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VA/DoD Clinical Practice Guideline

Rehabilitation of Lower-Limb Amputation

Clinician Tool Kit

Pain Management Management of Residual Limb Analysis & Treatment of Abnormal Gait

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Pain Management in Lower Extremity Amputation

Overview

Ph as e

I.

Preoperative

II.

Postoperative

III.

Pre-Prosthetic

Pai n Con t ro l

Assess for existing pain.

Assess and aggressively treat residual and phantom limb pain.

Assess for specific treatable causes of residual limb or phantom limb pain and apply specific treatments appropriate to the underlying etiology. If no specific cause can be determined treat with non-narcotic medications and other non-pharmacological, physical, psychological, and mechanical modalities.

IV.

Prosthetic

Assess for specific treatable causes of residual limb or

Training

phantom limb pain and apply specific treatments

appropriate to the underlying etiology. If no specific cause

can be determined treat with non-narcotic medications

and other non-pharmacological, physical, psychological,

and mechanical modalities.

V.

Long-Term

Assess and treat associated musculoskeletal pain that

Follow-Up

may develop with time.

Pain Management

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Phantom Limb Pain Pain distal to the end of the residual limb

Etiology Primary Phantom

Limb Pain (PLP)

Referred pain from proximal neurological or musculoskeletal source

Key Historical or Examination Features

Onset in early post amputation period

Often nocturnal

Gradually reduced in intensity and frequency over time

Can be exacerbated by residual limb pain

Evaluation

Diagnosis of exclusion once other causes of PLP have been ruled out

Consider symptoms of Imaging as appropriate

typical musculoskeletal, radicular, and other causes

EMG/Nerve conduction studies

Treatment

Non-pharmacological

Pharmacologic

Desensitization

TCAs

Mirror Therapy

Anticonvulsants

Residual limb compressive devices

Prosthetic use

Transcutaneous electrical stimulation (TENS)

Antispasmodics

SSRIs

NMDA receptor antagonists

Acupuncture

Alternative and complementary medicine

Mental health evaluation and treatment (Depression & PTSD)

Treat underlying cause Pharmacologic Rx as

as appropriate

appropriate

Referred pain from a Neuroma

Aggravated by prosthetic use

Local tinel or tenderness at the end of nerve

Diagnostic injection Ultrasound or MRI

Prosthetic modification to reduce mechanical loads

Corticosteroid injection

Phenol ablation

Surgical resection

Consider Pharmacologic Rx if non-responsive to other treatments:

? TCAs

? Anticonvulsants

? Antispasmodics

? SSRIs

? NMDA receptor antagonists

Pain Management

Non-painful sensations distal to the residual limb

P L S hantom imb ensation Wide spectrum of sensory experiences that vary in intensity frequency, and severity

Etiology

Key Historical or Examination Features

Evaluation

Treatment

Non-pharmacological

Pharmacologic

If mild and non-

None

functionally limiting

None

Educate and Reassure patient

None

If of adequate severity that is perceived as uncomfortable or distressing

Onset in early post amputation period

Often nocturnal

Gradually reduced in intensity and frequency over time

No specific

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Desensitization

Mirror therapy

Residual limb compressive devices

Prosthetic use

TENS

Acupuncture

Alternative and Complementary Medicine

Consider Pharmacologic Rx if non-responsive to other treatments:

? TCAs

? Anticonvulsants

? Antispasmodics

? SSRIs

? NMDA receptor antagonist

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 Amputation has been associated with increased prevalence of secondary musculoskeletal M P usculoskeletal ain pain in the lumbar spine and in the contralateral knee/hip

Etiology

Degenerative Arthritis

Key Historical or Examination Features

Evaluation

Exacerbation with

X-ray

increased mobility and mechanical loading

Include weightbearing views

Treatment

Non-pharmacological

Pharmacologic

Physical Therapy

Corticosteroid / Visco-supplementation injections

Surgical referral as appropriate

Non-narcotic pain medications

Non-specific low Exacerbation with

back pain

ambulation

Imaging and laboratory Physical Therapy studies if red flags or persistent symptoms

Non-narcotic pain medications

Pain Management

R L P esidual imb ain Pain in the limb between the end of the residual limb and the next most proximal joint

Etiology Mechanical

Key Historical or Examination Features

Evaluation

Exacerbated by use of the prosthesis

Associated with residual limb findings of redness, callous or ulceration

Evaluate prosthetic fit and alignment

Treatment

Non-pharmacological Refer to Prosthetist

Pharmacologic

Non-narcotic pain medications

Neuroma

Pain with prosthetic use Local tinel sign Possible palpable mass

Diagnostic injection Ultrasound or MRI

Prosthetic modification to reduce mechanical loads

Corticosteroid injection

Phenol ablation

Surgical resection

Consider pharmacologic Rx if non-responsive to other treatments:

? TCAs

? Anticonvulsants

? SSRIs

? NMDA receptor antagonist

Ischemic

Infection ? Cellulitis ? Abscess ? Osteomyelitis

Claudication with ambulation

Classical examination features

Unexplained poor glucose control

Pain unexplained by other causes

Neuropathic Central (CRPS) Peripheral

Hypersensitivity Autonomic features

Vascular evaluation Treat as appropriate

None

Laboratory evaluation: ? WBC ? CRP/ESR ? Glucose ? Imaging studies as appropriate

Treat as appropriate

None

Consider Triple Phase Bone Scan

Desensitization

Residual limb compressive devices

Prosthetic use

TENS

Acupuncture

Alternative and Complementary Medicine

Mental health evaluation and treatment (Depression, PTSD)

Consider pharmacologic Rx if non-responsive to other treatments:

? TCAs

? Anticonvulsants

? Antispasmodics

? SSRIs

? NMDA receptor antagonists

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Residual Limb Management

Overview

Ph as e

I.

Preoperative

Care Man ag e me nt

Desensitization exercises, skin hygiene, and description of types of pain

Explain and differentiate between residual limb pain, phantom pain, and phantom sensation

II.

Postoperative

Donning/doffing of ACE wrap or shrinker if appropriate

Desensitization exercises, skin hygiene, and description of types of pain

III.

Pre-Prosthetic

Care of residual limb

IV.

Prosthetic

Donning/doffing of prosthetic system

Training

Use of shrinker when out of the prosthesis

Skin checks and skin hygiene

Management of sock ply if appropriate

Observe pressure points and protect contralateral foot

V.

Long-Term

Foot care and skin checks

Follow-Up

Residual Limb Management

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Residual Limb Management

Management of Residual Limb

Problem Skin-Redness

Look for

Socket fit Suspension

Blister Rashes Callosity

Suspension Socket fit Thermal

Contact Fungal Bacterial

Folliculits or Epidermal Cyst

Shape

Dog ears Bulbous Cylindical?optimal for TTA Conical?optimal for TFA

Volume

Abnormal volume which interferes with prosthetic fit

Bursae

Identify

Heterotopic Identify Ossification

Infection

Unstable Bone/Joint

Warmth, erythema, discharge, fever, unexplained pain, poor glucose control

Tibio/fibular

Knee

Scar Formation

Excessive Adherent Skin grafts Burns

Assessment/Intervention

Assess prosthetic alignment Assess donning technique Assess for proper sock ply Limit wear-time if redness does not

resolve in 20 min Assess donning technique Assess for proper sock ply Assess prosthetic alignment End wear-time Instruct pt in Liner hygiene Instruct pt in skin hygiene Assess suspension system

Identify only

Limit wear-time Instruct pt in liner hygiene Instruct pt in skin hygiene Consider socket modification

Apply ace wrap/compression stocking Apply shrinker Consider custom gel liner Consider socket modification

Review weight control Review positioning Assess sock ply management Apply ace wrap/compression stocking Apply shrinker Consider custom gel liner Consider socket modification

Limit wear-time Modality ice/ultrasound Consider socket modification

Limit wear-time Possibly NSAID during inflammatory phase Consider socket modification

Identify only

Consider socket /suspension change Consult therapy to stabilize knee

Consider custom gel liner Perform scar massage Slow, gradual progression of

prosthetic use with frequent re-exam

Refer to Prosthetist for adjustment/

socket fit

Physician for wound care Prosthetist for adjustment/

socket fit If severe or not resolving,

physician referral

Physician and Prosthetist Prosthetist Dermatology referral for

recalcitrant cases

Prosthetist Therapist (PT/OT)

Dietitian Prosthetist PT/OT therapist

If bilateral edema physician Prosthetics If recalcitrant, consider surgical

referral Prosthetics If recalcitrant, consider surgical

referral Physician

Prosthetics Therapy (PT/OT) If recalcitrant consider referral

to ortho Prosthetics Therapy (PT/OT)

If recalcitrant consider plastics/ orthopedic

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Gait Abnormalities

Gait Analysis

Overview

Observational gait analysis involves the identification of gait deviations and determination of the causes associated with each deviation. The treatment team can then plan and recommend corrective actions to improve the situation. Clinical team should be familiar with normal gait, biomechanics, and prosthetic fit and alignment.

