Examination & Treatment of
the Lower Extremity Amputee
Training the LE
amputee
in the use of a
prosthesis
4-17-07
Focused reading for class
discussion:
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O’Sullivan
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pp. 624-629 (from last
week)
Physical Therapy
Management pp. 660670
Learning Objectives
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Discuss and apply the psychological impact of an
amputation.
Discuss in detail and apply the progression followed in gait
training an amputee with a prosthesis.
Discuss and apply the aspects of the home program for a
patient receiving a LE prosthesis (correct use,
maintenance/care, exercise, skin care, sock care, etc.)
When presented with a clinical case study, analyze &
interpret patient data; determine realistic goals/outcomes
and develop a plan of care.
What are likely limitations for
Mr. Howard?
IMPAIRMENTS
FUNCTIONAL LIMITATIONS
 Pain
 Inability to walk, work, play
 Decreased strength,
ROM, mobility
 Decreased skin
integrity
 Decreased
endurance
 Psychological issues
Early Post-op care:How should Mr.
Howard be taught to care for his
residual limb?
Wash nightly w/mild, nondrying soap (after sutures removed);
pat dry with terry cloth towel
 Small amt. of lotionsoft, pliable limb more tolerant of
prosthetic wear than tough, dry limb
 DON’T use alcohol
 Daily skin inspectionsuse mirror if necessary
 Desensitization;rub, tap, massage, touch w textures
 Soft tissue mobilization
*Don’t forget care of sound limbsame guidelines for washing &
inspecting plus don’t walk barefoot, don’t soak feet, avoid
extreme temperatures/binding socks, inspect shoeswatch for
skin changes: color, temperature, loss of hair, sores, etc.
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6
What functional activities should PT concentrate
on for Mr. Howard in early post-op period?
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Wheelchair
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Bed mobility
Transfers-try to use stand-pivot
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post-op & pre-prosthetic period & for long distances, very short TF
& double amputees often need indefinitely
Use anti-tippers or amputee axle if no prosthesis
Monitor vitals
May need sliding board
Balance: sit, hands and knees, tall kneeling, stand activities
Gait
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Begin in parallel bars
Single limb amb. with assistive device VERY energy intensive
Outside of bars try crutches, last resort wheeled walker
All LE amputees will need an ambulation aid to use when
prosthesis is off
2
Should PT be concerned with the
psychological impact of Mr. Howard’s
amputation?
 Absolutely!
 Affects all aspect of rehab.
 Often PT spends most time with pt. on team
and pt. will open up to PT
 Need to know what “normal” acceptance is
compared to depression
What should PT include in Mr.
Howard’s home program?
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Compression bandaging
Contracture prevention
Residual limb care/remaining limb care
Strengthening-UE/LE
ROM
Balance
Functional activities
General conditioning
Provide in writing, in layman’s terms,teach
pt.and family
Target Clinical Pathway (usually
longer than this, though)
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Day 0: Amputation surgery
Day 1-4: Acute hospital, pre-prosthetic PT
Day 5-21: Sub-acute rehabilitation hospital or
home for wound healing and continued preprosthetic PT
Day 21-28: Suture/staple removal followed by
casting for temporary prosthesis
7
Case Scenario
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Mr. Howard has been at home for the past 5
weeks performing pre-prosthetic program
with a home health PT. The prosthetist has fit
him with his temporary prosthesis and Mr.
Howard is now ready for OP daily physical
therapy to work on walking.
What are factors that can affect
Mr. Howard’s prosthetic training
success?
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Physical abilities (strength, ROM, endurance, skin,
pain, etc.)
Cognitive abilities
Prosthetic fit
Motivation
Financial resources-insurance often determines
LOS/type of prosthesis
Socio-economic circumstances-caregiver, car, living
situation, etc.
What will the PT examination
of Mr. Howard look like?
