Agnes Sturma

Bionic reconstruction to restore hand function after brachial plexus injury: a case series of three patients

BACKGROUND Brachial plexus injuries can permanently impair hand function, yet present surgical reconstruction provides only poor results. Here, we present for the first time bionic reconstruction; a combined technique of selective nerve and muscle transfers, elective amputation, and prosthetic rehabilitation to regain hand function. METHODS Between April 2011, and May 2014, three patients with global brachial plexus injury including lower root avulsions underwent bionic reconstruction. Treatment occurred in two stages; first, to identify and create useful electromyographic signals for prosthetic control, and second, to amputate the hand and replace it with a mechatronic prosthesis. Before amputation, the patients had a specifically tailored rehabilitation programme to enhance electromyographic signals and cognitive control of the prosthesis. Final prosthetic fitting was applied as early as 6 weeks after amputation. FINDINGS Bionic reconstruction successfully enabled prosthetic hand use in all three patients. After 3 months, mean Action Research Arm Test score increased from 5·3 (SD 4·73) to 30·7 (14·0). Mean Southampton Hand Assessment Procedure score improved from 9·3 (SD 1·5) to 65·3 (SD 19·4). Mean Disabilities of Arm, Shoulder and Hand score improved from 46·5 (SD 18·7) to 11·7 (SD 8·42). INTERPRETATION For patients with global brachial plexus injury with lower root avulsions, who have no alternative treatment, bionic reconstruction offers a means to restore hand function. FUNDING Austrian Council for Research and Technology Development, Austrian Federal Ministry of Science, Research & Economy, and European Research Council Advanced Grant DEMOVE.

Hand Transplantation Versus Hand Prosthetics: Pros and Cons

Composite tissue transplantation and new developments in the field of prosthetics have opened new frontiers in the restoration of function among upper limb amputees. It is now possible to restore hand function in affected patients; however, the indications, advantages, and limitations for either hand transplantation or prosthetic fitting must be carefully considered depending on the level and extent of the limb loss. Hand transplantation allows comprehensive hand function to be restored, yet composite tissue transplantation comes with disadvantages, making this method a controversial topic in the hand surgical community. Alternatively, prosthetic limb replacement represents the standard of care for upper limb amputees, but results in the known limitations of function, sensation, and usage. The indication for hand transplantation or prosthetic fitting strongly depends on the level of amputation, as well as on the extent (unilateral/bilateral) of the amputation. In this review, we discuss the advantages and disadvantages of hand transplantation and prosthetic replacement for upper limb amputees in general, as well as in regard to the different levels of amputation.

Prosthetic reconstruction in high amputations of the upper extremity

ZusammenfassungHintergrundDie Steuerung myoelektrischer Armprothesen erfolgte konventionellerweise über zwei Oberflächenelektroden, welche von zwei getrennt innervierten Muskelgruppen angesteuert werden. Zwischen den verschiedenen prothetischen Gelenken wird mittels Kokontraktion dieser Muskeln gewechselt und in der jeweiligen Ebene mit denselben Muskeln linear gesteuert. Ein harmonischer, dem natürlichen Bewegungsmuster entsprechender Bewegungsablauf ist mit diesem Steuerungsmechanismus nicht möglich.FragestellungÜbersicht über die chirurgischen, therapeutischen und prothetischen Möglichkeiten bei hohen Amputationen der oberen Extremität.Material und MethodeEs erfolgte eine selektive Literaturrecherche unter Berücksichtigung eigener Erfahrungen des klinischen Alltags und Durchsicht von Patientenakten.ErgebnisseDurch selektive Nerventransfers der amputierten Armnerven des Plexus brachialis auf verbliebene Stumpfmuskulatur können bis zu sechs Signalgeber geschaffen werden, welche intuitiv und simultan die verschiedenen prothetischen Gelenke steuern können. Auf diese Weise ist eine effiziente und harmonische Steuerung der Prothese gewährleistet ohne dass der Patient zwischen den verschiedenen Steuerungsebenen wechseln muss. Gleichzeitig werden etwaige Neurome behandelt und somit ein schmerzfreies Tragen der Prothese ermöglicht. Aufgrund der dadurch vermehrten Verwendung von myoelektrischen Prothesen steigen auch die Anforderungen an den Stumpf. Hier gilt es sowohl chirurgisch als auch orthopädietechnisch eine stabile Verbindung zwischen Stumpf und Prothese zu schaffen, um eine optimale Prothesenfunktion zu ermöglichen.AbstractBackgroundConventional upper arm prostheses are controlled via two surface electrodes that measure motor activity of two separately innervated muscle groups. The various prosthetic joints are chosen by co-contractions and controlled linearly by these two muscles. A harmonious and natural course of movements is not possible in this way.ObjectivesOverview regarding surgical, therapeutical and prosthetic options in high amputations of the upper extremity.MethodsSelective literature research including the authors’ own experience in everyday clinical practice as well as a review of medical records.ResultsSelective nerve transfers of the amputated nerves of the brachial plexus to the remaining stump muscles can create up to six myosignals for intuitive and simultaneous control of the different prosthetic joints. In this way, an efficient and harmonious control of the prosthetic device is possible without the need to change between the different control levels. At the same time, possible neuromas are treated and painless wear of the prosthesis is achieved. Due to the resulting extended use of the prosthetic device, the demands regarding stump quality are increased. Thus, both surgically and by the means of the orthopedic technician a stable stump-socket connection should be achieved to enable optimal prosthetic function.

