ATP Series

Striking the Right Balance

Lifestyle, extremity function and prosthetic use are crucial in determining a limb loss client's needs. How do you address them all?

rocks stacked to balance on top of each other


Of all the mantras that permeate the complex rehab technology (CRT) industry, one stands out from the rest: There is no one-size-fits-all solution for patients, who typically require customized devices that can evolve with their mobility needs.

This is especially true when it comes to clients with limb loss — a diverse patient population that includes people born with or without use of their upper or lower extremities, as well as amputees who lost limbs in traumatic incidents or because of medical conditions such as cancer. Within this category, Assistive Technology Professionals (ATPs) encounter cases ranging from kids with congenital limb loss to veterans finding ways to remain independent after losing extremities during their military service.

Solving the mobility equation for these clients is complicated by another factor: the specific ways that people use prostheses in their daily lives. While one adult prefers to wear prosthetic devices nearly every time they leave the home, another may only use prostheses when they head to work or travel.

But even as the varying uses of prostheses present challenges with balance, weight distribution and seating, complex rehab professionals say there is a common trait among nearly all clients they serve, limb loss included: a desire to get from point A to point B, and to do so with as much independence as possible.

Now, the CRT industry must recognize which solutions can help patients with limb loss reach that goal, said Steffen Tiskus, PT, Training and Development Coordinator, Power Positioning, at Motion Concepts.

“For greater levels of independence, especially for individuals with lower-extremity amputations who would have the ability to independently put on and take off their prosthetic limbs, there are products that have been on the market for a number of years that are just under-utilized,” Tiskus said. “We are creatures of habit, but we need to open doors to some of these products, even if we’re less familiar with them.”

The Balance Equation

At the core of any wheelchair evaluation for a client who has lost one or more limbs is their sense of balance. Children growing up with congenital limb loss, due to their limbs not fully developing in utero, develop their own sense of balance. This trait makes it easier for children to transition to a chair as they get older, says Angie Kiger, M.Ed, CTRS, ATP/SMS, who serves as the Clinical Strategy and Education Manager for Sunrise Medical.

“It’s kind of a different ballgame,” Kiger said. “Because they were born not knowing their limbs were there, they actually learn and create their own sense of balance as they become mobile independently. When they’re working on their core as they’re growing, it’s a bit different than someone who lost their limbs later in life.”

Compare that experience to the wheelchair transition made by Special Forces veteran and Sunrise Medical client Mark Holbert, who lost both legs and some fingers on his right hand after stepping on an IED during his 2010 tour in Afghanistan. Holbert, now an active wheelchair user who prefers a folding-frame ultralightweight manual chair, has had to try out several products to figure out the right solution for his lifestyle.

Due to his injuries, Holbert’s right leg was amputated above the knee, while his left side amputation goes up to his hip.

“For me to off-weight the pressure and try not to get pressure sores, that was the biggest need for me,” Holbert told Mobility Management. “I tried multiple seats and different kinds of cushions, and I was constantly getting pressure sores left and right, and that’s being out of the [prosthetic] socket.”

Holbert also experienced issues with balance when he wore his lower limb prostheses while in his chair.

“When I was in a socket, it was bad if I had a cushion that was pre-shaped foam because then my whole balance of sitting up straight was off,” he added. “Now I had my prosthetics interfering with the cushion.”

The best solution for Holbert, in his prosthetic devices and out, was an air-celled cushion. He is now able to sit on the softer, more adjustable surface all day without developing the painful and dangerous pressure injuries that can plague people with limb loss. But the air cushion presents some unique balance challenges of its own, Holbert and Kiger noted.

“Mark has got a super strong upper body, and so transfers for him, even though he is missing most of the left leg, are easier,” Kiger said. “Sometimes people will report the full air-cell cushion can be difficult to navigate because it doesn’t provide them the firm support that a foam cushion may provide them.”

Switching to the air cushion from a foam solution made it harder for Holbert to balance his upper body as he tried to propel

himself forward with a manual chair. Overall, though, it works better for his day-to-day lifestyle.

“When I tried to push forward, it was hard to lean further in because I had no support,” Holbert said. “So now when I use my racing chair, I’ll have a smaller cushion that’s foam, and that gives me a more stable platform for me to push forward when I’m racing or just working out.”

It’s not uncommon for clients with limb loss to wish they could switch out cushions based on the activity and whether or not they are wearing prostheses, Kiger said. The process of trial and error for civilian clients is more difficult since they do not have the same access to additional products as military patients may have, she added. The funding process differs in every situation.

Kiger and Sunrise Medical are also working to address a common complaint of both people with congenital limb loss and amputees: feeling constantly overheated while in their chairs. Limb loss means less ability to manage body temperature via sweating, as clients have a smaller overall skin surface area. Sunrise Medical recently began offering the JAY Fluid cushion with Cryo Technology, which aims to prevent pressure injuries and cool the patient’s skin for up to eight hours.

