Above-elbow amputation: A case study in restoring function

( CASE REPORT

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Above-elbow Amputation: A Case Study in Restoring Function Marilyn Gilin, OTR, CHT

Director of Hand Therapy Plymouth Physical Therapy Associates Plymouth, Michigan

P limb removed by amputation and in prosublic interest in persons who have had a

thetics reached a new high in 1994 because of reported news events of two men who amputated their own legs to free themselves from a potentially fatal situation. Their amputations were termed "traumatic," since injury was the cause. Loss of a limb can also result from a developmental or congenital deficit or may be the result of surgical removal due to disease. There are approximately 125,0001 incidences, of amputation yearly in the United States and of those, approximately 29% involve the upper extremity.' Traumatic amputations account for 33% of the total number of amputations, with most occurring in young adults under 40 years of age. Men are one third more likely than women to suffer an amputation.' The ratio of persons with upper-limb amputations to those with lower-limb amputations is 1:3.4.1 Therefore, since relatively few amputations result in upper-limb loss, only a small number of health practitioners, even those specializing in rehabilitation following amputation, have the opportunity to provide services for a si~nificant number of persons with arm amputations. It is the purpose of this paper to share this author's experiences using an effective approach in the treatment process. The loss of an upper extremity obviously affects independence in performing activities of daily living. As hand therapists, our aim is to return patients who have lost an arm to independence in an efficient, cost-effective manner.

Correspondence and reprint requests to Marilyn Gilin, OTR, CHT, 6522 Ellinwood, White Lake, MI 48383.

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ABSTRACT: Functional goals and treatment are the basis for occupational therapy. Following upper extremity amputation patients can benefit significantly from a program that concentrates on setting and achieving functional goals. Few hand therapists have the opportunity to treat a large number of amputees. This case study of treatment of above-elbow amputation discusses the use of an activities of daily living form as an aid to developing and meeting short-term goals in treatment planning. J HAND THER 11:278-283, 1998.

HISTORY OF UPPER EXTREMITY BODY-POWERED PROSTHETICS The use of prosthetics has been documented as far back as the 15th century. Pliny the Elder recorded the loss of the hand of a warrior during the second Punic war. That warrior was provided with an iron replacement." An iron hand with articulated fingers was discovered in Germany and was also thought to date from the 15th century. The fingers could be flexed passively and locked in position, and the mechanism also incorporated a wrist rotation unit. Baliff/ a dentist in Berlin, made the first belowelbow prosthesis operated by a harness and pull cords in 1912. His mechanical hand was operated by movements of the shoulder, upper arm, and forearm and was called a "body-powered prosthesis." This term is still used today. The commonly used split-hook terminal device was developed by Dorrance," an amputee himself, in 1909. Although the split hook is very functional, it may not be perceived by the user as aesthetically pleasing. The artificial hand or glove terminal device continues to evolve to match skin tones and includes detailed anatomic features of the skin and fingernails.

CASE STUDY K. H., a 27-year-old man, was referred to our hand therapy specialty clinic from a large trauma hospital for location reasons. His diagnosis was status post left upper extremity amputationabove the elbow. His injury had occurred approximately one year prior to his initial treatment at our facility.

