A Study on the Various Challenges of Amputees with Special Reference to Ernakulam District

 

Roopa S.

Research Scholar, School of Gandhian Thought and Development Studies, M.G. University, Kottayam.

 

ABSTRACT:

It is a much known fact that India is not a friendly country for the disabled people even though many programmes are offered by the Indian government. Compared to those who are disabled by birth, amputees are prone to suffer more difficulties as they lost their body parts abruptly. Hence the shock is too high. Most of the issues faced by these amputees are psychological than physical. It will also take a long time for them to adjust with their new environment.The study says that the people who are financially settled have lesser issues when compared to the non-settled and fitting of proper prosthesis in the earlier stage will help them to reduce the severity.The study reveals the fact that increased numbers of road accidents are the main reason behind increased level of amputation. The various challenges faced by this sector of people are numerous. This study is trying to find out some common issues of these groups.

              

KEYWORDS: Amputation, socio-economic, psycho-social issues, prosthesis, road accidents.

 

INTRODUCTION:

“I awoke in my hospital room. Still groggy, a flat sheet was all I saw-a flat sheet where my leg used to be. What am I going to do? How can I go on? It just isn’t fair. Why me, oh God, why me?” These thoughts from one amputee tell the story in the book ‘You Are Not Alone15, A story of pain and disbelief.

 

Amputation is removal of part or all of a body part enclosed by skin. [American Medical Association]. It is a surgical method used to control pain or a disease. It is done in case a part of limb is dead. Road accidents, arterial issues due to nicotine, cases of diabetics, bomb blasts are the main reasons behind amputation. Amputation is always a shock for the patients because of its abrupt nature.Our body parts allow us to interact intimately with our environment.

 

Loss of part or all of a limb forever changes how we move, touch work and play. The following days of amputation surgery can be difficult for anyone. Losing a limb can cause disbelief or shock.The patient might feel angry about the change in his life, sad aboutloss, uncertain about whether he will be able to return to work or perform favourite activities, worried about his appearance Thus for an amputee, it is a new birth and should learn everything as new and the limitation caused by amputation makes more problems in adjustments. They have to face many physical, psychological, economic and social problems in their life due to amputation. Hence it’s a life changing experience.

 

 


HISTORICAL BACKGROUND:

In the past, the word amputation was never intended to use in a surgical context but to denote punishment for criminals. Words like disarticulation, dismemberment, extirpation or simply cutting were used instead; and only by the end of seventeenth century the term amputation was accepted as a medical term. The word amputation is originated from the Latin word Amputare, It has the meaning cut away from ambi and putare. History of amputation has several stages during several periods. Initially, limb loss was usually the result of trauma or 'nonsurgical' removal. This was followed by the hesitant beginnings of surgical intervention, mainly on gangrenous limbs or those already terribly damaged, which developed through to surgical amputations around the 15th century; the distinction is marked by the choice of the patient and the aim of saving a life and achieving a healed stump, despite the difficulties with infection and the lack of effective control for pain or blood loss. Improvements in surgical techniques were marked with better hemorrhage control in the 19th century and in the 1840s with anesthesia and around twenty years later, efficient infection control. The 20th century noted marked improvements in surgical techniques and also a move to increasingly sophisticated prosthetic limbs.

 

Road accidents and diabetes –main causes in India

Western studies have found that complications caused by vascular problems is the major cause of amputation, but in India, more number of people loses their limb due to accidents14.Studies shows that Peripheral vascular disease and Diabetes are the other main reasons for amputation.

 

The causes for amputation may include any of the following:

        Diseases - such as blood vessel disease (called peripheral vascular disease or PVD), diabetes, blood clots, or osteomyelitis (an infection in the bones).

        Injuries (trauma)– Injuries from some accidents like vehicle accidents or in work place or serious burn can lead to amputation.

        surgery - to remove tumors from bones and muscles.

 

REHABILITATION AFTER AMPUTATION:

The disability caused by amputation has strong impact on patient’s social status, self-image and mobility.So rehabilitation should focus on physical, emotional and social requirements of the individual. The goal should be bringing back the person into the main frame of society with the highest level of function and independence possible. Rehabilitation of the patient with an amputation begins after surgery during the acute treatment phase.

 

The success of rehabilitation depends on many variables, including the following:

      level and type of amputation

      type and degree of any resulting impairments and disabilities

      overall health of the patient

      family support

 

The amputation rehabilitation team:

Rehabilitation programs for patients with amputations can be conducted on an inpatient or out patient basis. Many skilled professionals are part of the amputation rehabilitation team, including any/all of the following: Orthopaedic surgeons, phyiatrist, rehabilitation nurse, physical therapist, occupational therapist, orthotist, prosthetist, social worker, psychologist, psychologist/ psychiatrist, recreational therapist, case manager, vocational counselor.

