Rehabilitation Of Amputee

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Chapter 93 Amputation Rehabilitation

Alberto Esquenazi Edward Wikoff Maria Lucas

Amputation rehabilitation is not solely the provision of a prosthesis. Rather it is the restorative intervention necessary to return the patient who has had an amputation to the highest possible level of function and to minimize the impact of the amputation on his or her life. In the last two decades, with the advent of specialized treatment teams and new prosthetic devices, the outlook for the person who has had an amputation has improved. Outcomes that were never thought to be possible, such as exercising with a prosthesis or ambulation without the use of upper-limb support for the elderly, are now frequently achieved. We present our collective knowledge and understanding of the rehabilitation process, which represents the essential interventions necessary to optimize function for patients who are provided with a prosthesis and for those who are unable or choose not to use one.

CLASSIFICATION AND INCIDENCE OF AMPUTATION Amputations are classified based on the anatomic level and site at which the amputation has taken place. For example, an amputation between the wrist and elbow is termed a transradial amputation. Other levels include transfemoral, transtibial, Syme, partial foot, hip disarticulation, and knee disarticulation for the lower limb. For the upper limb, transhumeral and partial hand amputations, and shoulder, elbow, and wrist disarticulations are the most common.

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The congenital limb deficiencies are best classified following the International Organization of Standards and the International Society of Prosthetics and Orthotics classifications as modified from Frantz and O’Rahilly (1). The limb deficiencies can be transverse or longitudinal. The term terminal is used to describe the fact that the limb has developed normally to a particular level beyond which no skeletal element exists. With intercalary limb deficiency, there is a reduction or absence of one or more elements within the long axis of the limb, and there may be normal skeletal elements distal to the affected segments (2). Amputation of the lower limb is performed significantly more frequently than amputation of the upper limb. Amputation of the distal segment of the limb is more common than that of the proximal segment. Amputations can occur at any age, but for lower extremities, the elderly are most commonly affected, with men more frequently affected than women. Upper-limb amputation affects men between the second and fourth decades most frequently, and the right upper extremity is more likely to be amputated than the left. The most common reasons for lower-limb amputation are infection, arterial occlusive disease, and complications of diabetes mellitus. Less frequent but important causes are trauma, malignancy, and peripheral neuropathies. For the upper limb, trauma followed by malignancies and acute arterial insufficiency are the most common causes (Fig. 93-1).

Figure 93-1. Distribution of the causes of amputation.

REHABILITATION TEAM Limb loss is a condition that has physical, psychological, and social implications for the affected individual and the social support system. For treatment to be effective, it should include the care of the patient and his or her significant others. Expertise from various clinicians is required to accomplish this effectively. The development of a rehabilitation team working closely together to address each individual’s needs is vital to the efficient and timely delivery of services. This approach will provide the patient a comprehensive treatment regimen. A physician specializing in rehabilitation, or who has knowledge of biomechanics and prosthetics, assumes the role of team leader and coordinates the team’s resources. The prosthetist fabricates the prosthetic appliance and works closely in the training stages with the therapist and patient to prevent complications, achieve appropriate alignment, and ensure proper fit of the prosthesis. The prosthetist also acts as a resource to other team members for information on the latest technologic advances in the field of prosthetics. Physical and occupational therapists are critical members of the therapeutic team. The physical therapist participates in the care of the lower-extremity amputee by preparing him or her physically for using a prosthesis. This includes instructing the patient in management of the prosthesis, teaching functional mobility activities, and providing gait training to optimize the walking pattern. In the patient who has had a traumatic upper-extremity amputation, the intervention of the physical therapist is required only if there is a significant injury to joints or soft tissues. An occupational therapist will work closely with the team and the patient to incorporate use of the prosthesis during activities of daily living (ADLs) and for work simulation activities. For the upper-extremity amputee, the occupational therapist is frequently the primary therapist instructing the patient in the use of an upper-limb prosthesis. Owing to the immense psychological impact that an amputation has on many patients and their families, each patient should have an assessment with a psychologist (3,4).

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A psychologist specializing in limb loss or disability is particularly suited in addressing feelings of depression and body image changes associated with amputation. Along with these core members, the team should include other supporting clinicians. A social worker can assist patients with changes in family relationships and social status related to decreases in function or work abilities (5). Nurses can assist and instruct patients in medication management and with wound care. The recreational therapist provides information about community resources for recreational activities and support groups, and instructs patients in the adaptations necessary to participate in leisure activities. A vocational counselor, driving instructor, and when necessary, a school teacher may be involved in the care of the amputee as well. The patient and team members should work together to set goals and develop an overall treatment plan. Subsequently, each team member participates in the patient’s care as necessary to make the provision of services most efficient. With so many clinicians contributing to the care of an individual, communication is an essential component of team interaction. Good communication will ensure that all team members are providing patients with quality care while avoiding duplication of services. Each team should develop some method of communication that is appropriate for the clinical setting, whether it be daily or weekly rounds, written documentation, computer linking, or team meetings (6–8).

PREAMPUTATION EDUCATION AND COUNSELING The rehabilitation process for the individual with limb loss ideally should begin before any surgery occurs. The amputee can take better advantage of rehabilitation services once he or she has been educated regarding surgery, healing, exercise, future abilities and limitations, and the rehabilitation process. This education, as well as the actual multifaceted rehabilitation care, is best provided by a team of health care professionals with experience and expertise in the realm of amputation rehabilitation (9–11). Patients facing amputation often know little about the disease process that threatens their limbs, or about what the future holds. Understanding that arterial insufficiency, infection, trauma, or tumor may necessitate amputation may enable the patient to accept the amputation as the appropriate treatment (12). Lacking this insight, patients may resist or delay amputation, risking sepsis, a contracted nonfunctional limb, analgesic abuse, deconditioning or other avoidable medical complications. Others may fear social isolation or stigmatization stemming from the amputation, and view the amputation as the end of their useful life. Most fear losing independence and work productivity, and becoming a burden on family and friends (2,12–19).

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To fill these information gaps, the patient and family benefit from preamputation counseling from members of the rehabilitation team and from a prosthetic user who can provide firsthand information. The following topics should be covered, although with the apprehension of upcoming surgery, the patient may retain little of what is initially discussed. 1. Pain will certainly be present following surgery and its duration and intensity may not be predictable. The patient seeking pain relief as a result of amputation may not be satisfied, as the RL or phantom limb may also be painful (20). 2. Phantom sensation (and possibly pain) will likely be present following surgery (21). 3. Exercise and proper positioning in the early postoperative period will be very important to future rehabilitation. 4. A general time frame for acute hospitalization, wound healing, preprosthetic rehabilitation, and prosthetic use is very helpful to the patient. 5. The patient’s expectations for future functional status are often unrealistic. Future activities will require equipment previously unfamiliar to the patient (e.g., wheelchair, crutches, prosthesis, etc). A discussion of this information with an amputee as closely matched demographically as possible will provide the patient with a more credible view of the future. Early contact with the patient also allows members of the rehabilitation team to evaluate the patient’s premorbid status and current problems so that appropriate goals and plans can be made. The patient may also benefit from the continuity if the same members of the rehabilitation team are involved before and after the surgery.

EVALUATION OF THE AMPUTEE Evaluation of the patient with upper- or lower-limb loss is indispensable to preparing the overall rehabilitation treatment plan, including the development of goals and objectives. It is also important in the prosthetic prescription process. Although the overall evaluation process for all amputees is similar, some important differences exist in the evaluation of patients with limb loss at different levels. These are reviewed later in this section. A general physical examination that documents body weight, height, peripheral circulation, skin integrity, limb dominance, overall health, comorbidities, and mental status is necessary. The examination of the residual limb (RL) should include the soft-tissue length and shape, bone length and shape, and skin integrity, pliability, and mobility. Scar tissue is assessed as is the RL’s tolerance to pressure, traction, and weight bearing. Sensation is also evaluated as well as the presence of neuroma or areas of hypersensitivity. The clinician should document the range of motion

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(ROM) and strength of the proximal joints. The status of the contralateral limb and the ROM, strength, and sensation of the other limbs are critical data in the planning of the rehabilitation program. Balance and coordination are also essential and should be tested. Patients with peripheral neuropathy or skin grafts use vision as a compensatory mechanism for the lack of sensation in the prosthesis and the other limbs. Eye examination should be encouraged, as many patients need updated prescription eyeglasses and vision care. In the patient whose amputation was caused by ischemia related to atherosclerosis or diabetes mellitus, similar arterial insufficiency involving the cardiac and cerebral vessels should be suspected. Knowledge of cardiopulmonary status and endurance is of primary importance. The use of sophisticated tests to assess these systems in patients with a cardiac history is usually unnecessary. Simple clinical indicators such as the ability to ambulate with a walker or crutches for 30 to 40 ft, while blood pressure and pulse rate are monitored, are adequate to determine whether the patient will be able to achieve the goal of limited household ambulation. Patients with a documented ejection fraction of 15% should be able to ambulate very short distances with an artificial limb. The cardiac risk in this population does not appear to be significantly increased when using a prosthesis or walking short distances. Therapeutic walking is an appropriate technique for cardiovascular training. In addition, the capacity for short-distance ambulation will often permit a patient to remain out of a long-term-care facility. This has additional psychosocial benefits that may outweigh the potential risks. The patient’s willingness and ability to learn new techniques and to participate in a variety of new activities are critical. Thus, cognitive and psychological evaluations are very important. The psychological impact of limb amputation is huge. Patients experience a variety of emotional and psychological responses, including anxiety, shame, depression, anger, and fear. The rehabilitation team must provide support, treatment, and guidance for the patient and his or her family (2,12–19). Nutritional status, which has a considerable impact on wound healing and strength, must not be neglected (22–24). The presence of a variety of other comorbidities such as diabetic retinopathy, peripheral polyneuropathy, nephropathy, and degenerative joint disease may also influence the rehabilitation of the amputee. In short, a thorough medical evaluation of the patient is necessary. Other areas of importance that should be evaluated include the vocational and recreational activities that the patient performed in the past and wants to pursue in the future. Certain vocational or avocational activities may require alternative specialized prosthetic devices, training, or use of no prosthesis. Devices that may be exposed to extreme weather, water, or other elements that may be corrosive or destructive to the prosthesis should be made of special materials to protect the RL and the prosthesis.

Medical Rehabilitation for Diagnostic Groups

Social support systems play an important role in the amputee’s rehabilitation. The rehabilitation program for a person living with an able-bodied spouse in an elevatoraccessible single-floor apartment is different from that of a person living alone in a third-story walk-up apartment. Lastly, the rehabilitation team needs to evaluate and consider the patient’s motivation, preferences, and desires, as well as the importance of cosmesis as a factor in prosthetic fabrication. As previously mentioned, several important factors need to be considered during the evaluation of the patient with particular levels of limb loss. For the transfemoral level of amputation, assessing the length (short, mid, long) of the RL, ROM of the hip (particularly extension), and strength of the hip (particularly abduction, extension) is important. Knowledge of the type of surgical technique used for amputation is important; in particular, surgical reattachment of the adductor group (myodesis) has a significant impact on future function (25). The configuration of the distal end of the femur and the presence of heterotopic ossification or bone growth at the tip should be noted. Other characteristics of the RL that should be noted include location of surgical scars, position and type of grafts (skin or vascular), and ability to bear weight distally. These factors should be considered when the prosthetic socket is fabricated. Surgical revision should be considered when heterotopic bone, scars, grafts, or other features of the RL prevent adequate prosthetic fabrication. Assessment of the transtibial RL involves similar considerations. The length is categorized as short, mid, or long. Strength and ROM of the hip and knee are evaluated. Assessment of hip and knee extension is particularly important. As with the transfemoral RL, location of scars, presence of skin or vascular grafts, and the nature of the surgical technique (myodesis or myoplasty) are also noted. The configuration of the distal end and its ability to bear weight are also important factors. For the transradial level of amputation (short, mid, long), evaluation of the ROM and strength of the elbow, shoulder, and scapula and the quantification of pronation and supination are necessary. The position of surgical scars, configuration of the distal end, type of surgical closure carried out (myodesic or myoplastic), and the ability of the RL to receive distal pressure and weight bearing are assessed. Contractility of the underlying muscle is of particular importance if a myoelectric device is to be considered. For the bilateral upper-limb amputee, the ROM and strength of shoulder and neck and trunk flexibility are important factors. One should assess the ability to use lower limbs for functional activities such as opening doors, stabilizing objects, feeding, and other essential functions. The ideal length of the limbs is determined by using a ratio of height; for very-proximal-level amputations, the forearm section is made shorter to improve elbow lift power by reducing the lever arm length. It is necessary to

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determine the optimal prosthetic control systems to be used (body power versus external power or both). For externally powered devices, myoelectric or switch control can be used. This decision also requires knowledge of the availability of appropriate funding sources and access to maintenance. Externally powered devices require more maintenance than body-powered devices. Projecting the patient’s dependency on the prosthetic devices and the availability of help when the prosthesis fails will help to determine the need for a second set of artificial arms (usually of different control mechanism). For patients who have had bilateral lower-limb amputation, the evaluation should focus on the strength, dexterity, and ROM of the upper limbs and the ability to use the upper limbs for support during walking. Assessment of the cardiopulmonary systems is essential in view of the expected increase in metabolic cost during walking. Limblengths should be determined based on the ability to transfer from sitting to standing (18 inches to the knee may be sufficient) while keeping a lower center of mass for improved balance and more efficient energy utilization during standing and walking. Choosing prosthetic components based on needs, desires, and available funding sources, as well as accessibility to maintenance, is critical. Projecting the patient’s dependency on the prosthetic devices will permit determining the need for a wheelchair or a second set of artificial legs (maybe waterproof ones to be used also during showers). When a myoelectric prosthesis is prescribed, the evaluation should begin with determination of the level of amputation (short, mid, long). ROM of the shoulder and scapula and strength of the shoulder muscles, primarily those of flexion and abduction, should be assessed. The presence of myodesic or myoplastic closure and the available control at the residual muscles for the wrist for transradial level and at the elbow for transhumeral level should be determined. Assessment of electromyographic (EMG) signal strength (>20 units on Myotester) of the muscles to be used to trigger the prosthesis is necessary. If the patient is not able to generate separate signals for flexors and extensors and co-contract them for full utilization of myoelectric controls, appropriate training with EMG feedback is to be implemented.

