Physical Therapy Management of Adult Lower Limb Amputees

Robert S. Gailey PhD, PT, FAPTA

Anat Kristal PhD, MScPT

Ignacio Gaunaurd PT, PhD, MSPT

Dr. Gailey or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of Össur and serves as a paid consultant to or is an employee of Össur. Dr. Kristal or an immediate family member serves as a paid consultant to or is an employee of Össur. Neither Dr. Gaunaurd 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.

This chapter is copyrighted by Advanced Rehabilitation Therapy, Inc. Miami FL, 2024.

This chapter is adapted from Gailey RS, Gaunaurd IA, Laferrier JZ. Physical therapy management of adult lower-limb amputees. In: Krajbich JI, Pinzur MS, Potter BK, Stevens PM, eds. Atlas of Amputations and Limb Deficiencies: Surgical, Prosthetic, and Rehabilitation Principles. 4th ed. American Academy of Orthopaedic Surgeons, 2016, pp 597-620.

ABSTRACT

The physical therapy management of an individual with lower limb amputation is a critical component of the continuum of care. The physical therapist is often introduced to a patient preoperatively in preparation for amputation surgery and is one of the first members of the rehabilitation team to begin treatment postoperatively. From the preprosthetic phase through prosthetic gait training and community reentry, physical therapy interventions can have a profound effect on the outcomes of people with limb loss.

Introduction

As members of the rehabilitation team, the prosthetist and the physical therapist often develop a close relationship when working together with individuals with lower limb amputations. The prosthetist is responsible for fabricating a prosthesis that will best suit the lifestyle of the individual patient. The physical therapist has a multifaceted role that includes postoperative care, mobility, and residual limb care. Before the patient can be properly fitted with a prosthesis, the physical therapist helps the amputee become physically prepared for prosthetic training. After the prosthesis is received, the patient must learn how to use and care for it. Prosthetic gait training can be the most frustrating yet rewarding phase of rehabilitation for all involved. The patient must be reeducated in the biomechanics of gait while learning how to use a prosthesis. After success is achieved, the patient may look forward to resuming a productive life. The physical therapist should introduce the patient to higher levels of activities other than just learning to walk. The patient may not be ready to participate in recreational activities immediately; however, providing the names of support and recreational organizations serving the disabled population will enable the individual to seek involvement at the appropriate time.

Preoperative Care

When preoperative care is possible, the physical therapist should begin to establish rapport with the patient during the initial appointment. It is important to earn the patient’s trust and confidence. After introductions, the physical therapist should explain the expected timing of events during the rehabilitation process. The unknown can be extremely frightening to many patients. Fears can be addressed by explaining what the future holds and what will be expected of the patient throughout the process. Having another amputee visit and talk with the patient can often assist in this process. The amputee peer visitor should be carefully screened by appropriate personnel and should have a suitable personality for this task. Many hospitals have affiliations with local amputee support groups with members who are certified peer visitors (CPVs) who have received formal training from the Amputee Coalition.¹ Amputees who have successfully completed the CPV training program have been instructed in communication skills, have a basic knowledge of limb loss statistics, have provided references, and should have experience working with healthcare facilities and professionals who serve amputees. When pairing a CPV with a new amputee, consideration should be given to similarities between level of amputation, age, sex, and outside interests.² The Amputee Coalition in association with John Hopkins Hospital developed a program called Promoting
Amputee Life Skills (PALS).³ This program aims to reduce long-term secondary health effects, such as depression and pain, by improving self-efficacy and quality of life through the implementation of 10 weeks of education specifically designed for those with limb loss. Wegener et al⁴ found that the PALS program in conjunction with a peer support group was more effective in decreasing depression, managing pain, and improving function, self-efficacy, and quality of life than standard support group activities. Information on various prostheses, demonstrations of prosthetic capabilities, or videos showing recreational activities may be useful to the patient. The therapist must consider the amount of information the patient is psychologically prepared to absorb. The physical therapist may advise the patient preoperatively on the possibilities of phantom limb sensation and phantom limb pain, and the prevention of joint contracture and loss of mobility, and the benefits of general conditioning.

Acute Postoperative Evaluation

The acute postoperative evaluation consists of several important components. Baseline information is necessary to establish the goals of rehabilitation and formulate an individualized treatment plan. Viewing amputation surgery as a constructive procedure, not a destructive one, is important for all rehabilitation team members. Because preamputation functional capability is a strong predictor for postamputation mobility,⁵^,⁶^,⁷^,⁸^,⁹^,¹⁰^,¹¹^,¹² rehabilitation goals should focus on restoring the amputee to a premorbid lifestyle and preventing further adversity.

A complete medical history should be obtained from the patient or from the medical records to supply information that may be pertinent to the rehabilitation program. During the initial chart review, the physical therapist should note any history of coronary artery disease, congestive heart failure, peripheral vascular disease, hypertension, angina, arrhythmias, dyspnea, angioplasty, myocardial infarction, arterial bypass surgery, diabetes, and renal disease. Any medications that may influence physical exertion or mental status should be recorded. In addition, the cause of the amputation can influence the concomitant medical concerns for the amputee. For example, patients with diabetes should monitor blood glucose levels before, during, and after the exercise to avoid hypoglycemic-related events. Patients with traumatic amputations may present with undetected soft-tissue injuries, nerve damage, fractures, heterotrophic bone formation, or traumatic brain injuries that will need to be addressed if present.¹³

Cardiopulmonary Status

The heart rate and blood pressure of every patient should be closely monitored during initial training and thereafter as the intensity of training increases. If the patient experiences persistent symptoms such as shortness of breath, pallor, diaphoresis, chest pain, headache, or peripheral edema, further medical evaluation is strongly recommended. If the patient’s cardiopulmonary status is a concern, relatively inexpensive and simple tools such as the pulse-oximeter, the Dyspnea Index,² and the Borg Perceived Exertion Scale⁶ may be used to help monitor exertion or to assist the patient by providing guidelines for effort during ambulation. The cause of amputation (dysvascular or traumatic), amputation level, and number of lower limbs lost have a substantial effect on energy expenditure during ambulation.¹⁴ In addition, it is helpful to assess preamputation mobility using self-report measures to assist with predicting postamputation success.

Mental Status

An accurate assessment of the patient’s mental status can provide insight about the factors likely to affect future prosthetic care. The physical therapist should assess the patient’s cognitive potential to perform activities such as donning and doffing the prosthesis, residual limb prosthetic sock regulation, bed positioning, skin care, and safe ambulation. If the patient does not possess the necessary level of cognition, family members and/or friends should be encouraged to become involved in the rehabilitation process for a successful outcome.

Range of Motion

The range of motion (ROM) of both the upper and lower limbs should be assessed. A measurement of the ROM of the residual limb should be recorded for future reference. Joint contractures can hinder the patient’s ability to ambulate with a prosthesis and have been associated with postural imbalances that can contribute to other physical ailments such as low back pain. Every effort should be made by the physical therapist and patient to avoid any loss of ROM. Hip flexion, external rotation, and abduction are the most common contractures in an individual with a transfemoral amputation. Knee flexion is the most frequently observed contracture in a transtibial amputee. During the ROM assessment, the therapist should determine whether the patient has a fixed contracture, or muscle tightness from immobility that may be corrected within a short period of time with ROM therapy.

Strength

The strength of the major muscle groups is typically assessed by manual muscle testing of all limbs including the residual limb and the trunk, to determine the patient’s potential skill level to perform activities such as transfers, wheelchair mobility, and ambulation with and without a prosthesis. Hip abductor and extensor strength strongly influence how well a patient will ambulate with a prosthesis, regardless of the level of amputation.¹⁵^,¹⁶ A formal strengthening program for the residual and contralateral limb will enable the patient to more effectively negotiate stairs and different terrains and participate in sports.¹⁷^,¹⁸^,¹⁹

Sensation

An evaluation of sensation is useful to the patient and the therapist. Insensitivity of the residual limb and/or intact limb will affect proprioceptive feedback for balance and single limb stance, which in turn can lead to gait
difficulties. The patient must be made aware that decreased sensation to pain, temperature, and light touch sensation can increase the risk for injury to the skin and soft-tissue breakdown. Use of a monofilament is a simple, reliable method to assess sensory impairment of the skin over the intact foot or residual limb and determine patients at risk for potential injury or risk for ulceration.²⁰

Bed Mobility

The importance of good bed mobility extends beyond simple positional adjustments for comfort or getting in and out of bed. Skills are necessary to maintain correct bed positioning to prevent contractures and to avoid excessive friction of the bedsheets against the suture line or frail skin. If the patient is unable to perform the skills necessary to maintain proper positioning, assistance must be provided. As with most patients, adequate bed mobility is a prerequisite skill for higher level skills such as bed-to-wheelchair transfers.

Balance/Coordination

Balance while sitting and standing is a major concern when assessing the patient’s ability to maintain the center of mass over the base of support. Coordination assists with ease of movement and the refinement of motor skills. Introducing balance and coordination exercises early in the rehabilitation program can help improve weight bearing and proprioceptive control on the amputated side and promote symmetric ambulation when undergoing gait training in the later phases of rehabilitation.²¹^,²²^,²³ Both balance and coordination are required for weight shifting from one limb to another, thus improving the potential for an optimal gait. After evaluating mental status, ROM, strength, sensation, balance, and coordination, the therapist will have a good indication of what would be the most appropriate initial choice of an assistive device.

Transfers

Early assessment of an amputee’s ability to accomplish transfer skills is essential, especially when the rehabilitation team is planning discharge from the acute care setting. Many amputees can be discharged to home if they are able to complete transfers either independently or with limited help. When bed mobility is mastered, the amputee must learn to transfer from the bed to a chair or a wheelchair and then progress to more advanced skills such as transferring to a toilet, a tub, and a car. If moderate to maximal assistance for transfers is necessary, it is not uncommon for the amputee to be referred to an institutional living facility that provides skilled assistance until the amputee becomes more independent.

Potential Ambulation With Assistive Devices

A comprehensive evaluation of the patient’s potential for ambulation includes the strength of the intact lower limb and both upper limbs, single limb standing balance, coordination, and mental status. Performance-based outcome measures such as the Amputee Mobility Predictor (AMP) without a prosthesis can be used as a measure of functional capacity before prosthesis fitting, help predict mobility with a prosthesis, and assist with prosthetic prescription and assistive device selection.²⁴ The selection of an assistive device should match the patient’s level of skill, keeping in mind that the required assistive device may change over time. For example, a patient may initially require a walker; however, after proper training, forearm crutches may prove more beneficial as a long-term assistive device. Some patients who have difficulty ambulating on one limb because of obesity, blindness, or generalized weakness can achieve successful ambulation with the additional support provided by a prosthesis.

Setting Goals

The rehabilitation team should establish realistic goals that are consistent with the patient’s desired outcomes for employment, social interactions, and recreational endeavors. Regardless of the level of amputation or age, most patients have the ability to return to the lifestyle that they enjoyed before amputation with only minor accommodations.²⁵^,²⁶^,²⁷ Discussing the patient’s premorbid lifestyle and goals early in the rehabilitation process can provide the rehabilitation team with valuable information that will enable a personalized treatment plan that is appropriate and motivating.

Immediate Postoperative Treatment

General Management Principles

Generally, the goals of postoperative management for the new amputee are to reduce edema, promote healing, prevent loss of motion, increase cardiovascular endurance, and improve strength. Functional skills must be introduced as early as possible to promote independence in bed mobility, transfers, and ambulation techniques. Patient education concerning the self-care of the residual limb and intact limb can prevent adverse effects such as skin abrasions, excessive edema, delayed healing, loss of ROM, and trauma to the intact limb from overuse. In addition, each member of the rehabilitation team should be aware of the need to assist the patient with the psychological adjustment to limb loss.

Postoperative Dressing

The selection of postoperative dressing varies according to the level of amputation, surgical technique, healing requirements, patient compliance, and preference of the physician. The five major types are soft dressings, nonremovable rigid dressings, immediate postoperative prostheses (IPOPs), removable rigid dressings, and prefabricated postoperative devices. Soft dressings are most often used for patients with vascular dysfunction because regular dressing changes may be needed, and alternative wound environments may be used. The disadvantage to soft dressings is that patients frequently decrease their bed mobility, because they are more hesitant to move the operated limb.⁹ Rigid dressings, in addition to controlling edema and providing protection and support, assist in preventing knee flexion contractures in patients with transtibial amputations and provide greater confidence with bed mobility.

The IPOP offers the benefits of rigid dressings and allows ambulation with weight bearing and an assistive device. The IPOP also affords the patient the physiological and psychological advantage of early walking with a prosthetic limb. To date, IPOPs have not been associated with an increased number of falls or injury to the healing residual limb. In amputees with a neuropathic intact limb, providing additional support to the residual limb can potentially reduce foot pressures, improve balance, and reduce the effort of ambulation with an assistive device.

Removable rigid dressings originally were fabricated from plaster and suspended with a variety of supracondylar cuff systems. Currently, it is more common for surgeons to use a commercially available prefabricated copolymer plastic shell with a soft lining and, in some instances, the ability to attach a pylon and foot to create an IPOP. A removable rigid dressing provides the protection and other benefits of the classic rigid dressing with the flexibility of removal for wound inspection or bathing. In addition, socks may be added, or the system tightened for progressive shrinkage of the residual limb. These techniques have been shown to shorten the time to ambulatory discharge from hospital for patients with a temporary prosthesis.

Positioning

When supine, the patient with a transfemoral amputation should place a pillow laterally along the residual limb to maintain neutral rotation with no abduction. If the prone position is tolerable, a pillow should be placed under the residual limb to maintain hip extension. Patients with a transtibial amputation should avoid knee flexion for prolonged periods. A leg rest to elevate the residual limb will help maintain knee extension when using a wheelchair (Figure 1). All amputees must be made aware that continual sitting in a wheelchair without any effort to promote hip extension may lead to limited motion during prosthetic ambulation.

Transfers

After bed mobility is mastered, the patient must first learn to transfer from the bed to a chair or a wheelchair and then progress to more advanced transfer skills. In patients who use an IPOP or temporary prosthesis, weight bearing through the prosthesis can assist the patient in transferring and provide additional safety. For patients with transtibial amputation who are not candidates for ambulation, a lightweight transfer prosthesis may allow more independent transfers. A transfer prosthesis is typically fit when the residual limb is healed, and the patient is ready for training. Bilateral amputees who are not fitted with an initial prosthesis will transfer in a “head on” manner in which the patient slides forward from the wheelchair onto the desired surface by lifting the body and pushing forward with both hands.

Wheelchair Propulsion

A wheelchair will be the primary means of mobility for most dysvascular amputees, either temporarily or permanently. The combination of wheelchair and prosthetic use can enhance overall mobility.²⁸ The amount of energy conserved with wheelchair use compared with prosthetic ambulation is considerable with some levels of amputation.²⁹ Therefore, amputees should be taught wheelchair skills as a part of their rehabilitation program. Bilateral amputees and older amputees with more severe medical conditions may require greater use of a wheelchair, whereas unilateral and younger amputees with fewer comorbidities will be more likely to use other assistive devices when not ambulating with a prosthesis.³⁰ Because of the loss of body weight anteriorly, patients are prone to tipping backward while in the standard wheelchair. Adapters can set the wheels back approximately 2 inches (5 cm), thus moving the center of mass away from the axis of rotation to prevent tipping. This is especially helpful when ascending ramps or curbs. An alternative method is the addition of antitipping in place of or in addition to wheel adapters.

Patients who will be long-term wheelchair users for mobility within the community should be fit for a fully adjustable ultralight manual wheelchair. For example, while moving the rear wheels backward would increase chair stability, it would compromise overall maneuverability and place the amputee at increased risk for repetitive strain injuries to the upper limbs during active self-propulsion.³¹ Adjustable axle plates can allow the wheels to be set back early in rehabilitation for stability and moved forward to afford the amputee accessibility to the push-rims in a biomechanically safe and efficient position as they become more skilled. Adjustable backrests set at less than 90° can assist the amputee in keeping the center of mass in a forward position when the prosthesis is not worn and recline to greater than 90° to accommodate prosthetic wear. Transtibial amputees also require an elevating leg rest or residual limb support designed to maintain the knee in extension, thus preventing prolonged knee flexion and reducing the dependent position of the limb to control edema. It is also recommended that the wheelchair be fitted with removable armrests to enable ease of transfer to or from either side of the chair.

Ambulation With Assistive Devices

All amputees will need an assistive device for times when they choose not to wear their prosthesis, or on occasions when they are unable to wear their prosthesis secondary to edema, skin irritation, or a poor fit. Some amputees require an assistive device while ambulating with the prosthesis. Although safety is the primary factor when selecting the appropriate assistive device, mobility is an important secondary consideration. The criteria for selection should include the following factors: (1) the ability for unsupported standing balance, (2) the amount of upper limb strength, (3) coordination and skill with the assistive device, and (4) cognition. A walker is chosen when an amputee has fair to poor balance, strength, and coordination. If balance
and strength are good to normal, forearm crutches may be used for ambulation with or without a prosthesis. A quad cane or straight cane may be selected to ensure safety when balance is questionable while ambulating with a prosthesis.

FIGURE 1 Illustrations showing proper positioning of the residual limb. A, Neutral hip rotation with no abduction. B, Hip and knee extension when prone. C, Knee extension when in bed. D, Knee extension when sitting. (Copyright Advanced Rehabilitation Therapy, Inc, Miami, FL, 1990. Illustrator, Frank Angulo.)

Patient Education

Skin Care

Patients must be instructed about caring for the residual and intact limbs. The care of skin and scar tissue is extremely important to prevent skin breakdown during prosthetic gait training which would delay rehabilitation and lead to further deconditioning. Appropriate skin care is especially important for patients with diabetes mellitus and/or vascular dysfunction because these patients often require additional healing time. Patients must also be taught the difference between weight-bearing and pressure-sensitive areas in relation to the design and fit of the prosthetic socket. They should be instructed to visually inspect their residual limb on a daily basis or after any strenuous activity for evidence of any abnormal pressures from the socket, such as areas of persistent redness.

Inspection of the intact limb after amputation is important because the foot is subject to additional axial and shear force to compensate for prosthetic weight bearing. A hand mirror may be used to view the posterior residual limb and plantar aspect of the foot. Areas of redness should be monitored very closely as potential sites for abrasion or ulcer. Amputees with visual impairment should seek the assistance of a family member for daily inspections.

If a skin abrasion or ulcer develops, the amputee must understand that, in most cases, the prosthesis should not be worn until healing occurs. In some instances, a protective barrier may be used to avert further insult to the integrity of the tissue while permitting continued use of the prosthesis. Without exception, any lesion to the skin should be reported and followed clinically to avoid further complications.

Desensitization

Many amputees experience postoperative skin hypersensitivity as a result of the disruption of the
neuromuscular system and associated edema. Progressive desensitization of the residual limb is often necessary for restoring normal sensation, while using wound compression techniques to reduce the edema. Desensitization involves gradually introducing stimuli to reduce the hyperirritability of the limb. For example, a soft material such as cotton cloth or lamb’s wool is rubbed around the residual limb, followed by gradually coarser materials such as corduroy. The amputee should progress as quickly as possible to tapping massage with the hand. Eventually, when the suture line has healed, pressure can be applied to the residual limb during transfers, mobility skills, and exercise. These measures will help expedite the ability of the residual limb to wear the prosthesis.

Care of the Prosthesis

The socket should be cleaned daily to promote good hygiene and prevent deterioration of prosthetic materials. The patient should be informed of the best cleansing agent for their socket and liner. In general, laminate plastic, copolymer plastic and silicone materials are cleaned with a damp cloth and mild soap. Foam materials are cleaned with rubbing alcohol. Because some liner materials interact adversely with alcohol, manufacturers’ recommendations should be followed. After using the cleansing agent, a clean damp cloth should be used to wipe away any residue. To ensure maximum life and safety of the prosthesis, patients should be reminded that routine maintenance of the prosthesis should be performed by the prosthetist.

Sock Regulation

Prosthetic sock regulation is important to prevent both extreme loading on the distal aspect of the limb and excessive vertical motion or pistoning between the residual limb and the socket. The amputee should always carry extra socks to be added if pistoning or extreme perspiration occurs. Prosthetic socks are available in several thicknesses or plies, permitting the amputee to obtain the desired fit within the socket. The regular interactions between the physical therapist and the newer amputee provide numerous opportunities to reinforce the importance and technique of using prosthetic socks to manage changing limb volume. Socks should be applied wrinkle free with the seam horizontal and on the outside to prevent irritation or abrasion to the skin. Because most prosthetic socks today are seamless this problem has been greatly reduced.

Suspension sleeves and liners are fabricated from a variety of materials such as silicone, urethane, and gel composites. Some of the benefits of these materials include reduced pistoning, better management of unstable limb volume, improved cosmesis, and for some amputees with impaired hand function, easier donning of the prosthesis. Liners not only reduce shear forces over scar tissue and bony prominences, but also act as suspension devices.

Suspension sleeves and liners are widely accepted, but some amputees have problems with skin reactions from the materials used. Fortunately, a wide variety of materials are available with many alternative solutions should this problem become evident.

Donning and Doffing of the Prosthesis

A wide variety of suspension systems are available for all levels of amputation. The methods of donning a prosthesis are too numerous to describe in this chapter; however, it is important that the prosthetist instruct both the amputee and the physical therapist in the proper method of donning and doffing the particular prosthesis. The physical therapist can help patients develop proactive individualized donning strategies during the early phases of prosthetic rehabilitation.

Residual Limb Compression Dressing

Early rigid or semirigid dressings, compression wrapping, or shrinker socks for the residual limb decrease edema, increase circulation, assist in shaping, provide skin protection, reduce redundant tissue problems, reduce phantom limb pain and/or sensation, and desensitize the residual limb. The use of traditional compression wrapping versus the use of residual limb shrinker socks is controversial. Some institutions prefer commercial shrinker socks because they are easy to don. Advocates of compression wrapping suggest that they may provide more control over pressure gradients and tissue shaping.³²

Many programs prefer to wait until after the sutures or staples have been removed before using a shrinker sock. For amputees with diabetes mellitus, this period is often as long as 21 days. However, compression therapy can begin with wraps or rigid dressings and progress to shrinker socks after the suture line has healed. Compression therapy is a controversial topic, and each rehabilitation team should determine the best course of treatment for their patients. All compression techniques must be performed correctly and consistently to prevent constriction, decreased circulation, poor shaping, and edema. Patient compliance also is an intricate part of the compression program. All wrappings or shrinker socks should be routinely checked and/or reapplied several times per day. The application of a nylon sheath over the residual limb before wrapping or donning the shrinker sock may reduce shearing forces to skin and thus provide additional comfort and safety.

Issues Pertaining to the Intact Limb

The loss of a limb and its substitution by a prosthesis can clearly affect gait biomechanics in most amputees. Therefore, when planning treatment of these patients, management of the intact limb is critical. Preservation of the intact limb may permit continued bipedal ambulation and delay medical complications that can reduce quality of life. One reason for this concern is that the intact limb routinely compensates for the amputee’s inability to maintain equal weight distribution between limbs, resulting in altered gait mechanics. Two known effects on the intact limb are the altered forces being placed on the weight-bearing surfaces of the foot and the second is the increase in ground reaction forces
throughout the skeletal structures of the limb.³³^,³⁴^,³⁵

Amputees with diabetes mellitus may have deviations from normal gait kinematics that increase vertical and shear forces in addition to preexisting abnormal sensation, devascularization, scar tissue, and any foot and/or ankle deformity. Patients with diabetes mellitus have a 50% increased incidence of amputation in the same or contralateral limb within 4 years after the primary amputation.²⁰ Accordingly, expert care of the intact foot becomes even more critical after amputation for amputees with diabetes mellitus, because their chances of achieving functional ambulation as a bilateral amputee will decline.³⁶

Amputations performed because of trauma, congenital causes, or tumor result in a progressively increased risk of musculoskeletal imbalances or pathologies that often lead to secondary physical conditions that affect the patient’s mobility and quality of life. Because amputees tend to favor their intact lower limb, it is often stressed in performing daily activities. It has been found that osteoarthritis is more prevalent in the contralateral limb than the residual limb of amputees of those with lower limb amputation.³⁷^,³⁸ The prevalence of osteoarthritis has become an increasing concern, especially with individuals who have lived with an amputation for long periods of time.³⁹ Over time, the altered forces placed on the skeletal and soft tissues of the intact limb can lead to degenerative conditions.²³ Proper prosthetic fit and physical therapy training increase the probability of having equal force distribution across the intact and prosthetic limbs during ambulation and may decrease the risk of the development of osteoarthritis.⁴⁰ The patient should be advised about risks to the intact limb early in the rehabilitation process.

Strategies to Enhance Patient Education

Educating the amputee about self-care and a home exercise program are critical to the ultimate outcome of the rehabilitation process. The most difficult task is ensuring the patient retains the information and complies with instructions. A self-care checklist that the patient can take home may assist in achieving a positive outcome and provides the clinician with a format for ensuring that important points of care are explained.

Preprosthetic Exercises

General Conditioning

Decreased general conditioning and endurance often contribute to the difficulties in learning functional activities, including prosthetic gait. Regardless of age or current physical condition, amputees should begin a progressive general exercise program immediately after surgery, through the preprosthetic period and eventually as part of a daily routine.

There are many possible general strengthening and endurance exercise activities. Examples include using cuff weights in bed, wheelchair propulsion for a predetermined distance, dynamic exercises for the residual limb, ambulation with an assistive device before the prosthesis is fit, lower and/or upper limb ergometer, wheelchair aerobics, swimming, aquatic therapy, lower and upper body strengthening at the local fitness center, and any sport or recreational activity of interest. One or more of these activities should be selected and performed to tolerance initially, progressing to 1 hour or more each day. The advantages of activity extend beyond improving the chances of good ambulation with a prosthesis. Amputees have the opportunity to experience and enjoy activities they may have not thought possible. While still in the hospital or rehabilitation center, they may have access to a physical therapist or fellow amputee who has mastered a particular activity and is available to provide instruction.

Cardiopulmonary Endurance

Because the average physical and cardiac condition of amputees with dysvascular disease is poor, cardiopulmonary endurance training can directly affect functional walking capabilities, particularly distance and the type of assistive device required for walking.⁴¹^,⁴² Aerobic training improves overall ambulation capabilities regardless of the level of amputation.⁴³

Aerobic training typically begins immediately after surgery as the patient increases their sitting tolerance and early walking distance. Improving aerobic fitness should be incorporated into the rehabilitation program and remain as a part of the amputee’s general fitness after discharge. Initially, most amputees can perform upper limb ergometry safely.⁴⁴^,⁴⁵ After balance and strength return, lower limb ergometry may be performed, beginning with the intact limb and progressing to use of the prosthetic limb, when appropriate. As the amputee’s level of fitness improves other equipment such as treadmills, stair climbing, and rowing machines may be used. Because amputees enjoy the same activities as nonamputees, swimming and walking may be the exercises of choice for general fitness regardless of age or athletic ability.⁴⁶

Strengthening

Dynamic exercise of the residual limb require little in the way of equipment, just a towel roll and a step stool.⁴⁷^,⁴⁸^,⁴⁹ In addition to increasing strength, these exercises offer benefits such as desensitization, improving bed mobility, and maintaining joint ROM. While lying on an exercise mat, the patient depresses their residual limb into the towel roll and raises their pelvis off the surface for a count of 10 seconds. The four postural positions that strengthen the hip musculature include supine for the hip extensors, side-lying on the sound side for hip abductors, side-lying intact side for adductors, and prone for hip flexor muscles. A transtibial amputee can perform two additional exercises. To strengthen the knee flexors, the patient curls their residual limb over the towel roll or end of the plinth. To strengthen the knee extensors, the patient is prone with a pillow under their thigh, depressing their residual limb into the towel roll. The basic dynamic strength training program⁴⁹ for transfemoral and transtibial amputees is shown in Figure 2.

As soon as bed or mat exercises can be tolerated, patients should be introduced to the basics of core stabilization,
which focuses on intervertebral control, lumbopelvic orientation, and whole-body equilibrium, through strengthening of the transversus abdominis and multifidus muscles.⁵⁰ Strengthening the core musculature may minimize or prevent some negative effects, including low back pain, gait dysfunction, and functional impairments after lower limb amputation.⁵¹ Core stabilization strengthening can enhance transfer activities, balance, and ambulation by facilitating neuromuscular pathways, increasing strength, and improving balance through the coordination of the synergistic muscles of the trunk. The purpose of core stabilization is to control, prevent, or eliminate low back pain; increase patient education and kinesthetic awareness; increase strength, flexibility, coordination, balance, and endurance; and develop strong trunk musculature to enhance upper and/or lower limb functional activities. Low back pain is a frequent and debilitating impairment in amputees, and it can often limit physical performance and
reduce quality of life.⁵²^,⁵³ Lower limb amputees have been found to demonstrate alterations in trunk motion and spinal loading during gait that may contribute to a high risk for injury to the low back.⁵⁴

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