no such thing as deluxe

no such thing as deluxe 11.12.14

First, a belated thank you to those individuals who have served/are serving in the U.S. military. I’m lucky to have met many veterans who sacrificed their limbs in the line of duty and it’s an honor to know them and call them friends.

Second, I want to expand on one of my Random Thoughts from last week discussing the gap between how the media portrays “high-tech” prosthetic devices and the reality of the function they provide. Every day I read numerous articles trumpeting the amazing advances in prosthetic technology. Many of them go hand-in-hand with “feel good” stories about amputees overcoming their physical challenges. Invariably, these pieces include interviews with prosthetists who are understandably eager to emphasize the sophistication of the devices they fit, leading to virtually every piece including phrases like, “the first to fit the most technologically-advanced knee in the world.” (I’ve read phrases like that years after seeing the first article making that claim. It’s kind of depressing to see, actually, as it suggests the person making that claim either (a) has no idea that the device has been around and fit by others before, or (b) just doesn’t give a damn about the facts.) The patients, excited to receive these state-of-the-art components dutifully fan the flames, talking about how this prosthesis is the most amazing thing they’ve ever seen.

Even though I work for a prosthetic component manufacturer and have been fortunate to wear virtually every “next great” product for lower extremity amputees over the last 17 years, I feel compelled to set the record straight: wearing a prosthesis never provides better function than a properly-working biological limb.* Consider the following examples.

Can you move from side to side? When I had both my legs, this movement occurred without thinking, whether I wanted to go left or right. But prosthetic knees only move in one plane – from flexion (as they bend) into extension (as they swing forward). That’s it.

Now imagine that you have to dodge an oncoming object. With a prosthetic knee you’re not completely prevented from moving laterally, but your ability to do so is massively compromised when compared to what you can do with a biological joint. For example, after losing my leg I once tried to play goalie during warmups while my soccer team comprised of 20-somethings peppered me with shots. One player sent an absolute rocket towards me that I simply couldn’t escape. If I had still had two legs, I would’ve either stepped out of the way or bent down to make the save. But with a prosthesis, I couldn’t do much of anything. The ball hit my prosthesis and rocketed about 30 yards away from the goal. I made the save but ended up on my face. This was wildly amusing to the team, which proceeded to start kicking balls at me as hard as they could to try to hit my prosthesis. Even I found this funny, and I excused myself from my goaltending duties, doubled over in laughter.

But here’s the point – the most sophisticated, expensive knee in the world will not function any differently in that situation than the cheapest, most rudimentary device. Since no prosthetic knee addresses lateral movement, they’re all equally lousy.

Or, as winter fast approaches, consider walking on slippery surfaces. Whether you’re an above-knee or below-knee amputee, you lack the tactile feedback from your foot that allows you to make split-second adjustments that keep you upright. You become aware of the fact that you’re slipping when your prosthetic foot is suddenly 6 inches away from where you planted it (and accelerating away from your body at a frightening rate). No microprocessor-controlled or motor-powered ankle-foot system can replicate the proprioceptive feedback provided by a biological foot.

At this point you might be asking yourself, “Why is Dave being so negative? Did prosthetic technology betray him? Did he have a falling out with his employer and this is his passive-aggressive way of working out his anger?” (Answers: I’m not. No. And NO!) The reason I get worked up about this is because the myth of space-age prosthetic technology ultimately ties back to how payers – particularly private insurance companies – view these devices. And that affects amputees’ access to them.

*   *   *

I’m thinking particularly about insurance policies that exclude “deluxe items,” an ambiguous term that insurers would say refers to components that provide benefits that aren’t essential to users. (I say it’s really code for “more money than we want to pay.”) Now think about how the narrative I described at the beginning of this post interacts with this kind of policy exclusion.

When manufacturers and prosthetists start trumpeting how component X samples force sensor feedback 20,000 times per second, or how component y employs complex gyroscopes to evaluate where it is relative to other parts of the patient’s body, insurers reply,

That’s a deluxe item. You don’t need those features to walk. Want proof? Amputees have been walking on hinged knees and wood feet for most of the last 100 years.

Similarly, when articles repeatedly quote patients talking about how they’re using the most sophisticated device ever made by man, it feeds into the deluxe/luxury exclusion argument.

Now I know that high-tech prostheses capture the public’s imagination. I know that news organizations want to focus on sexy soundbites that make people feel good both about modern medical devices and the people using them. But it’s a double-edged sword – this narrative overexaggerates the effectiveness of prosthetic components at the expense of a fair and balanced discussion of the facts.

Fact: the best prosthetic knee in the world doesn’t come close to replicating biological knee function in all planes. So that device – sophisticated as it is – isn’t deluxe when compared to a natural knee. It’s a pale imitation.

Fact: the best prosthetic foot in the world doesn’t come close to replicating the full range of ankle motion or foot functionality. Hell, it doesn’t even have functioning toes! It’s not deluxe when compared to a biological ankle-foot system.

I’m willing to bet there are tens of thousands of amputees today who are walking on components that underserve them because their insurers denied more appropriate devices on the ground that they were “deluxe.” Only by adding some nuance to the “most technologically-advanced” narrative will these people gain access to the devices they need.

Yes, we’ve seen huge advances in prosthetic technology, particularly over the last 12 years. Yes, prosthetic components do a better job of replicating their biological counterparts today than they ever have before. But let’s keep things in perspective. Until a prosthesis allows an amputee to do everything she did in exactly the same way she did it before, there’s no such thing as a deluxe prosthetic component.


*For the sake of simplicity, I’m carving out individuals who have severe impairments in their biological limb(s) who opt for amputation. For these people, amputation actually can improve both their function and quality of life.

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