Rehabilitation of the Amputee

Before Amputation

The focus of the preamputation evaluation is counseling. The goal is to provide the patient and family with information and answer questions to help the patient to make an informed decision about whether to proceed with an amputation or not, and it will also help prepare the patient for what will occur following amputation. Most patients facing a major limb amputation are frightened, anxious, depressed, and uncertain of their future. They may be reluctant to proceed with their surgeon’s recommendation of amputation either as a treatment from among one of a number of treatment options or as the final treatment option after all other treatments for limb salvage have been explored and exhausted.

The rehabilitation team provides patients and family with information about life after amputation, which can help to allay their fears and allow them to make an informed decision on treatment course, if they have that option, or to move forward with their surgery. The rehabilitation team counseling should include discussion of several topics, including phantom limb sensation, phantom limb pain, residual limb pain, management of the residual limb after amputation, physical and occupational therapy to occur while on the acute surgical service, the possibility of additional rehabilitation care before discharge to home (whether in an acute or subacute facility), the anticipated timing of initial prosthetic fitting (typically 6 to 8 weeks after amputation for the dysvascular population), the processes of prosthetic fitting, expected prosthetic function (if the patient is deemed a candidate for prosthetic restoration) and the therapy necessary to learn to successfully use a prosthesis.

Assessment of the patients’ physical status and prior level of function is another key part of the physiatrist’s initial evaluation. In addition to the history of the patient’s chief complaint leading to amputation and any other acute or chronic medical conditions, the rehabilitation team must know the patient’s prior level of function, living situation, and family support. When did the patient last walk? Was the patient using a cane or walker to walk? Was the patient living at home or in a nursing home? If the patient lives at home, what is the home like? Is the home accessible, or are there stairs to be managed to get in or out of the home? Are there other environmental barriers that might prevent a return to home? Does the patient live alone, or is there a spouse or family available to assist with care upon return to home? Is the spouse’s or family’s health or time commitments such they can actually provide assistance if needed?

The physical examination must assess the patient’s general physical condition, strength of all extremities, endurance, joint range of motion, the status of the other lower extremity in the case of lower limb amputation, and the patient’s cognitive abilities. Being nonambulatory or having significant joint contractures, weakness, and/or significant cognitive impairments limiting the ability to learn new skills can preclude patients from ever being considered candidates for prosthetic restoration. This initial evaluation helps to define the patient’s rehabilitation goals, direct the therapies, and determine if the patient is likely to require continuing inpatient rehabilitation services after acute surgical care.