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Introduction
The prosthetic rehabilitation of an crucial aspects of the rehabilitation not only the socket design but also
individual with a humeral neck, gle- process, because this is when informa- the control strategy. The extent of
nohumeral, or interscapulothoracic tion is gathered, both clinically and contralateral limb loss, deficiency or
level of absence has traditionally been through open dialogue, that serves as other involvement, and the degree of
a significant challenge to the rehabili- the basis for subsequent rehabilita- function present should be noted. All
tation team, often resulting in poor tion. Failure to devote sufficient time the considerations that apply to the
success rates. Each of these levels is and focus to the preprosthetic phase ipsilateral remnant are relevant to the
anatomically unique, but the overall has directly contributed to the histor- contralateral limb, as harnessing de-
approach to the prosthetic manage- ically suboptimal prosthetic success sign and control strategies must in-
ment is similar (Figure 1). This chap- rates for individuals with limb ab- corporate contralateral involvement.
ter describes the three phases of sence or amputation at the gleno- Lower limb deficiencies also play a
prosthetic management that are criti- humeral and associated levels. significant role in balance, donning
cal to long-term prosthesis use and and doffing, and general upper limb
patient satisfaction: (1) the prepros- Assessment component selection. For example,
thetic phase, during which the pros- Initially, the practitioner should the prosthesis for an individual with
thetic rehabilitation plan is formu- record not only the level(s) and an upper limb deficiency who uses a
lated; (2) the interim phase, during side(s) of involvement but also cane or a walker should have suffi-
which the diagnostic prosthesis, whether or not a loss of dominance cient prehensile grip to withstand the
which evolves into the definitive occurred. An overall health assess- forces applied to these balance aids.
prosthesis, is created; and (3) the ment should be made, and particular Myotesting is important to deter-
postprosthetic phase, during which attention should be paid to cardiac mine the feasibility of using myoelec-
the focus is on prosthetic refinement and associated circulatory health be- tric control. The information myo-
and training. The systematic method cause such proximal levels of limb testing provides is also important as a
of care described in this chapter can loss require the user to expend con- feedback tool for teaching and train-
maximize the patients prosthetic re- siderable effort during operation of a ing and is a quantifiable assessment of
habilitation potential. body-powered or hybrid prosthesis. patient progress. The interaction of
Ipsilateral considerations include the the myoelectric signals during agonis-
cause of absence, the date and extent tic and antagonistic contractions in
Preprosthetic Phase of injury if applicable, tissue condi- each relevant muscle or muscle group
The preprosthetic phase includes the tion, range of motion and strength must be assessed, not simply the am-
physical assessment of the patient, a (for gross movement as well as the plitude of a single channel in isola-
thorough consideration of prosthetic myoelectric signal), and any associ- tion. (Agonist and antagonist are
design criteria, a discussion of pros- ated discomfort or sensitivity related loosely defined here as they relate to
thetic options and components, and, to the region, whether from contact prosthetic function, which may or
finally, the formulation of the pros- pressure, potential weight bearing, or may not differ from physiologic func-
thetic rehabilitation plan. The physi- motions required for operation of the tion, depending on the muscle or
cal assessment of the individual with prosthesis. All of these elements are muscle groups involved.) Finally, the
upper limb absence is one of the most vitally important when considering practitioner must define the optimal
Figure 1 Typical clinical presentation of residual limb at the humeral neck (A), shoulder disarticulation (B), and interscapulothoracic
levels (C).
from family, friends, or others should humeral or associated level. The pres-
be considered. Any prior prosthetic ence of an occupational therapist
experiences, such as the option used, during the assessment is very helpful
the socket design, and the patients in the psychological, physical, and
perception of its effectiveness, com- psychosocial preparation of the indi-
fort, and ease of use should be dis- vidual. Preprosthetic therapy should
cussed and noted. include strength training of the ipsi-
The patients level of cognitive lateral side, the contralateral upper
ability may also limit the options ap- limb, and the lower limbs; mainte-
propriate for successful prosthetic nance and enhancement of range of
use. Therefore, another goal of the motion; desensitization techniques;
evaluation is to understand the vari- edema control; and, if necessary,
ous control schemes and their cogni- wound care.
tive demands on the user. Unfortunately, patient information
The vocational and avocational on the various aspects of upper limb
pursuits and personal desires of the prosthetics is limited. Therefore, the
Figure 2 Infraclavicular socket showing
electrode placement.
individual must be discussed thor- practitioner should spend consider-
oughly during the patient assessment. able time educating the patient about
Individuals with similar levels of limb the basics of casting, fabrication,
placement of electrodes within socket absence may require completely dif- delivery, postprosthetic procedures,
confines, taking into consideration ferent strategies to attain a successful available technology, and potential
comfort from electrode contact pres- result. In addition to the obvious functional gains and other attributes
sure and the consistency of contact physical issues of choosing suitable for each option.
