451

Physical Therapy for the Polytrauma Casualty With Limb Loss

Chapter 17

PHYSICAL THERAPY FOR THE 

POLYTRAUMA CASUALTY WITH 

LIMB LOSS

ROBERT S. GAILEY, PhD, PT*; BARBARA A. SPRINGER, PhD, PT, OCS, SCS†; and MATTHEW SCHERER, PT, MPT, NCS‡

INTRODUCTION 

Physical Therapy Evaluation 

Bedside Management 

PHASE I. INITIAL MANAGEMENT PHASE

Functional Activities 

Flexibility 

Strengthening 

Cardiovascular Endurance

Balance 

Ambulation with Assistive Devices 

Patient and Family Education 

Goals for Progression to Phase II

PHASE II. PREPROSTHETIC PHASE 

Functional Activities 

Flexibility 

Strengthening

Cardiovascular Endurance 

Goals for Progression to Phase III

PHASE III. PROSTHETIC/AMBULATION PHASE 

Functional Activities 

Goals for Progression to Phase IV

PHASE IV. PROGRESSIVE ACTIVITIES/RETURN TO ACTIVE DUTY PHASE

Recreational/Sports Activities 

Core Stabilization 

Military Task Training/Military Operations

Special Considerations for Amputees with Comorbidities and Multiple Limb Loss

SUMMARY

ATTACHMENT: MILITARY AMPUTEE REHABILITATION PROTOCOL

*Director, Functional Outcomes Research and Evaluation Laboratory, Miami Veterans Affairs Healthcare System, 1201 NW 16th Street, Miami, Florida 

33125 and Associate Professor, Department of Physical Therapy, University of Miami Miller School of Medicine, 5915 Ponce de Leon Boulevard, Plumer 

Building, Coral Gables, Florida 33146

†Colonel, Medical Specialist Corps, US Army; Director, Propency Office for Rehabilitation & Reintegration, Office of The Surgeon General, Falls Church, 

Virginia 22041; formerly, Chief, Integrated Physical Therapy Service, National Naval Medical Center, 8901 Rockville Pike, Bethesda, Maryland and 

Walter Reed Army Medical Center, 6900 Georgia Avenue, NW, Washington, DC 

‡Captain, Medical Specialist Corps, US Army; Doctoral Student, Department of Rehabilitation Science, University of Maryland at Baltimore, 111 South 

Greene Street, Baltimore, Maryland 21212; formerly, Amputee Physical Therapy Section Chief, Physical Therapy Service, Department of Orthopaedics 

and Rehabilitation, Walter Reed Army Medical Center, 6900 Georgia Avenue, NW, Washington, DC 
452

Care of the Combat Amputee

INTRODUCTION

prepared for prosthetic gait training and educated 

about residual limb care before being fitted with the 

prosthesis. Second, the amputee must learn how to 

use and care for the prosthesis. Prosthetic gait training 

can be the most frustrating, yet rewarding phase of 

rehabilitation for all involved. The amputee must be 

reeducated in the biomechanics of gait while learning 

how to use a prosthesis. Once success is achieved, the 

amputee may look forward to resuming a productive 

life. Third, the therapist should introduce the amputee 

to higher levels of activities beyond learning to walk. 

The amputee may not be ready to participate in sport 

and recreational activities immediately; however, this 

is an anticipated goal within the military program. The 

current rehabilitation program includes higher level 

training as a standard and most, if not all amputees, 

are expected to participate as their injuries permit. 

For those amputees that may receive early discharge, 

contact information for support and disabled recreational organizations should be provided so they can 

participate when ready.

Physical Therapy Evaluation

The initial physical therapy evaluation is typically 

performed at bedside to assess mobility, strength, 

range of motion, and pain. Amputees with polytrauma 

will present with secondary injuries other than limb 

loss that will be evaluated and considered as the rehabilitation plan is prepared. 

Physical and occupational therapists can work 

together with acute patients to eliminate redundancy 

in the evaluation and cotreatment of mobility and 

activities of daily living (ADLs). Many ADLs can be 

evaluated and practiced during occupational therapy 

and physical therapy evaluations. For example, physical therapists can assess mobility, range of motion, 

and balance as occupational therapists evaluate and 

teach dressing activities. Adaptive clothing with tearaway access is helpful to have during an occupational 

therapist’s assessment and to protect patients’ modesty 

as they venture from their room. Every opportunity 

should be taken to encourage early supervised transfer 

training with a wheelchair provided when appropriate 

to allow mobility off the ward and enhance independence. Transfers and wheelchair training activities 

are examples of early mobility training. The initial 

evaluation can also be an opportunity to educate the 

patient and family members about the goals and course 

of rehabilitation and to develop initial rapport. SMs 

wounded in the global war on terror will consider 

their future plans but should be assured that every 

Service members (SMs) that are wounded during 

active duty often present with multiple injuries. Some 

of the most devastating wounds can result in the loss 

of one or more limbs in addition to concomitant injuries. Care of the injured SM is a complex process that 

requires a team effort that begins at the time of injury 

continuing throughout all stages of care including 

postsurgical rehabilitation and frequently persists after 

discharge. Physical therapists and physical therapy assistants have a central role in ensuring that these SMs 

with limb loss achieve the maximum possible level 

of functional ability permitting them to resume their 

recreational and occupational goals. 

SMs who sustain traumatic amputations are generally young and otherwise healthy. They were very 

active up to the moment of injury, and then suddenly 

their lives were dramatically changed. As devastating 

as their wounds may be, they do not want to stop living 

active and productive lives that include work, sports, 

and recreational activities. Because of the SMs’ pursuit 

of highly physical activities they are often referred 

to as “tactical athletes.” Therefore, the main focus of 

rehabilitation in this patient population is application 

of the orthopaedic sports medicine model to return 

wounded SMs to optimal levels of physical function. 

This chapter will present the US military’s four-phase 

program of functional progressive rehabilitation for 

SMs with lower limb loss. 

Rehabilitation should begin as soon after the 

amputation(s) as possible. Following a comprehensive 

physical evaluation the physical therapists and physical therapy assistants progress those amputees through 

the four-phase rehabilitation program: 

(1) initial management, 

(2) preprosthetic, 

(3) prosthetic/ambulation, and 

(4) progressive activities/return to active duty. 

Individual progression through these phases is 

a fluid process and will depend on tissue healing, 

surgical procedures, complications, and individual 

functional readiness. Patients who undergo further 

surgery, for example, will return to the earlier phases of 

rehabilitation. (For an in-depth outline of the Military 

Amputee Rehabilitation Protocol see attachment at 

the end of this chapter.) Functional outcome measures 

are administered at regular intervals to determine and 

document rehabilitation progress toward short- and 

long-term goals.

The physical therapist’s role in prosthetic training is 3-fold. First, the amputee must be physically 
453

Physical Therapy for the Polytrauma Casualty With Limb Loss

feasible opportunity will be made available to them if 

their goal is to remain on active duty. The wounded 

SM’s goals, which largely determine the long-term 

rehabilitation plan of care, are important to update as 

he or she progresses through rehabilitation.

Bedside Management 

Generally, the goals of postoperative treatment 

for the new amputee are to reduce edema, promote 

healing, prevent loss of motion, increase cardiovascular endurance, and improve strength. Functional 

skills must also be introduced as early as possible to 

promote independence in bed mobility, transfers, and 

ambulation. Further independence and prevention of 

complications may be addressed with education in the 

self-care of the residual limb and intact limbs. Moreover, each rehabilitation team member should be aware 

of the need to assist the patient with the psychological 

adjustment to limb loss.

PHASE I. INITIAL MANAGEMENT PHASE

The protective healing phase is the first phase of 

amputee rehabilitation that corresponds with the acute 

inpatient stay and on average ranges from 1 to 2 weeks 

depending on the severity and complexity of injury. 

Patient management strategies for the interdisciplinary 

team during the first phase include surgical management often with repeated irrigation and debridement 

of concomitant residual limb(s), wounds, or management of other comorbid conditions. Rehabilitation 

providers concurrently work together to promote early 

functional skills, provide patient and family member 

education, and initiate early conditioning activities as 

tolerated by the patient.

Functional Activities

Bed Mobility 

The importance of good bed mobility extends beyond 

simple positional adjustments for comfort or to get in 

and out of bed. The patient must acquire bed mobility 

skills to maintain correct bed positioning to prevent 

contractures or excessive friction of the sheets against 

the suture line(s), scar tissue, or frail skin secondary to 

burns and other surface wounds. If the patient is unable 

to perform the skills necessary to maintain proper positioning, then assistance must be provided. Promoting 

independence as soon as possible is always encouraged 

because adequate bed mobility is a basic skill required 

for bed to wheelchair transfers. Independent transfer 

to a wheelchair is the first step in providing a sense of 

freedom from the hospital bed and allows the patient 

to begin moving freely throughout the rehabilitation 

ward and interact with fellow amputees.

Transfers

Transfer ability is essential during early assessment 

especially when the rehabilitation team is determining 

discharge planning from the acute care setting. Independence or limited assistance with transfers makes it 

possible for the amputee to gain independence quickly 

and develop a sense of belonging with peers during 

rehabilitation. 

Once bed mobility is mastered, the patient must 

learn to transfer from the bed to a chair or a wheelchair 

and then progress to more advanced transfer skills 

such as toilet, tub, and car transfers. In cases where 

an immediate postoperative or temporary prosthesis 

is utilized, weight bearing through the prosthesis can 

assist the patient in the transfer and provide additional 

safety. For transtibial amputees who are not ambulatory candidates, a light-weight transfer prosthesis may 

facilitate more independent transfers. This prosthesis 

is typically fit when the residual limb is healed and the 

patient is ready for training. Bilateral amputees that are 

not fitted with an initial prosthesis transfer in a “head 

on“ manner where the patient slides forward from the 

wheelchair onto the desired surface by lifting the body 

and pushing forward with both hands. 

Wheelchair Management

The primary means of mobility during early rehabilitation for the majority of amputees will be the wheelchair. Therefore, wheelchair skills should be taught 

as a part of the early rehabilitation program. Bilateral 

amputees with complex injuries may require greater 

use of the wheelchair, while unilateral amputees will be 

more likely to choose other assistive devices when not 

ambulating with their prosthesis. Because of the loss of 

body weight anteriorly when sitting, the bilateral amputee will be prone to tipping backward during propulsion 

with a standard wheelchair. Amputee adapters set the 

axle approximately 5 centimeters back,thus moving the 

center of mass posteriorly to prevent tipping, especially 

when ascending ramps or curbs. However, this strategy 

may limit mobility of active wheelchair users by making propulsion less efficient. An alternative method to 

prevent tipping would be the addition of anti-tippers 

(simple devices attached to the back of the wheelchair 

that prevent it from accidentally tipping over backward) 
454

Care of the Combat Amputee

in place of or in addition to the amputee wheel adapters. Transtibial amputees will also require an elevating 

leg rest or residual limb board designed to maintain 

the knee in extension, thus preventing prolonged knee 

flexion and reducing the dependent position of the limb 

to control edema. Finally, it is recommended that the 

wheelchair be fitted with removable armrests to enable 

ease of transfer to or from either side of the chair.

Flexibility

Range of Motion 

Prevention of decreased range of motion (ROM) 

and contractures is a major concern. The best way to 

prevent loss of ROM is to remain active and ensure 

full available ROM of affected joints. Unfortunately, 

not all amputees have this option, and therefore 

proper limb positioning as previously described must 

be maintained, especially during the 6 months after 

amputation. A functional assessment of gross upper 

limb and sound lower limb motions should be made. 

A measurement of the residual limb’s ROM should be 

recorded for future reference. 

Contracture Prevention/Positioning 

Contractures are a complication that can greatly 

hinder the amputee’s ability to ambulate efficiently 

with a prosthesis; thus extra care should be made to 

avoid this situation. The most common contractured 

position for the transfemoral amputee is hip flexion, 

external rotation, and abduction, and knee flexion is 

the most frequently seen contracture in the transtibial 

amputee. During ROM assessment the therapist should 

determine whether the patient has a fixed contracture 

or just muscle tightness from immobility that can be 

corrected with stretching in the near term.

To reduce the risk of contractures, the transfemoral 

amputee, when in a supine position, should place a 

pillow laterally along the residual limb to maintain 

neutral rotation with no abduction. If the prone position is tolerable during the day or evening, then a 

pillow is placed under the residual limb to maintain 

hip extension. Transtibial amputees should avoid knee 

flexion for prolonged periods when sitting or reclining. A stump board will help maintain knee extension 

when using a wheelchair. 

Strengthening 

Strength of the major muscle groups should be assessed by manual muscle testing of all limbs including the residual limb and the trunk core stabilizers. 

Adequate muscle strength will help the patient’s 

functional skill level when performing activities such 

as transfers, wheelchair management, and ambulation 

with and without the prosthesis.

Therapeutic Exercise (Bedside and/or Mat) 

Lower limb strengthening is imperative to prepare 

the legs for prosthetic gait training and mitigate the 

effects of potentially prolonged periods of nonweight 

bearing secondary to healing of the residual limb(s). 

Therapeutic exercise progresses from early isometric 

and active exercise to progressive resistive strengthening and closed kinetic chain (CKC) exercises. During 

Phase I, specific surgical techniques and healing requirements may dictate the selection of strengthening 

methods. For example, isometric strengthening may 

be selected for longer durations where a myodesis 

was performed and adherence to the bone is required. 

If there are fewer surgical restrictions, patients may 

be progressed from isometric strengthening to open 

kinetic chain and CKC exercises as strength increases 

permit. Table 17-1 contains a list of early postoperative 

rehabilitation guidelines. All times annotated are from 

date of final closure (skin closure with sutures).

Core Stabilization 

As soon as bed or mat exercises can be tolerated, 

the patient with amputation(s) learns the basics of core 

(lumbopelvic) stabilization, which focuses on intervertebral control, lumbopelvic orientation, and whole 

body equilibrium, via strengthening of the transversus 

abdominis and multifidus muscles.1

Strengthening this core musculature may minimize or prevent the negative effects following lower 

limb amputation (eg, low back pain, gait dysfunction, and functional impairments).2–9 Theoretically, 

core strengthening can enhance transfer activities, 

balance, and ambulation because it has been used 

in athletic and therapeutic settings to enhance neuromuscular pathways, strength, proprioception, 

and balance and aids in coordination of synergistic 

and stabilizer muscles.10–12 Additionally, it has been 

shown to improve athletic performance and prevent 

low back pain.13–15 The transversus abdominis, which 

is the deepest abdominal muscle, is believed to be a 

key stabilizer of the lumbopelvic region. It is a thin 

muscle running horizontally around the abdomen, 

attaching to the transverse processes of the lumbar 

vertebrae via the thoracolumbar fascia.16 The muscle 

orientation is hoop-like and, when contracted, creates a rigid cylinder resulting in enhanced stiffness 

of the lumbar spine that creates lateral tension 
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Physical Therapy for the Polytrauma Casualty With Limb Loss

TABLE 17-1

EARLY POSTOPERATIVE REHABILITATION GUIDELINES

Postoperative Weight-bearing Surgical Therapeutic

Level(s) Dressing Guidelines Considerations Exercise Guidelines

Partial Foot Fit with shrinker as Heel pad weight bearing N/A CKC rehabilitation to

soon as possible upon allowed when cleared tolerance.

removal of sutures or by orthopaedic surgeon.

when cleared by 

orthopaedic surgeon. 

Symes Patients casted for 2 to NWB for additional 3 Heel pad and CKC exercises are

3 weeks to permit weeks after the cast is Achilles tendon appropriate once casted

stabilization of heel removed for a total of sutured to tibia. (however, no distal end

pad. 5 weeks NWB. bearing in cast).

Expect delayed prosthetic 

fitting.

Transtibial Dressing, figure 8 NWB at distal limb near If myodesis is Mat CKC exercise may

wrapping. suture line until sutures tenuous, the begin immediately if

Shrinker sock when removed and cleared by patient may be stabilization point on

sutures are removed. orthopaedic surgeon. casted in knee bolster is proximal to the

flexion. myodesis. 

Hamstring stretching is 

restricted for 2 weeks in

patients with tenuous 

myodesis. No other 

exercise restrictions. 

Knee Postoperative dressing NWB at distal limb near Patellar tendon is Straight leg raise is restricted

Disarticulation per protocol. suture line until sutures sutured into the to no weights for 2 weeks

removed and cleared by ACL during after surgery. No

orthopaedic surgeon. surgery. restrictions thereafter. 

No restrictions to abduction 

or adduction movement.

Transfemoral Hip spica configuration NWB at distal limb near Myodesis of No active adduction

for wrapping with suture line until sutures adductor magnus strengthening exercises 

progression to removed and cleared by tendon is secured for 4 weeks.

shrinker socks when the orthopaedic surgeon. to the lateral No active abduction

cleared by the femur during strengthening past neutral

orthopaedic surgeon. surgery. for 2 weeks (abduction to

neutral from adducted 

posture with supervision). 

No hip flexion for 2 weeks 

s/p myodesis to protect 

distal insertion.

Bridging in supine is 

permitted when performed 

with bolster under the 

distal residual limb.

Hip Hip spica configuration Patient may weight bear No muscle No exercise restrictions once

Disarticulation for wrapping. as tolerated at suture attachments wound healing complete

Shrinkers may be site (ie, sitting) unless stressed with for end bearing.

ordered to capture hip restricted for other end bearing/

and provide comorbidity (eg, pelvic sitting on the hip

compression. or acetabular fractures). disarticulation.

ACL: anterior cruciate ligament NWB: nonweight bearing

CKC: closed kinetic chain s/p: status post
456

Care of the Combat Amputee

through the transverse processes.16,17 Bilateral contraction of the transversus abdominis can contribute 

to lumbopelvic control by tensioning the fascial 

structures of the lumbar region via intra-abdominal 

pressure.18–20 This helps limit translational and rotational movements in the lumbar spine for which 

transfemoral and hip disarticulation amputees are 

extremely vulnerable. The other key deep core stabilizer is the multifidus, which is the largest and 

most medial of the lumbar muscles.21 This muscle 

co-contracts with the transversus abdominis via the 

thoracolumbar fascia and its functions are to reduce 

anterior shear force, stabilize the trunk, and act as a 

primary trunk extensor.22

The goals of core stabilization are to control, prevent, 

or eliminate low back pain; increase patient education 

and kinesthetic awareness; increase strength, flexibility, 

coordination, balance, and endurance; and develop 

strong trunk musculature to enhance upper and lower 

limb functional activities.

Co-contraction of these deep muscles for core stabilization is a difficult task to learn. Education and training 

are essential to achieving core stability. Illustrations of 

the specific muscles and explanations of the exercises 

are provided to the amputees before practice. Once 

visualization is established patients are taught how to 

maintain a neutral spine (the position of most comfort) 

and how to correctly “draw in” or correctly contract 

the muscles of the lower abdominal region. Usually 

this is first attempted in the “hooklying” position, but 

may need to be taught in the quadruped position using 

gravity for stretch reflex assistance. It is also important 

to explain that these muscles are predominantly type 

1 muscle fibers providing the longer endurance-type 

contractions that are important for proper posture. 

Following instruction and practice, rehabilitative ulFigure 17-1. Elizabeth Painter uses ultrasound to identify the transverse abdominis muscle of Gregory Gadson and provide 

visual feedback for muscle reeducation.
457

Physical Therapy for the Polytrauma Casualty With Limb Loss

trasound imaging may be utilized to provide further 

biofeedback and record direct outcome measures of 

the resting and contracted size of the transversus abdominis as illustrated in Figure 17-1. 

Once the basics of neutral spine and proper muscle 

contraction are learned, amputees will perform a basic core stabilization exercise program. Throughout 

the training program patients must be reminded to 

maintain neutral spine, “draw in,” or contract the 

lower abdomen, and gradually increase time spent 

performing the exercise. Examples of early/level-1 

exercises include the following:

	 •	 Hooklying:raising hands over head, alternating hands to knees(s), bridging with one leg, 

crunches, and leg circles;

	 •	 Prone: one arm, one leg, alternate arm, and

leg lifts;

	 •	 Quadruped (if able): one arm, one leg, or

alternate arm and leg lifts; and 

	 •	 Sitting: arms overhead, one leg out, alternate

hands to knee.

Advancement occurs by progressing from stable to 

unstable surfaces (ball, disc), large simple to smaller 

more complex movements, one plane of movement to 

multiple/combined planes, short lever arm to longer 

lever arm, no weights to weights, and slow to fast 

speed. It is important to maintain the neutral spine during the exercise. Figure 17-2 shows examples of advancing a bilateral transfemoral amputee through a prone 

back extension progression on a variety of surfaces.

Figure 17-2. (a–d) Elizabeth Painter and Barbara Springer assist Gregory Gadson, a bilateral transfemoral amputee, with 

exercises to advance through a prone back extension progression on a variety of surfaces.

b

a

d

c
458

Care of the Combat Amputee

Cardiovascular Endurance

Aerobic training typically begins immediately after 

surgery while increasing sitting tolerance and early 

ambulation. However, specific attention to improving 

aerobic fitness should be incorporated into the rehabilitation program and remain as a part of the amputee’s 

general fitness long after discharge. Bedside calisthenics are an excellent form of exercise when transfers to 

the rehabilitation gym are limited. Educating family 

members to assist with simple movement exercises 

is always suggested to help engage them into the 

amputee’s early recovery and introduce the need to 

reduce the number of sedentary hours each day. The 

three most beneficial exercises are the (1) upper body 

ergometer (UBE), (2) lower body ergometer, and (3) 

the treadmill. 

