JHT READ FOR CREDIT ARTICLE # 090

Managing the Upper Extremity Amputee:A Protocol for Success

TREATING THE WAR CASUALTY

CPT Lisa M. Smurr, OTR/L, CHTUnited States Army Health Clinic e Schofield Barracks,Schofield Barracks, Hawaii

Kristin Gulick, OTR/L, BS, CHTAdvanced Arm Dynamics, Portland, Oregon

MAJ Kathleen Yancosek, MS, OTR/L, CHTWalter Reed Army Medical Center, Washington, DC

Oren Ganz, MOT, OTR/LWalter Reed Army Medical Center, Washington, DC

As stated by Dillingham ‘‘the care of amputees is amajor problem facing any Army during wartime.’’2

The significant trauma experienced in battle resultsin substantial numbers of upper and lower extremityamputees. History demonstrates that these numbersfar outweigh those seen in civilian medicine. Forthis reason, amputee care in the military must remainat the forefront of technology, maintaining its readi-ness to assume the full care of treating Service mem-bers with a limb loss.1 The rehabilitation teams atWalter Reed Army Medical Center (WRAMC) inWashington, DC and Brooke Army Medical Center(BAMC) in San Antonio, TX have paved the way indevelopment of a comprehensive upper extremityamputee protocol. As of January 2007, there havebeen a total of 541 major limb amputations seenand of this population there have been 111 unilateral

Disclaimer: The views expressed in this abstract/article are those ofthe author(s) and do not reflect the official policy or position of theDepartment of the Army, Department of Defense, or the U.S.Government.

Correspondence and reprint requests to Lisa M. Smurr, OTR/L,CHT, United States Army Health Clinic e Schofield Barracks,Schofield Barracks, 95-1007 Kuauli St. #144 Mililani, HI 96789;e-mail: <lisa.smurr@us.army.mil>.

0894-1130/$ e This is a US government work. There are no restric-tions on its use.

Published by Hanley & Belfus, an imprint of Elsevier Inc.

doi:10.1197/j.jht.2007.09.006

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ABSTRACT: Since the beginning of Operation Enduring Freedomand Operation Iraqi Freedom, over 541 clients with major limb am-putations have been seen in the Military Healthcare System. As aresult of the nature and severity of injuries and the prevalence ofconcomitant injuries seen in this population, amputee care has be-come a specialized type of rehabilitative care at Walter Reed andBrooke Army Medical Centers. To streamline and accommodatethe needs of clients with upper extremity limb loss, a five-phasedupper extremity amputee protocol of care was developed. Thefive phases of the protocol include acute management; prepros-thetic training; basic prosthetic training; advanced prosthetic train-ing; and discharge planning. For the readers ease, these phases willbe presented in the following categories: acute care, subacute care,and long-term rehabilitation needs. Furthermore, this article seeksto offer insight into the ideal treatment of an individual with upperextremity limb loss based on experience and collective expertise ofthe authoring therapists.

J HAND THER. 2008;21:160–76.

upper limb amputees, 6 bilateral upper limb ampu-tees, and 13 combined upper and lower extremityamputees.1 Of the clients treated, 43 military person-nel have returned to active duty, 10 of which havebeen individuals with upper extremity limb loss.2

In the civilian sector, trauma is the leading cause ofupper extremity amputations (90%) and other causesinclude burns, peripheral vascular disease, neurolog-ical disorders, infections, malignancies, contractures,and congenital deformities.3 The causes of military am-putee injuries include mortars, gun munitions, impro-vised explosive devices (IEDs), and rocket propelledgrenade launchers. As a result of such high forces, ve-locities, and temperatures at the time of injury, mostcombat injured personnel seen at military medical fa-cilities have also sustained other concomitant injuriesin addition to amputation(s). Concomitant injuriesrange from traumatic brain injury to visual loss, hear-ing loss, massive soft tissue loss, fractures, and nerveand vascular damage. Frequently, multiple extremitiesare involved and although injuries may be similar, notwo clients are alike.

The environment for amputee rehabilitation atWRAMC and BAMC is ideal. Prosthetists specializ-ing in upper extremity prosthetics are present onsite working jointly with occupational therapists(OTs) and occupational therapy assistants in thecare and management of upper extremity amputees.Additionally, clients stay on the campus of each

facility while they undergo comprehensive rehabil-itation and reintegration into the community withtheir prosthesis.

A standardized, comprehensive, five-phased pro-tocol of care was developed to address the uniquerehabilitation needs of combat wounded individuals.Phase 1 addresses acute management and woundhealing; phase 2 marks the introduction of prepros-thetic training; phase 3 embarks on prosthetic train-ing; phase 4 focuses on advanced functional training;and phase 5 involves discharge planning. Overlapoccurs between each phase to allow flexibility ofclient progression based on severity of injuries,wound healing, and client tolerance. Throughouteach phase care is individualized to meet the needsof each client. As the client becomes medically stable,occupation-based goals are established. A differentaspect of therapy is introduced within each phase tohelp the client progress to full recovery. The goal forrehabilitation of the upper limb military amputee isprovision of the necessary skills and tools required toachieve prosthetic acceptance and reintegrate psy-chologically, socially, and physically back to themilitary unit or to civilian life.

For the purposes of this article, we have introducedthe management of the upper limb amputee from theacute treatment, subacute treatment, and long-termplanning needs. The objective of this article is forhand therapists to gain a general understanding ofhow to manage an upper extremity amputee througha client-centered approach to rehabilitation.

ACUTE MANAGEMENT

When managing an amputee acutely, the rehabilita-tion goals are to promote healing of the residual limbwound; achieve independence in self-feeding, toilet-ing, and oral hygiene; and provide the client and familyeducation on the rehabilitation process. This phasebegins at the time of injury and continues until allwounds have successfully closed and are free of infec-tion. The length of time spent in this phase variesdepending on the extent of the client’s injury. Clientsand family members are introduced to rehabilitativeand prosthetic services in the early stage of this phase. Itis imperative that these interventions begin early on toease client and family member’s fears, provide supportthroughout the grieving and recovery processes, andengage the client and family with the rehabilitativeteam. The components of this phase include compre-hensive evaluation, wound healing, edema control,desensitization and scar management, pain control,gross motor activity, and psychological support.

Evaluation

An orthopedic OT evaluation is administered ina holistic approach to obtain baseline information

of the client’s physical and emotional status. Theevaluation includes the client’s current status, back-ground, abilities, and future goals. Medical history isobtained with special attention to all injuries thatimpact inpatient care and injuries that impact theclient’s long-term goals. The evaluation includes anin-depth information gathering interview with theclient and family members to identify premorbidlifestyle, hand dominance, educational level, voca-tion, and recreational interests. The client’s currentliving situation is reviewed to determine the level offamily support available and any physical/environ-mental limitations, which may now pose problem-atic. Current medications and the client responses tothese medications are documented. It is critical toscreen each client’s psychosocial status to appropri-ately gauge treatment intervention.

