be taught how to safely and if possible independently transfer themselves between the following surfaces especially in the case of a double lower limb amputee, or a frail person.

  • Bed to fixed chair
  • Bed to wheelchair
  • Wheelchair to bed
  • Wheelchair to floor – if the patient has the muscle power to perform this
  • Floor to wheelchair – if the patient has the muscle power to perform this
  • Wheelchair to toilet
  • Wheelchair to shower/bath
  • Wheelchair to car
  • Car to wheelchair

See the videos below on transfers involving lower limb amputees.

[18]
[19]

Referral[edit | edit source]

The physiotherapist should always remember that even though they might often manage the rehabilitation process of an amputee [5], pre-prosthetic rehabilitation is a multidisciplinary task [3] [5], and physiotherapists should not operate in isolation of other health care professionals. Some of the health care professionals and other resources that should form part of the MDT and could be referred to are listed below.[3] [5] 

  • Psychologist - counselling
  • Nurse – specialist wound care
  • Dietician – in the case of poorly controlled diabetes
  • Physician –medical management of phantom pain
  • Prosthetist – prosthetic prescription and management
  • Occupational therapist – assessment and adaptation of the home environment
  • Social services – potential disability grant / financial support
  • Local or national amputation support group or disabled persons organisation for peer support

Useful resources[edit | edit source]

References[edit | edit source]

  1. ↑ Dillingham TD and Pezzin LE. Rehabilitation setting and associated mortality and medical stability among persons with amputations. Archives of Physical and Medical Rehabilitation 2008; 89; 1038-1045.
  2. ↑ World Health Organisation (WHO). International classification of functioning disability and health (ICF). World Health Organisation 2001. Geneva.
  3. ↑ 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 Lusardi MM, Postoperative and preprosthetic care. In Lusardi, MM, Jorge, M and Nielsen, CC editors. Orthotics and Prosthetics in Rehabilitation, Third Edition. Missouri: Elsevier, 2013.p. 532-594.
  4. ↑ Kaplan SL, Outcome measurement and management: First steps for the practicing clinician. Philadelphia, FA Davis Company, 2007.
  5. ↑ 5.0 5.1 5.2 5.3 5.4 Esquenazi A. Amputation rehabilitation and prosthetic restoration: from surgery to community reintegration. Disability and Rehabilitation, 2004; 26,(14/15); 831–6.
  6. ↑ Esquenazi A, Meier RH. Rehabilitation in limb deficiency. 4. Limb amputation.Arch Phys Med Rehabil. 1996 Mar;77(3 Suppl):S18-28.
  7. ↑ Esquenazi A. Amputation rehabilitation and prosthetic restoration. From surgery to community reintegration. Disabil Rehabil. 2004 Jul 22-Aug 5;26(14-15):831-6.
  8. ↑ Livingstone W, Van de Mortel TF, Taylor B. A path of perpetual resilience: Exploring the experience of a diabetes related amputations through grounded theory. Contemporary Nursing. 2011; 39(1):20-30.
  9. ↑ 9.0 9.1 9.2 9.3 9.4 9.5 9.6 9.7 Gaily RS, Clark CR.Physical therapy management of adult lower-limb amputees. In: Michael, JW editor. Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles. Rosemont, IL, American Academy of Orthopedic Surgeons,1992. http://www.oandplibrary.org/alp/(accessed 8 February 2015).
  10. ↑ O'Keeffe B, Rout S. Prosthetic Rehabilitation in the Lower Limb. Indian Journal of Plastic Surgery. 2019 Jan;52(01):134-43.
  11. ↑ AmputeeOT: Massage, Scar Mobilization, Desensitization, and End-Bearing Exercises for New Amputees. Jan 2014. Available from: https://youtu.be/AqmKhuT-mWw
  12. ↑ Ottobock. Skin care after amputation. Jan 2019. Available from: https://youtu.be/15gsqIrz8Ps
  13. ↑ Ottobock. Scar care & scar mobilisation after amputation. Available from: https://youtu.be/-IMV8j21kLw
  14. ↑ Johannesson A, Larsson GU, Öberg T. From major amputation to prosthetic outcome: a prospective study of 190 patients in a defined population. Prosthetics and orthotics international. 2004 Jan 1;28(1):9-21. Available at: https://www.researchgate.net/publication/8534355_From_major_amputation_to_prosthetic_outcome_A_prospective_study_of_190_patients_in_a_defined_population[Accessed 11 Oct 2017]
  15. ↑ 15.0 15.1 15.2 15.3 International Committee of the Red Cross (ICRC), ICRC physiotherapy reference manual: prothetic gait analysis, 2014 Prosthetic gait analysis, a course manual for physiotherapists, ICRC, 2014. Available from: https://members.physio-pedia.com/open-ebooks/prosthetic-gait-analysis-for-physiotherapists/view.php?start=44 [Accessed 27 Dec 2017]
  16. ↑ AmputeeOT: Using crutches etc to get around after amputation . Available from: https://www.youtube.com/watch?v=lugS_AmY2BU&t=86s[last accessed 16/12/17]
  17. ↑ IPOP Immediate Postoperative Prosthesis. Available from: https://youtu.be/9voyLE_9IMU[last accessed 16/12/17]
  18. ↑ Double amputee transferring from wheelchair to floor . Available from: https://www.youtube.com/watch?v=1l5447Hhfxc[last accessed 16/12/17]
  19. ↑ AmputeeOT: Safe Showers and Baths for Amputees . Available from: https://www.youtube.com/watch?v=16qdl_25xmQ[last accessed 16/12/17]
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