Rehabilitation after Below Knee Amputation
Short Note
Goals
Promote wound healing
Control incisional and phantom pain
Maintain Range of Movements of the joints
Promote positive nitrogen balance
Mobilize entire body
Promote healing
SSG / FSG when needed
address proper wound care and limb management
Control Pain
control incisional and phantom pain : narcotics, first three pod, subsequent oral analgesics
Positioning
1-Positioning is an important part of a patient's exercise program. Prevent shortening of soft tissue and joint(s) contractures, that can result from ;
(i) Soft tissue shortening .
(Ii) Muscle imbalance.
(iii) Protective withdrawal reflex.
(iv) Faulty position.
2. Lie prone intermittently to enhance hip and knee extension.
4-The positioning program should emphasize active or active assistive ROM of the joint (s) proximal to the amputation.
5-Elevation of residual limb on a pillow can lead to the development of hip flexion contracture and so should be avoided.
Positioning Approach
Supine position : hips and knees kept straight - firm surface - avoid pillows - legs together
Prone : avoid pillow - hip and staight; legs together - four times a day
Side lying : hip neutral; no large pillow between legs
Sitting : board to keep the residual straight
Exercises
ROM, isometric and isotoinc and endurance exercises; done without much discomfort less stress on suture line
Hip extensor abductors and knee extensor and flexors developed for prosthetic ambulation
Strengthening upper extremity and trunk and abdomen
active / active assistive ROM of the joints proximal joints at 1 & 2 days onwards
Unless precluded full ROM to be obtained by 10 - 14 days
gentle isometric exercises from the 5th POD
these exercises reduce edema and promote healing , maintain joint ROM, prevent contracture alow early mobility , maintain muscle strength and kinesthetic sense of residual and phantom limb,
hip abduction exercises
hip adduction exercises
straight leg raising
short arc quad sets
knee flexion exercises
Parallel bar activities
Ambulation
crutch training
Stair climbing up and down up : natural limb first; down : crutch and residual limb first
increase an individual's strength, flexibility, coordination and endurance, and decrease pain
provide the expert fitting and custom-manufacture of a prosthesis to meet personal lifestyle needs
train individuals to use their prosthesis with confidence and comfort, and avoid complications
Teach ambulation skills;
Flexion contracture of the hip or knee may develop rapidly, making fitting and using the prosthesis difficult; contractures can be prevented with extension braces made by occupational therapists.
Care for the stump
Recognize the earliest signs of skin breakdown.
Stump Conditioning and Prostheses
Stump (residual limb) conditioning promotes the natural process of shrinking that must occur before a prosthesis can be used. After only a few days of conditioning, the stump may have shrunk greatly. An elastic shrinker or elastic bandages worn 24 h/day can help taper the stump and prevent edema. The shrinker is easy to apply, but bandages may be preferred because they better control the amount and location of pressure. However, application of elastic bandages requires skill, and bandages must be reapplied whenever they become loose.
Early ambulation with a temporary prosthesis
Enables the amputee to be active
Accelerates stump shrinkage
Prevents flexion contracture
Reduces phantom limb pain
The permanent prosthesis should be lightweight
Permanent prosthesis is generally delayed a few weeks until shrinkage stops.
Teach Care of the stump and prosthesis
Patients should remove it before going to sleep.
At bedtime, the stump should be inspected thoroughly (with a mirror if inspected by the patient), washed with mild soap and warm water, dried thoroughly, then dusted with talcum powder.
