WCB Procedures

Externally-powered prosthetics

Procedure summary

Published On

Mar 28, 2023

Purpose

To determine if a worker is an appropriate candidate for an externally-powered prosthetic device.

Description

Decision makers are encouraged to use their discretion and reasonable judgement to guide their decisions and conversations to make the most appropriate and fair decision.

The decision maker reviews the worker’s request for an externally-powered prosthetic device to confirm it is medically recommended by their treating practitioner, related to the compensable injury and the worker meets the eligibility criteria outlined by the manufacturer and WCB’s determining factors.

The request is then sent to a supervisor and/or manager for approval to have the worker assessed. When the request is approved, the decision maker arranges the necessary assessments the worker must complete to confirm they are a suitable candidate. This includes a three-part assessment by the worker’s:

Treating physician
Treating prosthetist
Return-to-work clinician, such as an occupational therapist or physiotherapist, who will conduct an environmental assessment at the worker’s worksite (if applicable).

The decision maker actions the request based on the results of the assessments and obtains the necessary approvals for the prosthetic device.

They will document all discussions, review requests and approvals in file notes that are attached to the Medical Assistive Devices line.

Key information

The appropriate prosthesis is one very critical component in the overall rehabilitation and return to work process, and in some cases may improve the worker’s quality of life.

A number of different prosthetic designs are available, such as the microprocessor knee unit and myoelectric upper extremity, discussed in this procedure.

The appropriate prosthesis choice depends on many factors, including level of amputation, joints involved, physical and psychological conditions, prior level of functioning, work and home environment, worker preference, cost-benefit analysis of the device as compared to a body-powered mechanical device, etc.

The guiding criteria developed by the Prosthetic and Orthotic Advisory Committee assists the treating team identify whether an externally-powered device is the most appropriate prosthesis. The criteria are based on the use and safety parameters set out by the manufacturer and are divided into the following four categories:

Work
Medical
Functional
Environmental safety

The worker’s treating team conducts a multidisciplinary evaluation to assess the criteria.

The worker must meet all the criteria and all members of the assessment team must support this option for it to be approved.

