Case Management of the Amputee
Limb Loss, the
Statistics
There are three causes of amputation in today’s world; disease, trauma, and congenital defects. Statistically these break down to; 70% due to peripheral vascular disease, 22% to trauma, 4% to malignancies, and 4% due to congenital birth defects.
Statistics
are not current but the best information that I have found is that there are
over 130,000 amputations performed in the US every year and that number is on
the increase. It is estimated that there are well over 300,000 lower limb
amputees in the
United States
, alone and over 200,000 prosthetic limbs made on an annual basis.
Another
interesting statistic that you possibly were unaware of is that there is no
state regulation on Prosthetics or Orthotics in
Nevada
. There are only nine states that have some type of licensing for our profession and it is not likely that
Nevada
will invest in the infrastructure to regulate such a small industry. What this means is that whoever cuts your hair needs a license but whoever makes your prosthesis does not. This creates a wide variety of quality of care and service from practitioner to practitioner.
Prosthetic devices and the materials available to the prosthetist have improved dramatically over the thirty-two years that I have been an amputee. The result is that most trans-tibial (below the knee) amputees can often return to a style of life approximating the life they experienced prior to amputation.
In my experience, the critical factor for success is motivation. No matter what amount of resources that are provided for an unmotivated amputee, their likelihood of success is minimal. On the other hand, a highly motivate individual can even overcome multiple amputations to go on to experience a rich and rewarding life.
How do you change a person’s motivation? First you have to determine the attitude of the individual regarding their future expectations. A small percentage of people will not need any stimulation toward rehabilitation and conversely a small percentage will not respond to any stimulation. Often times, people are subject to their initial experience with the prosthetic and rehabilitation process. If they have a negative experience with their prosthetist or therapist, it can affect their future effort towards rehabilitation. If on the other hand; the experience is positive, than it can maximize their effort and success in dealing with their amputation.
Functional capability is also a factor of the level of amputation. The higher the level of amputation; the more energy that will be required to operate the device. Upper extremity amputees have a low incidence of prosthetic usage, especially if they are not fit with a prosthesis within the first ninety days. Bilateral or multiple levels of amputation also have an increased energy requirement to compensate for lack of musculature. Experience has shown me that with the proper team approach and good prosthetic care will allow an amputee to reach their full potential. Many manual labor jobs can still be accomplished but often times the amputee will require retraining in a field that is more suited to their prosthetic adaptations.
State of the Art of
Prosthetics
Prosthetics has come a long way since I lost my leg in 1974. Back then there were only two different feet available to amputees, today there are over fifty different feet. One of the biggest revolutions in the comfort of the amputee is the introduction of gel and silicones into socket interfaces. When I first became an amputee the most common problem was skin breakdown and abrasions. Today we see very little skin breakdown due to the friction absorption of the gels or silicones that now interface with the skin.
Does this mean that amputees no longer have socket problems? Not at all. There is still the basic dilemma; that we have to take a living, changing piece of human tissue and place it into a dead, unchanging prosthetic socket. The result is that pressures and forces can alter as the residual limb shrinks and swells. There is no substitute for a well fitted socket designed to accommodate the anticipated changes in the residual limb. Test sockets allow the prosthetist to analyze the socket fit prior to the actual fitting of the prosthesis and are one of our best tools to maximizing the amputee’s comfort.
Most of you have seen television programs or news articles about the newest microprocessor knees. I recently attended the C-leg course put on by Otto Bock, one of the manufacturers of microprocessor knees. The major advantage of these devices is that they provide a lifelike stumble control for the trans-femoral amputee (above knee) during that all important swing phase. If an amputee’s knee is not in full extension at heel strike, then the microprocessor monitors their gait and provides knee resistance even when the knee is flexed. This allows the trained AK to walk step over step down steps, ramps, and to slowly sit into a chair. This can be a huge advantage for the above knee amputee’s confidence in the prosthesis.
Upper extremity amputees also have an electric powered prosthetic option. Myoelectric prostheses have been around for twenty-five years and several companies have produced very viable systems that can return function to the amputee.
My observation over the years is that the most perfect prosthesis is still one that you put on in the morning and don’t have to think about until you take it off that night. Many high tech components are also high maintenance and therefore invasive to the user. Old time amputees invariably gravitate towards equipment that is low maintenance and simple. If you have a life then you don’t want to be spending your time going to the prosthetist for repairs and adjustments.
Realities of Our
Industry
The prosthetic industry, as has the rest of the medical profession, seen many changes in the past thirty years. Managed care has eroded the team approach to rehabilitation and taken the decision of prescription from the doctor and given it to the bureaucracy of the managed care company.
