A narrative review: current upper limb prosthetic options and design.

Purpose: This review was conducted to provide an overview of current literature as it relates to upper limb difference, available componentry, and prosthetic options and design. Emerging technologies combined with an increased awareness of the limb difference community have contributed to recent advancements in upper extremity prosthetics.Methods: A search of five major clinical databases utilizing keywords relating to upper limb prostheses, componenty and limb difference levels resulted in over 1200 articles. These articles were subjected to inclusion and exclusion criteria in order to identify current peer reviewed research relevant to this topic.Results: Fifty-five applicable articles and sources of standards were reviewed based on the inclusion and exclusion criteria, presenting five general options for prosthetic intervention. This information was assimilated and categorized in this article, which provides an overview of the aforementioned options.Conclusion: While a noteworthy amount of research focuses on technological advancements, the five options for prosthetic intervention are inherently represented in the current literature. For individuals with upper limb difference, as well as their care team, successful rehabilitation hinges on awareness of new components, the functional efficacy of these components, and the evolved techniques used in prosthetic design and fabrication. It is noted that the rapid evolution of upper limb prosthetics consistently outpaces research and publication of information.Implications for rehabilitationTo provide an overview of prosthetic design considerations and options to help create a more informed rehabilitation team, leading to improved outcomes in prescription and management of upper limb prosthetics.To bring awareness of current research in the field of upper limb prosthetics in order to provoke further exploration of the efficacy of prosthetic options and design considerations.

Capacity Assessment of Prosthetic Performance for the Upper Limb (CAPPFUL): Characterization of Normative Kinematics and Performance.

BACKGROUND: Evaluation of maladaptive compensatory movement is important to objectively identify the impact of prosthetic rehabilitative intervention on body mechanics. The Capacity Assessment of Prosthetic Performance for the Upper Limb (CAPPFUL) scores this type of compensation by comparing movements of the prosthesis user to movements of individuals with intact, sound upper limbs (ULs). However, expected movements of individuals with sound, intact ULs have not been studied for the set of tasks performed in the CAPPFUL. OBJECTIVE: To enhance the scoring approach for the maladaptive compensatory movement domain of the CAPPFUL by defining normative kinematic movement and characterizing variability and repeatability. DESIGN: Clinical measurement. SETTING: Laboratories at the U.S. Food and Drug Administration (FDA) and University of Texas-Arlington. PARTICIPANTS: Convenience sample of 20 participants with no upper limb (UL) disability or impairment. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASUREMENTS: Kinematic trajectories, range of motion, maximum angle, and completion time were calculated. Repeatability and intersubject variability were assessed by calculating Pearson's correlation coefficient (R), adjusted coefficient of multiple correlation (CMCadj), and max SD (SDmax) for nine joint angles at the elbow, shoulder, neck, and torso. RESULTS: For most joints evaluated, repeatability was lower (R < 0.8) for CAPPFUL 3-Zip vest, CAPPFUL 7-Cut w/ knife, and CAPPFUL 8-Squeeze water, implying inconsistent approaches within a subject from trial to trial for a given task. For most tasks, the joint angle SDmax across all participants was <20°. The approach for completing CAPPFUL 1 - Weights in crate and CAPPFUL 4 - Pick up dice was generally similar across participants (CMCadj >0.4). For other tasks, however, different approaches across participants at the torso and shoulder joint can be seen. CONCLUSION(S): This work established the expected movements of individuals with sound, intact ULs for tasks performed in the CAPPFUL that can be used to inform consistent, standardized scoring of the maladaptive compensatory movement domain.

Psychological distress among persons with upper extremity limb loss.