PREPROSTHETIC TRAINING Preprosthetic training ideally focuses on the goals of functional independence without a prosthetic device. In addition, for individuals who will receive a prosthesis, the RL is prepared for prosthetic use. The average age of the amputee population is 50 to 70 years old (26–28). Usually they will have several comorbidities and have lost strength and endurance in the weeks leading up to the amputation (29,30). A comprehensive supervised exercise program including ROM, strengthen-

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Figure 93-2. Inappropriate bed position of comfort that may promote contractures of the hip and knee.

ing, and endurance exercises, as well as functional activities, promotes improvement in these areas (31,32). Of course, precautions dictated by the patient’s comorbidities are to be observed. Patients are often eager to perform the upper-limb exercises that promote the strength and ROM required for self-care activities. However, most patients with recent limb loss are more concerned with mobility than bathing and dressing. Arms provide the power for wheelchair mobility and the use of walking aids. In particular, shoulder stabilizers, adductors, and depressors, elbow extensors, wrist stabilizers, and hand grasp strength are of prime importance for supporting the body for transfers and using the more common walking aids. Trunk balance and strength must not be neglected. Strong flexible rotators, flexors, and extensors of the back and abdomen and the extensors of the hips facilitate sitting balance and bed mobility and transfers. The importance of lower-limb exercise is obvious. The remaining limb for the unilateral amputee temporarily becomes the solitary support limb and frequently can develop symptoms consistent with overuse, particularly at the knee and ankle. Stance-phase stability requires adequate strength in the hip extensors, abductors, knee extensors, and plantarflexors. Swing-phase limb advancement and clearance require adequate hip flexor and ankle dorsiflexor strength. Lower-limb contractures are distressingly common in the amputee population. Unfortunately, the position of comfort is often the position that can result in contractures. Patients often need continual reminders that contractures can significantly impair their future mobility and compromise the integrity of the nonamputated limb. The transfemoral-level amputee often develops contractures of the hip flexors, abductors, and external rotators. The transtibial-level amputee frequently develops hip and knee flexion contractures (Fig. 93-2). Contractures of the hip flexors, knee flexors, and plantarflexors of the intact limb of the unilateral amputee often result from prolonged bed rest in the comfortable semi-Fowler position. If soft-tissue contracture results in an equinus posture, the normal weight-bearing posture of the foot is compromised. Pressure distribution to the heel is lost and forces are focused on the forefoot. The increased pressure on the forefoot can lead to local pain and tissue breakdown of particular concern in the presence of peripheral neuropathy or arterial insufficiency. The “ounce of prevention” approach certainly applies to limb contractures. Several factors can contribute

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to contractures: preoperative positioning, surgical technique, postoperative pain, deficient knowledge regarding ROM, and limited mobility related to ischemia, skin grafts, infection, or trauma that led to the amputation. Treatment of contractures may include heating modalities, prolonged passive stretch, spring-loaded orthoses, serial casting, nerve blocks, or further surgery. To avoid contractures, patients are instructed to move limbs through a full ROM frequently and to avoid postures of prolonged flexion. Periods of lying prone should be included in the lower-limb amputee’s exercise program. A posterior splint may help prevent knee flexion contractures in the transtibial-level amputee. Frequent reminders and encouragement help the patient follow through on these instructions. Contractures are readily prevented through the use of an immediate postoperative rigid dressing (33,34). The rigid dressing extends proximally, enclosing the knee, preventing a flexion contracture. The lower-limb amputee’s outlook brightens considerably when he or she is allowed out of bed. Independence in transfers and functional mobility are of great importance. Bed mobility exercises include rolling from side to side and sitting up, to allow the patient to position himself or herself without calling for help. Transfer training allows the patient to expand his or her world beyond the bed and room. The patient may utilize sliding board, fronton/back-off, or stand (squat) pivot transfers to move from one surface to another. Functional mobility for the amputee may take several forms. Most lower-limb amputees will use a wheelchair at some point and should learn proper wheelchair management, including using the leg rests and brakes. Safe techniques for propulsion and turns appear simple, but require teaching and practice. The wheelchair must be suitable for the individual. A person with limited strength or with significant cardiac impairment may be unable to safely propel a chair of normal weight. Removable armrests are needed for those who utilize a sliding board or squat pivot transfer to the chair (Fig. 93-3). The center of gravity of the person seated in a wheelchair shifts posteriorly if a lower limb is absent. Therefore, an off-set axle or antitippers are appropriate. These are of particular importance when going up a ramp or curb. Ambulation training without the prosthesis is very important to the amputee. Initially, standing balance and standing tolerance are addressed. Once the patient can manage standing, then ambulation (hopping) using the parallel bars can begin. As strength and endurance improve, the patient may advance to a walker and to crutches. In

Medical Rehabilitation for Diagnostic Groups

Figure 93-4. Elastic bandaging of the transtibial residual limb.

