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

542
Section III  Prostheses in Rehabilitation
so that shear forces on soft tissue will be minimal when the
prosthesis is donned and used.
Assessing Integumentary Integrity and Wound Healing
Assessment of skin condition and the vascular, sensory, and
motor status of both of the patient's limbs is imperative.
During assessment there is an opportunity to introduce the
individual with new amputation and family to strategies that
are likely to be used for compression/edema control after sur­
gery. Instructing the individual and family about proper posi­
tioning of the residual limb is also important, as well as the
need to maintain knee extension and neutral hip alignment to
minimize soft tissue tightness and joint contracture.
In most settings, the surgeon who performed the ampu­
tation assesses the condition of the surgical site at the initial
dressing change. This can occur as early as the first post­
operative day, when soft dressings and elastic wraps have
been used, or on the third postoperative day, if the residual
limb has been casted in a rigid dressing.71 After this initial
appraisal the status of the surgical wound is assessed by the
nurse or physician at each dressing change. In some settings,
the physical therapist is charged to inspect the residual limb
to monitor the stage of healing of the incision and the limb's
shape, length, sensory integrity, and volume; the therapist
works closely with the surgeon in postoperative wound man­
agement and timing of prosthetic replacement.
With each dressing change, the wound is carefully exam­
ined and the quantity and quality of drainage from the wound
are documented. Initially, drainage will be sanguinous (pri­
marily bloody); typically, as the surgical wound begins to heal
over the next few days, drainage transitions to serosanguine­
ous, and eventually to serous exudate. Much of this early drain­
age is absorbed by the wound dressing. Significant amounts of
bright red arterial blood (hemorrhage) or darker venous blood
(draining hematoma) should be reported to the surgeon for
further assessment. Although pre-, peri-, and postoperative
antibiotic administration is becoming the standard of care,72,73
the incidence of postoperative infection involving the incision
following amputation is relatively high: as many as one in four
patients will develop infected wounds.74 Increasing amounts of
drainage, as well as thickening, discolored exudate, may signal
infection of the wound; this must be immediately reported to
the physician, especially if it occurs in persons who are immu­
nocompromised or whose limbs may have been environ­
mentally contaminated during traumatic injury.74 Infection
can significantly delay healing, increase length of acute care
stay, require revision of the surgical construct or reamputation
to a more proximal level, increase risk of deconditioning
and ­contracture development associated with bed rest, and
­compromise ­rehabilitation outcomes.75,76
MJL
TT
FH
FIGURE 20-4  Limb volume and shape of a transtibial residual limb
is assessed by taking successive circumferential measures (dotted
lines) from a bony landmark such as the medial joint line (MJL) to
the suture line. FH, Fibular head; TT, tibial tubercle.
TABLE 20-2  Residual Limb Lengths and Associated Prosthetic Consequences
Segment
Level
Preserved
Inches
Centimeters
Functional Outcome
Adult tibia65
Intact
100%
14.5 ± 1.2
36.9 ± 3.0
Effective walking ability
Transtibial
residual
limb66,67
Short
<35%
<5 especially
if <3
<12.7 especially
if <7.6
Insufficient knee extension strength and power for
prosthetic control; intolerance of weight-bearing
pressures applied to skin and soft tissue by a
prosthetic socket
Standard
35% to 50%
5 to 7
12.7 to 17.8
Effective prosthetic control for safe and energy
efficient gait; relatively comfortable prosthetic fit66,67
Long
>50%
>7
>18
Distal anterior discomfort and skin irritation in
sitting and during swing limb advancement related
to high socket pressure at limb-socket interface.66,67
Adult femur65
Intact
100 %
17.1 ± 1.1
43.5 ± 2.865
Effective walking ability
Transfemoral
residual
limb66,67
Short
<35%
<5
<15.2
Insufficient hip extension and abduction strength and
power for stance control when using prosthesis
Standard
35% to 50 %
5 to 8.5
15.2 to 21.8
Effective prosthetic control for safe and energy
efficient gait; relatively comfortable prosthetic fit
Long
>50%
>8.5
>21.8
Long lever arm enhances prosthetic control in
stance; but may limit choice of prosthetic knee
units (if residual limb length and knee unit length
exceeds femur length of intact limb)

Chapter 20  Postoperative and Preprosthetic Care
543
In the first several postoperative days, signs of inflamma­
tion (erythema, edema and elevated tissue temperature sur­
rounding the incision) are likely present along the incision
line secondary to tissue trauma sustained during surgery.77
The edges of the wound should be closely approximated for
effective primary healing; any areas of wound separation
(dehiscence), scab or eschar formation, ecchymosis, or other
signs of tissue fragility or decreased viability must be care­
fully documented and monitored. Clinicians watch for signs
of epithelial resurfacing across the incision, as well as devel­
opment of a healing ridge along the incision, signal of colla­
gen deposition signals progression into the proliferative stage
of wound healing.77 Prolonged edema delays wound heal­
ing because the associated pressure compromises angiogen­
esis; which, in turn, increases risk of wound ischemia, tissue
necrosis, infection, and need for revision to a higher level.78
Risk of residual limb osteomyelitis should be suspected when
delayed healing and residual limb pain persist in the weeks
and months following amputation.79 Persons with recent or
current history of smoking are more likely to experience sig­
nificantly delayed healing following amputation.80
Many persons with traumatic or other nondysvascular
amputation have achieved sufficient healing and limb volume
control within 2 weeks to use a prefabricated adjustable pros­
thesis or to be casted for their initial (preparatory, training)
prosthesis (Figure  20-5).81 Those with amputation second­
ary to vascular disease often require 4 to 8 weeks or more to
achieve adequate healing and limb shaping to allow for pros­
thetic casting; this is greatly influenced by the strategy used
to manage edema in the immediate postoperative period.82
The surgeon may begin to remove sutures or staples from
the incision as early as 10 to 14 days after surgery. Initially,
every other or every third suture/staple can be left in place to
guard against wound dehiscence; remaining sutures or sta­
ples are removed over successive days. The surgical wound is
often reinforced with Steri-Strips when sutures or staples are
removed to protect the incision from shearing forces during
preprosthetic activity and early prosthetic training. The Steri-
Strips can remain on the limb for 2 or more additional weeks
after the sutures/staples have been removed. Gait training
with a prosthesis can cautiously begin, with the approval of
the surgeon, when clear evidence of primary healing is found,
even if several sutures have been left in place to protect an
area along the incision line that has been slow in closing.
Delayed healing of the surgical wound may postpone
prosthetic use. Older persons with diabetes and vascular
insufficiency, as well as those who smoke, are particularly at
risk for delayed healing.80 The healing process can also be
delayed as a consequence of infection, immunosuppression,
or traumatic damage sustained during activity or in a fall in
the days or weeks after surgery.83 Nutritional status is another
important determinant of wound healing in the early post­
operative and preprosthetic period; individuals with com­
promised nutritional status are more likely to experience
delayed wound healing and are at greater risk of postopera­
tive infection, as well as cardiopulmonary and septic compli­
cations.84 When transcutaneous oxygen and carbon dioxide
are carefully monitored, persons with small nonhealing inci­
sional wounds (1 cm × 1 cm) can safely use a pneumatic pros­
thesis to preserve/improve mobility and endurance before
being fit with a prosthesis.80
Assessing Circulation
Because so many amputations are associated with the dyad
of vascular insufficiency and polyneuropathy, it is particu­
larly important to examine and monitor vascular status and
skin integrity of the remaining (intact) limb, as well as of
the residual limb. One criterion for determining the level of
amputation is the likelihood of healing of the surgical con­
struct.7 Surgeons caring for persons with dysvascular limbs
typically determine the status of peripheral circulation using
both noninvasive and invasive tests before amputation; how­
ever, delayed healing or failure of the suture line to close
sometimes occurs even with careful preoperative evaluation.
In the days and weeks after amputation surgery, members of
the team watch for signs of vascular compromise that might
threaten adequate closure of the surgical wound.
The remaining limb becomes much more vulnerable to skin
and soft-tissue damage because of increased biomechanical
FIGURE 20-5  A well-healed, transtibial residual limb with equal
anterior posterior flaps 14 days after amputation. The edges of
the wound are approximate, and although several small scabs
have formed between sutures, primary healing is well established.
Strategies for control of edema and initial limb shaping have been
successful as well; this residual limb could be described as cylindri­
cal, with little redundant tissue present.

544
Section III  Prostheses in Rehabilitation
stress associated with single limb mobility following amputa­
tion surgery.85,86 Noninvasive strategies to assess the adequacy
of blood flow (described in detail in Chapter 18) include skin
temperature and turgor, skin color at rest and after position
change, palpation or auscultation of pedal and popliteal pulses,
segmental blood pressures, and calculation of an ankle-brachial
index. A thorough baseline assessment enables the team to
identify and respond to any circulatory problems that might
develop as rehabilitation continues.
Assessing Range of Motion and Muscle Length
Having near-normal range of motion (ROM) in the remain­
ing joints of the residual limb is essential for effective pros­
thetic use.87 Persons with recent amputation are much at risk
for developing soft tissue contracture at the joint proximal
to amputation during the preprosthetic period. The risk
of hip and knee flexion contracture formation is associ­
ated with spending long periods of time sitting in a wheel­
chair or resting in bed, before and after amputation surgery.
Other factors that contribute to the risk of flexion contrac­
ture formation include the protective flexion withdrawal
pattern associated with lower extremity pain, muscle imbal­
ances that result from loss of distal attachments, and the loss
of tonic sensory input generated by weight bearing on the
sole of the foot.88,89 Because limitation in the lower extrem­
ity ROM can have a significant impact on the quality and
energy efficiency of prosthetic gait, it is essential to assess
and monitor ROM.68 Equally important is implement­
ing strategies to prevent or minimize contracture develop­
ment as early in the postoperative, preprosthetic period as
possible.68,82
For persons with transtibial amputation, definitive mea­
surement of hip ROM is possible with standard goniometric
techniques. With the loss of the malleolus as a distal refer­
ence point, accurate measurement of knee extension ROM
can be challenging, especially when there is a short residual
limb (Figure 20-6). Familiarity with the normal anatomy of
the tibia improves the therapist's positioning of the mobile
arm of the goniometer and the accuracy of measurement. For
individuals with transtibial and transfemoral amputation,
the Thomas test may be an effective tool for determining
the severity of hip flexion contracture (Figure 20-7). Full hip
extension is critical for prosthetic knee stability when walk­
ing with a transfemoral prosthesis.87 The accuracy of standard
goniometric measurement of hip adduction and abduction
decreases as residual limb length decreases. There is no effec­
tive way to assess rotation of the transfemoral residual limb.
Hip flexor tightness is likely to result in increased lumbar
lordosis when standing and walking with a prosthesis later
in the rehabilitation process. Attempts to achieve an upright
posture over the prosthesis in the presence of hip flexion
­contracture can lead, over time, to excessive mobility of the
lumbosacral spine and the development of low back pain
when walking with a prosthesis.90 Individuals with bilateral
transtibial amputation, as well as those who wear a transfem­
oral prosthesis, are much at risk for this problem: Secondary
spinal dysfunction and low back pain can be more disabling
than the original amputation.90,91 Attention to the importance
of achieving near-normal joint ROM and soft tissue excur­
sion early in the preprosthetic period has a powerful impact
on effective prosthetic use over the long run.
When sitting or lying in bed, the natural tendency is for
the lower limb to roll outward into a slightly flexed, abducted,
and externally rotated position. Excursion of the hip is
important to assess; tightness of external rotators may be
masked by apparent tightness of hip flexors or abductors. The
functional length of two-joint muscles is also important to
consider. Adequate hamstring length is essential if the per­
son with recent transtibial amputation is to maintain a fully
extended knee when seated. If the knee is held in extension
by a rigid dressing or thermoplastic splint, hamstring tight­
ness will pull the pelvis into a marked posterior tilt. Instead
of sitting squarely on the ischial tuberosities, the person with
hamstring tightness sits in a kyphotic position with weight
shifted onto the sacrum. This compromised postural align­
ment increases the risk of spinal dysfunction and of skin irri­
tation and decubitus ulcer formation. Tightness in the rectus
femoris, sartorius, and tensor fascia latae can interfere with
advanced mobility skills such as the ability to kneel while
transferring to and from the floor.
FIGURE  20-6  Measurement of knee extension for persons with
transtibial amputation requires an understanding of the normal
anatomy of the tibia to compensate for loss of the distal malleolus as
a point of reference for the mobile arm of the goniometer.
FIGURE 20-7  The Thomas test can be used to assess the tightness
or contracture of hip flexors for patients with transtibial and trans­
femoral residual limbs. The patient is positioned in supine with both
limbs flexed toward the chest and the pelvis in slight posterior tilt.
While the opposite limb is supported in place, the residual limb is
gently lowered toward the support surface. Tightness or contracture
of hip flexors causes the pelvis to move into an anterior tilt before the
limb is fully lowered.

Chapter 20  Postoperative and Preprosthetic Care
545
Assessing Joint Integrity and Mobility
For individuals with transtibial residual limbs, the align­
ment and ligamentous integrity of the knee will be an impor­
tant determinant of socket design, suspension strategy, and
eventually the dynamic alignment of the prosthesis. Specific
assessment of joint function of the residual limb is often
deferred to later in the preprosthetic period when there has
been primary healing of the surgical site; however, history
of previous ligament injury or tear of the meniscus and con­
current degenerative joint disease or existing bony deformity
(e.g., genu recurvatum, genu valgus, genu varum) should be
noted during initial assessment.
The special tests used to assess knee function in those
with amputation are the same as those used to assess joint
integrity in individuals with musculoskeletal dysfunction in
intact limbs. They include joint play, medial and lateral gap
tests to assess the integrity of the collateral ligaments, ante­
rior and posterior draw test to assess cruciate integrity, and
the various tests for meniscus tear.92 The techniques, however,
must be adapted to the length of the residual limb; the loss of
the foot means that the examiner's distal point of stability is
moved upward on the limb, compromising the biomechani­
cal advantage, as well as the accuracy, of the examiner. It may
be helpful to first examine the knee of the intact limb using
traditional hand placement to get a sense of the individual's
baseline, then move the distal hand upward on the intact limb
and repeat the examination using hand placement appropri­
ate for the residual limb. Comparison of distal and proximal
test results of the intact limb provides a frame of reference for
subsequently testing the knee of the residual limb.
Assessing Muscle Performance and Motor Control
Although assessment of strength and muscle function is a
key component of preprosthetic and prosthetic rehabilitation,
definitive strength assessment beyond active, nonresisted
antigravity motion at the joint just proximal to the amputa­
tion is usually postponed until there is adequate healing of
the surgical site, so as to protect the new incision from sheer
forces associated with testing. Strength of key muscle groups
at the next most proximal joints can be specifically assessed
with standard manual muscle testing or handheld dyna­
mometry techniques.93 Given time constraints during initial
assessment, the therapist may opt to use functional antigrav­
ity activities to screen for impairments of strength and power
of the remaining limb and trunk, specifically testing strength
of particular muscles if functional problems are identified.
For those with transtibial amputation, observation of active
knee flexion and extension strength is used to determine if at
least fair (a rating of 3 out of 5) full antigravity strength is pres­
ent until the physician determines sufficient wound healing has
been accomplished. For those with transfemoral amputation,
assessment of hip muscle strength beyond active antigravity fair
muscle grade must also be postponed pending incisional healing.
Once the surgeon and rehabilitation team are confident
that enough healing has occurred so that the incision can­
not be compromised by externally applied resistance, defini­
tive strength testing can be implemented at the joint proximal
to amputation. Because of the length of the residual limb, the
examiner must apply the resistive force at a more proximal
position on the extremity than is defined by the standard man­
ual muscle test technique. With an altered manual contact,
the mechanical advantage of the examiner is reduced and the
subjective sense of strength grade may be somewhat inflated.
This altered point of force application affects the validity of
test results. Many therapists attempt to maximize validity by
first testing the intact or remaining limb (assuming similarity
of strength between the patient's limbs), using standard tech­
nique to assign a muscle grade (Figure 20-8, A). The intact limb
is then retested with a more proximal hand placement, sim­
ulating the position for testing of the residual limb (Figure 20-8, B).
This grade serves as a point of reference when the residual
limb is then tested (Figure 20-8, C). For persons with transtib­
ial amputation, the functional strength of hip extensors can be
assessed with the individual lying in supine, a small bolster or
towel roll positioned under the lower thigh of the residual limb
and the intact limb held flexed against the trunk (Figure 20-9, A).
The ability to lift the pelvis (bridge) up from the supporting
surface by pushing downward into the bolster suggests func­
tional hip extensor strength. Similarly, hip abduction can be
tested in side-lying position (residual limb down) against a
bolster, asking the individual to push downward to raise the
pelvis up off of the supporting surface (Figure 20-9, B) These
positions can also be used as strengthening exercises to repeat­
edly lift body weight in concentric, holding (at the top), and
eccentric (controlled lowering) contraction.
Because a healing transtibial suture line is vulnerable to
resistive forces applied during strength testing and strength­
ening exercise, resistance to knee extension should only be
applied if and when the suture line can be observed. Resistance
must not be applied through a soft dressing or compressive gar­
ment during the first several weeks of the preprosthetic pro­
gram. Unless healing has been delayed, most surgeons ­consider
A
B
C
FIGURE 20-8  Suggested points of force application for to improve
accuracy of manual muscle test (MMT) for knee extension strength
in a transtibial residual limb. A, Standard MMT position on the
remaining limb. B, Moving the point of force application proximally
on the intact limb provides a frame of reference for subsequent test­
ing (C) of the residual limb.

546
Section III  Prostheses in Rehabilitation
­initiation of conservative resistive exercise a few days after
sutures have been removed. Surgeon preference, tissue integ­
rity, and the individual's cardiovascular condition must be
factored into strength assessment and strengthening exercise
programs.
Function is influenced not only by the maximal force that
the individual can generate (as examined in standard manual
muscle test), but it also depends on the rate and efficiency at
which the individual can generate force (power); the ability
of the individual to grade and sustain an effective contraction
during activity (endurance); and the ability to control muscle
length in concentric (shortening), isometric (holding), and
eccentric (lengthening) contractions. Observation of func­
tional activities can identify if there are impairments of these
types of muscle function. More specific testing of power can
be accomplished using an isokinetic apparatus set at vary­
ing speeds or by asking the person to move at varying speeds
against manual resistance.
Assessment of the ability to switch between types of muscle
contraction can be accomplished by providing manual resis­
tance while asking the individual to “contract,” “hold,” and
“let go slowly” for key muscle groups. An example of a key
functional activity in which this type of control is important
is the task of rising from sitting to standing and then return­
ing to a seated position. Many persons can generate adequate
force in the intact lower extremity to stand up, but have dif­
ficulty controlling their descent back to sitting—“plopping”
back into their seat. This is especially true for individuals who
have been inactive or on prolonged bed rest.94,95
If there is any indication of previous or current neuro­
muscular dysfunction, examination of tone and motor con­
trol is also important. Assessment of muscle tone includes
deep tendon reflexes (DTR), response to passive movement
of limbs and trunk (hypotonicity or hypertonicity, rigidity),
placement and drop tests, coordination and fine-motor tests
(e.g., rapid alternating movement; fine, quick tapping or
clapping), as well as observation of any abnormal synergy
pattern, tremors, or involuntary movement.96 Qualitative
assessment of the individual's ability to initiate, sustain, and
terminate movement during functional activities will help
the therapist identify issues of motor control that may need
to be addressed as part of the plan of care.
Assessing Upper Extremity Function
Because most individuals use an ambulatory aid (e.g., four-
wheeled walker, standard walker, crutches) for single limb
ambulation until they are ready for prosthetic training, it
is important to screen for deformity or other musculoskel­
etal or neuromuscular impairments involving the upper
extremity. Many of those with dysvascular- and neuro­
pathic-related lower extremity amputation have age-related
degenerative joint disease that might make use of a walker
or crutches challenging. Screening for functional strength
and muscle endurance of muscles that stabilize the shoul­
der and elbow identifies individuals who would benefit
from a progressive resistive exercise program targeting the
upper extremity to enhance their ability to transfer, as well
as ambulate.
Polyneuropathy, in a “stocking-glove” distribution, is
the most common neuromuscular impairment encoun­
tered in those with diabetes who have undergone lower
extremity amputation. Diabetic polyneuropathy affects all
extremities—not only the sensory system, but also the vol­
untary motor and autonomic systems.97,98 For this reason,
it is important to at least screen for distal upper extremity
sensory loss, weakness of intrinsic muscles of the hand, and
autonomic impairment (e.g., postural hypotension) dur­
ing the preprosthetic period. Compromised upper extrem­
ity sensation and functional strength may affect the type of
assistive device used for mobility; compression strategy for
the residual limb; and, eventually, selection of a suspension
strategy for the prosthesis.
Assessing Aerobic Capacity and Endurance
Determining baseline (resting) vital signs (e.g., pulse, blood
pressure, respiratory rate, blood oxygen levels via pulse oxim­
etry) is the first step in assessment of aerobic capacity and
endurance. Screening for orthostatic (postural) hypotension
is important for any individual who has sustained a period of
inactivity and bed rest, especially if the individual is older, is
on medications that blunt blood pressure response, or has a
history of autonomic dysfunction from peripheral or systemic
pathology.99 Change in vital signs during transfers or early
mobility training and the time to return to resting baseline
values provide information about responsiveness to exercise.
Importantly, soon after surgery, anxiety about pain or risk
A
B
FIGURE 20-9  Strategies for functional testing of hip extensor (A)
and hip abductor (B) muscle strength following transtibial ampu­
tation. A small bolster or firm towel roll is positioned at the distal
thigh, and the individual attempts to lift the pelvis from the support­
ing surface. In persons with transfemoral amputation, these posi­
tions can be used once sufficient healing of the surgical construct
has occurred. These positions can later be used, with body weight as
resistance, for concentric (lifting), isometric (holding), and eccentric
(controlled lowering) strengthening exercises.

Chapter 20  Postoperative and Preprosthetic Care
547
of injury during activities may contribute to a ­physiological
“fight-or-flight” response, influencing vital signs.100 A calm
and focused demeanor on the part of the therapist, as well as
explanation and education about what will happen and the
reason for the assessment, can help an individual with recent
amputation better manage fears and concerns.
Ratings of perceived exertion and dyspnea are use­
ful assessment strategies in the postoperative/preprosthetic
period, both to assess how the person with new amputation is
tolerating increasing activity and to help the individual target
an appropriate level of activity.101,102 Upper extremity ergome­
try, single-leg cycling tests, or combined upper and lower
limb ergometry tests have been used as indexes of aerobic
capacity for those who have recently lost a limb if definitive
testing is indicated.103–105
Given the similarities in etiology and impact of peripheral
vascular, cardiovascular, and cerebrovascular disease, many
persons with dysvascular amputation are likely to be at risk
for, or have even had, heart attack (­myocardial infarction
[MI]) or brain attack (stroke).106–108 The ­rehabilitation team
must be alert for early signs and symptoms of cardiac com­
promise as the person with new amputation begins trans­
fer and single limb mobility training. Individuals who have
had previous cardiac rehabilitation following MI, angio­
plasty, or coronary artery bypass may better understand the
importance of conditioning exercise as part of their pre­
prosthetic program. Assessment of quality of motor control
and tone is important if there is history of stroke.
Assessing Attention and Cognition
The tool most commonly used to assess cognitive status in
the acute care setting is the Mini-Mental State Examination
(MMSE)109 (Figure 20-10). Typically, scores of 24 of 30 or less
indicate some form of cognitive impairment; however, the
MMSE does not identify the etiology or type of cognitive dys­
function. In older adults, the most common form of cognitive
Patient ________________________________ Examiner ___________________________ Date __________
Score
Orientation
What is the (year) (season) (date) (day) (month)?
Where are we (state) (country) (town) (hospital) (floor)?
Registration
Name 3 objects: 1 second to say each. Then ask the patient
all 3 after you have said them. Give 1 point for each correct answer.
Then repeat them until he/she learns all 3. Count trials and record.
Trials __________
Attention and Calculation
Serial 7’s. 1 point for each correct answer. Stop after 5 answers.
Alternatively spell “world” backward.
Recall
Ask for the 3 objects repeated above. Give 1 point for each correct answer.
Language
Name a pencil and watch.
Repeat the following “No ifs, ands, or buts”
Follow a 3-stage command:
“Take a paper in your hand, fold it in half, and put it on the floor.”
Read and obey the following: CLOSE YOUR EYES
Write a sentence.
Copy the design shown.
Maximum
5
5
3
5
3
2
1
3
1
1
1
( )
( )
( )
( )
( )
( )
( )
( )
( )
( )
( )
_____
Total Score
ASSESS level of consciousness along a continuum __________________________
Alert
Coma
Drowsy
Stupor
The Mini-Mental State Exam
FIGURE  20-10  The Mini-Mental State Examination. (From Folstein MF, Folstein SE, McHugh.
“Mini-mental state.” A practical method for grading the cognitive state of patients for the clinician.
J Psychiatr Res. 1975;12(3):189-198.)

548
Section III  Prostheses in Rehabilitation
impairment is a delirium, a temporary and ­typically ­reversible
problem that is associated with physiological stressors (e.g.,
clearing from anesthesia, psychotropic effects of narcotic pain
medications, stress of hospitalization, dehydration, onset of
infection).109–111 Table 20-3 presents risk factors for, signs and
symptoms of, and measures used to screen for and quantify
severity of delirium.
Cognition and the ability to learn may also be compro­
mised by depression associated with mourning the loss of
one's limb.22,112 Perception of acute surgical pain and phantom
pain tend to increase in persons with significant depression
following amputation, as well as in those who view amputation
as a catastrophic event.113,114 Persons whose amputation was
traumatic (accident related, combat related, or work related)
often must also contend with significant anxiety, anger, or
posttraumatic stress disorder, and may require psychiatric
referral for posttraumatic stress disorder symptoms that ham­
per rehabilitation.115–117 Measures commonly used to evaluate
depression in the preprosthetic period include the Geriatric
Depression Scale,118 the Beck Depression Inventory,119 and
the Center for Epidemiological Studies Depression Scale.120
Anxiety following amputation can be assessed using the
Hospital Anxiety and Depression Scale,121,122 and the Geriatric
Anxiety Inventory.123 Scores indicating moderate to high lev­
els of delirium, depression, or anxiety should prompt referral
to mental health services for further evaluation and inter­
vention. Participation in rehabilitation often reduces levels
depression and anxiety112; it can be more informative to track
how scores change over a period of time than to interpret a
single value.
It is important to note that, for those with amputation as
a result of dysvascular problems, the underlying mechanism
for peripheral arterial disease (PAD), cardiovascular dis­
ease, and cerebral vascular disease is the same; in population
studies, persons with severe PAD tend to have more cogni­
tive impairment than those without PAD.124 There is a positive
relationship between level of cognitive resources (e.g.,
memory, executive function, problem-solving ability), the
ability to walk with a prosthesis, and postamputation adjust­
ment and quality of life.125–127 Cognitive impairment should
not preclude postoperative rehabilitation and prosthetic ­
prescription: supervised use of ambulatory assistive devices
and eventually prostheses may improve safety during self-
care and reduce overall caregiver burden.128
TABLE 20-3  Risk Factors for, Signs/Symptoms of, and Screening Tools for Delirium
Risk factors for
delirium332,333
Patient-related
predisposing
Advanced age
Dementia
Previous stroke or head injury
Parkinson disease
Multiple comorbid diseases
Impaired vision and/or hearing (nonuse of typical glasses or hearing aids)
History of alcohol or other substance abuse
Functional impairment
Male gender
Patient-related
precipitating
Dehydration, electrolyte imbalance, hypo- or hyperglycemia, other metabolic abnormalities
Onset of acute medical problem, especially infection (pneumonia, urinary tract infections)
Exacerbation of chronic medical problem
Sepsis
Polypharmacy (>3 medications) and adverse drug reaction
Recent surgery and anesthesia
Pain with or without opioid/narcotic pain medication
Severe illness
Sleep deprivation
Urinary catheter use
Constipation or fecal impaction
Malnutrition
Hepatic or renal dysfunction or failure
Trauma
Head injury
Alcohol or other substance withdrawal
Hypo or hyperthermia
Fearfulness, loss of self-determination, altered self-esteem
Environment related



Transition to new or unfamiliar environment
Lack of privacy
Differences in noise (type, loudness) and lighting
Isolation
Physical or chemical restraint use

Chapter 20  Postoperative and Preprosthetic Care
549
Signs and symptoms
of delirium332,333
Hypoactive and
hyperactive
behaviors
Change from usual cognition over hours or several days
Confusion and disorientation
Difficulty concentrating, poor attention span, distractibility
Altered perception (illusion, delusion, visual and auditory hallucination)
Inability to multitask or parallel process
Impaired learning and memory
Noncompliance with interventions
Disorganized speech (rambling or inarticulate)
Emotional lability
Paranoia
Disordered sleep pattern (sundown syndrome)
Fearfulness
Aggressiveness and anger
Alternating lethargy and hyperactivity
Measures for diagnosis
of delirium






Cognitive screening
Mini-Mental State Exam334
Mini-Cog335
Delirium-specific





Confusion Assessment Method (CAM)336
One Day Fluctuation Scale337
Delirium Index338
Neelon and Champagne Confusion (NEECHAM) Scale339
Delirium Observation Screening Scale340
Delirium Rating Scale (DRS)341
Memorial Delirium Assessment Scale (MDAS)342
TABLE 20-3  Risk Factors for, Signs/Symptoms of, and Screening Tools for Delirium—cont'd
Readers are referred to the excellent chapter on motiva­
tion and patient education by Resnik and Avers in Geriatric
Physical Therapy as a resource on assessment of learning
styles and readiness to change health behaviors (as well as on
facilitation of learning).129
Assessing Sensory Integrity
Early in the postoperative period, screening of sensory func­
tion (vision, hearing, and somatosensation) is aimed at deter­
mining if strategies for enhancing communication may be
necessary and if the individual has sufficient “data-collection”
mechanisms in place to monitor the surgical wound condi­
tion, to inspect the condition of the remaining foot and limb,
and to scan the environment in preparation for and during
functional activities.130–132 Sensory integrity is also a factor
influencing selection of prosthetic components and suspen­
sion method.
Given the age and common morbidities of those with
vascular and neuropathic etiology of amputation, it is quite
likely that some degree of visual impairment will be pres­
ent in this group (Box 20-2).133,134 If the individual typically
wears glasses for daily function, glasses should be worn dur­
ing examination and subsequent intervention as well. Simple
strategies to reduce glare, increase contrast (e.g., handgrips
on walkers), and enhance acuity (e.g., large, simple, bold type
on written instructions) can be used to help those with com­
mon age-related visual changes be more functional during
the ­postoperative/preprosthetic period.135
Similarly, there are cumulative age-related changes in
structure, physiology and function of the auditory system
to be aware of (see Box 20-2) when interacting with older
persons with recent amputation.136 Attention to the ability to
hear and interpret sound is especially important when exam­
ining persons with concurrent confusion caused by postop­
erative delirium or acquired brain injury after trauma who
may have impairment of attention as well. Simple strategies
to enhance the ability to listen and hear include dropping
the pitch of the speaking voice; speaking more slowly and
projecting the voice without shouting; maintaining direct
eye contact; interacting in as quiet an environment as pos­
sible; and augmenting what is said with directive gestures,
simple diagrams, or brief written instruction in large print.137
Ensuring that hearing aids are in place and functional is
especially important during interviews and for patient/fam­
ily education. Importantly, hearing aids typically amplify all
sound; attention to volume and complexity of background
noise must always be considered.
In examining somatosensation the therapist is screen­
ing for areas of diminished sensation and areas of hyper­
sensitivity or dysthesias on the surface of the residual limb,
as well as on the remaining limb.138 Box 20-2 also summa­
rizes age- and ­pathology-related changes in sensation. For
those with ­neuropathic-dysvascular disease, it is especially
important to ascertain if there is adequate protective sen­
sation (ability to consistently perceive the 5.07 Semmes-
Weinstein filament) on weight-bearing surfaces of the
intact limb, which will be subject to repeated loading dur­
ing single limb ambulation.139 Standard sensory testing pro­
tocols for light touch, point and generalized pressure (am I
touching you? yes/no), the ability to localize (where am I
touching you?), and temperature ­discrimination (hot/cold)
are employed and often documented on a body chart.140

550
Section III  Prostheses in Rehabilitation
This information is used to guide patient–family ­education
about skin inspection and wound care, as well as decisions
about appropriate socket–limb interface for prosthetic pre­
scription. Screening for proprioceptive and kinesthetic
awareness at intact joints ­provides ­information that will be
useful when designing interventions for postural control
and, eventually, prosthetic gait training.
Sensory testing requires that the individual be able to
concentrate and focus so as to respond when a stimulus is
­presented. The reliability of sensory testing is diminished in
VISUAL SYSTEM
Age-Related Changes
Diminished visual acuity
Diminished ability to accommodate between near/far visual
targets
Delayed dark–light adaptation, especially sudden changes
in lighting
Diminished
contrast
sensitivity
and
figure–ground
discrimination
Diminished color discrimination
Diminished depth perception and visual–spatial sensitivity
Slowed pupillary light responses
Diminished corneal reflex
Diminished ability to converge eyes
Decreased ability to gaze upward/diminished upper visual
field
Diminished lateral peripheral field
Increased likelihood of ptosis
Diminished efficiency of vestibular–ocular reflexes
Functional Consequences
Susceptibility to glare
Increasing need for sharp contrast (in text style and color)
Difficulty recognizing and responding to subtle changes in
the visual environment
Need for gradual transition from dark-to-light environments
Need to keep directional signs at eye level
Use of bifocals/trifocals to improve visual clarity at near/far
distances
Pathologies Affecting the Visual System
Cataract
Age-related maculopathy/macular degeneration
Diabetic retinopathy
Glaucoma
Homonymous hemianopsia consequent to cerebrovascular
accident
AUDITORY SYSTEM
Age-Related Changes
Gradual progressive bilateral hearing loss, beginning with
high frequencies
Diminished sensitivity to low-volume sounds
Increasing pure tone auditory threshold
Diminished ability to screen background noise
Diminished discernment of speech sounds
Diminished word and sentence recognition
Decreased ability to accommodate to rapid speaking rates
Distortion of sound/sensitivity to shouting and emotional cues
Functional Consequences
Less efficient listening, especially in noisy environments
Compensation by watching facial expression, movement
of mouth
Need for adaptation of learning/listening environment:
Lower tone speech
Slower rate of speaking
Higher volume (loudness) without shouting
Use of hearing aids (most effective is conductive hearing loss)
Pathologies Affecting the Auditory System
Buildup of cerumen in the external auditory canal
Traumatic hearing loss from exposure to excessively loud
sounds
Acoustic neuroma
Vascular insufficiency in the brainstem auditory system
Cerebrovascular accident affecting auditory cortex function
Ototoxic medications
SOMATOSENSORY SYSTEM
Age-Related Changes
Decrease in number and distribution of receptors for dis­
criminatory touch
Loss of afferent nerve fibers in peripheral nerves
Degeneration of dorsal columns (central sensory discrimi­
natory pathway)
Increased latency for sensory stimulation (diminished con­
duction velocity)
Increased threshold of stimulation and decreased sensitivity
Point localization
Vibration (toe and ankle > upper extremity)
Two-point discrimination
Cutaneous pain
Temperature detection
Passive movement/joint position sense (lower extremity
> upper extremity)
Functional Consequences
Reduced ability to monitor environmental conditions
Less-efficient postural responses
Increased risk of tissue damage under low-load, repetitive
conditions
Pathologies Affecting Somatosensory Systems
Diabetic neuropathy
Entrapment neuropathy (e.g., carpal tunnel syndrome)
Toxic neuropathy (e.g., chronic alcoholism)
Sensory and perceptual impairment consequent to cerebro­
vascular accident
BOX 20-2  Age-Related and Pathological Conditions of the Sensory Systems in Later Life

Chapter 20  Postoperative and Preprosthetic Care
551
individuals with confusion or delirium or if the examiner uses
a consistent (predictable) pattern or rhythm during ­testing.141
To minimize the likelihood of “lucky guesses” in those with
suspected sensory impairment, it may be helpful to test spe­
cific sites multiple times, in random order and uneven tim­
ing, documenting the number of accurate responses versus
number of times stimulated (e.g., 0/3 1/3, 2/3, or 3/3) at each
testing site.
Noting how the individual with new amputation perceives
the residual limb is also important; is the individual willing to
look at the limb, watch it during dressing changes, touch it, or
freely move it? One challenge in the preprosthetic period is
to assist the incorporation of this “different” limb in the per­
son's body image and self-perception.21,22,142 Some individu­
als with dysvascular-neuropathic disease continue to perceive
their limb as fragile and needing protection. Those with trau­
matic amputation may become emotionally distressed when
confronted with the real evidence of their loss. These situa­
tions may interfere with readiness to wear and use a prosthe­
sis effectively. Awareness of the person's emotional response
to his or her altered body guides the therapist in patient edu­
cation and intervention activities aimed to accomplish adap­
tation of body image necessary for effective prosthetic use.
Assessing Mobility, Locomotion, and Balance
An individual with recent amputation may find that simple
mobility tasks (rolling over, coming to sitting/returning to
supine, transitioning from sitting to standing) are more dif­
ficult than anticipated following surgery. With the reduction
of body mass that results from lower extremity amputation,
for example, the individual's functional center of mass (COM)
shift slightly upward and to the opposite side of the body; the
degree of the shift is directly related to the amount of body
mass removed during amputation surgery.143 When this alter­
ation in body mass is paired with deconditioning associated
with bed rest, performance of mobility tasks degrades. It is
important to document baseline functional status, and to dis­
cern how much that altered body mass, altered muscle perfor­
mance, and even fear of pain or of falling may be contributing
to difficulty in moving. These alterations in COM may require
adaptation of strategies used before surgery for postural con­
trol; most persons with recent amputation can effectively adapt
their postural control mechanisms by practicing activities that
require them to anticipate or respond to postural demands.
One of the most functionally important aspects of preop­
erative assessment is determination of the person with new
amputation's usual (previous) and current (postoperative)
ambulatory status. The therapist is interested in the individ­
ual's familiarity with the use of assistive devices (e.g., walker,
crutches, canes), need for assistance to assume standing
and while walking, typical distances walked before surgery,
the overall effort (energy cost) of walking, the frequency of
walking, any other factors or comorbidities that limit walk­
ing, and the type of walking environment that the person is
most likely to encounter after discharge from acute care (e.g.,
level inside, uneven outside, stairs and ramps). Self-reports
and direct observation of walking provide this information.
Preamputation ambulatory status is a very strong predictor of
functional postoperative prosthetic use.144,145
At this early point in rehabilitation the priority is safety
and functionality of walking, rather than quality and precise­
ness of the gait pattern. Detailed observational gait analysis
is typically deferred until training with the prosthesis begins.
Quantitative kinematics (e.g., cadence, gait speed, step or
stride length) and ratings of perceived exertion can be used
to establish a baseline early in the postoperative period, as
a benchmark for progression and readiness for discharge.
Individuals with new amputation must be able to use a step-
to or swing-through gait pattern with the type of walker or
crutches that provides adequate stability and energy effi­
ciency with the least activity restriction.146
In acute care settings, initial examination and training of
gait is likely to focus on level, predictable surfaces in a rela­
tively closed environment. The ability to manage on a variety
of surfaces in active and open environments is examined as
care progresses; discharge from acute care approaches; and
preprosthetic rehabilitation continues at home, in subacute
settings, or on an outpatient basis. The individual with recent
amputation using an assistive device in single limb ambu­
lation must be able to walk forward, sideways, backward,
change direction, and turn, in addition to managing stairs
and inclines so as to be safe and functional in the home envi­
ronment. Familiarity with and effectiveness of propulsion
and maneuverability of a wheelchair are likely to be impor­
tant in the preprosthetic period for both the individual and
family caregivers.
Determining the effectiveness of the individual's postural
control is also important. This includes stability in quiet sit­
ting and standing; anticipatory postural adjustments in
reaching, transitions from sitting to standing as well as during
locomotion; and reactionary postural adjustments when there
is unexpected perturbation or unpredictable environmen­
tal conditions (e.g., a wet area on the floor, an area rug that
may shift when stepped on). Although testing protocols such
as functional reach, Tinetti Performance Oriented Mobility
Assessment, and measures of balance confidence are used
clinically for persons with recent amputation, the reliability,
validity, and norms for safe or impaired performance are not
well documented in the research literature.147–149 Subjective
assessment of postural control (poor, fair, good, excellent)
is somewhat influenced by the therapist's level of experience
and comfort with allowing an individual to move toward his
or her limits of stability.150 The Amputee Mobility Predictor
(Figure 20-11) may be a useful tool to establish baseline pre­
prosthetic balance and walking abilities, as well as an outcome
measure for preprosthetic rehabilitation.151 Minimal detect­
able change for the Amputee Mobility Predictor is reported to
be 3.5 points.152 Providing an opportunity for the individual
to practice moving from sitting to standing and ambulation
with an appropriate assistive device allows the therapist to
identify potential problems with balance and postural control.
This also helps the individual anticipate what mobility will
be like while the residual limb heals and while awaiting the
prosthesis.

552
Section III  Prostheses in Rehabilitation
FIGURE 20-11  Items of the Amputee Mobility Predictor scale. (Modified from Gailey RS, Roah KE,
Applegate EB, et al. The Amputee Mobility Predictor: an instrument to assess determinants of the
lower limb amputee's abilty to ambulate. Arch Phys Med Rehabil. 2002;83(5):613-627.)

Chapter 20  Postoperative and Preprosthetic Care
553
Assessing Posture, Ergonomics, and Body Mechanics
In the assessment of symmetry of alignment in sitting and
standing, it is important to differentiate habitual or preferred
postures from fixed postures, malalignments, and deformi­
ties.153 This might be accomplished by noting whether a par­
ticular postural orientation is maintained during different
functional activities, as well as whether the individual with
new amputation can change position or alignment when so
directed. Quantitative measures to document abnormalities
in posture and alignment include comparison with vertical
and horizontal using plumb line and grids, goniometry and
angle assessment, and passive movement.
Given the typical age group of persons with dysvascular-
neuropathic etiology of amputation, there may be kyphosis
associated with osteoporosis, especially if there is history of
pathological compression fractures of the spine.153 Assessing
the health and function of the lumbar spine in standing and
during reaching and lifting activity (including excursion of
hamstrings and flexibility of hip flexors and adductors) is
important because of the likelihood of developing low back
pain with the use of a prosthesis if there is contracture. This
is especially true for individuals with a transfemoral or any
bilateral amputation level.154 Considering back health early
in the preprosthetic program is a health promotion/wellness
activity that is a worthwhile investment in time and effort.
It is also important to note that, over time, persons with ampu­
tation are likely to develop osteopenia or osteoporosis of the
residual limb; those with transfemoral amputation may be at
increased risk of pathological hip fracture as they age.155,156
Assessing Self-Care and Environmental Barriers
In the acute care setting and in many acute rehabilitation cen­
ters the Functional Independence Measure (FIM) is commonly
used to determine how much assistance an individual with new
amputation requires for self-care and toileting, transfers and
locomotion, and with cognition-related aspects of task perfor­
mance157,158 (Table 20-4). Each item on the FIM is rated between
1 (complete dependence) to 7 (complete independence); pos­
sible FIM scores range between 18 and 126 points, with low
scores indicating that greater assistance is required. It is impor­
tant to note that because the FIM was designed to measure
burden of care in hospital settings, many of the criteria used
to indicate independence for mobility items do not necessar­
ily represent level of function required for community living.
In the early postoperative, preprosthetic period, use of the FIM
is appropriate; later during preprosthetic care or during pros­
thetic care, there is likely to be a ceiling effect that makes it less
sensitive to change in functional status.159,160 FIM scores may
not be particularly useful as indicators of improvement once an
individual has reached relative modified independence, espe­
cially on the locomotion and mobility subscales.161
Whether using the FIM or other measures of function, the
individual's ability to transfer to and from the toilet, in and
out of the shower or bathtub, and in and out of a car, bus, or
subway; to manage stairs, elevators and escalators; and to get
up from the floor (in case of a fall) should be examined as the
preprosthetic period advances. This is part of the assessment
of readiness to return to the home environment or determine
the need for continued rehabilitation. The rehabilitation team
must also consider the individual's ability to dress, perform
self-care and grooming activities, inspect his or her residual
and remaining limbs, and function in typical food preparation
roles and other instrumental activities of daily living (ADLs).
The team assesses the family caregiver's ability to pro­
vide appropriate and effective assistance at home if the
individual needs help or guarding during functional activi­
ties. Discussion about what work and leisure activities are
important for the individual to resume once home will guide
selection of appropriate adaptive equipment and adaptive
movement strategies necessary to carry out important tasks
and roles before receiving the prosthesis.
Finally, information about the accessibility of person's liv­
ing environment must be gathered, to determine whether it is
feasible to return home to function on a single limb during the
preprosthetic period. The therapist may ask family members to
measure doorway widths, determine whether there is adequate
space for maneuvering a wheelchair, and consider the need for
installation of ramps to make entering/exiting the home both
less effortful and safer. Readers are referred to Chapter  35:
Environmental Assessment: Home, Community, and Work
in M. Cameron and L. Monroe (eds.), Physical Rehabilitation:
Evidence-Based Examination, Evaluation, and Intervention,
St. Louis, MO: Elsevier Saunders, 2007 for more information.
TABLE 20-4  Dimensions of the Functional Independence
Measure
Self-Care Subscale
(8 to 56 points)
1. Eating
2. Grooming
3. Bathing
4. Dressing the upper body
5. Dressing the lower body
6. Toileting
7. Bladder management
8. Bowel management
Mobility Subscale
(5 to 35 points)
9. Transfers: bed to chair or wheelchair
10. Transfers: to and from toilet
11. Transfers: in and out of bathtub or shower
12. Locomotion: walking or wheelchair
propulsion
13. Stairs
Cognition Subscale
(5 to 35 points)
14. Communication: comprehension
(auditory and visual)
15. Communication: expression (verbal and
nonverbal)
16. Social interaction
17. Problem solving
18. Memory
Total FIM Score
Range 18 to 126 points
NOTE: The FIM is a proprietary measurement tool of the Uniform
Data System for Medical Rehabilitation (270 Northpointe Parkway,
Suite 300, Amherst, NY 14228, ). Readers are
encouraged to contact the UDSMR for detailed information about
administering, scoring, and interpreting the tool.

554
Section III  Prostheses in Rehabilitation
Monitoring for Postoperative Complications
Many individuals undergoing amputation, whether related
to an infected diabetic foot wound, peripheral vascular dis­
ease, or traumatic injury, carry a high comorbid burden of ill­
ness. It is important to be aware of potentially life-threatening
and rehabilitation-delaying complications in the postopera­
tive, preprosthetic period. In-hospital mortality following
amputation is estimated to be 7.5% to 12.5%.162–166 Predictors
of mortality during this vulnerable time include significant
renal disease, chronic obstructive pulmonary disease and
congestive heart failure (CHF), previous MI or ischemic
stroke, liver dysfunction, and an age of 75 years or older.161–166
Patients who require blood transfusion during or following
surgery tend to have both more postoperative complications
and a greater risk of mortality.167
There is high risk of morbidity during the immediate post­
operative period as well. The stress of surgery may contribute
to problematic hyperglycemia and need for insulin in persons
with diabetes, even those who had not previously required
insulin.168 Cardiac complications for persons with diabetes,
PAD, and coronary artery disease in the postoperative period
include arrhythmia (with associated risk of cerebral embo­
lism), exacerbation of CHF, and new MI or stroke.162–166 Bed
rest and inactivity are associated with risk of deep venous
thrombosis and associated pulmonary embolism, risk of
developing pneumonia, and risk of developing decubitus
(pressure) ulcer on the heel of the intact limb or sacrum.169,170
Placement of catheter for collection of urine increases risk of
urinary tract infection.171 Infection of the surgical wound has
been reported to be between 10% and 26% in dysvascular dis­
ease and 34% in those with amputation as a consequence of
trauma.170,172,173 Pneumonia, urinary tract infection, or infec­
tion of the wound may contribute to development of sepsis
and eventual multisystem organ failure.174,175
CASE EXAMPLE 1A
An 89-Year-Old Facing “Elective” Transtibial
Amputation for Severe Arterial Occlusive Disease
of Her Right Foot
N. H. is a slight but energetic woman who is referred to
your interdisciplinary team for preoperative examination
and education about the rehabilitation program she will be
involved in after her planned transtibial amputation. She
stands 5 ft 2 in tall with slight kyphosis and weighs 101 lb.
She rises to standing by scooting to the edge of her wheel­
chair (used for community mobility), then rocking back
and forth several times to build momentum. She tells you
that she spends her days reading the New York Times, writ­
ing to grandchildren and the few long-term friends still
alive, cooking (with help to assemble ingredients and take
things in and out of the oven), and talking to other “shut
ins” from her church on the phone. N. H. lives in the home
of her youngest son, a 67-year-old who has recently under­
gone quadruple coronary artery bypass grafting and is
recovering from an embolic stroke that left him with mild
left ­hemiparesis. Grandchildren and great-grandchildren
visit fairly often. According to her chart, N. H. has hyper­
tension controlled by β-blockers, had a mild MI 15 years
ago, has never smoked cigarettes, and enjoys a glass of wine
with her evening meal. She had lens implants for cataracts
bilaterally but still wears glasses to read. Over the past year,
claudication has become an increasing problem, mak­
ing it uncomfortable for her to walk from her bedroom at
one end of the ranch-style home to the kitchen and fam­
ily room at the other. When presented with the choice of
revascularization versus amputation, she decided that, in
the long run, she would rather take her chances with ampu­
tation surgery with spinal anesthesia than bypass graft with
general anesthesia. She expresses concern that she is “very
out of shape” because her walking has been so limited by
ischemic pain. She has a good friend whose husband used a
transtibial prosthesis for many years after losing his foot in
a lawnmower accident; this has assured her that a prosthe­
sis will allow her adequate mobility and function once she
heals after surgery. She tells you she has come through many
difficult times during her long life, and although sad at the
prospect of losing her leg, she looks forward to being free of
claudication pain and anticipates she will muster the deter­
mination necessary to get back on her feet.
Questions to Consider
• What additional data might you want to gather from
the medical record to build your understanding of her
current condition and medical prognosis?
• What are the most important questions to ask during
your interview with N. H. and her son as you begin to
formulate her PT diagnosis and plan of care?
• Given her age and general health status, what addi­
tional review of physiological systems would be impor­
tant to carry out before surgery? Why have you chosen
these systems? How might they affect her ability to
part­icipate in rehabilitation?
• What specific tests and measures, at an impairment
level, will be important to do during your physical
examination? How long do you think the assessment
might take? How might you prioritize if your time with
N. H. is limited? How reliable are the strategies that you
have chosen? How precise does the information you are
collecting at this preoperative visit need to be?
• What functional activities would you choose to assess
before her surgery? What tests and measures will you
use to document her functional status?
• What information would be important for you to share
with N. H. and her son about the first few days after her
surgery? Before discharge from acute care? During the
preprosthetic period until she is ready to be casted for
her initial prosthesis?
• Given the limited information currently available to
you, what impression or expectations do you have
about her postoperative care? How might this be differ­
ent if she had a medical diagnosis of type 2 diabetes?

Chapter 20  Postoperative and Preprosthetic Care
555
THE PROCESS OF EVALUATION, DIAGNOSIS,
AND PROGNOSIS
Understanding an individual's rehabilitation needs emerges
as baseline data are collected and integrated with health pro­
fessionals’ clinical expertise and judgment, as well as evidence
from the clinical research literature. As part of the evaluative
process, the team weighs factors that are likely to influence
the rehabilitation program and begins to formulate a plan of
care to address the individual's specific needs. The team iden­
tifies key problems that will need to be addressed, formulates
a PT (rehabilitation) movement dysfunction diagnosis, esti­
mates the level of function that will likely be reached and the
time and intensity of intervention necessary to reach it, speci­
fies measurable goals that will be used to judge progression
over time, and prioritizes interventions to be carried out as
part of the rehabilitation program. Readers are referred to the
Guide to Physical Therapist Practice to review for details about
the patient-client management process and the practice pat­
terns applicable to PT care of persons with recent amputation
() (Box 20-3).
CASE EXAMPLE 2A
A 25-Year-Old with Bilateral Traumatic Transtibial
Amputations Sustained in a Construction Accident
P. G. is a construction worker who was pinned between
the fenders of two vans when the driver of one van put the
vehicle in reverse as P. G. was walking between them. He
sustained severely comminuted and open fractures of the
mid tibia and fibula and significant damage to soft tissue
and neurovascular structures. Tourniquets were placed on
his limbs by emergency medical technicians responding
to the 911 call. In the emergency department trauma sur­
geons determined that neither of P. G.'s limbs met criteria
for limb salvage. Because the limbs were contaminated by
dirt and debris from the job site, the surgeon performed
bilateral open transtibial amputations to allow for frequent
wound inspection. P. G. was placed on intravenous anti­
biotics. Three days after the operation, there is no sign of
infection in either limb. Revision and closure of his resid­
ual limbs is scheduled for tomorrow, using an equal ante­
rior and posterior flaps closure, leaving approximately
5 inches of residual tibia in length. Adjustable polypropyl­
ene, removable, semirigid dressings are planned for com­
pression and protection of the wound postoperatively.
Review of the medical record indicates that P. G. was
in generally good health before his injury, although he has
been a pack-per-day smoker since the beginning of high
school. He was 6 ft 4 in tall, weighing 210 lb before his
injury. His only previous hospitalization was at age 17, for
open-reduction, internal fixation of a midshaft right femo­
ral fracture sustained in a motorcycle accident. P. G. has
been married for slightly more than 1 year, and his wife is
7 months’ pregnant. They live on the third floor of a three-
family home in the ethnic city neighborhood in which they
grew up. Extended family members have kept vigil at the
hospital since the accident to support P. G. and his wife.
When not working, P. G. is an avid motorcycle and quad
rider, competing locally in both speed and distance events.
He also participates in an intracity adult basketball league.
Pain management has been via a morphine pump;
even with this, P. G. reports typical pain levels of five to six
out of 10, increasing in severity during dressing changes.
When you come to discuss his postoperative rehabilita­
tion with him, he is in a semireclined position in bed,
with both lower limbs abducted and externally rotated at
the hip, resting in apparent 20 degrees of knee flexion. He
is anxious and quite angry over the situation, stating that
he “can't believe this has happened” and “doesn't want to
end up in a wheelchair” unable to work. The only experi­
ence he has with persons with amputation is an uncle with
poorly controlled diabetes who had successive amputations
of multiple toes as a consequence of vascular insufficiency,
subsequently revised to transmetatarsal because of osteo­
myelitis of a neuropathic wound, and then to transtibial
because of delayed healing. P. G.'s uncle's rehabilitation was
complicated by a significant stroke a week after transtibial
amputation, and although he wears a prosthesis, his mobil­
ity limitations keep him homebound.
Questions to Consider
• What additional data might you want to gather from
the medical record to build your understanding of
P. G.'s current condition and medical prognosis?
• What are the most important questions to ask during
your interview with P. G. and his family as you begin to
formulate his PT diagnosis and plan of care?
• What additional review of physiological systems would
be important to carry out before surgery? Why have
you chosen these systems? How might they affect his
ability to participate in rehabilitation?
• What specific tests and measures, at an impairment
level, will be important to do during your physical
examination? How long do you think the assessment
might take? How might you prioritize if your time with
P. G. is limited? How reliable are the strategies that you
have chosen? How precise does the information you are
collecting at this preoperative visit need to be?
• What functional activities would you choose to assess
before his surgery? What tests and measures will you
use to document his functional status?
• What information would be important for you to share
with P. G. and his family about the first few days after
the next surgery? Before discharge from acute care?
During the preprosthetic period until he is ready to be
casted for his initial prostheses?
• Given the limited information currently available to
you, what impression or expectations do you have
about his postoperative care? How might P. G.'s care be
similar to or different from that of his uncle and the
older woman in the previous case?

