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Virtual Didactic - Upper Limb Amputation Rehabilit ...
Upper Limb Amputation Rehabilitation Led by Mary M ...
Upper Limb Amputation Rehabilitation Led by Mary Matsumoto
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All right. Let's go ahead and get started. Appreciate everybody joining us today. My name is Sterling Herring. I'm a PGY3 at Vanderbilt, and we welcome everybody to AAP Virtual Didactics for today. As always, want to recognize and appreciate those of you who are on the front lines of the COVID-19 pandemic. We're very happy to hear that things tend to be leveling off, and we hope that applies to you as well. However, we recognize that the burden throughout the entirety of this pandemic has not been equitably distributed, so we appreciate those of you who have been professionally or personally more affected than many of the rest of us. The goals of this lecture series are to augment didactic curricula that are ongoing at your home institutions, to offload overstretched faculty, and provide additional learning opportunities for off-schedule residents given many of the logistical challenges associated with this pandemic, to develop further digital learning resources, and to support physiatrists in general during COVID-19. So we're going to keep everybody video and audio muted, as always. If you have any questions, if you click up in the participants list, you should see my name up near the top. Again, my name is Sterling Herring. If you double-click my name, you can send me any questions you have for our presenter, and I can pass them along at appropriate times, typically at the end of the lecture, but also as warranted. If you have any questions, suggestions, or concerns about this lecture series in general, please feel free to reach out to Candice at AAP. Her email is there on the screen. I want to appreciate everybody who has participated in this. We continue to get interest from people who are just recently joining us, asking how long the videos are going to be available on the website. I will reiterate this at the end of the talk, but the videos are available at least through the end of this calendar year. So if you have been redeployed or otherwise engaged and have been unable to watch these lectures, feel free to do so at your leisure, and the link will be at the end of this, at the end of today's lecture. Our last lecture is scheduled, currently scheduled for tomorrow. So again, thank you everyone for joining us through the course of these lectures. So without further ado, we're excited to have Dr. Matsumoto here with us from the University of Minnesota. Thank you for joining us today. Thank you, Sterling. All right. Should I take over the screen? Yes, please. If you want to click the green arrow, it'll ask you if you want to take over from me. Okay. Perfect. Thank you. Can you guys see the PowerPoint now? Yes. Yes. Looks great. Thank you. Great. My name is Molly Matsumoto. I work at the Minneapolis VA Healthcare System, which is part of the University of Minnesota Department of Rehabilitation Medicine. Today, I will be talking about upper limb amputation rehabilitation. I thought this would be a good topic since we often don't get as much exposure to it in clinic as lower limb amputation rehabilitation. It is a very large subject, as I have realized over the past week. So I won't be able to cover everything, but we will hopefully get to much of the bread and butter and board relevant information. So our learning objectives are to identify causes of upper extremity amputation, to describe levels of amputation, including advantages and disadvantages of each level, and to understand componentry and operation of both body-powered and myoelectric upper limb prostheses, to compare different upper limb prosthetic systems, and finally, to discuss phases of rehabilitation after amputation. So in terms of epidemiology, males are much more likely to have an upper extremity amputation than females. About 23% of amputations are upper extremity, so much less common than lower extremity. And then there are about 41,000 people currently living with major upper limb loss, so major being wrist or above, and then about half a million with minor upper limb loss, which would be partial hand or finger. Unlike lower extremity amputation, where the vast majority are due to dysvascular disease, in the upper extremity, most amputations are due to trauma, so 80 to 90% are due to trauma, primarily in men ages 15 to 45 years old. I won't make any comment on why that might be. In terms of another cause is congenital limb loss, so about four in 10,000 babies born with congenital limb loss, over 50% of these are upper limb. Most common is a left transradial. Most cases have no hereditary implications, but teratogenic agents and amniotic band syndrome are common causes. Other causes are cancer, and some are due to vascular disease. So looking at levels of amputation, starting distally, we have finger amputations, which is the most common, so of upper extremity amputations, about 70 to 80% are finger amputations. And then moving proximally, there's the partial hand or transmetacarpal amputation. Then the wrist disarticulation level, the transradial level, elbow disarticulation level, transhumeral level, shoulder disarticulation level, and forequarter amputation. And then those percentages are how common each of those levels are, not including the finger amputations. So we see that transradial would be the most common, followed by transhumeral. So now we'll discuss some of the more common levels, and we will see some parallels to the levels in the lower extremity. So for the wrist disarticulation level, benefits include that it preserves maximum forearm supination and pronation, and provides a longer lever arm in the residual limb. Disadvantages are poor cosmesis with the prosthesis, and that difficulty fitting prosthetic components in uneven lengths due to the long residual limb, which are the disadvantages that we often see with the disarticulation levels of amputation, both in the upper and lower extremities. Next is the transradial level, which we saw was the most common level, and a very functional level with good prosthetic outcomes. So a long residual limb is about half to 90% the length of the contralateral limb, which is the length measured from the longest residual bone to the medial epicondyle, compared on the sound side to the length from the ulnar styloid to the medial epicondyle. So the longer length is ideal, and it preserves some supination and pronation. Short is considered 35% to 55%, and very short, less than 35%. At that very short length, elbow range of motion and strength may be limited, and suspension is more challenging. Next up is the elbow disarticulation level. So advantages are improved suspension and reduced rotation, compared to the transhumoral level, because of having the humeral epicondyles. Having the long lever arm disadvantages, again, poor cosmesis and challenges with fitting the prosthetic elbow joint, so we can't have to use the external joint because of the length of the residual limb. This level is preferred to transhumeral in children, because it preserves the epiphysis for growth. And there's less risk of bony overgrowth. Moving proximally, there is the transhumeral level. The length percentages here, similar to the transradial level, so long 50% to 90%. Again, this is the preferred length. Short is 30% to 50%, and at this level length, the socket has to come over the acromion, and it will limit your shoulder motion. And then very short is less than 30%. At this length, the prosthesis will be fit as a shoulder disarticulation, and there is limited strength and leverage for prosthetic control. And most of the motion in terms of a body-powered prosthesis will be coming from the scapula. Finally, our most proximal and also most more rare levels are the shoulder disarticulation and the forequarter amputation. In the forequarter amputation, the scapula is also lost, as well as the entire limb. For these levels, the socket extends onto the thorax, as we can see in the picture. And at this level, it's difficult fitting and using a prosthesis due to the number of joints being replaced and challenging suspension. In the forequarter amputation, if an active prosthesis is not a goal to be used, you can also provide a shoulder cap for cosmetic purposes. So next, we are going to discuss upper extremity prosthetic rehabilitation. In terms of prosthetic systems, there are four options, passive, body-powered, externally-powered, and hybrid, which would be some mix of the first three options. In the pictures here, on the left is one of my patients in a body-powered system, and then on the right, he's in his myoelectric system. But first, we're going to discuss the passive system. So in this prosthesis, there is no active movement. Advantages are that it is lightweight and it provides good cosmesis. Typically, it doesn't need a harness, and it can assist with some functional tasks, supporting and stabilizing objects, or assisting with bimanual activities. So for instance, you could use the passive prosthesis to hold a paper down while you're writing with your other hand, or to help carry a box. And the disadvantages are that there is no active movement or grip. Next is the body-powered prosthesis, which is the most commonly prescribed system. So this system is powered by body movements. Looking at this picture, you see that it typically consists of a harness, a control cable, a socket, a wrist, and a terminal device. At the transradial level, you'll also usually have the triceps pad and elbow hinges. And then at the transhumeral level, you would have an elbow joint and a second control cable. So the harness is anchored around the proximal arms and shoulders and connected to the cable control so that the movement of the arms and shoulders will be transmitted to the cable, causing excursion, which can be used to open or close the terminal device. The harness will also often help provide suspension. The most commonly used harness is the figure eight, which we see in these pictures here. So it has an axilla loop around the contralateral shoulder. An anterior strap on the side of the amputation helps to suspend the prosthesis. And then there's a control strap, which is the strap in the back that goes down and attaches to the control cable and the O-ring or cross point in the middle of the back. Other types of harnesses include the figure nine. So, this style still has the axillary loop, but there's no interior strap, so it does not provide any suspension. There's also the chest strap or shoulder saddle. This can be used if the patient cannot tolerate the axillary loop or if the patient will be doing heavy lifting. And the harness in this case does provide suspension. So, this top picture here is of the figure nine. And then the bottom pictures are of the chest strap and shoulder saddle. In terms of the terminal devices, there are hooks and hands. So, hooks are the most common. They are more durable, functional, and lighter and can