Physiotherapy for Amputees

Physiotherapy for Amputees................................

LEVELS OF AMPUTATION

The decision to amputate a limb involves four principal considerations:
• preservation of life
• improvement of general health
• restoration of function
• reduction of pain.
The underlying causative factors that result in amputation are (Engstrom and Van de Ven 1999):
• peripheral vascular disease (arteriosclerosis, gangrene)
• diabetes mellitus
• renal disease
• trauma
• tumour
• congenital limb deficiency
• infection.
The level of amputation is decided by tissue viability. A limb needs to be amputated to a level which ensures that all necrotic tissue has been excised and that the residual portion of limb will heal and be viable. The decision must also take account of the length of
the residual limb and its suitability for prosthetic fitting, function and cosmesis. Table 22.1 lists the levels of amputation seen in clinical practice. The proprioceptive feedback from the joint receptors in joints is extremely important to gait re-education, so joints will be preserved if possible.

GENERAL APPROACH TO MANAGEMENT

The overall management of an amputee patient is aimed at improving general health, reducing pain and restoring function. A team approach with clinical reasoning, clinical effectiveness, evidenced-based healthcare and problem-solving at its centre is advocated.
Management spans all spheres of health and social care, from initial contact in a primary care setting through to tertiary care in a specialist centre. The partnership between health and social care is paramount to a successful outcome. Because amputation is the last resort when all other possible treatments have been exhausted, patients have often had other interventions such as angioplasty,
endarterectomy and pharmacological therapy (Pell et al. 1997; Robicsek 1997; Redhead 1984). Not all amputees are suitable for a prosthetic limb. Assessment of suitability is made by the multidisciplinary team and is based (for a lower-limb amputee) on the following criteria:
1 Does the patient want to walk?
2 Does the patient have the potential to walk?
3 Who will help the patient in the home setting?

PHYSIOTHERAPY MANAGEMENT
Basic Issues
Physiotherapy management includes assessment and management of all aspects of the patient's well-being. The physiotherapist needs to take into account the physical, psychological and social aspects of the patient's life. Rehabilitation is an inclusive process giving
due regard to the whole patient and not just his or her physical status (Buttenshaw and Dolman 1992). The overall aim of physiotherapy is to promote optimal independence in the use of a specific limb. The goals can be summarised as:
• recovery of good general health
• maximisation of functional outcome
• prevention of complications
• reduction of pain.
Accurate and ongoing assessment of the patient throughout the four stages of amputee management is an essential component of physiotherapy.

Principal amputation levels

Upper limb………………

Forequarter
Shoulder disarticulation
Transhumeral
Elbow disarticulation
Wrist disarticulation
Transmetacarpal

Lower limb……………………

Hindquarter
Hip disarticulation
Transfemoral*
Supracondylar
Transtibial
Gritti-Stokes
Knee disarticulation
Transtibial*
Symes
Choppat/Lisfranc
Transmetatarsal
* The most common levels seen in clinical practice (Fyfe 1990).
Initial assessment at the preoperative stage should be followed by regular reassessment and evaluation of the outcomes of the treatment process. A problemsolving approach to assessment is required. This type of approach allows the physiotherapist to 'tailor' a treatment programme that best suits an individual patient at any given time. The physiotherapist's knowledge of normal human movement is essential to provide effective limb re-education. The physiotherapist is involved in the management of a patient from the preoperative stage to the rehabilitation stage. Contact with the physiotherapist is often frequent and takes place over many months. The physiotherapist is instrumental to the decision regarding prosthetic prescription and works closely with the prosthetist to facilitate the best mobility outcome. It is often the physiotherapist who discovers problems with the prosthesis during the rehabilitation stage.
Physiotherapy intervention can be divided into four distinct stages: preoperative, postoperative, preprosthetic and prosthetic (the preprosthetic and prosthetic stages collectively make up the rehabilitation stage). Table 22.2 summarises these four stages of physiotherapy intervention, with lower-limb amputation used for illustrative purposes. Assessment is an integral part of
all stages.

