The patient history is the collection of health-related data from the past and present. It helps to establish what brought the person to seek PT services and to highlight the individual’s desires and expectations. The person’s perspective of his or her illness, functional limitations, and possible disability has a powerful influence on the rehabilitation process. In fact, a positive outlook is associated with constructive coping and positive adjustment to amputation.9,¹⁰

A number of important areas must be explored while taking the patient history (Table 26-1). Although all the areas provide important information, several are very integral to the establishment of the diagnosis and the treatment plan. The person’s general health status may impact the individual’s overall health perception, physical functions, psychological functions, and role and social functions. Discussion of the current condition/chief complaint gives the therapist a sense of the individual’s concerns, previous interventions, mechanism of injury or disease, and course of events. It also helps to understand what the goals and aspirations are for a person with a transtibial or transfemoral amputation. If the individual’s initial goals appear to be over- or underambitious, the therapist can address these issues with education and interaction with peers as possible interventions.

The interview process provides valuable insights about the person’s communication ability, emotional status, cognitive abilities, preferred coping strategies, insight into the rehabilitation process, and usual learning style, as well as the availability of emotional and instrumental support systems (assistance with activities of daily living). Information about the person’s pre-amputation level of activity and mobility are helpful in establishing a realistic prognosis. Patients who are ambulatory prior to the amputation surgery are more likely to recover at least a modest degree of ambulation ability with their prosthesis.¹¹ Specific and probing interview questions are often helpful in obtaining clear and accurate information. Although many individuals are accurate historians, others may have an incomplete understanding or imprecise memory of what has happened. It is always advisable to confirm information by interview with family members and review of the medical record.

The interview is a means to gather important information that is used to guide treatment interventions and to begin the process of education about amputation, treatment, and prosthetic training. Many individuals with transtibial or transfemoral amputation do not have a clear understanding of what to expect during rehabilitation or how their disease process might progress. Amputation is not selective to patients of a specific age group, cultural background, educational experience, or socioeconomic level. Every individual benefits by being well-educated about his or her condition and treatment. For many, the events that brought them to rehabilitation may be a blur of disjointed experiences and medical jargon, or a laundry list of conditions that seem unrelated or independent. The physical therapist can help individuals to place their history and experience in a meaningful context, which, in turn, assists them in forming realistic expectations, and may decrease the likelihood of a second amputation.

The third component of the examination is the employment of appropriate tests and measures to gather objective data about the individual with amputation’s various impairments and activity limitations. Combining this data with the history and systems review, the physical therapist is able to establish a working diagnostic hypothesis. The physical therapist chooses from among an array of possible tests and measures those that will best confirm or deny the developing diagnostic hypothesis. The information gathered in the interview, systems review, and examination allows the physical therapist to establish a suitable plan of care and develop the most appropriate interventions.1 It is important to note that some assessments, such as strength testing or joint play motions, might require modification of technique because loss of limb length necessarily changes where the therapist is able to hold or resist the limb. Table 26-2 provides categories of tests and measures that might be appropriate for the patient with transtibial or transfemoral amputation and some detail of how the therapist might assess each area.

Early and aggressive achievement of functional ROM of the involved lower extremity is of paramount importance. The flexor withdrawal pattern of hip flexion, abduction, and external rotation, and knee flexion, is a position associated with lower-extremity pain and is often a position of choice in individuals postsurgically. The elevation of the residual limb on pillows serves to reinforce this undesirable posture and puts these individuals at risk for contracture formation. The development of contractures or tightness of muscles consistent with this position of the residual limb, especially hip and knee flexors, can have a significant negative impact on ultimate prosthetic use.11,²⁰ Maintaining or increasing available ROM at the hip for persons with a transfemoral residual limb and at the hip and knee of the transtibial residual limb continues to be a primary treatment goal as the patient moves from preprosthetic into prosthetic rehabilitation. The prevention of loss of ROM is much easier than efforts to regain lost motion.²¹ Prone positioning is an excellent strategy to combat contracture formation of the hip flexors and should be prescribed (60 minutes daily) as early as possible for all individuals who are able to tolerate this position. Low load, long duration stretch is safe and can yield significant elastic and plastic changes in soft tissues.²¹ Active and passive stretching in the side-lying position may be used for those unable to lie prone. Full functional hip ROM into flexion, extension, and adduction is critical to achieving efficient ambulation and functional mobility with a prosthesis. Typical gait on level surfaces requires the hip to move from 30 degrees flexion to 10 degrees extension and requires adduction slightly beyond neutral.²² More extreme ranges of hip flexion are required for transitioning sit to/from stand or reaching forward from a seated position.

To avoid knee flexion contracture in the individual with a transtibial amputation, a postoperative rigid dressing or knee extension splint or board (extending from under seating cushion) can be an effective technique early in the process to position the knee resting in an extended position while seated. Full knee extension ROM is required in typical ambulation on level surfaces²² and for exploiting passive stability at the knee joint in static standing. Individuals with recent transtibial amputation should be encouraged to use the knee extension splint as long as tolerable throughout the day, supplemented with frequent active quadriceps exercises (“quad set”). The person must also be taught to regularly check the integrity of skin of the residual limb while using the splint or board, to minimize risk of pressure-related skin damage that would delay use of the prosthesis.

For individuals with transtibial amputations, achieving knee flexion ROM is sometimes overlooked early in rehabilitation. Typical gait on level surfaces generally requires approximately 60 degrees of knee flexion,²² and 90 degrees or more is required for efficient step-over-step stair ambulation, rising from a seated position, and high-level mobility activities such as kneeling or rising from the floor.

Assessment of ROM of the intact limb is also important, as loss of ROM of either limb has an impact on quality and energy efficiency of gait.²³ The importance of functional ROM is also emphasized in individual education and home exercise routines. Table 26-3 summarizes the potential prosthetic problems that are associated with loss of functional ROM. Utilization of a wide variety of active and passive ROM therapeutic exercise techniques is appropriate as early as possible. All exercises that are started during the preprosthetic phase are generally appropriate to continue as prescribed, or to be progressed as tolerated during the prosthetic training phase. Once full functional ROM is achieved, the person must be educated to maintain this level.

In a systematic review, van Velzen et al.24 found several studies that demonstrated significant strength differences between muscles of the amputated limb as compared to the sound limb in subjects with transtibial and transfemoral amputations. Deficits in muscular endurance of the amputated limb as compared to the sound limb²⁵ and weakness of both the amputated and the sound limb in comparison to age-matched norms²⁶ have also been demonstrated. Although we cannot draw direct relationships between strength impairment and specific activity limitations, there has been some evidence to support the impact of weakness on activity level performance. For instance, hip extensor strength in persons with lower-extremity amputation has been identified as a useful predictor of performance on the 6-minute walk test,²⁷ and increased abductor strength in individuals with transtibial amputation is correlated with improved weight bearing on the prosthetic limb in quiet stance.²⁸

Accurate strength assessment can help to elucidate the potential causes of gait deviations, as deviations are often related to strength deficits. Knowing which muscles are weak will serve to guide therapeutic exercise interventions. Gathering muscle strength measures in the initial stages of prosthetic training will also establish baseline strength levels against which progress can be demonstrated.

Early in the prosthetic training process, it is important to evaluate baseline strength in several ways. Assessing hip and, in persons with transtibial amputation, knee strength of the residual limb becomes somewhat more subjective, as the standard lever arm for providing resistance has been altered by the amputation. Isokinetic instrumentation or hand held dynamometers may be used to evaluate muscle strength, although the validity and reliability of these tests has not been well-established for this population.^26,29 Functional strength of the hip and knee during closed chain activities and eccentric control are equally important, as they reflect muscle activity during normal gait.

Although strengthening programs should address all muscles of the residual limb and sound limb, prioritizing exercises that address hip extensor strength in the amputated side is appropriate, as hip extension strength has been identified as a strong predictor of gait outcome in persons with amputation.^27,30 Hip abductor strength is a priority for frontal plane stability and knee extensor strength is key for knee stability in the sagittal plane in individuals with transtibial amputation, so these muscle groups must also be emphasized in a preprosthetic exercise program. Stability of the hip and pelvis, especially in stance on the prosthetic side, is one of the key ingredients in achieving effective forward progression over the prosthesis during gait. In persons with amputations appropriate hip extensor and abductor strength is critical to achieving stability of the pelvis over the prosthetic limb during single limb stance in gait.^27,30 Strengthening exercises targeting hip extensors and abductors should be initiated early and progressed appropriately.

Although pre-amputation weakness of proximal muscles is often subtle with little to no observable abnormalities in pre-amputation gait patterns, these impairments of strength and muscle endurance may be magnified in prosthetic gait. Periods of disuse prior to and following amputation typically produce further weakness in much of the involved limb’s musculature. Without adequate proximal muscle strength and with the loss of distal musculature because of the amputation, problems with gait are likely.

Attention to strengthening of the hip extensors, abductors, adductors, and, in the person with transtibial amputation, the quadriceps and hamstrings are paramount to achieving optimal ambulation abilities. This is best addressed in the early phases of rehabilitation but should continue throughout the rehab process. Core strengthening of the abdominal and paraspinal muscles is important to develop as a strong core is essential for trunk stabilization during mobility training for transfers and gait. The degree of strengthening for the extremities and the positioning of the individual’s limb in gravity resistance or gravity neutral position will depend upon existing strength levels. Utilization of closed chain (e.g., residual limb on bolster or gymnastic ball, or individual in kneeling position if tolerated) and open-chain exercise techniques, with both concentric and eccentric muscle contractions, are appropriate and effective. Progressive resistance protocols are often used to improve strength and muscle endurance. Resistance may be applied manually or with equipment, such as cuff weights, elastic bands, or pulley weights. Using body weight is an effective way to introduce resistance training. Resistance is generally not applied at or near the suture line until the surgical wound is well healed. Basic physiological principles of strengthening (e.g., overload principle, specificity of training) are employed in the design of an appropriate resistance training program. Resistance exercises should specifically target muscles identified as weak in the examination and muscles that are functionally required in gait, transfer, and mobility activities. Strengthening within the context of functional activities is desirable. Correct exercise technique is critical to achieving the desired strength gains with the ultimate goal of minimizing an individual’s activity limitations.

As an individual’s strength improves, exercises become more functionally oriented as well as more intense. Closed-chain exercises can take on greater emphasis during the latter stages of rehabilitation as the intervention focus may be exclusively on upright functional activities. Table 26-4 highlights some exercises that may be helpful in strengthening an individual with transtibial or transfemoral amputation.

The strength requirements for ambulation with a prosthesis are similar but not identical to those of normal gait. Both the involved and intact lower extremities display increased muscle activity during their respective stance phases. Specifically, activity of the ipsilateral hip extensors and, in the case of transtibial amputation, knee extensors is increased and prolonged during stance as compared to persons without amputation.30,³¹ The intact limb is subject to increased ground reaction forces, presumably a result of the absence of the normal foot and ankle mechanism of the involved side.^32,33 Hip abductors and extensors and knee extensors of the intact limb must respond to these increased forces. They demonstrate an increase in power generation and muscle activity.³⁴

It is clear that PT interventions must address the strength not only of the residual limb, but of the uninvolved limb and trunk as well. Persons with amputation often go through protracted periods of inactivity before and after amputation. Because of this “disuse,” the patient often experiences generalized loss of strength. Adding exercises that address the trunk, upper extremities, and uninvolved limb will generally be beneficial to overall functional mobility as the demand on them will be increased during preprosthetic and prosthetic training.

Effective postural control during functional tasks has two fundamental components: (a) controlling the body’s position in space for purposes of stability (maintaining center of mass over base of support) and (b) orientation of the trunk and limbs in space (appropriate relationship between body segments and between body and environment).35 The normal balance mechanism relies on visual, vestibular, and somatosensory input. Visual and vestibular information add awareness of position in space with respect to objects in the environment and to gravity and somatosensation provides information about the positions of the joints of the lower extremity and the pressures through those joints. With loss of the distal limb to amputation, somatosensation and proprioception can no longer provide direct information about limb’s interaction with support surfaces. Balance deficits are well documented in persons with amputation,^24,36 as are deficits in balance confidence.^37,38 Balance performance is associated with ambulation outcome following amputation^15,24,27,39 and reduced balance confidence has been linked to a loss of perceived ability with the prosthesis, a loss of performance with the prosthesis, and a reduction in a sense of social importance.⁴⁰ Additionally, the incidence of falls in persons with amputation is higher than in age-matched peers,^36,40 and many falls occur during the inpatient postoperative period,⁴¹ especially during transitional movements such as transfers to/from wheelchairs.⁴²

Before discussing standing balance, it is important to mention that some individuals will have difficulty adjusting to changes in sitting balance following transtibial or transfemoral amputation. Prior to receiving the prosthesis, lack of a second foot on the floor, or in the case of transfemoral amputation, loss of the surface area of the thigh on the seating surface, alters the base of support while sitting; and loss of the mass of the lower extremity impacts the location of the body’s center of gravity in sitting. Most individuals adjust fairly quickly in achieving static sitting stability, but the inability to weight shift onto that foot can challenge dynamic sitting balance, especially with reaching tasks requiring movement anterior and ipsilateral to the amputated side. For this reason, seated reaching ability is evaluated during the initial examination and is addressed in treatment as necessary. Once an individual is training with a prosthesis, practicing dynamic sitting balance activities usually progresses quite quickly.

In the preprosthetic phase, standing balance assessment and training might include single-limb standing in the parallel bars or at a support surface with decreasing reliance on upper-extremity support. Ability to stand on the sound limb without upper-extremity support has been associated with better prosthetic gait outcomes in individuals with unilateral lower-extremity amputation,^15,24,27 making this an important skill to assess and train as early as possible.

In patients with transtibial amputation, if the individual can tolerate a kneeling position over the healed surgical site, or in individuals with either transtibial or transfemoral amputations, if they can tolerate gentle pressure to the healed distal end, the individual may stand with the intact limb on the floor and the residual limb resting on an elevated surface (low mat, gymnastic ball, or foam block) that allows minimal weight bearing and balance support. Preprosthetic gait training with an appropriate assistive device is another useful and functional approach to upright balance training.

Because sensory and proprioceptive input from the distal segment is absent after amputation, a new prosthetic user must learn to compensate for this lack of important postural information. In individuals with nonvascular amputations (sensory status of remaining limb presumed intact), quiet stance is characterized by asymmetrical weight bearing (sound limb greater than prosthesis) and an alteration of the location and trajectory of the center of pressure on both the prosthetic limb and the sound limb.⁴³ These sound limb variations are strategies to compensate for the prosthetic limb in maintaining upright balance. Because the vast majority of lower-extremity amputations are the result of vascular pathology, the underlying sensory mechanisms that help to inform the balance compensation cannot be presumed to be intact. Balance assessment and training is, therefore, a significant and justifiable component of the prosthetic rehabilitation process.

Prosthetic users may learn to deduce the position of the prosthetic foot and contact with the support surface by the angle of the hip or, in the case of the person with transtibial amputation, the knee, and/or pressures felt within the prosthetic socket. Early in gait training, the person with a transfemoral amputation may make an exaggerated effort to dig the prosthetic heel into the floor at initial contact, so as to use the resulting pressure at the posterior residual limb as an indicator of contact with the floor and to assure prosthetic knee extension. The individual may learn to interpret this sensory experience as the secure position for proceeding with loading response and progressing into midstance.

In addition to the loss of direct sensory knowledge of contact with the floor, the loss of muscles at the ankle often compromises postural responses. Nashner⁴⁴ describes three stereotypical motor responses that are used to ensure that the center of mass stays within the base of support in response to unexpected anteroposterior perturbations: ankle, hip, and stepping strategies. These postural strategies are also evident during functional activities, such as ambulation.³⁵ The ankle strategy movement pattern, evident in normal postural sway, requires intact ROM and strength of muscles at the ankle. After amputation, this strategy is no longer available to the involved limb, so that the person may not be able to resolve the balance perturbation using intact limb response only, and instead may need to rely on a hip strategy (movement of the trunk over the base of support) or a stepping strategy (moving the base of support under the center of mass) when a postural response is necessary.

Individuals with transtibial and transfemoral amputations must be able to respond to environmental demands during ambulation and other functional tasks in anticipatory (feed forward) and reactive (feedback) modes. Therapists can design activities to assess and encourage postural control in varying tasks and environments.⁴⁵ For example, successfully catching and throwing a ball requires the person to anticipate postural demands (in an effort to throw) and react to postural disruptions (in an effort to catch). Reaching activities in standing help individuals develop skill and confidence in their anticipatory postural responses and, should the reach distance be excessive, their reactive postural responses as well. Individuals with higher functional demands will require more advanced training. Therapists must consider the person’s ultimate likely functional requirements and design a variety of balance tasks to help the individual achieve those levels.

A thorough assessment of a person’s cardiovascular status followed by appropriate cardiovascular endurance training is an integral part of pre-prosthetic and prosthetic management. The energy requirements for an individual who is using a prosthesis for ambulation are higher than those of an individual who ambulates on two intact lower limbs. Aerobic capacity of persons with amputations has been demonstrated to be lower than age-matched peers, even in younger individuals with traumatic amputations.46 An extensive literature review by Waters⁴⁷ identifies some of the key physiological considerations for gait in persons with prostheses:

The energy expenditure for overground walking in people with unilateral transtibial amputation may be 10% to 36% higher than that of individuals without amputation,48–52 with the lower end of the range representing those with non–vascular-related amputations, and subjects who were more physically active. Individuals with transfemoral amputations demonstrate even higher energy requirements, 27% to 65% higher than people without an amputation.^50,53–55 Physical conditioning is an essential component of rehabilitation for individuals with lower-extremity amputation, especially those with cardiopulmonary or vascular compromise. Individuals with vascular amputations are significantly less active than their peers.⁵⁶ Improving metabolic efficiency (aerobic capacity) has a direct impact on the potential for functional ambulation even for the frailest and most deconditioned individuals.⁵⁷ The ability to gain an exercise intensity of greater than or equal to 50% VO₂ has been associated with “successful” prosthetic outcome (i.e., ability to walk 100 m with or without cane) in older adults with high-level amputations (transfemoral and hip disarticulation).^58,59 Endurance activities during the preprosthetic rehabilitation phase (e.g., wheelchair propulsion, single-limb ambulation with an appropriate assistive device, bilateral upper or unilateral lower-extremity ergometry) can help improve cardiovascular status before prosthetic training. Individuals often continue these activities as they enter into the prosthetic phase of rehabilitation. As the condition of the person’s residual limb and wearing tolerance permit, ambulation with the prosthesis can be used as an additional cardiovascular endurance activity. The 2-minute walk test with prosthesis may be a useful tool to document changes in functional exercise capacity for an individual with amputation.^60,61 For those whose endurance may be a limiting factor for prosthetic ambulation, the PT plan of care must include a cardiovascular exercise component as a priority. Individuals who are taught to monitor their own pulse, respiratory rate, and/or perceived rate of exertion are able to participate more fully in prosthetic rehabilitation and prosthetic training. To develop an effective cardiovascular conditioning program, the therapist uses knowledge of the person’s past medical history and cardiovascular pathophysiology, adapting the program to provide an appropriate challenge without surpassing their physiologic capabilities. The therapist must recognize the influence of cardiopulmonary pathologies, such as unstable angina or advanced chronic obstructive pulmonary disease, on the individual’s ability to improve his or her endurance and adjust goals and intervention strategies as appropriate. For individuals with few cardiovascular restrictions, more advanced cardiovascular exercises can be utilized as rehabilitation progresses. Brisk walking and/or use of exercise equipment (e.g., treadmill, stationary bicycle, stair climber, or elliptical machine) are excellent endurance training activities for the appropriate person. An amputation need not prevent individuals from participating in health and wellness exercise programs during and following their rehabilitation.

Reduction of postsurgical edema is critical in the early postoperative rehabilitation phase. Use of rigid postoperative dressings (e.g., cast) after transtibial amputation appear to be superior to soft dressings (including ace wrapping) in controlling volume of the residual limb62,⁶³ and are associated with a shorter time frame from amputation to initial prosthetic fitting^64,65; however, this type of postoperative care is not routinely used throughout the United States, perhaps because of physicians’ hesitancy to be blinded to the surgical site for 5 to 7 days postsurgery. When the more common soft dressings are used, ace wrapping for compression is applied over the transtibial residual limb dressing. Ace wraps should be applied in oblique angles (not circumferentially, so as to avoid a tourniquet effect), with gradual increase in pressure from distal to proximal, and always extending above the knee (as the transtibial prosthetic socket engulfs the medial and lateral aspects of the knee). Patients and family members should be instructed in wrapping technique, as the Ace wrap typically needs to be reapplied several times per day.

The transfemoral residual limb does not lend itself to rigid postoperative dressings and is more challenging to Ace wrap, as it requires anchoring over the pelvis and it may be difficult for a patient to elevate the pelvis for wrapping. Nevertheless, efforts at compression wrapping postsurgically should be a part of the treatment plan.

After the staples or sutures are removed, use of a commercial pressure garment (“shrinker”) is suggested for persons with either transtibial or transfemoral amputation. Residual limb edema plays a big role in determining when initial prosthetic fitting will take place—if the prosthesis is fitted too early and the residual limb is still substantially shrinking, this will affect the intimacy of prosthetic socket fit, making training more difficult and increasing the risk of complications caused by a poorly fitting socket.

Prerequisites for initial prosthetic fitting include sutures removed, surgical wound healed or healing, and edema controlled, with distal measurements less than or equal to proximal measurements. The importance of continued shrinking efforts, even after prosthetic training has begun, should be emphasized. Individuals usually must continue to wear a shrinker sock when they are not wearing their prosthesis, at least during early training efforts. If patients allow the edema to return to the limb the socket may no longer fit and aggressive efforts to reduce limb volume will need to precede any further prosthetic training.

Initiation of weight-bearing activities in the prosthetic socket significantly decreases limb edema and accelerates maturation of the residual limb as a result of total contact within the socket and the pumping of muscle contractions during weight-bearing activities and movement. Shrinking of the residual limb in early prosthetic training is accommodated for with the addition of layers of appropriate ply thickness of prosthetic socks to maintain a snug residual limb-prosthesis interface. Given fluctuations in residual limb size during early training and the need for an intimate socket fit, new prosthetic users must carry extra socks with them whenever they are going to be out for longer than 2 to 3 hours.

As mentioned, during early prosthetic rehabilitation, individuals continue to use a shrinker when not wearing the prosthesis to reduce the likelihood of insidious edema when the prosthesis is not being worn. Individuals prone to fluid volume fluctuations (e.g., those with kidney dysfunction or congestive heart failure) will likely need to use a shrinker indefinitely. For others, whose residual limb ultimately reaches a stable size and shape, a shrinker may not be necessary once the prosthesis is consistently being used. The decision to discontinue the use of a shrinker permanently is based on two factors: (a) consistency in the number of sock ply worn during the day and (b) the ability to don the prosthesis without decreasing the usual number of sock ply after a night’s sleep without the shrinker.

Significant changes in body weight can also dramatically affect socket fit. Patients should be educated regarding the importance of limiting weight gain or loss so as not to compromise socket fit.

Soft-tissue and bony adhesions that limit tissue mobility around the incision scar and the surrounding area may have an impact on prosthetic tolerance, comfort, and use. Surgical amputation can include muscle-to-muscle (myoplasty), muscle-to-fascia (myofascial), and/or muscle-to-bone (myodesis) surgical fixations to stabilize the remaining muscle.66,⁶⁷ Scarring or adhesions can occur among any or all of these tissues. The normal stresses and shearing forces of cyclic loading and unloading during gait require that soft tissue throughout the residual limb be mobile. If the soft tissue is not able to move independently of the scar tissue or skeletal structures, the stress can lead to tissue breakdown and/or discomfort. Soft-tissue mobilization techniques early in the rehabilitation process can help establish appropriate tissue mobility in the residual limb. Once the surgical incision is securely closed, soft-tissue massage can be an effective tool in maintaining tissue mobility. Deep friction massage may be helpful in managing scar tissue that is restrictively adhered. Individuals can be instructed in the use of this modality with specific guidelines for proper technique. Appropriate deep friction massage targets movements between skin, subcutaneous soft tissue and fascia, and muscle layers. Improper deep friction massage technique is ineffective in managing scar tissue and potentially harmful for the person with fragile skin and soft tissue. Friction generated between the fingers and skin results in skin irritation, blistering, or breakdown and can delay prosthetic use until adequate healing occurs.

Ongoing assessment of the intact lower extremity should be made the responsibility of the individual with the amputation, with support of the physical therapist. Individuals with diabetes, peripheral neuropathy, or peripheral vascular disease who have lost one leg as a result of the disease process have a significant chance of losing the other leg, given the symmetrical distribution of these disease processes and the increased functional demand on the remaining limb after the amputation. The added burden to the remaining limb extends beyond the preprosthetic period. Once ambulatory with a prosthesis, individuals will preferentially initiate level surface walking with the prosthetic limb, placing a larger burden on the sound limb for stability and propulsion.82 And as an ambulatory individual makes adjustments to increase walking speed, this, too, will increased demands on the sound limb.⁸³

Contralateral major limb amputation has long been known to be a very real threat in those with diabetes and vascular compromise,⁸⁴ and this is continually being reaffirmed. A 2006 study by Izumi demonstrated amputation of the contralateral limb of 12% of subjects with diabetes within 1 year of initial amputation, 44% within 3 years, and 53% within 5 years.⁸¹ To minimize the risk of loss of the remaining limb, close monitoring of limb condition (especially for subtle or insidious trophic, sensory, or motor changes) and optimal foot care is essential. Ongoing, systematic, and frequent assessment of pulses, edema, temperature, and skin is suggested. Education about the importance of a daily routine of cleansing, drying, and closely inspecting the foot (including the plantar surface and between the toes) is crucial. Podiatric care of nails, corns, and plantar callus, appropriately fitting footwear or accommodative foot orthoses, and avoidance of barefoot walking are three additional imperatives for the longevity of the remaining foot. If unable to perform daily foot inspection independently because of disease or visual impairment or decreased agility, individuals must be able to direct a caregiver in inspecting the foot. Even if individuals are physically incapable of performing certain tasks for their own health and safety, they are ultimately responsible for their own care. Developing or improving on a person’s skill at directing assistance is a useful and realistic PT treatment goal.

The members of the interdisciplinary team involved in the care and rehabilitation of persons with amputation include the surgeon, a physiatrist, a prosthetist, a physical therapist, an occupational therapist, a social worker, a rehabilitation nurse, and a vocational rehabilitation counselor. Many hospitals and rehabilitation centers have established prosthetic clinics that bring together the appropriate professionals to address the needs and problems of prosthetic users. Determining prosthetic candidacy is the first major clinical decision to be made. Although the research literature has identified predictors of outcome of prosthetic use,11,^14,15,27 the team considers the individual’s needs, motivation, and functional capacity in deciding about prosthetic candidacy. Factors that are most often considered in determining whether to fit an individual with a prosthesis include: