After Amputation

Rehabilitation page 2

General fitness
Strength of limbs
Balance - Sitting/Standing
Care of other leg
Mobility/Transfer - Bed
- Wheelchair
- Bathroom/Toilet
- Car
Daily activities
House changes
- misc
Aging issues

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General Fitness

One of the best ways to maintain overall fitness of the heart and lungs is to walk. Immediately following an amputation you are unable to do this and you must use different ways of getting around. You may be supplied with a wheelchair or you may be taught to hop with a frame or crutches. Hopping will involve much greater effort than walking and you may tire quickly and find yourself out of breath.

Using a wheelchair requires much less effort than walking, although you are using your arms to push and they may tire quite quickly at first. Early on when you are not walking, pushing the wheelchair yourself or hopping are activities that will aid in maintaining your general fitness. For example, you may be encouraged to propel yourself to and from therapy each day to aid your general fitness. These activities are also using the muscles of the arms and legs, helping to strengthen them.

When your activity levels change you may find that you also gain weight. Excessive weight gain can contribute to long term ill health and problems with maintaining a good fit of your prosthesis therefore it is important to try and keep at a stable weight. Maintaining some level of aerobic activity is helpful in preventing excessive weight gain. Swimming has been identified as a good aerobic activity and is worth discussing with your physiotherapist.

Strength and flexibility of limbs
Following an amputation it is important to maintain the movement and strength of all your joints and muscles. The physiotherapist will assess the range of movement of your joints and the strength of your muscles. Many people are tight or weak in particular muscles or stiff in particular joints. Your physiotherapist will teach you specific exercises for these areas of concern. You will also need to regularly exercise to maintain the muscles in the legs and to help prevent the development of a joint contracture. It is likely you will be asked to attend therapy once or twice daily to participate in an exercise program.

Sitting balance
If you have had an above-knee amputation, or even higher such as a hip disarticulation or hemipelvectomy, your sitting balance will be affected.
The higher the amputation, the less area you have to sit on and distribute your weight through, you may hear this referred to as having a 'smaller base of support'. You may find that sitting for prolonged periods becomes uncomfortable. Some people require specialised cushions or seating to ensure they are comfortable and have good posture when sitting in a wheelchair or chair.
Your physiotherapist may instigate activities in sitting to help improve your sitting balance, if appropriate.

Standing balance
After the amputation your balance will be significantly affected. The shape of your body has now altered and you have a much narrower base of support. It is important that you re-adjust your balance and that you are able to stand on the remaining leg if possible. Your physiotherapist will assess your balance and ability to stand on one leg. They may instigate activities or exercises in standing to help improve your ability to stand without holding on, or to improve the time you are able to remain standing.

are of your other leg
The remaining limb needs to be carefully looked after, for example, by using appropriate footwear particularly if it has also been affected by the disease process which caused the amputation, such as vascular disease or diabetes.
With good care of the remaining limb, particularly the foot, the risk of further amputation can be minimized. You should check the skin on your remaining leg regularly. If you notice any sores or areas of broken skin you should consult your doctor to ensure you receive appropriate attention.
Regular Podiatry appointments are also recommended for cutting toe nails and to help maintain a healthy foot.

Getting around: Moving around in bed and getting out of bed
When you first meet the rehabilitation staff they will want to assess how much you can move by yourself. They may start by assessing how you move around in bed. For example, they may ask you to roll from side to side and move up and down the bed to see if you are able to do these activities independently. Next they will need to see whether you can independently sit up over the edge of a bed from a lying position. If you are unable to do these tasks you may need some practice and these tasks will be incorporated into your daily physiotherapy program of exercise. Some special equipment may also help you.
Moving from one place to another is often referred to as "transferring". Transferring out of the bed into a wheelchair or regular chair and back again is very important. If you have one leg amputated you may be taught how to do a low standing pivot transfer. You should always wear a slipper or a shoe when transferring, this will help protect your other foot. If you have both legs amputated you will need to use a forwards/backwards bottom shuffle or a sideways transfer. Sometimes with the sideways transfer, a slideboard is also helpful. Usually the physiotherapist will decide which is the most appropriate transfer and what equipment you need and they will teach you. Other staff members such as the nurses and the occupational therapist will also be assisting you with transfers and ensuring you are safe.

Getting around: Using a wheelchair
If you are provided with a wheelchair for your non-prosthetic mobility you will be taught the safety features first. You must know how to put the brakes on and off and move footplates and stump boards, if applicable. It is very important that you learn the features of your wheelchair well. You will also be taught how to propel the wheelchair with your arms and how to turn corners and manoeuvre in tight spaces.

Getting around: In the toilet and bathroom
Getting on and off the toilet is another activity that the therapy staff will assess. Staff are aware that being able to get to the toilet independently is very important to most people. In most hospital situations rails are located beside toilets and these can be used to assist you in moving from your wheelchair to the toilet safely. To begin with it is helpful to be able to position your wheelchair at a 900 angle to the toilet and do a low pivot transfer if you have one leg amputated. This way there is a minimum amount of distance to travel.

If you have both legs amputated then to begin with you may continue to use the frontward/backward transfer method and sit on the toilet facing the cistern. Alternatively you may position your wheelchair so that you can transfer sideways on to the toilet.
Shower transfers are another task that will be assessed and you may be given some assistance with. Safety is of paramount importance when transferring in the shower as this area is often wet and slippery. Ideally the shower base should be level with the floor to allow ease of transfers. You may use a shower chair or stool, and if there are grab rails in the shower, you can use these to assist with a low pivot transfer. Alternatively you may use a wheeled shower commode initially to get to the shower.
If you don't have a shower recess at home, only a bath, then there is equipment available to assist you to sit over the bath and have your shower. Some people who have had both legs amputated find this the safest and easiest method long-term.
You will need to practice these transfers with a variety of staff members while you are in hospital and they can advise you about the equipment you might need, and the methods you might use once you return to your home.

Getting around: In and out of the car
Getting in and out of the car is much the same as getting from your bed onto your wheelchair. When you begin you may find it easier to practice in the front passenger seat as this allows you the maximum room.
You should position your wheelchair as close as possible to the side of the car after you have taken off the footplates.
If you have one leg amputated then you should line up the front of your wheelchair with the back of the car seat. Then you can do a low pivot transfer with one hand on the arm of your wheelchair and one hand on the car seat.
If you have had both legs amputated then you should line up your wheelchair with the car seat and use a slideboard to move sideways in and out of the car. Always put your hand on the slideboard so it doesn't slip out of place.

Managing your daily activities
One of the key goals of rehabilitation is to assist you to carry out the activities that you want or need to be able to do to the best of your ability. Activities will include tasks that you may need to do at home, at work at school or university, or in other community settings. It is important that you can return to being as independent as possible at home but also within the community, e.g. shopping, visiting friends, attending church, playing bowls. Initially this may involve learning to carry out these activities from a wheelchair and later on may involve a trial of these and other activities using your prosthesis.
Following your amputation you will be encouraged to return to daily living activities as you are able. This may begin quite soon after the amputation in the acute hospital setting when you begin to complete some of your self-care activities (e.g. showering and dressing) with some help from the nursing staff. It will then continue as you begin to try some of the activities that you used to do before you had your amputation. This may include such things as cooking meals, completing housework, driving, gardening and returning to leisure activities-all the things that contribute to having a full and meaningful life.

Your occupational therapist will know of many different techniques and pieces of equipment that will help you to maximise your independence. Some equipment may be useful in the early stages while you are still getting stronger but you may not need it longer term. Sometimes when you leave hospital and you can find that you would benefit from a certain piece of equipment. You are advised to discuss these issues with your occupational therapist and to talk to them about what you hope to be able to do in the house.

Will I need to alter my house? Will I need to move house?
As one of the primary goals of the people looking after you is to help you to return home to a safe and independent lifestyle it is important that you discuss where your daily activities take place. While you are in hospital you may be asked questions about your home. The sorts of things you may be asked are:
Which entrance do you go in and out of?
How many steps do you have?
Is everything inside on the same level?
Do you have a shower or a bath?
Have you already got any equipment at home?
It is common for a member of your treating team (usually an occupational therapist) to arrange to visit your home soon after your admission to rehabilitation. They may take you with them if practical, but on some occasions they may not be able to e.g. if there are many stairs to your door. If you are unable to attend, then it is useful to have a family member or close friend there to help show the occupational therapist your home and help to give you information about the visit.

Following the visit, the occupational therapist will discuss their recommendations with you, and together you will make a plan for any equipment or changes which may be needed at home. The occupational therapist will make recommendations based on helping you to maximise your independence, ensuring you are safe at home, considering how you will manage activities independently as you get older, and financial issues. There may be some financial assistance available and you are encouraged to ask your occupational therapist or social worker about information regarding this if you are unsure.

Recommendations may include such things as:
Having a chair in the shower, or seat over the bath to assist you to shower independently.
Having a ramp built to enable you to get in/out of your home in the times when you need to use a wheelchair.
Putting rails beside the toilet to assist you to get up/down from the toilet.
Moving frequently used crockery to cupboards where you can reach it easily.
Having an extra phone point installed by the bed.
It is not only your home environment which needs to be considered but the other places you spend time should also be brought to the attention of your occupational therapist, e.g. homes of family or friends, the local shopping centre, the library or bowling club, church or school.
Some of these places may already be accessible for individuals who have had changes to their mobility. Some may present difficulties. Your occupational therapist may be able to recommend some strategies to assist in accessing these places.

