To properly address and treat patients with limb loss, physical therapists need to use unique evaluation skills and develop a specific plan of care. Before starting progressive treatment sessions we must first adequately evaluate the patient. Below are some tips to navigate this process.
Start treating patients in the evaluation process! Educating patients about their pain is one of the best methods of pain management for limb loss.1
Patients with limb loss experience three different types of pain. Each should be addressed at the first session to increase understanding of expected pain during this process.
- Surgical pain
Patients with recent amputations need to be reminded of their post-op protocols. Amputations are not an easy surgery. Patients should expect the typical surgical pain that accompanies any operation.
- Residual limb pain
The residual limb will experience pain for a myriad of reasons. Patients with limb loss may experience painful neuromas in their distal limb that could limit their rehabilitation potential. As muscles heal into their new positions and experience their altered movement patterns, pain may ensue. Therapists should also inspect the skin on the residual limb to assure proper wound care management and avoid potential break down.
- Phantom limb pain
The surgeon amputated the distal limb but did not alter the sensory receptors in the brain. In the Homunculus man model, the distal limb sensory receptors are located near the genital region. Because of this, patients with recent limb loss may feel increased levels of phantom pain with urination, defecation, and sexual arousal. Understanding that this pain is “normal” and will typically decrease with time is one of the best pain management techniques currently available.
Choose the Appropriate Functional Outcomes Measures
Functional outcomes measures have serious implications for patients with limb loss. Patients will need to be categorized as a functional level (or K level) to determine an insurance approved prosthetic limb. These outcomes measures need to be coordinated with the entire rehabilitation team, from the physician to the prosthetist. Therefore, it is important to have a good understanding of the measures available and appropriate for these patients.
A 21 section functional test that requires approximately 15 minutes to administer. The results of the test will reveal a numerical score that correlates with an appropriate K level for the patient.2
This valid and reliable survey will allow patients to quickly and efficiently self-report their functional status.3
Cardiopulmonary endurance is significantly impacted with limb loss. This test will reveal how the patient has been affected and offer goals for treatment.4
Determine the patient’s static and dynamic stability with a prosthesis. This reliable and valid test helps assess the patient’s fall risk.5
Collaborate with the Prosthetic Team
Prosthetic rehabilitation is a team effort.6 To effectively coordinate with team members it is important to understand where the patient is in the prosthetic development process. The patient may be waiting to receive their first prosthesis or may have recently received a new model and is seeking proper gait training. For this reason, it is important to contact the prosthesist to begin the collaboration process, offering a greater benefit the patient’s functional success.
Understanding the patient’s pain, applying the appropriate functional outcome measures, and collaborating with the prosthetics team will allow the physical therapist to develop a patient specific treatment plan, leading to improved functional independence for the patient.
- Butler DS, Moseley GL, Sunyata. Explain Pain 2nd Edn. Noigroup Publications; 2013.
- Gailey RS, Roach KE, Applegate EB, et al. The amputee mobility predictor: an instrument to assess determinants of the lower-limb amputee's ability to ambulate. Arch Phys Med Rehabil. 2002;83(5):613-27.
- Hafner BJ, Gaunaurd IA, Morgan SJ, Amtmann D, Salem R, Gailey RS. Construct Validity of the Prosthetic Limb Users Survey of Mobility (PLUS-M) in Adults With Lower Limb Amputation. Arch Phys Med Rehabil. 2017;98(2):277-285.
- Lin SJ, Bose NH. Six-minute walk test in persons with transtibial amputation. Arch Phys Med Rehabil. 2008;89(12):2354-9.
- Schoppen T, Boonstra A, Groothoff JW, De vries J, Göeken LN, Eisma WH. The Timed "up and go" test: reliability and validity in persons with unilateral lower limb amputation. Arch Phys Med Rehabil. 1999;80(7):825-8.
- Potter BK, Scoville CR. Amputation is not isolated: an overview of the US Army Amputee Patient Care Program and associated amputee injuries. J Am Acad Orthop Surg. 2006;14(10 Spec No.):S188-90.