Post-fitting management of the amputee

Introduction

The physiotherapy post-fitting management is essential to achieve the functional independence of the amputee. By improving the functional and cardio-respiratory capacity of the individual it is possible to enhance the prosthetic use. The patients’ social situation, psychological status, goals and expectations should be documented and taken into consideration when planning the amputee post-fitting[1].

Like in other stages of the rehabilitation process, the physiotherapist is included in a multi-disciplinary team. The post-fitting management is part of the physiotherapy intervention, that needs to be a continuous process, regarding the objectives established in the previous pre-prosthetic phase [2].    

The stage of intervention should include an initial assessment, exercise program appropriate to patient goals and according with the prosthetic choice made for the patient. A person with an amputation, in the prosthetic phase, can continue to improve greatly if he is taught about the major goals of the post-fitting stage. Physiotherapy treatment should include strategies for

  • range of motion,
  • strength, 
  • balance,
  • coordination,
  • agility and
  • endurance.

It must adjust the rehabilitation interventions to improve the patient’s physical and functional status. The Physiotherapist should teach and encourage the amputee to perform an exercise plan than can contribute to enhance all physical demands required for the prosthetic use. All exercises and treatment strategies should include efficient control of the prosthesis through postural control, weight transference, use of proprioception and specific muscle strengthening and stretching exercises to prevent and correct gait deviations[2]

A rapid prosthetic rehabilitation of the lower limb amputee ensures the best results in returning to an active, independent life-style[3][4][5][6][7][8][9].    

Range of Motion 

A functional assessment of gross upper-limb and sound lower-limb motions should be made. A measurement of the residual limb's range of motion (ROM) should be recorded with a standard goniometer for future reference. Joint contractures are complications that can greatly hinder the amputee's ability to ambulate efficiently with a prosthesis; thus extra care should be taken to avoid them. The most common contracture for the transfemoral amputee is hip flexion, external rotation, and abduction, while knee flexion is the most frequently seen contracture for the transtibial amputee. During the ROM assessment the therapist should determine whether the patient has a fixed contracture or just soft-tissue tightness from immobility that can be corrected within a short period of time. This may affect the manner in which the prosthesis is manufactured [10].    

Keypoints: 

Continuously monitor and maximize the range of motion to enhance postoperative outcomes[11].  

Evaluate:

  • Hip flexion
  • Knee flexion
  • Lumbar spine flexion and extension
  • Cervical spine ROM
  • Shoulder ROM
  • Rotator cuff monitoring
  • Consider Thomas test
  • Flexion contractures
  • Effects on gait
  • Osteoarthritis development
  • Ability to see ground, survey surroundings 

Catch deficits early.

The residual limb should always be properly positioned to avoid contractures that could interfere with future prosthetic fit and ambulation[10][11]. In a transtibial amputation, the residual limb should be placed in knee extension when in bed. For a transfemoral or transtibial amputation, the residual limb should be kept in neutral alignment for adduction/abduction and internal/external rotation.At no time should a pillow be placed under the residual limb. A stretching muscle program must be implemented. A prone lying program should be initiated with all patients who have a lower extremity amputation to avoid hip flexion contractures. Progressively advance the length of time from the patient’s tolerance to 30 minutes twice per day if possible.

Strength 

Throughout the continuum of care, assess and improve the strength of all muscle groups, a positive impact will arise with the use of a prosthesis and overall functional capacity[10][11].

The physiotherapist should prescribe a personalised programme incorporating specific muscle strengthening and stretching exercises to maintain and improve joint mobility[12][13][14][15][16].    

This program should also be initiated for the major muscle groups of the upper extremities, trunk, core stability, residual and contralateral limbs in order to maximize functional use of prosthesis and prevent the development of comorbidities such as low back pain[17].   

Functional strength of the major muscle groups are usually assessed by manual muscle testing of all limbs including the residual limb and the trunk. However if a isokinetic device is available the muscle evaluation should be made to provide exact and reliable monitoring of strength, even at very limited ranges of muscular potential[14].  This will help determine the patient's potential skill level to perform activities such as transfers, wheelchair management, and ambulation with and without the prosthesis.

Keypoints:

Progressive resistance exercise strengthening program for all extremities[18] must include:

  • rotator cuff
  • elbow extension
  • trunk
  • hip extensors
  • hip adductors
  • hip abductors
  • abdominal musculature
  • back musculature
  • knee extensors
  • residual and contralateral limbs
  • bilateral open and closed-chain exercises.

