F I S I O T E R A P I E AMPUTEE m a n a g e m e n t in g r o o t e s g h u u r h o s p it a l PROBLEMS IN USING A TEAM APPROACH MAART 1978 J. F. N O R T H * and D . W. S T U A R T t nie prosedure wat gevolg word deur die kliniek span ■ die aanpassingsprogram van ’n pasient wat ’n lede- ,n t verloor het, word bespreek. D ie voorstelle vir ’n 171 bruiksaanwysing by die kunsledem adt w ord uiteen- K sit Die rol van elke spanlid word o o k oorweeg. i/oorligting is van uiterste belang. P roblem e eie aan pasiente in die Kaapse Skiereiland w ord ondersoek. A m ultidisciplinary ap proach to am putee care is used in G ro o te Schuur H o sp ital and th e clinic team includes an orthopaedic surgeon, a vascular surgeon, -ro sth e tist, bioengineer, physiotherapist, occupational therapist, and a social w orker. E ach m em ber interacts Ivithin the team situ atio n and applies his own ex­ perience and expertise to solve the problem . T h e aim is to produce - the best possible p rescrip tio n and the surgeon m ust be capable o f directing the team tow ards the solution. E very p atien t is un iq u e an d the team must weigh up the pros-and-cons of fitting a p articu lar type o f appliance. T h e p atien t cannot be excluded from the clinic team and he should be encouraged to express his views and his own personal needs. A num ber o f factors go into the p re p a ra tio n o f a prescription, and these are: age, am p u tatio n level, medical history, sex, occupation, and p a tie n t m otiva­ tion. O ther relevant factors such as place of residence and degree of m aintenance required fo r a device have to be considered in the C ape Peninsula. Age is an im p o rtan t facto r in form ing a prescription. For example, th e mass of th e ap p lian ce and th e energy expenditure necessary to am bulate are critical to the geriatric patient, b u t th e fu nctional needs are som ew hat less im portant. T h e g eriatric p a tie n t needs a device th at is simple to don, easy to operate, and fulfils his fu n c­ tional requirem ents. As an ap pliance becom es m o re sophisticated, a higher level o f skill is required to o b ta in the best fro m the device. T h e younger p atien t can, in general, provide the necessary drive and energy to u tilise a com plex u n it effectively, and, therefore, it is im p o rtan t to m atch the |a t ie n t to the fu n ctio n al needs o f the appliance. ^Although it m ight ap p ear technologically feasible to fit a g eriatric p atien t w ith the latest fu nctional appliance, the latter m ay pro v e in the long term to be too energy taxing fo r th e patient. W ith h igher levels o f am p u tatio n , i.e. above the knee and elbow joint, appliances becom e m o re complex. The prosthesis is m o re energy taxing to use and suspen­ sion problem s increase. The m edical h isto ry o f the p atien t is a n im p o rtan t consideration as in som e cases p rescrip tio n o f a p a rti­ cular appliance can affect the w ell-being o f the o th er limb o r th e suspension technique can in terfe re w ith hernias, a rte ria l shunts an d so on. Cosmesis has becom e an im p o rta n t fa c to r to the patient, and p atien ts o f all ages are m uch m ore cos­ metically orientated. T h e sex o f th e p a tie n t has to be considered; the fem ale o f th e species is som ew hat * B.Sc. (H ons) D undee, Ph.D . (Strathclyde), S enior L ecturer in B ioengineering, D e p a rtm e n t o f B io­ engineering, U n iv ersity of C ape T ow n, t Senior T echnician, D ep artm en t of M edical Physics and N u clear M edicine. m ore outspoken on this facto r th a n h e r m a le co u n ter­ part. M odern appliances can achieve a h ig h level of cosm etic restoration, especially if m o d u lar units and sof( foam covers are used. T h e m o tiv atio n o f th e p atien t is a critic a l factor. P ro sth etic devices by design are exoskeletal structures, and th erefo re effort is required to use th e m correctly. N o m atter how good th e design, if the p a tie n t’s m o ti­ vation is lacking the result will b e poor. I t is difficult to assess the degree o f m o tiv atio n o f a p a tie n t b u t this facto r cannot be overlooked. T h e w illingness of a p atien t to re tu rn to em ploym ent is an im p o rta n t facto r since it will affect the p rescrip tio n . P a tie n ts who are well m otivated and are w illing to expend th e energy in learning to use th e device m ust b e fitted w ith th e best possible appliance. A ll patients can fit into this category. H ow ever, th e younger and m o re m otivated p atien t m ust b e considered