Management of the multiple limb amputee

Issue : Multiple limb amputations involving at least one upper extremity are very uncommon. The amputation of both an upper and lower limb is even more uncommon. Due to the rarity of these amputations therapists are uncertain regarding the most appropriate treatment methods. While the majority of the protocols used for single limb amputations are appropriate for these multiple limb amputees, there are differences. Loss of multiple limbs creates a problem of overheating for the individual. Loss of an arm and leg results in difficulty donning the prostheses and difficulty using crutches and parallel bars during mobilization. Method : A review is given of 16 multiple limb amputees seen in our rehabilitation centre in the last 15 years. Return to work was seen in one third and was not related to the number of the amputations. A higher proportion of these multiple limb amputations occur through alcoholism or attempted suicide behaviour than occurs with either single upper limb amputations or lower limb amputations. This existing behaviour can create a management problem for the rehabilitation team during rehabilitation. Conclusion : Guidelines as to appropriate prosthetic and preprosthetic care are provided to assist the practitioner who has the acute and long term care of these patients. All multiple limb amputees should be referred to a specialized rehabilitation centre to discuss prosthetic options and long term rehabilitation requirements. This paper does not discuss bilateral lower limb amputations when not combined with an upper limb amputation.     

Management of the multiple limb amputee

Issue : Multiple limb amputations involving at least one upper extremity are very uncommon. The amputation of both an upper and lower limb is even more uncommon. Due to the rarity of these amputations therapists are uncertain regarding the most appropriate treatment methods. While the majority of the protocols used for single limb amputations are appropriate for these multiple limb amputees, there are differences. Loss of multiple limbs creates a problem of overheating for the individual. Loss of an arm and leg results in difficulty donning the prostheses and difficulty using crutches and parallel bars during mobilization.

Method : A review is given of 16 multiple limb amputees seen in our rehabilitation centre in the last 15 years. Return to work was seen in one third and was not related to the number of the amputations. A higher proportion of these multiple limb amputations occur through alcoholism or attempted suicide behaviour than occurs with either single upper limb amputations or lower limb amputations. This existing behaviour can create a management problem for the rehabilitation team during rehabilitation.

Conclusion : Guidelines as to appropriate prosthetic and preprosthetic care are provided to assist the practitioner who has the acute and long term care of these patients. All multiple limb amputees should be referred to a specialized rehabilitation centre to discuss prosthetic options and long term rehabilitation requirements. This paper does not discuss bilateral lower limb amputations when not combined with an upper limb amputation.     

Performance of persons with juvenile-onset amputation in driving motor vehicles

OBJECTIVE: To study the driving of motor vehicles by persons with juvenile-onset amputation and to compare the percentage of drivers among them with that found in the general population. DESIGN: A follow-up study of subjects who were younger than 18 years of age at amputation and who underwent one-sided amputation, covering the period 1976 to 1996. SETTING: The Prosthesis Service of the Asturias Central Hospital, Spain. SUBJECTS: A total of 236 juvenile amputee patients. RESULTS: The percentage of women with amputations who drive is lower than that of their male counterparts (p<.05). The percentage of drivers with upper limb amputations is greater than that of drivers with amputation of the lower limb (p<.05). Motor vehicle adaptations were used more frequently by people with upper limb amputations (p<.05). The ability to drive was not affected by the etiology or the side of amputation, or by the use of a prosthesis. The level of amputation affected driving ability in cases of amputation of the lower limb, but not in those of amputation of the upper limb. CONCLUSION: The percentage of persons with juvenile-onset amputation who drive (47.4%) is similar to that found in the general population (40.8%), and the use of a prosthesis does not have any influence on the capacity to drive a car--89.2% of drivers and 93.5% of nondrivers used a prosthesis.     

Mirror treatment of lower limb phantom pain: a case study

PURPOSE: Phantom limb pain (PLP) can be an enduring and distressing experience for people with amputations. Previous research has shown that 'mirror treatment' can reduce PLP for some people who have an upper limb amputation, and that it can increase a sense of motor control over the phantom in people with lower limb amputations who are not reporting PLP. There has been no previous report of therapeutic 'mirror treatment' for lower-limb phantom pain. METHOD: We present the first case study of the use of 'mirror treatment' in a person with a lower limb amputation who was reporting PLP at the time of treatment. RESULTS: During the intervention there was a significant reduction in his PLP, an increase in sense of motor control over the phantom and a change in aspects of the phantom limb that was experienced. CONCLUSION: This case study, conducted in a conventional clinical setting, supports the potential of 'mirror treatment' for PLP in people with a lower limb amputation.     

Amputations associated with arteriovenous access

This study was performed to investigate the common characteristics of hemodialysis patients who need upper limb amputations. An index case was identified and involved questioning physicians and reviewing hospital and office records. Hemodialysis patients who have diabetes and leg amputations are at high risk for ischemic episodes that may lead to amputation of the arm, distal to the arteriovenous access site.     

Mirror treatment of lower limb phantom pain: A case study

Purpose: Phantom limb pain (PLP) can be an enduring and distressing experience for people with amputations. Previous research has shown that 'mirror treatment' can reduce PLP for some people who have an upper limb amputation, and that it can increase a sense of motor control over the phantom in people with lower limb amputations who are not reporting PLP. There has been no previous report of therapeutic 'mirror treatment' for lower-limb phantom pain.

Method: We present the first case study of the use of 'mirror treatment' in a person with a lower limb amputation who was reporting PLP at the time of treatment.

Results: During the intervention there was a significant reduction in his PLP, an increase in sense of motor control over the phantom and a change in aspects of the phantom limb that was experienced.

Conclusion: This case study, conducted in a conventional clinical setting, supports the potential of 'mirror treatment' for PLP in people with a lower limb amputation.     

The experience of men using an upper limb prosthesis following amputation: positive coping and minimizing feeling different

Purpose. Psychosocial factors are likely to play a crucial role in adjustment to upper limb amputation and prosthesis use, and yet have received only minimal exploration within the literature. This study therefore, sought to gain a rich understanding of the experience of living with an upper limb amputation and of using a prosthetic arm and hand.

Methods. The qualitative method of Interpretive Phenomenological Analysis was used. Purposive sampling culminated in a homogenous sample of 11 males with unilateral upper limb amputations, who wore a prosthesis at least weekly. Semi-structured interviews were carried out, transcribed and analysed according to the methodology.

Results. Participants identified a theme of ongoing awareness of difference in appearance and ability. Consequently, participants described themes of psychosocial and functional adjustment to minimize this sense of difference. This was facilitated by the participants' prostheses and their positive coping style. Within this, participants also identified the personal meanings of their prosthesis and highlighted the terms of its use. The minimization of their sense of difference resulted in participants regaining a sense of worth.

Conclusions. The findings offer a greater psychological insight into adjustment from an upper limb amputation and the role of prostheses. These findings have implications for both the clinical rehabilitation of patients who undergo upper limb amputations, as well as for future research into the use and value of prostheses in facilitating the adjustment to this experience.     

Validation of the orthotics and prosthetics user survey upper extremity functional status module in people with unilateral upper limb amputation.

OBJECTIVE: To evaluate the measurement properties of the Upper Extremity Functional Status module of the Orthotics and Prosthetics User Survey (OPUS). DESIGN: Methodological research on an outcome measure administered by clinical interview. PATIENTS: A convenience sample of 61 adults who had unilateral upper limb amputations and completed rehabilitation at the Institute for Rehabilitation in Ljubljana, Slovenia, at least one year prior to interview. Thirty-four patients had undergone amputation of the dominant hand. Four patients did not use a prosthesis. METHODS: Rating scale analysis (Rasch model) was used to evaluate functioning of the rating scale categories, the validity of the measure by examining fit of items to the latent trait, and the hierarchy of item difficulties compared with expectations of the construct. RESULTS: Rasch analysis allowed us to improve the Upper Extremity Functional Status by rescoring to reduce the response categories from 5 to 4, and identifying 19 of 23 items that are useful to measure upper extremity function. The results allow us to have high confidence in the consistency of both person-ability and item-difficulty estimates. CONCLUSION: This revised Upper Extremity Functional Status is a promising instrument to measure the degree of manual functioning after a unilateral upper limb amputation.     

