Chapter 30 - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
Special Considerations- Rehabilitation Without Prostheses: Functional Skills Training
Joan E. Edelstein, M.A., P.T.
Prosthetic technology does not serve all the needs of every person with amputation. Even those who wear prostheses perform some activities such as bathing and donning undergarments without the device. Some individuals, particularly those with very proximal or very distal amputations, may choose to forego prostheses altogether. Although a trial fitting may demonstrate some functional or cosmetic value of a prosthesis, the patient, family, and clinicians may decide not to proceed with definitive fitting. Other clients, particularly those with multiple disorders, cannot cope with the physical demands of prostheses. A few individuals do not wear prostheses simply because they are unaware of current componentry and funding sources.
The nonuser challenges scientists to improve the prosthetic armamentarium so that future devices can enable the wearer to obtain greater function at less physiologic and financial cost. Nevertheless, the clinical responsibility is to guide each patient to achieve the highest degree of personal, vocational, and recreational independence. The intent of this chapter, therefore, is to delineate means to accomplish representative activities. Physicians and prosthetists should be familiar with the function that can be achieved by people with particular amputations who do not wear prostheses. Therapists can incorporate the suggestions in this discussion when training children and adults to enhance their quality of life, even if a prosthesis is not used.
SKILLS FOR PATIENTS WITH UPPER-LIMB AMPUTATIONS
Clothing Selection and Dressing
Many garments and modifications suitable for patients with hemiplegia also serve the needs of individuals with unilateral amputation. Adaptations should be as inconspicuous as possible, with accessories such as loops and pressure-sensitive tape the same color as the garment. Loosely fitting clothing is more convenient than snug apparel. Larger buttons are easier to manipulate with one hand than are small ones; alternatively, pressure-sensitive tape can be sewn under buttons to preserve the appearance of a buttoned front yet facilitate dressing. Snaps and magnetic closure are even less cumbersome than buttons. Slippery fabric is more manageable than knitwear. Front rather than back or side openings simplify dressing. Step-in skirts and dresses are easier to don than those that must be pulled on overhead. Slip-on shoes are recommended, although styles with pressure-sensitive flaps are readily available. Some individuals replace regular laces with elastic ones. Many people, however, have no difficulty in tying shoe laces with one hand; lacing without crossing the ties aids tightening the laces because the end of the lace can be readily fashioned into a slip knot.
A button hook and a zipper pull may be handy. A dressing stick held in the antecubital fossa enables the user to don and remove coats and shirts rapidly. The stick has a large hook at one end.
Donning slacks is easiest if they are placed on a bed near a wall. The client inserts one leg and then leans against the wall to hold that side while putting the other leg into the garment. Shirts are donned by first inserting the amputated limb in its sleeve and then the sound limb into the other. A buttoned cuff should be fastened before donning the shirt; securing the cuff button with elastic thread may be needed to allow the hand to slide easily through the cuff. A necktie can be knotted one-handed, particularly if the narrow end of the tie is held to the shirt with a tie clasp. A pretied, clip-on necktie is another option. To don a glove, rub it against the hip in the same direction as the hand is inserted. Once the hand is part way into the glove, one can use the back of a chair to work the fingers into place. A mitten, however, is simpler to manage. A watch with an expandable bracelet goes on more quickly than one with a buckled strap. To put the watch on the sound wrist, the individual lays the watch on a table and cups the fingers inside the band, then uses the table edge to slide the watch onto the wrist.
The adult who acquires bilateral amputation should be guided to make maximum use of the remaining portions of the amputation limbs when performing daily activities such as dressing. The antecubital fossae and, to a lesser extent, the axillae are useful to hold items. Objects may be stabilized in the teeth and between the thighs. Some adults are limber enough to be able to grasp with the feet.
The child with congenital bilateral limb deficiencies should be encouraged to manipulate with the feet.They provide the individual with tactile sensation and considerable prehensile skill, thus reducing reliance on adaptive equipment and help from others. The family and patient may require psychological support to overcome societal aversion to seeing one accomplish ordinary tasks with the feet while sitting on the floor.
