Physical Therapy for Amputees

New amputees face many hours in rehabilitation to learn how to use their prosthesis and to get around when the prosthesis is not being used or needs to be removed and put back on again. The process begins with the preoperative phase.

In the preoperative phase of physical therapy, the patient learns how the prosthesis works and is educated on factors like phantom limb sensations, including phantom limb pain.  Sometimes, the hospital has ties with local support groups that deal with amputations.  A member of the support group can listen to the patient’s fears and can show the new amputee the various things that can be handled nicely once there is skill at learning how to use the prosthesis.

The new amputee often has lots of questions about the uncertainty of their future as an amputee and will need total body strengthening, both before and after the amputation surgery.

A lot of questions need to be asked before surgery, such as what the patient’s goals after surgery are, what the patient’s cardiovascular system is like, and whether or not the patient is emotionally prepared to handle the demands of months of therapy with a new prosthesis.  The range of motion of the residual joints of the leg or arm needs to be evaluated, and exercises to prevent or release contractures must be performed.

The physical therapist needs to assess the following things preoperatively:
  • Status of the heart.  As walking with a prosthesis can be difficult, the heart must be evaluated to make sure that it can tolerate the rigors of exercise with or without a prosthesis.
  • Mental status.  The patient must be able to understand the various aspects of physical therapy and must be cognizant of what it takes to do the activities of daily living.
  • Range of motion of all extremities.
  • Strength of the unaffected limbs. These will take the brunt of the energy put out after the surgery is done and the prosthetic device is attached.
  • Sensation of the stump and other limbs.
  • Mobility in bed.  In other words, will the patient have the strength and coordination to get around in bed in order to avoid bed sores?
  • Balance and coordination.  The patient must have reasonable balance and coordination, both with and without the prosthetic device.
  • Transfer ability.  How well can the patient assist in transferring from bed to chair and vice versa?
  • Goals the patient has after surgery.
There are many assessment tools that help the physical therapist and prosthetist to decide what kind of prosthesis is necessary and whether one is necessary at all.  There are patient-derived self-assessment tools that can help assess the functional outcome of the patient.

There are also performance-based assessment tools, such as the use of electronic step counters, measures of functional independence, the amputee mobility predictor, and the functional ambulation profile.  Walking speed is assessed during a screening measure known as the 6 minute walk test, which assesses the patient’s speed of walking.  Gains In physical therapy can help decide whether or not the patient is doing well in therapy.  The six minute walking test can help measure these gains.

In the Days after Amputation

The main goals of treatment after amputation include reduction of edema (swelling) of the stump, healing of the wound, strengthening and beginning life as an amputee.  There are various dressings applied to the wound, including soft dressings (which need to be changed frequently), rigid dressings without a prosthesis attached to it, or a rigid dressing with a prosthesis already attached.  There are advantages and disadvantages of each type of amputation dressing.  Sometimes, especially in ischemic amputation, a soft dressing is preferable because it allows careful follow up of the wound to see that it heals.  The other rigid dressings are better at controlling edema and those with a prosthesis can speed up the ability of the patient to ambulate with assistance of a walker or crutches.

Patients need to learn how to position themselves in bed after the amputation and many need instruction as to how to manually operate a wheelchair.  They also need to learn how best to transition themselves from the bed to the wheelchair.

These steps are necessary in order to get the patient as independent as possible as soon as possible after the amputation.  All lower extremity amputees will need an assistive device to help them when they don’t have a prosthesis on for whatever reason or can’t put weight on the prosthetic device right away.

In the days after amputation, the patient needs to learn how to take care of the skin of the stump as well as how to put on the socks and/or internal suspension sleeves that help prevent pistoning or vertical motion between the device and the leg.  Compression stockings must be learned how to apply so as to prevent swelling of the stump.  All of this takes a great deal of energy and practice on the part of the patient and the physical therapist.

The patient must improve his or her overall conditioning and strength; range of motion around existing joints needs to be maintained and the patient should be learning functional activities of daily living.

Ongoing physical Therapy Goals

The patient with a lower extremity amputation needs to learn how to stand and balance on one foot, don and doff the prosthetic device, and learn to maneuver more complex things like curbs and stairs.  Uneven surfaces are more difficult to walk on than even surfaces and this must be practiced as well.  Side stepping and walking backwards are more advanced techniques that must be practiced along with simpler techniques.  Things like turning around and tandem walking can be practiced as advanced forms of physical therapy.  Patients will fall down and must learn how to get up off the floor to a standing position using physical therapy techniques.  
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