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Section 2: Upper Limb
Figure 1
reduction. A, A self-adherent elastic wrap used after a partial hand amputation. B, A gure-of-8
elastic compression bandage was used after a transhumeral amputation. (Courtesy of Rehabilitation Institute of Chicago, Chicago, IL.)
necessary.6 The duration of a therapy
program is influenced by the number
Photographs showing the use of compression for residual limb shaping and edema
A caregiver may need to be trained if
the patient has bilateral upper limb loss.
of limbs amputated as well as the amputation level and the patient’s cognitive
function, executive skills, support system, and funding source.
Edema Reduction and
Residual Limb Shaping
Prolonged edema can lead to residual
limb pain, poor wound healing, in-
Immediate Postoperative
Considerations
Wound Care
A residual limb with wounds or a primary closure site with staples can be
cleaned with antibacterial soap and
water and covered with a silver-type
wound dressing. The use of a silver-type
dressing can reduce the risk of wound
complications, edema, or biofilm formation.7 If a mesh skin graft or sheet graft
was surgically applied to the residual
limb, close inspection may be required
during the first 10 to 14 postoperative
days to maintain the proper moisture
environment for the graft and to express
hematoma or serous fluid as needed.
Whether they are well closed with native tissue, have been treated with grafts,
or have healing wounds, most residual
limbs benefit from the application of a
figure-of-8 elastic compression bandage
to stabilize the dressing and begin edema
reduction. Many patients with unilateral
upper limb loss can be instructed in appropriate wound care and limb management in the early postoperative period.
creased firmness of scar tissue, and a
poor residual limb shape. Edema reduction can be initiated with the use of
an elastic compression bandage even if
wounds are still present. The application of bandage pressure can increase
the pliability of scar tissue and thereby
limit pain and skin irritation. Continuous compression is recommended until
the scar tissue matures 12 to 18 months
after wound closure. After a partial hand
amputation, a self-adherent elastic wrap
can be used to apply pressure (Figure 1).
For a transradial or transhumeral amputation, a 3- or 4-inch elastic compression
bandage can be used. After a shoulder
disarticulation, initial pressure from a 4to 6-inch elastic compression bandage
encompassing the trunk is beneficial,
with subsequent use of a noncustom,
moisture-wicking compression garment.
Elastic bandage compression should
be used until wounds are sufficiently
healed to tolerate the shear forces produced when a residual limb shrinker is
donned. An upper limb residual shrinker can be fabricated from compressive
Figure 2
with a residual limb shrinker fabricated by an
occupational therapist. (Courtesy of Rehabilitation Institute of Chicago, Chicago, IL.)
Clinical photograph of a patient
materials (Figure 2). Both elastic compression bandages and residual limb
shrinkers have been shown to reduce
residual limb edema, but the skilled use
of an elastic compression bandage can
facilitate greater edema reduction in less
time than the use of a shrinker.8 The
early application of compression also begins residual limb shaping, which can
lead to easy donning of the prosthetic
socket and minimize development of
redundant soft tissue. A conical residual limb shape is the goal. Even after
successful prosthetic fitting, continued
use of a residual limb shrinker or elastic
compression bandage may be required
throughout the first year after the amputation whenever the prosthesis is not being worn; this will continue the process
of edema reduction and limb shaping.
Pain Reduction
Ninety-five percent of individuals with
upper limb loss secondary to trauma
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
352
report phantom limb sensation or pain,
residual limb pain, or nonamputated
limb pain.
9,10
The type and level of upper limb pain should be assessed during
preprosthetic treatment. In phantom
limb sensation, the amputee feels that he
or she is experiencing various sensations
in all or part of the amputated limb;
these sensations may include a feeling of
movement in the phantom limb. Phantom limb pain includes sensations that
can be described as burning, twisting,
shooting, squeezing, cramping, or dull
aching of the amputated body part. Residual limb pain may be the result of the
initial injury, the amputation surgery,
persistent wounds, or neuromas. In addition, the contralateral, nonamputat
ed upper limb should be assessed for
pain resulting from a previously undiagnosed injury, an overuse syndrome,
cumulative trauma, or a repetitive stress
11-13
injury.
