Multiple Disabilities Challenges

Bilateral amputees are relatively rare. In fact, within the whole United Kingdom there are only two individuals a year who become bilateral upper limb amputees. Whereas amputees with one limb can often rely on the sound limb to perform some more difficult tasks and help compensate for the missing limb, bilateral amputees do not have this capability and must rely on prostheses to help them accomplish many tasks. However, many individuals with either congenital bilateral upper limb deficiencies or children with bilateral upper limb amputations may elect not to use a prosthesis at all. Instead these amazing individuals may rely on their lower limbs and feet to serve as functional upper limbs and may only rely on a prosthesis for cosmetic purposes. No matter whether the individual is young or old though, it is the amputee himself who must determine when it is most appropriate to first try a prosthesis or succeed by using compensatory strategies like the lower limbs.

Because they are relatively rare, individuals with this disability should be referred to facilities that are familiar with treating bilateral amputees and are comfortable with fitting them with the appropriate prosthesis. Individuals can then be trained by experienced occupational therapists on how to perform many ADLs. Some of these activities like bathing can be done without a prosthesis but may need adaptive equipment to be done successfully. For example, a scrubber attached to the wall makes for an ideal way for the bilateral upper limb amputee to wash his back or hair. These individuals can then use a combination of their feet and residual limbs to wash the rest of their bodies. Occupational therapists can then train the amputee on how to use a prosthesis with adaptive equipment as needed for other activities. It is also a good idea to educate the family members during this time, since many assume the amputee will need total assistance only to find that the bilateral amputee is able to do most if not all activities of life independently. These activities include being employed, caring for a child and playing recreational sports.

Body-powered systems are the most appropriate type of prosthesis for bilateral upper limb amputees, although some elect to use a combination of body-powered and electrical-powered. These are often known as hybrids. Usually one terminal device is used for more delicate activities such as writing, and a sturdier terminal device is used for more manual and physically demanding activities like lifting and moving objects. For example, split hooks of varied sizes with different numbers of rubber bands are used to control the strength of the grip. Some amputees may elect to use only one prosthesis and rely on the tactile stimulation and function of the residual limb on the opposite side to help with many tasks. Usually bilateral upper limb amputees are more likely to use a prosthesis than one-sided amputees who elect to use their normal limb to perform many of the normal activities. The combinations of prosthetic components that can be used in bilateral upper limb amputees can be numerous.

Bilateral lower limb amputees may use various strategies to get around. Because of the increased cardiac demand needed to walk with bilateral lower limb prostheses, some choose to use a wheelchair to meet their mobility needs. Stubbies are alternative prostheses that a bilateral above-knee amputee could use for walking short distances (Figure 89). The advantage of using stubbies is that they do not require a large amount of balance compared to regular prostheses. Cosmetically, though, they are sometimes considered unacceptable.

Amputees who also have a history of other disabilities or limitations may not be able to use a prosthesis to regain mobility. For example, people with an upper or lower amputation and also hand or leg weakness from a stroke or a neuropathy may have a difficult time putting on or using a prosthesis. For example, a person with a history of a stroke may have too much weakness in the arm or leg to don a prosthesis. Or he may have weakness in one leg in addition to an amputation on the opposite side, which may significantly impair the amputee’s ability to walk.

People with a new amputation who have had a stroke are more likely to walk after a lower limb amputation if they were able to walk before their stroke. However, having a lower limb amputation combined with a fairly severe stroke, can inhibit one’s ability to perform a single-leg-pivot transfer which has been shown to correlate with one’s inability to do ADLs independently. This does not mean that a prosthesis should not be given to the person. Even a simple prosthesis can help caregivers transfer the individual from a chair or toilet. This activity could be more physically demanding if a prosthesis was not used at all.

Finally and surprisingly, the ability to control one’s urine (continence) after having a stroke has been thought to be one of the biggest predictors of success for independently performing ADLs with a prosthesis. Again, every individual is unique and the decision to be fitted with a prosthesis needs to be discussed with the individual, family and the rehabilitation team.