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Meet The Healthcare Team
While each Limb Centre may operate in a slightly different way, most will provide treatment and rehabilitation to amputees via a full, multi-disciplinary team, consisting of various healthcare professionals. Because everyone is different, you may not need to come in to contact with every member of the team outlined below, but most patients will experience a similar rehabilitation process and therefore be assisted by most members of the team outlined below at some stage of their rehabilitation. This is a general overview and not a complete list of everyone who could be of assistance to you, so please ask at your Centre to find out what, and who, is available to help you.
The rehabilitation service is free to all NHS patients. The Doctor in clinical charge is a Consultant in Rehabilitation Medicine, and a specialist in upper and lower limb prosthetics. A multidisciplinary team, lead by the Consultant, provides a coordinated rehabilitation programme to meet the needs of the limbless person and people with severe permanent mobility problems.
The patient, and his/her family and carers, are considered to be members of the team and their views are taken into consideration. They are encouraged to participate in the treatment programme within the Centre and at home. The main responsibility of the Doctor is the clinical care of patients referred to him/her for prosthetic management. The Doctor maintains an ongoing consultation with the surgeons who perform the amputation in the catchment area, advising on the optimum level of amputation and on prospects of prosthetic ambulation. The Doctor may have visited you on the surgical ward prior to your amputation.
When you arrive at the Centre the Doctor will carry out a full physical examination, paying particular attention to the residual limb, or stump. He will discuss with yourself and members of your family the various factors on which successful rehabilitation depends, i.e. your general condition, motivation, eyesight, amputation level, the condition of your residual limb and so forth. Some amputees are not able to make use of prostheses but the majority are and you will be advised of the choices available and the procedures involved in the supply and after care of the prosthesis.
The type of prosthesis you are provided with and its various components would naturally depend on your needs, which are unique to each individual. The multidisciplinary team will work with you to arrive at a decision collectively on the type of prosthesis. The team would endeavour to provide the most appropriate prosthesis from both functional and aesthetic aspects and you will be given details of the full programme of rehabilitation that you will have to undertake in order to achieve self-sufficiency and a good gait.
If you live a long way from a Rehabilitation Centre, many of the services you require will be provided for you at your local hospital and the doctor will keep your general practitioner informed of your progress. If necessary, he will arrange for the services of a physiotherapy department, social worker, counselling, hospital doctor etc to be made available to you locally.
The Doctor, along with the team, will be able to provide you with a forecast (prognosis) of your rehabilitation potential and your prospects of independence at home. If you wish, he can arrange for you to undertake employment assessments and to have counselling and preparatory training in order to find a job. He can also refer you to a wheelchair service and for driving assessments. The ultimate aim is to achieve an optimal level of holistic rehabilitation in terms of walking, physical independence, driving, psychological adaptation, return to employment etc.
The Prosthetist is a pivotal member of the rehabilitation team whose views and expectations are very important. They will discuss (along with other members of the rehabilitation team) your past activities and your goals for the future and try to give a realistic expectation of what they feel you would be able to achieve with a prosthesis. In the case of young children, the parent/s carer/s would be active members of the rehabilitation team and full goal-setting and future expectations would be discussed and agreed upon.
They are always mindful of the extra effort required to use a lower limb prosthesis and how some disease processes can affect the ability to use a prosthesis, and this will be one of the criteria that will be taken into consideration when prescribing a prosthesis.
Following initial examination of your residual limb (stump) and discussions with other members of the rehabilitation team, the prosthetist will have formulated a prescription for the fabrication of a prosthesis. He/she will then take relevant measurements and a plaster cast of your residual limb to be able to fabricate the socket. This is the part of the prosthesis that fits onto your residual limb and, as such, needs to be very accurate. It is prudent to note that no matter how good the fit of a socket, it can in no way be called comfortable. The prosthetist will endeavour to make it tolerable. (The best way of thinking about this is the bicycle saddle which when used for the first few times can be quite a challenge to use for anything other than a short time, but with increased use becomes tolerable).
After you have been cast and measured for your prosthesis, you will be given an appointment for a “fitting” which is about a week later. At the fitting stage, the prosthesis is constructed without a cosmetic covering. This enables the prosthetist to adjust the setting of the prosthesis to suit your individual needs. It is at this stage that you will take your first steps. During this time, the prosthesis will need to be adjusted to the correct height, dynamically aligned and the socket is assessed for accuracy of fit.
Once the Prosthetist is satisfied with all these parameters, the prosthesis may be finished while you wait with soft foam or a temporary cosmesis, or you may be given a ‘delivery’ appointment for about a week later. Once the prosthesis has been “delivered” to you, physiotherapy will have been arranged for gait (walking) training.
During the first few weeks/months, your residual limb will be swollen but this will reduce with time. This will cause your socket to become loose and it will need adjusting. You may be taught how to make up for volume loss by your prosthetist or physiotherapist by adding additional stump socks. During the first year to eighteen months, you should expect the residual limb to change in shape and volume, which will require fairly regular adjustments by the Prosthetist. If the change in volume/size is too great for adjustment, you may need to be recast for another prosthetic socket.
Modern prostheses are sophisticated devices that are constructed to exacting standards and, as such, need to be looked after. If you feel something has gone wrong with it, or it starts to feel uncomfortable, it is important to contact the Rehabilitation Centre immediately and explain, in as much details as possible, the problems you are having. This will enable the person you are talking to to decide how urgently you need an appointment with your Prosthetist, nurse or the Doctor. It is very important that you do not attempt to alter, adjust or repair the prosthesis yourself as this may leave it in a dangerous state. If you have any queries or problems, you should contact your Rehabilitation Centre who are there to help.
The role of the Physiotherapist in the rehabilitation of a patient following amputation is to help enable the individual to achieve their maximum independence and functional ability. This depends on a number of factors, including the patient’s pre-amputation lifestyle, expectations and medical limitations.
The Physiotherapist works closely with other members of the rehabilitation team to achieve the individual goals of the amputee. If the patient’s condition allows, the Physiotherapist will see the patient before the amputation to explain their role and the proposed rehabilitation programme and to answer any questions and queries the patient or their family may have. Often, it is not possible to see the patient before the operation, but physiotherapy begins very soon post-operatively. It consists of advice and a carefully graded exercise programme to improve the strength and general fitness of the patient, as well as assessing their potential to use a prosthesis, with specific exercises to prepare for prosthetic use.
Some patients will stay in hospital until they are independent with their prosthesis, but most patients are discharged home as soon as they are able to manage a wheelchair safely at home. In either case, physiotherapy continues (as an in-patient or as an out-patient) using an Early Walking Aid (e.g. a Pneumatic Post Amputation Mobility Aid - PPAM aid) to retrain walking until the individual is ready to use a prosthesis. This is when the post-operative swelling has reduced, the wound has healed and the patient has shown they will benefit from and are able to manage a prosthesis.
By this time, the Physiotherapist knows the patient well and is able to advise the rehabilitation team and the patient, thereby contributing to the decision about prosthetic use and what type of componentry would best suit the individual. Rehabilitation continues with the Physiotherapist teaching the amputee how to walk with the prosthesis and how to get the most out of it. Many Prosthetic Centres offer a maintenance programme to make sure that the prosthetic user remains fit and able to use their prosthesis effectively. It is important to remember that an amputee’s rate of progress and their final functional outcome will be determined by their general state of health.
Some amputees find that they can achieve more independence by using a wheelchair rather than a prosthesis and therefore this is the right decision for them. The Physiotherapist will support them in this decision and they will still need a physiotherapy exercise programme to enable them to stay as fit as possible.
The Occupational Therapist (OT)
Occupational Therapists (OTs) usually wear dark green trousers with a white tunic. They work closely with physiotherapists and specialise in helping patients tackle many aspects of independent living; some of which might be initially difficult or embarrassing for you to manage, but that you may want to do on your own in the future.
The OT will initially work with you on the ward, and then in the Occupational Therapy Department within the hospital or Limb Centre, where you can practice everyday activities with a view to being discharged home. The main aim is to encourage personal independence, with and without prosthesis and activities might include:
- Dressing Practice – If you have problems balancing, it might be difficult for you to get dressed. The OT will show you how to dress yourself safely and advise on suitable clothing;
- Personal Care -This includes helping you to be independent in washing, getting in and out of the bath and on and off the toilet;
- Kitchen Practice – If necessary, the OT will help you to develop or regain independence and make sure you can cope in the kitchen, starting with a hot drink and maybe progressing to a meal;
- Upper Limb Strength – The OT may also carry out specific activities to strengthen your arms/ upper limbs, to make manoeuvring a wheelchair and wheelchair transfers easier;
- Wheelchair Usage (lower limb amputees) – If appropriate the OT will order a suitable wheelchair and cushion. This is normally ordered as early as possible to allow a degree of personal independence in mobility soon after the operation;
- Home Visit Assessment – In order to help you with any practical problems that you may have when you return home, a home visit may be arranged in advance of your discharge. The OT will note structural situations that will cause you difficulty and will work out practical solutions with you, perhaps in the form of ramps, rails and widening doors (for wheelchair access etc). An assessment will be made for the provision of equipment, e.g. for bathroom or kitchen use, which could be introduced into your home to make life easier for you;
- Upper Limb Usage – Occupational therapists also work with arm amputees. In hospital they will help you to regain your independence, solve practical problems and give you exercises to increase dexterity of your remaining hand, especially if your dominant hand is lost. You may be advised on aids to help you. Before discharge, a home visit may be carried out to ensure that you can manage safely & independently;
- General Rehabilitation – The OT from the hospital, Prosthetic Centre or community may continue your rehab as an outpatient after your discharge from hospital to help you plan for the future. This could take the form of further help to develop independence, giving advice on driving, resuming and developing hobbies/interests and also helping you to “live with” (increasing tolerance to and use of) your prosthesis. At the Prosthetic Centre, it is usually the OT who will teach you how to use your prosthesis. Occupational therapists also work in Social Services – they specialise in the home environment. They will oversee any housing adaptations that may be required. If your circumstances change once at home it may be these OTs who will help you to find solutions.
The Specialist Nurse
The Specialist Nurse works closely with consultant surgeons, the ward-staff and the multidisciplinary healthcare team involved in the care of amputees. They also liaise with the limb-fitting clinic, GPs and the community teams. This central role allows them to provide information and support for amputees and their families, throughout their treatment and rehabilitation, to help to coordinate and streamline the amputee’s care.
Patients and their relatives find it useful to use the Specialist Nurse as a ‘link’. Primary (new) amputees have a range of emotions to deal with. When faced with the need for amputation, patients understandably experience shock and upset, as well as fear and uncertainty for their future. Some find it hard to cope with changes in body image, and worry about how others will view them. Some may feel a sense of bereavement, anger or bitterness. Others may blame themselves. There are concerns about practical issues and most people worry about how they might manage physically.
The Specialist Nurse is available to discuss these emotions and to answer any questions people may have, particularly regarding surgery, treatment, and rehabilitation. Just knowing exactly what is going on and what to expect, may help patients to feel less anxious and more able to cope.
This is also a time of confusion and concern for families. The Specialist Nurse is available to offer support and provide information to them as well. Patients are usually confronted with a bewildering array of doctors, nurses and paramedical staff. It is not always obvious "who does what". The Specialist Nurse can explain which professionals they will meet and each of their roles. Each healthcare professional, while being an expert in their own field, is also genuinely interested in the patient as a person, as well as in their welfare and progress. Hospital staff do not mind patients asking questions. In fact, they should encourage amputees to do so, to help them feel confident about their rehabilitation. The Specialist Nurse can help them to understand their rehabilitation pathway step by step, so that they are able to aspire to attainable goals.
The Specialist Nurse also informs amputees as to those services, organisations and literature that are available and helpful. New amputees often find it helpful to meet a rehabilitated amputee. This should be arranged through the Limbless Association, (see the Volunteer Visitor section of our website) or a Specialist Nurse who can put patients in touch with a local support network.
On the practical side, the Specialist Nurse can be asked for advice and help with wound care or dressing issues. If applicable, they can counsel patients regarding recommended lifestyle changes, for example, smoking cessation and they will promote the health of remaining limbs, by giving foot and skin care advice. All patients are individuals, but what they go through, while difficult, is not unique. Those involved in their care understand that they can be emotionally fragile and confused. Allowances are made for this. There is always someone to talk to, who will listen to patients concerns or frustrations.
The Specialist Nurse is probably the one team member who is accessible to amputees throughout the full length of their hospital stay and subsequent rehabilitation. In fact, they often enjoy contact with amputees long after they have left hospital. Many patients become a valuable asset to the amputee support network in the months and years after their discharge from hospital.