A home exercise strengthening program should be designed and tailored to a patient’s individual needs for use on a long-term basis[15][16].

Balance and Coordination

Postural stability is essential to the performance of most daily activities and is necessary to lead an independent life. Early phase balance exercise is effective in controlling balance of unilateral lower limb amputees[19].

Gait and balance impairments may increase the risk of falls, the leading cause of accidental death. Sitting and standing balance are of major concern when assessing the amputee's ability to maintain the center of gravity over the base of support, and should be evaluated throughout the entire rehabilitation process[11].

Coordination assists with ease of movement and the refinement of motor skills. Both balance and coordination are required for weight shifting from one limb to another, thus improving the potential for an optimal gait. The dynamic balance control provides, in addition to weight distribution, information to what extent the stabilizing mechanism of the corrective ankle torque of both legs and contributes to balance control. Knowledge of the stiffness properties may optimize the prescription process of prosthetic foot in lower leg amputee subjects in relation to standing stability[20]

Keypoints:

Initiate, measure, and adjust a balance re-training program to minimize a patient’s risk of falling and increase the efficiency of gait[11], both with and without a prosthesis. Interventions should start with simple tasks and progress to more complex dynamic balance training:

  • sitting balance
  • sitting weight shifts
  • sit to stand
  • supported standing
  • single-limb balance [21] 
  • weight shifting on a soft surface,
  • weight shifting on a rocker board,
  • weight shifting on a ball rolling under the sound foot,
  • step-ups,
  • lunges.

Some of these more advanced balance activities should be used to equalize weight over bilateral lower extremities, when the patient is own prosthesis or wearing medical devices like Pneumatic Post-Amputation Mobility Aid (PPAM Aid), or Femurett[10][11]. This can be controlled during all stages of the rehabilitation process with a standard balance weighing.

Endurance 

For lower limb amputees the energy consumption required to walk with a prosthesis is very much higher than that required for the able-bodied[22]. The higher the level of amputation, the greater the energy consumption demands. Therefore the burden on the cardio-respiratory system of amputees can be expected to be considerably high. Advances in prosthetics in recent years, such as weight reduction of prosthesis and the “Intelligent Prosthesis”[23], have brought about a reduction in the energy consumption required for walking with a prosthesis. If, in addition, it is possible to improve the physical fitness of the amputee[24], a relative reduction in energy consumption can be expected with a reduction of the burden on the cardio-respiratory system of the amputee. During the initial chart review, the physiotherapist should make note of any history of coronary artery disease, congestive heart failure, peripheral vascular disease, arteriosclerosis, hypertension, angina, arrhythmias, dyspnea, angioplasty, myocardial infarction, arterial bypass surgery, as well as prescribed cardiovascular medications that may affect the blood pressure and heart rate. The heart rate and blood pressure of every patient should be closely monitored during initial training and thereafter as the intensity of training increases. If the amputee experiences persistent symptoms such as shortness of breath, pallor, diaphoresis, chest pain, headache, or peripheral edema, further medical evaluation is strongly recommended. Consultation to a cardiac rehabilitation program should be considered, particularly in patients with known cardiopulmonary disease or dysvascular amputation[10][11]

Keypoints: 

  • Increase cardiovascular fitness and endurance to maximize the efficiency of gait, both with or without a prosthesis. A tailored cardiovascular training program should be initiated as soon as possible in the postoperative phase and continue throughout the rehabilitation process. Maintain cardiac safety precautions, such as, persistent symptoms.
  • Encourage reducing risk factors, such as smoking and heavy drinking. The cardiovascular program should include upper body ergometry regardless of the ability to use a lower extremity prosthesis.
  • Gait training should progress from use of an appropriate assistive device and increase to community distances as cardiovascular fitness improves.
  • Higher level sporting activities should be pursued to supplement routine cardiovascular fitness in younger individuals with traumatic amputation.

Activities of daily living 

The aim of Prosthetic Rehabilitation is to enable the patient to achieve maximum functional independence, taking into account the patient’s pre-amputation lifestyle, their expectations and limitations[25].  Therefore, rehabilitation should be functional and integrated with activities of daily living[2]

Interventions to improve functional activities of daily living (ADL) should be initiated, measured [26] and adjusted as needed during the postoperative phases. 

Functional training to maximise independence in everyday activities including self-care like dressing, feeding, grooming, bathing, and toileting, with and without a prosthesis, and domestic recreational and community based activities also need to be addressed in the prosthetic phase[27][28][29].