The Preoperative Stage

The physiotherapist's full preoperative assessment should include the respiratory status of the patient, because the effects of anaesthesia can mean that this status is compromised following surgery. This preoperative stage is very important to the overall outcome as it is a time when the physiotherapist can explain to the patient what will occur postoperatively and prepare the person for the rehabilitation pro-

Table 22.2 Lower-limb amputation used to illustrate the four stages of physiotherapy management.

Stage of management Components

Preoperative………………Respiratory and musculoskeletal status Physical, psychological and social status Past medical, drug and social history Premorbid mobility Explanation of postoperative regimen

Postoperative……………………Respiratory status, Bed mobility exercises, Mobility and strength exercises for the residual limbs and trunk, Assessment for walking aid, transfers ,Wheelchair assessment, Balance and posture re-education ,Stump care and pain reliefAs above, plus:Use of pneumatic postamputation mobility

Preprosthetic rehabilitation stage (patient assessed for suitability for prosthesis)……………….. As above, plus:
Use of pneumatic postamputation mobility (PPAM) aid 7-10 days postoperatively Gait, posture and balance re-education
Activities of daily living (ADLs).

Prosthetic rehabilitation stage................................ As above, plus: Prosthetic management Continuing gait re-education Promotion of functional independence Stump care.

gramme. The physiotherapist is involved in the preparation of the patient for surgery (Cutson and Bougiorni 1996).
Ideally the preoperative stage involves assessing the patient several days prior to surgery. However, the decision to amputate may occur as an emergency, in which case the physiotherapist possibly has only a few hours to complete the assessment.

The Postoperative Stage

During the postoperative stage the physiotherapist is involved in the assessment of suitability for walking aids and wheelchair prescription. Early on, prior to the use of a temporary prosthesis, the walking aid of choice is a walking frame - except for the younger patient when crutches may be possible. Whilst there is no fixed protocol following surgery, Table 22.3 provides a guide to the type of programme used in clinical practice. The physiotherapist must work in line with the protocol stipulated by the operating surgeon, which may vary. An important role of physiotherapy during the postoperative stage is the prevention of contractures.
This is vital to ensure the success of the prosthetic stage. Contractures will severely hamper the rehabilitation process and could result in the inability to use a prosthesis. The physiotherapist educates the patient in the prevention of contractures through a range of exercises and posture management. The typical contractures associated with lower-limb amputation are transtibial and transfemoral:
• Transtibial contracture can be described as knee flexion. It is positional as patients may spend a lot of time sitting. The use of a stump board and regular supine lying will help to prevent this.

• Transfemoral contracture can be described as hip flexion. There may be abduction due to unopposed hip flexors and abductors. Adduction may be a problem with a long residual stump owing to unopposed adductor longus.

Table 22.3 Example of post-operative physiotherapy management

Day 7 - in bed
• Respiratory maintenance
• Exercises to include strengthening, mobility, balance
• Pain control

Day 2 - In chair
• Strengthening exercises (e.g. static quadriceps, upper limb exercise, knee flexion, bridging)
• Balance work
• Transfer practice
• Contracture prevention
• Assessment for wheelchair

Day 2-3 - Standing with walking frame
• Balance work
• Posture management

Day 3-4 - Walking with walking frame
Transfer practice
• Stump maintenance
• Balance work

Day 7-70
• Begin early walking (PPAM) aid
• Re-education in the gym: posture, balance work
• Continue contracture prevention and stump care

Day 10
• Discharge, or transfer to rehabilitation unit
• Refer to DSC for prosthetic assessment

The Preprosthetic Stage

Early mobility is an important element in the rehabilitation of the patient. Not only does it provide early ambulatory practice for the patient, it also provides a psychological boost. It helps to prevent the onset of contractures and to re-educate posture and balance,
two essential components of gait. The pneumatic postamputation mobility (PPAM) aid This mobility aid is advocated in the literature
(Engstrom and Van de Ven 1999). It is introduced approximately 7-10 days after the operation, provided the residual limb is healing and there are no complications. It provides the patient with the opportunity to bear weight through the residual limb. Care must be
taken when using the PPAM aid to ensure no damage to the stump. The PPAM aid uses inflatable bags inside a metal frame. The inflatable bags are placed over the stump and support the residual limb inside the frame. Owing to the vulnerability of the stump the bags should not be inflated beyond 40 mmHg. It is essential that a pump be used that is capable of measuring exactly the
amount of pressure in the bags. Over-inflation may compromise tissue viability. The decision whether or not to proceed to a prosthesis
is usually taken at this stage. Not all patients are suitable for prosthetic use. There is also little point providing
a prosthesis if it will gather dust in a cupboard! Some people are unable to cope with a prosthesis, for a variety of reasons. However, all patients should be assessed for prosthetic use on an equal basis. For those patients not going on to the prosthetic stage, an important
part of the physiotherapist's role is to promote wheelchair independence.

The Prosthetic Stage

The majority of amputees go on to successful prosthetic independence and often enjoy a greater degree of quality of life than they had prior to the amputation. The improvement in function after possibly years of pain, discomfort and poor function can mean that the
amputation has an eventual positive outcome. This does take time. Often it is the psychological impact of the change in body image that has a more significant effect on the patient (Henker 1979). For the lower-limb amputee this stage involves intensive re-education of gait, along with detailed education of stump maintenance. The ultimate outcome of physiotherapy at this stage is to ensure the functional independence of the patient with a definitive limb. Ideally the outcomes of this final stage should be:
• understanding of the components of the prosthesis
• independent fitting and removal of the prosthesis, and checking its fit
• care of the prosthesis
• independent mobility with or without a walking aid, inside and outside, and the ability to cope with obstacles
• functional tasks with the prosthesis
• ability to perform occupational and/or leisure activities
• ability to cope with falls.

Common gait abnormalities

The following lists are extracted from Engstrom and Van deVen (1999).

Transtibial
• Excessive knee flexion.
• Insufficient knee flexion.
• Delayed knee flexion during the swing phase.
• Early knee flexion ('drop off).
• Lateral shift of the trunk.
• Lateral shift of the prosthesis.
• Rotation of the foot.

Transfemoral
• An abducted pattern.
• Rotation of the foot.
• Circumduction.
• Uneven step length.
• Uneven timing.
• 'Drop off.
• 'Foot slap'.
• Uneven heel rise.
• Rising up on the toes of the opposite limb ('vaulting').
• Medial or lateral heel travel in swing phase ('medial whip'/'lateral whip').
• Terminal swing impact.
• Uneven arm swing.
• Lateral side bend of the trunk.
• Forward trunk flexion.
• Lumbar lordosis.

PAIN IN AMPUTATION
There are essentially two types of pain, residual limb pain and phantom pain.

Residual limb pain

Residual limb pain can be attributed to a variety of causes, including the formation of a neuroma - a nodule formed at the end of a cut peripheral nerve, whichfolds back on itself and creates an enlargement. Pain caused by an ill-fitting prosthesis is referred to as 'prosthetic pain' and has a number of causes. In addition, postoperative pain is likely.
Phantom limb pain

Phantom limb pain can be described as distressing pain sensation felt by patients in the limb that is no longer there. It is well documented and is a feature that can impact significantly on the life of a patient (Weiss and Lindell 1996; Williams and Deaton 1997; Hill et al. 1995). It is a pain that seems to be an increasing factor with increasing age (Houghton et al. 1994). The psychological status of the patient also has an impact on phantom limb pain. Phantom limb pain is described variously as cramping, squeezing, burning, sharp and shooting. Table 22.4 lists typical descriptions patients use to describe it.