This article reviews occupational therapy treatment and physical therapy treatment during preprosthetic training for upper and lower extremity amputees. Review of preoperative intervention, preparing the residual limb for the prosthesis, instruction in techniques, and adaptive equipment for activities of daily living, as well as suggestions for return to vocational and avocational activities are addressed.
Key points
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The occupational therapist can contribute important information to the team in deciding the proper prescription for the prosthesis.
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The functional goals of the patient in using the prosthesis should be acknowledged in planning the prosthetic components.
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Vocational and avocational needs should also be taken into consideration.
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The amputation surgery is just the start of a long, arduous process to get the patient back to as many of their previous activities as possible.
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The most vital participation in the whole process is the amputee’s participation.
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There are several exercise programs that can be integrated in between amputation surgery and prosthetic delivery that can improve outcomes for patients.
Occupational therapy intervention for preprosthetic training in the lower extremity amputee
General Evaluation
The occupational therapy evaluation for a lower extremity amputee should include assessment of upper extremity (UE) range of motion (ROM) and strength, including grip and pinch strength. Lower limb amputees will need to use crutches or propel a wheelchair before prosthetic fit. Upper extremity weakness or injury can impact the ability to ambulate with these assistive devices. Sensory deficits in the upper extremities can be due to injury or preexisting cumulative trauma, from after chemotherapy, or from diabetic neuropathy. Endurance compared with previous level of function should be noted because it requires more energy to walk with a prosthesis. Core strength and general conditioning are also very important in achieving the optimal level of function and are especially important if the amputee has been hospitalized for a long period of time.
Evaluation of Activities of Daily Living
A comprehensive activity of daily-living evaluation should be completed including evaluation of the home. It is important to note the number of steps for entry and exit of the home. A ramp may be indicated if the patient will return home in a wheelchair. If it is a 2-level home, then arrangements can be made for living on the main level or a stair glide or elevator can be installed. These arrangements are usually only indicated for bilateral lower extremity amputees or medically compromised individuals. The bathroom is a common place for falls. It is usually recommended for there to be a shower chair or transfer bath bench as well as grab rails for bathing. Some amputees will need a raised or higher toilet seat and/or bars next to the toilet for push off during standing. The patient should be educated to remove all throw rugs as they are easy to trip on in the home. A nonskid mat should be used in the bottom of the bath or shower. A hand-held shower is helpful in control of the water from a seated position. If the bathroom doorway is too narrow for a wheelchair to pass through, then the patient may enter with crutches or sideways with a walker. A transfer wheelchair is often narrow enough to navigate through the doorway because it does not have the outside wheels.
Evaluation for Driving
If the patient has had amputation of both lower limbs or the right leg, then adaptation may need to be completed for driving. Many right transtibial amputees (TTA) are still able to drive with their prosthesis; however, a left foot accelerator or hand controls can also be used for safety. An evaluation with a certified adapted driving instructor is recommended.
Occupational Therapy Treatment of Lower Extremity Amputees
Activities of daily living
All adaptive equipment for home safety should be ordered or purchased by the family and properly installed. At times a home evaluation is indicated to identify the safety needs of the client properly. Instruction should be given in homemaking activities from the wheelchair level or crutches as indicated.
Therapeutic exercise
Maximizing UE strength, core strength, and endurance will greatly help lower extremity amputees with function during activities of daily living (ADL) and in transitioning to prosthetic use.
Occupational therapy intervention for preprosthetic training in the lower extremity amputee
General Evaluation
The occupational therapy evaluation for a lower extremity amputee should include assessment of upper extremity (UE) range of motion (ROM) and strength, including grip and pinch strength. Lower limb amputees will need to use crutches or propel a wheelchair before prosthetic fit. Upper extremity weakness or injury can impact the ability to ambulate with these assistive devices. Sensory deficits in the upper extremities can be due to injury or preexisting cumulative trauma, from after chemotherapy, or from diabetic neuropathy. Endurance compared with previous level of function should be noted because it requires more energy to walk with a prosthesis. Core strength and general conditioning are also very important in achieving the optimal level of function and are especially important if the amputee has been hospitalized for a long period of time.
