The Boston Elbow

November 1984

NTIS order #PB85-145936
HEALTH TECHNOLOGY CASE STUDY 29

The Boston Elbow

NOVEMBER 1984

This case study was performed as part of OTA’s Assessment of

Federal Policies and the Medical Devices Industry

Prepared for OTA by:

Sandra J. Tanenbaum, Ph.D.

Health Policy Center

Brandeis University

OTA Case Studies are documents containing information — on a specific medical technology or area of application that supplements formal OTA assessments. The material

is not normally of as immediate policy interest as that in an OTA Report, nor does

it present options for Congress to consider.

CONGRESS OF THE UNITED STATES

OffIce of Technology Assessment

Washington D C 20510
Recommended Citation:

Tanenbaum, Sandra J., The Boston Elbow (Health Technology Case Study 29), OTAHCS-29, Washington, DC: U.S. Congress, Office of Technology Assessment, November 1984,

This case study was performed as part of OTA’s assessment of Federal Policies and the Medical

Devices Industry.

Library of Congress Catalog Card Number 84-601139

For sale by the Superintendent of Documents

U.S. Government Printing Office, Washington, DC 20402
Preface

The Boston Elbow is Case Study 29 in OTA’s

Health Technology Case Study Series. This case

study has been prepared in connection with OTA’s

project on Federal Policies and the Medical Devices Industry, which was requested by the Senate

Committee on Labor and Human Resources and

endorsed by the Senate Committee on Veterans’

Affairs. A listing of other case studies in the series

is included at the end of this preface.

OTA case studies are designed to fulfill two

functions. The primary purpose is to provide

OTA with specific information that can be used

in forming general conclusions regarding broader

policy issues. The first 19 cases in the Health Technology Case Study Series, for example, were conducted in conjunction with OTA’s overall project

on The Implications of Cost-Effectiveness Analysis of Medical Technology. By examining the 19

cases as a group and looking for common problems or strengths in the techniques of cost-effectiveness or cost-benefit analysis, OTA was able

to better analyze the potential contribution that

those techniques might make to the management

of medical technology and health care costs and

quality.

The second function of the case studies is to

provide useful information on the specific technologies covered. The design and the funding levels of most of the case studies are such that they

should be read primarily in the context of the associated overall OTA projects. Nevertheless, in

many instances, the case studies do represent extensive reviews of the literature on the efficacy,

safety, and costs of the specific technologies and

as such can stand on their own as a useful contribution to the field.

Case studies are prepared in some instances because they have been specifically requested by

congressional committees and in others because

they have been selected through an extensive review process involving OTA staff and consultations with the congressional staffs, advisory panel

to the associated overall project, the Health Program Advisory Committee, and other experts in

various fields. Selection criteria were developed

to ensure that case studies provide the following:

● examples of types of technologies by function (preventive, diagnostic, therapeutic, and

rehabilitative);

●

●

●

●

●

●

●

examples of types of technologies by physical

nature (drugs, devices, and procedures);

examples of technologies in different stages

of development and diffusion (new, emerging, and established);

examples from different areas of medicine

(e.g., general medical practice, pediatrics,

radiology, and surgery);

examples addressing medical problems that

are important because of their high frequency or significant impacts (e. g., cost);

examples of technologies with associated high

costs either because of high volume (for lowcost technologies) or high individual costs;

examples that could provide information material relating to the broader policy and methodological issues being examined in the

particular overall project; and

examples with sufficient scientific literature.

Case studies are either prepared by OTA staff,

commissioned by OTA and performed under contract by experts (generally in academia), or written by OTA staff on the basis of contractors’

papers.

OTA subjects each case study to an extensive

review process. Initial drafts of cases are reviewed

by OTA staff and by members of the advisory

panel to the associated project. For commissioned

cases, comments are provided to authors, along

with OTA’s suggestions for revisions. Subsequent

drafts are sent by OTA to numerous experts for

review and comment. Each case is seen by at least

30 reviewers, and sometimes by 80 or more outside reviewers. These individuals may be from

relevant Government agencies, professional societies, consumer and public interest groups, medical practice, and academic medicine. Academicians such as economists, sociologists, decision

analysts, biologists, and so forth, as appropriate,

also review the cases.

Although cases are not statements of official

OTA position, the review process is designed to

satisfy OTA’s concern with each case study’s

scientific quality and objectivity. During the various stages of the review and revision process,

therefore, OTA encourages, and to the extent

possible requires, authors to present balanced information and recognize divergent points of view.

111
Health Technology Case Study Seriesa

Case Study Case Study

Series Case study title; author(s); Series Case study title; author(s);

number OTA publication numberb number OTA publication numberb

1

2

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7

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12

13

14

Formal Analysis, Policy Formulation, and End-Stage

Renal Disease;

Richard A. Rettig (OTA-BP-H-9 (l))c

The Feasibility of Economic Evaluation of

Diagnostic Procedures: The Case of CT Scanning;

Judith L. Wagner (OTA-BP-H-9(2))

Screening for Colon Cancer: A Technology

Assessment;

David M. Eddy (OTA-BP-H-9(3))

Cost Effectiveness of Automated Multichannel

Chemistry Analyzers;

Milton C. Weinstein and Laurie A. Peadman

(OTA-BP-H-9(4))

Periodontal Disease: Assessing the Effectiveness and

Costs of the Keyes Technique;

Richard M. Scheffler and Sheldon Rovin

(OTA-BP-H-9(5))

The Cost Effectiveness of Bone Marrow Transplant

Therapy and Its Policy Implications;

Stuart O. Schweitzer and C. C. Scalzi

(OTA-Bp-H-9(6))

Allocating Costs and Benefits in Disease Prevention

Programs: An Application to Cervical Cancer

Screening;

Bryan R. Luce (Office of Technology Assessment)

(OTA-BP-H-9(7))

The Cost Effectiveness of Upper Gastrointestinal

Endoscopy;

Jonathan A. Showstack and Steven A. Schroeder

(OTA-BP-H-9(8))

The Artificial Heart: Cost, Risks, and Benefits;

Deborah P. Lubeck and John P. Bunker

(OTA-BP-H-9(9))

The Costs and Effectiveness of Neonatal Intensive

Care;

Peter Budetti, Peggy McManus, Nancy Barrand,

and Lu Ann Heinen (OTA-BP-H-9 (1 O))

Benefit and Cost Analysis of Medical Interventions:

The Case of Cimetidine and Peptic Ulcer Disease;

Harvey V. Fineberg and Laurie A. Pearlman

(OTA-BP-H-9(11))

Assessing Selected Respiratory Therapy Modalities:

Trends and Relative Costs in the Washington, D.C.

Area;

Richard M. Scheffler and Morgan Delaney

(OTA-Bp-H-9(12))

Cardiac Radionuclide Imaging and Cost

Effectiveness;

William B. Stason and Eric Fortess

(OTA-BP-H-9(13))

Cost Benefit/Cost Effectiveness of Medical

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

Technologies: A Case Study of Orthopedic Joint

Implants;

Judith D. Bentkover and Philip G. Drew

(OTA-BP-H-9(14))

Elective Hysterectomy: Costs, Risks, and Benefits;

Carol Korenbrot, Ann B. Flood, Michael Higgins,

Noralou Roos, and John P. Bunker

(OTA-BP-H-9(15))

The Costs and Effectiveness of Nurse Practitioners;

Lauren LeRoy and Sharon Solkowitz

(OTA-Bp-H-9(16))

Surgery for Breast Cancer;

Karen Schachter Weingrod and Duncan Neuhauser

(OTA-BP-H-9(17))

The Efficacy and Cost Effectiveness of

Psychotherapy;

Leonard Saxe (Office of Technology Assessment)

(OTA-BP-H-9 (18))d

Assessment of Four Common X-Ray Procedures;

Judith L. Wagner (OTA-BP-H-9( 19))e

Mandatory Passive Restraint Systems in

Automobiles: Issues and Evidence;

Kenneth E. Warner (OTA-Bp-H-15(20))f

Selected Telecommunications Devices for HearingImpaired Persons;

Virginia W. Stern and Martha Ross Redden

(OTA-BP-H-16 (21))g

The Effectiveness and Costs of Alcoholism

Treatment;

Leonard Saxe, Denise Dougherty, Katharine Esty,

and Michelle Fine (OTA-HCS-22)

The Safety, Efficacy, and Cost Effectiveness of

Therapeutic Apheresis;

John C. Langenbrunner (Office of Technology

Assessment) (OTA-HCS-23)

Variation in Length of Hospital Stay: Their

Relationship to Health Outcomes;

Mark R. Chassin (OTA-HCS-24)

Technology and Learning Disabilities;

Candis Cousins and Leonard Duhl (OTA-HCS-25)

Assistive Devices for Severe Speech Impairments;

Judith Randal (Office of Technology Assessment)

(OT’A-I-icS-26)

Nuclear Magnetic Resonance Imaging Technology:

A Clinical, Industrial, and Policy Analysis;

Earl P. Steinberg and Alan Cohen (OTA-HCS-27)

Intensive Care Units (ICUS): Clinical Outcomes,

Costs, and Decisionmaking;

Robert A. Berenson (OTA-HCS-28)

The Boston Elbow;

Sandra J. Tanenbaum (OTA-HCS-29)

aAvailable for sale by the Superintendent of Documents, U.S. Government dBackground paper #3 to The Implications of Cost-Effectiveness Analysis of

Printing Office, Washington, D. C., 20402, and by the National Technical Medical Technology.

Information Service, 5285 Port Royal Road, Springfield, Va,, 22161, Call ‘Background Paper #5 to The Implications of Cost-Effectiveness Analysis of

OTA’s Publishing Office (224-8996) for availability and ordering infor- Medical Technology.

mation. IBac&-ound paper +1 to OTA’S May 1982 report Technology and Handiborlgina] publication numbers appear in parentheses. capped People.

cThe first 17 cases in the series wem 17 separately issued cases in Background gBackground Paper #2 to Technology and Handicapped People.

Paper #2: Case Studies of Medical Technologies, prepared in conjunction

with OTA’s August 1980 report 77re Implications of Cost-Effectiveness Analysis of Medical Technology.

i~>
OTA Project Staff for Case Study #29

Roger Herdmanl and H. David Banta,2 Assistant Director, OTA

Health and Life Sciences Division

Clyde J. Behney, Health Program Manager

Jane E. Sisk, Project Director

Katherine E. Locke, Research Assistant

H. Christy Bergemann, Editor

Virginia Cwalina, Administrative Assistant

Rebecca I. Erickson, Secretary/Word Processor Specialist

Brenda Miller, Word Processor/P. C. Specialist
Advisory Panel for Federal Policies and

the Medical Devices Industry

Richard R. Nelson, Chair

Institute for Social and Policy Studies, Yale University

New Haven, CT

William F. Ballhaus Robert M. Moliter

International Numatics, Inc. Medical Systems Division

Beverlv Hills, CA General Electric Co.

.

Ruth Farrisey Washington, DC

Massachusetts General Hospital Louise B. Russell

Boston, MA The Brookings Institution

Peter Barton Hutt Washington, DC

Covington & Burling Earl J. Saltzgiver

Washington, DC Foremost Contact Lens Service, Inc.

Alan R. Kahn Salt Lake City, UT

Consultant Rosemary Stevens

Cincinnati, OH Department of History and Sociology of Science

Grace Kraft University of Pennsylvania

Kidney Foundation of the Upper Midwest Philadelphia, PA

Cannon Falls, MN Allan R. Thieme

Joyce Lashof

School of Public Health

Amigo Sales, Inc.

Albuquerque, NM

University of California Eric von Hippel

Berkelev, CA Sloan School

Penn Lupovich Massachusetts Institute of Technology

Group Health Association Cambridge, MA

Washington, DC — Edwin C. Whitehead

Victor McCoy Technicon Corp.

Paralyzed Veterans of America Tarrytown, NY

Washington, DC
Contents

CHAPTER 1:

Introduction .

Summary. . . .

CHAPTER 2:

A Description

A History . . .

INTRODUCTION AND SUMMARY . . . .

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THE BOSTON ELBOW

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An Assessment . . . . . . . . . . . . .

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CHAPTER 3: ALTERNATIVES TO THE BOSTON ELBOW..

Prosthetic Alternatives . . . . . . . . . . . . . . . .

Nonprosthetic Alternatives . . . . . . . . . . . .

. .

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. . . . . . . . . . . . . . . . .

CHAPTER 4: PUBLIC POLICY ANDTHE BOSTON ELBOW

The Amputee-Veteran. . . . . . . . . . . . . . . . . . .

The Amputee-Worker . . . . . . . . . . . . . . . . . . .

The Workers’ Compensation Beneficiary

. . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . .

The Social Security-Disability Insurance Beneficiary . . . . . . .

The Federal/State Vocational Rehabilitation Client . . . . . . . .

The Amputee-Citizen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

CHAPTER 5: CONCLUSIONS . . . . . . . . . . . . . . . . . . . . .

APPENDIX A: GLOSSARY OF TERMS AND ACRONYMS .

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APPENDIX B. ACKNOWLEDGMENTS AND HEALTH PROGRAM

ADVISORY COMMITTEE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Tables

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Table No. Page

I. Causes of Upper Extremity Amputation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

2. Traumatic Amputation by Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

3. Elbow Prostheses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

vii
Author’s Note

The background research on which this case study is based was in large part

funded by the Kaiser Family Foundation.

OTA Note

These case studies are authored works commissioned by OTA. Each author

is responsible for the conclusions of specific case studies. These cases are not statements of official OTA position. OTA does not make recommendations or endorse

particular technologies. During the various stages of review and revision, therefore,

OTA encouraged the authors to present balanced information and to recognize

divergent points of view.

. . . Vlll
Introduction and Summary
Introduction and Summary

INTRODUCTION

The Boston Elbow is an artificial arm, powered

by battery and controlled by signals from an amputees’ stump muscles (myoelectric). Electrodes

located in the socket of the prosthesis detect the

electrical charges that accompany contraction of

the stump muscles, A computer in the prosthesis

interprets these electromyographic signals and

transmits orders to the motor to flex or extend

the elbow. The elbow moves at speeds proportional to the intensity of the amputee’s muscle contraction. The Boston Elbow thus imitates the flexion and extension of a natural elbow joint.

Despite this technological achievement, the Boston Elbow is worn by only about 100 of the estimated 30,000 to 40,000 above-elbow amputees.

In the context of the OTA project entitled Federal Policies and the Medical Devices Industry,

interest arose in whether this low level of use

resulted from characteristics of the device or from

policies regarding rehabilitative devices. The case

study describes the development and use of the

Boston Elbow and compares it to prosthetic and

nonprosthetic alternatives. Public policies, such

as veterans’ benefits, Medicare, and workers’ comSUMMARY

The Boston Elbow is technologically distinctive,

but it is only one way to compensate for the loss

of an arm. The amputee may choose an alternative prosthesis: a body-powered, cable-operated

device, an externally powered switch-controlled

elbow, or another myoelectric prosthesis. These

devices vary in several respects, and each has

strengths and weaknesses. The Boston Elbow

seems to maximize features that are useful in the

workplace; it will lift a relatively heavy object and

has the capacity for simultaneous movement of

the elbow and terminal device (hook or hand).

The Liberty Mutual Insurance Co., a major propensation, are examined for their effects on the

use of the Boston Elbow and other options. The

study concludes that public policies have affected,

but have not substantially impeded, the adoption

and use of the Boston Elbow. Although the device has certain advantages, it is not clearly superior in price, appearance, and capability to

alternatives available to amputees.

It is important to note what this study is not.

It is not a discussion of the effects of industrial

policy on the “lifecycle” of the Boston Elbow. Nor

is it a controlled evaluation of competing aboveelbow prostheses. Rather than organizing inquiry

around the device, this study focuses on amputees

and the social policies that bear on their use of

the Boston Elbow. The reason for this approach

is the complexity of the Elbow’s purpose, i.e., to

alleviate disability. Functional impairment due to

structural loss, unlike other problems that invite

technology’s attention, is idiosyncratic, contextual, and, in a technology such as the Boston

Elbow, highly conditional and only part of a

disabled individual’s compensatory strategy.

vider of workers’ compensation insurance, financed design of the device and continues to develop and manufacture it.

Other alternatives to the Boston Elbow are nonprosthetic. First, many amputees learn to function without an arm. This does not mean that loss

of an arm is trivial, only that humans are immensely adaptable and that prostheses are a poor

substitute for the human arm. Second, monetary

compensation for functional

ing the forms of indemnity

nance, Cash benefits help to

loss is common, takand income maintereplace lost earnings

3
4 ● Health Technology Case Study 29: The Boston Elbow

and allow amputees to purchase assistance if

needed. Adaptation of the environment is a third

nonprosthetic option. Vehicles and dwellings can

be made more physically accessible to amputees,

and legislation can prohibit discrimination against

people with disabilities.

Distribution of the Boston Elbow and its alternatives is at least in part a function of public policy, especially the design and implementation of

disability benefits. For policy purposes, adults

with disabilities seem to fall into three groups—

veterans, workers, and citizens—each with eligibility criteria set by law. The group(s) into which

an amputee falls determines his or her eligibility

for the Boston Elbow and other compensatory

options.

The amputee-veteran has many alternatives to

the Boston Elbow, including an elbow prosthesis

that was originated at the Veterans Administration (VA). As of fall 1983, the Boston Elbow had

not yet been approved for VA funding, although

an evaluation of all externally powered prostheses was under way.

Amputee-workers face three sets of circumstances. If injured in the workplace, they are eligible for workers’ compensation benefits, including

monetary compensation and prosthetic devices.

They are most likely to be fitted with a Boston

Elbow if their employer’s insurer is the Liberty

Mutual Insurance Co. Workers with long-term

disabilities who have paid into the Social Security system receive Disability Insurance benefits

in the form of cash payments and Medicare. The

latter may provide a Boston Elbow, but program

coverage begins 2 years after cash benefits commence. Disabled individuals judged to be potential workers are entitled to enter the Federal/State

Vocational Rehabilitation Program and receive

services required for their rehabilitation. Potential workers may thus be entitled to a Boston

Elbow, but they must compete for limited Vocational Rehabilitation funds.

The amputee-citizen is unlikely to be provided

with a Boston Elbow. The Medicaid program in

most States provides low-income amputees with

prosthetic devices, but these must be “medically

necessary” and of reasonable cost. Federal policies do, however, support relevant research by

the National Institute of Handicapped Research,

regulation by the Food and Drug Administration,

and new legislative approaches to disability issues,

such as the Rehabilitation Act of 1973.

The Boston Elbow fares differently in different

programs. This situation, which is the result of

explicit mandates, institutional histories, and

ongoing allocation of public resources, can be difficult for the amputee.

The Boston Elbow and other compensatory

technologies will almost certainly benefit from the

disability rights movement associated with the

Rehabilitation Act of 1973. One result of this

movement will be more self-aware and assertive

consumers of rehabilitation technology.
2.

The Boston Elbow
2.

The Boston Elbow

A DESCRIPTION

The Boston Elbow looks like a whole arm, extending as it does from the wrist (to which various

hooks and artificial hands may be attached) to

a socket that fits the stump, but only the elbow

joint moves. 1 In engineering terms, the arm has

one degree of freedom. It reproduces the active

movement of the human elbow flexion and extension, but not, of course, other forearm movements

such as pronation, supination and flexion or extension at the wrist.

The Boston Elbow is, like some other elbow

prostheses (see ch. 3), battery powered. Like a few

of them, it is also myoelectrically controlled. This

means that electrodes located in the socket of the

prosthesis detect, on the surface of the wearer’s

skin, the electrical charges that accompany contraction of the stump muscles. These electromyographic (EMG) signals are transmitted to and interpreted by a computer housed in the prosthesis,

and the battery-powered motor “takes orders”

from the computer to flex or extend the elbow.

Although any muscle can provide an EMG signal,

the Boston Elbow is designed to tap residual biceps

and triceps muscles, precisely those that would

ordinarily flex and extend the arm. Thus an amputee’s control of the prosthesis imitates control

of the natural elbow.

The Boston Elbow is both myoelectric and proportional. As such, it moves at speeds directly

proportional to the intensity of muscle contraction by the amputee. Proportional control depends on the fact that muscle contraction produces an electrical signal the magnitude of which

varies with contraction intensity. This relationship is a continuous one, so by contracting more

‘A Description was compiled from interviews with Liberty Mutual

officials and MIT faculty.

or less intensely, the wearer of a proportionalcontrol prosthesis produces a full range of signal

magnitudes and, after electronic processing, is

able to flex or extend the elbow at a full range

of speeds.

Fitting a Boston Elbow involves making a cast

of the amputee’s stump and then a mold to which

socket material is shaped. The prosthetist works

down from the above-elbow socket with layers

of foam and attaches a prosthetic elbow unit that

includes a battery-powered motor. The Boston

Elbow’s forearm houses the batteries and electronics and offers the wearer a choice of terminal

devices: a mechanical hook or hand controlled

with a roll of the amputee’s shoulder, or an electric or myoelectric hook or hand with switch control. The prosthesis is designed so that hook and

hand are interchangeable and may be used by the

same wearer at different times.

The current Boston Elbow weighs 2.5 pounds.

It will lift 5 pounds and hold something over 50

pounds in a locked position. A fully charged battery will power the device for about 8 hours. The

prosthesis has a range of 145 degrees, i.e., full flexion is 145 degrees from full extension, and this

distance is traveled in a minimum of a second.

