Amputee Rehabilitation Notes

Patient Assessment & Rehabilitation

Subjective Assessment: TOTARPS

• T-TALK

• O-OBSERVE

• T-TOUCH

• A-ACTIVE

• R-RESTRICTED

• P-PASSIVE

• S-SPECIAL

Objective Assessment

• Stump condition:

  • Short TT stump

  • Medium TT stump

  • Long TT stump

• Palpation:

  • Edema

  • Skin condition

  • Scar condition

  • Wt., nervous and general sensitivity

  • Distal padding

  • Neuroma and trigger points

Edema Assessment

• 0+: No pitting edema

• 1+: Mild pitting edema. 2 mm depression that disappears rapidly.

• 2+: Moderate pitting edema. 4mm depression that disappears in 10-15 seconds.

• 3+: Moderately severe pitting edema. 6mm depression that may last more than 1 minute.

• 4+: Severe pitting edema. 8mm depression that can last more than 2 minutes.

K-Levels (Medicare's Functional Classification Level - MCFL)

• K0: Does not have the ability or potential to ambulate or transfer safely with or without assistance. A prosthesis does not enhance their quality of life or mobility.

• K1: Has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at a fixed cadence. Typical of the limited and unlimited household ambulator.

• K2: Has the ability or potential for ambulation with the ability to traverse low-level environmental barriers such as curbs, stairs, or uneven surfaces. Typical of the limited community ambulator.

• K3: Has the ability or potential for ambulation with variable cadence. Typical of the community ambulator who can traverse most environmental barriers and may have vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion.

• K4: Has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills, exhibiting high impact, stress, or energy levels. Typical of the prosthetic demands of a child, active adult, or athlete.

Amputee Rehabilitation Stages

• Pre-amputation phase: Elective and compulsory cases

• Post-amputation phase:

  • Pre-prosthetic stage: Medications, exercises, bandaging, positioning, temporary prosthesis.

  • Prosthetic stage: Gait training.

• Community and vocational rehabilitation

• Life-long management and follow up

Pre-operative Period

Involves:

1. Medical and physical assessment (power of crutch muscles, joint mobility, balance reactions in sitting & standing)

2. Patient education

3. Functional abilities

4. Discussion about phantom limb pain

• If possible, the patient should be placed in a cardiopulmonary conditioning program.

Exercise Management

• Breathing exercises to clear lung secretions

• Strengthening exercises for:

  • Shoulder extensors & adductors

  • Elbow extensors & other crutch muscles

  • Hip extensors, abductors & Quadriceps

• Mobilization for hip extension, knee flexion & extension

• Transfer from bed to chair & back

• Wheelchair mobility

• Stabilization for trunk in sitting & standing

Amputation Surgery/Dressing

Involves:

1. Surgical residual limb length determination

2. Closure of wound and soft-tissue coverage

3. Nerve management

4. Dressing application

5. Limb reconstruction

Acute Post-Surgical Phase

• Begins immediately post-operatively and continues until the patient is discharged from the acute care hospital.

• Goals:

  1. Pain control

  2. Optimization of range of motion (ROM) and strength of both lower and upper extremity musculature

  3. Promotion of wound healing

  4. Phantom limb pain/sensation management

  5. Functional mobility training

  6. Equipment prescription

  7. Continued patient education and emotional support

Phantom Limb Pain and Sensation

• Phantom limb sensation is the sensation that the limb is still present.

• Phantom pain includes various painful sensations in the body part that is no longer present.

• Immediate post-operative incidence:

  • Phantom pain: 72\%%

  • Phantom sensation: 84\%%

• Incidence at 6 months post-operatively:

  • Phantom pain: 67\%%

  • Phantom sensation: 90\%%

• Both phantom pain and sensation are generally localized to the distal part of the missing limb.

• Persons with phantom limb pain have worse or lower health-related Quality of Life.

Phantom Limb Pain Treatment

Based on the person's level of pain, multiple treatments may be combined:

1. Heat application

2. Biofeedback to reduce muscle tension

3. Relaxation techniques

4. Massage of the amputation area

5. Surgery to remove scar tissue entangling a nerve

6. Physical therapy

7. TENS (transcutaneous electrical nerve stimulation) of the stump

8. Neurostimulation techniques such as spinal cord stimulation or deep brain stimulation

9. Medications, including: pain-relievers, neuroleptics, anticonvulsants, antidepressants, beta-blockers, and sodium channel blockers

Relaxation Techniques:

• Tai Chi

• Relaxing Music

• Laughing

• Guided Visualization

• Progressive Muscle Relaxation

Pre-Prosthetic Rehab

Involves:

• Stump shaping and shrinking

• Care of stump

• Desensitization

• ROM and muscle strengthening

• Progressive functional mobility training without a prosthesis

• Restoring locus of control of the patient

• Patient education and preparation for prosthetic use

• During initial recovery, it is important to restore the individual's locus of control.

• Generally:

  1. 6-8 weeks post-op with soft dressings, or

  2. 3-6 weeks with use of an Immediate Post-Operative Prosthesis (IPOP).

• Preparatory or training prosthesis may be used to promote residual limb maturation and for use during gait training.

• Individuals are vulnerable to losses in strength and range of motion (contractures) during this period.

Immediate Post-Op Dressing

• Made of POP, rigid post-op is useful as:

  • ADV: post-op edema, pain, enhances healing

  • DISADV: expensive & special training required

• Semirigid dressing:

  • Unna's dressing, gauze with ZnO

  • DISADV: loosen easily

• Soft dressing:

  1. Elastic wrap (need frequent reapplication)

  2. Shrinkers (sock-like conical garments of knitted cotton cannot be used until primary healing has occurred)

Muscle Strength

• For Transfemoral amputation:

  • Hip extensors & abductors are needed

• For Transtibial amputation:

  • Hip extensors & abductors

  • Knee flexors & extensors are needed

Therapeutic Exercise Program

Above Knee (AK) Exercises:

• Hip Squeeze

  • Lie on back or stomach.

  • Try to squeeze your thighs together.

  • Special Instructions: Do Not Hold Breath. Perform 1 set of 10 Repetitions, once a day. Hold exercise for 10 Seconds.

• Hip Extend

• Side lying Hip

  • Lie on your uninvolved leg.

  • Bend knee slightly, for support

  • Lift your residual limb upward, towards ceiling.

  • Perform 3 sets of 20 Repetitions, once a day. Rest 1 Minute Between sets. Perform 1 repetition every 4 Seconds.

• Hip Lift Up

  • Lie on back

  • Lift residual lamb as high

  • Perform 3 sets of 20 Repetitions, once a day

  • Rest 1 Minute between sets

  • Perform 1 repetition every 4 Seconds

• Hip Extend Stretch

  • Lie face down

  • Keep residual limb straight in line with trunk.

  • To achieve more stretch, place a towel roll or pillow under end of residual limb

  • Perform 1 set of 5 Repetitions, twice a day. Use Towel Hold exercise for 30 Seconds

• Prone Hip Extend

• Bridge

  • Bend knee of uninvolved leg.

  • Lift buttocks up, of floor, keeping hips level

  • Perform 3 sets of 20 Repetitions, once a day.

  • Perform 1 repetition every 4 Seconds

Below Knee (BK) Exercises:

• AK/BK: Push Down

  • Lie on back.

  • Push residual limb down into the bed.

  • Special Instructions: Do Not Hold Breath, Keep your knee straight

  • Perform 1 set of 10 Repetitions, twice a day

  • Hold exercise for 10 Seconds

• Hip Press In

  • Lie on back or stomach.

  • Squeeze buttocks together.

  • Special instructions: Do Not Hold Breath. Perform 1 set of 10 Repetitions, twice a day. Hold exercise for 10 seconds

• Hip Press In

  • Lie on back

  • Place a pillow or ball between your thighs

  • Try to push your thighs together.

  • Special instructions: Do Not Hold Breath, Keep knee straight on resid

  • Perform 1 set of 10 Repetitions, twice a day,

  • Hold exercise for 10 Seconds.

• Ankle Pumps

  • Lie on back

  • Special Instructions:

  • Keep your knee straight

  • Perform 1 set of 10 Repetitions, twice a day.

  • Perform repetition every 4 Seconds.

• Hip Rotation

  • Rotate your residual limb inward and outward as show

  • Special instructions:

  • Keep knee straight as possible

  • Perform 1 set of 10 Repetitions, twice a day.

  • Perform 1 repetition every 4 Seconds.

• Bridge

  • Bend knee of uninvolved leg.

  • Lift buttocks up, off floor, Keeping hips level

  • Return to start position

  • Perform 1 set of 10 Repetitions, twice a day

  • Perform 1 repetition every 4 Seconds.

• Knee Extend Stretch

  • Sit in chair with knee of residual bent

  • Straighten knee as much as possible.

  • Return to start position

  • Perform 1 set of 10 Repetitions, twice a day.

  • Perform repetition every 4 Seconds

• Place towel roll or pillow under end of residual leg

  • Special Instructions

  • Keep leg in neutral position, that is do not allow leg to roll inward or outward.

  • Perform 1 set of 5 Repetitions, twice a day

  • Use Towel Hold exercise for 30 Seconds

Prosthetic Training

• Prosthetic management and training to increase wearing time and functional use.

• For patients with AKA and BKA using a soft dressing after amputation, a cast for a temporary socket is often fabricated 6-8 weeks postoperatively.

• Ambulation activities with a lower limb prosthesis often begin during weeks 10-11 after amputation.

• The more proximal the amputation, the more energy is demanded from the cardiovascular and pulmonary systems for prosthetic gait.