provide a stronger grasp. And then the hand is more cosmetic. It provides limited pinch force. It can block visual feedback, and it is heavier. This is in terms of the body-powered terminal devices. And then there's, the hooks can be voluntary opening or voluntary closing. So, voluntary opening is the most common that we use. You can see in the top picture here that the voluntary opening terminal device will be open, will be closed at rest. And then the cable pulling on this, the piece here, will cause it to open, whereas the voluntary closing device is open at rest. And then the cable pulling on the piece here will cause it to close. So, for voluntary opening devices, the grip strength is determined by the rubber bands, which you can see in the bottom picture. The rubber band around the hook provides the grip strength, and you can add additional rubber bands for additional strength. But however many you add, you have to overcome that when you're opening the hook. For the voluntary closing device, the grip strength is determined by the amount of tension the user places on the control cable. So, you can add variable grip strength, whereas with the voluntary opening, it would be constant. But one drawback is that the user must apply continuous cable tension to maintain the grasp, whereas with the voluntary opening, it would be grasping at rest. In terms of the cable control systems, the cable runs between the harness and the terminal device. The shoulder motion creates tension on the cable through the harness. In the transradial system, you'll have a single control cable that will operate the terminal device. You see in the bottom left picture, there is the control strap of the harness, which is labeled C. And then the control cable comes off of that. Usually it's attached on the triceps cuff, which is probably A. And then a tricep attached on the socket, which we can see there in B, and then runs to the terminal device, which is labeled E. And then the motions that will open it are forward humeral flexion, which we can see in the picture on the right, and then also biscapular abduction, which is the picture in the center, which those motions of the shoulder will cause tension on the harness and then excursion of the cable to open or close the terminal device, depending on what kind of terminal device you have. Oops. For a transhumeral system, it is more complicated because we need to use a dual control cable. So the dual control cable will flex the elbow unit when the elbow is unlocked and operate the terminal device when the elbow is locked. And that's operated by the same movements that we discussed in the last slide, forward humeral flexion and biscapular abduction. And then there's also a single control cable or an elbow lock cable, which will alternate between elbow locking and unlocking. And that is activated by shoulder depression, extension, and abduction. So the down, back, out movement. So for example, a user might operate the dual control cable to flex the elbow, then operate the single control cable to lock it, and then using the dual control cable could open the terminal device. And then if you wanted to unlock the elbow, would do the down, out, back, unlock the elbow, and the elbow would extend with gravity. So I found a video here of a user showing how he does that. we're unable to hear the audio that's but if you think we can still benefit from the video that can that's fine okay um it's just a couple seconds longer uh we can we'll just finish it Okay All right So All right, so, um the next system we're going to discuss is the uh Externally powered system which is powered by a battery instead of by body movements It can be controlled by a switch operated by the other hand or the chin Or by myoelectric signals which come from surface electrodes placed on the muscles of the residual limb and this uh picture, um On the right is a shows a below elbow myoelectric prosthesis So you can see that there's the double walled socket the interior wall providing Total contact with the residual limb where the electrodes to pick up the myoelectric signals are placed And then uh within the socket we have the control unit or battery pack Uh the wrist and then the electric hand um, so this is one reason it can be challenging with the wrist distarticulation level is there If you wanted to use a myoelectric prosthesis, there would be no place within the socket to put the uh control unit and battery pack Um so, um Delving a little deeper into my electrical myoelectric control. There are a few different options Um, the first is uh direct control usually with two sites and two functions So at the transradial level, it would typically be the wrist extensors and flexors and um Firing the flexors would cause the terminal device to close and firing the extensors would cause it to open Um at the transhumeral level it's often the biceps and the triceps Uh, if you only have one site, uh, you can have a two function, uh, my electric device and usually it's like a weaker Uh signal would would activate one function and a stronger signal would activate. Uh the other Another option is pattern recognition. This involves multiple electrodes. Um The picture on the right, uh is a Test socket, uh where they're using pattern recognition and programming it um so this is The user trains the system to recognize uh signal patterns for specific actions of a prosthesis Um, so for instance the user would think about closing the hand and certain signals would be sent to the electrodes The user and prosthetist would program the prosthesis