The initial evaluation included a detailed history and physical assessment. The patient had suffered an injury to his left upper extremity as a pedestrian in an auto accident and had undergone surgery on the same day to amputate his left arm above the elbow. He reported that prior to his accident he was ambidextrous but wrote with his left hand. He was not taking any medication and was in good physical health. He had not worked since his accident. Before the accident, he had worked as a laborer in a banquet hall. His job had required setting up and taking down tables and chairs. The patient presented with a body-powered prosthesis with a figure-S strap. He had both hook and hand terminal devices. His chief complaints included left upper extremity weakness, phantom sensations, and a hypersensitive stump. His goal in therapy was to be able to use his prosthetic arm as much as possible, with a future goal of becoming an architect. His previous therapy, which occurred in the year between his injury and referral to our clinic, consisted of range-of-motion and desensitization exercises, stump remodeling, wound care, and prosthetic fittings. Initial physical assessment revealed an ll-cm hypertrophic scar at the distal aspect of a 211/z-cm stump. Circumferential measurements were taken at specified distances proximal to the tip of the amputation, to provide a baseline value for comparison before and after exercise to determine whether edema was a factor that needed to be addressed in the treatment plan. The patient's skin tone was good, and no necrotic or ulcerating tissue was noted. Detailed pain, sensibility, and edema assessments were not indicated, since the patient denied significant pain, sensory loss, or problems with swelling. A visual assessment of his posture was made. Shoulder range of motion was assessed via goniometer, revealing 1350 flexion, 840 hyperextension, 1400 abduction, 1350 horizontal abduction, and 69° horizontal adduction. Normal muscle strength was confirmed via manual muscle testing through all shoulder motions, although the patient had difficulty isolating his supraspinatus and upper trapezius muscles. A brief activities-of-daily-living screening established that he was independent in driving, bathing, and feeding, but he required physical assistance to fasten his pants, tie his shoes, and cut meat. A wellestablished, comprehensive activities-of-daily-living form" was then utilized after several updates and adaptations were made to include his hobbies -basketball, fishing, cards, reading, using the telephone, and drafting (Figure 1). This form divides tasks into subgroups of personal needs, eating procedures, desk procedures, general procedures, use of tools, car procedures, housekeeping procedures, and hobbies. Activities that were not applicable, such as applying cosmetics, were deleted. Areas in which the patient was already independent were labeled as such, and the remaining areas became goals for the treatment plan.

The patient's primary deficits were identified as hypertrophic scarring, complaints of stump hypersensitivity, decreased independence in activities of daily living and functional abilities, and poor use of his prosthesis. He was not using his prosthesis as a functional assist, although he was wearing it for cosmesis. Goals were established to provide scar management and desensitization, to increase independence in activities of daily living, to increase functional use of the prosthesis/terminal devices, and to increase postural awareness. In addition to the initial evaluation, the patient received instruction in a home exercise program on his first day of therapy. The home exercise program consisted of a desensitization program and scar massage (Figure 2). He was scheduled to attend therapy three times per week. The patient was unable to hang up his coat on his second visit to therapy. Verbal guidance was provided, prompting him to flex the elbow of his prosthesis and lock it into position, then use his prosthetic hand to stabilize the coat on the hanger. He required moderate to maximum physical assistance to complete this task. Clinical activities were initiated, including desensitization" through the use of various textured dowels, by pushing his stump into therapeutic putty, and through massage. Practice in using the elbow control was achieved with cones, by having the patient lock his device in flexion, then grasp a cone with his prosthetic hook, walk to the end of the table, and release the cone. A pronation/supination task provided wrist control practice. The patient could independently change terminal devices, but he fatigued easily and required frequent rest breaks. He tolerated 45 minutes of tasks involving terminal device opening and closing using three rubber bands. Opening the device posed maximum difficulty (Figure 3). On the third treatment, one rubber band was removed to increase the opening function of the terminal device. The patient hung up his jacket independently. Two treatments later, he had difficulty closing his terminal device. The figure-S strap was readjusted. Increased shoulder shrugging was noted during a feeding simulation task. Middle-trapezius strengthening exercises were added to his home exercise program. Biofeedback using the Myolab II was added, with electrode placements to the supraspinatus and upper trapezius to encourage less co-contraction through more effective muscle isolation. To decrease shoulder elevation during prosthesis operation, biofeedback was utilized during a grasp-and-release activity using cones. Compensation decreased with biofeedback, although the patient reported fatigue on completion of his exercises. In the fourth week of treatment, the patient was instructed to open and close his terminal device ten times every waking hour. Biofeedback was no longer indicated, but natural use of his prosthesis was rarely noted at home, although he was reading the newspaper daily using his prosthetic October-December 1998

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I

Name H Therapist

I I PERSONAL NEEDS:

II

Activity

II

I

Hooks

Tie shoe laces

I

Shorts

I I I I

Shirt Trousers Tuck shirt in trousers Tie necktie Blow nose Put on watch Wind watch Put on topcoat Put on hat

n/a n/a

Powered

~

Use salt shaker Drink from bottle Pour liquid from pitcher Eat ice cream cone

I

DESK PROCEDURES: Use telephone Use phone and fake notes Use pay phone

r1.?k

6/2

I I I T

I T

I

*E

I

I I I I I I I I I

5/22 5/26 5/28 5/296/41 I I I

Sharpen pencil

I

Use eraser

I I

Use ruler

I I

Use scissors Remove and replace ink cap

I T

Fold and place in envelope Open sealed letter Use card file Use paper clip

n/a

Use stapler

I

n/a Cut finqernails

I

Date

<:; '??

