Lower limb amputation is a major undertaking and greatly affects the life of the individual, adding psychological stresses to the physical efforts of rehabilitation, fitting for a new limb and learning the skills of walking again. The surgeon will plan the process so that the patient can manage the prosthesis easily, participate as soon as possible in rehabilitation and expend the lowest levels of energy in gait. The patient has to learn a large number of new skills – putting the prosthesis on and taking it off, monitoring the skin for areas of excessive pressure, walking on even and uneven surfaces and getting around when they are not wearing the artificial limb.

To manage all these skills and learn how to be as independent as possible the patients need a skilled team to manage them which includes their own doctor, the surgeon, a physiotherapist, an occupational therapist a prosthetist and perhaps an employment adviser. The number of lower limb amputations is likely to continue to rise as the elderly populations increase in more advanced industrialised countries, with ischaemic vessel disease the primary cause. The proportion of above knee to below knee amputations has changed as surgeons became more skilled at preserving the knee joint so that the present ratio is 30% above knee to 70% below knee.

The most common reason for amputation is PVD, peripheral vascular disease, and a large number of the mostly elderly patients suffer a second amputation of the other limb within three years. This elderly patient group develops problems with ischaemia which results from diabetes, often developing into peripheral neuropathy and ulcers and eventually changes due to gangrene. If the lower limb suffers trauma involving the nerves and arteries then modern treatment can often salvage the limb but this may be unhelpful in some cases as amputation would allow rehabilitation to go ahead and the achievement of early independence.

Other reasons for amputation are less common and include tumours, infections and congenital abnormalities of the lower limbs. Overall amputation is considered an operation which involves reconstruction rather than just removal of a limb, as the patient’s future life and independence is the crucial matter. The higher that the surgeon has to amputate the limb the higher levels of energy are needed for walking, with the speed of walking decreasing and the required oxygen consumption increasing. Low below knee amputation may make little difference to the energy required for gait, however once the level moves up to mid thigh the load may be over 50% more.

The energy requirements for gait are extremely important as amputated patients frequently suffer from ischaemic tissue problems or other medical conditions which lead to walking consuming much of their energy abilities. Independence in functional activities may be hard to achieve as much of their limited energy supplies is taken up with simply walking. After the amputation, due to the skin viability and ischaemic diagnosis, healing may be delayed and this can have an important bearing on the eventual outcome for the patient’s independence. The soft tissues at the site of amputation must act as the connecting point between the leg and the prosthesis.

Allowing a bony area higher up to take some of the weight transfer indirectly can be successfully integrated with weight transfer sideways through the soft tissues of the lower leg. There may still be pain issues for patients despite the many advances made in modern prosthetics. Significant pain can lead to a reduction in function, reduced use of the prosthesis and even to further surgery.

More indirect weight transfer can be accomplished by allowing a higher bony area to take some of the force with other forces being transferred across the sides of the soft tissues of the leg. Pain may still be an issue for many patients despite the great advances made in prosthetic technology. If the pain is severe enough it can lead to further surgery, reduced function and limited wearing of the artificial limb.

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about physiotherapy, physiotherapy, physiotherapist in northampton, back pain, orthopaedic conditions, neck pain and injury management. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.

Acute wry neck or torticollis is relatively uncommon and precipitated typically by the sudden onset of significant neck pain which leads to reflex neck muscle contractions and the maintenance of an abnormal neck position. This abnormal posture is known as torticollis and is a sign of an underlying problem of some kind, but this article discusses an acquired torticollis secondary to an acute neck pain of mechanical origin. It is typical for patients to report they woke with severe neck pain and torticollis, with the process often assumed to be secondary to sleeping in an inappropriate position during the night.

Typical initial presentation a high level of neck pain with muscle spasms and the inability to restore the head to the central posture. A few days or up to a fortnight is enough to resolve most of these pains and treatment is analgesia, collar if needed, physiotherapy such as neck massage, neck stretching and neck exercises. When examined a patient exhibiting torticollis will keep their head flexed to the painful side to some degree and also rotated away from the painful side. The usual symptoms are stiff neck, limited range of motion and neck and scapular pain, with onset often sudden such as when hair drying with a towel or turning the head fast.

The first thing a person is aware of is the sudden pain on one side of the neck, often severe and lower in the neck. There may be pain radiating also down over the scapula and out over the shoulder. If a considerable amount of arm pain is present then this should raise the suspicion of a lesion of one of the cervical nerve roots. Nerve root problems are usually somewhat slower in onset but if the symptoms presented on waking this could be the diagnosis. The outcome is very likely to be just as good as the muscle or joint strain which is more common, but recovery typically takes longer over a period of weeks.

Examination of the patient by a physiotherapist will show a patient who is in some distress from their pain and may find sleeping difficult. They may hold the head carefully to guard against sudden movements of the painful structures. The head posture will be typically abnormal and efforts to restore the posture to normal are rewarded with strong increases in pain levels. The physio will record the neck position and the ranges of movement the patient can perform, with the results in terms of pain. The history will also be taken, to include any previous episodes and what precipitated this event, whether known or not.

It is important to enquire after any arm, scapular, thoracic and shoulder pain. The physiotherapist may need to test the C6 and C7 nerve root reflexes of the biceps and triceps muscles respectively should the situation require this and they may also test the sensibility to light touch of the skin for the same purpose. Muscle strength testing may be omitted due to the likelihood of increasing pain and the probability of an inaccurate result. The physio will include asking the standard series of exclusion questions which allow him or her to conclude the problem is mechanical and not due to medical illness.

The aim of physiotherapy for this neck condition is similar to that for all soft tissue injuries. The first goal is to reduce the pain and inflammation in the damaged tissues and so reduce the resulting muscle spasm which is perpetuating the pain. Anti-inflammatory medications and analgesics may be prescribed as to some extent the pain is the presenting problem rather than some underlying abnormality. Physiotherapists may use ice, immobilisation in a collar and gentle manual traction to attempt to relax the cervical musculature and relieve pain.

Progression on to further therapy techniques is planned once the pain is under control such as neck massage, gentle muscle neck stretches for muscle tightness and mobilisation of the joints. The patient is asked to perform active movements within reasonable pain limits. On restoration of more normal neck ranges of motion and head position the next stage of physiotherapy is to increase the neck muscle strength and endurance so that the person can return to normal.

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapy, back pain, orthopaedic conditions, neck pain, injury management and physiotherapists in Cambridge. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.