Functional Rehabilitation of a Patient with Triple Traumatic Amputations
Richard A. Sullivan, M.D. Felice Celikyol, O.T.R.
The patient with congenital, multiple, limb deficiencies challenges the physician and his treatment team to the extremes of their prosthetics innovative talents as they search for the best functional prosthesis or combination of prostheses. These cases with congenital absence, however, have an advantage in that it is possible for the treatment team to work with the patient from the time of birth. The patient has an opportunity to grow with his devices while learning to use them to become independent in meeting his functional needs. These patients do not have knowledge of any previous functional ability to interfere with their learning.
As each patient grows, the devices become an integral part of his body image, a prime necessity for the development of true functional integration. Many have some residual appendage or have developed substitute limb function with which they can operate effectively, at least in part. The most obvious example of this substitution is the bilateral shoulder-disarticulation amputee who functions better with his feet than with any type of prosthetic device. In the case of the triple or quadruple amputee, however, every effort is made to have the patient utilize his or her prostheses to meet daily activity needs since in most instances these are the patient's only means of attaining functional independence. The success of these training programs for the multi-limb congenital amputee has been documented frequently. The major problem that one has to deal with is the depression of the parents. Once that has been resolved, a successfully functional child amputee results.
The case of the amputee with multi-limb acquired losses, however, can be a much different story and a much more difficult one for the team. They face the problem of the child who can remember well the function he had before. This young patient is less prone to be easily satisfied with our "replacement parts" which we have the audacity to depict to him as "functional prostheses." The patient can remember only too well the feel and dexterity of the lost hand and arm; the functional agility and security of balance and ambulation provided by the missing leg and foot. Moreover, in these cases, one must face the psychological impact on both the child and his parents of the sudden traumatic transformation which has taken place. They need assistance in adjusting to the cruel reality of functional loss and disability, and need to be provided with the means of coping with the resultant depression.
Proving the value and function of the prosthetic hook and hand as replacements for the lost member requires a total, comprehensive, full-team rehabilitation effort. The same can be said for the prosthetic leg and foot, and the problem is increased with the number of limbs involved. The confidence of the patient and his family in the function, stability, and value of the prosthetic limb must be developed if successful use is to be attained.
Role of the Parents
All of our "accepting" children have one thing in common-and that is "accepting" parents. It has been the experience in our clinic that the child amputee with an accepting, cooperative, and enthusiastic mother and father is a successful achiever. Without this parental understanding, acceptance, and encouragement of prosthetics use, a truly functional result is seldom achieved.
Much of the time and effort spent in the prosthetics-use training of the child includes the parents, which encourages parental involvement and acceptance. This involvement includes, in addition to the standard clinic and therapy training sessions, parental group seminars where the parents of a new patient are exposed to other parents with similar problems. They enjoy the advantage of discussing many of the present and future problems with parents who have already faced and solved similar ones. Parents of both congenital and the acquired amputees are included in these group meetings. Both amputees and the parents of amputees present their experiences to the group, thus providing both a teaching and learning experience for the participants.
The results of this type of dynamic rehabilitation process are illustrated in the case presented in this article. It describes the history of a young man who became a triple amputee at the age of eight years. Through the team rehabilitation approach to his problems and those of his parents, a successful result was achieved. In addition, a functional home environment was developed. Architectural barriers were erased where possible, and eased when total abolition was not possible. A happy, confident, well-trained, and functional young man, with understanding and assistive parents, resulted. He functions independently in a planned home environment that minimizes his disability to the maximum extent possible.
A.B. ("Augie") was admitted to the inpatient service of the Institute on August 1, 1972. He was then eight years of age. He had required bilateral knee-disarticulation amputations and a right shoulder disarticulation following severe electrical burns. These burns occurred when he came in contact with live wires while playing in a restricted, fenced-in area which had been left unlocked inadvertently by a local utility company employee.
The accident occurred in March of 1972 following which he was hospitalized at Rahway Hospital in Rahway, New Jersey. He underwent several operative procedures including the amputations themselves and multiple skin-grafting procedures.
Hospital Course—First Admission
On August 1, 1972, the boy was admitted to the Amputee Service of the Kessler Institute. He was obviously frightened and depressed. His parents were anxious and over-solicitous, showing signs of severe anxiety and depression.
