Article

Bionic reconstruction to restore hand function after brachial plexus injury: A case series of three patients

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Abstract

Brachial plexus injuries can permanently impair hand function, yet present surgical reconstruction provides only poor results. Here, we present for the first time bionic reconstruction; a combined technique of selective nerve and muscle transfers, elective amputation, and prosthetic rehabilitation to regain hand function. Between April 2011, and May 2014, three patients with global brachial plexus injury including lower root avulsions underwent bionic reconstruction. Treatment occurred in two stages; first, to identify and create useful electromyographic signals for prosthetic control, and second, to amputate the hand and replace it with a mechatronic prosthesis. Before amputation, the patients had a specifically tailored rehabilitation programme to enhance electromyographic signals and cognitive control of the prosthesis. Final prosthetic fitting was applied as early as 6 weeks after amputation. Bionic reconstruction successfully enabled prosthetic hand use in all three patients. After 3 months, mean Action Research Arm Test score increased from 5·3 (SD 4·73) to 30·7 (14·0). Mean Southampton Hand Assessment Procedure score improved from 9·3 (SD 1·5) to 65·3 (SD 19·4). Mean Disabilities of Arm, Shoulder and Hand score improved from 46·5 (SD 18·7) to 11·7 (SD 8·42). For patients with global brachial plexus injury with lower root avulsions, who have no alternative treatment, bionic reconstruction offers a means to restore hand function. Austrian Council for Research and Technology Development, Austrian Federal Ministry of Science, Research & Economy, and European Research Council Advanced Grant DEMOVE. Copyright © 2015 Elsevier Ltd. All rights reserved.

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... Figure 10. A Titan model finger is inserted into a 3D-printed socket that is attached to the patient's body [16]. ...
... Individual differences in the anatomical and physiological characteristics of each person make the design of personalized prostheses a complex process. In many cases, even if an adequate initial adjustment is achieved, the prosthesis may not fit well over time due to changes in the user's body, such as growth or weight changes [16]. ...
... However, 3D printing allows for the production of low-cost robotic prosthetics, expanding access to a wider population. Nonprofit organizations, such as e-NABLE, have adopted 3D printing to create and distribute affordable prosthetic hands and arms, making functional devices accessible to individuals who might otherwise be unable to afford them [16]. ...
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Three-dimensional printing has significantly transformed the design and manufacture of robotic prostheses, making these devices more accessible, customized, and functional. This paper examines the historical evolution of prosthetic technology, tracing its development from rudimentary mechanical devices to the integration of advanced technologies, such as 3D printing. This innovation has enabled the production of prostheses at lower costs while enhancing their adaptability and performance. The review highlights how 3D printing has driven a disruptive shift in prosthetic customization, and how emerging technologies—including smart materials and artificial intelligence—have expanded the capabilities of prosthetic devices, offering more adaptive and natural movements. However, challenges persist, particularly regarding the need for standardization and infrastructural expansion to ensure equitable access to these technologies. Future research into novel materials and manufacturing techniques holds the potential to further improve the functionality, affordability, and accessibility of prosthetic devices. In conclusion, while 3D printing has marked a significant milestone in the evolution of robotic prosthetics, overcoming existing challenges is essential to realize its global impact and benefits fully.
... Bei der Versorgung dieser schweren Verletzungen und ihrer Folgen spielt die prothetische Rekonstruktion eine wichtige Rolle, wobei letztendlich das Wiedererlangen der Lebensqualität im Fokus steht. Dabei gewinnt diese auch in Situationen ohne primär notwendige Amputation an Bedeutung, beispielsweise nach massiven Schädigungen des Weichteils [3,4] oder des Plexus brachialis [5]. ...
... Neben der Amputationsversorgung kann eine bionische Prothese, wie oben bereits erwähnt, auch bei anderen Indikationen Anwendung finden. Ausgeprägte Weichteil-und Knochenschädigun-gen, sowie Defekte der neuronalen Strukturen führen nicht zwangsläufig zu einer notwendigen Amputation der betroffenen Extremität, können aber mit schwerwiegenden Einschränkungen bis zum völligen Funktionsverlust einhergehen und zudem die Ursache chronischer Schmerzen sein [3][4][5]. In ausgewählten Fällen kann eine elektive Amputation der funktionslosen Extremität mit einer anschließenden bionischen Rekonstruktion in Betracht gezogen werden. ...
... Bei Unversehrtheit des Plexus brachialis sowie der entsprechenden Zielmuskeln hat sich eine standardisierte Nerventransfermatrix durchgesetzt (siehe ▶tab. 1, 2) [18], wobei diese bei der Operationsplanung im Hinblick auf die kürzeste Reinnervationsstrecke pa- tientenspezifisch zu adaptieren ist. Wo nicht ausreichend Zielmuskeln für eine Reinnervation zur Verfügung stehen, kann ein freier funktioneller Muskeltransfer in den Stumpfbereich in Betracht gezogen werden, um zusätzliche Signale zu liefern [5]. So können beispielsweise mit einem Transfer des M. gracilis ein, beziehungsweise durch territoriale Differenzierung des Muskels [19], wenn notwendig, auch zwei weitere Signale gewonnen werden. ...
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Hintergrund Die obere Extremität und insbesondere die Hand sind für die Interaktion des Menschen mit seiner Umwelt von entscheidender Bedeutung – schwere Verletzungen oder Amputationen gehen daher mit einem erheblichen Funktionsverlust einher und beeinträchtigen die Lebensqualität der Patienten sehr. Wenn biologische Rekonstruktionsversuche nicht zu einem ausreichenden Erfolg führen oder nicht möglich sind, kommt der bionischen Rekonstruktion eine Schlüsselrolle in der Versorgung dieser Patienten zu. Konventionelle myoelektrische Prothesen werden über zwei Signale gesteuert, die über Oberflächenelektroden im Bereich der Stumpfmuskulatur abgeleitet werden. Insbesondere bei hohen Amputationen ist die Prothesensteuerung dann nur sehr eingeschränkt und umständlich möglich. Die Operationsmethode der Targeted Muscle Reinnervation (TMR) bietet hier einen innovativen Lösungsansatz: Die großen Armnerven, die durch Amputation ihre Zielorgane verloren haben, werden auf neue Zielmuskeln im Bereich des Amputationsstumpfes transferiert. Dadurch können kognitive Steuersignale etabliert werden, welche eine deutlich verbesserte Prothesensteuerung ermöglichen. Patienten/Material und Methoden Es erfolgte eine selektive Literaturrecherche zum Thema TMR und bionische Rekonstruktion mit Aufarbeitung und Diskussion relevanter Arbeiten, unter Berücksichtigung der klinischen Erfahrungen unserer Forschungsgruppe. Zusätzlich wird ein klinischer Patientenfall vorgestellt. Ergebnisse Die bionische Rekonstruktion in Kombination mit TMR ermöglicht eine intuitive Prothesensteuerung mit simultaner Bewegung verschiedener prothetischer Freiheitsgrade und bietet zudem einen neuen Ansatz in der Therapie von Neurom- und Phantomschmerzen. Langfristiger Erfolg erfordert ein hohes Maß an Patientencompliance und intensives Signaltraining während der prothetischen Rehabilitationsphase. Trotz technologischer Fortschritte bestehen weiterhin Herausforderungen, insbesondere hinsichtlich der Signalüberleitung und der sensiblen Integration bionischer Prothesen. Schlussfolgerung Die Operationstechnik der TMR stellt einen bedeutenden Fortschritt der prothetischen Versorgung von Amputierten dar. Durch selektive Nerventransfers zur Signalmultiplikation und -amplifikation ermöglicht sie, das Potential myoelektrischer Prothesen weiter auszuschöpfen und die Therapie dieser speziellen Patientengruppe zu verbessern. Entwicklungen im Bereich der externen Prothesenkomponenten, Verbesserungen der skelettalen Anbindung durch Osseointegration und flüssigere Signalübertragung durch drahtlose, vollständig implantierte Elektrodensysteme werden sowohl hinsichtlich der Bewegungspräzision, als auch des Embodiments deutliche Fortschritte in der bionischen Rekonstruktion ermöglichen.
... Elective amputation of a hand and bionic reconstruction have been done with functional improvements and satisfying results in cases of sequelae after critical soft tissue injuries (5). In a few cases of brachial plexus injuries (6,7), and in 1 case with arthrogryposis multiplex congenita with severe deficits of the hands, planned amputation and replacement with hand prosthesis with satisfying results have been described (8). However, even if an amputation is wished for, it is irreversible with potential pain problems, and a life-changing decision. ...
... To determine the patient's ability to control the planned myoelectric prosthetic hand, the muscle function proximal to the planned amputation was assessed with surface EMG (electromyography) electrodes (extensors and flexors). A myoelectric pros thetic hand built on an orthosis with an OttoBock Sensor Speed hand, was used at home for 6 months prior to the amputation (Fig. 2), as described by Aszmann (5,6). This gave the patient the opportunity to get familiar with how to control the prosthesis and was also a strategy to give reasonable expectations regarding grip ability. ...
... Grip function in a prosthetic hand has its limits, even though it, in this case, was an advanced Bebionic hand (OttoBock). Nevertheless, hand prosthesis offered better grip function than a poorly functioning hand (5,6,8). ...
Article
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Objective Evaluation of the hand function affected when replacing a malfunctioning hand by a bionic hand. Design Case report. Subjects One individual that wished for a better quality of life after unsatisfying hand function following a replantation. Methods A quantitative and qualitative evaluation of body functions as well as activity performance and participation before and after a planned amputation and prosthetic fitting is presented. Results Improvements were seen in the patient-reported outcome measures (PROMs) that were used regarding activity (Disability of the Arm, Shoulder and Hand [DASH] and Canadian Occupational Performance Measure [COPM]), pain (Neuropathic Pain Symptom Inventory [NPSI], Brief Pain Inventory [BPI], Visual Analogue Scale [VAS]), cold intolerance (CISS) and health related quality of life (SF-36), as well as in the standardised grip function test, Southampton Hand Assessment Procedure (SHAP). No referred sensations were seen but the discriminative touch on the forearm was improved. In the qualitative interview, a relief of pain, a lack of cold intolerance, improved appearance, better grip function and overall emotional wellbeing were expressed. Conclusions The planned amputation and subsequent fitting and usage of a hand prosthesis were satisfying for the individual with positive effects on activity and participation. Clinical relevance When the hand function after a hand replantation does not reach satisfactory levels, a planned amputation and a prosthetic hand can be the right solution. LAY ABSTRACT Here we present a case report of 1 individual who wished for a better quality of life after over 20 years’ experience of unsatisfying hand function following a replantation. Evaluation of body functions as well as activity performance and participation before and after a planned amputation and prosthetic fitting is presented. Improvements were seen in the patient-reported outcome measures regarding activity, pain, cold intolerance, and health-related quality of life, as well as in grip function test. In the interview, a relief of pain, a lack of cold intolerance, improved appearance, better grip function and overall emotional wellbeing were expressed. The planned amputation and the subsequent fitting and usage of a hand prosthesis were satisfying for the individual with positive effects on activity and participation. When the hand function after a hand replantation is not satisfactory, planned amputation and prosthetic hand can be considered.
... The procedure includes elective amputation of the hand, derotation osteotomy of the humerus for better positioning of the forearm, followed by prosthetic fitting. The feasibility of bionic reconstructions in patients suffering from brachial plexus injuries in adulthood is well-documented (9)(10)(11). However, studies investigating this treatment after OBPI are not found in literature. ...
... The prosthesis enhanced his self-confidence in terms of his appearance, which promoted enjoyment of social interactions and activities (22). Similar outcomes are reported for patients who had undergone a bionic reconstruction after severe traumatic brachial plexus injuries (9,10). In a first case series of three patients with brachial plexus injuries where the amputation was at a transradial level the mean ARAT score (±standard deviation) increased from 5.3 ± 4.7 to 30.7 ± 14, the mean SHAP from 9.3 ± 1.5 to 65.3 ± 19.4 and the mean DASH improved from 46.5 ± 18.7 to 11.7 ± 8.4 (10). ...
... Similar outcomes are reported for patients who had undergone a bionic reconstruction after severe traumatic brachial plexus injuries (9,10). In a first case series of three patients with brachial plexus injuries where the amputation was at a transradial level the mean ARAT score (±standard deviation) increased from 5.3 ± 4.7 to 30.7 ± 14, the mean SHAP from 9.3 ± 1.5 to 65.3 ± 19.4 and the mean DASH improved from 46.5 ± 18.7 to 11.7 ± 8.4 (10). Also for five patients with more severe brachial plexus injuries who underwent an amputation above the elbow with following prosthetic fitting the mean ARAT increased from 0.6 ± 1.3 to 17.3 ± 1.5, the mean SHAP from 4 ± 3.7 to 22 ± 9.2, the mean DASH decreased from 52.5 ± 9.4 to 31.2 ± 9.8 and the mean VAS from 8.5 ± 1 to 6.7 ± 2.1 (9). ...
Article
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Introduction: Many adults who had a severe Narakas IV obstetric brachial plexus injury (OBPI) suffer from extensive impairments in daily living due to limited hand-arm function. The dramatic loss of axonal support at this very early age of development often render the entire extremity a biologic wasteland and reconstructive methods and therapies often fail to recover any functional hand use. In this scenario bionic reconstruction, including an elective amputation and a subsequent prosthetic fitting, may enable functional improvement in adults suffering from the consequences of such severe brachial plexus injuries. We here describe our experience in treating such patients and lay out the surgical rational and rehabilitation protocol exemplified in one patient. Case Presentation/Methods: A 27-year-old adult with a unilateral OBPI contacted our center. He presented with globally diminished function of the affected upper extremity with minimal hand activity, resulting in an inability to perform various tasks of daily living. No biological reconstructive efforts were available to restore meaningful hand function. An interdisciplinary evaluation, including a psychosocial assessment, was used to assess eligibility for bionic reconstruction. Before the amputation and after the prosthetic fitting functional assessments and self-reported questionnaires were performed. Results: One month after the amputation and de-rotation osteotomy of the humerus the patient was fitted with a myoelectric prosthesis. At the 1.5 year-follow-up assessment, the patient presented with a distinct improvement of function: the ARAT improved from 12 to 20 points, SHAP score improved from 8 to 29, and the DASH value improved from 50 to 11.7. The average wearing times of the prosthesis were 5 to 6 h per day (on 4–5 days a week). Discussion: The options for adults suffering from the consequences of severe OBPIs to improve function are limited. In selected patients in whom the neurological deficit is so severe that biologic hand function is unsatisfactory, an elective amputation and subsequent restoration of the hand with mechatronic means may be an option. The follow-up results indicate that this concept can indeed lead to solid hand function and independence in daily activities after amputation, subsequent prosthetic fitting, and rehabilitation.
... 4,5 Although no consensus exists on the best reconstructive technique after transhumeral amputation, prosthetic devices have gained a primary role. 6 With ongoing advancements in microsurgical techniques and biomedical engineering, prosthetic technology has greatly improved, presenting a clinically viable option for the restoration of motor control in the human arm. 7 Although the bionic replacement of hand function is a remarkable achievement and continues to advance, it is important to note that these technologies have not yet matched the seamless and intuitive control inherent in the biological human hand. ...
... Recently, bionic reconstruction has advanced as a clinically valid approach to restoring certain hand functions lost with the loss of an upper extremity. 6 Although technological advances in bioengineering have outpaced the biological capacity of the human body to transfer commands to or from the high-fidelity electrodes of the prosthetic device, a robust and patient-friendly biomechanical fixation of the prosthesis remains a high priority in prosthetic embodiment. 7 Conventional socket fitting for a prosthesis has multiple limitations in terms of electrode alignment, coupled with unstable fixation typically utilizing straps, which significantly contributes to a decreased willingness of patients to use a prosthesis in their everyday activities and, consequently, prosthesis abandonment. ...
Article
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Background: Upper extremity limb loss profoundly impacts a patient’s quality of life and well-being and carries a significant societal cost. Although osseointegration allows the attachment of the prosthesis directly to the bone, it is a relatively recent development as an alternative to conventional socket prostheses. The objective of this review was to identify reports on osseointegrated prosthetic embodiment for transhumeral amputations and assess the implant systems used, postoperative outcomes, and complications. Methods: A systematic review following PRISMA and AMSTAR guidelines assessed functional outcomes, implant longevity and retention, activities of daily living, and complications associated with osseointegrated prostheses in transhumeral amputees. Results: The literature search yielded 794 articles, with eight of these articles (retrospective analyses and case series) meeting the inclusion criteria. Myoelectric systems equipped with Osseointegrated Prostheses for the Rehabilitation of Amputees implants have been commonly used as transhumeral osseointegration systems. The transhumeral osseointegrated prostheses offered considerable improvements in functional outcomes, with participants demonstrating enhanced range of motion and improved performance of activities compared with traditional socket-based prostheses. One study demonstrated the advantage of an osseointegrated implant as a bidirectional gateway for signal transmission, enabling intuitive control of a bionic hand. Conclusions: Osseointegrated prostheses hold the potential to significantly improve the quality of life for individuals with transhumeral amputations. Continued research and clinical expansion are expected to lead to the realization of enhanced efficacy and safety in this technique, accompanied by cost reductions over time as a result of improved efficiencies and advancements in device design.
... As a result, these gadgets provide intuitive control and a natural flow of experience from the artificial device to the user. Bionic hands were the first practical proof of concept [26][27][28][29][30][31][32]. 22 Depending on the implant utilized, the kind of tissue interfaced, and the bionic limb, three primary categories may be made: direct muscle, direct nerve, and nerve-transferred muscle interfacing (TMR) ( Figure 5) [25,[32][33][34][35][36][37][38]. Figure 5: Implants, nerve, and muscles transferring [25,[32][33][34][35][36][37][38] ...
... The most significant limitation of bionic prostheses is their high cost. The expense of bionic prostheses is a deterrent from the patient's 26 ied duties. Care for bionic prosthetic devices is expensive over the long term [65]. ...
Article
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From prehistoric people's subconscious bionic actions to significant bionic designs in modern engineering, bionic consciousness, ideas, and practice have paved the way for the advancement of humanity, the growth of society, and the invention of science and technology. The term "bionics" describes the fusion of technological innovations created by humans with natural structures and functioning systems. Following the trauma or disease, bionics devices stimulate the nerves or muscles to give therapeutic intervention, sensory feedback, or motor function; they may also record the electrical activity from the nerves or muscles to identify disease states; they can enable the voluntary control of devices like prosthetic limbs; or they can provide closed-loop feedback to modify neural prostheses. The kind of prosthetic limb a person can use depends on various factors, including the person, the reason for the amputation or loss of the limb, and the location of the missing limb. Novel bio-inspired therapies have emerged recently that work by rearranging the bodily parts already present in a person to improve physiology. Instead of substituting biological tissue in this case, engineering concepts are used to reorganize and manipulate the natural tissue and organs to replace or enhance physiological activities (auto-bionics). This research aims to investigate the history, summarize, and simplify the understanding of the application of bionics in medical treatment.
... Recientemente se ha publicado el uso de estas prótesis mioeléctricas, previa amputación electiva del miembro no funcional, para mejorar la funcionalidad del paciente (29,30). Se necesitan más estudios sobre este abordaje terapéutico. ...
... El procedimiento quirúrgico es una oportunidad para promover la actividad en las áreas de la corteza sensorial-motora de la parte del cuerpo sin movimiento, por esta razón los pacientes no pueden ser tratados con protocolos estándar (31). Los axones de los nervios donantes son la vía a través de la cual se transmite la información funcional necesaria para repoblar los receptores sensoriales y motores de la placa motora, para alcanzar el principal objetivo, el re-aprendizaje cortical para reparar la función periférica perdida (29,31). Este re-aprendizaje de nuevos patrones motores y sensitivos es el objetivo y mayor desafío con este tipo de técnica (31). ...
Article
Brachial plexus and peripheral nerve injuries are complex and suppose a great functional deficit. An early diagnostic and surgical exploration and reconstruction is essential in some cases. Muscular atrophy generated by the chronic denervation limits surgical treatments that can not be performed once overcoming a specific time frame. Radiologic and neurophysiological tests are essential to perform a correct diagnostic and follow-up of these injuries, and rehabilitation is crucial to achieve a good postsurgical outcome. Surgical treatments include primary nerve repair, repair with nerve grafts, nerve transfers, free functional muscle transfers and tendon transfers. Each technique should be adequate to the clinic and evolution time of the injury. Once muscle atrophy is established, nerve repair and nerve transfers do not achieve a good functional result. Due to the high complexity of these injuries and the need for different medical specialists, these patients must be treated in multidisciplinary units to achieve the best possible result.
... In addition to the force control measures, the clinically valid SHAP scores were also measured to check the prosthetic users' impairment level of the hand function compared to the healthy group. The SHAP score has been used to check the hand function of prosthetic users [25,[31][32][33][34]. Based on our findings, compared to the healthy subjects, all prosthetic users showed significantly lower for SHAP IOF, and lower for each FP score (Spherical, Tripod, Power, Lateral, Tip, Extension). ...
... Especially, he showed lower SHAP FP scores in power and tripod prehensile patterns compared to other SHAP FP scores. Previous studies reporting the SHAP score were to compare the control algorithm of prosthetic hands, different types of prosthetic hands [31][32][33], or assess hand function before and after surgical procedures or rehabilitation procedures [34] as case studies. Similar to previous studies [21,26,35,36], relatively lower scores in tip prehensile patterns were found in S2-S4 who were novice prosthetic users compared to S1 who had 10 years of experience on the myoelectric hand. ...
Article
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Force control abilities are essential to interact with objects in our environments. However, there is a lack of evaluation tools and methods to test the force control abilities of the upper limb in evaluating the upper limb functions of prosthetic users. This study aimed to quantify upper limb isometric force control abilities in healthy individuals and prosthetic users using a custom-built handle with a 6-axis force/torque sensor and visual cue, namely an Upper Limb End-effector type Force control test device (ULEF). Feasibilities of the test device were demonstrated through experiments by holding the ULEF with an intact hand among healthy subjects and transradial and wrist amputees with a myoelectric powered prosthetic hand, the bebionic hand. Compared to the healthy individuals, the prosthetic user group demonstrated poor isometric force control abilities in terms of higher control instability during the lateral direction task (p<0.05). Significantly higher variability in force-generating rates was also found in all task directions in the prosthetic user group (p<0.05). Compared to the healthy group, the prosthetic user group showed significant small peak biceps activities during the posterior task (p<0.05) and anterior task (p<0.05). Quantification of isometric upper limb force control abilities can potentially be beneficial to develop evaluation and research tools for investigating mechanisms underlying force control abilities of prosthetic users and provide guidelines for targeted isometric force control training and prosthesis development.