Co mpon e n t Part s

I.

Observation

Gait An aly s is Pro ce du re

It is essential to observe from at least two vantage points. Sagittal-plane motions are best seen from the side, while frontal-plane motions are best seen from the front or rear.

II.

Identification

Abnormalities are defined as any gait characteristic that

of gait abnormalities

differs from the normal pattern. Keep in mind that the single most outstanding characteristic of the normal

pattern is symmetry. Thus, for the unilateral amputee

deviations are often identified by observing

asymmetry, that is, differences in the patterns of the

prosthetic and normal sides.

III.

Determination

The obvious place to look is at the prosthesis, as there

of causes

are many prosthetic causes for gait deviations.

However, there are many non-prosthetic causes. The

individual patient may have restricted range of

motion at one or more joints, muscular weakness,

concomitant medical conditions, excessive fear, or old

habit patterns, any of which may cause deviant gait.

Analyze the prosthesis, but do not ignore the patient!

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Transtibial Gait Abnormalities

Gait Analysis ? Abnormalities in Transtibial Amputation

Gait Abnormality

Possible Causes

Patient Related Additional Evaluation

Interventions

Prosthetic Related

Prosthetic Causes

Additional Evaluation

1. Vaulting

An attempt to lengthen the stance phase on the intact limb by knee extension and ankle plantar flexion during mid stance phase

Inability to adequately flex the knee on the prosthetic side

Habit gait pattern

Test knee ROM (all other causes are excluded)

Step-ups with prosthetic leg Prosthetic limb too long

None

Repetitive Step forward- Poorly suspended

step back with prosthetic prosthesis

leg (sound leg remains

stationary)

Evaluate pelvic height in standing with equal weight through both limbs

Evaluate pistoning and/or a socket that is too loose

Excessive ankle plantar Posterior leaning prosthesis

flexion of the prosthetic when observed off of the

foot

patient

2. Circumduction

The prosthetic limb travels in an a lateral arch during swing phase

Inability to adequately flex the knee on the prosthetic side

Habit Gait Pattern

Test knee ROM None

Step-ups with prosthetic Prosthetic limb too long leg

Evaluate pelvic height in standing with equal weight through both limbs

Repetitive Step forwardstep back with prosthetic leg (sound leg remains stationary)

Poorly suspended prosthesis

Evaluate pistoning and/or a socket that is too loose

Weak hip flexors

Perform manual muscle test

Traditional exercises for hip strengthening

Excessive ankle plantar Posterior leaning prosthesis

flexion of the prosthetic when observed off of the

foot

patient

3. Abducted Gait Pattern

The prosthetic limb is carried in an abducted position throughout the swing and stance phase

Adaptation for

Knee joint

medial compartment evaluation

knee pain

Adaptation for focal Inspect residual residual limb pain limb integrity

Balance impairment/ Evaluate balance

Fear of falling

and stability

Weight shifting activities over prosthetic limb

Refer for management of residual limb problems

Advanced balance activities

Outset prosthetic foot can Evaluate iliac crest height in

give an apparent

standing

abducted gait pattern

Prosthesis is too long

Evaluate iliac crest height in standing

Medially placed foot

Evaluate static prosthetic alignment

4. Knee instability

Excessive knee flexion on prosthetic side in early stance

Knee flexion contracture

Quad weakness

Test knee ROM

Perform manual muscle test

Stretch accordingly

Excessive foot dorsiflexion Evaluate static prosthetic alignment

Closed chain strengthening exercises while wearing prosthesis

Excessive socket flexion

Posterior translation of the foot/ pylon

Evaluate static prosthetic alignment

Evaluate static prosthetic alignment assess heel

Excessively hard heel cushion or prosthetic heel keel

Evaluate compression during manual loading

5. Genu Recurvatum

The knee on the prosthetic side hyperextends during mid to late stance phase

Inadequate knee flexion range of motion Quad weakness

Hip flexion contracture

Test knee ROM

Perform manual muscle test Test hip ROM

Stretch accordingly

Excessively compliant Assess heel compression prosthetic heel cushion during manual loading or too rigid forefoot keel

Closed chain

Inadequate socket flexion Evaluate static prosthetic

strengthening exercises

alignment

while wearing prosthesis

Stretch accordingly

Excessively plantar flexion Evaluate static prosthetic

of the prosthetic foot

alignment

Anterior translation of prosthetic foot/pylon

Evaluate static prosthetic alignment

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