Amputations and Prosthetics

Causes and Incidence of Amputation

Most amputations may result from trauma; peripheral vascular disease (PVD); peripheral vasospastic disease; chronic infection; chemical, thermal, or electrical injury; or malignant tumor. Elective upper limb amputations may occur as a result of a severe or complete brachial plexus injury⁹ or other medical conditions that limit the neuromuscular function of the limb.

Calculation of the number of individuals with limb amputations worldwide is difficult to complete because many countries do not keep records of these data. The U.S. National Limb Loss Information Center estimated 1.7 million Americans with upper limb loss in 2007, based on an unpublished study out of John Hopkins University. This number is projected to reach 3.6 million by 2050. Lower limb loss (80%) is more prevalent than upper limb loss (10%) or multiple limb loss (10%). Upper limb loss due to trauma is increased during times of active warfare.^47a The incidence of amputation remains fairly constant between the ages of 1 and 15. From 21 to 64 years of age, however, a gradual increase in incidence occurs because of work-related injuries and highway accidents. Approximately 75% of upper limb amputations in adults are caused by trauma,^1,34,43,43a as was the case for Roberto.

Previously, the level of amputation of the upper limb was referred to by its relationship to the elbow joint. For example, the terms above-elbow (AE) amputation and below-elbow (BE) amputation were universally used to clarify the level. This terminology has changed to reference the anatomy of the body when describing the level of limb loss. Terms now used include trans-radial, trans-humeral, and partial hand. See Figure 43-1.

The major cause of lower limb amputation is PVD, often associated with smoking and diabetes.^36,39,56 Between 1988 and 1996, 82% of all lower limb amputations occurred as a result of vascular problems.¹⁵ Despite major improvements in noninvasive diagnosis, revascularization, and wound-healing techniques, 2% to 5% of individuals without diabetes but with PVD and 6% to 25% of those with both PVD and diabetes undergo amputation.^{28,29,41,45,68} Perioperative mortality rates of persons with lower limb amputation have been variously reported as between 7% and 13% and are usually associated with other medical problems, such as cardiac disease and stroke.^22,28,29

The second leading cause of lower limb amputation, accounting for approximately 17% of amputations, is trauma,¹⁵ usually the result of motor vehicle accidents or gunshots. Individuals with traumatic amputation are usually young adults and more frequently are men.^20,27 Improved imaging techniques, more effective chemotherapy, and better limb salvage procedures have reduced the incidence of amputation from osteogenic sarcoma. Tumor resection followed by limb reconstruction frequently provides an extremity that is as functional as a prosthesis and does not appear to affect the 5-year survival rate.^{30,38,61,67,75}

Surgical Management

The surgeon is an important team member. Before performing surgery, the surgeon should consult with the health care team to maximize the functional outcome. The surgeon attempts to preserve as much length as possible and to provide a residual limb that has good soft tissue coverage and vascularization. Preservation of limb length directly affects the type of prosthesis that the limb can support; thus the surgeon and the prosthetist ideally communicate before surgical amputation or closure is performed. Conservation of residual limb length and uncomplicated wound healing are important. During and after surgery, the primary goal is to form a residual limb that maintains maximal function of the remaining tissue and allows maximal use of the prosthesis.^6,34,64

Blood vessels and nerves are severed and are allowed to retract so that residual limb pain is minimized during prosthetic use. Bone beveling is a surgical procedure that smooths the rough edges and prevents the development of spurs (small projections of bone beyond the natural surface) on the remaining bone. Muscles are sutured to the bones distally by a surgical process called myodesis. The muscles involved in the function of the amputated limb are correspondingly affected by the loss.⁵¹

Surgical techniques vary with the level and cause of amputation.^63,64 A closed or open surgical procedure may be performed. The open method allows drainage as the surgical site heals and minimizes the possibility of infection. The closed method reduces the period of hospitalization but also reduces free drainage and increases the risk of infection.⁶⁴ The specific type of amputation performed is left to the discretion of the surgeon and is often determined by the status of the limb at the time of amputation. The surgery may be ablative (removal of devitalized tissues) only or reconstructive. In either case, the surgeon must remove the part of the limb that has to be eliminated and allow for primary or secondary wound healing. When the surgeon reconstructs a residual limb (sometimes referred to as a stump), this is done to achieve optimal prosthetic fitting and function. The residual limb that results should be strong and resilient.⁶⁴

Client Social, Cultural, Personal, and Spiritual Contexts

Profound psychological shock and disbelief are likely to accompany amputation, particularly for those who experience a sudden trauma that causes or necessitates amputation.^17,32,34 Seeing the residual limb for the first time can cause shock, panic, despair, self-pity, suicidal impulses, and even rage.⁴⁹ Feelings of hopelessness, despondency, bitterness, and anger may ensue. Some individuals may mourn not only the lost limb but also the possible loss of a job or the ability to participate in favorite sports or activities.

The person may feel lonely, isolated, and an object of pity. Concerns about the future, body image and function, the responses of family and friends, and employment all affect the person’s emotional status.⁴⁹ Reactions to amputation may be less severe in individuals who have had a chance to adjust before the surgery is performed.^17,32,34 Older persons may demonstrate postoperative confusion, whereas younger persons may have a sense of mutilation, emasculation, or castration.^17,32

The person’s personality; age; cultural background; and psychological, social, economic, and vocational resources influence the reaction to amputation. Ultimately, the individual must come to terms with the consequences of limb loss and the perception of diminished attractiveness. The person confronts discomfort, inconvenience, economic expense, loss of function, increased energy expenditure, and possible curtailment of favorite occupations. He or she may need to change employment because of social discrimination and to cope with resultant medical problems.¹⁷ Roberto expressed a strong desire to return to work. He recognized that his work capabilities had always been in the manual labor category. Roberto accepted consultation with a vocational counselor to assist him in the goal of returning to gainful employment as quickly as possible. He accepted the fact that some jobs identified by the counselor may be unfamiliar to him.

Cultural factors are important in the reaction to amputation. In some social, cultural, or religious groups, amputation may be considered a means of punishment or atonement. Such beliefs and the general aversion of society to amputation can cause the affected person to adopt the same viewpoint or to perpetuate his or her own preexisting viewpoint. Similar attitudes can result in self-hatred and self-deprecation, which may affect the person’s reaction and adjustment to the disability.¹⁷

Depression and a sense of futility are considered a normal part of the adjustment process.¹⁷ If depression is severe and prolonged, psychological or psychiatric referral is indicated. Medication may be necessary to reduce depression.¹⁷ The preexisting personality of the person determines the severity and duration of the reaction, and ultimately the adjustment to the amputation and to prosthetic use.^16,17 Roberto acknowledged his depression, reported that it was decreasing (6 months after the amputation), and said that he was actively involved in planning his life and attaining his goals for the future.

Postsurgical Physical Client Factors and Performance Skills

Several factors and potential problems can affect the outcome of rehabilitation. Length of the residual limb, skin integrity, edema, sensation, pain, time for healing, infection, and allergic reaction to the prosthesis are among the physical factors that affect rehabilitation potential.³⁷

Body-Powered Prostheses

Electric-Powered Prostheses

Externally powered electric upper limb prostheses have opened a new world of freedom and function for persons with upper limb amputations. The advent of electronic microminiaturization has allowed the development of prosthetic devices with totally self-contained services of power, motor units, and electrodes.²⁵ Powered prostheses have existed for decades, but it was not until the 1960s that myoelectrically controlled prostheses were clinically introduced. The activities of the Otto Bock Company in Duderstadt, Germany, began this process by aiming for the development of an electromechanically driven prosthetic hand that would match the technical and cosmetic demands of a human hand.⁴⁷

Clinical use of the electric devices began in Europe because of government-supported health care systems and a large client population of persons with congenital (post-thalidomide) amputations. By the late 1970s and early 1980s, clinicians in North America had increasing but limited experience with myoelectric prostheses.¹² When funding permits, hundreds of myoelectric prostheses are prescribed for children and adults throughout the United States.

The term myoelectric prosthesis is often used interchangeably with electric prosthesis.

A myoelectric prosthesis uses muscle surface electricity to control the prosthetic hand function. The muscle membrane generates an electric potential at the time of contraction. The myoelectric signal is sensed, amplified, and processed by a control unit that generates a motor, which in turn drives a terminal device.¹² This terminal device is often an electromechanical hand (Figure 43-21).¹⁰ Several different types of myoelectric hands are available. The myoelectric control can be a digital control or a dynamic mode control (proportional control). Digital systems are operated at only one speed, allowing them to turn on or turn off. Proportional control means that the myoelectric signal (power) to the hand is proportionate with the level of muscle signal that the wearer generates, so the wearer’s effort directly controls the speed of the hand.³ A SensorHand (Otto Bock, Minneapolis, MN), which provides automatic grasping when the object in the hand is slipping and its center of gravity is changing, is now available (Figure 43-22). The motor automatically increases pressure applied to the object being held to prevent dropping of the object.

Myoelectric controls require minimal physical effort for operation. Muscle groups in the forearm are most frequently used according to their physiologic function, that is, the wrist extensor muscles are used for hand opening and the wrist flexor muscles for hand closing. Surface electrodes recessed within the wall of the prosthetic socket (Figure 43-23) detect muscular contractions.

Commercially released in 2009 were two electric hands from Touch Bionics (Hilliard, OH), one of which offers a powered solution to a person with a partial hand amputation.

Summary

The rehabilitation process for clients with upper limb loss can be challenging and rewarding. In the case of a trans-humeral amputation, shoulder disarticulation amputation, or bilateral limb loss, training and expertise on the part of the therapist are essential. The therapist can review several resources to enhance his or her knowledge in this area of occupational therapy intervention.

The potential of individuals with upper limb loss is limitless; they often are able to accomplish activities that no one ever would have predicted. The success of rehabilitation does not rest solely on the quality of training in use of the prosthesis. Rather, success depends on such complex factors as the quality of medical management, the type and fit of the prosthesis, client factors, performance skills and patterns, and the client’s interest in learning to use the prosthesis, as well as conscientious follow-up once the rehabilitation phase is complete. Follow-up is critically important and is often overlooked.

Perhaps the most important aspect of a successful rehabilitation program is the client’s desire to become more independent. All team members should cultivate and reinforce this desire, which is a pivotal ingredient of successful intervention. The effectiveness of the occupational therapist during this important process will remain with the client for life.

Levels of Lower Limb Amputation

Lower limb (LL) amputations are typically discussed as above-knee or below-knee; however, variability exists even within these categories (Figure 43-32). Generally, the more proximal an amputation is, the greater is the functional challenge presented to the person with the amputation. Proximal LL amputations include hemipelvectomy and hip disarticulation amputations, resulting in loss of the entire lower limb; such severe amputations are typically performed in cases of trauma or malignancy. Wound healing from such proximal amputations is often slow, and skin grafting may be required for full healing. In cases of hemipelvectomy, a muscle flap will cover the internal organs.

A transfemoral or above-knee amputation (AKA) results in loss of the knee and everything distal to it. Residual limb length from an AKA typically varies from 10 to 12 inches (5.4 to 30.5 cm) from the greater trochanter⁷; transfemoral amputations can also be classified as upper, middle, or lower third, indicating the amputation distance from the ischium. A through-the-knee (disarticulation) amputation does result in loss of knee joint function, but it allows a high level of prosthesis control and mobility.

A transtibial or below-knee amputation (BKA) preserves the knee and thus eliminates the necessity for a mechanical knee joint in the prosthesis. The residual limb from a BKA typically varies from 4 to 6 inches (10.1 to 15.2 cm) in length from the tibial plateau.⁷ A Syme’s amputation, or ankle disarticulation, results in loss of both ankle and foot function and is typically performed in cases of trauma or infection. A transmetatarsal amputation results in severing the foot through the metatarsal bones, but the ankle remains intact. Clients may experience amputation of toes; although amputation of the first toe impairs ambulation by preventing toe-off (which is the end of the stance or support phase of gait), loss of the small toes does not usually result in impaired ambulation. In Lena’s case, the amputation is considered a BKA because her left leg was amputated approximately 5 inches below the tibial plateau.

Causes of Lower Limb Amputation

In the United States, 95% of LL amputations are performed as a result of complications of PVD²⁶; ultimately, 25% to 50% of these cases are due to diabetes mellitus.⁵⁴ Trauma is the second most common cause of amputation in the United States, but it is the leading cause in developing countries because of land mines and other environmental hazards.⁵⁴ Amputation may also be performed in cases of malignancy in an effort to prevent it from spreading to other sites or systems in the body.

In Lena’s case, diabetes mellitus and PVD resulted in poor circulation in her LLs. Because of this complication, blood flow to her left foot and leg was not adequate for her limb to heal, even from what initially appeared to be a small wound. Therefore, she was obliged to undergo progressive amputations of her left LL, eventually leading to her recent BKA.

Postsurgery Residual Limb Care

Skin care and positioning are extremely important throughout the course of rehabilitation, especially immediately after surgery. Once the surgical wound has begun to heal, some form of specialized postsurgical dressing will be used to help prevent swelling and to shape the residual limb for ease of future prosthesis use. Wrapping with an elastic bandage, such as an Ace wrap, is a common method to control edema after surgery. However, smooth wrapping does require skilled and consistent technique, which is necessary to prevent poor shaping of the residual limb. A series of gradually smaller residual limb shrinkers can be worn as an alternative to elastic bandage wrapping, to encourage constant, even shrinkage of the residual limb for fit with a final prosthesis. Both elastic bandages and shrinkers can be used early after surgery, even if the client’s surgical wound still has a dressing on it. In such a case, a nylon stocking would first be applied to prevent the bandage or shrinker from dislodging the dressing. Once the final prosthesis is made and adjusted, the client frequently will continue to wear a shrinker during the day when he or she is not wearing the prosthesis, as well as at night. This shrinking and shaping process can take up to 3 months or longer in some cases, depending on the client’s condition.

If the client (or his or her caregiver) is unable to demonstrate proper technique with wrapping or shrinker use, a Jobst compression pump may be used. The pump is an air-filled sleeve that surrounds the residual limb, placing constant, equal pressure on all sides, quickly shrinking and shaping the residual limb. A rigid dressing, or cast, is frequently used for active clients after surgery. The end of the cast is made to work with a simple training prosthesis, so the client can begin training for standing and walking immediately. Scar massage may be necessary later in the healing to prevent adhesions and enhance comfort around the surgical site; this massage technique can be taught to the client. The Ace wrap bandaging of Lena’s residual limb was performed by nurses in the hospital. After Lena’s arrival at the skilled nursing facility, the nursing staff consulted the occupational therapist to determine whether Lena had the cognitive and visual function, as well as the necessary motor skills, to learn how to apply her own wrap or shrinker and to perform her own scar massage.

Lower Limb Equipment and Prostheses

Movement and time out of bed are typically reduced immediately after LL amputation. The surgery itself can make movement uncomfortable, and many persons who have undergone amputation surgery have preexisting conditions that may further reduce mobility. For these reasons, clients may require the use of bed rails or a metal trapeze bar hanging over the bed to help reposition themselves in bed and to transition between supine and sitting. Wheelchairs also present a challenge because the client is no longer able to support the affected limb by resting the now absent foot on the floor or on the footrest of the wheelchair. A residual limb support is basically a padded board that is placed on the seat of the wheelchair; it has an extended component on the side of the affected limb that projects forward from the seat of the chair (Figure 43-33). This extension provides a surface for the residual limb to rest upon, thus placing the limb in a nondependent position and reducing stresses placed on the hip joint. A person with a BKA is often at risk for developing a flexion contracture of the knee joint, and residual limb support can facilitate extension of the knee in sitting, thus helping to prevent both edema in the residual limb and contracture of the knee joint.⁷³ A residual limb support is sometimes still referred to, in less acceptable terminology, as a stump support. For a person with bilateral LL amputations, the large wheels on the wheelchair must be placed farther back to accommodate the change in body weight distribution. Antitippers, commercially available wheelchair accessories, can also be used on the back of the chair to reduce the likelihood of tipping backward during weight shifting.

Most clients will use a walker during at least the initial phases of their rehabilitation. Some clients with LL amputations will go on to use a walker at all times for ambulation. Both four-footed (standard) and two-wheeled (rolling) walkers may be used, depending on the client’s individual characteristics and needs. It has been suggested that using a two-wheeled walker may allow those with prosthetic limbs to ambulate more quickly and with less interruption,⁶⁹ but walker choice should always be made on the basis of a total assessment of the client’s abilities and needs.

Many types of prostheses are available for the LL, and technology is improving daily. For all prostheses, comfort, ease of application, appearance, and function of a prosthesis, including the client’s ability to perform ADLs and IADLs with use of the affected limb, correlate significantly with the client’s walking distance and with his or her perceived quality of life after an LL amputation.⁴⁰ It is very important for the rehabilitation team to keep this in mind during a client’s fitting for and training with a prosthesis.

The main components of an LL prosthesis are the socket, a sock or gel liner, a suspension system, a pylon, and a terminal device. For some prostheses, an articulating joint is also necessary. The socket is the direct connection between the residual limb and the prosthesis. A person’s residual limb may change in volume during the day and over the course of time, presenting challenges for maintaining an adequate fit within the socket. This challenge is frequently addressed by adding to, or removing socks from, the residual limb to adapt to its volume changes. Smart variable geometry socket (SVGS) technology was developed to help reduce this challenge.²¹ SVGS adds and removes liquid from the intrasocket environment on the basis of intrasocket pressure during wear, continuously accommodating for residual limb volume changes and thus maintaining the fit of the socket without having to remove the prosthesis. Static elastomeric liners are also used for the prosthesis socket; the choice of liner is based on variables such as fit, comfort, friction tolerance, and price.⁵⁷ Various suspension mechanisms are used to attach the socket to the residual limb, including belts, straps, wedges, or suction; sometimes mechanisms are combined to ensure appropriate fit.

The pylon is the structure that attaches the socket to the TD (Figure 43-34). Vertical shock pylons function as shock absorbers for LL prostheses. Many clients who have had an LL amputation express a preference for walking with these devices.¹⁹ Such shock absorption is especially beneficial during high-impact activities, such as running, and for other activities that are part of daily life for many clients, such as descending curbs and stairs. A pylon can be a basic, static device that provides minimal cosmetic benefits; it can also be a dynamic device, such as that outlined in the preceding paragraph, and can be modified to provide a close cosmetic match with the client’s unaffected limb.

The TD is the prosthetic foot, which provides a stable weight-bearing surface and can itself function as a shock absorber. The many types of available TDs provide varying degrees of mechanical ankle movement and dynamic response, according to the needs and abilities of the client. Specialized TDs—indeed, entire LL prostheses—are designed to accommodate the challenges presented by various sports and activities (Figure 43-35). To help select the best prosthesis, Lena’s prosthetist consulted with her occupational therapist to explore the activities and lifestyle to which Lena wished to return.

Participation in Areas of Occupation

For some clients, particularly those who underwent a traumatic amputation, the activities to which they wish to return are ones that they engaged in right up to the point of injury or illness. However, given the nature of PVD and diabetes, many clients with LL amputations experience a progressive decline in function over the course of several years. For these clients, amputation and subsequent rehabilitation, although difficult, may allow a return to fulfilling occupations that had been absent from the clients’ repertoire for quite some time.

Participation in most ADLs will be affected by LL amputation. Although a client with an LL amputation will be learning new mobility techniques in physical therapy, he or she must also participate in occupational therapy to learn new functional mobility techniques with which to accomplish familiar tasks. Bathing, dressing, personal hygiene, grooming, and toilet hygiene will likely need to be addressed as part of an occupational therapy intervention program. Personal device care must be addressed if the client is using an LL prosthesis. Participation in IADLs will also be affected. Particular attention should be paid to care of others, care of pets, child rearing, community mobility, health management and maintenance, home establishment and management, meal preparation and cleanup, safety and emergency maintenance, and shopping. The areas of rest and sleep may also present challenges to a person with a new LL amputation. For example, one’s evening routine may be disrupted by having to perform it from a wheelchair instead of at an ambulatory level (sleep preparation). A client may experience difficulties interacting with his or her spouse in the sleeping space as they both adjust to a new amputation (sleep participation). The occupational therapist should assess how these areas of occupation may be impacted by the amputation, and should help the client develop adaptations that facilitate improved rest and sleep. Treatments addressing phantom sensations may also benefit the client’s rest and sleep. (See Chapter 13 for further information.)

Participation in educational, work, play, and leisure activities is usually affected by LL amputation and should be addressed during occupational therapy, as should social participation. Although intervention often assumes a greater role with these areas of occupation later in the rehabilitation process, they still can be addressed even during the acute rehabilitation phase, thus reinforcing to the client that these are areas of occupation in which a return to active participation is indeed possible. It is essential that the occupational therapist help clients to explore all avenues of an occupation in which they may wish to participate, ensuring that even activities that had been abandoned in the past are possible again.³³ As a result of changes in function after amputation, clients may not be able to return to participation in prior work or leisure activities or to participation at the level to which they were accustomed. In such cases, the occupational therapist should help clients explore other opportunities that they might find fulfilling through identification of interests, skills, and opportunities.

Early in her course of occupational therapy at the skilled nursing facility, Lena spoke with her therapist about how much she missed walking to her church and helping to bake pies for its annual autumn festival. Lena said that she stopped doing this about 10 years ago because it became so difficult; she then discussed feelings of isolation and uselessness. Lena said that she had been known throughout her town for her pies, and she proudly recounted how each year people would tell her that she should open her own restaurant. Although Lena and her occupational therapist had initially set her long-term goals for independence with self-care and basic home management, they decided to add a goal for community re-entry that focused on being able to re-engage in this occupation.

Client Factors

Structures related to movement, as well as skin and related structures, are always altered by an LL amputation. The status of other body structures must also be assessed, however, to determine the level of support or challenge that these structures might present during the rehabilitation process.

Neuromuscular and movement-related functions will be altered by LL amputation, and this will affect occupational performance after surgery. This alteration of function may occur not only in the affected limb but also in other parts of the body. Because of changes in the affected limb, greater stresses will be placed on the rest of the body; a person’s unaffected leg as well as his or her arms will experience increased weight bearing during many functional activities, and both surgical wound healing and increased time in bed will place greater demand on skin functions.

Of particular importance is attention to sensations of pain. Up to 84% of persons who have had an LL amputation have experienced phantom limb pain.¹¹ In such an instance, the client may experience sensations in the part of the limb that has been removed, such as feelings of cramping, squeezing, shooting, or burning pain. In these cases, the therapist can use desensitization techniques (such as massage of the residual limb), exercise, hot and cold therapy, or electrical stimulation⁵⁴ to help decrease these sensations and allow the client to more easily and comfortably participate in chosen occupations.

Clients with PVD already have compromised cardiovascular function, and care must be taken to determine how much activity can safely be tolerated during therapy. A client’s mental and sensory functions will affect the way in which therapy, including education, is delivered; they will also affect what types of prosthesis and equipment are used.³¹ Some clients may be able to incorporate new techniques quickly, recalling information from one session or even from reading material, and may be able to independently apply this learning to new situations. However, other clients will require adaptation of training and may require prolonged treatment to turn the new techniques that they have learned into habits. Understanding a client’s values, beliefs, and spirituality will further help the therapist to develop a treatment program and choose interventions that are tailored to that client and best meet his or her needs.

The occupational therapist found that Lena would need to increase her upper body strength to help support herself during transfers and ambulation with the walker. She also needed to improve her postsurgical postural alignment and gait patterns to participate in her chosen occupations. Lena was experiencing pain and sensitivity in her residual limb. However, Lena’s mental functions were found to be strengths, and her vision and the sensation in her hands, although slightly diminished, were functioning at a level sufficient to support her desired functional activities. Additionally, Lena’s belief that good efforts yield results, as well as her commitment to her spiritual and social communities, would facilitate her engagement in her occupational therapy program.

Performance Skills

The most overt effects of LL amputation will be evident in the area of motor and praxis skills. Adjusting posture, coordinating movements, maintaining balance, and bending are altered after surgery, and the client must address each of these skills in therapy to return to a full repertoire of occupations. Sensory and perceptual skills may also be affected by the amputation, and a client may have had prior difficulty with these skills caused by impaired sensory function. The client’s cognitive skills (such as judging, sequencing, and multitasking) and communication and social skills will affect his or her participation in treatment and the therapist’s choice of treatment methods.

Lena’s occupational therapist found that, as she expected, Lena exhibited impairment in stabilizing, aligning, positioning, walking, reaching, bending, moving, transporting, lifting while standing, and pacing. The therapist also found that cognitive skills were at functional levels for Lena. However, Lena did exhibit difficulty with adaptation as she began attempting to perform activities with a changed body structure and in different positions. The therapist also noticed that Lena was having difficulty with social skills, exhibiting trouble focusing and collaborating during many occupations. The therapist would need to address these areas in therapy to help Lena return to her optimal level of participation in occupations.

Performance Patterns

Whatever a client’s performance patterns were before the amputation, they are likely to be altered after amputation. The client may already have useful habits, routines, rituals, and roles that can be drawn upon in therapy to facilitate his or her return to prior levels of occupational performance. However, for many clients, the occupational history will reveal prior impoverished habits and lack of, or maladaptive, routines that may present challenges to the rehabilitative process. Although Lena’s diabetes and PVD placed her at increased risk for poor wound healing, she never developed the habit of routinely checking her feet and legs for cuts or infections. This impoverished habit led to three amputations on her left leg. Lena’s morning routine in her kitchen involved crossing the room many times and carrying multiple items in her hands at once. In conversations with her occupational therapist, Lena did indicate that she had already begun to drop things during this routine, that she had nearly fallen a few times, and that she worried about being able to safely make her own breakfast at home.

Psychosocial Repercussions

Amputation of a limb represents a loss and therefore involves a grief process. This process involves dealing with one’s feelings regarding change in body structure, functional abilities, and participation in occupations. It can also involve anger, acknowledgment of unpleasant realities regarding one’s health status, and fears about one’s functional and financial future. Social acceptance and community function are also significant concerns for a person who has undergone an amputation. These are all areas that can be addressed by an interdisciplinary rehabilitation team in an effort to help the client adapt and should inform all aspects of occupational therapy intervention.

The occupational therapist may use several techniques to help a person adapt to his or her amputation and create a new sense of self. The therapeutic relationship and the therapeutic use of self can provide a safe environment and catalyst for the client to discuss feelings of loss, thoughts regarding body changes, and fears for the future. The therapist can teach the client coping skills for dealing with anxiety and depression, as well as techniques for improving postsurgical body image.⁵² The consultation process can include recommendations for workplace adaptations, as well as suggestions for how to make the home more accessible to a client with a new amputation. The therapeutic use of occupations that have been graded to the client’s current abilities provides opportunities to master skills and experience success. The therapist’s encouragement during such sessions not only fosters development and provides support but also provides evidence to the client that recovery of function and return to participation in chosen occupations are indeed possible⁵²; this knowledge fosters hope and a vision of the future.

It is important to recognize that an outside observer’s rating of a person’s adaptation to an LL amputation may not be the same as that person’s self-rating. A surgeon may rate success on the basis of healing of the surgical wound, a prosthetist on the fit between residual limb and prosthesis, a physical therapist on the client’s ability to ambulate, and an occupational therapist on the client’s ability to participate in areas of occupation. However, clients may place greater emphasis on other criteria in their determination of successful adaptation to an LL amputation. Some related variables that appear of primary concern to clients include feeling comfortable while being active in the presence of strangers, not feeling like a burden to one’s family, being able to care for others, and being able to exercise recreationally.⁴⁰

Context and Activity Demands

An understanding of the client’s contexts, environments, and demands of daily activities will help the therapist design a treatment program that will best help the client re-engage in chosen occupations within his or her everyday environment. It will also help the therapist adapt the activity demands of the client’s chosen occupations to facilitate greater independence and development of proficiency. Lena’s occupational therapist took a detailed floor plan of Lena’s bedroom and was able to move the furniture in her room into the skilled nursing facility, so it closely approximated her bedroom setup at home. When Lena performed her morning and evening ADLs within the room, she was then doing so in a more natural environment. Lena’s therapist initially made significant adaptations to Lena’s morning routine demands, wheeling Lena up to the sink in the bathroom for sponge-bathing and bringing her clothes to her in the bathroom, where she would stand with the help of a grab bar, so the therapist could pull Lena’s pants up. Over the course of time, as Lena improved her performance skills, improved her performance patterns, and incorporated into her routine new ADL techniques taught during therapy, her occupational therapist was able to decrease the adaptation of activity demands, and Lena progressed to independence with routines that she would be able to sustain at home.

Additional Considerations for Elderly Clients

Although LL amputation may be performed to preserve function or to save the client’s life, it does carry an increased mortality risk as the age of the client increases. One study of older persons who underwent a BKA found the survival probability after BKA to be 77% at 1 year, 57% at 3 years, and 28% at years.³⁵ Because this increased mortality risk is related not only to the amputation surgery but also to preexisting health and environment factors, attention to the overall health status of the client is of utmost importance.

Many body structures and functions are already compromised in elderly clients, making the rehabilitation process longer and more delicate. An elderly person may take more time to recover from the effects of anesthesia after surgery, including effects on cognition and the respiratory system. For unilateral amputees, leg balance on the unaffected limb is a significant predictor for prosthetic use.⁵⁹ Because balance may already be decreased and cognitive skills may have declined, elderly clients learning to use a prosthetic limb may experience greater challenges. Elderly clients have already experienced many losses, which may include family and friends, home, health, and function; the psychological sequelae of amputation can be all the more traumatic when layered over these previous losses.

Review Questions

1. American Occupational Therapy Association. Occupational therapy practice framework: domain and process, ed 2. Am J Occup Ther. 2008;62:625.

2. Anderson, MH, Bechtol, CO, Sollars, RE. Clinical prosthetics for physicians and therapists. Springfield, IL: Charles C Thomas; 1959.

3. Andrew, JT. Prosthetic principles. In Bowker JH, Michael JW, eds.: Atlas of limb prosthetics: surgical, prosthetic, and rehabilitation principles, ed 2, St Louis: Mosby, 1992.

4. Atkins, DJ. Adult myoelectric upper-limb prosthetic training. In: Atkins DJ, Meier RH, eds. Comprehensive management of the upper limb amputee. New York: Springer-Verlag, 1989.

5. Atkins, DJ. Adult upper limb prosthetic training. In: Atkins DJ, Meier RH, eds. Comprehensive management of the upper-limb amputee. New York: Springer-Verlag, 1989.

6. Atkins, DJ. Postoperative and preprosthetic therapy programs. In: Atkins DJ, Meier RH, eds. Comprehensive management of the upper-limb amputee. New York: Springer-Verlag, 1989.

7. Banerjee, SJ. Rehabilitation management of amputees. Baltimore: Williams & Wilkins; 1982.

8. Bennett, JB, Alexander, CB. Amputation levels and surgical techniques. In: Atkins DJ, Meier RH, eds. Comprehensive management of the upper-limb amputee. New York: Springer-Verlag, 1989.

9. Bennett, JB, Gartsman, GM. Surgical options for brachial plexus and stroke patients. In: Atkins DJ, Meier RH, eds. Comprehensive management of the upper-limb amputee. New York: Springer-Verlag, 1989.

10. Billock, JN. Prosthetic management of complete hand and arm deficiencies. In Hunter JM, Mackin EJ, Callahan AD, eds.: Rehabilitation of the hand: surgery and therapy, ed 4, St Louis: Mosby, 1995.

11. Czerniecki, JM, Ehde, DM. Chronic pain after lower extremity amputation. Crit Rev Phys Med Rehabil. 2003;15:309.

12. Dalsey, R, Gomez, W, Seitz, WH, Jr., et al. Myoelectric prosthetic replacement in the upper extremity amputee. Orthop Rev. 1989;18:697.

13. DiMartine, C. Capturing the phantom. inMotion. 2000;10:7.

14. Evans, WE, Hayes, JP, Vermillion, BO. Effect of a failed distal reconstruction on the level of amputation. Am J Surg. 1990;160:217.

15. Fan, T, Fedder, DO, Smoking gun: the impact of smoking on amputees, Baltimore, Pharmaceutical Health Service Research Program, University of Maryland, Baltimore, 2003. Available at, http://www.amputee-coalition.org/related_articles/smoking_gun.html.

16. Friedman, LW. Rehabilitation of the amputee. In: Goodgold J, ed. Rehabilitation medicine. St Louis: Mosby, 1988.

17. Friedman, LW. The psychological rehabilitation of the amputee. Springfield, IL: Charles C Thomas; 1978.

18. Fryer, CM, Michael, JW. Body-powered components. In Bowker JH, Michael JW, eds.: Atlas of limb prosthetics: surgical, prosthetic, and rehabilitation principles, ed 2, St Louis: Mosby, 1992.

19. Gard, SA, Childress, DS. A study to determine the biomechanical effects of shock-absorbing pylons. Rehabil R&D Progress Reports. 1998;35:18.

20. Glattly, HW. A statistical study of 12,000 new amputees. South Med J. 1964;57:1373.

21. Greenwald, RM, Dean, RC, Board, WJ. Volume management: smart variable geometry socket (SVGS) technology for lower-limb prostheses. J Prosthet Orthot. 2003;15:107.

22. Harris, KA, van Schie, L, Carroll, SE, et al. Rehabilitation potential of elderly patients with major amputations. J Cardiovasc Surg (Torino). 1991;32:648.

23. Hill, SL. Interventions for the elderly amputee. Rehabil Nurs. 1985;10:23.

24. Hirschberg, G, Lewis, L, Thomas, D. Rehabilitation. Philadelphia: JB Lippincott; 1964.

25. Jacobsen, SC, et al. Development of the Utah Artificial Arm. IEEE Trans Biomed Eng. 1982;29:249.

26. Jelic, M, Eldar, R. Rehabilitation following major traumatic amputation of lower limbs: a review. Crit Rev Phys Rehabil Med. 2003;15:235.

27. Kay, HW, Newman, JD. Relative incidence of new amputations: statistical comparisons of 6,000 new amputees. Orthot Prosthet. 1978;59:109.

28. Knighton, DR, Fylling, CP, Fiegel, VD, et al. Amputation prevention in an independently reviewed at-risk diabetic population using a comprehensive wound care protocol. Am J Surg. 1990;160:466.

29. Krajewski, LP, Olin, JW. Atherosclerosis of the aorta and lower extremities arteries. In: Young JR, et al, eds. Peripheral vascular diseases. St Louis: Mosby, 1991.

30. Lane, JM, Kroll, MA, Rossbach, P. New advances and concepts in amputee management after treatment for bone and soft tissue sarcomas. Clin Orthop Relat Res. 1990;256:280.

31. Larner, S, vanRoss, E, Hale, C. Do psychological measures predict the ability of lower limb amputees to learn to use a prosthesis? Clin Rehabil. 2003;17:493.

32. Larson, CB, Gould, M. Orthopedic nursing, ed 8. St Louis: Mosby; 1974.

33. Legro, MW, Reiber, GE, Czernieck, JM, et al. Recreational activities of lower-limb amputees with prostheses. J Rehabil Res Dev. 2001;38:319.

34. Leonard, JA, Meier, RH. Prosthetics. In: DeLisa JA, ed. Rehabilitation medicine principles and practice. Philadelphia: JB Lippincott, 1988.

35. Levin, AZ. Functional outcome following amputation. Topics Geriatr Rehabil. 2004;20:253.

36. Levy, LA. Smoking and peripheral vascular disease. Clin Podiatr Med Surg. 1992;9:165.

37. Lind, J, Kramhhaft, M, Badtker, S. The influence of smoking on complications after primary amputations of the lower extremity. Clin Orthop Relat Res. 267(211), 1992.

38. Link, MP, Goorin, AM, Horowitz, M, et al. Adjuvant chemotherapy of high grade osteosarcoma of the extremity. Clin Orthop Relat Res. 270(8), 1991.

39. Malone, JM, Goldstone, J. Lower extremity amputation. In: Moore WS, ed. Vascular surgery: a comprehensive review. New York: Grune & Stratton, 1984.

40. Matsen, SL, Malchow, D, Matsen, FA. Correlations with patients’ perspectives of the result of lower-extremity amputation. J Bone Joint Surg Am. 2000;82:1089.

41. McIntyre, KE, Jr. The diabetic foot and management of infectious gangrene. In: Moore WS, Malone JHM, eds. Lower extremity amputation. Philadelphia: WB Saunders, 1989.

42. Meier, RH. Amputations and prosthetic fitting. In: Fisher S, ed. Comprehensive rehabilitation of burns. Baltimore: Williams & Wilkins, 1984.

43. Meier, RH, Atkins, DJ. Preface. In: Atkins DJ, Meier RH, eds. Comprehensive management of the upper-limb amputee. New York: Springer-Verlag, 1989.

43a. http://biomed.brown.edu/Courses/BI108/BI108_2003_Groups/Hand_Prosthetics/stats.html.

44. Michaels, JA. The selection of amputation level: an approach using decision analysis. Eur J Vasc Surg. 1991;5:451.

45. Moss, SE, Klein, R, Klein, BE. The prevalence and incidence of lower extremity amputation in a diabetic population. Arch Intern Med. 1992;152:610.

46. Muilenburg, AL, LeBlanc, MA. Body-powered upper-limb components. In: Atkins DJ, Meier RH, eds. Comprehensive management of the upper-limb amputee. New York: Springer-Verlag, 1989.

47. Nader, M, Ing, EH. The artificial substitution of missing hands with myoelectric prostheses. Clin Orthop Relat Res. 1990;258:9.

47a. National Limb Loss Information Center, Fact sheet: limb loss in the United States, Knoxville, TN, Amputee Coalition of America, 2007. [Updated 2008 Sep 18; cited 2009 Feb 25]. Available at, http://www.amputee-coalition.org/fact_sheets/limbloss_us.html.

48. NovaCare. Motion control: training the client with an electric arm prosthesis. King of Prussia, PA: NovaCare (videotape); 1997.

49. Novotny, MP. Psychosocial issues affecting rehabilitation. Phys Med Rehabil Clin North Am. 1991;2:273.

50. Olivett, BL. Management and prosthetic training of the adult amputee. In: Hunter JM, ed. Rehabilitation of the hand. St Louis: Mosby, 1984.

51. O’Sullivan, S, Cullen, K, Schmitz, T. Physical rehabilitation: evaluation and treatment procedures. Philadelphia: FA Davis; 1981.

52. Pendleton, HM, Schultz-Krohn, W. Psychosocial issues in physical disability. In: Cara E, MacRae A, eds. Psychosocial occupational therapy: a clinical practice. Clifton Park, NY: Thomson Delmar Learning, 2005.

53. Pinzur, MS, Angelats, J, Light, TR, et al. Functional outcome following traumatic upper limb amputation and prosthetic limb fitting. J Hand Surg Am. 1994;19:836.

54. Rand, JD, Paz, JC. Amputation. In: Paz JC, West MP, eds. Acute care handbook for physical therapists. Woburn, MA: Butterworth-Heinemann, 2002.

55. Raney, R, Brashear, H. Shands’ handbook of orthopaedic surgery, ed 8. St Louis: Mosby; 1971.

56. Ritz, G, Friedman, S, Osbourne, A. Diabetes and peripheral vascular disease. Clin Podiatr Med Surg. 1992;9:125.

57. Sanders, JE, Nicholson, BS, Zachariah, SG, et al. Testing of elastomeric liners used in limb prosthetics: classification of 15 products by mechanical performance. J Rehabil Res Dev. 41(175), 2004.

58. Santschi WR, ed. Manual of upper extremity prosthetics, ed 2, Los Angeles, CA: University of California Press, 1958.

59. Schoppen, T, Boonstra, A, Groothoff, JW, et al. Physical, mental and social predictors of functional outcome in unilateral lower-limb amputees. Arch Phys Med Rehabil. 2003;84:803.

60. Scott, RN, Parker, PA. Myoelectric prostheses: state of the art. J Med Eng Technol. 1988;12:143.

61. Simon, M. Limb salvage for osteosarcoma in the 1980s. Clin Orthop Relat Res. 1990;270:264.

62. Spencer, EA. Amputation and prosthetic replacement. In Hopkins HL, Smith HD, eds.: Willard & Spackman’s occupational therapy,, ed 8, Philadelphia: JB Lippincott, 1993.

63. Spencer, EA. Amputations. In Hopkins HL, Smith HD, eds.: Willard & Spackman’s occupational therapy,, ed 5, Philadelphia: JB Lippincott, 1978.

64. Spencer, EA. Functional restoration. III: Amputation and prosthetic replacement. In Hopkins HL, Smith HD, eds.: Willard & Spackman’s occupational therapy, ed 8, Philadelphia: JB Lippincott, 1993.

64a. Franz, EA, Rumachandran, VS. Bimanual coupling in amputees with phantom limbs. Nat Neurosci. 1998;1:443.

64b. Ramachandran, VS, Brang, D, McGeoch, PD. Size reduction using mirror visual feedback (MVF) reduces phantom pain. Neurocase. 2009;3:1.

65. Spencer, EA. Musculoskeletal dysfunction in adults. In Neistadt ME, Crepeau EB, eds.: Willard & Spackman’s occupational therapy, ed 9, Philadelphia: JB Lippincott, 1998.

66. Spiegal, SR. Adult myoelectric upper-limb prosthetic training. In: Atkins DJ, Meier RH, eds. Comprehensive management of the upper-limb amputee. New York: Springer-Verlag, 1989.

67. Springfield, DS. Introduction to limb-salvage surgery for sarcoma. Orthop Clin North Am. 1991;22:1.

68. Taylor, LM, Jr., Hamre, D, Dalman, RL, et al. Limb salvage versus amputation for critical ischemia. Arch Surg. 1991;126:1251.

69. Tsai, HA, Kirby, RL, McLeod, DA, et al. Aided gait of people with lower-limb amputations: comparison of 4-footed and 2-wheeled walkers. Arch Phys Med Rehabil. 2003;84:584.

70. Tsang, GM, Crowson, MC, Hickey, NC, et al. Failed femorocrural reconstruction does not prejudice amputation level. Br J Surg. 1991;78:1479.

71. Walsh, NE, et al. Treatment of the patient with chronic pain. In: DeLisa JA, ed. Rehabilitation medicine principles and practice. Philadelphia: JB Lippincott, 1988.

72. Wellerson, TL. A manual for occupational therapists on the rehabilitation of upper extremity amputees. Dubuque, IA: William C. Brown; 1958.

73. White, EA. Wheelchair stump boards and their use with lower limb amputees. Br J Occup Ther. 1992;55:174.

74. Wright G: Controls training for the upper extremity amputee (film), San Jose, CA, Instructional Resources Center, San Jose State University.

75. Yaw, KM, Wurtz, LD. Resection and reconstruction for bone tumor in proximal tibia. Orthop Clin North Am. 1991;22:133.

76. Definitions for levels of amputation as defined by ISO 8548-2:1993(E) and ISO 8548-3:1993(E). Available at http://www.iso.org/iso/products/standards/catalogue_ics_browse.htm?ICS1=01&26ICS2=040&26ICS3=11&26.

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