PT for Patients with Lower Limb Amputation

Yu Nan-Ying 2005/12/26

Introduction
The major cause of lower extremity amputation is peripheral vascular disease (PVD), particularly when associated with smoking and diabetes The second leading cause of amputation is trauma, usually from motor vehicle accidents or gunshot The incidence of amputation from osteogenic sarcoma has been reduced by better limb salvage

Surgical Process
Basic principles Skin flaps are as broad as possible and the scar should be pliable, painless, and nonadherent. For most transfemoral and nondysvascular transtibial amputations, equal length anterior and posterior flaps are used, placing the scar at the distal end Long posterior flaps are often used in dysvascular transtibial amputations

Surgical Process

Basic Principles
Muscle stabilization may be achieved by myofascial closure, myoplasty, myodesis, or tenodesis Severed peripheral nerves form neuromas (a collection of nerve ends) in the residual limb The neuroma must be well surrounded by soft tissue

Surgical Process

Basic Principles
Hemostasis is achieved ligating major veins and arteries Cauterization is used only for small bleeders Bones are sectioned at a length to allow wound closure without excessive redundant tissue at the end of residual limb and without placing the incision under greater tension

Healing Process
The surgeons goal is to amputate at the lowest possible level compatible with healing Factors that may affect healing include infection, cigarette smoking, the severity of vascular problems, diabetes, renal disease, and other physiological problems such as cardiac disease

The Major Outcomes of the Postsurgical Period

1. Promote as high a level of independent function as possible 2. Guide the development of necessary physical and emotional level for eventual prosthetic rehabilitation 3. Independence in mobility and self-care 4. Independence in bed mobility and basic transfers 5. Supervised or independent mobility with crutches or walker 6. Demonstrate knowledge of proper residual limb positioning, bandaging, and care

The Major Outcomes of the Postsurgical Program

1. Reduce postoperativ edema and promote healing of the residual limb 2. Prevent contractures and other complications 3. Maintain or regain strength in the affected lower limb 4. Maintain or increase strength in the remaining extremeties 5. Assist with adjustment to the loss of a body part 6. Demonstrate knowledge of basic residual limb exercise 7. Learn proper care of the remaining extremity 8. Determine the feasibility of prosthetic fitting

Postoperative Dressing
Rigid dressing An attachment incorporated at the distal end of the dressing allows the later addition of foot and pylon allowing limited weight-bearing ambulation within a few days or a week of surgery (immediate postoperative prosthesis)

The Advantage of Rigid Dressing

1. Limits the development of postoperative edema 2. Allows for early ambulation 3. Allows for early fitting of the permanent prosthesis by reducing the length of time needed for shrinking the residual limb 4. Configured to each individual residual limb

The Major Disadvantage of Rigid Dressing

1. Requires careful application by an individual knowledgeable about prosthetic principles 2. Requires close supervision during the healing stage 3. Does not allow for daily wound inspection and dressing changes

Semirigid Dressing
It provides better control of edema than the soft dressing (Unnas dressing, air splinting, and controlled environmental treatment .) The air splint is a plastic double wall bag that is pumped to the desired level of rigidity *It allows improved wound inspection *The constant pressure does not intimately conform to the shape of residual limb

Soft Dressing
Advantages 1. Relatively inexpensive 2. Light weight and readily available 3. Able to be laundered

Soft Dressing
Disadvantages 1. Relatively poor control of edema 2. The elastic wrap requires skill in proper application 3. The elastic wrap needs frequent reapplication 4. Either can slip and form a tourniquet 5. New shrinkers must be purchased as the residual limb gets markedly smaller 6. Shrinker cannot be used until the sutures have been removed and primary healing has occurred

Soft Dressing
Elastic Wrap
*The elastic wrap may be applied over the postsurgical dressing if care is taken to ensure proper compression *A dressing is applied to the incision followed by some form of gauze pad, then the compression wrap.

Shrinkers
*Socklike garments knitted of heavy rubber reinforced cotton; they are conical in shape and come in a variety of sizes.

Examination
Range of motion (if the dressing allows) Muscle strength (MMT of the involved lower extremity must wait until most healing has occurred) Residual limb (length, circumference, and shape, skin condition, sensation, and joint proprioception ..) Note: Exact landmarks should be carefully noted in length and circumference measurement

Examination

The phantom limb

Phantom is the sensation of the limb that is no longer there is often described as a tingling, pressure sensation, sometimes a numbness

The phantom pain

A cramping, squeezing sensation, or a shooting or a burning pain May be localized or diffuse; continuous or intermittent and triggered by some external stimuli It may diminish over time or may become a permanent and often disabling condition

Examination

The Phantom Pain

The patients are usually told to view the phantom as a part of themselves Sometimes, wearing a prosthesis will ease the phantom pain Ultrasound, icing, TENS, or massage have been used with varying success Chordotomies, rhizotomies, and peripheral neurectomies have been tried with limited success

Examination

Other Data
The vascular status of uninvolved lower extremity is determined and its condition noted Data gathered include condition of the skin, presence of pulses, sensation, temperature, edema, pain on exercise or at rest, presence of wound, ulceration, or other abnormalities ADL and functional mobility skill The persons apparent emotional status and degree of adjustment are noted

Emotional Adjustment
Psychological support The elderly

As with other physically challenged individuals, those with amputations need to be accepted and intergrated into the community because of their abilities not their disabilities

Interventions
Residual limb care Individuals not fitted with a rigid dressing or a temporary prosthesis use elastic wrap or shrinkers to reduce the size of the residual limb An intermittent compression unit can be used to reduce edema Proper hygiene and skin care are important Patients can learn to properly perform a gentle friction massage to mobilize the scar and help decrease hypersensitivity of the residual limb The patient is taught to inspect the residual limb with a mirror each night to make sure there are no sores or impending problems

Interventions
Residual limb care Individuals not fitted with a rigid dressing or a temporary prosthesis use elastic wrap or shrinkers to reduce the size of the residual limb An intermittent compression unit can be used to reduce edema Proper hygiene and skin care are important Patients can learn to properly perform a gentle friction massage to mobilize the scar and help decrease hypersensitivity of the residual limb The patient is taught to inspect the residual limb with a mirror each night to make sure there are no sores or impending problems

Residual Limb Wrapping

The transtibial bandage *Two 4-inch elastic bandages *The first bandage is started at either the medial or lateral tibial condyle and brought diagonally over the anterior surface of the limb to the distal end *It may be brought across the front of the residual limb in an X design

Residual Limb Wrapping

The transfemoral bandage *Two 6-inch and one 4-inch elastic bandages *The first bandage is started in the groin and brought diagonally over the anterior surface to the distal lateral corner, around the end of residual limb, and diagonally up the posterior side to the iliac crest and around the hip in a spica

Positioning
With the transtibial amputation, full range of motion in the hips and knee, particularly in extension is needed While sitting, the patient can keep the knee extended by using a posterior splint or a board attached to the wheelchair The patient with the transfemoral amputation needs full range of motion in the hip, particularly in extension and adduction Prolong sitting is to be avoided Elevation of the residual limb on a pillow can lead to the development of flexion contracture

Contractures
Some individuals will present with hip or knee flexion contracture Facilitated stretching techniques (PNF) are more effective than passive stretching Hold-relax, hold-relax active contraction that utilizes resisted contraction of antagonist muscles may increase range of motion Fit the patient with a Patellar-tendon-bearing (PTB) prosthesis aligned in a manner that places the hamstrings on stretch with each step

Exercises
The postsurgical dressing, degree of postoperative pain, and healing of the incision will determine when resistive exercises for the involved extremity can be started The hip extensors and abductors, and knee extensors and flexors are particularly important for prosthetic ambulation Sitting and standing balance activities are a useful part of the early postsurgical program Shoulder depression and elbow extension are necessary for crutch ambulation

Mobility
Walking is an excelent exercise and necessary for independence in daily life Gait training can start early in the postoperative phase (usually three-point gait pattern crutches) Walker is used only if the person cannot learn to walk with crutches A reciprocal walker is not safe during the postsurgical period when the patient is using a three-point gait pattern

Temporary Prostheses
Advantages in using a temporary prosthesis 1. It shrinks the residual limb more effectively than the elastic 2. It allows early bipedal ambulation 3. Many elderly people can walk safely with a temporary prosthesis and a cane who otherwise would not be ambulatory during the postsurgical period 4. Some individual can return to work 5. It provides a means of evaluating the rehabilitation potential of individuals with a questionable prognosis

Temporary Prostheses
Advantages in using a temporary prosthesis 6. It is a positive motivating factor; providing a replacement for the missing part of the body 7.It reduces the need for a complex exercise program because many people can return to full active daily life 8. It can be used by individuals who may have difficulty obtaining payment for a definitive prosthesis

Patient Education
1. A discussion of the disease process, the physiological effects of the symptoms, and life-style changes to reduce risk factors 2. Information on the benefits of exercises, lower extremity cleanliness, proper foot care, and proper shoe fitting 3. Methods of edema control 4. The use of exercise to improve circulatory status

Bilateral Amputation
The postsurgical program for the person with bilateral lower extremity amputation is similar to the program developed for unilateral amputation All individuals with bilateral amputations need a wheelchair on a permanent basis The postsurgical program includes mat activities designed to help the person regain a sense of body position and balance, upper extremity and residual limb strengthening exercise, and regular range of motion exercises

Bilateral Amputation
If possible, or at least spend some time in the prone position each day range of motion exercises The person with bilateral trasfemoral amputation can be fitted with shortened prosthesis called stubbies Stubby prostheses have regular sockets, no articulated knee joints or shank, and modified rocker bottoms turned backward to prevent the person from falling backward