Dụng Cụ Chỉnh Hình Và Chân Tay Giả Trong Phục Hồi Chức Năng (Ấn Bản Thứ 3)

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Section II  Orthoses in Rehabilitation
Passive and Active Seating Systems
Seating surfaces can also be described or classified as active
or passive devices.21 Most support surfaces discussed in this
­chapter are passive in nature; they react to pressure exerted by
the body but do not actively exert or change any forces. Recently,
however, active cushion technologies have led to the develop­
ment of various pressure management devices. These cushions
have an active (mechanical) mechanism, such as a battery-
powered pump system, that actually causes the ­cushion to
change in some way to systematically alter pressure ­distribution.
Although active cushions may be highly effective at pressure
management for certain individuals, they are quite expensive
and rely on a pumping system and a battery pack that make
them heavier than typical seat cushions. They also are subject
to malfunction and require more maintenance to be effective.
Noncontoured and Contoured Seating Systems
Regardless of the specific purpose of the cushion, seating
surfaces can be classified according to their shape or amount
of contour.22 The most basic surfaces are planar or noncon­
toured. These surfaces are most easily manufactured. They
are also most readily modified to allow for growth or other
changes in the patient's needs. The drawback for noncon­
toured seating surfaces is their inability to accommodate the
many body surfaces that are not flat in nature; the result is
a less-than-optimal surface area for contact with the body,
creating areas of relatively high pressure under bony promi­
nences and soft tissues that contact the seating surface. To
increase the amount of contact area and better distribute
pressures, increasing the surface's contour is typically nec­
essary to match the shape of the body more closely.22
Two levels of contoured surfaces exist: precontoured
(generically contoured) seating surfaces and custom-contoured
seating surfaces. Precontoured seating surfaces are designed
around generic molds intended to match the body's shapes
more precisely than planar components. Many are available in
a number of sizes. Precontoured surfaces are available as seat
components designed to match the shape of the pelvis better
and as trunk support components to match alignment of the
spinal column better (Figure 16-9). The effectiveness of these
surfaces for either postural support or pressure management
depends on the precision of fit. The clinician determines preci­
sion of fit at the time of the initial assessment and prescription.
Custom-contoured surfaces are constructed directly from
the shape of the patient. Many technologies are available to
assist measurement for custom seating surfaces, including
hand-shaping foam, computer-assisted design/computer-
assisted manufacturing systems, and “foam-in-place” tech­
nologies, among others.23 All these systems have the same
general purpose: to record the shape of a person's body as
precisely as possible to manufacture a support surface that
precisely matches the contours of the person.
Material
Another method of classifying seat cushions or other postural
supports is according to the component materials included
in the support device. A variety of materials are being used
to create postural support devices. The most commonly used
materials include various foams, air, gel materials, water-
based materials, or a combination of these. The properties
and characteristics (including advantages and disadvantages)
of the each material must be carefully considered to select the
seating system that will best meet a patient's seating needs and
minimize the major risk factors for the development of pres­
sure ulcers, such as pressure over bony prominences, shear
and friction forces, temperature, and moisture.24
Foams are the most common component material used in
making support surfaces. Two major categories of foam are
available: elastic (available as either a closed-cell or open-
cell material) and viscoelastic. Both types have advantages
that make them well suited for use in postural supports as
well as disadvantages that must be considered. Elastic foams
deform in proportion to the applied load, which helps them
reduce peak pressure over bony prominences.24 They do
not, however, provide good envelopment characteristics
and they tend to insulate heat and keep it near the body.
Viscoelastic foams are temperature sensitive, meaning they
become softer and more compliant at higher temperatures.24
This characteristic helps them provide even better pressure
distribution than elastic foams, but it depends on the heat­
ing effect of being positioned near the body.
Fluid-filled cushions are often composed of materials
such as air, water, or viscous fluids contained in one or more
­containers, either large or small.24 Most of these products
FIGURE 16-9  The Jay Care Back is an example of a precontoured
back support. The back can be tilted as necessary, and the cross­
hatched foam distributes pressures away from spinous processes
for patients with pronounced thoracic kyphosis. (Courtesy Sunrise
Medical, Longmont, CO.)

Chapter 16  Adaptive Seating in the Management of Neuromuscular and Musculoskeletal Impairment
443
provide greater immersion into the cushion, thus distributing
pressure over larger areas of the body and reducing pressures
at bony prominences (see Figure 16-8). The type of material
used in the cushion influences both skin temperature and
the moisture buildup where the body makes contact with the
support surface.25 Understanding the different kinds of mate­
rial helps the clinician select an appropriate seat cushion for
pressure management and support or positioning in wheel­
chair seating.
Covering material is important to the function of postural
support devices, especially seat cushions and back cushions.
Regardless of the materials comprising the support itself, the
covering material alters the performance characteristics of
the support.25 For example, an inflexible covering material
prevents a cushion from providing optimal envelopment for
the user. Also, if a covering material with a high coefficient of
friction encloses a material selected for its low coefficient of
friction, the advantage of the selected cushion material is lost.
Covering material also needs to be resilient, easy to clean, in
some cases moisture repellent, and aesthetically pleasing to
the user.
ACCESSING THE MOBILITY UNIT
For wheelchair users to be independent in mobility in their
environment, they must be able to perform some movement
that can be translated into wheel movement of the mobility
base. This movement is called the access method for wheeled
mobility.5 The access method can be entirely manual, entirely
powered, or manual with power assistance. The access
method for a manually propelled chair is different from that
needed for an electrically powered chair. Table 16-7 summa­
rizes the advantages, disadvantages, and indicators for the
various wheeled technologies. The best access method and
frame characteristics are those that allow wheelchair users to
obtain the most efficient mobility from their access method
(Figure 16-10).
Whether ordering a manual or powered wheelchair, the
team must also carefully consider the need for back support,
support of extremities, and type of locking mechanism that is
most appropriate for each patient's needs. Table 16-8 provides
an overview of the advantages and disadvantages of various
limb support and locking mechanisms.
MANUAL WHEELCHAIRS
Manual wheelchairs typically have one large pair of wheels,
most often at the rear, that cause the wheelchair to move
when pushed. These are sometimes called the drive wheels.
The diameter of these wheels is typically between 20 and 26
inches. The wheels are most often equipped with push rims
that are slightly smaller in diameter, attached to the outside
of the wheel itself. The push rims, rather than the wheel, are
the access point for most manual wheelchair users. By push­
ing the wheel rims, the user has control over both the speed
and direction of the wheelchair depending on how the user
pushes each of the wheels.
The axle position of these drive wheels is critical for opti­
mal wheel rim access for the user, as well as for maximal effi­
ciency in manual propulsion. Standard wheelchairs do not
have adjustable axle attachment points and are therefore
quite difficult to optimize for efficient mobility. Many ultra-­
lightweight and maximally adjustable wheelchairs do have
adjustability of this axle location, allowing for adjustment of
the wheelchair to the user's needs (Figure 16-11).
Although the majority (90%) of manual wheelchair users
propel in a traditional push rim propulsion method with both
upper extremities,26 this is not the only method for wheel­
chair propulsion and may not be the best in light of problems
such as repetitive strain injuries. Some wheelchair users have
only one functional upper extremity or one upper extrem­
ity and one lower extremity, often on the same side of the
body (such as individuals with hemiplegia). Still others have
severely weakened upper extremities but somewhat stronger
lower extremities. For individuals with these different skills,
alternative access for manual wheelchairs exists.26
Wheelchair users with only one strong upper extremity
may use a one arm drive or lever drive system on their wheel­
chairs. These systems connect the axles of both drive wheels
(either with a dual push rim or a lever system) so that the
user can control both wheels and have effective directional
control from one side of the chair. Wheelchair users with
one functional arm and leg often propel their wheelchairs by
pushing on one wheel rim and using their functional lower
extremity on the ground to assist in directional control and to
increase their speed or power of propulsion. Likewise, wheel­
chair users with stronger lower extremities and weaker upper
extremities often “foot propel” their wheelchairs by using
both lower extremities on the ground, bypassing the typical
wheel rim input and controlling the movement of the chair by
interfacing with the ground and indirectly causing the wheels
of the chair to react to these forces.
Regardless of the method used for manual wheelchair pro­
pulsion, maximal efficiency is critical to functional mobility.13
Upper extremity musculature is poorly suited to providing
the body with ambulation, and without efficiency obtained
through the technology, manual propulsion may be highly
stressful and fatiguing for the wheelchair user. The environ­
ments in which most wheelchair users must function are
much better suited to bipedal mobility, making it even more
difficult for wheeled mobility to be an adequate substitute
when an individual loses the ability to walk.
Many risks are associated with the use of a manual wheel­
chair. Some of these risks are manageable through other
therapeutic interventions (e.g., training) or technological
modifications. Others are more serious and must be carefully
considered when a manual mobility system is prescribed for
a user. Short-term risks include the potential for injury for a
new user who is not fully able to control the balance of a wheel­
chair. This may lead to tipping a wheelchair over (most often
falling backwards) when maneuvering up or down ramps or
curbs. Other common injuries include trauma involving fin­
gers and hands inadvertently caught in the wheel spokes or
wheel lock mechanisms, injuries to lower extremities that are

444
Section II  Orthoses in Rehabilitation
TABLE 16-7  Advantages, Disadvantages and Possible Applications of Various Wheeled Mobility Technologies
Wheeled Mobility Device
Advantages
Disadvantages
Possible Application
Semiadjustable manual wheelchair
(lightweight)
Simple to use
Folds for transportation
Lighter weight than standard wheelchair
Partial adjustability
Easier to propel
Durable
Will accommodate custom seating
Not custom fit
Lack of axle adjustability may limit manual
propulsion by user
Still may be too heavy for many users
Intermittent or temporary use
Possible use for in-home applications
if environment tolerates
Fully adjustable manual wheelchair
with a folding frame
(ultra-lightweight)
Very light frame
Maximal adjustability, especially
of rear axle position
Custom fit to user
Accommodates custom seating
Accommodates to uneven ground
by flexing
Folds side to side for easy transportation
Many adjustable or removable parts
More complex design, requires more
maintenance
Some propulsion energy lost in flex
of frame
Full-time wheelchair user with
permanent disability
User wants to transport in trunk of
vehicle
Environment includes travel over
uneven surfaces
Fully adjustable manual wheelchair
with a rigid frame
(ultra-lightweight)
Very light frame
Maximal adjustability, especially of rear
axle position
Custom fit to user
Fewer removable or adjustable parts than
folding frame
Accommodates custom seating
Does not accommodate to uneven terrain
as easily as folding frame
May be more difficult to transport in trunk
of car (less compact when folded)
Full-time wheelchair user with
permanent disability
User wants most efficient system for
propulsion
Used mainly indoors or on even
terrains
Power assist manual wheelchair





Light frame
Maneuvers like manual wheelchair
Minimizes stress on shoulders



Heavier than nonpower assist
More difficult to disassemble for transport




Lightweight manual wheelchair user
with limited endurance or shoulder
limitations
Manual wheelchair user with long-
distance ambulation needs or
difficulty managing outdoor terrain
independently

Chapter 16  Adaptive Seating in the Management of Neuromuscular and Musculoskeletal Impairment
445
Tilt-in-space frame wheelchair



Allows rotation in space for pressure
management or other benefits
Available for both manual and powered
wheelchairs
Frame often heavier and bulkier
Usually does not fold for transportation
If on manual wheelchair, typically has small rear
wheels, requiring an attendant to propel
Wheelchair user requires rotation
in space for pressure management
or other medical reason, such as
respiratory disease
Reclining frame
wheelchair
Allows for change in seat-to-back angle,
often to full supine position
Available for both manual and powered
wheelchairs
Frame often heavier and bulkier
Rear wheels set further back to provide
larger base of support when in recline
position
Difficult to propel if used with manual
wheelchair
Used when a need for change in seat to
back angle is required
Used for pressure management
May be used for self-care in wheelchair
May be used when supine bed transfers
are required
Often used when building sitting
tolerance during initial rehabilitation
Powered scooter



Allows simple-to-learn powered mobility
Good outdoor access
Swivel seat for ease of transfers
Baskets and other accessories for function,
such as shopping
Only one access method
Large turning radius; difficult to use in many
homes
Does not accommodate custom seating; few
seating support options
Used with individuals who have limited
endurance
Often used for primarily outdoor
mobility purposes


Powered wheelchair





Full access to powered mobility for both
indoor and outdoor use
Multiple access methods possible
Accommodates custom seating supports
Accommodates power seating options,
such as tilt or recline
Heavy
Requires van for transportation
Less maneuverable than manual wheelchair
Requires more initial training for optimal
safety and function

Individuals who cannot propel manual
wheelchair effectively
Used for indoor and outdoor mobility
for long distances
May be used in work or school
applications for part-time manual
wheelchair users

446
Section II  Orthoses in Rehabilitation
A
B
C
FIGURE 16-10  Examples of wheelchair support structure and mobility base options. A, A stan­
dard lightweight, semiadjustable wheelchair with arm support and swing-away leg rests. B, An ultra-­
lightweight wheelchair with rigid frame, precontoured seat and back support, and shock-absorbing
mechanism. C, A pediatric wheelchair with reclining back and precontoured seating system.
(Courtesy Sunrise Medical, Longmont, CO.)
TABLE 16-8  Advantages and Disadvantages of Various Wheelchair Components
Wheelchair
Component

Options

Advantages

Disadvantages
Leg and foot
supports
Swing-away foot rests
Lightweight
Support for lower extremities
Removable for transfers
Add to weight of wheelchair (vs. platform)
Require maintenance
Require management by wheelchair user
Flip-up foot platform
Lightweight
Few moving parts
Very stable
Often allows increased knee flexion
angle; more comfortable and compact
for user
Very little adjustability
Both lower extremities supported at same angle
Unable to accommodate moderate or severe
ankle contractures
Not removable; may interfere with transfers
for some users
Manual elevating
leg rests
Allows multiple leg positions
May prevent some dependent edema (true
edema management also requires recline or
tilt to elevate the legs above the heart level)
May increase lower extremity comfort
Heavier than standard leg supports
Many moving and adjustable parts; higher
maintenance needs
More strength and dexterity needed to manage
Arm supports















Flip-back arm rests
Stable arm support
Typically lightweight
Easy to manage
Multiple moving parts
Require maintenance to work properly
May not be adjustable enough for all individuals
Tubular swing-away
arm rest
Extremely lightweight
Easy for wheelchair user to manage
Requires very little hand dexterity and
strength
May not feel stable to user
May not tolerate extreme or repeated stresses
Attachment hardware requires maintenance
Detachable, adjustable-
height arm rest
Support upper extremities in multiple
positions
Removable for transfers
Heavier
More moving parts; higher maintenance requirement
May be difficult for users to manager; especially to
replace parts on the wheelchair
Desk-length arm rest
Allow wheelchair user to approach tables,
sinks, desks for improved function
Lighter in weight than full-length arm
supports
May not provide adequate support during transfers
Do not provide full arm support
Full-length arm rest
Provide full arm support
Provide improved support during transfers
Heavier than desk-length arm
Do not allow close approach to tables, sinks, or desks

Chapter 16  Adaptive Seating in the Management of Neuromuscular and Musculoskeletal Impairment
447
not properly supported, and injuries to limbs that fall off their
supports during propulsion. Most of these risks can be mini­
mized by adequate training and safety mechanisms added to a
wheelchair during the initial training period. The most com­
mon of these strategies is the use of rear antitip tubes until
a new wheelchair user gains enough strength and postural
control to master the “wheelie” maneuver and managing
steep inclines or steps.
Other risks associated with manual wheelchair propul­
sion are less-well understood and are the focus of much
current research. These risks include long-term risks of man­
ual wheelchair user for repetitive use strain injuries, leading
to impairment in function or pain in the shoulders and upper
extremities.16 The two main areas of focus are the shoul­
ders (e.g., rotator cuff tears) and wrists (e.g., carpal tunnel
syndrome).27 These risks may be much larger than previously
thought, particularly for individuals who have depended
on wheeled mobility use over long periods. Because of the
increased longevity of persons with different types of disabili­
ties who have relied on manual wheeled mobility for 20 years
or more, these injuries are becoming much more prevalent
and may be extremely detrimental to continued independent
function.
WHEN IS A POWERED CHAIR APPROPRIATE?
The choice of manual or powered mobility is straightforward
for many wheelchair users. For example, an individual with
tetraplegia who has little movement in the upper extremities
benefits most from powered mobility. Likewise, persons with
minimal trunk and upper body impairment are obvious man­
ual wheelchair candidates. The problem arises when individ­
uals have skills and abilities that are not so clearly indicative
of a particular variety of mobility, or when the environmen­
tal demands placed on the individual really require use of
powered mobility in spite of the individual's basic ability to
propel a manual mobility device.
One of the most important decisions for any wheelchair
user is that of manual versus powered mobility. Both types of
mobility have advantages and disadvantages, and overall func­
tion is greatly affected by this basic selection. Conditions and
impairments that often indicate need for powered mobility
include the following:
1. Severe upper extremity or upper trunk weakness
leading to an inability to propel any type of manual
wheelchair
2. Ataxic or uncoordinated movement of the upper
extremities
FIGURE 16-11  In maximally adjustable wheelchair frames, wheel position can be tailored to meet
the user's specific needs by adjusting the location of the wheel axis in an anteroposterior slide and ver­
tical position on the frame. A, A rigid frame in which the wheel bracket can be positioned as needed
on the frame. B, An actual chair. (Courtesy Sunrise Medical, Longmont, CO.)
A
Wheelchair
Component

Options

Advantages

Disadvantages
Wheel locks






Pull-to lock
Allow closer access for transfers to surfaces
Move away from wheels so hands do
not hit with propulsion
May be more difficult to lock
Push-to lock
Lock easily and securely
May interfere with propulsion
May interfere with transfers
Under-seat or
scissor locks
Complete clearance for hands during
propulsion
No interference in transfers
Significantly better balance and coordination
required for locking and unlocking
More difficult to adjust
TABLE 16-8  Advantages and Disadvantages of Various Wheelchair Components—cont'd

448
Section II  Orthoses in Rehabilitation
3. Endurance limitations, whether from muscular or
cardiopulmonary impairment
4. Progressive conditions that will likely lead to loss of
upper extremity strength or poor endurance (particu­
larly a rapidly progressing condition)
5. Orthopedic problems in the upper extremity joints
(e.g., arthritis or preexisting rotator cuff or carpal
tunnel impairments)
6. Environments that require long-distance travel on a
regular basis or travel over rough terrain
Once a determination has been made that powered mobil­
ity is necessary, one of the next decisions is the access method
for control of the device. If the powered mobility device is
a powered scooter, this decision is uncomplicated; a tiller
mechanism is the most efficient and effective choice. If, how­
ever, the device under consideration is a powered wheelchair
(Figure  16-12), the access methods available are far more
complex. Powered wheelchair access methods include stan­
dard joysticks, switch arrays, sip and puff input devices, and
head-controlled devices, among others. These options make
it more likely that an effective control system can be designed
for powered wheelchair users with various and significant
impairments and functional limitations. The decision making
process, however, is more complex for clinicians who must
evaluate and assist in the selection of an access method.
The best method of powered wheelchair access allows the
wheelchair user optimal control and function in the environ­
ment over the long term. Sometimes the simplest method to
learn may not ultimately be the best for the user over the long-
term. Some input methods, such as head control ­systems,
require a longer training period, but the ultimate function
of the user may be superior to a simpler joystick system.
A thorough evaluation with multiple episodes of training may
be required before an ultimate access method is selected. To
select appropriate power access options and effectively train a
wheelchair user in the proper use of these devices, clinicians
must be aware of the different types of equipment and how
each works to stop and start, turn or change direction, lock
and unlock, and alter velocity of movement. Ideally, clinicians
also must know how to adjust the control mechanism to allow
the user to be most energy efficient and effective. These skills
may take many years of training to develop, most often when
the clinician functions as a specialist who works with indi­
viduals with highly complex access needs on a regular basis.
TRAINING STRATEGIES
Regardless of the type of wheelchair selected or the access
method chosen, intensive training of the person using the
wheelchair is necessary. Training takes place across settings
and over time. Wheelchair skills are typically introduced
during inpatient rehabilitation but training usually con­
tinues either in home care or outpatient settings until the
new user gains independence with advanced skills. Initial
training may actually be accomplished with loaner or tem­
porary equipment used to assess options and designs that
will allow optimal mobility before a wheelchair prescrip­
tion is finalized. Additional training is typically necessary
once the permanent wheelchair and associated equipment
have been delivered.
Functional manual wheelchair users are well trained in the
safe use of equipment, are able to effectively manage obsta­
cles in the home environment and community (work and
leisure settings), are able to perform or direct basic main­
tenance of the equipment (including cleaning procedures
and maintaining moving parts), and know when and whom
to contact if something out of the ordinary occurs with the
wheelchair.
Power wheelchair users often require more extensive
periods of training than manual chair users to achieve
optimal mobility and function. This training must include
management of indoor terrain and obstacles such as turn­
ing in tight spaces, managing door frames and transitions
between flooring surfaces, and negotiating other indoor
obstacles such as elevators. Training should also include
outdoor terrain and obstacles, such as ramps, curbs, side
slopes, grassy surfaces, gravel surfaces, and safe operation
on crowded sidewalks or when crossing streets. If a pow­
ered seating system is prescribed, the user must be edu­
cated regarding the proper and safe use of this powered
seating system, including how often to use it, under what
conditions it should (and should not) be used, and whom
to contact if the powered seating system is not function­
ing properly.
Although the assessment and prescription for a wheelchair
usually takes place in a specialty clinic, functional training
after delivery of the equipment is typically provided by outpa­
tient or home care therapy services. A therapist who has ques­
tions about a particular piece of equipment that a patient is
learning to use should contact the seating clinician and work
on a training protocol that will be most effective.
FIGURE 16-12  In this powered wheelchair, the mobility compo­
nent includes the wheelbase as well as the joystick (or alternative
access method) used to control the movement of the chair. Note that
anterior–posterior wheelbase dimension is longer to accommodate
the weight of the batteries and motors of the chair. (Courtesy Sunrise
Medical, Longmont, CO.)

Chapter 16  Adaptive Seating in the Management of Neuromuscular and Musculoskeletal Impairment
449
SEATING SYSTEMS FOR PRESSURE
MANAGEMENT
Selection of the wheeled mobility device itself is only part of
the equation when working with individuals who use wheel­
chairs for much or all of their mobility. The seating system or
postural support system is as important as the wheeled mobil­
ity base and access method. The seating system is critical to
integrating the person and the wheeled mobility system, and
several major issues must be considered in its selection.
A major issue for many wheelchairs users is pressure man­
agement. Any person who sits for more than 4 hours per day
is at increased risk for pressure-related damage to the skin.28
This risk is exacerbated by many factors, including impaired
sensation, increased heat or moisture buildup near the skin,
inadequate nutrition or hydration status, and atrophy of mus­
cle tissue leading to decreased soft-tissue protection for bony
prominences.29
The major problem associated with pressure sustained over
long durations is skin breakdown. This problem has been the
focus of a great deal of research for more than 30 years and is
better understood than it used to be, but still mysterious. The
individual and interactive effects of pressure, friction, and
shear are the current focus of research regarding skin break­
down, its causes, and ways to prevent it. Skin breakdown is
an extremely costly and debilitating problem for many wheel­
chair users.30,31 Treatment for skin breakdown often involves
costly surgical interventions and prolonged hospital and reha­
bilitation stays. Skin breakdown may also be responsible for
ultimately reducing the life expectancy for individuals with
disabilities who use wheelchairs for mobility.30
Active and Passive Strategies
Many technologies have been developed to provide pressure
management. Recognizing that low pressure exerted over long
periods can be as dangerous for skin as high pressures exerted
over short periods, pressure management technologies pro­
vide options either to distribute pressure over as wide a surface
area as possible or to change position so that the forces exerted
on weight-bearing surfaces vary over time. Most rely on good
user training and use of the systems for optimal function and
outcome; no pressure management system can entirely pre­
vent skin breakdown if used improperly or inconsistently.
Technologies can be grouped into three general categories
on the basis of whether they use an active, rotational, or pas­
sive strategy to provide pressure relief. Active technologies,
such as active or dynamic seat cushions, are designed to relieve
areas of high pressure periodically. Dynamic seat cushions are
often divided into a series of alternating chambers. A motor
pumps air or fluid through chambers to change the configu­
ration of the support surface gently and continuously (much
like an alternating-pressure mattress used in hospital beds for
patients who are unable to change position). Rotational seat­
ing systems include those with a powered tilt or recline mech­
anism, a manual tilt or recline system, or a standing system
(Figure 16-13). Passive technologies for pressure management
focus on increasing seating surface area, usually by increasing
envelopment or compliance of the seating surface or by shifting
pressure from traditionally high-risk areas, such as ischial tuber­
osities, to lower-risk areas, such as distal femurs. Some passive
technologies completely offload areas such as the ischial
tuberosities, and others simply aim to reduce pressure in these
areas by using more compliant materials in certain zones of
the cushion (see Figure 16-8).
Some supports can cause skin “hammocking,” or stretch­
ing the skin and soft tissues across bony surfaces such as the
coccyx, when unloading other regions such as the ischial
tuberosities. This effect can cause skin breakdown even in the
absence of direct external tissue loading.
FIGURE 16-13  Rotational pressure management strategies include tilt, in which hip angle doesn't
change (A), and reclining (B), in which hip angle (extension) is opened (increased). Rotational pres­
sure management systems are available for both manual and powered wheelchairs. (Courtesy Sunrise
Medical, Longmont, CO.)

450
Section II  Orthoses in Rehabilitation
Size and Setup
In addition to the technological development of products for
pressure management, clinicians have learned a great deal
about seating intervention to manage pressure as effectively as
possible. Proper size and setup of wheelchairs is often critical
in appropriately managing pressure.21 The strategic use of
contoured surfaces, different types of materials and cover­
ings, and a well-planned mobility system and any active seat­
ing choices, such as tilting or reclining seating systems (also
known as rotational systems) must be integrated in a holistic
approach to protect wheelchair users from skin breakdown.28
Training
In addition to choices of technologies, proper training and
education of wheelchair users is essential to the effective
application of this technology. Most of the technologies devel­
oped rely on proper use, either through correct positioning
on the wheelchair and proper maintenance and adjustment,
or schedules by the user. Sometimes an apparent failure of a
particular technology has more to do with how it was used or
in what combinations different technologies were used than
the actual failure of the technology itself.
Seating for Function and Comfort
Although pressure management in seating often dominates
research and technological development, maximal function
and optimal comfort are equally important.7 Wheelchair users
who are not able to function optimally or become uncom­
fortable when seated will probably not reach their full poten­
tial. Individuals who have discomfort when seated also have
satisfaction problems with their equipment, which may cause
equipment abandonment.32 To function optimally individu­
als must be comfortable and secure in their seating systems.
The priorities of a seating system depend on the problems
and goals identified during the assessment process. If a patient
has a lack of sensation and a history of skin breakdown prob­
lems, then seating for pressure management will most likely be
the highest priority. However, if the problems identified focus on
a lack of optimal function or feelings of discomfort when using
the equipment, then goals for enhanced function and comfort
may be more critical. For some patients all three issues are priori­
ties, and equipment must be carefully selected that will balance
all needs and allow the individual to meet all goals of seating.
The determination of these priorities is often quite challeng­
ing. For a health care team, the primary medical concern might
be pressure management or improving comfort, but the user may
be focused on a particular functional goal that the user believes
is more critical than pressure management. Occasionally, equip­
ment selection will be difficult because some needs may have
to be compromised to meet other needs optimally. An air–
fluid cushion, for example, may provide the maximal pressure
management desired by the team but might feel unstable to the
wheelchair user, disrupting comfort, function, or both.
When compromises must be made, a conflict can occur bet­
ween the health care or seating team and the wheelchair user.
The best way to resolve conflicts is to find a technology interven­
tion that meets all the stated needs. If this is not possible, then the
wheelchair user must be properly educated regarding the risks
and benefits of the equipment selected and ultimately make an
informed choice. Health professionals should remember that the
user is the only one who can decide what is best for the user's
circumstances. Forcing choices on an individual often has very
negative consequences in terms of equipment abandonment or
improper use and can also negatively affect the individual's satis­
faction with the process and equipment provided. The best solu­
tion is one that meets all the needs to the greatest extent possible
and that yields optimal consumer satisfaction.
SUMMARY
The science associated with adaptive seating and mobility for
persons with disabilities is still in its infancy. Significant research
in this field only began in the 1960s, and serious growth of this
research has only been happening for the last 10 to 20 years.33
Recent work has focused on the development of wheeled
mobility that allows individuals to participate in a variety of lei­
sure and competitive sport activities (Figure 16-14). In spite of
this, several important research findings related to ­wheelchair
FIGURE 16-14  Examples of wheelchairs designed for wheelchair racing (A) and upper-extremity–
powered bicycling (B). (Courtesy Sunrise Medical, Longmont, CO.)

Chapter 16  Adaptive Seating in the Management of Neuromuscular and Musculoskeletal Impairment
451
­seating and mobility are now beginning to be applied to the
practice of wheelchair mobility seating.
A great deal of research has contributed to and resulted
from the development of international and national seating
and wheelchair standards. The Rehabilitation Engineering
and Assistive Technology Society of North America has
been actively working toward the development of wheel­
chair seating standards since 1979.34 These standards are
intended to provide objective information to consumers
about the safety and performance of wheelchairs.34 In addi­
tion, ­wheelchair standards have facilitated improvements
in quality and performance of wheeled mobility equip­
ment.35 Standards development also has provided a plat­
form for research into characteristics of wheelchairs that
are most beneficial to consumers and allowed the justifica­
tion of higher-quality products based on ultimate cost effec­
tiveness.36–39 Wheelchair seating standards regarding the
strength, efficacy, and safety of postural support devices are
currently under development to provide many of these same
benefits to the development and research related to adaptive
seating products.
In addition to the research being performed in the stan­
dards arena, a great deal of interest and research in evidence-
based practice exist for wheelchair seating and mobility.
Although many seating clinicians prefer to practice with an
evidence-based model, little research exists to support the
efficacy of either the intervention process used or the equip­
ment prescribed.40,41 Several researchers are developing and
validating outcomes measures to facilitate development of
evidence-based practice in this field.6,12,42–45 Once appropriate
seating and wheeled mobility outcomes measures are devel­
oped, applying these outcomes in clinical and research set­
tings and building the evidence so desperately needed in this
field will be possible. Few randomized, controlled clinical
trials assessing efficacy of seating and mobility intervention
have been performed.46,47 Such studies have primarily focused
on preventing pressure ulcers as an outcome of seat cushion
intervention. More research regarding the many other possi­
ble outcomes of wheelchair seating and mobility intervention
is still needed.
CASE EXAMPLE 1
Patient with a C5/C6 Complete Spinal Cord Injury
J. J. is a 24-year-old man who sustained an injury to his
spine at the C5 vertebral level in a motor vehicle accident
8 weeks ago. He has total loss of motor function on his
right side below the level of the C5 nerve root and on his
left side below the C6 nerve root level. He was referred to
the clinic for an evaluation for his first wheelchair after his
in-patient rehabilitation.
J. J.'s sensation is severely impaired below the level of
his shoulders, although he has some ability to feel in local­
ized areas of his body. At the time of his visit to the seat­
ing clinic, he was using a cervical orthosis for stabilization
of his surgically repaired cervical spinal column. He has
undergone surgery consisting of a spinal fusion from C4
through T1 vertebrae. J. J. will be returning home to live
with his wife and 2-year-old child. He is an architect and
works in an office approximately 20 miles from his home.
His job responsibilities include visiting construction sites
involved in his design projects.
During his rehabilitation, J. J. has been propelling a fully
adjustable manual wheelchair with specialty wheelchair
propulsion gloves and plastic-coated wheel rims. He is able
to propel his wheelchair on indoor surfaces for 300 feet at
a time but still has problems with fatigue and neck pain.
He requires assistance for outdoor surfaces and for propel­
ling up or down ramps. J. J. lives in a home with 3 steps to
enter, but his neighbors are building him a ramp that will
be ready by the time he returns home. He has wall-to-wall
carpeting throughout his home with the exception of the
kitchen and bathroom floors.
J. J.'s stated goals include the following:
• Being as independent as possible in his home and
workplace
• Being able to transport his wheelchair in a car
• Returning to work as soon as possible
• Helping care for his 2-year-old son and his home
• Improving his endurance and reducing his level of neck
pain so that he can sit up and function for a full day
• Maintaining skin integrity
Questions to Consider
• Given his history and stated goals, what should the
systems review include?
• What specific tests and measures will likely be used in
the examination?
• How might his current functional status and his prog­
nosis for recovery or accommodation of impairments
and associated functional limitations influence the
assessment of his needs?
Evaluation and Prognosis
J. J. has no active movement in his legs or trunk. He
has good strength in elbow flexion on the left side, fair
strength in elbow flexion on the right side, good strength
in both of his shoulders, but no evidence of triceps activ­
ity on either side. His range of motion is normal with
the exception of his neck range, which cannot be tested
because of the cervical orthosis. His conscious sensation
is spotty, and he has no sensation in his buttock region.
He requires assistance for all transfers and other mobil­
ity and for activities of daily living, such as bathing and
dressing. J. J. has a healed pressure sore in the region of his
coccyx; it developed during his acute hospitalization but
is now healed, and he is able to sit for 6 to 8 hours per day.
He has been using an ultra-lightweight, folding-frame,
manual wheelchair and a foam and gel seat cushion.
Continued

452
Section II  Orthoses in Rehabilitation
CASE EXAMPLE 2
Patient with Cerebral Palsy
S. W. is a 35-year-old woman with spastic quadriplegia
attributable to cerebral palsy. She has been using a fully
adjustable manual wheelchair for most of her life with good
success. Her current wheelchair is 10 years old and she
reports that it is falling apart (her rehabilitation technol­
ogy supplier confirms the extensive repair history of this
wheelchair). She came to the seating clinic for an assess­
ment for a replacement wheelchair and seating system.
S. W. has no functional movement in her lower extrem­
ities and has severe extensor tone in both legs. She has
impaired motor control in her arms but is able to propel
her manual wheelchair with some difficulty. She transports
her wheelchair in her car with some assistance from others
for disassembling the seating and folding the wheelchair
for stowing. The muscle tone in her trunk and arms fluc­
tuates, but she has significant intermittent extensor tone.
S. W. works independently in an office as an adminis­
trative assistant. Her home is wheelchair accessible and her
office setting does not require long-distance propulsion.
When she shops or goes to the mall, her friends assist her
with her mobility or she borrows a powered scooter from
the grocery store.
Questions to Consider
• What will the team's priorities be for J. J.'s seating and
mobility system? How are these priorities similar or
different from J. J.'s priorities? What compromises
might be necessary?
• What options might be considered for J. J. in terms of
seating system (noncontoured, contoured, or custom)?
Support frame (lightweight, heavy duty)? Mobility
component (manual or powered chair)?
• What recommendations should be made for manag­
ing pressure in J. J.'s seating system (active, rotational,
reclined, or passive)? Why?
Recommendations
General recommendations for J. J. include a manual wheel­
chair with a power assist add-on component to allow him
more independent mobility and access to all his environ­
ments while minimizing stress on his shoulders and neck
and accomplishing his goal of transportability by car.
Seating will consist of a gel and foam seat cushion con­
toured to match the shape of his buttocks and manage
pressure distribution as evenly as possible. J. J. requires a
solid back support with generic contour and angle adjust­
ability to allow appropriate upright posture to maximize
his function and balance and minimize future develop­
ment of spinal deformities. Plastic-coated wheel rims and
specialty gloves will maximize his wheel/rim interface,
allowing him optimal propulsion as well.
S.W.'s goals include the following:
• Maintaining or improving her current level of mobility
• Improving her perception of postural stability in her
wheelchair
• Being able to transport her wheelchair in her car with
no more difficulty than she currently has
• Having a wheelchair that is easy to manage and main­
tain (fewer moving parts to break)
Questions to Consider
• Given her history and her stated goals, what should the
systems review include?
• What specific tests and measures would likely be used
in the examination?
• How might her current functional status and the chronic
nature of her neuromuscular condition (coupled with the
aging process), with its associated impairments and func­
tional limitations, influence the assessment of her needs?
Evaluation and Prognosis
S. W. has severely impaired strength in her legs and trunk,
poor unsupported sitting balance, severe extensor spastic­
ity in both legs, hip flexion limited to a 100-degree pelvis-
to-thigh angle, moderate weakness in her arms with poor
motor control, and fluctuating muscle tone. S. W. also has
a severe scoliosis and a pelvic rotation and pelvic obliquity.
With moderate trunk support she is able to use her arms
functionally and feels secure.
Questions to Consider
• What will the team's priorities be for S. W.'s seating and
mobility system? How are the team's priorities similar
to or different than S. W.'s priorities? What compro­
mises might be necessary?
• What options might be considered for S. W. in terms of
seating system (noncontoured, contoured, or custom)?
Support frame (lightweight, heavy duty)? Mobility
component (manual or powered chair)?
• What recommendations should be made for managing
pressure in S. W.'s seating system (active, rotational, or
passive)? Why?
Recommendations
General recommendations for S. W. may include a new cus­
tom manual wheelchair with a folding titanium frame with
a fixed-axle position specified to her particular needs, a cus­
tom-contoured seat and back cushion to support and posi­
tion her, spring-loaded foot rests with elevating leg rests for
her lower extremities, a push-button pelvic belt with special
loops so that she can fasten and secure it around her hips,
and a hook-and-loop material chest belt to stabilize her
upper body. The combination of custom-contoured seat­
ing and anterior support devices that she can tighten herself
will improve her feeling of stability and the overall fit of the
wheelchair seating. This wheelchair will be more durable
with fewer moving parts and will meet her mobility needs.

Chapter 16  Adaptive Seating in the Management of Neuromuscular and Musculoskeletal Impairment
453
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3. Schoenman JA. Description of the US working age disabled
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13. McLaurin CA, Brubaker CE. Biomechanics and the wheelchair.
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14. Engstrom B. Seating and Mobility for the Physically Challenged,
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15. Zacharkow D. Posture: Sitting, Standing, Chair Design and
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16. Curtis KA, Drysdale GA, Lama D, et al. Shoulder pain in wheel­
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2003;16(6):18–22.
18. van der Woude LH, Veeger DJ, Rosendal RH, et  al. Seat
height in hand rim wheelchair propulsion. J Rehabil Res Dev.
1989;26(4):31–50.
19. van der Woude LH, Veeger HE, Rozendal RH. Propulsion tech­
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20. Garber SL. Wheelchair cushions: a historical review. Am J Occup
Ther. 1985;39(7):453–459.
CASE EXAMPLE 3
A Patient with Cerebrovascular Accident
M. L. is an 80-year-old woman who has been referred for
an assessment for wheeled mobility because of a recent
decline in her ability to walk. M. L. had a stroke 10 years
ago that impaired the strength on the left side of her body.
Although she regained the ability to walk and can do so
with a quad cane, she has begun to fall more frequently and
currently is severely limited by her mobility impairment.
She can walk only a distance of 10 feet and must have assis­
tance from another person to do so safely. Because of this
limitation, she spends most of her time sitting in a recliner
chair in her living room and is becoming quite depressed.
She has always been an active woman and would like to be
able to participate in activities outside her home as well as
move around inside her home by herself.
Questions to Consider
• Given her history and her stated goals, what should the
systems review include?
• What specific tests and measures should be used in the
examination?
• How might her current functional status and the chronic
nature of her neuromuscular condition (coupled with
the aging process), with its associated impairments and
functional limitations, influence the assessment of her
needs?
• What will the team's priorities be for M. L.'s seating and
mobility system? How are the team's priorities similar
or different from M. L.'s priorities? What compromises
might be necessary?
• What options should be considered for M. L. in terms of
seating system (noncontoured, contoured, or custom)?
Support frame (lightweight, heavy duty)? Mobility
component (manual or powered chair)?
• What recommendations should be made for managing
pressure in M. L.'s seating system (active, rotational,
reclined, or passive)? Why?
Recommendations
M. L. was evaluated in the seating and mobility clinic. The
team arranged for her to borrow a semiadjustable, light­
weight manual wheelchair and a powered wheelchair for
a week so that she could assess which might best meet her
needs. She was only able to propel the manual wheelchair
on smooth indoor surfaces and could not move the chair
up an incline without great difficulty. She was fully inde­
pendent in operating the powered wheelchair but was dis­
couraged by its large size.
The rehabilitation technology supplier obtained a
smaller powered wheelchair considered transportable and
that more closely resembles a manual wheelchair in over­
all size and shape. M. L. evaluated this wheelchair in her
home environment and was pleased with her increased
independence and access to all areas of her home and
immediate outdoor environment. For seating, M. L. was
prescribed a generically contoured foam seat cushion and
a solid, adjustable back support. With this equipment, her
posture was improved and she felt comfortable and secure.