The physical components of this evaluation in-clude assessment of the upper quadrant range ofmotion on the affected and unaffected sides; bilateralmanual muscle testing; limb volume measurement;wound description; scar evaluation; and sensitivityof the residual and intact limb. It is important todetermine the residual limb sensation as hyposensi-tivity or hypersensitivity is the necessary consider-ation in fabrication and fitting the prosthetic socket.The evaluation includes a thorough determinationof pain of the residual limb, phantom pain, andphantom pain as it differentiates from phantomsensation. Additionally, a functional evaluationsimilar to the Functional Independence Measure�(Uniform Data System for Medical Rehabilitation,Amherst, NY) is completed.

Prehension evaluations are performed as appropri-ate for each client to determine baseline function ofthe remaining limb as a sound limb will be responsiblefor performing all fine motor and dexterity tasks forvocational and leisure purposes. Common evalua-tions include Jebson-Taylor hand function evaluation;Minnesota Rate of Manipulation Test, Boxes andBlocks, and Nine Hole Peg tests.

Basic Self-care Activities of Daily Living

Training in self-feeding, toileting, and oral hygieneare introduced as soon as possible. Various commer-cial and custom adaptive equipment aids are pre-sented to facilitate independence in these areas, asnecessary. Regaining a sense of independence withbasic self-care tasks can assist the patient immenselyin their recovery both physically and psychologically.

Wound Healing

Due to the nature of explosive and thermal injuries,the wounds that remain are heavily contaminatedand are left open to allow for multiple washouts inthe operating room. This reduces the risk of infection

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and further tissue damage. Depending on the typeand size of the wound, various procedures to pro-mote healing are used to include the use of drains,intraoperative antibiotic bead placement, or negativepressure wound therapy through the vacuum-assistedclosure systems. A figure of eight wrap is used fordistal-to-proximal compression and shaping over thehealing distal aspect of the residual limb. Once thewound stops seeping, the client progresses to a sewnCompressogrip� sleeve (Alimed, Dedham, MA),which is tapered at the distal end of the residuallimb. As the wound closes and the mature scar tissueforms, the client is instructed in the wear of a siliconeliner that provides continuous force compression withthe added benefit of minimizing scar.

One of the goals for the client, or their familymember as appropriate, is to be able to indepen-dently don and doff compression garments. Thecompression garments are changed frequentlythroughout the day to maintain consistent concentricpressure distally to proximally on the residual limb.Edema control measures are implemented to assist indecreasing limb volume to prepare for fitting of apreparatory prosthesis.

Desensitization

Desensitization begins with the use of the afore-mentioned compression techniques, massage, tap-ping, and the use of texture bins for immersion ofthe hypersensitive limb. Desensitization is performed20e30 minutes three times per day as the client’s skinand scar tolerates. It is imperative that the client’sresidual limb not be hypersensitive as this will de-crease their tolerance to wear of the prosthetic socket.Clients and family members are also instructed in selflimb massage and desensitization outside of the clinicas this is such a critical part for success.

Pain Control

The pain experienced after an amputation can bebroken into two distinct categories: phantom limbpain and residual limb pain. Phantom limb pain isdescribed as pain in an absent limb or portion of alimb.4 Residual limb pain is described as pain in thepart of the limb left after the amputation.5 Althoughthese types of pain are distinct, there are commonand unique treatment approaches for management.

Regardless of the type of pain, management beginsin the immediate postoperative status with a patient-controlled analgesia (PCA) pump and is continuedusing long-acting opioids after discharge of thePCA. Short-acting opioids can be used for break-through pain. Anticonvulsants, tricyclic antidepres-sants, and nonsteroidal anti-inflammatories arefrequently also used. Appropriate therapeutic inter-ventions and modalities for managing both types of

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pain include the use of transcutaneous electricalnerve stimulation, ice, heat, massage, functional tasksto encourage normal motor pattern of the painful ex-tremity, desensitization, and continuous psychologi-cal support through the therapeutic use of self. Theuse of a mirror box in which the uninvolved side isvisually reflected as the missing side, has been shownto decrease phantom limb pain in some cases by Dr.Ramachandran and colleagues.6,7 Interventions forpain control are continuous through the multiplephases of rehab.

Phantom sensation is frequently experienced inamputee recovery. Phantom sensation is defined asany sensory phenomenon except pain, referred to anabsent limb or portion of a limb.5 The occurrence ofthis type of sensation can be very concerning to cli-ents; however, it is important to reassure them thatthis is a normal experience and it may change overtime.

Gross Motor

Gross motor refers to range of motion and bodysymmetry. After limb loss, the client frequently com-pensates with shoulder elevation on the affected side.To prevent additional postural compensations, visualfeedback is provided using a mirror during theperformance of basic range of motion exercises toproximal joints on bilateral sides.

Psychological Support

Psychological support is integral for successfulrehabilitation and it begins during the first interac-tion with the client. From the therapeutic standpoint,psychological support encompasses client and familyeducation throughout the recovery process, life skillsmanagement, and the therapeutic use of self.

Psychological issues frequently seen in an amputeepopulation include fear of the unknown; loss of self-esteem; loss of self-confidence; fear of rejection; andloss of occupational roles. Providing therapeuticintervention is not solely provided by the therapistbut by the team as a whole. Methods of psychologicalsupport include education on the rehabilitative pro-cess to allay fears of the unknown; reinforcement ofthe client’s personal style; reassurance of normalcy ofthe client’s response to amputation; engagementin empathetic interaction with both the client andfamily; provision of an amputee peer visitor trainedthrough the Amputee Coalition of America�

(Amputee Coalition of America�, Knoxville, TN);involvement in preventative medical psychiatry;engagement in weekly therapeutic outings; andhelping the client ascertain life skills to successfullytransition to ‘‘real life’’ after hospitalization.

In the acute stage, the client is supported appro-priately as their needs change. Therapists provideintroductory education on the rehabilitation process,

reassurance that the client can return to a successfuland productive life that he or she may choose,encouragement to engage in meaningful occupa-tions, reassurance of normalcy of feelings throughoutthe initial and subsequent stages of emotional andphysical recovery, and therapeutic use of self toengage the client in their recovery process.

SUBACUTE MANAGEMENT

Approximately, two to three weeks after injurydepending on medical circumstances, concomitantinjuries, and the ability to perform self-care in acontrolled living environment, Service members maybe discharged from inpatient status. Management ofthe amputee during the subacute phase encompassespreprosthetic, prosthetic, and advanced prosthetictraining.

Preprothetic Training

The rehabilitation goal of preprosthetic training isto prepare the client and their limb to receive a correctfitting and functional prosthesis. This begins uponwound closure and ends with acquisition of a pre-paratory prosthesis. Time spent in this phase variesdepending on changes in limb volume, sensitivity,ROM, physical condition of the residual limb, and theclient’s psychological status; therefore, portions ofacute management continue as necessary to addressthese deficits.

The client requires additional psychological sup-port from therapy as they progress emotionally from‘‘combat’’ survival mode, through the awareness thatthey have survived a combat-related injury, to therealization that they will have to live with an alteredbody throughout the rest of their life. It is imperativethat psychological support is continued and modi-fied to appropriately respond to the rapidly changingneeds of the client as they advance through thegrieving process. Education is provided regardingthe extensive possibilities of function with a prosthe-sis. Part of this education may include providing arealistic picture of prosthetic function as clients havevarying perceptions of a prosthesis from that of apicture of Captain Hook to the opposite extreme of anunrealistic superhuman bionic arm. Psychologicalsupport is further enhanced by the addition of apeer support or peer visitor, which provides a signif-icant aid in coping for the client.

