Women with Traumatic Amputations: Prosthetic Care for a Unique Population

[caption id="" align="alignnone" width="366"] Mery Daniel with her occupational therapist, Becky Buttiglieri. Photograph courtesy of Jesse Costa/WBUR.[/caption] The celebratory atmosphere at the finish line of the Boston Marathon on April 15 ended abruptly as two bomb blasts rocked the scene, killing three and leaving more than 260 people injured. Sixteen people suffered leg amputations, including eight women and a seven-year-old girl, who now face grueling rehabilitation and adjustment to new lives as individuals living with amputations. The number of women who have undergone one or more amputations as a result of injuries sustained in the Boston Marathon bombing and in recent military conflicts has increased awareness of women with traumatic amputations, a historically small patient population compared to men. Only about 20 percent of people in the United States with traumatic amputations are female, according to Amputee Coalition statistics. The higher numbers for men have been attributed to riskier behaviors and circumstances that include more high-risk jobs and recreational activities, aggressive driving, and illegal drug use. In many ways the experiences, rehabilitation, and prosthetic care of the Boston attack survivors who have undergone amputations are similar to other patients with traumatic amputations, but in other ways, they have been dramatically different. For instance, the shrapnel-filled pressure cooker bombs inflicted injuries consistent with combat blast injuries. One of the blasts drove debris, and even the car keys in his pocket, deep into J.P. Norden's thigh, causing heterotopic ossification, more often seen in combat injuries, and necessitating a series of surgeries, notes a Wall Street Journal news story ("Struggles of Boston Amputees Mount," by Jennifer Levitz and Jon Kamp, September 20, 2013). "As I made my rounds, people would often produce pieces of shrapnel that had worked their way through their skin," David Crandell, MD, staff physiatrist and inpatient medical director at Spaulding Hospital, Boston, Massachusetts, told The O&P EDGE . Fifteen survivors with amputations have been treated at Spaulding. Crandell's patients include family members who lost limbs in the blasts: a newlywed couple, Patrick and Jessica Downes; brothers J.P. and Paul Norden; and mother and daughter Celeste and Sydney Corcoran (Sydney suffered injuries but not amputation). [caption id="" align="alignnone" width="451"] Boston bombing survivors at the CAF San Diego Triathlon Challenge. Photograph courtesy of the Challenged Athletes Foundation.[/caption] Prompt medical care at the scene improved the prognosis for the injured as emergency responders rushed to the scene and other bystanders hurried to help. "All received excellent medical care at the scene and were transported within minutes to Boston trauma centers, some individually, some in police cars, some packed in with other people," Crandell says. "Everyone who made it to the hospital survived and was able to begin rehabilitation in reasonably good shape." The national and international tidal wave of sympathy and intense media coverage put the survivors in the world spotlight, as did various public events to honor them. The slogan "Boston Strong" rallied the city, and those who lost limbs as a result of the bombing were often viewed as exemplifying Boston's strength and resilience. But, as do most individuals who have undergone a traumatic amputation, they have had difficult days and setbacks including unexpected additional medical care and surgeries, longer-than-expected recoveries, difficulties in adjusting to prosthesis use, and bouts of depression over their changed lives. "It's a daily challenge," Crandell says. "They have good days and bad days. As a group, they received a tremendous outpouring of local, national, and international support, but they have this pressure to always be upbeat and 'Boston Strong.' Some were eager to chat with the media; others shut down, not wanting to be involved." Some patients held press conferences; People magazine did a feature story and photo shoot. "It's not very often that I have three of my patients on the front cover of People magazine," he says. The cover featured left transtibial amputees Mery Daniel, Adrianne Haslet (Haslet-Davis), and Heather Abbott. The Boston bombing survivors had waves of visitors from various amputee organizations including Walter Reed National Military Medical Center (WRNMMC), Washington DC, and the Semper Fi Fund, along with celebrities and notables such as movie star Kevin Spacey and former Arizona Congresswoman Gabrielle Giffords, who is recovering from disabling injuries she suffered from being wounded in a shooting while she met with