Initially, the UBE can be introduced and safely performed with most people.23–25 The UBE, which has been 

shown to quickly elevate the heart rate and is also good 

early conditioning for hand crank cycling, has become 

popular in the young, active, athletic, and competitive 

traumatic amputee population.26,27 Once balance and 

strength return, lower body ergometry may be performed at first with only the sound limb progressing 

to use of the prosthetic limb when appropriate. Over 

time and when the level of fitness improves other 

equipment may be used such as treadmills, stair climbing machines, and rowing machines. Amputees can 

enjoy the same activities as the nonamputee population. As a result, swimming and walking are still the 

ideal exercises for general fitness regardless of age or 

athletic ability.28

a b

c

Figure 17-3. (a–c) Elizabeth Painter assists Gregory Gadson, a bilateral transfemoral amputee, with sitting balance 

training.
459

Physical Therapy for the Polytrauma Casualty With Limb Loss

Figure 17-4. Andrew Forney, a transfemoral amputee, prepares the shrinker sock over the donning tube.

Figure 17-5. Andrew Forney dons a shrinker sock with a 

donning tube.

a

b

c

Figure 17-6. Elizabeth Painter assists Gregory Gadson, a 

bilateral transfemoral amputee, as he stretches the hip while 

maintaining a neutral spine for increasing or maintaining 

range of motion for the (a) hip flexors prone, (b) hip flexors 

side lying, and (c) hip extensors.
460

Care of the Combat Amputee

Balance 

After the loss of a limb, the decrease in body weight 

will alter the body’s center of mass (COM). Sitting 

balance is practiced first and then progressed to single 

limb balance. To maintain the single limb balance necessary during stance without a prosthesis, ambulating 

with an assistive device, or single limb hopping, the 

amputee must shift the COM over the base of support 

(BOS), which in this case is the foot of the sound limb. 

As amputees become more secure in their single limb 

support, there is greater difficulty in reorienting the 

amputee to maintaining the COM over both the sound 

and prosthetic limbs.29 Ultimately, amputees must learn 

to maintain the COM and their entire body weight 

over the prosthesis. Once comfortable with weight 

bearing equally on both limbs, the amputee can begin 

to develop confidence with independent standing and 

eventually with ambulation. 

Sitting Balance 

Sitting balance is instrumental for providing the stability required for standing and ambulation. Often the 

time spent in bed and sitting in a chair can contribute 

to the deconditioning of the trunk and pelvic musculature. The early rehabilitation period is an excellent time 

to introduce core stability strengthening exercises and 

to educate the amputee on the importance of maintaining the strength of the trunk and pelvic musculature 

often referred to as the core stabilizers. Many of these 

exercises can be performed in the supine, prone, and 

sitting positions and when properly prescribed can 

prove to be extremely challenging and beneficial for 

even the strongest of amputees. A well-constructed 

exercise program can provide a foundation of strength 

and stability that will ease the transition from sitting 

to standing and walking and create a positive rehabilitation experience. An example of sitting balance 

training for a bilateral transfemoral amputee is shown 

in Figure 17-3. 

Single Leg Balance 

In preparation for ambulation without a prosthesis 

all amputees must learn to compensate for the loss of 

weight of the amputated limb by balancing the COM 

over the sound limb. Although this habit must be broken when learning prosthetic ambulation, single limb 

balance must be learned initially to provide confidence 

Figure 17-7. Elizabeth Painter assists Gregory Gadson, a bilateral transfemoral amputee, as he performs dynamic stump 

exercises that are designed to strengthen (a) hip adductors, 

(b) hip abductors, (c) hip flexors against gravity, and (d) hip 

flexors against manual resistance.

a

b

c

d
461

Physical Therapy for the Polytrauma Casualty With Limb Loss

during stand pivot transfers, ambulation with assistive 

devices, and eventually hopping, depending on the 

amputee’s skill level.30 

Ambulation with Assistive Devices 

All single limb amputees will need an assistive device 

when they choose not to wear a prosthesis or on occasions when they are unable to wear a prosthesis due to 

edema, skin irritation, or a poor prosthetic fit. Bilateral 

transfemoral amputees usually require some form of an 

assistive device while ambulating with their prostheses. 

Ambulate in Parallel Bars 

Safety is the primary factor when selecting the 

appropriate assistive device; however, mobility is a 

secondary consideration that cannot be overlooked. 

As a result, initial ambulation training without prosthesis should begin early within the parallel bars. This 

provides the security of sturdy support while learning 

the prescribed gait pattern and simultaneously allows 

the therapist to evaluate the amputee’s ambulation 

potential. 

Ambulate with Assistive Devices 

The criteria for selection in the early phases and 

throughout rehabilitation should include the following: 

	 •	 the ability for unsupported standing balance,

	 •	 the degree of upper limb strength,

	 •	 coordination and skill with the assistive device, and 

	 •	 cognition.31

A walker is chosen when an amputee has fair to poor 

balance, strength, and coordination. If balance and 

strength are good to normal, Lofstrand (Canadian) or 

regular crutches may be used for ambulation with or 

without a prosthesis. A cane may be selected to ensure 

safety when balance is questionable while ambulating 

with a prosthesis.

A traditional evaluation of the amputee’s potential 

for ambulation includes the following: 

	 •	 strength of the sound lower limb and both

upper limbs, 

	 •	 single limb balance,

	 •	 coordination, and

	 •	 mental status.

The selection of an assistive device should meet with 

the amputee’s level of skill, considering that with time 

the assistive device may change. For example, initially 

an individual may require a walker during early healing, especially if balance is altered from traumatic brain 

injury (TBI), but with proper training Lofstrand crutches 

may prove more beneficial within a short period of 

rehabilitation and as a long-term assistive device. 

Teaching the amputee to negotiate uneven terrain, 

ramps, curbs, and stairs with assistive devices early 

in the rehabilitation process is essential. As mobility 

increases, the freedom and opportunity to independently travel throughout the rehabilitation center and 

into the community also increases. Often the amputee 

Figure 17-8. Matthew Scherer performs a semisupine resisted 

pelvic rotation drill on Joshua Bleill.

Figure 17-9. Joshua Bleill, a bilateral transfemoral amputee, 

performs unsupported push-ups.
462

Care of the Combat Amputee

embraces this ability to demonstrate the beginning levels of independence and the ability to spend time with 

family members and friends away from the hospital 

environment during weekly community outings. 

Patient and Family Education 

Compression Dressing 

Management of edema and postoperative swelling is 

critical to an amputee’s rehabilitation progression. There 

are numerous methods for controlling edema and avoiding skin compromise of the residual limb. Early rigid 

dressings, semirigid dressings, compression wrapping, 

or the use of shrinker garments for the residual limb can 

have several positive effects. They can (a) decrease edema, 

(b) increase circulation, (c) assist in shaping, (d) provide 

skin protection, (e) reduce redundant tissue problems, 

(f) reduce phantom limb pain/sensation, and (g) desensitize the residual limb. Rigid dressings with transtibial 

amputees casted in extension will prevent knee flexion 

contractures and aid in greater confidence with early bed 

mobility.32 In the case of transfemoral residual limbs, there 

may be some value in counteracting contracture forces 

a b

Figure 17-10. Joshua Bleill, a bilateral transfemoral amputee, performs upper limb ergometry on a (a) compliant surface and 

a (b) noncompliant surface assisted by Matthew Scherer.

with specific compression wrapping techniques. 

Controversy does exist around the use of traditional 

compression wrapping versus the use of stump shrinker 

socks. Currently, many institutions prefer commercial 

shrinkers for their ease of donning. Advocates of compression wrapping state that they provide more control 

over pressure gradients and tissue shaping.33 The use 

of a shrinker sock within 10 days after amputation has 

been found to be an equally and potentially more effective means to reduce time from amputation to prosthetic 

casting from those amputees using wrapping methods.34 

Likewise, even shorter time to prosthetic casting has 

been observed with transtibial amputees receiving 

semirigid and rigid dressings.33,34 Compression therapy 

can begin with wraps or rigid dressings and progress to 

shrinkers after the suture line has healed. 

Because this is a controversial area, each rehabilitation team should determine the best course for their respective clients and utilize a consistent method among 

team members. All compression techniques must be 

performed correctly and in a consistent manner to 

prevent (a) circulation constriction, (b) poor residual 

limb shaping, and (c) edema. Likewise, compliance is 

considered to be an intricate part of the compression 
463

Physical Therapy for the Polytrauma Casualty With Limb Loss

Figure 17-11. (a–c) Elizabeth Painter assists Luke Shirley, 

a unilateral transfemoral amputee, with descending stairs 

step-over-step.

a b

c

program. All methods of wrapping or shrinker sock 

use should be routinely checked or reapplied several 

times per day. A transfemoral amputee preparing the 

shrinker sock over the donning tube is shown in Figure 

17-4. Figure 17-5 illustrates the donning of a shrinker 

sock with a donning tube.

Goals for Progression to Phase II

Patient and provider goals for the first phase of rehabilitation include but are not limited to the following: 

	 •	 achieve independent bed mobility (turning

over and sitting up), 

	 •	 acquire the ability to correctly contract transversus abdominis and perform level-1 exercises for at least 3 minutes, 

	 •	 maintain independent sitting balance for at

least 1 minute, 

	 •	 prevent contractures and other complications,

and

	 •	 perform at least 10 minutes of cardiovascular

exercise.
464

Care of the Combat Amputee

b

c

a

Figure 17-12. (a–c) Elizabeth Painter assists as Joshua Bleill, 

a bilateral transfemoral amputee, picks an object off the floor 

using cane support.
465

Physical Therapy for the Polytrauma Casualty With Limb Loss

PHASE II. PREPROSTHETIC PHASE

The preprosthetic phase is the second phase of 

amputee rehabilitation and typically begins when 

the patient is discharged to an outpatient status and 

is characterized by independence with mobility and 

ADLs. The patient has usually undergone final closure 

of the residual limb(s) and prosthetic casting pending 

the removal of sutures. 

Functional Activities 

Encouraging community reintegration activities 

as soon as possible after amputation surgery helps 

speed recovery in several ways. First, it will offset the 

negative effects of immobility by promoting movement 

through the joints, muscle activity, and increased circulation. Second, the amputee may begin to reestablish 

his or her independence, which may be perceived 

as threatened because of the loss of limb. Third, the 

psychological advantage derived from activity and 

independence will impact the amputee’s motivation 

throughout rehabilitation. 

Flexibility

Amputees who have already lost ROM may benefit 

from many of the traditional therapy procedures such 

as passive ROM, active ROM, contract-relax stretching, soft tissue mobilization, myofascial techniques, 

joint mobilization, and other methods that promote 

increased ROM. Daily ROM and stretching exercises 

should be performed at the beginning of each rehabilitation session so that the routine is developed and 

carried over after discharge. Few differences exist 

between stretching activities for lower limb amputees 

and those stretches prescribed to nonamputees. The 

shorter residual limb—especially with transfemoral 

amputees—allows the amputee to hold the limb and 

move into the stretch position. Handling of the residual 

limb also can help to desensitize the limb while maintaining joint motion.35

Hip flexor tightness must be addressed aggressively 

with bilateral transfemoral amputees to minimize 

restriction of hip extension. A sustained stretching 

program coupled with the core strengthening exercises 

described previously will help maintain a neutral 

pelvis. Figure 17-6 shows examples of stretching a 

bilateral transfemoral amputee’s hip while maintaining a neutral spine.

