Amputation


Amputation is an acquired condition that results in the loss of a limb, usually from injury, disease, or surgery. Congenital (present at birth) limb deficiency occurs when an infant is born without part or all of a limb. In the U.S., 82% of amputations are due to vascular disease. Nearly 70% of amputations due to trauma involve the upper limbs. About 2 million individuals in the U.S. are living with a loss of a limb, with more than 185,000 amputations performed each year according to the National Limb Loss Information Center.

What causes the need for amputations?

The causes for amputation may include any of the following:

  • Diseases, such as blood vessel disease (called peripheral vascular disease or PVD), diabetes, blood clots, or osteomyelitis (an infection in the bones).

  • Injuries, especially of the arms. Seventy-five percent of upper extremity amputations are related to trauma.

  • Surgery to remove tumors from bones and muscles.

Rehabilitation after amputation

Loss of a limb produces a permanent disability that can impact a patient's self-image, self-care, and mobility (movement). Rehabilitation of the patient with an amputation begins after surgery during the acute treatment phase. As the patient's condition improves, a more extensive rehabilitation program is often begun.

The success of rehabilitation depends on many variables, including the following:

  • Level and type of amputation

  • Type and degree of any resulting impairments and disabilities

  • Overall health of the patient

  • Family support

It is important to focus on maximizing the patient's capabilities at home and in the community. Positive reinforcement helps recovery by improving self-esteem and promoting independence. The rehabilitation program is designed to meet the needs of the individual patient. Active involvement of the patient and family is vital to the success of the program.

The goal of rehabilitation after an amputation is to help the patient return to the highest level of function and independence possible, while improving the overall quality of life — physically, emotionally, and socially.

In order to help reach these goals, amputation rehabilitation programs may include the following:

  • Treatments to help improve wound healing and stump care

  • Activities to help improve motor skills, restore activities of daily living (ADLs), and help the patient reach maximum independence

  • Exercises that promote muscle strength, endurance, and control

  • Fitting and use of artificial limbs (prostheses)

  • Pain management for both postoperative and phantom pain (a sensation of pain that occurs below the level of the amputation)

  • Emotional support to help during the grieving period and with readjustment to a new body image

  • Use of assistive devices

  • Nutritional counseling to promote healing and health

  • Vocational counseling

  • Adapting the home environment for ease of function, safety, accessibility, and mobility

  • Patient and family education

The amputation rehabilitation team

Rehabilitation programs for patients with amputations can be conducted on an inpatient or outpatient basis. Many skilled professionals are part of the amputation rehabilitation team, including any or all of the following:

  • Orthopedists/orthopedic surgeons

  • Physiatrist

  • Internist

  • Other specialty doctors

  • Rehabilitation specialists

  • Physical therapist

  • Occupational therapist

  • Orthotist

  • Prosthetist

Types of rehabilitation programs for amputations

There are a variety of treatment programs, including the following:

  • Acute rehabilitation programs

  • Outpatient rehabilitation programs

Physical Therapy Management of Adult Lower-Limb Amputees

The prosthetist and the physical therapist, as members of the rehabilitation team, often develop a very close relationship when working together with lower-limb amputees. The prosthetist is responsible for fabricating and modifying the specific socket design and providing prosthetic components that will best suit the life-style of a particular individual. The physical therapist's role is threefold. First, the amputee must be physically prepared for prosthetic gait training and educated about residual-limb care prior to being fitted with the prosthesis. Second, the amputee must learn how to use and care for the prosthesis. Prosthetic gait training can be the most frustrating, yet rewarding phase of rehabilitation for all involved. The amputee must be patiently educated in the biomechanics of prosthetic gait. Once success is achieved, the amputee may look forward to resuming a productive life. Third, the therapist should introduce the amputee to higher levels of activities beyond just learning to walk. Although the amputee may not be ready to participate in recreational activities immediately, providing the names of support groups and disabled recreational organizations can furnish the necessary information for the individual to seek involvement when ready.

Mental Status

An accurate assessment of the patient's mental status can lend insight into the likely comprehension level for future prosthetic care. The therapist should be concerned with assessing the patient's potential to cognitively perform activities such as donning and doffing the prosthesis, residual-limb sock regulation, bed positioning, skin care, safe ambulation, and other functional activities of the amputee. If the patient does not possess the necessary level of cognition, family members and/or friends should become involved in the rehabilitation process to help ensure a successful outcome.

Range of Motion

A functional assessment of gross upper-limb and sound lower-limb motions should be made. A measurement of the residual limb's range of motion (ROM) should be recorded for future reference. Joint contractures are complications that can greatly hinder the amputee's ability to ambulate efficiently with a prosthesis; thus extra care should be taken to avoid them. The most common contracture for the transfemoral amputee is hip flexion, external rotation, and abduction, while knee flexion is the most frequently seen contracture for the transtibial amputee. During the ROM assessment the therapist should determine whether the patient has a fixed contracture or just soft-tissue tightness from immobility that can be corrected within a short period of time. This may affect the manner in which the prosthesis is fabricated.

Strength

Functional strength of the major muscle groups should be assessed by manual muscle testing of all limbs including the residual limb and the trunk. This will help determine the patient's potential skill level to perform activities such as transfers, wheelchair management, and ambulation with and without the prosthesis.

Sensation

Evaluation of the amputee's sensation is useful to both the patient and therapist alike. The therapist can gain insight into the possible insensitivity of the residual limb and/or sound limb. This may affect proprioceptive feedback for balance and single-limb stance, which in turn can lead to gait difficulties. The patient must be made aware that decreased pain, temperature, and light touch sensation can increase the potential for injury and tissue breakdown.

Bed Mobility

The importance of good bed mobility extends beyond simple positional adjustments for comfort or to get in and out of bed. The patient must acquire bed mobility skills to maintain correct bed positioning in order to prevent contractures or excessive friction of the sheets against the suture line or frail skin. If the patient is unable to perform the skills necessary to maintain proper positioning, assistance must be provided. As with most patients, adequate bed mobility is a basic requirement for higher-level skills such as bed-to-wheelchair transfers.

Balance/Coordination

Sitting and standing balance are of major concern when assessing the amputee's ability to maintain the center of gravity over the base of support. Coordination assists with ease of movement and the refinement of motor skills. Both balance and coordination are required for weight shifting from one limb to another, thus improving the potential for an optimal gait. After evaluating mental status, ROM, strength, sensation, balance, and coordination, the therapist will have a good indication of what would be the most appropriate choice of assistive device to use initially with the individual amputee.

Wheelchair Propulsion

The primary means of mobility for a large majority of amputees, either temporarily or permanently, will be the wheelchair. The energy conservation of the wheelchair over prosthetic ambulation is considerable with some levels of amputation. Therefore, wheelchair skills should be taught to all amputees during their rehabilitation program.

One limb secondary to obesity, blindness, or generalized weakness can still be successful prosthetic ambulators when the additional support of a prosthesis is provided.

Prosthetic Management

The socket should be cleaned daily to promote good hygiene and prevent deterioration of prosthetic materials. As a rule, solid plastic materials are cleaned with a damp cloth and foam materials with rubbing alcohol. The patient should also be reminded that routine maintenance of the prosthesis should be performed by the prosthetist to ensure maximum life and safety of the prosthesis.

Spinal Cord Injury Rehabilitation

There is life after spinal cord injury. We'll help you get there.

What Is a Spinal Cord Injury (SCI)?

It’s one of the most serious traumatic injuries. That’s because an SCI causes damage to the:

  • Vertebrae

  • Ligaments

  • Disc materials

That causes the spinal cord and/or its nerve fibers to experience bruising and tears. After an SCI, every nerve above the level of the injury keeps working. However, the spinal cord nerves below the point of injury can no longer transmit messages between the brain and parts of the body.

An SCI is classified according to its level and type. The level of injury for a person with SCI is the lowest point on the spinal cord below which there is a decrease or absence of feeling and/or movement.

The higher the spinal cord injury is in the vertebral column (the closer it is to the brain), the more effect it has on how the body moves, and the harder the recovery will be.

What Are the Symptoms of an SCI?

Here’s how you can tell if you are in serious need of spinal cord injury recovery:

  • Paralysis of the muscles used for breathing

  • Paralysis and/or loss of feeling in all or some of the trunk, arms, and legs

  • Weakness

  • Numbness

  • Loss of sexual function

  • Loss of bowel and bladder control

Recovery after Spinal Cord Injury Is Possible

Even if you experienced a severing of the spinal cord, spinal cord injury recovery is possible at our center. We can help you regain:

  • Strength

  • Independence

  • Function

  • Improved neuro-recovery

Experts agree that functional, repetitive motor exercise training is the key to recovery after a:

  • Stroke

  • Infarction

  • Spinal cord injury

Ongoing studies have proven that comprehensive, activity-based strength training in repeated patterns is essential. It can help muscles “re-learn” or “remember” a functional movement pattern.


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