Page Ten P H Y S I O T H E R A P Y July, 1956. R E H A B ILIT A T IO N O F THE AMPUTEE B y C. J. K A P L A N , M . Ch. O r t h . , F.R.C.S.(Eng.). Assistant Visiting Orthopaedic Surgeon, Addington Hospital, Durban. Visiting Orthopaedic Surgeon, King George V Hospital, Durban. P R O PE R m anagem ent of th e am putee patient demands m ore th an surgery alone. T he surgeon’s responsibility includes supervision o f a complete and integrated rehabili­ tation program m e em bracing psychological preparation, adequate surgery and after-care, teaching athe patient how to care for his stum p, training prior to fitting with the prosthesis and finally the use o f the prosthesis. Only by th e application o f this whole program m e is it possible to provide the am putee with the complete physical and psychological equipm ent that he requires. N one o f you who are disabled can forget the emotional experience at the realisation th at a p a rt o f your body has been perm anently lost. I have seen the bewilderment and desolation am ong the newly am putated who ask me “ Will I walk again,” “ Will I work again?” , an d who tell me th a t their lives are finished. Just as it is m y responsibility to allay these anxieties and to assure the patients o f what can be done for them, so is it your responsibility if you will accept it, those o f you who have m astered your diasbility, to help us in this task. D em onstrations by am putees who are already successfully adjusted will help the new am putee to realise th at he can teco m e a happy and productive unit in the society to which he m ust return. Let me tell you som ething abo ut am putations. In the leg we have three m ain levels fo r am putation. 1. Symes amputation: This is perform ed ju st above the ankle joint, leaving an end bearing stum p covered with the skin o f the heel which is naturally weight bearing skin. This am putation is gener­ ally out o f favour, except in C anada, because a. revision is so often necessary at a higher level due to nutritional changes in the stum p. I t is, however, o f value in South Africa, am ong the B antu, who cannot afford expensive prostheses, n o r are they able to care fo r them. 2. Below Knee— Site o f election. This is five o r six inches below the knee jo in t with the fibula slightly shorter than the tibia so as to give a conical stum p. This stum p is long enough to control the p ros­ thesis adequately and yet short enough to avoid nutritional changes. I t is a side bearing stum p, the weight being taken under the flare o f the tibia, the head o f the fibula and the crest o f the tibia. Pneum atic sockets have recently been introduced, but do n o t suit everyone. 3. Above Knee—site of election. This is 1 0 ''to 12" below the prom inence felt at the side o f the hip. I t gives excellent stum p control but the weight is transm itted to the ischium,—the bone one norm ally sits on. T he skin in this region is satisfactory as it is used to bearing weight. A recent advance is the suction socket, which requires n o suspension harness, and- is very satisfac­ tory. 4. O ther leg am putations are known, but are not much practised to-day. If the leg is lost a t or ju st below the hip joint, a special prosthesis with w hat is know n as a tilting table is worn. After operation it is several m onths before a stum p is ready for fitting with a prosthesis, as it has to be shrunk to skin and bone. This is encouraged by bandaging. Special exercises are needed for stump control. Eventually the stum p is measured and a prosthesis m ade and the great day comes when it is worn for the first time. Every leg amputee should have four weeks’ training, after which he should be proficient in the use o f the limb. There should be no rush to walk, because all one does then is to develop bad habits which are difficult to eradicate. 1st week: Putting on and taking off prosthesis. Standing. Balancing. Sitting. Swaying and transferring weight. The prosthesis should not be retained by the am putee during this week. Most amputees can, and want to do more but should be restrained as it invariably leads to sore stumps and bad habits. 2nd week: Walking on level ground, Turning, Walking backwards for B.K. amputees. 3rd week: Walking upstairs and downstairs. Walking on uneven ground. 4th week :Advanced instruction, Sports activities, Dancing. This programme goes for a single leg amputee, but more time and practice are necessary for the double leg amputee. A t the end o f the training period every single leg am putee almost without exception should walk w ithout a stick, and in the B.K. amputees it should be impossible to spot that there is any disability. I f this is not the case, it is due to incorrect fitting o r inadequate training. It is during this period o f training th a t all personal and vocational adjustments should be made and here the help o f completely rehabilitated amputees is invaluable. In the arm the problem is far more complicated by the fact that only 50% o f the effective function o f th e hand is dependant on movement and grasp, the other 50% being vested in the sense o f touch so th at with the best possible prosthesis we can offer less than complete restoration o f function. In arm amputations too there are three main levels: 1. Above the wrist. 2. Below the elbow. 