Chapter 28 - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
Psychological Adaptation to Amputation
John C. Racy, M.D.
*Portions of this chapter appeared previously in Racy JC: Psychological aspects of amputation, in Moore WS, Malone SJ (eds): Lower Extremity Amputation. Philadelphia, WB Saunders, 1989, chap 26. Used with permission.
Amputation is a triple threat. It involves loss of function, loss of sensation, and loss of body image. The wonder of it is that so many adapt so well, thanks to their resilience and the ingenuity and dedication of those who care for them. The experiences of many people at the University of Arizona College of Medicine and elsewhere have been incorporated into this chapter. Reference will be made to an amputee self-help group in the Tucson area, and quotes from its members will be inserted into the text to illustrate points under consideration.
DETERMINANTS OF PSYCHOLOGICAL RESPONSE
The observed psychological response to amputation is determined by many variables. These can be conveniently grouped into psychosocial variables and medical variables reflecting the premorbid health and the medical and surgical management of the amputee.
The degree of psychological difficulty associated with amputation generally increases with age, all other considerations being equal. Infants born with a congenially missing limb adapt adequately as they learn to make compensatory use of their remaining faculties. Children adapt well to the loss of function and manipulate prostheses and other limbs with great agility. They are particularly sensitive to peer acceptance and rejection. Amputation in the preadolescent or adolescent age group is a great threat to emerging sexual identity.For example, a 13-year-old member of the Tucson self-help group interviewed for this report reacted to the news that a leg amputation was necessary to cure her osteogenic sarcoma with the statement, "No boy is going to look at me."
Among young adults, the response to limb loss depends on its causes and the degree of disability and disfigurement. They do enjoy the advantages of an established identity, physical resilience, and social confidence. Hence, they tend to adapt well.
Among the elderly, ill health, social isolation (especially after the death of a spouse), financial stringencies, and occupational limitations may all conspire to complicate adjustment to the limb loss. There is some controversy in the literature over the correlation of age and long-term emotional consequences of amputation. Several early studies suggested that elderly amputees were at greater risk for psychiatric disturbances such as depression. More recent studies find just the opposite. In either case, the greatest challenges for the young amputee are in terms of identity, sexuality, and social acceptance, and for the elderly, in terms of livelihood, functional capacity, and interpersonal deal-ings.
Individuals who are narcissistically invested in their physical appearance and power tend to react negatively to the loss of the limb. They see it as a major assault upon their dignity and self-worth. Conversely, dependent individuals may cherish the sick role and find in it welcome relief from pressure and responsibility.
Those with a premorbid history of depression are more susceptible to dysphoria following amputation.The loss serves to crystallize notions of a basic defect, sometimes expressed in self-punishing behaviors.
Timid and self-conscious individuals who are excessively concerned about their social standing are more likely to suffer psychologically from limb loss than are self-assured individuals.
Unexpected reactions may arise from secondary gain. If disability results in improved financial or social status, psychological adjustment may be made easier, especially if those gains are not directly challenged.
Should the amputation bring about the resolution of a psychological conflict, be it conscious or otherwise, the individual may indeed be happy that it occurred.
Although Kolb and Brodie report that rigid personality style may predispose to a greater incidence of postoperative complications, including phantom pain, the recent literature review of Sherman et al. indicates no relationship between such a personality and phantom pain. Those tending toward a pessimistic or paranoid outlook are likely to find their worst expectations confirmed, and their rehabilitation may be colored by much bitterness and resentment.
Economic and Vocational Variables
It stands to reason that individuals who earn their living from motor skills that are lost with the amputation are especially vulnerable to adverse reactions. Others who have a wide range of skills or whose main line of work is not particularly dependent on the function of the lost limb may experience less emotional difficulty. Of course, no amputee is completely insulated from the emotional consequences of discriminatory practices, subtle or otherwise, in the workplace, the prohibition of which by federal law notwithstanding. Unemployment is associated with a greater degree of psychological stress and may be a predictor of phantom pain.
