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Interventions For Individuals with Upper Limb Amputations

This blog is focusing on Upper Limb Amputations and suitable interventions for those with upper limb amputations. Specifically, this blog will discuss the daily impacts of an upper limb amputation, some of the interventions and aids that can be provided to amputee patients to support independence, and the psychosocial impacts for individuals post amputation.

Upper Limb Amputations
Upper Limb Amputations
 

Amputations can occur for an array of reasons including accident – workplace, farming accidents, motor vehicle etc, injury, and premorbid conditions.

There are several types of upper limb amputations including:

  • Digit amputation
  • Wrist Disarticulation
  • Transradial
  • Transhumeral
  • Shoulder Disarticulation
  • Forequarter amputation.
Statistics in Australia
 

In Australia, the primary cause of upper limb amputations is trauma related, occurring at a rate of 3.8 individuals per 100,000. Of this 75% are caused by work-related accidents (crush injuries or burns). Cancer, birth deformities and vascular conditions are listed as secondary causes of upper limb amputations. Finger amputations are one of the most common upper limb amputations, followed by hand and trans-radial. Individual’s most commonly affects are individuals between the age of 20-40 years old and males have a greater risk of amputation (6.6 times) then women. Furthermore, Aboriginal and Torres Strait Islander People are 38 times more likely than Non-Indigenous Australians to experience major limb amputations, specifically those aged 25-49 years.

Psychological Implications
 

Individuals with planned amputations have more time to process this. In some cases, this can reduce the risk of mental implications. Whereas those who experience trauma accidents have no time to process the situation. Studies highlight that 32-84% of amputees experience depression or other mental conditions. Post amputation, individuals experience anxiety and depression with the emotional turmoil persisting through shock, causing grief (similar to the experience of losing a loved one). Body image changes can impact an individual’s self-worth and desire to engage in previously enjoyed or day-to-day occupations, leading to loss through the inability to fulfil their roles. Upper limb amputations may also lead to ongoing vulnerability, stigma and judgement, potentially causing self-isolation to avoid comparison to former self or experiencing pity from their friends.

Post Traumatic Stress Disorder (PTSD)
 

PTSD can be a significant concern for amputees, especially those who underwent amputation due to traumatic events. The physical trauma of losing a limb, coupled with the emotional and psychological impact of such an experience, can trigger PTSD symptoms. PTSD is not exclusive to traumatic amputations, it can also be experienced by amputees that follow chronic illnesses, though it is less common (<5%). Studies indicate that PTSD is more likely to occur in individuals with phantom limb pain.

Personal and Instrumental Activities of Daily Living
 

What are some things that need to be considered when trying to manage showering with one arm?

Upper Limb Amputations

Showering

Interventions:

Transfers/Balance –

  • Shower chair.
  • Grab rails (where appropriate).
  • Non-slip mats.
  • Referral to Multi-D team (Physio, EP) for support with improving transfer/balance and safety.

Assistive technology/Aids:

  • Long handled hair washer.
  • Long handled sponges (including toe washer).
  • Light weight towels (Microfibre material).
  • Towel gown.
  • Handheld shower hose.

Modified techniques:

  • Soap on a rope.
  • Pump bottles (for soap, shampoo and conditioner).
  • Assistance from formal/informal supports if required.

Dressing

Modified Techniques:

Overhead garments –

  • Place shirt onto lap front facing down.
  • Thread affected arm into sleeve and pull over elbow.
  • Thread unaffected arm into remaining sleeve.
  • Gather the body of the garment up to neck and pull it over your head.

Removal of overhead garments –

  • Grasp the collar at the base of your neck. Pull above your head and bend your neck.
  • Gather the body of the garment at the back and pull over your head.
  • Ease affected arm out of the garment using your unaffected arm and body.
  • Remove your unaffected arm from the garment.

Putting on a bra –

  • Grasp the collar at the base of your neck. Pull above your head and bend your neck.
  • Gather the body of the garment at the back and pull over your head.
  • Ease affected arm out of the garment using your unaffected arm and body.
  • Remove your unaffected arm from the garment.

Cardigan/Button up shirt –

  • Thread affected arm into sleeve and pull garment onto shoulder (ensure majority of the sleeve is pulled past your elbow).
  • Thread unaffected arm into remaining sleeve.
  • Adjust as required.

Removing Cardigan/Button up shirt –

  • Remove garment from affected shoulder, followed by your unaffected shoulder.
  • Slide the garment of the affected arm, followed by the unaffected.

Assistive technology:

  • Button hook.
  • Shoehorn.
  • Pick up stick.
  • Dressing stick.
  • Sock aid.
Upper Limb Amputations

Eating and Meal Prep

Aids available –

Carrying food:

  • Light weight crockery.
  • One handed tray.
  • Trolley.

Eating:

  • Non-slip mat.
  • Raised edges.
  • Adapted cutlery – rocker knife, splayed utensils.

Meal preparation:

  • Rocking knife.
  • Spiked chopping board.
  • Electric can opener.
  • Pan holder.
  • Non-slip mats.
  • Cooking baskets.

Modifications during meal preparation:

  • Leaving frequently used items out and accessible.
  • Sliding rather than lifting.
  • Pre-cut foods.
  • Formal/informal supports.

Transfer

Transfers for amputees will be related to their physical capacity and age.

If they were dependent on aids prior to having their upper limb amputated, what modifications are required to ensure they can still use these?

Use your clinical judgement and Multidisciplinary Team.

Driving

  • There is a greater likelihood of amputees being skilled workers, farmers, labourers where driving is in integral part of employment.
    • This is a significantly greater factor if working for themselves (i.e. farming).
  • Factors influencing return to driving:
    • Comfortable prosthesis (29% did not return due to uncomfortable prosthesis).
    • Vehicle modifications.
  • Medical clearance to return to driving.
  • Vehicle Modifications and Training.
  • Qualified Driving OT.
Upper Limb Amputations

Vehicle Modifications

  • Potential Modifications:
    • Steering knob
      • Several attachments including for prosthetics if necessary
    • Foot steering:
    • Bilateral Upper Limb Amputation

Cleaning and Laundry

  • Laundry:
    • Laundry Trolley to carry washing.
    • Pegless clothesline.
  • Cleaning:
    • Simple modifications and adjustments:
      • Cordless lightweight vacuum.
      • Using a damp cloth for crumbs, dirt and dry spills.
Phantom Limb Pain
 
  • Phantom pain: You feel pain in the missing limb after an amputation.
  • Phantom sensations: The missing limb still feels like it’s part of your body. No pain, however, sensations of touch, pressure, temperature changes still experienced.
  • Phantom pain syndrome: Sensation of pain and other sensations listed above are experienced within the area that has been amputated.
  • Residual limb pain: Pain experienced in remaining part of your limb (stump) and is often caused by infection or nerve damage.
Upper Limb Amputations
Mirror Therapy
 

Mirror therapy, or mirror box therapy, uses a mirror to create an illusion to send signals to the brain informing the affected limb is moving without pain. This process creates new neural pathways that prevent signals becoming confused and informing the brain that the limb is experiencing pain. The set up must ensure individuals are unable to see their amputated arm and only see the reflection provided from the mirror itself.

Prosthetics
 

Types

  • Passive
    • Mostly Cosmetic, offering minimal functional support.
  • Body-powered
    • Uses internal cable attached at the shoulder.
    • Transmits power to elbow or terminal device (i.e. wrist).
    • Unable to use both joint simultaneously.
  • Externally Powered (myoelectric)
    • Utilises residual motor impulses to contract corresponding muscle areas.
    • The more proximal the level of the amputation, the more challenging to use as there are fewer muscle control sites.

Hybrid

A combination of passive, body-powered and/or myoelectric depending on the person’s amputation site.

Activity Specific

Custom designed to be suitable for specific ADLs, leisure tasks, work, etc.

Return to Work
 

Statistics

  • ~80% of people return to work.
  • Factors influencing return to work:
    • Age.
      • Upper limb amputees more likely to be younger.
    • Prothesis.
    • Level of amputation (higher = decreased likelihood).
    • Rehabilitation.
NDIS
 

Assistive Technology

  • Prosthetics.
  • Low-cost items to assist with ADLs.

Improved Daily Living Skills

  • Therapies and assessments needed to fund AT, Home mods, etc.

Home Modifications

  • Handrails.
  • Improved Lighting (motion sensor lights).
  • Motion sensor doors, modified handles, locks.
  • Modified taps.

Vehicle Modifications and Driver Training

Case Study
 

A 24-year-old female, sustained significant injuries following an accident riding a quad bike on a private property – as a result required a R) arm trans humeral amputation. Post amputation, she presented with immense grief, and loss of her arm. Experienced resentment to herself and actions and experienced phantom limb pain. She lives rurally with her partner and worked as a receptionist pre accident. Her work is very supportive and willing to hold her position.

What are your initial thoughts or what would you attempt to engage with her?

Outcome

  • Due to her grief and resentment, she struggled to engage with others – turning therapists away, except psychology.
  • She only began engaging 2 weeks post op with other members of MDT.
  • Initial interventions – Phantom limb pain, commencing mirror box therapy daily.
  • Commencing functional re-training for independence at home, with a home assessment by referred OT.
  • Education provided to family and client, along with aid and modification recommendations.
  • The client was then able to go home and regain a level of independence to return to work and engage in her pre-accident activities.

Funding Body:

  • Unfortunately, given she was on private property at the time of the accident, the client was ineligible for financial support from the Motor Vehicle Accident Compensation – if on public road would have been considered.
  • This added additional stress as she lived rurally, working full time as a receptionist and would likely be unable to work for some time.
  • However, given her condition was permanent change to her functioning she was eligible for NDIS support.

At Ability Partners, we work in partnership with you to achieve goals that really matter. We deliver evidence-based practice and work with you as a team. We have an incredible and highly experienced team who are ready to assist you. We want the best outcome for you and to help you to live your most independent life. Please feel free to contact our friendly support team using the link before to engage in services.

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