Topics in Geriatric Rehabilitation

Vol, 21, No, 2, pp, 116-122

2005 Uppincott Williams & WUkins, Inc,

Motivating Elderly Patients

With Recent Amputations
Joan E. Edelstein, MA, PT, EISPO
Elderly adults who have sustained amputatioti are often unmotivated to participate in rehabilitadoti. Whether the itidividual has peripheral vascular disease, typically diabetic arteriosclerosis,
or traumatic amputation, the patient must confront the permanent, visible reality of limb loss as
well as markedly disturbed function. Patients are often discouraged by futile medical interventions, and by their lack of identification with the young healthy adults they watch exercising
on television. The Motivation Equation, in which motivation equals perceived chance of success times perceived importance of goal, divided by perceived cost multiplied by inclination to
remain sedentary provides physical therapists and occupational therapists with opportunities
to maximize success while minimizing the physical and emotional cost of rehabUitation. Key

words: amputation, motivation, rehabilitation

OST Our Motivation,"proclaimed the banner in the window of a shop about to

go out of business. The cartoon in the New
Yorker speaks aptly to the behavior of many
older people who have sustained amputation. Although legal requirements demand informed consent for surgery, the patient facing amputation has little choice in granting
permission. Either the person can watch gangrene advance up the lower limb or persist with the conservative management that
has failed to control claudicating and local
pain. Consequently the elderly individual often comes to rehabilitation after amputation
in a depressed state, with starkly visible evidence of hopes permanently dashed. Several
case studies illustrate varying degrees of motivation as well as suggest some means to increase the older adult's motivation for participating in rehabilitation,
AB, 73 years of age, a retired stationery
store owner, developed diabetic arteriosclerosis 7 years ago. Initially, he scoffed at his

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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MOTIVATING ELDERLY PATIENTS WITH RECENT AMPUTATIONS

his medical condition stabilized and pain

was reduced, but not eliminated. He was referred to physical therapy, but complained
that the exercises were pointless. His poor
participation in physical therapy prolonged
his stay. AB's behavior exemplifies the findings of Lenze et al,' who conducted a retrospective study of 242 inpatients, averaging 70 years of age. Those who participated
poorly in physical therapy and occupational
therapy sessions had a longer length of stay
than those who were active participants. AB
was discharged home and told to return in
2 weeks, when, presumably, the wound
would have healed. He was desolate and his
wife was unable to coax him out of bed, even
for meals. He had difficulty transferring into
the wheelchair lent by the rehabilitation department, and found propelling it very fatiguing. He stayed in his pajamas all day, took little
interest in personal hygiene, found reapplying the elastic bandage confusing, and demanded meals consisting largely of ice cream
and deep fried potatoes. His amputated limb
remained edematous and painful. At the 2week follow-up visit, his surgeon noted that
the wound remained unhealed and that AB's
overall physical condition had deteriorated.
The surgeon referred him to an outpatient rehabilitation department with a view toward
improving AB's general condition as well as
fostering healing and edema reduction of the
amputated limb. All this would eventually prepare him for fitting and use of a prosthesis.
The physical therapist (PT) introduced a series of simple aerobic exercises with graduated resistance and applied Unna bandage to
create a nonextensible amputated limb dressing that did not require frequent reapplication
and would stabilize the amputated limb volume faster than the elastic bandage.^ AB took
pleasure in having the weight resistance increased, likening it to increasing sales in his
store. The PT gave him an exercise log which
resembled an accounting profit and loss sheet
to extend the motivation for the home program. AB expressed relief that he did not
have to reapply elastic bandage on his amputated limb. Achieving positive results with the

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

exercising at home. Not at all athletic even as

a young woman, she now views exercise as
futile, "I'm not a young cutie like tbe girls I
see on television, I don't remember the way to
exercise and, besides, what's the point?" Her
physician told her that she was not a candidate for a prosthesis. Six times she has fallen
while attempting to transfer to or from her
w^heelcbair.
A neighbor suggested RM that she see a PT
who would come to the apartment. Evaluation indicated a 10-degree knee flexion contracture, 15-degree hip flexion contracture,
and marked generalized weakness. The PT's
short-term plan was to increase hip and knee
extensor strength, reduce the contractures,
and improve transfer safety. The treatment
program involved rubber ribbons and was
keyed to television commercials, so that RM
could exercise for brief periods throughout
the afternoon.
RM's physician arranged for an OT to assess
the home environment, primarily to reduce
the number of falls. Tbe 1-bedroom apartment was cluttered with piles of unread magazines and furniture RM had moved from her
4-bedroom house 20 years earlier. The living
room had frayed carpeting, while the bedroom had 3 throw rugs on the hardwood
floor. The bathroom had a deep tub and plastic towel bars glued to tbe wall, RM was too
discouraged and too frail to cope with the
hazards. Tbe OT convinced RM to donate tbe
magazines to a recycling center to open space
for the exercise program. She persuaded RM
to meet with a social worker who could arrange for assistance with inexpensive home
repairs. The modest changes in her apartment
augmented RM's motivation to persist with
the physical rehabilitation program.
The OT also put RM in contact with a local senior center that provided door-to-door
transportation. Initially RM was reluctant to
leave her home and her favorite television programs. When she finally agreed to visit tbe
center she was surprised to see peers who
w^ere involved in a wide range of activities.
She enjoyed the hot lunch and found herself drawn into a wheelchair dance program

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that resulted in improved sitting balance and

upper-limb strength. She was eager to tell her
PT about the center's activity schedule and
was more responsive to doing the lower-limb
exercises at home.
Trauma can also sap an individual's motivation, SN, 67 years of age, had left transfemoral amputation 4 months ago. He was
attempting to cross a busy avenue w^hen an
impatient truck driver made a left turn before the traffic light had turned green. Emergency midthigh amputation was performed.
During the course of inpatient rehabilitation,
the amputation wound healed and he was fitted witb a prosthesis that had a SACH (solid
ankle cushion heel) foot, locked knee unit,
and pelvic band suspension. He found it so
difficult to don the prosthesis that he relied
on his wheelchair at home. With the prosthesis, he walked stiffly and complained that tbe
socket was uncotnfortable. He was discouraged about tbe accident, which he viewed as
preventable if he had been more alert. His attorney's delays in pursuing the lawsuit and the
poor function he was achieving with tbe prosthesis added to his distress. Prior to the accident, SN worked full-time as an accountant
and enjoyed swimming, tennis, and golf. His
premorbid athleticism was a good predictor
of exercise behavior following tbe accident.
A history of exercise activity usually characterizes older adults who participate in a longterm exercise program,^
SN returned to bis prosthetist, who noted
that tbe thigh was edematous. SN admitted
that he was not wearing the prosthesis on a
regular basis. The prosthetist referred him to
a PT, who instructed him in the proper application of an elastic shrinker sock to reduce
edema of the thigh. The PT and prostbetist
conferred by telephone regarding more appropriate components for SN's prosthesis.
After discussing options with SN, the PT contacted his physician recommending an unlocked knee unit and a new socket that would
be suspended with partial suction and a
Silesian webbing belt around the lower torso.
The physician authorized the new^ prosthesis. Upon its delivery, the PT instructed SN

MOTIVATING ELDERLY PATIENTS WITH RECENT AMPUTATIONS

in the care of his amputated limb, as well as

strategies to don the prosthesis and control
the new^ knee unit, SN w^as so pleased with
his improved appearance and function that he
was able to divert his attention from tbe supposition that he was responsible for the accident. He also became more understanding of
the time his attorney needed for the lawsuit
against tbe truck driver.
These cases, composite studies created
from bebaviors exhibited by several actual
patients, illustrate various negative effects of
poor motivation, Tbe cases show positive
means of restoring the individuals' confidence
in their ability to care for themselves. Depending on the circumstance, interaction of
physical therapy, occupational therapy, social
work, and other rehabilitation specialties can
make the difference between a downward spiral of despair and loss of function rather than
physical and emotional growth in spite of the
amputation,
A constant theme of these cases is the
Motivation Equation devised by Phillips and
colleagues,'* namely.
Motivation = Perceived Chance of Success
X Perceived Importance of Goal/Perceived Cost
X Inclination to Remain Sedentary

Each patient initially doubted the likelihood of succeeding in rehabilitation and

demonstrated reduced self-efficacy,^ Their
passive behavior reflected their lack of motivation to participate wholeheartedly in physical therapy. AB, for example, had been seeking medical relief for his leg pain for several
years. He bad no reason to believe that be
could possibly acbieve function when the final catastrophe, amputation, befell him. Similarly, RM felt she could not possibly succeed in rehabilitation. She had never engaged
in intensive exercise, believing that athletics were the province of children and wellmuscled young adults. Her life experiences
conditioned her to lead a satisfying existence
caring for family and home. Only wben her
family left, tbrougb deatb and departure to
distant residences, did she have to confront
a new life situation. Her initially depressed

state of denial and inactivity following the

amputation shielded her from having to deal
with a new^ set of circumstances, w^ith w^hich
she felt she could not cope, SN ^vas literally in the wrong place at tbe wrong time.
He could not bave anticipated his amputation
and had no knowledge of contemporary prosthetic management. By ignoring the rehabilitation process he implicitly denied himself
any chance of success. Instead, he focused on
the one aspect of the accident with w^hicb he
was familiar, tbat of collecting punitive damages from tbe reckless defendant and compensatory damages to recoup lost income and
medical expenses. SN saw the world in terms
of profits and losses, witb neatly balanced
columns. When his bodily state did not fit that
model, he opted out of active participation in
physical therapy and the entire rehabilitation
process.
The importance of physical therapy eluded
all 3 subjects, SN skirted tbe entire issue
as belonging to a w^orld he had never entered and certainly did not want to acknowledge. As a layman, albeit educated, he had
only the most superficial information about
rehabilitation, mainly gained from sensational
episodes on television and in the press. He
could not identify with the heroic athletes
who performed superhuman feats witb tbeir
prostheses nor did he see himself as a seriously, permanently impaired elderly man, AB
also bad no conception of the relation or importance of physical therapy to his goal of
resuming walking. He was mired in repeated
discouragement at the failure of years of medical care and the ineffectiveness of the postoperative management. Until he met bis most
recent PT, AB did not realize how small successes in improving bis strength could culminate in his being cotnfortably fitted witb
a prosthesis and learning to use it. In a different vein, RM tacitly fought the goal of becoming more proficient with her wheelchair.
She rather enjoyed the secondary benefits
of greater attention paid her by her PT and
tbe participants at the senior center. She
was, after all, in her view, a "crippled old
lady'

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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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style reassuringly comfortable. Recognizing

her apathy is essential for her PT to develop a
realistic treatment program.^ Resnick and colleagues developed an Apathy Evaluation Scale
to document the degree of apathy present in
older patients. RM fits the profile that older
women are more inactive than their male
peers.^
What, then, can the PT do to increase
these patients' motivation for vigorous rehabilitation? Attention to psychosocial concerns needs to complement clinical concerns,
including carefully individualized therapeutic exercise and knowledge of contemporary
prosthetics practice.
Amputation is likened to death of one's
body part, irrevocable, permanent, omnipresent. The therapist must convey respect
for the patient's grief, disappointment, and
premonition of total bodily death. Calm
acceptance of the patient as a vital person,
regardless of the number or condition of the
individual's limbs, exerts a powerful effect
on the patient. Appreciating the person's
reluctance to acknowledge the truncated
limb can be addressed without a word as the
therapist confidently handles the amputated
limb during exercise, massage, and limb
dressing. Actively encouraging the patient,
while self-evident, has been demonstrated to
be a powerful motivator to urge older people
to exercise.^ The therapist should be able to
refer the patient and the family to local peer
groups and national advocacy organizations
as well as sotirces of current technical information. Continuing education for physical
therapists is paramount in order that they
render the most enlightened care. Some patients also benefit from brief psychotherapy
or cognitive behavioral therapy aimed to
help the person gain insight into feelings and
behaviors that are and are not constructive.
Within the sphere of therapeutic exercise,
one should not assume that the older person
tuiderstands that exercise is effective,^ given
the glorification of youth in the popular culture. Older people, especially, respond better
to goal-oriented activity, gradually progressed.
The therapist needs a repertoire of exercises

MOTIVATING ELDERLY PATIENTS WITH RECENT AMPUTATIONS

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

portraying old people as inactive, and thus

not motivated to exercise vigorously. Peer and
professional support can reverse negative bebavior, group activity is usually bighly motivating, and the ingenuity of tbe OT and PT in

keeping the program pertinent all contribute

to reversing tbe factors negating motivation.
Because patients do not exist in a vacuum, attention to the home environment and community are essential motivators.

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