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Guide to PT practice
Prosthetic checkout
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Static assessment
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Stand in parallel bars
sit
Dynamic assessment
Evaluation Data to Collect
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Aerobic Capacity and Endurance
Anthropometric Characteristics
Arousal, Cognition, and Attention
Assistive/Adaptive Devices
Circulation (Arterial, Venous, and Lymphatic)
Cranial and Peripheral Nerve Integrity
Environmental Barriers
Body Mechanics
Evaluation Continued
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Gait, other Locomotion, and Balance
Integumentary Integrity
Joint Integrity and Mobility
Motor Control and Motor Learning
Muscle Performance
Orthoses, and/or protective/supportive
devices
Pain – Location and Intensity
Evaluation Continued
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Posture
Prosthetic Requirements
Range of Motion (include muscle length)
Self-Care and Home Management
Sensory Integrity
Work (job/school/play)
Community Integration/reintegration
Mr. Howard’s PT Diagnosis
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Impaired Motor Function, Muscle
Performance, Range of Motion, Gait,
Locomotion, and Balance Associated With
Amputation
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Practice Pattern: Musculoskeletal, 4J
1
What are likely PT goals
for Mr. Howard? Pair & Share
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Remember:
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Audience
Behavior
Condition
Degree
What is the likely plan of care
for Mr. Howard?
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Teach donning/doffing prosthesis
Continue evaluation of skin/teach pt. care
Check fit of prosthesis
Teach transfers
Begin gait training
Continue strengthening/ROM/balance, etc.
How would you teach
Mr. Howard to don his prosthesis?
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Have sit in firm chair with arms
Identify and check prosthesis
Inspect condition of residual and remaining limb
Place sheath then prosthetic socks over residual
limbmake sure there are no wrinkles
Place insert over residual limb (if pt. has one)
“step” into prosthesis while sitting
Attach suspension
Reverse to doff, and check skin
4
What skin problems should PT
look for with Mr. Howard’s use
of LE prosthesis?
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Abrasion/blisters (poor distal contact)
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Most common sites: bony
Why? Settling, pistoning, tilting, torsion
Solutions: lamb’s wool
Distal edema
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Why? Not good contact
Solutions: add lamb’s wool
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Residual limb condition:
Prosthetic sock pattern-pinpoints high pressure area, shows whether
limb has total contact with prosthesis (should look the same all over)
Loss of hair/skin condition-indicates continued pressure and reduced
nourishment of tissues and skinsee Dr. ASAP
Sensation: throbbing pain indicates choking (ace wrapped improperly);
temperature: cold=impaired circulation, hot=infection possiblecall
Dr.
Skin-check every 15 minutes of prosthetic wear
 Texture
 Appearance
 Color
 Condition
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Reddened areas should disappear in 15 minutes. If red area noted, leave
shrinkers off and prosthesis off. If red area gone within 15 minutes, reapply
prosthesis. If red area not gone in 15 minutes, inform prosthetist.
No red areas, maintain wear schedule of 15 minutes on with activity, check skin
and continue as appropriate. Shrinkage devices should be applied when
prosthesis is removed.
3
Weight-shift activities
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Primary goal is to get weight shift onto prosthetic
side normalize gait
Pt. stands in parallel bars with an open hand, use
of full-length mirror helpful, feet approximately 4
inches apart
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Shift weight side to side
Shift weight forward and back
Shift weight diagonally
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Progress to doing activity with one hand (opposite prosthesis,
then same side as prosthesis), then to no hands, if possible
3
Stepping activities
Stand in parallel bars, feet 4 inches apart, both hand
on bars, can progress to one, then no hands
 Pt. steps forward, back with sound limb
 Pt. steps forward, back with prosthetic limb
*focus on forward rotation of pelvis, weight-shift,
flexing prosthetic knee at pre-swing for Mr. Howard
(foot placement for TF)
 Can also do side stepping
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3
Stool stepping
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Use 8 inch stool, pt. stands in parallel bars, stool in
front of sound limb, both hands on bars
Step onto stool slowly with sound limb, then back off
 Mr. Howard can also practice stepping up with
prosthesis, but this is not recommended with a TF
because requires hip hike/circumduction to get foot off
step which is undesirable and is a pattern to be avoided
*emphasize control of hip and knee of prosthetic side
*progress activity by removing one hand, then if possible,
two
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3
Stride
Stand in parallel bars, feet 4 inches apart, both
hands on bars, can progress to one, then no hands
 Alternate which leg begins stride
 Progress to two strides, then three, etc.
*can progress outside parallel bars when:
-pt. is able to shift weight A/P, R/L without deviations
-pt. is able to step forward with sound limb and shift
weight adequately onto prosthesis without deviations
-pt. is able to step forward with prosthetic limb, using
rotation then hip flexors, rather than trunk
-Pt. is able to walk length of parallel bars with flat
hands and minimal deviations
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3
What might Mr. Howard’s assistive
device progression look like?