All human beings require a support system throughout life in order to maintain emotional health. However, not all are so blessed, and many find themselves transiently or permanently in a state of isolation. Single and widowed individuals suffer more psychological distress and difficulty in adapting to amputation than do those who are married and have a family. Particularly helpful in the adjustment of the adult amputee is the presence of a supportive partner who assumes a flexible approach, takes over functions when needed, cuts back when the amputee is able to manage, but at all times maintains the amputee's self-esteem.
As might be predicted, parents are the major source of support for children and adolescent amputees.But peer acceptance beyond the family is critical in the successful adaptation of all amputees and, especially, as mentioned above, children and adolescents.
Healthy, young individuals who lose a limb traumat-ically have many advantages over older, frail individuals. Among the elderly-who, in fact, constitute the vast majority of amputees-the surgery usually comes after a prolonged period of treatment for peripheral vascular disease, often combined with at least two other medical disorders. These disorders are likely to set a limit on functional restoration and the return to an active life-style.
Mental health problems can easily enter into the picture through a complicated series of psychosomatic and somatopsychic responses to the loss. Shukla and coworkers studied 72 amputees prospectively in India and found that nearly two thirds manifested postoperative psychiatric symptoms, the most common of which was depression, followed by anxiety, crying spells, insomnia, loss of appetite, and suicidal ideation. In this regard, depression-with its attendant loss of energy, pessimism, and psychomotor retardation-may delay rehabilitation, a delay that in turn exerts a depressing effect on the individual. Furthermore, anger often underlies the depressive reaction described earlier. In a study of 46 amputees seen in London, Parkes found that
Among the 38 amputees who were thought to have some overall limitation of function attributable to psychological origin, factors inculpated, in order of frequency, were depression, timidity, fear of further self-injury, self-consciousness, low intelligence, senility, anger, resentment of the need to rely on others, and secondary gain.
Reason for the Amputation
Much of the earlier work on amputation in this century centered on wartime casualties. The current situation is quite different in that the amputation affects a much older age group and follows either trauma or chronic illness rather than combat. A wartime situation in which the injury to the limb might lead to evacuation, honorable discharge from the service, and rehabilitation to civilian life is not often seen today. Adults suffering a traumatic or accidental limb loss tend to react with varying forms of denial and bravado. Those who undergo an elective amputation for the cure of a malignancy benefit from the availability of time for preparation and exploration of alternatives. The reaction is usually one of realistic acceptance and cooperation with the treatment team. Such individuals seem to make an excellent adjustment, assuming of course that the malignancy has been cured.
For the elderly, surgery usually occurs after a long period of suffering resulting from diabetes and peripheral vascular disease. Most accept the surgery with relief since it often signals the end of suffering and the return to improved functioning. Some react indifferently or negatively and view the surgery as proof of failure.Amputation necessitated by the negligent or malicious behavior of others is likely to produce persistent feelings of resentment and self-doubt. Litigation can easily complicate the process of rehabilitation and recovery.
Preparation for the Amputation
There is little doubt that those individuals who have had adequate warning and preparation fare better in the immediate postsurgical period, whereas those who do not receive such preparation tend to react negatively or with massive denial. It is less clear whether these differences persist, given that adaptation is governed ultimately by many other variables preceding and following the amputation.
In general, the greater the loss, the greater the difficulty in adjustment. There are, however, instances of massive psychological reaction to small physical losses- for example, the loss of a toe or a thumb-and of minimal reaction to severe loss of several limbs. It is not clear whether lower-limb loss is harder to accept than upper-limb loss, as had been suggested.Above-elbow (transhumeral) amputation brings with it great anxiety and frustration, and bilateral transhumeral amputation is perhaps the most difficult situation of all. Contrarily, amputation of one leg below the knee allows relatively good adjustment, with restoration of both function and body image.
Those individuals who suffer pain, infection, and residual-limb revision tend to develop greater degrees of despair and withdrawal than those who do not. This highlights the importance of surgical skill in the performance of the amputation. As noted in an earlier communication, "A poorly performed amputation almost guarantees poor rehabilitation. While a well-performed amputation does not guarantee a successful rehabilitation outcome, it certainly makes successful rehabilitation more possible."
