Posted 11th August 2010
The devastating earthquake in Sichuan, China on 12 May 2008 left thousands of survivors requiring medical care and intensive rehabilitation. In view of this great demand, the Chinese Speaking Orthopaedic Society established the "Stand Tall" project to provide voluntary services to aid amputee victims in achieving total rehabilitation and social integration.
This article has been sourced from the Journal of Orthopaedic Surgery and Research
The devastating earthquake in Sichuan, China on 12 May 2008 left thousands of survivors requiring medical care and intensive rehabilitation. In view of this great demand, the Chinese Speaking Orthopaedic Society established the "Stand Tall" project to provide voluntary services to aid amputee victims in achieving total rehabilitation and social integration. This case report highlights the multidisciplinary rehabilitation of a girl who suffered thoracolumbar vertebral collapse and underwent bilateral transtibial amputation. The rehabilitation team was involved in all stages of the care process from the pre-operative phase, through amputation, into prosthetic training, and during her life thereafter. Despite this catastrophic event, early rehabilitation and specially designed bilateral prostheses allowed her a high level of functional ability. The joint efforts of the multidisciplinary team and the advancement of new technology have revolutionized the care process for amputees.
The patient, a 14-year-old girl living with her family in Sichuan, was a Form 3 student studying in Chui Yuen Secondary School at the time of the earthquake. Her premorbid level of functioning had been independent for all personal daily activities. She was outgoing and actively participated in sporting activities before the incident.
When the earthquake occurred, the patient was having a lesson at school. Her whole life was dramatically changed in that short period of time. The building collapsed and she was trapped underground for more than 20 hours. She was eventually rescued and sent to a local hospital. However, as she was trapped for so long, her spine and bilateral lower limbs suffered severe injuries. She was diagnosed with thoracolumbar vertebral collapse and both of her legs later became necrotic. A posterior spinal fusion and bilateral below knee amputations were performed on 12 June 2008
The first assessment of the patient was performed at Nanfeng Hospital, Guangzhou in June 2008. The patient was depressed and lacked motivation for exercise training. Her wounds had not yet healed and both stumps remained obviously swollen. She also experienced phantom limb pain and sensitization.
Due to prolonged bed rest, she had developed sacral sores and bilateral hip flexor contractures. Her bilateral lower limbs mobility and power had also decreased. Attributable to pain and weak trunk musculature she was highly dependent on medical staff, requiring manual assistance for bed mobility and transfers. She could neither sit unsupported nor tolerate prolonged supported sitting. This patient then underwent stages of rehabilitation and functional training under the rehabilitation team.
Rehabilitation following amputation is a complex long-term process and is the responsibility of a multidisciplinary team, with the patient focused at the centre. The core members of the rehabilitation team include physicians, nurses, physical therapists, occupational therapists and prosthetic experts. Psychologists, social workers and vocational counselors can also be called in as needed. The patient is at all times considered an active, equal member of the team and has the opportunity to explain his or her needs, preferences, and goals.
The multidisciplinary team implements comprehensive programs to meet the physical, psychological and functional needs of the client. Different professionals demonstrate competence in areas of expertise in planning and implementation of treatment process. Working with a specialist team produces the best outcome for an individual who has undergone life-changing amputation surgery.
The rehabilitation team was involved at all stages of the process, from the pre-operative phase, through amputation, into prosthetic training and during her life thereafter. The course of rehabilitation for this patient was focused into 8 stages namely post-operative, pre-prosthetic, prosthetic prescription/fabrication, prosthetic training, functional training, community reintegration, recreational/vocational rehabilitation, and long-term follow-up.
1. Post-operative: providing emotional support, promoting limbs hygiene and expediting wound healing, maximizing limbs shrinkage and stumps shaping, controlling phantom pain and alleviating phantom sensation
2. Pre-prosthetic: improving joint mobility and muscle strength, facilitating independence and exploring prosthetic options
3. Prosthetic prescription/fabrication: team consensus on prosthetic prescription
4. Prosthetic training: prosthetic management to increase wearing time and functional use
5. Functional training: advanced skills and daily activities training
6. Community reintegration: resumption of family and community roles, developing healthy coping strategies
7. Recreational/vocational rehabilitation: assessment and training for recreational activities, assessment of further education needs or job modification
8. Long-term follow-up: regaining emotional equilibrium, lifelong prosthetic, medical and functional assessment
The patient's latest assessment and outcome evaluation were completed in the Prince of Wales Hospital, Hong Kong. There, the patient was invited to run on a treadmill, go through isokinetic and balance training. She has a much improved mood and was motivated to undergo exercise training and recreational activities. Her wounds had healed and the bilateral stumps were in good condition and shape. The phantom limb pain and sensitization was significantly reduced. She was no longer disturbed by phantom pain and scarring discomfort.
She has regained her joint mobility and muscle power. She was independent in transfers and could walk and even run independently on level and uneven ground. She could walk for hours and her facial expression showed no signs of fatigue. She managed stairs with ease, and has demonstrated high ability in balance and coordination. She has resumed her normal school life and participated in various outdoor activities. She is satisfied with her condition and enjoys her new life. A long-term follow-up on body image and compliance of prosthetic use will be conducted periodically.
This patient is a very active and optimistic girl. She has shown an extremely positive attitude with full participation throughout the rehabilitation process and her progress has been profound. Her positive attitude brightens up everyone around her. She has already returned to school with an active school life and effectively manages her daily activities. During the first year ceremony of the Sichuan earthquake, she was invited to come to Hong Kong by "Stand Tall", and was interviewed by various media outlets, including the international news agency CNN. There she presented her views on the injury and rehabilitation process.
Despite this catastrophic event that led to the injury of thoracolumbar vertebral collapse and bilateral limbs loss, early rehabilitation and specially designed bilateral prostheses successfully prepared her to stand again. The team approach of the medical and allied health staff working in a coordinated fashion is of considerable value in the rehabilitation process.
The joint efforts of the multidisciplinary team and the advancement of new technology have revolutionized the care process for amputees. The loss of a limb may not necessarily impair a person's opportunities; instead the motivated ones have more incentives in brightening their prospects and lives.
The full referenced version of this article can be found by following this link;