– by Robert S. Gailey, PhD, PT
Although this article will discuss many factors that are often considered by the rehabilitation team, the majority of issues discussed probably will not pertain to every amputee.
One of the primary concerns is stump swelling. Swelling occurs in the stump in the same way it does around any other lesion or insult to the body. It is one of the body’s defense mechanisms associated with inflammation. The insult to skin, muscle, bone and other tissues results in swelling, pain, redness and loss of function. The body is trying to heal the tissues as quickly as possible, thereby producing a cellular response that far exceeds what is necessary. If ignored, the cellular response will continue to manifest itself and the time required for the swelling to subside will be much greater than it needs to be.
Treatment of the swelling is relatively simple: compression, elevation and activity. Compression is applied in the form of stump wrapping, shrinkers or some other form of pressure garment. The pressure created by compression garments helps move the fluids out of the recovering limb, reduce the pressure on other tissues, and, as a result, reduce pain. One of the key ingredients in successfully reducing swelling as quickly as possible is around-the-clock maintenance of pressure until the volume of fluids within the limb stabilizes. When the pressure garment is removed, however, it takes very little time for some fluids to return to the tissues and undo all the good swelling reduction that was accomplished in the previous days.
Elevating the limb can have a positive effect only if the limb is raised above the heart. Dangling the limb from a chair or long periods of standing can have a negative effect. Conversely, activity can have a very positive effect. Contractions of the muscles help to move the fluids out of the muscle and other surrounding tissues. The time it takes for the swelling to subside varies depending on age, body type and cause of amputation. Younger people will generally heal more quickly.
The suture line or the surgical incision site must heal before casting and fitting a socket. The stresses associated with the pulling and pushing of skin and other soft tissues during walking can easily damage the incision site if not permitted to heal completely. Reducing swelling, keeping the area clean, and following the physician’s directions for dressing care can help speed healing as well. Once again, age, cause of amputation, and associated diagnoses such as diabetes and vascular disease play a significant role in determining the time necessary for healing. Generally most sutures or staples are removed within 10 to 21 days after surgery, depending on the individual.
Other issues regarding the skin also significantly affect a clinician’s postoperative assessment. With age, the skin can become frail and require more time for healing. Traumatic amputations may take longer to close if the threat of infection is present or if skin grafts were used in the course of treatment. Occasionally, skin irritation secondary to medicines, allergic reactions or any other irritations to the skin can prolong the period before a person can be fitted with a prosthesis.
One of the most critical aspects of post-amputation rehabilitation is the prevention of further deconditioning resulting from inactivity. For many people, the time leading up to the amputation is a very sedentary period. Time is spent slowly watching an ulcer heal, and in the physician-prescribed bed rest with limited activity. During this time strength and cardio-vascular endurance diminish. Postoperatively, a good rehabilitation program should include upper and lower limb strengthening in addition to a well-planned cardiovascular program. Just walking with a walker or crutches around the house is frequently not enough to prepare for the demands of prosthetic rehabilitation and ambulation. The metabolic energy requirements of walking with a prosthesis are far greater than during normal walking and, thus, require preparation and training.
For optimal rehabilitation, it is important to consult with a physical therapist and begin an exercise program immediately after surgery. Then continue exercising at home independently or with a family member. This applies to people of all ages and those who lost a limb for any reason.
Other factors that help determine prosthetic candidacy and when a person is ready to begin the fitting process are related to functional potential. The clinician tries to predict what the prosthetic potential of an individual may be. Obviously, current health status and the number of associated diagnoses play a role – but frequently functional ability has a greater impact in the decision process.
The ability to put on and take off the prosthesis is important. This requires a certain degree of strength, balance and hand dexterity. When generalized weakness, poor balance and hand deformities are present, assistance in the home would be required.
The condition of the opposite foot in the case of people who have lost their limb because of vascular disease or diabetes must be monitored very closely. Walking with a walker, crutches and a prosthesis can be very traumatic to the fragile intact foot. In many cases, the question of using a wheelchair versus walking with a prosthesis is discussed when the intact foot is injured or shows signs of an ulcer. The involvement of amputees in their own care plays the most important role in this decision.
People who have lost a limb due to vascular disease or diabetes must be very careful not to injure the remaining foot. All too often, the intact foot is injured or develops an ulcer during the first three years after the initial amputation. The majority of first and second amputations can be prevented by regular clinic visits, wearing good orthopedic shoes, proper foot care and education. Each of these preventative measures is the responsibility of the amputee.
Amputees can do several things to create favorable conditions for an early prosthetic fit. They should learn how to improve their health from the rehabilitation team, how to become more physically fit, and how to take proper care of the healing limb. Regular clinical follow-up is essential, so they should never miss a clinic or doctor’s appointment. By learning about their care and participating in every step of the healing process, including taking prescribed medications, eating correctly, exercising, changing dressings and using the prescribed pressure garment, amputees will increase their readiness for a prosthetic fitting.
The rehabilitation team will determine readiness for a prosthesis based on the amputee’s health status. The team must be assured that the stress of walking with a prosthesis will not cause additional problems that could lead to further health complications. This decision is usually made when the stump is well-healed at the suture line, when there are no other open lesions on the stump or intact foot, and when the swelling has been significantly reduced.
Finally, the level of physical fitness must be determined for selecting the suitable type of prosthetic components. The physically fit who are very active and vary their cadence will need prosthetic components that allow them to change walking speeds and participate in recreational activities. Others who are able to walk about the house or in parts of the community but cannot vary their speed of walking will receive a prosthesis designed for mobility with minimal effort. And for those who, for whatever reason, do not possess the physical ability to walk, a prosthesis may still be considered to help them and their caretaker with transfers or with getting in and out of the various rooms in the house.
The goal of any prosthetic rehabilitation program is to assist the amputee from the time of surgery to successful prosthetic ambulation as quickly as possible and without complication. This is a team effort and requires participation by all the members, including the person who lost the limb. When the rehabilitation team works together, the time to prosthetic fitting can be relatively quick, barring any complications. Rehabilitation begins the day after surgery and for most becomes a part of everyday life. As frustrating as that can be for some, the truth is that the sooner the reality of limb loss is embraced, the sooner an amputee can get back to life. In the words of Dr. Heartsill Wilson, “God has given me this day to use as I will … what I do today is important, because I am exchanging a day of my life for it!”
About the Author:
Robert S. Gailey, PhD, PT, is an assistant professor at the University of Miami School of Medicine, Department of Orthopaedics, Division of Physical Therapy. He has authored over 40 publications and lectured around the world on a wide variety of topics related to prosthetics, amputee rehabilitation and sports medicine for athletes with disabilities.
Disclaimer: The following information is provided and owned by the Amputation Coalition of America and was previously published on the website http://www.amputee-coalition.org or the Coalitions Newsletter, inMotion.