Gait training specialist Shannon Seeley, MSPT (left), oversees client Rodney Beaugard as he learns to operate his myoelectric upper extremity prosthetic. The device is controlled through the use of muscle signal recognition.

The loss of a limb is a catastrophic event, to say the least. Patients often face weeks, if not months, of recovery waiting for their incision to fully heal before their residual limb can accept the forces and environment of today’s advanced prostheses. During their recovery, patients often experience a physical decline that manifests itself through muscle deterioration, limited joint mobility, and, most disheartening, impaired body awareness.

Thanks in part to advances in technology, there has been a rise in media coverage of prosthetics and the people who wear them. In recent years, there was even a television program dedicated to the process an amputee goes through from impression to fitting of a prosthetic device. We all need to realize that many of these “super prosthetic users” do not necessarily represent the limb loss population as a whole. These people and their stories are publicized in documentary style, but their stories also serve as inspiration for other amputees who may be struggling with the acceptance of their own limb loss. Despite the success stories of the super prosthetic user, most amputees struggle each day with the new challenges they are facing. Many of those challenges can be, or could have been, curtailed with the right rehabilitation program and a change in attitude for both amputees and their rehabilitation teams.

POSITIVE ATTITUDE

People’s attitudes toward amputees, and amputees’ attitudes toward themselves, have a profound impact on limb loss outcomes. Whether you are a friend, family member, or even rehabilitation professional, the thought of losing a limb can be overwhelming. While regaining the ability to walk is exciting, it is often viewed as such a difficult task that lowering expectations can be one way to reconcile these feelings. Then, if a patient “doesn’t do very well,” it simply meets an already low expectation.

Roger McIntosh (left) and Scott Neumiller work on their gait and mobility skills.

Many times the simple act of walking, regardless of how well it is done, is perceived as a great accomplishment. But “walking” is often not enough. Many limb loss patients can walk with, but too many rely on, either assistive devices or noticeable gait deviations that are characterized as a limp. Poor strength, poor flexibility, decreased endurance, and insufficient physical therapy are the primary reasons for an unfavorable rehabilitation outcome. Most lay people, and even many rehabilitation professionals, often regard walking with a limp or an assistive device as acceptable because they are simply surprised that a patient is even walking. The fact is, with the right team in place to provide very specialized physical therapy, most patients can walk without any deviations and many can walk with a lesser assistive device. Amputees need higher excellence in care while people around them need to assert higher expectations before patients can achieve what is truly possible. Very few patients are self-motivated and capable of overcoming such a loss on their own. Most patients need a structured program to teach them how to adapt and reach their fullest potential.

When patients are not provided with positive encouragement early in the process, hope of an optimal recovery can easily be compromised. Here is an example: Mr Jones was an avid water-skier and snow skier, but immediately following an amputation, several rehab professionals told him that “you won’t be able to do that anymore.” After receiving such limiting advice, Mr Jones could have accepted his misfortune and lowered his expectations accordingly. Yet, after completing a structured limb loss rehab program in a positive environment, Mr Jones was back on the ski slopes in less than a year and shortly after he water-skied. Health care professionals, especially those in the rehabilitation setting, need to tell patients and their families the truth: “What you achieve with a prosthesis is entirely up to you.” Then further clarify the statement by saying: “You should be able to do everything you did just prior to the amputation; it may take you a little longer or you may have to find a different method, but you can do it.” At least, you have created a realistic challenge for the patient to achieve what they desire, which would be better than never trying at all. Deflating a patient’s expectations early encourages them to accept their loss as a disability instead of an opportunity to develop their abilities.

CURRENT STANDARD OF CARE

With the current standard of amputee care, success is much too often measured in how far a patient can walk, instead of how well they walk. Unfortunately, being able to walk 300 feet down a straight hallway, or being able to navigate a few small environmental barriers, doesn’t demonstrate that an amputee’s gait is fully optimized. With the current standard of care, amputees are more likely to exhibit poor gait mechanics that produce a trunk forward posture, decreased stance time on their prosthesis, increased loading onto their sound side, and even a compensatory limp.

