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Section 2: Upper Limb
Tab le 1
Examples of Research Questions and the Recommended Applicable Measures (continued)
Field of Application Research
Question To Be Addressed ICF-Related
Component
How can we assess function for an individual with
upper limb loss/deciency not using a prosthesis?
c
AHA
b
COPM
b
GAS
How do we assess quality of life for an individual with
upper limb loss/deciency?
b
COPM
Disabkids
PedsQL
WHOQOL
A = Adult, ACMC = Assessment of Capacity of Myoelectric Control, AHA = Assisting Hand Assessment, COPM = Canadian Occupational Performance Measure, GAS = Goal Attainment Scale, ICF = International Classication of Functioning, Disability and Health, P = pediatric, PEDsQL =
Pediatric Quality of Life Inventory, PODCI = Pediatric Outcomes Data Collection Instrument, PUFI = Prosthetic Upper Extremity Functional Index,
QoL = quality of life, WHOQL = World Health Organization Quality of Life.
a
From Evidenced-based Review report and Upper Limb Prosthetic Outcome Measures Group
b
From Upper Limb Prosthetic Outcome Measures Group
c
From Evidenced-based Review report
Reproduced with permission from Miller LA, Swanson S: Summary of recommendations of the Academy’s State of the Science Conference. J
Prosthet Orthot 2009;21[suppl4]:83-89.
b
b
b
Function and activity P
Activity and
participation
Activity and
participation
Activity and
participation
N/A (related to QoL) P P
N/A (related to QoL) P
N/A (related to QoL) A
Development Clinical Patient
Care
P, A P, A
P, A P, A
P, A P, A
approach is required to care for a patient
with an upper limb prosthesis, and an
occupational therapist can be included
in the evaluation of the care plan. Many
outcome measures require specialized
training and/or the use of equipment
that often is available to an occupational therapist. Several outcome measures
are particularly relevant to the work of
a prosthetist.
Assessment of Capacity for
Myoelectric Control
The Assessment of Capacity for Myoelectric Control is based on observational
analysis of an adult or pediatric patient
with an upper limb prosthesis during
functional bimanual activities.
10,18
The
measure was designed to evaluate the
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
422
use of a myoelectric prosthetic hand but
has been applied to other types of prostheses and other levels of amputation.
A 4-point scale is used to evaluate 22
aspects of prosthesis use (for example,
the ability to hold an object over the
course of a task, with or without support; coordination with both hands; and
the ability to adjust grip force, with or
without visual feedback). Any bimanual
task can be evaluated, if it allows all 22
aspects of use to be observed. The use of
standardized activities in this measure
was recently validated.19 User scores are
entered into an online Rasch analysis to
generate an overall rating of myoelectric
control. In addition, prosthetists, therapists, and engineers are able to use the
Assessment of Capacity for Myoelectric
Control; however, raters are required
to complete a training course to obtain
certification. This measure has been
identified as appropriate in both patient
care and research settings, although the
amount of time required to use the tool
may be challenging for a newly certified
rater in the patient-care setting.
University of New Brunswick
Test of Prosthetic Function
The University of New Brunswick Test
of Prosthetic Function was specifically
developed to evaluate prosthesis use in
children with a unilateral upper limb
amputation.20 This observational function test was developed by an occupational therapist and an engineer to
measure the method and spontaneity of
Chapter 34: Outcome Measures in Upper Limb Prosthetics
Tab le 2
Upper Limb Prosthetic Outcome Measures Designated
as Recommended for Use or Appropriate to Consider
Measures Recommended by the
2009 State of the Science Conference or Later Recommended
Assessment of Capacity of Myoelectric
Control (pediatric and adult)
Canadian Occupational Performance
Measure (pediatric and adult)
Goal Attainment Scale (pediatric and
adult)
PODCI (pediatric) CAPP-PSI (pediatric)
PUFI (pediatric) Disabilities of the Arm, Shoulder and
Assisting Hand Assessment (pediatric) Southampton Hand Assessment
Diasbkids Questionnaire (pediatric) Sollerman Hand Function Test (pediatric
PedsQL (pediatrics) PUFI (adult)
World Health Organization Quality of Life
Assessment (adult)
Box and Blocks test (pediatric and adult) Patient-specic Functional Scale
Jebsen-Taylor Test of Hand Function
(adult)
Trinity Amputation and Prosthesis
Experience Scale (adult)
University of New Brunswick Test of Pros-
thetic Function (pediatric and adult)
AHA = Assisting Hand Assessment, CAPP-PSI = Child Amputee Prosthetics Project Prosthesis Satisfaction Inventory, PedsQL = Pediatric Quality of Life Inventory, PODCI = Pediatric
Outcomes Data Collection Instrument, PUFI = Prosthetic Upper Extremity Functional Index,
UBET = Unilateral Below Elbow Test, UEFS = Upper Extremity Functional Scale, UFI = Upper
Extremity Functional Index.
prosthesis use on a 5-point scale, and it
has been used in multiple studies.
4
The
test is suitable for use in children aged 2
to 13 years; four age-based modules are
designed to be developmentally appropriate for children within a 3-year age
range. The module for older children
has been validated for adult use.14 No
specific training is required to use this
test, and the tasks require only easy-to-
Measures to Consider, as
Designated by the 2009 State of
the Science Conference
Children’s Hand-use Experience
Questionnaire (pediatric)
UFI (adult)
AHA-prosthetics (pediatric and adult)
Hand Outcome Measure (adult)
Procedure (adult)
and adult)
UBET (pediatric)
(pediatric and adult)
Orthotics and Prosthetics Users’
Survey-UEFS (adult)
limb prosthesis.
8,15
This easily administered functional test evaluates gross
manual dexterity. Patients are asked
to transfer as many 1-inch blocks as
possible over a divider from one side
of a box to another, within a specified
time period (Figure 2). No specialized
training is required to administer the
test, and the necessary equipment can
be purchased or constructed.
obtain items.
Jebsen-Taylor Test of
Box and Block Test
The Box and Block test was recently validated for use in patients with an upper
Hand Function
The Jebsen-Taylor Test of Hand Function
is a seven-part timed dexterity test and
has been validated in other disciplines.21
The tasks include writing, flipping index cards, picking up small objects,
spooning beans into a jar, stacking
checkers, and moving light and heavy
cans (Figure 3). Each task is timed
separately. Recent validation work on
the Jebsen-Taylor Test of Hand Function (specific to prosthetics) resulted in
modification to the scoring method of
the original measure.15 Individuals using this measure may want to investigate
both the original and modified scoring
methods to determine which is most
appropriate for a specific application.
No specialized training is required to
administer the outcome measure, and
the necessary equipment can be purchased or made.
Southampton Hand
Assessment Procedure
The Southampton Hand Assessment
Procedure was designed to evaluate
the effectiveness of upper limb prostheses, but it has not yet been validated
because of funding difficulties and an
insufficient population size necessary
for validation; however, ongoing efforts
are being made to achieve validation.9
Nonetheless, this measure has been
widely used in recent prosthetic research. The tasks require manipulation
of eight light or heavy objects (abstract
tasks) and 14 simulated activities of
daily living (Figure 4). The purpose is
to evaluate hand function. Completion
of the tasks is self-timed by the user, and
scores are entered into a database that
generates an overall index-of-function
score. No specialized rater training is
required, but the equipment must be
rented or purchased from the University
of Southampton, England, as a condition of access to the database.
Trinity Amputation and
Prosthesis Experience Scale
The Trinity Amputation and Prosthesis
Experience Scale is a self-administered
measure originally designed to assess a
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
423
Section 2: Upper Limb
user’s adaptation to lower limb amputation and prosthesis use. Its scope has
been expanded to upper limb prosthesis
users. The self-reported questionnaire
has 54 items. Nine subscales assess
adjustment to prosthesis use (general
adjustment, social adjustment, and adjustment to limitations), activity restriction (restriction of functional, social,
and athletic activities), and user satisfaction with the prosthesis (satisfaction
with weight, function, and aesthetic
appearance).22 The user satisfaction
subscales have been validated for upper
limb prosthesis use.15 This measure can
be used to evaluate psychosocial topics
such as pain, perceived social reaction,
and satisfaction that are not included in
other functional measures.
22
Evaluation of User and
Clinician Goals
The Patient-Specific Functional Scale,
the Canadian Occupational Performance
Measure, and the Goal Attainment Scale
evaluate progress toward goals set by
the user and the clinician. One of these
measures may be more appropriate than
another for a specific application. The
Patient-Specific Functional Scale is the
simplest of the three measures to admin
ister. The user identifies five tasks perceived to be difficult and rates limitation
in performing each task on a 10-point
scale (range, 0 = unable to perform, 10
= no difficulty in performing).23 The
Canadian Occupational Performance
Measure is slightly more complex. The
user identifies goals in self-care, productivity, and leisure, which are rated
in terms of importance, user perception
of performance, and satisfaction with
performance.
24,25
The Goal Attainment
Scale originally was developed for use
in mental health settings and is the most
complicated of the three measures to
score. Five outcome levels are set for
each goal and are reassessed at predetermined times to determine progress
toward achieving the goal.
24
Figure 2
and Block test.
Photograph showing a man with an upper limb prosthesis participating in the Box
-
Figure 3
Function.
Photograph showing the small objects test of the Jebsen-Taylor Test of Hand
Other Measures of Interest
Although the Hanspal Socket Comfort
Score is not specifically validated for
upper limb prosthetics, it is an easily
administered outcome measure that has
been generally validated for prosthesis
users.26 Because of the importance of
socket comfort in the successful fitting
and use of a prosthesis, this outcome
measure may be useful in evaluating
new socket technology or socket design in a clinical or research setting.
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
424
Chapter 34: Outcome Measures in Upper Limb Prosthetics
Figure 4
abstract object task). B, Removing a jar lid (an activity of daily living task).
The Orthotics and Prosthetics Users’
Survey has two satisfaction subscales,
Satisfaction with Care and Satisfaction
Photographs showing two tasks from the Southampton Hand Assessment Procedure. A, Moving a lightweight cylindrical object (an
therapist. A team approach is likely to
improve overall outcomes and enhance
the benefit to patients.
with Device, both of which have been
validated for independent use and may
be useful in the clinical environment.
Summary
12
As prosthetic componentry continues
to evolve, so do the tools for assessing
Discussion
Some outcome measures are appropriate for use in both the research and patient-care settings, but there is no single
benchmark outcome measure. The research question must be framed before
selecting appropriate outcome measures
from a toolbox of recommended measures. Multiple sources are available to
assist in selecting an appropriate tool;
however, further research is needed to
determine which measures are suffi-
the effectiveness and use of devices.
Clinicians who need to evaluate up-
per limb prosthesis function should
continue to review the literature. New
measures are likely to be developed,
and existing measures will continue to
be vali dated for use in individuals with
an upper limb amputation. As research
pro gresses, it will be possible to answer
increasingly more complex research
questions through longitudinal studies
involving large populations.
ciently sensitive to evaluate users’ ultimate acceptance or rejection of a specific
prosthesis design.
3,4 ,6,7, 13,1 5,17, 24,2 7,28
If no
fully validated outcome measure exists,
other measures are available that have
been deemed worthy of consideration
by experts in the field. The use of many
of the recommended measures may require the involvement of an occupa tional
Acknowledgments
The recent work on upper limb prosthetic outcome measures has been a
group effort of occupational therapists,
engineers, physicians, and prosthetists.
The author would like to acknowledge
the dedicated work of the ULPOM volunteer group, participants in the State
of the Science Conferences, and funding
agencies that have supported the efforts
of the many investigators who are working to establish strong, clinically valid
outcome measures for users of upper
limb prostheses.
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Validation of the Orthotics and Prosthetics User Survey upper extremity
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with unilateral upper limb amputation. J Rehabil Med 2008;40(5):393-
399. Medline DOI
12. Heinemann AW, Bode RK, O’Reilly
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13. Miller LA, Swanson S: Summary and
recommendations of the Academy’s
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on Upper Limb Prosthetic Outcome Measures. J Prosthet Orthot
2009;21(9):P83-P89. DOI
14. Resnik L, Baxter K, Borgia M,
Mathewson K: Is the UNB test
reliable and valid for use with
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March 13, 2015.
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AC: Intra- and inter-rater reliability
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Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
426
Atlas of
Amputations and
Limb Deficiencies
Atlas of
Amputations and
Limb Deficiencies
Surgical, Prosthetic, and Rehabilitation Principles
Fourth Edition
Volume 2
Lower Limb
Management Issues
Editors
Joseph Ivan Krajbich, MD
Michael S. Pinzur, MD
LTC Benjamin K. Potter, MD
Phillip M. Stevens, MEd, CPO
Section 3Section 3
Lower Limb
Chapter 35
Lower Limb Prosthetic Components: Updated
Classication and Passive, Body-Powered Components
John W. Michael, MEd, CPO, FAAOP Phillip M. Stevens, MEd, CPO, FAAOP
Abstract
e range of commercially available lower limb prosthetic components continues to expand. e selection of appropriate components is made easier through the classication
of components according to their design and function. is classication process begins
with delineations between passive, body-powered components; the use of microprocessor
control; and the more recent development of active, externally powered components. It is
helpful to be familiar with the classication of current passive, body-powered prosthetic
foot/ankle units and passive, body-powered knee systems.
Keywords: lower limb prosthesis; prosthetic components; prosthetic
feet; prosthetic knees
Introduction
The range of commercially available
lower limb prosthetic components continues to expand with each passing year.
Although this expansion offers patients
and their rehabilitation teams greater
selection in prosthetic options, the number of choices may be overwhelming if
these options are not grouped into a logical classification scheme. The purpose
of this chapter is to propose a classification method that reasonably captures
the current diverse range of lower limb
prosthetic components. The chapter
also will address those components that
can be reasonably described as passive,
body-powered devices.
Classification
Considerations
The clinical classification of prosthetic components for prescription and
teaching purposes has continually
evolved as available technology has
advanced. In 1965, Earl Lewis1 noted
the following: “The relatively recent
introduction of fluid-controlled knee
mechanisms…has raised a number of
important considerations for clinicians.”
After explaining the biomechanics behind the higher level of performance of
cadence-responsive hydraulic and pneumatic knees, Lewis suggested the following: “The prescription process may have
to consider these two levels of performance.” The now widely accepted division of prosthetic knee components into
those with purely mechanical friction
versus those offering velocity-responsive
fluid damping reflects these insights.
In recent decades,2 worldwide acceptance of microprocessor-controlled
(MPC) lower limb components suggests
that it may now be useful to expand the
clinical classification to reflect contemporary advancements in function and
control for lower limb devices. Torrealba
et al3 proposed adding the concepts of
active movement and microprocessor
control to better characterize currently
available prosthetic knee components.
Mechanically Passive Devices
Prior to 2006, all commercially available lower limb prosthetic components,
including MPC knees at that time, were
mechanically passive (the wearer’s physical effort during ambulation causes motion). Applying an analogy from upper
limb prosthetics, these are body-powered designs, where all energy input
comes from the user’s force generation,
momentum, body weight, and similar
internal activation sources.
For example, flexion and extension
of the prosthetic knee joint occurs when
the transfemoral residual limb moves
the socket by means of hip joint motion.
The necessary compensations to induce
such motion—using the residual limb,
more proximal joints, the contralateral
leg, and the head/arms/trunk—have
been well documented4 and are believed to contribute to gait inefficiency
that progressively increases with more
proximal levels of amputation.5 Experts
also are increasingly cognizant of the
strain such compensations place on
the individual and the increased risk of
overuse syndromes.
6
Mr. Stevens or an immediate family member serves as a paid consultant to or is an employee of
Hanger Clinic and serve s as a board member, owner, ocer, or committee member of the Amer ican
Academy of Orthotists and Prosthetists. Neither Mr. Michael nor any immediate family member
has received anything of value from or has stock or stock options held in a commercial company
or institution related directly or indirectly to the subject of this chapter.
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
MPC Devices
Lower limb prosthetic components
with MPC activation have been commercially available since the release of
429
Section 3: Lower Limb
Tab le 1
Classifying Lower Limb Prosthetic Components
Into Functionally Similar Performance Categories
Design Characteristics Historic Methods Modern Methods
Movement damping Mechanical friction Fluid friction (1960)
Control method Mechanical design Microprocessor controlled
Movement generation Passive (body-
Force generation (during
ambulation)
a
Components with these design features generally result in a more normal gait pattern during
ambulation with a prosthesis than components without these features.
b
Date of the rst commercially available product in the United States.
the Intelligent Prosthesis (Blatchford
& Sons) in 1990 and have been shown
to offer clinical advantages compared
with mechanically controlled alterna-
2,7
tives.
However, most MPC knees sim-
powered)
Apropulsive Propulsive (2006)
muscle contractions to move a lower
limb device. Applying an analogy from
upper limb prosthetics, this was the first
example of an externally powered lower
limb component.
b
(199 0)
Active-external power (2006)
a
b
b
ply dampen motion by using software
algorithms, which has a modest effect on
gait efficiency. For example, the original
Blatchford Intelligent Prosthesis used
its microprocessor to vary only pneumatic swing phase flexion resistance.8
The clinical use of MPC knees became
more widespread after the C-Leg (Ottobock) added effective MPC hydraulic
stance stability damping in addition to
MPC hydraulic swing phase flexion and
extension damping.9 Since then, additional passive MPC prosthetic knees
have become available, and the benefits
of simulating eccentric muscle control
during gait in this manner have been
reported.
2,10
Force Generation
In 2006, the Power Knee (Össur) was
released. This knee is capable of flexing
and extending the prosthetic knee joint
during the stance and swing phases.
This was the first available component
that generated sufficient force to actively raise a user’s center of mass during
normal activities of daily living, such
as ramp and stair descent.
12
More recently, BiOM released a powered ankle-foot system that generates
enough force to actively propel a user’s center of mass during ambulation.
Preliminary studies suggest that generating forces of this magnitude at the
ankle during stance can increase gait
Active Lower Limb Devices
In 2006, Össur released the first mechanically active lower limb prosthetic
efficiency with a prosthesis considerably
more effectively than was previously
possible.
13
component: an MPC component with a
motor powerful enough to move the joint
in the sagittal plane during the swing
phase. The Proprio ankle/foot system
(Össur) changes the plantar-dorsiflexion
position of a carbon fiber foot during
the swing phase to enhance gait mechanics and safety for the wearer.11 For
the first time, a commercially available
component could simulate concentric
Categorization Proposal
Design improvements since 1960 require modifications in the categorization of lower limb components to reflect
the substantial biomechanical improvements resulting from major technologic advances. In addition to the familiar
classification of mechanical components
according to whether they include fluid
control, today’s clinician must consider
the growing number of MPC prostheses and the potentially higher function
they can provide. Although most lower
limb components are currently passive
devices, the recent availability of active
devices that simulate concentric mus-
a
cle control opens up new possibilities
for reducing the effects of lower limb
amputation on human function. Those
components with sufficient power to
add meaningful propulsion to gait seem
particularly promising and warrant further clinical application and research
investigation.
Table 1 shows the proposed clinical
categorization of lower limb prosthetic
components. This chapter focuses only
on the pre-MPC era of mechanical and
fluid-controlled components.
Passive, Body-Powered
Prosthetic AnkleFoot Mechanisms
Passive ankle-foot mechanisms that are
controlled only by their mechanical design have been historically classified into
a few conceptual groups based on their
overall biomechanical performance (Ta-
ble 2). Research consistently documents
that these components result in an apropulsive gait characterized by a lack of
ankle power generation in late stance.
This simplified classification remains
useful because the numerous commercially available components within
each conceptual group have very similar
indications and limitations, making it
relatively easy to rule out poor choices
and generate a functionally appropriate
prescription recommendation.
Solid Ankle Cushion Heel Foot
The Solid Ankle Cushion Heel (SACH)
foot has the most biomechanically
simple design. With its nonarticulated
ankle and the lack of complex internal parts, it is one of the lightest, lowest cost, and most durable options for
limited household ambulators. In the
United States, Medicare recognizes the
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
430
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