Early onset of rehabilitation produces greater potential for success26. A long delay is likely to result in the development of complications such as joint contractures, general debilitation, and depressed psychological state. The rehabilitation program can be arbitrarily divided into two phases: (1) the postsurgical phase is the time between surgery and discharge from the hospital; (2) the preprosthetic phase runs from hospital discharge to prosthetic fitting or a decision that the patient is not a candidate for prosthetic fitting. These, of course, are arbitrary periods but each has different goals and emphases within the POC. The desired expected outcome of the episode of care is to help the patient regain the presurgical level of function. For some, it will mean return to gainful employment with an active recreational life. For others, it will mean independence in the home and community. For still others, it may mean living in the sheltered environment of a retirement center or nursing home. If the amputation resulted from longstanding chronic disease, the rehabilitation approach may be to help the person function at a higher level than immediately before surgery.
The postsurgical phase is the time between surgery and discharge from the hospital. While the primary goal of this phase of care is to get the patient discharged, it is not adequate to give the patient a walker, teach the patient to transfer, and send him or her home. Box 22.1 outlines the general goals of the postsurgical phase of care.
Box 22.1 Postsurgical General Goals
Healing residual limb
Protect remaining limb (if dysvascular)
Independent in transfers and mobility
Demonstrate proper positioning
Begin psychological adjustment
Understand the process of prosthetic rehabilitation
Box 22.2 outlines the critical data necessary to develop a POC for the hospitalized patient following amputation. Naturally, the data gathering must be prioritized according to the person's physiological status and cause of amputation; however, the information obtained on initial examination and subsequent evaluation will influence discharge planning and future care. As indicated previously, it is of critical importance for the physical therapist to act as an ombudsman for the patient and ensure continuity of care following hospital discharge. For all patients, information on the current cardiovascular status, physiological response to surgery, presence of infection, pain level, and medication indicates to what extent the patient will be able to participate in the therapy program. Individuals amputated secondary to severe trauma, blast injuries in war, and similar problems will require a somewhat different approach from individuals with vascular disease. The type of postsurgical dressing will also influence both data gathering and interventions. The person with a rigid dressing will be able to move more easily in bed than someone with a soft dressing. At this point the physical therapy diagnosis will probably reflect an individual with limited mobility and functional capabilities. Depending on the specific findings the individual may also have compromised endurance and pain that interferes with participation in the program. The specific POC is, of course, aimed at the goals and the critical findings.
Box 22.2 Early Postsurgical Evaluation
The therapist treating a patient in the hospital has only limited time in which to achieve the goals. The intervention must be aimed at preparing for discharge from acute care and to some form of follow-up care, be it in an acute rehabilitation facility, through a home health service or agency, or an outpatient facility. Box 22.3 outlines the major components of interventions.
Box 22.3 General Plan of Interventions
Positioning to avoid contractures
Standing balance and transfer activities
Mobility training with crutches or a walker
Residual limb care and protection; bandaging if appropriate
Care of the remaining lower extremity (if circulation compromised)
Education on amputation and prosthetics
Figure 22.5 illustrates the major positions for either a patient with a transtibial or transfemoral amputation. Although the figure represents someone with a transtibial amputation, the general principles are the same. It is critical in both instances to prevent hip flexion contractures and the patient should be encouraged to spend some time in the prone position if at all possible. A pillow under the residual limb while the patient is supine is never recommended, nor is prolonged sitting. In the early days, the patient will want to avoid side-lying on the amputated side and the residual limb should be kept in extension at both hip and knee.
Proper transtibial position: (A) supine; (B) side-lying; (C) prone; (D) sitting. From May and Lockard,26, p. 67 with permission.
Sitting balance is usually not a problem with a unilateral amputation but must be a part of the intervention program for individuals with bilateral amputations. Standing balance exercises on the remaining extremity can be quite beneficial in helping the individual regain a sense of his or her body in space. The better the person can balance on the remaining extremity the more likely he or she will be to use crutches and lead a more active life during the period before prosthetic fitting. A variety of balance exercises may be used, including balancing on a compliant surface. In the early postsurgical period the person should stand and transfer leading with the unamputated limb to protect the residual limb from possible injury against the chair or bed.
Many physical therapists fit patients with a walker. Although this is appropriate for some individuals, trying to teach the patient safe and independent mobility with crutches is much more beneficial. While there is more stability in a walker, there is greater flexibility in accomplishing activities of daily living (ADL) on crutches. The added balance needed for crutches will also serve the individual well when it is time for prosthetic fitting.
If the patient has been fitted with an IPOP or an RRD and has good control of weight-bearing, the physician might decide to add a pylon and foot to the assembly making partial weight-bearing gait possible. In this instance, the patient must be fitted with crutches because the walker will inhibit the natural function of the prosthetic components.
When teaching mobility to someone with diabetes or any vascular compromise, it is critical that the patient wear a shoe on the remaining foot. Obviously, the remaining foot must be protected from any injury or assault, and hospital-provided slippers, or any slippers, do not provide the necessary protection. The family can bring in a regular shoe and this may be time to consider fitting the patient with an adapted shoe to prevent trauma to this foot.
The physical therapist will need to teach the patient and family how to properly wrap the limb, and, if the patient has been fitted with an IPOP or RRD, the physical therapist needs to be alert to excessive bleeding or draining through the cast. A primary focus at this point is to teach the patient how to protect the residual limb while moving in bed, coming to sitting, and transferring. Obviously the patient should not put pressure on the limb or drag it on the bed. Slightly raising the residual limb and moving it to the side while rolling to the unamputated side is the best way to come to sitting. Careful monitoring of healing status of the residual limb is important at this point. The patient can be encouraged to move the limb gently within a pain-free range both at the knee (transtibial) and at the hip (both levels). Gentle hip extension (for transtibial amputations, with the knee straight) is an excellent exercise to teach the patient while lying on the unamputated side. It can and should be done several times a day. Any resistive exercises for the residual limb are contraindicated at this time.
Care of the Remaining Lower Extremity
Since the majority of individuals undergoing amputation do so as a result of poor circulation, it is important to evaluate the status of the remaining extremity and teach the patient and family proper care as presented in Chapter 14, Vascular, Lymphatic, and Integumentary Disorders. As previously stated, a proper shoe must be obtained before standing and mobility activities.27
The more the patient and family understand about the amputation and rehabilitation process the better the outcome. Throughout the examination and implementation of the POC, the physical therapist continuously involves the patient and caregivers, answering questions and providing information at a level and rate commensurate with the capabilities of the individuals. The goals are to have the patient and caregivers assume responsibility for care, understand the need for continued care, and become active participants in the rehabilitation program.28 A home program needs to be developed and the patient should be encouraged to be as mobile as possible. By necessity, the home program will be limited until healing has occurred so the importance of continuity of physical therapy care is emphasized. Stineman et al,29 in a study of 2,673 older veterans, reported that those who received intensive inpatient rehabilitation services had significantly better outcomes than those who did not receive such services.
The preprosthetic phase is the time between discharge from the acute care hospital and fitting with a definitive prosthesis, or the decision not to fit the patient with an artificial limb. Regrettably, for many individuals this period lasts too long, does not include a regular program of physical therapy, and often results in poor outcomes. The general goals for the preprosthetic phase of care are presented in Box 22.4, and Box 22.5 provides a general preprosthetic examination guide.
Box 22.4 Preprosthetic General Goals
Independent in residual limb care
Independent in mobility, transfers, and functional activities
Partial weight-bearing crutch walking if fitted with IPOP or EPOP
Full weight-bearing when tolerated
Single-leg ambulation with crutches/walker if fitted with soft dressing
Demonstrate home exercise program accurately
Care of the remaining lower extremity if amputated for vascular reasons
Box 22.5 Preprosthetic Examination Guide
Cause of amputation (disease, tumor, trauma, congenital)
Associated diseases/symptoms (neuropathy, visual disturbances, cardiopulmonary disease, renal failure, congenital anomalies)
Current physiological state (postsurgical cardiopulmonary status, vital signs, shortness of breath, pain)
Scar (healed, adherent, invaginated, flat)
Other lesions (size, shape, open, scar tissue)
Moisture (moist, dry, scaly)
Sensation (absent, diminished, hyperesthesia)
Grafts (location, type, healing)
Dermatological lesions (psoriasis, eczema, cysts)
Residual Limb Length
Residual Limb Shape
Cylindrical, conical, bulbous end, and so forth
Abnormalities ("dog ears," adductor roll)
Vascularity (both limbs if amputation cause is vascular)
Pulses (femoral, popliteal, dorsalis pedis, posterior tibial)
Color (red, cyanotic)
Edema (circumference measurement, water displacement measurement, caliper measures)
Pain (type, location, duration, intensity)
Range of Motion
Pain (phantom [differentiate sensation or pain], neuroma, incisional, from other causes)
Cognitive status (alert, oriented, confused)
Transfers (bed-to-chair, to toilet, to car)
Mobility (ancillary support, supervision)
Home/family situation (caregiver, architectural barriers, hazards)
Activities of daily living (bathing, dressing)
Instrumental activities of daily living (cooking, cleaning)
Approximately 7 to 12 days after surgery, depending on the condition of the residual limb, the amount of healing, and the postsurgical dressing, specific data about the residual limb and adjacent joint(s) can be gathered. Healing is, of course, of primary importance and residual limb data gathering must be deferred until the residual limb has healed enough to tolerate the stress of handling and resistance. Residual limb measurements are generally taken and reported in centimeters for uniformity with others involved in the care of individuals who have had an amputation. Circumferential measurements of the residual limb are taken after initial postsurgical edema has diminished, then regularly throughout the preprosthetic period. Measurements are made at regular intervals over the length of the residual limb. Circumferential measurements of the transtibial residual limb are started at the medial tibial plateau and taken every 5 to 8 cm depending on the length of the limb. Length of the residual limb is measured from the medial tibial plateau to the end of the bone, then to the end of the skin. Circumferential measurements of the transfemoral residual limb are started at the ischial tuberosity or the greater trochanter, whichever is most palpable, and taken every 8 to 10 cm. Length is measured from the ischial tuberosity or the greater trochanter to the end of the bone, then to the end of the skin. For accuracy of repeat measurements, exact landmarks are carefully noted. If the ischial tuberosity is used in transfemoral measurements, hip joint position is noted as well. Other information gathered about the residual limb includes its shape (conical, bulbous, or cylindrical; presence of redundant tissue), skin condition, sensation, and joint proprioception.
