An Algorithm Proposal for Upper-limb Prosthetic Continuum of Care

An Algorithm for Upper-limb Prosthetic Continuum of Care (or Identifying the Elephant in the Room) is a concept that was inspired through my work and passion as a certified prosthetist/orthotist and clinical educator after working for the last 12 years exclusively in the area of upper-limb (UL) prosthetics. I would like to acknowledge those who have mentored me as well as the many UL specialists who have come before me and whose work has greatly bolstered my knowledge and skills. Some History Prior to 2007, my UL O&P experiences were minimal. I worked as a technician in western Montana in the late 1970s, and in later years as a student, resident, and CPO in Washington state and northern California. Because there is a higher rate of lower-limb (LL) amputations, most clinics treat a much higher volume of LL prosthetic patients than they do UL prosthetic patients, and many clinicians have limited exposure to UL prosthetic fittings. In Montana, my duties as a technician were fabricating and repairing prosthetic and orthotic devices. But my exposure to UL prosthetics in that job was greater than what I encountered during subsequent years in Washington and California. This increased exposure to UL prosthetics in Montana may have been due to the regional vocations with inherent risks of accident and injury, such as logging, farming, ranching, and mining, and the smaller number of clinics providing care. These UL users kept their prostheses longer than the devices' normal useful lifetimes (perhaps due to lack of workers' compensation, Veterans Affairs (VA), or other third-party payment that would allow for replacement), and repairs were the norm.

In the more urban areas of Washington and California, I noticed there were less frequent UL fittings and repairs. Industry in these areas had more safety measures and regulations associated with employment, thus reducing work-related accidents. The dense population also offered more O&P clinics, so the number of UL cases seen by each clinic was low.

In the late 1970s and 80s, I saw that body-powered UL systems were the most prevalent devices being fitted, delivered, and repaired. Most fittings were for men. The clinicians and technicians I worked with, because of the frequency of fittings and exposure to repairs, were very good at the fundamentals of socket fitting, harnessing, and servicing the devices, and it was not uncommon to see these devices last ten years or longer. Repairs to keep body-powered prostheses functional ranged from re-laminating existing frames to fortifying the existing prosthesis, swedging or silver-soldering existing cable systems, making spare cable systems, repairing and replacing figure-eight harnesses, remaking leather cuff and liners, replacing quick disconnect wrist units, replacing rubber bands, and replacing prosthetic hooks. Prosthetic socks were routine items that needed continual replacing. Silicone roll-on liners, prefabricated harnesses, and leather cuffs were rare, so repairs and replacements required more technical support than what is required today.

The first time I recall seeing an externally powered prosthesis was in 1983 while visiting Europe. Externally powered prostheses were not common, affordable, or practical for the users being fitted in Montana. I toured Ottobock, Duderstadt, Germany, and was shown the UL myoelectric department, where their research and development was being done. This was before multiarticulating hands and improved battery technologies and complex control systems with programming options became available. This was the first time I entertained specializing in UL myoelectric technology. What has become very clear to me since that time is just how small and specialized the field of UL prosthetics is. Due to the complex and intricate nature of UL prosthetics with the wide variety of upper-limb technologies and the skills needed to fit the various levels of amputations, I can see how one could become a specialist within the UL specialty area. For example, UL prosthetic specialty care in the United States is largely concentrated at Shriners Hospitals for Children; the Hanger Upper Extremity Prosthetic Program, an offshoot of Novacare's UL team started in 1992 by Randy Alley, CP, and John Miguelez, CP; Shirley Ryan Ability Lab; Arm Dynamics, established in 1998 by John Miguelez; biodesigns, established in 2003 by Randy Alley, CP; Handspring, established in 2012 by Tom Passero, CP; and a few select clinics in regions where prosthetists have established themselves as UL leaders.

Fall 2007 provided me with a unique opportunity to work with Touch Bionics, then based in Livingston, Scotland, and their i-limb hand, on integrating their technology into the US market. This work exposed me to other leading UL technology manufacturers, UL O&P clinicians, rehabilitation specialists, physicians, and researchers, which increased my knowledge and experience to a level that could never have been attained in my previous clinical work environments. It became clear that the existing training for UL prosthetics was insufficient for this new hand technology. We needed new ways to train prosthetists, therapists, and users, and ways to educate the prescribing physicians as to the functional benefits of this more expensive technology. We needed to develop new clinical evaluation procedures, including changes in the way prosthetists myotested for muscle sites, and coding justification.

The introduction of this technology, coupled with the increase in the cost of multiarticulating hands over the previously available hands, resulted in a paradigm shift in how UL care and technology was provided. Workers' compensation, the VA, and third-party payers such as Medicare and private insurance companies now assumed a greater financial risk. UL codes for the devices either did not exist or became more complicated than those for LL, and clinicians were faced with a greater financial investm ent up front to purchase unfamiliar technology. Because of the complexity of the devices and the increased knowledge base required for evaluation and training, any prosthetists who already had less knowledge and experience in UL found themselves with an increased information deficit, leaving them with the choice to either refer UL patients to a specialist or take a costly risk in unfamiliar territory.

Identifying the Elephant in the Room While O&P clinicians and allied healthcare team members are extremely skilled in their field of practice, most have minimal exposure to the care and treatment of individuals with UL loss. Combine this with minimal exposure to the full suite of traditional/advanced and emerging technologies and techniques and the result is the elephant in the room effect. Advanced UL technology and the complexity of the training necessary for clinicians proficient in LL prosthetics who wanted to work with UL patients made it difficult for the average practitioner to be successful in fitting UL prostheses. While there are a few principles that apply across the board, UL prosthetic practice is a different challenge than LL, and many LL techniques and procedures are insufficient for successful UL fitting and delivery. Often LL prosthetic techniques are applied to UL technology by skilled clinicians, unknowingly creating challenges that reveal themselves later in the fitting process or after the prosthesis has been delivered. These problematic fittings are the result of the clinical team's lack of knowledge and contribute to the UL rejection rate. It is paramount that clinicians recognize the prosthetic prescription, therapy modalities, advanced training techniques, and follow-up care specific to UL fittings and their subtle differences from those of LL protocols.

The authors of The Promise of Assistive Technology state, "the function of the upper extremities is far more difficult to replace than that of the lower extremities. This is the case because the primary functions of the lower limbs are more limited and concern primarily maintenance and achievement of upright stance and various types of locomotion (e.g., walking, running, hopping, jumping, stair climbing). In contrast, the primary functions of the upper extremities include not only gross and fine motor activities but also more complex combinations of activities, such as self-care, interaction with the environment and others, and self-expression." 2

Clinicians who want to experience UL prosthetics need help crossing the threshold into the realm of UL. While little compares to working side by side with a UL specialist (and I highly recommend getting a UL specialist on board as early as possible in the patient's care), there are a few concepts and tools that a clinician proficient in LL prosthetics can employ to help pave the way to a successful UL fitting and delivery. The first hurdle to leap is acknowledging the differences between LL and UL, understanding that they must be treated differently, being willing to listen to the voices of experience, and then preparing for the learning curve and the team approach.

A Proposal for Care " Rates of rejection of prosthesis use for people with upper-limb amputation range from 30 to 80 percent, (Tintle et al., 2010; Wright et al., 1995) with the rates typically being lowest for those with transradial amputations and highest for those with transhumeral or shoulder-level amputations as well as partial hand amputations (Burger and Marinček, 1994; Kruger and Fishman, 1993; Østlie et al., 2012 ; Silcox et al., 1993)." 2 The Novacare visionaries who developed their UL prosthetics program as a specialty in 1992 must have seen their unique approach as a way to solve this rejection rate dilemma. Subsequent specialty programs like those previously mentioned make it evident that this approach to UL prosthetic management, including expedited fittings, innovation of new socket designs, and the segregation of UL care, was more effective than the care model previously provided.

Additionally, in 1999, the first myoelectric control (MEC) symposium was launched by the Institute of Biomedical Engineering department at the University of New Brunswick in Fredericton, Canada. It is now a triennial event that draws several hundred specialists from around the world working to improve the lives of those living with UL loss.

As UL prosthetics has become more specialized to accommodate the rapid changes in technology and the more complex needs of the UL patient, and as it moves further away from the experience of general O&P clinics in an effort to improve UL care, there is a cost. Patients are denied the benefits of a local care provider team and must bear the expense and inconvenience of seeking out distant specialists. Prosthetists are denied the opportunity to successfully fit, deliver, and maintain UL prostheses, and to care for the UL patients in their communities. Prosthetists, because of lack of exposure, training, and the financial risk involved with UL, become reluctant and awkward with their UL patients, sacrificing their self-confidence and that of their patient.

While it is impractical that all prosthetists will or should become as proficient in UL care as they are in LL care, there is a certain amount that any prosthetist can learn that will improve continuity between the local prosthetist and the UL specialist. I have created a memorandum and algorithm checklist as tools to assist clinicians in facilitating a successful UL fitting and delivery while working with a UL specialist, hopefully integrating the pieces of UL patient care in a way that promotes cohesiveness and care management quality.

The Memorandum of Understanding Development of a front-end user agreement signed by individuals who need UL prosthetic care and clinicians can help set proper expectations by clarifying methods of evaluation, fitting, training, and follow-up monitoring. This Memorandum of Understanding will not only assist the clinician in setting the proper expectations for the patient, it will serve as a demonstration of the support team, process, and resources in place to encourage the patient moving forward. It can avert misunderstandings and assist in a collaborative relationship between user and prosthetist (Figure 1). UL Algorithm Checklist Adopting and adapting the advances in technology into our practice while still utilizing traditional technologies requires the streamlining of business practices and more effective and efficient patient care management. Drawing from my direct experience, it is clear that O&P clinicians presented with a UL case would benefit from specific guidelines and consultation with a trusted UL specialist, which could make the difference between success and failure of the UL prosthetic device and influence the rate of device adoption or rejection.

However, every clinician can understand how UL differs from LL prosthetics and adopt and implement a continuum of care model for UL patients. This is a vital component for successfully managing the UL prosthetic user. The VA and Department of Defense (VA/DOD) has produced a clinical practice guideline on the management of UL amputation rehabilitation, which includes a detailed algorithm for UL prosthetic fittings. (To view the algorithm and full guidelines, visit https://bit.ly/3adlOBs .) While the VA/DOD algorithm is an excellent tool for streamlining UL prosthetic fittings, its detail can be daunting.

I believe we can simplify and create an algorithm for use by prosthetists in conjunction with UL specialists. The use of a UL checklist to help identify and ensure that key factors in evaluation, treatment, and follow-up of the UL prosthetic candidate have been followed by the clinical team may be helpful. A checklist provides reminders of the most critical and important steps. This checklist can be boiled down by experienced specialists to help prevent oversights that can be costly later in the process. It can help practitioners consider access to and availability of proper resources and techniques. It might also identify how payment methods interfere with the prosthetic care and therapy continuum of the care model (Figure 2). While I've provided examples of tools for a transradial externally powered prosthesis, as advanced technology poses increased challenges for the non-UL specialist, these tools can be modified for all types of UL prostheses. The use of these two tools, the UL Memorandum of Understanding and a simple UL Algorithm Checklist may assist with improved outcomes. My passion for UL prosthetics continues and I look forward to continued collaboration and dialogue with those interested in refining this area of O&P. Karl Lindborg, CPO/LP, is a prosthetic and orthotic clinical practice consultant and upper-limb prosthetic specialist with 25 years of O&P experience and 12 years of concentrated experience in advanced upper-limb prosthetic technology. He can be contacted at karl@intersectops.com . References

1. Biddiss E., T. Chau. 2007. Upper extremity prosthesis use and abandonment: a survey of the last 25 years. Prosthetics and Orthotics International 31:236-57

2. Flaubert J. L., C. M. Spicer, A. M. Jette, editors. 2017. The Promise of Assistive Technology to Enhance Activity and Work Participation. National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Health Care Services; Committee on the Use of Selected Assistive Products and Technologies in Eliminating or Reducing the Effects of Impairments. Washington DC: National Academies Press (US).

3. Guwanda, A. 2009. The Checklist Manifesto: How to Get Things Right. New York: Metropolitan Books. The Hastings Center Report: Toward a Theory of Medical Fallibility 1975. 5(6):13-23.

4. VA/DOD Clinical Practice Guidelines for the Management of Upper Extremity Amputation Rehabilitation https://www.healthquality.va.gov/guidelines/Rehab/UEAR/WithinReacheBook508.pdf

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