Future Trends in Upper Extremity Prosthetics: What Do the Experts See?
By Judith Otto The O&P EDGE:
In your opinion, what are the most exciting future
trends in upper-extremity prosthetics?
Alley: I believe the ability to perform remote
diagnosis, adjustments, and other remote consulting services offers
tremendous promise for the patients and families, as well as the
other members of the rehabilitation team. Of course, the Internet
as a whole-with all its potential to educate in a variety of
formats and to promote greater communication-will only become a
more refined instrument over the next several years.
I also see a much greater depth and breadth of written material
intent on invalidating many misconceptions that have stigmatized
the field for years.
Finally, there is a great deal of interest in developing
clinical standards for upper-extremity prosthetic care, and as
chairman of the Upper-Limb Prosthetic Society, one of my most
significant projects is to work with the Academy [American Academy
of Orthotists and Prosthetists] in hopes of organizing the first
"Clinical Standards of Practice" Conference on upper-extremity
prosthetic initial and post-delivery assessment. As best practices
are identified and adopted, outcomes studies can begin to have more
credibility and offer real-world results, which in turn will offer
many new insights to patients, prosthetists, and other allied
health providers.
Atkins: Occupational therapists need to remain
aware that they need to enhance and update their knowledge and
skills with respect to current state-of-the-art prosthetic
practice, technology, and components.
Expedited fittings is another area where experienced UE
prosthetists have significantly reduced the amount of time required
to complete a complex, technically advanced UE prosthesis.
Ultimately, the sooner an amputee is fit with a prosthesis, the
better his functional outcome will be when learning to use a
prosthesis. This is a proven fact in a retrospective study of
hundreds of upper-limb amputees.
Billock: We need better controls. Myoelectric
control is without a doubt the best form of neuromuscular control
we have for a prosthesis-and the most natural. But it is
possible-and has been proven in other research circles-that you can
monitor EMG patterns. This is called EMG pattern recognition. If we
can do that-and utilize it for multifunction control of a
prosthesis-that's what I would hope to see in the future.
That would allow individual finger movements-and coordinated
movements of the hand, wrist, and elbow-unlike the robotic
movements allowed by the "six degrees of freedom" we find in
today's totally powered arm prostheses.
Going beyond myoelectric, there is also neuroelectric control,
in which the impulses between the motor nervous system and the
brain are monitored. There's a lot of information traveling there.
If we can understand and access that information, we'll be able to
achieve multifunctional control of a prosthesis this way, as
well.
Some of the techniques being applied to enable Christopher Reeve
are similar to what we've used in preprosthetic training for some
of my own upper-limb patients-teaching them how to facilitate the
muscle contractions without implants.
Brenner: Because we're dealing with fewer and
fewer numbers, upper-limb prosthetics is being identified as a
specialty area of practice within the field of prosthetics. We've
done a demographic analysis trying to determine where our patients
come from-particularly pediatric patients with congenital limb
deficiencies. In analyzing data from the Centers for Disease
Control, and comparing that data with the Canadian Congenital
Anomalies Surveillance system and data from Sweden and the UK, we
find that the incidence is maybe one child with a limb deficiency
out of every 9,000 or 10,000 live births. That means that in this
country we're seeing at most about 400 newborns per year that have
an upper-limb deficiency that would require or benefit from some
kind of prosthetic intervention.
When we look at other data related to the overall number of
prosthetic fittings-such as the 2000 Business Survey from AOPA-it
appears that the number of upper-limb fittings to lower-limb
fittings is about 1 in 15.
One of the trends I believe we'll continue to see is that
upper-limb fittings will become an even smaller portion of the
overall prosthetic experience. There are several reasons for this:
OSHA [Occupational Safety and Health Administration] has definitely
had an impact on creating a safer workplace. There are a lot fewer
people involved in agriculture (down from 30 percent in the last
century to currently 2 percent or less). The advances of
replantation and other surgical technology are getting better and
allowing more limbs to be saved.
Miguelez: The evolution of some of the terminal
devices from a couple of the manufacturers. We are very involved in
beta testing and product design with all the major manufacturers.
We always get to try the new stuff to help them refine new
componentry to suit the patients' needs, and I think that's really
important.
Previously they designed and delivered new items for us to use.
Now, our relationship with the manufacturers is such that they're
seeking feedback from us in order to help them design better
products. Instead of making the product and trying to integrate it
into the patient's scheme, we now have the patient contributing
input regarding what he's looking for and allowing the manufacturer
to respond.
Meier: From my perspective, there's very little
research going on in the upper-extremity field, possibly because
there are not many UE patients, and hence, not much money available
from this patient base.
Perhaps more emphasis should be placed on designing a better
hook-design terminal device rather than more exotic and less
cost-effective high-tech solutions. And with regard to high-tech
solutions, I don't feel that sensory feedback is going to be the
most useful possibility, despite its popularity as a topic for
speculation. Instead, I see a future with lighter prosthetic
designs, self-suspending designs, accurate and workable outcomes
measures, and hands that come closer to imitating natural
function. Judith Otto is a freelance writer based in Holly Springs, Mississippi. 
Table Of Contents - March 2003
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