Upper Extremity Prosthetics: Thinking Outside the Box

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By Judith Otto

The Round Table:

Randall Alley, BSc, CP, FAAOP , is the head of Clinical Research and Business Development for the Hanger Prosthetics & Orthotics Upper Extremity Prosthetic Program. He is chair of the Upper-Limb Prosthetics Society of the American Academy of Orthotists and Prosthetists (AAOP) and an international lecturer and consultant.

Diane Atkins, OTR , is a clinical assistant professor in Physical Medicine and Rehabilitation at the Baylor College of Medicine in Houston, Texas. Atkins is an occupational therapist who has specialized in amputee rehabilitation for more than 25 yearswith special focus on rehabilitation of the upper-limb amputee.

John Billock, CPO/L, FAAOP , is a past president of the American Academy of Orthotists and Prosthetists (AAOP). He is the clinical/executive director of the Orthotics & Prosthetics Rehabilitation Engineering Centre, Warren, Ohio.

Carl Brenner, CPO , is the director of Prosthetic Research at the Michigan Institute for Electronic Limb Development, Livonia, Michigan.

John M. Miguelez, CP, FAAOP , president of Advanced Arm Dynamics, serves as a clinical consultant worldwide on issues regarding upper-extremity prosthetics.

Robert H. Meier III, MD , is the founder of Amputee Services of America, a comprehensive "center of excellence" that addresses issues related to limb amputation. Meier's experience in rehabilitating persons with amputation encompasses some 2,700 amputees, 45 percent of whom are upper-limb amputees.

Regarding "thinking outside the box": How does this apply to serving upper-extremity patients? When are such solutions appropriate?

Alley:  One of the main reasons I became interested in upper-extremity prosthetics is the tremendous variance in how one must approach each case and attempt to provide the individual with what will maximize his or her functional and personal potential. One of the best examples I can relate occurred very early in my upper extremity career, when I felt compelled to design a new shoulder level interface, the Xframe, because the traditional interfaces at the time were simply not adequate to meet my patients' needs.

The appropriateness of a solution is a subjective issue, and can sometimes vary greatly from patient to practitioner to gatekeeper. For example, a solution is appropriate if it provides a large enough benefit to the individual to offset the propensity to reject the prosthesisand it is the education and communication skills of the prosthetist that often determine if such a solution is justifiable or not.

Atkins : Expedited fittings of UE prostheses make a huge difference to (1) the patient, by requiring significantly less time, effort, and expense; (2) the experienced prosthetist, by simplifying and shortening the fitting and adjustment process for the patient; and (3) the insurance companies and third-party payers, by creating a marked savings in time and money.

Additionally, the current trend is to look more at the option of hybrid fittings versus complete electric arms with electric elbow, forearms, and hands. This results in less weight, less cost, less repairs, and a limb that is often easier for the patient to learn how to use.

Brenner:  When you fit a highly irregular case, the use of diagnostic or preparatory prostheses is crucial. In our experience, we find that in order to completely evaluate patients, it's necessary for them to try as much of the available componentry and technology as possible in order to identify what works best for them. This process identifies the real needs of the patients and the best combination of components and control strategies. It also provides the documentation needed to meet third-party payer medical review criteria and approval for reimbursement.

Miguelez:  We approach cases differently, by spending a lot of time up-front with the patient before we ever put a splint or plaster on them. With regard to thinking outside the box, we don't HAVE a box! We tend to get the patients that no one else can fit: a lot of bilateral patients with severe scarring or electrical burns, bilateral shoulder disarticulations, and similar situations that require a real team approach to problem-solving.

There is no cookie-cutter solution from our perspective. We wouldn't have it any other way; it never gets boring. Every patient is completely different, although we learn solutions from all of them that may be indirectly applicable to other patients.

The team approach makes it workable for us; with all of us applying problem-solving skills, it's amazing what can be accomplished.

We were recently fitting a very tough patient who had injury to one of the two muscles in a short above-elbow injury. Prior to his visit, he had only been able to control the prosthesis with one muscle. After working with our therapist and the manufacturer, we were able to come up with some changes to the electronics that allowed him to control the prosthesis with two muscleswhich increased his function.

The cool thing is that we had that relationship with Motion Controlthey were right there in Salt Lake City and we were able to go up and spend time not just with the director, but also with the technicians and software designers who were able to help us develop a solution for this patient.

Meier:  There's nothing new about hybrid systems; I've used them for 30 years. The message here is that with the amputee population we serve, we MUST think outside the box. Any effective rehab program must be customized to the individual's needs and anatomy. Thinking outside the box doesn't necessarily mean an electronically powered prosthesis. It simply means that the rehab team must think innovatively to achieve solutions. Cost shouldn't be a factor, but you must also remember that the best solutions are not always the most expensive.

I've seen arms costing $120,000 used on a patient where a $17,000 alternative might be more useful and appropriate. Sometimes even the most innovative problem solving is useless, whether it's outside or inside the box: Many injuries are not clean amputations; their nature and extent determine whether the patient is capable of operating a prosthesis.

Billock:  In 1994, a prosthesis we designed for world-renowned photojournalist Mohamed "Mo" Amin required us to do some rather different things to develop a solution. That led to a different type of control for a prosthesis. We were the first ones to apply what is known as Multiplex control, which is achieved from two muscle sites that allow four degrees of control.

In anyone with a below-elbow limb absence or loss, there are two muscle groups to access; one to open and one to close the hand, and they can also be used to control wrist rotation. By using Multiplex control and co-contracting both muscle groups together, the individual can use the same two muscles that open and close the hand to switch to control of wrist rotation, as well.

I had had the idea of utilizing Multiplex control for some time previously, but Mo Amin's situation was the first that allowed me to put it into practice.

Reimbursement has not been a significant problem with regard to the creative solutions we devise. Whenever we can improve the function of a prosthesis and justify this with our own documentation, we have had few problems with the insurance companies. If we're going to do something outside the box, we simply need to explain why it's outside the box.

It is advisable, however, to dig a little before prejudging a patient's needs. I once made a cable-driven prosthesis with hook for a farmer, who complained that he wasn't able to use it for his needs. I ended up spending half a day with him on his dairy farm, where it became clear to me that his prosthesis couldn't manipulate the sophisticated milking equipment. Ultimately we made a specialized prosthesis just for his use, and learned a valuable lesson about carefully assessing a patient's lifestyle and needs.

Judith Otto is a freelance writer based in Holly Springs, Mississippi.