... After aperipheral nerve injury, axonal transport is blocked, causing degeneration and disintegration of the distal part of the axon from the proximal end. Subsequently, Schwann cells proliferate massively and secrete various neuroactive substances, such as nerve growth factors and fibroblast growth factors, toreestablish connections between axons and Schwann cells, promoting nerve regeneration (Wei et al., 2023;Aszmann et al., 2015). This process is lengthy and challenging, not only due to the extended regeneration period but also the slow growth rate, with an average daily growth speed of about 2 mm. ...
Article
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Background Injuries to the common peroneal nerve often result in significant sensory and motor function loss, severely affecting patients’ quality of life. Although existing treatments, including medication and surgery, provide some degree of efficacy, their effectiveness is limited by factors such as tolerance and adverse side effects. Methods This study aims to evaluate the effects of a 4-week regimen of mirror therapy combined with neuromuscular electrical stimulation on lower limb function, muscle strength, and sensation in patients with common peroneal nerve injuries. The objective is to identify novel therapeutic strategies for lower limb peripheral nerve injuries.30 patients with Common peroneal nerve caused by pelvic fractures were selected from the Rehabilitation Medicine Department of Tianjin Hospital between July 2023 and July 2024. They were randomly divided into two groups: the neuromuscular electrical stimulation group (n = 15) and the mirror therapy with neuromuscular electrical stimulation group (n = 15). Results After 4 weeks, it was found that mirror therapy with neuromuscular electrical stimulation has a significantly better therapeutic effect on Common peroneal nerve than simple electrical stimulation therapy, particularly in terms of superficial sensation, nerve conduction velocity and ROM.
... Current state-of-the-art prostheses enabling real-time user control are based upon sensed muscle-controlled signals using surface electromyography as the communicating 'interface' between human and machine (Bergmeister et al. 2017). However, in complex injuries, muscle targets are absent or weak, and the quality of extracted signals is variable (Aszmann et al. 2015). The influence of neighbouring 'noise' from adjacent muscle contractions limits signal quality (Solomonow 1984). ...
Article
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This systematic review evaluates the use of Normothermic Machine Perfusion (NMP) as a testbed for developing peripheral nerve and muscle interfaces for bionic prostheses. Our findings suggest that NMP offers a viable alternative to traditional models, with significant implications for future research and clinical applications. A literature search was performed using Ovid MEDLINE (1946 to October 2023), revealing 559 abstracts. No studies using nerve and/or muscle electrodes for the testing or development of bionic interface technologies were identified, except for one conference abstract. NMP could serve as a test bed for future development of interface biocompatibility, selectivity, stability and data transfer, whilst complying with ethical practices and potentially offering greater relevance for human translation. Implemention of machine perfusion requires experienced personnel. Encompassing artificial intelligence alongside machine learning will provide a significant contribution to advancing interface technologies for multiple neurological disorders.
... Bionic reconstruction is an established concept for restoring hand function in cases of traumatic amputation, malignancies, severe soft tissue, or brachial plexus injuries where biological reconstruction is no longer possible 1,2 . Surgical techniques, such as targeted muscle reinnervation (TMR), osseointegration, or regenerative peripheral nerve interfaces (RPNI), as well as technological innovations, such as implantable electromyography electrodes, multi-electrode arrays, and machine learning, have greatly improved prosthetic control in recent years [3][4][5][6][7] . ...
Article
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Neuromuscular control of bionic arms has constantly improved over the past years, however, restoration of sensation remains elusive. Previous approaches to reestablish sensory feedback include tactile, electrical, and peripheral nerve stimulation, however, they cannot recreate natural, intuitive sensations. Here, we establish an experimental biological sensorimotor interface and demonstrate its potential use in neuroprosthetics. We transfer a mixed nerve to a skeletal muscle combined with glabrous dermal skin transplantation, thus forming a bi-directional communication unit in a rat model. Morphological analyses indicate reinnervation of the skin, mechanoreceptors, NMJs, and muscle spindles. Furthermore, sequential retrograde labeling reveals specific sensory reinnervation at the level of the dorsal root ganglia. Electrophysiological recordings show reproducible afferent signals upon tactile stimulation and tendon manipulation. The results demonstrate the possibility of surgically creating an interface for both decoding efferent motor control, as well as encoding afferent tactile and proprioceptive feedback, and may indicate the way forward regarding clinical translation of biological communication pathways for neuroprosthetic applications.
... By rerouting residual arm nerves to muscle segments like the pectoral and serratus, TMR amplifies control signals and provides sensory feedback via connections to the ulnar and median nerves [17,18] . This technique has improved prosthetic functionality, aided in managing neuropathic pain, and offered a new approach to restoring hand functions and mitigating pain issues like neuromas [19][20][21] . ...
Article
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Background The review highlights recent advancements and innovative uses of nerve transfer surgery in treating dysfunctions caused by central nervous system (CNS) injuries, with a particular focus on spinal cord injury (SCI), stroke, traumatic brain injury, and cerebral palsy. Methods A comprehensive literature search was conducted regarding nerve transfer for restoring sensorimotor functions and bladder control following injuries of spinal cord and brain, across PubMed and Web of Science from January 1920 to May 2023. Two independent reviewers undertook article selection, data extraction, and risk of bias assessment with several appraisal tools, including the Cochrane Risk of Bias Tool, the JBI Critical Appraisal Checklist, and SYRCLE’s ROB tool. The study protocol has been registered and reported following PRISMA and AMSTAR guidelines. Results Nine hundred six articles were retrieved, of which 35 studies were included (20 on SCI and 15 on brain injury), with 371 participants included in the surgery group and 192 in the control group. These articles were mostly low-risk, with methodological concerns in study types, highlighting the complexity and diversity. For SCI, the strength of target muscle increased by 3.13 of Medical Research Council grade, and the residual urine volume reduced by more than 100 ml in 15 of 20 patients. For unilateral brain injury, the Fugl-Myer motor assessment (FMA) improved 15.14–26 score in upper extremity compared to 2.35–26 in the control group. The overall reduction in Modified Ashworth score was 0.76–2 compared to 0–1 in the control group. Range of motion (ROM) increased 18.4–80° in elbow, 20.4–110° in wrist and 18.8–130° in forearm, while ROM changed −4.03°−20° in elbow, −2.08°−10° in wrist, −2.26°−20° in forearm in the control group. The improvement of FMA in lower extremity was 9 score compared to the presurgery. Conclusion Nerve transfer generally improves sensorimotor functions in paralyzed limbs and bladder control following CNS injury. The technique effectively creates a ‘bypass’ for signals and facilitates functional recovery by leveraging neural plasticity. It suggested a future of surgery, neurorehabilitation and robotic-assistants converge to improve outcomes for CNS.
... As described in the various chapters of this book, all these technological advances have the potential to enhance the possibilities of individuals with an amputation. Additionally, new patient groups as people with severe brachial plexus injuries or hand injuries beyond biological reconstruction may be fitted with prosthetic devices to restore their extremity function [1,2,19]. All of these developments pose new challenges in regard to user training that need to be addressed by the occupational and physical therapy of the future. ...
... Devastating injuries to the upper extremities pose a substantial challenge for the global healthcare system and require a comprehensive, interdisciplinary approach for counteracting their effects (1,2). In recent decades, bionic reconstruction has considerably advanced, becoming a viable therapeutic modality for restoring extremity function in cases where biological hand replantation or transplantation is not feasible (3)(4)(5)(6). Recent surgical techniques, such as targeted muscle reinnervation (TMR), regenerative peripheral nerve interface (RPNI), and agonist-antagonist myoneural interface, have improved prosthetic control in upper and lower extremity by advancing the communication link between the nervous system and prostheses (7)(8)(9). ...
Article
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Advances in robotics have outpaced the capabilities of man-machine interfaces to decipher and transfer neural information to and from prosthetic devices. We emulated clinical scenarios where high-(facial) or low-neural capacity (ulnar) donor nerves were surgically rewired to the sternomastoid muscle, which is controlled by a very small number of motor axons. Using retrograde tracing and electrophysiological assessments, we observed a nearly 15-fold functional hyper-reinnervation of the muscle after high-capacity nerve transfer, demonstrating its capability of generating a multifold of neuromuscular junctions. Moreover, the surgically redirected axons influenced the muscle's physiological characteristics, by altering the expression of myosin heavy-chain types in alignment with the donor nerve. These findings highlight the remarkable capacity of skeletal muscles to act as biological amplifiers of neural information from the spinal cord for governing bionic prostheses, with the potential of expressing high-dimensional neural function for high-information transfer interfaces.
... In the field of upper limb trauma, the concept of bionic reconstruction has emerged as a promising option, broadening the spectrum of reconstructive possibilities beyond biological limitations (Aszmann et al., 2015). For individuals who have experienced severe brachial plexus injuries resulting in permanent hand dysfunction, standard biological treatments may not suffice to restore the missing function. ...
... Intact limb function is important for interactions with the external environment. Limb dysfunction owing to various external or internal adverse factors may impair an individual's ability to perform daily activities (Aszmann et al., 2015;Ray et al., 2016;Farina et al., 2021). Although surgical treatment of nerve injury, such as nerve transfer (Tsai et al., 2022), is widely used, inadequate sources of the surface electromyogram (EMG) signals from patients with an amputation are attributed to single function and clumsy movements of prostheses' control (Kuiken et al., 2007;Fan et al., 2015). ...
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[INLINE:1] Targeted muscle reinnervation has been proposed for reconstruction of neuromuscular function in amputees. However, it is unknown whether performing delayed targeted muscle reinnervation after nerve injury will affect restoration of function. In this rat nerve injury study, the median and musculocutaneous nerves of the forelimb were transected. The proximal median nerve stump was sutured to the distal musculocutaneous nerve stump immediately and 2 and 4 weeks after surgery to reinnervate the biceps brachii. After targeted muscle reinnervation, intramuscular myoelectric signals from the biceps brachii were recorded. Signal amplitude gradually increased with time. Biceps brachii myoelectric signals and muscle fiber morphology and grooming behavior did not significantly differ among rats subjected to delayed target muscle innervation for different periods. Targeted muscle reinnervation delayed for 4 weeks can acquire the same nerve function restoration effect as that of immediate reinnervation.
... After exit of these five BP nerves from the spinal cord, they merge to form three nerve trunks: the superior (formed by the merging of C5 and C6), medial (from C7), and inferior (branches of C8 and T1). Severe injuries, especially due to traffic accidents, often lead to avulsion of the BP nerve roots, and such dysfunction has a devastating effect on patients 1 . ...
... But the concern is that the amputation of involved limb is an irreversible procedure, and as we must conduct this early after the injury, the less conservative treatment time and opportunity is available for assessing for any possible neurologic recovery. Therefore, the decision regarding amputation must be made before adequate assessment of any possible recovery of motor and sensory function [23][24][25]. ...
Chapter
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The brachial plexus is a network of intertwined nerve that controls movement and sensation in arm and hand. Any injury to the brachial plexus can result in partial or complete damage of arm and hand. The surgery is a common indicative procedure in brachial plexus injury in case of non-spontaneous recovery. The loss of function of hand due to injury can be replaced by using body powered or externally powered devices. Recent development in treatment protocol of prosthetic and orthotic science using artificial intelligence helps in rehabilitating the persons with brachial plexus injury to regain his confidence and perform daily activities. Combination of advancement in surgical procedure along with artificially intelligent devices opens a new array to rehabilitate the person with brachial plexus injury.
... Besides rehabilitative approaches, a robotic hand to substitute a damaged limb has previously been proposed in patients with severe hand disabilities, including global plexopathies 29 and critical soft tissue injuries 30 . SoftHand-X has also been shown to compensate for severely impaired hand function in chronic stroke patients 19 . ...
