Hi Gary,
Its good to see you over here! I guess he would have to be assessed to see if he was able to drive safely. Can he use the controls on a car with no adaptations? If not, then he will have to have his car modified to whatever he needs. Maybe rehab places would have the info? Here in New Zealand we would find out from places like ACC. (Accident Compensation Corporation)or the land transport authority. The people who do lisence tests should have that sort of info too I think.

A Practical Approach

Kim Doolan, clinical coordinator for Allen Orthotics and Prosthetics in Midland, Tex, not only works in O&P, she is also a patient. Born with no right arm below the elbow and with only the heels of her feet, Doolan uses both upper and lower limb prostheses. Yet, she drives a car and is an avid weekend hiker. Doolan is also a member of the board of directors of the Barr Foundation, a national group that funds replacement limbs for patients who could not otherwise afford them. As a lifelong user of prostheses and an activist in O&P, Doolan says she has had more opportunities than most patients to try the latest technologies. Like many amputees, she opts for the simple approach. She wears a cable-driven arm with a hook hand while working and utilizes a passive hand that appears almost identical to her real hand at social events. The passive hand plays only a cosmetic role. Around the house, she mostly forgoes a replacement upper limb altogether.

Doolan says myoelectric devices are too heavy for her to use. Although a myoelectric below-elbow arm weighs only about 1 lb, that is twice as much as her cable-driven system. She did not like the suction suspension system either. “I did not like the feel of it against my skin,” she says.

Stasica frequently finds himself fitting patients with mechanically driven cable and hook arms even though the technology could be construed as old-fashioned. Most of his customers in the Midwest are men who have lost an arm in a farm accident. They cannot use a myoelectric device because they work in areas where dust builds up that would disrupt the sensitive EMG sensors. “Farmers do not want all the gadgets. They want something they can put on and function with. They still want that old locking elbow, which is a lot sturdier and more stable,” Stasica says.


Hybrid Designs

Many upper limb patients are fitted with what Billock calls “hybrid prostheses,” usually consisting of a myoelectric wrist and hand coupled with a mechanical elbow. One reason for this, says Billock, is that electric elbows cannot support much weight. Recent advances in the design of counterbalancing units to reduce the force needed to flex a mechanical elbow with a shoulder harness also make the mechanical devices attractive. “I am not an advocate of electric elbows unless absolutely necessary,” Billock says.

Patients that have lost both arms are also candidates for hybrid prostheses. Uellendahl says that a bilateral patient might be fitted with one myoelectric arm and one mechanically driven arm. The electric limb is used because two harnessing systems (which would be required if both arms were mechanically driven) would tend to get in the way of one another and be difficult for the patient to control. And the mechanical limb gives the patient better feedback on position, speed, and force of movement than two myoelectric devices. “It is necessary to provide a variety of tools so the patient can perform a wider range of tasks,” Uellendahl says.


Training

It is critical that patients are trained to use the prescribed limb replacement devices. Early fitting is key in both congenital and traumatic cases. If patients are left without an upper limb for too long, they adapt to having only one arm and become quickly exasperated with and tend to reject whatever replacement device they do receive. Billock estimates the rate of rejection for mechanical limbs is as high as 60%, and for myoelectric devices about 25%. To counteract this rejection, congenitally limb-deficient children are now being fitted with passive limbs at 3 months of age. According to Miguelez, upper-limb specialists are also turning to the technique called IPOP (Immediate Post-Operative Prosthesis), which was pioneered by lower limb prosthetists, and is getting good results. With IPOP, patients wake up from surgery wearing temporary replacement arms. “The patients are thrilled,” Miguelez says. “They never learn to be one-handed, so you don’t have to reprogram them to be two-handed again.”

Carolina Bulow, PT, who is a member of a rehabilitation and therapy team put together by Stasica’s clinic in St Paul, says half the battle with patients is getting them to accept their limb loss. After that, the other half is training them to use their replacement limbs. “If you leave them untrained, they build up bad habits,” says Bulow, who is herself a lower limb amputee.


Surgical Input

One of the frustrations frequently expressed by upper limb prosthetists is that orthopedic surgeons rarely consult them before amputations are performed. They recognize that with trauma cases where a patient’s life may be at stake, the surgeon has no time to consult with a prosthetist about the best amputation site, but they point out that surgical decisions do often determine what sort of device can be prescribed. Although the principle of leaving limbs as long as possible is generally agreed upon, there are situations where having a shorter residuum would benefit the patient. For example, using myoelectric limbs, which contain a wealth of microprocessor hardware, might produce a replacement arm that is longer than the patient’s natural arm. There are also cases where elbow disarticulation surgery is preferred to below-elbow surgery if the residuum below the elbow is only a few centimeters in length, making limb attachment impossible. “The likelihood of teamwork with the surgeon depends on how the treatment center is structured,” Uellendahl says. “If O&P is offered, there is more likely to be input, but that is quite rare.”


Reimbursement

“These managed health care companies are just strangling my profession and its ability to provide a high level of care for our nation’s amputees,” Billock says. “There are so many L-codes. For the upper limb there are probably 40 to 50 codes that apply. There is a code for the myoelectric device, a code for the suspension system, a code for the glove, for the battery, for the battery charger. It is a very complex system.”

Kathleen Fike, administrative director of Billock’s Ohio facility, calls getting reimbursed “a difficult mountain to climb.”

She says health carriers will often fund, or attempt to fund, only one prosthetic device per lifetime per patient, a ridiculous circumstance in the case of a child with congenital limb loss and a growing body. Even full-grown adults wear out prostheses every 5 to 6 years and need replacements, Fike adds.

Miguelez makes handling reimbursement part of the service he offers the O&P providers he contracts with. “We try to create a case that the insurance carrier cannot deny,” he says. “We detail the patient’s life, the activities of daily living, and then add the medical reason why the prosthesis will solve the patient’s need.” Miguelez says that keeping meticulous records showing the insurance carrier why each item of funding is needed and “making the reimbursement agency a partner with the prosthetics provider” have helped him achieve a low rate of turndown. “But you have to be a little tenacious, too