Technology for monitoring everyday prosthesis use: a systematic review

BACKGROUND Understanding how prostheses are used in everyday life is central to the design, provision and evaluation of prosthetic devices and associated services. This paper reviews the scientific literature on methodologies and technologies that have been used to assess the daily use of both upper- and lower-limb prostheses. It discusses the types of studies that have been undertaken, the technologies used to monitor physical activity, the benefits of monitoring daily living and the barriers to long-term monitoring. METHODS A systematic literature search was conducted in PubMed, Web of Science, Scopus, CINAHL and EMBASE of studies that monitored the activity of prosthesis-users during daily-living. RESULTS 60 lower-limb studies and 9 upper-limb studies were identified for inclusion in the review. The first studies in the lower-limb field date from the 1990s and the number has increased steadily since the early 2000s. In contrast, the studies in the upper-limb field have only begun to emerge over the past few years. The early lower-limb studies focused on the development or validation of actimeters, algorithms and/or scores for activity classification. However, most of the recent lower-limb studies used activity monitoring to compare prosthetic components. The lower-limb studies mainly used step-counts as their only measure of activity, focusing on the amount of activity, not the type and quality of movements. In comparison, the small number of upper-limb studies were fairly evenly spread between development of algorithms, comparison of everyday activity to clinical scores, and comparison of different prosthesis user populations. Most upper-limb papers reported the degree of symmetry in activity levels between the arm with the prosthesis and the intact arm. CONCLUSIONS Activity monitoring technology used in conjunction with clinical scores and user feedback, offers significant insights into how prostheses are used and whether they meet the user’s requirements. However, the cost, limited battery-life and lack of availability in many countries mean that using sensors to understand the daily use of prostheses and the types of activity being performed has not yet become a feasible standard clinical practice. This review provides recommendations for the research and clinical communities to advance this area for the benefit of prosthesis users

Quantifying prosthetic and intact limb use in upper limb amputees via egocentric video: an unsupervised, at-home study

Analysis of the manipulation strategies employed by upper-limb prosthetic device users can provide valuable insights into the shortcomings of current prosthetic technology or therapeutic interventions. Typically, this problem has been approached with survey or lab-based studies, whose prehensile-grasp-focused results do not necessarily give accurate representations of daily activity. In this work, we capture prosthesis-user behavior in the unstructured and familiar environments of the participants own homes. Compact head-mounted video cameras recorded ego-centric views of the hands during self-selected household chores. Over 60 hours of video was recorded from 8 persons with unilateral amputation or limb difference (6 transradial, 1 transhumeral, 1 shoulder). Of this, almost 16 hours of video data was analyzed by human experts using the 22-category ‘TULIP’ custom manipulation taxonomy, producing the type and duration of over 27,000 prehensile and non-prehensile manipulation tags on both upper limbs, permitting a level of objective analysis not previously possible with this population. Our analysis included unique observations on non-prehensile manipulations occurrence, determining that 79% of transradial body-powered device manipulations were non-prehensile, compared to 60% for transradial myoelectric devices. Conversely, only 16-19% of intact limb activity was non-prehensile. Additionally, multi-grasp terminal devices did not lead to increased activity compared to 1DOF devices

Use of stance control knee-ankle-foot orthoses : a review of the literature

The use of stance control orthotic knee joints are becoming increasingly popular as unlike locked knee-ankle-foot orthoses, these joints allow the limb to swing freely in swing phase while providing stance phase stability, thus aiming to promote a more physiological and energy efficient gait. It is of paramount importance that all aspects of this technology is monitored and evaluated as the demand for evidence based practice and cost effective rehabilitation increases. A robust and thorough literature review was conducted to retrieve all articles which evaluated the use of stance control orthotic knee joints. All relevant databases were searched, including The Knowledge Network, ProQuest, Web of Knowledge, RECAL Legacy, PubMed and Engineering Village. Papers were selected for review if they addressed the use and effectiveness of commercially available stance control orthotic knee joints and included participant(s) trialling the SCKAFO. A total of 11 publications were reviewed and the following questions were developed and answered according to the best available evidence: 1. The effect SCKAFO (stance control knee-ankle-foot orthoses) systems have on kinetic and kinematic gait parameters 2. The effect SCKAFO systems have on the temporal and spatial parameters of gait 3. The effect SCKAFO systems have on the cardiopulmonary and metabolic cost of walking. 4. The effect SCKAFO systems have on muscle power/generation 5. Patient’s perceptions/ compliance of SCKAFO systems Although current research is limited and lacks in methodological quality the evidence available does, on a whole, indicate a positive benefit in the use of SCKAFOs. This is with respect to increased knee flexion during swing phase resulting in sufficient ground clearance, decreased compensatory movements to facilitate swing phase clearance and improved temporal and spatial gait parameters. With the right methodological approach, the benefits of using a SCKAFO system can be evidenced and the research more effectively converted into clinical practice

The effect of prefabricated wrist-hand orthoses on performing activities of daily living

Wrist-hand orthoses (WHOs) are commonly prescribed to manage the functional deficit associated with the wrist as a result of rheumatoid changes. The common presentation of the wrist is one of flexion and radial deviation with ulnar deviation of the fingers. This wrist position Results in altered biomechanics compromising hand function during activities of daily living (ADL). A paucity of evidence exists which suggests that improvements in ADL with WHO use are very task specific. Using normal subjects, and thus in the absence of pain as a limiting factor, the impact of ten WHOs on performing five ADLs tasks was investigated. The tasks were selected to represent common grip patterns and tests were performed with and without WHOs by right-handed, females, aged 20-50 years over a ten week period. The time taken to complete each task was recorded and a wrist goniometer, elbow goniometer and a forearm torsiometer were used to measure joint motion. Results show that, although orthoses may restrict the motion required to perform a task, participants do not use the full range of motion which the orthoses permit. The altered wrist position measured may be attributable to a modified method of performing the task or to a necessary change in grip pattern, resulting in an increased time in task performance. The effect of WHO use on ADL is task specific and may initially impede function. This could have an effect on WHO compliance if there appears to be no immediate benefits. This orthotic effect may be related to restriction of wrist motion or an inability to achieve the necessary grip patterns due to the designs of the orthoses

The effect of prefabricated wrist-hand orthoses on grip strength

Prefabricated wrist-hand orthoses (WHOs) are commonly prescribed to manage the functional deficit and compromised grip strength as a result of rheumatoid changes. It is thought that an orthosis which improves wrist extension, reduces synovitis and increases the mechanical advantage of the flexor muscles will improve hand function. Previous studies report an initial reduction in grip strength with WHO use which may increase following prolonged use. Using normal subjects, and thus in the absence of pain as a limiting factor, the impact of ten WHOs on grip strength was measured using a Jamar dynamometer. Tests were performed with and without WHOs by right-handed, female subjects, aged 20-50 years over a ten week period. During each test, a wrist goniometer and a forearm torsiometer were used to measure wrist joint position when maximum grip strength was achieved. The majority of participants achieved maximum grip strength with no orthosis at 30° extension. All the orthoses reduced initial grip strength but surprisingly the restriction of wrist extension did not appear to contribute in a significant way to this. Reduction in grip must therefore also be attributable to WHO design characteristics or the quality of fit. The authors recognize the need for research into the long term effect of WHOs on grip strength. However if grip is initially adversely affected, patients may be unlikely to persevere with treatment thereby negating all therapeutic benefits. In studies investigating patient opinions on WHO use, it was a stable wrist rather than a stronger grip reported to have facilitated task performance. This may explain why orthoses that interfere with maximum grip strength can improve functional task performance. Therefore while it is important to measure grip strength, it is only one factor to be considered when evaluating the efficacy of WHOs

Predicting Walking Ability and Prosthetic Candidacy Following Lower Extremity Amputation: Systematic Review, Treatment Pathway and Algorithm

Purpose: The purpose of this study is a systematic review (SR) of existing literature to examine characteristics of persons with amputation which predict walking ability and prosthetic candidacy following lower extremity amputation (LEA). The identification, synthesis and summary of this evidence could assist in developing clinical practice guidelines, including a physical rehabilitation treatment pathway and a clinical algorithm. The importance of this project is the establishment to further develop evidence based LEA clinical practice guidelines. This evidence will assist the healthcare team in decision making, specifically considering evidence and patient-centric predictive characteristics. Background: Currently, there is no multi-disciplinary physical rehabilitation instrument known that can predict walking ability and prosthetic candidacy nor support a treatment pathway and algorithm for the LEA. Also, there is not a patient centric decision making protocol under consideration when determining prosthetic candidacy. Further, the evidence to support these guidelines and protocols has not been aggregated and summarized in a formal systematic approach, such as a comprehensive systematic review. In previous literature the prediction of walking ability has been reported. However, these studies are outdated and not comprehensive, nor do they offer a clinical treatment pathway regarding the prediction of walking ability and prosthetic candidacy following lower LEA. A comprehensive reporting of aggregated and newly synthesized evidence with information from current literature can develop an evidence based patient centric treatment pathway and a prosthetic candidacy algorithm to assist LEAs to receive the correct, initial definitive prosthesis to match their functional abilities. Methods: This search strategy was designed and similarly implemented considering previous systematic reviews based on a similar topic. It is a more comprehensive update of previously valuable predictive factors of walking ability and prosthetic candidacy. An electronic literature search was executed from 8/1/2007 to 12/31/2015 using MEDLINE, EMBASE, CINAHL, and Cochrane. Results: This SR performed a more comprehensive search and discovered an additional 26 articles. A total of 104 quality studies were identified through the electronic search. Of these, 78 were systematically reviewed by two former authors, leaving a total of 26 for full evaluation. Conclusions from this updated study are drawn from a total recruited sample of 46,651 subjects. This updated study increases the size of the original Kahle et al. report by including 300% more subjects for a total of 61,858 subjects studied in the two SRs. Conclusion: In these two combined SRs, cause of amputation (etiology), physical fitness, pre- amputation living status, amputation level, age, physical fitness, cognitive/mood disturbances, social support and comorbitities are included as moderate to strongly supported predictive factors of walking ability and prosthetic candidacy. These factors are supported in an earlier literature review and should be strongly considered in a complete history and physical examination by multi-disciplinary team. Predictive factors should be part of a patient healthcare record

DEVELOPMENT AND CROSS-VALIDATION OF A PREDICTION EQUATION FOR ESTIMATING STEP COUNT IN INDIVIDUALS WITH TRANSTIBIAL AMPUTATION

Outcome measures can be utilized to assess physical function in controlled settings, but do not provide a comprehensive view of free-living mobility for individuals with transtibial amputation (TTA). We sought to expand upon established clinical-based outcome measures by developing and cross validating two equations for predicting daily steps. The relationship between health state predictors and performance on 1) the Timed Up and Go (TUG) Test, and 2) the Prosthetic Limb User’s Survey of Mobility (PLUS-M) was also assessed via the model predictions. Adults with TTA were assigned activPAL and Fitbit accelerometers to wear for seven days. Participant data were randomly separated into training (n = 80) and testing (n = 26) groups. LASSO regression with 3-fold cross validation was implemented to construct each equation according to a participant’s health state, TUG Test, L Test of Functional Mobility, and PLUS-M data. Each equation’s validity was assessed in the testing group. An inverse relationship was noted between daily steps and TUG Test performance and higher PLUS-M T-scores were associated with greater daily steps. The equation overestimated steps for those with significantly low daily steps and underestimated steps for those with significantly high daily steps, which is to be expected given the nature of linear regression. We also assessed the validity of the Fitbit Inspire 3 for assessing steps among individuals with TTA. Daily step data were compared between the Fitbit Inspire 3 and the activPAL 3. The Fitbit overestimated physical activity by estimating higher daily steps compared to the activPAL. Because of the significant mean differences between the devices, the activPAL and Fitbit are not interchangeable for estimating steps in this group. The results will be interpreted and explored in the context of prosthetic rehabilitation and underscore the importance of personalized mobility assessments and interventions aimed at improving the free-living mobility of individuals with TTA

Enhancing Biomechanical Function through Development and Testing of Assistive Devices for Shoulder Impairment and Total Limb Amputation

Assistive devices serve as a potential for restoring sensorimotor function to impaired individuals. My research focuses on two assistive devices: a passive shoulder exoskeleton and a muscle-driven endoprosthesis (MDE). Previous passive shoulder exoskeletons have focused on testing during static loading conditions in the shoulder. However, activities of daily living are based on dynamic tasks. My research for passive shoulder exoskeletons analyzes the effect that a continuous passive assistance has on shoulder biomechanics. In my research I showed that passive assistance decreases the muscular activation in muscles responsible for positive shoulder exoskeleton. An MDE has the potential to have accurate and precise control of movement as well as restore a sense of proprioception to the user. Such a transformative and invasive device has never previously been tested. Therefore, my research focused on analyzing fundamental principles of the MDE in an in-vivo rabbit model. The two concepts I tested in my research were the feasibility of implanting an orthopedic device underneath the skin at the distal end of a limb following amputation and the locomotor restorative capabilities of an artificial tendon used for muscle-device connection. In my work I proved the feasibility of implanting fully-footed rigid endoprostheses underneath the skin and isolated the primary factors for a successful surgery and recovery. In addition, my research showed that although artificial tendons have the potential to restore locomotor function, proper in-situ tendon lengths must be achieved for optimal movement. This research informed the design and testing of a fully jointed muscle-driven endoprosthesis prototype

Peak Trailing Limb Angle and Propulsion Symmetry in Individuals with Below Knee Amputation

