Essential Therapy Interventions

People with upper limb loss or a congenital limb difference make up the smallest subset of the amputee population—less than 10 percent worldwide.

Because this group is statistically small, therapists receive limited education on the rehabilitation needs of upper limb amputees. As a result, when seeing these patients in acute, subacute or outpatient settings, therapists may be unsure of how to best assist them. With more than 20 years of experience focusing on people with upper limb loss, our therapy team is available as a helpful resource for therapists who would like to know more about the rehabilitation process.

Trauma is the most common cause (see introduction) of upper extremity amputations. This is a significant difference from lower limb loss, where the leading cause is disease and the amputation is often a planned surgical intervention. The experience of trauma can magnify the psychological impact of limb loss, resulting in issues with anxiety, depression and substance abuse.

Therapists are trained to address both the physical and psychosocial impact of traumatic injury. The early involvement of a therapist gives patients professional support and guidance to cope with their injury and begin the process of recovery. Initially, therapists can assist with care of the residual limb, including pain management, swelling, shaping and stretching. They also help patients maintain their range of motion, endurance and strength. If a patient needs more psychological support, the therapist can refer them to a counselor or support group.

Connecting patients with resources for upper limb prosthetic rehabilitation is another key service that therapists provide. As they learn more about what to expect, patients begin to set goals and make informed decisions about their care. Upper limb prosthetic rehabilitation is a challenging process, and patients experience better outcomes (see introduction) when an occupational or physical therapist is available to help them integrate a prosthesis into their life.

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Post-Operative Rehabilitation

In a post-operative setting, some patients may have consulted with an upper limb prosthetist prior to surgery. However, for patients with traumatic amputations, that is not typically the case. Upper limb amputees should be encouraged to meet with upper limb prosthetic specialists as soon as possible. The consultation can take place while the patient is hospitalized or may be scheduled to happen later, after they’ve returned home. This initial discussion is an opportunity for the patient and their family to learn about the range of prosthetic options and the prosthetic rehabilitation process, see actual devices and ask questions. Upper limb prosthetic specialists can also provide information and resources to the therapists who are assisting these patients during hospitalization.
 
The Arm Dynamics clinical team understands the importance of patient-centered care that includes the patient’s doctor, local therapist, psychologist or counselor, nurse case manager and insurance representatives. This collaborative team approach (pg.8) provides each patient with a prosthetic rehabilitation plan that can dramatically improve their functional ability and overall quality of life.
 
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Therapists who work with patients postoperatively provide many early interventions to help prepare the patient to wear and use a prosthesis:

  • Wound healing and scar management: Healing and closure of wounds is required prior to prosthetic intervention. Ensuring that scar tissue remains mobile and non-adherent is critical to prevent potential shearing of skin after prosthesis fitting.

  • Pain management: Traditional therapeutic approaches include desensitization protocols and modalities as well as graded motor imagery and mirror therapy. These can be introduced as part of an interdisciplinary approach.

  • Edema control and limb shaping: Swelling contributes to pain. It should be addressed immediately with strategies that include compression with ACE™ wraps and Compressogrip® tubing. It’s important to ensure that compression is applied in a way that improves limb shaping for future prosthesis fitting. This includes attention to graduated reduction of pressure from distal to proximal anatomy.

  • Maladaptive movement: New amputees may quickly develop poor body mechanics such as shoulder hiking, or holding the residual limb in a protective pattern that restricts shoulder rotation and elevation. Partial hand/finger amputees may avoid using shortened digits or the hand as a whole. The therapist should offer corrective guidance to improve body mechanics and reduce tension in the neck and the remaining joints of the arm.

  • Range of motion, strength and activity tolerance: To counteract deconditioning, the therapist should introduce exercise programs as soon as the patient is able to participate. Emphasis should be placed on maintaining range of motion, maintaining/building strength and encouraging endurance.

  • Hand dominance retraining: The patient should be introduced to strategies that make it easier to change hand dominance. It’s likely that the prosthesis will be used in an assisting/stabilizing role, and the uninjured hand will become dominant even if it was previously the non-dominant side.

