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Expert Speak

Disability : Loss of Limb and Rehabilitation

Accidents on the roads and in industrial environments can happen to anybody, resulting in severe limb injury and subsequent handicap. A loss of limb has a disastrous effect on a person physically, psychologically and economically. This three part patient information on Amputation, Rehabilitation and Prosthesis Fitting hopes to create greater awareness in avoiding and overcoming disability due to the loss of a limb.

Amputation

Amputation: Criteria (Trauma)
Who is at risk?
First Aid
Re attachment of the Limb
Prosthesis Fitment

Accidents on the roads and in industrial environments can happen to anybody. Severe injuries can lead to amputation and a permanent handicap. Under what conditions in a trauma case are orthopaedic surgeons forced to take the decision to amputate?

Though surgeons try to salvage the limb involved, they may be forced to perform an amputation in the following cases:

  • Extensive soft tissue damage
  • Grossly contaminated limb
  • Vascular (blood vessel) injury in the presence of a devitalised limb
  • Injuries with infection like gas gangrene
  • Badly crushed limb (crush syndrome)

Who is at higher risk of accidents?

The high risk groups are:

For Road Accidents:

  • Drunken drivers (or drivers under some kind of addiction)
  • Those who drive at night, especially on highways
  • Elderly drivers (especially those with failing vision and hearing powers)

In Industrial environments:

  • Those ignoring safety protocols and measures
  • Fatigued workers: overtimers, and those overworked
  • Those under stress at work/home environment

In a trauma case, there is bleeding, probable internal injury and threat to life. Are limbs at all attended to in this situation?

The priority is always to save the life first. Whatever is important for this is done. However, almost simultaneously, a good hospital works on all problems. A team of doctors usually attend to the injured person.

In an accident, what is the nature of the First Aid that has to be given to a person who has limb injury a) At the site of accident b) When being transported

The following measures can be taken:
a. At the site, by any lay person:

  • No tourniquet should be applied (That is, do not tie tightly around the wound to stop blood flow) In case there is excessive bleeding, press a clean cloth to the wound and rush the patient to the hospital.
  • Loosen the clothing on the patient. In case the person is wearing tight jeans etc, cut/loosen clothes over the injured limb.
  • If it is observed that a limb is broken, do not move the limb. Support it with a splint.
  • Note: There may be other injuries as well. Support the neck and shift the person without abrupt movement.

b. If an ambulance or trained First Aid staff can be called, they will focus on rushing the patient to the hospital, by shifting the person without jerky movements, or minimizing movements to individual body parts. They apply splints.

If a limb is cut off, they collect the limb and put it into a clean plastic bag, place the bag in an icebox and carry it with the patient.

If it is possible, the patient should be taken to specialised centres where highly trained staffs are available to perform reimplantation and where special instruments and microscope facilities exist.

In case a limb has been totally cut off, how should the limb be preserved so that the possibility of reattachment is high?

The simplest thing is to take the detached limb, put it in a clean/sterile plastic bag. Keep this in an icebox and rush the patient and the limb to the hospital ASAP (within six hours). The amputated limb should NOT come in direct contact with the ice.

What does re-implantation involve?

The severed limb is re-attached to the body by establishing a bone-to-bone contact and treating the surrounding area so that all soft tissues (blood vessels, muscles, tendons and nerves) are regenerated.

Is it better to reattach the limb or go in for a prosthesis?

It is always better to reattach the limb if the limb can be salvaged.

Have there been any advances in orthopaedic surgery that can reduce the chances of losing a limb?

Modern micro surgical techniques preserve as much muscle and nerve possible. Even if an amputation is inevitable, prosthesis available today can restore a good part of the limb function.

When, post operatively, should the patient go in for prosthesis fitting?

After amputation, the wound has to heal. After this the patient is taught exercises to reduce swelling. The stump is draped in crepe bandage to shape it for prosthetic fitting. When it is conical, the prosthesis can be fitted.

Are there parameters about where the limbs should be cut, so as to facilitate the fitting of prosthesis?

Both the technique and the level of amputation, so as to facilitate fitting of prosthesis, are defined in medical text books. In elective surgery, these rules are usually adhered to. But in an emergency, as in accident cases, the first priority is to save the life of the patient. Many crucial decisions have to be taken. So the surgeon prioritises these and the amputation is performed in order to overcome the life threatening crisis situation.

The length or type of amputation may not be the priority. The patient can always approach the surgeon after recovery for adaptation for prosthetic fitting. Also, today prosthesis are available to suit most lengths.

What is the advice you will give a patient who has undergone amputation?

It is a shattering experience. For many it might mean a loss of current occupation and lifestyle. However, it is important to remember:

  • The patient has lost a limb, not life.
  • Many amputees have been able to use prosthesis and continue most of their limb functions.
  • A positive approach helps in faster recovery.
  • Taking physiotherapy seriously helps healing.
  • If there are problems in the stump, while fitting prosthesis or during physiotherapy, the patient should not hesitate to check with the surgeon.

Source: The above information has been provided by Dr.N.Manikantan. He is a D.Ortho from Stanley Medical College, Chennai. He has about 20 years of experience in the Orthopaedic field and is a consultant in city hospital.

Limb Prosthesis

From heavy, immovable appendages prosthesis are becoming lighter, more articulate and functional.

Composite materials that are water and fire resistant and durable are being used. A lighter prosthesis reduces the shear forces and pistoning motion about the residual limb/stump.

Lighter prosthesis expends less patient energy. When fibrous materials are used the matrix structure of the material transfers the stress more evenly. Metal alloys, such as co-polymer, titanium etc. are also used to make lighter and stronger products.

In the field of design, laser and computer assisted technology has made it possible to contour prosthesis that fit snugly with the stump.

Prosthetists can now offer patients artificial feet with a range of knee and ankle movement which can help even an above knee amputee to run. Artificial hands can grasp a pencil, and perform fine motor movements.

Prosthesis: User Awareness
Indian Scenario: Mukti
Features of the Prosthesis
The Fitting Process
Callipers
Rehabilitation of Bilateral Amputees
Sponsor a limb

What a prosthesis user must know

  • Wait till the suture line heals and the swelling subsides, before you go for a prosthesis fit. The time this takes and depends on the individual and the medical team’s decision. But it would be wise to wait for 4-6 weeks atleast.
  • However, be keen to start on physiotherapy as early as possible.
  • You may experience some pain initially, but let this not deter you. If your wound has really healed and the prosthesis is a good fit, this pain will gradually reduce with time. The pain should not stop you from training and exercising. If the pain is too much, get in touch with your doctors.
  • Do not get used to languishing in bed, even if your family/caregivers think you need to rest. Be guided by your physiotherapist.
  • Choose a prosthesis that will suit your lifestyle. But also be sure that maintenance does not become too much of a problem. Prosthesis that have fine electronic parts that may require careful maintenance.
  • Train to use the prosthesis effectively.
  • Many adaptations can be made to your lifestyle : such as opening a bottle with your mouth (if you have an upper limb amputation). Or getting hand push switches, levers to operate your vehicle (if you are a leg amputee).
  • A limb prosthesis, especial a lower limb prosthesis, rarely lasts for more than five years. Even for this the maintenance must be pretty good. If there are changes in the body, ( such as weight/height) more frequent replacements will be required.
  • Therapists have found that personal motivation is crucial to recovery and readjustment in life. This, in their experience, does not depend on economic or educational status of the employee, but is a personal trait.

Prosthesis in India

In the Indian scenario, the Jaipur foot was a low cost breakthrough that enabled the disabled to adapt to the Indian environment. Both commercial and not for profit organisations in India manufacture artificial limbs, their products varying in features provided. Sophisticated prosthesis are usually imported and very expensive.

One of the leading charitable artificial limb manufacturers in India is Mukti, a unit of M/s Dadha Foundation.