The earlier a prosthesis is applied, the less the psychological distress observed after amputation. Conversely, if the prosthetic application is absent or delayed, greater degrees of anxiety, sadness, and self-consciousness are noted. The crucial elements appear to be the integration of the prosthesis into the body image and the concentration of attention on future function rather than on past loss.
Extremes of age are by no means intrinsic contraindications for prostheses. However, among the elderly, pre-existing illness may compound the difficulties of adjusting to such devices. For example, elderly amputees with chronic obstructive pulmonary disease are already compromised with respect to strength and endurance. Nonetheless, they deserve a trial period of rehabilitation with a prosthesis, albeit under close supervision.
The Team Approach
Because adaptation to amputation is so multifaceted and because it is an evolving process requiring different kinds of attention at each stage, the team approach has emerged as the standard approach to rehabilitation.
The range of skills and points of view represented in a team increases the probability that all aspects of rehabilitation will be addressed and none overlooked. The team may include members of the family and successfully treated amputees. Amputee self-help groups are further extensions of this approach.
Restoration of the capability for gainful employment is an integral part of the patient's recovery. Kohl notes that amputees may regard unemployment as a "denial of their 'right' to participate in the family's decision making processes." It is her view that "the success of rehabilitation efforts should not only be measured by return to income-producing work, but rather the return to the person of his decision-making abilities to choose the lifestyle that would be most fulfilling to him."
STAGES OF ADAPTATION
The psychological reactions to amputation are clearly diverse and range from severe disability at one extreme to a determined and effective resumption of a full and active life at the other. It is useful and customary to think of the process of adaptation as occurring in four stages. With the exception of the clear demarcation between preoperative and postoperative stages, most of the adjustment occurs in a gradual and often invisible continuum. A division into four stages, however, allows for the highlighting of issues that arise most critically at each point in time.
Among amputees for whom there is ample opportunity to be prepared for surgery, approximately a third to a half welcome the amputation as a signal that suffering will be relieved and a new phase of adjustment can begin. Along with this acceptance, there may be varying degrees of anxiety and concern. Such concerns fall into two large groups. First and, perhaps for most persons, the more important are such practical issues as the loss of function, loss of income, pain, difficulty in adapting to a prosthesis, and cost of ongoing treatment. Second are more symbolic concerns such as changes in appearance, losses in sexual intimacy, perception by others, and disposal of the limb. Most individuals informed of the need for amputation go through the early stages of a grief reaction, which may not be completed until well after their discharge from the hospital. Dise-Lewis suggests that the death and dying paradigm may be usefully applied to the amputees impending loss of a body part, a loss that may threaten the amputee's core identity.
The manner in which the surgery is presented by the surgeon can have much bearing on the magnitude and kind of affective response. Mendelson and coworkers recommend that the surgeon paint a realistic picture of the immediate and long-term goals for the patient and his family. Labeling the amputation as a reconstructive prelude to an improved life is a much different matter from implying that it is a mutilation and a failure. Furthermore, a hopeful attitude, detailed explanation of all aspects of the surgery and the rehabilitative process, and full response to all questions (especially those that seem trivial) appear to diminish anxiety, anger, and despair.
Several members of the self-help group interviewed for this report eloquently described the consequences of failed communication. One who regarded her impending amputation as "losing a member of my family" felt scared "out of my wits" and was repeatedly "horrified." She reported that her surgeon had described her as his "failure" and told her very little about the details of the surgery and the process beyond. Another, when informed that she would lose her leg, reacted with the thought, "They might as well take off my head."
Those group members who did have the opportunity to receive adequate preparation before the surgery commented on it as having contributed materially to their peace of mind after the event. But the process took time and effort. One member of the group described her reaction as one of ambivalence and oscillation. She switched repeatedly from acknowledging that the amputation was to be expected, and even desirable, to great fear and dread. "Like a ghost in my closet," she said, "I took it out now and then to scare myself with it."