  • Preventing overuse injuries: One of the goals of prosthetic rehabilitation is protecting the remaining upper limb from overuse since the person will need to rely on it for the rest of their life. Before prosthetic fitting, therapists introduce adaptive equipment to assist with activities of daily living and vocational tasks. They may also guide patients to begin using their residual limb to assist with tasks like bringing a cup or bowl to their mouth, basic grooming and dressing.

Prosthetic Rehabilitation

Prosthetic rehabilitation begins the first time a patient consults with an upper limb prosthetist, which may have been during hospitalization or in-patient rehabilitation. It continues after the patient has received a prescription for prosthetic care and is physically ready to initiate the fitting process. Upper limb prosthetic rehabilitation is both challenging and exciting. The patient starts to see how an upper limb prosthesis can help them regain independence and begin moving toward a new normal, but it can be confusing. It requires the patient to process a lot of new information, including how to:

 
  • Don and doff the prosthesis
  • Operate all of the components in their device
  • Care for the prosthesis and their residual limb
  • Implement a gradual wear schedule to build tolerance
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Going to a prosthetic care center may give the patient an opportunity to meet and talk with other amputees, some of whom are further down the road in the rehabilitation process. At our Arm Dynamics centers, new patients are often introduced to their peers and are able to see videos of prosthetic users who have a similar amputation level and prosthetic device. Peer support and discussion (pg. 14) are critical factors in successful upper limb prosthetic rehabilitation.

Before prosthetic fitting begins, the patient should be informed of the range of prosthetic options that are available. The patient and prosthetist discuss the activities the prosthesis will be used for in order to determine what type of device is most appropriate for the individual. Our Arm Dynamics clinical therapy specialists play a key role in the discussion of prosthetic options. Once a device is selected, a request for authorization of prosthetic rehabilitation is then submitted to the insurance provider.

The initial fitting is for a preparatory prosthesis that will be used to test and perfect the fit of the socket and the design of the prosthesis. The preparatory device allows the patient to feel what it’s like to wear a prosthetic limb. The final, or "definitive," fitting is when the patient receives the optimized version of the prosthesis that they’ll use for several years. Throughout the fitting process, Arm Dynamics patients receive prosthetic training from a therapist who specializes in upper limb prosthetics.

After patients receive their definitive prostheses, they often return to the care of a local therapist. This is an ideal time for local therapists to connect with an Arm Dynamics therapist to ensure a smooth transition of care and support successful use of the prosthesis in daily life.

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Lifelong Care & Follow-Up

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Upper limb prosthetic patients benefit from lifelong care. When a patient receives their definitive prosthesis and functional training from our Arm Dynamics clinicians, they’re contacted at regular intervals to check on their progress and offer assistance as needed.

We recognize the importance of professional collaboration. When a referred patient completes their expedited fitting and training process, our clinical therapy specialists make themselves available to collaborate with the patient’s local therapist to provide continued resources and guidance on:

  • Modifications to the patient’s home or place of work
  • Assistive devices that make self-care and daily activities easier/safer
  • Locating driver training and vehicle modification services
  • Helping the patient re-engage in community activities, recreation and hobbies
  • Optimizing use of their prosthesis for activities of daily living and vocational tasks

Prosthetic success rates improve dramatically when therapists focus on activities that relate to the patient's specific vocational and recreational interests. Our therapists may visit the patient’s workplace to guide them on how to efficiently use their prosthesis on the job, or collaborate with a patient’s local therapist so they can provide optimal support to their patient.

Over the course of a lifetime, the patient’s entire care team will help them adapt to shifts in lifestyle and health, and provide regular updates to their prosthesis to meet changing needs.

If you’re an occupational or physical therapist and would like to learn more about prosthetic options for all levels of upper limb loss, please consider participating in a continuing education course with the Arm Dynamics therapy team.

To find out more about initiating prosthetic rehabilitation for your patient, complete and submit the ‘Drop Us a Line’ form at the bottom of the page.