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Upper Limb Amputee Rehabilitation and Prosthetic Restoration Upper limb amputation is less common than of the lower limb amputation. Almost 60% of arm amputees are between the ages of 21 and 64. Most frequent causes for these are trauma and cancer followed by vascular complications. It is usually at the transradial level that accounts for 57% of all amputations and 23% accounts for transhumeral amputation. Limb Salvage versus Amputation Surgery Upper limb salvage should be based on providing an extremity sufficient sensation to provide positive feedback, durable soft tissue cover and the ability to be used to interact with environment. An upper limb that lacks sensation, with limited motion and multiple scars, functions poorly due to the constant risk of tissue injury. It may even function worse than prosthetic replacements. Severe hand injuries or ischemia with unreconstructable vascular injury are some factors that may lead to amputation. In these cases, amputation should not be viewed as a surgical failure but rather as a means to return the patient to a more functional status. Selection of the surgical level of amputation must be examined thoroughly; the viability of soft tissue and the amount of skin coverage with adequate sensation determines the most distal possible functional level of amputation. Residual limb must be surgically constructed with care to optimize intimacy of fit, maintain muscle balance and allow assumption of stresses necessary to meet the limb’s new function and because bony prominences, skin scars, soft tissue traction, shear, hypersensitivity and perspiration can complicate prosthesis. After the amputation the patient ideally should be able to wear prosthetics. Using a staged approached, delays prosthetic fitting and decreases the success of prosthetic restoration. Scar tissue adhesion formation and joint contracture prevention is critical during the healing period. Levels of Amputation 1. Finger Amputation and Wrist Amputation • • • •

Finger Amputation can occur at the distal interphalangeal, proximal interphalangeal, and metacarpophalangeal levels Transcarpal Amputation and Wrist Amputation are seen less frequently because of their limited functional outcome Multiple finger amputation, including thumb and partial hand amputation and those through the wrist need to be considered carefully in view of the possible functional and cosmetic implications of prosthesis fitting and restoration Inappropriate choice of amputation site can result in prosthesis with disproportional length or width.

2. Transradial Amputation • •

preferred in most cases can be performed in three levels – results in long, medium and short residual limbs

• • • • • •

Long Transradial Amputation – preferred when optimal body-powered prosthetic restoration is the goal – ideal level for the patient who is expected to perform physically demanding work Medium Transradial Amputation – preferred when optimal externally-powered prosthetics restoration is the goal – permits good function and cosmesis Short Transradial Amputation – can complicate suspension – limits elbow flexion strength and elbow range of motion All three requires the same type of rehabilitation interventions and make use of similar prosthetic components The suspension system for each one can be different Transradial amputation is the most common level and allows the highest level of functional recovery in the majority of cases

3. Elbow Disarticulation • •

•

• •

has both surgical and prosthetic advantages and disadvantages advantages: – surgical technique permits reduction in surgery time and blood loss, – provides improved prosthetic self-suspension while permitting the use of a less encumbering socket – reduces rotation of the socket on the residual limb as compared with the transhumeral level of amputation disadvantages – marginal cosmetic appearance caused by the required external elbow mechanism – current limitations in technology, which impede the use of externally powered elbow mechanisms at this level of amputation disadvantages often outweigh the advantages in the long run in patients for whom bilateral transhumeral amputation is the alternative, elbow disarticulation is a more desirable level when feasible, despite the possible cosmetic drawback

4. Transhumeral amputation • • • •

can be performed at three levels – long (three-quarters of bone length), medium and short (one-third of bone length) the long arm residual limb (7-10cm from the distal humeral condyle) is preferred for optimal prosthetic restoration the three amputation levels require the same type of rehabilitation interventions and in most cases, require similar prosthetic components prosthetics can be externally powered, body-powered, passive, or a combination of these assembled into a hybrid system

5. Shoulder Disarticulation and Forequarter Amputations • • •

seen less frequently than amputations at other levels made necessary as part of the surgical interventions to remove a malignant lesion or the result of severe trauma most difficult to fit with a functional prosthesis due to: – the number of joints to be replaced – multiple degrees of freedom available for control – problems related to maintaining secure suspension of the prosthesis

