Difficulty of Performing Activities of Daily Living with the Michelangelo Multigrip
and Traditional Myoelectric HandsAndreas Kannenberg, MD PhD
on behalf of the Strategic Consortium for Upper Limb Prosthetic Technologies (SCULPT)
| © Otto Bock HealthCareDr. Andreas Kannenberg – Michelangelo vs. regular myo – ORT, May 15, 2012 2
Introduction
Rejection rates are relatively high in upper limb prostheses*
Ø passive hands 53%
Ø body-powered hooks 50%
Ø myoelectric hands 39%
Main reasons for rejection of prosthetic hands:
Ø missing out on the “golden window“**
Ø poor dexterity
Ø glove durability
Ø lack of sensory feedback
*Bidiss E, Beaton D, Chau T: Consumer design priorities for upper limb prosthetics. Disabil Rehabil 2007, 2(6): 346-357***Bowker JH: The art of prosthetic prescription. In: Smith DG, Michael JW, Bowker, JH: Altlas of amputations and limb deficiencies. Rosemont, IL; American Academy of Orthopedic Surgeons (AAOS), 2004.
| © Otto Bock HealthCareDr. Andreas Kannenberg – Michelangelo vs. regular myo – ORT, May 15, 2012 3
Drives of the Michelangelo® hand
finger moving unit
main drive
The main drive is responsible for grasping movements and grip force
Ring finger and little finger are moved passively by the finger moving unit
active thumb drive
The thumb drive enables the user to use oppositionor lateral grip
| © Otto Bock HealthCareDr. Andreas Kannenberg – Michelangelo vs. regular myo – ORT, May 15, 2012 4
Michelangelo® multigrip hand: 3 modes and 7 hand positions
| © Otto Bock HealthCareDr. Andreas Kannenberg – Michelangelo vs. regular myo – ORT, May 15, 2012 5
| © Otto Bock HealthCareDr. Andreas Kannenberg – Michelangelo vs. regular myo – ORT, May 15, 2012 6
Methodology
Patient sample
16 unilateral transradial amputees using regular myoelectric prosthetic hands gave informed consent and participated in this study.
Ø average age 41 ± 14 years
Ø mean time since amputation: 12.8 ± 16.1 years
Ø all male
Ø amputation etiology: 6 congenital deformities, 8 trauma, 1 malignancy, 1 sepsis
Ø amputation side: 11 left hands, 5 right hands
Ø dominance of amputation side: 4 dominant hands (all right), 12 non-dominant hands
| © Otto Bock HealthCareDr. Andreas Kannenberg – Michelangelo vs. regular myo – ORT, May 15, 2012 7
Study design
Patients filled out two self-reported questionnaires
Ø OPUS-UEFS
Ø PUFI
for their existing myoelectric hands
as well as after a mean use of the Michelangelo® multi-grip handof 12.4 ± 7.3 weeks.
| © Otto Bock HealthCareDr. Andreas Kannenberg – Michelangelo vs. regular myo – ORT, May 15, 2012 8
Outcome measures
Basic challenge
“There is no one “gold standard“ outcome measure identified thatcovered all related components [of outcome] and would work in all fields of application (i.e., research or patient care). …
One recommendation of the ULPOM group was to build a “toolkit“ of“validated procudures for the entire development cycle [of a prosthesis] to be developed and promoted within the appropriateprofessions.“
The Upper Limb Prosthetic Outcome Measure (ULPOM) group: Upper Limb prosthetic outcome measures. Official findings of the State-of-Science-Conference, March 27-29, 2009. Proceedings of the American Academy of Orthotists & Prosthetists (AAOP), Number 9, October 2009
Hill W, Stavdahl O, Hermansson LN, et al.: Functional Outcomes in the WHO-ICF Model: establishment of the Upper Limb Prosthetic Outcome Measure Group. J Prosthet Orthot 2009: 21: 115-119
| © Otto Bock HealthCareDr. Andreas Kannenberg – Michelangelo vs. regular myo – ORT, May 15, 2012 9
Outcome measures: OPUS-UEFS
Orthotics & Prosthetics User Survey – Upper Extremity Functional Status (OPUS-UEFS)
Patients rate the perceived difficulty to perform 23 activities of daily living (ADL):
Ø very easy 3 points
Ø easy 2 points
Ø difficult 1 point
Ø cannot perform activity 0 point
Heinemann AW, Bode RK, O´Reilly C: Development and measurement properties of the Orthotics and Prosthetics Users´ Survey: A comprehensive set of clinical outcome measures. Prosth Orthot Int 2003, 27: 191-206
Burger H, Franchignoni F, Heinemann AW, Kotnik S, Giordano A. Validation of the orthotics and prosthetics user survey upper extremity functional status module in people with unilateral upper limb amputation. J Rehabil Med 2008; 40: 393–399.