 

Types of rehabilitation programmes :

        acute rehabilitation programs

        outpatient rehabilitation programs

        day-treatment programs

        vocational rehabilitation programmes

 

Psychological Problems

An amputee suffers from social and psychological trauma and loss of limb leads to long-term disorder in body experience .After losing a body part, psychological issues will be very high. Anger and frustration are very common. It will badly affect their self-concept and confidence level. The psychological issues may vary according to the attitude of the person. At this time the patient is highly vulnerable towards psychiatric problems. After amputation surgery, depression, anxiety, frustration, anger, insomnia are common among these people. 17

 

Physical Problems

After the surgery they have to start everything from the beginning itself. Using prosthesis can give many difficulties for the amputees such as skin problems, swelling and pain. Use of an artificial limb requires increased level of energy and it results in increased sweating to dissipate the heat.

 

The sweating causes maceration and it predisposes to bacterial infection and injury. Skin ulceration may also occur due to maceration. Prosthesis should be modified according to time. Skin problems have a high prevalence, up to 73.9% in amputee patients.7

 

Economical Problem

Economic problems are severe for an amputee since the possibility of losing one’s job is very high due to amputation and majority of them are from poor socio-economic background. Most amputees are coolie workers with poor qualification. After the surgery they usually don't have much option. As our countries people are not supporting the disabled to be independent by providing adequate jobs, they lose self-confidence and became dependent on others. Economic issues are too high among these people and as a result family and children are the victims of this. It won’t be an exaggeration to say that they are living in hell.

 

Phantom Sensation

This is the sensation of the presence of the amputated limb. The patient experiences the sensations as though from an intact limb, which is amputated. At first the phantom sensation can be so deceptive that the patient may attempt to scratch the chin with an absent hand or to walk on a missing leg. With the passage of time phantom sensation tends to diminish in a manner that has been described as “telescoping into the stump,”but occasionally it may persist for decades .Almost all amputees have phantom sensation except young children and those with brain damage.

 

Phantom Pain

Phantom pain must be distinguished from phantom sensation, stump pain, and referred pain. If the sensation of the absent limb is painful and disagreeable, with strong paresthesias, it is referred to as phantom pain.

 

REVIEW LITERATURE AND METHODOLOGY:

Comparing with developed countries, disabled has to suffer in developing countries. Here a majority of people believe everything happened because of fate and never go beyond it. After the amputation, most of them live within their home and they lose self-confidence and that makes them unproductive. Our society does not have a positive attitude towards these people. Richa Sinha in her study saysthat limb amputation has a major impact on the individual - not only in disturbing body image, but also with regard to loss of productivity, and increasing dependency. An amputee suffers from social and psychological trauma and loss of limb leads to long-term disorder in body experiences. Prosthesis is important to move independently, participate within the society, and resume work. Factors like depression, body image, and social and contextual factors influence the use of prosthesis by amputees, and also affect their quality of life.

 

S.P. Chow, in his study ‘social problems of lower limb amputees in Hong Kong’explains that the orthopedic care of a patient with an amputated lower limb does not stop after surgery. In order to integrate the patient back in society, various social problems will be encountered including difficulties in daily activity, in travelling around, employment, marriage and so on’, These problems will be compounded by psychological trauma of the loss of a limb. In many of the older patients, they also have concurrent medical diseases and senile dementia, posing a great problem for their families.

 

Statistics from The All India Institute of Physical Medicine and Rehabilitation, Bombay, indicate that at least 44 percent of the patients come from families with incomes less than 200 rupees per month and another 44 percent with incomes between 400 and 600 rupees per month. Similar results are reported by Sahasrabudhe and Sancheti. In their sample of the disabled from 22 villages in Pune district, 27 percent were unemployed and 87 percent were from families with per capita incomes less than 70 rupees per month. Even in the high-income countries, the disabled tend to come from low-income families. 

 

GD Shukla, SC Sahu, RP Tripathi and DK Gupta in their research a psychiatric study of amputees (1982) Psychiatric manifestations were studied in 72 amputees in the post- operative period. All were right handed. Besides phantom limb phenomena, which were observed in nearly four-fifths of the cases and are described in another paper, nearly two-thirds had psychiatric symptoms in the form of depression (45 patients), anxiety (38), crying spells (38), insomnia (34), loss of appetite (23), suicidal ideas (21) and psychotic behaviour (2). Right arm amputees had phantom phenomena and insomnia significantly more often than left. Nearly one-fifth of the cases were diagnosed as having psychotic depressive reactions, two- fifths as having depressive neurosis and two, both with right upper limb amputations, as schizophrenic.

A study done on reasons for amputation at the Government Institute of Rehabilitation Medicine, K.K. Nagar, has found that a majority of patients lose their limbs following a road accident .Amputation due to complications resulting from diabetes was ranked second. (R.Sujatha)

 

GENERAL OBJECTIVE

To study the various challenges facing by the amputees with special reference to Ernakulum District.

 

SPECIFIC OBJECTIVES

        To know the socio-demographic profile of the amputees

        To study the physical problems of the amputees

        To analyze the psychological problems faced by the amputees

        To understand the various socio-economic problems of the amputees  

 

Participants and Procedures

Total number of samples used for this study is sixty amputees. As the nature of disability associated with loss of external body parts, it usually is very difficult to gather large number of amputees in one location.So purposive sampling is adopted as sampling technique for this study. The samples were collected from General Hospital Ernakulum, Malankara Orthodox Syrian Church Medical College Hospital Kolencheri, Dynamic Techno Medicals Pvt. Ltd Aluva and home based data collections arealso done. Interview Schedule is used for collecting data and they were analyzed with the help of Statistical Package for Social Sciences (SPSS) version 16.

 

KEY FINDINGS

Socio-demographic Profile of the Respondents

·      In this study large number of respondents (25 Percent) belongs to old age group (>60) and among them males are high in number (81.7 Percent).

·      A large number of respondents have educational status below SSLC (50 Percent)   only 13.3 percent belongs to the highly educated group.

·      66.7 percent of the respondents were from rural background.

·      The study shows that 46.67 percent of the amputees are unemployed and 58.3 percent have no income, it includes students also.

 

FIGURE: 1 OCCUPATION OF THE RESPONDENTS

 

Physical Problems of the Respondents

·      Below knee amputation is the common type of amputation (48.3 Percent) in Ernakulam District according to this study.

·      70 Percent of the respondents decreased their outing after surgery.

·      Traveling, for 53.3 percent always a difficult task and 56.7percent travel in rented vehicles. The expenses due to traveling also a reason for decreased traveling.

·      43.3 Percent have the opinion that clothing is not always difficult for them and the same result in the case of bathing and toileting. Because of the difficulty 20 percent made changes to their toilet

·      Wearing of prosthesis is not affordable to a group of people and for another some, it is not a comfortable one (30 Percent).But 55 Percent of respondents have prosthesis always.

·      40 Percent of the respondents are receiving treatment for other diseases or for related diseases also.

·      Majority said that climbing steps is always difficult for them (80 Percent).

·      13.3 Percent of the respondents have asked for controlling their body weight

·      The common causes of amputation are road transport accidents (26.7Percent), peripheral vascular diseases (20Percent), and diabetes (15Percent).

 

FIGURE:2 CAUSES FOR AMPUTATION

 

Psychological problems of the Respondents

·      Sleep disturbances is a common problem among the amputees in the early stages (40 Percent). Symptoms of Depression (35 Percent), suicide thoughts (25 Percent) are the other mental disturbances seen among them. Frustration was a common feature among the respondents after knowing the reality. Fear anxiety, anger, denial were also shown by some of the respondents.

·      58.3 Percent have the Phantom sensation   in their lost body part and 20 percent have the phantom pain.

·      Among the respondents 58 percent are always thinking about their limitations.

·      46.7 Percent said that they are not able to face the problems in their life and this shows low self confidence among them.

·      31.7 Percent of the respondents believe that they are worthless after amputation.

·      From the 60 respondents 26.7 percent feels loneliness always.

·      40 Percent of the amputees believe the disability as their fate.

·      No single respondent received any kind of related counseling.

 

Socio-economic problems of the respondents

·      35 Percent of the respondents have the opinion that they have difficulty in attending social functions.

·      Half of the respondents (50 Percent) said that they do not want other’s sympathy.

·      21.7 percent have no interest to keep adequate relationship with the society.

·      The 10 percent of the respondents have the opinion that they are not getting any kind of encouragement from the society. 

·      Amputation is a life changing   process and it also affected the hobbies and interests of the amputees. The 62.3 percent of the amputees changed their hobbies after the surgery.

·      18.3 percent of respondents said that they are not sharing problems with no one and 53.3 percent share with their own family members.

·      68.3 percent   among the respondents were the bread winners of their family. They say that amputation made them unproductive.

·      For 58.3 percent of the respondents, they have financial difficulties and 70 percent of the respondents getting financial support within the family itself. But 3.3 percent of people not getting any kind of financial support.

·      Here the study says that 71.7 percent of the amputees are not a member in any kind of association.

·      From the government, 36.7 percent of the respondents getting disability pension and 13.3 percent got benefits from some NGO’s for their operation and for fitting of prosthesis. But 46.7 percent are not receiving / received any kind of benefits from anywhere.

·      Among the total respondents 58.3 percent have the opinion that their dreams and plans were broken because of amputation.

·      5 percent of the respondents said that their disability made changes in the attitude of the family members towards them and 13.3 percent said that amputation affected other relationships also.

·      41.7 percent have no hope towards their future.

 

RECOMMENDATIONS:

·      Prevention is always better than cure. So amputation can be prevented by the proper enactment of laws, rules and guidelines, and introduction of modern equipments. Number of accidents can be minimizedby making traffic rules strict. Smoking should be banned because it may cause nicotine deposit in human body and may lead to amputation. Diabetics is the another reason for the surgery, so people should maintain a proper control over it.

·      Proper prosthesis fitting is the first step to be done in the case of an amputee as a part of rehabilitation. The correct method of fitting of prosthesis contains 3 stages;

a.      Immediate Post-Operative Prosthesis (IPOP),

b.      Trial (temporary) Prosthesis,   and final stage is

c.      Definitive Prosthesis.

This will help to reduce the feelings of the lost limb and also it reduces the energy expenditure, but in our country very few follows this method.

·      Pre and post amputation counseling are necessary steps .To the person who is undergoing amputation must be explained the need and importance for the surgery and prepare him for it. After amputation adequate motivation should be given to him for proper running of life. Counseling should involve the proper usage of prosthesis, in which maintenance of prosthesis, don and doff of the prosthesis are very important.

·      Intervention programmes can be given for their psychological well-being.

·      The need of proper and regular exercises should be explain to them and how to keep the limb in the correct position also comes under the counseling process.

·      Employment helps a man to be independent and it solves a major part of issues in his life. Like government sector, the private sector also can engage these people in jobs. There are so many jobs these people can do with ease. So by giving this opportunity we are helping them to lead a better life.

·      Awareness of the different programmes of both the state and central government should be given to these people; like the pension schemes, concessions in job opportunities,    traveling concessions.

·      They are getting only a small amount of pension from the government and at present times, it never satisfies their needs.So the government should increase their pension.

·      Support groups can be created under the guidance of professionals. By seeing and hearing from the people with similar problems will reduce the psychological issues of the amputees.

·      Here in our country no special publication for this group, so from this study the researcher feels that magazines publishing the stories of successful amputees will inspire others to live with hope. That kind of approach will make them more confident.

·      The children of amputees should get some concessions in their studies according to their socio-economic background.

·      Mainly the cause of unemployment is lack of initiative from the part of the respondents so the motivation classes should be given to them which help them in finding out jobs that they can do comfortably.

·      Awareness should be given to family members and friends, instead of showing sympathy, treat them as normal persons. And that will help them to work for their future.

·      They must organize and show their strength.

·      The media should play a vital role in the promotion of the respondents.

·      Religious and Social institutions must take active part to giving awareness to people about the problems of amputees and help them to be active in the society.

·      People participation is the immediate help that can be provided to these people.

 

CONCLUSION:

As a summary, road accidents are the main cause and amputation results in an increased risk for functional disability, psychological distress and severe socio-economic problems among amputees. For a major portion of amputees, it is not affordable to buy a good prosthesis as most of them are from poor socio-economic background. Moreover   they have to wait for a long period to obtain free prosthesis provided by the government. Rather than giving sympathy, considering  them as normal persons will help them to face the challenges of life in a better way. Financial difficulty is the severe issues among amputees, instead of giving fish teach them how to catch fish. Doing a job will help them to regain their self-esteem and confidence. The attitude of society and family members need to be changed, high family-public consciousness will affects their activity level so promote their positive mental health and bring them back as a normal person to the society.                          

 

REFERENCES:

1.     Bhaskaranand, K., Bhat, A. K., and Acharya, K. N. (2003). Prosthetic rehabilitation in traumatic upper limb amputees(an Indian Perspective). Archieves of Orthopaedic and Trauma surgery.Springer Berlin / Heidelberg publishers, 123, pp 363-366.

2.     Brugger,P;(2008), The phantom limb in dreams, Journal of Consciousness and Cognition, Elsevier Inc,  17( 4),pp. 1272-1278   .

3.     Chow S.P,(1982)SocialProblems of  Lower limb Amputees  In Hong Kong- an exploratory study,Bulletin HK Med Association, Department of Orthopaedic Surgery, University of Hong Kong 34,81-85.

4.     Dudek,L.,Nancy,Marks.,B.Meridith,Marshall.,C.Shawn (2006), Skin Problems in an Amputee Clinic,American Journal of Physical Medicine and Rehabilitation, 85(5),pp 424-429.

5.     Francis, R. (2001), Facing amputation surgery, First Step, Amputee Coalition of America,2,pp5-6.

6.     Hall MK Donovan- , L Yardley, RJ Watts . (2002)Engagement in activities revealing the body and psychosocial adjustment in adults with a trans-tibial prosthesisProstheticOrthotic Int., l26 (1), pp15-22. Available at www.oandp.com/news/jmcorner/2001-09/i-xix.pdf.

7.     Koc, E., et al., (2008), Skin problems in amputees: a descriptive study, Departments of Dermatology, and Orthopedics and Traumatology, Gulhane Military Medical Academy, Etlik, Ankara, Turkey. Available at www.ncbi.nlm.nih.gov/pubmed/184128622008 May; 47(5):463-6.

8.     Kulkarni, J., Gaine, W.J, Buckley, J. G, Rankine, J. J., Adams, J., (2005).Chronic low back pain in traumatic lower limb amputees, Royal Society of Medicine, pp, 396-399.Available at www.ncbi.nlm.nih.gov/pubmed/15704512.

9.     Kitowski VJ, Leavitt LA (1968),Rehabilitation of a quadruple amputee, Southern Medical Journal,Sep; 61(9), pp 912-914. 

10.  Laatsch L, Rothke S, Burke WF (1993). Counter transference and the multiple amputee patients: Pitfalls and opportunities in rehabilitation medicine. Arch Physical Medicine Rehabilitation 74, pp 644-648.

11.  Mohan, D. (1986), A report on amputees in India, Digital Resource Foundation for the Orthotics and Prosthetics Community Virtual Library Project,40(1).

12.  Olaogun M.O.B., Lamidi E.R ( 2005), Appraisal of lower-limb amputations and some rehabilitation problems of amputees: a retrospective study in Nigeria,Journal, 15(1), pp1-7.

13.  Rick, B. (2003). The team approach to amputee rehabilitation. First Step, Amputee Coalition of America, Manassas, 3, pp. 24-26.

14.  Sujatha R. (2011),Road accidents are main cause of amputation. The Hindu, available at m.the hindu.com>Cities>Chennai, July 6, 2011.

15.  Sabolich, J., (1993),You are not alone, New York University of Prosthetic and Research Centre, New York.

16.  Shaw M, Kaplow M, Mitchell N, Stillwell D (1977),Traumatictriple amputation: psychosocial problems in rehabilitation. Arch Physical Medicine Rehabilitation 58(10), pp 460-462.

17.  Shukla GD, Sahu SC , Tripathi RP and Gupta DK (1982) A psychiatric study of amputees  The British Journal of Psychiatry The Royal College of Psychiatrists, 141: pp50-53.

18.  Sinha, R., Heuvel, W. V., and Arokiasamy, P. (2011). Factors affecting quality of life in lower limb amputees. Prosthetics and Orthotics international. March; 35(1):pp9096.

19.  Smith D.G.,et.al; (1995) Prosthetic History, Prosthetic Charges, and Functional Outcome of the Isolated, Traumatic Below-Knee Amputee,The Journal of Trauma: Injury, Infection, and Critical Care, 38(1): pp44-47.

20.  Winchell, E.,(2003), Self-Esteem:Isolation,Alienation and Loneliness, First-Step, Amputee Coalition of America, 3:pp7-9.

21.  Williamson, G. M., and Walters, A. S. (1992), Perceived Impact of Limb Amputation on Sexual Activity: A Study of Adult Amputees, Clinical Psychology Review, 12(3), pp 275-291.

 

 

Received on 13.03.2016

Modified on 30.05.2016

Accepted on 23.06.2016

© A&V Publications all right reserved

Research J. Humanities and Social Sciences. 7(3): July - September, 2016, 166-172

DOI: 10.5958/2321-5828.2016.00027.9