Surgical Techniques: • • • • • • •

• • • •

soft tissue handling is especially critical to wound healing and functional outcome in amputation surgery - risk of wound failure and infection is high when tissues are excessively traumatized flaps should be kept thick, and unnecessary dissection between the skin, subcutaneous, fascial and muscle planes should be avoided bone edges should be rounded, and prominences should be beveled for optimal force transmission during prosthetic use split-thickness skin grafts are usually discouraged, except as a means to save essential residual limb length skin grafts do best with adequate soft tissue support, and are most durable when not adherent to bone muscle loses its contractile function when the skeletal attachments are divided during amputation – stabilizing the distal insertion of the muscle can improve residual limb function and comfort Myodesis – the direct suturing of muscle of tendon to bone – most effective in stabilizing muscles that are needed to counteract strong antagonistic muscular forces Myoplasty – involves suturing of muscle to periosteum – does not provide a secure a distal stabilization of the muscle care must be taken to prevent having a mobile sling of muscle over the distal and of the bone, which can result in formation of painful bursa that could interfere with prosthetic fitting and use all transected nerves form a neuroma – nerves should be transected cleanly, allowing the cut end to retract into the soft tissues away from the scar and prosthetic pressure points traction injuries frequently result in temporary or permanent nerve injury that has direct implications for arm function as well as for rehabilitation and prosthetic restoration programs

Amputee Rehabilitation Program

The amputee rehabilitation program should be ideally designed to cover the wide range of care from patient to reintegration into the community. The OT’s primary responsibility in the rehabilitation program is the formulation and execution of preprosthetic program and prosthetic training. Stages of Upper Limb Amputee Rehabilitation Program 1. Pre-amputation counseling 2. Amputation surgery 3. Acute postamputation period 4. Preprosthesis training 5. Preparatory prosthesis fitting 6. Prosthesis fitting and training 7. Reintegration into the community 8. Long-term follow-up 1. Pre-amputation counselling It is important during this stage, that the occupational therapist develop direct communication involving the patient, the family, the surgeon and the rest of the treatment team regarding the need for amputation and the expected surgical outcome. It is appropriate for the clinician to have introductory discussions about phantom limb sensation, prosthetic devices, prosthesis fitting and training, and the timing of these events; a demonstration of prosthesis, if possible, would also be favorable. For all levels of amputation a “prehabilitation program” should include strengthening exercises for the trunk and remaining upper limb musculature and ROM exercises for the involved glenohumeral, scapulothoracic, and elbow joints. 2. Amputation Surgery Amputation surgery of the upper extremity should be directed toward saving all possible length in all areas. The underlying principle in choosing the level of amputation is to preserve as much limb length as possible that is consistent with wound healing, an acceptable soft-tissue envelope, and functional prosthetic fitting. It should also take into consideration the amount of space necessary for the appropriate prosthetic components with adequate cosmesis. a) Transradial and Transhumeral Amputations It is not uncommon to find a more proximal fracture, dislocation or occasionally a peripheral nerve injury that can temporarily interfere with optimal prosthesis fitting and arm motion. Early diagnosis is needed to ensure inclusion of the appropriate prosthetic modifications and alterations to the rehabilitation program. b) Shoulder Disarticulation and Forequarter Amputation Shoulder disarticulation is performed in severe electrical injuries, in trauma cases, and in tumor surgery. Prosthetic replacement is more successful for

those who are healthy, young, and male. The loss of the anatomical shoulder necessitates the use of an external prosthetic shoulder joint. Forequarter amputation is rarely performed, but it may required in some cases of severe trauma or malignant lesion involving the shoulder. Special considerations should be made for providing a shoulder cap to allow the patient to wear clothing more easily. Acute Postamputation Period The goals of this stage include pain control, maintenance of ROM and strength, and promotion of wound healing. It begins with the surgical closure of the wound and culminates in wound healing. Immediate application of postoperative rigid dressing (IPORD) or soft elastic bandage and subsequent pneumatic compression are indicated for edema control. The dressing should be extended to the proximal joint to better control swelling and to improve the dressing suspension. Proper postoperative positioning and rehabilitation are essential to prevent elbow flexion and shoulder adduction contractures when wounds are present over or close to the joints. This is most important if the wounds are caused by: • Burn injuries • Open reduction • or Internal fixation, • or if skin grafts were applied

Acute Pain Management Pain control can be best achieved initially with a patient-controlled analgesia system, followed by scheduled parenteral and oral analgesia. A skin desensitization program – gentle tapping, massage, soft tissue and scar mobilization, and lubrication – recommended for patients with a soft or elastic dressing. Medically stable – early mobilization, general endurance & strengthening exercise are started. Special attention is paid to the shoulder & scapula, & to the prevention of joint contractures. It is also important to observe for the strength and function of the remaining limbs. Emotional counseling, and psychosocial evaluation should be initiated to assess and manage depression and anxiety. It is important during this phase to promote patient participation in decision-making process to encourage independence and sense of control. General Post-Operative Amputation Management Guidelines I. Immediate Post-Operative Stage (1 to 21 days post amputation - sutures in place) A. Primary Goals:

1. Promote healing and protection of the operative incision line with sterile dressings. 2. Minimize soft tissue edema for improvement of circulation to the operative site. B. Recommended Control Options: 1. Introduce the use of an elastic compression bandage over the sterile dressings. 2. Introduce the use of a rigid cast over sterile dressings. II. Early Post-Operative Stage (21 to 42 days post amputation - sutures removed) A. Primary Goals: 1. Continue to promote healing and protection of the operative incision line. 2. Encourage initial soft tissue atrophy in preparation for the development of a preparatory prosthesis. 3. Begin developing soft tissue endurance if medically appropriate.