OBJECTIVE: We examined predictors of clinically significant levels of psychological distress among individuals with upper limb loss (ULL). DESIGN: A multisite, cross-sectional study completed at six prosthetic rehabilitation centres throughout the United States. METHODS: Oral administration of a brief assessment battery to 307 participants with ULL including demographic variables, injury information, screening instruments for PTSD and depression, pain interference, and activity restriction measures. Hierarchical multinomial logit models were conducted. Outcome groups were created using recommended cut-off scores on brief screening measures of depression and PTSD. Final models were assessed including relative risk ratios and marginal effects. RESULTS: Over half of the sample screened positive for depression, PTSD, or both. Eight individuals exceeded the recommended cut-off score indicative of PTSD only (2.6%), and 106 participants (34.5%) screened positive for depression only. Moreover, 64 participants (20.8%) reported co-occurring PTSD and depression. Subsequent models revealed women and ethnic minority participants were more likely to have clinically significant levels of depression and PTSD. Greater restriction in activity and increased pain interference also predicted psychological distress. CONCLUSIONS: These findings indicate a significant number of individuals with ULL experience clinically significant levels of psychological distress, and routine clinical assessment of depression and PTSD is warranted. Women and individuals from ethnic minorities may be particularly at risk, regardless of the severity and cause of ULL. Restrictions in preferred and goal-directed activities and persistent pain are also contributing factors. Psychological interventions that address these issues are indicated. Statement of contribution What is already known on this subject? Research investigating psychological reactions and adjustment after limb loss has primarily focused on lower limb loss. Little research has investigated psychological adjustment or distress following upper extremity loss. Lower extremity limb loss is more likely to be from a disease process while upper extremity limb loss is more likely to be due to traumatic injuries. Upper extremity limb loss possesses a qualitatively different experience as upper limb amputation is more readily apparent to others, impacts activities of daily living, and limits instrumental function in social and non-verbal communication. What does this study add? A significant percentage of individuals with upper limb loss report significant levels of depression, PTSD, and mixed depression and PTSD. Moreover, women and minority clients were more likely to report clinically significant levels of depression and mixed PTSD and depression. Activity restriction and pain interference's contributions in the final model helped to elucidate the clinical picture of psychological distress for persons with upper extremity limb loss. Greater activity restriction and limitations from pain interference increased the likelihood of reporting clinically significant levels of psychological distress.

Posttraumatic stress disorder symptom clusters and substance use among patients with upper limb amputations due to traumatic injury.

Purpose: Examining the relationship between posttraumatic stress disorder and posttraumatic stress disorder symptom clusters (re-experiencing, avoidance, hyperarousal, emotional numbing) on three substance use measures among individuals with upper limb amputation due to traumatic injury - an understudied population with high rates of posttraumatic stress disorder.Methods: Multi-site, cross-sectional design. Participants (N = 236) were recruited from seven prosthetic rehabilitation centres across the USA and completed measures of PTSD, alcohol use, prescription medication overuse, and illicit drug use.Results: Twenty-six percent of participants screened positive for posttraumatic stress disorder, 39% for problematic alcohol use, 12% for prescription medication overuse, and 7% for illicit drug use. No association was found between posttraumatic stress disorder or posttraumatic stress disorder symptoms clusters on problematic alcohol use. However, hyperarousal symptoms increased odds of overusing prescription medication (odds ratio = 3.30); further, a positive screen for posttraumatic stress disorder increased odds of illicit drug use (odds ratio = 2.95).Conclusions: These findings demonstrate the importance of assessing psychological well-being and a variety of substance use behaviours following amputation from traumatic injury. These findings may also provide clinically-relevant targets for prevention and intervention regarding prescription medication and illicit substance use, such as incorporating evidence-based treatment for posttraumatic stress disorder hyperarousal symptoms (e.g., prolonged exposure) and/or integrated treatment for posttraumatic stress-substance misuse (e.g., Seeking Safety) into patients' long-term inpatient/outpatient rehabilitation plans.Implications for rehabilitationPosttraumatic stress disorder hyperarousal symptoms increased odds of overusing prescription medication among individuals with upper limb amputation due to traumatic injury; a positive screen for posttraumatic stress disorder increased odds of illicit drug use.Psychological assessments should be incorporated into treatment and rehabilitation plans following amputation from traumatic injury.Rehabilitation specialists should consider adding or integrating evidence-based treatment for posttraumatic stress disorder into patients' long-term rehabilitation plan to reduce risk for problematic substance use.Findings support calls by the Centre for Disease Control and Prevention to overhaul prescription medication guidelines, including the need to assess risk and address harms concerning overuse of prescription medication.

