Exercises for lower limb amputation. Therapeutic physical training for amputation of limbs Method of using gymnastics for amputations

Starting position - lying on your back

1. Flexion and extension at the ankle joint of the healthy leg (10-12 times).

2. Bend your legs with your arms until your thighs touch your stomach (3-5 times).

3. Transition to a sitting position and then bend forward until your hands touch your toes (3-4 times).

4. Imitation of riding a bicycle with your feet.

Starting position – sitting on the floor

5. Rotate and tilt the body towards the stump with support on the hands (3-6 times).

6. Raise the stump and straighten the lower leg with your hands (6-8 times).

7. Abduction of the stump in the hip joint (5-8 times).

8. Raising the body with support on the hand (4-6 times).

9. Raising your legs.

Starting position – lying on your stomach

10. Bending the legs at the knee joints (6-8 times).

11. Alternate extension of the legs at the hip joints (4-8 times).

12. Arms to the sides (forward) – extension of the torso (4-6 times). Starting position – standing (holding a chair or headboard).

13. Squats (4-6 times).

14. Lifting onto your toes and rolling onto your heel (6-8 times).

15. Pulling the stump back (6-8 times).

16. Fixing balance while standing on one leg with different positions of the arms.

The period of mastering the prosthesis. At the final stage of rehabilitation treatment after amputation, the patient’s limb is taught to use a prosthesis. Before teaching the patient to walk, it is necessary to check the correct fit of the prosthesis to the stump and the correct fit. The technique of walking and the method of teaching it is determined by the design of the prosthesis, the characteristics of the amputation and the condition of the patient. When conducting classes with patients after amputation of the lower extremities due to obliterating endarteritis, diabetes, atherosclerosis, as well as in old age, it is necessary to especially carefully and consistently increase the load, monitoring the reaction from the cardiovascular system. Learning to walk with prostheses consists of three stages. At the first stage, they are taught to stand with equal support on both limbs and transfer body weight in the frontal plane. In the second stage, body weight is transferred in the sagittal plane, and the support and transfer phases of the step are trained with the prosthetic and preserved limb. At the third stage, uniform stepping movements are developed. Subsequently, the patient masters walking on an inclined plane, turning, walking up stairs and over rough terrain. Classes for young and middle-aged patients include elements of volleyball, basketball, badminton, table tennis, etc.

When supplied upper limb prostheses Therapeutic gymnastics is aimed at developing skills in using prostheses. Training depends on the type of prosthesis. For fine work (for example, writing), a prosthesis with a passive grip is used; for rougher physical work, a prosthesis with an active finger grip is used due to traction of the muscles of the shoulder girdle. Recently, bioelectric prostheses with active finger grip, based on the use of currents arising during moments of muscle tension, have become more widely used.

After amputation of fingers, hand or forearm in the lower or middle third, they are used reconstructive operations. At finger amputations an operation is performed to phalangize the metacarpal bones, as a result of which partial compensation of the function of the fingers is possible. At amputation of the hand and forearm split the forearm according to Krukenberg to form two “fingers”: radial and ulnar. As a result of these operations, an active grasping organ is created, which, unlike a prosthesis, has tactile sensitivity, due to which the patient’s everyday and professional ability to work is significantly expanded.

Exercise therapy during reconstructive operations on the stumps of the upper limbs is used in the pre- and postoperative period and promotes the rapid formation and improvement of motor compensations. Postoperative preparation of the forearm stump consists of massaging the muscles of the stump, pulling back the skin (due to the lack of it during local plastic surgery at the time of finger formation), restoring pronation and supination of the forearm using passive and active movements. After surgery, the goal of therapeutic exercises is to develop capture due to the bringing together and spreading of the newly formed fingers of the stump of the forearm. This movement is absent under normal conditions. Subsequently, the patient is taught to write, first with a specially adapted pen (thicker, with indentations for the ulnar and radial fingers). After forearm clefting for cosmetic purposes, patients are provided with a prosthetic arm.

Massage for amputated limbs. To eliminate swelling, prevent contractures and atrophy of the stump in complex treatment, it is recommended to use massage as early as possible. If the wound is in general good condition and healing is favorable, massage is prescribed on the 7-10th day after surgery.

Massage technique. In the early postoperative period, segmental reflex effects are applied in the area of the corresponding paravertebral zones. To reduce the tone of muscles affected by reflex contractures, techniques of planar and enveloping stroking, rubbing with the ends of the fingers, shading, and sawing are used. The joints are massaged using stroking and rubbing techniques. After the wound has healed and surgical sutures have been removed, the stump is massaged to prepare its supporting function for prosthetics. Differentiation using deep kneading and vibration techniques strengthens the adductor muscles and hip extensors that remain after amputation in the hip area; in case of amputation in the lower leg area - the calf muscle; for amputation in the shoulder area - the deltoid muscle, etc. The stump is massaged using the techniques of planar circular and grasping stroking, rubbing, and forceps-like kneading. To develop the support ability of the stump in the area of the distal cone, vibration is used - effleurage, chopping, quilting.

For persistent myogenic contractures, strong short-term, repeatedly repeated manual or mechanical vibrations are used. The duration of the procedure is 10-20 minutes, daily or every other day (course – 20-25 procedures). With a strengthened postoperative scar, an underwater shower is indicated - massage and mechanical massage. With the constant use of a prosthesis, patients during sanatorium treatment are prescribed massage in combination with balneophysiotherapeutic procedures and bathing: segmental reflex effects are used, massage of all remaining segments of the limb and stump using stroking, rubbing, kneading, and vibration techniques.

Physiotherapy for limb amputation. Phantom pain is a postoperative complication manifested by a sensation of pain in the amputated limb, which can be combined with pain in the stump itself. UV irradiation of the stump area is used in 5-8 biodoses (total 8-10 irradiations); diadynamic currents in the stump area (10-12 procedures); darsonvalization; electrophoresis of novocaine and iodine, applications of paraffin, ozokerite, mud on the stump area; general baths: pearl, radon, pine, hydrogen sulfide.