454
Section II  Orthoses in Rehabilitation
21. Ham R, Aldersea P, Porter D. Wheelchair Users and Postural
Seating: A Clinical Approach, vol 1. New York: Churchill
Livingstone; 1998.
22. Hobson DA. Seating and mobility for the severely disabled:
Technology overview and classification. In: Leslie J, ed. Rehabilitation
Engineering. Boca Raton, FL: CRC Press; 1988:201–218.
23. St-Georges M, Valiquette C, Drouin G. Computer-aided design
in wheelchair seating. J Rehabil Res Dev. 1989;26(4):23–30.
24. Brienza DM, Geyer MJ. Understanding support surface technol­
ogies. Adv Skin Wound Care. 2000;13(5):237–244.
25. Stewart SFC, Palmieri V, Cochran GVB. Wheelchair cushion
effect on skin temperature, heat flux, and relative humidity. Arch
Phys Med Rehabil. 1980;61(5):229–233.
26. van der Woude LH, Dallmeijer AJ, Janssen TWJ, et al. Alternative
modes of manual wheelchair ambulation: an overview. Am J
Phys Med Rehabil. 2001;80(10):765–777.
27. Boninger ML, Cooper RA, Roberson RN, et al. Wrist biomechanics
during two speeds of wheelchair propulsion: an analysis using a local
coordinate system. Arch Phys Med Rehabil. 1997;78(4):364–372.
28. Bergman-Evans B, Cuddigan J, Bergstrom N. Clinical prac­
tice guidelines: prediction and prevention of pressure ulcers.
J Gerontol Nurs. 1994;20(9):19–26.
29. Bergstrom N, Braden BJ, Laguzza A, et al. The Braden Scale for
predicting pressure sore risk. Nurs Res. 1987;36(4):205–210.
30. Allman RM. Pressure ulcer prevalence, incidence, risk factors,
and impact. Clin Geriatr Med. 1997;13(3):421–436.
31. Cuddigan J, Berlowitz DR, Ayello AE. Pressure ulcers in
America: prevalence, incidence, and implications for the future.
Adv Skin Wound Care. 2001;14(4):208–215.
32. Weiss-Lambrou R. Satisfaction and comfort. In: Scherer MJ,
ed. Assistive Technology: Matching Device and Consumer
for Successful Rehabilitation. Washington, DC: American
Psychological Association; 2002:77–94.
33. McLaurin CA. Current directions in wheelchair research.
J Rehabil Res Dev 1990;(Suppl 2):88–99.
34. Axelson P, Minkel J, Chesney DA. Guide to Wheelchair Selection:
How to Use the ANSI/RESNA Standards to Buy a Wheelchair.
Washington, DC: Paralyzed Veterans of America; 1994.
35. Hartridge M, Seeger BR. International wheelchair standards: a
study of costs and benefits. Assist Technol. 1990;2(4):117–123.
36. Cooper RA, Boninger ML, Rentschler A. Evaluation of selected
ultralight manual wheelchairs using ANSI/RESNA standards.
Arch Phys Med Rehabil. 1999;80(4):462–467.
37. Cooper RA, DiGiovine CP, Rentschler A, et al. Fatigue-life of
two manual wheelchair cross-brace designs. Arch Phys Med
Rehabil. 1999;80(9):1078–1081.
38. Cooper RA, Gonzalez J, Lawrence B, et  al. Performance of
selected lightweight wheelchairs on ANSI/RESNA tests. Arch
Phys Med Rehabil. 1997;78(10):1138–1144.
39. Cooper RA, Robertson RN, Lawrence B, et al. Life-cycle analysis
of depot versus rehabilitation manual wheelchairs. J Rehabil Res
Dev. 1996;33(1):45–55.
40. Rader JD, Jones D, Miller L. The importance of individual­
ized wheelchair seating for frail older adults. J Gerontol Nurs.
2000;26(11):24–32 46–47.
41. Scherer MJ. Outcomes of assistive technology use on quality of
life. Disabil Rehabil. 1996;18(9):439–448.
42. Aissaoui R, Boucher C, Bourbonnais D, et  al. Effect of seat
cushion on dynamic stability in sitting during a reaching task
in wheelchair users with paraplegia. Arch Phys Med Rehabil.
2001;82(2):274–281.
43. Demers L, Wessels R, Weiss-Lambrou R, et al. Key dimen­
sions of client satisfaction with assistive technology: a cross-
validation of a Canadian measure in The Netherlands. J Rehabil
Med. 2001;33(4):187–191.
44. Hobson D, Crane B. State of the science white paper on wheel­
chair seat comfort. Wheelchair Seating: A State of the Science
Conference on Seating Issues for Persons with Disabilities.
Orlando, FL: Rehabilitation Engineering Center on Wheeled
Mobility and the School of Health and Rehabilitation Sciences
at the University of Pittsburgh; 2001;29–33.
45. May LA, Butt C, Minor L, et al. Measurement reliability of func­
tional tasks for persons who self-propel a manual wheelchair.
Arch Phys Med Rehabil. 2003;84(4):578–583.
46. Conine TA, Hershler C, Daechsel D, et al. Pressure ulcer pro­
phylaxis in elderly patients using polyurethane foam or Jay
wheelchair cushions. Int J Rehabil Res. 1994;17(2):123–137.
47. Geyer MJ, Brienza DM, Karg P, et al. A randomized control trial
to evaluate pressure-reducing seat cushions for elderly wheel­
chair users. Adv Skin Wound Care. 2001;14(3):120–129.

455
Etiology of Amputation
Caroline C. Nielsen and Milagros Jorge
Throughout the history of medicine, amputation has been
a relatively frequently performed medical procedure and
has often been the only available alternative for complex
­fractures or infections of the extremities. The earliest ampu­
tations were generally undertaken to save lives; however,
their outcomes were often unsuccessful—many resulted in
death from shock caused by blood loss or onset of infec­
tion and septicemia in those who survived the operation.
In these early amputations, removal of the compromised
limb ­segment as quickly as possible was essential. With
the advent of antisepsis, asepsis, and anesthesia in the mid
­nineteenth century, physicians focused increasingly on the
surgical procedure and conservation of tissue.1 The develop­
ment of modern medical treatment has provided alternatives
to amputation. Today, when amputation is necessary, surgery
is undertaken with consideration for the functional aspects
of the residual limb. This chapter reports the epidemiology
of amputation; reviews the causes for amputation; describes
the expected outcomes for persons with limb pathology
­resulting in amputation; and discusses approaches to reha­
bilitation of the person with limb loss.
EPIDEMIOLOGY OF AMPUTATION
Surveillance data on persons living with limb loss is ­limited,
because in the United States there is no national database
for compiling data specific to persons with amputation.
Information on persons with amputation is derived from
a variety of sources including hospital discharge diagnoses
information. The 1996 National Health Interview Survey has
the most comprehensive data on amputation and ­persons
­living with limb loss.2 The number of Americans ­living
with limb loss is estimated at 1.6 million.3 In the United
States, each year, an estimated 185,000 persons lose a limb.
Limb loss occurs for a variety of reasons including dys­
vascular diseases, trauma, cancer, and congenital anoma­
lies (Figures 17-1 and 17-2). In 2008, Ziegler-Graham and
colleagues3 conducted an epidemiological study that estimated
the prevalence of limb loss in the United States for the
period 2005 to 2050. According to statistical analysis based
on the figure that 1.6 million Americans were living with
limb loss in 2005, it is estimated that the number of per­
sons living with limb loss will increase to 3.6 million by the
year 2050. It is anticipated that the number of persons living
with amputation will more than double in the next 45 years.
Increase in life span and health-related age factors will fig­
ure significantly in the increase number of persons living
with limb loss (Figure 17-3).3
LEARNING OBJECTIVES
On completion of this chapter, the reader will be able to do
the following:
1. Describe the epidemiology of nontraumatic, traumatic
and congenital amputation.
2. Compare and contrast the major causes of amputation.
3. Describe the interrelationships of the major risk factors for
dysvascular/neuropathic-related amputation.
4. Explain the differences in risk factors of amputation
among various racial and ethnic groups.
5. Describe health-promotion efforts for the prevention of
dysvascular disease.
6. Identify key issues considered by the rehabilitation team
when caring for older adults with amputation.
17
Prostheses in Rehabilitation
III

456
Section III  Prostheses in Rehabilitation
The leading cause of amputation is dysvascular disease.
Predisposing factors for amputation include diabetes, hyper­
tension, and dyslipidemia. Health conditions that affect the
blood vessels such as peripheral vascular disease (PVD),
peripheral arterial disease (PAD), and diabetes are the lead­
ing cause of amputation. Dysvascular disease accounts for
approximately 82% of all limb loss hospital discharges.4
Between 1988 and 1996, the estimated increase in the rate
of dysvascular amputations was 27%, with the highest per­
centage of disease-related amputations occurring in persons
65 years of age and older.4 Most of these were lower-extremity
amputations, which are performed 11 times more frequently
than upper-extremity amputations.5 More amputations occur
among men than women, and amputation rates increase
steeply with age.3,6 The health condition most frequently
related to amputation is dysvascular disease including PVD
and PAD complicated by neuropathy. Although PVD and
neuropathy are frequently associated with type 2 diabetes,
vascular disease also occurs independently of diabetes. The
increased frequency of amputation for PVD likely reflects
increased growth in the older population. This increase is
likely to continue with current population projections. The
population in the age group 45 to 64 years is projected to
increase 23.8% between 2002 and 2020, and the population at
greatest risk for amputation, those 65 to 85 years and older, is
expected to increase by 71%.7 The population of individuals
older than 85 years of age is projected to increase at the high­
est rate. Because the prevalence of dysvascular increases with
age, these demographic changes will likely have a large impact
on the amount of vascular reconstruction and ­amputation
that will be performed.3
Diabetes and smoking are the strongest risk factors for
developing PAD. Other well-known risk factors are advanced
age, hypertension, and hyperlipidemia.8 The number of
Americans with diabetes with limb loss will continue to rise
because of the persistent reports that diabetes is a national
health problem. In 2007, approximately 1.6 million new cases
of diabetes were diagnosed in people age 20 years or older.
If current trends continue, one in three Americans will
develop diabetes sometime in their lifetime.9 Diabetes is the
leading cause of new cases of nontraumatic lower-extremity
amputations among adults (Figure  17-4).9 The number of
hospital discharges for nontraumatic lower-extremity ampu­
tation with diabetes as a listed diagnosis increased from
45,000 in 1991 to 86,000 in 1996. From 1988 to 2006, the
number of hospital discharges for persons with diabetes who
had amputation increased by 20%.10,11
The second leading cause of amputation is trauma.
Traumatic amputation is most common in the young adult
age group (20-29 year olds). The leading causes of trauma-
related amputation are injuries involving machinery (40.1%),
power tools and appliances (27.8%), firearms (8.5%), and
motor vehicle crashes (8%).4 The incidence of trauma-
related major amputation continues to decrease over time.
This reduction in traumatic amputation is ­attributable to
Cancer
0.9%
Trauma
16.4%
Neuropathy & vascular conditions
81.9%
Congenital
anomalies
0.8%
FIGURE 17-1  Causes of amputation by percent. The majority of
amputations result from a disease process. (From Dillingham TR,
Pezzin LE, Mackenzie EJ. Limb amputation and limb deficiency:
epidemiology and recent trends in the United States. South Med J.
2002;95[8]:875-883.)
Cancer
Congenital
Amputation Statistics by Cause, United States, 1988 to 1996
per 100, 000 limb-loss related hospital discharges
Trauma
Dysvascular
0
20
40
97
3
31
68.6
76.1
23.9
41.5
58.5
60
80
100
Lower limb
Upper limb
FIGURE 17-2  Amputation statistics by cause in the United States, 1988 to 1996.
Causes of amputation per 100,000 as reported by the Amputee Coalition of America.
(From )

Chapter 17  Etiology of Amputation
457
­implementation of new safety regulations, the development
of safer farm and industrial machinery, improved safety
in work ­conditions, and medical advancement in tech­
niques for salvaging traumatized limbs. Whenever there is
a period of significant armed conflict, the number of veter­
ans with traumatic amputation increases. U.S. engagement
in the wars in Afghanistan and Iraq, has resulted in more
than 1000 service men and women who have sustained
traumatic amputations.12
The third cause of limb loss is cancer related. In the data
compiled by the U.S. National Center for Health Statistics,
Healthcare and Utilization Project 1988–1996, limb loss as a
consequence of cancer showed a marked decrease over this
period, from 0.62 per 100,000 persons in 1988 to 0.35 per
3000
Projected Number of Americans (1000s) Living with
Limb Amputation Secondary to Dysvascular Disease
Based on a Hypothetical Change in Incidence of Amputation post–2005
2500
2000
1500
1000
750
2000
2010
2020
2030
2040
25% Increase
10% Increase
10% Decrease
25% Decrease
No Change
2050
FIGURE 17-3  Projected number of Americans living with limb amputation secondary to dys­
vascular disease (log scale) from year 2000 to 2050. (From Ziegler-Graham K, MacKenzie EJ,
Ephraim PL, et al. Estimating the prevalence of limb loss in the United States: 2005 to 2050. Arch
Phys Med Rehabil. 2008; 89:426.)
15.6
Diabetes
No diabetes
9.8
7.5
3.4
0.02
0.16
0.62
1.78
75+
65–74
Age
Rate per 1,000
45–64
18–44
0
2
4
6
8
10
12
14
16
18
FIGURE 17-4  Hospital discharge rates for nontraumatic lower-extremity amputation for per­
sons with diabetes as a listed diagnosis in the United States for the period 1988 to 2006. (From
)

458
Section III  Prostheses in Rehabilitation
100,000 persons in 1996.4 The tumor most commonly associ­
ated with amputation is osteosarcoma, which primarily affects
children and adolescents in the 11- to 20-year-old age group.
Currently amputation is no longer the primary intervention
for osteosarcoma, and the current rate of amputation for this
disease is less than 1%.5 With development of new surgical
techniques, including bone graft and joint ­replacement, and
advancement in chemotherapy and radiation, the ­incidence of
amputation as a consequence of ­osteosarcoma has decreased
significantly.
Congenital limb deficiencies, as well as the amputations
used to adjust or correct them, are relatively rare, and little
has changed over time in the birth prevalence of congeni­
tal limb deficiencies. Rates have been reported ranging from
3.8 per 10,000 births to 5.3 per 10,000 births.4 This percent­
age has remained relatively stable and is less than 1% of all
amputations.
LEVELS OF AMPUTATION
Amputation can be performed as a disarticulation of a joint or
as a transection through a long bone. The level of amputation
is usually named by the joint or major bone through which
the amputation has been made (Table 17-1).5 An amputation
that involves the lower extremity can affect an individual's
ability to stand and walk, requiring the use of prosthetics and,
often, an assistive device for mobility. Amputation involving
the upper extremity can affect other activities of daily ­living,
such as feeding, grooming, dressing, and a host of activi­
ties that require manipulative skills. Because of the complex
nature of skilled hand function, prosthetic substitution for
upper limb amputation does not typically restore function to
the same degree that lower extremity prosthetics do.
The levels of amputation surgery that are most commonly
performed today involve the lower extremity below the knee
(including transtibial, foot, and toe amputations), account­
ing for 97% of all dysvascular limb loss hospital discharges
(Table  17-2). This high percentage reflects the prevalence
of PVD of the lower extremities. Transfemoral amputations
account for approximately 26% of all dysvascular ­amputations.4
In general, the proportion of lower-limb amputations in rela­
tion to upper-limb amputations is increasing. This most likely
reflects an increase in the number of older ­persons with lower-
extremity amputations rather than an actual decrease in the
number of upper-extremity amputations.
Because dysvascular disease typically affects both lower
extremities, a significant number of individuals eventually
undergo amputation of both lower extremities. Approximately
50% of persons undergoing diabetes-related amputation will
have contralateral amputation within 3 to 5 years.13 Between
25% and 45% of persons with amputations have had amputa­
tions of both lower extremities, most often at the transtibial
level in both limbs, or a combination of transtibial ­amputation
of one limb and transfemoral amputation of the other.13
Today, the majority of transtibial and ­transfemoral amputa­
tions are performed with an understanding of wound healing
and the functional needs and constraints of ­prosthetic fitting,
so that rehabilitation outcomes are usually ­positive. Other
levels of amputation, although less commonly performed
procedures, continue to pose challenges for the surgeon, pros­
thetist, physical therapist, and patient during prosthetic fitting
and rehabilitation.
CAUSES OF AMPUTATION
Currently the most likely reasons for amputation are poor
wound healing associated with diabetes4,14 and dysvascular
disease,4,15 trauma,4,16 or cancer.4,17 Children with congeni­
tal limb deficiencies are a special population group and may
require surgical revision during or after periods of ­significant
growth or after conversion to a more functional level for
­prosthetic fitting.
Diabetes and Peripheral Arterial Disease
Diabetic foot ulceration is a common complication of diabe­
tes that often results in lower-extremity amputation. Elevated
blood sugars associated with diabetes damage blood ­vessels
and nerve fibers, and impair circulation. Nerve damage
causes peripheral neuropathy, a condition of loss of sensation
TABLE 17-1  Terminology Used to Describe the Site
of Lower-Extremity Amputation
Site
Terminology
Toe
Phalangeal
Forefoot
Ray resection (one or more complete
metatarsal)
Transmetatarsal (across the metatarsal shaft)
Midfoot
Partial foot (e.g., Chopart, Boyd, Pirogoff)
At the ankle
Syme
Below the knee
Transtibial (long, standard, short)
At the knee
Knee disarticulation
Above the knee
Transfemoral (long, standard, short)
At the hip
Hip disarticulation
At the pelvis
Hemipelvectomy
TABLE 17-2  Incidence of Lower-Limb Amputation:
Average Annual Number and Percent of
Hospital Discharges After Lower-Extremity
Amputation, 1988-1996
Level of Amputation
Number
Percent (%)
Toe
338,288
33.11
Foot and ankle
116,302
11.38
Transtibial
287,295
28.12
Knee disarticulation
5291
0.52
Transfemoral
266,465
26.08
Hip and pelvis
6588
0.64
Bilateral amputations
1504
0.15
Total
1,021,733
100
Source: From Dillingham TR, Pezzin LE, Mackenzie EJ. Limb amputation
and limb deficiency. Epidemiology and recent trends in the United States.
South Med J. 2002;95(8):875-883.

Chapter 17  Etiology of Amputation
459
to the feet. The loss of protective sensation in the feet would
not alert an individual to foreign substance in their shoe such
as pebbles or gravel. This lack of awareness may lead to blis­
ters or other minor injuries. Once the skin is broken, sores on
the feet may not heal because of poor circulation. The Centers
for Disease Control confirms that neuropathy is a major con­
tributor to diabetic amputations.18
The prevalence of PAD in persons with diabetes is four
times greater than in persons without diabetes.19 Dysvascular
disease is the most common contributing factor for lower-
extremity amputations. In epidemiological studies, two
symptoms are classic indicators of vascular insufficiency: (a)
intermittent claudication and (b) loss of one or more lower-
extremity pulses. Intermittent claudication is a significant
cramping pain, usually in the calf, that is induced by walk­
ing or other prolonged muscle contraction and relieved by a
short period of rest. In arteriosclerosis obliterans, at least one
major arterial pulse (dorsal pedis artery at the ankle, popli­
teal artery at the knee, or femoral artery in the groin) is often
absent or markedly impaired (Figure 17-5).20 The major risk
factors for development of PAD are the same as those for
cardiovascular and cerebrovascular disease, most notably
poorly managed hypertension, high serum cholesterol and
triglyceride levels, and a history of tobacco use and smoking.
Peripheral neuropathy and PAD are the major predisposing
factors for lower-extremity amputation in individuals with
diabetes.21
According to the National Hospital Discharge Survey,
the number of hospital discharges that listed diagnoses of
amputation and diabetes increased 27% from 1988 to 1996.4
The prevalence of PAD among persons with diabetes,
whether men or women, is significantly greater than in those
without diabetes. The Framingham Heart Study22 found a
four to five times greater relative risk of intermittent clau­
dication in ­persons with diabetes, even when controlling for
blood pressure, cholesterol, and smoking. The age-adjusted
rate of lower-extremity amputation among persons with
­diabetes in the United States is approximately 28 times that
of the ­nondiabetic population. More than 50% of the lower-
limb amputations in the United States are diabetes related,
although persons diagnosed with diabetes represent only
3% of the population.23 Although major improvements have
been made in noninvasive diagnosis, surgical revasculariza­
tion procedures, and wound-healing techniques, between
2% and 5% of individuals with PAD and without diabetes
and between 6% and 25% of those with diabetes eventually
undergo an amputation.24,25
The three most common predisposing factors for lower
extremity amputation appear to be (a) concurrent diabetes
and hypertension, (b) hypertension without diabetes, and (c)
diabetes without hypertension (Figure 17-6). Other predis­
posing factors include race, gender, history of smoking, and
previous vascular surgery. The incidence of lower-­extremity
amputation among persons with diabetes is almost 50%
higher for men than for women.4 The most frequently cited
criteria for amputation among persons with diabetes include
gangrene, infection, nonhealing neuropathic ulcer, severe
ischemic pain, absent or decreased pulses, local necrosis,
osteomyelitis, systemic toxicity, acute embolic disease, and
severe venous thrombosis.19,21
In individuals with diabetes, the prevalence and ­severity
of dysvascularity increases significantly with age and the
­duration of diabetes, particularly in men. Initial amputation
may involve a toe or foot; subsequent revision to transtibial or
transfemoral levels is likely to occur with progression of the
underlying disease. In individuals with diabetes, dysvascular
disease increases the risk of a nonhealing neuropathic ulcer,
infection, or gangrene, all of which increase the likelihood
of amputation. Twenty percent to 50% of patients will have
FIGURE 17-5  This patient with atherosclerosis obliterans ­underwent
a femoral-distal popliteal bypass in an attempt to revascularize the
foot. The demarcation indicating ischemia at the ankle and foot is
clear. Transtibial amputation is necessary when revascularization
is ­unsuccessful. (From Robinson KP. The dilemma: amputation or reva­
scularization. In Murdock G, Wilson AB [eds], Amputation: Surgical
Practice and Patient Management. Oxford, UK: Butterworth-
Heinemann, 1996. p. 169.)
Diabetes
9.1
29.1
36.4
20.4
Percent
0
5
10
15
20
25
30
35
40
Other
Hypertension Diabetes with
hypertension
FIGURE 17-6  Lower-extremity amputations, classified by predis­
posing factors. Hypertension, especially in the presence of diabetes, is
a powerful risk factor. “Other” includes a combination of risk ­factors
including race, gender, cigarette smoking, and ­previous vascular sur­
gery. (Based on data reported by Lee CS, Sariego J, Matsumoto T.
Changing patterns in the predisposition for amputation of the lower
extremities. Am Surg. 1992;5[8]:474-477.)

460
Section III  Prostheses in Rehabilitation
amputation of the contralateral leg in 1 to 3 years.13,19 Patients
with diabetes who are 65 years old or older account for most
diabetes-related lower-extremity amputations. The estimated
amputation rate in 1996 was 1.4 times higher for persons with
diabetes who were 65 to 74 years old and 2.4 times higher
for those 75 years of age or older, compared with those 0 to
64 years of age.26,27
Peripheral neuropathy is a common complication of
diabetes. Neuropathy is as important and powerful as dys­
vascular disease as a predisposing factor for lower-extremity
amputation. Peripheral neuropathy is suspected when one or
more of the following clinical signs are present: deficits of
sensation (loss of Achilles and patellar reflexes, decreased
vibratory sensation, and loss of protective ­sensation),
motor impairments (weakness and atrophy of the ­intrinsic
muscles of the foot), or autonomic dysfunction (inadequate
or abnormal hemodynamic mechanism, tropic changes
of the skin, and distal loss of hair).20 The resulting loss of
thermal, pain, and protective sensation increases the vul­
nerability of the foot to acute, high-pressure and repeti­
tive, low-pressure trauma. Patients may also experience
significant numbness or painful ­paresthesia of the foot
and lower leg. Individuals with peripheral neuropathy may
not be aware of minor trauma, pressure from poorly fit­
ting shoes along the sides and tops of their feet, or pressure
from thickening plantar callus, all of which contribute to
the risk of ulceration, infection, and gangrene. Motor neu­
ropathy and associated weakness and ­atrophy ­contribute
to ­development of bony deformity of the foot. The bony
prominences and malalignments that are associated with
foot deformity change weight-bearing pressure dynamics
during walking, further increasing the risk of ulceration.
Peripheral neuropathy is one of the most crucial precursors
of foot ulceration, especially in the presence of dysvascular
disease. Nonhealing or infected neuropathic ulcers precede
approximately 85% of nontraumatic lower extremity ampu­
tations in individuals with diabetes.23
Lower-extremity amputation continues to be a major
health problem for the diabetic population. For this group of
patients, amputation is associated with significant morbid­
ity, functional limitation and disability, mortality, and high
health care costs. Approximately 185,000 persons undergo
amputation each year in the United States.3 The average cost
for a patient per hospitalization for amputation is approx­
imately $30,000. The cost of health care for persons with
chronic diseases such as diabetes and PAD is estimated by
the American Diabetes Association at $174 billion per year.28
According to the U.S. Public Health Service, reducing the
incidence of lower-extremity amputations in persons with
diabetes is a key health care objective in terms of quality of
life and containment of health care costs. It is estimated that
the current prevalence of 1.6 million persons living with limb
loss will more than double to 3.6 million by the year 2050.3
Planned health promotion efforts will hopefully reduce the
risk of diabetes and amputation, minimizing the impact of
risk factors and increasing access to care by multidisciplinary
health care teams.
Amputation Rates and Racial and Ethnic Populations
Evidence indicates that certain racial and ethnic groups
are at increased risk for lower-extremity amputation. This
increased risk appears to be linked to a higher prevalence of
diabetes complicated by PAD. Minority groups with the high­
est incidence of diabetes and greatest risk of lower-extremity
­amputation are Native Americans, African-Americans, and
CASE EXAMPLE 1
A Patient with Dysvascular Disease-Related Amputation
T. S., is a 67-year-old African-American man with a 10-year
history of type 2 diabetes mellitus. Until 2 years ago, he
smoked one pack of cigarettes daily, but he quit after coro­
nary artery bypass grafting (× 4) following acute myocar­
dial infarction. He became insulin dependent at the time of
his myocardial infarction and coronary artery bypass graft­
ing surgery. Comorbid medical problems include hyper­
tension, managed pharmaceutically with a β-blocker, and
moderate vision loss secondary to diabetic retinopathy.
T. S. underwent complete transmetatarsal amputation of
the left foot 6 months ago because of a nonhealing plan­
tar ulcer under the second and third metatarsal heads that
had progressed to osteomyelitis. Three weeks ago, intermit­
tent claudication of the right calf became severe enough to
warrant medical attention. On evaluation T. S. was noted
to have a neuropathic ulcer under his first ­metatarsal
head, probing to bone. Doppler studies were monopha­
sic, suggesting inadequate vascular supply for healing.
Arteriography indicated markedly diminished distal arte­
rial flow to his foot but adequate arterial ­supply to midtibial
levels. He had failed a revascularization attempt with stent
placement.
After an interdisciplinary meeting involving his inter­
nist (who helps him manage his diabetes), cardiolo­
gist (who helps him manage his hypertension and heart
­disease), vascular surgeon (who oversaw this evaluation),
physical therapist and prosthetist (who explained the
­process of rehabilitation), social worker (who explained
services and support available to those with amputation),
and family, T. S. concurred with the recommendation for
an “elective” transtibial amputation. His surgery occurred
2 weeks ago, and he is impatiently waiting for his wound to
heal sufficiently to begin prosthetic training.
Questions to Consider
• What possible medical and physiological factors
­contributed to this patient's loss of limb?
• What impact will his current health status and comor­
bid conditions have on his prognosis for rehabilitation,
both in terms of eventual outcome and in duration of
this episode of care?
• What plan of care for the preprosthetic phase of his
rehabilitation would you propose?
• How is the International Classification of Functioning
(ICF) disablement framework applied to T. S.?

Chapter 17  Etiology of Amputation
461
Hispanic Americans. Native Americans are 3.5 times more
likely to have lower-extremity amputation than their non-
Hispanic white counterparts.29 African-Americans are two
to four times more likely to lose a limb as a result of diabe­
tes complications.30 Hispanic Americans are diagnosed with
diabetes at twice the rate of whites31 and are 1.5 times more
likely to have an amputation.31,32
Native Americans have a two to five times higher preva­
lence of diabetes than the overall population in the United
States. This high prevalence is directly reflected in increased
amputation rates. Amputation rates among Native Americans
are three to four times higher than the general population.
Among Pima Indians with diabetes, the rate of amputation
is 3.7 times higher than the rate of other persons with dia­
betes.33,34 Why these populations have a significantly higher
rate of lower-extremity amputation is unclear. Potential
contributors include a genetic or familial predisposition to
­diabetes, a higher prevalence of hypertension and smoking,
or both. Health-promotion and education efforts that tar­
get this high-risk population (including programs aimed at
effective management of diabetes, minimization of other risk
factors, and special foot care programs for early ­detection of
neuropathic and traumatic lesions) are effective strategies
to reduce the likelihood of amputation. Further research is
­necessary to ­better understand the causes of racial ­differences
in ­amputation rates and to identify and promote health
­initiatives that will alleviate this excess risk among minority
populations.
Outcome of Dysvascular Conditions and Amputation
The morbidity and mortality risks associated with systemic
diseases, such as diabetes and vascular disease, continue after
amputation. As a result, death in the years immediately after
amputation is not uncommon. The 3-year survival rate after
initial lower-extremity amputation for persons with diabetes
is only approximately 50%; the 5-year survival rate ranges in
various studies from 39% to 68%.23 Because neuropathy and
PVD occur in a symmetric distribution, the risk of subse­
quent amputation of the contralateral lower extremity is high.
Even with successful healing of the primary amputation site,
amputation of part of the contralateral limb occurs in 50%
of patients within 2 to 5 years.13 The most common causes of
death in persons with amputation include complications of
diabetes, cardiovascular disease, and renal disease.
Evidence is growing that the incidence of ­lower-extremity
amputation in persons with diabetes can be significantly
reduced through particular kinds of preventive care. Large
clinical centers have demonstrated the effect of early inter­
vention for the diabetic population, using an interdisciplinary
team approach to preventive care. Interventions to prevent
neuropathy and PVD target smoking reduction programs, as
well as dietary, exercise, and pharmaceutical interventions,
to obtain better control of hypertension, hyperlipidemia,
and hyperglycemia. Reduction of these predisposing factors
is likely to further reduce the incidence of amputation, heart
disease, and stroke among people with diabetes. For those
with existing diabetic neuropathy or PVD, ­intensive foot
care programs should focus on prevention of ulceration and
early intervention to prevent expansion, infection, or gan­
grene of small lesions.35 Foot care programs are most effective
if they develop in a team setting and focus on patient edu­
cation. Surgical revascularization procedures are performed
to avoid amputation in persons with chronic foot ulceration.
The revascularization procedures include ­vascular bypass,
angioplasty, stent placement, and end-stage limb-­salvage
procedures.19
The decision to undergo amputation often follows a long
struggle to care for an increasingly frail foot by the patient,
the family, and health care providers. In this circumstance,
­elective amputation is often perceived by the patient and
­family as a positive step toward a more active and less stress­
ful life. The interdisciplinary team approach best addresses
the ­complex needs of the individual with diabetes, ­including
­clinical evaluation, determination of risk status, patient
­education, footwear selection, decision making about ampu­
tation, and rehabilitation after surgery.
Traumatic Amputation
Traumatic amputation is defined as an injury to an extremity
that results in immediate separation of the limb or will result
in loss of limb as a result of accident or injury.36 Traumatic
loss of a limb, the second most common cause of amputation,
occurs most frequently in vehicle- or work-related accidents,
as a result of violence such as gunshots or warfare, or after
severe burns and electrocution (Figure 17-7). Trauma-related
amputation occurs most commonly in young adult men but
can happen at any age to men or women. Because the mecha­
nism of injury in traumatic amputation is quite variable, this
type of amputation is usually classified or categorized accord­
ing to the severity of tissue damage. The extent of injury to
the musculoskeletal system depends on three interacting
­factors: (a) movement of the object that causes the injury; (b)
direction, magnitude, and speed of the energy vector; and (c)
the particular body tissue involved.
FIGURE 17-7  This patient sustained a traumatic amputation of his
left foot and distal tibia when he stepped on a buried land mine.
(From Coupland RM, Korver A. Injuries from antipersonnel mines:
the experience of the International Committee of the Red Cross.
BMJ. 1991;303[14]:1509. Reprinted with permission from the BMJ
Publishing Group.)

462
Section III  Prostheses in Rehabilitation
In partial traumatic amputations, at least one half the
diameter of the injured extremity is severed or damaged
­significantly. This kind of injury can incur extensive bleed­
ing, because all of the blood vessels involved may not be
­vasoconstrictive. A second type of traumatic amputation
occurs when the limb becomes completely detached from the
body. As much as 1 L of blood may be lost before the arteries
spasm and become vasoconstrictive.37
For optimal outcome, surgical intervention is usually
­necessary within the first 12 hours after the accident for
revascularization or for treatment of the amputated site.
One of the primary efforts of the surgical team for a person
with lower extremity amputation is to preseve limb length
to the extent that healing is possible.36 Replantation is the
surgical procedure to reattach a part of the body that has
been amputated.38 When replantation is considered, the
window of opportunity is much narrower. The decision to
replant is a difficult one and is influenced by the patient's
age and overall health status, the level of extremity injury,
and the condition of the amputated part. Replantation has
been most successful in the distal upper extremity. The goal
of upper extremity replantation is to provide a mechanism
for functional grasp rather than solely for cosmetic restora­
tion of the limb.38 The period of recovery and rehabilitation
after replantation is often significantly longer than that after
amputation.
Persons with trauma-related amputation undergo extreme
physiological changes, as well as psychological trauma. With
the sudden loss of a body part, the patient may experience
an extended period of grieving. Addressing the patient's
­psychological needs as well as physical needs is important
for optimal outcome. An interdisciplinary team approach to
rehabilitation is the most effective means of addressing the
comprehensive needs of a patient who has unexpectedly lost
a limb to trauma.36–38
Cancer
Cancer of the bone and joint is a rare form of cancer. The
U.S. National Cancer Institute Surveillance, Epidemiology
and End Results data from 1988 to 2001 reported 4062
cases of bone and joint cancer. Twenty-seven percent of
cases occurred in children ages 0 to 9 years. Bone cancers
have three ­typical histological types: (a) osteosarcoma; (b)
­chondrosarcoma; and (c) Ewing sarcoma. The cancers arise
from the growing end of long bones (osteosarcoma), cartilage
(chondrosarcoma), and the axial skeleton (Ewing sarcoma).39
The limb-presenting cancers are osteosarcoma and chondro­
sarcoma. Sixty-three percent of cancers were diagnosed as
osteosarcoma and 54% were chondrosarcoma. Amputation
because of a primary cancer generally results from osteo­
genic sarcoma (osteosarcoma) (Figure  17-8). This type of
­cancer occurs predominantly in late childhood, adolescence,
or the early young adult years. The incidence is slightly higher
among young males than among females. Osteosarcoma typ­
ically occurs at or near the epiphyses of long bones ­during
times of rapid growth, especially the distal femur, ­proximal
tibia, or proximal humerus. Most patients have a history
of worsening, increasingly deep-seated pain, sometimes
­accompanied by localized swelling. Children with osteosar­
coma are ­vulnerable to pathological fracture, an event that
often prompts diagnosis. Since the early 1990s, the need for
amputation in osteosarcoma has been greatly reduced by
advances in early detection, improved imaging techniques,
more effective chemotherapy regimens, and better limb
­resectioning and salvage procedures. Tumor resection fol­
lowed by limb reconstruction frequently provides a functional
extremity. Weight bearing is limited, and the limb is protected
by an orthosis early in rehabilitation. Once satisfactory heal­
ing occurs, full weight bearing and near-normal activity can
CASE EXAMPLE 2
A Patient with Traumatic Amputation
C. J. was a 20-year-old female in active duty with the
National Guard on a tour in Afghanistan. She sustained sig­
nificant shrapnel injury to both lower extremities when a
rocket-propelled grenade was aimed at the ­convoy in which
she was riding. After emergency care on the ground, C. J.'s
condition was considered critical enough to warrant imme­
diate transport to a military hospital in Germany. Trauma
surgeons at the center determined her wounds were severe
enough to require midlength transtibial amputation on
the right and a long transfemoral ­amputation on the left.
Because of wound contamination from shrapnel and debris
and a resulting high risk of infection, C. J.'s surgical wounds
were initially left open (unsutured) while local and intra­
venous antimicrobials were administered. After several
days of care, C. J. was returned to the ­operating room for
revision and closure of the residual limbs. She now has
significant edema and serosanguineous drainage on the
right limb with a small area of wound dehiscence in the
middle of the suture line. Although the left residual limb
is not as edematous, the suture line is inflamed and ecchy­
motic, with more than a dozen healing puncture wounds
from shrapnel fragments over the anterior and ­lateral
thigh. When medically stable, C. J. will be moved to a mili­
tary rehabilitation hospital in the United States for prepro­
sthetic care and rehabilitation.
Questions to Consider
• Given the circumstances of these traumatic amputa­
tions, how does this patient's prognosis differ from the
previous patient (Case Example 1) with dysvascular-
neuropathic amputation?
• How might the rehabilitation of this patient be
­similar to or different from the previous patient with
­dysvascular-neuropathic amputation, in terms of eventual
­outcome and duration of care?
• What plan of care would you implement to promote
wound healing?

Chapter 17  Etiology of Amputation
463
be resumed. With new techniques, 5-year survival rates for
individuals with ­osteosarcoma increased from approximately
20% in the 1970s to 80% in the 1990s.40 Rhabdomyosarcoma
is a rare ­malignant tumor occuring in the extremities that
predominantly affects children. Chemotherapy and radia­
tion therapy is often the ­primary medical management. On
­occasion ­amputation is performed along with chemother­
apy and ­radiation therapy.41,42
Congenital Limb Deficiencies
The incidence of congenital limb deficiency has remained
relatively stable over time, accounting for only approxi­
mately 0.8% of all limb loss-related hospital discharges. The
rate in 1996 was 25.64 per 100,000 live births. A slight male
preponderance in the incidence of limb reductions has been
reported, as well as a slightly higher incidence of upper limb
reductions among newborns with limb deficiencies.4
The actual incidence of congenital limb deficiencies is
difficult to determine because of lack of a common definition
and reporting mechanisms. Six categories of limb deficiencies
have been recognized43:
1. Failure of formation of parts, indicating a partial or com­
plete arrest in limb development
2. Failure of differentiation or separation of parts, when the
basic structures have developed but the final form is not
completed
3. Duplication of parts, such as polydactyly
4. Skeletal overgrowth, also called gigantism (not to be con­
fused with the syndrome caused by growth hormone
excess in adolescence)
5. Congenital constriction band syndrome, characterized by
constriction bands, which may compromise circulation to
the distal part
6. Generalized skeletal abnormalities
Upper limb deficiencies in children vary from minor abnor­
malities of the fingers to major limb absences. Embryological
differentiation of the upper limbs occurs most rapidly at 5 to
8 weeks after gestation, often before pregnancy has been rec­
ognized or confirmed. During this period the upper limbs are
particularly vulnerable to malformation. The etiology of limb
FIGURE 17-8  Magnetic resonance image of the distal femur of a
patient with an osteosarcoma of the bone and marrow canal. The
bright signal beyond the bone indicates invasion of surrounding
soft tissue. (From Lundon K. Orthopedic Rehabilitation Science:
Principles for Clinical Management of Bone. Boston: Butterworth-
Heinemann, 2000. p. 147.)
CASE EXAMPLE 3
A Patient with Osteosarcoma
R. K. is a 16-year-old male high school student who
­sustained an unexpected fracture of the distal femur in a
collision during playoffs for the state soccer title. He experi­
enced increasing lateral knee pain for the previous 4 weeks
but did not complain to his coaches and parents for fear
he would have to “sit out.” Examination in the emergency
department reveals a swollen and tender ­distal femur and
knee. A radiograph reveals a fracture just proximal to a
radiodense lesion of the medial femoral condyle, including
articular surfaces of the knee. Magnetic ­resonance ­imaging
reveals that the tumor extends posteriorly, close to the neu­
rovascular bundle in the popliteal fossa. Biopsy ­confirmed
osteosarcoma. The orthopedic surgeon and oncologist
review options for limb salvage and amputation with R. K.
and his parents, recommending ­amputation because the
location of the tumor precludes the wide clear margins at
the knee required for endoprosthetic knee replacement or
cadaver allograft salvage strategies. His fractured limb is
stabilized in a knee orthosis while a preoperative course of
chemotherapy is undertaken and the possibility of metas­
tasis to the lungs is evaluated by further testing. Resection
of the tumor to a midlength transfemoral level of ampu­
tation will occur once the initial course of chemotherapy
is completed and will be followed by a second course of
chemotherapy. R. K. and his family have been encouraged
by visits from a survivor of osteosarcoma who had trans­
femoral amputation 7 years ago and is now a competitive
runner at the national and Paralympic level.
Questions to Consider
• How does the diagnosis of a serious cancer affect the
rehabilitation of young people with medically ­necessary
amputations?
• What psychological factors must be considered?
• What physiological factors must be considered?
• What are the similarities and differences in the progno­
sis and plan of care for this patient with cancer-related
amputation, as compared with the previous patients
with dysvascular-neuropathic and trauma-related
etiology, in terms of eventual outcome, and duration of
this episode of care?

464
Section III  Prostheses in Rehabilitation
malformation is unclear. Potential contributing factors cited in
the research literature include (a) exposure to chemical agents
or drugs, (b) fetal position or constriction, (c) endocrine dis­
orders, (d) exposure to radiation, (e) immune reactions, (f)
occult infections and other diseases, (g) single-gene disor­
ders, (h) chromosomal disorders, and (i) other syndromes
with unknown causes.43 For many children, an upper limb
deficiency is their only anomaly. However, as many as 12% of
these children have coexisting nonlimb malformations.
Limb deficiencies present at birth are classified accord­
ing to an international standard based on skeletal elements
(Table 17-3). These deficiencies are referred to as transverse
or longitudinal. Transverse deficiencies are described by the
level at which the limb terminates. In longitudinal deficien­
cies, a reduction or absence occurs within the long axis of the
limb, but normal skeletal components are present distal to the
affected bones (Figure 17-9).43,44
The use of prosthetics is a common intervention for children
with congenital limb deficiencies. Sometimes surgery is neces­
sary to prepare the existing limb for the most effective use of a
prosthesis, especially after periods of rapid growth. The goals
of prosthetic training for the child should be to enhance the
function of the limb and provide a cosmetic replacement for a
missing limb. Rehabilitation efforts are designed with the child's
cognitive, motor, and psychological development in mind.
REHABILITATION ISSUES FOR THE PERSON
WITH AN AMPUTATION
Several factors influence the success of rehabilitation after
amputation. These include age, health status, cognitive status,
sequence of onset of disability, concurrent disease and comor­
bidity, and the level of amputation.45 With anticipated growth
in the aging segments of the population, and the presence of
chronic dysvascular conditions, amputation in the U.S. geriat­
ric population will probably double from 28,000 to 58,000 per
year by 2030.3 The number of persons living with limb loss will
more than double from 1.6 million in 2005 to 3.6 million in
2050. Prosthetic, physical therapy, and health care needs will
increase to ensure continued independence, quality of life, and
participation in activities of daily living. Persons with limb loss
will require considerable rehabilitation resources.
The physical rehabilitation process for persons with
amputation occurs in different stages beginning with a post­
operative acute phase where positioning, skin protection,
TABLE 17-3  Classification of Longitudinal Congenital Limb Deficiencies
Limb Segment
Upper-Extremity Bone Segment*
Lower-Extremity Bone Segment*
Proximal
Humeral
Femoral
Distal
Radial
Central
Carpal
Metacarpal
Phalangeal
Tibial
Central
Tarsal
Metatarsal
Phalangeal
Combined (indicated by the bone
segments that remain)
Partial or complete
Specific carpal, ray, or phalanx remaining
Partial or complete
Specific carpal, ray, or phalanx remaining
*May be partial or complete.
Source: Modified from May BJ. Amputations and Prosthetics: A Case Study Approach. Philadelphia: Davis, 1996. p. 221.
FIGURE 17-9  This child was born with a unilateral proximal focal
deficiency of the right lower extremity. To facilitate prosthetic use,
she has undergone an elective amputation of her foot at the ankle.
Note the popliteal crease near the diaper line, indicating where her
knee is located. (From Campbell SK, Vanderlinden DW, Palisano RJ
[eds]. Physical Therapy for Children, 2nd ed. Philadelphia: Saunders,
2000. p. 380.)

Chapter 17  Etiology of Amputation
465
sensory and proprioceptive training, joint range of motion,
muscle strengthening occurs in conjunction with general
­conditoning activities leading to functional training for
independence in mobility including transfer skills, balance
exercises, ­wheelchair mobility, and ambulation with assis­
tive devices that extends to the subacute phase of rehabilita­
tion. The preprosthetic phase includes management of the
residual limb including wound care, edema control, ­shaping,
desensitization, and increasing joint and muscle flexibility.
Strengthening of the trunk as well as the extremities is essen­
tial for prosthetic use. Traditionally, physical therapists have
focused on the ability to perform functional activities such as
walking, turning, and managing ramps and other uneven or
unpredictable surfaces safely, independently, and efficiently
with and without a prosthesis. Physical therapists assist phy­
sicians and prosthetists in determining an individual's readi­
ness for prosthetic fitting and are often involved in decisions
about prosthetic components. After initial fitting, physical
therapists coordinate prosthetic training, consulting with
prosthetists if problems with prosthetic alignment arise. Once
these basic mobility activities are mastered, the therapist can
serve as a consultant to assist the person with amputation in
returning to preamputation employment and leisure activi­
ties. Treatment programs, predictors of outcome, and mea­
sures of success or failure are often based on these functional
activities.
In one study46 of patient progression through postamputa­
tion rehabilitation (n = 459), between 85% and 89% of persons
with lower-extremity amputations mastered basic functional
activities, such as moving about the bed, moving from supine
into sitting position, and sitting balance, within the sec­
ond postoperative week. Between 65% and 75% of ­persons
with amputation demonstrated independence in transfers
and dressing of upper and lower limbs in the third to fifth
­postoperative week. Although steady gains were made in the
ability to doff and don the prosthesis and to walk indoors and
outside during the fifth to the twelfth postoperative weeks,
just one-third of people in the study achieved independence
within this time frame.46 Optimal rehabilitation outcome,
achievement of the highest functional level of which the per­
son with amputation is capable, requires ­ongoing contact
with and support of a transdisciplinary rehabilitation team.36
As many as 70% of persons with a lower-extremity amputa­
tion report using their prosthesis on a full-time basis: putting
it on in the early morning, wearing it all day, and taking it off
in the evening.47 Two major reasons for limited use or nonuse
are generally cited: physical discomfort when walking with
the prosthesis and psychological discomfort. The wide varia­
tion reported in the success of functional ambulation with a
prosthesis after below-knee amputation appears to be related
to age and concurrent disease.48 Healing time, indicated by
time between surgery and fitting for the first prosthesis, corre­
late with age but not with the cause of amputation. Age is also
more important than the etiology of amputation in predict­
ing the total length of time in rehabilitation and achievement
of functional ambulation: Older adults with amputation are
likely to require a longer rehabilitation period to accomplish
an ambulatory status equal to that of the younger group.49
Although most people recovering from amputation achieve
some level of upright mobility, a smaller percentage of older
persons with concurrent chronic disease become functional
ambulators when compared with younger persons who had
amputations because of trauma or osteomyelitis.
The typical age at the time of initial lower limb ampu­
tation is between 51 and 69 years; therefore consideration
must be given to the special rehabilitation needs of the older
patient. The complexity of issues during rehabilitation of the
older adult who is undergoing an amputation is often com­
pounded by comorbidity, fragile social supports, and limited
resources.48 In patients with dysvascular conditions, concom­
itant cerebrovascular disease can have a more complicated
rehabilitation process. A preamputation history of stroke or
occurrence of stroke during the course of rehabilitation is not
uncommon. Similarly, cardiovascular disease can limit endur­
ance and exercise tolerance; endurance training becomes a
critical component of the postamputation, preprosthetic reha­
bilitation program. Optimal rehabilitation care begins with
consultation and patient and family education efforts before
surgery. A specialized interdisciplinary team most effectively
provides this presurgical and perisurgical care (Table 17-4).
Team members often include a ­surgeon, physical therapist,
certified prosthetist, occupational therapist, nurse or nurse
practitioner, recreational therapist, psychologist, and social
worker.36 The patient and family members are active and
essential members of the team as well. Effective communi­
cation provides the team with the necessary information to
develop a tentative treatment plan from the time of amputa­
tion to discharge home.
With a specialized treatment team and the use of new
lightweight and dynamic prosthetic designs, the potential for
rehabilitation of the older patient has increased significantly
in the past decade. At the time of surgery, special consid­
eration is given to the optimal level of amputation. This is
a particularly important concern for the older patient. The
selection of the surgical level of amputation is probably one
of the most important decisions to be made for the patient
undergoing an amputation. A lower-limb prosthesis ideally
becomes a full body-weight–bearing device. However, bony
prominences, adhesions of the suture line scar, fragile skin
and open areas, shearing forces at the skin/socket interface,
and perspiration can complicate this function.45 The energy
cost of ambulation must be considered, especially for older
patients with significant deconditioning or comorbid condi­
tions. The higher the level of amputation and loss of joints,
long bone length, and muscle insertion, the greater the
impairment of normal locomotor mechanisms. This leads to
increased energy costs in prosthetic control and functional
ambulation and a greater likelihood of functional limitation
and disability.
Preservation of the knee joint seems to be a key determi­
nant in determining the potential for functional ambulation
and successful rehabilitation outcome. Persons with trans­
tibial amputation, who have an intact anatomical knee joint,
demonstrate a more energy-efficient prosthetic gait pattern

466
Section III  Prostheses in Rehabilitation
and postural responses and are more likely to ambulate with­
out additional assistive devices (walkers, crutches, or canes).
They are also more likely to be full-time prosthetic wearers
than are persons with transfemoral amputation. The benefits
of preserving the knee, particularly among older adults, are so
crucial that a transtibial amputation may be attempted even
with the risk of inadequate healing; this may necessitate later
revision to a higher level.45
The patient with a bilateral transfemoral amputation faces
additional rehabilitation challenges. The significant increase
in energy consumption that is required can ­prevent long-
distance ambulation. Many older patients, as well as younger
persons with bilateral transfemoral ­amputation, may choose
wheelchair mobility as a more energy-efficient and effective
means of locomotion. Ambulation ­potential depends on
cardiac function, strength, balance, and endurance.48
Options for prosthetic components for the older person
with an amputation have increased dramatically in the past
20 years. Selecting the most appropriate components for the
individual requires the input of the complete rehabilitation
team, in close communication with the patient and the ­family
members.
REHABILITATION ENVIRONMENT
Traditionally, preprosthetic and early prosthetic programs
have occurred in rehabilitation departments of acute care
hospitals. In this environment, the care may or may not
be specialized for the older person with an amputation.
A ­specialized postamputation rehabilitation treatment team
is best able to address the complex needs of this group of
patients. However, in today's health care environment,
it may not be possible for older persons with an amputa­
tion to receive inpatient intensive rehabilitation until they
are ready for prosthetic fitting. For patients with multiple
medical complications, rehabilitation may be continued in a
TABLE 17-4  Members and Roles of the Multidisciplinary Team for Rehabilitation after Amputation
Team Member
Role
Physician
Often serves as coordinator of the team
Assesses need for amputation, performs surgery, monitors healing of suture line
Monitors and manages patient's overall medical care and health status
Monitors condition of remaining extremity for patients with peripheral vascular disease (PVD), neuropathy,
or diabetes
Physical therapist
Provides preoperative education about the rehabilitation process and instruction in single limb mobility
Designs and manages a preprosthetic rehabilitation program that focuses on mobility and preparation for
prosthetic training
Evaluates patient's readiness for prosthetic fitting; can make recommendations for prosthetic fitting
Designs and manages a prosthetic training program that focuses on functional ambulation and prosthetic
management
Monitors condition of the remaining extremity for patients with PVD, neuropathy, or diabetes
Prosthetist
Designs, fabricates, and fits the prosthesis
Adapts the prosthesis to individuals, adjusts alignment, repairs/replaces components when necessary
Monitors fit, function, and comfort of the prosthesis
Monitors condition of the remaining extremity for patients with PVD, neuropathy, or diabetes
Occupational
therapist
Assesses and treats patients with upper extremity amputation, monitors readiness for prosthetic fitting,
recommends components
Assists with problem solving in activities of daily living for patients with upper or lower limb amputations
Makes recommendations for environmental modification and assistive/adaptive equipment to facilitate
functional independence
Social worker
Provides financial counseling and coordination of support services
Acts as liaison with third-party payers and community agencies
Assists with patient's and family's social, psychological, and financial issues
Dietitian
Evaluates nutritional status and provides nutritional counseling, especially for patients with diabetes
or heart disease or those who are on chemotherapy or are recovering from trauma
Nurse/nurse
practitioner
Monitors patient's health and functional status during rehabilitation
Provides ongoing patient education on comorbid and chronic health issues
Monitors condition of remaining extremity for patients with PVD, neuropathy, or diabetes
Vocational
counselor
Assesses patient's employment status and potential
Assists with education, training, and placement
Source: Modified from May B. Assessment and treatment of individuals following lower extremity amputation. In O'Sullivan SB, Schmitz TJ
(eds), Physical Rehabilitation: Assessment and Treatment. Philadelphia: Davis, 1994. p. 379.

Chapter 17  Etiology of Amputation
467
­subacute setting or skilled nursing facility. For patients with­
out complications and with a strong social support ­network,
an outpatient rehabilitation program may be preferable.
This plan allows them to reintegrate into home and com­
munity while maintaining support of the treatment team.
The most effective care and rehabilitation for individuals
undergoing an amputation require the skills and ongoing
support of an integrated treatment team.50,51
SUMMARY
Although the rehabilitation process after amputation pres­
ents many challenges for patients, their families, and the
­professionals involved in their care, it also allows many
opportunities for success and rewards. Understanding the
risk factors for amputation and the influence of comorbid
disease and age on progression of rehabilitation is ­important.
Optimal outcome after amputation is best achieved through
the interaction of a patient-centered, interdisciplinary health
care team.52 With effective physical rehabilitation and pros­
thetic care, most individuals with amputation can return to
a level of activity and lifestyle similar to their ­preamputation
status.
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469
Wound Care for Vulnerable Feet
Edward Mahoney and Carolyn B. Kelly
The thought of losing a limb has to be one of the most fright­
ening things a person will ever face. For the majority of the
population, the idea likely conjures up some sort of cata­
strophic event that can be pushed to the back of the mind as
something that is unlikely to occur. Unfortunately, individu­
als with a high-risk foot face the very real possibility of los­
ing a limb in the foreseeable future. A high-risk foot is one
that has an underlying disease process that puts the tissues
at a greater risk of breakdown. The largest group of people
with high-risk feet in the United States is the diabetic popu­
lation. In 2006, approximately 65,700 amputations were per­
formed on patients with diabetes, which accounted for more
than 60% of all nontraumatic amputations performed that
year.1 In the simplest designation, amputations can be divided
into traumatic and nontraumatic causes. Trauma can result in
extensive tissue damage and is often complicated by infection
and foreign materials in the wound bed, but healing gener­
ally proceeds appropriately when these factors are corrected.
Nontraumatic causes of amputations are not as straightfor­
ward. Unlike traumatic wounds, there may not be an isolated
incident that can be identified as a causative factor in non­
traumatic wounds. In many cases, the wound is the result of
an underlying disease, such as diabetes, or condition that will
negatively affect wound healing. In these individuals, the key
to effective treatment is often early intervention. This ­chapter
is designed to assist the reader in identifying feet at risk of
ulceration and implementing comprehensive examination
and treatment strategies to prevent or minimize the need for
amputation.
NORMAL WOUND HEALING
To fully appreciate the impact of different disease states on
wound healing, it is necessary to begin with an understanding
of normal wound healing. Wound healing involves a coor­
dinated interaction of three phases: inflammation, prolifer­
ation, and remodeling. Although these stages do overlap to
some degree, they are discussed individually for purposes of
clarity. The body's first response to injury during the inflam­
matory phase is to stop the bleeding at the site of injury
through a process known as hemostasis. In response to an
injury, platelets, which are formed in bone marrow and are
free floating in the vascular system, are attracted to the injury
site. The platelets also undergo activation, which causes them
to change from a round shape into a sticky form that enables
them to adhere to the injured area.2 The platelet plug may be
enough to stop the bleeding in minor injuries, or it may be
augmented by the coagulation cascade to form a larger clot.
An in-depth discussion on the coagulation cascade is beyond
the scope of this chapter. In terms of wound healing, coagu­
lation is only one part of the role of the platelet. The second
role, which is critical to wound healing, is the secretion of
numerous growth factors and cytokines that set the stage for
later phases of wound healing.
The first cells to arrive at the wound site in response to
the coagulation cascade are granulocytes, which are a form
of white blood cells. Neutrophils are the most abundant of
the granulocytes and are found in the wound within 24 hours
after injury. These cells are nonspecific and phagocytic, which
is crucial for disposing of damaged cells in the area. Other
granulocytes include phagocytic eosinophils and basophils,
which release histamine. The next leukocytic cells to respond
are monocytes, which become macrophages in the wounded
area. Macrophages are phagocytic, but can also be thought of
18
LEARNING OBJECTIVES
At the conclusion of this chapter the reader will be able to do
the following:
1. Explain the relationship between diabetes and foot
ulceration.
2. Identify the interactive factors that contribute to ulcer­
ation in the high-risk foot.
3. Describe the components of an effective high-risk foot
examination.
4. Explain the importance of each component of a thorough
wound examination.
5. Compare and contrast the efficacy and drawbacks of the
most commonly used options for reducing pressure to
promote ulcer healing and prevention.
6. Determine which wounds would benefit from the addition
of therapeutic modalities.
7. Develop a comprehensive treatment plan to manage
vulnerable feet, including those with open wounds.

470
Section III  Prostheses in Rehabilitation
as growth factor factories because they play such a critical role
in producing the growth factors that guide the remainder of
the healing process.
Toward the latter stages of the inflammatory response,
the wound is well into the proliferative phase of healing. The
goal of this phase is to resurface the wound with a layer of
viable epithelium. For this to occur, a well-vascularized der­
mal matrix is laid down in the wound bed. To accomplish this,
new blood vessels are formed (neovascularization), and col­
lagen is created by fibroblasts (fibroplasia). At the same time,
new skin is being produced through the process of reepithe­
lialization, and wound contraction is occurring, which helps
to approximate the wound margins and make the resultant
scar smaller. The duration of this phase is greatly influenced
by the size of the wound, but is generally considered to last
up to several weeks. Despite wound closure, the healing pro­
cess is not yet complete as tissues continue to remodel. In fact,
the remodeling phase is by far the longest and can last for
more than a year from wound closure until the tissues have
reached their maximum strength. Even after the wound has
completely remodeled, it will not regain the same strength
that uninjured tissue has, and will continue to require close
monitoring and protection to prevent reulceration.
ASSESSMENT OF THE HIGH-RISK FOOT
According to the most recent data from the Centers for
Disease Control, approximately 60% of all nontraumatic
lower-extremity amputations were the result of diabetes in
2006.3 With that in mind, it is of particular importance to
assess the patient's diabetes status (Figure 18-1).
Following a thorough review of systems, a quick, but thor­
ough objective examination of the foot should occur. This
examination should include assessments of the vascular,
sensory, motor, and autonomic systems, as well as a mobility
assessment and footwear inspection.
Vascular Assessment
It could be argued that a thorough vascular assessment is
the most crucial aspect of the evaluation of a high-risk foot.
No
Move on to next line of questioning
Do you have diabetes?
Yes
When were you diagnosed?
Not well controlled; A1C is
greater than 7%
How well is your diabetes controlled?
Do you know your hemoglobin A1C
level?
Do you have difficulty
avoiding large fluctuations in
blood sugar levels?
Well controlled;
A1C is normal or
improving
Yes
No
Have you had a recent
change to your diabetes
medications?
Have you had a recent
change to your diabetes
medications?
No
Consider referral to physician
Yes
Ensure patient has follow-up
visit with physician to assess
effect of new medications
Record
medications and
move to next line
of questioning
Consider referral to
physician
No
FIGURE 18-1  Flow sheet for diabetes assessment.

Chapter 18  Wound Care for Vulnerable Feet
471
Not only can impaired blood flow be a causative agent for the
development of ulceration, it will impact healing of ulcers
regardless of the etiology. A clinical vascular examination
can be performed quickly, and help the clinician decide if
circulation is adequate or if further, more advanced testing is
required. The examination should begin with an assessment
of the pedal pulses (dorsalis pedis and posterior tibial). Pulses
can be recorded as present or absent, or can be graded on a
more qualitative basis (Figure 18-2):
0 = Unable to palpate
1+ = Barely perceptible
2+ = Weak
3+ = Normal
4+ = Bounding pulse; possible Charcot joint or aneurysm
The assessment of pulses should not be used alone to
determine the extent of arterial compromise, but should be
correlated with other findings from the clinical examination.
The lack of a palpable pulse (grade 0) is not sensitive for the
detection of peripheral arterial disease. In a study by Collins
and colleagues, more than two-thirds of limbs with diagnosed
peripheral arterial disease still had palpable pulses.4 Pulse
palpation may be most useful for the comparison between
the left and right limb to detect abnormalities. If there is any
question as to the arterial status of a limb, an ankle-brachial
index (ABI) should be performed. The ABI is a comparison of
the systolic blood pressure of the pedal arteries with the bra­
chial artery. The systolic pressure is recorded in both arms,
unless contraindicated (lymphedema, dialysis port), and
the higher of the two values should be used. In the foot, the
dorsalis pedis and posterior tibial artery are both assessed and
the highest value is used (Figure 18-3).
A normal ABI is 1.0, which indicates normal arterial blood
flow to the foot. If an ABI value of less than 0.8 is obtained,
referral to a vascular specialist is warranted for further test­
ing. In the case of individuals with longstanding diabetes, an
ABI greater than 1.2 may be obtained because of calcified
vessels in the lower extremity. If this is the case, the ABI
value is of no significance as it pertains to arterial flow and
further testing is required. One test that can be performed
is a toe pressure. By using a specially designed cuff that fits
over the digit and a Doppler flowmeter, the pressure in the
digital arteries, which are less affected by calcification, can be
assessed (Figure 18-4). A systolic toe pressure greater than
50 mm Hg is generally considered normal; an increased risk
of amputation and failure to heal is associated with pressures
less than 30 mm Hg.5
Another noninvasive vascular assessment technique is
transcutaneous oxygen pressure (TcPO2). Low TcPO2 mea­
surement, a measurement of skin perfusion, is a predictor
of ulceration4 and healing.6 In 1999, the American Diabetes
Association's Consensus Development Conference on
Diabetic Foot Wound Care recommended use of abnormal
toe systolic pressures and TcPO2 measurements to predict
poor outcomes.7 Generally, no single noninvasive test pro­
vides enough information to make decisions about vascular
intervention. Analysis is usually done by a vascular specialist
who interprets the results of a combination of tests.
If signs of arterial insufficiency are present and the patient
has a foot wound, or if the patient has none of the typical
symptoms of ischemia but has a nonhealing wound despite
adequate control of infection and external pressure, referral
for further vascular evaluation is warranted. Many patients
ABI
highest ankle systolic pressure
highest brachial systolic pressure
=
A
B
C
FIGURE 18-2  Palpation of pedal pulses. A, Dorsalis pedis pulse. B,
Posterior tibial pulse. C, Popliteal pulse.

472
Section III  Prostheses in Rehabilitation
have significant arterial disease but few clinical signs, such as
pain or open wounds, that warrant the risks involved with an
invasive vascular procedure. They should still be educated in
foot care and proper shoe fit. Because better circulation may
be necessary to heal an open wound than to keep unbroken
skin intact, the goal for patients with arterial insufficiency is
to prevent foot wounds from occurring.
Sensory Assessment
Patients in all settings, with many different diagnoses, may
have impaired sensation. Diabetes is the most common rea­
son for impaired sensation, but it is also associated with
chronic alcoholism, syphilis, Hansen's disease (formerly
leprosy), spinal cord injury, and peripheral nerve injuries.
Regardless of the cause, when the ability to perceive an exter­
nal stimulus is diminished, it increases the risk for ulceration.
In patients with diabetes, a loss of protective sensation is
the leading cause of foot ulceration.8 Simply put, if a patient
cannot feel discomfort, there is no stimulus to change any­
thing. In the case of a foot rubbing on a shoe or brace, an
individual with intact sensation will stop to adjust the prob­
lem because of discomfort, whereas the person with impaired
sensation may be unaware of the problem until the shoes are
removed and blood is seen on the sock.
120
161
Stenosis
115
99
83
120
138
153
165
120
Abnormal
Ankle
Arm
0.7 =
=
83
120
Normal
Ankle
Arm
1.0 =
= 120
120
FIGURE 18-3  Segmental systolic pressures show a normal condition on the left. A 0.7 ankle-brachial
index on the right indicates a reduction in flow. Also of note is the greater than 30 mm Hg drop in
pressure between two successive thigh cuffs, which indicates stenosis or occlusion of the segment.
(From Hoffman AF. Evaluation of arterial blood flow in the lower extremity. In Robbins J [ed], Clinics
in Podiatric Medicine, Surgery, and Peripheral Vascular Disease. Philadelphia: Saunders, 1999. p. 42.)