Strengthening

Dynamic Stump Exercises

Dynamic stump exercises only require a towel roll 

and step stool.29,36 These exercises offer additional benefits aside from strengthening, such as desensitization, 

improving bed mobility, and maintaining joint ROM. 

While lying on an exercise mat the patient is asked to 

depress the residual limb into the towel roll by raising 

his or her pelvis off the surface for 10 seconds. The 

Figure 17-13. Christopher Millward, a transtibial amputee, 

performs ladder walking drills.
466

Care of the Combat Amputee

the patient can perform hip strengthening exercises for 

abduction, extension, flexion, and adduction incorporating components of both isometric and isotonic 

contractions in the standing position. Resistance can 

be applied to the exercise leg with manual resistance, 

resistive bands, or cable/pulley weight machines. 

Progressive resistance exercises may be augmented 

by having the patient perform isometric contractions 

at end range to facilitate fatiguing of the contracting 

muscle group. The stance limb will also benefit from 

this mode of strengthening because stability must be 

achieved through the stance limb as the contralateral 

exercising limb performs the resisted movements. This 

four postural positions that strengthen the hip musculature include (1) prone for the hip extensors, (2) side 

lying for hip abductors, (3) side lying opposite side 

for adductors, and (4) supine for hip flexor muscles. 

As strength improves, resistance can be increased by 

placing cuff weights over the patient’s hip or have 

him or her wear a weighted vest.35 Figure 17-7 shows 

examples of dynamic stump exercises for a bilateral 

transfemoral amputee.

Patients with transtibial limb loss can initially 

perform short arc quad exercises with or without the 

addition of resistance such as a cuff weight. Other 

exercises for the hip and knee musculature include 

performing a straight leg raise in prone, supine, and 

side-lying positions. Again, as strength improves 

a cuff weight can be used to increase resistance. 

Implementation of CKC strengthening for the prosthetic side limb musculature can be difficult before 

receiving a prosthesis. Electrical stimulation can be 

used to enhance quadriceps muscle reeducation and 

recruitment. 

As the amputee progresses, strengthening must be 

performed in multiple planes of motion. For example, 

Figure 17-14. Luke Shirley, an upper and lower limb amputee, uses the elliptical trainer.

Figure 17-15. Joshua Bleill, a bilateral transfemoral amputee, 

performs weighted ball swings to promote standing dynamic 

balance assisted by Matthew Scherer.
467

Physical Therapy for the Polytrauma Casualty With Limb Loss

mode of training is particularly useful in promoting 

functional stability in the patient with transfemoral 

limb loss. 

Semisupine Resisted Pelvic Rotation Drills 

Early preparation for resistive pelvic rotation during 

gait can be performed using resisted pelvic rotation 

drills. For proper execution of this drill, the patient 

should assume a semisupine position with his or her 

back partially supported with pillows or a bolster and 

the torso rotated to about 45 degrees between supine 

and side lying. The patient’s pelvis should remain free 

and not blocked with pillows to allow movement within the full range of rotation at the hips. In the correct 

starting position, the patient will be facing the therapist 

who is kneeling next to him or her. The therapist will 

assume hand placement at the anterior superior iliac 

spine on the side of the pelvis to be trained (the side 

not in direct contact with the treatment table, see Figure 17-8). The therapist’s other hand will prepare for 

positioning posterior to the iliac crest to provide cueing 

and counter resistance during the return phase of movement. To initiate the drill, the patient is cued to actively 

and forcefully rotate the anterior superior iliac spine 

into the therapist’s anterior hand placements, allowing the patient to train disassociation of pelvic rotation 

with respect to shoulder girdle rotation (shoulders are 

still supported and stabilized by the mat and pillows 

allowing the pelvis to rotate freely). When the patient 

has overcome applied resistance through the complete 

range, counter cueing will be applied posterior to the 

ipsilateral iliac crest to initiate movement along the 

same rotational axis back to the starting position. Multiple repetitions of this drill performed with prosthetic 

limb(s) on or off can provide the patient with effective 

motor cues immediately before resistive gait training 

in the parallel bars and can be very effective in teaching patients who have difficulty with pelvic rotation 

during gait. A semisupine resisted pelvic rotation drill 

is illustrated in Figure 17-8.

Figure 17-16. Joshua Bleill, a bilateral transfemoral amputee, 

performs resisted diagonal patterns to promote standing 

dynamic balance assisted by Matthew Scherer.

Figure 17-17. Joshua Bleill, a bilateral transfemoral amputee, 

performs pull-ups to promote upper body strength.
468

Care of the Combat Amputee

Progressive Resistive Exercise for Uninvolved Limbs

Access to isotonic strengthening equipment can 

be a tremendous advantage because of the numerous 

benefits derived from these forms of strengthening. 

There are few modifications in patient positioning on 

the weight machines and with most free weight programs. Moreover, this form of strengthening is very 

familiar to amputees who lifted weights before their 

injuries. When prescribing a program it is important 

to include the amputees in the exercise selection and 

choose familiar exercises. When they are ready, let 

them perform their general strengthening program 

with other amputees as they typically would with 

their unit. The sense of independence and ownership 

in their rehabilitation program can have lasting effects 

well beyond general strength increases. Figure 17-9 illustrates a bilateral transfemoral amputee performing 

unsupported push-ups.

Figure 17-18. Elizabeth Painter assists Luke Shirley, a transfemoral amputee, with performing a stool stepping exercise 

to promote single limb standing balance.

Figure 17-19. Elizabeth Painter assists Luke Shirley, a transfemoral amputee, with resisted gait training to promote 

pelvic rotation.

Figure 17-20. Elizabeth Painter assists Luke Shirley, a transfemoral amputee, with passive trunk rotation to improve 

balance during ambulation.
469

Physical Therapy for the Polytrauma Casualty With Limb Loss

Core Stabilization 

Amputees are not always able to rely on proprioceptive feedback, ankle strategies, knee strategies, or 

sometimes hip strategies to help them stand, balance, 

and ambulate. They must rely on visual, somatosensory, vestibular, and lumbopelvic stability cues to 

effectively function. It continues to be important in 

this phase to progress core stabilization exercises to 

maintain trunk strength, decrease the possible risk of 

back pain, and assist in the reduction of gait deviations 

associated with the trunk. 

Progression of core stabilization exercises occurs 

when level-1 exercises are mastered; endurance has 

improved; and the patient can perform at least one 

Figure 17-21. A ceiling suspension device is used during 

ambulation with Marco Robledo, a transfemoral amputee 

who is first learning to walk with a cane assisted by Matthew Scherer.

Figure 17-22. Christopher Millward, a transtibial amputee, 

works on rotational stability and eccentric lower limb control 

while on a dynamic surface.

Figure 17-23. Two amputees, Christopher Millward and 

Chad Watson, work as partners to develop dynamic core 

stability and lower limb control.

level-1 exercise for 3 minutes with good form/neutral 

spine, minimal cueing, and loaded postures are tolerated. Examples of more challenging core stabilization 

exercises include the following: 

	 •	 sitting on dynamic disc and moving arms/

legs, 

	 •	 therapist performing rhythmic stabilization,

	 •	 prone superman,

	 •	 supine “dead bug,”

	 •	 advanced exercise ball bridging,

	 •	 prone with heavier weights, and

	 •	 medicine ball drills.
470

Care of the Combat Amputee

Cardiovascular Endurance 

Because of the severity of injuries many SMs sustain and the deconditioning that occurs as a result of 

the prolonged postoperative periods, cardiovascular 

conditioning is compromised in many of the lower 

limb amputees. Cardiovascular endurance training 

can have a direct effect on the functional walking 

capabilities with regard to distance and assistive device required to ambulate.37–39 The ability to improve 

overall ambulation capabilities with aerobic training 

applies to all levels of amputation.39 Throughout the 

rehabilitation program cardiovascular fitness should 

be incorporated into every treatment plan. Progressing 

the amputee from the UBE to the lower limb ergometer 

can begin as early as their sitting balance and wounds 

permit. Once the ability to stand with the prosthesis(es) 

is achieved, balance training can be incorporated by 

standing on a compliant surface while working the 

arms with the UBE (Figure 17-10). Often single limb 

cycling with the nonamputated limb is introduced 

early in the rehabilitation program. Swimming, hand 

cycling, and rowing can also be encouraged once the 

wounds are healed and the amputee is ready for more 

dynamic training away from the rehabilitation gym.

Goals for Progression to Phase III

Patient and provider goals for the second phase 

of rehabilitation include but are not limited to the 

following: 

	 •	 independence with prescribed therapeutic

exercises in strengthening, core stability, balance, and cardiovascular conditioning; 

	 •	 functional range of motion of the lower limb

joints to allow optimal gait training with the 

use of prosthetic device(s); and

	 •	 independence with ambulation with appropriate assistive device (without prosthesis).

Figure 17-24. (a–e) Christopher Millward, a transtibial amputee, performs plyometric spot drills performed to increase 

lower limb strength, speed, and agility. 

a b

PHASE III. PROSTHETIC/AMBULATION PHASE

The prosthetic/ambulation phase is the third phase 

of rehabilitation and begins when the amputee receives 

his or her prosthesis(es) and is medically cleared by the 

physician to begin weight bearing on the amputated limb. 

Healing of the residual limb permits the amputee to begin 

weight bearing as tolerated. Initially the amputee focuses 
471

Physical Therapy for the Polytrauma Casualty With Limb Loss

on reestablishing standing balance that would include 

the ability to transfer weight equally between both limbs 

and maintain single limb stability over the prosthetic 

limb(s). Prosthetic gait training includes movement reeducation for a symmetrical gait and ambulation with 

the appropriate assistive device. As proficiency with the 

prosthesis improves, functional activities such as stairs, 

curbs, ramps, and uneven terrain may be introduced. 

Functional Activities

Falls/Recovery 

Falling or lowering oneself to the floor is an important skill to learn not only for safety reasons, but also as 

a means to perform floor level activities. During falling 

the amputee must first discard any assistive device to 

avoid injury. Amputees should land on their hands 

with the elbows slightly flexed to dampen the force and 

decrease the possibility of injury. As the elbows flex, 

the amputee should roll to one side, further decreasing 

the impact of the fall.

d

e

c
472

Care of the Combat Amputee

Lowering the body to the floor in a controlled 

manner is initiated by squatting with the sound limb 

followed by gently leaning forward onto the slightly 

flexed upper limbs. From this position the amputee 

has the choice of remaining in quadruped or assuming 

a sitting posture. 