For people of all ages, selection and modification of undergarments are especially important to foster independence. Underpants may have two tape loops sewn to the waistband. The client can then hang the pants on two wall hooks installed at a height suitable for stepping into the pants. Once they are on, the client rises on the forefeet to release the loops. A single padded hook or wooden knob on the wall can be used to aid dressing. One section of the trousers, skirt, or shirt is secured to the hook while the patient maneuvers into the garment. An alternative for donning both underpants and outer pants is placing them on the floor, then inserting the feet into the pants legs, and then raising one's legs. Shaking the torso and legs causes the pants to slide upward. When they are at the buttocks, the individual utilizes friction between the floor and trousers to work the garment into place.
Children with a phocomelic hand can manage underpants to which a tape has been sewn from the midfront waistband to the midback waistband; the tape drapes over the front and continues to the back of the garment. With a reacher, a stick with a hook at one end, the client can lower and raise the pants. Some girls and women find that underpants modified with a split crotch facilitate toilet activity. Undergarments designed for incontinence are another option to augment security.
Grooming and Hygiene
Although little difficulty should be encountered, some people like the convenience of scrub and denture brushes, nail file, and clipper each equipped with suction cups. One can also stabilize a nail file or emery board between the thighs. Shaving is speeded by filling the cheeks with air to make the skin taut.
Clients with bilateral below-elbow (transradial) amputation can use a sponge mitt over one forearm for soaping and scrubbing. Alternatively, a terry cloth mitt can hold a bar of soap. For cleansing while in the shower, the patient can loop one end of a strip of toweling over the shower head by maneuvering with both amputation limbs. The other end of the strip adheres to the tub floor by means of suction cups. Most individuals can operate faucets with the feet, particularly if the faucet has a flange rather than a knob handle. Similarly, flanged faucet handles at the wash basin are convenient. A terry cloth bathrobe simplifies drying one-self.
Before toileting, outer and undergarments must be loosened or removed. For men and boys, the trouser zipper may be left partially open, covered by the hem of an overshirt. The individual can urinate independently, particularly if he does not wear undershorts. Defecation is aided if the client wears slacks with suspenders so that he can pull the trousers down by grasping the pants leg with the toes.
Some individuals regulate the diet in order to defecate at home in the morning or at night. Perineal cleansing can be accomplished by foot and trunk motion. Paper is held in the toes or placed over the heel; the patient then rocks over the foot. Others drape paper over the rim of the toilet and straddle the bowl to wipe themselves. A bidet or special toilet seat equipped with a water spigot and warm airflow is suitable for the home.
Kuhn described a vaginal tampon applicator for women with bilateral amputation. Other hygienic aids can be constructed easily.
The individual with phocomelia can use a reacher stick with a padded hook or wire coil at one end to secure toilet paper. Various grooming aids may be attached to a similar stick, such as a comb, hairbrush, and toothbrush.
An electric floor model shoe buffer enhances one's appearance.
A commercial fork clip secures the utensil to the plate so that the sound hand can cut. A snap-on plate guard is useful for the beginner and serves as a stable area against which one can push food. The rocker knife facilitates one-handed cutting; one model has prongs so that the user can spear food morsels. Alternatively, the diet can omit meats and other foods that one would have to cut. Techniques for buttering bread and opening a milk carton are easy to learn.Chopsticks are another mode of one-handed dining.
A utensil holder designed for individuals with quadri-plegia can be worn on the forearm of the client with at least one transradial amputation limb. The holder accommodates a spoon or fork. If the amputation limbs are long enough, the patient does not need any device to hold eating utensils; he or she merely stabilizes the fork or spoon with both limbs.
The person with amputation of the right hand will find that writing with the left hand is easier with a table rather than a right-armed writing desk. The client should slant the paper in the opposite direction from that used by right-handers to avoid twisting the left arm into a cramped posture. One-handed touch-typing methods devised for individuals with cerebral palsycan be used by the person with unilateral amputation. Paper insertion is aided if the typewriter has a lever that positions the paper on the platen automatically. A self-correcting feature helps the one-handed typist. Special typewriters for one-handers are available, as are computer keyboards designed for unimanual use. For telephone dialing, the patient can place the receiver on the desk or use a commercial holder that eliminates the need to stabilize the receiver against the shoulder with one's head while writing a message.
