PHYSICAL THERAPY MANAGEMENT

Physical therapists participate in the management of patients

with amputation at several key stages:
1. Preoperative
2. Postoperative (preprosthetic)
3. Prosthetic prescription
4. Prosthetic examination
5. Prosthetic training
Stage 1: Preoperative/Presurgical Stage
• Rehabilitation of the lower limb amputee should begin as soon as
amputation is considered.
• The primary goals of the presurgical period are the ff:
1. Medical stabilization
2. Patient assessment for amputation level
3. Pain control
4. Psychological support
5. Initiation of a functional rehabilitation program
Selection of Amputation Level
Factors
1. Tissue viability
2. Prosthetic options
3. Gait dynamics
4. Cosmesis
5. Biomechanics of the residual limb
• Preservation of tissue is balanced with restoration of
function
• higher amputations = increased morbidity and decreased
rehabilitation potential.
• Prediction of healing requires careful evaluation of surgical
technique, postoperative care, nutritional status and arterial
circulation—particularly tissue perfusion.
Functional Rehabilitation
• initiate a functional rehabilitation program before the amputation
• stretch out a tight or contracted joint using the entire limb length
before the amputation, than it is after surgery when the limb is
shortened and tender.
• Should emphasize the following:
1. Range of motion
2. conditioning remaining limb segments
3. increasing endurance
4. improving transfers,
5. training the patient in one-legged gait with an assistive device
Pain Control
• Good perioperative pain control is essential for the patient
facing limb loss.
• Beyond patient comfort, adequate pain control minimizes
the patient’s stress, and allows the patient to participate
more fully in a rehabilitation program.
• Uncontrolled pain can result in the development of central
nervous system–mediated pain and chronic pain, as well as
impair postoperative healing and immune functions
• Opioid therapy -the mainstay of perioperative pain control treatment (oral
opiates)

• more aggressive pain control measures including transdermal,

subcutaneous, intramuscular, or intravenous routes+

• A sufficient dose of analgesia just before therapies often helps the patient
fully participate

• CAUTION - geriatric population given the risk of delirium in these

individuals, should be streamlined when prescribed with opiates
Psychological Support
• Psychological assessment and support for the patient facing limb loss
should be a high priority.

“Losing a limb is like losing someone you love..”

• Patients fear that they will never be able to walk again after
amputation and might not expect to be able to accomplish more
demanding occupational or recreational tasks
What to do?
• Describing the rehabilitation process in detail to patients and
educating them about prostheses can help to allay their fear of the
unknown.
• Providing educational literature and website addresses can be a
valuable and calming service to patients and their families
• use a peer counseling program in which patients who are successful
prosthesis users visit patients with new amputees on request.
Most important component………..

Discuss phantom limb sensation and phantom limb pain with patients
before surgery
• Phantom limb sensation - is the temporary nonpainful
feeling that the amputated limb is still present (fades over a
period of time)

• Phantom pain – is the temporary pain that can occur in a

limb after its amputation, especially in a patient with a long
history of preamputation limb pain.
Stage 2: Postsurgical/Postoperative (preprosthetic)
Stage
Wound Care
• Wound healing is dependent on adequate tissue perfusion, good
wound care, and adequate nutrition
• The limb should be washed on a daily basis either with normal saline
or simple soap and water
• antiseptic agents such as iodine solutions or hydrogen peroxide
inhibit wound healing and should be avoided unless there are signs of
infection.
• Dressings should be kept clean and changed daily
• After traumatic amputations there are often large open wounds that
could have been contaminated in the trauma, and additional
coverage procedures such as flaps and grafts might have been
performed
• In patients with vascular compromise, wound margin necrosis can
develop. The limb should be monitored closely in these cases, kept
clean, and protected from any trauma that could cause a dehiscence
in such a fragile wound.
Edema Control
• important to promote wound healing,
minimize postoperative pain, and shape the
limb for prosthetic fitting
• Postsurgical edema stretches a surgical
wound, which stretches nerve endings and
causes pain
• Swelling gives a bulbous shape to the residual
limb, which interferes with prosthetic fitting
and can slow the patient’s functional
recovery. An effective compressive Dressing
can minimize these problems
Different edema control systems
Elastic Wrap
• the most commonly used treatment
• can provide effective compression

Disadvantage
- high-maintenance (items that must be properly applied and
changed about every 4 to 6 hours to maintain consistent
compression)
• Elastic wraps that are improperly applied or displaced in the normal
course of regular movement can turn into tourniquets, causing
pressure wounds and even limb ischemia.
Elastic socks or elastic stockinette
• provides a better alternative than elastic wraps.
• It is inexpensive and easily applied
• Elastic stockinette (e.g., Compressigrip and Tubigrip) can be applied
in multiple layers to give graded and increasing compression toward
the end of the residual limb
Residual limb shrinkers
• For transfemoral amputees, a residual limb shrinker with a waist belt
must be used
• Prosthetic elastomeric liners can also be used as compression socks
for edema reduction in amputees Because of their suction fit, they
can be used on the transfemoral amputee without a waist belt.
Rigid Dressing
• provide additional benefits over soft dressings alone for transtibial
amputees
• help protect the residual limb from any inadvertent trauma (fall)
• They provide good compression to minimize edema, and the cast can
be conformed to minimize pressure over bony prominences
• Partial weight-bearing can also be started through the rigid dressing
to help desensitize the limb and build tolerance to pressure.
Non-removable rigid dressing
• a cast that is applied over the fully extended residual limb up to the
midthigh
• helpful in preventing knee flexion contractures and can be used as an
immediate postoperative prostheses

Disadvantage
- does not allow for wound inspection except at cast changes
- does not allow patients to massage their residual limbs, an important part
of the desensitization program.
Removable rigid dressing (RRD)
• Custom made cast that covers the residual limb up to the knee
• It is held in place with either elastic stockinette or a thigh cuff.
• As the limb shrinks, socks, shrinker socks, and elastic stockinette are
added underneath the RRD to keep it snug.
• The RRD allows for frequent wound inspection and massage of the
residual limb
• also helps to teach patients how to adjust sock ply, a necessary skill
for using most types of prostheses.
• suggested protocol is to start with a rigid nonremovable dressing
applied immediately after surgery.
• After the first 3 to 6 days, the cast should be changed to an RRD,
which should be used until most of the edema is resolved and the
wound is well healed.
• If more than 12 to 18 ply of sock is required to keep the RRD snug, a
new RRD is recommended
Functional Rehabilitation (presprosthetic)
• Early rehabilitation management is critical in the postoperative period
• Therapy staff work on a variety of areas
1. Self-care
2. Bed mobility
3. Transfers,
4. Wheelchair skills
5. Ambulation
6. Patient and family teaching
Amputee rehabilitation principles include
1. Proper positioning
2. Initiation of ROM
3. Early mobilization
4. Evaluation for durable medical equipment and adaptive
devices
Proper Positioning
• To prevent hip and knee contracture
• Patients should not have pillows placed under the knee because this
can lead to knee flexion contracture
• To prevent hip abduction contractures, pillows should not be placed
between the legs.
• Dangling the residual limb over the side of the bed or wheelchair
should be avoided
• A knee extension board can be fitted underneath the wheelchair or
chair to promote knee extension and help prevent dependent edema
• If knee flexion contractures are of great concern, a knee
immobilizer while the patient is in bed can be used to
maintain knee extension.
• Patients should be instructed to lie prone several times a day
for 10 to 15 minutes at a time to prevent hip flexion
contractures.
• Individuals who cannot tolerate prone positioning can lie
supine on a mat while performing hip extension exercises of
their affected limb
• ROM and strengthening exercises of the affected limb are important
adjuncts to positioning.
• Muscles that oppose the common sites of contracture must be
strengthened, especially knee and hip extensors
• Other important muscles groups that should be strengthened include
the hip adductors and abductors.
• Because patients are increasingly reliant on their arms to assist with
mobility, arm strengthening and conditioning are needed.
• Specific exercises include strengthening of the wrist, elbow extensors,
and scapular stabilizers
• Initiation of aerobic exercise

However, given the high incidence of concomitant cardiovascular

disease in individuals with a vascular etiology of amputation,
adherence to cardiac precautions is important.
Early mobilization
• Facilitates early functional improvements.
• Usually the first activities include bed mobility, transfers, and
mobilization to a chair or wheelchair
• As the patient progresses, the activities should increasingly
focus on standing and balance exercises in the parallel bars,
and hopping.
• The use of a walker or crutches is the next step in
mobilization
• Early partial weight-bearing can begin in the first few days if there are
no wound complications
• For transtibial amputees with rigid dressings, limited weight-bearing
can be performed through their cast using a strap across their
wheelchair
• When the patient is up in the parallel bars, weight-bearing
can be done via a tire jack or adjustable footstool.
• Inspection after weight-bearing is important in monitoring
wound tolerance of pressure for patients with impaired
sensation
• Evaluation for appropriate adaptive equipment and durable medical
equipment is important.
• Adaptive devices such as reachers, long handles, sponges, shoehorns,
dressing sticks, and sock aids can be issued as needed to assist with
activities of daily living
• Long-handled mirrors can also be helpful to allow patients to monitor
the status of their residual limb easily.
• Because sitting in a wheelchair makes
the amputee’s center of gravity higher
and more posterior, rear wheels
should be set posterior to the chair
back and antitippers should be placed,
to minimize the risk of tipping
backwards and sustaining a head
injury.
• This is particularly important for
transfemoral and bilateral amputees.
Summary:
• The acute postoperative period prepares the patient for a safe return
home with the temporary assistance of a wheelchair, walker,
crutches, or with an early fitted prosthesis.
• Early on, the key issues remain wound healing, edema control,
psychological adjustment, and pain control
• Patients need to be followed up closely for the first 12 to 18 months
• Prosthetic fitting and prosthetic gait training can usually be started
within 3 to 6 weeks of surgery, and patients are usually able to
ambulate independently (perhaps with an assistive device) within 1
month of starting therapy with their prosthesis.
• The residual limb continues to shrink during the first 6 to 8 months.
This requires constant monitoring to ensure an adequate fit of the
device by both the patient and the rehabilitation team.
• After shrinkage abates in 6 to 8 months, the patient can then be fitted
with a new, definitive prosthesis (or at least a new socket).
• Most amputees need a full year to completely adjust to their limb
loss.
• Regular physician is needed.
• Follow-up should be done, if possible, in multidisciplinary amputee
clinics (from physiatrist, prosthetist, nurse, and preferably, a physical
therapist)
Pain Management
• Identifying the etiology of postoperative limb pain is important for
successful control of the pain.
• Because of nerve fiber damage and ongoing stimulation of the nerves
in the residual limb, a generalized residual limb pain is initially
expected secondary to the surgical incision and postoperative edema.
• Ectopic activity at the cut end of nerves is expected and can be due to
unstable sodium channels or the uncovering of new pathologic
receptors
• Ephaptic transmission, which is the stimulation of afferent fibers
(nociceptors) by efferent neurons (motor or sympathetic), can also
contribute to limb pain
• This acute pain responds well to intravenous or intramuscular opiates.
It subsides fairly rapidly, and the parenteral opiates can usually be
discontinued within 2 to 3 days
Desensitization techniques
• should be added to the treatment plan within a few days of surgery.
• Patients should be instructed to start massaging and tapping their
residual limb, which can be performed through any soft dressing.
• This gentle stimulation can help to reduce residual limb pain pain by
closing the pain gate, and gives patients a technique for controlling
their pain independently.
• When generalized residual limb pain does not subside as expected,
the patient should be reevaluated.
• Patients with peripheral vascular disease, diabetes, or both
can have continued limb ischemia that is a form of
claudication (constant or intermittent)
• Patients with residual limb ischemia often exhibit poor skin
color, and the residual limb pain is frequently dependent on
the limb’s position.
• Over the course of weeks, ischemic pain often resolves as
the swelling goes down, the circulation remodels with the
decreased distal tissue load, and the limb heals
• During the interim, the patient needs to continue to receive adequate
analgesia, although giving adequate pain relief without excessively
sedating the patient can be difficult.
 Even after the immediate postoperative period and residual limb
healing, the incidence of pain is high in patients with amputation, with
68% reporting residual limb pain and 80% reporting phantom pain

Residual limb pain/stump pain

• Prosthesis use is a common cause of residual limb pain in individuals
with amputation pain
• tends to be worse with prosthetic use and during ambulation
• Usually there is skin irritation that correlates with the area of the
prosthesis causing the pain
• Multiple factors can contribute to prosthetic pain including
1. socket fit
2. suspension
3. alignment
4. gait pathology
 Phantom limb sensation and pain are neuropathic perceptions in
a portion of the limb that was amputated.

Phantom limb sensations

• described as numbness, tingling, pins and needles, or itching
• Some amputees report the sensation of the phantom limb becoming
shorter, known as telescoping
• Patients can also complain that the missing limb feels like it is moving
or is in a cramped or awkward position.
Phantom limb pain
• is often described as sharp, burning, stabbing, tingling, shooting,
electric, or cramping.
• The first line of treatment for bothersome phantom limb sensation,
phantom limb pain, and residual limb pain is desensitization
techniques.
• Massaging, tapping, slapping, wrapping, and friction rubbing of the
residual limb often diminish such sensations.
• Patients frequently find that their phantom limb pain diminishes with
the stimulation of using a prosthesis.
• If desensitization techniques are insufficient and these pains are
significantly interfering with quality of life, pharmacologic treatment
should be considered.
• antidepressants and anticonvulsants (gabapentin)
Psychological Support
• Grieving over the loss of one’s limb is necessary, and a brief
exogenous (reactive) depression is expected.
• Amputees are at high risk of developing more severe psychological
problems. The incidence of persistent clinical depression is estimated
to be 21% to 35% for people with limb loss.
• assist patients with their psychological adjustment by giving
encouragement about prognosis, providing educational materials, and
incorporating the patient’s specific goals into the rehabilitation plan.
• Team members can also reassure their patients by emphasizing gains made
in therapy.
• initiate discussions about prosthetic options with patients early on and
impress upon patients that their input in the decisionmaking process is
necessary.
• Peer counseling and amputee support groups are another important
emotional support mechanism.
• Each patient should be encouraged to have an evaluation by an
experienced psychologist
Skin Problems
Problems with skin are frequent in patients with amputation.

• Contact Dermatitis
• Hyperhidrosis
• Infections
Verrucose Hyperplasia Pressure/shear ulcer
Epidermoid Cysts
Other Complications
• Joint contractures are frequent complications during the
rehabilitation of people with limb loss
• For knee contractures, extension devices like knee immobilizers can
provide relief.
• For hip flexion contractures, prone lying on a daily basis is helpful.
• Ultrasound heating can also be an effective therapy when combined with
aggressive stretching, provided the patient’s vasculature is adequate for
vigorous heating.
• For transtibial patients who are expected to ambulate, the knee flexion
contracture is initially accommodated in the prosthetic alignment.
• In severe cases that do not respond to the above treatment, surgical
release can be considered
• Bony growths at the end of the amputated bone are called bone
spurs that occur frequently and are usually asymptomatic.
• If a bone spur or HO protrudes distally and is not covered by
adequate soft tissue, it can become painful and cause skin
breakdown.
• Accommodating the spur or HO with a relief and/or padding in the
socket might solve the problem. If this fails, surgical excision might be
required.
Pre-prescription Considerations
Physical Examination
a. Assess joint mobility
b. Measure the length of the amputation limb
c. Assess strength of all limb and trunk muscles
d. inspect the skin
e. Examination of sensory function
Stage 3: Prosthetic Prescription Stage
• Prosthetic sponsorship must be considered as soon as possible
• Prosthetic Fitting Is discussed with the patient when designing a
treatment plan.
• Determining when to fit the lower limb amputee with a prosthesis
and what kind of prosthesis to use are issues open to considerable
debate.
• One option for transtibial amputees is to use an immediate
postoperative prosthesis (IPOP).
• IPOPs traditionally have been thigh-high casts with a pylon and foot
attached
• Prefabricated devices are also now available
• allow for earlier bipedal ambulation
• Another option is early fitting of a custom prosthesis, which requires
a delay of 3 to 6 weeks until much of the surgical swelling has
resolved and the wound has started to heal.
• Ideally the limb has also become cylindrically shaped (i.e., the
circumference of the distal residual limb is equal to or less than the
proximal size).
• Much of the postoperative edema is gone, so the residual limb has a
better shape for fitting with a prosthesis.
• A custom device is used so there is a more intimate and secure fit
with the prosthesis, and full weight-bearing is allowed.
• The most conservative option is to wait until the wound on the
residual limb is completely healed and surgical edema has resolved
before the patient is fitted with a custom prosthesis.
• This generally takes 3 to 6 months with dysvascular amputees.
• Although this approach can minimize wound problems related to
early weight-bearing, there is a higher risk of complications such as
joint contracture, deconditioning, pressure ulcers, and an
unnecessarily long delay in returning to functional ambulation.
Stage 4: Prosthetic Examination
Transtibial Examination – Static Analysis
Static Analysis
• The prosthesis is examined while the wearer stands and sits the
amputation limb and details of the prosthesis are examined
• The new wearer should stand in the parallel bars or other secure
environment, attempting to bear equal weight on both feet
• The therapist should solicit subjective comments about comfort.
Transtibial Examination – Static Analysis
1. Is the prosthesis as prescribed?
2. Can the client don the prosthesis easily?
Standing
3. Is the client comfortable when standing with the heel midlines 6 in (15 cm) apart?
4. Is the anterior–posterior alignment satisfactory?
5. Is the medial–lateral alignment satisfactory?
6. Do the contours and color of the prosthesis match the opposite limb?
7. Is the prosthesis the correct length?
8. Is piston action minimal?
9. Does the socket contact the amputation limb without pinching or gapping?
Suspension
10. Does the suspension component fit the amputation limb properly?
11. Does the cuff, fork strap, or thigh corset have adequate provision for adjustment?
Sitting
12. Can the client sit comfortably with hips and knees flexed 90°?
Transtibial Examination -Dynamic Analysis
• For most patients, a major reason for prosthetic fitting is to resume
walking
• When walking, the person who wears a prosthesis compensates for
anatomical and prosthetic deficiencies
• prosthetic gait represents compensation for the patient’s altered
locomotor apparatus
• The term gait compensation may be a more accurate descriptor than
the more commonly used gait deviation
Transtibial Examination
• Inadequacies in the prosthesis compel the wearer to adopt gait
compensations
• Such problems include the ff:
-poorly fitted socket
-prosthetic misalignment
-malfunctioning components
-improper height of the prosthesis
• the patient is compelled to expend more energy walking and to
exhibit a more conspicuously abnormal gait
• Transtibial analysis focuses on action of the knee on the amputated
side during stance phase.
• The following are tabular presentations of common gait deviations as
well as the causes in transtibial amputation
Inspection of the Prosthesis Off the Patient
• The posterior wall should be approximately at the same level
as the build-up for the patellar ligament (tendon) when the
patient stands
• The amputation limb should be examined for signs of proper
loading with respect to the type of prosthesis worn.
Inspection of the Prosthesis Off the Patient
• Is the skin free of abrasions or other discolorations
• attributable to this prosthesis?
• Is the socket interior smooth?
• Is the posterior wall of the socket of adequate
• height?
• Is the construction satisfactory?
• Do all components function satisfactorily?
Transfemoral Examination – Static Analysis
• Is the client comfortable when standing with the heel midlines 6 in
(15 cm) apart?
• Is any flesh roll above the socket minimal?
• Is the client free from vertical pressure in the perineum?
• Do the contours and color of the prosthesis match the opposite limb?
• Is the prosthesis the correct length?
• Is the knee stable?
• When the socket valve is removed, is the distal tissue firm?
Transfemoral Examination – Static Analysis
Quadrilateral Socket
10. Does the ischial tuberosity rest on the posterior brim?
11. Is the posterior brim approximately parallel to the floor?
12. Is the adductor longus tendon located in the anterior–medial corner?

Ischial Containment Socket

13. Does the posterior–medial corner of the socket cover the ischial tuberosity?
14. Can the client hyperextend the hip on the amputated side comfortably?
15. Can the client flex the hip 90° comfortably, without socket gapping?
16. Can the client abduct the hip on the amputated side comfortably, without
socket gapping?
Transfemoral Examination – Dynamic Analysis
• The goal of walking with a transfemoral prosthesis is a comfortable,
safe, efficient gait, rather than duplicating the gait of someone
wearing a transtibial prosthesis or one who does not have amputation
Transfemoral Examination
Inspection of the Prosthesis Off the Patient
• Following the static evaluation, the therapist should examine the prosthesis
and amputation limb as indicated on the checklist.

üIs the skin free of abrasions or other discolorations attributable to this prosthesis?
üIs the socket interior smooth?
üWith the prosthesis fully flexed on a table, can the thigh piece be brought to at least
the vertical position?
üIf the socket is totally rigid, is a back pad attached?
üIs the construction satisfactory?
üDo all components function satisfactorily?
Facilitating Prosthetic Acceptance
• Amputation generally is regarded as a grievous occurrence, with its
visibility a constant reminder of the individual’s abnormality
• The physical therapist can help the patient and family accept the
reality of amputation and the prosthesis by verbal and nonverbal
communication
• Peer support groups are often very effective in aiding acceptance of
the prosthesis and in learning special procedures for accomplishing
activities
• Treat patient in in out-patient rather than bedside
Stage 5: Prosthetic Training
Learning to use a prosthesis effectively involves being able perform the
ff
1. don/doff it correctly
2. develop good balance and coordination,
3. walk in a safe and reasonably symmetrical manner
4. perform other ambulatory and self-care activities.
Prosthetic Training
Donning
• Patients with partial foot, Syme’s, and transtibial amputations can don the
prosthesis while seated, after having applied the correct number and
sequence of socks or sheath.
• Then, in most instances, the individual simply inserts the amputation limb
into the socket. With SC/SP suspension, one applies the liner to the
amputation limb, then inserts the limb and liner into the socket.
• The initial entry into the socket with corset suspension may be made while
sitting; however
• final tightening of laces or straps should be done in the standing position to
ensure that the limb is lodged suitably in the socket.
Prosthetic Training
Balance and Coordination
• All must learn to balance on the amputated side
• Increasing prosthetic tolerance minimizes the danger of skin abrasion,
particularly if the amputation limb presents skin grafts, poor
circulation, or diminished sensation
• The patient should strive for level pelvis and shoulders, vertical trunk
without excessive lordosis, and equal weight-bearing
• Symmetrical weight bearing
Prosthetic Training
Balance and Coordination
• The client must learn to use proximal sensory receptors to maintain
balance and perceive the position of the prosthesis without looking at
the floor.
• Some patients respond well to increased use of visual feedback (e.g.,
using a mirror).
• Dynamic exercises improve medial–lateral, sagittal, and rotary
control.
Prosthetic Training
Balance and Coordination
• The patient learns that hip flexion causes the knee to bend, and hip
extension stabilizes the knee during stance phase. Therefore, placing
the sound foot ahead of the prosthesis makes the prosthetic knee
more stable.
• Patients should be instructed in weight shifting in both symmetrical
and stride positions and in stepping movements.
Prosthetic Training
Balance and Coordination
• Stepping on a low stool or step platform with the sound foot obliges
the patient to shift weight onto the prosthesis and increases stance
phase duration on the prosthesis.
• Having all exercises performed rhythmically with both the right and
left LEs fosters symmetrical performance.
Prosthetic Training
Gait Training
• Patients tend to place greater load and exert more propulsive force
on the intact side
• gait training should emphasize symmetrical performance
• Rhythmic counting and walking in time with music in 2/4 time also
improves gait symmetry and speed
• a suspension harness (partial body weight support) may be used
because it provides a protected environment for the patient to learn
gradual weight-bearing on the prosthesis.
Prosthetic Training
Gait Training
• Either a cane or pair of forearm crutches is an appropriate aid for the
client who is unable to achieve a safe gait without undue fatigue
• Ordinarily the cane is used on the contralateral side to enhance
frontal plane balance.
• If bilateral assistance is required, a pair of forearm crutches is
preferable to two canes.
Prosthetic Training
Functional Training - Transfers
• Rising from different chairs, the toilet, and car are primary skills even
for people who are elderly or debilitated.
• Placing the sound foot close to the chair enables rising by extending
the knee and hip on the sound side.
• Sitting is accomplished by placing the sound foot close to the chair
and lowering oneself by controlled hip and knee flexion on the sound
side
Prosthetic Training
Functional Training - Transfers
• Rising from different chairs, the toilet, and car are primary skills even
for people who are elderly or debilitated.
• Placing the sound foot close to the chair enables rising by extending
the knee and hip on the sound side.
• Sitting is accomplished by placing the sound foot close to the chair
and lowering oneself by controlled hip and knee flexion on the sound
side
Prosthetic Training
Functional Training – Transfers
• For both standing and sitting, the beginner should have the
advantage of a chair with armrests that enables use of the hands to
control and assist trunk movement.
• Transfer into an automobile should be an integral part of the training
activities
Prosthetic Training
Functional Training – Climbing Stairs, Ramps, and Curbs
• Those with unilateral transfemoral amputation usually ascend by
leading with the sound foot and learn to descend by first placing the
prosthesis on the lower step.
• Ramps may be difficult if the prosthetic foot does not have sufficient
anteroposterior excursion.
• With steep stairs, ramps, and curbs, the individual may climb
diagonally or sidestep with the prosthesis kept on the downhill side.
Patients should also learn how to maneuver over obstacles on the
walking surface
Final Evaluation and Follow-up Care
• Before discharge, the patient and prosthesis should be reexamined to
make certain that socket fit, prosthetic appearance, and function are
acceptable.
• The new prosthesis wearer should return to the training site at
regular intervals so that the clinic team may examine socket fit.
• Follow-up visits are good opportunities to augment training and to
encourage the individual to engage in the widest possible range of
activities