Treatment of partial hand absence: from occupational therapy evaluation to prosthetic prescription

Limb amputations incidence

Etiology

Upper limb amputations

Thumb loss is not a “minor” amputation; it results in

40% loss of hand function

—> 36% loss of upper limb function

—> —> 22% whole person impairment

OTs / CHTs = key players

• Often first to evaluate partial hand patients

• Start building the interdisciplinary team

• Gather essential patient information

• Assess

  • Scar mobility and ROM

  • Edema

    • volumeter

    • figure 8

  • Pain

    • residual limb pain

    • phantom limb pain

  • Sensation and skin integrity

    • 2-point discrimination

    • microfilament, etc.

  • Strength

    • dynamometer

    • SQUEGG (squeezing oval to play games (e.g., shooting); used to improve grip strength)

  • Psychological status

    • be conscientious of gender differences

      • e.g., in appearance, perception of disabilities

Skin/wound care management

Pain management: phantom limb pain

• Graded motor imagery

  • Laterality

    • distinguishing between right vs left hands; especially on other people too- not just yourself

  • Motor imagery

    • visualizing actions (e.g., close your eyes and imagine bringing a cup to your mouth)

  • Mirror therapy

    • reflecting intact hand’s movements into a mirror to trick your brain

    • good for alleviating pain/discomfort

• Compression

• Virtual Reality

Pain management: residual limb pain

***Transcutaneous electrical nerve stimulation (TENS)

• electrodes being put onto the skin

• interrupts nerve pain signals to the brain

Scar tissue management

• gently massage the scar and surrounding tissue with thumb pads

• increase pressure as patient gets better

Edema management

• compression: apply tension most distally, lessen up on pressure proximally

  • coban

  • tubigrip

  • ACE wrap

• ice

• rest

Desensitization

grasping and rubbing in different textures

• start off light, e.g., silk;

• go up to harsher textures later, e.g., wool, toothbrush bristles

• e.g. activity, pick up small items in beans and rice

ROM and strength

Hand dominance retraining

Functional adaptations

Psychological support

6 solutions for digit absence

moveable

• positionable

  • heavy-duty ratcheting/tasks

  • set it and go

• body-powered

  • medium-duty tasks

    • e.g., holding a coffee, opening a bag of chips, opening a water bottle

  • requires active muscle contraction

  • grip strength is limited

• externally powered

  • light-duty tasks

    • e.g., holding papers, prepping meals

  • battery-operated

    • more advanced type of technology

    • must charge

    • must have routine maintenance

passive, or no prosthesis

• activity-specific

  • when other prostheses won’t work

  • for hobbies

    • e.g., holding a drumstick properly

  • insurance coverage can be tough, as these are considered 2nd-use after ADL-specific things

• passive functional

  • mostly aesthetic

  • offers some function

  • lack active motion

• no prosthesis

  • proprioception

  • most cost-effective

Positionable prostheses

Body-powered prostheses

Externally powered prostheses

Activity-specific prostheses

Passive functional prostheses

Reimbursement- workers comp

• Majority of partial hand cases

• Generally approved

Reimbursement- United States Department of Veterans Affairs

• Second largest case load

Reimbursement- Private insurance

• Strong clinical documentation needed

• Collaborative efforts are crucial for success

Reimbursement- Medicare/Medicaid

Some approvals have been noted

Roundtable of integrated care