When writing, the client can secure the paper in a clipboard and use the transradial amputation limb or the chin to nudge the paper into position. Some agile individuals can manage a commercial one-handed writing board that clamps the paper and has rubber feet to prevent the board from slipping. The pen can be held in a forearm cuff, the teeth, or if one is limber, the toes. The client with bilateral transradial or elbow disarticulation amputations can use both limbs to stabilize a pencil, pen, or crayon for writing and drawing. The beginner will find that a felt-tipped pen makes writing easier.
Homemaking and Other Vocations
A full range of cooking can be achieved by the one-handed person. An apron with a semirigid plastic clip rather than fabric ties can be slipped onto the waist with one hand. A board with stainless steel holding pins secures potatoes and other firm vegetables so that one can peel with the sound hand. One-handed jar openers, beaters, mashers, and choppers are readily available. Lightweight bowls and pans can be lifted single-handed. A mixing bowl can be stabilized by placing it on a rubber mat or setting it into a bowl holder or into a drawer that is closed snugly against the bowl. Eggs can be broken one-handed, or the novice can use an egg separator.
Some chores such as folding laundry are aided by using the teeth as a holder. Other activities such as those involved in child care can be managed efficiently by using one hand while securing the infant against one's torso with the amputated limb or relying on the crib or other flat surface for stability.
Sewing begins with threading the needle, which can be secured by slipping it into one's shirt sleeve, skirt, or trouser leg, or one can use an automatic needle threader. Left-handed scissors are sold in most needle-craft shops. Embroidery and extensive sewing are less arduous if one uses an embroidery hoop on a floor stand, which frees the hand to sew. One-handed knitting is expedited by a knitting holder clamped to a table.
The amputation limb makes an effective stabilizer in many carpentry and office tasks. The technique of setting nails with one hand relies on the force one can obtain from the hammer head against which the nail is held. Farm equipment and work site modifications enable the client with unilateral amputation to accomplish most tasks efficiently. Because farming and many other vocational and avocational pursuits involve operating a vehicle, the use of a spinner knob on the steering wheel should prove helpful.
A reacher stick can help the client engage in light household tasks. Those with bilateral transradial amputations may make considerable use of the antecubital fossae for holding packages, which can then be opened with the teeth.
Recreation: Games and Sports
One can shuffle cards one-handed or use a bowl or hat to hold them; commercial playing card shufflers are inexpensive alternatives. Simple devices aid the golfer, gardener, carpenter, and fishing enthusiast.For example, a one-hand fishing vest holds the rod so that the user can cast and retrieve. An alternative is a broad waist belt fitted with a pocket to hold the pole. The camera tripod can be modified to support a bow for the archer who has unilateral amputation. Cameras designed for one-handed operation feature a pistol grip, a trigger to snap the shutter, and an automatic focus mechanism. The billiards player can use a mobile bridge to support the cue stick; mounted on two wheels, the bridge has a hole for the stick. Wrist disarticulation does not preclude a career as a major league baseball pitcher.
Book holders are offered by many special equipment manufacturers. The reader turns pages with the bare amputation limb or a mouth stick; commercial page turners are an expensive alternative. A leather mitt riveted to the side of each aluminum ski pole accommodates the skier with transradial amputations. A champion tennis player has bilateral longitudinal deficiencies.
Among the recreational options for patients with upper-limb amputation is musical participation. Children and adults play many instruments, sometimes aided by simple modifications or variation from customary performance practice.
The individual with transradial amputation can support the trumpet on the amputation limb, with an adapted neck strap, or on a custom-made stand. Although valves are designed for the right hand, they can be depressed with either hand.
