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Crucial Collaboration 

Staff Writer


Vol. 12 •Issue 5 • Page 65 
Crucial Collaboration
 

Prosthetists and occupational therapists can help people with UE amputations achieve excellent outcomes.

 

 

Nearly 40,000 people in the United States lose a limb each year.1 Of these, approximately 30 percent lose an arm or hand. Rather than go through life without an arm or hand, people with upper extremity amputations have numerous prosthetic choices. These include body-powered, electric, hybrid (combination of body-powered and electric), passive-cosmetic and passive functional prostheses.

 

Because the field has experienced tremendous development?particularly with electric prostheses?a team approach is crucial. The "core" professionals should include the physician, prosthetist, occupational therapist and case manager. Each member plays an important role in successfully rehabilitating people with upper extremity limb loss.

 

Especially crucial is the collaboration between the skilled prosthetist and occupational therapist, both of whom have very distinct roles. The prosthetist must optimally fit the prosthetic device, taking into account comfort, stability, design and function.

 

The therapist prepares the limb for the prosthesis and comprehensively trains the person once he receives the device. While successful outcomes are possible when each discipline functions independently, the chances significantly improve when a skilled team approach is used.

 

Unfortunately, this doesn't happen often because it's hard to find prosthetists and occupational therapists skilled in upper extremity limb loss. The reason centers on the patient population. Quite simply, there are fewer people with an upper extremity amputation, compared to those with a lower extremity amputation. Therefore, most prosthetists aren't exposed to patients with upper extremity amputations in their practices. If they do come across this patient population, they most likely will refer them to another prosthetist who has the experience to work with them.

 

Complicating matters is that a "defined" therapist-prosthetist relationship doesn't exist. In fact, there's little collaboration between the CP and the OT because both are unaware of each other's roles. Usually one, or perhaps both, may not be experienced in upper extremity prostheses.

 

And because they lack experience, prosthetists and therapists may not know what functional outcomes are possible with each level of amputation. The patient, who may not know any better, accepts what the professional tells him and doesn't seek a higher level of function.

 

A person with a unilateral below-elbow amputation, for instance, should use his prosthesis to assist in bi-manual activities, such as holding a cup while the other hand pours the drink into the cup. Then to take a drink, the person should switch hands and use the sound arm to grasp the cup, raise it to his mouth and, finally, take a drink.

In the absence of collaboration, however, the patient probably won't practice in a rehab setting. Therefore, he won't learn basic grasp and release tasks, and then work his way up to functional activities, such as feeding or grooming. This lack of training in bi-manual tasks sets the patient up for almost certain failure.

 

He may go home, for example, and try to do a difficult task and fail. This leads to frustration, and he may give up using the prosthesis altogether. In fact, he may find he can do the same task faster and more easily without the prosthesis.

 

The longer the time between the amputation and the prosthetic fitting, the more the patient can develop one-handedness. In fact, the patient may become so proficient with one hand that he doesn't feel he needs to use the prosthesis. And if he's frustrated, he'll simply use his remaining arm to complete activities.

 

This situation is even more critical when it involves patients with difficult or highly involved bilateral amputations. The complex nature of this patient population requires that clinicians have even more skill, knowledge and experience to optimize outcomes.

 

The patient with a bilateral amputation, for example, is completely dependent on someone else for all activities of daily living, such as grooming, bathing, dressing, feeding and toileting. The skilled therapist, however, can help the patient use his prostheses to reach modified- to complete independence on the Functional Independence Measure with most, if not all, ADLs.

 

Open communication between the two disciplines is the key to this. If the therapist doesn't communicate with the prosthetist about the patient's functional abilities—or the lack of them?the patient may never fully achieve his potential with the prostheses. The therapist, who should be knowledgeable about the patient's potential, can pinpoint problems and take measures to correct them.

 

If it's user error, the OT can make suggestions to correct body movement or the position of the prosthesis. The OT also can help keep the patient motivated to use the device. If it's a problem with the device, the OT can call the prosthetist and ask appropriate questions so that modifications/repairs can be made to the prosthesis, if necessary.

 

A prosthetist who observes the rehab process is much more aware of the functional perspective of the OT. Certainly, knowing how to operate the different components (open and close the hand/hook, flex/extend the elbow and rotate the wrist) is important. But this knowledge falls short unless the person can apply these techniques to functional activities. With this increased awareness and knowledge, the CP is better prepared to manage patients with upper extremity amputations.

 

This further proves the need for a skilled team approach that includes open and continual communication. This also drives home the importance of a cross-training educational effort between the disciplines to raise awareness of each other's roles.

 

An improved relationship between prosthetists and therapists will ultimately lead to improved patient outcomes and increased prosthetic acceptance rates. Because this collaboration is crucial, the Upper Limb Prosthetic Society of the American Academy of Orthotists and Prosthetists is focusing on enhancing the clinical relationship between occupational therapists and prosthetists.

 

To that end, a unique and significant project was initiated by prosthetist Randall Alley, CP, FAAOP, and occupational therapist Diane Atkins, OTR, FISPO. These professionals have teamed together to establish a national directory of skilled therapists and/or those who have a significant interest in upper extremity prostheses. This project is still in the beginning stages.

 

In another initiative, a manufacturer has assembled a team of clinical specialists in upper extremity prostheses, which include prosthetists and occupational therapists. This team is traveling the country, presenting workshops to therapists on upper extremity limb loss rehabilitation. The team is also presenting to various prosthetic schools about the role of occupational therapists in rehabilitating .people with upper extremity amputations.

 

Other prosthetic companies and manufacturers, likewise, have recognized the need to enhance collaboration and have begun their own initiatives of occupational therapy education and training.

 

While these initiatives are promising, we need outcomes measures to increase funding and authorization for prosthetic and therapy services. Unfortunately, accurate outcome measures for people with upper limb prostheses are difficult to establish, mostly because compiling valid data takes time and is labor-intensive. Moreover, we must take an extraordinary amount of variables into account. The following are complex factors that only begin to scratch the surface:

 

- Each case is unique based on the patient's level and nature of injury. For example, the higher the level of amputation, the fewer points of control. (If the patient's elbow is missing, he cannot use that natural joint to his advantage.) Additionally, mechanical joints of prosthesis are insufficient in replacing natural arm movements. The mechanical joints, as opposed to the natural arm, are harder to control and tend to be much slower.

 

The patient with a unilateral below-elbow amputation has a higher likelihood of obtaining a better functional outcome than a patient who has sustained an above-elbow amputation. Outcomes are generally based on the person's level of functional independence and time he spends using the prosthesis throughout the day. The person with a unilateral amputation will most likely have a better outcome than someone with a bilateral amputation because he has fine motor control of the remaining arm and fingers. People with congenital limb deficiencies also will have different outcomes from those with acquired amputations because they've learned to adapt without a limb from birth.

 

- Psychological adaptation is a significant factor in assessing outcomes. Two patients who are being seen by the same interdisciplinary team, have the same level of injury and use identical componentry may experience two very different outcomes. The patient who is motivated and can problem-solve will have better outcomes than the person who doesn't.

 

- The level of experience of the prosthetist, therapist and physician is critical.

 

-Having a consistent evaluator at each stage of assessment is another important factor. This assessment should include the patient's initial functional ability and follow-up at regular intervals to determine whether he has fully integrated the prosthesis into his life.

 

Outcome measures, although elusive, are needed to document success, lower costs and attain authorizations for therapy. We hope the collaboration between therapist and prosthetist will validate future outcomes and studies. With an experienced team approach, we can improve patient outcomes and increase prosthetic acceptance rates. In doing so, we'll maximize rehabilitation potential and can help people get to where they need to be.

 

Reference

 

1. Leonard, J.A., & Meier, R.H. (1988). Prosthetics. In J.A. DeLisa (Ed.), Rehabilitation medicine principles and practice, Philadelphia, PA: Lippincott.

 

 

Shawn Swanson, OTR/L, lives in Houston and travels as a clinical specialist in upper extremity prostheses for a prosthetic manufacturer based in Minneapolis. Prior to this, she worked at The Institute for Rehabilitation and Research in Houston and treated patients with SCI, TBI, stroke, amputations, cerebral palsy and other neurological diagnoses. 

 



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