Mirror treatment of lower limb phantom pain: A case study

Purpose:?Phantom limb pain (PLP) can be an enduring and distressing experience for people with amputations. Previous research has shown that ‘mirror treatment’ can reduce PLP for some people who have an upper limb amputation, and that it can increase a sense of motor control over the phantom in people with lower limb amputations who are not reporting PLP. There has been no previous report of therapeutic ‘mirror treatment’ for lower-limb phantom pain.

Method:?We present the first case study of the use of ‘mirror treatment’ in a person with a lower limb amputation who was reporting PLP at the time of treatment.

Results:?During the intervention there was a significant reduction in his PLP, an increase in sense of motor control over the phantom and a change in aspects of the phantom limb that was experienced.

Conclusion:?This case study, conducted in a conventional clinical setting, supports the potential of ‘mirror treatment’ for PLP in people with a lower limb amputation.     

Nerve entrapment syndromes in the upper extremity contralateral to amputation

Five cases are reported of upper extremity amputation with no metabolic disease. Patients experienced pain, paresthesia and weakness in the intact extremity associated with electrophysiologic evidence of entrapment neuropathies. All patients did heavy manual work, and all had carpal tunnel syndrome. One patient also had cubital tunnel syndrome and compression of the medial cord of the brachial plexus in the axilla, and another patient had cubital tunnel syndrome and axillary neuropathy. Surgery did not relieve symptoms of carpal tunnel and cubital tunnel syndromes for prosthesis users until the figure-8 harness was changed. Patients who did not use a prosthesis felt relief of symptoms following surgical release. Possible mechanisms which produce nerve entrapment syndromes in patients with upper extremity amputations are use of one limb for heavy manual work over prolonged periods, direct compression of neural structures from the axilla loop of a figure-8 harness, and compression of neural structures in the axilla resulting in entrapment at a distal site. Changing the figure-8 harness should be considered prior to surgical decompression for patients who have upper extremity amputations with entrapment syndromes.     

Rehabilitation in dual disability of hemiplegia and upper extremity amputation: two case reports

Dual disability involving amputation and hemiplegia is relatively rare. The vast majority of these cases involve lower extremity amputations. In this report two patients sustained a right-sided hemiplegia complicating an old left upper extremity amputation. Through the comprehensive rehabilitation program these two patients were able to make gains, especially in some activities of daily living and in lower extremity functions. Since some of the upper extremity activities, such as dressing or bathing, could not be accomplished, it appears that patients with upper extremity amputation who have a contralateral hemiplegia have a poorer prognosis for achieving functional independence than patients with lower extremity amputation and similar neurologic loss.     

Goal attainment scaling in the rehabilitation of patients with lower-extremity amputations: a pilot study

OBJECTIVE: To assess the interrater reliability, construct validity, and responsiveness of Goal Attainment Scaling (GAS) among patients who have had lower-extremity amputations. DESIGN: Pilot study comparing GAS with 2 functional measures with established reliability, validity, and responsiveness values. SETTING: Regional amputee program in southwestern Ontario. PARTICIPANTS: Ten patients (6 women, 4 men; mean age +/- standard deviation, 72.3+/-10.7 y) with unilateral lower-extremity amputations who were consecutively admitted to a regional amputee program. The ratio of transtibial to transfemoral amputations was 6:4. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Subjects were assessed by using GAS, the Barthel Index, and the Locomotor Capabilities Index (LCI) of the Prosthetic Profile of the Amputee. RESULTS: The interrater reliability of GAS was r=.67, and 63% of goals developed were identified independently by both investigators. The construct validity between GAS and the Barthel Index and the LCI was r=.44 and r=.35, respectively. GAS was more responsive than both the Barthel Index and the LCI, as indicated by the calculation of effect sizes and relative efficiencies. CONCLUSION: This pilot study suggests that GAS is a promising outcome measure for the rehabilitation of patients with lower-extremity amputations.     

A comparison of upper limb amputees and patients with upper limb injuries using the Disability of the Arm, Shoulder and Hand (DASH)

PURPOSE: To use the Disability of the Arm Shoulder and Hand (DASH) scale to measure the disability of patients with upper limb amputation(s) and to compare these to other upper limb injuries. METHOD: All 274 patients over the age of 18 years presenting to Prince Henry Hospital in Sydney over a 4-year time frame were given the DASH assessment tool and asked to complete it under supervision of the Occupational Therapist. RESULTS: Patients with brachial plexus injuries, Complex Regional Pain Syndrome and bilateral upper limb amputations demonstrated significantly higher levels of disability to patients with unilateral upper limb amputations. Partial hand amputees reported a higher level of disability than major unilateral upper limb amputees. For the 48 patients who completed pre- and post-treatment assessments, there was a significant improvement in their health status. CONCLUSIONS: Further research is required to understand the factors that affect a patient's perceptions of their disability. Perhaps the definitive nature of an amputation and the immediate involvement of highly skilled health professionals serve to assist patients to accept their injury and therefore minimizes the level of disability.     

Motion pattern analysis for evaluation and design of a prosthetic hook

This study was designed to evaluate motion patterns of individuals with upper extremity amputations while performing a manual task. The objectives were to analyze performance time of repeatable motion elements that constituted the locomotion of upper extremity amputees, and to develop the performance profile which could be used as an evaluation method of hand prostheses. The findings identified a significant difference in performance ability for motion element grasp, as compared to motion elements reach, move, position, and release. Performance profile of amputee patients was introduced. The profile displayed the contribution of the various motion elements to the overall performance time. The performance profile was used to evaluate the standard prosthetic hook, and served as a criterion for the design of a new functional hook.     

Targeted reinnervation for improved prosthetic function

Target motor reinnervation can produce additional myoelectric control signals for improved powered prosthesis control. This reinnervation allows simultaneous operation of multiple functions in an externally powered prosthesis with physiologically appropriate pathways, and it provides more intuitive control than is possible with conventional myoelectric prostheses.Target sensory reinnervation has the potential to provide the sensory feed-back to the amputee that feels like it is in the missing limb. This concept has great potential for improving the function of people with upper limb amputations, especially for high-level amputations, in which the disability is greatest. It is hoped that future research will develop the technique further and build synergistically with other exciting research areas.     

Transmetatarsal amputation prosthesis with carbon-fiber plate: enhanced gait function

OBJECTIVE: To determine whether the design of a transmetatarsal amputation prosthesis with a carbon-fiber plate would improve gait pattern in patients with transmetatarsal amputations. DESIGN: In the gait laboratory in a tertiary medical center, eight male patients with transmetatarsal amputations were recruited. Nine able-bodied male volunteers were recruited as the control group. A full-length standard shoe and a transmetatarsal amputation prosthesis with a carbon-fiber plate were the footwear used. Our transmetatarsal amputation prosthesis included a custom-molded insole, a mounted toe filler, and a thin, lightweight, carbon-fiber plate incorporated directly beneath the insole. RESULTS: After wearing the transmetatarsal amputation prosthesis with a carbon-fiber plate, the results of the kinetic and kinematic studies were summarized. CONCLUSION: The transmetatarsal amputation prosthesis with a carbon-fiber plate improved gait pattern significantly in patients with transmetatarsal amputations. Drastic shoe modifications are not necessary to have the prosthesis inserted. The carbon-fiber plate functions like the spring-steel shank within the sole of the shoe. The carbon-fiber plate, the toe filler, and the total-contact insole are all mounted as a whole to ensure better foot contact. Therefore, our transmetatarsal amputation prosthesis with a carbon-fiber plate can be a good alternative choice of footwear in patients with transmetatarsal amputations.     

A comparison of upper limb amputees and patients with upper limb injuries using the Disability of the Arm, Shoulder and Hand (DASH)

Purpose: To use the Disability of the Arm Shoulder and Hand (DASH) scale to measure the disability of patients with upper limb amputation(s) and to compare these to other upper limb injuries.

Method: All 274 patients over the age of 18 years presenting to Prince Henry Hospital in Sydney over a 4-year time frame were given the DASH assessment tool and asked to complete it under supervision of the Occupational Therapist.