It has been the experience of this rehabilitationteam that the client rapidly progresses through thegrieving process once preprosthetic training is initi-ated. The supportive psychological services avail-able, the therapeutic milieu, participation with otherclients or peers with limb loss, and the performanceof occupation-based activities in an environmentpromoting recovery provide the basis to achieve

psychological healing. Clients who overcome thegrieving process frequently begin to verbalize ordisplay their injury in a humorous light. Clientspurchase and wear various clothing paraphernaliawith sayings such as ‘‘dude where’s my leg,’’ or‘‘IEDs suck.’’ Although many of the statements are acrude representation of humor, it is a valuable clinicalsign that the client has ‘‘broken through’’ the grievingprocess, entered the acceptance phase of recovery,and is able to project humor in regard to amputation.

Postural Exercises and Strengthening

In addition to maintaining upper quadrant rangeof motion, it is necessary to introduce postural exer-cises for body symmetry and upper quadrantstrengthening. Clients participate in physical therapyto achieve improved trunk and lower body flexibilityand strength as well as aerobic condition. Emphasis isplaced on educational awareness of altered bodypatterns with use so as not to develop incorrectpostures that may lead to cumulative trauma oroveruse injuries of the upper extremities, neck, orback. The client is educated on the signs and symp-toms of various cumulative trauma disorders and isencouraged to seek initial medical attention early onif theses signs or symptoms develop. Little informa-tion has been published on the prevalence of overuseinjuries in the upper limb amputee population;however, a small study published by Jones andDavidson8 found overuse injuries were much morecommon in the unilateral amputee population thanthe nonamputee population.

Body symmetry awareness training often beginswith observation of static postures in front of a mirrorand is rapidly progressed to dynamic postural aware-ness by incorporating the use of a mirror duringtherapeutic dynamic activities. For example, the cli-ent performs exercises and tasks in front of a mirrorand the therapist provides additional verbal andtactile cues as necessary. The client is encouraged touse muscle memory to re-learn correct posturalcontrol during activity outside of the clinic.

Isometric and isotonic strengthening exercises areinitiated with the use of a mirror to provide the clientvisual feedback on proper form. Strengtheningequipment is modified as necessary to allow for theuse of the residual limb. Scapular stabilization exer-cises and core strengthening are also introduced tosupport good posture. In addition to strengthening,the client participates in aerobic conditioning regime.

Activities of Daily Living, AdaptiveEquipment, and Change of Dominance

As wounds heal, the client progresses to morecomplex activities of daily living (ADLs) such asshowering, facial hygiene, dressing, simple meal

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prep, and laundry activities. To aid in independence,the client is trained in compensatory techniques inaddition to the introduction of a wide array ofcommercial and custom adaptive equipment.Ultimately, each client chooses the method(s), whichwork most effectively for him or her. Most clientsprefer to minimize the number of adaptive aids thatthey use due to the constrictions equipment may posefor flexibility in task performance in different envi-ronments. Focus is specifically placed on the clientmastering independence in one-handed ADLs asthere will be times when the prosthesis is unavail-able. The client must have mastery in performingone-handed ADLs independently, efficiently, andergonomically correct to avoid the possibility ofdeveloping cumulative trauma disorders. As masteryin basic ADLs is found, the client begins to exploreinstrumental ADLs.

Change of hand dominance training is introducedas necessary. On the basis of the limitation of finemotor prehension capabilities of any available pros-thesis, it is important to teach the client change ofdominance in handwriting to ensure one-handedindependence. Some clients perform this task withhesitation as they hope to use the prosthesis toperform writing tasks. Time will be spent for abilateral upper extremity amputee to gain necessaryskills for writing with a prosthesis using a hookterminal device (TD). Fine motor activities usedinclude use of tweezers, spray bottles, twisting capson and off, twisting nuts on and off of bolts, lacingactivities on a vertical surface, and rolling putty balls.These types of activities encourage radial digit coor-dination, separation of radial and ulnar sides of thehand, and wrist extension. These are necessary motorcomponents of handwriting. The client is instructedin rote penmanship exercises using progressive mo-tor writing activities culminating in sentences with atleast one character each from the alphabet: ‘‘Thequick brown fox jumped over the lazy dogs.’’ Clientsalso spend time learning one-handed keyboarding tofacilitate success in computer operations. All therapytasks aim to improve overall fine motor control, handcoordination, and dexterity skills.

Myosite Testing and Training

Due to the rapid medical evacuation of a Servicemember from the battlefield to WRAMC or BAMC,early and aggressive prosthetic rehabilitation is pos-sible. For this reason, Service members are fit withelectric prosthetic systems that create less shear forceand end bearing forces on the healing residual limb.In instances where early prosthetic fitting is notpossible, the residual limb will require furtherpreparation for either a body-powered or electricprosthesis. Many Service members are fit with anactivity-specific prosthesis, which allows them to

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participate in meaningful leisure and recreationalpursuits or interests.

Research has demonstrated that individuals fitwith a prosthesis within 30 days of amputationexhibited a 93% rehabilitation success rate with a100% return to work rate within four months ofinjury and those fit beyond 30 days exhibited a 42%rehab success rate with a 15% return to work ratewithin six to 24 months.9 This 30-day period istermed the ‘‘golden window.’’10 The extensive multi-ple injuries incurred during combat can challenge therehabilitation teams at WRAMC and BAMC inachieving initial prosthetic fitting on combat injuredclients within this golden window. The impact ofthis problem has been managed through the use oftechnology. Within two- to three-week postinjury, cli-ents treated at these two facilities begin socket elec-trode site identification and training necessary foroperation of a myoelectric prosthesis. The goals ofthis early intervention training are to identify, in-struct, and train the client to independently, correctly,and efficiently use specific residual limb musculatureto activate and perform basic myoelectric prosthesisfunctions, resulting in the ability to immediatelyoperate the myoelectric prosthesis at first fitting.

Electrode site identification takes place in therapywith use of socket electrodes (see Figure 1) and either/or MyoBoy� software (Otto Bock�, Minneapolis,MN), the MyoLabII (Motion Control, Inc., Salt LakeCity, UT), or therapeutic biofeedback units. The pro-cess of site selection involves multiple factors andrequires specialized skill of trained therapists andprosthetists to identify the best possible electrode

FIGURE 1. Socket electrode used for myoelectric training.This same type of electrode is placed within the myoelectricprosthetic socket. Courtesy of Otto Bock�, Minneapolis,MN.

placement and the most effective control scheme foreach client’s particular abilities and needs.

For ease of learning, optimal muscle sites areselected based on what is most intuitive to thepatient. Flexors are used to activate TD closing andpronation, and extensors are used to activate TDopening and supination. Electrodes pickup signalsmost effectively over superficial muscle bellies withhealthy skin coverage. Selecting the placement ofelectrodes requires knowledge of socket design. Thisknowledge aids the therapist in locating a muscle sitethat is well contained within the limits of the socket.Furthermore, the sites located in training are used toidentify the correct placement of the electrodeswithin the future prosthetic socket. Once ideal sitesare identified, motor training begins.

