I found this article interesting. It was surprising that a delay in fitting led to better results and that marital status had apparently no impact.

Unfortunately there is too often a lack of adequate care on the part of prosthetists for various reasons of training, supervision, job pressures, and unfortunately attitude. Prosthetics is a small, specialized field that has been allowed to deviate from general standards of care that were once considered essential. Often physical therapists are not adequately educated or experienced in amputee care to evaluate the nature of what can be fairly subtle problems. Frequently I have seen otherwise well-educated and well-meaning therapists try to evaluate the correctness of prosthetic limb length with the patient lying down.Likewise few physicians have the background to sort out the details of amputee care and fitting. There is a huge gap that can only be filled by having experienced , dedicated, and knowledgable people from the various disciplines working as a team to insure that critical aspects are covered. The role of the amputee clinic is essential. The majority of amputations are more and more due to systemic illnesses that are expensive to treat but can be ameliorated by the kind of follow-up care such clinics can provide.

Education level generally reflects something about financial resources and the ability to adapt. The poorer a person is or the fewer resources they can muster the less likely they are to have a better outcome. Less education and poverty are always obstacles and lead to accepting outcomes that seem inevitable but can be greatly improved. This happens more easily when a person is not adequately informed ,is handed along without proper oversight, and is not educated enough to know or expect anything different. The complexity of medical care and appointments and medications and funding can easily become an endless litany that is impossible to keep track of and imposes its own burdens and negative outcomes. This kind of poor,fragmented care is the final breaking point in the goal of independence.

Thank you Dr Nunes for a well researched timely article.

A major benefit of this study is that it identifies subgroups of patients at risk prior to amputation so that special proactive interventions can be planned preoperatively with the rehabilitation team to optimze the rehab care and potential for successful prosthesis use. Very nice research study.

The care of people with disabilities is complex and requires trained and highly qualified technical teams in rehabilitation processes. But I also believe that the commitment of the health system is needed as they are individuals with multiple chronic associated illnesses that require the attention of the entire health care team and not just the group involved with rehabilitation. The primary care team must also be involved in the rehabilitation process and therefore should be trained in this type of care.

Dear all,

Congratulations for this wonderful work and discussion of high level. Marco, I am a Vascular Surgeon from Brazil, Rio de Janeiro and I'm proud of your paper .

In my opinion there is a legion of amputees in our country, is a social problem and adaptation of prosthesis is a major dilemma that goes through personal issues, family and social problems.

Excellent study and one that needs to be expanded. The data that has been collected should be further analyzed and more papers presented on this unique population. Without direct comparison, your numbers associated with the trauma group appears consistent with our work on returning soldiers.

However, I am curious of the definition of adaptation. it is not well defined in the study but appears to be that anyone that uses the prosthesis only for transfers or cosmetic purposes has not "adapted" and that anyone else, regardless of how much they use the device or assistive device has "adapted"... is this correct? If so, can we say that 1 hour of use per day is adapted or not adapted, even if it is used only for therapy or if associated with poor fit or poor surgical technique does that impact the concept of adaptation (as you appropriately discuss)?. If we can agree on what adaptation is for each individual I think we can present this in a very clinically relevant and meaningful way and the beginning of methodology to determine, in a proactive manner, who may be a candidate for a prosthesis.

With regards to the question as to why the longer time since amputation leads to improved adaptation, it is implied that as you get further from amputation time and have started using a prosthesis, that as time goes on the limb becomes more stable and the fit of the prosthesis becomes more consistent, leading to improved use, comfort and function. Assuming they are using a prosthesis through the "maturation" phase of care. This is consistent with what we see clinically as well.

Thank you for your great work.

I agree with Prof. Paulo Eduardo Reis Ocke that in Brazil there are legions of amputees and that it has indeed become not only a medical problem but also a very serious social problem. The adaptation of the prosthesis is directly related to a suitable rehabilitation service. And is indirectly related to the patients' own desire, because these are usually elderly, diabetic, have poor eyesight and are very afraid of falling with the prosthesis. So they need to rely on social support that usually comes from family and this was the reason why I reported earlier about the need to have a primary care team empowered to provide technical support in this process.

Prof. Gary Berke, the reality of the amputee is hard and it is very hard in Brazil. I think due to the very limited space of the article the concept of adjust was not very clear. In the region where I work the prosthesis is provided only to the patient who participates in the rehabilitation process and it is this team that prescribes the prosthesis. So I defined prosthesis adjustment as related to the patient that potentially was able to use the prosthesis after prescription and training for its use. However its use was defined as ambulation in the community or just in the home environment. The cosmetic use or the use only for transportation has not been considered.

Regarding the time for the adjustment I believe it may be related to the stabilization of the stump, but patients are more experienced with their reality and know their limitations. Moreover, I believe there is an inability of the healthcare team for patient care in primary and secondary level which delays the referral to rehab, but this was not evaluated for this article.

Professor James Bowman, the main purpose of this line of research is to collect a large volume of information to support the planning of public policies aiming to provide better care for the patient. So our ambition is to help qualify our health care system.

Professor David Gross, I agree with your report that the reality is that the professionals who work with the rehabilitation of amputees, although they have professional competence, do not have proper training to care for this population, since it is a highly specialized job.

I believe that educational level is important for understanding the orientations of the health team and especially for their empowerment when they are trained to self-care that is extremely necessary in this type of patient.

Dear Marco Antonio

In the paper published by Lilian Fatima Dornelas in Orthopedic Brazilian Acta, vol.18 n.4, 2010 with the title: Use of prosthesis and return to work on amputees from traffic accidents aimed to verify the use of a prosthetic limb and return to work in amputees the conclusion was:

The use of the prosthesis is commonly to ride and the rate of return to work after rehabilitation is low . The low level of education and qualification may have been responsible for these results.