556
Section III  Prostheses in Rehabilitation
Physical Therapy Diagnosis
The PT diagnosis reflects the problems with body structure
and function (impairments) and activity (functional limita­
tions) that the person with recent amputation encounters as a
consequence of their surgery and current health status. The PT
diagnosis differs from the medical diagnosis in that it focuses
on the functional consequences of a condition at the level of the
system and, more importantly, at the level of the whole person.7
The models used to frame the rehabilitation process
has evolved from the process of disablement176 to a focus on
­enablement, based on the World Health Organization's
(WHO) International Classification of Functioning, Disability
and Health (ICF).177–179 The models provide a way of organiz­
ing information collected in the patient-client interview and
examination process, to facilitate development of a PT move­
ment diagnosis, prognosis and goals, and plan of care. For
students and new therapists, it may be helpful to complete
an organizational table on the basis of the ICF model that
lists all relevant descriptors of active disease/comorbidity, the
impairments and resources of body structures and function,
and the activity and participation level issues that need to be
addressed during the episode of care (Table 20-5). The entries
in each column in the table can be prioritized, with notations
about which issues are likely to improve or change and which
will require adaptive equipment or alternative strategies. The
statement of PT diagnosis for the particular individual begins
with a prioritized list of activities to be addressed during the
episode of care, followed by the contributing impairments of
body systems and structures elated to or result from the indi­
vidual's constellation of active pathologies and comorbidities.
Formulating the PT diagnosis in this way clearly guides estab­
lishment of goals and appropriate interventions.
Plan of Care: Prognosis
Forecasting the length of the proposed episode of PT care and
the potential for prosthetic replacement and rehabilitation
can be challenging. Decisions must be informed by several
factors:
1. The overall health, cognitive, and preamputation func­
tional status of the individual;
2. The level of amputation as it affects prosthetic control
and the energy cost of walking;
3. The likely contribution of prosthetic use to perform basic
and instrumental ADLs, for the individual or for the care­
givers who will be assisting and managing daily function;
4. The resources (financial and instrumental) available to the
individual during the entire rehabilitation process; and
5. Knowledge of typical length of stay for patients with
amputation in the setting in which care if being pro­
vided (acute care, inpatient rehabilitation, subacute
care, home care, or outpatient care).
The premorbid factors that tend to predict successful pros­
thetic use (i.e., rehabilitation potential) include the ability to walk
functional distance in the months prior to surgery, overall level of
physical fitness, requiring little assistance in ADLs, and the abil­
ity to maintain single limb stance without assistance.180 Persons of
advanced age often require a longer period of rehabilitation, but
eventually become functional prosthetic users. Delayed wound
healing (which delays prosthetic fitting), as well as knee and hip
flexion contracture, reduce the likelihood of successful pros­
thetic use.181 A long list of past or chronic illnesses does not pre­
dict poor rehabilitation potential: Approximately 75% of persons
with amputation are able to return to independent living, man­
aging multiple chronic conditions effectively to become highly
functional prosthetic users.182 Premorbid health conditions what
make prosthetic use less likely (odds ratio >2.0) include moderate
to severe dementia, end-stage renal disease, and advanced coro­
nary artery ­disease.183 Persons with very low body mass (under­
weight) may have more difficulty with prosthetic ambulation and
functional independence than those who are overweight and
obese, given a similar comorbid burden of illness.182 Hip exten­
sor strength is a powerful contributor to overall function with
a prosthesis for persons with both transtibial and transfemoral
­amputation.184 Difficulty learning has more of an impact during
the postoperative and preprosthetic period than does depression
or ­anxiety.185 The sooner an individual is fit for a prosthesis and
begins rehabilitation following amputation, the more likely the
individual will become a functional prosthetic user.186
Long-term outcome of function and survivorship follow­
ing amputation is more difficult to forecast: The relatively high
morbidity and mortality for patients with ­amputation sec­
ondary to vascular disease have been well documented.187–189
Unless there is clear evidence that ambulation will not be
possible and that provision of prosthesis will not improve the
patient's mobility (e.g., reducing the amount of assistance that
is necessary to transfer), prosthetic replacement should and
must be considered.
MUSCULOSKELETAL SYSTEM
Impaired motor function, muscle performance, range of
motion, gait, locomotion, and balance associated with
amputation
NEUROMUSCULAR SYSTEM
Impaired motor function and sensory integrity associ­
ated with acute or chronic polyneuropathies
CARDIOVASCULAR/CARDIOPULMONARY
SYSTEM
Primary prevention/risk reduction for cardiovascular/
pulmonary disorders or
Impaired aerobic capacity/endurance associated with
deconditioning
INTEGUMENTARY SYSTEM
Primary prevention/risk reduction for integumentary
disorders
Impaired integumentary integrity associated with skin
involvement extending into fascia, muscle, or bone
and scar formation
BOX 20-3  Guide to Physical Therapist Practice
Patterns Relevant for Individuals
with Amputation

TABLE 20-5  Application of the WHO International Classification of Functioning, Disability and Health (ICF) Model, Completed Postoperatively, for Case Example 1: N. H.,
an 89-Year-Old, Following with Elective Transtibial Amputation Secondary to Severe Peripheral Arterial Disease


Overall Health Status
Body Structure and Function
(Physiological Systems)

Activity (Overall Functional Status)
Participation (Ability to
Engage in Social Roles)

Buffers or Confounding Factors
Resources
(preoperative)
Effective management of
chronic conditions prior
to surgery
Intact cognitive status
and effective executive
function preoperatively
Self-rated health “good”
other than claudication
Effective vision and hearing
Effective communication
Highly motivated: determined to
eventually return to own home
Previous use of walker and wheelchair
Able to ambulate independently with assistive
device functional (in home) distances
Self-selected walking speed .85 m/s
preoperatively
Independent in self-care (toileting, bathing with
tub seat and handheld shower, dressing)
Independent in stair management, step up
to step pattern, with rail
Active and engaged in
community (church)
Able to manage food
preparation and
cleanup with minimal
assistance
Knowledge of successful prosthetic
use by friend
Understanding of the rehabilitation
process: previous participation in
cardiac rehabilitation
Lives in 1 story home, with ramp
at entry
Significant emotional and
instrumental support available
by a number of family caregivers
Active problems
(examination
findings)






















Medical diagnosis:
Peripheral arterial disease
with critical limb ischemia
Status post right transtibial
amputation, posterior flap
(2/15/12)
Removable rigid dressing
2″ square ecchymosis
suture line
Moderate amount of
serosanguineous drainage
at mid suture line
Postoperative pain
(morphine pump)
Comorbid conditions
Hypertension (β blockers)
Status post MI (1997)
Cataract (lens implants
6/12/07)
Recent fall in hospital
bathroom (2/17/12)
Mild postoperative delirium
with sundown syndrome
Stress incontinence
Possible osteoporosis
Possible sarcopenia
Postoperative pain (4/10 VAS)
Phantom sensation (cramping)
Potential for delayed healing
because of injury to surgical site
sustained in fall
Postoperative edema
Limited excursion right knee
flexion and hip extension ROM
Less than 3/5 muscle strength
right knee extension, hip
abduction, hip extension
Diminished functional core
and upper extremity muscle
strength
Limited muscular endurance
Limited cardiovascular endurance
Limited short-term memory
and distractibility (MMSE
preoperation 28/30,
postoperation 18/30)
Hypersensitivity to touch and
pressure bordering suture line
Inadequate protective sensation
left forefoot
Impaired postural control in single
limb support (static and dynamic)
Difficulty with transitions
Effortful but functional rolling side to side
Minimal assistance to shift upward in bed
(difficulty sustaining “bridge” position)
Minimal assistance supine to/from sitting
with directional cuing
Moderate assistance sit to stand, with
directional cuing
Maximal assistance stand to sit with poor
eccentric control upper extremity and left
lower extremity
Inability to ambulate functionally
Moderate assist of 1, hop to pattern in parallel
bars, requires consistent cueing
Step length 6 inches, perceived exertion 7/10,
distance 10 ft
Diminished exercise and activity tolerance
Difficulty with toileting, dressing, and other
self-care activities
Quickly becomes frustrated and agitated
when encounters difficulty with mobility
and self-care tasks
Possible difficulty with carryover of new learning
from session to session until delirium clears
Difficulty self-monitoring status of residual
limb and remaining limb
Inability to function in
typical premorbid roles
in interactions with
family at home
Inability to function
in premorbid roles
in interactions with
members of her
communities (church,
friends, extended
family)














Left lower extremity claudication
may limit activity























Physical Therapy Diagnosis: N. H. has difficulty with functional activity (mobility and transfers, ambulation, and self-care activities) secondary to postoperative dysfunction of body structure and
systems (transient cognitive impairment, pain, impaired muscle strength and motor control, diminished endurance, limited range of motion of at key lower extremity joints, impaired postural control)
related to recent transtibial amputation, postoperative delirium, and various comorbidities.

558
Section III  Prostheses in Rehabilitation
A key component of prognosis is delineation of the fre­
quency, intensity, and duration of the episode of care. In
the acute care setting, hospitalization for an uncomplicated
amputation may be 4 to 7 days and PT may occur for 30 to 45
minutes, once or twice daily. For frail or chronically ill older
adults coping with multiple comorbidities, length of stay often
increases to 21 or more days. For individuals with amputation
as a result of trauma affecting multiple systems, the period
of hospitalization depends on the severity of damage across
all systems, so that duration of care may be longer. Postacute
care occurs in inpatient rehabilitation settings (approximately
55%), subacute rehabilitation settings (approximately 21%),
or by discharge to home with referral for in-home nursing
and rehabilitation services (approximately 24%).190 Discharge
location is determined by overall health status and need for
care, availability and capacity of family caregivers, the type
of rehabilitation settings or care that is available in the area,
as well as by insurance and financial considerations. In sub­
acute settings, for those on Medicare, the rehabilitation stay
may be for a month or more and care is much more intense,
with PT typically occurring twice daily with an hour of more
of PT and occupational therapy planned each day. Care pro­
vided at home and in outpatient settings may be somewhat
less intense, occurring three times a week for an hour or more,
but is certainly supplemented by an active home program.
CASE EXAMPLE 2B
Determining a Physical Therapy Diagnosis for P. G.
Following Revision of Bilateral Transtibial Amputations
You have collected the following information in your chart
review, interview, and brief initial examination:
• Surgery: Underwent revision and closure of bilateral
open amputation 2 days ago (under general anesthesia)
with equal anterior and posterior flaps closures; 5.25-
inch residual tibia on left, 4.75-inch residual tibia on
right. Placed in bulky dressing and Ace wrap for com­
pression, then into bilateral adjustable prefabricated
semirigid dressings to hold knees in full extension and
protect surgical construct. Moderate serosanguineous
drainage noted at first dressing change. Wound edges
slightly inflamed consistent with operative trauma. No
dehiscence noted. Proximal circumference at joint line
10.25 inches bilaterally, distal circumference (4 inches
below) of right residual limb 11.25 inches and of left
residual limb 11 inches.
• Postoperative health: Elevated temperature postopera­
tively, with diminished breath sounds in posterior bases
of lungs bilaterally. Radiograph suggests early pneumo­
nia. Cough nonproductive.
• Cognition/affect: Signs of agitation and distress in recov­
ery room, being mildly sedated for combination of pain
relief and calming. Currently lethargic and somewhat
distractible, requiring consistent cueing to stay on task
during examination.
• Pain/phantom sensation: Reports postoperative pain
at seven out of 10 level. Complains of shooting pains
in phantom right lower extremity and is distressed by
“itchy” toes on phantom left lower extremity. Currently
IV narcotics every 3 hours for pain management.
• ROM/muscle length: Reports “pulling” behind knees
when head of bed elevated into long sitting position.
Requests time out of semirigid dressing to allow knee
flexion and be more comfortable.
• Muscle performance/motor control: Able to actively
extend both knees to approximately 10 degrees from full
extension, stops because of “pulling” behind knee.
• Upper extremity function and transfers: Able to “push
up” to lift body weight when assisted to bedside chair,
requiring contact guard/minimal assist, using a sliding
board to transfer.
• Aerobic capacity/endurance: Reports transfer effort six
out of 10 on perceived exertion scale. Reports dyspnea
five out of 10 immediately following transfer.
• Rolls independently: Able to come to sitting from side-
lying with minimal assistance.
• Postural control: Maintained static sitting balance on
edge of bed 2 minutes. Able to reach forward 7 inches,
sideward more than 10 inches bilaterally, reluctant to
turn and reach behind because of discomfort. Effective
postural responses to mild perturbations forward and
backward, moderate ­perturbations sideways.
Questions to Consider
• List all of the active pathologies and comorbidities that
will influence P. G.'s postoperative/preprosthetic care.
• List and prioritize the impairments, across physiologi­
cal systems and from a psychological perspective, that
should be directly addressed or considered in his reha­
bilitation plan of care.
• List and prioritize the functional limitations that will
be addressed during his acute care stay. Suggest addi­
tional functional limitations that will be addressed as
his rehabilitation progresses at home or at a subacute or
rehabilitation facility.
• List and prioritize disabilities that P. G. is likely to
be concerned about and that the rehabilitation team
will be attempting to minimize over the course of
his care.
• Develop a definitive PT diagnosis for P. G. on the basis
of the disablement model.
• Develop a rehabilitation prognosis for P. G. and explain
or justify your expectations.
• Develop a list of prioritized goals for P. G. for the next
2 weeks in the acute care hospital. Expand these goals
as if care would continue after discharge in a rehabili­
tation center, at home, or on an outpatient basis. What
will frequency, duration, and intensity of his rehabili­
tation sessions be? How will you judge if he is making
progress toward achieving these goals?

Chapter 20  Postoperative and Preprosthetic Care
559
Plan of Care: Determining Appropriate Goals
Goals to be achieved during a particular episode of care are
influenced by the setting in which care is provided. Although
the overall goal of the preprosthetic period is to prepare the
individual for prosthetic fitting and training, the specific
goals of the acute care setting may be to achieve primary
wound closure, initiate an effective strategy for compres­
sion, and achieve supervision or minimal assist in transfers
and in locomotion using a wheelchair or ambulatory device
on level surfaces during the days or week that the person is
hospitalized. In subsequent subacute, home care, and outpa­
tient settings, goals expand to include strengthening of core
and key muscle groups; ensuring adequate ROM for pros­
thetic use; improving cardiovascular fitness; and achieving
more advanced ADLs, instrumental activities of daily living
(IADLs), and mobility skills over a longer period of interven­
tion.191 An effective goal is directly linked to the impairments
and functional limitation identified in the PT diagnosis and
is stated in measurable terms so that progression can be
assessed as postoperative and preprosthetic care continues
(Box 20-4).
INTERVENTIONS FOR PERSONS
WITH RECENT AMPUTATION
After amputation surgery the focus shifts to preparation for
prosthetic use.192 Strategies for control of edema, pain manage­
ment, and facilitation of wound healing are implemented. The
person with a new amputation and his or her caregivers receive
instruction and the opportunity to practice single limb mobility
with an appropriate assistive device. For persons with dysvas­
cular or diabetes-related amputation, condition of the remain­
ing foot must be carefully monitored as single limb mobility
training begins.193 Handling of the residual limb during dress­
ing changes and skin inspection, as well as the consistent use
of compression devices, helps to desensitize the residual limb,
enhancing readiness for prosthetic use. Exercises to strengthen
key muscle groups in the residual and remaining limb and to
assist effective postural responses are implemented to assist
function and prepare for prosthetic gait. Functional training
in self-care and transfers begins in the acute care setting and is
followed up in home care, subacute, or outpatient settings. The
therapist may employ a combination of manual therapy, ther­
apeutic exercise, facilitation techniques, physical agents, and
mechanical or electrotherapeutic modalities to help manage
pain, assist healing, minimize risk of soft tissue contracture, and
enhance ­mobility. A rigid dressing or temporary socket may be
fabricated or adapted to protect the residual limb while it heals.
Postoperative Pain Management
In addition to reducing acute discomfort, effective postop­
erative pain management is important for several other rea­
sons. Pain is a significant physiological stressor that affects
homeostasis, as well as the patient's ability to concentrate
and learn.8,9,113 In the early postoperative period persons
with recent amputation are faced with learning how to care
for their new residual limb including monitoring for signs of
infection, using strategies to control edema, and appropriate
positioning to minimize the risk of contracture formation.
They must also learn a variety of new motor skills including
exercises to preserve strength and ROM and how to protect
their healing suture while moving around with crutches or a
walker on their remaining limb. If postoperative discomfort
and pain are kept to a minimum, they can better learn and
retain these new cognitive and motor skills.
Pain can also be fatiguing and demoralizing; those with
significant pain may be reluctant to participate fully in active
rehabilitation programs because they fear that movement will
only increase their pain. Individuals with significant pain may
be erroneously labeled as unmotivated or uncooperative, when
their primary goal is to find a way to escape their discom­
fort. Importantly, although certain types of pain medications
(opioid and narcotic analgesics) are effective in providing
relief, they may compromise cognitive function or increase
the risk of postural hypotension.53 Therapists must be aware of
the actions and side effects of the pain medication being used.
In the days immediately after amputation the goal is to
minimize the severity of acute postoperative pain. Because
prevention is more effective than reduction of significant
N. H. is an 89-year-old woman with recent transtib­
ial amputation secondary to peripheral arterial disease.
By the conclusion of this episode of care (projected 4 to
5 days), N. H. will be able to do the following:
• Actively participate in inspection of her surgical
wound during dressing changes and of her remaining
limb.
• Describe and recognize signs of inflammation, dehis­
cence, ecchymosis, and infection along her incision
site and of inflammation or developing neuropathic
or vascular ulceration of her remaining extremity.
• Direct caregivers in the proper application of her com­
pressive dressing and removal of her rigid dressing.
• Safely perform rolling and bridging activities, without
assistance, for effective bed mobility with perceived
exertion of no more than three out of 10.
• Demonstrate active contraction into full-knee exten­
sion in supine and seated positions.
• Demonstrate understanding of proper stretching and
flexibility for knee extension and hip extension in
multiple functional positions.
• Safely rise and return from sitting to standing position
from a standard arm chair or wheelchair with mini­
mal assistance and occasional verbal cues, with per­
ceived exertion of four out of 10.
• Ambulate with contact guard and occasional cues,
using a hop-to pattern using a standard walker for 25
feet, with a perceived exertion of four out of 10.
• Direct caregivers in assisting her with toilet transfers
and clothing management during toileting and other
self-care activities
BOX 20-4  Acute Care Goals for Case Example 1A

560
Section III  Prostheses in Rehabilitation
pain, those with recent amputations are encouraged to request
pain medication before pain becomes severe.54 Preoperative
and intraoperative pain management also affects postopera­
tive pain: In patients undergoing amputation due to vascular
insufficiency who receive epidural analgesia before surgery,
problematic phantom limb pain after amputation may be less
likely to develop.61,62 Effective management of postoperative
edema is an important element in the control of postopera­
tive pain as well.
Dealing with Phantom Limb Sensation
and Phantom Pain
A variety of pharmacological and nonpharmacological inter­
ventions have been used for individuals with significant
phantom limb sensation or pain, although management of
phantom pain is often challenging and frustrating for all
­involved.55,60,64,194,195 Table  20-6 summarizes the results of a
recent Cochrane Review focused on efficacy of pharmaco­
logical management of phantom limb pain.196 Current best
evidence is, at best, limited as a result of differences in study
methodology and design, insufficient control groups, and
­acuity/chronicity of the pain. Readers are encouraged to fol­
low developing evidence from future randomized controlled
trials of pharmacological agents in the management of phan­
tom limb pain. One strategy designed to impact development
of phantom limb pain in the postoperative period is contin­
uous analgesic infusion to control the severity of phantom
limb pain in the immediate postoperative period; the success
of this intervention varies with pharmacological agents and
the rate of their administration.62,63,197 Pulse radiofrequency
ablation198 and botulinum toxin type A injection199 are being
investigated as possible interventions for severe longstanding
phantom limb pain that has not been responsive to more con­
servative approaches. Sympathetic blocks appear to reduce
pain intensity over the short-term (up to 1 week) but not over
the long-term (up to 8 weeks).200 Implantation of spinal cord
stimulators has been explored for persons with severe, intrac­
table phantom limb pain, however results appear to be equiv­
ocal, and complications of the implantation worrisome.201
Physical Therapy for Postoperative and Phantom Pain
The success of early rehabilitation is influenced by the effec­
tiveness of postoperative pain management; for this reason,
physical therapists must be aware of medications being used
and be involved in assessing the effectiveness of the pain
management strategy and its impact on patient learning and
function.202 When epidural anesthesia has been used during
surgery or in the immediate postoperative period, it is imper­
ative that the patient's cognitive, autonomic, sensory, and
motor function is carefully evaluated before transfer training
TABLE 20-6  Results of a Cochrane Review of Prescription Medications Used in the Management of Moderate to Severe
Phantom Limb Pain and Their Side Effects
Medication
Class
Primary and Secondary Outcomes*
Adverse Effects Reported
Oral or IV morphine
Opioid
Short-term decrease in pain intensity
Better sleep
No impact on mood
Satisfaction higher in oral vs. IV
Sedation, fatigue, dizziness/vertigo,
constipation, sweating, difficulty
voiding, itching, respiratory
depression
Ketamine or
dextromethorphan
N-methyl-d-aspartate
(NMDA) receptor
antagonists
Short-term decrease in pain intensity
Better sleep
Better sense of well-being
No impact on functional status
Sedation, hallucinations, loss of
consciousness, hearing impairment,
balance problems, insobriety
Gabapentin
Anticonvulsant
Trend toward short-term decrease
in pain intensity
No impact on mood
No impact on functional status
No impact on sleep
Somnolence, dizziness, headache,
nausea
Amitriptyline
Tricyclic antidepressant
No impact on pain intensity
No impact on mood
No impact on functional status
Negative impact on sleep
Dry mouth, drowsiness, blurred vision,
dizziness, constipation, altered sleep,
nausea/vomiting/diarrhea, tinnitus,
urinary retention
Calcitonin infusion
Polypeptide hormone
Trend toward decreased intensity and
frequency of phantom limb pain in
persons with recent amputation
Facial flushing, nausea, sedation,
dizziness
Lidocaine; bupivacaine
Anesthetics
No different than morphine
Stinging sensation at injection site
*Primary outcomes: change in phantom limb pain intensity; possible secondary outcomes: changes in mood (depression), functional status,
quality of sleep, patient satisfaction with intervention, severity of adverse effects.
Adapted from Alviar MJ, Hale T, Dungca M. Pharmacologic interventions for treating phantom limb pain. Cochrane Database Syst Rev.
2011;(12):CD006380.

Chapter 20  Postoperative and Preprosthetic Care
561
and single limb mobility activities are begun. In whatever set­
ting PT care is provided, it is important that administration
of medications be timed so that pain control is optimal dur­
ing PT activities. If the patient is experiencing phantom sen­
sation or pain, the physical therapist plays an important role
in educating the patient and family about these sensations.
Noninvasive alternatives such as relaxation techniques, imag­
ery, desensitization, hypnosis, or therapeutic touch may be
effective adjuncts for pharmacological interventions aimed at
pain reduction.203,204
Transcutaneous electrical nerve stimulation (TENS) is
an effective adjunct for pain management for patients with
acute postsurgical pain.205–207 TENS may also play a role in
the management of troubling phantom sensation or pain in
the immediate postoperative period; however, its efficacy in the
prevention or management of phantom limb pain over time is
not well supported in the clinical research literature.208–210
Additional PT interventions that have been used to man­
age on postoperative pain include mechanical stimulation
(massage, vibration, percussion) and superficial heat (ultra­
sound, hot packs, cryotherapy) or cold; although there are
clinical reports of short-term pain relief, there are few stud­
ies that have carefully evaluated their efficacy.210 For any PT
intervention in the postoperative/preprosthetic period, it is
imperative to pay careful attention to the healing status of
the wound: wound closure must not be compromised by any
intervention that is aimed at reducing discomfort or pain.
Energy-based medicine therapies (e.g., mind–body con­
nection approaches, therapeutic touch, eye-movement
reprocessing and desensitization, and motor imagery) may
be alternative approaches to the management of acute and
chronic phantom limb pain, although there are few well-
designed and well-controlled studies of their efficacy.211,212
Mirror box therapy is being investigated as a strategy to min­
imize the development and severity of phantom pain after
amputation.213,214 This approach attempts to facilitate corti­
cal reorganization by accessing the mirror motor and sen­
sory neuron systems and prefrontal cortex in the brain.215–217
In the most commonly used paradigm, persons with amputa­
tion attempted to move their “missing” limb while simultane­
ously moving and observing reflected image of the movement
of the intact limb.218 Although preliminary evidence sug­
gests that this strategy may be helpful,218–221 more carefully
designed and controlled studies are necessary before it can be
widely adopted for clinical use. Mirror therapy is not without
adverse effects: Some individuals experience dizziness and
disorientation, or sense of irritation in their residual limb, or
do not tolerate the intervention, especially if mirror therapy is
concurrent with traditional prosthetic training.222
Limb Volume, Shaping, and Postoperative Edema
The management of postoperative edema is important for
four reasons: Edema control strategies are essential compo­
nents of pain control, enhance wound healing, protect the
incision during functional activity, and assist preparation
for prosthetic replacement by shaping and ­desensitizing the
residual limb.7 A variety of postsurgical dressing and edema
control strategies are available. These include soft dressings
with or without Ace wrap compression, semirigid dressings,
various removable rigid dressings (RRDs) applied over soft
dressings, or the application of a rigid cast dressing in the
operating room.223,224 An immediate or early postoperative
prosthesis (IPOP or EPOP) is a rigid dressing with an attach­
ment for a pylon and prosthetic foot.225,226 Pneumatic IPOP/
EPOP options are also available for early ambulation. Each
option contributes to pain control, wound healing and pro­
tection, and preparation for prosthetic use in a significantly
different way. The choice of strategy is determined by the eti­
ology and level of amputation, the condition of the skin, the
medical and functional status of the patient, access to pros­
thetic consultation and care, the preference and experience of
the surgeon, and established institutional protocol. Table 20-7
compares characteristics of the most commonly used postop­
erative/preprosthetic options.223–225
Soft Dressings and Compression
The traditional postoperative edema-control and wound-
management strategy is a soft dressing with or without com­
pression wrap. A nonadherent dressing is placed over the
suture line, sterile absorbant gauze fluff is then placed over
this, and one or more rolls of gauze is loosely overwrapped in
figure-of-eight pattern around the residual limb. A compres­
sive Ace bandage wrap may then be used in an effort to con­
trol some of the postsurgical edema. Although this method
continues to be the most frequently used immediate postsur­
gical option for patients with transfemoral amputation, or
when significant wound drainage and a high risk of infection
are present, soft dressings with Ace wraps are ineffective for
limiting postoperative edema.107,223,224 Soft dressings cannot
protect a healing incision from bumps, bruising, or shearing
during activity, or from fall-related injury. The other practical
disadvantage of elastic Ace bandage compression of the resid­
ual limb is the need for frequent reapplication: Movement
during daily activities quickly loosens the bandages, com­
promising the effectiveness of the compression. Most reha­
bilitation professionals suggest that Ace bandages should be
removed and reapplied every 4 to 6 hours and should never be
kept in place for more than 12 hours without rebandaging.227
Effective application of an Ace wrap requires practice,
manual dexterity, and attention to details if the desired distal-
to-proximal pressure gradient is to be achieved (Figures 20-12
and 20-13).67,227,228 It may be difficult for patients with limited
vision, arthritis of the hands and wrist, limited trunk mobil­
ity, or compromised postural control to master this technique
for independence in control of edema. Nurses, residents, sur­
geons, therapists, prosthetists, and family members (and any­
one else who may be taking down the soft dressing to care
for the wound) must be consistent and effective in reappli­
cation of the Ace bandage if maximal control of edema is to
be achieved. Ineffectively applied elastic wraps can lead to a
bulbous, poorly shaped residual limb, which is likely to delay
prosthetic fitting.228 Tight circumferential wrapping can sig­
nificantly compromise blood flow, compromising healing of
the incision and even leading to skin breakdown.228

562
Section III  Prostheses in Rehabilitation
TABLE 20-7  Comparison of Various Postoperative Options for Management of New Transtibial Residual Limbs Following Amputation
OUTCOMES

STRATEGY

Cost

Ease of Application

Wound Healing
Protection from
Trauma
Degree of
Postoperative Edema
Postoperative
Pain
Knee Flexion
Contracture Risk
Time to First
Prosthetic Fitting
Soft gauze dressing
without Ace
Inexpensive
Not difficult
Little impact
on primary
or secondary
healing
None
Significant
Often severe
Very high
Prolonged
Soft gauze with
Ace wrap
Inexpensive
Figure-of-eight
wrap requires
skill, frequent
reapplication
Little impact
on primary
or secondary
healing
None
Significant
Often severe
Very high
Prolonged
“Shrinker”
garment
Low to
moderate
cost
Requires UE
strength, dexterity
Used after primary
healing has
occurred
Minimal
Moderate
Somewhat less
Very high
Slightly shortened
Rigid dressing
(above knee cast)
Low cost
Requires training;
MD or CP
Reduces time to
primary healing
Excellent
Minimal
Minimized
Extremely low
Shortened
RRD (below knee)
Plaster/custom
Low to
moderate
cost
Requires training;
PT or CP
Reduces time to
primary healing
Very good
Minimal
Minimized
Moderate
Shortened
RRD
Prefabricated
(thigh level)
Moderate cost
CP custom fits
Reduces time to
primary healing
Very good
Minimal if worn
consistently
Minimized
if worn
consistently
Extremely low
Shortened
IPOP
Rigid dressing
Plaster/custom
Low to high
cost
CP applies in the
OR, or fabricates
Reduces time to
primary healing
if protected WtB
only
Very good
when worn,
protected WtB
only
Reduced if worn
consistently
Minimized
if worn
consistently
Low if worn
consistently
Shortened
IPOP: pneumatic



Moderate to
high cost


PT uses as part of
rehabilitation


Less evidence
about impact on
healing available

Very good
when worn,
protected WtB
only
Reduced if shrinker
worn between
IPOP use

Depends on
options
in place
between
IPOP use
Moderate if not
in thigh RRD
between use

Shortened



CP, Certified prosthetist; IPOP, immediate postoperative prosthesis; MD, physician; OR, operating room; PT, physical therapist; UE, upper extremity; ROM, range of motion; RRD, removable
rigid dressing; WtB, weight-bearing.
Data from Nawijn SE, van der Linde H, Emmelot CH, Hofstad CJ. Stump management after transtibial amputation: a systematic review. Prosthet Orthot Int. 2005;29(1):13-26; Smith DG,
McFarland LV, Sangeorzan BJ, et al. Addendum 1: Post-operative dressing and management strategies for transtibial amputations: a critical review. J Prosthet Orthot. 2004:16(S3):15-25; and
Walsh TL. Custom removable immediate postoperative prosthesis. J Prosthet Orthot. 2003;15(4):158-161.

Chapter 20  Postoperative and Preprosthetic Care
563
Some patients with bulbous or pressure-sensitive residual
limbs do not tolerate Ace wrap for compressions. An alterna­
tive to these patients, as well as for those with limited dexter­
ity, is application of a elasticized stockinet or Tubigrip sock
(Seton Health Care Group TLC, Oldham, England). Both
materials are available with various levels of elasticity; mini­
mal to significant compression can be achieved, depending on
the patient's tolerance of pressure. The double-layer method
starts with careful application of a long piece of elastic stocki­
net or Tubigrip over the transtibial residual limb to midthigh
level (Figure 20-14). The remaining length of elastic stocki­
net or Tubigrip is turned or twisted 180 degrees (to minimize
pressure over the new incision) and rolled over the residual
limb as a second layer of compression. As residual limb vol­
ume decreases and the limb becomes more pressure tolerant,
stockinet or Tubigrip with progressively narrower diameters
is used to increase compressive forces and assist limb shrink­
age and maturation. These materials are relatively inexpen­
sive, but they are not as durable as commercially available
elastic shrinker socks.
Pressure Garments: “Shrinkers”
Once the suture line has healed sufficiently, many prosthetists
and therapists recommend the use of a commercially man­
ufactured elasticized “shrinker” pressure garment whenever
the prosthesis is not being worn (Figure  20-15).82,228 These
garments are designed to apply significant distal to proxi­
mal graded compressive force to the residual limb, and it may
be difficult for individuals with limited manual dexterity or
upper extremity strength to apply them. Patients with recent
amputation must be careful to minimize or avoid excessive
shear forces over the incision as the shrinker is being applied.
Although shrinkers are effective for control of edema and
limb volume, it is not possible to create “relief” for bony
prominences or pressure-vulnerable areas on the residual
limb. As with other soft dressings, commercial shrinkers can­
not protect the residual limb from trauma during daily activi­
ties or in the event of a fall. It is not unusual for patients to
continue to use a shrinker for limb volume control, whenever
they are not wearing their prosthesis, for 6 months to a year
after amputation.82
Although a number of edema control options are available
for persons with transtibial amputation, those with trans­
femoral residual limbs have fewer strategies from which to
choose. Commercially manufactured shrinkers are more con­
venient to don and are more likely to remain in place than
the more cumbersome Ace wraps, but those who choose this
option must be just as careful to capture all the soft tissue high
in the groin within the shrinker to avoid the development of
an adductor roll, redundant tissue that may make prosthetic
1
2
3
4
5
6
FIGURE 20-12  The application of an effective Ace wrap to a transtibial residual limb uses succes­
sive diagonal figure-of-eight loops between the distal residual limb and thigh to create a distal-to-
proximal pressure gradient. This creates a distal-to-proximal, tapering, cylindrical residual limb with
minimal excess distal soft tissue. (Modified from Karacollof LA, Hammersley CS, Schneider FJ. Lower
Extremity Amputation. Gaithersburg, MD: Aspen, 1992. pp. 16-17.)

564
Section III  Prostheses in Rehabilitation
fitting more challenging. Another alternative for those with
transfemoral amputation is a custom-fit Jobst pressure gar­
ment. Jobst garments can be fabricated either as a half-pant or
full pant garment; the full pant garment achieves a more con­
sistent suspension and compression, especially for patients
who are obese. A Jobst garment may be the only effective
alternative for patients with short transfemoral amputation.
Because shrinkers, Tubigrip, and prosthetic socks worn
over a healing residual limb are permeable, they absorb per­
spiration from the skin of the residual limb, as well as any
1
4
5
9
10
2
3
6
7
8
FIGURE 20-13  The application of an effective Ace wrap to a transfemoral limb also strives to cre­
ate a distal-to-proximal pressure gradient using a modified figure-of-eight pattern. For patients with
transfemoral amputation, the wrap is anchored around the pelvis and applied to pull the hip toward
hip extension and adduction. Note the importance of capturing soft tissue high in the groin within the
Ace wrap, to reduce the risk of developing an adductor roll of noncompressed soft tissue. (From May
BJ. Amputation and Prosthetics: A Case Study Approach. Philadelphia, PA: F. A. Davis, 1996. p. 84.)
FIGURE 20-14  One strategy to control edema and manage limb volume is to use a double layer of
an elastic stockinet or Tubigrip to apply compressive forces to the limb. After the initial layer
(A) has been smoothly applied, the stockinet is twisted closed (B) at the end of the limb and the excess
is applied (C) as a second layer of compression.

Chapter 20  Postoperative and Preprosthetic Care
565
drainage from the suture line. For this reason they must be
laundered daily in warm water and a mild soap. Cotton, wool,
or elasticized materials do not tolerate the heat and turbu­
lence of a clothes dryer; most prosthetists recommend that
shrinkers and socks be smoothed out on a flat surface to dry.
The person wearing the garment must have a sufficient num­
ber available in order to apply compression around the clock.
Nonremovable Rigid Dressings
Many surgeons opt to use a cylindrical plaster or fiberglass
cast placed on the new transtibial residual limb in the operat­
ing room immediately after amputation (Figure 20-16).71,82,229
Rigid dressings accomplish three very important postopera­
tive goals: (a) control of immediate postoperative edema (and
subsequently, reduction of postoperative pain); (b) protection
of the vulnerable newly sutured residual limb from inadver­
tent trauma during bed mobility, transfers, and single limb
ambulation; and (c) prevention of postoperative knee flexion
contracture. All three of these goals help to reduce time to ini­
tial prosthetic fitting.88,229,230
A rigid dressing is a simple postoperative cast applied in
the same way as a cast that is used to immobilize a frac­
ture of the proximal tibia or distal femur. The newly sutured
surgical construct is dressed with gauze, and a cottonette or
Tubigrip “sock” is pulled over the residual limb. A layer of
cast padding is applied smoothly over the stockinette, and
extra cushioning is placed to protect the patella and femoral
condyles. The knee is placed in as close to a fully extended
position as possible, and fast drying plaster of paris or fiber­
glass casting material is wrapped around the limb, at least to
the level of upper thigh (2 to 4 inches below the perineum).
The stockinette is then folded over the proximal edge of
the newly applied cast, and is incorporated into one or two
addition wraps of casting material to finish the proximal
border of the cast.
Modifications of the cast as it is setting or drying, such as
molding it fit closely over the supracondylar thigh are used to
aide suspension. A strip of webbing may be incorporated on
the anterior surface for attachment to a waist belt to further
aide to suspension. If the cast is to be used as the base for an
immediate postoperative prosthesis (discussed in more detail
below), the prosthetist modifies the cast as in a patellar ten­
don bearing socket to insure that weight-bearing forces are
directed to pressure tolerant areas of the limb and that bony
prominences and the suture line are well protected.
The initial rigid dressing stays in place on the residual
limb for 2 to 5 days postoperatively (or more), depending on
the patient's condition and the surgeon's preference.82,88,223,224
When the cast is removed, the status of the wound is carefully
inspected. If the wound is healing well, the physician may opt
for reapplication of the cast for an additional period, which
varies by protocol used, of between 5 and 21 days. If the status
of the wound is questionable or risk of infection high, an alter­
native method of edema control that allows more frequent
wound inspection and care must be used. Some physicians
opt to replace a thigh-encasing rigid dressing with a remov­
able rigid dressing after the first cast is taken off, regardless of
wound status.
Application of a rigid cast, especially if it is the base of
an immediate postoperative prosthesis (discussed below)
requires careful attention to anatomy and alignment, well-
developed manual skills, and a clear understanding of pros­
thetic principles. A poorly applied or inadequately suspended
rigid dressing can lead to skin abrasions or pressure-related
ulcerations over bony prominences, delaying prosthetic fit­
ting until wound healing occurs. Pistoning or rotation of the
rigid dressing on the residual limb can apply distracting forces
over the suture line, compromising healing and increasing the
risk of ecchymosis or dehiscence.
A major criticism of thigh-level nonremovable rigid dress­
ings is that the cast prevents visual inspection and monitor­
ing of the new surgical wound, and limits access for wound
care.229 For this reason a nonremovable rigid dressing may
not be appropriate for those with significant risk of infection,
especially if wounds were potentially contaminated during
traumatic injury. Wound status can only be monitored indi­
rectly, using body temperature, white blood cell count, size
and color of drainage stains on the cast, and patient reports
of increasing discomfort and pain as indicators of a develop­
ing infection.
There are several strategies that physicians and prosthe­
tists have to address access to the healing while providing the
protection and other benefits of nonremovable rigid dressing.
FIGURE  20-16  A plaster or fiberglass cast, applied immediately
after amputation in the operating room, is an effective method of
edema control, protection of the residual limb, and prevention of
knee flexion contracture.
FIGURE 20-15  Examples of commercially available transfemoral
(left) and transtibial shrinkers used for edema control and shaping
of the residual limb.

566
Section III  Prostheses in Rehabilitation
One is to bivalve the cast, so that it can be removed for short
periods to allow wound care (Figure  20-17). Prefabricated
rigid dressings, custom fit by the prosthetist to the individual
with new amputation, are also available.231
Removable Rigid Dressings
The RRD is a “cap” cast worn over a soft or compressive dress­
ing (Figure 20-18).232 This edema-control strategy effectively
protects the healing residual limb and helps to limit the devel­
opment of edema. RRDs are used in three circumstances. For
some individuals managed with a nonremovable rigid dress­
ing applied in the operating room, the next step in postopera­
tive edema control may be fabrication of an RRD. For others
the RRD is applied instead of a cylindrical cast in the operat­
ing room. The RRD can also be fabricated after surgery for
those initially managed with soft dressings and elastic ban­
dages. The physical therapist may be responsible for fabrica­
tion of the RRD, working in collaboration with the surgeon,
surgical nurse, or prosthetist.
One of its major advantages, when compared with a cylin­
drical cast, is the ability to doff (remove) and don (apply) the
RRD quickly and easily to monitor wound healing and pro­
vide daily wound care. Use of an RRD also assists residual
limb shaping and shrinkage; patients who wear RRDs are
often ready for prosthetic fitting more quickly than those
managed with soft dressings or Ace wraps alone.233,234 Because
the RRD limits the development of edema, it is an important
adjunct in the management of postsurgical pain. The protec­
tive cap limits shearing across the incision site as the person
recovering from amputation surgery moves around in bed
or during therapy; this soft tissue immobilization can assist
wound healing.
The RRD is not as likely to become displaced or dislodged
during activity when compared to Ace wrap compression.
The ease of donning and doffing means that individuals with
new amputation can quickly become responsible for this task
FIGURE 20-17  Example of a custom, removable, immediate post­
operative cast (A) bivalved at first dressing change and held closed
with Velcro straps. B, Interior view of the immediate postoperative
prosthesis with gel pads placed to protect the distal anterior tibia and
patella. (From Walsh TL. Custom removable immediate postopera­
tive prosthesis. J Prosthet Orthot. 2003;15(4):160.)
B
A
FIGURE 20-18  A, This removable rigid dressing has been donned over a nylon sheath and five-ply wool prosthetic sock, with an additional foam
pad at the proximal anterior edge for comfort and protection of the skin. Marking the anterior midline of the cast ensures that it will be applied in opti­
mal alignment. B, The removable rigid dressing is held onto the limb by application of an elasticized Tubigrip, sewn closed at one end and pulled up to
midthigh level for a sleeve suspension. A Velcro-closing thermoplastic or woven supracondylar strap is applied over the sleeve to ensure suspension.

Chapter 20  Postoperative and Preprosthetic Care
567
component of caring for their residual limb. Because the RRD
is removed and reapplied several times a day for wound care,
the residual limb quickly becomes desensitized and toler­
ant of pressure, which assists transition to prosthetic wear.
Fabrication and use of an RRD provide the opportunity to
educate those new to prosthetic use about the fabrication of
a preparatory prosthesis and the use of prosthetic socks to
obtain and maintain socket fit.
The RRD is most appropriate for patients whose trans­
tibial incision appears to be in the initial stages of healing.
Although the wound may be inflamed secondary to the
trauma of surgery, no signs of infection, significant ecchy­
mosis, or large areas of wound dehiscence should be pres­
ent. Those with substantial drainage from their surgical
wound requiring bulky soft dressings and frequent dress­
ing changes are not good candidates for RRD; it is difficult
to accommodate distally placed bulky dressings within the
RRD shell. Those with fluctuating edema secondary to
CHF or dialysis can be managed with an RRD if it is fabri­
cated when limb volume is high: Layering prosthetic sock
ply over the limb before putting on the RRD accommo­
dates for volume loss. The RRD works best if distal residual
limb circumference is no more than 0.5 inch larger than
its proximal circumference. Compressive dressings may
be more appropriate for patients with extremely bulbous
residual limbs.
The residual limb is prepared for casting by first plac­
ing a protective layer of gauze fluff over the suture line.232,235
The limb can be loosely wrapped in plastic wrap to assist
removal of the completed RRD after casting. Next, a “sock”
made from elasticized cotton stockinet or Tubigrip is applied
over the limb, with particular care to avoid shearing across
the suture line. Pieces of Webril or a similar filler material are
layered around the limb to create reliefs within the RRD for
bony prominences (tibial crest, fibular head, distal tibia) and
the hamstring tendons. When the distal residual limb has a
larger circumference, additional padding is added proximally
to ensure that the RRD will be cylindrical and easily donned.
A long sock made from regular cotton stockinet is carefully
donned over the padding; this will be the inner layer of the
finished RRD. The outline of the patella marked on the stock­
inet will serve as a guide for trim lines after the cast has dried.
Typically, two rolls of fast-setting plaster cast material are suf­
ficient for an RRD. The residual limb is supported in full knee
extension, and successive layers of plaster are smoothed into
place, building a cast with an anterior trim line at midpatella
and a slightly lower posterior trim line to allow knee flexion
without tissue impingement.
The cotton stockinet sock is then folded down over the
cast at the knee, and several additional circumferential layers
of plaster are used to finish and reinforce the proximal brim
(to ensure that the RRD can subsequently withstand repeated
donning/doffing). An Ace wrap can be applied to provide
additional compression while the plaster sets. Once the RRD
has hardened sufficiently, the patient is asked to flex the knee
slightly and the cast is carefully removed from the residual
limb. The extra Webril or padding is pulled out of the RRD,
and the inner surface is inspected for potentially problematic
rough areas or ridges. Because the RRD is almost cylindrical,
it is helpful to mark the front of the cast to ensure that it is
correctly donned.
Before the completed RRD is applied, one or two gauze
pads are placed over the suture line for protection. A pros­
thetic sock, Tubigrip, elasticized stockinet sock, or com­
mercially manufactured “shrinker” is carefully donned, with
minimal shear stress across the suture line. Additional ply of
prosthetic socks are used as needed to ensure a snug fit within
the RRD. A small amount of Webril or other fluffy padding
is placed in the distal anterior RRD to protect the distal tibia
and suture line; then the RRD is carefully slipped onto the
residual limb, aligning the markings on the front of the RRD
with the patella for optimal fit (see Figure 20-18, A). A small
foam filler or cushion can be placed between the anterior
brim and residual limb to minimize the risk of friction during
activity. The outer Tubigrip or stockinet suspension sleeve is
then rolled over the RRD and onto the thigh, the supracondy­
lar strap is secured in place, and the sock is folded back down
over the strap to minimize the risk of loss of suspension. The
skin must be inspected within the first 60 to 90 minutes of
initial fitting with an RRD to assess skin integrity and iden­
tify potential pressure-related problems. If no skin problems
develop, routine wound inspection once per nursing shift is
usually adequate.
The RRD is designed to be worn continuously, even when
sleeping, except during routine wound care or bathing. If the
individual with recent amputation is expecting to be out of
the RRD for more than several minutes, another form of com­
pression such as a shrinker or several layers of Tubigrip must
be available to minimize the development of edema. The
individual wearing an RRD must be encouraged to report
any localized pain or discomfort as signs of potential prob­
lems with RRD fit or function. Layers of prosthetic sock are
added, over time, as the residual limb “shrinks.” There is some
evidence polymer gel socks worn under a removable rigid
dressing may help to control edema and associated pain, and
reduce the time to prosthetic fitting.236 Sometimes short distal
socks are necessary to provide for distal compression without
excessive proximal bulkiness that can prohibit donning. The
consistent use of 12- to 15-ply socks to achieve appropriate fit
usually indicates the need for fabrication of a smaller RRD.
Significant change in the shape or configuration of the resid­
ual limb also requires fabrication of a new RRD.
The referral for fabrication of the initial (preparatory or
training) prosthesis can occur within 12 to 17 days of sur­
gery if the incision has healed sufficiently. Many individuals
continue to use their RRD in conjunction with a shrinker
for control of edema and limb protection whenever they are
not wearing their prosthesis for as long as 6 months after
surgery.
Removable Polyethylene Semirigid Dressings
An alternative to a plaster RRD is a removable polyethylene
semirigid dressing (SRD; Figure 20-19).237 Like the RRD, the
SRD is an effective strategy for control of edema, protection
of the healing incision, and shaping of the residual limb.238
Unlike the RRD, however, the SRD requires the skill of a

568
Section III  Prostheses in Rehabilitation
prosthetist for fabrication. The prosthetist may take a nega­
tive mold of the patient's residual limb while in the operating
room or when the rigid dressing is removed on the third or
fourth postoperative day. A positive model is created using
the negative mold and is modified to incorporate reliefs for
pressure-intolerant areas of the residual limb. The polyethyl­
ene is heated and vacuum molded over the positive model in
the same way that a thermoplastic socket would be. The poly­
ethylene SRD is often ready for delivery in 2 or 3 days after
casting. When someone is initially casted for a polyethylene
SRD in the operating room before being placed in a plaster or
fiberglass cast, the SRD may be delivered on the day that the
rigid plaster dressing is removed.
The polyethylene SRD has several advantages when com­
pared with the plaster of Paris RRD. First, polyethylene is
easier to clean; as a result, hygiene of the residual limb may
be improved. The polyethylene SRD is lighter in weight and
somewhat more durable than a plaster RRD; it does not melt
if exposed to liquids. The flexibility of the material makes
it easier to don and doff than the stiff plaster RRD. Because
the polyethylene SRD closely resembles a transtibial socket,
greater carryover about proper use of prosthetic socks for
optimal fit in the socket of the initial (preparatory, temporary,
or training) prosthesis is likely.
The major disadvantage of a polyethylene SRD is the cost
associated with casting and fabrication. Because most resid­
ual limbs become progressively smaller with maturation in
the weeks and months after amputation, several successfully
smaller SRDs may need to be fabricated as the limb shrinks.
In some settings plaster RRDs are used until the initial pros­
thetic fitting. At that point the prosthetist makes a polyethyl­
ene SRD in addition to the socket for the training prosthesis.
Some companies now offer a prefabricated adjustable SRD
with Velcro closures as an alternative to the custom-molded
polyethylene SRD.
Zinc Oxide Impregnated Semirigid Dressing
Another postoperative strategy is the fabrication of a SRD
using a zinc oxide impregnated Unna bandage. Unna is most
often used in the management of chronic venous stasis ulcers
(Unna boot)239; because it appears to enhance healing, it has
been also been used as a strategy to control edema and facili­
tate healing following transtibial amputation.240 As the unna
dressing dries, it provides nonelastic external support to the
residual limb, preventing development of edema. The Unna
dressing is, basically, a roll of gauze impregnated with zinc
oxide, triglycerine, calamine, and gelatin. This pasty dressing
easily adheres to the skin on application, drying to a semi­
rigid leathery consistency within 24 hours. Typically, an Unna
dressing would be applied to the residual limb immediately
after wound closure in the operating room.240 Although not as
rigid and protective as a RRD or SRD, Unna paste dressings
are more effective in limiting postoperative edema than are
soft dressings and Ace wrapping.240 An Unna SRD can be left
on for as long as 5 to 7 days; if more frequent wound inspec­
tion is desired, it can be easily removed with bandage scissors.
Because the Unna dressing remains in place for an extended
period, fewer opportunities are available for limb desensiti­
zation and patient education about socket fit compared with
those for the RRD and polyethylene SRD.
Pneumatic Compression for Early Ambulation
The deconditioning associated with inactivity is a particu­
lar concern in the postoperative and preprosthetic periods.
Ambulation on a single limb, however, can be quite chal­
lenging for persons with a high comorbid burden of illness.
Although pneumatic compression (such as the air splints use
for immobilization following acute fracture) is relatively inex­
pensive and can be quickly removed and reapplied for wound
inspection, the compression tends to be uneven, so shaping
of the residual limb is not as effective as other methods. The
splint can be uncomfortably hot if worn for more than 20 to
30 minutes. Its major benefit, however, is that it allows early
protected weight bearing on the residual limb; this is espe­
cially beneficial for individuals who are physically or func­
tionally frail.241 The air splint provides limited mobility for
patients who would not otherwise be ambulatory and may be
a useful means of assessing the potential for prosthetic reha­
bilitation. Several air-filled early prosthetic options exist for
compression in the postoperative and preprosthetic periods
(Figure 20-20).242–245
When donning a pneumatic compression device for early
ambulation, the suture line is covered with smooth gauze pads
for protection. Prosthetic socks, stockinet, or Tubigrip is then
applied over the residual limb before the air splint is inflated. Felt
pads are strategically placed over the residual limb's soft dress­
ing, or a shrinker loads pressure-tolerant areas (medial tibial
flare and patellar tendon) while protecting ­pressure-sensitive
FIGURE 20-19  A flexible, polyethylene semirigid dressing is fab­
ricated by a prosthetist over a positive model of the patient's resid­
ual limb. This ensures an intimate fit for effective control of edema,
protection of the healing incision, and optimal “shaping” of a new
residual limb.

Chapter 20  Postoperative and Preprosthetic Care
569
areas (crest of the tibia and fibular head) after inflation
of the air splint. The sleeve is zipped into place around the
limb, and the limb is positioned in the frame before infla­
tion. The sleeve is inflated with a hand or foot pump to an
air ­pressure of 35 to 40 mm Hg. This low pressure sustains
toe touch to partial weight without compromising capillary
blood flow to the healing suture line. Recently a variety of
prefabricated pneumatic immediate postoperative prosthe­
ses, with inflatable air bladders within an adjustable closure
polyethylene “socket,” has become available.246–249
Rigid Dressing as a Base for Immediate Postoperative
Prosthesis
When a nonremovable rigid dressing is to be used as an IPOP,
a prosthetist joins the surgical team in the operating room
during cast application to incorporate the features of a patel­
lar tendon-bearing socket and an attachment for a pylon into
the cast (Figure 20-21).250 Several felt or gel pads are posi­
tioned on the limb to direct and distribute weight-bearing
forces more effectively onto pressure-tolerant areas (e.g.,
medial tibial flare, anterior muscle compartment, patellar
tendon). The residual limb is then supported with the knee
extended, and several layers of elastic or nonelastic plaster of
Paris or fiberglass casting material are applied. The proximal
edges of the cast are finished at the upper thigh (2 to 4 inches
below perineum) level. Modifications of the cast (as it is set­
ting) are used to aid suspension or, for an IPOP, to ensure
that weight-bearing forces are directed to pressure-tolerant
areas. Pressure applied to the outside of the cast just above the
femoral condyles captures normal femoral anatomy to create
supracondylar suspension. For an IPOP, the prosthetist incor­
porates a patellar tendon bar, a broad “shelf” for the medial
tibial flare, and a stabilizing popliteal bulge by applying man­
ual pressure to these areas as the cast begins to set. The pros­
thetist also incorporates a point of attachment and alignment
into the distal cast for subsequent attachment of a pylon and
prosthetic foot. Finally, the prosthetist or surgeon can incor­
porate a suspension attachment, which will connect to a waist
belt, into the proximal anterior surface of the cast.
The early mobility afforded by application of an IPOP may
be important for individuals with new amputation who would
otherwise be unable to achieve single limb ambulation with a
walker or crutches, especially those who are at significant risk
A
B
FIGURE 20-20  A, An air splint and prosthetic frame may provide
limited ambulation for patients who are unable to accomplish sin­
gle limb gait with an assistive device. The splint is inflated within
the frame to 35 to 40 mm Hg, allowing toe touch to partial weight
bearing, with minimal risk to the healing incision. B, The Aircast
Airlimb, an example of a commercially available, noncustom, pneu­
matic, immediately postoperative prosthesis. (Courtesy Aircast Inc.,
Summit, N.J.)
FIGURE 20-21  Incorporation of a pylon and features of a patel­
lar tendon–bearing socket in an immediate postoperative prosthesis
(IPOP) can facilitate early mobility in selected patients.

570
Section III  Prostheses in Rehabilitation
of functional decline, physiological deconditioning, or atelec­
tasis and pneumonia secondary to inactivity and immobiliza­
tion. Although an IPOP replaces the amputated limb with a
pylon and prosthetic foot, limited and protected weight bearing
is essential in the early postoperative period: most physicians
suggest toe-touch or ­partial weight bearing. Shearing forces that
result from excessive weight shift and repeated loading of the
residual limb in an IPOP can compromise or delay wound heal­
ing.250 Because of this risk, an IPOP is inappropriate for frail or
confused individuals who are likely to be unreliable about lim­
iting weight bearing. Many proponents of IPOP suggest that
gradual controlled application of mechanical stress to healing
connective tissues actually assists tissue modeling for better tol­
erance of the mechanical stresses of prosthetic wear and ambu­
lation. Although the early application of mechanical stresses is
apparently well tolerated by wounds with adequate blood sup­
ply, ischemic wounds tolerate only minimum stress in their
healing phase.
Selecting the Appropriate Compression Strategy
In deciding which edema control and limb-shaping strategy
is most appropriate, the rehabilitation team should consider
the following questions:
1. Can the person don/doff the device independently? If
not, is a family member available who can assist with
this task?
2. Given the individual's physical characteristics and
likely level of activity, will the device remain securely in
place on the residual limb?
3. Will the device apply enough compression for effective
progressive limb shrinkage?
4. Will the device apply enough compression for symmet­
ric shaping of the residual limb?
5. Will the device protect the skin and healing suture line
during daily activities, and does use of the device carry
any risk of skin irritation or breakdown?
6. Is the device comfortable for the patient to use or wear
over the long periods of time that are required for effec­
tive control of edema and limb shaping?
7. Is the device relatively cost-effective in terms of fabrica­
tion, modification, and replacement?
Monitoring tissue tolerance and potential areas of pressure
closely in whatever edema control method is chosen is very
important, especially in the first few days and weeks after ampu­
tation. Although rigid dressings, IPOPs, and Unna dressing
remain on the limb for extended periods, each other method
of edema control and shaping should be removed and reap­
plied a minimum of three times each day to assure appropriate
fit and tissue tolerance in the acute phase of healing. When a
rigid cast or IPOP is removed, it must be quickly replaced with
an alternative compression device so that limb volume does
not increase substantially. Individuals with recent amputation
must wear the compression device at all times unless walking
in a training prosthesis (even time out of compression during
bathing should be as short as possible). Most people find that
a compression device is necessary to maintain the desired limb
volume for 6 months to a year after surgery. Some persons with
mature residual limbs who have fluctuation in volume because
of concurrent medical conditions continue to require compres­
sion well beyond the first postoperative year.
Many people with amputation experience a transient
increase in residual limb volume after a shower or bath­
ing; they often choose to bathe in the evening so that vol­
ume change does not interfere with prosthetic use. Those
who prefer to bathe in the morning may need to use a com­
pression device immediately after bathing to achieve optimal
prosthetic fit and suspension, especially if suction suspension
(which requires consistent limb volume) is used. Those who
use prosthetic socks may require a few less ply of sock imme­
diately after bathing but need to add a few more ply after a few
hours as limb volume decreases.
Skin Care and Scar Management
It is important that the healing incision move without adher­
ence to underlying deep tissue or bone as healing progresses.
There must be sufficient gliding between skin and underlying
layers of soft tissue after healing so that shear forces will be
minimal while the prosthesis is donned and used for func­
tion. An adherent scar at the distal tibia can be quite prob­
lematic: If a point of adherence is present along an incisional
scar, the mobility of tissues will be compromised. The result­
ing traction and shear forces are likely to lead to discomfort,
skin irritation, and often recurrent breakdown of soft tissues
with prosthetic use. Once primary healing has been estab­
lished, the person with recent amputation learns to use gentle
manual massage to enhance tissue mobility in preparation for
prosthetic use. At first, this is performed above and below, but
not across, the incision to minimize the risk of dehiscence.
When the wound is well closed and Steri-Strips are no lon­
ger necessary to support and protect the incision, gentle mobi­
lization of the scar itself can begin. Handling of the limb during
soft tissue mobilization and massage not only minimizes adhe­
sion formation but also helps the individual to adapt his or her
body image to include the postamputation residual limb and
prepare for the sensory experience of prosthetic use.251,252
Persons with new amputation may have surgical scars from
previous vascular bypass or from harvesting veins for coronary
artery bypass surgery. These may require carefully applied soft
tissue mobilization or friction massage to free adhesions and
restore the mobility of the skin. Those with traumatic amputa­
tion may have healing skin grafts or abrasions from road burn,
thermal injury, or electrical burn. In such cases wound care
and debridement are important components of preprosthetic
rehabilitation. For individuals with healing burns or skin graft,
the use of an appropriate compression garment or shrinker
assists healing and maturation of skin, controls postoperative
edema, and shapes the residual limb.
Once the sutures have been removed, normal bathing
resumes and a routine for daily skin care is established. Most
physicians, prosthetists, and therapists recommend daily
cleansing of the residual limb with a mild, nondrying soap.
Patting or gently rubbing the limb with a terry cloth towel
until it is fully dry also helps to desensitize it in preparation for
prosthetic use. A small amount of moisturizer or skin cream

Chapter 20  Postoperative and Preprosthetic Care
571
can be applied if the skin of the residual limb is dry or flaky.
A limb with soft, healthy pliable skin is much more tolerant
of prosthetic wear than a limb with tough, dry, easily irritated
skin. Persons with new amputation and their caregivers are
taught to inspect the skin of the entire residual limb carefully,
using a mirror if necessary to visualize difficult-to-see areas.
Areas over bony prominences that may be vulnerable to high
pressure within the socket are especially important to assess.
Persons with amputation are as likely to have other derma­
tological conditions such as eczema or psoriasis as the general
population.253–255 Those with hairy limbs or easily irritated
skin may be more at risk of folliculitis and similar inflamma­
tory skin conditions once the prosthesis is worn consistently.
Effective early management of skin irritation or other skin
problems is important: Serious skin irritation or infection
precludes prosthetic use until adequate healing has occurred.
Some persons with new amputation mistakenly assume
that something must be used to “toughen” the skin in prepa­
ration for prosthetic use. They may opt to rub the skin with
alcohol, vinegar, salt water, or even gasoline, erroneously
thinking that this will make the skin thicker and more pres­
sure tolerant. In fact, these “treatments” can damage the skin,
making it more susceptible to pressure-related problems.
Patient and family education about effective cleansing and
skin care strategies is essential in the early postoperative/­
preprosthetic period.
Range of Motion and Flexibility
Persons with transtibial amputation are at significant risk of
developing both knee and hip flexion contractures. Those with
transfemoral amputation are very likely to develop hip flexion
and external rotation contracture. Such contractures cause sub­
stantial problems for prosthetic fit and alignment, as well as on
efficiency of walking with a prosthesis. Impairment of extensi­
bility of two joint muscles, such as the hamstrings and rectus
femoris, may not be obvious when an individual is seated, but
may have profound impact on comfort when wearing a pros­
thesis during functional activities. For this reason, proper posi­
tioning is a key component of preprosthetic rehabilitation.
Prolonged dependence of the residual limb held in
knee flexion when sitting also leads to development of dis­
tal edema, which can delay readiness for prosthetic fitting.
Persons with transtibial amputation must maintain the knee
in as much extension as possible, whether in bed, sitting in
a wheelchair or lounge chair, or during exercise and activity.
Although it may be comfortable to place a pillow under the
knee when sitting or lying in bed, a more effective strategy is
to position a small towel roll under the distal posterior resid­
ual limb to encourage knee extension (Figure 20-22). Use of a
wheelchair with elevating leg rests on the side of the amputa­
tion helps to keep the residual limb in an extended position,
although a “bridge” between the seat and calf support may
be necessary for those with short residual limbs. In some set­
tings the therapist fabricates a posterior trough splint from
low-­temperature thermoplastic materials; this splint supports
the limb in knee extension when the individual with recent
amputation is ­resting in bed or sitting in a wheelchair.
If the individual is able to assume prone position, the weight
of the limb can be used to assist elongation of the hamstring
muscles and soft tissue of the posterior knee (Figure 20-23).
A small towel roll positioned just above the patella effectively
positions the limb for elongation. Although there is little con­
clusive evidence in the research literature about contracture
management in persons with recent lower limb amputation,
evidence from studies of soft tissue contracture following
total knee arthroplasty suggest that prolonged stretching,
dynamic splinting, and manual therapy may be effective fol­
lowing amputation as well.256–258 Stretching programs also
have a positive impact on the quality and efficiency of gait
in older adults.259 What is not well understood is the inten­
sity necessary if stretching is to prevent or minimize degree
A
B
FIGURE  20-22  The optimal position for individuals with recent
transtibial amputation is in full extension. A, A small rolled towel,
bolster, or pillow placed under the distal posterior residual limb
encourages knee extension, while (B) support under the knee makes
development of knee flexion contracture more likely.
FIGURE  20-23  Prone positioning for stretching of the posterior
soft tissue and prevention of knee flexion contracture. A small towel
roll placed just above the patella elevates the residual limb from
the surface of the mat or bed. The therapist can use hold–relax or
contract–relax techniques, or the patient can actively contract the
quadriceps to assist elongation of the hamstrings and posterior soft
tissues.

572
Section III  Prostheses in Rehabilitation
of contracture formation, especially if there is also evidence
of central nervous system dysfunction.260–262 Intervention
strategies currently used to target joint ROM and flexibility
include proprioceptive neuromuscular facilitation hold-relax
or contract-relax263,264 and myofascial release.265 Although the
strength of the clinical research evidence on interventions for
stretching and flexibility following lower limb amputation is
low, the consequences of not attending to risk of contracture
development are substantially negative. Converging recom­
mendations by experts strongly support that interventions
aimed at contracture prevention or minimization are essential
in the postoperative/preprosthetic period.266–270 Readers are
referred to Stretching and Strengthening for Lower Extremity
Amputees (Miami, FL: Advanced Rehabilitation Therapy Inc.)
and to Facilitated Stretching (Champaign, IL: Human Kinetics),
for more detailed information about designing exercise
programs for stretching and flexibility.
Persons with recent amputation are instructed how to
perform exercises (done at the bedside while an inpatient
or at home while an outpatient) that are designed to elon­
gate muscles and soft tissue to counteract the tendency to
develop tightness, especially in two-joint muscles. Performed
independently or with the assistance of a family member or
caregiver several times a day, these stretching exercises are as
important as individualized PT sessions during preprosthetic
and prosthetic rehabilitation.
Significant hip flexion contracture can render a person
with transfemoral amputation ineffective in controlling a
prosthetic knee unit and walking with a prosthesis. Persons
with recent transfemoral amputation tend to hold their resid­
ual limb diagonally outward when seated, unconsciously
and automatically increasing their seated base of support to
enhance postural stability. If they spend significant amounts
of time in a seated position, development of hip flexor,
abductor, and external rotator tightness is almost inevitable.
PT interventions that elongate these soft tissues, including
manual stretching, active exercise, and functional postural
training, are used to counteract the tendency for tightness
to develop.266–272 Resting in a prone position with a towel roll
under the distal anterior residual limb provides prolonged
elongation for tight hip flexors. Care must be taken, however,
to maintain a neutral pelvis or slight posterior tilt when lying
prone. Excessive hip flexor tightness leads to lordosis of the
lumbosacral spine.
Muscle Performance
Strengthening programs have two goals: (a) remediation
of specific weaknesses detected in the examination and (b)
maximization of overall strength and muscular endurance
for safe, energy-efficient prosthetic gait. Because functional
activities require use of muscles at varying lengths and types
of contraction, effective preprosthetic exercise programs
include activities that require concentric, holding (isometric),
eccentric, and cocontraction in a variety of positions and
muscle lengths.266–272 In the immediate postoperative period
the specific strengthening program is often a combination of
isometric and active isotonic exercise within a limited ROM
of the joint just proximal to the amputation.266–272 This strat­
egy minimizes stress or tension across the incision while pre­
serving and improving the strength of key muscle groups. It is
as important to include strengthening exercise for the intact
(nonamputated limb) as for the residual limb. Core stability
also needs to be addressed.
Incorporation of controlled exhalation during isomet­
ric contraction minimizes the risks to cardiac function and
fluctuations of blood pressure that are associated with the
Valsalva maneuver.273 For persons with transtibial ampu­
tation, exercises to strengthen knee extension that are ini­
tiated within the first week of amputation might include
“quad sets” in the supine position or “short arc quads” per­
formed in the supine or sitting position. For those with
transfemoral amputation, “glut sets” in the prone or supine
position or “short arc” hip extension and abduction in a
gravity-eliminated position would be initiated. Gailey269
­recommends an exercise strategy of slow, steadily controlled,
10-second muscular contraction, followed by 5 to 10 seconds
of rest, for 10 repetitions as one that is easily learned and
physiologically sound. As wound healing is accomplished,
exercises can be progressed to include active exercises
through larger arcs of motion, active resistive exercise
(using weights or manual resistance), or isokinetic train­
ing. Application of manual resistance during functional
activities, as in proprioceptive neuromuscular facilitation,
allows the therapist to provide appropriate resistance as
muscle strength varies throughout the active ROM while
providing facilitation and augmented sensory feedback to
the patient.274,275 Progressive resistive exercise for strength
development (low repetition-high load) as well as muscu­
lar endurance (high repetition-low load) are key should also
be included.276–279 Readers are referred to ACSM's Exercise
Management for Persons with Chronic Disease and Disability
(Champaign, IL: Human Kinetics, 2002), Therapeutic
Exercise: Foundations and Techniques (Philadelphia, PA:
F.A. Davis, 2007) and Essentials of Strength Training and
Conditioning (Champaign, IL: Human Kinetics, 2008) for
information on designing progressive resistive exercise pro­
grams of adequate intensity and duration.
Isokinetic exercise, involving both concentric and eccen­
tric contraction, allows the patient to develop muscle strength
and control at a variety of movement velocities and has a
marked positive impact on functional ability.278–282 Isokinetic
exercise, if prescribed properly, is well tolerated by older
adults, even at speeds of 180 degrees per second angular
velocity.283
For individuals with transtibial amputation, attachments of
the quadriceps and hamstrings are typically intact, and pre­
prosthetic strengthening exercises emphasize control of the
knee, as well as hip extensor and abductor strength for sta­
bility in stance. There is evidence that older men who are
unable to develop knee extension force above 1.13 Newton-
meters(Nm)/kg (measured by handheld isokinetic dynamom­
eter, normalized by body weight) and older women who are
unable to develop knee extension force above 1.01 Nm/kg have
a high risk for functional decline, morbidity, and mortality.284

Chapter 20  Postoperative and Preprosthetic Care
573
These strength values may represent the minimum threshold
for community function and could serve as evidence-based
functional goals for persons recovering from transtibial ampu­
tation (both limbs) and transfemoral amputation (remaining
limb). Those with transtibial amputation are also very likely to
have deficits in muscle performance around the hip; strength­
ening programs must include hip abductors (for stance phase
stability) and hip extensors,285 much like those who are receiv­
ing rehabilitation following total knee arthroplasty.286,287
Persons with transfemoral amputation must develop
strong hip extension capabilities to control the prosthetic
knee unit. They must also have effective hip abduction power
if the pelvis is to remain level during stance.285 It is important
to recognize that the distal attachments of the hamstrings,
rectus femoris, sartorius, tensor fasciae latae/iliotibial band,
adductor longus, and adductor magnus are relocated by myo­
desis or myoplasty or are lost entirely (for patients with short
residual limbs) during transfemoral surgery. The combina­
tion of an altered line of pull and loss of muscle mass often
creates an imbalance of muscle action around the hip.288–290
The gluteus maximus, gluteus medius, and iliopsoas, with
their intact distal attachments, are more powerful in deter­
mining resting hip position than the altered adductor group.
If the tensor fasciae latae/iliotibial band and gluteus maxi­
mus become secondarily shortened, function of the adductor
group is further compromised. Because of this imbalance, it
is important to include activities that strengthen the remain­
ing hip adductors, as well as hip extensors and hip abductors,
to prepare the patient for effective postural control in sitting
and standing and stance phase stability in prosthetic gait.290
Readers are referred to Stretching and Strengthening for Lower
Extremity Amputees (Miami, FL: Advanced Rehabilitation
Therapy) for more examples of postoperative, preprosthetic
strengthening activities.
General strengthening exercises for the trunk and upper
extremities are also essential components of an effective pre­
prosthetic exercise program. Back extensors and abdomi­
nal muscles play an important role in postural alignment
and postural control. Activities that involve trunk rotation
or diagonal movements activate trunk and limb girdle mus­
cles in functional patterns, addressing strength and flexibility
for functional activities and enhancing reciprocal arm swing
and pelvic control in gait. Upper extremity strengthening,
targeting shoulder depressor and elbow extensors, enhances
the patient's ability to use an assistive device for single limb
ambulation before prosthetic fitting.
Endurance
Many older adults with dysvascular amputation begin reha­
bilitation with compromised cardiopulmonary endurance
because of the effects of comorbid cardiac and pulmonary
diseases, and on deconditioning associated with inactivity
and bed rest.291 In persons with significant peripheral vas­
cular disease without amputation, endurance training on
treadmill improved endurance (6-minute walk distance)
and physical function (SF-36 physical functioning values).292
Although treadmill training is not appropriate in the pre­
prosthetic period, other strategies, such as cycle ergometer
driven by the intact limb, upper extremity ergometer, or cycle/­
recumbent combined upper- and lower extremity ergometers
(e.g., NuStep Inc, Ann Arbor, MI) (Figure 20-24) can be safely
and successfully used for persons with lower limb amputa­
tion.293–295 Endurance and physical conditioning are predic­
tors of prosthetic use: the ability to exercise at or above 50%
of age-predicted VO2max differentiated between persons with
amputation able to walk functional distances (100 m) with a
prosthesis and those who were unable to do so.296–298 Because
energy cost of walking with a prosthesis increases as limb
FIGURE 20-24  Example of a combined upper- and lower extremity recumbent ergometer appro­
priate for endurance exercise as part of the preprosthetic program for persons with amputation.
(Courtesy of NuStep Inc., Ann Arbor, MI.)

574
Section III  Prostheses in Rehabilitation
length decreases, endurance training is particularly important
for persons with transfemoral amputation.299 Persons with
amputation can substantially improve level of fitness (VO2max)
and with that, their potential for physical activity and pros­
thetic use.300 Readers are referred to the ACSM's Guidelines for
Exercise Testing and Prescription, 8th edition (Philadelphia,
PA: Wolters Kluwer, Lippincott Williams & Wilkins, 2009)301
and ACSM's Exercise Management for Persons with Chronic
Disease and Disabilities, 3rd edition (Champaign, IL: Human
Kinetics, 2009) for additional information about exercise test­
ing and endurance exercise prescription.
Postural Control
Loss of a limb shifts the position of the body's COM, mov­
ing it slightly upward, backward, and toward the remaining
or intact extremity; the magnitude of this shift is determined
by the extent of limb loss. The shift may have relatively little
impact on postural control and functional ability in patients
with partial foot or Syme amputation. It may, however, have
a significant impact on sitting balance, transitions between
sitting and standing, and single limb ambulation for persons
with transtibial, transfemoral, or hip disarticulation amputa­
tion. An effective preprosthetic program incorporates activi­
ties that challenge patients to improve core stability, postural
control, and equilibrium responses, learning how to control
the repositioned COM effectively over an altered base of sup­
port. In sitting, this can be accomplished using a variety of
reaching tasks including forward reaching, diagonal reaching
across and away from the midline, reaching down to a lower
surface or objects, reaching up and away from their center, and
turning to reach behind them. Anticipatory and reactive pos­
tural responses can also be practiced by throwing and catch­
ing games that require an automatic weight shift as part of
the activity. The difficulty of the task can be advanced by pro­
gressively shifting the location of the catch or toss away from
the midline of the patient's trunk; alternating locations from
side to side or upward or downward; increasing the speed of
the activity; increasing the weight of the object or ball that is
being used; or performing the activity on a less stable seat­
ing surface (e.g., theraball, large bolster, or air-filled balance
cushion). Similar activities can be implemented in single limb
stance, initially within the parallel bars with physical guard­
ing to insure safety. Such opportunity to practice anticipatory
and reactionary postural control in single limb stance lays
the foundation for the postural control necessary for single
limb ambulation with an assistive device, as well as for even­
tual prosthetic use. Readers are referred to Balance, Agility
and Coordination for Lower Extremity Amputees (Miami, FL:
Advanced Rehabilitation Therapy) for more activities that
can be used to enhance postural control.
The effectiveness of postural responses is influenced
by efficiency of the somatosensory system and visual sys­
tems, flexibility and strength of the trunk and limb girdles,
as well as the length and power of the residual limb.184,302,303
The prosthetic replacement of a missing limb increases the
functional base of support in sitting; for some individuals
the weight of the prosthesis serves as a stabilizing anchor
during ­functional activity. For those with limited flexibility or
strength, such a replacement might be essential for effective
postural responses and the ability to reach, even if the poten­
tial for functional ambulation is small.
Wheelchairs, Seating, and Adaptive Equipment
Many patients with amputation rely on a wheelchair for at
least some of their mobility needs during the postoperative,
preprosthetic period.304 Some patients with short trans­
femoral amputation, hip disarticulation, or bilateral ampu­
tation prefer the relative energy efficiency of wheelchair
mobility to ambulation with or without a prosthesis.305,306
For others, comorbid cardiovascular or cardiopulmonary
dysfunction precludes ambulation and the wheelchair
becomes their primary mode of locomotion.307 The shift
in COM after amputation has important implications in
choice of wheelchairs.
The design of many standard or traditional wheelchairs is
based on the anthropomorphic characteristics of an ­“average”
adult male with intact lower extremities. With the loss of a
limb, the COM shifts in a posterior and lateral direction;
when the patient is seated in a wheelchair, this moves the
COM closer to the axis of rotation of the chair's wheels. If
the patient with lower extremity amputation turns or reaches
backward during a functional activity, the COM shifts even
farther toward, or even beyond, the wheel axis, and the chair
may tip backward. The provision of simple antitip devices
reduces the risk of posterior tipping during functional activi­
ties. For those with transfemoral or bilateral amputation, a
wheelchair with wheels that can be offset posteriorly is rec­
ommended. Patients with recent amputation must also be
aware of altered dynamics when they reach forward while
sitting in a wheelchair: High downward pressure on the wheel­
chair foot plate by the intact limb when reaching forward is
likely to lead to anterior tipping.
Specific wheelchair assessments and prescription are war­
ranted for all individuals who will be using a wheelchair
as their primary means of locomotion and mobility (see
Chapter  16). This individual evaluation and prescription
process ensures that the wheelchair will provide adequate
support of the thighs to increase seating stability and reach,
effective seating with an appropriate cushion for pressure dis­
tribution, and configuration of components that provides
ease of wheelchair locomotion.
Wheelchair skills to be mastered by persons with new
amputation and their caregivers include effective propulsion
over level, carpeted, and uneven ground; turning and back­
ing up; positioning of the wheelchair for safe bed, toilet, bath­
tub, furniture, and car transfers; ascending and descending
thresholds, curbs and ramps, and getting the wheelchair into
and out of the family's motor vehicle. In addition, practice
getting to and from the floor and opportunity to react to a
controlled fall (lowering backward to the ground) may allay
concerns about aftermath of falls. Readers are referred to
textbooks on spinal cord injury rehabilitation, which contain
chapters on wheelchair skill development that can be applied
to persons with amputation.308,309

Chapter 20  Postoperative and Preprosthetic Care
575
Along with a wheelchair, many persons with new ampu­
tation would benefit from provision of adaptive equipment
for their homes (e.g., tub benches, grab bars, toilet frames,
raised toilet seats, handheld shower adapter) and installation
of temporary (or permanent) ramps to entrance/egress to the
home. Consideration must also be given to access to sinks, as
well as to using insulated coverings of exposed hot water and
drain pipes. In some cases, if the individual is likely to use
the wheelchair for a long period of time as primary means of
mobility, modification of the home may be recommended for
both safety and efficiency of function. Although these con­
cerns are more typically addressed in inpatient and subacute
rehabilitation settings, many patients with new amputation
may be discharged to home to await sufficient healing prior to
beginning prosthetic rehabilitation. Therapists in acute care
must consider referral to home care services if there is insuf­
ficient time to address wheeled mobility and accessibility
during hospitalization. Once again, textbooks on spinal cord
injury are good sources of information about durable medi­
cal equipment and home modifications for accessibility.310,311
Bed Mobility and Transfers
In the acute care setting, PT intervention at the bedside
includes instruction about optimal positioning of the resid­
ual limb and activities to assist the patient's ability to change
position in bed and move to or from a seated position. Early
mobility and activity significantly reduce the risk of atelectasis,
pneumonia, and further physiological deconditioning.312 The
therapist must, however, be aware of the risk of postural hypo­
tension and of postoperative complications including deep
venous thrombosis and pulmonary embolism. Assessment
and monitoring of the patient's vital signs (pulse, respiratory
rate, blood pressure, pulse oximetry) are recommended as bed
mobility and out-of-bed activity begin.313 Care must also be
taken to minimize the risk of trauma to the newly amputated
limb during activity, exercise, or transfers.
Many individuals with recent amputation can roll from
supine to or from the prone position without great difficulty,
although those with transfemoral amputation of the domi­
nant limb may need to develop an adapted movement pat­
tern or sequence. The strategies for transition into sitting
are not substantially different from preferred preoperative
strategies; however, efficiency of postural responses may be
challenged by the alteration in body mass after amputation.
Those who have become deconditioned by inactivity in the
days and weeks before amputation may find bed rails, a tra­
peze, bed ladders, or other devices helpful early in rehabili­
tation. Strategic placement of a bed table or walker near the
bedside at night serves as a reminder of the amputation for
individuals who are likely to get up during the night to go to
the bathroom (without otherwise fully awakening), reducing
the risk of falling.
An important goal of postoperative preprosthetic rehabili­
tation is development of the ability to move between seating
surfaces or from sitting to standing as safely and independently
as possible. The majority of falls for persons with new amputa­
tion in acute care settings occur during self-transfer between
wheelchair and bed or toilet.314 Depending on the individu­
al's preamputation level of activity, transferring between seat­
ing surfaces may require some degree of assistance or use of
adaptive devices or may be accomplished relatively smoothly
and easily. Those who are deconditioned or who have previ­
ous neuromuscular-related postural impairment may require
a mechanical lifting aid, multiperson lifting, or some level of
assistance in the early postoperative period. Others may benefit
from a strategically placed transfer board as they develop their
ability to perform a pivot transfer on their remaining limb.
Some persons require a walker or crutches for extra stabil­
ity in single limb stance in the midst of their pivot transfers.
Still others quickly master scooting in sitting and pivoting
on their remaining limb to become independent in transfers.
Persons with single limb amputation initially prefer trans­
ferring toward their remaining limb, but should be encour­
aged to master moving in either direction. Individuals with
bilateral limb loss or injury that precludes weight bearing
on the remaining limb can scoot across a sliding board to a
wheelchair or commode that is positioned diagonally from
the bed. Those with bilateral transfemoral amputation (and
those with bilateral transtibial amputation who have suffi­
cient hamstring excursion) may prefer the surface-to-surface
stability that is provided when the entire anterior edge of the
wheelchair seat abuts the side of the bed, allowing them to
scoot directly forward. Some individuals who require signifi­
cant assistance to transfer without a prosthesis become nearly
independent in pivot transfers when a prosthesis is worn: The
sensory feedback that is provided to the residual limb within
the socket when there is contact between the prosthetic foot
and the floor enhances sitting balance during sliding board or
pivot transfers. Persons with transfemoral amputation must
learn that, although they can wear a prosthesis when seated,
the prosthesis cannot be counted on for stability during trans­
fers. Readers are referred to Patient Care Skills, 6th edition
(Upper Saddle River, NJ: Prentice-Hall, 2010)315 for sugges­
tions about interventions to enhance bed mobility, transfers,
and ambulation with assistive devices.
Mastery of single limb or non–weight-bearing transfers
in the postoperative period is the foundation for functional
transfers whenever the person with amputation is not wearing
his or her prosthesis. At times in the future, mechanical prob­
lems with the prosthesis, skin problems on the residual limb,
or a medical problem (e.g., CHF or renal failure) may affect
socket fit, temporarily precluding prosthetic use. Providing
opportunities for patients to practice transferring between
surfaces at different levels (e.g., wheelchair to stool to floor)
in the postoperative preprosthetic period is very important,
especially if delayed prosthetic fitting is anticipated.
Ambulation and Locomotion
Single limb ambulation with an appropriate assistive
device provides an opportunity to enhance postural con­
trol and to build strength and cardiovascular endurance,
in addition to allowing patients with recent amputation
to move about in their environment. A number of fac­
tors (e.g., safety, balance and postural control, endurance,

576
Section III  Prostheses in Rehabilitation
lower extremity muscle performance, fear of falling) must
be considered in recommending an ambulator assistive
device.315,316 Although use of a standard or rolling walker
may be appropriate in the initial PT sessions, many indi­
viduals with new amputation quickly master a two- or
three-point swing-through pattern with crutches on level
surfaces and are ready to build advanced gait skills on
uneven surfaces, inclines, and stairs. Others are fearful of
using crutches, preferring the stability provided by a walker
to the mobility of crutches. A walker may be appropriate
for patients with limited endurance and balance impair­
ment who would otherwise be limited to wheelchair use.
Therapists must be aware, however, of the potential long-
term limitation in gait patterns imposed by walkers: The
halting hop-to gait pattern interrupts forward progression
of the COM. Individuals who have adapted to this pattern
of motion before receiving a prosthesis may have difficulty
developing a smooth step-through pattern or becoming
comfortable with a less supportive ambulation aid once
they are using their prosthesis. Walkers are also more
difficult to use on inclines and are dangerous to use on
stairs. Whenever possible, patients are encouraged to use
crutches.315,316 Table 20-8 summarizes the progressive sin­
gle limb ambulation skills for preprosthetic rehabilitation.
TABLE 20-8  Progressive Strategies for Preparing for and Mastering Single limb Mobility After Amputation
Phase
Purpose
Target
Examples of Activity Progression
Preparation
Strengthening

All activities: concentric, holding, eccentric contraction
All activities: intact limb and residual limb
Hip extensors
Hip interior and exterior
rotators
Hip abductors
Bridging; uniplanar, diagonal antigravity, with resistance
Gluteal sets
Hip extension in prone, in standing, adding resistance, open chain, closed chain
Hip abduction side-lying, in standing, adding resistance, open chain, closed chain
Knee extensors
Quad sets, short arc quads
Sit to stand at varying heights and speeds
Progressive resistive exercise
Low load, high repetition (endurance)
High load, low repetition (strength)
Ankle dorsiflexors
Toe raises in standing
Manual resistance of active movement
Flexibility
Hip flexor tightness
Knee flexor tightness
Tensor fascia lata/
iliotibial band
Plantarflexor tightness
Prolonged passive stretching, positioning antigravity
Thomas test position or prone
Proprioceptive neuromuscular facilitation: hold-relax/contract-relax followed
by concentric exercise in new ROM
Active stretching in various positions
Stability in
standing




















Rising to
standing
Control of COM
during transition
Part-to-whole practice progressing to serial practice of sit-to-stand transition
Scooting to edge of seating surface
Forward lean with trunk extension (anterior weight shift)
Weight transfer onto foot
Extension into upright position
Achieving stability in upright position
Controlled lowering back into sitting position
Practice with varying speeds
Adding appropriate resistance for sensory feedback and/or strengthening
Practice with higher to lower seating surfaces
Practice with various seating surfaces (firm to soft chair, toilet seat, tub seat)
Practice with transfers into/out of car
Postural control
in single limb
stance







Discovering limits
of stability
Developing postural
control






Static: standing in parallel bars
Bilateral upper extremity support, single upper extremity support, no upper
extremity support
Anticipatory: directional reaching
Forward, diagonal toward stance limb, diagonal away from stance limb
Throwing activities: lightweight to heavier weighted balls; forward to diagonal
directions; various distances
Reactionary: gentle unexpected perturbations; catching activities; lightweight
to heavier weighted balls; toward body center, away from body center; various
speeds and distances
All activities: initially standing on firm surface, progressing to compliant surface

Chapter 20  Postoperative and Preprosthetic Care
577
Individuals with limited endurance or poor balance spend
much time practicing a hop-to or swing-through gait in the
parallel bars before they acquire the confidence and motor
skill necessary to move out of the parallel bars with a walker
or crutches. Importantly, single limb ambulation with an
assistive device is often more energy intensive than walking
with a prosthesis.317 Achievement of functional single limb
ambulation is not a prerequisite for prosthetic fitting.318 All
individuals who can stand and use an assistive device to walk
should be encouraged to ambulate as much as possible, even
if they are walking for aerobic exercise rather than to accom­
plish a functional task. For those with single limb amputa­
tion, wheelchair use should be reserved for long-distance
transportation unless ambulation is not medically advisable.
Wheelchairs are appropriate for patients with bilateral ampu­
tation; self-propulsion provides some aerobic conditioning,
as well as an energy-efficient means of locomotion.319
Patient and Family Education:
Care of the Remaining Limb
Patient and family education begins in the initial interview
process and continues throughout the acute hospital stay, as
illustrated in the preceding discussions of positioning, resid­
ual limb care, remaining/intact limb care, and enhancing
motor performance and functional training.
Patient education about the risk of decubitus ulceration
and strategies to reduce this risk are also important compo­
nents of early postoperative care. Individuals with vascular
disease and neuropathy are particularly at risk, with the heel
and lateral border of the remaining foot most vulnerable.320
Those with dysvascular limbs may have barely enough circu­
lation to support tissue health in an intact or noninjured foot;
once a wound has occurred, circulation may be inadequate
for tissue healing. An open wound on the remaining limb
would preclude single limb ambulation, increasing the risk
of inactivity-related postoperative complications and making
prosthetic rehabilitation even more challenging. Pressure-
related wounds significantly delay ­rehabilitation, increase
disability, and multiply health care costs for patients with
amputation. Vulnerability to pressure increases with sensory
impairment; altered mechanical characteristics of injured,
calcified, or scarred tissues; poor circulatory status; micro­
climate of the skin; and (in combination with these factors)
advanced age.321 For those who have limited ability to change
position, a pressure-distributing mattress and well-designed,
carefully applied heel protectors can reduce the risk of
decubitus ulcer formation. A routine of frequent position
change, weight shifting, and exercise reduces weight-bearing
pressures and enhances circulation to vulnerable tissues.
Before discharge, the rehabilitation team must ascertain
how close to functional independence the individual and
caregivers are in a variety of self-care activities, in mobility
and locomotion, and in performance of preprosthetic exer­
cises (Figure 20-25). As the program progresses, the ability
of the individual and family in these areas is a key determi­
nant of discharge readiness and placement (home with home
care, home with outpatient follow-up, or to a rehabilitation or
subacute facility).
Phase
Purpose
Target
Examples of Activity Progression
Mobility


















Ambulation


















Forward progression
Changing direction
Backing up
Sideward stepping
In parallel bars to overground with appropriate assistive devices
Over simple (tile) surface to more challenging (carpet, grass, etc.)
surfaces
In closed (predictable) environment, to open (unpredictable) environment
Over level surfaces, inclines (ascend and descend)
Stair management
Bilateral railings, to railing and one crutch
Low to standard height steps
Provide opportunity for family caregiver to practice guarding
Managing
environmental
challenges
Opening doors: away from self, toward self, weighted doors, revolving doors
Managing thresholds
Managing curbs
Environmental scanning: avoiding obstacles in walking path
Home safety evaluation
Crossing the street at times crosswalks
Fall management




At least: demonstration/observation of chair to floor, stand to floor
transition
Discussion of risk factors for falls from wheelchair, from standing, on stairs
Develop plan of action should fall occur
Practice chair-to-floor and stand-to-floor transitions in controlled
circumstances
TABLE 20-8  Progressive Strategies for Preparing for and Mastering Single limb Mobility After Amputation—cont'd

578
Section III  Prostheses in Rehabilitation
ACTIVITY
INDICATOR
Wound Inspection ____
Individual or caregiver is able to independently inspect status of
incision and residual limb
____
Individual or caregiver is able to describe signs of inflammation,
infection, dehiscence, bleeding, orecchymosis requiring
contact/visit with health professional
____
Individual or caregiver is able to effectively inspect and care for
intact limb
____
Supervision or assistance by a health professional is necessary for
wound inspection and care of either residual limb or intact limb
Residual Limb Care ____
Individual or caregiver is able to change wound dressings
effectively, maintaining clean environment
____
Individual or caregiver is able to appropriately cleanse and care for
residual limb
____
Individual or caregiver is able to safely effectively self-mobilize
skin around incision site
____
Individual or caregiver is able to apply appropriate compression
strategy (circle: Ace wrap, RRD or SRD, commercial shrinker
garment, other)
____
Individual with transtibial amputation is able to maintain limb in
extended knee position
Mobility
____
Individual is able to move around in bed as needed
Level of assistance________________
Equipment used ________________
____
Individual is able to transition from supine to sitting and return
Level of assistance ________________
Equipment used ________________
____
Individual is able to transfer from bed or chair to wheelchair and
return
Level of assistance________________
Equipment used ________________
____
Individual is able to transfer sit to single limb standing and return
Level of assistance ________________
Equipment used ________________
____
Individual is able to transfer to toilet and return
Level of assistance ________________
Equipment used ________________
____
Individual is able to transfer to shower or tub and return
Level of assistance________________
Equipment used ________________
Locomotion
____
Individual is able to ambulate on level surfaces using appropriate
assistive device
Level of assistance________________
Assistive/ambulatory device used ________________
Gait pattern ________________
Distance ________________
Perceived exertion ________________
____
Individual is able to ascend/descend stairs using railing and
appropriate assistive device
Level of assistance________________
Assistive/ambulatory device used________________
Gait pattern________________
Number of steps________________
Perceived exertion________________
____
Individual is able to ambulate on inclines and outdoor surfaces
Level of assistance________________
Assistive/ambulatory device used________________
Gait pattern________________
Distance________________
Perceived exertion________________
FIGURE 20-25  Example of checklist of key patient and family knowledge and skills after lower limb
amputation.

Chapter 20  Postoperative and Preprosthetic Care
579
Level of assistance________________
Assistive/ambulatory device used________________
Gait pattern________________
Distance________________
Perceived exertion________________
____
Individual/caregiver is able to safely propel wheelchair functional
distances
Level of assistance________________
Distance________________
Perceived exertion________________
Self-Care Activities ____
Individual is able to manage clothing during ADL and dressing
activities
Level of assistance________________
Positions________________
Adaptive equipment needs________________
Perceived exertion________________
____
Individual is able to manage bathing and grooming activities
Level of assistance________________
Positions________________
Adaptive equipment needs________________
Perceived exertion________________
____
Individual is able to manage key IADL activities
Level of assistance________________
Types of activities________________
Adaptive equipment needs________________
Perceived exertion________________
____
Sufficient and safe transportation is available
Type of transportation ________________
Level of assistance________________
Equipment used________________
Perceived exertion________________
Exercise Program ____
Individual and caregiver demonstrate mastery of
stretching/flexibility component of program
Positions/activities ________________
Assistance required________________
Equipment used________________
Repetitions and frequency________________
____
Individual and caregiver demonstrate mastery of strengthening
component of program
Positions/activities ________________
Assistance required________________
Equipment used________________
Repetitions and frequency________________
____
Individual and caregiver demonstrate mastery of aerobic
conditioning component of program
Positions/activities ________________
Assistance required ________________
Equipment used________________
Repetitions and frequency________________
____
Individual and caregiver demonstrate mastery of
balance/coordination components of program
Positions/activities ________________
Assistance required________________
Equipment used________________
Repetitions and frequency________________
Follow-Up Care
____
Plans for return to surgeon for post-op visit are in place
____
Plans for continued rehabilitation care are in place
____
Additional services are in place as appropriate
Nursing ________________
Dietician ________________
Counseling________________
Home health________________
Others________________
____
Individual is able to ambulate on inclines and outdoor surfaces
FIGURE 20-25—cont'd

580
Section III  Prostheses in Rehabilitation
CASE EXAMPLE 1B
Interventions for N. H., an 89-Year-Old with “Elective” Transtibial Amputation
N. H. is now 4 days postsurgery, and her delirium is clear­
ing. She is conversing with her typical sense of humor with
family and staff. Her casted fiberglass rigid dressing was
removed yesterday; the surgical wound is draining mod­
erate amounts of serosanguineous fluid; edges are closely
approximate. An area of pressure-related abrasion and
inflammation at the anterior distal tibia was noted when
the cast was removed; granulation is now evident. N. H.
can transfer to a bedside chair with moderate assistance of
one person, with noted moderate impairment of postural
control. N. H. tolerates being up in a bedside chair for 45
minutes. She rates her postoperative pain as four out of 10,
except at dressing change, when it increases to six out of 10.
She laughs but feels concern that she feels mild cramping
in the instep of the limb that is no longer there, wanting to
stretch her foot and toes into dorsiflexion to relieve her dis­
comfort. She is somewhat reluctant to look at or to touch
her residual limb, but does not mind if nurses, physicians,
or PT staff handle it during dressing changes or functional
activities. She transferred sitting to standing with a walker at
bedside with moderate assistance of one person, complain­
ing of dizziness after standing for more than a minute and
requesting to return to sitting. She tells you that she is “ready
to get going” and wants to return to her own home to use
her wheelchair as soon as possible.
Questions to Consider
• Given her postoperative pain and phantom sensation,
what PT interventions would be appropriate at this time
for N. H.? Why would these be most appropriate from
among available options? What are the pros and cons of
each, with respect to attention, memory, and ability to
learn?
• Given the status of her wound and condition of her resid­
ual limb, what strategies for management of edema and
limb shaping would you recommend? What are the pros
and cons that you considered when deciding among
options for compression and residual limb protection?
Why do you think the option you selected is the most
appropriate? How would this be similar or different if her
amputation was at the transfemoral level?
• What strategies for intervention and patient–family edu­
cation would you implement for skin care and scar man­
agement for N. H.? What issues or factors will assist or
inhibit her ability to take responsibility for her skin care?
• What specific strategies for intervention and patient–
family education aimed at ROM and flexibility do you
recommend for N. H.? What impairments or functional
limitations are you particularly concerned about for
N. H.? What activities will you engage her in? What posi­
tions? For what period of time? With what ­equipment?
What would you emphasize if her amputation was at a
transfemoral level? What issues or factors will assist or
inhibit her ability to take responsibility for exercises
aimed at ensuring adequate ROM and flexibility in prep­
aration for prosthetic use?
• What specific strategies for intervention and patient–
family education aimed at improving muscle perfor­
mance do your recommend for N. H.? How do you
address strengthening of key muscle groups of extremi­
ties and trunk? How do you address power and muscle
endurance? How do you address concentric, isometric,
and eccentric control and performance? What issues or
factors must be considered regarding exercise tolerance,
intensity, frequency, and duration during her acute care
stay? How will you address her concerns about her low
level of aerobic fitness and conditioning?
• What specific strategies for intervention and patient–
family education aimed at improving static, dynamic,
and reactionary postural control during functional activ­
ities do you recommend for N. H.? During which activi­
ties is postural control most likely to be problematic?
What apparatus, equipment, and activities might you use
to assist her postural control?
• What are your concerns about seating and wheelchair
mobility for N. H.? Do you think that a standard wheel­
chair will adequately meet her needs? Do you think she
will be able to propel her chair? What tasks does she need
to master if the wheelchair will be her primary source of
mobility during the preprosthetic period?
• What types of bed mobility and transfer activities are
important for N. H. and her family caregivers to master?
What specific intervention and patient–family education
strategies will you use to help her move toward safe and,
hopefully, independent performance of bed mobility
and transfer activities? How will you vary environmen­
tal conditions and task demands to ensure that she can
adapt her strategies and skills?
• What strategies for intervention and patient–family edu­
cation will you use to get her up and walking? What
assistive or ambulatory device do you feel would be most
appropriate? Why have you chosen this particular device
from among available options? What gait pattern will she
use? For what other dimensions or ambulatory skills (in
addition to walking forward) will you provide instruc­
tion and opportunity for N. H. to practice? How will you
address the likelihood that she will experience a fall at
some point in her preprosthetic period? What is “func­
tional distance” for ambulation for N. H. and her family?
• Are there any additional interventions that would be
appropriate for N. H. at this point in her postoperative,
preprosthetic rehabilitation?
• How will you determine her readiness for prosthetic
fitting?

Chapter 20  Postoperative and Preprosthetic Care
581
CASE EXAMPLE 2C
Interventions for P. G., an Individual with Recent Amputation of Both Lower Extremities
Following a Construction Accident
Now 3 days postoperation, P. G. is beginning his rehabil­
itation in preparation for discharge to home until there
is adequate healing for prosthetic fitting and prosthetic
training. Pain continues to be a serious concern, generally
reported as five or six out of 10 on the visual analog scale.
Postoperative agitation has cleared, although P. G.'s wife
reports he is more subdued in affect than usual, and she is
concerned about possible depression. Low-grade tempera­
ture persists, but white cell counts are within normal lim­
its. P. G. can actively flex and extend both knees to within
10 degrees of full ROM, with effort and a “tight pulling
sensation” behind the knee, when out of his SRD for dress­
ing changes and wound inspection. Although he reports
feeling “weak as a baby” and is quickly fatigued, P. G. can
use upper extremity and body strength for contact guard
sliding board transfers to and from bed to a bedside chair.
Moving between sitting and supine is effortful and fatigu­
ing, but P. G. manages these transitions with occasional
standby assistance. He was previously involved in both
aerobic and strengthening exercise at the local YMCA, but
he is not sure how to use the weights and equipment now
that he has lost his limbs. Plans are being made to move
temporarily to his parent's home, on the first floor of a
three-­family house (although there are six steps to reach a
front porch and entryway), as it is more accessible than his
third-floor walk-up apartment. In the meantime, family
and friends are apartment hunting for housing that will be
less challenging for P. G. in the months ahead. P. G.'s major
goal is to achieve independent mobility with a wheelchair
before the birth of his child.
Questions to Consider
• Given his postoperative pain and phantom sensation,
what PT interventions would be appropriate at this time
for P. G.? Why would these be most appropriate from
among available options? What are the pros and cons of
each, with respect to attention, memory, and ability to
learn?
• Given the status of his wound and condition of his resid­
ual limb, what strategies for management of edema and
limb shaping would you recommend? What are the pros
and cons that you considered when deciding among
options for compression and residual limb protection?
Why do you think the option you selected is the most
appropriate? How would this change if his amputations
were at the transfemoral level?
• What strategies for intervention and patient–family edu­
cation would you implement for skin care and scar man­
agement for P. G.? What issues or factors will assist or
inhibit his ability to take responsibility for his skin care?
• What specific strategies for intervention and patient–
family education aimed at ROM and flexibility do you
recommend for P. G.? What impairments or func­
tional limitations are you particularly concerned
about for P. G.? What activities will you engage him
in? What positions? For what period of time? With
what equipment? How would these be similar or dif­
ferent if his amputations were at the transfemoral
level? What issues or factors will assist or inhibit his
ability to take responsibility for exercises aimed at
insuring adequate ROM and flexibility in preparation
for prosthetic use?
• What specific strategies for intervention and patient–
family education aimed at improving muscle per­
formance do you recommend for P. G.? How do you
address strengthening of key muscle groups of extremi­
ties and trunk? How do you address power and muscle
endurance? How do you address concentric, isometric,
and eccentric control and performance? How would
this be similar or different if his amputations were at
the transfemoral level? What issues or factors must be
considered regarding exercise tolerance, intensity, fre­
quency, and duration during his acute care stay? How
will you address his concerns about low level of aerobic
fitness and conditioning?
• What specific strategies for intervention and patient–
family education aimed at improving static, dynamic, and
reactionary postural control during functional activities
do you recommend for P. G.? During which activities
is postural control most likely to be problematic? What
apparatus, equipment, and activities might you use to
assist his postural control?
• What are your concerns about seating and wheelchair
mobility for P. G.? Do you think that a standard wheel­
chair will adequately meet his needs? Do you think he
will be able to propel his chair? What tasks does he need
to master if the wheelchair will be his primary source of
mobility during the preprosthetic period?
• What additional bed mobility and transfer activities
do you think are important for P. G. and his family
caregivers to master? What specific intervention and
patient–family education strategies will you use to
help him move toward safe and, hopefully, indepen­
dent performance of bed mobility and transfer activi­
ties? How will you vary environmental conditions and
task demands to ensure that he can adapt his strategies
and skills?
• How will you address the likelihood that he will experi­
ence a fall at some point in his preprosthetic period?
• Are there any additional interventions that would be
appropriate for P. G. at this point in his postoperative,
preprosthetic rehabilitation to assist with his coping and
adjustment to his limb loss?
• How will you determine his readiness for prosthetic fitting?

582
Section III  Prostheses in Rehabilitation
TABLE 20-9  Examples of Outcome Measures for Preprosthetic Rehabilitation
Tool
Purpose
Level of Measurement
Comments
Activity Measure for Post-Acute
Care (AM-PAC)
Assess limitations in three ICF Activity
domains:
1. Physical and Movement
2. Personal Care and Instrumental
3. Applied Cognitive
Ordinal (raw score)
Interval (standardized score)
Paper and computerized instruments available
Physical and Movement and Personal Care and
Instrumental subscales have minimal ceiling
effect as compared to Functional Independence
Measure323,343,344
Amputee Mobility Predictor–no
prosthesis
(AMP-noPro)
Sitting balance, transfers, standing
balance, gait, stairs, use of assistive
device
Ordinal scale
21 items in 6 domains
Score range: 0 to 42
Performance-based
MDD = 3.4
Predicts likelihood of prosthetic use; also used as
outcome measure in preprosthetic period151,161,345
Barthel Index (BI)
Activities of Daily Living
Ordinal
10 items; weighted ratings
0 to 100 range
Performance based or by interview (self-report)
Developed initially for persons with neurological
problems; applied to those with amputation.
Ceiling effect possible as rehabilitation
progresses346,347
Functional Independence
Measure (FIM)157–161
Burden of care, activities of daily living
Ordinal
18 items for 6 categories
Score range: 18 to 126
Performance based or self-report (interview)
Marked ceiling effect; does not reflect community
function. May be more appropriate in acute care
than for intensive rehabilitation159,323,348–350
Office of Population Consensus
and Surveys Scale (OPCS)
WHO International Classification of
Impairments, Disabilities, Handicaps-
based measure of functional capacity
Ordinal
108 items over 13 disability categories
Weighted overall “Disability Score”
(requires computer)
Developed for assessment community-living
individuals with disability; useful for inpatient
rehabilitation351
Patient Generated Index (PGI)
Impact of amputation (or other medical
event) on quality of life
Ordinal
Respondents identify 5 activities impacted by
amputation, rate severity and importance of impact
on quality of life
Overall score (0 to 10) mathematically derived
Patient Specific Functional Scale: rate current
ability to
Can be challenging for patients to understand352,353
Patient Specific Functional
Scale (PSFS)
Impact of amputation (or other medical
event) on functional performance of
important activities
Ordinal
Respondents identify 3 to 5 activities impacted
by amputation then rate their ability to perform
(0 to 10)
Mean of items used as PSFS score
MDD: 3 to 4.5 per item
Effective measuring change for the individual
patient345,354,355
Prosthetic Profile of the
Amputee (PPA)
Assesses predisposing, enabling,
and facilitating factors for eventual
prosthetic use
Nominal and ordinal data
38 questions in 6 sections
Self-report or interview
Requires training to score (computer)
For adults with unilateral amputation
Recommended for use in research, rather than
clinical settings346,356,357

Chapter 20  Postoperative and Preprosthetic Care
583
Rivermead Mobility Index
(RMI)
Capacity to perform mobility activities
Ordinal
15 Items
Forced choice format
Self-report or interview
Ceiling effects in late preprosthetic and prosthetic
rehabilitation358–360
Short Form-36 or
Short-Form-12
Health-related quality of life
Ordinal
8 subscales over 2 domains (physical and mental
functioning)
Self-report or interview
MDD for SF-36 Health: 17.1
MDD for SF-36 Physical Functioning: 34.2
MDD for SF-36 Physical Role: 26.3
Designed for general population; has not been
specifically evaluated for use with persons
with amputation345,346,361,362
Function Component of the
Late Life Function and
Disability Instrument (LLFDI)
Function and disability in community-
living older adults
Ordinal
Interview or self-report
32 questions: rated 1 to 5
8 additional questions if assistive device
is routinely used
Raw score transformed to scaled score (0 to 100)
Overall function score
Upper extremity subscale
Basic lower extremity subscale
Advanced lower extremity subscale
High scores = better function
Has been used for a variety of conditions and
health care settings but not fully evaluated
for persons with amputation363–366
Walking Speed (self-selected
and/or fast)
Overground mobility
Proxy for overall health/functional
status
Continuous
Performance based
MDD range: 0.10 to 0.2 m/s for most medical
diagnoses
Minimal equipment: stopwatch and hallway
Use of assistive device during testing possible
4-m walk protocol effective (6 to 8 m total
walkway) comparable to 10 m (20 m total
walkway)367
Norms available for healthy adults by decade
of age and gender368
2-Minute Walk Test (Brooks)
Cardiovascular endurance
Continuous
Performance based
Distance (m) covered in 2-minute period
Developed as alternative to exercise stress test
for persons with CHF; applied to wide variety
of medical diagnoses369,370
Wheelchair Skills Test
Version 4.1





Assessment of performance and
safety of manual wheelchair use





Ordinal
Performance or questionnaire
32 items
Indoor use
Community use
Advanced skills
Scoring: performance: pass/fail
Safety: safe/unsafe
Used to assess ability of users of manual
wheelchair, caregivers, and power chairs371,372





ICF, International Classification of Functioning, Disability, and Health; MDD, minimal detectable difference.

584
Section III  Prostheses in Rehabilitation
PREPROSTHETIC OUTCOME ASSESSMENT
Current models of health care practice (and reimbursement)
require assessment of the efficacy of intervention that has
been provided, often by comparing information collected at
initial and discharge examinations. A number of tools and
measures can be used to assess outcome of intervention in
the pre-prosthetic period; Table 20-9 provides examples of
such measures. The selection of the most appropriate tools
from among those available can be challenging.322 The first
consideration is to determine which “population” the tool
has been designed and validated for. Some measures have
been evaluated for use with older adults who are hospital­
ized, others specifically for persons with lower limb ampu­
tation.323,324 The next concern is the domain that the tool
evaluates: outcomes can be assessed at the level of body
structure and function (e.g., wound healing, limb volume);
activity ability or limitation (e.g., ability to ambulate, com­
plete ADLs); or at the level of participation (e.g., quality of
life, ability to participate in meaningful social roles).325,326 It
is also important to understand the level of measurement of
the tool, so as to be able to interpret findings.327 The various
scales and tools may provide descriptive/categorical informa­
tion (e.g., Medical Functional Classification Levels), ordinal
­information (e.g., ranking, severity, FIM scores) or robust
continuous data (e.g., walking speed, limb circumference,
functional reach distances). How the information is collected
is also a factor: tools may be based on self-report, observa­
tion of performance, or require use of precise measurement
tools. Given all of these aspects of measurement, it becomes
obvious that there is no single “perfect” outcome measure
for preprosthetic rehabilitative care; instead the rehabilita­
tion team should collectively select those measures that best
meet the needs of the patient, therapeutic goals, and expec­
tations of the practice environment.328–330 Although it would
be wonderful to have professional consensus of the type and
scope of data that should be routinely collected, the reality is
that outcome measurement in rehabilitation, although not in
its infancy, is at least in its troubling teenage years! We have a
lot of growing up to do.
What makes a good outcome measure for preprosthetic
rehabilitation? The selection of measures should be based
on the primary goals of the setting in which care is pro­
vided and the specific patient-centered goals that have
been defined for  the individual: What concepts, function,
or attribute needs to be measured? In choosing an outcome
measurement tool, we look for evidence of
• Reliability: Can we trust the numbers that the tool pro­
vides? Is the tool consistent in measurement over time?
Do different raters tend to come up with similar scores?
How much measurement error might be present in the
“score”?
• Validity: How well does the tool measure what it intends
to measure? Is it designed for patients like the ones that
we provide care for? How well do scores on the ­measure
discriminate between persons with and without the
problem that the measure attempts to examine?
• Responsiveness: How well can this measure cap­
ture change? What is the minimal change in status
or function that it can predict (minimal detectable
difference [MDD] or minimal detectable change
[MDC])? Do we understand what a clinically mean­
ingful change might be (minimal clinically important
difference)?331
Readers are referred to Portney LG, Watkins MP. Founda­
tions of Clinical Research: Applications to Practice, 3rd ed. (Upper
Saddle River, NJ: Prentice Hall, 2009) for more information on
the process of measurement, and to Stokes EK, Rehabilitation
Outcome Measures (Philadelphia, PA: Elsevier/Churchill
Livingstone, 2011) as a resource for evaluating and selecting
outcome measures.
SUMMARY
Early rehabilitation in the postoperative preprosthetic
period lays the foundation for prosthetic rehabilitation.
Initial emphasis is placed on wound healing and control of
edema, essential prerequisites for prosthetic use. Early in
the process, the individual with new amputation and fam­
ily caregivers become actively involved in the rehabilita­
tion process and decision making, assuming responsibility
for limb compression, skin care, and desensitization. The
therapist is alert for postoperative medical complications
such as postural hypotension or deep venous thrombosis,
as early mobility begins. The therapist implements strate­
gies to prevent secondary impairments and functional lim­
itations such as further deconditioning and contracture
formation. Strengthening exercises, targeting the residual
limb and overall fitness, begin in the acute or subacute set­
ting and continue as an aggressive home program to pre­
pare the individual for prosthetic training. Persons with new
amputation are encouraged to become as independent as
possible in transfers, single limb gait, and wheelchair mobil­
ity, depending on their medical status and functional capa­
bility. As the wound heals and edema subsides, the individual
with new amputation, family caregivers, therapist, prosthe­
tist, and physician begin discussion about future prosthetic
rehabilitation. The postoperative, preprosthetic per­iod is a
time of transition in which many individuals mourn the loss
of their limb and question their future yet are challenged
and encouraged by the possibilities offered by prosthetic
replacement of their limb. If the consensus is that pros­
thetic fitting is not viable, emphasis shifts to development
of wheelchair mobility skills and adaptation of the patient's
environment as rehabilitation continues. If the consensus
is that prosthetic fitting is likely, rehabilitation during this
time focuses on building the physical and psychological
resources that will ensure the person with new amputation
will become a successful prosthetic user.

Chapter 20  Postoperative and Preprosthetic Care
585
REFERENCES
1. Robinson V, Sansam K, Hirst L, Neumann V. Major lower limb
amputation—what, why and how to achieve the best results.
Orthopaed Trauma. 2010;24(4):276–285.
2. Kratz AL, Williams RM, Turner AP, et al. To lump or to split?
Comparing individuals with traumatic and nontraumatic
limb loss in the first year after amputation. Rehabil Psychol.
2010;55(2):126–138.
3. Livingstone W, Van de Mortel TF, Taylor B. A path of per­
petual resilience: Exploring the experience of a diabetes-
related amputation through grounded theory. Contemp Nurse.
2011;39(1):20–30.
4. Sigford BJ. Paradigm shift for VA amputation care. J Rehabil
Res Dev. 2010;47(4):xv–xix.
5. Pasquina PF. DOD paradigm shift in care of service members
with major limb loss. J Rehabil Res Dev. 2010;47(4):xi–xiv.
6. Hakimi KN. Pre-operative rehabilitation evaluation of the dys­
vascular patient prior to amputation. Phys Med Rehabil Clin
N Am. 2009;20(4):677–688.
7. Smith DG. General principles of amputation surgery. In: Smith
DG, Michael JW, Bowker JH, eds. Atlas of Amputation and Limb
Deficiencies: Surgical, Prosthetic, and Rehabilitation Principles. 3rd
ed. Rosemont, IL: American Academy of Orthopaedic Surgeons;
2004:21–30.
8. Richardson C. Nursing aspects of phantom limb pain following
amputation. Br J Nurs. 2008;17(7):422–426.
9. Melsom H, Danjoux G. Perioperative care for lower limb
amputation in vascular disease. Contin Educ Anaesth Crit Care
Pain. 2011;11(5):162–166.
10. Goldberg T. Postoperative management of lower extrem­
ity amputations. Phys Med Rehabil Clin N Am. 2006;17(1):
173–180.
11. Bowker JH. The art of prosthesis prescription. In: Smith DG,
Michael JW, Bowker JH, eds. Atlas of Amputation and Limb
Deficiencies: Surgical, Prosthetic, and Rehabilitation Principles.
3rd ed. Rosemont, IL: American Academy of Orthopaedic
Surgeons; 2004:739–744.
12. McFarland LV, Choppa AJ, Betz K, et al. Resources for wounded
warriors with major traumatic limb loss. J Rehabil Res Dev.
2010;47(3):1–13.
13. Dillingham TR, Yacub JN, Pezzin LE. Determinants of post­
acute care discharge destination after dysvascular lower limb
amputation. PM R. 2011;3(4):336–344.
14. Gajewski D, Granville R. The United States Armed Forces Amputee
Patient Care Program. J Am Acad Orthop Surg. 2006;14(10 Spec
No):S183–S187.
15. Who are physical therapists? Guide to Physical Therapist Practice.
Alexandria, VA: American Physical Therapy Association.
Accessed 04.08.11.
16. Dillingham TR, Pezzin LE. Rehabilitation setting and asso­
ciated mortality and medical stability among persons with
amputations. Arch Phys Med Rehabil. 2008;89(6):1038–1045.
17. Stineman MG, Kwong PL, Kurichi JE, et al. The effectiveness
of inpatient rehabilitation in the acute postoperative phase of
care after transtibial or transfemoral amputation: study of an
integrated health care delivery system. Arch Phys Med Rehabil.
2008;89(10):1863–1872.
18. Basics of Patient/Client Management: The Five Elements of
Patient/Client Management. Guide to Physical Therapist Practice.
Alexandria, VA: American Physical Therapy Association. http://
guidetoptpractice.apta.org. Accessed 18.08.11.
19. Strauss SE, Richardson WS, Glaszious P, Haynes RB. Evidence-
Based Medicine: How to Practice and Teach EBM. 3rd ed.
Philadelphia, PA: Churchill Livingstone; 2005.
20. Spector RE. Cultural Diversity in Health and Illness. 7th ed.
Saddle River, NJ: Prentice-Hall; 2008.
21. Horgan O, MacLachlan M. Psychosocial adjustment to
lower limb amputation: a review. Disabil Rehabil. 2004;
26(14/15):837–850.
22. Coffey L, Gallagher P, Horgan O, et  al. Psychosocial adjust­
ment to diabetes-related lower limb amputation. Diabet Med.
2009;26(10):1063–1067.
23. Arnett JJ. Human Development: A Cultural Approach. New
York, NY: Pearson; 2012.
24. Lusardi MM. Older adults and their families. In: Guccione AA,
Avers D, Wong RA, eds. Geriatric Physical Therapy. 3rd ed.
St. Louis, MO: Elsevier Mosby; 2012:207–227.
25. Anderson
SA,
Sabatelli
RN.
Family
Interaction:
A
Multigenerational Developmental Perspective. 5th ed. Upper
Saddle River, NJ: Prentice Hall; 2010.
26. Ainsworth E, de Jonge D. An Occupational Therapist's Guide to
Home Modification Practice. Thorofare, NJ: Slack; 2011.
27. Couture M, Desrosiers J, Caron CD. Cognitive appraisal and
perceived benefits of dysvascular lower limb amputation: a lon­
gitudinal study. Arch Gerontol Geriatr. 2011;52(1):5–11.
28. Martz E, Livneh H. Coping with Chronic Illness and Disability:
Theoretical, Empirical, and Clinical Aspects. New York, NY:
Springer; 2007.
29. Gillis A, MacDonald B. Deconditioning in the hospitalized
elderly. Can Nurse. 2005;101(6):16–20.
30. Cohen B, Vittinghoff E, Whooley M. Association of socio­
economic status and exercise capacity in adults with coronary
heart disease. Am J Cardiol. 2008;101(4):462–466.
31. Kurichi JE, Stineman MG, Kwong PL, et al. Assessing and using
comorbidity measures in elderly veterans with lower extremity
amputations. Gerontology. 2007;53(5):255–259.
32. Landry GJ, Silverman DA, Liem TK, et al. Predictors of heal­
ing and functional outcome following transmetatarsal amputa­
tions. Arch Surg. 2011;146(9):1005–1009.
33. Aragón-Sánchez J, Hernández-Herrero MJ, Lázaro-Martínez JL,
et al. In-hospital complications and mortality following major
lower extremity amputations in a series of predominantly dia­
betic patients. Int J Low Extrem Wounds. 2010;9(1):16–23.
34. Neil JA. Perioperative care of the immunocompromised
patient. AORN J. 2007;85(3):544–564.
35. Shih T, Lindely C. Bevacizumab: an angiogenesis inhibi­
tor for the treatment of solid malignancies. Clin Ther.
2006;28(11):1779–1802.
36. Olascoaga A, Vilar-Compte D, Poitevin-Chacon A, Contreras-
Ruiz J. Wound healing in radiated skin: pathophysiology and
treatment options. Int Wound J. 2008;5(2):246–257.
37. Remes L, Isoaho R, Vahlberg T, et al. Predictors for institution­
alization and prosthetic ambulation after major lower extrem­
ity amputation during an eight-year follow-up. Aging Clin Exp
Res. 2009;21(2):129–135.
38. Richardson J, Letts L, Chan D, et al. Rehabilitation in a primary
care setting for persons with chronic illness—a randomized
controlled trial. Prim Health Care Res Dev. 2010;11(4):382–395.
39. Wells CL, Walker M. Evaluation of the acute, medically com­
plex patient. In: Guccione AA, Avers D, Wong RA, eds. Geriatric
Physical Therapy. St. Louis, MO: Mosby; 2012:153–182.
40. Billek-Sawhney B, Wells CL. Oncology implications for exer­
cise and rehabilitation. Acute Care Perspect. 2009;18(4):12–19.

586
Section III  Prostheses in Rehabilitation
41. Chapman S. Pain management in patients following limb
amputation. Nurs Stand. 2011;25(19):35–40.
42. Ketz AK. Pain management in the traumatic amputee. Crit
Care Nurs Clin North Am. 2008;20(1):51–57.
43. Derman W. Antihypertensive medications and exercise. Int
Sport Med J. 2008;9(1):32–38.
44. Di Stasi SL, MacLeod TD, Winters JD, Binder-Macleod SA.
Effects of statins on skeletal muscle: a perspective for physical
therapists. Phys Ther. 2010;90(10):1530–1542.
45. Green S, Askew CD, Walker PJ. Effect of type 2 diabetes mel­
litus on exercise intolerance and the physiological responses
to exercise in peripheral arterial disease. Diabetologia.
2007;50(4):859–866.
46. Knight J, Nigam Y, Jones A. Effects of bedrest 1: cardiovas­
cular, respiratory and haematological systems. Nurs Times.
2009;105(21):16–20.
47. Mason SE, Noel-Storr A, Ritchie CW. The impact of general and
regional anesthesia on the incidence of post-operative cognitive
dysfunction and post-operative delirium: a systematic review
with meta-analysis. J Alzheimers Dis. 2010;22(suppl 3):67–79.
48. Boissonnault WG, Umphred DA. Differential diagnosis phase 1:
medical screening for the therapist. In: Umphred DA, ed.
Neurological Rehabilitation. 5th ed. St. Louis, MO: Mosby;
2007:149–163.
49. Marcantonio ER. In the clinic. Delirium. Ann Intern Med.
2011;154(11): ITC61–ITC6-15.
50. What are tests and measures? Guide to Physical Therapist
Practice. Alexandria, VA: American Physical Therapy
Association.
body. Accessed 04.08.11.
51. Institute for Clinical Systems Improvement. Assessment and
Management of Acute Pain. 6th ed.
acute/pain__acute__assessment_and_managementof__3.
html; 2008. Accessed 15.12.11.
52. Pasero C, McCaffrey M. Pain Assessment and Pharmacologic
Management. St. Louis, MO: Mosby; 2011.
53. Ciccone CD. Opioid analgesics. In: Ciccone CD, ed.
Pharmacology in Rehabilitation. 4th ed. Philadelphia, PA: FA
Davis; 2007:183–198.
54. Ciccone CD. Patient-controlled analgesia. In: Ciccone CD, ed.
Pharmacology in Rehabilitation. 4th ed. Philadelphia, PA: FA
Davis; 2007:237–249.
55. Casale R, Alaa L, Mallick M, Ring H. Phantom limb related
phenomena and their rehabilitation after lower limb amputa­
tion. Eur J Phys Rehabil Med. 2009;45(4):559–566.
56. Richardson C, Glenn S, Nurmikko T, Horgan M. Incidence of
phantom phenomena including phantom limb pain 6 months
after major lower limb amputation in patients with peripheral
vascular disease. Clin J Pain. 2006;22(4):353–358.
57. Schley MT, Wilms P, Toepfner S, et al. Painful and nonpainful
phantom and stump sensations in acute traumatic amputees.
J Trauma. 2008;65(4):858–864.
58. Probstner D, Thuler LC, Ishikawa NM, Alvarenga RM.
Phantom limb phenomena in cancer amputees. Pain Pract.
2010;10(3):249–256.
59. Rayegani SM, Aryanmehr A, Soroosh MR, Baghbani M.
Phantom pain, phantom sensation, and spine pain in bilat­
eral lower limb amputees: results of a national survey of iraq-
iran war victims’ health status. J Prosthet Orthot. 2010;22(3):
162–165.
60. Wolff A, Vanduynhoven E, van Kleef M, et al. Phantom pain.
Pain Pract. 2011;11(4):403–413.
61. Wilson JA, Nimmo AF, Fleetwood-Walker SM, Colvin LA.
A randomized double blind trial of the effect of pre-emptive
epidural ketamine on persistent pain after lower limb amputa­
tion. Pain. 2008;135(1/2):108–118.
62. Borghi B, D'Addabbo M, White PF, et al. The use of prolonged
peripheral neural blockade after lower extremity amputation:
the effect on symptoms associated with phantom limb syn­
drome. Anesth Analg. 2010;111(5):1308–1315.
63. Subedi B, Grossberg GT. Phantom limb pain: mechanisms and
treatment approaches. Pain Res Treat. 2011;2011:864605.
64. Giummarra MJ, Moseley GL. Phantom limb pain and bodily
awareness: current concepts and future directions. Curr Opin
Anaesthesiol. 2011;24(5):524–531.
65. Shultz SJ, Nguyen A. Bilateral asymmetries in clinical measures
of lower extremity anatomic characteristics. Clin J Sports Med.
2007;17(5):357–361.
66. Arwert HJ, van Doorn-Loogman MH, Koning J, et al. Residual-
limb quality and functional mobility 1 year after transtibial
amputation caused by vascular insufficiency. J Rehabil Res Dev.
2007;44(5):717–722.
67. Standard of Care: Lower Extremity Amputation. Boston, MA:
The Brigham and Women's Hospital, Department of
Rehabilitation Services; 2011.
68. Sanders JE, Fatone S. Residual limb volume change: Systematic
review of measurement and management. J Rehabil Res Dev.
2011;48(8):949–986.
69. de Boer-Wilzing VG, Bolt A, Geertzen JH, et  al. Variation
in results of volume measurements of stumps of lower limb
amputees: a comparison of 4 methods. Arch Phys Med Rehabil.
2011;92(6):941–946.
70. Geil MD. Consistency, precision, and accuracy of optical
and electromagnetic shape-capturing systems for digital
measurement of residual-limb anthropometrics of persons
with transtibial amputation. J Rehabil Res Dev. 2007;44(4):
515–524.
71. Bowker JH. Transtibial amputation: surgical management. In:
Smith DG, Michaels JW, Bowker JH, eds. Atlas of Amputation
and Limb Deficiencies: Surgical, Prosthetic, and Rehabilitation
Principles. 3rd ed. Rosemont, IL: American Academy of
Orthopaedic Surgeons; 2004:481–501.
72. McIntosh J, Earnshaw JJ. Antibiotic prophylaxis for the pre­
vention of infection after major limb amputation. Eur J Vasc
Endovasc Surg. 2009;37(6):696–703.
73. Sadat U, Chaudhuri A, Hayes PD, et  al. Five day antibiotic
prophylaxis for major lower limb amputation reduces wound
infection rates and the length of in-hospital stay. Eur J Vasc
Endovasc Surg. 2008;35(1):75–78.
74. Tintle SM, Forsberg JA, Keeling JJ, et  al. Lower extremity
combat-related amputations. J Surg Orthop Adv. 2010;19(1):
35–43.
75. Lim TS, Finlayson A, Thorpe JM, et al. Outcomes of a contem­
porary amputation series. ANZ J Surg. 2006;76(5):300–305.
76. Carney ML, Ullrich P, Esselman P. Early unplanned trans­
fers from inpatient rehabilitation. Am J Phys Med Rehabil.
2006;85(5):453–462.
77. Bates-Jensen BM, Woolfolk N. Acute surgical wound manage­
ment. In: Sussman C, Bates-Jensen BM, eds. Wound Care:
A Collaborative Practice Model. 3rd ed. Philadelphia, PA:
Wolters Kluwer–Lippincott Williams & Wilkins; 2007:322–335.
78. Stasik CN, Berceli SA, Nelson PR, et  al. Functional out­
come after redo below-knee amputation. World J Surg.
2008;32(8):1823–1826.

Chapter 20  Postoperative and Preprosthetic Care
587
79. Smith E, Ryall N. Residual limb osteomyelitis: A case
series from a national prosthetic centre. Disabil Rehabil.
2009;31(21):1785–1789.
80. VanRoss ER, Johnson S, Abbott CA. Effects of early mobiliza­
tion on unhealed dysvascular transtibial amputation stumps: a
clinical trial. Arch Phys Med Rehabil. 2009;90(4):610–617.
81. Kapp SL, Fergason JR. Transtibial amputation: prosthetic man­
agement. In: Smith DG, Michaels JW, Bowker JH, eds. Atlas
of Amputation and Limb Deficiencies: Surgical, Prosthetic, and
Rehabilitation Principles. 3rd ed. Rosemont, IL: American
Academy of Orthopaedic Surgeons; 2004:503–515.
82. Smith DG, Berke GM. Standards of care in post operative
management of the lower extremity amputee: Proceedings
of the Clinical Standards of Practice Consensus Conference.
J Prosthet Orthot. 2004;16(3 S):6–12.
83. Yu JC, Lam K, Nettel-Aguirre A, et al. Incidence and risk fac­
tors of falling in the postoperative lower limb amputee while on
the surgical ward. PM R. 2010;2(10):926–934.
84. Eneroth M, Apelqvist J, Larsson J, Persson BM. Improved
wound healing in transtibial amputees receiving supplemen­
tary nutrition. Int Orthop. 1997;21(2):104–108.
85. Robertshaw D, Robertshaw L. What role do we play post-
amputation? Diabetic Foot J. 2003;6(1):43–44 46–77.
86. Evans KK, Attinger CE, Al-Attar A, et  al. The importance
of limb preservation in the diabetic population. J Diabetes
Complications. 2011;25(4):227–231.
87. Perry J. Amputee gait. In: Smith DG, Michaels JW, Bowker JH,
eds. Atlas of Amputation and Limb Deficiencies: Surgical,
Prosthetic, and Rehabilitation Principles. 3rd ed. Rosemont, IL:
American Academy of Orthopaedic Surgeons; 2004:367–384.
88. van Velzen AD, Nederhand MJ, Emmelot CH, Ijzerman MJ.
Early treatment of trans-tibial amputees: retrospective analy­
sis of early fitting and elastic bandaging. Prosthet Orthot Int.
2005;29(1):3–12.
89. Gottschalk F. Transfemoral amputation: surgical manage­
ment. In: Smith DG, Michaels JW, Bowker JH, eds. Atlas of
Amputation and Limb Deficiencies: Surgical, Prosthetic, and
Rehabilitation Principles. 3rd ed. Rosemont, IL: American
Academy of Orthopaedic Surgeons; 2004:533–540.
90. Gailey R, Allen K, Castles J, Kucharik J, Roeder M. Review of sec­
ondary physical conditions associated with lower limb amputation
and long-term prosthesis use. J Rehabil Res Dev. 2008;45(1):15–29.
91. Uellendahl JE. Bilateral lower limb prosthesis. In: Smith DG,
Michaels JW, Bowker JH, eds. Atlas of Amputation and Limb
Deficiencies: Surgical, Prosthetic, and Rehabilitation Principles.
3rd ed. Rosemont, IL: American Academy of Orthopaedic
Surgeons; 2004:621–632.
92. Magee DJ. Knee. In: Magee DJ, ed. Orthopedic Physical
Assessment. 5th ed. St. Louis, MO: Saunders; 2008:727–843.
93. Kendall FP, McCreary EK, Provance PG, et al. Muscles: Testing
and Function. 5th ed. Philadelphia, PA: Lippincott Williams &
Wilkins; 2005.
94. Krebs DE, Scarborough DM, McGibbon CA. Functional vs.
strength training in disabled elderly outpatients. Am J Phys
Med Rehabil. 2007;86(2):93–103.
95. Marimuthu K, Murton AJ, Greenhaff PL. Mechanisms regulat­
ing muscle mass during disuse atrophy and rehabilitation in
humans. J Appl Physiol. 2011;110(2):555–560.
96. O'Sullivan SB. Assessment of motor function: motor control
and motor learning. In: O'Sullivan SB, Schmitz TJ, eds. Physical
Rehabilitation: Assessment and Treatment. 5th ed. Philadelphia:
F.A. Davis; 2007:227–271.
97. Bales JG, Meals R. Peripheral neuropathy of the upper extrem­
ity: medical comorbidity that confounds common orthopedic
pathology. Orthopedics. 2009;32(10):758–765.
98. May O, Arildsen H. Long-term predictive power of simple func­
tion tests for cardiovascular autonomic neuropathy in diabetes:
a population-based study. Acta Diabetol. 2011;48(4):311–316.
99. Pop-Busui R. Cardiac autonomic neuropathy in diabetes:
a clinical perspective. Diabetes Care. 2010;33(2):434–441.
100. Umphred DA. The limbic system: influence over motor control
and learning. In: Umphred DA, ed. Neurological Rehabilitation.
5th ed. St. Louis, MO: Mosby; 2007:71–118.
101. Borg G, Domserius M, Kaijser L. Psychophysical scaling with
applications in physical work and the perception of exertions.
Scand J Work Environ Health. 1990;16(suppl 1):55–58.
102. Borg GA. Psychosocial bases of perceived exertions, basis of
perceived exertion. Med Sci Sports Exerc. 1982;14(5):377–387.
103. Erjavec T, Presern-Strukelj M, Burger H. The diagnostic
importance of exercise testing in developing appropriate reha­
bilitation programmes for patients following transfemoral
amputation. Eur J Phys Rehabil Med. 2008;44(2):133–139.
104. Vestering MM, Schoppen T, Dekker R, et al. Development of an
exercise testing protocol for patients with a lower limb amputa­
tion: results of a pilot study. Int J Rehabil Res. 2005;28(3):237–244.
105. Chin T, Sawamura S, Fujita H, et al. %VO2max as an indicator
of prosthetic rehabilitation outcome after dysvascular amputa­
tion. Prosthet Orthot Int. 2002;26(1):44–49.
106. Yosefy C. Diabetic heart and the cardiovascular surgeon.
Cardiovasc Hematol Disord Drug Targets. 2008;8(2):147–152.
107. Belmont PJ, Davey S, Orr JD, et al. Risk factors for 30-day post­
operative complications and mortality after below-knee ampu­
tation: a study of 2,911 patients from the national surgical quality
improvement program. J Am Coll Surg. 2011;213(3):370–378.
108. Aragon-Sanchez J, Hernandez-Herrero MJ, Lazaro-Martinez JL,
et al. In-hospital complications and mortality following major
lower extremity amputations in a series of predominantly dia­
betic patients. Int J Low Extrem Wounds. 2010;9(1):16–23.
109. Avers D, Williams AK. Cognition in the aging adult. In:
Guccione AA, Avers D, Wong RA, eds. Geriatric Physical
Therapy. 3rd ed. St. Louis, MO: Elsevier Mosby; 2012:121–152.
110. Schulte OJ, Stephens J, Ann J. Brain function, aging, and
dementia. In: Umphred DA, ed. Neurological Rehabilitation.
5th ed. St. Louis, MO: Mosby; 2007:902–930.
111. Balasundaram B, Holmes J. Delirium in vascular surgery. Eur J
Vasc Endovasc Surg. 2007;34(2):131–134.
112. Singh R, Ripley D, Pentland B, et al. Depression and anxiety
symptoms after lower limb amputation: the rise and fall. Clin
Rehabil. 2009;23(3):281–286.
113. Ide M. The association between depressive mood and pain
amongst individuals with limb amputations. Eur J Trauma
Emerg Surg. 2011;37(2):191–195.
114. Vase L, Nikolajsen L, Christensen B, et al. Cognitive-emotional
sensitization contributes to wind-up-like pain in phantom limb
pain patients. Pain. 2011;152(1):157–162.
115. Copuroglu C, Ozcan M, Yilmaz B, et al. Acute stress disorder
and post-traumatic stress disorder following traumatic ampu­
tation. Acta Orthop Belg. 2010;76(1):90–93.
116. Cheung E, Alvaro R, Colotla VA. Psychological distress in
workers with traumatic upper or lower limb amputations fol­
lowing industrial injuries. Rehabil Psychol. 2003;48(2):109–112.
117. Cavanagh SR, Shin LM, Karamouz N, Rauch SL. Psychiatric
and emotional sequelae of surgical amputation. Psychosomatics.
2006;47(6):459–464.

588
Section III  Prostheses in Rehabilitation
118. Friedman B, Heisel MJ, Delavan RL. Psychometric proper­
ties of the 15-item geriatric depression scale in functionally
impaired, cognitively intact, community-dwelling elderly pri­
mary care patients. J Am Geriatr Soc. 2005;53(9):1570–1576.
119. Schoppen T, Boonstra A, Groothoff JW, et al. Physical, mental,
and social predictors of functional outcome in unilateral lower
limb amputees. Arch Phys Med Rehabil. 2003;84(6):803–811.
120. Behel JM, Rybarczyk B, Elliott TR, et al. The role of perceived
vulnerability in adjustment to lower extremity amputation: a
preliminary investigation. Rehabil Psychol. 2002;47(1):92–105.
121. Pritchard MJ. Using the Hospital Anxiety and Depression Scale
in surgical patients. Nurs Stand. 2011;25(34):35–41.
122. Desmond DM, MacLachlan M. The factor structure of the
hospital anxiety and depression scale in older individu­
als with acquired amputations: a comparison of four models
using confirmatory factor analysis. Int J Geriatr Psychiatry.
2005;20(4):344–349.
123. Pachana NA, Byrne GJ, Siddle H, et al. Development and vali­
dation of the Geriatric Anxiety Inventory. Int Psychogeriatr.
2007;19(1):103–114.
124. Rafnsson SB, Deary IJ, Fowkes FG. Peripheral arterial disease
and cognitive function. Vasc Med. 2009;14(1):51–61.
125. Phelps LF, Williams RM, Raichle KA, et al. The importance of
cognitive processing to adjustment in the 1st year following
amputation. Rehabil Psychol. 2008;53(1):28–38.
126. O'Neill BR, Evans JJ. Memory and executive function predict
mobility rehabilitation outcome after lower limb amputation.
Disabil Rehabil. 2009;31(13):1083–1091.
127. Sansam K, Neumann V, O'Connor R, Bhakta B. Predicting
walking ability following lower limb amputation: a systematic
review of the literature. J Rehabil Med. 2009;41(8):593–603.
128. Taylor SM, Kalbaugh CA, Blackhurst DW, et al. Preoperative
clinical factors predict postoperative functional outcomes after
major lower limb amputation: an analysis of 553 consecutive
patients. J Vasc Surg. 2005;42(2):227–235.
129. Resnik B, Avers D. Motivation and patient education. In:
Guccione AA, Avers D, Wong RA, eds. Geriatric Physical
Therapy. St. Louis, MO: Mosby; 2012:183–206.
130. Dhital A, Pey T, Stanford MR. Visual loss and falls: a review.
Eye (Lond). 2010;24(9):1437–1446.
131. Tideiksaar R. Sensory impairment and fall risk. Generations.
2002–2003;26(4):22–27.
132. Lord SR, Menz HB, Tiedemann A. A physiological profile
approach to falls risk assessment and prevention. Phys Ther.
2003;83(3):237–252.
133. Servat JJ, Risco M, Nakasato YR, Bernardina CR. Visual impair­
ment in the elderly: impact on functional ability and quality of
life. Clin Geriatr. 2011;19(7):49–56.
134. Dillon CF, Gu Q, Hoffman HJ, Ko CW. Vision, hearing, bal­
ance, and sensory impairment in Americans aged 70 years
and over: United States, 1999–2006. NCHS Data Brief 2010;
Apr:1–8 .
135. Wharton MA. Environmental design: accommodating sensory
changes in the older adult. In: Guccione AA, Avers D, Wong RA,
eds. Geriatric Physical Therapy. St. Louis, MO: Mosby; 2012:
104–120.
136. Pratt SR, Kuller L, Talbott EO. Prevalence of hearing loss in
black and white elders: results of the cardiovascular health
study. J Speech Lang Hear Res. 2009;52(4):973–989.
137. Middleton A, Niruban A, Girling G, Myint PK. Communicating
in a healthcare setting with people who have hearing loss. BMJ.
2010;341(7775):726–729.
138. Mold JW, Vesely SK, Keyl BA, et al. The prevalence, predictors,
and consequences of peripheral sensory neuropathy in older
patients. J Am Board Fam Pract. 2004;17(5):309–318.
139. Andrews KL. The at-risk foot: What to do before and after
amputation. J Vasc Nurs. 2011;29(3):120–123.
140. Schmitz TJ. Examination of sensory function. In: O'Sullivan SB,
Schmitz TJ, eds. Physical Rehabilitation. 5th ed. Philadelphia,
PA: FA Davis; 2007:121–156.
141. Fuller G. Neurological Examination Made Easy. Edinburgh, UK:
Churchill Livingstone; 2008.
142. Hamill R, Carson S, Dorahy M. Experiences of psychoso­
cial adjustment within 18 months of amputation: an inter­
pretative
phenomenological
analysis.
Disabil
Rehabil.
2010;32(9):729–740.
143. Ward SR. Biomechanical applications to joint structure and
function. In: Levangie PK, Norkin CC, eds. Joint Structure and
Function. 5th ed. Philadelphia, PA: FA Davis; 2011.
144. Munin MC, Espejo-DeGuzman MC, Boninger ML, et  al.
Predictive factors for successful early prosthetic ambulation
among lower limb amputees. J Rehabil Res Dev. 2001;38(4):
379–384.
145. Sansam K, Neumann V, O'Connor R, Bhakta B. Predicting
walking ability following lower limb amputation: a systematic
review of the literature. J Rehabil Med. 2009;41(8):593–603.
146. May BJ. Amputation. In: O'Sullivan SB, Schmitz TJ, eds.
Physical Rehabilitation. 5th ed. Philadelphia, PA: FA Davis;
2007:1031–1055.
147. McGuire
TL.
Performance-based
measures
following
transtibial amputation: a case report. Top Geriatr Rehabil.
2004;20(4):262–272.
148. Burger H, Marincek C. Functional testing of elderly sub­
jects after lower limb amputation. Prosthet Orthot Int.
2001;25(2):102–107.
149. Miller WC, Deathe AB, Speechley M. Psychometric properties
of the Activities Specific Balance Confidence Scale among indi­
viduals with a lower limb amputation. Arch Phys Med Rehabil.
2003;84(5):656–661.
150. Alghwiri AA, Whitney SL. Balance and falls. In: Guccione AA,
Avers D, Wong RA, eds. Geriatric Physical Therapy. 3rd ed.
St. Louis, MO: Mosby; 2012:331–353.
151. Gailey RS, Roach KE, Applegate EB, et al. The amputee mobil­
ity predictor: an instrument to assess determinants of the lower
limb amputee's ability to ambulate. Arch Phys Med Rehabil.
2002;83(5):613–627.
152. Resnik L, Borgia M. Reliability of outcome measures for people
with lower limb amputations: distinguishing true change from
statistical error. Phys Ther. 2011;91(4):555–565.
153. Lindsey C. Impaired posture. In: Guccione AA, Avers D, Wong RA,
eds. Geriatric Physical Therapy. 3rd ed. St. Louis, MO: Mosby;
2012:292–315.
154. Gailey R, Allen K, Castles J, et al. Review of secondary physical
conditions associated with lower limb amputation and long-
term prosthesis use. J Rehabil Res Dev. 2008;45(1):15–29.
155. Smith CC, Comisky RN. A study of bone mineral density in
lower limb amputees at a national prosthetics center. J Prosthet
Orthot. 2011;1:14–20.
156. Sherk VD, Bemben MG, Bemben DA. BMD and bone geome­
try in transtibial and transfemoral amputees. J Bone Miner Res.
2008;23(9):1449–1457.
157. Granger CV, Hamilton BB, Linacre JM, et al. Performance pro­
files of the functional independence measure. Am J Phys Med
Rehabil. 1993;72(2):84–89.

Chapter 20  Postoperative and Preprosthetic Care
589
158. Masedo AI, Hanley M, Jensen MP, et al. Reliability and valid­
ity of a self-report FIM (FIM-SR) in persons with amputation
or spinal cord injury and chronic pain. Am J Phys Med Rehabil.
2005;84(3):167–179.
159. Passalent LA, Tyas JE, Jaglal SB, Cott CA. The FIM as a
measure of change in function after discharge from inpa­
tient rehabilitation: a Canadian perspective. Disabil Rehabil.
2011;33(7):579–588.
160. Franchignoni F, Orlandini D, Ferriero G, Moscato TA.
Reliability, validity, and responsiveness of the locomo­
tor capabilities index in adults with lower limb amputa­
tion undergoing prosthetic training. Arch Phys Med Rehabil.
2004;85(5):743–748.
161. Gailey RS. Predictive outcome measures versus functional out­
come measures in the lower limb amputee. J Prosthet Orthot.
2006; Proceedings 6: P51–P60.
162. Belmont PJ, Davey S, Orr JD, et  al. Risk factors for 30-day
postoperative complications and mortality after below-
knee amputation: a study of 2,911 patients from the national
surgical quality improvement program. J Am Coll Surg.
2011;213(3):370–378.
163. Aragón-Sánchez J, Hernández-Herrero MJ, Lázaro-Martínez JL,
et al. In-hospital complications and mortality following major
lower extremity amputations in a series of predominantly dia­
betic patients. Int J Low Extrem Wounds. 2010;9(1):16–23.
164. Bates B, Stineman MG, Reker DM, et al. Risk factors associ­
ated with mortality in veteran population following trans­
tibial or transfemoral amputation. J Rehabil Res Dev.
2006;43(7):917–928.
165. Kobayashi L, Inaba K, Barmparas G, et  al. Traumatic limb
amputations at a level I trauma center. Eur J Trauma Emerg
Surg. 2011;37(1):67–72.
166. Harris AM, Althausen PL, Kellam J, et al. Complications fol­
lowing limb-threatening lower extremity trauma. J Orthop
Trauma. 2009;23(1):1–6.
167. D'Ayala M, Huzar T, Briggs W, et  al. Blood transfusion
and its effect on the clinical outcomes of patients under­
going major lower extremity amputation. Ann Vasc Surg.
2010;24(4):468–473.
168. Rizvi AA, Chillag SA, Chillag KJ. Perioperative management of
diabetes and hyperglycemia in patients undergoing orthopae­
dic surgery. J Am Acad Orthop Surg. 2010;18(7):426–435.
169. Huang ME, Johns JS, White J, Sanford K. Venous thromboem­
bolism in a rehabilitation setting after major lower extremity
amputation. Arch Phys Med Rehabil. 2005;86(1):73–78.
170. Ploeg AJ, Lardenoye JW, Vracken-Peeters MP, Breslau PJ.
Contemporary series of morbidity and mortality after lower
limb amputation. Eur J Vasc Endovasc Surg. 2005;29(6):633–637.
171. Nicolle LE. Catheter-related urinary tract infection. Drugs
Aging. 2005;22(8):627–639.
172. Lim TS, Finlayson A, Thorpe JM, et al. Outcomes of a contem­
porary amputation series. ANZ J Surg. 2006;76(5):300–305.
173. Tintle SM, Keeling JJ, Forsberg JA, et al. Operative complica­
tions of combat-related transtibial amputations: a compari­
son of the modified Burgess and modified Ertl tibiofibular
synostosis techniques. J Bone Joint Surg Am. 2011;93-A(11):
1016–1021.
174. Goodman CC, Peterson C. Infectious disease. In: Pathology:
Implications for the Physical Therapist. 5th ed. St. Louis, MO:
Elsevier Saunders; 2009:298–347.
175. Awad SS. State-of-the-art therapy for severe sepsis and multi­
system organ dysfunction. Am J Surg. 2003;186(5A):23S–30S.
176. Jette AM. Physical disablement concepts for physical therapy
research and practice. Phys Ther. 1994;74(5):380–386.
177. Masala C, Petretto DR. From disablement to enablement: con­
ceptual models of disability in the 20th century. Disabil Rehabil.
2008;30(17):1233–1244.
178. Roush SE, Sharby N. Disability reconsidered: the paradox of
physical therapy. Phys Ther. 2011;91(12):1715–1727.
179. Jette AM. Toward a common language for function, disability,
and health. Phys Ther. 2006;86(5):726–734.
180. Sansam K, Neumann V, O'Connor R, Bhakta B. Predicting
walking ability following lower limb amputation: a systematic
review of the literature. J Rehabil Med. 2009;41(8):593–603.
181. Munin MC, Espejo-De Guzman MC, Boninger ML, et  al.
Predictive factors for successful early prosthetic ambu­
lation among lower limb amputees. J Rehabil Res Dev.
2001;38(4):379–384.
182. Kalbaugh CA, Taylor SM, Kalbaugh BA, et al. Does obesity pre­
dict functional outcome in the dysvascular amputee? Am Surg.
2006;72(8):707–713.
183. Taylor SM, Kalbaugh CA, Blackhurst DW, et al. Preoperative
clinical factors predict postoperative functional outcomes after
major lower limb amputation: an analysis of 553 consecutive
patients. J Vasc Surg. 2005;42(2):227–235.
184. Raya MA, Gailey RS, Fiebert IM, Roach KE. Impairment vari­
ables predicting activity limitation in individuals with lower
limb amputation. Prosthet Orthot Int. 2010;34(1):73–84.
185. Larner S, Van Ross E, Hale C. Do psychological measures pre­
dict the ability of lower limb amputees to learn to use a prosthe­
sis? Clin Rehabil. 2003;17(5):493–498.
186. Wasiak K. Analysis of prognostic factors for locomotion in
patients after amputation of the tibia performed due to ath­
erosclerotic critical limb ischemia. Ortop Traumatol Rehabil.
2005;7(4):411–417.
187. Icks A, Scheer M, Morbach S, et al. Time-dependent impact
of diabetes on mortality in patients after major lower extrem­
ity amputation: survival in a population-based 5-year cohort in
Germany. Diabetes Care. 2011;34(6):1350–1354.
188. Faglia E, Clerici G, Caminiti M, et  al. Mortality after major
amputation in diabetic patients with critical limb ischemia who
did and did not undergo previous peripheral revascularization
Data of a cohort study of 564 consecutive diabetic patients.
J Diabetes Complications. 2010;24(4):265–269.
189. Moxey PW, Hofman D, Hinchliffe RJ, et al. Epidemiological
study of lower limb amputation in England between 2003 and
2008. Br J Surg. 2010;97(9):1348–1353.
190. Dillingham TR, Yacub JN, Pezzin LE. Determinants of post­
acute care discharge destination after dysvascular lower limb
amputation. PM R. 2011;3(4):336–344.
191. Gailey RS, Clark CR. Physical therapy. In: Smith DG, Michaels JW,
Bowker JH, eds. Atlas of Amputation and Limb Deficiencies:
Surgical, Prosthetic, and Rehabilitation Principles. 3rd ed.
Rosemont, IL: American Academy of Orthopaedic Surgeons;
2004:589–619.
192. Uustal H. Prosthetic rehabilitation issues in the diabetic
and dysvascular amputee. Phys Med Rehabil Clin N Am.
2009;20(4):689–703.
193. Kanade RV, van Deursen RW, Price P, Harding K. Risk of plan­
tar ulceration in diabetic patients with single-leg amputation.
Clin Biomech (Bristol, Avon). 2006;21(3):306–313.
194. Halbert J, Crotty M, Cameron ID. Evidence for the optimal
management of acute and chronic phantom pain: a systematic
review. Clin J Pain. 2002;18(2):84–92.

590
Section III  Prostheses in Rehabilitation
195. Hanley MA, Ehde DM, Campbell KM, et  al. Self-reported
treatments used for lower limb phantom pain: descriptive find­
ings. Arch Phys Med Rehabil. 2006;87(2):270–277 310–311.
196. Alviar MJ, Hale T, Dungca M. Pharmacologic interventions for
treating phantom limb pain. Dec 7 Cochrane Database Syst Rev.
2011;(12): CD006380.
197. Grant AJ, Wood C. The effect of intra-neural local anaesthetic
infusion on pain following major lower limb amputation. Scott
Med J. 2008;53(1):4–6.
198. West M, Wu H. Pulsed radiofrequency ablation for resid­
ual and phantom limb pain: a case series. Pain Pract.
2010;10(5):485–491.
199. Kollewe K, Jin L, Krampfl K, et  al. Treatment of phan­
tom limb pain with botulinum toxin type A. Pain Med.
2009;10(2):300–303.
200. Cohen SP, Gambel JM, Raja SN, Galvagno S. The contribution
of sympathetic mechanisms to post-amputation phantom and
residual limb pain: a pilot study. J Pain. 2011;12(8):859–867.
201. Viswanathan A, Phan PC, Burton AW. Use of spinal cord stim­
ulation in the treatment of phantom limb pain: case series and
review of the literature. Pain Pract. 2010;10(5):479–484.
202. Kuiken T. Perioperative rehabilitation of the transtibial
and transfemoral amputee. Phys Med Rehabil State Art Rev.
2002;16(3):521–537.
203. Leskowitz ED. Phantom limb pain treated with therapeutic
touch: a case report. Arch Phys Med Rehabil. 2000;81(4):522–524.
204. Department of Veterans Affairs/Department of Defense. VA/
DoD Clinical Practice Guideline for Rehabilitation of Lower
Amputation. Washington, DC: Department of Veterans Affairs,
Department of Defense; 2007. Available at:
line.gov/content.aspx?id=11758&search=amputation. Accessed
29.12.11.
205. Freynet A, Falcoz PE. Is transcutaneous electrical nerve stimu­
lation effective in relieving postoperative pain after thoracot­
omy? Interact Cardiovasc Thorac Surg. 2010;10(2):283–288.
206. Gregorini C, Cipriano G, Aquino LM, et  al. Short-duration
transcutaneous electrical nerve stimulation in the postoperative
period of cardiac surgery. Arq Bras Cardiol. 2010;94(3):325–331,
345–351.
207. Desantana JM, Santana-Filho VJ, Guerra DR, et al. Hypoalgesic
effect of the transcutaneous electrical nerve stimulation fol­
lowing inguinal herniorrhaphy: a randomized, controlled trial.
J Pain. 2008;9(7):623–629.
208. Halbert J, Crotty M, Cameron ID. Evidence for the optimal
management of acute and chronic phantom pain: a systematic
review. Clin J Pain. 2002;18:84–92.
209. Mulvey MR, Bagnall AM, Johnson MI, Marchant PR.
Transcutaneous electrical nerve stimulation (TENS) for phan­
tom pain and stump pain following amputation in adults.
Cochrane Database Syst Rev. 2010 May 12;(5): CD007264.
210. Casale R, Alaa L, Mallick M, Ring H. Phantom limb related
phenomena and their rehabilitation after lower limb amputa­
tion. Eur J Phys Rehabil Med. 2009;45(4):559–566.
211. Leskowitz E. Energy medicine perspectives on ­phantom-limb
pain. Alternative and Complementary Therapies. 2009;15(2):
59–63.
212. Moseley GL. Graded motor imagery for pathologic pain: a ran­
domized controlled trial. Neurology. 2006;67(12):2129–2134.
213. Diers M, Christmann C, Koeppe C, et al. Mirrored, imagined
and executed movements differentially activate sensorimotor
cortex in amputees with and without phantom limb pain. Pain.
2010;149(2):296–304.
214. Rothgangel AS, Braun SM, Beurskens AJ, et  al. The clinical
aspects of mirror therapy in rehabilitation: a systematic review
of the literature. Int J Rehabil Res. 2011;34(1):1–13.
215. Weeks SR, Anderson-Barnes VC, Tsao JW. Phantom limb pain:
theories and therapies. Neurologist. 2010;16(5):277–786.
216. Egsgaard L, Petrini L, Christoffersen G, Arendt-Nielsen L.
Cortical responses to the mirror box illusion: a high-resolution
EEG study. Exp Brain Res. 2011;215(3/4):345–357.
217. Diers M, Christmann C, Koeppe C, et al. Mirrored, imagined
and executed movements differentially activate sensorimotor
cortex in amputees with and without phantom limb pain. Pain.
2010;149(2):296–304.
218. Chan BL, Witt R, Charrow AP, et al. Mirror therapy for phan­
tom limb pain. N Engl J Med. 2007;357(21):2206–2207.
219. Hanling SR, Wallace SC, Hollenbeck KJ, et al. Preamputation
mirror therapy may prevent development of phantom limb
pain: a case series. Anesth Analg. 2010;110(2):611–614.
220. Murray CD, Pettifer S, Howard T, et al. The treatment of phan­
tom limb pain using immersive virtual reality; three case stud­
ies. Disabil Rehabil. 2007;29(18):1465–1469.
221. MacLachlan M, McDonald D, Waloch J. Mirror treat­
ment of lower limb phantom pain. Am J Phys Med Rehabil.
2004;26(14–15):901–904.
222. Casale R, Damiani C, Rosati V. Mirror therapy in the rehabili­
tation of lower-limb amputation: are there any contraindica­
tions? Am J Phys Med Rehabil. 2009;88(10):837–842.
223. Nawijn SE, van der Linde H, Emmelot CH, Hofstad CJ. Stump
management after transtibial amputation: a systematic review.
Prosthet Orthot Int. 2005;29(1):13–26.
224. Smith DG, McFarland LV, Sangeorzan BJ, et  al. Addendum
1: post-operative dressing and management strategies for
transtibial amputations: a critical review. J Prosthet Orthot.
2004;16(S3):15–25.
225. Walsh TL. Custom removable immediate postoperative pros­
thesis. J Prosthet Orthot. 2003;15(4):158–161.
226. Tang PC, Ravji K, Key JJ, et al. Let them walk! Current pros­
thesis options for leg and foot amputees. J Am Coll Surg.
2008;206(3):548–560.
227. Seymour R. Clinical use of dressings and bandages. In:
Seymour R, ed. Prosthetics and Orthotics: Lower Limb and
Spinal. Philadelphia, PA: Lippincott Williams & Wilkins;
2002:123–142.
228. Broomhead P, Dawes D, Hancock A, et al. Clinical Guidelines
for the pre and post operative management of adults with lower
limb amputation. London: Chartered Society of Physiotherapy;
2006.
229. Woodburn KR, Sockalingham S, Gilmore H, et  al. A ran­
domised trial of rigid stump dressing following trans-
tibial amputation for peripheral arterial insufficiency. Prosthet
Orthot Int. 2004;28(1):22–27.
230. Vermeulen H, Ubbink DT, Goossens A, et al. Dressings and
topical agents for surgical wounds healing by secondary inten­
tion. Cochrane Database Syst Rev. 2004;(1): CD003554.
231. Ladenheim E, Oberti-Smith K, Tablada G. Results of managing
transtibial amputations with a prefabricated polyethylene rigid
removable dressing. J Prosthet Orthot. 2007;19(1):2–6.
232. Wu Y, Krick H. Removable rigid dressing for below-knee
amputees. Clin Prosthet Orthot. 1987;11(1):33–44.
233. Deutsch A, English RD, Vermeer TC, et al. Removable rigid
dressings versus soft dressings: a randomized, controlled study
with dysvascular, trans-tibial amputees. Prosthet Orthot Int.
2005;29(2):193–200.