Living With Limb Loss

Living With Limb Loss Even though the psychological and Notion of Embodiment emotional experience of wearing a has been shown that using a tool quickly of their prosthesis in their judgment. prosthesis is different for every patient, modifies (i) the perception of the space Yet, the real reaching space was found very few use theirs all day long (25%), surrounding the body (also known as to be smaller with their prosthesis than most of them only when they need it for peripersonal space), (ii) the kinematic of with their healthy limb, showing a large a particular activity (50%), and around subsequent bodily movements and (iii) error between reachability judgment and 25% abandon it after a time. However, the perceived size of the limb6. These actual capacity. An overestimation was the loss of a limb is a major handimodifications can even occur in hemiplealso found on the healthy side (comparcap for those patients who are mainly gic patients when the tool is hold by the atively to healthy subjects) suggesting young active people, and technological examiner’arm in a position allowing its a bilateral modification of body repreadvances keep on making prostheses embodiment by the patients. Yet, little is sentation in amputated patients. Finally, more and more efficient to compensate known about the subjective dimension a correlation was found between the for this disability. One hypothesis to of tool embodiment. Prostheses can be quality of integration of the prosthesis explain why their use remains limited conceived as tools insofar as they are a and the way the body representation is that, more than the specific technotechnical medium between the body and changed. This study therefore illustrates logical issues described by patients the environment. However, they are pethe multifaceted nature of the phenom(weight, battery failure, discomfort on culiar tools because they look like bodily enon of prosthesis integration, which the residual stump, etc.), the problem is parts and their aim is to replace the missinvolves its incorporation as a tool, but the sensorimotor challenge to embody a ing limb instead of extending an existing also various specific subjective aspects. prosthetic limb. one. The crucial question is whether these differences make their embodiment In conclusion, amputation and the wearOne can define the notion of embodieasier or more difficult. On the one hand, ing of a prosthesis modifies the body ment at two distinct levels. At the imMiller et al.9 found that morphological representation on both the prosthetic plicit level of body representations, an similarity between a tool and an effector and healthy sides. The subjective quality object is said to be embodied if some of increased its embodiment at the implicit of the integration of the prosthesis, its properties – or all of them – are prolevel9. On the other hand, it has been including the feeling of embodiment, cessed in the same way as the properties shown that subjective feelings of embodappears to influence these modificaof biological body parts. Embodiment iment could be induced for non-bodily tions. It seems that good integration of can also be associated with a large range shaped objects10. Here we thus analyzed prostheses depends as much on their of subjective explicit feelings, including the embodiment of prostheses in ampuuse, sparing the healthy limb as much as feelings of bodily ownership, feelings of tees, at both implicit and explicit levels. possible, as on the knowledge of their bodily control, of bodily integrity, affecimperfections and limitations. tive feelings, and so forth. Both implicit In Summary and explicit levels of embodiment for Amputated patients are hardly satisfied The negotiation of an embodied self extraneous objects have been extensivewith upper limb prostheses, and tend to arguably becomes more visible and ly discussed in the context of the Rubber favor the use of their contralateral arm complex when inhabiting a body that is Hand Illusion in healthy participants. to partially compensate their disability. seen as ‘non-normative’, ‘damaged’ or In the classic experimental set up, one This may seem surprising in light of ‘disabled’ (Murray, 2008, 2009; Radsits with one’s arm hidden behind a recent evidences that external objects ley, 1998). According to Rapala and screen, while fixating on a rubber hand (rubber hand or tool) can easily be Manderson (2005), when a body is dispresented in one’s bodily alignment; the embodied, namely incorporated in the abled, conventions of normative sexualrubber hand can then be touched either body representation. An investigated of ity and gender are actively challenged; in synchrony or in asynchrony with both implicit body representations (by as Gershick and Miller (1995) argue, one’s hand. In brief, in the synchronous evaluating the peripersonal space using a the experience of becoming disabled condition participants mis-localize their reachability judgment task) and the qualcan hence lead to a crisis, or at least a hand in the direction of the location of ity of bodily integration of the patient’s renegotiation, of gender identity. Specifthe rubber hand and report that it seems prosthesis (assessed via questionnaires) ically, they argued that the construction as if the rubber hand was their own4. was performed. of masculinity as strength was problemA similar illusion can be induced by atical by a contradictory construction of visuomotor congruency. Tool use is As expected, the patients estimated that disability as weakness. the other main paradigm to assess the they could reach further while wearing malleability of body representations. It their prosthesis, showing an embodiment