Chapter 18  Wound Care for Vulnerable Feet
473
Protective sensation can be assessed in several different
ways in the clinic, with very little special equipment needed.
The two simplest methods are Semmes-Weinstein mono­
filaments, and tuning forks. A 5.07 monofilament, which
takes 10 g of perpendicular force to bend, is the most widely
used clinical tool for the assessment of protective sensation
(Figure 18-5).
The patient is instructed to close his or her eyes and the
monofilament is applied perpendicular to the skin surface
with enough pressure to cause it to bend. Inability to sense the
monofilament is considered to be a positive test for the loss of
protective sensation. Care must be taken to avoid areas with
thick callus, as the test results will not be valid. Alternatively, a
tuning fork can be used for vibratory testing. A study by Oyer
and associates found a vibrating 128-Hz tuning fork placed on
the toe was more sensitive to the onset of neuropathic changes
than monofilament testing.9 In this testing procedure, a clang­
ing tuning fork is placed on the area to be tested and remains
there until the subject can no longer feel the vibration. The
tuning fork is then quickly moved to an area of known intact
sensation on either the subject or examiner. If the vibration
can still be felt in that site, the test is positive for a loss of vibra­
tory sensation. Other authors have found similar results using
similar methods with tuning forks of different frequencies, for
example, 512 Hz, which may be more convenient as the 512 Hz
tuning fork is smaller (Figure 18-6).10
FIGURE 18-4  Toe cuff for the assessment of digital blood flow.
FIGURE 18-5  Semmes-Weinstein monofilament.
FIGURE 18-6  Tuning fork for the assessment of neuropathy.

474
Section III  Prostheses in Rehabilitation
Motor Assessment
A thorough musculoskeletal evaluation is necessary to deter­
mine a given patient's likelihood for ulceration. Deformities
and abnormal biomechanics often change pressure distri­
bution in the foot and can lead to discomfort, callus, and,
ultimately, ulceration. The clinician can begin to assess for
motor impairments while the patient is seated. The wear pat­
tern on shoes, as well as the presence of calluses on the foot,
can identify potential pathologies that ultimately may lead
to ulcer formation. Following a visual inspection of the feet
and footwear, a musculoskeletal examination that includes
reflexes, strength, and range of motion should be performed.
Particular attention should be paid to toe extension and
dorsiflexion range of motion, as limitations in either one
greatly increases weight-bearing forces through the forefoot
in the latter stance phases of gait. This becomes increasingly
important to assess if the patient has diabetes, as a loss of dor­
siflexion has been widely documented in that population.11,12
If a patient is ambulatory, a gait assessment should be a stan­
dard part of the high-risk foot assessment. Major deviations
from the normal gait pattern can be assessed with a quick
visual inspection. For example, patients with peroneal nerve
injuries have difficulty with foot clearance and have a shorter
loading response, which increases pressure at the forefoot.
Alternatively, a patient could have increased forefoot pressure
in terminal stance as a result of limited dorsiflexion range of
motion. A mild limitation in motion may present as an early
heel rise, while a more severe restriction can lead to excessive
knee flexion for clearance during the swing phase of gait. With
a static foot assessment, it may be apparent that both indi­
viduals have increased forefoot pressure, but the cause would
not be known, with the result that the optimal intervention
could not be selected. With careful gait analysis, the clinician
can determine the cause of the pressure and choose appropri­
ate interventions, such as a rocker bottom shoe to substitute
for the midfoot rocker in the first case or an ­orthosis to aid
in dorsiflexion in the second case. Chapter 5 provides an in-
depth review of the gait assessment.
Many of the deformities that occur as a result of motor
neuropathy are more subtle than the examples above. As neu­
ropathy advances, the intrinsic muscles atrophy and become
weaker, leading to muscle imbalances and changes in joint
alignment.13,14 When tissues over these joints are then loaded,
they are unable to withstand the same amount of pressure and
begin to break down. As extensor muscles on the dorsum of
the foot overpower flexor muscles of the plantar aspect, the
net result is extension at the metatarsophalangeal joint, which
increases pressure at the plantar aspect of the metatarsal head
(MTH). This occurs with both claw, and hammer toe defor­
mities; the difference being that claw toes are characterized by
flexion of both interphalangeal (IP) joints, whereas hammer
toes have flexion at the proximal IP and extension at the distal
IP joint. Care must also be taken to protect the distal tips of
the toes as well as the dorsum of the IP joints, as these areas
are easily injured from rubbing on shoes. Persons with diabe­
tes who have motor neuropathy may develop a high-risk foot,
commonly referred to as an “intrinsic minus” foot because of
the impairment in function of the small muscles of the foot.
The intrinsic minus foot presents as a pes cavus (high arch)
deformity with prominent MTHs. Compounding matters
is the distal migration of the metatarsal fat pad into the toe
sulcus as a result of muscle imbalance. Now the metatarsal
region has increased pressure because of the foot shape, as
well as the loss of fat pad over the MTH that would normally
increase the total surface area being loaded.15
Partial foot amputation is another deformity that alters
plantar pressure distribution. Because the surface area to carry
the force of body weight is smaller, pressure on the remain­
ing structures increases. Studies that have looked at great toe
amputation in patients with diabetes have found an increase
in plantar pressure and the development of new deformities
and ulcerations after amputation.16,17 As loss of parts of the
foot occurs, the mechanics of the foot change, transferring
stresses to new areas with the potential for ulceration.
Plantar ulceration has been associated with lower extrem­
ity peripheral neuropathy and excessive plantar pressures.18–21
Pressure on the soft tissues of the foot is related to three vari­
ables: the magnitude of the force applied to the foot, the
amount of surface over which the force is applied, and the
length of time over which the force is sustained.22 Because
much of the focus in treating and preventing foot ulcers is
on reducing pressure, one must understand the relationship
of pressure to these three variables. The following formula
should be considered:
As indicated, anything that increases the magnitude of
the force applied to the foot or decreases the area over which
the force is applied increases pressure and makes tissue dam­
age more likely. Immediate injury can occur from extremely
high force applied over a small area, as when a patient steps
on a tack or piece of glass. Injury occurs because tremen­
dously high pressure exceeds the tensile strength of the
skin. Pressure on the foot can also become excessive when a
moderate amount of force is repeatedly applied over a small
surface area—when bony deformities cause small localized areas
of weight bearing or when partial foot amputations decrease the
patient's weight-bearing surface. The force applied to the foot
(body weight) remains essentially the same, but the actual
pressure on the tissues is greater because of reduction of the
surface area. In patients with diabetes, factors such as limited
joint mobility,23–27 structural abnormalities,28–30 and previous
amputation16,17 can lead to increased force or decreased sur­
face area. All of these are associated with increased plantar
pressures and ulceration.
Further complicating this picture is the time factor. In
looking at tissue ischemia and resultant ulceration, Kosiak
found an inverse relationship between the amount of pres­
sure applied to tissues and length of time that the pressure
was sustained.31 Low pressures sustained over long periods of
time caused tissue necrosis. This is the mechanism of tissue
injury when decubitus ulceration occurs in bedridden, poorly
mobile patients. Tissue necrosis also occurs along the medial
or lateral borders of the feet or tops of hammer toes when
=
Pressure
Force/Area

Chapter 18  Wound Care for Vulnerable Feet
475
patients wear shoes that are too tight. Kosiak found that as the
magnitude of pressure increased, fewer hours were necessary
to induce injury.
The most common cause of skin breakdown in the neu­
ropathic foot is repeated bouts of moderate pressure during
every-day walking.32 Dr. Brand demonstrated this fact by
applying repeated bouts of moderate pressure to the anesthe­
tized foot pads of rats. Repeated bouts of moderate pressure
caused inflammatory changes, and with continued repeti­
tion, this inflammation progressed to ulceration.22 For health
professionals who care for patients with diabetic foot prob­
lems, two facts from this research hold particular significance.
First, when the inflammatory changes (heat and swelling)
began to persist from one day to the next, breakdown of the
tissue was prevented by discontinuing the repeated stress.
Second, breakdown was prevented by either decreasing the
amount of pressure per repetition or by reducing the number
of repetitions. The findings of Brand and Kosiak suggest that
the variables of force, area, and time and repetition contrib­
ute to tissue breakdown and that changing one or more of
these variables must be considered in the treatment plan for
patients with a high-risk foot.
Autonomic Assessment
Autonomic changes represent the third category of changes
associated with polyneuropathy. With roles including the
regulation of moisture and blood flow, as well as control­
ling hair and nail growth and overall skin integrity, the auto­
nomic system is crucial to healthy feet. Cracks and fissures in
the foot, as well as nail pathologies, can predispose people to
ulceration or infection. As these are all end products of auto­
nomic dysfunction, patients need to be educated on how to
prevent them from occurring. Patients with autonomic dys­
function, most commonly from diabetes, should be educated
to moisturize their feet often so as to avoid drying and crack­
ing of the skin. Creams or non–alcohol-based lotions should
be applied liberally to the feet and legs, but the areas between
the toes should be avoided as the excess moisture can lead to
fungal infections. Not only is moisturized skin more com­
fortable, it is also stronger and less likely to develop cracks
and fissures, which are easy entries for infections. If nails are
too thick to be trimmed safely at home with regular nail clip­
pers, the patient should be encouraged to seek professional
help for nail care.
One of the most damaging outcomes related to dysfunc­
tion of the autonomic system is diabetic neuropathic osteo­
arthropathy, also known as Charcot foot. This destructive
process can significantly alter the bony architecture of the
foot, and can lead to excessive plantar pressures33 and subse­
quent ulceration if left unchecked (Figure 18-7). This process
was first recognized in patients with syphilis during the nine­
teenth century by Jean-Martin Charcot. Although several
neuropathic diseases, including syphilis and Hansen's dis­
ease, can cause a Charcot arthropathy, it is most commonly
seen in persons with diabetes.34 Charcot foot is a progressive
disorder that leads to joint dislocation, fractures, and defor­
mity of the foot.35
Charcot surmised that when the proper functioning of
the autonomic system was impaired by disease, it led to an
increase in blood flow to the bones, which then led to bone
resorption. Over time, this became known as the neuro­
vascular theory.36 A second theory states that development
of a Charcot foot is related to trauma in an insensate foot.
Because of the lack of sensation, there is no perception of the
trauma, and thus no adjustments to compensate for it. If the
joint continues to be loaded, it will stay inflamed and eventu­
ally break down. This became the neurotraumatic theory.36
In most experts’ opinions, the cause of Charcot foot is likely to
be some combination of the two theories.35,37 A commonality
of the two theories is that Charcot foot starts with an insen­
sate foot.36,38,39 As a result, the Charcot foot is most likely to
occur in someone with sensory neuropathy, adequate blood
flow, and a history of trauma, whether they were aware of it
or not. Upon clinical examination, the foot is erythematous,
edematous, has an elevated skin temperature, and a bounding
pulse indicative of excessive blood flow.39,40
Charcot foot can become debilitating if not recognized
early enough to arrest the development of the rocker bottom
deformity that is characteristic of the disease. It is often mis­
diagnosed because no single diagnostic test can confirm its
presence. Medical history, clinical manifestations, and radio­
graphic findings all must be considered. Unfortunately, the
clinical presentation of a red, hot, swollen foot often leads to
FIGURE 18-7  Charcot foot with ulceration of the plantar midfoot.

476
Section III  Prostheses in Rehabilitation
the diagnosis of cellulitis, which is treated with antibiotics.
During the time the patient is being treated with antibiot­
ics for an infection that does not exist, they are continuing to
damage the foot by walking on it. Radiographs taken in the
acute phase are not sensitive to the development of neuro­
pathic fractures and bone scans do not differentiate Charcot
foot from osteomyelitis. MRI, on the other hand, is capable
of identifying bone injury prior to complete fracture.37,40 MRI
may be cost-prohibitive, making the medical history and
physical examination that much more important.
Charcot foot should be suspected if a patient with neuropa­
thy presents with sudden onset of localized swelling, warmth,
and erythema in the absence of an open wound. Appropriate
treatment for Charcot foot should be initiated until this
condition is ruled out on further testing. During acute Charcot
arthropathy, joint destruction can be minimized by immo­
bilization in a total-contact cast and avoidance of weight
bearing until signs of healing become apparent (decreased
temperature, decreased swelling, and improved radiographic
findings). Both lack of compliance with non–weight bearing
and use of orthotic devices in place of cast immobilization
have shown prolonged healing times.41,42 When cast immo­
bilization is discontinued, the use of an orthotic device for
continued protection of the joints during the initial return to
weight bearing should be considered.33,42
The architectural changes that occur in the foot second­
ary to neuropathic osteoarthropathy result in high-pressure
areas.33 Because of this, following the period of immobiliza­
tion and limited weight bearing, patients with a history of
Charcot foot must be provided with appropriate footwear to
stabilize the foot and reduce plantar pressure. Surgical inter­
vention may be indicated for unstable or severely malaligned
fractures or dislocations, which create problems with recur­
rent ulceration, fitting of shoes, ability to ambulate,43,44 as
well as recalcitrant ulcers.45 Some of these procedures require
months of immobilization and avoidance of weight bearing,
which can be difficult for many patients with diabetes and
neuropathy. Such surgery is usually advocated only if nonsur­
gical management fails.
Footwear Assessment
The analysis of the high-risk foot truly begins before the
patient sits on the examination table. The type and appear­
ance of the footwear they are wearing can give insight as to the
cause of their pathology. Shoes that either do not fit properly
or are excessively worn can cause problems including blisters,
calluses, and wounds. On the other hand, shoes that someone
refuses to wear are not useful as they will just sit in the closet.
Characteristics of the proper shoe for the high-risk foot
include:
• Snug fit at the heel to prevent pistoning (moving up and
down) of the heel
• Wide toe box to accommodate for deformities such as
bunions and hallux valgus
• Deep toe box to accommodate claw/hammer toes and
molded inserts
• Fashionable enough that the patient will wear the shoes
It is recommended that people shop for new shoes in the
mid to late afternoon to ensure the best fit. Because foot size
changes throughout the day, a shoe purchased to fit the foot
early in the morning may be too small by late evening, and
conversely a shoe bought at night may be too large for the foot
in the morning.
Gait and Balance
Motor neuropathy causes weakness of foot and ankle muscu­
lature that may result in gait deviations that change plantar
pressure patterns or contribute to instability. Gait and bal­
ance are also affected by damage to sensory nerves, which
leads to an inability to sense where the foot is in space. The
use of ankle-foot orthoses or shoe modifications may help
restore a more normal gait, stabilize joints, or improve bal­
ance. Studies have found that patients with peripheral neu­
ropathy secondary to diabetes have problems with gait and
postural stability.46–50 In examining a patient with a high-risk
foot, physical therapists must include not only the patients’
foot problems but also their overall functional status.
To reduce the morbidity associated with falls, recommenda­
tions that address safety and function should be included in
the treatment plan.
WOUND ASSESSMENT
Although it is clear that the most effective way to prevent
amputations is to avoid getting wounds in the first place, that
is not always possible. When a wound does develop, regard­
less of the etiology, a thorough wound assessment becomes
a necessity. The comprehensive wound assessment begins
with a thorough patient history, which helps the clinician not
only gain a better understanding of the cause of the wound,
but also forecast healing rates of the wound more accurately.
Refer to the previous section on risk factor assessment for
more information pertaining to patient history. It is often
helpful to take the entire patient history prior to undress­
ing the wound, as there is a tendency to focus solely on the
wound once it is visible and forget about other factors that
may be important.
Once the patient history is reviewed, the wound can be
carefully undressed. In addition to the components already
discussed for the evaluation of the high-risk foot, the assess­
ment also includes an examination of the immediate wound
and periwound area. The wound should be assessed for loca­
tion, color, odor, size/depth, and drainage type and amount,
and the periwound tissues should be assessed for any abnor­
malities (Figure 18-8).
Location
If a thorough medical history has been taken, the exam­
iner may have a good hypothesis as to the cause of a wound
before even seeing it. The objective examination can either
confirm or refute this hypothesis. One of the first objec­
tive findings that should be documented is wound location.
Although traumatic wounds can occur in any anatomic
location, many of the common wound etiologies tend

Chapter 18  Wound Care for Vulnerable Feet
477
to occur most frequently in certain areas. Diabetic foot
(neuropathic) ulcers are most common on the plantar aspect
of the digits and MTHs, more specifically, the great toe and
first MTH, but they can occur in any area of high stress.51
Ulceration secondary to neuropathy is also common on the
dorsum of the toes, as well as bony prominences, such as
the lateral aspect of the first and fifth MTHs and the base
of the fifth metatarsal, and anywhere a shoe or brace may
be rubbing. Wounds secondary to vascular insufficiency
can occur in any location that has impaired blood flow, but
are most frequently found on the toes, dorsum and lateral
aspects of the foot, as well as the lateral leg. In contrast,
wounds of venous origin tend to be in what is often referred
to as the “gaiter” area, just proximal to the medial malleolus.
It should be noted that these are general guidelines, and an
accurate diagnosis cannot be made based solely on location.
When describing wound location, the clinician should be as
precise as possible, often using bony landmarks as descrip­
tors. This becomes increasingly important when multiple
wounds are present.
FIGURE 18-8  Wound assessment flow sheet.
(Continued)
Subjective exam:
Objective exam:
Assistive device:
Wound location:
If other, enter location:
Sensation:
Range of motion:
Pain:
Last dressing change:
Comments:
Mode of arrival:
Wearing prescribed dressings/footwear?
Wound stage:
Wound color:
Color
Pre-
debridement
Post-
debridement
%
%
%
%
%
%
Odor:
Size:
cm2
L:
W:
D:
Drainage amount:
Drainage type:
Periwound:
Nails:
Edema:
Pulses:
(L) (R)
DP
PT
Popliteal
ABI
Special Tests:
Results:

478
Section III  Prostheses in Rehabilitation
Wound Color
A simple designation for wound color is to use the red-­
yellow-black staging system, which was first published in the
United States in 1988 and had been used in Europe prior to
that.52 Red wounds are generally healthy, well vascularized,
and are progressing through the normal stages of healing.
The red appearance is attributed to the deposition of highly
vascularized collagen, known as granulation tissue. This tis­
sue is fragile, and may bleed with excessive force or friction.
Granulation tissue that bleeds with minimal ­pressure or has
a dusky appearance is called friable and should be inves­
tigated further as it is typically a sign of increased bacte­
ria present in the wound. Yellow wounds indicate fibrinous
slough or infection is present. Slough has a stringy, adher­
ent characteristic and can be removed by a variety of meth­
ods, which are discussed later in this chapter (Preparing the
Wound Bed by Eliminating the Source of Inflammation or
Infection). Wounds also may have a black appearance, which
signifies the presence of eschar. Eschar is often hard to the
touch, but can be soft or boggy if there is a lot of fluid present.
Modalities:
Sensation:
Range of motion:
Comments:
Treatment:
Wound cleansed with
Debridement performed today?
Debridement type:
Dressings:
Offloading:
Comments:
Assessment:
Tolerance to treatment:
Comments:
Plan:
Comments:
Follow up:
Nails:
Edema:
Pulses:
(L) (R)
DP
PT
Popliteal
ABI
Special Tests:
Results:
FIGURE 18-8  Cont'd

Chapter 18  Wound Care for Vulnerable Feet
479
In most cases, it is beneficial to remove the eschar because the
necrotic tissue promotes the proliferation of bacteria. Several
instances when this is not advised are intact eschar on heels
and vascular wounds that would not be able to heal follow­
ing debridement. In addition to the red-yellow-black system
that is focused on the dermis, the clinician must also be aware
of deeper structures that may be apparent in the wound bed.
The first tissue encountered beneath the dermis is known as
subcutaneous tissue, fat, or adipose. This should have a pale
yellow, moist appearance when healthy, but dries out and
darkens when it is nonviable. Healthy, muscle has a bright
red color, and the striations are often visible in the tissue.
Damaged muscle takes on a dusky gray appearance with a
much-less-pliable texture. The remaining structures that will
be encountered in a deep wound bed—ligaments, tendons,
bone—all should be white if well vascularized. If these tissues
are compromised, they will take on a dusky yellow appear­
ance, and continue to darken as damage proceeds.
For documentation purposes, the use of percentages is
helpful in describing the wound color. For example, a wound
could be 80% red, with 20% firmly adhered yellow fibrin.
It is also suggested that the percentage should be documented
before and after treatment if there is any significant change in
the wound appearance.
Odor
One of the most troubling aspects of a wound from a patient's
perspective is odor. Most significant wounds will have some
odor when dressings are removed. As a clinician, it is impor­
tant to know whether or not the odor is caused by infec­
tion, or simply from the dressing having been in place for an
extended period. Before making this determination, dress­
ings should be removed and the wound should be rinsed with
sterile water or saline. Odors that are eradicated are likely
caused by drainage on the dressings. This is especially true
of occlusive dressings, such as hydrocolloids. If cleansing the
wound does not eliminate the odor, it is more likely caused by
necrotic or infected tissue. Wounds with a strong odor often
contain anaerobic and aerobic bacteria, and are referred to
as polymicrobial53; anaerobic bacteria create odor by releas­
ing compounds including putrescine and cadaverine. These
odors can be extremely strong, and are often described as
acrid smelling. Aerobic bacteria also are capable of producing
foul odors. Because the strength of an odor is subjective, it is
recommended that descriptions such as sweet, fishy, necrotic,
putrid, and the like also be included in the assessment of the
odor. Infection should be considered when previously odor-
free wounds develop an odor, but it should also be pointed
out that some infections do not produce any odor at all.
Size
Wound size should be documented on a routine basis as it is
an easy way to monitor progress in wound healing. For most
wounds, unless they are perfectly symmetrical, a diameter or
even length and width may not give an accurate representation
as to the true size of the wound. When length and width are
used, the largest length is recorded, and the width is recorded
perpendicular to the length. Although improvements can be
seen as these numbers decrease, it is difficult to accurately
calculate a total surface area for the wound or a percent area
reduction because wounds are irregularly shaped. Alternative
methods include photography with a transparent film over
the wound, wound tracings with transparent film, and digi­
tal cameras that can calculate the surface area of the wound.
All of these options enable the clinician to calculate surface
area, and percent reduction in size (Figures 18-9 and 18-10).
Regardless of the method used to calculate wound size, the
orientation of the wound should be standardized to ensure
that subsequent measurements are assessing the same dimen­
sion. Bony landmarks can be used for this purpose, but it is
most common to describe length in a cephalocaudal (head-to-
toe) fashion and width perpendicular to that. Unfortunately,
the largest dimensions of most wounds will not line up per­
fectly with axes along the cephalocaudal and perpendicular
plane. For this reason many clinicians describe wound ori­
entation using a clock face, with 12 o'clock being at the head
and 6 o'clock at the feet. Using this system, a wound could
be described as 6 cm in length from 10 o'clock to 4 o'clock
and 3 cm in width from 1 o'clock to 7 o'clock. Undermining,
tunneling, or any other abnormality in the wound can also
be described using the clock face, which will help with con­
sistency in measurement, especially if another clinician is
measuring the wound.
FIGURE 18-9  VISITRAK wound measurement system (Courtesy
of Smith & Nephew, Hull, United Kingdom).

480
Section III  Prostheses in Rehabilitation
Depth
A thorough understanding of anatomy is necessary for an accu­
rate staging of wounds. In turn, an accurate staging of wounds
relies on being able to assess wound depth properly. Before
depth can be measured, the wound must be free of nonvia­
ble tissue so the wound base can be visualized or probed. The
wound can then be probed with a sterile probe held perpendic­
ular to the skin surface. As wounds do not all have a uniform
depth throughout, the deepest point should be measured
and the location where the measurement was taken should
be documented. After the depth measurement is obtained,
wounds can be classified in several ways, depending on the
etiology. Table 18-1 reviews different wound classification sys­
tems that rely on wound depth as a part of the staging criteria.
Drainage
The ideal wound will have enough moisture to prevent desic­
cation of the wound bed, but not so much that it causes break­
down of periwound tissues. The characteristics of wound
drainage will vary depending on multiple factors, includ­
ing wound location, vascular status, and presence of infec­
tion. Drainage should be classified by amount and type to
­accurately describe what is occurring in the wound. Assessing
TABLE 18-1  Wound Classification Systems
Classification System
Intended Wound
Etiologies
Grades
Comments
Wagner128
Diabetic foot
0 = Intact skin
1 = Superficial ulcer
2 = Deep ulcer (through dermis)
3 = Infection
4 = Partial foot gangrene
5 = Full foot gangrene
University of Texas129
Diabetic foot
A0 = Preulcerative or postulcerative lesion
AI = Superficial wound
AII = Involves tendon or capsule
AIII = Involves bone or joint
Letter stage changes as follows:
B = Infection
C = Ischemia
D = Infection and ischemia
Partial/full
All wounds
Partial = Involves epidermis and up to part
of the dermis
Full = Involves structures deep to the dermis
Burns130
Burns
Superficial = Epidermis only
Superficial partial = Superficial dermis involved
Deep partial = Deep dermis involved
Full thickness = Subcutaneous tissue involved
Subdermal = Muscle, tendon, bone involved
Some experts do not make a
distinction between full-thickness
and subdermal burns, as both
require surgery to heal130
National Pressure
Ulcer Advisory
Panel131






Pressure ulcers








I = Nonblanchable skin, or abnormal color;
skin is intact
II = Partial loss of dermis
III = Down to, but not through fascia
IV = Injury to subfascial tissues (muscle, tendon,
ligament, capsule, bone)
Unstageable = Wound bed cannot be visualized
Suspected deep tissue injury = Purple or maroon
area of discolored skin; may progress to deep,
open ulceration rapidly
Do not reverse stage—a stage IV ulcer
does not become a stage III ulcer,
it is a healing stage IV






FIGURE 18-10  ARANZ Medical Silhouette wound imaging device
(Courtesy of ARANZ Medical, Christchurch, New Zealand).

Chapter 18  Wound Care for Vulnerable Feet
481
the amount of drainage is somewhat subjective in that it is not
practical, or even possible in many cases, to weigh the amount
of exudate from the wound. Instead, the clinician describes the
amount of exudate along a continuum, such as the one below:
This can be difficult to quantify, especially for the inexperi­
enced clinician, as different dressings will absorb vastly differ­
ent amounts of fluid and thus could make a heavily draining
wound appear drier, or vice versa. Wounds with underlying
arterial insufficiency tend to be drier because less circulation is
getting to the wound bed, whereas patients with wounds that
are venous in nature often experience heavy drainage because
of the edema present. If the amount of exudate increases, and
a reason is not clearly related to changes in treatment (i.e. sur­
gical intervention to increase blood flow, discontinuation of
compression therapy, or resting in dependent positions), then
infection should be considered as a likely cause. The presence
of infection causes the wound to remain in the inflammatory
phase of wound healing, which results in increased drainage.
Infected wounds often exhibit purulent drainage, which can
be yellow, green, tan, or even creamy or cloudy. These wounds
often require a combination of local and systemic agents to treat
the infection. In addition to purulent drainage, drainage can
also be serous (watery), sanguineous (bloody), or serosanguine­
ous (pink or reddish, watery).
Periwound Skin
The area immediately surrounding a wound, known as the
periwound skin, should be assessed carefully because it can give
clues as to the state of the wound. Evidence of excessive pres­
sure, excess moisture, decreased vascularity, and the presence
of infection can all be found in the periwound skin with a quick
visual inspection and palpation. Table  18-2 lists periwound
findings and their significance.
None
Scant
Minimal
Moderate
Heavy
Copious
→
→
→
→
→
TABLE 18-2  Periwound Skin Assessment
Appearance
Description
Significance
Callus
Area of hyperkeratosis, typically in
response to high pressures54,132,133
Frequently associated with neuropathy and/or bony
deformity. Indicates area susceptible to breakdown132
Blister
Fluid-filled area causing separation of
epidermis from dermis
Shearing forces from rubbing on shoes, brace, bed, etc.;
may also be caused by adhesive dressings on skin
Erythema
Redness
Indicates inflammation caused by local stress or infection;
redness in immediate periwound area is normal in acute
wounds, but excessive redness or redness that persists
for 30 to 60 minutes after the stress is removed requires
intervention; erythema associated with infection is often
well demarcated; if red streaks are noted (lymphangitis),
consult physician as it is a sign of spreading infection
Maceration
Changes in tissue caused by excessive
moisture
Can lead to skin breakdown; may be a result of excessive
sweating, heavy wound drainage, incontinence, or
inappropriate dressings
Induration
Hardening of the tissue because of edema
Chronic edema impairs wound healing; induration is often
associated with infection or venous disease
Hemosiderin
Brownish discoloration of the skin around
a wound. Associated with deposition
of hemoglobin in extravascular tissues
Often associated with venous disease
Excoriation
Wearing away of the skin
Indicates an area of trauma; often preceded by maceration
and/or blistering
Presence of scars
A scar is the final result of a previous injury
May give clues to the chronicity of the problem as well as
the extent of damage in the area
Temperature
Can be palpated or assessed with infrared
thermometer; is typically compared with
adjacent areas or to contralateral side
Nonspecific indicator of inflammation; helpful to monitor
“hot spots” that may be at risk of breakdown, or for
resolution of a Charcot fracture
Edema
Swelling in the tissues
Bilateral edema suggests a systemic problem; unilateral
edema indicates a localized problem; can occur with
infection, inflammation, venous dysfunction, and
lymphedema; consider Charcot foot if insensate
Other changes

Taut, shiny, hairless, cracked skin

Taut, shiny skin with a loss of hair indicates impaired blood
flow; cracked skin is associated with aging, diabetes, or
vascular disease. Important to moisturize skin frequently

482
Section III  Prostheses in Rehabilitation
In addition to the factors listed in Table 18-2, the amount
of soft tissue over prominent areas also can be assessed.
Decreased amounts of soft-tissue bulk have been identified in
persons with diabetic neuropathy in comparison to persons
without diabetes used as controls.13,54–67 With less soft tissue
present, peak pressures at the prominent areas are increased,
which increases the likelihood of ulceration.12,54
WOUND MANAGEMENT
It is truly incredible how much the field of wound manage­
ment has changed over the last few decades. It can be an over­
whelming endeavor for the inexperienced clinician as it seems
there are constantly new modalities, dressings, and devices
coming out on the market. Further complicating things is the
fact that there are frequently conflicting results when one
therapy is compared to another. This leaves the clinician with
the difficult task of developing the best treatment plan for
a given individual, without having a gold standard of treat­
ment in many instances. Luckily, the basic tenets of wound
healing have remained largely unchanged, and a practical
approach remains effective. Successful wound healing inter­
ventions can be categorized into a few simple steps, which are
discussed in detail. These overlapping steps are:
1. Preparing the wound bed by eliminating the source of
inflammation or infection;
2. Providing an optimal wound healing environment;
3. Reducing further trauma to the wound; and, finally,
4. Keeping the wound healed once it has closed and
preventing new ulcers from forming.
Preparing the Wound Bed by Eliminating the Source
of Inflammation or Infection
The current model of infections that is most widely used
involves the interaction between the host response and the
amount of bacteria present in the wound. As outlined by this
model, a patient with a healthy immune response is able to
tolerate a higher bacterial load without developing signs of
infection than a patient with an impaired immune response.
The amount of bacteria in a wound is usually described on
a continuum from sterile to a systemic infection. Sterile
wounds have no bacteria, whereas systemic infections have
overwhelmed the wound with bacteria and cause systemic
immune responses. Intermediate stages include contami­
nated wounds, characterized by bacteria that is present, but
not invading the tissue; colonized wounds which are still
capable of healing despite invading bacteria; and critical colo­
nization in which the bacteria are overwhelming the immune
system and are creating a localized response.58 It is in the
colonized and critically colonized wounds, and in infected
wounds in conjunction with systemic medications, that selec­
tive debridement, modalities, and topical dressings are most
helpful in optimizing the wound environment.
A very effective means of reducing inflammation and the
risk of infection is removal of the tissue that may harbor bacte­
ria, through a process known as debridement. There are many
ways that debridement can be performed, and all of them are
within the scope of practice of the physical therapist except
for surgical debridement. Because surgical debridement may
involve the excision of viable and nonviable tissue to ensure
that all of the necrotic or infected tissue is removed from the
area, it is called nonselective debridement. Slightly less aggres­
sive is sharp debridement. Sharp and surgical debridement
both use sterile sharp instruments to remove tissue, but the
tissue that is being debrided is limited to nonviable tissue
in sharp debridement. For this reason, sharp debridement
is referred to as selective debridement. Despite being widely
accepted, or perhaps because it is so widely accepted as a
standard of care, there is limited evidence on the effectiveness
of sharp or surgical debridement. Debridement with sharp
instruments is the quickest way to remove undesirable tissue,
but is also the riskiest method, and is best employed by the
experienced clinician. Risks can be minimized by using the
appropriate equipment, and assessing the patient thoroughly
to ensure that they do not have any of the contraindications/
precautions listed in Box 18-1.
In addition to sharp and surgical debridement, mechanical,
acoustic, enzymatic, larval, and autolytic forms of debridement
are also viable options. Of these, all are classified as selective
with the exception of mechanical debridement. Mechanical
debridement can be performed using a variety of methods,
including abrasion, wet-to-dry dressings, and whirlpool.
All of these methods may remove nonviable tissue, but can be
detrimental to healthy tissue, and if used at all, should be lim­
ited to cases in which the majority of the wound is nonviable.
Historically, whirlpools were frequently included in the
treatment plan for an individual with a wound. Proposed bene­
fits were increasing blood flow to the area because of the warm
water, as well as the ability to remove dressings and necrotic
tissue. The whirlpool also has many shortcomings as a wound
care modality, including the risk of cross-­contamination,
unregulated pressures on the wound, exacerbation of depen­
dent edema, and excessive maceration. As a result, pulsatile
lavage with suction (PLWS) has largely replaced the ­whirlpool
as the hydrotherapy of choice for wound management. There
are no absolute contraindications to the use of PLWS, but
care must be taken around exposed vessels, vital organs, and
fistulas. Precautions must also be taken to reduce the risk
of cross-contamination, including using personal protec­
tive equipment, treating in a private room, using a shield to
prevent backsplash, and disposing of single-use components
properly (Figure 18-11 and Table 18-3).
Medically unstable patient (surgical only)125
Dry gangrene or lack of vascular supply to heal wound125
Intact, dry eschar on heel126
Impaired clotting mechanism or on anticoagulants127
Pyoderma gangrenosum126
Clinician without a thorough knowledge of anatomy of
the area to be debrided
BOX 18-1  Contraindications and Precautions to
Sharp and Surgical Debridement

Chapter 18  Wound Care for Vulnerable Feet
483
PLWS delivers a stream of irrigant solution that can be
directed at the area of interest to debride slough and reduce
bacterial counts on the wound.59,60 It appears that the effec­
tiveness of lavage improves as the amount of irrigant used to
flush out bacteria is increased.60 With PLWS, the water pres­
sure can be controlled, and can be delivered within the safe
range of 4 to 15 psi, which is effective at removing nonviable
tissue and bacteria without traumatizing healthy tissue.61 For
the purposes of reducing bacterial levels, the higher end of
that range is recommended, as nearly 85% of bacteria can be
removed from a wound with 15 psi.59,62 It should be noted that
although PLWS seems to reduce bacterial counts in wounds,
some researchers believe the effect may have less to do with
mechanical debridement and more to do with the negative
pressure exerted by the suction component.63
Acoustic, or ultrasonic, energy is the newest form of debride­
ment to enter the wound care arena. Currently, there are several
ultrasonic debridement devices on the market that are capable of
performing selective debridement. These devices are ­classified
as low frequency (kilohertz range, as opposed to ­megahertz
with conventional ultrasound) and high-intensity ultrasound
devices. Studies have demonstrated effectiveness of these devices
at increasing fibrinolysis, improving blood flow to the wound,
reducing bacterial counts, and anecdotally seems to be faster than
sharp debridement in many cases.64–70 Although capable of pro­
ducing extremely rapid debridement and a reduction in bacteria,
the use of ultrasonic debridement will likely be cost-prohibitive for
clinics that do not specialize in wound healing. For that reason, an
­in-depth discussion of ultrasonic debridement is not included in
this chapter.
The remaining forms of debridement tend to be slower,
but are less harmful to healthy tissue. Larval therapy involves
the use of sterile maggots, which secrete enzymes to ­liquefy
necrotic tissue, but have no negative effect on granulation
tissue. Similarly, enzymatic debridement involves the appli­
cation of an enzyme to the wound surface. The enzyme
works to denature the protein in the necrotic tissue on the
wound bed. In the past, papain urea products were frequently
used as debriding agents without the U.S. Food and Drug
Administration (FDA) approval. This is no longer available
as the FDA banned the manufacturing of and distribution of
unapproved topical papain products in late 2008 and early
2009, respectively. As none of the papain products had FDA
approval, there are currently none on the market.71 The only
enzymatic agent that is available is Santyl (Healthpoint, Fort
Worth, TX), which is a collagenase, and thus breaks down
unwanted collagen in the wound. The final form of debride­
ment is autolysis, which is the most selective, but also the
slowest. Autolysis, or autolytic debridement, uses moisture-
retentive dressings to provide an environment that allows the
body's natural enzymes to debride necrotic tissue. It is the
simplest form of debridement to perform, but requires care­
ful monitoring for infection, primarily because of the slow
nature of this method. These debridement strategies should
not necessarily be thought of as independent of each other.
For example, sharp debridement is often done in conjunction
with enzymatic or autolytic debridement. All of the forms of
debridement serve to reduce the risk of infection by remov­
ing the energy source for the bacteria. There also are inter­
ventions that specifically target the bacteria, rather than the
necrotic tissue.
Over the last decade or so, the number of dressings that
have been developed to reduce bacteria in the wound has
increased dramatically. These include a variety of dressings
that contain silver, methylene blue, gentian violet, polyhexa­
methylene biguanide, iodine, or honey. These dressings have
been shown to be superior to non–antimicrobial dressings in
the reduction of bacteria, but there is insufficient evidence
FIGURE 18-11  Pulsatile lavage with suction.
TABLE 18-3  Pulsatile Lavage with Suction
Recommendations for Infection
Pressure
12 to 15 psi
Suction
60 to 100 mm Hg
Amount of irrigant
Dependent upon wound size
Frequency
At least daily if possible
Location
Private treatment room with closed door
Data from Albaugh K, Loehne H. Wound bed preparation/
debridement. In McCulloch JM, Kloth LC (eds), Wound Healing:
Evidence-Based Management, 4th ed. Philadelphia: Davis, 2010.
pp. 155-179; and Bukowski EL, Nolan TP. Hydrotherapy: the use of
water as a therapeutic agent. In Michlovitz SL, Bellew JW, Nolan TP
(eds), Modalities for Therapeutic Intervention, 5th ed. Philadelphia:
Davis, 2011. pp. 109-134.

484
Section III  Prostheses in Rehabilitation
to state one antimicrobial dressing is superior to another in
terms of promoting wound healing.72,73 These dressings are
available in so many varieties ranging in absorptive capacity,
adhesive versus nonadhesive, amorphous versus sheet form,
and the like, that there is likely a good option for nearly any
wound type. What is most important to remember is that
none of these dressings should be used as a replacement for
systemic antibiotics.
It is common to use topical antimicrobial dressings along
with systemic medications, especially in the case of arterial
insufficiency. For example a patient with a diabetic foot ulcer
may have an infected toe, with poor vascularity. In this case,
the amount of the systemic antibiotic getting to the infected
area may be limited and could benefit from a topical agent
to reduce the degree of surface bacteria. There are several
problems with the continued use of antimicrobial dressings,
namely cost and the concern over developing resistance.
Because they are impregnated with antimicrobial agents,
these dressings are more expensive than a comparable non–
antimicrobial dressing and are not intended to be used for
the duration of wound healing. Likewise, there is some con­
cern in the wound care community that overuse of silver
dressings may lead to the development of resistant strains of
bacteria, similar to what happened with the widespread use
of antibiotics.
In addition to antimicrobial dressings, and the interven­
tions already discussed, two therapeutic modalities that have
strong evidence supporting their use in the management
of infections are electrical stimulation and ultraviolet light.
Electrical stimulation is likely to be found in most physical
therapy clinics because of its use in strengthening and pain
reduction. The most common waveforms for electrical stimu­
lation in wound healing are high-voltage pulsed current and
low-intensity direct current (or microcurrent). Both of these
currents are monophasic, meaning current will only flow in
one direction. As a result of this, charged particles will be
drawn toward the oppositely charged electrode, and repelled
from the like-charge electrode, just as a positive pole and neg­
ative pole on a magnet will stick together and two positives
will push each other apart. This concept is known as galva­
notaxis, and is the basis for the use of electrical stimulation
in tissue healing. When the goal is to treat an infection, the
negative pole (cathode) should be used at the wound site, and
the positive pole (anode) can be placed approximately 15 to
30 cm away. By applying cathodal stimulation to the wound,
activated neutrophils are recruited which can attack the bac­
teria that is present.74 The treatment electrode may be placed
on the immediate periwound skin, or directly in the wound.
If stimulation is applied directly to the wound, the wound
must be filled with hydrogel or saline-moistened gauze.
Treatment is usually continued until signs of infection are no
longer present, or until progress halts, at which time polarity
is reversed to jump start healing (Table 18-4).
Ultraviolet C (UVC) light is another effective modal­
ity for the treatment of infection, although it may not be
­readily available in many offices. The carcinogenic effects of
ultraviolet A and B lights are well known, but do not seem
to be a problem with UVC because the light is absorbed
by the epidermis, and those cells that may have been dam­
aged are constantly sloughing off.75 Complete eradication
of bacteria has been demonstrated with UVC in  vitro as
well as in vivo in animals.76,77 In humans, UVC is very effec­
tive for the treatment of colonized wounds; however, if the
wound is grossly infected, or is too deep for proper applica­
tion of the light, outcomes are not as impressive,78 although
positive outcomes have been demonstrated in small case
series.79 If any form of ultraviolet light is to be used, care
must be taken to prevent injury to the patient and clinician
by wearing protective eyewear, and covering the area sur­
rounding the treatment area with towels, or a thick layer
of petroleum jelly to prevent penetration of the ultraviolet
light (Table 18-5).
Providing an Optimal Wound-Healing Environment
As mentioned previously, it is somewhat of an artificial delin­
eation to break wound healing down into different steps
because there is so much overlap. Early in the wound-healing
process the primary goal may be removal of nonviable tissue,
as mentioned in the previous section, but selective debride­
ment would be of no use if concurrent steps were not taken
to optimize the wound-healing environment. Once bacteria
in the wound are controlled and an adequate arterial ­supply
is assured, the focus of therapy can shift to moist wound
­healing. Moist wound healing includes the use of dressings,
and in some cases, compression therapy to create a wound bed
that is neither too wet (macerated) or too dry ­(desiccated) to
TABLE 18-4  Electrical Stimulation Treatment
Recommendations for Infection
Waveform
LIDC or HVPC
Polarity
Negative
Duration
60 minutes
Frequency
Daily
Intensity
100 to 800 μA (LIDC) or 75 to 150 V (HVPC)
HVPC, high-voltage pulsed current; LIDC, low-intensity direct
current.
Data from Kloth LC, Zhao M. Endogenous and exogenous electrical
fields for wound healing. In McCulloch JM, Kloth LC (eds), Wound
Healing: Evidence-Based Management, 4th ed. Philadelphia: Davis,
2010. pp. 450-513.
TABLE 18-5  Ultraviolet C Treatment Recommendations
for Infection
Wavelength
UVC (200 to 290 nm)
Time
180 seconds
Distance from wound
1 inch
Frequency
Bacteria reduced in as little as one treatment
Data from Thai TP, Houghton PE, Keast DH. Ultraviolet light
C in the treatment of chronic wounds with MRSA: a case study.
Ostomy Wound Manage. 2002;48(11):52-60; and Kloth LC. Physical
modalities in wound management: UVC, therapeutic heating, and
electrical stimulation. Ostomy Wound Manage. 1995;41(5):18-27.

Chapter 18  Wound Care for Vulnerable Feet
485
be suitable to wound healing. An analogy to a beach is com­
monly used to help explain this concept, in which the optimal
wound environment is the wet sand, and suboptimal environ­
ments are underwater or on dry land.
To create a moist wound bed, the clinician must have
a good understanding of the wound etiology, and a famil­
iarity with the available wound care dressings. Certain
wounds, such as those associated with infection, venous
insufficiency, and lymphedema, tend to drain heavily and
require ­absorbent dressings, whereas wounds without an
adequate blood supply tend to be dry and often require the
addition of moisture. With the appropriate use of cleans­
ing agents, protection of the periwound skin, and selec­
tion of suitable dressings, wound healing can be positively
influenced. Educating a patient about appropriate cleansing
agents is particularly important if a patient will be cleans­
ing the wound at home. The patient should be educated not
to scrub the wound and to avoid the use of harsh chemi­
cals such as bleach, iodine, hydrogen peroxide, alcohol, or
surgical scrub brushes for daily cleansing, unless specifically
prescribed for the management of a heavily colonized
wound. Although some of these chemicals can be extremely
effective at controlling bacteria, they are all cytotoxic and
can impede wound healing. The general rule of thumb “if
you wouldn't put it in your eye, don't put it on your wound”
works well. For healthy granulating wounds, normal saline or
sterile water are effective for mild cleansing and the removal
of small particles of adhered dressing that may be present.
Some wounds have bacteria that are adhered to the surface
forming a matrix known as a biofilm. In these cases, a non­
cytotoxic wound surfactant is a better option.
Once the wound is clean, consideration can shift to the
periwound area. This skin is vulnerable to injury from adhe­
sive dressings or excess wound drainage, but damage can be
limited or prevented with the use of a skin protectant. There
are literally hundreds of dressings on the market, making it
impractical, if not impossible, to keep up with all of them.
By having a general understanding of each class of dressings,
the clinician should be able to choose a dressing that is not
only safe, but effective in the management of the wound at
hand. Table 18-6 outlines the characteristics of some of the
most commonly used classifications of dressings.
No single dressing is intended to treat a wound through all
phases of wound healing. Nor is each patient with the same
diagnosis going to respond the same. It is important to reassess
the characteristics of the wound at each patient visit to ensure
that the dressing being used remains the best option. Factors
such as ease of use, whether or not the patient can change
the dressing independently, how often it will need changing,
the degree of discomfort associated with dressing changes,
and cost need to be considered. For example, a hydrocolloid
is easy to apply, but would not be cost-effective for a wound
that needs to be changed twice per day, and a transparent film
may be inexpensive and easy to use but inappropriate for an
individual with poor periwound skin integrity.
Acute wounds in an otherwise healthy individual may heal
without difficulty if appropriate dressings are used. In chronic
wounds, or patients with impaired wound healing poten­
tial, the use of certain modalities can be used to stimulate
wound healing. Electrical stimulation, pneumatic compression,
­negative-pressure wound therapy, ultrasound, and laser have all
been shown to be effective in the management of wounds. It is
beyond the scope of this chapter to go into an in-depth discus­
sion of each of these modalities. Table 18-7 lists the proposed
indications and contraindications for each modality; however,
the reader is referred to other resources that will provide a
more detailed analysis than space in this chapter permits.80–82
Reducing Further Trauma to the Wound
Regardless of the advanced wound care dressing used, wounds
will not heal unless the wound can be protected from further
trauma. In most cases, trauma comes in the form of weight-
bearing forces. In a bed-bound individual, dynamic air
mattresses and air-fluidized beds are used to disperse forces,
which in turn, reduce the amount of pressure at the wound
site and allow it to heal. For persons who are more active,
offloading can be even more of a challenge as there is a bal­
ance that needs to be met between maintaining function and
providing pressure relief to the wound. Take the case of an
individual with dropfoot whose ankle foot orthosis is causing
a wound on the plantar aspect of the fifth MTH. The patient
needs to continue to wear the orthosis in order to walk, but
if the patient does so, the wound will continue to deteriorate.
The challenge for the clinician is to offload the foot so that the
wound can heal as quickly as possible, enabling the patient to
return to the patient's normal activities.
Many of the advances in pressure reduction strategies
for the foot have come about because of diabetes. Between
the years 2007 and 2011 the number of Americans with
diabetes increased by more than 2 million to 25.8 million
(8.3% or one of every 12 people).1 As a result of the neuropathic
and arterial changes discussed previously, many of these indi­
viduals will develop foot ulcers that will require offloading.
Many of these wounds would respond well to several weeks of
complete bed rest as all weight-bearing forces would be elim­
inated from the bottom of the foot. This is not practical for
most patients, and even if it was a possibility, it is not without
risk, that is, blood clots, deconditioning, and pressure ulcers.
Maintaining non–weight bearing at home is also a major chal­
lenge for most patients. When a patient sustains an orthope­
dic fracture to the foot, pain serves as negative feedback and
prevents the person from weight bearing. In the presence of
neuropathy, the sensation of pain is diminished so the deter­
rent from putting the foot on the floor is absent. Although
non–weight bearing or partial weight bearing is encouraged
through the use of an assistive device, it is prudent to assume
the device will not be used all the time and to protect the foot
as if you intend weight bearing to occur.
Total Contact Casting
The “gold standard” for offloading the neuropathic foot has
traditionally been the total contact cast (TCC) (Figure 18-12).
Initially used in the management of Hansen's disease (for­
merly leprosy), the TCC was first brought to the United States

486
Section III  Prostheses in Rehabilitation
by Dr. Paul Brand.83 Using the simple equation, pressure =
force/area, it is evident that pressure can be reduced by reduc­
ing the amount of weight (force) going through the wound,
and by increasing the total area that the patient's weight is
spread over. The TCC has intimate contact with the entire
plantar aspect of the foot, with the exception of the wound
location. This serves to increase the weight-bearing surface
area and reduce the force through the wound. Additionally,
immobilization of the ankle in neutral prevents dorsiflexion
and weight transfer toward the front of the foot during the
late stance phases of gait. The TCC reduces vertical and shear
forces acting on the foot.84,85
Numerous studies report favorable results in healing dia­
betic foot ulcers with the use of the TCC.51,83,84,86–88 Particularly
interesting are the results of a prospective, randomized, con­
trolled clinical trial done by Mueller and colleagues12 that com­
pared the effectiveness of total contact casting and reduced
weight bearing with traditional treatment (debridement, daily
TABLE 18-6  Common Wound Care Dressings
Indication
Dressing Type
Contraindications
Comments
Absorption
Alginate
Excessively dry wounds
Full-thickness burns
Secondary dressing required
Hydrofiber
None
Secondary dressing required
Foam
Excessively dry wounds
Adhesive and nonadhesive varieties
Absorptive capacity varies between
brands
Active bleeding
Alginate
Excessively dry wounds
Full-thickness burns
Secondary dressing required
Silver nitrate
Skin hypersensitivity
Effective on hypergranulation
Add moisture
Hydrogels
Moderate to heavy exudate
Gel or sheet forms
Maintain moisture
Hydrocolloids
Local or systemic infection
Caution with fragile periwound skin
May increase wound odor at dressing
removal
Transparent films
Cavity wounds
Tracts, tunnels, undermining
Infection
Excessive exudates
May decrease need for unnecessary
dressing changes because wound
can be visualized
Fragile skin
Silicone
None
Reduces scarring
May be used to prevent an absorbent
secondary dressing from adhering
Antimicrobial
Silver
Avoid use with enzymatic debriders
Most dressing classifications have a
silver version
Honey
None
Requires secondary dressing
Polyhexamethylene
biguanide
Avoid gauze-based dressing over
exposed nerves, vessels, and tendons
Important to keep gauze moist to
avoid adhering to wound bed
Methylene blue/gentian
violet
Full-thickness burns
Requires premoistening with sterile
water or saline
Requires secondary dressing
Cadexomer iodine
Iodine sensitivity
Hashimoto thyroiditis
Nontoxic nodular goiter
Graves disease
Pregnant or lactating women
Sheet and gel forms available
Requires secondary dressing
Debridement










Hydrocolloid
Local or systemic infection
Caution with fragile periwound skin
May increase wound odor at dressing
removal
Transparent film
Cavity wounds
Tracts, tunnels, undermining
Infection
Excessive exudates
No absorptive capacity
Collagenase
Hypersensitivity to collagenase
Do not use with silvers
Requires daily application
Requires secondary dressing
Gauze


Directly on healthy granulation tissue
Exposed nerves, vessels, tendons

Wet-to-dry dressing is not
recommended; if used, it should be
restricted to necrotic wounds
Effective as a secondary dressing

Chapter 18  Wound Care for Vulnerable Feet
487
dressing changes, the use of accommodative footwear, and
instruction to avoid weight bearing through the use of assis­
tive devices). Of 21 ulcers in the TCC group, 19 healed, com­
pared to six of 19 in the traditional treatment group. Ulcers
treated by total contact casting healed in 42 ± 29 days, whereas
the traditionally treated ulcers healed in 65 ± 29 days. Five of
19 patients in the traditional treatment group required hospi­
talization for infection, versus no one in the TCC group.
One study showed that although some removable cast
walkers were as effective as TCCs in relieving pressure from
ulcer sites,89 the TCC still healed a higher number of foot
ulcers in a shorter time period.88 The traditional TCC was
made of plaster material, which required the patient to be
non–weight bearing for at least 24 hours. Many clinics now do
a combination of plaster and fiberglass or all fiberglass casts
to allow patients to return to weight bearing more quickly.
The initial TCC also had contact with the entire foot, includ­
ing the wound. Since that time, a modified approach in which
the wound site is isolated has been shown to reduce pressure
significantly more than the true “total contact” method.90
Although it has demonstrated superiority in offloading,
the TCC is not appropriate for all cases. It should not be used
in cases of excessive drainage, vascular insufficiency, infec­
tion, fluctuating edema, and for wounds that are deeper than
they are wide. Because the condition of the foot cannot be
monitored while it is enclosed in a cast, the patient must be
able to recognize the warning signs indicating the need to
have the cast changed. These signs include excessive ­swelling
of the leg that causes the cast to become too tight, loosening of
the cast that allows the foot and leg to move within the cast, a
sudden increase in body temperature or of blood glucose level
that might indicate infection, staining and drainage through
TABLE 18-7  Indications and Contraindications/Precautions for Modalities Associated with Tissue Healing
Modality
Indications Related to Tissue Healing
Contraindications/Precautions
Electrical stimulation80,134
Stimulates blood flow
Promotes epithelialization
Stimulates angiogenesis
Stimulates collagen synthesis
Impedes bacterial growth
Malignancy in the wound area
Osteomyelitis
In proximity to demand-type pacemakers
or defibrillators
Pregnancy
Active hemorrhage
Carotid bodies
Eyes and gonads
Intermittent pneumatic
compression135
Venous insufficiency
Arterial insufficiency* (short duration,
high-pressure pumps)
Prevention of DVT
Lymphedema (requires specialized pump)
Arterial compromise (ABI < 0.8)
Acute infection
DVT
Uncompensated congestive heart failure
Negative-pressure wound
therapy136–138
Pressure ulcers
Traumatic wounds
Diabetic ulcers
Flaps/grafts
Abdominal wounds
Dehisced wounds
Fasciotomy
Arterial and venous ulcers
Exposed vital organs
Untreated osteomyelitis or sepsis in the wound
Necrotic tissue with eschar
Inadequately debrided wounds
Untreated coagulopathy or anticoagulant
medications
Malignancy in the wound
Unexplored fistulas
Active bleeding
Exposed blood vessels
Ultrasound81
Accelerate inflammatory phase
Stimulate capillary and blood vessel
formation
Cancer
Pregnancy or over reproductive tissue
Circulatory impairment
Epiphyseal plates in children
Implants
Infection
Exposed neural tissue
Laser139


Fibroplasia
Collagen synthesis
Improves immune response
Cancer
Over the eyes
Pregnancy
Over the thyroid gland
ABI, ankle-brachial index; DVT, deep vein thrombosis.
*Kavros SJ, Delis KT, Turner NS, et al. Improving limb salvage in critical ischemia with intermittent pneumatic compression: a controlled study
with 18-month follow-up. J Vasc Surg. 2008;47(3):543-549.

488
Section III  Prostheses in Rehabilitation
the cast, excessive odor from the cast, new complaints of pain,
and damage to the cast.
Posterior Walking Splints
An alternative to the TCC is the posterior walking splint
(Figure  18-13). Fabrication of a walking splint is much like
that of the TCC; however, with the anterior portion removed,
the splint requires more reinforcement posteriorly. Elastic
bandages are used to secure it to the foot and leg. The splint
still allows for total contact with the plantar aspect of the foot
and ankle immobilization. There are several advantages of the
splint over the cast. The most obvious advantage is that it can
be removed to cleanse the leg, inspect the skin, and change
dressings. It is also a good alternative in most cases in which
the cast is contraindicated. Another advantage is that it may
reduce the cost to heal the wound since it does not need to be
refabricated at each visit. Conversely, the splint is not without
its disadvantages. It requires the same amount of skill and typi­
cally slightly more time to fabricate than the cast, and can be
just as cumbersome. The most important clinical disadvantage
is the fact that it can be removed, so there is no guarantee that
the wound is being protected at all times, as it is in the cast.
Removable Cast Walkers
Despite being the “gold standard” for offloading the neuro­
pathic foot, the TCC is not widely used because of concerns
over iatrogenic complications as well as a lack of experience
among clinicians. In its place, removable cast walkers have
become the most widely used method to offload the foot.
The removable cast walker is an orthotic device with double
uprights fixed at a 90-degree angle to a rocker-soled walking
platform (Figure 18-14). As with the TCC and walking splint,
the fixed position of the ankle prevents propulsion at the fore­
foot, where the greatest pressures tend to occur. Removable
cast walkers are available from various manufacturers.
Because they are not custom made for each patient, care must
be taken when fitting the device to ensure that it accommo­
dates the contours of the patient's foot and ankle, particularly
in the area of the uprights. A custom-molded insert can be
added to most manufactured walkers. One variation of the
removable cast walker, the DH Pressure Relief Walker (Ossur
North America, Aliso Viejo, CA), has a removable, multiden­
sity padded insole made up of individual plugs. This insole
can be modified by removing plugs to create a relief area for
the ulcer site. Studies show this walker to be more effective in
reducing plantar pressures than other offloading devices.89,91
Instant Total Contact Cast
A major advantage of the TCC over the removable walker is
the forced compliance because of the inability of the patient
to remove the cast. Because the cast cannot be removed, it
is assured that the wound is being offloaded 24 hours per
day. Several studies show the removable cast walkers to be
comparable to the TCC for pressure reduction.91–93 However,
other investigators report faster healing times with the
TCC as opposed to removable cast walkers.88,94 Under the
FIGURE 18-13  Posterior walking splint held in place by an elastic
bandage.
FIGURE 18-12  Total contact cast.

Chapter 18  Wound Care for Vulnerable Feet
489
assumption that the seemingly conflicting data was a func­
tion of the cam walker being removed, researchers designed
studies that compared TCCs and removable cast walkers to
cast walkers that were made irremovable by wrapping them
with a layer of fiberglass (Figure 18-15). These irremovable
cast walkers were named instant total contact casts (iTCCs).
Results of one study found the iTCC to be equivalent to the
TCC in the proportion of wounds that healed in 12 weeks,95
whereas the second study found healing rates with the
iTCC to be comparable to healing rates of the conventional
TCC in previous studies and superior to the removable cast
walker.96 Based on the available evidence, the iTCC seems
like a viable option for a neuropathic wound, especially for
the clinician that has not been trained in the application of,
or does not have the time to apply, a TCC.
Wound-Healing Shoes
The cast, splint, and cam walker should all be considered as
therapies of choice to offload neuropathic ulcerations. It is
tempting to use less-restrictive devices because the devices
that cover the leg seem like such an inconvenience to the
patient. For most patients, putting them in devices that will
be less than optimally effective is doing them a disservice. In
some cases where a cast is contraindicated or the leg will not fit
in a cam walker, devices that only go as high as the ankle may
be useful. One of these devices is the wedge shoe, which has
an elevated toe portion in relation to the heel so as to offload
the forefoot (Figure 18-16). The wedge shoe causes the body
weight to shift back toward the heel, decreasing forces at the
forefoot, albeit not to the same extent as the devices that trans­
fer weight up the leg.89 For pressure to be reduced, the area to
be offloaded must be distal to the fulcrum of the shoe. To max­
imize pressure reduction, patients should be instructed to take
short steps with the contralateral leg. This assures that they do
not propel over the wedge causing contact between the distal
end of the shoe and the ground. In clinical ­experience, this
is often difficult for patients to do, and the telltale “clicking”
of a patient in a wedge shoe can ­usually be heard as soon as
FIGURE  18-14  DH Pressure Relief Walker (shown with pegs
removed) (Courtesy of Ossur North America, Aliso Viejo, CA).
FIGURE  18-15  Instant total contact cast fabricated by applying
fiberglass to a removable walker.
FIGURE  18-16  OrthoWedge shoe (Courtesy of Darco Inter­
national, Huntington, WV).

490
Section III  Prostheses in Rehabilitation
the patient walks into the clinic. When a patient takes a large
enough step to allow the front of the shoe to hit the ground,
pressure at the forefoot is increased, but may still be less than
if the patient was ambulating in a regular shoe because of the
rigidity of the wedge shoe's sole. This rigidity serves to reduce
the transfer of weight toward the forefoot that typically hap­
pens in terminal stance, but it does not isolate the at risk area
in relation to the rest of the forefoot. The addition of a custom
molded insert with a relief area has been shown to be effective
at addressing this problem.97
The issue of compliance with the wedge shoe, and all shoe
offloading devices, remains a question. On one side, it could
be argued that wedge shoes are less cumbersome, so are more
likely to be worn; and on the other side that they are easier to
remove, making it more likely that the foot will be left unpro­
tected. Another issue is that wedge shoes are difficult for
patients with limited dorsiflexion, and could actually increase
forefoot pressure if a patient has a limited range of motion.
Walking in a wedge shoe feels very unnatural because of
the functional leg-length discrepancy created. This can be
­difficult to manage for patients with balance issues, and can
also lead to back discomfort. Finally, one last drawback to
the wedge shoe is that it cannot be used to offload bilaterally
because it shifts the patient's weight too far posteriorly.
An alternative shoe-type device to the wedge shoe is a shoe
with modifiable insoles. An example of this device, the DH shoe
by Royce Medical Co. (Ossur North America, Aliso Vejo, CA),
has an insole with pegs that can quickly be removed to relieve
pressure to the at-risk area (Figure 18-17). Advantages of this
shoe type versus the wedge shoe include the ability to offload
any part of the foot, not just the forefoot, a flat sole that is
safer for those with balance issues, and the ability to offload
bilateral feet simultaneously. A disadvantage to this type of
shoe is that the flexible sole allows for a toe break during the
gait cycle, which allows weight to transfer anteriorly.
Other Pressure-Relieving Options
There are several temporary offloading options that
can be applied directly to the foot in cases in which the
above options either are unavailable or undesirable. The
first option is adhesive felted foam (Figure  18-18).98,99
A ­custom-fit piece of 1⁄4-inch felt-backed foam is adhered
to the plantar surface of the foot. A U-shaped aperture is
cut in the foam to reduce pressure around the ulcer. The
margins of the aperture are positioned close to but not
overlapping the wound edge, extending distally beyond
the wound. The entire plantar surface of the foot must be
examined to identify all vulnerable spots that need accom­
modation before the pad is applied. For forefoot ulcers,
the pad extends proximally along the midfoot to increase
the weight carriage in this area. All edges of the foam pad
should be beveled to minimize chances of skin breakdown
from edge pressure. When a bony deformity is particu­
larly prominent, an additional layer of foam can be used
to relieve pressure adequately from the ulcer site. A thin
dressing is placed flatly over the ulcer. A healing sandal is
used for ambulation. If the area is preulcerative or postul­
cerative, an extra-depth shoe can be worn. The felted foam
should be thought of as temporary because the pressure
relief provided by the foam pad decreases significantly by
the fourth day.100 Consequently, changing the pad every 3
or 4 days might be beneficial.
Felted foam is generally well accepted by the patient.
Because this method allows for easier mobility than a TCC
or walking splint, patients tend to walk more. This may
not be desirable considering the possible effect of cumula­
tive pressure. Despite walking more, patients using felted
foam as an offloading method seem to respond well to the
therapy as measured by the percentage of wounds that heal
and the amount of time they take to heal.99–103 The major
benefit of the felted foam appears to constant wear time,
FIGURE 18-18  Felted foam pressure relief. Edges of the foam have
been beveled.
FIGURE  18-17  DH Wound Healing shoe, with pegs removed
(Courtesy of Ossur North America, Aliso Viejo, CA).