[Untitled]

Levy, Charles

3/21/2000

Dear Members: I am writing learning objectives for the American Association
Physical Medicine and Rehabilitation's Study Guide on Limb Deffeciency
(amputation). I have been asked to write about the special considerations
for multi-limb amputees. I would be very interested to receive feedback on
the rough draft below. I would particularly appreciate any relevant
references.

Learning Objective 3.4: Discriminate special considerations for a
48-year-old woman with multi-limb amputations secondary to polytrauma.

This patient is a bilateral trans-radial, bilateral trans-tibial amputee:

There are non-prosthetic issues that should be addressed in every amputee.
These include pain, adjustment to disability, cosmesis, body image, mood,
and vocational role/ social expectation . The impact of multi-limb
amputation should be expected to even more devastating than single limb
amputation. The practitioner should actively explore these issues and
prescribe pharmacological, physical, psychological, and social therapies as
appropriate. Peer counseling with someone with a similar injury can be very
helpful. Besides these considerations, the following should be addressed:

1. Donning and doffing:

        For the bilateral upper limb amputee, donning the prosthesis is
typically accomplished by use of a hook attached to a wall on which the
prostheses hang. The amputee then wriggles into the prostheses. This can
be accomplished independently.

2. Weight, componentry: For multiple limb amputees, the over-riding
philosophy is usually to keep the units as light weight and simple as
possible. It is better to allow the amputee to master a simple system, and
then increase the complexity, then to start with an overly complex system
that may discourage the user.

Although philosophies concerning myoelectric versus mechanical prosthesis
differ amongst various professionals, the following approach is reasonable:

For the upper limb start with bilateral mechanical prosthesis with voluntary
opening terminal devices. A wrist flexion unit on one side will facilitate
midline activities (dressing, toileting). As the user masters this system,
need/ability for myoelectric prostheses can be evaluated. Myoelectric
advantages include the ability to produce greater pinch strength, rotational
potential (grieffer), and overhead activities. Limitations include weight,
mechanical complexity, dysfunction of the units if they get wet or dirty.
By mastering a set of mechanical upper limb prostheses, the user will have a
back-up system when they try a myoelectric unit. Body power becomes less
practical the higher the level of the amputation.

For bilateral lower limb amputees that lack prehension (ie, also bilateral
upper limb amputees,) the same principles of simplicity and lightness apply.
Lack of hand pinch and dexterity generally rule out roll-on suction
suspension in the trans-tibial amputee. Roll-on liners that need
application of lubricants or frequent cleaning or frequent replacement
represent additional barriers to the multi-limb amputee. Soft liners may be
modified with loops that can aid donning. If the contours allow, patellar
tendon bearing supra-condylar suspension can be very helpful. Another
possible solution would be a Velcro cuff strap suspension with a loop to aid
in fastening. Ultralightweight componentry should be used. An
ultralightweight pylon attached to a lightweight energy storing foot is
often sufficient. Depending on use and terrain, consideration for an ankle
unit or a lightweight multiaxial foot (Dycor) may be reasonable.


Thank you very much for your consideration,

Charles E. Levy, MD