"Finally," I thought, "a scientific paper that accurately describes my prosthetic use."

I have been an amputee all my life and have worked in the prosthetic field since 1990, but I never personally identified with articles discussing upper-extremity amputees. Then, a colleague sent me a study published by Occupational Therapy Services, Addenbrooke’s NHS Trust, Cambridge, titled "An Evaluation of The Use Made of Cosmetic and Functional Prostheses by Unilateral Upper Limb Amputees."

The paper, written by C.M. Fraser, states: "There is currently a distinction drawn between a prosthesis considered to be provided for purely cosmetic reasons and a functional prosthesis provided to enable the amputee to achieve basic hand function." Using video analysis, the study demonstrates that for non-manipulative actions cosmetic prostheses are actively used in the performance of everyday tasks as frequently as functional prostheses.

I, like many amputees I’ve met, had a poor understanding of what it meant to be a good user. This paper taught me to rethink the phrase "successful prosthesis user." Researchers asked amputees with functional hooks or hands (which could open and close) and passive hooks or hands (which could not) to participate in the Cambridge study. Amputees with passive prostheses reported they were not good users. This was congruent with past studies in which amputees with similar prostheses completed surveys through the mail stating they didn’t use their passive hands.

What is remarkable about this study is that the researchers didn’t rely on self-reporting alone. They went to the homes of the amputees and videotaped them making and serving a hot beverage, buttering and slicing a piece of toast, writing on a piece of paper, sealing it into an envelope and then removing it. What the videos revealed was a surprise: "There was no significant difference between the groups in relation to the number of actions made for non-manipulative descriptors." Or, more simply put, actions like supporting, stabilizing, pushing or balancing were done as often by amputees with passive prostheses as by those with mechanical or electrical prostheses.

These findings do not diminish the fact that other amputees in the study with functional hands or hooks used the grasping capabilities of their prostheses; however, the findings do emphasize the definition of "functional" and the importance of appearance. "Functional" should not be limited to a prosthesis that can grasp an object. That definition ignores the majority of tasks that the prosthesis is actually used to perform. Holding objects up or down, pushing or pulling and wedging objects between the prosthesis and the wearer’s body are frequently accomplished without opening or closing a hand or hook. Even amputees who have prostheses capable of active grasp, will predominantly use their sound hand - reserving their prosthesis for use as an assistive, rather than a primary device.

If a prosthesis is fitted to an amputee based on "functional needs" only, which many consider the ability to grasp, then the majority of activities the prosthesis will actually be used for have been overlooked. Considering that most amputees will want an artificial arm that looks more like the arm they lost, they should be provided with a tool they will wear and use. If they do not like the appearance of their prostheses, they will probably not wear them. Thus, whether functional or passive, if the prosthesis lives in the closet, it will not be available to assist with activities.

I have heard many fellow amputees say they didn’t think they were vain until they lost their arm. They believe that their desire to wear a prosthesis that looks like the hand they lost is tantamount to requesting a luxury item. I believe just the opposite. Vanity is associated with seeking attention. Wanting a natural-looking prosthesis is wanting a prosthesis that will cause fewer people to take notice.

The Cambridge study also discusses the important role therapy can play in rehabilitation: "In training amputees to use their prostheses they are frequently encouraged to practice picking up small objects with their TDs [terminal devices]. The unilateral amputee may well demonstrate a high level of skill in the performance of these tasks in the clinic situation but is more likely to use his intact hand to execute these tasks in everyday life.... If the role of the prostheses in supporting, stabilizing, pushing, pulling, holding and facilitating balance in everyday life situations is accepted as more useful than that of manipulating small objects in the clinical situation, this could have a major influence on the design of prostheses and TDs and also influence training."

I remember when I was little, therapists required me to complete a list of things I had never done before and don’t believe I have done since. I realize some of the tasks were necessary to help me master control of the prosthesis; however, it wasn’t until 30 years later that an occupational therapist showed me I could stabilize (not grasp and crush) a banana with my prosthesis. Then, in my sound hand, I could hold a knife and make a cut to start peeling the banana. Before that, much to my dentists’ dismay, I had preferred my teeth to my hook for many "two-handed" activities. I hope one of the results of the study is to change healthcare providers’ and amputees’ ideas about what the prosthesis will really be used to do and how best to efficiently complete those tasks.

Even with therapy, I have never become proficient with mechanical or electric hands. As a small person, I find their weight to be a more negative feature than I find their ability to grasp to be a positive one. So, I have surprised myself by becoming a convert to a "passive" hand. This has made me realize that the findings of the Cambridge study apply to me. I never used the grasping capabilities of the other hands or hooks; however, many times each day, I do use the length of whatever prosthesis I’m wearing to help me stabilize objects. This isn’t to take any credit away from arm amputees who have mastered their mechanical or electric terminal devices - more power to them. They are getting maximum use from all parts of their prostheses. What the Cambridge study has taught me is to rethink the phrase "successful prosthetic user." Talking to other arm amputees, I realized I wasn’t the only one who felt like a traitor leaving my hook in the closet while I sported my passive hand around. I found for myself what I have heard from many others: We actually volunteer the use of the prosthesis more with a naturally shaped hand than with other terminal devices. Having people not notice our prostheses actually increases our use.

With luck, the Cambridge study will encourage us (amputees and healthcare providers) to be more open-minded about the function that passive prostheses provide and the comfort many wearers feel by blending in while functioning in society.

About the Author:

Kim Doolan is marketing and public relations director at Aesthetic Concerns Prosthetics in Midland, Texas. She has worked in the field of upper-extremity prosthetics since 1990 and has assisted in fitting all levels of passive, mechanical and electric prostheses. For more information go to the Web site: www.livingskin.com

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