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Contraindications (with regard to certain positions)

Leaving the limb on the amputated side unsupported as this can:

— exacerbate pain

— hinder wound healing

— increase stump oedema.

Principles of care

The main goals of moving and positioning with regard to amputee management are to:

maximize function by preventing contractures (particularly if the patient’s goal is prosthetic rehabilitation)

help to control stump oedema in order to assist wound healing

assist the regaining of functional independence as soon as possible.

There are also two important points to consider when assisting an amputee patient.

Firstly, any level of amputation, either of an upper or lower limb, will alter the patient’s centre of gravity, potentially resulting in decreased balance. This in turn will increase the risk of falls for these patients.

Secondly, body symmetry and posture will be altered which can also affect balance and may lead to poor postural habits that will hinder recovery and function.

Where possible, the process of positioning starts at the preoperative stage when the affected limb is often painful and the patient is frequently less able to mobilize. As a result, the patient may adopt positions of comfort that can lead to contractures. These positions are often maintained post amputation due to comfort and habit but are also due to changes in muscle balance (Engstrom and van de Ven 1999). For example, above-knee amputees may adopt a flexed and abducted position of their stump due to an alteration in muscle balance and pain but this can lead to contracture over time if not corrected.

Contractures can profoundly affect the potential for prosthetic rehabilitation and overall function so early correct positioning is paramount in this cohort of patients (Munin et al. 2001).

Preoperatively, patients should also be encouraged to keep as mobile as possible within pain limits to reduce the effects of deconditioning.

Pain, including phantom limb pain*, can be a major problem with these patients in the early postoperative stages.

In order to ensure that everyone works together towards a common goal, BACPAR (2006) recommends a comprehensive assessment by key professionals to establish rehabilitation goals. This assessment should be carried out as soon as possible following the decision to amputate and will need to undergo regular review.

The general principles of care mentioned earlier in the chapter are all relevant to this section. However, in addition, particular attention should be given to any possible balance issues for both upper limb and lower limb amputations as previously mentioned.

Note: Following lower limb amputation patients should be mobilized with caution, particularly if a prosthetic assessment is planned. This is because standing for long periods or hopping can:

negatively influence stump oedema and wound healing

overtire a patient, particularly elderly patients or those who are physically deconditioned prior to the amputation

encourage the patient to adopt poor gait patterns due to excessive weight bearing on the remaining limb, leading to difficulty with prosthetic rehabilitation.

Preprocedural considerations

Equipment

Stump board

This will be required when sitting out in a wheelchair to ensure that the limb is fully supported and help prevent knee flexion contractures for below-knee (transtibial) amputees (Figure 7.19).

Figure 7.19 Two designs of stump board. (a) An adjustable stump board: the angle can be varied for comfort. (b) A fixed stump board: this slides underneath the wheelchair cushion.

Reproduced from Engstrom and van de Ven (1999).

Wheelchair and seating cushion

Occupational therapy will assess and provide a wheelchair and a suitable cushion for lower limb amputees. If a patient has a bilateral lower limb amputation then they will need a specially adapted wheelchair with the wheels set back in order to provide sufficient stability.

Procedure guideline 7.11 Positioning the preoperative and postoperative amputee patient

Essential