- 1 TRAINING OF PHYSIOTHERAPISTS AND DOCTORS IN HOSPITALS PT PROTOCOL FOR PATIENT S SUFFERING FROM AMPUTATION 1. General information on amputation 1.1. Definition An amputation is the loss of a part of the body. The person that suffers from an amputation is called an amputee. 1.2. Causes The causes of an amputation can be various. The amputation can be caused by a traumatism (for instance: traffic accident, job accident, a fall ), by an illness (cancer, leprosies, diabetes, gangrene caused by frostbite ), or by a congenital deformity (a part of the body was missing when the baby was born). 1.3. Types Any part of the body can be amputated. The name given to the amputation depends on the part of the body that the amputee has lost. The main types of amputation are: The shoulder disarticulation 1 The arm amputation 2 The elbow disarticulation 3 The forearm amputation 4 The partial amputations of the hand 5 The hip disarticulation 6 The trans-femoral amputation (AK)7 The knee disarticulation 8 The trans-tibial amputation (BK)9 The ankle disarticulation 10 The partial amputations of the foot 11
- 2 1.4. Stump surgery The stump is the part of the amputated limb that remains (for example, in case of BK amputation, the stump is the part of the leg between the amputation and the knee). The quality of the stump depends on the quality of the surgery (the quality of the surgery does not depend only on the surgeon's skill but also on surgery conditions, on the condition of the stump before surgery, and on the general condition of the patient). A good stump condition is important to facilitate the patient's prosthesis fitting. There are rules for this surgery, and we present here 3 of the most important: Stump length (a) Bone covering (b) Special rules for the BK (below knee) amputation (c) (a) Stump length The length of the stump is very important when fitting a patient with a prosthesis: a too short stump will give the patient difficulties in controlling his prosthesis well, and it will be more difficult for the technician to fit (if he has to adapt the prosthesis with, for example, a thigh belt above the knee). A too long stump will also give the technician problems (difficulties making the prosthesis alignment). For these reasons, the ideal length for a stump is when the amputation is made at the level of the medium third of the limb (this means: at least 10 cm below the proximal joint or 8 cm above the distal joint). Between these 2 points (10 cm below the superior joint and 8cm above the inferior joint), all levels of amputation are possible and considered as ideal. The longest stump (between those two points) will help the patient to control his prosthesis (higher force). (b) Bone covering After he cuts the bone and before he closes the stump, the surgeon must cover the bone s extremity with smooth tissue (muscle and skin) in order to protect the stump. For that, in general, the anterior muscles of the stump are stitched up with the posterior muscles.
More or less 2 centimeters of smooth tissue is necessary to cover the extremity of the bone well. If there is less than 2 cm, the extremity of the bone will be prominent below the skin and could create pain or a wound. If there is too much smooth tissue (more than 2 cm), the extremity of the stump will be too floppy and will complicate the patient's prosthesis fitting. (c) Special rules for BK amputation For Below Knee amputations, there are 2 rules that must be followed during surgery: The anterior part of the extremity of the tibia should be cut obliquely so it won t hurt and the bone won t grow. The fibula should be cut 2 cm shorter than the tibia. 1.5. Complications - 3 Possible amputation complications are varied: Infection (a) Exostosis (b) Nevroma (c) Phantom pain (d) Muscle shortness (e) Muscle weakness (f) Stump oeadema (g) (a) Infection Like any kind of wound, the scar after an amputation is an open door to bacteria or a virus. An infection could appear easily at the scar. This infection can also go up to the bone and cause a major infection (osteomyelitis). In that case, the patient will need new surgery, otherwise the infection can become general and even kill the patient). (b) Exostosis Exostosis is an abnormal bone growth. After amputation, sometimes the extremity of the cut bone can grow. This bone growth appears below the skin and can cause pain or a wound. The only possible treatment for exostoses is surgery. It often happens when the tibia was not cut well, obliquely, as explained previously.
- 4 (c) Nevroma Nevroma is an abnormal growth of a nerve that was cut during amputation. The nerve grows in a ball. If the skin is closed over it (it lies just below the skin), that zone can be very painful (kind of electric shock when we touch it). In this case also, the only solution is surgery. (d) Phantom pain Phantom pain is an abnormal sensation around the amputated limb. The patient has the impression, for example, that the foot that was amputated is still painful (the patient feels pain in the foot that does not exist anymore). The real cause of those pain is unknown. Some theories say that the part of the brain that was responsible for the sensitivity of the amputated limb starts to work abnormally, which lead to perception that the body part is still existing. Other theories say that the sensory nerve that was cut will still send messages to the brain. Since the messages that were carried by that nerve were coming before the amputation from the amputated limb, the brain interprets them as still coming from the same place (the amputated part of the limb). Those pains are not dangerous but they can be very boring because they can be present for a long time after amputation. Nevertheless, most patient say that the pain decreases after a while, even without treatment. (e) Muscle shortness After the surgery and before receiving prostheses, the patient won t use much his amputated limb. In that case; some muscles might become shorter very quickly. This mainly happens with the hip flexors, the hip abductors and the knee flexors (for lower limb amputation) and with the shoulder adductors and elbow flexors (for upper limb amputation). Muscle shortness might be a problem for the use of prostheses (if the knee or hip flexors are too short, the ranges of motion in the hip or the knee will be decreased which will make walking difficult) (f) Muscle weakness For the same reason as for the muscle shortness (non-use of the amputated limb), the muscles around the limb might quickly become weaker. Weak muscles will make the use of the prostheses quite difficult as using prostheses requires stronger muscles than usual. This is particularly true with the lower limb amputation; walking with prostheses requires strong hip extensors, hip abductors and (if the amputation is below the knee) knee extensors.
- 5 (g) Stump oedema Stump oedema very often occurs right after the surgery and is a normal reaction. But if it persists and is not addresses properly, the oedema will make the fitting of prostheses harder. When starting to use the prostheses, the stump will, at first, quickly become thinner (the oedema will decrease). If the stump becomes much thinner (which will happen if there is still swelling in the stump when the prostheses is produced), new prostheses will be needed after only a few days. 1.6. Notions about the prosthesis Prostheses are fake limbs that are made to replace the missing part of the amputated limb. There are two main kinds of prostheses: The lower limb prostheses (a) The upper limb prostheses (b) (a) The lower limb prostheses The BK (Below Knee) prosthesis The BK prosthesis corresponds to an amputation at the level of the leg (the tibia -below the knee joint and above the foot). It is composed of 3 main parts: The socket (1) The pipe (ppp or metal) (2) The foot (3) The AK (Above Knee) prosthesis The AK prosthesis corresponds to an amputation at thigh level (the femur - below the hip joint and above the knee joint). It is composed of 4 main parts: The socket (1) The knee (2) The pipe (metal) (3) The foot (4) Note: There also other types of prostheses for the lower limb amputation such a the hip disarticulation prosthesis (that includes a hip joint), the knee disarticulation prosthesis (which look like the AK prosthesis but have some particularities with the socket) or the partial foot amputation. In a general way (which is not always true) we can say that the lower is the amputation, the easier it will be for the patient to walk properly with the prostheses. This means that a patient with a foot amputation should be able to walk better the a patient with BK amputation or a patient with knee disarticulation or with AK amputation. This
- 6 can be explained by the fact that the less joint there is in the prostheses, the easier it gets to control it (controlling the prosthetic knee can be a bit difficult). Also, the weight-bearing site (the place where the patient take support to bare his body weight on the prostheses) change from one prostheses to another and the weightbearing site in a BK is better adapted than the weight-bearing site on an AK which makes it easier to walk. (b) The upper limb prostheses The forearm prosthesis Such prosthesis is composed of a socket and a prosthetic hand. The arm prosthesis Such prosthesis is composed of a socket, a prosthetic elbow and a prosthetic hand. Note: Nowadays, new technologies allow developing mio-electric upper limb prostheses. Those allow controlling the hand (and the elbow) using the muscles of the shoulder. Electrodes are placed on some muscles of the shoulder and by contracting them, the person can control the movements of the prosthetic hand and elbow. This makes those prostheses more useful because it is possible to control finer movements with mechanic prosthesis, the patient can just open and close the hand, which is not always very functional.
2. PT protocol for amputees - 7 2.1. Assessment Before setting up a treatment plan for an amputated patient, it is important to collect some information on the patient, on his/her history and on the amputation. Beside the general information on the patient (name, age, sex ), here is a non-exhaustive list of the main pieces of information that need to be collected: (a) History of the amputation What is the cause of the amputation? Was it an accident? What kind? Was is a illness? Which one? Is the amputation congenital (present from birth)? When was the patient amputated (date of amputation)? Which part of the body is amputated? The lower limb? Which part of the limb? The upper limb? Which part of the limb? Since the amputation, did the patient receive medical care (beside the normal scar care)? How was the healing of the scar? No infection? No complications? Since the amputation, did the patient receive rehabilitation care? What kind? For how long? What did it consist in? (b) Assessment of the stump How is the scar? Is it healed? Is it infected? Are there other wounds on the stump? How is the shape of the stump? Is it conic? Is it square? Is there oedema (compare the perimeter of the stump with the perimeter of the sound limb to confirm swelling)? How long is the stump? Too long? Too short? Is it the right length to produce a prosthesis? Is there complications such as exostoses? Does the patient feel pain in the stump? What kind of pain? When? (c) Assessment of the muscle strength Are the main muscles strong or is there weakness? Which muscles are weak?
- 8 (d) Assessment of range of motion Is there any decrease of ROM? What causes that decrease of ROM? Muscle shortness or joint deformity? Which ROM are limited? (e) Assessment of the balance (if lower limb amputation) How is the patient s balance? Can he maintain standing position? Can he jumps? Can pick up something from the ground? (f) Assessment of the functionality Does the patient face difficulties with daily life activities (moving around, feeding, dressing, using toilets)? What kind of difficulties? Gathering those pieces of information is important in order to be able to set up a treatment plan (what exercises to do) and to have a record of the patient s situation before starting the treatment (such record will allow the PT evaluating the efficiency of the exercises later on during the treatment- by comparing the present situation and the initial situation such comparison allows to see if the patient s abilities and condition are improving). 2.2. Treatment in the hospital (early rehabilitation) Early rehabilitation will take place in the hospital, starting as soon as possible after the amputation. The main purpose of the treatment will be to prevent complications from appearing and to prepare the patient and the stump for receiving a device. In order to do so, and according to the information collected during the assessment, the following exercises should be done with the patient: (a) Starting right after the surgery (day 1) Passive mobilization: Passive mobilization aims to prevent muscle retraction and decrease of ROM as well as other complications such as bedsores and blood circulation problems. All limbs should be mobilized, included (and especially) the amputated limb. For details, refer to the passive mobilization protocol. Active mobilization: Active mobilization aims to prevent muscle retraction and muscle weakness as well as other complications such as bedsores and blood circulation problems. All limbs should be mobilized, included (and especially) the amputated limb. For details, refer to the active mobilization and strengthening protocol. Positioning: The patient should learn which position should be avoided in order to prevent muscle shortness. Some of those positions cannot be completely avoided (for example, the sitting position is not a very good position for AK amputees, but we cannot ask the patient to avoid sitting for the whole day. In that, we
- 9 should recommend him to avoid that position as much as possible and recommend him other positions which are better Position to prevent (for BK amputation) Laying on the back with a pillow under the knee Sitting with the knee in flexion Position to recommend (for BK amputation) Standing with the knee in flexion (taking support on the crutch) Laying on the back with the knee in complete extension Sitting with the knee in extension (using support for the stump) Position to prevent (for AK amputation) Laying on the back with a pillow under the thigh Sitting Standing with the hip in flexion (taking support on the crutch) Position to recommend (for AK amputation) Laying on the belly with a pillow under the thigh Other: if the patient has to stay in bed (bedridden patient), other common complications (respiratory problems, bedsores, blood circulation problems) also have to be prevented using specific methods. For details, refer to the bedridden patients protocol.
- 10 Patient information and training: Information on the patient s situation, his/her needs and his/her future should be provided to the patient or to his/her family. Information brochures can be used to do that. Also, when possible, the patient or his/her family should be taught how to do basic exercises by themselves. Material is also available to ease the teaching. For details, refer to the Teaching and informing the patient and his/her family members protocol. (b) Starting on day 2-3 Muscle strengthening: all limbs should be strengthen, included the amputated limb. For lower limb amputation, special attention should be given in strengthening the muscles important for a good gait (the hip extensors, the hip abductors and the knee extensors) and the upper limb (for walking with crutches). For classic muscle strengthening exercises, refer to the active mobilization and strengthening protocol. With lower limb amputees, the following three specific exercises can also be used: Hip extensors (lift up the pelvis, count until 5, then rest. Repeat the movement 20 times, 3 times/day) Hip abductors (lift up the pelvis, count until 5, then rest. Repeat the movement 20 times, 3 times/day) Knee extensors (lift up the buttocks, count until 5, then rest. Repeat the movement 20 times, 3 times/day) (c) Starting on day 3-4 Standing up: The patient should get out of the bed as soon as possible to prevent bedridden patient s common complications. Balance in standing position: Some balance exercises can be done in standing position. For details, refer to the balance exercises protocols. Walking with crutches/walking frame: If the patient is amputated from one of the lower limbs, he should learn how to move around using crutches or a walking frame (if the balance is not good enough to use crutches). Using a wheelchair: If the patient is amputated from both lower limb, he should learn how to move around using a wheelchair.
- 11 (d) Starting after the stitches have been removed (if there is no opened wound or signs of infection) Stump bandage: the stump bandage aims to prevent or decrease the stump swelling and give a good shape to the stump. Rules to respect for the stump bandage: A bandage should be made in a figure of "8". We cannot do a circular bandage (this means that the bandage should always go up or down and not go in circles around the stump). The pressure made by the bandage should be more at the extremity of the stump than at its proximal part (so it won't prevent the blood from circulating normally). The extremity of the stump should be completely covered by the bandage (the skin cannot be visible). There must not be folds in the bandage. The bandage must not be painful. If it is, it means that the bandage is too tight. The PT should teach the patient how to do the bandage by himself, so he can put it on alone. The bandage should be reapplied everyday, after treatment, until the day of the first fitting (the day the patient receives his prosthesis). Technique for AK stump bandage Technique for BK stump bandage The bandage should be kept the whole day. Note: The same technique and rules can be used for upper limb amputation too. (e) Starting when the scar is healed Scar massage: The purpose of scar massage is to maintain the scar flexible by preventing it from getting attached to underneath tissues (like muscles or bones). This is important because an attached scar will make more difficult for wearing a prosthesis (the scar would be painful and wound can appear).
- 12 Rules to respect during a scar massage: The patient should be installed in a comfortable position. The PT cannot use talcum powder for this kind of massage (because of the talc, the finger will slip and won't be able to "grab" the scar properly). Only fingers are used during scar massage (not the whole hand). The movements should always be made in the direction of the scar. The massage is not made directly on the scar but around it. The following techniques should be used: Scar massage should be done for about 10 minutes, 2 times/day. Note: If for some reason the patient has to stay in bed for a long time after the amputation, he/she might develop bedridden complications. Those complications have to be prevented or addressed properly. To do so, PT exercises can be used. For details, refer to the PT protocol for bedridden patients. Note: If the patient complains from phantom pain, the following techniques can be used (their efficiency cannot be guarantied): Before using any kind of treatment, explain to the patient what is happening (the brain misinterprets messages) and that the pain is not linked to any kind of mental illness, it s a very common problem that most of the time decreases and disappears after a while. TENS, acupuncture, medications (pain-killers, antidepressant, muscle relaxant), massage, heat or cold, ultrasound are reported as being useful to decrease phantom pain. An innovative technique uses a mirror box in which the sound limb and the stump are placed. The mirrors give the impression to the patient that the amputated limb is still there (the patient, thanks to the arrangement of the mirrors, sees two legs or two arms in the box while there is actually only one). Then, the patient moves the sound limb and he/she has the impression that the amputated limb is also moving. This can help to release phantom pain.
- 13 2.3. Treatment in the rehabilitation centre and in the community (long-term rehabilitation) Long-term rehabilitation will take place in a rehabilitation centre (or in a rehabilitation department in a hospital) and in the community. Note: For details on long-term rehabilitation, institution-based rehabilitation and community based rehabilitation, refer to the information brochure ( Information on rehabilitation ). (a) In a rehabilitation centre The main purposes of the treatment in a rehabilitation centre will be to provide the patient with a prostheses and to teach him how to use it. In case of problems such as muscle shortness, muscle weakness, poor balance or stump problems, exercises will have to be done to address those problems before producing the prosthesis. Therefore, the treatment in the rehabilitation centre might be composed of the 3 following steps: Pre-fitting treatment (muscle stretching, muscle strengthening, balance exercises, stump bandage, scar massage, care of wounds ). Production of the prosthesis Post-fitting treatment (exercises to teach the patient how to use the prostheses properly). Note: For details on exercises done in a rehabilitation centre, refer to the training document (PT management of patient suffering from lower limb amputation). (b) In the community CBR program can be helpful for amputees in various ways: Home visit to check up on the general patient s physical situation Home visit to check up on the device (does it still fit? Is it broken?), and referral to specialized structure (rehabilitation centre) if needed Guidance for home accessibility Guidance for access to school or vocational training centre or job Participation to self-help groups Awareness raising activities for the community members on disability-related issue (disability, rehabilitation, disabled persons needs and abilities).