Targeted Muscle Reinnervation Treats Neuroma and Phantom Pain in Major Limb Amputees: A Randomized Clinical Trial.

OBJECTIVE: To compare targeted muscle reinnervation (TMR) to "standard treatment" of neuroma excision and burying into muscle for postamputation pain. SUMMARY BACKGROUND DATA: To date, no intervention is consistently effective for neuroma-related residual limb or phantom limb pain (PLP). TMR is a nerve transfer procedure developed for prosthesis control, incidentally found to improve postamputation pain. METHODS: A prospective, randomized clinical trial was conducted. 28 amputees with chronic pain were assigned to standard treatment or TMR. Primary outcome was change between pre- and postoperative numerical rating scale (NRS, 0-10) pain scores for residual limb pain and PLP at 1 year. Secondary outcomes included NRS for all patients at final follow-up, PROMIS pain scales, neuroma size, and patient function. RESULTS: In intention-to-treat analysis, changes in PLP scores at 1 year were 3.2 versus -0.2 (difference 3.4, adjusted confidence interval (aCI) -0.1 to 6.9, adjusted P = 0.06) for TMR and standard treatment, respectively. Changes in residual limb pain scores were 2.9 versus 0.9 (difference 1.9, aCI -0.5 to 4.4, P = 0.15). In longitudinal mixed model analysis, difference in change scores for PLP was significantly greater in the TMR group compared with standard treatment [mean (aCI) = 3.5 (0.6, 6.3), P = 0.03]. Reduction in residual limb pain was favorable for TMR (P = 0.10). At longest follow-up, including 3 crossover patients, results favored TMR over standard treatment. CONCLUSIONS: In this first surgical RCT for the treatment of postamputation pain in major limb amputees, TMR improved PLP and trended toward improved residual limb pain compared with conventional neurectomy. TRIAL REGISTRATION: NCT02205385 at ClinicalTrials.gov.

Resolving the effect of wrist position on myoelectric pattern recognition control.

BACKGROUND: The use of pattern recognition-based methods to control myoelectric upper-limb prostheses has been well studied in individuals with high-level amputations but few studies have demonstrated that it is suitable for partial-hand amputees, who often possess a functional wrist. This study's objective was to evaluate strategies that allow partial-hand amputees to control a prosthetic hand while allowing retain wrist function. METHODS: EMG data was recorded from the extrinsic and intrinsic hand muscles of six non-amputees and two partial-hand amputees while they performed 4 hand motions in 13 different wrist positions. The performance of 4 classification schemes using EMG data alone and EMG data combined with wrist positional information was evaluated. Using recorded wrist positional data, the relationship between EMG features and wrist position was modeled and used to develop a wrist position-independent classification scheme. RESULTS: A multi-layer perceptron artificial neural network classifier was better able to discriminate four hand motion classes in 13 wrist positions than a linear discriminant analysis classifier (p = 0.006), quadratic discriminant analysis classifier (p < 0.0001) and a linear perceptron artificial neural network classifier (p = 0.04). The addition of wrist position data to EMG data significantly improved performance (p < 0.001). Training the classifier with the combination of extrinsic and intrinsic muscle EMG data performed significantly better than using intrinsic (p < 0.0001) or extrinsic muscle EMG data alone (p < 0.0001), and training with intrinsic muscle EMG data performed significantly better than extrinsic muscle EMG data alone (p < 0.001). The same trends were observed for amputees, except training with intrinsic muscle EMG data, on average, performed worse than the extrinsic muscle EMG data. We propose a wrist position-independent controller that simulates data from multiple wrist positions and is able to significantly improve performance by 48-74% (p < 0.05) for non-amputees and by 45-66% for partial-hand amputees, compared to a classifier trained only with data from a neutral wrist position and tested with data from multiple positions. CONCLUSIONS: Sensor fusion (using EMG and wrist position information), non-linear artificial neural networks, combining EMG data across multiple muscle sources, and simulating data from different wrist positions are effective strategies for mitigating the wrist position effect and improving classification performance.

