Losing a Limb & Living with Prostheses

1. Losing a Limb&Living with Prostheses Presented by Melita Theyagaraj, MBBS Assistant Professor in Neurology University of Maryland School of Medicine Attending Physician, Multi-trauma Unit Kernan Orthopedics and Rehabilitation

2. STATISTICS In the US, there are approximately 1.9 million people living with limb loss Tumor ~ 5% Congenital ~ 5% Trauma ~ 15% (males>females) Vascular ~ 70-80% (50% are due to diabetes) Losing a Limb

3. Peripheral Vascular Disease • Risks • Diabetes • Smoking • Hypertension • Hyperlipidemia • Obesity • Inactivity • Family history of CAD or PVD

4. Every Day in the U.S. • 225 people have amputations due to complication of diabetes Remember that is every single day !

5. Statistics (continued) • Ratio of upper limb to lower limb amputation is 1:4.9 • 75% of all amputations occur in those older than 75 • Amputations in the geriatric population in the U.S. is expected to double by the year 2030

6. Amputee Rehabilitation program • Covers a wide spectrum of care from pre-amputation to reintegration into the community Includes: • Pre-amputation counseling • Amputation surgery • Acute post- amputation period • Preprosthesis training • Preparatory prosthesis fitting • Prosthesis fitting and training • Reintegration to the community • Long Term Follow up Physical Medicine and Rehabilitation, Randall L. Braddom

7. Milestones after limb loss • Getting out of bed • Walking with an assistive device • Meeting family and friends for the first time • Joining a peer group • Restoring physical conditioning • Reducing residual limb swelling • Meeting the prosthetist • Receiving the first prosthesis • Learning to use the prosthesis • Getting back to work/ leisure activities • ACCEPTING THE NEW BODY IMAGE

9. Pre-amputation Counseling • Direct communication with patient, family and surgeon to discuss need for amputation and surgical outcome • Meet with physiatrist, therapist and other members of the treatment team • Talk about pain management, phantom pain, realistic expected functional outcomes • ‘Pre-rehabilitation’ program when possible to strengthen the trunk and other muscle groups

10. After the amputation patients experience: -PAIN -GRIEF -FEAR -Sometimes a sense of relief

11. Common Amputee Problems • Dermatological • Bone Problems • Pain • Depression

12. Dermatological Problems • Folliculitis • Boils or abscesses • Epidermoid cysts • Tinea Corporis or Tinea Cruris • Hyperhidrosis • Allergic Dermatitis • “Choked Stump” • Verrucous Hyperplasia

13. Problems relating to the Bone • Bone Spurs • Hypermobile fibula • Bony overgrowth (in children) • Heterotopic Ossification

14. Bone Spurs • If the periosteum is not stripped properly during surgery or trauma, bone spurs can arise • Cause pressure on the skin and pain • Socket modifications help • May require surgery

15. Hypermobile fibula • Occurs when a balanced myodesis was not performed in a transfemoral amputation causing the femur to extrude through the muscle • Causes pain • May need prosthetic adjustments or surgery

16. Bony overgrowth • Occurs mainly in children after amputation of a long bone before it reaches maturity • Continued bone growth that pushes through the skin • Skin Traction is preferred but surgery may be required

17. Heterotopic ossification • Bone formation in the soft tissue • Risk factors include immobility, fracture of long bones, pressure ulcers and edema • Causes pain and decreased ROM • Medications and surgery

18. Heterotopic Bone

19. Heterotopic Bone

20. Heterotopic Bone

21. PAIN • Residual limb pain • Post operative incision pain • Edema of the limb • Presence of a neuroma (nerve ending exposed after surgery) • Pain referred from the back • After tumor amputation, there could be local recurrence of the tumor • Infection • Problems with the prosthesis • Bone spurs

22. Phantom Pain or Sensation It is an awareness of pain in the portion of the extremity that has been amputated.

23. Common Examples of Phantom Sensation Phantom Sensation or Phantom Pain Gnawing/eating Stabbing Burning Squeezed Painfully twisted Terrible cramps Shocking/shooting Sherman, Richard A.  Phantom Pain.  New York: Plenum Press, 1997

24. Treating the Pain • Physical Intervention • Decrease swelling of the residual limb-shrinker/ace wrap • Acupuncture • Transcutaneous Electrical Stimulation (TENS) • Vibration or Ultrasound • Desensitization by tapping ,rubbing or massage of the residual limb • Medical Intervention • Narcotic pain medication- mainly in the acute post operative period • Tricyclic antidepressants, Gabapentin • Anticonvulsants • Capsacin • Lidoderm patches

26. Treating the Pain (contd.) • Psychological Intervention • Hypnosis • Biofeedback • Cognitive therapy • Support Groups • Relaxation therapy • Voluntary control of the phantom limb • Procedures and Surgical Intervention • Less favorable • Nerve blocks with Phenol • Steroid injections

