Objectives: For amputees, the use of prostheses can be a vital part of their lives improving function and independence.  Unfortunately, rejection and non-functional use of prostheses can be high especially in upper extremity amputees.  Regardless of technological advances, motor learning is a fundamental principle of prosthetic integration that must be considered in the brain injured population.  In brain inured patients’ impairment in memory and executive control may account for difficulty applying procedural knowledge and independently using an upper limb prosthesis.  In this case report we five factors that must be considered in the comprehensive rehabilitation of a brain injured upper extremity amputee: (1) Acceptance of adult functional role; (2) capacity of independent use; (3) learning, memory, and cognition; (4) functional performance; and (5) physical and mental health.

Methods: 26-year-old male patient with no past medical history was working on a roof when he came in contact with a high-voltage electrical supply line and sustained electrocution and severe electrical burns to the bilateral hands and forearms, fell 20 feet off of the roof, and was found in ventricular fibrillation arrest and was successfully resuscitated by emergency medical services.  Computed tomography imaging revealed bilateral loss of gray-white matter differentiation at the parieto-occipital regions and basal ganglia with progressive cerebral edema. There was no hemorrhagic focus or midline shift. Magnetic resonance imaging of the brain showed symmetric T2/FLAIR hyperintensity involving the right occipital regions as well as the deep gray structures with associated diffusion restriction consistent with anoxic injury.  Due to extent of his electrical burns he underwent bilateral below elbow amputations with skin grafting.  He was subsequently fitted for bilateral body powered upper limb prostheses that he was unable to use.  He was referred to the Brain Injury Medicine service for cognitive evaluation.  


Results: The patient was admitted to acute inpatient rehabilitation with a goal of training the patient to use his prostheses.  In regard to learning, memory, and cognition, the results of neuropsychological battery indicated that the patient’s memory and executive functioning were impaired.  Impairments in executive control may account for the patient’s difficulty applying procedural knowledge.  While the patient had good memory in a structed environment he had memory failures during unstructured, novel, or complex task. These were all barriers that led to the patient’s poor functional performance with prostheses use. To facilitate improvement in memory the patient was started on Donepezil 5 mg nightly and titrated up to 10 mg nightly after one week. The patient demonstrated improvements with procedural memory with using his prostheses with donepezil combined with comprehensive therapy and task specific training.  The patient’s health problems profoundly affected his rehabilitation course with frequent debilitating anxiety, post-traumatic stress, and agitation.  The patient continued Effexor and was prescribed Depakote and propranolol.  The patient was also started on gabapentin for neuropathic residual limb pain. Improvements in pain, mood, and anxiety facilitated participation in rehabilitation. Over the course of the patient’s injury he had developed a reliance on others with a tendency to rely on others rather than complete tasks independently.  This reliance on others impacted the patient’s ability to independently utilize his prostheses.  The patient was not ready to accept an adult independent functional role with limited adoption of normative adult roles.  Over the course of rehabilitation, the patient demonstrated that he could perform basic device functions but his poor ability to trouble-shoot spontaneously and over reliance on others raise doubts of his ability to independently manage his prosthesis at home.


Conclusions: The findings suggest that the prosthetic prescription should be considered within the context of a larger plan to address the patient’s health and disability.  Through this case we identified five measures that may provide critical information useful for clinical decision making.  Neuropsychologic testing and early brain injury medicine consultation to medically optimize the patient using our five measures should be considered prior to writing the prosthetic prescription.

Challenges of Neurorehabilitation and the Prosthetic Prescription for a Patient with an Anoxic Brain Injury: Understanding how Neuropsychological Changes Affect Functional Rehabilitation