Chapters Transcript Video Improving Outcomes Following Limb Loss Stephen T. Wegener, Ph.D., A.B.P.P. presents at the Johns Hopkins Department of PM&R’s Grand Rounds on May 7, 2015. Good day. I'm Doctor Steve Wagoner, the Director of Rehabilitation Psychology and Neuropsychology in the Department of Physical Medicine and Rehabilitation. We're going to talk today about the role of rehabilitation psychology in improving outcomes following limb loss. Approximately 2 million people in the United States are living with limb loss. Today, the most common causes of limb loss are peripheral vascular disease, trauma and cancer. We need to remember that most people who experience a limb loss, recover well and lead full and active lives. However, there are challenges in recovery. One issue is access to rehabilitation and appropriate prosthetic care. Folks are challenged to regain their function, maximize their independence, activities of daily living, manage the comorbidities that can come from the conditions that lead to limb loss. And finally, they will seek to integrate into the community and return to participation in life activities. While many do well, there are problems in recovery. Access to care is an issue for many which we are working to solve here at Hopkins. In addition, approximately 25 to 30% will develop clinical depression at some point in their lifetime living with limb loss and often overlooked are the elevated levels of anxiety, specifically PTSD for individuals who experience traumatic amputation. Finally, chronic pain is a condition that impacts many people recovering with limb loss, including phantom, limb pain, residual limb pain, back pain, and pain. In the non amputated leg. Often due to overuse to get good rehabilitation outcomes following limb loss. We need a team approach. This includes the physiatrist, the rehabilitation physician, PTOT, a prophet, a psychologist, most importantly, the patient and their family play the key role. And also we need to think about the role of peer support and consumer organizations in this process. Let's talk briefly about a case study where these factors came to play. This is a case of a 52 year old man who had a traumatic transtibial that is below the knee amputation following a motor vehicle crash, he had no significant preexisting medical or psychiatric history. There was a brief loss of consciousness approximately less than five minutes but no head trauma was noted on imaging and the cognitive functioning on assessment was within normal limits. He was married, college educated and was full time employed prior to his injury. Fortunately, he received comprehensive rehabilitation, a team approach that we described earlier, the patient had achieved independence in all their ADLs and was able to emulate for long distances and had returned to work part time. The patient presented for psychological evaluation approximately one year, post amputation. Something we often see once people begin to return to life problems do emerge. He presented with a case of mild depression on the patient health questionnaire. Nine, a common screening instrument hit a score of eight which suggested mild depression characterized by loss of pleasure in living periods of sadness withdrawal. However, his vegetative functions were undisturbed. He also demonstrated a mild anxiety reflected in a general anxiety scale of seven characterized by worries about negative events that could befall his family. Finally, he was experiencing chronic pain with an average score of 5 to 10 in the residual limb. And in the back, he had been treated with gamma pentin and physical therapy and had some improvement but he was reluctant to use opioids for fear of complications and addiction. We took a comprehensive psychological approach to his care. First of all, we addressed his depressive and anxiety symptoms which in fact, often complicate pain control. We started with cognitive behavioral therapy, identifying negative thinking and managing his negative catastrophizing thoughts. We developed behavioral activation to address his withdrawal and had him begun to maintain a positive events diary. So he became associated with the positive events happening in his life. We monitored his symptoms and deferred referral for medication evaluation. At this time, we then tackled the chronic pain problem beginning with relaxation training to help him calm his mind and calm his body and the use of cognitive therapy to manage negative thinking and develop his self efficacy or sense of control over his pain. And in conjunction with his rehabilitation, developed a comprehensive pain management plan he could use when his pain became exacerbated. In addition, we referred him to a peer support group. So we connect with others who are experiencing similar problems, heed him to the amputee coalition to connect with a broader group of people who are experiencing limb loss. And he completed our next step self management program course online. The outcome in this particular case was good. His depression symptoms improved, his anxiety symptoms improved as well as his pain control. He returned to working full time and in fact began to give back as a peer visitor in our amputee program here at Hopkins. If you'd like to learn more about how to access rehabilitation psychology services, visit our website. Thank you for your interest. Created by
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