No matter its cause, an amputation is a life-altering, traumatic event for a patient and his or her family. But thanks to new technology—particularly, better prostheses—and advances in rehabilitation, the shock can be minimized and the patient can return to his or her preamputee life much more quickly and fully.

According to Vinod Sahgal, MD, chairman of the Cleveland Clinic's Physical Medicine and Rehabilitation Department, successful rehabilitation begins with successful preparation of the residual limb. "It has to be properly prepared to receive the prosthesis," he says.

Preparation includes shaping the residual limb into as cylindrical a form as possible. Contractures near the site of the amputation have to be managed. The patient's cognition—his or her mental state—and general health also have to be managed and assessed. The health management includes making sure that the intact limbs are also strong and healthy enough to help compensate for the energy needed to keep the patient stable and mobile. "In most patients, amputations are a result of diseases—diabetes and vascular disease—and you need to make sure that the other [leg] has good sensation, blood supply, proprioception," Sahgal says. "Also in nontraumatic amputees, there can be comorbidities [that need to be addressed]."

But the most important thing that needs to be managed, according to Sahgal, is pain—particularly prior to the amputation. "A painful limb results in painful residual limb and phantom pain, and that's very difficult to work with," he explains.

Following the amputation, it is up to a multidisciplinary team comprised of the physician, PT, OT, prosthetist, psychologist, and family members to help the patient return to a normal, productive life.

DAY 1

At the Cleveland Clinic, Sahgal says, rehabilitation begins the day after surgery. "This is the newest concept," he says. "We used to wait, and the patient would be totally deconditioned."

This rehabilitation is done prior to fitting the patient with his or her prosthesis. Instead, the patient is fitted with a rigid dressing that has a weight-bearing pylon and foot. "This allows early ambulation and better psychological acceptance," Sahgal says.

In a multidiciplinary program, such as the one at the University of California Davis Medical Center (UCDMC), the physical therapist attends Amputee Clinic, along with the PM&R physician and community prosthetists. According to Julie Gross, PT, a clinical specialist at UCDMC, the physical therapist's primary role is to teach the patient how to ambulate and manage their prosthesis and residual limb. The goal for every patient, she says, is to "be able to walk at the most independent level with their prosthesis."

Gross challenges her patients, using stairs, ramps, and uneven surfaces, which simulates real-world obstacles. She also practices fall recovery, teaching the patients how to get up off the floor. Many of her rehab activities take place in the medical center's outpatient gym, but also includes training outside, over grass and unlevel surfaces.

Typically, a transtibial amputee will visit Gross between six and 12 times. A transfemoral amputee patient will see her between 12 and 20 times. She sees each patient twice per week. Her typical amputee patient load ranges from four to six different patients.

Perhaps the most important factor driving the patient's rehab is the choice of the prosthesis—and this is ultimately determined by the needs of the patient.

CHOOSING COMPONENTS

Sahgal says that, fundamentally, the goal of the prosthesis is to "make the body as symmetrical and energy-efficient as possible." This concept is different from the thinking in the past, when the amputee patient was seen as dependent. Now, independence is the goal and the norm.

The choice of the prosthesis is dictated by the functional demands of the patients. For instance, Sahgal explains, older patients—particularly those with a less active lifestyle—want a leg that will give them stability. However, a younger patient—particularly one who is active and even athletic—will want a prosthesis that is more dynamic. This is where running, lightweight materials, and ease of movement—particularly in the knee, ankle, wrist, and shoulder joints—come into play.

Even though Gross' patients skew to an older demographic who may not need such an elaborate prosthesis, she does work closely with the hospital's prosthetist to find out all the information about the artificial limb. "One of the keys to a successful outcome is a good relationship between the PT and the prosthetist," she says. "I talk to our prosthetist frequently."

She says that for her the most important thing to know is the kind of knee the prosthesis has. Each knee has different types of stance and flexion and extension control, requiring a different set of strategies and techniques to ambulate efficiently. Although the prosthetic prescription is dependent on the anticipated outcome, the goal remains for the patient to walk independently, with an assistive device as needed. The cost is an element as well—and driven by what a payer will or will not pay for.

Gross does have a favorite prosthetic knee—a microprocessor one that includes a stumble-recovery feature and that patients find more comfortable than more conventional designs. However, its cost makes it typically out of bounds for the normal patient.

However, no matter what knee or prosthesis the patient is prescribed, Gross sees herself in the same role. "My job is to find the best [walking] strategy for the prosthetic the patient has," she says.

Microprocessor knees are only one of the advanced functions available on many of the prosthesis currently available. Sahgal notes that there are some that are electronically controlled, some have the ability to be mind controlled, and others have cross-control functions. Though this is a great advance from heavy, fairly immobile artificial limbs of the past, Sahgal is cautious about endorsing them without reservation. "The more complicated the control, the less they will be used," he says. "They're good devices, but not very functional in a day-to-day setting. They're expensive, cumbersome, and difficult to use."

The solution, he says, is in the hands of the technologists who need to make devices that are more user-friendly and less expensive.

This challenge may have a bit more urgency in light of today's geopolitical situation. Sahgal notes that the wars in Iraq and Afghanistan mean there are more traumatic amputees now—many of whom are young, active, and want to return to the lives they had before being wounded.

While the prosthesis and its use is an important aspect of the rehab process, patients must learn how to care for their residual limb as well.

CARE OF THE LEG

Being able to walk wearing one's prosthetic leg is only part of the equation. Gross also teaches her patients how to put it on properly and care for the residual limb, to prevent skin breaking down or pressure sores from developing.

Gross says that there are number of new liners on the market, including gel liners.

She also monitors skin integrity during the initial phases of using the prosthesis. Assistive devices might be necessary in order to avoid skin shear and skin breakdown.

Improvements in technique and technology are only part of the trends in amputee care.

THE FUTURE OF AMPUTEE CARE

What are the elements of a multifaceted approach to lower-extremity amputee rehab? Read our November 2006 article, "Back on Track."

Sahgal notes that the complexity of care—from the physical to the psychological to the social—necessitates the multidisciplinary team approach. "No one person can address all the problems," he says.

Among the issues that have to be determined by the team is the return on investment for the prosthesis. These include the patient's cost, maintenance of the limb, and the social cost—whether the patient will be able to return to the workforce and be a contributing member of society.

For Gross, educating her patients about how to stay healthy is as important as gait training with the prosthesis.

Sahgal says that the future of amputee rehabilitation is a commitment to spending the money to take the ideological and technological issues and introduce them into the marketplace, much as the way access issues tied to the Americans with Disabilities Act were. "Fitting the prosthetic limb is the easy part," he says.

Though there may not be any easy answers for the rehabilitation of amputees, there is no question that care continues to improve.

C.A. Wolski is a contributing writer for Physical Therapy Products. For more information, contact .