Wednesday, July 11, 2007


(Part 1 of 2)

First published in The Jakarta Post, July 11, 2007

Alpha Amirrachman,
Contributor, Jakarta

Four years ago, Riska*, who worked as a cashier in a modest textile shop in Tanah Abang, North Jakarta, was on way to work when the Metro Mini (public bus) she was riding was hit on its rear left by another, speeding bus.

Riska, sitting in a rear seat, was sandwiched between the metal door and body of the bus, her leg crushed.

She had to have her leg amputated from above the knee. She did not receive any compensation from the bus company.

Now, using a transfemoral prosthesis, Riska is still able to work. Her superiors at the same textile shop have placed her where she did not need to walk much.

A transfemoral prosthesis is an artificial limb that replaces a leg from knee to foot.

"Most of the cases of people who needed artificial limbs, I think around 60 percent, are caused by accidents -- mostly traffic accidents and the rest, work-related accidents," said medical rehabilitation specialist Dr. Peny Kusumastuti, who is head of the Medical Rehabilitation division at Fatmawati General Hospital, which was established in 1970.

"Others are caused by diseases like polio, diabetes, bone cancer and severe infections," she added.

Peny further lamented that no comprehensive national statistics were available with regard to prosthetics and orthotiscs cases.

Hospital records show that it handled 376 cases of prosthetics and orthotics in 2004, 38 cases in 2005, and 439 cases in 2006.

A prosthesis is an artificial extension that replaces a missing part of the body. Traumatic injuries and congenital defects are characteristic causes that require supportive equipment for the disabled to pursue normal lives.

The complete recovery of range of movement, however, is not always achievable.

In developing countries, vehicular and industrial calamities, as well as conflicts, are the leading causes of amputations. In more developed countries, amputations are generally required due to diseases such as cancer, infections and circulatory diseases.

Following independence, Indonesia saw many of its freedom fighters receiving treatment for amputations at the first medical rehabilitation hospital in Surakarta, Central Java. The hospital was established by the "founding father" of medical rehabilitation, Prof. Dr. Suharso, who specialized in prosthetics in the U.K.

Now, 62 years after independence with the rush of investment and material development, but still with an "underdeveloped" mentality where safety is still largely ignored, traffic and work-related accidents appear to dominate prosthetic cases.

This is evident in many cases found in general hospitals such as Fatmawati and Cipto Mangunkusumo. However, other causes are also noticeable, such as diabetes, cancer and even congenital amputation.

Although relatively infrequent, cases of congenital amputation need assiduous treatment at an early stage, so that the patient can "feel" they have a normal life during growth.

For example, 7-year-old Iwan had a below-knee congenital amputation.

"Because he is still growing, we have to produce a new transtibial prosthesis every six months," said prosthetist and orthotist Sumedi of Fatmawati General Hospital.

A prosthetist is a specialist who designs and fits prostheses to the remaining limbs of amputees; an orthotist is one who designs and applies an external device to a part of the body to correct any malformation.

Both specialists technically design, measure, fabricate, fit and service prostheses or orthoses under the prescription of a physician.

Sumedi, who started working at the hospital in 1976, invited The Jakarta Post to tour his workshop at the hospital to see how prostheses are made.

Some factors taken into account when producing prostheses include energy storage and return, energy absorption, ground compliance, rotation, weight and suspension.

Initially, a prosthetist would work with gypsum on an affected part of the body, he said.

A socket that fits the stub of the limb is needed when fitting for lower-limb prostheses. Carbon fiber or glass infused with acrylic resin is used to make the socket, which is later linked to a foot assembly.

An aluminum tube with a two-part pyramidal alignment, with one device at each end, functions as connecting gears for the artificial limb.

The ankle and the socket are connected by two devices each. In order to support the patient's weight and to avoid any tangential movement, the foot is initially allowed to be in proper position.

Prosthetists then observe the way the patients walk. They jot down the positions when the leg is lifted, as well as when the toes lift off and the heel strikes the ground, and later correct anything considered deviant.

Depending on the affected limb, prostheses have four prime non-natural limb parts: transtibial, transfemoral, transradial and transhumeral.

An artificial limb that replaces a leg missing below the knee is called a transtibial prosthesis. Because the knee is largely retained, movement is still relatively easier than those with a transfemoral amputation.

Hence, transtibial amputees can regain normal movement with a prothesis.

An artificial limb that replaces a leg missing from above the knee is called a transfemoral prosthesis, and those with this condition must use more to walk than a person with two normal legs.

"Since the knee is somewhat broken or disturbed, learning to walk with a normal movement could be a hardship for a transfemoral amputee," said Sumedi, who has many years of experience with such patients.

An artificial limb that replaces an arm missing below the elbow is a transradial prosthesis, and one that replaces an arm missing from above the elbow is a transhumeral prosthesis.

Due to the similar complexities of elbow and knee movement, transhumeral amputees may undergo similar problems as transfemoral amputees when learning to use their prothesis.

While a prosthesis replaces a missing limb, an orthosis is a device that is applied externally to a part of the body to correct a malformation, improve function or mitigate symptoms of a disease by supporting or assisting the musculo-neuro-skeletal system, such as a brace.

"Orthoses are mostly needed by those with polio, stroke, nerve breakdown and also scoliosis," explained Sumedi.

The medical field concerned with the manufacture and application of orthoses is known as orthotics.

Sumedi recalled his experience with a 10-year-old girl who had scoliosis of 35 degrees asymmetrical.

Scoliosis is a condition when the spinal column displays abnormal lateral curves, which can affect the balance and alignment of the torso over the pelvis. Surgery, braces or chiropractic treatments are available to deal with scoliosis, but are very much dependent on the degree of scoliosis.

"Our medical rehabilitation specialist prescribed that she use a Milwaukee brace. She was a determined young girl, taking off her brace only when she took a bath. After 12 years of treatment, her scoliosis has been corrected to 5 degrees. It is almost a miracle. She is now a normal girl," Sumedi recalled of his patient, who would cry if her orthosis was taken away from her.

Before the 1997-98 economic crisis, the hospital's workshop had produced prostheses and orthoses on a regular basis and in mass, "but many were left unused because many did not fit the size of the patients," said Sumedi.

As the government subsidy became increasingly restricted, the hospital was forced to find ways to produce prostheses and orthoses in a more economical way.

It opted to use a collaborative mechanism, called UKS (Usaha Kerja Sama), where the prosthetists and orthotists of the workshop were to produce a number of products based on need or on an ad hoc basis.

"We produced 234 prostheses and orthoses in 2002, 231 in 2003, 376 in 2004, 461 in 2005 and 439 in 2006," said Sumedi, citing statistics.

They also accepted orders from other hospitals, he said.

"Many of the patients here are from low-income families," added medical rehabilitation specialist Dr. Ria Tobing, so they tried to make prices as affordable as possible.

Another prosthetist-orthotist, Bebeng, concurred.

The use of local material for a below-knee prosthesis for an adult would cost Rp 1,500,000 (US$), including servicing. The same prosthesis could cost up to Rp 9,000,000 if produced using imported material.

When low-income patients undergo physiotherapy as part of their a post-surgery rehabilitation, the hospital's social workers are tasked with contacting donors to contribute in producing the prostheses.

"It is unfortunate that many insurance companies and even the government-sanctioned ASKESKIN only cover surgery, not prostheses and orthoses," said Peny, referring to the national insurance scheme for the poor.

Peny asserted that the policy should change, as coverage for prostheses and orthoses would greatly help patients from low-income families lead a more productive life and contribute to society.

No comments: