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Amputation rehabilitation and prosthetic restoration. From surgery to

community reintegration

Article  in  Disability and Rehabilitation · July 2004

DOI: 10.1080/09638280410001708850 · Source: PubMed

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 DISABILITY AND REHABILITATION, 2004; VOL. 26, NO.
Amputation rehabilitation and prosthetic
restoration. From surgery to community
reintegration
ALBERTO ESQUENAZI*
Department of Physical Medicine and Rehabilitation, Moss Rehab Regional Amputee
Rehabilitation Centre, Philadelphia, USA
Disabil Rehabil Downloaded from informahealthcare.com by University of Montreal on 11/17/10
Abstract
Purpose: The purpose of this review is to summarize the
literature related to the advances that have taken place in the
management and rehabilitation care of limb amputation.
Results: Prostheses for the lower and upper limb amputee
have changed greatly over the past several years, with advances
in components, socket fabrication and fitting techniques,
suspension systems and sources of power and electronic
controls. Higher levels of limb amputation can now be fitted
For personal use only.
with functional prostheses, which allow more patients to
achieve independent life styles. This is of particular importance
for the multi-limb amputee. The rehabilitation of more
traditional lower limb levels of amputation have also greatly
benefited from the technological advances including energy
storing feet, electronic control hydraulic knees, ankle rotators
and shock absorbers to mention a few. For the upper limb
amputee, myoelectric and proportional controlled terminal
devices and elbow joints are now used routinely in some
rehabilitation facilities. Experimental prosthetic fitting techni-
ques and devices such as the use of osseo-implantation for
suspension of the prosthesis, tension control hands or
electromagnetic fluids for knee movement control will also
be briefly discussed in this paper.
Conclusion: It is possible to conclude from this review that
many advances have occurred that have greatly impacted the
functional outcomes of patients with limb amputation.
Introduction
The exact number of people who have had amputa-
tions worldwide is difficult to ascertain, as many coun-
tries do not keep records of the number of people with
limb amputation. Based on information available from
the National Center for Health Statistics there are
* Author for correspondence; Chair, Department of Physical
Medicine and Rehabilitation and Director, Moss Rehab
Regional Amputee Rehabilitation Centre. Philadelphia, Penn-
sylvania, USA. e-mail aesquena@einstein.edu
Disability and Rehabilitation ISSN 0963–8288 print/ISSN 1464–5165 online # 2004 Taylor & Francis Ltd
http://www.tandf.co.uk/journals
DOI: 10.1080/09638280410001708850
14/15, 831–836
approximately 50 000 new amputations every year in
the USA.1, 2 Extrapolating data from this and other
health statistics data available from Europe,3, 4 Asia5
and various countries around the world6 one can deter-
mine that the major causes of amputation in order of
incidence are trauma, including war related injuries,
diseases and congenital limb deficiencies.
The causes of amputation vary from country to coun-
try.1 – 4 In the developing world, trauma is the leading
cause of amputation caused by inadequately treated
fractures, motor vehicle accidents (motorcycle and train)
and other motorized machinery. In countries with recent
history of warfare or civil unrest, trauma can account
for up to 80% of all amputations. In developed nations,
vascular complications of diabetes are the principal
cause of amputations, which, can be aggravated by the
use of tobacco. The major diseases that contribute to
amputation are atero-occlusive vascular disease,
diabetes mellitus and tumor.7, 8 In developed countries
like the United States, Denmark and Japan, disease
accounts for 68% of all amputations performed each
year.1, 2 Trauma related amputations usually occur as a
result of motor vehicle, industrial or farming accidents
and may account for approximately 30% of new limb
amputations. Estimates indicate that there are 135
million people with diabetes around the world and this
number will continue to grow rapidly with changes in
dietary habits.5, 6. Unless appropriate educational and
preventative measures are taken, a further increase in
the incidence of limb amputation is likely to occur.
Congenital limb deformities account for a small portion
of reported limb amputations (up to 3% of reported
limb losses).7
The worldwide statistics on amputations by age are
very difficult to obtain. In general those individuals with
 A. Esquenazi
limb loss due to disease are older with the amputation
occurring after age 60.8 Traumatic amputations occur
in a much younger, active and economically productive
population. Because of the high number of trauma
related amputations and preferential use of tobacco by
men, this gender has a higher incidence of limb amputa-
tion.
Because of the etiology of amputation related to
medical co-morbidities more lower limb than upper limb
amputations are performed with a ratio of almost 5 to 1.
Transtibial level accounts for 39%, transfemoral level
31%, transradial level for 15% and transhumeral level
for 8% of all amputations. Hip and shoulder disarticu-
lation, through knee and through elbow and wrist level
account for the remaining (see figure 1). For the upper
Disabil Rehabil Downloaded from informahealthcare.com by University of Montreal on 11/17/10
limb the right arm is more frequently involved in work
related injuries. Sixty per cent of arm amputees are
between the ages of 21 and 64 years and 10% are under
21 years of age.8 Congenital upper limb deficiency has an
incidence of approximately 4.1 per 10 000 live births.7
With regard to phases of amputee rehabilitation (see
table 1), each of these phases contains specific evalua-
tion items, treatment goals and objectives. Optimal
rehabilitation care of the amputee begins, if feasible,
prior to the amputation and should be provided by a
For personal use only.
specialized treatment team. Communication between
the members of the team and with the patient and
family members is essential and should provide the
team with the necessary information to develop a
treatment plan from amputation to home discharge.
The team should tell the patient what to expect after
surgery and rehabilitation taking into account physical
status, level of amputation, cognition, premorbid life-
style and socioeconomic level and prepare the patient
with realistic short and long term expectations.
The viability of the soft tissues and skin coverage with
adequate sensation will usually determine the most
distal possible functional level for amputation, whenever
possible amputation at the transtibial and transradial
Figure 1 Incidence of limb amputation by level.
832
level is preferred. Preserving length of the residual limb
to improve prosthetic suspension and force transmission
from the residual limb to the socket is a principal
responsibility and goal of the surgeon. The residual limb
must be surgically constructed with care to optimize the
intimacy of fit, maintain muscle balance, and to allow it
to assume the stresses necessary to meet its new func-
tion.9 Bony prominences, (see figure 2) skin scars, soft
tissue traction, shear and perspiration can complicate
this function.10
After surgery the patient with a limb amputation
should ideally be able to use a prosthesis, be it body
or externally powered, during most of the day through
a newly created man-machine interface (the socket/
residual limb).10 After limb amputation, fitting of the
first prosthesis should be implemented as soon as
possible after wound healing. Application of an
immediate postoperative rigid dressing can expedite
wound healing and maturation. Elastic bandages can
also be used for this purpose as seen in figure 3. In
the upper limb amputee, this is of particular impor-
tance, where there is a direct relationship between
the time of fitting and long-term prosthetic use and
a 1 – 6 months window of opportunity exists when
there is a much greater rate of acceptance and func-
tional integration of the artificial arm for the unilat-
eral upper limb amputee.10, 11
Pain in amputation
The pain perceived by the patient with an amputation
can be divided into four possible categories. These are
post-surgical pain, residual limb pain, prosthetic pain
(caused most frequently by standing and ambulating
with the prosthesis), and phantom pain (pain perceived
as coming from the amputated body part). Each one
of these pain categories is described as separate entities
but overlap of the different types of pain may occur.12
Pain may originate from other regions in the body unre-
lated to the amputation and referred to the amputated
limb. Such pain may be cardiogenic, neuropathic or
radiculopathic in origin. Systemic diseases such as
diabetes, ischemia or arthritis can also be the cause of
the pain and should be ruled out prior to attempting
treatment of the pain complaints. With a wide variety
of pain sources and treatment options available, treat-
ment of pain in the amputee must begin with accurate
diagnosis. Once the nature of the patient’s pain has been
clarified, appropriate interventions can proceed to allow
the patient to function comfortably. More in depth
discussion of the management of amputation related
pain is beyond the scope of this paper. The reader is
 Amputation rehabilitation and prosthetic restoration

Table 1 Phases of amputee rehabilitation

Phase Hallmark

Preoperative
Amputation Surgery/Reconstruction
Acute Post surgical
Pre prosthetic
Prosthetic Prescription
Prosthetic Training
Community Integration
Vocational Rehabilitation
Follow-up
Assess body condition, patient education, surgical level discussion, postoperative prosthetic plans
Length, myoplastic closure, soft tissue coverage, nerve, handling, rigid dressing
Wound healing, pain control, proximal body motion, emotional support
Shaping, shrinking, increase muscle strength, restore patient locus of control
Team consensus on prosthetic prescription and fabrication
Increase prosthetic wearing and functional utilization
Resumption of roles in family and community activities. Emotional equilibrium and healthy coping
strategies. Recreational activities.
Assess and plan vocational activities for future. May need further education, training or job modification.
Life long prosthetic, functional, medical assessment and emotional support

Modified from Esquenazi and Meier.7

Disabil Rehabil Downloaded from informahealthcare.com by University of Montreal on 11/17/10
For personal use only.

Figure 3 Transradial residual limb volume control with

elastic bandages.
Figure 2 Abnormal bone formation in the distal femur.

more traditional levels of amputation have greatly bene-

directed to other sources for further discussion of this
topic.12
Prosthetic components
Prosthetic limb choices have increased greatly over
the past several years, with improvements in compo-
nents, for the upper limb prosthetic terminal devices
such as hooks and hands, wrist, electronic elbows and
electric shoulders; for the lower limb energy storing,
multiaxis feet, shock absorbers and rotators as well as
computer controlled knee units. There has been
improvement in the socket fabrication materials (carbon
graphite or high temperature flexible thermoplastics)
and fitting techniques (mini frame shoulder disarticula-
tion sockets and ischial containment transfemoral sock-
ets, etc.), suspension systems (silicone, osseo-integration,
etc.), and power sources and electronic controls.13, 14 The
fited from the technological advances including the
incorporation of myoelectric and proportional
controlled terminal devices and slip sensors. The higher
levels of upper limb amputation such as the shoulder or
hip disarticulation can now be fitted with functional
prostheses, which allow more patients to achieve inde-
pendent life styles. This is of particular importance for
the individual with bilateral upper limb amputation,
particularly those with very high levels of amputa-
tion.10, 15
Prosthetic prescription
The prosthetic prescription should be carefully
prepared to satisfy the needs and desires of the patient.
A team approach to prescription writing should be used
whenever possible in close communication with the
patient. Appropriate training to be accomplished by a