Amputees constitute less than 5% of the total rehabilitation population; stroke and head injury rehabilitation occupies a larger portion of the pie. It is easy to see why rehabilitation facilities offer greater specialization in those areas than they do for the limb loss population. The low incidence of limb loss cases also causes a lack of expertise among rehabilitation professionals, especially therapists. Most therapists see only one or two amputee cases a year, so many of them are unable to develop the expertise required to generate the outcomes that are truly possible.

Some hospital systems try to better serve this population by holding monthly “amputee clinics.” While an amputee clinic is a great concept, it still leaves a patient’s weekly prosthetic and therapy services disconnected between two locations, the therapy clinic and the prosthetic clinic. This separation creates a significant communication barrier between the therapist and the prosthetist. It also creates an inefficient system of care because patients are required to travel between the two facilities. When a patient experiences a problem under the current system of care, a therapist can only telephone or e-mail the prosthetist their understanding of the difficulty. This creates the possibility of misinterpretation or mistranslation. When a prosthetist is unable to actually see the problem while it occurs in therapy, and have an opportunity to discuss the issue with the therapist, it is very difficult to successfully rectify the problem or discuss alternative solutions. There are often numerous trips back and forth between the therapy clinic and the prosthetic clinic. Each time a problem goes unsolved, the patient returns to therapy unable to perform exercises and activities meant to improve their function. With enough unsuccessful visits to both professionals, a patient will not only lose faith in their ability to achieve a higher level of walking stability, they inevitably lose faith in the rehabilitation process as a whole. An inefficient system of care combined with a lack of clinical expertise leads to a reduced quality of care, wasted time, and lost dollars.

A BETTER TEAM

Any therapist who has gait trained an amputee with high-level therapy techniques has learned that an ill-fitting or misaligned prosthesis doesn’t uphold therapy activities. This is especially true in the early stages of limb loss rehabilitation when the residual limb undergoes the greatest amount of change. It is important that limb loss rehabilitation starts with specific isometric mat exercise that begins to build a foundation of strength to support upright standing posture. Once the patient graduates to standing activities with the prosthesis, their goals and activities shift dramatically. Focus shifts toward continuing strength building under single-leg weight-bearing conditions with some walking. Once a patient is able to demonstrate proper walking mechanics, objectives should shift toward therapy activities that build a patient’s walking endurance.

When a prosthesis becomes loose due to limb shrinkage, the socket pressures are not maintained in weight-tolerant areas. This loss of limb to socket interface reduces the patient’s control of the prosthesis, and their ability to properly manage their body mechanics. If the fit of the prosthesis is not properly maintained, weight-bearing exercises/activities will not be possible. This is the time where there needs to be seamless coordination between prosthetist and therapist, both working to balance prosthetic fit with therapy activities. Alternatively, if the fit of the prosthesis is not maintained and the patient doesn’t express there is a problem, they will automatically shift their weight off the prosthesis in avoidance. Essentially, the patient will compensate with one or more common gait deviations. In these cases, therapy progress is not possible because the patient’s gait deviation prevents proper muscle function.

When a proper gait has been established and the rehab focus switches to endurance training, this is a great time for the therapist and prosthetist to analyze the patient’s gait and fine-tune prosthetic alignment. A rehabilitation program that follows this pathway will direct a patient toward building a quality and functional gait that yields a more favorable outcome. It is impossible for a patient to make meaningful progress in therapy if the fit of their prosthesis isn’t monitored and adjusted throughout all stages of gait training.

It is also virtually impossible for a therapist to provide quality care and anticipate good outcomes unless three things are in place: first, the therapist needs advanced knowledge of amputee gait and mobility; they are openly and regularly communicating with the patient’s prosthetist; and the patient’s prosthesis is regularly monitored and adjusted throughout the rehabilitation process. This can best be achieved if both practitioners operate in the same facility.