Butter bread Pass dishes

I I

Brushing teeth Hang up coat

Eat potato chips

I

Brush and comb hair

Put on/fasten bra

Eat sand wich

*A

Toileting

Squeezing toothpaste

Cut meat Eat soup

I

Shower procedures

Apply cosmetics

Eat with fork

n/r>.

Shave

Set hair

Eat with a spoon

I I I I I I

Clean glasses

Pulling chair from table

Drink from cup

I I

Put on belt with buckle

EATING PROCEDURES:

Drink from glass

I

Put on socks

Activity

Pick up utensils

I I I

Lacing

Type of Amputation AEA Type of Terminal Device Bodv

Use napkin

I

Snaps

Use umbrella

I

5/22 5/26 6/2

Buttoning

Put on overshoes

II

Date

Zippers

Earrings

II

K

Marilyn Gilin, OTR, CHT

Wrap package

I

*F

Unwrap package Turn pages Type Write

T

I,

I T

I T

*B

I I

T

I I

FIGURE 1. "Upper Extremity Amputation: Activities of Daily Living" form, updated and adapted for use in the treatment of a patient with above-elbow amputation The form is shown as it appeared at the end of treatment. The original form was adapted from a form published by the Institute for the Crippled and Disabled" Above, I indicates that the patient could perform this task independently; *A, patient required assistance to wash back and so was provided with long-handled brush; *F, nail clipper vended for one-handed use; *E, nonslip plastic sheeting vended to hold plate; *B, patient required minimal assistance. Facing page, *C indicates that the nonslip plastic sheeting patient had moderate to maximum difficulty with the task; *G, one-handed scrub brush vended; *H, cutting board vended; *D, patient provided with mobile bridge.

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Activity I GENERAL PROCEDURES: I Take mo ney f rom purse

Date

~

5 / 22 5/2 9

n/a

Tak e m on ey f rom t rouser Pick up ch enge Use k ey in loc k Turn on ligh ts Use door knobs Turn on faucet Open and close window Open and close drawers Use radi o & television Play cards Play checkers Ligh t a m atch Ught a lighter W ind a clock Open and close safety pin

Oper ate window blind Use cam ere

I USE OF TOOLS: Saw

Plane

File Drill

Crack egg Store in refrigerator Cook on t op of stove Cook i n ove n M anipulate hot pots

Raise hood Pump gas Check oil

Fast en seatbelt

n/a

I

Sweeping Oust

5m2

Use m op

I

Plug in iron

I I I

Set up iron bo ard I Iron n/:>

Th read needle

n/a

Sew on bu tton

n/a n/a

Use pin s

I HOBBIES:

5/22 5729 674

Fis hing po le

C

I??

hi?

Golf putter

Catch · Velcro mitt Rifle

I I

Baseb all bat Billiards Tennis Crafts Bowli ng

I

I

I

Golf iron

I I I

I I I ots

I I

Use vacu um cl eaner

I I

wit I I

Use du st pan

n/a

CAR PROCEDURES:

I I I I I

M ix w ith spoon

I

Drive

*H

Open can

I I *C

Sco op ice cream

Sand Power tools

Peel veget able

Laundry

n/a n/a

I

Cut vegetab le

n/a n/a *C

I I

Put dishes o n shelt

5/22 5/29

Hammer

I *G

Dry dishes

I

Drive screws

I

W esh dishes

I

Carry suitc ase

5/29 6/2 6 / 4

n/a n/a

Operate wa ter fa ucet

I I I

Ho ok scree n door

Plac e dishes on tr ay

I

Date

HOUSEKEEPING PROCEDU,BI ;~ :..,

Pick up obje cts f rom fl o or

I

Open a co ke bottle

I

II

Activity

Carry tra y

I I I I I I I I I I I I I I I

Ring do or bell

II

n/a n/a

-

I

nl e. n/a not tested n/a n/a

*D

I

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Desensitization Purpose: To make a hypersensitive area less sensitive. Methods: 1. Stroking. Rub various materials across the sensitive area, beginning with soft, tolerable textures and gradually increasing to cottcn, felt, velvet, terry cloth, denim, upholstery, and burlap. 2. Immersion. Using largecontalners filled with textured particles, place your hand lnto the container and stir. Gradually increase to moretextured or resistive particles. Particles may include craft pom-poms, plastic bingo chips, birdseed, rice, popcorn kernels, uncooked macaroni, and marbles. 3. Vibration. Place vibratorover the sensitive area. If the area is tQQ sensitive to tolerate the vlbratlon, put layers ot towels betweenthe vibrator and your skin. Remove the towel layers as tolerated once your skin becomes less sensitive.