Figure 93-3. Sliding board transfer to a bed for the bilateral transfemoral amputee.

addition to allowing greater mobility, the activities improve lower-limb strength and ROM and serve to remind the patient that bipedal walking may soon be a reality. Stairs are often a source of concern for the amputee. When walking up and down stairs is not yet possible, many individuals use a “bumping” technique to ascend or descend. The patient sits on the steps and uses the arms and remaining lower limb to propel himself or herself up or down. Of course, the floor transfer at the top or bottom of the stairs must also be addressed. Many amputees use a low box or stool as a “step” between the floor and the wheelchair or standing posture. Not all patients can tolerate standing activities initially. For patients who cannot, because of orthostatic hypotension or other reasons, a more gradual approach is needed. Allowing the patient to press his or her foot against a foot board while in bed can simulate lower-limb weight bearing. Alternatively, the patient may hold a towel, a length of cloth, or a length of elastic tubing looped under the foot and apply pressure to the plantar surface of the foot. Gradual progression to a more erect posture may be achieved by elevating the head of the bed or using a tilt table. While many amputees focus their attention on walking, their ability to perform self-care activities may be more important to their going home. As safe techniques

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for bathing and dressing and toileting are mastered, the amputee realizes that he or she need not fear being “a burden.” Self-esteem and optimism are restored. In addition to self-care activities, many amputees must also perform homemaking activities to resume their life roles. Using a wheelchair, walker, or crutches, the amputee learns to prepare meals, do laundry, and perform other household chores. Most of the preceding discussion is appropriate for the lower-limb amputee. For the upper-limb amputee, transfers and mobility are less problematic while self-care activities may be more difficult. Regardless of previous right- or left-handedness, the remaining limb becomes dominant for the upper-limb amputee. Thus, there may be considerable time spent on change of dominance. The patient will also learn various single-handed techniques for bathing, dressing, grooming, and other self-care activities (35). Care of the RL focuses on several areas including wound healing, volume containment, optimization of strength and ROM, and desensitization. Needless to say, the healing wound should be kept clean and monitored for signs of infection. Volume containment can be achieved through several approaches. Ideally, the immediate postoperative rigid dressing, applied in the operating room, provides edema control as well as mechanical protection for the limb (33,34,36). As an alternative, the removable rigid dressing can be used, allowing the patient greater participation (37,38). The Unna boot also prevents swelling but requires no particular skill in its application (39–42). Ace bandages, tubular compression dressings, or stump shrinkers provide elastic compression and may be favored for their simplicity and neatness (Fig. 93-4) (43,44).

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Because the RL is an end organ, responsible for the manipulation, positioning, control, and general operation of the prosthesis, exercises for the RL are crucial. Normal strength and ROM of the RL will help to optimize prosthetic use. Many amputees will not receive a prosthesis. There may be cognitive, physical, psychological, financial, or other reasons for this. Other amputees may simply decline the option of using a prosthesis. For this group, therapies to optimize strength, endurance, and ROM and to achieve independence in mobility, self-care, and other life tasks without a prosthetic device are provided. There are also patients for whom functional independence is not a realistic goal. Some patients will always need some assistance for mobility and self-care. Therapies for these people will focus on caregivers as well as on the patient (18). Family members or other individuals involved in the care of the amputee are educated and trained in appropriate techniques for RL care, mobility, bathing, dressing, and hygiene.

REHABILITATION WITH PREPARATORY PROSTHESIS Return to bipedal ambulation is the stated goal of most lower-limb amputees. Amputees often feel that only by returning to ambulation can they resume their previous lives, roles, activities, and socialization (12). Walking again is an enormously important transition for the amputee. Starting with an accurate knowledge base is important for the patient and health care provider alike. A review of goals and expectations is appropriate at this point. Not all patients will recall the prior discussions regarding these topics, so reminders may be necessary. It is also appropriate for the therapist to review the patient’s diagnosis and comorbidities as well as precautions, to minimize the complications that may develop as gait training proceeds. Rehabilitation with the preparatory prosthesis begins by introducing the patient to the components of the preparatory prosthesis and its management. Explanations of how the prosthesis fits, where weight is borne, where and why discomfort may occur, and how adjustments can be made help put the patient at ease. It is useful to remind the patient that his or her weight must be supported by some pressure-tolerant portion of the RL, or walking would be impossible. Pressure is to be expected and this may be uncomfortable at first but should not be painful. With experience and the teachings of the treatment team, the patient learns the appropriate fit of the prosthesis and the way to adjust the fit with stump socks when necessary. The patient needs to learn that the prosthetic fit is a dynamic entity and that he or she needs to be aware of subtle changes in socket fit or alignment that provide clues to necessary adjustments (43,45).

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Gait training begins with weight bearing and weight shifting, using the parallel bars for upper-limb support. The patient gradually progresses to ambulation in the parallel bars. The therapist may find it difficult to focus the patient on proper technique including equal step length and appropriate weight shifting. Gait deviations frequently develop owing to the patient’s eagerness to begin walking. As the patient establishes a consistent gait pattern and can maintain good form, he or she advances to use of a walker, crutches, and unilateral support devices. Once the patient is comfortable with level surfaces, he or she progresses to walking on stairs, curbs, and ramps, as well as uneven terrain. The patient also learns safe techniques for transfers, including to and from the floor (32). Frequent monitoring of the skin allows for prompt corrections of socket-fit problems and avoids skin breakdown. Skin checks are done more frequently for the new prosthetic user and for the patient with delicate skin. Initially, checking the skin every 10 to 15 minutes or after every one or two walks may be necessary. Once the patient and therapist are comfortable with the socket fit, skin monitoring can occur less frequently. Prosthetic wearing tolerance gradually increases over the first few weeks. Some patients can only wear the prosthesis for 2 to 3 hr/day during the first week of gait training. This gradually increases until it is worn all day (12–16 hours). Throughout the rehabilitation process, the patient should become well versed in skin care. The patient learns to monitor the skin of the RL, noting signs of appropriate weight bearing and watching for evidence of skin irritation or breakdown. When the prosthesis is not worn, the patient wears a stump shrinker or an Ace bandage to prevent edema and provide volume containment (43,44). As the amputee progresses with ambulation and management of the prosthesis, ambulatory self-care activities and homemaking activities can be addressed. Occupational therapy works with the patient to learn safe techniques for bathing, dressing, and toileting using the prosthesis. Some patients may find that initially, certain activities are more easily performed without the prosthesis. In these situations, it is important to remember that the primary goal of therapy is functional independence, not necessarily continuous prosthetic use. Many patients need to perform homemaking tasks as well. The therapist should include meal preparation, laundry, shopping, and other household chores in the training routine of these individuals, using the prosthesis if possible. As the patient progresses through ambulation training, emotional and psychological needs must not be neglected. New anxieties or unfilled expectations may arise during training with the prosthesis and should be addressed by the psychologist and other members of the rehabilitation team. The patient is encouraged to express concerns and disappointments so that steps can be taken to rectify these problems. While some problems may not have

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solutions, the patient can be reassured that the rehabilitation team does not ignore the patient’s perceived issues. Few patients can proceed through ambulation training without experiencing problems with pain. Phantom discomfort has been extensively investigated (20,46–49). Approaches to treatment include biofeedback (50), imagery (51), relaxation techniques (52), massage, ultrasound (53), transcutaneous electrical nerve stimulation (TENS) (54), oral and injectable medications (20,46), and surgery (20,46). This topic is discussed in detail elsewhere in this text. RL pain is frequently related to socket fit and prosthetic alignment. By listening to the patient’s complaint, examining the RL, and watching the patient use the prosthesis, the clinician can generally solve fit and alignment problems. Prosthetic component changes and alignment adjustments are more readily performed when modular, adjustable components are used. Because the RL and the patient’s gait pattern are continually changing, it is common for pain problems to develop or recur without apparent provocation. Therefore, it is helpful for the members of the rehabilitation team to remind the patient that occasional difficulties and setbacks are common and are not reasons for despair.

REHABILITATION WITH PERMANENT PROSTHESIS Ideally, rehabilitation of the amputee involves testing the definitive prosthetic componentry on the preparatory device. This allows the therapist and other team members to train the patient immediately in the appropriate use of the components that will be used in the definitive prosthesis. However, this is not always possible, because of reimbursement issues or various other factors, such as an inability to predict a patient’s level of function early in the rehabilitation course. Therefore, a patient who receives different componentry in the definitive prosthesis than in the preparatory device will require retraining in the specifics of the new componentry. The socket and some components of a preparatory prosthesis are not as durable as those of the definitive prosthesis, thus limiting the patient’s functional capabilities. Patients should refrain from using the pylon or preparatory prosthesis without an assistive device, even though they may eventually progress to this level when they receive their permanent prosthetic device. With more sophisticated componentry, patients may face higher functional expectations such as work simulation, ambulation on varied surfaces, and sports. Concerning the socket, it is vital to allow the patient’s RL to mature before fabrication of the permanent socket. The soft-tissue bulk of the RL decreases significantly, owing to resolution of edema as well as disuse atrophy of muscles and adipose tissue. These changes occur primarily during the first 2 to 5 months following the amputation. The definitive prosthesis frequently uses a

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suction suspension mechanism that is not usually recommended for a preparatory pylon because of fluctuations in RL girth (43). Patients often will require new instruction on donning techniques for the suction socket. Transfemorallevel amputees will have significant changes in their abilities depending on the knee unit prescribed, and instruction in mobility and gait should vary based on the type of mechanism used in the permanent prosthetic device. For example, patients ambulating with a cadence-responsive knee with swing and stance control will require a different gait pattern compared to patients using a weight-activated knee unit. They will also have different mechanisms for transferring from sitting to standing and ascending and descending stairs and inclines. For the upper-limb amputee, early prosthetic fitting is vital to the acceptance of the prosthesis (36). Generally, the first prosthesis uses conventional or body-powered componentry. Myoelectric or externally powered prostheses are not usually recommended at this stage because of the fluctuation in girth as the RL matures. This fluctuation will make it difficult to achieve the intimate fit between the skin and socket needed for the myoelectric system to work properly. Additionally, one should verify that the patient will be a prosthetic user before incurring the higher cost of an externally powered prosthesis. Upper-limb amputees who are progressing from conventional to myoelectric prosthetics require a period of retraining, to instruct them in the proper use and care of the new prosthesis. In conclusion, the transitions from a preparatory prosthesis to a permanent prosthesis will necessitate education of patients on any changes in the way that they don and doff their prostheses and the performance of their new componentry. Patients are made aware that whenever they receive a new socket, they must be vigilant about skin inspection, as there is potential for new areas of pressure or breakdown of the skin.

VOCATIONAL AND AVOCATIONAL TRAINING It is important to note that a successful outcome for an amputee means returning as close as possible to the previous level of function. For the working-age patient, return to some gainful employment should be expected. Similarly, patients at any age should be able to return to previous or modified leisure activities including sports or hobbies. The patient should know early in rehabilitation that the longrange expectation is to return to work and play. In the case of employment, work simulation activities should be incorporated into the patient’s therapy programs early and should intensify in the latter part of the rehabilitation program. The rehabilitation team should make attempts to contact the patient’s employer to establish the physical demand of the jobs. Wherever possible, employers should be informed and involved in the retraining. Worksite evaluations can be very helpful in understanding job

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Table 93-1: Sport Organizations for the Amputee American Amputee Foundation, Inc. Amputee Coalition of America Amputee Sports Association National Amputee Golf Association National Association of Disabled Swimmers National Association of Handicapped Outdoorsmen National Wheelchair Athletic Association Shake-A-Leg

(501) (708) (912) (800) (813)

666-2523 698-1628 927-5406 633-NAGA 755-1078

(618) 532-4565 (719) 635-9300 (401) 849-8898

demands and making recommendations for work environment modifications or changes in the patient’s job description. In some cases it is not feasible for the patient to meet the physical requirements of the previous job. Limiting factors often include heavy manual labor, prolonged standing periods, or jobs that require well-developed balance. For such situations it is very important to have the patient receive career counseling and job retraining (55). Contact with the local branch of the state office of vocational rehabilitation or its equivalent can be of great assistance as patients re-enter the workforce. Similarly, the patient should be encouraged to return to his or her prior leisure activity. Participation in sports is often very important to younger amputees and sometimes older amputees. The patient should be provided with information on various sports groups, for example, the National Amputee Golf Association, amputee ski groups, and national disabled sports organizations (Table 93-1). Participation in some sports will require specific prosthetic componentry, and consideration of recreational goals should be given when one is formulating the prosthetic prescription (56). Efforts should be made to teach the patient specific sport skills. A commonly stated desire for athletic ability is to be able to run again. This goal should be considered for all active amputees, even if it is to run just a short distance for a bus or to get out of danger. A good socket fit is crucial for running for both transtibial-level and transfemoral-level amputees. A good fit allows the patient to tolerate the tremendous amount of pressure and reaction forces translated to the limb without too much discomfort. For the healthy, active transtibial-level amputee, running is fairly easy to achieve (57,58). When the patient is ambulating independently without an assistive device, he or she is ready to begin training. Hopping and jumping activities will assist with building the patient’s tolerance for increased force transmitted to the limb. A gradual progression from fast walking, to a trot and then a run is usually successful. The treadmill can be useful to progress the patient to higher speeds. The transfemoral-level amputee requires increased training to achieve running. For

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them the appropriate components such as cadence-responsive knees are vital to achieve a step-over-step running pattern. Without a cadence-responsive knee unit, the patient has to wait for the shank of the prosthesis to come forward, resulting in an extra hop on the sound limb. Training techniques for the transfemoral running gait often begin with weight-bearing activities, balance activities, and exercise to improve pelvic and hip control. Initially there is an emphasis on hopping and jumping, to increase tolerance to increased forces translated to the residual limb. Fast walking and ambulating with an exaggerated step length and then a progression to jogging or running can occur. Again, once patients have achieved limited success at a step-over-step running pattern, running on a treadmill at gradually higher speeds can help to increase their cadence (59).

COMMUNITY REINTEGRATION While many amputees simply say, “I want to walk again,” ambulation is only a portion of comprehensive rehabilitation. The goals of a thorough rehabilitation program include helping the patient resume previous roles in the “family” and community. The entire rehabilitation team should help identify the patient’s goals and roles. Each patient may not “open up” equally to all team members. The patient often has difficulty communicating because fear, anger, and depression dominate the thoughts in the days, weeks, and even months following amputation (3,12–17,19). Several questions can help clarify the patient’s previous role in the family or social network. What was the person’s level of independence? Was the patient the primary homemaker or “breadwinner” in the family? If so, then who (if anyone) has taken on these roles during the patient’s illness? Does the patient expect to return to these roles? Is the patient a spouse, parent, child, or other member of the family unit? Was the patient a caregiver or a care recipient prior to the amputation? Does the amputation change this role? If so, how? It may be difficult to anticipate how the patient and the family will adapt to the amputee’s return. There is often a confusing mixture of expectations on the part of each. The patient generally wants to get “back to normal” but may find it quite difficult. He or she may be expecting some assistance, but resenting assistance when it is provided. Members of the family may want to assist but not know how much or how little assistance is needed or welcomed. In general, an awkward situation frequently exists until communication, education, and experience occur. It is useful for members of the rehabilitation team to meet with the patient and family, individually and together, to facilitate resolution of these issues. Long-term counseling may be needed as the patient and family adjust. Discussing the

Medical Rehabilitation for Diagnostic Groups

importance of previous family roles and how the amputation may have changed these roles is helpful. This will help the patient and family reach decisions regarding which roles are most important and which may be abandoned or modified (18). The new amputee’s role in the community should be similarly examined. Was the patient an active participant in community events? Was he or she a passive spectator? Was he uninvolved? How does the amputation affect the person’s participation in community outings such as shopping trips, trips to restaurants, or trips to the movies or theater? The previously active patient may find it difficult to resume these activities, for physical reasons or because of self-conscious feelings. Therapeutic outings with members of the rehabilitation team to restaurants, malls, or movie theaters can help desensitize the patient to these awkward feelings and facilitate resumption of these activities. Frequently, the patient must learn to be more aggressive or assertive to make use of programs or facilities not obviously available. This may be quite difficult for a person who is normally shy or passive. The patient should also be educated about community programs and resources that may facilitate participation by people with disabilities (60,61). Returning to driving plays a significant role in many patients’ resuming normal activities. Frequently, a minor modification or no modification to the vehicle is required for the amputee to resume driving. Without relying on others for mobility, the amputee’s independence grows.

SPECIAL CONSIDERATIONS FOR THE COMPLEX AMPUTEE AND THE PATIENT WITH DUAL DISABILITY It is increasingly common in the rehabilitation population to encounter patients with dual disability such as hemiplegia and limb loss, blindness and limb loss, and multiple limb loss. Each individual disability can be catastrophic on its own; the dual disability may be even more so, resulting in long-term placement of the patient in a nursing home. With the appropriate interventions and social support systems, many patients with dual disability can return to their home environment. A rehabilitated limb after amputation prior to the onset of hemiparesis from stroke has a better functional outcome than if the stroke had preceded the amputation (62). A right hemiparesis or an ipsilateral hemiplegia and limb loss also have a better prognosis, compared with a left hemiparesis or limb loss contralateral to the hemiplegia. Clear simple step-by-step instructions and a modified prosthesis are very useful for these patients. For the blind patient, sensory input using raised markings, Velcro closures, and step-by-step sequencing is useful. A cane should be used whenever possible to provide protective auditory

Chapter 93

Amputation Rehabilitation

and tactile feedback to the patient. Appropriate home environment modifications should be carried out. Fifty percent of patients who have had a lower-limb amputation due to disease are at risk for a second amputation within 3 years. If no other concurrent disabilities occur, the patient with a second transtibial amputation should achieve a level of independence similar to that attained prior to the second amputation. The heights of the prostheses are routinely decreased to improve balance and possibly decrease the energy required to maintain standing balance. For patients with bilateral transfemoral amputation, there is a significant increase in energy consumption, estimated at over 100% (63), that may prevent long-distance ambulation. In general, most transfemoral bilateral amputees over 50 years old will find the wheelchair an easier and more practical means of locomotion. Ambulation should be attempted only when adequate cardiac function, strength, balance, and endurance exist; the use of multiaxis ankle-feet systems with lower height and weightactivated knee-locking mechanisms should facilitate the patient’s ability to ambulate (64). The clinician can avoid unnecessary expenditures of resources in the geriatric population by careful selection of potentially functional ambulation candidates who have had bilateral transfemoral amputations (65).

Bilateral Amputation Intuitively ambulation with bilateral lower-limb loss should be much more difficult than with single lower-limb loss. The limited data available support this thesis (65,66–69), but many bilateral amputees ambulate nonetheless, with varying degrees of proficiency. For all these individuals, there should be a long discussion on the difficulties they face, the risks (including falls and increased cardiac demand), and realistic goals before prosthetic fabrication commences. Many bilateral transtibial-level amputees will achieve independence in ambulation with prostheses (Fig. 93-5). Several prosthetic modifications can be performed to make ambulation with bilateral transtibial prostheses less difficult. Although some patients may object, shortening the prostheses by 1 or 2 inches lowers the center of gravity and can improve balance and decrease energy consumption during standing and ambulation. Of course, the height can be restored later if the patient so chooses, and if walking skills have progressed satisfactorily. By out-setting the feet, the base of support is widened and balance is also enhanced (Fig. 93-6). Flexing the sockets or dorsiflexing the feet promotes a forward lean and slightly crouched posture, which also gives most bilateral transtibial-level amputees a sense of improved stability. Using articulated single-axis feet rather than fixed ankles may also improve balance and ambulation by reducing the knee flexion moment during the loading response. During normal gait, in the earlystance phase (initial contact and loading response), the

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ground reaction force falls behind the ankle, generating a plantarflexion moment (70). This plantarflexion is controlled by the activity of the pretibial muscles, allowing the foot to gradually descend to the floor. The ground reaction force lies behind the knee as well, requiring the knee extensors to prevent buckling of the knee. The magnitude of the knee flexion moment increases with the perpendicular distance between the ground reaction force and the knee

Figure 93-5. Bilateral transtibial amputee with prosthesis (digital image).

joint center (71). For the transtibial-level amputee whose prosthesis has a fixed ankle, the ground reaction force is located farther behind the knee and remains there for a longer period of time. This generates a more significant flexion moment. When an articulated ankle is used, the prosthetic foot plantarflexes to a foot-flat posture promptly after initial contact. This moves the ground reaction force farther anterior, reducing the distance to the knee center and reducing the magnitude and duration of the flexion moment. Most patients will appreciate the flexibility of the articulated ankle, but others may find the ankle motion a source of instability and increased weight. Some patients report that the solid ankle of a SACH (solid-ankle cushion-heel) foot or most energy-storing feet feels more firm and stable, and therefore, more comfortable. The bilateral amputee who has had one transtibial and one transfemoral amputation can benefit from some of the modifications indicated above. Widening the base of support, moving the center of mass forward, and lowering the center of mass can be helpful. Articulated ankles should also enhance standing and walking stability. The design of the knee on the transfemoral amputation side should be chosen carefully. If stability is a great concern, a simple lightweight manual-lock knee removes the risk of knee buckling. The data are limited, and studies have yielded conflicting conclusions about the energy costs of ambulation with a locked or swinging prosthetic knee. Traugh et al (72) found no significant difference in the energy cost of ambulation using a locked compared to an unlocked knee. Isakov et al (73) found that ambulation with a locked knee is more energy efficient. Meanwhile many patients prefer an unlocked knee because of the more natural-appearing gait and improved ability to transfer. A weight-activated or polycentric knee allows flexion during the swing phase but still resists knee flexion during stance. A hydraulic or pneumatic knee will provide a more

Figure 93-6. Alignment modifications to improve the base of support for bilateral amputees, outset foot.

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physiologic function for the vigorous, high-activity-level patient, but its use in the geriatric population may be limited by weight and cost. Many patients who have had transtibial and transfemoral amputations use the prosthesis on a limited basis, in the home or for social events, and may use alternative means of mobility such as a wheelchair most of the time. Other patients may use only a single prosthesis (usually the transtibial) for transfers, standing, and limited swingthrough ambulation. For many individuals with significant cardiac or muscle strength limitations or contractures, no prostheses or only a transtibial prosthesis may be the best alternative for transfers. Few bilateral transfemoral-level amputees will be functional long-distance ambulators, although many will achieve limited independence in ambulation with prostheses. The energy required for the bilateral transfemoral-level amputee to ambulate is simply too great (67,69). The modifications mentioned earlier can be utilized to make ambulation less difficult. Some patients may initially use “stubbies,” short nonarticulated limbs with broad feet (74), and then graduate to taller limbs with knees. The choice of knees should be made after considering stability, safety, weight, cost, and activity level. As with the transtibialtransfemoral amputee population, many bilateral transfemoral-level amputees choose wheelchair mobility with no prostheses because of simplicity, energy efficiency, and comfort. Several factors are relative contraindications to prescribing prostheses for the bilateral lower-limb amputee. These include lack of motivation, significant cognitive impairment, severe cardiac disease, severe contractures, and severe neurologic impairment (75). The degree of cardiac compromise a patient can tolerate while walking with bilateral prostheses is unclear. An ejection fraction of 20% may be chosen as an arbitrary cutoff, but no hard data exist to substantiate this. Prosthetic ambulation is possible in the setting of significant cardiac compromise because amputees adjust their walking speed to keep relative energy demands at a manageable level (76). Patients must participate in this decision-making process and should understand the rationale behind the decision. They should never feel that they were not given the opportunity to walk with prostheses “just because the doctor said I couldn’t.” When patients are presented with appropriate information regarding the risks and advantages of ambulation, and are provided with an accurate idea of what ambulation with bilateral prostheses will be like, they are generally able to reach rational decisions. The sequence of amputations is thought to have an impact on future bilateral prosthetic ambulation (75). People who are able to ambulate with a transfemoral prosthesis are likely to be able to achieve bilateral prosthetic ambulation after a subsequent transtibial amputation. However, the transtibial prosthetic user who has a subsequent contralateral transfemoral amputation may have a

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more difficult time achieving ambulatory status following the second amputation. The issue of rehabilitation for bilateral amputees has become increasingly important as the prevalence of bilateral lower-limb amputations rises and resources become scarcer. Kerstein et al (77) in 1974 noted that 23% of their amputee rehabilitation population were bilateral amputees. Esquenazi et al (26) in 1984 reported an increasing number of amputees readmitted for bilateral prosthetic training. Nondiabetic patients who undergo an amputation for ischemia have a 5% to 13% risk at 1 year and 28% risk at 5 years for contralateral amputation (78,79). For the diabetic population, the risk is higher, approximately 50% at 3 years (80).

The Blind Amputee Since many amputees are diabetic with an increased incidence of retinopathy (81), they will frequently develop comorbidity of blindness or visual impairment. Patients who recently became blind should receive a program of instruction in compensatory techniques related to their new-onset blindness, to complement the amputation rehabilitation. More often, patients have had long-standing blindness. These patients should use tactile clues to allow them to manage their prostheses appropriately. Most people can identify sock ply simply by feeling the different thicknesses, so this is usually not an issue. However, donning the prosthetic device with the correct orientation can be difficult. When this is a problem, tactile cues such as bumps or ridges should be placed on the socket or the insert to give the patient a reference point for donning. Also the suspension straps may require alternative fasteners such as those made of Velcro, to make them easier to manage. The blind patient should be instructed to inspect the skin of the RL and intact foot by feeling for wounds, abrasions, skin irregularities, or changes in temperature. If the patient has neuropathies that decrease the sensation in the hands, a caregiver should be instructed in assisting patient with skin inspection and prosthetic management (82). The rehabilitation of the blind amputee should also address the environment. Ambulation with the appropriate cane for protective sensory and auditory feedback is taught. If the patient needs to use the upper limbs for support and balance, then it may be necessary to recommend walking with a companion who can serve as a guide. Of course, a home assessment should be performed before discharge of the person who is blind and has had an amputation. Modifications to the home environment can promote independence and improve safety.

Hemiplegic Amputee As the elderly population increases and survival after stroke and amputation improve, we can expect to see more patients with generalized vasculopathy who have simultaneous vascular-related disabilities. In addition, many

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patients survive high-impact collisions with resulting head injuries and amputations. The dual disabilities of hemiparesis and limb loss present a spectrum of problems (62,83). The characteristics that complicate or simplify the rehabilitation process for a patient with these two disabilities are similar to the exacerbating and mitigating factors for the individual disabilities. For example, the rehabilitation of a patient after a transfemoral amputation would generally be more difficult than after a transtibial amputation, and the rehabilitation of a patient with severe hemiplegia with neglect and cognitive impairment would be more difficult than that of a patient with mild pure motor hemiparesis. The sequence of the onset of disabilities and the location (ipsilateral or contralateral) also influence the rehabilitation outcome. The individuals who first undergo an amputation and then later sustain a stroke generally achieve better functional status than do those who first are afflicted by the neurologic event (61). Ipsilateral involvement also suggests better outcome than contralateral involvement. In general, patients with right-sided hemiparesis tend to have a better functional outcome than do those with left-sided neurological residual. As one would expect, younger patients with these dual disabilities generally attain better functional outcomes than older patients. The patient who is ambulatory after a lower-limb amputation and subsequently has a stroke with ipsilateral weakness can often regain independent ambulatory status, unless the stroke is very severe. The height and alignment of the prosthesis are adjusted to compensate for strokeinduced gait deviations where possible. Shortening the prosthesis may improve swing-phase clearance problems. Increased prosthetic ankle plantarflexion can assist weak knee extensors by providing mechanical stability to the knee joint during the stance phase. When flexor tone interferes with knee stability, the use of a thigh corset with external knee joints may be of benefit. The orthotic knee joints may be offset or single axis and equipped with drop locks to enhance stability during the stance phase. Widening the base of support by “outsetting” the prosthetic foot reduces balance problems. For the patient with severe hip adductor tone, the use of interventions to decrease spasticity focally, such as phenol block of the obturator nerve or surgical interventions (obturator neurectomy or adductor tenotomy), should be considered. When necessary markings are placed on the prosthesis, the suspension straps, and even the socks, to make the task of donning the prosthesis a more structured process that can be made routine by a patient with cognitive deficits. Patients with significant upper-limb involvement will need to learn one-handed prosthetic management techniques. For the transtibial-level amputee, certain devices can be used to achieve one-handed donning, such as neoprene, spandex, or silicone sleeves, which can be rolled on with one hand. For the transfemoral-level amputee, the prosthesis, because of its size and weight,