B. Recommended Control Options: 1.Continue use of an elastic compression bandage over the sterile dressings. 2. Introduce use of a prosthetic residual limb compression sock. 3. Initiate friction massaging of residual limb if medically appropriate. III. Late Post-Operative Stage (42 days and beyond - operative site healed) A. Primary Goals: 1. Maximize further soft tissue atrophy in preparation for the development of the initial preparatory prosthesis. 2. Maximize further soft tissue endurance in preparation for the development of the initial preparatory prosthesis. B. Recommended Control Options:

1. Continue with use of the prosthetic compression sock. 2. Introduce the preparatory prosthesis to begin physical rehabilitation and developing functional use. Sterile Dressing A sterile dressing must be in place during the immediate and early post-operative stages until the incision line is adequately healed and no drainage is present from the residual limb. Rigid Cast Dressing A rigid cast dressing is sometimes used during the immediate post-operative stage in place of an elastic compression bandage for edema control and protection of the operative site. The initial rigid cast dressing is generally not removable by the patient or hospital staff and is not changed by the attending surgeon until sutures or surgical clips are to be removed. Elastic Compression Bandage An elastic compression bandage with a sterile dressing is more commonly used during the immediate post-operative stage for edema control and protection of the operative site. An elastic compression bandage and sterile dressing is generally removed and reapplied daily during the immediate post-operative stage. An elastic compression bandage should be removed and reapplied a minimum of three (3) times per day following the immediate post-operative stage and removal of all surgical clips and sutures in order to maximize soft tissue edema control Prosthetic Compression Sock The use of a prosthetic compression sock is not generally recommended for use until the incision line is adequately healed, and there are no areas of open drainage. This is to avoid soft tissue trauma to the distal incision line while pulling compression socks into place. Prosthetic compression socks are normally kept in place at all times except during bathing or use of a prosthesis for approximately the first three (3) months following the amputation to maximize soft tissue edema control. Preprosthetic Rehabilitation

Patients with amputation are given artificial limbs with much focus on prosthetic training and other special needs. A preprosthetic rehabilitation program/ preprostheic assessment ad treatment/ acute post surgery is initiated as soon as possible. During this first phase, pain control, residual limb maturation and edema control should be promoted. The key goals of this phase are emotional adaptation, soft tissue desensitization, early mobilization, strengthening, improving general endurance, basic skill learning, avoidance of joint contractures and emotional counseling. This is a phase where pain should be controlled. Usually, physicians manage pain pharmacologically. But this can also be done by applying transcutaneous electrical nerve stimulation to the residual limb or instructing patients in isometric exercises. Residual limb maturation should also be promoted. A residual limb, the remaining portion of the amputated limb has fully matured, if its volume has already stabilized or the changes in volume are small enough to not interfere with the prosthetic fitting. It is done by increasing weight bearing and initial gait training of the residual limb. Edema control is addressed by application of soft elastic bandages, ace wraps, a rigid removable dressing, or a residual limb (stump) shrinker. Adjustment and grief reaction are common for new amputees and this is being addressed during this stage. Therapist helps the patient adapt to his new self image and prepares him for his new prosthesis. Soft tissue desensitization is to retrain and reset the residual limb to new end points. It is done through tapping, vibration, fluidotherapy, massage (light, deep and with different textures), wrapping and weight bearing. Early mobilization is done by teaching ROM to patients and to let them perform it at home. ROM exercise can be active; passive, with help from another person; or self-administered, with assistance from the other arm, a towel, pulleys or an amputee cuff. Strengthening is done with the use of cuff weights, elastic bands, a pulley system and amputee cuffs to improve strength in the upper body, back, neck and arms. Endurance training is done through cardiovascular and aerobic exercise—walking, jogging, low-impact aerobics, aquatics- to strengthen the heart and lungs and improve the body's ability to use oxygen. Exercising every other day helps increase the patient's ability to tolerate a full day of activity without fatigue. Basic skill learning is established through teaching the patient onehanded and compensatory techniques or adaptive equipment, until the prosthesis arrives. By doing this, patient regains the feeling of independence and self worth. Prevention of Joint contractures or limited joint movements are done through early prosthetic fitting and weight bearing, combined with an aggressive physical therapy program. Emotional counseling with a therapist along with family and friends is done to help patient overcome his emotional experiences due to his amputation. Use of first prosthesis is implemented as soon as possible. A three to six month window of opportunity is given for upper limb amputee. If prosthesis is fitted during this time then there is a greater chance for the acceptance and integration of the artificial limb. First prosthesis is intended for limb maturation and desensitization. Body powered or switch controlled externally powered prosthesis is most commonly used. Suction suspension or myoelectric control is not practical due to limb volume fluctuation. If fluctuation is present, there will be no intimate contact between the socket and the soft tissue. If after two months no fluctuation was noted then the permanent prosthesis is fitted. Prosthesis Fitting and Training

