493

Occupational Therapy for the Polytrauma Casualty with Limb Loss

Chapter 18

OCCUPATIONAL THERAPY FOR THE POLYTRAUMA CASUALTY WITH LIMB LOSS

LISA M. SMURR, MS, OTR/L, CHT*; KATHLEEN YANCOSEK, MS, OTR/L, CHT†; KRISTIN GULICK, OTR/L, BS, 

CHT‡; OREN GANZ, MOT, OTR/L§; SCOTT KULLA, MS, OTR¥; MELISSA JONES, PhD, OTR/L¶; CHRISTOPHER 

EBNER, MS, OTR/L**; and ALBERT ESQUENAZI, MD††

INTRODUCTION

FOUR-PHASE UPPER LIMB AMPUTEE PROTOCOL OF CARE

PHASE ONE: INITIAL MANAGEMENT AND PROTECTIVE HEALING

PHASE TWO: PREPROSTHETIC TRAINING

PHASE THREE: INTERMEDIATE PROSTHETIC TRAINING

PHASE FOUR: ADVANCED PROSTHETIC TRAINING

COMMUNITY REENTRY AND REINTEGRATION

DISCHARGE PLANNING

REHABILITATION FACTORS

RECENT ADVANCEMENTS IN PROSTHETIC DEVELOPMENT: IMPACT ON 

TREATMENT

SUMMARY

*Major, Medical Specialist Corps, US Army; Assistant Chief of Occupational Therapy, Brooke Army Medical Center and Officer in Charge of Occupational Therapy, Center for the Intrepid, Brooke Army Medical Center, 3851 Roger Brooke Drive, Fort Sam Houston, Texas 78234; formerly, Chief 

of Occupational Therapy, Orthopaedic Podiatry, Schofield Barracks Health Clinic, Tripler Army Medical Center, 1 Jarrett White Road, Tripler Army 

Medical Center, Hawaii 

†Major, Medical Specialist Corps, US Army; Graduate Student, Department of Rehabilitation Science, University of Kentucky, 923 Forest Lake Drive, 

Lexington, Kentucky 40515; formerly, Chief of Amputee Section of Occupational Therapy Service, Walter Reed Army Medical Center, 6900 Georgia 

Avenue, NW, Washington, DC 

‡Occupational Therapist; formerly, Director of Therapy Services, Advanced Arm Dynamics, 123 West Torrance Boulevard, Suite 203, Redondo Beach, 

California 

§

Occupational Therapist, Department of Orthopaedics and Rehabilitation/Occupational Therapy Services, Amputee Section, Walter Reed Army Medical 

Center, 6900 Georgia Avenue, NW, Washington, DC 20307 

¥

Captain, Medical Specialist Corps, US Army; Chief, Department of Occupational Therapy, HHC 121 Combat Support Hospital, Box 238, APO AP 

96205; formerly, Chief, Amputee Services, Department of Occupational Therapy, Center for the Intrepid, Brooke Army Medical Center, 3851 Roger 

Brooke Drive, Fort Sam Houston, Texas 

¶

Lieutenant Colonel (Retired), Medical Specialist Corps, US Army; formerly, Research Coordinator, Department of Orthopaedics and Rehabilitation, 

Walter Reed Army Medical Center, 6900 Georgia Avenue, NW, Washington, DC 

**Occupational Therapist, Department of Orthopaedics and Rehabilitation, Brooke Army Medical Center, Center for the Intrepid, 3851 Roger Brooke 

Drive, Fort Sam Houston, Texas 78234; formerly, Occupational Therapist, Department of Orthopaedics and Rehabilitation, Brooke Army Medical 

Center, Fort Sam Houston, Texas

††Chair, Physical Medicine and Rehabilitation, Chief Medical Officer, MossRehab/Einstein at Elkins Park, 60 East Township Line Road, Elkins Park, 

Pennsylvania 19027 
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Care of the Combat Amputee

INTRODUCTION

injuries in addition to upper limb amputation(s), a 

standardized, comprehensive, and multidimensional 

four-phase protocol of care was developed with a 

focus of achieving maximum reintegration into the 

community and resuming previous or assuming new 

occupational roles. The development of this protocol 

was most influenced by the Model of Human Occupation by Gary Kielhofner.3

 This theoretical framework 

facilitates understanding of the impairments, activity 

limitations, and participant restrictions resulting from 

limb loss, especially when accompanied by the comorbidities experienced by many patients.3

The Model of Human Occupation addresses the acquisition of preliminary and advanced performance 

skills, the underlying volition or motivation of patients 

required to engage in occupation, and the habituation 

required for use of the prosthesis while engaging in 

multiple roles and daily routines in their social and 

physical environments.3 The goal of OT intervention 

for patients with limb loss is returning them to their 

potential for maximum performance of daily occupations that lead to a meaningful and satisfying life. OT 

provides the patient the necessary skills and tools to 

reintegrate back into the military unit or to civilian 

life physically, psychologically, and socially. Inherent 

in this overall goal is for SMs to successfully integrate 

the use of a prosthesis into their basic motor skill set if 

they so choose. The authors have termed the successful 

integration of the prosthesis as prosthetic acceptance 

or prosthetic integration.

The environments for amputee rehabilitation at 

the military amputee centers of excellence, such as 

Brooke Army Medical Center, Walter Reed Army 

Medical Center, and Naval Medical Center San Diego, 

are ideal settings because occupational therapists and 

prosthetists specializing in upper extremity amputee 

rehabilitation and prosthetics, respectively, are on 

site working jointly in the care and management of 

upper extremity amputees. Additionally, SMs stay 

on the campus of each facility while they undergo 

comprehensive rehabilitation and reintegration into 

the community with their prosthesis. 

As stated by Dillingham “the care of amputees is 

a major problem facing any Army during wartime.”1

Historically, trauma experienced in battle results in 

substantial numbers of upper and lower extremity 

amputees that far exceed those seen in civilian medicine. For this reason, amputee care in the military must 

remain at the forefront of rehabilitation and technology 

while simultaneously maintaining readiness to assume 

the full care of treating service members (SMs) with 

limb loss.1 

Since the beginning of Operation Enduring Freedom/Operation Iraqi Freedom, over 904 patients 

with major limb amputations have been managed in 

the military healthcare system.2 The causes of injuries 

include mortars, gun munitions, improvised explosive 

devices, vehicle-borne improvised explosive devices, 

and rocket-propelled grenade launchers. Given the 

nature of these explosive and thermal injuries, the 

heavily contaminated wounds are left open to allow for multiple debridements and washouts in the 

operating room. Frequently, multiple extremities are 

involved and although injury patterns may be similar, 

no two patients are alike. As a result of the high force 

velocity and high temperatures at the time of injury 

concomitant injuries often occur. These range from 

traumatic brain injury (TBI) to visual loss, hearing loss, 

massive soft tissue loss, fractures, burns, and nerve 

and vascular damage. The severity and complexity of 

these polytrauma injuries in addition to amputation(s) 

complicate rehabilitation. Occupational therapy (OT) 

is critical in the treatment of patients with upper limb 

amputation. The focus of OT is on the patient’s ability to engage in purposeful and meaningful activities. 

Human occupations may be work, leisure, or self-care 

related. Most occupations are performed with the 

hands and thus the role of the occupational therapist 

is to assist the amputee to perform these occupations 

with and without a prosthesis through the use of compensatory strategies or adaptive and durable medical 

equipment. 

To address the rehabilitation needs of those individuals who have sustained complex polytrauma 

FOUR-PHASE UPPER LIMB AMPUTEE PROTOCOL OF CARE

As previously stated, the goal of OT intervention 

is for patients with limb loss to return to their highest 

potential for performance of daily occupations that 

lead them to a meaningful and satisfying life. To meet 

this objective a four-phase upper limb rehabilitation 

protocol is used. Phase one addresses initial management and protective healing; phase two marks the 

introduction of preprosthetic training; phase three 

addresses intermediate prosthetic training; and 

phase four focuses on advanced prosthetic training. 

Throughout each phase, discharge planning and community reintegration are incorporated and addressed 

to meet the patients’ needs. Overlap occurs between 

each phase that is bidirectional to allow flexibility 

of patient progression based on severity of injuries, 

wound healing, and patient tolerance. The patient 
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Occupational Therapy for the Polytrauma Casualty with Limb Loss

may regress in the protocol because of secondary 

problems of wound infection and delayed closure, 

heterotropic ossification, residual limb hypersensitivity, or other conditions resulting from concomitant injuries. Throughout each phase care is individualized 

to meet the needs of each patient, and as the patient 

becomes medically stable occupation-based goals 

are established. Also phases are repeated as necessary with each prosthesis that the patient acquires. 

With training of subsequent prosthetic use, the user’s 

ability to master the foundational skills and perform 

functional tasks is rapid.

PHASE ONE: INITIAL MANAGEMENT AND PROTECTIVE HEALING

The primary overarching rehabilitation goals of 

this phase are to promote wound closure and educate 

the patient and family (Exhibit 18-1). This phase begins immediately after the injury and continues until 

all wounds have successfully closed and are free of 

infection. The time in this phase varies depending on 

the extent of the injury, but generally lasts from 1 to 3 

weeks after admission. Patients and family members 

are introduced to rehabilitative and prosthetic services 

in the early stage of this phase. It is imperative that 

these interventions begin early to reduce uncertainties 

and fears, provide support throughout the grieving 

and recovery processes, and engage the patient and 

family with the rehabilitative team. The components of 

this phase include comprehensive evaluation, wound 

healing, edema control, desensitization and scar management, pain control, exercise, flexibility, gross motor 

activity, and psychological support. Basic activities of 

daily living (ADLs) include those activities that are 

involved in personal body care.4

Evaluation

A comprehensive evaluation of the patient is administered in a holistic and multidisciplinary approach to 

obtain baseline information about functional status, 

background, abilities, and future goals. This complete 

evaluation provides the rehabilitation team with a 

EXHIBIT 18-1

PHASE ONE: BASIC REHABILITATION GOALS

Goals: 1 to 3 Weeks after Admission

1. All open wounds will be clean, dry, and free from infection.

2. Patient will perform self-feeding, oral hygiene, and toilet hygiene with the use of adaptive equipment and set up as necessary.

3. Patient will wear a form of compressive limb wrap 24 hours a day that extends above the most 

distal joint.

4. Patient will elevate the limb(s) as appropriate.

5. Patient will visually inspect residual limb.

6. Patient will tolerate tactile input on residual limb.

7. Patient will demonstrate independence in desensitization home exercise program.

8. Patient will tolerate scar massage.

9. Patient will assist in massage.

10. Patient will have functional active range of motion in bilateral extremities.

11. Patient will perform therapeutic exercise daily to prevent de-conditioning.

12. Patient will perform postural exercises with a focus on body symmetry.

13. Patient will receive support from the therapist through discussion of future function, which may 

include video of other prosthetic users.

14. Patient and the patient’s family will receive information about the prosthetic rehabilitation process.

15. Patient and the patient’s family will receive information about available types of prostheses and 

their differences.

16. Patient and the patient’s family will receive information about the stages of grieving the loss of 

a limb and change in body image.
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Care of the Combat Amputee

comprehensive assessment of the patient’s physical 

and emotional baseline status. 

The patient’s medical history is obtained with 

special attention to all injuries that impact care and 

long-term goals. Current medications and the patient’s 

response to these medications are documented. The 

evaluation includes an indepth information-gathering 

interview with the patient and family members to 

identify premorbid lifestyle and occupational roles, 

hand dominance, educational level, vocation, and 

recreational interests. Given the military’s mobile nature, the patient’s current living situation is reviewed 

to determine the level of family support available and 

any physical or environmental limitations within the 

current home environment that may be problematic 

once the patient returns home. 

It is critical to screen each patient’s psychosocial 

status. Information is gathered on the patient’s current 

emotional state and his or her premorbid emotional 

resiliency. This helps the therapist to prepare for the 

next therapy session because it provides an understanding of where the patient came from and what he 

or she is going through emotionally. If possible, current 

knowledge, thoughts, and fears regarding amputation 

are also assessed. An understanding of the patient’s 

previous exposure to amputees informs the therapist 

of the patient’s possible perception of their injury. At 

the end of the evaluation, depending on the mental and 

emotional status and interest of the patient, a discussion is initiated regarding prosthetic rehabilitation and 

prosthetic options. 

The objective components of the evaluation include 

the following: 

	 •	 basic ADLs,

	 •	 upper quadrant range of motion (ROM) on

the intact side, 

	 •	 bilateral manual muscle testing,

	 •	 limb volume measurement,

	 •	 wound description,

	 •	 scar evaluation,

	 •	 pain (phantom and residual limb pain), and

	 •	 sensation of the residual and intact limb.

It is important for the therapist and prosthetist to assess 

residual limb sensation because areas of hyposensitivity or hypersensitivity are necessary considerations in 

the fabrication and fitting of the prosthetic socket. The 

evaluation includes a thorough assessment of pain of 

the residual limb, phantom pain, and its differentiation 

from phantom sensation. 

A functional evaluation is completed to assess 

baseline basic ADL performance in bathing/showering, bowel and bladder management, toilet hygiene, 

upper and lower body dressing, personal hygiene 

and grooming, eating, sleep/rest, and functional 

transfers to include bed, chair, wheelchair, toilet, and 

shower transfers. Each area is assessed to determine 

the amount of physical and/or cognitive assistance 

that is required to complete the task. A rating of modified independent is given if the patient can complete 

the task with increased time or the use of adaptive 

equipment; a rating of supervision is given if the patient requires supervision to safely complete the task; 

a rating of minimal assistance is given if the patient 

requires contact guard-25% assistance to complete the 

task; moderate assistance if the patient requires 25% 

to 50% assistance; maximum assistance if the patient 

requires 50% to 75% assistance; and total assistance if 

the patient requires 75% to 100% assistance. All aspects 

of this ADL evaluation may be completed in one or 

several days depending on the patient’s tolerance. 

Prehension evaluations are performed as appropriate for each patient. Although no standardized 

evaluation for prehension deficits is identified in 

this population, it is necessary to determine baseline 

function of the remaining limb because the intact limb 

will be responsible for conducting all fine motor and 

dexterity tasks for vocational, leisure, and occupational 

purposes. Useful evaluations include the Jebson Taylor 

test of hand function; Minnesota Rate of Manipulation 

Test, Boxes and Blocks; and Nine Hole Peg tests.

Activities of Daily Living 

The evaluation findings and assessment provide a 

foundation on which to build the treatment program. 

One of OT’s major goals is to help the individual gain 

independence in self-care. This is a critical component 

that should be addressed very early when working 

with an amputee because a sense of dependence can 

lead to feelings of helplessness. This sense of helplessness is a common response after the loss of a limb; 

however, the degree of helplessness tends to be greater 

in the bilateral upper limb amputee. Therefore, it is essential for the rehabilitation team to assist the patient in 

gaining a sense of independence and control over his or 

her environment as soon as possible, preferably while 

still in the acute phase. Three ADLs that the occupational therapist should address in the first treatments 

include (1) toilet hygiene, (2) self-feeding, and (3) oral 

hygiene. These are some of the most rudimentary 

basic ADLs that can help the patient feel some sense 

of independence. Such adaptive equipment as toilet 

hygiene devices, use of foot-operated bidet, universal 

cuffs, and pump bottles can improve self-sufficiency 

in these tasks for the unilateral amputee.

Depending on the severity of injuries and medical 
497

Occupational Therapy for the Polytrauma Casualty with Limb Loss

stability of the patient, performance in additional basic 

ADLs may not be appropriate. Areas such as dressing, 

showering, and facial hygiene are addressed in phase 

two. However, if patients are medically stable and 

wounds are healed, phase two ADL training may be 

initiated earlier. Patients whose wounds and medical 

status do not allow progression to these ADLs are encouraged to wear loose-fitting pullover shirts, athletic 

shorts or pants, and slip-on shoes with traction on the 

sole to prevent falls. Adaptive equipment, such as a 

reacher and a dressing stick, is issued to patients as 

appropriate. Patients who are unable to use adaptive 

equipment require creativity on the part of the occupational therapist to achieve maximal independence 

in one-handed dressing strategies. See ”Activities of 

Daily Living, Adaptive Equipment, and Change of 

Dominance” under phase two for some of these additional strategies. 

Wound Healing

Wounds are left open for operative washouts and to 

avoid closed-space infections and tissue loss. Various 

procedures to promote healing are utilized depending on the type and size of the wound. If allograft soft 

tissue is used for skin coverage, drains are placed as 

appropriate. Wounds greater than 5 cm in depth are 

kept free from infection through intraoperative placement of antibiotic beads that are replaced surgically 

as necessary. Another strategy involves the use of 

vacuum-assisted closure systems, or negative pressure wound therapy. This technique is designed to 

promote the formation of granular tissue in the wound 

bed through intraoperative placement of sterile foam 

dressing with an evacuation tube placed over the 

dressing via an adhesive barrier creating an airtight 

seal around the wound. Negative pressure is applied 

by way of the evacuation tube, which is attached to 

an external canister to collect the wound exudate. The 

negative pressure therapy system is maintained until 

the wound enters the granulation stage and the wound 

edges draw closer together. 

During initial residual limb wound healing, occupational therapists perform wound care and dressing 

changes according to physician guidelines. Also, a 

figure-of-eight wrap is used for distal to proximal 

compression and shaping over the healing distal aspect 

of the residual limb. Once the wound stops draining, 

the patient progresses to a sewn Compressogrip sleeve 

(AliMed, Dedham, Mass) or the use of Tubegrip (Valco 

Cincinnati Inc, Cincinnati, Ohio), which is tapered 

at the distal end of the residual limb. As the wound 

closes and the mature scar tissue forms, the patient 

and the family are instructed in the application and 

wear of a silicone liner that provides continuous force 

compression with the added benefit of minimizing 

hypertrophic scar tissue formation. 

One of the goals for the patient, or his or her family 

member as appropriate, is to be able to independently 

don and doff compression garments. The compression 

garments are changed frequently throughout the day to 

maintain consistent concentric pressure from the distal 

to proximal margins of the residual limb. Edema control 

measures are implemented to assist in decreasing limb 

volume to prepare for fitting a preparatory prosthesis. 

Desensitization

Desensitization is initiated promptly through the 

use of the aforementioned compression techniques. 

When the wound progresses to the granulation stage 

and drainage ceases, antibacterial ointment is applied 

to the wound bed for use with gentle massage and 

wound debridement, if necessary. As the wound closes, 

desensitization is initiated through tapping and the 

use of texture bins for immersion of the hypersensitive 

limb. Desensitization is critical and is performed daily 

as the patient’s skin and scar tolerates. Reduction in 

residual limb hypersensitivity improves tolerance to 

wearing the prosthetic socket. Desensitization training is tailored for each patient depending on level 

of hypersensitivity and wound status. Patients and 

family members are also instructed in limb massage 

and desensitization to continue therapy outside of the 

clinic because this is critical for success. 

Upper Limb Flexibility, Body Symmetry, and Exercise 

The weeks immediately postamputation are the 

most critical in terms of implementing a comprehensive 

exercise program. The specific exercise program goals 

are established with physician guidance and coordinated between occupational, physical, and recreational 

therapies. The exercise program focuses on four main 

components: (1) flexibility, (2) body symmetry with exercise, (3) incorporation of the residual limb into activity 

to assist with desensitization and increase residual limb 

tolerance to pressure, and (4) muscle strengthening, the 

latter being addressed in phase two. 

Daily maintenance of upper limb flexibility following amputation is critical to prepare the residual limb 

for prosthetic use. Initially, mat exercises should be 

utilized to promote independent upper limb mobility. 

Low load prolonged stretch to the shoulder flexors, abductors, and rotators as well as the scapular protractors 

and retractors is a priority because limitation of shoulder motion may result in rejection of the prosthesis.5

The patient is then instructed to consistently increase 
498

Care of the Combat Amputee

the duration and daily frequency of the stretch. Each 

stretch should be performed for a minimum of five 

repetitions and held for 30 seconds in each joint direction. If self-stretches are not successful, then manual 

assisted stretching must be implemented with possible 

augmentation through facilitatory techniques. Good 

success has been achieved using proprioceptive neuromuscular facilitation techniques of contract-relax and 

slow-reversal for those patients demonstrating significant muscle guarding.6

 Pain medication, hydrotherapy, 

ultrasound, and other physical modalities may also be 

incorporated into the stretch program.

Incorrect postures may lead to cumulative trauma 

or overuse injuries of the upper limbs, neck, or back; 

therefore, emphasis is placed on proper body mechanics and awareness of body symmetry during activity. 

Visual feedback is the technique of choice for body 

symmetry awareness training and instruction often 

begins with observation of static postures in front of 

a mirror. Training quickly progresses to performance 

of dynamic therapeutic activities in front of a mirror. 

Additionally, the therapist provides verbal and tactile 

cues as necessary to maintain proper body symmetry. 

The patient is educated and encouraged to check his or 

her posture regularly when in front of a mirror during 

routine daily activities such as oral hygiene. 

Patients with transradial level amputations or longer 

should be able to bear some weight directly through 

their residual limb. Early weight-bearing activities can 

reduce complaints of residual and phantom limb pain 

and prepare the residual limb for prosthetic usage.

Amputees must develop improved aerobic fitness 

levels because of the increased demands associated 

with prosthetic use. Exercise after limb loss is further 

enhanced through patient participation in physical 

therapy to address core strengthening and cardiovascular endurance (see Chapter 17, Physical Therapy for 

the Polytrauma Casualty With Limb Loss). 

Pain Management Strategies throughout 

Rehabilitation 

Amputee associated pain is broken into two distinct 

categories: (1) phantom limb pain and (2) residual limb 

pain. Phantom limb pain is described as pain in an 

absent limb or portion of a limb.7 Residual limb pain is 

described as pain in the part of the limb remaining after 

the amputation.8 These types of pain are acknowledged 

as two separate entities and have both common and 

unique treatment approaches for management. 

Nonpharmacological pain management in the immediate postoperative period includes appropriate 

therapeutic interventions based on the type and origin 

of the pain. Treatment modalities include transcutaneous electrical nerve stimulation, ice, heat, contrast 

baths, massage, functional tasks to encourage normal 

motor pattern of the painful extremity, desensitization, 

and continuous psychological support in addition to 

psychiatric and pain management services. In some 

cases, an individual with a severely hypersensitive 

residual limb may benefit from desensitization 20 minutes five times per day until the sensitivity improves.9

The use of a mirror box, in which the uninvolved 

side is visually reflected as the missing side, has been 

shown to decrease phantom pain in some cases.10,11 

Interventions for pain control are continuous through 

the multiple phases of the rehabilitation program. 

Phantom sensation is any nonpainful sensory 

phenomenon in an absent limb.7 Phantom sensation 

is frequently experienced after limb amputation and 

can be a concern to patients; therefore, it is important 

to reassure them that this is normal. The patient’s experience of phantom limb sensation may change over 

time; research suggests that use of a prosthesis may 

improve phantom limb pain.12,13

Psychological Support

Psychological support is essential for successful 

rehabilitation and begins during the first interaction 

with the patient. Psychological support offered by OT 

during this phase encompasses patient and family 

education that facilitates coping and management of 

limb loss.

Psychological issues frequently seen in an amputee 

population include (a) fear of the unknown, (b) loss of 

self-esteem, (c) loss of self-confidence, (d) change in 

body image, (e) fear of rejection, and (f) loss of occupational roles. In the initial stage, patients are supported 

appropriately as their needs change. Intervention is 

provided by the entire interdisciplinary team. The 

goal is to successfully transition the patient to ”real 

life” after hospitalization. Methods of psychological 

support include the following: 

	 •	 education on the rehabilitative process to allay

fears of the unknown, 

	 •	 reinforcement of the patient’s personal style,

	 •	 reassurance of normalcy of the patient’s response to amputation,

	 •	 involvementinpreventativemedicalpsychiatry,

	 •	 engagement in empathetic interaction with

both the patient and family, 

	 •	 development of confidence and self-esteem,

	 •	 promotion of success in tasks and activities,

	 •	 encouragement to develop his or heridentity,

and 

	 •	 engagement in weekly therapeutic outings.
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Occupational Therapy for the Polytrauma Casualty with Limb Loss

PHASE TWO: PREPROSTHETIC TRAINING

Psychological Support through the Grieving Process to Acceptance

Patients entering the second phase may require 

additional psychological support from therapy as 

they progress emotionally from combat survival 

mode, through the awareness that they have survived 

a combat-related injury, to the realization that they 

will have to live with an altered body. Psychological 

support is continued and modified as necessary to appropriately respond to the patients’ rapidly changing 

needs as they advance through the grieving process. 

As the patient demonstrates signs of acceptance of 

the injury, he or she is informed about the many 

Approximately 2 to 3 weeks after injury, depending on the patient’s medical circumstances 

and concomitant injuries, he or she progresses into 

phase two of the protocol (Exhibit 18-2). The goal 

of this phase is to prepare the patient and the limb 

to receive a well-fit prosthetic socket and functional 

prosthesis. This phase begins at wound closure and 

ends with acquisition of a preparatory prosthesis, or 

an early postoperative prosthesis. Time spent in this 

phase varies depending on limb volume, sensitivity, 

ROM, physical condition of the residual limb, and 

the patient’s psychological status. Therefore, portions of phase one continue as necessary to address 

these deficits. 

EXHIBIT 18-2 

PHASE TWO: PREPROSTHETIC TRAINING: UNILATERAL AND BILATERAL AMPUTEE 

REHABILITATION GOALS

Rehabilitation Goals Specific to Unilateral Amputee

Goals: 1 to 4 Weeks after Admission

1. Patient will be independent in dressing using one-handed techniques.

2. Patient will be independent in light hygiene and showering with use of adaptive equipment as 

necessary.

3. Patient will be independent in donning compressive garment.

4. Patient will demonstrate in-hand manipulation without dropping items.

5. Patient will demonstrate functional prehensile patterns with an eating utensil.

6. Patient will demonstrate functional prehensile patterns with a writing utensil in the residual 

hand.

7. Patient will demonstrate proper position of body and paper for writing.

8. Patient will sign his or her name.

9. Patient will write a sentence.

Rehabilitation Goals Specific to Bilateral Amputee

Goals: 1 to 4 Weeks after Admission

1. Patient will receive adaptive equipment and technique training to maximize independence in 

self-feeding, oral hygiene, toileting, and dressing.

Common Unilateral and Bilateral Amputee Rehabilitation Goals

1. Patient will tolerate a compressive garment on the residual limbs 24 hours a day.

2. Once full range of motion is achieved, patient will tolerate a resistive upper body strengthening 

program.

3. Patient will be able to isolate two opposing myosites (ie, flexors and extensors).

4. Patient will be able to equally co-contract two opposing myosites.

5. Patient will tolerate myosite training daily.

6. Continue phase one goals as necessary (ie, scar management and desensitization).
500

Care of the Combat Amputee

possibilities of function with a prosthesis. Patients 

who choose to wear a prosthesis are educated on the 

reality of prosthetic function because individuals have 

varying perceptions of a prosthesis ranging from that 

of a picture of Captain Hook to the opposite extreme 

of a superhuman bionic arm. Adding peer support or 

a peer visitor significantly helps the patient. A peer 

support with a similar level of amputation can help 

educate about realistic expectations, provide a real 

life perspective of living with such an injury, and may 

potentially become a support with whom the patient 

can relate to throughout recovery. These peer visitors 

are trained individuals accessed through organizations such as the Amputee Coalition of America in 

Knoxville, Tennessee.

Patients may also participate in the Promoting Amputee Life Skills program, an 8-week course designed 

to teach persons with limb loss the skills to help them 

deal with problems they may encounter. The goals of 

the course are to reduce pain, depression, and anxiety, 

and to improve each person’s ability to problem solve, 

communicate with family and friends, and improve 

overall quality of life. 

Peak performance training, developed at the Center 

of Enhanced Performance at the US Military Academy, 

provides a method to effectively train individuals to 

develop mental and emotional attributes to efficiently 

operate in a fluid and ambiguous environment. The 

specific topics introduced include (a) confidence building, (b) goal setting, (c) attention control, (d) stress 

and energy management, and (e) visualization and 

imagery. Education and training to develop each skill 

is provided with the goal of the individual being able 

to ultimately achieve self-awareness, mental agility, 

and adaptability to overcome and thrive in demanding environments throughout recovery and future 

challenges.14 This training may assist amputees to 

overcome the psychological hurdles throughout their 

emotional recovery and rehabilitation.14

It has been the experience of this rehabilitation team 

that the patient rapidly progresses through grieving 

during phase two. The supportive psychological 

services available, the therapeutic milieu, participation with other individuals with limb loss, and the 

performance of ADLs in an environment promoting 

recovery provide the basis to achieve psychological adjustment. Patients who successfully negotiate 

the grieving process frequently begin to verbalize 

or display their injury in a humorous light. For example, patients purchase and wear various clothing 

paraphernalia with sayings such as ”dude where’s my 

leg,” or ”IEDs suck.” Although many of the statements 

are a crude representation of humor, they provide a 

valuable clinical sign that the individual has ”broken 

through” the grieving process, entered the acceptance 

phase of recovery, and can project humor in regards 

to amputation.

Activities of Daily Living, Adaptive Equipment, 

and Change of Dominance

During phase two the patient becomes more independent with basic ADLs as the wounds heal. Independence in toileting, self-feeding, and oral hygiene is 

achieved during phase one, and the patient progresses 

to showering, dressing, personal hygiene, grooming, 

sexual activity, functional mobility, and laundry activities during phase two. The patient is introduced to various adaptive aids and compensatory techniques for 

one-handed ADL performance. Adaptive equipment 

offered includes (a) modified long-handled sponges, 

(b) one-handed nail clippers, (c) nail brush, (d) wash 

mitt, and (e) any other additional equipment necessary to achieve independence. In addition, custom 

adaptive equipment is fabricated as necessary for the 

patient to return to one-handed ADL independence. 

Data obtained through patient report revealed that 

the most helpful adaptive aids include the following:

	 •	 one-handed nail clipper and nail brush,

	 •	 modified long-handled sponges,

	 •	 elastic shoe laces,

	 •	 wash mitts,

	 •	 pump bottles,

	 •	 rocker knives or Knorks (Phantom Enterprises

Inc, North Newton, Kans), and

	 •	 one-handed cutting boards.

Most patients prefer to minimize the number of adaptive aids because of the constrictions that equipment 

may pose for flexibility in task performance in different 

environments. 

The bilateral upper limb amputee requires special 

attention to complete basic ADLs. Techniques and 

modifications listed in Table 18-1 (also shown in 

Figure 18-1) are basic ideas to assist the individual 

in achieving independence in ADLs. This table is not 

an exhaustive list. Once patients receive ADL training, they may continue to modify techniques and the 

environment to meet their individual needs. Many 

bilateral upper limb amputees become adept at using 

the environment, body movements, their mouths, and 

their lower extremities to assist themselves. However, 

significant use of the mouth is discouraged to prevent 

damage to the teeth and jaw. It is reasonable to expect 

that patients with bilateral transradial amputations 

will be independent with all ADLs and active in their 

chosen occupations. A patient with bilateral shoulder 
501

Occupational Therapy for the Polytrauma Casualty with Limb Loss

TABLE 18-1 

BILATERAL UPPER EXTREMITY ACTIVITY OF DAILY LIVING TASK SAMPLE TECHNIQUE 

OPTIONS AND CONSIDERATIONS

ADL Task Sample Technique Options Considerations

Toileting	 •Use of a bidet.

• Squatting down and using one’s heel that is covered

with toilet paper or hygienic wipes.

• Placing toilet paper that is folded back on itself

repeatedly on the toilet seat with the tail of the toilet 

paper dropped into the water to secure it. 

• The prosthetic device must have wrist flexion

and rotation if the prosthetic user is to perform 

toilet hygiene without other aids. This ability is 

patient dependent.

• It is helpful for patients to try to develop a regular

bowel program so that they can plan to be in a 

location where the environment is ideal for them 

to care for themselves. Otherwise it can be helpful 

to carry a supply of hygienic wipes when they are 

out in public.

Feeding • Use of Dycem (Dycem Limited, Warwick Central Industrial Park, RI) or some nonskid material secures 

the plate or bowl and prevents sliding. 

• Use of a rocker knife or Knork (Phantom Enterprises

Inc, North Newton, Kans) for cutting. When in a 

restaurant the person can ask for meat to be pre-cut 

before being brought to the table. 

• Use of a straw for liquids.

• Use of a plate with a rim or a broad bowl to allow

for ease in loading the utensil.

• Some patients are comfortable bringing their mouth

to the tabletop.

• A prosthesis that supports maximal elbow flexion, wrist rotation, and wrist flexion will allow 

patients to feed themselves with unmodified 

utensils.

• Fingerfoods are often the most difficult due to the

significant amount of ROM required to get to the 

mouth without the added length of the utensil.

Dressing Upper body dressing 

• Pullover clothing should be placed at a higher

height to allow patients to easily bend over and use 

their residual limbs in concert with their mouth to 

get the shirt over their limbs and head. At this point 

using body motion will assist in getting the shirt 

down over the torso. If patients have difficulty getting the shirt over their torso, have them lie down 

and maneuver on a bed.

• Open-front shirts can be donned while hanging

from a hook or hanger, again using the lower extremities to hold the tails of the shirt or the mouth 

to hold the collar to adjust the fit.

• Jackets are donned easier if the cuffs are loose.

• Buttons can be fastened using hook terminal devices or a button hook, or they can be modified by 

applying Velcro (Velcro USA Inc, Manchester, NH) 

closures. Buttons higher up at the neck are the most 

challenging.

• Zippers can be more easily fastened with stable

catches and a good pull tab or added string or 

monofilament line pull.

• Pretied ties are the easiest to don.

• The patient with bilateral upper limb loss may

find that loose-fitting clothing with limited fasteners will be easier to manage.

(Table 18-1 continues)
502

Care of the Combat Amputee

Lower body dressing

• Garments with elastic waists will ease lower body

dressing. Using a non-skid material like Dycem 

(Dycem Limited, Warwick Central Industrial Park, 

RI) mounted on the wall slightly below waist height 

can be used to assist in raising or lowering lower 

body garments.

• Socks with loose cuffs that have been rolled down

facilitate donning. Sock aids are useful to some 

patients.

• Donning shoes is made easier by using slip-on

shoes, Velcro (Velcro USA Inc, Manchester, NH) 

closures, elastic laces, or a variety of lace holders.

• Preplacing a belt in the loops before donning pants

makes donning a belt easier.

• The hooks mounted on a donning stand orin a wall

can be helpful for various aspects of dressing.

Bathing • Bathing may be performed by using elastic shower

mitts over the end of the residual limb or by using a 

suction-mounted brush or scrubbing material.

• Soap and shampoo can be applied from a wallmounted soap dispenser or from pump dispenser 

type of bottles.

• Drying oneself can be done easily with a terry cloth

type of robe that hangs allowing ease of donning.

• Drying can also be done with a wall or countertopmounted hairdryer.

• It is critical to ensure a safe environment during

bathing because a fall, when one does not have 

upper limbs to protect oneself, can be devastating. 

Using a nonskid mat in the tub provides secure 

footing in a slippery environment. Some patients 

may prefer to use a tub bench. A floor-to-ceiling 

pole can assist with getting in or out of a tub if a 

patient has one transradial length limb. 

Hygiene • Shaving is more easily performed with an electric

shaver. A modified gooseneck with a clamp that 

is mounted to the wall can hold the shaver and 

be moved to access areas of the face (Figure 18-1). 

Women can sit and use a prosthetic device to shave 

their lower extremities. Women can consider laser 

hair removal, waxing, or electrolysis as an option 

for hair removal.

• Brushing teeth can be performed with prosthetic

devices or a mounted extension with a clamp. Using an electric toothbrush can facilitate better oral 

hygiene. 

• Trimming toenails can be done with a larger nail

clipper mounted on a suction board. This can be 

operated with a prosthesis or the other foot depending on dexterity.

• Use of a gooseneck arm with a clamp that is wall

mounted can be useful to hold shavers, toothbrushes, and hair dryers. Commercially available 

hair dryer holders are helpful as well.

• Performing hygiene activities independently can

be done with use of prosthetic devices, adaptive 

equipment, modifications to the environment, 

and use of many products made for the general 

public.

ADL: activity of daily living

ROM: range of motion

Table 18-1 continued

ADL Task Sample Technique Options Considerations
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Occupational Therapy for the Polytrauma Casualty with Limb Loss

disarticulation amputation will most likely require 

some assistance for certain ADLs despite the use of 

prosthetic devices and environmental modifications.

As a bilateral upper limb amputee becomes more 

independent in some basic ADLs, the learned skills 

necessary to achieve independence in these tasks will 

transfer when learning more complex daily living 

tasks. Initial training will require the therapist to be 

creative and the patient to be willing to try various 

approaches to a task to identify the best option. Once 

an ideal approach is identified repetition is necessary to 

habituate the new skill set into the motor repertoire to 

become more efficient in task performance. Additionally, learning more complex tasks will often occur with 

less frustration and more ease. Ultimately, each patient 

chooses the method(s) and equipment that work most 

effectively for him or her. 

As mastery in basic ADLs is achieved the patient 

begins to explore instrumental ADLs, which are those 

activities that are complex and involve interaction with 

the physical and cognitive environment.4 Instrumental 

ADLs addressed during phase two include the use 

of communication devices, light meal preparation 

and cleanup, financial management, mobility in the 

community, and safety and emergency response procedures. Depending on the patient’s circumstances 

additional adaptive equipment recommendations are 

made in preparation for discharge. 

In addition to progression toward instrumental 

ADLs, change of hand dominance training is introduced as necessary. Some patients perform this task 

with hesitation because they hope to use the prosthesis to perform writing tasks. However, based on 

the limitation of fine motor prehension and dexterity 

capabilities of any available prosthesis, it is important to transfer hand dominance for writing skills to 

reestablish independence in written communication. 

Fine motor activities include using tweezers, pumping spray bottles, twisting caps on and off, twisting 

nuts on and off of bolts, performing lacing activities 

on a vertical surface, and rolling putty balls. These 

activities encourage radial digit coordination, separation of radial and ulnar sides of the hand, and wrist 

extension. These are necessary motor components 

of handwriting. The patient learns rote penmanship 

exercises through progressive motor writing activities 

culminating in sentences with at least one character 

each from the alphabet: ”The quick brown fox jumped 

over the lazy dogs.” Bilateral upper limb amputees 

are encouraged to use a terminal device (TD) of their 

choice in order to gain the necessary skills for writing 

with a prosthesis.

At some point during the second phase of the protocol, most patients may be discharged from inpatient 

status, depending on medical status, comorbidities, 

and ability to perform self-care in a controlled living 

environment, such as a hotel on the military campus. 

This event marks a transition in the patient’s recovery 

as he or she leaves the structure and safety of the hospital environment and is encouraged and successfully 

challenged to regain full independence. Evaluations 

similar to home evaluation are performed as necessary 

in this new living environment to ensure competence 

and confidence in ADL performance and reinforce the 

family members’ caregiving responsibilities. 

Postural Exercises and Strengthening

During phase two upper quadrant flexibility, 

postural exercises for body symmetry, residual limb 

weight bearing, and physical therapy are continued. Once the patient is medically stable and pain is 

controlled, early mobilization, general progressive 

strengthening and muscular endurance exercises are 

initiated with emphasis on the shoulder girdle and 

proximal residual limb to prevent joint contractures. 

Strengthening of the remaining upper limb musculature is aggressively pursued to prepare the patient 

for the weight and upper body strength demands of 

the donned prosthesis. Specificity of training is the 

preferred method to emphasize the remaining limb 

strength and function. 

Strengthening exercises include isometric and 

isotonic contraction with modification to allow for 

use of the residual limb. Individuals who receive a 

body-powered prosthesis must strengthen the muscles 

that control shoulder flexion and scapular protraction, retraction, and depression because these gross 

body movements are used to control the prosthesis. 

Figure 18-1. An example of a modified gooseneck clamp 

mounted to a wall. It provides a versatile method for a patient 

with bilateral limb loss to perform a variety of activities of 

daily living tasks independently.
504

Care of the Combat Amputee

Rote practice of these movements early in rehabilitation will encourage muscle memory of those motions 

allowing for easier training once the patient receives 

the prosthesis. 

The muscles that stabilize the gleno-humeral and 

scapulo-thoracic joints include the trapezius, serratus 

anterior, rotator cuff, and deltoid groups. These muscles 

play an important role in functional activity; therefore, 

a balance in muscle strength between these groups is 

critical to optimize prosthetic use. Scapular protraction, shoulder shrugging, and seated push-ups will 

help ensure proper scapular positioning for smooth 

gleno-humeral rhythm.15 A spectrum of internal and 

external rotation up to 90 degrees in the scapular plane 

will maintain proper humeral head depression during 

shoulder elevation motions. Additionally, elbow stability should be maintained through bicep and tricep 

strengthening. Various therapeutic equipment and 

tools utilized for strengthening include Thera-Band 

and Baltimore Therapuetic Equipment (BTE Technologies, Hanover, Md). As the patient’s endurance and 

residual limb tolerance to pressure improves, resisted 

exercises and weight-lifting activities involving the 

upper extremities should be considered. Trunk stability 

and core strengthening are also emphasized.

Myosite Testing and Training

Due to the rapid medical evacuation of an SM from 

the battlefield to the medical center, early and aggressive prosthetic rehabilitation is possible. For this 

reason, SMs are fitted with electric prosthetic systems 

that create less shear force and end-bearing forces on 

the healing residual limb. In instances where early 

prosthetic fitting is not possible, the residual limb may 

require further preparation for either a body-powered 

or electric prosthesis. Many SMs are fit with an activityspecific prosthesis that allows them to participate in 

meaningful leisure and recreational activities.

Research has demonstrated that individuals in 

the general amputee population fit with a prosthesis 

within 30 days of amputation exhibited a 93% rehabilitation success rate with a 100% return to work rate 

within 4 months of injury. Those fit beyond 30 days 

exhibited a 42% rehabilitation success rate with a 15% 

return to work rate within 6 to 24 months. This 30-day 

period is termed the “golden window.”16 The extensive 

polytrauma incurred during combat complicates the 

rehabilitation team’s ability to achieve initial prosthetic 

fitting on combat-injured patients within this golden 

window. The impact of this problem has been managed through the use of training technology. Within 

2 to 3 weeks postinjury, patients treated begin socket 

electrode site identification and training necessary 

for operation of a myoelectric prosthesis. The goals of 

this early intervention training are to identify, instruct, 

and train the patient to independently, correctly, and 

efficiently use specific residual limb musculature to 

activate and perform basic myoelectric prosthesis functions resulting in the ability to immediately operate the 

myoelectric prosthesis at first fitting. 

Electrode site identification occurs in OT with 

use of socket electrodes (Figure 18-2) hooked up to 

a biofeedback unit, such as the MyoBoy (Otto Bock, 

Minneapolis, Minn), or the MyoLabII (Motion Control, Inc, Salt Lake City, Utah). Site selection involves 

multiple factors and requires the specialized skill of 

trained therapists and prosthetists to determine the 

proper and best available sites. The sites located in the 

training are used to identify the correct placement of 

the electrodes within the future prosthetic socket. The 

rehabilitation team works closely together during this 

stage to identify the best possible electrode placement 

and the most effective control scheme for each patient’s 

particular abilities and needs.

Many factors affect the optimal muscle site selection. 

Ideally a flexor muscle—used to operate TD closing 

and pronation—and an extensor muscle—used to 

operate TD opening and supination—are identified.

However, many patients do not have two available 

sites or have undergone reconstruction resulting in 

nonanatomic tissue presentation of the residual limb.

These cases require team creativity and individual 

encouragement. Other issues to consider include (a) 

scar and graft site locations because the signal is not 

as easily transmitted through dense tissue, (b) identification of an appropriate superficial muscle site for a 

stronger signal, and (c) continuous contact between the 

skin and electrode at the selected myosite throughout 

the maximum ROM of the residual limb. The latter 

requires special attention during this process. For 

Figure 18-2. Socket electrode used for myoelectric training. 

This same type of electrode is placed within the myoelectric 

prosthetic socket. 

Photograph courtesy of Otto Bock.
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Occupational Therapy for the Polytrauma Casualty with Limb Loss

example, if an electrode is placed over a proximal 

residual limb muscle that is activated during an activity such as reaching, the individual will perform 

inadvertent operation of the prosthesis and experience 

frustration.A quality muscle signal is characterized by 

an adequate electromyogram output that is isolated 

from the antagonist muscle. Once the best sites are 

identified, motor training begins. 

Motor training takes place using computer-based 

MyoSoft software attached to the MyoBoy hardware 

(Otto Bock, Minneapolis, Minn) and the socket electrodes. On an electromyogram-like screen, the patient 

can visualize color-coded signals, representative of 

each of the selected electrode site muscles, as they are 

activated for the corresponding TD operation (Figure 

18-3). Initially, the focus of training is on independent 

activation of each muscle. When the patient is able 

to demonstrate separation of these muscle signals, 

the concept of proportional control is introduced. 

Proportional control is a term used to describe the 

proportional relationship of the elicited strength of the 

selected muscle contraction to the speed and grip force 

of the TD. Many myoelectric components use this type 

of control. It is more physiologic and predictable for the 

patient than previously used digital control systems. 

Depending on the manufacturer of the system, the 

gain (sensitive) of the electrodes may be manually adjusted. This allows the therapist to amplify or dampen 

the strength of the received signal from the muscle 

contraction to modulate prosthetic output. Changes 

in the gain may need to be made frequently as the 

individual develops mastery of control and increased 

muscle strength. 

The initial myosite training takes place with the 

upper limb in a relaxed position at or near midline. As 

the patient develops control in this plane, introduction 

of limb placement in various positions is initiated to 

Figure 18-3. MyoBoy software (Otto Bock, Minneapolis, 

Minn) computer screenshot demonstrating a patient performing signal separation. For example, signal 1 (blue line) 

represents the flexor muscle or the muscles identified to 

most commonly perform terminal device closing and pronation; signal 2 (red line) represents the extensor muscles or 

the muscles identified to most commonly perform terminal 

opening and supination. The goal is for the patient to be able 

to activate each muscle signal (1 and 2) separately without 

co-contracting the other muscle (1 or 2). 

Courtesy of Otto Bock.

Figure 18-4. Various games are available on the MyoBoy 

software (Otto Bock, Minneapolis, Minn) package. (a) The 

object of the virtual hand game is for the patient to exercise 

the proper force of contraction to grasp and release the ball. 

(b) In this example, the car represents one of the two muscle 

signals used to control the terminal device. The object of this 

game is for the patient to master accuracy with contraction 

force and to increase contraction endurance to navigate the 

car over the wall without crashing. This game can be further graded with the addition of a second simultaneous car 

representing the opposing muscle used for terminal device 

operation.

a

b
506

Care of the Combat Amputee

simulate reaching to heights, across midline, and to 

the floor. Use of an isolated muscle in such a way, especially following major trauma, is foreign and fatiguing; therefore, the individual’s endurance should be 

considered during initial training. The MyoSoft offers 

programs with a virtual hand that respond to muscle 

signal as a myoelectric TD would and a car game 

that uses accuracy and a score for the competitive at 

heart (Figure 18-4). The excitement of success and the 

involvement of competition in the training process are 

contagious, but must be monitored to prevent fatigue 

and subsequent overuse.

The electrodes used for the myosite training can be 

attached to the patient’s actual TD before fabrication 

of the early postoperative prosthesis (Figure 18-5). 

This step provides a three-dimensional perception of 

the prosthesis. The concepts of pre-positioning for the 

most efficient grasp patterns with different shapes of 

objects and appropriate force control with different 

densities of objects are effectively introduced during 

this stage.

The skills and knowledge that the patient gains 

during the preprosthetic training phase are critical 

to continued motivation and success with his or her 

prosthesis. Patients that receive preprosthetic training demonstrate some initial success at first fitting. 

This phase promotes motivation, gain of function in 

the residual limb, and a preliminary sense that the 

patient will once again have control over his/her life. 

The earlier the individual learns these valuable principles, the easier it is to transition to actual prosthetic 

use and refrain from poor ergonomic postures during 

prosthetic use that may lead to cumulative trauma 

disorders. For those individuals with limited muscle 

site access or injury-related denervation, other options 

are available. The use of one site to control mechanisms 

can be explored or the use of nonmyoelectric tension 

control systems can be very useful.

Figure 18-5. The socket electrodes attached to the actual terminal device are placed on the corresponding myosites. The 

patient is instructed to activate each muscle to perform the 

specified terminal device function. This approach provides 

three-dimensional, real-time feedback to the patient.

PHASE THREE: INTERMEDIATE PROSTHETIC TRAINING

Rehabilitation of the upper limb amputee is complex 

for three primary reasons. First, the human mind is 

powerful and it quickly retrains the body to accomplish daily life tasks such as cooking, eating, bathing, 

grooming, and toileting with the use of only one 

hand and occasionally adaptive equipment. Second, 

unlike the lower extremity that serves a purpose for 

propulsion during walking and balance during standing, the upper limb is extremely complex in its many 

functional operations at multiple joints and requires 

many integrated motions to accomplish preferred occupational tasks. Third, by comparison to the human 

limb, current prosthetic systems are heavy, bulky, and 

uncomfortable, and they require unfamiliar motor 

pattern performance to produce a simulated function 

that is rudimentary. Overall, it is a challenge to return 

an upper limb amputee, who quickly adapts to onehanded living, to a contrived two-handed world with 

one intact limb and one artificial limb. 

A valid question often posed by the upper limb 

amputee, especially younger ones, is ”Why do I have 

to wear a prosthesis?” As previously mentioned, it is 

true that most unilateral amputees can function independently with the use of one hand. The prosthesis will 

never truly replace the loss of a human limb. Instead, 

a prosthesis is a primitive facsimile of the original 

arm, which can be clumsy and uncomfortable and 

feel foreign to the wearer. However, with early, skilled 

prosthetic training the improvement in independent 

functional performance cannot be understated. 

Phase three marks a major turning point in the 

rehabilitative care of the upper limb amputee. Phases 

one and two lay the foundation for success in phase 

three. Phase one and two wound healing, strengthening/endurance training, desensitization, residual limb 

shaping, and myosite testing and training provide the 

foundation for actual practice and prosthesis use. The 

focus during phase three is for the patient to master 

and habituate the mechanical actions required for prosthetic limb control, integrate prosthesis use in activity 

performance, and ultimately achieve independence in 

all purposeful and meaningful daily life activities. The 

goals of phase three training include (a) knowledge on 

the operation and performance of the prosthesis, (b) 

initiation of controls training, and (c) initiation of ADL 

training (Exhibit 18-3).
507

Occupational Therapy for the Polytrauma Casualty with Limb Loss

EXHIBIT 18-3

PHASE THREE: INTERMEDIATE PROSTHETIC TRAINING: UNILATERAL AND BILATERAL 

AMPUTEE GOALS FOR MYOELECTRIC AND BODY-POWERED PROSTHESIS 

Unilateral Goals: 2 to 8 Weeks after Receiving Prosthesis 

Bilateral Goals: 4 to 10 Weeks after Receiving Prosthesis

Common Unilateral and Bilateral Transradial and Transhumeral Amputee Rehabilitation Goals

1. Patient will be independent donning and doffing select prosthesis (M, B). 

2. Patient will know, understand, and demonstrate compliance with the prosthetic wear schedule 

as directed by therapist (M, B).

3. Patient will independently perform limb hygiene daily (M, B).

4. Patient will be able to perform basic care of the prosthesis (M, B).

5. Patient will progress to tolerate prosthetic wear 6 to 8 hours per day (M, B).

6. Patient will be able to change the cable system (B).

7. Patient will be able to adjust the harnessing system (B).

8. Patient will be able to identify components and understand terminology of select prosthesis (M, B).

9. Patient will be able to change the TD independently (M, B). 

10. Patient will be able to open and close the TD through the full range (M, B). 

11. Patient will be able to open and close the TD to 1/3, 1/2, and 3/4 ranges (M, B).

12. Patient will be able to operate the wrist flexion component if applicable (M, B).

13. Patient will be able to operate the wrist rotation unit (M, B). 

14. Patient will be independent in the battery change and charge process (M). 

15. Patient pre-positions TD without verbal cueing (M, B).

16. Patient will become modified independent, using prosthesis, in basic ADLs within a reasonable 

time period with minimal extraneous movement and energy expenditure (M, B). 

Specific Elbow Disarticulation and Transhumeral Rehabilitation Goals (in addition to goals 1 - 16)

1. Patient will demonstrate locking/unlocking of the elbow unit (M, B). 

2. Patient will be able to position the elbow at 1/3, 1/2, and 3/4 range with and without weight (M, B).

3. Patient will demonstrate free swing if available (M, B).

4. Patient will demonstrate simultaneous control of the elbow unit and the TD concurrently (M).

5. Patient will position turn table component for internal/external rotation (B).

6. Patient pre-positions elbow unit without verbal cueing (M, B).

Specific Shoulder Disarticulation or Scapulo-thoracic Rehabilitation Goals (in addition to goals 1 - 16, and 

Elbow Disarticulation and Transhumeral Goals)

1. Patient will demonstrate unlocking/locking of the shoulder unit (M, B).

2. Patient will demonstrate free swing of the shoulder unit (M, B).

3. Patient pre-positions shoulder unit without verbal cueing (M, B).

Common Advanced Control Training Goals for Unilateral and Bilateral, Transradial, and Transhumeral 

Amputee (Initiate once all above goals have been achieved)

1. Patient will demonstrate simultaneous control of the TD concurrent with elbow unit operations 

(and shoulder unit if applicable) (M, B).

2. Patient will demonstrate proficiency in grasping and releasing objects in various planes away 

from midline (M, B).

3. Patient will demonstrate proficiency in proportional control when grasping objects without crushing (M, B). 

(Exhibit 18-3 continues)
508

Care of the Combat Amputee

Additional Bilateral Advanced Control Training Goals (in addition to common goals 1 - 3) 

1. Patient will be able to operate one prosthesis without inadvertently operating the other prosthesis.

2. Patient will be able to operate prostheses simultaneously or in isolation. 

ADLs: activities of daily living

B: body-powered 

M: myoelectric

TD: terminal device

Operational Prosthetic Knowledge and Performance

Initially, most patients receive a myoelectric prosthesis. However, in some instances fabrication of a 

body-powered prosthesis may be prescribed. A bodypowered prosthesis, also known as a conventional or 

cable-driven prosthesis, is powered by the patient’s 

own body motions. Depending on the amputation level 

more cables are attached for control from the prosthetic 

harness system to the TD and if necessary the elbow 

joint. Gross muscle movements of the residual limb, 

shoulder, scapula, and chest are captured by the prosthetic harness system, and the force produced through 

these motions generates tension on the cable(s) affording prosthetic use. 

There are two main types of prehensile TD systems 

available for body-powered systems: (1) voluntary 

open and (2) voluntary close. In the voluntary open 

system, the TD remains in the closed position until the 

user exerts specific gross body motions to open the 

TD. The force to sustain prehensile grasp is produced 

by elastic bands or springs on or in the TD. With the 

voluntary close system, the TD remains open until the 

user produces gross body movements to close the TD 

around an object. Springs within the TD provide the 

force to sustain grip in this system.

As previously mentioned, ROM and upper body 

strengthening of the intact proximal muscle groups 

improve the overall condition of the upper body and 

aid the prosthetic user in achieving full functional use 

of his or her prosthesis without the need for additional 

prosthetic and environmental modifications. The gross 

body movements used to control the body-powered 

prosthesis include (a) shoulder flexion, abduction, 

and extension; (b) scapular protraction, retraction, and 

depression; and (c) chest expansion.17-19

Scapular Protraction, Retraction, and Shoulder 

Flexion

Opening and closing of the body-powered TD is 

controlled primarily through shoulder and scapular 

movements depending on the type of TD system. 

Exhibit 18-3 continued

Protraction (or retraction in a voluntary open system) 

of one or both shoulder blades and forward flexion 

of the residual limb causes the contralateral side to 

stabilize the harness at the axilla and shoulder, thereby 

producing tension across the control cable, which is 

attached between the harness and TD. In a voluntary 

open system, scapular protraction will cause the TD 

to open and scapular relaxation/retraction will cause 

the TD to close. In a voluntary close system, scapular 

protraction will cause the TD to close and relaxation/

retraction of the scapula will cause the TD to open. 

Forward flexion is also used to flex and extend the 

forearm of an above elbow prosthesis when the elbow 

is in unlocked position.17-19

Scapular Depression and Shoulder Extension and 

Abduction

Unlocking and locking of the elbow for an above 

elbow prosthesis is controlled through scapular depression and shoulder extension and abduction. The 

combination of the movements lengthens the attachment between the harness and elbow unit and in turn 

activates the locking mechanism of the elbow. When 

the elbow is unlocked the forearm can be controlled 

through shoulder movements.17-19

Chest Expansion

Although this motion provides less excursion force 

than shoulder and scapular movements, chest expansion can be helpful to provide improved prosthetic 

control to patients with high-level amputations, nerve 

involvement, or other comorbid injuries. Modifications in harness design may be needed to capture this 

motion.17-19

Regardless of the type of prosthesis, it is critical that 

the individual obtain and demonstrate knowledge 

of component terminology, a general understanding 

of how the components make up the prosthesis, and 

instructions on how to perform basic maintenance 

on the prosthesis. This education affords the patient 

a basic vocabulary to effectively articulate with the 
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Occupational Therapy for the Polytrauma Casualty with Limb Loss

the patient’s ability to wear the prosthesis is hindered. 

Buried fragments, development of heterotropic ossification, peripheral nerve injuries, or the development of 

a neuroma are several type of injuries that may make 

the residual limb more susceptible to skin disruption. 

The rehabilitation team should inform the patient 

about the signs and symptoms of potential significant 

changes related to these areas. 

Along with inspection of the residual limb, establishing a wearing schedule for the prosthesis is also 

important. Initially the prosthesis should be worn for 

no more than 15 to 30 minutes, 2 to 3 times daily. Upon 

doffing of the prosthesis, the residual limb should be 

thoroughly inspected for any skin redness, irritation, 

and breakdown. If no signs of ill fit are evident, the 

user can increase the wearing time by 30-minute increments, 2 to 3 times daily. Improper socket fit must be 

immediately addressed by the prosthetist. Inspection 

of the residual limb should continue to be a daily 

routine even after the patient has progressed to allday wear and use of the prosthesis. Along with limb 

inspection, proper hygiene of the residual limb is also 

essential. This includes daily washing of the residual 

limb with mild soap followed by thorough drying 

before donning the prosthesis.

Donning/Doffing Prosthesis

The eventual goal is for the prosthetic user to be able 

to tolerate approximately 8 hours of prosthesis wear 

and use within 1 to 2 weeks from the start of training. 

Therefore, early independence in donning and doffing 

is important to achieve. The patient must be able to 

independently don and doff the full prosthetic system 

that includes (a) residual limb sock, (b) prosthetic donning liner, (c) prosthetic socket, and (d) harnessing(s) 

as appropriate. 

There is a range of different methods for donning/

doffing each type of prosthesis. When training the patient on donning and doffing the myoelectric prosthesis, the Reduced Friction Donning System (Advanced 

Arm Dynamics, Inc, Redondo Beach, Calif) is used 

(Figure 18-6). With the use of a special donning sock 

and socket design, the limb is placed into the socket 

and the sock is pulled out of the socket. The result is 

secure soft tissue placement within the socket trim 

lines ensuring optimum electrode contact. Individuals 

with a transhumeral amputation use the same donning 

system for application of the myoelectric prosthesis. 

However, on the socket a prosthetic valve is added to 

create a suction or semisuction fit of the socket on the 

limb. Once the sock is removed from the socket the 

excess air is removed at the touch of a button allowing 

for a vacuum seal. In the transradial socket, valves are 

rehabilitation team any mechanical difficulties or 

operational malfunctions of the prosthesis. Ability 

to articulate malfunctions using correct terminology 

greatly assists the prosthetist in diagnosing and fixing 

any repair issues. The prosthetist provides equipment 

education and reinforces it during therapy. Each patient should possess common terminology including—

but not limited to—the following: 

	 •	 socket and harnessing design,

	 •	 component terminology care,

	 •	 types of TD(s),

	 •	 type of control system(s) used, and

	 •	 basic mechanics of the prosthesis.

The patient must communicate with the prosthetist 

when maintenance is required. When basic repairs are 

necessary, the goal is for the patient to have enough 

knowledge to perform such maintenance. The patient 

is expected to be able to perform the following: 

	 •	 socket maintenance to include daily cleaning

and inspection of the socket; 

	 •	 battery charging and component maintenance

to include routine cleaning and application of 

lubricant; and 

	 •	 harness adjustment,rubber band replacement,

and cable system changes, as needed. 

Patients are provided with this education for use in 

settings where a prosthetist may not be available. The 

occupational therapist is responsible for ensuring that 

patients receive ample functional training to make 

them efficient and proficient in functional maintenance performance and prosthetic care in various 

environmental and physical circumstances relative to 

their everyday operational environment. Also, the occupational therapist is responsible for considering any 

other existing injuries that may hinder efficient performance of maintenance tasks and identifying ways for 

the patient to perform these tasks independently. For 

example, a patient that wants to return to the theater 

of operation would practice—while participating in 

OT—prosthetic maintenance under simulated conditions to mimic such an environment. 

Residual Limb Tolerance/Care

With traumatic amputation, the limb continues to 

heal beneath the surface of the skin well beyond wound 

closure and that makes the limb more susceptible to 

pathology. Frequent inspection of the residual limb(s) 

should become a daily ritual for all prosthetic users. If 

the skin integrity of the residual limb is compromised 
510

Care of the Combat Amputee

a b

c d
511

Occupational Therapy for the Polytrauma Casualty with Limb Loss

rarely used because the sockets are typically suspending via bony anatomy. 

When training to don the body-powered prosthesis 

the patient is instructed in the pullover method, where 

the harness is donned over the head, or the jacket 

method, where the harness is donned over one extremity and then the other (Figure 18-7 and Figure 18-8). 

The methods for donning and doffing the prosthetic 

system for bilateral amputees vary significantly based 

on level of amputation. However, the end goal is for the 

patient to perform this task independently. Additional 

creativity on the part of the therapist and patient is 

required to achieve this goal. Sample technique options 

for donning and doffing the prosthesis are listed in 

Table 18-2 and Figure 18-9. All patients are informed 

about the most appropriate method for them and they 

may even develop their own technique. 

Initiation of Controls Training 

Learning to use any type of prosthesis is similar 

to learning the operation of other multicomponent 

mechanical devices. For example, when beginning 

to drive, the first step is learning to control the individual components required for operating a vehicle. 

This includes turning it on and off; adjusting the mirrors and seats; and operating the gear shift, gas, and 

brake. These components are eventually combined 

into the actual performance of driving a vehicle. 

Similarly, when an amputee begins his or her prosthetic training, the first step is to learn how to control 

the individual components to operate the prosthesis. 

Subsequent steps in the newly learned motor patterns 

are combined to accomplish tasks creating a hierarchy 

of progression through the controls training. The goal 

is to achieve smooth movement of the prosthesis with 

minimal amount of delays and awkward motions in 

daily activity task performance.20

The tasks used to achieve mastery of each control 

skill depend on the therapist’s creativity. Media appropriate for training include objects of various shape, texture, density, and weight, such as 1-inch wood square 

blocks, round blocks, cotton balls, Styrofoam cups, or 

a cup filled with water. This type of media provides 

various different ways to grade the task at hand to 

achieve mastery of control. Initial training is frequently 

rote. However, with mastery of each skill, motions are 

combined resulting in performance of an activity. A 

multisensory approach is also useful. Verbal, tactile, 

and visual cues can be helpful to attain success. The 

progression through the hierarchy of body-powered 

and myoelectric prosthetic controls training described 

by each level of upper limb amputation is depicted in 

Figure 18-10 and Figure 18-11, respectively. 

Patients performing controls training with the use of 

a preliminary myoelectric prosthesis may find that the 

gains of the imbedded electrodes require adjustment 

to perform the task at hand. The prosthetist can more 

specifically set the electrode sensitivity with customizing software that is specific to each manufacture. 

Activities of Daily Living Prosthetic Training

The final stage of phase three is to apply the skills 

learned during the controls training portion to begin 

functional use of the prosthesis. The user may become 

Figure 18-6. The patient is trained to don the myoelectric 

prosthesis with the use of a limited friction donning sock 

with a lanyard secured to the end. (a) The sleeve is inverted 

over the residual limb. (b) The lanyard is dropped through 

a pull tube that is located in the distal end of the socket. (c)

The sock-covered limb is placed in the prosthesis. The patient places tension on the lanyard to begin to pull the sock 

through the socket, thus pulling the limb into the socket. (d)

Additional tension to pull the sock is achieved by placing 

the loop of the lanyard around the foot and subsequently 

pulling the sock out of the socket while the residual limb 

provides counterforce to the prosthetic socket. (e) The sock 

is pulled through the tube via the lanyard gently bringing 

the soft tissue into the socket. 

e
512

Care of the Combat Amputee

Figure 18-7. Sample donning methods for a transradial amputee with a body-powered pin lock suspension prosthetic 

system. (a) The roll on silicon liner is inverted and rolled onto the residual limb. (b) The residual limb is placed through 

the harness (note the locking pin at the distal end of the liner). (c) The limb is guided into the socket with slight pressure to 

secure the pin into the pin lock within the socket. This creates a secure relationship between the patient and the prosthesis 

to allow for more aggressive activities or for reduced harnessing. This type of suspension has been found to be necessary 

for the activity level in this population. (d) Instructing in the jacket method of donning, the harness is pulled across the back 

and the residual limb is placed through the remaining figure-of-eight harness. (e) Instructing in the over the head method, 

the residual limb is placed through the figure-of-eight harness anteriorly before guiding the harness overhead. (f) The completed figure-of-eight body-powered prosthetic system is donned. It is important that the patient adjust the placement of 

the figure-of-eight ring when donning this system to ensure the harness is centered both medially and laterally and distally 

and proximally between the scapulae. 

a b

c d

e f
513

Occupational Therapy for the Polytrauma Casualty with Limb Loss

more frustrated because of the awkward and artificial 

nature of a prosthesis. In addition, those with unilateral 

amputation quickly learn to adapt to one-handed 

task performance that can become habitual. The rehabilitation team must continue to provide support and 

encouragement during basic daily living skills to help 

the individual use a prosthesis.

Rating guides developed by Atkins titled ”Unilateral Upper Extremity Amputation: Activities of Daily 

Living Assessment” (Figure 18-12) provide a comprehensive list of activities the patient should be able to 

perform with the use of the prosthesis.20 A rating guide 

is also available for bilateral upper limb amputations. 

The patient is observed performing the identified tasks 

and is graded on task performance using a zero to three 

a

Figure 18-8. Sample donning method for a transhumeral amputee. (a) Preparation for donning a suction socket prosthesis 

using the jacket method, the elbow is locked into 90 degrees 

flexion and the prosthesis is laid out with the harness system 

toward the outside of the body. (b) The residual limb is placed 

into the socket using downward force with the prosthesis stabilized using the remaining limb. (c) The harness is donned 

across the back and under the residual arm. The harness 

is secured to the anterior portion of prosthesis with snaps, 

buckles, or Velcro (Velcro USA Inc, Manchester, NH). 

b

c

scale; zero identifies tasks that are impossible for the 

individual to complete; one identifies tasks that are 

accomplished with much strain or many awkward motions; two identifies tasks that are somewhat labored, 

or few awkward motions; and three identifies tasks 

that are performed smoothly, with minimal amount 

of delays or awkward motions. With the permission 

of Diane Atkins through direct communication, these 

rating guides were modified to include tasks relevant 

to military duties. It is unreasonable to expect a unilateral amputee to use a prosthesis to the same extent 

because he or she spontaneously uses the preexisting 

sound limb. 

The level of difficulty in training and the amount 

of training time needed may vary from one prosthetic user to another. Factors that may influence this 

include the level of amputation (ie, transhumeral vs 

transradial), unilateral versus bilateral amputation, 

and the type of prosthetic device fitted to the user (ie, 

body-powered vs myoelectric prosthesis). Additional 
514

Care of the Combat Amputee

factors include the individual’s (a) motivation, (b) 

cognitive and emotional status, and (c) physical condition and comorbid conditions. The ultimate goal is for 

the patient to achieve maximum independence in the 

performance of ADLs and instrumental ADLs through 

the integration and use of the prosthesis. 

Although using a prosthesis to perform ADLs is 

supported, patients are also encouraged to master 

independence in one-handed ADLs because there 

will be times when the prosthesis is unavailable. The 

patient must master one-handed ADL performance 

TABLE 18-2 

BILATERAL UPPER EXTREMITY PROSTHETIC SAMPLE DONNING AND DOFFING STRATEGIES 

AND CONSIDERATIONS

Strategies Body Powered Myoelectric Considerations

Donning prostheses:

This will be dependent on 

the type of prostheses and 

the harnessing system used. 

Donning methods vary based 

on the suspension system and 

whether the prosthetic devices are harnessed independently or connected through 

harnessing. 

• If each prosthesis has an independent harness system, 

the longer of the residual 

limbs is donned first. This 

prosthesis is then used to 

assist with donning the 

second prosthesis. 

• If the prostheses are connected by harnessing, the 

shorter residual limb prosthesis will be donned first. 

The two most common 

methods of donning attached prostheses is to 

don the prostheses as you 

would a coat or to place 

both limbs simultaneously 

in the prostheses and don 

them overhead like a Tshirt.

• Self-suspending sockets

are often donned using a 

reduced friction donning 

sock. The patient will use 

the lower extremities or the 

other prosthesis to pull the 

sock through the pull tube 

that pulls the soft tissue 

into the socket providing 

an intimate fit with skin 

traction. 

• Suction sockets are donned

using an evaporative moisture technique, such as Cal 

Stat (Steris Corporation, 

Mentor, Ohio), or other 

products. Air is expelled 

through the valve as the 

limb is pushed into the 

socket creating a suction fit. 

• A donning stand may be

helpful for high-level 

amputee patients (Figure 18-9). Additionally, 

patients with high-level 

amputations will require 

more creativity from the 

prosthetic team for independence in donning. 

Doffing prostheses:

Doffing is often easier than 

donning.

• If the prosthesis is donned

using the jacket or T-shirt 

method, the prosthesis is 

doffed using the method 

in reverse.

• To doff a self-suspending

type of prosthesis, patients 

will typically use their 

lower extremities or the 

environment to assist in 

removing the prosthesis. 

In the case of a suction 

suspension, patients will 

often use an object in their 

environment to assist them 

to press the button on the 

valve that will release the 

suction. The donning stand 

can also be used as needed.

independently, efficiently, and ergonomically correctly 

to avoid the possibility of developing cumulative 

trauma disorders. The patient is taught the signs and 

symptoms of various cumulative trauma disorders 

and encouraged to seek initial medical attention early 

if they develop. Little information has been published 

on the prevalence of over-use injuries in the upper limb 

amputee population; however, a small study published 

by Jones and Davidson found over-use injuries were 

more common in the unilateral amputee population 

than the nonamputee population.21
515

Occupational Therapy for the Polytrauma Casualty with Limb Loss

Muscle Strengthening and Endurance

The patient should be independent with a postoperative self-stretching program of the same frequency 

and duration as previously discussed. The patient 

can incorporate the prosthesis into the stretching 

program. The therapist emphasizes strict adherence 

to this program because many patients neglect joint 

stretching once they begin to reach their goal of ADL 

independence. However, the patient remains at risk 

for shoulder and elbow contractures because scar and 

surgical incisions continue to mature. 

Muscle endurance training and strengthening 

require a more demanding, yet specific mode. The patient continues to participate in a regular cardiovascular program with physical therapy and is encouraged 

to incorporate the use of the prosthesis during such 

physical activity. Supervised progressive strengthening 

is initiated through weight training. Programs begin 

conservatively for 15 to 20 minutes at low resistance 

with minimal distal end weight bearing of the residual 

limb. There is no published set protocol for progressing resistance training for the upper limb amputee. 

Skin and residual limb tolerance are the confounding 

factors when progressive upper limb conditioning is 

initiated. During weight training the patient must have 

a properly fitting socket with adequate suspension and 

a TD that will allow completion of the weight-lifting 

task. A snug prosthesis will increase total surface area 

contact and thus reduce the incidence of skin trauma 

from shearing or abnormal forces. Weight lifting may 

not be well tolerated in the transradial amputee or 

the amputee with a self-suspending socket because 

abnormal leverage or the traction of tissues, respectively, coupled with the need for full elbow extension 

as part of an exercise may increase socket pressure in 

Figure 18-9. An example of a donning stand that may allow 

a patient with bilateral upper extremity limb loss independence in the donning and doffing of a body-powered 

prosthesis.

the antecubital region or the condyles. A safety point 

as weight lifting increases is to secure the weight to 

the TD.

PHASE FOUR: ADVANCED PROSTHETIC TRAINING

Phase four begins approximately 8 to 16 weeks 

after the initiation of rehabilitation (Exhibit 18-4). 

This time frame is not fixed, however, and it depends 

on the patient’s medical and rehabilitation progress. 

Individuals who reach this stage can accomplish all 

basic skills from phase three. They can don and doff the 

prosthesis independently, tolerate a full day’s wearing 

schedule, and are proficient in basic operations of the 

prosthesis. The goals of this phase are for the patient to 

complete basic and advanced daily tasks incorporating 

the prosthesis efficiently and demonstrating a natural 

motor pattern. The outcome of this phase is for the 

patient to save body energy, decrease biomechanical 

stress to the intact limb, and learn the best approach 

to tasks without extraneous body movements and the 

reliance on adaptive equipment. 

Five characteristics of advanced prosthetic rehabilitation are available to guide therapists during this phase. 

The first characteristic is that advanced rehabilitation is 

highly individualized. Overall, successful rehabilitation 

of upper limb amputees involves knowing the whole 

person and what meaningful occupations they previously selected; however, phases one, two, and three 

follow more of a predictable therapy guide to treatment 

activities. When the patient progresses to phase four, 

therapy becomes more individualized, incorporating 

his or her particular vocational and avocational goals. 

The second characteristic is that this phase most as-
516

Care of the Combat Amputee

Figure 18-10. Controls training for body-powered prosthesis by level of amputation. 

TD: terminal device 

suredly requires the use and operation of a tool, or 

interaction with an object, such as a carpenter’s tool, 

a musical instrument, a cooking utensil, or a machine. 

The third characteristic is that advanced training involves completing a multistepped complex task with 

many required bimanual movements. In the language 

of the occupational therapist, it could best be said that 

advanced prosthetic training is ”occupation-based.” 

Treatment activities in this phase are less static and 

generally challenge the therapist to remove the patient 

from the clinic setting. In this way, the advanced rehabilitation is not a series of similar, repetitive movements 

such as moving one object after another to the same 

location, as would be the case for phase three training. 

Mimic motions of therapist for shoulder, elbow, and TD control

Progress to grasping and releasing objects placed to the right/left of midline and at varying heights,

and varying weights (encourage proper body mechanics)

With prosthesis positioned and locked in midline:

Grasp objects of similar size, weight, and density and transfer from one area to another in standing position

Same as above but in sitting position

Progress to grasping and releasing objects of various shapes, sizes, and densities in standing and in sitting

Have user grasp objects of various textures and densities without crushing

(eg, cotton ball, Styrofoam cup, potato chip)

Demonstrate locking/unlocking

of shoulder unit

Apply/Remove TD Demonstrate unlocking/locking of

elbow unit

Demonstrate free swing of

shoulder unit

Grasp and release with TD:

 -through full range 

 -open to 1/3, 1/2, and 3/4

 range

Position and lock elbow to 1/3, 1/2, 

and 3/4 range

Perform control training of

elbow, wrist, and TD unit as

appropriate

Demonstrate pre-positioning

of joints as necessary

Demonstrate body motions for 

Demonstrate rotation of TD locking

Perform control training of wrist 

and TD unit as appropriate 

For transhumeral: position turn

table component for 

internal/external rotation

Demonstrate free swing

Elbow disarticulation and midhumeral amputation 

(additional component includes

elbow unit)

Shoulder disarticulation or

scapulo-thoracic amputation 

(additional component includes

shoulder joint)

Wrist disarticulation and

transradial amputation 

(components include wrist unit

and TD)
517

Occupational Therapy for the Polytrauma Casualty with Limb Loss

Figure 18-11. Controls training for myoelectric prosthesis by level of amputation.

TD: terminal device

The fourth characteristic is that this type of training 

should involve the prosthesis of choice for the patient. 

Users are encouraged to try different TDs during activity 

performance to determine which device best meets their 

needs. Whether the individual self-selects the myoelectric or body-powered prosthesis as his or her preferred 

Have user complete specific tasks in a reasonable time period with minimal extraneous movement and energy expenditure

Mimic motions of therapist for shoulder, elbow, and TD control with prosthesis positioned and locked in midline:

Grasp objects of similar size, weight, and density and transfer from one area to another in standing position

Same as above but in sitting position

Progress to grasping and releasing objects of various shapes, sizes, and densities in standing and in sitting

Progress to grasp/release of objects placed to the right/left of midline and at varying heights (encourage proper body mechanics)

Have user grasp objects of various textures and densities without crushing (eg, cotton balls, Styrofoam cup, potato chip)

Demonstrate unlocking/locking 

of shoulder unit

Apply/Remove TD Demonstrate unlocking/locking of

elbow unit

Demonstrate free swing 

Grasp and release with TD:

 -through full range 

 -open TD to 1

/3, 1/2, and 3/4

 range

Demonstrate operation of wrist 

flexion

Position and lock elbow to 1/3, 1/2, 

and 3

/4 range

Perform control training of elbow unit, 

wrist unit, and TD unit as appropriate

Demonstrate pre-positioning

of joints as appropriate

Demonstrate body motions for 

locking

Demonstrate wrist rotation

Perform control training of wrist 

and TD unit as appropriate 

Demonstrate free swing

Demonstrate simultaneous controls

Elbow disarticulation and midhumeral amputation

(additional components include 

elbow unit)

Shoulder disarticulation or

scapulo-thoracic amputation 

(additional component includes

shoulder joint)

Wrist disarticulation and

transradial amputation 

(components include wrist unit

and TD)

Turn prosthetic system on and off

and demonstrate battery charge, if

applicable

Demonstrate simultaneous control of componentry
518

Care of the Combat Amputee

ACTIVITIES OF DAILY LIVING 0 1 2 3

PERSONAL NEEDS:

Don/doff pull-over shirt

Dress button-down shirt: cuffs and front

Manage zippers and snaps

Don/doff pants

Don/doff belt

Lace and tie shoes

Don/doff pantyhose

Tie a tie

Don/doff bra

Don/doff glove

Cut and file finger nails

Polish finger nails

Screw/unscrew cap of toothpaste tube

Squeeze toothpaste

Open top of pill bottle

Set hair

Take bill from wallet

Open pack of cigarettes

Light a match

Don/doff prosthesis

Perform residual limb care

EATING PROCEDURES:

Carry a tray

Cut meat

Butter bread

Open milk carton

DESK PROCEDURES:

Use phone and take notes

Use pay phone

Sharpen pencil

Use scissors

Use ruler

Remove and replace ink pen cap

Fold and seal letter

Use paper clip

Use stapler

Wrap package

Use computer: typing, access Internet

Demonstrate handwriting

COMMENTS:

Name:

Therapist:

Age:

Sex:

Occupation:

Type of terminal device:

Date of Test:

RATING GUIDE KEY:

0 Impossible 1 Accomplished with much strain, or

many awkward motions

2 Somewhat labored, or few 

awkward motions

3 Smooth, minimal amount of

delays and awkward motions

ACTIVITIES OF DAILY LIVING 0 1 2 3

GENERAL PROCEDURES:

Turn key in lock

Operate door knob

Place chain on chain lock

Plug cord into Wan outlet

Set time on watch

HOUSEKEEPING PROCEDURES:

Perform laundry

Fold clothes

Set up ironing board

Iron clothes

Hand wash dishes

Dry dishes with a towel

Load and unload dishwasher

Use broom and dustpan

Operate vacuum cleaner

Use wet and dry mop

Make bed

Change garbage bag

Open/close jar

Open lid of can

Cut vegetables

Peel vegetables

Manipulate hot pots

Thread a needle

Sew a button

USE OF TOOLS:

Saw

Hammer

Screw drivers

Tape measure

Wrenches

Power tools: drill, sander

Plane

Shovel

Rake

Wheelbarrow

CAR PROCEDURES:

Open and close doors, trunk and hood

Perform steps required to operate vehicle

COMMENTS:
519

Occupational Therapy for the Polytrauma Casualty with Limb Loss

prosthesis, the advanced training should be geared 

toward fine-tuning the operation and control of that 

prosthesis as needed to engage in the appropriate tasks 

at this level of rehabilitation. The fifth characteristic is 

that there is a meaningful product or outcome upon task 

completion. For example, the patient would have built 

the frame, weeded the garden, assembled the weapon, 

dug the hole, or repaired the engine. It is helpful to 

encourage patients to complete a ”prosthesis thesis” 

as a capstone assignment from this phase of training. 

Several individuals have completed carpentry projects, 

leather belt or wallet projects, and complex stained glass 

or wood-burning crafts (Figure 18-13). 

Phase four includes a variety of advanced tasks 

that patients perform once they demonstrate proficiency with the prosthesis in phase three. Additionally, 

these advanced activities are specific to the patient’s 

interests, hobbies, family, and work goals. Patients are 

trained on tasks such as military warrior tasks, yard 

work, home repair and maintenance, shopping, meal 

preparation, child care, pet care, and recreational and 

sports activities. Tasks within these general categories 

challenge the individual to complete the task successfully with the prosthesis. The patient who passes the 

rigors of this level of training is often identified by the 

rehabilitation staff as ”integrator” because of his or her 

success at integrating the prosthesis into the motor skill 

repertoire, thereby attaining the goal of this phase of 

rehabilitation. Overall, the patient’s movements should 

be coordinated, smooth, and precise with accurate and 

consistent control of the operations of the prosthesis using ergonomically sound postures proximally. Patients 

who elect to not utilize a prosthesis should be able to 

perform these tasks as independently as possible or 

have an identified plan to complete such tasks with 

the assistance of others as necessary. 

Military Warrior Tasks

The military warrior tasks category includes tasks 

specific to basic warfighter skills such as assembling 

and disassembling, firing, repairing, and cleaning a 

military service weapon; donning and doffing a gas 

mask; using a military radio; and assembling a ruckFigure 18-12 (left page). The “Unilateral Upper Extremity 

Amputation: Activities of Daily Living Assessment” is a 

rating guide that provides a comprehensive list of activities 

of daily living that a unilateral amputee should be able to 

accomplish. 

Adapted with permission from Atkins DJ, Meier RH. Comprehensive Management of the Upper-Limb Amputee. New York, 

NY: Springer-Verlag; 1989.

EXHIBIT 18-4

PHASE FOUR: ADVANCED PROSTHETIC 

TRAINING: UNILATERAL AND 

BILATERAL, ALL LEVELS

Goals: 4 to 10 Weeks after Prosthetic Delivery

1. Patient will be able to perform self-selected 

advanced prosthetic activities with smooth 

movements, minimal amount of operational 

delays, or awkward motions and postures.

2. Patient will be able to identify community 

resources for prosthetic needs.

3. Patient will be able to identify resources for 

vocational planning. 

sack with all appropriate military gear. Many SMs are 

interested in completing these tasks because they solidify their compromised identity. Furthermore, those 

who wish to remain on active duty can demonstrate 

that they can meet the minimum standards of required 

skills for military service.

Yard Work, Home Repair, and Maintenance

The responsibilities of yard work and home maintenance are complex and varied and the patient must 

work with a variety of tools to complete the identified 

task. Yard work activities are performed outside of the 

clinic utilizing gardening tools such as spades, shovels, 

hedge clippers, and wheelbarrows. These tasks require 

movements in many planes with various tools that 

require difficult postures and much upper body and 

trunk muscle strength. As the patient identifies his or 

her previous home responsibilities or predicts those 

of a future living environment, the therapist may set 

up simulated tasks in a functional apartment. The 

individual may perform tasks such as taking garbage 

out, fixing a leaky sink, replacing a light bulb, changing 

bed sheets, running the vacuum, unloading groceries 

into the pantry, and replacing the bathroom shower 

curtain liner. Whatever the task, the patient gains 

self-confidence to return to independence in a home 

environment through practice of ”real-life” chores. 

Shopping

Shopping is its own distinct category of training because of the many functional obstacles to 

overcome in the commercial market square. The 
520

Care of the Combat Amputee

individual must shop for groceries and be able 

to reach many types of packages from shelves of 

variable heights. Now that most supermarkets 

have self-service check-out lanes, the patient must 

train to complete the entire gamut of tasks related 

to purchasing, scanning, bagging, and paying for 

groceries. The final money transaction should be 

practiced using the automated credit card machine 

and the automated cash machine. 

Shopping for clothes and shoes must be addressed 

for the specifics inherent in such tasks. For example, 

upper limb amputees who choose to use elastic shoe 

laces must be aware of the difficulty they will have 

when shoe shopping. This makes the case for learning 

to tie one’s shoes one-handed or using a prosthesis, 

even if the individual often relies on elastic shoe laces. 

For clothes shopping, it can be awkward and tiresome 

for an upper limb amputee to shop for shirts that accommodate the prosthesis and possible harnessing 

systems if a body-powered system is the individual’s 

preferred prosthesis. 

Meal Preparation

Meal preparation makes up a special category of this 

phase of rehabilitation. Throughout the patient’s rehabilitation, he or she participates in a weekly cooking 

group. This group is the individual’s first exposure to 

one-handed adaptive equipment such as one-handed 

cutting boards, can openers (Dycem Limited, Warwick 

Central Industrial Park, RI), and electric mixers. When 

the patient reaches this phase of training, he or she 

must complete the entire meal preparation process 

from cooking to serving to cleaning. There are many 

challenges and rewards in cooking. Completion of this 

high-level training gives the individual a sense of accomplishment and a strong sense of independence. 

Child Care and Pet Care

Child care and pet care are addressed at this phase of 

rehabilitation. The tasks in this category are numerous, 

changing, and varied. The patient must identify his or 

Figure 18-13. This patient is using the body-powered prosthesis to assemble a sailboat made of wood. This project requires 

fine-tuned prosthetic skill and control; these skills are addressed during advanced prosthetic training. 
521

Occupational Therapy for the Polytrauma Casualty with Limb Loss

her responsibilities related to child and pet care, and 

the therapist must perform careful task analysis to offer 

detailed training. The use of therapy dogs allows for 

training in pet care to be realistic. It is best to address 

child care training as it relates to the specifics of the 

patient’s own children. Therapists have often used a 

doll to practice diapering, holding, bathing, swaddling, 

and to improve the confidence of the individual who 

can be apprehensive about hurting or dropping his or 

her own child while using the prosthesis. 

Introduction to Driver’s Training 

It is not uncommon for an SM returning from 

combat to experience some amount of difficulty acclimating to driving again. Some SMs have informally 

reported physical incompatibilities to driving while 

others identify issues with hyper-vigilance that left 

them uncomfortable and unsure about returning to 

it. SMs have informally reported that the following 

situations made them the most nervous while driving: (a) potholes, (b) traveling under or over bridges or 

overpasses, (c) unexpected sudden flashes or sounds 

out of the periphery of vision, and (d) vehicles quickly 

approaching from the rear. 

The rehabilitation team may use a cursory treatment 

as necessary to prepare the patient for driver’s training 

utilizing driving simulators within the military training facility. The driver’s training simulator provides an 

opportunity for cursory exploration of possible modifications to assist the SM in physically operating his or 

her vehicle and a method to assist in desensitizing the 

SM to driving again. Various scenarios are introduced 

in a progressive desensitization method with the goal 

of returning confidence and comfort with driving. 

Reaction time and appropriateness of the reaction can 

be documented and recorded allowing for subjective 

and objective data to determine progress. This process 

also is a method to demonstrate and mitigate safety 

concerns that the SM or treatment team may have 

about returning to the road. 

During rehabilitation, once the SM has acclimated 

and is ready to progress to community driving, he or 

she is enrolled in driver’s training evaluation at local 

Veterans Affairs (VA) facilities. VA-certified driver’s 

training is a multidisciplinary program and links the 

patient with available VA benefits related to driving. 

These specialists identify appropriate vehicle modification equipment used as needed to assist the patient in 

performing driving tasks and provide training on this 

equipment. They also assist in acquiring the necessary 

vehicle modifications. OT in the military training facility is not responsible for performing this evaluation.

Vocational Planning and Training

The vocational training category is specific to the 

individual’s particular occupational pursuit. Those 

patients who choose to remain on active duty may be 

faced with learning new skills to complete their current military occupational specialty (MOS), consider 

changing their MOS, and learning new skills. Others 

may choose to leave the service and pursue a new or 

familiar civilian occupation. This decision can be further complicated by the addition of a prosthesis(es). 

The occupational therapist must help patients 

sort through the various tasks associated with their 

particular occupational pursuits or MOS demands. 

To facilitate this all patients should receive an initial 

screen to determine appropriateness for a functional 

capacity evaluation (FCE). This evaluation may be 

completed to determine an individual’s ability to 

perform work-related activities through assessment 

of strength, flexibility, endurance, cardiovascular 

function, and maintenance of certain positions. This is 

an intense evaluation performed by the occupational 

therapist and includes, but is not limited to, assessment 

of the following: 

	 •	 repetitive heavy lifting,

	 •	 carrying,

	 •	 pushing/pulling,

	 •	 repetitive squatting,

	 •	 stair climbing,

	 •	 ladder climbing,

	 •	 kneeling,

	 •	 bending, and

	 •	 overhead work.

Completion of an FCE may take anywhere between 3 to 

5 hours over 1 to 2 days, depending on the individual 

and his or her specific diagnosis(es). 

Flexibility of the FCE allows variation in the prosthesis utilized during testing. For example, therapists 

may choose to test an upper limb amputee in his or 

her ability to utilize both a body-powered and a myoelectric prosthesis in various functional tasks including lifting, carrying, and positional tolerance tasks. 

Individual prosthetic manufacturer recommendations 

for maximum weight guidelines should be carefully 

considered to ensure patient safety while performing 

lifting and carrying tasks.

Occupational therapists also may choose to design 

individualized custom FCE protocols to objectively 

measure a patient’s ability to perform basic military 

warrior tasks. In addition, custom FCE protocols may 

be established to objectively measure a patient’s ability 
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Care of the Combat Amputee

to perform the specific tasks in his or her MOS/area 

of concentration (AOC). Further identification of a 

patient’s vocational and educational interests may be 

necessary if an individual does not wish to or is unable 

to remain in the military secondary to physical and/

or cognitive deficits.

Findings from FCE testing may be used to support a patient’s medical evaluation board or physical 

evaluation board. Specifically, data obtained during the 

FCE testing may be used to determine an individual’s 

fitness to return to duty. Furthermore, individualized 

retraining may be necessary to enable an individual to 

remain in his or her current MOS or AOC or preparation for transition to a new MOS or AOC.

If the SM decides to leave the military and pursue 

a civilian occupation, he or she is linked with a vocational rehabilitation counselor and resources through 

the Department of Veterans Affairs (VA). To facilitate 

this relationship, it is recommended that the VA vocational rehabilitation counselor be colocated with the 

OT service in the military training facility. Once linked 

to the VA vocational rehabilitation counselor, patients 

undergo appropriate evaluation if necessary and may 

see a VA occupational therapist for an FCE. Additionally, VA rehabilitation counselors provide software and 

training packages to all eligible beneficiaries. 

Whether or not the patient decides to remain on 

active duty, therapists should research vocational resources and plan for future vocational pursuits with 

patients. For example, those who elect to pursue a 

welding career in their hometown may benefit from 

individualized research and planning with the therapist to ensure that they have a formidable plan to meet 

this vocational pursuit. An example is identifying a 

local welding union and locating what companies may 

have job openings. 

Adaptive Equipment and Environmental 

Modifications

To maximize independence and function in ADLs, 

wounded SMs may require various adaptive equipment and environmental adaptations. Assessment is 

made early for adaptive equipment or environmental modification needs and continues until patients 

prepare for discharge and transition into their future 

occupational and home environment. OT serves a 

significant role in this assessment. While still an inpatient the therapist can assess the SM’s current use of 

electronics and help him or her acquire the resources 

to begin this process. Once determination is made on 

needs and previous premorbid use of electronics, items 

may be ordered. SMs may be trained and begin using 

these devices to assist in return to duty or eventual 

discharge to the VA system.

Programs, such as the Computer/Electronic Accommodations Program (CAP) offered through Tricare, 

offer SMs various types of adaptive equipment to 

enhance independence in vocational activities. CAP 

equipment can be obtained to increase independence 

for individuals with vision loss, low vision, or are deaf 

or hard of hearing, and those with cognitive, communication, and dexterity disabilities, which frequently 

occur as a result of combat. As the patient progresses 

through the final phase of rehabilitation, he or she 

explores vocational options. If adaptive equipment 

facilitates independence in work-related tasks, a CAP 

assessment is initiated as soon as possible. Patients 

who elect to transition to civilian occupations should 

initiate a CAP assessment as early as possible in their 

final phase of rehabilitation to facilitate a rapid and 

seamless transition to the VA vocational rehabilitation 

counselors. 

Environmental modifications necessary within 

the home are acquired through the VA. A therapist 

certified in adaptive technology from the regional VA 

Medical Center completes the necessary assessments 

of various environmental modifications needed within 

the home.

Exercise Prescription Considerations

For those who enjoy activities of low to moderate 

intensity, fishing, gardening, walking, golf, biking, 

and swimming are exercise options. Swimming, in 

particular, is ideal recreational activity secondary to its 

relatively low overload on skin, muscles, and joints as 

well as its accessibility and no requirement to use an 

activity-specific prosthesis. Cardiovascular demands 

vary because the sport can be geared to target heart 

ranges as low as 50% of maximum heart rate. Intensity 

begins with 5- to 15-minute exercise sessions that follow established target heart ranges for the individual. 

Progression to a continuous exercise session lasting 

30 to 40 minutes will guarantee sport-specific aerobic 

conditioning while in the water. 

The amputee seeking moderate to high activity 

levels of exercise has even greater recreation choices including sports such as running, aerobic dance, weight 

lifting, and skiing as well as racquet and team sports 

to address these needs. Those who choose to exercise 

with their prosthesis must have a proper fit because of 

the significant shear forces experienced during these 

activities. A prosthetist may be consulted regarding 

sport-specific prosthetic options and special prosthetic 

modifications before engaging in a sport.
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Occupational Therapy for the Polytrauma Casualty with Limb Loss

Recreational and Sports Activities

Recreational and sports activities during this phase 

of training are appealing to young active SMs. Various recreational choices exist for low to moderate and 

moderate to high levels of exercise intensity. Many 

customized prostheses and TDs are available on the 

commercial market to facilitate the return to previously 

enjoyable activities. 

