“Limb loss” refers to the absence of any part of an arm or leg due to surgical or traumatic amputation. “Limb difference” is used to describe congenital limb absence or malformation.¹ About 2 million Americans already have some form of limb loss, and more than 185,000 new amputations are done each year.^1,2 Losing a limb or being born with a limb that is partially or completely missing is a life-altering experience. Part 1 of this series outlines causes of limb loss; amputation procedures; and postoperative care and rehabilitation, including the role PTs play in helping patients regain function and prevent further amputation. Part 2 focuses on artificial limbs, including developments in prosthetic technology.

Causes of Limb Loss

The primary causes of acquired limb loss are diabetes, peripheral vascular disease, trauma, infection and cancer. About 90% of amputations done in the United States are lower extremity amputations.^2,3 The chance of having an amputation increases with age, with most amputations occurring in people 65 and older.² Most lower limb amputations in this age group are related to two conditions that can occur alone or in combination. The first condition is poor circulation, or ischemia, in the feet and legs due to peripheral vascular disease. The most common symptom of chronic limb ischemia is intermittent claudication, severe pain in the calf muscles that is precipitated by walking and is relieved by rest. The second condition is circulatory impairment and loss of protective sensation in the feet caused by uncontrolled diabetes mellitus.⁴ The percentage of Americans with diabetes and at risk of amputation is expected to increase dramatically in the next several decades.⁵

Trauma rather than disease is the primary cause of upper extremity amputations in adults. In the civilian population, motor vehicle accidents, along with work-related accidents among farmers and factory and construction workers, are the most common causes of traumatic amputations.⁶ About 5% of amputations are due to malignant tumors, generally affecting young people ages 10 to 20.⁴ About one in every 2,000 newborns will have some form of limb difference, ranging from missing parts of fingers or toes to the complete absence of all limbs.² Limb differences may be prevented by encouraging pregnant women to take only essential medications under the supervision of a physician.² Although rates of cancer and trauma-related amputations are decreasing, the incidence of amputations due to diabetes and peripheral vascular disease is rising alarmingly.² Advances in microvascular surgery, antibiotic therapy, cancer treatment and orthopedic reconstructive procedures may make limb preservation or salvage an attractive alternative to amputation.³ Although limb salvage may delay or avoid amputation, it can lead to years of suffering with a limb that is no longer functional or that causes chronic pain. Whether reimplantation surgery is done following a traumatic amputation depends on the mechanism of injury and extent of associated tissue damage, the person’s overall health status, how long the amputated part has been detached, and how it has been preserved.⁶

Battlefield Injuries

The Iraq and Afghanistan wars have resulted in an increasing number of amputees. Wounds caused by modern munitions and explosive devices are much more complex than those experienced in civilian life.⁷ Many injuries caused by combat or terrorist attacks result in amputations of the upper extremities or amputation of more than one limb. Because of the impact of explosive devices, rocket-propelled grenades, missiles, land mines and high-velocity gunshot wounds, there is often extensive soft tissue injury and an increase in infection rates and delayed healing time.⁷ Combat wounds are usually left open to control infection. Often, the patient has a staged approach to amputation to ensure wound closure and to create a residual limb that has optimum function. As a result, reconstructive procedures are often done months after the initial trauma to prevent infection and to eliminate the need for additional amputation procedures at a higher level.⁷ Military personnel injured by explosives may also experience mild to moderate traumatic brain injury due to the effects of concussion and skull injury when hitting the ground. Military psychologists conduct traumatic brain injury testing to assess cognitive or other deficits that can affect the veteran’s recovery and rehabilitation.⁷

Amputation Procedures

Amputation surgical procedures may be open or closed. Open, or guillotine, amputation is done when the patient has a serious infection or extensive soft tissue damage that occurs due to combat. In an open procedure, the wound is left open and skin flaps are later used to close the wound.³ In a closed amputation, also referred to as a flap or myoplastic amputation, skin flaps are prepared and closed over the site during the primary surgical procedure.³ The remaining part of the limb is known as the “residual limb” or stump. Amputation level refers to the location where the amputation occurs. The term “trans” now is used to describe an amputation across the axis of a long bone.

When a limb is amputated, there are two important surgical goals: first, to remove the diseased, damaged, or dysfunctional part of the body; and second, to reconstruct the remaining part of the limb in a way that promotes wound healing and creates the most functional residual limb possible. Vascular studies may be done to determine how much oxygen is being supplied to the affected limb. The amputation level depends on the circulation to the limb, the disease process involved, the patient’s other medical problems, and for the lower limb, whether the patient is ambulatory. Surgeons select an amputation site that allows the creation of bone shape, muscle and soft tissue padding, and a residual limb with the best interface with a prosthetic device. When a limb is being amputated because of cancer, choosing an amputation level may affect the possibility of tumor recurrence.

Postoperative Care and Rehabilitation

Before surgery, the patient should know what type of procedure will be done, how postoperative pain will be managed, and rehabilitation goals and strategies. The possibility of syndromes such as phantom sensation and phantom pain also should be discussed.³ Phantom sensation, the feeling that all or part of a missing limb is still intact, is common among people with limb loss.3 This phenomenon tends to occur early in the postoperative period and is usually self-limiting.³

Phantom pain, episodic sharp or burning pain felt in the missing part of the limb, can occur immediately after surgery or several months later. Chronic pain occurs frequently among people with limb loss, regardless of the time since amputation. One study showed that 95% of amputees reported experiencing some type of amputation-related pain. The survey also concluded that having depressive symptoms is a common predictor of pain frequency and intensity after amputation.⁸ Medications such as calcitonin (Miacalcin) or ketamine (Ketalar) may be given immediately before or after surgery to help prevent phantom pain from developing.⁹ Antidepressant medications are also used postoperatively to help relieve phantom pain symptoms.⁹ Transcutaneous electrical nerve stimulation (TENS), acupuncture or surgical procedures such as spinal cord stimulation, intrathecal medication delivery or deep brain stimulation may be used if more conservative measures don’t relieve phantom pain symptoms.⁹

The focus of immediate postoperative care is to reduce edema, promote wound healing, prevent muscle contractures and complications of bed rest, maximize functional independence and help the person begin to adjust to limb loss.

Diagnoses for a patient having an amputation include pain related to surgical procedure and phantom limb sensation; body image disturbance related to amputation; potential for alteration in skin integrity related to disease process, surgical procedure, and immobility; activity intolerance related to immobility; and ineffective individual coping related to loss.¹⁰ The type of postoperative dressing used depends on the type of prosthesis that will be used. The dressing is important for prosthetic fitting because it shapes the residual limb for the prosthesis.¹⁰ Prostheses can be fitted at the time of surgery or may be applied later. Because older adults, who account for the majority of lower extremity amputations, may be debilitated from the chronic condition that prompted the amputation, along with other health problems, they are often candidates for delayed prosthetic fitting.¹⁰ When a prosthetic fitting is delayed, the wound dressing is either rigid or soft. The advantage of a rigid dressing is that it decreases wound edema. Soft dressings consist of gauze covered with an elastic wrap that acts as a compression dressing to promote residual limb shrinkage. For the first 24 hours after a lower extremity amputation, the limb may be elevated to reduce swelling. After this time, the limb should remain fully extended to prevent hip and knee contractures that will interfere with a functional gait. Patients should be educated about why limb extension is important and why lying regularly in a prone position will help stretch their hip muscles into full extension. When the patient’s condition stabilizes, a physical therapy program consisting of active range of motion, upper extremity strengthening, and gait training begins.¹⁰

After healing has occurred, the patient should be instructed to wash the residual limb daily, dry it thoroughly and inspect the skin daily for redness, abrasions, or irritation.^3,11 The patient can also use a cream to massage the suture line to loosen any crustlike formation. The skin of the residual limb is particularly susceptible to irritation, breakdown, and infection, as it is stretched, pulled and rubbed hundreds of times a day by the prosthetic socket.¹¹ Stump socks and elastic wraps must be changed daily and washed with mild soap and water.³ The residual limb also must be shrunk and shaped so a prosthesis will fit well at the distal end. Limb shrinkage techniques include using an elastic bandage, a removable rigid dressing or an elastic sock in the shape of the limb known as a stump shrinker, or applying an early prosthesis.³ The residual limb also must be desensitized so it will more easily accommodate the pressure of a prosthetic socket. Ways of desensitizing the residual limb include having the patient bear weight on the residual limb against various surfaces and tapping, rubbing and using a vibrator.³

In addition to preventing complications such as deep vein thrombosis and pulmonary edema, early mobilization after amputation surgery also reduces edema in the residual limb. Some of the most important factors involved in the successful rehabilitation of people with limb loss are early prosthetic fitting, the appropriate selection of a prosthesis, collaboration between the patient and the rehabilitation team, and long-term follow-up care.¹² During the rehabilitation process, patients must learn to recondition muscles and relearn activities, balance, and coordination. Not all patients are appropriate rehabilitation candidates; the person’s mental status and level of functioning before the amputation are key indicators of rehabilitation potential.

In addition to caring for patients who have had amputations, physical therapists have an important role in preventing subsequent amputations. Without a significant change in health status, the mortality rate after amputation over a five-year period is higher than that for most malignancies.¹³ Patients who have one leg amputated as a result of peripheral vascular disease or diabetes are at greatly increased risk of losing the other leg. Controlling blood glucose, stopping smoking and practicing careful foot care are essential to preventing further amputation. Patients with diabetes and peripheral vascular disease are taught how to inspect and care for their feet. Instructions include information on promptly notifying a healthcare provider if there are changes in temperature, sensation and color. Methods to protect the lower extremity from injury should be included in the teaching plan.¹⁰ Many amputees are 65 and older, and health problems such as decreased cardiopulmonary functioning, poor neuromuscular coordination, visual impairment and weakened muscles can make their rehabilitation more difficult. Particularly for older people, amputation can create a number of other health problems, such as skin irritation and breakdown and back and hip pain. Because an amputation can result in decreased activity, the risk increases for health problems associated with developing obesity as a result of a sedentary lifestyle.

Adjusting to Limb Loss

Both the decision to amputate or the adjustment to a sudden traumatic amputation are difficult and emotional for the patient and significant others.³ Patients often worry about how the amputation will change their ability to walk or to work, how family and friends will react to them as an amputee, and what their own reaction will be to changes in self-image. Loss of a body part is permanent, leaving a person with alterations in mobility and body image and with potentially significant self-care deficits. An upper extremity amputation can produce severe psychological stress. Hands are necessary for work, recreation and communication. A touch, handshake or hand signal has significant social and communicative meaning.¹⁴ When both upper extremities are amputated, a person experiences an immediate sense of helplessness. Amputation affects not only physical function but also the patient’s role performance, including self-care, family and home management, advancement as a worker or student and participation in leisure and community activities. Whether the amputation is the result of trauma, an acute or chronic disease process or a malignant tumor, to achieve optimum rehabilitation, the patient needs support to adapt to the loss of the limb and the resulting change in body function and image. An early response to limb amputation is often shock and disbelief. Grieving is a normal response to an amputation, and each person grieves at his or her own pace.³ The person’s age, maturity level, coping strategies and the extent of social support are all important factors influencing the grieving process.²

Body image is a person’s subjective perception of the body.¹⁰ Gradual changes in body image are easier to adapt to than those that have an abrupt onset, such as the change experienced by an unplanned amputation. Malignant tumors that require amputation usually occur in people younger than 20, whose body image, sexuality and independence are most vulnerable. The adaptation to the change in body image does not always reflect the extent of the injury, but it is related to that person’s feelings toward self as a total person.¹⁰ Each person’s reaction depends on what the amputated part means to him or her, not just the amount of tissue lost. Accepting a major body image change associated with amputation may be a long process. Symptoms of body image disturbance or ineffective individual coping include a patient’s refusal to look at or touch the residual limb, unwillingness to discuss predicted limitations or to use a prosthesis, refusal to participate in self-care activities and social withdrawal.

Suggest that the patient and family become involved with a support group to help them in the psychological, social and physical adjustment to amputation. The Amputee Coalition of America is an excellent source to recommend for support group information. Its National Limb Loss Center provides free information about limb loss to amputees, family members and caregivers, and healthcare professionals. In addition to First Step, a publication for new amputees, the coalition also publishes Side Step for people with diabetes and has partnered with the U.S. Armed Forces Amputee Patient Care Program to produce Military In-Step, a guide for amputee veterans. Peer group support plays a vital role in rehabilitation. Amputees who participate in such groups learn important lessons: that others have similar feelings of grief and loss, how to deal with changes in family relationships, and how others cope with amputation.¹⁵

As the population ages and the complications of diseases such as diabetes and peripheral vascular disease increase, physical therapists can expect to care for more people with amputations. Together with other healthcare professionals, physical therapists can help amputees learn to discover a new self and can help them view their amputation as a reconstructive procedure that can restore function and help improve quality of life.³

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