Medicare sets the fees as the standard for our industry and due to the fact that our profession is very fractured they have continued to cut fees for services even though costs have increased. What does that mean for the amputee? Many companies focus more on what can be justified for their patient then what is necessarily the most appropriate prescription for the amputee. If insurance will pay for an energy storing foot, then the amputee will get one even if a simple SACH foot is more appropriate. Is this unethical? Hey, these guys are just trying to make a living in an industry that continually reduces fees for services and rewards discounts, regardless of quality.
Due to the lack of long term follow up, there is little tracking of costs over time. One way to make a profit in this type of system is to replace sockets frequently. A well designed socket that is adaptable to anatomical change gets the same reimbursement as a socket that is quickly made to the volume of the residual limb. Only difference is that the volumetric socket will need to be replaced frequently since it has not been constructed to be adaptable. If you had to make the business decision, what would you choose?
Returning to
Work/Recreation and Quality of Life
I believe that most amputees want to return to some type of gainful employment. Certainly there is a minority who are looking for some way to milk the system so that they won’t have to work but they are in the minority.
Employment or vocation is one of the main keys to successful rehabilitation. It is one of the deciding factors in positive self-esteem and the fight to overcome depression. Most amputees will require encouragement and training to achieve this. Another very effective tool to help amputees is for them to associate with other amputees who have returned to employment. Amputee support groups or other amputees within your system will provide an alternative role model to a person’s worst fears.
Amputee sports organizations also provide positive role models as well as a fun way to experience the rewards of exercise. Most trans-tibial amputees can return to recreational activities similar to their pre-amputation life. Trans-femoral amputees and upper extremity amputees may need to alter their activities or use adaptive equipment to reengage a recreational component.
Adaptive prostheses can take many forms. One of the most common types of adaptive limbs is the shower/swim prosthesis. This limb is designed to be submerged in water and allows the amputee to stand safely in a shower, go to the beach or pool, and not to damage their regular prosthesis by subjecting it to moisture.
Other sports and recreational prostheses include; skiing limbs, climbing and hiking, running, hunting, golf, bicycling, and a myriad of upper extremity attachments that allow for specific activities. These limbs are often cost effective when compared to the cost of replacing a regular limb more often due to the abuse it takes while engaging in activities for which it wasn’t designed.
Legal Issues and
Projecting the Costs of the Amputee
One of my specialties in the prosthetics field is providing expert witness testimony for litigation. I have developed a systematic approach to projecting how much it will cost to keep someone in prostheses for the rest of their life.
I break an amputee’s life expectancy into three phases. The initial phase is the first three to five years (unless the amputee is a child, then the initial phase lasts until the end of their growth phase). This is the time when an amputee encounters the most rapid anatomical changes as well as experimenting with different components to find what combination of materials and equipment works best for them.
The next phase is the stable phase where the amputee’s residual limb has stabilized and they have settled into a more predictable lifestyle. This phase results in fewer prosthetic replacements.
The third phase is the geriatric phase and describes the amputees lessening of activities due to age. This phase sees the least amount of prosthetic replacements.
I also generally project a backup and ancillary prosthesis for each individual. The backup prosthesis is usually made from components salvaged from an older limb. The socket is new to maintain an adequate fit. Ancillary prostheses can be for sports or more often for water applications.
Replacement and
Maintenance of Prostheses
Prostheses don’t last forever. The average life expectancy of a prosthesis is four to eight years, depending on the activity of the amputee. Quality of components is also an issue as is initial construction and attention to fit.
Nearly all prostheses require consumable products to keep them fitting comfortably. Stump socks, suction liners, suspension sleeves, cosmetic covers, all need periodic replacement. There will be an annual maintenance expense for any prosthesis and amputees should be made aware of this by their prosthetist. A prosthesis should come with all of the components and supplies to last for a prescribed period of time. I provide a years worth of consumable materials with each prosthesis. If an amputee is going through more supplies than usual it could point to a problem with the fit or design.
Summary
Prosthetics has come a long way in the past decades. Today’s materials and components provide motivated amputees the ability to return to most employment opportunities. Ancillary prostheses allow amputees to experience and enjoy a recreational component to their lives permitting them far greater integration into normal society. Prostheses require maintenance and soft goods on a yearly basis in order to function optimally, with the average prosthesis lasting from 4-8 years. If the team approach is used and amputees are followed with an adequate plan then they can typically return to a style of life similar to their pre-amputation experience.
Email rickjillriley@hotmail.com
Visit my
website at prostheticconsulting.com
