Physiotherapy for people with major amputation

Introduction

Rehabilitation following amputation is the responsibility of the multi-disciplinary team (MDT), with the patient focussed in the centre. Working with a specialist team will produce the best outcome for the individual who has undergone life-changing amputation surgery (Pernot 1997). The physiotherapist is a key member of this team, involved at all stages of the process from the pre-operative phase, through amputation and discharge home, to prosthetic training and during life thereafter.

This chapter provides an overview of the physiotherapy management of people with amputation, outlining the role and importance of the physiotherapist’s intervention. Readers will need to refer to the appropriate texts for details of specific treatment modalities and knowledge of causative factors, surgical techniques, prosthetic componentry and associated equipment. A list of reading material and resources will help you source this information, as will many of the other chapters in this book. This chapter will predominantly address the management of adult lower limb amputation.

Amputation is performed for life threatening disease, pain or unsalvageable injury, where all other treatments have failed. The goal is to preserve life and improve function and general health. Having a limb amputated is a life-changing event with potentially devastating consequences to every aspect of living, not just physical functioning. Becoming disabled in this way can affect a person’s personality: affecting body image and relationships, and sometimes threatening the family unit. If amputation occurs when someone is of a young age it can affect earning potential and ambition, and, in most cases, can result in the person having to move home to more suitable accommodation. For many, meeting these challenges is the incentive that drives the determination to overcome their physical disability to achieve a good quality of life.

Causes and levels of amputation

According to the Limbless Statistics (currently replacing the National Amputee Statistical Database, or NASDAB, and managed by UNIPOD), over 72% of lower limb amputations performed in the UK are as a result of vascular deficiencies, such as peripheral arterial disease and/or diabetes (Van de Ven and Engstrom 1999), whereby 50% of these people have diabetes. In fact, this is the case for the majority of lower limb amputations performed in the Western world (Ebskov 1999). Most patients in this category will be over the age of 65 years and may have other comorbidities associated with the ageing process and vascular dysfunction, such as arthritis and cardiac disease (Fyfe 1992, Ham and McCreadie 1992). As most vascular pathologies are progressive in nature, the patient may have undergone earlier intervention in the form of arterial bypass operations (to relieve blockages and narrowing in arteries) or toe amputations (as a result of tissue death) prior to a major amputation. When planning a treatment regime, these concurrent pathologies and history must be accounted for.

The next most common cause of amputation is trauma, where an individual has, perhaps, been involved in a road traffic accident or industrial incident. Amputation may be the only option if the injury to bone, soft tissue, blood vessels and/or nerves cannot be treated and made viable. Amputation may be at the time of the accident or, in some cases, days, months or even years afterwards, when the injured part becomes a burden.

Trauma is the major cause of upper limb amputation, which is often a result of a work-related accident. This population of patients are usually therefore young and of working age. Overall, however, people with amputation owing to trauma remain a very small population in comparison with those with vascular issues.

Historically, the field of prosthetic limbs develops significantly at times of war owing to the increased demand for such services by the young war-injured. Injuries caused by bomb blasts are particularly challenging for the MDT owing to the extensive nature of injury.

Other reasons for major amputation of an arm or leg are tumours, infection and congenital deficiencies. Children born with limb absences or deformity do not always have an amputation; however, their limb dysfunction is often managed like an amputation. In general, it is fair to say that people born with full or partial limb absence cope better mentally and physically with their impairment than someone with acquired limb amputation – particularly those with upper limb involvement who tend to be less reliant on a prosthesis.

The decision regarding amputation level is determined by the need to remove all non-viable tissue while creating a healed, pain-free, functional and potentially prosthetically suitable residuum (stump), also called residual limb. Incidentally, many patients do not like their leg being referred to as a ‘stump’ and appropriate references should be found. Where possible, when an amputation is a planned event, the physiotherapist should be involved in the amputation level decision as their assessment findings can predict postoperative functional ability and therefore the likely rehabilitation outcome. Tables 20.1 and 20.2 list the causes of amputation seen in the developed world and the recognised levels of surgical amputation.

Table 20.1

Causes of amputation in the developed world (Van De Ven 1999)

Developed world cause	Relative percentage (%)
Lower limb
Peripheral arterial disease (25–50% of which also have diabetes mellitus)	85–90
Trauma	9
Tumour	4
Congenital deficiency	3
Infection	1
Upper limb
Trauma	29
Disease	30
Congenital deficiency	15
Tumour	26

Table 20.2

Levels of amputation (Van de Ven 1999)

Lower limb	Upper limb
Hemipelvectomy Hip disarticulation Transfemoral * Supracondylar, transcondylar and Gritti-Stokes Knee disarticulation Transtibial * Symes Chopart/Lisfranc Transmetatarsal Interphalangeal	Forequarter Shoulder disarticulation Transhumeral * Elbow disarticulation Transradial * Wrist disarticulation Transmetacarpal Interphalangeal

^*Denotes the most commonly seen levels in clinical practice.

Key point

The MDT consists of surgeons, nurses, physiotherapists, occupational therapists, counsellors and psychologists, prosthetists and orthotists, wheelchair therapists, rehabilitation doctors, podiatrists and chiropodists, social workers and homecare agencies. Specialist regional units, sometimes known as Disablement Services Centres (DSCs) are the usual hub of management. Services are provided by primary, secondary and tertiary establishments, and the patient will meet numerous clinicians throughout their rehabilitation. The physiotherapist has a key role, often providing the constant link between all the professionals.

The psychosocial impact of amputation

The physiotherapist, as for all team members, must have an understanding of the psychological implications associated with having a limb amputated. This will help in building a rapport with the patient, aiding agreed goal-planning and facilitating a motivating rehabilitation regime for the individual.

Loss of a body part and consequent change to body image can potentially lead to loss of confidence; loss of function; loss of a lifestyle; loss of role, income and status; and loss of independence and control. Having an amputation can result in people feeling vulnerable, worthless and isolated. People will be affected by each of these aspects to differing degrees and their ability to accept their new situation will also vary greatly. The normal reactions to grief and bereavement are well documented (Kubler-Ross 1969; Parkes 1972, 1975; Campling 1981); for some patients the reaction is transient and minor, while for others it is profound, disabling and longer lasting (Bradway et al. 1984; Butler et al. 1992; Krueger 1984).

Key point

Models of grief and bereavement offer frameworks for understanding grief associated with loss. It must be recognised that grief affects people in different ways and does not always manifest itself in a set pattern to a set timeframe. The physiotherapist must be sensitive to patients’ emotional needs at all stages of the rehabilitation process.

Anyone who has an amputation needs to be given time to adjust. They need to be given accurate information about their rehabilitation programme and realistic ideas of what they can expect. Amputation affects the whole family and loved ones should be included in any rehabilitation process (Caron 1989). A successful outcome in restoring independence and self-worth is dependent on adjustment and acceptance by the individual and their close support network. People with disability often lack choice and other people make decisions on their behalf (O’Shea and Kennelly 1996). This has the impact of denying them a role in society. The physiotherapist must take time to talk with their patient, to understand their fears and their hopes, to recognise barriers to progress and work together to set goals. Recovering after an amputation is not just about functional recovery, for example being able to ‘walk’ or to make a cup of tea.

Pain and pain relief

There are three potential types of pain following amputation.

Residual limb pain

Amputation surgery creates tissue disruption and trauma. This produces a natural inflammatory response resulting in oedema (swelling). Refer to Chapter 12 for details. The oedema results in pressure on already injured nerve endings, causing pain. This pain is usually managed postoperatively with analgesics and possibly epidurals. Managing the oedema itself will also help with pain relief. The physiotherapist can use limb elevation, elastic compression such as Tubifast, intermittent compression and exercise to improve the circulation thereby promoting the healing process, reducing swelling and thus pain (see Figure 20.1). Normal primary healing takes around three weeks. Any delays in healing can result in greater scar tissue which can become adherent to the underlying bone and therefore be painful on skin movement, especially when under pressure. Massage and ultrasound can be helpful at relieving this type of scar pain.

Figure 20.1 Elevation with a wheelchair stump board and compression garment.

Following amputation, when a cut nerve heals there is a growth of nerve cells at the distal end. As the dissected nerve has no neural sheath to grow into it forms a bundle called a neuroma. The surgeon endeavours to bury major nerve endings within soft tissue, as they can be very sensitive. If the neuroma is superficial, direct pressure from wearing a prosthesis can create pain. Sometimes ultrasound therapy can ease symptoms.