Development and Psychometric Validation of Capacity Assessment of Prosthetic Performance for the Upper Limb (CAPPFUL).

OBJECTIVES: (1) To develop a performance-based measure for adult upper limb (UL) prosthetic functioning through broad (ie, overall performance) and functional domain-specific (eg, control skills) assessment of commonplace activities; (2) to conduct initial psychometric evaluation of the Capacity Assessment of Prosthetic Performance for the Upper Limb (CAPPFUL). DESIGN: Internal consistency of CAPPFUL and interrater reliability for task, functional domain, and full-scale (sub)scores among 3 independent raters were estimated. Known-group validity was examined comparing scores by amputation level. Convergent validity was assessed between CAPPFUL and 2 hand dexterity or function tests; discriminant validity was assessed against self-reported disability. SETTING: Six prosthetic rehabilitation centers across the United States. PARTICIPANTS: Subjects (N=60) with UL amputation using a prosthesis. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Not applicable. RESULTS: Interrater reliability was excellent for scoring on the task, domain, and full-scale scores (intraclass correlation coefficients=.88-.99). Internal consistency was good (α=.79-.82). Generally, subjects with higher UL amputation levels scored lower (worse) than subjects with lower UL amputation levels. CAPPFUL demonstrated strong correlations with measures of hand dexterity or functioning (rs=-.58 to .72) and moderate correlation with self-reported disability (r=-.35). CONCLUSIONS: CAPPFUL was designed as a versatile, low-burden measure of prosthesis performance for any UL functional prosthetic device type and any UL amputation level. CAPPFUL assesses overall performance and 5 functional performance domains during completion of 11 tasks that require movement in all planes while manipulating everyday objects requiring multiple grasp patterns. Psychometric evaluation indicates good interrater reliability, internal consistency, known-group validity, and convergent and discriminant validity.

Differences in level of upper limb loss on functional impairment, psychological well-being, and substance use.

PURPOSE/OBJECTIVE: The present study examines associations between levels of limb loss (partial hand vs. higher levels of limb loss) and eight clinically relevant measures of functional impairment, psychological well-being, and substance use. Research Method/Design: A cross-sectional, multisite study conducted at seven prosthetic rehabilitation centers across the United States. A total of 305 participants with upper limb loss (Mage = 44.28, SD = 15.45; 68.5% male; 70.5% white) completed orally administered self-assessments of pain interference, perceived activity restrictions, posttraumatic stress disorder (PTSD), depression, emotional reaction to their physical condition, problematic alcohol use, prescription medication overuse, and illicit drug use. RESULTS: Results showed individuals with partial hand loss were at significantly greater odds of endorsing pain interference and screening positive for PTSD. Results also showed level of limb loss was significantly associated with emotional reaction to their physical condition, such that participants with partial hand loss scored significantly above those with higher level limb loss. Conclusions/Implication: The current study highlights level of limb loss as an important correlate of several functional impairments and psychological measures among individuals with upper limb loss. These findings may inform clinicians and occupational therapists in their development of treatment and rehabilitation. In particular, practitioners should be cognizant of their patient's level of limb loss, as individuals with partial hand loss may be more susceptible to greater emotional reactions to their physical condition and increased psychological distress due to pain interfering with their work and elevated posttraumatic stress symptoms. (PsycINFO Database Record

Evaluation of Performance-Based Outcome Measures for the Upper Limb: A Comprehensive Narrative Review.