as a c an d id a te fo r the latest design available. T h e ap p lian ce m ust be able to cope w ith v ariatio n s in th e terrain , i.e. it m ust be ab le to a d a p t to use in th e ro u g h sandy areas in w hich m any p atien ts live; fitting sophisticated m echanism s to prostheses will p ro b ab ly lead to failures. C onsequently th e team m ust consider th e degree o f m ain ten an ce re q u ire d by a specialised appliance b efo re prescribing it f o r a p atien t who lives m any kilom etres from an o rth o p a e d ic centre. A fte r th e prescrip tio n has been m ade th e prosthesis is m anufactured an d fitted to the patient. I t is im p o rtan t th a t th e ap p lian ce is carefully checked o u t to see th a t it is com fortable, reliable, fu nctional, cosm etic, and acceptable to the patient. E rro rs in m an u factu re should bg corrected at this stage and th e p atien t should im m e­ d iately go to the th e ra p y d ep artm en t f o r training. T h e tim e delay betw een p rescrip tio n and fitting should be as sh o rt as possible so th a t th e p a tie n t can quickly becom e accustom ed to w earing a p ro sth etic appliance. Surgeon T h e surgeon carries o u t th e a m p u ta tio n and form s the term in al end organ. H e also leads th e clinic team and has resp o n sib ility fo r p rep arin g the p ro sth etic p re ­ scription. T h e m ajo r obstacle to progress is often th e surgeon’s lack o f p ro sth etic know ledge. A m p u tatio n s are o ften carried o u t by surgeons who a re u n aw are o f the o p tim um requirem ents o f th e stum p fo r an ad eq u ate prosthesis to b e fitted, an d thus the task o f th e p ro sth etist is m ade m ore difficult. T h e re­ q uirem ents o f an ideal stum p include a n u m b er of factors w hich in teract to provide o p tim u m conditions fo r pro sth etic fitting. Stum p strength is created by good m uscle stab ilisatio n using techniques such as m yodesis and m yoplasty. I t is very im p o rta n t th a t m uscle attach ­ m ent to th e bo n e u n d e r the a p p ro p ria te tension o r to opposing muscles be carried out, because th e reten tio n o f m uscle size, shape and pow er produces a m ore fu n c ­ tio n al end organ. S tum p strength is created by good m uscle stab ilisatio n an d ad eq u ate so ft tissue covering fo r th e carefully rounded bone ends. H ig h lig atio n of nerves to rem ove neu ro m a sites and pliable, sensitive b u t n o t tender skin an d scar areas a re required. T h e aim is to p roduce a n o n -ad h eren t and n o n -tender scar. M anagem ent o f th e skin w ill be d ictated by the n a tu re o f th e blood supply to th e am p u tatio n site, and R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) the physical condition o f the patient. It is n o t possible to dictate positions of scar placem ent. H ow ever, the surgeon should consider the p rosthetic consequences in electing fo r a p a rtic u la r procedure. T o som e extent a prosthesis can be fitted w ith the scar in a w ide variety o f p o sitio n s as long as the stump is stabilised and the scar well healed, non-adherent, and non-tender. T he ab ility an d experience of the prosthetist do to a large extent affect this decision, and the surgeon m ust be aw are o f th e problem s involved in pro sth etic fitting if a good fu nctional end-organ is to be constructed .1,2 Prosthetist E xoskeletal p ro sth etic devices are used to replace arm s and legs eith er tem porarily o r perm anently. A prosthesis consists o f a socket, w hich closely fits the p a tie n t’s stum p, a mechanism to replace th e knee o r elbow function, a shank section sim ulating the shin o r fo rearm , and a prosthetic foot o r hand. M odern socket designs achieve optim um function an d com fort w hen the socket totally contacts the stum p. T he p ro sth etist is responsible fo r m aking the socket, setting the alignm ent, and fitting the device to th e patient. Sockets a re eith er m ade from m etal o r plastic m aterial. M etal is still being used fo r conventional socket design and they req u ire highly skilled fa b ric a tio n tech­ niques. I t is very difficult, if not im practical, to m ake a to tal contact socket w ith metal, and to a large extent m etal is being superseded by plastics. T hese socket m aterials are m uch easier to fabricate and they can be m ade to fit th e stum p very closely. Plastic sockets are fab ricated using a cast o f the p a tie n t’s stum p. T h e cast is m ade using stockinette and plaster-of-paris bandages. T his is a highly skilled technique because