In view of the long-term goals of upper-limb amputation rehabilitation care,1 occupational therapy has a significant role in the rehabilitation of a patient with upper-limb loss across all prosthetic control systems. This article presents a brief overview of this therapy. Readers are referred to the references for more detailed information about specific aspects of the therapy.
Depending on where individuals live and the availability of local systems for care, patients should be referred to the occupational therapist (OT) at different time points throughout their rehabilitation. The rehabilitation process continues in different phases throughout the patient’s life.1 However, there is some uncertainty as to whether occupational therapy differs in terms of content and time to perform between patients fitted with upper-limb prostheses using different control systems.
The aim of this article is to describe occupational therapy in upper-limb prosthetic rehabilitation and discuss potential differences in therapy between patients fitted with body-powered or myoelectric control systems.
STAGES OF REHABILITATION
THE PRESURGERY AND POSTSURGERY PHASE
When possible, an OT should see the patient before surgery to determine the basis for the future rehabilitation. A comprehensive assessment of the patient’s preamputation and postamputation medical status, life roles, and activity repertoire is necessary to manage the patient’s rehabilitation.1–3 If an OT is able to see the patient before amputation, providing education on one-handed tasks and adaptive equipment options can be of great benefit. When possible, the development of a home exercise program with a focus on maintaining range of motion (ROM) is also beneficial. Such information, typically facilitated in one or two sessions, can provide the patient with the necessary tools to maintain greater independence with functional activities and alleviate anxiety and frustration. If the OT is unable to see the patient before surgery, these sessions should be provided as soon as possible after surgery. Depending on the patient’s condition, phantom limb pain treatment, such as mirror therapy,2,4 augmented reality,5 or medications, as well as isometric exercises, may begin 5 to 7 days postoperatively.
Approximately 2 to 3 weeks after surgery,6 limb shaping, desensitization, maintenance of joint ROM, and muscle strengthening are important areas of focus.2 A home program with a focus on maintaining ROM and strengthening all remaining joints of the residual limb is essential to allow independence with donning/doffing the prosthesis and regaining functional ability. A preparatory prosthesis7 may be applied early in the shaping process (2–4 weeks postoperative), and final prosthetic fitting should, if possible, occur within 1 month8 to 2 months6 after amputation. However, these timelines must be viewed as a goal, as fitting of the preparatory and final prosthesis may be delayed because of insurance authorization. During this time, it is important for the OT and the certified prosthetist (CP) to work closely together to discuss and solve any prosthetic issues that come up during training.9 Independence in activities of daily living (ADLs), change of hand dominance, one-handed techniques, adaptive equipment, and assistive technology should also be addressed during this period.
For individuals who have undergone targeted muscle reinnervation (TMR) surgery, an exercise program can begin once the surgical incisions have healed, approximately 3 to 4 weeks after surgery. The exercise program should use motor imagery that involves attempting to move each segment of the missing limb to strengthen reinnervated muscles for myoelectric prosthetic control.10,11
During the preprosthetic period, exploration of patient goals, job responsibilities, and expectations, as well as lifestyle, is discussed. Decisions about future prostheses should be based on body structure (level, laterality, shape, and skin integrity of residual limb), body function (ROM and strength), activity limitations (patient specific), personal factors (desire/need for function or cosmesis, attitude, and motivation), and environmental factors (work, availability for prosthetic fitting and training, and family preferences). Even if the amputation is on the dominant side, the prostheses will always be used as an assist or nondominant hand by those with unilateral limb loss. With bilateral limb loss, in contrast, when a dominant side is required, it is usually the side with the longest residual limb.
If the assessment and discussions end with a decision to start using a myoelectric prosthesis, myoelectric site testing and training can be initialized during this period. For individuals who have undergone TMR, exercises that incorporate gross muscle patterns involving the function of transferred nerves should begin when muscle twitching occurs in response to specific attempted movements—approximately 6 to 15 weeks after surgery. When the OT is able to palpate consistent muscle activation, exercises should shift to discrete motions, again targeting the functions of the transferred nerves.12,13
A final prostheses is optimally fitted within 1 to 2 months from injury,6 although this period is sometimes longer depending on residual limb skin integrity or insurance authorizations. With regard to prosthetic training, some elements are common to all types of control system.6,9
First, developing a habit of wearing the prostheses should be established. This includes an orientation to prosthetic components and terminology, donning and doffing,9 and a wearing schedule that starts with 15 to 30 minutes, three times per day, and increases until the end of the first week,6 when the prosthesis is worn all day. The habit of wearing the prosthesis is essential for future use and, in myoelectric prosthetic users,14 development of prosthetic control skill. During this period, the OT should also teach the patient care of the residual limb and the prosthesis.15
Concurrently, controls training is initiated. The goal of this training is to enable the patient to learn how to operate the prosthetic components, for example, terminal device (TD), wrist, elbow, or shoulder joint, in a skillful and spontaneous manner. Before starting the exercises using the final prosthesis, it is essential that the prosthetic control system (i.e., harnessing or electrode amplifiers) is adjusted properly. Prosthetic fit should also be checked before initiating controls training because this may influence the control system. Training involves both prepositioning and using the TD. Controls training is most often executed as repetitive drills to help the patient automatize the operation of the prosthetic device; one control or function is taught at a time and then combined with others.6 Controls may be practiced with objects of different shape, size, density, and weight, at different angles or levels relative to the body, before moving to functional use training, including bimanual tasks.16
Specific elements of controls training differ based on device type. In body-powered prostheses, the gross body motions that control the device are practiced. Movements such as scapular abduction, humeral flexion, shoulder depression, and chest expansion may be used for various purposes.17 These motions are used for control of active functions, for example, elbow flexion, elbow lock/unlock, TD open or close, and practiced in this order, from proximal joints that preposition the TD in space, to actuation of the device itself once correctly positioned.17,18 In addition, special attention to body mechanics should be made while the patient is using his/her prosthesis. Awkward or compensatory movements to operate the prosthesis should be discouraged whenever possible while educating the patient on how to use the prosthetic functions to complete tasks.
In contrast, in myoelectric control systems the actions that create an activity in the device should be practiced with no simultaneous body motion. With conventional or direct control, after palpation and determining appropriate muscle sites, the patient practices control by contracting the muscles when being connected to an external myo-system or training prosthesis.9
With a pattern recognition system, less time is spent identifying muscle sites and electrode location. The OT initially works with the patient to identify unique and repeatable muscle patterns associated with the available prosthetic movements. In addition, the patient is instructed on the calibration process for the prosthesis, which allows the patient to recalibrate the system any time the patient feels that his/her control has decreased. Both of these training tasks occur while the patient is connected to a training prosthesis or external system.
In addition, in all of the control systems mentioned above, supplementary manual controls, for example, positioning the TD through a passive wrist unit, passive rotation of the elbow joint, or adjusting the position of a friction shoulder joint, are performed by the sound hand or by creating forces against an object in the environment.
The skill in operating a prosthetic hand is something that continues to develop and becomes more refined over time, as the prosthesis is used in daily life activities. However, it is essential that the patient reach some level of skill before introducing functional use training and performance of more complex tasks.
Functional use training should be performed in daily life activities that are meaningful and purposeful to the patient to automatize the use of the prosthesis in everyday life.19 This training is more or less similar between control systems; the basic concepts, preposition, approach, grasp, move, and release, are adjusted to the different control systems and to the laterality of amputation.6,9 One aim is to establish both “use patterns” and “wear schedule,” that is, habits of performing activities using the prosthesis. This is based on the earlier assessment of patients’ goals, life roles, and work situation. Independence in self-care and leisure activities should be a priority for the OT when planning functional use training.
Although the areas of focus for functional use training are essentially the same for the difference device types, the time required to acquire these skills is typically more for myoelectric devices—especially at transhumeral level or higher and for patients with bilateral limb loss. This is probably due to position feedback from the body-powered system. In patients with unilateral amputation, training is more focused on nondominant item stabilization tasks and simple bilateral activities, whereas in patients with bilateral amputation, more advanced bilateral activities are introduced toward the end of the training period. Hence, patients with bilateral limb loss require a longer period of training, typically twice the number of hours compared with those with unilateral amputation.17
DISCHARGE PLANNING, DISCHARGE
Overall, discharge planning does not differ by type of device but is dependent on patient function. When the patient has a prosthesis with good fit and shows ability to operate the device well in most areas of daily activities of his/her choice, then the patient is ready for discharge. Revisiting prosthetic maintenance, service, updating of componentry or casting for a new socket, is a matter for the CP. Also, the CP can initiate bringing the patient back for additional occupational therapy or when there is a change in overall health condition.
According to literature and clinical experience, there are no significant differences in evaluation of patients with body-powered or externally powered prostheses. The examinations, assessments, self-reported measures, and interviews have the same purpose and are for most situations the same. To cover all consequences of upper-limb amputation, assessments should be performed in all areas of human functioning.20
The domains of body functions/body structures are commonly examined by either an OT or a physical therapist (PT). Phantom limb pain or residual limb pain is assessed using different methods, for example, visual analog scale or the McGill Pain Questionnaire,21 and could be administered by either an OT or PT. Posture, ROM of all joints of the residual limb, muscle strength of remaining musculature, balance, and endurance are often measured by the PT but can be done by an OT as well.2 All these examinations are made for potential users of either body-powered or externally powered prostheses.
Aspects of activity and participation are evaluated by the OT through performance tests, interviews, or self-report measures. The action/capacity part of activity is covered by timed and observation-based performance tests that could be either generic or specific. The timed tests mostly reflect the patient’s skill in operating the device. Among the generic timed tests that are suggested for upper-limb prostheses users are Southampton Hand Assessment Procedure (SHAP)22 and Jebsen Taylor Test of Hand Function.23 However, these tests are extensive and time consuming and generally more suitable for research than for a busy clinic. The Box & Blocks and the Clothespin relocation tests, which are also suggested for use in clinical settings, are easily administered and take little time to perform.
Observation-based tests are scored by a trained rater that observes the patient’s performance on a specific number of items. In the literature, there are two such tests for adults (ADL and instrumental ADL),3,6 both originating from Chicago’s Northwestern University: the Unilateral3,6 and the Bilateral Upper Extremity Amputation: Activities of Daily Living Assessment. These assessments are both suggested for use in either body-powered or externally powered prostheses. It is, however, unclear if they still are in use.
Instead, two more recent specific tests for action/capacity are available. Of these, the first, the Assessment of Capacity for Myoelectric Control (ACMC), is specifically designed for myoelectric prosthetic users24 and is currently undergoing evaluation for use in body-powered prostheses. The second, the Activities Measure for Upper Limb Amputees (AM-ULA),25 is indicated for any type of active prostheses. Both tests use performance of daily activities as a basis for the observation; the ACMC uses two-handed activities and the AM-ULA uses both one-handed and two-handed activities. The ACMC ratings are based on spontaneity and skill, whereas AM-ULA is more comprehensive and also includes quality of movement and use of assistive devices other than the prosthesis in the ratings. Similar to SHAP, AM-ULA requires the patient to perform all of the one-handed activities with the prosthesis to score all items, which by most patients with unilateral amputation is un-natural and awkward. When performing tasks that require bilateral engagement, such as in ACMC and some tasks in AM-ULA, the patient is asked to use the prosthesis as much as possible.
