After the leg amputation
Read about residual limb healing, phantom pain, initial exercises after the amputation and the fitting with an interim and definitive prosthesis.
What lies ahead for you after the amputation?
After an amputation, you are undoubtedly wondering: What happens next? Directly after the operation, your recovery and the healing of the residual limb are initially the main concerns. Both are important so that you can begin with rehabilitation soon and a prosthesis can be fitted.
To start rehabilitation:
You should have little to no pain in the residual limb
Your residual limb should be capable of bearing weight
Swelling and water retention should have gone down and stabilised
You should be able to move your residual limb as much as possible in all directions
Your personal situation will determine how long it takes you to reach this point. However, you can promote healing by actively working towards it. While this often demands patience and a lot of endurance, it pays off: The more mobile you are when you start rehabilitation, the sooner you can be fitted with a prosthesis.
You should also use the time after the amputation in the hospital to choose a suitable clinic for your rehabilitation phase in cooperation with your O&P professional. Our list of experts helps you find facilities that specialise in working with amputees.
Prepare your residual limb for wearing a prosthesis
The healing of your residual limb after the leg amputation forms the basis for the subsequent prosthetic fitting and is therefore especially important. In the hospital, the doctors treating you will continuously monitor and check the healing process, while the inpatient nursing staff looks after the daily treatment of your residual limb. In addition to wound treatment, this includes oedema and compression therapy, desensitising the skin and scar care, among other approaches.
Residual limb healing
Residual limb pain
Various types of pain may occur in your residual limb after an amputation. These may include bone pain, wound pain, nerve pain or phantom pain. Each type of pain is treated according to its cause. Various treatment options are available, such as medication, warming/cooling or wrapping the residual limb. You can talk to your specialist and/or pain therapist about this.
When you wake up from the anaesthetic, your leg will usually already have a dressing consisting of simple bandages or a cast with a small tube coming out of it. This tube was inserted into the wound during the operation in order to drain fluid and blood from the wound. Known as drainage, it is removed in the course of healing. The initial wound healing phase is usually completed within the first fourteen days, when the wound has closed. After this, the connective tissue cells grow stronger and are converted into specific connective tissue. But even if the scar appears to have healed well from the outside and only the colour of the scar tissue changes slightly from this point on, the overall scar healing process takes much longer. It can take up to one and a half years before it is fully healed beneath the skin. The duration of the wound healing process depends on your individual constitution.
After the operation, the tissue around the residual limb will usually swell up at first. This swelling (oedema) is a normal reaction to the operation. It usually subsides after about one week. Only a loose wound dressing is applied until the sutures are removed. No pressure can be applied to the residual limb at first.
The circumference of the residual limb should be measured regularly to evaluate how the swelling is going down. The same measuring points always have to be used for this, and the results must be documented on measurement forms. If this isn’t done, the results are not comparable with each other and there is no way to tell whether the swelling is decreasing.
Early compression therapy
After the operation, a wound dressing is applied and changed at regular intervals. Compression therapy begins after that, for example, with a compression bandage. Your doctor will determine the exact timing. The purpose of compression therapy is to reduce the residual limb oedema and prepare your residual limb for your subsequent prosthesis. Residual limb compression helps optimise the fitting of your prosthesis. Compression also promotes blood circulation in the residual limb. This reduces pain and promotes scar healing.
Desensitising the skin
The skin on your residual limb is very sensitive following the operation. You can help desensitise your skin by working closely with your treatment team – and with your therapist. One example is gently rolling a rough towel or washing mitt over the sensitive skin. You can also lightly massage the residual limb with a brush using an upward motion. Using a massage ball with nubs helps make the skin less sensitive as well. Make sure to only do all of this in close coordination with your treatment team. They will also show you the proper techniques.
The surgical wound on the residual limb generally closes within three to four weeks and a scar is formed. Even when it has healed well from the outside, the underlying scar tissue may not be entirely healed yet. This may take up to 18 months. Talk to your doctor or the nursing staff about scar care that is suitable for you. It may be advisable to moisten the scar shortly after the operation. Your therapist will train you in the best way to clean and massage the skin, because the more soft and flexible your skin is, the better your residual limb is prepared for wearing a prosthesis.
Causes of phantom pain, types and therapy options
Many people are affected by phantom pain, which means pain in the limb that was amputated. Experts believe that up to 70 per cent of all amputees experience this, temporarily in most cases. The psychological strain is sometimes very high for affected individuals. There are various theories regarding the causes of phantom pain. Nevertheless, various and also promising therapy options are now available. Unfortunately, there is no treatment that helps everyone equally. We want to inform you about possible causes and the various therapy options here. In any case, talk to your O&P professional, therapist or doctor. They will work with you to find solutions that give you relief.
Causes of phantom pain
Experts have various theories regarding the origin of phantom pain. One of the most common ones is that different areas in the brain are responsible for different body regions. When a body part is missing and doesn’t produce any feedback anymore, the brain interprets this lack of a signal as pain. In this context, it’s interesting to note that people with a congenital limb difference, known as dysmelia, do not experience phantom pain as often. This suggests that there is a sort of “learning effect” in the brain. Pain memory appears to play an important role as well. If the patient was already experiencing pain before the amputation, this can affect the development of phantom pain and should also be taken into account in selecting the therapy.
Types of phantom pain
Phantom pain is very individual and depends on many factors. It affects individuals with leg or arm amputations equally. The pain may be triggered or intensified by certain types of weather, exposure to cold temperatures or emotional stress. It may occur only at certain times, gradually decrease or increase, or always be present. The type, intensity and characteristics of the pain can differ as well. Affected individuals describe pulling and piercing or burning and cramp-like pain.
Phantom pain is different from phantom sensations, feelings in the lost limb that are not painful.
Therapy options for phantom pain
Various kinds of pain may occur in the residual limb after an amputation. It is important to differentiate between residual limb pain and phantom pain, since these types of pain are treated differently.
There are many different therapy approaches for both types of pain. Combining several types of therapy is recommended for phantom pain. There is no standard therapy that helps all affected individuals. Furthermore, many therapies are of a long-term nature and require the active participation of the affected person. You may need a great deal of patience and endurance. But we can only encourage you to do the therapy, even if it is challenging. Be sure to talk to your doctor, O&P professional and therapist. They will work closely with you and support you to the best of their ability. The following methods are suitable means of therapy for phantom pain after an amputation and complement each other
Mirror therapy: sitting in front of a mirror, the patient’s sound limb is reflected with the help of mirrors. This makes it appear as though the amputated limb is there again. Known as the phantom limb, it can now be moved purposely via the sound side and therefore influenced. This makes it possible to release the phantom limb from cramped and painful positions with the help of movements by the sound side, moving it into a more comfortable, pain-free position. Comparable results can be obtained by looking at photographs (known as lateralisation training). This is intended to practise right/left memory.
Sensorimotor therapy: massaging the residual limb with various materials stimulates nerves via the skin. Ultrasound, thermal or electrotherapy can be used here as well.
Wearing a prosthesis or liner: for many affected individuals, pain is alleviated by wearing a prosthesis or liner. This may be due to sensory stimulation of the residual limb as well as the idea that, with a prosthesis, the body part is still there so the brain is receiving corresponding feedback.
Pain therapy: a pain therapist is a doctor specialising in the treatment of pain. Your doctor will put you in contact with such a specialist. It’s important that you do not try to treat yourself with pain medication in any case.
Residual limb pain
Residual limb pain and phantom pain are different types of pain and are therefore treated differently. For this reason, it’s important that you are thoroughly examined in order to determine whether you are experiencing phantom pain or another form of residual limb pain. Residual limb pain can also be caused by a poorly fitting prosthesis. Medical examinations help clarify whether you may have bothersome scar tissue, painful residual limb neuromas, inadequate soft tissue coverage or excess soft tissue. These causes of pain can be eliminated on a long-term basis by adapting the components or via another surgical intervention.
Certain operating techniques can also help reduce residual limb pain and especially the pain originating from some nerves in the residual limb after the amputation. If possible, preventive pain therapy should commence during the operation with a local anaesthetic or begin directly after the operation to prevent the onset of pain or the development of chronic pain.
Even while your residual limb is healing, you can prepare for the stay in a rehabilitation centre by doing specific exercises. Talk to your doctor or physiotherapist and ask them to show you some important things: the proper position in bed so that the muscles and the joint closest to the residual limb do not shorten or stiffen, regular breathing exercises and light movement and mobilisation exercises, which also help stabilise the circulatory system. These measures help ensure that your treatment with a prosthesis is fast and straightforward so you can stay mobile and active.
Correct positioning of the residual limb
Lying still for a long time directly after the operation will certainly be difficult for you. You probably won’t be able to roll over on your own in bed yet either. For this reason, you should have nursing staff help you change your position several times a day. This repositioning is important, since it ensures that you are as pain-free as possible and also prevents pressures sores from developing.
The correct positioning of your residual limb is important as well. If you are lying on your back, your residual limb should not be propped up on pillows. Also do not let the residual limb hang down while sitting in a wheelchair or on the bed. This could reduce the mobility of your residual limb – and limited mobility of the residual limb means you will not be able to properly control your prosthesis later on. Correct positioning with the joint extended – insofar as this is possible for you – prevents what are called contractions or shortening of the muscles.
Mobilisation to counteract muscle contractures after the amputation
Stretching exercises to counteract muscle contractures after the amputation
Exercises to strengthen the torso, arm and leg muscles are highly recommended to ensure your body is as well-prepared as possible for the subsequent treatment steps, and to keep you moving. You should talk to your doctor or therapist to determine which exercises are suitable. The exercises can be performed with light weights and therapy bands, from a lying, sitting or standing position. The residual limb should also be included in the exercises. These movement exercises prevent the muscles and joints from becoming stiff. Also familiarise yourself with movement patterns that are unfamiliar with the amputated leg at first. Your physiotherapist should show you all the exercises and check that you are doing them correctly. They can tell you which exercises are right at the respective time.
After a bit of time, you can practise your mobility. Sitting up in bed on your own and transferring to a wheelchair will probably be difficult for you at first. However, you will soon master this with some practice. Once again, your physiotherapist should give you detailed instructions. Often there are straps or handles on the bed which you can use for assistance. Soon you will also stand up for the first time. Since the familiar balancing weight of the amputated limb will be missing, you should expect balance problems at first. A walker or other walking aid can initially help you keep your balance after a leg amputation.
How do I find the right rehabilitation facility?
After being released from hospital, your care will usually continue in a rehabilitation centre. The goal here is to prepare you for everyday life with a leg prosthesis. In order to use this time to best advantage, you should definitely choose a rehabilitation centre with experience in the rehabilitation of amputees.
The more experience a rehabilitation facility has, the better it will be able to meet your needs. As a general guideline, a centre should have at least 50 patients per year. Ask the rehabilitation centre you are considering about the number of patients they treat.
Talk to your O&P professional – they can also help you make the right choice.
Your doctor will tell when it would be useful to visit a rehabilitation centre and whether inpatient or outpatient rehabilitation is appropriate in your case. All of this depends on numerous factors, such as your healing progress and how adequately you can prepare yourself at home.
The process of getting a prosthesis
After your amputation, you will have many urgent questions: When will I get a prosthesis, how do I get a prosthesis and which prosthesis will I get? We want to provide you with all the details about the next steps here.
Generally speaking, your prosthesis fulfils numerous functions: On the one hand, it restores your mobility to a large extent. By wearing a prosthesis, you also reduce or avoid posture problems and balance disorders that could result because of the missing weight of the amputated leg. It also prevents your sound leg from being overloaded, which could result in problems over the long term. Talk to your O&P professional right after the amputation. They can explain the process leading up to your fitting with a prosthesis. Please note that many factors determine when you get a prosthesis and whether you are first fitted with an interim (temporary) prosthesis. Your O&P professional can give you detailed advice.
How do I get a prosthesis?
To get a prosthesis, contact an O&P professional who is familiar with prosthetic fittings. You are free to choose your O&P professional and also to change providers if you are not satisfied. Ideally, you have already got in touch with them before the amputation or while in hospital. Our list of experts can help you find an O&P professional with experience in prosthetic fittings near you.
When do I get a prosthesis?
The question of when you get a prosthesis, whether you are first fitted with an interim (temporary) prosthesis and when that happens is always decided on a case-by-case basis. The healing and recovery process is different for everyone. It might take some patience, but it’s worth trusting the advice of your doctor and O&P professional here. But one thing is certain: The better your residual limb is prepared for wearing a prosthesis, the better you will subsequently be able to use your prosthesis.
As a guideline, your O&P professional will examine your residual limb shortly after the amputation and determine whether an interim (temporary) prosthesis is an option for you. After the wound has closed (which takes between two weeks and three months), measurements are generally taken on the residual limb and an interim prosthesis is fabricated at this point. You wear this interim prosthesis for three to six months. It allows you to get used to the prosthesis and helps the residual limb develop its final shape. The process of fitting you with your definitive prosthesis can begin when this has happened, the residual limb of your leg has healed sufficiently and you are once again in good physical condition.
Which prosthesis will I get?
Various factors determine which prosthesis is an option for you. Factors that influence the selection of a suitable leg prosthesis for you include your physical fitness and health, the amputation level, your requirements for the prosthesis and your personal and working environment. Your O&P professional will advise you on all these aspects and work with you to select the corresponding components for your prosthesis.
The alignment of a prosthesis
The components a prosthesis is made of depend on the amputation level. In principle, a prosthesis replaces your missing limb, for instance your foot, knee or hip joint, and is made of various corresponding prosthetic components. Your residual limb goes into a prosthetic socket that connects the prosthesis to your body. There are connecting elements between the individual prosthetic components. These are used, for example, to individually adapt the height of the prosthesis and in some cases also fulfil additional functions.
Your O&P professional will start by selecting the individual prosthesis components together with you, based on your needs. Once the proper fit of the socket has been achieved after several fittings, the socket and components are assembled. Your O&P professional bases the alignment of the prosthesis on the results of the exams and existing alignment guidelines. Additional fittings follow once the prosthesis is ready. The O&P professional checks the prosthetic alignment with the help of technical equipment such as the L.A.S.A.R. Posture and adapts the prosthesis even more precisely to your requirements. You can then take your first steps with your new prosthesis.
The interim prosthesis
In some cases, an initial prosthesis can be fitted soon after the amputation. You wear this interim prosthesis, which is fabricated for you by your O&P professional, until you can be fitted with a final prosthesis (definitive prosthesis). An interim prosthesis can have a favourable influence on the therapy process. It allows you to put some weight on your residual limb early on and to begin with initial walking and standing exercises. However, an interim prosthesis is not suitable for every amputation. Ideally, your doctor, physiotherapist and O&P professional will decide together whether this is an option for you.
An interim prosthesis also serves to gradually adapt a prosthetic socket to fit you and to identify the suitable prosthetic components. Your O&P professional continually improves the fit of the prosthesis during this test and trial phase so that there shouldn’t be any problems with the fit of your final prosthesis (definitive prosthesis).
The definitive prosthesis
Following interim treatment, you receive a definitive prosthesis that is tailored exactly to your needs. Once volume fluctuations have abated so a definitive prosthetic socket can be fabricated, you are fitted with a definitive prosthesis.
You may need additional walking devices aside from the prosthesis. Various walking aids such as canes, forearm crutches and anterior walkers are available, depending on your physical fitness. Many amputees are also provided with a wheelchair. All of these devices are obtained at the hospital or from a medical supply company. Your O&P professional or contact person at the hospital can help you with this. They can also advise you regarding additional devices in your home environment.