After amputation, as with other types of surgical interventions, infiltration may form in the area of the postoperative suture. When treating infiltration in the acute stage, cold is used to limit its development and ultraviolet radiation. UHF is used for 10-12 minutes daily, SMV, ultrasound, inductotherapy, ozokerite and paraffin applications to the infiltrated area, and ultraviolet radiation. 2-3 days after the acute inflammatory phenomena subside, they switch to thermal procedures.

3.6. Exercise therapy for amputation of limbs
Amputation – surgery to remove the peripheral part of a limb
or organ.
Exercise therapy is of great importance for the social adaptation of this category of patients, which makes it possible to well prepare the patient for prosthetics, and in the future avoid complications associated with the use of a prosthesis.
After amputation of limbs, the exercise therapy technique distinguishes three main periods:
1)
early postoperative (from the day of surgery until the removal of sutures);
2)
the period of preparation for prosthetics (from the moment the sutures are removed until the permanent prosthesis is received);
3)
period of mastering the prosthesis.
Early postoperative period.
Objectives of exercise therapy:
1) prevention of postoperative complications (congestive pneumonia, intestinal atony, thrombosis, embolism) improvement of blood circulation in the stump) prevention of atrophy of the muscles of the stump) stimulation of regeneration processes.
LH classes should be started on the first day after surgery. They include breathing exercises and exercises for healthy limbs. Co 2 – On the next day, isometric tension is performed for the remaining segments of the amputated limb and truncated muscles; facilitated movement
60

movements in the joints of the stump free from immobilization, movements of the body, lifting of the pelvis, turns. C 5 – day of use phantom gym
nastika(mentally performing movements in the missing joint, which is very important for the prevention of contracture and atrophy of the muscles of the stump.
After amputation of the upper limb, the patient can sit, stand, and walk.
After amputation of the lower limb, the patient mainly remains in bed. However, with a satisfactory general condition with 3 –
On the 4th day the patient can take a vertical position – to train balance and support ability of a healthy limb. He is taught to walk on crutches.
After the stitches are removed, the 1st period begins – period of preparation for prosthetics. In this case, the main attention is paid to the formation of the stump; it must be of a regular (cylindrical) shape, painless, supportable, strong, and resistant to load. First, mobility is restored in the remaining joints of the amputated limb. As pain decreases and mobility in these joints increases, exercises for the muscles of the stump are included in the classes. So, during amputation of the lower leg, the extensors of the knee joint are strengthened during amputation of the thigh – extensors and abductors of the hip joint. The muscles that determine the correct shape of the stump, necessary for a tight fit of the prosthetic socket, are uniformly strengthened. LH includes active movements in the distal joint, performed by the patient first with the support of the stump, and then independently and with the resistance of the instructor’s hands. Training the stump for support consists of pressing its end first on a soft pillow, and then on pillows of varying density (stuffed with cotton wool, hair, felt) and walking with the stump resting on a special soft bench. They start this type of training with 2 minis and increase its duration to 10 minutes or more.
To develop muscle-joint sense and coordination of movements, exercises should be used to accurately reproduce a given range of movements without vision control. After amputation of the upper limb (and especially both), much attention is paid to developing self-care skills for the stumps – using such simple devices as a rubber cuff placed on the stump, under which a pencil, spoon, fork, etc. is inserted.
Amputation of limbs leads to postural disorders, so corrective exercises should be included in the PH complex.
For amputation of the upper limb – due to upward displacement of the shoulder girdle on the amputation side – forward, as well as the development of the winged shoulder blades, against the background of general developmental exercises for the shoulder girdle, movements are used aimed at lowering the shoulder girdle and bringing the shoulder blades together.
When amputating a lower limb, the statics of the body is significantly disturbed; the center of gravity shifts towards the remaining limb, which
61

causes changes in the tension of the neuromuscular system necessary to maintain balance. The consequence of this is a tilt of the pelvis to the unsupported side, which, in turn, leads to curvature of the spine in the lumbar region in the frontal plane. Scoliotic curvatures can develop compensatoryly in the opposite direction in the thoracic and cervical spine.
When walking on crutches and with a cane, patients quickly develop fatigue in the muscles of the shoulder girdle, since the support is mainly carried out on the remaining leg, and its flat feet develop.
In this regard, PH classes include exercises for the muscles of the shoulder girdle. To prevent flat feet, exercises aimed at strengthening the musculo-ligamentous apparatus of the foot are used.
In 3 – 4 weeks after the operation, training in standing and walking on a therapeutic-training prosthesis begins, which facilitates the transition to walking on permanent prostheses.
The period of mastering the prosthesis. At the final stage of rehabilitation treatment after amputation, the patient’s limb is taught to use a prosthesis. Before learning to walk, you need to check the correct fit of the prosthesis to the stump.
Walking technique and teaching methods are determined by the design of the prosthesis, the characteristics of the amputation and the patient’s condition.
Learning to walk with prostheses consists of three stages. At the first stage, the patient learns to stand with equal support on both limbs and transfer body weight in the frontal plane. At the second stage, body weight is transferred in the sagittal plane, and the support and transfer phases of the step are trained with the prosthetic and preserved limb.
At the third stage, uniform stepping movements are developed. Subsequently, the patient masters walking on an inclined plane, turning, walking up stairs and over rough terrain.
Activities with young and middle-aged patients include elements of sports games (volleyball, basketball, badminton, table tennis, etc.).
In case of amputation of the upper limb, physical therapy is aimed at developing skills in using prostheses. The teaching method depends on the type of prosthesis.
For fine work (for example, writing), a prosthesis with a passive finger grip is used for rougher physical work. – prosthesis with an active finger grip (due to the traction of the mouse of the shoulder girdle. Recently, bioelectric prostheses with an active finger grip, based on the use of biocurrents arising during moments of muscle tension, have become more widely used.

A burning sensation in the legs below the knee periodically worries a certain part of the population. Discomfort in the lower extremities can accompany a huge list of pathological conditions, so it is important to promptly determine the cause and undergo therapy.

This information

The causes of pain and burning sensation in the lower extremities, both below and above the knee, can be various endo- and exofactors - from wearing uncomfortable shoes, a sedentary lifestyle and to serious disturbances in the functioning of visceral organs and systems. Often symptomatic and develops as a result of physiological transformations

Circulatory disorders

Discomfort may be associated with a disorder of circulatory processes in the lower extremities. Provoking factors for the development of the pathological process can be thrombophlebitis, varicose veins, and impaired venous outflow in the area of the knee joint.

