Key points

Levels of amputation

For both upper and lower limbs, amputations are classified into specific levels ( Fig. 1 ).

Levels of limb amputations.

Levels of amputation

For both upper and lower limbs, amputations are classified into specific levels ( Fig. 1 ).

Levels of limb amputations.

Rehabilitation team

Ideal outcomes for the amputee are best achieved by a multidisciplinary team including physicians, nurses, physical and occupational therapists, prosthetists, psychologists, vocational counselors, and social workers. Returning to independence and the highest level of function is the goal of the rehabilitation team. It is crucial for the team to identify issues such as pain, depression, and acceptance of changes experienced by the patient and his or her level of disability as a result of the amputation. Adapting to the use of a prosthesis is best accomplished by the team identifying and addressing potential barriers to wearing and using a prosthesis effectively.

Prosthetic candidacy

Multiple factors that must be considered in determining whether a patient is an appropriate candidate for a prosthesis include cardiovascular endurance, level of amputation, cognitive ability, mobility goals, and comorbidities. For an upper extremity amputee, especially a unilateral amputee, depending on the timing of fitting a prosthesis one may be more functional without a cumbersome prosthesis. Others use their prosthesis only for a few hours a day as a tool to assist with certain activities. Early fitting for an upper limb amputation is essential because acceptance and compliance of wearing a prosthesis declines significantly after the third postoperative month. The Atkins Prosthetic Functional Adaptation Rating Scale rates compliance of using the prosthesis and how the prosthesis is used for bimanual tasks, and gross and fine motor tasks.

• 
  

  Atkins Prosthetic Functional Adaptation Rating Scale

  
  
• 
  

  100%: Wearing all day, using well in bilateral tasks, incorporating well in body scheme

  
  
• 
  

  75%: Wearing all day, using in gross and fine motor tasks

  
  
• 
  

  50%: Wearing all day, primarily for cosmetic reasons, using in gross motor tasks

  
  
• 
  

  0%: Not wearing or using the prosthesis; unilaterally independent

Lower extremity prostheses are more likely than upper extremity prostheses to be accepted, whereby appearance is often a factor. Function is more difficult to achieve with an upper limb prosthesis. Patients should be fitted within the first 3 months after an amputation to ensure the best acceptance rate of wearing a prosthesis, otherwise they tend to learn to accomplish tasks without the need of a prosthesis. Often patients require training for a new occupation that does not require using adaptive equipment. Driving should be achievable. Bilateral amputees are more likely than unilateral amputees to wear prostheses.

For lower limb amputees who may be bed bound or at a wheelchair level, especially for an AK, a prosthesis would not add any benefit for mobility goals, meaning that a prosthesis would not assist in transfers and only add weight and a cumbersome contraption. In this case the patient should focus on strengthening the sound limb and learning to transfer with a sliding board or walker. For a BK that is K1, a prosthesis may be helpful for transfers but ambulation may not be a realistic goal; for an AK transfers will not be enhanced or assisted with a prosthesis, and these patients transfer better with only an assistive device such as a sliding board or walker.

Energy expenditure and requirements increase significantly after an amputation, and are directly related to the length or level of amputation: the higher or more proximal the level of amputation, the more energy is required to ambulate with a prosthesis. Bilateral amputees have the highest energy requirement; in these cases, a wheelchair provides a faster and more effective mode of mobility.

Etiology also plays a role in the amount of energy that is expended in amputees. For amputations that occur from trauma, patients are often younger and healthier so their baseline level of activity is higher and can compensate better, reducing the amount of energy required to use their prosthesis. For amputations that occur from vascular disease, the baseline level of activity is typically much lower and, therefore, the energy requirement is often higher because these patients do not compensate as well from an endurance and cardiovascular standpoint ( Table 1 ).

The Centers for Medicare and Medicaid (CMS) has devised a system to assign a potential level of ambulation function, called the K-level, which is determined by a physician and defines which prosthetic components are appropriate for that patient. The range is from 0 to 4, with K0 not being prosthetic candidates because they do not have the ability to ambulate or transfer with a prosthesis, whereas a K4 is a child or highly active adult. A K3-level amputee qualifies for energy-storing feet and higher-level knee units including pneumatic, hydraulic, or microprocessor knees ( Table 2 ).

CMS requires the physician to document many items in the medical record to justify providing a prosthesis to a Medicare beneficiary. For specific documentation requirements, a recommended template is currently being discussed to establish what information is needed in the physician’s note. The required information is listed in the Physician Clinic Checklist ( Appendix 1 ). Key objective outcome measures are used to identify the potential of a patient, which are addressed in an article by Heinemann and colleagues elsewhere in this issue. Some suggested measures include the following.

• 
  

  Objective Measures

  
  
• •
  

  The amputee mobility predictor

  
  
• •
  

  6-minute walk test

  
  
• •
  

  Timed Up and Go (TUG) test

Subjectively physicians can determine the patient’s potential by clinical observation and/or using patient questionnaires.

• 
  

  Subjective Measures

  
  
• •
  

  Locomotor Capabilities Index

  
  
• •
  

  Activities-specific Balance Confidence (ABC) Scale

  
  
• •
  

  Socket Fit Comfort Score

  
  
• •
  

  Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)

  
  
• •
  

  Oswestry Disability Questionnaire

• 
  

  Medical Record Documentation Required by CMS

  
  
• 
  

  See the Physician Clinic Checklist in Appendix 1 .

Prosthetic fitting usually can be done within the first 3 to 6 weeks postoperatively with a preparatory or provisional prosthesis, with a definitive prosthesis at 6 to 8 months; a definitive prosthesis can eliminate the need for a preparatory one if aggressive shrinking is done in the first few weeks after sutures are removed. After continued shrinking occurs in the first year to 18 months, only replacement of the socket may be needed.