A Paradigm Shift in Amputee Rehabilitation: An Experience from Level I Trauma Centre of India

Mir N, Sagar S^*

Division of Trauma Surgery and Critical Care, JPNATC, AIIMS, New Delhi, India

Loss of limb/ body part has always been a very traumatic experience for any person. It is considered to be a mutilating surgery often seen in war victims. Amputation of extremity carriers a huge burden, particularly in developing nations, as they are one of the major causes of morbidity and mortality among trauma patients^1,2,3. According to the 2019 Global Burden of Diseases (GBD) report, India has over 23,500 new cases of amputations annually, with about 20,200 of these cases being men and 3,300 being women⁴. As per an epidemiological study published in 2022 from a level I trauma centre, post-trauma amputation incidence in road and industrial accidents is 2.5%, highlighting the need for road safety protocols, patient transfer methods, and hospital up-gradation⁵. The average footfall of amputees at level -I trauma centre is 200-220 patients, but there is lack of regular update of amputation registry in India, leading to knowledge gap. This has resulted in improper planning, policies, and programs for the same. It is urgently necessary to maintain registry data of amputees in order to formulate policies at various levels for prevention and treatment, as well as to ensure their good health, better opportunities in life, and early rehabilitation. To overcome such challenges, the idea of multidisciplinary team (MDT) originated as an amputation clinic that included a team of surgeons, physiotherapists, wound care nurses, psychologists, prosthetists, and medical social workers to meet the needs of an amputee without any further delay or hassle because amputee care necessitates a holistic approach to their management⁶.

There are multiple challenges faced in a developing nation like India in managing patients following trauma. To begin with, the first and foremost factor for predicting outcome is arrival of patient at the earliest. A study published from a tertiary care centre of India states, rapid transport to the hospital is crucial in road traffic injuries, as the limb salvageability percentage decreases significantly if the patient presents more than 24 hours after injury⁷. Another factor is the brunt of injury is mainly borne by the young adult males, often the only bread winners of the family⁸. To manage such patients, early rehabilitation is essential because it maximizes recovery, avoids problems, and promotes long-term independence and quality of life. It reduces physical limitations, manages pain and psychological distress, improves body image and self-esteem and makes it easier to return to work and social interactions.

Presence of shock at the time of arrival of patient is another important factor predicting mortality of the patients, which was found to be statistically significant in the current study.  Similar kind of findings are available in literature from other parts of the globe on trauma patients⁹. There is a considerable delay in admission to the trauma center following a referral from a peripheral hospital.  However, there is no indication that primary treatment at a peripheral hospital has a beneficial or negative impact on mortality. Similar findings were seen in a study conducted at a medical university of India¹⁰. Despite the efforts, the current state of affairs is unsatisfactory and requires an appropriate referral policy that has been developed and approved by all service providers and that needs to be immediately and strictly enforced in a developing nation like India. Although knowledge of mechanism of injury was considered useful at the scene and making decision while triaging patients, but our study shows strong correlation in predicting outcome of the patients. Similar findings were seen in study conducted in United States, where mechanism of injury is an independent predictor of mortality and functional impairment, and that MOI is an unappreciated determinant of trauma outcomes.  It is suggested that MOI should be regularly taken into account in trauma outcome studies because trauma patients who suffered otherwise comparable injuries showed notable changes in their outcomes depending on the mechanism of their injuries¹¹. Trauma scoring systems provide a quantitative evaluation of the severity of injuries and help in predicting mortality by taking into account a number of variables. The current study shows strong correlation in predicting mortality of amputation patients following trauma, which is supported by a study published in 2024¹².

Apart from physical injuries, an amputee needs psychological help to overcome the trauma of losing the limb. Bed-side grief counselling sessions is one of the first step towards managing psychological distress and acceptance to limb loss¹³. The other physical challenges in an amputation patient are pain management, wound management, stump preparation, early mobility, prosthesis acceptance, gait training and correction and psychosocial reintegration. The ultimate goal of amputee rehabilitation is back to work as early as possible especially in young trauma patients so they become productive in life. Although, females are less affected but only a small number of female amputees successfully receive prosthetic limbs as compared to males. Prosthesis rejection rates among women may be influenced by patriarchal societies in India' prioritization of men's comfort over women's needs, leading to dismissal of genuine concerns as emotional or natural phenomena¹⁴. 

At our level I trauma centre and tertiary care hospital, we receive direct as well as referred patients from neighboring states of Delhi. Out of pocket expenses, inability to procure prosthesis is the major cause of disability; often create a cycle, worsened by stigma and denial of rights. In India, only a few organizations, including Ministry of Social Justice and Empowerment, provide prosthetic devices for disabled individuals at either free of cost or at low cost making it difficult for all to access. With more than 12 years dedicated experience in amputee care, multiple RCTs have been done and are ongoing to provide better care to such patients. Some of them include primary versus delayed closure of stump in lower limb amputation patients following trauma⁸, understanding psychiatry comorbidity after traumatic limb amputation¹⁵, yoga intervention in lower limb amputees following trauma in relation to behavior and quality of life¹⁶, application of immediate post operative prosthesis in traumatic below knee amputation patients¹⁷, immediate post operative prosthesis in transfemoral amputees¹⁸, use of rTMS for managing phantom limb pain in lower limb amputees¹⁹.

Some of our ongoing researches include targeted muscle reinnervation in lower limb amputees, gait analysis in above knee amputees following application of immediate post operative prosthesis, isokinetic versus conventional exercises in amputees, comparison of surgical techniques myodesis versus myoplasty, targeted muscle reinnervation in pediatric population, use of low cost indigenous knee joint in above knee amputees, acceptance and clinical validation of bionic hand in below elbow amputees following trauma,  deployment of low cost robot in managing phantom limb pain in below elbow amputees etc.

An umbrella care and a holistic approach is the need of the hour for managing such patients.

References

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