It is important to remember that the earlier the onset of rehabilitation, the greater the potential for success will be. The patient needs to receive physiotherapy treatment early to avoid complications such as joint contractures, pathological scars and depressed psychological state. The main post-surgical complications are cardio-vascular, residual limb pain and phantom sensation, oedema, contracture and wound dehiscence. [1] Show
Goals of acute post-surgical rehabilitation [edit | edit source]
It is intended that prior to any treatment, an assessment will be carried out by the physiotherapist. In this early stage, a functional assessment can be done including both upper-limb, lower-limb and trunk in order to evaluate the patient potential to carry out activities such as transfer, wheelchair mobility and ambulation (with or without prosthesis)[1] Treatment modalities[edit | edit source]Treatment modalities to prevent complications include:
Breathing exercises[edit | edit source]Deep breathing exercises and relaxation exercises will help to increase vital capacity, decrease anxiety and prevent bronchopneumonia. Active range of motion (AROM)[edit | edit source]Amputated side (from the 1st post op day unless the post surgical dressing restricts motion):
Amputated side (from the 3rd post op day)
These active exercises must be performed at regular intervals during the day (10 repetitions per hour). Resistance exercises[edit | edit source]From the 1st post op day
From the 3rd post-op day
[4] PROM[edit | edit source]Passive extension of a TT residual limb.[5] The physiotherapist's hands should be positioned as proximal as possible to avoid any contact with the end of the stump, which is a very sensitive area. Massage, tapping, desensitisation, and scar mobilisation[edit | edit source]Desensitisation is believed to reduce pain, help with tolerance and touch in the residual limb and may help the patient with an amputation adjust to his or her new body image that now includes limb loss. Massage and tapping can be started early on and could be done over the soft dressing or when it is off.[6] All these techniques could be done by the therapist and also taught to the patient/family member to do. Also, instruct the patient how to perform desensitization and distraction techniques to reduce the phantom pain.
[7] Stump management[edit | edit source]The ideal stump is one that is well-healed, has good vascular supply, soft and mobile scars, minimal pain, minimal oedema, a length sufficient for biomechanical leverage but not too long to restrict choices for prosthetic components, and large surface areas for distribution of pressure. While the surgery plays a large part in creating the ideal stump, Physiotherapy is required to maximise chances of achieving this ideal. One of the main acute post-operative factors affecting the time to prosthetic fitting and the speed of rehabilitation, is the wound healing of the stump, especially in the vulnerable vascular compromised population[8]. Oedema in the residual limb is also a common complication after LLA surgery[9]. Controlling the amount of oedema post-surgically is vital for promoting wound-healing, pain control, protecting the incision during rehabilitation and assisting in shaping the stump for prosthetic fitting[10]. Traditionally soft dressings or non-adhesive elastic bandages are used to prevent oedema of the stump post-surgically, but no evidence supports the use of these bandages[11][12]. The use of immediate post-surgical Rigid or semi-Rigid dressings to prevent acute oedema have increased in popularity in the developed world and is well supported by evidence in the literature[10][11]. Post-operative dressing[edit | edit source]Post operative dressings are used to protect the limb, reduce swelling, promote limb maturation and prevent contractures. There are two major classifications of post operative dressing that are commonly used:
Oedema control (shrinking)[edit | edit source]In the BACPAR guidelines for oedema management in lower limb amputees[16] they conclude that based on the best current available evidence Rigid/semi-Rigid dressings should be used when expertise, time and resources allow; the benefits are well documented in the literature. The PPAM aid, compression socks and stump boards have been shown to have some evidence base for oedema control and may be used in addition or in the absence of Rigid dressings dependent on clinical judgement. However, these modalities are not necessarily primarily intended for use for oedema control. Their advantages include preparation for prosthetic rehabilitation, reduction in flexion deformities and maintenance/improvement in muscle tone and are important components of amputee rehabilitation. Compression socks and the PPAM aid are the only tools available for transfemoral amputees. Although compression socks are widely used as a form of oedema control there is very limited evidence on aspects such as the timing of the application, who should assess the appropriateness and the frequency it should be worn for. It is suggested that further research is required in order to offer more clarity for clinicians in these areas.[16] Read the full guidelines here Another option is the use of a post-op silicone liner:[17]
Wound healing[edit | edit source]Wound healing is always a cause of concern, but especially in the dysvascular population. Adequately controlling oedema of the stump can assist with healing, but some evidence also supports the use of low intensity laser in order to facilitate and speed up wound healing in diabetic patients [8]. However the exact dosages for optimal effect has not yet been established. Pain[edit | edit source]Pain is a very common physiological stressor that occurs during the acute postoperative period and affects the patient’s ability to learn new skills [10] . Adequately controlling the new amputee’s levels of pain greatly facilitates their early rehabilitation [10] . Physiotherapists should take this into consideration, and treat patients shortly after receiving their pain medication. Controlling oedema in the residual limb through positioning also assists in relieving acute postoperative pain [10]. Various physiotherapy interventions are used for the management of phantom limb pain, but very few of these have been studied to prove their efficacy in the research literature [18]. One of the few physiotherapy modalities that has been proven to be effective for the management of phantom limb pain, is a 60 minute application of Transcutaneous Electrical Nerve Stimulation (TENS) [9]. For more information see the pain management of the amputee page. Patient information[edit | edit source]A series of useful patient information guides from the Amputee Coalition. Bed Mobility [edit | edit source]
Transfers[edit | edit source]
Positioning[edit | edit source]The main goal of a good positioning at any time is to prevent adjacent joint contractures.
Full ROM will ease prosthetic fitting and ambulation. [1] Patient should be advised on how to position themselves while sitting and lying in the hospital bed or standing to prevent contractures.
Bed positioning for trans-femoral [22] Bed positioning for trans-tibial [22] Sitting in a wheelchair for trans-tibial [22] Wheelchair Management[edit | edit source]
Mobilising with Crutches or a Walking Frame[edit | edit source]
Resources[edit | edit source]References[edit | edit source]
|