Physical Therapy for Amputation

Physical Therapy for Amputation

Definition: Amputation means the absence of the whole or part of a limb.

Causes of Amputation
I. Congenital amputation: Absence or abnormality of a limb evident at birth.
II. Acquired amputation:
1) Traumatic amputation: loss of a limb or part of a limb due to trauma. It includes industrial injuries, severe burns, or road traffic accidents. It occurs in younger adults.
2) Surgical amputation: surgical loss of the whole or part of a limb due to:
1. Peripheral vascular disease (PVD) which accounts for 80% of lower limb amputations, primarily affects people older than 60 years of age, as diabetic gangrene.
2. Trauma.
3. Malignancy and incurable bone disease as a life-saving measure for people with bone cancer as osteosarcoma or incurable bone disease, such as osteomyelitis.
4. Gross deformities as the absence of the foot.
5. Flail limb

Goals for surgical amputation
• To save the patient’s life as in crush syndrome and tumors.
• To prevent the spread of infection as in gas gangrene.
• To improve mobility and function as in gross deformity.

Levels of amputation of the lower limb
1. Partial toe: trans phalangeal amputation.
2. Toe disarticulation.
3. Tarsometatarsal amputation.
4. Partial foot: Resection of the 3rd, 4th, 5th metatarsals and digits
5. Symes amputation: Ankle disarticulation with an attachment of heel pad to the distal end of the tibia.
6. Below-knee amputation: (transtibial)
a. Ideal standard level: Between 20 and 50% of the tibial length.
b. Short transtibial amputation: less than 20% of the tibial length.
7. Knee disarticulation: Amputation through the knee joint; femur is intact. It is not preferred.
8. Above-knee amputation: (Transfemoral):
a. Ideal standard level: Between 35 and 60% of femoral length.
b. Short transfemoral amputation.
9. Hip disarticulation: Amputation through the hip joint; pelvis remains intact. The entire femur is removed.
10.Hemipelvectomy: Hindquarter amputation: Resection of the lower half of the pelvis with the entire lower limbs.
11.Hemicorpororectomy: The entire pelvis and limbs are removed, usually at the L4-5 level.

Levels of Amputation of the Upper Limb
1. Trans phalangeal amputation
2. Partial hand amputation
3. Trans metacarpal amputation
4. Trans carpal amputation
5. Wrist disarticulation (Through-wrist)
6. Below – elbow amputation.
7. Elbow disarticulation.
8. Above - elbow amputation.
9. Shoulder disarticulation.
10. Forequarter amputation: this involves the removal of the whole arm, part of the scapula, and most of the clavicle, usually because of a malignancy.

Importance of the residual limb
1. Lever control
2. Complexity of fitting
3. Muscle mass retained
4. Force distribution
5. Proprioception
6. Weight loss
7. Degree of balance disturbances
8. Number of mechanical joints
9. Weight of prosthesis

Problems Related to Amputation
1) Phantom Limb Sensationr
The amputee has the sensation that the missing limb is still present and 'normal'. The limb often seems to move and may feel hot, cold or sweaty, especially in highly innervated areas such as the hands and feet. In most instances, this PLS is present immediately after surgery and often continues for weeks, months, or even years.

2) Phantom Limb Painr
Phantom limb pain (PLP) usually affects only a small number of amputees, severe pain that is variable in frequency, intensity, and duration. Onset may not occur for weeks. The reason why PLP occurs is uncertain, but it seems to be linked with psychological and physiological mechanisms. It is exacerbated by emotional stress or cold weather.

3) Skin problemsr
Sweating
Maceration
Infection.
Friction and bad pressure distribution.
4) Infection
5) Edema
6) Contractures:
Hip: flexion, abduction, and external rotationr
Knee: flexionr
Shoulder: flexion, abduction, and external rotationr
Elbow: flexion.
7) Acceptance or rejection of the prosthesis.
8) Bone problems: osteoporosis, spurs.
9) Scoliosis: Patient with unequal leg length.
10) Neuroma: at the end of the cut nerve.
11) Psychological problems: Depression.