The French horn is particularly suitable for those with amputation. Conventional performance assumes valve control with the left hand; thus the musician with right transradial amputation places the bare amputation limb in the bell. A cupped cardboard or plastic fixture mounted in the bell facilitates pitch regulation. A person with left amputation can play in reverse, although balancing the horn will be cumbersome. If the player develops a serious interest, an instrument with tubing coiled in reverse can be ordered from the manufacturer. Instrumentalists with left amputation can manage the larger brasses such as the tuba by supporting the instrument on the lap or on a commercial chair-stand and working the valves with the right hand.
Numerous ways of striking percussion instruments such as drums and xylophones make them accessible to virtually all individuals with amputation. The musician with transradial amputation holds the mallet or stick in the intact hand and has the other mallet secured to a snugly fitting leather cuff on the forearm. A double-headed drum stick enables the bass drummer to play while marching. Tambourines and bells are ideal for the person who can hold the instrument in the sound hand.
The person with transradial amputation can strum a guitar with a pick secured in a forearm cuff. Some musicians with transcarpal amputation who retain wrist motion hold the pick in the wrist. Those with left amputation reverse the strings and bridge and, for the steel-stringed guitar, the pick guard also. Commercial left-hand guitars are another option. The conventional strap aids in supporting the guitar, as does the footrest ordinarily used on the right side. The banjo and ukulele can be played in a similar manner.
The piano and other keyboard instruments can be played one-handed, with music chosen from the large literature ranging from elementary to virtuoso pieces. Electronic keyboard instruments are another option for unimanual playing.
The musician with bilateral transradial amputation can sit and support the bell of a trumpet on the leg; valves are pushed with either or both amputation limbs, depending on the note. The bugle can be held and played by anyone with unilateral or bilateral transradial or above-elbow (transhumeral) amputations without prostheses. It can be held by either intact limb or by a neck strap or floor stand; because it has no valves, pitch is determined by the musicians mouth. Assembling the instrument is accomplished by asking a friend to assist, or the player can use the broad, resilient surfaces of the transradial limbs to stabilize the brass segments.
Borrowing from the one-man-band tradition, persons with unilateral and bilateral amputation can obtain a rigid neck support for the harmonica to facilitate playing by moving the mouth along the instrument rather than the usual method of moving the instrument along the mouth. One or a pair of leather cuffs worn by a percussionist with bilateral transradial amputations enables playing the triangle, chimes, and gong suspended from a stand. Shaken instruments such as mara-cas can be secured with the cuffs, particularly if the handle is covered with friction tape to increase stability in the cuff. A snugly fitting sandal modified to hold a plastic pick enables one to play stringed instruments with the foot. One guitarist simply strums with the pick held in the toes.
The piano and other keyboard instruments are accessible to children with phocomelia who play by sitting on a low stool so that they can extend their small limbs to reach the keys with bare fingers.
SKILLS FOR PATIENTS WITH LOWER-LIMB AMPUTATIONS
The functional problems that attend lower-limb amputation differ from those associated with loss of the upper limb. The foregoing section indicates that the patient with unilateral upper-limb amputation who does not wear a prosthesis can accomplish daily and vocational activities rather easily, often without using assistive devices; basic skills are, however, much more daunting for the client with bilateral upper-limb amputation. In contrast, the individual with amputation of one or both legs who does not wear prostheses is likely to experience considerably more difficulty during certain tasks, especially locomotion, than those who are able to use prostheses.
Dressing and Clothing Selection
The individual who intends to ambulate with a pair of crutches should select a low-heeled shoe for the sound foot. The shoe should also have a laced or strap fastening high on the dorsum of the foot to prevent the shoe from slipping off the foot when the patient swings the leg while walking.
Unilateral and Bilateral Amputation
A bath chair with a plastic seat and rubber-tipped legs contributes to safety in the shower or bath. Some models of chair have an extension that fits over the edges of the tub to aid transfer. Strategically placed wall-mounted bars increase safety during transfers. A survey of 500 patients indicated that 80% sat on the shower floor to bathe; those who stood or used a stool, predominantly those with bilateral amputations, relied on grab bars to assist balance.
