Acute post-surgical management of the amputee

Original Editor - Liezel Wegner as part of the WCPT Network for Amputee Rehabilitation Project

Top Contributors - Admin, Tarina van der Stockt, Tony Lowe, Aicha Benyaich, Kim Jackson, Naomi O'Reilly, Rucha Gadgil, Olajumoke Ogunleye, Jorge Rodríguez Palomino, Sheik Abdul Khadir and Andeela Hafeez  

Introduction

It is important to remember that earlier the onset of the rehabilitation and the greater the potential for success will be. Patient need to recieve physiotherapy treatment early to avoid complication such as joint contractures, pathological scars and depressed psychological state. The main post-surgical complications are cardio-vascular, residual limb pain and phantom sensation, oedema, contracture and wound dehiscence. 

Learning outcomes

At the end of this module, you should be able to:

• Discuss and apply (where applicable) treatment options in an effective & safe manner based on current best practice and evidence.
• Demonstrate (where applicable) safe techniques and manual handling.
• Devise appropriate exercises programmes
• Identify common challenges associated with amputees post operatively and their management.

Goals of acute post-surgical rehabilitation 

• Obtain maximum independence
• Prevent the oedema
• Maintain joint ROM • Prevent amyotrophy
• Decrease the muscular activation
• Prevent muscular weakness
• Prevent bronchopneumonia
• Prevent pressure sore
• Control pain
• Sensory reeducation
• Support the client psychologically

It is intented that prior to any treatment, an assessment will be carried out by the physiotherapist. In this early stage, a functional assessment can be done including both uper-limb, lower-limb and trunk in order to evaluate the patient potential to carry out activities such as transfer, wheelchair mobility and ambulation (with or without prosthesis)

Treatment modalities

Treatments modalities to prevent complications include:

• Breathing exercises
• AROM
• Resistance exercises
• PROM
• Desensitising techniques
• Bed mobility and transfers
• Positioning
• ADL
• Prevention of oedema
• Walking and wheelchair use

Breathing exercises

Deep breathing exercises and relaxation exercises will help to increase vital capacity and decrease anxiety and prevent bronchopneumonia

Active range of motion (AROM)

Amputated side (from the 1st post op day unless the post surgical dressing restricts motion):
• First Hip flexion, ext, ADD, ABD 
• Knee flexion exercises (for below-knee amptutations)

Amputated side (from the 3rd post op day)
• To reduce oedema TT amputee can imagine the performance of alternate dorsi flexion and plantar flexion.
• The knee disarticulation and TF amputee must perform alternate hip flexion and extension, hip ADD and ABD.
These active exercises must be performed at regular intervals during the day (10 repetitions per hour).
Bilateral activities often achieve a more vigorous contraction in the amputated side.

Resistance exercises

From the 1st post op day
• Isometric contraction of the quadriceps (TT)
• Isometric contraction of gluteus, ADD and hip int rot
• Strengthening exercises of the sound lower limb (in progression)

From the 3rd post-op day

• Resistance exercises of the upper limbs
• Resistance exercises of the torso

PROM

Passive extension of a TT residual limb.

   

The physiotherapist's hand have to stay as proximal as possible to avoid any contact with the end of the stump, which is a very sensitive area. 

Desensitising techniques

Desensitization is believed to reduce pain in the residual limb and may help the patient with an amputation adjust to his or her new body image that now includes limb loss:

• Instruct the patient how to perform desensitization and distraction techniques to reduce the phantom pain
• Tap the residual limb, to include tapping the rigis dressing
• Gently massage the proximal residual limb, to include pressure points in the inguinal regions
• If the phantom toes or foot feel like they are twisted or cramping, move the intact limb in a position of comfort thatwould mimic the improved position of the phantom side.

Stump management

Patient informations

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Post operative dressing

Post operative dressing are used to protect the limb, reduce swelling, promote limb maturation and prevent contractures. There are two major classifications of post operative dressing that are commonly used: soft dressing and rigid dressing.

