Issues Prosthetists, Physiotherapists Face During Lower-Limb Prosthetic Rehab

Successful prosthetic rehabilitation is crucial for improving the physical and mental outcomes of people with lower-limb amputation. And throughout the years, studies have been conducted to determine the challenges faced by individuals with amputations during prosthetic rehabilitation. However, no study has been dedicated to determining what issues frustrate prosthetists and physiotherapists. Knowing these could provide a different perspective for patients undergoing prosthetic rehabilitation and their families, who could seek and build better support systems for the patients.

In 2022, a UK study published in the journal Frontiers in Rehabilitation Science aimed to understand the frustrations and impacts of clinicians during lower-limb prosthetic rehabilitation. The researchers identified five themes: Body Impactors, Consequences of Ill-Fit, Limitations of Practice, Prosthesis Irritants, and Service Disparity. The study's findings were then used to inform other studies focusing on prosthetic and socket design and fitting.

Service disparity  

One of the most frustrating issues for clinicians is the difference in quality of service between private, military, and NHS settings. The longer appointment waiting times and socket refitting in NHS facilities can impede a patient's progress. 

There is also a need for continuity in care brought on by changes in management and temporary clinicians. According to the study participants, contracted clinicians often change every eight to twelve weeks, which disrupts patients’ treatment plans. The variations in team setups and locations also impact how clinical teams work together. 

It would be best if patients get the services of prosthetists and physiotherapists that work together. This setup allows for minor issues with prosthetic limbs discovered during physiotherapy to be solved quickly. Furthermore, clinical teams working together can treat patients from multiple perspectives. This approach ensures that patients receive well-rounded treatment and the best possible care.

Body impactors  

It’s normal for the residual limb to change in shape and volume depending on changes in weather and activity levels. After just one physiotherapy session, the residual limb may undergo enough changes to make the prosthetic socket uncomfortable or difficult to wear. So, a socket that fit well before may become loose, leading to residual limb damage. It may also become too tight, causing pain or skin conditions that keep a user from wearing the prosthetic limb.

The study participants pointed out another issue with wearing the prosthesis: the residual limb can become hot due to the prosthetic socket’s non-breathable materials, along using prosthetic socks or liners. The temperature buildup in the socket can also lead to moisture buildup due to sweat, which can cause further issues for the residual limb’s health, such as skin breakdown and infection, as well as problems with prosthesis use.

Although the residual limb shape and volume may have stabilized, the study participants noted that the tissue in the limb may not be suitable for prosthesis use. Skin grafts and adherent scars are common, especially for amputations caused by trauma. The internal tissue can become stiff and immobile, causing significant pain and skin breakdown. It’s essential to address these issues before continuing with prosthesis use. 

In addition to the physical challenges, the psychological impact of prosthetic rehabilitation is also crucial. New amputees are dealing with a significant change in their lives, and many are motivated not to let their amputation affect their daily lives. However, the study participants highlighted that demotivation is not uncommon, especially when patients are not making the expected progress.

Consequences of ill-fit  

The prosthetic socket is a crucial prosthesis component, and it is complex due to its interface with the body. Ill-fitting sockets can negatively impact the physical health of the residual limb and the patients’ ability to use a prosthetic limb.

Poorly fitting sockets contribute to health issues of the residual limb, such as skin breakdown and the development of pressure sores. These problems can impact the residual limb's health and affect the rest of the body. Physiotherapists recommend discontinuing prosthesis use if there is rubbing in any way.

Continued prosthesis use with an ill-fitting socket can adversely affect the entire body. Individuals often compensate for pain and discomfort by altering their weight distribution or movement, which can impact the body's biomechanics. This can lead to musculoskeletal overuse injuries, affecting rehabilitation, function, and long-term health.

Prosthesis Irritants    

Another area for improvement is irritations with the prosthesis, which are not easily solvable due to their make and design. In particular, the prosthetic socket is a constant cause of frustration for most clinicians because it does not adapt to the changing body. Although there are now adjustable prosthetic sockets, clinicians understand these products have limitations.

A solution for this problem is the Confidence Socket, developed by the German company amparo. The prosthetic socket can be remolded to accommodate changes in the residual limb by simply using hot air. However, it is essential to note that this technology only makes sockets more adaptable to slower changes in the residual limb and doesn't compensate for any short-term changes.

Moreover, some prosthetic liners used in prostheses can also cause issues, particularly around the build-up of heat and sweat in the socket. These issues are worsened when liners are paired with socks inside the socket for added comfort or to minimize movement in the socket. These problems can lead to residual limb health issues if not dealt with.

Limitations of practice  

Although fixing known issues may not take much time, building a solid relationship between clinician and patient does. In the NHS, appointments are often restricted, leaving little room to establish a rapport with patients. This can make patients uncomfortable discussing personal issues that may affect their rehabilitation.

Participants in the study also felt that there are gaps in support that affect clinicians' time with their patients. Patients may often talk to their clinician about many things, especially new amputees who are going through a difficult time. Spending more time with one patient can affect the time allotted for the next patient. Study participants pointed out this is a problem because patients do not always receive the mental health support they need outside consultation hours.

However, when it comes to solving patient issues, the study participants agreed that there is no standard practice, which may become a problem. For example, some clinicians prefer to remove the prosthetic limb when it comes to wound healing. In contrast, others believe wearing it and encouraging activity increases blood flow and healing minor wounds. This can make clinicians unsure of the correct way to proceed, resulting in a trial-and-error process.

The bottom line  

This was the first study that gave insight into the perspectives of prosthetists and physiotherapists involved in lower-limb prosthetic rehabilitation. Patients and families can use these insights to help improve rehabilitation outcomes as well as seek better support systems.