Advanced Rehabilitation for Amputees after Selective Nerve Transfers: EMG-Guided Training and Testing

A special kind of selective nerve transfer, targeted muscle reinnervation, can provide upper limb amputees with up to 6 intuitive myosignals to govern their myoelectric prosthesis. Following surgery, a comprehensive rehabilitation package is required. It should include electromyographic (EMG) feedback training to facilitate recruitment of newly reinnervated muscles. In order to select appropriate tasks for training, an EMG testing tool is required that can provide clinicians with scores directly reflecting the patient’s ability to generate myoelectric signals. Here, an EMG testing tool implementing the Item Response Theory for ability classification is presented. Used for testing healthy subjects and patients, the tool was able to detect an increase of muscular coordination with training, as well as existing deficits in motor control. These findings suggest that this tool can assist in rehabilitation planning for patients after selective nerve transfers.

Functional and Psychosocial Outcomes of Hand Transplantation Compared with Prosthetic Fitting in Below-Elbow Amputees: A Multicenter Cohort Study

Background Hand-transplantation and improvements in the field of prostheses opened new frontiers in restoring hand function in below-elbow amputees. Both concepts aim at restoring reliable hand function, however, the indications, advantages and limitations for each treatment must be carefully considered depending on level and extent of amputation. Here we report our findings of a multi-center cohort study comparing hand function and quality-of-life of people with transplanted versus prosthetic hands. Methods Hand function in amputees with either transplant or prostheses was tested with Action Research Arm Test (ARAT), Southampton Hand Assessment Procedure (SHAP) and the Disabilities of the Arm, Shoulder and Hand measure (DASH). Quality-of-life was compared with the Short-Form 36 (SF-36). Results Transplanted patients (n = 5) achieved a mean ARAT score of 40.86 ± 8.07 and an average SHAP score of 75.00 ± 11.06. Prosthetic patients (n = 7) achieved a mean ARAT score of 39.00 ± 3.61 and an average SHAP score of 75.43 ± 10.81. There was no significant difference between transplanted and prosthetic hands in ARAT, SHAP or DASH. While quality-of-life metrics were equivocal for four scales of the SF-36, transplanted patients reported significantly higher scores in “role-physical” (p = 0.006), “vitality” (p = 0.008), “role-emotional” (p = 0.035) and “mental-health” (p = 0.003). Conclusions The indications for hand transplantation or prosthetic fitting in below-elbow amputees require careful consideration. As functional outcomes were not significantly different between groups, patient’s best interests and the route of least harm should guide treatment. Due to the immunosuppressive side-effects, the indication for allotransplantation must still be restrictive, the best being bilateral amputees.

Attachment of upper arm prostheses with a subcutaneous osseointegrated implant in transhumeral amputees

Background: The stump–socket interface is of utmost importance for prosthetic function in transhumeral amputees. Stability of this connection may be improved using a newly designed subcutaneous implant. Objectives: The purpose was to determine the effect of the implant together with customized socket designs on the range of motion of the shoulder and the prosthetic function compared to conventional fitting. Study design: Case series. Methods: The range of motion was measured with scaled metrics and the prosthetic function evaluated with the Southampton Hand Assessment Procedure and the Box and Block Test. Maximal loading was measured in straight and 90° flexion of the elbow. Results: The restriction of range of motion after conventional fitting was decreased from 42.55% ± 6.56% to 9.23% ± 14.89% in Patient I and from 62.18% ± 15.19% to 2.51% ± 2.49% in Patient II using the implant with customized sockets compared to range of motion without prosthesis. Both patients showed improved prosthetic function with the new system compared to conventional fitting. Conclusion: The presented subcutaneous humeral implant, together with customized socket designs without straps and harnesses to the contralateral shoulder, can maintain almost complete range of motion of the shoulder. This resulted in improved prosthetic function and comfort for the patient without constant risk of infection. Clinical relevance Discomfort and limited prosthetic function are the main reasons for abandonment especially in transhumeral amputees. Shoulder straps and harnesses within conventional socket designs may not only lead to pain and skin irritations at the contralateral shoulder but also limit the range of motion of the shoulder joint and therefore prosthetic function.