Gross range of motion (ROM) estimations are generally adequate for examination of the uninvolved extremity but specific goniometric measurements are necessary for the amputated side, bilateral hip extension, and ankle dorsiflexion of the unamputated side. Good balance requires good ankle motion, and many older individuals have developed limited range in ankle dorsiflexion leading to stumbling and catching of toes. Hip and knee measurements are taken following transtibial amputation. Hip flexion, extension, abduction, and adduction measurements are taken following transfemoral amputation. Measurement of internal and external hip rotation is difficult to obtain and unnecessary if no gross abnormality or pathology is evident. Hip flexion contractures are particularly important to note because the patient cannot stand and bear weight properly without adequate hip extension (Fig. 22.6). Additionally, hip extension participates in prosthetic knee control for some transfemoral prostheses.
Hip flexion contractures prevent balanced standing. From May and Lockard,26, p. 111 with permission.
Gross manual muscle testing (MMT) of the upper extremities (UEs) and uninvolved LE is performed as part of the initial examination. MMT of the involved LE must usually wait until most healing has occurred. With a transtibial amputation, good strength in the hip extensors and abductors, as well as the knee extensors and flexors, is needed for satisfactory prosthetic ambulation. For the patient with a transfemoral amputation, good strength of the hip extensors and abductors is a requirement. The strength of these muscles should be monitored throughout the preprosthetic phase. The intervention program addresses these areas.
Status of the Uninvolved Limb
The vascular status of the uninvolved LE is determined and documented. Data gathered include condition of the skin, presence of pulses, sensation, temperature, edema, pain on exercise or at rest, presence of wounds, ulceration, or other abnormalities. Chapter 14, Vascular, Lymphatic, and Integumentary Disorders, presents further information on examination and evaluation of peripheral vascular status.
Activities of daily living and functional mobility skills including transfer and ambulatory status are examined and documented. Balance both sitting and standing on the remaining extremity is very important and should be examined as long as the person's condition permits. Data regarding presurgical activity level and the person's own expected outcomes are obtained through interview and are often indicative of potential functional prosthetic use. An individual who had an active lifestyle before the amputation, regardless of age, is more likely to be able to learn to use a prosthesis well. Individuals with a long history of a sedentary lifestyle may encounter more difficulty, particularly if the amputation is at the transfemoral level.
The majority of individuals will encounter phantom limb sensations following amputation. In its simplest form, the phantom is the sensation of the limb that is no longer there. The phantom, which may occur initially immediately after surgery or as long as a year after amputation, is often described as a tingling, burning, itching, or pressure sensation, or sometimes a numbness. The distal part of the extremity is most frequently felt although, on occasion, the person will feel the whole extremity. Phantom sensation has been around as long as individuals survived the loss of a limb; however, there has been little agreement over the centuries regarding its cause or treatment. Current researchers are investigating areas of sensory reintegration and reorganization in the somatosensory cortex.30 A majority of individuals report phantom limb sensation and some report the feeling as noxious, yet it usually does not interfere with prosthetic rehabilitation. It is important for the patient to understand that the sensations are quite normal.31
Phantom limb pain is a generalized noxious sensation in the absent limb that is so strong as to interfere with prosthetic fitting. It may be localized or diffuse, continuous or intermittent, and may be triggered by some external stimuli. It may diminish over time or become a permanent and disabling condition. It occurs in only a small number of patients. It is important to differentiate phantom pain from the more common phantom sensations, residual limb pain, or neuroma pain. Sometimes, wearing a prosthesis will ease the phantom pain. On occasion, in the presence of trigger points, injection with steroids or local anesthetic has reduced the pain temporarily. Although the literature is replete with information and studies on phantom sensation, phantom pain, and residual limb pain, there is little agreement about the best approach to treatment of these phenomena.31 In some studies, particularly of individuals who experienced considerable preoperative pain, intrathecal or epidural anesthetic drips with opioids were used both preoperatively and postoperatively with success.32 However, others have reported no success with such treatments.31 Noninvasive treatments such as ultrasound, icing, transcutaneous electrical nerve stimulation (TENS), and massage have been used with varying success. Mild nonnarcotic analgesics have been of limited value; biofeedback, guided imagery, psychotherapy, nerve blocks, and dorsal rhizotomies have all been used with inconsistent results. The treatment of phantom pain can be very frustrating for the clinic team as well as the patient.31,32,33,34,35
Initial reaction to the traumatic loss of a limb is usually grief and depression. The person may experience insomnia and restlessness, and have difficulty concentrating. Some individuals may actually mourn the possible loss of a job or the ability to participate in a favorite sport or other activities rather than the lost limb per se. In the early stages, the person's grief may alternate with feelings of hopelessness, despondency, bitterness, and anger. Socially the patient may feel lonely, isolated, and the object of pity. Concerns about the future, about body image and sexual function, about the responses of family and friends, and about employment all affect the individual's reactions.
