Working with patients with lower extremity amputations is not particularly common. Unless you work in a clinic that specializes in prosthetics rehab, you are unlikely to see this patient population.
So what do you do when you have a patient with bilateral transfemoral amputations who just received his or her microprocessor knees a week ago and hasn’t walked in the past year? One option is to call in sick. Another is to read my top 6 tips for working with patients with lower extremity prostheses.
1. Know the types of amputations
First, it would be prudent to know the types of lower extremity amputations you will most likely be seeing. Transtibial or below-knee amputations make up approximately one-half of all amputations, with transfemoral or above-knee amputations coming in second place at approximately one-third of all amputations. Much less commonly, you may see hip or knee disarticulations, as well as partial foot or toe amputations. Together, these surgeries make up less than 15% of lower extremity amputations.
2. Know the types of prosthetic legs and their components
It is absolutely essential that you have a basic understanding of the patient’s prosthesis. The basic components of a lower extremity prosthesis include the foot and ankle assembly, the pylon, and the socket.
For patients with transfemoral amputations, their prosthesis will include a knee joint. This knee joint can be mechanical or controlled by a microprocessor computer. Lastly, you should know the different types of suspension systems, which are the methods that keep the prosthesis attached to the patient’s residual limb. These include suction systems, lanyards, pin systems, sleeves, or vacuum-assisted systems.
Patients will have many questions about these things. They won’t know how to put the prosthesis on. The prosthesis might fall off while you are walking with them, or you may need to adjust it about 8 times throughout your session. Having a working understanding of the parts of each prosthesis is critical for working with this patient population.
Prosthetic technology is an ever-expanding world and it can be overwhelming at first glance. However, you can start collecting knowledge by reaching out to a local prosthetist with your questions and concerns. In my experience, the best way to reach out to prosthetists is to just simply call them and talk. The prosthetists I have worked with are more than happy to give advice and answer questions. Sometimes they will even come to your treatment sessions and work with you and the patient directly. Also, you will occasionally see inservices and presentations by them at their own facilities.
3. Understand the psychosocial considerations
Having a part of your leg surgically removed is a life-changing experience. You need to be sensitive to this person’s emotions, thoughts, and feelings while going through this journey. It is important to understand that losing a limb has implications for every aspect of this person’s life.
A patient might have lost their leg after a long battle with cancer. It might mean that they can’t walk their daughter down the aisle at her wedding next month. It might mean that a trip to the grocery store becomes an all day affair. This person might not be able to drive anymore. It may lead to financial trouble from medical bills, public transportation, home health aides, etc. It may even mean that this person will be wheelchair bound for the rest of their life.
You could also see a patient where none of these things apply and having an amputation just means that putting on a prosthesis is just an extra step in their morning routine before breakfast. However, no matter how a person handles their amputation, taking a biopsychosocial approach to treatment will enable you to better understand what they are going through.
4. You need to be the gait EXPERT
Patients with amputations typically have one goal: walking. Therefore, the majority of your session with them will be just focused on walking. So prior to seeing these patients, you may want to brush up on your gait analysis. Go through the phases of gait and understand the things that need to happen at each body part.
It is also critical for you to be familiar with typical gait deviations seen with patients with prosthetics. These include asymmetrical weight bearing, increased weight bearing on assistive devices, significantly decreased cadence, hesitation with stepping, circumduction, minimal knee flexion engagement (in the case of patients with a microprocessor knee), and plenty more. Gait analysis is a skill that you absolutely must develop.
5. Keep track of the co-morbidities associated with amputations
A large percentage of amputations are associated with comorbidities that have significant, life-long health consequences.
These diseases are associated with multiple-system complications. They put these patients at risk for future amputations. Assessing vitals, carefully dosing exercise, and advocating for general healthy behaviors are an absolute must!
I have had many treatment sessions where I have had to debate whether or not to call emergency services due to changes in vitals. A patient I am currently treating regularly has his oxygen saturation levels drop to 87-93% after a few short walks. I have sent a patient home after about 20 minutes because their blood pressure wasn’t cooperating. Another patient of mine lost his right foot due to complications from diabetes and is now going down a similar path with his left foot.
6. Educate on the importance of skin hygiene
One of the most important tips I can give you is to ensure that you are teaching your patients about the importance of residual limb skin care and regular skin checks, especially in the early stages of getting a prosthesis. Skin integrity is likely already impaired with these patients. The comorbidities associated with amputations, i.e. vascular disease and diabetes, will limit blood flow to the area and prolong healing time following the amputation surgery. Having ongoing issues with skin integrity or wounds that do not heal can severely limit a patient’s ability to wear their prosthesis and thus limit overall recovery.
I have seen this first hand. Sometimes overzealous patients will walk too much, put too much pressure on their residual limb, and have previous cuts and blisters open up, sidelining them until they heal. I am seeing another patient whose surgical wound is taking months to heal and is not even allowed to get fitted for a prosthetic until it gets better. And there are some patients who may have an infected wound, which may ultimately require another amputation. We can be one of the first lines of defense against these types of issues.
Educating about appropriate skin hygiene, including the importance of keeping it clean, general wound care, recognizing signs of infection, and knowing when to take a break from wearing the prosthesis is one of the most important aspects of working in prosthetics rehab.
While a comprehensive article on how to treat patients with lower extremity prostheses would be longer than you would want to read, these 6 tips can get you started. And while I am still learning myself, these are the best lessons I have picked up along the way.
Learn about the different types of amputation surgeries and the health conditions typically associated with them. Study prosthetic technology and don’t be afraid to reach out to a local prosthetist with questions. They will be more than happy to answer them and they will ultimately gain a contact that they can refer future patients to. And make sure that you brush up on your gait analysis because there is a good chance (100%) you will be doing some walking. The world of prosthetics rehab is truly unique and is an amazing opportunity to leverage all of your skills and interests as a physical therapist, so take the challenge in stride.
Bhuvaneswar CG, Epstein LA, Stern TA. Reactions to amputation: recognition and treatment. J Clin Psychiatry. 2007;9 (4): 303–8
Raichle K, et.al. Prosthesis use in persons with lower- and upper-limb amputation. J Rehabil Res Dev. 2008; 45(7): 961–972.
Ziegler-Graham K, MacKenzie EJ, Ephraim PL, Travison TG, Brookmeyer R. Estimating the prevalence of limb loss in the United States: 2005 to 2050. Arch Phys Med Rehabil 2008;89:422-9.