The discomfort is also complemented by:

A burning sensation of the venous vessels on the legs and their bulging above the surface of the skin;
numbness, decreased sensory indicators;
hyperemia of the dermal surface;
development of compactions and tumor formations in the area of damaged areas of the lower extremities.

Pathologies of endocrine organs

A burning sensation in the muscle groups of the lower extremities, itching may be a consequence of the progression of pathologies of the endocrine system, which are accompanied by general weakness, increased fatigue, and damage to articular joints. With endocrine disorders, the lower limbs predominantly “bake” and “twist” at night or after physical activity.

Cardioneural diseases

A feeling of tingling and burning in the legs often occurs due to a disorder in the functioning of the nervous system and vascular network. The latter lead to the development of dystrophy due to insufficient blood circulation.

The following manifestations are typical for neurovascular diseases:

feeling of "goosebumps";
dermal itching;
instability of blood pressure indicators;
emotional instability and depression;
sleep disorder;
decreased myotonia.

Due to the progression of the disease, the patient becomes lethargic and apathetic.

Diseases of the musculoskeletal system

These pathological processes can cause a burning sensation in the right or left femoral region, the area of the knee and ankle joint, and fingers. Discomfortable symptoms are caused by pathologies accompanied by degenerative transformations of osteochondral tissue and muscle-ligamentous fibers.

Destroyed articular components irritate the neuronal endings, and this provokes the development of a burning sensation. With pathological processes in the motor system, discomfort is mainly localized in the right or left limb, generalizing from the femur to the foot.

Mechanical action

One of the causative factors may be mechanical effects or traumatic injuries. A similar clinical picture is characteristic of bruises, sprains, and fractures, which appear during the first 24 hours immediately after injury.

Discomfort is accompanied by:

pronounced swelling;
hematomas, hemorrhages;
intense painful syndrome of the injured leg;
deformation

Metabolic diseases - diabetes mellitus

Diabetic diseases can be a causative factor in the development of an uncomfortable burning sensation in the extremities. It will also help to diagnose such diseases:

frequent urination;
frequent feeling of thirst;
erectile dysfunction in men;
swelling of the arms and legs;
ulcerative damage to the skin.

Having identified at least some of the listed manifestations, you should immediately contact a specialist to clarify the diagnosis and subsequently carry out adequate therapy.

Pregnancy

Pregnant women often complain of pain and swelling of the entire lower limb - both above and below the knee. According to experts, discomfort develops due to hormonal changes and a lack of potassium in the body. A burning sensation in muscle groups occurs due to convulsive syndrome, a circulatory disorder of the lower extremities.

Diagnosis and treatment tactics

Diagnosis of such discomfort is always characterized by complexity:

electromyographic examination;
laboratory analysis of urine and blood;
assessment of neuroconductivity;
Ultrasound examination;
CT and MRI.

Based on the results of instrumental studies, the doctor will make an appropriate diagnosis.

Therapeutic tactics completely depend on the underlying pathology that provoked the discomfort. The treatment complex consists of drug therapy, physiotherapeutic procedures, and exercise therapy. And in especially severe cases, sometimes they resort to surgical intervention aimed at eliminating the causative factor.

Medications. Depending on the type of causative pathology, the following drugs may be used:
- venotonics (preparations based on horse chestnut) and angioprotectors;
- NSAIDs (Ibuprofen, Movalis, etc.);
- antioxidant drugs (Mexidol);
- complexes of vitamins and minerals.
Additional means are preparations for external use (ointments, gels), which also contain the above components.

In the case of a specific causative factor (diabetes mellitus, etc.), medications are used aimed at treating precisely these diseases.
Physiotherapy. For vascular diseases, neural disorders, pathologies of the musculoskeletal system, the patient is advised to undergo physiotherapeutic procedures (electrophoresis, magneto-, cryo-, laser therapy, phonophoresis, applications with therapeutic mud).

Massage and exercise therapy

Important elements of the therapeutic complex are massage and exercise therapy. Such procedures normalize the blood circulation in the legs and increase myotonus.

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Previously, complaints of pain in the legs could only be heard from older people. But now the diseases are getting younger. Even a child can complain that their legs hurt from the knee to the foot. The causes of these unpleasant sensations are different and depend on age and concomitant pathologies.

Causes of pain

Pain in the lower leg area can occur due to fatigue or illness. To correctly recognize the cause, you need to navigate the variety of symptoms. Pain often occurs due to the following reasons:

Muscle damage. This condition manifests itself after severe physical overload, which causes muscle damage. The patient is bothered by severe nagging pain in the lower leg and spasms. If the muscle fibers are stretched, the calves swell, and every movement is painful. It is impossible to step on your foot.
Damage to tendons and ligaments. Lesions may vary. Under excessive loads, stretching and even rupture may occur. Tendon inflammation is common. The most severe injury is considered to be torn ligaments. After maximum stress, a sharp pain appears in the leg from the knee to the foot. Mobility is limited and a tumor grows. Hematoma and redness may develop.
Damage to joints and bones. The diseases are different - rickets, cracks, fractures, osteomyelitis, osteoarthritis, tumors, dislocations, etc. The patient is concerned about pain, redness, and increased temperature at the site of the lesion. Injuries may cause swelling and blue discoloration of the tissue.
Diseases of blood vessels and nerves. With sudden movements or physical activity, nerve endings can be pinched. With thrombosis, narrowing of arteries and veins, pain occurs. There is a feeling of numbness, itching in the lower leg area, and a paroxysmal burning sensation on the skin. Acute pain can develop even at rest. There is aching pain on the outer and inner surfaces of the leg from the knee to the foot. The patient's general condition worsens, and complaints of weakness arise.
Pain for other reasons. Uncomfortable sensations can occur during pregnancy, be a symptom of radiculitis or metabolic disorders (obesity, diabetes). Your calves may become sore for natural reasons after playing sports. Children also complain of pain in their legs during periods of intensive growth.

Only a doctor can determine the exact cause of pain.