Floor to Standing. Many techniques exist for teaching amputees how to rise from the floor to a standing 

position. The fundamental principle is to use the assistive device for balance and the sound limb for power as 

the body begins to rise. Depending on the type of amputation and the level of skill, the amputee and therapist 

must work closely together to determine the most efficient and safe manner to successfully master this task. 

Figure 17-25. (a–c) Matthew Scherer assists Christopher Millward, a transtibial amputee, with plyometric depth jumps to 

increase lower limb power and prosthetic control.

a c

b
473

Physical Therapy for the Polytrauma Casualty With Limb Loss

ascending stairs transtibial amputees that do not have 

the ability to dorsiflex their foot/ankle assembly must 

generate a stronger concentric contraction of the knee 

and hip extensors to successfully transfer their body 

weight over the prosthetic limb.

Descending stairs is very similar to normal descent 

with one exception: only the prosthetic foot heel is 

placed on the stair. This compensates for the lack of 

dorsiflexion within the foot/ankle assembly.29 

Picking up Objects 

Single limb balance and bending to pick objects off 

the floor is taught during the early stages of rehabilitation for crutch walking, hopping, and other skills. 

Single limb squatting is considerably more difficult but 

can help improve balance and strength. When first attempting this skill, half squats with a chair underneath 

the amputee are recommended. Progression from 

picking larger objects off the floor to smaller objects 

requires deeper or lower squats (Figure 17-12).

Core Stabilization, Closed Kinetic Chain Exercises, 

and Balance/Proprioception 

Core stabilization exercises in Phase III may be 

progressed to include standing and more challenging 

balance activities. The same principles apply: maintain 

neutral spine, correctly draw in the lower abdominal 

wall, and work on endurance. Core strengthening occurs while also performing CKC strengthening and 

balance exercises. Examples in this phase follow: 

	 •	 standing on foam or DynaDiscs (Exertools,

Rohnert Park, Calif); 

	 •	 cone walking;

	 •	 single leg balance on eitherlimb/steamboats;

	 •	 medicine ball exercises in standing, sitting,

prone, or supine exercise ball progression; 

	 •	 Plyoback (Exertools, Rohnert Park, Calif)

training with increasing weight; 

	 •	 wall squats;

	 •	 quadrant and plane stepping activities;

	 •	 ball rolling with sound limb;

	 •	 ladder walking drills (Figure 17-13); and

	 •	 elliptical trainer or stair stepper(Figure 17-14).

Bilateral lower limb amputees will benefit from 

standing and dynamic balance activities. Therapeutic 

interventions designed to improve core stability in 

standing include diagonal movements with resistance 

cables or medicine balls (Figure 17-15, Figure 17-16, 

and Figure 17-17). Functional challenges may include 

similar activities performed outside on grassy surfaces. 

Stairs 

Ascending and descending stairs is most safely 

and comfortably performed one step at a time (stepby-step). A few exceptional transfemoral amputees 

can descend stairs step-over-step. Most transtibial 

amputees have the option of either method, although 

hip disarticulation and hemipelvectomy amputees are 

limited to the step-by-step method. 

Step-by-Step. This method is essentially the same 

for all levels of amputees. When ascending stairs, the 

body weight is shifted to the trailing prosthetic limb 

as the leading sound limb firmly places the foot on the 

stair. The trunk is slightly flexed over the sound limb as 

the knee extends raising the prosthetic limb to the same 

step. The same process is repeated for each step. One of 

the primary goals for ascending stairs step-over-step is 

to increase the ascent speed. To decrease the effort and 

increase safety, the easiest method to increase ascent 

speed is to skip a step. The amputee simply skips a 

stair with the leading sound limb and raises the body 

placing the prosthetic limb on the same step. 

When descending stairs, the body weight is shifted 

to the sound limb as the prosthetic limb is lowered to 

the step below by eccentrically flexing the knee of the 

sound limb. Once the prosthetic limb is securely in 

place, the body weight is transferred to the prosthetic 

limb and the sound limb is lowered to the same step. 

Transfemoral Amputees: Step-over-Step. Timing 

and coordination become critical factors in executing 

stair climbing step-over-step. As the transfemoral 

amputee approaches the stairs, the prosthetic limb is 

the first to ascend the stairs by rapid acceleration of 

hip flexion to clear the step. With the prosthetic foot 

firmly on the step, the residual limb must exert a great 

enough force to fully extend the hip so that the sound 

foot may advance to the step above. As the amputee 

advances to the next step, the sound side hip extends 

and the prosthetic side hip must once again flex at an 

accelerated speed to achieve sufficient knee flexion to 

place the prosthetic foot on the next step above.

Descending stairs is achieved by placing only the heel 

of the prosthetic foot on the stair below, then shifting the 

body weight over the prosthetic limb, thus, passively 

flexing the knee. The sound limb must quickly reach the 

step below in time to catch the body’s weight. The yield 

rate control of the prosthetic knee will dictate the speed 

of descent, but the key to most knee systems is maintaining body weight over the prosthesis. The process is 

repeated until a rhythm is achieved.29 Most transfemoral 

amputees who have mastered this skill descend stairs at 

a fast pace, so the therapist should consider if the speed 

of descent is safe for each individual (Figure 17-11).

Transtibial Amputees: Step-over-Step Stairs. When 
474

Care of the Combat Amputee

a b

Figure 17-26. (a–e) Chad Watson, a transfemoral amputee, 

performs a series of weapon drills to prepare to return to 

active duty.

Weight-Shifting Progression 

Orientation of the COM over the BOS to maintain 

balance requires that the amputee become familiar 

with these terms and aware of their relationship. 

Learning to shift the COM over one foot and then 

the other will assist with lateral displacement of the 

COM. As the displacement from side to side increases, 

amputees should take their sound side hand off the 

parallel bars and eventually both hands off the parallel 

bars. Increased weight bearing will be a direct result 

of improved COM displacement and will establish 

a firm foundation for actual weight shifting during 

ambulation.29 

Standing Progression with Prosthetic Limb

Single limb balance over the prosthetic limb 

while advancing the sound limb should be practiced in a controlled manner so that when called 

to do so in a dynamic situation, such as walking, 
475

Physical Therapy for the Polytrauma Casualty With Limb Loss

c d

e

this skill can be used with relatively little difficulty. 

The stool stepping exercise is an excellent method 

in which this skill may be learned.32 The amputee 

should stand in the parallel bars with the sound 

limb in front of a 10- to 20-centimeter high stool 

(or block). The height depends on the ability level. 

The amputee should step slowly onto the stool 

with the sound limb while using bilateral upper 

limb support on the parallel bars (Figure 17-18). To 

further increase these weight-bearing skills, the amputee should remove the sound side hand from the 

parallel bars and then eventually the other hand. 

Initially, the speed of the sound leg will increase 

when upper limb support is removed. However, 

with practice the speed will become slower and 

more controlled, thus promoting increased weight 

bearing on the prosthesis.29 
476

Care of the Combat Amputee

Ambulation 

Once the amputee has the base strength and balance, 

resistive gait training techniques are implemented to 

reeducate the amputee to the normal gait movements 

necessary to maximize prosthetic performance and 

promote economy of gait.29,40 Advanced gait training exercises are also offered to assist the amputee 

to negotiate environmental conditions that require 

multidirectional movements and superior dynamic 

balance. 

Pelvic Rotation 

To restore the correct pelvic motion, resistive gait 

training for lower limb amputees has been demonstrated to improve balance and normalize gait.29,40 Restoration of pelvic rotation requires that the therapist use 

rhythmic initiation through the anterior superior iliac 

spines, giving the amputee the feeling of rotating the 

pelvis forward as passive flexion of the prosthetic knee 

occurs. The amputee will gradually begin to actively 

rotate his or her pelvis during this time. The therapist 

can gradually progress from active assistive motions to 

resistive while continually facilitating proper motion 

of the pelvis and prosthesis (Figure 17-19). Once the 

therapist is satisfied with pelvic motions, the amputee 

progresses to the swing phase of gait stepping forward 

and backward with the prosthetic limb. 

When both the therapist and the amputee are comfortable with the gait demonstrated in the parallel bars, 

the same procedure as described above is practiced out 

of the parallel bars with the amputee initially using 

Figure 17-27. A transfemoral/transradial amputee performs 

prone position weapons training in the firearms training 

simulation center to prepare to return to duty.

the therapist’s shoulders as support and progressing 

to both hands free when appropriate. The therapist 

may or may not continue to provide proprioceptive 

input to the pelvis. 

Trunk Rotation and Arm Swing

During human locomotion, the trunk and upper 

limb rotate opposite to the pelvic girdle and lower limb. 

Trunk rotation is necessary for balance, momentum, 

and symmetry of gait. Arm swing, which provides 

balance, momentum, and symmetry of gait, is directly 

influenced by the speed of ambulation.29,41 As the walking speed of gait is accelerated, arm swing increases, 

thus permitting a more efficient gait.

Many amputees have a decreased trunk rotation 

and arm swing, especially on the prosthetic side. This 

may be the result of fear or lack of confidence when 

walking with the prosthesis. Returning trunk rotation 

and arm swing is easily accomplished by utilizing 

rhythmic initiation or passively cueing the trunk as 

the amputee walks. The therapist stands behind the 

amputee with one hand on either shoulder. As the 

amputee walks the therapist gently rotates the trunk. 

When the left leg steps forward the right shoulder is 

rotated forward and vice versa. Once the amputee feels 

comfortable with the motion, he or she can actively 

take over the motion29 (Figure 17-20).

Stride Length, Width, and Cadence 

As the amputee begins to ambulate independently, 

verbal cueing may be necessary as a reminder to keep 

the sound foot away from mid-line to maintain the 

Figure 17-28. Computerized simulation allows amputees to 

begin preparation for weapons-related activities.
477

Physical Therapy for the Polytrauma Casualty With Limb Loss

a b

c

Figure 17-29. (a–c) Matthew Scherer performs a Dix-Hallpike 

maneuver on Marco Robledo, an amputee with benign paroxysmal positional vertigo.

proper BOS. Maintenance of equal stride length may 

not be immediately forthcoming because many amputees tend to take a longer step with the prosthetic limb 

than the sound limb. When adequate weight bearing 

through the prosthetic limb has been achieved, the amputee should begin to take longer steps with the sound 

limb and slightly shorter steps with the prosthetic 

limb. This principle also applies when increasing the 

cadence. When an amputee increases his or her speed 

of ambulation, the prosthetic limb often compensates 

by taking a longer step, thus increasing the asymmetry. 