The patient who does not wear a prosthesis may be able to manage with a pair of axillary or forearm crutches. Some individuals in good physical condition, with particular regard to the upper limbs, heart, and lungs, walk smoothly and efficiently for long distances with crutches. Young adults with hip disarticulation or transpelvic amputations are likely to opt for crutches rather than wear a relatively cumbersome prosthesis. For those who rely on a wheelchair, crutch walking may facilitate maneuvering in small or crowded rooms. Occasional use of crutches counteracts the negative consequences of prolonged sitting, such as the formation of contractures and pressure sores.
Crutches must be the proper length. The hand piece should be set at a point that permits the user's elbow to be slightly flexed. A rubber hand cover reduces the risk of the patients hand slipping, especially if the hand is wet with perspiration. Alternatively, some individuals prefer to wear gloves to increase control of the crutches. The top of the axillary crutch should be two finger widths from the axilla to avoid compression of the superficially located radial nerve. A rubber cover increases the friction of the axillary piece, which should be kept next to the chest. For both styles of crutch, the tip should be a large suction one to increase traction on the floor.
Good posture requires that the crutches be kept parallel to the trunk to minimize pressure on the chest. The body should progress forward in a continuous manner. The patient should move the amputation limb in the opposite direction from the sound leg rather than maintaining the residuum flexed in order to create a rhythmic, swinging gait.
Walking with crutches without a prosthesis is stressful and associated with markedly elevated heart rates for those with amputations, whether for vascular disease or trauma. Waters and colleagues found that heart rates were elevated to an average of 130 beats per minute among crutch users, comparable to the stress that jogging imposes on nondisabled persons. Consequently, for most individuals, crutches should be considered only for traveling short distances.
Forearm crutches are safer on stairs and uneven ground than are axillary crutches. Among subjects with above-knee (transfemoral) amputation, the use of forearm crutches resulted in a freely selected speed that was 15% to 40% slower than that chosen by nondisabled persons; energy cost per unit distance ranged from 48% to 70% greater. When the same subjects were tested with their prostheses, walking speed was 12% to 33% slower than control subjects, at a metabolic cost 30% to 40% greater than normal.
Patients whose balance is poor or whose arms are not strong require the added support of axillary crutches. Erdman and coworkers reported that nine subjects with transfemoral amputations consumed approximately the same amount of energy whether walking with axillary crutches or with a prosthesis, although the pulse rate averaged 39% higher with the crutches. Six of the subjects were younger than 40 years of age. Using a single axillary crutch often promotes a significant shift of body weight toward the crutch and subjects the patient to the risk of impinging vessels and nerves in the axilla.
Stair ascent on crutches is somewhat less intimidating than descent. One can increase safety by keeping the crutch tips close to the edge of the step with the crutches inclined toward the top of the stairs. Evaluation of ten young adults demonstrated that they consumed 49% more energy on stair ascent with axillary crutches than did nondisabled control subjects. Ten patients with below-knee (transtibial) amputations performed more poorly with crutches than when wearing prostheses. Crutch use was associated with greater energy cost and slower speed; subjects had to lead with the intact leg and then raise the crutches. With the prosthesis, they could climb step over step. Young adults with transtibial amputation were 48% less efficient with crutches but only 29% less efficient with prostheses as compared with nondisabled adults.
Hopping is another means that patients in good physical condition use to move over relatively short distances. Even those individuals who use a prosthesis may hop to get to the swimming pool from the locker room. The patient should endeavor to land lightly with a springy step on each hop to prevent spraining or fracturing the foot. The trunk should incline slightly forward, and the individual should lift the foot from the ground as short a distance as possible.
To traverse very brief distances, the patient may prefer to pivot on the foot, alternately on heel and forefoot. The maneuver is less stressful than hopping.
To operate an automobile, the driver with a right amputation should have a car equipped with a hand parking brake, hand dimmer switch, and left foot accelerator pedal.