constituents. The O&P EDGE spoke with prosthetists involved in the women's care about perspectives they have gained throughout their professional experience in treating female traumatic amputees. Cosmetics and Function Cosmesis is often a more important consideration for women than for men; men generally show the "bones" of their prostheses, especially if it is a high-tech device. When financial resources permit, patients often have multiple artificial limbs, such as a cosmetic prosthesis, a sports prosthesis, and a water prosthesis. However, some individuals find their options limited to one prosthesis and must decide what best fits their needs and lifestyle goals and thus whether to go primarily for cosmesis or a high-activity prosthesis. "We're seeing interest in cosmetic, or 'realistic restoration,'" says Matt Albuquerque, CPO, president of Next Step Bionics & Prosthetics, based in Manchester, New Hampshire. "We need to create awareness of the potential benefits a realistic-looking limb provides amputees, such as self-esteem and being able to dress the way you want. It's yet to be documented in literature and research, but we know that all those things correlate with one's general health." [caption id="" align="alignnone" width="206"] Abbott at CAF's Össur Leg Amputee and Mobility Clinic in Boston, October 6. Photographs courtesy of Next Step Bionics & Prosthetics.[/caption] [caption id="" align="alignnone" width="283"] Abbott shows off her new prosthesis that allows her to wear high-heeled shoes.[/caption] Cosmesis is important to Next Step patient Abbott, so one of her prosthetic limbs is covered in a highly lifelike creation from Dorset Orthopaedic, headquartered in Hampshire, England. "They are literally handmade out of a block of silicone by fine art students to recreate the translucence of skin," Albuquerque explains in a news story ("Walking Tall," by Dave Solomon, New Hampshire Union Leader, August 31, 2013). The new prosthesis allows Abbott to wear a four-inch, high-heel shoe and joins her everyday and waterproof prostheses. Abbott also now has a running leg crafted by Next Step, which incorporates a Cheetah foot donated by Össur Americas, headquartered in Foothill Ranch, California, the Challenged Athletes Foundation (CAF), and the Knights of Columbus. Next Step patient Roseann Sdoia was fitted with an Ottobock Genium® knee; she lost her right leg in the bombing. Eventually she hopes to have a running leg so she can get back to jogging regularly, plus a cosmetic prosthesis from Dorset Orthopaedic with a two-inch heel and a silicone cover that matches the freckles and veins of her skin, according to a news story on WBUR.org online ("Marathon Bombing Victim Makes Strides Toward Her New Normal," by Martha Bebinger, September 24, 2013). [caption id="" align="alignnone" width="315"] Sdoia uses the parallel bars to practice her gait using her new Ottobock Genium knee.[/caption] [caption id="" align="alignnone" width="313"] Above right: Arthur Graham shows Sdoia an example of a silicone cover. Photographs courtesy of Next Step Bionics & Prosthetics.[/caption] Paul Martino, CP, president of United Prosthetics, based in Dorchester, Massachusetts, however, sees a shift toward women choosing higher function over cosmesis when a choice has to be made. "Women tend to be more athletic than men today in some cases. You see more women out running, getting involved in CrossFit®, and competing in more physical activities. We've seen a greater increase in female athletes than we've seen in a very long time." United Prosthetics has provided prosthetic care for several survivors of the Boston bombing including Daniel and seven-year-old Jane Richard. "Some high-tech componentry doesn't always lend itself to cosmesis," Martino continues. "Our first goal, of course, is to get the patient up and functional. And then when it comes to cosmesis, we discuss custom socket laminations, and in patients that want the most natural look, we consider components you can easily put a cover and a skin over and get a pretty good shape." "For [a woman's] first prosthetic leg, cosmesis is often the most important," according to Julianne Mason, CPO, a staff prosthetist at United Prosthetics. "Since they use it for work, for going out, for everything they do, they want to look the best they can. We let them try the componentry that is best for them cosmetically and provides heel-height adjustability. They do lean toward higher-functioning componentry that will bring them back more to their previous function over the more cosmetically pleasing componentry. We let them try everything, and they can make the choice." "Although cosmesis is still huge in some other parts of the world, we've seen a shift here in the United States," says Stan Patterson, CP, owner and president of Prosthetic & Orthotic Associates (POA), Orlando, Florida. "When I first entered this profession over 20 years ago, cosmesis was important to a far larger percentage of women than men, but now I'd say over 90 percent of our patients, both men, and women, do not even wear covers." Patterson believes the positive image of individuals with amputations generated through media coverage of high-tech prosthetic advances and high-achieving sports stars, along with ads featuring elite athletes, has been a factor in the change. [caption id="" align="alignnone" width="315"] Corcoran shows how far she's come in her rehabilitation, testing out the climbing wall at POA.