Myo Plus Occupational Therapy Training Please Note…

Myo Plus Occupational Therapy Training Please note…..

The MyoPlus initial system set-up should be done in conjunction with the attending Certified Prosthetist. For further details on this process, please see our online training course @ https://shop.ottobock.us/Online-Training

It is recommended that the evaluation video be viewed prior to taking this therapy course: https://www.youtube.com/watch?v=gwtLVLShOpU&list=PLpvGLdlXdCU0Es_No CFSlTxb6V2r8IvEq&index=2

There are also helpful documents found under the Resources tab in the upper right hand corner, including the MyoPlus Therapy Brochure and Quick Guide.

| © Otto Bock HealthCare Myo Plus Fitting Process…

• Introduction

• Features & Benefits

• Componentry

• MyoPlus App

• Fitting Process

• Therapy Protocol

1. Controls Training 2. Repetitive Drills 3. ADLs

• Outcome Measures 3 | © Otto Bock HealthCare OT Myoelectric Rehabilitation General Program

2 PROSTHETIC TRAINING 1 MUSCLE SITE 1. Controls CONTROL 2. Repetitive Drills PRE-PROSTHETIC 1. Standard 2-site 3. ADLs TRAINING 2. Pattern Recognition *Specific to TD & control method 1. Post-op 2. Pre-prosthetic

Atkins, DJ. Functional Skills Training with Body-Powered and Externally Powered Prostheses. In: Atkins DJ, Meier RH (eds), Functional Restoration of Adults and Children with Upper Extremity Amputation. 2004 | © Otto Bock HealthCare Myoelectric Control Previous Limitations…

SITE 1 SITE 2 Modal Control

| © Otto Bock HealthCare 5 Myoelectric Control Why is advanced control necessary?

• OPEN/CLOSE • OPEN/CLOSE • OPEN/CLOSE • PRONATE/SUPINATE • PRONATE/SUPINATE • PRONATE/SUPINATE • OPPOSITION/LATERAL • 8 PROGRAMMED GRIPS

| © Otto Bock HealthCare 6 Myo Plus Introduction

• To gain full potential of the multiarticulating bebionic hand

• To operate a hand and wrist rotator more naturally

| © Otto Bock HealthCare 7 Myo Plus 4 5

How it works 3 6

2 7 Myo Plus Control 1 8

| © Otto Bock HealthCare 8 https://www.youtube.com/watch?v=B8Z_2tMUeiw&list=PLpvGLdlXdCU0Es_NoCFSlTxb6V2r8IvEq&index=1

Myo Plus Fitting Process…

• Introduction

• Features & Benefits

• Componentry

• MyoPlus App

• Fitting Process

• Therapy Protocol

1. Controls Training 2. Repetitive Drills 3. ADLs

• Outcome Measures 9 | © Otto Bock HealthCare Myo Plus Advantages

• Recording of the movement patterns is done through a simple process via the Ottobock MyoPlus app

• Each movement of the prosthesis is assigned a pattern established by a unique movement of the phantom hand and stored in the prosthesis

• The user determines which thoughts will control the prosthesis

Myo Plus – Introduction | Academy | 06.01.2020| © Otto Bock HealthCare 10 Myo Plus User Benefits

• Customization of patterns by the user makes for intuitive control

• Direct selection of movements; no switching between grips or wrist rotation

• More precise proportional control of prosthetic functions

• New prosthetic movements can bed added via the easy-to-follow app

• Settings, feedback and training can also be accessed through the app

• Prosthesis control adjusts accordingly to the connected terminal device

| © Otto Bock HealthCare 11 Myo Plus Clinical Application

Myo Plus is recommended for….

• New or existing prosthetic users who can produce EMG signals • Transradial & transcarpal amputation levels (minimum requirement = 4 cm) • Traumatic or congenital etiology • Unilateral or bilateral amputations • Difficulty with myo-signal separation • Weak or unbalanced signals • Standard 2-site control has failed • Mode switching challenges • Desired fast & intuitive control

| © Otto Bock HealthCare 12 Myo Plus Contraindications

Currently, Myo Plus is not available for users with these amputation levels…

• Transhumeral

• Partial hand

• Shoulder disarticulation

Patients who are not able to generate patterns that are unique enough to be separable from each other will not be successful with this system

| © Otto Bock HealthCare 13 Myo Plus Handling & Risks

User Information:

• Must not be used for the operation of motor vehicles

• Must not be used for the operation of heavy equipment

• Do not handle firearms while using the product

• Keep system free of solid particles or liquids

• Switch off the prosthesis when changing the terminal device

• This product was developed for everyday use and must not be used for unusual activities such as extreme sports (free climbing, paragliding, etc.)

| © Otto Bock HealthCare 14 Myo Plus Fitting Process…

• Introduction

• Features & Benefits

• Componentry

• MyoPlus App

• Fitting Process

• Therapy Protocol

1. Controls Training 2. Repetitive Drills 3. ADLs

• Outcome Measures 15 | © Otto Bock HealthCare Myo Plus Componentry Overview

Myo Energy Integral 757B35=5

Myo Plus TR 13E520

Myo Plus App 560X18-*

Dome covers 13Z166

Electrode dome Myo cuff 757M20=* 13Z161, 13Z162, 13Z163

Remote electrodes

13E401=* Electrode positioning gauge 623F50

13E400=*/

| © Otto Bock HealthCare 16 Myo Plus Components

For testing and training, the following is required: • Healthy muscles in the residual limb • Cognitive understanding of the new control system • A Myo cuff or prosthetic socket with Myo Plus components • A smartphone or tablet with the associated Myo Plus App

Myo Plus App 560X18-* Myo cuff 757M20=*

| © Otto Bock HealthCare 17 Myo Plus Compatibility

Myo Plus

bebionic Hand

MyoBock

https://shop.ottobock.us/Online-Training

| © Otto Bock HealthCare 18 Myo Plus Fitting Process…

• Introduction

• Features & Benefits

• Componentry

• MyoPlus App

• Fitting Process

• Therapy Protocol

1. Controls Training 2. Repetitive Drills 3. ADLs

• Outcome Measures 19 | © Otto Bock HealthCare Myo Plus Myo Plus App

The Myo Plus App is the central adjustment software to:

 check system functionality

 evaluate movement patterns

 record data for prosthetic control

 train and improve movement patterns

 adjust speed and advanced settings

 disable selective movements in specific situations

 available for download from the Google Play Store or the Apple App Store | © Otto Bock HealthCare 20 Myo Plus Myo Plus App

My Myo Plus Spiderplot/training Add pattern Prosthesis movements Movement quality Manual Control Myo Cuff Basic Set Settings Bluetooth Connections Clinician Mode Login

General Imprint/information

| © Otto Bock HealthCare Myo Plus Myo Plus App

User Access: Practitioner Access:

• Spiderplot/training Everything patient can access, plus: • Adding patterns (calibration) • The ability to create a test set • Prosthesis movements • Ability to create basic set • Movement quality • Delete all patterns • Manual control of prosthesis • Reset to factory setting

Settings: • Speed of open/close and rotation • Accuracy of pattern recognition • Interference suppression • Threshold value • Reset to basic set

| © Otto Bock HealthCare 22 Myo Plus Myo Plus App

Compatible operating systems and devices

• Apple iPhone 5, iPhone 6 Plus, iPhone 6s, iPhone 7, iPhone 8 Plus, iPhone X, iPod • Touch Generation 5, iPod Touch Generation 6 • Samsung Galaxy S5, Galaxy S7 Edge, Galaxy S8, Galaxy Note 3, Galaxy A3 (2016), Galaxy A3 (2017), Galaxy Tab A, Galaxy Tab S • Sony Xperia Z, Xperia Z1 • Xiaomi Mi A1, Redmi Note 3 • Acer Iconia One • Amazon Fire 10 • Blackberry Keyone • Google Nexus 6, Pixel • Huawei P9 Lite, P10 • LG Optimus G4, Optimus V30 • Motorola Moto X, Moto G3, Moto G5 Plus • One Plus 5T | © Otto Bock HealthCare 23 Myo Plus Fitting Process…

• Introduction

• Features & Benefits

• Componentry

• MyoPlus App

• Fitting Process

• Therapy Protocol

1. Controls Training 2. Repetitive Drills 3. ADLs

• Outcome Measures 24 | © Otto Bock HealthCare Myo Plus Fitting Process…

| © Otto Bock HealthCare Myo Plus Fitting Process

1. Initial Session • Needs to be done in conjunction with the attending Certified Prosthetist who has taken the Myo Plus Qualification course

• Residual limb assessment: - Length - Strength - ROM - Sensation/Nerve condition - Skin condition - Discover if phantom sensation is present * Other considerations: • Prosthetic history • Hand dominance • Environment • Goals & daily activities • Gadget tolerance | © Otto Bock HealthCare Myo Plus Fitting Process 2. Evaluating Phantom Sensation

Differentiated movements of the phantom hand ... • facilitate training with Myo Plus • enable an intuitive prosthesis control • increases the range of possible movement patterns

| © Otto Bock HealthCare 27 Myo Plus Fitting Process 2. Evaluating Phantom Sensation

• Mirror therapy can assist in pattern development

• Always focus vision on the mirror, not the sound side

• Start with 4 basic motions: hand open/close and palm up/down

• Look at each position for 10 seconds

• Next introduce motions/patterns (see next 3 slides for details) Mirror Therapy

• Most effective for 2 weeks, 8-10 sessions per day

• Monitor for grimacing/nausea; may need to revert to visualization

Stralka, Susan, PT, DPT, MS: Mirror Mirror on the Wall: Motor Imagery Program, 2015 [Online | © Otto Bock HealthCare Course] Retrieved from https://myaota.aota.org/shop_aota/product/OL4911

Myo Plus Movement Patterns

| © Otto Bock HealthCare Myo Plus Movement Patterns

| © Otto Bock HealthCare 30 Myo Plus Movement Patterns

| © Otto Bock HealthCare 31 Myo Plus Fitting Process

2. Evaluating Phantom Sensation

• For existing myo-users, it´s recommended to use the same phantom hand movement for hand open and hand close, which is already used in the current fitting

• For new myo-users, it´s recommended to use the physiological movement for hand open and hand close

• For existing and new myo-users it´s recommended to use the physiological movement for wrist rotation (pronate and supinate)

• For new users, phantom training will be needed

| © Otto Bock HealthCare 32 Myo Plus Fitting Process

Pairing

1 2

Turn on the Myo cuff by pressing the charging receptacle for 2 sec. until Start the Myo Plus App by the LED lights up green clicking the Myo Plus icon

| © Otto Bock HealthCare 33 Myo Plus Fitting Process

Pairing

3 4

Add a new Bluetooth connection by clicking on the icon If Bluetooth is deactivated on your device, confirm the Bluetooth Bluetooth mode OFF Bluetooth mode ON (Default)

Bluetooth is active for 5 minutes after the Bluetooth is permanently active request with “Allow” battery is switched on - within this time after the battery is switched on window, a connection to the prosthesis or Myo cuff can be established | © Otto Bock HealthCare 34 Myo Plus Fitting Process

Pairing

5 6

• Select Myo Cuff serial number (on PIN card delivered in box)

• Enter PIN of Myo cuff • (also on PIN card)

| © Otto Bock HealthCare 35 Myo Plus Fitting Process

Pairing

7 8

If a Bluetooth connection request • App is now successfully connected to cuff pops up, confirm with “OK” • Spiderplot is displayed

| © Otto Bock HealthCare 36 Myo Plus Fitting Process

3. Evaluating Movement Patterns (Myo Cuff) • It´s recommended, to position the Myo cuff so that the ulna is placed between electrode no. 1 and no. 8

• Electrode no. 1 should be positioned laterally so that the electrode number increases in the medial direction

• Regardless of whether the cuff is applied to a left or right forearm, the extensor muscles are then placed between electrode no. 1 and no. 4 and the flexor muscles are placed between electrode no. 5 and no. 8

ALWAYS position cuff in the same way!

| © Otto Bock HealthCare 37 Example: Placement on the right forearm Example: Placement on the left forearm Myo Plus Fitting Process

3. Evaluating Movement Patterns (Myo Cuff) • Testing the muscle activity in the limb • Intuitive movements • Number of patterns depends on the prosthetic hand (and if using rotator)

