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I recently attended a monthly meeting of my local CMSA Chapter.  The sponsor for the meeting was Snell Orthotics and Prosthetics of Little Rock who had invited BiOM to come and speak to us about advanced prosthetics.  John Braddock of BiOM and a patient model showed us an example with the iWalk PowerFoot.  During the presentation, John shared with us that select service members are participating in a program that will allow them to return to active duty.

The Tactical Defense Institute (TDI) in West Union, Ohio, is where the participants went to attend this pilot program designed to help learn how to better handle firearms while using these advanced “bionic” limbs.  The U.S. Departments of Defense (DoD) and Veterans Affairs (VA) have funded the development of advanced prosthetic devices that can help amputee veterans who want to return to active duty achieve this goal. However, to make optimal use of these devices users must be well trained in a high-stakes environment. TDI is just the place for that training due to its rural, 186-acre setting complete with seven shooting ranges, three live-fire houses, and more.  The tactical skills training helps participants overcome feelings of vulnerability.  The first event at TDI event was so successful that an official firearms course for individuals with amputations will take place next May.

Related articles

• “Bionic” limbs in development at Vanderbilt University (vp-medical.com)
• PowerFoot: The Next Step (oandp.com)

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• “Bionic” limbs in development at Vanderbilt University (vp-medical.com)
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Professor Michael Goldfarb, right, with amputee Craig Hutto who is wearing the new bionic leg developed at Vanderbilt (Photo: John Russell, Vanderbilt University)

A project at Vanderbilt University is building  a “smart” prosthesis that gives amputees a more natural gait.  Michael Goldfarb, a professor of mechanical engineering, at Vanderbilt’s Center for Intelligent Mechatronics, has been working for several years with Craig Hutto, who lost his leg in 2005 when he was attacked by a shark. Hutto, who is a lab assistant, has offered valuable input on what works and what doesn’t work for amputees. That has gone a long way towards making the bionic leg comfortable and workable in real-world conditions.

As a life care planner specializing in amputation injury, I always follow new technologies and refinements in prosthetics.  Lately, there have been an extraordinary number of improvements, both from the perspective of making prostheses safer as well as making them perform more “naturally”.

Stumble recovery is a feature of many of the “bionic” type lower extremity limbs on the market today, as well as on the one featured in this article by GizMag.  This is an extremely important feature, as without it, above knee amputees have a tremendous tendency to fall when walking over different terrains.

I attended a seminar a couple of years ago, and one of the speakers was an above knee amputee whose story brought to my attention the amount of mental energy that not having stumble recovery takes.  This gentleman told the group about how, prior to having his “bionic” limb, he would have to visually survey every single potential fall hazard and memorize those hazards everywhere he went.  He compared having a traditional, mechanical knee to driving in a snow- storm versus driving on a beautiful fall day.  That was how much mental energy it took him all day, every day.  This  expenditure was in addition to the amount of physical energy it took to ambulate.

V-Leg has taken decreasing energy expenditure a step farther.  According to Vanderbilt’s Center for Intelligent Mechatronics website:  “Despite significant technological advances over the past decade commercial above knee prostheses remain limited to energetically passive devices.

That is, the joints of the prostheses can either store or dissipate energy, but cannot provide any net power over a gait cycle. During level walking, transfemoral amputees expend up to 60% more  metabolic energy relative to healthy subjects, and exert as much as three times the affected-side hip power and torque relative to healthy subjects (which also results in significantly increased socket interface forces), presumably due to the lack of power generation at the knee and ankle joints. The inability to deliver joint power also impairs or precludes other locomotive functions, such as walking upstairs and up slopes or ramps.

It is our hypothesis that a prosthesis with actively powered knee and ankle joints will significantly enhance the mobility of these transfemoral amputees, both by diminishing the biomechanical disparity between transfemoral amputees and healthy persons during level walking, and by enabling forms of locomotion, such as ramp and stair climbing, not presently afforded by passive prostheses.” (http://research.vuse.vanderbilt.edu/cim/research_leg.html)

Of note is that there are other component manufacturers, such as Otto Bock and Ossur that offer power knees with power ankles in development.  As things continue to develop, I will continue to provide updates on the progress of these bionic and biometric devices.

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• Amputees Walk Farther, More Naturally With New Prosthesis from Vanderbilt (medgadget.com)
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My friend Ramona, recently posted about the Orlando, Florida student, Linda Lu, who has just received a hand transplant in her blog Suture for a Living.  Dr. Bates is a surgeon and also a phenomenal quitter.  So you see she certainly understands how important her hands are, yet she noted, “Just because we can do a procedure, doesn’t mean we always should.” I share her sentiments.

