Artificial Limbs

What an Artificial Limb is – and isn’t

(Written for the new amputee)

Some people, when they hear the term 'artificial limb', think of the Bionic man and that it means a replacement limb. The truth is that artificial limbs allow amputees to make whatever they want of their lives and we read of high achievers doing extraordinary things. However, there are some restrictions to which most amputees must learn to adjust. Remember that artificial limbs take time and practice to use well, so do not expect instant results.

Because an artificial limb is exactly that - an artificial limb - it will never be comfortable all the time. You may from time to time have minor irritations, blisters and chafing from your limb. You will also feel a different kind of balance. After your prosthetist, with your help, has made sure your limb is as well-fitting and comfortable as it can possibly be, you will learn to cope with these minor difficulties and discomforts.

Artificial Legs

Basically there are two types of leg amputation - above-knee and below-knee. You will probably hear these, and their respective prosthetic legs, referred to as AK and BK.

A well-fitting and well-used below-knee leg can give you a normal gait and no-one but experts - not even other amputees - may realise that you have an artificial leg.

An above-knee artificial leg will take longer to learn to use, because it needs more balance. It will also require more concentration to walk with and will be a little more tiring.

There are a variety of feet, ankles and knees available for AK and BK limbs. Most are of a modular construction so that parts can be exchanged at the fitting stage to determine which has the best function for the particular amputee. The range of knees available is extensive, from a simple lock knee for walking which unlocks when you sit to a safety knee so that if you stumble the knee will lock with weight bearing. There are also a wide range of pneumatic and hydraulic knees and your prosthetist will discuss the options for your particular amputation.

There are also a range of liners, including urethane and silicone liners with differing levels of cushioning and these can be used for AK and BK limbs but generally after your stump has matured.

Artificial Arms

Because your arms and hands are so complex, their movements are very difficult to reproduce mechanically, so even though an artificial arm is a complicated type of prosthesis, functionally it is much more limited than a human arm and hand. Because artificial arms are so much more complicated than artificial legs, they take more training, practice and perseverance to learn to use. But the results are worth it. You can do so much more with an arm and hook than with your residual limb. Another good reason for wearing an artificial arm is that it can prevent the later development of arthritic problems from excessive overwork of your sound arm over many years.

Refer to Artificial Arms for more information.

Artificial Legs

First impressions on Learning to Walk

It is the most amazing feeling to be on two feet again and yet strange, as you need to develop a new perception of where your artificial limb is and how to move it. The first time, you will probably get the impression that it is too heavy. Actually, a human leg weighs about 12kg (26lb) and few, if any, prosthetic limbs weigh that much. The reason your artificial limb seems so heavy is that you are not used to using it. Our own limbs seem to be almost weightless because they are highly efficient machines and we have had a lifetime of practice in using them. Of course, the artificial limb is not as efficient as your own leg, but as you get better at using the new one, it will not seem heavy.

One step at a time

When you were a baby, it took a lot of time and practice before you could walk well. Learning to walk again needs just as much effort. Developing good posture and walking technique early on certainly enhances the quality of your walking.

When learning to walk with your artificial limb, it is extremely important to learn each part of the walking process separately and in the right order. You must learn each part, and practise till you are very good at it, before you go on to the next step. These steps are:

  •     Balancing
  •     Weight transference
  •     Single stepping without moving forward;
  •     Marking time on the spot.
After you have mastered each of these steps, then, and only then, must you actually start to move forward. You will begin to walk between walking rails. Resist the temptation to take most of your weight on your hands instead of using your prosthetic and normal leg. After you have learnt to walk between the walk rails, you will continue with walking sticks. Finally, it is quite likely that you will be able to walk without any help at all.
Artificial Arms
Because artificial arms are so much more complicated than artificial legs, they take more training, practice and perseverance to learn to use. But the results are worth it. You can do so much more with an arm and hook than with your stump.
 
Another good reason for wearing an artificial arm is that it can prevent the later development of arthritic problems from excessive overwork of your sound arm over many years.
 
The split hook can perform only two actions - gripping and steadying. It is operated by cables attached to a shoulder harness. A below-elbow amputee opens and closes the hook by moving the upper arm. An above-elbow amputee operates the hook by moving the opposite shoulder. This needs quite a bit of practice and concentration, but after a while, these arm and shoulder movements become second nature.
 
