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April is Limb Loss Awareness Month. Nichola Fosler, a partner in our Personal Injury team, talks with Christa Wright, occupational therapist, about the occupational therapist’s role in rehabilitation for upper limb amputees.
Since qualifying as an occupational therapist (OT) in Australia in 1998 and moving to the UK in 2003, Christa has gained extensive experience at a senior level providing rehabilitation and disability management to adults with a wide range of complex orthopaedic and neurological conditions, both in the NHS and private rehabilitation and community settings.
Christa has over 24 years’ experience as an occupational therapist and 17 years as a vocational consultant. She also has over 16 years’ experience working as a case manager, managing complex, catastrophically injured clients. Over the past seven years, she gained a specialism as an amputee OT, training clients to use upper limb prosthetic devices, including myoelectric hands. Christa currently provides a service across three private prosthetic providers in the London area.
Do you consider it essential for an OT to be part of the pre-amputation multidisciplinary team (MDT) when a client is considering undergoing an elective upper limb amputation, ie in addition to prosthetic and rehabilitation consultants and physiotherapy and psychology input?
Absolutely, I think occupational therapy should be an integral part of the MDT in any pre-amputation assessment process. The choice to amputate a limb, especially an upper limb, will have radical functional implications for a person, and all aspects of the decision should be considered and supported.
What OT input would you recommend as part of the pre-amputation rehabilitation, and over what period in the lead-up to planned surgery?
Ideally, I think a few sessions in the months prior to the surgery would be helpful. For occupational therapists, it is mostly about education about the different prosthetic solutions available post-amputation and, with guidance jointly with the prosthetist, talking through the options. Often, it is about managing expectations and explaining the post-surgery rehabilitation process, timeframes and the different types of training needed to use various types of prosthetic limbs.
If the hope is to use a myoelectric limb, for example, it is important a client continues using or moving the residual part of the limb (non-amputated) pre- and post-amputation to maintain muscle strength so that electrical signals remain strong enough to operate a limb using electrodes.
In my experience, the OT should play a crucial role in rehabilitation post-amputation. Do you agree?
I strongly believe and advocate for a specialist amputee OT to be an integral part of any prosthetic rehabilitation process as soon after amputation as possible. Limb loss, both upper and lower limb, has significant implications for activities of daily living (ADLs) and almost always will significantly impact a person’s ability to engage in family life, sports and leisure activities.
Early on, there will be the need for equipment and adaptations in the home, especially for lower limb amputees and very often wheelchairs and driving adaptations are required. The ability to work is commonly affected, and often, big decisions need to be made regarding returning to work or vocational redirection if a former occupation is no longer possible following amputation. The impact of amputation on a person spans the physical, emotional, psychological and social, and these challenges need to be addressed in a trauma-informed way.
Providing initial training for prosthetic limb use is a very important aspect of rehabilitation, but a more holistic approach to address wider needs and functional goals is always best practice.
What OT input would you recommend as part of the MDT post-amputation and during the patient’s progression onto learning to use a myoelectric prosthesis?
In an ideal scenario, the OT will meet the client on the first clinic treatment day jointly with a prosthetist and maybe also with a specialist physiotherapist to determine the potential to use a myoelectric limb, based on myo-testing (to check if there are sufficient signals from the residual muscles).
An interdisciplinary MDT approach to myo-training works best. The myo-training process, both without and with a socket, can be carried out by a specialist OT or physiotherapist, but once the practice with the prosthetic hand and mastering various grasps commences, an OT’s functional expertise can be an advantage. Technical ability is important, but equally, functional goals are essential to explore with a client so that the end result is a success and they truly integrate a myoelectric prosthesis into their daily lives. This takes time and practice.
I recommend an OT is involved as soon as possible in this process to guide the client from practising separate hand grasps and sequences to functional practice in clinic and then in the home, including essential skills such as independently donning and doffing the limb.
Practising ADLs, domestic tasks or other interests and hobbies in a client’s own environment is invaluable and gives real-world experience within the training process. I recommend approximately 30 hours of OT input spanning across the clinic and the home to facilitate a client from novice to competent user. Too often, I see upper limb prosthetic users being given little to no functional practice in the home, which can lead to low levels of use or outright rejection of the limb.
So many aspects come into play, such as comfort, socket fit, mental fatigue, body image and hand grasp settings that all need careful problem solving for a myoelectric limb to become a truly useful device that a client is committed to using in the long-term.”
What about OT input in the longer term, for example, to consider equipment needs and prosthetics due to the ageing process?
We all change as we age, both physically and emotionally, and changes happen also to our activities and life choices. This can impact a client’s equipment prosthetic needs as the activities they choose or are able to engage with change. An OT is well placed to assess a person’s activity changes over time, which may bring, for example, the introduction of mobility aids or a scooter or needing a simpler or lighter prosthetic limb if strength or fitness reduces. An OT functional review can help whenever major life changes occur for a person with a disability, and several things may need to be considered, such as housing adaptations or increased care and equipment.
Are you able to provide some information about how you assisted a client recently?
I worked with one client throughout the training process to use his first below-elbow myoelectric prosthetic limb. He took to it so well that we almost needed to slow him down at times as he built up his time and skills quickly to use it for at least eight hours per day.
Working with him at home opened up a world of possibilities not feasible in clinic. We practised a wide range of activities, including making breakfast for his kids, making his bed, opening packets of crisps, using a TV remote control, hanging up clothes and brushing his teeth, to name a few.
One of his biggest goals was to be able to play with wrestling figurines in a mini-ring with his boys, for which he needed two hands; something so simple but a task you would never know to ask about in clinic.
Outside the house, he spent much of his time in a shed he’d built where he was filming a podcast. We were able to provide a myoelectric hook to swap with his myoelectric hand, depending on the task. The hook was fantastic to use outdoors where he liked to get stuck into DIY tasks, using power tools, building outdoor toys and gardening.”
