Upper-Extremity Patient Care: Personal Visions

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By Judith Otto

The panelists:

Randall Alley, BSc, CP, FAAOP, is the head of Clinical Research and Business Development for Hanger's Upper Extremity Prosthetic Program. He is the Academy's Upper Limb Prosthetic Society Chair and an international lecturer and consultant.

Diane Atkins, OTR, is A clinical assistant professor in Physical Medicine and Rehabilitation at the Baylor College of Medicine, Houston, Texas. Atkins is an occupational therapist who has specialized in amputee rehabilitation for more than 25 years-with special focus on rehabilitation of the upper limb amputee.

John Billock, CPO/L, FAAOP, and past president of the AAOP, is the clinical/executive director of the Orthotics & Prosthetics Rehabilitation Engineering Centre, Warren, Ohio.

Carl Brenner, CPO, is the director of prosthetic research at the Michigan Institute for Electronic Limb Development, Livonia, Michigan.

John M. Miguelez, CP, FAAOP, president of Advanced Arm Dynamics, Rolling Hills Estates, California, serves as a clinical consultant worldwide on issues regarding upper-extremity prosthetics.

Robert H. Meier III, MD, is founder of Amputee Services of America, Thornton, Colorado, a comprehensive center of excellence that addresses issues related to limb amputation. Meier's experience in rehabilitating persons with amputation encompasses about 2,700 amputees, 45 percent of whom are upper-limb amputees. 

What are your own personal visions, goals, and desires for the upper-extremity field?

Alley: My ultimate goal is patient empowerment and industry advancement. I have tried to achieve this by helping to create and develop the Upper Extremity Prosthetic Program, whose chief mission was and is to improve patient care; by utilizing the principles of kinesiology in designing more effective, efficient and comfortable prosthetic interfaces; by writing articles that attempt to bring to light relevant and timely topics for patients and health professionals; by driving education and innovation through my development and research role at Hanger, and finally by introducing initiatives into the charter for the Upper Limb Prosthetic Society that will attempt to refine the overall prosthetic approach.

My ultimate hope is to work together with the dedicated members of this field to coalesce the building blocks of an enhanced care delivery process, improved outcomes, and a more comprehensive educational and support system into a brighter future for patients and the individuals who care for them.

Atkins: My goals for the UE field are fourfold:

(1) To establish a National Directory of experienced occupational therapists in UE prosthetics;

(2) To promote education and an ongoing awareness in UE amputee rehabilitation-particularly its technological advances-to doctors (rehabilitation, orthopedic, and plastic), OTs, and rehabilitation nurses/case managers;

(3) To enhance opportunities for UE amputees to network with each other, particularly those with bilateral UE amputations; and

(4) To reinforce the importance of the experienced team approach in all aspects of treatment for the UE amputee.

Billock: There really need to be more OTs trained to work with patients to provide comprehensive functional use training after they're provided with an upper-limb prosthesis. They never seem to get the vocational rehabilitation training they need. There are vocational counselors available, yes-but no occupational therapists skilled at providing the functional use training.

And with an upper-limb issue, the functional need is much greater than with a lower limb.

I'd like more component options to be available to answer patient demands: I recently saw a young woman who lost her arm in a lion attack and was seen elsewhere, where it was recommended that she be fitted with an electric elbow that was unacceptable to her because it was too large, too heavy, and too noisy. Because of the aesthetic importance to her and its overall weight, we developed a dramatically modified prosthesis for her, which will have custom-sculptured foam and Livingskin® restoration cover to better address her needs-until a more acceptable functional elbow is developed.

As per her request, the prosthesis was also self-suspended, without straps or harnessing, and had a dramatically modified myoelectrically controlled hand with lightweight lithium polymer batteries for power. Until faster hands with more grip force are developed, along with better controls and lighter elbows, we won't be able to provide patients with what they want, need, and deserve.

Some manufacturers like Otto Bock have made a significant investment in this area-but it is in manufacturers' best interests to use of all their existing inventories before moving on and making more sophisticated prosthetic solutions widely available to their customers.

The rapid escalation of technology keeps pushing us all along. It's moving at a faster and faster pace. If we don't stay ahead, we'll get run over. Providing prostheses with components that rapidly become obsolete and eventually impossible to replace or repair will increasingly challenge the delivery of upper- limb prosthetic care in the future!

Brenner: There are a couple of things I would like to see: Cosmetic gloves for powered prostheses that are more durable, stain-resistant, and not only more cosmetic, but also more cost-effective and affordable as well.

Another area that I think severely limits the effectiveness of any upper-limb prosthesis is the lack of truly effective feedback. If anything were to be developed at my choice, I would like to see realistic and practical tactile feedback systems for upper-limb prostheses, so the user doesn't have to rely primarily on visual observation as a substitute for a real sense of touch.

Miguelez: Personally, my goal is to help patients know that despite their terrible loss, they don't need to worry about the rehab process. All they have to focus on is their rehab, not all those ancillary issues.

I'd like to improve the success rate with upper-extremity prosthetics: the number that's cited most often is 50 percent-and that is just terrible. My goal is to educate referral sources and reimbursement agencies that, given the right approach and the right resources, the success rate should be expected to be very high.

Meier: Our largest goal-almost complete at this moment-is a current textbook designed for use by UE amputees, practitioners, physicians, and therapists.

*Note: "Functional Restoration of Adults and Children with Upper Extremity Amputation" is scheduled to be available in July 2003, according to the publisher, Demos Medical Publishing, Inc. For more information, call 212.683.0072 or e-mail dschneider@demos.pub.com.