833
 A. Esquenazi
specialized team of professionals should follow the
provision of a prosthetic device and implemented again
after new components are prescribed.15 The upper limb
device prescription should have a terminal device, wrist,
socket, suspension system and if appropriate an elbow
mechanism. Selecting between body power, external
power or passive components and their activation mode
(myoelectric, switch or cable) should be predeter-
mined.10, 15 Similarly for the lower limb device prescrip-
tion should include a foot, pylon, socket, suspension
system and if appropriate a knee mechanism.13, 14, 16
Terminal devices
The human hand is a very complex anatomical and
Disabil Rehabil Downloaded from informahealthcare.com by University of Montreal on 11/17/10
physiological structure that cannot be replaced or
emulated with current prosthetic technology. The func-
tional activities of the hand are extensive but can be
grouped into non prehensile (touching, feeling, tapping,
etc.) and prehensile activities (three-jaw, and lateral or
key grip, power grip, hook grip and spherical grip). A
variety of prosthetic terminal devices are available and
include passive, body and external powered hooks and
hands (see figure 4). Manipulators are used in less tech-
nologically developed environments. They all lack
For personal use only.
sensory feedback and have limited mobility and dexter-
ity. Prosthetic hands provide a three-jaw chuck pinch
and hooks provide the equivalent of lateral or tip pinch.
Electric devices can have digital (on/off) or proportional
(stronger signal = faster action) control systems.10 Slip
control is a recently introduced technology that can
increase prehension to prevent accidental dropping of
objects.
Figure 4 External powered hand without cosmetic cover
(Otto-Bock) and body powered voluntary opening hook
(Hosmer/Dorrance). Reproduced with permission from the
manufacturer.
834
Feet
The human foot is a marvelous physiological struc-
ture that can generate significant power to support
and propel the human body during walking. The
complex anatomy responsible for this function cannot
be fully reproduced with the current level of prosthetic
technology. A variety of prosthetic feet are available
and range from the simple SACH foot to the sophisti-
cated energy storing and multiaxis function of some feet
with multiple intermediate devices with many attri-
butes.16 Feet are to be prescribed based on the functional
needs of the patient with the intent to allow the highest
feasible level of function.
Prosthetic elbows
The prosthetic elbows available in the treatment of
the transhumeral amputee can be passive, body powered
or externally powered. The mechanical elbows have a
locking mechanism that is manually applied using the
contralateral hand, the chin or the ipsilateral shoulder
via a cable system. Electric elbows have an electro-
mechanical brake (Utah or Boston Arms) or a switch
controlled lock mechanism to maintain the selected
position.10
Prosthetic knees
The prosthetic knees available in the treatment of the
transfemoral amputee can have a single axis or be poly-
centric. The most basic knee has a locking mechanism
that is manually applied to provide knee stability in
stance phase. Stability can also be provided through
optimal application of the line of force, weight activated
brake or a fluid control cylinder. Such knees include the
single axis, four and seven bar knee joints. To control
the displacement of the limb during the swing phase
several options are also available and include friction,
springs, and fluid resistance.14 Electronic controllers
for the timing and amount of fluid resistance have
become recently available (C-Leg) resulting in a less
effortful and safer walking pattern (see figure 5).
Sockets
Old sockets were carved out of wood. With the devel-
opment of high temperature rigid plastic materials such
as polyester resin, sockets could be molded to have total
contact with decreased weight and increased durability.
Sockets are custom made by obtaining a negative
impression of the residual limb (commonly a plaster of
 Amputation rehabilitation and prosthetic restoration
Figure 5 Electronic controlled C-Leg (Otto-Bock). Repro-
duced with permission from the manufacturer.
Disabil Rehabil Downloaded from informahealthcare.com by University of Montreal on 11/17/10
Paris wrap). More recently acrylic lamination, the use of
carbon graphite and the introduction of flexible thermo-
plastics have permitted the design of sockets with
windows lined with flexible materials that are even more
adaptable, comfortable, lighter and durable. Alternative
suspension systems such as the constant suction socket,
the silicon sleeve and others are all useful in the appro-
priate clinical case.13, 17 Of recent introduction and
For personal use only.
considered experimental is the use of osseo-integration
as means to suspend a prosthesis directly from the bone.
It requires a titanium implant that is externalized and
used to directly attach the prosthetic device without
the need of a socket. This type of suspension system
allows shorter residual limbs to be interfaced with pros-
thesis without the need of a socket.18, 19
Cosmetic covers
The hand terminal device can be covered with a
cosmetic glove. These cosmetic covers can range from
of the shelf to custom made from a mirror image of
the opposite hand. Covers for the leg may be as impor-
tant and in addition of providing cosmetic appearance
can provide water protection if desired.
Conclusion
Appropriate selection of componentry for prosthetic
restoration of the amputee is an extremely important
and challenging task in view of the variety and complex-
ity of available prosthetic devices and the functional
requirements of our patients. After prescription and
fitting of the device, training is indispensable and should
include prosthetic management and functional training
with the goal of achieving community reintegration.
Community reintegration should include recreation
activities and sports and when appropriate work or
return to school as part of the rehabilitation program.
These are essential characteristics of the successful reha-
bilitation program for the person with limb amputa-
tion.20 A well-integrated and experienced team can
better achieve the goal of returning the patient to their
highest functional level.15, 21
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For personal use only.

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