Amputation rehabilitation and prosthetic restoration. From surgery to community reintegration

PURPOSE: The purpose of this review is to summarize the literature related to the advances that have taken place in the management and rehabilitation care of limb amputation. RESULTS: Prostheses for the lower and upper limb amputee have changed greatly over the past several years, with advances in components, socket fabrication and fitting techniques, suspension systems and sources of power and electronic controls. Higher levels of limb amputation can now be fitted with functional prostheses, which allow more patients to achieve independent life styles. This is of particular importance for the multi-limb amputee. The rehabilitation of more traditional lower limb levels of amputation have also greatly benefited from the technological advances including energy storing feet, electronic control hydraulic knees, ankle rotators and shock absorbers to mention a few. For the upper limb amputee, myoelectric and proportional controlled terminal devices and elbow joints are now used routinely in some rehabilitation facilities. Experimental prosthetic fitting techniques and devices such as the use of osseo-implantation for suspension of the prosthesis, tension control hands or electromagnetic fluids for knee movement control will also be briefly discussed in this paper. CONCLUSION: It is possible to conclude from this review that many advances have occurred that have greatly impacted the functional outcomes of patients with limb amputation.     

Amputation rehabilitation and prosthetic restoration. From surgery to community reintegration

Purpose: The purpose of this review is to summarize the literature related to the advances that have taken place in the management and rehabilitation care of limb amputation.

Results: Prostheses for the lower and upper limb amputee have changed greatly over the past several years, with advances in components, socket fabrication and fitting techniques, suspension systems and sources of power and electronic controls. Higher levels of limb amputation can now be fitted with functional prostheses, which allow more patients to achieve independent life styles. This is of particular importance for the multi-limb amputee. The rehabilitation of more traditional lower limb levels of amputation have also greatly benefited from the technological advances including energy storing feet, electronic control hydraulic knees, ankle rotators and shock absorbers to mention a few. For the upper limb amputee, myoelectric and proportional controlled terminal devices and elbow joints are now used routinely in some rehabilitation facilities. Experimental prosthetic fitting techniques and devices such as the use of osseo-implantation for suspension of the prosthesis, tension control hands or electromagnetic fluids for knee movement control will also be briefly discussed in this paper.

Conclusion: It is possible to conclude from this review that many advances have occurred that have greatly impacted the functional outcomes of patients with limb amputation.     

Amputation rehabilitation and prosthetic restoration. From surgery to community reintegration

Purpose:?The purpose of this review is to summarize the literature related to the advances that have taken place in the management and rehabilitation care of limb amputation.

Results:?Prostheses for the lower and upper limb amputee have changed greatly over the past several years, with advances in components, socket fabrication and fitting techniques, suspension systems and sources of power and electronic controls. Higher levels of limb amputation can now be fitted with functional prostheses, which allow more patients to achieve independent life styles. This is of particular importance for the multi-limb amputee. The rehabilitation of more traditional lower limb levels of amputation have also greatly benefited from the technological advances including energy storing feet, electronic control hydraulic knees, ankle rotators and shock absorbers to mention a few. For the upper limb amputee, myoelectric and proportional controlled terminal devices and elbow joints are now used routinely in some rehabilitation facilities. Experimental prosthetic fitting techniques and devices such as the use of osseo-implantation for suspension of the prosthesis, tension control hands or electromagnetic fluids for knee movement control will also be briefly discussed in this paper.

Conclusion:?It is possible to conclude from this review that many advances have occurred that have greatly impacted the functional outcomes of patients with limb amputation.     

Bone overgrowth in the adult traumatic amputee

Bone overgrowth of the residual limb after an amputation is a well documented complication in the pediatric amputee population. Bone overgrowth can cause pain, problems with skin breakdown, and poor prosthetic fit. There have been few reports of bone overgrowth in the adult amputee. Two cases of traumatic transfemoral amputations after extensive tissue damage are presented. Both patients successfully completed an in-patient amputee rehabilitation program and achieved functional ambulation with their prostheses. However, each developed distal residual limb pain within a year after their amputations that significantly limited the amount of time they could wear their prostheses and the distance they could walk. Radiographs demonstrated additional bone growth from the residual femur into adjacent soft tissues in both patients. These case examples demonstrate that bone overgrowth should be considered in the differential diagnosis of residual limb pain in the adult amputee.     