Motor training takes place using computer-basedMyoBoy� software (Otto Bock�, Minneapolis, MN)and the socket electrodes. On an EMG-like screen,the client can visualize color-coded signals, represen-tative of each of the selected electrode site muscles, asthey are activated for the corresponding TD opera-tion (see Figure 2). Initially, the focus of training ison independent activation of each muscle. Whenthe client is able to demonstrate separation of thesemuscle signals the concept of proportional controlis introduced. Proportional control is a term used todescribe the proportional relationship of the elicitedstrength of the selected muscle contraction to thespeed and grip force of the TD. Many myoelectricsystems today use this type of control. It is morephysiologic and predictable for the client than previ-ously used digital control. Each electrode has a dial

FIGURE 2. MyoBoy� software (Otto Bock�, Minneapo-lis, MN) computer screenshot demonstrating a client per-forming signal separation. For example , s ignal1 represents the flexor muscle or the muscles identified tomost commonly perform terminal device closing and pro-nation; signal 2 represents the extensor muscles or themuscles identified to most commonly perform terminalopening and supination. The goal is for the client to beable to activate each muscle signal (1 and 2) separatelywithout co-contracting the other muscle (1 or 2).

that can manually be adjusted to increase or decreasegain for the signal. This allows the therapist to am-plify or dampen the strength of the received signalfrom the muscle contraction to modulate prostheticoutput. Changes in the gain may need to be made fre-quently as the client develops mastery of control andincrease muscle strength.

The initial myosite training takes place with theupper extremity in a relaxed position at or nearmidline. As the client develops control in this plane,introduction of limb placement in various positions isinitiated to simulate reaching to heights, across mid-line, and to the floor. The client’s endurance shouldbe considered during initial motor training as the useof an isolated muscle in such a way is foreign andfatiguing. The MyoBoy� software is very motivatingfor clients. It has programs which use a virtual handthat responds to muscle signal as a myoelectric proth-esis would, a car game that uses accuracy and a scorefor the competitive at heart (see Figures 3A and 3B).The excitement of success and the involvement ofcompetition in the training process are contagious,but must be monitored to prevent fatigue and subse-quent increased discomfort.

The electrodes used for the myosite training can beattached to the client’s actual TD before fabrication ofthe preparatory prosthesis (see Figure 4). This stepprovides three-dimensional perception of the pros-thesis. Introduction of the concepts of prepositioningfor the most efficient grasp patterns with differentshapes of objects and appropriate force control withdifferent densities of objects is effectively introducedduring this stage.

The skills and knowledge that the client gains withpreprosthetic training are critical to motivation andsuccess with his or her prosthesis. Clients that receivepreprosthetic training demonstrate some amount ofimmediate success at first fitting. This promotesmotivation, gain of function in the residual limb,and a preliminary sense that the client will once againhave control over his or her life. The earlier the clientlearns these valuable principles, the easier it is totransition to actual prosthetic use and refrain frompoor ergonomic postures leading to cumulativetrauma disorders.

Prosthetic Training

A valid question often posed by the upper limbamputee, especially among those who are younger inage, is ‘‘Why do I have to wear a prosthesis?’’ It is truethat most unilateral amputees can function indepen-dently with the use of one hand. It is also true that theprosthesis will never truly replace the loss of ahuman limb. Instead, a prosthesis is a primitivefacsimile of what was once real, which can be clumsy,uncomfortable, and feel foreign to the wearer.However, with correct skilled prosthetic training the

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FIGURE 3. (A, B)Various games are available on the MyoBoy� software (Otto Bock�, Minneapolis, MN) package. (A)The object of the virtual hand game is for the client to exercise the proper force of contraction to grasp and release theball. (B) In this example, the car represents one of the two muscle signals used to control the terminal device (TD). Theobject of this game is for the client to master accuracy with contraction force and to increase contraction endurance to nav-igate the car over the wall without crashing. This game can be further graded with the addition of a second simultaneous carrepresenting the opposing muscle used for TD operation.

improvement in independent functional perfor-mance cannot be understated.

This training marks a major turning point inrehabilitative care of the upper limb amputee. Thegoal is for the prosthesis to become an integrated partof the client’s life; therefore, the therapy focus is forthe client to master and habituate the mechanicalactions required for prosthetic control, integrate theuse of the prosthesis in activity performance, andultimately achieve independence in all activities of

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daily living. This is achieved through training in thefollowing: knowledge on the operation and perfor-mance of the prosthesis; initiation of controls train-ing; and initiation of ADL training.

Service members are provided three different typesof prostheses: myoelectric, body powered, and passive(esthetic only). In some cases, clients are fit with ahybrid prosthesis that is part body powered and partmyoelectric. Additionally, there are many differentbasic TD (hook, hand, Greifer) and activity-specific

TD that are prescribed to the client. A full explanation isbeyond the scope of this article. Clients train on themyoelectric and the body powered and generally self-select one type as their primary or preferred choice.However, many clients will select their prosthesisbased on the task at hand, rather than to completelyabandon one type of prosthesis altogether. Embeddedwithin the client’s selection for body powered versuselectric powered, is the question of TD selection. Again,this decision can be task driven and therefore not a one-time decision. It is common to hear a client say that heprefers the myoelectric for one type of activity and thebody powered for another task. Here is a nuance inamputee rehabilitation that underscores the impor-tance of the client working diligently with the therapistto train on the various types of TD, and for the client tohave a variety of experiences accomplishing manytasks to gauge and refine his skill sets in operation ofthe different types of prostheses provided.

Operational Knowledge

The client must be able to effectively communicatewith the rehabilitation team any mechanical difficultiesor operational malfunctions with the prosthesis duringthe rehabilitation period and when maintenance isrequired. Common terminology each client shouldpossess includes but is not limited to knowledge ofsocket and harnessing design, the type of TD(s), andtype of control system(s) used by the prosthetic wearer.This education provides the client with basic vocabu-lary and skills for prosthetic use, maintenance, and theability to articulate malfunctions using correct termi-nology which greatly assists the prosthetist in diag-nosing and fixing repair issues that arise.

Self-maintenance and Care of the Prosthesisand its Components

Clients are trained to do basic maintenance andrepair of the prosthesis in settings where a prosthetist

FIGURE 4. The socket electrodes attached to the actualterminal device (TD) are placed on the corresponding my-osites. The client is instructed to activate each muscle toperform the specified TD function. This approach providesthree-dimensional, real-time feedback to the client.

may not be available including socket maintenance,daily cleaning, and inspection of the socket; compo-nent maintenance, routine cleaning, and applicationof lubricant; and harness adjustment and cable sys-tem changes, as needed.

Residual Limb Tolerance/Care

With traumatic amputation, the limb continues toheal beneath the surface of the skin well beyondwound closure, which makes the limb more suscep-tible to pathology. Frequent inspection of the residuallimb(s) should become a daily ritual for all prostheticusers. If the skin integrity of the residual limb iscompromised, the client’s ability to wear the pros-thesis is hindered.

