Early therapy contributes to greater treatment success, and ideally begins even before the amputation. Directly after the surgery the focus is on oedema therapy, initial mobilisation and scar care.
Scar and skin treatment
The surgical wound on the residual limb generally closes within three to four weeks and a scar is formed. Even when it is well healed from the outside, the underlying scar tissue may not be entirely healed yet. This may take up to 18 months. If you as a therapist are uncertain whether to start with the first therapeutic measures, please consult the responsible doctor.
It is recommended to keep the scar tissue moist and supple once the scar is healed. Patients should be trained on cleaning and massaging the skin. Soft and supple skin makes it easier for patients to start wearing a prosthesis.
The residual limb is often very sensitive following the surgery. To counteract this sensory discomfort, desensitisation therapy should be provided. It helps to show the patient to gently roll a massage ball with nubs over the sensitive area- but be careful, the healing status and the beginning of this treatment has to be clarified with the doctor. Alternatively, the residual limb can be massaged with a rough towel/washcloth in distal to proximal direction. Brush massages are also suitable for desensitization.
To prevent the skin from becoming rough and scaly, the patient should wash the residual limb with water and mild soap in the morning and evening (e.g. Derma Clean). Then the patient dry the skin thoroughly or carefully dab it dry and apply a cream. Derma Repair and Derma Prevent are two products from Ottobock developed especially to care for residual limbs and highly stressed skin. Derma Prevent for example helps prevent chafing by covering the skin with a protective film, keeping it soft and supple. Furthermore it's usually used in combination with the liner and therefore applied directly before putting on the prosthesis. Derma Repair alleviates the consequences of heavily stressed skin and protects it against damaging external influences.
The repositioning of the residual limb is important, since it ensures that the patient is as pain-free as possible and also prevents the development of pressures sores and contractures.
If the patient is lying on the back, the residual limb should not be supported of pillows under the leg. Also the residual limb should not hang down while sitting in a wheelchair or on the bed. This could reduce the mobility of the residual limb that can, in worst case, lead to not being able to properly control the prosthesis later on. Correct positioning with the joint extended – insofar as this is possible for the patient – prevents contractions or shortening of the muscles.
To prepare the body optimally for the subsequent treatment steps, exercises to strengthen the torso, arm, and leg musculature are highly recommended. The exercises can be performed with light weights and resistance bands, from a lying, sitting or standing position. The residual limb should also be included in the exercises. Also familiarise the patient with movement patterns that are initially unfamiliar with the amputated leg. You, as a therapist, should show all relevant exercises to the individual needs of your patient and make sure that they are performed correctly.
In the following videos you will find some useful tips that you can show to your patient.
The wound dressing is changed frequently after surgery. After this, it is time for lymphatic drainage and subsequent compression therapy with a compression dressing or similar method. The objective is to further reduce the swelling of the residual limb and prepare it for the first prosthesis. Compression also stimulates blood circulation within the residual limb, reduces pain, and promotes the healing process.
The level of compression can be assessed based on skin discoloration or temperature. The bandage/liner must be removed occasionally to check the residual limb for any circulation problems or impaired sensitivity. This is particularly important for elderly patients with the corresponding comorbidities.
In the following pictures you can see how to apply a compression bandage (only to be carried out by qualified staff). When bandaging you must be careful not to build up too much or too little pressure, so that the blood circulation is not interrupted. If too little pressure is applied, the residual limb volume may not decrease. In addition, when bandaging, the pressure must be reduced from distal to proximal.
What type of residual limb care is most suitable for the patient – with elastic bandages, compression socks or a silicone liner – depends on various factors such as the amputation level, wound conditions, and also the personal experiences of the treatment team.
Although the level of compression is not as individually adjustable as with compression bandages, silicone liners or compression sockets are a fast and easy alternative. However, to apply even compression with the liner, there must not be any air between the end of the residual limb and the liner.
Initially, there is often increasing perspiration inside the liner – this decreases after a while. To prevent skin irritation, we firstly recommend applying Ottobock Procomfort Gel to the skin at the upper edge of the liner and secondly, cleaning the liner regularly.
In the following videos you will find information about different compression methods, which you can also show to you patient.