Approximately 50% of individuals are fitted with prostheses [Muilenburg and LeBlanc 1989]. Of the 50% fitted with a prosthesis, only half actually wear the device. Experts cite numerous reasons for this trend [Shurr and Cook 1990]. Fit and prosthetic training appear to be the most salient factors that affect prosthetic wear [Bennett and Alexander 1989]. The role of the prosthetist is to provide a well-fitting prosthetic device. It is the role of the occupational therapist to assist the individual to become an independent user of the device. The prosthesis is often heavy and awkward to use. If the fit is not tolerable, or if the potential wearer has not been properly trained to use the device, the prosthesis may end up on the closet shelf.

Unfortunately, only a small number of health care providers have extensive knowledge of the rehabilitation of the person with an upper extremity amputation. The typical therapist may encounter few individuals with upper extremity amputations. Thus, it is difficult to remain abreast of the current prosthetic trends and technologic developments that affect how therapists promote the maximal level of independence for the client with an upper extremity amputation. However, occupational therapists can make a substantial difference in the lives of individuals with amputations if they possess knowledge of the various factors that impact the life of a person with an amputation.

This chapter provides the therapist with general knowledge on upper extremity amputations and their impact on function. Next, the chapter delineates roles of the team members and discusses the various prosthetic options and componentry. Goals for occupational therapy (OT) throughout the prosthetic rehabilitation process are described. Finally, this chapter describes marketing strategies and recommendations for a therapist wanting to increase the number of prosthetic referrals received.

Amputation Levels and the Impact on Function

Figure 18-1 provides an outline of the various amputation levels, along with abbreviations associated with them [Santschi 1958]. The more distal the amputation the greater the degree of natural function retained. Consequently, less is demanded of the prosthesis [Law 1981]. For example, an individual who has an amputation at the midhumeral level may be functionally able to use shoulder internal and external rotation along with other shoulder motions. However, the person lacks elbow flexion and extension and forearm supination and pronation. This is a disadvantage. If an individual with a midhumeral amputation wants to receive money from a cashier, more effort is required.

Figure 18-1 Levels of upper extremity amputation.

First, positioning and locking the elbow in flexion is necessary. Next, the person manually rotates the terminal device to the palm-up position with the sound side. Finally, the person is ready to perform the act of receiving the money. Conversely, an individual with an amputation at the wrist level is functionally able to pronate and supinate, flex and extend the elbow, and retain full shoulder function in the completion of activities of daily living (ADL).

The ability to pronate and supinate serves as a substantial advantage, enabling the person with the amputation to turn the prosthetic hand palm up as if to receive money from a cashier without the substitution movements of shoulder external rotation. Whether or not an individual chooses to wear a prosthesis, the level of amputation directly impacts function. The estimated frequencies of levels of amputation of the 50% who wear a prosthesis are presented in Table 18-1, indicating which level is most common [Muilenburg and LeBlanc 1989]. It is apparent that most amputations occur at the transradial level.

Table 18-1

Percentage of Amputation Level for Prosthetic Users

Causes of Upper Extremity Amputations

The causes of upper extremity amputations differ from the causes of lower extremity amputations. Lower extremity amputations are largely a result of disease. The majority of upper extremity amputations result from trauma [Leonard and Meier 1988]. Other causes include disease, tumors, elective surgery, and genetic anomaly [Bennett and Alexander 1989]. Commonly, therapists work with individuals who before injury used their hands extensively in their daily occupations. Often these persons hope to regain a similar level of independence. A power-line worker describes his experience in the following words.

The 7,200-volt power line was approximately five feet from where I came in contact with it. It’s a strange thing, but I don’t remember touching it. According to my co-workers, I started screaming and there was a bright electrical arc between my hands for about 10 seconds. The foreman shut off the power and got the boom truck to get me down…. I noticed there was no flesh on my hands anymore. Both hands were charcoal black! I knew they would have to be amputated, but the only thing I was concerned with was getting to a hospital to relieve some of the unbearable pain…. I’ve had four major operations at St. Elizabeth for amputations. I didn’t know for sure at the time how much they would have to take off. They amputated just above the elbow the first time. And I remember that the stumps looked pretty long the first time, but the second time they got a little shorter, and then the third time they really got short. On the fourth operation they removed an infected area from my right stump and armpit. I was given medication to help build tissue to fill those holes back in [Crane 1979, p. 10].

The Team Members

The team treating a person with an amputation is instrumental in the prosthesis-fitting process. The team consists of the person with the amputation, the prosthetist, and the therapist. The primary goal of therapy is to provide the individual with the proper tools and techniques to regain independence. A team approach combines expertise and experience, creating a synergy of professionalism, with team members working together and promoting the maximal level of independence for the individual with the amputation. The best results in upper extremity rehabilitation include interdisciplinary teamwork [Baumgartner and Bota 1992].

The Client

The primary member of this team is the person with the amputation. Individual goals, desires, and needs establish the foundation for which the team develops the action plan. Clients’ priorities for rehabilitation can vary. Common concerns include cosmesis, function, weight, maintenance, and funding for the prosthesis [Atkins et al. 1996]. For example, the needs of an individual with a transradial amputation who works full-time and desires to return to work may vary from those of an individual who is a stay-at-home parent. The type of prosthesis selected would vary, depending on a precise analysis of the client’s work, leisure activities, and ADL.

An important aspect to the client is early postoperative prosthetic fitting. The advantages of early fitting are decreased edema, reduced postoperative and phantom pain, accelerated wound healing, improved rehabilitation, and decreased length of hospital stay [Malone et al. 1984].

The Prosthetist

The prosthetist has knowledge of the technology and componentry available. The prosthetist specializes in componentry, fit, and prosthesis fabrication. It is the responsibility of the prosthetist to understand the client’s primary diagnosis as it relates to the need for prosthetic services [Billock 2003]. The prosthetist must introduce, educate, and orient the client to the controls and functions of the prosthesis. Daily care and maintenance of the prosthesis are taught to the client by the prosthetist and should be reinforced by the therapist. The prosthetist and the therapist may collaborate when exploring the prosthetic options with the client.

The Occupational Therapist

A well-rounded rehabilitation program is advised because the quality of training will directly determine how the individual uses the prosthesis for the rest of his or her life [Lake 1997]. The therapist has many responsibilities. It is important that therapists know the basic differences in prostheses to make proper recommendations of components to the team. Therapists should also recognize the importance of collaboration with skilled upper extremity prosthetists, with the purpose of maximizing the training process and the degree of independence [Atkins and Alley 2003]. Without proper therapy, the benefits of prosthetic use may be limited.

The therapist reinforces and builds on residual movement, developing functional applications of the prosthesis to address the distinct ADL (e.g., brushing teeth) and instrumental ADL (e.g., driving) of each individual [Toren 2002]. The therapist is responsible for ensuring the client knows how to clean and maintain the prosthesis. In addition, the therapist provides opportunities for the client to practice using the prosthesis in specific daily activities. The therapist focuses on bilateral activities. Often, after amputation the individual becomes successful in performing some ADLs unilaterally. Thus, therapy must begin early in the rehabilitation process to facilitate use of the prosthesis in bilateral activities.

Initial prosthetic training begins with a reorientation to the prosthesis and basic open-and-close control. Training then includes controlled grasp, such as opening in small increments to grasp small items and then more fully to grasp larger items. Training emphasizes grasping objects of varied texture and density to be handled. Sessions incorporate work on prehension and timing of release. Functional and appropriate tasks are encouraged and require the client to use the prosthesis for gross and fine motor activities. Training also emphasizes tasks to achieve all of these components in a variety of planes [Patterson et al. 1991, Keenan 1995]. With the combined efforts of the team members, the appropriate prosthetic components are chosen so that the individual can achieve goals through therapy, practice, and education.

Prosthetic Options

Generally, four categories of prosthetic options are available for the person with an upper extremity amputation. The options include (1) no prosthesis; (2) a passive (semiactive), cosmetic prosthesis; (3) a cable-driven body-powered prosthesis; and (4) an externally powered, electrically controlled prosthesis with either myoelectric sensors or specialized switches.Table 18-2 outlines the pros and cons of each prosthetic option [Law 1981, Muilenburg and LeBlanc 1989].

Table 18-2

Advantages and Disadvantages of Prosthetic Options

A prosthetic device cannot mechanically duplicate the amount of function, reliability, and cosmesis the human hand naturally provides. Therefore, it is important for the health care provider to possess knowledge of the various options continually being developed for future selection of prostheses. A fundamental understanding of these five components is necessary. These five components include the harness, socket, cable, terminal device, and glove.

Body-powered Prosthetic Components

The Harness.: The purpose of the harness is to suspend the prosthesis on the residual limb. It transmits force from the body to the prosthesis for independent operation of the prosthetic components [Muilenburg and LeBlanc 1989]. The body-powered prosthesis always requires harnessing. There are two primary types of harness: a figure-of-eight and a chest strap. The figure-of-eight harness passes over the shoulder, across the back, and under the contralateral axilla. “The ring lies flat in the back, inferior to C-7 and just to the sound side of the center of the spine” [Shurr and Cook 1990].

The standard figure-of-eight shoulder harness (Figure 18-3A) for the upper extremity has an axilla loop on the sound side that is commonly uncomfortable and can cause numbness and nerve damage [Collier and Le Blanc 1996]. The chest strap offers an alternative method of harnessing. It travels across the back, under the contralateral axilla, and across the chest (Figure 18-3B). It is important that the harness, either figure-of-eight or chest strap, be tight enough to activate the terminal device (TD) without excessive effort and loose enough to be comfortable and allow freedom of movement of both arms and shoulders.