Making the perfect match
How to help clients select prostheses
A Missouri man recently was fitted with the nation’s first SensorHand, a myoelectric hand developed by Otto Boch Orthopedic Industry in Vienna, Austria, that grips like a real hand. Fitting him with the hand was expensive, but his case manager decided the $30,000 bill was worth it.
"I really fought to get him this hand. He was a very motivated person who wanted to get back to work. He was only off work four weeks. He started back doing one-handed work until his myoelectric hand was ready. He was also young, only 35, with five children," says Mavis Benner, RN, BSN, CCM, case manager with The Traveler’s Property Casualty in the Overland Park, KS, office.
Benner sent her client to Rehab Designs of America, an Overland Park, KS-based orthotics and prosthetics company with offices nationwide. "I sent him there simply because Rehab Designs opened a local office and one of their staff came to speak about prosthetics to a graduate class I was taking."
What Benner didn’t know was that John M. Miguelez, CP, senior upper-extremity specialist with Rehab Designs and a prosthetic consultant in Rolling Hills, CA, recently had been asked by Otto Boch Orthopedics to beta test its new SensorHand in the United States. "We set the SensorHand down next to another prosthetic hand and asked the client to make the decision.
In the end, the client chose the SensorHand because it has several advantages over other myoelectric hands," notes Miguelez, including the following:
• The SensorHand can be worn without a harness. "Because it doesn’t require a harness, the SensorHand allows the patient to move in any plain. This gives the wearer much greater mobility in all directions," he explains. The client had several issues that made fitting him with the SensorHand a special challenge. "He didn’t want to use a harness. In those cases, we might consider using the wrist bones to grab on to. However, this client had unusually shaped wrist bones for an adult male, so we couldn’t grip on to the wrists."
Miguelez designed a suction socket technique with a valve on the end and a plastic cuff that comes up over his elbow for good suspension. "The harness often creates issues with back pain, irritation, chafing, and limits range of motion," he says.
The large amount of residual limb also meant there was a smaller space to store the hand’s electronic components, he points out. "At his amputation level, we had to be very creative and still keep the circumference of the prosthesis small enough that the client could pull a jacket on over his arm in cold weather."
• The SensorHand can be cosmetically finished. "It was clear that this patient wanted his myoelectric hand to look as similar to his natural hand as possible," Miguelez says. "The SensorHand can easily be fitted with a cosmetic finish that even includes freckles to closely match the patient’s normal skin tones. The lithium ion battery in the SensorHand gives it a low profile that makes fitting it with a cosmetic cover easier."
• Sensors in the fingers that respond to changes in force and can prevent slippage. "For example, if you’re in bed holding a book and want to reach for a glass of water with one hand, the hand automatically tightens to allow you to hold the book with one hand as you reach for the glass with the other," he says. "Normally, myoelectric hands can’t respond to changes in force."
• It only requires a couple of hours to recharge. Other myoelectric prosthesis may take up to 16 hours.
Is there a job waiting?
Of course, case managers must consider not only the benefits of different prosthetics available on the market, but the needs and personalities of their clients as well. Factors that Miguelez and Benner suggest case managers consider when helping clients select a prosthesis include the following:
o Motivation.
"When clients lose a limb due to an accident, they go through a period of grief. Some patients have a harder time bouncing back," notes Benner. "There are people who give up. It may not be possible to successfully fit them with a prosthesis. This client was anxious to get back to a normal life with his family and his work."
o Lifestyle.
"Before you spend money on any prosthesis, you must consider what job is waiting for the client when he returns to work," Benner says. "This client was a die setter. He lost his hand in an industrial accident. His employer was willing to make accommodations from the beginning. He won’t be going back and running machinery, but the company plans to use him as a trainer and supervisor."
o Support system.
"This client was a very resilient person with a supportive wife. He’s also very spiritual and close to his church community," she says. "I thought that would serve him well as he adjusted. I had another client who had substance abuse problems and a poor social support system. I didn’t feel he was a good candidate for an expensive prosthesis."
o Expectations.
"He was a very bright guy with fairly reasonable expectations," she says. "It’s very important for case managers to work with clients on their expectations. There is a downside to even the most sophisticated prosthetics that we have a responsibility to discuss with clients."
In the case of the SensorHand, issues Benner discussed with her client include these:
• The hand feels pressure, not the patient.
• The hand has a limited life.
• The hand can’t get wet.
"I had him fitted for a hook at the same time as his SensorHand for several reasons," she adds. "First, if he ever wants to go out and shovel snow, or do water sports, he can’t wear his myoelectric hand. Second, if his myoelectric hand needs repair or recharging, I wanted him to have an alternative."
o Cost.
The SensorHand eventually will sell in this country for about $6,000, which does not include the total cost of the prosthesis, which came to $30,000 for Benner’s client. "Many insurance companies wouldn’t pay for a hand that expensive," she notes. "This was a workers’ comp case, by law the client must receive a functional prosthesis that allows return to work. Judges are now more willing to look at cosmetic issues as well as functional issues depending on the age and motivation of the injured worker."
Remember that the stump will change in the first year and budget roughly $1,000 to make a new socket during the first 12 months following injury, she advises. Other factors she suggests case managers consider when helping clients select prosthetics include:
o Speed.
"I can’t overemphasize the importance of facilitating the process as quickly as possible," she says. "It lessens the psychological impact of the limb loss and also keeps expectations more realistic and prevents muscles from atrophying."
o Convenience.
"I wanted it to be easy and convenient for him to get in for fittings and for training. He had to be fitted and trained how to use the hand. It was going to take many trips. I didn’t want it to be a burden," she explains.
In fact, she ran into an early stumbling block in her client’s rehabilitation. A few phone calls made it clear that there were no local occupational therapists with any experience in training clients how to use myoelectric hands. "I thought to myself, Here we’ve bought this expensive hand, and we won’t be able to find anyone to train him to use it,’" she says. "The only option looked like driving to Kansas City, which was a two hour drive one way."
However, Benner finally located a local therapist willing to take her client. "Rehab Designs sent her videotapes, and she basically trained herself."
Credit where it’s due
Benner then took an unusual step in her continued efforts to advocate for her client, even after fighting to get him the best possible prosthetic hand for his needs. "I wanted to get him even more committed than he already was to using his new hand and also to get him the attention I thought he had earned by maintaining such a positive outlook. I also wanted to bring some hope to others who may have lost a limb."
She contacted local television stations and newspapers and told them her client’s story. "Even CNN ran a piece on him. The local paper did a nice story with pictures of him picking up an egg with his new hand," she says, conceding that publicity isn’t appropriate in every situation.
"I wouldn’t do it [seek media coverage for a patient] or recommend doing it for every case, but this was special. It allowed him to publicly profess that this was his hand. I also appreciated the hard work the prosthetics company and the therapist had done for this man, and I wanted everyone to get some recognition."
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