Upper Extremity Prosthetics: Thinking Outside the Box
By Judith Otto The Round Table:
 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.
Diane Atkins, OTR , is 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.
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.
Carl Brenner, CPO , is the director of
Prosthetic Research at the Michigan Institute for Electronic Limb
Development, Livonia, Michigan.
John M. Miguelez, CP, FAAOP , president of
Advanced Arm Dynamics, serves as a clinical consultant worldwide on
issues regarding upper-extremity prosthetics.
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. Meier's
experience in rehabilitating persons with amputation encompasses
some 2,700 amputees, 45 percent of whom are upper-limb
amputees.
Regarding "thinking outside the box": How does this apply to
serving upper-extremity patients? When are such solutions
appropriate?
Alley: One of the main reasons I became
interested in upper-extremity prosthetics is the tremendous
variance in how one must approach each case and attempt to provide
the individual with what will maximize his or her functional and
personal potential. One of the best examples I can relate occurred
very early in my upper extremity career, when I felt compelled to
design a new shoulder level interface, the Xframe, because the
traditional interfaces at the time were simply not adequate to meet
my patients' needs.
The appropriateness of a solution is a subjective issue, and can
sometimes vary greatly from patient to practitioner to gatekeeper.
For example, a solution is appropriate if it provides a large
enough benefit to the individual to offset the propensity to reject
the prosthesisand it is the education and communication skills of
the prosthetist that often determine if such a solution is
justifiable or not.
Atkins : Expedited fittings of UE prostheses
make a huge difference to (1) the patient, by requiring
significantly less time, effort, and expense; (2) the experienced
prosthetist, by simplifying and shortening the fitting and
adjustment process for the patient; and (3) the insurance companies
and third-party payers, by creating a marked savings in time and
money.
Additionally, the current trend is to look more at the option of
hybrid fittings versus complete electric arms with electric elbow,
forearms, and hands. This results in less weight, less cost, less
repairs, and a limb that is often easier for the patient to learn
how to use.
Brenner: When you fit a highly irregular case,
the use of diagnostic or preparatory prostheses is crucial. In our
experience, we find that in order to completely evaluate patients,
it's necessary for them to try as much of the available componentry
and technology as possible in order to identify what works best for
them. This process identifies the real needs of the patients and
the best combination of components and control strategies. It also
provides the documentation needed to meet third-party payer medical
review criteria and approval for reimbursement.
Miguelez: We approach cases differently, by
spending a lot of time up-front with the patient before we ever put
a splint or plaster on them. With regard to thinking outside the
box, we don't HAVE a box! We tend to get the patients that no one
else can fit: a lot of bilateral patients with severe scarring or
electrical burns, bilateral shoulder disarticulations, and similar
situations that require a real team approach to
problem-solving.
There is no cookie-cutter solution from our perspective. We
wouldn't have it any other way; it never gets boring. Every patient
is completely different, although we learn solutions from all of
them that may be indirectly applicable to other patients.
The team approach makes it workable for us; with all of us
applying problem-solving skills, it's amazing what can be
accomplished.
We were recently fitting a very tough patient who had injury to
one of the two muscles in a short above-elbow injury. Prior to his
visit, he had only been able to control the prosthesis with one
muscle. After working with our therapist and the manufacturer, we
were able to come up with some changes to the electronics that
allowed him to control the prosthesis with two muscleswhich
increased his function.
The cool thing is that we had that relationship with Motion
Controlthey were right there in Salt Lake City and we were able to
go up and spend time not just with the director, but also with the
technicians and software designers who were able to help us develop
a solution for this patient.
Meier: There's nothing new about hybrid
systems; I've used them for 30 years. The message here is that with
the amputee population we serve, we MUST think outside the box. Any
effective rehab program must be customized to the individual's
needs and anatomy. Thinking outside the box doesn't necessarily
mean an electronically powered prosthesis. It simply means that the
rehab team must think innovatively to achieve solutions. Cost
shouldn't be a factor, but you must also remember that the best
solutions are not always the most expensive.
I've seen arms costing $120,000 used on a patient where a
$17,000 alternative might be more useful and appropriate. Sometimes
even the most innovative problem solving is useless, whether it's
outside or inside the box: Many injuries are not clean amputations;
their nature and extent determine whether the patient is capable of
operating a prosthesis.
Billock: In 1994, a prosthesis we designed for
world-renowned photojournalist Mohamed "Mo" Amin required us to do
some rather different things to develop a solution. That led to a
different type of control for a prosthesis. We were the first ones
to apply what is known as Multiplex control, which is achieved from
two muscle sites that allow four degrees of control.
In anyone with a below-elbow limb absence or loss, there are two
muscle groups to access; one to open and one to close the hand, and
they can also be used to control wrist rotation. By using Multiplex
control and co-contracting both muscle groups together, the
individual can use the same two muscles that open and close the
hand to switch to control of wrist rotation, as well.
I had had the idea of utilizing Multiplex control for some time
previously, but Mo Amin's situation was the first that allowed me
to put it into practice.
Reimbursement has not been a significant problem with regard to
the creative solutions we devise. Whenever we can improve the
function of a prosthesis and justify this with our own
documentation, we have had few problems with the insurance
companies. If we're going to do something outside the box, we
simply need to explain why it's outside the box.
It is advisable, however, to dig a little before prejudging a
patient's needs. I once made a cable-driven prosthesis with hook
for a farmer, who complained that he wasn't able to use it for his
needs. I ended up spending half a day with him on his dairy farm,
where it became clear to me that his prosthesis couldn't manipulate
the sophisticated milking equipment. Ultimately we made a
specialized prosthesis just for his use, and learned a valuable
lesson about carefully assessing a patient's lifestyle and
needs. Judith Otto is a freelance writer based in Holly Springs, Mississippi. 
Table Of Contents - February 2003
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