Diseases with characteristic symptoms

The lower limbs bear increased load, so there are many diseases that cause discomfort. This:

injuries - fractures, cracks of the fibula and tibia, sprains of muscles and ligaments, dislocations of the knee and ankle joints;
atherosclerosis of the arteries below the knees;
arthritis, arthrosis, osteoporosis;
flat feet and other foot deformities;
thrombosis of arteries and veins, varicose veins, lymphostasis;
polyneuropathy;
osteomyelitis, myositis;
micronutrient deficiency;
tumors of soft tissues and bones of the leg.

Only diagnostics, determination of the nature and intensity of pain, its location (internal or external, front or back, deep or external) will help to accurately identify pathology.

Who to contact and how to treat?

If you experience pain in your leg for the first time, you should first consult a traumatologist. If no injuries are identified, you should go to a therapist or general practitioner, who will prescribe tests and additional examinations. Based on their results, the patient is referred for treatment to a specialist.

If the legs hurt due to vascular pathology, the patient will undergo therapy from a vascular surgeon. For nerve diseases, see a neurologist. Joint diseases should be treated by a rheumatologist or orthopedist. If there is a suspicion of a malignant process, you need to contact an oncologist. Treatment will depend on the diagnosis and can be medication, surgery, exercise therapy and physical therapy.

Conservative drug therapy will depend on the disease that caused discomfort in the legs, and may include:

NSAIDs;
antibiotics;
chondroprotectors;
anticoagulants and venotonics;
vitamins and calcium preparations;
medications that improve tissue trophism;
chemical drugs to fight cancer.

The type of surgery also depends on the diagnosis. If joints are damaged, they are replaced; if there is thrombosis, thrombectomy is performed. For varicose veins, phlebectomy is performed. If the pain is caused by a displaced fracture of the bones, the fragments are repositioned. The oncological process requires complete removal of the affected area, sometimes even amputation of a limb.

Physiotherapy

Physiotherapeutic treatment methods may include:

phonophoresis;
mud therapy;
paraffin therapy;
electrophoresis;
magnetic therapy.

Other treatments

Therapeutic exercise is carried out under the guidance of an instructor. If your leg ache after physical activity, it is useful to conduct massage courses 2 times a year.

If pain in the leg is caused by an injury (dislocation, bruise, sprain), you need to immobilize the injured limb and provide motor rest for several days. A cold compress is applied to the injury site. To relieve pain, the leg is tightly bandaged. When the recovery process begins, you can do warm baths and compresses. It is useful to carry out light massage and gentle movements to develop the limb.

With the initial manifestations of atherosclerosis, discomfort in the legs is practically not disturbing, but as the pathology progresses, the pain increases and is disturbing even at rest. In the treatment of atherosclerosis, it is important to follow a low-cholesterol diet. In the hospital, droppers with Actovegin and Ilomedin are prescribed. To lower cholesterol levels, the drugs Kwantalan, Questran, Kolestide can be prescribed.

Varicose veins of the lower extremities require constant use of compression stockings. To increase the tone of the veins, drugs such as Venarus, Rutin, Aescusan, etc. are used. There is a treatment method called sclerotherapy - the introduction of a special adhesive drug into the affected veins. But the main method is surgery. It is now possible to remove veins using a laser.

For pain caused by polyneuropathy, drug therapy is prescribed. Requires painkillers, magnesium preparations, glucocorticoids, vitamin complexes, and immunosuppressants.

How to relieve pain

To provide first aid for leg pain, you need to roughly determine the cause.

If this is an injury, then the injured limb needs to be immobilized and a cold compress applied to it. You can take available painkillers (Ketorol, Ibuprofen, Nise, etc.).

If your legs ache from overwork, you need to lie down and put them on a raised platform.

If the pain is caused by physical activity, you need to take a warm shower and then massage your legs (if injury can be ruled out).

If you have cramps in your calves during pregnancy, you need to sit down and forcefully stretch the cramped muscle.

If intense pain in the legs suddenly arises, you should not self-medicate; it is better to consult a doctor as soon as possible.

Prevention

To prevent the occurrence of pathologies that cause pain in the legs, you need to lead a healthy lifestyle, monitor your weight, and eat right. You need to take vitamin and mineral complexes 2 times a year. Avoid physical inactivity, do exercises every day, but avoid heavy loads. Rest every evening with your feet raised above your head. If close relatives have varicose veins, it is recommended to wear compression stockings.

Igor Petrovich Vlasov

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Disarticulation and amputation of limbs: indications, technique, complications

One of the most unpleasant and difficult operations in surgical practice is amputation of limbs. Very often this term is confused with disarticulation, although in fact these concepts are far from equivalent.

Let's figure out what the difference is between them, when medical indications require such radical measures and how long the rehabilitation period lasts.

Amputation and disarticulation: concept and difference

Amputation refers to the truncation of a limb (leg or arm) along the bone. Disarticulation is the separation of a limb from a joint. Thus, disarticulation is in its own way one of the types of amputation.

Each time there is a need for such an intervention, the question of the location of the incision and the method of performing the operation is decided by the doctor on an individual basis, based on the nature of the injury or disease, as well as the patient’s condition.

Most often, the final decision about amputation is made only after consultation with an orthopedist.

Indications for radical measures

Medical practice distinguishes between absolute and relative indications for removing part or all of a limb. All of them must be justified in the patient’s medical documents.

Absolute readings:

malignant tumors;
gangrene of any origin (diabetes, thrombosis, electrical trauma, as a result of a burn, etc.);
separation of the limb (while maintaining the connection with tendons or bridges made of skin);
severe infection that threatens the patient's life, for example, sepsis;
open injuries with bone fragmentation;
injuries with rupture of great vessels and nerve trunks;
injuries with crushing muscles.

Relative readings:

severe defects of bone tissue, excluding the possibility of prosthetics;
chronic osteomyelitis with amyloidosis;
long-existing trophic ulcers that cannot be treated;
congenital limb problems that exclude the possibility of prosthetics;
irreparable paralytic or post-traumatic changes in the limbs.

When planning an operation, the doctor must also take into account the possibility of subsequent prosthetics for the damaged limb.

Types of surgery

There are several main types of amputation:

Primary. It is also called amputation for primary indications. Produced as a primary treatment for injury. In this case, the surgeon quickly and accurately removes the non-viable limb. The operation is performed as soon as possible after the injury, when clinical signs of infection have not yet developed. The specific level of cutting is selected individually, based on the general condition of the wounded person, as well as the location of the wound.
Secondary amputation is performed in cases where conservative treatment methods have already shown their ineffectiveness. The operation is performed in case of complications that threaten the patient’s life at any stage of treatment.
Late amputation is performed as a result of long-term treatment of osteomyelitis, when it already begins to threaten the degeneration of organs. It is performed due to long-term non-healing injuries and fistulas, as well as on a non-functioning limb in the presence of multiple ankylosis. In simple words, late amputation is performed during long-term treatment that does not give a positive result.
Reamputation. A repeated operation, which is performed in cases where the previous truncation did not have the desired result. Most often it is performed in case of defective stumps that do not allow prosthetics, in case of tissue necrosis after surgery due to gangrene and in other similar cases.

Preparing for surgery

First of all, even before starting all procedures, doctors must determine the severity of the injury and assess the possibility of saving the limb. In some cases, it is possible to restore blood flow if measures to restore blood vessels were previously carried out in a timely and competent manner.

Also, as part of the preparation for the operation, doctors carry out measures to combat shock until the victim’s condition stabilizes. In case of diabetes mellitus, the disease is corrected.

In case of local infection, the operation is postponed if possible, and in case of wet gangrene, they try to reduce the degree of spread by covering the leg with ice.

The patient is also given anesthesia. Most often, spinal anesthesia is used in its role, but in some cases infiltration, inhalation or conduction anesthesia can be used.

Technique and stages of the truncation procedure

During the operation, the patient is positioned on the edge of the table, with the affected limb abducted as much as possible: the arm is extended, the leg is raised to enhance the outflow of blood. Next, a tourniquet is applied depending on the location of the lesion. The exception is atherosclerosis, since in this case the blood flow in the stump may worsen.

In the case of minor amputations, the skin on the damaged limb is treated with an antiseptic, and elastic bandages are pinned to the base of the fingers. In case of amputation of a leg above the knee or an arm above the elbow, the limb is wrapped in sterile film.

The main rule when truncation is the rule of preserving the greatest length. In the case of the lower extremities, there may be exceptions, but the doctor will always try to preserve the knee.

At the same time, due to the peculiarities of blood circulation, supracondylar amputation is often performed. It is performed as quickly as possible and ensures subsequent healing in a short time. The most difficult are transcondylar and knee disarticulation, which complicates further fastening of the prosthesis.

The procedure itself takes place in several stages:

formation of skin flaps;
dissection of muscle fibers;
dissection of the periosteum and subsequent shifting to the sides;
sawing bone and processing the saw cut;
ligation of blood vessels;
suppression of nerves;
suturing and treating the wound.

In the case of amputation of the leg below the knee, the rule of greatest length is not used due to subsequent difficulties in adapting to the prosthesis.

The anterior edge of the tibia is beveled, this allows you to create a long flap that can cover the bone and provide the affected area with sufficient blood circulation.

The optimal bone length for trimming is 12 to 18 cm. When disarticulating the knee, surgeons try to preserve a small stump that will help attach the prosthesis. The tibia is amputated above the tibia, since it will not be able to withstand the pressure of the prosthesis.

Other features of the procedure:

When amputating a hand, doctors try to leave a postoperative scar. This will allow the prosthesis to be attached to the lateral surface.
To cover the stump during minor operations, plantar or palmar flaps are cut out.
Toe trimming uses racket-shaped incisions to expose the metatarsal bones. In cases of finger amputation, similar incisions are used to preserve length. This version of the cut greatly shortens the arm or leg, but gives the limb the most aesthetic appearance.
Arteries and veins are ligated separately.
During truncation, nerves are tried to be crossed as high as possible.

Rehabilitation period

Upon completion of the operation, a cotton-gauze bandage is applied to the stump. At first, until the swelling subsides, it needs to be changed once a day. First, the stump is raised on pillows and lowered after 1-2 days. After another 2-3 days, rehabilitation exercises begin.

In case of guillotine amputation, special care is used. In particular, peripheral traction is applied to the damaged area, after which the edges are tightened with skin grafting.

It is very important to begin rehabilitation care as quickly as possible - this will reduce the period of post-amputation depression.

The temporary prosthesis is installed immediately after the sutures are removed. This will reduce pain after truncation and also speed up healing. In addition, this approach helps reduce the number of psychological problems and helps the patient return home and to work as soon as possible. If timely fitting of the prosthesis was not carried out, the doctor prescribes a special course of exercises.

Possible complications

Among the most common complications are pain, swelling of the stump and suppuration. These early symptoms are related to the wound healing process and the postoperative period.

It is worth remembering that this period takes place in a hospital, so the prevention of complications lies in strictly following the doctor’s instructions. It is enough for patients to carefully follow the instructions, as well as consult before performing independent actions.

Later complications, including phantom pain, persistent swelling of the stump and the like, are most often treated with medication or physical therapy. Cases of repeated amputation are quite rare.

Today, as many years ago, amputation is a serious operation. However, modern medicine makes it possible to reduce the negative consequences for the body, and the surgical intervention itself is performed quickly and most often painlessly. If the doctors' instructions are properly followed, the postoperative period and restoration of work capacity also occurs in the shortest possible time.

When amputating a part of the lower limb, therapeutic exercises in the first period are done from the starting positions lying on the back, stomach and side on the side of the healthy limb. If, for example, the leg is amputated to the knee joint, then the following special exercises are performed to prevent contracture: movements of the patella; flexion and extension in the knee and hip joints; raising and lowering the stump, abducting the stump straightened at the knee joint; circular movements clockwise and counterclockwise in the hip joint, as well as swinging movements back.

During amputation, flexion contracture in the hip joint develops very quickly, which in the future will interfere with walking in the prosthesis. The fact is that when using a prosthesis, when stepping with the healthy leg and moving the body forward, an angle of 20-30 degrees is formed in the hip joint, and with contracture, these movements are eliminated and a fall occurs when walking.
When amputating the femur in the first period, perform all the above exercises from the same starting positions.

