Special communication
Advanced Upper Limb Prosthetic Devices: Implications for Upper Limb Prosthetic Rehabilitation

https://doi.org/10.1016/j.apmr.2011.11.010Get rights and content

Abstract

Resnik L, Meucci MR, Lieberman-Klinger S, Fantini C, Kelty DL, Disla R, Sasson N. Advanced upper limb prosthetic devices: implications for upper limb prosthetic rehabilitation.

The number of catastrophic injuries caused by improvised explosive devices in the Afghanistan and Iraq Wars has increased public, legislative, and research attention to upper limb amputation. The Department of Veterans Affairs (VA) has partnered with the Defense Advanced Research Projects Agency and DEKA Integrated Solutions to optimize the function of an advanced prosthetic arm system that will enable greater independence and function. In this special communication, we examine current practices in prosthetic rehabilitation including trends in adoption and use of prosthetic devices, financial considerations, and the role of rehabilitation team members in light of our experiences with a prototype advanced upper limb prosthesis during a VA study to optimize the device. We discuss key challenges in the adoption of advanced prosthetic technology and make recommendations for service provision and use of advanced upper limb prosthetics. Rates of prosthetic rejection are high among upper limb amputees. However, these rates may be reduced with sufficient training by a highly specialized, multidisciplinary team of clinicians, and a focus on patient education and empowerment throughout the rehabilitation process. There are significant challenges emerging that are unique to implementing the use of advanced upper limb prosthetic technology, and a lack of evidence to establish clinical guidelines regarding prosthetic prescription and treatment. Finally, we make recommendations for future research to aid in the identification of best practices and development of policy decisions regarding insurance coverage of prosthetic rehabilitation.

Section snippets

Why is New Technology Needed? Upper Limb Prosthetic Use and Rejection

Many studies show that upper limb amputees are not satisfied with available technology. Many abandon their prostheses or reject using a prosthesis altogether.3, 4 Numerous factors are related to rejection and abandonment such as proximal level of amputation, type of device, poor training, late fitting, limited usefulness of devices, and cost of repairs.4, 5, 6, 7, 8, 9, 10 Rates of abandonment are higher for those with more proximal levels of limb loss.3 Transradial users are reported to have

Role of Rehabilitation

Several studies18, 19 suggest that prosthetic training, early fitting and functional training, an experienced team, and patient education are critical in increasing the likelihood of prosthetic acceptance. Prosthetic training may double the likelihood of long-term, full-time use,13 and receipt of early (within 3mo of amputation) and specialized prosthetic training appears to be more effective than nonspecialized or delayed specialized prosthetic training.20 There is some evidence that persons

The Rehabilitation Process

Rehabilitation after traumatic limb amputation can be separated into 4 phases: acute postsurgical, subacute preprosthetic training, basic prosthetic training, and advanced long-term rehabilitation.18, 24 The length of basic prosthetic training depends on amputation level, prosthesis complexity, functional needs, learning ability, and motivation.7, 20 There is no clear consensus on the amount of prosthetic training upper limb amputees should have. The VA and Department of Defense (DoD) share

The Rehabilitation Team

A well-coordinated, multidisciplinary approach to improving functional outcomes and enhancing emotional adjustment of patients with amputations is well recognized.7, 8, 9, 11, 13, 20, 23, 24, 27, 28, 29, 30, 31 Ideally, the team approach centers on the patient who is engaged in development of treatment goals and care decisions. If possible, the rehabilitation team, including the prosthetist, are included in determining the type of surgery and the overall length of the residual limb, and

Who Pays for Prosthetic Rehabilitation?

The VA has developed a unique Amputation System of Care (ASoC) to provide consistent and specialized care for veterans with amputations. The ASoC classifies each facility in the VA system into 1 of 4 designations based on the level of services provided at the facility. The facility classification levels are as follows: level I, Regional Amputation Centers (RACs); level II, Polytrauma/Amputation Network Site (PANS); level III, Amputation Care Teams (ACTs); and level IV, Amputation Points of

Prosthetic Rehabilitation Using the DEKA Arm

Our experience with the VA Study to Optimize the DEKA Arm affirmed the need for close therapist-prosthetist collaboration. It also pointed to the need for expansion of clinical roles and receipt of specialized clinical training in the use of advanced technology. The Gen 2 DEKA Arm system that we tested incorporated multiple degrees of powered movement and endpoint control of movement (at the shoulder configuration level), and was set up via a sophisticated computer interface.

The Gen 2 system

Need for Future Research

Our experience highlights the need for future research to ensure that this technology is deployed appropriately. As new prosthetic technologies are introduced, it is crucial to conduct comparative effectiveness studies to support clinical deployment and reimbursement. Such studies should examine rates of abandonment, as well as functional benefits and impact on the user's quality of life. This research is needed to aid in the development of policy decisions that promote consistent coverage of

Conclusions

The U.S. government has made a major investment in developing technologically advanced upper limb prosthetic devices through the Revolutionizing Prosthetics program. Much work is needed to ensure that this investment will benefit persons with amputations. Implementation of advanced prosthetic technology requires a coordinated approach offered by a specialized, colocated rehabilitation team. Integrated health systems, such as the VA and military treatment facilities, are ideally suited to offer

References (48)

  • E.A. Biddiss et al.

    Upper limb prosthesis use and abandonment: a survey of the last 25 years

    Prosthet Orthot Int

    (2007)
  • E. Biddiss et al.

    Consumer design priorities for upper limb prosthetics

    Disabil Rehabil Assist Technol

    (2007)
  • D.J. Atkins et al.

    Epidemiologic overview of individuals with upper-limb loss and their reported research priorities

    J Prosthet Orthot

    (1996)
  • T.V. Reyburn

    A method of early prosthetics training for upper-extremity amputees

    Artif Limbs

    (1971)
  • K. Bhaskaranand et al.

    Prosthetic rehabilitation in traumatic upper limb amputees (an Indian perspective)

    Arch Orthop Trauma Surg

    (2003)
  • M.T. MaGuire

    Empowering prosthetics: a team approach to prosthetics and limb loss

    Rehab management

    (December 2008)
  • E. Biddiss et al.

    Upper-limb prosthetics: critical factors in device abandonment

    Am J Phys Med Rehabil

    (2007)
  • P. Herberts et al.

    Rehabilitation of unilateral below-elbow amputees with myoelectric prostheses

    Scand J Rehabil Med

    (1980)
  • E. Berger

    The reimbursement challenge for advanced prosthetics

  • G.H. Kejlaa

    Consumer concerns and the functional value of prostheses to upper limb amputees

    Prosthet Orthot Int

    (1993)
  • M.A. Hanley et al.

    Chronic pain associated with upper-limb loss

    Am J Phys Med Rehabil

    (2009)
  • C. Rock Gambrell

    Overuse syndrome and the unilateral upper limb amputee: consequences and prevention

    J Prosthet Orthot

    (2008)
  • D. Atkins

    Adult upper limb prosthetic training

  • S. Fletchall

    Returning upper-extremity amputees to work

    The O&P Edge

    (August 2005)
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    Supported by Veterans Administration Rehabilitation Research and Development (VA RR&D), VA RR&D A6780, and VA RR&D A6780I. DEKA's support of the VA optimization studies was sponsored by the Defense Advanced Research Projects Agency and the U.S. Army Research Office. The information in this manuscript does not necessarily reflect the position or policy of the government; no official endorsement should be inferred.

    No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated.

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