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

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Original Editor - Liezel Wegner

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 on 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 a transdisciplinary 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  , namely:

• pre-operative,
• amputation surgery,
• acute post-surgical,
• pre-prosthetic,
• prosthetic prescription,
• prosthetic training,
• community integration,
• vocational rehabilitation and
• follow up.

Table 1: Phases of amputee rehabilitation: Modified from Esquenazi &Meier (1996) cited in Esquenazi (2004).

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 REHABILITATION PHASE

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

1. Physiotherapist preparation
2.  Assessment of the amputee (see section 6 not covered in this section)
3. Patient education
4. Stump management
5. Exercise therapy
6. Restoring locus of control
7. Referral
   

1. 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:

• 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)
  

1.1 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 . 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  .

• Link to full-text articles:  www.amputee-coalition.org/first_step_2003/psychological-aspects-amputation.html
• Reaction to amputation: Recognition and treatment : www.ncbi.nlm.nih.gov/pmc/articles/PMC2018851/pdf/i1523-5998-9-4-303.pdf
• Slideshow on grief amongst amputees: www.slideshare.net/jrod_reggie/grieving-and-psychological-impact-on-amputees-presentation

1.2.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 )

1.3 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).

2. 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 Assessment of the amputee

3.Patient education

3.1 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 his potential options for assistive and prosthetic devices .

3.2 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   .

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

3.4 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 .

4. Stump management

4.1 Oedema control (shrinking)

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 . Oedema in the residual limb is also a common complications after LLA surgery . 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 . 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  . 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  . 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   . 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 .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 . The advantages of this vacuum-formed rigid dressing include the ease of application, and ease of access for wound inspection .

•  Video of Ossur semi-rigid dressing immediately post operatively

•  Iceross post op liner for compression post operatively

4.2 Wound healing

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 . However the exact dosages for optimal effect has not yet been established.

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 - www.scielo.br/pdf/jvb/v6n3/v6n3a09

4.3 Pain management

Pain is a very common physiological stressor that occurs during the acute postoperative period and affects the patient’s ability to learn new skills  . Adequately controlling the new amputee’s levels of pain greatly facilitates their early rehabilitation  . 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 . 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 .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) .
See recent full-text article on the management of phantom pain

•  Know Pain Know Gain: proposing a treatment approach for phantom limb pain : jramc.bmj.com/content/160/1/16.full.pdf+html

4.4 Desensitisation of the stump and scar massage

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   and teach the patient how to perform it themselves.

• See the video below, for techniques that can be used :