Multivariate prediction of upper limb prosthesis acceptance or rejection

Objective. To develop a model for prediction of upper limb prosthesis use or rejection.

Design. A questionnaire exploring factors in prosthesis acceptance was distributed internationally to individuals with upper limb absence through community-based support groups and rehabilitation hospitals.

Subjects. A total of 191 participants (59 prosthesis rejecters and 132 prosthesis wearers) were included in this study.

Methods. A logistic regression model, a C5.0 decision tree, and a radial basis function neural network were developed and compared in terms of sensitivity (prediction of prosthesis rejecters), specificity (prediction of prosthesis wearers), and overall cross-validation accuracy.

Results. The logistic regression and neural network provided comparable overall accuracies of approximately 84 ± 3%, specificity of 93%, and sensitivity of 61%. Fitting time-frame emerged as the predominant predictor. Individuals fitted within two years of birth (congenital) or six months of amputation (acquired) were 16 times more likely to continue prosthesis use.

Conclusions. To increase rates of prosthesis acceptance, clinical directives should focus on timely, client-centred fitting strategies and the development of improved prostheses and healthcare for individuals with high-level or bilateral limb absence. Multivariate analyses are useful in determining the relative importance of the many factors involved in prosthesis acceptance and rejection.     

Evaluation of prosthetic usage in upper limb amputees

Purpose:?Upper limb amputations cause severe functional disability and lower the patient's self body image, with severe psychological implications. Many parameters are involved in the successful rehabilitation of upper limb amputations. The aim of this study was to investigate whether there are any parameters that might predict the successful prosthetic rehabilitation of upper limb amputees.

Method:?The records of 45 patients who had undergone an upper limb amputation were traced. The patients were evaluated according to four parameters: (1) Modified upper extremities amputees' questionnaire; (2) Pain level according to Visual Analog Scale (VAS), range from 1 (lowest) up to 10 (highest); (3) Pain type – phantom or pain in the stump; (4) Functional assessment of prosthetic usage.

Results:?Thirty (71.43%) of the patients reported difficulties with prosthesis usage. Twenty-three patients (54.76%) were satisfied with their prosthesis – 19 had cosmetic prosthesis and four had body-powered prosthesis.

Conclusion:?No significant affect of the amputation level except for trans-wrist amputation with 100% prosthesis use. No significant difference was found between prosthesis type and the correlation to stump problems.

The above-elbow amputees, with dominant hand amputation, who used functional prosthesis (body-powered), achieved the best functional outcome and result.     

Amputation rehabilitation and prosthetic restoration. From surgery to community reintegration

Purpose:?The purpose of this review is to summarize the literature related to the advances that have taken place in the management and rehabilitation care of limb amputation.

Results:?Prostheses for the lower and upper limb amputee have changed greatly over the past several years, with advances in components, socket fabrication and fitting techniques, suspension systems and sources of power and electronic controls. Higher levels of limb amputation can now be fitted with functional prostheses, which allow more patients to achieve independent life styles. This is of particular importance for the multi-limb amputee. The rehabilitation of more traditional lower limb levels of amputation have also greatly benefited from the technological advances including energy storing feet, electronic control hydraulic knees, ankle rotators and shock absorbers to mention a few. For the upper limb amputee, myoelectric and proportional controlled terminal devices and elbow joints are now used routinely in some rehabilitation facilities. Experimental prosthetic fitting techniques and devices such as the use of osseo-implantation for suspension of the prosthesis, tension control hands or electromagnetic fluids for knee movement control will also be briefly discussed in this paper.

Conclusion:?It is possible to conclude from this review that many advances have occurred that have greatly impacted the functional outcomes of patients with limb amputation.     

Differences in quality of movements made with body-powered and myoelectric prostheses during activities of daily living

BackgroundUpper limb prostheses likely do not enable movements having the same kinematic characteristics as anatomical limbs. The quality of movements made using body-powered and myoelectric prostheses may further differ based on the availability of sensory feedback and method of terminal device actuation. The purpose of this work was to compare the quality of movements made with body-powered and myoelectric prostheses during activities of daily living.MethodsNine transradial body-powered and/or myoelectric prosthesis users and nine controls without limb loss performed six activities of daily living. Movement quality, defined as duration, straightness, and smoothness, for the reaching and manipulation phases was compared between prostheses, as well as prostheses and anatomical limbs.FindingsThe quality of reaching movements were generally similar between prostheses. However, movements with body-powered prostheses were slower (P = 0.007) and less smooth (P < 0.001) when reaching to a deodorant stick and movements with myoelectric prostheses were slower when reaching to place a pin on a corkboard (P = 0.023). Movements with myoelectric prostheses were slower (P ≤ 0.021) and less smooth (P ≤ 0.012) than those with body-powered prostheses during object manipulation, but these differences were not present for all tasks. Movements with prostheses were slower, more curved, and less smooth compared to those with anatomical limbs.InterpretationDifferences in the quality of movements made with body-powered and myoelectric prostheses primarily occur during object manipulation, rather than reaching. These differences do not exist for all tasks, suggesting that neither prosthesis type offers an absolute advantage in terms of movement quality.     

Prosthesis use in adult acquired major upper-limb amputees: patterns of wear,prosthetic skills and the actual use of prostheses in activities of daily life

Purpose: To describe patterns of prosthesis wear and perceived prosthetic usefulness in adult acquired upper-limb amputees (ULAs). To describe prosthetic skills in activities of daily life (ADL) and the actual use of prostheses in the performance of ADL tasks. To estimate the influence of prosthetic skills on actual prosthesis use and the influence of background factors on prosthetic skills and actual prosthesis use. Method: Cross-sectional study analysing population-based questionnaire data (n?=?224) and data from interviews and clinical testing in a referred/convenience sample of prosthesis-wearing ULAs (n?=?50). Effects were analysed using linear regression. Results: 80.8% wore prostheses. 90.3% reported their most worn prosthesis as useful. Prosthetic usefulness profiles varied with prosthetic type. Despite demonstrating good prosthetic skills, the amputees reported actual prosthesis use in only about half of the ADL tasks performed in everyday life. In unilateral amputees, increased actual use was associated with sufficient prosthetic training and with the use of myoelectric vs cosmetic prostheses, regardless of amputation level. Prosthetic skills did not affect actual prosthesis use. No background factors showed significant effect on prosthetic skills. Conclusions: Most major ULAs wear prostheses. Individualised prosthetic training and fitting of myoelectric rather than passive prostheses may increase actual prosthesis use in ADL.

Implications for Rehabilitation

• Arm prostheses are important functional aids for adult acquired major upper-limb amputees (ULAs).

• Despite being mainly satisfied with their prostheses, reporting their prostheses as useful and showing good prosthetic skills, prosthesis-wearing major ULAs do not use their prostheses for more than about half of the activities of daily life (ADL) tasks carried out in everyday life.

• In unilateral ULAs, individualised and targeted prosthetic training may increase optimal, active prosthesis use in ADL.

• Fitting the amputee with myoelectric rather than passive prostheses may increase prosthesis use in ADL, regardless of amputation level.

     

Adjustment to finger amputation and silicone finger prosthesis use

Purpose: Finger amputations are the most common amputations of upper limbs. They influence hand function, general functioning and quality of life. One of the possibilities for rehabilitation after finger amputation is fitting a silicone finger prosthesis. We wanted to evaluate the adjustment to amputation and prosthesis use in patients after finger amputation.

Methods: We included 42 patients with partial or complete single or multiple finger amputation of one hand who visited the outpatient clinic for prosthetics and orthotics at our institute and received a silicone prosthesis. We assessed their adjustment to amputation and prosthesis with the Trinity Amputation and Prosthesis Experience Scales (TAPES).

Results: Most of the patients (28, 67%) had a single finger amputated. The average scores on all TAPES subscales (except adjustment to limitation) were above 50% of the maximum possible score. On average, the scores were the highest on the general adjustment and satisfaction with the prosthesis subscales.

Conclusions: Silicone prostheses for finger amputation of upper limb play an important role in the process of adaptation to amputation. They offer aesthetically satisfying results and alleviate social interactions, which influences overall quality of life.

• Implications for Rehabilitation

• Silicone prostheses for finger amputation of upper limb offer an aesthetically satisfying result and alleviate problems with social interactions.

• Their influence on hand function is not optimal, but the prosthesis improves the amputee's quality of life.

     

Compensatory strategies of body-powered prosthesis users reveal primary reliance on trunk motion and relation to skill level

BackgroundWhile body-powered prostheses are commonly used, the compensatory strategies required to operate body-powered devices are not well understood. Kinematic assessment in addition to standard clinical tests can give a comprehensive evaluation of prosthesis user function and skill. This study investigated the movement compensations of body-powered prosthesis users and determined whether a correlation is present between compensatory strategies and skill level, as measured by a standard clinical test.MethodsFive transradial body-powered prosthesis users completed two standardized upper limb tasks. A 12-camera motion capture system was used to obtain three-dimensional angular kinematics for eight degrees of freedom at the trunk, shoulder, and elbow. Range of motion was compared to a normative dataset. Pearson's correlation was used to assess the relationship between the Activities Measure for Upper Limb Amputees and range of motion for each degree of freedom.FindingsParticipants displayed a statistically significant (P < .05) increase in range of motion at the trunk for both tasks. Shoulder flexion/extension range of motion was significantly reduced (P < .05) compared to normative values, but shoulder abduction/adduction range of motion did not show a consistent difference compared to norms. Skill level was correlated with range of motion for specific degrees of freedom at the trunk, shoulder, and elbow.InterpretationBody-powered prosthesis users compensated with trunk movement and showed reduced motion for shoulder flexion/extension, with relatively normal shoulder abduction/adduction. Skill level was correlated with angular kinematic strategies, which may allow targeting of specific therapeutic interventions for reducing compensatory movements.     

3D-printed upper limb prostheses: a review

Goal: This paper aims to provide an overview with quantitative information of existing 3D-printed upper limb prostheses. We will identify the benefits and drawbacks of 3D-printed devices to enable improvement of current devices based on the demands of prostheses users.

Methods: A review was performed using Scopus, Web of Science and websites related to 3D-printing. Quantitative information on the mechanical and kinematic specifications and 3D-printing technology used was extracted from the papers and websites.

Results: The overview (58 devices) provides the general specifications, the mechanical and kinematic specifications of the devices and information regarding the 3D-printing technology used for hands. The overview shows prostheses for all different upper limb amputation levels with different types of control and a maximum material cost of $500.

Conclusion: A large range of various prostheses have been 3D-printed, of which the majority are used by children. Evidence with respect to the user acceptance, functionality and durability of the 3D-printed hands is lacking. Contrary to what is often claimed, 3D-printing is not necessarily cheap, e.g., injection moulding can be cheaper. Conversely, 3D-printing provides a promising possibility for individualization, e.g., personalized socket, colour, shape and size, without the need for adjusting the production machine.

• Implications for rehabilitation

• Upper limb deficiency is a condition in which a part of the upper limb is missing as a result of a congenital limb deficiency of as a result of an amputation.

• A prosthetic hand can restore some of the functions of a missing limb and help the user in performing activities of daily living.

• Using 3D-printing technology is one of the solutions to manufacture hand prostheses.

• This overview provides information about the general, mechanical and kinematic specifications of all the devices and it provides the information about the 3D-printing technology used to print the hands.

     

A survey on what Australians with upper limb difference want in a prosthesis: justification for using soft robotics and additive manufacturing for customized prosthetic hands

Abstract

Purpose: Upper limb prostheses are part of a rapidly changing market place. Despite development in device design, surveys report low levels of uptake and dissatisfaction with current prosthetic design. In this study, we present the results of a survey conducted with people with upper limb difference in Australia on their use of current prostheses and preferences in a prosthetic in order to inform future prosthetic hand design.

Methods: An online survey was conducted on upper limb amputees, with 27 respondents that completed the survey. The survey was a mixture of open-ended questions, ranking design features and quantitative questions on problems experienced and desired attributes of future prosthesis designs.

Results: Common key issues and concerns were isolated in the survey related to the weight, manipulation and dexterity, aesthetics, sensory feedback and financial cost; each of which could be addressed by additive manufacturing and soft robotics techniques.

Conclusions: The adaptability of additive manufacturing and soft robotics to the highlighted concerns of participants shows that further research into these techniques is a feasible method to improve patient satisfaction and acceptance in prosthetic hands.

• Implications for rehabilitation

• Even with recent developments and advances in prosthetic design, the needs and desires of prosthetic users are not being met with current products.

• The desires and needs of those with upper limb difference are diverse.

• Using additive manufacturing to produce prosthetics allows for mass customization of prosthetics to meet these diverse needs while reducing costs.

• A soft robotic approach to prosthetics can help meet the desires of reducing weight and costs, while maintaining functionality.

     

Controlling a multi-degree of freedom upper limb prosthesis using foot controls: user experience

Abstract

Purpose: The DEKA Arm, a pre-commercial upper limb prosthesis, funded by the DARPA Revolutionizing Prosthetics Program, offers increased degrees of freedom while requiring a large number of user control inputs to operate. To address this challenge, DEKA developed prototype foot controls. Although the concept of utilizing foot controls to operate an upper limb prosthesis has been discussed for decades, only small-sized studies have been performed and no commercial product exists. The purpose of this paper is to report amputee user perspectives on using three different iterations of foot controls to operate the DEKA Arm. Method: Qualitative data was collected from 36 subjects as part of the Department of Veterans Affairs (VA) Study to Optimize the DEKA Arm through surveys, interviews, audio memos, and videotaped sessions. Three major, interrelated themes were identified using the constant comparative method: attitudes towards foot controls, psychomotor learning and physical experience of using foot controls. Results: Feedback about foot controls was generally positive for all iterations. The final version of foot controls was viewed most favorably. Conclusions: Our findings indicate that foot controls are a viable control option that can enable control of a multifunction upper limb prosthesis (the DEKA Arm).

• Implications for Rehabilitation

• Multifunction upper limb prostheses require many user control inputs to operate. Foot controls offer additional control input options for such advanced devices, yet have had minimal study.

• This study found that foot controls were a viable option for controlling multifunction upper limb prostheses. Most of the 36 subjects in this study were willing to adopt foot controls to control the multiple degrees of freedom of the DEKA Arm.

• With training and practice, all users were able to develop the psychomotor skills needed to successfully operate food controls. Some had initial difficulty, but acclimated over time.

     

Frequency and characteristics of goal attainment following BoNT-A injection for management of spasticity

Purpose: To determine which Goal Attainment Scale (GAS) goals are commonly achieved in patients with upper limb and/or lower limb spasticity following Botulinum Neurotoxin Type A (BoNT-A) injection.

Method: Adults who attended a Spasticity Management Clinic for upper and/or lower limb BoNT-A injection were included in this prospective cohort study. Goals were set by participants and/or carers in conjunction with the therapist using the GAS, prior to injection and reviewed at one month following the injection. Three out of the five categories of goals were passive. Goals were categorised into: mobility/transfers, pain/comfort, upper limb use, hygiene, and cosmesis. The number of responders for the GAS total score, and in each of the GAS categories, was calculated.

Results: Sixty-seven participants were recruited (mean age 51?±?16 years; range 18–85), 70% had a stroke. Responders for mobility and transfer goals were further post injury or disease onset than non-responders (median 5.9 vs. 1.2 years, p?=?0.03). Clients with stroke were less likely than other participants to achieve mobility and transfer goals (p?=?0.02). There was a trend for those who achieved mobility and transfer goals to be younger (mean 49 years vs. 55 years, p?=?0.06). Although active goals are more commonly identified, passive goals were more likely to be achieved.

Conclusions: Although active goals are commonly identified by people with spasticity, passive goals were more likely to be achieved following BoNT-A injection. A long duration of spasticity does not preclude patients from achieving mobility and transfer goals. Non-stroke participants were more likely to achieve mobility and transfer goals.

• Implications for Rehabilitation

• Patients with chronic spasticity should be considered for BoNT-A as clinically meaningful outcomes can be achieved.

• When spasticity is present in multiple muscles, the GAS can be an assistive tool to guide clinicians in determining which muscles are a priority for injection, because the client will be more motivated to improve those specific goals.

• Although carers and patients are more willing to set active goals, these are more difficult to achieve possibly because follow up intervention or independent practise is required.

     

Psychosocial and physical adjustments and prosthesis satisfaction in amputees: a systematic review of observational studies

Abstract

Background: Adjustment to amputation is a complex process because it encompasses physical and psychosocial aspects as well as satisfaction with the artificial limb.

Purpose: To review the scientific production on psychosocial and physical adjustments to amputation and prosthesis use as well as prosthetic satisfaction in people with lower limb amputation in the last 10?years.

Methods: This review was conducted on the MEDLINE via Pubmed, Web of Science and Scopus databases. Original and observational studies published in the last 10?years were included, with topics related to adjustment to amputation and prosthesis use as well as prosthetic satisfaction in people with lower limb amputations.

Results: A total of 1042 articles were identified in the initial search, but after analysing the criteria 16 articles were used for analysis in their entirety. Regarding psychosocial adjustments, higher rates of depression, anxiety and body image disorders were observed among people with amputations. Phantom and residual limb pain, gender, employment status and daily hours of prosthesis use may influence psychosocial adjustment. Physical adjustment may be influenced by the level of amputation, educational background, age, daily prosthesis use, ambulatory assistive devices and presence of comorbidities. The areas of greatest prosthetic dissatisfaction were colour and weight.

Conclusion: Considering that most of the studies related to the satisfaction and adjustment of the prosthesis are cross-sectional studies, longitudinal studies should be conducted, since monitoring individuals over the years and verifying how these variables change over time may contribute to obtaining more data on the factors that influence prosthetic fitting and satisfaction.

• Implications for rehabilitation

• Adjustment to amputation and prosthesis use involves both physical and psychosocial issues, it is important that besides physical rehabilitation, psychological interventions and education and communication activities between the patient and the health professionals are carried out.

• The adaptation to the prosthesis and the recovery of walking capacity are important goals in the rehabilitation process and the knowledge of the physical and psychosocial factors associated with amputation and the use of the prosthesis can help the health team to provide better care to these subjects.

• Well-adjusted, comfortable and easy-to-use prostheses are of great importance as they enable the patient to perform their daily activities and maintain their independence.

• It is important to encourage the participation of the individual in both rehabilitation and choice of prosthesis.

     

Comparison of transhumeral socket designs utilizing patient assessment and in vivo skeletal and socket motion tracking: a case study

Purpose: This case study compares the impact of two prosthetic socket designs, a “traditional” transhumeral (TH) socket design and a Compression Released Stabilized (CRS) socket. Methods: A CRS socket was compared to the existing socket of two persons with transhumeral amputation. Comparisons included assessments of patient comfort and satisfaction with fit, as well as dynamic kinematic assessment using a novel high-speed, high-resolution, bi-plane video radiography system (XROMM, for X-ray Reconstruction of Moving Morphology). Results: Subjects were more satisfied with the comfort of the traditional sockets, although they had positive impressions about aspects of the fit and style of the CRS socket, and thought that it provided better control. Dynamic kinematic assessment revealed that the CRS socket provided better control of the residual limb within the socket, and had less slippage as compared to a traditional TH socket design. Conclusions: The TH CRS socket provided better control of the residual limb within the socket, and had less slippage. However, participants were less satisfied with the comfort and overall utility of the CRS socket, and stated that additional fitting visits/modifications to the CRS socket were needed. It is possible that satisfaction with the CRS socket may have improved with prosthetic adjustment and more acclimation time.

• Implications for Rehabilitation

• A comfortable, good fitting prosthetic socket is the key factor in determining how long (or if) an upper limb amputee can tolerate wearing a prosthesis.

• This case series was a comparison of two socket designs, a 'traditional' socket design and a Compression Released Stabilized (CRS) socket design in persons with transhumeral amputation.

• The CRS socket provided better control of the residual limb within the socket, and had less slippage. However, its tightness made it more difficult to don.

• Both subjects were less satisfied with the comfort and overall utility of the CRS socket. However, satisfaction might have been improved with additional fitting visits and more acclimation time.

     

Evaluation of rehabilitated bilateral lower limb amputees – an Indian study

Objective: This study assessed activities of daily living (ADL) and ambulation of rehabilitated bilateral lower limb amputees with relation to their level of amputation in an Indian setting. Subjects and Methods: This retrospective study of 25 subjects comprised 12 bilateral Trans-femoral (TF) amputees, 8 bilateral Trans-tibial (TT) amputees and 5 a combination of ipsilateral Trans-femoral and contralateral Trans-tibial amputation. All subjects were contacted by post/telephone, were physically examined and assessed at the Orthopaedic clinic at a mean follow-up of 6.6 years. Physical rehabilitation was evaluated using ADL score and by grading the level of ambulation. Results: ADL scores showed no significant difference according to level of amputation (p > 0.05), but the scores of prosthetic users were significantly higher than non-prosthetic users (p?=?0.002). Only 11/25 amputees became prosthetic ambulators and most (50%, 6/12) were TF amputees. All prosthetically rehabilitated subjects were mobilising with their prostheses at follow-up and graded as unlimited or limited community ambulators. Conclusion: Though it is well documented that the potential for successful rehabilitation is best for bilateral TT amputees, given the subjects’ economic constraints, higher prosthesis rehabilitation among bilateral TF amputees indicates that successful rehabilitation is possible in most subjects irrespective of the level of amputation.

Implications for Rehabilitation

• Rehabilitation of a bilateral lower limb amputee requires a team effort and constitutes a very difficult challenge for the subject.

• Low prosthesis ownership is largely due to subjects’ inability to afford a pair of prostheses in a developing country like India.

• Activities of daily living improve significantly with use of prostheses.

• Though it is well documented that the potential for successful rehabilitation is best for a bilateral TT amputee, higher prosthesis rehabilitation among bilateral TF subjects in this study indicates that successful rehabilitation is possible in most subjects irrespective of the level of amputation.

     

Management of shoulder and proximal upper limb spasticity using botulinum toxin and concurrent therapy interventions: A preliminary analysis of goals and outcomes

Purpose. To explore the role of Botulinum Toxin type A (BoNT-A) in the management of the spastic hemiplegic shoulder and identify the common achievable goals for treatment.

Method. Set in a regional spasticity management service in the UK, a prospective observational cohort study was undertaken. Patients (n = 16) were receiving BoNT-A (Dysport©) injection and concurrent therapy for spasticity of the shoulder girdle or proximal upper limb following stroke/other acquired brain injury. Mean age 54.5 (SD 15.7) years. Mean time since injury: 15.7 months. Functional goals for intervention were determined through agreement with the patient or their carers using Goal Attainment Scaling (GAS). Evaluation of spasticity (Modified Ashworth Scale), pain (numbered graphic rating scale) and three standard passive function tasks (washing, dressing and positioning) were also undertaken.

Results. Sixteen weeks post-injection, significant improvements were identified in spasticity (Z = ?3.535, p <0.0001), pain (Z = ?1.942, p = 0.052) and passive function (Z = ?3.172, p = 0.002). GAS scores had improved in all but one subject, with goals either achieved or over-achieved.

Conclusions. BoNT-A injection of the proximal upper limb, with combined therapy, produced a reduction in spasticity, improvement in passive function and pain. Management of upper limb spasticity should include evaluation and, if necessary treatment, of the shoulder girdle and proximal musculature.