Though Danny is a fictional character, his case
demonstrates some of the real problems people
with limb loss face. In fact, losing a limb or limbs
can be the beginning of a host of other issues,
including pain, depression, low self-esteem,
diabetes, circulatory problems, cancer, skin
irritation and breakdown, back and hip problems,
bone density and muscle loss, heart problems
and obesity.
“To avoid many of these problems, the
prosthetist must first ensure that the prosthesis
is optimal in terms of fit, alignment and
appropriate componentry so that the individual
has the potential to return to ‘as normal a state
as possible,’” says Robert Bedotto, PT, CPO.
“Unfortunately, even in a well-fitting prosthesis
with the best components, activities are more
difficult for people with limb loss, and the total
body is affected. Therefore, as prosthetists,
we have not achieved our goal simply because
patients are walking well on their prosthesis and
returning to a ‘normal life.’ I suggest that true
rehabilitation has only just begun.”
Pain, depression, and low self-esteem
resulting from limb loss are certainly major
issues for amputees; however, since these
problems have been discussed elsewhere in this
publication, we will not deal with them here.
Diabetes, Circulatory
Problems, and Cancer
Many of the secondary conditions that can
result from limb loss are caused by a poor
diet and a sedentary lifestyle. To the extent
that limb loss causes an amputee to become
less active, it may also increase his or her risk
for these problems. It is essential, therefore,
that amputees who might be more prone to a
sedentary lifestyle remain active through regular
exercise or participation in a sports program. Many amputees participate in able-bodied
exercise and sports programs, and there are also
numerous programs that are for amputees only.
(For information on such programs, please see
the listing on pages 94-98 or contact the ACA.)
Before beginning any new exercise program,
you should talk with a doctor. If desired, a
physical therapist (PT) who has experience with
amputees can help you design an exercise
program that fits your needs.
Skin Irritation and Breakdown
For amputees who wear prostheses, the skin
of the residual limb is especially susceptible
to irritation, breakdown and infection as it is
stretched, pulled and rubbed by the prosthetic
socket. Friction, heat, pressure, shear and
moisture within the socket combine
to bring about damage to the skin. As
with shoes, a properly fitting prosthesis
is essential to preventing this painful
problem. Unfortunately, swelling, weight
fluctuations and muscle changes
caused by atrophy, disease, and loss
of soft tissue can all affect the size of
the limb and the fit of the prosthesis.
In fact, the volume of the limb can
even change throughout the day as the
amputee walks around. Although they
will not solve the problem completely,
a proper diet, regular exercise, and the
maintenance of muscle tone and weight
can help minimize these fluctuations.
Skin damage can also result from
the use of certain detergents to clean
the residual limb and the use of certain
kinds of topical medications inside the
socket.
Ultimately, attention to hygiene and
skin care is essential. “There are a
few basic rules for skin care, the first
of which is cleanliness,” says Paddy
Rossbach, RN and ACA president and
CEO. “If you wear a prosthesis, your
residual limb is encased in a completely
or partially airtight socket that does not
breathe or allow sweat to evaporate.
Sweat is acidic and salty, and when it is
allowed to dry, it forms tiny crystals (like
sandpaper) on your skin. If this sweat is
left on the skin and socket, bacteria can
grow. If the skin is broken, infections
may occur and can become severe if
left untreated.”
She warns: “Always consult your
physician or prosthetist if sores or
blisters erupt because they could lead
to ulcers and serious infections. If you
have diabetes or circulatory disease and
have anything more than a mild rash,
consult your physician immediately.”
Although cleanliness is essential, the
details of how it is achieved may vary
depending on your specific condition
and the type of prosthesis you use.
(For more detailed information on
basic skin care, see pages 76-77 or
contact your physician, prosthetist or
dermatologist.)
One thing is essential: Amputees
should pay attention to any pain in their
residual limb, and if any kind of problem
is detected, it should not be ignored.
Back and Hip Problems
Back and hip problems caused by the
stress and strain of walking with an
improper gait, using prostheses, or
using crutches are sometimes even
more of a problem for amputees than
other types of pain.
“Lower-extremity amputation
causes a change in the center of
gravity, disrupting the biomechanical
symmetry of the back and hips,”
explains Terrence P. Sheehan, MD, a
physiatrist and the medical director
of Kessler-Adventist Rehabilitation
Hospital. “The joints of the lower back
and sound limb are stressed and
muscles are used abnormally. This often
leads to chronic pain, a propensity to
repeated acute spasm and strain, and
acute inflammatory processes such as
bursitis.”
Although back problems in amputees
are not always related to their gait or
their prosthesis, it is important that PTs
and prosthetists deal with any such
problems that they can alleviate through
proper prosthetic fit, more appropriate
components, or gait training. In
addition, the patient should learn about
good body mechanics to avoid as many
problems as possible. A physiatrist and
a chiropractor can help.
