Health

What are some of the goals an amputee should strive for?
A physical therapist or occupational therapist can help amputees achieve many goals that are important for daily activities. Some of these goals may involve using a prosthesis and some may not. Occupational therapists usually help amputees with getting dressed, bathing and toileting and may be more heavily involved with upper limb amputees. If the dominant hand was amputated, an occupational therapist may help the amputee learn how to use the other upper limb as the new dominant limb. This is important for many activities especially writing and feeding. Physical therapists in general usually deal with issues pertaining to mobility and therefore may work more closely with a lower limb amputee. However these therapists work together with the rest of the rehabilitation team in order to return people with disabilities back to full function. Part of a therapist’s role involves ordering various types of equipment or assistive devices that will help accomplish these goals. Each amputee is different, though, and therefore therapists may set different goals and order different equipment for each individual.

Common Goals for Amputees

• Transferring in and out of bed, chairs and wheelchairs
• Donning and doffing an upper- or lower limb prosthesis
• Transferring on and off a toilet
• Walking with and without a prosthesis
• Bathing, dressing, toileting and eating (ADLs) with or without a prosthesis
• Walking over different surfaces such as stairs, ramps, curbs and uneven terrain
• Getting in and out of a bathtub
• Getting up off of the floor after a fall
• Education regarding care of the residual limb and prosthesis

The amputee should always arrive promptly for therapy to enable the therapist to use the necessary time for teaching. Comfortable clothing should be worn. Often it is a good idea to take pain medication, if it is needed, prior to coming to therapy. This strategy may be helpful so that pain does not limit the therapy session.
After the person is discharged from the hospital, therapy should ideally take place in the outpatient therapy department. This location is important for two reasons. One is that it forces the amputee to get out of the house and become accustomed to dressing and moving around in order to get to the therapy session. Although the home may be more convenient, there is also more suitable equipment in an outpatient therapy gym that will help the amputee accomplish established goals.

If rehabilitation is slow or if there are other medical problems prohibiting completion of rehabilitation and discharge to home, then the new amputee may need to go to a rehabilitation facility, assisted living facility or nursing home until the patient or his loved ones can properly care for him and his medical problems.

As the goals listed above are reached, the amputee and therapists can focus on more advanced skills such as those needed in vocational and recreational activities. These activities may include working with tools or equipment needed to do a particular job. Other types of adaptive prosthesis can also be made with the prosthetist’s assistance that will enable the amputee to do other pleasurable things such as swimming, playing an instrument or running. The amputee should express what his most important goals are when participating in occupational and physical therapy. In this way, both the therapists and the amputee know what the most important exercises and tasks should be.

What is a rehabilitation team and what do they do?
The individual with a limb amputation will often work closely with a rehabilitation team to help improve function. The purpose of this team is to understand the goals of the individual as they relate to having a limb deficiency or amputation and help integrate the disability into normal activities. For instance, an individual with a newly acquired upper limb amputation may need to learn how to put on their socks and shoes. An individual with a lower limb amputee may need to know how to get in and out of a tub or off the floor. For these functional issues, the rehabilitation team can assist the amputee with various techniques to attain normal function as well as chose the best prosthesis, if needed, to achieve these goals. They can also prescribe exercises and adaptive tools such as shower chairs, transfer boards and sock donners to assist with various activities. Additionally, as the rehabilitation process continues, the rehabilitation team can help recommend a prosthesis used in various athletic or recreational activities.

The rehabilitation team typically consists of a physician (usually a physiatrist or rehabilitation specialist), nurse, physical therapist, occupational therapist and a prosthetist. A more intensive team would also include a psychologist, social worker and recreational therapist. Each of these team members serves a role that helps the individual and loved ones adapt to life with an amputation.

The physician typically oversees the team and serves to coordinate the efforts of the other team members and addresses any medical concerns that may be associated with the person’s disability. The nurse can serve as an excellent liaison between the rehabilitation team and the individual and can provide education regarding limb care, medication usage and other medical issues. The physical therapist (PT) often deals with issues regarding mobility and can recommend exercises that integrate the amputated limb and prosthesis into a functional working unit for ambulation or recreational activities. An occupational therapist (OT) can provide strategies utilizing the residual limb or prosthesis that assist with activities of daily living (ADLs) such as bathing, dressing, toileting and feeding. They also deal with assisting in transferring from one surface to another, such as from a wheelchair to a toilet. The prosthetist is actually the individual responsible for making and modifying the prosthesis. They are extremely helpful in providing expert opinion regarding the best and most functional components that best serve the individual with an amputation.

What exercises should an amputee perform after surgery?
Physical and occupational therapy should be instituted immediately following amputation, as soon as the individual is medically stable enough to perform exercises. Often these exercises can begin even while medical equipment such as drains and IVs are attached to the individual. While performing these therapeutic exercises, however, it is advisable to wear some type of protection such as an RRD or compressive wrap as described above over the residual limb so as to prevent trauma to the wound. A common lower limb abnormality following amputation is a loss of range of motion either at the knee or hip joint. This is often referred to as a hip or knee contracture.

When this happens it may be difficult to walk normally with a prosthesis. For both the below- and above-knee amputee, the tendency is for the hip to stay in a flexed position, while a below-knee amputee may also develop a flexed knee contracture. Although it may feel comfortable to do so, putting pillows under the hip or knee should be avoided as this only encourages the contracture to develop.