As a life care planning expert in amputation injury and limb loss, I find hand transplantation somewhat disturbing.  I can appreciate the technology and biological advances that have allowed transplantation to occur.  I certainly understand the desire the patient has to obtain a flesh and blood hand.  It’s just that I personally don’t feel this is an appropriate answer for most individuals and particularly not those who seem to have adapted well without. I wonder just how many of the 14 transplants done thus far were performed because the patient wanted a flesh and blood hand rather than weighing the risks and benefits concerning what the functional outcome would be.

According to the Fox News story, Ms. Lu lost her hand at one year of age secondary to Kawasaki disease.  A small child who grows up without a limb is very adaptive and typically does not wear a routine hand prosthesis.  Most single limb loss individuals will adapt and use a prosthesis for cosmetic reasons or on occasion, a body powered device for specific tasks.  While I do not know Ms. Lu, nor have I obtained any information outside of this news article, I am surprised she was accepted for this procedure with limb loss at such a young age.  I wonder what expectations she has for her life moving forward. I would certainly hope that the work up for a hand transplantation included a psychological evaluation to determine if her expectations were realistic.

One need only to review the case of Mr. Jeff Kepner, a bilateral hand transplant patient, to understand the concerns of such a procedure.  One year after his transplant he still regretted his life changing decision. In his words…

“I got it,” he said about the surgery. “And I regret it. It’s over and done with. I didn’t dream there would be this much therapy.”

“When I had the hooks, I worked and drove,” he said. “I did lots of things.”

“I don’t see the light at the end of the process,” Kepner said. “If three or four years later, nothing’s going to happen, yes, I would say take them off.”

Mr. Kepner sits in therapy for six hours a day…every day.  As of the report, he was unable to bend his fingers or distinguish textures. He is no longer as independent as he was with his bilateral prosthetics; requiring help to dress and bath.  The former culinary chef lost 60 pounds following the transplantation surgery which tells me he isn’t spending his time in the kitchen any longer. I would like to think he has improved and has made much progress since this news story, but his website hasn’t been updated since last summer. I take that as bad news.

Advances in medicine gave us the ability to perform hand transplantation, but tremendous advances have also been made in prosthetics. In upper limb loss prosthetics we now have transhumeral and shoulder disarticulation amputees able to wear a prosthesis which is controlled by activating muscles in their chest using a procedure called targeted muscle reinnervation. The i-Limb by Touch Bionics is a prosthesis which has five individually powered digits allowing the wearer to open and close the hand while articulating the fingers to close tightly around objects. Bebionic hands moves and grips in a natural and coordinated way and features individual motors for each digit of the hand. Otto Bock is developing the Michelangelo hand which features multiple grip functions and a flexible positionable wrist joint for a more natural shape and movement. This hand is expected to increase grip force and reliability without compromising speed seen in other prostheses. Even functional partial hand prostheses are possible with ProDigits by Touch Bionics.

The advantages of hand transplantation over prosthetic use is that of sensation. The expectation is that the transplanted hand will eventually be able to distinguish some textures and temperature changes.  A below the elbow amputee (BEA) patient of mine recently attended an appointment with his prosthetic provider.  He was looking into a new technologically advanced prosthetic to replace his old one.  He broke down crying and stated, “I just want to be able to reach over and caress my wife’s cheek as I kiss her or stroke her hair.”  The likelihood of obtaining a prosthesis with tactile sensation won’t be possible until we have cyborg ability to be both machine and flesh and blood.

When one compares the cost of surgery, therapy, immunosuppressive medications, psychological evaluation, follow up, and other necessary care, the medical costs for hand transplantation are higher than even the most highly advanced arm prosthesis.  The question becomes is the transplanted hand more functional than our most sophisticated prosthesis?  I think not, at least not at this time.  Regardless of the choice between hand transplant surgery or the most highly advanced prosthetic hand, the replacement is never going to be an adequate replacement for the God given hand. Any patient who thinks otherwise is going to be sorely disappointed.

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• Bionic prosthetic hands: Budding artist Tilly, 5, can hold a paintbrush for the first time thanks to her new hand after losing limbs to meningitis (dailymail.co.uk)
• High Tech Prosthetics: Compliments of our Veterans
• Life Care Planning for Limb Loss (VP-Medical)

Prosthetic technology continues to improve dramatically (as evidenced by this old prosthetic fitting image!), and the Department of Defense is one of the key drivers in these developments.  While reading this article about Mr. Loosen, the vet who is the first in the older group to receive this new X2 knee, I recalled a presentation that I attended on prosthetics about a year ago.  The amputee that presented was describing how much concentration was required to simply walk across the room on the “standard” type of above knee prosthesis.

He showed a slide of a lovely curving road on a beautiful fall day and asked the group how we would feel driving down it.  Then he showed a traffic-congested road in blizzard conditions, and asked how much more attention the audience would have to pay to simply driving  in those conditions, versus the first one.

His point?  Prior to having a microprocessor knee, similar to the knee mentioned in the article, just walking across a room was like the snowy road.  The energy expenditure for having to be that on alert was tremendous.  And, he still fell on a regular basis.