Many people with bilateral amputation require a wheelchair. The chair should have its rear wheels set back to compensate for the posterior shift of the user's center of gravity. While swing-out footrests are appropriate for those who wear cosmetic or functional prostheses, those who do not wear prostheses can transfer to and from the chair more easily if there are no foot-rests. A reclining wheelchair relieves the discomfort of prolonged sitting. An overhead trapeze bar facilitates moving from the bed to the wheelchair, particularly when elbow extensors are not strong enough to lift the body weight. For other transfers, a wood or plastic sliding board may be used. The board bridges the gap between the wheelchair and the transfer goal, such as the bed. With the board in place, the individual can shift weight from one buttock to the other in a diagonal manner to maneuver from one surface to the next. Another option is a series of sturdy boxes of graduated height leading from the floor to the wheelchair seat. The patient shifts from one box to the next with support by the buttocks and hands.
Some individuals who can tolerate weight bearing through the ends of the amputation limbs, such as a person with bilateral knee disarticulations, can walk either unassisted or with the support of short canes or crutches. Others may find a cart or a low platform on casters suitable for scooting about the home, with the hands used for propulsion. Such a vehicle can be used in areas too narrow for a wheelchair.
In an emergency, the patient can negotiate stairs by sitting on the top stair and lowering the trunk. Descent is controlled with the hands, which are placed on the tread or bannister posts. Climbing stairs in this fashion is more difficult but is less likely to be required.
The automobile should be equipped with hand controls for safe operation. The controls, however, should augment rather than replace conventional foot controls so that the car can be driven by other family members or a mechanic.
Numerous adaptations, described elsewhere in this book, enable many individuals with unilateral and bilateral leg amputations to engage in a wide variety of sports and other pastimes.
While many clients choose to swim and scuba dive without a prosthesis, they must have a means of moving from the dressing room to the water's edge, such as by hopping or using crutches. Swimming provides superb recreation as well as good exercise. Agile individuals can play several sports while balancing on crutches, for example, kick ball and soccer. Other sports that do not require the use of a prosthesis include mountain climbing, skiing, and sky diving.
Swimming is popular with some people having bilateral amputation, for they can use their upper limbs as the power source. The water enthusiast can obtain a wet suit or swim fins to fit the amputation limbs. A plastic wheelchair is ideal for beach use. Activities popular with paralyzed wheelchair users also suit individuals with leg amputation. Tennis, basketball, bowling, hockey, and dancing can be enjoyed by the seated individual. Other recreational pursuits enjoyed by those with bilateral leg amputation include horseback riding, motorcycling, skateboard stunts, mountain climbing, and weight lifting.
Individuals with amputation, whether upper or lower limb, accomplish many personal activities without prostheses. Occasionally, patients do not wear any appliances because of the inordinate exertion of walking with prostheses or a preference for being unencumbered by devices or because they or their professional counselors fail to present financially, mechanically, or cosmetically acceptable options.
Patients with unilateral or bilateral upper-limb absence can be guided to select clothing that is easy to don, with or without prostheses. The clinic team should encourage the child with bilateral upper-limb deficiency to capitalize on the tactile and prehensile capabilities of the feet so that the youngster may develop proficiency in dressing as well as writing, feeding, and other skills. At all ages, the teeth are useful for grasping. Many nonprosthetic techniques enable adults and children to complete grooming and hygienic care and eat a varied diet gracefully. Writing and keyboard usage, important for school and vocation, can be done with simple adaptation of basic implements and thoughtful selection of typewriters, computers, and other equipment. Virtually all homemaking duties can be managed without prostheses, sometimes borrowing techniques developed for persons with hemiplegia. A wide range of games, sports, and other recreational pursuits are within the compass of those who do not wear prostheses.
Similarly, children and adults who do not wear lower-limb prostheses can learn suitable clothing styles and safe bathing procedures. Alternatives to prosthetic locomotion include crutches, hopping and pivoting, and operation of a wheelchair and automobile. Recreational endeavors with and without prostheses and with or without special equipment are burgeoning.
Rehabilitation of the client with amputation is not synonymous with prosthetic fitting and use. Rather, the individual should be assisted to maximize personal, vocational, and recreational function whether or not prostheses are worn. Then can the goal of community entry, or re-entry, be achieved.
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Chapter 30 - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles