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Sep 16

Prosthetic Rehabilitation with Limited Potential

This is a difficult question to ask, on a site which is dedicated to rehabilitation of amputees. I understand that all amputees should be given opportunity to use a prosthesis, with all the physical and social benefits of being able to stand and walk. But what do you do when you have a patient and deep down are sure that their prosthetic rehab will not be successful? Is it OK to convince them that focussing on a prosthesis and attempting to walk may not be the best use of their time in rehab?

We have had a couple of patients in our unit recently, both vascular amputees. One had a transfemoral amputation, the other a bilateral TFA/TTA. Neither had particularly good mobility prior to their amputations due to their vascular disease and other comorbidities. Both were insistent on wanting a prosthesis, even if it was just to be used to get up and go to the toilet. We had a lot of discussion about how they were unlikely to spend prolonged periods sitting in their chairs with a potentially uncomfortable quad socket, or try to quickly don one at the time of need, only to find it was possibly more a hindrance when they got there.

Both patients were disappointed, one felt we had let him down by not “giving him a go”. The team felt similarly disappointed, despite what would be called a successful rehabilitation outcome in terms of wheelchair independence.

So my question is, how do other places handle this sort of scenario? How do you convince patients that prosthetic rehab is not the only sort of rehab, and that just because you can’t walk at the end of it that it is not a failure?

What sort of goals, or measurement tools do you use in your units to show whether prosthetic training should be attempted because there is a chance of succeeding? Please, any advice is appreciated, as we would not want any of our future patients to experience this same sort of disappointment.

3 comments

  1. lynette wakefield

    This is always a difficult situation and I think all you can do is be honest with your opinion.

    We have produced a booklet which outlines the rehab process for patients and asks them to consider the commitment involved from them to learn to be a successful prosthetic user both during rehab and on a ongoing basis. It also suggest that succesful wheelchair use is an OK option. This is our attempt to make sure that the amputees know what the work icommitment is from them. Its also fair to tell them what a prostheits will and won’t do for them in terms of activity. You are welcome to a copy of this which may help in your discussions and goal setting.

    I usually recommend that TTA be given a prosthesis for transfers first and if this is succcessful then consider walking options, This probably would have been an option for your bilateral amputee.

    For TFA then a trial of airbaging is an option to demonstrate the demands, but I usually start with builidng up standing endurance to around 15minutes which is about the time it takes for a cast and this is very difficult for some boarder line cases and helps make the decision.

    Ultimately you will disapoint some amputees but the door is not closed on a permanent basis. If their health and fitness improved then you can reconsider and they can always seek a second opinion.

    Additional Note (AustPAR Site Admin)
    The booklets Lynette refers to are now available on the AustPAR site, on the Acute Care page, Documents and Presentations sidebar, or via these links:
    Above Knee Amputation
    Below Knee Amputation

  2. Marnie Jones

    We have had great success and satisfaction by providing “sitting balance prostheses” and provide the therapy toward reaching from the sitting position with feet taking some weight bearing or propelling wheelchairs with both feet. Suspension and fitting is adjusted accordingly eg not a PTK.
    Alternatively, the goal is standing pivot transfers and standing for clothing and hygiene purposes, so very light weight components, and practice sit to stand (or pull to stand at a rail).

    Conditions such as cardiac, excessive hip/ knee contractures will prohibit prosthetic trial/ goals as above. Rationale then is not based on the amputee rehab “giving up on them” but issues which have potential to change with a focus on that as a “pre-requisite”.

    The other issue is the amount of carer/ assistance. If there is enough of this available, the goal may be altered to suit them as a unit.

  3. Craig

    It seems counter intuitive to want to tell our amputee patients not to pursue the goal of using a prosthesis doesn’t it? It is however an important role in our job to provide sound objective advice so that our patients and their significant others are fully informed and that we fulfil our role as health professionals.
    One of my previous mentors once said, “do you think they would still be as keen to get a leg if they had to pay for it out of their own pocket?” It’s a valid point from a budget point of view but not the right tack.
    I think there are several points to reflect on for patient and physio:
    Are they motivated? Do they have capacity/cognition to make informed decisions? What are the goals? What will the leg be used for? Are the goals practical from a time and effort perspective? Will their co-morbidities impact on their ability to manage the prosthesis (don correctly, walk a stated distance)? What was their pre-morbid functional status?
    Ultimately there are the physical requirements of managing a prosthesis for a trans-femoral amputee which can help make the decision for the patient:
    • Can the patient stand up – a trans-femoral prosthesis (at least at the moment) will not help with this. A trans-femoral prosthesis will not assist a patient with transfers so if that is their goal (easier/independent transfers)
    • Can they stand up long enough for the prosthetist to take an adequate cast – our prosthetist can manage a quadsocket cast with the patient standing for 10 mins. I would suggest if your patient can’t do this then they will not manage to get the cast done. I’m not sure if there are other methods of casting which allow people to sit down during the cast.
    • Can they (with or without a carer) sequence the procedure of putting on the prosthesis correctly. Again it takes a period of time in standing and balancing just to fit the prosthesis correctly as well as putting garments on at appropriate times in sequence. There is also the question of adjusting the prosthetic fit with the use of socks. Inappropriate donning of the prosthesis may lead to pressure areas developing.
    • The patient should be aware of the heightened falls risk in the case of the trans-femoral amputee – the consequences of falls (hospitalisation, pain, bruising, fractures, mortality) should be clearly pointed out. Additionally, the load on the intact foot/leg should be considered in light of the degenerative changes that are likely to take place as a result of prosthetic mobility.
    Carers and family should be made aware of the patient’s goal of prosthetic use and the potential hazards and physical requirements. I find Relative interviews /family meetings to be the appropriate platform for this discussion and sometimes it can resolve the issue.
    Appropriate peer support may not be out of the question – some patients just want to have a sense of worth; that they can still achieve quality of life without a limb. A peer can help explain that this is possible.
    I’m not sure there is the perfect answer to your question. I would like to think that most people can make a rational decision if given the facts and not just want to get a leg because of an overwhelming feeling of entitlement. It will not replace their limb from a physical or emotional perspective.
    In the end we all want to see our people wearing their prosthesis so it looks well used rather than standing in a corner collecting dust as an ornamental flower pot stand.

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