The Physiotherapist should instruct the patient in a range of functional tasks relevant to the goals specific for that individual[2][10][11]. These may include:

  • sit to stand
  • bed to chair
  • chair to toilet
  • chair to tub
  • obstacle crossing
  • getting in and out of a car
  • going up and down stairs, kerbs, ramps and slopes
  • walking in a crowded environment
  • carrying an object whilst walking
  • walking over uneven ground outdoors
  • changing speed and direction
  • picking up objects from the floor
  • floor transfers
  • opening and closing a door
  • the use of public transport
  • the use of escalators

It is important for the person to remain as active as possible to prevent deconditioning and to improve functional capacity[27]. Rehabilitation should be functional and integrated with activities of daily living, deemed by the Physiotherapist according with the patient’s physical ability to safely undertake the tasks[2]

Activities should be taught, observed and eventually corrected. There should be a progressive raise in the difficulty of the activities performed by the amputee[30]

Prosthetic users should be encouraged start again their hobbies, sports, social activities and driving[2].

Social and leisure integration 

The physiotherapist should include the family has part of this process. Resumption of family and community roles is essential; regaining emotional equilibrium and trying to develop healthy coping strategies through recreational activities[25]

Patients should be encouraged to return to their usual activities if possible, for eg. sports and leisure/recreacional activities. They will have the utility to work as an exercise therapy and all also help to contribute to the psychosocial well-being of the amputee[30][31]

Return to work

The return to work is important to the successful reintegration of the amputee. The physiotherapy has the role to advice the amputee so that this return to work takes place gradually, with time and workload increasing over time. Any doubts or work changes should be advised or made. Return to work when this is safe and possible is advisable and is one important step to allow the full integration of the amputee[32]

Sensation

Evaluation of the amputee's sensation, with a Semmes-Weinstein sensitivity test kit, is useful to both the patient and physiotherapist alike. The physiotherapist can gain insight into the possible insensitivity of the residual limb and/or sound limb. This may affect proprioceptive feedback for balance and single-limb stance, which in turn can lead to gait difficulties. The patient must be made aware that decreased pain, temperature, and light touch sensation can increase the potential for injury and tissue breakdown[15].

