Acute Care

The acute care phase of amputee management ideally involves input from all members of the multidisciplinary health care team, as well as active participation by the amputee and their family / carers. If using the Phases of Amputee Rehabilitation defined by Esquenazi (2001), acute care involves the first four phases:

1. The pre-operative period
2. The surgery & immediate post-operative dressing
3. The acute post-surgical period
4. The pre-prosthetic period

The length of these phases can be highly variable, and indeed some goals set within these phases may extend into the subacute and rehabilitation phases. Factors influencing the acute care phase can include:

• The urgency for surgery (planned/elective versus traumatic)
• Pre-amputation fitness and mobility, and presence of co-morbidities
• The rate of immediate post-operative healing and oedema management
• The degree to which pain is managed
• The cognitive level of the patient
• The availability of carers and their ability to participate
• Progress towards the goals set during these phases

Physiotherapy during acute care focuses on the following broad objectives:

• Chest care.
• As well as the effects of an anaesthetic, patients often have pulmonary co-morbidities. Assess and treat as appropriate, including specific respiratory techniques, and early sit out of bed / mobilisation.
• Management of the amputation stump. This involves several more specific objectives:
  • Prevention / reduction of oedema, through use of modalities such as rigid dressings, stump bandaging or shrinkers, stump massage, elevation, silicon liners, and compression pumps.
  • Promotion of surgical wound healing. This includes use of rigid dressings and oedema management to reduce the possibility of wound dehiscence, as well as protection of the stump from infection and further trauma.
  • Pain management & desensitisation.
  • Early prosthetic fitting.
• Maintenance / improvement of range of motion & strength.
  • Use of thigh-length rigid dressings / backslabs if necessary to limit knee flexion / contracture prevention.
  • Positioning in bed and chair, including prone lying, and discouraging use of pillows under the stump.
  • Post-operative range of motion and strengthening exercises, of the limbs and the core.
  • Early mobilisation
• Maintenance / improvement of cardiorespiratory fitness.
  • Early mobilisation.
  • Specific exercise regimes, both for strength & fitness. This can include aerobic training (arm ergometers or wheelchair fitness courses).
• Promotion of early mobility and independence.
  • Early sitting out of bed, and transfer training.
  • Early mobilisation with crutches or frames.
  • Early fitting of an interim prosthesis.
• Prevention of other secondary complications related to co-morbidities, including education on looking after the remaining limb.

Information on these objectives is available across this site, including the documents and links from this page.

References

• Esquenazi A, DiGiacomo R (2001). Rehabilitation After Amputation. J Am Podiatr Med Assoc 91(1): 13-22