The objectives of physical therapy in the second period for any amputation of a limb are: to promote the formation of a mobile, soft, elastic scar that is not fused to the underlying tissues; prevent atrophy of the muscles of the stump; prepare the stump for prosthetics; train a sense of balance and coordination of movements, especially with amputation of the lower limb; develop compensatory motor skills as much as possible (learn to do everything with one hand or stand, step over and walk on one leg, leaning on crutches). The exercises are performed from the starting positions lying on the back, stomach, side opposite to the amputation; sitting; standing (leaning on crutches, the back of a chair and without support); on a gymnastic wall, gymnastic bench and exercise equipment, in water (bath, pool).. It is very important to strengthen and train the muscles of a healthy leg and back (natural muscle corset), as well as restore the full range of motion in all joints of the stump. The support of the stump is restored by walking first on a soft surface (Fig. a), then on a hard one (Fig. b).

A set of special exercises for amputation of the lower limb in the second period

1. I. p. - standing on a healthy leg. Raise your hands up. Repeat 6-8 times.
2. I. p. - the same. Spread your arms to the sides. Repeat 6-8 times.
3. I. p. - the same. Pull your stump back, stretch both arms back and arch your back. Repeat 4-6 times.
4. I. p. - the same, hands on head. Tilt your torso to the right, then to the left. Repeat 4-6 times.
5. I. p. - standing on a healthy leg, arms down. Bend your torso forward, spreading your arms to the sides. Repeat 4-6 times.
6. I. p. - standing, holding a stick. Raise your arms above your head and lower them; Move the stick, holding the ends, to the right, then to the left. Repeat 4-6 times.
7. I. p. - the same. Sit down, holding the stick in outstretched arms. Repeat 4-6 times.
8. I. p. - standing, holding a volleyball or rubber ball. Throw the ball up and catch it, hit it on the floor and catch it. Repeat 6-8 times.

One learns to walk on crutches using the same method as for a hip fracture. Remember the main rule: when walking on crutches, the principle of the triangle must be strictly observed - the crutches are in front, and the supporting leg is behind at a distance of the length of the foot. If the supporting leg goes forward beyond the crutches, the person will fall on his back; if the foot is on the line of the crutches, it will fall forward. Turn towards the stump, stepping with the supporting leg. When descending the stairs, both crutches are placed on the step below and the supporting leg is placed; When climbing stairs, the supporting leg is placed on a step higher and crutches are attached to it. In the second and third periods of recovery, it is imperative to massage the back, healthy leg and stump, and if the arms become very tired, massage them too. At the same time, therapeutic exercises in water (bath or pool) are prescribed. Each exercise is performed 4-8 times in a row, breathing - 3 times, and the whole complex - 3-4 times a day, including exercises in water. Dosed walking 2-3 times a day is required.

Therapeutic physical education in the third period with amputation of the lower limb helps to master different options for walking with a prosthesis: leaning on crutches, on sticks, on one stick and without support; back, sideways in both directions; climbing stairs (the healthy leg is placed on a step higher and the prosthetic leg and crutches are pulled up to it); going down the stairs (crutches and a prosthetic leg are lowered down one step and the healthy leg is placed next to them). The turn is performed as follows: both crutches and the prosthetic leg are turned in its direction, and the healthy leg is moved in place towards the prosthesis (if you turn in the direction of the healthy leg, the person will fall). They also strengthen the muscles of the back and the whole body, improve balance and coordination of movements in the prosthesis, perform the following exercises (without removing the prosthesis): swinging and circular movements in the hip joint with the injured leg; squats; exercises on the gymnastic wall - push-ups, squats, dance steps; stepping over obstacles.

When amputating a lower limb, you need to select crutches and sticks according to your height and learn how to use them. If the crutches are short, gait and posture are disturbed (walking with a hunched back, a sharp tilt of the body forward leads to stooping), it is difficult to move the leg in the prosthesis (the hands get tired, calluses appear, pain in the arms, back and lower back), correct coordination and balance are lost during while walking, lameness often occurs. If the crutches are high, then complications develop: abrasions in the armpits, inflammation of the axillary lymph nodes, weakness in the arms and even paresis and paralysis of the arms.
The length of the crutches is determined in a standing position in the prosthesis - the distance from the armpit to the floor is measured. The crossbar - the handle by which the crutches are held - should be at the level of the greater trochanter of the thighs, and the arms are bent at the elbows at an angle of 150-160 degrees, then when supported on the hands, the armpits will be freed from heavy load. A soft foam pad or sponge is attached to the crutch recess (adjacent to the armpits) along its entire length so that the pressure on the armpits is minimal.

The optimal length of the stick is determined by bending the arm at the elbow at an angle of 135 degrees - measuring the distance from the hand to the floor. The ends of the crutches and the end of the stick should have elastic bands, which are replaced as they wear out.
In the third period, when amputating the lower limb, the patient is taught how to put on the prosthesis correctly. If the amputation is performed on the lower leg, then the prosthesis is put on while sitting; on the hip - standing and sitting, and in case of amputation on both hips - lying and sitting.

When amputating a leg at any level, a thin woolen cover or stocking without seams or folds is put on the stump, as it should fit tightly. If redness appears on the stump, you must immediately consult a prosthetist, otherwise abrasion of the stump or skin ulceration may form.
It is important to maintain balance while walking on a prosthesis. After putting on the prosthesis, you need to stand upright for several minutes, distributing your body weight on both legs and the load with your arms on the crutches. The first steps are taken of the same length (but not more than the length of the foot) in a straight line, starting with the prosthetic leg. Then, at a slow pace, the weight of the body is transferred to the healthy leg standing in front and the prosthetic leg is brought forward due to the pendulum-like movement of the prosthesis in combination with the active movement of the stump. Make sure that the prosthetic leg does not drift to the side.

Learn to get up, stand and walk first in front of a mirror. Then they master fast walking with turns, sudden stops, get used to carrying small loads in their hands or a backpack, learn to lie down, stand up, pick up objects from the floor, fall and get up.

Physical therapy exercises for amputations on the upper limb in the first (postoperative) period begin literally a few hours after the operation, performing breathing, general developmental and special exercises (breathing - after each general developmental or special exercise 3 times in a row, and other exercises 4-6 times) .