Detailed business procedure

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1. Review the request and determine the worker’s eligibility Confirm the myoelectric upper extremity or the microprocessor knee prosthetic device is needed because of the compensable injury and the worker meets the eligibility criteria specific to the requested device in the following areas: Work and functional Medical Environmental and safety See Microprocessor knee unit or Myoelectric upper extremity device for details. In addition to the eligibility criteria, consider: Is the worker functioning independently? Is the worker currently employed? Is the worker already successfully using a body-powered mechanical device? Will the externally-powered prosthetic device enhance the worker's employability and/or their quality of life? The review has three outcomes: Criteria are met Contact the worker and explain the next steps and the additional assessments needed to make the decision. Explain the request is being referred to the supervisor and manager for approval to continue. Criteria are partially met or there is reason to proceed When there are questions or concerns, but there is a reason to believe the prosthetic device will support the worker’s return to work and/or improve their quality of life, request an opinion from the medical consultant. When the consultant’s opinion supports further assessments, obtain approval from the supervisor and manager to proceed with the necessary assessments to confirm the worker is an eligible candidate. Criteria not met and further investigation is not required When the worker does not meet the criteria and the medical consultant and/or the supervisor and manager do not support further assessments, contact the worker to discuss the decision. Clearly explain the rationale. Have an open conversation about whether the request can be considered in the future and, if so, the next steps. Send a letter outlining the details of the conversation.	Administrative tasks Add a file note (Medical payment processing, Prosthetic inventory) documenting the rationale for proceeding with the assessments and send it to the supervisor for approval. From the eCO Create Referral screen, select Medical Consultant Review and complete the FM555C form. Send the Upper Myoelectric Initial Info (CL071E) letter or the Above Knee Unit Initial Info (CL071B) letter to advise the worker of the criteria that need to be met. Send the Upper Myoelectric Denial (CL071G) or the Above knee unit work denial (CL071D) letter to the worker with a copy to the requesting prosthetist. Add a file note (Contact, Worker Contact).
2. Proceed with the assessments when the request is approved Following approval, make referrals for the three assessments required to consider the prosthetic device: The prosthetist The treating physician The referral for a return-to-work planning meeting	Administrative tasks Send the Prosthetist the: Upper Myoelectric Prosthetist (SP071D) letter or Above Knee Unit Info to Physician (SP071B) And attach the Prosthetist Assessment form (C-989) form. Send the physician the: Upper Myoelectric Physician (SP071C) letter or Above Knee Unit Info to Physician (SP071A) letter And attach the Physician Assessment (C-988) form. From the eCO Create Referral screen, select Return to Work Centre Referral and complete the script. Select Myoelectric Upper Extremity or Microprocessor Knee in the Return-to-Work Planning Meeting field.
3. Review the assessment results and action them based on the outcome Review the assessment findings to determine if the worker meets medical, functional, environmental and safety criteria. When the results of the assessments indicate the worker meets the criteria, continue to step 4. In some cases, the recommendations from the three assessments may differ, such as when two assessors recommend the device, and one does not. If this is the case, contact the assessors to discuss the findings and work to reach a consensus. Consider a referral to a medical consultant when: Assistance interpreting the results and/or a medical opinion is needed to determine whether the prosthetic device should be approved or if future assessments are needed. Consensus cannot be reached between the assessors. Review the opinion provided by the medical consultant. Arrange for further medical assessments, if recommended. When the results of the assessments indicate the worker does not meet all the criteria but there are solid reasons that support the possibility of the worker’s request, make a recommendation to the supervisor and manager for approval to proceed.	Administrative tasks Add a file note (Contact, Treatment provider contact) and document details of the discussion. Complete the MC review referral (FM555C) form on the eCO Create Referral screen to request a consultant’s opinion. Follow the Internal consultant referral procedure Add a file note (Medical payment processing, Prosthetic inventory) documenting the reasons for the recommendation and send it to the supervisor.
4. Make and communicate the decision Review all opinions from the supervisor and manager. Action any recommendations, if required. Contact the worker and explain the decision to the worker and discuss any next steps, such as the worker following up with their prosthetist and discussing insurance. When the decision is to approve the device, ensure the worker understands that WCB is not responsible for the replacement of the prosthesis if it is lost or stolen. Advise the worker to consider adding it to their personal insurance and that they are entitled to be reimbursed for any additional insurance costs. When the decision is to deny the request, have an open conversation, clearly explaining which criteria (work, functional, medical and environmental/safety) they have not met. Answer any questions and discuss what needs to happen, if anything, for the request to be considered again in the future. Review their right to appeal the decision. Follow up the discussion with the worker by sending the appropriate letter. Clearly express the rationale used to reach the decision (citing the evidence used to make the decision) and address any concerns the worker expressed during the discussion.	Administrative tasks Update the Medical Assistive Device line with the required information. Review the Prosthetics and Orthotic Services Service Information and/or Authorization (C998) form to confirm cost information for the prosthetic device. Send the appropriate letter from the CL071 series with a copy to the physician and prosthetist. The Medical Aid team will pay the invoices as they are received.

Eligibility criteria

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Microprocessor knee unit

A microprocessor prosthetic device has an internal computer that gives an amputee better control and enhances their overall mobility by sensing a change in the person’s movement and adjusting in response.

Eligibility criteria

To fully benefit from the prosthetic device, a worker must meet the criteria used to identify the ideal user the device was designed for, as outlined by both the manufacturer and the WCB.

Work criteria Rationale: The WCB’s mandate is to involve the injured worker, employer and health care provider(s) in a cooperative relationship aimed at getting the worker back to work safely, as soon as possible.	Assessor
*1. The worker is employed or is capable of returning to work and actively engaged in a job search.	Decision maker
Medical criteria Rationale: Physical instability issues and other medical conditions, both compensable and non-compensable, can impact the fit, use and safety of the C-Leg. Progression to full use of a standard, body-powered mechanical prosthesis ensures the worker is at a stage where they can fully utilize and benefit from the C-Leg.	Assessor
2. The worker is medically stable.	Treating Physician
3. The worker is in a permanent socket and for the last six-months has been able to tolerate wearing their current body-powered mechanical prosthesis for a minimum of five-hours a day for seven-days a week.	Treating Physician
4. The worker’s weight is below 275 pounds. Otto Bock Instructions for Use: 1.2 Field of Application, pg. 24	Return-to-work planning meeting clinician
Functional criteria Rationale: The manufacturer of the C-Leg (Otto Bock) has outlined the functional criteria the user must have to be consider an ideal user the C-Leg was ideally developed for. Workers who do not meet the suggested functional criteria will not fully benefit from the C-Leg.	Assessor
5. The worker is a through-knee or above amputee.	Prosthetist
6. The worker needs to walk on uneven ground during the course of a work day.	Return-to-work planning meeting clinician
7. The worker frequently needs to negotiate stairs or steps during the course of a work day.	Return-to-work planning meeting clinician
8. The worker is currently or has the potential to be an unlimited community ambulatoryThe worker is independently mobile outside the home, which includes the ability to confidently negotiate uneven terrain, private venues, shopping centres and other public venues. (Otto Bock Mobility Grade Level 3 or Grade Level 4 ).	Prosthetist
*9. The worker needs to walk faster than a normal walking speed and to vary their pace during the course of a work day.	Return-to-work planning meeting clinician
*10. The worker participates in activities that require them to bear weight on the prosthetic device and maintain a relatively smooth gait. For this they need a high level of stance phaseThis is the amount of time the foot is on the ground and the limb is bearing weight. safety and efficient swing phaseThe swing phase gives the momentum to take a step and is necessary to maintain smooth walking control. control during the course of a work day.	Prosthetist
*11. The worker needs to change direction and speed suddenly during the course of a work day.	Return-to-work planning meeting clinician
*12. The worker will benefit from automatic swing phase The swing phase gives the momentum to take a step and is necessary to maintain smooth walking control.adjustments because of their daily activities.	Prosthetist
*13. The worker needs to stand for long periods of time during a work day.	Return-to-work planning meeting clinician
* Note: The decision maker can waive criteria marked by an asterisk (*) with approval from a manager.
Environmental and safety criteria Rationale: The manufacturer of the C-Leg (Otto Bock) has outlined the environmental conditions needed for the C-Leg to operate safely and optimally.	Assessor
14. The worker is not exposed to an environment that varies from the operating and storage limitations outlined for the C-LegThis is not the ambient temperature. The working temperature in the knee unit must not drop to -10℃ or rise to +60℃. while at work. Otto Bock Instructions for Use: 3.3 Technical Information, pg. 40	Return-to-work planning meeting clinician
15. The worker is not exposed to an environment with intense smoke, dust, mechanical vibrations or jolts while at work. Otto Bock Instructions for Use: 1.5 General Safety Instructions, pg. 26	Return-to-work planning meeting clinician
16. The worker is not exposed to an environment with strong magnetic or electric interference while at work. Otto Bock Instructions for Use: 1.5 General Safety Instructions, pg. 26	Return-to-work planning meeting clinician
17. The worker is not exposed to an environment with excessive moisture while at work. Otto Bock Instructions for Use: 1.5 General Safety Instructions, pg. 26	Return-to-work planning meeting clinician
18. The worker has the cognitive ability to perform or has a living situation to support proper care of the C-Leg. Indications for Otto Bock Microprocessor knees, Contraindication	Prosthetist

Myoelectric upper extremity prosthetic

A myoelectric prosthesis is an externally-powered artificial hand, wrist or elbow controlled using the electrical signals generated naturally by the existing muscles in the worker’s residual limb. One or more sensors in the prosthetic socket receive electrical signals from engaged muscles in the residual limb and relay information to a controller that moves the joints. The worker may use switches with a rocker or pull-push or a touch pad when muscles signals cannot be used.

A skin-like glove covers the prosthesis for a natural appearance.

All requests for hand myoelectric prostheses should be discussed with one of the supervisors from the Special Care Services unit for advice and assistance in deciding if the request should be considered.

Eligibility criteria

The worker's expectations and understanding the limitations of the myoelectric prosthesis are a key consideration in deciding who is a suitable candidate.

Work and functional criteria Rationale: The WCB’s mandate is to involve the injured worker, employer and health care provider(s) in a cooperative relationship aimed at getting the worker back to work safely, as soon as possible. The worker's expectations of the myoelectric prosthesis are a key consideration in deciding who is a suitable candidate. The worker needs to understand the limitations of the myoelectric prosthesis.	Assessor
1. Worker is capable of returning to work and is actively engaged in a job search, or the worker is already employed. Note: The decision maker may waive criteria marked by an asterisk (*) with approval from a manager.	Decision maker; Supervisor; Manager
2. The myoelectric prosthesis improves the worker's performance at work versus a body-powered mechanical prosthesis, and the job demands do not exceed the limitations and specifications of the device. Note: See the Environmental and safety section for more job-related considerations.	Return-to-work planning meeting clinician; Occupational therapist; Decision maker
Medical criteria Rationale: Physical instability issues and other medical conditions, both compensable and non-compensable, can impact the fit, use and safety of the myoelectric prosthesis. Full utilization of mechanical prosthesis is required before the myoelectric prosthesis can be considered.	Assessor
1. The worker is medically stable: The residual limb is fully healed and has been free of neuromata for at least one-year. There are no recurrent skin lesions or skin breakdowns. There is no scheduled or planned surgery on the upper extremity. The worker is at maximum medical recovery.	Physiatrist with amputation experience
2. The worker is in a permanent socket and for a minimum of six-months has been able to tolerate wearing their current body-powered mechanical prosthesis for a minimum of five hours a day, seven days a week.	Physiatrist with amputation experience
3. The worker demonstrates the patience, perseverance and commitment to apply themselves to the training necessary to become confident with using the device.	Occupational therapist; Psychologist
4. The worker has high quality skin sites required for the myoelectric connection that operates the device.	Prosthetist
Environment and safety criteria Rationale: The myoelectric prosthesis has limitations that need to be considered when evaluating whether it is suitable for a worker.	Assessor
1. The worker is not exposed to dust or moisture in their work environment.	Return-to-work planning meeting clinician; Occupational therapist
2. The worker is not exposed to cold temperatures in their work environment that can compromise the device’sCold temperatures will slow down the operation of the myoelectric prosthesis. operation.	Return-to-work planning meeting clinician; Occupational therapist
3. The worker is not exposed to electrically charged conditions, including welding, strong magnetic or static electricity conditions in their work environment.	Return-to-work planning meeting clinician; Occupational therapist
4. The worker is not exposed to mechanical vibrations or jolts in their work environment.	Return-to-work planning meeting clinician; Occupational therapist
5. The worker will not be expected to perform tasks that require them to suddenly releaseThe myoelectric prosthesis is not able to quickly release a gripped object in an emergency. objects or controls for safety reasons. Note: The myoelectric prosthesis is not able to quickly release a gripped object in an emergency.	Return-to-work planning meeting clinician; Occupational therapist
* Note: The decision maker can waive criteria marked by an asterisk (*) with approval from a manager.

WCB does not usually approve the following myoelectric prostheses:

Individual finger prosthetic devices as these are typically very costly and do not provide increased function and may be a hazard.
Devices considered experimental are not generally approved. These include:
- Myoelectric fingersIndividually powered prosthetic fingers that replicate natural finger movements, like bend, touch, pick up and point. for partial hand amputees or brands like Touch Bionic.
- OsteointegrationA titanium coated implant is surgically anchored and integrated into the bone of the worker’s residual limb, which then grows into the implant..
- Targeted Muscle Reinnervation (TMR)(TMR) and is also called MYO-BIO. The nerves in the residual arm are reattached to healthy muscle elsewhere in the body, such as a chest muscle. The nerve signals originally used for arm movement cause the chest muscle to contract and the electrodes placed on the chest send a signal to the prosthetic causing it to move..

Note: Myoelectric fingers may be considered for approval on a vocational basis only.

Contact the Special Care Services team to discuss whether the worker is a candidate to be approved for Myoelectric fingers.

Supporting references

Policies

Procedures

11-2 Internal consultant referrals

Workers’ Compensation Act

Applicable sections

Section 78 (1)(3)
Section 79
Section 89 (2)(3)

General Regulation

Applicable sections

Related Legislation

Applicable sections

Compatibility Warning

WCB Procedures

Externally-powered prosthetics

Procedure summary

Detailed business procedure

Administrative tasks

Administrative tasks

Administrative tasks

Administrative tasks

Eligibility criteria

Supporting references

Policies

Procedures

Workers’ Compensation Act

General Regulation

Related Legislation