Dr. Anne McCarthy Jacobson teaches DPT students what they need to think about working with a patient with limb loss

Early in Dr. Anne McCarthy Jacobson’s career as a physical therapist, there were three types of prosthetic legs for people with limb loss. Which one someone got was based on the where on the leg the amputation occurred and why they needed the amputation. They didn’t have a choice.

Now, surgical and technological innovations give patients a lot more options. As new innovations are created, educators like McCarthy Jacobson, who has been an MGH Institute faculty member since 1997, have to decide which ones to include in their curriculum and what physical therapists will have to learn about them to provide optimal care for their patients. 

“I'm always staying up on date on research as part of being in my role as an academician as well as a clinician so I can give students the current research they need to keep an eye on things because it is going to be coming into their clinical practice,” said McCarthy Jacobson. 

For example, a recently published study looked at how a new surgery can help people with amputations walk more naturally. McCarthy Jacobson was already familiar with the work and then had the opportunity to attend grand rounds at Spaulding Rehabilitation Hospital to hear the latest updates on the research. 

“Surgeries like these that allow people to control the prosthetic will impact how PTs will work with them,” she noted.    

The process of updating the curriculum starts early. For a course that begins this September, McCarthy Jacobson began evaluating the research and potential changes to her course in January. However, every new study doesn’t require changing the curriculum. 

“It is a balancing act between nice to know and need to know,” said McCarthy Jacobson. “Entry level DPT students are not going to master how to facilitate a patient how to use their new prosthetic at first. That doesn’t happen until they are working with patients and clients with upper or lower extremity limb loss during their clinical experiences as part of the DPT Program or in the future in their clinical practice.”

Instead, this professor and clinician may add the information into the course as additional resources so if a student is interested in working with people with limb loss, they have information that is important to know but isn’t necessary to meet the objectives of the course. That also is a place where students can find other relevant resources for grant funding, patient advocacy options, adaptive clothing, and other topics that will have a major impact on patients’ lives.

Part of the curriculum does include information on the surgeries that the patients have and the different componentry currently available in prosthetics, which McCarthy Jacobson likens to buying a car in terms of the number of choices. “There are a lot of different lower extremity and upper extremity prosthetics with many different types of components such as types of hands, hip, knee, and ankle joints,” she said. “Some of these are more basic, more mechanical joints, but the newer types of prosthetic joints use hydraulics or computerized joints.

“There are what they call bionic knees. The knee flexes based on where the hip is, and the patient needs to learn to control that. There are computerized ankles and feet and PTs have to know which type of hip, knee, or ankle they have because that will change how they train them to walk using their prosthetic.”

Besides needing to know the componentry options to help someone learn to walk, students need to know what to recommend to the patient and what feedback to give the prosthetist to help determine what would work best for the patient based on their goals, their lifestyle, and other factors. 

“We teach them what they have to think about,” said McCarthy Jacobson. “Do they have issues with their hands that will make it hard to put a certain prosthetic on? How do they get out of bed in the morning? What is going to make the person most functional? It’s the critical thinking that is so important.” 

Students perform case studies where they look at two people with the same amputation and medical history and decide what they might recommend. For a person who is healthy and wants to hike up in the Alps, they will need a foot that allows them to do that. If the patient has co-morbidities, they need to think about how those might affect what components they choose, or if they choose to get a prosthetic at all. 

To really help students have the information and perspective needed in clinical practice, McCarthy Jacobson brings patients to the class, or in some cases, brings the class to the patients while they are still in the hospital.  “It’s their favorite day,” said McCarthy Jacobson. “The students work in small groups to evaluate them and practice their skills. They hear the good and the bad from the client.”

It is also an opportunity to have their biases challenged about what people need or are going to accomplish. “We have an 83-year-old who comes and students might think, ‘Oh, they are older. They are going to get a very basic prosthetic,’” stated McCarthy Jacobson. “But this person is an athlete who likes to run. They may assume that when people get older, they want less technology but someone who is older may need a more flexible foot – and with that, more technology - because their balance isn’t as good.” 

They also see that just because technology is available, it isn’t always what is best. 

“We had a young client who came and spoke to the students. She had a fancy foot and ankle, but it was noisy. She wanted to walk around school and work without people hearing the robotic noise,” explained McCarthy Jacobson. “The client said, ‘All that stuff makes it heavy and noisy.’ She also wanted to walk without having to think about using the device. She went with a high-tech knee but basic foot. Light, easy to get on and off, and she didn’t have to worry about where her hip needs to be.” 

Besides seeing the newer prosthetics, these days often introduce students to some of the realities that clients face. “They see the ‘wows’ but they also hear how the person paid for it, so they are cognizant of the inequities in terms of access to care and access to these technologies,” observed McCarthy Jacobson. 

Just as every new piece of research doesn’t make the cut for the course, not every person should consider a high-tech prosthetic.

“Insurance coverage for Durable Medical Equipment (DME) is often capped at $1,800 and that's going to have to cover a wheelchair, walker, crutches,” said McCarthy Jacobson. “If you want that fancy leg, it may be $80,000. So, we encourage students to think about advocacy, and how to advocate for people and when to advocate for not having that technology.”

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