To measure activity performance and participation, patient reported outcome measures should be used to cover what the patients actually do in their home environment. There are a multitude of generic outcome measures for this purpose. The Disability of the Arm Shoulder and Hand (DASH)26 questionnaire covers many areas relevant to the patient with upper-limb loss. Recently, the validity of the short form, Quick-DASH,27 was demonstrated in patients with upper-limb amputation.28 Another measure, the Patient-Specific Functional Scale (PSFS),29 is validated for patients with upper-limb musculoskeletal problems. Similar to the Canadian Occupational Performance Measure,30 much used in upper-limb prostheses, it enhances the client-centered approach by asking the patients what activities they need and wish to perform. In these instruments, the patient sets goals and expectations regarding the prosthesis, leading to an evaluation of relevant and meaningful activities. When mapping the PSFS to the International Classification of Functioning,31 it was found that this measure also covers aspects of participation.32
There are only two specific, validated questionnaires specifically designed for use in upper-limb prostheses: the Upper Extremity Functional Scale (UEFS) in Orthotics Prosthetics Users Survey33 and the Trinity Amputation and Prosthesis Experience Scales.34 Both have potential but also some shortcomings and are therefore not much used.20,35,36 Work is in progress to improve the UEFS.
In a recent clinical practice guideline released collaboratively by the US Department of Veteran Affairs (VA) and the US Department of Defense (VA/DoD), there is a review of the current evidence in support of the various measurement properties of functional status outcome measures for upper-limb amputations. The results are somewhat discouraging—for the self-report measures, there are only methods with insufficient research or evidence from poor quality studies. Among performance measures, there are only two methods that are rated as excellent.1 This emphasizes the need for more studies and perhaps even further development of outcome measures for this patient group.
In this article, we described occupational therapy for prosthetic rehabilitation in adult-acquired upper-limb loss and discussed similarities and differences for different control systems. Essentially, no differences in assessments, goal settings, or structure of training are required for myoelectric or body-powered devices. The areas that differ are the content of the controls training and training time required. This is not surprising because the controls are built on two completely different systems: contracting a muscle not natively related to the desired joint motion to generate electrical control signals versus gross motor actions to generate movement in the prosthesis through a cable system.
Rehabilitation of adults with bilateral acquired upper-limb amputation differs from treatment of individuals with unilateral limb loss. Typically, patients with bilateral upper-limb loss need more inpatient care, more adaptive equipment, and more extensive rehabilitation. Patients with unilateral amputation are most often served as outpatients, whereas patients with bilateral amputations are inpatients. Because of the role of the prostheses, as a nondominant helper or as a replacement of a dominant hand, the prosthetic choice is also somewhat different compared with the patients with unilateral limb loss. Bilateral limb loss patients often prefer body-powered prostheses with hooks37 because of proprioceptive feedback, increased fine-motor dexterity, and low maintenance.
In their extensive review of literature comparing body-powered and myoelectric prostheses, Carey et al.38 found similar outcome measures as described in this article. Besides these standardized outcome measures, they concluded that study-specific questionnaires and measures were the second most used method to report outcome from prosthetic fittings. A striking finding within the review is that there are no studies comparing activity- and participation-related issues. This highlights the need for studies on these aspects of prosthetic use. Another area in need of studies is OT training methods. There is no evidence to support any specific OT training method. So far, only studies that describe the methods are available. In the Netherlands, a group of researchers based in rehabilitation and movement science have performed several studies in both laboratory and clinical settings where they examine different methods for training and learning to operate upper-limb prostheses.39–41 This is done both in body-powered16 and myoelectric control systems. The results are interesting and should be followed by similar studies in occupational therapy.
There are some limitations to this article. First, the article reflects the clinical experience of two OTs, the authors of this article. Although the authors have a great number of years of experience working with this population, there still may be experienced OTs who could add information on other aspects of rehabilitation for patients with upper-limb loss. Second, the literature used is not derived from a systematic search but from a targeted search based on different topics, which means that potentially pertinent papers may be missing. Despite these limitations, we believe that most aspects of occupational therapy for prosthetic rehabilitation in acquired adult upper-limb loss are covered. Readers that are interested in learning more are referred to the reference list.
Occupational therapy for prosthetic rehabilitation in adults with acquired upper-limb loss follows a basic structure that is common to several types of prosthetic control systems. Controls training differs between systems, based on their underlying nature. Increased time is required for training with myoelectric systems for patients with high-level limb loss and in bilateral limb loss. There is a shortage in validated outcome measures that restricts the ability to evaluate all aspects of upper-limb prosthetic use. Further studies to provide evidence in support of different training methods for upper-limb prosthetic users are warranted.
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