General Rehabilitation Principles and Strategies for the Lower Limb Amputee

Israel Dudkiewicz MD, MHA

Lisa Prasso PT, DPT

Neither of the following authors nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this chapter: Dr. Dudkiewicz and Dr. Prasso.

ABSTRACT

Lower limb amputation affects an average of 150,000 people per year in the United States and causes severe disability that may devastate a person’s quality of life. The rehabilitation programs should be encoded to the International Classification of Functioning, Disability and Health. These rehabilitation programs should be started as soon as possible and have a multidisciplinary approach and include everything from pain management to assist with phantom pain prevention, psychological support to help process the loss of a limb, contraction prevention for ideal socket fit, range of motion to complete functional activities, muscle strengthening to promote proper gait mechanics, and activities of daily living. Initially these tasks should be completed at a wheelchair or crutch level and then, when cleared for weight bearing, be completed with the prosthesis donned. A major barrier that affects participation is accessibility. Rectifying this takes time and should be addressed in the early stages of rehabilitation. All disciplines and modalities should be taken into consideration to assist in the recovery from lower limb amputation including but not limited to traditional physical therapy, occupational therapy, hydrotherapy, behavioral therapy, and advanced technology such as virtual reality, gait laboratory assessments, or even dog-assisted therapy to facilitate the chances of success.

Introduction

Lower limb amputation (LLA) can cause severe functional disability and negatively affect a person’s quality of life. Most LLAs are induced by the combination of peripheral vascular disease and diabetes mellitus with an annual incidence in the United States of 120 new cases per 100,000 people: 20 of them are minor amputations (occurring distal to the ankle) and 100 are major amputations (ankle disarticulation or proximal).¹^,² Between 1990 to 2017, in Europe, there were between 16.7 and 27.9 new amputations per 100,000 people and in Australia between 31.4 and 41.9 per 100,000 people.³ LLAs are mainly performed on an emergency basis, either to save a limb or to save a life when possible prehabilitation treatment should be initiated to improve function, independence, and quality of life.

It is important to outline the rehabilitation process according to the International Classification of Functioning, Disability and Health (ICF) principles. This will assist clinicians in understanding the main target of the rehabilitation plan of care to help patients achieve functional independence.

The ICF describes the parameters that affect human health (Table 1). It includes the body structure and function, activity, and participation according to the health condition (disorder or disease) and contextual factors (environmental and personal)⁴ (Figure 1).

The rehabilitation program should incorporate all ICF principles to achieve full participation and return the patient to prior level of function with a prosthesis. Timing of the rehabilitation process is important for success and should focus on body function and structure (residual limb, etc) first, then proceed to activity and participation. Personal and accessibility issues can be deterrents that slow progress and prevent full recovery and therefore should be treated as soon as possible to manage, solve, and remove barriers.

The main ICF-related targets in LLAs are outlined in Table 2.

Health Conditions Associated With Amputation

The most common cause of LLA is diabetes mellitus, accounting for more than 80% of the cases.⁵ These patients are at risk for further deterioration, with a 23% to 34.5% incidence of ipsilateral re-amputation and an 11.9% incidence of contralateral limb amputation within 1 year,⁶^,⁷ 17.8% after 2 years, 27.2% after 3 years, and 44.3% after 4 years⁶ and with an overall mortality
rate of 47.9%, 61.3%, 70.6%, and 62.2% at 1-, 2-, 3-, and 5-year follow-up, respectively.⁸ These extreme numbers of diabetes-associated LLAs with high risk of deterioration make the need for secondary prevention (glucose balance, complication treatment, and engagement of diabetic foot program) a major part of the rehabilitation program.

TABLE 1 International Classification of Functioning, Disability and Health Parameters That Affect Human Health

Parameter	Definition
Body function	Physiologic functions of body systems (including psychological functions)
Body structure	Anatomic parts of the body such as organs, limbs, and their components
Impairments	Problems in body function or structure such as a significant deviation or loss
Activity	The execution of a task or action by an individual
Participation	Involvement in a life situation
Activity limitations	Difficulties an individual may have in executing activities
Participation restrictions	Problems an individual may experience in involvement in life situations
Environmental factors	The physical, social, and attitudinal environment in which people live and conduct their lives

FIGURE 1 Algorithm of the International Classification of Functioning, Disability and Health model of disability.

TABLE 2 International Classification of Functioning, Disability and Health-Related Targets in Lower Limb Amputation

Parameter		Target
Health condition		General medical treatment and secondary prevention
Body structure		Pain management and residual limb treatment
Body function		Range of motion, contraction prevention, muscle strength, and balance
Activity		Practicing activities of daily living, wheelchair, and prosthesis fitting and training
Participation		Access home, work, education, and leisure
Contextual factors
	Personal	Profession, education, psychological, social, and family status
	Environmental	Accessibility (stairs, elevators, ramps), transportation, house, and neighborhood

Another issue that should be considered is the high prevalence of cardiovascular disease, especially myocardial ischemia and heart failure, in patients with diabetes mellitus. The presence of severe heart disease or heart failure may limit prosthetic rehabilitation because of the high energy expenditure rate. As an example, individuals who have undergone transfemoral amputation expend 30% to 60% more energy than nonamputees when completing activities of daily living and ambulation.⁹

Therefore, a clinical and, if needed, a laboratory assessment of heart function should be done prior to prosthetic rehabilitation to address possible cardiovascular barriers to care. In addition, kidney function should be screened because it can affect fluid accumulation, which influences the volume and shape of the residual limb.

Body Structure/The Residual Limb

The surgical site should be monitored and the patient educated about red flags that might indicate infection. Compression wrapping (using a figure-of-8 technique) or shrinkers should be used for volume management and limb shaping to optimize initial prosthetic fit and prepare the patient for functional success.

Pain can be a major barrier in the rehabilitation process and should be addressed with a multidisciplinary approach. Management of preoperative and postoperative pain increases success with prosthetic use and can reduce the possibility of the development of phantom limb pain (PLP), which is a predictor of poor functional outcomes.¹⁰ PLP is one of the most common problems that affects quality of life; it decreases prosthetic use and can occur in 60% to 80% of patients.¹¹

There are many theories about the etiology of PLP, including peripheral (ectopic impulses, structural changes of nerves, and alterations in neurotransmitter function), spinal (increased response of spinal cord neurons due to continued peripheral input, interference of the normal spinal inhibitory mechanisms, abnormal firing of neurons, and structural changes), and central (cortical remapping or reorganization and the neuromatrix theory) causes.¹¹^,¹²

Risk factors proposed for the development of PLP include severity of preamputation pain and postoperative
pain due to infection or tissue ischemia,¹³^,¹⁴ improper prosthetic fit,¹⁴ older patient age,¹⁵ depression, and coping style characterized by excessive negative thoughts and emotions in relation to pain.¹⁶^,¹⁷ The connection between preoperative and postoperative pain can be seen in patients with diabetes and those with paraplegia who have reduced peripheral nociceptive inputs and hence less PLP.¹⁸

Patients with LLA-related pain are difficult to treat because many of them have a history of analgesic drug use, including opioids, and there is no single origin for the pain that can be induced.¹⁹ The pain can be preoperative and postoperative ischemic pain, with intensity prior to amputation being a significant predictor of the development of chronic limb pain.²⁰^,²¹ If residual limb pain does not improve in the first 2 weeks following surgery, complications such as infection, tissue necrosis, wound dehiscence, osteomyelitis, or neuroma formation should be suspected.²⁰^,²²^,²³^,²⁴ Therefore, such patients will benefit from the involvement of an acute pain service team and use of a multimodal analgesic regimen to optimize their pain management before and immediately after the amputation.¹⁹ This is also useful in patients with PLP, as onset can occur 1 to 7 days postoperatively or later in the rehabilitation process.¹⁰^,²⁰^,²²^,²³^,²⁵

FIGURE 2 Photographs showing the development of contraction. A, Prolonged wheelchair sitting without maintenance of knee extension. B, Consequently in standing: Hip and knee flexion contractures can be seen. (Reprinted with permission from Orthopedic Rehabilitation Department, Rehabilitation Division, the Integrated Rehabilitation Hospital, Sheba Medical Center, Tel-Hashomer, Israel.)

Body Functions

Limitations in joint range of motion complicate prosthetic usage. It is crucial to provide patient education on contracture prevention in early rehabilitation stages. Postoperative positioning is known to cause knee and hip flexion contractures. A patient with a transfemoral amputation should be guided to lie in a prone position if possible so that the hip is extended, in contrast to a patient with a transtibial amputation who should lie in a supine position or sit with an extended knee. Although it is much more comfortable, a pillow should not be placed under the knee because of the danger of the development of a knee flexion contracture (Figure 2). For patients who are not fully aware of their position or cannot cooperate, such as unconscious patients or those in intensive care units, a brace or cast should be considered.

Only gold members can continue reading. Log In or Register to continue