If the amputation was the result of vascular disease or other long-term problem, the amputation may actually come as a relief. The fight to save the limb, sometimes long and painful, is finally over. Responses vary by individuals. Some older individuals may relate the loss of the limb to the loss of independence and may become quite depressed. While not giving the individual false hope, it behooves the physical therapist to educate the patient on the rehabilitation process and the steps toward independence. Often seeing others in the treatment area with similar problems, particularly if involved in prosthetic training, may help the patient with a new amputation realize what can be achieved.
Long-term adjustment depends to a great extent on the individual's basic personality structure, sense of accomplishment, and place in the family, community, and world. In general, many individuals with amputations make a satisfactory adjustment to the loss and are reintegrated into a full and active life. In achieving final acceptance, the individual may go through a number of stages including denial, anger, euphoria, and social withdrawal. Although it is difficult to predict long-range adjustment initially, there is some evidence that early counseling and the opportunity to explore the feelings associated with amputation and rehabilitation may be beneficial for individuals in all age groups.36
Some individuals may try to avoid distressing thoughts of the lost limb through conscious self-control or by avoiding situations or people that remind them of the lost limb. Some may display temper tantrums or irrational resentment. Some may revert to childlike states of helplessness and dependence.
Many individuals are not fully aware of the consequences of amputation and may fear other physical limitations as a result of the surgery. Fear of impotence or sterility may lead some men to make grandiose statements or display reckless behavior to mask the fear. Thorough explanations of the amputation process and its implications by the surgeon or other rehabilitation team members may alleviate many of these fears.
Generally, people who have had an amputation may dream about themselves as having an intact limb. This image may be so vivid that they fall as they get up at night and attempt to walk to the bathroom without a prosthesis or crutches. Individuals who have lost their leg through injury may dream about the battle or accident in which they were injured. Such reenactments may lead to insomnia, trembling fits, speech impediments, and difficulty with concentration. In general, individuals with congenital amputations or acquired amputations before age 5 do not have some of the problems mentioned above because their amputation is a part of their developed self-image.
The patient needs to receive reassurance and understanding from the entire rehabilitation team. Team members should create an open and receptive environment and be willing to listen. The patient should know what to expect during the entire process. The surgeon and therapists should carefully explain the steps and expectations of rehabilitation. Audiovisual media, such as films or photographs, may be helpful. The Amputee Coalition of America (ACA) is a national, nonprofit amputee consumer educational organization representing people who have experienced amputation or were born with limb differences (www.amputee-coalition.org). Members include individuals with amputations, health professionals, family members, and friends of those with amputations. The ACA supports a volunteer visitation program where individuals with amputations who have been trained to provide support will visit patients soon after surgery to help with emotional support. Therapists should be cognizant of the existence of a local ACA chapter and make use of the organization to provide support and education to their patients regardless of age or cause of amputation. The mili tary services also have support programs for individuals with amputations, and a group of veterans organized the Wounded Warrior Project (www.woundedwarriorproject.org) as a nonprofit organization to assist severely disabled veterans.
Patients have various attitudes toward the prosthesis. Most are concerned with function and regaining the greatest level of function possible; others are concerned about its appearance, hoping that it will conceal their disability and give the illusion of an intact body. If individuals with amputations have been told that the prosthesis will replace their own limb, they may have unrealistic expectations that function will be as good as in the nonamputated extremity. Realistic adjustment will be necessary as the person learns to use the artificial substitute. Good predictors for adjustment to the prosthesis are active involvement in the postsurgical and preprosthetic program and consistent attempts to return to an active lifestyle.
The older individual with a LE amputation is not content to sit in a wheelchair or limp with a walker, but seeks effective rehabilitation services and a meaningful lifestyle. Maintaining independence is a critical issue with the older adult. Any disability requiring the use of an external device, especially amputation, may be seen as the end of an independent lifestyle. To some extent, the previous level of pain and disability and the sudden or gradual onset of the disability will affect the reaction. Individuals who have suffered considerable pain may be grateful that the pain has ended. Clients who underwent extensive medical and surgical procedures may experience a sense of failure that the efforts were not successful. If preoperative attitudes are unrealistically hopeful, postoperative disturbances may be more severe. The elderly person should not be led to expect a total cure. Learning to use an artificial limb may be a slow and discouraging ordeal, and the client may not express distress or depression in front of the optimism of others. However, the physical therapist must keep in mind that the majority of older individuals, particularly those amputated at transtibial levels, make excellent adjustments to prosthetic function.37
Elderly individuals are subject to considerable stress from concerns about financial limitations, loss of control over their lives, and fear of becoming dependent. An elderly individual who requires an amputation must often cope with multiple physical problems. Loss is a part of normal aging—loss of physiological capabilities, loss of a spouse or friends, loss of the self-esteem related to one's career or job, and now, loss of function. It is helpful to give the client as much control over decision making as possible, to provide opportunities to be involved in goal setting and sequencing of activities. As with any client, physical therapists need to be aware of the stressors affecting the client and assist with coping by being reflective listeners and enablers.
It is a myth that elderly individuals cannot learn a new skill, have difficulty remembering, and cannot achieve at the same level as younger individuals. Some elderly individuals may have difficulty learning a new skill, but many are able to adapt successfully to a disability such as an amputation and lead a full and normal life. Although some suffer from dementia, others who are labeled as having dementia because of confusion in the acute care setting may actually only be responding to medications, metabolic imbalances, infection toxicity, insecurity in a strange environment, or the sequelae of anesthesia. It is important to remember that cognitive dysfunction does not preclude satisfactory rehabilitation. Understanding the client's cognitive capabilities will help structure learning experiences appropriately. Goal-oriented statements may be clearer than step-by-step instructions. We do many activities almost automatically—getting up from a chair, turning in bed, and walking. Most of us have developed particular patterns of movements over the years. The physical therapist can draw on such patterns while focusing on the movement goals.
The residual limb needs to be completely healed and have lost the postoperative edema and much of the soft tissue slackness to be ready for prosthetic fitting. The residual limb is subjected to considerable and varied pressures during prosthetic walking and is generally not fully healed and prepared for such stresses for 8 to 12 weeks. The most effective method of preparing the residual limb for prosthetic fitting is the rigid dressing, but it is more expensive than the elastic wrap and many insurers will not pay for such fitting. Individuals not fitted with a rigid dressing use elastic wrap or shrinkers to reduce the size of the residual limb. The patient, family member, or professional staff member applies the bandage, which is worn 24 hours a day, except when bathing. Using an elastic wrap or a shrinker to reduce edema is a slow process. Edema in the residual limb may be difficult to control in individuals with diabetes, particularly if they have renal involvement.
Patients tend to wrap their own residual limb in a circular manner, often creating a tourniquet, which may compromise healing and foster the development of a bulbous end. Although the transtibial residual limb can be effectively wrapped in a sitting position, it is difficult to properly wrap and anchor the transfemoral limb while sitting. Older patients often cannot balance themselves in the standing position while wrapping. An effective bandage is smooth and wrinkle free, emphasizes angular turns, provides pressure distally, and encourages proximal joint extension. The ends of bandages are fastened with tape or safety pins, rather than clips, which can cut the skin and do not anchor well. A system of wrapping that uses mostly angular or figure-of-eight turns was developed specifically to meet the needs of the older patient.
Figure 22.7 outlines the preferred methods of wrapping the transtibial residual limb. Two 4-in elastic bandages are usually enough to wrap most transtibial residual limbs. Very large residual limbs may require three bandages. The transtibial bandages should not be sewn together so that the weave of each bandage can be brought in contraposition to the other to provide more support. Although an elastic wrap does not provide as much pressure as a rigid dressing, the development of postsurgical edema must be deterred as much as possible; therefore, a firm, even pressure against all soft tissues is desirable. If the incision is placed anteriorly, an attempt should be made to bring the bandages from posterior to anterior over the distal end.
Transtibial residual limb bandaging. From May and Lockard,26, p. 75 with permission.
The first bandage is started at either the medial or lateral tibial condyle and brought diagonally over the anterior surface of the limb to the distal end. One edge of the bandage should just cover the midline of the incision in an anterior-posterior plane. The bandage is continued diagonally over the posterior surface, then back over the beginning turn as an anchor. At this point, there is a choice; the bandage may be brought directly over the beginning point as indicated in Figure 22.7 (step 2a), or it may be brought across the front of the residual limb in an "X" design (Fig. 22.7 [step 2b]). The latter technique is particularly useful with long residual limbs and aids in bandage suspension. An anchoring turn over the distal thigh is made making sure that the wrap is clear of the patella and is not tight around the distal thigh.
After a single anchoring turn above the knee, the bandage is brought back around the opposite tibial condyle and down to the distal end of the limb. One edge of the bandage should overlap the midline of the incision and the other wrap by at least 1/2 in (1.25 cm) to ensure adequate distal end support. The figure-of-eight pattern is continued as depicted in Figure 22.7 (steps 5 through 8) until the bandage is used up. Care should be taken to completely cover the residual limb with a firm and even pressure. Semicircular turns are made posteriorly to position the bandage to cross the anterior surface in an angular line. This maneuver provides greater pressure on the posterior soft tissue while distributing pressure anteriorly where the bone is close to the skin. Each turn should partially overlap other turns so the whole residual limb is well covered. The pattern is usually from proximal to distal and back to proximal, starting at the tibial condyles and covering both condyles as well as the patellar tendon. Usually, the patella is left free to aid in knee motion, although with extremely short residual limbs, it may be necessary to cover it for better suspension.
The second bandage is wrapped like the first, except that it is started at the opposite tibial condyle from the first bandage (Fig. 22.7 [step 9]). Bringing the weave of each bandage in contraposition exerts a more even pressure. With both bandages, an effort is made to bring the angular turns across each other rather than in the same direction.
Figure 22.8 depicts the preferred method of wrapping the transfemoral residual limb with the task being done by a family member or caregiver. The side-lying position is preferred for better control of the residual limb with the hip neutral or slightly extended. Wrapping the transfemoral residual limb in the sitting position is difficult and usually leaves an area on the medial thigh uncovered. The patient with good balance on the remaining limb can bandage the residual limb in the standing position.
Transfemoral residual limb bandaging. From May and Lockard,26, p. 76 with permission.
For most residual limbs, two 6-in bandages and one 4-in bandage will adequately cover the limb. The two 6-in bandages can be sewn together end-to-end taking care not to create a heavy seam; the 4-in bandage is used by itself. The 6-in bandages are used first. While it was noted that the transtibial wraps should not be sewn together to allow for a firmer bandage, sewing the transfemoral 6-in bandages or using a double bandage reduces the end of bandage attachments and makes for a smoother wrap. The first bandage is started in the groin and brought diagonally over the anterior surface to the distal lateral corner, around the end of the residual limb, and diagonally up the posterior side to the iliac crest and around the hips in a spica. The bandage is started medially so that the hip wrap (hip spica) will encourage extension. After the turn around the hips, the bandage is wrapped around the proximal portion of the residual limb high in the groin, then back around the hips. Although this is a proximal circular turn, it does not create a tourniquet as long as it is continued around the hips. Going around the medial portion of the residual limb high in the groin ensures coverage of the soft tissue in the adductor area and reduces the possibility of an adductor roll, a complication that can seriously interfere with comfortable prosthetic wear. In most instances, the first bandage ends in the second hip spica and is anchored with tape or pin.
The second 6-in bandage is wrapped like the first but is started a bit more laterally. Any areas not covered with the first bandage must be covered at this time. If a double bandage is used, this wrap can be a continuation of the first anchoring turn. The second bandage is also anchored in a hip spica after the first figure-of-eight and after the second turn high in the groin. While more of the first two bandages are used to cover the proximal residual limb, care must be taken that no tourniquet is created. Bringing the bandage directly from the proximal medial area into a hip spica helps to keep the adductor tissue covered and prevents rolling of the bandage to some degree.
The 4-in bandage is used to exert the greatest amount of pressure over middle and distal areas of the residual limb. It is usually not necessary to anchor this bandage around the hips because friction with the already applied bandages and good figure-of-eight turns limit slippage. The 4-in bandage is generally started laterally to bring the weave across the weave of previous bandages. Regular figure-of-eight turns in varied patterns to cover the entire residual limb are the most effective.
The transtibial elastic shrinker is rolled over the residual limb to midthigh and is designed to be self-suspending. Individuals with heavy thighs may need additional suspension with garters or a waist belt. Currently available transfemoral shrinkers incorporate a hip spica, which provides good suspension except with obese individuals (see Fig. 22.4). Care must be taken that the patient understands the importance of proper suspension; any rolling of the edges or slipping of the shrinker can create a tourniquet around the proximal part of the residual limb. Shrinkers are easier to apply than elastic bandages and may be a better alternative, particularly for the transfemoral residual limb. Shrinkers are more expensive to use than elastic wrap; the initial cost is greater, and then new shrinkers of smaller sizes must be purchased as the limb volume decreases. However, shrinkers are a viable option for individuals who are not able to properly wrap the residual limb. Shrinkers may not be used until the incision has healed and the sutures have been removed. Sutures can be caught in the shrinker's mesh, and the distal distraction forces that accompany donning may cause wound dehiscence (splitting open). In a small study involving individuals who were taught proper bandaging techniques, Louie et al38 found that residual limb wrapping was slightly more effective in reducing edema among individuals with transtibial amputations.
Proper hygiene and skin care are important. The residual limb is treated as any other part of the body; it is kept clean and dry. Individuals with dry skin may use a good skin lotion. Care must be taken to avoid abrasions, cuts, and other skin problems. Friction massage, in which layers of skin, subcutaneous tissue, and muscle are moved over the respective underlying tissue, can be used to prevent or mobilize adherent scar tissue. The massage is done gently, after the wound is healed and when no infection is present. Patients can learn to properly perform a gentle friction massage to mobilize the scar tissue and help decrease hypersensitivity of the residual limb to touch and pressure. Early handling of the residual limb by the patient is an aid to acceptance and is encouraged, particularly for individuals who may be repulsed by the limb.
The patient is taught to inspect the residual limb with a mirror each night to make sure there are no sores or impending problems, especially in areas not readily visible. If the person has diminished sensation, careful inspection is particularly important. Because the residual limb tends to become a bit edematous after bathing as a reaction to the warm water, nightly bathing is recommended, particularly once a prosthesis has been fitted. The elastic bandage, elastic shrinker, or removable rigid dressing is reapplied after bathing. If the person has been fitted with a prosthesis, the residual limb is wrapped at night and any time the prosthesis is not worn until it is fully mature (i.e., does not develop edema when not wearing a prosthesis). Patients have been known to apply a variety of "home and folk remedies" to the residual limb. Historically, it was believed that the skin had to be toughened for prosthetic wear by beating it with a towel-wrapped bottle. Various ointments and lotions have been applied; residual limbs have been immersed in substances such as vinegar, salt water, and gasoline to harden the skin. Although the skin does need to adjust to the pressures of wearing an artificial limb, there is no evidence to indicate that "toughening" techniques are beneficial. Such methods may actually be deleterious; research indicates that soft pliable skin is better able to cope with stress than tough dry skin. Patient education regarding proper skin care can reduce the use of home remedies.
The skin of the residual limb may be affected by a variety of dermatological problems such as eczema, psoriasis, or radiation burns. Some of these conditions may mitigate against fitting or wrapping. Dudek et al39 found 528 reports of skin problems among 337 residual limbs in a 6-year retrospective study. Each skin problem was treated as a separate entity, whether it occurred in one or more than one individual. Treatment may include ultraviolet irradiation, whirlpool, reflex heating, hyperbaric oxygen, or medication. Care must be taken in using ultraviolet or heat in the presence of vascular disease. The whirlpool may not be the treatment of choice because it increases circulation and edema in the part under treatment.
One of the greatest deterrents to functional prosthetic rehabilitation is contracture of hip or knee. Contractures can develop as a result of muscle imbalance or fascial tightness, from a protective withdrawal reflex into hip and knee flexion, from loss of plantar stimulation in extension, or as a result of faulty positioning such as prolonged sitting or placing the residual limb on a pillow. The patient should understand the importance of proper positioning and regular exercise in preparing for eventual prosthetic fit and ambulation. For all levels of amputation, full ROM in hip extension is critical in allowing the individual to assume a balanced upright posture.
With the transtibial amputation, full ROM in the hips and knee, particularly in extension, is needed. While sitting, the patient can keep the knee extended by using a posterior splint or a board attached to the wheelchair. The patient with a transfemoral amputation needs full ROM in the hip, particularly in extension and adduction. Prolonged sitting is to be avoided. Some time each day should be spent in the prone position.
Some individuals will present with hip or knee flexion contractures. Mild contractures may respond to manual mobilization and active exercises, but it is almost impossible to reduce moderate to severe contractures by manual stretching, especially hip flexion contractures. Some practitioners advocate holding the extremity in a stretched position with weights for a considerable length of time. There is little evidence that this traditional approach is successful. Facilitated stretching techniques (e.g., proprioceptive neuromuscular facilitation [PNF]) are more effective than passive stretching; hold–relax and hold–relax active contraction that utilizes resisted contraction of antagonist muscles may increase ROM, particularly of the knee. One of the more effective ways of reducing a knee flexion contracture is to fit the patient with a patellar-tendon-bearing (PTB) prosthesis aligned in a manner that places the hamstrings on stretch with each step. Such prosthetic alignment provides a stretch that is quite effective. Hip flexion contractures are more frequently found in persons with transfemoral amputations. It is difficult to "walk out" a hip flexion contracture with the transfemoral prosthesis. In some instances, depending on the severity of the contracture and the length of the residual limb, the contracture can be accommodated in the alignment of the prosthesis. A knee flexion contracture of less than 15° is not usually a problem. Prevention, however, continues to be the best treatment for contractures.
The exercise program is individually designed and includes strengthening, balance, and coordination activities. The type of postsurgical dressing, degree of postoperative pain, and healing of the incision will determine when resistive exercises for the involved extremity can be started. The exercise program can take many forms and must include a home exercise program (HEP). The hip extensors and abductors and knee extensors and flexors are particularly important for prosthetic ambulation. Studies have shown a correlation between strength of the key muscle groups and ability to use a prosthesis effectively.40,41,42,43 Figures 22.9 and 22.10 depict a series of exercises particularly well designed to strengthen key muscles around the hip and knee. These exercises can be adapted for a HEP because they are simple to perform and require no special equipment. Exercises need to be progressed with increased resistance.
Transtibial exercises: (A) quad set, (B) hip extension with knee straight, (C) straight leg raise, (D) extension of the residual limb with the knee of the other leg against the chest, (E) hip abduction against resistance, and (F) bridging. From May and Lockard,26, p. 77 with permission.
Transfemoral exercises: (A) gluteal sets, (B) hip abduction supine, (C) hip abduction against resistance, (D) hip extension prone, and (E) bridging. From May and Lockard,26, p. 78 with permission.
A general strengthening program that includes the trunk and all extremities is often indicated, particularly for the older person who may have been quite sedentary before surgery. Proprioceptive neuromuscular facilitation exercises (PNF) are also beneficial. The exercise program needs to be individually developed and emphasize those muscles that are most active in prosthetic function. The exercises depicted in Figures 22.9 and 22.10 are particularly well suited to an HEP and combine the strengthening and coordination necessary for prosthetic ambulation. Corio et al44 studied the effects of spinal stabilization exercises on the gait of individuals wearing a prosthesis for at least a year. Although a small sample of 34 individuals was used, the results suggest that improvement in spinal stabilization and trunk control may positively influence gait parameters.44
Balance and Mobility Activities
Early mobility is important to total physiological recovery. The patient needs to resume independent activities as soon as possible. Balance is a key element to effective mobility and an area too often overlooked. Poor balance and fear of falling have been found to negatively affect successful prosthetic rehabilitation.45,46 Although individuals with unilateral amputation usually do not have a problem with sitting balance, it is important for the individual to develop good standing balance on the remaining limb. Figure 22.11 shows one type of standing balance exercise on a compliant surface. While care must be taken to protect the remaining foot from injury, particularly in patients with vascular disease, balance exercises with and without shoes as well as with eyes open and closed is an integral part of the program. Weight-bearing through the residual limb is also beneficial to future prosthetic training. This can only be safely achieved in patients with transtibial amputations. Figure 22.12 depicts a person kneeling on a cushion in a chair of the appropriate height and shifting her weight on and off the amputated side.
Standing balance exercise on a compliant surface. From May and Lockard,26, p. 73 with permission.