Results: Patients with brachial plexus injuries, Complex Regional Pain Syndrome and bilateral upper limb amputations demonstrated significantly higher levels of disability to patients with unilateral upper limb amputations. Partial hand amputees reported a higher level of disability than major unilateral upper limb amputees. For the 48 patients who completed pre- and post-treatment assessments, there was a significant improvement in their health status.

Conclusions: Further research is required to understand the factors that affect a patient's perceptions of their disability. Perhaps the definitive nature of an amputation and the immediate involvement of highly skilled health professionals serve to assist patients to accept their injury and therefore minimizes the level of disability.     

A comparison of upper limb amputees and patients with upper limb injuries using the Disability of the Arm,Shoulder and Hand (DASH)

Purpose:?To use the Disability of the Arm Shoulder and Hand (DASH) scale to measure the disability of patients with upper limb amputation(s) and to compare these to other upper limb injuries.

Method:?All 274 patients over the age of 18 years presenting to Prince Henry Hospital in Sydney over a 4-year time frame were given the DASH assessment tool and asked to complete it under supervision of the Occupational Therapist.

Results:?Patients with brachial plexus injuries, Complex Regional Pain Syndrome and bilateral upper limb amputations demonstrated significantly higher levels of disability to patients with unilateral upper limb amputations. Partial hand amputees reported a higher level of disability than major unilateral upper limb amputees. For the 48 patients who completed pre- and post-treatment assessments, there was a significant improvement in their health status.

Conclusions:?Further research is required to understand the factors that affect a patient's perceptions of their disability. Perhaps the definitive nature of an amputation and the immediate involvement of highly skilled health professionals serve to assist patients to accept their injury and therefore minimizes the level of disability.     

Spinal cord injury: prognosis for ambulation based on sensory examination in patients who are initially motor complete

The purpose of this retrospective study was to document that patients with motor complete injury, but preserved pin appreciation, in addition to light touch, below the zone of injury have better prognoses with regard to ambulation than patients with only light touch preserved. Medical records were examined of all spinal cord injury (SCI) patients admitted between 1982 and 1988. Twenty-seven Frankel B patients with upper motor neuron lesions admitted within 72 hours of injury were identified. These patients were divided into two groups (B-1 and B-2). Group B-1 (n = 18) were patients who had touch sensation but no pin appreciation below the zone of injury. Group B-2 (n = 9) were patients who had partial or complete pin appreciation and light touch below the zone of injury. The charts were examined for the patient's ability to walk independently using a reciprocal gait for at least 200 feet. The data were analyzed by the Fisher Exact test. Eight of the nine Group B-2 patients ambulated as compared to two of the 18 Group B-1 patients (p less than .0002). Frankel B SCI patients with only touch preserved below the zone of injury had poor prognoses for ambulation; those with preserved pin appreciation below the zone of injury had excellent prognoses to regain functional ambulation.     

Evaluation of prosthetic usage in upper limb amputees

Purpose: Upper limb amputations cause severe functional disability and lower the patient's self body image, with severe psychological implications. Many parameters are involved in the successful rehabilitation of upper limb amputations. The aim of this study was to investigate whether there are any parameters that might predict the successful prosthetic rehabilitation of upper limb amputees.

Method: The records of 45 patients who had undergone an upper limb amputation were traced. The patients were evaluated according to four parameters: (1) Modified upper extremities amputees' questionnaire; (2) Pain level according to Visual Analog Scale (VAS), range from 1 (lowest) up to 10 (highest); (3) Pain type - phantom or pain in the stump; (4) Functional assessment of prosthetic usage.

Results: Thirty (71.43%) of the patients reported difficulties with prosthesis usage. Twenty-three patients (54.76%) were satisfied with their prosthesis - 19 had cosmetic prosthesis and four had body-powered prosthesis.

Conclusion: No significant affect of the amputation level except for trans-wrist amputation with 100% prosthesis use. No significant difference was found between prosthesis type and the correlation to stump problems.

The above-elbow amputees, with dominant hand amputation, who used functional prosthesis (body-powered), achieved the best functional outcome and result.