More Than Aesthetics: The Role of Prosthetic Covers

When Joan MacDonald’s foot was amputated, it opened a new world to her. It was a world without pain and one that she felt deserved to be celebrated. MacDonald, the owner and CEO of Socket Socks, headquartered in Antigonish, Canada, was hit by a car when she was five years old and for decades had struggled with chronic pain and trauma-induced osteoarthritis. At age 49, she decided on amputation. “It was the best decision I’ve ever made,” she says, noting that she couldn’t walk up stairs before the amputation and now she does CrossFit. Her prosthesis was a symbol of her newfound freedom. “When I lost my leg in 2018, from the get-go I was proud and wanted to show off my device because of all of the work it took me to get from my accident to that point,” she says. “It’s a big deal and you want to shout to the world ‘I did it! I survived!’” She knew that some people with amputations try to hide their devices under clothes or disguise them with realistic covers. She chose the opposite approach. She wanted the world to see her prosthesis as it was. “I didn’t realize at the time that this was a new trend—showing your metal,” she says. More and more, people with amputations are taking that approach. As prosthetic devices become more accepted worldwide and regularly appear in the media, there is less of a stigma for those who use them, MacDonald says. Another contributing factor was the Tokyo Paralympics in September 2021, she says. The world tuned in and saw athletes wearing prostheses who were able to run faster or jump further than ever before. An estimated 14 million people watched worldwide, an increase of 81 percent from the Rio Paralympics five years before. “When you see people running and throwing and cycling, amputees start to realize there is more to life,” she says. As O&P patients are more likely to take pride in their prostheses and are not afraid to show off the bionic look of their devices, what role do prosthetic covers play? We asked the experts if there was still a place for prosthetic covers. A Growing Definition of Beauty and Strength Twenty years ago, prosthetic cosmesis generally meant that prosthetists tried to make the device resemble the human anatomy as closely as possible, says Nancy Snyder, CPO/L, clinic manager for Hanger Clinic in Brunswick, Georgia. At the time, that narrow definition was what many people considered beautiful, she says. As awareness has spread about limb loss and limb difference, and as technology has improved to make covers and sockets personalized, that definition of beauty has expanded, she says. “Now every patient can decide what cosmesis means to them,” she says. “Their device doesn’t have to match their skin color; it could mean putting rhinestones on their sockets. In our world that is evolving and changing, what is beautiful is what makes you feel beautiful.” Some patients enjoy showing off the bionic look of their devices, Snyder says, and others might still prefer that they resemble their sound limbs. The point, she says, is that patients now have the option to do whatever they want. “This is a pivotal moment in our field to give our patients the opp ortunity to feel beautiful and not feel funneled into one mindset,” she says. “It’s very refreshing that we can individualize the devices, so you don’t get this cookie-cutter idea of what cosmesis is.” Sometimes that idea of what the patients think looks good or what they want to wear surprises even the designers. At Alleles Design Studio, headquartered in Victoria, Canada, the designers intentionally did not gender their leg covers that bring fashion to covers that mimic the shape of a human calf. “In the past if we sent out a flashy pink floral cover, we would assume it was going to a woman…. Then a picture would get sent to us of some male hockey player rocking the heck out of it and absolutely owning it,” says McCauley Wanner, president and cofounder of Alleles. “Had we gendered our designs with our own pre-existing assumptions of them, perhaps that would have never happened (and this happens often). Our goal has always been to create choice and put the power in the hands of the patient to decide how they want to be perceived.” MacDonald says there is plenty of desire for prosthetic covers in a world where patients are proud of their devices. She considered purchasing a unique 3D-printed cover, but the $700 cost was prohibitive to her. Since she is a seamstress, she instead decided to make a Lycra cover for her socket. The first design she wore in public was a red maple leaf in honor of Canada Day. Before wearing the cover, people had talked to her in sympathy about her device, she says. With the cover, they talked about that instead of her injury, she says. “It opens a whole different world when they ask about your cover instead of your amputation,” MacDonald says. “It’s a total shift and you are in control of the conversation, which is nice.” She was so excited about her interactions with others that she decided to turn the covers into a business. Because the Lycra covers are inexpensive, people can accessorize their devices in a variety of ways, she says. Snyder says she sees a profound impact when patients can personalize their devices. She tells the story of a woman who wanted her device cosmetically covered to match her other limb, but after seeing someone with a personalized socket the woman changed her mind. Instead, she wanted her socket to include fabric that she had made. The fabric had quotes about her life and what she had gone through up until that point. “There were things she had gone through that I hadn’t known as a clinician, and it was breathtaking to me,” Snyder says. “There were moments on there that made her who she is today. It reminded me that there is often a lot beneath the surface that our patients are dealing with.” Covers Improve Outcomes and Mental Health While many people may associate prosthetic covers with decoration, they are much more than that, argues Ryan Palibroda, design director and cofounder of Alleles Design Studio. His covers are made to order based on user specifications and fall directly under protective cover billing codes, he says. Despite this, they are still categorized by many as accessories because they are attractive. “We could never understand why functional products couldn’t also be attractive, which is why we started our studio in the first place,” he says. “There are so many products in the medical industry that, while functional, lack any design consideration. This leaves the user of these devices ashamed and oftentimes not wanting to use or wear them at all.” When patients like the look of their devices, they are more likely to be compliant and feel good about themselves, he says. Research backs this up, says Eythor Bender, CEO and founder of UNYQ, a prosthetic cover business headquartered in San Francisco. A 2018 Veterans Affairs study asked US military veterans what concerns they had about their devices. Their number one concern was their balance. Next on the list, above mobility, was body image. 1 “It’s good to see research that backs up what our gut feeling told us seven years ago when we started UNYQ,” Bender says. Snyder agrees. Many of her patients have gone through trauma or sufferfrom multiple comorbidities. When she offers them a personalized look for the device, it can empower them by reflecting their personality and interests, and simultaneously encourage them to use their device more. “When you offer personalized options, you start seeing their faces light up,” she says. “For what may be the first time, they feel they can outwardly show who they are. That is innovative and profound.” One of Snyder’s patients was capable of wearing her device daily and moving more, but she rarely did. When they talked, the patient told her that she didn’t care that much about the device. “I said, ‘If I cover it with your skin color, would that make a difference?’” Snyder says. “She said, ‘I would wear it every day, all of the time. I hadn’t realized how much the appearance had impacted me.’ Lo and behold that was what had been keeping her from being motivated.” The impact of covers can go beyond just motivation for use as well. Erik Schaffer, CP, owner and president of A Step Ahead Prosthetics, headquartered in Long Island, New York, tells of the power of cosmesis. One of Schaffer’s patients suffered from phantom limb pain for more than a decade after a traumatic lower-limb amputation. The prosthesis Schaffer made was a recreation of the sound side limb. When the man put it on for the first time, he started crying. “He sat down and asked for a garbage pail and threw up,” Schaffer says. “He kept on saying that he wasn’t in pain anymore. His mind saw that his leg was back, [which] untwisted the knot that had been there for ten years and healed his ailment.” More Options for Covers Than Ever Before These days, prosthetist graphic designers and engineers specializing in 3D printing can create almost any cover a patient could want, Schaffer says. “The sky is the limit,” he says. “There is no limit to what you can do. If you can pay for it, you can have it.” He says patients who visit his 20,000- square-foot facility feel like kids in a candy store. “We’re creators and we’re designers,” he says. “Anybody can get all of these options.” He has made covers with Gucci and Versace materials. “I had a lady who lost both her arms and legs and wanted restoration at first, and now she’s all about the bling,” Schaffer says. Her socket had 250 crystals on it, making it look like a chandelier. “I dreaded doing it, but she wanted it really badly. It took us three tries, but it looks absolutely badass.” Snyder, who majored in art with an emphasis in sculpture in college before becoming a prosthetist, loves it when a patient gives her a challenge. “I have tested the limits to what works and what doesn’t when it comes to cosmesis,” she says. “I’ll do anything. I leave no door closed.” She’s found the best way to embed rhinestones in sockets. She’s put flags onto the sockets of veterans. Steve Madden’s shoes has inspired more than a few of her sockets. “People like to put their lives on their prostheses,” she says. It’s a testament of who they are without them having to talk about it.” Even though many patients are very imaginative in how they want to display their devices, they are still many who want their devices to look as realistic as possible, the experts say. “A lot of new amputees want to restore what they lost and try to get back to where they were,” Schaffer says. “They don’t want to be a one-person parade. I’d say we’re split probably 50-50. A lot of people want to show the bones, the bionic look, and a lot of people like to conceal it.” MacDonald says she had wanted to show off her prosthetic device as soon as she got it, but she knows there will always be others who do not share that desire and choose realistic covers or other ways to disguise the devices. For instance, many patients have to focus on serious comorbidities. “Being an amputee is the last thing on their mind,” she says. “They are more concerned with managing their medication, figuring out how to live, and managing their pain.” Others, she says, are still recovering from the trauma that led to their lost limb. “There are people out there who lost a limb and have PTSD,” she says. “Some people can’t get over it, and I get it.” Even Covered Devices Need to Work While covers are great, patients still need to wear devices that work best for their needs, the experts say. While the impact of media has given many patients more confidence in their devices, it has also sometimes led to patients requesting products or devices that may not be the best fit, Snyder says. For example, the Paralympics are inspirational, and running blades have piqued the public’s interest. But patients who have no plans to take up running or outdoor sports would not necessarily benefit from one, she says. In 2014, Paralympic athlete Amy Purdy impressed audiences when she came in second place on Dancing with the Stars . Purdy had bilateral transtibial amputations at age 19 after contracting bacterial meningitis and on the show wore legs customized to help her dance in high heels. “All of a sudden, I had patients who were interested in dancing legs,” Snyder says. “Media platforms bring options to the forefront of our minds, and this is why it’s critical for clinicians to keep examples of devices in their clinics that patients can hold and see for themselves. Very often, when patients can experience the device they’ve seen on TV or online, they realize it isn’t for them. The device that a patient has should always be what suits them best.” The good news, says Bender, is that these days form and function can work together. Patients and prosthetists once could only worry about how well a patient could walk in their device or use their prosthetic arm. “Twenty or thirty years ago the issue was more about walking and running. Nowadays, what we see is that patients don’t fear that as much because it is something we’ve solved and almost taken for granted. Now a major issue for patients is the image,” he says. “We wanted to go from stigma to style, and here we are.” Maria St. Louis-Sanchez can be contacted at msantray@yahoo.com. References Erbes, C.R., J. E. Ferguson, and S. R. Koehler- McNicholas, et al. 2018. Evaluating participation in 235 veterans with amputation. American Academy of Orthotists & Prosthetists, 44th Academy Annual Meeting & Scientific Symposium.

More Than Aesthetics: The Role of Prosthetic Covers

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More Than Aesthetics: The Role of Prosthetic Covers

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Academy Society Spotlight: Adaptive Communication Techniques for O&P

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