Background: Individuals with lower extremity amputation often present with kinematic and kinetic gait asymmetries and often have difficulty achieving symmetrical walking using their prescribed prosthesis. To understand the impact of limb loss on gait measures, studies often compare individuals with lower limb amputation to healthy control participants or compare the amputated limb to the uninvolved limb while completing a specified task like steady state walking. Commonly implemented treatments for individuals with lower limb amputation are based upon the assumption that equal use of both legs (symmetry) while completing bipedal tasks (e.g., walking) would be beneficial, matching the behavior seen in healthy control individuals. Underlying kinematic or kinetic symmetry, as well as a potential relationship of the two biomechanical gait variables in individuals with below knee amputation have not been thoroughly evaluated during steady state treadmill walking. Methods: We explored potential underlying (a)symmetries in peak trailing limb angle (kinematic) and peak anterior ground reaction force (kinetic) in individuals with below knee amputation walking at self-selected walking speed on a treadmill without upper extremity support. We then implemented real-time visual feedback to alter symmetry and examine the potential relationship between peak trailing limb angle and peak anterior ground reaction force. Later, we recruited and tested healthy control individuals with and without a solid ankle foot orthosis (SAFO) walking at their self-selected walking speed on a treadmill and exposed them to a similar visual feedback program to alter their baseline (a)symmetry. Population: We enrolled eleven of the planned twenty-four individuals with unilateral below knee amputation and fourteen healthy control participants without any lower extremity pathology or gait abnormality. Results: We found that individuals with below knee amputation do have peak trailing limb and anterior ground reaction force asymmetries and unencumbered healthy control individuals demonstrate symmetry of the same outcome measures while walking on a treadmill at self-selected walking speed. The use of real time visual feedback yielded statistically significant differences in peak trailing limb angle in healthy control participants without a solid ankle foot orthosis (p=0.04), peak and impulse anterior ground reaction forces when wearing a solid ankle foot orthosis (p=0.04). Statistically significant correlation between peak trailing limb angle and peak anterior ground reaction force were found in individuals with below knee amputation at baseline (p=0.0004), with real time visual feedback for peak trailing limb angle (p\u3c0.0001), and peak anterior ground reaction force (p=0.0002). Conclusions: Real time visual feedback is one intervention used to alter walking symmetry. Our results do not demonstrate an overwhelming response to real time visual feedback by individuals with below knee amputation or their healthy control counterparts and should be interpreted with caution. This work does provide meaningful information for further studies and interventions to alter symmetry during steady state walking and begins to explore the potential relationship between peak trailing limb angel and peak anterior ground reaction force production during self-selected treadmill walking in individuals with below knee amputation as well as otherwise healthy control individuals

Technology for monitoring everyday prosthesis use : a systematic review

Abstract: Background: Understanding how prostheses are used in everyday life is central to the design, provision and evaluation of prosthetic devices and associated services. This paper reviews the scientific literature on methodologies and technologies that have been used to assess the daily use of both upper- and lower-limb prostheses. It discusses the types of studies that have been undertaken, the technologies used to monitor physical activity, the benefits of monitoring daily living and the barriers to long-term monitoring, with particular focus on low-resource settings. Methods: A systematic literature search was conducted in PubMed, Web of Science, Scopus, CINAHL and EMBASE of studies that monitored the activity of prosthesis users during daily-living. Results: Sixty lower-limb studies and 9 upper-limb studies were identified for inclusion in the review. The first studies in the lower-limb field date from the 1990s and the number has increased steadily since the early 2000s. In contrast, the studies in the upper-limb field have only begun to emerge over the past few years. The early lower-limb studies focused on the development or validation of actimeters, algorithms and/or scores for activity classification. However, most of the recent lower-limb studies used activity monitoring to compare prosthetic components. The lower-limb studies mainly used step-counts as their only measure of activity, focusing on the amount of activity, not the type and quality of movements. In comparison, the small number of upper-limb studies were fairly evenly spread between development of algorithms, comparison of everyday activity to clinical scores, and comparison of different prosthesis user populations. Most upper-limb papers reported the degree of symmetry in activity levels between the arm with the prosthesis and the intact arm. Conclusions: Activity monitoring technology used in conjunction with clinical scores and user feedback, offers significant insights into how prostheses are used and whether they meet the user’s requirements. However, the cost, limited battery-life and lack of availability in many countries mean that using sensors to understand the daily use of prostheses and the types of activity being performed has not yet become a feasible standard clinical practice. This review provides recommendations for the research and clinical communities to advance this area for the benefit of prosthesis users