The early application of firm pressure, such as pressure applied with an
elastic compression bandage, can reduce nerve or wound irritation, pain
from edema, and sometimes phantom
limb pain. The therapist also may need
to use visual feedback, guided mental
motor imagery, or mirror or visual therapy to treat phantom limb sensation or
phantom limb pain (Figure 3). Many
individuals can be trained to use these
techniques while in the clinic and then
progress to incorporating the techniques
into the home and work environments.
Structured, guided visual feedback techniques can be used to reduce selected
pain issues by means of cortical reorganization.
14-17
In contrast, the use of
electrical modalities was found to lead
to only minimal pain reduction.
18,19
In comparison with the general population, individuals with upper limb
loss are more likely to have an overuse pain syndrome, most commonly
affecting the neck, lower back, and/or
shoulder.11 Individuals with unilateral upper limb loss often report lateral
epicondylitis, carpal tunnel syndrome,
Chapter 29: Upper Limb Prosthetic Training and Occupational Therapy
Figure 3
mirror therapy to achieve pain reduction. Mirro r
therapy assists with decreasing the pain cycle
-
in the amputated limb by watching the reection of movement of the nonamputated limb
in a mirror; this creates positive feedback in the
motor cortex of the brain. (Courtesy of Rehabilitation Institute of Chicago, Chicago, IL.)
Photograph showing the use of
cubital tunnel syndrome, or stenosing
tenosynovitis in the contralateral upper limb. A simple off-the-shelf orthosis
may be useful in managing an overuse
syndrome in the contralateral upper
limb (Figure 4).
Flexibility, strength, and correct mechanics can help alleviate pain. Accordingly, preprosthetic and postprosthetic
occupational therapy should include an
emphasis on increasing and maintaining flexibility of the trunk and extremities. In addition, the therapy program
should focus on strengthening associated muscle groups and providing instruction in appropriate body and arm
mechanics and posture.
Positive coping skills related to anger and stress also are useful in managing pain. An individual with limited
or poor coping skills or a tendency to
depression may benefit from early integration of positive coping skills into the
therapy program, with reinforcement
from the individual’s support system.
A medical professional who is experienced and knowledgeable in limb
Figure 4
a noncustom armband and wrist support orthosis to assist with pain reduction associated
with lateral epicondylitis in the nonamputated
limb. (Courtesy of Rehabilitation Institute of
Chicago, Chicago, IL.)
Photograph showing the use of
loss treatment can provide additional
techniques for pain reduction.20 The
therapist should continue to assess the
individual for overuse syndrome issues
related to changes in work, avocational
activities, or aging. Techniques to minimize pain and enhance a return to function should be used as needed.
Preprosthetic Program
Essentials
Limb and Core Assessment
and Treatment
The therapist’s assessment should not be
limited to the affected limb because other
body areas may also require treatment.
The range-of-motion assessment should
include joint and soft-tissue movement
in both the limbs and the trunk. Soft-tissue limitations can be promptly treated
with an aggressive elongation program
focusing on increasing trunk flexibility
and active movement of the upper and
lower limbs. Similarly, a strengthening
program can minimize abnormal trunk,
back, and limb changes secondary to
upper limb amputation.21 In bilateral
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
353
Section 2: Upper Limb
Figure 5
use of the residual limbs in a person with bilateral upper limb loss. The patient is using a universal cu with a low thermoplastic pointer/
turner fabr icated by the occupational th erapist.
(Courtesy of Re habilitation Institute of Chic ago,
Chicago, IL.)
Photograph showing midline
upper limb loss, progressive treatment
to bring both upper limbs to midline can
be useful in implementing preprosthetic
self-care tasks (Figure 5).
General age-based physical fitness
assessments can be used to identify the
physical condition of the individual and
the general safety skills needed for the
home environment.22 Muscle strength
can be assessed by manual muscle examination, as needed. Assessment of
peripheral nerve function is sometimes
indicated because peripheral nerve dysfunction can limit voluntary muscle
function and may require the therapist
to develop a treatment program that will
compensate for the losses and allow independence in activities of daily living.
The preprosthetic therapy program
can initiate both core and extremity endurance and strengthening tasks. Core
stabilization during resistive upper limb
exercises can prepare the individual for
assuming the weight of the prosthesis (Figure 6). Good muscle strength
can allow relatively rapid progression
to extended periods of prosthesis use.
Similarly, increasing cardiovascular
endurance contributes to a tolerance
for wearing and using an upper limb
prosthesis.
Figure 6
core and extremity strength (A) and cardiovascular endurance (B). (Courtesy of Rehabilitation Institute of Chicago, Chicago, IL.)
Perceptual Motor Skills
Perceptual motor skills influence the
Photographs showing an individual with quadrilateral limb loss training to improve
performance in preparation for using
self-care skills outside of the clinic.
ability to resume dynamic balance
and change hand dominance. A brief
assessment of perceptual motor skills,
including hand-eye coordination, bodyeye coordination, postural adjustment,
and visual skills, helps the therapist determine how to provide training for new
tasks and functional prosthesis use.
Home Assessment
For more complex cases, such as indi-
viduals affected by bilateral limb loss, a
home assessment should be completed
before prosthetic training begins. The
basic home recommendations should
23
include independence in entering and
leaving the home, showering (includ-
Preprosthetic Self-Care Training
Before beginning training to use a
prosthesis, an individual with unilateral upper limb loss can benefit from
training that will help him or her become independent in cutting food, tying
shoes, bathing, and donning upper torso
garments. For individuals with bilateral
upper limb loss, adaptive equipment is
used for training in self-feeding, grooming and hygiene tasks, showering, and
donning upper torso garments (Fig‑
ure 7). The efficient performance of selfcare tasks is influenced by total body
endurance, strength, and flexibility. For
ing turning the water on and off and
washing the body), toileting, removing
items from the refrigerator or microwave
oven, and managing internal doors and
light switches. Many individuals benefit
from instruction in the use of electron-
ic technology for managing door en-
trances, lights, and other items in the
home. Architectural modifications may
be recommended, if funding allows. If
architectural modifications cannot be
considered, the recommendations can
emphasize portable devices, especially
for the bathroom, that can be relocated
to another residence.
those individuals with limited perceptual motor skills or difficulty in transferring newly learned skills to multiple
tasks, repetitive training in the clinic can
enhance the timeliness and efficiency of
Support System
An individual’s ability to regain function
can be fostered by appropriate family,
community, work, and school support
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
354
Chapter 29: Upper Limb Prosthetic Training and Occupational Therapy
Figure 7
upper limb amputation using an adaptive device for feeding (B). (Courtesy of Rehabilitation Institute of Chicago, Chicago, IL.)
systems. Each support system should be
assessed to determine the feasibility of
integrating it into the rehabilitation program. The therapist should understand
the individual’s family, community,
work, and school roles in the interest of
assisting in the resumption of medically,
physically, and emotionally appropriate
aspects of these roles. Having the ability to interact with others in previously
established roles contributes to reestablishing a sense of self-worth. Shared
occupational therapy treatment sessions
for individuals with a similar limb loss
can serve as an important additional
source of support.
Sleep Patterns
Referral to a psychologist or the attending physician is indicated if the individual’s sleep habits have changed since the
amputation. A change in sleep pattern is
common and may be attributable to the
use of pain medication, recent surgery,
reduced physical activity, or emotional
responses. Often the sleep pattern improves with a structured therapist-initiated program to enhance total body
endurance and strength.
Hand Dominance
If the dominant hand was part of the
amputated limb, the therapist can begin
hand dominance retraining activities
Photographs show ing an individual with qua drilateral limb loss using an ad aptive device for self-c are (A) and an individual with bilateral
as part of the preprosthetic program.
Changing the hand dominance affects
handwriting, keyboard use, and dexterity in work-related tasks and activities of
daily living. Specific computer software
may be useful for increasing keyboard
speed and accuracy.
Types of Prostheses and
tension through a control cable that operates the terminal device. In addition,
an individual with a transhumeral amputation must work on strengthening
the movements of scapular depression
with shoulder extension because these
movements may be needed for operating
the cable that will lock and unlock the
elbow.
Prosthetic Control
Motor and Movement Skills
for Prosthetic Function
The goal of the preprosthetic therapy program is to sufficiently increase
endurance, mobility, and strength to
allow multiple hours of daily prosthesis use. During the preprosthetic program, the individual can be trained in
the motor skills or movement needed
for operating the anticipated prosthesis. However, the style and operation
of the prosthesis must be determined
in consultation with a prosthetist who
is knowledgeable about upper limb
amputations.
Body-Powered Prosthesis
The use of a body-powered prosthesis after a transradial or transhumeral
amputation requires scapular abduction training, with strengthening of
the serratus anterior, pectoralis major,
and pectoralis minor muscles. Scapular
abduction is commonly used to create
Myoelectric Prosthesis
A myoelectric prosthesis uses electromyographic signals captured through
surface electrodes in the prosthetic
socket. In consultation with the prosthetist, the therapist should identify one
or more muscle groups appropriate for
this use. Individuals with a transradial
amputation often use two-site muscle
control composed of forearm flexors and
extensors. The therapist should provide
a program to increase the endurance
of the forearm muscles to allow a long
period of daily myoelectric prosthesis
use. The voluntary firing of the forearm
muscle groups must be independent of
the position of the elbow or shoulder to
allow functional use of the prosthesis in
multiple degrees of movement. An individual with a transhumeral amputation
can often use upper arm elbow flexors
and extensors to operate the terminal
device and elbow. Preprosthetic training
should include the general strengthening
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
355
Section 2: Upper Limb
terminal devices can serve in multiple
activity-related functions. Most indi-
viduals with a body-powered prosthe-
sis choose the functional utility of a
hook-style terminal device, but a hand
terminal device can be used in social
environments (Figure 8). Those indi-
viduals with a myoelectric or hybrid
prosthesis can use interchangeable ter-
minal devices including a basic hand,
a multifunctional hand, an electronic
terminal device, or a Greifer (Ottobock)
(Figure 9). Some terminal devices are
effective for most daily activities and
should be the focus of training. Others
are used only for specific activities, but
require training in proper use and stor-
age. The user should be instructed on
which terminal devices are appropriate
for strenuous activity or in the presence
of moisture, dust, or vibration.
Figure 8
hook and hand terminal devices (left and right, respectively). Hooks are available in various sizes
and opening capabilities. (Courtesy of Rehabilitation Institute of Chicago, Chicago, IL.)
and endurance of these muscle groups
as well as their discrete control in different shoulder positions. Throughout
the training, the individual should be
reminded to avoid using the myoelectric
prosthesis in activities involving moisture, vibration, dust, or high voltage.
Photograph showing a body-powered prosthesis (center) with interchangeable
Targeted Muscle Reinnervation
Targeted muscle reinnervation and
associated follow-up consultations on
the design of the proposed prosthesis as
well as any training on its use should be
performed at a medical center that specializes in this unique treatment. Until
the muscles are fully innervated, the
Hybrid Prosthesis
A hybrid prosthesis can be used after a
transhumeral or forequarter amputation
or a shoulder disarticulation. Prosthetic
component operation at these proximal
amputation levels can include control
of a terminal device as well as wrist,
forearm, elbow, and shoulder joint
movement. In close consultation with
the treating prosthetist, the therapist
individual should be fitted and trained
with a myoelectric or hybrid prosthesis.
