Prosthetic Rehabilitation Issues in the Diabetic and Dysvascular Amputee

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Post-operative evaluation

The history and physical examination remain the most important components of post-operative evaluation. A thorough review of patients’ previous activities leading up to the amputation is necessary, but there are key issues that have an impact on the immediate care and future care of patients with lower limb amputation. These key issues include the date when the problem first started, which may have limited patient mobility; the date of hospitalization, which may have severely limited patient

Patient education

After the history and examination of patients are completed, it is the role of physicians and prosthetic and orthotic teams to educate patients and families regarding the entire program associated with prosthetic fitting and training, including a review of medical findings that are relevant to a prosthetic fitting and training program. An estimate of the time frame of prosthetic fitting and training is helpful to families and patients, because they have no sense of how long this process may

Pre-prosthetic therapy program

A physical therapy program should be instituted almost immediately after amputation surgery. Most patients are able to participate in a therapy program, at least incorporating the upper limbs and remaining limb, shortly after surgery. Strengthening and range of motion of the amputation limb may be delayed a few days because of pain issues or concerns on the part of a surgeon; however, these should be treated or addressed as soon as possible. Strengthening of critical muscles to prepare for

Wound care

All patients with amputations must be assessed for wound care issues. The amputation surgical site itself is essentially a healing wound with sutures or staples in place. In the acute care setting immediately after surgery, a surgeon applies a soft compressive dressing. Once this is removed, daily dressing changes can be instituted. If wound healing seems to be progressing appropriately, the surgical site can be simply covered with a nonstick dressing and appropriate roll gauze applied to cover

Pain management

Pain management in the post-operative phase is helpful to allow patients to mobilize rapidly and successfully. Surgical pain is treated with opioids or nonopioids that are tapered rapidly over 7 to 14 days. Other pain management treatment should be instituted, including application of topical anesthetic gels if a surgical site is healed, application of a TENS unit to control nerve pain, and continued use of nonopioids for residual limb pain. All patients should be reassured that phantom

Footwear

Prevention of injury to the remaining foot is a critical goal for an entire prosthetic team. Assessment of the remaining foot for physical and physiological deficiencies is important. It is common for diabetic/dysvascular patients to have deformities, such as hallux valgus, hammertoes, and prominent metatarsal heads. The presence of peripheral neuropathy indicates that a patient has impairment of sensation and may have atrophy of the intrinsic muscles of the foot due to the underlying

Time frame of rehabilitation

In an ideal setting, patients spend only the first 2 to 5 days in an acute care hospital during the post-operative time period. During this time, residual limb shaping with Ace wrap should be taking place. A pre-prosthetic therapy program of ROM strengthening and mobility should be started 1–2 days after surgery. Patients should be mobilizing out of bed as soon as tolerated. Treatment of pain should take place in this early time period. The next phase, from approximately day 5 through day 21

Energy requirements

There is an increase in energy requirement for ambulation with lower-limb amputation with or without prosthesis. Review of the literature on this subject over the past 30 years shows that there has been variability in results and findings related to the increase in energy requirements at various levels of amputation.14, 15, 16, 17, 18 If patients are required to walk at a fixed speed and compared with normal controls, there is always an increase in energy closely associated with the level of

Medicare functional level and prosthetic componentry

Evaluation of patients by a physician and prosthetist helps determine a patient's Medicare functional level. These levels were established in 1995 by Medicare as an attempt to guide physicians and prosthetists in providing appropriate componentry for patients’ level of function. Based on patients’ medical conditions and level of amputation, it is a physician's role to estimate what a patient's functional level will be after fitting of a prosthesis and completion of an appropriate rehabilitation

Prosthetic design and componentry

For patients with transtibial amputation, contemporary socket designs include total contact, patellar tendon bearing of the residual limb via a soft interface and rigid frame. The patellar tendon and medial tibial flare area still are used most often to take additional pressure. Less pressure is tolerated at the tibial crest, at the distal and proximal fibula, and the distal tibia. These areas are relieved within the socket to allow less pressure but still maintain gentle contact. All

Prosthetic training

Once patients are fitted with a preliminary prosthesis, education of patients continues. Prosthetic education starts with a prosthetist and includes a therapist and physician. Proper donning and doffing technique of a prosthesis is learned first. Initial wearing schedule for a prosthesis should be 1 to 2 hours per day with advancement of 1 additional hour each day if tolerated. This should be monitored by a physical therapist, prosthetist or physician. Patients initially start partial weight

Complications

Unfortunately, morbidity and mortality after lower limb amputation in the older dysvascular population have not changed in decades. The 50/50 rule still applies to morbidity and mortality. There is an approximately 50% survival rate over 5 years after amputation in the older dysvascular population. Of the survivors, up to 50% have a second major amputation during that 5-year time period.25 In addition, there are intermittent issues with skin irritation or breakdown as volume loss and muscle

Summary

The rehabilitation management of diabetic patients with amputation is complicated by the comorbidities associated with diabetes. Delays in wound healing, cardiopulmonary compromise, and peripheral neuropathy are some of the many issues taken into account when assessing this patient population. The impact of these medical issues on patients’ functional status before amputation provides some of the most valuable information in formulating the rehabilitation program after amputation. Thorough

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      Skin interfacing biomaterials are utilized in numerous clinical applications, including, but not limited to, prosthetics [1,2], tissue regeneration [3,4], wound repair [5] and dental implants [6]. For example, limb loss occurring as a result of trauma [7], diabetes [8], osteosarcoma [9], vascular diseases [10] and the effects of aging [11] is a major injury that currently affects nearly 20,00,000 people in the USA. Such conditions are often treated by intra-osseous transcutaneous implantable devices that penetrate through the depth of the skin and provide support to the natural tissue to maintain normal function [2,12].

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