Establishing a wearing schedule for the prosthesisis also important. Initially, the prosthesis should beworn for no more than 15 to 30 minutes, two to threetimes daily. Upon doffing of the prosthesis, theresidual limb should be thoroughly inspected forany signs of skin redness, irritation, and/or break-down. If no signs of ill fit are evident, the user canincrease the wearing time by 30-minute increments,two to three times daily. Improper socket fit must beimmediately addressed by the prosthetist. The even-tual goal is for the prosthetic user to be able to tolerateapproximately eight hours of wear and use of theprosthesis within one to two weeks from the start oftraining.

Inspection of the residual limb should continue tobe a daily routine even after the client has progressedto all day wear and use of the prosthesis. Along withlimb inspection, proper hygiene of the residual limbis also essential. This includes daily washing of theresidual limb with mild soap followed by thoroughdrying before donning the prosthesis.

Donning/Doffing Prosthesis

Early independence in donning and doffing theprosthesis is important. This includes the residuallimb sock, prosthetic donning liner, prosthetic socket,and/or harnessing(s) as applicable. There is a rangeof different methods for donning/doffing each typeof prosthesis. When training the client on donning/doffing of the myoelectric prosthesis, the ReducedFriction Donning System (Advanced Arm Dynamics,Inc., Redondo Beach, CA) is used (see Figures5Ae5C). This prosthetic donning system results inan intimate fit of the residual limb within the socketensuring optimum electrode contact. When trainingto don the body-powered prosthesis, the client is in-structed in the pullover method, for example, the har-ness is donned over the head, or the jacket method,for example, the harness is donned over one extrem-ity then the other. Each client is educated in the mostappropriate method for them and they may even

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FIGURE 5. (AeC) The client is trained to don the myoelectric prosthesis with the use of a limited friction donning sockwith a lanyard secured to the end. (A) The sleeve is inverted over the residual limb. (B) The sock-covered limb is placed in theprosthesis. The client places tension on the lanyard to begin to pull the sock through the socket, thus pulling the limb into thesocket. (C) The sock is pulled through the tube via the lanyard gently bringing the soft tissue into the socket.

develop their own technique. The methods for don-ning and doffing the prosthetic system for bilateralamputees vary significantly based on level of ampu-tation. The end goal is for the client to be able to per-form this task independently. Additional creativityon the part of the therapist and client is required toachieve this goal.

Initiation of Controls Training

Learning to use a prosthesis is similar to learningthe operation of other complex mechanical devices.For example, when beginning to drive, the first step islearning to control the individual components re-quired for operation of the vehicle. This includesturning on and off the vehicle; adjusting the mirrorsand seats; and operation of the shifter, gas, and brake.These components are eventually combined into theactual performance of driving a vehicle. Similarly,when an amputee begins his or her prosthetic train-ing, the first step is to learn how to control theindividual components to operate the prosthesis.Subsequent steps in the newly learned motor pat-terns are combined together to accomplish taskscreating a hierarchy of progression through the con-trols training. The goal is to achieve smooth move-ment of the prosthesis with minimal amount ofdelays and awkward motions11 in daily activity taskperformance.

The tasks used to achieve mastery of each controlskill depend on the creativity of the therapist. Mediaappropriate for training include objects of variousshape, texture, density, and weight, such as one-inchwood square blocks, round blocks, cotton balls,Styrofoam cups, or a cup filled with water. This

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type of media provides a variety of different ways tograde the task at hand to achieve mastery of control.Initial training is frequently rote in nature howeverwith mastery of each skill, motions are combinedtogether resulting in performance of an activity. Amultisensory approach is also useful. Verbal, tactile,and visual cues can be helpful to attain success. Theprogression through the hierarchy of controls train-ing described by each level of upper extremity ampu-tation is depicted in Figures 6 and 7.

ADL Prosthetic Training

The client is trained to apply the skills learnedduring the controls training portion to begin actualfunctional use of the prosthesis. This may causeincreased user frustration due to the awkward andartificial nature of a prothesis. Those with unilateralamputation quickly learn to adapt to one-handedtask performance, which can become habitual. Ratingguides developed by Atkin’s titled ‘‘Unilateral UpperExtremity Amputation - Activities of Daily Living’’(see Figure 8) provides a comprehensive list of activ-ities the client should be able to perform with the useof the prosthesis.12 A rating guide is also available forbilateral upper extremity amputations. It is unreason-able to expect a unilateral amputee to use a prosthesisto the same extent as they spontaneously used thepreexisting sound limb. The level of difficulty intraining and the amount of training time neededmay vary from one prosthetic user to the other.

Advanced Prosthetic Training

The goals of advanced training are for the clientto complete basic and advanced daily tasks

Shoulder disarticulation orscapulo-thoracic amputation(components and TD includeshoulder joint, elbow unit,

wrist unit, and TD)

Elbow disarticulation and mid-humeral amputation(components include

elbow and wrist units, and TD)

Demonstrate unlocking/locking ofelbow unit

Demonstrate of rotation of TD

Position and lock elbow to 1/3, ½,and ¾ range

Perform control training ofwrist and TD unit as appropriate

Demonstrate body motions forlocking

Demonstrate unlocking/lockingof shoulder unit

Demonstrate free swing ofshoulder unit

Perform control training ofelbow, wrist and TD unit as

appropriate

Mimic motions of therapist for shoulder, elbow and TD control

With prosthesis positioned and locked in midline:-Grasp objects of similar size, weight and density and transfer from one area to another in standing position

-Same as above but in sitting position-Progress to grasping and releasing objects of various shapes, sizes, and densities in standing and in sitting

Progress to grasping and releasing objects placed to the right/left of midline and at varying heights (encourageproper body mechanics)

Have user grasp objects of various textures and densities without crushing(i.e. cotton ball, Styrofoam cup, potato chip)

For transhumeral: position turntable component for

internal/external rotation

Apply/Remove TD

Demonstrate pre- positioning ofjoints as necessary

Wrist disarticulation andtrans-radial amputation

(components include wristunit and TD)

Demonstrate free swing

-through full range-open to 1/3, ½, and ¾ range

Grasp and release with TD:

FIGURE 6. Controls training for body-powered prosthesis by level of amputation.

incorporating the prosthesis efficiently and demon-strating a natural motor pattern. The outcome of thisphase is for the client to save body energy, decreasebiomechanical stress to the intact limb, and learn themost efficient approach to tasks without extraneousbody movements and the reliance on adaptiveequipment.