After targeted muscle reinnervation sur
gery, the therapy program should focus
on developing motor patterns for eliciting muscle contraction of the amputated
limb. Time is required for the nerve to
reinnervate muscles of the upper torso,
and a program of 3 to 6 months or longer may be required.
should identify the movements and
muscle functions needed for operating
the proposed prosthetic components
and develop a program to increase the
individual’s endurance in preparation
for use of the prosthesis.
Terminal Devices
The many functions of the hand cannot be effectively reproduced by a single prosthetic terminal device. However,
appropriately designed interchangeable
Prosthetic Training
The therapist should ensure a smooth
transition from the preprosthetic pro-
gram into the prosthetic skills training
program, usually as soon as the pros-
thesis is delivered.
Initial Training Sessions
Prosthetic training should begin with
terminology, component function and
operation, time-efficient donning and
doffing of the prosthesis, residual limb
care, and general prosthesis mainte-
nance. For many with a transhumeral or
transradial amputation, the prosthesis
-
is donned using an overhead technique
(Figure 10). For those with a shoulder
disarticulation or forequarter ampu-
tation, donning often can be accom-
plished in a manner similar to donning
of a front-opening garment. Some indi-
viduals with bilateral upper limb loss
need to use a prosthetic dressing tree,
which is custom designed and fabricat-
ed based on the individual’s flexibility,
motor skills, and balance. The donning
method ultimately is based on the indi-
vidual’s functional abilities, which may
be influenced by the presence of other
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
356
injuries as well as flexibility and muscle
strength. Training in the general maintenance of the prosthesis includes topics
such as application of tension bands to a
body-powered hook and changing terminal devices.
Control Training
Control training should be done separately for each prosthetic component.
As each prosthetic operation is mastered, a subsequent operation is added.
Training should progress from tabletop
activities to the use of the prosthesis
while standing or reaching (Figure 11).
Control training often begins with the
patient manipulating unbreakable items
positioned on a table and progresses to
fragile or crushable items. The patient
should attempt to move the objects from
the table to each side of the body and to
the midline. Learning to open the terminal device to the specific diameter of
the object being manipulated increases the efficiency of prosthetic function
and minimizes the use of other body
parts. The training progresses to prepositioning of the terminal device,
wrist, forearm, elbow, and shoulder
before engaging in an activity. Continued training leads to prosthesis use
while the opposite limb or the body is in
motion. Prosthesis use in coordination
with other body movements can facilitate the transference of skills to complex
activities.
Chapter 29: Upper Limb Prosthetic Training and Occupational Therapy
Figure 9
devices (left to right): an interchangeable hand, an electronic terminal device, and a Greifer (Ottobock). (Courtesy of Rehabilitation Institute of Chicago, Chicago, IL.)
Photograph showing a myoelectric prosthesis (center) with a variety of terminal
Self-Care, Activities of Daily
Living, and Work Tasks
Integration of the prosthesis into selfcare tasks should begin when success
with component operation has been
achieved. The use of the prosthesis in
these activities should be reinforced be-
Figure 10
person with unilateral limb loss (A) and a person with bilateral limb loss (B).
Photographs showing the use of an overhead prosthesis donning method by a
cause the individual may have become
independent in some tasks before receiving the prosthesis. Using the prosthesis to perform these core tasks will
positively affect its overall usage rate and
may minimize overuse or stress injuries
to other body areas.
Training should progress to basic meal preparation tasks and skills
required for independent living
(Figure 12). Training to incorporate
prosthesis use into child care may be
important (Figure 13). The individual
should also learn how to safely carry
items using the prosthesis (Fi g u r e 14).
Ultimately, there should be a progression from home and community tasks
to lifting, carrying, and work-related
tasks. Instruction must be provided on
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
357
Section 2: Upper Limb
the dynamic and static lift abilities of
the prosthetic components and should
be reinforced to minimize component
failure, residual-limb skin irritation, and
the potential for an overuse syndrome.
Training in the use of the prosthesis
in homemaking, work tasks, and leisure
activities must include prepositioning of
the prosthetic components and proper
body and arm positioning to minimize
the risk of overuse syndromes. With
appropriate training, most individuals
can acquire independence in self-care
and selected homemaking and work activities without the need to frequently
change the terminal device (Figure 15).
A return to work may require the thera
pist to complete an onsite work assessment and recommend environmental
modifications, assistive technologies,
or ways to integrate the prosthesis into
work tasks. The onsite work assessment
may also result in the need for changes
in the prosthesis or additional occupational therapy sessions.
-
Figure 11
training in individuals with upper limb loss. A, A tabletop-activity competition using unbreakable
objects. B, Manipulation of fragile objects. C, Positioning of objects at the midline of the body.
D, Overhead reaching. (Courtesy of Rehabilitation Institute of Chicago, Chicago, IL.)
Figure 12
such as packing a suitcase (B). (Courtesy of Rehabilitation Institute of Chicago, Chicago, IL.)
Photographs showing the progression of prosthesis and terminal device control
Photographs showing the use of a shoulder disarticulation prosthesis for support in meal preparation (A) and for functional tasks,
Leisure Activities and Mobility
Many people with a unilateral or bilateral upper limb amputation wish
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
358
to resume driving an automobile and
can benefit from assessment or training by a certified driver rehabilitation
specialist (Fig ure 16). A therapist can
help individuals seeking to regain or
obtain a driver’s license. The therapist’s
assessment of preinjury activities can
determine whether adaptations are
needed for operating special equipment such as a lawn mower, a boat,
an all-terrain vehicle, or a tractor. The
therapist should inquire about leisure
pursuits and provide recommendations and training to allow a return to
preinjury activities. For those with a
specific avocational interest, referrals
to established resources or groups may
be appropriate. For many individuals,
a return to a preinjury activity such as
hunting, fishing, golfing, or swimming
can improve self-esteem and emotional
outlook (F i g u re 17). Some individuals
may benefit from information about or
exposure to Paralympic or other competitive adaptive sports activities. Notfor-profit organizations devoted to the
welfare of individuals living with an
amputation may be helpful in locating
local agencies.
Chapter 29: Upper Limb Prosthetic Training and Occupational Therapy
Figure 13
tation Institute of Chicago, Chicago, IL.)
Photograph showing training for tasks related to child care. (Courtesy of Rehabili-
The Effect of Prosthetic
Training on Outcomes
Promoting Long-term
Use of a Prosthesis
The goal of an occupational therapy
prosthetic training program is to facilitate the individual’s return to preinjury activities in the home, community,
school, and work environments. Sustained use of a prosthesis can be compromised if training is not provided
immediately after fitting and delivery
of a prosthesis. Structured sessions
can have a direct, measurably positive effect on the long-term use of a
prosthesis.
the effects of preprosthetic therapy on
prosthesis use, two groups of individuals with upper limb amputation were
compared. Members of the first group
received early occupational therapy
24-26
In a study comparing
Figure 14
heavy load (B). (Courtesy of Rehabilitation Institute of Chicago, Chicago, IL.)
and preprosthetic training lasting an
average 7.16 weeks from the date of
injury to the prosthetic fitting. Those
in the second group received delayed
prosthetic training of an average 41.04
weeks’ duration from the date of injury to the prosthetic fitting. One year
Photographs showing training in positioning and carrying a food tray (A) and a
after completing their program, 98%
of the members of the first group were
using their prosthesis, and 74% had
returned to work or school. Among
members of the second group, the per
centages were approximately 56% for
both outcomes.27 This study showed
-
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
359
Section 2: Upper Limb
Figure 15
M-nger (Partial Hand Solutions) cable-driven prosthesis being used by an individual to accomplish a task involving electrical wiring. (Courtesy of
Rehabilitation Institute of Chicago, Chicago, IL.)
Photographs showing the use of prostheses in job tasks. A, A body-powered transradial prosthesis used in tool manipulation. B, An
that early, aggressive preprosthetic
occupational therapy training leads
to improved outcomes for users of a
prosthesis.