Prosthesis prescription options for the amputee have changed greatly since the mid1980s. Selecting the most appropriate componentry for prosthetic restoration of upper limb is an extremely challenging task in view of the variety and complexity of available prosthetic components, socket fabrication techniques, suspension systems, and source of power and control. This task should be accomplished by an expert team of professionals in close communication with the patient. Members of the team ideally should include the surgeon, physiatrist, certified prosthetist, occupational therapist, physical therapist, a recreational therapist, a psychologist, a social worker, and the patient and family. Terminal Devices The functional capacity of the upper limb is determined by the development of multiple integrated spheres of action by the shoulder complex, elbow, wrist, and hand. Given the normal proportions of limb segments, this capacity is limited in relation to the surrounding space. The functional activities of the hand are extensive, but they can be grouped into nonprehensile and prehensile activities. The former include touching, feeling, pressing down with the fingers, tapping, vibrating the cord of a musical instrument, and lifting or pushing with the hand. Prehensile activities are grouped into precision and power grips. Three-jaw chuck involves grip with the thumb and index and middle fingers. A lateral or key grip involves contact of the pulp of the thumb with the lateral aspect of the corresponding finger. These two patterns provide precision prehension. Power grip predominantly involves the ulnar aspect of the hand, with less involvement of the ring and little fingers. The hook power grip involves flexion of both interphalangeal joints and minimal participation of the metacarpophalangeal (MCP) joint. This grip pattern is used in carrying a briefcase. The spherical grip is very much like the power grip but with minimal flexion of the fingers, which are abducted and rotated; the thumb is used to stabilize the object and to provide counter-pressure. Most patients who have had an upper limb amputation and undergo prosthetic restoration require a terminal device for their prosthesis. The human hand is a very complex anatomical and physiological structure whose functions cannot be replaced by the current level of prosthetic technology. A variety of prosthetic terminal devices are available and inclusive passive, bodypowered, and externally powered hooks and hands. They all lack sensory feedback and have limited mobility and dexterity. Prosthetic hands provide a three-jaw chuck pinch and hooks provide the equivalent of lateral or tip pinch. Body-powered terminal devices can be voluntarily-opening (most common and practical) or voluntary-closing (most physiological). •

The voluntary-opening device is maintained in the closed position by rubber bands or tension springs. The patient can open the device by “pulling” with the cable on the harness system in preparation to grasp. To grasp, the patient releases the opened terminal device on an object: the rubber bands or spring provide the prehensile force. The

maximum prehensile force possible is predetermined by the number of springs or rubber bands. To control the amount of prehensile force, the patient must generate an opening force all the time. •

Voluntary-closing terminal devices require that the patient close the device by “pulling” with the cable on the harness system to grasp an object. To release, the patient releases the pull on the harness, and a spring in the terminal device opens it. The maximum prehensile force possible is determined by the strength of the individual. One major disadvantage of this system is that prolonged prehension requires constant pull on the harness. The human hand normally does not reach out to grasp an object in the closed position, but rather uses the semi-open position to facilitate the interaction with the environment.

Externally powered devices can have digital (on/off) or proportional (stronger signal = faster action) control systems. More recently, a slip control system was introduced by the Otto Bock Company to improve hand grip. The device has a sensor that maintains a constant pressure on an object to prevent slippage. If the sensor perceives that the object is slipping, it automatically slightly increases the pressure on an object. Prosthetic Wrists Prosthetic wrists are divided into mechanical and electric devices. The mechanical type which allows pronation and supination is further divided into subtypes. The Friction Wrist Units permit supination and pronation by rotating the device manually using the normal hand; and for the bilateral amputee, by striking the devices against each other. There are Friction Wrist Units designed for wrist disarticulation level of amputation. This device is so called because as the terminal device stud is screwed into the wrist unit, a rubber washer is compressed to create friction. It is highly desirable that wrist units provide constant friction. Quick-disconnect Wrist Unit has the advantage of rapid interchange of terminal devices and control for wrist rotation. It also allows the removal of the terminal device, the replacement of one terminal device to another, manual positioning and locking in the desired position. The Wrist Flexion Unit is vital for bilateral upper limb amputee because this permits the client to reach the body’s midline to perform ADLs. This device permits manual positioning of the hook in neutral, 30 degrees of volar flexion or 50 degrees of volar flexion. The Rotational Wrist Unit is cable controlled and has a locking mechanism that does not permit unwanted rotation when subjected to heavy loads. In its unlocked mode, this provides positioning in supination or pronation. The electric type is also divided into subtypes. A myoelectric prosthetic wrist uses signals from voluntarily contracted muscles within a person's residual limb on the surface of the skin to control the movements of the prosthesis.