Resources

References

  1. World Health Organization (2004). A Manual for the Rehabilitation of People with Limb Amputation. United States Department of Defense. Moss Rehab Amputee Rehabilitation Program. Moss Rehab Hospital, USA.
  2. 2.0 2.1 2.2 2.3 2.4 2.5 Broomhead P, Clark K, Dawes D, Hale C, Lambert A, Quinlivan D, Randell T, Shepherd R, Withpetersen J. (2012) Evidence Based Clinical Guidelines for the Managements of Adults with Lower Limb Prostheses, 2nd Edition. Chartered Society of Physiotherapy: London.
  3. Bowker HK, Michael JW (eds): Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles. Rosemont, IL, American Academy of Orthopedic Surgeons, edition 2, 1992, (reprinted 2002)
  4. Dingwell, JB, Davis, BL (1996) Use of an instrumented treadmill for real time gait symmetry evaluation and feedback in normal and trans tibial amputee subjects. Prosthet. Orthot. Int. 20: 101-110
  5. Geurts, AC, et al. (1991) Dual-task assessment of reorganization of postural control in persons with lower limb amputation. Arch Phys Med Rehabil, 72(13): 1059-64.
  6. Quinlivan, DH (1994) Weight distribution in below knee amputees. ISPO Conference Blackpool.
  7. James, U (1973) Effect of physical training in healthy male unilateral above knee amputees. Scand J Rehabil Med,. 5: 88-101
  8. Wolf, E, et al. (1989) Prosthetic Rehabilitation of elderly bilateral amputees. Int J Rehabil Res. 12(3): 271-78.
  9. Sapp, L and CE Little (1995) Functional outcomes in a lower limb amputee population. Prosthet Orthot Int. 19: 92-96.
  10. 10.0 10.1 10.2 10.3 10.4 10.5 Geertzen, J. et al. Dutch evidence-based guidelines for amputation and prosthetics of the lower extremity: Amputation surgery and postoperative management. Part 1. Prosthet Orthot Int. 2014 Jul 24.
  11. 11.0 11.1 11.2 11.3 11.4 11.5 11.6 11.7 VA/DoD Clinical Practice Guideline for Rehabilitation of Lower Limb Amputation, Department of Veterans Affair, Department of Defence, January 2008.
  12. Seroussi, RE, et al. (1996) Mechanical work adaptations of above-knee amputee ambulation. Arch Phys Med Rehabil,. 77(11): 1209-14.
  13. Barnett C, Vanicek N, Ploman R, Hancock A, Brown B, Smith L, Chetter I (2009) Kinematic gait adaptations in unilateral transtibial amputees during rehabilitation. P&O Int. 33(2); 135-147
  14. 14.0 14.1 Moirenfeld I, et al, (2000) Isokinetic strength and endurance of the knee extensors and flexors in trans-tibial amputees. Prosthet Orthot Int, 24:221-225
  15. 15.0 15.1 15.2 British Association of Chartered Physiotherapists in Amputee Rehabilitation (BACPAR). (2006). Clinical Guidelines for the Pre and Pos Operative Physiotherapy Management of Adults with Lower Limb Amputation.
  16. 16.0 16.1 British Association of Chartered Physiotherapists in Amputee Rehabilitation (BACPAR). (2012). Evidence Based Clinical Guidelines for the Physiotherapy Management of Adults with Lower Limb Prostheses.
  17. Gailey R AK, Castles J, Kucharik J, Roeder M,. Review of secondary physical conditions associated with lower-limb amputation and long-term prosthesis use. J Rehabil Res Dev. 2008;45(1):15-29.
  18. Nadollek H., Brauner S & Isles R. (2002). Outcomes After Trans-tibial Amputation: the Relationship Between Quiet Stance Ability, Strength of Hip Abductor Muscles and Gait. Physiotherapy Research International, 7(4): 203–fckLR214.
  19. Sethy D., Kujur E. S. & Sal K. (2009). Effect of Balance Exercise on Balance Control in Unilateral Lower Limb Amputees. The Indian Journal of Occupational Therapy. XLI (3): 63-68.
  20. Nederhand MJ, Van Asseldonk EH, van der Kooij H, Rietman HS. Dynamic Balance Control (DBC) in lower leg amputee subjects; contribution of the regulatory activity of the prosthesis side. Clin Biomech (Bristol, Avon). 2012 Jan;27(1):40-5.
  21. Bohannon (1994) One-legged Balance Test Times. Perceptual and Motor Skills: Volume 78, Issue , pp. 801-802.
  22. Waters RL, Perry J, Antonelli D, Hislop H. Energy cost of walking of amputees: the influence of level of amputation. J Bone Joint Surg 1976;58:42–6.
  23. Bukley JG, Spence WD, Solomonidis SE. Energy cost of walking: comparison of “Intelligent Prosthesis” with conventional mechanism. Arch Phys Med Rehabil 1997;78:330–3.
  24. Chin T, Sawamura S, Fujita H, Nakajima S, Oyabu H, Nagakura Y, Ojima I, Otsuka H, Nakagawa A: Physical fitness of lower limb amputees. Am J Phys Med Rehabil 2002;81:321–325.
  25. 25.0 25.1 British Society of Rehabilitation Medicine. Amputee and prosthetic rehabilitation – standards and guidelines, 2nd edition. Report of a working party. 2003. British Society of Rehabilitation Medicine, London.
  26. Burguer H., Marincek C. Functional testing of elderly subjects after lower limb amputation Prosthetics and Orthotics International, 2001, 25, 102-107.28. Esquenazi A, DiGiacomo R (2001) Rehabilitation After Amputation. J Am Podiatr Med Assoc 91(1): 13-22.
  27. 27.0 27.1 Hockley D, Flanagan G. Design and implementation of interdisciplinary care guidelines for hospital management of amputees in Christchurch. New Zealand Artificial Limb Board. 2005.
  28. Wegener ST, Mackenzie EJ, Ephraim P, Ehde D, Williams R. Self Management Improves Outcomes in Persons with Limb Loss. Archives of Physical Medicine and Rehabilitation. 2009: 90: 373-80.
  29. Esquenazi & DiGiacomo (2001) Rehabilitation after amputation. Journal of the American Podiatric Medical Association. 91(1):13-22
  30. 30.0 30.1 Bruins M, Geertzen J, Groothoff J, Schoppen T (2003) Vocational reintegration after a lower limb amputation: A qualitative study. Prosthet Orthot Int. 27(1): 4-10.
  31. Couture M, Caron C, Desrosiers J (2010) Leisure activites following a lower limb amputation. Disabil & Rehab. 32(3): 57-64.
  32. Fisher K, Hanspal R, Marks L (2003) Return to work after lower limb amputation. Int J Rehabil Res. 26(1): 51-6.