It is essential that the individual receives specific care during the immediate postoperative period until full rehabilitation, because any failure in this process may make it difficult the functional recovery

Dr Nunez, thank you for your response.

My educational experience was a BS(1979) in physical therapy in a 4 year program and a Certificate in Prosthetics(1981) from a 4 1/2 month course at Northwestern University. Fortunately in both cases I worked under the guidance of experienced, dedicated mentors. For over 20 years I was the primary prosthetic consultant to a busy weekly county amputee clinic that encompassed most of the rehab team. It was a great opportunity to observe the work of various prosthetists , therapists, physiatrists, social workers, etc.

In both the fields of therapy and prosthetics I found that at a certain point experience was the seasoning element in enhancing appropriate evaluation, care, and decision-making. I do not see the extension of time and expense added for the higher academic standing of a master's degree or "doctorate" to be cost effective on the part of practitioners in physical therapy and prosthetics or the outcomes of patients.

I think in the field of prosthetics several endemic problems have arisen. The use of ischial containment sockets for above knee amputees requires a much higher skill level to fit appropriately than quadrilateral sockets and also require the added time and expense of check sockets. They can offer definite advantages in some circumstances in the hands of experienced specialists. Unfortunately the benefits of ischial containment use are often outweighed by the problems of more time consuming , costly, and less comfortable results and motivated more by higher billing and the direction of education.The other problematic development is the widespread misapplication of total surface bearing in trans-tibial fittings where the casting procedure is often a circumferential wrap as opposed to three-stage methods. This approach (along with scanning techniques) fails to accurately capture underlying skeletal contours and generates a generic round socket shape. The result is predictably excessive anterior distal pressures and breakdowns.

I have discussed these matters with colleagues and while there is some dissent there seems to be generally broad agreement. It would be interesting to see the results of a broad survey of opinions of prosthetists along with their length of experience.

Sorry for the protracted length of this discussion and thanks again for your stimulating work and responses.

Hi Aria Tsam? How can I refer on VA/DoD Evidence-Based Practice Working Group site?

Thank you

Hello

I am an RN who worked with Trauma patients who sustained traumatic amputations or who had to decide at a later time to have an amputation....  I developed the program and created a position of "Amputee Liaison Nurse'.  I met with patients and families within a few days of their admission. Unfortunately people have no concept of what happens when this type of event occurs and looking in the yellow pages under fake legs is not the way to find a prosthetic leg.  I brought articles.  I showed video's of below the knee and above the knee amputees skiing and running etc.  In the first days of being overwhelmed with the events - I gave a measure of hope.  3am is a horrible time - the patient is alone and staring at the ceiling worrying about ... life missing a body part.  I met my husband at Trauma.  A drunk driver hit him on his motorcycle and he became a below the knee amputee.  He asked me in the recovery room one day - what now?  I did not know.  So I accumulated articles and talked to experts.  And I developed the program to help other patients.  (and married that one!).  I sent letters out to the patients and families that I worked with and I now am going to send out letters to find out what their lives have been like in the last 10-15 years. (I want to continue to be able to provide information to other patients).  I found that if patients knew they would be functional and that there were options - they did well.  Women wanted to look 'normal'.  There is a difference between traumatic injuries and recovery expectations - and chronic illness amputations.  If a diabetic patient had adjusted to a life of sitting with the leg up for years....  their expectation and life after amputations did not change much.  They  continue to sit or added minimal activity to their lives.   (in my experience)

I did not see a significant difference in the attitude of using a prosthesis in 'education level'.  If you mean lower income/lower education status - once I gave them information and stayed available for them to call - they came back to the Clinic walking!  I approached the whole process as - it is just a high top tennis shoe.  One tennis shoe is a bit higher on the other side.  (meaning the prosthesis).  Of course the options for the type of leg is limited in the type of insurance that is available to each patient. 

Unfortunately nurses do not have the time to sit with patients and address their fears and concerns.  Doing this program on my own time outside of my work - gave me the ability to spend time with patients and families.  And I gave my phone number to patients/families so they could call.  Sometimes family members just needed to talk to someone who understood and say things they could not discuss with other family members.  While awesome advances have been made in the production of limbs and arms (I worked with arm amputees also) - the human side of things gets pushed aside.  Physicians don't necessarily get special training in amputations/artificial limbs.  Even pain centers treat 'physical symptoms' and patients end up on a fist full of pain/psych meds.  It is important that there be the support and encouragement - it truly makes the difference in the rest of the person's life. 

I apologize for the length of my reply.  The end result is that the adaptation to the loss of a limb - be it a finger, toe, leg or arm - is affected by education and support given to the patient/family.  Nursing is not just a science - it is an art.  And the human side of the patient experience is lost in the economic reality of efficient time utilization of the provider.

Thanks,  Dee for  a  very  thoughtful  and  enlightening  post.

Thanks for contributing to this much needed discussion (paper attached)

As amputations results in a variety of limitations that have emotional consequences for patients, we evaluated non-psychotic disorders and their associated factors in a sample of people with lower limb amputations.

We detected a prevalence of 43% of mental disorders assessed with the SRQ-20 questionnaire.

Patients with associated chronic diseases and lack of independence remained significant showed a higher positivity in relation to psychological morbidity.

Reference

https://pubmed.ncbi.nlm.nih.gov/22362046-common-mental-disorders-in-patients-undergoing-lower-limb-amputation-a-population-based-sample/