How a diverse research ecosystem has generated new rehabilitation technologies: Review of NIDILRR's Rehabilitation Engineering Research Centers.

Over 50 million United States citizens (1 in 6 people in the US) have a developmental, acquired, or degenerative disability. The average US citizen can expect to live 20% of his or her life with a disability. Rehabilitation technologies play a major role in improving the quality of life for people with a disability, yet widespread and highly challenging needs remain. Within the US, a major effort aimed at the creation and evaluation of rehabilitation technology has been the Rehabilitation Engineering Research Centers (RERCs) sponsored by the National Institute on Disability, Independent Living, and Rehabilitation Research. As envisioned at their conception by a panel of the National Academy of Science in 1970, these centers were intended to take a "total approach to rehabilitation", combining medicine, engineering, and related science, to improve the quality of life of individuals with a disability. Here, we review the scope, achievements, and ongoing projects of an unbiased sample of 19 currently active or recently terminated RERCs. Specifically, for each center, we briefly explain the needs it targets, summarize key historical advances, identify emerging innovations, and consider future directions. Our assessment from this review is that the RERC program indeed involves a multidisciplinary approach, with 36 professional fields involved, although 70% of research and development staff are in engineering fields, 23% in clinical fields, and only 7% in basic science fields; significantly, 11% of the professional staff have a disability related to their research. We observe that the RERC program has substantially diversified the scope of its work since the 1970's, addressing more types of disabilities using more technologies, and, in particular, often now focusing on information technologies. RERC work also now often views users as integrated into an interdependent society through technologies that both people with and without disabilities co-use (such as the internet, wireless communication, and architecture). In addition, RERC research has evolved to view users as able at improving outcomes through learning, exercise, and plasticity (rather than being static), which can be optimally timed. We provide examples of rehabilitation technology innovation produced by the RERCs that illustrate this increasingly diversifying scope and evolving perspective. We conclude by discussing growth opportunities and possible future directions of the RERC program.

Targeted Muscle Reinnervation for the Upper and Lower Extremity.

Myoelectric devices are controlled by electromyographic signals generated by contraction of residual muscles, which thus serve as biological amplifiers of neural control signals. Although nerves severed by amputation continue to carry motor control information intended for the missing limb, loss of muscle effectors due to amputation prevents access to this important control information. Targeted Muscle Reinnervation (TMR) was developed as a novel strategy to improve control of myoelectric upper limb prostheses. Severed motor nerves are surgically transferred to the motor points of denervated target muscles, which, after reinnervation, contract in response to neural control signals for the missing limb. TMR creates additional control sites, eliminating the need to switch the prosthesis between different control modes. In addition, contraction of target muscles, and operation of the prosthesis, occurs in reponse to attempts to move the missing limb, making control easier and more intuitive. TMR has been performed extensively in individuals with high-level upper limb amputations and has been shown to improve functional prosthesis control. The benefits of TMR are being studied in individuals with transradial amputations and lower limb amputations. TMR is also being investigated in an ongoing clinical trial as a method to prevent or treat painful amputation neuromas.

Robotic leg control with EMG decoding in an amputee with nerve transfers.

The clinical application of robotic technology to powered prosthetic knees and ankles is limited by the lack of a robust control strategy. We found that the use of electromyographic (EMG) signals from natively innervated and surgically reinnervated residual thigh muscles in a patient who had undergone knee amputation improved control of a robotic leg prosthesis. EMG signals were decoded with a pattern-recognition algorithm and combined with data from sensors on the prosthesis to interpret the patient's intended movements. This provided robust and intuitive control of ambulation--with seamless transitions between walking on level ground, stairs, and ramps--and of the ability to reposition the leg while the patient was seated.

Transfemoral amputee recovery strategies following trips to their sound and prosthesis sides throughout swing phase.

BACKGROUND: Recovering from trips is challenging for transfemoral amputees, and attempts often result in falls. Better understanding of the effects of the sensory-motor deficits brought by amputation and the functional limitations of prosthetic devices could help guide therapy and fall prevention mechanisms in prostheses. However, how transfemoral amputees attempt to recover from trips on the sound and prosthesis sides throughout swing phase is poorly understood. METHODS: We tripped eight able-bodied subjects and eight unilateral transfemoral amputees wearing their prescribed prostheses. The protocol consisted of six repetitions of 6 and 4 points throughout swing phase, respectively. We compared recovery strategies in able-bodied, sound side and prosthesis side limbs. The number of kinematic recovery strategies used, when they were used throughout swing phase, and kinematic characteristics (tripped limb joint angles, bilateral trochanter height and time from foot arrest to foot strike) of each strategy were compared across limb groups. Non-parametric statistical tests with corrections for post-hoc tests were used. RESULTS: Amputees used the same recovery strategies as able-bodied subjects on both sound and prosthesis sides, although not all subjects used all strategies. Compared to able-bodied subjects, amputees used delayed-lowering strategies less often from 30-60 % of swing phase on the sound side, and from 45-60 % of swing phase on the prosthesis side. Within-strategy kinematic differences occurred across limbs; however, these differences were not consistent across all strategies. Amputee-specific recovery strategies-that are not used by control subjects-occurred following trips on both the sound and prosthesis sides in mid- to late swing. CONCLUSIONS: Collectively, these results suggest that sensory input from the distal tripped leg is not necessary to trigger able-bodied trip recovery strategies. In addition, the differences between sound and prosthesis side recoveries indicate that the ability of the support leg might be more critical than that of the tripped leg when determining the response to a trip. The outcomes of this study have implications for prosthesis control, suggesting that providing correct and intuitive real-time selection of typical able-bodied recovery strategies by a prosthetic device when it is the tripped and the support limb could better enable balance recovery and avoid falls.

Intuitive control of a powered prosthetic leg during ambulation: a randomized clinical trial.

IMPORTANCE: Some patients with lower leg amputations may be candidates for motorized prosthetic limbs. Optimal control of such devices requires accurate classification of the patient's ambulation mode (eg, on level ground or ascending stairs) and natural transitions between different ambulation modes. OBJECTIVE: To determine the effect of including electromyographic (EMG) data and historical information from prior gait strides in a real-time control system for a powered prosthetic leg capable of level-ground walking, stair ascent and descent, ramp ascent and descent, and natural transitions between these ambulation modes. DESIGN, SETTING, AND PARTICIPANTS: Blinded, randomized crossover clinical trial conducted between August 2012 and November 2013 in a research laboratory at the Rehabilitation Institute of Chicago. Participants were 7 patients with unilateral above-knee (n = 6) or knee-disarticulation (n = 1) amputations. All patients were capable of ambulation within their home and community using a passive prosthesis (ie, one that does not provide external power). INTERVENTIONS: Electrodes were placed over 9 residual limb muscles and EMG signals were recorded as patients ambulated and completed 20 circuit trials involving level-ground walking, ramp ascent and descent, and stair ascent and descent. Data were acquired simultaneously from 13 mechanical sensors embedded on the prosthesis. Two real-time pattern recognition algorithms, using either (1) mechanical sensor data alone or (2) mechanical sensor data in combination with EMG data and historical information from earlier in the gait cycle, were evaluated. The order in which patients used each configuration was randomized (1:1 blocked randomization) and double-blinded so patients and experimenters did not know which control configuration was being used. MAIN OUTCOMES AND MEASURES: The main outcome of the study was classification error for each real-time control system. Classification error is defined as the percentage of steps incorrectly predicted by the control system. RESULTS: Including EMG signals and historical information in the real-time control system resulted in significantly lower classification error (mean, 7.9% [95% CI, 6.1%-9.7%]) across a mean of 683 steps (range, 640-756 steps) compared with using mechanical sensor data only (mean, 14.1% [95% CI, 9.3%-18.9%]) across a mean of 692 steps (range, 631-775 steps), with a mean difference between groups of 6.2% (95% CI, 2.7%-9.7%] (P = .01). CONCLUSIONS AND RELEVANCE: In this study of 7 patients with lower limb amputations, inclusion of EMG signals and temporal gait information reduced classification error across ambulation modes and during transitions between ambulation modes. These preliminary findings, if confirmed, have the potential to improve the control of powered leg prostheses.

