Amputee Rehabilitation

Chapter 2 Amputee Rehabilitation



Introduction







Context, United Kingdom




The number of persons with amputation (the amputee) in the UK – 62 000 (Limbless-statistics, 2012) – is small relative to the total population, i.e. approximately 9 per 100 000, in comparison to approximately 180 stroke patients (per 100 000) (ONS, 1994–1998). The likelihood of every undergraduate student or novice physiotherapist experiencing amputee rehabilitation is therefore small.


Most amputees receive early rehabilitation as in-patients in an acute hospital setting and form part of a physiotherapist’s caseload that includes non-amputee patients. Depending on the cause of amputation the amputee may be managed on a surgical, orthopaedic or care of the elderly ward and this may be for a prolonged period. Exceptions to this are a vascular unit within a hospital or a specialist rehabilitation ward attached to a prosthetic rehabilitation unit in a disability service centre (DSC).


Physiotherapists are well placed as key health professionals in amputee management since initial contact can be prior to amputation surgery, in the community or later in the care pathway at review and follow up of the ‘established’ amputee. Irrespective of the setting, guidelines recommend that physiotherapists specialised in amputee rehabilitation be responsible for the physiotherapy management of amputees (Broomhead et al 2003, 2006). A holistic multidisciplinary approach is advocated at all stages of rehabilitation from pre-operative assessment through to prosthetic discharge (Broomhead et al 2003, 2006). At all stages patients’ and carers’ wishes must be considered.


Following amputation the common goal for most amputees is to achieve functional independence, ideally using a prosthesis. Amputees face many challenges, particularly physical and psychosocial ones which can change with age and acquired conditions affecting potential for rehabilitation, mobility and overall function (Schoppen et al 2003). Physiotherapy assessment is indicated at several stages during rehabilitation and at further and often unrelated times during the life of an amputee.



Assessment






General considerations








Additional information to consider




Anatomy of the lower and upper limbs


Vascular system


Pathology of causes of amputation, associated conditions and complications including:











Specific investigations prior to amputation surgery:






Examples of vascular intervention (Beard et al 2009)


Depending on the location and extent of the vascular disease the following may be options







Amputation surgical techniques (Smith et al 2004), e.g.




Other investigations include




Pain – causes and influencing factors include, infection, joint pain, psychological (Engstrom & Van de Ven 1999; Ehde et al 2000; Hanley et al 2004, 2006)


Gait, i.e. normal gait (Whittle 2007)


Grieving process (Fischer 2009)


Multidisciplinary team approach (Ham et al 1987; Stewart & Jain 1993; Pernot et al 1997)


Prosthetics, i.e. basic examples and fit of prosthesis (Smith et al 2004).



Considerations immediately prior to undertaking an assessment




Therapeutic setting.


Type of surgical anaesthesia used – general versus spinal or chemical block.


Primary or established amputee.


Timing, e.g. postoperative, preprosthetic or prosthetic stage of rehabilitation, prosthetic review.


Pain control. Ensuring that pain is adequately controlled will enable the amputee to engage effectively in the assessment process and allow the therapist to perform a thorough and accurate assessment.


Therapy/MDT assessment approach, i.e. profession-specific or joint assessment (e.g. OT and PT). Joint assessments reduce repetition for the amputee and can enrich the quality of the information obtained.


Next of kin and/or carers. In some instances it is necessary to seek permission from others, e.g. for children, vulnerable adults.


Awareness of prior or associated assessments.


Access to existing reports, e.g. home access visit. These can help target assessment questions.


Environment, e.g. gym setting with adjustable plinth, ward and hospital bed, home.


Patient to be suitably dressed for assessment.


Removal of footwear to allow inspection of remaining foot.


Acknowledge cause and associated physical problems, e.g. neural damage or fractures.


Awareness of feelings of anxiety and loss, sadness and sometimes depression. There may be associated family or personal loss. In cases of severe trauma some amputees may experience post traumatic stress disorder (PTSD).


Early identification of cognitive problems will influence the extent of assessment, goal setting, treatment plan and outcomes of rehabilitation. If not performing a joint assessment early referral to an occupational therapist or psychologist may be required.




Subjective assessment






Nov 5, 2016 | Posted by in MANUAL THERAPIST | Comments Off on Amputee Rehabilitation

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