Returning Upper-Extremity Amputees to Work

As those who work in amputee healthcare fields agree, there is much more to rehabilitation than fitting an amputee with the appropriate device. To achieve the optimum outcomes we all desire for the patient, it requires teamwork, commitment, and a willingness to develop solutions uniquely tailored for each individual. Patients at Capabilities For Living learn to incorporate adaptive devices and techniques in order to perform daily tasks with their prostheses. I chose the field of occupational therapy when I was 19, and by the time I was 21 I had graduated from the professional program, had earned my credentials, passed the national exam, and was teaching and working at the University of Missouri in Columbia. From the first, I gravitated toward catastrophic injuries, which include amputations, spinal cord injuries, burns, and crush injuries. Injuries in this category usually occur in less than five seconds, and alter an individual's lifestyle instantly and drastically. For these injuries, there are no simple "cookbook" treatments to apply. The more catastrophic the injury, the greater the likelihood of multi-system involvement, and therefore, the greater the challenge to the team dealing with it. Upper-extremity amputations in particular are often related to trauma situations that create abnormal tissue, involving skin grafts, free muscle/ fascia flaps, and salvaging procedures. Frequently with such clients, the residual limb is actually one of the sounder parts of the body. A significant number of my clients are bilateral upper-extremity amputees, and ironically, teaching them to adapt to their amputations is less challenging than treating the burns and scar tissue associated with the original injury. Loosening up these areas is an essential part of the program, in addition to working with the residual limbs. Sandra Fletchall, FAOTA, OTR/L, CHT, MPA Although current occupational therapy programs now require the therapist to have a masters degree, there is no designated educational program to guide therapists in dealing specifically with catastrophic injuries. The skills and knowledge I have developed in this area are the result of many years of experience with catastrophic injury clients, during which I have developed and perfected the techniques and methods that have proved most successful. Prioritizing catastrophic injuries is a process that calls for logical problem-solving skills. There is a real cognition-judgment aspect to such analysis, which requires a good understanding of neuro-anatomy, bone structure, and soft tissue structure and stability. An understanding of cognition and psychology is vital in determining whether the client is exhibiting normal depression-anxiety linked to the catastrophic injury, or whether it is long-term depression that requires medication. A catastrophic injury is literally a catastrophe that affects its victims on all levels, interfering with every aspect of their physical, mental, and emotional life. At the time when catastrophic clients most desperately need to rely on their learning abilities in order to adapt to a whole new lifestyle, they are least able to do so, since their learning mechanism has also been disastrously affected by the trauma. An understanding of the multiple body system involvement in each case is essential in creating an appropriate therapy program for each individual. In developing such a program, every effort is made to integrate the client's own specific goals: I ask them first what they hope to accomplish. Here's a sample conversation: CLIENT : I want to go home. ME : What does it take for you to go home? CLIENT : I've got to be able to walk. ME : And once you walk out of here, what do you have to do at home? Randy, a shoulder disarticulation amputee, learns safety and function with adaptive devices and a prosthesis. I guide them in re-analyzing what they are missing. It may be feeding the cows, or it may be going to work or fishing. Then I explain to them on the front end that this is not a long-term relationship. They are not sick. If they were sick, they would be in the ICU with IVs. They are stable; they are well. They may choose to stay as they are, or they can choose to follow my program and my instructions and achieve their goals. Together we lay out a game plan, and it is essential that they follow it to the letter. One 60-year-old gentleman had lost his arm on one side, but the hand that was amputated had a great thumb on it. At the same time, the thumb on the other hand had been amputated, so the surgical team transferred the thumb. They kept the "good hand" immobilized for four months, and for the same period, the residual limb wasn't moved. At 60 years old, he could neither feed himself nor accomplish the simplest tasks. Following his May injury, he entered my program in September. We identified his goals and drafted a plan to accomplish them. His goal was to be able to turkey hunt by November. I promised him that we could achieve that goal, but only if he adhered to the program and followed all the rules. Four weeks later, I learned that he had arbitrarily stopped taking one of his medications, insisting that he didn't need it. I pointed out that he had obviously set a goal that he didn't really want to achieve, since he had failed to uphold his end of the bargain, and I moved on to another client. The next day he returned and said he had started back on his medication, and we got back to work. He went turkey hunting in November, and he brought the turkeys and fixed them here in the clinic for the patients. This is one of the aspects that make our return-to-work amputee program unique: A "tough-love" approach to goal setting and program development. Other aspects are a creative approach to solving each client's individual problem, and a very intense approach to implementing the program. Goal-Setting, Attitude Adjusting In our facility, there is a "No Whining Allowed" sign prominently displayed. That sums up our no-nonsense philosophy toward making progress. There's simply no time for self-pity if our clients are serious about pursuing their goals. Not all cases have rosy endings, because not all clients are able to set realistic goals. For example, there was the 53-year-old gentleman who headed his