Amputee Rehabilitation

Introduction

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

Overview of the rehabilitation process

The rehabilitation process of the lower limb amputee consists of nine phases [5], namely:

  1. pre-operative
  2. amputation surgery
  3. acute post-surgical
  4. pre-prosthetic
  5. prosthetic prescription
  6. prosthetic training
  7. community integration
  8. vocational rehabilitation and
  9. follow up.


Table 1: Phases of amputee rehabilitation: Modified from Esquenazi & Meier[6]cited in Esquenazi[5].

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


Throughout all of these phases, a rehabilitation treatment plan is utilised to guide the care of an individual who has undergone an amputation. The treatment plan is based on evaluation by all specialties involved in the rehabilitation process and acts as a guide for all team members to address goals important to the patient and family. The level of rehabilitation intervention is contemplated from the date of admission to the hospital and determined after the amputation surgery and prior to discharge from the hospital. The rehabilitative process includes:

  • Ongoing medical assessment of impairments, and
  • Therapy interventions to address disabilities or activity limitation

Below we define this more detailed team-focused rehabilitation process in 8 phases:



Patient Journey The team management Physiotherapy management
1. Pre-operative

Subjective assessment - History of present condition; Past medical history; Drug history; Social History.

Objective assessment - Range of movement (ROM); Muscle power; Limb for amputation; Pulses; Skin integrity.

Collaborating all findings to decide on most appropriate level of amputation for the individual and, if they are likely to become a limb wearer, which level of amputation would be most appropriate.

Focus is on the objective assessment looking at ROM and muscle power. Using assessment findings, knowledge of prosthetic componentry and gait patterns, provide a clinically reasoned recommended level of amputation to the consultant. Provide patient with appropriate exercises to aid post-amputation mobility.

2. Amputation surgery/reconstruction

Amputation surgery and reconstruction is the responsibility of the surgeon.


3. Acute post-operative

Medical care; Wound care; Discharge planning; Rigid dressing used rigid material such as plaster of Paris applied immediately after surgery and kept in place for 5-7 days (only for below knee and below elbow).

Post-operative chest physiotherapy. Transfer practice, and specific exercises to improve strength; increase exercise tolerance; maintain ROM.

4.  Pre-prosthetic rehabilitation

Monitoring patient progress; counselling if required; Patient goals; deciding on prosthetic prescription with whole team and all appropriate information [including how the patient has managed with Early walking aids (EWA) and patient goals ]

Early walking aids (EWA) can be used to help decide on a patient’s suitability for a prosthetic limb.

Exercise therapy to prepare the limb for a prosthesis.

Liaison with the whole team regarding pre-fitting management of the amputee.

5. Prosthetic prescription

Casting and measuring - Prosthetists cast and measure a patient’s residuum.

Fitting of the prosthesis - Prosthetists fit the primary prosthesis to the patient, ensuring the alignment and length are correct in a standing and walking.

Physiotherapist may be needed to assist in the cast appointment, to ensure a neutral alignment of the pelvis is obtained.

Physiotherapy provides intervention on mobility guidance, static balance and weight bearing.


6. Prosthetic Training

Prosthetists will help problem solve and adjust prosthesis as required.


The physiotherapist takes a lead role at this stage. Beginning with educating the patient about donning and doffing the prosthesis, skin integrity and weight bearing areas on their residuum.

A gait rehabilitation programme can then commence.

7 Discharge Management


The occupational therapists take a large role in this phase to aid the resumption of roles in family, recreational and community activities.

They will also assist with vocational rehabilitation by assessing and planning vocational activities for the future. May need further education, training or job modification.

Counsellers will be involved with emotional equilibrium and healthy coping strategies.


The physiotherapist should ensure that they include education for ongoing management, strategies for coping and training for resumption of functional activities.

8. Follow up

Patient will be reviewed regularly by the consultant the physiotherapist, and the prosthetic team.

Assessing the individual is still suitable for prosthetic use, the prosthetic prescription is still the most appropriate option for the patient and any required changes are made to the prosthesis as the patient changes.

The consultant and/or prosthetist may ask for physiotherapy input. For example, if the patient is having a change of prescription, their goals have changed, their mobility has decreased/increased. The physiotherapist may be required to re-commence a gait rehabilitation programme with the patient or advice only may be required.


Resources

Rehabilitation in limb deficiency. 4. Limb amputation, Alberto Esquenazi and Robert H. Meier III, MD, 1996

References

  1. Dillingham TD , Pezzin LE. Rehabilitation setting and associated mortality and medical stability among persons with amputations. Archives of Physical and Medical Rehabilitation 2008; 89; 1038-1045.
  2. World Health Organisation (WHO). International classification of functioning disability and health (ICF). World Health Organisation 2001. Geneva.
  3. Lusardi MM, Postoperative and preprosthetic care. In Lusardi, MM, Jorge, M Nielsen, CC editors. Orthotics and Prosthetics in Rehabilitation, Third Edition. Missouri: Elsevier, 2013.p. 532-594.
  4. Kaplan SL, Outcome measurement and management: First steps for the practicing clinician. Philadelphia, FA Davis Company, 2007.
  5. 5.0 5.1 Esquenazi A. Amputation rehabilitation and prosthetic restoration: from surgery to community reintegration. Disability and Rehabilitation, 2004; 26,(14/15); 831–6.
  6. Esquenazi A, Meier RH. Rehabilitation in limb deficiency. 4. Limb amputation. Arch Phys Med Rehabil. 1996 Mar;77(3 Suppl):S18-28.