Immediate Postoperative Stage
The period between the surgery and the start of rehabilitation may last a matter of hours or days, depending, among other things, on the reason for the amputation, the extent and condition of the residual limb, and the kind of rehabilitation thought to be feasible. Psychological reactions noted in this phase are concerns about safety, fear of complications and pain, and in some instances, loss of alertness and orientation. In general, those who sustain the amputation after a period of preparation react more positively than do those who sustain it after trauma or accident. Most individuals are, to a certain degree, "numb," partly as a result of the anesthesia and partly as a way of handling the trauma of loss. For those who have suffered considerable pain before the surgery, the amputation may bring much-needed relief. This was true for four of the eight members of the self-help group interviewed for this report.
In-hospital rehabilitation, in many ways, is the most critical phase and presents the greatest challenges to the patient, the family, and the amputation team. It calls for a flexible approach addressed to the rapidly evolving needs of the individual. Initially, the patient is concerned about safety, pain, and disfigurement. Later on, the emphasis shifts to social reintegration and vocational adjustment. Some individuals in this phase experience and express various kinds of denial shown through bravado and competitiveness. A few resort to humor and minimization. Mild euphoric states may be reflected in increased motor activity, racing through the corridors in wheelchairs, and overtalkativeness. Others make wisecracks such as "You see more when you walk slowly."
Eventually sadness sets in. The grief response to limb loss is probably universal and time limited.Parkes describes the response as similar to that seen in widows. He lists four phases: (1) "numbness," in which outside stimuli are shut out or denied; (2) "pining" for what is lost; (3) disorganization, in which all hope of recovering the lost part is given up; and (4) reorganization. The degree to which individuals go through these four phases varies from individual to individual, and indeed, the process often lasts well beyond the period of in-hospital rehabilitation. It is also during this time that some experience phantom limb sensations and phantom pain (see the discussion that follows).
Factors that are noted to facilitate adjustment and rehabilitation in this phase are early prosthetic fitting, acceptance of the amputation and the prosthesis by family and friends, and introduction of a successfully rehabilitated amputee to the recovering patient.
Almost all the members of the group interviewed for this report agreed that early prosthetic introduction was of the highest importance. For two women who sustained below-knee (transtibial) amputations, awakening to find that they had two "legs" in bed was most reassuring. The 13-year-old delighted in throwing back the bedclothes and flaunting her artificial leg to her adolescent visitors. Those who did not, for one reason or another, obtain a prosthesis looked forward to it and often fantasized about it. One young man who lost the upper part of his arm as a result of an electrical injury dreamed of becoming a "bionic man."
Sadness, although keenly felt, may be concealed. A young mother who lost her hand in a paper shredder tried to put on a happy face for her family. "Sometimes," she said, "we have to joke so that people around us can deal with it."
By all accounts, the amputee's return home can be a particularly taxing period because of loss of the familiar surroundings of the hospital and attenuation of the guidance and support provided by the rehabilitation team. Hence, the attitude of the family becomes a major determinant of the amputee's adaptation. Family members should be involved in all phases of the rehabilitative process.
It is during this phase that the full impact of the loss becomes evident. A number of individuals experience a "second realization," with attendant sadness and grief.Varying degrees of regressive behavior may be evident, such as a reluctance to give up the sick role, a tendency to lean on others beyond what is justified by the disability, and a retreat to "baby talk." Some resent any pressure put upon them to resume normal functioning. Others may go to the other extreme and vehemently reject any suggestion that they might be disabled or require help in any way. An excessive show of sympathy generally fosters the notion that one is to be pitied. In this phase, three areas of concern come to the fore: return to gainful employment, social acceptance, and sexual adjustment. Of immense value in all of these matters is the availability of a relative or a significant other who can provide support without damaging self-es-teem.
