White Paper: Work-Related Upper Limb Amputation
By Jennifer McCarthy, Clinical Review Manager and Craig Uejo, MD, Medical Director at Scripps Health.
The amputation of the upper limb associated with a work-related injury can present a complicated scenario for catastrophic case management.
One manuscript published in 2017 from Canada noted that 18 percent of those with an upper limb amputation never return to employment, and those that do return do so only after prolonged time off. The range of time off varied from 20 to 1,645 days with a median value of 172 days, or nearly six months out of the workforce.1
The ultimate goal must be to return an injured worker suffering from an upper limb amputation to their pre-injury functional level. This involves physical rehabilitation of the amputation site, emotional rehabilitation for the psycho-social impact of limb loss, prosthetic intervention, environmental accommodation and therapy.
Importance of Rapid Recovery:
The pace at which an injured worker moves through the recovery process often determines their ability to return to work– therein lies the problem with most cases treated under a workers’ compensation benefits program. Treatment referrals and authorization create a slow pace of prosthetic selection, fitting and care. This leads to delayed recovery with poor rehabilitation outcomes even if a prosthetic is finally fitted on the patient.2
Complications – such as infection, chronic wounds, poor activity, co-morbidities, limited range of motion, and pain management - may also slow the pace of prosthetic selection, fitting and delivery.3 If the wound is free of infection, revision surgery could be required to improve range of motion, reduce hypersensitivity, or create a more acceptable limb presentation. The individual will be released for prosthetic intervention once the physician has determined the limb is stable enough for manipulation.
The healing of an amputation site typically takes four to six weeks;however, complications can add another four to eight weeks of recovery time. Emotional acceptance of limb loss also significantly impacts recovery.
The good news is that advances in prosthetic medicine have created more options of prosthesis and individualized rehabilitative care in a shorter period of time. The most critical factor to ensuring successful outcomes is a trusted partner who shepherds carriers through these complicated claims.
Behavioral Health Factors:
Individuals experience both physical and psychological injuries related to the loss of a limb. The psychological factors are often multifactorial with grief and depression playing a significant role. Add any financial concerns due to an inability to return to work quickly, and this begins to weigh heavily on an injured worker’s mental outlook on life.
The quicker one can see the potential for healing, the sooner an individual can gain a positive outlook. This is one of the keys to the benefits of a speedy prosthetic fitting and rehabilitation program. Grief resolution is often a primary focus in the counseling of amputees, with effective coping strategies being a critical component. Common coping strategies include relaxation training, use of exercise, maintaining a balanced diet, addressing negative self-talk, and eye movement desensitization and reprocessing (EMDR).4
Prosthetic Device Options:
Prosthetic devices are extremely varied in function and cost. Technology advances at such a rapid pace that there seems to be a new type of prosthesis offered each year. Some devices serve only as a cosmetic restoration while others can involve neuromuscular control of elbow, wrist and hand. These more advanced devices can cost nearly $300,000.
If an investment is made in new technology, it’s important to maximize the chances that the injured worker will accept the prosthesis rather than reject it shortly after it’s delivered. Retrospective studies show that fitting injured workers within the first 30 days after they are released and having them participate in the selection of the device will have the most influence on patient acceptance of an upper limb prosthesis. When carriers delay prosthetic intervention to make their own decision, without input on the type of prosthesis an injured worker should receive, they increase the risk of rejection.
Injured workers who suffer amputations are accustomed to using tools. If they can identify the prosthesis as a tool that enables them to complete required tasks, they will be more likely to accept it. In cases where individuals were born without an upper limb, they learn to accommodate without a prosthesis and are more likely to reject a prosthesis.
Prosthetists have varied levels of experience with fitting upper limb prosthetics. Some clinics may have never fit someone with a transhumeral amputation while others fit several dozen a year.
A specialized prosthetist can assist with finding the right device for an individual. The most expensive and advanced device is not always the best fit. Specialized prosthetists will also associate themselves with occupational therapists who have experience with upper limb prosthetics. This can guarantee higher functional outcomes as the team utilizes their combined advanced skills to optimize socket fit, suspension and device function during required tasks at home, work and in the community.
When an injured worker suffers a traumatic accident resulting in an upper limb amputation, multiple factors play a critical role in the recovery of the individual. Some are clearly medical-related, such as limb surgery complications. Others are related to the delay in authorization for the prosthesis or rehabilitation of the prosthesis. Prolonged delays in fitting and rehabilitation set the stage for an injured worker to never return to work, let alone return to pre-injury functional level. Psychological factors also impact recovery.
Solution - One Call® CarePathTM Amputation PathwaySM
It is important to establish a projected recovery path - complete with realistic goals and timeframes - at the onset of an injury. For example, implement or utilize a cohesive program that establishes a holistic, patient-centric path forward. Patient-centric programs will often combine on-staff prosthetists and specialized providers, expedited device authorization and rehabilitation, and psychological support. The earlier an amputee can see the potential for returning to work or just life, the sooner the patient can gain a positive outlook and ultimately, return to maximum functionality.