Amputation

Jen Thompson, MS, OTR/L and Marissa Rewak, DPT, PT

Helpful definitions

• Acquired amputation: limb loss that occurs after birth
• Residual limb: the remainder of the amputated limb
• Sound limb:  the patient’s intact limb, or non-amputated limb 
• BKA: below knee amputee
• AKA: above knee amputee
• Desensitization: tactile techniques to retrain the brain to correctly identify the patient’s new body habitus
• Phantom pain: improperly directed pain signals to the limb that has been lost/amputated.
• Phantom sensation: sensation in the limb that has been lost/amputated.

Levels of Amputation:  

https://www.physio-pedia.com/Amputations

Things to be aware of before treatment:

Perform a thorough chart review, including orders from MD and surgeon.

• Comorbidities and other pre-existing medical conditions that may impact patient care and approach.
• Weight bearing restrictions
• Consider other precautions if the patient has polytrauma
• Other things to be aware of: lines, drains, tubing, IVs, etc.

Areas to assess on evaluation:

• Pain
• Cognition/ ability to follow directions
• Safety awareness, insight, judgment and impulsivity – this is so important as patients may “feel” that their limb is intact which may lead the patient to attempting to transfer on their own…leads to falls!!
• Skin integrity
• Range of motion and manual muscle testing
• Hand strength, dexterity and coordination
• Proprioception
• Sensation
• Vision
• Vitals management

Self-Care areas to assess 

• Grooming
• Feeding 
• Bathing 
• Dressing
• Toileting

Areas of mobility to assess:

• Bed mobility
• Surface to surface transfer
• Sit to stand transfer 
• Ambulation
• Stair mobility
• Wheelchair mobility
• Balance

Additional Factors impacting residual limb healing:

• Consider the patient’s mental health, body image/ self- awareness, support system and willingness to look at their residual limb throughout evaluation. Continue these assessments throughout patient treatment
• Evaluate the patient’s social network- can get the patient connected with peers and soldiers undergoing a similar limb loss recovery and rehabilitation process. Don’t underestimate the power of peer support … we know a lot as clinicians but if we have not experienced limb loss ourselves, we do not truly understand the patient’s experience.
  • Assess patient’s ability to assist in residual limb wrapping and monitoring their own skin with mirror or using phone for photo diary.

• Comorbidities:
  • Vascular conditions including diabetes and peripheral vascular disease- decreased blood flow to extremities increases healing time.
  • Polytrauma
  • Mental health considerations – PTSD, anxiety, depression, sleep difficulties
  • Pressure sores or wounds
• Cognition
  • Can patient follow directions for positioning of residual limb, limb wrapping, desensitization strategies, weightshifting for pressure relief?
    • See resources re: TBI and cognition 
  • Impulsivity

References:

Author Unknown. Mmlearn.org. Adaptive Equipment and Exercises for daily living. Retrieved on 1/12/2021 from https://www.youtube.com/watch?v=zMBe4THillc

Borokosky, S.L., & Roukis, T.S. (2012). Incindence of re-amputation following partial first ray amputation associated with diabetes mellitus and peripheral sensory neuropathy: A systematic review. Journal of Diabetic Foot and Ankle, 3(10). https://www.doi.org/10.3402/dfa.v3i0.12169

Bragaru, M., Dekker, R., Geertzen, J.H.B. et al. (2011).  Amputees and sports: A systematic review. Sports Med, 41 (9), 721-740. ttps://doi.org/10.2165/11590420-000000000-00000

Centers for Disease Control and Prevention. (2015).Osteoarthritis (OA). Retrieved on September 31, 2018 from http://www.cdc.gov/arthritis/basics/osteoarthritis.htm

Coffey, L., O’Keeffe, F., Gallagher, P., Desmond, D., & Lombard-Vance, R. (2012). Cognitive functioning in persons with lower limb amputations: A review. Disability and Rehabilitation, 34 (23), 1950-1964. https://doi.org/10.3109/09638288.2012.667190

Czerniecki, J. M., Turner, A. P., Williams, R. M., Hakimi, K.N., & Norvell, D.C. (2012). The effect of rehabilitation in a comprehensive inpatient rehabilitation unit on mobility outcome after dysvascular lower extremity amputation. Archives of Physical Medicine and Rehabilitation, 93, 1384-1391. https://doi: 10.1016/j.apmr.2012.03.019

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Gillen, G., Berger, S., Lotia, S., Morreale, J., Siber, M., & Trudo, W. (2007). Improving community skills after lower extremity joint replacement. Physical and Occupational Therapy in Geriatrics, 25, 41–54. https://doi: 10.1080/J148v25n04_03

Kashani J.H., Frank, R.G., Kashani S.R., Wonderlich S.A., & Reid J.C. (1983). Depression among amputees. Journal of Clinical Psychiatry, 44, 256-258.

Larner, S., van Ross, E., & Hale, C. 2003. Do psychological measures predict the ability of lower limb amputees to learn to use a prosthesis? Journal of Clinical Rehabilitation, 17(5) 493-498. https://doi.org/10.1191/0269215503cr641oa

Lee, D.J., & Costello, M.C. (2017). The effect of cognitive impairment use in older adults who underwent amputation due to vascular-related etiology: A systematic review of the literature. Prosthetics and Orthotics International, 42(2), 144-152. https://doi.org/ 10.1177/0309364617695883

Lombard-Vance et. al (2018). Comprehensive neuropsychological assessment of cognitive functioning of adults with lower limb amputation in rehabilitation. Archives of Physical Medicine and Rehabilitation, 100 (2), 278-288. doi:  https://doi.org/10.1016/j.apmr.2018.07.436

Spiliotopoulou, G., & Atwal, A. (2012). Is occupational therapy practice for older adults with lower limb amputations evidenced based? A systematic review. Prosthetics and Orthotics International, 36, 7-14. https://doi: 10.1177/0309364611428662 

St. Joseph’s Health Care London. Accessed 12/13/2020.: https://www.youtube.com/watch?v=PHO2cH1BoNs

Wegener, S.T., Mackenzie, E.J., Ephraim, P., Ehde, E., & Williams, R. (2009). Self-management improves outcomes in persons with limb loss. Archives of Physical Medicine and Rehabilitation, 90, 373-380. https://doi.org/10.1016/j.apmr.2008.08.222

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