There are five characteristics of advanced pros-thetic rehabilitation that can guide therapists duringthis phase of training. The first is that advancedrehabilitation is individualized in its very nature.Overall, successful rehabilitation of a client withupper limb amputation involves knowing the wholeperson and what meaningful occupations they pre-viously selected. When the client progresses to thistraining, therapy becomes more individualized, in-corporating the client’s particular vocational andavocational goals. Second, this training requires theuse and operation of a tool, or interaction with anobject, such as a carpenter’s tool, a musical

instrument, a cooking utensil, or a machine. Thethird notable characteristic is that advanced traininginvolves completing a multistepped complex taskwith many required bimanual movements. Treat-ment activities in this phase are less static andgenerally challenge the therapist to take the clientout of the clinic setting. The fourth characteristic isthat this type of training should involve the prosthe-sis of choice for the client. The client is encouraged totry different TDs during activity performance to helpthem decide which device best meets their needs.Whether the client self-selects the myoelectric orbody-powered prosthesis as the preferred prosthesis,the advanced training should be geared toward fine-tuning the operation and control of that prosthesis asneeded to engage in the appropriate tasks at this levelof rehabilitation. The fifth and final characteristic isthat there is a meaningful product or outcome upontask completion. For example, the client would havebuilt the frame, weeded the garden, assembled the

AprileJune 2008 169

Wrist disarticulation andtrans-radial amputation

(components include wrist unit and TD)

Shoulder disarticulation orscapulo-thoracic amputation

(additional components includeshoulder joint, elbow and

wrist units, and TD)

Elbow disarticulation and mid-humeral amputation

(additional components includeelbow unit, wrist unit, and TD)

Grasp and release with TD: -through full range-open TD to 1/3, ½, and ¾range

Demonstrate unlocking/locking ofelbow unit

Demonstrate free swing

Apply/Remove TD

Demonstrate operation of wristflexion

Position and lock elbow to 1/3, ½,and ¾ range

Performcontrol training of wristand TD unit as appropriate

Demonstrate body motions forlocking

Demonstrate unlocking/lockingof shoulder unit

Demonstrate free swing

Perform control training of wristand TD unit as appropriate

Progress to grasp/release of objects placed to the right/left of midline and at varying heights (encourage proper body mechanics)

Mimic motions of therapist for shoulder, elbow and TD control with prosthesis positioned and locked in midline:-Grasp objects of similar size, weight and density and transfer from one area to another in standing position

-Same as above but in sitting position-Progress to grasping and releasing objects of various shapes, sizes, and densities in standing and in sitting

Have user grasp objects of various textures and densities without crushing (i.e. cotton balls, Styrofoam cup, potato chip)

Have user complete specific tasks in a reasonable time period with minimal extraneous movement and energy expenditure

Demonstrate wrist rotation

Turn prosthetic system on and off

Demonstrate battery change

Demonstrate simultaneous controls

Perform control training ofelbow unit as appropriate

Demonstrate pre-positioning ofjoints as appropriate

FIGURE 7. Controls training for myoelectric prosthesis by level of amputation.

weapon, dug the hole, or repaired the engine. AtWRAMC, the clients complete a ‘‘prosthesis thesis’’as a capstone assignment from this phase of training.Several clients have completed carpentry projects,leather belt or wallet projects, and complex stain glassor wood burning crafts.

Ten categories of advanced prosthetic tasks per-formed at WRAMC and BAMC include militaryWarrior Tasks; yard work; community reintegration;shopping; driver’s training; vocational evaluationand training; recreational and sports activities; childcare and/or pet care; home repair and maintenance;and meal preparation. See Table 1 for more details.

Many clients are interested in completing militaryWarrior tasks as they solidify the client’s

170 JOURNAL OF HAND THERAPY

compromised identity as a Service member. The tasksencompassing this category allow clients who wish toremain on active duty in the military the ability todemonstrate that they can meet the minimum stan-dards of required military skills for military service.Clients in the military who choose to explore optionsfor civilian employment are challenged in the cate-gory of vocational evaluation and training. Somemilitary clients have a job history and a collegedegree that qualifies them for work outside themilitary; however, many of the young Service mem-bers lack the education and training required toperform their preferred line of work in the civiliansector. For example, many military personnel whohave worked as mechanics on military vehicles lack

RATING GUIDE KEY:0 Impossible 1 Accomplished with much strain, or

many awkward motions2 Somewhat labored, orfew awkward motions

3 Smooth, minimal amount of delays and awkward motions

ACTIVITIES OF DAILY LIVING 0 1 3 ACTIVITIES OF DAILY LIVING 0 1 3

Don/doff pull-over shirt Turn key in lockDress button-down shirt: cuffs andfront Operate door knobManage zippers and snaps Place chain on chain lockDon/doff pants Plug cord into wan outletDon/doff belt Set time on watchLace and tie shoes HOUSEKEEPING PROCEDURES:Don/doff pantyhose Perform laundryTie a tie Fold clothesDon/doff brazier Set up ironing boardDon/doff glove Iron clothesCut and file finger nails Hand wash dishesPolish finger nails Dry dishes with a towelScrew/unscrew cap of toothpastetube Load and unload dishwasherSqueeze toothpaste Use broom and dustpanOpen top of pill bottle Operate vacuum cleanerSet hair Use wet and dry mopTake bill from wallet Make bedOpen pack of cigarettes Change garbage bagLight a match Open/close jarDon/doff prosthesis Open lid of canPerform residual limb care Cut vegetables

EATING PROCEDURES: Peel vegetablesCarry a tray Manipulate hot potsCut meat Thread a needleButter bread Sew a buttonOpen Milk Carton USE OF TOOLS:

Name: Age: Occupation: Date(s) of Test:

Therapist: Sex: Type of terminal device:

DESK PROCEDURES: SawUse phone and take notes HammerUse pay phone Screw driversSharpen pencil Tape measureUse scissors WrenchesUse ruler Power tools: drill, sanderRemove and replace ink pen cap PlaneFold and seal letter ShovelUse paper clip RakeUse stapler Wheel barrelWrap package CAR PROCEDURES: Use computer: typing, accessInternet

Open and close doors, trunk andhood

Demonstrate handwritingPerform steps required to operatevehicle

COMMENTS: COMMENTS:

2 2

PERSONAL NEEDS: GENERAL PROCEDURES:

FIGURE 8. The ‘‘Unilateral Upper Extremity Amputation: Activities of Daily Living Assessment,’’ is a rating guide thatprovides a comprehensive list of activities of daily living that a unilateral amputee should be able to accomplish. Adaptedwith permission from Atkins DJ. In: Atkins DJ, Meier RH, eds. Comprehensive Management of the Upper-Limb Amputee.New York: Springer-Verlag; 1989:49.

the required education and certification needed towork as a mechanic in the civilian market. Thiscategory is crucial in exploring additional vocationaloptions.

Each of the ten categories challenges the client tocomplete the task successfully with the prosthesis.The client who passes the rigors of this level oftraining is often identified by the rehabilitation staff

AprileJune 2008 171

TABLE 1. Advanced Prosthetic Training Activity Categories

Task Description Key Points or Subtasks

Military Warrior Tasks: tasks specific to basic Warfighter skills d assemble and disassemble, fire, repair, and clean a military serviceweapon

d don and doff a gas maskd operate a military radiod assemble a rucksack with all appropriate military gear

Yard Work: tasks require movements in many planes with varioustools that require difficult postures and much upper body and trunkmuscle strength

d Manipulate garden tools outside of the clinic:o spadeso shovels,o hedge clipperso wheelbarrows

Community Re-integration: advanced training in the environmentoutside the rehabilitation clinic’s confines

d visit a mall:o manipulate bills or a credit card from a purse, wallet, or pocketo try on clotheso carry multiple packages

d negotiate a food court:o carry the tray from the restaurant counter to the tableo manage the multiple fine and gross motor tasks of eatingo manage to carry the tray to a central garbage receptacle

Shopping d shop for groceries:o reach packages/items from shelves of variable heights

d negotiate self-service check-out lanes:o complete tasks related to purchasing, scanning, bagging, and

paying for grocerieso use the automated credit card machineo use the automated cash machine

d tasks inherent to shoe and clothes shopping using the preferredprosthesis

Driver’s Training d Referral to a Driving Rehabilitation Specialist for:d driving evaluationd identification of appropriate vehicle modification equipmentd training with adaptive driving equipment

