Upper extremity limb loss is a devastating injury that interferes with the way a person interacts with almost everything in their environment. Imagine waking up and leaving for work with the use of only one arm. Almost every task involved in bathing, grooming, dressing, meal preparation, child care, carrying items, and driving is seamlessly integrated as a bimanual task, the individual performances of which have to change drastically. Rehabilitation is the best way to assist patients with limb deficiency in this transformational period. Prosthetic limbs offer an opportunity for return of some function, which in turn allows individuals to return to participation in meaningful activities. Rehabilitation is vital to ensuring the successful return of the individual to their environment with or without a prosthetic limb. A prosthesis needs to fit well, the control strategy and suspension need to be comfortable, prosthesis fitting needs to happen in a timely manner, the individual needs to have a good fit between function and the user task requirements, and the individual needs to understand how best to incorporate their new limb into tasks. There are many moving parts in the previous description, and this is why rehabilitation is so important to successful reintegration of the individual in all the activities they need to perform daily.

The role of rehabilitation serves to guide individuals through a complex recovery and return them to an active engaged life. Many adjustments are required of the individual while dealing with pain, emotional challenges, and an incredibly stressful time. Some individuals are more resilient to dealing with the complexities of recovery, but the role of the clinicians is to accept them wherever they are mentally and compassionately support them through this transition. Individuals will need to determine what a prosthesis can offer them and be encouraged to identify what needs are the most important to them. Clinicians are there to educate, train, support, and encourage individuals with limb deficiency as they redefine how to interact with the environment.

Prosthetic limbs have their advantages and disadvantages, but nothing replaces the ability of a native hand. Individuals with limb deficiency should always be given the opportunity for a prosthesis and training to return to full bimanual performance. Robotic technology is advancing at an incredible rate, but nothing comes close to offering the range of motion, strength, sensation, and dexterity of the human hand. Occasionally, prosthesis users find that covering sensate skin with a prosthesis socket interferes with the function of a sensate residual limb. Sensation is very important to inform the individual about how much control they have over an object. Partial hand prostheses are uniquely challenging because they often cover sensate distal skin to gain more prosthetic device function, which is insensate. The same prosthesis does not work for everyone, all the time, in all situations. No one intentionally goes to sleep wearing their device. Everyone has a sliding scale of comfort with when and why they like to wear a prosthesis and when they do not. This also applies to specific terminal devices; a person would not want to wear a swimming terminal device to dinner with friends or take an electric arm kayaking. There are many needs to be met after losing an arm. Many factors go into determining what and when an individual with a limb deficiency may desire to incorporate a prosthesis. If someone learns to be comfortable performing tasks one-handed, then why would they put on an uncomfortable device that may not work perfectly all the time? Individuals need to see the value and purpose of wearing a device. If someone chooses not to wear an artificial limb, clinicians need to be supportive of that choice as well and facilitate independence as best as possible. A prosthesis may be too painful or limiting, but the clinician’s role is to eliminate these barriers and help the individual find a system that may increase their function. Whether the individual chooses to wear a prosthesis or not is subjective if the clinicians have done their jobs. Factors involved in prosthetic acceptance and rejection will be discussed in greater detail in this section. There appears to be a limited window of time to learn how an artificial limb can add value to a patient’s day and tasks.¹ Individuals can have a variety of motivators such as additional pinch to help them with tasks, a cosmetically identical device that goes unnoticed, a device with the most strength or versatility, or something that looks cool. Remarkably, it has been noted that individuals at the time of their amputation may be concerned about not being accepted by a potential partner because of their limb difference. This is another reason why people need to grieve, talk, voice concerns, identify negative self-talk, enhance coping skills, and accept their changes to move forward as Belon and Vigoda² summarized emotional adaptation for amputees in a 2014 review. The work of Elizabeth Kubler-Ross is apt for identifying stages of grieving and moving toward acceptance after amputation.^2,3 There are many factors involved in the adaptation of the person as they transition to life without an intact extremity, and clinicians need to be familiar with the complexities to best serve their clients.