| © Otto Bock HealthCareDr. Andreas Kannenberg – Michelangelo vs. regular myo – ORT, May 15, 2012 10
Outcome measures: PUFI
The Prosthetic Upper Extremity Functional Index (PUFI) is well validated for children of various age groups to measure the
Ø way of using the prosthesis
Ø perceived difficulty to perform activities with and without the prosthesis
Ø perceived usefulness of the prosthesis
with age specific activities but no PUFI questionnaire for adult prosthesis users exists.
An “adult PUFI“ was created by using the 23 ADLs of the OPUS-UEFS with the scaling scheme of the PUFI.
Wright FV, Hubbard S, Naumann S, Jutai J: Evaluation of the validity of the Prosthetic Upper Extremity Functional Index for children. Arch Phys Med Rehabil 2003, 84: 518-527
| © Otto Bock HealthCareDr. Andreas Kannenberg – Michelangelo vs. regular myo – ORT, May 15, 2012 11
Adult-PUFI: Way of using the prosthesis
How do you usually do this activity?
□ both arms together with prosthetic hand used actively to grasp the (object)
□ both arms together with the prosthesis used passively to position orstabilize (the object) on a surface or against (another object)
□ with assistance of the residual limb
□ non-prosthetic hand alone
□ with some help from another person
□ other way (please describe)
Wright FV, Hubbard S, Naumann S, Jutai J: Evaluation of the validity of the Prosthetic Upper Extremity Functional Index for children. Arch Phys Med Rehabil 2003, 84: 518-527
| © Otto Bock HealthCareDr. Andreas Kannenberg – Michelangelo vs. regular myo – ORT, May 15, 2012 12
Adult-PUFI: Perceived difficulty and usefulness
How well do you do this activity with / without the prosthesis?
□ with no difficulty□ with some difficulty□ with great difficulty□ with some help from another person□ cannot do it with/without the prosthesis
How useful is the prosthesis for this activity?
□ very useful□ somewhat useful□ not useful
Wright FV, Hubbard S, Naumann S, Jutai J: Evaluation of the validity of the Prosthetic Upper Extremity Functional Index for children. Arch Phys Med Rehabil 2003, 84: 518-527
| © Otto Bock HealthCareDr. Andreas Kannenberg – Michelangelo vs. regular myo – ORT, May 15, 2012 13
Previous hand prostheses
Ø Sensor Hand Speed: 10 patients
Ø VariPlus Speed: 3 patients
Ø DMC Plus: 1 patient
Ø Motion Control: 1 patient
Ø Greifer: 1 patient
One patient used both a Sensor Hand Speed and a Greifer.
| © Otto Bock HealthCareDr. Andreas Kannenberg – Michelangelo vs. regular myo – ORT, May 15, 2012
0
10
20
30
40
50
60
All (23) activities 19 activities monomanual bimanual
Score
traditional myo Michelangelo
14
Results: Perceived ease of performing ADLs (OPUS-UEFS)
p=.03
p=.01p=.07
Sound hand
+37%
54%
| © Otto Bock HealthCareDr. Andreas Kannenberg – Michelangelo vs. regular myo – ORT, May 15, 2012 15
OPUS-UEFS difficulty rating per individual ADLs
Ø 5 ADLs were significantly easier to perform with Michelangelo®§ wash face p=.04§ put on socks p=.03§ tie shoe laces p=.03§ cut meat with knife and fork p=.03§ carry laundry basket p=.01
Ø 16 ADLs were easier to perform with Michelangelo®, but differences did not reach statistical significance
Ø 2 ADLs were easier to perform with the previous hands, but differences did not reach statistical significance
| © Otto Bock HealthCareDr. Andreas Kannenberg – Michelangelo vs. regular myo – ORT, May 15, 2012 16
OPUS-UEFS: Prosthesis use
0
2
4
6
8
10
12
14
16
18
traditional myo Michelangelo
Number of ADLs performed with the prosthesis
9.5 ± 3.711.1 ± 4.2
p=.04
| © Otto Bock HealthCareDr. Andreas Kannenberg – Michelangelo vs. regular myo – ORT, May 15, 2012 17
PUFI – Way of using the prosthesis
0 2 4 6 8 10 12 14 16
non-prosthetic hand alone
with assistance of the residual limb
prosthetic hand used passively
prosthetic hand used actively to grasp
Number of activities
Michelangelo
conventional myo
p=.04
| © Otto Bock HealthCareDr. Andreas Kannenberg – Michelangelo vs. regular myo – ORT, May 15, 2012 18
PUFI: Usefulness of the prosthesis
0
2
4
6
8
10
12
14
16
traditional myo Michelangelo
Average number of activities for which prosthesis is rated "very useful"
p=.01
6.4 ± 4.19.1 ± 4.3
| © Otto Bock HealthCareDr. Andreas Kannenberg – Michelangelo vs. regular myo – ORT, May 15, 2012 19
Discussion
Thus far only case reports on the use of multigrip prosthetic hands have been published with mixed results.
This is the first bigger observational study to compare a multigrip with traditional single-grip myoelectric hands.
| © Otto Bock HealthCareDr. Andreas Kannenberg – Michelangelo vs. regular myo – ORT, May 15, 2012
Discussion
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When using the Michelangelo® multigrip hand individuals with a unilateral transradial amputation
Ø perceive it easier to perform ADLs
Ø use the prosthesis in more activities
Ø use the prosthesis more often toactively grasp objects
Ø perceive the prosthesis more useful
than when using traditional myoelectric hands.
| © Otto Bock HealthCareDr. Andreas Kannenberg – Michelangelo vs. regular myo – ORT, May 15, 2012
Limitations and future research directions
Limitations
Ø no standardized follow-up period and occupational training(“real world scenario“)
Ø use of self-reported outcome measures only
Ø OPUS-UEFS is still work in progress; “adult PUFI“ not validated
Future research should
Ø use performance-based outcome measures
Ø study compensatory movements
Ø compare multigrip prosthetic hands
21
| © Otto Bock HealthCareDr. Andreas Kannenberg – Michelangelo vs. regular myo – ORT, May 15, 2012
Conclusions
Multigrip myoelectric hands such as Michelangelo® are a promising technological progress towards improved prosthetic hand function.
Patients with a transradial amputation perceive multigrip hands more useful than traditional single-grip myoelectric hands.
The gap between prosthetic hands and a sound human hand is still huge with lots of room for further improvement.
22
| © Otto Bock HealthCareDr. Andreas Kannenberg – Michelangelo vs. regular myo – ORT, May 15, 2012
Acknowledgements
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Strategic Consortium for Upper Limb Prosthetic Technologies (SCULPT)
John Miguelez, CPO, Dan Conyers, CPO, Tiffany Ryan, OT –Advanced Arm Dynamics, Redondo Beach, CA, USA
Rehabilitation Institute of Chicago (RIC), Chicago, IL, USA
Trond A. Schonhowd, CPO – Norsk Teknisk Ortopedi (NTO), Harmar, Norway
Andrea Cutti, PhD – INAIL (Italian Workers´ Compensation), Budrio, Italy
Erik Andres, CPO – Ottobock, Germany
Wolfgang Gröpel, CPO, Novavis, Germany
| © Otto Bock HealthCareDr. Andreas Kannenberg – Michelangelo vs. regular myo – ORT, May 15, 2012 24Courtesy: Andrea Cutt, PhD, Italian Workers´ Compensation INAIL, Budrio/Italy,publication accepted by JRRD
Biomechanical study of compensatory movements
Ø 8 patients with a unilateral transradial amputation
Ø previous hands: Myohand Variplus or DMC plus
Ø psychosocial assessments
Ø performance-based and self-reported functional outcomes
Ø motion capture at baseline and after 3 months of Michelangelo use
| © Otto Bock HealthCareDr. Andreas Kannenberg – Michelangelo vs. regular myo – ORT, May 15, 2012 25
| © Otto Bock HealthCareDr. Andreas Kannenberg – Michelangelo vs. regular myo – ORT, May 15, 2012 26
| © Otto Bock HealthCareDr. Andreas Kannenberg – Michelangelo vs. regular myo – ORT, May 15, 2012 27
| © Otto Bock HealthCareDr. Andreas Kannenberg – Michelangelo vs. regular myo – ORT, May 15, 2012 28
| © Otto Bock HealthCareDr. Andreas Kannenberg – Michelangelo vs. regular myo – ORT, May 15, 2012 29
| © Otto Bock HealthCareDr. Andreas Kannenberg – Michelangelo vs. regular myo – ORT, May 15, 2012 30
Prosthesis use
| © Otto Bock HealthCareDr. Andreas Kannenberg – Michelangelo vs. regular myo – ORT, May 15, 2012 31
| © Otto Bock HealthCareDr. Andreas Kannenberg – Michelangelo vs. regular myo – ORT, May 15, 2012 32
| © Otto Bock HealthCareDr. Andreas Kannenberg – Michelangelo vs. regular myo – ORT, May 15, 2012 33
| © Otto Bock HealthCareDr. Andreas Kannenberg – Michelangelo vs. regular myo – ORT, May 15, 2012 34
| © Otto Bock HealthCareDr. Andreas Kannenberg – Michelangelo vs. regular myo – ORT, May 15, 2012 35
Results: Video DMC plus hand
Courtesy: Andrea Cutt, PhD, Italian Workers´ Compensation INAIL, Budrio/Italy,publication accepted by JRRD
| © Otto Bock HealthCareDr. Andreas Kannenberg – Michelangelo vs. regular myo – ORT, May 15, 2012 36
Results: Video Michelangelo
Courtesy: Andrea Cutt, PhD, Italian Workers´ Compensation INAIL, Budrio/Italy,publication accepted by JRRD
| © Otto Bock HealthCareDr. Andreas Kannenberg – Michelangelo vs. regular myo – ORT, May 15, 2012 37
Kinematics (1)
conventional myo handMichelangeloable-bodied subjects
Courtesy: Andrea Cutt, PhD, Italian Workers´ Compensation INAIL, Budrio/Italy,publication accepted by JRRD
| © Otto Bock HealthCareDr. Andreas Kannenberg – Michelangelo vs. regular myo – ORT, May 15, 2012 38
Kinematics (2)
conventional myo handMichelangeloable-bodied subjects
Courtesy: Andrea Cutt, PhD, Italian Workers´ Compensation INAIL, Budrio/Italy,publication accepted by JRRD
| © Otto Bock HealthCareDr. Andreas Kannenberg – Michelangelo vs. regular myo – ORT, May 15, 2012 39
Compensatory movements
| © Otto Bock HealthCareDr. Andreas Kannenberg – Michelangelo vs. regular myo – ORT, May 15, 2012 40