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Transhumeral Amputation: Case Study
498 Plays2 years ago
Josh talks about a recent case he has and some the tips for hand therapists.
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Transcript
Introduction and Case Study Overview
00:00:06
Speaker
Hi, I'm Josh McDonald. And I'm Miranda Materi, and we are Hand Therapy Academy. Let's talk a little bit about a case study. We do these every once in a while, where we go through a patient we have and kind of take you through our thought process. So I have another patient I kind of want to share information on and see if it helps you and any patients you may have. And Josh, you've been telling me a little bit about this patient, and it's such an interesting, I think, story and so like. I'm glad that you're going to be sharing it with everyone.
Therapy Post-Cancer and Amputation
00:00:35
Speaker
Yeah. Yeah. And this patient has a fantastic outlook on life. So it sounds like a very sad case to start with, but he is the most positive person. He works for Sheriff's department and immigration control here in Arizona. And he had, he had been having wrist pain long-term and then he had been having elbow pain. No one really gave any solutions. He went to therapy for it.
00:00:56
Speaker
turns out he had what they thought was an osteochondroma that they then realize was an osteosarcoma and resulted in an amputation trans humoral amputation of his dominant right upper extremity.
00:01:10
Speaker
And so went through this whole huge trauma of dealing with cancer and then within days going through an amputation. And the prosthetics company that he was referred to, we do a lot of work with. And so they said, we know who you need to go to. And they referred him to me. Super nice guy comes in and is
00:01:28
Speaker
and still kind of post COVID stuff is going through chemotherapy starts coming in to see me because we've got to do stump work. We've got to work on all the things to get that stump conditioned. He's got a lot of adhesions going on postoperatively, a lot of hypersensitivity, phantom pain. And then now we've got to start thinking about getting him ready for prosthetic eventually. Yeah, so a lot going on there. And how long ago, like how long have you been seeing him for, would you say?
Social Contact and Therapy During Chemotherapy
00:01:58
Speaker
I would say I've been seeing him for probably six months, and that is not necessarily the typical timeline. In a kind of heart-wrenching way, when he was going through his chemotherapy, he would be in a corner with a mask on. I'd put a mask on. This is when everyone's not wearing masks anymore.
00:02:18
Speaker
For him, for chemotherapy, he desperately needed work on shoulder stability. At first it was range of motion because he couldn't get his shoulder up past 90 degrees. So range of motion and then scapular stability. He desperately needed this if he's going to get a device. Come to find out later that during chemo, the grocery store at 2 a.m. and coming in for therapy were the only human interactions he had face-to-face with anybody. So he is like,
00:02:41
Speaker
like intimately close with us. Like we know him really well and he's a really nice guy. So really intimately connected with this patient. But now that we're working on some prosthetic stuff, we also find out he's having some contralateral pain because his now non-dominant primary hand is having some really significant decuar veins pain. And so what is our normal treatment for decuar veins? It's, you know, protect it.
00:03:06
Speaker
back off on using it and try to, well, he can't. That's the only hand he has for everything he has to do. And so now we're looking at doing normal, like iStim and functional movement stuff with it. We tried dry needling and that was moderately successful. We tried Class 4 laser and he had the best success with Class 4 laser treatment to it. So that was hugely successful for him. Started to get some relief for that. But now it's time to test him for myoelectric devices.
Prosthetic Training and Federal Certification Goals
00:03:34
Speaker
yeah so what um so he does he doesn't have a body powered or anything like that you're going straight to myoelectric he did get body powered first so you're i kind of jumped that gun a little bit he did get body powered and so we worked for a while and him getting comfortable with how to use the body powered device and he was a fast learner he's a very resourceful guy and he figured this stuff out very quickly some of her patients need
00:03:57
Speaker
12 visits to understand how to activate this two cable system. He got it, saw me. By the second visit, he was figuring out workarounds and was activating the thing. But he has some very specific work requirements, because he wants to go back to work. In order to go back to work in law enforcement, he needs to be able to fire a weapon. But not just he can fire a firearm. He needs to be able to do this federal testing process, where he has to be involved with both hands.
00:04:25
Speaker
He has to be able to fire discharge the weapon with one hand. He gets penalized if you can't use the other, but he has to be able to use the other to change out a clip, rack the rack, the new chamber or the new round of the chambers. He has to do all this stuff. So he was bringing in a firearm and we're testing like, how is he going to go through this when he's standing at the table? Because he is going to be the first guy in federal employment. He's like, I'm going to do this. He's going to be the first upper limb amputee to be firearms certified for the federal government.
00:04:54
Speaker
Well, that is awesome. Yeah. He is charting new territory and he's got some supervisors that are excited about it and some that say we can't have this. This isn't okay.
Advanced Prosthetic Preparation and Testing
00:05:03
Speaker
So we're kind of helping him navigate like, what are you capable of doing? Let's, let's set some new standards for the, for everybody. Right. And what's safe to do. Yeah. And you're right. He's very aware of what's safe and what, what is.