By simply having the amputee take a longer step with 

the sound limb and a moderate step with the prosthetic 

limb, increased speed of gait is accomplished without 

increased asymmetry. As balance and confidence and 

symmetry in stride length improve, the amputee’s 

cadence will increase.29 

Assistive Devices and Gait Training 

Amputees who will be independent ambulators 

and those who will require an assistive device can 

benefit from the above systematic rehabilitation program. Most patients can be progressed to the point of 

ambulating out of the parallel bars. At that time, the 

amputee must practice ambulating with the chosen 
478

Care of the Combat Amputee

assistive device and maintaining pelvic rotation, 

adequate BOS, equal stance time, and equal stride 

length, all of which can have a direct influence on the 

energy cost of walking. Trunk rotation would be absent with amputees utilizing a walker as an assistive 

device; however, those ambulating with crutches or a 

cane should be able to incorporate trunk rotation into 

their gait. Amputees will also find ceiling suspension 

tracks useful for early ambulation when developing 

confidence with the prosthesis and assistive device 

(Figure 17-21).

Resistive Rollover Drills 

Inability to roll over the prosthetic foot during late 

stance phases can lead to asymmetrical gait patterns. 

Therapists can facilitate more efficient rollover on the 

prosthetic foot by cueing the patient to push into a cane 

held in both hands at waist level by both the therapist 

and the patient. During this drill, the therapist and 

patient face one another with the therapist’s back 

to the direction of movement. The therapist applies 

mild to moderate resistance to the cane beginning at 

mid-stance on the prosthetic side. The patient must 

overcome this resistance while maintaining upright 

posture throughout the late stance. The therapist can 

vary resistance to the patient during the rollover phase, 

thereby enhancing proprioceptive feedback in the 

residual limb, core recruitment, and balance. 

Excessive Lateral Trunk Movement 

Patients with knee disarticulation and transfemoral amputations commonly present with excessive 

lateral trunk lean over the prosthetic side limb(s) 

during ambulation. Decreased force production by 

the hip abductors secondary to decreased length 

of femur may be compensated for by increased 

lateral trunk lean over the prosthetic stance limb. 

Strengthening the hip musculature with emphasis 

on the hip abductors may increase single leg stance 

stability. CKC exercises and resistive gait training 

may help reduce lateral trunk lean over the prosthetic side limb. 

a b

Figure 17-30. (a–b) Marco Robledo is a traumatic brain injury patient with a unilateral transradial amputation and a 

unilateral transfemoral amputation.
479

Physical Therapy for the Polytrauma Casualty With Limb Loss

Multidirectional Movements—Sidestepping

Sidestepping, or walking sideways, can be introduced 

to amputees at various times throughout their rehabilitation. Amputees can begin with simple weight shifting 

in the parallel bars and later perform higher level activities such as unassisted sidestepping around tables or a 

small obstacle course that requires many small turns. 

During early rehabilitation this skill provides amputees 

with a functional exercise for strengthening the hip 

abductors, and later in the rehabilitation process, an opportunity to progress into multidirectional movements.

Multidirectional Movements—Backward Walking

Walking backward is not difficult for transtibial 

amputees but it does pose a problem for amputees 

requiring a prosthetic knee because they cannot actively flex the knee for adequate ground clearance. The 

most comfortable method of backward walking is by 

vaulting upward (plantarflexing) on the sound foot to 

obtain sufficient height so that the prosthetic limb that 

is moving posteriorly can clear the ground.

Goals for Progression to Phase IV

Patient and provider goals for the third phase of rehabilitation include but are not limited to the following: 

	 •	 able to tolerate progressive weight-bearing

and weight-shifting activities; 

	 •	 independent with Phase III rehabilitation

drills and exercises;

	 •	 minimal gait deviations that are not worsened

with higher level activity; 

	 •	 independent with falls recovery;

	 •	 progressing ambulation to modified independence or independence with appropriate 

assistive device over level surfaces, inclines, 

and stairs; 

	 •	 able to transition from standard foot to a high

energy foot for those with transtibial amputation; and

	 •	 able to start pre-running drills in free swing

mode (microprocessor knee) with progression 

to running drills in mechanical knee for those 

with a transfemoral amputation. 

PHASE IV. PROGRESSIVE ACTIVITIES /RETURN TO ACTIVE DUTY PHASE

The progressive activities/return to active duty phase 

is the fourth phase in which amputees specifically train 

for and return to recreational and sporting activities, 

and for those who wish to remain on active duty. The 

active duty military population will typically set goals of 

achieving the highest level of physical function possible 

regardless of the extent of their injuries. Their unique 

qualities include young age, good health before injury, 

and high motivation. As a result, many SMs have raised 

the bar of expectations traditionally held by rehabilitation professionals for young people with limb loss. 

Walter Reed Amputee Patient Care team policy stipulates that patients undergo a total body Dexa Scan (hip, 

spine, residual limb) to assess overall fracture risk (osteopenia/osteoporosis) due to rapid bone loss in proximal 

amputated limb (proximal portion of an amputated limb) 

or other extremities that have been partial or nonweight 

bearing for prolonged periods of time (eg, from external fixaters). The bone density must be within normal 

limits before receiving an advanced running prosthesis. 

Recreational/Sports Activities 

Agility, sports-specific drills, and strength training 

continue to be an important part of rehabilitation. The 

sports medicine model is used to prepare amputees 

for an active lifestyle. Agility drills and strengthening exercises that are geared toward specific sports 

or recreation are practiced individually or in group 

sessions. In addition, training for hand crank cycling, 

SCUBA, and kayaking are provided to those who wish 

to participate. 

Core Stabilization 

By Phase IV, core stabilization should be incorporated 

into all agility, sports-specific drills, strength training, 

plyometrics, balance, and proprioception activities (Figure 17-22). Plyometrics begin when the residual limb(s) 

can withstand the forces during this training for power 

enhancement. Rotational drills with medicine balls are 

frequently performed with a partner or as group exercises (Figure 17-23). Other advanced core stabilizing 

exercises in this phase include balancing while standing 

on a DynaDisc (Exertools, Rohnert Park, Calif), using an 

exercise ball during single leg wall sits, single leg balance with perturbations, plyometric jumps, and other 

higher level exercises (Figure 17-24 and Figure 17-25). 

Amputees are verbally reminded to maintain a strong 

core by sustaining a regular exercise program to help 

prevent secondary health conditions such as low back 

pain and to enhance physical performance.
480

Care of the Combat Amputee

Military Task Training/Military Operations

Although not every amputee wishes to return to 

active duty, those that do will have the option of participating in military specific tasks before returning 

to their units. Performing military specific tasks and 

drills with a prosthesis(es) can be difficult initially; 

however, learning the “tricks” of prosthetic use can 

often make the difference for success. Amputees must 

meet the established criteria for a warrior and successfully perform common tasks to remain on active 

duty. The training requirements and preparation will 

be even greater for those amputees who seek to return 

to an operations type unit. Examples of military task 

training that can be incorporated into rehabilitation 

include but are not limited to the following: 

	 •	 road marching;

	 •	 rescues and buddy carries;

	 •	 reaction drills;

	 •	 site picture drills and room clearing drills; and

	 •	 physical fitness test training such as push-ups,

sit-ups, and running. 

Road Marching

Tasking an amputee to march with a weighted rucksack over a prescribed distance challenges dynamic 

postural stability, ambulation tolerance, cardiovascular 

reserves, residual limb integrity, and prosthetic capabilities. Distance and cadence should be progressed as 

tolerated by the amputee. 

Rescues and Buddy Carries

Amputees can be challenged to carry or extract 

fellow SMs using various carrying or extraction techniques to simulate such tasks in an operational environment. Drills with weights and heavy sacks should 

be practiced initially to develop movement skills with 

the prosthesis(es), progressing to live maneuvers with 

a partner when appropriate. 

Immediate Action Drills and Reacting to Contact

Reaction drills require quick transitions from standing to kneeling, kneeling to supine, back up to standing, and advancing with a simulated weapon. 

Site Picture Drills and Room Clearing Drills

Site picture drills and room clearing drills simulate 

movement in tactical environments to include urban 

terrain with a simulated weapon either aimed or “at 

the ready” in preparation for deployment. These basic 

drills can be progressed by challenging an amputee’s 

ability to negotiate uneven terrain, compliant surfaces, 

and obstacles while maintaining an operational posture and efficient and effective continuous forward 

movement (Figure 17-26).

Firearms Training Simulator Centers 

Firearms training simulator centers, which are 

located within military training facilities, allow amputees the opportunity to reestablish firearms qualifications with various weapons using video simulation 

(Figure 17-27 and Figure 17-28). Physical therapists 

work closely with occupational therapists and the 

firearms training simulator trainer to promote ADLs 

by training amputees who stay on active duty and/

or have the vocational/leisure interest in recreational 

activities such as hunting or skeet shooting. Specialized 

terminal devices, adaptive techniques, and hand or 

eye dominance retraining can all be incorporated for 

enhanced experiences. Improving basic firearm skills 

with these modifications allows amputees to succeed 

and improve their confidence.

Special Considerations for Amputees with Comorbidities and Multiple Limb Loss

Comorbidity Considerations

Overcoming the challenges of limb loss can be 

complicated by the effects of comorbidities including 

soft tissue injuries and abdominal injuries, fractures, 

peripheral nerve injuries, vestibular pathology, and 

TBI. Varying degrees of severity of these conditions 

can significantly affect early weight bearing, mobility, tolerance for rehabilitation, and potentially even 

the ability to concentrate and follow commands. 

All interdisciplinary team members have a role in 

evaluating, treating, and advising their colleagues on 

comorbid conditions, the resultant level of the patient’s 

functionality, and how this clinical picture should be 

best managed. 

Abdominal/Visceral Trauma 

Patients with external stomas will require the assistance of a wound care nurse for initial patient and 

family member education. They will not be allowed 

prone for stretching or conditioning exercises. Therefore, great care must be taken to ensure that transfemoral amputees use alternate hip flexor stretching 

techniques (side lying or supine with leg off edge of 

bed) in preparation for gait training. 
481

Physical Therapy for the Polytrauma Casualty With Limb Loss

Fractures

Patients with fractures in one or more limbs, the 

pelvis, or vertebrae will likely have weight-bearing 

restrictions that will affect their mobility and ability 

to participate in certain types of therapeutic exercise. 

It is not uncommon for polytrauma patients to bear 

weight on their prosthetic side before their fractured 

contralateral lower limb. Although devices such as 

external fixators may stabilize comminuted fractures 

and allow for earlier weight bearing, they are often 

painful and require diligent pin care to guard against 

infection. Those patients with fractured upper limbs 

will be limited in the use of their upper limbs for 

transfers, ADLs, and upper limb muscular endurance 

and resistance training. Fractures in the pelvis or the 

vertebrae will limit the patient’s ability to sit, participate in gait training, and perform CKC strengthening 

and conditioning. 

Peripheral Nerve Injuries 

Patients with limb loss may have to contend with 

the effects of peripheral nerve injuries in residual 

upper or lower limbs. For example, deep and superficial fibular nerve injuries from blast shrapnel 

on the “sound side” limb can cause difficulty or 

the inability to effectively dorsiflex the foot during 

gait, necessitating the use of an ankle foot orthosis. 