They also learn compensatory everyday movements: turning on their side, moving to a sitting position, standing up without leaning on their hands, eating independently, washing their face, combing their hair, brushing their teeth. If the elbow joint is preserved, then the arm should lie for 1-2 hours in the following positions: bent at the elbow joint, straightened, moved to the side at the shoulder joint, pressed to the body.

From the 3-4th day, classes include exercises for tension and relaxation of the preserved segments of the amputated limb, isolated and in combination with movements in the preserved joints (shoulder or elbow). Great importance is attached to movements in the shoulder joint (abduction to the side, flexion, straightening, circular movements), as well as movements in the elbow joint (extension, turning the stump up and down, circular movements in both directions). These exercises
help reduce postoperative swelling of the stump, prevent the development of contractures and muscle atrophy.

All exercises are performed at a slow pace. From the 5th to 6th day, the number of repetitions of general developmental and special exercises is increased to 10 times.
In the second period, after the stitches are removed, exercises with resistance are recommended (with a healthy arm or leaning on a table, crossbar, gymnastic wall, etc.); with weights (for example, with a load on a block), on coordination of movements (with a rubber ball) and active relaxation of the muscles of the amputated limb and torso. Movements to maintain correct posture, strengthen the muscles of the upper shoulder girdle (raising and lowering the shoulder girdle, spreading and joining the shoulder blades, circular movements of the shoulder girdle in both directions), massage and self-massage of the stump and scar are required.

If there is a stump of the forearm, especially a split one (when the two bones of the forearm are separated), then they learn to grasp objects. It is also advisable to use devices in the form of various cuffs and fasteners to develop compensatory skills necessary in everyday life.
In the third period, they learn to use cosmetic and working prostheses. The task of physical therapy in this period is to teach the patient to put on and take off prostheses independently (except for cases of complete articulation of a limb in the shoulder joint, when outside help is needed). If one arm is amputated, the prosthesis is put on using the healthy arm; When amputating both arms, the prosthesis is first put on the longer stump, then on the shorter one, and some prostheses are put on both arms at the same time. The dentures are removed in any convenient way.

Depending on the design of the prosthesis, different possible movements are sequentially mastered: opening the hand and closing the fingers into a fist, flexion and extension at the elbow and shoulder joints, abduction to the side, moving objects (working devices have special devices for grasping and holding objects of different sizes - glasses , spoons, matches, etc.), movements of a gaming nature (throwing the ball from hand to hand, table tennis, playing the drum, etc.).

You can master movements in two prostheses separately or together. It is advisable to first learn to take and hold large and medium-sized objects while standing, then sitting (the objects are gradually moved from the edge of the table to the middle), then they learn to eat independently, take a spoon, fork, and later to write, draw, paint, draw. In addition to prosthetics, there are working devices that are simple in design, forming motor skills for self-service in everyday life (closing and opening doors, latches, locks, etc.), as well as providing complex movements (writing, typing, drawing, playing chess) .

It has been established that the use of prostheses (both upper and lower limbs) and learning motor skills in them take place in three stages. On the first, the movements are not entirely coordinated and constrained; on the second, as a result of repeated systematic training, movements are mastered, coordination develops to the maximum, and stiffness disappears; at the third stage, automaticity of movements is achieved. Therefore, when learning to use prostheses, special attention is required at the first stage.

In recent years, doctors have been performing constructive surgeries that provide non-prosthetic restoration of compensatory motor skills.

Physical therapy exercises after amputation of a limb in the first period are carried out only individually; in the second and third periods, therapeutic exercises in water (in a bath or pool) are recommended.

Those who have learned to use a prosthesis must perform special exercises 2 times a day, regularly undergoing medical monitoring in physical therapy rooms. Once or twice a week they can practice table tennis, swimming, skiing, cycling and even take part in sports competitions.

The loss of two lower limbs was previously considered a severe disability, completely excluding the victim from work and social life due to the inability to move independently. The practice of recent years has shown that a person deprived of two legs can master walking on prosthetics, can successfully work and participate in public life.

The most effective method to help the victim adapt to new living conditions is physical therapy and occupational therapy. Physical therapy is a necessary link connecting the work of a surgeon and an orthopedist and facilitating the tasks of each of them. In addition, physical therapy is a highly effective psychotherapeutic factor that has a powerful beneficial effect on the entire nervous system, on the patient’s behavior, and stimulates his vital activity, activity and desire for creative work.

In order to help the victim master walking on prostheses, it is necessary to present a number of requirements to the amputation stump.

The stump should be painless, well covered with soft tissue, well supplied with feeding vessels, not swollen, and should not have scars on the supporting part. Nearby joints must be fully mobile, the muscles of the stump must have sufficient strength.

In the process of healing a patient, three periods can be clearly seen, but these periods do not completely coincide with the pattern of periods for surgical patients.

In amputees, strength is restored faster than the stump heals. The patient remains in a lying position for a short time, but his transition to a standing position is delayed due to the unpreparedness of the stump for prosthetics. The periods for these patients were determined based on the clinical condition and the ability to perform physical exercises of a certain difficulty.

This section describes the method of physical therapy for amputations of both lower extremities. The method of physical therapy for amputation of one lower limb is based on the same principles and pursues the same goals as the method of physical therapy for amputation of both lower limbs, only the treatment periods are significantly shortened, since the presence of one leg allows the patient to get on crutches much earlier and, Naturally, mastering one prosthesis is much faster and more successful.

In the first period (5-6 weeks), the patient who has undergone amputation is always in serious condition. Significant blood loss (if amputation was performed due to injury), a large wound surface, the severity of the surgical intervention itself, and especially the consciousness of irreparable loss, the thought of inferiority, unfitness for usual work, sharply worsen the general condition of the patient.

The patient usually lies motionless on his back, the stumps have a wound surface, and movements in the remaining joints of the limb are often limited. The patient is very weak, passive, apathetic.

The objectives of therapeutic physical culture in this period are: to establish contact with the victim; improve the patient’s mental state, make him believe in the possibility of independent movement, in the opportunity to be a full-fledged member of society; restore the overall strength of the body; prevent the formation of contractures; help develop the necessary self-care skills.

