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Prosthetics Course 2016 Esquenazi 1 Amputation Rehabilitation And Prosthetics Course 2016 Amputation Rehabilitation Educational Objectives and Prosthetic Use • Review amputation epidemiology A. Esquenazi, MD • Describe the Phases of Amputation John Otto Haas Chair and Professor Rehabilitation Department of PMR • Compare prosthetic components Director Gait & Motion Analysis Lab • Contrast Lower vs Upper Limb and Amputation Rehabilitation Program • Review Prosthetic Prescription MossRehab Amputation a definition Prevalence of Amputation • Amputation surgery should be considered a reconstructive procedure intended to • Based on data from the NHIS-D there are 1.2 - 1.9 create a functional residual limb capable million persons living in the U.S. with limb loss http://www.cdc.gov/nchs/about/major /nhis_dis/nhis_dis.htm of pain free weight bearing and function: – Meticulous technique and gentle tissue • The patient population with limb amputations is handling expected to double in 25 years – Avoidance of skin grafts and adherent scars Estimating prevalence of limb loss : 2005 to 2050 Ar c h PMR , Mar 2008 – Minimal periosteal stripping with balance of muscle forces should always be attempted Esquenazi Esquenazi Incidence of Amputation Amputation Levels • There are approximately 50,000 new major limb amputations every year in the US • Transcarpal 18% National Health Interview Survey, 2005 • Wrist Disarticulation 10% • Worldwide estimated number of new amputations • Transradial 31% range between 1,000,000 and 1,500,000 per year • Elbow Disarticulation 5% Inter national c ompar is on of LE amputation r ates Ann Vas c Sur g 2009 • Transhumeral 27% • Shoulder Disarticulation 7% • US rate for LE amputation 47/100,000 vs. • Forequarter 2% 5/100,000 UE amputation http://www.amputee-coalition.org/people-speak-out/background.html Es quenaz i, Disability and Rehabilitation 2004 Esquenazi Esquenazi 1 Prosthetics Course 2016 Incidence of Limb Amputation by Level Prevalence of UL Amputation Shoulder Disarticulation 40% Trashumeral Of the 5/100,000 UE amputations in the US Transradial 3.8/100,000 were trauma related, 30% Transtibial 1.3/100,000 were dysvascular related, <1/100,000 were congenital or cancer related. 20% Transfemoral http://www.amputee-coalition.org/people-speak-out/background.html Hip Disarticulation Esquenazi, Disability and Rehabilitation 2004 10% 0% Esquenazi Causes of Upper Limb Amputation Upper Limb Amputation by at MossRehab Age Distribution 0-15 16-35 Malignancy Trauma 36-55 56-90 70% 60% 50% 60% Vascular 40% 50% 63% Congenital 30% 40% 20% 30% 5% 10% 0% 20% 24% 0-15 16-35 36-55 56-90 10% 4% Age Group 0% Esquenazi Esquenazi Transcarpal Wrist Disarticulation Esquenazi Esquenazi Esquenazi 2 Prosthetics Course 2016 Transradial Elbow Disarticulation Esquenazi Esquenazi Transhumeral Shoulder Disarticulation Esquenazi Esquenazi Forequarter Amputation Prosthetic Control Options External Body Cosmetic Hybrid Power Power (Passive) • Myoelectric • Voluntary • External • Switch control opening • Prefabricated power • Tension * • Voluntary • Customized • Body power • Brain Interface* closing • Custom • Cosmetic Esquenazi Esquenazi Esquenazi 3 Prosthetics Course 2016 Passive Terminal Devices Terminal Device Activation Systems • Cosmetic Restoration Body Powered • Voluntary Opening • Voluntary Closing External Powered Esquenazi Esquenazi Active Terminal Devices Active Terminal Devices: Body Power BP Voluntary Opening, Hook Voluntary Opening, Hook Esquenazi Esquenazi Active Terminal Devices: Active Terminal Devices: BP Voluntary Closing, Hook BP Voluntary Opening Farmers Hook Esquenazi Esquenazi Esquenazi 4 Prosthetics Course 2016 Active Terminal Devices: Active Terminal Devices: Body Power, VO & VC Hands BP Voluntary Closing, Hook More Acceptable Cosmesis Esquenazi Esquenazi Partial Hand Partial Hand 3D Printed Esquenazi Esquenazi External Power Terminal Devices Myoelectric Control System Makes use of Powerful Grip + remaining Graded Prehension muscle signals after amputation + Ease of Operation to control Better Cosmesis prosthetic functions Esquenazi Esquenazi Esquenazi 5 Prosthetics Course 2016 External Powered UL Multi Articulate Hands prosthetic use • From lateral or tip pinch to multiple grip styles Esquenazi Terminal Device Opening Comparative T.D. Force Generation (myo hand vs myo hook) Michellangelo 40 Lbs. of Pinch Force iLimb Proportional Greifer Myo Hand Mechanical Hand 30 V.O. Hook 10 Bands 20 Average adult male 10 0 Esquenazi Wrist Components T.D. Opening at Tip for grasp in cm 15 Greiffer Myo Hand Mechanical Hand V.O. Hook Average adult male ETD hook TRS External flexion External flexion 10 I limb Michellangelo 5 centimeters Internal flexion Friction rotation 0 Esquenazi Esquenazi Esquenazi 6 Prosthetics Course 2016 Electric Wrist Rotation