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physician's recommendations for dietary control combined with moderate exercise. The
little walking he did was confined to assisting
customers in bis store. After work, he drove
home and relied on his car even for 2-block
errands. At his wife's insistence, he began taking evening strolls with her, but found tbat calf
cramping made walking uncomfortable. Eventually, he capitulated to his children's urging
that he sell the business. Thereafter, he stayed
home except for when he had medical appointments. The medication his intertiist prescribed did not alleviate his leg pain. His wife
noted that AB had developed an ulcer on the
plantar surface of the right foot. He was tinaware that a tack had worked its way through
the sole of his favorite shoe. The internist prescribed topical ointment intended to heal the
ulcer. Soon after, the foot became gangrenous.
The couple consulted an acupuncturist recommended by a neighbor. Two sessions
proved futile. They made an appointment
with a podiatrist, who insisted that they go directly to the emergency room of the local hospital. After examining AB's foot, the attending stirgeon amputated the right leg below the
From the College of Physician and Surgeons,
knee at the musculotendinous junction.
Columbia University, New York, NY
The surgeon applied an elastic compresCorresponding author:Joan E. Edelstein, MA, PT, FISPO,
200 E 74th St - 12 E, New York, NY 10032 (e-mail: sion dressing to the amputation limb. AB rejoaneedelstein hotmail. com).
mained in the hospital for several days until
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strengthening program, AB was willing to alter his diet to one more appropriate for diabetes management.
AB also met with the occupational therapist (OT) at the center. She assessed his
functional skills and psychosocial status, especially his expectations regarding rehabilitation. She questioned AB regarding the home
environment, particularly the presence of
door sills, stairs, and other potential mobility hazards. After the initial assessment
the OT conferred with the PT and physician to develop a comprehensive rehabilitation program. Occupational therapy for
AB emphasized self-care, particularly managing trousers, socks, and shoes; maintaining unipedal balance while standing to urinate, and selecting an appropriate wheelchair.
She made certain that the wheelchair provided stable seating for AB who was 50 lb
overweight. She obtained an adaptor to the
wheelchair to displace the rear wheels posteriorly so that the wheelchair would not tip
when AB ascended ramps. After evaluating
the adequacy of the w^heelchair, the OT taught
AB how to maneuver it indoors, on sidewalks
and streets, and the best way to transfer it
to the automobUe. AB responded positively
to his growing repertoire of functional skills,
both from an overall sense of self-confidence
and from relief that he would not have to
burden his wife quite as much. He w^as especially thankful that he could use the toilet
independently.
RM, 84 years of age, sustained right
transtibial amputation 6 months ago, as a result of arteriosclerosis. Since her hospital discharge in a wheelchair without a prosthesis,
she has remained at home staring at television situation comedies. She is a widow who
never worked outside the home. Her children
and grandchildren live 500 miles away and
visit her once or twice a year. Her only regular caller is the delivery man who brings her
meals on wheels 5 days a week. Before she
w^as discharged from the acute care hospital,
her PT showed RM several simple strengthening exercises. She did the exercises under the
therapist's supervision, but has not continued
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EDELSTEIN
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None of the subjects was willing to accept the emotional cost of involving oneself in
physical therapy. Although the monetary cost
was meticulously documented by the accountant, SN, he and the other two were reluctant to invest in the physical effort demanded
by physical therapy. It is one thing to be a
passive recipient of medical care, including
physical therapy, and quite another to exercise actively on a regular basis. Practical considerations also undermined participation in
physical therapy. Arranging for home visits
from a PT w^as overwhelming, particularly for
RM. Maneuvering into automobiles was daunting for all 3. Although the cost of physical
therapy w^ould be reimbursed by Medicare
for all of them, they carried with them the
indelible lesson of the Great Depression of
1929 which taught that money could vanish
overnight and thus must be spent very carefully. RM was a 9-year-old girl at the time of
the stock market crash. Her family could not
afford to continue her piano lessons, vacation
trips were eliminated, and even meals became
skimpy.
The final component of the motivation
equation. Inclination to Remain Sedentary, is
most exemplified by RM. She had a negative, stereotypical view of herself as someone who never did and never could exercise.
