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Rehabilitation of Amputee

Rehabilitation of Amputee

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03/02/2013

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The congenital limb deficiencies are best classifiedfollowing the International Organization ofStandardsand the International Society ofProsthetics and Orthoticsclassifications as modified from Frantz and O’Rahilly (1).The limb deficiencies can be transverse or longitudinal.The term
terminal
is used to describe the fact that thelimb has developed normally to a particular level beyondwhich no skeletal element exists.With intercalary limbdeficiency,there is a reduction or absence ofone or moreelements within the long axis ofthe limb,and there maybe normal skeletal elements distal to the affected segments(2).Amputation ofthe lower limb is performed signifi-cantly more frequently than amputation ofthe upper limb.Amputation ofthe distal segment ofthe limb is morecommon than that ofthe proximal segment.Amputationscan occur at any age,but for lower extremities,the elderlyare most commonly affected,with men more frequentlyaffected than women.Upper-limb amputation affects menbetween the second and fourth decades most frequently,and the right upper extremity is more likely to be ampu-tated than the left.The most common reasons for lower-limb amputa-tion are infection,arterial occlusive disease,and complica-tions ofdiabetes mellitus.Less frequent but importantcauses are trauma,malignancy,and peripheral neu-ropathies.For the upper limb,trauma followed by malig-nancies and acute arterial insufficiency are the mostcommon causes (Fig.93-1).
1744
Alberto EsquenaziEdward Wikoff Maria Lucas
Chapter 93
Amputation Rehabilitation
Amputation rehabilitation is not solely the provision ofaprosthesis.Rather it is the restorative intervention neces-sary to return the patient who has had an amputation tothe highest possible level offunction and to minimize theimpact ofthe amputation on his or her life.In the last twodecades,with the advent ofspecialized treatment teamsand new prosthetic devices,the outlook for the person whohas had an amputation has improved.Outcomes that werenever thought to be possible,such as exercising with aprosthesis or ambulation without the use ofupper-limbsupport for the elderly,are now frequently achieved.Wepresent our collective knowledge and understanding oftherehabilitation process,which represents the essential inter-ventions necessary to optimize function for patients whoare provided with a prosthesis and for those who areunable or choose not to use one.
CLASSIFICATION AND INCIDENCEOF AMPUTATION
Amputations are classified based on the anatomic level andsite at which the amputation has taken place.For example,an amputation between the wrist and elbow is termed a
transradial amputation
.Other levels include transfemoral,transtibial,Syme,partial foot,hip disarticulation,and kneedisarticulation for the lower limb.For the upper limb,transhumeral and partial hand amputations,and shoulder,elbow,and wrist disarticulations are the most common.
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Chapter 93Amputation Rehabilitation
1745
REHABILITATION TEAM
Limb loss is a condition that has physical,psychological,and social implications for the affected individual and thesocial support system.For treatment to be effective,itshould include the care ofthe patient and his or her signif-icant others.Expertise from various clinicians is required toaccomplish this effectively.The development ofa rehabili-tation team working closely together to address each indi-vidual’s needs is vital to the efficient and timely delivery of services.This approach will provide the patient a compre-hensive treatment regimen.A physician specializing in rehabilitation,or who hasknowledge ofbiomechanics and prosthetics,assumes therole ofteam leader and coordinates the team’s resources.The prosthetist fabricates the prosthetic appliance andworks closely in the training stages with the therapist andpatient to prevent