The Boston Elbow has a 30-degree free swing that

lends it a more natural appearance. Even so, the

device is not easily mistaken for a human arm,

especially because the forearm, which houses batteries and electronics, is noticeably boxy. But neither is the Boston Elbow unpleasant to look at,

and its variable speed reduces the robotic aspect.

Like many machines, it hums, but the addition

of auditory to visual feedback can be advantageous. The prosthesis does not provide tactile

feedback, a widely acknowledged (and as yet

unrealized) feature of the perfect upper extremity

device.

-?
8 ● Health Technology Case Study 29: The Boston Elbow

A HISTORY2

The Boston Elbow is a cybernetic limb prosthesis, and mathematician Norbert Wiener is considered its “godfather. ” Having raised the possibility of cybernetic applications to prostheses in

the late 1940s (6), Wiener was moved to reconsider electronic limbs, when, in 1961, he was hospitalized for a broken hip. Wiener’s orthopedist

at Massachusetts General Hospital was Melvin

Glimcher, who also headed the amputee clinic at

the Liberty Mutual Insurance Co., a major carrier of workers’ compensation policies.

Glimcher had found in his work for Liberty

Mutual that below-elbow amputees were using

prostheses to recoup much more of their lost functioning than were above-elbow amputees. Even

with the most advanced body-powered prosthesis, the above-elbow amputee had to: 1) position

and 2) open or close the terminal device sequentially. The single-cable design did not allow for

simultaneous execution of these two functions,

and the result was unnatural body movements

that were unattractive and inefficient. Glimcher

visited the Soviet Union where he observed a

myoelectric hand prosthesis. When he returned

to Boston, he took advantage of Wiener’s temporary disability to discuss with him the feasibility of surpassing Soviet technology with a myoelectric elbow. To Glimcher’s mind, myoelectric

control seemed less necessary for below-elbow

amputees, who could function well with conventional devices. As one collaborator on the Boston Elbow project explained, the mission of its

creators was and continues to be to make aboveelbow counterparts, that is, to allow above-elbow

amputees to use a terminal device well.

Weiner encouraged Glimcher’s interest in the

elbow and put him in touch with two Massachusetts Institute of Technology (MIT) professors,

Amar Bose, an electrical engineer, and Robert

Mann, a mechanical engineer. By 1965, two graduate theses had been written about the possibility of a myoelectric elbow prosthesis. Both were

supported in part by Liberty Mutual, and, in 1966,

the company hired two of Mann’s former students

2 A History was compiled from interviews with Liberty Mutual

officials and MIT faculty.

to develop a real prosthesis from the MIT research. The Boston Elbow Version I was produced

in 1968 and made its debut that fall with a press

conference at Massachusetts General Hospital.

Eighteen Version I Elbows were manufactured.

They were by all accounts failures. Every amputee

fitted rejected the prosthesis, and a National Academy of Sciences evaluation found the device unsatisfactory (15). The most serious problem was

that the first Boston Elbow ran on a battery so

large it had to be mounted on the wearer’s belt.

At about the same time, another MIT graduate

student was modifying the Elbow’s design to incorporate a battery into the prosthetic forearm.

Liberty Mutual hired this engineer when he finished his training, and he went on to build 25 Boston Elbow prototypes during his l-year tenure

with the firm. In 1973, Liberty Mutual added a

production engineer to the project, and in 197’4,

25 working prostheses were manufactured. Twelve

of these are still being worn. A batch of 100 Boston Elbows followed in 1976; these featured a

slimmer forearm and more reliable electronics.

One hundred still slimmer and more reliable prostheses are being sold at this time. Liberty Mutual

itself manufactures the Boston Elbow. The electronic components are supplied by small firms in

the Boston area.

Neville Hogan, a mechanical engineer at MIT,

conducts further research on the Boston Elbow.

He maintains that the usefulness of the device is

limited by the fact that, unlike the natural arm,

the Boston Elbow is rigid. It is not, in Hogan’s

words, “floppy” or “springy” and so does not respond to the press of other objects the way the

intact arm does, i.e., with variable force. Hogan

proposes to design a Boston Elbow with the same

viscosity, stiffness, and inertia as the natural limb.

In addition to imitating more exactly the characteristics of the human arm, a floppy Boston Elbow

might be positioned more accurately without tactile feedback. Recent research in neurophysiology

(4) suggests that animal subjects deprived of all

sensory information about a limb are able to return it to its resting position when a human investigator pushes it away. Presumably this occurs

because the muscles return the limb to the posi-
Ch. 2–The Boston Elbow ● 9

tion dictated by the balance of normal tension of

opposing muscles. Although tactile data are

widely thought to be critical to positioning an artiAN ASSESSMENT

In 1983, approximately 100 amputees wore Boston Elbows, and, for them, as Glimcher had

hoped, elbow flexion and operation of the terminal device were simultaneous. But the Boston

Elbow might have been expected to have been

more widely diffused by now, and skeptics wonder about the value of the device.

Assessing the diffusion of the Boston Elbow requires knowledge of its clientele. Unfortunately,

data specifically about above-elbow amputees are

relatively scarce. The number of upper extremity

amputees (both below- and above-elbow) in the

United States is usually set at 75,000 to 100,000

(19). It has been estimated from data collected in

1967 (9) that 43 percent of the total number of

upper extremity amputations (in some cases bilateral) are above-elbow, and the 1977 National

Health Interview Survey (43) found the number

of arm (as opposed to hand) amputees to be about

53,000, or 58 percent of all upper extremity amputees. More plentiful and timely data are available about limb amputation generally, but lower

extremity amputation is far more common—at

least three times as common—as upper extremity

amputation, making combined statistics unrepresentative of the latter. Loss of an upper extremity

usually results from trauma and that of a lower

extremity from disease. Thus, above-elbow amputees are likely to be younger than their lower extremity counterparts and to be in better general

health.

Amputation denotes loss of an extremity from

any cause. It is estimated that 9 percent of the

above-elbow amputations in this country are congenital (see table 1). Eight percent result from

tumors, 6 percent from disease, and 77 percent

from trauma. There were 773 trauma-related, upper extremity amputations identified in a sample

drawn from case records provided by 44 prosthetics facilities in 30 States. (Only amputees fitted

with prostheses were included. ) Industrial, farm,

ficial limb, such feedback continues to elude bioengineers. Hogan believes that floppy arms will

enable amputees to function well without it.

Table 1 .—Causes of Upper Extremity Amputation

Congenital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.9°\0

Tumor. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.2°/0

Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.8°/0

Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .......77 0

/0

SOURCE E. J. Davies, B R. Fnz, and F. W Cl!pplnger, “Amputees and Their Prostheses, ” Artificial Limbs 14(2) 19-48, 1970

and automobile accidents accounted for almost

all amputations in women and 68 percent of amputations in men, who are far more likely than

women to lose an arm for any reason (9). The

typical above-elbow amputee, then, is a young

male who has been injured in some way (see table

2).

As in all evaluative undertakings, asking the

right questions about the Boston Elbow is critical, especially in this case study, because, surprisingly, the objectives of prosthetic technology are

not obvious. “It is manifestly unrealistic to think

one could write down all the criteria and performance specifications of the normal arm and hope

even to begin to be able to reproduce them in a

man-made device” (23). Any prosthesis, then, will

embody only some subset of the original functions

of the human arm; choosing among them is a

complex process. Judgments must be reached

again and again as new needs materialize, and the

Table 2.—Traumatic Amputation by Cause

Male Female Total

Car. . . . . . . . . . . . . . . . . . . . . . . . 73

Industrial . . . . . . . . . . . . . . . . . . 253

War . . . . . . . . . . . . . . . . . . . . . . . 58

Farm . . . . . . . . . . . . . . . . . . . . . . 164

Train . . . . . . . . . . . . . . . . . . . . . . 18

Gunshot . . . . . . . . . . . . . . . . . . . 46

Thermal . . . . . . . . . . . . . . . . . . . 19

Lawnmower . . . . . . . . . . . . . . . . 5

Other. . . . . . . . . . . . . . . . . . . . . 87

12

10

0

7

1

5

3

2

10

85

263

58

171

19

51

22

7

97

Total . . . . . . . . . . . . . . . . . . . . 723 50 773

SOURCE E J Davies, B R Friz, and F W Cllpplnger, “Amputees and Their Pros.

theses, ” Artficial Limbs 14(2) 19-48. 1970

25-313 0 - 84 - 3
10 ● Health Technology Case Study 29: The Boston Elbow

real priorities may be evident only after a provisional device has been fitted (20).

The variety of possible approaches to the design of an arm is startling. First, there is the gross

dichotomy between efforts to start from first principles and those directed at improving existing

prostheses (12). A more specific list includes simulation of normal arm movement, recreation of

command outputs and sensory inputs, and design

for specific tasks (23). Goals of functional and

cosmetic replacement frequently conflict, and the

goal of economy further complicates the choice.

Evaluating the results of the design process

means raising these issues again. Should evaluation focus on how well the prosthesis is engineered, how much functioning it restores, how

easy it is to use, or simply how satisfied its users

are? Even the most comprehensive study entails

choosing how to weight the several factors. One

engineer notes that because explicit evaluation of

prosthetic limbs means attending to so many factors, design decisions are often made intuitively

(14). Another anticipates that in the face of all

the things a natural arm can do, “each worker will

seize on a particular feature he wishes to sustain . . . and a multiplicity of attempted ‘solutions’ is inevitable” (23). It would be difficult to

overstate the divergences of viewpoint expressed

by the prosthetics experts interviewed for this

study. What was a critical feature for one was a

red herring for another, and, although some disagreements rested on data, others concerned ideas

about what an artificial arm should be expected

to do.

The Boston Elbow is one attempted solution to

the problem of amputation. The overriding concern of those who created it seems to have been

what Mann calls “innateness” (20) —i.e., the extent to which control of the device imitates control of the natural arm. As described above, the

Boston Elbow taps the amputee’s residual biceps

and triceps muscles—the very muscles that control the human elbow. Innateness is further served

by the proportionality of the Boston Elbow, which

gives the wearer control of the speed of the elbow

movements, and by the independent operation of

the elbow and terminal device. Theoretically, innateness makes a prosthesis easier to use. To the

extent that it mimics the natural arm, amputees

already “know” how to use it. A prosthesis that

acts like an arm is also arguably more assimilable

into the amputee’s body image.

On the other hand, innateness often trades off

against “access” (20), the latter meaning accessibility to the user—how easy it is to understand

and maintain, how safe and convenient it is to

use. The Boston Elbow is less accessible than it

is innate. Although it is perfectly safe, the device

is technically complex and requires specialized

components and personnel for maintenance. An

Elbow needs attention on the average once a year,

and on these occasions the prosthesis must be

returned to Liberty Mutual. Because the Boston

Elbow is a battery-powered device, it must also

be recharged after about 8 hours of use, and complete recharging is a 2-hour process (see table 3).

Anecdotal data seem to confirm this mixed

evaluation. All of the several Boston Elbow

owners contacted for this study found the device

useful, some extremely so, and those who had

used other prostheses as well found the Elbow a

significant improvement. Users reported that they

could do more things more easily with the myoelectric device, although two owners who were not

wearing their Boston Elbows had experienced mechanical failure and were unable to return to Boston for repairs. Apart from this, the most common complaints were about the Elbow’s noisiness

and weight, both of which were said to be greater

than those of a conventional prosthesis. Still, neither of these factors deterred any of the owners

from using their Boston Elbows, and most owners

considered the devices to be helpful to them in

doing their jobs. An accountant and lawyer found

the Elbow to be of some importance; a benefits

examiner, a technician at a utility company, and

a machine operator said it was very important;

but a janitor gave up wearing his Boston Elbow

for heavy work because this activity drained the

battery too quickly. It should be noted that almost

every owner contacted was a worker’s compensation client and therefore did not pay for his

prosthesis directly.

The cost of the Boston Elbow is $3,500. When

it has been fashioned into an artificial arm and

fitted to an amputee, the cost rises to an average
Ch. 2—The Boston Elbow ● 11

Table 3.—Elbow Prosthesesa

Boston Elbow Cable Elbow VA Elbow Utah Arm

Power . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . battery

Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . myoelectric

Proportional . . . . . . . . . . . . . . . . . . . . . . . . . . . ... ..yes

Number of powered joints. . . . . . . . . . . . ........1

Weight. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...2.5 lb

Lift . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... ...51b

Hold . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .......50 lb

Speed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ....1 second

Range . . . . . . . . . . . . . . . . . . . . . . . .. .. ... ... ... .145°

Free swing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..30°

Repair cycle.... . . . . . . . . . . . . . . . . . . . . . . . ... ..l/yr

Repair local . . . . . . . . . . . . . . . .. .. .. ... ... .....no

Time without recharge . . . . . . . . . . . . . . . ........8 hours

Recharge time . . . . . . . . . . . . . . . . . . . . . . ........2 hours

costs:

Elbow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .$3,500

Fitting and other costs .. .. .. .. .. .. ... ... ..$6,000

Total (includes socket, fitting, etc) ... ... ..$9,500

Annual repair . . . . . . . . . . . . . . . .. ... ... ......$ 250

Service Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 years

body

mechanical

yes

o

1.51b

very variable

very variable

very variable

165°

total

Ilyr

yes

NA

NA

$ 400

$1,100

$1,500

$ 25

10 years

battery

switch

no

1

1+ lb

31b

10lb

1.5 seconds

135°

120’

1.51yr

some

8 hours

2 hours

$ 900

$1,100

$2,000

$ 100

10 years

battery

myoelectric

yes

1

2 lb 1 OZ

2+ lb

50 lb

0.5 seconds

135°

total

2/yr

yes

8 hoursb

16 hours

$10,000

$10,000

$20,000

$ 150

6 years

aDataf~r Pewered~ms provided bymanufacturers Dataforcablearm provided by independent prosthetist Alldataar eapproximate Experts dtsagreeabout the impor”

tanceof these features

bBut Immediately replaceable so can run 24 hours per day

SOURCE S J Tanenbaum, Brandeis Un!verslty, 1983

of about $9,500. The cost effectiveness of the Boston Elbow is harder to determine. An engineer at

the National Institute of Handicapped Research

describes the prosthesisas “essentially overkill,’

i.e, an unnecessarily complex technology at a cordespondingly high price. Is the extent to which the

Boston Elbow outperforms conventiona! pros thesesso great as to warrant the difference in its cost?

He believes not. But proponents of the Boston

Elbow and other myoelectrically controlled arms

assert that the enhanced innateness of the devices

more than justifies their high price.

Whether the marginal benefits are worththe extra costs is ultimately a very personal calculus.

loss of an arm means different things to different

people and to the same individuals over time.

Thus a long and elaborate evaluative study of

below-elbow prostheses concludes:

The mental load, gain in function and acceptance cannot be described with one single scalar

quantity. It is therefore not possible to”give a

general rule for selection of a prosthesis on the

basis of these variables, because of the fact that

each individual amputee appreciates and weights

the various aspects of these quantities differently. . . (32).

These remarks apply as well to the above-elbow

amputee’s alternative responses to functional loss.

Functional loss is idiosyncratic and contextual;
3.

Alternatives to the Boston Elbow
3.

Alternatives to the Boston Elbow

PROSTHETIC ALTERNATIVES

There are three major prosthetic alternatives to

the Boston Elbow. In order of technical sophistication they are: the conventional, body-powered

elbow prosthesis; a switch-controlled electric

elbow; and another myoelectrically controlled

arm, Each can be found in a small prosthetics market, where five firms account for 95 percent of

the sales, and sales to prosthetists were an estimated $31 million in 1981. About 55 percent or

$17 million was spent on upper extremity prostheses, although (less costly) lower extremity

devices were bought in larger numbers. An estimated $5 million was spent on above elbow prostheses in 1981 (37).

The largest prosthetics firm by market share is

Otto Bock, U. S. A., a division of a West German

company. Bock, U.S.A. reported earnings of $11

million in 1981, and this represented about onethird of all U.S. prosthetics industry earnings. The

firm does not make elbows, although it does furnish prosthetists with switches to be used in

assembling elbows made by other companies. A

myoelectric hand prosthesis is one of Bock’s most

widely used products (37).

The body-powered elbow is the oldest and most

frequently worn of the above-elbow prostheses.

It is designed so that a steel cable running the

length of the arm is under the control of the amputee, who rolls his or her shoulder to flex the

elbow and relaxes to allow gravity to extend the

prosthesis.

A body-powered prosthesis is not an innate device. It requires unnatural shoulder movements

on the part of the user and does not permit the

elbow and terminal device to operate at the same

time. Because the prosthesis is powered by the amputee, it is less powerful than prostheses with batteries and less likely to be good for lifting and

‘Unless otherwise noted, data for Prosthetic Alternatives are from

interviews with prosthetists and manufacturers, and promotional

materials from the latter.

holding. On the other hand, the cable-operated

arm is lighter than most externally powered devices (see table 3 in ch. 2), and weight is an important consideration for most amputees. A conventional elbow is also virtually noiseless and has

a relatively long life of more than 10 years. Its

cost is about $400 for the elbow alone and $1,500

fitted to the amputee.

The Hosmer Dorrance Corp. sells the largest

number of body-powered elbows. Hosmer is the

second largest firm in the prosthetics market, with

earnings of $7 million in 1981 (37). In 1983 Hosmer began to market a switch-controlled electric

elbow as well.

All commercially available externally powered

elbows are electric, that is, they run on batteries.

Means of controlling the prostheses differ, however. A control mechanism less sophisticated than

the Elbow’s is the pull-switch found on the Veterans Administration (VA) Elbow (sometimes

called the VA Prosthetics Center or VAPC Elbow).

Amputees are able to turn pull-switch prostheses

on and off with very slight shoulder movements

and, of course, need not power the device themselves. The VA Elbow weighs less than the Boston Elbow (table 3) and has a slimmer forearm.

But the VA Elbow is not proportional, so it moves

at only one (relatively slow) speed. Nor is it strong

enough to lift more than 3 pounds or hold more

than 12 pounds. The cost of the VA Elbow is $900

alone and about $2, 000 fitted to the amputee.2 It

was designed at the VA but is manufactured currently by Fidelity Electronics, the third largest

manufacturer of upper extremity devices. Fidelity

offers an externally powered hand as well as the

VA Elbow and earned an estimated $1 million

from the manufacture of limbs in 1981 (37).

The Utah Arm is the only commercially available myoelectric alternative to the Boston Elbow.

“’Fitted to the amputee” includes such items as socket and training.

15
16 ● Health Technology Case Study 29: The Boston Elbow

It is, in fact, progeny of the latter, having been

designed by Stephen Jacobsen, who studied with

Mann at MIT. Jacobsen’s original idea was to extend the logic of the Boston Elbow to multiple arm

functions. He found that myoelectric control was

possible not only with biceps and triceps muscles

but with muscles around the shoulder as well.

These “anticipate” what joints such as the elbow

are about to do. The Utah Arm is designed to use

this information for as full a set of arm functions

as possible. At present, the elbow is still the Arm’s

only powered joint (excluding a powered terminal

device, which may be worn with a Boston Elbow

as well). The Utah Arm elbow costs $10,000 alone

and an average of $20,000 fitted to the amputee.

It is manufactured by a firm called Motion Control, which was founded by Jacobsen in 1974 for

the purpose of marketing the Utah Arm.

The Boston Elbow and the Utah Arm are derived from the same idea; as a result, both are

myoelectric and proportional. They do, however,

diverge at several points, and these differences

seem to indicate a divergence of objectives as well.

First, the Utah Arm is a more attractive prosthesis than the Boston Elbow. The former has a slimmer forearm and is less noisy, and because it has

completely free swing, the Utah Arm is also more

natural looking. The Boston Elbow, in contrast,

has a boxy forearm and only 30 degrees of free

swing. It weighs more than the Utah Arm but will

lift more weight. The makers of the Boston Elbow

favor a capacity for simultaneous movement of

the elbow and terminal device— this having been

Glimcher’s concern in initiating the Boston Elbow

project. When the Utah Arm is worn with a powered terminal device, the 2 degrees of freedom

have a single control site and therefore can be

operated only sequentially. The Arm thereby loses

what, at least according to Glimcher, is an important aspect of functioning. Technically, the

Utah Arm and the Boston Elbow both can be

wired for simultaneous movement of the elbow

and the terminal device or for single-site control.

Liberty Mutual has chosen to implement the first

and Motion Control, maker of the Utah Arm, the

second option.

An additional point of contrast is that the Boston Elbow will run for about 8 hours and then

requires 2 hours of recharging, during which time

the amputee must do without it. The Utah Arm

runs for about the same amount of time (half as

long if a powered terminal device is being worn),

but the battery pack can be removed for recharging and replaced on the spot with batteries that

are fully charged. This means that although

recharging the Utah Arm takes 16 hours as opposed to 2 hours for the Boston Elbow, users of

the Utah Arm can acquire a sufficient number of

batteries and chargers to have a functional prosthesis whenever they wish.

The Boston Elbow emerges from this discussion

as a “worker’s” arm. If it is to be worn primarily

at work, cosmetic strengths may be less important than functional ones, and 8 hours of power

are likely to be enough. Liberty Mutual also markets the Boston Elbow as a worker’s arm. Promotional materials feature a photograph of a

middle-aged man in a tie repairing a television set.

The caption reads: “Soldering requires the precise

positioning of both the solder and the iron. ” Later

in the same advertisement, the Boston Elbow battery is described as powering “a full 8-hour workday.” The Utah Arm brochure, in contrast, features a young woman in blue jeans who is shown

socializing with other young people. In correspondence for this study, a Liberty Mutual official listed Boston Elbow wearers by name, address, and occupation. One retired amputee

whose Elbow needed adjustment said he would

not return to Liberty Mutual for the repair because younger people deserved the firm’s full attention. In conversation about the same man, a

Liberty Mutual official indicated that his own interest in making the repair was diminished because

the amputee no longer needed the prosthesis for

work.

A work orientation is not implicit in aboveelbow prosthetics. In a limited number of interviews, Motion Control officials spoke consistently

about reproducing the human arm, about building a device that feels real to the amputee. Work

is, however, the lens through which Liberty

Mutual views its prosthesis—hardly surprising

given the firm’s interest in the workers’ compensation insurance market and the fact that the Boston Elbow’s development and refinement themselves took place among workers’ compensation

clients. These were individuals who had been injured in the workplace, and whose reemployment

was at the heart of the rehabilitation process.
Ch. 3–Alternatives to the Boston Elbow ● 1 7

Photo credit” Ltberty Mutual Insurance Co , Boston, MA

Left: This woman is wearing a Utah Arm, which has a slim forearm and a completely free swing. Top right: The Boston

Elbow, which this man is using, was originally developed to facilitate reemployment of people who had been injured

in the workplace. Botton right: A person using a Boston Elbow, shown here, can simultaneously move the elbow

and the terminal device
18 ● Health Technology Case Study 29: The Boston Elbow

NONPROSTHETIC ALTERNATIVES

Some alternatives to the Boston Elbow are not

limb prostheses at all. Many amputees, for instance, learn to function with one arm. Some learn

by trial and error. Others work with occupational

and physical therapists. It is estimated that approximately half of the above-elbow amputees decline to wear a prosthesis. Although some rehabilitation professionals consider this defeatist and

unacceptable, even prosthetists admit that it is

possible, with good training, to do most of what

is essential with one arm. Loss of the upper extremity differs from that of the lower on just this

point. Legs do things in pairs, while a single arm

can function independently. Amputees who have

lost both arms of course have a greater need for

prosthetic devices.

Not wearing a prosthesis can have a psychological as well as physical aspect. Rehabilitation

entails psychic accommodation to a new reality,

and coming to terms with functional loss can

lessen the need for and desirability of an artificial limb. One blind speaker told a recent workshop that the approach of rehabilitation technology

to disability was counterproductive and certain

to fail. Technology, he argued, serves only to impede adaptation, which he defined as a set of compensatory behaviors and beliefs (17). Some amputees feel that not wearing a prosthesis is more

self-affirming. Max Cleland, for example, a triple amputee and former head of the Veterans

Administration, related that he was relieved when

his physician ordered him off his artificial legs.

Wearing them, according to Cleland, was a matter of “machismo,” something he had to get over

before he could love himself again (7). Other amputees forego a prosthesis to make a political

statement—to make able-bodied people come to

terms with the physical impairments of others.

That above-elbow amputees sometimes decide

against prosthetic devices is in no way an indication that their loss is trivial. One need only tie

an arm behind one’s back to discover how great

a functional loss upper extremity amputation is.

Rather, abstention from prostheses testifies to the

adaptability of human beings and to how poor

a substitute devices are for the human arm.

Money is a second kind of nonprosthetic compensation for the loss of an arm. Private and public programs provide amputees with monetary

benefits designed to mitigate impairment; these

replace lost earnings and purchase services for amputees should they require help. Money may

come in two forms, indemnity and income maintenance. An indemnity is a previously established

sum considered fair compensation for a specific

anatomical loss. Thus, every individual with the

same amputation receives an indemnity payment

of the same amount from any one program. Benefits are set to reflect lost wages in a very general

way, but an indemnity is not means-tested. An

amputee receives the full sum regardless of his or

her employment status or assets. As will be discussed further in chapter 4, veteran disability compensation and most worker’s compensation programs provide indemnity benefits.

The second form of monetary compensation is

income maintenance. This is a program of cash

transfers, usually scaled to need and based on the

assumption that impairment has a negative effect

on labor force participation. Benefit levels are set

to provide for basic needs, but because amputees’

earnings may make them ineligible for the program, income maintenance is widely thought to

be a disincentive to work. Veterans pensions,

Social Security Disability Insurance, and Supplemental Security Income pay income maintenance

benefits. They will be discussed more fully in

chapter 4.

Yet a third alternative to prosthetic arms is to

adapt the environment in which the amputee lives

and works. Environmental strategies may seem

more appropriate for people in wheelchairs than

for upper extremity amputees, but the latter can

benefit from automobile adaptation, specialized

kitchen and bathroom equipment, and assistive

devices such as a button hook or an adapted telephone. Moreover, environmental modifications

may be social as well as physical, i.e., they may

mitigate functional loss by modifying the human

relationships in the amputee’s environment. Rehabilitation legislation of the last decade, for example, has outlawed discrimination against people
Ch. 3–Alternatives to the Boston Elbow ● 1 9

with disabilities by some employers and service To summarize, the above-elbow amputee has

providers. This makes jobs and services more both prosthetic and nonprosthetic alternatives to

accessible to amputees, which in turn has mone- the Boston Elbow. Each replaces some of what

tary and social benefits. Specific environmental was lost with the arm. None provides complete

programs will be discussed in the next chapter. restoration.
4

Public Policy and the

Boston Elbow
Public Policy and the Boston Elbow

Public policy plays a part in the distribution

of the Boston Elbow and its alternatives. The design and implementation of disability policy especially exert considerable influence on the way(s)

in which someone who loses a limb may compensate for it. U.S. disability policy is complex, not

the least because it is actually many policies addressed to different classes of disabled persons.

Adults with disabilities seem to fall, for public polTHE AMPUTEE= VETERAN

All veterans with honorable or general discharges are eligible for veterans benefits. Although

the exact number of above-elbow amputee-veterans is not known, there were about 4,600 receiving service-connected disability compensation for

loss of one or both upper extremities in 1980 (45).

(A service-connected disability is one that results

from an injury or illness suffered while in the

armed services. ) According to the Veterans Administration (VA), approximately 135 aboveelbow amputees are reported to have externally

powered prostheses of some kind, but Liberty

Mutual reports that only two or three could be

Boston Elbows. The Veterans Administration offers its own Elbow and has not yet approved the

Boston Elbow for general distribution by the VA.

The veteran-amputee receives prosthetic services through amputee clinics in VA hospitals.

Clinic teams of physicians, physical/occupational

therapists, prosthetists, and counselors meet with

the amputee to decide which if any prosthesis

should be prescribed. They choose primarily

among devices that have been approved for contract, i.e., for purchase at a specific price, by the

Prosthetic and Sensory Aids Service (PSAS) of

the VA. The PSAS decides on contract items on

the basis of evaluative research conducted by the

VA and other investigators. In some cases, amputee-clinic staff may recommend a prosthesis that

has not yet been evaluated. VA Central Office (in

Washington, DC) is asked to rule on these cases

icy purposes, into three major groups—veterans,

workers, and citizens—each with eligibility criteria set by law. These classes of beneficiaries and

the disability benefits to which they are entitled

will be discussed more fully below. Suffice it to

say here that the group(s) into which an amputee

falls determines both his or her eligibility for the

Boston Elbow and the availability of alternative

measures for coping with the loss of an arm.

individually and may approve unapproved devices on a case-by-case basis (38).

The PSAS is said to be evaluating the Boston

Elbow and other externally powered arms at this

time. One VA official suggested that the Boston

Elbow was not evaluated sooner because of the

VA’s commitment to its own Elbow. More than

one member of the VA’s Prosthetic Technology

Evaluation Committee expressed favorable attitudes toward the Boston Elbow and the Utah

Arm. They were less positive about the VA

Elbow.

Like other amputees, the veteran has nonprosthetic alternatives. First, the VA provides monetary compensation for functional loss and pays

both indemnities and income maintenance. The

veteran whose amputation is service-connected receives veterans’ “compensation,” a monthly sum

scaled to the amount of disability suffered. As an

indemnity, veterans’ compensation is received

regardless of the beneficiary’s financial situation

and whether or not he or she wears a prosthesis.

Amputee-veterans who have lost a dominant arm

above the elbow while in the service are rated 90

percent disabled and as of October 1982 received

$729 a month in tax-free compensation (11,44).

On the second track of VA cash benefits, “pensions” are provided to some disabled veterans.

Low-income veteran-amputees whose amputations are not service-connected and whose age and

2 3
24 ● Health Technology Case Study 29: The Boston Elbow

functional loss constitute total and permanent

disability receive monthly payments that vary inversely with income. Unlike disability compensation described above, pensions are means-tested

(and so unlikely to accrue to service-connected

disabled veterans, who receive relatively large indemnities); the recipient must file only a simple

yearly income report that is generally not subject

to investigation by the VA. Although annual pensions are admittedly small, with a maximum for

veterans without dependents of about $5,000 (46),

they are relatively easy to obtain and keep (27,34).

Pensions, like veterans’ compensation, do not bear

directly on the use of prostheses, but they do represent another way to compensate for the same

functional loss.

Disabled veterans are eligible for environmental

modifications, as well as monetary benefits. Upper

extremity, service-connected amputees are entitled

to as much as $4,400 for the purchase of an automobile or other vehicle plus adaptive equipment

(46). When the veteran is a unilateral amputee injured on the right side and not using a prosthesis, for example, the VA believes he or she can

operate an automobile with an automatic transmission and left-handed steering knob, directional

signals, and parking brake (36). The amputeeveteran’s social environment, which comprises interactions with people and institutions, is also

modified, The Vietnam Era Veterans’ Readjustment Assistance Act of 1974 (Public Law 98-77),

for example, requires that all Federal agencies

establish affirmative action plans to facilitate the

THE AMPUTEE-WORKER

The amputee-worker encounters public disability policy under three sets of circumstances. First,

almost all workers with work-related injuries or

disease are eligible for workers’ compensation

benefits. Secondly, workers with total long-term

disabilities who have paid into the Social Security system receive Disability Insurance benefits

including Medicare. Finally, disabled individuals

judged to be potential workers are entitled to enter the Federal/State Vocational Rehabilitation

Program and receive the services their rehabilidisabled veteran’s reemployment (46). Section 402

of the act extends to discrimination in the private

sector. Employers with Federal contracts of $10,000

or more may not discriminate against disabled

veterans and must take affirmative action to

employ and advance them. Among the benefits

of veteran-amputees, then, are “concessions” regarding their physical and social environments,

adaptations that may lessen the necessity or desire for a prosthesis.

The final nonprosthetic alternative to the Boston Elbow is learning to function with one arm.

There are incentives that weaken or strengthen

the likelihood that the amputee-veteran will

choose this course. The veteran is entitled to a

prosthesis and encouraged to wear one. If his or

her amputation is service-connected, the benefit

is two prostheses of the same or different types

and their replacements (38). But veteran-amputees

are also entitled to long-term physical or occupational therapy and vocational rehabilitation (46),

and so have the opportunity to maximize their

functioning without a prosthesis.

In either case, the amputee-veteran has a great

many alternatives to the Boston Elbow, including

an externally powered prosthesis originating at

the VA. As things stand now, amputees and their

physicians may request approval for Boston Elbows on a case-by-case basis. Once PSAS has

completed its evaluation, the Elbow’s status in the

VA system will be resolved.

tation requires. The Boston Elbow is treated differently in each set of circumstances.

The Workers’ Compensation Beneficiary

Workers’ compensation is a State program. (Although the U.S. Congress has on several occasions

considered setting Federal standards for workers’

compensation benefits, legislation to this effect has

never been passed. ) The program varies greatly

from State to State, but in most places, private
Ch. 4–Public Policy and the Boston Elbow ● 2 5

companies, such as Liberty Mutual, write and

handle workers’ compensation insurance policies.

Employers pay premiums that cover the cost of

the program and in turn are represented in all

claims by their insurers. Benefits are paid when

an individual can show that illness or injury has

resulted from his or her work; payment is predicated on the understanding that illness and injury

result in functional loss and that this functional

loss is compensable (25).

Amputee-workers receiving workers’ compensation benefits are almost always eligible for prosthetic devices. (Specific examples below are drawn

from Massachusetts workers’ compensation law.)

It is usually the amputee’s physician who decides

in favor of one prosthesis or another, and the

State in which the injury occurred is relevant to

his or her decison. In some States, workers are

entitled to a single prosthesis only, even if it fails.

In others, such as Massachusetts, prostheses are

provided for the rest of a worker’s life. Not only

is a wornout device replaced, but changes in the

amputee’s stump are accommodated. The amputee-worker from a one-prosthesis State may not

derive much benefit from an externally powered

device such as the Boston Elbow, with a service

life of only 5 years. Similarly, such a sophisticated

arm is more likely to require expert repair. Thus,

the Boston Elbow is probably not appropriate for

an amputee who has neither a backup prosthesis

nor the availability of expert repair (16,21).

Still, workers’ compensation is the program for

which the Boston Elbow was designed. As detailed

in chapter 2, the device was conceived at the Liberty Mutual Insurance Co. when the firm’s orthopedist resolved to improve the rehabilitation of

above-elbow amputees. Liberty Mutual is the largest writer of workers’ compensation insurance in

the world. Glimcher treated mostly beneficiaries

of this program, who are still more likely than

other amputees to wear a Boston Elbow. Liberty

Mutual’s interest in prosthetics is most clearly

viewed through the lens of the workers’ compensation benefits and the competitiveness of the insurance market itself.

Cash benefits are the mainstay of workers’ compensation. In Massachusetts, they take the two

forms previously mentioned: indemnity and income maintenance. First the disabled worker receives payment for his or her specific anatomical

loss, which itself is considered in two parts: functional loss and disfigurement. In the case of the

amputee-worker, functional loss of the dominant

arm means a fixed payment, or indemnity, which

in 1983 was $9,000. The maximum disfigurement

benefit for an above-elbow amputee was $6,600

in 1983. (Note that Massachusetts workers’ compensation benefits acknowledge multiple aspects

of the lost arm. ) Neither wearing a prosthesis nor

returning to work bears on the size of this onetime award (18,21).

The second form of workers’ compensation

cash benefits is weekly income maintenance, temporary and permanent. Usually the amount received is a percentage of the recipient’s former

wage up to some cumulative maximum. In Massachusetts, the benefit for temporary total disability

is two-thirds of the workers’ average weekly wage

or about $300 (in 1983), whichever is less. Temporary partial disability is considered to exist

when beneficiaries are capable of working, but

at lower wages than they were being paid when

they became disabled. The benefit in this case is

the difference between the old and the new wage.

After 250 weeks of temporary income maintenance payments, a worker must be judged permanently and totally disabled or be dropped from

the workers’ compensation rolls (18,21).

An important difference between the two forms

of workers’ compensation cash benefits is that income maintenance is paid only as long as the

amputee-worker is unable to work. If a prosthesis such as the Boston Elbow can return an amputee to work or mean the difference between

partial and total disability, the workers’ compensation insurer stands to gain from the availability of the device. Moreover, since workers’ compensation premiums are experience-rated—i .e.,

employers’ premiums vary with the amount of

benefits paid to their employees—firms are likely

to choose an insurer who in whatever way minimizes benefits paid. Income maintenance might

serve as a disincentive to wear a Boston Elbow.

If the device means a reduced level of benefits,

the amputee might choose not to wear it. But

according to a member of the Massachusetts In-
26 ● Health Technology Case Study 29: The Boston Elbow

dustrial Accidents Board, a workers’ compensation beneficiary whose employability is enhanced

with a prosthesis is expected to wear one.

The Boston Elbow is good for Liberty Mutual

in another way. The company has for many years

distinguished itself by conducting research on industrial and automobile safety. Similarly, the firm

has its own Rehabilitation Center, located in Boston but open to workers of all Liberty Mutual

clients. In this context, the Boston Elbow maybe

taken as evidence of the company’s commitment

to research and restoration. Potential clients are

undoubtedly drawn to such an insurer, and Liberty Mutual personnel in several capacities deem

the Boston Elbow a successful effort to differentiate Liberty Mutual from other insurers. On the

other hand, Liberty Mutual may hesitate to diffuse the device to competing workers’ compensation insurers. One Liberty Mutual official describes the situation as “touchy,” one that evokes

the firm’s mixed motives: to diffuse the Elbow and

to protect its distinctiveness. Similarly, other insurers have not been willing to buy the Boston

Elbow; that would make them customers of a

competitor.

The Social Security Disability

Insurance Beneficiary

Workers who suffer total, long-term disability

are eligible for Social Security Disability Insurance (SSDI) benefits if they have paid into the

Social Security system during at least half the 40

quarters preceding their claims. SSDI beneficiaries

receive cash payments based on past earnings and

after 2 years are also eligible for the Medicare program. Unlike VA and workers’ compensation programs described above, SSDI does not recognize

partial disability. Claimants are either totally

disabled or not disabled at all. If the disability is

expected to last at least 12 months or result in

death, the claim is paid. An average wage-earner

with a nonworking spouse and two children received an annual SSDI benefit of $4,470 in 1978 (5).

Medicare provides the SSDI beneficiary with

prostheses and occupational or physical therapy.

Outpatient therapy and medical devices are covered at 80 percent of their “reasonable” cost under

Medicare Part B, and the beneficiary may choose

to wear a prosthesis or learn to function with one

arm. Medicare, however, will not pay for every

prosthesis. A device must be “medically necessary”—it must provide functional replacement for

a lost limb, it must be the most basic replacement

strategy, and it must be medically necessary in

the case for which it is being prescribed (33).

Is the Boston Elbow a “medically necessary”

prosthetic device? It might be, especially for individuals with amputations so high as to preclude

the use of a conventional prosthesis. But Medicare’s Boston Elbow policy will not be formulated

until a claim for the device has been made, and

no such claim has been filed, at least in Massachusetts. In that State, requests for items for which

there are no policies are referred to Physician

Advisory Panels. Medicare decisionmakers at the

Federal level consider the reimbursability of devices that, like the CT scanner, will probably be

of major significance to the program. Another influence on Medicare prosthetics coverage is the

providers’ professional association, the American

Orthotics and Prosthetics Association (AOPA).

In 1983 AOPA was negotiating with Medicare

to expand the program’s “procedures codes” for

prosthetics. One addition to the very limited codes

in use at this time would be “externally powered,

above-elbow prosthesis, ” but this would not guarantee reimbursability. The reimbursement question would be more clearly defined, but even a

coded Elbow might not be covered (3,33). And

even a covered Elbow is covered for only 80 percent of its cost.

As noted above, Medicare benefits are extended

to SSDI recipients only after they have received

cash benefits for 2 years. The SSDI beneficiaries

are by definition people who have worked; it is

likely that they have private medical insurance

when they are first disabled. If that insurance does

not provide for the Boston Elbow, however, the

2-year Medicare lag may incline the amputee

away from the device. It is widely thought that

the period immediately following amputation is

the best time for a prosthetic fitting. This not only

has a strong restorative effect on the amputee, but

makes the prosthesis part of his or her body image. Moreover, many amputees whose fittings are

delayed find they can function well enough with

one arm and therefore never wear a prosthesis.
Ch. 4—Public Policy and the Boston Elbow ● 27

The new Medicare beneficiary, then, may already

have adapted to life without a device or with one

less costly than the Boston Elbow. A Medicarereimbursable Boston Elbow might still be chosen

as a replacement device.

The Federal/State Vocational

Rehabilitation Client

The Federal/State Vocational Rehabilitation

(VR) Program provides work-related training and

services to disabled individuals who are potential workers, i.e., who are deemed employable by

program staff. Clients come to the program from

many situations. Some have long work histories,

others do not. Some are receiving cash benefits,

others are not. What distinguishes VR clients is

that they qualify for vocational rehabilitation on

two counts: 1) their disability prevents them from

functioning satisfactorily in the workplace, and

2) there is reason to believe that VR services will

solve the problem. In other words, the VR client

is impaired enough to need help, but not so impaired as to be unemployable (41).

Unlike workers’ compensation and SSDI, Vocational Rehabilitation is not an insurance program.

Neither the recipients of VR services nor their

employers pay into its operation directly. The

Federal/State VR Program receives 80 percent of

its funds from general Federal revenues allocated

to the Rehabilitation Services Administration

(RSA), currently in the Department of Education.

The remaining 20 percent of the program’s funds

are raised by the individual State agencies through

which VR services are delivered (41).

Vocational rehabilitation services include prosthetic devices when these are expected to facilitate employment. Not infrequently, the State VR

agency will contribute to the cost of a desirable

prosthesis by paying, for example, the 20 percent

Medicare coinsurance. But the VR Program is also

mandated to pay for devices other programs do

not cover and to buy environmental technologies

when these are appropriate. A client’s home might

be modified to make it easier to go to and come

from a job, and a vehicle might be adapted to

make transport to and from work possible. These

are large, one-time expenditures, expected to

enhance the client’s earning power enough to pay

for their replacement (1,2).

A modified social environment is another feature of the VR Program. Potential workers form

relationships with rehabilitation counselors who

act in the clients’ interests and secure for them

access to other professionals, vocational training

programs, and the world of work generally. A

second kind of social adaptation has been achieved

through the Rehabilitation Act of 1973 (Public

Law 93-112). This legislation calls for many compensatory measures, among them affirmative action by the Federal Government and its contractors. Federal agencies and all firms holding Federal

contracts for $2,500 or more (as of 1983) are required to take affirmative action in hiring and promoting people with disabilities. Employers are expected to make a “reasonable accommodation”

to the special needs of disabled employees.

