1. Occupational Therapy For Lower Limb Amputation Rehabilitation
Lauren Hawkins, OTS & Jennifer Tom, OTS
Touro University Nevada

2. Purpose
Outline the role occupational therapy in lower extremity amputation care
Provide evidence-based occupational therapy practice
Discuss protocol for mirror therapy to reduce phantom limb pain
Kalapatapu, V. (2014). Lower extremity amputation. Retrieved from
College of Occupational Therapy. (2011). Occupational therapy with people who have had lower limb amputations. Great Britain: Lavenham Press

3. Causes Dysvascular Trauma Cancer-related Congenital
(Center for Orthotic & Prosthetic Care, N.D.)

4. Statistics More than 500 Americans lose a limb daily
An estimated 1.9 million people living with limb loss in the United states
Annually, the immediate health care costs of limb amputations-not including costs for prosthetic devices or rehabilitation costs, total more than $8.3 billion
(CDC, 2015)

5. Evidenced-Based Research
College of Occupational Therapists Specialist Section –Trauma and Orthopaedics is a subsidiary of the British Association of Occupational Therapists
29 critically appraised papers
Articles are assigned
An evidence score V-I (Low-high)
A quality score 0-10 (Low-high)
(College of Occupational Therapists, 2011)
Level of evidence
Systematic review of all relevant RCT
At least one properly designed RCT
III-1. Pseudo-RCT
III-2. Comparative studies
III-3. Comparative studies with historical control
IV. Case series, Post/pre test
V. Surveys, correlation studies, reliability and validity studies, case studies and focus groups
Quality:
High quality at least 7/10
Medium quality 4-6/10
Poor quality 3/10 or less
An evidence score V-I (Low-high)
>26 level V , 1 level IV, 1 level III-3, 1 level III-2
A quality score 0-10 (Low-high)
>5 high quality, 19 medium quality, 5 poor quality

6. Areas of OT Interventions
Functional rehabilitation
Environment
Psychology
Prosthetic use
Assessment tools and outcome measures
Cognition
Work
Leisure and recreation
(College of Occupational Therapists, 2011)

7. Functional Rehabilitation
In regards to OT for functional rehabilitation we need to work closely with PTs to meet milestones especially in regards to mobility
(College of Occupational Therapists, 2011)

8. Environment (College of Occupational Therapists, 2011)
Consider age of the individual when recommending w/c versus prosthetics
(College of Occupational Therapists, 2011)

9. Psychology (College of Occupational Therapists, 2011)
Consider the individual’s self-concept, psychosocial factors such as depression and anxiety, phantom pain
Numerous assessments that can be utilized in order to assess things such as coping and body image
(College of Occupational Therapists, 2011)

10. Prosthetic Use (College of Occupational Therapists, 2011)
Consider the following
-level of amputation, condition of residual limb and prognosis
-co-morbidities
-cognition
-pre-amputation lifestyle and roles
Common reason for not wearing prosthesis: cosmetic problems, or discomfort at follow up
Meuleembelt et all (2006) systematic review of literature of skin disorder and conclude that it is a prevalence in residual limb, thus, skin, checks are important
(College of Occupational Therapists, 2011)

11. Assessment Tools and Outcome Measures
Purpose: appraise and monitor service effectiveness
-assess rehabilitation needs
-set client-centered goals
-evaluate outcomes
-determine whether goals have been achieved
Outcome measures should have validity and reliability and responsiveness to change
Amputee Activity Score (AAS):
-ability to don or doff prosthesis
-hours per day wearing prosthesis
-use of walking aids
-amount of walking
-type of house
-ability to climb stairs
(College of Occupational Therapists, 2011)

12. Assessment Tools Cont.
(College of Occupational Therapists, 2011)

13. Cognition (College of Occupational Therapists, 2011)
1. Sansam et all (2009) found that cognitive impairment is a predictor of poor prosthetic use following lower limb amputation
2. Kendrick Object Learning Test (KOLT)
>assesses older people’s cognitive abilities through immediate recall of visual and auditory information, assessing speed of processing and recording information
>Larner et all (2003) found that KOLT correctly predicted whether people with lower limb amputation will use a prosthesis during the inpatient rehab programme
3. CAPE
>measures the degree of cognitive and behavioural impairment through orientation, mental abilities, psychomotor performance tests and behavior rating scale e
>can be used to help facilitate wheethere the prostheesis should be prescribed
(College of Occupational Therapists, 2011)

14. Work (College of Occupational Therapists, 2011)
Schoppen et all (2001b) found that people who had to stop work as a result of their amputation showed a worse health experience than those people with an amputation who continued working
Factors preventing/delaying return to work
>problems related to the stump (Bruins et all 2003)
>wearing comfort of the prosthesis (Schoppen et all 2001a)
>educational level (Schoppen et all 2001a)
>age at the time of amputation (Schoppen et all 2001a)
>co-morbidity (Schoppene et all 2002)
>workplace modifications (Schoppen et all 2001b, Bruins et all 2003)
(College of Occupational Therapists, 2011)

15. Leisure and Recreation
Constraints on participate in leisure activities for people with lower limb amputations were lack of accessibility, material considerations, functional abilities, affective constraints, social constraints (Couture et all 2009).
Benefits of leisure activities
>natural opportunities for social interaction and friendship, and provide a sense of identity and social inclusion (Lloyd ete all 2000, Pegg and Moxham 2000, Taylor 2003)
>reduce psychological distress (Waters and Moore 2002)
>protect against and enable individuals to manage stress (Iwasaki 2001, Kleiber et all 2002).
>increase self-esteem and confidence (Baxter et al 1995, Passmore and French 2000)
>enhance physical health (Cassidy 1996)
3. Consider the Pt.’s age as older individuals may prefer solitary leisure
(College of Occupational Therapists, 2011)

16. Areas of OT Intervention Con’t
Prevention of contractures at hip and knee
Edema reduction
Fall prevention
Trunk stability
Assist with other deficits/comorbidities

17. Care of the Remaining Limb
Skin inspection to avoid skin breakdown and infections
Do not cut on corns or calluses
Have a podiatrist cut your nails
Avoid walking barefoot
Do not wear socks that have holes, change socks daily
Break in new shoes slowly
Wear only well-fitting shoes
(Hall, 2009)
Lauren Starts

18. Foot Care for People with Diabetes
Check feet daily
Wash feet daily
Keep skin soft and smooth
Smooth corns and calluses
Trim toenails regularly
Wear shoes and socks
Keep blood flowing to the feet
(National Institute of Health, 2014)
Steri Shoe. (2014). Retrieved from

19. Care for the Residual Limb
Wash residual limb regularly
Inspect residual limb daily and can be completed using a long-handled mirror
Skin desensitization
Do not shave residual limb
Do not soak residual for prolonged time to prevent swelling
(Hall, 2009)
Wash residual limb every evening with lukewarm water and mild soap. Evening bathing is recommended beceause bathing may cause residual limb to swell and may affect prosthesis fitting (Hall, 2009).
Inspect limb for signs of infections
--Signs of infection:
>warm, red and tender skin
>discharge of fluid or pus
>increasing swelling (
>
Your stump looks redder or there are red streaks on your skin going up your leg
Your skin feels warmer to touch
There is swelling or bulging around the wound
There is new drainage or bleeding from the wound
There are new openings in the wound, or the skin around the wound is pulling away
Your temperature is above °F more than once
Your skin around the stump or wound is dark or it is turning black
Your pain is worse and your pain medicines are not controlling it
Your wound has gotten larger
A foul smell is coming from the wound
Skin desensitization
-gently massage residual limb daily helps decrease sensitivity and increase pressure tolerance (Hall, 2009)
-steps:
>gently tapping skin with face cloth
>using compression bandages to help reduce swelling and prevent fluid buildup
-rubbing and pulling the skin around bone to prevent excessive scarring (

20. Prosthesis and Socks Prosthesis and socks should be cleaned and dried
Wear new socks daily
Inspect residual limb with a mirror for signs of irritation/infection
Don sock prior to prosthesis to protect skin from sores and injury with seams facing out
Ensure socks fit without folds or wrinkle as this can irritate the skin
(Hall, 2009)

21. Management of Phantom Pain
Phantom limb pain: Painful sensation that is perceived in a body part that no longer exists
Exercise limb to increase circulation
Distraction, change position
Soak in warm bath or shower massage on residual limb
Massage gently to increase circulation
Keep a diary of pain to help identity recurring causes
Relaxation techniques
(Hall, 2009)

22. Mirror Therapy for Phantom Limb
>90% experience phantom limb
Experimental groups: Mirror group, covered mirror, visual imagery
Sample size: 18/22 completed the study
Results: After 4 weeks of therapy, findings indicated mirror therapy reduced phantom limb pain in patients with lower limb amputation
Mirror therapy video: (5:44)
(Chan, B., Witt, R., Charrow, A., Howard, R., Pasquina, P., Heilman, K., &Tsao, J, 2007)

23. Protocol for Mirror Therapy
Condition of limb: normal and pain-free ROM
No visual impairments
Normal cognition level
Remove all jewelry and cover tattoos or scars
Sitting tolerance WFL
Complete daily for at least 10 mins
Some patients are unable to tolerate the image of having two intact limbs
May sweat, become dizzy or emotional
Have patient focus on another point in the room, the intact limb or stop the session all together
Removing jewelry/covering tattoos helps facilitate the vividness of the mirror illusion
(Rothgangel, Braun, Witte, Beurskens, & Smeets, 2015)

24. Protocol for Mirror Therapy
Sit without prosthesis with mirror in between legs at patient’s midline in a comfortable and supported position
Start with simple motor or sensory exercises
Increase difficulty as sessions continue
Aim for high repetitions (at least 15)
Try to include patient’s hobbies or interests in sessions
Prepare patient at end of session to view the amputated limb
(Rothgangel et al., 2015)

25. Examples of Interventions
(Rothgangel et al., 2015)

26. April is Limb Loss Awareness Month
CDC supports and provides funding for Amputee Coalition National Limb Loss Resource Center (
In 2013, the Amputee Coalition launched Show Your Metal with the goal of showing that amputees are resilient by encouraging amputees to display their strength of character by showing their metal, such as prosthetic devices or wheelchairs
(CDC, 2015)

27. References CDC (Apr. 20, 2015). Limb loss awareness. Retrieved from
Center for Orthotic & Prosthetic Care. (N.D.). Amputation statistics.
Retrieved from
Chan, B., Witt, R., Charrow, A., Howard, R., Pasquina, P., Heilman, K., &Tsao, J. ( 2007). Mirror
therapy for phantom llimb pain. The New England Journal of Medicine, 357, doi:
/NEJMc071927
College of Occupational Therapists. (2011). Occupational therapy with people who have had lower limb
amputations. Retrieved from

28. References cont.
Hall, C. (2009). Occupational therapy toolkit. Timonium. MD.
National Institute of Health. (2014). Diabetic Foot. Retrieved from
NCBDE. (n.d.). Eligibility requirements. Retrieved from
Rothgangel, S. A., Braun, S. M., Witte, L. D., Beurskens, A. J., & Smeets, R. J. (2015).
Practical protocol mirror therapy phantom limb pain. Retrieved from