Preprosthetic Therapy: Is It Needed? Does It Help?

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By Miki Fairley

What helps patients to have satisfying quality of life and achieve their functional goals after amputation? "Approximately 75 percent of older adults can regain their ability to walk without assistive devices if they undergo the proper rehabilitation program before and after they receive a...prosthesis."

This is the heartening message of the American Geriatrics Society (AGS) (www.healthinaging.org ), which comprises more than 6,800 healthcare professionals with an interest in issues of aging. More than 75 percent of all amputations are performed on persons older than 65 years, according to the AGS. About 90 percent of those involve the lower limb, and approximately two-thirds of lower-limb amputations are below the knee. More than 65 percent of all amputations performed on people age 50 and older are due to diabetes or peripheral vascular disease (PVD), according to the Amputee Coalition of American (ACA).

What can help these older adults with non-traumatic lower-limb amputations achieve good quality of life and functional independence?

Preprosthetic therapy plays an important role; however, this type of therapy also benefits those who are not candidates for a prosthesis or opt not to wear one. Preprosthetic therapy includes post-surgical wound care, edema and pain control, residual-limb shaping, learning to make transfers safely and perform other activities of daily living (ADL), standing independently, and walking between parallel bars or with a walker. Preprosthetic exercise therapy combats the effects of deconditioning and improves strength, flexibility, stamina, and cardiopulmonary function.

Meeting Physical Therapy Challenges

Edelstein
Edelstein

One of the biggest challenges for physical therapists is dealing with deconditioning, according to Joan Edelstein, PT, MA, FISPO, adjunct faculty member at Columbia University, New York, and former associate professor of clinical physical therapy and director of the Columbia Program in Physical Therapy, and Melissa Wolff-Burke, PT, EdD, ATC, associate professor and director of clinical education in the Division of Physical Therapy at Shenandoah University, Winchester, Virginia. These patients tend to have poor cardiopulmonary and overall bodily strength, as well as decreased stamina and flexibility. Accompanying comorbidities may be sapping the patient's physical and emotional strength and motivation.

"If this is an older person with vascular disease, the chances are that the person is not very active," Edelstein says. "He may have considerable aching in his leg due to intermittent claudication. Flexibility is an important issue because if the patient has just been spending his time sitting and watching television, he's going to lose his flexibility and strength. So to whatever extent the patient is medically suited, we want to start a therapy program to improve his condition."

"I think the biggest challenge as a physical therapist is that you're working with people who are not and have not been for some time, physically healthy, for a variety of reasons," Wolff-Burke says. "There's a lot of energy needed to use a prosthesis and walk again, and this is a challenge for many persons who are already energy deficient."

Ideally a patient would receive physical therapy to increase strength, stamina, flexibility, and improved heart and lung function to be optimally prepared before the amputation surgery. And while this type of therapy is about as rare as snow in the Sahara, many clinicians agree it would be very desirable. Typically, strength and flexibility programs begin after the amputation and the immediate postoperative care.

Melissa Wolff-Burke, PT, EdD, ATC, works with a patient during gait training.
Melissa Wolff-Burke, PT, EdD, ATC, works with a patient during gait training.

"There's a perception that the only time persons who undergo an amputation are going to need physical therapy is when they are going to be fitted with a prosthesis-and then only after they get the prosthesis," Wolff-Burke says. "This viewpoint is not in the patient's best long-term interests. Physical therapists need to get the word out-not only to patients but also to the medical field-on when our skills can be used. Even if patients opt not to use a prosthesis, there are benefits to seeing a physical therapist: increasing strength and flexibility and protecting joints that could be damaged through extensive use of a wheelchair or crutches."

The good news is that a physical therapy program can quickly produce positive results. Says Edelstein, "An exercise program can have measurable changes in as little as two weeks. The person is not going to suddenly become a Paralympic weight lifter but will have increased heart and lung efficiency and will be able to function better." The patient should also have an exercise program he can follow for the rest of his life, Edelstein adds. "This is important for everyone, but especially for persons with an amputation."

"Any kind of aerobic conditioning that's supervised is very beneficial," says Wolff-Burke. "The program should be under medical supervision because if people have vascular or heart complications, they don't want to just start on their own." Pool therapy, seated aerobics, and walking are good choices, she says. Aquatic therapy provides the benefits of flexibility and strength training, while the buoyancy of the water helps ease pain and joint stress. "Patients don't need to know how to swim to participate in a pool program," Wolff-Burke notes. For different types of exercise, "There are videos and DVDs for levels from beginning on up-all of these could be useful."

