Dr Raghav Shrotriya
Department of Plastic Surgery
KEM Hospital, Mumbai
dr.raghav.s@gmail.com
REHABILITATION OF UPPER
EXTREMITY AMPUTEE

Introduction
 Despite the impressive advances in reparative
surgery, management of amputations remains an
important part of upper limb surgery.
 Initial treatment substantially determines long-
term outcome
 Goal for the remaining limb : is that it heal pain
free and be left in as useful a condition as
possible

Rehabilitation
 Functional
 Psychological
 Social

Exercise for the person with an
amputation
• A person with an amputation improves greatly if
he is taught some of the basic goals of
exercising, which are:
1. To improve or maintain the range of motion
of all the limbs.
2. To Improve the strength of the limbs.
3. To Improve endurance for daily activities.

 It is very important to avoid contractures
because contractures cause many problems
with prosthetic use and fitting.
 Positioning
 Stretching exercises to be started on
 Strengthening exercises day 2 or 3 after
amputation

Functional Activities Without a
Prosthesis
• Taking care of oneself after an upper limb
amputation is difficult and time consuming.
New ways of doing familiar tasks should be
explored for bathing , feeding, dressing,
toileting etc.
• Sometimes a change of hand dominance or
the use of adaptive devices to assist with
activities will enable the person to do the
activities.

• Another way to perform self care is to use
the mouth or the feet.
• Whenever possible these activities should be
done using a prosthesis

Parts of prosthesis

 Socket : comes in contact with the skin. It
must be comfortable or the person will not be
able to use the prosthesis

 Harness : prosthesis is held on to the body using
straps or a harness. The straps are made out of
leather, cloth or canvas. The straps extend in a figure
of “eight” shape behind the back and under the
opposite arm holding the prosthesis in place

 Mechanical elbow: simple hinge that allows
movement of the arm up and down, extend the
arm in space and allow the hand or terminal
device to bring objects to the mouth or body

 upper limb prosthesis can have different types of
terminal devices.
 Hands :
functional
mechanical
electric

 Hooks : allow more rugged use and allow the
person to see objects that are being handled, this
will make manipulation of objects easier because
you must rely on vision instead of feeling to
manipulate objects

 Manipulators push or pull objects. These devices
are simple to use and fabricate and can allow great
degree of independence

 Other assistive devices

 The proximal interphalangeal (PIP) joint of the
fingers is most important and in general should
be saved
 Preservation of length for thumb amputations is
almost always indicated and very often requires a
flap to accomplish.
 If the ring finger is lost, balance is improved by
transposition of the small finger on to the fourth
metacarpal with advancement to reduce gross
shortness compared to the adjacent middle finger

 If any finger has a length of 12 to 15mmdistal to
the inter digital web, preservation of length is
important and often requires flap closure. With
middle finger ray resection (through its
metacarpal),index finger transposition onto the
base of the third metacarpal gives excellent
restoration of balance to the hand

Transverse amputations
 There should be a conservative attitude about
constructing a unit to oppose the thumb by
flapbone- grafts or by toe transfers
badly accentuate the disfigurement
 rarely improve needed capability significantly
 preclude prosthetic development, which most
patient’s will choose if aware of what is available
today.

Upper Limb Prostheses
 To minimize physical, emotional, social, and
economic consequences of the loss.
 Generally the more distal the level of amputation,
the more useful will be prosthetic fitting. This is
because the more distal the amputation, the more
sensory feedback systems will be functioning to
give automatic control.

Type of prosthses
 two types –
 active (mechanical)
 or passive (purposely without internal mechanical units)
 Active prostheses are no more than simple clamping
devices that have none of the manipulating capability
characteristic of our hands. They may be body
powered or externally powered.
 Passive prostheses purposefully have no internal
mechanical units, but best meet the needs of the vast
majority of hand amputees today as the big numbers
are in partial hand and digital amputations. While not
containing motors, the digits of passive prostheses
can be constructed with armatures that permit change
in their configuration by the normal hand.

Congenital arm amputees
 Fit early in life: prosthesis may become a
part of there body image
 Change serially:6 month to 5 yr- new
prostheses every year
 6 – 10 years: every 2 years because of growth
 11-16 years: every 3 years
 Later : every 3-5 yrs depending on wear and
tear

Contraindications to aesthetic
prostheses
 Lack of motivation or unrealistic
expectations
 Voluminous or poorly aligned stump
prevents
 Prostheses that does not confirm to the
patient’s specific needs

Body powered vs Externally
powered prostheses
 Function : Body powered is a better choice as
proprioceptive feedback is seen
 Comfort: Externally powered is more comfortable
 Appearance: Externally powered has better
appearance
 Reliability: Body powered has simpler design and
hence more reliable

Advances in Prosthetics

Multi-articulating Hands
• Most advanced terminal devices
• Independently powered and controlled fingers
• Articulating fingers and rotating thumb
• Myoelectric control
• Microprocessors used to process information

In order for a robotic prosthetic limb to work, it must have several components to
integrate it into the body's function:
Biosensors detect signals from the user's nervous or muscular systems. It then
relays this information to a controller located inside the device, and processes
feedback from the limb and actuator (e.g., position, force) and sends it to the
controller. Examples include wires that detect electrical activity on the skin,
needle electrodes implanted in muscle, or solid-state electrode arrays with
nerves growing through them. One type of these biosensors are employed in
myoelectric prosthesis.

Mechanical sensors process aspects affecting the device (e.g., limb position,
applied force, load) and relay this information to the biosensor or controller.
Examples include force meters and accelerometers.
The controller is connected to the user's nerve and muscular systems and the
device itself. It sends intention commands from the user to the actuators of the
device, and interprets feedback from the mechanical and biosensors to the user.
The controller is also responsible for the monitoring and control of the movements
of the device.

An actuator mimics the actions of a muscle in producing force and movement.
Examples include a motor that aids or replaces original muscle tissue.
Targeted muscle reinnervation (TMR) is a technique in which motor
nerves which previously controlled muscles on an amputated limb
are surgically rerouted such that they reinnervate a small region of a large,
intact muscle, such as the pectoralis major.
As a result, when a patient thinks about moving the thumb of his missing
hand, a small area of muscle on his chest will contract instead. By placing
sensors over the reinervated muscle, these contractions can be made to
control movement of an appropriate part of the robotic prosthesis.

An emerging variant of this technique is called targeted sensory reinnervation
(TSR). This procedure is similar to TMR, except that sensory nerves are
surgically rerouted to skin on the chest, rather than motor nerves rerouted to
muscle
The patient then feels any sensory stimulus on that area of the chest, such as
pressure or temperature, as if it were occurring on the area of the amputated
limb which the nerve originally innervated.

In the future, artificial limbs could be built with sensors on fingertips or
other important areas. When a stimulus, such as pressure or temperature,
activated these sensors, an electrical signal would be sent to an actuator,
which would produce a similar stimulus on the "rewired" area of chest
skin. The user would then feel that stimulus as if it were occurring on an
appropriate part of the artificial limb.

Disadvantage of myoelectric
prostheses
 Weight
 Cost

bebionic v3 hand
• The myoelectric hand reacts quickly for smooth,
proportional control
• Onboard microprocessors continually monitor the
motion of individual digits for the creation of grip
patterns that may be reliably repeated
• The weight distribution of the hand has been
optimized
• More closely resembles the natural form in
movement and appearance.
• A custom silicone glove is available

Michelangelo® Hand by Otto Bock
• 4 movable fingers and a thumb that can be
separately positioned
• Innovative gripping kinematics and new degrees of
freedom
• Actively driven components are the thumb, index
finger and middle finger
• “neutral mode” for resting the hand in a natural
position, and a repositionable wrist joint offers a
more natural shape and movement

DEKA Arm Design Features
• •“Strap and Go” System
• •Primarily for proximal amputation levels
• •Multiple degrees of Powered Movement (10
degrees)
• •Multiple control options (EMG signals, FSRs,
gyroscopes)
• •End-point control – coordinated, simultaneous
control scheme of multiple joints

Future Considerations
 Advanced Surgical Reconstructive Techniques
 Osseointegration
 Targeted Muscle Reinnervation

Psychological support
 Providing information is important
to reduce the person’s and the family’s anxiety,
obtain cooperation in the treatment program
 to help the person with an amputation to adjust to his
new condition.
 Feeling of complete change in reality due to
 lack of function
 alteration of limb sensation
 change in body image
 lack of understanding of medical treatments

Response to amputations
 Phase1 :denial and disbelief. This is a short
phase during which the patient gets lots of
attention, and most patients handle it well.
 Phase2 :recognition of reality. Characterized by
anxiety about the future and sometimes anger
with a sense of being victimized.”
 Phase 3: emotional responses goes in one of
two directions. The majority of patients make
appropriate accommodation to their losses and
fully use their remaining assets, whereas a few
find “a new friend” on whom they can blame
failures or who can act as a vehicle for secondary
gains.

The Grieving Process
• Five stages of the grieving process:
Denial : may deny that the loss will change her life in
any significant manner
Bargaining : person may bargain with any individual
they believe has control over her physical well being
 Anger
Depression : crying to withdrawal, loss of appetite and
difficulty sleeping
Acceptance: starts to adapt to the physical loss of the
limb and begins to make adjustments in her activities of
daily living

• Psychological treatment interventions should
address both the person with an amputation and the
family
• Peer counseling or support groups
• Support the person as he reenters society and to
continue to discuss with him his changed body
image and how people may react poorly to him in
public
• Person with an amputation should be encouraged to
return to work or previous life roles

Thank you…