[/caption] [caption id="" align="alignnone" width="313"] Corcoran shows off her driving foot. Photographs courtesy of Prosthetic & Orthotic Associates.[/caption] Karen Hughes, POA's web and social media director, who also has a transfemoral amputation, prefers wearing a cover most of the time, including when she is attending her children's school events or running errands. "I want people's attention focused on the kids, not me. If I want to run over to Target, I like to do that without calling attention to myself. [But] if I'm running a 5K, I leave it uncovered to show what I can do." Patterson treated Celeste Corcoran, who has a right knee disarticulation and a left transtibial amputation. Corcoran met Eric Fregger, a sales representative from Ottobock, Minneapolis, Minnesota, at the Amputee Coalition National Conference in June. Because Corcoran said that she really wanted to be able to go swimming and take showers with a prosthesis, Fregger helped her get the new, high-tech, waterproof X3 just being introduced to the public. "He told her she was one of the first people in North America to get an X3 with a threaded top—that's where you can just thread it into the socket," Patterson says. "She took to it like a fish to water. She was not only ambulating but also walking without a cane, using stairs, and driving. She accomplished a lot in a very short time." Prosthetic Care: Are There Differences? "Women tend to be more emotional," Patterson says. "For instance, if they're frustrated in trying to accomplish certain tasks, they may break down in tears." Like many men, he is sometimes mystified by such reactions and admits, "I don't deal very well with that." But Patterson firmly believes that being a good prosthetist means not only dealing with artificial limbs but with the patient's psyche, and he tries to help patients with what they are going through emotionally as well. [caption id="" align="alignnone" width="332"] Patterson adjusts Corcoran's prosthesis as her daughter Sydney and two others look on.[/caption] "Women are used to taking care of everybody else, so when we are the ones who need to be cared for and can't do what we usually would for our family, it's emotionally tough and can lead to tears of frustration," Hughes says. "However, those tears quickly change to tears of joy as we regain our abilities, as was the case when Celeste drove a car for the first time using her prosthetic legs." Martino, however, says that he hasn't seen any marked differences between men and women in their psychological and physical adjustment to amputation and prosthetic use. "It's more about the individual," he says. "Everybody's different." U.S. Army veteran, paratriathlon champion, and Paralympian Melissa Stockwell, CP, LP, a staff prosthetist at Scheck & Siress, Chicago, Illinois, echoes Martino's comments. She says she believes that how well a person adapts to amputation depends on the individual rather than gender. "It's person-dependent—how well they do in recovery, support from family and friends, seeing other amputees' success, and their confidence that 'I can accomplish this.'" Stockwell, the first woman to lose a limb in combat in Iraq, says, "We're seeing more women amputees that show the metal leg, often with a [socket] design that expresses who they are." Some female patients do want a realistic, silicone restoration that enables them to wear high heels, she says. However, perceptions are changing, with robotic-looking prostheses seen as cool, and "coming from the veteran community, I like to show off my [high-tech] prosthesis." [caption id="" align="alignnone" width="273"] Stockwell competing in a triathlon. Photographs courtesy of Melissa Stockwell.[/caption] Peer Visits Although they are well-meaning, celebrities and others with expensive, extremely natural-looking cosmetic legs can sometimes create unrealistic expectations in new amputees. Martino believes that peer visits can be tremendously helpful when the visitors are experienced amputees who can be supportive and provide practical, realistic tips and advice. "Those are the ones we like to see interact with our patients." Symposium Explores Women's Concerns Among other recent research efforts, a State of the Science Symposium on Medical Rehabilitation of Wounded, Injured, and Ill Women at the University of Pittsburgh (Pitt), Pennsylvania, was held May 8, under the auspices of Pitt, the WRNMMC, and the Center for Rehabilitation Science Research at the Uniformed Services University of the Health Sciences, Bethesda, Maryland. The symposium explored different aspects of women's healthcare with a focus on female veterans ( www.herl.pitt.edu/rehabilitation-women ). A presentation, titled "Unique Considerations for Women with Traumatic Extremity Injuries and Amputations," by Billie Randolph, PhD, PT, OCS, deputy director, Department of Veterans Affairs (VA) Extremity Trauma and Amputation Center of Excellence, reviewed research findings that also can be extrapolated to civilian women with traumatic amputations. Her presentation looked at several factors. Regarding physical factors, her review found that although age, cause, and amputation level impact functional outcomes, gender does not; lower-limb amputees of both genders are at significant risk for knee and hip osteoarthritis; women with lower-limb amputations tend to demonstrate significantly lower bone mineral density (BMD) values (increasing the risk for osteoporosis) than did men; individuals with traumatic amputations have lower BMD than do individuals with nontraumatic amputations; and women with lower-limb amputations report more skin problems than their male counterparts. Veteran-Specific Concerns Women who have undergone traumatic amputations and are also veterans may have additional factors that complicate treatment due to their military experience. In general, female veterans are at greater risk for homelessness and unemployment than male veterans and are more likely to live alone, according to Randolph. Also highlighting issues faced by female veterans, the nonprofit Society for Women's Health Research (SWHR), based in Washington DC, testified before the House Appropriations Subcommittee on Military Construction, Veterans Affairs and Related Agencies on March 26, 2012. The SWHR included information on differences in how men and women in the Armed Forces respond to traumatic events. For example, female veterans are more than twice as likely to develop post-traumatic stress disorder (PTSD) as are their male counterparts (about 10 percent of women compared with about 4 percent of men) and are also four times more likely to develop chronic PTSD. Sexual assault also may be a contributing factor to military servicewomen's higher rate of PTSD, since "it has been found that sexual assault is more likely to cause PTSD than any other event, and nearly one in five women veterans spanning all generations accessing VA care report that they have been a victim of military sexual trauma," according to the SWHR. Pregnancy Considerations Special concerns for pregnant amputees include weight management and regular exercise, Randolph points out. Prosthetic alignment and abnormal wear of components should be checked regularly. She notes that women with amputations at the transfemoral level are most affected by pregnancy due to larger amounts of soft tissue present and adds that transfemoral amputees who are scheduled to give birth via cesarean section should have the incision made higher to prevent irritation by the socket brim. Treatment Factors to Consider Clinical and environmental factors affecting women who undergo amputation include the following, according to Randolph: Providers may need to offer enhanced communication to maximize encounter satisfaction. Women report a greater need for privacy, modesty, and sense of dignity during the evaluation process. Women often prefer a female prosthetist or orthotist. Women describe different rehabilitation goals. Women often prefer female peer visitors. Many women believe that "men don't see this the same way women do." Prosthetists' Goals The Boston bombing survivors as well as other individuals with amputations, whether female or male, traumatic or elective, are adapting to new lives as amputees. As prosthetists, "Our main goals are proper fit, proper function, and use of proper componentry to get patients back to their functional lifestyle as fast as we can," Martino says. "That helps their overall feeling about themselves—they're up, they're laughing again, they're participating in their lives. The quicker we can make that happen, the better for all concerned. Miki Fairley is a freelance writer based in southwest Colorado. She can be contacted via email at miki.fairley@gmail.com

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Women with Traumatic Amputations: Prosthetic Care for a Unique Population

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