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In patients with subacute stroke, task specific training (TST) has been shown to accelerate functional recovery of the upper limb. However, many patients do not have sufficient active extension of the fingers to perform this treatment. In these patients, here we propose a new rehabilitation technique in which TST is performed through a soft robotic hand (SoftHand-X). In short, the extension of the robotic fingers is controlled by the patient through his residual, albeit minimal, active extension of the fingers or wrist, while the patient was required to relax the muscles to achieve full flexion of the robotic fingers. TST with SoftHand-X was attempted in 27 subacute stroke patients unable to perform TST due to insufficient active extension of the fingers. Four patients (14.8%) were able to perform the proposed treatment (10 daily sessions of 60 min each). They reported an excellent level of participation. After the treatment, both clinical score of spasticity and its electromyographic correlate (stretch reflex) decreased. In subacute stroke patients, TST using SoftHand-X is a well-accepted treatment, resulting in a decrease of spasticity. At present, it can be applied only in a small proportion of the patients who cannot perform conventional TST, though extensions are possible.
... In the native state, somatic efferent fibers are indispensable for the functioning of NMJ (Sanes and Lichtman, 1999). Rewiring motor nerve fibers from one motor neural source to another target muscle has been shown to be a successful approach in restoration of motor function (Aszmann et al., 2015;Bergmeister et al., 2019;Ortiz-Catalan et al., 2020). The effect of different neuronal sources (e.g., somatic efferent and visceral efferent axons) on the reinnervation of an alternate target organ is scarcely explored (Langley and Anderson, 1904;Brushart, 1988). ...
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The surgical redirection of efferent neural input to a denervated muscle via a nerve transfer can reestablish neuromuscular control after nerve injuries. The role of autonomic nerve fibers during the process of muscular reinnervation remains largely unknown. Here, we investigated the neurobiological mechanisms behind the spontaneous functional recovery of denervated facial muscles in male rodents. Recovered facial muscles demonstrated an abundance of cholinergic axonal endings establishing functional neuromuscular junctions. The parasympathetic source of the neuronal input was confirmed to be in the pterygopalatine ganglion. Furthermore, the autonomically reinnervated facial muscles underwent a muscle fiber change to a purely intermediate muscle fiber population myosin heavy chain type IIa. Finally, electrophysiological tests revealed that the postganglionic parasympathetic fibers travel to the facial muscles via the sensory infraorbital nerve. Our findings demonstrated expanded neuromuscular plasticity of denervated striated muscles enabling functional recovery via alien autonomic fibers. These findings may further explain the underlying mechanisms of sensory protection implemented to prevent atrophy of a denervated muscle. SIGNIFICANCE STATEMENT Nerve injuries represent significant morbidity and disability for patients. Rewiring motor nerve fibers to other target muscles has shown to be a successful approach in the restoration of motor function. This demonstrates the remarkable capacity of the CNS to adapt to the needs of the neuromuscular system. Yet, the capability of skeletal muscles being reinnervated by nonmotor axons remains largely unknown. Here, we show that under deprivation of original efferent input, the neuromuscular system can undergo functional and morphologic remodeling via autonomic nerve fibers. This may explain neurobiological mechanisms of the sensory protection phenomenon, which is because of parasympathetic reinnervation.
... ADLs are basic activities which have been identified as essential for independent living 12,89,90 . Examples of these are the Jebson Taylor Hand Function Test (JTT) 91 and the Southampton Hand Assessment Procedure (SHAP) [92][93][94] , shown in Figure 17. The JTT assesses a person's overall hand function using seven tasks: writing, turning over cards, picking up small objects (e.g. ...
Article
Upper limb prostheses offer those with limb loss a solution to restore some of their lost functionality by allowing them to participate in bilateral tasks, especially those required for daily living. Whilst there is a wide range of upper limb prostheses available, there remain high device rejection rates. Low functionality and discomfort are major factors in prosthesis rejection, which had been identified as challenges more than 60 years ago. These issues have not been effectively addressed due the lack of design tools for engineers and clinicians. Upper limb prostheses have seen greater technological advances than the methods to evaluate them effectively, which has resulted in over-engineered designs which do not meet the needs of their user. In this thesis , I aim to improve future upper limb prostheses through the development of three design tools. These design tools seek to quantify the functionality of prosthetic devices using motion capture analysis, virtual environments, and joint optimisation. By developing these tools, there is greater opportunity to optimise prostheses earlier in the design cycle which can result in improved functionality. It is anticipated that improvements in functionality will increase user satisfaction and therefore reduce device rejection rates Motion capture analysis was used to study the compensatory movements that arise from operating an upper limb prosthesis. Using a motion capture suit, the motor strategy of a participant was compared between using their biological hand and using a prosthesis through the use of an able-bodied adaptor. It was found that the shoulder and trunk had to make the most compensatory movements to complete several grasping tasks due to the lack of degrees of freedom at the distal end of the prosthesis. Without forearm supination/pronation and wrist extension/flexion, the participant had to approach the grasping tasks from a different angle, sometimes having to lean backwards and abduct their upper arm. The methodology of utilising a motion capture suit as a design tool to quantitatively assess the compensatory movements caused by a prosthetic device was successfully demonstrated. Virtual environments, in conjunction with quantitative grasp quality metrics, can be used to assess the performance of the upper limb prosthesis extremity alone, uninfluenced by user bias. A dynamic virtual environment is presented to simulate several grasping tasks with five upper limb prosthetic devices. Contact information from these grasping tasks are used to calculate the quality of the grasp and provide an overall grasping functionality score. From the simulation results, it was found that more degrees of freedom do not necessary equate to better grasping performance. The positions of force vectors during grasp formation are vital and they must be well- balanced in order to result in stable grasps. Simulated grasping and quantitative analysis in a virtual environment has been demonstrated, which can be used to better plan grasping paths and therefore improve the grasping functionality of upper limb prosthesis designs. Prosthesis users desire their devices to have a low mass, have a low cost, and have high functionality. However, these are conflicting design objectives and decisions must be made to which design considerations to prioritise. A multi-objective model was used to balance these three objectives and select the most suitable components that make up a prosthesis. A modularity scheme was used to divide an upper limb prosthesis into three categories: socket, forearm, and terminal device. In each category, several components were considered which can either be manufactured by conventional engineering or additive manufacturing. Each component would provide a unique value determined by a several quantitative utility functions. Based on satisfaction studies in the literature, the multi-objective optimisation model found that a Split Hook terminal device with an additively manufactured socket and forearm was the optimal design as it provided a low mass and excellent grasping functionality. This model has been demonstrated to work with different user requirements to intelligently select the most appropriate upper limb components within the modularity scheme. Overall, methods were developed which covered aspects of prosthesis design from clinical testing of prosthetic devices, functionality assessments of Computer Aided Design models, and intelligent selection of prosthesis components for individual requirements. It is hoped that these design tools may enable better communication between engineers and clinicians to ensure that users receive devices that are to their satisfaction.
... More invasive approaches, on the other hand, promise to provide more focussed, clearer signals, and, as the technology of man-machine integration advances, their appeal increases (Farina et al., 2021). PNS invasive techniques entail different degrees of invasiveness, from the injection of miniaturised EMG sensors into the muscles (Weir et al., 2009) to osseointegration (Ortiz-Catalan et al., 2014) and targeted muscle reinnervation (Aszmann et al., 2015); depending on the severity of the impairment then, patients might agree to stand surgery. ...
... Peripheral nerve injury occurs in ∼2-5% of all trauma patients [1,2] and often leads to functional impairment and significant deterioration in quality of life [3,4]. Primary end-to-end anastomosis of the nerve stumps shows the best results and is preferred [5,6]. ...
Article
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Background: Nerve transfer is an important clinical surgical procedure for nerve repair by the coaptation of a healthy donor nerve to an injured nerve. Usually, nerve transfer is performed in an end-to-end manner, which will lead to functional loss of the donor nerve. In this study, we aimed to evaluate the efficacy of 3D-printed branch nerve conduits in nerve transfer. Methods: Customized branch conduits were constructed using gelatine-methacryloyl by 3D printing. The nerve conduits were characterized both in vitro and in vivo. The efficacy of 3D-printed branch nerve conduits in nerve transfer was evaluated in rats through electrophysiology testing and histological evaluation. Results: The results obtained showed that a single nerve stump could form a complex nerve network in the 3D-printed multibranch conduit. A two-branch conduit was 3D printed for transferring the tibial nerve to the peroneal nerve in rats. In this process, the two branches were connected to the distal tibial nerve and peroneal nerve. It was found that the two nerves were successfully repaired with functional recovery. Conclusions: It is implied that the two-branch conduit could not only repair the peroneal nerve but also preserve partial function of the donor tibial nerve. This work demonstrated that 3D-printed branch nerve conduits provide a potential method for nerve transfer.
... Beide vorgenannten Verfahren (TMR und TSR) haben neben der hohen Amputation an der oberen Extremität weitere Indikationsfelder wie die schwere Plexusbrachialis-Läsion und das Management problematischer Neurome und Phantomschmerzen erschlossen [1,5,7,10,11]. Der Erfolg des Eingriffs hängt nicht allein vom Outcome der komplexen chirurgischen Intervention ab, sondern auch von der Weiterentwicklung bionischer Exo-Prothetik, die perspektivisch einen bidirektionalen Transfer motorischer und sensibler Informationen zwischen der Prothese und deren Träger erlauben soll [4]. ...
... www.advancedsciencenews.com electrophysiological signals can be derived through brain interfaces, [270][271][272] using electrocorticography (ECoG) [273,274] on the cortical surface as well as local field potentials (LFP) [275,276] extracted from electrodes inserted into the cortex. Invasive recording techniques routinely use peripheral in vivo tissues with electroneurography (ENG) [277,278] and electromyography (EMG), [279,280] which can record peripheral nerve activity and muscle electrical signals, respectively. Non-invasive electrophysiological recording is also widely accepted and can be extracted on the skin's surface. ...
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Medical robots are invaluable players in non-pharmaceutical treatment of disabilities. Particularly, using prosthetic and rehabilitation devices with human-machine interfaces can greatly improve the quality of life for impaired patients. In recent years, flexible electronic interfaces and soft robotics have attracted tremendous attention in this field due to their high biocompatibility, functionality, conformability, and low-cost. Flexible human-machine interfaces on soft robotics would make a promising alternative to conventional rigid devices, which could potentially revolutionize the paradigm and future direction of medical robotics in terms of rehabilitation feedback and user experience. In this review, the fundamental components of the materials, structures, and mechanisms in flexible human-machine interfaces are summarized by recent and renown applications in five primary areas: physical and chemical sensing, physiological recording, information processing and communication, soft robotic actuation, and feedback stimulation. This review further concludes by discussing the outlook and current challenges of these technologies as a human-machine interface in medical robotics. This article is protected by copyright. All rights reserved
... After exit of these five BP nerves from the spinal cord, they merge to form three nerve trunks: the superior (formed by the merging of C5 and C6), medial (from C7), and inferior (branches of C8 and T1). Severe injuries, especially due to traffic accidents, often lead to avulsion of the BP nerve roots, and such dysfunction has a devastating effect on patients 1 . ...
Article
Background Restoration of hand function after traumatic brachial plexus injury (BPI) remains a formidable challenge. Traditional methods such as nerve or free muscle transfers yield suboptimal results. Advancements in myoelectric prostheses, characterized by novel signal acquisition and improved material technology, show promise in restoring functional grasp. This study evaluated the ability of adults with a BPI injury to control an externally powered prosthetic hand using nonintuitive signals, simulating the restoration of grasp with a myoelectric prosthesis. It also assessed the effectiveness of a comprehensive multidisciplinary evaluation in guiding treatment decisions. Methods A multidisciplinary brachial plexus team assessed adults with compromised hand function due to BPI. The feasibility of amputation coupled with fitting of a myoelectric prosthesis for grasp reconstruction was evaluated. Participants' ability to control a virtual or model prosthetic hand using surface electromyography (EMG) as well as with contralateral shoulder motion-activated linear transducer signals was tested. The patient’s input and injury type, along with the information from the prosthetic evaluation, were used to determine the reconstructive plan. The study also reviewed the number of participants opting for amputation and a myoelectric prosthetic hand for grasp restoration, and a follow-up survey was conducted to assess the impact of the initial evaluation on decision-making. Results Of 58 subjects evaluated, 47 (81%) had pan-plexus BPI and 42 (72%) received their initial assessment within 1 year post-injury. Forty-seven patients (81%) could control the virtual or model prosthetic hand using nonintuitive surface EMG signals, and all 58 could control it with contralateral uniscapular motion via a linear transducer and harness. Thirty patients (52%) chose and pursued amputation, and 20 (34%) actively used a myoelectric prosthesis for grasp. The initial evaluation was informative and beneficial for the majority of the patients, especially in demonstrating the functionality of the myoelectric prosthesis. Conclusions The study indicates that adults with traumatic BPI can effectively operate a virtual or model myoelectric prosthesis using nonintuitive control signals. The simulation and multidisciplinary evaluation influenced informed treatment choices, with a high percentage of patients continuing to use the myoelectric prostheses post-amputation, highlighting its long-term acceptance and viability. Level of Evidence Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.
Article
Traumatic adult brachial plexus injuries typically cause immediate loss of upper limb function. Timely multidisciplinary treatment in specialized centres often results in a useful helper arm. Both the patient and the surgical team can benefit from an open discussion to set realistic expectations. Surgical reconstruction is customized for each patient, considering their injury factors and functional objectives. Optimizing pain control, adherence to procedure indications and using meticulous surgical techniques help minimize the risk of failing to meet the patient’s goals. The need for potential alternative treatment(s) if the desired result is not achieved should be detailed before the initial reconstruction. This review discusses late treatment options, including tendon transfers, joint fusions, free functioning muscle transfers and prosthetics, for managing the failed primary reconstruction of the traumatic adult brachial plexus.
Article
Selective nerve transfers are used in the setting of upper limb amputation to improve myoelectric prosthesis control. This surgical concept is referred to as targeted muscle reinnervation (TMR) and describes the rerouting of the major nerves of the arm onto the motor branches of the residual limb musculature. Aside from providing additional myosignals for prosthetic control, TMR can treat and prevent neuroma pain and possibly also phantom limb pain. This article reviews the history and current applications of TMR in upper limb amputation, with a focus on practical considerations. It further explores and identifies technological innovations to improve the man–machine interface in amputation care, particularly regarding implantable interfaces, such as muscle electrodes and osseointegration. Finally, future clinical directions and possible scientific avenues in this field are presented and critically discussed.
Chapter
We include here two major articles from other departments whose responsibles became friends over the years. The first deals with upper limb amputation and targeted muscle reinnervation, the second with hand allotransplantation.
Chapter
Primary and secondary limb amputations are a common consequence of blast-induced extremity injuries. The resulting limb loss can lead to a severe decrease in quality of life, affecting both the social and mental status. The severity of this problem is historically well recognised, prompting the development of more primitive prosthetics. The last decade has seen rapid technological advancements, with significant impact in the dexterity of bionic limbs. The current market offers highly functional upper and lower limb systems with a variety of design options tailored towards different needs. However, the improvements in the functionality of bionic hardware are not yet matched with the quality of control offered to the users. This results in high device abandonment among the amputees. Here we provide a technical overview of the prosthetic solutions, reflect upon the clinical and user challenges, and indicate the most recent clinical and technical advancements made in the field. We also identify the most promising technologies that are likely to have a strong clinical impact and constitute the basis for the next generation of bionic limbs.KeywordsProstheticsAmputationUpper limbLower limbProsthetic controlSensory feedbackSurgeryTechnology
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Blast causes severe and complex injury patterns and significant rehabilitation challenges. By 2011/12, the peak of the Afghanistan conflict, complex trauma admissions into the Defence Medical Rehabilitation Centre Headley Court were equivalent to the total admissions into specialist inpatient NHS rehabilitation for the whole of England. These high casualty numbers enabled the rehabilitation specialists to evolve practice and challenge expectations. The service was built upon existing principles, namely early assessment, exercise-based rehabilitation, cross-disciplinary working, active case management, and rapid access to specialist opinions and investigations. Rehabilitation commenced at the earliest possible point in the intensive care unit in the deployed setting. This then progressed through to the inpatient trauma ward to the delivery of outpatient rehabilitation even while the patients were still in hospital. Finally, the integration of medical rehabilitation and transitional support agencies is critical in the support of the casualty in the final stages of their recovery.KeywordsRehabilitationComplex injuryAmputeesDMRCInterdisciplinarityPainProstheticsOsseointegration
Article
Introduction: A variety of approaches have been described to obtain rudimentary grasp following traumatic pan brachial plexus injury in the adult. The aim of this study is to evaluate hand prehension after a Gracilis Single-Stage Free Functioning Muscle Transfer (SSFFMT). Materials and methods: Twenty-seven patients who underwent gracilis SSFFMT for elbow flexion and hand prehension following a pan-plexus injury were included. All patients presented with a minimum of 2 years of follow-up. Postoperative finger flexion, elbow flexion strength, preoperative and postoperative DASH scores, secondary hand procedures, complications as well as demographic characteristics were analyzed. Results: Twenty patients (74%) demonstrated active finger pull-through. Only 6 (25%) patients considered their hand function as useful for daily activities. DASH score improved by 13.1 ± 13.7 (p-value < 0.005). All patients were expected to require one secondary procedure: combined wrist, thumb CMC and thumb IP fusions, as no extensor reconstruction was performed. These were actually performed in 89%, 78% and 74% of patients, respectively. Four postoperative complications included hematoma, seroma, wound dehiscence and skin paddle loss. No flap loss occurred. Conclusion: In pan-plexus injuries, the use of a gracilis SSFFMT is an alternative to the Doi double FFMT procedure and cC7 transfer, especially for patients that cannot afford (economically or mentally) two to three important surgeries in a short period of time. Further research and studies are required to improve hand function in these patients.
Article
Background: A cohort of patients with traumatic brachial plexus injuries (BPIs) underwent elective amputation following unsuccessful surgical reconstruction or delayed presentation. The results of amputation with and without a myoelectric prosthesis (MEP) using nonintuitive controls were compared. We sought to determine the benefits of amputation, and whether fitting with an MEP was feasible and functional. Methods: We conducted a retrospective review of patients with BPI who underwent elective upper-extremity amputation at a single institution. Medical records were reviewed for demographics, injury and reconstruction details, amputation characteristics, outcomes, and complications. Prosthesis use and MEP function were assessed. The minimum follow-up for clinical outcomes was 12 months. Results: Thirty-two patients with BPI and an average follow-up of 53 months underwent elective amputation between June 2000 and June 2020. Among the cases were 18 transhumeral amputations, 12 transradial amputations, and 2 wrist disarticulations. There were 29 pan-plexus injuries, 1 partial C5-sparing pan-plexus injury, 1 lower-trunk with lateral cord injury, and 1 lower-trunk injury. Amputation occurred, on average, at 48.9 months following BPI and 36.5 months following final reconstruction. Ten patients were fitted for an MEP with electromyographic signal control from muscles not normally associated with the intended function (nonintuitive control). Average visual analog scale pain scores decreased post-amputation: from 4.8 pre-amputation to 3.3 for the MEP group and from 5.4 to 4.4 for the non-MEP group. Average scores on the Disabilities of the Arm, Shoulder and Hand questionnaire decreased post-amputation, but not significantly: from 35 to 30 for the MEP group and from 43 to 40 for the non-MEP group. Patients were more likely to be employed following amputation than they were before amputation. No patient expressed regret about undergoing amputation. All patients in the MEP group reported regular use of their prosthesis compared with 29% of patients with a traditional prosthesis. All patients in the MEP group demonstrated functional terminal grasp/release that they considered useful. Conclusions: Amputation is an effective treatment for select patients with BPI for whom surgical reconstruction is unsuccessful. Patients who underwent amputation reported decreased mechanical pain, increased employment rates, and a high rate of satisfaction following surgery. In amputees with sufficient nonintuitive electromyographic signals, MEPs allow for terminal grasp/release and are associated with high rates of prosthesis use. Level of evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Transhumanism is a philosophical, cultural and political revolutionary movement. It proposes a radical transformation of the human being and the society in which it develops. Transhumanism is revolutionary on a philosophical level because it collects ontological traditions of the past that posed this transformation, from British Marxist and non-Marxist left-wing thinkers of the 19th and 20th centuries to Soviet and Russian cosmism. But going further back one can find proto-transhumanist proposals from Christian theologians and Enlightenment philosophers. And it is revolutionary at a political level because it can be traced back to proto-transhumanist ideas in political revolutionaries of the past. The revolutionary doctrine par excellence of the 19th and 20th centuries is Marxism. Marxism also influenced certain transhumanists authors, although there are no transhumanist movements that claimed to be Marxist themselves, because none of them put into question capital as the basic social relation of capitalism. In the texts of Marx, Engels and Lenin there can be found proto-transhumanist ideas. Philosophical connections between Marxism and transhumanism are numerous. But beyond this, in this article we suggest that it is possible to develop a Marxist transhumanism movement that exceeds the actual individualistic and pro-capitalist prism on transhumanism. Also, we suggest transhumanism can serve to revitalize Marxist materialism in this 21st century and for the future. Marxist transhumanism would comply with the definition of communism of Marx and Engels, and it could even be said that Marxism is, essentially, transhumanist in its foundations, even when it defines posthumans as New Men, or Men Made In Property. And it could even be said that transhumanism is, in essence, Marxist. In this article, we present a historical cartography of inherent class relations in techno-scientific development and try to show the ideological impact that these relations made on transhumanists. We describe actual transhumanism as transcapitalism, and analyze its theoretical influences, proposing a theoretical itinerary for Marxist transhumanism, from Marx to more contemporary authors that would pave its political and philosophical roots. In addition, we define transcapitalism as BTA-Politics-biopolitics, thanatopolitics and anatomopolitics-in the sense of Michel Foucault. Finally, we propose that it is precisely the inherent contradictions of current Transcapitalism that set the paths for the construction of Marxist transhumanism.
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Surgical nerve transfers are used to efficiently treat peripheral nerve injuries, neuromas, phantom limb pain, or improve bionic prosthetic control. Commonly, one donor nerve is transferred to one target muscle. However, the transfer of multiple nerves onto a single target muscle may increase the number of muscle signals for myoelectric prosthetic control and facilitate the treatment of multiple neuromas. Currently, no experimental models are available. This study describes a novel experimental model to investigate the neurophysiological effects of peripheral double nerve transfers to a common target muscle. In 62 male Sprague-Dawley rats, the ulnar nerve of the antebrachium alone (n=30) or together with the anterior interosseus nerve (n=32) was transferred to reinnervate the long head of the biceps brachii. Before neurotization, the motor branch to the biceps’ long head was transected at the motor entry point. Twelve weeks after surgery, muscle response to neurotomy, behavioral testing, retrograde labeling, and structural analyses were performed to assess reinnervation. These analyses indicated that all nerves successfully reinnervated the target muscle. No aberrant reinnervation was observed by the originally innervating nerve. Our observations suggest a minimal burden for the animal with no signs of functional deficit in daily activities or auto-mutilation in both procedures. Furthermore, standard neurophysiological analyses for nerve and muscle regeneration were applicable. This newly developed nerve transfer model allows for the reliable and standardized investigation of neural and functional changes following the transfer of multiple donor nerves to one target muscle.
Chapter
Nerve grafting and transfer techniques have resulted in reliable restoration of function after brachial plexus injuries when the procedure is undertaken within 6–9 months of injury. In many instances, however, delay in treatment or complete avulsion of the brachial plexus limits the reconstruction options. This has resulted in the use of free functional muscle transfers in conjunction with extraplexal motor nerves to restore function in the setting of brachial plexus avulsions or when the interval between injury and surgery is greater than 1 year. Free functional muscle transfer is a complex but reliable procedure for elbow flexion when treatment delay prevents nerve grafting or nerve transfers for restoration of biceps function, or when previous nerve grafting and/or nerve transfer has given into unsatisfactory results and proximal muscle strength is insufficient to allow tendon transfers. This chapter will attempt to highlight our current free functional muscle transfer strategies and techniques in acute and chronic brachial plexus injuries.
Chapter
In most adult brachial plexus injuries, a high-energy mechanism results in extensive longitudinal axonotmetic damage, frequently with multiple nerve root avulsions. Resources for restoring function are limited by the resulting absence of most or all proximal plexal nerves. When extradural injury permits nerve grafting, limited autogenous sources of nerve graft often prove insufficient. Delay in surgical management, slow rates of nerve regeneration, and long distances required for axon growth to reach a target muscle often prevent a successful outcome. These factors require prioritization of desired functions to make best use of limited available resources. Best options for restoring elbow, shoulder, and grasp function are discussed based upon pattern of injury, with an analysis of published results to aid the reader in evaluation and treatment of these complex and challenging injuries.
Article
This review article presents the history, indications and techniques for the usual nerve transpositions in the upper extremities. By means of nerve transposition paralyzed muscles are reinnervated using dispensable donor motor axons. Many standard operations on the upper extremities are attributable to concepts of German-speaking surgeons and orthopedists. The reliable return of function by the short-range and selective motor reinnervation using nerve transfer results in a renaissance of these techniques. The spectrum of applications has been substantially extended in recent years. In order to achieve an optimal result, a subtle microsurgical technique is necessary. In this way excellent results can be achieved even for complex proximal nerve injuries.
Article
Hand amputation can be discussed after traumatic brachial plexus injury when the patient’s hand is non-functional, painful and/or insensitive. That indication is more common in English-speaking countries than in European or Latin countries. New prostheses are now on the market and can be used after hand amputation to improve the functional prognosis in well-selected patients. A 26-year-old male was involved in a road accident in January 2016. He had a traumatic brachial plexus injury and underwent nerve surgery to restore the biceps brachii and triceps brachii. One year after nerve transfer, his hand was insensitive and non- functional. After multidisciplinary consultation, it was decided to amputate his hand to replace it with a myoelectric prosthesis. Shoulder subluxation pain and complications associated with an insensitive and heavy arm were improved after hand amputation. Functional outcomes were improved with this revolutionary myoelectric prosthesis technique. The patient was able to use his prosthesis for many daily activities. Selective amputation indications after traumatic brachial plexus injury are a heavy and stiff arm with shoulder subluxation pain and an unusable claw hand. The patient’s motivation must be high.
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Targeted reinnervation was introduced as a surgical procedure to improve myoelectric control signals for proximal upper limb amputation. From the first case studies in patients with shoulder disarticulation and transhumeral amputation, it was noted that in addition to increased motor control signals, there was restoration of sensations related to the missing arm and hand. The neural remapping of hand sensation has been explored as an avenue for tactile feedback related to the cutaneous reinnervation, and kinesthetic feedback related to the reinnervation of the muscle sensory fibers. Advances in robotic haptic devices and prosthesis sensorization have led to fully integrated wearable prosthesis systems that noninvasively provide real-time somatotopically and modality-matched feedback. These bidirectional neural human–machine interface systems provide insight into the underlying neural mechanisms of sensory processing and integration. Planning for targeted reinnervation should include a thorough assessment of potential motor sites, nerve management, and sensory restoration options.
Article
Targeted muscle reinnervation (TMR) is a surgical procedure, whereby nerves without muscle targets after extremity amputation are transferred to residual stump muscles. Thereby, the control of prosthesis is improved by increasing the number of independent muscle signals. The authors describe indications for TMR to improve prosthetic control and present standard nerve transfer matrices suitable for transhumeral and glenohumeral amputees. In addition, the perioperative procedure is described, including preoperative testing, surgical approach, and postoperative rehabilitation. Based on recent neurophysiological insights and technological advances, they present an outlook into the future of prosthetic control combining TMR and implantable electromyographic technology.
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This paper describes the development of an evaluative outcome measure for patients with upper extremity musculoskeletal conditions. The goal is to produce a brief, self-administered measure of symptoms and functional status, with a focus on physical function, to be used by clinicians in daily practice and as a research tool. This is a joint initiative of the American Academy of Orthopedic Surgeons (AAOS), the Council of Musculoskeletal Specialty Societies (COMSS), and the Institute for Work and Health (Toronto, Ontario).Our approach is consistent with previously described strategies for scale development. In Stage 1, Item Generation, a group of methodologists and clinical experts reviewed 13 outcome measurement scales currently in use and generated a list of 821 items. In Stage 2a, Initial Item Reduction, these 821 items were reduced to 78 items using various strategies including removal of items which were generic, repetitive, not reflective of disability, or not relevant to the upper extremity or to one of the targeted concepts of symptoms and functional status. Items not highly endorsed in a survey of content experts were also eliminated. Stage 2b, Further Item Reduction, will be based on results of field testing in which patients complete the 78-item questionnaire. This field testing, which is currently underway in 20 centers in the United States, Canada, and Australia, will generate the final format and content of the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. Future work includes plants for validity and reliability testing. © 1996 Wiley-Liss, Inc.
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We review our experience treating 335 adult patients with supraclavicular brachial plexus injuries over a 7-year period at the University of Southern Santa Catarina, in Brazil. Patients were categorized into 8 groups, according to functional deficits and roots injured: C5-C6, C5-C7, C5-C8 (T1 Hand), C5-T1 (T2 Hand), C8-T1, C7-T1, C6-T1, and total palsy. To restore function, nerve grafts, nerve transfers, and tendon and muscle transfers were employed. Patients with either upper- or lower-type partial injuries experienced considerable functional return. In total palsies, if a root was available for grafting, 90% of patients had elbow flexion restored, whereas this rate dropped to 50% if no roots were grafted and only nerve transfers performed. Pain resolution should be the first priority, and root exploration and grafting helped to decrease or eliminate pain complaints within a short time of surgery.
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Approximately two thirds of stroke survivors continue to experience motor deficits of the arm resulting in diminished quality of life. Conventional rehabilitation provides modest and sometimes delayed effects. Virtual reality (VR) technology is a novel adjunctive therapy that could be applied in neurorehabilitation. We performed a meta-analysis to determine the added benefit of VR technology on arm motor recovery after stroke. We searched Medline, EMBASE, and Cochrane literature from 1966 to July 2010 with the terms "stroke," "virtual reality," and "upper arm/extremity." We evaluated the effect of VR on motor function improvement after stroke. From the 35 studies identified, 12 met the inclusion/exclusion criteria totaling 195 participants. Among them, there were 5 randomized clinical trials and 7 observational studies with a pre-/postintervention design. Interventions were delivered within 4 to 6 weeks in 9 of the studies and within 2 to 3 weeks in the remaining 3. Eleven of 12 studies showed a significant benefit toward VR for the selected outcomes. In the pooled analysis of all 5 randomized controlled trials, the effect of VR on motor impairment (Fugl-Meyer) was OR=4.89 (95% CI, 1.31 to 18.3). No significant difference was observed for Box and Block Test or motor function. Among observational studies, there was a 14.7% (95% CI, 8.7%-23.6%) improvement in motor impairment and a 20.1% (95% CI, 11.0%-33.8%) improvement in motor function after VR. VR and video game applications are novel and potentially useful technologies that can be combined with conventional rehabilitation for upper arm improvement after stroke.
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This article presents information about the development and evaluation of the SF-36 Health Survey, a 36-item generic measure of health status. It summarizes studies of reliability and validity and provides administrative and interpretation guidelines for the SF-36. A brief history of the International Quality of Life Assessment (IQOLA) Project is also included.
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Obstetric brachial plexus palsy is a devastating birth injury. While many children recover spontaneously, 20-25% are left with a permanent impairment of the affected limb. So far, concepts of pathology and recovery have focused on the injury of the peripheral nerve. Proximal nerve injury at birth, however, leads to massive injury-induced motoneuron loss in corresponding motoneuron pools and therefore limits the extent of functional recovery. In the present study, the role of spinal cord plasticity after injury and recovery from obstetric brachial plexus lesions was investigated. A selective injury to spinal roots C5 and C6 was induced in newborn Sprague-Dawley rats, leading to motoneuron loss in corresponding motoneuron pools. Recovery of extremity function was evaluated with different behavioural paradigms. Permanent changes of adjacent motoneuron pools were quantitatively evaluated by retrograde tracing and functional muscle testing. We report that the adjacent C7 motoneuron contribution to biceps muscle innervation increased four-fold after upper trunk lesions in newborns, thus compensating for the injury-induced motoneuron loss. These results indicate that, in obstetric brachial plexus palsy, changes in spinal cord architecture are an integral part not only of primary pathology but also of the subsequent recovery process. While present treatment is directed towards the restoration of neural continuity, future treatment strategies must recognize and take advantage of CNS participation in the injury and recovery process.
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The authors report the functional outcomes after functioning free muscle transfer (FFMT) for restoration of the upper-extremity movement after brachial plexus injury (BPI). The authors conducted a retrospective review of 36 gracilis FFMT procedures performed in 27 patients with BPI between 1990 and 2000. Eighteen patients underwent a single gracilis FFMT procedure for restoration of either elbow flexion (17 cases) or finger flexion (one case). Nine patients underwent a double free muscle transfer for simultaneous restoration of elbow flexion and wrist extension (first muscle) and finger flexion (second muscle), combined with direct triceps neurotization. The results obtained in 29 cases of FFMT in which the follow-up period was 1 year are reported. Neurotization of the donor muscle was performed using the musculocutaneous nerve (one case), spinal accessory nerve (12 cases), or multiple intercostal motor nerves (16 cases). Two second-stage muscle flaps failed secondary to vascular insufficiency. Mean electromyography-measured reinnervation time was 5 months. At a minimum follow-up period of 1 year, five muscles achieved less than or equal to Grade M2, eight Grade M3, four Grade M4, and 12 Grade M5. Transfer for combined elbow flexion and wrist extension compared with elbow flexion alone lowered the overall results for elbow flexion strength. Seventy-nine percent of the FFMTs for elbow flexion alone (single transfer) and 63% of similarly innervated muscles transferred for combined motion achieved at least Grade M4 elbow flexion strength. Functioning free muscle transfer is a viable reconstructive option for restoration of upper-extremity function in the setting of severe BPI. It is possible to achieve good to excellent outcomes in terms of muscle grades with the simultaneous reconstruction of two functions by one FFMT, making restoration of basic hand function possible. More reliable results are obtained when a single FFMT is performed for a single function.