to recognize that pattern of activation as the signal for closing the hand So then when the user did it again, uh, the hand would close So this is a bit more intuitive But can also be error prone for instance if the prosthesis moves or rotates Uh, the signals may be different and may not be recognized appropriately And then there is targeted muscle, uh re-innervation, which is a relatively, uh New surgical approach first performed in 2004 Which was designed to improve, uh prosthetic control in proximal upper extremity amputations Uh, so proximal muscle groups are re-innervated with nerves that previously controlled distal muscle groups um, typically like median radial muscular typically like median radial muscular cutaneous nerve Uh, and then those re-innervated muscles produce myoelectric activity Uh that can be detected by surface electrodes and used to control a prosthesis This allows for intuitive pairing between a transferred nerve signal and previous function of the nerve So for instance the median nerve would signal closing the hand Um This is a most benefit for the more proximal level So it's typically done with a transhumoral or shoulder disarticulation level where there's more function needed but fewer muscles available for to create the myoelectric signal Interestingly, this procedure was developed for prosthetic control, but another benefit was found which is that it has been found to improve neuroma and phantom limb pain Um As with body powered, uh, the myoelectric terminal device can be either a hand or a hook so in this picture here on the Far right are two examples of electric hooks and then uh in the middle are some two pictures of myoelectric hands these hands can be uh are usually multi-articulate and can have Uh 30 or more unique grasps or gestures All right, so this is a video of someone using a myoelectric, uh hand and uh, no sound is needed I think Okay, finally the last type of system is a hybrid system. So as I mentioned, it's a combination of two other systems. So part would be passive and body-powered myoelectric, most common in a higher level of amputation. So you might commonly see like a body-powered elbow and a myoelectric terminal device, which I think is what we're seeing in the picture here. So when we compare body-powered versus myoelectric systems, the advantages of a body-powered system are that it's lighter weight, more durable, less expensive, provides better sensory feedback, is easier to repair, and can be used in dirty or wet environments. Drawbacks are that it's less cosmetic, it requires a harness, and motor strength. For the myoelectric system, advantages are that it's more cosmetic, no harness is required, and a greater pinch force is possible. But the disadvantages are that it's heavier, more maintenance is required, it's more expensive, and the batteries need to be recharged. Given all these options, how do we decide on a prosthetic prescription for a patient? The most important thing to consider is the functional goals. So what do they want to be able to do with the prosthesis? I saw someone who was independent with ADLs with one hand. He was a unilateral upper extremity amputee, but was a welder and couldn't do that one-handed, so his main goal was to use a prosthesis to be able to weld. Other considerations is, do they want to be outdoors or doing manual labor? In that case, a body-powered system might work better. Is cosmesis very important? In that case, you might want to use a hand terminal device instead of a hook. You also have to consider any other impairments. If there is shoulder weakness, they may not be able to operate a body-powered system. If they have cognitive impairments, you would not want to choose a hand with 30-grip patterns, where they need to be able to use a smartphone to switch between modes. We also have to be mindful of the weight of the device, because if it is too heavy, that is a common reason that a user will reject it. And it is one reason to use a hybrid system, rather than a totally mild electric system. And then, residual limb length also should be considered, because similar to with a lower extremity amputation, you have to consider how much room you have for componentry, particularly with the myoelectric systems. You also need to consider durability and need for maintenance. A patient may live in a rural area, so they may not have a lot of room for maintenance. You also need to consider durability and need for maintenance. A patient may live in a rural area and not have easy access to a prosthetist, so you'll want to give them something that doesn't break easily, or make sure they have a backup. So, the prosthetic prescription is designed for the patient, considering their functional goals with the prosthesis, their physical and cognitive abilities, their social situation, prior function, and other factors. There's no best component for your best system. There is a best system for a specific patient. So, that is the art and skill of amputee rehab, and is to come up, and one of the things I love most about my job, and why I think that as physiatrists, we have the best background and training to create the prosthetic prescription. And having the appropriate prosthetic prescription is important to having good outcomes and acceptance of the prosthesis. In general, upper extremity amputees have lower acceptance, so about 60%. There are many reasons for this. One is that a unilateral upper extremity amputee can be totally independent without the use of a prosthesis. Many feel that the prosthesis responds too slowly, and