advancements in upper limb prosthetic technology and ... - advancements in upper limb...
TRANSCRIPT
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© 2015 Hanger Clinic
Advancements in Upper Limb
Prosthetic Technology and Rehabilitation
Bambi Lombardi, OTR/LPatrick McGahey, LCPO
Upper Limb Prosthetic ProgramHanger Clinic
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© 2015 Hanger Clinic
DISCLOSURE STATEMENT
Bambi Lombardi, OTR/L and Patrick McGahey, LCPO
both work as specialists for Hanger Clinic in the
Upper Limb Prosthetics Program.
All material presented is the copyright of Hanger Clinic.
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LEARNING OUTCOMES
• Attendees will learn about the advancements in the
different types of technology available to the upper
limb prosthetic end user.
• Attendees will understand the functional differences
between each type of upper limb prosthetic technology
presented.
• Attendees will be able to engage the patient in various
training methods specific for the prosthetic technology
used.
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© 2015 Hanger Clinic
Therapist as Coach
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© 2015 Hanger Clinic
Upper LimbAmputation
Levels
Shoulder
Disarticulation
Transhumeral
Elbow
Disarticulation
Transradial
Wrist Disarticulation
Transcarpal
Finger
Amputations
}
Interscapulothoracic
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© 2015 Hanger Clinic
UPPER LIMB FUNCTIONS
Fine Manipulation
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© 2015 Hanger Clinic
UPPER LIMB FUNCTIONS
Power Grasp
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Communication
UPPER LIMB FUNCTIONS
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UPPER LIMB FUNCTIONS
Interact with environment
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Self-Image
UPPER LIMB FUNCTIONS
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MULTIPLE PROSTHESES
• No single prosthetic system meets all needs.
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© 2015 Hanger Clinic
PROSTHETIC GOAL
Provide appropriate
appearance and function
to increase
independence with ADLs
and improve quality of
life
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• VOCATION• TOOL HANDLING• CUSTOMER INTERACTION• GRASP & PREHENSION REQUIRED• PRECISION VERSUS POWER REQUIRED
• BODY COMPOSITION• STRENGTH• ROM• SKIN CONDITION
• MENTAL & PSYCHE HEALTH• PROSTHETIC MAINTENANCE• HYGIENE• APPROPRIATE ACTIVITIES• LIMB/PERSONAL CARE
• SECONDARY OR SUPPLEMENTS• AVOCATIONS• SPECIAL CONSIDERATIONS DURING FABRICATION AND
DESIGN• APPROPRIATENESS
PRESCRIPTION CRITERIA - GOALS
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© 2015 Hanger Clinic
PROSTHETIC OPTIONS
• No Prosthesis
• Oppositional prosthesis / Passive functional prosthesis
• Body powered prosthesis
• Externally powered prosthesis (myoelectric)
• Hybrid prosthesis
• Activity-Specific prosthesis
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OPPOSITIONAL / PASSIVE FUNCTIONAL
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Oppositional/Passive Functional Prosthesis
Benefits:
• Provides opposition
• Can be lightweight
• Most are simple
• Usually little maintenance
Limitations:
• No active prehension
• Limited function
• Patient can have unreal expectations for cosmesis
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BODY POWERED PROSTHESISPowered and controlled by gross body movements captured by a harness system.
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Body Powered Prosthesis
Benefits:
• Can be less expensive
• Can be heavy duty construction and function
• Environmentally resistant
• Increase in sensory feedback
Limitations:
• Grip strength or pinch force limited
• Restrictive and uncomfortable harness –functional envelope limited
• Poor static and dynamic cosmesis
• Axilla anchor (possible sound side nerve problems)
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VOLUNTARY OPENING
Standard hook Work hook
1 RB =
1-1.5 lbs.
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EXTERNALLY POWERED PROSTHESIS SWITCH OR MYOELECTRIC CONTROL
• Powered by battery systems
• Controlled by various input devices such as switches or electrodes
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Benefits:
• Increased grip strength
• Harness system reduced or eliminated
– Improved comfort
– Increased functional range of motion
• Minimal energy expenditure
Limitations:
• Initial cost
• Maintenance cost
• Weight*
• Requires battery power
EXTERNALLY POWERED PROSTHESIS SWITCH OR MYOELECTRIC CONTROL
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© 2015 Hanger Clinic
Greifer DMC VariPlus
MyoHandVariPlus Speed®
SensorHand Speed®
MyoHands and GreiferOttobock
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Program 1 = Four Channel ControlProgram 2 = Co-ContractionProgram 3 = Safety Co-contractionProgram 4 = Switch ControlProgram 5 = One-Electrode Control(Default Program is Program 1)
Electronic RotatorOttobock
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© 2015 Hanger Clinic
Motion Control HandMotion Control
Multi-flex or
flexion wrist
option
Wide grasp
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Motion Control Hand – Wrist Flexion UnitMotion Control
Easier to get to midline for dressing,
zipper
Multi-flex or flexion
wrist
Hand is in better position for reading
Hand is in better position. Minimizes
compensatory motions at shoulder and trunk
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Electric Terminal Device (ETD)Motion Control
High pinch force
Good visibility Wide opening
Slender tips and
high pinch force Water-Resistant
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MICHELANGELOOTTOBOCK
• Fast and powerful
• Powered thumb rotation
o 2 positions
o Return to neutral option
• Natural appearance
• Relaxed hand posture
• Flexible OVAL wrist - 8 lock options
• Powered Wrist Rotation Option
• 7 grasp patterns
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Axon Hook Interchange with Michelangelo Hand
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BEBIONICRSL STEEPER
• Individually powered fingers
• 2 position thumb rotation
• Thumb position determines grip pattern
• 14 different grip patterns and hand positions
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i-limb HANDTouch Bionics
ultra revolution• All features of ultra
• Automatic or manual thumb
• 24 grip features
• 12 my grips
• grip chips™
quantum• imo™ technology …..the first upper limb
prosthesis that can change grips with a simple gesture
• Available in 4 sizes and up to 30% stronger and faster
• The battery life is 50% longer
ultra • 5 individually powered digits
• Friction thumb rotation
• 14 grip patterns, some custom
• Pulsing for grip strength
• Flexion wrist option
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ACTIVITY-SPECIFIC
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ACTIVITY-SPECIFIC
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New Advancements: Pattern Recognition and Targeted Muscle Reinnervation (TMR)
Targeted muscle reinnervationcan create new myoelectric
control sites
Multiple joints can be simultaneously controlled
with myoelectric signals
Pattern Recognition:Instead of one or two
electrode sites, an array of electrodes is used to capture a pattern of movement that is more intuitive for the end user
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Osseointegration
• Titanium fixture implanted directly to bone
• Fixture protrudes through skin
• Prosthesis directly attaches to fixture
– Solves many current socket fitting problems
– Has problem with infection at fixture site
• Recently, FDA just awarded SLC/VA group permission for human subject testing
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PHASES OF CARE
• Preprosthetic Management
• Prosthetic Training Phase
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PREPROSTHETIC MANAGEMENT
KEY COMPONENTS:
• Patient Education
• Psychological Support in the Grieving Process
• ADLs and Change of Dominance
• Edema Control and Limb Shaping
• Desensitization / Scar Massage
• Mirror Therapy
• Functional AROM, Strengthening, Body Symmetry
• Myosite testing / training
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PSYCHOLOGICAL SUPPORT IN THE GRIEVING PROCESS
The Five Stages of the Grieving Process
Denial
Denial is usually experienced by people who go through traumatic amputations. Meaningless,
overwhelmed. How can I go on, how can I get through another day?
Anger
Often people will blame God, the doctor, or others for their loss.
Bargaining
In this stage, patients may attempt to postpone the reality of amputation and most patients will
try to bargain with their doctor to go back in time or through a higher authority such as a
religious figure, alternative therapies or experimental drugs.