“Many patients don’t understand why
their backs hurt,” explains Bill Sheppard,
DC, a chiropractor and below-knee
amputee. X-rays sometimes show
misalignment of their back, he explains,
and usually one side is rather high or
rather low because of the improper fit
of the prosthesis.
“Medicine can only do so much,
and you can’t take it for long periods
of time,” he explains. “Chiropractors
understand human biomechanics
and concentrate on healing the
body naturally with techniques like
stretching, weight training and musclestrengthening. They are a good
alternative to medicine, which just
masks the symptoms.”
Dr. Sheppard also uses modalities,
such as electrical stimulation, heat
therapy, traction and spinal adjustments,
to take pressure off of disks and nerves
and to relax muscles. He also suggests
some nutritional supplements that he
says can help with lower back pain and
help regenerate cartilage and lubricate
joints.
The most important thing above
medicine, chiropractics and physical
therapy, Dr. Sheppard stresses, is
general health. “A lot of people just
don’t know how to exercise properly,”
he explains. Although he helps patients
devise exercise regimens, he says the
hardest thing is getting them to follow
them.
Bone Density and
Muscle Loss
Bone density and muscle loss can be
problems for anyone who is inactive.
“After amputation, there are specific
muscles that remain but are not used
as they had been, and this disuse of the
muscle leads to shrinkage,” explains
Dr. Sheehan. “The bone also needs
to be stimulated such as when the
muscle pulls on the bone or when we
bear weight through the bone. If this
does not happen, the bone gets thin
(osteoporosis) from ‘disuse.’”
There are specific bone scans and xrays
that are used to evaluate a person’s
osteoporosis and specific medications
and nutritional supplements that are
currently recommended for it. The
primary care physician, the physiatrist
and the physical therapist can be
especially helpful with these issues,
but the best solution is to avoid the
problems altogether if possible. Sufficient exercise is one component
of the solution, explains Bedotto, and
proper technique and frequency are
important.
“One of the best ways to develop
strong bones is to do weight-resistance
training, Dr. Sheppard says. “Not only
can weight training help amputees build
up their general health, it can also help
them build up their self-esteem and
body image and make them feel better
about themselves. Weight training just
makes everything better.”
Heart Problems
Because amputees generally use more
energy to walk than those who don’t
require assistive devices, good overall
physical health is essential for them.
For some amputees, the problem
is even more severe, explains Dr.
Sheehan. “For many amputees, loss
of a limb is part of a larger problem
with the blood vessels, including
the blood vessels to the other major
structures such as the heart. If the
heart is not functioning well, all efforts
will take more energy and the stress of
ambulating with a limb deficiency can
exacerbate the heart problems.”
The primary care physician, the
cardiologist, the physiatrist and the PT
can help with these issues through
assessment, proper medication and
physical training to help the amputee
develop the stamina needed to handle
the added strain of walking with
assistive devices.
Obesity
“Obesity in America is probably the
most serious health hazard we face and
the most costly,” says Bedotto. “Hip
and back problems, cardiac problems,
diabetes and various other problems
are all affected by obesity, and, in
some cases, obesity may even be their
cause.”
“If the amputation has led to
decreased activity, weight gain often
follows,” says Dr. Sheehan. “The
obesity causes further stress to the
heart and other systems, and weight
gain changes the custom fit of the
prosthesis.”
Diet and exercise are, of course,
the main solutions to this problem,
but it is a vicious cycle: Weight gain
exacerbates existing problems and
causes new problems, making it more
difficult for the amputee to exercise and
leading to even more weight gain.
Amputees must, therefore, take
the problem seriously and should,
if necessary, seek the help of a
nutritionist, a primary care physician and
a physical therapist.
Medication Side-Effects
and Reactions
Amputees with these additional
problems may also end up having to
take a lot of medications. In addition
to side-effect risks, some medicines
may cause harm when used together
or even when certain foods or herbs
are used along with them. Even eating
something as seemingly innocuous
as onions can be hazardous if one
is taking blood-thinning medication.
Some combinations can even be fatal.
Unfortunately, the pharmacist and the
doctor often have no warning that the
patient is at risk because they don’t
usually know what the patient eats and
drinks or what herbs and supplements
he or she is taking.
To avoid any of these potential
dangers, patients should be proactive
and ask their pharmacists about any
side-effects and interactions of the
medications they are taking.
Prevention and the
Rehabilitation Team
“Prevention is the key to good health
and longevity and is also the most
economical in the long run,” says
Bedotto. “For every dollar spent on
rehabilitation, there is a tremendous
savings not only in dollars but in human
suffering.”
To prevent or repair most of the
secondary conditions caused by
limb loss, patients need to be aware
of the risks and work with their
rehabilitation team to address each of
them, explains Dr. Sheehan. “First and
foremost is education of the amputee
and their significant supports. It is in
this collaboration with the amputee
that proper care of the body, such as
training with the physical therapist,
treatment by the physician, and strong
communication with the prosthetist,
can lead to maximizing functional
outcomes.”
—by Rick Bowers
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