I just had an amputation… now what?
Well, initially, frustration!
I have treated many new amputees that describe feelings of pure frustration, helplessness, fear of the unknown, lack of confidence, embarrassment, and shame. I just recently met an amputee that inspired me to write this article. He is a 40-year-old man whose occupation is a physical education teacher. He is married with two children and, when we met, was just recovering from a traumatic amputation of the left leg below the knee. The disposition of this man was heartbreaking and it seemed as though he had lost all hope of living a fulfilling life. His first questions were “What now? Will I be able to walk? What do I need to where a shrinker before I get fitted? Is it going to hurt?” He had never known anybody who was an amputee. The reasons for an amputation can vary, but most amputees experience similar feelings afterwards, regardless of the amputation cause.
I empathized with this man and explained to him what to expect in his immediate future. The best way I could help him move forward was to explain the process of being fit with a prosthesis. When I finished my explanation, he was appreciative and felt better equipped for this journey. We transformed the ‘unknown’ to the ‘known’ and he was then able to set down a new path towards a successful rehabilitation. This man had a very strong support system, which is critical, and could now focus on the task ahead, rather than wallowing in self despair. Weeks later he reminisced about our early conversations and how it helped him become more confident. It became clear to me that learning the prosthetic fitting process was essential for a new amputee.
Immediately After Amputation
Once an amputation has taken place, the physician either chooses to have the patient fit with an IPOP (Immediate Post-Operative Prosthesis), or an elastic ace wrap. Both techniques have one common goal and that is to reduce the swelling and post surgical edema in the residual limb. Normally the residual limb has either sutures or staples in to keep the incision closed. This stage usually lasts 2 weeks until the sutures/staples are removed. At the conclusion of the first two weeks, the physician usually determines if the incision has healed enough to remove the sutures or staples. Once they are removed, the residual limb is fit with a more aggressive compression garment, called a stump shrinker, to reduce any residual edema. This stage lasts another two weeks. The shrinker is usually worn 24 hours a day and is only removed for bathing.
These first 4 weeks are easily described as the most frustrating period of the process. The patient is waiting for their residual limb to heal and is stuck either using a wheelchair, walker, or crutches until he or she is ready for prosthetic fitting. The amputee is usually very dependent on others and can easily fall into depression. All the feelings that I have described previously are most evident at this time. I strongly encourage new amputees to meet with a prosthetist at this time to help you begin the rehabilitation process. There are many things a new amputee can be doing to make this month as productive as possible, to prepare for prosthetic fitting.
Prosthetic Fitting Preparation: The First 4 Weeks Post-Amputation
The first step in the prosthetic fitting process is an evaluation meeting between the amputee and prosthetist. Amputees looking for a prosthetist can ask the physician for a referral, or can locate a 360 Certified O&P Practitioner in the 360 directory.
During the initial evaluation appointment, a new amputee must assess the personality of the prosthetist and decide if the two personalities are compatible. The prosthetist is an extremely important individual in the rehabilitation team and plays a vital role in determining the rehabilitation success. New amputees should choose a prosthetist very carefully.
One the new amputee has chosen a prosthetist, the evaluation process will assess the amputee’s lifestyle, hobbies, occupation, and activity level, in order to fabricate the most appropriate prosthesis.
The prosthetist and facility insurance coordinator should help the amputee determine if he or she has the appropriate insurance coverage for prosthetic services (see Insurance Tips for more information). Ideally the insurance situation should be settled during these initial weeks, so that the fitting process can begin immediately after the physician prescribes the prosthesis.
A new amputee should find a physical therapist, preferably one who has experience working with amputees, and begin a pre-prosthetic rehabilitation program. This program would include exercises, stretching, strengthening, and well as independence training. All of this will prepare the amputee’s mind and body for the prosthetic fitting process.
Amputee support groups can provide a valuable support network where new amputees can share with people who have already undergone the prosthetic rehabilitation process. Most amputee support groups meet several times a year, even monthly, and have speakers and forums that relate to amputee issues. This can be a remarkable experience for an amputee, who will learn that he or she is not alone.
Clearly there is a lot a new amputee can accomplish in the weeks leading to prosthetic fitting. Once the physician gives the new amputee a referral for prosthetic fitting, the new challenge begins.
Prosthetic Fitting
First, the prosthetist will take either a plaster impression or computer image of the amputee’s residual limb in order to fabricate the first socket. It takes approximately two to seven days to fabricate the initial socket. Many prosthetists will fit the amputee with an initial test socket as a diagnostic tool to ensure the socket will fit comfortably.
The next socket is either made of plastic or graphite lamination, to which a prosthetic foot is then attached. At this time a new journey begins. It is time to learn to walk with a prosthesis.
Even at this stage the residual limb is still healing and going through many changes. The stump shrinker does not fully eliminate swelling prior to prosthetic fitting. With weight bearing, the residual limb will go through many more changes. This is why the first prosthesis is normally referred to as a temporary prosthesis.
The residual limb will fluctuate in volume up to 10% throughout the day. This is when the next phase of frustration may set in. The reason for the frustration is because what may fit comfortably in the morning may change in comfort 2 hours later. Again, the residual limb is fluctuating. This will continue to happen for the next two years as the residual limb will experience further edema loss and muscle atrophy. The bulk of this will be reduced in the first two years. In the future, after the initial two years has passed, weight gain or loss of 8-10 lbs could also affect the prosthetic fit.
In order to accommodate this volume loss throughout the day, an amputee must add prosthetic socks. This is a specially designed prosthetic sock that fits over the residual limb. Each sock ply is equal to 1/8" of circumference. These socks come in all thicknesses from 1 ply to 8 plys. For example, if the average volume loss throughout the residual limb is 5/8", the amputee will be required to add a 5 ply sock to accommodate the volume loss. This sock ply management is a tough and frustrating concept to learn because the residual limb is changing so rapidly. Sock ply management should be reviewed thoroughly with the prosthetist (see Health & Wellness section for more information)
During this time the amputee should be involved with physical therapy. No matter how well a new amputee may think he or she is doing, visits to a physical therapist can ensure that the amputee does not pick up any bad habits. I encourage patients to visit a therapist at least twice a year even after they have grasped walking. The reason is because it prevents any bad habits from occurring and also helps them through transitional times such as manipulating various terrains, walking without a cane, or learning to run.
As the amputee continues with this regimen of training, he or she is preparing the residual limb for the next phase of rehabilitation.
The initial prosthesis is usually worn for three to nine months, during which time the residual limb changes and the amputee increases in activity level. Once the amputee stabilizes, he or she will be re-assessed for the definitive, or permanent, prosthesis. Increasing sock ply will eventually become inadequate at compensating for anatomical change. Our gauge is usually at 10-12 ply of prosthetic socks. Also, the new amputee may have exceeded the functional level of the initial knee and/or foot components. These components may need to be replaced for higher level units, appropriate for the amputee’s new functional level. The definitive prosthesis may also include cosmetic finishing, so that the prosthetic limb looks more life-like.
Even long-time prosthetic users experience occasional anatomical and activity level changes that require prosthetic replacement. However, the most changes do occur in those first two years. It is encouraging for most amputees to know that they will eventually ‘find a groove’ once they become long time users.
Greg Bauer, CPO