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Chapter 93 Amputation Rehabilitation
Alberto Esquenazi Edward Wikoff Maria Lucas
Amputation reh abilitation is not solely solely the provis provision ion of a prosthesis.. Rat her it is the restorative inter prosthesis inter vention necesnecessary to return the patient who has had an amputation to the highest possible possible level level of function and to minimize the impact of the amputation on his or her life. life. In the last last two decades,, wi decades with th the advent of spe special cialize ized d treatment teams and n ew prosthetic prosthetic devices, devices, the outlook for for the per son who who has had an amputa tion has improv improved. ed. Out comes that were never thought to be possible, possible, such as exercisi exercising ng with a prosthesi pros thesiss or ambulation without without th e use of upper-l upper-limb imb support for the elderly, are now frequently achieved. achieved. We present prese nt our col collec lectiv tivee knowledg knowledgee and understanding of the rehab ili ilitation tation process, process, whic which h represents the essential essential interinterventions necessary to optimize function for patients who are provided with a prosthesis and for those who are unable or choose not to use one.
CLASSIFICATION AND INCIDENCE OF AMPUTATI AMPUTATI ON Amputations are classified based on the anatomic level and site at which the amputat ion has taken place. place. For example, an amputation between the wrist and elbow is termed a transradial transr adial amputation. Oth er levels levels include include transfemoral, transfemoral, transtibi trans tibial, al, Sy Syme, me, partial foot, foot, hip disartic disarticula ulatio tion, n, and kne kneee disarticulation for the lower lower limb. For the up per limb, transhumeral and partial hand amput ations ations,, and shoulder shoulder, elbow, and wrist disart disart iculations are the most common.
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The congenital limb deficiencies are best classified foll ollow owing ing the International Organization of Standards and the Intern ational Socie Society ty of Pros Prosthetics thetics and O rthotics classifications 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 the limb has developed normally to a particular level beyond which no skeletal skeletal element exists. exists. With intercalary limb deficiency defic iency, there is a reduction or absence absence of one or more elements ele ments within within the long long axis axis of of the limb, limb, and there may be normal skeletal elements distal to the affected segments (2). Amputation of the lower lower limb is performed signifisignificantly more frequently frequently than amputa tion of the upper limb. Amputation Amputati on of the distal distal segme segment nt of the limb limb is more common than that of the proximal proximal se segment. gment. Amputatio Amputations ns can occur at a ny age, age, but for lower lower extremities extremities,, the elderly elderly are most commonly affec affected, ted, with men more frequen frequen tly affected aff ected than wo women. men. Upper-li Upper-limb mb a mputation affects affects men between the second and fourth decades most frequently, and the right upper extremity is more likely to be amputated than the left. left. The most common reasons for lower-limb amputation are inf infecti ection, on, arterial occlusi occlusive ve disease disease,, and compl complicaications of diabetes mell mellitus itus.. Les Lesss frequent frequent but important causes caus es are trauma, malig malignancy nancy,, and peripheral neuropathies.. For the upper limb, trauma foll ropathies ollow owed ed by maligmalignancies and acute arterial insufficiency are the most common causes (Fig (Fig.. 93-1) 93-1)..
Figure 93-1. Distribution of the causes of amputation.
REHABI REHABILI LITA TATI TIO ON TEAM TEAM Limb loss is a condition th at h as physical, physical, psychologic psychological, al, and social implications for the affected individual and the social social suppor suppor t system. system. For treatmen t to be effecti effective ve,, it should should include the care of the patient and his or her signif signif-icant other s. Expertise from from various clinicians clinicians is is required t o accomplish accomplish this effectivel effectively y. T he development development of a rehabilitation team working closely together to address each individual’s needs is vital to the efficient and timely delivery of services services.. T his appr oach will will provide provide the patient a comprehensive treatment regimen. A physic physician ian specializing specializing in rehabilitation, or who has knowledg knowledgee of biomechanics biomechanics and prosthetics, prosthetics, assumes assumes the role of team leader and coordina tes the team’s resources. resources. The prosthetist fabricates the prosthetic appliance and works closely in the training stages with the therapist and patient to prevent complications, complications, achieve appr opriate alignment, and ensure ensure proper proper fit of the prosthes prosthesis is.. The prosthetist also acts as a resource to other team members for information on the latest technologic advances in the field of prostheti prosthetics cs.. Physical and occupational therapists are critical members of the therapeutic team. Th e physi physical cal therapist participates in the care of the lower-ex lower-extremity tremity amputee by preparing him or her physically for using a prosthesis. Th is includes includes instructi instructing ng the patient in management of the prosthesis, prosthesis, teaching functiona functiona l mobility activities, activities, and providing viding gait training to optimize optimize the walking walking pattern. In th e patient who has had a tr aumatic upper-extremity upper-extremity amputation, the intervention intervention of the physi physical cal therapist therapist is required on ly if there is a significant significant injury to joints or soft soft tissues. tissues. An occupationa l thera pist will will work work closely closely with with th e team and the patient to incorporate incorporate use of the prosthesi prosthesiss during activities of daily living living (ADLs) (ADLs) and for work simusimulation lation activities activities.. For the u pper-extremity pper-extremity amputee, amputee, the occupational therapist is frequently the primary therapist instructing instructing the patient in in the use of an upper-limb upper-limb prosthesis. Owing to the immense psychological impact that an amputation has on ma ny patients and their familie familiess, each patient should have an assessment with a psychologist (3,4).
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A psychologist specializing in limb loss or disability is particularly suited suited in ad dressing dressing feelings feelings of depression and body image changes associated with amputation. Along Along with with these core members, the team should include other suppor ting clinicians. clinicians. A social social worker worker can assist assist patients with changes in family relationships relationships and social status related to decreases in function or work abilities (5) (5).. Nurses can assis assistt and instruct patien ts in medication management management and with wound wound care. T he recreational recreational therapist provides information about community resources for recreationa l activities and support groups, and instructs patients in the adaptations necessary to participate in leisure leisure activities. activities. A vocational vocational counselor, counselor, driving instructor, instructor, and when necessary necessary,, a school teacher ma y be involv involved ed in the care of the amputee as well well.. T he patient and team members should should work together to set goals and develop an overall treatment plan. Subsequently Subsequently, each team member part icipates icipates in the patient’s care as necessary necessary to make the p rovision rovision of services most efficient. With so many clinicians contributing to the care of an individual, individual, communication communication is an esse essential ntial component of team interaction. Good communication communication will will ensure that all team members are providing patients with quality care while while avoiding avoiding duplication duplication of servic services es.. Each team should should develop develop some some method of communication communication that is appropriate for the clinical setting, setting, whether it be da ily or weekly weekly rounds, rounds, written written documentation, computer linking linking,, or team meetings (6–8).
PREAMPUTA PREAMPUTATI TION ON EDUCATI EDUCATI ON AND COUNSELI COUNSELING NG The rehabilitation process for the individual with limb loss ideally should begin before before any surgery occurs. T he amputee can take better advantage of of rehabilitation rehabilitation serservices once he or she has been educated regarding surgery, healing, healing, exercis exercise, e, future abilitie abilitiess and limitations limitations,, and th e rehabilitation rehabilitation process process. T his education, education, as well well as the actual multifaceted multifaceted reha bilitation care, is best provided provided by a team of health care professionals professionals with experience experience and expertise in the realm of amputation rehabilitation rehabilitation (9–11) (9–11).. Patients facing amputation often know little about the disease disease process process that thr eatens their limbs, limbs, or about what the future holds. holds. Understanding that arterial insuffiinsufficiency ciency,, infecti infection, on, trauma, or tumor may necessi necessitate tate amputation may enable the patient to accept the amputation as the approp riate treatm ent (12) (12).. Lacking this insig insight, ht, patients may resist resist or delay amput ation, risking risking sepsis sepsis,, a contracted nonfunctional nonfunctional limb, limb, analgesic analgesic abuse, abuse, deconditioning or other avoidable avoidable medical medical complications complications.. Ot hers may fear social isolation or stigmatization stemming from the amputation, and view view the amputation amputation as the end of their useful lif life. e. Most fear fear losing independence a nd work productivity, productivity, and becoming a burden on family and friends (2,12–19).
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To fill fill these informa informa tion gaps, the patient a nd family benefit from preamputation counseling from members of the rehabilitation team and from a prosthetic user who can provide firsthan firsthan d inform inform ation. T he follow following ing topics should be cove covered, red, although with with the apprehension apprehension of of upcoming surgery surgery,, the patient may retain little of what is initiall initially y discussed. 1.
Pain wil willl certainly certainly be present present foll follow owing ing surgery surgery and its duration and intensity may not be predictable. Th e patient patient seek seeking ing pain relief relief as a result result of of amputation may not be satis satisfie fied, d, as the RL or phantom limb may also be painful (20).
2.
Phantom sensation sensation (and (and possibl possibly y pain) will will lik likely ely be present following surgery (21).
3.
Exercis Exercisee and proper positioni positioning ng in in the early early postoppostoperative period will be very important to future rehabilitation.
4.
A general general time time frame frame for for acute hospital hospitaliz izatio ation, n, wound wound healing, healing, preprosthetic preprosthetic rehabilitation, rehabilitation, and prosthetic use is very helpful to the patient.
5.
