Mrs T Case Study

Mrs T is a lady who sustained quadruple amputations following sepsis secondary to pneumonia, she attended Dorset Orthopaedic London Clinic for intensive upper limb myoelectric training

The Individual
Mrs T was an active 45-year-old lady at the time of her illness. She worked as a teacher in a primary school in London and lived with her partner and two young children. A lot of her time involved taking her children to and from their extra-curricular activities, however, as a family they all enjoyed going on holiday, swimming and bodyboarding. Family life was, and remains, extremely important to Mrs T and became a huge motivational factor during her rehabilitation.

Cause of Amputations
Mrs T started to become unwell with breathlessness and a cough and was admitted to hospital with severe pneumonia and sepsis. Mrs T had a complex and prolonged admission to intensive care, where she needed special medication to keep her blood pressure up and improve the contractility of her heart. Unfortunately, a side effect of this medication is that it reduces blood flow to your limbs in order to ensure that your vital organs have sufficient blood supply. This meant that Mrs T’s upper and lower limbs became necrotic and unfortunately, were not salvageable. Mrs T required bilateral above wrist (transradial) amputations and bilateral below knee (transtibial) amputations. After almost a year in hospital, Mrs T was discharged home as a wheelchair user and started to learn how to walk again with prosthetics at home.

Initial Assessment
Mrs T was first seen at the Dorset Orthopaedic London Clinic in November 2020, where she was seen by our prosthetist and clinic manager, Steve Cox to assess and fit myoelectric Hero arms. She started her intensive myoelectric physiotherapy training in March 2021.

By now, Mrs T was walking independently with her lower-limb prostheses and had started trying to activate her muscles to move her prosthetic hands. She was able to sporadically open or close her right hand but could not yet do this consistently or use the hands for any purpose. Mrs T is right-handed so it is no surprise that this is the hand she was able to start contracting first, however, at this point, she had no activation of her left Hero arm.

On assessment, Mrs T had a very slumped posture with muscle imbalance and reduced range of movement in her shoulders. Mrs T also had weakness in some of the muscles around her shoulder blades and reduced power throughout her upper limbs.

Mrs T’s upper limbs had healed well and her sockets were well fitting. She was currently only wearing her Hero arms for a maximum of 1 hour a day to try and practice contracting muscles to open/close the hands.

Goals of Intensive Myoelectric Training
Following an in-depth assessment, we were able to identify Mrs T’s main problems and aspirations and identified some key goals, some of which are described below:

To regain full range of movement in shoulders
To increase power to 5/5 on the Oxford Muscle Scale in the rotator cuff muscles around the shoulders
To consistently open and close left and right hands at different speeds
To hold cutlery and eat independently
To be able to brush hair independently

And Mrs T’s main personal goal to achieve by the end of the training was:

To walk to the bakery independently whilst carrying a bag, buy lunch, carry the lunch back to the clinic and eat lunch (all whilst using Hero arms)

Mrs T had not yet been outside wearing her UL prostheses and was keen to work towards wearing them all day and being able to undertake functional activities/tasks in “real life scenarios”.

Progress
Mrs T undertook 3 hours of myoelectric training 3 x a week (over a 3 week period). Training was varied and designed to increase functional use of the Hero arms without the development of compensatory movement patterns.

It was extremely important that Mrs T engaged with a home exercise programme to improve her posture, muscle balance, range of movement and strength. We reviewed her exercises regularly and progressed them accordingly; adding resistance bands and challenging her range of movement further. In conjunction with this, Mrs T also received some manual therapy and soft tissue massage to reduce tightness and shortening in the muscles surrounding her shoulder blades. As her range of movement and muscle balance improved, Mrs T’s posture also noticeably improved which provided a stable base from which her upper limbs could function.

Activating and using myoelectric prostheses requires patience, repetition and perseverance. Initially we focused on unilateral contraction drills both with the prostheses off and on. Palpating the muscles allows the physiotherapist to determine whether the right muscles are contracting at the right time, how strong the contraction is and how best the upper limbs are positioned within the sockets. With a lot of repetition and perseverance, Mrs T started to intermittently open and close the hands of the Hero arms (initially just with the right, but the left soon followed) at different speeds and in different positions. With practice, this became more consistent and we were able to commence unilateral drills with the Hero arms; picking up different sized objects, picking up objects with different textures, picking up objects of different weights and then trying this at different speeds, positions etc.

As Mrs T’s skills developed, we started to undertake more functional tasks of progressing difficulty e.g. picking up counters and playing connect 4, putting on a jumper independently, using cutlery to cut food, brushing hair, opening jars and packets, turning a key in a lock and pouring drinks in different cups. Throughout these functional tasks, Mrs T worked with the physiotherapist to reduce compensatory movement patterns, increase her participation in tasks which required bilateral upper limb use and remain mindful of posture.

By the end of her treatment, Mrs T was wearing her Hero arms for most of the day and was now able to walk indoors and outdoors independently with them on (initially Mrs T had found the arms quite heavy when walking and needed to increase her strength to cope with this). Mrs T’s posture, upper limb power and range of movement had also significantly improved but most importantly, Mrs T was able to undertake functional activities that she had not even thought possible when she first had her amputations. Mrs T achieved her goal of walking to the bakery, buying lunch, carrying it back to the clinic and eating it independently – a few weeks prior to this, Mrs T could not even open or close the hands of her prostheses let alone take objects from a stranger and carry a bag home. Mrs T was now able to play games with her children again, start to eat by herself and had even discussed returning to work in person as a teacher for short periods. Mrs T’s confidence and abilities grew significantly in this short period and whilst she still needs to refine her skills and increase endurance, with 4 weeks of intense training, Mrs T was able to start using her upper limbs again in day to day tasks.

Outcome Measures
During Mrs T’s intensive myoelectric arm training, we undertook a range of outcome measures to monitor any improvements in functional ability, acceptance and use of upper limb prostheses, posture, range of movement and power. We also monitored Mrs T’s goals and the impact of her upper limb prosthetic use on general wellbeing. Outcome measures were completed at the start of the training block to identify areas of focus and repeated at the end of the training period to determine areas of improvement. The results were as follows:

Disabilities of the Arm, Shoulder and Hand Questionnaire (DASH):
This 30-item self-report questionnaire looks at the ability of a patient to perform certain upper extremity activities and helps describe the disability experienced by people with upper-limb disorders. Patients can rate difficulty and interference with daily life on a 5 point Likert scale which helps monitor changes in symptoms and function over time.

The DASH is scored in two components: the disability/symptom questions and the optional high performance sport/music or work section. Scores range from 0 to 100, 0 being mild disability and 100 being most severe disability.

Mrs T almost halved her disability experience score by the end of this training period and had considerably improved her ability to use her upper limbs in day to day life.

Trinity Amputation and Prosthesis Experience Scales (TAPES)

This is a self-administered questionnaire that explores psychosocial adjustment, activity restriction, and prosthetic satisfaction. It aims to enable an examination of the psychosocial processes involved in adjusting to an artificial limb, the specific demands of wearing a prosthesis, and the potential sources of maladjustment. TAPES can facilitate the exploration of the relationships between different variables and the identification of those factors, which promote successful rehabilitation and adjustment to wearing a lower-limb prosthesis.

Mrs T almost halved her disability experience score by the end of this training period and had considerably improved her ability to use her upper limbs in day to day life.

Trinity Amputation and Prosthesis Experience Scales (TAPES)

The score is broken down into subsections, high score is indicative of positive adjustment -

Mrs T’s experience of myoelectric prosthetic use had considerably improved by the end of treatment. Her scores indicated that following intensive training, she had no issues in terms of her general and social adjustment and noted an improvement in her perceptions of her limitations. Mrs T’s restrictions in terms of activity participation were reduced and her satisfaction with the prostheses improved to over 90%.

OPUS Upper Extremity Functional Status

This is a self-reporting questionnaire that measures the degree of manual functioning after upper limb amputation. A higher score indicates greater functional use.

As you can see, Mrs T’s results indicate a statistically significant improvement in her functional use of prostheses.

Summary
Myoelectric prosthetic use is often associated with high levels of abandonment, however, this is largely because people lack guidance, patience and knowledge of how to get the best from their prosthetics. Intensive myoelectric training under the guidance of a qualified therapist can dramatically improve prosthetic adjustment, functional ability and independence and whilst patience and perseverance is important, outcomes can be optimised by a graded and progressive approach to treatment. Using a myoelectric arm functionally is important but using a myoelectric arm without compensatory movement patterns is even more important to prevent any long-term muscle imbalance and the difficulties associated with this. This case study is an example of someone who at some points, thought that it would be almost impossible to use upper limb prosthetics and return to the tasks that they took for granted prior to amputation. However, with their determination, perseverance and the guidance, support and graded treatment of a qualified therapist, was able to dramatically improve their upper limb function and day to day ability.

Quote from Patient - My three week myo-electric training at the Dorset Orthopeadic London clinic was a fantastic experience. Lauren worked me and my new hero arms hard, incorporating strengthening exercises and drills into our sessions as well as many functional tasks. My posture has improved immensely and I now wear my hero arms with confidence. I use them for a range of daily activities at home such as preparing meals and playing games with my children. Lauren also took me on my first trip shopping, preparing me to further integrate back into the world after my quadruple amputations just over a year ago.