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Amputation Rehabilitation and Prosthetic Restoration. From Surgery To Community Reintegration
Amputation Rehabilitation and Prosthetic Restoration. From Surgery To Community Reintegration
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with functional prostheses, which allow more patients to try.1 – 4 In the developing world, trauma is the leading
achieve independent life styles. This is of particular importance
cause of amputation caused by inadequately treated
for the multi-limb amputee. The rehabilitation of more
traditional lower limb levels of amputation have also greatly fractures, motor vehicle accidents (motorcycle and train)
benefited from the technological advances including energy and other motorized machinery. In countries with recent
storing feet, electronic control hydraulic knees, ankle rotators history of warfare or civil unrest, trauma can account
and shock absorbers to mention a few. For the upper limb for up to 80% of all amputations. In developed nations,
amputee, myoelectric and proportional controlled terminal
vascular complications of diabetes are the principal
devices and elbow joints are now used routinely in some
rehabilitation facilities. Experimental prosthetic fitting techni- cause of amputations, which, can be aggravated by the
ques and devices such as the use of osseo-implantation for use of tobacco. The major diseases that contribute to
suspension of the prosthesis, tension control hands or amputation are atero-occlusive vascular disease,
electromagnetic fluids for knee movement control will also diabetes mellitus and tumor.7, 8 In developed countries
be briefly discussed in this paper.
Conclusion: It is possible to conclude from this review that
like the United States, Denmark and Japan, disease
many advances have occurred that have greatly impacted the accounts for 68% of all amputations performed each
functional outcomes of patients with limb amputation. year.1, 2 Trauma related amputations usually occur as a
result of motor vehicle, industrial or farming accidents
and may account for approximately 30% of new limb
Introduction
amputations. Estimates indicate that there are 135
The exact number of people who have had amputa- million people with diabetes around the world and this
tions worldwide is difficult to ascertain, as many coun- number will continue to grow rapidly with changes in
tries do not keep records of the number of people with dietary habits.5, 6. Unless appropriate educational and
limb amputation. Based on information available from preventative measures are taken, a further increase in
the National Center for Health Statistics there are the incidence of limb amputation is likely to occur.
Congenital limb deformities account for a small portion
of reported limb amputations (up to 3% of reported
* Author for correspondence; Chair, Department of Physical
Medicine and Rehabilitation and Director, Moss Rehab limb losses).7
Regional Amputee Rehabilitation Centre. Philadelphia, Penn- The worldwide statistics on amputations by age are
sylvania, USA. e-mail aesquena@einstein.edu very difficult to obtain. In general those individuals with
Disability and Rehabilitation ISSN 0963–8288 print/ISSN 1464–5165 online # 2004 Taylor & Francis Ltd
http://www.tandf.co.uk/journals
DOI: 10.1080/09638280410001708850
A. Esquenazi
limb loss due to disease are older with the amputation level is preferred. Preserving length of the residual limb
occurring after age 60.8 Traumatic amputations occur to improve prosthetic suspension and force transmission
in a much younger, active and economically productive from the residual limb to the socket is a principal
population. Because of the high number of trauma responsibility and goal of the surgeon. The residual limb
related amputations and preferential use of tobacco by must be surgically constructed with care to optimize the
men, this gender has a higher incidence of limb amputa- intimacy of fit, maintain muscle balance, and to allow it
tion. to assume the stresses necessary to meet its new func-
Because of the etiology of amputation related to tion.9 Bony prominences, (see figure 2) skin scars, soft
medical co-morbidities more lower limb than upper limb tissue traction, shear and perspiration can complicate
amputations are performed with a ratio of almost 5 to 1. this function.10
Transtibial level accounts for 39%, transfemoral level After surgery the patient with a limb amputation
31%, transradial level for 15% and transhumeral level should ideally be able to use a prosthesis, be it body
for 8% of all amputations. Hip and shoulder disarticu- or externally powered, during most of the day through
lation, through knee and through elbow and wrist level a newly created man-machine interface (the socket/
account for the remaining (see figure 1). For the upper residual limb).10 After limb amputation, fitting of the
Disabil Rehabil Downloaded from informahealthcare.com by University of Montreal on 11/17/10
limb the right arm is more frequently involved in work first prosthesis should be implemented as soon as
related injuries. Sixty per cent of arm amputees are possible after wound healing. Application of an
between the ages of 21 and 64 years and 10% are under immediate postoperative rigid dressing can expedite
21 years of age.8 Congenital upper limb deficiency has an wound healing and maturation. Elastic bandages can
incidence of approximately 4.1 per 10 000 live births.7 also be used for this purpose as seen in figure 3. In
With regard to phases of amputee rehabilitation (see the upper limb amputee, this is of particular impor-
table 1), each of these phases contains specific evalua- tance, where there is a direct relationship between
tion items, treatment goals and objectives. Optimal the time of fitting and long-term prosthetic use and
rehabilitation care of the amputee begins, if feasible, a 1 – 6 months window of opportunity exists when
prior to the amputation and should be provided by a there is a much greater rate of acceptance and func-
For personal use only.
specialized treatment team. Communication between tional integration of the artificial arm for the unilat-
the members of the team and with the patient and eral upper limb amputee.10, 11
family members is essential and should provide the
team with the necessary information to develop a
Pain in amputation
treatment plan from amputation to home discharge.
The team should tell the patient what to expect after The pain perceived by the patient with an amputation
surgery and rehabilitation taking into account physical can be divided into four possible categories. These are
status, level of amputation, cognition, premorbid life- post-surgical pain, residual limb pain, prosthetic pain
style and socioeconomic level and prepare the patient (caused most frequently by standing and ambulating
with realistic short and long term expectations. with the prosthesis), and phantom pain (pain perceived
The viability of the soft tissues and skin coverage with as coming from the amputated body part). Each one
adequate sensation will usually determine the most of these pain categories is described as separate entities
distal possible functional level for amputation, whenever but overlap of the different types of pain may occur.12
possible amputation at the transtibial and transradial Pain may originate from other regions in the body unre-
lated to the amputation and referred to the amputated
limb. Such pain may be cardiogenic, neuropathic or
radiculopathic in origin. Systemic diseases such as
diabetes, ischemia or arthritis can also be the cause of
the pain and should be ruled out prior to attempting
treatment of the pain complaints. With a wide variety
of pain sources and treatment options available, treat-
ment of pain in the amputee must begin with accurate
diagnosis. Once the nature of the patient’s pain has been
clarified, appropriate interventions can proceed to allow
the patient to function comfortably. More in depth
discussion of the management of amputation related
Figure 1 Incidence of limb amputation by level. pain is beyond the scope of this paper. The reader is
832
Amputation rehabilitation and prosthetic restoration
Phase Hallmark
Preoperative Assess body condition, patient education, surgical level discussion, postoperative prosthetic plans
Amputation Surgery/Reconstruction Length, myoplastic closure, soft tissue coverage, nerve, handling, rigid dressing
Acute Post surgical Wound healing, pain control, proximal body motion, emotional support
Pre prosthetic Shaping, shrinking, increase muscle strength, restore patient locus of control
Prosthetic Prescription Team consensus on prosthetic prescription and fabrication
Prosthetic Training Increase prosthetic wearing and functional utilization
Community Integration Resumption of roles in family and community activities. Emotional equilibrium and healthy coping
strategies. Recreational activities.
Vocational Rehabilitation Assess and plan vocational activities for future. May need further education, training or job modification.
Follow-up Life long prosthetic, functional, medical assessment and emotional support
833
A. Esquenazi
Sockets
Old sockets were carved out of wood. With the devel-
opment of high temperature rigid plastic materials such
Figure 4 External powered hand without cosmetic cover as polyester resin, sockets could be molded to have total
(Otto-Bock) and body powered voluntary opening hook contact with decreased weight and increased durability.
(Hosmer/Dorrance). Reproduced with permission from the Sockets are custom made by obtaining a negative
manufacturer. impression of the residual limb (commonly a plaster of
834
Amputation rehabilitation and prosthetic restoration
References
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A. Esquenazi
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For personal use only.
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