Similarly, upper limb injuries to the radial, median, 

or ulnar nerves can affect a patient’s ability to perform ADLs, transfer independently, or even operate 

a power wheelchair. 

Vestibular Insult 

Although the incidence of vestibular pathology 

across the broad spectrum of polytrauma patients 

is unknown, blast injury survivors with limb loss 

often present with vestibular deficits such as benign paroxysmal positional vertigo and vestibular 

hypofunction.42 Vestibular dysfunction can diminish 

rehabilitation tolerance, affect static and dynamic 

balance, and increase risk of falls during ambulation. Early management of these conditions may 

include use of the Canalith Repositioning Maneuver 

for benign paroxysmal positional vertigo or adaptation, substitution, and habituation exercises for 

unilateral or bilateral vestibular hypofunction. Early 

and aggressive static and dynamic balance training 

and gait training can help patients compensate for 

vestibular deficits as they work through vestibular 

rehabilitation. Figure 17-29 demonstrates the DixHallpike maneuver being performed on an amputee 

with benign paroxysmal positional vertigo.

Traumatic Brain Injury 

Amputees with TBI must be assessed for the severity of their brain injury before the initiation of 

the standard rehabilitation protocol. Patients’ ability 

to attend to tasks and participate in therapy usually 

dictates whether they are appropriate candidates for 

polytrauma rehabilitation immediately or whether 

they should be first managed by the Veterans Affairs 

Healthcare System for more intensive neurological 

rehabilitation and neuropsychological needs. Amputees with mild TBI may present with balance deficits, 

vestibular pathology, difficulty with learning (or 

relearning) motor tasks, and changes in affect. These 

deficits can complicate the typical course of rehabilitation and interventions should be incorporated into 

the overall plan of care to address them. Although 

numerous other conditions complicate a patient’s ability to participate in full spectrum amputee and polytrauma rehabilitation, the aforementioned are among 

the most common. It is imperative to document all 

pathologies, impairments, and functional limitations 

so that they can be prioritized and addressed in the 

interdisciplinary plan of care. Figure 17-30 shows a 

patient with a TBI, a unilateral transradial amputation, 

and a unilateral transfemoral amputation undergoing 

physical therapy.

Special Considerations for the Patient with Multiple Limb Loss 

Since the initiation of hostilities in Iraq and Afghanistan the incidence of bilateral lower limb loss 

is 18%.43 For patients with bilateral lower limb loss 

prosthetic and rehabilitation management continues 

to improve because of increased attention to this 

population of amputees. The attachment at the end 

of this chapter displays the bilateral transfemoral 

amputee protocol. 

The altered anatomy of a bilateral lower limb 

amputee offers additional considerations when 

planning a standing and gait training program. 

For example, the physical therapist may observe 

increased lordosis during standing, loss of balance 

strategies, and altered postural stability. These 

considerations can contribute to reduced standing 

or dynamic balance and the increased possibility 

of falls. Thus, the importance of initiating core and 

postural stability exercises early in the rehabilitation 

program is even more pronounced for the bilateral 

lower limb amputee. Furthermore, it is essential to 

perform thorough vestibular assessments and TBI 
482

Care of the Combat Amputee

screening to document and address any neurologic 

impairments that may contribute to balance reduction. 

The use of low profile prosthesis or “stubbies” can 

assist bilateral transfemoral amputees with learning 

to use their hip and trunk musculature. Stubbies by 

design lower the COM closer to the BOS, therefore 

requiring less muscular effort to maintain standing 

balance. Although body image can be an issue for some 

patients, the early bipedal locomotion and increased 

mobility in most instances outweigh the body image 

issues. Other benefits identified with use of stubbies 

include facilitating early weight-bearing activities in 

the parallel bars, achieving improved weight shifting 

during ambulation, assisting in the development of 

core stability and postural stability, and decreasing 

the risk of falls with early ambulation training in the 

clinic. 

SUMMARY

Rehabilitative care of SMs with limb loss has 

evolved from the elementary goal of healing wounds 

and returning home to a comprehensive rehabilitative philosophy: restoration of function to the highest possible degree. The multifaceted rehabilitation 

programs go beyond daily activities and mobility 

training to include the opportunity to train for return 

to duty, vocational preparation, sports, or other leisure activities. The US military’s four-phase program 

of functional progressive rehabilitation for wounded 

SMs with lower limb loss presented in this chapter 

is designed to promote a rehabilitation philosophy 

of treating the amputee as a “tactical athlete” applying the highest level training similar to that 

of sports medicine rehabilitation. The four-phase 

rehabilitation program includes (1) initial management, (2) preprosthetic, (3) prosthetic/ambulation, 

and (4) progressive activities/return to active duty. 

Within each phase of rehabilitation evidence-based 

rehabilitation techniques and innovative exercise 

applications are applied with the goal of maximizing the rehabilitation potential of every amputee. 

The information in this chapter presents the most 

current rehabilitation techniques and philosophy 

in an ever evolving process of providing the best 

care possible.

Acknowledgments

The authors would like to thank the following individuals for their valuable assistance in writing the 

clinical protocols and their contributions to this chapter: Janet Papazis, Justin LaFerrier, Greg Loomis, Bo 

Bergeron, Jacqueline Coley Moore, Don Gajewski, Brandon Goff, and Stuart Campbell.

The authors would also like to thank the following for their participation as patient models for the figures

included in this chapter and more importantly for their service to the United States: Joshua Bleill, Andrew 

Forney, Gregory Gadson, Christopher Millward, Marco Robledo, Luke Shirley, and Chad Watson.
483

Physical Therapy for the Polytrauma Casualty With Limb Loss

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Care of the Combat Amputee

ATTACHMENT: MILITARY AMPUTEE REHABILITATION PROTOCOL

Note: Each surgeon has preferred methods or guidance that may deviate from the below stated recommendations based on 

the specifics of the case or other parameters. This protocol should not be used in lieu of clear and regular communication 

between attending surgeon and the patient’s physical therapist.

PHYSICAL THERAPY SECTION

WALTER REED ARMY MEDICAL CENTER

6900 Georgia Ave NW, Wash. D.C.

(202) 782-6371

AMPUTEE REHABILITATION

Revised May 2007

Phase I: Protective Healing (Post-op Days 1–7)

Note: Exercise prescription is dependent upon the tissue healing process and individual functional readiness in all 

stages. If any concerns or complications arise regarding the progress of any patient, physical therapy will contact the 

orthopedist or physiatrist.

Immediate post-operative therapy focuses on bed mobility, transfers, wheelchair management and/or ambulation with 

appropriate assistive device (AD), therapeutic exercise for deconditioning, contracture avoidance, pain management assistance, and self-care.

Goals: 1. Restore functional mobility/basic ambulation

 Bed mobility

 Transfers (bedside chair/wheelchair)

 Ambulation with appropriate AD

 Wheelchair management

2. Teach appropriate residual limb management and self-care

3. Maintain/restore baseline conditioning and balance 

4. Assist with pain management

5. Institute range of motion (ROM) and stretching exercises to avoid contractures

6. Address any potential barriers to rehabilitation at earliest opportunity

Cardiovascular

•	 Upper body ergometer

•	 Seated calisthenics

Functional Activities

•	 Bed mobility 

•	 Rolling

•	 Transfers

•	 Wheelchair management/mobility

Range of Motion (see addendum for stretching and ROM restrictions during Phase I)

•	 Contracture avoidance/stretching program (static, contract relax)

•	 Passive ROM 

•	 Active Assistive ROM (AAROM) to tolerance

•	 Active ROM (AROM) as needed for activity

Strengthening (see Phase I addendum for restrictions by level during Phase I)

•	 Isometrics—Quadriceps, Gluteals, Hamstrings

•	 Ankle pumps

•	 3- or 4-way hip/sliding board (Abduction, Adduction, Flexion) Prone hip extension

•	 Lumbar stabilization (initiate instruction on Transversus Abdominis contraction)
487

Physical Therapy for the Polytrauma Casualty With Limb Loss

Balance

•	 Seated mat

•	 Shifting on mat

•	 Sit to stand

•	 Stand in parallel bars

•	 Single leg balance

Gait

•	 Ambulate in parallel bars

•	 Ambulate with appropriate AD on level surfaces

•	 Ambulate with appropriate AD on unlevel surfaces

Phase I Addendum: Post Surgical Restrictions

During the acute phase of rehabilitation patients will need to be carefully monitored to ensure appropriate healing of the 

myodesis/ surgical repair. The following are guidelines established by the PT AMP section in accordance the primary lower 

extremity amputee surgeon. 

Note that each surgeon has preferred methods or guidance that may deviate from the below stated recommendations based on the specifics of the case or other parameters. This protocol should not be used to the exclusion of clear communication between attending surgeon 

and the patient’s physical therapist.

1. Partial foot amputations: 

•	 Heel Weight Bearing permissible. 

•	 Fit with shrinker ASAP to control swelling

•	 No therapeutic exercise restrictions 

2. Symes amputations: 

•	 Patients are casted x 2-3 weeks to stabilize the heel pad which is secured into the tibia. Non weight bearing for 

additional 3 weeks after the cast is removed (5 weeks NWB total). 

•	 Closed Kinetic Chain Exercises appropriate once casted (no distal end bearing in cast)

•	 Expect delayed prosthetic fitting.

3. Transtibial amputations:

•	 If myodesis is tenuous, the patient may be casted in knee flexion.

•	 Hamstring stretching restricted x 2 weeks with tenuous myodesis. Otherwise, no therex restrictions. 

•	 CKC immediately if stabilization point on bolster is proximal to the myodesis. 

4. Knee Disarticulation:

•	 Patellar tendon is sewn into the ACL during surgery

•	 Straight Leg Raise without weight x 2 weeks s/p surgery. No restrictions thereafter. 

•	 No restrictions to abduction or adduction therex. 

5. Transfemoral amputations: 

•	 Myodesis of adductor magnus tendon secured to lateral femur during surgery.

i. No active adduction strengthening exercises x 4 weeks, 

ii. No active abduction strengthening past neutral x 2 weeks (abduction to neutral from adducted posture is 

permissible) 

iii. No forward flexion x 2 weeks s/p myodesis to protect distal HS attachment

iv. Bridging in supine is authorized (distal HS attachments are stabilized with proximal placement of bolster)

6. Hip Disarticulation:

•	 No muscle attachments stressed with endbearing/ sitting on the hip disarticulation

•	 No therex restrictions once wound healing complete for end bearing. 