Expediting Progress Toward
Prosthetic Goals
Frequent therapy sessions serve to reinforce and enhance learning and skill
retention related to prosthesis use. Clinical trials have reported on individuals
who underwent treatment two or three
times a week.
28,29
However, those who
received treatment 5 days per week for
2 to 4 hours each day made more rapid
progress in prosthesis use and daily
wear, which led to an earlier return to
work.
Individuals with difficulty in processing new information, those with
amputation at a high level, or those with
bilateral upper limb loss need additional
time to learn and implement self-care
techniques and to incorporate the movements and muscle function required for
operating the prosthesis. Some individuals can achieve successful prosthetic
Figure 16
eral prosthesis buckling a seatbelt. Training for driving resumption should progress from seatbelt
buckling to do or and steering whee l manipulation. (Courtesy o f Rehabilitation Institu te of Chicago,
Chicago, IL.)
Photograph showing a person with bilateral upper limb amputation and a unilat-
operation within the first 15 to 20 hours
of training, but others require a longer
period of occupational therapy.
30
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
360
Chapter 29: Upper Limb Prosthetic Training and Occupational Therapy
Figure 17
prostheses u sed to operate a hunting rie; inf ormation and training can mi nimize the need for change s to the gunstock. B, A unilateral prosthesis used
to operate a power saw. (Courtesy of Rehabilitation Institute of Chicago, Chicago, IL.)
Long-Term Considerations
Individuals with a traumatic upper limb
amputation are usually younger and
healthier at the time of injury than those
with a lower limb amputation.
completion of an upper limb prosthetic
occupational therapy program, scheduled, structured annual or semiannual
follow-up visits to an amputee rehabilitation team are useful to monitor the
need for prosthetic repair, replacement,
or upgrade; treat skin issues; minimize
pain from an overuse syndrome; and
preserve functionality throughout the
aging process.
Atrophy of the residual limb is exacerbated if the original amputation
required soft-tissue loss and skin graft
coverage. The identification of skin issues in the clinic can minimize time
away from prosthesis use and may provide justification for socket replacement
or a change in style or components. Individuals should be advised to contact the
rehabilitation team if a neuroma, skin
sensitivity, or overuse syndrome arises
between appointments.
Photographs show ing prosthesis use in activities that require good body-arm function and a high level of pros thetic skills. A, Bilateral
Life-Care Planning
Life-care plans are often required for
throughout the aging process and can
provide rationale for prosthetic changes.
individuals when a workers’ compen-
1,2
After
sation determination or legal claim is
involved. The occupational therapist’s
contribution to a life-care plan should
be based on general knowledge of upper
limb amputation and prosthetic devices
and detailed knowledge of the individual’s medical and emotional condition,
prosthesis use, and support system.
Acknowledgments
Hector Torres, BS IT, the author’s husband, and Bill Hickerson, MD, FACS,
the director of the Amputee Clinic at
Firefighters’ Burn Center, Memphis,
TN, are thanked for the support and
encouragement they provided during
the development of this chapter.
This information can inform decisions
related to funding for future medical,
prosthesis, and training needs over the
individual’s lifetime.
Summary
Preprosthetic and postprosthetic occupational therapy can foster a faster return to function for an individual with
upper limb loss. Immediate and frequent
occupational therapy after prosthesis delivery can enhance the incorporation
of the device into daily activities and
work tasks. Structured long-term fol-
References
1. Ziegler-Graham K, MacKenzie EJ,
Ephraim PL, Travison TG, Brookmeyer R: Estimating the prevalence
of limb loss in the United States:
2005 to 2050. Arch Phys Med Rehabil
2008;89(3):422-429. Medline DOI
2. Sheehan TP, Gondo GC: Impact of
limb loss in the United States. Phys
Med Rehabil Clin N Am 2014;25(1):9-
28. Medline DOI
3. Rondinelli RD: AMA Guides to the
Evaluation of Permanent Impairment,
low-up at an amputee clinic can assist
the individual with remaining function
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
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