The mother of the young man who lost his arm as the result of an electrical injury spoke of the profound change that occurred in his behavior on his return home. He regressed to the point that she felt she "had another baby in the house." (The young mother who lost her hand in the paper shredder) was concerned that people would look at her as though she were a "freak." She found her anxiety greatly relieved when both her children and their schoolmates took her amputation in stride and asked matter-of-factly about it. A middle-aged woman who sustained her amputation after a prolonged period of disability resulting from poliomyelitis found herself one day facing a sinkful of dishes and a request from her husband that she wash them. She did so with tears running down her face and thoughts running through her mind of her husband as cruel and mean. Later she recognized that it was "the best thing that he could have done for me" and was rather amused to learn that the scenario was contrived by her surgeon and her husband in order to encourage her independence. Equally helpful to her was her children's startled response on learning that their mother was receiving disability benefits. To them, she did not seem to be disabled at all and therefore did not need benefits. In fact, they were intrigued by her new leg prosthesis and expressed the wish that perhaps they too could don and remove their limbs when they grew up.
The group members were unanimous in rejecting the "handicapped" label, and each thought that his affliction was lighter than those of the others. One of them said, "Most well-adjusted people prefer to accept what happened to them" and thus "would not trade with another amputee." All conceded that the adaptation would have been immensely more difficult without the active support of their families.
A subtle but often overlooked issue is the ease with which the disability can be concealed in social settings. One group member, for example, remarked that one advantage of a leg amputation over an upper-limb loss was that it could escape detection in such settings.
Not surprisingly, those amputees able to resume a full and productive life tend to fare best; this is much easier for those with marketable skills who sustain the amputation while still in vigorous health. For elderly amputees who have limited skills, particularly if they have other medical disorders, the probability of a full return to an active life is considerably diminished. This can be partially or fully balanced by a more philosophical acceptance of a new, more leisurely way of living and by reduced responsibility and pressure to produce.
SPECIAL AREAS OF CONCERN
Phantom Limb Sensations
The feeling that the amputated limb is present and moving is so common as to be regarded as a universal occurrence after surgery. It tends to abate rapidly, however, so only a few individuals continue to perceive their limbs as still present and active a year after surgery. Many, however, continue to have occasional experiences of itching or locomotion, sometimes after residual-limb stimulation. Phantom limb experience has not been noted in those who are born congenially missing a limb and in those who sustain the limb loss at a very early age.
In general, phantom limb sensations present no particular problem. The members of the self-help group had all experienced them at one time or another. Some of them still do, 10 or 15 years after amputation, in the form of an intermittent itch that, curiously, is relieved by scratching the prosthesis.
Pain experienced in the missing limb is a much more serious issue than phantom limb sensations. At the University of Arizona, phantom pain has been reported by fewer than 2% of amputees. Early work on phantom pain led to the assumption that antecedent and concurrent medical states as well as psychological factors combined to explain its existence.
In the series of 2,284 amputees studied by Ewalt and colleagues at the end of World War II, phantom pain was extremely rare and was noted in individuals who also showed psychopathology. The authors wrote that pain "tended to come and to go with psychopathological symptoms, irrespective of what type of external treatment was carried on."
Parkes found that phantom pain could be predicted by certain immediate postoperative phenomena such as the presence of residual-limb pain, prior illness of more than 1 year, the development of residual-limb complications, and interestingly, other factors not related to surgery (e.g., continued unemployment and a rigid personality). Some amputees experience phantom pain in association with micturition, climatic changes, and emotionally disturbing events.
Sherman et al. argue that the vast majority of amputees experience phantom pain to varying degrees and that it is probably a complex form of referred pain with a physiologic rather than a psychological etiology.Pinzur regards phantom pain as a variant of sympathetic dystrophy. There is general agreement that phantom pain and life stresses are related. In a study of 24 male amputees, Arena et al. found an isomorphic pain-stress relationship, namely, a roughly contemporaneous increase in phantom pain with increased stress and vice versa. The typical psychological profile of the amputee suffering phantom pain does not differ from that of the general population of chronic pain sufferers.Thus, phantom pain, which can be serious and disabling, remains incompletely understood but approaches the model of a chronic pain syndrome with evidence of physiologic and psychological components.
