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REHABILITATION IN PRACTICE
Pre prosthetic mobility: The amputees’ perspectives
D. STOKES1, J. CURZIO1, A. BERRY2, E. BACON2, M. MORTEN2 & L. BARKER2
1London South Bank University, and 2Harold Wood Disablement Services Centre, Romford, Essex, UK
Accepted November 2007
AbstractPurpose. It is considered good practice that amputees remain in a wheelchair until fitted with a prosthesis. However, thispractice is not evidence based. In the first of a series of studies in pre prosthetic mobility, this study will explore the individualamputees’ perspective.Method. A total of 25 participants from a regional disablement service centre were interviewed focusing on their experiencesof getting around the home post discharge. The transcripts were coded for types of mobility methods used and the contentanalysed.Results. Whilst the wheelchair was the predominant method of mobilizing, this was not viewed positively by amputees.Crutches were frequently used, even if crutches were not provided by therapists. Participants cited space and choice asreasons behind this, in particular the psychological impact of being ‘stuck’ in a wheelchair. Other methods cited includedcrawling and bottom shuffling.Conclusion. Amputees do not always comply with therapists’ advice and frequently use other methods of mobilizing as amatter of choice as well as necessity. The risk factors associated with these methods is a priority for future research.
Keywords: Amputation, mobility, qualitative analysis, wheelchair
Introduction
Following an amputation and in the period before
patients are fitted with a prosthesis there is the issue of
limited mobility. At present there is no evidence-based
research on this issue. When the physiotherapy guide-
lines were published in 2006 by British Association of
Chartered Physiotherapists in Amputee Rehabilitation
[1], this absence of any published literature was
acknowledged and consequently the guidelines for
post-operative mobility were based on consensus
opinion gained by the Delphi process. According to
guideline 6.4.5: ‘mobility pre prosthetically should be
in a wheelchair unless there are specified reasons to
teach a patient to use crutches/zimmer frame/ rollator’.
The theory behind the guidelines is that hopping
with an aid is inadvisable for five reasons [2]: (i) It is
thought that hopping may impair healing and cause
swelling of the residual limb; (ii) during hopping there
is an increase in ground reaction force and those with
a dysvascularity will be at risk of damage to the intact
foot; (iii) prolonged hopping may lead to postural
defects and risk of careless knocking of the residual
limb; (iv) there is the perceived safety risk and lack of
confidence in the elderly amputee population; and
(v) it is considered that bilateral amputees who hop on
one prosthesis may cause excessive stress to the
residual limb and are considered unsafe. However,
there is a professional dilemma when planning
discharge from hospital as some amputees’ homes
may not be easily adapted for wheelchair use and
some amputees are reluctant to use the wheelchair.
Anecdotally, amputees do report hopping and
using other methods of mobility, with and without
the teaching and support of health professionals.
However, there has been no published investigation
into the impact of pre prosthetic mobility issues on
the individual. This study is the first of a series and
will focus on the amputees’ perspective on mobility,
in particular, the individuals’ experiences and solu-
tions to the pre prosthetic mobility. Future studies are
under way and being planned to investigate
Correspondence: Dr Dawn Stokes, Research Fellow, Faculty of Health and Social Care, London South Bank University, Havering Campus, Harold Wood
Hospital, Gubbins Lane, Romford, Essex, RM3 0BE, UK. Tel: þ44 (0)2078155926. Fax: þ44 (0)2078155906. E-mail: [email protected]
Disability and Rehabilitation, 2009; 31(2): 138–143
ISSN 0963-8288 print/ISSN 1464-5165 online ª 2009 Informa Healthcare USA, Inc.
DOI: 10.1080/09638280701795543
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the therapists’ perspectives as well as exploring the
physical effects of hopping with and without an aid.
This study will use a qualitative approach to allow
amputees to talk about the different methods they
employ to get around the home in this pre prosthetic
time period. The interviews will also explore the
reasons behind the methods adopted.
Method
Participants
Participants were recruited from a local regional
Disability Services Centre. Ethical approval was
obtained from the Local Regional Ethics Committee
and the Primary Care Trust Research and Develop-
ment department. Twenty male and five female
participants were recruited, aged 32 – 83 years,
median 60 years. Table I summarizes the amputation
characteristics of the participants.
All participants were provided with a prosthetic
limb. Three participants were discharged from hos-
pital to a place of rehabilitation, two of whom
because they were unable to return to their previous
place of living and were waiting for a more suitable
accommodation.
Materials
A topic guide of questions was devised for this study
and included questions such as ‘Can you tell me
what it was like getting around your place of
discharge?’ And ‘Did you use a wheelchair to get
around the home? (See appendix) However, a
potential problem arose when, to the direct question
on hopping, a participant answered:
No it wouldn’t work at all I’m too heavy too heavy in the
body. (p7).
However, later in the interview the same partici-
pant said:
I’m in the kitchen, my kitchen is straight, I get up on one
leg and bounce along, hold on to the work surface. (p7).
It was felt that there was perhaps a potential
confusion in terminology. The interviewer there-
fore clarified phrases using several alternatives, for
example both phrases ‘hop’, and ‘moving around
standing on your good leg’ were used. In
addition, the interviewer picked up on related
comments by the participants, such as when they
talked about the house layout, whether there were
steps which would cause difficulties with wheel-
chair use.
Procedure
Over a period of three months, staff at the disable-
ment services centre identified potential participants
from the appointment list for the following week.
Staff contacted the client by telephone to see if they
would be willing to consider participating. An
information sheet and consent form was then sent
by post to their home address. Participants were
interviewed in a private office at the centre, fitting in
with their existing appointment. The interviews were
recorded for later transcription.
Results
Transcripts were made of the interviews which
ranged from 7.33 min to 30.26 min with a mean of
18.96 min. The content of these transcripts were
coded for methods of mobility. The initial codes
used were based on anecdotal reporting of amputees
to therapists which prompted this study; wheelchair
use, crutches use, hopping without walking aid and
to ensure that all methods of mobilizing were
included a code of other methods was used. Two
raters who had not been involved in the interviews
verified the reliability of the coding by coding a
random selection of the transcripts.
An overview of all categories looking at the
predominant methods of mobilizing used was taken
before further analysis exploring participants’ per-
spectives on individual methods of pre prosthetic
mobilizing regardless of the predominant method
used.
Predominant method used
An initial exploration focused on what participants
implied was their predominant method of mobilizing
before they were provided with a prosthetic limb.
This data is presented in Figure 1.
As can be seen the predominant method used was
the wheelchair. However, nine participants within
this predominant wheelchair user group used other
methods of mobilizing. Five participants used
crutches occasionally, three hopped, one crawled
and one used a shower chair.
Table I. Characteristics of participants.
Level of
amputation
Cause of
amputation
Time since
amputation
Time to
casting
14 Transtibial 19 Dysvascularity Range
1 – 59
mths
Range
1 – 14
mths
9 Transfemoral 3 Trauma Mean
17.52
mths
Mean
4.5
mths
2 Bilateral 2 Neoplasia
1 Infection
Amputees’ perspectives 139
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Wheelchair use
All the participants were issued with a wheelchair,
although three participants had delivery delays
between 1 and 6 weeks. Seven participants talked
about the ease of learning to use the wheelchair, ‘I
took to the wheelchair really well’ (p10). In contrast
one wheelchair-using amputee talked about the
difficulties he had with acquiring the skill. ‘You
think it’s simple, but it’s not that simple’. (p13).
Seven participants commented on how restrictive
they found a wheelchair, ‘I’m restricted to what I can
do and where I can go’. (p16). When asked what it
was like getting around the house, 11 participants
commented on the limited physical space in the
house/flat, whilst six participants commented on how
spacious their houses were. Two had fortuitously
recently moved into homes where the previous owner
was disabled, and had not converted the properties
before the amputation.
Other people’s perception of the amputee in the
wheelchair was another recurring theme, although
this was not cited as a reason for using other forms of
mobility. Several participants used the phrase ‘sec-
ond class citizens’ whilst others illustrated this feeling
with examples.
Sitting in the wheelchair people would be talking over
my head, a prime example was one of our friends come
round . . . er we were going shopping . . . walking around
and rather than say to me, oh how are you Dave, she
went ‘oh how’s he been, has he been alright?’ And I’m
thinking, hang on, I’m here you know, and it was it
really got to me and I know she wasn’t joking. It sort of
threw me a little bit and that’s why I’ve got this aversion
to using the wheelchair really umm. (p2)
Using a wheelchair was not viewed very positively.
Alright I got the wheelchair and I was sitting there
thinking this oh this is my life now. Bloody wheelchair.
(p9)
Throughout the interviews negative words and
phrases such as ‘frustrated’, ‘nightmare’, ‘awkward’,
‘exhausting’, ‘monotonous’, and restricted,’ were
used to describe wheelchairs. Fifteen participants
talked about wheelchairs in a negative way, eight
participants used no adjective or made any emotive
comments. There were only two positive comments,
one participant described the wheelchair as easier
and one described it as practical.
Crutches use
There appears to be no consistency in the advice
given by therapists to amputees post lower limb
amputation regarding mobilizing on crutches. Five
participants were not able to recall being given any
advice. Ten participants were given crutches
although not always with advice and instructions on
using them. Ten participants were told categorically
not to use crutches or hop, and even when they asked
to be given crutches this was met with a refusal.
However, this led to participants using other
methods to obtain crutches. This interview extract
Figure 1. Predominant methods of mobilizing.
140 D. Stokes et al.
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is from a 73-year-old man talking about when he
asked his physiotherapist for crutches;
p22: They wouldn’t have it at all
I: No, Have you tried using crutches before in your life?
p22: Er, well to be honest, my brother has a couple of
crutches, he’s more disabled than I am and er, I er, but I
didn’t get on with them, I only tried but I didn’t I didn’t
use them really.
I: So you had a go, to practice, to see if you could do it.
p22: Yes, to see if I could
I: But you could have done with a bit of training to
p22: Oh yeah I think so.
In these circumstances there were no checks as to
whether the crutches themselves were suitable. The
participant above then found other methods of
getting around that will be presented later.
Using crutches was what some considered a
necessity.
I must say I wasn’t that inaugurated with the crutches
really but there are times when you do need them. (p24).
Two main reasons were apparent from the
transcripts. Firstly space,
No, I don’t have the space in the house to use a
wheelchair. (p4).
Even when the physical space is there, when there
are other people the physical space can be further
compromised:
I find it restrictive going round in the wheelchair, in my
house, basically because there is five of us in a three-
bedroom house there is not a lot of room around, so I find
it a lot easier to move around on the crutches myself. (p2).
The second important reason identified from the
transcripts for using crutches was labelled choice;
this participant was able to access the toilet with a
wheelchair but chose to use crutches:
Because it was more convenient getting in and out of the
loo. (p20).
Sitting in the wheelchair for long periods also
became uncomfortable,
Well simply because of the discomfort of the chair after,
you know, a long time, you know. (p15)
In addition to the physical choice of crutch use, the
psychological impact of using crutches was well
articulated by one participant:
I feel if I’m using crutches it is a psychological thing. If
I’m using crutches I don’t feel like a cripple, in the fact
that I’m upright and I’m standing on the same level as
everyone else and I can get around . . . . On occasion it
was just sort of get up off the sofa and just sort of
standing a little while, staring out the window, things
like that you know being able to do that and look at a
different view, you know, and from the bed to the
window in the bedroom, or from the sofa to the patio
door and just look out and watch silly things like
squirrels running up and down the fence. (p2).
None of the participants used crutches to travel
long distances, mostly it was moving around the
home. The participants seemed to make their own
risks assessments of when or whether they should use
crutches. A non-user described his attempt:
I tried to walk on crutches and fell over so after that that
made me nervous so er, er, I wouldn’t try to walk
again . . . I was shaking all over the place. (p11).
Wet and slippery falls are an obvious risk and
participants talked about this as a factor in
crutch use,
We got the shower which I use and obviously that
is when you are most vulnerable slippery surface,
one leg, crutches, that’s when I am most vulnerable.
(p18).
. . . slippery leaves, that time of year it was October . . . so
you know you get damp weather. (p25).
For some amputees there was a pre-existing level
of expertise and this may diminish the potential risks.
Two participants, one with 13 years’ experience of
crutches and the other with five years, felt their
ability on crutches was good and couldn’t under-
stand why they shouldn’t use them.
I am proficient on them. (p15); I was very confident on
them. (p20)
Hopping was viewed as distinctly different from
using crutches by the participants and was used by
ten participants. Hopping seemed to cause a greater
physical strain than using crutches.
. . . . on the crutches of course, you are not jumping, you
are really walking normally except for using the two legs
you are using your arms and one leg, so there’s no,
there’s no . . . jarring motion (referring to hopping) so
that’s fine. (p20).
I did hop without me crutches, but er . . . most of the
time it was with me crutches, I was quite happy to get
about . . . hopping hurt more than crutches, ’cos you
tend to strain your body more. (p25).
Amputees’ perspectives 141
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Other methods
The amputee that neither used crutches or wheel-
chair as the predominant method of mobility
describes how he went around the house:
Yes, I walked on my hands and knees; I also had one of
these office chairs with wheels on the bottom, the kids
use them for their computer, so I started going around
on that down the long passageway to the, um, to the,
um, downstairs toilet and the kitchen and in the kitchen
I would just stand and hop into the dining room. (p6).
Whilst not the predominant form of mobilizing,
five participants also used their hands and knees to
go around the home and this included the gentleman
presented earlier who was refused to be issued with
crutches.
On hands and knees, and my knees got very, very sore
and so I bought myself a couple of these, er, kneeling
pads, but um . . . (p22).
Another method talked about by four participants
was shuffling along on their backside, predominantly
used on stairs.
. . .going up on me bottom and go along the landing to
get into bed. You’ve got to try these things, you’ll never
know. (p8).
During the interviews one participant with many
medical problems including scoliosis who could not
use crutches, hop, or crawl easily came up with a
novel, yet highly dangerous method of mobility.
No I didn’t use crutches I basically used my wheelchair
as my lower half of my leg which was kneeling on the
chair and pushing, pushing around that way. (p3)
Discussion and conclusion
Using qualitative methods for this study enabled
information to be collected in a flexible way. In some
interviews there appeared to be inconsistencies,
which on reflection can be interpreted as misunder-
standing of terminology, for example, the participant
who denied hopping, yet ‘bounced’. This has
implications for practice, notably history taking,
ensuring that the information by amputees accurately
reflects their experiences. In addition, amputees are
learning new terminology connected with the pros-
thesis and gait retraining, and so therapists may need
to clarify amputees understanding.
The majority of amputees used the wheelchair as
the predominant method of mobilizing, but only
eight participants used the wheelchair as the only
method of mobilizing. Wheelchairs were considered
easy to use, but were not viewed positively by most
participants. Problems with manoeuvring space and
other people’s perception were the main themes that
emerged, nonetheless, the necessity of a wheelchair
was acknowledged. However, it does appear that a
large proportion of amputees will use alternative
methods of mobilizing at some time in this pre
prosthetic time period.
Whilst the guidelines [1] indicate that in certain
circumstances teaching of using walking aids may be
necessary, participants did not report consistency in
advice given. Current practice of discouraging other
methods of mobilizing even when a client asks for
support does lead to amputees engaging in perhaps
risky behaviours using equipment which has not been
issued and adjusted to an individual’s specification,
and for which they have not received suitable
instructions or training.
Nearly half of the sample had access to crutches
and the two main reasons identified from the
transcripts were space and choice. When assessing
homes for discharge attention needs to be paid not
only to the physical aspects of the property but the
implications of multiple people living in the home
and how this will impact upon wheelchair manoeuvr-
ing space. The reason of choice seemed important to
participants, the convenience factor of hopping
around on crutches, as well as avoiding feelings of
being a disabled person in a chair.
The risk factors associated with mobility following
an amputation were recognised by participants who
talked about surrounding contexts when making
decisions about transferring, using crutches and daily
activities. Where participants had been using crutches
for a long time before the amputation they were quite
adamant that their ability was sufficient. However,
the risk factors outlined by the standard text [2] relate
more to healing of the stump and potential damage to
the intact limb and these were rarely raised by
participants who were more concerned with falling
when using crutches. The evidence for these risk
factors needs investigation to determine if all ampu-
tees are at risk of damage when using crutches or if
some amputees may be taught to use them safely.
Whilst some therapists would equate hopping with
use of crutches, this study found that participants
differentiated between the two with the physical
effects they felt on the body when hopping as
opposed to using crutches. Amputees talked about
short journeys both in time and distance. Hopping
was often one or two hops to get to a final destination
like the toilet. Therapists need to bear in mind that if
use of crutches is being discouraged, amputees may
resort to hopping, which is perhaps more dangerous
both in terms of risks and potential impact with the
jarring motion.
142 D. Stokes et al.
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Two other methods of mobilizing were reported by
several participants. Crawling around on hands and
knees like a baby is not conducive to client dignity.
The gentleman who was refused crutches by his
therapist went out and bought knee pads, which
indicates that he was crawling frequently; it should
be noted that he was not a young amputee, he was 73
years old. There has been no research on the effect of
crawling on wound healing. In addition, this motion
may cause damage to the intact limb in dysvascular
amputees. Perhaps crutch use would be preferable.
Shuffling on the bottom is also a technique used by
pre walking infants. However, it may be considered a
safe means to negotiate stairs and is taught by some
therapists.
The final example presented in the results section
indicates the importance to amputees of being
alternately mobile even if it involves dangerous
methods. This is a challenge to therapists who must
advise and ensure client safety. Current practice
leads to a conflict between patient choice and
therapists’ guidelines. It is clear that not all amputees
need to use other methods of mobilizing, but many
choose to.
In conclusion, it is clear from this initial research
that amputees choose to mobilize apart from the
wheelchair; to go upstairs, even when it is not strictly
necessary, to be upright, or to be independent.
Further research is essential to explore the implica-
tions of this ‘patient choice’.
References
1. Broomhead P, Dawes D, Hancock A, Unia P, Blundell A,
Davies V. Clinical guidelines for the pre and post operative
physiotherapy management of adults with lower limb amputa-
tion. London: Chartered Society of Physiotherapy; 2006.
2. Engstrom B, Van de Ven C. Therapy for amputees. London:
Churchill Livingstone; 1999.
Appendix
Interview topic guide
I’d like to ask you about what it was like going out of
hospital after your amputation.
. How long did you stay in hospital when you
first had your amputation?
. Where were you discharged to?
. Thinking back to your first week at x can you
tell me about it?
. Can you tell me about first arriving at place of
discharge?
Can you tell me about something in particular that
happened when you first got to your ‘place of discharge?’
. Can you tell me what it was like getting around
your place of discharge?
. What difficulties did you have getting around
place of discharge?
. Did you use a wheelchair/gait aid?
. How often?
. Did you need a lot of help to get around the
house? Who helped?
Can you tell me about someone in particular who
helped you?
. Did you fall?
� Were you wearing your prosthesis at the
time of the fall?
� What was the cause of your fall?
� Were you injured?
Can you tell me about one fall in particular?
. Did you hop at all?
� How much did you hop?
� Where did you hop to?
� Could you only get there by hopping?
� Were you told by a member of staff not to
hop?
� Were you taught to hop by your physio/or
any member of staff?
Can you tell me about one time in particular that you
hopped?
. How well do you think you recovered from
your amputation?
Amputees’ perspectives 143
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