Table Of ContentAmputation, Prosthesis Use,
and Phantom Limb Pain
Craig Murray
Editor
Amputation, Prosthesis Use,
and Phantom Limb Pain
An Interdisciplinary Perspective
Editor
Craig Murray
School of Health & Medicine
Division of Health Research, Bowland Tower East
Lancaster University
Lancaster LA1 4YT, UK
[email protected]
ISBN 978-0-387-87461-6 e-ISBN 978-0-387-87462-3
DOI 10.1007/978-0-387-87462-3
Springer New York Dordrecht Heidelberg London
Library of Congress Control Number: 2009939836
© Springer Science+Business Media, LLC 2010
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Contents
1 Developing an Interdisciplinary Perspective on Amputation,
Prosthesis Use, and Phantom Limb Pain: An Introduction .................. 1
Craig Murray
2 Need-Directed Design of Prostheses and Enabling Resources .............. 7
Elaine Biddiss
3 Ethical and Medico-Legal Issues in Amputee Prosthetic
Rehabilitation ............................................................................................ 23
Jai Kulkarni
4 Monitoring of Upper Limb Prosthesis Activity
in Trans-Radial Amputees........................................................................ 33
Mohammad Sobuh, Laurence Kenney, Phil Tresadern,
Martin Twiste, and Sibylle Thies
5 Adaptation to Amputation and Prosthesis Use ...................................... 65
Elisabeth Schaffalitzky, Pamela Gallagher, Deirdre Desmond,
and Malcolm MacLachlan
6 Understanding Adjustment and Coping to Limb Loss
and Absence through Phenomenologies of Prosthesis Use .................... 81
Craig Murray
7 Return to Work After Amputation .......................................................... 101
Helena Burger
8 Gender, Sexuality and Prosthesis Use: Implications
for Rehabilitation ...................................................................................... 115
Craig Murray
9 Post Amputation Chronic Pain Profile and Management ..................... 129
Jai Kulkarni and Kate Grady
v
vi Contents
10 Phantom Limb Pain; Prevalence, Mechanisms
and Associated Factors ........................................................................... 137
Cliff Richardson
11 Management of Phantom Limb Pain .................................................... 157
Kate MacIver and Donna Lloyd
12 Virtual Solutions to Phantom Problems: Using Immersive
Virtual Reality to Treat Phantom Limb Pain ....................................... 175
Craig Murray, Stephen Pettifer, Toby Howard,
Emma Patchick, Fabrice Caillette, and Joanne Murray
Index ................................................................................................................. 197
Contributors
Dr. Elaine Biddiss is a researcher at the Bloorview Research Institute, University of
Toronto, Canada. Her research interests include wearable sensors and actuators; user-
centered, context aware interfaces; and multi-modal feedback. She has published
widely on prosthesis use, including on consumer design priorities for prostheses.
Helena Burger is a researcher at the Institute of Rehabilitation, Ljubljana,
Slovenia. She has published extensively on amputation and prosthesis use, includ-
ing the topics of service provision and evaluation of prosthesis use.
Dr. Deirdre Desmond is a Lecturer in Psychology in the Department of Psychology
at the National University of Ireland Maynooth and co-director of the Dublin
Psychoprosthetics Group. Her interest in psychosocial adjustment to amputation
and prosthesis use stems from her doctoral work which was completed at Trinity
College Dublin in collaboration with the British Limbless Ex-Service Men’s
Association. Dr. Desmond is currently serving as an Associate Editor with
Prosthetics and Orthotics International, the official journal of the International
Society for Prosthetics and Orthotics (ISPO).
Dr. Pamela Gallagher is a Senior Lecturer in Psychology in the Faculty of Science
and Health, School of Nursing, Dublin City University, Ireland. She co-directs the
Dublin Psychoprosthetics Group (www.tcd.ie/psychoprosthetics): a unique multi-
disciplinary group of international researchers and clinicians interested in applying
many and varied aspects of psychology to prosthetic use.
Dr. Kate Grady is a Consultant in Anaesthesia & Pain Medicine at University
Hospital of South Manchester, UK.
Toby Howard is a Senior Lecturer in the School of Computer Science at The
University of Manchester, UK, and a founder member of the Advanced Interfaces
Group. His research interests include applications of virtual environments to inter-
disciplinary research such as psychology, and to real-world problems, with particu-
lar application to scene-of-crime reconstruction and forensic analysis. He also
works on non-photorealistic computer graphics, and is enthusiastic about academic
outreach and public understanding of science.
vii
viii Contributors
Laurence Kenney is a Senior Research Fellow with the Centre for Rehabilitation
and Human Performance Research at the University of Salford, UK. His research
focuses on the development and evaluation of rehabilitation technologies, particu-
larly prosthetics and functional electrical-stimulation systems. He received his PhD
in engineering design from the University of Salford and is a member of the
Institute of Physics and Engineering in Medicine. He has recently been appointed
Associate Editor for Prosthetics and Orthotics International.
Dr. Jai Kulkarni, MA, FRCP, is a Consultant and Honorary Reader in Rehabilitation
Medicine at the University Hospital of South Manchester, UK. His main interests
are amputee rehabilitation and neurological rehabilitation. In the field of amputee
rehabilitation his active interests are in falls, post-amputation pain management,
post-amputation arthritis and congenital limb deficiencies. He has co-authored a
succinct white coat pocket book on prescribing upper limb prosthesis and has close
links with both the University of Salford and the University of Manchester.
Dr. Donna Lloyd is a Lecturer in Psychology at the University of Manchester, UK.
Her main research interests are the mechanisms underlying sensory processing,
body perception and spatial awareness in healthy and clinical populations using
cognitive neuroscience techniques including functional magnetic resonance imag-
ing (fMRI). More recently, her work has explored the behavioural and neural
mechanisms underlying phantom sensations and illusory sensations of touch. Her
recent papers include “Phantom limb pain, cortical reorganisation and the therapeu-
tic effect of mental imagery” (Brain, 2009), and “Development of a paradigm for
measuring somatic disturbance in clinical populations with medically unexplained
symptoms” (Journal of Psychosomatic Research, 2008).
Kate MacIver has worked in pain management for the past 13 years – for the past
4 years as a Research Fellow at the Pain Research Institute in Liverpool, UK, and
prior to that as a Clinical Nurse Specialist in pain management at the Walton Centre
for Neurology and Neurosurgery also in Liverpool. Her research interests include
quantitative sensory testing and mechanisms of neuropathic pain; phantom limb
pain; central pain in multiple sclerosis and spinal cord injury.
Professor Mac MacLachlan is an Associate Professor in the School of Psychology
and Centre for Global Health, Trinity College Dublin. His research interests are in
psychoprosthetics and disability, culture and health, and organisational aspects of
international aid. Much of his research is currently based in Africa. He is Extraordinary
Professor of Disability and Development, at the Centre for Rehabilitation Studies,
Stellenbosch University, South Africa; and Research Advisor to the Southern African
Federation of the Disabled. Mac has a longstanding interest in disability spanning
voluntary work, practice as a clinical psychologist, consultancy and as a researcher
and lecturer.
Dr. Craig Murray is a Senior Lecturer in Psychology in the Institute of Health
Research at Lancaster University, UK. He is particularly interested in embodiment and
mental health and has been involved in a number of projects surrounding amputation,
Contributors ix
prosthesis use and phantom limb pain for the past 15 years. He is editor of the
Psychological Scientific Perspectives on Out-of-Body Experiences (2009 Nova Science
Publishers, New York).
Joanne Murray is a Research Associate at the Institute of Health Research,
Lancaster University, UK.
Emma Patchick is a Research Associate in the School of Psychological Sciences
at the University of Manchester, UK.
Dr. Steve Pettifer is a Senior Lecturer in The School of Computer Science at The
University of Manchester, UK, and a member of the Advanced Interfaces Group.
His research interests include virtual environments, scientific visualisation, distrib-
uted computing and human computer interaction. Much of his current research
revolves around making data in the life sciences comprehensible through interac-
tive visualisation techniques.
Elisabeth Schaffalitzky is a Research Student in the School of Nursing, Dublin
City University, Ireland.
Mohammad Sobuh received the BSc degree in Orthotics and Prosthetics from
the University of Jordan in 2004, and his MSc by research degree in upper limb
prostheses from Salford University in 2008, and is currently carrying out his PhD
in upper limb prostheses, also at Salford, UK. His MSc research has focused on
upper limb prosthetic evaluation and activity monitoring. His research interests
include upper limb prosthetic kinematics, upper limb prosthetic evaluation and
activity monitoring.
Cliff Richardson, BSc (Hons), RGN, MSc, PhD, is a Lecturer in Adult Nursing at
the University of Manchester, UK. His nursing career (London, Manchester,
Bolton) was mainly focussed on the care of surgical patients. In 1993 he set up and
ran an acute pain service. In 1999 he took up a fellowship at Liverpool John Moores
University and the Pain Research Institute where he completed his PhD on phantom
limb pain. He moved to Manchester University in 2004.
Dr. Martin Twiste is a Senior Lecturer at the University of Salford, UK, within the
Directorate of Prosthetics & Orthotics. His research focuses on upper and lower
limb prostheses with particular emphasis on motion analysis, quantifying prosthetic
component behaviour, and designing improved prosthetic components. Recent
studies investigated the effects of lateral whip gait deviations, of a self-aligning
prosthetic foot, of alignment changes, and of prosthesis properties on amputee gait,
as well as the characteristics of upper limb prosthetic movement in reaching and
grasping, and the relationship between socket design and low levels of usage and
functionality in myoelectric prostheses.
Chapter 1
Developing an Interdisciplinary Perspective
on Amputation, Prosthesis Use, and Phantom
Limb Pain: An Introduction
Craig Murray
The impetus for the current book developed from the establishment of the
Interdisciplinary Prosthetics Research Network in the United Kingdom, which held
a conference to develop the book in June 2008. The aim of the conference was to
encourage dialogue between the range of professionals and disciplines engaged in
research and practice related to limb loss and prosthesis use. To this end, the
Network and contributors to the book include biomedical engineers, computer sci-
entists, nurses, prosthetists, psychologists, neuroscientists, and rehabilitation con-
sultants, along with world-renowned research groups that have specialisms in the
themes of the book (for example the Advanced Interfaces Group at the University
of Manchester, the Pain Research Institute at Liverpool University, and the Centre
for Rehabilitation and Human Performance Research at the University of Salford).
In addition, the group has a wide range of multi-disciplinary, world-wide research
collaborators, some of whom have made chapter contributions here.
The book focuses on the related topics of amputation, prosthesis use and phantom
limb pain, written by contributors who are leading researchers in their field. It com-
prises three broad inter-related sections, which together elucidate key developments
and thinking within these topic areas. Following this introductory chapter in which
the topics and chapters of the book are overviewed, the first section concentrates on
the work of prosthetists and biomedical engineers and comprises three chapters.
Together these chapters explicate the processes involved in prosthetists’ work with
clients in a manner which will be of interest to students and professionals from a
range of disciplines.
In the first of these, Elaine Biddiss, a biomedical engineer, argues that user-
centred design is essential to the development of prostheses that better meet con-
sumer needs. Consideration of this leads to priorities directed towards improving
comfort (e.g., by reducing the weight of current devices), life-like function and
appearance, and enhanced sensory feedback. Biddiss discusses how prosthesis
C. Murray
School of Health and Medicine, Division of Health Research, Bowland Tower East,
Lancaster University, Lancaster, LA1 4YT, UK
e-mail: [email protected]
C. Murray (ed.), Amputation, Prosthesis Use, and Phantom Limb Pain:
1
An Interdisciplinary Perspective, DOI 10.1007/978-0-387-87462-3_1,
© Springer Science+Business Media, LLC 2010
2 C. Murray
acceptance and quality of life can be increased with reduced costs and more
efficient funding for prostheses and healthcare services, better access to repairs
and maintenance, and by having multiple and activity-specific prostheses. She
also suggests that prosthesis acceptance rates and consumer satisfaction can be
improved with timely fitting and by involving consumers actively in the selection
of their prosthesis.
Next, Jai Kulkarni, a clinician responsible for the provision of prosthetics in a
large regional area of the UK, presents a range of ethical and medico-legal issues
for rehabilitation professionals in the supply and withdrawal of prostheses and
assistive technology for people with limb loss or deformity. He argues that the
primary duty of the clinician is to act in the best interests of the patient. However,
until recently the ethical considerations involved in amputee prosthetic rehabilita-
tion have not been fully reflected upon. The ethical principles of relevance here
include respect for autonomy, non-maleficence, beneficence and justice. Kulkarni
outlines how ethical dilemmas arise in relation to goal setting, patient selection,
resource allocation, teamwork issues and the expectations of patients. In consider-
ing these issues as they arise in the UK, Kulkarni notes there is an element of
rationing in health service provision due to lack of resources and doctors are pushed
into the role of gatekeepers. The issues discussed here are not particular to the UK,
indeed Kulkarni suggests that these issues are common concerns for different coun-
tries and settings, even when the practical mechanisms by which service provision
is implemented differ.
In the final chapter in this section, members of the Centre for Rehabilitation and
Human Performance Research at the University of Salford present the development
of an innovative computerised technique for monitoring upper limb prosthesis
activity. These researchers argue that the traditional methods for evaluating the
functionality provided by upper limb prostheses lack sufficient validity. In response,
they report on the development of technology to classify upper limb activities using
an artificial neural network as a first step towards the development of an
accelerometer-based activity monitor for prosthetic evaluation. Presenting their
empirical data on this, the authors suggest that movement patterns of upper limbs
in amputees associated with a particular tightly-defined set of tasks are sufficiently
characteristic to be distinguished from each other using a neural network. They
conclude by discussing further work needed to explore the performance of the
classifier in a less constrained environment as a requirement before a definite
conclusion can be drawn as to the viability of such an approach.
The next section of the book focuses on psychological and practical aspects of
amputation, limb deficiency and prosthesis use. The first of four chapters, written
by members of the Dublin Psychoprosthetics Group, explores the ways in which
people adapt and cope with limb loss and using a prosthesis, the potential for positive
adjustment and strengths emerging from the experience, pain, affective distress,
issues around identity, body image and the construction of self and quality of life.
It also considers the importance of these issues for health service providers across
the multi-disciplinary team who work with people with limb loss. The authors con-
clude that the ways in which people respond to amputation and prosthesis use are