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Tendon transfers are a routine procedure used to improve hand function in brachial plexus injuries; however, muscles from forearm donors are not always available for transfer. In this situation a distant muscle may be used. This study describes transfer of the brachialis muscle to the forearm muscles to reconstruct finger flexion or wrist extension in patients with brachial plexus injuries. In 6 patients the brachialis muscle was transferred to the flexor digitorum profundus and the flexor pollicis longus to restore finger and thumb flexion with the goal of reconstructing a key pinch and hook grasp. In 3 patients the brachialis muscle was transferred to the extensor carpi radialis brevis to restore wrist extension. The patients were evaluated at regular intervals and had final assessments between 10 and 12 months after surgery. Brachialis transfer to the flexor digitorum profundus and the flexor pollicis longus resulted in active motion with full range of digital flexion in the 2 patients who had partial flexion before surgery, and for the 4 patients who had no finger flexion before surgery it resulted in a pulp-to-palm distance for the middle finger of 1 cm in 3 patients and of 2 cm in 1 patient. A lateral key pinch and hook grasp reconstruction was achieved in all patients. Grasping and lateral pinch strengths averaged 110 and 94 mm Hg, respectively. When the brachialis was transferred to the wrist extensors the patients recovered 20 degrees of active wrist extension against resistance. Brachialis muscle transfer to the forearm muscle constitutes a valid strategy in the reconstruction of finger and thumb flexion and wrist extension after brachial plexus injury when forearm donor muscles are not available. Therapeutic, Level IV.
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Control algorithms for upper limb myoelectric prostheses have been in development since the mid-1940s. Despite advances in computing power and in the performance of these algorithms, clinically available prostheses are still based on the earliest control strategies. The aim of this review paper is to detail the development, advantages and disadvantages of prosthetic control systems and to highlight areas that are current barriers for the transition from laboratory to clinical practice. Current surgical strategies and future research directions to achieve multifunctional control will also be discussed. The findings from this review suggest that regression algorithms may offer an alternative feed-forward approach to direct and pattern recognition control, while virtual rehabilitation environments and tactile feedback could improve the overall prosthetic control.
Article
The results of repairing a divided mixed nerve are usually less satisfactory than those of repairing purely sensory or motor nerves because of inability to identify the various funiculi and the inevitable and non-functioning union of sensory fibres to motor fibres. Sunderland (1945) tried to solve this problem by mapping the topography of the funiculi at various levels but there is such individual variation (Dustin, 1918; Forster, 1929; Holle et al., 1975) that his data cannot be relied on. It is possible to differentiate motor from sensory bundles in the proximal and distal cut end by electrical stimulation of the individual funiculi (Hakistan, 1968; Vandeput et al., 1969). These techniques however are only suitable in conscious patients and are difficult to apply clinically. We present a new approach to the problem which depends on a histochemical technique for acetylcholinesterase activity which differentially stains motor and sensory funiculi (Gruber and Zenker, 1971, 1973). The method is applicable to recently cut nerves and we have used it in a number of injuries to the median and ulnar nerves proximal to the wrist.
Article
Die Bewegung myoelektrischer Armprothesen erfolgt bis dato über 2 transkutane Elektroden, welche über zwei getrennt innervierte Muskelgruppen angesteuert werden. Die verschiedenen Steuerungsebenen werden durch Kokontraktionen dieser Muskeln angewählt und in der jeweiligen Ebene mit denselben Muskeln linear gesteuert. Ein harmonischer, dem natürlichen Bewegungsmuster entsprechender Bewegungsablauf ist mit diesem Steuerungsmechanismus nicht möglich. Eine wesentliche Verbesserung wäre eine Ansteuerung der einzelnen Bewegungsebenen mit Signalen, welche neuronal mit dem natürlichen Bewegungsablauf übereinstimmen. Technisch sind Prothesen mit 6 Steuerungsebenen seit Kurzem realisiert. Ziel ist es, die wesentlichen Armnerven wie N. musculocutaneus, N. radialis, N. medianus und N. ulnaris aus dem proximalen Armnervengeflecht herauszulösen und an verbliebene Nervenäste von stammnahen Muskeln zu transferieren, um so sinnvolle neuromuskuläre Einheiten zu schaffen, die als Impulsgeber für eine myoelektrische Prothese dienen können. Als Zielmuskeln würden sich hier vor allem der M. pectoralis major/minor beziehungsweise M. latissimus dorsi anbieten. Diese Muskeln würden schließlich entsprechend der Aktivität der Spendernerven anspannen und über transkutane Elektroden die Prothese steuern. Auf diese Weise ist eine harmonische, intuitive dem natürlichen Bewegungsmuster entsprechende Steuerung gewährleistet, ohne dass der Patient ständig zwischen den verschiedenen Steuerungsebenen wechseln muss. Voraussetzung sind intakte proximale Muskelgruppen und weitgehend intaktes proximales Armnervengeflecht mit der Möglichkeit, Spendernerven entsprechend topografisch-anatomisch isolieren zu können. Diesbezüglich ist eine präoperative MRT-Untersuchung, hochauflösender Ultraschall und bilanzierende NLG und EMG des verbliebenen Armnervengeflechtes notwendig. In der präoperativen Planungsphase als auch in der postoperativen Verlaufskontrolle ist gemeinsam mit der Innovationsabteilung der Fa. Otto Bock ein detailliertes Prozedere ausgearbeitet worden, um möglichst sinnvolle Schaltebenen zu schaffen, die Elektrodenpositionierung zu optimieren und auch die Prothesenanbindung zu klären. Schließlich ist ein komplexes Rehabilitationsprogramm notwendig, um dem Patienten ein optimales Ergebnis zu ermöglichen.
Article
In brachial plexus injuries with nerve root avulsions, the options for nerve reconstruction are limited. In select situations, half or all of the contralateral C7 (CC7) nerve root can be transferred to the injured side for brachial plexus reconstruction. Although encouraging results have been reported, CC7 transfer has not gained universal popularity. The purpose of this study was to critically evaluate hemi-CC7 transfer for restoration of shoulder function or median nerve function in patients with severe brachial plexus injury. A retrospective review of all patients with traumatic brachial plexus injury who had undergone hemi-CC7 transfer at a single institution during an eight-year period was performed. Complications were evaluated in all patients regardless of the duration of follow-up. The results of electrodiagnostic studies and modified British Medical Research Council (BMRC) motor grading were reviewed in all patients with more than twenty-seven months of follow-up. Fifty-five patients with traumatic brachial plexus injury underwent hemi-CC7 transfer performed between 2001 and 2008 for restoration of shoulder function or median nerve function. Thirteen patients who underwent hemi-CC7 transfer to the shoulder and fifteen patients who underwent hemi-CC7 transfer to the median nerve had more than twenty-seven months of follow-up. Twelve of the thirteen patients in the shoulder group demonstrated electromyographic evidence of reinnervation, but only three patients achieved M3 or greater shoulder abduction motor function. Three of the fifteen patients in the median nerve group demonstrated electromyographic evidence of reinnervation, but none developed M3 or greater composite grip. All patients experienced donor-side sensory or motor changes; these were typically mild and transient, but one patient sustained severe, permanent donor-side motor and sensory losses. The outcomes of hemi-CC7 transfer for restoration of shoulder motor function or median nerve function following posttraumatic brachial plexus injury do not justify the risk of donor-site morbidity, which includes possible permanent motor and sensory losses.
Article
We report a case of targeted muscle reinnervation of a muscle free flap for improved prosthetic control in a patient who had an amputation of the left upper extremity at the level of the shoulder after a severe electrical burn. The reinnervated muscle free flap receives signals from the brachial plexus, and these signals are amplified to provide an interface for a myoelectric prosthesis. This allows for more coordinated and efficient control of the artificial limb. (J Hand Surg 2011;36A:890-893. Copyright (C) 2011 by the American Society for Surgery of the Hand. All rights reserved.)
Article
In lower root avulsion plexopathies, free muscle transfers for hand reanimation provide the only hope for the paralyzed hand, as the outcomes of hand functional restoration after primary brachial plexus reconstruction are uniformly poor. The purpose of this study was to analyze the outcomes of free gracilis muscle transfers for hand reanimation in severe brachial plexus injuries in relation to the respective motor donors. Since 1981, 71 free gracilis muscles have been transplanted for hand reanimation. Thirty-eight were for finger flexion and 33 were for finger extension. Neurotizations included motor donors such as intercostal nerves (n = 29), contralateral C7 root (n = 28), spinal accessory nerve (n = 7), or upper roots of the ipsilateral plexus (n = 5). Preoperative and postoperative muscle grading and range of motion were found to be significantly different. The strongest motor donor for finger extension was the distal spinal accessory. The medial antebrachial cutaneous nerve as a conduit nerve carrying motor axons yielded worse results than other motor donors. Intercostals were useful for finger flexion and the contralateral C7 root was useful for finger extension. Scar formation in the volar wrist area was frequently a problem. After securing the stability and function of the proximal joints of the upper limb, attention should be shifted to the hand, and in compliant patients with supple finger joints, hand reanimation should be attempted. It is only through these efforts that the future of the paralytic limb can be upgraded to a useful assist extremity.
Article
Large experience in Asia has shown that the contralateral C7 nerve transfer has proved one of the major treatments for brachial plexus root avulsions. The authors report their experience in North America using the selective contralateral C7 transfer for neurotization of multiple targets. A retrospective review of 56 patients with posttraumatic root avulsion brachial plexus injuries who underwent contralateral C7 transfer using selective technique was conducted. The targets included the axillary, musculocutaneous, radial, and median nerves. Additionally, neurotization of future free muscle transplantation was performed. The mean follow-up period was 6.1 years (range, 2.5 to 14 years). Motor recovery reached a level of M3+ or greater in 20 percent (two of 10) of patients for the deltoid, 52 percent (12 of 23) for the biceps, 24 percent (five of 21) for the triceps, 34 percent (10 of 29) for the wrist and finger flexors, and 20 percent (two of 10) for the wrist and finger extensors. In addition, sensory recovery of S2 or greater was achieved in 76 percent (22 of 29) of patients with median nerve neurotization. As far as the postoperative morbidity of the donor limb, by 6 months, there was no discernible motor or sensory deficit. Patients with a surgical delay of 9 months or less and patients aged 18 years or younger achieved significantly better results. Brachial plexus root avulsions, long considered to be irreparable, are by no means unreconstructable. The selective contralateral C7 transfer appears to be a safe procedure, and it can be successfully applied for simultaneous reconstruction of several different nerves and/or for neurotization of future free muscle transfers.
Article
Since the description by Smellie in 1764, in a French midwifery text, that first suggested an obstetric origin for upper limb birth palsy, great strides have been made in both diagnosis and early and late treatment. This report presents an overview of selected aspects of this complex and extensive subject. Early treatment options are reviewed in the context of the present controversies regarding the natural history and the indications for and timing of microsurgical intervention in infants with brachial plexus birth injuries.
Article
Simultaneous reconstruction of elbow and finger function with free muscle and nerve transfers after complete avulsion of the brachial plexus (nerve roots C5 to T1) and its long-term results are presented. The basic procedure combined free or vascular pedicle latissimus dorsi muscle transfer with reinnervation by the spinal accessory nerve to obtain elbow and finger flexion, intercostal nerve transfer of the radial nerve to activate elbow and wrist extensors, and suture of the supraclavicular nerve or intercostal sensory rami to the median nerve to restore hand sensibility. Six patients had some or all of these procedures. Postoperative follow-up ranged from 2 to 5 years. Elbow function was restored completely, and some finger flexion was achieved in all cases, although a dynamic splint was necessary to straighten the digits. Patients have continued to improve in grasp power and finger control. This procedure appears to be promising for the restoration of basic hand function in severely handicapped patients.
