Amputees

Chapter 2 Amputees



Introduction




The student or novice physiotherapist may treat the ‘primary’ and/or the ‘established’ amputee.


Where there is no on-site specialist physiotherapist available for supervision and guidance it is important that the therapist knows when, where to seek specialist support, e.g. via a regional prosthetic centre or specialist physiotherapist in the acute setting.


This volume covers the treatment of the adult amputee with acquired lower limb amputation, with some reference to the adult upper limb amputee.


Advice on the treatment of the child with acquired amputation or congenital absence should be sought from regional specialist centres.


Treatment planning requires a holistic, integrated, multidisciplinary approach, enabling effective exchange of information with all involved in the treatment of the patient.


To encourage patient adherence to rehabilitation, SMART goals for treatment must be agreed initially, between the patient and the team members involved in the patient’s management.


Ongoing evaluation by the physiotherapist (and other team members) of the amputee’s ability to achieve treatment goals during the early treatment stage will assist in determining the amputee’s suitability for prosthetic referral.


Physiotherapy treatment is defined by assessment findings. Physical, personal, social and environmental factors will influence the plan and determine how attainable rehabilitation goals will be.


The amputee and physiotherapist should consider goal setting as something to be done in partnership and the plan should include short and long-term goals.


The International Classification of Functioning, Disability and Health (WHO 2001) model can assist the evaluation of the assessment findings (Geertzen 2008).


It is recommended that the ‘SOAP’ format is used for recording treatment.


Appendices 2.1 and 2.2 provide additional material for students.



Physiotherapy treatment goals


image denotes specific treatment rationale for UL physiotherapy treatment.




Pain management



Early management




Pain after amputation is common and to be expected.


Communication and co-ordination of treatment with other members of the MDT is essential and the timing of physiotherapy treatment must coincide with pain control.


The physiotherapist should have an understanding of prescribed pain medication and side effects (BNF 2010).


The amputee experiencing significant postoperative pain will find it difficult to co-operate and engage with physiotherapy treatment, therefore the physiotherapist should provide reassurance and explanation of underlying postoperative pain in the residuum (RLP).


The patient should be alerted to the possible presence of phantom limb sensation (PLS) which may include phantom limb pain (PLP) (Broomhead et al 2006).


Information about PLS should be provided by health professionals with appropriate knowledge and training (Mortimer et al 2002).


It should be explained to the patient that PLS is a normal response and consequence of amputation surgery, which handling, exercise and medication will help to reduce.


This is important for the safety of the amputee who may sense their amputated limb as being present and could unconsciously attempt to weight bear through it, resulting in a fall.


Handling the residuum helps to desensitise nerve endings, helps the remodelling of the homunculus and contributes to the amputee’s adjustment to their new body image (Ramachandran and Hirstein 1998).


‘Stump handling’ enables the amputee to apply early individual control over the management of their pain and it is important to reassure the amputee that gentle handling will not harm the wound.


Stump handling along with daily observation is important at all stages of rehabilitation and must become part of normal daily routine for the amputee post discharge to check for skin changes resulting from pathology, prosthetic fit or positioning.




Active exercises will encourage resolution of postoperative oedema, which can cause pain.


Appropriate positioning of the residuum to avoid prolonged and excessive flexion must be emphasised – the patient will instinctively want to flex their residuum if it is painful, therefore maintaining full range and a good resting position is essential and must be reinforced.




Wound healing must be monitored daily by a team member; the physiotherapist should take the opportunity to observe the wound.



Ongoing management




The amputee may continue to experience either RLP or PLP, or both.


Where RLP or PLP persists, investigations should be made to identify the cause, e.g. infection, vascular insufficiency, soft tissue injury, referred pain, including joint pain, or breakdown in the myodesis.


If pain is related to wound breakdown, physiotherapy should be carried out with caution. Exercising may provide some distraction from the pain.


Where wound healing is compromised and contributing to pain, the use of laser therapy has been reported to be effective (Baxter 1999).


The physiotherapist must be vigilant in monitoring and evaluating the amputee’s pain and communicating this with relevant colleagues, irrespective of the stage of rehabilitation.


Assessment findings may indicate interventions including:







Reference to a ‘pain pathway’ can facilitate clinical reasoning and support the decision-making processes for a team approach to pain management (Appendix 2.3).


Progressing with a general exercise programme and use of an early walking aid (EWA) will assist in the management of an amputee’s phantom sensation and/or pain (Barnett et al 2009).



Improve functional mobility and balance



Early management







Transfers




This is an essential requirement for independence and meeting criteria for prosthetic rehabilitation.


In some instances amputees will not be able to initiate independent transfers; they may be apprehensive, in discomfort or unable to follow appropriate instructions.


A manual handling risk assessment should be carried out to identify appropriate assistive devices, e.g. sliding boards, hoists.


All amputees need to be supervised until assessed as safe to transfer independently.






All transfer procedures can be applied and progressed in relation to setting, e.g. toilet, car.





Maintain and increase joint range



Early management




When the amputee is ready to attend the therapy gym, provided it is practical and safe to do so, he/she should be encouraged to make their own way in their wheelchair.




Active exercises for the remaining and residual limb maintain joint range, improve circulation and wound healing, reduce residual oedema and prevent postoperative complications, e.g. deep vein thrombosis.


It is important for the amputee to appreciate that the responsibility for practising exercises is theirs for achieving and maintaining functional mobility and independence.


Frequent exercise practice should be encouraged, i.e. daily exercise sheets designed specifically for the patient can facilitate commitment to exercise.




The same principles of exercise apply to the UL amputee:




Use of EWAs is another way to maintain joint mobility.




Maintenance and increase in muscle strength








Oedema management





Early oedema management







Use of compression therapy





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