The features of the Mukti Limb

The prosthesis are:

  • Made of high-density polyethylene (HDPE), based on a French design.
  • Lighter in weight than the conventional prosthesis made in India.
  • Waterproof and durable
  • Technically simple.
  • Permit squatting and walking on uneven ground. Farmers and fishermen are able to use it. Barefoot walking, sitting on the floor are possible.
  • Shaped like the human foot (upto the ankle), giving the natural "feel" to the user.
  • Have knee folding capability,(with clips that have to be locked and unlocked) for limbs made for amputations above the knee.
  • Leather straps to strap the limb onto the thigh.

The process of limb fitting at Mukti

  • The limb is given free, but the amputee has to register himself, as there is a waiting list.
  • Patients are asked come for measurements only six months after amputation.
  • The prosthesis is made in a day or two.
  • While the hand prosthesis is not very functional, the lower limb prosthesis enable many basic functions that rural and urban Indians perform.
  • Some patients start off on a temporary prosthesis and once balance and gait training has been given, a long term prosthesis is made.
  • The prosthesis is hardy and fairly easy to maintain, and is aimed to endure for 5 years.
  • Once a limb is fitted, the patient is expected to come for follow up, till he is fairly comfortable with the device.
  • Mobility training, including stair climbing training, is given.
  • As part of rehabilitation, if required, vehicle driving is taught.
  • Army personnel are given preference but otherwise there is no discrimination based on economic or social differences.

Mukti’s Callipers for Polio Victims

Mukti makes light weight callipers for polio victims. These permit good air circulation around the limb and thereby preventing complications.

They do not come with a fitted shoe, permitting victims to walk barefoot, which is a cultural necessity in Indian conditions ( such as visiting a temple).

Mukti’s technicians have introduced light weight callipers for children.

Callipers and other rehabilitation aids or appliances, medicines and special shoes, etc. are provided to polio affected and other disabled persons, free of charge.

The therapists advise that the polio victim should be brought to the centre as early as possible, even if he or she is a toddler. This way the rehabilitation will be faster.

Rehabilitation of Bilateral Amputees

One of the special achievements of Mukti is the bilateral amputee rehab. This is done stage by stage, with gradual rise in prosthesis height from small to normal.

At stage one, the amputee is given a very short prosthesis, which makes him look rather like a midget. As a bilateral amputee is not likely to have used a bipedal gait for some time, and therefore has to learn to balance himself. Also, he has got used to himself as a short person. Giving the amputee natural height limbs (even based on average family height measurements) may make him feel like a stilt walker and unsure of himself.

Very short leg prosthesis help the patient attain balance quickly. When wobbly, he simply leans a little and rests his hand on the floor and supports himself.

After this, sometimes a middle level prosthesis is used, but if balance is good, the patient is given a natural height prostheses.

Physiotherapists work with the patients through rehab.

Sponsor a Limb

Mukti, with the assistance of the Rotary Club, Lion’s Club, Round Table, Jaycees and other philanthropic organisations has provided mobility devices for more than 80,000 victims in 18 years since its inception in 1986. The victim does not pay anything.

Mukti incurs a cost of Rs 2000 -- Rs 5000 ($50 -$100)for an upper limb prosthesis and a Rs 1000 – Rs 3000 ($25 - $75) for a lower limb prosthesis. Mukti’s running costs need also to be covered.

For those who would like Mukti in its endeavour the following programmes are available:

Artificial limb – 15 year plan – sponsorship amount : Rs 15,000 ($500) Calliper for polio victim - 15 year plan - sponsorship amount: Rs 10,000 ($250)

One time fit of artificial limb - sponsorship amount Rs 1000 ($25) One time fit of calliper for polio affected.- Rs 700 ($35)

Donations exempt under 80G Act of Income Tax Act of India, 1961

CONTACT:
Ms Meena Dadha
Chairperson, Mukti.
1, Station Road, Meenambakkam,
Chennai – 600027,
India.
Phone: 91 44- 2234 6973
Fax: 91 44- 2233 3168
Email:
meenadadha@vsnl.com

Fitting of Prosthesis and Rehabilitation

“Early ambulation, physiotherapy and personal motivation help a patient achieve the best results in terms of readjusting and returning to an almost normal lifestyle,” says Anand Kumar, Asst Professor , BS College of Physiotherapy.

A Physiotherapist’s work begins with an amputee on the day of the surgery, and continues till the patient has been fitted with a prosthesis and rehabilitated. Below Knee and Above Knee amputation involve more effort as in a leg amputation locomotion is affected.

Day 1: On the day of the surgery the patient is still probably under anaesthesia. The physiotherapist visits the patient and assesses the amputation. He takes note of the cause of amputation and gets patient details. The amputated limb is extended. Caregivers are advised not to use pillows below the limb or in anyway alter the position of the limb, other than as the physiotherapist has advised. It is important to keep the limb extended.

Otherwise complications like contractures set in and fitting prosthesis will be a problem.

Day 2: Breathing exercises are taught to the patient. This is important for enhancing the lung capacity and the energy level of the patient so that he can attempt early ambulation.

Day 4/5: Chest physiotherapy is given. This helps the patient clear the sputum/secretion in the lungs. Techniques such as clapping/ tapping are used to help the patient clear his lungs.

Day 7/9: Stitches are removed around this time and the physiotherapist can actually view the stump. He takes note of the idle length of the limb. Crepe bandages are used and the stump is shaped, usually conically to facilitate the fitting of prosthesis.

Limb exercises are taught to strengthen muscles. If a leg is amputated, “crutch muscles” are strengthened, as these are important for ambulation.

Day 12 /13: Usually prosthesis training begins. But for this Orthopaedic surgeon, Neurologist and Vascular Surgeon have to give their clearance.

At first the patient is briefed about how he should adapt to the use of prosthesis and adapt to life with the prosthesis. Patient is trained on the parallel bar. He is taught the three point gait (walk).

Phantom Limb Sensation: Most patients who have been amputated feel sensations like itch, ache, cramp, burning etc in the limb which seem to relate to the amputated limb. Even though they know the limb is not there they feel as if it is itching. Quite often doctors/physiotherapists are requested by patients to “scratch” or manage pain in the absent limb.

Though called “ Phantom pain,” it is a real sensation. The patient is not going crazy. This phenomenon is not really understood very well. However, the nerves seem to indicate to the brain that there are sensations of pain etc are emanating from the limb, which has been amputated.

To get rid of this worrying sensation, the physiotherapist uses exercise, massage and electrical impulses to manage this pain. It may disappear quite soon or may linger on and off for a year or more. But rarely over a year.

Motivation is the most important component in therapy. Motivation is a very individual variant. Education or economic status has no bearing on motivation. Some patients from humble backgrounds have known to be very proactive in getting adjusted to a life with a prosthesis. On the other hand, some educated and wealthy accident victims have been known to neglect the crucial post op period, or be un co operative as they are in shock or depression, thereby letting the best chance of recovering slip by.

Neglect If early ambulation and physiotherapy are not taken seriously chances of complications are high. If the patient is in bed for longer than necessary, bed ridden complications like sores and breathing difficulties.
In the damaged limb complications like contracture set in.

Post Prosthesis Physiotherapy: This involves getting used to the apparatus. Apart from gaining balance, the patient should know where to apply pressure and where not to. The muscles which will be articulating/taking the stress of the prosthesis should be strong enough to do the job. Exercising these muscles is important.

Today light and sophisticated prosthesis for limbs allowing quite a bit of articulation are available. The patient has to get trained in usage, maintenance and troubleshooting of these devices.

Common Problems:
Pressure sores can result if the prosthesis is not used or fitted right.
If the area is not aired properly oedema may result
Friction can cause pain and blisters. Cushions are available to redress this.

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