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may be difficult to manage. In this situation, use of the TC-3 (84) socket, developed at the Tokyo Metropolitan Rehabilitation Center in Japan, permits the patient to handle the socket with the suspension system of choice, separate from the prosthesis. This option provides the patient with the advantage of handling a smaller section of the prosthesis, with decreased bulk and weight. Then the socket is inserted into a thin receptacle and attached with a Velcro strap. In addition, this system permits donning and doffing in the seating position. Similar prosthetic adjustments improve the functional mobility of a person with a preexisting hemiplegia and new ipsilateral limb loss. Learning new concepts of prosthetic management such as donning and doffing the limb or adjusting the number of stump socks used may be difficult if the new amputee has preexisting cortical dysfunction. For the nonambulatory patient after a stroke and amputation, independence in transfers should still be possible, as the “intact” side should provide adequate strength and stability for standing and pivoting. Contralateral hemiplegia and amputation pose more difficult problems. The severity of the stroke and the level of amputation determine which will be the patient’s dominant leg and whether future ambulation is likely. For the transtibial-level amputee with contralateral hemiparesis, ambulation with an assistive device should be possible unless the stroke is very severe. Even with severe stroke sequelae, the patient will likely benefit from a prosthesis for standing and transfers. If the amputation is at the transfemoral level, then ambulation will be quite difficult or impossible unless the stroke is mild. For many such patients, prosthetic fabrication is not indicated.

LONG-TERM FOLLOW-UP Long-term follow-up of the amputee involves not only prosthetic maintenance and skin checks, but also psychosocial rehabilitation and wellness behavior. For many amputees, the physiatrist is viewed as the primary physician, perhaps because the physiatrist sees the amputation as the most important health and medical issue in their lives. Thus, the physiatrist is likely to confront many health-related issues besides those associated with the RL or the prosthesis. During a follow-up visit, the patient’s prosthetic usage is discussed. Is the prosthesis worn daily? All day long? If not, are there problems with comfort that need to be addressed? If the prosthesis is not incorporated into the normal daily routine of the patient, it will always be viewed as heavy, clumsy, abnormal, and difficult to manage, despite hours of adjustments by the prosthetist and physician. It is appropriate to review the patient’s lifestyle. Does he or she leave the home for shopping, recreation, socialization, or work? People may choose to stay at home for

Medical Rehabilitation for Diagnostic Groups

different reasons. However, if architectural barriers or mobility dysfunction are the cause, then the patient may benefit from the physician’s intervention. Further outpatient therapies to address mobility on stairs or other obstacles may be appropriate. Ramps, rails, stair glides, or other equipment may free the patient from unnecessary confinement. If the patient stays at home for medical or psychological reasons, then further evaluation and treatment of those specific problems may be necessary. The fit and condition of the prosthesis warrant periodic evaluation. Over time, repairs to the components of the prosthesis are necessary. Changes in the size and shape of the RL require that a new socket be made periodically (85,86). Changes in the patient’s condition will often dictate changes in the prosthetic prescription. For example, the transtibial-level amputee with a patellar tendon–bearing socket and elastic sleeve suspension may develop degenerative changes in the knee and may benefit from the addition of a thigh corset and mechanical knee joints for pressure relief and additional stability. While may amputees are resistant to changes in their prostheses, newer materials or components may prove advantageous. The physiatrist will need to educate the patient about the potential benefits of new technology. Routine skin care needs to be reviewed. The patient is reminded of the importance of good hygiene. Skin irritation and breakdown may result from poor cleaning techniques. For the diabetic patient in particular, meticulous skin care is imperative. The patient is reminded to clean the skin gently with mild soap and warm water and to blot the skin dry, including between the toes of the intact foot. A skin moisturizer helps to keep the skin soft and supple, avoiding dryness, cracking, and fissures, which may lead to superficial infection. Lamb’s wool placed between the toes helps avoid maceration and “kissing” ulcers. The patient is taught to avoid any potential trauma to the feet, including thermal injury. Cold feet deserve warm socks rather than a burn from a heating pad or hot water bottle. Socks should be worn with footwear, and walking barefoot is forbidden. The patient should check shoes before putting them on. At

least one person required a transtibial amputation for a foot infection that began with an ulcer caused by walking with a coin in their shoe (87,88). The routine follow-up visit is also the time to review health maintenance behavior. Cessation of smoking is an important topic for many amputees. Most people are aware that smoking leads to cardiac and pulmonary problems, but many are unaware that smoking increases the risk for limb ischemia and amputation. The patient with lower-limb ischemia and claudication would likely benefit from a regular exercise program (89). The follow-up visit is the time to introduce, clarify, or reinforce such an exercise regimen. The patient may also benefit from counseling regarding nutrition and proper body weight. While exercise and diet are important for all, it is beneficial to remind the diabetic patient that diet and exercise are the mainstays of therapy for diabetes. The patient may also need reminders regarding blood pressure checks, cholesterol monitoring, flu vaccinations, and general medical follow-up. Finally, the routine check-up is a good time to remind the patient of his or her achievements and to discuss new goals. Absorbed in the daily routine, the amputee may lose sight of the fact that he or she overcame significant trauma. Positive feedback is very therapeutic. The clinician may want to suggest new activities such as cycling or swimming. Of course, rehabilitation professionals need not be reminded that the truly rehabilitated amputee does much more than simply walk.

CONCLUSIONS Comprehensive rehabilitation of the amputee should be more than the provision of a prosthetic device. This is especially true for the geriatric amputee whose needs are greater because of comorbidity, fragile social supports, and limited resources. For the young, active patient, optimization of the prosthetic device and appropriate rehabilitation are necessary to preserve the patient in good health.

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Amputation Rehabilitation

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