27. Stretching

28. Stretching

29. Depression • Reaching out is the first step in emotional recovery from limb loss • Peer support in the form of Peer visitation, online support group and local support groups • Contacting the National limb loss Information Center at 888-AMP-KNOW

30. Phases of Recovery Amputee Coalition of America uses these six phases to describe the recovery process : • Enduring • Suffering • Reckoning • Reconciling • Normalizing • Thriving

31. Wound and Skin Care • Phase 1: Pre-closure of the Residual limb • Goal: Promote healing of the underlying soft tissue and to treat or reduce the risk of infection • Keep the wound dry • Wash the hands and wear gloves when cleaning or dressing the wound • Exercise caution when moving in bed or getting out of bed • Eat a good diet – helps with wound and tissue healing • Talk to the rehab team if they experience pain or any discharge or discoloration of the wound

32. Wound and Skin Care • Phase 2: Definitive Closure of the residual limb • Goal: to prepare the residual limb for prosthetic fitting • Sutures removed in 14-21 days • Wear a shrinker or a rigid dressing or ace wrap to help shape the limb • Desensitization techniques like massage and tapping • scar mobilization • Inspection of the residual limb using a mirror

33. Does every amputee need a Prosthesis ? A prosthesis is just a tool and choosing to use one or not or merely to use one part time, depends on the amputee’s personal needs, desire and ability.

34. Reasons to wear a Prosthesis • Its ability to help them adjust emotionally • Its ability to help them avoid drawing attention to themselves if it looks like a real limb • Its ability to achieve advanced levels of function (work, sports and hobbies)

35. Reasons not to wear a Prosthesis • Lack of mental ability • Increased energy expenditure • Pain • Loss of sensation because the prosthesis is a barrier between skin and environment • Expense

36. Process of getting a Prosthesis • Choose a prosthetist ( www.abcop.org) • Getting a prescription from the primary care doctor or a physician in an amputee clinic • Being sized and measured for the prosthesis. • Delivery of your prosthesis • Progressing a wear schedule for the prosthesis • Receiving training ( usually with a physical therapist) to learn how to use the prosthesis

37. Time line for getting a Prosthesis • Day 1-15: Stitches and staples are intact • Day 15-Week 4: Sutures and staples are out and patient progresses to wearing a shrinker. First appt with the Prosthetic team • Week 4-6:Visit prosthetist for fitting of the trainer limb • Week 8-10: After approval from the insurance company the trainer limb is built and fitting and training starts • Months 3 -6: Wearing schedule is progressed with the temporary prosthesis

38. Time line for getting a Prosthesis(cont..) Months 7-9: Gait training with the physical therapist is completed. Residual limb is now fully shaped. Prescription is given for a permanent prosthesis. Every 6-9 months: Return to the amputee Clinic or the prosthetist for basic check-ups of the skin and prosthesis.

39. Remember to inspect the skin daily before and after wearing the prosthesis. • If there are any areas that remain red for greater than 10 minutes the prosthesis should not be worn for the rest of the day. • If the redness persists or worsens then see the prosthetist and do not wear the prosthesis.

40. Types of Prosthesis

42. Reintegration into the Community • Disability Rights Laws These laws serve to prevent discrimination,set up systems to provide services for the disabled, and/or allow people with disabilities to participate in all aspects of their lives without barriers.

43. Disability Rights Laws • Architectural barriers Act of 1968 • Urban Mass Transit Act of 1970 • Rehabilitation Act of 1973 • Civil Rights Restoration Act 1988 • Air Carrier Access Act of 1988 • Fair Housing Act of 1988

44. American With Disability Act 1990 • Four Major Areas • Title I: Employment • Title II: Public Services • Title III: Public Accomodation and Commercial Facilities • Title IV: Telecommunications

45. Disability Rights Laws • Social Security Act • New Freedom Initiative • Resources for Disability rights: • http://www.ada.gov • www.mdod-maryland.gov • htttp://www.dors.state.md.us/dors • Maryland Statewide Independent Living Council 410-544-5412

46. Driver Education and Training • Obtain a physician referral for driver education or training • Pre-driving screening assesses • Vision , perception, cognition, functional ability, motor /sensory function and reaction time • Once completed a prescription for vehicle modification will be given • Vendor performs modifications and the modified vehicle is taken back to the program for inspection

47. Driver Education and Training • Driver training programs • Workforce and Technology Center 410-554-9205 www.dors.state.md.us • Sinai Hospital 410-601-8823 www.lifebridgehealth.org

48. Home Accessibility Resource Guide • Home Modification Equipment Supplies • Funding sources and Loan Programs • Home Assessment and Equipment Evaluation • Information and Referrals • Licensed Home Improvement Contractors • Volunteer Organizations

49. Vocational Rehabilitation(VR) • Vocational rehabilitation is a national program for assisting eligible people with disabilities to define a meaningful career goal and become employed • VR accomplishes its mission through Vocational Counseling and Guidance, VR services, Training and Education and Job Placement

50. Therapeutic Recreational Rehabilitation • BARS • Relaxation Training • Sports Education Series • Leisure Skill Development