Planting the Seeds

In high school I loved academics almost as much as athletics. I was fortunate to attend a school that believed in the importance of both – exercising your brain and your body. I carried my love for academics and athletics through college and beyond. It remains a core of my being even today, despite the occasional pain of tearing tendons and muscle fiber, such an enjoyable aspect of “the golden years.” No, I am not officially there yet, but “golden” can not possibly apply to the body.

Academic challenges

With regard to academics, I find it is critical to challenge my brain, if possible, everyday. Today, my challenges come from owning a prosthetic business. Those of you who are business owners know that you are constantly being challenged, and from many directions at once. I can not begin to list the challenges we face every day. But these challenges, while often stressful, are also exciting. I hope at least some of the time those of you who own your business can stop, take a deep breath and feel grateful of your independence. It is a gift that only those who have taken the risk can truly appreciate. My hat is off and my glass is raised to you all.

Part of the reason I expanded my clinical practice into product development is because I yearned to be involved in the challenges that arise from conceiving, producing and distributing a new product. Undertaking new adventures, while adding stress and uncertainty, yields benefits to the brain in much the same way our body and mind benefit from appropriately applied physical exercise, known as the SAID principle, or Specific Adaptation to Imposed Demand. This is also why I have chosen to focus on – and looking back on it now I can say truly dedicate my career to – improving the interface, because this is an area where I can experiment, innovate and create. And let’s face it, some of those 30- and 50-year-old socket designs are up for retirement.

Creative culture

Too often in corporate life, I see complacency rewarded and creativity squashed. As you contemplate your current situation and surroundings, does the environment promote or inhibit creativity? Are you challenging yourself everyday or are you floating along, constantly checking the clock, hoping the day ends soon? If you are a business owner, have you created a culture that encourages your employees to develop and excel or do you stifle them?

I remember a conversation I had with a senior manager at a previous place of employment. I was interested in attending a course that would enable me to better perform my specific duties and when I asked if the company had an advanced education reimbursement program I was told, “We are not a personal development company.” I knew at that moment that corporate life – at least at this company – was a dead-end for those who wished to grow and excel. It was not so much a lack of caring, although antipathy was in ample supply, but rather a lack of the big picture. This lack of awareness is a marker for the heart and soul of the corporate culture.

Physical benefits


In terms of my physical being, when I am working out, life just seems to fall into place. These last few years, it has been more difficult to actually find the time to go to the gym or get outside to run a trail because of the commitment in time and energy involved in running a business, not to mention the relatively new addition to our family, Naya. However, I understand the importance of maintaining body and mind, as does each member of our little family.

Let’s take my dog Buddy for instance. Without his walk every day, he lays around visibly depressed. And without Naya running around burning calories at the park, just try and get her to go to bed. It becomes quite a challenge. Besides, the endorphins that working out produces allow me to alleviate stress and feel whole.

Finally, let’s try and connect the dots and tie the above into a relevant clinical issue. Let’s imagine that someone told you that although we know the many benefits of getting regular physical activity — including controlling your weight; reducing your risk of cardiovascular disease, type 2 diabetes and some cancers; strengthening your bones and muscles; and improving your mental health and mood — we do not think you should do it. And what would you say if someone in the medical profession told you that physical exercise was not deemed “medically necessary?” What would you think? What would you do?

The case for upper limb prostheses

Unfortunately, we have faced this issue in the world of upper extremity prosthetics for a long time. With regard to lower extremities, if a wearer receives a prosthetic leg there is a better than average chance he or she will be able to perform many, if not all, of their daily activities.

So how is it different for upper extremity wearers? Even with all the advancements we have seen in the last few years such as dexterous hands, which allow for improved control systems and more functional interface designs, it is still extremely difficult to replicate the complexities of the human arm and hand. We so often deliver solutions that are limited in their capabilities and many of our patients discover they can only perform a limited set of tasks. In other words, upper extremity prostheses, by their very nature, are activity-specific. This is not to say there aren’t incredible individuals figuring out new ways to get by with what they have, but upper extremity technology has a long way to go in pursuit of a single prosthesis doing it all.

When I am working with an upper extremity wearer, I will review all of his or her goals with them so I can best create a rehabilitation strategy focused around their unique needs. If a set of goals revolve around a specific physical activity, we will submit to their insurance company a request for an adaptive prosthesis in addition to a daily wear prosthesis.

Reach out to payers

However, insurance companies often reject adaptive prostheses based on a belief that it is not “medically necessary.” This is a huge disservice to our patients, and does not recognize that wearers are no different than non-wearers. What is frequently considered a luxury by insurance companies is indeed often the difference between a shorter or longer life for those with limb loss or amelia. Payers are concerned with cost, but that is a short-term view. If insurance companies were concerned with the overall long-term cost of a patient, they would without a doubt approve adaptive prostheses. By allowing these wearers to participate in their favorite hobbies and sports, they will not only be much healthier people in terms of both physical and mental health, but will likely be much more successful wearers of their so-called “functional” or daily-wear prosthesis.

Many insurance companies rely on outside prosthetic consultants, including certified prosthetists and doctors to render an opinion of the clinical and occupational relevance of prosthetic recommendations. Some of these “experts” accept insurance companies’ stated policy to deny adaptive prostheses instead of offering an alternative opinion and challenging them on this policy. It is understood that a written policy is a written policy. This does not mean this position can not be amended if appropriate pressure is applied.

Submit claims

I will continue to submit for adaptive prostheses with the appropriate upper extremity wearer even if it means I need to do extra work in the face of tremendous odds. It is a long shot with many insurance companies, despite the creation of a new L-code for recreational terminal devices. I will continue to do this for several reasons:

  • It exposes insurance companies to the increasing need for adaptive prostheses.
  • It allows the prosthetist and the patient, if rejected, to appeal the decision, again paving the way for or at least allowing the possibility of greater empathy being felt by someone in the decision-making process.
  • It is the right thing to do. All clinicians need to ask themselves if they have done their best to change the mindset of payers.

At this point we are simply armed with common sense. We understand that hobbies and exercise are not just alternative ways to spend time but are essential components of our well-being. The insurance companies know this too. They are waiting for you to stand up and force them to acquiesce to your demands.

In their quest for outcomes data lies a double-edged sword. While they may determine that some high-tech devices do not offer much in the way of functional advantage over their more simple brethren, an unintended consequence will be the determination that adaptive prostheses are medically necessary.

For all the clinicians out there who never submitted for recreational or adaptive prostheses because you never expected to get paid, start right now. You may not get short-term satisfaction but you will be planting the seeds for a generation to come. It is the least we can do.

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