In the self-help group, only one member reported persistent phantom pain accompanied by residual-limb pain. He detailed long and complicated procedures after the initial amputation, all designed to relieve his phantom pain. These included nerve stimulation, acupuncture, residual-limb revision, and even spinal block. At the time of the interview, his only relief came from the use of oxycodone (Percodan) on a regular basis. So distressed was he by his pain that he had repeatedly entertained the fantasy of taking a gun and shooting his "leg" off in order to rid himself of it. Other members experienced fleeting episodes of pain described as an electric shock sensation or, as one put it, "like putting your finger in a 220 [volt] outlet." A few described cramping sensations and feelings of constriction that diminished over time. Two mentioned aching when the weather changed and rain was approaching. Several members of the group spontaneously volunteered the view that the support of the family members was of great help in reducing phantom pain when it occurred.
Amputation, of necessity, requires a revision of body image. This is reflected in dreams and in the draw-a-person test. It has been reported that amputees who adapt well draw a person with a foreshortened limb or without any limb at all, whereas those who adapt poorly draw the missing limb larger than the opposite limb or with increased markings. Similarly, dreams that incorporate the prosthesis or do not particularly dwell on the missing part are consistent with a more positive adaptation. In one prospective study of 67 patients who had suffered severe hand trauma, much of the dreaming included nightmares of further injury or incapacity.However, the frequency of such nightmares decreased significantly about 1 month postoperatively. It has been suggested that the amputee, in a sense, must contend with three body images: intact, amputated, and with prosthesis. Individuals who are unable to accept the last two are likely to reject the prosthesis and to experience difficulty in functional and social adjustment. Related to the issue of revised body image is concern with social appearances and acceptance by others. Even when considerable success is achieved in functional restoration, there often remains some shyness about revealing the amputated body to others.
The members of the group confirmed these observations and saw a connection between accepting one's new bodily configuration and accepting a prosthesis. One viewed her body more positively after amputation because her prosthetic leg worked better than the leg that she had lost. Most had come to regard their prosthesis as part of themselves, at times revealed in dreams. Nonetheless, despite their successful adaptation and acceptance of the new body image, all of them continued to experience self-consciousness in social situations. For example, they tended to walk more clumsily when they felt observed by other people in public. They described a pool party to which they had invited their friends and relatives. Significantly, the only people who actually went into the pool were the nonampu-tees.
This is an area of some anxiety for most amputees, especially those who are young and in the prime of life. Concern arises from the following sources: (1) fear that the body would not be accepted by the partner, (2) the loss of a functioning body part such as the hand, and (3) the loss of an area of sensation.
Whereas a prosthesis can provide functional restoration and some return to normal appearance in most situations, it is absolutely of no use in the sexual area. A comparison with the sexual experience of paraplegics is instructive. Those who suffer paralysis still enjoy sensation from the affected part and continue to see their body as intact. They may also entertain hope of a return of function in the affected part. The amputee enjoys none of these advantages.
Among the members of the group, sexuality was an important issue that had to be faced by each of them. Most reported success in facing it, mainly attributed to the supportive response of the partner. Yet, despite verbal and behavioral reassurance of the partner, several spoke of lingering difficulty in seeing themselves as adequate sexual partners rather than as repulsive sexual "freaks." As one group member put it, "There is still a small part that doesn't accept." It would appear that the passage of time aids in this adjustment; one member stated that 15 years after the event, her missing limb was "a nonissue" in the sexual sense. This was not the case for the 13-year-old, who had expressed the concern that no boy would ever look at her. She lived for 2 years after her surgery but did not have occasion to go out on a date. She maintained the hope that one day she would do so and was greatly comforted by her brother-in-law, who told her that her amputation would "weed out the creeps."
Six principles of psychological management of the amputee are implied in the foregoing discussion.
Although it is hard to prove statistically that preparation has a bearing on ultimate outcome, common sense, clinical observation, and the reports of amputees all suggest that proper preparation is highly desirable. Such preparation must include a clear explanation of the reasons for the amputation; the viable alternatives, if any; the exact surgical procedure; and the rehabilitative process following it. Anticipating and dealing with the various issues that patients will face, even if these are not raised by the patients themselves, is of great help. Such issues include disposal of the limb, relationship with friends and family, degree of functional loss and return, work capability, costs of surgery and rehabilitation, sexual adjustment, and social impact.
