Physical therapists participate in the management of patients with amputation at several key stages: (1) preoperative; (2) postoperative–preprosthetic; (3) prosthetic prescription; (4) prosthetic examination; and (5) prosthetic training.
The first two stages are described in Chapter 22, Amputation. The following discussion emphasizes the responsibilities of the physical therapist with regard to the patient and prosthesis. Ideally, the therapist works as a member of a clinic team, together with the physician and prosthetist. Others, such as a social worker, vocational counselor, and psychologist may participate in the team on a regular basis or as needed. The clinic team provides the best environment for exchange of information and viewpoints regarding the patient and fostering efficient treatment;55,56 the team meets to formulate the prosthetic prescription, examine the newly delivered prosthesis, and reexamine the patient and prosthesis upon completion of prosthetic training. The therapist, therefore, has an integral part to play in these critical points in rehabilitation, as well as conducting prosthetic training. If a formal clinic team is not established in the therapist's work setting, one must coordinate the recommendations of the physician and prosthetist.
With either administrative situation, the physical therapist:
Addresses nonprosthetic considerations
Contributes to prosthetic prescription
Examines the prosthesis
Facilitates prosthetic acceptance
Instructs the patient in donning, use, and maintenance of the prosthesis
Successful prosthetic rehabilitation depends on matching the individual's physical and psychosocial characteristics to a prosthesis composed of carefully selected components. Although everyone who wears a prosthesis has an amputation or comparable limb deficiency, the reverse is not true. That is, some people with amputations are not candidates for prostheses or prefer not to use prostheses. Prostheses are contraindicated for patients with severe dementia or depression or advanced cardiopulmonary disease. If the person displays significant changes associated with organic brain syndrome, prosthetic fitting is contraindicated. Individuals with bilateral amputations who are unable to transfer independently or don underwear by themselves are unlikely to benefit from definitive prostheses. Similarly, a patient with bilateral amputations who had sustained unilateral amputation previously and was unable to don and walk with a unilateral prosthesis is not a candidate for a pair of prostheses. Some people with high amputations, especially hip disarticulation, find that a prosthesis is unduly cumbersome; they prefer to ambulate with a pair of crutches or depend on a wheelchair. Several sports, particularly swimming, are generally easier to perform without a prosthesis.
The physical therapist should examine joint mobility and active and passive range of motion of all joints on both LEs. Knee and hip flexion contractures compromise prosthetic alignment and appearance. A knee lock may be needed in a transfemoral prosthesis. A patient with knee contracture requires an alternative transtibial socket design. Severe contractures may contraindicate provision of a prosthesis. The deleterious effects of contractures are especially serious with bilateral amputations.
The length of the amputation limb should be measured. The individual with a short transtibial amputation may require SC/SP suspension. Every attempt should be made to fit the patient with a short transfemoral amputation with suction or partial-suction suspension to retain the prosthesis on the thigh.
Strength of all limb and trunk muscles should be examined. Frequently, the elderly patient with vascular disease experiences reduced physical activity as LE pain and foot ulceration develop. Such an individual may present with marked debility, which would interfere with prosthetic use or necessitate use of a unit with a knee lock.
The therapist should inspect the skin, noting the status of the incision and any other lesions. The patient may require a nylon or silicone sheath to provide a smooth interface between socket and skin to avoid irritating tender or grafted skin.
An examination of sensory function should be performed. For example, someone with impaired proprioception at the knee will need extra prosthetic stability in the form of higher medial and lateral socket walls, or side joints attached to a thigh corset, on the transtibial prosthesis. Blindness does not preclude fitting, but it does pose problems with regard to selecting components that are easy to don, as well as altering the training program. If the patient complains of a neuroma, the problem must be addressed surgically or conservatively (e.g., cortisone injection) before fitting can proceed.
The therapist should examine the patient's ability to learn and retain new information, including both short- and long-term memory. Neurological conditions, such as cerebrovascular accident, complicate fitting and training. Ipsilateral hemiplegia is not as detrimental to prosthetic rehabilitation as contralateral paralysis. In both instances, the prosthesis should be designed for maximum stability. Patients with mild neurological impairments often respond favorably to altered training strategies, which the therapist designs on an individualized basis.
The circulation and anthropometric dimensions of the amputation and sound limbs require careful scrutiny. The physical therapist should teach the patient to inspect the intact foot, using a hand mirror to visualize the plantar surface. Inspection aims to identify skin lesions and incipient areas of abrasion so that corrective measures may be instituted before ulceration or infection ensues. In addition, the patient should be taught to keep the sound foot clean and should wear clean socks or stockings and a well-fitting shoe (see Chapter 14, Vascular, Lymphatic, and Integumentary Disorders, for additional guidelines for managing the patient with peripheral vascular disease). Sequential measurements of amputation limb circumference as well as palpation will indicate whether the individual has edema. Measures should be instituted to stabilize limb volume so that the patient can retain the fit of the prosthetic socket. The patient with vascular impairment may benefit from prosthetic fitting, which transfers some stress from the contralateral limb. In addition, should the person come to bilateral amputation, previous experience with donning and controlling a unilateral prosthesis is invaluable in adjusting to a pair of prostheses.
Prosthetic prescription is also based on the patient's aerobic capacity and endurance. The clinic team must formulate realistic goals based on the individual's physical capacity, particularly related to exercise tolerance and level of deconditioning. The person who is not expected to walk rapidly is an unlikely candidate for an energy-storing/releasing foot or a fluid-controlled knee unit. Nevertheless, a fluid-controlled knee unit that incorporates a braking mechanism is appropriate for selected patients with generalized weakness.
Obesity is another factor to be considered in the preprescription examination. The obese individual is more apt to fluctuate in body weight, necessitating provision of socket liners and several socks to compensate for changing limb circumference. Similarly, those who have renal disease, especially if requiring dialysis, experience volume changes that need prosthetic accommodation.
Arthritis affects prosthesis prescription. Diminished LE mobility or deformity may compromise prosthetic alignment. Patients with hip or knee arthroplasty, however, function quite well with a prosthesis. Hand and wrist function affects the mode of donning; a laced corset should be avoided. Canes and crutches may require modification.
Functional examination is an essential component of physical therapy management (see Chapter 8, Examination of Function). Among the most useful examination procedures involves observing the patient's ability to transfer from sit-to-stand and bed-to-wheelchair. To accomplish these maneuvers, the individual must have reasonable strength, balance, and coordination, as well as adequate comprehension.
Ordinarily, the physical therapist treats the patient more frequently than any other member of the clinic team and thus is more likely to be attuned to changes in the individual's psychosocial status. Ample evidence supports the psychological, as well as physical, benefit of clinic team management.55,56 Many people with amputation confront psychosocial issues, which should be recognized and addressed.57,58,59,60,61,62,63,64 For example, the patient who is excessively fearful may be served best by prosthetic rehabilitation beginning with a temporary (provisional) prosthesis.
Transtibial Temporary Prosthesis
Most transtibial temporary prostheses have sockets made of thermoplastic material that becomes malleable at temperatures low enough to permit forming directly on the patient. One can also obtain mass-produced adjustable sockets; it may be necessary to pad the socket bottom so that the amputation limb does not develop distal edema. Some temporary prostheses have a plaster socket molded to the amputated limb. Plaster is inexpensive, readily available, and easy to use. The resulting socket, however, is rather heavy and bulky. Suspension is usually by a cuff or thigh corset. The pylon can be an aluminum component manufactured for this purpose; such a pylon has a proximal fixture that permits small changes in prosthetic alignment. A simpler pylon can be made with polyvinylchloride piping, such as used for plumbing. The pipe is lightweight and can be spot-heated to enable slight alteration in alignment. A SACH foot is customarily used on temporary prostheses.
Transfemoral Temporary Prosthesis
The easiest approach is to use a polypropylene socket (Fig. 31.35), which is manufactured in several sizes and has straps for circumferential adjustment. The socket can be suspended with a Silesian bandage or pelvic band, and is mounted on a knee unit, which may include a manual lock. Alternatively, a custom-fabricated socket of plaster or low-temperature thermoplastic can be used. Some individuals with bilateral transfemoral amputations use a pair of short prostheses. These are nonarticulated prostheses; the sockets are mounted on short platforms, drastically reducing the wearer's height in order to increase balance stability. The platforms each have a rearward projection to protect the patient from a backward fall.
Transfemoral temporary prosthesis with adjustable polypropylene socket, pelvic band, knee unit with manual lock, and adjustable shank with SACH foot.
Motivation is a cardinal determinant of prosthetic outcome. Again, strong motivation demonstrated through use of a temporary prosthesis and adherence with other elements of the rehabilitation program is a reliable predictor of prosthetic success. One should guard against unrealistic expectations. Involving the patient and family in group situations with other persons with amputation in the physical therapy department and in social environments fosters constructive attitudes. The therapist should also weigh the likelihood that the individual will be able to care for complex prosthetic mechanisms and have the financial resources to obtain prosthetic servicing, especially of less durable components, such as the foam rubber covering of the endoskeletal shank.
No prosthetic component is ideal for all clients. It is necessary to select components that are most apt to meet each individual's needs. Alternatives to every element of the prosthesis have advantages and disadvantages. The task of the physical therapist, in conjunction with other team members, is to judge the relative merits of various feet, shanks, and other components in light of objective and subjective information pertaining to the prosthetic candidate. In 1995, Medicare identified functional levels applicable to individuals with unilateral transtibial and transfemoral prostheses:65
K0: Not a candidate
K1: Household ambulation
K2: Limited community ambulation
K3: Community ambulation and the ability to vary cadence with vocational, therapeutic, or exercise needs
K4: High levels of activity such as demonstrated by active adults and athletes
These levels determine the medical necessity of knee and ankle-foot units.
Some people can be expected to function best with a sophisticated prosthesis that enhances the wearer's ability to engage in vigorous walking and athletics. Others are well served by simple, inexpensive devices. The most accurate predictor of future function is the patient's performance with a previous prosthesis. For the wearer who seeks a replacement prosthesis, the clinic team should consider the extent of use of the previous limb, together with any changes in the patient's health status and lifestyle. For example, if the person fitted with one prosthesis now returns with bilateral amputation, never having used the original prosthesis, that patient is a very poor candidate for bilateral prosthetic fitting. In contrast, another person who had been fitted with a simple transfemoral prosthesis expresses the wish to participate in sports. By demonstrating good use of the original prosthesis, that individual is likely to derive considerable benefit from a new prosthesis with a fluid-controlled knee unit and an energy-storing/releasing foot.
Prescription for the new patient is more difficult. Depending on the interval between amputation surgery and prescription, the amputation limb may not have stabilized in volume; the patient may not have achieved the maximum benefit from the preprosthetic program. The best criterion for prosthetic prescription in such an instance is performance with a temporary (provisional) prosthesis. As mentioned earlier, this appliance includes a well-fitting socket, suitable suspension, pylon, and foot; the transfemoral model usually has a knee unit. The temporary prosthesis allows preliminary gait and activities training. The major difference between the temporary and definitive (permanent) prosthesis is appearance. The temporary socket is designed for easy alteration to accommodate change in amputation limb volume. Ordinarily, little attention is paid to the color and exterior shape of the temporary prosthesis.
The prosthesis should be examined before the patient engages in prosthetic training and should be reexamined at the conclusion of training. The procedure is intended to determine the adequacy of prosthetic fit and function, as well as the wearer's opinion of appearance and overall satisfaction. This process typically follows a sequence of examining the prosthesis while the patient stands (static analysis), examining the patient's gait (dynamic analysis), and finally examining the prosthesis off the patient (additional static analysis). In many institutions, the physical therapist examines the prosthesis and presents a summary of findings to the clinic team. The team makes the final determination regarding the acceptability of the prosthesis.
No special materials are needed to examine the prosthesis, except for a checklist, a straight (armless) chair, a few sheets of paper, a ruler, lift blocks, and colored chalk. For final evaluation, stairs and a ramp are needed. The checklists referred to in the following sections can be found in Appendices 31.A and 31.B.
At initial evaluation, the team has three options: (1) pass, (2) provisional pass, or (3) fail. Pass indicates that no changes are needed in the prosthesis and the patient can proceed to training. Provisional pass signals that one or more minor problems require correction, none of which would interfere with training. Failure is the team's judgment that the prosthesis has a major fault that should be corrected to the team's satisfaction before commencement of prosthetic training. For example, poor finishing of the prosthetic foot merits a provisional pass, whereas a socket that abrades the amputation limb should be graded as fail. If the therapist intends to provide treatment to a patient who is not managed by a formal clinic team, it is especially critical that one examine the prosthesis before initiating instruction and training to discover any problems that would interfere with the future program. At the final evaluation, two ratings are available: pass indicates that no problems exist and the patient uses the prosthesis in a manner commensurate with that individual's physical capacity; fail means that major or minor problems remain.
Most items on the checklist in Appendix 31.A are self-explanatory. Each contributes to forming an accurate judgment of the adequacy of the prosthesis.
The prosthesis is examined while the wearer stands and sits. In addition, the amputation limb and details of the prosthesis are examined. The prosthesis should be compared with the prescription. The individual who authorized the prescription must approve departures from the original specifications.
The new wearer should stand in the parallel bars or other secure environment, attempting to bear equal weight on both feet. The therapist should solicit subjective comments about comfort. Estimates of anteroposterior and mediolateral alignment are aided by slipping a sheet of paper under various parts of the shoe. Ideally, the patient should stand with both heels and soles flat on the floor. Misalignment, indicated by excessive weight-bearing on one portion of the shoe, may be confirmed by subsequent analysis of gait.
Most prostheses are constructed so that when the individual stands, the pelvis is level;36 if the pelvis tilts, the therapist should place lifts under the foot on the shorter side to restore a level pelvis. If the total lift measures 1/2 in (1 cm) or less, no attention is needed. For greater discrepancy, one should seek causative factors. An amputation limb that sinks too far into the socket will make the prosthetic side appear short, and the wearer will probably complain of discomfort.
Piston action refers to vertical motion of the socket when the patient elevates the pelvis. Slippage can be determined by chalk marking the sock at the posterior margin of the socket, and then having the patient elevate the ipsilateral pelvis. The socket should slip less than 1/4 in (0.5 cm). Looseness, inadequate suspension, or both cause socket slippage. Socket walls should fit snugly, as should the thigh corset if it is part of the prosthesis.
Comfortable sitting is a primary need for all people. The posterior brim should not impinge into the popliteal fossa, and hamstring reliefs should be adequate, especially on the medial side where the semitendinosus and semimembranosus insert relatively distally. Placement of the tabs of the cuff or the joints of the corset also influences sitting comfort.
Analysis of the gait pattern and performance of other ambulatory activities is an essential part of rehabilitation. For most patients, a major reason for prosthetic fitting is to resume walking. Nevertheless, no prosthesis eradicates entirely the anatomical and physiological changes produced by amputation. When walking, the person who wears a prosthesis compensates for anatomical and prosthetic deficiencies.66,67,68,69,70,71 Some are inherent to amputation; others are abnormalities of the body or the prosthesis. Because virtually all people walk with a prosthesis in a manner different from the nondisabled walking pattern, prosthetic gait represents compensation for the patient's altered locomotor apparatus. The term gait compensation may be a more accurate descriptor than the more commonly used gait deviation inasmuch as the patient with amputation is most unlikely ever to walk exactly like a nondisabled person.
No prosthesis restores sensation, skeletal continuity, muscle integrity, or full body weight. Anatomical deficiencies are aggravated in the presence of pain, contracture, weakness, instability, or incoordination. Similarly, prosthetic components do not replace every function of the missing limb. For example, prosthetic feet do not move through the full excursion of the human counterpart. Inadequacies in the prosthesis compel the wearer to adopt gait compensations. Such problems include a poorly fitted socket, prosthetic misalignment, malfunctioning components, and improper height of the prosthesis. Compounding the problem are incorrect donning of the prosthesis and wearing inappropriate shoes. The physical therapist must determine when gait compensation exists and the potential causes so that remedial action may be taken. Otherwise, the patient is compelled to expend more energy walking and to exhibit a more conspicuously abnormal gait. The new wearer will have had brief experience walking in the prosthesis during the course of prosthetic fabrication. Although a smooth gait is unlikely on the day of the initial examination, gross departure from the usual gait exhibited by others with similar prostheses should be noted and causes sought.
Transtibial analysis focuses on action of the knee on the amputated side during stance phase. Both knees should flex in a controlled manner during their respective early and late stance phases. Excessive flexion of the knee on the amputated side indicates that the socket is aligned too far anterior in relation to the foot or is excessively flexed; this deviation may cause the patient to fall. If the knee flexes too much only during early stance, the cause may be a heel cushion that is too firm for that wearer. Conversely, insufficient knee flexion results from posterior displacement of the socket or inadequate socket tilt. When viewed in the frontal plane, the socket brim should maintain reasonable contact with the leg; excessive lateral thrust of the prosthetic brim suggests that the prosthetic foot has been positioned too far medially. Table 31.1 summarizes the prosthetic and anatomical causes of transtibial gait compensations/deviations.
Table 31.1Transtibial Prosthetic Gait Analysis ||Download (.pdf) Table 31.1 Transtibial Prosthetic Gait Analysis
|Compensation/Deviation ||Prosthetic Causes ||Anatomical Causes |
|Early Stance |
|1. Excessive knee flexion || |
High shoe heel
Stiff heel cushion
Socket too far anterior
Socket excessively flexed
Cuff tabs too posterior
|2. Insufficient knee flexion || |
Low shoe heel
Soft heel cushion
Socket too far posterior
Socket insufficiently flexed
|1. Lateral thrust ||Excessive foot inset || |
|2. Medial thrust ||Excessive foot outset || |
|Late Stance |
|1. Early knee flexion: also referred to as "drop off" || |
High shoe heel
Keel too short
Dorsiflexion stop too soft
Socket too far anterior
Socket excessively flexed
Cuff tabs too posterior
|Flexion contracture |
|2. Delayed knee flexion: perception of walking uphill || |
Low shoe heel
Keel too long
Dorsiflexion stop too stiff
Socket too far posterior
Socket insufficiently flexed
|Extensor spasticity |
At the initial evaluation, performance on stairs and inclines may be omitted because the patient has not had training in these activities.
Inspection of the Prosthesis Off the Patient
The posterior wall should be approximately at the same level as the build-up for the patellar ligament (tendon) when the patient stands. To check this, the prosthesis is stood upright on a table; one end of a ruler is then placed on the anterior socket bulge and the opposite end on the posterior brim. In a well-constructed prosthesis, the ruler will slant upward toward the rear, indicating that when the individual stands in the prosthesis and compresses the heel cushion, the posterior wall will be at the proper height.
The amputation limb should be examined for signs of proper loading with respect to the type of prosthesis worn. Any straps or cuff should provide reasonable adjustability. Construction is a guide to future durability, as well as contributing to acceptable appearance of the prosthesis.
A similar checklist is used to evaluate the transfemoral prosthesis (Appendix 31.B). It is important to recognize that seldom is one item of major significance. The therapist and entire team should look for patterns that might herald future difficulty. For example, misalignment detected in static analysis should be confirmed during gait.
The patient who has a flesh roll above the socket either did not don the socket properly or has a thigh that is larger than that for which the socket was made. Perineal pressure results from sharpness of the medial brim or insufficiency of the adductor longus relief in a quadrilateral socket.
The knee unit should be stable enough to withstand a blow delivered by the therapist to the posterior aspect of the unit when the patient stands. Stability is influenced by the alignment of the knee in relation to the hip and prosthetic ankle. The farther posterior the knee bolt, the more stable the knee will be. Polycentric linkage and mechanical stabilizers also contribute to stability. If the socket is opaque, the only way to judge its snugness is by palpating tissue protruding through the valve hole when the valve is removed.
The checklist is designed to help the clinician determine the fit of the socket, regardless of shape or material. If the prosthesis has a quadrilateral socket, proper location of the adductor longus tendon and ischial tuberosity ensures that the patient has donned the socket correctly. A horizontal posterior brim allows weight to be borne on the gluteal musculature as well as the ischial tuberosity. The ischial containment socket is intended to cover the ischial tuberosity, yet allows the client to move the hip in all directions comfortably, without socket gapping.
The lateral attachment of the Silesian belt should be superior and posterior to the greater trochanter for best control of prosthetic rotation. Anteriorly, the attachment should be at the level of the ischial tuberosity, or slightly below, to aid in adducting the prosthesis.
The pelvic joint and band should fit the torso snugly for optimum control of the prosthesis and to minimize bulkiness. The joint axis should be superior and anterior to the greater trochanter.
The patient should be able to sit comfortably with the prosthesis. Posterior discomfort may indicate inadequate hamstring relief, or a sharp or thick posterior brim.
Gait analysis gives the clinic team members the opportunity to determine the adequacy of socket fit and of prosthesis alignment and adjustment. The patient also influences the walking pattern by the timing and force of muscular contraction and the presence or absence of contractures. The goal of walking with a transfemoral prosthesis is a comfortable, safe, efficient gait, rather than duplicating the gait of someone wearing a transtibial prosthesis or one who does not have amputation.72 Table 31.2 summarizes the prosthetic and anatomical causes of transfemoral gait compensations/deviations.
Table 31.2Transfemoral Prosthetic Gait Analysis ||Download (.pdf) Table 31.2 Transfemoral Prosthetic Gait Analysis
|Compensation/Deviation ||Prosthetic Causes ||Anatomical Causes |
|Lateral Displacements |
|1. Abduction: stance || |
Abducted hip joint
Inadequate lateral wall adduction
Sharp or high medial wall
Adductor redundancy instability
|2. Circumduction: swing || |
Locked knee unit
Poor knee control
|Trunk Shifts |
|1. Lateral bend: stance || |
Inadequate lateral wall adduction
Sharp or high medial wall
Short amputation limb
|2. Forward flexion: stance || |
Unstable knee unit
Short walker or crutches
|3. Lordosis: stance ||Inadequate socket flexion || |
Hip flexion contracture
|1. Medial (or lateral) whip: heel off || |
Faulty socket contour
Knee bolt externally (or internally) rotated
Prosthesis donned in malrotation
|With sliding friction unit, fast pace |
|2. Foot rotation at heel contact || |
Stiff heel cushion
|Excessive Knee Motion |
|1. High heel rise: early swing || |
Slack extension aid
|2. Terminal impact: late swing || |
Taut extension aid
|Forceful hip flexion |
|Reduced Knee Motion |
|1. Vault: swing ||See above: circumduction ||With sliding friction unit, fast pace |
|2. Hip hike: swing ||See above: circumduction || |
Weak hip flexors
|Uneven Step Length || |
Insufficient socket flexion
Hip flexion contracture
Compensations/Deviations Best Viewed from Behind
Many individuals with transfemoral amputation abduct the prosthesis to improve frontal plane balance (abducted gait). Hip abduction contracture predisposes patients to this deviation, which is seen in stance phase. Inadequate socket adduction, socket looseness, or medial discomfort also causes the fault. Circumduction is a displacement exhibited in swing phase if the prosthesis is too long or if the patient is reluctant to allow the knee unit to bend. Socket looseness also may result in circumduction. The patient may shift the trunk excessively. Lateral trunk bending toward the prosthetic side during stance phase generally accompanies abducted gait. It should be noted, however, that all individuals with transfemoral amputation have an incomplete abductor mechanism, and tend to compensate by bending toward the prosthetic side, especially when fatigued. Although the anatomical hip and gluteus medius are usually in good condition, lack of skeletal continuity to the ground (imposed by the amputation) compromises the effectiveness of abductor contraction. If the prosthesis is too long, the patient will abduct; if it is too short, the patient will bend the trunk laterally.
Whips refer to medial or lateral rotation of the heel at late stance. If the socket does not fit well, contraction with bulging of the thigh musculature will cause the prosthesis to rotate abruptly as it is being unloaded at the end of stance phase. Although less likely, malrotation of the knee unit or foot-ankle assembly may contribute to whipping. Rotation of the foot on heel contact is a much more serious deviation. It indicates inadequate compression of the heel cushion or plantar bumper and can result in a fall.
Compensations/Deviations Best Viewed from the Side
Forward trunk shifting in stance phase is a compensation that some patients use to cope with knee instability. If the walker or crutches are too short, the individual will lean forward. Lumbar lordosis results from inadequate socket flexion and is aggravated by a hip flexion contracture.
Improper adjustment of the knee unit gives rise to uneven heel rise (excessive knee flexion) and terminal swing impact (abrupt knee extension). If both deviations are present, the probable cause is insufficient friction. If the knee exhibits impact without undue heel rise, it is more likely that the extension aid is too tight.
To compensate for reduced knee motion, the vigorous walker may demonstrate vaulting by excessively plantarflexing the sound ankle to afford extra room to clear the prosthesis during prosthetic swing phase. A less strenuous compensation for excessive actual or functional prosthesis length is hip hiking, when the patient elevates the pelvis on the prosthetic side.
Unequal step length will be evident if the patient has a hip flexion contracture or inadequate balance. A longer step taken with the prosthesis gives the person more time on the sound limb. A flexion contracture or insufficient socket flexion (limiting hip extension range) prevents the sound limb from passing the prosthetic side during swing phase on the sound side (i.e., shorter step length on the sound side).
Inspection of the Prosthesis Off the Patient
Following the static evaluation, the therapist should examine the prosthesis and amputation limb as indicated on the checklist. A resilient back pad (placed externally on the posterior wall) enables the patient to sit quietly without undue trouser or skirt abrasion. The pad is unnecessary with a flexible socket.
Facilitating Prosthetic Acceptance
Amputation generally is regarded as a grievous occurrence, with its visibility a constant reminder of the individual's abnormality. The physical therapist can help the patient and family accept the reality of amputation and the prosthesis by verbal and nonverbal communication. One's calm respect for the patient as a worthy human being, regardless of limb condition, should set a model for the attitudes of others. Clinic team management accords not only the benefits of better prosthetic provision but also brings the individual in contact with clinicians who convey experience and confidence in dealing with problems that the person may have considered unique.
As soon as possible, the hospitalized patient should be treated in the physical therapy department, rather than at bedside. The bustle of the department should help dispel despondency. Although postoperative mourning is expected, prolonged depression is not constructive. Peer support groups are often very effective in aiding acceptance of the prosthesis and in learning special procedures for accomplishing activities. Observation and eventual participation in specially designed sports programs is another way people learn to cope and gain the most from rehabilitation. The physical therapist, by virtue of close daily contact with the patient, is also in a position to recommend to the clinic those who might profit from psychological counseling or psychiatric services, particularly when pain is an issue. Appendix 31.C provides website-based prosthetic resources for clinicians, families, and patients.
Learning to use a prosthesis effectively involves being able to don it correctly, develop good balance and coordination, walk in a safe and reasonably symmetrical manner, and perform other ambulatory and self-care activities. Anticipated goals and expected outcomes depend on the patient's physical and psychological status, preprosthetic experience, and quality of prosthesis. Using the prosthesis only to assist in transferring from the wheelchair to the toilet may be an appropriate outcome for an elderly person with multiple disabilities, whereas the program for the youngster with traumatic amputation might extend to a full range of sports.
Correct application of the prosthesis and frequent inspection of the amputation limb are very important, especially for the beginner and those with poor circulation. Patients with partial foot, Syme's, and transtibial amputations can don the prosthesis while seated, after having applied the correct number and sequence of socks or sheath. Then, in most instances, the individual simply inserts the amputation limb into the socket. With SC/SP suspension, one applies the liner to the amputation limb, then inserts the limb and liner into the socket. The initial entry into the socket with corset suspension may be made while sitting; however, final tightening of laces or straps should be done in the standing position to ensure that the limb is lodged suitably in the socket.
Those with transfemoral amputation also can begin the donning process while seated. Total suction wearers may use either a pulling or pushing method. To pull oneself into the socket, the patient applies a light dusting of talcum powder to the thigh to reduce friction. Then one applies a pulling sock, a tubular cotton stockinet approximately 30 in (76 cm) long, a roll of elastic bandage wound around the thigh, or a nylon stocking. Whatever the donning aid, it should be placed high in the groin to pull in proximal tissues. After placing the sock-encased thigh into the socket, one draws the distal end of the aid through the valve hole. Although it is possible to complete the donning process while seated, most people prefer to stand while pulling the sock or other aid out through the valve hole. By leaning forward, the body's weight line will prevent the prosthetic knee from flexing inadvertently. The patient alternately flexes and extends the sound hip and knee while tugging downward on the donning aid until it slips out from the prosthesis. Finally, one inserts the valve. Another approach to donning is to coat the thigh with lubricating lotion, push it into the socket, and then install the valve.
Patients who use partial suction apply a sock, making certain the proximal margin of the sock extends to the inguinal ligament. The patient then introduces the amputation limb into the socket, taking care that the thigh is correctly oriented; pulls the distal end of the sock down through the valve hole enough to ensure that the skin is smooth; tucks the sock back into the socket; and inserts the valve. Finally, one secures the pelvic band or Silesian belt. If suction is not used, donning is similar to the method used with partial suction, except that there is no valve.
Exercises are similar for all patients with LE amputations, although the individual with a transfemoral or hip disarticulation prosthesis may be expected to encounter more difficulty controlling the mechanical knee, as compared to those with two anatomical knees. All must learn to balance on the amputated side.73,74,75,76,77 A graduated program for increasing prosthetic tolerance minimizes the danger of skin abrasion, particularly if the amputation limb presents skin grafts, poor circulation, or diminished sensation. The patient should alternately exercise and rest, with cardiopulmonary monitoring a routine part of the program, especially for high-risk individuals.
Some clinicians eschew parallel bars because the fearful patient pulls on them, which will be fruitless when progressing to a cane. When bars are used, the therapist should encourage the patient to rest the open hand on the bar for support, rather than using a viselike grip. A plinth or sturdy table offers the dual advantages of providing good support on only one side, ordinarily the contralateral side, and unidirectional control, because the patient can only push, never pull, for balance.
Static erect balance reintroduces the novice to bipedal posture. The patient should strive for level pelvis and shoulders, vertical trunk without excessive lordosis, and equal weight-bearing. The therapist should guard and assist the patient as necessary. When the physical therapist stands near the prosthesis, this encourages the patient to shift his or her weight onto it. To suggest symmetrical performance, refer to the limbs as "right" and "left," or "sound" and "prosthetic," rather than discouraging the patient with "good" and "bad." The client must learn to use proximal sensory receptors to maintain balance and perceive the position of the prosthesis without looking at the floor. Some patients respond well to increased use of visual feedback (e.g., using a mirror).
Dynamic exercises improve medial–lateral, sagittal, and rotary control. The patient learns that hip flexion causes the knee to bend, and hip extension stabilizes the knee during stance phase. Placing the sound foot ahead of the prosthesis makes the prosthetic knee more stable. Patients should be instructed in weight shifting in both symmetrical and stride positions and in stepping movements. Stepping on a low stool or step platform with the sound foot obliges the patient to shift weight onto the prosthesis and increases stance phase duration on the prosthesis. Having all exercises performed rhythmically with both the right and left LEs fosters symmetrical performance.
Walking is a natural progression from dynamic balance exercises as the patient takes successive steps. Patients tend to place greater load and exert more propulsive force on the intact side; consequently, gait training should emphasize symmetrical performance.67,68,69,70,71,72,73 Inas much as hamstrings become the main muscles of propulsion, strengthening exercises are indicated. Some people respond well to proprioceptive neuromuscular facilitation.74 Rhythmic counting and walking in time with music in 2/4 time also improves gait symmetry and speed. In the physical therapy department, an apparatus that includes a suspension harness (partial body weight support) provides a protected environment for the patient to learn gradual weight-bearing on the prosthesis. A balance apparatus (e.g., Balance Master®) providing electronic feedback with or without emphasis on psychological awareness of bodily position is another training option.
Either a cane or pair of forearm crutches is an appropriate aid for the client who is unable to achieve a safe gait without undue fatigue. Sometimes the cane is used only outdoors to aid in negotiating curbs and other ground irregularities and to signal oncoming traffic. Ordinarily the cane is used on the contralateral side to enhance frontal plane balance. If bilateral assistance is required, a pair of forearm crutches is preferable to two canes. The crutches remain clasped around the forearms when the user opens a door. Axillary crutches tempt the patient to lean on the axillary bars, risking impingement of the radial nerves; they are also inconvenient when climbing stairs. An aluminum walker provides maximum stability, which is particularly useful for patients with generalized weakness. The walker should be adjusted so that the user does not lean too far forward.
Patients with transtibial amputation walk faster with a two-wheeled walker as compared with a four-footed walker.75 Fear of falling can undermine walking and social activity participation. Improving the patient's balance confidence is essential to lessen this concern.76,77
The prosthesis wearer who is learning to walk also should gain experience in performing a wide variety of functional mobility skills. Activities such as transferring to various chairs add interest to the program and, for some patients, may be more important than long-distance ambulation.
The training program for vigorous individuals includes stair climbing, negotiating ramps, retrieving objects from the floor, kneeling, sitting on the floor, running, driving a car, and engaging in sports. The fundamental difference between these activities and walking is the way each LE is used. Walking implies symmetrical usage, but the other activities are done asymmetrically, with greater reliance on the strength, agility, and sensory control of the sound limb.
Generally, the patient should have the opportunity to analyze each new situation and arrive at a solution to the problem, rather than depending on directions from the therapist. Most tasks can be accomplished safely in several ways. The learner profits from practice in clinical decision making and observing other prosthesis wearers as well as from professional instruction.
Rising from different chairs, the toilet, and car are primary skills even for people who are elderly or debilitated. Most patients enter the physical therapy department in a wheelchair. Initially, the patient can park the chair at the parallel bars or at a plinth. After locking the wheelchair and raising the footrests, the patient should sit forward and transfer weight to the intact leg, then push down on the armrests. The individual will find that placing the sound foot close to the chair enables rising by extending the knee and hip on the sound side. Sitting is accomplished by placing the sound foot close to the chair and lowering oneself by controlled hip and knee flexion on the sound side.
For both standing and sitting, the beginner should have the advantage of a chair with armrests that enables use of the hands to control and assist trunk movement. Later the person should practice sitting in deep upholstered sofas and low chairs, as well as benches, the toilet, and other seats that do not have armrests. Transfer into an automobile should be an integral part of the training activities; otherwise, the patient faces a gloomy future, confined to home or dependent on special transportation systems. To enter the right (passenger) side of an automobile, the prosthetic wearer faces toward the front of the car. The person with a right prosthesis puts the right hand on the door post and the left hand on the back of the front seat, then swings the left leg into the car, slides onto the car seat, and finally places the prosthesis in the car. The individual with a left prosthesis may find that sitting sideways with both feet out the car door is easiest. One then pivots on the seat while swinging the prosthesis into the car, then puts the intact right foot inside the car.
Climbing Stairs, Ramps, and Curbs
Patients with Syme's and transtibial amputations generally ascend and descend stairs and inclines with steps of equal length in step-over-step progression.78,79,80 Those with unilateral transfemoral amputation, in contrast, usually ascend by leading with the sound foot and learn to descend by first placing the prosthesis on the lower step. A few individuals with transfemoral amputation subsequently learn to control prosthetic knee flexion in order to descend step-over-step. Those fitted with the Power Knee® may be able to ascend stairs step-over-step.
Curbs present a slightly different problem, because there is no handrail. The techniques are basically the same, however.
Ramps may be difficult if the prosthetic foot does not have sufficient anteroposterior excursion.81,82 With steep stairs, ramps, and curbs, the individual may climb diagonally or sidestep with the prosthesis kept on the downhill side. Patients should also learn how to maneuver over obstacles on the walking surface.83
Final Evaluation and Follow-up Care
Economic strictures may compel the therapist to conclude the training program after the patient is able to walk and to negotiate basic transfers and stair climbing but before the full range of training activities is completed. Before discharge, the patient and prosthesis should be reexamined to make certain that socket fit, prosthetic appearance, and function are acceptable. The checklist used for initial evaluation can be used. The physical therapist should instruct the patient with regard to the patient's responsibility for reporting skin redness and any loose or missing parts from the prosthesis.