Patient thinks about e.g. open the hand, performs the movement bilaterally, thereby producing a pattern in the spider plot

 Evaluate all possible phantom hand movements with the cuff | © Otto Bock HealthCare 38 Myo Plus Fitting Process

3. Evaluating Movement Patterns (Myo Cuff)

Example: A bebionic hand with active wrist rotation requires four well-separated and unique motion patterns:

Hand open Power grip / Key grip Palm up Palm down

Pattern scaling active

| © Otto Bock HealthCare 39 Myo Plus Fitting Process

3. Evaluating Movement Patterns (Myo Cuff)

• Watch the four movement patterns alternately during execution

• Unique movement patterns show in different directions and have little overlapping:

| © Otto Bock HealthCare 40 Myo Plus Fitting Process

3. Evaluating Movement Patterns (Myo Cuff)

Poorly separated movement patterns point in the same direction and present with overlapping positions; these two are not unique enough for the system to adequately understand which component should move.

| © Otto Bock HealthCare 41 Myo Plus Fitting Process

4. Training and Recording Test Set

• After the evaluation of the movement patterns is done, the patterns are recorded and stored for testing

• This is done under the menu “Basic Set“ by the practitioner logged in as a specialist.

• Creating a test set is recommended to check if the movement patterns are clearly separated and can be used for the Basic Set

| © Otto Bock HealthCare 42 Myo Plus Fitting Process

4. Training & Testing Patterns

• By clicking on "Create test set" a test set is created from the two recordings and stored temporarily in the Myo cuff  The test set is lost after switching off the Myo cuff

• Now there are 2 options to test the reliability of the control. | © Otto Bock HealthCare Myo Plus Fitting Process

4. Recording a Pattern

• Make sure the elbow is flexed to 90 degrees

• Start the recording by clicking on the symbol

• The previously set pause time (blue bar) begins to expire Contraction strength

• During this phase, prepare the user for the movement 40% 60% shown in the picture 20% 80% • The muscles should be relaxing during the pause time

• When the pause time has expired, the contraction phase (red) begins | © Otto Bock HealthCare 44 Myo Plus Fitting Process

4. Evaluating the Recorded Test Set

Use Spiderplot: Use movement display:

| © Otto Bock HealthCare 45 Myo Plus Fitting Process

4. Training & Testing Patterns

Use Spiderplot:

• Compare generated movement patterns (gray) to the recorded (color-coded) patterns; should be very similar!

• If the current movement pattern is detected as a prosthesis movement, the pattern is highlighted in color and the associated prosthesis movement is displayed in the symbol image

• Each prosthesis movement is displayed in a different color (scroll down)

• Free text space to enter cues as needed (extend finger, etc.) | © Otto Bock HealthCare 46

Myo Plus Fitting Process

4. Training & Testing Patterns

Use movement display:

• If the Spiderplot is displayed, and it is swiped to the right, the movement display appears - the movement display simulates the real prosthesis

• The current contraction strength is shown in the contraction bar (red)

• The current detected movement is shown in the symbol picture

• Evaluate the prosthetic control together with the user by using the spider plot or the movement display

• If the prosthesis control is working reliable, continue with the basic set

• Reliable means that the prosthesis generates the desired movements and the user has just little or no problems with the execution of the movement patterns

| © Otto Bock HealthCare 47 Myo Plus Fitting Process

5. Creating the basic set

• If all 6 recordings are done, the basic set can be created by clicking on “create basic set”

• A star symbol next to the checkbox indicates that this recording has been recorded but not yet added to the basic set

• After creating the basic set, evaluate the stored patterns during the control

• Proceed in the same way as with the "test set"

• If one or more recordings do not work reliably, you can test them individually

| © Otto Bock HealthCare Myo Plus Fitting Process

5. Evaluating Basic Set

Selecting Individual Patterns to Test:

1. Uncheck the desired recording in the menu “basic set” and create a test set Now only the selected recordings are used for the control 2. If the control works better, record the desired pattern again To do this, click on the corresponding arrow symbol 3. Pay attention to the correct arm position and start the recording 4. Then create a new basic set and test the prosthesis control again

| © Otto Bock HealthCare 49 Myo Plus Fitting Process

5. Creating the basic set

Adding Additional Patterns • In total 30 recordings can be added to the system - the number of remaining recordings is shown by the counter