Rehabilitation of the amputeer
Stages of Treatment
1) Pre-operative stage.
2) Post-operative:
a. Pre-prosthetic stage.
b. Prosthetic training stage.
c. Functional adaptation stage.
Pre-operative stager
This stage refers to people with chronic disease (such as PVD, malignancy, and diabetes) for whom amputation has become the final option. Such people have a long medical and/ or surgical history.
Pre-prosthetic stager
It is the time between surgery and fitting with a definitive prosthesis. The major goal of the pre-prosthetic period is to prepare the individual physically and psychologically for prosthetic rehabilitation.
Prosthetic stager
Initial healing of the stump may be rapid in young, fit people, but can be delayed in people with vascular disease or diabetes. In all cases, the residual limb will initially be edematous and tender, and a permanent prosthesis cannot be fitted until tissues can tolerate some pressure, and the edema and post-operative swelling have dispersed. The patients usually use a temporary prosthesis in this stage.
Temporary prosthesis: It is immediately applied in few days.

Advantages of a temporary prosthesis
1. It shrinks the residual limb more effectively than the elastic wrap.
2. It allows early bipedal ambulation.
3. Many elderly people who otherwise would not be ambulatory can walk safely with a temporary prosthesis and crutches during the pre-prosthetic period.
4. Certain individuals can return to work.
5. It reduces the need for a complex exercise program because many people can return to full active daily life.
Permanent prosthesis: is fitted later. 6-8 weeks of stump wrapping usually will bring the stump to a satisfactory condition for fitting with a prosthesis.

Physical therapy interventionr
Aims
1- To control stump edema.
2- To provide stump conditioning.
3- To treat phantom pain.
4- To prevent post-operative complications:
Infection, joint stiffness, contracture, and deformities
5- To teach proper positioning for the stump.
6- To maintain end increase strength of the whole body:
• Trunk muscles for double amputees
• Arms muscles for crutch walking
• Scapular muscles for upper limb amputees
7- To increase the strength of all muscles controlling the stump.
8- To maintain and increase the general mobility of the joints.
9- To maintain and increase the flexibility of the soft tissues and muscles.
10- To improve balance.
11- To educate, train the sound limb.
12- To improve the general mobility of the patient and to train ambulation.
13- To re-educate walking
14- Teach using prosthesis.
15- To evaluate prosthesis and using it.
16- To restore functional independence.
• ADL
• Walking
• Work
17- To provide psychological support.
• Depression / frustration
• Prescription of disability.
18- To instruct the patient about
• Skincare
• Stump care
• Prosthetic care
• Donning/doffing

Methods of treatmentr
I. Stump and Prosthetic care
1. Stump care is of primary importance.
2. Prosthetic fitting is dependent on a good 'cone-shaped' stump, and initially, this shaping is controlled using a bandage, elasticized stump socks, or figure-of-eight stump bandaging.
3. Gentle massage will help to desensitize the limb
4. Help the patient to adjust to his changed body image, as well as accepting his loss.
5. It is essential to establish good routines of hygiene and self-care as the stump must always be washed daily, and areas that cannot be seen should be inspected with a mirror for any signs of skin irritation or abrasion.
II. Positioningr
One of the major goals of the early postoperative program is to prevent secondary complications such as contractures of adjacent joints. The patient should understand the importance of proper positioning and regular exercises in preparing for eventual prosthetic fit and ambulation.
III. Exercises
1. The exercise program is designed individually and includes strengthening and coordination activities. The hip extensors and abductors and knee extensors and flexors are particularly important for prosthetic ambulation. A 'general strengthening program that includes the trunk and all extremities is indicated particularly for the elderly person who may have been quite sedentary prior to surgery.
2. Active and resistive exercises for the uninvolved lower extremity, trunk, and upper extremities are initiated immediately after surgery.
3. Upper extremity strengthening exercises using weights, elastic bands, or manual resisted exercises are important.
4. Walking is an excellent exercise and necessary for independence in daily life. Gait training can start early in the postoperative phase.

VI. Prosthetic trainingr
It starts with the delivery of a permanent replacement limb. Prosthetic training usually begins with a temporary prosthesis, which allows gait training or bilateral upper limb activities to begin during the later stages of healing.