A switch control prosthetic device uses straps or cables triggered by body movements to operate the switches that control the prosthesis. These are most commonly prescribed for bilateral transhumeral or higher level of amputation. Prosthetic Elbows For the treatment of transhumeral amputation, the prosthetic elbows available have external or internal joints. These joints may be passive, body-powered or externally powered. These are controlled through mechanical cables, electrical switches or myoelectric signals. The mechanical devices have a locking system that is applied by the contralateral hand, the chin or the ipsilateral shoulder. The externally powered devices on the other hand have digital or proportional control systems. Electric elbows have an electromechanical brake or a switch control lock system to maintain the selected position. A turntable is responsible for the internal and external rotation function of the device. However, the flexion allowable is limited, depending on the client’s strength, the comfort of the socket fit and the ability to transfer power from the residual limb to the prosthesis. The external elbow joint is indicated in an attempt to maintain optimal strength of the arm for elbow disarticulation. This is larger and protrudes in the medial side. The problems encountered in this type of joint are limited flexion and increased maintenance. Prosthetic sockets The prosthetic socket of upper limb prosthesis typically has a dual wall design fabricated from lightweight plastic or graphite composite materials. Its functions include comfortable residual limb interface, efficient energy transference to the prosthesis, secure suspension to the prosthesis, and for adequate cosmetics. A patient often fails to accept the prosthesis if the socket design does not have these functional characteristics. Sockets in the past were usually made out of wood which are open ended and brought distal residual swelling and chronic edema to its users. With technological advancements high temperature rigid plastic materials as well as carbon graphite and thermoplastics were produced to make a more durable, lighter, and comfortable prosthetic socket. Making socket designs also is now more, from the use of POP solution and now with the help of a computer and MRI we can make sockets with ease. Parts of the socket include an inner layer which is contoured to the residual limb while the external layer gives the necessary length and shape to the socket and gives it its structural integrity. The frame socket design has the added advantage of allowing replacement of the inner socket to accommodate residual limb changes without changing the outer socket frame. It is this frame design that is appealing for externally powered prosthesis and self suspended ones the only disadvantage of this design is its poor insulation which can be corrected by using clothing layers to cover the arm. Suspension Systems The suspension system must hold the prosthesis securely to the residual limb, as well as accommodate and distribute the forces associated with the weight of the prosthesis and any superimposed lifting loads. Suspension systems can be classified as follows harnessed-base system, self suspending sockets, suction sockets.

Harnessed-based systems and their variants are the most commonly used systems. For the figure-8 strap, a harness loops around the axilla on the sound side. This anchors the harness and provides the counterforce for suspension and control-cable forces. On the prosthetic side, the anterior (superior) strap carries the major suspending forces to the prosthesis by attaching directly to the socket in a transhumeral prosthesis or indirectly to a transradial socket through an intermediate Y-strap and triceps cuff. The posterior (inferior) strap on the prosthetic side attaches to the control cable. For heavier lifting or as an alternative to the figure-8 harness, a shoulder saddle with a chest-strap suspension can be used with a transradial prosthesis. A chest strap alone is sometimes used to suspend a transhumeral prosthesis. The figure-9 harness is an alternative for a patient with a long transradial amputation or a wrist disarticulation, in order to provide the control cable's necessary attachment point and counterforce. Although the figure-9 harness provides minimal suspension and requires a self-suspending socket, it is more comfortable than a figure-8 harness. Self-suspending and suction sockets are capable of providing adequate prosthetic suspension without the use of a harness. However, either design can also be used with a harness suspension to provide for a more secure suspension of the prosthesis. Self-suspending sockets are largely limited to wrist or elbow disarticulations and to transradial amputations. This socket design is most commonly utilized with externally powered, myoelectrically controlled transradial prosthesis. An example of this type is the Munster socket. Proper fit of this socket precludes full elbow extension. Suction suspension is similar to lower extremity options. These sockets use an external, elastic suspension sleeve; a one-way air valve; or roll-on gel suspension liner with a pin-locking mechanism. Upper limb suction sockets (unlike nonsuction sockets) require a total contact socket design and ideally a residual limb with no skin invagination, scarring, and stable volume to avoid skin problems, such as a choke syndrome. Suction socket designs are most commonly used for the patient with a transhumeral amputation. Table 1.1. shows the three types of suspension system and their differences

Suspension Systems The suspension and control system of a body-powered prosthesis needs to provide two Suspension Harness

Figure-8

Shoulder saddle and chest strap

Indications Transradial Transhumeral Light to normal activities Transradial Transhumeral Heavy lifting

Advantage Simple, durable, adjustable

Disadvantage Axillary pressure produces discomfort

Greater lifting ability, more comfortable than figure-8 harness

Reduced control compared with figure-8 harness, difficult to adjust in women because straps cross breasts Limited lifting capacity compared with harness systems, compromised cosmesis, reduced elbow flexion Requires stable residual volume, harder to put on than other suspension systems Greater cleaning and hygiene requirements, can be uncomfortable in hot climates

Self-suspending

Muenster Northwestern Supracondylar

Wrist disarticulation Elbow disarticulation Short transradial Myoelectric transradial

Ease of use

Suction

Suction socket with air valve

Transhumeral with good soft tissue cover

Secure suspension, elimination of suspension straps

Gel sleeve with locking pin

Transradial Accommodate Transhumeral limb volume Compromised change with limbs with socks, scarring or reduced skin impaired skin shear integrity distinct important functions to make the prosthetic device work. One of these is suspension, which is the means of securing the prosthetic device to the body; the other is to permit control of the prosthesis, including the terminal device. The more secure the suspension system, the more secure the suspension system. The traditional suspension mechanisms for the upper limb include a strap that suspends the prosthesis over the shoulder (figure-of-8 harness). The harness is used as a control mechanism to transmit body power to the terminal device and elbow. For the more proximal level amputation, a chest strap or shoulder saddle can be used to further improve suspension. Patients with wrist or elbow disarticulation or transradial amputation can use bony

prominences for suspension. The Muenster or condylar suspension is the best type of this kind, this type of suspension uses a figure-of-9 harness for control purposes only. In most cases, a sock is used as an interface between the residual limb and the socket. Using different number of sock layers can adjust for the physiological volume changes that occur from day to day. Socks also protect the skin and improve hygiene. The only exceptions are suction sockets, which require direct skin-to-socket contact, and socks cannot be used. Hypobaric and semi-suction suspension is best thought of as a transition between nonsuction and full-suction suspension. This suspension system utilizes socks that have a special silicone band in them, and the socket is provided with a one-way valve that permits the expulsion of air during donning. Silicone Suction Suspension Application to Upper Limb Body and External Powered Prostheses The silicon liner provides improved suspension function by creating a negative atmospheric pressure and an adhesive bond to the skin. The silicone sleeve also improves the socket-residual limb interface by protecting the skin through significant reduction of shear forces and added cushioning. Donning of the prosthesis is simplified and can be done with one hand. Silicone sleeves systems do not interfere with elbow range of motion, unlike other types of self-suspension such as supracondylar sockets. The prosthesis tends to be lighter and more comfortable to be used when silicone is used. The system consists of a silicone sleeve with a distal attachment pin that interfaces with a shuttle lock mechanism built into the prosthetic socket. Silicone sleeves are best used by patients who are likely to have problems with skin integrity, such as patients who have undergone skin grafting for burns or degloving injuries, those with delicate, insensate skin and other skin conditions. Silicone sleeves afford excellent skin protection and are a good prosthetic suspension system for patients who are very active users, play sports or have short, very sensitive or delicate residual limbs. In the upper limb externally powered socket design, silicone suspension can be implemented and can permit the use of myoelectric controls if the residual limb is not extremely short and other selection characteristics.

Control Mechanism When a body harness is used as a control mechanism far a body-powered prosthesis, the patient needs to be able to produce movements that generate the power requirements to activate the terminal device. These movements can be difficult to perform if the residual limb is short,

painful, or has limited motion, or if the prosthetic socket does not fit well. A poorly adjusted harness decreases the power transmission of the movements. Electric switch control mechanism can be activated with residual limb movements that depress a switch inside the socket. For other cases, a chest strap, waist belt, or figure of nine harness can be used. Servo controls that sense tension have been introduced into clinical use. Myoelectric controls use the electrical activity generated during a muscle contraction to control the flow of energy from a battery to a motor in the prosthetic device. The control signals come from muscle sites in the amputated limb that still have normal innervation and voluntary control. Systems that use single-channel control mechanisms use two electrode sites, one to trigger hand closure or elbow flexion and the other to trigger hand opening or elbow extension. Multichannel systems permit the use of one muscle to control two different functions. This requires that the patient be able to produce a slow, gentle muscle contraction for one function and a strong, faster one for the other function. Myoelectric prosthetic components, such as the Boston or Utah arms, use an “electric switch” to alternate between tha hand and the elbow function. Some systems also include proportional controls, which respond to the speed and strength of the muscle contraction by correspondingly producing a faster or slower movement of the hand or elbow. Hybrid systems on the other hand combine two or more of the available control mechanims, either electric or body-powered. Shoulder disarticulation and forequarter amputation There has been little change in the basic socket design for shoulder disarticulation or forequarter amputation. The main changes have been modifications of the socket trim lines and suspension, and use of lighter materials to construct the socket. Most of the advances in prosthetic design for these levels have occurred with externally powered components. Cosmetic Covers: •