A rehabilitation team approach is generally considered the gold standard for optimal patient care and outcomes, but this type of comprehensive care is generally limited to university and military medical centers. In a team approach, the prosthetist and the physical therapist are often involved, along with the surgeon, physiatrist, and other team members, in evaluating the patient and developing a treatment plan. This allows them to collaborate before the amputation surgery to prepare the patient to adapt optimally to amputation and a prosthetic fitting.

Carroll
Carroll

In most independent prosthetic and physical therapy practices, this level of collaboration does not occur; however, the prosthetist and physical therapist can still tap the expertise of other healthcare professionals when caring for an individual patient. "You have to be willing to make a phone call or send an e-mail or a fax," Wolff-Burke says.

There does seem to be a trend of increased communication between health­care providers across the healthcare continuum. Kevin Carroll, MS, CP, FAAOP, vice president, prosthetics, Hanger Orthotics & Prosthetics, Bethesda, Maryland, notes that surgeons are more and more frequently consulting with a prosthetist before surgery to aid in optimal prosthetic fitting later.

Promoting Psychological Health

Preprosthetic therapy doesn't involve strength and condition only. Healthcare professionals also stress another vital component of preprosthetic therapy that is often overlooked or minimized-the psychological and emotional aspects of amputation.

"Before surgery, it is highly desirable that attention be paid to the emotional state of the patient," Edelstein says. "Amputation is very frightening for anyone."

"One of the most important aspects of preprosthetic care, whether before or after surgery, is psychological-helping patients to see [the amputation] not as an end or a failure, but as a new beginning and as a chance to set functional goals," says Katherine Binder, MS, CP, LAc, Dankmeyer Inc., Easton, Maryland. An amputation often liberates the patient from the pain and frustration of long efforts to save a limb and helps him or her regain the strength and motivation to set new goals and achieve better quality of life.

All healthcare professionals can have a role in this vital part of positive outcomes for an amputation patient. Although it has been noted that psychological counseling and treatment is best left to professionals in this area, all healthcare professionals can have a role in this-including prosthetists and physical therapists.

One subtle but effective way to make a positive difference is simply choosing appropriate words when talking with a patient. "There's a strong movement in the disability field called 'people-first terminology',?" Edelstein points out. "People-first" language is a semantic technique used when discussing disabilities to avoid perceived and subconscious dehumanization of people with disabilities, according to Wikipedia (www.wikipedia.org). The aim is to avoid reducing individuals to a series of labels, symptoms, or medical terms. "The basic idea is to replace, for example, "disabled people" with "people with disabilities," "deaf people" with "people who are deaf," etc., thus emphasizing that they are people first...and anything else second," the Wikipedia article explains.

Further, the concept favors the use of "having" rather than "being;" for instance, "she has a learning disability" instead of "she is learning-disabled." Putting the person first is thought to carry implications about which part of the phrase is more important. "Many people with disabilities have expressed unease at being described using person-second terminology, seeing it as devaluing them as people, with the implication that the most significant facet of their existence is their disability," Wikipedia continues. "Person-first terminology is therefore widely preferred in the discussion of most disabilities."

In keeping with this, Edelstein prefers to say "man [or woman] with an amputation," rather than "amputee," and "residual limb," not "stump."

"?'Stump' has a very negative connotation," she says. Regarding wheelchair use, Edelstein points out that "wheeled mobility" carries the thought of freedom and movement; whereas, "confined to a wheelchair" or "wheelchair-bound" sounds like being in prison. For the wheelchair user, thinking in terms of mobility and freedom helps promote a feeling of independence and possibilities for accomplishment much more than "I'm confined to a wheelchair."

The Institute on Disability (IOD) at the University of New Hampshire ( http://iod.unh.edu ) provides a list of preferred terms as well as terms to avoid. Here are some examples:

  • "Accessible parking/accommodations" (preferred); "handicapped accessible" (avoid).
  • "Children with disabilities" (preferred); "special children" (avoid).
  • "Individual with a disability" (preferred); "crippled," "physically challenged," "handicapped" (avoid).

In the same vein, many persons with diabetes and healthcare professionals dislike using the term "a diabetic."

Even though not all persons with disabilities and healthcare professionals agree with the "people-first" terminology preferences, it's helpful to be aware of these terms when caring for patients. "Positive words promote positive images," sums up the Prince Edward Island, Canada, Special Olympics organization ( www.sopei.com ).

Age Not a Defining Factor

Stereotypes can also be involved when working with older patients. Clinicians and even patients themselves may have preconceived ideas about what older patients can achieve.

"We need to see the potential of the patient and give them the chance that they deserve," Carroll says. "We need to evaluate the patient as they are, and then ask their age if we need to. Age should have nothing to do with what we need to do for the patient." Carroll continues, "There are people who are 80 years old and still skiing, and people 40 years old who have just given up on life." Carroll should know. Among the multitude of successful prosthesis users among his older patients was Jonas Dennis, now deceased, who underwent amputation at age 102 and was still going strong at 107, enjoying gardening and other activities. (Editor's note: To read the story, visit www.oandp.com/edge/issues/articles/2005-02_11.asp )

"We need to look at the individual regardless of age," Binder concurs. "People in any age range vary considerably in the comorbidities and amount of deconditioning they have. For instance, some people may have been undergoing unsuccessful limb salvage and have been non-ambulatory during that time, or problems with edema and pain may have postponed prosthetic fitting and caused other issues."

The physical therapy exercise programs discussed earlier in this article, besides their obvious benefits in increasing strength and flexibility, can also help psychologically.

The first study to look at exercise alone in treating mild to moderate depression in adults aged 20 to 45, conducted at the University of Texas Southwestern, Dallas (UT Southwestern) and published in the January 2008 issue of the American Journal of Preventive Medicine, shows that depressive symptoms were reduced almost 50 percent in individuals who participated in 30-minute aerobic exercise sessions three to five times a week. The results are comparable to results from studies in which patients with mild to moderate depression were treated with antidepressants or cognitive therapy, according to Madhukar Trivedi, MD, professor of psychiatry and director of UT Southwestern's mood disorders research program. (Editor's note: For more information, visit www8.utsouthwestern.edu/utsw/cda/dept37389/files/203820.html ) Although persons with amputations may not be able to exercise at the levels of time and intensity used in this study, even moderate exercise can have psychological benefits, according to the Mayo Clinic.

Patient's Responsibility

The patient's motivation to become a successful prosthetic user and to achieve and maintain a healthy lifestyle is a primary factor in positive long-term outcomes. Although prosthetists and physical therapists can offer encouragement and positive ideas, the buck stops with the patient. "What it really comes down to is the patient's choice," Wolff-Burke says. Often lifestyle issues, such as smoking, obesity, and being sedentary have helped cause or have exacerbated the conditions leading to their amputation, she notes. People tend to return to the lifestyle they had before, whether it was active or relatively sedentary, she says, adding, "People have to decide they want to make a change."

How important is it for a person with amputation to actively work to achieve and maintain a healthier body and lifestyle if his lifestyle has been a contributing factor to the need for amputation? A study titled "Reactions to Amputation: Recognition and Treatment," by Chaya G. Bhuvaneswar, MD, Lucy A. Epstein, MD, and Theodore A. Stern, MD, published in the Journal of Clinical Psychiatry, September 2007, notes that persons with diabetes who have undergone a lower-limb amputation have a 20- to 50-percent risk of losing the contralateral leg to vascular disease over the subsequent four years. Thus, improving controllable health factors improves the patient's odds of not losing the other leg.

Help from Those Who Have 'Been There'

A large part of fear and anxiety is anticipating the unknown, and resources that educate the patient on what to expect and what potential exists for a successful life after amputation ease these fears. Educational information, peer visitations, and amputee support groups can be a major source of inspiration, motivation, confidence, and hope, according to the experts interviewed for this article. The ACA's peer-visitation program received high marks. "I try to put my patients in contact with the ACA whenever possible," says Binder.

Edelstein also recommends the ACA's peer-visitor program. Local amputee support groups or patients who have successfully adapted to amputation and want to help others are resources also, Binder adds.

"Trained peers help new amputees jump-start their transition to a new life by sharing information, by serving as a model of success, and by offering understanding and support," according to the ACA's website ( www.amputee-coalition.org ). The ACA maintains a growing database of trained, experienced people with limb loss or limb difference who are willing to communicate by phone, fax, e-mail, postal mail, and, when possible, in-

person visits. People who have had a limb amputated are matched as nearly as possible with and then referred to people who have experienced similar limb loss and are of comparable age. 

In addition, the ACA provides various print and electronic media resources and operates the National Limb Loss Information Center (NLLIC), in cooperation with the Centers for Disease Control (CDC).

All parts of the rehabilitation whole can come together to produce successful outcomes for persons with amputation. Many realize, "Hey, maybe I've lost a leg-but I've still got a whole lot of living yet to do!"

Miki Fairley is a contributing editor for The O&P EDGE and a freelance writer based in southwest Colorado. She can be contacted via e-mail: miki.fairley@gmail.com

Editor's Note: For more information on this topic visit www.oandp.com/edge