00:05:17
Speaker
He has an awareness of firearms that I'm not a gun person, but he has an awareness of firearms that is well beyond my scope. And so I'm asking questions about like, what do you need and how would you do that normally? And how are we going to do that now? So it's been a very interesting activity analysis thing to get him
00:05:34
Speaker
To be able to pass this, he's got the accuracy. He can do this like on the range with a with an officer supervisor next to him. He can do it. It's just the stressful situation of, you know, having a group of people around who don't want him to succeed and having that pressure going into it too.
00:05:49
Speaker
Yeah, that's a good point. Okay, so we did the body power. Now you're getting ready for myoelectrics. So you're doing myocyte testing? Is that where you're at right now? Yes, that actually happens tomorrow. We're doing myocyte testing. We're going to use the m trigger device, which is a fantastic. It's a little box that charges and it has leads that come off of it. And you put the stickies on motor points.
00:06:10
Speaker
and i've tried to find the exact motor point that's going to give them the most successful firing of that muscle while also not putting his arm in an in an offline position so if it's deltoid but every time he fires that it brings his arm forward into flexion that's not safe for the firearm so it has to be probably bicep tricep maybe we can find brachialis in there so we're going to have to find
00:06:34
Speaker
where those motor points are now that those muscles have been pulled around that residual bone to pat it, things are going to be a little different. So we got to get creative. Yeah. And then you brought up an interesting point. So since he doesn't have an elbow, right? Yeah. Are you guys doing a prosthetic elbow?
00:06:50
Speaker
So he's hopefully, this is our plan, he's gonna have a powered elbow that he will use co-contraction or sustained contraction to toggle between elbow or forearm slash wrist rotation. And then other signals to activate open and close of a hand, of an anatomic hand, but I'm gonna see if I can't sell the prosthetician on an ETD as well.
00:07:20
Speaker
The patient wants a hand, but I really think he'd be successful because his body powered hook is hugely successful. If you can have a powered hook, it's going to give him more grasp strength. It's going to give him more sturdiness, more hardiness of that device. Yeah, that's definitely. And interesting that he has the elbow and forearm component too, right? That's going to require a lot of extra training and steps. And so I imagine when you go through training him, it'll be like doing one thing at a time for
00:07:50
Speaker
Yeah, so what we'll do first is let's find motor points. Let's see if we can find three that gives us tons of options. If we're stuck with two, I've got a quad amputee who can do amazing things with two motor points when he does co-contraction, sustained, burst, double, triple contractions. So there's a lot of variety you can put into that he has on the iLIM. But ideally we find three and let's say let's consistently fire bicep.
00:08:17
Speaker
I want to know that at any given time, if I set, whether it's a metronome, or if I set a random queue, that you can fire that and make the little iPad icon for the M trigger jump a noticeable amount. Let's do that, and then tricep. And then let's see if we can do tricep-bicep. Let's see if we can do both and contract everything like you're freezing your arm with muscle. And we'll work all these variations, but we're starting baby steps, and we'll only accelerate as he's able to.
Prosthetic Control and Training Techniques
00:08:43
Speaker
Yeah, and I think that's key. Whenever you're seeing a prosthetic patient is do things in small steps, right? And so once you've like done the steps you say, and then they get the prosthetic, you're doing stuff close to body first. And then once they master it, then you're doing stuff away from body. Otherwise, I think the user gets very frustrated.
00:09:01
Speaker
Yeah. And you want success early. And when they have a device that can do 57 things, give them two. You want them chomping at the bit for the next one, rather than getting frustrated because I can't figure out how to do these 17 things. Let's just master one or two and make that happen. Yeah. And then for our audience that may not know, if they don't have good myocytes,
00:09:26
Speaker
or say it's a more proximal amputation, there are other technologies that they've come out with now that are more of a pattern recognition, right? So you just have to get some sort of signal, it doesn't have to be a strong signal, it can be any nerve signal, and it's not based on a specific muscle, it's just based on nerve activity,
00:09:44
Speaker
and you can basically calibrate these devices to fire for different things. I do think they take a little, there's a little bit of a steeper learning curve than just mile sites, but I do think that's an option as well. Yeah. Yeah. This is a guy who's going to be out there on the range firing weapons.
Patient's Positivity and Future Plans
00:10:00
Speaker
He's going to have, he's not going to be doing like actual law enforcement. He's going to be more of a desk job when the time comes, but he has to be out in a range firing multiple different types of weapons. So he's going to need a pretty hardy device, but it's exciting to see where he's going with this. And he,
00:10:14
Speaker
He has the most fantastic outlook on life, and he comes in with a good mood almost every single day and is just a joy to work with. So it's a fun one to get to explore with. Yeah, I'll be excited to hear an update on how he's doing. Yeah, we can do a follow up on this. Yeah, prosthetics can be a little bit overwhelming at times, but once you get into it can be a very fun, fun little niche market to find if you find a prosthetician in your area that it does some upper extremity stuff. Tap into that market, offer your services to help do training, functional stuff, get more successful usage of that device.
00:10:44
Speaker
Yeah, definitely. All right. For more information, you can check us out at handtherapyacademy.com or you can find our end of Instagram hand therapy Academy.