Rajiv Hanspal

Body image and patients with amputations: does the prosthesis maintain the balance?

This paper attempts to establish whether dissatisfaction with the artificial limb and/or body image relate to achieved mobility following lower limb amputation in established limb wearers. Patients attending limb fitting clinics (n = 107, 62% male, mean time from amputation 13.9 years; range 1-54) participated. The measures were a specially designed Attitude to Artificial Limbs Questionnaire, a Body Image Questionnaire adapted from an eating disorders instrument including reference to body shape, the Hospital Anxiety and Depression Scale and the Harold Wood Stanmore Mobility Scale. The rehabilitation physician rated prosthetic suitability on a Numerical Rating Scale. The results showed patients were moderately satisfied with their artificial limb, had little experience of body image disruption or distress and there was no overall relationship between these variables and mobility. However, those with a more negative body image were more anxious and in younger patients who sustained more traumatic than vascular amputations, the correlation between body image and mobility was significant, anxiety was higher and physician satisfaction with the prosthesis was lower. It is concluded that body image disruption, anxiety and depression are not common in established limb wearers except in young people with traumatic amputations.

ICEROSS - a consensus view: A questionnaire survey of the use of ICEROSS in the United Kingdom

The management of the individual with a trans-tibial amputation has been strongly influenced by the increasing use of the ICEROSS socket system over recent years. Despite this growth in clinical experience, there has been very little research into its place in current prosthetic practice, and prescribing activity is largely determined by personal experience. In order to formulate the current consensus view on the use of ICEROSS, questionnaires were sent to 42 doctors and 43 senior prosthetists around the UK. The influence of 38 different factors on prescribing activity was assessed using a grading system (ranging from “primary indication” to “absolute contraindication”). An 85% response rate was achieved and no significant differences in response between the two professional groups were identified. Those factors considered by most to be positive indications for using ICEROSS were “pistoning”, “shear-sensitive skin / split-skin grafts”, “patient unsuccessful with supracondylar (s/c) or cuff suspension” and “insufficient suspension due to change in type or level of activity”. Those considered by most to be absolute contra-indications were “ulceration / unhealed scars”, “poor patient hygiene” and “poor patient commitment to prosthetic rehabilitation”. This consensus of opinion is in keeping with the results of the few published audits of ICEROSS usage. There was a lack of consensus, however, about the use of ICEROSS in some situations, including skin complications. Whilst some consensus does exist about the use of ICEROSS, the results of this survey indicate significant variations in clinical practice which serve to illustrate the urgent need for data from prospective clinical trials.

Analyses of prosthetic episodes in lower limb amputees.

The provision and maintenance of prostheses in 100 trans-femoral amputees and 73 trans-tibial amputees were retrospectively analysed over a 10-year period. The aim of the study was to analyse the prosthetic episodes, i.e., the need for maintenance, repairs and replacements to a trans-femoral and a trans-tibial prosthesis and frequency of new sockets prescribed over the same period of use by established adult amputees. The study showed that the trans-femoral amputees needed 0.96 new prostheses, 3.27 new sockets, 2.31 major repairs, 3.36 component changes and 21.85 minor repairs. Younger trans-femoral amputees aged less than 60 years needed 1.1 new prostheses, 3.15 new sockets, 2.06 major repairs, 4.23 component changes and 20.49 minor repairs. Younger trans-femoral amputees needed significantly more changes of prosthetic components (p = 0.04). The associated study on 73 trans-tibial amputees showed that they needed 1.4 new prosthesis, 2.9 new sockets, 3.2 major repairs and 14.1 minor repairs over the same 10-year period. The introduction and prescription of modular prosthesis as opposed to conventional limbs used earlier has possibly allowed components to be easily replaced thus reducing the need to replace a whole new prosthesis.

The Locomotor Capability Index in Diagram Form: The Stanmore-Kingston Splat

The Stanmore-Kingston Splat is a graphical display of the goals and achievements of amputee rehabilitation patients using the Locomotor Capability Index. The chart is in a radial polygram form with the sectors coloured and shaded. Three scores can be shown: The patients capability at delivery of the prosthesis, the goals set for rehabilitation, and the final achievement after the programme. The main advantages are rapid, easy reading for a therapist and convenient use when discussed with the patient at goal setting or progress review. The Splat is being used at Stanmore Disablement Services Centre and an extension to other centres is planned.

Use of two torque absorbers in a trans-femoral prosthesis of an amputee golfer

This single case study reports the successful trial of the use of 2 torque absorbers in a single trans-femoral prosthesis. The adapted prosthesis enabled a greater degree of rotation on a vertical axis which can be a significant advantage to amputee golfers.

The effect of electromagnetic shielding on phantom limb pain: A placebo-controlled double-blind crossover trial.

Background: Environmental electromagnetic fields influence biological systems. Evidence suggests these have a role in the experience of phantom limb pain in patients with amputations. Objectives: This article followed a previous study to investigate the effect of electromagnetic field shielding with a specially designed prosthetic liner. Study design: Randomised placebo-controlled double-blind crossover trial. Methods: Twenty suitable participants with transtibial amputations, phantom pain at least 1 year with no other treatable cause or pathology were requested to record daily pain, well-being, activity and hours of prosthetic use on pre-printed diary sheets. These were issued for three 2-week periods (baseline, electromagnetic shielding (verum) and visually identical placebo liners – randomly allocated). Results: Thirty-three per cent of the recruited participants were unable to complete the trial. The resulting N was therefore smaller than was necessary for adequate power. The remaining data showed that maximum pain and well-being were improved from baseline under verum but not placebo. More participants improved on all variables with verum than placebo. Conclusion: Electromagnetic field shielding produced beneficial effects in those participants who could tolerate the liner. It is suggested that this might be due to protection of vulnerable nerve endings from nociceptive effects of environmental electromagnetic fields. Clinical relevance Electromagnetic field shielding with a suitable limb/prosthesis interface can be considered a useful technique to improve pain and well-being in patients with phantom limb pain.

Graphical representation of the five point Locomotor Capability Index

The Locomotor Capability Index (LCI) is widely used for assessing goals and achievements of patients receiving prostheses. The Stanmore-Kingston Splat method for graphical display of the results has previously been described and is based on four levels of achievement for each of the 14 tasks in the index. Recently a modified version of the LCI with five levels for each task has been described (LCI-5). We have thus developed and applied the system for graphical display of the LCI-5 in Splat form. The new Splat can help to highlight the difference in ability of the prosthetic user who can achieve tasks without a walking aid compared to those using a walking aid.

Comment on: 'Post amputation syndrome'

We feel that the use of the word ‘syndrome’ in the context appears inappropriate. The Oxford Concise Medical Dictionary defines syndrome as ‘a combination of signs and/or symptoms that forms a distinct clinical picture indicative of a particular disorder’. In clinical practice, syndrome assumes a common causative factor, e.g., Horner’s syndrome, with eye signs and lack of sweating on the side of the face due to pathology in the cervical sympathetic ganglion, or Down’s syndrome, with clearly associated genetic factors. Following lower limb amputations many of the conditions described by Dr Kulkarni could have different aetiologies, for example, altered mechanics of gait for back pain, local pathology for wound and skin problems, vascular pathology for the increased vulnerability of the surviving leg and co-morbidities for decreased life expectancy. Some of the sequelae may be iatrogenic. There is no clear precise clinical pattern in the three suggested categories that has a strong association with a particular aetiology or level of amputation. If this were to be called a Syndrome, there would be several other post-operative syndrome complexes, e.g., Post Coronary Bypass Syndrome to describe local problems in the chest wound, leg problems from the graft donor site, cardiac complications and recognized psychological problems. Some surgical procedures do have specific post-operative syndromes. Thus postgastrectomy syndrome is a condition where a patient may have abdominal cramps, diarrhoea, light headedness along with increased heart rate and a drop in blood sugar levels. This is specifically due to a lowered tolerance for large meals and rapid emptying of the stomach. It does not include other sequelae of this operation such as wound problems, abdominal hernia and peritoneal adhesions. Use of the word syndrome in this context could mislead practising clinicians into considering the listed entities are expected sequelae in all amputees. It may also dishearten patients undergoing planned amputation and could result in confusion by patients applying for benefits. It is of course important that clinicians should recognize all symptoms following Prosthetics and Orthotics International December 2009; 33(4): 399–400

Reply to Rommers and Wiggerts

Sir: We wish to thank Drs Rommers and Wiggerts for their encouraging comments and recognition of the Stanmore-Kingston Splat. We agree that goal-setting is of major importance in all rehabilitation programmes as confirmed in the Royal College of Physicians’ standards for rehabilitation medicine quoted in our paper. We believe that these goals must be set by the patients and the most effective way to set realistic goals is jointly in consultation with the therapist or rehabilitation team. It is acknowledged that tasks in the LCI are pre-set and as such may not be suitable or appropriate for an individual. In this case, a goal of zero would be set. However, the tasks in the LCI are building blocks and the therapist helps the patient to achieve their goal in daily living by breaking it down into the component tasks in the LCI. Figure 2 in our article was intended as an example to show how a clinical anomaly, where the performance at delivery is better that at discharge, would be shown using the Splat. The scores at delivery should simply record the patient’s ability when they first receive the prosthesis and before they have had any prosthetic gait re-education. The LCI Splat will then help to demonstrate achievements following rehabilitation.