Depression
In this stage, anger is replaced by depression. This is probably the most complicated stage of
grief, but it too will go away. This is not clinical depression. It is normal. Common symptoms
include sleeping either too much or too little, negative feelings about the environment and the
future, feelings of hopelessness, and talking about death. Depression is not a sign of
weakness, however, and should not be seen as such. It is treatable, and you should not
hesitate to seek help from your doctor, nurse, family and friends.
Acceptance and Hope
Eventually, you will come to terms with your loss and start living again. This is more easily
achieved if you have a visit from a peer counselor who has been through this entire process
and can give you some tips on coping with your loss.
The Psychological Aspects of Amputation, by Saul Morris, PhD
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PSYCHOLOGICAL SUPPORT IN THE GRIEVING PROCESS
Peer support and community resources:
www.amputee-coalition.org
HangerClinic.com/AMPOWER
AMPOWER
Beyond clinical care, Hanger Clinic created and supports the AMPOWER Program, a
three tiered program designed to empower and strengthen those affected by amputation
or limb difference through peer mentorship, education and community.
EmpoweringAmputees.org, which was established to provide guidance and
encouragement for those with limb deficiency and limb loss.
AMPOWER also provides in-person and over-the-phone support, education and the
opportunity for community connection.
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CIRCADIAN RHYTHM
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ADL’s / Assistive Devices: SELF-CARE
Button hook Nail brush
Elastic shoelaces
Hair dryer stand
Nail clipper
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ADL’s / Assistive Devices: SELF-CARE
Hands-free wall mounted
shower dispenser
Wash mitt
Sensor soap
dispenserBody scrubber
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ADL’s / Assistive Devices: HOME MGMT.
Chopper / food processor
Can Opener
Zimjar opener Cutting board
Rocker knife
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ADL’s / Assistive Devices: HOME MGMT.
Dycem(non-skid mat)
Keyless entry
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CHANGE OF HAND DOMINANCE
RADIAL
DIGIT
COORDINATION
SEPARATION OF
RADIAL & ULNAR
SIDES OF HAND
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CHANGE OF HAND DOMINANCE
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EDEMA CONTROL / LIMB SHAPING
Compressive Wrap
Compressogrip, Tubigrip
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DESENSITIZATION / SCAR MASSAGE
Elastomer
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Graded Motor Imagery (GMI) Phantom Pain
Mirror Therapy
12-15 minutes/day5 days/week 4 - 8 weeks
3 Stages of GMI
• Left Right Discrimination
• Explicit Motor Imagery
• Mirror Therapy
http://www.gradedmotorimagery.com/
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AROM, STRENGTHENING, SYMMETRY
Weight Bearing
Body Symmetry
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MYOSITE TESTING AND TRAINING
Fit of Socket
Myoelectrode Position
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PHASES OF CARE
• Preprosthetic Management
• Prosthetic Training
o Prosthesis: non-dominant role, assists sound limb
• Lacks sensation and fine motor control
o Encourage RELAXED posture
• Minimizes compensatory motions and inadvertent co-contraction
o With comprehensive training, most patients can become independent in all functional activities
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PROSTHETIC TRAINING
• Communication with Prosthetist
• Independent donning and doffing
• Changing terminal devices
• 3 Phases of Prosthetic Training
- Basic Control
- Gaining Control
- Bi-manual Skills Training
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DONNING PROSTHESIS
53
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CHANGING TERMINAL DEVICE
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PROSTHETIC TRAINING
• Communication with Prosthetist
• Independent donning and doffing
• Changing terminal devices
• 3 Phases of Prosthetic Training
- Phase 1: Basic Control
- Phase 2: Gaining Control
- Phase 3: Bi-manual Skills Training
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PROGRESSION OF TREATMENT
• Begin in sitting with tasks at midline.
• Progress to right/left of midline, overhead, close to
ground
• Standing
• Walking / dynamic activities
Encourage normal movement patterns and watch
for compensatory motions.
To Challenge Patient…
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PHASE 1: BASIC CONTROL
Mirroring
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PHASE 1: BASIC CONTROL
POSSIBLE SOURCES OF DIFFICULTY
• Co-contraction of muscles
• Improper fit of socket
• Gains may need to be adjusted
DO NOT PROCEED UNTIL PATIENT HAS MASTERED THESE
MANEUVERS.
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PHASE 2: GAINING CONTROL
UNILATERAL ACTIVITIES to master 3 control skills:
• Prepositioning of terminal device (TD)
• Proportional control
• Opening width
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PHASE 2: GAINING CONTROL
PREPOSITIONING of terminal device (TD)
• Placing the terminal device in the most optimal
position before initiating grasp/release.
• Minimizes compensatory movements at the trunk,
shoulder and elbow.
• Reduces unnecessary or awkward movements.
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PHASE 2: GAINING CONTROL
Compensatory Movement
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PHASE 2: GAINING CONTROL
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PHASE 2: GAINING CONTROL
UNILATERAL ACTIVITIES to master 3 control skills:
• Prepositioning of terminal device (TD)
• Proportional control
• Adjust opening width
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PHASE 2: GAINING CONTROL
PROPORTIONAL CONTROL: Precise control of TD
• Strong muscle contraction fast grasp
• Light muscle contraction slow, delicate grasp
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PHASE 2: GAINING CONTROL
Prehension Control
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GOALS IN PHASE 2: GAINING CONTROL
• Master each control skill independently
o Prepositioning
o Prehension Control
o Opening width
• Then, practice applying these skills simultaneously.
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PHASE 3: BI-MANUAL SKILLS TRAINING
• The longest and most challenging phase of prosthetic
training.
• Patient directed. Use checklist to identify goals that are
important and meaningful to the patient.
• Allow patient to problem solve. Intervene only as needed.
• As therapists, we may learn more from our patients than
we may be able to teach them.
• Repetition and practice. Takes time to learn a new way
of doing things.
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© 2015 Hanger ClinicSource: Journal of Hand Therapy 2008; 21:160-176 (DOI:10.1197/j.jht.2007.09.006 )
Copyright © 2008 Terms and Conditions
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BI-MANUAL FUNCTIONAL SKILLS TRAINING
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PRACTICE
• Tying shoelace
• Opening a tube of toothpaste
• Using scissors to cut paper
• Zipping a jacket
• Donning socks
• Buckling a belt
• Applying a Band-Aid®
• Cutting food
• Using a fork and knife
• Folding towels
• Buttering bread
• Stirring (in a bowl)
• Opening and closing various packages, boxes, containers and jars.
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TYING SHOE LACES (ETD)
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THE SHAPE OF SUCCESS
Patient
S
U
C
C
E
S
S
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REFERENCES
• Smurr, Lisa M; Gulick, K; Yancosek, K; Ganz, O, (2008). Managing the Upper Extremity Amputee: A Protocol for Success. J of Hand Therapy, 21(2), 160-176.
• Smurr, L., Yancosek, K., Gulick, K., Ganz, O., Kulla, S., Jones, M., Ebner, C., Esquenazi, A. (2009). Occupational therapy for the polytraumacasualitywith limb loss. In P.F. Pasquina& R.A. Cooper (Eds.), Care of the Combat Amputee, Textbooks of Military Medicine (pp. 493-533). Washington D.C: Borden Institute, Walter Reed Army Medical Center.
• Wise, M, (2007). Rehabilitation for persons with upper extremity amputation. In M.M. Lusardi& C.C. Nielsen (Eds.), Orthotics and Prosthetics in Rehabilitation (pp. 859-874). St. Louis, Mo.: Saunders/Elsevier.
• Keenan, D. D., & Glover, J.S. (2013). Amputations and Prosthetics. In L.W. Pedretti, H. M. Pendleton, & W. Krohn (Eds.), Pedretti’sOccupational Therapy: Practice Skills for Physical Dysfunction (7th ed., pp. 1149-1193). St. Louis, MO: Mosby/Elsevier.
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THANK YOU!!