The roles of the amputee clinical team are interdependent when attempting to train the patient for 

recreational and sport activities. The occupational 

and/or recreational therapist interviews the patient 

to determine his or her leisure history or recreational 

interests and conveys this information to the rehabilitation team to ensure future treatment is targeted at 

achieving the physical demands of the chosen activity 

within a timely manner. The physical and occupational 

therapists should train the patient in the prerequisite 

conditioning components of the sport. In addition, the 

team prosthetist is consulted to determine appropriate prosthetic adaptations necessary for proficiency in 

the identified task. These devices are purchased and/

or modifications are completed and the occupational 

therapist trains the amputee accordingly with the new 

equipment. Once all minimal physical and adaptive 

needs are met, the recreational therapist begins the 

sport- or activity-specific training with other clinicians 

acting as consultants. Often a patient’s love of and desire to resume a certain leisure interest or sport serves 

as a reward for participation during previous phases of 

the protocol to advance to this category of training. 

COMMUNITY REENTRY AND REINTEGRATION

The community reentry and reintegration processes 

are a significant component of life that any individual 

recovering from trauma must face. No matter how 

well an individual is prepared for interactions in the 

community, the demands of the community cannot be 

re-created within the confines of the clinic. Furthermore, a challenging first experience without support 

can result in a major setback for the patient, whereas 

a positive and supportive first experience typically 

leads to more. Although these experiences may be 

overwhelming and frightening for the patient, they 

are invaluable in recovery. 

Occupational and physical therapists coordinate 

programs for injured SMs with input from all interdisciplinary team members. The program, which is 

an important part of recovery, is an early reminder of 

the crux of the entire program—to return the patient to 

the highest attainable level of participation in life. The 

goal is to get the patient back into the community—at 

some level—very early in recovery. This alleviates the 

fear and stress of reentry that is common following 

a devastating and physically altering injury such as 

limb loss. 

To participate in the therapeutic outing the patient 

must be medically cleared. He or she must be off 

contact precautions, be able to tolerate sitting in a 

wheelchair for at least 2 hours, and be allowed to stop 

intravenous medications for 2 hours. The patient may 

still require wound vacuums, but they are portable. 

The patient does not have to be able to complete transfers independently because therapists and nurses can 

assist with them. Wheelchair accessible transportation 

is utilized for the therapeutic outings. The patient also 

must be psychologically ready to encounter the world 

outside the hospital and be willing to participate in 

the therapeutic outing. The entire team believes that 

the sooner the patient overcomes the fear of reentry 

into the community, the easier each subsequent trip 

becomes.

Early in their rehabilitation patients tend to manage 

better on a small trip, such as to a local shopping mall 

or restaurant. These are often the most meaningful 

trips for the therapists because they accompany the 

patient across a new threshold toward independence 

outside of the hospital. 

For most patients, it has been some time since 

they have been back in the United States, so the readjustment to life outside the combat zone must be 

addressed. Patients often comment that they are ”lost 

without their weapon” and feel unsafe without having the protection of ”being armed.” As discussed 

previously in the ”Introduction to Driver’s Training” 

section, patients become frightened or anxious on 

bridges or underpasses while traveling on the busy 

highways in a bus or van. Patients also may feel a sense 

of powerlessness and panic in crowded places, such 

as restaurants and malls. The hyper-vigilance while 

riding in a vehicle and the lack of tolerance for public 

places are often other sources of anxiety because patients did not expect to feel this way once they returned 

home. Patients need to be reassured by accompanying 

staff that this is a normal part of community reentry 

and their feelings and concerns should be openly 

discussed and addressed. The therapist discourages 

the patient from isolation, avoidance of public places, 

and traveling while reassuring the patient that his or 

her emotions and reactions will get easier with each 

subsequent outing. 
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Care of the Combat Amputee

The community reentry and reintegration program 

has gained much support from outside not-for-profit 

organizations. These organizations have made phenomenal opportunities available to patients allowing 

them to engage in all types of sports such as golfing, fishing, bowling, wheelchair basketball, snow 

and water skiing, canoeing, and horseback riding. 

Also, a program created through the American Red 

Cross in the national capitol region establishes tours 

around such sites as the White House, FBI building, 

US Treasury Department, US Capital building, Pentagon, and the Spy Museum. The therapist is encouraged to seek out local community opportunities for 

participation. 

Therapists plan and coordinate the outings well in 

advance. Due to patient volume and patients’ individual needs and demands when participating coupled 

with the community reentry program’s growth, there 

are often two or more trips each week. This demands 

astute attention by team members that care for these 

patients and therefore community reintegration is a 

topic at the weekly team meetings. The interdisciplinary team is interested in knowing how the patient 

tolerates the community outing because this provides 

valuable information about the psychosocial status of 

the recovering patient.

The Adaptive Sports Program: An Extension of 

Community Reentry

Occupational therapists understand disability and 

have the skill set to address all areas of performance 

with special consideration to the patient factors and 

context of sport. The use of therapeutic sports as part 

of community reentry addresses all patient factors 

including (a) sensory, (b) neuromuscular skeletal, (c) 

cardiovascular, and (d) mental. Sports can generally be 

adapted to meet the patients where they are along a 

continuum of skill level.22 The physical task demands 

of balance, strength, dexterity, and endurance inherent in sports continually prove challenging to the 

military patient population. Therapists understand 

that satisfaction in life is directly related to one’s ability to participate fully in life, with as few restrictions 

as possible. In this way, therapists use sports to place 

the spotlight on the ability while de-emphasizing the 

disability.22

Therapeutic recreation has long been used to 

promote the achievement of optimal health through 

sports and leisure.23 Adaptive sports consist of any 

sporting activity that has been modified to enable 

participation by someone with a disability. The Adaptive Sports Program (ASP) raises the performance 

bar from basic ADLs to extreme sports of all kinds. 

The engagement in sports as a therapeutic medium 

increases motivation, eases feelings of idleness, and 

alleviates loneliness and depression.23 Sports naturally promote high-level skills, so occupational and 

physical therapy staff work in tandem to prepare 

patients for participation in sports. 

Occupational and physical therapists utilize 

government and private organizations that offer adaptive sports opportunities. The Disabled 

American Veterans (Cold Spring, Ky) and Paralyzed 

Veterans of America (Washington, DC) offer opportunities to the military patients. The National Veterans Wheelchair Games are one of many sporting 

opportunities sponsored by the Paralyzed Veterans 

of America. Private nonprofit organizations such as 

the Disabled Sports USA (Rockville, Md) and Project 

Healing Waters (Washington, DC) are two of many 

organizations that also contribute to the mission 

of integrating sports into the recovery plan of the 

war-wounded SMs. Many of these organizations 

were established by veterans of prior and current 

conflicts to aid in the recovery of injured SMs returning from Operation Enduring Freedom/Operation 

Iraqi Freedom. 

Overall, participation in the ASP facilitates the 

intrinsic motivation of the competitive and athletic 

military patient population. Patients learn adaptive 

skiing and snowmobiling in various Colorado cities; they learn adaptive kayaking in Maryland and 

Virginia; and they learn adaptive fly fishing in Montana. Some take on more physical challenges through 

participation in the Baton Death March, the Army 

Ten Miler, or National Veterans Wheelchair Games 

where they compete for medals in wheelchair sports 

such as quad rugby, basketball, skeet shooting, and 

softball.24

Through the ASP, the energy of the military culture 

physical competition and camaraderie is harnessed. 

The ASP simulates a familiar culture of competitiveness, in which the young, active, and adrenalineseeking military patients thrive. The built-in activity 

demands of sports allow therapists to transcend the 

traditional activities of cones, blocks, and pegs that are 

familiar and necessary to most OT clinics. Moreover, 

the ASP represents ”the doing” that defines so much 

of the therapeutic process innate to OT resulting in 

an evolution of recovery of function that can lead the 

SM to an active lifestyle following a disabling injury. 

This active lifestyle might likely include an adapted 

sporting activity. 
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Occupational Therapy for the Polytrauma Casualty with Limb Loss

DISCHARGE PLANNING

Before the global war on terror, the options for 

SMs with limb loss were more limited. Now SMs can 

requalify for active duty or pursue civilian careers. 

Whether or not the SM has the desire or the ability to 

return to active duty, the goal of the rehabilitation team 

is to help each patient achieve maximal function and 

the highest quality of life possible.

The discharge plan begins on the day the rehabilitation team is introduced to the injured patient. As is 

true with civilian patients undergoing rehabilitation, 

the information gathered during the initial evaluation serves as the foundation for discharge planning. 

The intent of a discharge plan is to provide a smooth 

transition from one level of care to another. 

Discharge planning is best performed by a multidisciplinary team, along with the patient and the 

family. The medical members of this team may 

consist of a physiatrist who acts as coordinator for 

medical and surgical subspecialists, nurses, occupational and physical therapists, prosthetists, social 

workers, psychologists, dieticians, pharmacists, and 

psychiatrists. This group may also include a physical 

evaluation board liaison officer and a VA counselor 

to assist with the military medical disability system. 

It is suggested that this team meet weekly through 

team conferences and outpatient amputee clinics to 

ensure communication for quality and efficient care 

of every patient. 

Many injured SMs have severe concomitant injuries 

in addition to an upper limb amputation that affect 

the choices that they must make about the lifestyle 

they will strive to live. Understanding the individual’s 

lifestyle before admission will give insight into possible future goals. Knowledge about the patient’s 

preexisting family/support system, physical condition, emotional/cognitive status, educational level, 

vocation, and avocations cannot be understated. The 

patient’s culture and primary language—if other than 

English—also will impact discharge planning.

Follow-up Care

Many combat-injured military personnel will need 

provision for ongoing medical care that includes—at 

minimum—regular follow-ups with a physiatrist who 

will act as a coordinator for any specialty care required. 

Ongoing medical care includes regular follow-up visits 

with a prosthetist, psychologist, and/or psychiatrist, 

and intervention as needed with occupational and 

physical therapy, vocational rehabilitation, social work, 

and subspecialty medicine. 

Resources

Providing the patient with resources to support 

ongoing rehabilitation is critical. For persons who 

have undergone rehabilitation in a protected hospital environment with significant support systems in 

place, transitioning to care outside the hospital is a 

very turbulent time. Transitions to different levels of 

care outside of this support system bring new stresses 

that frequently go understated in discharge planning. 

The individual does not often recognize these stresses 

until after the transition has occurred. To reduce the 

occurrence of feelings of isolation, the rehabilitation 

team introduces patients to numerous resources in 

preparation for discharge including the (a) Amputee 

Coalition of America (Knoxville, Tenn), (b) peer support, (c) local support groups, and (d) specialty interest 

groups for amputees. A number of nonprofit organizations for disabled veterans as well as for civilians with a 

disability provide recreational opportunities and other 

types of support. Paralyzed Veterans of America and 

Disabled American Veterans are two groups that support wounded veterans. Publications such as InMotion

magazine (Amputee Coalition of America, Knoxville, 

Tenn) and Challenge magazine (Disabled Sports USA, 

Rockville, Md) can be great resources for both military 

and nonmilitary persons. 

REHABILITATION FACTORS 

Concomitant Injuries 

As stated throughout this text, individuals who 

have sustained combat injuries frequently have 

concomitant injuries that must be considered when 

planning the rehabilitation process. Such injuries may 

influence available treatment options, treatment progress, and progression through rehabilitation phases. It 

is critical that the team communicate at least weekly 

on patient progress to ensure that all care the patient 

receives meets his or her needs. Additionally, communication among facilities actively engaged in the 

provision of treatment to those individuals who require 

highly specialized treatment in conditions, such as 

TBI, visual loss, or burns, is critical. Highly specialized 

centers may be located throughout the United States 
526

Care of the Combat Amputee

and communication may be facilitated through video 

teleconferencing or telephone conferences. 

Once medically stable, those individuals with TBI 

are rehabilitated through one of five VA hospitals 

across the United States. Coordination of care is 

through the accepting physician and team and also 

through visual and administrative patient handoff 

between the gaining and losing facilities. The same process is repeated once the patient completes his or her 

TBI rehabilitation and returns to the gaining amputee 

center of excellence. The patient initiates the phase of 

amputee rehabilitation as appropriate. Depending on 

the severity of his or her TBI, rehabilitation must be 

adjusted according to the patient’s needs. 

Other factors that must be addressed or considered 

throughout rehabilitation include burns or skin grafts, 

infections, multiple organ injuries or failures, visual 

deficits, hearing and/or vestibular deficits, multiple 

extremity amputations, fractures, shrapnel injuries, 

peripheral nerve injuries, neuroma(s) development, 

heterotropic ossification, and risk of joint contracture. 

Psychosocial injuries and posttraumatic stress disorder also play a factor in rehabilitation. The impact of 

comorbid injuries sustained in combat adds to the 

complexity and intensity of rehabilitation but must 

be addressed appropriately to achieve a successful 

patient outcome. 

Bilateral Upper Limb Amputee Training

Considerations 

Although any upper limb amputation challenges 

a person’s physical and emotional self, a patient 

who loses both upper limbs will require more inner 

strength, patience, and willingness to persevere. A 

solid support system will augment the inner strength 

required during some of the challenges of rehabilitation. Additionally, the needs of a patient with bilateral 

upper limb loss requires an experienced team that 

can blend all of the current technology and creativity 

required to maximize the patient’s independence and 

performance in his or her desired occupational performance areas. As soon as the team deems appropriate, 

a visit from a trained, matched peer visitor can be 

crucial to enhancing the patient’s hope and vision for 

his or her future.

All areas of care previously described in this chapter 

apply to the bilateral limb loss amputee. However, 

some applications are unique to the bilateral limb loss 

amputee that would not be used by the unilateral limb 

loss amputee. In general, the traumatic bilateral upper 

limb loss amputee will usually choose to use at least 

one prosthesis to gain independence in ADLs. Also, 

he or she will require more adaptive equipment and 

environmental modification, and will have a stronger 

tendency to use the environment to achieve the most 

efficient task performance possible.

Another significant factor that influences a bilateral 

upper limb amputee’s decision to use a prosthesis is 

the length of the residual limbs. Length significantly 

impacts a patient’s ability to function independently 

and influences his or her choice of prostheses and 

adaptive devices. A patient with longer residual limbs 

can utilize the available sensory feedback area on the 

residual limb to oppose each limb during functional 

grasping. Length is also a critical factor in determining 

limb dominance. Typically the longer residual limb 

will become the chosen dominant side because of the 

increased functionality of either the prosthesis or the 

increased sensory area and sound joints available to engage in activities. Therefore, in general, the longer the 

length of the residual limb(s), the more independent 

the person will be and fewer environmental modifications will be necessary. Patients with congenital 

bilateral limb loss develop unique motor patterns at 

a young age, such as the use of foot skills. Therefore, 

prosthetic use varies more as compared to those with 

traumatic limb loss. 

Figure 18-14. This is an example of a hands-free tool changing station.

Photograph courtesy of Texas Assistive Devices. 
527

Occupational Therapy for the Polytrauma Casualty with Limb Loss

Of note regarding specific types of prosthetic 

componentry, for the bilateral upper limb prosthetic 

user wrist flexion is a benefit that allows the user to 

gain closer access to midline and to the facial area. 

This is critical for ADLs in which patients will use 

their prostheses. Certain prosthetic componentry and 

modified TD attachments can assist in providing increased degrees of freedom or task-specific function. 

Manufacturers have begun to fabricate componentry 

including the Five Function Wrist unit from Texas Assistive Devices (www.n-abler.org) that increases the 

patient’s options for wrist positioning. Texas Assistive 

Devices (Brazoria, Tex) and TRS Inc (TRS Inc, Boulder, 

Colo) manufacture TD attachments that are task or 

activity specific, such as wrench sets, knives, hygiene 

items, and sports equipment. Texas Assistive Devices 

manufactures a hands-free tool changing station that 

allows a bilateral upper limb amputee to independently change the TD tool (Figure 18-14). 

Many household items designed to address weakened grasp or pinch for the general population are 

useful to a bilateral upper limb loss amputee. A few 

examples include lever door handles, number pad 

key locks, motion sensor lighting, touch pad light 

switches, particular drawer pulls and handles, liquid 

bottle dispensers, refrigerators with in-door water 

dispensers, robotic vacuum cleaners, and computer 

controlled environments. Thanks to the evolution of 

computers and computer search engines, many options 

for bilateral limb loss amputees can be found through 

the Internet. As patients develop the ability to problem 

solve tasks that are specifically related to their needs, 

they begin to formulate their own solutions or ideas 

for problematic or difficult tasks.

RECENT ADVANCEMENTS IN PROSTHETIC DEVELOPMENT: IMPACT ON TREATMENT

In the 1980s Malone et al demonstrated that upper 

limb amputees fit with a prosthesis within 30 days 

had higher rehabilitation success.25 This was supported by Fletchall’s work evaluating ”the value of 

specialized rehabilitation of trauma and amputation” 

in 2005.26 Research and development in prosthetics are 

rapidly evolving, providing more prosthetic options 

with improved functional abilities for upper limb loss 

amputees. 

Advances in prosthetic technology for partial hand 

and finger amputation levels, which have moved 

beyond traditional cosmetic and passive prosthesis, 

provide more functional joint components and incorporate remaining functionality of the residual hand 

and/or finger. Access to various finger prosthetic 

devices requires greater lead time than most other 

prostheses. Prosthetic options range from devices that 

are connected to a wrist-hand orthosis, utilization of 

the X-finger (Didrick Medical Inc, Naples, Fla), customized orthosis, and cosmesis that take advantage 

of residual active digit motion for increased function. 

Furthermore, future developments are underway as 

a result of research funded through the global war on 

terror to allow greater prosthetic fine motor control. 

These advances and others will influence future rehabilitation approaches and possibly a new rehabilitation 

standard of care will evolve.

Targeted reinnervation is a surgical option to provide an increased number of myosites by utilizing 

remaining distal peripheral nerves that are surgically 

placed over motor end points on healthy proximal denervated musculature of the residual limb. Ultimately, 

this procedure provides additional available muscle 

sites to control componentry necessary for prosthetic 

control for a high-level amputee. Another benefit of 

this procedure is the potential of sensory feedback from 

the skin over the reinnervated areas. SMs interested 

in this procedure are considered for eligibility once 

they have demonstrated proficiency with both a bodypowered and a myoelectric prosthesis and have intact 

cognitive abilities to properly control and operate the 

prosthesis. It takes a minimum of 6 months to recover. 

During this time the SM is educated in scar management and followed as needed by OT. After recovery, 

the residual limb is evaluated to determine reinnervation of the newly created myosites. It is expected that 

by month six, reinnervation is complete and the SM 

should be able to be refit with the prosthesis and begin 

training with the new myosites and prosthesis. Once 

reinnervation occurs, prosthetic retraining is initiated 

in the same manner as described in this protocol but 

faster as the patient tolerates (see chapter 27, Future 

of Artificial Limbs, for more details).

Although engineering and electronic developments 

for the mass market continue to influence prosthetic 

technology development, federal and military sources 

have significantly increased their support for development of upper limb prosthetic technology. The Defense 

Advanced Research Projects Agency (Arlington, Va) 

Revolutionizing Prosthetics initiative is an example 

of this type of support. There are two programs under 

this initiative: (1) Revolutionizing Prosthetics 2007 

and (2) Revolutionizing Prosthetics 2009. The intent 

of Revolutionizing Prosthetics 2007 is to develop a 

robotic prosthesis that looks and performs like a human arm. The prosthesis will perform functional range 

of motion at the shoulder, elbow, wrist, and digits; 

have a cosmetic cover that is durable and appears 
528

Care of the Combat Amputee

like skin; and weigh less than 8 pounds, the weight 

of the human arm.27 Revolutionizing Prosthetics 2009 

program will provide the upper limb prosthetic user 

with proprioceptive, sensory, temperature, and vibratory sensations.28 Furthermore, the prosthetics that 

result from both Defense Advanced Research Projects 

Agency programs will be controlled through a neural 

interface, meaning they will be controlled through the 

user’s brain as opposed to myosites.27

Research Updates

At the established centers of excellence across the 

country, the recent influx of polytrauma patients managed and treated has provided research opportunities 

that will result in the advancement of medical care and 

rehabilitation of these patients. Multiple studies have 

been proposed and are in various stages of research. 

A review of completed and current studies as well as 

discussion for future research will be presented in the 

following paragraphs. 

 Firearm Training Simulator

In 2004 the Telemedicine and Advanced Technology Research Center funded a study to assess the use of 

a virtual reality training simulator called the Firearm 

Training System (FATS). FATS is a projection-based 

type of virtual reality (VR) that uses a computergenerated image that creates a virtual environment 

to allow the patient to be part of a scenario in three 

dimensions, a virtual world. FATS has distinct weapons that look and feel authentic to SMs; however, 

instead of live ammunition,carbon dioxide discharges 

from the muzzle, which mimics the recoil of an actual 

weapon. Through FATS, patients work on weapons 

marksmanship. In the scenarios generated through 

FATS VR, patients complete training to replicate a 

live-firing range or select participation in a situation 

that places them in the middle of a simulated battle. 

The use of VR in physical rehabilitation can bring the 

complexity of the real world to rehabilitation while 

eliminating the associated risks.29 The funded study 

enrolled 35 patients, two female and 33 male, with 

upper limb amputation or severe peripheral nerve, 

bone, or soft tissue injury.30 The purpose of the study 

was to assess the number of patients that—with 

guided training—would achieve a basic proficiency 

status of ”qualified” to fire a military service weapon. 

The patients had a choice of weapon selection. Six 

patients shot the M-9, 20 patients shot the M-4, and 

nine patients shot the M-16. 

Eighteen failed to qualify with their chosen weapon 

on the initial marksmanship test; and in surprising 

contrast, 17 did qualify on the initial weapons fire.30 By 

the conclusion of the study, all but one qualified with a 

military service weapon, yielding an overwhelmingly 

successful outcome of the FATS study. The patients 

were able to remaster a basic military skill that would 

not have been possible to train for safety reasons 

using real weapons at a live-fire range. The average 

time spent training was 9 hours; 23 SMs completed 

the recommended 10 hours of training.30 Seventeen of 

the study participants were upper limb orthopaedic 

patients. They averaged 69% of targets hit on their 

initial marksmanship score and 88% of targets hit on 

their exit score, an average increase of 19%.30 Eighteen 

participants were upper limb amputees. Eight of the 

study participants were transradial amputees, three of 

whom lost their dominant hand and therefore learned 

to shoot cross-dominance. The transradial amputees 

averaged 71% of targets hit on their initial marksmanship score and 84% of targets hit on their exit score, an 

average increase of 13%.30

Ten of the study participants were classified as 

transhumeral amputees and two were shoulder disarticulation amputees. Six of the participants lost their 

dominant arm. They averaged 68% of targets hit on 

their initial marksmanship score and 82% of targets 

on their exit score, an average increase of 14% (Table 

18-3). Therapists believed that the patient’s premorbid 

skill and training level, strong intrinsic motivation to 

return to soldier skills, and keen interest in VR aided 

in the pilot study’s success. Many reported that the 

skills learned through FATS training were beneficial 

to their overall rehabilitation. Based on feedback from 

therapists and patients who were involved in the pilot study, the use of VR for weapons training offered 

identity-restoring therapeutic benefits, as well as the 

inherent task demands of eye-hand coordination and 

motor control. FATS is a standard treatment in OT for 

combat-wounded veterans.

Voice Recognition Software

Assistive technology offers a modern day portal 

to independence for people with disabilities.31 Voice 

recognition technology is a type of assistive technology that allows a patient with compromised use of 

one or both upper limbs the opportunity to control 

voice-sensitive electronic devices that respond to 

human speech. Computer assistive technology systems called environmental control units enable the 

patient to control such items as lights, doors, and 

home appliances. Some less complicated systems 

based on computer software allow human speech 

to operate a personal computer. The technology of 

voice recognition software offers a viable alternative 
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TABLE 18-3

FIREARMS TRAINING SIMULATOR DATA: PERCENTAGE CHANGE FROM INITIAL TO FINAL 

WEAPONS TESTING BASED ON TYPE OF INJURY SUSTAINED BY PARTICIPATING SERVICE MEMBER

Average Targets Average Targets

Injury Type Hit on Initial Test Hit on Final Test Percentage Change

Upper extremity orthopaedic 69% 88% 19%

Transradial amputation 71% 84% 13%

Transhumeral amputation 68% 82% 14%

Source: Yancosek K, Daugherty SE, Cancio L. Treatment for the service member: a description of innovative interventions. J Hand Ther. 

2008;21:189–195.

for standard computer keyboard operation that may 

be disrupted by the loss of function with one or both 

hands. In 1990 Lazzaro suggested that technology 

may serve as an electronic bill of rights to the physically challenged.31

The Telemedicine and Advanced Technology Research Center funded a qualitative pilot study that 

evaluated the functional outcome of training patients 

on voice recognition software for basic computer operation. The objective of this study was to determine 

the usefulness of integrating voice recognition software 

training into a comprehensive rehabilitation program 

for individuals with upper limb amputation(s) or 

orthopaedic injuries impairing upper limb function. 

Patients referred for OT services meeting inclusion 

criteria were considered for the study.30 Fifteen patients, 13 male and 2 female, participated in this study. 

The software utilized was Dragon Naturally Speaking 

(DNS) version 7.0. Resources for assistive technology 

were provided through CAP.32 Training occurred in 

three phases and included (1) instruction on software 

use, (2) command memorization, and (3) the opportunity to take a laptop out of the clinic for personal use 

and practice time.30 Software training was conducted 

by a certified software instructor over the course of five 

class rotations with four separate class dates composed 

of 2 hours of training per class.30 Participants in each of 

the five class rotations received a minimum of 8 hours 

of instruction. Investigators tracked the number of 

hours each person spent training on the software. This 

intervention was provided in addition to the standard 

rehabilitation care plan, and the patient consented to 

the time commitment inherent in study participation. 

All of the subjects included participated throughout 

the study.30

A post-training survey was mailed to participants 

after completion of their individual Medical Evaluation Board. The survey obtained qualitative data 

related to the ultimate usefulness of the software 

and the training. Questions sought to determine 

the subject’s final occupational outcome (ie, did he 

or she remain in the military, enroll in a college, or 

obtain employment) and whether he or she utilized 

the DNS software. Of the 15 follow-up surveys sent 

to participants, 9 were completed and returned. The 

six participants that did not reply were unable to be 

contacted by telephone or e-mail. The average training time of the nine participants who returned the 

survey was 7.25 hours. Of the nine surveys returned, 

six of the study participants had enrolled in college 

and four stated they used DNS version 7.0 to write 

all of their papers and long e-mails and to surf the 

Internet. The two remaining participants went to college but did not use DNS. One explained that despite 

having been trained on the software it was easier to 

”hunt-and-peck” and the other ”nonuser” stated the 

orthopaedic condition that had rendered him unable 

to type during rehabilitation had resolved. Therefore, 

he was able to type. Three participants who completed the follow-up surveys did not go to college 

and all reported continued use of DNS for e-mails 

and word processing for employment and personal 

tasks. A quote from a survey by one of these three 

participants reads, ”Voice makes it easier to navigate 

my PC and also increases my speed with writing letters and e-mail.” Another participant commented, 

”Dragon was outstanding for me. It enabled me to 

continue to enjoy the computer. I don’t feel like it’s 

a challenge anymore.” Another participant wrote, 

”Voice, on a daily basis, makes tasks that used to be 

difficult seem easy. It helped make things with PCs 

easier, faster, and less complicated once I became 

familiar with the software.”30

The resounding positive comments of the participants and training results indicated that this training 

was effective. For patients with permanent disability 

to one or both upper limbs, the learning investment 

of training and utilizing voice recognition software is 
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Care of the Combat Amputee

worth the benefit of being able to replace typing with 

voice activation text entry.33 Additionally, the ability 

to interact with a computer is important to younger 

persons because they regularly engage in interactive 

communication to connect with others through the 

Internet or e-mail. These reasons provide credence 

to using voice recognition software in the standard 

rehabilitation care plan.33

Targeted Muscle Reinnervation 

In collaboration with Brooke Army Medical Center 

and Walter Reed Army Medical Center, the Rehabilitation Institute of Chicago conducted a study titled 

”Targeted Reinnervation in Upper Limb Amputees to 

Improve Myoelectric Prosthesis Function.” The goal 

of the study was to improve myoelectric prosthetic 

control for high-level upper limb amputees through 

targeted reinnervation surgery. A successful surgery 

may result in the availability of additional myoelectric 

control sites in the residual limb, the ability to control 

motion at multiple joints simultaneously creating a 

more natural motor pattern with prosthetic use, and 

a sensory feedback mechanism. 

Recruited subjects who met inclusion and exclusion 

criteria were tested before the surgery with their current prosthesis. Both objective and subjective evaluations were performed on the subjects. The objective 

tests completed consisted of a modified version of the 

Box and Blocks Test, Clothes Pin Relocation Test, and 

Cubicle Reach Test. Subjective evaluations included a 

series of timed commonly performed ADL tasks that 

were designed to incorporate multiple joint movements of the upper limb in both standing and seated 

positions. Subjects underwent surgical intervention 

targeted at reinnervation of residual limb musculature 

using nerves remaining in the upper extremity. This 

technique is called targeted reinnervation. 

Following surgery, patients were given approximately 5 to 8 months to heal before fitting of the dedicated targeted reinnervation prosthesis. The socket was 

modified to accommodate any changes that may have 

occurred in the residual limb shape and to incorporate 

additional myosites as a result of the targeted reinnervation surgery. Once the subject healed and fitting 

was completed the patient re-engaged in prosthetic 

training with OT to further enhance control of the 

myoelectric prosthesis with the additional myosites. 

Upon completion of prosthetic training and the patient’s demonstration of adequate prosthetic control, 

the aforementioned tests were repeated. Follow-up 

evaluation was completed at 4 months and 8 months 

to measure and compare performance with the surgically created myosites. 

The Type of Prosthesis and Its Effect on Functional 

Activities

The overall success of prosthetic users is still a 

highly debated issue. What makes a user prefer a bodypowered over a myoelectric over no prosthesis use? 

This question remains unanswered. To provide further 

insight, a research project is underway to examine 

differing functional capabilities with a body-powered 

versus a myoelectric device. The purpose of the current 

study titled ”The Effect of Upper Limb Prostheses Type 

on Functional Activity” is to determine the effectiveness of upper limb body-powered prostheses versus 

myoelectric prostheses when performing functional 

activities to more accurately assess an SM’s potential 

to return to his or her MOS or AOC. The goal is to provide prosthetic engineers and therapists with pertinent 

data regarding the effectiveness of body-powered and 

myoelectric prostheses currently being provided to Operation Enduring Freedom/Operation Iraqi Freedom 

SMs. This study will promote a better understanding of 

body mechanics and pre-positioning techniques used 

by SMs when performing MOS/AOC relevant tasks 

while wearing an upper limb prosthesis. 

Military upper limb amputation rehabilitation 

programs will benefit from the results of this study 

because SMs and therapists will be better prepared 

to select prostheses that best support SMs in their 

return to a specific MOS. Also, prosthetists will gain 

insight regarding prosthetic mechanical failures. This 

knowledge will aid in the development of prostheses 

that are effective and reliable in a field environment, 

allowing SMs to meet the physical demands of their 

MOS/AOC. 

Community Reintegration Survey

Community reintegration is a critical component 

in rehabilitation. These activities provide motivation 

while simultaneously providing an opportunity to challenge and integrate the SM into everyday life, sports, 

and the workplace. To address difficulty in defining 

the parameters of community reintegration and measuring its success for a patient, a survey tool is being 

developed. It will aid in goal setting and prioritizing 

events/activities in which the SM may select to participate. Survey questions will address physical abilities 

and psychosocial status, both of which are important.

Multiple Exposure/Progressive Desensitization

Many SMs returning from combat have combat 

stress reaction and posttraumatic stress that influence rehabilitation. Graded treatment approaches 
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Acknowledgments

The authors would like to acknowledge Harvey Naranjo, COTA, and Ibrihim Kabbah, COTA, for their 

effort and dedication to the development of the Walter Reed Army Medical Center Amputee Program. 

In addition, they also would like to acknowledge Colonel (Retired) William J. Howard, III, OTR/L for 

his enthusiastic leadership, unwavering support, and his extraordinary vision for the Walter Reed Army 

Medical Center Amputee Program. 

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the influence of these disorders on return to certain activities. The use of virtual simulators during 

firearms training and driver’s training simulators 

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