The Promise of Assistive Technology to Enhance Activity and Work Participation (2017) / Chapter Skim
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4 Upper-Extremity Prostheses
4 Upper-Extremity Prostheses
Pages 99-164
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From page 99... ...
. Although congenital limb absence is properly defined with a slightly altered taxonomy, individuals are fit with prosthetic devices according to the corresponding amputation level regardless of whether the limb deficiency is congenital or acquired (Schuch and Pritham, 1994)
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From page 100... ...
. Partial hand amputations are amputations
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From page 101... ...
An upper extremity is a high degree-of-freedom system, allowing for great mobility to move the hand into a range of positions around the body. The complexity of the uman h upper extremity is illustrated by the massive proportion of space within the motor and sensory areas of the brain (the motor and sensory homunculi)
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From page 102... ...
Given that the most prevalent type of externally powered device is a myoelectric prosthesis, the following description focuses on those devices. A typical myoelectric control scheme, direct control, uses EMG signals from two antagonist muscle contractions to operate two directions of movement.
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From page 103... ...
FIGURE 4-3 Myoelectric prosthesis on a person with a transradial amputation. SOURCE: iStock.com/Horsche.
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From page 104... ...
The benefits of myoelectric prostheses are that they typically use no harnessing or less harnessing than body-powered systems; they often can be operated in more planes of movement; the terminal devices (i.e., hands/ hooks) can generate more force; and because there are no cables and straps on the outside of the device, they can appear more cosmetic.
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From page 105... ...
. Instead, numerous sensors are placed on the residual limb, and a micro processor is "trained" to recognize the various patterns of movement, with the goal of making movements more intuitive and less mentally taxing (Deeny et al., 2014)
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From page 106... ...
Many varieties of terminal devices (hooks or hands) are available for both myoelectric and body-powered prostheses.
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From page 107... ...
The amount of force required varies across types of VC terminal devices (Smit and Plettenburg, 2010)
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From page 108... ...
Hosmer 7 Work Hook, voluntary opening.
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From page 109... ...
NOTE: A Electronic Terminal Device (ETD)
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From page 110... ...
110 THE PROMISE OF ASSISTIVE TECHNOLOGY FIGURE 4-8 Single-degree-of-freedom hand showing cutout of glove and hand shell to display internal mechanism. SOURCE: Courtesy of Motion Control division of Fillauer.
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From page 111... ...
, and the user can connect the prosthesis to the rod as desired. Although this technique does eliminate the need for a socket, challenges remain in interfacing with the residual limb to record EMG signals for a myoelectric prosthesis or to connect the control straps for a body-powered
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From page 112... ...
Terminal device: This is the distal portion of a prosthesis, often replacing hand function or appearance. Terminal devices provide the primary function of the ability to grip.
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From page 113... ...
, suggesting that children adapt to limb deficiency at a young age and maximize function without the use of a prosthetic limb. It is clear that currently available upper-limb prostheses cannot replace the complex functions of the missing upper limb because of limitations inherent in their control and design, their lack of sensory feedback, and the methods required to suspend them onto the residual limb.
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From page 114... ...
. Thus, some people with limb loss may prefer terminal devices that resemble more closely the shape of the hand than a hook because they appear more like an unimpaired hand, and so may draw less attention to the prosthesis (Flannery and Faria, 1999; Hanson, 2003)
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From page 115... ...
Although some advances have been achieved in improving the movements of multiarticulating prosthetic hands, even the most advanced of these devices, which may allow passive movement of the thumb or other digits, do not possess all of the passive range of motion of the human hand. The most commonly used terminal devices -- body-powered and myoelectric hooks -- have only a single degree of freedom, meaning that they can be moved only in two opposing directions -- open and closed.
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From page 116... ...
Further, no currently available devices allow active control over wrist flexion and extension or radial and ulnar deviation, humeral rotation, or powered shoulder movement in any direction. Limitations in the active range of motion of any joint negatively impact the size of the functional envelope and are considered a contributing factor in the compensatory movements of the trunk observed in kinematic studies of upper-limb prosthesis users (Carey et al., 2008)
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From page 117... ...
. Few studies have directly compared the dexterity of myoelectric and body-powered terminal devices or multiarticulating and conventional myoelectric terminal devices.
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From page 118... ...
Even when individuals with amputation have use of their own shoulder joint for reaching activities, they may be unable to use their prosthesis when reaching overhead because of the constraints of the harnessing that operates the cable. Users of myoelectric devices may also have difficulty operating their device in a full range of body positions because involuntary co-contraction of residual limb muscles that often occurs when stabilizing the limb against gravity can interfere with voluntary control of residual musculature.
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From page 119... ...
Thus, even those who wish to wear an upper-limb prosthesis may be unable to do so to the extent that they desire. Comorbid injuries and conditions that affect vision, cognitive ability, or the upper extremity/trunk proximal to the limb deficiency will make using a prosthesis more challenging and will limit the impairment mitigation effects of a prosthetic device.
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From page 120... ...
In general, these studies have found that young children with acquired amputation are more likely to become users of upper-extremity prosthetic devices if they begin using them at a younger age (Dabaghi-Richerand et al., 2015; Meurs et al., 2006)
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From page 121... ...
. A study of people with partial hand amputation found that fewer than half were able to return to the same job, and most found prosthetic devices insufficient to meet the demands of their work, although cosmetic prostheses were important to their work success (Burger et al., 2007)
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From page 122... ...
. Similar findings also emerged from a study showing higher rates of return to work following upper-limb amputation in the building industry than in agriculture, presumably because agriculture offers fewer job opportunities compatible with a missing upper limb (Fernandez et al., 2000)
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From page 123... ...
. In addition, professions in which interactions with the public or social interactions are integral to job function may be more challenging for people who experience perceived social stigma or public self-consciousness due to their upper-limb loss (Saradjian et al., 2008)
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From page 124... ...
Primary rejection rates (rejecting any use of a prosthesis) appear to be related to the level of amputation, age at the time of amputation, gender, and discrepancies between perceived needs and the availability of prosthetic devices that will meet those needs (Burger and Marinček, 1994; Dougherty et al., 2010; McFarland et al., 2010; Østlie et al., 2012a)
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From page 125... ...
Overall, those with unilateral and bilateral acquired amputation had similar rejection rates. However, those with congenital bilateral limb absence had significantly higher rejection rates (75 percent)
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From page 126... ...
. EVALUATION AND MONITORING The need for a multidisciplinary team approach is acknowledged in the first evidence-based clinical practice guidelines for the rehabilitation of persons with upper-limb amputation, released in 2014 (Management of Upper Extremity Amputation Rehabilitation Working Group, 2014)
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From page 127... ...
. However, experienced prosthesis users may require fewer training sessions than inexperienced users to learn to use a new type of device (Management of Upper Extremity Amputation Rehabilitation Working Group, 2014)
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From page 128... ...
. Prosthetic training can improve skill in prosthesis use and help those with upper-limb amputation make better functional use of their prostheses (Atkins, 2004; Management of Upper Extremity Amputation Rehabilitation Working Group, 2014; Silcox et al., 1993)
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From page 129... ...
describe four phases of rehabilitation for the upper-limb amputee: perioperative care, preprosthetic training, prosthetic training, and lifelong care (Management of Upper Extremity Amputation Rehabilitation Working Group, 2014)
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From page 130... ...
. The current evidence-based guidelines state that prosthetic training should include the following components: education, controls training, and functional training (Management of Upper Extremity Amputation Rehabilitation Working Group, 2014)
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From page 131... ...
. A study of four approaches to grasp training for users of myoelectric prostheses recommends that training programs begin with indirect grasping tasks but ultimately emphasize fine motor tasks (Bouwsema et al., 2014)
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From page 132... ...
. These data suggest that overall, veterans with major upper-limb amputation received a new prosthesis once every 3.6 years.
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From page 133... ...
Instead, the billing of a code (L–code in the case of prosthetic devices) is assumed to include the time needed to evaluate, fit, deliver, and follow up on the given device.
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From page 134... ...
TABLE 4-3 Estimated Percentage of Upper-Limb Prosthetic Devices by Amputation Category Amputation Category Percentage Cumulative Percentagea Transradial/wrist disarticulation 54.3 54.3 Transhumeral 23.9 78.3 Level/side unspecified 19.6 97.8 Partial hand 2.2 100.0 NOTE: Information from 5 percent random sample of 2013–2014 Durable Medical Equipment (DME) Medicare beneficiaries aged 20–67.
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From page 135... ...
The committee recognizes that limited or lack of evidence about the impact of upper-limb loss, prosthesis use, and amputation rehabilitation on activity and participation may affect decisions by funding sources about which devices and services to cover. Such information on outcomes could contribute to studies on the effectiveness or cost-effectiveness of different types of prostheses and help inform the development of rational resource utilization, including use by insurers and other funding sources to inform their coverage decisions.
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From page 136... ...
. Prosthesis users receive training from occupational or physical therapists, depending on the clinical environment and team.
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From page 137... ...
There also exist a range of socket interfaces, suspension methods, terminal devices, and other compo nents for each of these categories.
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From page 138... ...
The consistency of impairment mitigation also depends on the con dition and volume of the residual limb, which impact socket fit and comfort.
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From page 139... ...
4-23. Within the United States, people with limb loss or limb deficiency experience significant barriers to accessing and successfully using prosthetic devices.
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From page 140... ...
Despite advances in prosthetic designs and research, currently avail able UEPs are limited in their ability to mitigate impairments related to limb loss. [Findings 4-4, 4-5, 4-6, 4-8]
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From page 141... ...
4-7. Comprehensive efforts to study the impact of upper-limb loss, pros thesis use, and amputation rehabilitation on activity and participa tion, including work participation, are needed.
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From page 142... ...
2007c. Upper limb prosthesis use and abandonment: A survey of the last 25 years.
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From page 143... ...
2016. A survey of overuse problems in patients with acquired or congenital upper limb deficiency.
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From page 144... ...
2007. Coping, affective distress, and psychosocial adjustment among people with traumatic upper limb amputations.
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From page 145... ...
2014. Comparison of upper limb amputees and lower limb amputees: A psychosocial perspective.
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From page 146... ...
2003. Upper limb prosthetic components: Function vs.
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From page 147... ...
2011. Survey of upper limb prosthesis users in Sweden, the United Kingdom and Canada.
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From page 148... ...
2010. Unilateral upper limb loss: Satisfaction and prosthetic device use in service mem bers from Vietnam and OIF/OEF conflicts.
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From page 149... ...
2012. Reliability and validity of outcome measures for upper limb amputation.
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From page 150... ...
2012. Advanced upper limb prosthetic devices: Implications for upper limb pros thetic rehabilitation.
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From page 151... ...
2016. Competency, risk, and acceptance of upper limb prosthetic technology.
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From page 152... ...
1995. Prosthetic usage in major upper extremity amputations.
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From page 154... ...
needed to help patient learn to use effectively Myoelectric Transradial $15,100 • kin integrity that allows an intimate S socket fit to maintain electrode Transhumeral $56,200 contact Shoulder disarticulation $65,700 • bility to contract isolated muscles A voluntarily to activate myosites • onsistent access to electricity C • killed prosthetist and OT needed to S help patient learn to use effectively Hybrid Transhumeral $19,200 • kin integrity that allows an intimate S socket fit to maintain electrode Shoulder disarticulation $32,500 contact • bility to contract isolated muscles A voluntarily to activate myosites • onsistent access to electricity C • killed prosthetist and OT needed to S help patient learn to use effectively
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From page 155... ...
• Weight limitations -- lifting • equires less maintenance R and carrying activities • ser can make some U depend on the positioning adjustments/self-repair of the object in relation to • ess expensive option L the body than myoelectric or hybrid • ocket style and S harnessing may limit shoulder ROM in shoulder level amputees • erminal devices have only T one grasp • ot recommended for N • ses no harnessing or less U • eavier than body H driving and operating harnessing compared with powered systems heavy equipment body-powered systems • ess resistant to water and L • luctuating limb volume F • an be used for overhead C dust exposure can interfere with activities/in more planes • Requires more electrode contact, and • an be used with a wider C maintenance, more prone make performance erratic range of terminal devices to breakage that can generate more • May function force inconsistently as a result • an have better cosmesis C of excessive sweating, • Externally powered change in limb volume terminal devices typically • ost users unable to M provide greater grip force control terminal device than body-powered hooks and any other movement and hands simultaneously • an be cognitively taxing C to use • imited shoulder ROM/ L • oth elbow and hand B • May function strength or shoulder pain can be operated inconsistently as a result may limit use of harness simultaneously of excessive sweating, • luctuating limb volume F • ighter than a full L change in limb volume (transhumeral) can myoelectric system for • Requires more interfere with electrode higher levels maintenance than body contact and make • Externally powered powered systems (battery performance erratic terminal devices typically charging, more prone to provide greater grip force breakage)
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From page 156... ...
156 THE PROMISE OF ASSISTIVE TECHNOLOGY ANNEX TABLE 4-1 Continued Device Estimated Costa Indications/Requirements for Use Terminal Devices Passive hand $500b • sed to stabilize objects and for U cosmesis Body-powered hook $400–$1,420 • se of body-powered system U Single-degree-of-freedom $1,100–$1,500 • se of body-powered system U (DOF) , body-powered hand Single-DOF powered hand $6,800 • se of myoelectric system U Multiarticulating hand $32,000b • se of myoelectric system U powered hand
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From page 157... ...
UPPER-EXTREMITY PROSTHESES 157 Relative Contraindications Benefits of Device Limitations of Device • ot appropriate if need to N • rovides the best P • nable to use functionally U grasp objects cosmetic restoration to grasp objects -- very • equires no training to use R limited in function • an be interchanged with C • arge variability in price L other terminal devices between off-the-shelf and custom designs • VC designs can stain P easily, and silicone, while stain-resistant, can tear • ess expensive than L • Nonanthropomorphic powered systems • an grasp small objects C • vailable in multiple A materials and grip styles • llows good visibility of A object manipulation • ess expensive than L • ore effort required to M powered systems operate than a body powered hook • imited visibility of object L manipulation • imited to a single grasp L position -- limits use for specific activities that require different hand positions • east expensive powered L • imited visibility of object L option manipulation; makes grasp of smaller objects more challenging • imited to a single grasp L position -- limits use for specific activities that require different hand positions • annot get wet C • ore grasp positions -- M • ess durable/more prone L may be used for a wider to breakage range of activities • ust be used with a M • ore cosmetic than hook M myoelectric or hybrid prosthesis • More expensive • ay require more M extensive training to use effectively continued
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From page 158... ...
Shoulder disarticulation myoelectric includes codes L6646, L6648, L6684, L6689, L6965, L7181, L7259, L7368, L7402, and L7405. Transhumeral hybrid includes codes L6638, L6693, L6655, L6675, L6682, L6688, L6955, L7368, L7401, and L7404.
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From page 159... ...
UPPER-EXTREMITY PROSTHESES 159 Relative Contraindications Benefits of Device Limitations of Device • ailored grasp positions T • Less cosmetic for specific activities • ften needs to be O • an be more durable than C interchanged with other multiarticulating hands terminal devices to • an be water-resistant C accomplish the broad range of activities people need to do
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From page 160... ...
160 THE PROMISE OF ASSISTIVE TECHNOLOGY ANNEX TABLE 4-2 Ability of Upper-Limb Prosthetic Devices to Mitigate the Effects of Impairment Body-Powered TR TH Shoulder Sensation Proprioception No No No Touch function No No No Passive Range of Motion Fingers Partial Partial Partial Thumb No No No Wrist ulnar/radial deviation No No No Wrist flexion/extension Var/partial Var/partial Var/partial Wrist pronation/supination Variable Variable Variable Elbow flexion/extension NA Variable Variable Shoulder flexion/extension NA NA Var/partial Shoulder abduction/adduction NA NA Var/partial Shoulder rotation NA NA Variable Shoulder horizontal ad/abduction NA NA Var/partial Active Range of Motion Fingers Partial Partial Partial Thumb No No No Wrist ulnar/radial deviation No No No Wrist flexion/extension No No No Wrist pronation/supination Var/Yes NA NA Elbow flexion/extension NA Variable No Shoulder flexion/extension NA NA No Shoulder abduction/adduction NA NA No Shoulder rotation NA NA No Shoulder horizontal ad/abduction NA NA No
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From page 161... ...
UPPER-EXTREMITY PROSTHESES 161 Myoelectric Hybrid TR TH Shoulder TH Shoulder No No No No No No No No No No Var/partial Var/partial Var/partial Var/partial Var/partial Var/partial Var/partial Var/partial Var/partial Var/partial No No No No No Var/partial Var/partial Var/partial Var/partial Var/partial Variable Variable Variable Variable Variable NA Partial Variable Variable Variable NA NA Var/partial NA Variable NA NA Var/partial NA Variable NA NA Variable NA Variable NA NA Var/partial NA Var/partial No No No No No No No No No No Var/Yes Var/Yes Var/Yes Var/Yes Var/Yes NA Yes Yes No No NA NA No NA No NA NA No NA No NA NA No NA No NA NA No NA No continued
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From page 162... ...
162 THE PROMISE OF ASSISTIVE TECHNOLOGY ANNEX TABLE 4-2 Continued Body-Powered TR TH Shoulder Activities Grasp Partial Partial Partial Fine motor use Partial Partial Partial Dexterous activities Partial Partial Partial Handling objects Partial Partial Partial Lifting <20 pounds Partial Partial Partial Lifting >20 pounds Partial Partial Partial Carrying <20 pounds Partial Partial Partial Carrying >20 pounds Partial Partial Partial Reaching forward Variable Partial Partial Overhead reaching Var/partial Var/partial Var/partial Considerations Indications • kin integrity that allows socket wear and S harness use Contraindications • imited shoulder range of motion/strength or L shoulder pain may limit use of harness Clinical expertise/training • eeds trained prosthetist and occupational N therapist to help patient learn to use effectively Limitations • ocket style for some transradial-level S amputees may limit elbow range of motion • ocket style and harnessing may limit shoulder S range of motion in shoulder level amputees. • eight limitations -- lifting and carrying W activities depend on the positioning of the object in relation to the body NOTE: NA = not applicable; TH = transhumeral; TR = transradial; Var = Variable.
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From page 163... ...
UPPER-EXTREMITY PROSTHESES 163 Myoelectric Hybrid TR TH Shoulder TH Shoulder Partial Partial Partial Partial Partial Partial Partial Partial Partial Partial Partial Partial Partial Partial Partial Partial Partial Partial Partial Partial Partial Partial Partial Partial Partial Var/partial Var/partial Var/partial No No Partial Partial Partial Partial Partial Var/partial Var/partial Var/partial Var/partial Var/partial Partial Partial Partial Partial Partial Partial Partial Partial Partial No • kin integrity that allows socket wear S • kin integrity that allows S • equires active myosites R socket wear • ost unable to control terminal device and any M • equires active myosites R other movement simultaneously • annot get wet C • imited shoulder range of L motion/strength or shoulder pain may limit use of harness • annot get wet C • eeds trained prosthetist and occupational N • eeds trained prosthetist N therapist to help patient learn to use effectively and occupational therapist to help patient learn to use effectively • ay function inconsistently as a result of M • ay function inconsistently as M excessive sweating, change in limb volume a result of excessive sweating, • ust have consistent access to electricity M change in limb volume
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