Rehabilitation After Amputation

1 Volume 91 Number 1 January 200113In the fairly recent past, patients who had undergoneamputation received artificial limbs, but found thatlittle attention was paid to Rehabilitation training orother special needs. In the last two decades, with theadvent of specialized treatment teams and betterprosthetic devices, the prospects for the amputee,old and young alike, have are performed for a variety of adults, the most frequent causes of amputationare arteriosclerotic occlusive disease and complica-tions of diabetes mellitus, followed by trauma is usually present in theelderly amputee; this may involve such conditions ashypertension, peripheral neuropathy, nicotinism, re-duced vision, balance and flexibility problems, anddeconditioning.

2 Lower-limb amputees are usually inthe 51- to 69-year-old age bracket, although theyrange from children with congenital limb deficienciesto patients in late life. In children, the primary causesof limb Amputation are congenital limb deficiencies,trauma, and amputations are done at the transtibial levelthan at any other level. In some highly specialized re-habilitation facilities, upper-limb Amputation may ac-count for up to 30% of all patients Amputation should not be viewed as a fail-ure but as a way of enabling the patient to function ata higher level. The importance of approaching ampu-tation with a positive, constructive frame of mindcannot be of RehabilitationRehabilitation After limb Amputation can be dividedinto nine discrete periods of evaluation and interven-tion (Table 1).

3 Each phase involves specific evalua-tion items and treatment goals and objectives. Thestages of Amputation Rehabilitation and the types ofinterventions to be used can be delineated accordingto the specific Rehabilitation , Rehabilitation of the amputee beginsprior to the Amputation and should be provided by aspecialized treatment team. Communication amongthe team members, the patient, and family membersis essential. The team needs information to develop atreatment plan. From the team, the patient shouldlearn what to expect After surgery and providing this information, the treatment team willtake into account the patient s physical and medicalstatus, level of Amputation , premorbid lifestyle, andcognition and will help the patient set realistic short-and long-term goals.

4 The information given by theteam should include the implications of amputationand the phenomenon of phantom PhaseThe preprosthetic stage of Rehabilitation begins withthe surgical closure of the wound and culminates inRehabilitation After AmputationAlberto Esquenazi, MD*Robert DiGiacomo, PT The principles of amputee Rehabilitation , from preamputation to reinte-gration into the work force and community, are reviewed. The authorsdiscuss exercise techniques, training programs, and environmentalmodifications that have been found to be helpful in the Rehabilitation ofthe amputee. The exercise programs presented here are divided intofour main components: flexibility, muscle strength, cardiovascular train-ing, and balance and gait.

5 The programs include interventions by thephysical, occupational, and recreational therapist under the supervisionand guidance of a physician. (J Am Podiatr Med Assoc 91(1): 13-22,2001)*Director, Gait and Motion Analysis Laboratory and MossRegional Amputee Rehabilitation Center, 1200 W Taber Rd,Philadelphia, PA 19141. Team Leader, Musculoskeletal Service, Moss RegionalAmputee Rehabilitation Center, Philadelphia, of the American Podiatric Medical Associationsuture removal and wound healing. The patient whohas undergone a lower-limb Amputation may becomedeconditioned and will probably be depressed. A pre-prosthetic Rehabilitation program must be initiatedas soon as possible.

6 The physician should expect pa-tients to attain high functional levels and should helpthem attain this goal, especially if the Amputation isseen as a reconstructive procedure that is intendedto remove the burden of pain and open all patients should participate in a program ofmultidisciplinary Rehabilitation , 3 The goals at this stage are pain control, mainte-nance of range of motion and strength, and promo-tion of wound healing. To prepare for this stage, pa-tients should, whenever possible, be placed in acardiopulmonary conditioning program before theamputation. As soon as the patient is medically sta-ble After the Amputation , general endurance andstrengthening exercises should be implemented; theexercises should emphasize the muscles that stabi-lize the proximal muscles and the avoidance of jointcontractures.

7 In this stage, Rehabilitation interven-tions to improve balance are also initiated. Strength-ening of upper-limb musculature is essential forwheelchair propulsion, transfers, and ambulationwith crutches or a rigid dressing as proposed by Burgess et al4or aremovable rigid dressing as proposed by Wu et al5can be used to help control pain and aid residuallimb maturation in the transtibial amputee. Manycenters use elastic compressive dressings as an skin-desensitization program that includesgentle tapping, massage, and soft-tissue and scar mo-bilization and lubrication is the lower-limb amputee, such devices as theUniversal Below-the-Knee Bicycle Attachment (AlliedOrthotic/Prosthetics, Philadelphia, Pennsylvania),6the Versa-Climber (Heart Rate Inc, Costa Mesa, Cali-fornia), or a modified stationary bicycle ergometercould be used to assist in strengthening and en-durance exercises.

8 This type of exercise allows forcardiovascular training that uses large lower-limbmuscles with controlled weightbearing while woundhealing preparatory or training prosthesis should beused at this stage. This promotes residual limb matu-ration and acts as a short-term gait-training toolwhile permitting progression in physical fitness andexercise. In most instances, the prosthetic compo-nents are of simple design. All unilateral lower-limbamputees should be taught to ambulate safely with-out a prosthesis but using bilateral crutches; this skillis needed because there may be occasions when theartificial limb will not be amputees will need upper-limb support forbalance in the preparatory prosthesis-fitting the unilateral amputee, a cane or single crutchheld on the side opposite to the amputated limbshould suffice.

9 Some patients with comorbidity willneed a wheeled or reciprocating walker or twocrutches during ambulation. Gait training shouldstart on flat surfaces with emphasis initially on tech-nique and style and then on velocity, and should thenprogress to uneven surfaces and elevations as toler-ated. Weight-shifting training using stepping tech-niques and a balance board should be addition to the involved limb, the remaininglimbs must be evaluated as to range of motion,Table 1. Phases of Amputee RehabilitationPhaseHallmarks1. PreoperativeMedical and body condition assessment, patient education, surgical-level discussion, functional expectations, phantom limb discussion2. Amputation surgery/dressingResidual-limb length determination, myoplastic closure, soft-tissue coverage, nerve handling, rigid dressing application, limb reconstruction3.

10 Acute postsurgicalWound healing, pain control, proximal body motion, emotional support, phantom limbdiscussion4. PreprostheticResidual-limb shaping, shrinking, increasing muscle strength, restoring patient s sense of control5. Prosthetic prescription/fabricationTeam consensus on prosthetic prescription6. Prosthetic trainingProsthetic management and training to increase wearing time and functional use7. Community integrationResumption of family and community roles; regaining emotional equilibrium; developinghealthy coping strategies, recreational activities8. Vocational rehabilitationAssessment and training for vocational activities, assessment of further education needs or job modification9. Follow-upLifelong prosthetic, functional, and medical assessment; emotional supportVolume 91 Number 1 January 200115strength, sensation, coordination, skin integrity, vas-cularity, and deformities.