under varying conditions (Figure 2). components, psychological and psy-
This is discussed more fully later in chosocial elements must be consid- Components
this chapter. ered carefully when designing the Regardless of the prosthetic option or
The prosthetist should discuss the appropriate prosthesis.1 The loss or control strategy selected, prostheses
limitations of terminal devices and absence of a limb at any level, for these levels require components at
other components to help the patient whether from an acquired amputa- the shoulder, elbow, and wrist as well
develop a realistic set of expectations. tion or congenital deficiency, dramat- as a terminal device. The three basic
The tendency to become one- ically affects an individuals body shoulder joint options are nonarticu-
handed and overuse the unimpaired image and self-esteem, and this psy- lated, friction, and locking. In some
limb should be discussed during the chological impact should be a pri- situations, such as for children or for
assessment. Important prosthetic de- mary focus of the evaluator. the patient requiring an activity-
sign considerations include whether Therapeutic intervention during specific prosthesis, a nonarticulated
donning and doffing will be assisted the preprosthetic, interim, and post- shoulder is preferred because this
or unassisted and whether any move- prosthetic phases is critical to the minimizes the added weight, bulk,
ments are to be avoided during this prosthetic rehabilitation of the indi- and complexity of this portion of the
process. The availability of assistance vidual with absence at the gleno- artificial limb. A friction shoulder
joint (Figure 3) allows the patient to lope. The selection of a wrist unit is
position the arm in space, which is based on the functional requirements
helpful for eating, self care, and other of the patient, not the level of ampu-
tasks. The friction shoulder joint is tation or deficiency.
the simplest articulated joint, but it Hooks generally have been consid-
has the disadvantage that the con- ered more functional than body-
tralateral limb must be used to assist powered hands. The prehension pat-
with positioning. A locking shoulder tern was considered superior for
joint allows the patient to position activities of daily living that involve
and then lock the humeral section in precision. In addition, patients and
space, permitting bimanual activities. rehabilitation professionals preferred
The locking mechanism can be acti- hooks because of their more rugged
vated by using a nudge control with design and usefulness for heavy-duty
the chin. Biscapular abduction, shoul- activities. The preference for hooks is
der elevation, and humeral remnant especially pronounced with body-
motion including flexion, extension, Figure 3 Infraclavicular socket with pas-
powered prostheses because body-
sive ball-and-socket friction shoulder
and abduction can be captured powered hands provide less grip force joint.
through a harness system to activate a and require significantly greater ex-
pull switch. The nudge lever and the cursion and force to operate. There-
pull switch are offered in either me- fore, patients with these high levels of have experienced complete loss of the
chanical or electric locking versions. absence often find body-powered arm or who were born with such
The latter requires significantly less hands difficult to operate because of high-level absence may find the dis-
excursion and force but is heavier and the inherently short lever arm of the comfort of high-level prostheses too
more complex. residuum at these levels. Because great an obstacle to overcome. The
Far more excursion and force are electric-powered hands offer in- loss of tactile sensation caused by
required to activate a body-powered creased grip force yet require less wearing a socket can be another rea-
elbow than an electric-powered one. gross body motion to operate, they son for rejection of a prosthesis.
At these high levels, the skeletal lever Many high-level amputees find that
have been used more widely during
arm is sufficiently compromised that an active prosthesis offers only lim-
the past several decades for individu-
many patients find it difficult, if not ited functional advantages.
als with amputations and deficiencies
impossible, to produce sufficient ex-
at these levels. Passive Prostheses
cursion to fully flex and lock a body-
powered elbow. Without the use of a Prosthetic Options Many types of passive prostheses are
multiposition elbow, the amputee can- designed for individuals with high
It is imperative to discuss the pros-
not effectively position the terminal levels of limb absence (Figure 4), in-
thetic options available to facilitate
device in space to accomplish activities cluding shoulder caps, which are of-
the patients participation in the re-
of daily living. In the past, an excur- ten used as cosmetic restorations at
habilitation process. Primary pros-
sion amplifier was sometimes used to the shoulder disarticulation and in-
compensate for the reduced excursion thetic options include independence terscapulothoracic (ISO term: fore-
available at these levels. The improved without a prosthesis, use of a passive quarter) levels. The most common
excursion required the user to gener- prosthesis, or use of an active pros- reasons an individual with a high-
ate increased force, however, which thesis. Active prostheses can be fur- level loss opts for a passive prosthesis
many found objectionable. In recent ther classified by the control method over an active one are reduced weight,
decades, electric-powered elbows have provided: body-powered, externally improved cosmesis, and reduced en-
been more widely used for such high- powered, or a hybrid system combin- ergy and cognitive requirements. Ini-
level fittings because they require far ing both body- and externally pow- tial, maintenance, and repair costs are
less effort to operate than does a body- ered components. Some patients pre- typically lower than for other types of
powered component, with or without fer an activity-specific prosthesis prostheses, although a high-definition
an excursion amplifier. optimized for one task. These devices silicone restoration may be more ex-
The four basic wrist units are fric- may incorporate active or passive ter- pensive than a simple mechanical
tion, locking, flexion, and quick- minal devices. prosthesis. The passive prosthesis of-
disconnect. A wrist unit allows the fers little or no pinch force. Some pas-
user to position the terminal device
Independence Without a sive prostheses have embedded wires
using the contralateral hand or com- Prosthesis in the hand component that allow
pensatory gross body movements, ex- The choice not to wear a prosthesis is prepositioning of the prosthetic digits
panding the users functional enve- an important option. Individuals who by shaping the fingers manually.
Interim Prosthetic
Phase
After a thorough prosthetic and ther-
apeutic rehabilitation plan has been
formulated, the interim prosthetic
phase starts. During this phase, the
prosthesis is created and therapy tran-
sitions from general residual limb
Figure 10 Body-powered socket design
preparation to specific prosthetic
covering less of the torso surface area training. Therapy could include elec-
than did early designs. tromyographic (EMG) site selection
and specific muscle differentiation for
Figure 9 Early body-powered socket de- members of the rehabilitation team, a myoelectric prosthesis or further
sign demonstrating extensive coverage of shoulder complex strengthening for
the ipsilateral torso.
including the physician, the physical
and occupational therapists, the psy- body-powered components. This
chologist, and the rehabilitation coor- phase also includes the cast impres-
To create an effective prosthesis, dinator, should be concurrent with sion, creation of a diagnostic prosthe-
the prosthetist must be able to assess the prosthetic assessment. Interaction sis, and the assessment of functional
the many design criteria both individ- and communication among rehabili- use of the diagnostic prosthesis, and it
ually and as they relate to one an- tation team members is critical to concludes with fabrication and deliv-
other. The harness system must be de- success at these levels. Once all mem- ery of a definitive prosthesis. The di-
termined during the preprosthetic bers of the rehabilitation team have agnostic prosthesis ensures that opti-
offered their recommendations, a fi- mal socket fit and comfort and
phase, as this will influence the socket
nal rehabilitation plan can be formu- prosthesis control/function, align-
design. The harness is especially criti-
lated. The recommendations must ment, and definitive fabrication spec-
cal in bilateral deficiencies or when
take into account the patients physi- ifications have been achieved.
significant areas of scarring or skin
cal capacity and willingness to com- The type of prosthesis control cho-
graft are present. With amputations at
mit to what is often a rigorous fitting sen influences socket design and
the humeral neck (see Case Study 2),
and training schedule.5 A patient who should therefore occur before an im-
the remnant humerus can often be
has a sense of control and active par- pression of the patients residual limb
used for primary or secondary con-
ticipation in the formulation of the is taken. Regardless of which pros-
trol strategies, which may affect com-
rehabilitation plan is more likely to thetic option is selected, all gleno-
ponent selection and socket design.
put forth the effort necessary to exe- humeral and associated level prosthe-
Finally, it is important to clarify the ses require a stable and comfortable
cute the plan successfully.
patients cosmetic expectations for the socket to support the prosthetic
The rehabilitation plan integrates
prosthesis because these consider- shoulder, elbow, wrist unit, and ter-
the patients prosthetic, therapeutic,
ations may also affect component se- minal device components.
psychological, and medical needs
lection, socket design, control strate-
based on short- and long-term goals.
gies, and long-term acceptance. The Prosthetic options affect occupational Socket Design
optimal socket is the one that bal- therapy, physical therapy, and psy- Despite differences in anatomy, socket
ances these interrelated goals to meet chological counseling.6 One of the designs for humeral neck amputa-
the needs of the individual amputee. greatest challenges is orchestrating tions, glenohumeral disarticulations,
the interaction of the various services. and interscapulothoracic-level ampu-
Formulation of the tations are similar and have gradually
When treatment team schedules are
Rehabilitation Plan not coordinated in advance, lapses evolved to cover less of the torso.
The preprosthetic phase culminates in care can delay the rehabilitation Early socket styles, which contained
with the formulation of a detailed process and lead to patient frustration all of the shoulder girdle and covered
prosthetic rehabilitation plan. Com- and discouragement. Progress evalua- much of the trunk, were bulky and
prehensive evaluations by the other tions should be scheduled regularly, hot and sometimes impinged on the
ses have allowed this patient to live in- of Adults and Children With Upper Ex- 12. Sears HH, Andrew JT, Jacobsen SC:
dependently in the community. tremity Amputation. New York, NY, Experience with the Utah arm, hand,
Demos, 2004, pp 125-126. and terminal device, in Atkins DJ,
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Recent improvements in components
Rehabil 1984;65:24-26. pp 200-201
and control options have achieved
3. Mckenzie DS: Powered prosthesis for 13. Alley RD, Sears HH: Powered upper
successful prosthetic fitting of many
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