These can be manufactured for a single digit, for the hand, or to extend to the elbow.

•

These are considered as an integral part of the prosthesis, because for many patients the cover is the factor that determines success or failure of prosthetic restoration.

Activity- specific devices: •

To optimally perform at work, sports, or recreational activities, it might be necessary to provide the patient with a specially designed terminal device.

Prosthetic Prescription The prosthetic prescription should be carefully prepared to satisfy the needs and desires of the patient. A team approach to prescription writing should be used. The prescription should clearly spell out the components, control system, suspension, materials and any special features

that might be required. The prescription should serve to clearly communicate with the prosthetist and insurance company. Prosthetic Training Training is integral to the rehabilitation process. A new amputee or an experienced one who receives a prosthetic device that has different components should participate in such training. This program in most cases should be a coordinated effort among the occupational, physical and recreational therapists and the prosthetist with frequent physiatric input (kinesiotherapists are also used in some centers). Each of the members uses different techniques to teach what needs to be learned by the amputee. Before initiating a program of upper limb prosthetic training, one must realistically orient the patient to what the prosthesis can and cannot do. Patient should learn: • • • •

Prosthetic management o basic principles behind function, care and maintenance of prosthesis Cleaning and doffing the prosthesis Skin care and inspection techniques Dismounting the harness for washing and replacing it o For body powered devices

Training process should include bimanual activities such as: • • • • • • •

Grooming Dressing Feeding Driving Sports Work Recreation activities

Special Considerations for the Bilateral Upper Limb Amputee In the case of patients who are bilaterally amputated on the upper extremities, extra care than usual are taken into serious consideration. Training is focused, more often than not, on the development of a dominant prosthesis and skills for independent donning. And to promote autonomy for the person, alternative techniques which include bed for set-up and suspending the prosthetic apparatuses from special wall hooks or frames are advised for him/her to use. Access to the body midline is also recommended which explains the reason for a need of prosthetics to have a wrist rotation and flexion component. Modifications around the patient’s environment are also something that OT’s pay attention to. For example, in the bathroom, a shower area with wall brushes and liquid soap dispensers should be provided. In some cases, simplified shower prostheses (waterproof types) are essential for the reason that the patient can move around and about the place on his/her own, thus, giving him/her the chance to lead for himself/herself.

Brachial Plexus and Other Nerve Injuries There are two main categories that carve up brachial plexus damages, these are: closed injuries along with open penetrating trauma. And closed injuries are more frequent than the second case. Traction on the upper plexus and the C5 & C6 roots occur when the head and neck are stretched away from the shoulder. When the arm is stretched overhead, traction to the lower plexus and the C8 & T1 roots occur more commonly. The injuries can be pre-ganglionic (indicating injury or avulsion of the nerve root proximal to the spinal ganglion); with resulting severe or even complete motor and sensory loss. This can also be accompanied by Horner Syndrome. Postganglionic injuries occur distal to the spinal ganglion and tend to have a more favorable prognosis. CLOSED INJURIES Traction: the act of drawing or pulling; it can either be elastic, skeletal, or skin type. Compression: the act of pressing upon or together; the state of being pressed together. Combination Radiation: divergence from a common center.

PENETRATING INJURIES Gunshot Fracture: a break or rupture in a bone. Knife Wound

Reintegration into the community -

This process is done in a procedure that can be initiated early in the rehabilitation program. This is best done over a few weeks or months in a gradual scale. This can have supervision with organized trips for shopping, recreation, or school. To foster good community integration the patient participants can be in rehabilitation six hours a day, 5 days a week in special programs. The patient can return to work safely on the following concerns. Modified or restricted work should be provided initially. Patient must have work simulation or work supervision. Use of partial day rehabilitation program. (Patient is in rehab 3 h a day, 5 days a week/6 h a day, 2 to 3 days a week). And the availability of psychologic counselling.

Functional outcomes -

The basic goal of rehabilitation in occupation is the independence of the patient in all activities of daily living, most household activities, driving and work. This is true for majority of unilateral transradial or transhumeral amputees. When handling heavy objects restrictions must be made to the patients. Examples are a patient with a typical transradial amputation can be expected to lift 20-30 lbs (unless residual limb is short or sensitive.) Or, a patient with trashumeral amputation which can be expected to lift 10-15 lbs.(affected by type of elbow used). In the case of bilateral transhumeral amputee

realistic goals are self independence in the activities of daily living with environmental modifications. Restrictions of course are applied when carrying delicate heavy objects not over 20 lbs, unless the residual limb is short and sensitive. Psychosocial issues -

It is important to attend to the social and psychologic issues and not just the physical and technological factors that play a role for the people who will be using this technology. Psychosocial perspectives are very significant to the individual’s response; as a result the need to measure the results of treatment has been the catalyst for steady progress in the development of outcome tools appropriate for patients using prosthetic services. Examples of these are the trinity amputation and prosthesis experience scales.

Long-Term Follow-Up The person who completed a rehabilitation program should be seen for follow-up by a minimum of two team members at least every three months for the first 18months. The patient should be seen at least every six months to ensure adequate prosthetic function and fit, assess the need for maintenance and the overall medical condition and functional level of the patient. The prosthesis or parts of it could be replaced every 18months to three years for body-powered devices and every two to four years for myoelectric prosthesis when the patient’s condition is stable (Braddom, 2008). According to DeLisa, routine follow-up should occur initially four to six weeks after delivery of the prosthesis then every two to six months until a definitive prosthesis is prescribed. If the prosthesis is clinically stable, yearly clinic visits or whenever a problem arises is usually adequate. What is evaluated during the follow-up visits are the individual’s use and function with the prosthesis, the difficulties or problems, the fit and condition of the limb and the condition of the residual limb. With average use, the upper extremity prosthesis can last for three to five years before complete replacement is necessary. However, the socket, of all its parts, is to be replaced frequently. Neuromas. Neuromas are formations of the scar tissue around the distal end of the severed nerve. There is pain perceived at the site of neuroma that moves distally to residual limb caused by compression of the nerve, sometimes by adhesions of the tissues or even by the complications from surgical techniques. It is usually palpable especially the painful neuroma. Desensitization techniques, prosthetic modification, use of flexible materials with windowed frame construction decrease the pressure over the neuroma. Local anesthetics and corticosteroids are the ones that reduce scar tissue pressure. Surgical removal of neuroma is reserved for those cases in which all other interventions have failed and allows the repositioning of the neuroma to a less pressure-exposed location. Dermatologic Problems. Prevention of appropriate air circulation caused by most prosthetic sockets trap perspiration moisture, which results to problems such as Hyperhydrosis, Folliculitis, Allergic Dermatitis and Skin breakdown. Poor hygiene is the frequent cause so the

patient must be trained the proper washing technique of the residual limb, silicone liners, socks and the socket and its interfaces. Support Groups. These are sources of information, peer counseling and motivation for patients. These should ideally constitute one more component of the comprehensive rehabilitation approach to the patient with amputation. Pediatric Limb Deficiency and Amputation Rehabilitation An acquired or congenital limb deficiency can be seen by a pediatric patient. In a congenital limb deficiency, a child has no sense of loss and doesn’t need to go through the psychological adjustment process. The prosthesis is perceived as an aid rather than as a replacement. If the device cannot serve in this role it will be discarded. These children try to engage in the same type of activities as other children. Their only limitations are usually those imposed by adults. In contrast, the child with an acquired limb deficiency goes through the natural readjustment process of limb loss. Their acceptance of an artificial limb has a direct impact on their ability to adjust in their condition. There are some special considerations that should be made for the pediatric patient with upper limb deficiency or amputation. Here are three points that should be considered: first, normal growth and development, which will necessitate frequent prosthetic adjustments or replacements; second, bony overgrowth; third, the more rigorous use that the device will be subjected to. It can be expected that a prosthesis will need to be replaced yearly in the first 5 years of life, every 18 months from 5 to 12 years of age, and every 2 years until age 21 years. To address growth problems, multilayered sockets (onion sockets) for body-powdered devices can be used. These allow removal of one layer at a time to accommodate growth. This results in gradual enlargement of the socket to coincide with periods of growth. The socket made in this fashion increases the life span of the prosthesis from 6 months to as much as 18 months. Length adjustment is also important, although it is not critical as with lower limb prostheses. This can be adjusted by adding material at the wrist or elbow sites when necessary. Harnesses and cables need to be adjusted for length and replaced more frequently. For bony overgrowth, surgery with bony capping may be necessary. There are integral components that are needed in the rehabilitation of the pediatric patients and these are parental counseling and support. At 3 to 9 months of age of the pediatric patient with upper limb deficiency or amputee, prosthetic fitting should already be done.