Vocational Training: a newly acquired upper limb amputation greatlychallenges the client’s career direction therefore training is specificto the client’s particular occupational pursuit

d spend time helping the client sort out his or her desired vocationalpursuit

d customize a treatment plan that address the specific task demandsof the various occupations of interest

Recreation and Sports Activities: many customized prostheses andTDs are available on the commercial market to facilitate the returnto previously enjoyable activities

d review the clients ‘‘hobby history’’d explore available activity-specific TDsd train the client in use of the activity-specific TD

Child Care and Pet Care: the tasks and responsibilities in the categoryof child and pet care are many, changing, and quite varied

d therapist must perform careful task analysis of each taskd use of therapy pets to make training in pet care quite realisticd address child care training as it relates to the specifics of the cli-

ent’s own childreno use a doll to practice the skills of diapering, holding, bathing,

and swaddling with prosthesisHome Repair and Maintenance: the client identifies his or her previoushome responsibilities, or predicts those of their future

d perform simulated tasks in a functional apartment to include:o take out the garbageo fix a leaky sinko change the sheets on the bedo run the vacuumo unload groceries into the pantryo replace the shower curtain liner in the bathroom

d additional practice of ‘‘real-life’’ chores, as necessary

Meal Preparation: completion of this high level training gives theclient a sense of accomplishment and a strong sense ofindependence

d participate in a weekly cooking group and complete the entiremeal preparation process:o cooko serveo clean up

d exposure to one-handed adaptive kitchen aids

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as ‘‘integrator’’ because of his or her success atintegrating the prosthesis into his or her motor skillrepertoire, thereby attaining the goal of this phase ofrehabilitation. Overall, the client’s movementsshould be coordinated, smooth, and precise withaccurate and consistent control of the operations ofhis or her prosthesis using ergonomically soundpostures proximally.

It is important to note that each phase of rehabil-itation is repeated with additional prosthesis asappropriate. With training of subsequent prostheticuse, the client’s ability to master the foundationalskills and perform functional tasks is rapid.

LONG-TERM DISCHARGE PLANNING

The discharge planning phase of the protocol beginson the day the rehabilitation team is introduced to theinjured client. As would be true with civilian clientsundergoing rehabilitation, the information that is gath-ered during the initial evaluation serves as the foun-dation for the discharge planning process. The intent ofa discharge plan is to provide a smooth transition fromone level of care to another level of care.

Discharge planning is a process that is best per-formed by a multidisciplinary team, along with theclient and the client’s family. At WRAMC and BAMC,the medical members of this team consist of a phys-iatrist who acts as coordinator for medical and surgi-cal subspecialists, nurses, occupational and physicaltherapists, prosthetists, social workers, psychologists,dieticians, pharmacists, and psychiatrist. This groupalso includes a Physical Evaluation Board LiaisonOfficer and a Veterans Affair (VA) counselor to assistwith the military medical disability system. This teammeets on a weekly basis through team conferencesand outpatient amputee clinics. These meetings en-sure communication among the team, and quality andefficient care for every client. In the civilian sector, aclient will typically be discharged from the hospital toa subacute rehabilitation facility or to home.

Preinjury Status

Understanding the client’s lifestyle before admis-sion will give insight into possible future goals.Knowledge about the clients’s preexisting family/support system, physical condition, emotional/cog-nitive status, educational level, vocation, and avoca-tions cannot be understated. The client’s culture andprimary language, if other than English, will impactdischarge planning as well.

Postinjury Physical Status

Ongoing medical care for combat wounded ampu-tees at a minimum will include regular follow-upswith a physiatrist who will act as a coordinator for

any specialty care required. Depending on the client’sduty status and medical care choices, he or she willreceive care at a military hospital, a Veteran’sAdministration hospital, or through a TriCare mili-tary health system provider.

Current Status

As the client becomes medically stable and maxi-mizes therapy services, a reevaluation of his or hercurrent physical, cognitive, and emotional status willprovide information necessary to guide proposals forthe appropriate living situation and referrals to otheragencies. This information directs recommendationsfor transition to a safe level of care. Referrals forequipment, home health, and transportation needsare made based on these recommendations. Resultsof vocational testing will direct further training or jobplacement.

Community Reintegration

The experiences that the clients have during com-munity outings assist in identifying other possibleneeds as they transition away from the hospitalcampus. No matter how well a client is preparedfor interactions in the community, the demands of thecommunity cannot be recreated with the walls of theclinic. Experiences in the community are invaluablefor the client. A challenging first experience withoutsupport can result in a major setback, whereas apositive, supported first experience typically leads tomore of the same.

Resources

Providing the client with resources to support therehabilitation that he or she received is critical.Rehabilitation is provided to persons who haveundergone a life-altering event. This rehabilitationis a very turbulent time; however, those in theprogram experience new life in a protected environ-ment with significant support systems in place.Transitions to different levels of care outside of thissupport system bring with them new stresses, whichfrequently go understated in the discharge planningprocess. Often these emotions are not recognized bythe client until the transition has occurred. In prep-aration for discharge and to reduce the feelings ofisolation, those receiving care at WRAMC and BAMCare introduced to numerous resources by multiplemembers of the rehabilitation team.

RECENT ADVANCEMENTS INPROSTHETIC DEVELOPMENT

Although it has been acknowledged that a pros-thetic limb does not provide all of the preamputation

AprileJune 2008 173

functionality of a human limb, there have been manyrecent advances to improve upper limb prostheticrestoration. These advances can be categorized asfollows: prosthetic interface, microprocessor technol-ogy, TDs, and treatment protocols.

Prosthetic Interface

Comfort for the client has been enhanced byimproved socket design. This includes developmentof suction silicone roll-on liners, which decrease theneed for harnessing; flexible sockets that improveforce distribution; and anatomically contouredsockets for improved prosthetic fit.12e15

Microprocessor Technology

Microprocessors provide customization for indi-vidual control inputs and thresholds in the electricprostheses. This improves the responsiveness of theprosthesis for each client.16

Terminal Devices

Terminal devices for electric systems have seen thegreatest changes. Water resistant TDs are now avail-able allowing function in a greater diversity of envi-ronments. An increase in the speed of certain TDs hasdramatically impacted the function and satisfactionof clients with electric systems as the prosthesisoutput is more ‘‘real time.’’ Additionally, functionalprosthetic devices for partial hand amputees havebeen developed to provide another option to thepassive prosthesis for this population.16

Treatment Protocols

In the 1980s, Malone et al.9 demonstrated that cli-ents fit with a prosthesis within 30 days had higherrehabilitation success. This was supported byFletchall’s work evaluating ‘‘the value of specializedrehabilitation of trauma and amputation’’ in 2005.17

With this knowledge, it is hopeful that the futurestandard of care for the upper limb amputee willinclude immediate treatment by a specialized upperextremity team using a client-centered approach torehabilitation to maximize function.

