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My Wishlist Sign In Join. Be the first to write a review. Add to Wishlist. Ships in 15 business days. Link Either by signing into your account or linking your membership details before your order is placed. Description Product Details Click on the cover image above to read some pages of this book! In Stock.

Heal Order a signed copy! Make It Happen. From 0 To Properties In 3. Happy Money Zen path to a happier and more prosperous life. Reinventing Your Life Breakthrough program to end negative behaviour Marriageology Art and Science of Staying Together. Amputee self-help groups are further extensions of this approach. Arch Phys Med Rehabil ; Restoration of the capability for gainful employment is an integral part of the patient's recovery.

Kohl notes that amputees may regard unemployment as a "denial of their 'right' to participate in the family's decision making processes. The psychological reactions to amputation are clearly diverse and range from severe disability at one extreme to a determined and effective resumption of a full and active life at the other. English AWG: Psychology of limb loss. Br Med J ; Caine D: Psychological considerations affecting rehabilitation after amputation. Med J Aust ; Can Med Assoc J ; J Hand Surg [Br] ; A division into four stages, however, allows for the highlighting of issues that arise most critically at each point in time.

Among amputees for whom there is ample opportunity to be prepared for surgery, approximately a third to a half welcome the amputation as a signal that suffering will be relieved and a new phase of adjustment can begin. Along with this acceptance, there may be varying degrees of anxiety and concern.

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Such concerns fall into two large groups. First and, perhaps for most persons, the more important are such practical issues as the loss of function, loss of income, pain, difficulty in adapting to a prosthesis, and cost of ongoing treatment. Second are more symbolic concerns such as changes in appearance, losses in sexual intimacy, perception by others, and disposal of the limb. Most individuals informed of the need for amputation go through the early stages of a grief reaction, which may not be completed until well after their discharge from the hospital.

Dise-Lewis suggests that the death and dying paradigm may be usefully applied to the amputees impending loss of a body part, a loss that may threaten the amputee's core identity. The manner in which the surgery is presented by the surgeon can have much bearing on the magnitude and kind of affective response. Mendelson and coworkers recommend that the surgeon paint a realistic picture of the immediate and long-term goals for the patient and his family. Furthermore, a hopeful attitude, detailed explanation of all aspects of the surgery and the rehabilitative process, and full response to all questions especially those that seem trivial appear to diminish anxiety, anger, and despair.

Several members of the self-help group interviewed for this report eloquently described the consequences of failed communication. One who regarded her impending amputation as "losing a member of my family" felt scared "out of my wits" and was repeatedly "horrified. Another, when informed that she would lose her leg, reacted with the thought, "They might as well take off my head.

Those group members who did have the opportunity to receive adequate preparation before the surgery commented on it as having contributed materially to their peace of mind after the event. But the process took time and effort. One member of the group described her reaction as one of ambivalence and oscillation. She switched repeatedly from acknowledging that the amputation was to be expected, and even desirable, to great fear and dread. The period between the surgery and the start of rehabilitation may last a matter of hours or days, depending, among other things, on the reason for the amputation, the extent and condition of the residual limb, and the kind of rehabilitation thought to be feasible.

Psychological reactions noted in this phase are concerns about safety, fear of complications and pain, and in some instances, loss of alertness and orientation. Most individuals are, to a certain degree, "numb," partly as a result of the anesthesia and partly as a way of handling the trauma of loss. For those who have suffered considerable pain before the surgery, the amputation may bring much-needed relief.

This was true for four of the eight members of the self-help group interviewed for this report. In-hospital rehabilitation, in many ways, is the most critical phase and presents the greatest challenges to the patient, the family, and the amputation team.

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It calls for a flexible approach addressed to the rapidly evolving needs of the individual. Initially, the patient is concerned about safety, pain, and disfigurement. Later on, the emphasis shifts to social reintegration and vocational adjustment. A few resort to humor and minimization. Mild euphoric states may be reflected in increased motor activity, racing through the corridors in wheelchairs, and overtalkativeness.

Others make wisecracks such as "You see more when you walk slowly. Eventually sadness sets in. The grief response to limb loss is probably universal and time limited. References 7. Datta D, Psychology of limb loss, letter. The degree to which individuals go through these four phases varies from individual to individual, and indeed, the process often lasts well beyond the period of in-hospital rehabilitation. It is also during this time that some experience phantom limb sensations and phantom pain see the discussion that follows.

Factors that are noted to facilitate adjustment and rehabilitation in this phase are early prosthetic fitting, acceptance of the amputation and the prosthesis by family and friends, and introduction of a successfully rehabilitated amputee to the recovering patient. Bowker JH: Amputation rehabilitation: Critical factors in outcome. J Ark Med Soc ; Almost all the members of the group interviewed for this report agreed that early prosthetic introduction was of the highest importance.

For two women who sustained below-knee transtibial amputations, awakening to find that they had two "legs" in bed was most reassuring.

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The year-old delighted in throwing back the bedclothes and flaunting her artificial leg to her adolescent visitors. Those who did not, for one reason or another, obtain a prosthesis looked forward to it and often fantasized about it. One young man who lost the upper part of his arm as a result of an electrical injury dreamed of becoming a "bionic man. Sadness, although keenly felt, may be concealed. A young mother who lost her hand in a paper shredder tried to put on a happy face for her family.

By all accounts, the amputee's return home can be a particularly taxing period because of loss of the familiar surroundings of the hospital and attenuation of the guidance and support provided by the rehabilitation team. Hence, the attitude of the family becomes a major determinant of the amputee's adaptation.

Family members should be involved in all phases of the rehabilitative process. It is during this phase that the full impact of the loss becomes evident. A number of individuals experience a "second realization," with attendant sadness and grief. Kerstein MD: Group rehabilitation for the vascular disease amputee.

Others may go to the other extreme and vehemently reject any suggestion that they might be disabled or require help in any way. An excessive show of sympathy generally fosters the notion that one is to be pitied. In this phase, three areas of concern come to the fore: return to gainful employment, social acceptance, and sexual adjustment.

Of immense value in all of these matters is the availability of a relative or a significant other who can provide support without damaging self-es-teem. The mother of the young man who lost his arm as the result of an electrical injury spoke of the profound change that occurred in his behavior on his return home.

He regressed to the point that she felt she "had another baby in the house. A middle-aged woman who sustained her amputation after a prolonged period of disability resulting from poliomyelitis found herself one day facing a sinkful of dishes and a request from her husband that she wash them. She did so with tears running down her face and thoughts running through her mind of her husband as cruel and mean.

Later she recognized that it was "the best thing that he could have done for me" and was rather amused to learn that the scenario was contrived by her surgeon and her husband in order to encourage her independence. Equally helpful to her was her children's startled response on learning that their mother was receiving disability benefits. To them, she did not seem to be disabled at all and therefore did not need benefits. In fact, they were intrigued by her new leg prosthesis and expressed the wish that perhaps they too could don and remove their limbs when they grew up.

The group members were unanimous in rejecting the "handicapped" label, and each thought that his affliction was lighter than those of the others. One of them said, "Most well-adjusted people prefer to accept what happened to them" and thus "would not trade with another amputee. A subtle but often overlooked issue is the ease with which the disability can be concealed in social settings.

One group member, for example, remarked that one advantage of a leg amputation over an upper-limb loss was that it could escape detection in such settings. Not surprisingly, those amputees able to resume a full and productive life tend to fare best; this is much easier for those with marketable skills who sustain the amputation while still in vigorous health. For elderly amputees who have limited skills, particularly if they have other medical disorders, the probability of a full return to an active life is considerably diminished.

This can be partially or fully balanced by a more philosophical acceptance of a new, more leisurely way of living and by reduced responsibility and pressure to produce. The feeling that the amputated limb is present and moving is so common as to be regarded as a universal occurrence after surgery.

Pinzur MS: Phantom pain: A lesson in necessity for careful clinical research on chronic pain problems letter. Many, however, continue to have occasional experiences of itching or locomotion, sometimes after residual-limb stimulation. Phantom limb experience has not been noted in those who are born congenially missing a limb and in those who sustain the limb loss at a very early age.

In general, phantom limb sensations present no particular problem. The members of the self-help group had all experienced them at one time or another. Some of them still do, 10 or 15 years after amputation, in the form of an intermittent itch that, curiously, is relieved by scratching the prosthesis.

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Pain experienced in the missing limb is a much more serious issue than phantom limb sensations. In the series of 2, amputees studied by Ewalt and colleagues at the end of World War II, phantom pain was extremely rare and was noted in individuals who also showed psychopathology. The authors wrote that pain "tended to come and to go with psychopathological symptoms, irrespective of what type of external treatment was carried on. Parkes found that phantom pain could be predicted by certain immediate postoperative phenomena such as the presence of residual-limb pain, prior illness of more than 1 year, the development of residual-limb complications, and interestingly, other factors not related to surgery e.

Sherman et al. Sherman RA: Stump and phantom limb pain. Neurol Clin ; In a study of 24 male amputees, Arena et al. Reference 1. In the self-help group, only one member reported persistent phantom pain accompanied by residual-limb pain. He detailed long and complicated procedures after the initial amputation, all designed to relieve his phantom pain. These included nerve stimulation, acupuncture, residual-limb revision, and even spinal block. At the time of the interview, his only relief came from the use of oxycodone Percodan on a regular basis.

So distressed was he by his pain that he had repeatedly entertained the fantasy of taking a gun and shooting his "leg" off in order to rid himself of it. Other members experienced fleeting episodes of pain described as an electric shock sensation or, as one put it, "like putting your finger in a [volt] outlet. Two mentioned aching when the weather changed and rain was approaching. Several members of the group spontaneously volunteered the view that the support of the family members was of great help in reducing phantom pain when it occurred.

Amputation, of necessity, requires a revision of body image. This is reflected in dreams and in the draw-a-person test. It has been reported that amputees who adapt well draw a person with a foreshortened limb or without any limb at all, whereas those who adapt poorly draw the missing limb larger than the opposite limb or with increased markings.

In one prospective study of 67 patients who had suffered severe hand trauma, much of the dreaming included nightmares of further injury or incapacity. It has been suggested that the amputee, in a sense, must contend with three body images: intact, amputated, and with prosthesis. Individuals who are unable to accept the last two are likely to reject the prosthesis and to experience difficulty in functional and social adjustment.


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Even when considerable success is achieved in functional restoration, there often remains some shyness about revealing the amputated body to others. The members of the group confirmed these observations and saw a connection between accepting one's new bodily configuration and accepting a prosthesis. One viewed her body more positively after amputation because her prosthetic leg worked better than the leg that she had lost. Most had come to regard their prosthesis as part of themselves, at times revealed in dreams.

Nonetheless, despite their successful adaptation and acceptance of the new body image, all of them continued to experience self-consciousness in social situations. For example, they tended to walk more clumsily when they felt observed by other people in public. They described a pool party to which they had invited their friends and relatives. Significantly, the only people who actually went into the pool were the nonampu-tees. This is an area of some anxiety for most amputees, especially those who are young and in the prime of life. References 8. Whereas a prosthesis can provide functional restoration and some return to normal appearance in most situations, it is absolutely of no use in the sexual area.

A comparison with the sexual experience of paraplegics is instructive. Those who suffer paralysis still enjoy sensation from the affected part and continue to see their body as intact. They may also entertain hope of a return of function in the affected part. The amputee enjoys none of these advantages. Among the members of the group, sexuality was an important issue that had to be faced by each of them. Most reported success in facing it, mainly attributed to the supportive response of the partner.

Yet, despite verbal and behavioral reassurance of the partner, several spoke of lingering difficulty in seeing themselves as adequate sexual partners rather than as repulsive sexual "freaks. This was not the case for the year-old, who had expressed the concern that no boy would ever look at her. She lived for 2 years after her surgery but did not have occasion to go out on a date. She maintained the hope that one day she would do so and was greatly comforted by her brother-in-law, who told her that her amputation would "weed out the creeps.

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Six principles of psychological management of the amputee are implied in the foregoing discussion. Although it is hard to prove statistically that preparation has a bearing on ultimate outcome, References 5. Anticipating and dealing with the various issues that patients will face, even if these are not raised by the patients themselves, is of great help. Such issues include disposal of the limb, relationship with friends and family, degree of functional loss and return, work capability, costs of surgery and rehabilitation, sexual adjustment, and social impact.

It is important to present the amputation as a desirable lifesaving or life-improving option rather than as a last resort or an indication of failure. There is indeed some evidence in the literature that the quality of life can sometimes be improved by an amputation as compared with limb-sparing treatments.

Surgery ; It should be obvious to the readers of this book that good technique is of the essence.

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What perhaps is not so obvious is the need for the senior surgeon to perform the surgery or to be involved intimately in its performance. It is an error to relegate this procedure to inexperienced hands. As Bradway and associates wrote, "In our program, the senior surgical attending physician is directly involved in the performance of all amputations and supervises the entire process of amputation rehabilitation.

There is little doubt that the earlier the prosthesis is applied, the better are the results in terms of functional capacity and psychological adaptation. Reference 9. Int Disabil Stud ;