by Rick Bowers
DANNY, A BILATERAL LOWER-EXTREMITY AMPUTEE FROM A WAR INJURY, ROUTINELY DEVELOPS SKIN PROBLEMS ON HIS RESIDUAL LIMBS AND IS HAVING BACK PAIN AND PROBLEMS WITH MUSCLE LOSS. HE HAS ALSO RECENTLY PUT ON A FEW EXTRA POUNDS SINCE HE DEVELOPED HIS LAST SKIN ULCER AND STOPPED WALKING AS MUCH. AS A RESULT, HE HAS BECOME DEPRESSED AND DOESN’T FEEL LIKE DOING ANYTHING ANYMORE.
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 Amputee Coalition.)
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 Amputee Coalition 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.”
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 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
|Disclaimer: The views and opinions expressed in this publication are those of the authors and are not necessarily those of the Amputee Coalition, the Department of the Army, the Army Medical Department, or any other agency of the US Government.|