Recall from above that one advantage of an RRD is that it extends above the knee and is helpful in preventing a knee contracture. However if this dressing is not used, other stretching exercises may be needed to prevent a knee contracture. One simple way to do a knee flexor stretch is to sit and then push the knee down into the bed forcing the knee into a flat or extended position. This exercise should be done several times a day. If available, an assistant can also help stretch the knee flexors.

Another helpful tip to prevent a knee contracture is to use a board under the residual limb to keep the knee straight.

Other types of stretching exercises can prevent hip flexion contractures from developing. A hip flexion contracture can occur for various reasons in both an above- and below-knee amputee. One reason is that the amputee may spend a significant amount of time in a wheelchair encouraging the development of a hip flexion contracture. Therefore sitting for prolonged periods especially in a wheelchair should be avoided.

Another reason a hip flexion contracture may result is muscle imbalances that develop in the leg resulting from the amputation. Therefore, it is also advisable for both the above- and below-knee amputee to focus on stretching the hip flexor muscles. These are the muscles that run in front of the hip joint. One way to accomplish this is to lie in bed face up. Both lower limbs are then brought to the chest. Then, while the normal limb is held close to the chest, the residual limb is then lowered down into the bed, thereby stretching the flexors of the hip.

A family member or loved one can also help by pushing the limb down.

Again, great care should be taken not to traumatize the surgical wound. Another alternative to stretch the hip flexors would be to lie face down on the bed. Then either the person himself or an assistant can push the pelvis down into the bed. This exercise is an effective method used to prevent hip flexion contractures. A more aggressive stretch of the hip flexors on the amputated side involves putting the normal leg on the floor while the rest of the body and residual limb remain on the level surface of the bed. Then the amputee pushes himself up so as to feel a stretch in the front of the hip on the amputated side.

Figure 13

The individual should relax after holding each of these stretches for about 30 seconds. The patient should remember not to hold his breath while performing any type of exercise but instead to breathe normally. Each exercise should be done two to three times, and the amputee should do these several times a day for them to be most effective.

The strength of the hip and lower limb muscles is very important when an individual learns to walk with a prosthesis. These muscles help stabilize the knee and pelvis on the prosthesis as well as help provide stability and power needed to walk. Strengthening exercises of the muscles around the hip and lower limb during the period following surgery, therefore, are very important and can prevent reconditioning while assisting with successful use of a prosthesis. When the individual becomes comfortable using the prosthesis, a physical therapist can then begin to teach more challenging strengthening exercises. In the early stages following surgery, only basic strengthening exercises like those in the next paragraph should be started. More advanced strengthening exercises can be learned with the proper instruction of a physical therapist.

The first strengthening exercise targets the muscles on the side of the hip which are important at stabilizing the pelvis. These muscles are known as abductors. The individual should lie on the good side and the hips should not roll from side to side. Then the residual limb is lifted up towards the ceiling in line with the opposite limb, held for five counts and then slowly lowered back down.

 The second strengthening exercise targets the gluteal or buttock muscles, which are extremely important for propelling the lower leg forward with walking as well as keeping the knee joint from buckling. There are a few different ways to strengthen these muscles when lying in bed. A very simple way to perform a gluteal strengthening exercise without moving the hips involves lying on one’s stomach. Then the gluteal muscles are squeezed together making a strong contraction. This contraction can be held for a few seconds and then the muscles can be relaxed. This can be repeated 10 times or more depending on the individual.

Another, slightly more difficult gluteal strengthening exercise also begins with the individual lying on his stomach. The thigh of the residual limb is then lifted towards the ceiling.

The limb is held in that position for a count of five and then slowly lowered back down to the bed. The nice thing about this strengthening exercise is that it also helps stretch the hip flexors, thereby preventing hip flexion contractures as well. This exercise can aggravate any back problems, so it is important that the individual not try to push the limb up too far and risk straining the low back. A more challenging strengthening exercise involves lying face up while a small rolled-up towel is placed under the far end of the residual limb. The person then lifts his pelvis towards the ceiling using the residual limb and then keeps it there for a count of five. The pelvis is then lowered back down to the bed. This maneuver is sometimes referred to as a bridge maneuver in the rehab setting but is often used by many who also practice yoga. Both above-knee (Figure 17) and below-knee amputees (Figure 18) can do different variations of this exercise, which should also be done on the normal side.

Figure 17: Above the Knee Amputee Bridge

Figure 18: Below the Knee Amputee Bridge with Pillow

The final two strengthening exercises are more appropriate for a below-knee amputee. The hamstring muscles in back of the thigh can be strengthened by having the individual lie face down on the bed. Then the knee of the residual limb is repetitively bent while the pelvis remains flat on the bed.

Comparatively, the muscles in front of the thigh or quadriceps can be strengthened by first sitting erect at the end of a firm surface. The knee on the amputated side is then straightened and held in that position for a count of five then slowly lowered back down to the starting position.

Each of these strengthening exercises can be done 10 times. Individuals, especially right after surgery, may find it difficult to do even just one repetition. This is why it is advisable to do these exercises only under the supervision of a physical therapist. It should also be emphasized that the individual should not hold his breath while performing any of these exercises and if he feels any discomfort when performing them alone, they should stop the exercise and consult with the physician. The use of weights, sandbags or therapeutic tubing is also inadvisable early on since the pressure from these objects may reduce the blood flow to the healing surgical wound. The surgeon and rehabilitation team must clear the new amputee to do these exercises so he is not risking injuring the surgical wound or creating a new medical problem.