The role of psychology in multidisciplinary preparation of pediatric patients undergoing limb lengthening and reconstruction

Abstract

The purpose of this paper is to review the role of psychology within the multidisciplinary preparation process for pediatric patients considering limb lengthening and reconstruction (LLR) and establish best practices for a staged preparation workflow. This work is grounded in the collective clinical experience of a well-established LLR team that treats nearly 300 patients considering or undergoing LLR per year.Preparation of pediatric patients and caregivers/families considering LLR is approached as a multidisciplinary process, spearheaded by the orthopaedic surgeon and accompanied by expert nursing, psychology, and physical therapy/occupational therapy support. Treatment planning and preparation occurs in a staged, developmentally appropriate fashion, guided by the individual patient's (and family's) understanding of treatment, goals for treatment, motivation for treatment, physical and emotional readiness for treatment, and demonstrated history of adherence. Particularly for pediatric patients, educational information is provided at an appropriate level, to support the child or adolescent's sense of autonomy and control over their body. Caregiver and family factors must also be considered, including caregiving support, division of responsibilities within the home, and the logistical feasibility of treatment tasks for the family unit. Additionally, connecting pediatric patients and families with peer supports (i.e., patients who have previously undergone the same or similar treatments) is very beneficial from an expectation setting standpoint and allows patients an opportunity to see what it may be like to incorporate LLR activities into their daily lives. With this approach, treatment progress is dependent upon the individual patient's and family's completion of each of these tasks that may take anywhere from weeks to years to complete. While certainly time and labor intensive, this method ensures the appropriateness of a patient and family's comprehension of, motivation for, and capacity to manage treatment expectations.

Key concepts: (1)Treatment preparation for pediatric patients considering LLR includes a staged, multidisciplinary assessment; this includes assessment by the orthopaedic surgeon, team nurse, psychologist, and physical/occupational therapist.(2)Treatment preparation and timing is guided by the individual patient and family's demonstrated interest in, motivation for, and capacity to manage treatment.(3)Inadequate understanding of treatment expectations, lack of motivation for treatment, and inappropriate treatment goals are likely to negatively impact a patient's adherence to treatment tasks, ability to sustain motivation and grit, pain management capability, and overall satisfaction with treatment.

Keywords: External fixator; Limb lengthening; Limb reconstruction; Psychological preparation; Psychology; Surgical preparation.

Figure 1

Visual depiction of patient treatment plan*. *The language utilized in the visual treatment plan should be matched to the developmental level of the patient and family.

Figure 2

Sample hip pain prehabilitation exercises.

Figure 3

Routine nutrition lab panel.

Figure 4

Psychologist facilitating a peer introduction.

Figure 5

Older patient who mentored younger patient.

Figure 6

Two patients motivating one another during the physical therapy session.

Figure 7

Flowchart of pediatric LLR multidisciplinary preparation process.