Rehabilitation of the Amputee Brian M. Kelly and James A. Leonard, Jr. Approximately 100,000 to 150,000 persons experience some level of major lower limb amputation in the United States each year. The majority of these patients have diabetes and/or peripheral vascular disease (approximately 90%). A rehabilitation medicine physician (physiatrist) has much to offer the patient who is going to require an amputation. The physiatrist can provide counsel to the patient and family about rehabilitation and the possibility of future prosthetic function, comment on the advantages or disadvantages of the proposed level of amputation for future prosthetic fitting and function, determine and direct the patient’s rehabilitation needs during the acute hospital stay, determine the need for and oversee any additional inpatient rehabilitation care before discharge home, and manage the patient’s ongoing prosthetic restoration and rehabilitation once the amputation incision has healed. The earlier rehabilitation professionals are involved in the care of patients who are to have or who have had an amputation, the more they can contribute. The rehabilitation care of an amputee is best organized temporally in relation to the amputation surgery because specific rehabilitation activities are appropriate for the different time periods. The time periods are best identified as preoperative, postoperative, preprosthetic, and prosthetic rehabilitation. This care is a team effort and can require the contributions of many individuals including physical and occupational therapists, prosthetists, social workers, psychologists, vocational specialists, and peer counselors. Before Amputation The focus of the preamputation evaluation is counseling. The goal is to provide the patient and family with information and answer questions to help the patient to make an informed decision about whether to proceed with an amputation or not, and it will also help prepare the patient for what will occur following amputation. Most patients facing a major limb amputation are frightened, anxious, depressed, and uncertain of their future. They may be reluctant to proceed with their surgeon’s recommendation of amputation either as a treatment from among one of a number of treatment options or as the final treatment option after all other treatments for limb salvage have been explored and exhausted. The rehabilitation team provides patients and family with information about life after amputation, which can help to allay their fears and allow them to make an informed decision on treatment course, if they have that option, or to move forward with their surgery. The rehabilitation team counseling should include discussion of several topics, including phantom limb sensation, phantom limb pain, residual limb pain, management of the residual limb after amputation, physical and occupational therapy to occur while on the acute surgical service, the possibility of additional rehabilitation care before discharge to home (whether in an acute or subacute facility), the anticipated timing of initial prosthetic fitting (typically 6 to 8 weeks after amputation for the dysvascular population), the processes of prosthetic fitting, expected prosthetic function (if the patient is deemed a candidate for prosthetic restoration) and the therapy necessary to learn to successfully use a prosthesis. Assessment of the patients’ physical status and prior level of function is another key part of the physiatrist’s initial evaluation. In addition to the history of the patient’s chief complaint leading to amputation and any other acute or chronic medical conditions, the rehabilitation team must know the patient’s prior level of function, living situation, and family support. When did the patient last walk? Was the patient using a cane or walker to walk? Was the patient living at home or in a nursing home? If the patient lives at home, what is the home like? Is the home accessible, or are there stairs to be managed to get in or out of the home? Are there other environmental barriers that might prevent a return to home? Does the patient live alone, or is there a spouse or family available to assist with care upon return to home? Is the spouse’s or family’s health or time commitments such they can actually provide assistance if needed? The physical examination must assess the patient’s general physical condition, strength of all extremities, endurance, joint range of motion, the status of the other lower extremity in the case of lower limb amputation, and the patient’s cognitive abilities. Being nonambulatory or having significant joint contractures, weakness, and/or significant cognitive impairments limiting the ability to learn new skills can preclude patients from ever being considered candidates for prosthetic restoration. This initial evaluation helps to define the patient’s rehabilitation goals, direct the therapies, and determine if the patient is likely to require continuing inpatient rehabilitation services after acute surgical care. Amputation Level The goal when selecting an amputation level for a particular dysvascular patient is to choose the level that will most likely heal while preserving the most function for the patient. In general, the more joints that are preserved and the longer the residual limb is, the more function and the lower the energy expenditure the amputee is likely to experience when using a prosthesis. In addition to this general guideline to preserve length and joints, there are some considerations that will result in better prosthetic outcomes for the amputee patient. It is important that all amputations have a secure myoplasty or myodesis, with a minimum of redundant soft tissue to maximize the efficiency of force transfer from the bone of the residual to the prosthesis. The more the major long bone of the residual limb (femur and tibia for lower limb amputations and humerus and ulna for upper limb amputations) has to move through soft tissues before contacting and initiating movement of the prosthetic socket, the greater the loss in efficiency and the greater the decrease in prosthetic function. Sometimes, as a result of posttraumatic swelling, complications of cellulitis, associated compartment syndrome, or other morbidity, the soft tissues cannot be closed as ideally as desired, resulting in significant soft tissue redundancy. It is better to have the outcome of redundant distal soft tissue with a preserved knee than an ideal closure at a transfemoral amputation level. If the resulting prosthetic function is less than optimal or problematic as a result of redundant soft tissue, a plastic and reconstructive revision of the residual limb to remove redundant tissue can be considered at a later date. Toe amputations and most transmetatarsal amputations are very functional levels of amputation that can be accommodated quite easily with shoe modifications for walking on level surfaces in most cases. Very proximal transmetatarsal amputations, Lisfranc amputations, Chopart amputations, and amputations through the hind foot have the advantage of preserving some or all of the weight-bearing surface of the foot together with maintaining normal limb length. These amputation levels, however, can result in significant functional difficulty if special care is not taken to balance the opposing plantar and dorsiflexion forces about the ankle by relocating the attachment of the ankle dorsiflexors. When this is not done properly the patient develops an equinus deformity of the ankle, making it difficult or impossible to walk. Amputations through the mid and hindfoot while preserving length can also be quite challenging to impossible to provide a good functional prosthetic option. A more proximal level amputation can often be a better option for improved function. A Syme amputation or ankle disarticulation can be a very acceptable and functional amputation level with reasonable prosthetic options. Because the limb length difference is relatively small, the patient is capable of walking without a prosthesis by flexing the contralateral knee and hip to accommodate for the limb length difference. These same advantages also present some disadvantages when considering prosthetic restoration, which may be unexpected or unacceptable to patients if they are not aware of them when discussing options for amputation level. The long length of the residual limb significantly limits the options for prosthetic foot choice because of the limited space between the end of the residual limb and the floor (about 2 ½ to 3 inches) and precludes the use of specialized components such as shock pylons and rotators commonly used in prostheses for a more proximal transtibial amputation. The bulbous distal limb must be accommodated for in the design of the prosthesis and requires a socket that may be much larger in circumference than the contralateral limb, resulting in a prosthesis that might be either esthetically unpleasing or unacceptable to the patient. Similar advantages and disadvantages are associated with knee disarticulation amputations. The advantages of a knee disarticulation are a good end-bearing residual limb able to tolerate distal residual limb weight bearing in a prosthesis, long residual limb or lever arm to reduce energy expenditure, and a bulbous shape to the distal residual limb allowing anatomic suspension of the socket. The bulbous shape of the distal femur from the retained condyles can also be one of its disadvantages, necessitating a less-than-cosmetically acceptable shape to the socket for some patients. The greatest disadvantage of the knee disarticulation has always been the long length of the residual limb because the entire femur remains, leading to a knee axis center in the prosthesis that is longer than that on the nonamputated lower extremity. The resulting longer thigh length (full femur, prosthetic socket, and prosthetic knee) can result in functional problems for the amputee where seating space may be limited as in theater, airplane, and automobile seats. Fortunately this is somewhat less of a problem than it used to be with the availability of prosthetic knee units designed to minimize this difference. Disarticulation level amputations have a unique advantage in children requiring an extremity amputation because this minimizes the risk of bony overgrowth that occurs in approximately 15% of trans–long bone amputations in children. This bony overgrowth often results in a prosthetic misfit and use problems, necessitating revision of the bone to eliminate the spurring. Maintaining the distal cartilage with disarticulation-level amputations prevents this overgrowth. Saving a functional knee, even if it results in a short transtibial residual limb, conveys advantage to the amputee for prosthetic function over that of a transfemoral amputation. Only gold members can continue reading. Log In or Register to continue Share this:Click to share on Twitter (Opens in new window)Click to share on Facebook (Opens in new window) Related Related posts: Technical Aspects of Percutaneous Carotid Angioplasty and Stenting for Arteriosclerotic Disease In-Situ Treatment of Aortic Graft Infection with Prosthetic Grafts and Allografts Treatment of Acute Upper Extremity Venous Occlusion Intraoperative Assessment of the Technical Adequacy of Carotid Endarterectomy Stay updated, free articles. 