Later on, use of a prosthesis can cause pain in the residual limb owing to sheer friction or excessive pressure. This can damage skin, which can result in bruising, skin breakdown, infected hair follicles and blisters. The physiotherapist must ensure that the user has put it on correctly and ensure a correct fit. Liaison with the prosthetist is essential (see the section related to prostheses further on in the chapter). Skin hygiene and skin care is also very important.

Phantom limb pain and sensations

Phantom limb is described as sensation experienced in the missing limb part (phantom limb sensation (PLS) ) and it can, in many cases, be experienced as pain (phantom limb pain (PLP) ). It is well documented and symptoms are well recognised, if not poorly understood (Fraser et al. 2001). It is a feature that can impact significantly on the life of a patient (Hill et al 1995; Weiss and Lindell 1996; Williams and Deaton 1997). Experiencing a phantom limb can be alarming to people and they need to be reassured that this is normal, as 70% of people with amputation experience PLP (Butler and Moseley 2008).

There are two reasons why someone may still perceive the amputated body part. Firstly, the brain has an area of tissue dedicated to that body part (the homunculus map) which expects sensory information. This area of the brain is obviously not removed during limb amputation and thus still tries to process information. As a result, it can acknowledge sensory input from the adjacent brain tissue. When the sensory feedback is painful, this can be more troublesome for the individual as it is perceived as real pain.

A second reason to perceive pain is owing to the surgical cut of the nerve causing damage and inflammation. In addition, at the time of injury or disease, the nerve tissue may have been crushed or starved of a vascular supply, also resulting in painful symptoms.

Types of phantom pain described are: ‘burning’, ‘electric’, ‘shooting’, ‘twisting’, ‘cramping’, ‘crushing’ and ‘sharp’. PLP can be intermittent or constant, and can be felt in any part of the removed limb. This can take a long time to settle down and in a few cases never resolves. It can seem worse when the individual is stressed or unwell, throughout a lifetime. It is important that the physiotherapist assesses pain carefully to determine its cause and allay patient fears that something is wrong. Effective pain relieving modalities for phantom include: transcutaneous electrical nerve stimulation (TENS), acupuncture, relaxation, massage, exercise, compression and analgesia. Chapter 17 (‘Pain’) will be useful to consult. Alternative methods can include reflexology, counselling and hypnotherapy.

Key point

Phantom pains are often exacerbated by stressful life events, such as illness, changing house or job, or divorce and bereavement.

PLP should not be confused with PLS, which are sensations in the missing limb that are not painful. These are often sensations of the limb as it was before amputation, often in normal orientation, but sometimes in a strange position. People have described such sensations as ‘foot facing backwards’, ‘tight shoes’, ‘itching’ and ‘pins and needles,’ as well as feeling that their hand or foot is now at the end of the residual limb, known as the telescoping effect. These sensations can be equally distressing and as distracting as phantom pain.

Secondary pain

Another significant area of pain can be the secondary pain caused by the stress to the remaining musculoskeletal system, owing to the asymmetry of the posture caused by amputation and the use of a prosthesis. It is well known that lower limb prosthetic users are prone to early onset osteoarthritis, particularly in the lower back and in the hip and knee on the remaining side (Ehde et al. 2001; Norvell et al. 2005) Your skills in the assessment and management of musculoskeletal problems will be vital.

The role of the physiotherapist following lower limb amputation

Physiotherapy involves the continuous assessment of patients’ goals, needs and abilities in order to set realistic and agreed treatment plans. The physiotherapist will rely on all their skills for treating a number of conditions.

The physiotherapist must re-educate movement patterns to optimise independent function for activities of daily life such as self-care, wheelchair and prosthetic use, and normal occupation, while managing all influencing factors.

Physiotherapy aims

Rehabilitation following lower limb amputation is a continual process, involving all aspects of a person’s life: physical, mental, emotional and socioeconomic. For a successful physiotherapeutic outcome all these aspects must be addressed.

The final goal should be optimal independence, with or without a prosthesis, to return to as normal a life as possible. Ideally, the person should achieve:

• independent self-caring;

• independent indoor mobility;

• independent outdoor mobility;

• being able to get in/out of a car or other transport;

• a return to leisure/hobbies/work/society.

Considerations

The following are reasons why some patients have difficulties achieving goals:

• poor residual limb condition, e.g. adherent scar tissue, unhealed, bulbous shape, failed myodesis, neuroma, bony prominences, pain, hypersensitivity, poor vascularity, short leverage, skin frailty;

• concurrent pathologies leading to an inability to learn, reduced range of motion, reduced strength and stamina, pain, poor balance, poor dexterity, socket intolerance;

• social and environmental difficulties, e.g. living alone, unsuitable accommodation for wheelchairs or prostheses, poor access to accommodation, unhealthy lifestyle, dominant carers;

• lack of motivation – fear, fatigue, emotional barriers to achieving success;

• inappropriate equipment, e.g. poor prosthetic socket fit or alignment, a too big or too small wheelchair, incorrect prescriptions;

• lack of specialist rehabilitation services.

The inability to learn new skills is probably the largest determining factor to successful outcome. Sometimes this can be influenced by physiotherapy intervention but not in every case.

Patients must be involved in co-ordinating all aspects of their treatment-planning, goal-setting and monitoring as self-responsibility and self-management are the foundations of rehabilitation (Watson 1996).

Physiotherapy assessment

Assessment

A thorough subjective and objective assessment will ensure accurate and realistic goal planning. Table 20.3 outlines the content of both a subjective and objective assessment. It is important during the assessment that the physiotherapist gains an understanding of what the patient has been through, their current situation and their goals for the future. This needs to be in terms of their physical and psychosocial well-being. The objective assessment needs to carefully assess any musculoskeletal or neurological dysfunction and current movement control.

Table 20.3

Subjective assessment
Present complaint	Level of amputation and cause, time since amputation. Current symptoms
History of present complaint	Ulcers, gangrene, bypass surgery, intermittent claudication, rest pain, sympathectomy, embolectomy, heparinisation, stages of amputation. Accident details and orthopaedic history, salvage operations, oncology treatment
Past medical history	Related: diabetes, myocardial infarction, cerebrovascular accident, angina, renal status, eyesight and neuropathy, concurrent injuries
Past medical history	Other: respiratory disorders, osteoarthritis, rheumatoid arthritis, major surgery, old injuries, hearing and sight, depression, epilepsy, low back or peripheral joint pain
Social history	Home environment, cohabiters, family support and dependants, home care package, district nurse, access (ramps), doorways, bathroom upstairs, rails/stair lift, employment, school and education, hobbies, finances, compensation claim status (related to trauma), driving, smoking and lifestyle, attitude to exercise and fitness
Drug history	Drugs that may affect rehabilitation programme
Mobility	Pre-amputation – distance covered, walking aids used, stairs, outdoors, wheelchair, exercise and sports, limiting factors
	Post-amputation – as above plus transfers and bed mobility
	Type of wheelchair, walking aids and prosthesis
Function	Self-care, domestic tasks, shopping, laundry, carrying objects, picking up objects, stairs, steps/kerbs, slopes, energy expenditure, limiting factors, compensations, safety, falls, aids used
Prosthetic rehabilitation history	Current and previous prostheses: prescription, delivery date, socket fit, ability to don/doff, maintenance, pattern of use (how long, daily, how far) and reasons for no prosthesis. Current and previous physiotherapy intervention
Psychological status	Attitudes, emotions, depression, goals and aspirations
Objective assessment
Residual limb	Wound, scar, healing status, dressings, oedema, pain (visual analogue scale 0–10*), sensation, colour, temperature, compression therapy, reflexes, joint range, contractures, weakness, strength, co-ordination
Remaining limb	Vascularity, strength, joint range, scars, wounds, risk level, temperature, ulcers, footwear, colour, pulse, pain, oedema, numbness, joint dysfunction and adaptations, sensation, reflexes, motor control
Trunk and balance	Sitting, standing, pain, trunk range and control of movement, alignment, posture and core stability, abdominal strength, compensation reactions (see Figure 20.2 – postural alignment changes following amputation)
Gait/function with prosthesis	Gait pattern, deviations and possible causes, speed, indoor and outdoor use, varying surfaces, exercise tolerance