Evaluation of Activities of Daily Living
A comprehensive activity of daily-living evaluation should be completed including evaluation of the home. It is important to note the number of steps for entry and exit of the home. A ramp may be indicated if the patient will return home in a wheelchair. If it is a 2-level home, then arrangements can be made for living on the main level or a stair glide or elevator can be installed. These arrangements are usually only indicated for bilateral lower extremity amputees or medically compromised individuals. The bathroom is a common place for falls. It is usually recommended for there to be a shower chair or transfer bath bench as well as grab rails for bathing. Some amputees will need a raised or higher toilet seat and/or bars next to the toilet for push off during standing. The patient should be educated to remove all throw rugs as they are easy to trip on in the home. A nonskid mat should be used in the bottom of the bath or shower. A hand-held shower is helpful in control of the water from a seated position. If the bathroom doorway is too narrow for a wheelchair to pass through, then the patient may enter with crutches or sideways with a walker. A transfer wheelchair is often narrow enough to navigate through the doorway because it does not have the outside wheels.
Evaluation for Driving
If the patient has had amputation of both lower limbs or the right leg, then adaptation may need to be completed for driving. Many right transtibial amputees (TTA) are still able to drive with their prosthesis; however, a left foot accelerator or hand controls can also be used for safety. An evaluation with a certified adapted driving instructor is recommended.
Occupational Therapy Treatment of Lower Extremity Amputees
Activities of daily living
All adaptive equipment for home safety should be ordered or purchased by the family and properly installed. At times a home evaluation is indicated to identify the safety needs of the client properly. Instruction should be given in homemaking activities from the wheelchair level or crutches as indicated.
Therapeutic exercise
Maximizing UE strength, core strength, and endurance will greatly help lower extremity amputees with function during activities of daily living (ADL) and in transitioning to prosthetic use.
Preprosthetic care for the UE amputee
Preoperative Care
When it is possible to see a patient before amputation, it is helpful to evaluate the patient for the status of the limb and the possible goals in having the limb amputated. Occupational therapy can assist in helping to determine the optimal level of amputation for function as well as helping to determine the functional outcome goals for having the amputation performed.
Evaluation
The comprehensive evaluation should include the following:
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Assessment of ROM of all joints
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Strength of the entire upper quadrant
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Pain level and cause of pain
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Sensation of the limb
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Current ADL function of the patient
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Psychological and social support
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Vocation and avocation needs.
Treatment
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ADL training should include instruction in one-handed techniques and adaptive equipment that may be helpful at the time and/or after amputation. Dominance retraining can begin at this stage and assist in the transition for change of dominance if it is the dominant hand that will be amputated. ROM of both upper extremities should be maximized before surgery. There should be careful focus on scapulothoracic motion as well. All individuals will also benefit from maximizing UE strength, core strength, and endurance.
Team Collaboration
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The occupational therapy evaluation can give useful information to the patient and the team in deciding the level of amputation as well as whether amputation will improve function for an individual. For example, if muscle testing reveals weak bicep function, the patient may not benefit from a transradial amputation because the weight of the prosthesis would make it difficult or impossible to bend the elbow. A patient may be considering amputation due to limited function of an extremity, but may have unrealistic expectations of the capabilities of prosthetics. It then becomes the responsibility of the team to educate the patient in the functional abilities of prosthetics.
Postoperative care
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For many individuals, the period of time immediately after an amputation can be a difficult one. Patients may have questions about what they will be able to do. Will they be able to drive, return to work, be accepted by their family and friends? Information and reassurance about return to activity with or without a prosthesis is critical at this time for the amputee and their family. Referral to a support group and/or individual counseling may be appropriate. Early treatment after surgery should include incision/wound care, active ROM of the residual limb and sound limb, ADL training in one-handed techniques and equipment, if it was not already done preoperatively, edema control, and pain management.
Preprosthetic training for the UE amputee
During this phase of treatment, it is important to educate the patient on the process of preparing the residual limb for the prosthesis. A home program should be established for ROM, scar mobilization, desensitization, and volume reduction.
Shaping and Shrinking
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Once the sutures have been removed, shaping and shrinking the limb can be initiated and can be accomplished with figure-of-8 wrapping ( Fig. 1 ), use of a shrinker, or a compressive stockinette. If the residual limb has a bulbous end or invagination in the skin, then the figure-of-8 wrap may be the best choice, because you can control the direction of pull and the amount of tension on each area of the limb. The amputee can be taught to wrap the limb themselves by holding the end of the ace wrap down with the residual limb until it is secure or using tape to hold it. Wrapping should be performed distal to proximal with decreasing amount of tension as the wrap is brought proximal to guide the edema out of the distal limb. To main constant compression, it is recommended that the figure-of-8 wrap be rewrapped every 4 hours. Compression should be worn at all times except for showering. Multiple wraps should be issued to allow for washing daily.
Fig. 1
Figure-of-8 wrapping.
