There are an estimated 500,000 persons with upper-limb amputation (ULA), 41,000 of which are considered “major” ULAs.1 After amputation, edema, pain, and other postamputation factors can delay the ability to move, maintain strength and range of motion (ROM), use a prosthesis, and complete activities of daily living.2 Once these factors have subsided and the patient is cleared to begin exercising the residual limb, a common progression is to maintain ROM and begin to restore strength.2 Therapists may employ a sequence of movement and strengthening activities including active ROM, manually resisted ROM, and resisted strengthening.3,4 Early in the resisted strengthening portion of such a sequence, elastic bands may be utilized. There are few resources available to guide the patient with ULAs to maintain comfortable and secure grasp of elastic resistance bands. Therefore, the purpose of this technical note was to develop a low-cost solution to this challenge that could be used by persons with multiple different levels of ULA.
The primary problem addressed in this technical note is loss of grasp and an inability to hold elastic bands (Figure 1A), a popular clinical and home exercise tool, throughout an entire ROM during strengthening exercise. In addition, other joints may be lost (i.e., wrist, elbow), which can complicate grasp maintenance and control. Furthermore, the patient's residual limb may still have a healing or remodeling scar with variable sensitivity. It may also be the case that the patient has minimal experience with any prosthetic componentry. A gel liner was selected as the platform upon which to establish grasp for holding elastic strengthening bands.
An appropriately sized silicone gel liner was first selected and tested for proper fit and comfort on a sample patient's transradial residual limb. The selected liner included a distal umbrella with 3/8-in diameter coarse thread (16 threads per inch). It was fitted with a 3/8-in-diameter eyebolt (loop, 1 in or 25 mm inside diameter; Figure 1B). The eyebolt was used to be able to attach a 2-in aluminum carabiner clip so that the elastic strength band could attach to the caribiner and not the eyebolt (Figure 1A). This was important so that the band could be removed quickly and easily for changing position or resting between exercise sets. After the attachment of the eyebolt into the liner, elastic band (Figure 1C) was selected by a physical therapist, cut long enough to tie a knot to attach to a door knob, reach the patient in whichever configuration was desired for the selected exercise and to tie around the caribiner. Exercises were demonstrated for elbow flexion (Figures 2A, B) and elbow extension (Figures 2C, D) in the short sitting position. In standing, the following shoulder exercises were demonstrated: scaption (scapular plane elevation; Figures 3A–C), horizontal abduction (Figures 3D–F), lateral rotation (Figures 4A, B), extension (Figures 4C, D), lateral pull-downs (Figures 5A, B), and horizontal rows (Figure 5C, D).
After donning the liner, the case patient was able to attach the carabiner to the eyebolt without difficulty once the prosthetist attached the eyebolt to the liner and the therapist attached the elastic band to the door and carabiner. The case patient was then able to complete a full set of all the exercises demonstrated in both sitting and standing. Visual inspection of the residual limb revealed no unusual or problematic findings after exercise. Similarly, the patient reported no adverse effect. He further indicated he found the approach simple and repeatable.
We hypothesized that a simple solution for maintaining grasp of elastic strengthening bands would be feasible with a readily available eyebolt and carabiner in a manner typically used by able-bodied persons. This technical note demonstrates that our hypothesis is correct. This work extends the utility of commonly used gel liners in persons with ULA. In addition, it extends the base of prehensile options documented in the literature. For instance, prehensile tools and approaches have been reported for eating, dressing, and toileting.5,6 More recently, novel devices have been described for recreational pursuits such as kayaking.7,8
Benefits of designing elastic exercise band grasp around a silicone gel liner include:
- building experience with a prosthetic suspension component
- learning a don/doff procedure
- provision of a distal attachment site
- dispersion of exercise-related forces across a large portion of the residual limb
- favorable scar effects related to potential desensitization and potential scar size reduction9,10
- minimal restriction to proximal joints
This technical note offers one approach for introducing strength and ROM maintenance options to the patient with ULA(s). The added benefits of acclimating patients to using prosthetic componentry are learning a donning/doffing procedure and learning the potentially favorable effects that silicone has on minimizing the risk of developing abnormal scars.9,10 For multiple reasons such as allergic contact, hypersensitivity, and other potential contraindications, use of a liner may not be an option for all patients (Table 1). Thus, additional non-liner-dependent exercise alternatives should also be considered. Other means of maintaining grasp of an elastic band include attaching a common exercise cuff. Cuff attachments may include adjustable Velcro® (Velcro USA, Inc, Manchester, NH, USA) closure to adjust strap closure tension. A tradeoff may be that focal pressure could be created at the cuff's edge, which could cause discomfort or skin issues. A more simple solution could be to simply tie a knot at the end of the band; however, the same focal loading issue will likely result. Both of the aforementioned solutions could slip off the residual limb in extremes of joint range while loaded during exercise. In the nonamputated limb, the cuff or band is prevented from slipping off the end of the limb because the hand is larger than the forearm. With the exception of the elbow disarticulation level, amputated upper limbs are typically narrow distally and are unlikely to retain the basic loop created by a cuff or loop from a knotted elastic band. The resulting slippage could result in skin abrasion or injury to the limb during the resulting ballistic change in load.
When the residual limb is healed and matured, means to progress to more advanced exercise should be considered. Options for this include recreational terminal device use. For instance, terminal devices are available that enable firm grip of an exercise hand weight (i.e., Black Iron Master, TRS, Inc, Boulder, CO, USA). Furthermore, activity-specific recreational devices are available for a myriad of activities including swimming, basketball, baseball, and others.
This technical note is limited as it has not been rigorously, systematically tested in a generalizable sample of persons with ULA.
This technical note has limited generalizability as only a single case patient was assessed. The solution relies on a gel liner which may not be appropriate for all patients. In addition, liners are not tested for material strength under these conditions so the nature of failure under these conditions is unknown.
After a period of instruction and supervised use by a therapist and appropriate liner selection by a prosthetist, this application may be beneficial for patients. This novel liner utilization poses some additional unknown risk to patients and may void product warranty as liners are not intended for use and loading in this manner. These points should be reviewed with patients. The use of a liner that incorporates a distal attachment can permit attachment of an eyebolt and carabiner to permit attachment of an elastic exercise band. This permits routine strengthening and ROM exercises for use in the clinic or home settings for persons with ULA where grasp has been a challenge previously.
1. Zeigler-Graham K, Mackenzie EJ, Ephraim PL, et al. Estimating the prevalence of limb loss in the United States: 2005 to 2050. Arch Phys Med Rehabil
2008; 89(3): 422–429.
2. Smurr LM, Gulick K, Yancosek K, et al. Managing the upper extremity amputee: a protocol for success. J Hand Ther
2008; 21(2): 160–175; quiz 176.
3. Kisner C, Colby LA, eds. Therapeutic Exercise. Foundations and Techniques. 5th Ed. Philadelphia: F.A. Davis Co; 2007.
4. Nyland J. Clinical Decisions in Therapeutic Exercise. Planning and Implementation. Upper Saddle River: Pearson Education, Inc; 2006.
5. Friedmann L. Special equipment and aids for the young bilateral upper-extremity amputee. Artif Limbs
1965; 9(2): 26–33.
6. Friedmann L. Toileting self-care methods for bilateral high level upper limb amputees. Prosthet Orthot Int
1980; 4(1): 29–36.
7. Highsmith MJ, Carey SL, Koelsch KW, et al. Kinematic evaluation of terminal devices for kayaking with upper extremity amputation. J Prosthet Orthot
2007; 19(3): 84–90.
8. Highsmith MJ, Carey SL, Koelsch KW, et al. Design and fabrication of a passive-function, cylindrical grasp terminal device. Prosthet Orthot Int
2009; 33(4): 391–398.
9. Juckett G, Hartman-Adams H. Management of keloids and hypertrophic scars. Am Fam Physician
2009; 80(3): 253–260.
10. O'Brien L, Jones DJ. Silicone gel sheeting for preventing and treating hypertrophic and keloid scars. Cochrane Database Syst Rev