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Between October 4th and October 10th 2017, it is National Amputee Awareness Week (The Department of Health 2017).
The Department of Health (2017) provides the following link http://limbs4life.org.au/ to Limbs4Life. Limbs4Life (2013) offers support to amputees, their families, their carers and health professionals.
The main causes of amputation are trauma, cancer, diabetes, vascular disease, congenital differences, and infection. Alarmingly, Limbs4Life (2013) state that ‘every 3 hours in Australia a limb will be lost as a direct result of diabetes-related foot disease’.
Healthdirect (2016) highlights that amputation can be prevented. For example, people with diabetes can prevent amputation via implementation of a healthy diet, exercise, regular foot checks and blood sugar level management (Healthdirect 2016). According to Healthdirect (2016), each week as many as seventy Australians that have diabetes are likely to have a foot amputation.
VTE Leading to Amputation
Robertson and Roche (2013) convey that leg amputations may be necessary due to conditions such as gangrene, ulceration, tumours or poor perfusion. Inadequate blood supply can result from narrowed leg arteries and this reportedly contributes to as many as 70% of amputations (Robertson & Roche, 2013).
People who undergo an amputation are at a greater risk of developing blood clots (Robertson & Roche, 2013). Yeager (1995, cited in Robertson & Roche, 2013) expresses that ‘Risk factors for VTE that are common to people undergoing amputations are advanced age, sedentary lifestyle, longstanding arterial disease and an identifiable hypercoagulable condition’.
Robertson and Roche’s (2013) study found that there was insufficient evidence to identify which approach (drugs or compression devices) were most successful at preventing venous thromboembolisms for clients that are having an amputation of the lower limb. Evidently, further research is necessary to determine how best to prevent blood clots for people undergoing amputations.
Similarly, Cumming, Barr and Howe’s (2015) study determined that there is a pressing need for more randomised controlled trials (RCTs) regarding ‘key interventions’. Cumming et al. (2015) found that there was insufficient evidence from RCTs to support decision-making for prosthetic rehabilitation (e.g. best weight of prosthesis) post unilateral transfemoral (at or above the knee joint) amputation in people aged over sixty with poor circulation in their legs.
When people undergo amputation, their independence and ability to utilise their prosthesis effectively may be affected by the following components (Cumming et al. 2015):
- Fear of falling
- Amount of falls
- Social situation
- Support from other people
- Prior mobility level
- Additional energy required to use the prosthesis
- How easy it is to use the prosthesis
Johnson, Mulvey and Bagnall (2015) additionally put forward that phantom pain or ‘stump pain’ is a significant issue for up to 80% of amputees. Johnson et al. (2015) describe ‘phantom pain’ as being a pain felt in a body part that has been removed, and ‘stump pain’ as being pain at the amputation site itself. Johnson et al. (2015) indicate that some people may experience both forms of pain and that these conditions are not fully understood and not well managed.
Instead of resorting to medications, Johnson et al. (2015) highlight that there is a place for non-pharmacological interventions for managing pain in amputees. Johnson et al.’s (2015) study aimed to examine the use of TENS (transcutaneous electrical nerve stimulation) for phantom pain and stump pain post amputation for adults. However, this study (Johnson et al, 2015) was unable to determine the efficacy of TENS for phantom and stump pain, nor the risk of harm from utilising TENS for said pain types.
It was made apparent by Johnson et al. (2015) that there is a strong need for further RCTs regarding TENS use for phantom and stump pain. This need is reinforced by the awareness that most amputees suffer pain that affects their quality of life and ability to use prosthetic limbs or progress with rehabilitation (Ephraim, 2005, cited in Johnson et al. 2015; Nikolajsen, 2001, cited in Johnson et al. 2015).
The ANZSVS (Australian and New Zealand Society of Vascular Surgeons) (2017) suggest that it is usually easier for an amputee to walk using their prosthesis if they have had an amputation below the knee as opposed to an amputation above the knee. Having a minor amputation (e.g. a toe) may mean that walking is less difficult for a person compared to if they were to have a more major amputation (e.g. above the knee).
The ANZSVS (2017) emphasise the importance of persevering with rehabilitation and not delaying rehabilitation following amputation. Rehabilitation often takes 6 to 12 months with many people that have had an amputation suffering from feelings of loss or grief.
It is suggested that the key goal for most older clients undergoing amputation is to be able to walk again (ANZSVS, 2017). According to the ANZSVS (2017), walking with a prosthetic leg post major amputation takes one-and-a-half or two times the energy needed pre-amputation. Rehabilitation thereby needs to incorporate regular strength/muscle training (ANZSVS, 2017).
- Australian and New Zealand Society of Vascular Surgery 2017, Amputation, ANZSVS, viewed 22 September 2017, http://www.anzsvs.org.au/patient-information/amputation/
- Cumming J, Barr, S & Howe TE 2015, ‘Prosthetic rehabilitation for older dysvascular people following a unilateral transfemoral amputation’, Cochrane Database of Systematic Reviews 2015, iss. 1, no. 1, viewed 22, September 2017, http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005260.pub3/full
- The Department of Health 2017, Calendar of events, Australian Government, viewed 22 September 2017, http://www.health.gov.au/calendar#oct
- Healthdirect Australia 2016, Amputation, Australian Government, viewed 22 September 2017, https://www.healthdirect.gov.au/amputation
- Johnson, MI, Mulvey, MR & Bagnall, AM 2015, ‘Transcutaneous electrical nerve stimulation (TENS) for phantom pain and stump pain following amputation in adults’, Cochrane Database of Systematic Reviews 2015, iss. 8, no. 8, viewed 22 September 2017, http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007264.pub3/full
- Limbs4Life 2013, Home, Limbs4Life, viewed 22 September 2017, http://limbs4life.org.au/
- Robertson, L & Roche, A 2013, ‘Primary prophylaxis for venous thromboembolism in people undergoing major amputation of the lower extremity’, Cochrane Database of Systematic Reviews 2013, iss. 12, no. 12, viewed 22 September 2017, http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD010525.pub2/full
Author Madeline Gilkes
Madeline Gilkes, CNS, RN, is a Fellow of the Australasian Society of Lifestyle Medicine. She focussed her master of healthcare leadership research project on health coaching for long-term weight loss in obese adults. In recent years, Madeline has found a passion for preventative nursing, transitioning from leadership roles (CNS Gerontology & Education, Clinical Facilitator) in hospital settings to primary healthcare nursing. Madeline’s vision is to implement lifestyle medicine to prevent and treat chronic conditions. Her brief research proposal for her PhD application involves Lifestyle Medicine for Type 2 Diabetes Mellitus. Madeline is working towards Credentialled Diabetes Educator (CDE) status and primarily works in the role of Head of Nursing. Madeline’s philosophy focuses on using humanistic management, adult learning theories/evidence and self-efficacy theories and interventions to promote positive learning environments. In addition to her Master of Healthcare Leadership, Madeline has a Graduate Certificate in Diabetes Education & Management, Graduate Certificate in Adult & Vocational Education, Graduate Certificate of Aged Care Nursing, and a Bachelor of Nursing. See Educator Profile