LAS VEGAS — Many factors contribute to prosthesis rejection among amputees, according to research presented at the American Orthotic & Prosthetic Association National Assembly.
Lynsay Whelan, MS, OTR/L, director of remote training and occupational therapy at Touch Bionics, contributed to the development of an online platform for multi-articulating upper limb prosthesis users, which can identify and address those factors before the patient is fitted for a device.
“Looking at different studies out there, you see rejection rates anywhere from 0% to 100% depending on the population,” Whelan said.
Rejection rates for passive prostheses reached 39% in the adult population during the past 25 years, according to Upper Limb Prosthesis Use and Abandonment: A Survey of the Last 25 Years. Rejection reached 26% for body-powered and 23% for externally powered prostheses during the same time frame, the study found.
Some factors of rejection, such as level of amputation, cannot be controlled by the clinician. However, it is possible to compensate for the type of device, difficulty controlling the device, poor fit and training, Whelan said.
“We can have an influence on a number of areas … getting certain information up front is going to help us make sure that [patients] have the best outcomes.”
Patient Care Pathway
Along with a research team at Touch Bionics, Whelan developed the Patient Care Pathway, an online pre-fitting assessment tool that determines appropriate fit, functionality and type of prosthesis in order to maximize positive outcomes.
“Filling this out before [the patient] is fit[ted] creates a template treatment plan … to get some sort of baseline,” Whelan said. “It helps us be in line with realistic expectations and goals [that the patient would like to achieve].”
In the form of a self-reported survey, the Patient Care Pathway determines the initial functional status of the patient, as well as areas that need further attention during prosthetic fitting or training. It can be completed independently by the patient or in conjunction with a clinician. A post-fitting assessment also is used at the delivery of the prosthesis, and at 3 month intervals thereafter. This measures progress of the amputee over an extended period.
The platform uses two outcome measures. The first, the Disabilities of the Arm, Shoulder and Hand (DASH) assessment, is a 30-item self-report completed by the patient.
“The DASH measures function [of the entire upper limb], the role of pain in daily activities, impact on social role and asks questions about work, sports or some sort of performing arts area that [the patient] is interested in.”
The second outcome measure assessment is the Trinity Amputation and Prosthesis Experience Scales-Revised (TAPES-R). This is an independently evaluated self-report, which measures general, social and psychosocial adjustments to the prosthesis. Limitations and overall satisfaction also are evaluated.
A total of 90 individuals at the full hand amputation level, and 55 individuals at the partial hand level took part in the DASH assessment with their local prosthetists.
The assessment was measured on a zero to 100 scale, with zero representing a patient with a self-perception of having no disability and 100 representing a self-perception of the most severe level of disability.
In the pre-fitting stage, the partial hand group rated themselves at an average 38.8 level of disability. The full hand group came in at 35.3. Differences were even greater at the post-fitting stage, but the partial hand group ranked themselves as having a lower level of disability at 24.5. The full hand group averaged a 27.2.
The team also measured differences between i-limb ultra revolution users with congenital limb deficiency vs. patients with an acquired amputation. In the pre-fitting stage, those with congenital deficiency rated themselves at a 16.92 level of disability. Patients with an acquired amputation averaged a 39.83. In the post-fitting stage, those with congenital deficiency rated themselves at 11.88 level of disability; acquired amputation rated 30.21.
Whelan said post-fitting DASH scores for those with congenital limb deficiencies is comparable to normative scores for the general population at 10.1. She added that overall findings of the pre-DASH score showed higher self-reports of disability for partial hand amputees vs. more proximal levels.
In the TAPES-R assessment, the team evaluated overall satisfaction of the prosthesis on a scale of 8-34. For i-limb ultra revolution users, pre-fitting satisfaction with their previous prosthesis was rated at 16.7; i-limb digits users averaged 19.8. There were significant improvements in the post-fitting stage. The i-limb ultra revolution users ranked satisfaction at 24.8 and i-limb digits users averaged 27.9.
The team also looked at the percentage of individuals in the full hand group vs. the partial hand group who received therapy, scar, edema or initial acute management. A total of 33% of patients in the full hand group received pre-fitting therapy; 41% received post-therapy or formal prosthetic training. In the partial hand group, 16% received pre-fitting therapy and 87% received post-therapy.
“I cannot say [these percentages] are directly correlated to the partial hand group getting the better increase in their DASH scores,” Whelan noted. “There are a number of other factors. Partial hand [amputees] typically have wrist range of motion, sensation and other things that come into play.”
Many areas of satisfaction reported in the TAPES-R outcome measure included common areas of rejection noted in past research, Whelan added. Findings show that more than 80% of users were satisfied with the overall function of their prosthesis.
Whelan said some aspects of the Patient Care Pathway could benefit from further research. She said the impact of functional training can play key important role in improving overall scores.
Collaboration with occupational therapists also is a key focus, as it could maximize functional outcome measures for upper limb amputees, she added. The team is currently collaborating with Ohio State University to find additional functional benefits and subjective data to examine motion analysis with different terminal devices. Satisfaction levels are being monitored over an extended time frame and limitations of self-reported data are being addressed.
Whelan said the team will continue to develop the Patient Care Pathway in the hopes of creating a vast database of outcomes for upper limb amputees that is accessible worldwide.
“We need to start with something,” she said. “Outcomes make a big difference. I am sure all of us in this room – that is what we live for, that is what we do this for. This is a way to start.” — by Shawn M. Carter
Biddiss EA. Prosthet Orthot Int. 2007;doi:10.1080/03093640600994581
Touch Bionics: Patient Care Pathway. Available at www.touchbionics.com/support/patient-care-pathway. Accessed Sept. 25, 2014.
Whelan L. Patient Care Pathway: Outcomes for individuals with upper limb loss/deficiency fit with multi-articulating hands. Presented at: American Orthotic & Prosthetic Association National Assembly; Sept. 4-7, 2014; Las Vegas.
Disclosure: Whelan has no relevant financial disclosures.