The team at SCIL who create an array of prostheses aim to give patients new life after the trauma of physical loss
Matthew Carvalho sits in an examining room in the Sunnybrook Centre for Independent Living (SCIL) and takes off both his legs. He's here at the centre, tucked away in a sunny, treed corner of Sunnybrook's campus, for a fitting for a new socket for his left leg.
Matthew, who was born without three of his limbs (he has his own left arm), has used a variety of prostheses over the years and has had countless fittings for new parts. "I feel like the alignment is definitely off on this one," he says to Winfried Heim, manager of prosthetics and pedorthics, after one of the legs has been adjusted. "Okay, let's take it off again," says Heim, jokingly adding, "Tell me if I'm tickling you."
"This is the life of an amputee," says Matthew, of Mississauga, Ont. "Trial and error."
But he says the last two years, during which time he's been a Sunnybrook patient, have been the best. The experts at SCIL have allowed him to be a collaborative partner in his ongoing prosthetic treatment, experimenting with different materials and lighter prostheses. It could also be his close relationship with Heim, whose easygoing and gentle manner with his patients, along with his willingness to try new things, is one of the reasons patients here thrive. "It's all Winfried – everything has changed. My legs are a lot more comfortable … my way of life has been a lot better for sure," says Matthew.
Heim and the 25-member team of prosthetists, technicians and other experts at SCIL helped more than 7,000 patients last year through the prostheses, pedorthics, podiatry and rehabilitation programs. The group is known for assisting people, including complex trauma patients, regain their independence and mobility by fitting them with customized prostheses and providing them with individualized rehab and treatment.
SCIL serves individuals who lose limbs in a variety of ways, from diabetes and cancer to congenital disorders and trauma. Heim says that one of the most important things the team at SCIL must do when meeting each new patient is to appreciate that amputees are "terrified" when they first arrive, and that the team's role is as much psychological as medical. "It is a big trauma. People really do not want to lose a body part. It becomes part of our duties to help them overcome that – to make them believe there is life after that."
Above: A prosthetic device for an above-elbow amputation. Matthew's prosthetic legs include carbon frame sockets and hydraulic controlled multi-axial knee joints.
Prostheses are made in the on-site lab by a team of technicians and prosthetists. "Creating a custom prosthesis is a marriage of art and science", says Iona MacRitchie, Managing Director of SCIL and the Working Condition Program. "There is the artistic part of trying to achieve the right fit and look; and then there is the science of it in properly distributing the weight and forces, calculating correct alignment and helping make the prosthesis a functional part of the person."
The first step to create a new limb is to make a socket, which is the part that the stump, or residuum, sits inside and attaches to the artificial body part. The prosthetist takes detailed measurements of the residuum and then creates a cast of it – similar to that for a broken limb. When that cast dries, plaster is poured into it to make a form of the limb. The form is then carefully smoothed down and filed until it becomes an exact replica of the residuum.
Prosthetist Jody Riggs, who presides over an area filled with plaster forms of all sorts of stumps and looks more like an artists' workshop than something you'd find in a hospital, says it takes a lot of experience to make a proper socket that minimizes discomfort for the patient while being worn. If it's even a little off, it could cause sores and injury. "A lot of it is by the feel."
To get the amputee started, typically a "test" piece or "clear check socket" is made using the plaster form, usually out of a see-through plastic. This allows the prosthetist to attach the leg or arm and check the fit before the definitive socket is made. The reason is that patients' stumps often change shape and size as fluids and swelling go down following amputations, says Riggs. Once satisfied with the clear socket, technicians use the form to make the permanent, laminated socket by pulling a PVA (water-soluble plastic) sheet and layers of sockinets and carbon tape or fibre over the form and then topping it with liquid resin that hardens into a shell. After it hardens, the completed socket can then be attached to another plastic shell containing the mechanics of the leg.
Technician Paul Russell says the job has "a bit of an artistic feel and flow," as some need their sockets to be very strong and others want them to be light. "You're trying to walk the line between something that's strong enough and something that is not too heavy."
Leg and arm parts can be merely cosmetic (made at SCIL), myoelectric or robotic. Some of the more complex limbs are made off-site. But the most important part is the custom socket, Heim emphasizes. "It is the fitting on the person that is the most important part. If you cannot wear it, you cannot use it."
It's also why patients often develop a strong, lifelong bond with their prosthetist. The more the experts get to know the amputees, the better they are able to create sockets that work for their lifestyle. Getting the artificial limb for the first time can be a life-changing experience for amputees.
Judith Reid, a 57-year-old diabetic from Toronto, had her below-the-knee amputation in September 2013 after complications from gangrene. Like many patients who come through SCIL, after her wounds healed she was sent to Sunnybrook's St. John's Rehab to learn how to use her prosthesis. After some preprosthetic training to strengthen her body and to learn how to balance, Judith was given her new leg and was shocked that "it felt quite natural" and she was able to take some steps immediately. She attributes her success to the staff, who "struck the right balance between giving me encouragement and telling me [that based on] what I did yesterday, maybe I could do a little more tomorrow."
Rehab is done very methodically, says physiotherapist Betty Cheung, to ensure the patient is successful in being able to use a prosthesis. Patients receive both physio and occupational therapy during an intensive in-patient stay that typically lasts two to four weeks.
What many people don't know is how difficult it is to use prostheses. Cheung says those with above-the-knee amputations can expend 50 per cent more energy walking than able-bodied people. Patients begin walking using parallel bars, then graduate to walkers, crutches and canes. The best moments come when they meet their goal of being able to go home.
Another patient, Kevin Godsell, had an above-the-knee amputation in January after he cut himself and it led to an infection in his foot, which moved up his leg. The 35-year-old from Scarborough, Ont., says even though when he first put on his prosthesis he found it "horrendous, bulky and unnatural," he kept at it with the encouragement of staff. Within a week he was walking and encouraging other patients with his progress. And he's looking forward to his new goal – to run five kilometres with Cheung next year.
He has nothing but praise for the Sunnybrook staff in helping him get his life back. "The experience was amazing – it blew me away. I didn't think I would be able to walk … It was like they had goals for me that I couldn't even see," he says. "They are really good at what they do."
This content was produced by The Globe and Mail's advertising department, in consultation with Sunnybrook. The Globe's editorial department was not involved in its creation.