Article
This is an extension review on mammalian motor units including the different 0,6979 muscle types, eye, ear, and larynx. (403 references).
Article
Management of patients with brachial plexus injuries requires a team approach so that all aspects of their care are addressed simultaneously. This report examines elective amputation and prosthetic rehabilitation in a patient with brachial plexus avulsion of the left arm. The best possibility for good prosthetic rehabilitation is the early application of prosthetic devices with intensive occupational therapy. Using this type of approach, we have achieved significant improvement in amputation rehabilitation of upper extremity amputees treated with immediate postoperative conventional electric and myoelectric prostheses.
Article
This study examines muscle recovery and related changes in the motor unit population of 'hyper-reinnervated' rat skeletal muscle. Medial gastrocnemius (MG) muscles were hyper-reinnervated by either cutting the MG nerve and implanting it on the MG muscle together with additional hind limb nerves, or by crushing the MG nerve and excising the medial portion (50-70%) of the MG muscle. Our findings were that muscles hyper-reinnervated with multiple nerves recovered muscle mass and strength more fully than did the self-reinnervated muscles, more motor units were formed (up to three times the normal number were found), and the mean motor unit size was significantly smaller. A relatively small percentage of muscle fibers became polyneuronally innervated. In contrast, the number of motor units that were formed in the muscle reduction experiments were not significantly larger than was expected considering the mass of the muscles. We conclude that hyper-reinnervation improves muscle recovery, it may be a useful technique for improving function in denervated muscle, and may serve to provide added sources of EMG control signals in some amputees.
Article
Advantages of coping assessment for the understanding of individual impacts of severe illness are pointed out, the benefit for a better understanding of the rehabilitation process is demonstrated. After the basic positions and preliminary assumptions are described, the guidelines of the development of the inventory are introduced: Assessment of a broad spectrum of coping with chronic diseases with ratings by the patient himself and by others (doctors, relatives), suitability for process measuring, good acceptance, and economical application. Statistical properties of the questionnaires are reported with respect to achieved acceptance, reliability, and validity data. Using selected results as examples, possible applications in psychosomatic research are pointed out for issues such as illness-specific components of coping with chronic diseases, discrepancies between patients' and doctors' views of coping, and adaptational success. Finally, possibilities and limits of the inventory are discussed in terms of research issues and methodology.
Article
Thus far, devastating injuries of the adult brachial plexus have had a poor prognosis. This article presents the possible outcomes of aggressive microsurgical reconstruction in the largest series of patients in North America to date. It should change the pessimistic outlook that has surrounded these lesions. In this study, the outcomes of surgery were analyzed in relation to the type and level of injury, the age of the patient, and the denervation time; stronger donors for neurotization in relation to the various targets were delineated. The results were analyzed in 204 patients with adequate follow-up from a total of 263 patients who were operated on between 1978 and 1996. The mean age of the patients was 25.9 years, and the injuries were caused by high-velocity motor accidents involving avulsion in 55 percent of the patients. Nerve reconstruction included 577 nerve repairs (140 direct neurotizations and 437 cases of nerve grafting). Microneurolysis was performed in 89 cases. Vascularized nerve grafts were used in 120 repairs. Muscle transfers (29 pedicled and 78 free) were used to enhance function. The results were good or excellent in 75 percent of suprascapular nerve reconstructions, 40 percent of deltoid reconstructions, 48 percent of biceps reconstructions, 30 percent of triceps reconstructions, 35 percent of finger-flexion reconstructions, and 15 percent of finger-extension reconstructions. The majority of the patients had protective sensation and pain relief postoperatively.
Article
We report the results of 15 patients who underwent nerve transfer for restoration of shoulder and elbow function at our institution for traumatic brachial plexus palsy. We present these results in the context of a meta-analysis of the English literature, designed to quantitatively assess the efficacy of individual nerve transfers for restoration of elbow and shoulder function in a large number of patients. One thousand eighty-eight nerve transfers from 27 studies met the inclusion criteria of the analysis. Seventy-two percent of direct intercostal to musculocutaneous transfers (without interposition nerve grafts) achieved biceps strength > or =M3 versus 47% using interposition grafts. Direct intercostal transfers to the musculocutaneous nerve had a better ability to achieve > or =M4 elbow strength than transfers from the spinal accessory nerve (41% vs 29%). The suprascapular nerve fared significantly better than the axillary nerve in obtaining > or =M3 shoulder abduction (92% vs 69%). At our institution 90% of intercostal to musculocutaneous transfers (n = 10) achieved > or =M3 bicep strength and 70% achieved > or =M4 strength. Four of seven patients achieved > or =M3 shoulder abduction with a single nerve transfer and 6 of 7 regained > or =M3 strength with a dual nerve transfer. This study suggests that interposition nerve grafts should be avoided when possible when performing nerve transfers. Better results for restoration of elbow flexion have been attained with intercostal to musculocutaneous transfers than with spinal accessory nerve transfers and spinal accessory to suprascapular transfers appear to have the best outcomes for return of shoulder abduction. We conclude that nerve transfer is an effective means to restore elbow and shoulder function in brachial plexus paralysis.
Article
Phantom limb pain is a frequent consequence of the amputation of a body part. Based on the finding that phantom limb pain is closely associated with plastic changes in the primary somatosensory cortex and animal data showing that behaviourally relevant training alters the cortical map, we devised a sensory discrimination training programme for patients with intractable phantom limb pain. Compared with a control group of medically treated patients, the training group had significant reductions in phantom limb pain (p=0.002) and cortical reorganisation (p=0.05) that were positively associated with improved sensory discrimination ability.
Article
To develop a new assessment procedure, the Southampton Hand Assessment Procedure (SHAP), that allows contextual results of hand function to be obtained readily in a clinical environment. Reliability (test-retest, interrater) and validity (criterion, content) of new assessment procedure against standard medical outcome measure techniques. Normative data collected in a university laboratory. Twenty-four volunteers selected on the basis of optimum hand function using these criteria: age (range, 18-25 y), and no adverse hand trauma, neurologic condition, or disabling effects of the upper limb. Not applicable. The normative control group was assessed for variability, and the procedure measured in terms of interrater and test-retest reliability. The absence of a direct comparison prevents a criterion standard from being established; however, content validity was shown by expert peer review. The control group data were shown to be multivariate gaussian; test-retest and interrater reliability were demonstrated at the 95% confidence level. The content validity was demonstrated by peer panel approval. Results of the control group established the statistical integrity of SHAP. Clinical trials are underway, although more extensive use of the procedure is advocated in primary care and rehabilitation centers where physiotherapy and occupational therapy are actively used in hand rehabilitation.
Article
Nerve transfer procedures are increasingly performed for repair of severe brachial plexus injury (BPI), in which the proximal spinal nerve roots have been avulsed from the spinal cord. The procedure essentially involves the coaption of a proximal foreign nerve to the distal denervated nerve to reinnervate the latter by the donated axons. Cortical plasticity appears to play an important physiological role in the functional recovery of the reinnervated muscles. The author describes the general principles governing the successful use of nerve transfers. One major goal of this literature review is to provide a comprehensive survey on the numerous intra- and extraplexal nerves that have been used in transfer procedures to repair the brachial plexus. Thus, an emphasis on clinical outcomes is provided throughout. The second major goal is to discuss the role of candidate nerves for transfers in the surgical management of the common severe brachial plexus problems encountered clinically. It is hoped that this review will provide the treating surgeon with an updated list, indications, and expected outcomes involving nerve transfer operations for severe BPIs.
Article
Phantom pain refers to pain in a body part that has been amputated or deafferented. It has often been viewed as a type of mental disorder or has been assumed to stem from pathological alterations in the region of the amputation stump. In the past decade, evidence has accumulated that phantom pain might be a phenomenon of the CNS that is related to plastic changes at several levels of the neuraxis and especially the cortex. Here, we discuss the evidence for putative pathophysiological mechanisms with an emphasis on central, and in particular cortical, changes. We cite both animal and human studies and derive suggestions for innovative interventions aimed at alleviating phantom pain.
Article
The function of current artificial arms is limited by inadequate control methods. We developed a technique that used nerve transfers to muscle to develop new electromyogram control signals and nerve transfers to skin, to provide a pathway for cutaneous sensory feedback to the missing hand. We did targeted reinnervation surgery on a woman with a left arm amputation at the humeral neck. The ulnar, median, musculocutaneous, and distal radial nerves were transferred to separate segments of her pectoral and serratus muscles. Two sensory nerves were cut and the distal ends were anastomosed to the ulnar and median nerves. After full recovery the patient was fit with a new prosthesis using the additional targeted muscle reinnervation sites. Functional testing was done and sensation in the reinnervated skin was quantified. The patient described the control as intuitive; she thought about using her hand or elbow and the prosthesis responded appropriately. Functional testing showed substantial improvement: mean scores in the blocks and box test increased from 4.0 (SD 1.0) with the conventional prosthesis to 15.6 (1.5) with the new prosthesis. Assessment of Motor and Process Skills test scores increased from 0.30 to 1.98 for motor skills and from 0.90 to 1.98 for process skills. The denervated anterior chest skin was reinnervated by both the ulnar and median nerves; the patient felt that her hand was being touched when this chest skin was touched, with near-normal thresholds in all sensory modalities. Targeted reinnervation improved prosthetic function and ease of use in this patient. Targeted sensory reinnervation provides a potential pathway for meaningful sensory feedback.
Article
To date, the movement of myoelectrical arm prostheses proceeds via two transcutaneous electrodes that are controlled by two separately innervated muscle groups. The various control levels are chosen by co-contractions of these muscles and the respective level is linearly controlled by the same muscles. A harmonious course of movement as in the corresponding natural pattern of motion is not possible in this way. An appreciable improvement would be given by the control of the individual movement levels by signals that correspond neuronally with the natural pattern of motion. Just recently, prostheses with six control levels have been realised technically. The objective is to separate the major arm nerves, such as the musculocutaneous nerve, radial nerve, median nerve and ulnar nerve, from the proximal arm nerve plexus and to transfer them to the residual nerve branches of muscles near the stem in order to create meaningful neuromuscular units that can serve as impulse sources for myoelectrical prosthesis. As target muscles, above all, one can consider the major/minor pectoral muscles or, respectively, the latissimus muscle. According to the activity of the donor nerves, these muscles would contract and control the prosthesis via transcutaneous electrode. In this way, a harmonious control corresponding intuitively to the natural pattern of movement would be possible without the necessity for the patient to continuously switch between the various control levels. Prerequisites for this are intact proximal muscle groups and a more or less intact arm nerve plexus with the possibility to isolate donor nerves according to the topographic-anatomic situation. For this reason, a preoperative MRI examination, a high resolution sonographic study and balancing NLG and EMG of the residual nerve plexus are necessary. For the preoperative planning phase as well as for the postoperative follow-up, a detailed procedure has been established, in cooperation with the innovation department of the Otto Bock company, to create the most meaningful switch levels, to optimise electrode placement as well as to clarify prosthesis incorporation. Finally, a complex rehabilitation programme is necessary for the patient to achieve an optimal result.
Brachial plexus birth palsy
  • D E Ruchelsman
  • S Pettrone
  • A E Price
  • Jai Grossman
Ruchelsman DE, Pettrone S, Price AE, Grossman JAI. Brachial plexus birth palsy. Bull NYU Hosp Jt Dis 2009; 67: 83-89.
  • Mikrochirurgie Handchirurgie
  • Plast Chir
Handchirurgie, Mikrochirurgie, Plast Chir Organ der 2008; 40: 60-65 (in German).