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Rehabilitation After Limb Amputation

by Alex Moroz, MD, FACP

Before surgery, a surgeon, prosthetist, and physical therapist discuss plans and goals with the person who requires amputation. A prosthetist is an expert who fits, builds, and adjusts artificial limbs (prostheses) and provides advice about how to use them. The exercises used in rehabilitation may be started before the amputation.

A prosthesis for a limb (arm or leg) consists of a socket in a rigid frame (interface), components, and a cover. The interface enables the prosthesis to be attached to the body. Components include terminal devices (such as artificial hands, feet, fingers, or toes) and artificial joints (see Limb Prosthetics).

Arm (upper-limb) amputation

Most arm amputations result from occupational injuries. Rarely, all or part of an arm is removed surgically to treat a disorder (such as cancer). The arm can be amputated below the elbow, above the elbow, or at the shoulder. Or a hand or one or more figures can be amputated.

After arm amputation, most people are fitted for an artificial arm (an upper-limb prosthesis). Components may include fingers, a hook or hand, a wrist unit, and, for an above-the-elbow amputation, an elbow unit. Movement of the hook or hand is controlled by movement of the shoulder muscles. A hook may be more functional, but most people prefer the way a hand looks. Control of an above-the-elbow prosthesis is more complicated than that of a below-the-elbow prosthesis. Newer prostheses that are controlled by microprocessors and powered myoelectrically (using energy produced by the person’s muscles) have been developed, enabling the person to control movements with more precision. Bionic components, which are just now becoming available, may enable people to function even better.

Rehabilitation includes general conditioning exercises and exercises to stretch the shoulder and elbow and to strengthen arm muscles. Endurance exercises may also be necessary. The specific exercise program prescribed depends on whether one or both arms were amputated and how much of the arm was amputated. People learn how to do activities of daily living using the prosthesis, adaptive devices, or other parts of the body (such as the mouth and feet).

Did You Know...

  • People who have lost a limb may choose artificial limbs with microprocessors or bionic parts that provide more precise control of movements.

Leg (lower-limb) amputation

These amputations result almost equally from an injury (as in a motor vehicle crash or during combat) or from a surgical procedure to treat a complication of a disorder (such as decreased circulation due to atherosclerosis or diabetes). The leg can be amputated below the knee, above the knee, or at the hip. Or a foot or one or more toes may be amputated.

After leg amputation, most people are fitted for an artificial leg (a lower-limb prosthesis). Components may include toes, a foot, and, for an above-the-knee amputation, a knee unit. Newer prostheses that are controlled by microprocessors and powered myoelectrically or prostheses with bionic components enable people to control movements with more precision.

Rehabilitation includes exercises for general conditioning and exercises to stretch the hip and knee and to strengthen all arm and leg muscles. The person is encouraged to begin standing and balancing exercises with parallel bars as soon as possible. Endurance exercises may be needed. The specific program prescribed depends on whether one or both legs were amputated and how much of the leg was amputated.

The muscles near the amputated limb or at the hip or knee joint tend to shorten. This shortening (called contractures) usually results from sitting in a chair or wheelchair for a long time or from lying in bed with the body out of alignment. Contractures limit the range of motion. If a contracture is severe, a prosthesis may not fit correctly, or the person may become unable to use the prosthesis. Therapists or nurses teach the person ways to prevent contractures.

Therapists help people learn how to condition the stump, which promotes the natural process of shrinking. The stump must shrink before a prosthesis is fitted. An elastic shrinker or bandages worn 24 hours a day can help shape the stump and prevent fluid buildup in tissues. Soon after the amputation, people may be given a temporary prosthesis so that they may begin walking sooner and thus help the stump shrink. With a temporary prosthesis, people can start ambulation exercises on parallel bars and progress to walking with crutches or a cane until a permanent prosthesis is made. Sometimes people use a prosthesis with permanent components but with a temporary socket and frame. Because some parts remain the same, people may adjust to the new parts more quickly.

If a permanent prosthesis is made before the stump stops shrinking, adjustments may be needed to make it comfortable and to enable people to walk well. A permanent prosthesis is usually made several weeks after amputation to give the stump time to shrink completely.

When people receive the prosthesis, they are taught the basics of using it:

  • How to put the prosthesis on

  • How to take it off

  • How to walk with it

  • How to care for the prosthesis and the skin of the stump

Training is usually continued, preferably by a team of specialists. A physical therapist develops a program of exercises to improve strength, balance, flexibility, and cardiovascular fitness. The therapist teaches people more about how to walk with a prosthesis. Walking begins with direct assistance and progresses to walking with a walker, then with a cane. Within a few weeks, many people walk without a cane. The therapist teaches them to use stairs, walk up and down hills, and cross other uneven surfaces. Younger people may be taught to run and participate in athletic activities. Progress is slower and more limited for people who have above-the-knee amputation, for older people, and for people who are weak or poorly motivated.

The prosthesis needed for an above-the-knee amputation weighs much more than that for a below-the-knee amputation, and controlling a prosthetic knee joint requires skill. Walking requires 10 to 40% more energy after a below-the-knee amputation and 60 to 100% more energy after an above-the-knee amputation.

Care of the stump

People must learn to care for their stump.

Because a leg prosthesis is intended only for walking, people should remove it before going to sleep. At bedtime, the stump should be inspected thoroughly (with a mirror if the person is inspecting it), washed with mild soap and warm water, dried thoroughly, then dusted with talcum powder.

If certain problems occur, people should treat the problem:

  • Dry skin: Apply lanolin or petrolatum to the stump

  • Excessive sweating: Apply an unscented antiperspirant

  • Inflamed skin: Remove the irritant immediately, and apply talcum powder or a low-potency corticosteroid cream or ointment

  • Broken skin: Not wear the prosthesis until the wound has healed and see a doctor

A sock and/or liner is worn between the prosthesis and the skin. The sock and liner should be washed every day, and mild soap may be used to clean the inside of the socket.

Prostheses are usually not water-proof. If any part of the prosthesis becomes wet, it must be dried immediately and thoroughly. But heat should not be used to try to dry it. If people swim or prefer to shower with a prosthesis on, they can get a prosthesis that can be immersed.

Pain

After an arm or a leg amputation, people may feel pain that seems to be in amputated limb (phantom pain—see Stump Pain). The pain is real, but the location is wrong. Phantom pain is more likely if pain before amputation was severe or lasted a long time. Phantom pain is often more severe soon after the amputation, then decreases over time. For many people, phantom pain is more common when the prosthesis is not being worn (for example, during the night). If a spinal anesthetic and a general anesthetic are used during surgery, the risk of having this pain is reduced.

Some people experience phantom limb sensation, which is not painful but feels as if the amputated limb is still there. When people with an amputated leg have this sensation, they may stand up (and thus fall back down). This experience usually occurs at night when people wake to use the bathroom. Phantom limb sensation is more common than phantom pain.

The stump itself may be painful. Massaging the stump sometimes helps relieve this pain. The pain may be due to infection or wearing away of the skin (skin breakdown). In such cases, people may need to see a doctor.

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