Overheating is a constant issue for a Sunrise Medical client named Gabe, born without upper or lower extremities.

“He gets so hot so quickly, so he needs to make sure whatever his seating is made out of is breathable, because his temperature instability is crazy,” Kiger said. “It’s not just what’s in the material as far as what’s inside the seating support, but it’s also: Is there a way to cool the person?”

Customizing Power Systems for Protheses

Holbert, a proponent of ultralightweight manual chairs that allow him to travel and more efficiently get in and out of a vehicle, has the upper-body strength to propel himself forward, and prefers it that way. While power chairs may also be the choice for limb loss clients, Kiger said the focus is on the functional abilities of the client and their priorities.

“I had one young man that I met that said his therapist had tried for years to push him toward a power chair and he said: ‘I don’t want it. I want to be able to go into the city streets and hang out with my buddies. If I get a power chair, I’m actually slower,’” she said. “With kiddos, they just want to get out and play and interact as fast as possible.”

But most limb loss clients do require a power chair system, whether it’s due to age, strength levels or their ability to use their extremities, said Tiskus of Motion Concepts. CRT companies already offer devices and customizations that can increase independence for clients while using the chair and when transferring in and out of it.

“The reality is, depending on the age of the patient, our bodies were never meant to do that type of repetitive motion, coupled with the patient’s body weight, coupled with the weight of a manual chair, even the lightweight wheelchairs,” Tiskus said. “We tend to gravitate more towards power chairs to save their shoulder joints so they still have the ability to do activities of daily living with their upper extremities, and reduce the amount of fatigue that they experience.”

The power chair systems they use are dependent on what type of prostheses they use, and how much dexterity they have with the prosthetic limbs, he said.

“If they have limited dexterity, there’s different types of switches, different types of specialty input devices like head arrays or chin booms,” Tiskus said. “We have a power chin boom, a separate switch wherever it makes sense to mount it, that allows them to independently adjust height and swing the device out of the way when they need it to for transfers or to have a conversation without the joystick in front of them.”

Independent transfers can also be difficult without the help of a customized power system, according to Tiskus. His company offers a power-down transfer arm for lateral transfers, as it can be hard for someone with non-functional extremities to scoot off a slide board to transfer out of their chair.

“It’s very difficult for somebody with no use of their upper extremities to position a slide board and make sure it’s in an appropriate position for their specific needs,” Tiskus said. “The system is mounted directly on a dual-post armrest, they hit a switch, and this will actually power down and convert them to a transfer support system, such as a modified slide board that can be padded, solid, gels.”

One product that Tiskus has seen consistently help limb loss clients is the vertical platform lift, an elevator in the front part of the seating system that can allow somebody to shift body weight as they come forward out of the chair.

“From there, they have the ability to hit whatever switch makes sense for them that they can access that will lower them to the ground and then they can scoot forward,” Tiskus said. “It allows for safe transfers from the floor to the seat and back and vice versa.”

Evaluating What CRT Can Offer

There is no lack of solutions for people with limb loss. But amputees and clients with congenital limb loss can certainly benefit from ATPs and other CRT professionals evaluating how they can better cater to this patient population.

Kiger said the CRT team should remember small aspects of a mobility system that can make clients’ lives more comfortable, such as putting in a piece on chairs for residual limbs.

“If they don’t have their prosthetic on or do not have a prosthetic, it’s uncomfortable from a pressure standpoint, depending on where the limb was amputated, for it to be hanging there,” Kiger said. “Sometimes people don’t think to add that extra component to support it. If you’ve got your prosthetics on, in theory, they would be able to use the footplate. But if you don’t have it on at that point, it could be uncomfortable.”

Other solutions can be considered for pressure management as well. Beyond traditional tilt and recline systems and lateral tilt systems for clients who cannot tolerate a full range of redistribution, Tiskus has seen anterior (forward) tilt work well for clients with lower-extremity amputations.

“We worked with several patients who have lower-extremity limb loss, and they have the ability to independently put on and take off those prosthetic limbs,” Tiskus said. “They just need to be in a position more anterior to allow them to access the prosthetic limb and be able to take it on and off and then help transition from that seated to a standing position.”

Motion Concepts’ UpFront system allows for up to 45° of anterior tilt, reflecting a growing trend among manufacturers that are increasingly offering forward tilt. Tiskus noted that anterior tilt appears under-utilized, and clients could immediately benefit from its broad adoption.

“I’d love to see people taking a closer look at this because those systems can really make a difference to give a greater level of independence to somebody, especially for sit-to-stand transfers,” Tiskus said. “Hopefully with more exposure, with more manufacturers making products like this, it will open a door and give greater levels of independence for these individuals.”

This article originally appeared in the Apr/May 2020 issue of Mobility Management.

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