it doesn't provide sensory feedback. So, the highest acceptance rate is among the transradial level amputees. One study showed about 94% acceptance than the more distal and proximal levels. So, that same study showed about 50% acceptance at the bristis articulation level, and 43% at the transhumeral level. So, the more distal levels may prefer to use the residual limb, because they can be very functional with it, and it provides sensory feedback that they don't get from the prosthesis. And then at the more proximal levels, above the elbow, it is more challenging to use a prosthesis, and it's heavier. Decreased shoulder range of motion and brachial plexus injuries were associated with discontinuing prosthetic use. Some studies also show increased acceptance with early fitting. One study showed increased acceptance with fitting within the first month, and among bilateral amputees who may not, who would not be able to be independent without using a prosthesis, as independent without using a prosthesis. So, I wanted to show this slide showing some of the activity-specific terminal devices that are available. So, there's one, most of these are passive terminal devices. The top left one is for basketball, obviously. Below that is a terminal device to hold a golf club. Then moving right, one to attach onto a bike handle. You can actually have a hammer as your terminal device. The one on the top right is a weight lifting terminal device. And then the bottom for archery. So, finally, we're going to talk about rehabilitation. First, we have the post-operative or pre-prosthetic rehabilitation in education. Goals of this are to maintain joint range of motion and strength, to prevent contractures, and to practice and strengthen motions needed to control the prosthesis. If you anticipate that the patient would be fit with a myoelectric prosthesis, you can also do myocyte testing and training at this point. To regain independence and self-care and mobility, so OT will work with the patient on one-handed techniques and providing adaptive equipment, and then to retrain hand dominance if needed. Residual limb healing and shaping, so edema control and use of residual limb dressings. Pain control, as with all amputees, phantom sensation and pain are common. And we can train the patient in desensitization techniques. Adjustment to disability, so the patient can meet with peer support or rehab psychology. The picture on the right is one of our upper extremity amputees meeting with a peer support over telemedicine. Because upper extremity amputation is less common, there may not be peer support available locally. And finally, education, the timeline for healing and getting a prosthesis, what prosthetic fitting will involve, what componentry they may be using, and then expectations and functional goals with a prosthesis. Once fit with a prosthesis, goals are for, first of all, independence with donning and doffing the prosthesis, managing sock ply and caring for the prosthesis, and then training on how to use the prosthesis, so starting with being able to open and close the terminal device, and then progressing to using it for ADLs, IADLs, and then higher level activities, vocational and recreational activities. After initial fitting and training is completed, the patient will have long-term, lifelong follow-up with their rehabilitation team. This is very important to troubleshoot barriers with prosthetic use, which could be skin problems, pain, changes in residual limb volume, or psychological issues with the prosthesis. And finally, the patient will be able to use the prosthesis could be skin problems, pain, changes in residual limb volume, or psychological issues, and then work on goals such as return to work or school, return to hobbies or sports or other activities, and then ensuring that the prosthetic fit system and componentry is appropriate as the patient's needs may change. This is a picture of my fellowship director, Dr. Jeff Heckman, at the Puget Sound VA in Seattle, providing great care to an upper extremity amputee, which is to say that there are amputation rehabilitation fellowships available for those interested in gaining further knowledge in this field after residency. There are three VA-based fellowships that I know of at Seattle, Richmond, and Tampa. I completed the fellowship in Seattle and greatly enjoyed and benefited from that experience. So that is the end of my presentation. Thank you for attending this virtual didactic. If you like working with an interdisciplinary team, amputee rehab is a great field. This is the team that I work with at the Minneapolis VA of physiatrists, prosthetists, PTs, OTs, psychologists, and nurses. Thank you very much. A couple of questions for you. I appreciate this lecture. This was a lot of great information, as you mentioned, both clinically and academically relevant, so appreciate that. You mentioned your fellowship and you're currently working in an academic VA setting. Can you kind of talk about some of the differences in accessibility? I know the VA is unique in terms of the U.S. medical system. I know we often have an international audience, so it's kind of a social medical system within the greater U.S. medical system. Can you kind of discuss some of the differences in access there? Sure, absolutely. So we are within the VA. All prosthetic care is covered through the VA benefits, so we have a great access to prosthetics care for veterans. Outside of the VA, working with Medicare or private insurances, there are more limitations. I think, for instance, patients usually only qualify for one prosthesis, and then in terms of componentry, the componentry you choose has to be justified by the K-level. So the Medicare functional classification, you know, for like a microprocessor, well, in lower extremity for like a microprocessor knee, for instance, K-3 or above for an energy-storing foot, K-3 or above. Within the VA, as clinicians, we're allowed to make what we consider the most appropriate choice and are able to provide our patients with that. We are also able to provide activity-specific limbs, so more than one prosthesis. So we have a lot of resources within the VA for prosthetic and amputee rehab care, I think, compared to working with Medicare and private insurance. Okay, that's helpful. The video you showed of the myoelectric device was really kind of amazing. Can you talk about some of the kind of up-and-coming issues with myoelectric devices? Well, I think with myoelectric prostheses, so in that video, you know, you could see him touching the back of the hand, and I think that was probably to switch modes. So he had some myocytes that he was using and then would switch modes, and those same sites could be used to activate like different grip patterns. Oftentimes, there'll be like a smartphone and an app that the patient can use to switch modes as well. So it's very sophisticated, but depending on the patient, I think you have to have the right patient to take advantage of that sophistication. Okay. Some of the body power devices sometimes appear, anyway, to allow for finer tuning of some of the motions, which can kind of act as a surrogate for tactile feedback. Are there any of these newer devices, or is there talk about newer devices? Is there any ability at all to provide actual tactile feedback? So I don't know of any ability to do that through the myoelectric devices at this point, but that is one advantage that to the body-powered devices is that through the harness and the cable, the user feels like they get some sensory feedback from the device. Okay, that makes sense. In the setting of COVID-19, you know, I think prostheses in general, but certainly upper extremity prostheses present a very specific concern in the sense that, you know, we're all being told to wash our hands 20 seconds, 40 seconds, however long, several times a day. What advice are you giving to your individuals with upper extremity limb loss in the current environment? You know, that's a great question, and I had not really thought of that. We have really limited our clinical services right now, so it actually hasn't come up yet, but I guess, but I would give them the advice to clean it and disinfect the terminal device. All right, yeah. In a similar, you know, manner to hand washing. Yeah, right. So yeah, just kind of things for all of us to think about probably as we're kind of ramping back up our clinical responsibilities. If we have, let me see, I believe we have information here. Yes, is that email address appropriate if people have questions that can direct them directly to you? Yes, absolutely. All right, so if anybody has any questions that come up, and again, I may have mentioned this before, but many of our webinar participants or our virtual didactics participants are now watching delayed just due to, you know, increased clinical responsibilities now that things have kind of, knock on wood, kind of leveled off. So they're watching the recordings later. So as a result, questions are coming up later than they otherwise would. So if anybody has any questions or if you're watching this later and you have questions, please feel free to reach out to her directly. Her email is there on the screen. If anybody has any questions about the series in general, feel free to reach out to me on Twitter or AAP, and then the link for tomorrow's lectures and all of these videos are available there on physiatry.org slash webinars. They will be available there through at least the end of this calendar year. So if anybody has any questions, please feel free to reach out. Otherwise, thank you so much, Dr. Matsumoto, for joining us today. We appreciate this very much. My pleasure. Thank you, Sterling. Thank you. And everybody else, we'll get started here the next 10-15 minutes with the next lecture.
Video Summary
In this video, Dr. Matsumoto discusses upper limb amputation rehabilitation. She provides an overview of the different levels of amputation, ranging from finger amputations to forequarter amputations, and discusses the benefits and disadvantages of each level. Dr. Matsumoto also explains the different types of prosthetic systems available, including passive, body-powered, externally-powered, and hybrid systems. She discusses the advantages and disadvantages of each system, and highlights the importance of considering the patient's functional goals and needs when choosing a prosthetic system. Additionally, Dr. Matsumoto discusses the post-operative and pre-prosthetic rehabilitation phase, as well as the long-term follow-up and adjustment phase. She emphasizes the importance of interdisciplinary team collaboration and the role of physiatrists in creating appropriate prosthetic prescriptions. She concludes by addressing the issue of acceptance of upper limb prostheses and the challenges associated with myoelectric devices.
Keywords
upper limb amputation rehabilitation
levels of amputation
prosthetic systems
functional goals and needs
post-operative rehabilitation
interdisciplinary team collaboration
physiatrists
myoelectric devices
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