Many clients of the VR Program receive monetary compensation, but the public sources of these

moneys are usually SSDI and Supplemental Security Income (SS1) (see below). The real cash benefits of vocational rehabilitation are eventual salary checks, and wages are the unambiguous goal

of the VR Program. The term “rehabilitation” is

itself defined by the program as employment in

the competitive labor market or a sheltered work

setting. Of the approximately 370,000 cases closed

nationally in fiscal year 1982, 61 percent or about

227,000 were rehabilitations; 39 percent of the

clients who finished the program were unable to

find jobs they could do and keep (42). The Massachusetts Rehabilitation Commission (MRC) successfully closed more than 4,600 cases in fiscal

year 1982. Four hundred and forty of them were

public assistance recipients-now able to leave the

rolls (22)—and while rehabilitation of these individuals is especially gratifying to public officials

and taxpayers, the Vocational Rehabilitation Program in general derives its legitimacy from the

number of wage-earners it contributes to the economy. The rehabilitation literature offers many

cost-benefit analyses indicating that vocational

rehabilitation is a good investment (26). The program confers economic benefits on both worker

and society, and this end might justify the cost

of a Boston Elbow. Liberty Mutual knows of at

least one case in which it did.
28 ● Health Technology Case Study 29: The Boston Elbow

On the other hand, the Boston Elbow remains

an expensive device, and VR funds are limited.

As of 1983, basic State grants had not been cut

back under the current Administration, but neither had they been increased. Moreover, the mandate of the program seems to be getting costlier

to fulfill. In fiscal year 1981, the percentage of

rehabilitations not only fell from the previous year

but constituted the lowest success rate since 1946.

The RSA cites as a factor in this decline the policy, set by the 1973 Rehabilitation Act, that people with severe disabilities be served first (41). In

Massachusetts, severely disabled people were 80

percent of all rehabilitants in 1982 (22), and at

least some of these individuals received services

more intensive and expensive to provide than

those delivered to less disabled clients. A related

influence on the use of the Boston Elbow in the

VR Program is that hard choices among technologies have to be made. Clients who use wheelchairs, for example, can also benefit from sophisticated devices. Although body-powered and

THE AMPUTEE= CITIZEN

Every amputee is an amputee-citizen. This

status does not thereby entitle a person to a prosthesis (except in some States under the Medicaid

program) but there are several Federal policies that

bear on his or her securing a prosthesis from some

other source. These represent common Federal

concerns—research, regulation, and civil rights.

The amputee’s experience with prosthetics is

shaped by federally funded research in the fields

of rehabilitation and rehabilitation technology.

Agencies as diverse as the National Aeronautics

and Space Administration and the National Institutes of Health have participated in this research, and the VA has long studied questions of

importance to veterans. At present, the National

Institute of Handicapped Research (NIHR) has primary responsibility for rehabilitation research.

The agency was created by the 1978 Amendments

(Public Law 95-602) to the Rehabilitation Act of

1973 and sited in the Rehabilitation Services

Administration. When in 1980 RSA was moved

to the newly created Department of Education,

sometimes even electric wheelchairs are provided

through such programs as Medicare and Medicaid, what is “medically necessary” may not allow

for participation in the work force. Wheelchair

users are thus in a position similar to that of the

above-elbow amputee. There are many more of

the former, however, and their technological alternatives are probably more widely understood and

appreciated.

To summarize, amputee-workers may wear

Boston Elbows. If injured on the job, they are

more likely to be fitted with the device if their

employers’ insurer is Liberty Mutual. If disabled

under other circumstances, they may receive Boston Elbows from Medicare, but only after 2 years

on SSDI. And potential workers are entitled to

Boston Elbows if the devices will increase their

employability, but they must compete for limited

VR dollars with other clients who benefit from

sophisticated technologies.

NIHR was separated from RSA and made a sister

agency within the department. NIHR”does not

have its own research capacity. Rather the institute sets priorities and enters into cooperative

agreements with researchers, usually at universities (28). The NIHR budget for fiscal year 1983

exceeded $30 million.

Research conducted for NIHR is largely applied

and includes development and evaluation of

devices. The institute funds four kinds of projects,

but most of its resources are expended on Research

and Training Centers (RTCS) and Rehabilitation

Engineering Centers (RECS). Each of the former

focuses on a single disability or group of disabilities and does research that may not be immediately applicable but from which applications

may be drawn. The RECS are more directly concerned with hardware. Center staff design and

build prototypical equipment-embodied technologies and improved prostheses, including externally powered above-elbow prostheses, are an explicit objective in NIHR’s Long-Range Plan. In
Ch. 4—Public Policy and the Boston Elbow ● 29

fiscal year 1983 the institute did fund research

broadly relevant to the Boston Elbow. But NIHR’s

mission is wide-ranging—to improve the quality

of life of all Americans with disabilities—and

prosthetics is only one of the agency’s 14 areas

of “prioritized technology research. ” The agency’s

funding is clearly inadequate to its task and has

in fact been decreasing from its 1981 level of $35

million (40,42).

At the other end of the research and development process stands the Food and Drug Administration (FDA), but the agency has had little effect on the development and distribution of the

Boston Elbow. The FDA considers prostheses

medical devices, and they fall within its mandate

to classify and regulate. Prosthetic parts are

assigned to Class I, where controls include regulation of manufacturing practices, recall and seizure authority, etc., but not the (as yet unspecified)

performance standards found in Class II. Prosthetic limbs are usually fabricated from components by prosthetists and technicians. As long as

the prosthetist “customizes” the device in this way,

the FDA does not require that the components

meet specific performance standards. When a

manufacturer sells a fully assembled prosthesis,

however, it falls into Class II, and the potential

of performance standards does apply. The Boston Elbow has not yet been classified and may

be assigned to Class II. In any case, Class I controls apply in Class 11 as well and are unlikely to

pose a problem for Liberty Mutual.

The amputee-citizen may actually be provided

with a prosthesis if he or she is eligible, on the

basis of income, for SSI and the Medicaid benefits

that in most States accompany it. SSI pays cash

benefits to citizens with low incomes whose disabilities are total and expected to last at least 12

months or result in death. The 1978 annual SSI

benefit for a man with a nonworking wife and

two children was $3,864 in California and $2,273

in Texas (5). SSI parallels SSDI, although the

former is not an insurance program and is financed through general revenues. SSI also offers

Medicaid rather than Medicare, and, because

Medicaid is a State-administered program, it

varies significantly from State to State. Prosthetic

and rehabilitation services (e.g., learning to function with one arm) may be among a State’s Medicaid benefits but need not be. All prostheses

funded through the program must be “medically

necessary” (39).

In Massachusetts, the Medicaid program does

provide prosthetic devices. Medical necessity is

asserted and defended by the physician prescribing the prosthesis and confirmed by the Medicaid officials who review the claim. Unlike durable

medical equipment, which may not be “substantially more costly than medically appropriate and

feasible alternatives” (8), prostheses are covered

if there is an adequate “medical justification” for

their expense (13). Medicaid officials are unable

to say whether a Boston Elbow has ever been approved or disapproved, and they claim they

would seriously consider providing an Elbow if

its advantages could be shown to have a medical

purpose (13). Still, it seems unlikely that Medicaid, which has been labeled “welfare medicine”

(35), would purchase a prosthesis as costly in both

absolute and relative terms as the Boston Elbow.

An exception might be made in the case of a very

high amputation that makes use of a cable-operated device impossible, but according to one Massachusetts physiatrist, Medicaid has a reputation

for expending its resources conservatively. He

does not prescribe more than basic rehabilitation

technology for his patients on Medicaid.

Amputee-citizens have an additional alternative to the Boston Elbow. It is the considerable

modification of their environment by the rehabilitation legislation of 1973 and 1978. The Rehabilitation Act of 1973 made significant changes in

both the human and manmade environments, creating for people with disabilities points of access

to mainstream America. Section 502 established

the Architectural and Transportation Barriers

Compliance Board to ensure the physical accessibility of Federal buildings and those built with

Federal funds since 1968. As noted in The Amputee-Worker, section 503 requires Federal contractors to take affirmative action in employing disabled

people. And section 504 prohibits discrimination

against people with disabilities by organizations

receiving Federal aid of any kind.

This mandate to achieve accessibility can be

(and is being) interpreted more or less generously.

In either case, it represents a break with the tradi-
30 ● Health Technology Case Study 29: The Boston Elbow

tional vocational orientation of rehabilitation policy. The Federal/State Vocation Rehabilitation

Program served many clients between 1920 and

1970, but its success was modest among individuals with severe disabilities. In the early 1970s,

some severely disabled people began to challenge

the apparent strategy of the VR Program: to place

as many clients as possible in jobs by accepting

the least severely disabled people as clients. This

critique ultimately took the form of the Rehabilitation Act of 1973, which targeted people with

severe disabilities for VR services. But the 1970s

were also the beginning of the post-Progressive

Era (29), when social welfare came to be thought

of less as a matter of services and more as a matter of rights. The Rehabilitation Act of 1973—

clearly an instance of post-Progressive legislation—not only reallocated services, but broadened

“rehabilitation” to mean the integration of people with disabilities into the larger society.

The 1978 Amendments to the 1973 Act further

modified the disabled person’s environment

through title VII, the independent living program.

Title VII mandates State rehabilitation agencies

to establish independent living centers (ILCS)

where severely disabled people without the potential for employment can be assisted to live as

independently as possible. The legislation grew

out of the independent living movement, which

began in the early 1970s among disabled people

living in institutions. They believed that even people with very serious impairments could, with

training and support, live in a deinstitutionalized

setting. The ILC, then, was designed to be the

locus of whatever services would prove necessary

in attaining maximum independence.

Title VII has never been fully funded. Federal

and State moneys have been made available for

the establishment and operation of ILCs—including skills training, advocacy, and out-reach—but

not the purchase of services per se. As a result,

an independent living center is highly unlikely to

provide a Boston Elbow, even if the prosthesis

promises an amputee more independence. Instead,

center staff will assist him or her in finding other

sources of funds for the device. ILCS also provide

skills training in daily activities, such as homemaking and financial management and help in

finding accessible housing, transportation, and

social activities (10,24,47).

The rehabilitation legislation of 1973 and 1978

has had an indirect but not inconsequential effect

on the Boston Elbow. By redefining services as

rights, the Rehabilitation Act envisions disabled

people independent of their service-givers and

raises expectations about how much independence

is possible. By providing support for independent living, the amendments further increased the

disabled individual’s chances for self-determination. Thus, there has been renewed interest in

“technology the enabler’ ’—compensatory technology that extends independent functioning. Paradoxically, this same affirmation of the disabled

person’s humanity has led some amputees to give

up the prostheses that they felt they were expected

to wear.

The amputee-citizen, in summary, is only tenuously connected to the Boston Elbow. But Federal research, regulation, and restatement of old

issues do contribute to the fate of the Boston

Elbow and other rehabilitation technologies.
59

Conclusions
5.

Conclusions

This case study has made three points: that the

Boston Elbow is technologically distinctive; that

it is only one way to compensate for the loss of

an arm; and that public policy plays a substantial role in distributing the Boston Elbow and other

compensatory measures.

Although this study has not had the benefit of

a controlled evaluation of the Boston Elbow and

its prosthetic alternatives, it is reasonable to conclude from the data at hand that for some, perhaps for many, above-elbow amputees, the Boston Elbow is an appropriate response to the loss

of an arm, The study also indicates that the Boston Elbow is not equally available to every amputee who might want or need it and that the government’s role in distributing the device operates

on several levels.

First, public policy sometimes works directly

on the existence of a prosthetic device. The Boston Elbow is a product of workers’ compensation

insurance and has been designed to restore abilities

valued in the workplace. Second, the government

makes explicit decisions about what may be purchased with public funds. The Veterans Administration prosthesis approval process, for example, and Medicare and Medicaid reimbursement

practices control the provision of specific prostheses to specific clienteles.

A third government influence is less direct but

equally potent. It is the extent to which prostheses are made part of large public programs. In the

Vocational Rehabilitation Program, for example,

physical restoration is one means to further the

objective of increasing the employability of amputees. The Boston Elbow is or is not provided

to Vocational Rehabilitation clients depending on

whether the device contributes significantly to

vocational potential. Finally, the government is

influential in making society more accessible to

people with disabilities. The Rehabilitation Act

of 1973, for example, opened several routes into

mainstream America and has made prosthetic

compensation simultaneously more of a right and

less of a necessity.

It remains to be seen whether the sum of the

influences described above constitutes the most

appropriate relationship between government and

the amputee: What should public policy be with

respect to the Boston Elbow? Given that disability

is idiosyncratic and contextual, government might

favor the match of individual amputees to whatever prostheses they and their physicians choose.

Government might also increase the likelihood of

such a match by making every device widely

available to potential wearers and their agents.

This, however, would be a rare show of universalist in a system where health and welfare policies painstakingly distinguish among clienteles.

The programmatic boundaries that shape diffusion of compensatory technologies such as the

Boston Elbow are firmly fixed. It is unrealistic to

think that a single judgment on the merits of the

device can influence the diverse mandates, histories, and resources of the several programs that

impinge on it. Rather, the Boston Elbow is more

or less appropriate to each of these programs, as

it is more or less appropriate to individual amputees.

Public policy is not providing adequate compensation to the extent that individuals’ needs diverge from the goals of the program(s) for which

they are eligible. Ironically, it is the array of programs available to the amputee-citizen, which do

not include provision of the Boston Elbow, that

promises to advance the cause of matching amputees to suitable prosthetic technologies and

other options. The independent living and disability rights movements encourage people with disabilities to become informed consumers of rehabilitation technologies and to view assistive

devices as part of larger compensatory strategies.

One result of this movement will be more selfaware and assertive participants in the design

and development of compensatory technologies.

Another result will be an awareness among disabled people that responses to functional loss derive from political as well as technical intentions.

33
Appendixes

.
.

Appendix A.— Glossary of Terms and Acronyms

Glossary of Terms

degree of freedom: capacity for active movement

electrode: conductor through which EMG signals are

transmitted from the stump to the prosthesis

EMG signals: electromyographic signals, i.e., electrical

charges that accompany muscle contraction

extension: movement of straightening a joint

flexion: movement of bending a joint

hold: amount of weight a prosthesis will support

lift: amount of weight a prosthesis will raise

mental workload: amount of conscious thought required to operate a prosthesis

myoelectric: controlled by EMG signals

proportional speed: speed that varies with the strength

of muscle contractions

prosthesis: artificial limb

range: distance a prosthesis travels from full flexion

to full extension

repair cycle: how often a prosthesis needs repair

service life: how long a prosthesis lasts,, with repairs

socket: hollow part of a prosthesis that holds the amputee’s stump

speed: how long it takes for a prosthesis to travel from

full flexion to full extension

stump: part of limb left after amputation

terminal device: hook or artificial hand

Glossary of Acronyms

AOPA –

FDA

IAB

ILC

MIT

MRC

NIHR

PSAS

REC

RSA

SSDI

SS1

VA

VR

—

—

—

—

—

—

—

—

—

—

—

—

—

American Orthotics

Association

and Prosthetics

Food and Drug Administration,

Department of Health and Human

Services

(Massachusetts) Industrial Accidents

Board

independent living center

Massachusetts Institute of Technology

Massachusetts Rehabilitation

Commission

National Institute of Handicapped

Research, Department of Education

Prosthetic and Sensory Aids Service,

Veterans Administration

Rehabilitation Engineering Center

Rehabilitation Services Administration,

Department of Education

Social Security Disability Insurance

Supplemental Security Income

Veterans Administration

Vocational Rehabilitation

3 7
Appendix B.—Acknowledgments and

Health Program Advisory Committee

In addition to the advisory panel, this case study has benefited from the advice and review of experts in

rehabilitation, health policy, and technology assessment. The author and OTA staff wish to thank the following

people for their valuable guidance:

Richard Arcangeli

Massachusetts Rehabilitation Commission

Boston, MA

Mary Hope Arostegui

Massachusetts Medicaid Program

Boston, MA

Beverly Bajek

Massachusetts Rehabilitation Commission

Brookline, MA

Robert J. Baughman

American Orthotics and Prosthetics Association

Alexandria, VA

Judith Bentkover

Arthur D. Little

Cambridge, MA

Katherine L. Bick

National Institute of Neurological and Communicative

Disorders and Stroke

National Institutes of Health

Bethesda, MD

Frank Bowe

Cedarhurst, NY

Robert J. Britain

National Center for Devices and Radiological

Health

Food and Drug Administration

Silver Spring, MD

Joseph M. Cestaro

Washington Prosthetic Supplies

Washington, DC

Dudley S. Childress

Northwestern University

Chicago, IL

Mark D. Goodhart

American Hospital Association

Chicago, IL

Stephen J. Greelish

Liberty Mutual Research Center

Hopkinton, MA

Werner Greenbaum

Veterans Administration

New York, NY

Richard J. Jones

American Medical

Chicago, IL

38

Association

Evan Kemp

Citizens for Disability Rights

Washington, DC

John R. Kimberly

The Wharton School

University of Pennsylvania

Philadelphia, PA

Dorothy Leonard-Barton

Graduate School of Business Administration

Harvard University

Boston, MA

L. Anthony Magliozzi

Liberty Mutual Insurance Co.

Boston, MA

Robert W. Mann

Massachusetts Institute of Technology

Cambridge, MA

Harold Margulies

Public Health Service

Department of Health and Human Services

Rockville, MD

John Martin

Massachusetts Industrial Accidents Board

Boston, MA

Colin A. McLaurin

Rehabilitation Engineering Center

University of Virginia

Charlottesville, VA

Michael Muehe

Office of Handicapped Affairs

Boston, MA

Eugene F. Murphy

Veterans Administration

New York, NY

William S. Partridge

Technical Research Associates

Salt Lake City, Utah

Jacquelin Perry

Rancho Los Amigos Hospital

Downey, CA

James B. Reswick

National Institute of Handicapped Research

Department of Education

Washington, DC
App, B—Acknowledgments and Health Program Advisory Committee ● 39

Harvey Sapolsky

Massachusetts Institute of Technology

Cambridge, MA

Richard Sclove

Massachusetts Institute of Technology

Cambridge, MA

Mark Segal

Massachusetts Institute of Technology

Cambridge, MA

David Wayne Smith

The University of Arizona

Southwest Arthritis Center

Tucson, AZ

Myron F. Splitgerber

Health Care Financing Administration

Department of Health and Human Services

Boston, MA

Deborah Stone

Massachusetts Institute of Technology

Cambridge, MA

Joseph E. Traub

National Institute of Handicapped Research

Department of Education

Washington, DC

Gregg C. Vanderheiden

Trace Research and Development Center for the

Severely Communicatively Handicapped

University of Wisconsin-Madison

Madison, WI

Linda Johnson White

American College of Physicians

Philadelphia, PA

Robert Williams

Boston Center for Independent Living

Boston, MA

Dennis R. Wyant

Veterans Administration

Washington, DC

Donald Young

Prospective Payment Assessment Commission

Washington, DC

Armand Thiboutot Irving Zola

Veterans Administration Brandeis University

Boston, MA Waltham, MA

HEALTH PROGRAM ADVISORY COMMITTEE

Sidney S. Lee, Committee Clajr

President, Milbank Memorial Fund

New York, NY

Stuart H. Altman*

Dean

Florence Heller School

Brandeis University

Waltham, MA

H. David Banta

Deputy Director

Pan American Health Organization

Washington, DC

Carroll L. Estes**

Chair

Department of Social and Behavioral Sciences

School of Nursing

University of California, San Francisco

San Francisco, CA

Rashi Fein

Professor

Department of Social Medicine and Health Policy

Harvard Medical School

Boston, MA

Harvey V. Fineberg

Dean

School of Public Health

Harvard University

Boston, MA

● Until April 1983.

‘*Until March 1984.

● **Until October 1983.

● ** ‘Until August 1983
40 . Hea/th Technology Case Study 29: The Boston Elbow

Melvin A. Glasser***

Director

Health Security Action Council

Committee for National Health Insurance

Washington, DC

Patricia King

Professor

Georgetown Law Center

Washington, DC

Joyce C. Lashof

Dean

School of Public Health

University of California, Berkeley

Berkeley, CA

Alexander Leaf

Professor of Medicine

Harvard Medical School

Massachusetts General Hospital

Boston, MA

Margaret Mahoney* ***

President

The Commonwealth Fund

New York, NY

Frederick Mosteller

Professor and Chair

Department of Health Policy and Management

School of Public Health

Harvard University

Boston, MA

Norton Nelson

Professor

Department of Environmental Medicine

New York University Medical School

New York, NY

Robert Oseasohn

Associate Dean

University of Texas, San Antonio

San Antonio, TX

Nora Piore

Senior Advisor

The Commonwealth Fund

New York, NY

Mitchell Rabkin*

President

Beth Israel Hospital

Boston, MA

Dorothy P. Rice

Regents Lecturer

Department of Social and Behavioral Sciences

School of Nursing

University of California, San Francisco

San Francisco, CA

Richard K. Riegelman

Associate Professor

George Washington University

School of Medicine

Washington, DC

Walter L. Robb

Vice President and General Manager

Medical Systems Operations

General Electric Co.

Milwaukee, WI

Frederick C. Robbins

President

Institute of Medicine

Washington, DC

Rosemary Stevens

Professor

Department of History and Sociology of Science

University of Pennsylvania

Philadelphia, PA
—

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