10.5 Amputation, Prosthetic Devices & Prosthetic Training

Amputation, Prosthetic Devices & Prosthetic Training

Orthotics and prosthetics sit in the same blueprint task, and candidates who prepare only the splinting half walk into the exam missing a scored knowledge statement. Domain 2, Task 4 requires knowledge of types and functions of prosthetic devices for upper and lower extremity amputations and of client-centered education and training methods for the safe and effective use of orthotic and prosthetic devices.

1. Levels & Etiology

Etiology matters clinically. Dysvascular disease — diabetes and peripheral vascular disease — is the leading cause of lower extremity amputation, which means the client usually has neuropathy, impaired healing, and a contralateral limb at real risk. Trauma is the leading cause of upper extremity amputation, which means a younger client, a sudden loss with no adjustment period, and often work and identity questions. Cancer and congenital limb difference make up most of the remainder.

2. The Pre-Prosthetic Phase

Everything that determines prosthetic success happens before the prosthesis arrives.

• Edema control and limb shaping. Elastic bandage wrapping is applied in a figure-8 pattern from distal to proximal, with more pressure distally, and is rewrapped several times daily; a shrinker sock is used once the limb tolerates it. The shaping goal is a smooth, tapered limb that will load evenly in a socket.
• Contracture prevention — level-specific and heavily tested.
  • Transtibial: the enemy is knee flexion contracture. Never place a pillow under the knee, do not let the limb hang dependent over a chair edge for long periods, and use a limb board on the wheelchair. Prone lying and knee extension positioning are used.
  • Transfemoral: the enemy is hip flexion, abduction, and external rotation contracture. Prone lying for roughly 15–20 minutes several times daily is the classic intervention; no pillow between the legs; avoid prolonged sitting.
• Desensitization and scar management once the incision is closed: graded textures, tapping, massage, and scar mobilization.
• Range of motion and strengthening, with attention to the shoulder girdle for upper extremity clients (the harness will be driven by scapular motion) and the hip extensors and abductors for lower extremity clients.
• Skin inspection using a long-handled mirror, taught as a daily habit from the beginning.
• Change of dominance training after a dominant-side upper extremity amputation: one-handed ADL techniques, adapted writing, and adaptive equipment such as a rocker knife, cutting board with spikes, and buttonhook.
• Psychosocial adjustment. Grief, altered body image, and identity disruption are part of the caseload, not a distraction from it. Peer visitor programs are well established in this population.

3. Phantom Sensation, Phantom Pain & Residual Limb Pain

Distinguishing the three matters because the responses differ: phantom sensation needs explanation, phantom pain needs a neurological intervention such as mirror therapy, and residual limb pain usually means something mechanical or medical needs fixing.

4. The Three Upper Extremity Control Systems

Terminal device choice: a hook gives better visibility of the object and finer precision for small-object handling; a hand gives better cosmesis and cylindrical grasp. Many users own both and switch. Advanced options such as targeted muscle reinnervation create additional EMG control sites and can also reduce neuroma pain.

5. Prosthetic Training: Four Stages

1. Pre-prosthetic — everything in Section 2 above.
2. Controls training — operate each component in isolation, without a functional task: open and close the terminal device, lock and unlock the elbow, position the wrist unit in pronation and supination. Practice until each motion is automatic.
3. Repetitive drills — grasp and release objects that vary in size, shape, weight, texture, and fragility, in different planes and positions. This is where the client learns how much cable excursion or muscle contraction each object needs.
4. Functional use — ADL, IADL, work, school, and leisure tasks. For a unilateral amputation, the essential teaching point is that the prosthesis functions as the assistive and stabilizing hand while the sound limb remains the primary manipulator. A client trained to expect the prosthesis to replace the dominant hand will abandon it.

Donning, Wearing Schedule & Daily Care

• Wearing schedule: begin at roughly 15–30 minutes, two to three times a day, inspecting the skin at every removal, and increase tolerance gradually. Redness that resolves within about 20 minutes is acceptable; redness that persists, blistering, or an open area means stop and return to the prosthetist for a fit adjustment.
• Wash the residual limb at night, not in the morning. Washing swells the tissue, and a limb washed at 7 a.m. will not fit the socket that was cast to its normal volume.
• Clean the socket interior daily with mild soap and water and let it dry fully overnight.
• Wear a clean prosthetic sock every day, and add or remove sock ply to compensate for daily volume change — more ply when the limb has shrunk, fewer when it has swollen.
• Never modify the prosthesis. Heating, grinding, padding, or re-strapping a socket is the prosthetist's job; the COTA reports fit problems and refers.

Who Does What

The prosthetist fabricates, fits, and adjusts the device. Occupational therapy trains upper extremity prosthetic control and function and retrains ADL and IADL for either level. Physical therapy trains gait and lower extremity prosthetic ambulation. For a lower extremity amputation, the OT contribution is ADL retraining, transfers, energy conservation, home modification, donning and doffing the liner and prosthesis, fall prevention, and — because so many of these clients are dysvascular — preservation of the contralateral limb through skin inspection and foot care education.