• If the basic set is recorded, 24 additional recordings of the same or new prosthesis movements can be added in the menu “Add movements”

• Adding of additional patterns may be necessary:

 if more than four hand movements of the bebionic hand should be controlled (more as hand open, power grip / key grip, palm down, palm up)

 when a movement in certain situations or arm positions is detected not to be reliable - e.g. hand above the head | © Otto Bock HealthCare 50

Myo Plus Fitting Process

5. Creating the basic set

MyoBock hands – Adding Patterns:

• When using a MyoBock hand, the four available prosthesis movements are already recorded in the basic set

• The selected movements can be added to the basic set by selecting the checkbox and clicking on "Continue to recording”

| © Otto Bock HealthCare Myo Plus Fitting Process

5. Creating the basic set

Bebionic hand: Adding Patterns • When using the bebionic hand, 4 prosthesis movements are recorded in the basic set

• Each movement pattern (except hand open and rotation) controls two grip types, depending on whether the thumb is in opposition or lateral

• These grip pairs are pre-defined and can be seen in the menu "Add pattern" or “Movement selection“

• If more prosthetic movements should be controlled with Myo Plus, the movements must be selected here and added to the basic set by clicking "Continue to record" | © Otto Bock HealthCare

Myo Plus Fitting Process

5. Creating the basic set

• In the menu "Prosthesis movements", one or more prosthesis movements can be deactivated

• Example 1: Palm down and Palm up is disabled during activities in which the prosthesis should not rotate involuntarily

• Example 2: Certain movements deactivated while working on improving others

| © Otto Bock HealthCare 53 Myo Plus Fitting Process

5. Basic Set: Additional App Features

• In the menu “Movement Quality", the quality of the recorded movement patterns is represented by a simple rating system

• Per recorded movement up to 5 stars can be awarded

• A movement rated with 5 stars can be clearly recognized

• The fewer stars awarded, the harder it is for Myo Plus to distinguish the movements: 3 stars is acceptable

• Movement patterns are exported to the Android / iOS device

• May be useful for documentation and are stored in the image folder of the device

| © Otto Bock HealthCare 54 Myo Plus Fitting Process

5. Settings Adjustments

| © Otto Bock HealthCare 55 Myo Plus Fitting Process

5. Basic Set: Additional App Features

Settings Adjustments: bebionic hand

When controlling the bebionic hand, the user can choose between two options:

1. Control of the bebionic hand with Myo Plus via movement patterns or

2. Control of the bebionic hand analogous to the classic control, with open/open switching and program switch on the back of the hand

| © Otto Bock HealthCare 56 Myo Plus Fitting Process

5. Basic Set: Additional App Features

Settings Adjustments

• The name of the prosthesis can be defined – when movement patterns are exported, a folder with the name is created on the Android/iOS device

• The speed of the terminal device and rotation can be chosen:

| © Otto Bock HealthCare 57 Myo Plus Fitting Process

5. Basic Set: Additional App Features

Settings Adjustments • Choose to have hand automatically move into glove-donning mode when powered on – this function is very useful for getting dressed

• Choose if prosthesis should be reset to the basic set – necessary, for example, if the user added additional movement patterns which lead to trouble with prosthetic control

| © Otto Bock HealthCare 58 Myo Plus Fitting Process

5. Basic Set: Additional App Features

ADVANCED Settings Adjustments: Accuracy of Pattern Recognition

• A high adjustment means, that the prosthesis reacts sensitively and quickly to generated patterns - a high setting is recommended for highly accurate reproducible patterns

• A low adjustment means, that less accuracy in creating the patterns is required - the control of the prosthesis is thereby more reliable but slower | © Otto Bock HealthCare 59 Myo Plus Fitting Process

5. Basic Set: Additional App Features

ADVANCED Settings Adjustments: Interference Suppression

• A high interference suppression means that many external interference signals are filtered out successfully but some intentional EMG signals might also be filtered out. This may lead to a loss of intended movements.

• EXAMPLE: While shopping, a shopping bag is worn over the prosthetic socket - the prosthesis rotates unintentionally • Increasing the interference suppression could suppress the unwanted signal generated by the socket rotation | © Otto Bock HealthCare 60 Myo Plus Fitting Process

5. Basic Set: Additional App Features

ADVANCED Settings Adjustments: Threshold Value

• A low threshold value means that the prosthesis responds even to minor muscle contraction – however, unintentional muscle contractions may cause unintentional prosthesis movements

• The button “Use default values” sets all adjustments to default

| © Otto Bock HealthCare 61 Myo Plus Fitting Process

5. Basic Set: Additional App Features

ADVANCED Settings Adjustments:

Reset advanced settings to default values • All three advanced settings will be returned to their default settings (Accuracy of pattern recognition, Interference Suppression, & Threshold Value)

Delete all Patterns: CLINICIAN MODE ONLY • With this button, the basic set and all added patterns will be deleted - other settings remain unchanged

Reset to factory setting: CLINICIAN MODE ONLY • With this button, all saved patterns will be deleted and all settings will be reset to factory settings - the Bluetooth connections are also deleted and the app will be closed automatically

| © Otto Bock HealthCare 62 Myo Plus Fitting Process

6. Prosthetic Training

• Largely depends on terminal device used

• Differs with control methods

• If MyoPlus control is not yet sufficient, training should focus on distinguishing movement patterns

• Some movements may need to be deactivated in the beginning to simplify things

• Proceed step by step until desired number of patterns/prosthetic movements can be used in daily life

| © Otto Bock HealthCare Myo Plus Fitting Process…

• Introduction

• Features & Benefits

• Componentry

• MyoPlus App

• Fitting Process

• Therapy Protocol

1. Controls Training 2. Repetitive Drills 3. ADLs

Training phases at a glance:

Follow-Up Visits: Monitor the need for programming changes, prosthetic repair, replacement, or upgrade; treat skin issues; manage pain from overuse; and preserve functionality throughout the aging process.

Physical Training: GOALS  Prevention of body asymmetries and compensatory movements  Integration of prosthesis into movement patterns  Muscle strengthening  Enhancing self-confidence

66 Prosthetic Training Rehabilitation Protocol

Physical Training Exercises:

• Complete with and without the prosthesis • Complete before and after prosthetic fitting • Should be easy to complete in the clinic or at home

Focus Areas: Balance Endurance Strength Muscle coordination

Physical Training: Compensatory Motions NOTE: • Is the body posture upright? Monitor for these movements throughout all 3 tiers of training as • Is the body weight distributed evenly between both legs? well: compensatory motions become difficult to correct over • Is the spine rotated as little as possible or not at all? time, and can lead to future injury. • Are both shoulders at the same height? • Balance and coordination should be maintained while on balance board and uneven surfaces

Physical Training: Strength Training

• Exercises while sitting (e.g. exercise ball) and standing • Use two weights (e.g. bottles or barbell), therabands, etc.

• The weight of the prosthesis may be enough for most exercises • Regular and long-term training is important to achieve sustained success

• Strengthening and overall training of established movement patterns should also continue

Physical Training: Coordination & Balance

Exercises that can be done on level ground, on balance board or foam base:

• Catch and throw a balloon, progress to using a ball • Lift light weights (trunk stability) • Interactive games ( Wii, Xbox etc…) • Laser pointer (tracking commands)

Controls Training: GOALS

 Follow explicit commands  No random movements  Focus on optimal use of the prosthesis  Become more familiar with the prosthesis  Learn control without using objects  Learn all passive and active functions

Controls Training: Passive Functions of Hand

 Turning the prosthesis ON/OFF  Passive wrist rotation  Detaching/reattaching hand from prosthesis; changing from hand to hook (if applicable)  Feeling how fingers bend (if multi-articulating hand)  Operating extra wrist functions (if applicable, such as flexion unit, locking positions)  Charging the prosthesis

Controls Training: Active Functions

• Hand (open / close in all available grip patterns) • Electric Wrist Rotator (pronation / supination) NOTE: • Vary speed and range of motion Not all patients will have an • Switching between components using electronic wrist rotator; please established movement patterns check with attending prosthetist for all componentry included in prosthesis. Sequences: 1. Entire movements (e.g. open / close totally) 2. Partial movements (e.g. open / close halfway) 3. Combination of movements (e.g. open hand quickly, close slowly) 4. Changing control between components (e.g. hand to wrist) 5. Combining movements into sequences involving all componentry

Controls Training: HAND

Example Exercises (10 reps each): • Open completely, fast • Close completely, fast

• Open halfway, slowly • Open a little more, slowly

• Close halfway, slowly • Close a little more, slowly

Open/close NOTES:  Some hands may offer multiple grip patterns; perform exercises in all available grips  Exercises are best completed through mirroring of therapist movements | © Otto Bock HealthCare Prosthetic Training Rehabilitation Protocol

Controls Training: WRIST ROTATION

Example Exercises (10 reps each):

• Pronate 35º, 70º, slow, medium, fast • Supinate 40º, 85º, slow, medium, fast • Return to neutral after pro/supination • Full 360º rotation; stop on command • Change directions on command

Pro/supinate NOTE:  Exercises are best completed through mirroring of therapist movements | © Otto Bock HealthCare Prosthetic Training Rehabilitation Protocol

Controls Training: Combination Sequences

Vary Positions: • Sitting • Standing Vary Planes: • Close to the body / far from the body • Crossing midline • Overhead • Out to the side • Below transverse midline Vary Speed: • Slow, medium, and fast • Stopping the movement on command 30 min, 2-3 times a day

Completion Checklist:

 All passive functions can be independently controlled and adjusted  All active functions are controlled in any plane of movement  No random movements are occurring, only purposeful, consistent actions under the control of the user: myo-sites are strengthened, controlled, and isolated.  Sequences are completed with a minimum of 90% accuracy  Compensatory movements have been minimized

NOTE: This stage of training should not be rushed!

Repetitive Drills: GOALS • In any situation being able to reliably and confidently handle objects using appropriate grip force, speed, precise opening width of hand, and hand pre-positioning using rotator • Focuses on training with objects • Many variations, repetitions, and combinations of exercises with a wide variety of objects • Watch for compensatory motions! Can you identify one shown here?

Repetitive Drills: Example Objects

CUSTOMIZED Clothes pins BASIC - adapt grip force Pens, pencils - small diameter, plain surface Small wooden blocks - different shapes, different grip patterns Cup, softball - precise adaptation of the grip force CDs, deck of cards - thin, flat objects, precision

Repetitive Drills

1. INDIRECT GRASPING 2. DIRECT GRASPING

Initially, the object is passed from the sound side Directly grasping an object with the prosthetic to the prosthetic hand. hand only:

• Train using all grip patterns in hand The proprioceptive and visual feedback received will support the user in operating the • Full, then minimized visual feedback hand properly. • 3 elements of proportional control: - Grip force - Speed - Opening width (as approaching object) • Integrate varied wrist positions • Improve coordination

Repetitive Drills

• Start with single tasks for individual components

• Progress to using all components

• Start with large, hard objects

• Progress to smaller, lighter, softer objects • Incorporate rotational function of the hand (passive and/or active) • 10 reps of each exercise

• 1-3 hours each day

• Integrate the passive functions • Monitor compensatory movements

Repetitive Drills: Training Tips

Be sure to vary….

• Starting positions (of object and prosthesis) • Planes of motion

• Speeds

• Objects / materials

Customize exercises to user’s interests to increase motivation; games can be used to increase motivation and participation.

Repetitive Drills: Tests

• Both of these outcome measures work well as drills during this training stage

• Progress can be documented

Repetitive Drills “Boring”

 Most disliked training phase  Reassure user there is a method to the madness  Provides a stress-free environment “Silly  No consequences if tasks are done incorrectly “Childish” Games”  Provides an opportunity to troubleshoot Why?  Use activities of interest to the user  Game format can increase motivation

“Not Learning” Goal: Internalize all functions & control of the prosthesis In any situation being able to reliably and confidently handle objects using appropriate grip force, speed, precise opening width, and hand/wrist position.

Repetitive Drills Completion Checklist:  Drills can be completed with a minimum of 90% accuracy with objects of all shapes, sizes, and durometers  Objects are grasped with appropriate grip force, speed, and opening width of hand, and can be grasped, held, and released using appropriate wrist rotation

 Drills can be completed in varied planes of motion and starting positions  Compensatory movements are minimized  User presents with full understanding and internalization of prosthetic functions

ADL Training: GOALS • Carry out bimanual functional activities confidently using objects which are regularly used in daily life • Use prosthesis to its best advantage • Attain fully integrated daily prosthetic use • Achieve maximum autonomy & independence

Activities of Daily Living

• Customize activities by interest and importance to user • BADLs first; then IADLs • Bimanual activities to increase coordination • Determine when prosthesis is best used as a functional assist to the sound side, and when it is best used as the primary actuator of an activity • Monitor for compensatory movements such as trunk rotation, shoulder elevation, etc. • Introduce adaptive equipment and techniques as needed

Activities of Daily Living

Training activities should…

• Vary grip force of the hand • Vary speed of hand and wrist • Integrate rotation (wrist) • Use different types of materials • Be completed sitting, standing and moving if applicable • Be creative and customized – this will go a long way with engaging the user! • Start with 3-5 activities; user should be completing these activities at home once the proper techniques are established

ADL Training

Completion Checklist:  All basic activities of daily living can be completed with a minimum of 90% accuracy  Instrumental activities of daily living of highest importance to the user can be completed with a minimum of 90% accuracy  Return to work issues have been examined and resolved (if applicable)  User is able to endure a full day of prosthetic use  User can determine when to use prosthesis to its best advantage, as a functional assist to the sound side or as a primary actuator of an activity

1. CONTROLS TRAINING 2. REPETITIVE DRILLS Unique & reliable patterns No objects used 3. ADLs Passive & active controls Focus on proportional control Purposeful, consistent Vary object sizes & durometers Customize activities movements Vary planes of motion Active vs stabilizing use Mirrored commands & Vary speed (hand & wrist) sequences Indirect grasp, then direct grasp Adaptive strategies Arm supported vs no support Grip strength, speed & opening width Assistive devices Unilateral progressing to bilateral Community reintegration Internalize all available functions

Training Progression Tips

Visual Feedback Distance 1. Proximal 1. With Visual Control 2. Distal Movement 2. Minimal Visual Control

1. Cross Midline 2. Overhead Position 3. Side Objects 1. Sitting 1. Hard 2. Standing 2. Soft 3. Walking 4. Uneven Ground

• Introduction

• Features & Benefits

• Componentry

• MyoPlus App

• Fitting Process

• Therapy Protocol

1. Controls Training 2. Repetitive Drills 3. ADLs

WHY? • Assess current level of performance with prosthetic device to compare with outcome after further prosthetic use and training.

WHEN? • At initial fitting • At definitive fitting • Regular follow up visits

Recommended Criteria:

• Involve tasks similar to those completed in daily life • Easy to perform, not too complicated (feasibility) • Valid for prosthetics

 The following assessments are only recommendations!

 SHAP - Southampton Hand Assessment Procedure  ARAT - Action Research Arm Test  ACMC - Assessment of Capacity for Myoelectric Control  Clothespin Relocation Test  Box and Blocks Test

- OPUS: Orthotics & Prosthetics User Survey

– DASH - Disabilities of the Arm, Shoulder and Hand – SF-36: RAND 36-Item Short Form Health Survey – COPM - Canadian Occupational Performance Measure – WHOQOL BREF – WYH MPI - Multidimensional Pain Inventory – PDI - Pain Disability Inventory – VAS - Visual Analog Pain Scale

Debra Latour, Single-Handed Solutions, LLC. bebionic3 Training Manual. 2017

Ottobock, bebionic Therapy Guide. 2018 [Online Document] Retrieved from https://shop.ottobock.us/media/pdf/BebionicTherapyBrochure2018.pdf

Ottobock, Myo Plus Pattern Recognition In Practice. 2019 [Resources Tab of this course]

Stralka, Susan, PT, DPT, MS: Mirror Mirror on the Wall: Motor Imagery Program, 2015 [Online Course] Retrieved from https://myaota.aota.org/shop_aota/product/OL4911

www.ottobock.com Myo Plus Online Training Quiz CEUs Optional

Quiz Link: