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Mike Kacer practices unlacing his worn-out combat boots.
He doesn’t use his fingers. He left those in Afghanistan, along with much of his left arm.
He maneuvers two silver pincers, oversized tweezers that tug his laces loose. It does not go well.
“I could actually tie the shoe faster without the prosthesis,” Kacer says.
Despite practicing with this artificial arm –- and with more than a dozen other Army-issued prosthetic limbs at his disposal –- Kacer said that most of the time he doesn’t wear the devices. Even though the government has probably spent more than $117,000 to provide him with artificial arms over the past five years. Just one of the more sophisticated devices he owns cost more than $100,000, and it’s a device he doesn’t often use.
“If I had to put a timeframe on it,” he says, "[in] a 13-hour day I probably wear a prosthetic four to five hours out of it.”
Kacer is far from alone. Of the roughly 1,600 veterans who have suffered major limb losses from the wars in Iraq and Afghanistan, about 319 have faced amputations of some part of their arms. And although they have little trouble getting artificial arms, many abandon them. Former soldiers criticize the devices as uncomfortable, unreliable and painful to wear regularly, according to a 2012 study by the inspector general’s office at the Department of Veterans Affairs. “Consistently, veterans with upper limb amputations only reported lower psychosocial adjustment, physical abilities, and prosthetic satisfaction than those with lower limb amputations,” the inspector general’s investigators wrote.
In other words, soldiers who lost legs adjusted better than those who lost arms. Scientists have greatly improved prosthetic legs during the past decade with better technology, materials like carbon fiber and urethane, and rehabilitation. Improvements to artificial arms have not kept pace, according to many specialists. “The state of the art of upper limb technology is not as good as lower limb technology,” said Dr. Linda Resnik, a Brown University scientist who works at the VA Medical Center in Providence, Rhode Island.
A key reason is that artificial arms have not gotten the same priority, according to experts and the VA inspector general. The inspector general reported that veterans found VA staff were unfamiliar with arm prosthetics, lacked expertise and had not kept up with the latest technologies. Repairs took longer for artificial arms than for legs, and arm amputees sensed that the VA did not really listen to their needs.
Since 2007, the VA has had detailed guidelines for working with soldiers getting prosthetic legs. Similar guidelines for those who lost arms were issued –- at the inspector general’s urging -– only this year.
Arm amputees now account for 22 percent of all new amputees according to Resnik.
But in the last fiscal year, the VA’s Prosthetic and Sensory Aids Service spent $70.2 million went for artificial legs, while just $5.9 million was allocated for prosthetic arms.
In addition, artificial arms are proving more complex than legs. Since the 1950s, researchers have vastly improved the materials in prosthetics, but gains have been slower on mechanics, according to research by Gary Berke, a Stanford University instructor who operates a private clinic providing prosthetics. This has especially benefitted those who use artificial legs. Materials like polyurethane have helped decrease the mechanical forces applied to the remaining stump. Additionally, carbon fiber and other lighter, durable materials have allowed leg amputees to exert less energy when walking, making the task easier than before.
“Walking is relatively straightforward,” Berke said. Artificial legs essentially can do everything that real ones do. Artificial arms, however, are not nearly as adept as the real ones. “We're behind the eight ball in terms of [artificial arms’] functional ability,” said Berke.
Confounding slow progress is rising expectations. In the Vietnam era, soldiers died on the battlefield from injuries that are treatable today. Survivors who made it home were not given many choices for prosthetics, said Lynne McFarland, an epidemiologist with the VA in Washington state. “When they were injured ￼there wasn't a lot of research on upper limb prosthetics,” she said. “It was basically the kind of hook and grasper thing that was available ￼to them.”
Rather than old-fashioned, pirate-style hooks, today’s amputees get the choice of robot-like arms. These new devices may look like the real thing – but they still can’t act like real arms. Many veterans are not impressed. “Even with all the high tech stuff, even then they kind of went, ‘You know, it's not worth the bother,’ ” said McFarland, referring to reality that many veterans abandon their arm prosthetics
Another part of the difficulty is replicating sensations. Robotic motors can grasp everyday objects. But they are unable to feel what they are doing. Scientists call this a feedback loop: Those who have their natural arms use their muscles and nerves to work together. In artificial arms, that’s missing. Berke said, “There’s no feedback from the hand to the limb, so people can’t say, ‘Yes I have a grip on my cup of coffee and I'm not going to smash it.’ ”
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Despite difficulties, researchers believe that if the military put a greater emphasis on making prosthetic arms more functional, the results could be a lot different.
If anyone understands the differences between arm and leg amputations, it’s Army veteran John E. Masson.
He was part of the surge of U.S. troops in Afghanistan. On Oct. 16, 2010, the medic stepped on an explosive device in southern Kandahar province. His left hand, the one he favored for writing and throwing, was blown off below the elbow. Both of his legs were decimated and were almost entirely amputated.
Now, when the 42-year-old veteran sits up, his lower body is wedged into a carbon fiber bucket. He finds it very uncomfortable. He perseveres, struggling to adapt and, with his wife, raising their three children.
While he lost almost all of both legs, and comparatively little of his left arm, Masson is emphatic, weighing the pain and other difficulties: “I’d rather lose a leg than lose an arm.”