It is important to present the amputation as a desirable lifesaving or life-improving option rather than as a last resort or an indication of failure. There is indeed some evidence in the literature that the quality of life can sometimes be improved by an amputation as compared with limb-sparing treatments. In connection with this, it has been suggested that the term "reconstructive surgery" is preferable to "amputation" and can certainly be used along with it. It should go without saying that much of the preparation should be conducted by the operating surgeon; although the information is widely available and may be imparted by any member of the team, no other person can communicate the same degree of authority and confidence that patients need as they contemplate the imminent loss.
It should be obvious to the readers of this book that good technique is of the essence. What perhaps is not so obvious is the need for the senior surgeon to perform the surgery or to be involved intimately in its performance. It is an error to relegate this procedure to inexperienced hands. As Bradway and associates wrote, "In our program, the senior surgical attending physician is directly involved in the performance of all amputations and supervises the entire process of amputation rehabilitation."
Early Prosthetic Fitting and Mobilization
There is little doubt that the earlier the prosthesis is applied, the better are the results in terms of functional capacity and psychological adaptation. As Bradway and associates wrote, "Early prosthetic fitting and rehabilitation enable the patient to incorporate all of his physical and emotional efforts into recovery from the earliest possible moment, rather than allowing the patient to focus only on disabilities and pain." Introducing the patient to a successfully rehabilitated amputee may be of great assistance in this effort. Of paramount importance to patients, and perhaps a predictor of prosthetic use, is the comfort and usefulness of the device.The level of the amputation also seems to be a significant determinant in the ultimate use of appliances. Sturup and colleagues found a higher rate of prosthetic use among below-elbow (transradial) amputees than among transhumeral amputees and a clear tendency toward nonuse among younger amputees and among those whose amputation was of the nondominant arm. Durance and O'Shea report that amputees are least likely to use prostheses during leisure activities.
The Team Approach
A team approach is optimal in amputee rehabilitation and should include the surgeon, surgical nurses, pros-thetist, physical therapist, occupational therapist, social worker, vocational counselor, and if indicated, a psychiatrist or psychologist. With this variety, each member of the team is in a position to address one aspect or another of the patients needs. As these needs evolve, flexibility and adaptation to new realities are required not only of amputees but also of those who help them. To the extent that it is possible to do so, the involvement of members of the family at all of these stages can be of tremendous help. Perhaps the most valuable contribution of the team approach is the facilitation of a more rapid return to familiar surroundings and to independence. The prospective study by Ham et al. of 223 British amputees found that team management reduced hospital stays significantly and increased the long-term effectiveness of rehabilitation. No less important, as Dise-Lewis points out, is the role of the team in validating the amputee's right to be in control of his own rehabilitation and in providing a safe haven for emotional expression.
No approach to amputation can be considered successful without some resolution of the issue presented by the loss of skill, job, and livelihood. Even in the absence of pressing financial need, the loss of earning capacity may entail a profound loss of self-esteem, which brings with it a variety of adverse psychological phenomena. It is not essential that the person resume work, but it is essential that the person accept whatever new role and capacity that can now be enjoyed. This is an issue to be approached with an open mind. Some, for example, prefer returning to employment, with all the security, stimulation, and structure that it presents. Others may find that thanks to personal wealth or to disability and retirement benefits, they are in a position to stay away from work. As Kohl wrote, "It is important that there not be a judgmental response from the staff toward those patients who do not seek paid employment." Several workers have attempted to find predictors of success in the rehabilitation of amputees. Pin-zur and coworkers have suggested that psychological testing using standard personality inventories and measures of cognitive abilities may be helpful in deriving a scale of rehabilitation potential for amputees. Kull-man found that the Barthel index of activities of daily living had a direct correlation with the general condition of the amputee and the fitness of his prosthesis and suggested its prognostic value for rehabilitation outcome. But as Mendelson and colleagues point out, any psychological testing ought to be deferred until the patient is physically and emotionally prepared to withstand the stress of its administration.