the prosthetist m ust tak e account o f the w eight-bearing areas of the stum p. A p ositive plaster model is m ade up fro m the cast. T h e m odel is modified by adding plaster to certain areas and rem oving it fro m others. T herefore, w hen th e socket is m ade using the m odel, areas o f the stum p su itab le fo r w eightbearing will be m ade available fo r loading w hilst sensitive pressure regions w ill be relieved. T h e socket can now be fabricated using polyester resin, the gel tim e being controlled to perm it room tem p eratu re curing. N ylon, dacron and glass fibre can be used as fa b ric reinforcem ents, an d th e elasticity of th e socket depends on the q u an titativ e relatio n sh ip betw een th e resins em ployed and ■ the reinforcing m aterials. * Once th e socket has been com pleted, it is fitted w ith a knee m echanism , sh^nk and foot. T h e alignm ent and suspension o f the prosthesis are adjusted and the device is fitted to th e patient. F u rth e r adjustm ents are m ade to obtain optim um alignm ent conditions and a g ait free o f deviations. Bioengineer M any of th e advances in prosthetics over the past tw enty years are directly a ttrib u ta b le to the recognition o f the biom echanical principles involved in fitting and alignm ent o f prosthetic devices. T he influence of the engineer has helped launch and com plete re-evaluations of existing designs and concepts, and th e n ett result is a rem ark able im provem ent in pro sth etic devices. D a ta fo r use in pro sth etic design evaluations can be gathered in a n u m b er o f ways, i.e. from w alkpath and treadm ill studies o r fro m direct com parison o f pro sth etic devices in n o rm al use by a n u m b er o f test subjects. T h e bioengineer is to som e extent an unknow n q u an tity in a clinic team situation. H is engineering training' has been augm ented by specialised m edical courses a t p ost-graduate level. T he bioengineer has to be able to com m unicate th e engineering concepts in ­ 6 volved in a prosthetic design to o th e r m em bers o f the team who are n o t well versed in mechanics. In turn the bioengineer m ust be conversant w ith the problems involved in form ing a functional stum p, fitting a defini- tive appliance, an d train in g a p a tie n t if he is to operate well in an am putee team . Physiotherapist T h e ph y sio th erap ist is responsible fo r exercising the stabilised stum p m usculature. Isom etric exercises fo r the muscles involved and early tra in in g techniques fa]| w ithin the sphere o f th e therapist. I t is necessary to tra in the am putee to use the appliance correctly. T rain in g is very im p o rtan t as it can elim inate bad p ro sth etic h ab its at an early stage. T h e th erap ist can teach th e p atien t how to o b tain the m axim um utility from his appliance, and can to a large extent increase his m o tiv atio n to use the device. E v alu atio n o f the p a tie n t’s problem s w hen using the appliance w ill help to elim inate g ait problem s in the low er extrem ity p atien t and lack o£ u tilisa tio n of the device in the upper lim b am putee. D ifficulties in p atierl use of an appliance can be traced to self-imposed problem s o r to basic p ro sth etic errors. T h e problems o f donning and suspending a prosthesis m ust be under­ stood as m any gait problem s can be attrib u te d to im­ p ro p er ap p licatio n o f th e appliance. In the train in g p rogram m e patients can be taught to cope w ith inclines, steps, rough ground, sitting down and standing up, and general te rra in problem s that occur in everyday situations. D u rin g train in g the am putee can be instructed in stum p care, cleaning o f th e prosthesis, and in general day-to-day problem s th a t occur using a prosthesis. A m putees req u ire a high level of physiotherapy care during train in g and adequate staff m ust be made av ailable in th e train in g areas. C o n tin u ity of care is also essential o r the treatm en t w ill becom e ineffective. T o o b tain continuity of treatm ent, educational courses in prosthetics m ust be provided fo r therapists. Short­ term courses are available abroad and instructions on am p u tatio n techniques, biom echanics, prosthetics, and checkout procedures can be ob tain ed in one-w eek in­ tensive courses. Occupational Therapist T h e occupational th erap ist deals w ith the train in g of the u p p e r lim b am putee and this can be a difficult taskj A high level o f skill is required to use th e ap p lia n « | and the p a tie n t has' to be w ell m