Job satisfaction and health experience of people with a lower-limb amputation in comparison with healthy colleagues

OBJECTIVES: To describe indicators of job dissatisfaction among amputee employees and to compare job satisfaction and health experience of working amputee employees with that of control subjects. DESIGN: A cross-sectional study, mailed questionnaire. SETTING: Patients were recruited by the orthopedic workshops of the Netherlands. PARTICIPANTS: One hundred forty-four patients who had an acquired unilateral major amputation of the lower limb at least 2 years before, were aged 18 to 60 years (mean age, 43y), and were living and working in the Netherlands. One hundred forty-four control subjects matched for age, gender, and type of job. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Statistical analysis of responses to a questionnaire regarding patient characteristics and amputation-related factors, amputee patients' opinions about their work and the social atmosphere at work, and their general health (RAND 36-Item Health Survey [RAND-36]). RESULTS: People with an amputation had greater job satisfaction (70%) than did the able-bodied control group (54%). The wish for (better) modifications in the workplace and the presence of comorbidity were significantly related to job dissatisfaction in people with limb loss. Amputee employees were less often hindered by the failures of others and by fluctuations in temperature. People with limb loss showed a worse physical health experience than controls on the RAND-36. CONCLUSIONS: The vocational satisfaction of people with limb loss may be improved by better workplace modifications, depending on the functional capabilities of the person and the functional demands of the job; improvement may also be achieved by vocational rehabilitation programs, especially for those with an amputation in combination with other morbidity. Despite experiencing more health problems, the amputee group expressed greater job satisfaction than the able-bodied group, reflecting a great appreciation of job reintegration by people with a lower-limb amputation.     

Walking and balance in children and adolescents with lower-limb amputation: A review of literature

BackgroundChildren with lower limb loss face gait and balance limitations. Prosthetic rehabilitation is thus aimed at improving functional capacity and mobility throughout the developmental phases of the child amputee. This review of literature was conducted to determine the characteristics of prosthetic gait and balance among children and adolescents with lower-limb amputation or other limb loss.MethodsBoth qualitative and quantitative studies were included in this review and data were organized by amputation etiology, age range and level of amputation.FindingsThe findings indicated that the structural differences between children with lower-limb amputations and typically developing children lead to functional differences. Significant differences with respect to typically developing children were found in spatiotemporal, kinematic, and kinematic parameters and ground-reaction forces. Children with transtibial amputation place significantly larger load on their intact leg compared to the prosthetic leg during balance tasks. In more complex dynamic balance tests, they generally score lower than their typically developing peers.InterpretationThere is limited literature pertaining to improving physical therapy protocols, especially for different age groups, targeting gait and balance enhancements. Understanding gait and balance patterns of children with lower-limb amputation will benefit the design of prosthetic components and mobility rehabilitation protocols that improve long-term outcomes through adulthood.     

Amputation stump management: A narrative review

In this review intended for medical staff involved in patient rehabilitation, we provided an overview of the basic methods for managing amputation stumps. After the amputation surgery, it is imperative to optimize the remaining physical abilities of the amputee through rehabilitation processes, including postoperative rehabilitation, desensitization, and continuous application of soft or rigid dressings for pain reduction and shaping of the stump. Depending on the situation, a prosthesis may be worn in the early stage of recovery or an immediate postoperative prosthesis may be applied to promote stump maturation. Subsequently, to maintain the range of motion of the stump and to prevent deformation, the remaining portion of the limb should be positioned to prevent contracture. Continuous exercises should also be performed to improve muscle strength to ensure that the amputee is able to perform activities of daily living, independently. Additionally, clean wound or edema management of the stump is necessary to prevent problems associated with wearing the prosthesis. Our review is expected to contribute to the establishment of basic protocols that will be useful for stump management from the time of completion of amputation surgery to the fitting of a prosthesis to optimize patient recovery.     

A survey of physiotherapists involved in paediatric lower limb amputee rehabilitation in the British Isles

Objectives

Children require extensive rehabilitation following lower limb amputation and there are few reports describing this rehabilitation process. A survey to assess opinions, practice and caseloads amongst physiotherapists involved with paediatric amputee rehabilitation in the British Isles was therefore undertaken.

