16.3 Amputation & Prosthetic Rehabilitation
Key Takeaways
- Domain 3 Task 4 requires knowledge of the types and functions of prosthetic devices for upper and lower extremity amputations, and of client-centered education and training for their safe and effective use.
- Contracture prevention is the highest-yield pre-prosthetic intervention: after a transtibial amputation avoid knee flexion contracture by never placing a pillow under the knee, and after a transfemoral amputation avoid hip flexion and abduction contracture with prone-lying and neutral positioning.
- Residual limb wrapping uses a figure-8 pattern applied distal to proximal with greater pressure distally; circular wrapping creates a tourniquet effect and is contraindicated.
- Body-powered prostheses use a figure-8 harness and control cable, most commonly with a voluntary-opening hook whose grip force is set by rubber bands or springs; myoelectric prostheses are driven by surface electromyographic signals from residual musculature.
- Phantom limb SENSATION is a normal non-painful perception of the missing limb, while phantom limb PAIN is painful and responds to mirror therapy, graded motor imagery, desensitization, and early prosthetic use.
Amputation & Prosthetic Rehabilitation
Domain 3, Task 4 pairs orthotics with prosthetics: the OTR must know types and functions of prosthetic devices for upper and lower extremity amputations and client-centered education and training methods for the safe and effective use of orthotic and prosthetic devices. Occupational therapy owns the upper extremity prosthetic training program outright and contributes substantially to lower extremity rehabilitation through ADL, transfers, home modification, and skin care.
1. Amputation Levels and Etiology
| Upper Extremity (proximal to distal) | Lower Extremity (proximal to distal) |
|---|---|
| Forequarter (scapulothoracic) | Hemipelvectomy |
| Shoulder disarticulation | Hip disarticulation |
| Transhumeral (above elbow) | Transfemoral (above knee) |
| Elbow disarticulation | Knee disarticulation |
| Transradial (below elbow) — most common upper level | Transtibial (below knee) — most common lower level |
| Wrist disarticulation | Syme's (ankle disarticulation) |
| Partial hand / digit | Partial foot (transmetatarsal, ray) |
Etiology drives the plan:
- Dysvascular disease — diabetes and peripheral arterial disease — causes the large majority of lower extremity amputations. These clients are typically older, have comorbid neuropathy, cardiac disease, and vision loss, and the remaining limb is also at risk, making protective foot care education a life-and-limb intervention.
- Trauma causes the majority of upper extremity amputations and typically involves younger clients with high vocational and functional demands.
- Malignancy and congenital limb difference account for the remainder; congenital limb difference is not a "loss" — the child has never had the limb, so intervention is habilitation, not rehabilitation, and prosthetic fitting decisions follow the child's function and preference.
2. The Pre-Prosthetic Phase
This phase determines whether the client will ever wear a prosthesis successfully.
Edema Control and Limb Shaping
The goal is a cylindrical or gently conical, non-bulbous residual limb that will accept a socket.
| Method | Technique |
|---|---|
| Elastic bandage wrapping | Figure-8 pattern, applied distal to proximal with greater pressure distally, re-wrapped every 3 to 4 hours and whenever it loosens |
| Shrinker sock | Graded-compression sleeve; easier for clients and caregivers to apply correctly than bandaging |
| Rigid or semi-rigid dressing | Applied post-operatively; superior edema control and protection from trauma |
Circular wrapping is contraindicated. It produces a tourniquet effect that restricts circulation, delays healing, and creates a bulbous distal end that will not fit a socket.
Contracture Prevention — The Most Tested Content
Contractures form in the position of comfort, and once fixed they can make prosthetic fitting impossible.
| Level | Contracture at Risk | Positioning Program |
|---|---|---|
| Transtibial | Knee flexion | Never place a pillow under the knee. Keep the knee extended in sitting with a board or extension on the wheelchair; prone-lying; avoid prolonged sitting with the knee flexed |
| Transfemoral | Hip flexion and abduction | Prone-lying several times daily; avoid pillows under the residual limb; keep the limb adducted and in neutral rotation; limit continuous wheelchair sitting |
| Transradial | Elbow flexion | Positioning in extension; active elbow extension |
| Transhumeral | Shoulder adduction and internal rotation | Positioning in abduction and external rotation; active shoulder range of motion |
The Rest of the Pre-Prosthetic Program
- Wound and skin care; daily inspection with a long-handled mirror.
- Desensitization: graded textures, tapping, massage, and weight-bearing progression through the residual limb.
- Strengthening of the residual limb and the whole body, plus trunk and remaining-limb conditioning.
- Range of motion at every joint of the residual limb and the contralateral limb.
- One-handed and compensatory ADL training for upper extremity amputation — dressing, grooming, cutting food, fastening — so the client is functional whether or not a prosthesis is eventually worn.
- Change of dominance training when the dominant hand is lost.
- Psychosocial adjustment: grief, altered body image, and identity. Peer support from an experienced prosthesis user is one of the most effective interventions available.
Phantom Sensation and Phantom Pain
- Phantom limb sensation — a non-painful perception that the limb is still present — occurs in nearly all clients and is normal. Reassurance and education are the intervention.
- Phantom limb pain is painful and can be disabling. Evidence-supported approaches include mirror therapy, graded motor imagery, desensitization, transcutaneous electrical nerve stimulation, and early prosthetic use, alongside medical management.
- Residual limb pain is localized to the limb itself and may indicate a neuroma, poor socket fit, or infection — it warrants prosthetist or medical referral, not desensitization alone.
3. Upper Extremity Prosthetic Types
| Type | Control Mechanism | Advantages | Limitations |
|---|---|---|---|
| Passive / cosmetic | None; positioned with the sound hand | Lightest, best appearance, low maintenance | No active grasp |
| Body-powered | Figure-8 harness and control cable driven by scapular abduction and humeral flexion | Durable, lower cost, excellent proprioceptive feedback through the cable, tolerates dirty and wet environments | Harness discomfort, limited grip force, less cosmetic |
| Externally powered (myoelectric) | Surface electromyographic signals from residual muscles drive motors | Stronger grip, no harness, better appearance, proportional control | Heavier, expensive, battery-dependent, moisture-sensitive, slower response |
| Hybrid | Combines both — for example, a body-powered elbow with a myoelectric terminal device | Balances strengths at the transhumeral level | Complex training |
| Activity-specific | Task-designed terminal devices | Optimized for a sport, instrument, or job | Single-purpose |
Terminal Devices
- Voluntary opening (VO) hook — the most common body-powered device. It is closed at rest by rubber bands or springs, and cable tension opens it. Each rubber band adds roughly one pound of pinch force, so grip strength is set by the number of bands.
- Voluntary closing devices are open at rest and close under cable tension, giving the user graded, proportional grip force.
- Hooks offer better visual feedback and precision for small objects; prosthetic hands offer better cosmesis with less precision. Many users own both and switch by task.
Suspension may be harness-based, suction, or a pin-lock liner. Targeted muscle reinnervation — surgically transferring residual nerves to spare muscle — expands the number of available myoelectric control sites and often reduces neuroma pain.
4. Prosthetic Training Progression
- Prosthetic education: the names and functions of each component, care and cleaning, and the wearing schedule.
- Independent donning and doffing. Non-negotiable before any functional training.
- Wearing schedule build-up: begin with short periods — commonly around 15 to 30 minutes — with skin inspection after every wearing period, increasing gradually. Any redness that does not resolve within about 20 minutes means the socket needs adjustment by the prosthetist.
- Controls training: isolated practice of each motion — terminal device opening and closing, wrist rotation, elbow flexion and locking — first without an object.
- Repetitive drills: graded grasp and release of objects varying in size, weight, texture, and fragility (a foam block, then a paper cup, then an egg).
- Bimanual functional training: the prosthesis serves as the stabilizing assist for a unilateral amputee while the sound hand performs the fine work — holding the jar while the sound hand turns the lid, stabilizing paper while writing.
- ADL and IADL integration: dressing, grooming, cooking, driving, and childcare.
- Vocational, leisure, and community reintegration, including work-site assessment and activity-specific terminal devices.
Skin and Limb Care Education
Daily washing and thorough drying of the residual limb; daily inspection with a mirror; clean socks changed daily; sock ply management to accommodate volume fluctuation (add plies as the limb shrinks, and see the prosthetist when plies no longer suffice); never apply lotion immediately before donning; report any breakdown, blister, or persistent redness immediately.
5. The Occupational Therapy Role in Lower Extremity Amputation
Although physical therapy leads gait training, occupational therapy owns a substantial share:
- ADL retraining — bathing and dressing with and without the prosthesis, including the high-risk period at night when the prosthesis is off.
- Transfers and functional mobility, including floor-to-chair recovery after a fall.
- Home modification — bathroom access, ramp evaluation, bed height, and a safe path for prosthesis-free nighttime toileting.
- Energy conservation. The metabolic cost of walking rises substantially after amputation and increases with the level of amputation, which is why energy conservation and activity pacing are core rather than optional.
- Protective care of the remaining limb in dysvascular amputees: daily foot inspection, properly fitted footwear, no barefoot walking, prompt reporting of any wound.
- Driving evaluation and vehicle adaptation referral.
- Work and leisure reintegration.
An occupational therapist is providing acute care to a client on postoperative day two following a right transtibial amputation. The client reports that the residual limb aches and asks the nurse to place a pillow beneath the knee for comfort. What should the therapist do?
A client with a left transradial amputation is being fitted with a body-powered prosthesis using a voluntary-opening hook. The client reports the hook cannot hold a full coffee mug securely. What adjustment addresses this problem?
A client three months after a transhumeral amputation reports a persistent perception that the missing hand is still present, describing it as "just there" without pain, and asks whether something is wrong. What is the MOST appropriate therapist response?