Objective performance-based outcome measures (OMs) have the potential to provide unbiased and reproducible assessments of limb function. However, very few of these performance-based OMs have been validated for upper limb (UL) prosthesis users. OMs validated in other clinical populations (eg, neurologic or musculoskeletal conditions) could be used to fill gaps in existing performance-based OMs for UL amputees. Additionally, a joint review might reveal consistent gaps across multiple clinical populations. Therefore, the objective of this review was to systematically characterize prominent measures used in both sets of clinical populations with regard to (1) location of task performance around the body, (2) possible grips employed, (3) bilateral versus unilateral task participation, and (4) details of scoring mechanisms. A systematic literature search was conducted in EMBASE, Medline, and Cumulative Index to Nursing and Allied Health electronic databases for variations of the following terms: stroke, musculoskeletal dysfunction, amputation, prosthesis, upper limb, outcome, assessments. Articles were included if they described performance-based OMs developed for disabilities of the UL. Results show most tasks were performed with 1 hand in the space directly in front of the participant. The tip, tripod, and cylindrical grips were most commonly used for the specific tasks. Few measures assessed sensation and movement quality. Overall, several limitations in OMs were identified. The solution to these limitations may be to modify and validate existing measures originally developed for other clinical populations as first steps to more aptly measure prosthesis use while more complete assessments for UL prosthesis users are being developed. LEVEL OF EVIDENCE: Level III.

Resilience, Pain Interference, and Upper Limb Loss: Testing the Mediating Effects of Positive Emotion and Activity Restriction on Distress.

OBJECTIVE: To test mediating effects of positive emotion and activity restriction on the associations of resilience and pain interference with distress reported by individuals with traumatic upper limb loss evaluated for prosthetics. DESIGN: Cross-sectional correlational study of several demographic and self-report measures of resilience, pain interference, activity restriction, positive emotions, and symptoms of depression and posttraumatic stress. SETTING: Six regional centers throughout the United States. PARTICIPANTS: A total of 263 prospective participants consented to be evaluated for eligibility and need for upper extremity prosthetics; participants (N=202; 57 women [28.2%] and 145 men [71.8%]; mean age, 41.81±14.83y; range, 18.01-72.95y) who sustained traumatic injuries were retained in this study. Most of them were identified as white (70.8%; n=143), followed by black (10.4%; n=21), Hispanic (9.9%; n=20), Asian (3.0%; n=6), other (1.5%; n=3), and missing (4.5%; n=9). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Primary Care Posttraumatic Stress Disorder Screen and depression screen. RESULTS: Resilience and pain interference were significantly correlated in predicted directions with positive emotions, activity restriction, and the 2 distress variables. A path model revealed that the associations of resilience and pain interference with both distress variables were completely mediated by positive emotions and activity restriction. There were no significant direct effects of resilience or pain interference on either distress variable. CONCLUSIONS: Resilience may facilitate adjustment via beneficial and predicted associations with positive emotions and active engagement with the environment. These relations are independent of the significant and inverse associations of pain interference with these same variables. Longitudinal research is needed to understand interactions between positive emotions and activity over time in promoting adjustment after traumatic limb loss. Individuals reporting depression and/or posttraumatic stress disorder symptoms may require interventions that reduce avoidance and promote activities that may increase the likelihood of experiencing positive emotions.

Outcomes and Perception of a Conventional and Alternative Myoelectric Control Strategy: A Study of Experienced and New Multiarticulating Hand Users.

Introduction: The development of multiarticulating hands holds the potential to restore lost function for upper-limb amputees. However, access to the full potential of commercialized devices is limited due to conventional control strategies for switching prosthesis modes, such as hand grips. For example, to switch grips in one conventional strategy, the prosthesis user must generate electromyogram (EMG) triggers (such as a cocontraction), which are cumbersome and nonintuitive. For this reason, alternative control strategies have emerged, which seek to facilitate grip switching. One specific application uses radio frequency identification (RFID) tags programmed with grip information. These tags can be placed on objects in the environment or carried on person. Upon approaching an RFID tag, the user's prosthesis reads the grip programmed on the tag and commands the hand into that grip. The purpose of this study was to compare the conventional strategy (using EMG triggers) with the alternative strategy (using RFID tags). Methods: The study evaluated three subjects: two users who actively use multiarticulating hands ("experienced" users) and one user who had never worn a multiarticulating hand ("new" user). Subjects were evaluated on two performance metrics: trigger completion time and the percentage of triggers that were successful on first attempt (first attempt success rate). Subjects also rated the difficulty, effort, and frustration with each strategy. Results: Results suggested faster trigger completion times with the EMG strategy for the experienced users and mixed results for the new user. Overall, the three subjects rated the RFID strategy as less difficult, tiring, and frustrating than the EMG strategy. Discussion and Conclusions: Continued studies with a larger subject pool are necessary to determine factors influencing performance and patient preference. This would allow identification of best strategies to access the full potential of new commercial devices. Still, the authors suggest that the synergistic use of both strategies can yield great benefits for both experienced and new multiarticulating hand users.

Predictors of readiness to change young adult drug use in community health settings.

This study evaluated readiness to change drug use in young adult patients aged 18-25 years who were provided screening and brief intervention as part of a Substance Abuse and Mental Health Services Administration (SAMHSA) Treatment Capacity Expansion Project. Non-treatment-seeking young adults at risk for drug problems (n = 1,560) were assessed for readiness to change. Structural equation modeling examined latent constructs: emotional distress, age, drug use severity, criminal behavior, gender, and race/ethnicity. Drug use severity fully mediated the relationship between emotional distress and readiness. In addition, females and young adults with more severe drug problems may be more amenable to behavior change.

Perspectives on housing among homeless emerging adults.

Homeless emerging adults need the safety and stability of housing programs if they are to avoid the elements and victimization of the streets, however, barriers to obtaining housing are numerous. This study identified factors associated with perspectives of housing services among 29 homeless emerging adults (ages 18-23 years) through one-on-one interviews. Data were gathered and analyzed using grounded theory methodology for qualitative information. Major themes of peer support and positive personal and programmatic interactions in the context of emerging adult development were noted as important factors in housing service utilization. These major themes should be taken into consideration for current housing programs, due to homeless emerging adults' oscillation between their desire for formal support and personal independence. Greater emphasis on services that do not require long term commitments and are more flexible in addressing specific barriers to housing for homeless emerging adults may increase use.

Factors influencing gross motor development in young children in an urban child welfare system.

PURPOSE: To determine whether young children involved with child welfare (CW) have gross motor (GM) delay; to examine relationships between GM skills and the influence of multiple factors on GM skills. METHODS: One hundred seventy-six children involved with CW received GM assessment, physical examinations, and caseworker interviews. Descriptive statistics, correlations, t tests, analysis of variance and covariance, and multiple regression analyses were completed. RESULTS: GM scores, lower than population norms, were associated with growth parameters. Children in kinship care had significantly higher GM scores compared with children in foster care and those with in-home protective services when adjusted for differences in time in CW. Abuse/neglect, medical neglect, and parental substance abuse produced lower scores; referral for abandonment produced higher scores. Age was most strongly related to GM outcome, with multiple regression explaining 19% of GM variance. CONCLUSION: Children involved with CW have lower mean GM scores than population norms. Several factors specific to CW experiences may influence GM outcome.

Incidental word learning in a hearing child of deaf adults.

It is unclear how children develop the ability to learn words incidentally (i.e., without direct instruction or numerous exposures). This investigation examined the early achievement of this skill by longitudinally tracking the expressive vocabulary and incidental word-learning capacities of a hearing child of Deaf adults who was natively learning American Sign Language (ASL) and spoken English. Despite receiving only 20% of language input in spoken English, the child's expressive vocabularies at 16 and 20 months of age, in each language, were similar to those of monolingual age-matched peers. At 16 months of age, the child showed signs of greater proficiency in the incidental learning of novel ASL signs than she did for spoken English words. At 20 months of age, the child was skilled at incidental word learning in both languages. These results support the methodology as it applies to examining theoretical models of incidental word learning. They also suggest that bilingual children can achieve typical vocabulary levels (even with minimal input in one of the languages) and that the development of incidental word learning follows a similar trajectory in ASL and spoken English.