Upper Limb Amputation/Absence Strategies for Successful Rehabilitation AOTA, San Diego 2013, Session #SC356

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1 Upper Limb Amputation/Absence Strategies for Successful Rehabilitation AOTA, San Diego 2013, Session #SC356 Kerstin Baun, MPH, OTR/L Rehabilitation Coordinator Advanced Arm Dynamics Northwest Center of Excellence Portland, OR Introduction UBC 1990, UNC 2008 Specializing in Upper Limb Prosthetic Rehabilitation since 2011 Advanced Arm Dynamics o Upper Limb Specialists o Unique collaborative environment Presentation is based on the work of many excellent practitioners at AAD and beyond! Presentation Overview Statistics, Terminology and Timelines Collaboration Evaluation Treatment Phases Prosthetic Options Emerging Technology Conclusions Amputation Level Nomenclature Interscapulothoracic Shoulder Disarticulation Transhumeral Elbow Disarticulation Transradial Wrist Disarticulation Partial Hand

2 Statistics Almost 91% of Upper Limb amputations are distal to wrist Approximately 16,000 upper limb amputations annually 30:1 ratio, lower to upper limb amputations Upper limb: 1,908/year Lower limb: 56,912/year (Excluding finger, thumb, toe and foot levels) (Dillingham, et al. Limb Deficiency and Amputation Epidemiology and Recent Trends in the US. Southern Medical Journal, 2002;95: ) Pediatric Statistics--Congenital Absence Upper Limb 60%/Lower Limb 40% Only 1 to 2% hereditary/chromosomal Cause generally unknown Acquired intrauterine Banding, constraints, vascular injuries 1 in 2000 births (Atkins & Meiers, 2004) Pediatric Statistics--Acquired Absence Cause: Trauma twice as often as disease Single limb--90% of cases Lower limb 60 %, Upper limb 40% Boys:Girls (3:2) (Physical Medicine and Rehabilitation Board Review, Cuccurullo S, editor, 2004) Prosthetic Rehabilitation Timeline (graph) Ideal Prosthetic Timeline--Congenital Limb Absence 6 month Evaluation and Initial Device 18 month Body powered and/or Myo-electric Options Preschool Activity Specific, Myo and/or Body-Powered Options Expedited Fitting Protocols Start to finish in as little time as possible Patient involved in therapy during fitting process Patient in a preparatory device as son as possible Success is found immediately

3 Glossary Socket the interface that contacts and contains the residual limb Frame the typically rigid outer structure that supports the socket and contains or allows fixation of components Component non-custom prosthetic part designed to be used in a prosthesis, i.e. hand, wrist, elbow Suspension the means of holding the prosthesis on the user Harness a system designed to transmit excursion created by body motion of a user to a prosthetic component and/or also a type of suspension Self-Suspending a prosthesis designed to suspend without the aid of a harness Suction Suspension - A means of self-suspension that requires an air-tight seal and suspends with suction Terminal Device the component at the distal portion of the prosthesis that creates function i.e. hook, hand, etc. Preparatory the first prosthesis a patient is fit with which is intended to be temporary but is fully functional Definitive a prosthesis that is intended to be used until replacement is necessitated. Success IS Possible! We want to change the perception of some that upper limb prosthetic patients ultimately fail. The patient must be set up for success with a team approach and defined prosthetic plan. How do we achieve Success? Collaboration Evaluation Treatment Phases Prosthetic Options Additional Considerations Choices and Alternatives

4 Amber s Story (Video) Collaboration Evaluation and Earlier Continuous process Team members: Patient Family Doctor OT/PT Prosthetist Others Results in: Efficiency Best choices Support Lower costs (not always immediately evident) Patient s needs met Evaluation When? Where? Who? How? Ongoing Process What? o Pre-morbid and current status: physical, ADL, recreational, vocational, social and psych o Physical: ROM, strength, sensation, wounds, pain (residual vs. phantom ) o Myoelectric site testing Data we gather needs to result in mutually established goals that address patient s values, needs and priorities. Client Centered Phases of UL Amputee Prosthetic Rehabilitation Phase I: Healing Phase II: Pre-prosthetic training (Can begin prior to amputation) Phase III: Basic Prosthetic training (After initial prosthetic fitting) Phase IV: Advanced Prosthetic training

5 Phase I: Healing Edema control & Shaping Address Pain o General Body o Residual Limb o Phantom Pain ROM, Scar Management Strength/Activity Tolerance ADLs with Residual Limb Adaptive Equipment Phase II: Pre-prosthetic training Education & Expectations Strength, ROM, and Endurance Desensitization and Pain Management ADL training, change of dominance, foot use Education to prevent overuse, scoliosis, body mechanics, energy conservation Myo training isolated contractions, cocontraction, proportional control Special Adaptations and Modifications Home Modifications Phase III: Basic Prosthetic Training Prosthetic care & limb care Donning & Doffing Operation of components Controls training Pre-positioning ADL training with prosthesis Video Phase IV: Advanced Prosthetic Training Job site Assessment Home Assessment Community Re-integration/IADLs Driver Evaluation/Training Recreational Activities Pain Management--Phases I-IV Medication & Modalities Alternative Treatments Graded Motor Imagery 3 stage program: Left/Right Discrimination, Imagery, Mirror Therapy (noigroup.com)

6 Prosthetic Options Prostheses don t replace a hand they are tools. Until they are replacements, Prostheses that do not fulfill the personal requirements of the user are frequently rejected Rarely does one prosthesis accomplish all of personal requirements of a user Prosthetic Options: No Prosthesis Passive Body powered Electric Hybrid Activity Specific No Prosthesis Many people with upper limb loss who could wear a prosthesis do not wear one: Bad First Experience (poor comfort or poorly made) Unnatural Look Reactions from Others Development of One-Handedness Financial Concerns Unaware of Options Limited Functional Ability Lack of Sensation Lack of Sufficient Prosthetic Training Pros No expense Low maintenance Intuitive Sensory feedback Cons Lack of prehension Compensatory proximal body use Incidence of overuse syndrome Cosmesis Cosmetic or Passive Restoration Pros Lightweight No or minimal harnessing Little maintenance Used functionally*

7 Cons Less functional ability than activated devices Increased reliance on sound side Custom silicone can be costly Body-Powered Standard hook Work/Farm hook V2P Prehensor Body powered hands Mechanical Fingers M-finger and partial M-finger X finger RCM Enterprises Pros Durability / Ease of maintenance Proprioceptive feedback Lightweight Cons Restrictive harness Decreased ROM Decreased functional envelope Shoulder, nerve compression, and neck concerns Body powered hands not very functional Electric and Myoelectric Prostheses Various Control Options: Myoelectric - Single or Dual Site Switch - Rocker, Pull, Push Touch Pads Linear Transducer Powered by a Battery System Electric Finger Systems--Video Compliant Hands: I Limb, Bebionic, Michelangelo I Limb Revolution 24 grasping patterns I pad & smart phone control

8 Thumb actively or manually positionable Compatible with current production myoelectric components Bebionic Hand Fourteen grasp patterns including: Tripod pinch Index Point Power Grip Hook Grip Lateral Pinch or Key Grip Michelangelo Hand Seven grasp patterns including: Opposition Mode Lateral Mode Finger Abd/Add Neutral Mode Open Palm Flexible or Lockable Wrist Positions Electric Prosthesis Pros Increased grip force Increased functional envelope Reduced or absent harnessing Electric hands are functional and aesthetic Cons Increased weight Increased cost Maintenance Concerns with environmental exposure: dust, water Hybrid Prosthesis Elbow disarticulation or higher levels A combination of options: Body powered elbow with an electric TD Electric elbow with a body powered TD Activity Specific Prosthesis Usually limited to specific activities and may not provide function outside of its intended use. Can provide enormous benefits, by allowing patients to participate in previously valued activities.

9 Activity Specific Sports Related Partial hand Newer & Developing Technology OsseoIntegration Targeted Muscle Reinnervation TMR Pattern Recognition Cognitive Control through CNS implant (BCI: Brain Controlled Interface) Sensory Feedback Factors that negatively influence successful rehabilitation: Therapist goals are not the goals of the client Client does not have the intrinsic motivation to achieve the goals Psychosocial limitations (e.g. support, post traumatic stress) Cognitive limitations (e.g. TBI) Physical limitations (blindness, age and overall body condition, multiple amputations) Summary of Strategies for Success: Teamwork from start to finish Evaluation and Re-evaluation Client centered goals Excellent Prosthetic Fit Intensive and focused training Maximizing Options and Choices Success is Possible!

10 Resources: Advanced Arm Dynamics Armdynamics.com Pain Management: Noigroup.com Gradedmotorimagery.com Assistive Technology/Home Modifications: List of state based assistive tech providers/consultants federal $ Body Dryer: Bidets: medical supply catalogs, local plumbing suppliers/stores Books: Functional Restoration of Adults and Children with Upper Extremity Amputation, by Diane Atkins, OTR and Robert (Skip) Meier, MD. Handwriting for Heroes, by Kathleen Yancosek, PHD, OTR/L, CHT and Kristin Gulick, OTR/L, CHT. Amputee Coalition of America The Amputee Coalition of America (ACA) is a national, non-profit amputee consumer educational organization representing people who have experienced amputation or are born with limb differences. The ACA includes individual amputees, education and support groups for amputees, professionals, family members and friends of amputees, amputation or limb loss related agencies and organizations. amputee-coalition.org inmotion Magazine A comprehensive information source for people with limb loss, their families and the professionals who care for them. Each issue: Reports on new technologies and products designed to increase mobility and self-management skills Provides peer support group information Provides personal profiles that spotlight the achievements and triumphs of amputees and those born with congenital limb differences

11 amputee-coalition.org/inmotion_about.html Arms Within Reach Foundation A 501(c)(3) non-profit organization that helps provide upper limb amputees with resources for high quality upper limb prosthetic rehabilitation and an enhanced quality of life. Social Security and Disability Resource Center The Social Security and Disability Resource Center provides a detailed overview of how the federal disability system works (social security disability and SSI). This site also provides answers to many questions that applicants typically have,but often have trouble finding answers to. Paralympic Games The Paralympic Games are a major international multi-sport competition for athletes with a physical disability, including athletes with mobility disabilities, amputations, blindness and cerebral palsy. There are winter and summer Paralympic Games which are held immediately following the winter and summer Olympic Games and use the same facilities and venues. Disabled Sports USA Disabled Sports USA is a national non-profit organization that provides opportunities for people with disabilities to develop independence, confidence and fitness by participating in sports, recreation and educational programs. Community-based chapters across the country offer a range of activities including snow skiing, water sports, cycling, climbing, horseback riding, golf, summer and winter competitions, fitness and special sports events, and social activities.

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