Although engineering and electronic develop-ments for the mass market continue to influenceprosthetic technology development, there has been asignificant increase in support that is specificallytargeted at development of upper limb prosthetictechnology from federal and military sources.Currently sponsored projects by Defense AdvancedResearch Projects Agency (Arlington, VA) are exam-ples of this type of development. Some of the two- tofive-year goals for these projects include local control,state sensing, and task-based mode shifting with-in the device to enable improved functionality;

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simultaneous function of three to five joints; in-creased degrees of freedom for the wrist and hand;a minimum of three to five grasp patterns; fingertipforce detection; increased elbow lift strength; andincreased wrist flexion strength.18

CONCLUSION

Providing an environment to try previous activitiesor new challenges can lead to some of the mostrewarding experiences. At both WRAMC andBAMC, there are a wide variety of activities availablewith support for the Service member to experiencebefore leaving the hospital. The athletic activitieshave been some of the most popular. Members of thearmed forces are young, athletic, and competitive,so harnessing this desire has been incredibly success-ful. The programs available include snow skiing,water skiing, rafting and kayaking, hunting andshooting, and rock climbing to mention a few.Providing resources and contacts to enable the clientto pursue or continue with new activities in theirhome community can be a critical component to fullreintegration.

Life is forever changing and challenging. Provid-ing dynamic and supportive skilled upper extremitylimb loss rehabilitation in a comprehensive methodbeginning with the medical model and progressing toan occupation-based model in a controlled livingenvironment and community provides the clientwith a solid foundation to approach their changedlife with its new challenges upon discharge. Theupper extremity amputee rehabilitation efforts atWRAMC and BAMC are designed to provide clientswith fundamental upper extremity prosthetic skills tolive balanced, filled, and productive lives both in andout of the military system with a prosthesis(es).Efforts are underway to research the qualitativeoutcomes of upper extremity amputees to includetheir occupational outcomes, their perceived qualityof life, and their continued use of the upper extremityprosthesis(es).

Additional information on management and reha-bilitation of the upper extremity amputee can befound in Textbook of Military Medicine, Care of theCombat Amputee.

Acknowledgments

The authors would like to acknowledge Harvey Naranjo,COTA and Ibrihim Kabbah, COTA for their hard work anddedication to the development of the WRAMC AmputeeProgram.

REFERENCES

1. Dillingham TR. Rehabilitation of the upper limb amputee. In:Dillingham TR, Belandres PV (eds). Textbook of Military

Medicine Part Iv Surgical Combat Casualty Care: Rehabilita-tion of the Injured Combatant, Vol. 1. Washington, DC: Officeof The Surgeon General at TMM publications, 1998, pp 33–77.

2. Walter Reed Amputee Care Program Database. Washington, DC:Military Amputee Care Program, 2003. Updated Jan 18, 2007.

3. Atroshi I, Rosberg HE. Epidemiology of amputations andsevere injuries of the hand. Hand Clin. 2001;17:343–50.

4. Huston C, Dillingham TR, Esquenazi A. Rehabilitation of thelower extremity amputee. In: Dillingham TR, Belandres PV(eds). Textbook of Military Medicine Part IV Surgical CombatCasualty Care: Rehabilitation of the Injured Combatant, Vol.1. Washington, DC: Office of The Surgeon General at TMMpublications, 1998, pp 79–159.

5. Jefferies GE. Pain management: post-amputation pain [serialonline]inMotion. 1998;8:2, Available at: Amputee Coalition ofAmerica, Knoxville, TN. Accessed Jan 13, 2007.

6. Ramachandran VS, Hirstein W. The perception of phantomlimbs: the D.O. Hebb Lecture. Brain. 1998;121(Pt 9):1603–30.

7. Ramachandran VS, Rogers-Ramachandran D. Synaesthesia inphantom limbs induced with mirrors. Proc Biol Sci. 1996;263(No.1369):377–86.

8. Jones LE, Davidson JH. Save that arm: a study of problems inthe remaining arm of unilateral upper limb amputees. ProsthetOrthot Int. 1999;23(1):55–8.

9. Malone JM, Fleming LL, Roberson J, Whitesides TE, Leal JM,Poole JU, Sternstein-Grodin R. Immediate, early, and late post-surgical management of upper-limb amputation. J Rehabil ResDev. 1984;21:33–41.

10. Bowker JH. The art of prosthesis prescription. In: Smith DG,Michael JW, Bowker JH (eds). Atlas of Amputations and

Limb Deficiencies. Rosemont, IL: American Academy ofOrthopaedic Surgeons, 2004, pp 742.

11. Atkins JD, Meier RH (eds). Comprehensive Management ofthe Upper-Limb Amputee. New York: Springer-Verlag, 1989,pp 48.

12. Lake C. Partial hand amputation: prosthetic management. In:Smith DG, Michael JW, Bowker JH (eds). Atlas of Amputationsand Limb Deficiencies—Surgical, Prosthetic and RehabilitationPrinciples. 3rd ed. Rosemont, IL: American Academy of Ortho-pedic Surgeons, 2004, pp 209–17.

13. Miguelez JM, Lake C, Conyers D, Zenie J. The transradial ana-tomically contoured (TRAC) interface: design principles andmethodology. J Prosthet Orthot. 2003;15:148–56.

14. Miguelez JM, Miguelez MD. The microframe: the next genera-tion of interface design for glenohumeral disarticulation andassociated levels of limb deficiency. J Prosthet Orthot. 2003;15:66–71.

15. Lake C, Dodson R. Progressive upper limb prosthetics. PhysMed Rehabil Clin N Am. 2006;17:49–72.

16. Lake C, Miguelez J. Comparative analysis of microproces-sors in upper limb prosthetics. J Prosthet Orthot. 2003;15:48–63.

17. Fletchall S. Returning upper-extremity amputees to work.The O&P Edge. 2005;4:28–33, [serial online] Available at:http://www.oandp.com/edge/issues/articles/2005-08_04.asp.Accessed Feb 13, 2007.

18. Ling G. Prosthesis 2007 [proposal]. Defense Advanced Re-search Projects Agency [serial online]. Available at: http://www.darpa.mil/baa/baa05-19mod5.htm. Accessed Feb 13,2007.

AprileJune 2008 175

JHT Read for CreditQuiz: Article # 090

Record your answers on the Return Answer Formfound on the tear-out coupon at the back of this is-sue. There is only one best answer for each question.

#1. As of the writing of this article how many upperlimb amputees have returned to active duty?a. 50b. 25c. 10d. 1

#2. The vast majority of the prosthetic rehabilitationfor service personnel takes place ata. Brooke Army and Walter Reed Medical

Centersb. MASH unitsc. Army field hospitalsd. Valley Forge Army Hospital

#3. Goals for training the military amputees are di-rected at anticipated eventual return to

a. primarily military functionsb. primarily civilian functionsc. social acceptance of the prosthesisd. civilian and military functions

#4. The nature of most of the combat injuries that re-sult in eventual amputation of the upper limbproducea. sharp lacerations at the level of the amputationb. grossly infected woundsc. potentially contaminated woundsd. concomitant head injuries

#5. Almost all the interventions described for a mili-tary amputee’s rehabilitation can be applied tothe typical civilian amputee populationa. trueb. false

When submitting to the HTCC for re-certification,please batch your JTHT RFC certificates in groupsof 3 or more to get full credit.

176 JOURNAL OF HAND THERAPY