Elbow Components • Mechanical • Electro-Mechanical • Spring assisted • External power –Switches and sensors – Myoelectric controls Esquenazi Esquenazi Mechanical Elbow Designs Shoulder Components Single Axis ❚ Bulkhead Polycentric ❚ Flexion-Abduction Step-up Hinges Stump Activated ❚ Universal Joint Locks External Locking Internal Locking Elbow Esquenazi Esquenazi Prosthetic Suspension Systems 63% of persons with Harness Upper Extremity amputation use a Anatomical Body Powered Prosthesis Suction Friction Esquenazi Esquenazi Esquenazi 7 Prosthetics Course 2016 How does a BP prosthesis Prosthetic Harness Function works • TD is closed by rubber bands Suspension • TD is opened by tension on harness via cable Activation of TD • TD closes when harness relaxes Activation of Elbow • For TH, elbow flexes then locked before TD opens Actuation of elbow lock Esquenazi Esquenazi Body Powered Control Systems TR Harness Functions Ter m i nal Elbow Flexion Elbow Lock Figure 8 Harness Device Functions Biscapular Biscapular Shoulder Scapular abduction & abduction & Disarticulation elevation Latissimus Dorsi Latissimus Dorsi ❚ Suspension, Shoulder ❚TD Activation Biscapular Biscapular Depression & Transhumeral Abduction & Abduction & Humeral Humeral Flexion Humeral Flexion Abduction & Extension Biscapular Transradial Abduction & NA NA Humeral Flexion Esquenazi Esquenazi TR Harness Functions TH Harness Functions Dual-control principle Triple-control principle Figure 9 Harness Elbow Locking Dual Control Harness Function ❚ ShoulderFair lead elevation cable system FunctionsBowden cable system Fair-lead ❚ Suspension,European - ❚TD Activation harness Northwestern - harness ❚ Elbow Activation, ❚ TD Activation Elbow most be locked to activate terminal device Esquenazi Esquenazi Esquenazi 8 Prosthetics Course 2016 Alternative Harness System ShoulderShoulder Disarticulation Disarticulation Harness ExternalBody PoweredPowered ProsthesisProsthesis Esquenazi TR Anatomical Suspension Supracondylar Münster socket Silicone Suspension ■ Useful in cases where skin is delicate 2nd to scars ■ Short residual limb friction provides suspension Esquenazi Esquenazi Silicone Suspension for TR Suction Suspension body powered prosthesis Myoelectric systems can be suspended with suction Improves the suspension and comfort for some transradial amputees Esquenazi Esquenazi Esquenazi 9 Prosthetics Course 2016 Suction & Friction Suspension Bilateral Shoulder for myoelectric THA Disarticulation Esquenazi Esquenazi Targeted Muscle Re-innervation (TMR) Targeted Reinnervation • Nerves must regenerate: 3 months for detectable signal • Need intact brachial plexus • Utilizes existing technology • Time to proficiency much shorter, once training starts • Potential for sensory feedback Courtesy of Dr. Kuiken Esquenazi Evolution of Transhumeral Prosthesis Future Developments 22 Movements 22 movements 3 movements 7 movements Esquenazi Esquenazi Esquenazi 10 Prosthetics Course 2016 Toileting and Showering Drinking Differences Esquenazi Virtual Reality Rehabilitation Primary use of UL prosthesis 60%# 50%# 40%# 30%# General function and prosthetic-device use by site of major traumatic limb loss and conflict. 20%# Vietnam OIF/OEF # % # % 10%# Unilateral Upper Limb N = 47 50 Prosthesis used to Majority of daily tasks 13 27.7 18 36.0 0%# Grasp#/#Li2# Push#/#Pull# Cosmesis# perform: Minority of daily tasks 20 42.6 20 40.0 Total 33 70.3 38 76.0 No prosthesis used 14 29.8 12 24.0 Bilateral Upper Limb Only Self Management N = interventions6 for amputees7 in a virtual world environment. Winkler, Cooper, Esquenazi 2016 Esquenazi Prosthesis used to Majority of daily tasks 1 16.7 5 71.4 perform: Minority of daily tasks 2 33.3 1 14.3 Total 3 50.0 6 85.7 GeneralNo prosthesis function used and prosthetic-device use by site of major3 traumatic50.0 limb loss and1 conflict.14.3 Unilateral Lower Limb N = 178 172 Vietnam OIF/OEF Prosthesis used to Do not walk (1, 2) #2 1.%3 #1 0.6% performUnilateral (by Upper LimbHousehold walker (3) N = 15 47 8.4 10 50 5.8 functionalProsthesis level):used to CommunityMajority of dailywalker tasks (4) 3134 19.127.7 2318 13.436.0 perform: VaryingMinority speed of daily walker tasks (5) 6203 35.442.6 3920 22.740.0 General function and prosthetic-device use by site of major traumatic limb loss and conflict. Unilateral Upper Limb Loss: Total FunctionLow-impact and activities prosthetic (6) 2933 170.3 6device.3 4438 25.676.0 Vietnam OIF/OEF No prosthesis used High-impact activities (7) 147 29.3.98 4512 26.24.20 Satisfaction and Prosthetic Device Use in Vietnam and # % # % TotalUnilateralBilateral Upper Upper Limb Limb Only NN == 150 476 84.3 162 507 94.2*** OIF/OEF Soldiers NoProsthesis prosthesis used used to MMajoriajorityty of daily tasks 21318 127.716.75.7 10185 5.836.71.4*0* • Prostheses use is more
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