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 . This negatively impacts on their participation and integration into society .The ultimate goal of rehabilitation after limb loss, is to ambulate successfully with the use of a prosthesis . 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 .

Overview of the rehabilitation process

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

• pre-operative,
• amputation surgery,
• acute post-surgical,
• pre-prosthetic,
• prosthetic prescription,
• prosthetic training,
• community integration,
• vocational rehabilitation and
• follow up.

Table 1: Phases of amputee rehabilitation: Modified from Esquenazi &Meier (1996) cited in Esquenazi (2004).

Phase	Hallmark
Pre-operative	Assess body condition, patient education, surgical level discussion, postoperative prosthetic plans
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
Prosthetic Prescription	Team consensus on prosthetic prescription and fabrication
Prosthetic Training	Increase prosthetic wearing and functional utilization
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

The rehabilitation treatment plan is utilized to guide the care of a patient who has undergone an amputation throughout the entire course of rehabilitation. 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,
• Therapy interventions to address disabilities or activity limitation,

	Patient Journey	The team management	Physiotherapy management
1.	Pre-amputation	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. Assessment of the amputee
2.	Immediately post-amputation	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 and days (only for below knee and below elbow).	Transfer practice, and specific exercises to improve strength; increase exercise tolerance; maintain ROM. Discharge management of the amputee
3.	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 EWA and patient goals)	Early walking aids(EWA) assessment: Pneumatic post amputation mobility aid (PPAM aid)- below knee amputees, through knee amputees and above knee amputees. Femurett – through knee amputees and above knee amputees.  Using EWA to help decide on a patient’s suitability for a prosthetic limb, and liaising with whole team regardPre-fitting management of the amputee
4.	Casting and measuring	Prosthetists cast and measure a patient’s residuum. Prosthetics	Physiotherapist may be needed to assist in the cast appointment, to ensure a neutral alignment of the pelvis is obtained.
5.	Fitting of prosthesis	Prosthetists fit the primary prosthesis to the patient, ensuring the alignment and length are correct in a standing and walking. Prosthetics	Physiotherapy provides intervention on mobility guidance, static balance and weight bearing. Post-fitting management of the amputee
6.	Gait Re-education	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. Gait in prosthetic rehabilitation
7.	Review	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.

Mechanisms and importance of communication systems between services

Communication within the IDT is critical and should regularly occur to ensure that the members of the team are informed and aware of a patient’s progress. This is most commonly achieved by a goal setting meeting.This may be held fortnightly or monthly depending on the limb centre and their service. This meeting allows the team to discuss patient goals (which have been clearly defined in the outcome measure COPM) enabling the team to decide on patient focused SMART goals.

Additionally the regular meeting ensures that all team members are aware and up to date with patient progress and any issues or concerns can be discussed with a joint approach to problem solving.

Alternatively an email system may be set up, which can be particularly useful for satellite clinics at different hospital sites. This can be set up as a generic email within the nhs mail system, and works well if all team members are check it regularly and respond in a timely manner.

Telephone contact is also a very useful option to connect members of staff at different sites, and again is particularly useful for team members at satellite clinics to liaise and problem solve with the wider team.

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