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Returning Upper-Extremity Amputees to Work
By Sandra Fletchall, FAOTA, OTR/L, CHT, MPA 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.
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Patients at Capabilities For Living learn to incorporate adaptive devices and techniques in order to perform daily tasks with their prostheses. |
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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.
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Sandra Fletchall, FAOTA, OTR/L, CHT, MPA |
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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?
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Randy, a shoulder disarticulation amputee, learns safety and function with adaptive devices and a prosthesis. |
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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
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Upper-extremity and hip disarticulation amputee applies adaptive techniques in a work setting |
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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 
Table Of Contents - August 2005
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