Posture Training
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Most new amputees will hold the shoulder on the affected side higher or lower than the sound side shoulder. Observation in the mirror and frequent cues to correct posture will often help the amputee to begin self-correction and improve balance.
Desensitization
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Hypersensitivity of the residual limb is common after amputation. The patient should be encouraged to touch the limb and rub the limb with various textures of material to help desensitize it. Light massage and tapping are also helpful. Running the limb through a tub of rice, beans, or macaroni is a useful home program activity.
Scar Management
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Once the incision and all wounds are healed, it is important to ensure that all tissue on the residual limb is mobile. If scar is adherent, then this could be an area of friction in the socket and cause a blister or skin breakdown to occur. Scar massage and silicone or fabricated scar pads can be useful in mobilizing scar. The patient should be educated in scar massage as part of the home program.
ROM
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At this time it is critical to maximize ROM of both upper extremities. Special attention should be paid to internal and external rotation for the transhumeral amputee and forearm supination and pronation for the transradial amputee. These motions will be essential for positioning the prosthesis for function. A transhumeral residual limb that is more than two-thirds the length below the elbow may be able to supinate and pronate to position the prosthesis. Transhumeral amputees can use internal and external rotation to position the terminal devi e toward midline or away from the body for daily activity. Scapular mobility is also very important for use with cable-operated prostheses. Limited shoulder mobility makes donning and doffing of a prosthesis difficult if there is a harness. Adaptations may be made to the harness for independent donning and doffing.
Pain Management
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During the initial occupational therapy evaluation, it should be established whether pain is in the residual limb or phantom limb. The patient should understand the distinction between phantom pain and phantom sensation. Phantom sensation can be present and not painful. Initially decreasing edema and sensitivity can be helpful in reducing pain. Electrical stimulation such as transcutaneous electrical nerve stimulation, interferential, and high-volt pulsed galvanic stimulation can all be used for pain. If use of the electric stimulation is helpful in the clinic, then a home unit can be obtained to manage pain at home and reduce the use of pain medication. Mirror therapy is another useful tool in managing pain. Mirror therapy is a technique in which the amputee is positioned so that they are holding their sound hand in front of a mirror and the amputated limb is hidden behind the mirror. The patient then performs a series of movements in the mirror while watching what appears to be both hands moving through the range of movement. It is important that the patient is educated in the purpose of this treatment and the need for consistency in the home program. The patient is asked to complete this exercise 5 times per day for 15 minutes. Exercises should continue for 1 month. If their pain is increased by the mirror therapy, then they should decrease the intensity of the motion and possibly the frequency. The treatment is discontinued if pain continues to be elevated ( Fig. 2 ).
Fig. 2
During the initial occupational therapy evaluation, it should be established whether pain is in the residual limb or phantom limb.
Strengthening of UEs
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Strengthening of the residual limb should not begin until the surgeon thinks that there is sufficient healing to provide resistance safely without compromising the surgical tissues. Progress from gentle isometrics to resistive exercise such as cuff weights on the residual limb and use of theraband to gain strength usually begins after clearance by the physician.
Conditioning and Endurance Training
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Conditioning and endurance training is covered later in the physical therapy section, but general conditioning of core strength, balance, and endurance are essential to the optimal outcome after this type of devastating injury and is especially true for bilateral UE amputees. They will need to have maximal mobility of the cervical and thoracic spine, as well as mobility of the hips to complete ADL.
ADL
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Dominance retraining should begin early if the amputated limb was the dominant hand before injury. This training can include writing practice, instruction in position of the paper, and fine-motor coordination activities. Instruction in one-handed techniques and adaptive equipment for independence in ADL is important at this stage. Every amputee should be independent in daily activity without the prosthesis because the amputee may choose not to wear the prosthesis at all times or it may not be available due to breakage or repairs. Education in one-handed shoe tie ( Fig. 3 ) and use of the residual limb to stabilize objects is useful. Adaptive equipment can be helpful to some people for ease in completing daily activities. It is important to assess what the patient is having difficulty with and explore options to make the task easier. At times the patient just needs to learn a new way of doing things, but sometimes an adapted aid can make things go faster. Some examples of this equipment are elastic shoelaces, suction nailbrush, electric can opener, rocker knife, and adapted cutting board. Many amputees can drive with little or no adaptation; however, this may need to be assessed by a qualified driving evaluator especially if the amputee has lost both limbs. It is important to identify the goals of the patient for return to work and/or avocational activities. Many sports activities like skiing and swimming can be accomplished without prostheses. Prosthetic adaptations are available for recreational activities and the amputee should be educated in these as appropriate.
