Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_921_Библиотеки_им_академика_М_И_Перельмана
.pdf
Section 2: Upper Limb
(and understand) how to best design
the socket.
Certain commonly accepted socket
designs, such as X-frames for shoulder
disarticulation fittings, may not have
enough material to cover the area and
EMG sites resulting from TMR
12-15
(Fig-
ure 2). Traditional myoelectric prostheses are designed with two electrode sites.
After TMR, at least four sites should be
available. In these cases, greater surface
coverage of the socket may be necessary to capture the reinnervated sites
over areas such as the pectoralis major,
latissimus dorsi, and serratus anterior
muscles.
It has been noted that in both transhumeral and shoulder disarticulation
limbs, substantial movement occurs
in particular areas of superficial tissue overlying reinnervated muscle
1-9,12
sites
Figure 2
der disarticulation socket with trim lines
insucient to cover the newly created electromyographic sites. (Courtesy of Rehabilitation
Institute of Chicago, Chicago, IL.)
(Figure 3). Such movement is
Clinical photograph of a shoul-
problematic because the electrode poles
must maintain surface contact with the
soft tissue to prevent inadvertent move
ment of the prosthesis. Sockets may
need to be modified for a tighter fit over
these regions or, alternatively, utilize a
concept where both the socket and the
electrodes over this area can move and
still maintain contact with the skin surface.12 In addition to the movement of
superficial tissues, subcutaneous muscle
may shift during contraction. This may
occur because the newly targeted muscle
did not undergo myodesis or myoplasty
during the initial amputation surgery.
Alternatively, during TMR, the origin
of the muscle may not have been detached, allowing for a “floating muscle
belly.” Because this muscle with only
a proximal attachment is reinnervated,
a contraction makes the muscle move
proximally toward its origin.9 In these
instances, it may be necessary to install
the electrodes quite proximally on the
socket. Remote electrodes may be necessary because a packaged electrode may
not fit into this region of the socket. An
additional advantage of using remote
electrodes is that during the test socket
fitting stage, these metal domes can be
easily relocated to achieve a more preferential EMG signal acquisition location.
12
Transhumeral Fittings
Originally designed for individuals
with a transhumeral amputation, TMR
allows more natural and intuitive operation of myoelectric prostheses. In the
first few individuals with transhumeral
amputations treated with TMR surgical procedures, the distal radial nerve
was transferred to the brachialis muscle16 (Figure 4). Although the nerve
reinnervation proved successful, some
difficulty in prosthetic design occurred
because the lateral-distal location of this
site proved challenging for consistent acquisition of EMG signals. The two main
reasons for this challenge are as follows:
(1) The distal location of the reinnervated site required that the electrode
be quite distal within the socket, and
(2) any distal migration of the socket
with respect to the muscle site and/
or soft tissue during loading (whether
because of gravity or other axial loads)
made it difficult for the user to operate
the prosthesis. In addition, when the
user attempted to operate the prosthesis
in abduction, the distal electrode site
would experience pressure against the
lateral distal humerus because of the
force couple created by the weight of the
prosthesis leveraging the transhumeral
socket. In both scenarios, inadvertent
signals of hand opening would occur
and either open the prosthetic hand or
prevent it from closing, producing undesired results.
Since these first initial fittings, the
standard surgical procedure for TMR for
individuals with a transhumeral amputation has changed to include coapting
the distal radial nerve to the lateral head
of the triceps17 (Figure 5). This change
improved the success of the subsequent
Figure 3
in a patient after targeted muscle reinnervation. A, Relaxed. B, Hand close. C, Elbow up. (Courtesy of Rehabilitation Institute of Chicago, Chicago, IL.)
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
342
Clinical photographs of soft-tissue movements of the transhumeral residual limb associated with generating various control signals
Chapter 28: Targeted Muscle Reinnervation: Prosthetic Management
Figure 4
placement over the reinnervated brachialis
muscle by the distal radial nerve, which is used
for the hand opening signal. The distal location
can compromise the consistency of this muscle
as a control signal. (Courtesy of Rehabilitation
Institute of Chicago, Chicago, IL.)
Clinical photo graph of electro de
prosthetic fittings. With the natively innervated long and medial heads of the
triceps available for physiologic control
of elbow extension, the reinnervated
lateral head of the triceps can be used
for intuitive control of the hand opening signal. In addition, the ulnar nerve
is transferred to the brachialis muscle
for potential use as a single site for controlling the electronic wrist rotator.