The new prosthesis wearer should return to the training site at regular intervals so that the clinic team may examine socket fit. Most will require major socket revision or replacement during the first year to accommodate amputation limb volume reduction. Follow-up visits are good opportunities to augment training and to encourage the individual to engage in the widest possible range of activities.
Functional capacities refer to the individual's ability to walk, transfer from chairs, climb stairs, and perform other ambulatory activities, including recreational endeavors. A primary responsibility of the clinic team is to predict the probable function of the person with a new amputation, to determine whether the individual would benefit from a prosthesis, and what degree of activity is likely. Because many people with LE amputation are elderly with several medical problems, the need for accurate forecasting and ongoing monitoring is especially critical.
Walking with a prosthesis increases energy cost.84,85,86,87,88 Compared with those people with two sound limbs, the individual with a unilateral transtibial prosthesis requires slightly more oxygen when walking at a comfortable speed;89,90 the person wearing a transfemoral prosthesis consumes nearly 50% more oxygen than normal,91 al though selection of prosthetic feet and knee units usually modifies the energy demand.92,93,94,95 The prosthesis wearer chooses a comfortable pace, because at a speed that is natural for the individual, the energy cost per minute is similar to that of the person who does not require a prosthesis, although speed is slower. The lower the amputation level, the less the metabolic disadvantage. Among persons with transtibial amputations older than 40, those with long amputation limbs average minimal increase in energy, but persons with shorter limbs work harder. Those with bilateral transtibial amputations expend less energy than those with unilateral transfemoral amputations. Individuals whose amputation was traumatic perform more efficiently than those whose amputation was caused by vascular disease at every amputation level. People who sustained trauma walk faster and use less oxygen than their dysvascular counterparts.
The increased metabolic expenditure results in part from the socket, which surrounds semifluid tissue, giving imperfect anchorage imposing challenges to limb control. The foot-ankle assembly transmits no plantar tactile or proprioceptive sensation, does not move through as large an excursion as the anatomical foot, and does not initiate the dynamic propulsion characteristic of normal gait. The transfemoral prosthesis also incorporates a knee unit that provides no proprioception to the wearer. The problem is aggravated by the fact that a prosthesis is operated by remotely located muscles that contract longer and more forcefully than in normal gait. With transfemoral amputation, for example, the wearer positions the prosthetic foot by hip motion. The resulting alteration of motion is reflected in asymmetry of timing, further disturbing gait smoothness. Individuals with prostheses walk with greater vertical movement, inasmuch as the knee, whether mechanical for the transfemoral prosthesis wearer or anatomical in the transtibial wearer, does not flex as much as the contralateral knee during stance phase.
Use of a hip disarticulation prosthesis demands considerable energy expenditure.96
People wearing bilateral prostheses consume even more oxygen and walk more slowly than those with unilateral amputation at a given level.97
With the exception of patients on beta-blockers, heart rate response is an important indication of the metabolic cost of prosthetic use for most individuals. Overall, strength, balance ability, etiology of amputation, and level of amputation predict the extent of impairment.98
Other measures of functional capacities include utilization of prostheses99,100,101,102 and quality-of-life surveys.103,104,105,106,107,108,109,110,111,112,113,114,115,116 Return to work117,118 and ability to drive an automobile119,120 are other indicators of rehabilitation success.
Sports participation (Fig. 31.36) is an excellent extension of rehabilitation for patients of all ages.121,122,123,124,125,126,127,128,129,130,131,132,133,134 Older adults may enjoy fishing, golfing, dancing, Tai Chi Chuan, and shuffleboard, and younger people may add basketball, tennis, archery, and track events to their range of activities. Most sports do not require any adaptation to the prosthesis. Horseback riding is a superb activity that fosters trunk control and seated balance. The hiker should pack extra amputation limb socks or a sheath to protect the skin; a well-fitting, comfortable hiking boot is essential. Bowling and participating in shot put are facilitated by emphasizing balance on the intact LE. For sports that involve running, an energy-storing/releasing foot is most suitable. The socket should fit snugly with very secure suspension to minimize abrasion of the amputation limb. Clients with Syme's or transtibial amputations usually run with reasonably symmetrical step lengths, although they will favor the sound limb, which has greater propulsive ability.7 Those with a knee disarticulation or transfemoral amputation will derive most of the propulsive force from the sound leg and use the prosthesis as a momentary prop. Many marathon competitions have a category for people with disabilities. Jumping, as in basketball, requires the athlete to generate a substantial upward force with the sound leg; landing is more comfortable on the sound leg, particularly for those who wear transfemoral prostheses. Some activities are facilitated by minor modification of the equipment, such as a toe loop on a bicycle pedal or an adapted prosthesis.
Participants in a distance run (left) and long jump (right) event. Courtesy of Ossur, Aliso Viejo, CA 92656.
Other activities are generally performed without a prosthesis, such as swimming and skiing. The skier will probably use ski poles equipped with small rudders, in a "three-track" manner. Soccer is usually played without a prosthesis, with the player using a pair of crutches. Some individuals enjoy playing tennis and field events in a wheelchair. Equipment and techniques developed for individuals with paraplegia usually can be adapted for people with amputations.
Recreational programs designed for adults with amputations help the participants to return to active lifestyles. The physical therapist should be able to refer patients to convenient recreational clubs and sporting events. The desired outcome is to maximize each person's functional capacity and quality of life.