Reintegration & Adjustment as Seen by the Amputee
Excerpts from an article by
H. Clifford Chadderton, CC, O.Ont., OStJ, CLJ CAE, DCL, LLD
Chief Executive Officer
Editor's Note: This article by Cliff Chadderton draws on his many years of experience as Chief Executive Officer of The War Amps and as an amputee. He lost his leg during World War II.
The reintegration and rehabilitation of amputees involve many disciplines, governments at all levels and both medical and educational institutions. However, that being said the major contribution in rehabilitation can, and must, come from the amputees themselves. Without the amputee's desire to succeed, applied with a generous measure of ingenuity, improvisation and sheer determination, very little can be accomplished.
The investment in providing artificial limbs for all amputees including an aged person, and training them in the use of artificial arms and legs, not only contributes to the well-being of the amputee, but can, when an amputee is advanced in years, provide more freedom to family members involved in the care of the individual.
Longevity has its rewards - and its own particular set of problems, including a high number of amputations from cardiovascular diseases, and from diabetes and cancer. It is believed that some 80% of amputations are now caused by disease. Accidents from power machinery, recreational vehicles and other equipment in our highly mechanized society are bringing in a higher toll in the number of amputees. Farm machinery and car accidents are, as well, among the chief culprits.
Psychological Factors
It is interesting to reflect that amputation due to accident can leave a different mark on the psyche of the amputee, depending upon the circumstances under which the accident occurred. It can raise questions of guilt and blame, directed inwardly in some instances to the amputee himself or herself (i.e. Did I bring this on myself?). Blame is sometimes laid by the amputee on the doorstep of others if the circumstances of the accident would appear to support this.
Another set of problems of a psychological nature surround congenital amputees. Questions of cause and blame may run through all levels of the family. This negativity will be sensed by the child and, thereby, will affect the child's attitude too.
Setting aside all attempts at psychology, a simple fact becomes very clear indeed. There is absolutely nothing to be gained (and the risk of increased disability can result) if the amputee attempts to dwell upon the reasons for having become an amputee. Those involved in amputee care - and the amputee - must strive never to look back. The goal should be occupational and social rehabilitation.
From the time of surgery until return to a normal life in the community, the majority of amputees are beset by many doubts and fears. The problems may involve relationships with the medical staff, the physiotherapist, the prosthetist, the family (including those with whom there are the closest ties), and friends. A major concern also is the amputee's place in the work force and the reaction of employers and fellow employees.
Sometimes misunderstandings can arise because those around the amputee - in the hospital, in the home and at work - are unsure how they should respond to the amputation. They are unsure whether to extend sympathy, and are fearful that if they do, they may be rebuffed. Or they may feel that if they treat the new amputee in a light-hearted manner, making light of the amputation, it may lead to the accusation that they neither care nor understand. Most amputees do have the need for reassurance and constructive advice but because amputation is a visible disability, there is usually a hesitancy on the part of others to consider amputees as normal, healthy individuals who want, and need, to take their place in society.
Excess sympathy, too readily offered physical aid by family, friends and co-workers, or in some instances complete avoidance of mentioning the amputation, could instill in the amputee the feeling that they are now somehow inferior and cannot live a full and active life.
Amputees must learn to recognize these attitudes in others, and realize they are based on misunderstanding and a lack of knowledge concerning amputation. If, instead, amputees make their own evaluation of their abilities and potential, and make constructive plans for the future, they will be beyond the stage where the thinking of others can influence their own attitudes.
Once the psychological and physical factors of amputation are accepted, the amputee is no longer in danger of being affected or hindered by others; and can get on with the job of returning to as nearly a normal life as possible.
Vocational Rehabilitation for Amputees
It is often a mistake for the amputee to assume that the officials charged with the responsibility for administration of academic and vocational training institutions are fully enlightened in regard to the abilities and rights of the amputee. If necessary, any denial of such rights should be brought to the attention of the governing body of the institution and should be pursued. In Canada, human rights legislation exists which guarantees access on an "equal opportunity" basis for the disabled. If necessary, an application should be made to the appropriate jurisdiction such as the Human Rights Commission, Ombudsman, etc. These measures may seem harsh but when you encounter this type of attitude strong action is required.
Employer prejudice is still an issue for amputees, and sometimes perseverance and "teaching" others about your capabilities will be part of the job search.
Once access to training is established, the onus is often on amputees to make the special effort required to ensure they avail themselves of the education and training. Some examples are:
- Special arrangements for transportation to and from the facility, and in some cases within the institution, so that the amputee can be at the proper place at the proper time in accordance with the syllabus and timetable of the course of study involved.
- Adaptive equipment to enable an amputee to take part. This may require ingenuity on the part of the educator, the prosthetist and the amputee.
"Yes you can" is probably the most important lesson to be learned by an amputee in connection with employment potential. A secondary requirement is to seek out sources which may be of assistance.
Where necessary, special arrangements concerning transportation and accommodation may be required, particularly in the case of multiple amputation. The amputee must not be reluctant to put forward strong arguments for the right to training and education.
