Postprosthetic training helps patients adapt to a new limb.

By Shawn Swanson, OTR/L

In this second of a two-part series, the author looks at the occupational therapist's role during postprosthetic adaptation.

During the preprosthetic phase, clinicians must prepare the patient for the eventual arrival of a new upper extremity device. When the patient moves from the preprosthetic to the postprosthetic phase, he's entering a new stage of life.

In the process, a patient must adapt to new situations and relearn basic, rudimentary functions. It's a time for creativity and attention to details.

And, if you're going to have a successful outcome, you must have a motivated, dedicated patient who's intent on engaging in functional tasks and practicing realistic situations. But even with the best prosthesis, a patient still needs occupational therapy to maximize the capabilities of the device.

Initially, you should repeat portions of the preprosthetic evaluation to note limb changes and condition, such as range of motion (ROM), circumference, length, pain, skin integrity and sensation.

Postdelivery treatment should cover several areas, all of which help the patient adapt to the new limb. The treatment plan also should be based on the evaluation results and a patient's goals. Componentry varies for each person, and choices include body-powered or myoelectric devices. In addition, amputation level will affect ability.

Start with a basic orientation to componentry and determine how well the patient can manage the device. Can he open and close the terminal device? Can he flex and extend the elbow and lock it in place? Can he flex the wrist or rotate the device for proper prepositioning? Can he grasp and release different objects? Can he change terminal devices or replace batteries?

If it's a cable-operated prosthesis, does he have the appropriate body movements to accomplish these actions? Look for separation of control. For example, does the patient use hip flexion to compensate for the lack of ability to control elbow extension while transferring objects?

After determining basic capabilities, focus on specific tasks.

-Teach independence donning and doffing a prosthesis. Instruct the patient to put the prosthesis on and take it off independently. Every patient learns differently. A patient with good problem-solving skills may have already developed his own techniques.

For most patients, the "coat" or "sweater" methods work best. With the coat method, the patient puts the harness on one arm at a time. The sweater method uses an overhead motion, such as pulling on a sweater, with one arm following the other.

-Establish a prosthetic wear and care schedule. Do this during the first therapy visit. Write schedules down, so the patient and family can refer to them in the future. A new prosthesis can be an overwhelming experience, and verbal instructions are easy to forget.

This step helps someone develop tolerance to the socket and/or harness system by gradually increasing wearing time. Initial wearing time should be 30 minutes, followed by a thorough skin inspection each time he removes the prosthesis. Redness or irritation that persists longer than 20 or 30 minutes after removing the prosthesis may indicate improper fit. In these situations, a patient should return to a prosthetist for socket modification.

If the skin responds appropriately, the patient increases wear time in increments of 30 minutes to one hour, until he can tolerate wearing the device for more than an eight-hour workday.

Teach the patient how to care for and clean the prosthesis. Use mild soap and water to clean the socket interior. Clean the harness with household ammonia or wash it in the sink, then rinse and air dry thoroughly.

Instruct your patient to routinely examine the cables and look for frayed or worn areas. In addition, make sure you review electrode care and battery charging procedures for a myoelectric prosthesis.

-Maintain residual limb hygiene. The limb is enclosed in a socket in which constant perspiration can cause skin to soften and break down. Instruct the patient to wash the limb with mild soap and pat dry daily.

-Review body control motions. Before allowing a patient to practice prosthetic controls training, review body motions. To open the terminal device, a patient should be able to use biscapular abduction and humeral flexion. He should lock and unlock the elbow in various degrees of flexion by using a combination of shoulder depression, extension and abduction, known as "down, back and out. " Shoulder depression is the downward motion, shoulder extension is back, and shoulder abduction is out. This combination of movements transferred through the harness allows a patient to lock and unlock the elbow joint on a prosthesis.

-Continue muscle training. The patient should have completed muscle training before receiving a myoelectric prosthesis. But that's not always the case. You should practice isometric contractions to flex isolated muscle groups, which gives the patient an advantage before receiving a myoelectric prosthesis. Encourage the patient to practice these exercises at home as well.

In addition, visual or auditory biofeedback can enhance muscle training because the patient can learn the correct muscle activation pattern. With a biofeedback training program, he receives information about physiological processes, with the goal of gaining conscious control over specific motions. Biofeedback is a computer software program that provides visual feedback of a client's muscle activity or electromyography signals. These signals are represented on a "real-time" graph on a computer screen.

-Practice repetitive drills and activities. Once the patient masters the ability to don and doff a prosthesis, you can then initiate repetitive drill activities. During this phase, he learns how to control a terminal device.

These drills can include grasping and releasing objects of various sizes, shapes and densities, such as peg boards and clothespins of different tensile strengths. Initiate these activities first during sitting, then progress to standing and walking.

The patient also should practice reaching in different planes to transfer objects. For example, ask him to move an object from overhead to waist level, from the floor to overhead, left or right side to midline, and from midline to the other hand. If the client can't perform any of these tasks, contact a prosthetist to discuss adjustments to the device.

-Promote energy conservation and work simplification. The person with a prosthesis will expend more energy than someone who doesn't have a prosthetic device. Therefore, you must address energy conservation during training. He must learn to use the body's energy supply more efficiently and minimize efforts to perform ADLs.

Common techniques include establishing a daily routine, setting priorities, pacing, planning ahead, resting frequently, sitting to work, using good body mechanics, organizing a workspace and eliminating unnecessary tasks.

-Apply functional use training. This may be the most difficult and lengthy aspect of post-delivery treatment. Functional training includes teaching basic ADLs, such as dressing, feeding, grooming, meal preparation, household management and returning to work.

Each patient is unique and learns tasks differently. What works for one may not work for another. Create the best solution that helps someone achieve the greatest level of independence. For instance, ask a patient to fold laundry and give him a trial-and-error period to figure out his own way of doing things. If he has problems, intervene to provide an easier solution.

During functional training, repetition and practice are the keys. It takes time to get used to new ways of doing things. Consider asking a former patient or another person with an upper extremity prosthesis to attend therapy. The experienced user can demonstrate certain tasks so the new patient can see that an activity is possible.

-Incorporate recreational activities. Recre.ational activities are just as important as ADLs. Inquire about hobbies and leisure activities, such as bowling, fishing, playing pool, golfing, swimming or playing an instrument.

Incorporating hobbies keeps a patient interested in therapy and allows you to help modify his favorite activities. You can always make a referral for an adaptive prosthesis or interchangeable implements for task-specific activities.

-Determine return-to-work status. Returning to work can be tricky. What was his line of work and can he return in the same capacity?

If the job was labor-intensive and requires lifting extremely heavy objects, the patient may not be able to return without modifications. For example, the client can use a hand cart or another assistive lifting device to keep him independent with job requirements.

In some cases, a work hardening or work transition program can help. These programs help a patient gradually adapt to job demands. It's also important to perform a worksite evaluation to determine any functional training issues or adaptive equipment needs.

Discharge a patient when he has completed his goals or reached a plateau. You can always recommend a re-evaluation after a "short break" from therapy to assess progress during home therapy.

But remember, a prosthesis won't do any good if the patient doesn't incorporate it into his daily life. It will sit in a closet, collecting dust. And what good is that?

Shawn Swanson, OTR/L, lives in Houston and travels as a clinical specialist in upper extremity prostheses for a prosthetic manufacturer based in Minneapolis. Diane Atkins, OTR, FISPO, and Laura Tingleaf, OTR, contributed to this article. Atkins is a clinical assistant professor in the department of physical medicine and rehabilitation at the Baylor College of Medicine in Houston. Tingleaf practiced occupational therapy at Baylor Rehabilitation in Dallas and T.I.R.R. in Houston, and specialized in SCI, TBI, CVA and upper extremity amputations.