The patient’ patient’ss expect expectatio ations ns for for future future functio functional nal status are often often un realistic. realistic. Future a ctivities ctivities will will require equipment previously unfamiliar to the patient (e.g., e.g., wheelc wheelchair hair,, crutches, crutches, prosthesi prosthesiss, etc). etc). A discus discussi sion on of this info information rmation with an amputee as closely matched demographically as possible will provide provide the patient with a more credible credible view view of the future. Early contact with the patient also allows allows members of the rehabilitation rehabilitation team to evaluate evaluate the patient’s premorbid status and current problems so that appropriate goals goals and plans plans can be made. made. T he patient may also also benefit from from the continuity if if the same members of the rehabilitation rehabilitation team are involv involved ed b efore and after t he surgery. surgery.
EVALUATI EVALUATION ON OF OF THE AMPUTEE Evaluation of the patient with upper- or lower-limb lower-limb loss loss is indispensable to preparing the overall rehabilitation treatment plan, including including the deve development lopment of goals goals and objectives. tives. It is also import import ant in th e prosthetic prescription process. process. Although the overall evaluation evaluation p rocess for all ampu tees is similar similar,, some important differences differences exist exist in th e evaluation of patients with limb loss loss at different different levels. levels. These are reviewed later in this section. A general physical examination that documents body weig weight, ht, height, height, peripheral circulatio circulation, n, skin skin integrity integrity,, limb limb dominance, overall overall health, comorbidities comorbidities,, and mental status is neces necessary sary. Th e examination examination of the residual limb limb (RL) should should include th e soft-tiss soft-tissue ue length and shape, bone length length and shape, shape, and skin skin integrity, pliabili pliability ty,, and mobility mobility. Scar tissue is assessed as is the RL’s tolerance to pressure, traction, and weight weight bearing. bearing. Sensation Sensation is also also evaluated evaluated as well well as the presence presence of neuroma or areas of hypersens hypersensitiv itiv-ity. Th e clinic clinician ian should should document document the range of motion
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(ROM) and strength strength of the proximal proximal joints joints.. T he status of the contralateral contralateral limb limb and the ROM ROM , strength, and sensasensation of the other limbs are critical critical data in the planning of the rehabilitation rehabilitation program. Balance Balance and coordination are also essential and should be tested. Patients with peripheral neuropathy or skin grafts use vision vision as a compensatory mechanism for for the lack of sensasensation in the prosthesis prosthesis and th e other limbs. limbs. Eye examination examination should should be encouraged, as many patients patients need updated prescription eyeglasses and vision care. In the patient whose amputation was caused by ischemia related to atherosclerosis or diabetes mellitus, similar arterial insufficiency involving the cardiac and cerebral vesse vessels ls should should be suspected. suspected. Knowledge Knowledge of cardiopulcardiopulmonary status status and endurance is of of primary importance. importance. T he use of sophisticated sophisticated t ests to assess assess these systems systems in in patients with a cardiac history is usually unnecessary unnecessary.. Simple clinical indicators such as the ability to ambulate with a walker walker or crutches for for 30 to 40 ft, while while blood pressure and pulse rate are monitored, are adequate to determine whether the patient will be able to achieve the goal of limited limited household household ambulation. ambulation. Patients Patients with with a documented ejection ejection fraction fraction of 15% should should be able to ambulate very very short short distances with with an art ificial ificial limb. limb. T he cardiac risk in this population does not appear to be significantly increased when using a prosthesis or walking short distances. tances. T herapeutic walki walking ng is an appropriate technique for cardiovasc cardiovascular ular training. training. In ad dition, dition, the capacity for for short-distance ambulation will often permit a patient to remain out of a long-term-care long-term-care facil facility ity. T his has additional additional psychosocial benefits that may outweigh the potential risks. The patient’s willingness and ability to learn new techniques and t o participate in a variety of new activitie activitiess are critical. critical. T hus, cognitiv cognitivee an d psychol psychologi ogical cal evaluations evaluations are very very important. important. Th e psyc psycholog hological ical impact of limb limb amputation is huge. Patients Patients experience experience a variety variety of of emotional an d psychological psychological responses responses,, including anxiety, anxiety, shame, depres depression, anger anger, and fear. fear. The rehabili rehabilitatio tation n team must must provide provide support, support, treatment, and guidance for the patient a nd his or her family (2,12–19). 2,12–19). Nutr itional status, which has a considerable impact on wound healing and strength, strength, must must not be neglected neglected (22–24). 22–24). T he presence presence of of a variety of other comorb idities such as diabetic retinopa thy, thy, peripheral polyneuropathy polyneuropathy, nephropathy, nephropathy, and degenerative degenerative joint disease disease may also also influence influence the rehabilitation of the amputee. amputee. In short, short, a thorough thorough medical medical evaluat evaluatio ion n of the patient is necessary. Ot her areas of importance that should should be evaluated evaluated include the vocational and recreational activities that the patient performed in the past and wants to pursue in the future. Cer tain vocational or avocational activities activities may require alter native specialized specialized prosthetic devices devices,, tra ining, or use of no prosthesis prosthesis.. Devices Devices that may be exposed exposed to extreme weather weather,, water, water, or other elements that may be corrosive or destructive to the prosthesis should be made of special materials to protect the RL and the prosthesis.
Medica ical Rehabilit ilitaatio tion for for Dia Diaggnostic tic Grou roups
Social support systems play an important role in the amputee’s amputee’s rehabilitation. rehabilitation. T he rehabilitation rehabilitation program for a person living with an able-bodied spouse in an elevatoraccessible accessible single-fl single-floor oor apa rtmen t is different different from that of a person living alone in a third-story walk-up apartment. Lastly, the rehab ilitation team needs to evaluate evaluate and consider consider th e p atient’s atient’s motivation, motivation, preferences preferences,, and desires desires,, as well well as the impor tance of cosmesis cosmesis as a factor in prosthetic fabrication. As previously previously mentioned, several several importa nt factors need to be considered considered during the eval evaluation uation of the patient with with pa rticular rticular levels levels of of limb limb loss. loss. For the transfemoral transfemoral level level of amputation, asses assessi sing ng the length length (short, (short, mid, long) long) of the RL, ROM of the hip hip (partic (particular ularly ly extens extensio ion) n),, and strength strength of the hip (particularly (particularly abduction, abduction, extension) extension) is important. important. Knowle Knowledge dge of the type of surgic urgical al technique technique used used for amputation is important; in particular, particular, surgical surgical reatta chment of the add uctor group (myodesis (myodesis)) has a sigsignificant nificant impact on future function (25) (25).. T he configuration configuration of the dis distal end end of the femur femur and the presence presence of heteroheterotopic ossification or bone growth at the tip should be noted. noted. Other characteri characterisstics tics of the RL that should hould be noted include include location location of surgical surgical scars, scars, position position and type of grafts (skin skin or vascular) vascular),, and ab ility to bear weight weight distally. T hese factors factors should be considered when the prosthetic socket socket is fabricated fabricated . Surgical revisi revision on should be considered considered when when heterotopic bone, scars, scars, grafts, grafts, or other features features of the RL pr event event adequate prosthetic fabrication. fabrication. Asses Assessment sment of the tr anstibial RL involves involves similar similar considerations considerations.. Th e length length is categorize categorized d as short, mid, or long long.. Strength Strength and ROM of the hip and knee knee are evaluevaluated. Asse Assess ssment ment of hip and knee extensi extension on is particularly particularly important. As with with the transfe transfemoral moral RL, location location of of scars, scars, presence presence of of skin kin or vascul vascular ar grafts grafts,, and the nature of the surgical technique (myodesis or myoplasty) are also noted. Th e configuration configuration of the distal distal end and its ability ability to bear weight are also important factors. For the transradial lev level el of of amputation (s (short, mid, long) long), evaluation evaluation of the ROM and strength strength of the elbow elbow,, shoulder shoulder,, and scapula scapula and the quantification quantification of pronation and supination supination are necessary necessary.. T he position position of surgical surgical scars, cars, configurat configuration ion of the distal distal end, type type of surgical urgical closure closure car ried out (myodesic (myodesic or myoplastic) myoplastic),, and t he ability of the RL to receive distal pressure pressure and weight weight bearing are asse assess ssed. ed. Contractility of the underlying underlying muscle muscle is is of particular importance if a myoelec myoelectric tric device device is to be considered. For the bilateral upper-li upper-limb mb amputee, the ROM and strength strength of shoulder shoulder and neck and trunk flexibili flexibility ty are importa nt factors. O ne should assess assess the ability to use lower limbs for functional activities such as opening doors, stabilizing stabilizing objects, feeding, feeding, and other essential essential functions. functions. Th e ideal length length of the limbs is determined determined by using using a ratio of height; height; for very-pro very-proximal ximal-le -leve vell amputations, amputations, the forearm section is made shorter to improve elbow lift power by reducing the lever arm length. It is necessary necessary to
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determine the optimal prosthetic control systems to be used (body (body power versus versus external power or b oth). For externa lly powered devices, devices, myoelectric myoelectric or switch switch contr ol can be used. T his decis decision ion also also requires knowledg knowledgee of the availability availability of approp riate funding sources sources and access access to maintenance. Externally powered powered devices devices require more mainten ance than body-powered body-powered devices devices.. Projecting the patient’s dependency on the prosthetic devices and the availability availability of help when th e prosthesis fails fails will will help to determine the need for for a second set set of artificial artificial arms (usually of different different cont rol mechanism). mechanism). For patients who have had bilateral lower-limb amputation, the evaluation evaluation should focus focus on the strength, dexterity dexterity,, and ROM of the upper limbs limbs and the ability ability to use the up per limbs for support during walking. walking. Asses Assessment sment of the cardiopulmonary sys systems tems is is esse essential ntial in view view of the expected increase in metabolic cost cost dur ing walking walking.. Limblengths should be determined based on the ability to transfer from sitting to standing (18 inches to the knee may be sufficient) sufficient) while keeping keeping a lower center of mass for for improved balance and more efficient energy utilization during standing and walking walking.. Choosing prosthetic prosthetic components based based on needs, needs, desires desires,, and available available funding funding sources, sources, as well well as accessibility accessibility to maint enan ce, is critical. Projecting the patient’s dependency on the prosthetic devices will permit determining the need for a wheelchair or a second set set of artificial artificial legs legs (maybe waterproof waterproof ones to be used also during showers). When a myoelectric prosthesis prosthesis is is prescribed, prescribed, the evaluation should should begin with with determination of the level level of amputation amputation (s (short, mid, long) long).. ROM of the shoul shoulder der and scapula scapula and strength of the shoulder shoulder muscles muscles,, primarily those of flexio flexion n and abduction, abduction, should should be asses assesse sed. d. T he presence of myodesic myodesic or myoplastic myoplastic closure closure and th e availavailable control at the residual muscles for the wrist for transradial level and at the elbow for transhumeral level should should be determined. Asse Assess ssment ment of electromy electromyographic ographic (EMG) signal strength (>20 units on Myotester) Myotester) of the muscles to be used to trigger the prosthesis is necessary. If the patient is not able to generate separate signals signals fo forr flexors and extensors and co-contract them for full utilization of my myoele oelectric ctric controls controls,, appropriate training with with EMG feedback is to be implemented.
