Lower-extremity amputations may be the result of a number of etiologies ranging from traumatic injury to cancer to peripheral vascular disease to a nonhealing diabetic ulcer. Goal setting during rehabilitation for the lower-extremity amputee patient should consider the patient’s medical history, including etiology of amputation; medical comorbidities, including time frame of physical decline; and the patient’s age, prior level of function, amputation level, social support, pain control, and motivation.

Just about every amputee who enters the outpatient clinic has this on their minds: “Will I be able to walk again?” Or, they express a desire to rid themselves of a limp while walking. Other concerns often expressed are the desire to have better control of the prosthesis while standing and walking, and to decrease his/her fear of falling. Often, the concerns trace back to inadequate strength and balance, and to the prosthetic adjustments necessary as the patient’s time using the prosthesis increases.

According to a recent survey conducted by Miller et al in 2001, 52.4% of the persons surveyed reported a fall in the past year, and 49.2% reported a fear of falling.¹ However, the sample size was relatively small, and a person’s perception of a fall may differ. For example, the person surveyed may not consider unexpectedly leaning into a wall or furniture a fall, but only a fall to the floor as a true fall. According to this study, incidences of falls within 1 year after receiving the prosthesis were found to be correlated to, among other things, higher amputation levels (for example, transfemoral amputations versus transtibial amputations) and multiple residual limb and prosthesis problems.¹ Prosthetic malalignments may also affect the person’s balance or perceived balance, and may ultimately lead to inefficient gait patterns or falls.² 

This article will examine certain considerations for unilateral lower-extremity amputees during various phases of their rehabilitation, the special challenges presented to prosthetists and PTs during the stance and gait-training phases, the importance of daily exercise (especially stretching and strengthening of the gluteal group), and prosthetic alignment commonly used to improve stability.

Preoperative Intervention
If a PT is involved in the preoperative phase, this is an ideal time to introduce reading materials related to the upcoming surgery; the healing times; therapeutic exercises, if appropriate, for upper and lower extremities; hygiene for wound management; and edema management. If possible, evaluate the patient’s preoperative activity level, including length of activity decline. If a vascular patient has been on bed rest for a year in an attempt to heal an ulcer prior to his amputation, he will likely have extensive recovery times, cardiovascular involvement, and poor activity endurance in comparison to an active person undergoing amputation as a result of a tumor.

Consulting with an empathetic peer who has undergone an amputation and can attest to his or her recovery and current abilities often has a profound effect on reducing anxiety and creating an open line of communication. Clinically, I have found that amputee patients appreciate being able to talk to someone who has “been there,” and often ask questions more openly to a peer than to me as a therapist. I try to encourage patients to become involved in peer-support groups, which encourage them to become proactive in their care and are activity oriented, such as ballroom dancing.

Postoperative Considerations
Protection of the incision site, edema management of the residual limb, and early mobilization are of primary importance in the acute postoperative phase. In this stage, the patient is often limited in his/her weight-bearing status and spends a significant amount of time in bed. At this time, the patient can be taught stretching and strengthening exercises to perform in bed, with caution to protect the incision site. The patient also needs to be educated about proper positioning to prevent contractures during this time of relative immobility. The PT should make an effort to teach the hospital staff and the patient’s family members or caregivers these techniques and exercises to help motivate the patient and hopefully encourage compliance.

Fall prevention is an essential part of amputation rehabilitation because falls may result in increased healing time, additional surgical intervention, other injuries, and increased hospitalization.³ Our clinic uses rigid removable dressings that offer postoperative limb protection from sheer forces associated with early bed mobility and from risk of trauma associated with falls which, if they occur, commonly occur during transfers (bed, toilet, tub, or car). This rigid postoperative protection device may have a pylon and foot attached for the early weight-bearing candidate, and use of the rigid dressing with the pylon and foot has been shown to decrease the number of falls.⁴ 

“Our immediate postoperative prosthesis enables an amputee to mobilize early and encourage reconditioning. Certain patients, elective patients, are ideal for postoperative rigid dressings with pylon and foot and early weight-bearing and early mobility,” says Joe Pongratz, CPO, FAAOP, clinical director of Pongratz Orthotics & Prosthetics, Phoenix.

According to Pongratz, candidates for early weight-bearing include certain elective cases, such as ankle nonunions, cancer patients, and some traumatic-injury patients if the surgery is uncomplicated and they do not suffer from multiple medical problems. The early weight-bearing candidate may begin gait training with limited weight-bearing as early as the first postoperative day.

“There is a huge emotional advantage to getting patients up on the first day post-op. It does not allow them time to think about the surgery and their situation, but makes them start on the recovery and beginning mobility,” Pongratz says.

Emphasis on teaching the patient, staff, and family to correctly don/doff the postoperative prosthesis/protective device and check skin integrity are a few therapy goals. If no complications exist with the closure, a patient may begin a limited wearing schedule of compression garments to control edema and prevent sheer forces, which is helpful for controlling pain associated with the surgery, as well as for reducing phantom pain.

Strengthening exercises should focus not only on the lower-extremity musculature but also on back extensors, abdominals, and upper extremities, for a true whole-body approach. Obviously, the lower-extremity conditioning is necessary to prepare for prosthetic use. However, back extensors and abdominal exercises are needed to increase core stability and to manage back pain, which is often associated with transfemoral-amputation gait training.

Upper-extremity strengthening is necessary for walking with assistive devices and for transfer training to the mat, wheelchair, floor, etc. Gailey and Clark recommend the “rule of 10,” which involves teaching 10-second isometric contractions at the peak of isotonic movement with 10 repetitions during strengthening exercises.⁵ Goals for independence in donning and doffing the postoperative prosthesis, compliance with the wearing schedule of the prosthesis and compression garments, independent transfers, and ambulation with assistive devices are appropriate in the acute-rehabilitative and home-health phase.

Ideally, when the patient begins out-patient physical therapy, the wound is well-healed and the patient has received a formal prosthesis. At this time, the patient can begin full weight-bearing activities, such as standing balance, pregait training, and gait training. Loss of proprioception and muscle mass, and decreased bony lever arm, lead to weakness, balance deficits,⁶ and a lack of trust of the affected side. This, in turn, leads to the common deviation associated with standing positions, as patients generally shift their center of mass toward the sound limb, abducting the prosthetic limb, and thereby limiting the amount of weight acceptance on the prosthetic side. Inadequate gluteal group muscle firing follows, causing altered gait mechanics, imbalance, and overuse syndrome of the sound limb.

For the purpose of this article, the role of the gluteal muscle group will be grossly oversimplified in the stance phases. In the sagittal plane, the gluteus maximus is the primary mover of the center of mass in stance phases. Inadequate firing of the gluteus maximus muscle will cause the trunk to lurch forward. Hip-flexion contractures, which are commonly seen in the transfemoral amputee, can cause significant implications to the gait pattern and may deny the transfemoral patient from prosthetic use.

“The problem is there are not a lot of components available to accommodate a severe flexion contracture. Alignment is very challenging once you get past 25 degrees, and it causes a cosmetic concern. Because of limited range of motion, patients who have a severe contracture demonstrate a horrible step-to-gait and a lot more energy is expended to ambulate. Actually, these patients are not considered a prosthetic candidate, and we refer the patient to physical therapy to reduce contracture,” says David E. Vowels, BS, CPO, clinical associate at Pongratz Orthotics & Prosthetics.

As the gluteus maximus role is important for gait mechanics in the sagittal plane, the gluteus medius role is equally important in the coronal plane. The gluteus medius must control femoral stabilization against the socket in weight-bearing to allow the sound limb to advance in swing phase, allowing equal stride length. For the transfemoral amputee, the gluteus medius is ideally placed in stretch by adducting the socket to hasten muscle firing in weight-bearing to provide lateral femoral stability inside the socket.

As the patient begins ambulation training and increases the prosthetic’s wearing time and use, he or she often experiences vast volume changes. Diligent use of compression garments when not wearing the prosthesis is imperative for volume stabilization. This period often becomes a time of frustration, because the patient will experience a well-fitting prosthesis at the beginning of the week, but by the end of the week he or she will wear 10 sock ply due to soft-tissue atrophy.

Close communication with the prosthetist is vitally important throughout the rehabilitative process, because frequent socket adjustments may be necessary as the patient advances with gait training. A therapist may believe that the patient has reached a functional “plateau” in his or her recovery, when, in actuality, a few minor twists of the wrench by a skilled prosthetist are in order. If geographically possible, cotreating or simultaneously visualizing the patient by the PT and prosthetist together may be indicated for the amputee patient’s benefit.

From the patients’ perspective, he or she should be educated by the PT regarding realistic recovery goals and adequate time frames. Transfemoral patients frequently express frustration and surprise at the level of difficulty to recover their ability to walk. It is important for us as therapists to not only educate them, but to remind them often that rehabilitation following amputations is not measured in weeks but in months. Changes in limb volume will continue to occur well after physical therapy intervention is over, up to 12 to 18 months after initial healing, according to Berke.³ 

As previously stated, close communication between the PT and the prosthetist is essential throughout the rehabilitative process to ease patient transitions between stages, as well as to adjust the prosthetic fit to correlate with patient progress in a timely manner. PTs can emphasize compliance with compression garments, prosthesis-wearing schedules, and daily exercise programs to prevent complications as well as to teach the patient to walk using the prosthesis. However, it is ultimately up to the patient to be compliant, to learn independence in his or her own care and recovery, and to become proactive with the follow-up care.

Anissa Pongratz, MPT, manages Pongratz Physical Therapy, which is a division of Pongratz Orthotics & Prosthetics in Phoenix. She can be reached at anissa@pongratzop.com.

References
1. Miller WC, Speechley M, Deathe B. The prevalence and risk factors of falling and fear of falling among lower extrem-ity amputees. Arch Phys Med Rehabil. 2001;82:1031–1037.

2. Czerniecki JM. Rehabilitation in limb deficiency. 1. Gait and motion analysis. Arch Phys Med Rehabil. 1996;77(Suppl 3):S3–S8.

3. Berke G. Standards of Care. JPO.2004;16(Suppl 3): S6–S12.

4. Schon LC, Short KW, Soupiou O, et al. Benefits of early prosthetic management of transtibial amputees: a prospective clinical study of a prefabricated prosthesis. Foot Ankle Int. 2002;23:509–514.

5. Gailey RS, Clark CR, Bowker JH, Michael JW. Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles. 2nd ed. St Louis, Mo: Mosby-Year Book Inc; 1992:575.

6. Gailey RS. One Step Ahead. An Integrated Approach to Lower Extremity Prosthetics and Amputee Rehabilitation. Miami, Fla: Advanced Rehabilitation Therapy Inc. 1994:79–82.