Increasingly, group support is part of the help being provided to amputees. One such modality is Schwartz's situation-transition (ST) group, which is different from other self-help groups for alcoholics, smokers, and overeaters in that "members are not required to espouse a particular moral or behavioral value system." Whether a trained person leads the group or it is conducted entirely by its own members, the group experience is likely to be of great value to both the participants and their families. It has been noted that amputee self-help groups shy away from self-pity or self-designation in terms of disability and emphasize strength and participation in a full and healthy life.
Psychotherapy may be indicated for individuals who suffer difficulty in any of the stages previously described and who are unable to resume a normal existence that otherwise should be possible for them. It is important to recall in this connection that the various stages of grief described by Parkes and others may not be accomplished in the predictable sequence or within the expected time. There are those individuals who may continue to mourn the loss of their limb for a long time or who, having shelved the issue, return to it at a much later date (delayed grief reaction). Vivid flashbacks have been reported as among the most common early reactions to amputation. Reclusiveness, hy-pervigilance, and delusions have also been noted as manifestations of body image disturbances. With the possible exception of the use of low-dose, low-potency neuroleptics to extinguish flashbacks, the opportunity to ventilate feelings is probably the most effective therapeutic activity for the amputee and is a crucial phase that should not be aborted. Feelings of sorrow, anger, and anxiety must be expressed before further therapeutic work can be accomplished. Occasionally, family therapy may be indicated to assist in reaching the proper balance between the legitimate support amputees need and the independence that they must regain. It is, of course, perfectly possible for psychological problems that have been avoided or disregarded in the past to surface after surgery and, indeed, to be blamed on it. This might be the case, for example, in longstanding marital discord, chronic depression, anxiety disorder, drug dependence, alcohol abuse, and antisocial behavior.
These psychiatric challenges can be addressed therapeutically on their own merit, without the necessity of determining the degree to which they are related to the amputation. If and when such a determination becomes desirable, such as in complicated legal situations, the individual's previous history and former level of adjustment can be of great value in clarifying the issue. For most amputees, however, psychiatric consultation and therapy are not indicated.
With respect to phantom pain, biofeedback and relaxation appear to be useful adjuncts to medical care of the stump and pain control measures. Neither psychotherapy nor psychoactive medicine appear to be of efficacy in treating phantom pain. Psychological sophistication and sensitivity on the part of members of the team, however, are indispensable.
In the self-help group that was interviewed for this report, there was unanimous agreement with these principles of management. Furthermore, most individuals noted an improvement in the quality of their lives after surgery. As one member put it, "You become a more compassionate and less critical person towards others." Another, who had suffered greatly both before and after his amputation, said, "When you become an amputee, you become a better person because you have to work for everything."
This chapter was written with the assistance of Richard E. D'Alli.
Many individuals have assisted materially in all aspects of preparing this report. I wish in particular to acknowledge my debt of gratitude to John Bradway, M.D., who, as a third-year clinical clerk in psychiatry, piqued my interest in this area by preparing a paper on psychological adaptation to amputation, which in turn formed the basis of a report written by him, myself, and a number of others; to James Malone, M.D., for sharing his extensive knowledge and experience; to Joseph Leal, C.P., who put me in touch with the amputee self-help group in Tucson; to Sharon Stites, leader and organizer of the self-help group; to Diane Atkins, occupational therapist and coordinator for the Houston Center for Amputee Services, who shared a wealth of experience with hundreds of amputees at that center; to Sybil Kohl, social worker at the Houston Center for Amputee Services, for her profound observations and reflections on the lives of amputees; to Jan Pankey and Sandy Levitt, third-year clinical clerks, who assisted me greatly in my meeting with the self-help group in Tucson; and to the eight members of the group who, although unnamed, were the source of information, guidance, and inspiration to all who study amputation and those who must adapt to it.
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Chapter 28 - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles