The State of the Art in Upper-Limb Prosthetics: Reflections from Respected Voices

Our panel of experts: Randall Alley, BSc, CP, FAAOP 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. John M. Miguelez, CP, FAAOP , president of Advanced Arm Dynamics, Rolling Hills Estates, California, serves as a clinical consultant worldwide on issues regarding upper-extremity prosthetics. 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. John Billock, CPO/L, FAAOP Diane Atkins, OTR , 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. Carl Brenner, CPO , is the director of Prosthetic Research at the Michigan Institute for Electronic Limb Development, Livonia, Michigan. 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. Meiers experience in rehabilitating persons with amputation encompasses some 2,700 amputees, 45 percent of whom are upper-limb amputees. Question One John M. Miguelez, CP, FAAOP What are some of the most significant recent advances in upper-limb prosthetic technology? Alley: In the component sector, Otto Bock's sensor hand, Motion Control's flexion wrist for its electric prehensor, LTI's Boston Elbow 3, and Animated Prosthetic's PDA-based wireless controller and battery technology have all contributed greatly to both patient and practitioner capabilities. Atkins: Microprocessors that allow a prosthetist to modify a variety of control options without changing componentsas was necessary in the pastare a huge advantage. An experienced prosthetist can do this "troubleshooting" in an initial fitting; an experienced OT [occupational therapist] can learn to change the control thresholds as the amputee's strength increases; and in certain cases, the user can be taught to make these adjustments himself as he progresses. The transcarpal myoelectric hand is also a terrific advance. Billock: The lithium-polymer battery technology just introduced into prostheses is very impressive. These smaller batteries are 80 percent lighter than nickel-cadmium batteries, 70 percent smaller, and offer 30 percent more storage capacity. We've been after these batteries for two years, but if you can't buy them in extremely large quantities, they're unavailableand, unfortunately, the needs of the prosthetic field are relatively small. We were only able to get them by appealing to the humanitarian instincts of their suppliers and manufacturers, with regard to a young patient in their own backyard. [This humanitarian response also made] them available for others. The child was born with complete hand absences just below the wrist. She was fitted with two myoelectric hands, but routinely ran them out of power within four to five hourscouldn't get through a day of active exploration and learning. The new lithium-polymer batteries hadn't really been applied to prosthetics before, and we had to meet special requirements in the circuit design of the prosthesis to satisfy the manufacturer of the batteries. These are the batteries that for 25 years I've been waiting for. There are also improvements in motor technology that we're aware of, but which still haven't been introduced into some of the systems that are out there. They offer enhanced durability, speed, and torque. There's a lot going onenhanced control systems are becoming available. We've developed our own electronic control system for a myoelectric prosthesis, which is the smallest available today; others are also making similar advances. Brenner: I find that our patients are delighted with the new batteries that are available. There have been a lot of advances, but for patients that have been wearing externally powered prostheses, the lithium-ion power systems that are available now are very fast, easy to charge, a little lighter in weight, and have much greater capacity than nickel-cadmium power systems. Hanger Upper Extremity Prosthetic Specialist Steve Mandacina, CP, helps five year old Ethan Wright don his new myoelectric prosthesis. Photos courtesy of Hanger Prosthetics & Orthotics Another welcome advance is the availability of programmable microprocessor circuits, which allow the prosthetist to truly customize and fine-tune the control strategies for each patient. Also, new components, such as the transcarpal hand, allow us to fit longer forearm lengths than ever before and come up with a more cosmetic result. Improved silicone suction suspension systems have been very helpful, as have lighter and cooler socket designs that provide more patient comfort and better cosmesis. Miguelez: I think there are two different aspects to consider here: 1) the evolution of third-generation electronics, including the wider use of microprocessors and all their benefits. We've just submitted a paper to JPO [Journal of Prosthetics and Orthotics] on that subjecta comparative analysis of microprocessor controllers. There's just so much more we can do now with using an electrically powered terminal device or elbow, and how we can control that by the types of inputs, and by the way we refine the EMG signal and how it's filtered. All of that really wasn't available several years ago, so that's very exciting to us. That's one phase. 2) There have also been some neat advancements in terms of body-powered designs: The ERGO Arm elbow system is a very exciting elbow for the body-powered user because of its lock. It allows a counter-balance system that makes it easier for amputees to flex the elbow. They don't have to work against the weight of the forearm. The locking device in the elbow is also much more advanced and allows more efficient control. Photo courtesy of Motion Control, Inc. Another significant advance is in interface design. The introduction of the MicroFrame, which is the shoulder disarticulation four-quarter humeral-neck type of socket design that does not encapsulate the shoulder, has now allowed us to fit a lot of patients that, until a few years ago, were not considered prosthetic candidates. That's exciting. For several years now, we've been using the Anatomical Contoured Interface, which is an interface for either the transradial, styloid, or transhumeral level that really grasps the skeletal anatomy and creates pockets or areas for expansion for the muscles. This is important because we want to promote hypertrophy or muscle growth in an interface, as opposed to an interface that creates atrophy or muscle shrinkage. This provides more stability, comfort, and suspension for patients. The more comfortable it is, the longer patients will wear it and the more things they will do with it, increasing their overall functionality. Meier: The most significant technology I have seen is the electric locking shoulder joint, closely followed by proportional controls for electric technology and the increasing use of the silicon cosmetic glove within the last ten years. Question Two: What are some of the most significant recent advances in clinical practice? Photo courtesy of Liberating Technologies Inc. Alley: I feel that interface designs have significantly improved in the last decade. The anatomically contoured and controlled interface (ACCI) for radioulnar or below-elbow level, the dynamic socket for humeral or above-elbow level, and the XFrame for thoracic applications have all had a tremendous impact on prosthesis comfort, stability, suspension, and overall function, which in turn have had a favorable impact on patient acceptance of the prosthesis. I also believe the utilization of the expedited fitting procedure that was originally developed within NovaCare's Upper Extremity Prosthetic Program and has been adopted by Hanger Prosthetics & Orthotics Inc. as well as others, is an extremely significant advance in clinical practice. I feel that the push for justifying multiple prostheses and the increase in trial fittings are tremendously beneficial for upper-extremity patients. Atkins: I'm seeing a more acute awareness and effort on the part of prosthetists to work closely with an OTand vice versain order to optimally fit and train the upper-limb amputee. There is still a significant distance to go to develop an effective network and "bridge" of communication with each other, but educational efforts are underway and the AOTA [American Occupational Therapy Association] is strongly behind these initiatives. Also, a conference to better address the need, functional issues, and challenges of the bilateral UE amputee was held in Denver in September 2002. It was taught by prosthetists, therapists, a physician, and also by bilateral UE amputees themselvesand it was a huge success. Only 10-15 amputees were expected, but 25 attended and participated, in addition to 25 professionalsplus exhibi-tors, spouses, etc. Billock: Clinically there has been little progress from my viewpoint. There are some clinical procedures that aren't being applied&that folks could pay closer attention to. For example, all the myoelectric control systems that are being developed today have higher gain sensitivity, so that if someone has weak muscles, they can control the system. It has taken the focus away from the pre-prosthetic training that needs to go on to improve the physiological condition of the muscles and that person's proprioceptive control of the muscles. There has never been enough focus on that particular aspect, from my point of view, and now there is less. Prosthetists are relying too much on the electronic system itself to pick up the signal from a muscle that is weak, rather than focusing on pre-prosthetic muscle development. Additionally, there is difficulty in finding a trained therapist who understands upper-limb prosthetics and the rehabilitation needs of someone with an upper-limb prosthesis. When I work with therapists, I often find that they ask me what they should be doing with the patientessentially, I'm training the therapist. Like everything else, this takes time? reimbursement becomes an issue when I spend too much of my time in unbillable pursuits, even though it is a necessity. Brenner: We're seeing more focus now on the need for early intervention. With upper-limb prosthetics, there has historically been up to a 50 percent rejection rate prior to the 1980s. Within the last decade, however, we've seen more focus on early fittingswithin just a week or at most 30 days from the date of amputation. That has improved outcome measures significantly in terms of patient utilization of the prosthesis as incorporated into their daily wear and use patterns. The development of specialty teams and the whole concept of expedited fittings has also improved care. About 90-95 percent of our practice is upper-limb prosthetics, and over half of that is pediatrics. We have children coming to us from all over the country. They have to be fitted in an expedited fashion, receiving the prosthesis usually within 72 hours from the time they are first seen. I believe comparable things are being done by other specialty teams around the country. Miguelez: I think the biggest advance that we see is the expedited delivery and fitting protocols. The old model for patient care in upper-limb prosthetics involved an initial meeting with the prosthetist, who took the cast and essentially told you what you were going to get. In two weeks the patient returned for a fitting with a test socket; in another two weeks the patient returned again for the fitting of the prosthesis, followed by adjustments and harnessing, so the process took from six to eight weeks. Patient involvement in terms of choice of prosthesis and how it is fit was minimal. Not only were these repeat visits to the office difficult and expensive for the patient, but during this time, residual limb changes were taking place. As a result a lot of patients discontinued use since their prosthesis never fit and maybe wasn't the appropriate prosthetic option. In our system, we do a very comprehensive prosthetic evaluation, which involves our psychologist, who [tries to] figure out how the patient learns and helps us tailor a rehab plan to maximize his or her learning abilities. The occupational therapist is also involved in the evaluation and develops a therapeutic plan. If there are medical complications such as edema or nerve issues, a physician is also involved. Typically we spend two to three hours in the evaluation process, exploring and discussing all the prosthetic options. We let patients see and touch them, before we arrive together at a game plan, including the best prosthetic choice for that patient. In our system, the patient is the hub of the wheel, and the rest of the team are the spokesso patients really have a feeling of control, which tends to encourage more buy-in and greater commitment to fulfilling the rehab plan. Following through on the expedited program, the patient typically receives his or her prosthesis within one to three days. The casting and test socket fittings occur within a few hours of each other, rather than taking weeks. Adjustments are made along the way as the patient progresses through therapy, with the prosthesis being modified as needed. Editor's note: Payers are increasingly demanding outcomes data. Why have outcomes measurements been so elusive in upper-extremity prosthetic care? To read our panel's answers in an exclusively online article, visit www.oandp.com/edge/issues/articles/2003-01_09.asp . In upcoming issues, our panelists will discuss, among other subjects, exciting future trends in upper-extremity prosthetics, thinking "outside the box," and their personal vision and goals for the upper-extremity field. Judith Otto is a freelance writer based in Holly Springs, Mississippi.

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The State of the Art in Upper-Limb Prosthetics: Reflections from Respected Voices

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