otivated. V In spite o f advances in u p p e r extrem ity devices th ro u g h the use o f new fa b ric a tio n m ethods and m aterials in co rp o ratin g sophisticated controls',: the acceptance level has never ap p ro ach ed th a t of lower lim b devices. Body pow ered devicies are still used to p o sitio n the term inal device f o r o p e ra tio n and open it against som e fo rm o f elastic resistance. T erm inal devices are typically spring loaded and each unlit is generally adapted to a special function. A g reater level of u tility is provided by a p ro sth etic hoo k and it is norm ally prescribed in preference to pro sth etic hand units. C osm etic hand devices are n orm ally supplied to the p atien t to replace th e hoo k w hen required. Pow ered u p p er extrem ity devices a re available using b o th com pressed gas and electric pow er units. Myo­ electric control units can now give m ore reliable pre­ hension and control to th e patient. H ow ever, these appliances are m ore com plex th an body pow ered units, and a g reater level o f skill is needed by both therapist and p atient to achieve a successful result. A dequate educational courses are necessary to bring the occupational th erap ist u p to date w ith modern pro sth etic devices, an d the train in g needs o f the MARCH 1978P H Y S I O T H E R A P Y R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) nutee. S hort term courses are av ailable overseas and have pro v ed very successful. Social Worker Taking am putees as a gro u p there is no d irect re­ lationship betw een the extent of th e physical loss and the p atien t’s psychological difficulties. T hese difficulties re m ore dependent u pon the p ersonality a ttrib u te s of The individual th a n the type o f am p u tatio n . Because of this a p atien t w ith a ‘lim ite d ’ physical loss m ay present far greater adjustm ent problem s th an an o th e r w ith a ‘major’ los?. T h e social w o rk er has to deal w ith the p r o b le m s o f th e p a tie n t in adjusting to his disability and coping w ith the p ractical im plications of being an amputee in his social environm ent. The social w orker helps the p atien t overcom e m any of the ad m in istratio n problem s associated w ith dis­ ability grants, fam ily care during hospitalisation, tran s­ port and so on. A lthough this is often a tim e con­ suming task, the benefits to the p atient are very worth l^Short-term prosthetics courses are available overseas ?o bring the social w o rk er u p to date w ith m o d e m con­ cepts in prosthetics. D iscussion The team ap p ro ach has definite advantages fo r the patient, and th ro u g h the in teractio n o f disciplines it is useful to the team m em bers. I t provides a fo ru m fo r discussion o f p a rtic u la r p ro sth etic problem s, needs fo r training the p atien t, and m atching th e appliance to the requirem ents o f th e am putee. T h e team ap p ro ach has to be geared to the needs o f the R ep u b lic, and it is quite im practical to superim pose procedures th a t are in use overseas w ith o u t allow ing fo r the differences in prosthetic services. Such an ap p ro ach can only lead to problems fo r the team and the patient. T here a re p roblem s involved in using a team a p ­ proach in the C ape P eninsula, and to som e extent they can be a ttrib u te d to th e lack o f pro sth etic knowledge. Each m em b er m ust be aw are o f p ro sth etic concepts and be w illing to in teract in a team situ atio n in a p ro ­ fessional m anner. \ A t present in G ro o te S chuur H o sp ital it is not possible to evaluate th e p a tie n t before am p u tatio n , and the team usually sees the am putee a fte r surgery has been com pleted. T h is is certain ly n o t as effective as evaluating the p a tie n t b efo re am p u tatio n , b u t it is the ) orm in m any hospitals. U nless the surgeon is con- ersant w ith the needs o f a fu nctional stum p, problem s can occur rig h t from the outset. Im m ediate post- surgical fitting procedures can overcom e th is deficiency. However, this req u ires a rigorous team ap p ro ach using the latest p ro sth etic equipm ent to be. successful. T he only o th er m ethod o f elim inating this problem is to improve th e p ro sth etic education o f the surgeon. Since th ere w ill be a tim e delay betw een prescrip tio n and delivery o f the appliance th e p a tie n t requires physiotherapy treatm en t to im prove m uscle strength and gain confidence in crutch w alking. Once th e appliance has been fab ricated it has to be assessed on th e patient. It