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Tuesday, July 19, 2011

Psychosocial implications of amputation

Psychophysiological Implications of Amputation
James Price, PhD, CPO, FAAOP

Disease and Amputation
Common medical knowledge implies that amputation due to disease is the ultimate result of insufficient vascular supply to the affected limb. The major contributor to vascular insufficiency resulting in limb amputation is diabetes (American Orthotic and Prosthetic Association, 1999). This section will focus on the physiologically and psychologically complicating effects of diabetes, as well as the implications of peripheral vascular disease as the two primary causes of limb amputation.

Vascular disruptions relating to the diabetic foot include neuropathic ulcers, gangrene, charcot arthropathy, and microcirculatory disturbances resulting in uncontrollable edema. Each disruption commonly results in amputation of the affected limb because of the structural breakdown of body tissues and the inability for the tissues to regenerate due to compromised blood supply. Ulcers present as open wounds that cannot heal. Gangrene is necrotic tissue that proliferates if left unchecked. Charcot arthropathy is a collapse of the skeletal structure of the foot. Edema due to microvascular disease constricts circulation, which can eventually lead to any of the aforementioned disorders related to diabetes. In each of these cases an absent pulse in the foot, followed by ischemia and ultimate tissue breakdown, precede invasive treatments.

Other risks associated with diabetes include peripheral vascular disease and coronary thrombosis. Coronary thrombosis is the leading cause of death in diabetics (Edmonds & Foster, 1994). Those who suffer renal disease preceded by diabetes are predisposed to amputation after kidney transplant. Lifestyle-oriented risk factors for amputations in diabetics are smoking, obesity, insulin sensitivity, blood glucose control, and lipoprotein patterns (Grenfell, 1994). Grenfell emphasizes haemostatic function as the culprit in diabetic disorders. Stagnancy in the bloodstream exacerbates the nature of the disease in that the accumulation of sugar in the blood and the attachment to proteins is the root problem.
Although diabetes is the major contributing malady of those who suffer limb loss, and is primarily responsible for vascular insufficiency leading to amputation, vascular disease does present apart from diabetes and ranks second as a cause for amputation by disease (American Orthotic and Prosthetic Association, 1999). The underlying problem in vascular disease is venous stasis, a condition similar to the diabetic circulatory condition, yet being manifested void of the inefficient processing of insulin (McCarthy, 1983). In venous stasis disorders there is stagnation of blood, bacterial growth, and ultimately infection. Lymphatic edema is a complicating condition of venous stasis and presents another similarity to the diabetic vascular condition. Predisposing factors to nondiabetic peripheral vascular disease are diet (high fat intake), lifestyle deficits (lack of physical exercise), and genetic influence such as the hereditary predisposition to a high percentage of low-density lipoproteins (bad cholesterol).

Educators should:
1. Advise the client concerning the ubiquitous nature of diabetes and its affect on all body structures.
2. Promote awareness of the importance of positive lifestyle habits; including proper diet, sleep, and exercise.
3. Instruct the client on proper skin care or refer the client to someone who can provide guidance concerning skin care issues.

Psychological and Biopsychosocial Issues and the Phantom Phenomenon
Psychological issues of those suffering diabetic conditions are categorized by Jacobson and Leibovich (1985) as (a) psychosocial stress, (b) diabetic control, (c) environmental supports and importantly, (d) predictable phases of life crises. Jacobson and Leibovich present a model for understanding psychological issues faced by those with diabetes. The model includes the consideration of the risks that are present, personal abilities, and coping, and determines the individual’s predisposition to being resilient or symptomatic. Individuals who follow the pattern of resiliency are able to better cope with the predictable phases of life crises that are associated with diabetes.

Gray (1983) examined social aspects of peripheral vascular disease. These categories can be added to psychosocial issues important to the diabetic and are pertinent constructs due to the influence of psychological conditions on pain perception. Aging and disease, education, religious attitudes, fearful attitudes, frustration, and resignation are considered instrumental in the resolution of social issues.

Once disease has progressed to the point that amputation becomes necessary, it is reasonable to expect that the victim of limb loss will have significant and complex issues to resolve. The pain associated with the disease has been replaced and sometimes coupled with the pain of surgery, and the psychological implications of disease have become psychological implications of body image and disease (Breakey, 1997). One of these issues of immense complexity and profuse suffering is that of experiencing the phantom limb (Melzack & Wall, 1988).

According to Melzack and Wall (1988), phantom limb pain is the most terrible and fascinating of all clinical pain syndromes. Melzack and Wall claim that the experience of the phantom limb is not always described as painful, yet the sensation of the missing limb being intact after amputation is extremely prevalent. Phantom limb sensation has been shown to be present in 65% of amputees 6 months after amputation, and in 60% at 2-year and 7-year intervals (Melzack & Wall, 1988). Pinel (2000) reports that 50% of amputees experience phantom pain classified as chronic or severe. In the Melzack and Wall research the phantom limb experience was characterized as one of pain or void of pain and categorized as phantom limb sensation.

The majority of amputees report phantom limb sensation immediately after surgery. It is described as a tingling feeling in which the original shape of the extremity is perceived. The phantom limb reacts the same when moving, sitting, and lying down, and the tendency for the missing extremity to feel present has caused some amputees to step out of bed expecting their foot to touch the floor, or to reach out to grasp an object with a missing hand. With time, the shape of the phantom extremity begins to change and Melzack and Wall describe a “telescoping” effect in which the foot or hand begins to recede back into the body until it seems to be attached right at the stump. In some cases the phantom foot or hand subsequently disappears. Melzack and Wall suggest that the central nervous system produces the phantom in response to lack of normal input and that it manifests as a neural substrate of our perception of body position.

Phantom pain is described as cramping, shooting, burning, or crushing and is reported on a broad spectrum from occasionally to frequently in those who experience it. The pain may vary with respect to quality and intensity. Rather than simply feeling the shape of the absent extremity, those who suffer phantom limb pain report the feeling that the appendage is contorted. Phantom pain can be triggered by emotional upsets as well as bodily functions.

The research of Melzack and Wall (1988) concerning phantom pain has been extensive. They have determined that phantom pain may endure long after the tissue damaged from disease and surgery has healed and that “trigger zones” may spread to healthy areas of the body.

Melzack (1989) maintains that the experience of the phantom limb is realistic to the limb loss patient because the same brain processes that are present when the body is intact remain present after amputation. Melzack describes the body as being unitary with an integrated quality that includes the “self” and the incorporation of a neural network that can be changed by sensory experience although the “body-self” is genetically determined. Melzack describes experiences of the body as having a quality of self, thereby influencing the individual’s perception and response to pain.

There is ample controversy in determining the causal mechanisms of phantom limb sensation. The major problem is the attempt to identify a single problem as the entire explanation when it is more likely that there are a variety of contributing factors. Melzack and Wall (1988) suggest that theories emphasizing a progression from the periphery to the central nervous system as a means of explaining the phantom limb phenomenon are inadequate. According to Melzack and Wall, more than 40 types of therapy to address phantom limb pain have been developed, with a meager success rate of 15%. This is understandably frustrating to the individual who suffers limb loss. It is more frustrating to the individual who has experienced disease and pain resulting in amputation only to experience little or no relief once the amputation is performed. This low success rate is indicative of a predominant ignorance of the mechanisms that underlie phantom limb pain.

Melzack (1989) cites psychological evidence that perceptual experience is influenced by past history and current state of mind. In other words, state of mind, or emotion, under certain circumstances may determine responses to pain or pain sensation thresholds. Melzack adds that phantom limb pain perplexes the investigation by beginning as signals of serious body damage and may persist, spread, and increase in intensity to the point that it becomes a malady in its own right because the pain may become worse than the original injury that caused it. He goes on to say that phantom limb pain is more likely in those who have suffered pain prior to amputation. Evidence reveals that prolonged pain can have deleterious effects resulting in immunosupression due to extended periods of stress, anxiety, or depression (Kludt, 2000).

Educators should:
1. Discuss phantom pain issues with amputee clients.
2. Investigate alternatives for management of phantom pain for the client.
3. Explore emotional and social variables with the client that might contribute to phantom pain and distress.

Pain, Stress, and Immunologic Compromise
Critical to the diabetic patient are the effects of pain and stress on the immune system. Immune dysfunction has been examined by Vedhara, Fox, and Wang (1999), who concluded that the consequences of stress on the immune system can be profound. Vedhara et al. investigated immunologic response by exploring lymphocyte subsets and proliferation, cytokine levels, cytotoxicity assays, virus and viral components including antigen detection. According to Kemeny and Laudenslager (1999) there are measurable differences in the immune systems in both humans and animals under conditions of stress. The authors provide a reminder that individual patterns of affective, behavioral, and cognitive responses significantly influence reaction to stress and physiologic consequences. Whether the stress is classified as a major or minor event also may play an important role in the immune response.

The work of Tracey, Walker, and Carmody (2000) provides evidence that the stress-pain connection may be a reciprocal event. Not only does pain produce stress, which contributes to immunologic consequences, but also prolonged stress may produce a predisposition to chronic pain. This is supported by Bragdon (2000), who studied the stress responses of individuals suffering from temporomandibular pain, and by Moxham (1999), who investigated pain in fibromyalgia patients experiencing the stress of unrestorative sleep. Interestingly, the Bragdon study revealed a correlation between depression and pain sensitivity with blunted cortisol stress response. Cortisol excretion promotes basic survival functions including quick thinking, fast reflexes, and increased strength. All are components of the fight or flight response. It is important to recognize that while excessive amounts of cortisol can actually produce stress, small amounts of the hormone are necessary to ensure proper glucose metabolism, insulin release for blood sugar maintenance, and proper immune function. The Moxham study revealed a cyclic event in which unrestorative sleep contributed to fatigue, which mediated pain. Another fibromyalgia study presented stress as a predictor of both pain and depression (Kim, 2000). Similarly, life stress and depression have been associated with experiences of chronic pain (Catley, 2000). Specific to the phantom phenomenon, Angrilli and Koester (2000) provide evidence as to the impact of stress on pain intensity and suggest a connection between the long-term emotional memory of amputation and the occurrence of phantom pain. In the Angrilli and Koester study, cardiovascular hyperactivity was observed during the reports of subjects concerning their amputation experience.

Other examples of stress producing pain with physiological consequences include work-related stress and musculoskeletal pain with catecholamine compromises, elevated blood pressure, increased heart rate, and psychosomatic symptoms (Lundberg et al., 1999); chronic psychoemotional stress and reduced pain thresholds (Ashkinazi & Vershinina, 1999); stress producing injury and resulting prolonged chronic pain (Melzack, 1998); posttraumatic stress disorder, alterations of hypothalamic adrenal axis, and chronic pain (Heim, Ehlert, Hanker, & Hellhammer, 1998); and the development of pain in pain-free subjects after prolonged mental stress (Bansevicius, Westgaard, & Jensen, 1997). Specifically pertinent to the diabetic patient is evidence suggesting that degenerative disease processes combined with major stress producing constructs such as bereavement have been shown to result in immunologic decrement (Burkhalter, 1998).

Educators should:
1. Provide information to the client about immunosupression and the complicating effects of diabetes.
2. Discuss stress reduction techniques and/or provide resources for stress management for the client.
3. Discuss with the client the potential implications of stress regarding pain and phantom pain and vice versa.

Depression and Disability
Depression is defined as “a state of low mental vitality” or “dejection” (New Webster’s Lexicon, 1992). Hay, Hay, and Sperry (1998) describe depression as a generic term that has been used to explain a variety of disorders. Situational and biological depression may present interactively or exclusively in related or unrelated phenomena. Depression in the elderly is generally reported differently than the depression of middle-aged or younger counterparts specifically with increased somatic concerns and less guilt. Hypochondriasis, psychotic depression, and pseudodementia are more prevalent with age. Physical illnesses, sociological considerations, and other psychological concerns may also play an interactive role.

The following themes are consistent in many individuals diagnosed as depressed:
1. Depressed mood most of the day nearly every day.
2. Markedly diminished interest or pleasure in all or almost all activities
most of the day.
3. Significant weight loss or weight gain.
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day.
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt.
8. Diminished ability to think or concentrate.
9. Recurrent thoughts of death, suicidal ideation, or a suicide attempt.

The aforementioned characteristics have remained static over time for determining depression and were utilized as a basis for diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (3rd ed.) [DSM-III]. The newer version, DSM-IV-TR, no longer states a requirement of the presence of five of these characteristics; however the same qualities remain inherent in determining higher and lower levels of depression as well as depressive symptoms as defined by the more recent manual. According to Albus, Dozier, and Stovall (1999), major depression might be genetically determined.

Individuals who are diagnosed as depressed may exhibit depression in any or all stages of the life cycle (Greenspan & Pollock, 1998). Furthermore, depression may be manifested prior to, during, or just after major life events. Onset of disability is a salient example of major life events that produce depression. Whitbourne’s (1998) characterization of physical identity in which appearance, competence, and limitations combine to develop a sense of self depends heavily on the individual’s capability to function physically. Physical impairment may arise from trauma or from the results of disease.

The predisposition of the elderly to physical disease justifies investigating to what extent compromise of well-being is mediated by disease. Dent et al. (1999) suspected that the incidence of disease revealed few independent connections with depressive symptoms in older people, whereas disability produced a marked impact on depressive symptoms in every circumstance. In other words, physical disease may not always lead to disability; however, when it does it is usually followed by depressive symptoms. Ormel, Kempen, Pennix, Brilman, Beekman, and Van Sonderen (1997) support this finding by asserting that the nature of the physical condition does not determine psychological distress; however, the severity of the disability along with availability of psychological resources and personality traits of the affected individual does. In a study concerning correlates of depression in older adults, Roberts, Kaplan, Shema, and Strawbridge (1997) found that healthy elderly individuals are at no greater risk of depression than younger adults; however, older adults with physical health problems or disability are.

Landreville and Gercais (1997) state that depression is the most frequent type of psychological distress that occurs subsequent to disability. Elderly people who are depressed have a significant amount of comorbidity such as physical disability (Katona, Manela, & Livingston, 1997). Katona et al. maintain that the majority of elderly people with depression receive no pharmacological treatment and surmise that primary physical or psychiatric symptoms may obscure the diagnosis of depression.

A study by Langer (1994) revealed that among the various types of disabilities exhibited by her subjects, amputees displayed more indecisiveness, thoughts of death, and thoughts of self-harm. Rybarczk, Szymanski, and Nicholas (2000) discuss the need for amputees to come to terms with loss of limb as well as consequential functional limitations.

Restriction of activity is interrelated with public self-consciousness and depression (Williamson, 1995; Williamson, Schultz, Bridges, & Behan, 1994). Williamson (1995) determined that amputees who exhibited restricted levels of activities were reluctant to go out in public because of feelings of self-consciousness, and at the same time felt vulnerable and less able to defend themselves. Perceived social stigma has been found to contribute significantly to depression (Rybarczyk, Nyenhuis, Nicholas, & Cash, 1995). Rybarczk et al. (2000) outline a broad spectrum of psychological responses of the amputee that range from extreme despair to feelings of relief after eliminating the source of pain.

Perceptual changes after amputation are a potential source of emotional despair (Knecht et al., 1996). Knecht et al. determined by magnetic source imaging that organizational and perceptual changes correlated with the number of sites from which painful stimuli could evoke referred sensation. The work of Knecht et al. gives insight into the psychophysiological influences of amputation by revealing that phantom sensations can be evoked by stimulating sites adjacent to the amputation site as well as stimulating certain points on the face. This relates to the work of Melzack and Wall (1988), who reported that phantom limb pain can mediate depressive symptoms, especially when the phantom limb is evoked by unrelated body functions.

Modification of the sense of self, sense of loss, awareness of mortality, loss of confidence, disfigurement, loss of balance, guilt, and phantom limb sensations are among the traumatic effects of amputation that can cause this population to have a bleak outlook for the future (McGarry, 1993). McGarry places a sense of urgency on the importance of the development of coping strategies to promote positive social change through addressing the issues of the limb loss population.

Educators should:
1. Discuss the potential for distress to develop as a result of the disease process.
2. Identify various contributors to the development of depressive symptoms.3. Advise clients about available resources for management of stressful situations.
4. Discuss the importance of identifying proper expectations related to the disease process.

Health Promotion and Social Change
Dunn (2000) maintains that social psychological aspects are undeniably linked to issues concerning rehabilitation because coping, adaptation, and responses to these issues are determined by the social perception, judgment, and action of the perceiver. Perhaps the most salient point of Dunn’s position is with respect to perception, and according to Dunn, the experience of disability as perceived by the affected individual may be influenced by personality characteristics.

Personality characteristics can have significant influences on the ability to adapt to (cope with) specific circumstances. Coping strategy has been shown to mediate adjustment to prosthesis use in amputees (Gallagher & MacLachlan, 1999). Friedman, Hawley, and Tucker (1994) provide an overview of the dichotomous categorization of adapting personalities. Specifically, the “disease-prone” personality is characterized by (a) perfectionism, (b) introversion, (c) procrastination, (d) external locus of control, (e) nonbelief in just world, (d) low self-efficacy, (e) pessimism, (f) negativity, (g) outcomes avoidance, (h) neuroticism, (i) maladjusted personality, (j) low self-esteem, (k) unsure tendencies, and (l) dependency. The “self-healing” personality is characterized by a preponderance of the opposite of the aforementioned qualities of the disease-prone personality and, according to Baron and Byrne (2000), has a less difficult time developing coping abilities. Furthermore, Baron and Byrne assert that most people fall somewhere along a continuum between the two personality types, with those positioned closer to the disease-prone personality on the continuum having the most difficulty.

For those who have personality types that gravitate away from the self-healing category, attention should be given to strategies that promote positive methods of dealing with stress, as well as general coping with negative circumstances. Baron and Byrne (2000) provide an overview of the application of social psychological strategies to health related behaviors. The authors stress the importance of consistent positive lifestyle habits that include (a) nutritious foods, (b) adequate sleep, and (c) regular exercise.

Those faced with overcoming the detrimental psychological effects of a disabling condition frequently find themselves in the pivotal position of requiring lifestyle change. Various studies suggest that exercise, and specifically intensity of exercise, is a predictor of self-efficacy, while self-efficacy has been shown to predict positive lifestyle behaviors such as exercise.

According to Winett (1998), the most effective exercise programs are those that include high intensity activities. Winett calls attention to the recent promotion by psychologists of high-volume activity programs and notes that the time-consuming nature of such programs results in the predictable outcome of nonmaintenance. Winett stresses that the high-intensity exercise theory leads to greater potential for “self-mastery” and “self-efficacy.” Self-mastery being the control an individual acquires through positive lifestyle practices, while self-efficacy is the state of well-being that results after developing that control. Jessor, Turbin, and Costa (1998) support the notion that 15 minutes of exercise per day, or even every other day, is enough to increase fitness, well-being, and self-efficacy.

Acute bouts of exercise produce self-efficacy changes and consequential feelings of well-being, and reduce perceptions of fatigue and psychological distress (Mihalko, McAuley, and Bane, 1996). The significance of understanding the efficacy change process is demonstrated by Mullan and Markland (1997), who studied individuals participating in exercise programs. Self-determination was identified as a prominent characteristic of behavioral regulation, and the authors endorse motivational considerations relating to the process of change.

Self-efficacy contributes significantly to predicting exercise behavior. Those who have high levels of self-efficacy may adapt to disability more proficiently by virtue of emotion-based coping. Proper training and education after the onset of disability might help boost self-efficacy and consequential success concerning rehabilitation intervention through problem-based coping.

Recent research provides insight into the importance of positive health behaviors such as exercise, diet, and proper sleep; however, these behaviors are generally considered to be strategies that help to circumvent the negative effects of stress. To complete a thorough investigation of social psychological tactics for positive behavior, specific coping strategies of a social psychological nature should be examined. For instance, Compas, Banez, Malcarne, and Worsham (1991) outlined a two-level process of coping, coping being defined as an effective response to stress. Emotion-focused coping is compared to problem-focused coping with the former being an attempt to deal with negative feelings and the latter involving a focus on threat and gaining control of that threat. According to Baron and Byrne (2000), those who tend to cope through the problem-focused method are generally those who are identified as having self-healing personalities. Baron and Byrne discuss regulatory control, which is a coping tactic that involves thought control, control over feelings, control over actions, and direction of energy and attention. Creating positive affect is discussed as a method of counteracting negative emotions that are the potential producers of stress, anxiety, and subsequent depression.

Gallagher and MacLachlan (2000) determined that those who found positive meaning in the experience of amputation demonstrated more favorable adjustment to limitations, physical capabilities, health ratings, and athletic aptitude. Examples might include individuals who have entered “helping” professions because of exposure to those professions as a result of their own disease experience, those who have become involved in amputee athletics as a result of amputation, or those who have conquered specific lifestyle deficits (drug abuse, sedentary lifestyles, emotionally destructive behavior, etc.) after becoming disabled.

The capacity for an individual to exhibit resilience may be determined by various influences such as education, income, and occupational status; however, according to Ryff et al., (1998), the reflection of resilience is evident in the ultimate outcome of mind-body integration regardless of sociodemographic variables. Mind-body integration in this respect involves concern with positive mental strategies such as not becoming depressed, anxious, or physically ill in the face of adversity, as well as positive physical strategies such as diet, exercise, sleep, and aerobic capacities. Positive self-appraisal in spite of objective decline is cited as an important dynamic for maintenance of the sense of well-being (Borchelt, Gilberg, Horgas, & Geiselmann, 1999). Participation in religious activities is purported by Koenig (1994) to result in “successful aging” regardless of physical health or environmental conditions.

Friendships and social networks have been shown to be essential aspects of an individual’s support system (Cavenaugh, 1998). Support systems, while important to all disabled, become even more valuable to the disabled elderly. Gallagher, Allen, and MacLachlan (2001) found that absence of support prior to amputation correlated with phantom limb pain after amputation. In a similar qualitative study, Gallagher and MacLachlan (2001) used a focus group methodology to examine adjustment to amputation. Support among others was found to be important in the adjustment process. It has been determined that the single most positive experience for a new amputee is communication and interaction with other amputees (Foort, 1974).

The perception of minimal support has been shown to correlate with depressive symptoms and reduced quality of life in elderly individuals with physical impairments (Newsom & Schultz, 1996). Each member of a social network has a distinct character, yet there is a simultaneous context that influences and is influenced by the individual, consequently setting the parameters of group social change (Stones, 1992). Members of social networks who are initially strangers begin to relate to each other because of their commonalities (Brown, 1995). Longino and Mittelmark (1996) emphasize the importance of sociodemographic dimensions as well as social resources as mechanisms that link the social environment to health status. This implies that the support of friends, siblings, and others can have a positive effect on physical health by reducing the potential for stress and anxiety brought on by isolation and is supported by the work of Antonucci and Akiyama (1997) who state that social relations are associated with reduced morbidity. Similarly, Antonucci and Akiyama cite longitudinal studies in which people reporting the existence of high quality social relationships had reduced rates of mortality between times of follow-up compared to those who did not.

Just as social support is associated with physical health, Antonucci and Akiyama (1997) maintain that there is empirical evidence supporting an association between positive social relations and mental competence in old age. The most significant supporters identified by the elderly were the spouse (if alive), children, siblings, and friends. Antonucci and Akiyama determined that the most valuable types of support given were (a) confiding, (b) reassurance, (c) respect, (d) sick care, and (e) conversation concerning problems and health.

Comprehensive amputee programs can provide the opportunity for amputees to participate in a network that provides peer counseling to new amputees. This type of network potentially provides a much-needed service for new patients, and also gives participants a sense of purpose, a primary component for addressing their own needs. Involvement enables individuals to avoid feelings of being disenfranchised by reconceptualizing their lives and maintaining a sense of place and continuity of identity. Patients who have remained uninvolved tend to exhibit more distress and less communicative effort.

Educators should:
1. Examine with the client the roles of personality and perception in response to disability.
2. Discuss the relationship between positive lifestyle practices and self-efficacy.
3. Help the client to understand the concept “positive meaning in disease experience” as well as ways to apply positive meaning social network strategies.

Education and Patient-Practitioner Communication
Illness and medical treatment can be stressful from various standpoints. The patient has been thrust into the unknown, so to speak, and has to deal not only with the illness from a prognostic view, or the pain of the illness, but the contemplation of treatment for the illness and the thoughts that are generated from such contemplation. Wills and DePaulo (1991) assert that the decision to seek medical help is a coping mechanism in and of itself. In fact, it may be the first step in taking control of the situation through a problem-focused strategy, and also the first step in self-education from which control may be manifested.

Rall, Peskoff, and Byrne (1994) support the concept of individuals learning as much as possible about their particular conditions to enhance sense of control, and consequently well-being. Learning as much as possible about the condition by seeking out those with similar problems is imperative.

Patients should make it their hobby to educate themselves in the newest areas
of medicine that affect their particular condition. They should read, write, and
seek professionals who can make a difference in their lives by helping them
be successful. (Ratto, 1991 p. 88)

Rall et al. conducted a study of 444 adults concerning perceptions of physicians and patient interaction and determined that the perception of the physician’s information-giving behavior elicited positive affective and evaluative ratings. This showcases the need for positive communication between clinicians and patients.

Thompson, Nanni, and Levine (1994) identify perceived control as instrumental in coping with illness and other potentially stressful situations. Thompson et al. investigated various levels of control with their subjects and identified two dimensions of control; primary versus secondary and central versus consequence related control. All levels of perceived control were correlated with better adjustment and low depression. These findings are supported by Griffin and Rabkin (1998), who examined perceptions of control over illness and psychological adjustment. In the study, perceptions of control were associated with less depressive symptoms and less anxiety regarding death. The results of these studies are consistent with the results of Lachman and Weaver (1998), who investigated perception of control across various socioeconomic classes. The study revealed through multiple regression analyses that higher perceived mastery and lower perceived constraints correlated with better health, life satisfaction, and lower depressive symptoms regardless of income group.

It has been suggested that another moderating coping influence is the availability of choice (Paterson & Neufeld, 1995). Paterson and Neufeld evaluated 278 subjects by providing the availability of various courses of action in some scenarios versus the elimination of choice in others. It was determined that situations are viewed as more stressful when it is necessary to select coping options blindly or when significant information must be processed within a short period of time to determine a prospective coping option. This finding becomes more significant when the variable of disability is introduced. Specifically, those faced with the prospect of amputation may initially feel that the ability to choose has been eliminated. Applying the principles of Paterson and Neufield, the perception of choice after amputation surgery then becomes crucial to psychological recovery. Dunn (1996) determined that amputees who found positive meaning in disabling experiences achieved higher levels of well-being.

While many aspects of the physical, emotional, and social domains that impact coping during and after the initial rehabilitation process are to a certain degree under the patient’s control, examination of a holistic continuum representing a collaborative and comprehensive approach to patient management would not be complete without investigating those issues for which the patient has little or no control. Within the social domain there are many subcategories instrumental in contributing to the continuity and quality of the patient’s care and involve clinician-patient interaction via nonverbal communication and various learning methods.

The purpose of this discussion is to examine techniques that can be employed and interpreted by the practitioner and that provide potentially positive influences on the practitioner-patient relationship. Symbolism and multiple intelligences theory are presented as gateways to positive rapport and potential patient adjustment. While beneficial to virtually all patient populations, these techniques might be particularly helpful in the management of the disabled, including those who suffer limb loss or other physical or emotional trauma.

A symbol is “any entity that can denote or refer to another entity” (Gardner, 1993, p. 301). Gardner speaks of how various images, elements, or words are used to stand for “real life” objects in the world and asserts that language alone cannot satisfy requirements for conveying thoughts. Without being aware, individuals tend to express feelings without using words (Lopicic-Pericic, 1996). Facial expressions, gestures, look, voice, silence, posture, and movement are virtually continuous replacements for conventional linguistics.

In examining body knowledge as well as body prejudice as they relate to practitioner-patient interaction, cultural variables, biological considerations, and environment all seem to play an important part in how nonverbal communication takes place. According to Edelstein and Schein (1997), body image becomes a significant part of this equation for those who suffer limb loss. Edelstein and Schein maintain that self-esteem, anxiety, and life satisfaction are correlated with perception of body image, and it is understandable that a compromise in this perception interferes with nonverbal communication that depends on body knowledge. This is supported by Cleveland and Fisher (1978), who found that amputees as well as stroke victims have altered body images, necessitating the careful interpretation of signals. Stroke victims sometimes are restricted to using nonverbal communication, and even when the right hemisphere of the brain has been affected (which generally results in intact speech but impaired motor function), it is imperative that nonverbal cues are interpreted with care. Using symbolism in professional practice and practicing a variety of communication skills in patient management can be further explored through an evaluation of the theory of multiple intelligences.

The theory of multiple intelligences posits that intelligence is more than a single property of the mind and that multiplicity may be evident within creativity, leadership, and morals (Gardner, 1999). Just as social structures within cultures exhibit a variety of nonverbal communicative skills, individuals within those cultures are purveyors of their own unique way of communicating thoughts and utilize methods that reflect major focuses or interests in their lives to convey those thoughts. One example of this type of unique communication style might be a patient who happens to be a pilot and uses a lower-limb prosthesis. In an attempt to describe how the prosthesis is responding during gait, the patient describes a “three-stage landing,” a term familiar to pilots. The pilot is relating the “landing” of the prosthesis to the landing of an airplane. Torff and Gardner (1999) describe a vertical theory of intelligence in which separate cognitive mechanisms are utilized to address particular kinds of information or tasks. This is in contrast to horizontal theories of intelligence, which emphasize the mind’s handling of tasks through a single, centralized system. The pilot who describes the response of the prosthesis as a three-stage landing might use other personal experience to describe additional aspects of the prosthesis. For instance, if the prosthesis squeaks, the patient might use language that reflects knowledge of music. For instance, “My prosthesis hits a high C whenever my heel contacts the floor.” The communication techniques of each individual are a product of how learning has taken place during the life cycle.

Snyder (2000) found that 81% of participants in a study on learning styles were tactile/kinesthetic learners who prefer actually doing things as opposed to listening and watching during efforts to learn. This suggests that learners in any population should be assessed to determine the most effective manner of teaching them. Identification of multiple intelligences can be a basis for discovering strengths, minimizing weaknesses, and lead to realistic goal interventions.

Educators should:
1. Advise clients as to the importance of communication between patients and practitioners as well as the importance of willingness to communicate.
2. Discuss the various methods of human communication including verbal and non-verbal cues.
3. Review the significance of “choice” and “control” of the client in coping with disease and disability.

The topics presented, while covering a broad spectrum, exemplify the essence of an approach that includes physical, social, and emotional constructs in addressing the needs of those who experience disease and limb-loss.

Disease and amputation, immunologic compromise, and health promotion strategies have an overarching physical theme, however social and emotional implications can be found within these categories. A salient example is biopsychosocial concerns, which involve the physical, social, and emotional realms. Yet another example of the meshing of domains is the phantom phenomenon, which has physical and emotional origins and social ramifications. Likewise, mental resilience, personal control, self-efficacy, and stress and anxiety are emotional or psychological constructs that are affected by physical and social influence. Finally, education, support systems, body image, and clinician-client interaction are social- centered, but are influenced by physical and emotional stimuli.

The continua represented by each psychophysiological category of inquiry (physical, social, and emotional), and the tendency of each domain to cross the boundaries of other domains, showcases the holistic perspective and supports the philosophies of multidimensional support and multidimensional care in clinical patient management.


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Dr. James Price is president of Faith Prosthetic-Orthtotic Services, Inc., a clinical practice specializing in artificial limb technology and orthopedic design based near Charlotte, North Carolina. Dr. Price consults, practices, and lectures nationwide. He received a B.A. in Psychology and M.Ed. in Health Promotion from the University of North Carolina-Charlotte and a Ph.D. in Health Psychology from Walden University in Minneapolis. Dr. Price earned professional certificates in Orthotics from Northwestern University Medical School in Chicago and in Prosthetics from Shelby State Community College in Memphis. He is board certified in prosthetics, orthotics, and pedorthics. Dr. Price received the Howard R. Thranhardt Lecture Award in 2004 for his work on the topic of phantom pain, is a ember of Psi Chi, the national honor society in psychology, and has achieved Fellow status in the American Academy of Orthotists and Prosthetists. Research interests include psychophysiological issues in those who experience limb amputation and applied technology in prosthetic systems design. Dr. Price holds a United States patent for transfemoral prosthetic socket design.

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