After much practice, the list of things you can do with a hook is almost endless. They are limited for fine movements like picking up change, but seasoned hook-wearers can get quite dexterous. Double-arm amputees who use two hooks can get by very well.
 
Whether you were right-handed or left-handed before the amputation, your second hand will become the dominant one and your hook will play a supporting role in two-handed activities. Becoming left-handed if you have always been right-handed (or vice-versa) is not as difficult as you may think. The muscles are there, but you are probably not used to using them.
 
Besides being so functional, a hook has other advantages over a cosmetic hand. Because the hook has an open design compared to the cosmetic hand, it is easier to see exactly what you are doing or holding. A cosmetic hand also tends to deaden sound, which is another drawback that the hook does not have. As you have lost the ability to feel with your hand, these sight and sound cues become very important.
 
Grip Prehensors are voluntary closing as opposed to voluntary opening which means you can get some feeling of how tight you are gripping an object. These are generally for below-elbow amputees.
 
Cosmetic hands are soft, skin-coloured and as realistic as possible. There are two types of cosmetic hand, working and passive.
 
Passive hands do not have any movement. Working hands perform a limited gripping function in the same way as a hook. However, because they are soft, they can only grip a pen or be used for light clerical work.
 
Some types of replacement hands are quickly interchangeable. This means that you can use your hook at work, then clip in a cosmetic hand when you go out in the evenings
 
Hints for Arm Amputees
 
Arm amputees should wear a light T-shirt or vest under the harness to absorb any perspiration and stop the webbing from chafing. Shirts and tops should be loose-fitting, especially around the cuff. Tight cuffs may stop the cables of your artificial arm working properly.
 
When getting dressed, place your artificial arm in your clothing first. There are many ingenious ways of adapting clothes to make it easier to get dressed; for example, sewing cuff buttons on with elastic thread and using Velcro fasteners. However, most arm amputees find that it is a lot simpler to buy clothes that are easy to cope with. Choose slip-on or elastic-sided shoes, rather than ones that fasten with laces, buckles or zips; Western-style shirts with press-studs, and skirts and slacks with elasticised waists. Women find that bras with stretch straps are easier to put on and more comfortable under their prosthesis.
Repairs and Adjustments

When your limb is in need of repair, you should contact your Artificial Limb Centre for advice. No small repair should be left until such time as a major repair becomes necessary. All repairs are free of charge. It is preferable that, except in an emergency, you make an appointment to attend a Limb Centre. All Centres have toll-free numbers.

Adjustments to the socket of your limb will be required from time to time, particularly if your weight has a tendency to fluctuate. If it becomes uncomfortable, you should make an early appointment to attend your Limb Centre.

It is not absolutely necessary for you to attend only the Centre nearest your home. If you are away from home and need urgent attention, contact the nearest Limb Centre where the prosthetist can access your records.

Clinics by prosthetists are occasionally held in some cities outside the Limb Centres (e.g. Whangarei, Rotorua, Napier, Gisborne, Palmerston North, Nelson, New Plymouth, and Invercargill). These are arranged through the Limb Centres with the assistance in some areas of the local Amputee Society.

Some people feel that, because they are receiving their limb and treatment free, if they have any complaints or problems they may be refused treatment or charged for their limb or repairs. This is not so. Prosthetists are highly skilled and trained people, who take a personal and a professional pride in their work. They want you to be completely happy with your prosthetic limb. If you walk out of the Limb Centre all thanks, praise and brave smiles on the outside when you are really full of doubt, dissatisfactions and unanswered questions, you have just wasted everyone's time, including your own. A good client is an assertive one!

Your First Visit to an Artificial Limb Centre

Finding the Best Artificial Limb

Referral to an Artificial Limb Centre is generally arranged by the hospital staff who take into account your general health and the condition of your stump. However, it may be that you will need to contact an Artificial Limb Centre yourself. If there is some doubt as to whether you are able to wear a limb, you are still entitled to an assessment as it may be appropriate for you to have an artificial limb for cosmetic or transfer purposes. The first appointment to a Limb Centre is commonly 3-6 weeks following surgery.
 
On your first visit to the Limb Centre, you will meet the orthopaedic surgeon, the clinical prosthetist, and a physiotherapist, and together you will work out which type of limb is best for you. Your first limb is usually of a basic type and is unlikely to last very long due to stump shrinkage, which will necessitate a new limb within the first few months.
 
Although all artificial limbs are made to the same basic principles, a large range of components and materials are available. The type of limb that the specialists prescribe for you will depend on your age, how active you are, whether or not you play sport, the type of amputation you had, and any medical problems you may have. More than one type of limb might be suitable for you. Ask your prosthetist if any other options are available. If any special kinds of limb interest you, ask about these.
 
Making the Artificial Limb
 
The traditional method of making a limb is by taking a plaster cast. On your first or second visit, a plaster of paris mould and a series of measurements are taken of your residual limb - this takes about an hour. Later the prosthetist will use this hollow cast to make a solid plaster cast of your stump, so that the finished socket will fit well. Whether you have an upper or lower limb loss, the same process applies.
 
Some artificial limbs can also be made using the Tracer CAD method. This is a very sophisticated and advanced process for artificial limb manufacturing that is more convenient, cleaner and time-saving for amputees. Tracer CAD provides a number of ways to capture the shape of the residual limb, with measurements being entered on a computer. A digitised image is then sent to a carver where a model is carved in polystyrene and used to make the socket.
 
Lower limb amputees will be requested to take to the Limb Centre a pair of shoes that they feel comfortable to walk in. As it is difficult to adjust the leg to fit a variety of different heights, the artificial limb is generally adjusted to one heel height.
 
Lower Limb Amputees
 
Other technologies have come into play in recent years which your prosthetist may use depending on what socket you will have. One is to take the plaster cast whilst weight bearing through your residual limb. Another new method is the direct socket. This technology allows for your prosthetist to make your new socket directly over your limb which will enable you to have your socket that day. No one method is better than another and what you have will depend on a number of factors. It is unlikely that the socket will be perfect on first fitting and may need minor adjustments to ensure that it is comfortable. In the early stages, the socket is attached to a metal rod onto which a foot is fitted to allow you to stand and take your first few steps between parallel bars.It is important that the socket is a good fit. You will be working closely with the prosthetist to ensure that this is achieved. If there is any discomfort, you must let your prosthetist know. Your mobility depends on a good fit and a leg which functions well for you.
 
Trial Socket
 
With AK amputees, a prototype socket is often made. This is made of a transparent material like Perspex to allow the prosthetist to see how the socket is fitting and to identify and correct any pressure points. This trial socket is generally worn only at the Artificial Limb Centre. Once it feels comfortable, the final socket is made of a more solid plastic material and the leg is shaped to match the existing limb.
 
Upper Limb Amputees
 
It is important to discuss your lifestyle and occupation with your prosthetist so that the most appropriate componentry and socket are prescribed. The fitting of an upper limb prosthesis is often a complicated process involving setting up a harness system and cable to operate the hook or hand (commonly known as the terminal device). It is very important that the harness is correctly positioned and tensioned to allow easy operation of the hook/hand. The socket is designed to allow maximum movement but may feel fairly restrictive due to the need to suspend the prosthesis. This may need a very enclosed type of socket. The fitting stage of an artificial arm is often the final stage of the construction and it can then be taken home for practice. Occupational therapy is often required for fine-tuning the use of the prosthesis.
Artificial Limb Centres in New Zealand

There are six Artificial Limb Centres in New Zealand administered by the NZ Artificial Limb Service. They are located at:

Auckland
    7 Horopito Street, Mt Eden
    Freephone 0508-630-630

Hamilton
    222 Pembroke Street
    Freephone 0508-838-838

Tauranga
    160 Fraser Street
    Freephone 0508-434-434

Wellington
    42 Mein Street, Newtown
    Freephone 0508-389-389

Christchurch
    330 Burwood Road
    Freephone 0508-383-383

 Dunedin
    Fraser Building, 464 Cumberland Street
    Freephone 0508-474-474

 

Travel to Artificial Limb Centres

WORK & INCOME

Reimbursement for travel and/or accommodation is available from Work & Income for all Ministry of Health amputees who are required to attend a Limb Centre (ACC clients are catered for separately - see below). This assistance is to ensure that people are not prevented from attending a Limb Centre to have an artificial limb adjusted or repaired because they are unable to meet the cost of travel and accommodation. It applies equally to amputees or people who were born without a limb. This assessment is not subject to an income or asset test.

What you can claim
  • You can claim for travel in a private car either by mileage or petrol costs if a receipt is produced (but this should not be more than mileage). The amount paid per kilometre depends on the cc rating of the vehicle.
  • You can claim for travel by public transport to and from the Limb Centre.
  • You can claim for the cost of travelling by taxi to a Limb Centre where a receipt is produced and you are not physically able to use public transport. Note that when a mobility taxi is used and you have received a 50% reduction in fare, only the remaining 50% is reimbursed.
  • You may claim for the cost of air travel where there is written evidence that this is the most appropriate form of travel (such as a letter from an orthopaedic surgeon or Manager of the Limb Centre).
  • You can claim for accommodation costs if your appointment time or the distance travelled means that an overnight stay is necessary. The actual cost of accommodation or $100, whichever is the lower, may be paid. Accommodation and meal costs incurred will not be paid for more than ten days per assessment. You can be paid for the cost of each meal required during travel times and overnight stays when attending a Limb Centre. The actual cost of the meal or $13.05, whichever is the lower, may be paid. If applying for assistance in advance, you must provide confirmation of the accommodation booking and details of the cost.
  • Assistance can be granted to cover the costs of one attendant if the person travelling to the Limb Centre is a child aged under 15 years or medical evidence is provided stating that the person cannot travel by themselves. The loss of earnings of an attendant cannot be reimbursed.
  • Payment for loss of earnings may be made only where you do not have any sick leave available. You must provide a letter from your employer confirming you have no sick leave available and stating the wages (net) lost. Reimbursement must not be more than the current rate paid for ordinary time weekly wage. Overtime or penal rates cannot be reimbursed.
How to apply
For payment before your appointment, you must provide
  •     confirmation of your appointment date and time at the Limb Centre; and
  •     quotes or estimates; and
  •     confirmation of any loss of earnings from your employer if you don't have sick leave available.
Work & Income can grant you the financial assistance you're entitled to from the date you first contact them if you complete your application within 20 working days of that date.
You can apply to have your costs reimbursed if the amount you were paid in advance did not meet all your costs, or you chose not to be paid before your appointment. You need to:
  •     claim your costs within six months of attendance at the Limb Centre; and
  •     provide proof of your attendance at the Limb Centre; and
  •     provide receipts of your costs; and
  •     provide confirmation of any loss of earnings from your employer if you don't have sick leave available.

ACC

ACC assists amputees with travel if they travel more than 20 kilometres (one way per trip) within 14 days of injury, travel more than 80 kilometres within any calendar month, or spend more than $45 on scheduled surface public or other transport within any calendar month.

Services for which ACC can help with travel costs include treatment, rehabilitation assessment or reassessment, obtaining or having fitted an aid or appliance (e.g. artificial limb), training for independence programmes, ACC approved inpatient, residential or outpatient rehabilitation programmes, ACC agreed vocational rehabilitation services, courses or programmes, or transport for maintaining pre-incapacity employment. They only pay for the distance to the nearest place where you can get rehabilitation. However, if you are travelling to receive counselling, they may pay for the distance to the nearest appropriate counsellor.

If you meet these criteria above, they pay the actual scheduled surface public transport fare or 28 cents per kilometre. They also help towards the return fare, providing you return to where you started.
You need to fill in a transport and accommodation claim form (ACC 250) and have this signed by each rehabilitation provider you visit. You must enclose your ticket or the transport provider’s receipt when scheduled public or other non-private transport is used. ACC will pay their contribution into your bank account.
 
ACC may be able to help with your accommodation costs if there is no transport available to get you home after your rehabilitation service. They can contribute $56.30 per night.

ACC may pay for air transport if that is the only way you can travel because of the nature of your injury, or you have to travel a long distance from where you live to the nearest place of rehabilitation, and this is the most cost-effective way of reaching your provider.

 
If ACC gives prior approval, they may be able to pay the actual cost of other transport to rehabilitation, such as taxi or non-scheduled shuttle, to get to your nearest place of rehabilitation.
 
When you need an attendant to travel with you, ACC can help pay travel costs for that person if you are under 18, or your medical condition requires that you travel with an escort, or the transport provider requires you to have an escort. If you share private transport with your escort, ACC will only pay the private transport rate for one person.

 

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