3. Above the elbow. In the arm there are several possibilities. T he basic demands are either dress or utility. A light dress arm is n o t o f great use, but looks better and is best fo r people Whose work brings them into contact with the public. T he labourer or artisan on the other hand requires the maximum function possible, for which he frequently sacrifices appearance. In Britain the artisan uses a prosthesis into which his tools are made to lock. In America the split hook is favoured and while more functional is probably less aesthetic. With 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. ) July, 1956i P H Y S I O T H E R A P Y Page Eleven this, objects can be grasped quite strongly and the hook can’be used for lifting heavy weights. There are two o ther special procedures used in arm amputations.. 1. The Krukenberg procedure: Here th e tw o bones o f the forearm are separated by a plastic procedure so as to provide som e prehensile power. It is certainly very ugly and is probably best confined to its country o f origin—G erm any—although it w ould be quite useful in C entral Africa. 2. The Kineplastic Procedure: This gives the am putee excellent control. T he live muscle remaining in the stum p is canalised and lined with skin, the superficial defect being covered with a skin-graft. A peg connected to the mechanism is inserted through the canal, and by contraction o f muscles the am putee can m otivate his prosthesis. T his process can be applied to both above and below elbow stum ps but is naturally far more effective in the lower am putation. I t can be worn either with a functional dress hand o r a hook for utility, and is naturally o f great value in the double arm amputee I have outlined rapidly and briefly how much we can do to help the am putee, but the spirit must come from the amputee himself. T he com m unity to o must play its p art but cannot be expected to do so unless it is educaited to appreciate th e potentialities o f the am putee and fo r this task there can be no better teachers than the members o f the St. Giles Club. I wish to convince all o f you and through you, the public, that am putations are not an d m ust not be allowed to become insurm ountable obstacles to a norm al and satisfying life. VACANCIES V ANDERB1JL PA R K M E D IC A L B E N E F IT F U N D . V acancy: FU L L -T IM E P H Y S IO T H E R A P IS T . A pplications are invited from qualified Physiotherapists for the above position. T he commencing salary will be determined in accordance with qualifications and experience but will not be less than £750 per annum. In addition to the above a variable cost o f living allowance is paid) at present am ounting to £27 2s. 6d. per m onth for married persons and £14 14s. 8d., per m onth for single persons. A holiday leave bonus equivalent to one m o n th ’s basic salary is also paid in term s o f the F u n d ’s Leave Regulations. T he successful applicant will be required to furnish a satisfactory certificate o f health, to contribute to the Iscor Pension F und and to become a m em ber o f the Vanderbijl Park Medical Benefit F u n d and the Iscor R ecreation and Social Club. A pplications giving full details o f qualifications, experi­ ence, age, m arital state and earliest date duties can be assumed should reach the underigned, P.O. Box 1, Vander- bijlpark, not later than M onday, 30th July, 1956. A pplication form s will be forw arded to bona fide appli­ cants on w ritten application to the undersigned. H . A. LAM BR ECH TS, Secretary. V a n d e r b i j l P a r k M e d i c a l B e n e f i t F u n d . 18th June, 1956. V A N D E R B IJL P A R K M E D IE SE BYSTA N D SFO N D S. V akature: V OLTYD SE FIS IO T H E R A PE U T . Aansoeke w ord ingewag van gekwalifiseerde Fisio- therapeute vir bovermedle betrekking. Die aanvangssalaris sal ooreenkom stig opleiding en ondervinding bepaal word, m aar sal nie m inder as £750 per ja a r beloop nie. Benewens die basiese salaris sal ’n wisselende lewens- duurte toelaag wat tans £27 2s. 6d. per m aand vir getroude perone en £14 14s. 8d., per m aand vir ongetroude persone beloop, betaal word, ’n Vakansie bonus gelykstaande aan een m aand se basiese salaris, w ord ook betaal, ooreen­ komstig die F onds se V erlof Regulasies. D it sal van die suksesvolle applikant verwag word om ’n bevredigende gesondheidsertifikaat te voorsien, en om tot die Y skor Pensionfonds by te dra. Lidm aatskap van die Vanderbijl Park Mediese Bystandsfonds en die Y skor Ontspannings—en Geselligheidsklub sal verpligtend wees. A ansoeke w aarin voile besonderhede aangaande op­ leiding, ondervinding, ourderdom en huwelikstaat vermeld word, en wat die vroegste datum w aarop dienste aanvaar kan w ord aandui, m oet die ondergetekende, Posbus 1, V anderbijlpark, voor o f op M aandag, 30 Julie 1956, bereik. Op skriftelike aansoek sal aansoekvorm s aan bona fide applikante gestuur word. H . A. LA M BRECH TS, Sekretaris. V a n d e r b i j l P a r k M e d ie s e B y s t a n d s f o n d s . 18 Junie 1956. P E T E R R O T H E N B E R G E L E C T R I C A L A N D I N D U S T R I A L I N S T R U M E N T S E L E C T R O - S U R G I C A L R E P A I R S P E C I A L I S T S 9 8 c M O O I STR EET, JO H A N N E S B U R G P.O. B O X 3 9 0 4 PH O N E 2 3 - 0 7 3 0 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. )