<!-- PERSPECTIVE --> One of the most challenging clinical presentations for a prosthetist is a patient with bilateral upper-limb loss or absence. Of the myriad upper-limb prosthetic componentry available, how can the prosthetist be sure that his or her prescription recommendation meets the patient's needs? First, consider that some patients with bilateral upper-limb involvement also present with lower-limb loss and must be able to use their upper-limb prostheses to don lower-limb prostheses; patients with congenital bilateral upper-limb absence may use their feet for some tasks; and a child's spine can be affected by the imbalance of weight if the initial fitting includes only one prosthesis. In addition, the patient may have high expectations about prosthetic appearance and performance. Does the patient have a family member or caregiver to assist with donning the prostheses or performing activities of daily living (ADLs)? Is the patient seeing an experienced occupational therapist (OT)? As with any prosthetic fitting, establishing goals and setting realistic expectations with the patient is paramount. Have samples of hooks, hands, and elbows available to show the patient. If the patient is a child, make sure the parents will teach compliance and encourage prosthetic use. Introduce the patient to peer mentors with similar limb-loss involvement; I have found this to be very powerful, as peers can teach new patients practical aspects of daily prosthetic use. As for the devices, body-powered prostheses are a sensible first step, unless contraindicated. Hands, hooks, and task-specific or custom terminal devices (TDs) can be interchanged to provide various types and combinations of prehension. The independent patient must be able to successfully and routinely perform ADLs. An experienced OT will be able to determine if adaptive equipment is necessary and if changes to the socket, devices, or programming would be helpful, and discuss the challenges of ADLs. Providing components with the most degrees of freedom possible will help the patient complete ADLs more easily; consider wrist units that allow for flexion, extension, pronation, and supination. Conventional body-powered prostheses perform in wet environments better than externally powered prostheses, and a voluntary closing TD can be incorporated to provide the patient with greater pinch force than a voluntary opening TD. Externally powered prostheses are viable options for these patients. An external-powered TD offers even greater pinch force than most patients can generate with a voluntary closing body-powered TD. Electric elbows allow greater ease of flexion and extension as they reduce the effort (and/or the cable excursion) required by the user. If the patient began his or her rehabilitation process using conventional body-powered prostheses, those can become backup prostheses, which are necessary when his or her everyday prostheses are undergoing repairs and maintenance. For some patients, I even keep one of their old, rebuilt components in the office for emergencies. Finally, it benefits patient care when we collaborate with other members of the healthcare team, such as OTs, physicians, social workers, and case managers. Communication between all involved, including the patient and family, is essential and will maximize the patient's potential during the rehabilitation process. <em>Ryan Spill, CP/L, is a clinical specialist at RJ Rosenberg Orthopedic Lab, Cincinnati.</em>
