Living with amputation - how does specialist physiotherapy help?

The road to rehabilitation, restored mobility and independence can be rough for an amputee. So, what’s the secret to successful use of prosthetics? We asked Kat Sizer, Clinical Specialist Physiotherapist at Pace Rehabilitation to share her insights into the importance of her role as physiotherapist in the amputee’s rehab team.

What are the most common problems that a lower limb amputee faces from a physio perspective?

We may see a wide range of issues relating to the amputation, prosthesis and the illness or accident that may have led to it. We often see impairments to muscle movement patterns, balance, falls, pain, reduced fitness and difficulties managing functional movements, such as stairs, slopes and getting on and off the floor. We may also see associated musculoskeletal problems around the remaining joints or lower back.

Are these different from problems faced by upper limb amputees?

The impairments can often be the same – upper limb amputation affects muscle patterns, balance, pain, reduced fitness and compromised function. The functional problems experienced by upper limb amputees tend to affect patients throughout all their activities of daily living (ADL). As a physio, I work with the patient to manage musculoskeletal problems around the neck and shoulder, to help maintain good postural strength and stamina to support prosthetic use.

Our occupational therapy (OT) colleagues at Pace train patients to use the many intricate levels of a prosthetic hand, as it takes significant physical and cognitive (mental) effort to manage ADL tasks.

What type of issues are you assessing when you first meet a patient?

At assessment we assess the remaining part of the patient’s limb for skin quality, muscle bulk, pain and sensation. Patients whose limb loss arose from trauma may have scarring and skin grafts that may cause problems. We then assess muscle power and range of movements in all the major joints. If a patient needed a significant period of recovery post-surgery with prolonged wheelchair use or bed rest, muscle and joint movement patterns may be impaired. We constantly observe function and movement through tasks from transferring in and out of a wheelchair through to walking with a prosthesis, if they already use one. We also assess patients’ ability to problem solve and their goals, as these affect how successfully they will use a prosthesis or orthosis (supportive splint or brace).

What exercises might you recommend for amputees?

Everyone with amputation, regardless of upper or lower, needs exercises for strength, fitness and flexibility. We also recommend specific exercises to suit the level of amputation and the individual’s personal ‘problem areas’:

Lower limb amputees

It is essential that lower limb amputees can weight transfer fully onto the prosthesis.

• Lower limb below knee amputees
  Recommended exercises for below knee amputees depend on the problems identified in assessment, but the priority is always to build up tolerance and strength to weight bear through the prosthesis. We do this by working on weight transfer and balance exercises, with thigh and buttock muscle strengthening, to ensure activation of muscles is timed correctly. Targeted areas are likely to be the hip stabilising muscles and thigh muscles that support the knee joint.
• Above knee amputees
  The priorities are similar to that of a below knee amputee, but with greater emphasis on weight bearing and trust of the prosthesis. Full control of the prosthesis comes from the hip, pelvis and lower back, so these muscles need to be very strong. Balance and trust building exercises using steps, uneven cushions and small objects on the floor also help. In the above knee amputee, pilates based exercises are essential to ensure stability around the pelvis and reduce the risk of back pain.
  Specialist training is then needed to master the use of more advanced components, such as commonly fitted microprocessor-controlled knees which take training to control fully, especially out in the real world where nothing is flat.

Upper limb amputees (above/below elbow)

For the upper limb amputee, physiotherapy exercises focus on shoulder stability and postural setting. There are then more specific exercises for functional use of a prosthesis with ADL tasks. Our OT colleagues work in a functional environment, in the clinic equipped with specific tools and kitchen items, or at home or work for more specific goals for the patient’s needs.

Can physiotherapy help an amputee before they have a prosthetic?

The pre-prosthetic phase of rehabilitation is important. We work with clients to help manage swelling and pain in their residual limb and use exercises to maintain range of movement, build cardiovascular fitness and strength in targeted areas. If pilates-based exercises begin before a prosthesis is fitted, we provide hands on assistance to ensure correct technique, safety and pain management.

Why is it so important to have physiotherapy treatment alongside prosthetic provision?

In a nutshell, the physio can teach the individual to stand and move correctly, helping with alignment and settings of the prosthesis to suit the individual’s movement patterns.

Successful prosthetic use requires full trust in the prosthesis. The socket interface (where the prosthesis fits onto the limb) must be comfortable for the patient to place their full body weight on the prosthesis and achieve this vital step in learning to use the prosthesis. For this reason, we aim to do our physiotherapy alongside and jointly with prosthetic appointments, so that we can resolve problems quickly and get on with the rehab. This also helps us give accurate feedback to the prosthetist, especially whilst the patient is still learning what is ‘normal’ for prosthetic use and what is not.

Is it important to have been active and healthy before amputation?

Being active and healthy previously certainly helps a new amputee cope with the mentally and physically intense and tiring rehabilitation process.

What are the longer term benefits of physiotherapy treatment for an amputee?

Amputation is permanent, therefore the need for physiotherapy is intermittent and lifelong.

A physiotherapy maintenance routine is important for all amputees as movement patterns need regular monitoring, review and progression. Amputees can have an increased risk of musculoskeletal injuries to the remaining joints, which will require treatment. Amputees benefit from specialist prosthetic physiotherapy input when their prostheses are replaced throughout their lifetime, especially as training will be needed to adapt to advances in technology.  

Can an amputee benefit from massage and management of their residual limb?  

Yes, it can offer a number of benefits such as: pain relief, desensitisation of the nerves, swelling management, scar management and relaxation of muscles. Care of the residual limb has a huge impact on daily successful use of a socket.

Is there any reason why an amputee cannot work out in the gym?

No, however, for some the gym environment can be intimidating, so some home gym equipment can be useful. Guidance from a personal trainer, under the supervision of a specialist physiotherapist, will support an effective and interesting exercise programme.

Do you always work in a workout room/gym?

No, not always. Exercise can be done anywhere. A typical physio plan would involve: gym exercises, functional exercises using our clinic room stairs and slopes, general fitness exercise, such as swimming, then outdoor mobility training. We are often found walking through the local trails and footpaths to practice certain skills with patients. For some, the programme may then be more specific to individual goals, activities or sports.

How do you use a multidisciplinary (MDT) approach to get the best from the patient?

Teamwork provides a much easier process for the patients and communication allows for better care. The rehabilitation process is stressful, so we aim to ease this as much as possible by consolidating visits and speaking to each other, so the patient doesn’t have to remember it all. We recognise that patients have emotional, mental, functional and physical needs, so our MDT provide co-ordinated, holistic care. This approach is especially beneficial when working with our paediatric patients, as consolidating appointments is less disruptive to school and family life.

If you or a family member have had or are facing amputation as a result of negligence, and would like to find out more about making a claim, contact us by email at mednegclaims@boyesturner.com.