Amputation, Planned or Traumatic: How Practitioners Plan and Prepare for Both
January 2020 Issue
After a car accident caused a 15-year-old girl to undergo a transfemoral amputation, her clinicians at Total Care Orthotics and Prosthetics, Tulsa, Oklahoma, worked patiently with her as she healed emotionally and physically, says John Brestovansky, CO, LPO, CPed, who owns the practice and is a second-generation practitioner. In addition to losing her leg above the knee, the girl sustained significant neurological damage on her contralateral side in the accident that also claimed the life of one of her best friends. "She was depressed and did not feel the desire or motivation to move forward," Brestovansky says. "Through time, patience, and communication on all levels with the rehabilitation team, she is now able to ambulate with an above-knee prosthesis without using a walker or other assistance."
The process lasted more than five months, Brestovansky says. "But it has worked out greater than we could have expected."
In 2012, an arsonist set fire to an apartment building where Alina Miller was living in Aurora, Colorado. She had to jump from the fourth floor to the concrete to escape the flames. She broke both feet and her back.
"We spent four years trying to salvage my leg," she says.
She endured nearly a dozen surgeries, infections, and terrible pain. "Finally, in 2016, after thinking about it for a year, we amputated it," she says. "I woke up very happy from the surgery, and it has completely turned my life around. I run. I hike. I live almost exclusively in high heels."
Planned amputations can be done by a physician in a hospital setting such as in Miller's case or due to other complications from diabetes to cancer. An amputation can also happen quickly, traumatically, during a work-related or motor vehicle accident or during military combat in which surgery or treatment is performed after the initial injury.
O&P practitioners are sought out for their advice before, during, and after a planned amputation, but in the case of a traumatic amputation, their initial contact with a patient is often in a hospital setting almost immediately afterward. Since either situation is difficult for patients, practitioners employ a variety of methods to help them navigate through the process.
Preparing For a Planned Amputation: Knowledge Is Power
The most common conditions resulting in amputation that provide a patient a window of time to prepare for the procedure include diabetes, peripheral vascular disease, and multiple medical issues including post-trauma limb salvage failure.
Education and knowledge are key to helping patients through a planned amputation from a physical standpoint, clinicians agree.
"Any opportunity to meet with an individual prior to their amputation is golden to initiate education," says Betsy Trumble, MS, PT, who has been the director of inpatient rehabilitation at WellSpan Surgery and Rehabilitation Hospital, York, Pennsylvania, since 2018, and has been a physical therapist for nearly 25 years. "Knowledge is power and can reduce anxiety and fear and also lead to better outcomes. The sooner we can impart knowledge to someone is ideal. Our patients deserve to know all they can about their opportunities. Proper education and rehabilitation for amputees and their families makes a significant difference in their lives."
Brestovansky agrees. "Our goal with a planned amputation is to prepare the patient to be able to safely return to their maximum mobility," he says. "We like to include the entire rehabilitation team during this process. We have a full-time physical therapist in our clinic who does a comprehensive evaluation of every planned amputation."
One of the best ways to help a patient prepare for a planned amputation is to have him or her meet with another person who has an amputation at that similar level and cause, says Zach Harvey, CPO, Creative Technology Orthotic & Prosthetic Solutions, Denver.
Harvey has hired patients like Miller as clinical assistants to operate Creative Technology's Comprehensive Acute Rehabilitation Empowerment program, which is designed to keep the lines of communication open to ensure their patients are heard and don't fall through the cracks. "Depending on the situation, one of them will talk with patients and families at various stages of their amputation and rehabilitation process," Harvey says. "It's often reassuring to have that point of contact along the way so that when questions or anxiety arise, there's someone to turn to."
Bill Beiswenger, CPO, FAAOP, Abilities Unlimited, Colorado Springs, Colorado, agrees. "We like to schedule a peer visit with a prosthetic user with a similar amputation. This seems to provide the best emotional support," he says. "As a prosthetist, early prosthetic education regarding socket fit, prosthetic components, function, and timeframe are also helpful for the patient."
Total Care O&P offers a peer-to-patient program. "This allows patients to discuss any issues or fears they may have prior to a planned amputation," Brestovansky says. The program is offered for all ages, he says. "We see this as being most beneficial to the current patient, but it also allows the peers who have already gone through an amputation being able to give something back."
Like Miller, Tyler Coleman is a clinical assistant for Creative Technology. He has a transtibial amputation caused by a work-related accident in July 2009, when a piece of machinery rolled over and crushed his left heel. He has been a patient of Harvey's for seven years.
Coleman concurs that knowledge is important. "Whether it be due to diabetes or limb salvage, I like to tell the patient there can be a grieving process much like losing a loved one," he says. "I also tell them knowledge is power, especially in this situation, and it's always a good idea to bring in a loved one when doing the consult prior to an amputation. There can be a lot of information being told so it's good to have a second or third set of ears to help absorb everything."
The lead prosthetist at Body in Motion Sports & Orthopedics, Toms River, New Jersey, has a transfemoral amputation and is an active peer counselor with the Amputee Coalition, says John Caputo, CO/L, CEO of Body in Motion. "He brings a unique perspective to patients who undergo planned or traumatic amputations."
The method of preparation for a patient who has tried multiple approaches to save a limb before an amputation presents its own challenges, practitioners say.
"Let's face it, any amputation is mentally and physically traumatic," Caputo says. Wound care management and offloading diabetic ulcerations can consume much of the patient's time preceding an amputation, he says. "Quality of life at this stage is almost nonexistent. The quality of life for a patient with a prosthetic, following years of trips to a wound care center to save a limb is significant and cannot be understated."
Often the process can be easier emotionally when attempts to save a limb have not worked compared to an amputation in which there was no choice, Harvey says. "At that stage, a person might have already mourned the loss of function of the affected limb and the amputation is viewed as a way to get one's life back," he says.
Total Care O&P clinicians treat many patients who have had revisions to their limbs, Brestovansky says. "In many cases, the patient has dealt with infection and is on a variety of pain medications. Our conversations and preparations take on a focus: 'Where are you now?' and 'Where do you want to be a year from now?' In most cases [once the amputation has been performed], the patient's overall quality of life improves and then we'll get asked by the patient, 'Why didn't I choose amputation sooner?'"
Quickly and Traumatically
The most common types of traumatic amputations are industrial- and work-related accidents and motor vehicle accidents primarily involving motorcycles. Patients with traumatic amputations typically tend to be younger and healthier with no other comorbidities, practitioners say.
Preparation for recovery after a traumatic amputation from a physical standpoint should initially include focus on the limb, with proper wound healing, edema management, contracture prevention, and pain control, clinicians say. Alternative methods to phantom limb pain management may be introduced as needed, as well as care of the residual limb and wound/scar care in preparing the limb for a prosthesis, clinicians say. Cardiovascular conditioning should also be included.
"Rehabilitation should include strategies to prevent loss of motion on the limb that has been amputated and the sound limb and loss of strength and core stability," Trumble says. "Functional mobility is an important aspect to be able to return to one's home environment as soon as possible." Specifically, Trumble says, being able to get in and out of bed, chairs, the bathroom, shower, and car are areas that should be concentrated on.
Recovery takes time and that timeframe is different for each patient, Caputo says. "Each traumatic amputation will have to be grieved and is unique to each patient," he says. When it comes to a planned procedure, Caputo says his team can usually reference someone with an amputation who has an inspiring story. "When faced with a patient's negativity or doubt we can usually point out Mark Inglis, who is the first double amputee to summit Mount Everest."
However, most patients beginning to recover from a traumatic amputation don't want to hear about other inspiring patients, Caputo says. "We give them their space and let them have this grief. It is part of the overall grieving process."
Coleman says the recovery process can be daunting. "I like to talk about the milestones that come along in the process," he says, which also depends on whether the patient has had other injuries from the accident leading to the amputation. That first milestone could be getting discharged from the hospital or a rehabilitation facility, he says. Second, typically after two weeks, the surgeon will remove the sutures. The third milestone can be that six-to-eight week post-op mark when, as long as the healing has been on track and no major falls have occurred, the surgeon will clear the patient for weight bearing and the practitioner will get approval to prepare the patient to begin standing, Coleman says. "Depending on the patient's mobility, there can be other milestones to look forward to, such as moving from a wheelchair to a walker to crutches," he says.
Preparing Mentally and Emotionally, Planned and Traumatic
When it comes to a planned amputation, it's important to discuss the eventuality of the patient and their families going through the five stages of grief after the amputation, Trumble says. "I emphasize that loved ones are affected, too, and are often overlooked in this discussion," she says.
Information should also be provided about depression after amputation, and there are behavioral team members who can assist in the process, Trumble says. "It's helpful to acknowledge the aspect of mental and emotional recovery as part of the process and treating them as a whole individual."
Professional counseling is also recommended in both scenarios, clinicians say.
"We include the entire family, if possible," Caputo says. "We feel this is one of the most beneficial advantages from a mental and emotional standpoint."
Harvey says it's important not to overwhelm the person or the family. Harvey says he'll paint a picture with broad strokes—timelines, phantom/residual pain, how a prosthesis works, number of appointments, volume changes, back to sports or work, insurance limitations and costs—about the reality of what living life with a prosthesis will be like, initially as well as long term.
Success and the Rehabilitation Team, Planned and Traumatic
Success is most likely when an interdisciplinary clinical team works with the patient and the composition of that team varies depending on the patient's needs, practitioners say. Ideally, for a planned amputation, a core team would include the surgeon, physiatrist, physical and occupational therapists, and a prosthetist, clinicians agree. For patients experiencing a traumatic amputation, the team could expand to include a psychologist, chaplain, or other behavioral health team member.
Rehabilitation should begin as soon as possible. "Taking the appropriate steps regarding strength and range of motion are paramount," Brestovansky says.
Understanding the process of wearing a prosthesis, proper fit and function, and limitations are also important, Brestovansky says. Total Care O&P has a dedicated prosthetic gym in its clinic to provide all levels of therapy, including gait training and strength and endurance, with advanced terrain for providing measured outcomes, he says.
Not every patient needs to stay in a rehabilitation facility to convalesce, according to Harvey. "Those at high risk of falling benefit the most by spending a week or more," he says. Harvey gives a recent example of a man with a transfemoral amputation who also had a total knee replacement on his sound side. At the rehabilitation facility, the man was able to learn new ways of safely transferring as well as sitting and standing, Harvey says. Other examples of patients who may not necessarily benefit from a stay in a rehabilitation facility include a person with an amputation undergoing a revision, an otherwise healthy person with single upper-limb amputation, or a person with a unilateral lower-limb amputation who has been using crutches while undergoing limb salvage.
The bond the patient forms with his or her prosthetist is also vital, Caputo says. "This should supersede all else," he says. "Therapy and doctor visits are important, but when the physical therapy ends and the patient no longer needs to be seen by their physician [except to get medical documentation], the patient/prosthetist relationship is the one that matters most."
Advice to Caregivers
Clinicians say they treat caregivers as an extension of the patient.
"[Caregivers] may be at a better place emotionally and cognitively to remember information and instructions," Harvey says. "So I treat them with the same expectation of responsibility as the patient."
Beiswenger says it is important for the caregiver to learn proper donning and doffing of the prosthesis, as well as wear and care procedures.
Be patient and supportive, Brestovansky tells caregivers. Total Care O&P offers a prosthetic care guide that provides information and education to caregivers. "We also encourage all caregivers to attend as many appointments with the patient as possible and be familiar and trust your prosthetist."
Caregivers should be included in the entire process during rehabilitation as well as before an amputation when possible, Trumble says. "It allows the caregiver to also process and deal with emotional issues," she says. "The more knowledge the caregiver has leads to a better support system for the amputee and better outcomes."
Miller's mother was one of her caregivers. Once Miller had her amputation, her mother initially feared her daughter would only be seen by others as someone who had an amputation. Her mother's view has changed over the years, she says. "She realizes she still sees me as Alina," Miller says. "She's a nurse, and she tells people my story and uses it to help others. It's really cool."
Betta Ferrendelli can be contacted at firstname.lastname@example.org.