Clinicians assist an individual with limb deficiency to return to function after limb loss through education, support, training, and exposure to the appropriate tools at the right time. People with limb difference have a variety of options for a primary prosthesis, but the individual must see the value in its use. Whether it helps them function, is cosmetically appealing, does not draw undue attention, makes them feel whole again, helps them accomplish a meaningful task; all of these reasons help support a need of the individual. Clinicians should encourage the patient with developing this priority of needs of a prosthesis to ensure the device matches those needs. Ideally, clinicians would like to encourage the individual to explore the possibility of using a device to add a functional grasp to return bilateral upper extremity interactions. The clinician’s goal for the patient is to achieve a certain level of dexterity, comfort, knowledge, and ability to make an informed choice. It is not always easy for an individual, who has recently undergone trauma, to be open-minded and assertive about all the factors involved in selecting, training, and wearing an artificial limb. Under the time-constrained cost-containment medical model, given the amount of one-on-one clinician time patients receive, how do clinicians distill the most important aspects of a medical issue and motivate them to take on these challenges? One of the biggest selling points for use of a prosthesis is the additional function. How does one hold their wallet to take out something without a prosthetic grasp? How does one carry a coffee and unlock a door with keys? Or hold vegetables in place while cutting them? Or tie shoes? Or carry a bag and put sunglasses on? The list goes on. Assisting an individual to achieve a level of competency with a prosthesis to make an informed decision is the best for which clinicians can strive. That is easier said than done as many moving parts, emotions, clinicians, reimbursements, appointments, and training need to come together in a relatively short amount of time. The individual with a limb deficiency and their family need to advocate for a high quality of care and the results they desire. Clinicians can encourage, educate, train, remove barriers, and assist the patient in their recovery, but ultimately the individual determines what course is the best fit for them.

Repetitive stress disorders (RSDs) and musculoskeletal conditions (MSCs) of the intact limb are additional reasons for prosthesis use. In a retrospective cohort study of combat-related amputations by Cancio et al⁴ in 2021, it was found that 1 year following amputation overuse upper limb conditions, neck and upper back conditions, lower limb conditions, and low back pain were more likely to develop in service
members with upper limb amputations than in those who sustained minor combat-related injuries. Repetitive stress disorders such as carpal tunnel syndrome, cubital tunnel syndrome, radial tunnel syndrome, tendinopathies, and medial and lateral epicondylitis are some of the possibilities. Other overuse challenges may involve arthritis, ligamentous damage, rotator cuff tears, and muscle and tendon trauma. Another study identified that MSCs were 65% higher than in those without amputation.⁵ If these individuals do not use a prosthesis, they are potentially at increased risk for MSCs and they may have very limited function while recovering from injury or surgery to the intact limb.⁶ Good evidence identifies the link between limb loss and RSD or MSC, but there is not good evidence for the use of a prosthesis decreasing the burden on the intact upper extremity. There is a tendency for individuals with limb deficiency to use their teeth to assist with opening or stabilizing items. This is not advised because of the increased wear or damage to the teeth. Individuals with limb deficiency need to be educated in prevention of these secondary traumas through ergonomics education, workplace ergonomic assessment, activity modification, stretching, strengthening, and joint protection techniques. Yoga and Pilates-type exercises can be an excellent tool to promote proper alignment, symmetry, range of motion, strength, and endurance after limb loss. The use of a single upper extremity has been shown to increase the risk of repetitive stress disorders and/or musculoskeletal disorders; individuals need to be educated in prevention of these disorders, as well as the potential benefits of prosthesis use.

Individuals with limb deficiencies have varying levels of interest to train and rehabilitate in the use of a new prosthesis. Unfortunately for the individual with a limb deficiency, learning to use a prosthesis is a little more complicated than switching out a part. The clinician roles are clear as the physician prescribes the intervention, the prosthetist crafts a limb replacement device, and a therapist trains them in the application of the device. A prosthesis is essentially a tool, and some tools require more practice than others. A golf club is made to hit a golf ball, but the execution of the user is the main variable determining success. To become a skilled user of a golf club takes many hours of practice and education to do one thing: strike a ball. Learning how to use a prosthesis to assist with many tasks is more complicated, and the individual may have to adapt the task or tool to find success. Clinicians work hard to lead patients with limb deficiency to a level of competence with accuracy, knowledge of the device, dexterity, problem solving, and task adaptation, and the rest is up to the patient. Therapy is crucial to educate and inform quality use of the device by the user. Working with individuals going through major life stressors requires compassion, flexibility, and resilience of the clinician. When and where the individual wants to use the device is a personal choice. Engaged participation in therapies can be encouraged by matching the patient’s personality and interests, assisting in solving problems, providing a safe atmosphere for patients to share their feelings, facilitating humor (the best coping technique), and finding mutual interests in common. To get the most engagement out of an individual, physicians themselves need to be engaged, enjoying their time, learning, sharing, and appreciating the individuals and work involved. Motivational interviewing skills are also a wonderful method to help meet a person where they are mentally, and gently develop aspects of what they are communicating into positive opportunities for growth with prosthesis use. Rehabilitation is vital for the patient to start thinking about when and how to use the prosthesis and ideally habituate its use in a number of daily tasks.

Individuals with limb deficiency have a number of different interests when using a prosthesis. Some individuals prefer something that appears as close to lifelike appearance as possible but is passive and only used as a stabilizer without prehension. Other individuals prefer body-powered terminal devices and harnessing systems with the use of a Hosmer hook to allow fine pinch and to not occlude sight. Still other individuals prefer the power and harnessless myoelectric devices. More technologically advanced multiarticulating terminal devices that bridge design gaps are coming to the field every year, but there is not necessarily evidence that advanced devices have improved acceptance rates.⁷ Myoelectric devices are also available with custom-painted silicone covers to appear real while offering the benefits of prehension. Activity-specific devices offer a more task-oriented approach to device selection. Individuals may choose one of these devices to use as their primary prosthesis to assist them with a specific need such as wheelchair transfers or wheelchair propulsion. For more information see details about activity-specific devices discussed later in the chapter. Typically, activity-specific devices are used for a particular sport or activity and then switched out for a more versatile prehension device once the sport or task is finished. For example, if someone uses a terminal device to assist with an afternoon of biking, it will help them bike, but would not be helpful if they stop to shop or eat because it does not have prehension. There are advantages and disadvantages to all prosthetic systems, which the patient should be educated on and consider their needs before receiving a prescription.

There are many factors involved in successful prosthesis acceptance. A study conducted with bomb blast survivors with upper extremity limb loss demonstrated that revision surgery to improve the residual limb improved prosthesis compliance from 19% before amputation to 87% after amputation.⁸ This demonstrates that limb quality plays a crucial role in prosthesis acceptance. Education of
individuals in the quality of their residual limb and changes that may happen over time could ensure more prosthesis acceptance. Malone et al refer to a golden period of prosthesis acceptance if a patient is fitted within 1 month of amputation.¹ This study goes on to state that the initial type of prosthesis did not matter for long-term acceptance, but the time frame was more important.¹ In another survey study, factors associated with prosthesis acceptance included having fewer than two complicating health factors and being employed.⁹ The average speed of delivery of the prosthetic devices in this study was from 6.5 to 15.4 months after amputation. Fewer than two complicating factors, completion of high school education, employment during the time of amputation and review, rapid return to work, acceptance of the amputation by the time of review, and the perception that the prosthesis was expensive were factors associated with successful rehabilitation.⁹ Biddiss and Chau¹⁰ identified perceived need of prosthetic limb and satisfaction with the prosthetic technology as the most important aspects to acceptance. Factors that increase the likelihood of rejection include pain/discomfort, female sex, partial hand amputation, transhumeral amputation, non-full-time workers, and those with low satisfaction with health care and prosthetic options. Work seems to play a role as full-time employed individuals recorded 20% rejection versus part-time employed individuals at 35% rejection. The occupational roles with the most rejection, at greater than 40%, included students and homemakers.¹⁰ There are many factors that can decrease the likelihood of prosthetic acceptance and practitioners can assist the patient in overcoming these. There is an opportunity to help individuals with limb deficiency benefit from prostheses over the life span but this depends on informed quality care. Biddiss and Chau described the importance of establishing need, enabling resources, involving the patient in the prescription process, and fostering peer support.¹⁰ Another study from Austria identified that advanced prosthetics have not corresponded to increased acceptance.⁷ Most of the participants in the study were myoelectric users and most complained about the poor comfort and weight of the devices.⁷ Østlie et al identified primary prosthesis rejection and secondary or delayed prosthesis rejection as being highest in elderly, female patients whose amputations were more proximal.¹¹ The questionnaire based in Norway found less primary rejection (4.5%) than secondary rejection (13.4%) among the 224 participants. The rationale for rejection followed a similar theme of perceived need as well as dissatisfaction with comfort, function, and control.¹¹ The aforementioned items indicated the need for quality patient-centered care with experienced clinicians and maximization of comfort and function. Further research is needed to determine the causes of prosthetic rejections with current devices and health care delivery processes.

Individuals are confronted with challenges to many parts of their lives after amputation, and clinicians are there to support them in this transition. Faced with a loss of function, individuals must determine the best option to support their return to successful performance of tasks. Although a prosthesis may not be beneficial for everyone, it has a remarkable ability to assist function. There have been advances in upper extremity prosthetics devices, but this does not correlate to increased rates of acceptance.⁷ Timeliness of prosthesis fitting, perceived need of a prosthesis, comfort, residual limb quality, and full-time employment all play a role in acceptance.^1,8,9,10 The key to success is finding a fit between the individual and a device that meets their needs to interact in their environment.

Postamputation pain (PAP) encompasses the various types of pain that an amputee can experience. Under that umbrella term, phantom limb syndrome (PLS) is a unique phenomenon associated with limb loss.

The concept of phantom sensations and pain dates back centuries, described a “ghost” pain from an amputated limb no longer present. The term phantom limb pain was coined to label the symptoms that patients experience after an amputation. Phantom limb syndrome (PLS) is a broader term used when referring to any sensation (pain or otherwise) localized distal to the amputated limb. People with limb loss experiencing PLS may describe feeling the hand or fingers present (sensation) or they may report pain (PLP) described as electrical, shooting, stabbing, burning, throbbing, cramping, numbness, or pins and needles (Figure 1). In severe cases, amputees with PLP report feeling as if their hand is being crushed and twisted, causing excruciating pain, which prevents them from sleeping or carrying out activities of daily living (ADLs).

PLS is thought to be neuropathic in nature, with the mechanism occurring along the sensory nervous system in three specific areas: supraspinal, spinal, and peripheral. Supraspinal involves pathways in the somatosensory cortex, which has been shown to reorganize the area in the brain mapped to the amputated limb as a result of the sensory input (the deafferentiated limb), termed neuroplasticity. In the spinal cord, the dorsal horn is reorganized after the peripheral nerve injury. The severed peripheral nerve results in axonal nerve damage initiating inflammation, subsequent regenerative sprouting of the nerve endings, and ultimately increased ectopic afferent input. The perceived experience is pain distal to the residual limb from this disrupted reorganized sensory feedback loop resulting in PLP.

Pain localized in the residual limb may be attributed to several causes, which include problems with the bone, soft tissue, or incision. Acutely, pain in the limb could be intrinsic pain from surgical manipulation of the soft tissue or may be due to an underlying infection, which may be accompanied by localized fever, tenderness, redness, or purulent drainage
(Figure 2). In the subacute phase, muscle spasms result from surgical procedures performed to cover the distal end of the limb such as a myodesis, where the muscle is sewn into the bone to provide appropriate shape and structure in an ideal level of amputation.

Once the incision is healed, another common cause of intrinsic residual limb pain is the development of neuroma, which occurs when the peripheral nerves cut during the amputation tend to regenerate, forming a bundle of nerve endings (Figure 3). These neuromas produce neuropathic-type pain when the mass is palpated causing a sharp, electrical sensation radiating proximally along the nerve.

Residual limb pain may also result from causes external to the limb such as pressure from a dressing or a shrinker being too tight or from a prosthesis exerting uneven pressure in an anatomic area that is sensitive, such as the bony protuberance (humeral condyles) in the elbow.

Pain can also arise from wearing or not wearing a prosthesis. Conventional body-powered prostheses have a cable harness system that relies on suspension around the shoulder/axilla region (Figure 4). Fitting and alignment are key to ensuring proper functioning and prevention of abnormal positioning, which might result in pain during use. Alternatively, many upper limb amputees choose not to wear a prosthesis or unfortunately do not have the resources to obtain a prosthesis. Regardless, studies have shown that not using a prosthesis places an upper limb amputee at risk for the development of overuse syndrome in the contralateral limb or in a joint proximal to the amputation. Additionally, in the case of traumatic traction injuries causing an amputation, for example, an arm pulled into a machine, damage to the brachial plexus could result in pain in the residual limb separate and apart from the amputation causing pain. Musculoskeletal pain in the cervical and thoracic spine can be from the biomechanics as a complication of an upper limb amputation, such as an overactive shoulder girdle musculature without the gravitational weight of an arm.

Other complications that can cause pain include abnormalities related to the bone, soft tissue, and skin interface. Examples include bone spurs or heterotopic ossification (Figure 5), joint contractures, and bony prominences post upper limb amputation. Skin complications include infections (bacterial, fungal), allergic reactions, and adherent skin grafting.

Evaluating pain in an amputee is critical to diagnosing and treating the various types and complications associated with upper limb loss. Aside from the standard visual analog pain scale,
asking specific questions about descriptors and locations of their pain assists with differentiating the various types of pain outlined previously that amputees can experience.