Translating Research on Myoelectric Control into Clinics—Are the Performance Assessment Methods Adequate?

Missing an upper limb dramatically impairs daily-life activities. Efforts in overcoming the issues arising from this disability have been made in both academia and industry, although their clinical outcome is still limited. Translation of prosthetic research into clinics has been challenging because of the difficulties in meeting the necessary requirements of the market. In this perspective article, we suggest that one relevant factor determining the relatively small clinical impact of myocontrol algorithms for upper limb prostheses is the limit of commonly used laboratory performance metrics. The laboratory conditions, in which the majority of the solutions are being evaluated, fail to sufficiently replicate real-life challenges. We qualitatively support this argument with representative data from seven transradial amputees. Their ability to control a myoelectric prosthesis was tested by measuring the accuracy of offline EMG signal classification, as a typical laboratory performance metrics, as well as by clinical scores when performing standard tests of daily living. Despite all subjects reaching relatively high classification accuracy offline, their clinical scores varied greatly and were not strongly predicted by classification accuracy. We therefore support the suggestion to test myocontrol systems using clinical tests on amputees, fully fitted with sockets and prostheses highly resembling the systems they would use in daily living, as evaluation benchmark. Agreement on this level of testing for systems developed in research laboratories would facilitate clinically relevant progresses in this field.

A Structured Rehabilitation Protocol for Improved Multifunctional Prosthetic Control: A Case Study.

Advances in robotic systems have resulted in prostheses for the upper limb that can produce multifunctional movements. However, these sophisticated systems require upper limb amputees to learn complex control schemes. Humans have the ability to learn new movements through imitation and other learning strategies. This protocol describes a structured rehabilitation method, which includes imitation, repetition, and reinforcement learning, and aims to assess if this method can improve multifunctional prosthetic control. A left below elbow amputee, with 4 years of experience in prosthetic use, took part in this case study. The prosthesis used was a Michelangelo hand with wrist rotation, and the added features of wrist flexion and extension, which allowed more combinations of hand movements. The participants Southampton Hand Assessment Procedure score improved from 58 to 71 following structured training. This suggests that a structured training protocol of imitation, repetition and reinforcement may have a role in learning to control a new prosthetic hand. A larger clinical study is however required to support these findings.

Elective amputation and bionic substitution restore functional hand use after critical soft tissue injuries.

Critical soft tissue injuries may lead to a non-functional and insensate limb. In these cases standard reconstructive techniques will not suffice to provide a useful outcome, and solutions outside the biological arena must be considered and offered to these patients. We propose a concept which, after all reconstructive options have been exhausted, involves an elective amputation along with a bionic substitution, implementing an actuated prosthetic hand via a structured tech-neuro-rehabilitation program. Here, three patients are presented in whom this concept has been successfully applied after mutilating hand injuries. Clinical tests conducted before, during and after the procedure, evaluating both functional and psychometric parameters, document the benefits of this approach. Additionally, in one of the patients, we show the possibility of implementing a highly functional and natural control of an advanced prosthesis providing both proportional and simultaneous movements of the wrist and hand for completing tasks of daily living with substantially less compensatory movements compared to the traditional systems. It is concluded that the proposed procedure is a viable solution for re-gaining highly functional hand use following critical soft tissue injuries when existing surgical measures fail. Our results are clinically applicable and can be extended to institutions with similar resources.

A surface EMG test tool to measure proportional prosthetic control.

Abstract In upper limb amputees, prosthetic control training is recommended before and after fitting. During rehabilitation, the focus is on selective proportional control signals. For functional monitoring, many different tests are available. None can be used in the early phase of training. However, an early assessment is needed to judge if a patient has the potential to control a certain prosthetic set-up. This early analysis will determine if further training is needed or if other strategies would be more appropriate. Presented here is a tool that is capable of predicting achievable function in voluntary EMG control. This tool is applicable to individual muscle groups to support preparation of training and fitting. In four of five patients, the sEMG test tool accurately predicted the suitability for further myoelectric training based on SHAP outcome measures. (P1: “Poor” function in the sEMG test tool corresponded to 54/100 in the SHAP test; P2: Good: 85; P3: Good: 81; P4: Average: 78). One patient scored well during sEMG testing, but was unmotivated during SHAP testing. (Good: 50) Therefore, the surface EMG test tool may predict achievable control skills to a high extent, validated with the SHAP, but requires further clinical testing to validate this technique.