Amputation

The NHS defines amputation as the surgical removal of part of the body.  Commonly a limb. However, amputation can also occur as a result of a trauma or accident. It has also been used as a deterrent in some cultures and, shockingly, as a tactical instrument of war. 

More detailed information can be found on the NHS website.  Here we deal with some of the causes, the surgery, recovery, rehabilitation and mobility needs.

Causes:

  • Infection: a bone infection such as osteomyelitis or as a result of gangrene following injury
  • Circulatory disorders: such as sepsis, diabetic vasculopathy or peripheral artery disease.
  • Trauma: where serious and irreparable damage to a limb has occurred. This can happen at the scene of an accident, or later following assessment.
  • Congenital Anomalies: which may lead to restricted movement, pain or restrictive circulation.
  • Neoplasm: cancerous bone or soft tissue.

Assessment

Unless emergency surgery is required a full assessment is carried out to determine the most suitable form of amputation.

A full medical examination will assess your nutritional status, bowel and bladder function, cardiovascular system (heart, blood and blood vessels) and your respiratory system (lungs and airways).

If the remaining limb will likely suffer additional strain following amputation, the doctor will give advice on how to cope with this.

In most cases, an amputee will undergo a psychological assessment to determine how well they will cope with the loss of a limb.  At this stage, sensitive advice regarding support groups will be passed on and a program of rehabilitation arranged.

A physiotherapist is involved at an early stage as they will be able to support individuals through pre-amputation assessment and work closely with the medical team to develop the most appropriate post-operative care program.

It’s important that consideration is given to post-operative mobility. This may include introduction to a a specialist in prosthetic limbs and developing a plan to minimise the impact on mobility. In the first instance, if the lower limbs are affected, this may mean a wheelchair. Choosing the right wheelchair will involve assessing both the short term (post-operative recovery and rehab’) and the long-term needs of the person involved and potentially, the carers.

Post-Operative Recovery

Immediately following the operation, as with any other major surgery an amputee will begin their recovery in hospital.  It is unlikely that in the days immediately following the operation that patients will be able to move from their bed.  In these instances, going to the loo is taken care of via a catheter and a bedpan. Fluids will be given via a drip and an oxygen mask may be provided.

Clearly the site of the operation will be painful. Painkillers will be available.  It is important that patients tell their medical team how effective the painkillers are in reducing pain. It’s possible that the dose will have to be increased, or a different, perhaps stronger, painkiller administered. Don’t suffer in silence!  A small tube may also be used to deliver a local anaesthetic directly to the nerves in the stump.

The physiotherapist will visit to discuss exercise techniques to prevent blood clots and to help circulation whilst recovering in hospital.

Rehabilitation.

It’s extremely important that rehab’ is taken seriously.  It may be both painful, long, frustrating and tedious, but taking the physiotherapists advice and sticking to the program is crucial in returning to as normal a routine as possible. Rehab usually begins within a few days following the procedure.

Learning ‘transfer techniques’ like moving from your bed to a wheelchair is a first step. If you’ve had a leg amputation you will be encouraged to practice using a wheelchair as a matter of course.

As healing begins, it is likely that the physiotherapist will work on an exercise program to improve mobility and gain muscle strength.

If a prosthetic limb is an option the patient will start to learn how to use it to walk, in the case of a leg amputation, or to grip with a prosthetic hand.

At Home and Following Up

Naturally, how long it takes to recover sufficiently to go home will depend on the extent of the amputation and the general heath of the individual.

Before the patient is discharged, an occupational therapist will visit the home to see if it requires adaptation to best suit your new circumstances.

Often homes will require some modification to aid access. A wheelchair ramp for instance or a stair lift. Bathrooms may require special shower stools and handles.   It may be a while before the stump can be immersed in water or get wet and so special water-proof sleeves need to be available. MobShop has a vast range of these mobility and bathing aids which can be found here. The occupational therapist will advise on which of these you will need.

Maintaining close contact with the medical team is important to continued wellbeing. It may be that it is more difficult to cope, or there are unforeseen issues that being at home has highlighted. Use follow-up contact with the medical team to ensure any difficulties that are being experienced are stressed so that these problems can be addressed.

Prosthetic Limbs

Unfortunately, prosthetics are not suitable for all amputees because of the extensive physiotherapy and rehabilitation programme required.

Adapting to life with a prosthetic limb can be exhausting and energy sapping as the body has to compensate for the loss of muscle and bone.

Clearly this makes it difficult for the frail, elderly or those with compromised health conditions to have a prosthetic limb.

If it is possible to have a prosthetic limb, the type of limb depends on the following criteria as laid out by the NHS.

  • The type of amputation
  • The amount of muscle strength in the remaining section of the limb
  • General health
  • Tasks the prosthetic limb will be expected to perform
  • A desire for how the limb looks or how it functions

With reference to that final point, it’s possible that should functionality not be a priority or the strain of using a prosthetic limb is too strenuous, a cosmetic limb might be more suitable.  This type of limb is one that looks much like a real limb but has no functionality.

It is possible to have a prosthetic limb that both looks like a real limb and is functional. However, there may have to be an element of compromise between realism and functionality.

Caring for the Stump.

Once healed, caring for skin on the surface of the stump is very important to reduce irritation and infection.

Wash the stump, at least once a day, and more frequently in hot weather, using soap without additives or perfume and warm water. Ensure the stump is dried carefully.

Do not leave the stump submerged for long periods as this will soften the skin and make it prone to injury and infection.

Use moisturising cream to ensure the skin over the stump doesn’t become dry. Do this before bedtime or when you’re not wearing a prothesis.  The socket of the prothesis must be kept clean and dry.  Use warm water and soap to do this.

It’s common for people to wear a sock around the stump. This helps absorb sweat to reduce irritation to the skin. Change the socks around the stump every day. More frequently in hot weather.

The NHS advises It’s important to check the stump regularly for signs of infection:

  • Warm, red and tender skin
  • Discharge of fluid or pus
  • Increasing swelling

If you need further advice, or are concerned you may have an infection, contact your care team immediately.

Caring for the Remaining Limb

Whist all focus might be on coming to terms with caring for the stump, it’s equally important that the remaining limb stays in good health.  This is particularly important if the amputation was of the leg or foot and as a result of diabetes.

Regular health checks and the wearing of well fitted, comfortable footwear is important.  Take the advice of a podiatrist and ensure that professional care of the remaining foot or leg is a priority

Undertake regular reviews of your remaining limb to ensure continuing good health and functionality.

Potential Complications

Any operation carries with it a risk of complication. Amputation is no different. It also carries the possibility of additional problems associated directly with the loss of a limb.

As with any operation, there are a number of factors that influence the possibility of complications following amputation.  Planned amputations carry a lower risk than emergency amputations.

Possible complications are as follows:

  • Heart problems and/or heart attacks
  • Deep vein thrombosis
  • Wound infection and slow healing
  • Pneumonia
  • Stump and ‘phantom limb’ pain

Neuromas (thickened nerve tissue) are a possible cause of pain. The affected cluster of nerves may need to be removed.

Stump and “Phantom Limb” Pain

There is likely to be some pain associated with he amputation. The severity of this will vary from person to person. However, treatments rea available to help relieve the symptoms.

The following is updated advice from the NHS. It will be further updated and reviewed in August 2022.

 PLEASE BE AWARE THAT THIS IS FOR GUIDANCE ONLY. IT IS IMPORTANT TO CONSULT YOUR CARE TEAM BEFORE TAKING ANY MEDICINES OR EMBARKING ON ANY SELF-HELP MEASURES/COMPLIMENTARY THERAPY.

Medicines

Medicines that may be used to help relieve pain include:

Self-help measures and complementary therapy

There are several non-invasive techniques that may help relieve pain in some people. They include: 

  • adjusting the way your prosthesis fits to make it more comfortable.
  • applying heat or cold to your limb, such as using heat or ice packs, rubs and creams.
  • massage to increase circulation and stimulate muscles.
  • acupuncture is thought to stimulate the nervous system and relieve pain.
  • transcutaneous electrical nerve stimulation (TENS), which uses a small, battery-operated device to deliver electrical impulses to the affected area of your body, to block or reduce pain signals.

 Pain Relief via Mental Imagery

 Mental imagery has been shown to be particularly helpful in reducing phantom limb pain.  Amputees who spend forty minutes a day imagining using part of the limb that was amputated: stretching out fingers or bunching the toes, have experienced a reduction in pain symptoms.

Researchers postulate that the brain ‘looks’ for nerve feedback from the amputated limb. By employing mental imagery and substituting the ‘real’ feedback for imagined feedback, it reduces the instances and severity of phantom limb pain. However, the consistency and efficacy of this method varies from person to person.

Psychological Impact

There is no doubt that amputation does have a significant psychological and emotional impact. It would be difficult to imagine otherwise.

Therefore, it is obvious that recovery and rehabilitation is as much a psychological effort as it is a physical one.  As with any ‘loss’ a likely emotion is one of grief and bereavement. Not dissimilar to experiencing the loss of a close friend or family member.

People who have undergone an emergency amputation are particularly prone to ‘negative’ thoughts. Primarily because they have not had the time to adjust to the reality of losing a limb.

According to the NHS, common emotions and thoughts would be as follows;

People who’ve had an amputation as a result of trauma (particularly members of the armed forces) also have an increased risk of developing post-traumatic stress disorder (PTSD).

It is important to share thoughts and emotions with the care team. Particularly if emotions begin to spiral out of control and depression and thoughts of suicide become overwhelming. Antidepressants or counselling, will help improve the ability to cope after having an amputation

Support Groups and Help

There is no doubt that amputation is both a brutal and deeply harrowing experience. However, it is possible that the amputation was required to actually improve the quality of life and general well-being.  Nevertheless it will be very challenging.  There are a number of charities that can offer support. These include:

We hope that you have found this, the third in our series of ‘conditions that require a wheelchair’  helpful.  The majority of the links provided are to the NHS which we think is a relevant and appropriate resource.  Much of the advice and information given has been sourced from the NHS for the reasons of continuousness and practicality.

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