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Stages of Care

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Postoperative Management of the Lower Extremity Amputation

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Stages of Care
Understanding the time frame of recovery from lower limb amputation is essential to the design and
implementation of any postoperative management strategy . Although today 's health care sy stem has placed
an emphasis on speed, the consensus committee participants agreed that placing an emphasis on shortening
the time of healing and recovery following limb loss is not necessarily the wisest path.
Regardless of the etiology , the postoperative recovery period after the amputation of a lower extremity
ty pically is 12 to 18 months and simply cannot be rushed. 1 This 'recovery period' includes activity recovery ,
reintegration, prosthetic management, and training. Some members of the expert panel of the consensus
committee felt that setting fast-paced and often unrealistic goals can lead to a sense of failure in an individual
who is actually progressing normally .
The postoperative y ear-long continuum does not separate easily into "stages". However, an attempt to define
the stages of recovery has been made to facilitate discussion of how the goals evolve throughout the rehabilitative process.
A. Preoperative Stage
The preoperative stage ty pically starts with the very difficult decision of whether to amputate. This stage also
includes an assessment of the vascular status and decisions on attempts to improve circulation. The difficult
process of level selection, preoperative education, emotional support, phy sical therapy and conditioning,
nutritional support, and pain management also all occur in this stage of care.

B. Acute Hospital Postoperative Stage

The acute hospital postoperative stage is the time in the hospital after the amputation surgery . This hospital
time ty pically ranges from 5 to 14 day s.
C. Immediate Postacute Hospital Stage
In general, this stage begins with hospital discharge and extends 4, 6, or even 8 weeks after surgery . This is the
time of recovery from surgery , a time of wound healing, and a time of early rehabilitation. Frequently , end
points of this stage are characterized as the point of wound healing and the point of being ready for prosthetic fitting. However, it
should be noted that healing of a residual limb is a continuous process, and the limb does not have a clear and decisive point of "being
healed." Furthermore, prosthetic readiness is a transition point that is difficult to standardize and measure. Much of the current
research comparing different postoperative management strategies attempts to use these two elusive end points with vary ing results.
D. Intermediate Recovery Stage
This is the time of transition from a postoperative strategy to the first formal prosthetic device. Historically , this
device was called the "preparatory " prosthesis, but with the use of higher technology earlier in the process, it is
sometimes simply called the "first prosthesis." The term "preparatory " has traditionally been linked to very basic
prosthetic sty les and components. The consensus committee participants felt that the historical interpretation of
"preparatory prosthesis" is no longer adequate.
It is during this stage that the most rapid changes in limb volume occur, due to the beginning of ambulation and
prosthetic use. The immediate recovery period begins with the healing of the wound and usually extends 4 to 6
months from the healing date. Although difficult to define, this stage ends with the relative stabilization of the
residual limb size, as defined by consistency of prosthetic fit for several months.
E. Transition to Stable Stage
This period is defined as a period of relative limb stabilization after the fourth stage when rapid limb volume changes
occurred. Although limb volume changes are not as drastic as in this stage, the limb will continue to change to some
degree, for a period of 12 to 18 months after initial healing. Historically , this stage was marked as a transition from
the "preparatory " to the definitive prosthesis. Currently , with the use of higher technology and modular sy stems in
the previous stage (Intermediate Recovery Stage), this transition is no longer defined by a change in the prosthesis,
but rather a change from a rapidly changing limb to a slower maturation of the limb. The prosthesis will still require
occasional adjustments, and visits to the prosthetist will remain relatively frequent until after the first y ear of
prosthetic use. Modular sy stems are appropriate and encouraged to enhance ease of socket replacement in this stage.
In this phase the patient should move toward social reintegration and higher functional training and development as well as becoming
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more empowered and independent from his or her health practitioner.

The fitting of the definitive prosthesis may certainly occur within this time period; however, limb stabilization must
occur before definitive fitting. Residual limb volume must be stable so the device can be used for an extended period
of time. This extended period of time is ty pically 2-5 y ears in adults and as long as 1 y ear in growing children.
Defining limb stability is very difficult. For most patients, the period of limb stabilization requires at least 6 months
of prosthetic use.

Clinical Concerns
The expert panel for this consensus committee identified fourteen clinical concerns in the stages of recovery .
1. Determination of Amputation Level
2. Minimize sy stemic complications
3. Prevent contractures
4. Bed mobility and transfers
5. Pain management
6. Protect amputated limb from trauma
7. Fall prevention
8. Emotional care/education
9. Manage and teach about wound healing
10. Promote residual limb muscle activity
11. Early ambulation
12. Advanced ambulation
13. Control limb volume changes
14. Trunk and body motor control and stability
Each concern will take on a different level of importance at different stages of the healing process. Since the goals of care change at each
stage of rehabilitation, a table of clinical concerns and treatment goals was established by the consensus committee for each stage.
(Table 1) There may be overlap between stages which may vary with individual differences.

Table 1. Changing clinical concerns during the stages of recovery after a lower limb amputation

These clinical concerns and treatment goals may be used by clinicians for development of treatment protocols and guidelines within
their communities. Each goal of the table is ranked in relative importance with regard to the level of clinical concern at each stage of
rehabilitation. For example, the determination of amputation level is of concern at the preoperative stage however, it is usually of
little concern after the surgery . Conversely , emotional care is of high clinical concern through most of the rehabilitation process, with
a slight drop off in the intermediate recovery stage and with a renewed concern at around 1 y ear after the amputation.
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a slight drop off in the intermediate recovery stage and with a renewed concern at around 1 y ear after the amputation.
Although progression through these phases is largely individual, the time needed to progress is reported consistently between 12 and
18 months. It is during this extended time that many individuals still have significant changes in limb volume that must be
considered and managed. During this 12 to 18 month period, social reintegration, life planning, and goal setting all progress as well.
For pediatric amputees, the stages of recovery and the clinical concerns are modified to take into account the developmental milestones
of the growing child. Finally , in the later portions of the process come the mastery of prosthetic use and a desired range of activities.
Physical Therapy and Prosthetic Management
Although the role of all team members is to assess, educate, and motivate the patient, the role of two particular members of the team,
the phy sical therapist and the prosthetist, during this long period is often underestimated.
Physical therapy treatment continues throughout this entire period with specific
rehabilitation protocols designed to meet the specific needs of each amputee. Continual
reevaluation and updating of the amputee's program is essential to ensure that each patient
reaches his or her maximal activity level with a prosthesis.
Although the patient must be an active participant in his or her rehabilitative care, the
treatment guidelines and specific exercises are the therapist's responsibility and an integral
component of the continuum of care for the first 12 to 18 months.
Initial prosthetic management after amputation requires strategies different from those used during the period after
residual limb stabilization.
During the initial time frame, the prosthetist is "chasing a moving target," as the residual limb
changes dramatically in volume and shape. - Therefore, the definitive prosthesis should not be
prescribed or fit until the limb has begun to stabilize and the "moving target" has slowed
considerably .
Stabilization is difficult to define and needs to be further researched. However, when a patient has
used a prosthesis full time for a period of at least 6 months and when the limb volume has stabilized
to a point that socket fit remains relatively consistent for at least 2 to 3 weeks, a definitive prosthesis
may be indicated.
Intermediate prosthetic management concentrates on edema reduction and to define limb stabilization.
Additional studies need to be done to determine the most appropriate technique to achieve this stabilization.
Little literature is available that attempts to define when adjustment of the current socket may meet the needs of the
patient versus when socket replacement is required. Clearly , research is needed in this area.
Finally , it should be noted that a patient may return to work during this rehabilitative period, not just at the end of the process.

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