As mentioned previously, skilled
prosthetists have their own methods of
socket design and myosite selection. This
chapter’s author believes that the signals
obtained from the proximal aspect of the
long head of the triceps, which is located
medially and posteriorly just distal to the
axillary level, are the most promising
control inputs for elbow extension because of the natural lack of adipose tissue
covering the long head of the triceps in
this region. The antagonistic muscle is
the native innervation of the long head
of the biceps, which controls elbow
flexion. Myosite selection is analogous
Figure 5
cle, reinner vated by the distal radi al nerve and used for th e hand opening signal (HO) an d the elbow
down (ED) signal. (Courtesy of Rehabilitation Institute of Chicago, Chicago, IL.)
to that of traditional myoelectric fittings
with the exception of now having two
pairs of antagonistic actions from which
to differentiate EMG signals. Because it
is necessary to locate the reinnervated pair of antagonistic muscle actions,
palpating for distinct muscle contraction is imperative. The lateral head of
the triceps should now contract when
the individual is asked to open his or
her hand, whereas the short head of the
biceps should contract when the individual is instructed to close his or her
hand. Because of the close proximity of
these reinnervated muscles to the adjacent muscle heads, it is often challenging to isolate these signals. As previously
mentioned, although adipofascial flaps
have been surgically created to separate
the muscles (signals),
must be spent to adjust the signal parameters (for example, gains, thresholds, and
motor speeds) to optimize signal separation and control of the intended action.
Training an individual with a transhumeral prosthesis after TMR is easier
if the user has not had substantial previous myoelectric experience, where the
necessary substitution of nonphysiologic
muscle signals was ingrained into his or
her thought control process. Users with
prior myoelectric experience will have
Clinical photo graph of electrode p lacement over the lateral head o f the triceps mus-
to “unlearn” many of the previous strategies for controlling the elbow and hand
10,11
motors.
After TMR, the native muscles will control their intended movements of elbow flexion and extension.
Users should now be able to activate
hand closing and opening signals by
sending nerve signals to reinnervated
muscles by means of natural thought
processes.
Control of the wrist motor may be
less intuitive. As with more traditional
myoelectric fittings, the wrist motor may
be controlled by the same signals that
open and close the hand. This can be
accomplished through a distinct mode
selection switch or through a control
scheme that involves differentiation between a slow-soft or fast-hard onset of
8,17
additional time
the input muscle signal to select the motor being driven (that is, the hand or the
wrist). In a third strategy, wrist rotation
may be activated by a separate switch
integrated within a control harness,
which permits simultaneous control of
the three prosthetic joint components.
Regardless of the strategy chosen, it will
be less intuitive than direct, native myoelectric signals.
Changing the grasp patterns in multiarticulating hands also requires some
form of mode selection. Although the
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
343
Section 2: Upper Limb
Figure 6
with a shoulder disarticulation who is generating electromyographic signals for nger movement and hand grasp in response to observed
hand and nger movements being performed
by the treating prosthetist. (Courtesy of Rehabilitation Institute of Chicago, Chicago, IL.)
Clinical photograph of a man
individual with either a transhumeral
amputation or a shoulder disarticulation
may feel that he or she can differentiate
finger movements (Figure 6) or hand
grasp patterns with reinnervated muscles, the electronics within the various
systems cannot recognize the subtle
differences in these input contractions
or relay these varied signals to the multiarticular hand to both change the grasp
pattern and perform the desired action.
Rather, the grasp pattern must be se
lected by using the EMG signals for the
hand. Switching strategies available in
multiarticular hands include co-contraction, double impulse, and triple impulse
switching signals. After the grasping
strategy has been selected, the signal
to close or open the hand within the
newly selected hand grasp pattern may
be used. The option of using a dual-site
multistate control strategy, such as a
slow-soft/fast-hard strategy described
earlier for both the hand and the wrist
control, is likely nullified in the case of
multiarticulating hands because of the
necessity to use hand EMG signals to
switch hand grasp patterns.
Shoulder Disarticulation
Fittings
Although TMR was originally intended
for individuals with transhumeral amputations, the first TMR was performed
Figure 7
nerves. Coaptations of the ulnar and radial nerves are more patient specic. (Courtesy of Rehabilitation Institute of Chicago, Chicago, IL.)
on an individual with bilateral shoulder
disarticulation.
chosen because the optimal circumstances presented themselves: viable
nerves and muscles, revision surgery al-
-
ready planned, and a candidate who had
proven compliant use with a high-level
prostheses and could comprehend the
surgical technique and outcomes. These
circumstances are important factors
when evaluating candidates for TMR and
prosthetic fitting. Similar to individuals
with transhumeral amputations, the goal
of the procedure is to allow individuals
with shoulder disarticulations to operate
myoelectric prostheses with more natural and intuitive control, with the hope
of improving both the outcome and the
desire to wear the prosthesis.
main difference for non-TMR shoulder
disarticulation fittings is that no native
muscles with physiologically analogous
motions to prosthetic actions are being
used. Firing of the pectoralis and trapezius muscles does not naturally correlate with arm movements. Similarly,
the gross body motions (shoulder protraction, elevation, and retraction) used
Illustration of standard nerve coaptations of the musculocutaneous and median
to activate control inputs such as force
1-4,7
This candidate was
sensing resistors, cable pull switches, or
electronic “first-class lever” switches are
not natively associated with movements
of the upper limb.
The TMR procedure for shoulder
disarticulations has also varied greatly. The two most common nerves and
sites for reinnervation are the musculocutaneous nerve and the median nerve
to the clavicular head and sternal head
(upper portion) of the pectoralis major
muscle, respectively.8 The musculocutaneous nerve/site is responsible for
elbow flexion and will be located just
inferior to the clavicle. This positioning
provides for a good signal because of its
proximity to the clavicle itself, but it has
1-4,7-9
The
various complications as any site near a
bony prominence would have. Median
nerve reinnervation is used for the signal
to close the hand (Figure 7). Beyond
these two coaptations, the remaining
peripheral nerves of the brachial plexus may be transferred to any number
of sites, depending primarily on which
skeletal, muscular, and neural structures
remain after amputation. For example,
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
344
Chapter 28: Targeted Muscle Reinnervation: Prosthetic Management
Figure 8
control signals in a patient after targeted muscle reinnervation. Note the dierences in the orientation of both the “marked” electromyographic sites
and the skin underlying the soft tissue when the individual is relaxed (A), and during muscle contraction for hand opening (B) and hand closing (C).
(Courtesy of Rehabilitation Institute of Chicago, Chicago, IL.)
if the surgical procedure was not a true
shoulder disarticulation but a humeral
neck amputation, the proximal aspect of
the radial nerve may still be innervating
the proximal aspect of the triceps and/
or the axillary nerve may still be innervating the posterior deltoid. In these patients, one of these sites may be used for
elbow extension. Thus, the distal radial
nerve may be coapted to the latissimus
dorsi muscle or the sternal head (lower
portion) of the pectoralis major muscle
for use with hand opening signals. Another approach may be to use the ulnar
nerve reinnervation as the hand-open
site. In the first TMR preformed, the
ulnar nerve was coapted to the pectoralis minor muscle, which was drawn
out from behind the pectoralis major
muscle and sustained laterally. Another
approach is to attach the entire radial
nerve to the serratus anterior muscle to
control elbow extension and/or hand
opening.8 This option is preferred when
performing TMR on female patients
because it will minimize disruption to
breast tissue.
Many challenges arise with these alternative sites, including the fact that
the serratus anterior muscles are used
frequently in postural control, which
may result in unwanted signals during
certain activities.
both the amputation and TMR occur on
the left side of the body, cardiac signal
Clinical photographs of soft-tissue movements of the shoulder disarticulation residual limb associated with the generation of various
19-21
In
In addition
1-6,8,12
After the TMR procedure and the
reinnervation period, site selection will
occur in a similar, methodical procedure. Once again, minimal retraining
of the mind is necessary unless users
have had substantial experience using
their innate pectoralis and latissimus
dorsi muscles for prosthetic control.
Because these two muscles—and possibly others—have been reinnervated
with signals that correspond to elbow
flexion/extension, hand close/open, and
wrist pronation/supination, these are
the thoughts and actions that the user
should be performing to contract the
newly innervated sites rather than substituting nonphysiologic movements for
the aforementioned actions.
10-12
Site selection should begin on the basis of the
nerves that have been used and the areas
of the body to which they have been
coapted. The actions that the user is
prompted to perform by the prosthetist
or the therapist should begin with the
basic (gross) movements of elbow flexion and extension, wrist pronation and
supination, and opening and closing of
the hand. It is advised not to attempt a
different set of actions until substantial
testing and training have occurred.
Ultimately, the movement visualized by
the user may be a variant of one of these
basic motions, a combined movement,
or another action that is innervated by
10-12
8,18
12,18
In addition, when
interference must be considered.
such cases, electrodes with modified filtering may be necessary. As described
with the transhumeral fittings, regardless of the surgical technique, it is crucial for the prosthetist and the therapist
to obtain a report that identifies the
nerves that were transferred and the
locations to which they were coapted.
Socket designs for shoulder disarticulation fittings after TMR must incorporate all the electrode sites created
from the surgical procedure. Changes
in the prosthetist’s style of fitting may
be necessary to envelope these areas.
Frame type (perimeter) sockets generally have more surface area inherent in
their designs compared with microframe or X-frame designs.
13-1 5
to accommodations for breast tissue in
females, some changes to these designs
may be necessary, including adding a
bladder or adjustable pressure components to ensure that the electrodes
maintain contact with the skin and
other electrodes during contraction.18
As with transhumeral limbs, tissue in
the area of the shoulder disarticulation
reinnervation can move quite substantially during muscle contractions
(Figure 8). Maintaining good skin contact is crucial for sound myoelectric
control and may be even more difficult
to achieve after a TMR procedure.
that targeted nerve/muscle location. For
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
345
Section 2: Upper Limb
example, spreading the fingers may provide a more distinct and isolated signal
for hand opening than a more passive
hand opening attempt. As mentioned
previously, consistency in the method
and magnitude of muscle contractions is
of utmost importance to reliable, sound,
isolated prosthetic performance. After
the particular movement strategy has
been selected and adjusted for in the
software, it should remain the strategy
that the user performs when movement
of the prosthesis is desired.
Similar to the transhumeral amputation, additional inputs may be
needed to control the wrist rotator and
to change the grasp pattern in multiarticular hands. Methods of mode selection may be somewhat analogous to
those described in the management of
transhumeral amputation (for example, EMG-based switching strategies or
the use of electromechanical switches).
After TMR, fewer, if any, native sites
exist that the user must control, thus
making switching more challenging.
Although using reinnervated muscles
for either co-contraction, quick impulses, or slow-soft/fast-hard strategies may
be more difficult, they are nonetheless
worth exploring. Individuals with externally powered prostheses generally
prefer using EMG signals to control motors because it is much easier and more
intuitive than performing gross body
movements.
Application of
Technological
Advancements
Since the inception of TMR, technological advancements have continued
to meet the needs of both the user and
the prosthetist. Many of these changes
relate to the ability to incorporate a
greater number of EMG inputs and adjustments to a system. All of the leading manufacturers of electronic elbow
systems (Liberating Technologies, Otto
Bock HealthCare GmbH, and Motion
Control) have developed advanced
products that meet the requirements
of TMR. In addition, work has started
at many other institutions to enhance
the prosthetic outcomes of individuals
who have undergone amputations. The
advantages from emerging technologies
such as pattern recognition and sensory feedback combined with externally
powered prosthetics have created direct
benefits for TMR recipients.
22-32
Pattern Recognition
Although pattern recognition for myoelectric control is not a new concept,
the commercial availability of such a
product is currently in its infancy. Pattern recognition has many uses and
complex variables.
22-25
In the context of
myoelectric prostheses, pattern recognition or advanced pattern recognition are
the terms used to describe a method by
which all EMG signals being collected
are analyzed, resulting in a single decision for how the prosthesis should move
(or not move). The result of this decision
is often referred to as the classifier. Examples of classifiers are elbow flexion,
hand opening, and no movement.
A major benefit of pattern recognition is that the isolation of muscles, although it may improve classification, is
not necessary to distinguish one intended movement from another. Even for antagonistic muscle groups, coactivation of
muscles may provide a distinct pattern
that can be classified as a particular
movement of the prosthesis. A simple
example may be present in a dual-site
myoelectric system, where an individual
can isolate his or her biceps EMG signals
for an elbow flexion signal, but when he
or she attempts to provide isolated triceps EMG signals for extension of the elbow, unintentional coactivation of both
biceps and triceps EMG signals occurs.
In traditional myoelectric systems, even
with adjustments to thresholds, gains,
and the control strategy, the prosthetic
elbow might not consistently extend
because the coactivation may compromise the signal output such that it is not
clean enough to represent an isolated elbow extension signal. Suppose, instead,
that the isolated EMG signal from the
biceps was used for elbow flexion, and
the “combined signals” from the biceps
and triceps coactivation were used for
elbow extension. Controlling the prosthesis in this manner is plausible when
a pattern recognition control algorithm
is used, which substantially reduces the
burden on the user to isolate distinct
muscle signals as well as decreases the
prosthetist’s time for adjusting settings
and strategies.
TMR has created an increased number of EMG sites and, thus, an increased
set of data from which to draw.25 Earlier, it was explained that although the
surgical procedure proved effective,
prosthetic control may still be difficult
because of the coactivation of muscles
with synergistic actions. The application
of pattern recognition can help eliminate this signal confusion because it collectively examines all the signals before
deciding how the prosthesis should or
should not move. If powered shoulder
units become commercially available, it
is quite feasible that these movements
will be added to the classifiers of the
pattern recognition algorithms.
One key to pattern recognition
control is analogous to that of all myoelectric prostheses: consistency in signal
intent and level. The user must create
the same pattern and level of contraction
to control the prosthesis as when these
classifiers were created. An additional
feature of the pattern recognition controllers available from Coapt LLC (Fig-
ure 9) is that the user can recalibrate
the system whenever he or she thinks
that the prosthesis is not responding
to current EMG signals. Similarly, recalibration can be performed when the
user wishes to add multiple classifier
settings for times when the prosthesis
may be used in different positions or
for different tasks. With this feature,
the user does not need the prosthetist
to alter the settings within the graphic
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
346
Chapter 28: Targeted Muscle Reinnervation: Prosthetic Management
Figure 9
wiring, and calibration switch to p ermit the user to recalibrate s ettings without having to se e his or
her prosthetist. (Courtesy of Rehabilitation Institute of Chicago, Chicago, IL.)
interface and system; the user can simply recalibrate the settings by donning
the prosthesis, pushing the button to
recalibrate the settings, and providing
signals to the prosthesis while following
a predefined sequence of movements.
The microprocessor within the prosthesis automatically uses the new data to
redefine the user’s settings to the current
signal classifiers that were just provided.
