Pre-Fitting Management of the Patient with a Lower Limb Amputation

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

The loss of a lower limb has severe implications for a person’s mobility, and ability to perform activities of daily living . This negatively impacts their participation and integration into society . The ultimate goal of rehabilitation after limb loss is to ambulate successfully with the use of a prosthesis. 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 .

Overview of the Rehabilitation Process

The rehabilitation process of the lower limb amputee consists of nine phases as shown in the table below (modified from Esquenazi &Meiercited in Esquenazi):

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

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

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

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. 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 .

• Emotional and psychological reactions to amputation
• Reaction to amputation: Recognition and treatment
• Slideshow on grief amongst amputees

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 try not to create false hope (Outcome Measures for Patients with Lower Limb Amputations)

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 (Prosthetics).

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 Assessment of the amputee

Patient Education

Rehabilitation Process

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

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  .

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-amputation. Patients should be educated on diabetic foot care and advised to visually inspect the sound limb daily for any signs of redness.

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 are taught to the patient in order to improve patient compliance on discharge.

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.

Desensitisation of the Residuum, Scar Massage and Skin Care

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   and teach the patient how to perform it themselves.

Shaping of the Residuum (bandaging)

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   . 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:

Transfemoral residuum Bandaging:

Post-op Silicone Liner

• 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

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 .

Basic Training and Skills

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

Pre-gait Training

• Balance and Coordination
  • Single limb balance
  • Seated balance on Bosu or therapy ball
  • Balance training while transitioning from lying, sitting, or standing
  • Training should occur in a safe environment like between parallel bars
• 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

Strengthening of residual limb with and without thera-band	Transfemoral amputation BOSU ball balance retraining

Follow these links to YouTube playlists with exercise videos:

• Below knee amputee exercise video collection
• Above knee amputee exercise video collection
• Bilateral leg amputee exercise video collection

Restoring locus of control

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 pneumatic compression splint prosthesis is advised for patients with limited physical function and mobility . 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 . Another alternative for early mobilisation in high-risk patients is the application of an immediate postoperative prosthesis (IPOP) . 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 .  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:

• Using elbow crutches with an amputation
• Using axillary crutches with an amputation
• Alternatives: Hands-free crutches

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

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.

• 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.

Referral

The physiotherapist should always remember that even though they might often manage the rehabilitation process of an amputee , pre-prosthetic rehabilitation is a multidisciplinary task  , 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.  

• 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

• Physical therapy management of adult lower limb amputees
• The Rehabilitation of People with Amputations
• VA/DoD clinical practice guideline for rehabilitation of lower limb amputation
• Exercise tick-sheet for transtibial amputation strengthening exercises
• Care of Your Wounds After Amputation Surgery - Amputee Coalition
• YouTube presentation: Transfemoral Strength and Balance Exercises
• Focus on IPOPs, EPOPs: Does Early Mobility Benefit Amputees?
• Improving Outcomes With Immediate Postoperative Prostheses
• Post-Op Prostheses offer Benefits After Amputation Surgery
• Below Knee Amputation – Surgery, Recovery and Maintaining Mobility