Clinical praction rehabilitation of lower limb amputation  p72-73

Oedema control (shrinking)

One of the main acute post-operative factors affecting the time to prosthetic fitting and the speed of rehabilitation, is the wound healing of the stump, especially in the vulnerable vascular compromised population . Oedema in the residual limb is also a common complications after LLA surgery . Controlling the amount of oedema post-surgically is vital for promoting wound-healing, pain control, protecting the incision during rehabilitation and assisting in shaping the stump for prosthetic fitting . Traditionally soft dressings or non-adhesive elastic bandages are used to prevent oedema of the stump post-surgically, but no evidence supports the use of these bandages  . The use of immediate post-surgical rigid or semi-rigid dressings to prevent acute oedema have increased in popularity in the developed world, and is well supported by evidence in the literature  . Some of the reported benefits of the rigid dressing include promotion of wound healing, shaping of the stump, pain management, protection against trauma during falls, stump volume control and increased speed of prosthetic fitting   . The conventional method of application of rigid dressings is a plaster cast rigid dressing that is usually applied in theatre under anaesthesia. This method has proven to be effective, but often surgeons choose not to opt for this method of rigid dressing since it is time-consuming, and requires some skill to apply .Another disadvantage of this technique is that the wound cannot be inspected for 5-7 days post surgically. An alternative vacuum-formed removable rigid dressing has proven to be as effective as the conventional rigid dressing in a randomized controlled trial, and is an useful alternative to the plaster casting method . The advantages of this vacuum-formed rigid dressing include the ease of application, and ease of access for wound inspection .

For more information about rigid dressing  http://www.austpar.com/portals/acute_care/rigid_dressings.php

•  Video of Ossur semi-rigid dressing immediately post operatively

•  Iceross post op liner for compression post operatively

Wound healing

Wound healing is always a cause of concern, but especially in the dysvascular population. Adequately controlling oedema of the stump can assist with healing, but some evidence also supports the use of low intensity laser in order to facilitate and speed up wound healing in diabetic patients . However the exact dosages for optimal effect has not yet been established.

Free full text article: Effects of low-level laser therapy on the progress of wound healing in humans: the contribution of in vitro and in vivo experimental studies - www.scielo.br/pdf/jvb/v6n3/v6n3a09  

Pain management

Pain is a very common physiological stressor that occurs during the acute postoperative period and affects the patient’s ability to learn new skills  . Adequately controlling the new amputee’s levels of pain greatly facilitates their early rehabilitation  . Physiotherapists should take this into consideration, and treat patients shortly after receiving their pain medication. Controlling oedema in the residual limb through positioning also assists in relieving acute postoperative pain . Various physiotherapy interventions are used for the management of phantom limb pain, but very few of these have been studied to prove their efficacy in the research literature .One of the few physiotherapy modalities that has been proven to be effective for the management of residual phantom limb pain, is a 60 minute application of Transcutaneous Electrical Nerve Stimulation (TENS) .
See recent full-text article on the management of phantom pain

•  Know Pain Know Gain: proposing a treatment approach for phantom limb pain : jramc.bmj.com/content/160/1/16.full.pdf+html
• For more information about pain management: http://www.austpar.com/portals/acute_care/pain_management.php

Bed mobility and transfers

Bed Mobility 

• Bridging

• Rolling from one side to the other

              

• Sitting forward bilateral amputation

                                

• Moving up and down on the bed.
• Push-ups using arms (after drain has been removed).

Transfers

• Standing pivot transfer (for a patient that can participate only partially) 

          

• Backwards forwards transfer (for patient with a bilateral amputation)

• Lateral transfer with a sliding board transfer 

          

Positioning

The main goal of a good positioning at any time is to prevent adjacent joint contractures.  For trans-tibial amputee complete knee extension and flexion is needed and for the trans-femoral amputee and knee desarticulation amputee the full ROM of the hip, especially extension and adduction. Full ROM will ease prosthetic fitting and deambulation. 

Patient should be advised on how to position themselve while sitting and lying in the hospital bed or standing to prevent contractures. 

For below-knee: avoid as much as possible long position with a knee flexion (cushion under the knee for example)

For trans-tibial: avoid position with hip flexion and abduction (cushion under the stump for example). 

Bed positioning for trans-femoral 

                

Bed positioning for trans-tibial                    

Sitting in a wheelchair for trans-tibial 

         

ADL, Walking and wheelchair use

For further details on the acute post-surgical phase refer to http://www.austpar.com/portals/acute_care/post-op.php 

References

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