 Your work as a physical therapist with an above knee or below knee amputee will be designed around what you want to accomplish with the patient before he is discharged from your care. There are several major goals to be achieved. The patient should understand the importance of proper stump care and hygiene, and the same with bandaging. He should be able to demonstrate proficiency in wrapping his stump. Your program will have taught him to walk with crutches without his prosthesis smoothly, skillfully, and with a minimum of wasted effort. He should have developed adequate range of motion of the stump, and you will expect him to be capable of applying his prosthesis independently. His muscles should be strong enough to function with his prosthesis. Finally, he should be comfortable in ambulating with the correct gait while wearing the prosthesis. The first phase of your work with a new patient is, of course, the pre-prosthetic care. We'll first consider the above the knee amputee. A major aim of physical therapy is to prevent joint contracture. Early recognition and correction of undesirable positions is essential. If contractures occur, it will make the later work much more difficult for you and delay the rehabilitation of the patient. Early in the post-operative period, the patient is given instructions in bed positioning. He should stay in the prone physician as much of the day as he can manage. It may not be a comfortable position for long periods, but you should emphasize to him how important it is to prevent contractures. If the patient insists on propping his stump, prop it in extension, not flexion. For periods throughout the day, it should be positioned in extension to stretch the hip flexor muscles. Make sure also that he keeps his stump adducted and internally rotated to prevent abduction or external rotation contractures. The object of stump bandaging is to both shrink and shape the stump. Briefly, the key points are these. Utilizing oblique and overlapping turns, exert slightly more pressure distally. Slacking a bit as you work proximally. Wrap the bandage high into the groin to prevent an adductor roll. Anchor the bandage with the hip positioned in extension, not flexion. Cross the bandage in back, not in front, so that the stump will not tend to be pulled forward into flexion. To assist you in the planning of your treatment program and evaluation of the patient as necessary. From early on and throughout the course of treatment, you regularly evaluate and record the range of motion. You also keep a record of stump girth measurements. The patient will not be ready for a prosthesis until the stump girth has stabilized or matured. Another assessment is done of muscle strength. Utilizing various standard test positions. Keeping records on each of these evaluation techniques gives you a basis for planning and monitoring the treatment program. Once evaluated, a regimen of active and active assistive exercises aids in maintaining joint range of motion and strength of the remaining muscles. These exercises can be done in a variety of different ways. Here is an example of a hip abduction exercise which is important to prevent a gluteus medius limp. And here's an example of a hip extension exercise. This exercise strengthens the gluteus maximus muscle and aids in preventing a hip flexion contracture. Full excursion of active hip flexion and abduction range of motion should be deferred until the severed muscle groups have sufficiently reattached. There are some significant differences in the preprosthetic care of the below knee amputee. In a misguided effort to make the patient more comfortable, well-meaning others will occasionally malposition the amputee. The optimum bed position for the BK patient is flat on the back with legs together but without support under hip or knee. The highlights of bandaging the BK stump include these points. Utilize spiral rather than circular turns, again exerting slightly more pressure distally. Secure the bandage above the knee and enclose the femoral condyles as they are contained within the prosthesis. Leave the patella exposed to allow knee motion. With either type of amputee, don't forget to teach as you work. The patient must learn in time to do everything for himself and it's your job to help him acquire the techniques. The BK amputee is started on exercises soon after his amputation. This isometric exercise for maintaining tone in the quadriceps muscle may be initiated from the first day. Approximately three days post-surgery, he is ready to begin mild active range of motion exercises. He works toward achieving full knee extension and a normal range of motion. In some treatment centers where a rigid plaster dressing or an immediate post-operative prosthesis is applied, these early active exercises as well as stump bandaging may be restricted. Both the AK and the BK patients advance to resistive exercises as their stumps mature. There are several ways this can be accomplished. The resistance can be applied by you manually. It can be applied utilizing the patient's own body weight. It can be done mechanically. Resistive exercises build strength in the remaining muscles. During the pre-prosthetic period you will also be teaching the patient about stump hygiene. He needs to understand that he is to inspect and cleanse his stump, his stump sock, and his prosthetic socket every night and do it with care. A nightly routine of stump cleansing with a mild soap is important. The patient should rinse and dry the skin carefully and completely. It's essential that he keep the skin in good condition. A rash or skin irritation will keep him from wearing the prosthesis. In addition to exercises for strengthening the stump musculature, you also need to be concerned about general body conditioning exercises. This is more than just a matter of good physical therapy. The opposite leg and the arms have to be strong for walking with crutches. Instructing the patient in the use of crutches is yet another pre-prosthetic activity of the physical therapy department. The patient should be reasonably comfortable, strong, and skilled with crutches before being allowed independent ambulation. Practice in hopping should be addressed as many patients find this method of ambulation more convenient for short distances. This prosthesis for the AK patient is a quadrilateral total contact suction socket prosthesis. It is suspended by both muscle contraction and a negative air suction. On this device the knee unit is hydraulic. Friction types are also used. It's called quadrilateral because of the shape. This is the ischial seat, the major weight-bearing area, the medial rim, the channel for the adductor longus and grassless muscles, the scarpus bulge which forces the stump back onto the ischial seat. As part of acquainting the patient with the device, take time to explain first-level maintenance such as cleaning the valve, the valve seat, and the socket. And make sure he understands that he must not try to make any changes in the device himself. Occasionally a patient will try to remedy a discomfort by going at it with a file. The amputee must learn to apply his own prosthesis. After the first application you check the fit. There are a number of items you want to evaluate during your prosthetic checkout. See that the stump makes total contact with the end of the prosthesis. There should be no air pocket inside. Around the top there should be an appropriate amount of skin tension. A roll of flesh above the rim indicates improper seating of the stump. Feel the medial rim to make sure that it isn't too high. The adductor longus muscle should be located in its channel for proper rotation alignment. The tuberosity of the ischium should ride on the ischial seat. Check its position by having the patient lean forward. You then palpate as he straightens up. Is the pelvis level? An important question. With his weight evenly distributed, see if the anterior superior spine of the ilium is the same height on each side. Finally, is the anterior wall too high? If he can sit comfortably, the height is acceptable. At hospitals where specialized x-ray equipment is available, you can obtain plates like these to help evaluate the fit. Major points to be considered are the position of the ischial seat, acceptable height of the femoral heads, equal femoral adduction, and total contact at the bottom of the prosthesis. This x-ray, for example, reveals that the tuberosity of the ischium is off the ischial seat. Also note the position of the head of the femur with respect to the grid line. On the other side, it is not in the same position. The prosthesis in this instance may not be the correct length. An inadequate femoral adduction angle, a major contributor to gait deviations, and a lack of total contact as evidenced by this air pocket are other criteria readily checked by x-ray evaluation. With the patellar tendon bearing prosthesis for the BK patient, the weight is born in the pre-tibial area. The socket will be set in slight flexion. This is the popliteal bulge which forces the stump forward onto the weight bearing area. On the first application, check these items of fit. When sitting, the cuff suspension should be loose enough for comfort. Check the height of the posterior wall by making sure you can get a finger over the rim. To be certain, it's not choking the stump. When standing, the cuff suspension should be taut. The upper rim should bisect the patella for proper seating of the stump. A level pelvis indicates appropriate length of the prosthesis. Throughout this stage, and until the patient has become ambulatory with the prosthesis, he should be continuing to use the bed positions described earlier to avoid the inadvertent development of joint contractures. Training with the prosthesis begins with balancing drills, which build the patient's confidence and his skill. One early drill involves shifting the weight laterally. And another, shifting his weight backward and forward. A third balancing drill uses a stepping motion, shifting the weight both forward and laterally onto the prosthetic leg. It's essential that you work closely with him on these drills. Two basic gait training skills must be mastered by the AK patient. First, he must learn to step so that heel strike occurs just at the end of the swing phase. And second, he must learn to lock his knee by extending his hip for support during the stance phase. The BK patient does the same balancing drills, but requires a different stepping action. First, the PTB wearer must learn to bear weight on a slightly flexed knee and to control knee flexion from heel strike to mid stance. Second, while keeping the foot flat in mid stance, he must learn to control knee extension. In time, the patient progresses from walking in the parallel bars to walking with the support of crutches, then to walking with a cane, and finally to walking unaided. Throughout this training period, you play a vital role, carefully watching his gait to ensure that he is not forming bad habits. As soon as he's able to walk unaided, he performs for a small select audience. This is a gait analysis using the clinical team approach. The audience is made up of the physical therapist, the physician, and the prosthetist. Each from the vantage point of his own expertise observes for any faults in the walking technique or the prosthesis. Again, it's essential to catch any problems early so corrections can be made before detrimental patterns develop. Once the walking gait has been successfully mastered, the patient goes on to advanced functional exercises. On stairs, the AK amputee usually ascends one or two at a time, whereas the BK patient can go up in the more normal step over step manner. Both types of amputees descend stairs step over step, but must learn to place the foot so that the edge of the step is just in front of the heel. This compensates for limited ankle door suplexion. Certain advanced AK patients can develop the skill to ascend stairs step over step. Other advanced exercises include ramp walking and the techniques for falling and for getting up again, and for getting places in a hurry. Your work with the patient does not end with your functional checkout nor hospital discharge. You should arrange at least one post discharge follow-up conference. This gives you a chance to make sure that he is following a strict hygiene regimen and is getting proper exercise. Patients will vary in the kinds of activities they can return to. Many patients will find they can still do things they thought they would have to give up. And for some, even active sports like gymnastics and skiing will again be possible. With modern medical technology and the expert help of the physical therapist, lower extremity amputees will return to most of their former activities and will continue to enjoy the quality of life.