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Gait training in parallel bars
Gait training with suspension harness
Axillary crutches-risk radial nerve
impingement/ Forearm crutches
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Walker-only if can’t use crutches
Cane
Advanced activities should include:
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Transfers to various chairs/car/toilet
Curbs/stairs
Inclines
Uneven terrain
Picking up dropped object
Clearing obstacles/barriers
Falling and rising
Sitting/kneeling to floor and rising
Running, single leg stance, dynamic balance
3
What new information should
be included in Mr. Howard’s
HEP now that he has a
prosthesis?
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Don/doff
Wear Schedule
Care for prosthesis
How should Mr. Howard care
for his prosthesis?
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Wash socket daily with a damp cloth dipped in mild
sudsy water
Rinse cloth, wring dry, and wipe socket again
Clean valve in a suction socket with a small brush
Check joints/locks regularly for wear/proper
functiondo not oil or grease any parts
Do not make any adjustments yourself
Keep away from heat
4
When will PT discharge/
discontinue
Mr. Howard from PT?
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Ideally when he can do all functional skills, gait on all
surfaces, fall/get up, care of skin/prosthesis, etc.
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Without pain, huge energy cost or abnormal gait
When pt. has reached maximum potentialfails to
progress
Often determined by insurance coverage
Ideally Mr. Howard will be wearing prosthesis for 3-4 hours
a day, good knowledge of skin care and prosthetic
management, proficiency with prosthetic skills
Transfemoral amputee may only wear prosthesis for 30-60
minutes at discharge
4
Discharge/discontinue PT
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Guide to PT Practice p. 311
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Discharge=ending PT secondary to pt. reached
anticipated goals/outcomes
Discontinuation=ending PT secondary to:
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Patient request/preference
Unable to continue secondary to insurance, lack of
finances, no transportation, medical complications,
etc.
Pt. no longer benefits (i.e. no progress)
1
When will Mr. Howard most
likely require a socket
revision?
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Most new wearers need a major socket
revision/new socket within a year to
accommodate shrinkage
5
Energy Expenditure
5
% Functional
Recovery
% Increased
Energy
Requirement
Transmetatarsal
> 95%
~ 0%
Transtibial
70-75%
20-40%
Transfemoral
20-40%
50-80%
*Up to 300 % increased energy expenditure for bilateral
transfemoral amputee 6
Medicare Functional Levels
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Level 0-Pt. is non-ambulatory
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Level 1-Transfers or limited household ambulator
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Sach/single axis foot
Manual knee lock, stance control
Level 2-Limited community ambulator
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Medicare won’t pay for prosthesis
Multi-axis foot
Polycentric, pneumatic knee
Level 3-Unlimited community ambulator
Level 4-High energy activities
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Level ¾: energy storing feet and
hydraulic/microprocessor knee7
Timeline
Seymour, R. Prosthetics
and Orthotics: Lower Limb
and Spinal. Philadelphia:
Lippincott, Williams and
Wilkins; 2002, p. 163.
Prosthetic Rehabilitation
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Transtibial: 4-6 weeks outpatient PT/day pt.
Transfemoral: 6-12 weeks outpatient PT/day
pt.
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Temporary prosthesis 4-5 weeks after amputation
Provide permanent prosthesis 3-6 months post-op
Annual re-evaluation of fit and function
Replacement prosthesis every 4-5 years 7
References:
1.
2.
3.
4.
5.
6.
7.
American Physical Therapy Association. Guide to Physical Therapy
Practice. 2nd ed. Alexandria, Va: American Physical Therapy
Association; 2001.
Lusardi MM & Nielsen CC. Orthotics and Prosthetics in
Rehabilitation. Woburn, MA: Butterworth-Heinemann; 2000.
May, BJ. Amputation and Prosthetics: A Case Study Approach.
Philadelphia: Davis; 1996.
Northwestern University Prosthetics Training Handouts, 2003.
O’Sullivan SB & Schmitz TJ. Physical Rehabilitation: Assessment
and Treatment. 4thed. Philadelphia: Davis; 2001.
Seymour, R. Prosthetics and Orhtotics: Lower Limb and Spinal.
Philadelphia: Lippincott, Williams and Wilkins; 2002.
University of Missouri-Columbia Department of Physical Medicine
and Rehabilitation Handouts. Lower Limb Prosthetics; 2005.