Massage for the Amputee

I have probably spent more time around amputees than most massage therapists. As a nurse I worked in various surgical settings, including general and orthopaedic surgery where I cared for a few above and below knee amputations, usually due to either diabetes or infection. In fact the first surgery I ever saw as a student nurse was a leg amputation. I also used to attend sports camps for disabled children twice a year, at which there were often children who were amputees. 

Amputation rehabilitation can be quite complex and is not simply a physical health issue, but involves psychological, emotional and social factors too. It is certainly one of those issues where individualised care is needed more than ever, but the rehabilitation process can be limited in terms of resources and types of therapy and prosthesis, for example, that can be funded. However, this is where massage therapy can play an important role, because the therapist has more time to offer both physiological and psychological support which is tailored to the individual client. 

Amputees will feel pain, muscular spasms and tightness, and stiffness in muscles outside the area of amputation, because they are compensating for the limitations that come with amputation. In addition to compensatory muscle tension, biomechanical and postural changes will bring their own challenges. Massage therapy can incorporate a combination of myofascial release techniques, trigger point therapy, postural alignment, joint mobilisation and stretching exercises to create an individualised plan which treats physical dysfunction and pain. . All this, while also offering positive psychological support, reducing anxiety and improving sleep patterns which also impact on quality of life, in addition to the trauma itself and intensive rehabilitation process. Massage can be used as a short term solution, but is particularly beneficial when incorporated into the rehabilitation process, alongside prosthetic training,to combat muscle strain and postural and biomechanical issues, and as a maintenance measure in the long term to deal with the usual amputation related conditions that arise.

 Obstacles in fitting new prosthetics and enabling ambulation, are reduced range of motion and development of contractures due to poor fit and pain due to soft tissue changes. These are obstacles that can be overcome with the help of massage,not only because of the effects on the musculature and pain levels, but also in terms of maintaining skin integrity, which in itself can impact on range of motion. Also by including massage in a pain management programme, factors such as anxiety, circulatory problems and soft tissue dysfunction, which impact on pain intensity, are also being treated. In this way, massage can really help improve a client's quality of life. 

Obviously, each amputee's rehabilitation is dependant on age, the reason for the amputation, general health and whether they are post-surgery, undergoing prosthetic training or in a general maintenance programme, and as a therapist, it is important to liaise with the multidisciplinary team. 

BENEFITS OF MASSAGE THERAPY 

- reduced muscle tightness and stiffness

 - reduced muscle spasms

 - increased muscle length 

- reduced pain

 - reduced swelling

 - increased circulation 

- maintaining skin integrity 

- reduced scar tissue tightness

 - reduced anxiety and stress 

- improved sleep

 - increased relaxation  

REHABILITATION GOALS ASSISTED BY MASSAGE

 PHANTOM LIMB PAIN

 70-80% of amputees suffer with phantom limb pain, which is the subjective sensation of burning/stabbing/crushing/throbbing pain in the part of the limb that is no longer physically present. While it generally happens in the post surgical stage, 40% may continue to suffer after the first year. For some, massage therapy has been an important factor in overcoming phantom pain, as it is thought to increase sensory input from peripheral nerves in the amputated limb, over-riding the brains perception of pain, thus potentially relieving the phantom pain . Massage may be direct to the amputated stump, to the muscle and soft tissues above the stump(the residual limb), or to soft tissues at the proximal end of the affected limb. 

RESIDUAL LIMB PAIN

Residual limb is the pain experienced at the distal end (stump) of the amputated limb, due to :-

 - poor prosthetic fit 

- surgery related tissue damage

 - swelling 

- joint dysfunction

 - scar tissue/adhesions 

- neuroma 

- referred pain from tight muscles/trigger points 

- muscle spasms

 - poor circulation 

DESENSITIZATION 

Hypersensitivity in the residual limb is common, particularly around areas of scar tissue or hypertonic muscles, causing a pain cycle which interferes with functionality. Manipulation of the soft tissues of the stump can reduce nerve sensitivity and myofascial pain, thus helping to break the cycle. 

INCREASE CIRCULATION

Massage therapy is known for its effect on the circulation, with good blood flow being essential in the recovery process to supply oxygen and nutrients to the tissues and enable waste elimination. Poor circulation of the residual limb, can cause cold sensations and burning pain, even more so in cold weather when peripheral blood flow is naturally reduced. This is due to nerves, arteries and capillaries, which regulate blood flow, being damaged during the amputation, and the inevitable muscle atrophy due to reduced functional requirements of the muscles. When muscles atrophy, the muscle pump action, which assists with blood circulation, no longer functions, but massage therapy can mimic this pump action, thus passively assisting with fluid movement. The localised increase in blood supply to the skin surface during massage can also help to warm the cold residual limb, and therefore help reduce the burning pain. 

SCAR TISSUE

Any surgery will introduce tough scar tissue, on top of any scar tissue caused by any injury leading up to the amputation, for example, in military service, or through infection. 

Scar tissue will negatively impact on the adjacent tissues, not only causing pain and reduced range of motion, but also itching which may reduce the amount of time a client can tolerate wearing their prosthetic. Massage can release scar tissue, improving muscle tightness, reduced range of motion, pain and itching, thus potentially increasing prosthetic tolerance levels. 

SWELLING 

Swelling may occur due to surgery or prolonged prosthetic wearing, but this can be improved with manual lymphatic drainage, which can:- - drain excess fluid which may compress internal structures and cause tingling/numbness/discomfort - help maintain skin integrity - assist with finding a good prosthetic fit and therefore improving functionality, 

MUSCLE TIGHTNESS, STIFFNESS AND SPASMS

 Compensatory muscle tension, pain, repetitive strain and stiffness in joints occurs in amputees due to increased function to counterbalance the limitations of the amputated limb. These imbalances will further impede functional abilities and require early intervention to avoid additional problems, eg:-

 - carpal tunnel is common in upper limb amputees due to increased use of remaining arm

 - persistent lower back pain in lower limb amputees due to altered weight distribution

 - muscle spasms in residual limb due to supporting weight of the prosthetic

 - contractures in joints above the amputation site is common but if left untreated may promote poor prosthetic fit, abnormal gait , pain and potentially inability to walk with a prosthetic 

- headaches often occur due to medications, reduced sleep, stress, dehydration, muscle tightness and referred pain from trigger points. All of these imbalances can be treated with massage, but for some amputees this may require more regular maintenance treatments. As always ensure that you see a registered and experienced therapist who has experience of dealing with this issue.