With the microprocessor knee, all of that changed.  He can walk with confidence, and he rarely falls—(falling is a tremendous hazard for an above knee amputee).

So, I was delighted to read that our returning soldiers as well as our older vets, will have the well-deserved opportunity to obtain microprocessor type knees that are even an improvement over what the presenter at that meeting wears.

Here is a quick look at the statistics:

• Since 2001, 900 soldiers have lost a limb in battle

• Total veteran amputee population right now is 45,000

• Each year 5000 veterans become amputees—primarily through disease processes and traumatic injuries.

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• Quadruple Amputee Swims the English Channel (vp-medical.com)
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• High-Tech Knee Holds Promise of Improving the Lives of Veterans Young and Old (nytimes.com)
• Breakthrough Prosthetic Socket System Greatly Improves Comfort and Performance for Individuals with Limb Loss (prweb.com)

USA Today reported that quadruple amputee, Frenchman Philippe Croizon, swam across the English Channel using customize flipper prosthesis in 13.5 hours.  This article is one that is both heartwarming and also provides a real life look at how an amputee can excel at anything he or she puts their mind to.  In my role of life care planner for an amputee, one of my primary goals is to gain a clear understanding of the types of activities and interests the individual has so that we can make sure that these interests and goals are factored into the plan.

Providing an amputee with the proper prosthetic devices is an essential part of the life care plan and is required (in addition to other equipment and services) to help the individual maintain their quality of life after an amputation.  Terminal devices, such as a swimming leg or golfing “hand” allows the amputee to be able to participate in activities that will also ensure that they are active and getting exercise, which in turn, prevents obesity, muscular atrophy, urinary tract disease and other conditions associated with a sedentary lifestyle.

Philippe Croizon, the amputee who made this swim, is an inspiration to us all!

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• Quadruple Amputee Swims English Channel (cbsnews.com)

Cody McCasland, 8 year old from Colleyville, Texas participated in the Ranger Triathlon at the Texas School for the Deaf.  Code is a double above the knee amputee.  He was born with a rare birth defect that caused his legs to form without knees and tibias (large bones of the lower legs).  Cody completed a 100m swim, 2.2 mile bike ride and 800 meter run in under thirty minutes.

Cody uses prostheses to walk around, but removes them for the swim.  He also uses a special push bicycle and racing wheelchair to complete the race.  He received assistance to carry him from each event to the transition area.

Cody is certainly inspiring for this abled body adult!  If you want to read more about Cody and see some other photos from the event, check out Statesman.com.

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Once again members of the amputee community will be jumping with a group of Wounded Warriors to demonstrate their independence and prove that the sky is the limit following amputation.  There will be live music, games, children’s activities, and WWII era planes will be on display.  It is a Guinness Book of World Record events for Limbs of Love.  The event is scheduled for Saturday, May 1st (a change secondary to inclement weather).  The event will be held at Skydive Spaceland just south of Houston.  For more information about the event, check out Airborne Amputees.

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Lineman, Shawn Spiwak’s was working when he was hit by 7,200 volts of electricity by what was thought to have been a dead wire. His elbow had brushed against the line when electricity ran through his body, sparks flying from his chest.  He fell backwards and was left dangling upside down from his safety harness.  His arm had been burned through and through.  There were entry and exit points left by the electricity.  He was severely burned and eventually lost his right leg at the hip and his right arm and shoulder well into his clavicle.

Electrical injuries often lead to amputation as well as a multitude of other problems which result with the nervous system of the body is short circuited.  The electricity literally burns from the inside out.  What you see on the outside is far worse on the inside.  Treating a patient with electrical burns is very complex and usually have a host of other issues which come up during the treatment.  The body is unable to regulate temperature.  The dead tissue (eschar) has to be cut away daily.  Typically the patient is placed on a ventilator and oftentimes placed into a medical coma.  Feeding tubes are placed to help provide the increased protein needed for wound healing.

These injuries leave an individual with many deficits.  Mr. Spiwak’s walked with a limp secondary to the prosthetic limb.  He is stared out and children often ask about his prosthesis to which he replies, “robot parts”.  Like others with severe injuries, Mr. Spiwak notes it takes more time to do everything.  Simple things like buttoning your clothes, putting on your shoes, opening a bottle, brushing your teeth; all require additional effort and sometimes assistive devices in order to complete the tasks.  Scar management is life long which requires multiple surgeries, compressive devices, and therapy.

Electrical amputation is one of the many topics of an upcoming Nurse Life Care Planning conference scheduled for October 2010.  As a Nurse Life Care Planner and Nurse Case Manager, I am often called on to coordinate care for or develop a life care plan for persons suffering amputation injuries.  If you want to learn more about this devastating injury, please join us in Boston on October 8-110, 2010.

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