The physical examination revealed an alert, highly intelligent, extremely apprehensive white male who appeared older than his stated age. The knee-disarticulation stumps were extensively scarred, and the thighs showed a considerable degree of muscular atrophy. They were extremely tender to palpation, and the patient cried out with fear and pain when any type of palpation or manipulation was attempted. The right arm was totally absent, and a small area of granulation was seen in the midst of the extensive graft and scar covering the right shoulder.
Psychological test results showed that the patient had advanced reading ability for his age-5.4 grade level, and an arithmetic ability of 3.6 grade level. Augie had just completed the third grade.
He was placed on a program of physical therapy as pre-prosthetic training. His program consisted of range-of-motion exercises and stump bandaging for the lower limbs, and occupational training for the development of independence through the use of his one remaining hand. Fortunately, the patient was left-handed. He also began an activities-of-daily-living program designed to develop total independence in self-care activities. These therapy programs were interrupted when he returned to Rahway Hospital on September 8, 1972, for excision of excessive cartilage that was causing recurrent ulcerations at the terminal portion of the left femur. At the time of this interim discharge, the patient's condition had improved but he had not achieved independence. He still had limitations in hip flexion and external rotation ranges of motion and needed assistance in many areas of self-care including transfer activities. He was able to operate a one-arm-drive wheelchair. Emotionally, both the patient and his parents showed less anxiety and depression, and gradually developed more confidence in the staff and the hospital.
Augie was readmitted on October 2, 1972, and his pre-prosthetic therapy as well as retraining in self-care activities continued. Gradually, substantial gains in ranges of motion and strength of both lower-limb stumps, as well as independence in self-care, were achieved. The initial intense hypersensitivity of the stumps had disappeared completely. The improvement was due in part to wound and graft healing, therapies, gradual psychological adjustment, and improved emotional stability of both the patient and his parents. During this hospitalization, permanent bilateral lower-limb prostheses and a right shoulder-disarticulation-type prosthesis were prescribed. He was then discharged to his home on October 20, 1972, to await completion of these limbs. Parental and patient adjustment to the disability and its effect on their daily lives continued during the boy's initial return to his home.
Third Admission—Prosthetics Training
The prostheses were completed and Augie was readmitted on December 26, 1972. The lower-limb prostheses consisted of quadrilateral plastic sockets with medial openings for insertion of the bulbous knee stumps, Silesian suspension, Lange polycentric knee joints, and conventional feet with single-axis ankle joints (Fig. 1 ). The right shoulder-disar-ticulation prosthesis consisted of a plastic shoulder-cap socket with an abduction hinge, an internal elbow lock with chin-nudge control and spring assist, a biceps cuff harness (on the left arm) for terminal-device control, a cheststrap, and a 10X Dorrance hook. The biceps cuff was found to be restricting and was replaced by an axilla loop with an excursion amplifier of the type described in the UCLA Manual1 (Fig. 2 ). The prosthesis has since been upgraded functionally through incorporation of the Michigan Electric Hook which the boy operates by a button located within the shoulder socket, activating it by shoulder elevation. In addition, he now has a Variety Village or OCCC Electric Elbow which he activates by a chin-nudge control (Fig. 3 ). The patient has become a more enthusiastic prosthetics user since these motorized items have been added. He feels they have made the otherwise bulky and relatively inert prosthesis a more functional assistive element.
On discharge Augie was able to ambulate independently using first a Lofstrand crutch and then a cane on the left side (Fig. 4 ). He needed only minimal supervision on level ground and smooth rugs; but more on inclined surfaces and outdoor terrain; and moderate assistance on stairs. He progressed to independence in all transfers and could independently don and remove his prostheses. He used his right shoulder-disarticulation prosthesis as an assist but was limited functionally due to the severity of the amputation.
Adaptions at Home
At the time the accident occurred, the parents were in the process of building a new home. Therefore, they decided that any modifications necessary to accommodate their son's disability should be built in from the outset rather than be made at a later date. They met with the director of our activities-of-daily-living program, blueprints in hand, and carefully discussed all possible barriers and solutions.
Among the adaptions carried out in their home are:
All entries are ramped (Fig. 5 ).
Two stair-lifts have been installed, one to the upstairs level and the other to the basement (Fig. 6 ).
All doors to the outside contain horizontal hand grips approximately 2 1/2 feet from the ground so that they can be reached from a wheelchair (Fig. 7 ).
Augie's bedroom contains his own adjoining bathroom. All doors, including those to closets, are sliding and are more easy to manage than standard doors (Fig. 8 ).
The dressers are designed so that all drawers can be reached from a wheelchair, and they have fingertip controls; that is, the drawers are on casters and open easily; the handles are recessed.
All tabletops have rounded corners for safety. All wall light switches and outlets are set low enough to be reached by someone in a wheelchair.
The door to Augie's bathroom is a sliding-pocket type which slides into the wall. The toilet is a standard type and originally had a portable rail installed. This has been removed since Augie's balance has improved. The bathroom contains a shower stall, and attached to the wall is a flexible six-foot hand-shower hose. There is a special mixing valve which allows the temperature of the water to be preset and, of course, a one-knob control. To the right, in the stall, is a contoured shower seat which was specially designed. Shower fixtures located at lower heights allow the water to spray horizontally (Fig. 9 ). The bathroom also contains two overhead sunlamps fitted into the ceiling for independent drying.
The sink (Fig. 10 ), designed by the Koehler Plumbing Company, is for use from a wheelchair and extends outward. The faucet is controlled by one knob. Mrs. B. has glued a dome-shaped sponge to the side of the sink to allow Augie to wash his remaining left arm on it.
The swimming pool, installed this past summer, contains "Roman" seats in three corners so that Augie can easily reach any of them if he should tire. Augie has developed into an excellent swimmer; he is able to dive from poolside and his swimming movements are similar to those of a dolphin.
Before the time for his discharge from Kessler Institute, Augie's parents had doubts about sending him to public school. Were they doing "the right thing?" They were concerned about his ability to adjust and get along with strange children in a new school setting. On our advice, the mother contacted the school in advance, met with school officials, and preparations were made for Augie's return to school. Fortunately, this school is built on one level with no steps. Augie was enrolled in a regular fourth-grade class. At first his teachers noted a somewhat poorer scholastic level than was expected, and attributed this to emotional factors. With time Augie progressed to the superior scholastic level that had been expected of him, thus attesting to progress in his emotional adjustment.
Augie is now in the sixth grade and attending "open classroom" (Fig. 11 , Fig. 12 , and Fig. 13 ). He keeps an extra wheelchair at school for traveling longer distances, but is capable of extensive independent walking, with or without a cane. His teacher reports that he requires little assistance from the staff with the exception of help in picking up items from the floor. All his teachers are amazed that he experiences so few problems-architecturally, socially, and functionally. He has proven to be a very remarkable and responsible young man, and is doing exceptionally well scholastically.
This boy was active before his amputations, and he remains so despite his disability. His parents are realistically protective, but not overly so, and functional independence is encouraged and demanded. Augie has a motorized dune cycle with a pull-switch throttle which has been changed to the left side. He bowls and plays basketball from his wheelchair. He also enjoys being a ham radio operator, and flying his motorized model airplane in the park. He has gone horseback riding and has just recently joined the Boy Scouts.
He attempts to involve himself fully in all the school and play activities of his peers and is encouraged to do so by his teachers and parents. His total adjustment physically, socially, educationally, and emotionally has been spectacular. Parental interest, understanding, loving concern, and guidance illuminate this total adjustment like a beacon. Recalling the initial period of concern and anxiety, the members of the therapeutic team feel a just pride at having had a part in such a dynamic example of total rehabilitation. The team is well aware that most of the credit goes to a fine child and his truly outstanding parents. Nevertheless, each team member, in his or her own way, played a part in easing the period of adjustment and providing a brave young man with the functional prostheses and training that he required. On these foundations, he was able to achieve this exceptional level of physical, social, and emotional adjustment.
The problem of the child with congenital versus acquired limb losses is considered, and the case of an eight-year-old with triple acquired amputations is reviewed. An in-depth analysis of his rehabilitation, and the social and emotional adjustment of the patient and his parents are presented.
Richard Sullivan is the Medical Director at the Kessler Institute for Rehabilitation, West Orange, New Jersey
Felice Celikyol is the Director, Occupational Therapy, Kessler Institute for Rehabilitation, West Orange, New Jersey
Santschi, W. R., ed., Manual of upper extremity prosthetics, 2nd ed. Department of Engineering, University of California (Los Angeles), 1958.