Phase II: Preprosthetic Training (Weeks 2–10)

Patient is likely recovering from final closure and emphasis is on preparation for the prosthesis. Phase II concentrates on 

continued limb management to include wrapping, don and doff shrinker, contracture avoidance, desensitization/pain management, cardiovascular endurance, balance and coordination, and ambulation with AD or wheelchair activities as appropriate.
488

Care of the Combat Amputee

Goals: 1. Independent with Phase I and Phase II exercises in the following areas of rehabilitation: 

 Strengthening

 Core stability/lumbar stabilization

 Balance

 Cardiovascular conditioning

2. Independent with residual limb care and volume management

3. Sufficient ROM to allow optimal gait training with use of prosthetic device(s)

4. Independent with mobility and ambulation with appropriate AD(s)

5. Continue to assist with pain management

Cardiovascular

•	 Upper body ergometer

•	 Well leg bike

•	 Aquatic physical therapy when wounds well healed

Functional Activities

•	 Bed mobility

•	 Transfers

•	 Fall training

•	 Community re-integration

•	 Household activities

Range of Motion

•	 ROM progression as tolerated without other contraindications

•	 Continue contracture avoidance/stretching program

•	 Prone positioning, prone on elbows to prone press ups

•	 Scar massage 

Strengthening/Lumbar Stabilization

•	 Isometrics

•	 Progressive resistive exercise of uninvolved extremities

•	 4-way hip with weight progression

•	 Short arc quadriceps exercise with weight progression (if have painfree knee)

•	 Bridging

•	 Sky divers

•	 Crunches (with Transversus Abdominis contraction)

•	 Total gym squats

•	 Controlled dips

•	 Standing 4-way hip 

Balance

•	 Sitting with PNF patterns (ball, resisted)

•	 Balance board or disk sitting

•	 Medicine ball catch

•	 Bolster under base of LE support

•	 Weight shift arms and legs

•	 Add perturbation or unstable base (Swiss Ball)

•	 Trunk stabilization

•	 Quadruped/Biped to push up (can use large round bolster)

•	 Wand trunk rotations with/without weights

•	 Diagonal movements

Gait

•	 Ambulation with assistive device

•	 Unlevel surfaces, uneven terrain, ramps

Phase III: Prosthetic Training (Weeks 11– 20)

During this phase the patient learns to use the prosthesis. Initially the amputee focuses on weight shifting and weight bearing, normalizing mechanics of available joints and motion (trunk, pelvic, hip), and ambulation with various assistive devices 

and prosthesis.
489

Physical Therapy for the Polytrauma Casualty With Limb Loss

Goals: 1. Progressive weight bearing and weight shifting activities 

2. Independent with Phase III rehab drills and exercises 

3. Normalize gait

4. Progress gait to modified independence or independence with appropriate AD 

Cardiovascular

•	 Upper body ergometer

•	 Calisthenics

•	 Bike

•	 Swim

•	 Circuit training

•	 Treadmill walk

•	 Stairmaster/Elliptical Trainer

Functional Activity

•	 Prosthesis management 

•	 Picking up objects

•	 Stepping up curbs/ramps/hills/stairs

•	 Floor to chairs, floor to stand, stand to floor transfers

•	 Falling/ falls recovery strategies

Range of Motion

•	 Contracture avoidance

•	 HEP stretching program

Strengthening

•	 Upper/Lower extremity progressive resistive exercise and general strength conditioning

•	 Closed chain: wall squats, step ups, quadrant and plane stepping activities, steamboats, ball rolling with sound 

limb, trunk stabilization

•	 Isokinetics

Balance

•	 Sitting Swiss ball with activities

•	 Standing with prosthesis: weight shift forward, backward, lateral with progression to diagonal

•	 Weight shifting on soft surface

•	 Rocker board

•	 Ball rolling with sound limb

•	 Balance recovery

•	 Single leg stepping

•	 Single leg balance

Gait

•	 Component training: pelvic rotation, knee flexion

•	 Single leg to well leg step

•	 Stride width, length, cadence

•	 Trunk rotation

•	 Ambulate in parallel bars

•	 Ambulate with walker/crutches/canes level surfaces

•	 Treadmill walk

Progression

•	 Sideways walk

•	 Tandem walk

•	 Backward walk

•	 Multiple prostheses (C-leg, mechanical)

Phase IV (Months 3 – 6) 

Return to progressive activities is where patients return to recreational activities and prosthetic use. For most of our population active duty military have a high level of activity prior to amputation. For others return to prior activity level may be 

household and family daily activities.
490

Care of the Combat Amputee

Goals: 1. Return to high level/ high impact conditioning activities (agility drills, lower extremity plyometrics and ladder 

drills)

2. Initiate the return to run protocol (Transfemoral/Transtibial)

3. Return to organized and individualized sport activity utilizing developed conditioning, balance and running 

training base. 

4. Return to vocation or MOS specific skill and task training 

Cardiovascular

•	 Activity specific

•	 Walking

•	 Upper body ergometer

•	 Bike/Stairmaster/Elliptical Trainer

ROM 

•	 Home exercise program for maintenance

•	 Stretching

Strengthening

•	 Progressive resistive exercise for overall strengthening program

•	 Closed chain with prosthesis

•	 Trunk and core strengthening

Balance

•	 Bilateral standing on rocker board

•	 Single leg standing with progressive perturbation, unlevel surfaces with ball/bodyblade

•	 Single leg hops

•	 Agility drills

•	 Climbing

Gait

•	 Progressive run/walk

Functional and Sport Specific Drills

Plyometrics

Military Skills

OUTCOME MEASURES/ FUNCTIONAL INDEX MEASURES

Gait Lab Analysis with Prosthesis

AMPPRO/AMPnoPRO

Timed Up and Go

6 Minute Walk Test (distances marked on veranda)

Transversus Abdominis Measurements

Sensory Organization Test (NeuroCom Balancemaster)

Oswestry Disability Index (ODI) for low back pain related disability

WRAMC Blast Injury Questionnaire (for blast related sequallae)

No sports until goals are met

BARBARA A. SPRINGER, PhD, PT, OCS, SCS

COL, SP

Chief, Physical Therapy Service

Integrated Department of Orthopaedics and Rehabilitation

National Naval Medical Center

Walter Reed Army Medical Center

DONALD GAJEWSKI, MD

LTC, MC

Orthopaedic Surgery Service

Integrated Department of Orthopaedics and Rehabilitation

National Naval Medical Center

Walter Reed Army Medical Center
491

Physical Therapy for the Polytrauma Casualty With Limb Loss

PHYSICAL THERAPY SECTION

WALTER REED ARMY MEDICAL CENTER

6900 Georgia Ave NW, Wash. D.C.

(202) 782-6371

AMPUTEE REHABILITATION ADDENDUM

BILATERAL TRANSFEMORAL PROTOCOL

Revised May 2007

Days 1–5 on Short Prostheses 

Goals: 1. Independently don/doff liners and short prostheses & liners

2. Independently roll prone/supine and transition to long sitting 

3. Independently transfer in and out of wheelchair wearing prostheses 

4. Independently transfer down to and up from 15 inch bench and/or bolster

5. Transfer to and from floor with stand by assist (SBA) 

6. Stand in parallel bars on prosthesis x 30 minutes with no skin break down

7. Stand in parallel bars and perform tennis ball circles x 60 seconds each leg

8. Independently ambulate in parallel bars x 50 feet

9. Step up and off 3 inch step in parallel bars forward and laterally x 30 repetitions

10. Ambulate in clinic with 2 canes x 160 feet with contact guard assist (CGA) 

11. Ambulate backward and laterally with 2 canes x 30 feet with CGA

Activities: 

1. Don/doff liners and prostheses

2. Bed mobility/Transfers with wheelchair, bolster, to/from floor

3. Standing in parallel bars (add tennis ball circles, trunk rotation with medicine ball)

4. Ambulation in/out of parallel bars forward/backward

5. Stepping up/down from 3 inch step

6. Ensure aggressive HF stretching to allow full extension at bilateral hips

7. Patient education on importance of neutral pelvis, flat back and the role of postural alignment in functional 

bilateral gait

Days 5 – 15 on Short Prostheses 

Gait/Stairs Goals: 

1. Take prostheses home to increase wear time and tolerance to 4 hours per day

2. Ambulate with one cane x 30 feet

3. Ambulate forward with 2 canes x 600 feet with supervision s. restbreak

4. Ambulate backward and laterally with 2 canes x 50 feet with CGA and theraband around legs

5. Ambulate with one cane x 400 feet and CGA

6. Step up and off 6 inch step in parallel bars forward and laterally 

7. Ascend and descent 4 steps using hands and railings with CGA 

Balance/Strength Goals:

1. Perform standing chopping movements with weighted ball in parallel bars

2. Standing throw and catch weighted ball in parallel bars with supervision 

3. Standing throws with weighted ball against rebounder

4. Stand on 2 dynadisks in parallel bars 1-2 minutes x 4 repetitions

5. Standing 4 way open kinetic chain hip exercises with theraband in parallel bars (can hold bars with one 

hand)

6. Standing upper body ergometer in prostheses x 10 minutes

7. Standing cone reaching/cone lifting in semicircle

8. Standing chest and arm exercises with universal cable pulley weights 

9. Perform supine bicycle core strengthening exercise 3 x 60 seconds in prostheses

10. Perform Pelvic Girdle PNF patterns to facilitate pelvic rotation in semi-supine
492

Care of the Combat Amputee

Activities:

1. Increase wear time of prostheses

2. Ambulation progression (see goals)

3. Stepping progression (see goals)

4. Standing balance (see goals) 

Days 16-30: Raise pylon 1⁄2 length/Add microprocessor knee if 8-10 inches clearance

Goals (reset from days 5-15 at increased height):

1. Tolerate wear of prostheses 4-6 hours per day

2. Independently ambulate with one cane x 1000 feet without rest break

3. Independently ambulate with one cane x 100 feet holding weighted ball

4. Perform weighted ball throws against rebounder standing on one dynadisk (progress to one under each 

foot)

5. Independently ambulate without assistive device x 50 feet 

Activities:

1. Increase wear of prostheses to 4–6 hours per day (use for daily functional activities, eg, going to dining hall)

2. Ambulation progression (see goals)

3. Standing balance (see goals) 

Days 31-40: Progress to bilateral microprocessor knee prostheses with one microprocessor knee locked in extension

Goals (reset from days 5-30 at increased height):

1. Stair-climbing using one microprocessor knee prosthesis to ride down step with CGA

2. Use microprocessor knee correctly (hit toe load) 95% of time during ambulation

Activities: Ambulation/balance/functional activity progression (see goals)

Note: Only after meeting all above goals will patient be progressed to bilateral fully programmed and functioning prostheses 

with microprocessor knee. 

Days 41+: Progress to bilateral microprocessor knees prostheses with one microprocessor knee in second mode for free 

swing as tolerated

1. Aggressively pursue heel strikes, single leg step ups, terminal knee extension drills to develop quick contractile 

hamstring and gluteus maximus musculature. 

2. Pursue return to running drills with one mechanical knee and one pylon when able to perform single leg step 

up to a 14” step x 10 repetitions or 20 unilateral LE repetitions on the total gym on level 10 with each lower extremity. 

BARBARA A. SPRINGER, PhD, PT, OCS, SCS

COL, SP

Chief, Physical Therapy Service

Integrated Department of Orthopaedics and Rehabilitation

National Naval Medical Center

Walter Reed Army Medical Center