Social Activities
In the life of an amputee the general public cannot always be expected to understand the limitations or adjustments that may be necessary because of the amputation. In carving out a social life which has meaning and quality, amputees must often take the initiative to educate their peers about their needs and in so doing make them feel comfortable about discussing the amputation. Very often, the general population tends to regard amputees with an air of mystique. They have difficulty understanding how a person can cope with the loss of one or more limbs. Amputees should be counselled to speak freely and frankly about their amputation. They should approach their social life accepting the fact that amputation does make them somewhat different. While their amputation may represent some limitation in regard to mobility or function, they should emphasize that they can enjoy an interesting and rewarding social life.
Recreational Activities
Recreational activities are a different issue. In this area, amputees must learn to "cut the coat according to the cloth" and accept that amputation may impose some physical limitations. Once they have had an opportunity to measure this, they can develop for themselves a recreational lifestyle which makes allowances for the effects of their amputation.
The objective, for most amputees, should be to enjoy the sport or activity, realizing that adjustments may be necessary which may in turn affect their ability to participate competitively with able-bodied persons.
The level of amputation will also be a factor when it comes to recreational activities. The unilateral below-knee or below-elbow amputee can usually attain satisfactory proficiency in most sports and activities. (An exception might be team sports requiring considerable physical activity such as football, and this will depend on the individual.) The degree of difficulty will be increased for the unilateral above-knee amputee who would obviously experience more restrictions than the below-knee amputee, but who can with instruction, adjustment and possibly adaptive equipment, manage to enjoy many activities. The multiple amputee would require more adjustments but, again, with proper training and equipment, adjustments can be made to allow them to participate.
Adaptive equipment is readily available for many sports and activities.
Consumer Participation in Amputee Care
Probably the most important factor in the life of an amputee is the artificial limb(s). The amputee must be motivated and stay involved all the way through the process. The first point of contact by the amputee will be with the doctor - usually an orthopaedic surgeon or specialist in physical medicine. Amputees must be prepared to discuss what they expect of their artificial limb(s). In some cases financial considerations will be involved but, even if amputees must dig a little deeper into their own pockets, it will pay dividends to ensure there are sufficient funds to finance their prosthetic requirements. The medical social worker can play an important role at this juncture if outside financing is required.
During the clinic experience amputees have an opportunity to avail themselves of the services of a physiotherapist or occupational therapist. This is an important facet of the prosthetic rehabilitation, particularly if it is necessary to retrain certain muscles.
Also, general physical fitness is important, as wearing an artificial limb means more energy is used and can place additional stress upon the remaining limb and the spine - specifically the lumbar area for lower extremity amputees and the cervical area for those with an amputation of the upper extremity.
In the final analysis, the prosthetist will carry a major responsibility of ensuring that the amputee is properly fitted. A close and harmonious relationship between the prosthetist and the amputee is essential. This will be enhanced if the amputee makes an effort to understand the prosthetist's role, while at the same time showing the necessary perseverance to work together in a cooperative manner to attain a comfortable and functional artificial limb(s).
Philosophy
The amputation of a limb or limbs is translated as the anatomical loss of a major portion of the body - with subsequent loss of function, only part of which (even under the most favourable circumstances) can be restored by an artificial limb. Depending on the individual, amputation can bring with it a host of other concerns, one of which is a loss of "body image." There may be psychological problems and the amputee may show an inclination to wonder about acceptance by family, friends, employer and members of the public.
Coming to terms with being an amputee will require a great deal of courage and, having gained acceptance, that courage can be put to excellent use for the remainder of the amputee's life. Amputees are different, but that difference makes them something special. It is a badge of honour which sets an amputee apart. It can represent an added dimension in life which will bring out qualities which otherwise may have lain dormant. In the area of philosophy, the amputee must adopt a very special feeling for the artificial limb.
The evolution of amputation as a successful technique in the treatment of injuries in World War I resulted in the first large group of amputees in history. Many of those men wore crude appliances. Given the fact that the vast majority of them returned to the unskilled labour force from which they had been recruited, they had, of necessity, to rely on their artificial limbs in order to earn a livelihood. The one significant lesson learned by them - and very quickly - was to develop a sense of pride and ownership in regard to their artificial limb(s). Their secret was to "learn to love" the artificial leg or arm; to think of it as part of themselves.
Sequelae of Amputation
A survey of 19 veterans organizations reported that persons who had worn artificial limbs for 25 years or more showed an increase in the development of certain illnesses and conditions arising from amputation. These include: premature arthritic chances in the spine and remaining limb; circulatory problems; and gastrointestinal problems due to long-standing discomfort, and to ingestion of drugs to control pain.
Medical histories on long-time amputees will undeniably show a very distinct pattern of the sequelae of amputation, which manifests itself in new medical conditions which are secondary to the actual limb loss.
While the development of such sequelae may be inevitable, it can be slowed and possible effects can be minimized, if the amputee, and those responsible for his/her care, will take necessary precautions to ensure that he/she has a properly-fitting artificial limb which is prescribed in accordance with the indications of the amputee and other factors such as his/her physical make-up and his/her employment. It goes without saying that if the amputee can initiate and maintain a program of physical exercise, designed to develop the non-amputated parts of the body and the interrelated muscles, ligaments and tendons, the incapacity of such sequelae can be minimized.