Abstract

This paper discusses amputation and its causes, its effect on the person, and the different
rehabilitation techniques used by therapeutic recreation specialists. Amputations can occur due to
a variance of reasons as well as at a variance of levels. Many studies are focused on diabetes or
trauma-induced amputations. This paper will endeavor to provide ample information on others.
There are numerous amounts of different rehabilitation techniques and activities, briefly this
paper will discuss five and focus more closely on one activity.

Activities Analysis for People Who Have Had an Amputation

Amputation, as defined by the Johns Hopkins Health Library (What is an amputation?
para. 1), is an acquired condition that results in the loss of a limb, usually from injury, disease,
or surgery (What is an amputation, para. 1). The loss of a limb can be caused by trauma,
cancer, infection, diabetes, peripheral vascular disease, and others (TEXTBOOK, p. 208). People
of all ages can have an amputation. According to Johns Hopkins, amputations are most
commonly the result of peripheral vascular disease (What is an amputation? para.1). Trauma
related amputations are 75% upper extremity (Johns Hopkins, What is an amputation? para. 1).
Military veterans can account for at least twenty of the amputations yearly, even in times of
peace (VHI, p. 1). The effects of amputation are physical and emotional to the patient and can
even have effects on the patients social network. Because the disability is now permanent, the
patient will need rehabilitation and leisure education to help cope with the impact on self-image
and activity (Johns Hopkins, Rehabilitation after amputation, para. 1). Problems with
movement and self-care arise. Therapeutic recreation specialists need to employ the use of many
different modalities with each individual to encompass the range of changes that amputation has
on the client. These modalities and the activities associated with them can improve the clients
quality of life and outlook on their own self-image and therefore are important to understand
completely.
Categorization of amputation is specified by the placement on the limb and the severity
of the limitations on function. There are three major categories; above-the-knee, below-the-knee,
and other (TEXTBOOK, p. 208). These can be broken down even further in order to accurately
describe the placement of the amputation site. Lower-limb amputations can be partial foot,
Symes (ankle disarticulation), below-knee, knee disarticulation, above-knee, hip disarticulation,
and hemipelvectomy while upper-limb amputations can include partial hand, wrist

disarticulation, below-elbow, elbow disarticulation, above-elbow, shoulder disarticulation, and

fore-quarter (Winchell, p. 11). Unilateral amputation occurs when one limb, upper- or lower-, is
taken (Winchell, p. 11). However, a person can have multiple amputations to their body. Bilateral
amputation is when either both upper-limbs or both lower-limbs are lost, double occurs when one
of each is lost (Winchell, p. 11). A person who has lost three or four have multiple amputations
(Winchell, p. 11).
For people who have had amputations, they face new hardships to deal with in their
everyday lives. Individuals respond to their amputation in a variety of ways. Coping with the loss
of a limb can be very difficult. The individual may have responses from transitory shock and
loss, to relief at the cessation of pain or disease, to long-term grief and severe depression (VHI,
p. 20). Their body is different than it had been and self-image issues may arise; the individual
may see themselves as less as they had been (). Having a support system, be it family, friends, or
group of people who have had an amputation, provides the individual with a foundation they can
produce results on. However, an amputation can have negative effects on the individuals
emotional support group. The individual now needs to learn how to live their daily life in a new
way with mobility or movement issues that can impact everyone around them. Those individuals
who suffer a traumatic experience, such as members of the armed forces or motorcycle accidents,
and have an amputation as a result have to overcome the psychological issues that may arise
(VHI, p. 22).
Secondary conditions for amputation are varied among physical, emotional, and mental
facets of the patient. Osteoarthritis, osteopenia/osteoporosis, muscular imbalance, and extreme
back pain concern those with lower limb amputation, according to the NCHPAD (para. 1). Gait
differences can account for osteoarthritis in individuals (NCHPAD para. 1). The Veterans Health
Initiative adds phantom limb sensation, phantom limb pain, mechanical skin issues, pressure

sores, muscle contractures, and degenerative joint disease to secondary concerns (p. 28-33).
Phantom limb sensation in which the person has a distinct sense that the limb is intact, to the
extent that he may attempt to stand or walk on the missing limb (VHI, p. 31) and phantom limb
pain in which the pain varies in intensity, duration and specific quality, ranging from mild
feelings of electrical shock or tingling, to debilitating sensations of shooting, throbbing, or
burning (VHI, p. 31). Skin issues arise from the rubbing and presence of non-permeable
materials covering the limb stumps. These can range from irritation caused by sweat to blisters.
Individuals who have had or need amputation face many aspects of their lives changing.
By focusing their pre-operation time, if that is an option, on making sure the individual
understands the reasoning and scope of the amputation physicians make the mental transition
easier post-operation (VHI). Post-operation, the individual will most likely be having self-image
issues and problems with needing to learn new ways to care of them. Well-balanced program of
body awareness activities, activities that promote constant change, and increase endurance and
balance to promote better physical conditioning are all components to aiding the individual
become accustomed to their new life (TEXTBOOK, p. 48). The Veterans Health Initiative
recommends efforts are directed toward pain control, emotional support, prevention of joint
contractures, skin breakdown and general deconditioning (VHI, p. 19). Individuals who have
had an amputation can lead normal lives and partake in many activities to make more out of the
quality of their life. Adaptive prosthetics open up more opportunities for these individuals. More
and more, adaptive sports programs are being created with all sorts of audiences in mind.
Modalities
Therapeutic recreation specialists use modalities to aid individuals in accomplishing their
goals as they recuperate and learn to live their lives in a new way. Modalities that could be used
to help treat individuals with amputations include sports, community re/integration, animalassisted therapy, meditation, and storytelling. Each of these modalities uniquely assists in the

treatment of the individual. Sports, specifically adaptive sports, according to Zabriskie,

Lundberg, and Groff (2005) contributes to establishing a sense of autonomy and independence
for individuals with disabilities (Heo, Lee, Lundberg, McCormick, & Chun, 2008). Typically
sports provide a community of individuals, a team, vying for the same goal which fosters a
support group for the individual. Community re/integration is supposed to reduce stigma
associated with an acquired disability, practice in a real-world setting the skills that have been
learned in treatment, and gain familiarity with community resources (TEXTBOOK, p. 73).
Animal-assisted therapy uses the animal to help the individual realize their therapy goals. This
can come through taking care of the animal, the animal being trained for symptom recognition,
or activities with the animal, such as horseback riding. Storytelling helps through the individuals
reading, writing, and sharing stories that are meaningful to them (TEXTBOOK, p. 72).
Sports provides opportunities for positive enforcement in individuals. The use of sports
for people with disabilities can reinforce identity, self-satisfaction, determination, and self-worth
in achieving personal goals within the sporting activity. Individuals with amputations can excel
in sports and reaffirm their identity within their own body. Zabriskie, Lundberg, and Groff
posited that involvement in sport to have had a positive influence on their overall health, quality
of life, quality of family life, and quality of social life (Heo, Lee, Lundberg, McCormick, &
Chun, 2008). Quality of life can be enhanced by consistently experiencing positive mood states
(Lundberg, Bennett, and Smith, 2011). In a study done by Lundberg, Bennett and Smith (2011)
the results showed a decrease in total mood disturbance after participation in adaptive sport
programs.
Sports needs the individual to be prepared to physically engage in order to participate.
Dependability, ability to be coached, ability to work with others are all needed for an individual
to do well in an sport, even if it is a single person sport, such as water skiing. Upon assessment,

the individual could be looking for an activity with some amount of risk and need for adrenaline
to make their life more enjoyable. The goals that the individual and therapeutic recreation
specialist (TRS) should target are building up skill level in the sport, safety, self-dependence,
social engagement, focus on capability rather than on their disability, and focus on teamwork.
There are numerous specific goals an individual could have for the sport as well, such as getting
a base hit in baseball, prolong the time they can play tennis, or being able to swim for water polo.
The TRS would need to communicate with the individual about what it is they are expected to
accomplish through the adaptive sport and that the specialist is expected to do the same. By
participating in the sport program in some way, as a member of the team, coaching staff, or as a
supporter, the TRS is promoting a sense of comradery and fostering a relationship that the
individual will benefit from. When evaluating the individual, it would be important to assess the
physical ability, sense of self-importance, level of determination to win, ability to work with
other members of the team, and quality of life. The TRS should be constantly assessing the
individuals physical health through formative observation. The individual should also evaluate
the sport; what they think and feel about their participation and their goals.
There are a multitude of activities that fall under sports, each with their own positive and
negative effects on individuals. Focused in this paper are tennis, ultimate Frisbee, basketball,
softball, and golf. Tennis is a sport in which the players must hit the tennis ball within the
boundaries before it bounces a second time on their side of the net. It is a physically engaging
sport that needs skill, concentration, and patience to fulfill its rules and be successful. Ultimate
Frisbee requires the individual to work in a team setting to get the Frisbee from one end of the
field to the other without letting it touch the ground. Basketball is a team sport in which the goal
is to get the ball into the hoop and score points. Softball is also a team sport in which the goal is
to score by having runners on the bases and bring them around to home plate. Golf is an

individual sport in which the goal is to hit using specialized clubs a small ball into a small hole a
set distance away, numerous times. These activities are organized, specified, and goal-oriented.
Sports are not necessarily team oriented.
Activity and Analysis
Basketball is a sport where two teams oppose each other in order to score the most points
during a set time. The basketball court can be indoors, a gymnasium, or outside. A basketball and
backboard are two other necessary components to play basketball. The size of the ball, height of
the hoop, and diameter of the hoop depends on the level of play. There are regulations for high
school, college, and professional as well as womens and mens basketball. The court is made up
of two sides, in which one team defends one side and tries to score on the other teams half court.
There are designations on the court demarcating three-point arc, free-throw line, and . There are
five players on the court for each team and referees that enforce the rules and regulations of
basketball. For the ball to travel around the court, the players are expected to either pass it or
dribble the ball while moving. Dribbling is bouncing the ball against the floor while the player is
in play.
Baskets are made when the ball enters the hoop and exits the net attached underneath the
hoop. Two points are awarded within the three-point arc and three outside. A team can turn over
possession of the ball by failing to get a shot off within the shot clock limit, typically of thirtyfive seconds, or taking the ball out of the boundaries of the court. Penalty shots are given when
one player fouls another during the course of a shot. They made from the free-throw line and are
one point with the times offered to shoot determined by the severity of the penalty. Fouls without
a shot being taken require the ball to be turned over to the team of the player that was fouled.
There are multiple ways to incur a foul. Travelling with the basketball, which means that the ball
was carried instead of dribbled or holding the ball and restart dribbling more than twice. A player
that guards the hoop by slapping away a ball that has already started its descent has committed a

foul called goaltending. Players can foul each other by reaching in, excessive force, and . Calls
could be called by the referees that are more typically thought of as judgment calls and are
controversial. To win, one team must have more points than the other at the end of regulation
play. If they are tied, the game goes into overtime until there is a winning team. Regulation play
is four quarters of play with half time for professionals and two halves for collegiate.
Playing basketball requires the ability to stand and run, the use of ones arms to dribble,
pass, and shoot the ball. Due to the length and physicality of the game, the individual needs to
have enough strength and endurance to play the game, even with the use of substitutes. There is
physical contact in basketball as the players are trying to steal the ball away from one team to the
other and to disrupt the offense. Basketball requires acuity in recognition of the rules, memory of
the game and strategy, communication with teammates and the coaches, and concentration on
only the game. Skills in reading and writing are not important to the game, but recognition of
numbers and addition are good to know. Identifying the ball, different body parts, and direction
of play are important to ensure that the game is played properly. Because of the physicality and
adrenaline of playing basketball, there is a natural outlet of happiness, anger, frustration, and
pain. Fear and guilt are also expressed but not to the extent the previous four emotions are.
A team is led by a coach who teaches the players how to play, different methods of play,
and the strategy behind the different plays. The coach also makes decisions during the game in
regards to substitution and strategy. The players are expected to wear clothes that allow
movement, typically gym shorts and a tee-shirt with socks and shoes that are not black-marking
on in indoor basketball court. Running shoes or other athletic shoes are fine on outdoor courts.
Activity Adaptation
As an activity, basketball has many opportunities to be adapted to fit the needs of a
person with a disability. Specifically, wheelchairs can be adapted for those with lower-limb
amputations and different rules can be applied to basketball for upper-limb amputation.

Wheelchair basketball is so popular, in fact, that there is a national organization for it as well as a
Paralympic designation. Wheelchairs are considered a part of the athletes body, therefore are
allowed to contact others. According to the Museum of Disability, wheelchairs are not to have
their seats exceed twenty-one inches height from the floor (SITE Basketball, para. 1). They
must also have roll bars to provide support. Those with upper-limb amputations can play
basketball in which there is limited contact to no contact, no running, and modified hoop height
to provide ease of access. Other variations include shootout, HORSE, bankshot basketball, and
Traumatic Brain Injury
Traumatic Brain Injury (TBI) is, according to the National Institute of Neurological
Disorders and Stroke, a form of acquired brain injury that occurs when a sudden trauma causes
damage to the brain (What is Traumatic Brain Injury?, para. 1). There are two ways that TBIs
manifest; closed head trauma and penetrating head injury. TBIs can range from a mild
concussion to coma (TEXTBOOK, p. 117). Initial brain damage rarely can be fixed, but TBIs
can have averse reactionary problems. The Glascow coma scale, which evaluates the individuals
functions in the areas of eye response, motor response, and verbal response (TEXTBOOK, p.
118) grades the severity of the individuals TBI. However, because the injuries can evolve, new
ways to look at the brain are being looked into (Risdall 2014). According to Bruns, Jr, and
Hauser (2003), TBIs affect all age groups and demographics but have a higher incidence in
infants, adolescents and young adults, and geriatrics. TBI from trauma and motor vehicle
accidents are the most common forms that have a far more severe effect on the individual (Bruns,
Jr and Hauser, 2003). Secondary concerns for individuals that have sustained a TBI are posttraumatic epilepsy (Risdall and Menon 2014), loss of executive functioning, mood alterations,
and inappropriate behavior (TEXTBOOK, p. 117). Other issues that can arise due to TBIs
include cognitive, physical, and psychological deficits (TEXTBOOK, p. 119).