Kneeling on a pillow on a chair provides an opportunity for some weight-bearing. From May and Lockard,26, p. 74 with permission.
Walking is excellent exercise and necessary for independence in daily life. Gait training can start early and the person with a unilateral LE amputation can become quite independent using a three-point gait pattern on crutches. Many older individuals have difficulty learning to walk on crutches. Some are afraid, some lack the necessary balance and coordination, and others lack endurance. Walking with crutches without a prosthesis requires a greater expenditure of energy than walking with a prosthesis.
Independence in crutch walking is an outcome worthy of therapy time. The individual who can ambulate with crutches will develop a greater degree of general fitness than the person who spends most of the time in a wheelchair. Crutch walking is good preparation for prosthetic ambulation and the person who can learn to use crutches generally will not have difficulty learning to use a prosthesis. However, the individual who cannot learn to walk with crutches independently may still become a very functional prosthetic user. An early graduated mobility program is also important for cardiovascular training and the development of endurance. Cardiovascular endurance is necessary for effective prosthetic ambulation, particularly at the transfemoral level.
There are advantages and disadvantages to using a walker for support. Certainly, walking with a walker is physiologically and psychologically more beneficial than sitting in a wheelchair, but it should be used only if the person cannot learn to walk with crutches. A walker is sturdier than crutches but cannot be used on stairs and curbs. It is sometimes difficult for the person who has used a walker following the amputation to switch to crutches or a cane when fitted with a prosthesis. The gait pattern used with a walker is not appropriate with a prosthesis and should not be used for any part of prosthetic training. A walker encourages a step-to gait pattern whereas efficient prosthetic use requires a step-through gait pattern. All individuals with an amputation need to learn some form of mobility without a prosthesis for use at night or when the prosthesis is not worn for some reason.
Many individuals are not fitted with any type of prosthetic appliance until the residual limb is free from edema and much of the soft tissue has shrunk, a process that can take many months of conscientious limb wrapping and exercises. During this period, the patient is limited to a wheelchair or to ambulation with crutches or a walker. Most individuals cannot return to work or fully participate in ADL while waiting for the residual limb to mature. Once fitted with a definitive prosthesis, the residual limb continues to change in size and a second prosthesis is often required within the first 2 years. A temporary prosthesis today is the same as the definitive prosthesis and uses the same components. Many third-party payers will not fund a temporary prosthesis, so early permanent fitting is advocated, even though the socket will be too big quite quickly. Early bipedal ambulation is a desired goal for most individuals following amputation. The longer the delay in fitting with a prosthesis, the lower the potential for effective rehabilitation. Care should be taken that the patient is fitted with optimum components for his or her expected level of function. Too often, older individuals are fitted with low-cost, low-function components when they probably could have achieved a higher level of function with more functional components. It becomes a vicious cycle with insurance companies depicting statistics showing that older individuals do not achieve independence but not considering that the components that were authorized either do not fit properly or they do not provide the necessary function. There is also a problem with insurers not providing adequate prosthetic training by a physical therapist.
Patient education is an integral and ongoing part of the rehabilitation program. Information on the care of the residual limb, proper care of the uninvolved extremity, positioning, exercises, and diet, if the patient has diabetes or is overweight, are necessary for the patient to be a full participant in the rehabilitation program. Discussions should also be held regarding patient goals, projected activity levels, funding, and prosthetic components. If the patient underwent the amputation for vascular problems, the education program should include information on proper footwear.
Care must be taken not to overwhelm the patient with too much information at one time; information overload leads to forgetfulness. It is more effective to prioritize the information and ask the person to remember one new thing each session rather than try to teach a complex program at one time. Written materials are necessary to supplement the teaching and help the patient remember what is required. It is also important for the program to be tailored to the individual's way of life. Involving the patient in establishing priorities enhances adherence. Appendix 22.A includes web-based resources for clinicians, families, and patients with amputation.
Intervention for the person with bilateral LE amputations is similar to the program developed for someone with a unilateral amputation except possibly ambulation. If the individual was fitted and ambulated after unilateral amputation, the prosthesis is useful for transfer activities and limited ambulation in the home. Some individuals may be able to use the prosthesis with external support to get around the house more easily, particularly for bathroom activities.
All individuals with bilateral amputations need a wheelchair on a permanent basis. The chair should be as narrow as possible with removable desk arms and removable leg rests. Elevating armrests are useful to assist in sit-to-stand transfers. Amputee wheelchairs with offset rear wheels and no leg rests are not recommended unless the therapist is sure that the person will never be fitted with prostheses, even cosmetically. It is easier to add anti-tipping devices to the rear of the wheelchair or attach small weights to the front uprights (counterbalance) for use when the footrests are removed.
The exercise program includes mat activities designed to help the person regain a sense of body position and balance, UE and residual limb strengthening exercises, and regular ROM exercises. Functional mobility training should stress independence in bed mobility, transfers, and wheelchair use. With bilateral amputations, individuals spend considerable time sitting and are therefore more prone to develop flexion contractures, particularly around the hip joints. The patient should be encouraged to sleep prone if possible, or at least spend some time in the prone position each day. The therapy program also emphasizes ROM of the residual limbs.