At the beginning of the period, when the patient cannot yet sit, classes are carried out lying down. Various movements of the arms, movements of the head, lateral turns and bends of the torso, bending of the torso with support on the back of the head and buttocks, possible movements of the stumps, bending them, rotating them and especially extending them to prevent flexion contracture are given.

If the general condition of the patient and the condition of the wound surface of the stump allows, you need to carry out the exercises while lying on your side and stomach. These starting positions make it possible to more actively influence the back muscles and help prevent the formation of contractures of the stump joints. All exercises are performed at a slow pace in rhythm with deep breathing.

When the patient is able to sit, the exercises become more difficult. From a sitting position, the torso is tilted in all directions, movements of the stumps are introduced with resistance, if the amputation wound allows, and in the presence of knee joints, exercises are given in a lying position.

Before starting classes, it is necessary to carry out a lot of preparatory work, starting from conversations and ending with demonstrating the success of comrades who have mastered prostheses well. During training, the purpose of each type of exercise should be explained.

It is necessary to take into account the mental state of patients, their mood and make various changes to the lesson plan in accordance with this. It is necessary for the victim to believe in the desire to help him and in the actual possibility of this. Classes should be conducted calmly, be persistent and achieve the goal, while at the same time sparing the patient, without causing negative reactions to the classes. Classes are held 1-2 times a day; The duration of each lesson is 10-15 minutes.

In the second period (duration 5-6 months), the patient somewhat gets used to the loss of limbs, severe depression passes, and the mental state gradually becomes balanced. The patient's strength is restored, and he spends most of the day in a sitting position. In most cases, the amputation wound has healed by this time, but sometimes wound healing is delayed due to a number of reasons, for example, a sluggish epithelization process, fistulas, etc.

The objectives of therapeutic physical culture in the second period are: increasing the general mental tone of the victim; active development of contractures; stump support training; balance training; general training of the patient; further development of self-care skills.

1. Movements of the upper limbs in all directions without objects and with objects (medicine balls, dumbbells, sticks, etc.).

2. Climbing a gymnastic wall and a rope.

3. Balance exercises, sitting on an elevated support, kneeling (if any).

4. Throwing and catching the ball.

5. Tilts of the body in all directions with and without securing the stumps.

Moving with the help of hands while sitting on a high support.
Exercises to strengthen your back muscles.

8. Standing exercises, first on the shoulder blades, then on the head and hands.

9. Walking on parallel bars while resting on the hands.

10. Walking on the mat in a handstand.

11. Training of the supporting stump, which is achieved by pressing on the supporting surface of the stump with objects, first soft, then more and more rigid with a gradual increase in pressure.

During the exercises, the trainer must provide insurance for those participating.

If there are similar patients, group classes should be conducted, since a person’s presence in a group always has a beneficial effect on his morale. It is better to conduct classes in an office or physical therapy room, where it is advisable to have special equipment and apparatus. The duration of classes in the second period is from 20 to 30 minutes.

The third period (duration 3-6 months) is characterized by healing of the wound on the stump. The patient's general strength is restored, the mental state is usually balanced, activity and perseverance in achieving the goal appear. The patient engages in physical therapy a lot and willingly.

Tasks of the third period: maintaining the patient’s confidence in a quick return to normal life and work; general training of the patient; special training in walking on prostheses; training of special skills in mastering prostheses.

The duration of this period is individual and depends on the moral and volitional qualities of the patient, on the length and location of the stumps, the patient’s age, his physical strength and fitness.

Putting on prostheses for the first time and standing on them for the first time causes great fatigue for the patient, which is associated not so much with physical fatigue as with great nervous tension. Therefore, it is very important to instill confidence in the patient for the first time that he can master the prostheses. To do this, the patient is forced to raise his legs one by one, holding the gymnastic wall with his hands, so that the patient feels that he is able to stand not only on two notes, but also on one leg. The patient’s insurance is very important here, since falling for the first time while wearing prostheses can frighten the patient and delay the formation of new motor skills for a long time.

When the patient feels that he can stand (with support) on prostheses, he should move on to learning to walk on parallel bars, which are installed at a height equal to the patient’s crutches. After 2-3 days, they move on to walking with sticks, deliberately avoiding crutches, so that the patient develops confidence that the prostheses are holding him securely.

The first lessons must be carried out individually to ensure good insurance. When the patient begins to walk confidently with two canes, he can be included in group classes, where the patient sees the successes of his comrades and begins to believe more in his own abilities. Then they move on to walking with one stick, stepping over objects of varying heights, walking without a stick along lines drawn on the floor, etc.

Therapeutic physical education in this period includes climbing a gymnastic wall and a rope; resistance exercises with fellow practitioners (necessarily on mats); bending the arms while lying down; squats and lunges (if there are knee joints); tilting the torso to the sides from the starting position of standing at the gymnastic wall and holding onto it with your hand.

A good exercise is to lift objects of varying weights from the floor and place them on shelves of varying heights. When amputating two hips, it is necessary to teach self-insurance in case of a fall.

Self-insurance in this case is that the patient, when losing balance, must quickly bend at the hip joints and place his hands on the floor, which is easy to do, since prostheses are always shorter than normal legs. If there is at least one knee joint, the patient must be taught to quickly bend the knee when falling, which reduces the height of the fall.

For fluent use of prostheses, exercises that distract the patient’s attention should be given, for example, games and exercises with the ball: dribbling the ball in a circle, passing the ball through a volleyball net, playing a basketball against a wall (with the back resting on something and without support), dribbling a basketball ball on the floor (supported by a stick), walking and dance steps to music.

Pair dances (with a healthy partner) are very effective, during which the patient begins to fluently use prostheses. Dances are usually given at the end of the third period.

If two legs are amputated, patients can go skiing on flat terrain in winter.

Working with people who have lost two lower limbs is very difficult and requires a lot of patience, tact, perseverance and love for your profession. A physical therapy methodologist in his work should always strive to help the victim return to his favorite work, instill in him a thirst for life, and make him again a full member of our socialist society. The image of the hero pilot Maresyev serves as an example of a return to active social life and full-fledged creative work.