is essential th a t the p h y sio th erap ist w orks w ith the Prosthetist during this in itial checkout to ensure a smooth tran sfer to a train in g schedule. A t this p o in t the alignment is adjusted and a lteratio n s to th e fit and suspension are m ade by the prosthetist. T herefore, prosthetic problem s due to fabrication are elim inated at an early stage and the p atien t is h anded directly to the Physiotherapist to continue th e reh a b ilita tio n process. Sending th e p ro sth etic device d irectly to the physio­ therapist has n o t been entirely successful as in a number of cases appliances have been m islaid. Sending the ap pliance to the p a tie n t has also proved to be in ­ MAAf l T 1978 efficient because a n u m b er o f am putees have failed to tu rn u p fo r treatm en t after receip t o f th e ir prosthesis. T h erefo re, it is im p o rta n t th a t th e th e ra p ist an d the p ro sth etist w ork hand-in-hand a t th e in itia l checkout stage. T h e train in g p erio d is very variable. I t depends upo n the age o f th e p atien t, m o tiv atio n , level o f am p u tatio n , an d th e skill o f th e therapist. C learly an educated th e ra p ist well versed in p ro sth etic appliances can do b etter th an a general therapist, an d achieve a high level of p ro sth etic ultilisation. In m any ways th e key lies w ith th e th e ra p ist because she m otivates th e am putee to strive fo r a good gait and teaches the necessary skills to use the appliance on a day-to-day basis. A fter the am putee has reached a utilisation level acceptable to th e th erap ist he is referred back to the am putee clinic fo r final checkout. T h e com plete team exam ines the prosthesis and checks ou t the gait, func­ tion, and cosmesis. T h e p a tie n t’s com m ents are care­ fully considered and if he an d the team are satisfied w ith th e appliance he is discharged. P a tie n t review is carried o u t a t least once a year; how ever, in th e event o f tro u b le w ith th e stum p or the ap p lian ce the p a tie n t rep o rts im m ediately to the am p u tee clinic fo r exam ination. C ertain patients w ith vascular disease re q u ire m ore freq u en t exam ination. Juvenile p atien ts are checked regularly to exam ine stum p changes due to grow th. M odular', p rosthetic devices a re excellent fo r this type o f am putee, as appliances have to be refitted ap p ro x im ately every six m onths. , Som e am putees w ill n o t be capable o f using a pro sth etic appliance ow ing to in h eren t problem s of the stum p, physical incapabilities, o r m ultiple am p u ­ tations. S tum p revision to rem ove neurom as, adherent scars an d so on, m ay be necessary so th a t a prosthesis can be fitted adequately. T h e success ra te fo r g eriatric bilateral am putees is n o t very good because o f the energy requirem ents needed to am bulate, so w heel­ chairs m ay have to be prescribed. T h erefo re, a m u ltid iscip lin ary team app ro ach can be used in the p rescrip tio n o f appliances fo r am putees. T h e re are problem s in carrying th is ou t b u t the advan­ tages to the p a tie n t a re im m ense. T h e re is no doubt th a t team in teractio n w ill, in itself, give rise to greater understanding o f th e requirem ents o f an am putee, and h ig h lig h t the p a rtic u la r problem s o f each team m em ber in the reh a b ilita tio n process. W ith practice the team can o p erate in an efficient m anner, an d a high, level o f p ro ­ fessionalism can b e engendered. I t is im p o rta n t to be professional an d to accept unreservedly th a t o ther team m em bers are professionals in th e ir ow n disciplines. Acknowledgements T h e au th o rs wish to th an k the m em bers o f the am putee clinic team in G ro o te Schuur H o sp ital w here this study was carried out. References 1. Burgess, E. M. T h e below knee am putation, Inter­ clinic Inform at. Bull., V III, 4 (1969). 2. M urdoch, G. Levels of am putation and limiting factors. A n n. R o y Coll. Surg., 40, 3 2 0 4 -2 1 6 , (1967). 3. Burgess, E. M. and R om ano, R. L. T h e m anagem ent o f low er extrem ity am putees using im m ediate post- surgical prostheses. Clin. O rthop and R elated Res. 57, 137 - 146 (1968). 4. Stolov, W. C. et al. Progression o f w eight bearing afte r im m ediate prosthesis fitting follow ing below- knee am putation. Arch. Phys. M ed. R ehab., 52, 4 9 1 -5 0 2 , (1971). 5. M urdoch, G . P rosthetic-O rthotic Practice. A rnold, L ondon, (1970). 7F I S I O T E R A P I E R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )