Close
Chapter 93
Amputation Rehabilitation
Amputation rehabilitation is not solely the provision of a
prosthesis. Rather it is the restorative intervention neces-
sary to return the patient who has had an amputation to
the highest possible level of function and to minimize the
impact of the amputation on his or her life. In the last two
decades, with the advent of specialized treatment teams
and new prosthetic devices, the outlook for the person who
has had an amputation has improved. Outcomes that were
never thought to be possible, such as exercising with a
prosthesis or ambulation without the use of upper-limb
support for the elderly, are now frequently achieved. We
present our collective knowledge and understanding of the
rehabilitation process, which represents the essential inter-
ventions necessary to optimize function for patients who
are provided with a prosthesis and for those who are
unable or choose not to use one.
CLASSIFICATION AND INCIDENCE
OF AMPUTATION
Amputations are classified based on the anatomic level and
site at which the amputation has taken place. For example,
an amputation between the wrist and elbow is termed a
transradial amputation. Other levels include transfemoral,
transtibial, Syme, partial foot, hip disarticulation, and knee
disarticulation for the lower limb. For the upper limb,
transhumeral and partial hand amputations, and shoulder,
elbow, and wrist disarticulations are the most common.
1744
Alberto Esquenazi
Edward Wikoff
Maria Lucas
The congenital limb deficiencies are best classified
following the International Organization of Standards
and the International Society of Prosthetics and Orthotics
classifications as modified from Frantz and O’Rahilly (1).
The limb deficiencies can be transverse or longitudinal.
The term terminal is used to describe the fact that the
limb has developed normally to a particular level beyond
which no skeletal element exists. With intercalary limb
deficiency, there is a reduction or absence of one or more
elements within the long axis of the limb, and there may
be normal skeletal elements distal to the affected segments
(2).
Amputation of the lower limb is performed signifi-
cantly more frequently than amputation of the upper limb.
Amputation of the distal segment of the limb is more
common than that of the proximal segment. Amputations
can occur at any age, but for lower extremities, the elderly
are most commonly affected, with men more frequently
affected than women. Upper-limb amputation affects men
between the second and fourth decades most frequently,
and the right upper extremity is more likely to be ampu-
tated than the left.
The most common reasons for lower-limb amputa-
tion are infection, arterial occlusive disease, and complica-
tions of diabetes mellitus. Less frequent but important
causes are trauma, malignancy, and peripheral neu-
ropathies. For the upper limb, trauma followed by malig-
nancies and acute arterial insufficiency are the most
common causes (Fig. 93-1).

Figure 93-1. Distribution of the causes of amputation.
REHABILITATION TEAM
Limb loss is a condition that has physical, psychological,
and social implications for the affected individual and the
social support system. For treatment to be effective, it
should include the care of the patient and his or her signif-
icant others. Expertise from various clinicians is required to
accomplish this effectively. The development of a rehabili-
tation team working closely together to address each indi-
vidual’s needs is vital to the efficient and timely delivery of
services. This approach will provide the patient a compre-
hensive treatment regimen.
A physician specializing in rehabilitation, or who has
knowledge of biomechanics and prosthetics, assumes the
role of team leader and coordinates the team’s resources.
The prosthetist fabricates the prosthetic appliance and
works closely in the training stages with the therapist and
patient to prevent complications, achieve appropriate align-
ment, and ensure proper fit of the prosthesis. The pros-
thetist also acts as a resource to other team members for
information on the latest technologic advances in the field
of prosthetics.
Physical and occupational therapists are critical
members of the therapeutic team. The physical therapist
participates in the care of the lower-extremity amputee
by preparing him or her physically for using a prosthesis.
This includes instructing the patient in management of the
prosthesis, teaching functional mobility activities, and pro-
viding gait training to optimize the walking pattern. In the
patient who has had a traumatic upper-extremity
amputation, the intervention of the physical therapist is
required only if there is a significant injury to joints or soft
tissues. An occupational therapist will work closely with the
team and the patient to incorporate use of the prosthesis
during activities of daily living (ADLs) and for work simu-
lation activities. For the upper-extremity amputee, the
occupational therapist is frequently the primary therapist
instructing the patient in the use of an upper-limb
prosthesis.
Owing to the immense psychological impact that an
amputation has on many patients and their families, each
patient should have an assessment with a psychologist (3,4).
Chapter 93 Amputation Rehabilitation
A psychologist specializing in limb loss or disability is par-
ticularly suited in addressing feelings of depression and
body image changes associated with amputation.
Along with these core members, the team should
include other supporting clinicians. A social worker can
assist patients with changes in family relationships and
social status related to decreases in function or work abili-
ties (5). Nurses can assist and instruct patients in medica-
tion management and with wound care. The recreational
therapist provides information about community resources
for recreational activities and support groups, and instructs
patients in the adaptations necessary to participate in
leisure activities. A vocational counselor, driving instructor,
and when necessary, a school teacher may be involved in
the care of the amputee as well.
The patient and team members should work
together to set goals and develop an overall treatment plan.
Subsequently, each team member participates in the
patient’s care as necessary to make the provision of ser-
vices most efficient.
With so many clinicians contributing to the care of
an individual, communication is an essential component of
team interaction. Good communication will ensure that all
team members are providing patients with quality care
while avoiding duplication of services. Each team should
develop some method of communication that is appropri-
ate for the clinical setting, whether it be daily or weekly
rounds, written documentation, computer linking, or team
meetings (6–8).
PREAMPUTATION EDUCATION AND COUNSELING
The rehabilitation process for the individual with limb loss
ideally should begin before any surgery occurs. The
amputee can take better advantage of rehabilitation ser-
vices once he or she has been educated regarding surgery,
healing, exercise, future abilities and limitations, and the
rehabilitation process. This education, as well as the actual
multifaceted rehabilitation care, is best provided by a team
of health care professionals with experience and expertise
in the realm of amputation rehabilitation (9–11).
Patients facing amputation often know little about
the disease process that threatens their limbs, or about
what the future holds. Understanding that arterial insuffi-
ciency, infection, trauma, or tumor may necessitate ampu-
tation may enable the patient to accept the amputation as
the appropriate treatment (12). Lacking this insight,
patients may resist or delay amputation, risking sepsis, a
contracted nonfunctional limb, analgesic abuse, decondi-
tioning or other avoidable medical complications. Others
may fear social isolation or stigmatization stemming from
the amputation, and view the amputation as the end of
their useful life. Most fear losing independence and work
productivity, and becoming a burden on family and friends
(2,12–19).
1745
 To fill these information gaps, the patient and family
benefit from preamputation counseling from members of
the rehabilitation team and from a prosthetic user who can
provide firsthand information. The following topics should
be covered, although with the apprehension of upcoming
surgery, the patient may retain little of what is initially
discussed.
1. Pain will certainly be present following surgery and
its duration and intensity may not be predictable.
The patient seeking pain relief as a result of ampu-
tation may not be satisfied, as the RL or phantom
limb may also be painful (20).
2. Phantom sensation (and possibly pain) will likely be
present following surgery (21).
3. Exercise and proper positioning in the early postop-
erative period will be very important to future
rehabilitation.
4. A general time frame for acute hospitalization,
wound healing, preprosthetic rehabilitation, and
prosthetic use is very helpful to the patient.
5. The patient’s expectations for future functional
status are often unrealistic. Future activities will
require equipment previously unfamiliar to the
patient (e.g., wheelchair, crutches, prosthesis, etc). A
discussion of this information with an amputee as
closely matched demographically as possible will
provide the patient with a more credible view of the
future. Early contact with the patient also allows
members of the rehabilitation team to evaluate the
patient’s premorbid status and current problems so
that appropriate goals and plans can be made. The
patient may also benefit from the continuity if the
same members of the rehabilitation team are
involved before and after the surgery.
EVALUATION OF THE AMPUTEE
Evaluation of the patient with upper- or lower-limb loss is
indispensable to preparing the overall rehabilitation treat-
ment plan, including the development of goals and objec-
tives. It is also important in the prosthetic prescription
process. Although the overall evaluation process for all
amputees is similar, some important differences exist in the
evaluation of patients with limb loss at different levels.
These are reviewed later in this section.
A general physical examination that documents body
weight, height, peripheral circulation, skin integrity, limb
dominance, overall health, comorbidities, and mental
status is necessary. The examination of the residual limb
(RL) should include the soft-tissue length and shape, bone
length and shape, and skin integrity, pliability, and mobility.
Scar tissue is assessed as is the RL’s tolerance to pressure,
traction, and weight bearing. Sensation is also evaluated as
well as the presence of neuroma or areas of hypersensitiv-
ity. The clinician should document the range of motion
1746 Part V Medical Rehabilitation for Diagnostic Groups
(ROM) and strength of the proximal joints. The status of
the contralateral limb and the ROM, strength, and sensa-
tion of the other limbs are critical data in the planning of
the rehabilitation program. Balance and coordination are
also essential and should be tested.
Patients with peripheral neuropathy or skin grafts use
vision as a compensatory mechanism for the lack of sensa-
tion in the prosthesis and the other limbs. Eye examination
should be encouraged, as many patients need updated pre-
scription eyeglasses and vision care.
In the patient whose amputation was caused by
ischemia related to atherosclerosis or diabetes mellitus,
similar arterial insufficiency involving the cardiac and cere-
bral vessels should be suspected. Knowledge of cardiopul-
monary status and endurance is of primary importance.
The use of sophisticated tests to assess these systems in
patients with a cardiac history is usually unnecessary.
Simple clinical indicators such as the ability to ambulate
with a walker or crutches for 30 to 40 ft, while blood pres-
sure and pulse rate are monitored, are adequate to deter-
mine whether the patient will be able to achieve the goal
of limited household ambulation. Patients with a docu-
mented ejection fraction of 15% should be able to ambu-
late very short distances with an artificial limb. The cardiac
risk in this population does not appear to be significantly
increased when using a prosthesis or walking short dis-
tances. Therapeutic walking is an appropriate technique
for cardiovascular training. In addition, the capacity for
short-distance ambulation will often permit a patient to
remain out of a long-term-care facility. This has additional
psychosocial benefits that may outweigh the potential risks.
The patient’s willingness and ability to learn new
techniques and to participate in a variety of new activities
are critical. Thus, cognitive and psychological evaluations
are very important. The psychological impact of limb
amputation is huge. Patients experience a variety of emo-
tional and psychological responses, including anxiety,
shame, depression, anger, and fear. The rehabilitation team
must provide support, treatment, and guidance for the
patient and his or her family (2,12–19). Nutritional status,
which has a considerable impact on wound healing and
strength, must not be neglected (22–24). The presence of a
variety of other comorbidities such as diabetic retinopathy,
peripheral polyneuropathy, nephropathy, and degenerative
joint disease may also influence the rehabilitation of the
amputee. In short, a thorough medical evaluation of the
patient is necessary.
Other areas of importance that should be evaluated
include the vocational and recreational activities that the
patient performed in the past and wants to pursue in the
future. Certain vocational or avocational activities may
require alternative specialized prosthetic devices, training,
or use of no prosthesis. Devices that may be exposed to
extreme weather, water, or other elements that may be cor-
rosive or destructive to the prosthesis should be made of
special materials to protect the RL and the prosthesis.
 Social support systems play an important role in the
amputee’s rehabilitation. The rehabilitation program for a
person living with an able-bodied spouse in an elevator-
accessible single-floor apartment is different from that of a
person living alone in a third-story walk-up apartment.
Lastly, the rehabilitation team needs to evaluate and
consider the patient’s motivation, preferences, and desires,
as well as the importance of cosmesis as a factor in pros-
thetic fabrication.
As previously mentioned, several important factors
need to be considered during the evaluation of the patient
with particular levels of limb loss. For the transfemoral
level of amputation, assessing the length (short, mid, long)
of the RL, ROM of the hip (particularly extension), and
strength of the hip (particularly abduction, extension) is
important. Knowledge of the type of surgical technique
used for amputation is important; in particular, surgical
reattachment of the adductor group (myodesis) has a sig-
nificant impact on future function (25). The configuration
of the distal end of the femur and the presence of hetero-
topic ossification or bone growth at the tip should be
noted. Other characteristics of the RL that should be
noted include location of surgical scars, position and type
of grafts (skin or vascular), and ability to bear weight dis-
tally. These factors should be considered when the pros-
thetic socket is fabricated. Surgical revision should be
considered when heterotopic bone, scars, grafts, or other
features of the RL prevent adequate prosthetic fabrication.
Assessment of the transtibial RL involves similar
considerations. The length is categorized as short, mid, or
long. Strength and ROM of the hip and knee are evalu-
ated. Assessment of hip and knee extension is particularly
important. As with the transfemoral RL, location of scars,
presence of skin or vascular grafts, and the nature of the
surgical technique (myodesis or myoplasty) are also noted.
The configuration of the distal end and its ability to bear
weight are also important factors.
For the transradial level of amputation (short, mid,
long), evaluation of the ROM and strength of the elbow,
shoulder, and scapula and the quantification of pronation
and supination are necessary. The position of surgical
scars, configuration of the distal end, type of surgical
closure carried out (myodesic or myoplastic), and the
ability of the RL to receive distal pressure and weight
bearing are assessed. Contractility of the underlying
muscle is of particular importance if a myoelectric device
is to be considered.
For the bilateral upper-limb amputee, the ROM and
strength of shoulder and neck and trunk flexibility are
important factors. One should assess the ability to use
lower limbs for functional activities such as opening doors,
stabilizing objects, feeding, and other essential functions.
The ideal length of the limbs is determined by using a
ratio of height; for very-proximal-level amputations, the
forearm section is made shorter to improve elbow lift
power by reducing the lever arm length. It is necessary to
Chapter 93 Amputation Rehabilitation
determine the optimal prosthetic control systems to be
used (body power versus external power or both). For
externally powered devices, myoelectric or switch control
can be used. This decision also requires knowledge of the
availability of appropriate funding sources and access to
maintenance. Externally powered devices require more
maintenance than body-powered devices. Projecting the
patient’s dependency on the prosthetic devices and the
availability of help when the prosthesis fails will help to
determine the need for a second set of artificial arms
(usually of different control mechanism).
For patients who have had bilateral lower-limb
amputation, the evaluation should focus on the strength,
dexterity, and ROM of the upper limbs and the ability to
use the upper limbs for support during walking. Assessment
of the cardiopulmonary systems is essential in view of the
expected increase in metabolic cost during walking. Limb-
lengths should be determined based on the ability to trans-
fer from sitting to standing (18 inches to the knee may be
sufficient) while keeping a lower center of mass for
improved balance and more efficient energy utilization
during standing and walking. Choosing prosthetic compo-
nents based on needs, desires, and available funding
sources, as well as accessibility to maintenance, is critical.
Projecting the patient’s dependency on the prosthetic
devices will permit determining the need for a wheelchair
or a second set of artificial legs (maybe waterproof ones to
be used also during showers).
When a myoelectric prosthesis is prescribed, the eval-
uation should begin with determination of the level of
amputation (short, mid, long). ROM of the shoulder and
scapula and strength of the shoulder muscles, primarily
those of flexion and abduction, should be assessed. The
presence of myodesic or myoplastic closure and the avail-
able control at the residual muscles for the wrist for
transradial level and at the elbow for transhumeral level
should be determined. Assessment of electromyographic
(EMG) signal strength (>20 units on Myotester) of the
muscles to be used to trigger the prosthesis is necessary.
If the patient is not able to generate separate signals for
flexors and extensors and co-contract them for full utiliza-
tion of myoelectric controls, appropriate training with
EMG feedback is to be implemented.
PREPROSTHETIC TRAINING
Preprosthetic training ideally focuses on the goals of func-
tional independence without a prosthetic device. In addi-
tion, for individuals who will receive a prosthesis, the RL is
prepared for prosthetic use.
The average age of the amputee population is 50 to
70 years old (26–28). Usually they will have several comor-
bidities and have lost strength and endurance in the weeks
leading up to the amputation (29,30). A comprehensive
supervised exercise program including ROM, strengthen-
1747
Figure 93-2. Inappropriate bed position of
comfort that may promote
contractures of the hip and
knee.
ing, and endurance exercises, as well as functional activi-
ties, promotes improvement in these areas (31,32). Of
course, precautions dictated by the patient’s comorbidities
are to be observed.
Patients are often eager to perform the upper-limb
exercises that promote the strength and ROM required for
self-care activities. However, most patients with recent limb
loss are more concerned with mobility than bathing and
dressing. Arms provide the power for wheelchair mobility
and the use of walking aids. In particular, shoulder stabiliz-
ers, adductors, and depressors, elbow extensors, wrist stabi-
lizers, and hand grasp strength are of prime importance
for supporting the body for transfers and using the more
common walking aids.
Trunk balance and strength must not be neglected.
Strong flexible rotators, flexors, and extensors of the back
and abdomen and the extensors of the hips facilitate
sitting balance and bed mobility and transfers.
The importance of lower-limb exercise is obvious.
The remaining limb for the unilateral amputee temporarily
becomes the solitary support limb and frequently can
develop symptoms consistent with overuse, particularly at
the knee and ankle. Stance-phase stability requires ade-
quate strength in the hip extensors, abductors, knee exten-
sors, and plantarflexors. Swing-phase limb advancement
and clearance require adequate hip flexor and ankle dorsi-
flexor strength.
Lower-limb contractures are distressingly common in
the amputee population. Unfortunately, the position of
comfort is often the position that can result in contractures.
Patients often need continual reminders that contractures
can significantly impair their future mobility and compro-
mise the integrity of the nonamputated limb. The
transfemoral-level amputee often develops contractures of
the hip flexors, abductors, and external rotators. The
transtibial-level amputee frequently develops hip and knee
flexion contractures (Fig. 93-2). Contractures of the hip
flexors, knee flexors, and plantarflexors of the intact limb
of the unilateral amputee often result from prolonged bed
rest in the comfortable semi-Fowler position. If soft-tissue
contracture results in an equinus posture, the normal
weight-bearing posture of the foot is compromised. Pres-
sure distribution to the heel is lost and forces are focused
on the forefoot. The increased pressure on the forefoot can
lead to local pain and tissue breakdown of particular
concern in the presence of peripheral neuropathy or arte-
rial insufficiency.
The “ounce of prevention” approach certainly
applies to limb contractures. Several factors can contribute
1748 Part V Medical Rehabilitation for Diagnostic Groups
to contractures: preoperative positioning, surgical tech-
nique, postoperative pain, deficient knowledge regarding
ROM, and limited mobility related to ischemia, skin grafts,
infection, or trauma that led to the amputation. Treatment
of contractures may include heating modalities, prolonged
passive stretch, spring-loaded orthoses, serial casting, nerve
blocks, or further surgery. To avoid contractures, patients
are instructed to move limbs through a full ROM fre-
quently and to avoid postures of prolonged flexion. Periods
of lying prone should be included in the lower-limb
amputee’s exercise program. A posterior splint may help
prevent knee flexion contractures in the transtibial-level
amputee. Frequent reminders and encouragement help the
patient follow through on these instructions. Contractures
are readily prevented through the use of an immediate
postoperative rigid dressing (33,34). The rigid dressing
extends proximally, enclosing the knee, preventing a flexion
contracture.
The lower-limb amputee’s outlook brightens consid-
erably when he or she is allowed out of bed. Independence
in transfers and functional mobility are of great impor-
tance. Bed mobility exercises include rolling from side to
side and sitting up, to allow the patient to position himself
or herself without calling for help. Transfer training allows
the patient to expand his or her world beyond the bed and
room. The patient may utilize sliding board, front-
on/back-off, or stand (squat) pivot transfers to move from
one surface to another.
Functional mobility for the amputee may take several
forms. Most lower-limb amputees will use a wheelchair at
some point and should learn proper wheelchair manage-
ment, including using the leg rests and brakes. Safe tech-
niques for propulsion and turns appear simple, but require
teaching and practice. The wheelchair must be suitable for
the individual. A person with limited strength or with sig-
nificant cardiac impairment may be unable to safely propel
a chair of normal weight. Removable armrests are needed
for those who utilize a sliding board or squat pivot transfer
to the chair (Fig. 93-3). The center of gravity of the person
seated in a wheelchair shifts posteriorly if a lower limb is
absent. Therefore, an off-set axle or antitippers are appro-
priate. These are of particular importance when going up
a ramp or curb.
Ambulation training without the prosthesis is very
important to the amputee. Initially, standing balance and
standing tolerance are addressed. Once the patient can
manage standing, then ambulation (hopping) using the par-
allel bars can begin. As strength and endurance improve,
the patient may advance to a walker and to crutches. In

Figure 93-3. Sliding board transfer to a bed for the
bilateral transfemoral amputee.
addition to allowing greater mobility, the activities improve
lower-limb strength and ROM and serve to remind the
patient that bipedal walking may soon be a reality.
Stairs are often a source of concern for the amputee.
When walking up and down stairs is not yet possible, many
individuals use a “bumping” technique to ascend or
descend. The patient sits on the steps and uses the arms
and remaining lower limb to propel himself or herself up
or down. Of course, the floor transfer at the top or bottom
of the stairs must also be addressed. Many amputees use a
low box or stool as a “step” between the floor and the
wheelchair or standing posture.
Not all patients can tolerate standing activities ini-
tially. For patients who cannot, because of orthostatic
hypotension or other reasons, a more gradual approach is
needed. Allowing the patient to press his or her foot
against a foot board while in bed can simulate lower-limb
weight bearing. Alternatively, the patient may hold a towel,
a length of cloth, or a length of elastic tubing looped
under the foot and apply pressure to the plantar surface of
the foot. Gradual progression to a more erect posture may
be achieved by elevating the head of the bed or using a tilt
table.
While many amputees focus their attention on
walking, their ability to perform self-care activities may be
more important to their going home. As safe techniques
Chapter 93 Amputation Rehabilitation
Figure 93-4. Elastic bandaging of the transtibial residual
limb.
for bathing and dressing and toileting are mastered, the
amputee realizes that he or she need not fear being “a
burden.” Self-esteem and optimism are restored. In addi-
tion to self-care activities, many amputees must also
perform homemaking activities to resume their life roles.
Using a wheelchair, walker, or crutches, the amputee learns
to prepare meals, do laundry, and perform other house-
hold chores.
Most of the preceding discussion is appropriate for
the lower-limb amputee. For the upper-limb amputee,
transfers and mobility are less problematic while self-care
activities may be more difficult. Regardless of previous
right- or left-handedness, the remaining limb becomes
dominant for the upper-limb amputee. Thus, there may be
considerable time spent on change of dominance. The
patient will also learn various single-handed techniques for
bathing, dressing, grooming, and other self-care activities
(35).
Care of the RL focuses on several areas including
wound healing, volume containment, optimization of
strength and ROM, and desensitization. Needless to say,
the healing wound should be kept clean and monitored for
signs of infection. Volume containment can be achieved
through several approaches. Ideally, the immediate postop-
erative rigid dressing, applied in the operating room, pro-
vides edema control as well as mechanical protection for
the limb (33,34,36). As an alternative, the removable rigid
dressing can be used, allowing the patient greater partici-
pation (37,38). The Unna boot also prevents swelling but
requires no particular skill in its application (39–42). Ace
bandages, tubular compression dressings, or stump
shrinkers provide elastic compression and may be favored
for their simplicity and neatness (Fig. 93-4) (43,44).
1749
 Because the RL is an end organ, responsible for the
manipulation, positioning, control, and general operation
of the prosthesis, exercises for the RL are crucial. Normal
strength and ROM of the RL will help to optimize pros-
thetic use.
Many amputees will not receive a prosthesis. There
may be cognitive, physical, psychological, financial, or
other reasons for this. Other amputees may simply decline
the option of using a prosthesis. For this group, therapies
to optimize strength, endurance, and ROM and to achieve
independence in mobility, self-care, and other life tasks
without a prosthetic device are provided. There are also
patients for whom functional independence is not a realis-
tic goal. Some patients will always need some assistance for
mobility and self-care. Therapies for these people will focus
on caregivers as well as on the patient (18). Family
members or other individuals involved in the care of the
amputee are educated and trained in appropriate tech-
niques for RL care, mobility, bathing, dressing, and
hygiene.
REHABILITATION WITH PREPARATORY
PROSTHESIS
Return to bipedal ambulation is the stated goal of most
lower-limb amputees. Amputees often feel that only by
returning to ambulation can they resume their previous
lives, roles, activities, and socialization (12). Walking again
is an enormously important transition for the amputee.
Starting with an accurate knowledge base is impor-
tant for the patient and health care provider alike. A
review of goals and expectations is appropriate at this
point. Not all patients will recall the prior discussions
regarding these topics, so reminders may be necessary. It is
also appropriate for the therapist to review the patient’s
diagnosis and comorbidities as well as precautions, to mini-
mize the complications that may develop as gait training
proceeds.
Rehabilitation with the preparatory prosthesis begins
by introducing the patient to the components of the
preparatory prosthesis and its management. Explanations
of how the prosthesis fits, where weight is borne, where
and why discomfort may occur, and how adjustments can
be made help put the patient at ease. It is useful to remind
the patient that his or her weight must be supported by
some pressure-tolerant portion of the RL, or walking
would be impossible. Pressure is to be expected and this
may be uncomfortable at first but should not be painful.
With experience and the teachings of the treatment
team, the patient learns the appropriate fit of the prosthe-
sis and the way to adjust the fit with stump socks when
necessary. The patient needs to learn that the prosthetic fit
is a dynamic entity and that he or she needs to be aware of
subtle changes in socket fit or alignment that provide clues
to necessary adjustments (43,45).
1750 Part V Medical Rehabilitation for Diagnostic Groups
Gait training begins with weight bearing and weight
shifting, using the parallel bars for upper-limb support.
The patient gradually progresses to ambulation in the par-
allel bars. The therapist may find it difficult to focus the
patient on proper technique including equal step length
and appropriate weight shifting. Gait deviations frequently
develop owing to the patient’s eagerness to begin walking.
As the patient establishes a consistent gait pattern and can
maintain good form, he or she advances to use of a
walker, crutches, and unilateral support devices. Once the
patient is comfortable with level surfaces, he or she pro-
gresses to walking on stairs, curbs, and ramps, as well as
uneven terrain. The patient also learns safe techniques for
transfers, including to and from the floor (32).
Frequent monitoring of the skin allows for prompt
corrections of socket-fit problems and avoids skin break-
down. Skin checks are done more frequently for the new
prosthetic user and for the patient with delicate skin. Ini-
tially, checking the skin every 10 to 15 minutes or after
every one or two walks may be necessary. Once the patient
and therapist are comfortable with the socket fit, skin mon-
itoring can occur less frequently.
Prosthetic wearing tolerance gradually increases over
the first few weeks. Some patients can only wear the pros-
thesis for 2 to 3 hr/day during the first week of gait train-
ing. This gradually increases until it is worn all day (12–16
hours). Throughout the rehabilitation process, the patient
should become well versed in skin care. The patient learns
to monitor the skin of the RL, noting signs of appropriate
weight bearing and watching for evidence of skin irritation
or breakdown.
When the prosthesis is not worn, the patient wears a
stump shrinker or an Ace bandage to prevent edema and
provide volume containment (43,44).
As the amputee progresses with ambulation and
management of the prosthesis, ambulatory self-care activi-
ties and homemaking activities can be addressed. Occupa-
tional therapy works with the patient to learn safe
techniques for bathing, dressing, and toileting using the
prosthesis. Some patients may find that initially, certain
activities are more easily performed without the prosthesis.
In these situations, it is important to remember that the
primary goal of therapy is functional independence, not
necessarily continuous prosthetic use. Many patients need
to perform homemaking tasks as well. The therapist should
include meal preparation, laundry, shopping, and other
household chores in the training routine of these individu-
als, using the prosthesis if possible.
As the patient progresses through ambulation train-
ing, emotional and psychological needs must not be
neglected. New anxieties or unfilled expectations may arise
during training with the prosthesis and should be
addressed by the psychologist and other members of the
rehabilitation team. The patient is encouraged to express
concerns and disappointments so that steps can be taken to
rectify these problems. While some problems may not have
solutions, the patient can be reassured that the
rehabilitation team does not ignore the patient’s perceived
issues.
Few patients can proceed through ambulation train-
ing without experiencing problems with pain. Phantom
discomfort has been extensively investigated (20,46–49).
Approaches to treatment include biofeedback (50), imagery
(51), relaxation techniques (52), massage, ultrasound (53),
transcutaneous electrical nerve stimulation (TENS) (54),
oral and injectable medications (20,46), and surgery
(20,46). This topic is discussed in detail elsewhere in this
text. RL pain is frequently related to socket fit and pros-
thetic alignment. By listening to the patient’s complaint,
examining the RL, and watching the patient use the pros-
thesis, the clinician can generally solve fit and alignment
problems. Prosthetic component changes and alignment
adjustments are more readily performed when modular,
adjustable components are used. Because the RL and the
patient’s gait pattern are continually changing, it is
common for pain problems to develop or recur without
apparent provocation. Therefore, it is helpful for the
members of the rehabilitation team to remind the patient
that occasional difficulties and setbacks are common and
are not reasons for despair.
REHABILITATION WITH PERMANENT PROSTHESIS
Ideally, rehabilitation of the amputee involves testing the
definitive prosthetic componentry on the preparatory
device. This allows the therapist and other team members
to train the patient immediately in the appropriate use of
the components that will be used in the definitive prosthe-
sis. However, this is not always possible, because of reim-
bursement issues or various other factors, such as an
inability to predict a patient’s level of function early in the
rehabilitation course. Therefore, a patient who receives dif-
ferent componentry in the definitive prosthesis than in the
preparatory device will require retraining in the specifics of
the new componentry. The socket and some components
of a preparatory prosthesis are not as durable as those of
the definitive prosthesis, thus limiting the patient’s func-
tional capabilities. Patients should refrain from using the
pylon or preparatory prosthesis without an assistive device,
even though they may eventually progress to this level
when they receive their permanent prosthetic device. With
more sophisticated componentry, patients may face higher
functional expectations such as work simulation, ambula-
tion on varied surfaces, and sports.
Concerning the socket, it is vital to allow the
patient’s RL to mature before fabrication of the perma-
nent socket. The soft-tissue bulk of the RL decreases sig-
nificantly, owing to resolution of edema as well as disuse
atrophy of muscles and adipose tissue. These changes
occur primarily during the first 2 to 5 months following the
amputation. The definitive prosthesis frequently uses a
Chapter 93 Amputation Rehabilitation
suction suspension mechanism that is not usually recom-
mended for a preparatory pylon because of fluctuations in
RL girth (43). Patients often will require new instruction on
donning techniques for the suction socket. Transfemoral-
level amputees will have significant changes in their abili-
ties depending on the knee unit prescribed, and instruction
in mobility and gait should vary based on the type of
mechanism used in the permanent prosthetic device. For
example, patients ambulating with a cadence-responsive
knee with swing and stance control will require a different
gait pattern compared to patients using a weight-activated
knee unit. They will also have different mechanisms for
transferring from sitting to standing and ascending and
descending stairs and inclines.
For the upper-limb amputee, early prosthetic fitting is
vital to the acceptance of the prosthesis (36). Generally, the
first prosthesis uses conventional or body-powered compo-
nentry. Myoelectric or externally powered prostheses are
not usually recommended at this stage because of the fluc-
tuation in girth as the RL matures. This fluctuation will
make it difficult to achieve the intimate fit between the skin
and socket needed for the myoelectric system to work
properly. Additionally, one should verify that the patient
will be a prosthetic user before incurring the higher cost of
an externally powered prosthesis. Upper-limb amputees
who are progressing from conventional to myoelectric pros-
thetics require a period of retraining, to instruct them in
the proper use and care of the new prosthesis.
In conclusion, the transitions from a preparatory
prosthesis to a permanent prosthesis will necessitate educa-
tion of patients on any changes in the way that they don
and doff their prostheses and the performance of their
new componentry. Patients are made aware that whenever
they receive a new socket, they must be vigilant about skin
inspection, as there is potential for new areas of pressure
or breakdown of the skin.
VOCATIONAL AND AVOCATIONAL TRAINING
It is important to note that a successful outcome for an
amputee means returning as close as possible to the previ-
ous level of function. For the working-age patient, return
to some gainful employment should be expected. Similarly,
patients at any age should be able to return to previous or
modified leisure activities including sports or hobbies. The
patient should know early in rehabilitation that the long-
range expectation is to return to work and play.
In the case of employment, work simulation activities
should be incorporated into the patient’s therapy programs
early and should intensify in the latter part of the rehabili-
tation program. The rehabilitation team should make
attempts to contact the patient’s employer to establish the
physical demand of the jobs. Wherever possible, employers
should be informed and involved in the retraining. Work-
site evaluations can be very helpful in understanding job
1751

Table 93-1: Sport Organizations
for the Amputee
American Amputee Foundation, Inc. (501) 666-2523
Amputee Coalition of America (708) 698-1628
Amputee Sports Association (912) 927-5406
National Amputee Golf Association (800) 633-NAGA
National Association of Disabled (813) 755-1078
Swimmers
National Association of (618) 532-4565
Handicapped Outdoorsmen
National Wheelchair Athletic (719) 635-9300
Association
Shake-A-Leg (401) 849-8898
demands and making recommendations for work environ-
ment modifications or changes in the patient’s job descrip-
tion. In some cases it is not feasible for the patient to meet
the physical requirements of the previous job. Limiting
factors often include heavy manual labor, prolonged stand-
ing periods, or jobs that require well-developed balance.
For such situations it is very important to have the patient
receive career counseling and job retraining (55). Contact
with the local branch of the state office of vocational reha-
bilitation or its equivalent can be of great assistance as
patients re-enter the workforce.
Similarly, the patient should be encouraged to return
to his or her prior leisure activity. Participation in sports is
often very important to younger amputees and sometimes
older amputees. The patient should be provided with infor-
mation on various sports groups, for example, the National
Amputee Golf Association, amputee ski groups, and
national disabled sports organizations (Table 93-1). Partici-
pation in some sports will require specific prosthetic com-
ponentry, and consideration of recreational goals should be
given when one is formulating the prosthetic prescription
(56). Efforts should be made to teach the patient specific
sport skills.
A commonly stated desire for athletic ability is to be
able to run again. This goal should be considered for all
active amputees, even if it is to run just a short distance for
a bus or to get out of danger. A good socket fit is crucial
for running for both transtibial-level and transfemoral-level
amputees. A good fit allows the patient to tolerate the
tremendous amount of pressure and reaction forces trans-
lated to the limb without too much discomfort. For the
healthy, active transtibial-level amputee, running is fairly
easy to achieve (57,58). When the patient is ambulating
independently without an assistive device, he or she is
ready to begin training. Hopping and jumping activities
will assist with building the patient’s tolerance for increased
force transmitted to the limb. A gradual progression
from fast walking, to a trot and then a run is usually
successful. The treadmill can be useful to progress the
patient to higher speeds. The transfemoral-level amputee
requires increased training to achieve running. For
1752 Part V Medical Rehabilitation for Diagnostic Groups
them the appropriate components such as cadence-respon-
sive knees are vital to achieve a step-over-step running
pattern.
Without a cadence-responsive knee unit, the patient
has to wait for the shank of the prosthesis to come
forward, resulting in an extra hop on the sound limb.
Training techniques for the transfemoral running gait often
begin with weight-bearing activities, balance activities, and
exercise to improve pelvic and hip control. Initially there is
an emphasis on hopping and jumping, to increase toler-
ance to increased forces translated to the residual limb.
Fast walking and ambulating with an exaggerated step
length and then a progression to jogging or running can
occur. Again, once patients have achieved limited success
at a step-over-step running pattern, running on a treadmill
at gradually higher speeds can help to increase their
cadence (59).
COMMUNITY REINTEGRATION
While many amputees simply say, “I want to walk again,”
ambulation is only a portion of comprehensive rehabilita-
tion. The goals of a thorough rehabilitation program
include helping the patient resume previous roles in the
“family” and community. The entire rehabilitation team
should help identify the patient’s goals and roles. Each
patient may not “open up” equally to all team members.
The patient often has difficulty communicating because
fear, anger, and depression dominate the thoughts in the
days, weeks, and even months following amputation
(3,12–17,19).
Several questions can help clarify the patient’s previ-
ous role in the family or social network. What was the
person’s level of independence? Was the patient the
primary homemaker or “breadwinner” in the family? If so,
then who (if anyone) has taken on these roles during the
patient’s illness? Does the patient expect to return to these
roles? Is the patient a spouse, parent, child, or other
member of the family unit? Was the patient a caregiver or
a care recipient prior to the amputation? Does the ampu-
tation change this role? If so, how?
It may be difficult to anticipate how the patient and
the family will adapt to the amputee’s return. There is
often a confusing mixture of expectations on the part of
each. The patient generally wants to get “back to normal”
but may find it quite difficult. He or she may be expecting
some assistance, but resenting assistance when it is pro-
vided. Members of the family may want to assist but not
know how much or how little assistance is needed or wel-
comed. In general, an awkward situation frequently exists
until communication, education, and experience occur. It is
useful for members of the rehabilitation team to meet with
the patient and family, individually and together, to facili-
tate resolution of these issues. Long-term counseling may
be needed as the patient and family adjust. Discussing the
importance of previous family roles and how the amputa-
tion may have changed these roles is helpful. This will help
the patient and family reach decisions regarding which
roles are most important and which may be abandoned or
modified (18).
The new amputee’s role in the community should be
similarly examined. Was the patient an active participant
in community events? Was he or she a passive spectator?
Was he uninvolved? How does the amputation affect the
person’s participation in community outings such as shop-
ping trips, trips to restaurants, or trips to the movies or
theater? The previously active patient may find it difficult
to resume these activities, for physical reasons or because
of self-conscious feelings. Therapeutic outings with
members of the rehabilitation team to restaurants, malls,
or movie theaters can help desensitize the patient to these
awkward feelings and facilitate resumption of these activi-
ties. Frequently, the patient must learn to be more aggres-
sive or assertive to make use of programs or facilities not
obviously available. This may be quite difficult for a person
who is normally shy or passive. The patient should also be
educated about community programs and resources that
may facilitate participation by people with disabilities
(60,61).
Returning to driving plays a significant role in
many patients’ resuming normal activities. Frequently, a
minor modification or no modification to the vehicle is
required for the amputee to resume driving. Without
relying on others for mobility, the amputee’s independence
grows.
SPECIAL CONSIDERATIONS FOR THE COMPLEX
AMPUTEE AND THE PATIENT
WITH DUAL DISABILITY
It is increasingly common in the rehabilitation population
to encounter patients with dual disability such as hemiple-
gia and limb loss, blindness and limb loss, and multiple
limb loss. Each individual disability can be catastrophic on
its own; the dual disability may be even more so, resulting
in long-term placement of the patient in a nursing home.
With the appropriate interventions and social support
systems, many patients with dual disability can return to
their home environment. A rehabilitated limb after ampu-
tation prior to the onset of hemiparesis from stroke has a
better functional outcome than if the stroke had preceded
the amputation (62). A right hemiparesis or an ipsilateral
hemiplegia and limb loss also have a better prognosis,
compared with a left hemiparesis or limb loss contralateral
to the hemiplegia.
Clear simple step-by-step instructions and a modified
prosthesis are very useful for these patients. For the blind
patient, sensory input using raised markings, Velcro clo-
sures, and step-by-step sequencing is useful. A cane should
be used whenever possible to provide protective auditory
Chapter 93 Amputation Rehabilitation
and tactile feedback to the patient. Appropriate home envi-
ronment modifications should be carried out.
Fifty percent of patients who have had a lower-limb
amputation due to disease are at risk for a second amputa-
tion within 3 years. If no other concurrent disabilities
occur, the patient with a second transtibial amputation
should achieve a level of independence similar to that
attained prior to the second amputation. The heights of
the prostheses are routinely decreased to improve balance
and possibly decrease the energy required to maintain
standing balance.
For patients with bilateral transfemoral amputation,
there is a significant increase in energy consumption, esti-
mated at over 100% (63), that may prevent long-distance
ambulation. In general, most transfemoral bilateral
amputees over 50 years old will find the wheelchair an
easier and more practical means of locomotion. Ambula-
tion should be attempted only when adequate cardiac
function, strength, balance, and endurance exist; the use of
multiaxis ankle-feet systems with lower height and weight-
activated knee-locking mechanisms should facilitate the
patient’s ability to ambulate (64). The clinician can avoid
unnecessary expenditures of resources in the geriatric pop-
ulation by careful selection of potentially functional ambu-
lation candidates who have had bilateral transfemoral
amputations (65).
Bilateral Amputation
Intuitively ambulation with bilateral lower-limb loss should
be much more difficult than with single lower-limb loss.
The limited data available support this thesis (65,66–69),
but many bilateral amputees ambulate nonetheless, with
varying degrees of proficiency. For all these individuals,
there should be a long discussion on the difficulties they
face, the risks (including falls and increased cardiac
demand), and realistic goals before prosthetic fabrication
commences.
Many bilateral transtibial-level amputees will achieve
independence in ambulation with prostheses (Fig. 93-5).
Several prosthetic modifications can be performed to make
ambulation with bilateral transtibial prostheses less diffi-
cult. Although some patients may object, shortening the
prostheses by 1 or 2 inches lowers the center of gravity
and can improve balance and decrease energy consump-
tion during standing and ambulation. Of course, the
height can be restored later if the patient so chooses, and if
walking skills have progressed satisfactorily. By out-setting
the feet, the base of support is widened and balance is also
enhanced (Fig. 93-6). Flexing the sockets or dorsiflexing the
feet promotes a forward lean and slightly crouched posture,
which also gives most bilateral transtibial-level amputees a
sense of improved stability. Using articulated single-axis
feet rather than fixed ankles may also improve balance and
ambulation by reducing the knee flexion moment during
the loading response. During normal gait, in the early-
stance phase (initial contact and loading response), the
1753
ground reaction force falls behind the ankle, generating a
plantarflexion moment (70). This plantarflexion is con-
trolled by the activity of the pretibial muscles, allowing the
foot to gradually descend to the floor. The ground reaction
force lies behind the knee as well, requiring the knee exten-
sors to prevent buckling of the knee. The magnitude of
the knee flexion moment increases with the perpendicular
distance between the ground reaction force and the knee
Figure 93-5. Bilateral transtibial amputee with prosthesis
(digital image).
Figure 93-6. Alignment modifications to
improve the base of support
for bilateral amputees, outset
foot.
1754 Part V Medical Rehabilitation for Diagnostic Groups
joint center (71). For the transtibial-level amputee whose
prosthesis has a fixed ankle, the ground reaction force is
located farther behind the knee and remains there for a
longer period of time. This generates a more significant
flexion moment. When an articulated ankle is used, the
prosthetic foot plantarflexes to a foot-flat posture promptly
after initial contact. This moves the ground reaction force
farther anterior, reducing the distance to the knee center
and reducing the magnitude and duration of the flexion
moment. Most patients will appreciate the flexibility of the
articulated ankle, but others may find the ankle motion a
source of instability and increased weight. Some patients
report that the solid ankle of a SACH (solid-ankle
cushion-heel) foot or most energy-storing feet feels more
firm and stable, and therefore, more comfortable.
The bilateral amputee who has had one transtibial
and one transfemoral amputation can benefit from some of
the modifications indicated above. Widening the base of
support, moving the center of mass forward, and lowering
the center of mass can be helpful. Articulated ankles
should also enhance standing and walking stability. The
design of the knee on the transfemoral amputation side
should be chosen carefully. If stability is a great concern, a
simple lightweight manual-lock knee removes the risk of
knee buckling. The data are limited, and studies have
yielded conflicting conclusions about the energy costs of
ambulation with a locked or swinging prosthetic knee.
Traugh et al (72) found no significant difference in the
energy cost of ambulation using a locked compared to an
unlocked knee. Isakov et al (73) found that ambulation
with a locked knee is more energy efficient. Meanwhile
many patients prefer an unlocked knee because of the
more natural-appearing gait and improved ability to trans-
fer. A weight-activated or polycentric knee allows flexion
during the swing phase but still resists knee flexion during
stance. A hydraulic or pneumatic knee will provide a more
physiologic function for the vigorous, high-activity-level
patient, but its use in the geriatric population may be
limited by weight and cost.
Many patients who have had transtibial and trans-
femoral amputations use the prosthesis on a limited basis,
in the home or for social events, and may use alternative
means of mobility such as a wheelchair most of the time.
Other patients may use only a single prosthesis (usually the
transtibial) for transfers, standing, and limited swing-
through ambulation. For many individuals with significant
cardiac or muscle strength limitations or contractures, no
prostheses or only a transtibial prosthesis may be the best
alternative for transfers.
Few bilateral transfemoral-level amputees will be
functional long-distance ambulators, although many will
achieve limited independence in ambulation with prosthe-
ses. The energy required for the bilateral transfemoral-level
amputee to ambulate is simply too great (67,69). The mod-
ifications mentioned earlier can be utilized to make ambu-
lation less difficult. Some patients may initially use
“stubbies,” short nonarticulated limbs with broad feet (74),
and then graduate to taller limbs with knees. The choice of
knees should be made after considering stability, safety,
weight, cost, and activity level. As with the transtibial-
transfemoral amputee population, many bilateral
transfemoral-level amputees choose wheelchair mobility
with no prostheses because of simplicity, energy efficiency,
and comfort.
Several factors are relative contraindications to pre-
scribing prostheses for the bilateral lower-limb amputee.
These include lack of motivation, significant cognitive
impairment, severe cardiac disease, severe contractures,
and severe neurologic impairment (75). The degree of
cardiac compromise a patient can tolerate while walking
with bilateral prostheses is unclear. An ejection fraction of
20% may be chosen as an arbitrary cutoff, but no hard
data exist to substantiate this. Prosthetic ambulation is pos-
sible in the setting of significant cardiac compromise
because amputees adjust their walking speed to keep rela-
tive energy demands at a manageable level (76). Patients
must participate in this decision-making process and
should understand the rationale behind the decision. They
should never feel that they were not given the opportunity
to walk with prostheses “just because the doctor said I
couldn’t.” When patients are presented with appropriate
information regarding the risks and advantages of ambula-
tion, and are provided with an accurate idea of what
ambulation with bilateral prostheses will be like, they are
generally able to reach rational decisions.
The sequence of amputations is thought to have an
impact on future bilateral prosthetic ambulation (75).
People who are able to ambulate with a transfemoral pros-
thesis are likely to be able to achieve bilateral prosthetic
ambulation after a subsequent transtibial amputation.
However, the transtibial prosthetic user who has a subse-
quent contralateral transfemoral amputation may have a
Chapter 93 Amputation Rehabilitation
more difficult time achieving ambulatory status following
the second amputation.
The issue of rehabilitation for bilateral amputees has
become increasingly important as the prevalence of bilat-
eral lower-limb amputations rises and resources become
scarcer. Kerstein et al (77) in 1974 noted that 23% of their
amputee rehabilitation population were bilateral amputees.
Esquenazi et al (26) in 1984 reported an increasing
number of amputees readmitted for bilateral prosthetic
training. Nondiabetic patients who undergo an amputation
for ischemia have a 5% to 13% risk at 1 year and 28% risk
at 5 years for contralateral amputation (78,79). For the dia-
betic population, the risk is higher, approximately 50% at 3
years (80).
The Blind Amputee
Since many amputees are diabetic with an increased inci-
dence of retinopathy (81), they will frequently develop
comorbidity of blindness or visual impairment. Patients
who recently became blind should receive a program of
instruction in compensatory techniques related to their
new-onset blindness, to complement the amputation reha-
bilitation. More often, patients have had long-standing
blindness. These patients should use tactile clues to allow
them to manage their prostheses appropriately. Most
people can identify sock ply simply by feeling the different
thicknesses, so this is usually not an issue.
However, donning the prosthetic device with the
correct orientation can be difficult. When this is a
problem, tactile cues such as bumps or ridges should be
placed on the socket or the insert to give the patient a ref-
erence point for donning. Also the suspension straps may
require alternative fasteners such as those made of Velcro,
to make them easier to manage. The blind patient should
be instructed to inspect the skin of the RL and intact foot
by feeling for wounds, abrasions, skin irregularities, or
changes in temperature. If the patient has neuropathies
that decrease the sensation in the hands, a caregiver should
be instructed in assisting patient with skin inspection and
prosthetic management (82).
The rehabilitation of the blind amputee should also
address the environment. Ambulation with the appropriate
cane for protective sensory and auditory feedback is
taught. If the patient needs to use the upper limbs for
support and balance, then it may be necessary to recom-
mend walking with a companion who can serve as a guide.
Of course, a home assessment should be performed before
discharge of the person who is blind and has had an
amputation. Modifications to the home environment can
promote independence and improve safety.
Hemiplegic Amputee
As the elderly population increases and survival after stroke
and amputation improve, we can expect to see more
patients with generalized vasculopathy who have simulta-
neous vascular-related disabilities. In addition, many
1755
patients survive high-impact collisions with resulting head
injuries and amputations. The dual disabilities of hemi-
paresis and limb loss present a spectrum of problems
(62,83). The characteristics that complicate or simplify the
rehabilitation process for a patient with these two
disabilities are similar to the exacerbating and mitigating
factors for the individual disabilities. For example, the
rehabilitation of a patient after a transfemoral amputation
would generally be more difficult than after a transtibial
amputation, and the rehabilitation of a patient with severe
hemiplegia with neglect and cognitive impairment would
be more difficult than that of a patient with mild pure
motor hemiparesis. The sequence of the onset of disabili-
ties and the location (ipsilateral or contralateral) also influ-
ence the rehabilitation outcome. The individuals who first
undergo an amputation and then later sustain a stroke gen-
erally achieve better functional status than do those who
first are afflicted by the neurologic event (61). Ipsilateral
involvement also suggests better outcome than contralat-
eral involvement. In general, patients with right-sided
hemiparesis tend to have a better functional outcome than
do those with left-sided neurological residual. As one
would expect, younger patients with these dual disabilities
generally attain better functional outcomes than older
patients.
The patient who is ambulatory after a lower-limb
amputation and subsequently has a stroke with ipsilateral
weakness can often regain independent ambulatory status,
unless the stroke is very severe. The height and alignment
of the prosthesis are adjusted to compensate for stroke-
induced gait deviations where possible. Shortening the
prosthesis may improve swing-phase clearance problems.
Increased prosthetic ankle plantarflexion can assist weak
knee extensors by providing mechanical stability to the
knee joint during the stance phase. When flexor tone inter-
feres with knee stability, the use of a thigh corset with
external knee joints may be of benefit. The orthotic knee
joints may be offset or single axis and equipped with drop
locks to enhance stability during the stance phase. Widen-
ing the base of support by “outsetting” the prosthetic foot
reduces balance problems. For the patient with severe hip
adductor tone, the use of interventions to decrease spastic-
ity focally, such as phenol block of the obturator nerve or
surgical interventions (obturator neurectomy or adductor
tenotomy), should be considered.
When necessary markings are placed on the prosthe-
sis, the suspension straps, and even the socks, to make the
task of donning the prosthesis a more structured process
that can be made routine by a patient with cognitive
deficits. Patients with significant upper-limb involvement
will need to learn one-handed prosthetic management
techniques. For the transtibial-level amputee, certain
devices can be used to achieve one-handed donning, such
as neoprene, spandex, or silicone sleeves, which can be
rolled on with one hand. For the transfemoral-level
amputee, the prosthesis, because of its size and weight,
1756 Part V Medical Rehabilitation for Diagnostic Groups
may be difficult to manage. In this situation, use of the
TC-3 (84) socket, developed at the Tokyo Metropolitan
Rehabilitation Center in Japan, permits the patient to
handle the socket with the suspension system of choice,
separate from the prosthesis. This option provides the
patient with the advantage of handling a smaller section of
the prosthesis, with decreased bulk and weight. Then the
socket is inserted into a thin receptacle and attached with a
Velcro strap. In addition, this system permits donning and
doffing in the seating position.
Similar prosthetic adjustments improve the functional
mobility of a person with a preexisting hemiplegia and
new ipsilateral limb loss. Learning new concepts of pros-
thetic management such as donning and doffing the limb
or adjusting the number of stump socks used may be diffi-
cult if the new amputee has preexisting cortical dysfunc-
tion. For the nonambulatory patient after a stroke and
amputation, independence in transfers should still be possi-
ble, as the “intact” side should provide adequate strength
and stability for standing and pivoting.
Contralateral hemiplegia and amputation pose more
difficult problems. The severity of the stroke and the level
of amputation determine which will be the patient’s domi-
nant leg and whether future ambulation is likely. For the
transtibial-level amputee with contralateral hemiparesis,
ambulation with an assistive device should be possible
unless the stroke is very severe. Even with severe stroke
sequelae, the patient will likely benefit from a prosthesis for
standing and transfers. If the amputation is at the trans-
femoral level, then ambulation will be quite difficult or
impossible unless the stroke is mild. For many such
patients, prosthetic fabrication is not indicated.
LONG-TERM FOLLOW-UP
Long-term follow-up of the amputee involves not only
prosthetic maintenance and skin checks, but also psychoso-
cial rehabilitation and wellness behavior. For many
amputees, the physiatrist is viewed as the primary physi-
cian, perhaps because the physiatrist sees the amputation
as the most important health and medical issue in their
lives. Thus, the physiatrist is likely to confront many
health-related issues besides those associated with the RL
or the prosthesis.
During a follow-up visit, the patient’s prosthetic
usage is discussed. Is the prosthesis worn daily? All day
long? If not, are there problems with comfort that need to
be addressed? If the prosthesis is not incorporated into the
normal daily routine of the patient, it will always be
viewed as heavy, clumsy, abnormal, and difficult to
manage, despite hours of adjustments by the prosthetist
and physician.
It is appropriate to review the patient’s lifestyle. Does
he or she leave the home for shopping, recreation, social-
ization, or work? People may choose to stay at home for
different reasons. However, if architectural barriers or
mobility dysfunction are the cause, then the patient may
benefit from the physician’s intervention. Further outpa-
tient therapies to address mobility on stairs or other obsta-
cles may be appropriate. Ramps, rails, stair glides, or other
equipment may free the patient from unnecessary confine-
ment. If the patient stays at home for medical or psycho-
logical reasons, then further evaluation and treatment of
those specific problems may be necessary.
The fit and condition of the prosthesis warrant peri-
odic evaluation. Over time, repairs to the components of
the prosthesis are necessary. Changes in the size and shape
of the RL require that a new socket be made periodically
(85,86). Changes in the patient’s condition will often
dictate changes in the prosthetic prescription. For
example, the transtibial-level amputee with a patellar
tendon–bearing socket and elastic sleeve suspension may
develop degenerative changes in the knee and may benefit
from the addition of a thigh corset and mechanical knee
joints for pressure relief and additional stability. While may
amputees are resistant to changes in their prostheses,
newer materials or components may prove advantageous.
The physiatrist will need to educate the patient about the
potential benefits of new technology.
Routine skin care needs to be reviewed. The patient
is reminded of the importance of good hygiene. Skin irri-
tation and breakdown may result from poor cleaning tech-
niques. For the diabetic patient in particular, meticulous
skin care is imperative. The patient is reminded to clean
the skin gently with mild soap and warm water and to blot
the skin dry, including between the toes of the intact foot.
A skin moisturizer helps to keep the skin soft and supple,
avoiding dryness, cracking, and fissures, which may lead to
superficial infection. Lamb’s wool placed between the toes
helps avoid maceration and “kissing” ulcers. The patient is
taught to avoid any potential trauma to the feet, including
thermal injury. Cold feet deserve warm socks rather than a
burn from a heating pad or hot water bottle. Socks should
be worn with footwear, and walking barefoot is forbidden.
The patient should check shoes before putting them on. At
least one person required a transtibial amputation for a
foot infection that began with an ulcer caused by walking
with a coin in their shoe (87,88).
The routine follow-up visit is also the time to review
health maintenance behavior. Cessation of smoking is an
important topic for many amputees. Most people are
aware that smoking leads to cardiac and pulmonary prob-
lems, but many are unaware that smoking increases the
risk for limb ischemia and amputation. The patient with
lower-limb ischemia and claudication would likely benefit
from a regular exercise program (89). The follow-up visit is
the time to introduce, clarify, or reinforce such an exercise
regimen. The patient may also benefit from counseling
regarding nutrition and proper body weight. While exer-
cise and diet are important for all, it is beneficial to remind
the diabetic patient that diet and exercise are the mainstays
of therapy for diabetes. The patient may also need
reminders regarding blood pressure checks, cholesterol
monitoring, flu vaccinations, and general medical
follow-up.
Finally, the routine check-up is a good time to
remind the patient of his or her achievements and to
discuss new goals. Absorbed in the daily routine, the
amputee may lose sight of the fact that he or she overcame
significant trauma. Positive feedback is very therapeutic.
The clinician may want to suggest new activities such as
cycling or swimming. Of course, rehabilitation profession-
als need not be reminded that the truly rehabilitated
amputee does much more than simply walk.
CONCLUSIONS
Comprehensive rehabilitation of the amputee should be
more than the provision of a prosthetic device. This is
especially true for the geriatric amputee whose needs are
greater because of comorbidity, fragile social supports, and
limited resources. For the young, active patient, optimiza-
tion of the prosthetic device and appropriate rehabilitation
are necessary to preserve the patient in good health.

REFERENCES
1. Frantz CH, O’Rahilly R. Congenital
skeletal limb deficiencies. J Bone
Joint Surg [AM]. 1961;43a:
1202–1224.
2. Kay H, Working Group, Interna-
tional Society of Prosthetics and
Orthotics. A proposed international
terminology for the classification of
congenital limb deficiencies.
Orthot Prosthet 1974;28(2):
33–48.
3. Dise-Lewis JE. Psychological adap-
tation to limb loss. In: Atkins D,
Meier RH, eds. Comprehensive
management of the upper limb
amputee. New York: Springer,
1989:165–172.
4. Thompson DM, Haran D. Living
with an amputation: what it
means for patients and their
helpers. Int J Rehabil Res 1984;7:
283–292.
5. Pohjolainen T, Alaranta H,
Karkkainen M. Prosthetic use and
functional and social outcomes fol-
lowing major lower limb amputa-
tion. Prosthet Orthot Int
1990;14:75–79.
6. Ham R, Regan JM, Roberts
VC. Evaluation of introducing the
team approach to the care of
the amputee: the Dulwich study.
Prosthet Orthot Int 1987;11:
25–30.
7. Kaplow M, Muroff F, Fish W,
et al. The dysvascular
amputee: multidisciplinary
management. Can J Surg
1983;26:368–369.

Chapter 93 Amputation Rehabilitation 1757

 8. Thompson RG, Kramer S.
The amputee clinic team. In:
Atlas of limb prosthetics. Ameri-
can Academy of Orthopedic
Surgeons. St. Louis: CV Mosby,
1981:63–66.
9. Malone JM, Moore WS, Goldstone
J, et al. Therapeutic and economic
impact of a modern amputation
program. Ann Surg 1979;189:
798–802.
10. Pinzur MS, Gottschalk F, Smith
D, et al. Functional outcome of
below-knee amputation in
peripheral vascular insufficiency: a
multicenter review. Clin Orthop
1993;286:247–249.
11. Stewart CPU, Jain AS. Dundee
revisited—25 years of a total
amputee service. Prosthet Orthot
Int 1993;17:14–20.
12. Friedman LW. The psychological
rehabilitation of the amputee.
Springfield, IL: Charles C Thomas,
1978.
13. Bradway JK, Malone JM, Racy J,
et al. Psychological adaptation to
amputation: an overview. Orthot
Prosthet 1984;38:46–50.
14. Kashani J, Frank R, Kashani S,
et al. Depression among amputees.
J Clin Psychiatry 1983;44:
256–258.
15. Malchow D, Clark J. Interviewing
the amputee: a step toward reha-
bilitation. Orthop Rev 1984;13:
639–648.
16. Parkes CM. The psychological
reaction to loss of a limb: the
first year after amputation. In:
Howells JG, ed. Modern perspec-
tives in the psychiatric aspects of
surgery. New York: Brunnel/Mazel,
1976:515–532.
17. Thompson D, Haran D. Living
with an amputation: the patient.
Int Rehabil Med 1983;5:
165–169.
18. Thompson D, Haran D. Living with
an amputation: the helper. Soc Sci
Med 1985;20:319–323.
19. Racy JC. Psychological aspects of
amputation. In: Moore WS, Malone
JM, eds. Lower extremity amputa-
tion. Philadelphia: WB Saunders,
1989:330–340.
1758 Part V
20. Davis R. Phantom sensation,
phantom pain, and stump pain.
Arch Phys Med Rehabil
1993;74:79–91.
21. Melzak R. Phantom limbs and the
concept of a neuromatrix. Trends
Neurosci 1990;13:88–92.
22. Dickhaut S, DeLee J, Page C.
Nutritional status: importance in
predicting wound healing after
amputation. J Bone Joint Surg
[AM] 1984;66:71–75.
23. Hadley SA, Fitzsimmons L. Nutri-
tion and wound healing. Top Clin
Nutr 1990;5(4):72–81.
24. Kay S, Moreland J, Schmitter E.
Nutritional status and wound
healing in lower extremity amputa-
tions. Clin Orthop 1987;217:
253–256.
25. Gottschalk FA, Kourosh S, Stills
M, et al. Does socket configuration
influence the position of the femur
in above-knee amputation? J Pros-
thet Orthot 1989;2:94–102.
26. Esquenazi A, Vachranukunkiet T,
Torres M, Demopoulos JT. Charac-
teristics of a current lower extrem-
ity amputee population: review of
919 cases. Arch Phys Med
Rehabil 1984;65:623.
27. Glattly HW. A statistical study of
12,000 new amputees. South Med
J 1964;57:1373–1378.
28. Kay HW, Newman JD. Relative
incidences of new amputations:
statistical comparisons of 6000
new amputees. Orthot Prosthet
1975;29:3–16.
29. Muller EA. Influence of training
and inactivity on muscle strength.
Arch Phys Med Rehabil
1970;51:449–462.
30. Saltin B, Blomqvist G, Mitchell
JH, et al. Response to exercise
after bedrest and training.
Circulation 1968;38(suppl VII):
1–78.
31. Mensch G. Exercise for amputees.
In: Basmajian JV, Wolf SL, eds.
Therapeutic exercise. 5th ed.
Baltimore: Williams & Wilkins,
1990:251–279.
32. Mensch G, Ellis P. Physical
therapy management of lower
Medical Rehabilitation for Diagnostic Groups
extremity amputations. Rockville,
MD: Aspen, 1986.
33. Berlemont M, Weber R, Willot
JP. Ten years of experience with
the immediate application of pros-
thetic devices to amputees of the
lower extremities on the operating
table. Prosthet Int 1969;3:8–18.
34. Burgess EM, Romano RL, Zettl JH.
The management of lower-
extremity amputations. Washing-
ton, DC: US Government Printing
Office, 1969.
35. Atkins D. Postoperative and pre-
prosthetic therapy programs. In:
Atkins D, Meier RH, eds. Compre-
hensive management of the upper
limb amputee. New York: Springer,
1989:11–15.
36. Malone JM, Fleming LL, Robenson
J, et al. Immediate, early and late
postsurgical management of upper-
limb amputation. J Rehabil Res
Dev 1984;21:33–41.
37. Wu Y, Keagy RD, Krick HJ, et al.
An innovative removable rigid
dressing technique for below-knee
amputation. J Bone Joint Surg
[AM] 1979;61:724–729.
38. Wu Y, Krick H. Removable rigid
dressing for below-knee amputees.
Clin Prosthet Orthot 1987;
11:33–44.
39. Fish S. Semirigid dressing for
stump shrinkage. Phys Ther
1976;56:1376.
40. Ghiulamila R. Semirigid dressing
for postoperative fitting of below
knee prosthesis. Arch Phys Med
Rehabil 1972;53:186–190.
41. MacLean N, Fick G. The effect of
semirigid dressings on below knee
amputations. Phys Ther 1994;74:
668–673.
42. Menzies H, Newnham J. Semi-
rigid dressings: the best for lower
extremity amputees. Physiother
Can 1978;30:225.
43. Golbranson F, Wirta R, Kuncir E,
et al. Volume changes occurring in
postoperative below-knee residual
limbs. J Rehabil Res Dev 1988;
25:11–18.
44. Manella K. Comparison of the
effectiveness of elastic bandages
and shrinker socks for lower
 extremity amputees. Phys Ther
1981;61:334–337.
45. English RD, Hubbard WA. McElroy
GK. Establishment of consistent
gait after fitting of new compo-
nents. J Rehabil Res Dev 1995;
32:32–35.
46. Kamen LB, Chapis GJ. Phantom
limb sensation and phantom pain.
Phys Med Rehabil State Art Rev
1994;8(1):73–88.
47. Sherman RA. Published treatments
of phantom limb pain. Am J Phys
Med Rehabil 1980;59:232–244.
48. Sherman RA, Sherman CJ, Gall
NA. Survey of current phantom
limb treatment in the United
States. Pain 1980;8:85–99.
49. Sherman RA. Tippens JK.
Suggested guidelines for treatment
of phantom limb pain. Orthopedics
1982;5:1595–1600.
50. Sherman RA. Case reports of treat-
ment of phantom pain with a com-
bination of electromyographic
biofeedback and verbal relaxation
techniques. Biofeedback Self
Regul 1976;1:353.
51. Siegel EF. Control of phantom pain
by hypnosis. Am J Clin Hypn
1979;21:285–286.
52. Sherman R, Gall N, Gormly R.
Treatment of phantom pain with
muscular relaxation training to
disrupt the pain-anxiety-tension
cycle. Pain 1979;6:47–54.
53. Anderson M. Four cases of
phantom limb treated with ultra-
sound. Phys Ther Rev 1958;
38:419–420.
54. Winnem M, Amundsen T.
Treatment of phantom limb pain
with TENS. Pain 1982;12:
299–300.
55. Millstein S, Bain D, Hunter GA. A
review of employment patterns of
industrial amputees—factors influ-
encing rehabilitation. Prosthet
Orthot Int 1985;9:69–78.
56. Michael JW, Gailey RS, Bowker
JH. New developments in recre-
ational prosthesis and adaptive
devices for the amputee. Clin
Orthop 1990;256:64–74.
Chapter 93 Amputation Rehabilitation
57. Prince F, Allard P, Therrien RG,
McFadyen BJ. Running gait
impulse asymmetries in below
knee amputees. Prosthet Orthot
Int 1992;16:19–24.
58. Enoka RM, Millwer DI, Burgess
EM. Below knee amputee running
gait. Am J Phys Med Rehabil
1982;61:66–83.
59. Czerniecki JM, Gitter A. Insights
into amputee running. A muscle
work analysis. Am J Phys Med
Rehabil 1992;71:209–219.
60. Mackenzie L, ed. The complete
directory for people with disabili-
ties. Lakeville, CT: Grey House
Publishing, 1991.
61. Shrout RN. Resource directory for
the disabled. New York: Facts on
File, 1991.
62. Varghese G, Hinterbuchner C,
Mondall P, Sakuma J. Rehabilita-
tion outcome of patients with dual
disability of hemiplegia and ampu-
tation. Arch Phys Med Rehabil
1978;59:121–123.
63. Friedman LW. The surgical rehabil-
itation of the amputee. Springfield,
IL: Charles C Thomas, 1978:
205–209.
64. Torres MM, Esquenazi A. Bilateral
lower limb amputee rehabilitation.
A retrospective review. West J Med
1991;154:583–586.
65. Esquenazi A. Geriatric amputee
rehabilitation. Clin Geriatr Med
1993;9:731–743.
66. Fisher SV, Gullickson G Jr. Energy
cost of ambulation in health and
disability: a literature review. Arch
Phys Med Rehabil 1978;59:
124–133.
67. Waters RL, Perry J, Chambers R.
Energy expenditure of amputee
gait. In: Moore WS, Malone JM,
eds. Lower extremity amputation.
Philadelphia: WB Saunders,
1989:250–260.
68. DuBow LL, Witt PL, Kadaba
MP, et al. Oxygen consumption of
elderly persons with bilateral
below knee amputations: ambula-
tion vs. wheelchair propulsion.
Arch Phys Med Rehabil 1983;64:
255–259.
69. Huang CT, Moore NB, Jackson JR,
et al. Energy cost of ambulation
for amputees: a study using the
mobile automatic metabolic ana-
lyzer. Arch Phys Med Rehabil
1977;58:521.
70. Hughes J, Jacobs N. Normal
human locomotion. Prosthet Orthot
Int 1979;3:4–12.
71. Lehman JF. Biomechanics of
ankle-foot orthoses: prescription
and design. Arch Phys Med
Rehabil 1979;60:200–207.
72. Traugh GH, Corcoran PJ, Reyes
RL. Energy expenditure of ambula-
tion in patients with above knee
amputations. Arch Phys Med
Rehabil 1975;56:67–71.
73. Isakov E, Susak Z, Becker E.
Energy expenditure and cardiac
response in above knee amputees
while using prostheses with open
and locked knee mechanisms.
Scand J Rehabil Med Suppl
1985;12:108–111.
74. Wainapel SF, March H, Steve L.
Stubby prostheses: an alternative
to conventional prosthetic devices.
Arch Phys Med Rehabil 1985;
66:264–266.
75. Sakuma J, Hinterbucher C, Green
RF, Silber M. Rehabilitation of
geriatric patients having bilateral
lower extremity amputations. Arch
Phys Med Rehabil 1974;55:
101–111.
76. Waters RL, Perry J, Antonelli D,
Hislop H. Energy cost of walking
of amputees: the influence of level
of amputation. J Bone Joint Surg
[Am] 1976;58:42–46.
77. Kerstein MD, Zimmer H, Dugdale
FE, Lerner E. Amputations of the
lower extremity: a study of 194
cases. Arch Phys Med Rehabil
1974;55:454–459.
78. Mazat R, Schiller FJ, Dunn OJ, et
al. Influence of prosthesis wearing
on health of geriatric amputee.
Washington, DC: Project 431.
Office of Vocational Rehabilitation,
March 1963.
79. Malone JM. Complications of lower
extremity amputation. In: Moore
WS, Malone JM, eds. Lower
extremity amputation. Philadel-
1759
 phia: WB Saunders, 1989:
208–214.
80. Fylling CP, Knighton DR. Amputa-
tion in the diabetic population:
incidence, causes, cost, treatment,
and prevention. J Enterostom Ther
1989;16:247–255.
81. Aiello LM, Cavallerano JD. Ocular
complications of diabetes mellitus.
In: Kahn CR, Weir GC, eds.
Joslin’s diabetes mellitus. 13th ed.
Philadelphia: Lea & Febiger,
1994:772.
82. Altner PC, Rusin JJ, DeBoer A.
Rehabilitation of blind patients
with lower extremity amputations.
Arch Phys Med Rehabil 1980;
61:82–85.
1760 Part V Medical Rehabilitation for Diagnostic Groups
83. O’Connell PG, Gnatz S. Hemiple-
gia and amputation: rehabilitation
in the dual disability. Arch Phys
Med Rehabil 1989;70:451–454.
84. Koike K. Ishikura Y, Kakurai S, et
al. The TC double socket above-
knee prosthesis. Prosthet Orthot
Int 1981;5:129–134.
85. Lowry R. Durability of lower
extremity prostheses. Arch Phys
Med Rehabil 1966;47:742–743.
86. Smith DG, Horn P, Malchow D, et
al. Prosthetic history, prosthetic
changes, and functional outcome
of the isolated traumatic below-
knee amputee. J Trauma 1995;
38:44–47.
87. Levin ME, O’Neal LW, Bowker JH,
eds. The diabetic foot. St. Louis:
CV Mosby, 1993.
88. Malone JM, Snyder M, Anderson
G, et al. Prevention of amputation
by diabetic education. Am J Surg
1989;158:520–524.
89. Jonason T, Jonzon B, Ringqvist I,
Oman-Rydberg A. Effect of physi-
cal training on different categories
of patients with intermittent clau-
dication. Acta Med Scand
1979;206:253–258.