es, the soles, and the heels, inspecting for cracks, blisters or bullae, hyper/ hypopigmentation, fissuring, calluses, Clinicals and ulcers. The footwear should also be ed or ingrown, these could be a potential a major amputation the contralateral inspected for signs of wear patterns, forarea for skin breakdown and possible limb develops a serious lesion in 50% of eign bodies, and any irregularities. Any infection. Other nail issues to be aware cases.36 The 5 year adjusted mortality gross deformities as described above of are onychomycosis (fungal nails), rate after a major amputation of a limb is can be identified during this rapid visual dystrophic nails, atrophy or hypertrophy, 46%;6 this is alarming and is higher than screening. or paronychia (infected ingrown nail), as the mortality rate for many forms of canall can be potential problems. cer. It has also been shown in more than Neurological examination 85% of lower extremity amputations a As stated earlier, peripheral sensory Evaluation for any ulceration to the foot wound was a critical aspect of the causal neuropathy is the major risk factor for or lower leg should be assessed. Importpathway. The cost of treating diabetic the development of a diabetic foot ulcer. ant characteristics of ulcers are depth, foot ulcers is also growing at a staggerThere are many simple, noninvasive exsize, presence of fibrotic or granulation ing pace, reaching nearly $30 billion in aminations that can be performed to test tissue, location, and whether or not the the United States in 2007.39 and monitor sensation. A simple history area appears to be infected. of neuropathic symptoms such as tinOffloading gling, burning, numbness, the feeling of Clinical Problems and Principles of Numerous products are available to insects crawling on the feet (formication) Management assist in redistributing pressure over can help to identify those patients at risk a larger unit area (off-loading) on the for developing foot ulceration. Ulceration foot. Some examples include removable Initial presentation of the diabetic foot cast walkers, non-weight bearing casts Monofilament Testing usually entails the presence of an open with crutch/walker assist, wedge sandals One of the most common methods used ulcer, located on the plantar aspect of a (either forefoot or heel wedge), healing to assess neuropathy is the use of the patient’s foot. Most patients will not sussandals with a multilaminar, multiduSemmes-Weinstein monofilament (10-g) pect an ulcer on the bottom of their foot rometer foot bed. However, the choice wire. The nylon monofilament is placed until they, or a loved one, notices blood of modality should be chosen with on ten different pre-determined locations either on the floor after walking or on a respect to the patient’s functional status. on the foot and pressed down manually sock. Advising the patient that ambulaFor example, if a patient presents with until there is a slight bend in the wire. tion is contraindicated with an open ula plantar forefoot ulcer, a wedge shoe The patient is instructed to say ‘yes’ if he cer is often challenging especially if the that does not allow the forefoot to bear or she thinks they feel slight pressure or patient is neuropathic, as they have lost weight would be an appropriate device. sensation. If the patient is unable to feel the ‘gift of pain.’33 However, reduction However, if the patient is not properly the sensation at two or more locations of pressure to the foot is essential for educated on use of the device and/or then it is safe to assume that protective treatment. By effectively off-loading the has issues with balance, the offloading sensation is lost. area, the risk of continued trauma and modality could cause the patient be resultant infection is decreased. unstable when walking. In regards to Dermatologic Examination diabetic shoes, whether custom-made or Following assessment for any loss of Epidemiology and risk factors off the shelf, it is important to keep in sensation, evaluation of the integumen is Ulceration of the diabetic foot is one mind one key fact. While diabetic shoes a critical part of the foot screening. The of the single most common problems are effective in preventing ulcerations, skin can be evaluated for color, texture, for which medical assistance is sought they are (in general) not very effective in turgor, quality, and presence of any areas in a diabetic individual. Up to 25% healing them. of dryness or fissures. Calluses, if presof patients with diabetes will have a ent, can be problematic as they indicate foot ulceration during their lifetime.4 For many years the gold standard in areas of increased pressure and an ulcer Remarkably, at least 50% of those offloading an ulceration on the foot has can form under the hyperkeratotic lesion, ulcerations will become infected, and been the total contact cast (TCC). This which may cause hemorrhage beneath in 20% of those cases an amputation is fully weight-bearing cast consists of a the callus. Debridement of these areas is required.34 There are 81,000 major ammultiple layers of both fiberglass and recommended in order to reduce a potenputations performed on individuals with plaster with minimal padding. When tial focus of pressure. diabetes in the United States annually. applied properly, the TCC allows the Conservatively, 60% of all non-traupatient to be ambulatory. The TCC Appearance of the nails should also be matic amputations occur in the diabetic redirects pressure from the bottom of noted. If there are nails that are incurvatpatient.35 Studies have shown that after the foot, which is then redistributed over

A prosthetic limb is defined as a mechanical device that is used to replace a missing human limb. The device is designed to help the user coordinate better control of an amputated limb. This could be as a result of motor control loss by a traumatic event, a congenital-related defect, or dysvascular related.

According to statistics by Ziegler-Graham, et al. (2008), an estimated 1.6 million civilians were living with the loss of a limb. The research also revealed that approximately 38% of these people suffered an amputation of a limb as a secondary consequence to a dysvascular disease. Shockingly, it has been predicted that this statistic is likely to double to 3.6 million by 2050. information back to the actuator. • Actuator - the end device that will Dysvascular disease is only one major receive information from the controller contributing factor to the amputation of a and mimic the movement of a muscle. limb. It is commonly known that war veterans often become wounded in combat and The study of prosthetic limbs is vast considering the current affairs, it is estimatand complex. For the scope of this ed that the number of veterans wounded in article, attention will focus on the Afghanistan is increasing. According to the prosthetic hand in more detail. As Department of Defense statistics, to-date mentioned, the main pathway involved more than 1000 soldiers have returned from in the function of a prosthetic limb Afghanistan with the loss of a limb. With is based on three main components: current limb-loss statistics in perspective, a biosensor, controller, and actuator. there is a clear demand for the use of prosUser preferences need to be considered thetics from the healthcare angle. before designing a prosthetic limb and if focusing on a hand prosthesis, the Robotic Prosthetics - Structural Comfollowing preferences are important: ponents • Grasp function for a size range of objects A robotic prosthetic limb is made up of the • Intricate finger movements should following components: be possible for grasping and pinching motions • Biosensors - these are required to detect • A prosthetic hand needs to be neural transmission from the human nervous lightweight to allow for better and neuromuscular junctions (i.e., wires to movement in continuous space track neural activity near the surface of the • Finger projections need to be deskin). The video below by Bio Tac is a great signed with active joints to allow example of how biosensors are applied to for intricate movement study sensing modalities of a robotic finger. • Aesthetically, the prosthetic hand • Controller - the main connection between the neuromuscular systems and the needs to appeal to the patient and allow for comfort of use end device and so this receives the information from the biosensors and feeds this The use of biosensors is fundamental

Andrii Zastrozhnov / Shutterstock

to initiating a pathway that will result in movement of the actuator. To allow for the control of a prosthetic limb, the actuators are attached to the residual part of an amputated area, which will provide feedback on tactile information generated by the biosensors.

The actuators are also connected to a hardware interface system that acts as the controller, which initiates sensory feedback to the actuators.

The actuator is the key element to a fully functioning prosthetic hand and it is what displays the end result (i.e., grasping an object). To begin with, the actuator system to this prosthetic hand is made up of micro-actuators. These drive the metacarpophalangeal (MP) joints of the thumb and the proximal interphalangeal (PI) joints. The distal interphalangeal (DIP) joint is controlled by a link connected to the proximal interphalangeal (PIP) finger joint.

It is important to consider the number of individual pieces of information that will predict how

Almost everyone is unusually anxious because of COVID-19. However, being in a constant state of anxiety and stress will not do you any good. After all, stress is known to affect our immune system. So, what should we do? We can try coping with anxiety and building mental resilience by turning to psychology. If you ever face a Brown Bear in the woods, stand together, and the bear will think you are an even bigger bear. It counteracts the ill effects of social distancing. You will find you can put a lid on that free-floating anxiety. A robust social network,

This pandemic has rearranged our self-perceptions. What we took for normal has been substantially challenged. We must bend in the wind rather than break because of our resistance. Now is the time to live with uncertainty and a profound lack of leadership. Self-tolerance is the new rule. We need to counterbalance the desire for stability when this virus takes its toll. We create a new sense of certainty about the future. However, in times like this, it’s okay to be anxious, and the first step to coping with anxiety is being patient with yourself.

However, watch out that your anxiety doesn’t turn into sustained stress, which is detrimental to your health. Instead, identify the things that you can control. Practice self-care whether this comprises the people you live with at home or a by adhering to the World Health Organization’s guidelines: group that you meet virtually, will go a long way in helping you wash your hands frequently; maintain social distancing; become mentally resilient. avoid touching your eyes, nose, and mouth; and practice cough etiquette. If you have a cough, fever, and difficulty Make time for reflection breathing, seek medical care as soon as possible. Control Your News Input Experts say that crises often bring significant societal changes. Setting aside time to process everything that’s happening is When a virus that you don’t know you have infects everyvital for your mental well-being. Reflection can mean a long one around you before you even suspect it is time to rethink conversation with a friend or a family member, or you can write what you do control. Realize what is burning you like a in your journal. Whatever your chosen method of reflection is, press gone wild will show how much you need to control make sure to do it regularly to avoid feeling emotionally overyour news input. We are in uncharted territory, which is whelmed. why we may feel helpless and anxious. More often than not, we turn to the news and social media platforms to seek About the Editor information and maintain an illusion of control. However, As a fellow amputee, I know the psychological difficulties consuming too much news or related content can lead to a people face after losing a limb. I have helped people on the vicious anxiety cycle. phone and texting for the last ten years as a Life Coach with these specific issues. I understand what you are up against when We recommend controlling your news diet by identifying you realize you have lost a limb. Prior to that, I was a clinical when to read or watch the news from reputable sources. psychologist for over thirty years specializing in treating panic This can be an hour once a day or twice a day. A schedule disorders and post-traumatic stress. My post-doctoral work was ensures that you get essential information. Remember that at the VA in San Francisco with vets coming back with lost not every bit of news helps. limbs and traumatic body images. Stand Together

Clinicals into this category with the exception of an amputation. Rarely are amputations done as an elective procedure. the bottom of the entire foot and up Only in the case of severe deformity the cast. Some disadvantages of using or instability from a previous injury or a TCC is the time it takes to apply, the surgical procedure, will an amputation bulkiness for the patient, and the fact be considered. Assuming good glycemic that the patient must wear the cast for 1 control, patients grouped to this class are week intervals requiring weekly visits not at any increased risk for the developto the clinic. Newer TCC variants have ment of complications than correspondreduced the time required for application ing patients without diabetes. of a traditional device whilst retaining many of the desirable therapeutic charClass II: Prophylactic acteristics. Procedures in this class are indicated to alleviate a deformity in a patient who is In many instances, proper off-loading neuropathic however does not have the may be all that is necessary to achieve presence of an ulcer. The goal of prowound healing. However, if wound phylactic surgery is to reduce the plantar healing fails in the midst of proper sheer and vertical stresses. Many proceoff-loading, adequate blood flow, and dures for prophylactic surgery would be satisfactory nutritional status, surgical considered elective if the patient did not intervention may be warranted. suffer from neuropathy. Several examples of procedures in this class include a Non-vascular surgical treatment Charcot foot reconstruction, a metatarsal Surgical management of the diabetic head resection, a Keller arthroplasty, an lower extremity can be a challenging a chilles tendon lengthening or a hamand frustrating task, but can be ultimatemertoe repair. ly rewarding both to the physician and patient upon healing of an ulcer and Class III: Curative correction of the underlying cause of Curative surgery often is identical to the deformity. Surgery in the absence of prophylactic surgery with the exception critical limb ischemia is based on three that procedures in this class are designed fundamental principles: presence or to speed the healing rate of an open absence of neuropathy (LOPS), presence wound but also to eliminate any potenor absence of an open wound, and prestial recurrence of the ulceration. Surgience or absence of acute limb-threatencal procedures frequently utilized in this ing infection. category may include exostectomy, digital arthroplasty, sesamoidectomy, single A classification system has been develor multiple metatarsal head resection, oped outlining non-vascular surgical joint resection or partial calcanectomy treatment of patients with diabetes and as well as Achilles tendon lengthening. has been divided into four categories Some surgeons may also elect to comand highlighted in Table 26.4 and is bine a plastic surgical flap and/or skin based on indications and perceived risk. graft to help expedite healing.

The goal of elective surgery is to reduce or eliminate any pain associated with a particular deformity and improve function. Examples of these deformities include bunions, hammertoes and bone spurs, all in patients without peripheral neuropathy and with a low chance for ulceration. Basically any type of reconstructive surgical procedure can fall

Urgent procedures are performed to limit the spread of acute, limb and potentially life-threatening infection. Most often these procedures are done in the presence of significant ischemia. They require the removal of all infected and necrotic tissue to the level of viable soft tissue and bone and usually involve some level of amputation. When at all possible these procedures should be performed to allow for maximum