Design

A 17-item structured telephone survey was developed to include the main aspects of physiotherapy rehabilitation of children following lower limb amputation. Physiotherapists working in paediatrics and/or amputee rehabilitation in a range of acute, outpatient and community settings were surveyed.

Results

Data were collected between November 2001 and October 2002. Physiotherapists from 70 centres were contacted, and 52 treated paediatric lower limb amputees. A variety of causes of amputation were managed. All physiotherapists commented that they saw very few paediatric patients. No centre had protocols in place for any stage of management. In all geographical areas, rehabilitation was available throughout recovery for all causes of lower limb amputation. Core elements of rehabilitation were similar; however, additional elements differed between centres.

Conclusions

This survey indicates that the small population of children with lower limb amputation has access to rehabilitation throughout their recovery. However, there is variation in the provision of physiotherapy rehabilitation services throughout the British Isles. Redesigning physiotherapy rehabilitation services for paediatric lower limb amputees, and formalisation of cross-speciality links between paediatric and amputee physiotherapists may help to address these issues and better equip these children for future function.     

The potential for non-invasive brain stimulation to improve function after amputation

Purpose: Lower limb amputee rehabilitation has traditionally focussed on restoration of gait and balance through use of prosthetic limbs and mobility aids. Despite these efforts, some amputees continue to experience difficulties with mastering prosthetic mobility. Emerging techniques in rehabilitation, such as non-invasive brain stimulation (NIBS), may be an appropriate tool to enhance prosthetic rehabilitation outcomes by promoting “normal” brain reorganisation and function. The purpose of this review is to highlight the potential of NIBS to improve functional outcomes for lower limb amputees. Methods: To demonstrate the rationale for applying NIBS to amputees, this study will first review literature regarding human motor control of gait, followed by neurophysiological reorganisation of the motor system after amputation and the relationship between brain reorganisation and gait function. We will conclude by reviewing literature demonstrating application of NIBS to lower limb muscle representations and evidence supportive of subsequent functional improvements. Results: Imaging, brain stimulation and behavioural evidence indicate that the cortex contributes to locomotion in humans. Following amputation both hemispheres reorganise with evidence suggesting brain reorganisation is related to functional outcomes in amputees. Previous studies indicate that brain stimulation techniques can be used to selectively promote neuroplasticity of lower limb cortical representations with improvements in function.

Conclusions: We suggest NIBS has the potential to transform lower limb amputee rehabilitation and should be further investigated.

• Implications for Rehabilitation

• Despite extensive rehabilitation some amputees continue to experience difficulty with prosthetic mobility

• Brain reorganisation following amputation has been related to functional outcomes and may be an appropriate target for novel interventions

• Non-invasive brain stimulation is a promising tool which has potential to improve functional outcomes for lower limb amputees

     

Care planning for children with lower limb amputation

This article explores the pathways of care for children who undergo lower limb amputation, from pre-surgery to rehabilitation. The consequences of surgery are manifold, including that children and their families must cope with life with a disability, effects on mobility, greater demands on metabolic reserve, disfigurement, pain and discomfort. Care can be divided into multidisciplinary pre-operative, post-operative, mid-term rehabilitation, including prosthetic limb casting and fitting, and long-term rehabilitation over many weeks and years. The involvement of the multidisciplinary team as the child progresses is described. It is recommended that care should be co-ordinated by a nominated lead professional. Effective discharge planning is crucial to a successful transition home and continuing rehabilitation.     

40例地震截肢患儿的院外康复护理

目的 分析2008年汶川地震后40例地震截肢患儿出院后存在的问题,有针对性地实施相应的院外康复护理,使患儿得到最大可能的康复.方法 2009年8～9月首次现场评估,对都江堰市友爱学校截肢惠儿进行残肢皮肤情况、残肢形状、残肢肿胀、关节活动度、肌力、疼痛等几个方面的调查与分析,根据调查结果,护理人员每周1次进行院外探访,有针对性地进行护理及康复指导.2010年9月进行二次评估,评价1年以后院外康复护理的效果.结果 对40例患儿的残肢皮肤情况、残肢形状、残肢肿胀、关节活动度、肌力、疼痛等方面进行评价,康复有效率达80％～100％,康复效果明显.结论 对出院后截肢患儿进行有针对性的康复护理指导能够有效减少并发症的发生.     

Prevalence and aetiology of amputation in Kolkata,India: A retrospective analysis

This study is an epidemiological report of the medical records of amputees in Kolkata, West Bengal, India. This retrospective study included 155 amputees who had undergone an amputee physiotherapy rehabilitation program and prosthetic training at the National Institute for the Orthopaedically Handicapped in Kolkata, West Bengal, from January 2008 to January 2010. The paper reports on the prevalence, aetiology, and levels of amputation. The causes of amputation classified under vascular diseases, trauma, and carcinoma are discussed. The most common cause of amputation was trauma (70.3%), the second most common cause being peripheral vascular disease. Lower limb amputation, more common than amputation at the upper limb, accounted for 94.8% of all amputations.     

Limb loss in the elderly peripheral vascular disease patient.

Limb loss in the elderly is a significant problem for a number of reasons. One of the primary problems this patient population experiences is rehabilitation. Regaining independence following amputation is often a slow and painful process. In addition, studies reveal a high incidence of depression as well as increased mortality rates in the elderly population following amputation. Nurses can play a key role in assisting the patient in attaining the highest level of function possible following limb loss. Nursing interventions should focus on coordinating a team approach to care of the amputee, educating both patient and family, as well as encouraging patient participation in support groups.     

Inertial sensor-based measures of gait symmetry and repeatability in people with unilateral lower limb amputation

BackgroundPeople with lower limb amputation often walk with asymmetrical gait patterns potentially leading to long-term health problems, ultimately affecting their quality of life. The ability to discreetly detect and quantify the movement of bilateral thighs and shanks using wearable sensor technology can provide additional insight into how a person walks with a lower limb prosthesis. This study investigated segmental symmetry and segmental repeatability of people with unilateral lower limb amputation, examining performance of the prosthetic and intact limbs.MethodsGyroscope signals were recorded from four inertial measurement units worn on bilateral lower limb segments of subjects with unilateral lower limb amputation during the 10-m walk test. Raw angular velocity signals were processed using dynamic time warping and application of algorithms resulting in symmetry measures comparing similarity of prosthetic to intact limb strides, and repeatability measures comparing movement of one limb to its consecutive strides.FindingsBiomechanical differences in performance of the prosthetic and intact limb segments were detected with the segmental symmetry and segmental repeatability measures in 128 subjects. More asymmetries and less consistent movements of the lower limbs were exhibited by subjects with transfemoral amputation versus transtibial amputation (p < .004, Cohen's d = 0.65–1.1).InterpretationSensor-based measures of segmental symmetry and segmental repeatability were found to be reliable in detecting discreet differences in movement of the prosthetic versus intact lower limbs in amputee subjects. These measures provide a convenient tool for enhanced prosthetic gait analysis with the potential to focus rehabilitative and prosthetic interventions.     

Expectations of rehabilitation following lower limb amputation: a qualitative study

Abstract

Purpose: To explore the expectations of patients about to undergo prosthetic rehabilitation following a lower limb amputation. Method: Design: Qualitative study using semi structured interviews. Setting: Interviews were conducted at two district general hospitals. Participants: Eight patients who had undergone a major lower limb amputation due to vascular insufficiency were interviewed within two weeks of their amputation. All patients had been referred for prosthetic rehabilitation. Results: Five key themes emerged from the interviews: uncertainty, expectations in relation to the rehabilitation service, personal challenges, the prosthesis and returning to normality. These findings illustrate how participants faced uncertainty both pre- and postoperatively and often looked towards established amputees for the provision of accurate information. Conclusions: As no previous research has specifically explored patients’ expectations following an amputation, this study adds valuable insight into the patient experience. Patient expectations following lower limb amputation appeared to be vague and uninformed which may lead to uncertainty and passivity. It was found that patients did not know what to expect in relation to the rehabilitation process. They expected to return to a normal life following an amputation and this expectation appeared to be an important coping mechanism. Patient information and discussions should form an important part of the rehabilitation process before as well as during prosthetic rehabilitation, to help shape realistic expectations. This will allow patients to take a more active, informed role in the process. Psychoeducation interventions (talking) appears to be as important as “walking” within prosthetic rehabilitation services.

• Implications for Rehabilitation

• Patients’ expectations following lower limb amputation need to be informed by the rehabilitation team and established amputees from an early stage as part of the short- and long-term process of adjustment following amputation.

• Patient expectations of a return to normality appear to be an important part of coping following lower limb amputation, exploration of a new normal, both physically and psychosocially should be addressed as part of the rehabilitation process.

     

Functional assessment scales and lower limb amputation]

INTRODUCTION: This paper is a review of the literature on assessment tools in lower limb amputees.MATERIAL AND METHODS: The authors have research on Medline(R) data base the different tools with keys words "lower limb amputee or amputation, functional evaluation or outcome assessment tools, activity of daily living", and have completed the research with the references of papers.RESULTS: A comprehensive approach of the consequences of an amputation and of the outcome of prosthetic care should include an evaluation of gait, use of the prosthesis in activities of daily life, acceptability and satisfaction with the device.DISCUSSION: Functional assessment tools that are validated are recent, and most of them were developed in English. They take into account the use and the acceptance of the device, but there is no study using them for an important sample population.CONCLUSION: It is now necessary to translate the recent tools into French, and to confirm their validity and sensitivity to change.     

Management of the multiple limb amputee

Issue : Multiple limb amputations involving at least one upper extremity are very uncommon. The amputation of both an upper and lower limb is even more uncommon. Due to the rarity of these amputations therapists are uncertain regarding the most appropriate treatment methods. While the majority of the protocols used for single limb amputations are appropriate for these multiple limb amputees, there are differences. Loss of multiple limbs creates a problem of overheating for the individual. Loss of an arm and leg results in difficulty donning the prostheses and difficulty using crutches and parallel bars during mobilization. Method : A review is given of 16 multiple limb amputees seen in our rehabilitation centre in the last 15 years. Return to work was seen in one third and was not related to the number of the amputations. A higher proportion of these multiple limb amputations occur through alcoholism or attempted suicide behaviour than occurs with either single upper limb amputations or lower limb amputations. This existing behaviour can create a management problem for the rehabilitation team during rehabilitation. Conclusion : Guidelines as to appropriate prosthetic and preprosthetic care are provided to assist the practitioner who has the acute and long term care of these patients. All multiple limb amputees should be referred to a specialized rehabilitation centre to discuss prosthetic options and long term rehabilitation requirements. This paper does not discuss bilateral lower limb amputations when not combined with an upper limb amputation.     

Sprint kinematics of athletes with lower-limb amputations.

OBJECTIVE: To determine and compare the kinematics of the sound and prosthetic limb in five of the world's best unilateral amputee sprinters. SUBJECTS: Five men, all unilateral lower-limb amputee (one transfemoral, four transtibial) athletes. The individual with transfemoral amputation used a Endolite Hi-activity prosthesis incorporating a CaTech hydraulic swing and stance control unit, a Flex-Foot Modular III, and an ischial containment total contact socket. Those with transtibial amputations used prostheses incorporating a Flex-Foot Modular III and patellar tendon-bearing socket, with silicone sheath liner (Iceross) and lanyard suspension. DESIGN: Case series. Subjects were videotaped sprinting through a performance area. Sagittal plane lower-limb kinematics derived from manual digitization (at 50 Hz) of the video were determined for three sprint trials of the prosthetic and sound limb. Hip, knee, and ankle kinematics of each subject's sound and prosthetic limb were compared to highlight kinematic alterations resulting from the use of individual prostheses. Comparisons were also made with mean data from five able-bodied men who had similar sprinting ability. RESULTS: Sound limb hip and knee kinematics in all subjects with amputation were comparable to those in able-bodied subjects. The prosthetic knee of the transfemoral amputee athlete fully extended early in swing and remained so through stance. In the transtibial amputee athletes, as in able-bodied subjects, a pattern of stance flexion-extension was evident for both limbs. During stance, prosthetic ankle angles of the transtibial amputee subjects were similar to those of the sound side and those of able-bodied subjects. CONCLUSION: Prosthetic limb kinematics in transtibial amputee subjects were similar to those for the sound limb, and individuals achieved an "up-on-the-toes" gait typical of able-bodied sprinting. Kinematics for the prosthetic limb of the transfemoral amputee subject were more typical of those seen for walking. This resulted in a sprinting gait with large kinematic asymmetries between contralateral limbs.