10 minutes, threetjmes a day Qr mQre!

Scar Massage

ties-of-daily-living evaluation. The patient would select several activities from the activities checklist to perform at each treatment session. When he could perform the task independently, that activity was removed from the list, with the goal of his becoming independent in all activities-of-daily-living tasks. After six weeks of treatment, the patient could perform most tasks independently, including opening and closing a safety pin, using a camera, driving screws, using a hammer, sanding, fastening seatbelts, checking the oil in his car, washing dishes, sweeping and using a dust pan, playing catch using a Velcro mitt, casting a fishing pole, tying a necktie, opening and closing fasteners, using an umbrella, and using an eraser and ruler. A week later he could also tie his shoelaces, cut his fingernails, wrap and unwrap a package, and cut and peel vegetables. During his last week of treatment he could use a mop, cut meat, and type. He passed the final challenge victoriously: That task was to scoop and serve ice cream cones to all the other patients in the clinic (Figure 4)! Adaptive equipment was issued as needed and included a long-handled brush, nonslip plastic sheeting, one-handed nail clipper, one-handed scrubbing brush, cutting board, and mobile bridge for billiards. The patient was seen for a total of 20 sessions, with most sessions lasting Ph to 2 hours. He demonstrated independence in activities of daily living using adaptive equipment as needed. He was proficient in the use of both the hook and the glove

PurpQse: To break up adheslons, sotten scars, and decrease sensitivity of the scar to touch. Method: Using your fingertip, knuckle, eraser end of a pencil, or vibrator, massage your scar using a circularmonon. Apply as much pressure as YQU can tolerate. Lotion may be used if desired.

10 minutes. threetimes a day Qr more! FIGURE 2. Home exercise program, consisting of instructions for desensitization and scar massage.

arm to hold the paper. Treatment was graded by increasing the number of rubber bands on his prosthesis. Proficient control of the terminal device was needed for tasks such as holding a polystyrene coffee cup and ice cream cones without squashing them. Maintaining a grasp was graded by tasks such as holding a glass of water and walking several steps, then increasing the distance until he could walk the length of the room while carrying the glass without losing his grip. Treatment activities were based on his activi282

JOURNAL OF HAND THERAPY

FIGURE 3. Patient with above-elbow amputation practices grasp and release with his prosthesis using a peg game.

terminal devices but for aesthetic reasons preferred to use the glove when he was out in public. He reported wearing and using his prosthesis at home for an average of 8 hours a day. The "Bilateral Upper Extremity Amputation: Activities of Daily Living" evaluation form was a valuable tool in developing short-term treatment goals. It provided the patient with some control over the direction of his treatment, since he chose the particular tasks to work on during each session. The form provided a visual record of his progress, which helped increase his motivation. On completion of his therapy, he was referred to vocational retraining to learn drafting skills. Treatment of a person who has lost a limb can be very challenging and rewarding. Watching our patients regain their independence is what makes our profession so rewarding.

REFERENCES

FIGURE 4. Patient with above-elbow amputation performs a bilateral upper extremity task, scooping ice cream and serving it to other patients and staff

1. American Board for Certification in Orthotics and Prosthetics. National Health Interview Survey. Alexandria, VA: ABCOp, 1994. 2. Atkins DJ, Meier RH III. Comprehensive Management of Upper Limb Amputee. New York: Springer-Verlag, 1989. 3. Putti V. Historic artificial limbs. Am J Surg. 1929;6:111,265. 4. Baliff P. Description d'une main et d'une jambe artificielles. Berlin, Germany, 1818. 5. Lamb D. State of the art in upper-limb prosthetics. J Hand Ther.1993;6:1-8. 6. Bilateral Upper Extremity Amputation-Activities of Daily Living. New York: Institute for the Crippled and Disabled. 7. Hardy MA, Moran CA, Merritt WHo Desensitization of the traumatized hand. Va Med. 1982;109:134-7.

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