Negotiating the New World of Upper-Limb Prostheses

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It has taken two wars, innumerable improvised explosive devices (IEDs), and thousands of injured servicemen and women to push prosthetists forward in the management of upper-limb amputations. The terminal device has undergone a metamorphosis from rubber bands to microprocessors. The new generation of electronic hands emulates the delicacy and the rigor of a human grip while maintaining their robotic "purrs." These anatomically correct hands can have grip patterns programmed to patient-specific tasks with multiple control schemes, which add to their versatility and applications. Finally, they can be covered with a silicone skin that imitates the real morphology of the hand.

This groundbreaking technology has found its way to the U.S. market as prescribed by the State Department. Our nation has become the global beneficiary of emerging upper-limb componentry. Recently injured servicemen and women are fitted with beta test componentry prior to final Food and Drug Administration (FDA) approval, which aids them in restoring their function and mobility. In some outstanding cases, the prosthetic device has even helped them to return to active duty.

The delivery of care within the military setting has demonstrated once more the importance of the interdisciplinary rehabilitation team. Our military hospitals and the Department of Veterans Affairs (VA) system provide great examples of the positive outcomes created by the team approach.

Occasionally we have the honor to collaborate in the care of a veteran or an injured service person, fulfilling our part as an essential member of the rehabilitation team. On other occasions it is up to us to provide leadership that sparks the interest of the occupational therapist, physical therapist, mental health practitioner, and the physician to collaborate on a particular case and create a team approach. It may require stepping out of our comfort zone and sacrificing some of our time and monetary investment; however, it is almost certain to produce better prosthetic outcomes and, above all, deliver a small dose of good rehabilitation medicine.

The art of providing specialized upper-limb prosthetic care can be complicated. It requires the understanding that often the patient has already done research in the cyber world and comes to the evaluation with preconceptions of a solution for his or her situation. You, as the clinician, then have to juggle that with the physical findings from the evaluation and the emotional status of the patient, while taking leadership in the rehabilitation team that has to be assembled, many times with new individuals, for each case. At the same time you must take into consideration the realities of insurance coverage.

In the same nation that has promoted this new era in prosthetic componentry, publicized by the military examples, there are still many individuals with limb loss who are at the mercy of insurance carriers and third-party payers. Many insurance carriers deny coverage for prosthetic advancements because they consider them experimental, computerized technology, and too costly. Therefore, they hinder patients by cost containing their benefits and allowing a lower, less-advanced level of prosthetic capabilities.

Some instances may require legal intervention to overcome insurance company gridlock. It takes an aggressive practitioner to create awareness and leadership to make things happen for the patient and, ultimately, the profession. This is evidenced by a recent Florida case where a judge of workers' compensation claims ordered an employer to provide an injured worker with a more advanced prosthesis (see the news article Employer Must Provide Worker with i-LIMB Hand Prosthesis).

The upper-limb practitioner of today needs to understand the latest programming ability of the new-generation terminal device, yet never forget how to harness a figure eight to power a 5XA hook. Today's upper-limb practice will contain extremes—from body-powered devices developed in the 1950s to microprocessor-controlled hands just barely out of the trial stage. Understanding how and when to apply these technologies will make you a good practitioner. Delivering these applications in a team setting, in a professional manner, will make you a better practitioner. Providing the human touch to your care can make you a friend at a time when so much is at stake.

With the increased technological advances in prostheses, we have benefited from the wars, but the cost has been so, so high.

Waldo O. Esparza, CP, LP, is the founder and owner of Tampa Bay Prosthetics, Florida. He has been in practice for more than 30 years. His subspecialty is upper-limb prosthetics and he has lectured and published extensively on the subject.

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