global construction company, and who was injured in a foreign country. On his residual limb side, he had a brachioplexus injury as well as rib fractures. He was laid up for six months without therapy. His goal was to have an arm that worked just like his old arm. Although we identified things to help him toward independence, and we clearly stated what we could and could not hope to accomplish, he left angry and frustrated, because his arm didn't grow back. Upper-extremity amputees who are seen in a clinic are frequently the only one with that type of amputation, so they are set on a pedestal. In my clinic, however, those patients are not special; they're surrounded by catastrophic injuries similar to or worse than their own. As far as attitude goes, we are not a support group. The environment is the support group; I am just the facilitator. But if I have done my job properly, "graduates" of our program are just too busy living their lives to have time for a support group. They are either taking their kids to baseball practice, they're out fishing, or they're building onto their house. When people tell me they're trying to find a support group for their 26-year-old amputee, I'm inclined to recommend that they find him a job instead. Creative Approach Upper-extremity and hip disarticulation amputee applies adaptive techniques in a work setting We specialize in designing unique methods of problem-solving for people who need to learn to manipulate such simple everyday gadgets as buttons, zippers, needles, and kitchen utensils. Over the years we have developed a variety of techniques and "tricks" for simplifying such tasks for catastrophic injury clients. Not all button hook adapters work on men's blue-jean buttons. We've developed a small and portable adapter that does the job better. But the answer is not always a special adaptive device; no one wants to carry a suitcase full of such devices, however clever. The key lies in identifying those that are necessary, and which problems can be solved by learning to manipulate the body. We suggest techniques for how to stabilize a bowl while not wearing a prosthesis, for example-in case the client gets up for a midnight snack. And together, we find a way that works for each person. We work on using a dolly, using a fishing rod, using power tools and hand tools; we take clients to a store to show them what is the most appropriate tool for them and how to shop intelligently. Our experience has also prepared us to deal with the full spectrum of associated adaptations and modifications needed for each client. If they have wounds, we can manage the wounds. If they need surgery, we conference with the physician concerning timing and our recommendations for the type of residual limb best suited for the client's needs. Home or work assessments, modifications, and vehicle adaptations all fall within our capabilities. Most of the companies that modify vehicles are prepared to customize for spinal cord injuries, which are not appropriate for an individual with an upper-extremity prosthesis, whether it's a 5X, a 7, a 6X, a Griefer, or a hand. They have surface texture differences and resistance levels and motion differences, as well. They have good intentions, but don't have an understanding of what is required without guidance. Intense Implementation It is desirable to have clients working in the facility on a daily basis for a minimum of four hours a day. The best scenario is to have them there every day for about six hours a day. This frequency helps reinforce-on both a cognitive level and an emotional level-how to use the body again, how to learn to think again, how to learn to motor-plan. The less time off, the quicker their progress, so even while they're eating their lunch, I might pass by and comment, "Todd! I am so sorry you suffered a stroke! Obviously you must have, since you're not using your arm." It's just a reminder that their arm is a part of their life-it doesn't quit for lunch. This strongly reinforces the program and goals, as opposed to working with the client for an hour three times a week which is just not enough. We don't prolong the program unnecessarily; they're here, we push, we accomplish their goals, and they're on their way to wherever they wanted to go. The length of time a program takes will naturally depend on the patient and the nature and severity of the injury. One example of a non-complicated injury: A 48-year-old bridge crane operator with 27 years of experience had a smashed hand. The accident had occurred in another state. The case manager knew it was probably going to result in an amputation, and she called me within six hours. I made the recommendation that if they were going to do an amputation, at what anatomical site the amputation should be accomplished, and emphasized that we needed to get our hands on him ASAP. One week after his amputation we had him in our program; and one month later he had been fitted, he had been trained, we had adapted his bridge crane and he was back at work half-days-and he progressed to full days within six weeks. The accident occurred in 1998, and he remains working to this day. Prior to our program he had never seen anyone use a prosthetic hook, and had his doubts about them. Today, he has three prostheses and continues to use them. Another example: A 26-year-old man in good health prior to his injury had sustained a 47-percent body surface burn in January and had contracted multiple infections. His death had been predicted several times. During the process, he lost not only his right arm below the elbow, but also his ears and his fingers and thumb on the left hand. He came to our program in a wheelchair on April 15, weakened and immobile, with massive wounds. By August, when he finished the program, he was mowing yards, driving a car, preparing meals, and caring for his three young children, and doing an excellent job of it. Additional surgery will be required, but in the meantime, he was able to be fitted with a prosthesis, trained in its use, and became totally independent. Studies on the Value of Prompt Therapy In a study prepared for the American Burn Association, I examined trauma related amputees that had been referred immediately to our program, within 24 hours of their discharge, as compared to amputees that had been treated elsewhere for whatever reason, and were later admitted to our program. The delay group averaged an interval of four months from their discharge to the time they entered our program, and during that time, they had been seen elsewhere by some other therapist, be it a physical or occupational therapist. All amputees were legitimate candidates for prostheses. When they entered our program, both sets of patient groups were dependent in the activities of daily living. In the group that had just gotten out of the hospital 24 hours before, such dependency was to be expected-but the other set had been treated at least a minimum of four months elsewhere, yet still could not be left alone in the house for a few hours, nor could they manage their own self-care tasks. Even one who had been in therapy every day for a year still was not independent. He could not feed himself, cut his food, or bathe himself. Some clients reported receiving therapy in the same group with stroke patients, where therapy consisted of raising their arms, kicking their feet out of the chair, and stacking cones. The outcomes were interesting: Both groups-immediate and delayed-achieved independence in terms of being able to stay by themselves all day at home. When I researched how many of the subjects remained prosthetic users one year after finishing our program, however, the findings were dramatically different. Almost 96 percent of those in the immediate therapy group remained a prosthetic user one year after finishing our program. In the delayed therapy group, only 56 percent of the subjects continued to use a prosthesis on a daily basis. In additional, 84 percent of those in the immediate therapy group continued to maintain contact with their prosthetist/therapist team as compared to only 41 percent in the delayed therapy group. (The lower figures in this group reflect the number of patients who moved from the area, away from their team.) This supports the theory that if an amputee receives therapy from a source that specializes, understands, fits him properly the first time, and trains him immediately, the amputee is going to retain the skill and knowledge for a longer period of time. Another interesting discovery was that, in the immediate-therapy group, subjects possessed a significantly greater number of prostheses per client. The immediate group averaged two sets of prostheses per client, with some possessing three and even four prostheses. In the delay group, the average was one prosthesis, with only two subjects in the group possessing two prostheses. The probability is that these subjects never carried the use of the prosthesis forward into regular tasks of daily living, even though they had been shown how. They were not as easily able to integrate the knowledge into life skills, supporting the proposition that there is truly a "golden period" immediately following injury when it is best to initiate therapy. Team Approach I regard myself as the trainer. I am not the fabricator. As a team player it is my role to communicate with the prosthetist regarding what function the patient is physically capable of developing. I know what function we can elicit from each client, and this is information that it is vital for the prosthetist and physician to know. The specific tasks that we will begin in his therapy program should be an essential factor in helping the prosthetist to identify the most appropriate componentry to facilitate those tasks. If I should happen to identify specifics such as a socket problem, my responsibility to the client requires me to share that information with the prosthetist, although my objective is certainly not to perform critiques of the componentry. It is also important for the prosthetist to observe the patient in the rehab environment whenever possible. The same circumstances will not be in evidence a week later, in the prosthetist's office, after the patient has neglected wearing the prosthesis for that intervening week. The prosthesis itself may then appear to be perfectly fine. The problem may only be evident when the patient is lifting the brick, using the shovel, manipulating the chainsaw, or performing the tasks he or she must be able to accomplish with the prosthesis. Most clients are incapable of adequately describing the situation to their prosthetist in the anatomical and locomotor terms that allow professionals to be precise. Thus the prosthetist's observation of the client in action within the therapy environment can be vital to the appropriate fit and function of the prosthesis, and the solution of any problems. There is so much valuable information and experience that can be shared by the amputee's rehab team to achieve the best results on his behalf, and so much more that we can learn together: studying the over-abuse syndrome of the body in prosthesis wearers, examining how changes in age, body structure, and activities can create a need for a different prosthesis; dealing with peripheral nerve loss in an amputee's remaining extremities and the effect of that loss on the amputee's independence. Cooperation is not only desirable but essential, for our clients' sakes. For me, each case I begin is a new and exciting challenge. Although I have never physically given birth, I feel that I have birthed many new lives. Not only do clients leave the clinic using their prosthesis, but they are fishing, they are competing in tournaments, they are working, they are getting married, they are going back to school. They are much healthier than if I had just shown them how to use the prosthesis, how to pick up the blocks, and go through the motions of "therapy." They have a life. Sandra Fletchall, FAOTA, OTR/L, CHT, MPA, is internationally known for her creative solutions and skills in rehabilitating persons who have suffered catastrophic injuries. For more than 30 years she has specialized in treating the most challenging cases, including patients who have suffered traumatic amputations, disfiguring burns, extensive hand injuries, and paralyzing spinal cord damage. She has received numerous awards for her work in specialized rehabilitation, and has authored a chapter in Ways of Living, an occupational therapy textbook. She can be contacted at HECSAND@aol.com

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