Upper Limb Prosthetic Training and Occupational Therapy

Sandra Fletchall OTR/L, CHT, MPA, FAOTA

Sandra Fletchall or an immediate family member has stock or stock options held in Stedman Medical.

ABSTRACT

To assist an individual with upper limb loss in improving functional performance and the ability to return to work, the occupational therapist should provide both preprosthetic and postprosthetic care programs. The preprosthetic program is focused on edema and pain reduction, wound care, general strengthening, and gaining specific personal care skills. The postprosthetic program begins with delivery of a device and progresses to training in activities of daily living and work skills important to a particular user.

Introduction

More than 80% of upper limb amputations in the United States are performed following a traumatic injury.¹ The remaining upper limb amputations are necessitated by a congenital deficiency or a medical condition such as end-stage renal disease or cancer. Four times as many men as women undergo upper limb amputation, and most patients are 15 to 30 years old.² Amputations distal to the wrist are more common that those proximal to the wrist, with three-quarters of upper limb amputations occurring at the digit level.¹^,³ In such cases there is often a concerted effort to salvage at least two digits that can oppose.⁴

The loss of an upper limb at any level influences the ability to participate in tasks and other activities. According to the American Medical Association, amputation of a single digit leads to a hand impairment of 20% to 40%. The loss of an upper limb below the elbow can lead to 70% impairment, and shoulder disarticulation causes as much as 90% impairment.⁵ Upper limb loss at any level, especially if it is the result of trauma, can also lead to a change in roles within the family, home, community, and work environments. A structured occupational therapy program can facilitate an individual’s efforts to develop skills for returning to his or her highest level of functional independence.

Preprosthetic Therapy

Because of the traumatic nature of most upper limb amputations, it is usually not possible to plan a preoperative occupational therapy program. In those rare instances where there is a short time between the injury and amputation, patients and their families can benefit from information on the abilities and skills that can be acquired after surgery. This information should include a plan for postoperative, preprosthetic occupational therapy.

Many patients are discharged from the hospital a few days after the surgery and are able to immediately begin a preprosthetic occupational therapy program on an outpatient basis. The objectives of such a program should include psychologic support, coping techniques, wound care, edema reduction, residual limb shaping, pain reduction, scar and soft-tissue elongation and pliability, total body muscle endurance and strengthening, training in selected self-care, and changing hand dominance where appropriate.⁶ In addition, some studies have identified that those with upper limb loss experience standing/dynamic balance issues,⁷^,⁸ therefore the incorporation of balance training during the preprosthetic OT program can minimize fall risk.

The duration of a therapy program is influenced by the number of limbs amputated as well as the amputation level and the patient’s cognitive function, executive skills, support system, and funding source. An experienced amputee team should develop documentation to rationalize the need for the initial preprosthetic program, subsequent prosthetic training, and life-long follow-up through an amputee clinic. During the preprosthetic phase, the OT can also perform a home assessment with recommendations for durable medical equipment and/or architectural modifications.

Immediate Postoperative Considerations

Wound Care

A residual limb with wounds or a primary closure site can be cleaned with antibacterial soap and water and covered with a silver-type wound dressing. The use of a silver-type dressing can reduce the risk of wound complications, edema, or biofilm formation.⁹ If a mesh skin graft or sheet graft was surgically applied to the residual limb,
close inspection may be required during the first 10 to 14 postoperative days to maintain the proper moisture environment for the graft to express hematoma or serous fluid as needed.

Whether the limb is closed with native tissues or skin grafts, the application of elastic compression through bandage wraps or a compressive shrinker sock will stabilize wound dressings and initiate edema reduction. Many patients with unilateral upper limb loss can be instructed in appropriate wound care and limb management in the early postoperative period. However, a caregiver may need to be trained if the patient has bilateral upper limb loss.

Edema Reduction and Residual Limb Shaping

Prolonged edema can lead to residual limb pain, poor wound healing, increased firmness of scar tissue, and a poor residual limb shape. Edema reduction can be initiated with the use of an elastic compression bandage even if wounds are still present. This is often followed with the use of compressive shrinker socks once the limb will tolerate the associated sheer forces. The application of compression can increase the pliability of scar tissue and thereby limit pain and skin irritation. Continuous compression is recommended until the scar tissue matures 12 to 18 months after wound closure. After a partial hand amputation, a self-adherent elastic wrap can be used to apply pressure (Figure 1). For a transradial or transhumeral amputation, a 3- or 4-inches elastic compression bandage can be used for initial edema management. After a shoulder disarticulation, initial pressure from a 4- to 6-inches elastic compression bandage encompassing the trunk is beneficial, with subsequent use of a noncustom, moisture-wicking compression garment.

Elastic bandage compression should be used until wounds are sufficiently healed to tolerate the shear forces produced when a residual limb shrinker is donned. An upper limb residual shrinker can be fabricated from tubular compressive fabrics (Figure 2). Both elastic compression bandages and residual limb shrinkers have been shown to reduce residual limb edema, but the skilled use of an elastic compression bandage can facilitate greater edema reduction in less time than the use of a shrinker.¹⁰ The early application of compression also begins residual limb shaping, which can lead to easy donning of the prosthetic socket and minimize development of redundant soft tissue. A conical residual limb shape is the goal. Even after successful prosthetic fitting, continued use of a residual limb shrinker or elastic compression bandage may be required throughout the first year after the amputation whenever the prosthesis is not being worn; this will continue the process of edema reduction and limb shaping.

FIGURE 1 Photographs showing the use of compression for residual limb shaping and edema reduction. A, A self-adherent elastic wrap used after a partial hand amputation. B, A figure-of-8 elastic compression bandage was used after a transhumeral amputation. (Courtesy of Sandra Fletchall OTR/L, CHT, MPA, FAOTA, Firefighters Burn Center, Memphis, TN.)

Pain Reduction

Ninety-five percent of individuals with upper limb loss secondary to trauma report phantom limb sensation or pain, residual limb pain, or nonamputated limb pain.¹¹^,¹² The type and level of upper limb pain should be assessed during preprosthetic treatment. In phantom limb sensation, the amputee feels that he or she is experiencing various sensations in all or part of the absent segments of the amputated limb; these sensations may include a feeling of movement of the phantom limb. Phantom limb pain includes sensations that can be described as burning, twisting, shooting, squeezing, cramping, or dull aching of the amputated body part. By contrast, residual limb pain is experienced in the remaining tissues of the limb and may be the result of the initial injury, the amputation surgery, persistent wounds, or neuromas. In addition, the contralateral, nonamputated upper limb should be assessed for pain resulting from a previously undiagnosed injury, overuse syndromes, cumulative trauma, or a repetitive stress injury.¹³^,¹⁴^,¹⁵

FIGURE 2 Clinical photograph of a patient with a residual limb shrinker fabricated by an occupational therapist. (Courtesy of Sandra Fletchall OTR/L, CHT, MPA, FAOTA, Firefighters Burn Center, Memphis, TN.)

The early application of firm pressure, such as pressure applied with an elastic compression bandage, can reduce nerve or wound irritation, pain from edema, and sometimes phantom limb pain. The therapist also may need to use visual feedback, guided mental motor imagery, or mirror therapy to treat phantom limb sensations or phantom limb pain (Figure 3). Many individuals can be trained to use these techniques while in the clinic and then progress to incorporating the techniques into the home and work environments. Structured, guided visual feedback techniques can be used to reduce selected pain issues by means of cortical reorganization.¹⁶^,¹⁷^,¹⁸^,¹⁹ In contrast, the use of electrical modalities was found to lead to only minimal pain reduction.²⁰^,²¹

In comparison with the general population, individuals with upper limb loss are more likely to develop an overuse pain syndrome, most commonly affecting the neck, lower back, and/or shoulder.¹³ Individuals with unilateral upper limb loss often exhibit lateral epicondylitis, carpal tunnel syndrome, cubital tunnel syndrome, or stenosing tenosynovitis. A simple off-the-shelf orthosis may be useful in managing some overuse syndromes in the contralateral upper limb (Figure 4).

FIGURE 3 Photograph showing the use of mirror therapy to achieve pain reduction. Mirror therapy assists with decreasing the pain cycle in the amputated limb by watching the reflection of movement of the nonamputated limb in a mirror; this creates positive feedback in the motor cortex of the brain. (Courtesy of Sandra Fletchall OTR/L, CHT, MPA, FAOTA, Firefighters Burn Center, Memphis, TN.)

Flexibility, strength, and correct body and arm mechanics can help alleviate pain. Accordingly, preprosthetic and postprosthetic occupational therapy should include an emphasis on increasing and maintaining the flexibility of the trunk and extremities. In addition, the therapy program should focus on strengthening associated muscle groups and providing instruction in appropriate body and arm mechanics and posture.

Positive coping skills related to anger and stress also are useful in managing pain. An individual with limited or poor coping skills or a tendency to depression may benefit from early integration of positive coping skills into the therapy program, with reinforcement from the individual’s support system.

A medical professional who is experienced and knowledgeable in limb loss treatment can provide additional techniques for pain reduction.²² The therapist should continue to assess the individual for overuse syndrome issues related to changes in work, avocational activities, or aging. Techniques to minimize pain and enhance a return to function should be used as needed.

FIGURE 4 Photograph showing the use of a noncustom armband and wrist support orthosis to assist with pain reduction associated with lateral epicondylitis in the nonamputated limb. (Courtesy of Sandra Fletchall OTR/L, CHT, MPA, FAOTA, Firefighters Burn Center, Memphis, TN.)

Preprosthetic Program Essentials

Limb and Core Assessment and Treatment

The therapist’s assessment should not be limited to the affected limb because other body areas may also require treatment. The range-of-motion assessment should include both joint and soft-tissue movements in both the limbs and the trunk. Soft-tissue limitations can be promptly treated with an aggressive elongation program focusing on increasing trunk flexibility and active movement of the upper and lower limbs. Similarly, a strengthening program can minimize abnormal trunk, back, and limb changes secondary to upper limb amputation.²³ With bilateral upper limb loss, treatment should focus on the ability to actively bring both residual upper limbs to midline to facilitate self-care tasks in the preprosthetic phase (Figure 5).

General age-based physical fitness assessments can be used to identify the physical condition of the individual and the general safety skills needed for the home environment.²⁴ Muscle strength can be assessed by manual muscle examination as needed. When there is peripheral nerve loss or atrophied muscle mass, the OT should develop a treatment program to compensate for the losses while facilitating independence in activities of daily living.

FIGURE 5 Photograph showing midline use of the residual limbs in a person with bilateral upper limb loss. The patient is using a universal cuff with a low thermoplastic pointer/turner fabricated by the occupational therapist. (Courtesy of Sandra Fletchall OTR/L, CHT, MPA, FAOTA, Firefighters Burn Center, Memphis, TN.)

The preprosthetic therapy program can initiate both core and extremity endurance and strengthening tasks. Core stabilization during resistive upper limb exercises can prepare the individual for assuming the weight of the prosthesis (Figure 6). Good muscle strength can allow relatively rapid progression to extended periods of prosthesis use. Similarly, increasing cardiovascular endurance contributes to an improved tolerance for wearing and using an upper limb prosthesis.

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