complications,achieve appropriate align-ment,and ensure proper fit ofthe prosthesis.The pros-thetist also acts as a resource to other team members forinformation on the latest technologic advances in the fieldofprosthetics.Physical and occupational therapists are criticalmembers ofthe therapeutic team.The physical therapistparticipates in the care ofthe lower-extremity amputeeby preparing him or her physically for using a prosthesis.This includes instructing the patient in management oftheprosthesis,teaching functional mobility activities,and pro-viding gait training to optimize the walking pattern.In thepatient who has had a traumatic upper-extremityamputation,the intervention ofthe physical therapist isrequired only ifthere is a significant injury to joints or softtissues.An occupational therapist will work closely with theteam and the patient to incorporate use ofthe prosthesisduring activities ofdaily living (ADLs) and for work simu-lation activities.For the upper-extremity amputee,theoccupational therapist is frequently the primary therapistinstructing the patient in the use ofan upper-limbprosthesis.Owing to the immense psychological impact that anamputation has on many patients and their families,eachpatient should have an assessment with a psychologist (3,4).A psychologist specializing in limb loss or disability is par-ticularly suited in addressing feelings ofdepression andbody image changes associated with amputation.Along with these core members,the team shouldinclude other supporting clinicians.A social worker canassist patients with changes in family relationships andsocial status related to decreases in function or work abili-ties (5).Nurses can assist and instruct patients in medica-tion management and with wound care.The recreationaltherapist provides information about community resourcesfor recreational activities and support groups,and instructspatients in the adaptations necessary to participate inleisure activities.A vocational counselor,driving instructor,and when necessary,a school teacher may be involved inthe care ofthe amputee as well.The patient and team members should work together to set goals and develop an overall treatment plan.Subsequently,each team member participates in thepatient’s care as necessary to make the provision ofser-vices most efficient.With so many clinicians contributing to the care of an individual,communication is an essential component of team interaction.Good communication will ensure that allteam members are providing patients with quality carewhile avoiding duplication ofservices.Each team shoulddevelop some method ofcommunication that is appropri-ate for the clinical setting,whether it be daily or weeklyrounds,written documentation,computer linking,or teammeetings (6–8).
PREAMPUTATION EDUCATION AND COUNSELING
The rehabilitation process for the individual with limb lossideally should begin before any surgery occurs.Theamputee can take better advantage ofrehabilitation ser-vices once he or she has been educated regarding surgery,healing,exercise,future abilities and limitations,and therehabilitation process.This education,as well as the actualmultifaceted rehabilitation care,is best provided by a teamofhealth care professionals with experience and expertisein the realm ofamputation rehabilitation (9–11).Patients facing amputation often know little aboutthe disease process that threatens their limbs,or aboutwhat the future holds.Understanding that arterial insuffi-ciency,infection,trauma,or tumor may necessitate ampu-tation may enable the patient to accept the amputation asthe appropriate treatment (12).Lacking this insight,patients may resist or delay amputation,risking sepsis,acontracted nonfunctional limb,analgesic abuse,decondi-tioning or other avoidable medical complications.Othersmay fear social isolation or stigmatization stemming fromthe amputation,and view the amputation as the end of their useful life.Most fear losing independence and work productivity,and becoming a burden on family and friends(2,12–19).
Figure 93-1.
Distribution of the causes of amputation.
 
1746Part
VMedical Rehabilitation for Diagnostic Groups
(ROM) and strength ofthe proximal joints.The status of the contralateral limb and the ROM,strength,and sensa-tion ofthe other limbs are critical data in the planning of the rehabilitation program.Balance and coordination arealso essential and should be tested.Patients with peripheral neuropathy or skin grafts usevision as a compensatory mechanism for the lack ofsensa-tion in the prosthesis and the other limbs.Eye examinationshould be encouraged,as many patients need updated pre-scription eyeglasses and vision care.In the patient whose amputation was caused byischemia related to atherosclerosis or diabetes mellitus,similar arterial insufficiency involving the cardiac and cere-bral vessels should be suspected.Knowledge ofcardiopul-monary status and endurance is ofprimary importance.The use ofsophisticated tests to assess these systems inpatients with a cardiac history is usually unnecessary.Simple clinical indicators such as the ability to ambulatewith a walker or crutches for 30 to 40ft,while blood pres-sure and pulse rate are monitored,are adequate to deter-mine whether the patient will be able to achieve the goaloflimited household ambulation.Patients with a docu-mented ejection fraction of15% should be able to ambu-late very short distances with an artificial limb.The cardiacrisk in this population does not appear to be significantlyincreased when using a prosthesis or walking short dis-tances.Therapeutic walking is an appropriate techniquefor cardiovascular training.In addition,the capacity forshort-distance ambulation will often permit a patient toremain out ofa long-term-care facility.This has additionalpsychosocial benefits that may outweigh the potential risks.The patient’s willingness and ability to learn newtechniques and to participate in a variety ofnew activitiesare critical.Thus,cognitive and psychological evaluationsare very important.The psychological impact oflimbamputation is huge.Patients experience a variety ofemo-tional and psychological responses,including anxiety,shame,depression,anger,and fear.The rehabilitation teammust provide support,treatment,and guidance for thepatient and his or her family (2,12–19).Nutritional status,which has a considerable impact on wound healing andstrength,must not be neglected (22–24).The presence ofavariety ofother comorbidities such as diabetic retinopathy,peripheral polyneuropathy,nephropathy,and degenerative joint disease may also influence the rehabilitation oftheamputee.In short,a thorough medical evaluation ofthepatient is necessary.Other areas ofimportance that should be evaluatedinclude the vocational and recreational activities that thepatient performed in the past and wants to pursue in thefuture.Certain vocational or avocational activities mayrequire alternative specialized prosthetic devices,training,or use ofno prosthesis.Devices that may be exposed toextreme weather,water,or other elements that may be cor-rosive or destructive to the prosthesis should be made of special materials to protect the RL and the prosthesis.To fill these information gaps,the patient and familybenefit from preamputation counseling from members of the rehabilitation team and from a prosthetic user who canprovide firsthand information.The following topics shouldbe covered,although with the apprehension ofupcomingsurgery,the patient may retain little ofwhat is initiallydiscussed.1.Pain will certainly be present following surgery andits duration and intensity may not be predictable.The patient seeking pain reliefas a result ofampu-tation may not be satisfied,as the RL or phantomlimb may also be painful (20).2.Phantom sensation (and possibly pain) will likely bepresent following surgery (21).3.Exercise and proper positioning in the early postop-erative period will be very important to futurerehabilitation.4.A general time frame for acute hospitalization,wound healing,preprosthetic rehabilitation,andprosthetic use is very helpful to the patient.5.The patient’s expectations for future functionalstatus are often unrealistic.Future activities willrequire equipment previously unfamiliar to thepatient (e.g.,wheelchair,crutches,prosthesis,etc).Adiscussion ofthis information with an amputee asclosely matched demographically as possible willprovide the patient with a more credible view ofthefuture.Early contact with the patient also allowsmembers ofthe rehabilitation team to evaluate thepatient’s premorbid status and current problems sothat appropriate goals and plans can be made.Thepatient may also benefit from the continuity ifthesame members ofthe rehabilitation team areinvolved before and after the surgery.
EVALUATION OF THE AMPUTEE
Evaluation ofthe patient with upper- or lower-limb loss isindispensable to preparing the overall rehabilitation treat-ment plan,including the development ofgoals and objec-tives.It is also important in the prosthetic prescriptionprocess.Although the overall evaluation process for allamputees is similar,some important differences exist in theevaluation ofpatients with limb loss at different levels.These are reviewed later in this section.A general physical examination that documents bodyweight,height,peripheral circulation,skin integrity,limbdominance,overall health,comorbidities,and mentalstatus is necessary.The examination ofthe residual limb(RL) should include the soft-tissue length and shape,bonelength and shape,and skin integrity,pliability,and mobility.Scar tissue is assessed as is the RL’s tolerance to pressure,traction,and weight bearing.Sensation is also evaluated aswell as the presence ofneuroma or areas ofhypersensitiv-ity.The clinician should document the range ofmotion

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