BEYOND PHYSICAL THERAPY

Once new patients excel in a quality rehab program, the importance of prosthetic technology can not be overstated. Some of the newest socket interface and suspension technology embraces the use of elevated vacuum applied within the socket. For the right candidate, vacuum technology provides the wearer with a great many benefits, including limb volume management, improved linkage, and increased prosthetic control. When a well-fitting socket and suspended socket are paired with one of two new prosthetic feet, patient satisfaction and function are greatly enhanced.

Two of the newest technology prostheses on the market, provide wearers with improved ground compliance. While one model utilizes a microprocessor and battery to provide improved ankle movement, the other employs a small hydraulic cylinder that offers passive motion. While the operation of these two feet is dissimilar, their benefits are not. Both feet provide increased ankle movement in both plantar flexion and dorsiflexion. Increasing movement in these two motions substantially improves a wearer’s comfort and ability to walk on uneven ground. Simply put, walking up hills is easier due to less posteriorly directed forces, while walking down hills is equally improved because the wearer’s knee is allowed to stay straight longer before the knee is forced forward with the grade. When the user walks on level terrain, the these protheses remain in a dorsiflexed position after “toe off.” This offers the user a greater ground clearance during swing phase, minimizing the risk of catching the toe and precipitating a fall. This is especially important when a wearer walks in grass. While these feet are improvements over standard foot technology, they are only the beginning of a never-ending quest for improving amputee mobility.

OUTCOMES FOR UPPER EXTREMITY AMPUTEES

As with lower extremity amputation, upper extremity amputation can come with social, psychological, and physical conditions that need to be recognized and all treated with a team approach. Patients often experience a greater sense of loss with upper extremity amputation as it is uncommon and less easily concealed than that of a lower extremity amputation. It is due to these factors that a prosthetist and therapist must consider the emotional status of a patient and look towards guiding care with sensitivity towards the psychological needs.

Prosthetist Jeff Boonstra, CP, adjusts client Deborah Coonrod’s lower extremity prosthetic.

Technology has fortunately placed an emphasis on meeting the emotional needs of a patient who has suffered an upper extremity loss. We can now utilize suspension designs, cosmetic restoration and myoelectric EMG amplification to enable function and improved self image. Gone are the days of amputees being relegated to presenting their “hook” in a social setting. Through the use of myoelectronics we can minimize the impact of a prosthesis being harnessed to the body which traditionally created unsightly bulk, uncomfortably tight strapping about the sound side limb and feelings of separation from the norm in society. With the emergence of custom silicone restoration technology it is now possible to create cosmetic renderings that are similar to the sound side hand including hair, nails, and skin color.

With emerging technology, we are coming closer to providing function which closely emulates the function of the human hand. In the proper clinical setting, a patient can train with a prosthetist and therapist on a virtual simulator enabling patients to learn to use the control strategies for a prosthetic hand prior to actually being fitted. The obvious advantage is acceptance and early function with the intent of driving an outcome. A team approach can provide significant advantages rather than hoping the patient can learn to accept a new device and the tolerances that come along with it. Traditionally this includes incorporating prosthetic function into ADLs and everyday life situations without the close guidance of the therapist and prosthetist.

POSITIVE OUTCOMES

The loss of a limb is indeed a catastrophic life-changing event, and the patient’s future achievements will be the direct result of their recovery and rehabilitation experiences. Amputees who receive positive encouragement early in their recovery process and then receive specialized therapy in a multidisciplinary team setting will experience the swiftest and most favorable outcome possible. The amputee population may be relatively small, but the commitment they require to succeed is large. Rehab professionals who elevate themselves to the cause will help people live more productive lives that were once thought unimaginable.

Mark T. Maguire, CPO, is founder of Advanced Prosthetics Center LLC (www.betterlimbs.com), Omaha, Neb. A board certified prosthetist and orthotist, he specializes in excellence in the delivery of limb loss rehabilitation. Maguire is a member of the Academy of Orthotists and Prosthetists and the American Orthotic and Prosthetic Association. For more information, contact .