Academy Society Spotlight: Experiences Within a Pediatric Myoelectric Clinic
October 2020 Issue
One of the smallest demographic groups cared for by orthotics and prosthetics professionals are members of the pediatric population who present with acquired or congenital upper-limb differences and have been identified as appropriate candidates for myoelectric technology. We have been fortunate to work with this niche population for almost four decades at the Variety Myoelectric Center (VMC) in metropolitan Detroit. During that time, the VMC has had the opportunity to provide myoelectric-controlled prosthetic devices and upper-limb prosthetic care to children from all areas of the country.
Founded in 1981, the VMC was conceived as a multidisciplinary prosthetic clinic that would use a comprehensive, holistic approach to provide an electronically controlled upper-limb prosthesis to any child who could benefit from the technology, regardless of the family's ability to pay for it. Since its inception, the VMC program has been funded by Variety, the Children's Charity, a Michigan 501c3 charitable organization that has delivered medical equipment, services, and healthcare to children and children's healthcare organizations for almost 90 years.
How the VMC Program Works
When a child is born with a limb difference, especially when the limb difference is entirely unexpected, parents begin searching for answers to their many, and understandably overwhelming, questions. Oftentimes, the answers are difficult to uncover. Parents who eventually contact the VMC program are provided with a broad picture of the options available to them. If they decide to continue down the path of prosthetic intervention, the clinic team creates a treatment plan that outlines the process that will best meet the family's goals and expectations. Most families who reach out to the VMC are from out of state and are often unable to carve out more than a week's time to come to Detroit for their child's myoelectric fitting. In these cases, an expedited 72-hour fitting process is implemented. The expedited fitting includes a comprehensive itinerary for prosthetic care and occupational therapy training. Table 1 (pg 43) shows an example schedule that an out-of-state family would follow.
Success and Therapy
A crucial aspect of upper-limb prosthetic care, regardless of the patient's age, is the need for occupational therapy. In the pediatric population, this need is even more essential, especially considering the many developmental milestones a typical child must reach before starting grade school at age six. We have found that to achieve successful functional outcomes, occupational therapy must be integral, seamless, and consistent. Teaching children to integrate the prosthesis into task completion and problem solving is only a portion of an occupational therapist's challenging job. He or she also needs to periodically update the parents on how to incorporate the prosthesis into their child's daily activities and suggest creative and developmentally relevant ways to encourage and reinforce usage where appropriate.
Funding State-of-the-art Care
Although some health insurance plans initially deny authorization for electronic upper-limb prostheses for children on the grounds that such devices are experimental or investigational, other private health insurance policies provide partial payment for these services. However, even the most generous plans can still burden a family with thousands of dollars in out-of-pocket expenses for deductibles and copayments.
From the beginning, Variety, the Children's Charity understood that providing state-of-the-art electronic prostheses for any child who was an appropriate candidate would require significant funding. In addition to the administrative and logistical costs to set up and operate VMC, the charity has also provided funding for an electronic limb bank of pediatric upper-limb components and any out-of-pocket deductible and copayment expenses that families cannot afford to pay.
Dividends From the Limb Bank
Since the VMC program was founded, it has benefited from having an electronic limb bank to resolve some of the challenges that are unique to its mission. It does so by:
- Providing state-of-the-art technology within budget parameters
- Providing evidence-based clinical documentation to justify componentry and reimbursement
- Providing timely and seamless component maintenance and repairs
Considering that many of the children being fitted with myoelectronic prostheses are underinsured or uninsured, the VMC program is able to use the full range of limb bank components to significantly reduce the overall cost of providing this expensive technology.
The limb bank also provides an assortment of readily available components that are needed to evaluate patients using the Multi-Function Prosthetic Testing Module (MFPTM). This protocol is routinely used to quantify a child's function with body-powered components compared to that with electronic components when evidenced-based documentation is helpful or required for reimbursement authorization.
Any prosthesis that is regularly worn and used requires maintenance. If a prosthesis is not regularly and properly maintained it can cause significant functional deficits for the user. For children who wear electronic upper-limb prostheses and do not live near their prosthetist, this is even more crucial. Fortunately, the VMC limb bank allows for the easy exchange of any malfunctioning components. This limits a child's time without the electronic prosthesis to 48 hours or less, regardless of the family's location in the United States.
Anyone who has worked with pediatric patients knows how fulfilling it can be to provide something to a child that helps the child to expand his or her functional world. Working with pediatric patients also comes with its own set of challenges. Toddlers and young children often lack the vocabulary needed to explain the what, where, and how necessary for the prosthetist to achieve optimal fit and function. As clinicians, we learn that to establish communication with a child, we first need to develop a rapport with the parents. When trust is created, the parents can serve as a conduit to garner the information needed to provide prosthetic care. Once the parents understand the process and begin to see small successes, their confidence blossoms. Parents soon come to see themselves as an essential and integral part of the rehabilitation team, helping to increase wear time at home and encouraging integration of the prosthesis into their child's day-to-day activities.
Our experience in providing children with electronic prostheses over the past 30-plus years has been very fulfilling, mostly because of the extraordinary team and resources made available by the VMC program to all of the participants involved. Our hope is that anyone wishing to implement a similar process would consider the VMC approach as a practical clinical model for caring for this niche pediatric population.
Joseph K. Brenner, CP, clinical prosthetist, Hanger Clinic, headquartered in Austin, Texas.
Carl D. Brenner, CPO(E), formerly of Hanger Clinic.
Academy Society Spotlight is a presentation of clinical content by the Societies of the Academy in partnership with The O&P EDGE.