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Rehabilitation of the Amputee Brian M. Kelly and James A. Leonard, Jr. Approximately 100,000 to 150,000 persons experience some level of major lower limb amputation in the United States each year. The majority of these patients have diabetes and/or peripheral vascular disease (approximately 90%). A rehabilitation medicine physician (physiatrist) has much to offer the patient who is going to require an amputation. The physiatrist can provide counsel to the patient and family about rehabilitation and the possibility of future prosthetic function, comment on the advantages or disadvantages of the proposed level of amputation for future prosthetic fitting and function, determine and direct the patient’s rehabilitation needs during the acute hospital stay, determine the need for and oversee any additional inpatient rehabilitation care before discharge home, and manage the patient’s ongoing prosthetic restoration and rehabilitation once the amputation incision has healed. The earlier rehabilitation professionals are involved in the care of patients who are to have or who have had an amputation, the more they can contribute. The rehabilitation care of an amputee is best organized temporally in relation to the amputation surgery because specific rehabilitation activities are appropriate for the different time periods. The time periods are best identified as preoperative, postoperative, preprosthetic, and prosthetic rehabilitation. This care is a team effort and can require the contributions of many individuals including physical and occupational therapists, prosthetists, social workers, psychologists, vocational specialists, and peer counselors. Before Amputation The focus of the preamputation evaluation is counseling. The goal is to provide the patient and family with information and answer questions to help the patient to make an informed decision about whether to proceed with an amputation or not, and it will also help prepare the patient for what will occur following amputation. Most patients facing a major limb amputation are frightened, anxious, depressed, and uncertain of their future. They may be reluctant to proceed with their surgeon’s recommendation of amputation either as a treatment from among one of a number of treatment options or as the final treatment option after all other treatments for limb salvage have been explored and exhausted. The rehabilitation team provides patients and family with information about life after amputation, which can help to allay their fears and allow them to make an informed decision on treatment course, if they have that option, or to move forward with their surgery. The rehabilitation team counseling should include discussion of several topics, including phantom limb sensation, phantom limb pain, residual limb pain, management of the residual limb after amputation, physical and occupational therapy to occur while on the acute surgical service, the possibility of additional rehabilitation care before discharge to home (whether in an acute or subacute facility), the anticipated timing of initial prosthetic fitting (typically 6 to 8 weeks after amputation for the dysvascular population), the processes of prosthetic fitting, expected prosthetic function (if the patient is deemed a candidate for prosthetic restoration) and the therapy necessary to learn to successfully use a prosthesis. Assessment of the patients’ physical status and prior level of function is another key part of the physiatrist’s initial evaluation. In addition to the history of the patient’s chief complaint leading to amputation and any other acute or chronic medical conditions, the rehabilitation team must know the patient’s prior level of function, living situation, and family support. When did the patient last walk? Was the patient using a cane or walker to walk? Was the patient living at home or in a nursing home? If the patient lives at home, what is the home like? Is the home accessible, or are there stairs to be managed to get in or out of the home? Are there other environmental barriers that might prevent a return to home? Does the patient live alone, or is there a spouse or family available to assist with care upon return to home? Is the spouse’s or family’s health or time commitments such they can actually provide assistance if needed? The physical examination must assess the patient’s general physical condition, strength of all extremities, endurance, joint range of motion, the status of the other lower extremity in the case of lower limb amputation, and the patient’s cognitive abilities. Being nonambulatory or having significant joint contractures, weakness, and/or significant cognitive impairments limiting the ability to learn new skills can preclude patients from ever being considered candidates for prosthetic restoration. This initial evaluation helps to define the patient’s rehabilitation goals, direct the therapies, and determine if the patient is likely to require continuing inpatient rehabilitation services after acute surgical care. Amputation Level The goal when selecting an amputation level for a particular dysvascular patient is to choose the level that will most likely heal while preserving the most function for the patient. In general, the more joints that are preserved and the longer the residual limb is, the more function and the lower the energy expenditure the amputee is likely to experience when using a prosthesis. In addition to this general guideline to preserve length and joints, there are some considerations that will result in better prosthetic outcomes for the amputee patient. It is important that all amputations have a secure myoplasty or myodesis, with a minimum of redundant soft tissue to maximize the efficiency of force transfer from the bone of the residual to the prosthesis. The more the major long bone of the residual limb (femur and tibia for lower limb amputations and humerus and ulna for upper limb amputations) has to move through soft tissues before contacting and initiating movement of the prosthetic socket, the greater the loss in efficiency and the greater the decrease in prosthetic function. Sometimes, as a result of posttraumatic swelling, complications of cellulitis, associated compartment syndrome, or other morbidity, the soft tissues cannot be closed as ideally as desired, resulting in significant soft tissue redundancy. It is better to have the outcome of redundant distal soft tissue with a preserved knee than an ideal closure at a transfemoral amputation level. If the resulting prosthetic function is less than optimal or problematic as a result of redundant soft tissue, a plastic and reconstructive revision of the residual limb to remove redundant tissue can be considered at a later date. Toe amputations and most transmetatarsal amputations are very functional levels of amputation that can be accommodated quite easily with shoe modifications for walking on level surfaces in most cases. Very proximal transmetatarsal amputations, Lisfranc amputations, Chopart amputations, and amputations through the hind foot have the advantage of preserving some or all of the weight-bearing surface of the foot together with maintaining normal limb length. These amputation levels, however, can result in significant functional difficulty if special care is not taken to balance the opposing plantar and dorsiflexion forces about the ankle by relocating the attachment of the ankle dorsiflexors. When this is not done properly the patient develops an equinus deformity of the ankle, making it difficult or impossible to walk. Amputations through the mid and hindfoot while preserving length can also be quite challenging to impossible to provide a good functional prosthetic option. A more proximal level amputation can often be a better option for improved function. A Syme amputation or ankle disarticulation can be a very acceptable and functional amputation level with reasonable prosthetic options. Because the limb length difference is relatively small, the patient is capable of walking without a prosthesis by flexing the contralateral knee and hip to accommodate for the limb length difference. These same advantages also present some disadvantages when considering prosthetic restoration, which may be unexpected or unacceptable to patients if they are not aware of them when discussing options for amputation level. The long length of the residual limb significantly limits the options for prosthetic foot choice because of the limited space between the end of the residual limb and the floor (about 2 ½ to 3 inches) and precludes the use of specialized components such as shock pylons and rotators commonly used in prostheses for a more proximal transtibial amputation. The bulbous distal limb must be accommodated for in the design of the prosthesis and requires a socket that may be much larger in circumference than the contralateral limb, resulting in a prosthesis that might be either esthetically unpleasing or unacceptable to the patient. Similar advantages and disadvantages are associated with knee disarticulation amputations. The advantages of a knee disarticulation are a good end-bearing residual limb able to tolerate distal residual limb weight bearing in a prosthesis, long residual limb or lever arm to reduce energy expenditure, and a bulbous shape to the distal residual limb allowing anatomic suspension of the socket. The bulbous shape of the distal femur from the retained condyles can also be one of its disadvantages, necessitating a less-than-cosmetically acceptable shape to the socket for some patients. The greatest disadvantage of the knee disarticulation has always been the long length of the residual limb because the entire femur remains, leading to a knee axis center in the prosthesis that is longer than that on the nonamputated lower extremity. The resulting longer thigh length (full femur, prosthetic socket, and prosthetic knee) can result in functional problems for the amputee where seating space may be limited as in theater, airplane, and automobile seats. Fortunately this is somewhat less of a problem than it used to be with the availability of prosthetic knee units designed to minimize this difference. Disarticulation level amputations have a unique advantage in children requiring an extremity amputation because this minimizes the risk of bony overgrowth that occurs in approximately 15% of trans–long bone amputations in children. This bony overgrowth often results in a prosthetic misfit and use problems, necessitating revision of the bone to eliminate the spurring. Maintaining the distal cartilage with disarticulation-level amputations prevents this overgrowth. Saving a functional knee, even if it results in a short transtibial residual limb, conveys advantage to the amputee for prosthetic function over that of a transfemoral amputation. Only gold members can continue reading. Log In or Register to continue Share this:Click to share on Twitter (Opens in new window)Click to share on Facebook (Opens in new window) Related Related posts: Technical Aspects of Percutaneous Carotid Angioplasty and Stenting for Arteriosclerotic Disease In-Situ Treatment of Aortic Graft Infection with Prosthetic Grafts and Allografts Treatment of Acute Upper Extremity Venous Occlusion Intraoperative Assessment of the Technical Adequacy of Carotid Endarterectomy Stay updated, free articles. Join our Telegram channel Join