Will I be able to continue driving?
Driving is a significant activity allowing independence and freedom. For some people it is an activity that does not appear to require much skill and can almost be done automatically. It is actually highly skilled and demanding-both physically and mentally.
Many people with an amputation continue to drive following their operation. In some cases individuals are advised not to drive due to age-related changes, problems with vision associated with diabetes or pain that may affect concentration. Some of these factors may improve following medical intervention and you may be able to resume driving at a later stage.
The doctor looking after you will be able to advise you when it is safe for you to return to driving. Following your amputation the licensing authority for your state, and your car insurance company, should be notified. In some Australian States a driving assessment is required. This assessment is conducted by an occupational therapist with specific training and skills in assessing the many and varied demands of driving. The assessment may include checking your reaction time, an eye test; an assessment of road knowledge, and a driving component.

In some circumstances there may be certain recommendations made (following your amputation) for example:
You may need to have modifications to your vehicle
You may be licensed to drive an automatic vehicle only
You may be limited in the times of day that you drive or within a certain distance of your home.
You are encouraged to talk to your occupational therapist about issues associated with driving and they will advise you about the process and timing relevant for you to return to driving. You may also wish to talk to your occupational therapist about strategies to assist with transferring in and out of the car, loading and unloading the wheelchair from your car, parking permits, and public transport considerations.

Will I be able to return to my work and leisure activities?
Often individuals find that their health condition or the amputation has forced them to have a break from their work or leisure pursuits or, perhaps they have stopped them all together. If you have had an active life prior to your amputation then you may find this frustrating. After your amputation you may need a period of time to recover physically, but part of your return to 'normal life' is also to return to your work or leisure activities. The therapy staff taking care of you may ask you questions about your work activities (whether paid or unpaid; inside or outside the home) and about the activities you do to relax or enjoy yourself. This will help the therapists to work with you in constructing a plan for your rehabilitation that will be relevant to your daily activities.
When it is appropriate for you to return to work, therapy staff might arrange to have a meeting with you and your employer, and they might arrange to do a work assessment with you. Sometimes they may refer you to another agency whose job it is to specifically help you with work issues. They will need to consider with you:

The demands of the job-both physically (e.g. balance; energy requirements, etc.) and mentally (e.g. concentration, planning, etc.).
Whether some aspects of your work or the work environment can or need to be modified.
Travel to and from work.
Whether you can build up your work hours over a period of time if you need to begin in a part-time capacity.
You may not work in paid employment. It may be that you are involved in volunteer work; working with your family; or doing the household work in your own home. Some of these activities may also require some modifying following rehabilitation or it may be helpful to talk to the occupational therapy staff or other staff about how you might return to these activities independently and effectively during your rehabilitation.
It is important to have a balance in your life between the things you have to do and the things you want to be able to do. Returning to your leisure activities and hobbies are important parts in your rehabilitation as well as being able to look after yourself or return to work

Some of your leisure activities may be active and require physical skill, some may be more passive activities. Sometimes talking to the therapy staff about the hobbies that you enjoy, and the places that you carry out various activities will enable them to assist you to return to these activities or to pursue new hobbies and activities.

Many public facilities will be accessible for people with reduced mobility or specific mobility requirements. Some venues, e.g. theatres, cinemas, sporting facilities, etc. may assist with special seating requirements. Some venues may have a hire or loan system for wheelchairs or provide specially located disabled parking facilities. If you are attending a venue for the first time it is worthwhile ringing in advance to ensure that they can meet your individual needs.

Consideration should be given to holidays as there are specific issues when planning to travel away from home. You may need to think about issues such as arranging accommodation that is wheelchair accessible or has appropriate equipment; considering the sort of transport you might use during your holiday; or the location of a local prosthetic facility near your holiday destination. These things should not stop you going on holidays but some pre-planning will ensure that you enjoy your break with a minimum amount of fuss.

Will there be other issues as I get older?
An amputee goes through phases of life and it is important that there be regular specialised clinic reviews, not just focussing on your amputation but your whole body and other relevant issues. Needs change over time and other issues may become important, for example, managing with arthritis, increase in body weight or loss of general fitness, all of which may be associated with aging, but not necessarily.

In reality it becomes more difficult to compensate for amputation as one gets older. The aim is to keep walking. By paying attention to good health management and dealing with some of the issues mentioned mobility can often be maintained. At times, it may be necessary to fall back to wheelchair use, for example, over longer distances.
Sometimes people make a pragmatic decision that it is easier to use the prosthesis over shorter distances. At higher levels of amputation and with other medical problems a decision not to wear prosthesis at all, and use a wheelchair as the main form of mobility is reasonable.

However, it is still necessary for an amputee be reviewed by a specialised clinic team, not just in relation to the prosthesis, but for all other aspects of being an amputee.

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