PREPROSTHETIC TRAINING Preprosthetic tra ining ideally foc focuses uses on the goals of functional independence without without a pros prosthetic thetic device. device. In a ddition, for individuals individuals who who will will receive receive a prosthesis, prosthesis, the R L is prepared for prosthetic use. T he average average age of of the amputee population is 50 to 70 years old (26–28). (26–28). Usually they will will have several several comor bidities and have lost strength and endurance in the weeks leading up to the amputat ion (29,30) (29,30).. A comprehen si sive ve supervised supervis ed exercis exercisee program including ROM , strengthen-
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Figure 93-2. Inappropriate bed position of comfort that may promote contractures of the hip and knee.
ing, and end uran ce exercis exercises, es, as well well as functiona functiona l activities, ties, promotes improv improvement ement in th ese ese areas (31,32) (31,32).. Of course, precau tions dictated by the patient ’s comorbidities are to be observed. Patients are often eager to perform the upper-limb exercises that promote the strength and ROM required for selfself-care care activities. activities. However, However, most patients with with recent limb loss are more concerned with mobility than bathing and dressing. dressing. Arms provide the power for wheelchair wheelchair mob ility and the use of walki walking ng aids. aids. In particular, particular, shoulder shoulder stabili stabilizzers, ers, adductors, adductors, and depresso depressors, rs, elbow elbow extensors extensors,, wrist wrist stabistabilizers lizers,, and hand grasp strength strength are of prime importance importance for supporting the body for transfers and using the more common walking aids. Trunk balance and strength must not be neglected. Strong flexibl flexiblee rotators, rotators, flexors flexors,, and extensors extensors of the back and abdomen an d the extensors extensors of the hips facil facilitate itate sitting balance and bed mobility and transfers. T he importa nce of lower-limb lower-limb exercise exercise is obvious. obvious. T he remaining limb for for the unilateral amputee temporarily becomes the solitary support limb and frequently can develop develop symptoms consis consistent tent with overuse, part icularly at the knee and ankle. Stance-pha se stability requires adequate strength strength in the hip extensors, extensors, abductors, knee extenextensors, sors, and plantarflexors. plantarflexors. SwingSwing-phase phase limb advancement and clearance require adequate hip flexor and ankle dorsiflexor strength. Lower-limb contractures are distressingly common in the amputee population. population. Unfortunately, the position position of of comfort is often the position that can result in contractures. Patients often need continual reminders that contractures can significantly impair their future mobility and compromise mise the integrity integrity of of the nonamputated nonamputated limb. limb. The transfemoral-level amputee often develops contractures of the hip flexo flexors rs,, abductors abductors,, and external external rotators rotators.. The transtibial-level amputee frequently develops hip and knee flexio flexion n contractures (Fig. Fig. 93-2). 93-2). Contractures of the hip flexors flexors,, knee flexors flexors,, and plantarflexors plantarflexors of of the intact limb limb of the unilateral amputee often often result result from prolonged prolonged bed rest in the comfortab comfortab le semi-F semi-Fowl owler er position. If soft-tiss soft-tissue ue contracture results results in in an equinus posture, posture, the norma l weig weight-bearing ht-bearing posture posture of the foot is compromis compromised. ed. PresPressure distribution to the heel is lost and forces are focused on the forefoot. forefoot. T he increased pressure pressure on the forefoot forefoot can lead to local local pain and tissue tissue breakdown breakdown of particular concern in the presence presence of peripheral neuropathy or arterial ria l insuffi in sufficiency ciency.. The “ounce of preventi prevention” on” approach approach certainly certainly applies to limb limb contract ures. Several Several factors can contribut e
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to contractures: preoperative preoperative positioning positioning,, surgical surgical technique, postoperativ postoperativee pain, deficient deficient knowledg knowledgee regarding ROM, and limited mobility mobility related related to ischemia, ischemia, skin skin grafts, grafts, infectio infection, n, or trauma that led led to the amputation. Treatment of contractures may include include heating modalities modalities,, prolonged prolonged passiv passivee stretch, stretch, spring-l spring-loaded oaded orthoses orthoses, serial serial casting, casting, nerve blocks blocks,, or further surgery surgery.. To avoid avoid contractures, contractures, patients are instructed to move limbs through a full ROM frequently and to avoid avoid postures postures of prolonged prolonged flexion. flexion. Periods Periods of lying lying prone should be included included in the lower-limb lower-limb amput ee’s ee’s exercise exercise program . A posterior posterior splint may help prevent knee flexion contractures in the transtibial-level amputee. Frequent reminders and encouragement encouragement help the patient follow follow through through on th ese ese instructions instructions.. Contractures are readily prevented prevented through the use of of an immediate postoperative rigid dressing dressing (33,34) (33,34).. T he rigid dressing extends proximally proximally, enclosing enclosing the knee, preventing a flexion flexion contracture. The lower-limb amputee’s outlook brightens considerably when he or or she is is allow allowed ed out of bed. Independence in transfers transfers and functional mobili mobility ty are of great importance. Bed mobility exercise exercisess include rolling from from side to side side and sitting up, to allow the pat ient to position himself himself or herself without without calling calling for for help. Transfer Transfer training allows allows the patient to expand his or her world beyond the bed and room. Th e patient may utilize utilize sli sliding ding board, frontfronton/ back-off, back-off, or stand (squat) (squat) pivot pivot tra nsfers nsfers to move from one surface to another. Functional mobility for the amputee may take several forms. Most lower-limb lower-limb amput ees will will use use a wheelchair at some point and should learn proper wheelchair management, including including using using the leg rests rests and brakes. brakes. Safe Safe techniques for for propulsion propulsion and turns appear simple simple,, but require teaching and pra ctice. ctice. T he wheelchair wheelchair must be suitable suitable for the individual. A person with with limited strength strength or with significant cardiac impairment may be unable to safely propel a chair of normal weig weight. ht. Removable Removable armrests armrests are needed for those who utilize a sliding board or squat pivot transfer to the chair chair (Fi (Fig g. 93-3) 93-3).. The center of gravity gravity of the person person seated in a wheelchair shifts shifts posteriorly posteriorly if a lower limb limb is absent. T herefore, herefore, an off-s off-set et axle or or antitippers are appropriate. T hese are of particular importance when going going up a ramp or curb. Ambulation training without the prosthesis is very important to the amputee. Initially Initially, standing balance and standing tolerance tolerance are addressed. addressed. On ce the patient can manage standing, standing, then a mbulation mbulation (hopping) (hopping) using using the parallel bar s can begin. As strength and end uran ce improve, improve, the patient may advance to a walker walker and to crutches. crutches. In
Medica ical Rehabilit ilitaatio tion for for Dia Diaggnostic tic Grou roups
Figure 93-4. Elastic bandaging of the transtibial residual limb.
Figure 93-3. Sliding board transfer to a bed for the bil ateral ateral transfemora transfemorall amputee. amputee.
addition t o allowing allowing greater m obility, the a ctivities ctivities improve improve lower-limb strength and ROM and serve to remind the patient that bipedal walking may soon be a reality. Stairs are often often a source of of concern for for the amputee. When walking up and down stairs is not yet possible, possible, many individuals individuals use use a “bumping” technique to ascend or descend. descend. Th e patient sits sits on the steps and uses the arms and remaining low lower er limb limb to propel himself himself or herself herself up or down. down. Of course course,, the floor floor transf transfer at the top or bottom bottom of the stairs stairs must must also also be addressed. addressed. Many amputees use a low box or stool as a “step” between between the floor and the wheelchair or standing posture. Not all patients can tolerate standing activities initially tially. For patients who cannot, because because of orthostatic orthostatic hypotensi hypotension on or other reasons reasons,, a more gradual approach is needed. Allowi Allowing ng the patient t o press his or her foot foot against a foot board while in bed can simulate lower-limb weight weight bearing. Alternatively, the patient may hold a towel, towel, a length length of cloth, cloth, or a length length of elas elastic tic tubing tubing looped looped under the foot and apply pressure to the plantar surface of the foot. foot. Gradua l progressi progression on to a more erect posture posture may be achieved achieved by elevati elevating ng the head of the bed or using a tilt tilt table. While many amputees focus their attention on walking, walking, their a bility to perform self-care self-care activities may be more importan t to their going going home. As safe safe techniques
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for bathing and dressing dressing and toileting toileting are mastered, the amputee realizes that he or she need not fear being “a burden.” SelfSelf-es esteem teem and optimism optimism are restored. In addition to self-care self-care activities, activities, many ampu tees must must also perform homemaking activities to resume their life roles. Using Using a wheelc wheelchair hair,, walker walker,, or crutches, crutches, the amputee learns to prepare meals meals, do laundry, laundry, and perform other househousehold chores. Most of the preceding discussi discussion on is appr opriate for the lower-l lower-limb imb amputee. For th e upper-limb amputee, tran sfers sfers an d m obility are less less problematic while self-care self-care activities may be more difficult. difficult. Regardless of previous right- or left-han left-han dedness, the remaining limb limb becomes dominant for for the upper-li upper-limb mb amputee. T hus, there may be considerable considerable time spent spent on change change of of dominance. T he patient will also learn various single-handed techniques for bathing, dressing dressing,, grooming, grooming, and other self self-care -care activitie activitiess (35). Care of the R L focus focuses es on sev several eral areas including including wound wound healing, healing, volume volume containment, containment, optimization optimization of strength strength and ROM, and desensi desensitizati tization. on. Needless Needless to say, the healing wound should be kept clean and monitored for signs signs of infectio infection. n. Volume containment containment can be achieved achieved through several several approaches. Ideally Ideally, the immediate postoperative erative rigid rigid dressing dressing,, applied in the operating room, room, provides edema control as well as mechanical protection for the limb (33,34,36) (33,34,36).. As an alter native, the removable rigid dressing dressing can be used, allowing allowing the patient greater participation (37,38). (37,38). T he Unn a boot also prevents swelli swelling ng but requires no pa rticular skill in its application (39–42). (39–42). Ace bandages, bandages, tubular compression compression dressings dressings,, or stump shrinkers provide elastic compression and may be favored for their simplicity simplicity and neatn ess (Fig (Fig.. 93-4) (43,44) (43,44)..
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Because Bec ause the RL is an end organ, res responsi ponsible ble for for the manipulation, pos manipulation, positioni itioning, ng, control control,, and general operation of the prosthesi prosthesiss, exe exercis rcises es for the RL are crucial. crucial. Normal strength streng th and RO M of the RL will will help help to optimize optimize prosprosthetic use. Many ampu tees wil willl not receive receive a prosthesis prosthesis.. T here may be cogniti cognitiv ve, phys physical ical,, psy psychol chologi ogical, cal, financial financial,, or other rea sons for this. this. O ther am putees may simply decline the option of of usi using ng a prosthesi prosthesiss. For this group, therapies to optimize optimize stre strength, ngth, endurance, and ROM and to achieve achieve indepen dence in mobility, sel selff-care, care, and other life life tasks tasks without wi thout a pros prosthetic thetic device device are provided. provided. T here are a ls lso o patients for whom functional independence is not a realistic goal. Some pat ients will will always need some assis assistance tance for mobility and self-care. self-care. T hera pies for for th ese people will will focus focus on caregivers as well well as on the patient (18) 18).. Family members or other individuals individuals inv involv olved ed in the care of the amputee are educated and trained in appropriate techniques for RL care, mobil mobility ity, bathing, dres dressi sing, ng, and hygiene.
REHABILI REHABI LITA TATI TIO ON WITH WITH PREPARATO PREPARATORY RY PROSTHESIS Return t o bipedal ambulation ambulation is the stated goal of mos mostt lower-limb low er-limb amputees. Amputees often often feel that only by returning to ambulation can they resume their previous lives, liv es, roles roles,, activities activities,, and socialization socialization (12) 12).. Walk Walking ing again is an enormously important transition for the amputee. Starting with an accurate knowledge base is important for the patient and health care provider provider alike. alike. A review revi ew of goal goalss and expectations is is appropriate at t his point. Not all patients will will recall the prior discussi discussions ons regarding these topics, topics, so reminder s may be necessary necessary.. It is also appropriate for the therapist to review the patient’s diagnosis and comor bidities as wel welll as precautions, to minimize the complications that may develop as gait training proceeds. Rehabilitation with the preparatory prosthesis begins by introducing introducing the patient to the components components of the preparatory prosthesis prosthesis and its management. management. Explanatio Explanations ns of how the prosthesi prosthesiss fits fits,, where weig weight ht is borne, where and why discomfort discomfort may occur, occur, and h ow adjustments can be made help put th e patient at ease. It is usef useful ul to remind the patient that his or her weight must be supported by some so me pressurepressure-tolerant tolerant portion portion of the RL, or walki walking ng would be impossi impossible. ble. Press Pressure ure is to be expected and th is may be uncomfortable at first but should not be painful. With Wi th experience experience and the teachings of the treatment team, the patient patient learns learns the appropriate fit fit of the prostheprosthesis and the way to adjust the fit with stump socks when necessary neces sary. Th e patient needs to learn t hat the pros prosthetic thetic fit fit is a dynamic entity and that he or she needs to be aware of subtle changes in socket fit or alignment that provide clues to necessary adjustments (43,45).
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Gait training begins with weight bearing and weight shifting, using the par allel bar s for shifting, for upper -limb suppor suppor t. The patient gradually progresses to ambulation in the parallel bar s. T he ther apist may find find it difficult difficult to focus focus the patient on proper technique including equal step length and app ropriate weight weight shifting. shifting. Gait deviations frequently develop owing to the patient’s eagerness to begin walking. As the patient establishes a consistent gait pattern and can maintain good good form, form, he or she she advances advances to use use of a walker wal ker,, crutches crutches,, and unilateral support devi devices ces.. On ce the patient is comfortable with with level surfaces surfaces,, he or she progresse gres sess to walki walking ng on stairs, stairs, curbs curbs,, and ramps, as well well as uneven unev en terr ain. Th e patient a ls lso o learns safe safe techniques for for tran sf sfers, ers, including to and from the floor (32) (32).. Frequent monitoring of the skin skin allows allows for prompt corrections of sock socket-fit et-fit problems and avoi avoids ds skin skin breakdown. Skin checks checks are done mor e frequently for for the new prosthetic user and for for the patient with delicate skin. skin. Initially, checking the skin skin every 10 to 15 minutes or after every one or two walks walks may be necessary necessary.. O nce the pa tient and th erapist are comfortable with with the socket socket fit, sk skin in monitoring can occur less frequently. Prosthetic wearing tolerance gradually increases over the first few week weeks. s. Some patient s can only wear wear t he prosthesiss for thesi for 2 to 3 hr/ day during the first first week week of of gait training.. T his gradually increases until it is worn ing worn all day (12–16 (12–16 hours).. T hroughout the rehabili hours) rehabilitation tation process process,, the patient should become well well versed in skin skin care. T he patient lear ns to monitor monitor the ski skin n of the RL, noti noting ng sig signs ns of of appropri appropriate ate weight wei ght bearing and watching for evidence of sk skin in irritation or breakdown. When the p ros rosthesi thesiss is not worn, the patient wears a stump shrinker or an Ace bandage to prevent edema and provide volume containm ent (43,44) 43,44).. As the amputee progresses with ambulation and management of the prosthesis prosthesis,, ambulatory self self-care -care activiactivities and homemaking homemaking activities activities can can be addressed. addressed. O ccupational therapy works with the patient to learn safe techniques for bath ing ing,, dress dressing ing,, and toil toileting eting using using the prosthesis.. Some patients may find prosthesis find that initially, certain activities are more easily performed without the prosthesis. In these situations situations,, it is important to remember that the primary goal goal of therapy is is functional functional independence, independence, not necessarily necess arily continuou continuou s prosthetic use. use. Many patients need to perform homema king tasks as well. well. T he thera pist should should include incl ude meal preparation, laundry laundry,, shoppi shopping, ng, and other other household house hold chores in the tr aining routine routine of these indivi individuduals,, usi als using ng the pros prosthesi thesiss if pos possi sible ble.. As the patient progresses through ambulation training, emotional and p sy sychologi chological cal needs must must not be neglected. New anxieties or unfilled expectations expectations may arise during training with the prosthesis and should be addressed address ed by the psycholog psychologis istt an d other members of the rehabilitation rehabili tation team. T he patient is encouraged encouraged to express express concerns and disappointments so that steps can be taken to rectify these problems. While some some problems may not h ave
Medic icaal Rehabililit itaati tioon fo forr Dia Diaggnosti ticc Gro rouups
solutio solutions ns,, the patient can be reassured reassured that the rehabilitation team does not ignore the patient’s perceived issues. Few patients can proceed through ambulation training without without experiencing experiencing problems problems with with pain. Phantom discomfort has been extensively investigated (20,46–49). Approaches to treatment include biofeedback (50) (50),, imagery (51), 51), relaxation techniques (52), 52), massage, massage, ultrasound (53) (53),, tran scutaneous electrical n erve stimulation (TENS) (54), (54), oral and injectable medications (20,46), 20,46), and surgery (20,46). 20,46). T his topic is discuss discussed ed in detail elsewhere elsewhere in this text. RL pa in is frequently related to socket socket fit fit and p rosthetic alignment. By listening listening to the pat ient’s ient’s complaint, examining examining the RL, and watching the patient use use the prosthesis, thesis, the clinician can genera lly solve solve fit fit and alignment problems problems.. Prosthetic Prosthetic component changes and alignment alignment adjustments are more readily performed when modular, adjustable adjustable components components are used. Because Because the RL and the patient’s gait patter n are continually changing, it is common for pain problems to develop or recur without apparent provocation. provocation. T herefore, herefore, it is helpful helpful for for the members of the rehabilitation rehabilitation team to remind remind the patient that occasional difficulties and setbacks are common and are not reasons for despair.
REHABI REHABILI LITA TATI TIO ON WITH WITH PERMANENT PERMANENT PROSTHE PROSTHESI SIS S Ideally Ideally, rehabilitation rehabilitation of the ampu tee involv involves es testing testing the definitive prosthetic componentry on the preparatory device. device. T his allow allowss the therapist and other team members to train t he patient immediately immediately in the appropriate use of the components that will be used in the definitive prosthesis sis. However However,, this is is not always always possi possible ble,, because because of reimbursement issues issues or various other factors, such as an inability to predict a patient’s level level of function early in in the rehabilitation rehabilitation course. course. Th erefore, erefore, a pat ient who receive receivess difdifferent componentry in the definitive prosthesis than in the preparatory device will require retraining in the specifics of the new componentry. componentry. T he socket socket and some some components of a preparat ory prosthesi prosthesiss are not as durable as those those of the definitive prosthesis, prosthesis, thus limiting the patien t’s t’s funcfunctional capab ilities. ilities. Patients should should refrain from using using the pylon or preparatory prosthesis without an assistive device, even though they may eventually progress to this level when they receive their per manen t prosthetic device. device. With more sophisticated sophisticated componen try, try, patients may face face higher functional expectations such such as work work simulation, simulation, ambulation on varied varied surfaces, surfaces, and sports. Concer ning the socket, socket, it is vital to allow allow the patient’s patient’s RL to mature before before fabrication fabrication of the permanent socket. socket. T he soft-tis soft-tissue sue bulk bulk of the R L decreases decreases sigsignificantly, nificantly, owing owing to resolution resolution of edema as well well as disuse disuse atrophy of muscle muscless and adipose adipose tissue tissue.. T hese changes changes occur primarily during the first 2 to 5 months following the amput ation. T he definitive definitive prosthesis prosthesis frequently uses uses a
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suction suspension mechanism that is not usually recommended for a preparat ory pylon pylon because because of fluctuations fluctuations in in RL girth (43). (43). Patients often often will require n ew instruction instruction on donning techniques for for the suction suction socket. socket. Tran sfemoralsfemorallevel level ampu tees will will have significant significant changes in their abilities depending on the knee unit prescribed, and instruction in mobility and gait should vary based on the type of mechanism mechanism used in the p ermanent prosthetic prosthetic device. device. For example, patients ambulating with with a cadence-responsive cadence-responsive knee with swing and stance control will require a different gait pattern compared to patients using a weight-activated knee unit. T hey will will also also have different different m echanisms for for transferring from sitting to standing and ascending and descending stairs and inclines. For the upper -limb amputee, early prosthetic prosthetic fitting is is vital vital to the acceptance of the prosthesis prosthesis (36). 36). Generally, the first prosthesis uses uses conventiona conventiona l or body-powered componentr y. Myoelectric or extern ally powered prostheses are not usually recommended a t this stage because because of the fluctuation in girth as the R L matures. T his fluctuation fluctuation will will make it difficult to achieve the intimate fit between the skin and socket needed for the myoelectric system to work properly. properly. Additionally, one should should verify verify that the pat ient will be a prosthetic user before incurring the higher cost of an externally powered prosthesis. prosthesis. Upp er-limb ampu tees who are progressing from conventional to myoelectric prosthetics require a period period of retraining, retraining, to instruct instruct them in the proper use and care of the new prosthesi prosthesiss. In conclusion, conclusion, the transitions transitions from from a prepar atory prosthesis to a permanent prosthesis will necessitate education of patients on on any changes in in the way that they don and doff doff their prosthes prostheses es and the performance performance of their new componen componen try. try. Patients are made aware aware that whenever they receive receive a n ew socket, socket, they must be vigilant vigilant ab out skin inspectio inspection, n, as there is potential for for new areas of pressure pressure or breakdown breakdown of of the ski skin. n.
VOCAT VOCATII ONAL ONAL AND AVO AVOCAT CATII ONAL ONAL TRAINI TRAINING NG It is important to note that a successful outcome for an amputee means returning as close as possible to the previous level level of of function. function. For the worki working-ag ng-agee patient, return to some gainful employment employment should be expected. Similarly Similarly,, patients at any age should be able to return to previous or modified leisure leisure activities activities including sports sports or hobbies. T he patient should know early in rehabilitation that the longrange expectation is to return to work and play. In the case case of employment, employment, work work simul simulation ation activitie activitiess should be incorporated into the patient’s therapy programs early and should intensif intensify y in the latter part of the rehabilitation program. T he rehabilitation rehabilitation team should should make attempts to contact the patient’s employer to establish the physical physical demand of the jobs. jobs. Wherever Wherever possibl possible, e, employe employers rs should be informed informed a nd involved involved in the retraining. Worksite evaluations can be very helpful in understanding job
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Table 93 -1: Sport Sport Orga Organiza nizati ti ons for the Amputee Ame meric rica an Ampu Ampute tee e Fo Foun unda datio tion, n, Inc. Inc. Amput ee ee Coal it it io ion of Ameri ca ca Amput ee Sport s Associ at at i on on Natio Na tiona nall Ampu Ampute tee e Go Golf Ass Associa ciatio tion n National As Asso sociati ciati on of Disa Disabled bled Swimmers National Na tional As Asso sociation ciation of Handicapped Outdoorsmen National Na tional Whe heelcha elchair ir Athle Athletic tic Association Shake-A-Leg
(501) 666-2523 (7 08 08 ) 6 98 98 -1 -1 62 62 8 (9 12 12 ) 9 2 7 -5 4 06 06 (800) 633-NA 633-NAGA (81 3) 75 5-1 07 8 (618 ) 532 -456 5 (719 ) 635 -930 0 (4 0 1 ) 8 4 9 -8 8 9 8
demands and making recommendations for work environment modifications or changes in the patient’s job description. In some cases it is not feasible feasible for the patient t o meet the physical physical requirements requirements of the previous previous job. job. Limiting Limiting factors often often include heavy manu al labor, labor, prolonged standing periods, or jobs that require well-devel well-developed oped balan ce. For such situations it is very important to have the patient receive career counseling and job retra ining (55) (55).. Cont act with with the local branch of the state offi office ce of vocational vocational rehabilitation bilitation or its equivalent equivalent can be of great assis assistance tance as patients re-enter the workforce. Similarl Similarly y, the patient should should be encouraged to return to his or her pr ior leisure leisure activity. activity. Participation in sports is often very important to younger amputees and sometimes older amputees. amputees. T he patient should be provided provided with inforinformation on various sports sports groups, groups, for for example, example, the National Amputee Golf Asso Associati ciation, on, amputee ski ski groups, groups, and nationa l disabled disabled sports organizations (Table (Table 93-1). 93-1). Participation in some sports will require specific prosthetic componentry, ponentry, and consideration consideration of recreational recreational goals goals should should be given when one is formulating the prosthetic prescription (56). 56). Efforts Efforts should be made to tea ch the pa tient specific specific sport skills. A commonly stated desire for athletic ability is to be able to run again. Th is goal goal should should be considered considered for all active active amputees, amputees, even even if it is to run just a short distance distance for for a bus or to get out of danger. danger. A good good socke sockett fit is crucial for running for both transtibial-level and transfemoral-level ampu tees. A good fit fit allows allows the patient to tolerat e the tremendous amount of pressure pressure and r eaction eaction forces forces transtranslated to the limb without without too much discomf discomfort. ort. For th e healthy, healthy, active tra nstibial-level nstibial-level ampu tee, runn ing is is fairly easy to achieve (57,58) (57,58).. When the pa tient is ambulatin g indepen dently without without an assistive assistive device, device, he or she is ready to begin training. training. Hopping and jumping activi activities ties will will assist assist with building t he p atient’s tolerance for increa sed force tran smitted to the limb. limb. A gradu gradu al progression progression from fast fast walking, walking, to a trot an d then a r un is usually usually successf successful. ul. T he trea dmill can be useful useful to progress the patient to higher speeds. speeds. T he tr ansfemoral-l ansfemoral-lev evel el amputee requires increased training to achieve achieve runnin g. For
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them the appropriate components such as cadence-responsive knees are vital to achieve a step-over-step running pattern. Without Without a cadence-res cadence-responsi ponsive ve knee knee unit, the patient has to wait for for the shank of the prosthesis prosthesis to come come forward, resulting resulting in in an extra hop on the sound limb. limb. Training techniques for the transfemoral running gait often begin with weight-bear weight-bear ing activities, activities, balance activities, activities, and exercise exercise to improve pelvic pelvic and hip con trol. Initially there is an empha sis sis on hopping and jumping, to increase increase tolerance to increased forces translated to the residual limb. Fast walking and ambulating with an exaggerated step length and then a progression to jogging or running can occur. Again, once patients have have achieved achieved limited limited success success at a step-over-s step-over-step tep running pattern , running on a treadmill at gradually higher speeds can help to increase their cadence (59).
COMMUNI COMMUNITY TY REINTE REI NTEG GRATI RATIO ON While many amput ees simply simply say say,, “I want to walk again,” ambulation ambulation is only a portion of comprehensiv comprehensivee rehabilitation. tion. The goals goals of of a thorough thorough rehabilitati rehabilitation on program include helping the patient resume previous roles in the “family “family”” and community. T he entire rehabilitation rehabilitation team should help identify the pa tient’s goals and r oles. oles. Each patient may not “open up” equally equally to all team members. members. The patient often has difficulty communicating because fear, fear, anger, anger, and depression depression dominate the thoughts thoughts in the days, days, weeks weeks, and even month s follow following ing ampu tation (3,12–17,19). Several questions can help clarify the patient’s previous role in in the family or social social network. network. What was the person’s person’s level level of indepen dence? Was Was the patient the primary homemaker homemaker or “breadwinner” “breadwinner” in the family family?? If so, so, then who (if (if anyone) has taken on these roles during the patient’s illness? Does the patient expect to return to these roles? roles? Is the patient a spouse spouse,, parent, child, child, or other member of the family family unit? Was Was the patient a caregiv caregiver or a care recipient prior to the amputation? Does the amputation change change this role? If so, so, how? It may be difficult to anticipate how the patient and the family family will will adapt to the a mputee’s mputee’s return. T here is often often a confusi confusing ng mixture of expectations expectations on the part of each. T he patient generally generally wants wants to get “back to normal” but may find it quite difficult. difficult. He or she may be expecting some assistance, assistance, but resenting assistan assistan ce when it is provided. vided. Members of the family family may want want to a ssis ssistt but not know how much or how little assistance is needed or welcomed. In general, an awkward awkward situation situation frequently exis exists ts until communication, communication, education, and experience experience occur. occur. It is is useful useful for for members of the rehabilitation rehabilitation team to meet with the patient and family, individually and together, to facilifacilitate resolution resolution of these issues issues.. Long-term Long-term counseli counseling ng may be needed as the patient and family adjust. Discussing Discussing the
Medica ical Rehabilit ilitaatio tion for for Dia Diaggnostic tic Grou roups
importance of previous previous family family roles and h ow the amputation may have changed t hese roles is helpful. helpful. T his will will help the patient and family reach decisions regarding which roles are most important and which may be abandoned or modified (18). The new amputee’s role in the community should be similarly similarly examined. Was the patient an active participant in community events? Was he or she a passive spectator? Was he uninvolved? How does the amputation affect the person’s participation in community outings such as shopping trips, trips, trips to restaurants, restaurants, or trips to the movies movies or theater? The previously active patient may find it difficult to resume these activities, activities, for physical physical reasons or because of selfself-conscious conscious feelings feelings.. T hera peutic outings with members of the rehabilitation rehabilitation team to restaurants, restaurants, malls, malls, or movie theaters can help desensitize the patient to these awkward awkward feelings and facilitate resumption of these activities. ties. Frequently Frequently, the patient must learn to be more aggresaggressive sive or assertive assertive to make use of progra ms or facilities facilities not obviously obviously available. available. T his may be quite difficult difficult for a per son who is nor mally shy shy or passiv passive. e. T he patien t should also be educated about community programs and resources that may facilitate participation by people with disabilities (60,61). Returning to driving plays a significant role in many patients’ patients’ resuming resuming normal activities activities.. Frequently, a minor modification or no modification to the vehicle is required for for th e amputee to resume driving driving.. Without Without relying on other s for for mobility, mobility, the amp utee’s utee’s indep indep endence grows.
SPECIAL SPECI AL CONSI CONSI DERATI DERATIO ONS FOR THE COMPLEX COMPLEX AMPUTEE AND THE PATIENT PATI ENT WITH DUAL DISABILITY It is increasingly common in the rehabilitation population to encounter patients with dual disability such as hemiplegia and limb loss loss,, blindness and limb loss, loss, and multiple limb loss. loss. Each individual disability can be cat astrophic on its own; the dua l disability disability may be even even more so, so, resulting in long-term long-term placement of the patient in a nursing home. With the appropriate interventions and social support systems systems,, many patients with dual disability disability can can ret urn to their home environment. environment. A rehabilitated rehabilitated limb limb after amputation prior to th e onset of hemiparesis hemiparesis from from stroke stroke has a better functional functional outcome than if the stroke stroke had preceded the ampu tation (62). (62). A right hemipar esis esis or an ipsilatera ipsilatera l hemiplegia and limb loss also have a better prognosis, compared with a left hemiparesis or limb loss contralateral to the hemiplegia. Clear simple step-by-step instructions and a modified prosthesis are very useful useful for these patients. For th e blind patient, sensory sensory input using using raised markings, markings, Velcro closures, sures, and step-by-step step-by-step sequencing is useful. useful. A cane cane should be used whenever possible to provide protective auditory
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and ta ctile ctile feedback feedback to the patient. Appropriate home envienvironment modifications should be carried out. Fifty Fifty percent of patient s who have have had a lower-limb lower-limb amputation due to disease are at risk for a second amputation within within 3 years. years. If no other concurrent disabili disabilities ties occur, occur, the patient with a second transtibial transtibial amputation should achieve achieve a level level of independ ence similar similar to that attained prior to the second second amputation. Th e heights heights of the prostheses are routinely decreased to improve balance and possibly decrease the energy required to maintain standing balance. For patients with bilateral transfemoral amputation, there is a signifi significant cant increa se in in energy consumption, estimated at over 100% (63) (63),, that m ay prevent long-distance long-distance ambulation. ambulation. In general, general, most most transfemoral transfemoral bilateral bilateral amputees over 50 years old will find the wheelchair an easier easier and more practical practical means of of locomotion. locomotion. AmbulaAmbulation should be attempted only when adequate cardiac function, unction, strength, trength, balance, balance, and endurance exis exist; t; the use use of multiaxis ankle-feet systems with lower height and weightactivated knee-locking mechanisms should facilitate facilitate the patient’s ability to ambulate (64). (64). T he clinician can avoid unnecessary expenditures of resources in the geriatric population by careful selection selection of potentia lly functional ambulation candidates who have had bilateral transfemoral amput ations (65). 65).
Bilateral Amputation Intu itively itively ambulation with bilatera l lower-limb lower-limb loss should should be much more difficult than with single lower-limb loss. The limited data available support this thesis (65,66–69), but many bilateral bilateral amputees ambulate nonetheless, nonetheless, with varying degrees of proficiency. For all these individuals individuals,, there should be a long discussion on the difficulties they face, the r isks isks (including falls falls and increased car diac deman d), and rea listic listic goals goals before prosthetic prosthetic fabrication commences. Many bilateral t ran stibial-lev stibial-level el amp utees will achieve achieve independ ence in ambulation with pr ostheses (Fig. Fig. 93-5). 93-5). Several prosthetic modifications can be performed to make ambulation with bilateral transtibial prostheses less difficult. Although Although some some patients may object, object, shortening shortening the prostheses by 1 or 2 inches lowers lowers the center of gravity and can improve balance and decrease energy consumption tion during standing and ambulatio ambulation. n. Of course course,, the height height can be restored later later if the patient so choos chooses es,, and if walking skills skills have progr essed satisfactor satisfactor ily. By out-setting out -setting the feet, feet, the base of support is is widened widened and balance is also also enhan ced (Fig (Fig.. 93-6). 93-6). Flexing the sockets sockets or dorsiflexing dorsiflexing the feet promotes a forward lean and slightly crouched posture, which also gives gives most bilatera l tra nstibial-level nstibial-level amputees a sense sense of improved stability. Using art iculated single-axi single-axiss feet rather than fixed ankles may also improve balance and ambulation by reducing the knee flexion moment during the loading loading response response.. During normal gait, gait, in the earlyearlystance phase (initial (initial contact and loading response), response), the
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ground rea ction force force falls falls behind th e ankle, generating a planta rflexion moment (70). (70). T his planta rflexion is controlled troll ed by the a ctiv ctivity ity of the pretibial muscles muscles,, allo allowi wing ng the foot to gradually descend descend to the floo floorr. T he ground reaction force lies lies behind t he knee as well, well, requiring th e knee extensors so rs to preve prevent nt buckling buckling of of the knee. knee. T he magnitude of the knee flexion moment increases with the perpendicular distance between the ground reaction force and the knee
Figure 93-5. Bilateral transtibial amputee with prosthesis (digital image).
joint center (71). (71). For the t ran stibialstibial-lev level el amputee whose prosthesis has a fixed fixed ankle, the groun d reaction force is located farther behind the knee and remains there for a longer long er period of time. T his generates a more signifi significant cant flexio fle xion n moment. When an articulated ankle ankle is is used, used, the prosthetic foot plantarflexes to a foot-flat posture promptly after initial initial contact. T his move movess the ground reaction force farther anterior, anterior, reducing the distance distance to the knee center and reducing the magnitude magnitude and duration of the flexion flexion moment. Most patients patients wil willl appreciate the flexi flexibili bility ty of the articulated articulate d ankle, but others may find the ankle motion a source so urce of ins instabili tability ty and increased increased weight. weight. Some patients patients report that the solid solid ankle of a SACH (soli (solid-ankl d-anklee cushion-heel) foot or most energy-storing feet feels more firm and stable, stable, and therefore, therefore, more comfortable. comfortable. T he bilateral amputee who has had one tr ansti anstibial bial and one transfemoral amputation can benefit from some of the modifications indicated above. Widening the base of support, mov moving ing the center center of mass fo forward, rward, and lowe lowering ring the center of mass can be helpful. helpful. Arti Articulated culated ankles ankles should also also enhan ce stand stand ing and walking walking stability stability.. T he desig des ign n of the knee on the tran sf sfemoral emoral amputation side side should shoul d be chosen chosen carefull carefully y. If stabi stabili lity ty is a great concern, a simple lightweight manual-lock knee removes the risk of knee buckl buckling ing.. T he data are limited, and studies have yielded conflicting conclusions about the energy costs of ambulation with a locked or swinging prosthetic knee. Traugh et al (72) found no significant difference in the energy cos costt of ambulatio ambulation n using a locked locked compared to an unlocked knee. Isako Isakov v et al (73) (73) found that a mbulation with a locked locked knee is more energy efficient. efficient. Mean whil whilee many patients pref prefer er an unlock unlocked ed knee because because of the more natural-appearing gait and improved ability to transfer.. A weight-activated fer weight-activated or p oly olycentric centric knee allows flexion flexion during the swing phase but still resists knee flexion during stance. A hydrau hydrau lic or pneum atic knee will will provide a more
Figure 93-6. Alignment modifications to improve the base of support for bilateral amputees, outset foot.
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physiologi physiologicc function for the vigorous, vigorous, high-activity-lev high-activity-level el patient, but its use use in the geriatric geriatric population population may be limited by weight and cost. Many patients who have had transtibial and transfemoral amputations use the prosthesis on a limited basis, in the home or for social social events, events, and ma y use use altern ative means of mobility mobility such such as a wheelc wheelchair hair most of the time. Other patients may use only a single prosthesis (usually the tran stibial) for tran sfers, sfers, standing, and limited swingswingthrough am bulation. For many individuals with signifi significant cant cardiac or muscle muscle strength strength limitations limitations or contractures, no prostheses or only a transtibial prosthesis may be the best alternative for transfers. Few Few bilatera l tr ansfemoral-level ansfemoral-level amputees will be functional long-distance long-distance ambulators, although many will will achieve limited independence in ambulation with prostheses. ses. T he energy required for the bilatera bilatera l transfemoral-level transfemoral-level amput ee to ambulate is simply simply too great (67,69) (67,69).. T he modifications mentioned earlier can be utilized to make ambulation less difficult. difficult. Some patient s may initially use “stubbies,” “stubbies,” short nona rticulated limbs with with broad feet (74) (74),, and then graduate to taller limbs limbs with with knees. knees. Th e choice choice of knees should should be ma de after considering stability, safety safety,, weig weight, ht, cost, cost, and a ctivity ctivity lev level. el. As with with th e transtibialtranstibialtransfemoral transfemoral amputee population, population, many bilateral bilateral tran sfemoral-lev sfemoral-level el amp utees choose wheelchair mob ility with no prostheses because of simplicity simplicity, energy efficiency efficiency, and comfort. Several factors are relative contraindications to prescribing prostheses for the bilateral lower-limb amputee. Th ese ese include lack of motivation, motivation, signifi significant cant cognitive cognitive impairment, seve severe re cardiac disease, disease, seve severe re contractures, contractures, and severe severe neurologic impair ment (75) (75).. T he degree of cardiac compromise a patient can tolerate while walking with bilateral prostheses is unclear. unclear. An ejection fraction fraction of 20% may be chosen chosen as an arbitrar y cutoff cutoff, but no hard data exist to substantiat substantiat e this. Prosthetic ambulation is pospossible sible in the setting setting of significant significant cardiac compromise because amputees adjust their walking speed to keep relative energy deman ds at a man ageable level level (76) (76).. Patients must participate in this decision-making process and should should understand the rationale behind the decision. decision. T hey should never feel that they were not given the opportunity to walk with prostheses “just because the doctor said I couldn’ couldn’t.” t.” When patients are presented presented with appropriate information information regarding the risks risks and advantages of ambulation, and are provided provided with with an accurate accurate idea of what ambulation with bilatera l prostheses prostheses will will be like, like, they are generally able to reach rational decisions. T he sequence sequence of amputations is is thought thought to have an impact on future bilateral prosthetic ambulation (75). People who are able to ambulate with a transfemoral prosthesis are likely to be able to achieve bilateral prosthetic ambulation after a subsequent transtibial amputation. However, However, the tra nstibial prosthetic prosthetic user who has a subsequent contralateral transfemoral amputation may have a
Chapter ter 93 93
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more difficult difficult time achieving ambulator y status followi following ng the second amputation. T he issue issue of rehabilitation rehabilitation for for bilateral amputees has become increasi increasingly ngly important important as the prevalence of bilateral lower-limb amputations rises and resources become scarcer scarcer.. Kerstein Kerstein et al (77) (77) in 1974 noted that 23% of their amputee rehabilitation population were bilateral amputees. Esquenazi et al (26) in 1984 reported an increasing number of amputees readmitted readmitted for bilateral bilateral prosthetic prosthetic training. training. Nondiabetic patients patients who who undergo an amputation for ischemia have a 5% to 13% risk at 1 year and 28% risk at 5 years years for for contra lateral amput ation (78,79) (78,79).. For the diabetic population, population, the risk is is higher higher,, approximately approximately 50% 50% at 3 years (80).
The Blind Amputee Since many amputees are diabetic with an increased incidence of retinopat hy (81), 81), they will will frequently develop develop comorbidity comorbidity of blindness blindness or visual visual impairment. Patients Patients who recently became blind should receive a program of instruction in compensatory techniques related to their new-onse new-onsett blindness blindness, to complement the amputa tion rehabilitation. bilitation. More often, often, patients have had long-s long-standing tanding blindness. blindness. T hese patients should use tactile clues to allow them to manage their prostheses approp riately. riately. Most people can identify sock ply simply by feeling the different thicknesses thicknesses,, so this is usually usually not a n issue. issue. However, However, donnin g the prosthetic prosthetic device with the correct orientation can be diffic difficult. ult. When this is a problem, tactile cues such such as bumps or ridges should should be placed on the socket or the insert to give the patient a reference point for donn ing. ing. Also Also the suspension suspension straps may require alter native fasteners fasteners such such as those made of Velcro, to make them easier easier to mana ge. ge. T he blind patient should should be instructed instructed to inspect inspect the skin skin of the RL a nd intact foot by feeli feeling ng for wounds, wounds, abrasions, abrasions, skin skin irregularities irregularities,, or changes in temperature. If the patient patient has neuropathies that d ecrease ecrease the sensati sensation on in the ha nds, a caregiver caregiver should be instructed in assisting patient with skin inspection and prosthetic management (82). T he rehabilitation rehabilitation of the blind amputee should should also also address the environment. environment. Ambulation Ambulation with the appropriate cane for protective sensory and auditory feedback is taught. If the patient needs to use use the upper limbs limbs for support and balance, then it may be necessary necessary to recomrecommend walking with a companion who can serve as a guide. Of course, course, a home asses assessme sment nt should should be performed before before discharge discharge of the person who who is blind blind and h as had an amputation. Modifications Modifications to the home environment environment can promote independence and improve safety.
Hemiplegic Amputee As the elderly population increases and survival after stroke and a mputation improve, improve, we can expect expect to see more patients with generalized vasculopathy who have simultaneous vasc vascular-rel ular-related ated disabilitie disabilitiess. In addition, many
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patient s survive survive high-impact collisions collisions with with r esulting head injuries injuries and amputations. amputations. T he dual disabili disabilities ties of hemiparesis and limb loss loss present a spectrum of problems (62,83). 62,83). T he chara cteristics that complicate or simplify simplify the rehabilitation process for a patient with these two disabilities are similar to the exacerbating and mitigating factors for the individual disabilities disabilities.. For example, the rehabilitation rehabilitation of a patient after a transfemoral transfemoral amputation would generally be more difficult than after a transtibial amputation, and the rehabilitation rehabilitation of a patient with with sev severe ere hemiplegia with neglect and cognitive impairment would be more diffic difficult ult than that of a patient with with mild pure motor motor hemiparesis hemiparesis.. The sequence equence of the onset onset of disabil disabiliities and the location (ipsilateral or contralateral) also influence the rehabilitation rehabilitation outcome. T he individuals individuals who who first undergo an amputation and then later sustain a stroke generally achieve better functional status than do those who first are afflicted afflicted by the n eurologic event event (61). (61). Ipsilateral involvement also suggests better outcome than contralateral involv involvement. ement. In general, patients with with right-sided right-sided hemiparesis tend to have a better functional outcome than do those with left-sided left-sided neur ological ological residual. As one would expect, expect, younger patients with with these dual disabilities disabilities generally attain better functional outcomes than older patients. The patient who is ambulatory after a lower-limb amputation and subsequently has a stroke with ipsilateral weakness can often regain independent ambulatory status, unless the stroke is very severe. severe. T he height an d alignment of the prosthesis are adjusted to compensate for for strokeinduced gait deviations where possible. possible. Shorten ing the prosthesis may improve swing-phase swing-phase cleara nce problems. Increased prosthetic ankle plantarflexion can assist weak knee extensors by providing mechanical stability to the knee joint joint during the stance phase. When flexor flexor tone interferes with knee knee stability, the use of a thigh corset with with external knee knee joints joints may be of benefit. Th e orthotic knee joints may be offset or single axis and equipped with drop locks locks to enhan ce stability stability during the stance stance pha se. se. Widening the base base of support by “outsetting” “outsetting” the prosthetic prosthetic foot foot reduces balance problems. For the pa tient with severe severe hip adductor tone, the use of interventions interventions to decrease decrease spasticspasticity focall focally y, such such as phenol block of of the obturator nerve or surgical interventions (obturator neurectomy or adductor tenotomy), should be considered. considered. When necessary markings are placed on the prosthesis sis, the suspensi suspension on straps, straps, and even the socks socks,, to make the task of donning the prosthesis prosthesis a more structured process process that can be made routine by a patient with cognitive deficits. deficits. Patients with significant significant upp er-limb involv involvement ement will need to learn one-handed prosthetic management techniques. techniques. For th e tra nstibialnstibial-lev level el amputee, certain devices can be used to achieve achieve one-hand ed donning, such as neoprene, neoprene, spandex, or silic silicone one sleev sleeves es,, which which can be rolled on with with one hand . For the tra nsfemoral-lev nsfemoral-level el amputee, the prosthesi prosthesiss, because because of its size size and weig weight, ht,
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may be diffic difficult ult to manage. In this situation, situation, use of the TC -3 (84) (84) socket, socket, developed developed at t he Tokyo Tokyo Metropolitan Rehabilitation Rehabilitation Center in Japan, Japan, permits the patient patient to han dle the socket socket with the suspension suspension sys system tem of choice, separate from the prosthesis prosthesis. T his option provides provides the patient with with the a dvantage of handling a smaller smaller sectio section n of the prosthesis prosthesis,, with with decreased decreased bulk and weight. weight. T hen the socket is inserted into a thin receptacle and attached with a Velcro elcro strap. In add ition, ition, this sys system tem permits donning and doffing in the seating position. Similar prosthetic adjustments improve the functional mobility of a person with a preexisting preexisting hemiplegia and new ipsil ipsilateral ateral limb loss loss. Learning new concepts of prosthetic management such as donning and doffing the limb or adjusting the number of stump socks socks used may be diffidifficult if the new amputee has preexisting preexisting cortical dysf dysfuncunction. For the nona mbulatory patient patient after a stroke stroke and amput ation, independ ence in transfers should still still be possipossible, ble, as the “intact” side side should should provide provide adequate strength and stability for standing and pivoting. Contralateral hemiplegia hemiplegia and amputation pose more diffic difficult ult problems. problems. Th e severity severity of the stroke stroke and the level level of amputation determine which will will be the patient’s patient’s domidominan t leg and whether future ambulation is likely likely. For the transtibial-level amputee with contralateral hemiparesis, ambulation with an assistiv assistivee device should b e possible possible unless the stroke is very severe. severe. Even with severe stroke stroke sequelae, the p atient will likely likely benefit from a prosthesis for standing and transfers transfers.. If the amputation is is at the transfemoral level, level, then a mbulation will be quite difficult or impossible impossible unless the stroke is mild. mild. For m any such patients, prosthetic fabricat fabricat ion is is not indicated.
LONG LONG- TERM TERM FO FOLLOWLLOW- UP Long-term follow-up follow-up of the ampu tee involv involves es not only prosthetic mainten ance an d skin skin checks, checks, but also psychosopsychosocial rehabilitation and wellness wellness behavior. behavior. For many amput ees, ees, the physiatrist is viewed viewed as the prima ry physiphysician, perha ps because the physiatrist physiatrist sees sees the amput ation as the most important health and medical issue in their lives. lives. T hus, the physiatrist physiatrist is likely likely to confront many health-related issues besides those associated with the RL or the prosthesis. Dur ing a follow follow-up -up visit, visit, the pa tient’s prosthetic usage is discuss discussed. ed. Is the prosthesis worn d aily? All All day long? long? If not, are there problems problems with with comfort comfort that need to be addressed? addressed? If the prosthesis prosthesis is is not incorporated into the normal daily routine of the patient, it will will alway alwayss be view viewed ed as heavy, clumsy clumsy, abnorma l, and diffic difficult ult to manage, despite despite hours of of adjustments adjustments by the prosthetist prosthetist and physician. It is appropr iate to r eview eview the pat ient’s ient’s lifes lifestyle tyle.. Does he or she leave leave the home for shopping, shopping, recreation, recreation, social social-ization, or work? People may choose choose to stay stay at home for
Medica ical Rehabilit ilitaatio tion for for Dia Diaggnostic tic Grou roups
diffe different rent reasons reasons.. However However,, if architectural architectural barriers or mobility mobility dysf dysfunction unction are the cause, cause, then the patient may benefit from from the physician’ physician’ss intervention. Furth er outpatient therapies to address mobility on stairs or other obstacles cles may be appropriate. appropriate. Ramps, rails, rails, stair stair glide glidess, or other equipment may free the patient from unnecessary confinement. If the patient stays stays at home for for medical medical or psy psychological logical reasons reasons,, then further evaluation evaluation and treatment of those specific problems may be necessary. T he fit and condition condition of the prosthesi prosthesiss warrant periodic eval evaluation. uation. Over time, time, repairs to the components of the prosthesis are necessary. necessary. Cha nges in in the size and shape of the RL require that a new sock socket et be made periodically periodically (85,86). 85,86). Cha nges in the pat ient’s ient’s condition will will often dictate changes in the prosthetic prescription. prescription. For example, the tran stibial-lev stibial-level el ampu tee with with a patellar tendon–bearing socket and elastic sleeve suspension may develop degenerative changes in the knee and may benefit from from the addition of a thigh corset corset and mechanical knee knee joints for pressure pressure relief and additiona l stability. While may amputees are resistant to changes in their prostheses, newer materials or components may prove advantageous. The physiatrist will need to educate the patient about the potentia l benefits of new technology technology.. Routine skin skin care needs to be reviewed. reviewed. T he patient is reminded of the importance importance of good hygie hygiene. ne. Skin Skin irriirritation and breakdown may result from poor cleaning techniques. niques. For the diabetic patient in particular, particular, meticulous meticulous skin skin care is imperative. T he patient is reminded to clean the skin gently with mild soap and warm water and to blot the skin skin dry, dry, including including between between the toes of the intact foot. foot. A skin moisturizer helps to keep the skin soft and supple, avoidi avoiding ng dryness, dryness, cracking cracking,, and fissures fissures,, which which may lead to superficial infection. Lamb’s wool placed between the t oes helps avoid avoid maceration maceration and “kiss “kissing” ing” ulcers. ulcers. T he patient is taught to avoid avoid any potential trauma to the feet, feet, including including ther mal injury. injury. Cold feet deserve deserve war war m socks socks rath er than a burn from from a heating pad or hot water bottle. Socks Socks should should be worn with footwear, footwear, and walking walking barefoot is forbidden. Th e patient should check check shoes shoes before before putting them on. At
least one person required a transtibial amputation for a foot infection that began with an ulcer caused by walking with a coin in their shoe (87,88). The routine follow-up visit is also the time to review health maintenance behavior behavior.. Cessation Cessation of smoki smoking ng is an important topic for for many amputees. Most people people are aware that smoking leads to cardiac and pulmonary problems, lems, but many are unaware th at smoking smoking increases the risk risk for for limb ischemia ischemia and amputa tion. Th e patient with lower-limb lower-limb ischemia ischemia and claudication would likely likely benefit from a regular exercise exercise progra m (89). (89). T he follow-up follow-up visit visit is the time to introduce, clarify, or reinforce such an exercise exercise regimen. regimen. T he patient may also also benefit from counseli counseling ng regarding nutrition nutrition and proper body weig weight. ht. While While exercise cise and diet are importa nt for all, all, it is beneficial to remind the diabetic patient that diet and exercise are the mainstays of therapy for for diabetes. diabetes. Th e patient patient may also also need reminder s regarding blood pressure pressure checks, checks, cholesterol cholesterol monitoring, monitoring, flu vaccinati vaccinations ons,, and general medical medical follow-up. Finally, the rout ine check-up is a good time to remind the patient of his or her achievements achievements and to discus discusss new goals goals.. Absorbed Absorbed in t he daily routine, routine, the amputee may lose lose sight sight of the fact that h e or she overcame overcame signific significant ant t raum a. Positiv Positivee feedback is very therapeut ic. The clinician may want to suggest new activities such as cycli cycling ng or swimming swimming.. Of course, course, rehabilitation rehabilitation professi professiononals need need not be reminded that the truly rehabilitated rehabilitated amputee does much more than simply walk.
CONCLUSIONS CONCLUSIONS Comprehensive Comprehensive rehabilitation rehabilitation of the amputee should be more than the provis provision ion of a prosthetic prosthetic device device.. T his is especially true for the geriatric amputee whose needs are greater because because of comorbidity comorbidity,, fragile fragile social social supports, supports, and limited limited resources resources.. For the young, young, active active patient, optimizaoptimization of the prosthetic prosthetic device device and appropriate rehabilitation rehabilitation are necessary to preserve the patient in good health.
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