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116 HIGHSMITH ET AL.

INTRODUCTION physical activity, difficulty performing activities of
Rehabilitation for persons with lower extrem- daily living and occupational tasks, increased fall risk,
ity amputation (LEA) is complex and requires an decreased exercise tolerance, weight gain, financial
interprofessional healthcare team. Members of the hardship, and psychological implications.
multidisciplinary healthcare team for individuals with Alteration to RL shape and volume are common,
LEA may include orthopedic and vascular surgeons, with fluctuation, daily and over the lifespan, contrib-
physiatrists, prosthetists, physical therapists, derma- uting to mismatch between prosthetic socket and RL.
tologists, mental health professionals, and others. Socket to RL volume mismatch is a common prob-
Patients with amputation spend considerable time lem often contributing to skin ulceration. Patients
with physical rehabilitation professionals to learn self- can have a high level of influence on this situation,
care with their new prostheses. During this period, for example, by adding socks. Therefore, monitoring
rehabilitation professionals frequently encounter skin fit and comfort along with other self-management
ulceration of the patient’s residual limb (RL) related techniques are vital to minimize a breakdown of
to prosthetic use. Continuously referring patients skin integrity and function. This project’s aim was to
to a dermatologist for every skin condition may not review the intervention and management of RL ulcers
be practical. Therefore, it is important that physical in persons with LEA who use prostheses. The purpose
rehabilitation professionals are prepared to recognize of this literature review was specifically to determine
and manage common non-emergent skin conditions the quantity, quality, and strength of available evi-
in this population. Proper management should be dence to formulate evidence statements supporting
recommended and may include teaching self-care treatment methods for prosthesis-related RL ulcers.
strategies to the patient as well as recognition of con-
ditions requiring referral. Methods
Currently, more than 80% of amputations in the An interprofessional team was recruited to design
U.S. are the result of complications from vascular dis- the search term set that would best capture man-
ease and diabetes (1,2). Less than 10% of LEA results uscripts to address the project’s aim and purpose.
from trauma (3,4). People with amputation experience The team included the following disciplines: pros-
nearly 65% more dermatologic issues than the general thetics, physical therapy, physiatry, dermatology,
population. Skin problems are experienced by approx- and information science. The PICO (Participants,
imately 75% of patients with LEA who use lower limb Interventions, Comparison, Outcome) framework
prostheses (5). With LEA, the normal pressure-dis- was used to identify key terms relevant to the project’s
tributing anatomy is missing or altered. Therefore, the aim and purpose (7). On the assumption that available
RL is exposed to several atypical conditions with pros- evidence regarding the treatment of pressure ulcers
thetic use. These include elevated shear forces, stress in lower extremity prosthetic users would be lim-
risers, increased humidity, and prolonged moist con- ited, PICO related search terms were selected, tested,
tact within the prosthesis, which can macerate tissue and kept non-specific to identify as many potential
and contribute to ulceration. Ulcers or pressure sores, manuscripts as possible. On November 1, 2014, the
among the more common skin conditions in pros- following search terms, Medical Subject Headings
thetic users, may be mitigated with minor prosthetic (MESH) terms, and Boolean Operators were agreed
adjustments to redistribute pressure (6). However, upon and utilized to search the MEDLINE (Pubmed),
The Cumulative Index to Nursing and Allied Health
the size of areas over which pressures are applied Literature (CINAHL)(Ovid) and Embase databases:
and their magnitude can be considerable and may
require recovery time out of the prosthesis or even ((((((((((((((((((((((lower extremity OR lower
a new socket to be fit (5). Prosthetic disuse can have extremit*)) OR (lower limb OR lower limb*))
many adverse consequences for the patient. These OR leg) OR hip) OR foot) OR knee) OR ankle)
may include weakness, decreased flexibility, reduction OR (above knee OR AK)) OR (below knee OR
of ambulatory ability, functional decline, decreased BK)) OR (transfemoral OR “trans-femoral”))