ADAPTIVE PROSTHETICS

Deficits and devices of upper & lower limb amputees

Lorin Merkley, CP

Nextremity Prosthetic DesignNEXTREMITY PROSTHETIC DESIGN

TOPICS COVERED

■ Major amputation levels and prosthetic overview

■ Adaptive Prosthetics – definitions and history

■ Lower Limb overview

■ Upper Limb -

– Amputation deficits

– Upper Limb prosthetic overview

– Activity specific/adaptive prosthetics

– Indications/Contraindications

– The therapist-prosthetist team

MY BACKGROUND

■ AZ Native

■ Studied Biomedical Engineering

at ASU

■ Practiced in Phoenix for 8 years

■ Faculty at Baylor College of

Medicine

■ Returned to AZ to make a

difference

home.

Baylor College of Medicine·

MAJOR AMPUTATION LEVELS – Lower Limb

■ Lower Limb Amputations

– Partial foot

– Ankle disarticulation

– Transtibial

– Knee disarticulation

– Transfemoral

– Hip disarticulation

·l'-- f:""1.1--\'!l'--- V.ry

s

t-+-:t--~ ---M

ovek

kn

S rt below knee

$ nd r, b .tow n

Chop rt -

Ind oot, ,uch 89 Boyd

Toe ,serti onore~tion

MAJOR AMPUTATION LEVELS – Upper Limb

■ Upper Limb Amputations

– Digital amputation

– Partial Hand

– Wrist disarticulation

– Transradial

– Elbow Disarticulation

– Transhumeral

– Shoulder Disarticulation

– Inter-scapulothoracic

Fore quarter amputation (Implies removal of part of scapula, clavicle and all of

upper limb)

Shoulder disarticulation (Amputation through

glenohumeral joint)

Above elbow (AE)

Elbow disarticulation

Below elbow (BE)

a) Short BE

b) Medium BE

c) Long BE

Wrist disarticulation

Metacarpophalangeal disarticulation

Phalangeal amputation

lnterphalangeal disarticulation

PROSTHETIC OVERVIEW■ Terminology:

– Prosthesis (noun) – Any device that replaces a missing part of

the body.

– Prosthetic (adjective) – Describing anything that deals with a

prosthesis.

– Socket - The part of the device that encapsulates and interacts

with the residual limb.

– Foot – It’s a foot…

– Terminal Device – The part of an upper limb prosthesis that

interacts with the environment (hook, hand, etc…).

– Suspension – The method of holding the prosthesis on to the

body.

ADAPTIVE PROSTHETICS

■ Adaptive Prostheses – “Any component or

group of components that enable the amputee

to engage in (adapt to) a specific Physical

activity” 1

■ A lot of overlap

[1] Caroll, Kevin. Adaptive prosthetics for the lower extremity. Foot and Ankle Clinics

, Volume 6 , Issue 2 , 371 - 386

HISTORY ADAPTIVE PROSTHETICS

■ Adaptive prostheses were among the first type of prostheses

■ 201 BC - Marcus Sergius was a Greek general who had an iron hand made to

support his shield.

HISTORY ADAPTIVE PROSTHETICS - 2

■ 1509 AD - A hand made representing armor for Goetz von Berlichingen. The fingers

could be locked shut to hold a weapon

coilhouse.net

HISTORY ADAPTIVE PROSTHETICS - 3

■ Late 19th Century - The civil war left many amputees to fend for themselves and

create novel "home brew" devices. The prosthesis shown here was made out of a

gun stock.

Invention.smithsonian.org

HISTORY ADAPTIVE PROSTHETICS - 4

■ Post WWII - Much was done to get veteran amputees back to their specialized work

LOWER LIMB PROSTHETICS

Ottobock.com

LOWER LIMB ADAPTIVE PROSTHETICS -OVERVIEW

■ Socket

■ Suspension

■ Knee

■ Alignable components

■ Ankle

■ Foot

Ottobock.com

LOWER LIMB ADAPTIVE PROSTHETICS –GOALS & BENEFITS

■ Activity specific

■ Mostly recreational

■ The major goal is increase in

performance

Ottobock.com

LOWER LIMB ADAPTIVE PROSTHETICS -EXAMPLES

■ Knees

– Focus on shock absorption, rather than stance and swing phases of gait

■ Feet

– Running

– Swimming

– Skiing

– Etc…

Hedef prostheticsOssur.com Freedom Innovations

360oandp.com

UPPER LIMB PROSTHETICS

Alternative Limb Project

UPPER LIMB ADAPTIVE PROSTHETICS –Amputation Statistics by site ■ Difference in Goals, in numbers, and in cause of amputation

Kathryn Ziegler-Graham, PhD, et al. “Estimating the Prevalence of Limb Loss in the United States - 2005 to

2050,” Archives of Physical Medicine and Rehabilitation 89 (2008):422-429.2

86% Lower Limb

Upper Limb 14 0

0% 20% 40% 60% 80% 100%

Kathryn Ziegler-Graham, PhD, et al. “Estimating the Prevalence of Limb Loss in the United States - 2005 to

2050,” Archives of Physical Medicine and Rehabilitation 89 (2008):422-429.2

UPPER LIMB ADAPTIVE PROSTHETICS –Amputation Statistics by cause

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

Dysvacular Trauma

• Upper Limb

• Lower Limb

Cancer Congenital

UPPER LIMB ADAPTIVE PROSTHETICS –AMPUTATION DEFICITS – Partial Hand

•Precision finger manipulation

•padded distal end

functional Deficiencies

•Fine palmer positioning (Wrist movement, pronation/supination)

•Elbow and shoulder movement

•Possible fine digital opposition remaining

•Suspension in cubital fold

•Bilateral Oppositional force

•Sensation

Remaining functions

•thumb: 38%UE, 23%WP

•full partial hand: 90%UE, 54%WP

Percent impaired

UPPER LIMB ADAPTIVE PROSTHETICS –AMPUTATION DEFICITS - Transradial

• Large surface area for load bearing

• Pronation/supination?

