Patient rehabilitation following lower limb amputation

Patient rehabilitation following lower limb amputation is essential to provide optimum patient outcomes and to improve the amputee's quality of life. The age of the patient and the stump length or level of amputation emerge as dominant factors affecting the outcome of rehabilitation. A variety of outcome measures are available to assess the patient's rehabilitative potential to maximise functional ability. This article focuses on the factors affecting rehabilitation, outcome measures to assess rehabilitative potential and the nurse's role in providing care for patients following lower limb amputation.     

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.

     

Return to work after lower limb amputation

Purpose. To review the literature on return to work after lower limb amputation.

Method. A comprehensive review of literature on return to work after lower limb amputation was carried out, searching MEDLINE and PubMED.

Results. Most authors found return-to-work rate to be about 66%. Between 22 and 67% of the subjects retained the same occupation, while the remainder had to change occupation. Post-amputation jobs were generally more complex with a requirement for a higher level of general educational development and were physically less demanding. The return to work depends on: general factors, such as age, gender and educational level; factors related to impairments and disabilities due to amputation (amputation level, multiple amputations, comorbidity, reason for amputation, persistent stump problems, the time from the injury to obtaining a permanent prosthesis, wearing comfort of the prosthesis, walking distance and restrictions in mobility); and factors related to work and policies (salary, higher job involvement, good support from the implementing body and the employer and social support network).

Conclusions. Subjects have problems returning to work after lower limb amputation. Many have to change their work and/or work only part-time. Vocational rehabilitation and counselling should become a part of rehabilitation programme for all subjects who are of working age after lower limb amputation. Better cooperation between professionals, such as rehabilitation team members, implementing bodies, company doctors and the employers, is necessary.     

Return to work after lower limb amputation

Purpose. To review the literature on return to work after lower limb amputation.

Method. A comprehensive review of literature on return to work after lower limb amputation was carried out, searching MEDLINE and PubMED.

Results. Most authors found return-to-work rate to be about 66%. Between 22 and 67% of the subjects retained the same occupation, while the remainder had to change occupation. Post-amputation jobs were generally more complex with a requirement for a higher level of general educational development and were physically less demanding. The return to work depends on: general factors, such as age, gender and educational level; factors related to impairments and disabilities due to amputation (amputation level, multiple amputations, comorbidity, reason for amputation, persistent stump problems, the time from the injury to obtaining a permanent prosthesis, wearing comfort of the prosthesis, walking distance and restrictions in mobility); and factors related to work and policies (salary, higher job involvement, good support from the implementing body and the employer and social support network).

Conclusions. Subjects have problems returning to work after lower limb amputation. Many have to change their work and/or work only part-time. Vocational rehabilitation and counselling should become a part of rehabilitation programme for all subjects who are of working age after lower limb amputation. Better cooperation between professionals, such as rehabilitation team members, implementing bodies, company doctors and the employers, is necessary.     

Deep vein thrombosis after lower limb amputation

OBJECTIVE: The purpose of this study is to prospectively document the incidence of deep vein thrombosis (DVT) in the residual limb after a below-knee amputation. DESIGN: Eight of 13 male patients, admitted to the acute rehabilitation floor after a below-knee amputation, were included in the study. Patients already receiving anticoagulants were excluded. An investigator questioned the patient regarding the patient's risk factors for DVT and history of DVT and pulmonary embolus. A coagulation profile was obtained for all patients. A Doppler ultrasound was completed on the residual limb 2 wk after amputation, and if negative, it was repeated 2 wk later. Patients found to have a DVT were treated appropriately. The incidence of DVT was calculated by a point estimate, and a 95% confidence interval was calculated using simple large sample methods. RESULTS: Four of the eight patients had ultrasound evidence of DVT in the thigh. Two of the four patients had signs or symptoms of a DVT. There were a comparable number of risk factors for DVT in both groups. Laboratory values were not statistically significant in predicting the occurrence of DVT, probably because of the limited number of subjects. CONCLUSIONS: The present study supports the assumption that the diagnosis of lower limb DVT is frequently associated with lower limb amputation. However, a larger sample may be necessary to conclude that a routine screening ultrasound of the lower limbs is indicated after a below-knee amputation.     

Return to work after lower limb amputation

This study investigated the proportion of patients who returned to work following amputation and the factors that influenced a positive or negative outcome. One hundred patients of working age who had sustained unilateral lower limb amputation at least 1 year previously and who were established prosthesis users participated in the study. A specially designed questionnaire similar to a guided interview was administered by the rehabilitation physician at the patients' routine follow-ups. The questionnaire yielded a unique score dependent on whether return to work (or a different or preferred occupation) had been achieved with good or reduced productivity. All patients were eligible for mobility benefit, including schemes to purchase suitably adapted vehicles if necessary. However, no vocational rehabilitation was available. Sixty-six per cent of patients returned to employment and this was related to mobility, time since amputation and Handicap Scale scores. Age, socket comfort, level and cause of amputation, type of previous work or the presence of other medical problems did not differ between those who did and did not return to work. The Employment Questionnaire showed good correspondence with the London Handicap Scale, indicating some concurrent validity, although future development might include consideration of psychological factors, which could explain more of the reasons for continued unemployment.     

The effect of rehabilitation in a comprehensive inpatient rehabilitation unit on mobility outcome after dysvascular lower extremity amputation

Czerniecki JM, Turner AP, Williams RM, Hakimi KN, Norvell DC. The effect of rehabilitation in a comprehensive inpatient rehabilitation unit on mobility outcome after dysvascular lower extremity amputation.ObjectivesTo (1) compare the total volume of rehabilitation therapy for patients ever attending a comprehensive inpatient rehabilitation unit (CIRU) versus never during the 12 months after amputation; (2) determine whether rehabilitation in a CIRU at any time in the first year after amputation results in greater mobility success compared with other types of rehabilitation environments of care; and (3) determine for those patients treated in a CIRU, which specific patient characteristics were associated with improved mobility outcome.DesignProspective cohort study.SettingTwo Veterans Affairs medical centers.ParticipantsPatients (N=199) with peripheral vascular disease or diabetes undergoing a first unilateral major amputation were screened for participation between September 2005 and December 2008. Among these, 113 (57%) met study criteria; of these, 72 (64%) participated.InterventionEver attending a CIRU versus never attending a CIRU in first 12 months after amputation.Main Outcome MeasuresNumber of rehabilitation therapy visits, Locomotor Capability Index scores, and mobility success.ResultsThe mean number of all therapy visits for patients ever attending a CIRU was significantly greater than that for those never attending over a 12-month period (48.6 vs 22.6; P=.001). Mean total time per any rehabilitation visit was .83±.27 hours for those ever attending and .60±.20 hours for those never attending (P<.001). Patients who ever were treated in a CIRU were 17% more likely to achieve mobility success than those who were not, controlling for amputation level, major depressive episode, alcohol use, social support, total number of rehabilitation visits, and hospital site (risk difference=.17; 95% confidence interval, .09–.25; P<.001).ConclusionsRehabilitation in a CIRU resulted in improved mobility success for veterans undergoing major lower extremity amputation secondary to peripheral vascular disease or diabetes. Among those admitted to a CIRU, younger patients with greater social support, healthy weight, and without chronic obstructive pulmonary disease had the greatest probability of mobility success.     

Falls in the inpatient rehabilitation facility

Older adults are rehabilitated for a variety of conditions in an inpatient rehabilitation facility (IRF), and they are often at an increased risk for falling during their stay. This article (1) provides an overview of the incidence, prevalence, and impact of falls in facilities that provide inpatient rehabilitation; (2) provides some key factors to be considered in the assessment of the patient admitted to the IRF for risk factors associated with falling; and (3) identifies strategies that can help reduce the risk of falling in patients admitted to an IRF.     

Mobility of persons after traumatic lower limb amputation

The objective of this study was to determine the influence of time span since amputation on mobility of persons experiencing traumatic lower limb amputation. A special questionnaire was sent to such persons and responses were analysed statistically. The subjects comprised 223 persons after traumatic lower limb amputation, residents of Slovenia. We discovered that 186 (74.2%) are using their prosthesis for more than 7 hours per day, 109 (52.2%) are able to walk outdoors without crutches, and 129 (57.8%) climb more than 20 stairs per day. In addition, those who are walking without crutches, walking longer distances, still cycling and driving a car are, on average, 5–10 years younger than the others. However, around one-third of persons who were young at the time of amputation face limitations of mobility later in life. A total of 76 (35.3%) are able to walk only up to 500 m out of doors, 38 (18.2%) can walk only with a pair of crutches, 62 (29.7%) need a cane or one crutch, and 37 (16.6%) cannot climb stairs. We conclude that successful fitting and usage of a prosthesis by persons after lower limb amputation promotes independent walking and mobility in everyday life. The level of independence achieved is related to time span since amputation.     

Preventing falls and stump injuries in lower limb amputees during inpatient rehabilitation: completion of the audit cycle

OBJECTIVES: To study the factors contributing to falls among recent lower limb amputees, and to reduce the number of falls during inpatient rehabilitation and resulting injuries. DESIGN: Retrospective, followed by prospective, cohort study, then a follow-up study conducted after interventions. SETTING: Twenty-bedded inpatient rehabilitation unit for amputees. SUBJECTS: Lower limb amputees. INTERVENTIONS: Patient education, environmental modifications and application of a bivalve plaster of Paris stump protector to patients who were aged 70 or over, or cognitively impaired. MAIN OUTCOME MEASURES: Numbers of falls and other accidents, and resulting injuries. RESULTS: In phase 1 of the study, a retrospective audit of incident forms that had been completed on lower limb amputees who had an accident during their inpatient rehabilitation, between 1 April 1996 and 31 Ocotber 1998, was carried out. This showed that approximately a third of admissions (32%) were complicated by an accident. Most accidents were falls. In phase 2, a prospective study of 113 patients admitted to the unit was undertaken. Patients who fell were significantly older than those who did not. In phase 3, 62 consecutive patients were studied. There were 37 accidents in total, of which 35 were falls. Compared with the phase 2 study, there was no reduction in the proportion of patients who had a fall or other accident in phase 3, but significantly fewer falls resulted in any injury (p = 0.05). CONCLUSIONS: Although the interventions employed did not reduce the proportion of patients who had falls or other accidents, significantly fewer falls resulted in injuries.     

Physical capacity and walking ability after lower limb amputation: a systematic review

OBJECTIVE: To review the influence of physical capacity on regaining walking ability and the development of walking ability after lower limb amputation. DESIGN: A systematic search of literature was performed. The quality of all relevant studies was evaluated according to a checklist for statistical review of general papers. SUBJECTS: Lower limb amputees. MAIN MEASURES: Physical capacity (expressed by aerobic capacity, anaerobic capacity, muscle force, flexibility and balance) and walking ability (expressed by the walking velocity and symmetry). RESULTS: A total of 48 studies that complied with the inclusion criteria were selected. From these studies there is strong evidence for deterioration of two aspects of physical capacity (muscle strength and balance) and of two aspects of walking ability (walking velocity and symmetry) after lower limb amputation. Strong evidence was found for a relation between balance and walking ability. CONCLUSION: Strong evidence was only found for a relation between balance and walking ability. Evidence about a relation between other elements of physical capacity and walking ability was insufficient. Training of physical capacity as well as walking ability during rehabilitation following lower limb amputation should not be discouraged since several parameters have been shown to be reduced after amputation, although their relation to regaining walking ability and to the development of walking ability remains unclear.     

下肢截肢后不良残肢的临床评估和处理

目的分析下肢截肢后不良残肢发生的原因，并介绍其临床处理方法。方法对109例下肢截肢者(共计110个残肢)进行评定，评定内容包括：残肢皮肤软组织状况、长度、形状、关节活动度、肌力、幻肢痛、残肢痛等，然后对不良残肢进行相应的理疗、体疗或手术处理。结果本组合格残肢64肢(占58％)，不合格残肢46肢(占42％)。不合格残肢主要表现为：残端形状不规则20肢，短残肢18肢，残端不稳定瘢痕伴感染13肢，残端肿胀及臃肿14肢，关节屈曲挛缩畸形18肢，神经瘤2肢，经理疗、体疗或手术处理后，均达到装配假肢的条件。结论对不良残肢要进行对症处理，使之能装配或穿戴假肢。由于假肢技术的不断改进，现在残肢的长度不再是影响假肢装配的主要原因，而残端皮肤软组织的条件已成为影响假肢装配的主要因素。     

针灸联合康复治疗汶川地震伤员截肢后幻肢痛疗效观察

目的探讨针灸联合康复对幻肢痛的治疗效果。方法将44例存在幻肢痛的5.12汶川地震伤员分为治疗组和对照组各22例,治疗组采用针灸联合康复方法综合治疗,对照组单纯采用康复方法治疗。以简明McGill疼痛问卷表（SF-MPQ）评分作为评价指标,观察两组治疗效果。结果治疗组总有效率为100%,对照组总有效率为81.9%,两组比较差异有显著性意义（P〈0.05）;两组治疗前后组内SF-MPQ评分比较,差异均有显著性意义（P〈0.01）;治疗后组间SF-MPQ评分比较,差异有显著性意义（P〈0.01）。结论针灸和康复治疗联合运用对幻肢痛有很好的疗效,远期疗效稳定。     

Comorbidities in amputation: a systematic review of hemiplegia and lower limb amputation

Purpose: The purpose of this review of the scientific literature was to investigate the incidence and prevalence of hemiplegia with lower limb amputation, and to identify outcomes following the dual disability of hemiplegia and amputation. Methods: Electronic searching of the literature identified major studies examining the effects of hemiplegia on rehabilitation following amputation. Data were extracted and levels of evidence assigned for each subtopic area. Results: The summary conclusions are Level 4 evidence. The prevalence of amputation and hemiplegia is 8-18% and amputation and hemiplegia occur most often in the same leg. Once individuals with hemiplegia and lower limb amputation are selected for prosthetic rehabilitation, rate of successful functional ambulation is greater than 58%. In general there is a lower rate of prosthetic success and independence with hemiplegia than without. Predictive factors associated with success include less severe hemiplegia, laterality of hemiplegia (ipsilateral and right side), transtibial level of amputation and absence of impaired mental function. There is wide variation in length of hospital stay, but a specialty multidisciplinary team reduces length of stay. Conclusions: Patients with dual disability of hemiplegia and amputation generally benefit from a prosthetic rehabilitation program. Further study on predictive factors for outcome would be beneficial. [Box: see text].     

The rapid resolution of depression and anxiety symptoms after lower limb amputation

OBJECTIVE: To ascertain the course of depressive and anxiety symptoms shortly after amputation and again after a period of inpatient rehabilitation. DESIGN AND SETTINGS: A cohort study in inpatients admitted to a rehabilitation ward after lower limb amputation. SUBJECTS: One hundred and five successive admissions over a one-year period. INTERVENTIONS: Nil. MAIN MEASURES: Hospital Anxiety and Depression Scale (HADS) on admission and discharge with correlation to demographic and patient features. RESULTS: At admission, 28 (26.7%) and 26 (24.8%) patients had symptoms of depression and anxiety respectively. This dropped to 4 (3.8%) and 5 (4.8%) by time of discharge, a mean of 54.3 days later. These reductions were statistically significant, as was the association between patients having symptoms of both depression and anxiety (P < 0.001). Patient stay was longer in those with symptoms (depression, P < 0.03; anxiety P < 0.001). There was no association with level of amputation, success of limb-fitting, age or gender. Depressive symptoms were associated with presence of other medical conditions (P < 0.01) and anxiety scores with living in isolation (P < 0.05). CONCLUSION: Depression and anxiety are commonly reported after lower limb amputation and previously thought to remain high for up to 10 years. We have found that levels of both depression and anxiety resolve rapidly. It is possible that a period of rehabilitation teaching new skills and improving patient independence and mobility may modify the previous bleak outlook of amputees. This positive finding may be useful in the rehabilitation of even the most distressed of amputees.     

Effect of fluid collections on long-term outcome after lower limb amputation

Singh R, Venkateshwara G. Effect of fluid collections on long-term outcome after lower limb amputation.ObjectiveTo ascertain the long-term outcome for individuals found to have fluid collections in residual limbs after amputation.DesignProspective cohort study.SettingOutpatient follow-up at a prosthetic rehabilitation unit.ParticipantsSuccessive lower limb amputations (N=105) scanned for fluid collections after operation and followed up after 3 years.InterventionsNot applicable.Main Outcome MeasuresSurvival; secondary outcomes of prosthetic limb use, hours of prosthetic limb-wearing, anxiety and depression levels.ResultsAfter 3 years, 70 individuals were alive, of whom 21 (30%) had fluid collections originally. There was no significant difference at follow-up between the group that had fluid collections in their residual limbs after surgery and the group that did not in terms of survival (χ²₁=.21, P=.64), numbers wearing prosthetic limb (χ²₁=.102, P=.75), hours of limb wearing (t₃₇=.35, P=.72), anxiety (χ²₁=.77, P=.78), and depression (χ²₁=1.98, P=.16). A multivariable logistic regression confirmed that presence of fluid collection was not associated with survival.ConclusionsFluid collections in residual limbs after amputation are common, but patients can be reassured that their long-term outcomes are not affected.