"Nice girls do not sweat." Years ago, moving
against resistance was viewed as unseemly;
exercise was solely the province of child's
play. She was raised to be a wife, mother, and
homemaker, roles that she fulfilled magnificently. The message was reinforced by her
steady diet of television viewing. Advertisers often display glamorous young women
as spokespersons, and RM's favorite situation
comedies often depict older adults as doddering, out-of-touch fuddy-duddies. Exercise
programs show svelte, well-muscled men and
women vigorously swaying and stepping. Promoters of exercise equipment, while promising strength and stamina in "jtist a few minutes a day," usually cast male and female
body builders as their representatives. None
of these are productive role models for RM,
so understandably she found a sedentary life
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to accomplish a given clinical goal to maintain tbe patient's motivation by adding variety to the program. For example, quadriceps
strengtbening can be achieved witb seated
leg lifts with various resistance media, such
as sand bags, plastic bags of rice or dried
beans, rubber ribbons, or manual resistance
provided by the therapist or family member.
Standing quadriceps exercises might be done
one day witb knee bends with hands on a
stable surface, and another day by kicking a
bean bag in a game playing mode. The therapist must be aware of the cost of exercise,
not just the reimbursed dollar amount, but
also the metabolic toll tbat the patient is likely
to experience. Safety should be overt, especially for older patients, Tbe therapist should
direct the person's attention to monitoring
techniques, such as periodic pulse measurement and questioning regarding perceived exertion. Some individuals are afraid of injuring
arthritic joints or precipitating an adverse cardiopulmonary event. Instructions sbould be
written,'" printed in a font large enougb for
those with diminished vision to read. Written instructions are more likely to be followed
than are oral directions. Language sbould take
into account tbe patient's English reading ability. Urging tbe patient to record activity in
a diary or logbook can be highly motivating, wbether or not measurable strengtbening
occurred.
Pbysical tberapy can take place in many
venues. While most people with amputations
are treated as outpatients once tbe amputation wound has healed, home care becomes
increasingly important. Keying exercises to
television commercials is one way of sustaining motivation while providing ample opportunity to exercise witbout risking an excessive
number of repetitions. Participation by family or neighbors can also make exercise more
enjoyable.
Senior centers offer varied programs of
physical and intellectual offerings in a social environment. Being able to get back
into the community is a major motivation
for many older people. Exercising witb peers
who also must defeat negative, ageist stereo-
types is emotionally and physically advantageous. Being able to partake in senior center activity, however, involves coping with
transportation,"'^ The patient must be able
to depart from the home and transfer into the
van or other vehicle. Some centers have home
outreach via telephone contacts, A local center, for example, has a daily conference call
with 12 members wbo are led in seated exercises by a pbysical tberapist phoning from
the center. Mall walking is highly motivating
for some people. The climate-controlled environment is constantly changing witb new
store displays. Ramps and curved walkways
provide additional variety, and benches are
placed at convenient intervals. As with senior centers, mall walking lends itself to
group activity, which in itself creates a motivating atmosphere,'^ Wherever rehabilitation
occurs, for exercise to be sustained over a
long period the patient must derive enjoyment from developing skills througb therapeutic exercise,''' Tburston and Green analyzed exercise on prescription schemes as an
alternative to biomedical approaches to the
management of healtb problems.
Three older adults with lower-limb amputation illustrate the 4 components of tbe
motivation equation. All indicated tbat tbey
thought tbey never could succeed witb
rehabilitationeither because of focusing on
other aspects of tbeir amputation sucb as
monetary compensation, or discouragement.
Until the person can recognize the importance and relevance of physical therapy and
occupational therapy to achieving short-term
goals, such as secure sitting balance and
safe transfers, and long-term goals of using a prostbesis successfully, motivation will
be minimal. Some individuals, such as RM,
require additional rehabilitation services in order to thrive. The other aspects of tbe motivation equation also pertain to treating patients
witb lower-limb amputation. The PT, OT, and
other rehabilitation team members need to acknowledge the costs of exercise, both monetary and physiological, as well as the incentive to resist change and remain sedentary.
The media exerts a powerful influence by
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EDELSTEIN
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