• Fine palmer positioning

• Precision finger manipulation

• Padded distal end

Deficiencies

• Elbow and shoulder movement

• Suspension in cubital fold

• Bilateral oppositional force

• Sensation

Remaining functions

• TR deficiency: 95%UE, 57%WP

Percent impaired

UPPER LIMB ADAPTIVE PROSTHETICS –AMPUTATION DEFICITS - Transhumeral

•Bilateral opposition

•Humeral Rotation

•Elbow flexion

•Large surface area for load bearing

•Pronation/supination?

•Fine palmer positioning

•Precision finger manipulation

•padded distal end

•Usable sensation

Deficiencies

•Shoulder movement

•Axilla Oppositional force

Remaining functions

•Elbow deficiency: 95%UE, 57%WP

Percent impaired

I

UPPER LIMB ADAPTIVE PROSTHETICS –PROSTHETIC OVERVIEW - BASICS

■ Socket

■ Suspension

■ Elbow

■ Wrist

– Pronation, Supination, Flexion, quick

change

■ TD

– Hook

– Hand

– Activity SpecificOttobock.com

UPPER LIMB ADAPTIVE PROSTHETICS –PROSTHETIC OVERVIEW - BASICS

■ Main types of

Prostheses

– Passive

– Active

– Activity Specific

UPPER LIMB ADAPTIVE PROSTHETICS –PROSTHETIC OVERVIEW - Passive

■ Psychosocial

function

■ Basic Opposition

■ Protection

■ Very Costly

UPPER LIMB ADAPTIVE PROSTHETICS –PROSTHETIC OVERVIEW - ACTIVE

■ Controlled articulations at the elbow

– Flexion & Extension

– Passive humeral rotation

■ Controlled articulations at the wrist

– Supination & Pronation

■ Control of the Terminal Device

– Open and Close

Mobius Bionics

UPPER LIMB ADAPTIVE PROSTHETICS –PROSTHETIC OVERVIEW – BODY POWERED

■ Controlled by shoulder and arm

movements

– Glenohumeral flexion

– Scapular abduction

■ Feedback available

■ Greater precision and speed

■ Less adaptable

O&P Library

UPPER LIMB ADAPTIVE PROSTHETICS –PROSTHETIC OVERVIEW–EXTERNAL POWERED

■ Controlled by:

– Myoelectric signals (EMG)

– Force pads

– Potentiometers

■ Less compensatory movements

■ No harnessing

■ Less effort

■ More adaptive

UPPER LIMB ADAPTIVE PROSTHETICS –Overall Goals

■ Improve function/Ease of

use

■ Reduce onset of overuse

symptoms

UPPER LIMB ADAPTIVE PROSTHETICS –Ease of Use

■ Many tasks require complex

manipulation or movement, but not a

variety of manipulations.

■ Specialization

UPPER LIMB ADAPTIVE PROSTHETICS –Overuse symptoms

■ Overuse in Contralateral Side

– Approximately 50% of patients with a

unilateral amputation will experience

overuse syndrome2

■ Overuse in residual limb

[2] Jones LE, Davidson JH: Save that arm: A study of problems in the remaining arm

of unilateral upper limb amputees. Prosthet Orthot Int 1999;23:55-58

UPPER LIMB ADAPTIVE PROSTHETICS –Examples - Employment

UPPER LIMB ADAPTIVE PROSTHETICS –How to implement

Cuff

Wrist Orthosis

Custom Socket

UPPER LIMB ADAPTIVE PROSTHETICS –So many options

UPPER LIMB ADAPTIVE PROSTHETICS –Examples – House ADL’s (Kitchen)

■ Eating

■ Food Preparation

UPPER LIMB ADAPTIVE PROSTHETICS –Examples – House ADL’s (Outdoors)

H

GC02-0N2

Hand Hoe

Hand Cultivator GS01•0N2

Hand Spade

UPPER LIMB ADAPTIVE PROSTHETICS –Examples – House ADL’s (Out and About)

UPPER LIMB ADAPTIVE PROSTHETICS –Examples - Recreations

UPPER LIMB ADAPTIVE PROSTHETICS –Changing devices

■ Can be difficult for

bilateral patients

■ Quick change

stands are

available

Hands·F ree Tool Changing Station

UPPER LIMB ADAPTIVE PROSTHETICS –Other considerations

■ More than just the terminal device you use.

■ Socket alignment, materials, and flexibility are also critical.

1970 2009

/

UPPER LIMB ADAPTIVE PROSTHETICS –Limitations

■ Task specific

■ No sensation

■ Learning curve

UPPER LIMB ADAPTIVE PROSTHETICS –Indications/Contraindications

■ “The most expensive prosthesis is the

one in the closet.”

■ Aspects to look at

– Gaps in function

– Overuse possibilities

– Motivation

www.motherearthnews.com

WHO WOULD BENEFIT FROM A PROSTHETIC CONSULTATION?

■ Any individual with limb loss

“Education is more empowering than any device.”

THERAPISTS & PROSTHETISTS

■ A team that is…

– Exciting

– Necessary

– Beneficial to all

parties

– Overlooked

no pain TD function

reliefs Trim lines Force

compression required

Ft~ ROM f='tt"'-C~tO"'-

Suspension Working

skin health purchase envelope

loading Cosmesi

cosmetic capacity Excur~io n

QUESTIONS?Thank you for your time!

480-747-1885