Although pattern recognition has
proven to be a very powerful tool in
the prosthetist’s arsenal, it still has some
limitations. With traditional control, us-
Photograph of the Coapt LLC pattern recognition system with controller, electrode
pattern recognition classifiers. As in traditional control, the user is required to
perform hand grasp selection by means
of the hand EMG signals previously described. However, co-contraction can no
longer be used because it now may be
recognized as a particular classifier for
another motor movement. It is the opinion of the author of this chapter that this
limitation will be overcome when the
manufacturers of multiarticular hands
and pattern recognition software begin
to work together to permit direct hand
grasp selection.
ers who have had TMR can simultaneously control two or more motors with
EMG signals alone. This action is feasible with pattern recognition control but
generally only in the research setting;
simultaneous control of multiple motors
by means of EMG signals is not a current
feature of commercially available systems. There are still questions regarding
the necessity of this function. Since the
inception of TMR, users have had the
ability to move multiple motors simultaneously, but they have infrequently
used this advantage spontaneously. In
addition, the frequency at which the
pattern recognition software analyzes
the signals is such that the transition
from one action to another may appear
seamless.
Another current limitation is the inability to change the grasp patterns of
multiarticular hands by using only the
Sensory Feedback
The advent of terminal devices (and
systems) that provide refined sensory
feedback are another advancement in
powered prosthetics that will prove
highly beneficial to TMR recipients.
Forms of sensory (also known as haptic) feedback to the prosthesis user have
been explored for many years, but most
of these applications remain confined
to the research setting.
26 -33
Stimuli have
been applied to the residual limb or
other parts of the body to relay senses
of force, pressure, vibration, or simulated temperature. The difference for individuals with TMR is that, although the
stimulus will still be over the residual
limb, it will provide signals to the brain
that the stimulus is elsewhere (for example, in the missing hand) because sensory reinnervation has spontaneously
Figure 10
nervation that spontaneously arose from the
motor reinnervation of the pectoralis region
in a patient with a shoulder disarticulation and
targeted muscle reinnervation. Sensory nerves
grew to the surface of the patient’s chest so
that when certain stimuli were given, the signals were felt in the missing hand. (Courtesy of
Rehabilitation Institute of Chic ago, Chicago, IL.)
occurred in some TMR recipients.
Illustration of sensory rein-
8,32
Sensory nerves have grown to the surface of the skin in several TMR recipients and have since become a planned
part of the surgery. Nerve patterns, often
replicating those of normal dermatomes,
have developed in the residuum. For example, in the first TMR recipient with
a shoulder disarticulation and TMR to
the left pectoralis region, sensory nerves
grew to the surface of the patient’s chest
so that when certain stimuli were given, the signals were felt in the missing
hand.32 This is clearly different from previous work because now the feedback
from the prosthesis is perceived in the
user’s hand versus pressure on the resid
ual limb (Figure 10). With the refined
work on tactile elements for prosthetic
hands that is now occurring worldwide,
the benefits for TMR recipients may be
dramatic. Many in the field of prosthetics believe that a direct sensory link is
the missing variable for greater acceptance and use of upper limb prostheses.
-
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
347
Section 2: Upper Limb
Figure 11
voluntary control of knee exion in a virtual human while using an EMG pattern recognition classier. (Courtesy of Rehabilitation Institute of Chicago, Chicago, IL.)
It is yet to be proven if a direct sensory
link is truly the case, but there is a possibility of such a link in the future.
Clinical photograph of a woman with a transfemoral amputation demonstrating
and internal and external rotation of the
lower leg in virtual reality
38-40
(Figure
11). These achievements have been accomplished by incorporating electrodes
Lower Limb Fitting
Several variables distinguish TMR of
the lower limb from the upper limb.
Although the benefits of preventive neuroma management
both appendages, the use of lower limb
TMR for this benefit has superseded its
applicability for prosthetic control compared with upper limb TMR. Studies
have proven that the lower limb, most
notably the thigh, has important motor
points to which the nerves could be reinnervated.34 To date, few powered lower limb components are available, and of
those available, limited benefit exists for
EMG data that may be generated from
lower limb TMR.
viduals with transfemoral amputations
have generated EMG data to effectively
34 -36
may be applied to
37-4 0
However, indi-
within the user’s socket (Figure 12) and
using pattern recognition algorithms to
interpret the EMG data in both TMR
and non-TMR recipients.
37-4 0
One individual with TMR of the posterior thigh
with a knee disarticulation was tested
with a powered lower limb prosthesis
ambulating over level ground, up and
down ramps, and up and down stairs.
It was found that the classification accuracy was greater for this individual
with TMR compared with the non-TMR
participants who had been tested.39 As
advancements in powered lower limb
prostheses continue and transition to
true myoelectrically controlled devices,
the potential for lower limb TMR to enhance the prosthetic control of these devices will increase accordingly.
flex and extend the knee and plantarflex and dorsiflex the ankle in powered
prostheses, with the added control of
internal and external rotation of the hip
Summary
Fitting myoelectric prostheses can be
challenging because of the lack of a
Figure 12
socket with remote electrodes incorporated to
collect electromyographic data while the user
is ambulating with the prosthesis. (Courtesy of
Rehabilitation Institute of Chic ago, Chicago, IL.)
Photograph of a transfemoral
direct correlation between the remaining EMG source(s) from the user and
the actions required by the device. The
addition of a TMR procedure enables
some individuals with amputations to
have physiologically appropriate signals
and additional data available to control
the multiple motions of their prostheses.
The prosthetist should have a thorough
understanding of myoelectric control
and the additional benefits of TMR to
provide successful fittings. The prosthetist and entire rehabilitation team must
be familiar with the different fitting and
training strategies that can be used for
TMR candidates. TMR, in conjunction
with traditional EMG control, has enhanced control of transhumeral and
shoulder disarticulation prostheses. In
the future, the development of advanced
pattern recognition control and sensory reinnervation will likely add to the
benefits of this surgical procedure and
improve outcomes for users of upper
and lower limb myoelectric prostheses.
References
1. Kuiken TA, Dumanian GA, Lipschutz RD, Miller LA, Stubbleeld
KA: e use of targeted muscle reinnervation for improved myoelectric
prosthesis control in a bilateral
shoulder disarticulation amputee.
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
348
Chapter 28: Targeted Muscle Reinnervation: Prosthetic Management
Prosthet Orthot Int 2004;28(3):245-
253. Medline
2. Kuiken T: Targeted reinnervation for
improved prosthetic function. Phys
Med Rehabil Clin N Am 2006 ;17(1):1-
13. Medline DOI
3. Lipschutz R, Kuiken T, Miller LA,
Dumanian GA, Stubbleeld KA:
Shoulder disarticulation externally
powered prosthetic tting following
targeted muscle reinnervation for improved myoelectric control. J Prosthet
Orthot 2006;18(2):28-34. DOI
4. Hijjawi JB, Kuiken TA, Lipschutz RD,
Miller LA, Stubbleeld KA, Dumanian GA: Improved myoelectric
prosthesis control accomplished
using multiple nerve transfers. Plast
Reconstr Surg 2006;118(7):1573-1578.
Medline DOI
5. Miller LA, Lipschutz RD, Stubbleeld
KA, etal: Control of a six degree of
freedom prosthetic arm aer targeted
muscle reinnervation surgery. Arch
Phys Med Rehabil 2008;89(11):2057-
2065. Medline DOI
6. Kuiken TA, Li G, Lock BA, etal:
Targeted muscle reinnervation for
real-time myoelectric control of
multifunction articial arms. JAMA
2009;301(6):619-628. Medline DOI
7. Kuiken T: e scientic basis of
targeted muscle reinnervation, in
Kuiken T, Schultz-Feuser A, Barlow
A, eds: Targeted Muscle Reinnerva-
tion: A Neural Interface for Articial
Limbs. Boca Raton, FL, CRC Press,
2013, pp 9-20. DOI
8. Dumanian G, Souza J: Surgical techniques for targeted muscle reinnervation, in Kuiken T, Schultz-Feuser
A, Barlow A, eds: Targeted Muscle
Reinnervation: A Neural Interface for
Articial Limbs. Boca Raton, FL, CRC
Press, 2013, pp 21-44. DOI
9. Kuiken T: Rehabilitation of the
targeted muscle reinnervation
patient, in Kuiken T, Schultz-Feuser
A, Barlow A, eds: Targeted Muscle
Reinnervation: A Neural Interface for
Articial Limbs. Boca Raton, FL, CRC
Press, 2013, pp 67-76. DOI
10. Stubbleeld K, Kuiken T: Occupational therapy for the targeted muscle
reinnervation patient, in Kuiken T,
Schultz-Feuser A, Barlow A, eds:
Targeted Muscle Reinnervation: A
Neural Interface for Articial Limbs.
Boca Raton, FL, CRC Press, 2013, pp
99-120. DOI
11. Stubbleeld KA, Miller LA, Lipschutz RD, Kuiken TA: Occupational
therapy protocol for amputees with
targeted muscle reinnervation.
JRehabil Res Dev 2009;46(4):481-488.
Medline DOI
12. Miller L, Lipschutz R: Prosthetic tting before and aer targeted muscle
reinnervation, in Kuiken T, Schultz-Feuser A, Barlow A, eds: Targeted
Muscle Reinnervation: A Neural
Interface for Articial Limbs. Boca
Raton, FL, CRC Press, 2013, pp 77-98.
DOI
13. Miguelez J, Miguelez M: e Microframe: e next generation of
interface designs for glenohumeral
disarticulation and associated levels
of limb deciency. J Prosthet Orthot
2003;15(2):66-71. DOI
14. Sauter W: Experience with electrically powered and myoelectric control
systems in upper extremity prosthetics in children and adults. Med
Orthop Tech 1992;112:13-16.
15. Farnsworth T, Uellendahl J, Mikosz
MJ, Miller L, Petersen B: Shoulder region socket considerations. J Prosthet
Orthot 2008;20(3):93-106. DOI
16. O’Shaughnessy KD, Dumanian GA,
Lipschutz RD, Miller LA, Stubbleeld
K, Kuiken TA: Targeted reinnervation to improve prosthesis control
in transhumeral amputees: A report
of three cases. J Bone Joint Surg Am
2008;90(2):393-400. Medline DOI
17. Dumanian GA, Ko JH, O’Shaughnessy KD, Kim PS, Wilson CJ,
Kuiken TA: Targeted reinnervation for transhumeral amputees:
Current surgical technique and
update on results. Plast Reconstr Surg
2009;124(3):863-869. Medline DOI
18. Kuiken TA, Miller LA, Lipschutz
RD, et al: Targeted reinnervation for enhanced prosthetic arm
function in a woman with a proximal amputation: A case study.
Lancet 2007;369(9559):371-380.
Medline DOI
19. Zhou P, Kuiken TA: Eliminating
cardiac contamination from myoelectric control signals developed
by targeted muscle reinnervation.
Physiol Meas 2006;27(12):1311-1327.
Medline DOI
20. Zhou P, Lock B, Kuiken TA: Real
time ECG artifact removal for
myoelectric prosthesis control.
Physiol Meas 2007;28(4):397-413.
Medline DOI
21. Hargrove L, Zhou P, Englehart K,
Kuiken TA: e eect of ECG interference on pattern-recognition-based
myoelectric control for targeted muscle reinnervated patients. IEEE Trans
Biomed Eng 2009;56(9):2197-2201.
Medline DOI
22. Englehart K, Hudgins B: A robust,
real-time control scheme for multifunction myoelectric control. IEEE
Trans Biomed Eng 2003;50(7):848-
854. Medline DOI
23. Parker P, Englehart K, Hudgins
B: Myoelectric signal processing
for control of powered limb prostheses. JElectromyogr Kinesiol
2006;16(6):541-548. Medline DOI
24. Hargrove LJ, Li G, Englehart KB,
Hudgins BS: Principal components
analysis preprocessing for improved
classication accuracies in pattern-recognition-based myoelectric
control. IEEE Trans Biomed Eng
20 09;56(5):14 07-1414. Medline DOI
25. Hargrove L, Lock B: Future research
directions, in Kuiken T, Schultz-Feuser A, Barlow A, eds: Targeted
Muscle Reinnervation: A Neural
Interface for Articial Limbs. Boca
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
349
Section 2: Upper Limb
Raton, FL, CRC Press, 2013,
pp 165-184. DOI
26. Wurth SM, Hargrove LJ: A real-time
comparison between direct control,
sequential pattern recognition control and simultaneous pattern recognition control using a Fitts’ law style
assessment procedure. JNeuroeng
Rehabil 2014;11(1): 91. Medline DOI
27. Kuiken TA, Marasco PD, Lock BA,
Harden RN, Dewald JP: Redirection of cutaneous sensation
from the hand to the chest skin
of human amputees with targeted
reinnervation. Proc Natl Acad Sci
U S A 2007;104(50):20061-20066.
Medline DOI
28. Schultz AE, Marasco PD, Kuiken
TA: Vibrotactile detection thresholds for chest skin of amputees
following targeted reinnervation
surgery. Brain Res 2009;1251:121-129.
Medline DOI
29. Marasco PD, Schultz AE, Kuiken
TA: Sensory capacity of reinnervated skin aer redirection of
amputated upper limb nerves to the
chest. Brain 200 9;132(6):1441-1448.
Medline DOI
30. Sensinger JW, Schultz AE, Kuiken
TA: Examination of force discrimination in human upper limb amputees
with reinnervated limb sensation
following peripheral nerve transfer.
IEEE Trans Neural Syst Rehabil Eng
2009;17(5):438-444. Medline DOI
31. Marasco PD, Kim K, Colgate JE, Peshkin MA, Kuiken TA: Robotic touch
shis perception of embodiment to a
prosthesis in targeted reinnervation
amputees. Brain 2011;134(3):747-758.
Medline DOI
32. Marasco P: Targeted sensory reinnervation, in Kuiken T, Schultz-Feuser
A, Barlow A, eds: Targeted Muscle
Reinnervation: A Neural Interface for
Articial Limbs. Boca Raton, FL, CRC
Press, 2013, pp 121-148. DOI
33. Sabolich J, Ortega G: Sense of feel for
lower limb amputees: A phase-one
study. J Prosthet Orthot 1994;6:36-41.
DOI
34. Agnew SP, Schultz AE, Dumanian GA, Kuiken TA: Targeted
reinnervation in the transfemoral
amputee: A preliminary study of surgical technique. Plast Reconstr Surg
2012;129(1):187-194. Medline DOI
35. Ho J, Kim P, Smith, DG: Targeted
muscle reinnervation as a strategy
for neuroma prevention, in Kuiken
T, Schultz-Feuser A, Barlow A, eds:
Targeted Muscle Reinnervation: A
Neural Interface for Articial Limbs,
Boca Raton, FL, CRC Press, 2013, pp
45-66.
36. Cheesborough J, Souza J, Dumanian
GA, Bueno RA Jr Targeted muscle
reinnervation in the initial management of traumatic upper extremity
amputation injury. Hand (N Y)
2014;9(2):253-257. Medline DOI
37. Huang H, Kuiken TA, Lipschutz RD:
A strategy for identifying locomotion
modes using surface electromyography. IEEE Trans Biomed Eng
2009;56(1):65-73. Medline DOI
38. Hargrove LJ, Simon AM, Lipschutz
RD, Finucane SB, Kuiken TA: Real-time myoelectric control of knee
and ankle motions for transfemoral
amputees. JAMA 2011;305(15):1542-
1544. Medline DOI
39. Hargrove LJ, Simon AM, Young
AJ, et al: Robotic leg control with
EMG decoding in an amputee with nerve transfers. N Engl
J Med 2013;369(13):1237-1242.
Medline DOI
40. Hargrove LJ, Simon AM, Lipschutz
R, Finucane SB, Kuiken TA: Nonweight-bearing neural control of a
powered transfemoral prosthesis.
JNeuroeng Rehabil 2013;10(1):62.
Medline DOI
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
350
Chapter 29
Upper Limb Prosthetic Training
and Occupational erapy
Sandra Fletchall, OTR/L, CHT, MPA, FAOTA
Abstract
To assist an individual with upper limb loss in improving functional performance and the
ability to return to work, the occupational therapist should provide services for preprosthetic
and postprosthetic programs. e preprosthetic program is focused on edema and pain
reduction, wound care, general strengthening, and gaining specic personal care skills.
e postprosthetic program begins with delivery of a device and progresses to training in
activities of daily living and work skills important to a particular user.
Keywords: occupational therapy; upper limb amputation; upper limb
outcomes; upper limb prosthetic training
Introduction
More than 80% of upper limb amputations in the United States are performed
after a traumatic injury.1 The remaining
upper limb amputations are necessitated
by a congenital deficiency or a medical
condition such as end-stage renal disease
or cancer. Four times as many men as
women undergo upper limb amputation,
and most patients are 15 to 30 years old.
The loss of an upper limb at any level
influences the ability to participate in
tasks and other activities. According to
the American Medical Association, amputation of a single digit leads to hand
impairment of 20% to 40%.3 The loss
of an upper limb below the elbow can
lead to 70% impairment, and shoulder
disarticulation causes as much as 90%
impairment. Upper limb loss at any
level, especially if it is the result of trauma, can also lead to a change in roles
within the family, home, community,
and work environments. A structured
occupational therapy program can
Neither Ms. Fletchall nor any immediate family member has received anything of value from or
has stock or stock options held in a commercial company or institution related directly or indirectly
to the subject of this chapter.
facilitate an individual’s efforts to develop skills for returning to his or her highest level of functional independence.
Preprosthetic Therapy
Because of the traumatic nature of most
upper limb amputations, it is usually
not possible to plan a preoperative occupational therapy program. During
2
the short time between the injury and
amputation, patients and their families
often need information on the abilities
and skills that can be acquired after surgery. This information should include a
plan for postoperative, preprosthetic occupational therapy, because all patients
benefit from such therapy immediately
after an amputation.
The literature supports the value
of expediting prosthetic training after
upper limb amputation. In one study,
patients who were fitted and trained
in the use of a prosthesis within 4 to
6 weeks after amputation were found
to be more successful in long-term
prosthesis use than those who received
a later postoperative fitting and delayed training.4 Another study found
that individuals who were fitted within
6 months of amputation were likely to
achieve long-term functional prosthesis
use.5 Preprosthetic training can expedite
the patient’s preparation for prosthetic
fitting and training.
A timely preprosthetic therapy program should focus on the issues of
movement, strength, edema, self-care,
independence, education, and preparation for prosthetic training. An experienced rehabilitation team specializing in
upper limb loss can aid in formulating
a plan for early preprosthetic treatment
and follow-up care. Although instruction in essential movement and strength
is useful even after a prosthesis is fitted
and the training program is well underway, it is advantageous to begin adjustment and adaptation as early as possible
during a preprosthetic program; this
allows a smooth transition into a prosthetic training program. A home assessment can be completed, and associated
recommendations can be made during
the preprosthetic phase.
Many patients are discharged from
the hospital a few days after the surgery and are able to immediately begin
a preprosthetic occupational ther apy
program. The treatment program
should provide emotional support and
structure in addition to wound care,
edema reduction, residual limb shaping, soft-tissue elongation, joint movement, core strengthening, and training
in endurance, selected self-care tasks,
and changing hand dominance, if
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
351
Соседние файлы в папке Библиотека им академика М.И. Перельмана