Targeted muscle reinnervation: a novel approach to postamputation neuroma pain.

BACKGROUND: Postamputation neuroma pain can prevent comfortable prosthesis wear in patients with limb amputations, and currently available treatments are not consistently effective. Targeted muscle reinnervation (TMR) is a decade-old technique that employs a series of novel nerve transfers to permit intuitive control of upper-limb prostheses. Clinical experience suggests that it may also serve as an effective therapy for postamputation neuroma pain; however, this has not been explicitly studied. QUESTIONS/PURPOSES: We evaluated the effect of TMR on residual limb neuroma pain in upper-extremity amputees. METHODS: We conducted a retrospective medical record review of all 28 patients treated with TMR from 2002 to 2012 at Northwestern Memorial Hospital/Rehabilitation Institute of Chicago (Chicago, IL, USA) and San Antonio Military Medical Center (San Antonio, TX, USA). Twenty-six of 28 patients had sufficient (> 6 months) followup for study inclusion. The amputation levels were shoulder disarticulation (10 patients) and transhumeral (16 patients). All patients underwent TMR for the primary purpose of improved myoelectric control. Of the 26 patients included in the study, 15 patients had evidence of postamputation neuroma pain before undergoing TMR. RESULTS: Of the 15 patients presenting with neuroma pain before TMR, 14 experienced complete resolution of pain in the transferred nerves, and the remaining patient's pain improved (though did not resolve). None of the patients who presented without evidence of postamputation neuroma pain developed neuroma pain after the TMR procedure. All 26 patients were fitted with a prosthesis, and 23 of the 26 patients were able to operate a TMR-controlled prosthesis. CONCLUSIONS: None of the 26 patients who underwent TMR demonstrated evidence of new neuroma pain after the procedure, and all but one of the 15 patients who presented with preoperative neuroma pain experienced complete relief of pain in the distribution of the transferred nerves. TMR offers a novel and potentially more effective therapy for the management of neuroma pain after limb amputation.

Activation of individual extrinsic thumb muscles and compartments of extrinsic finger muscles.

Mechanical and neurological couplings exist between musculotendon units of the human hand and digits. Studies have begun to understand how these muscles interact when accomplishing everyday tasks, but there are still unanswered questions regarding the control limitations of individual muscles. Using intramuscular electromyographic (EMG) electrodes, this study examined subjects' ability to individually initiate and sustain three levels of normalized muscular activity in the index and middle finger muscle compartments of extensor digitorum communis (EDC), flexor digitorum profundus (FDP), and flexor digitorum superficialis (FDS), as well as the extrinsic thumb muscles abductor pollicis longus (APL), extensor pollicis brevis (EPB), extensor pollicis longus (EPL), and flexor pollicis longus (FPL). The index and middle finger compartments each sustained activations with significantly different levels of coactivity from the other finger muscle compartments. The middle finger compartment of EDC was the exception. Only two extrinsic thumb muscles, EPL and FPL, were capable of sustaining individual activations from the other thumb muscles, at all tested activity levels. Activation of APL was achieved at 20 and 30% MVC activity levels with significantly different levels of coactivity. Activation of EPB elicited coactivity levels from EPL and APL that were not significantly different. These results suggest that most finger muscle compartments receive unique motor commands, but of the four thumb muscles, only EPL and FPL were capable of individually activating. This work is encouraging for the neural control of prosthetic limbs because these muscles and compartments may potentially serve as additional user inputs to command prostheses.

Development of a mechatronic platform and validation of methods for estimating ankle stiffness during the stance phase of walking.

The mechanical properties of human joints (i.e., impedance) are constantly modulated to precisely govern human interaction with the environment. The estimation of these properties requires the displacement of the joint from its intended motion and a subsequent analysis to determine the relationship between the imposed perturbation and the resultant joint torque. There has been much investigation into the estimation of upper-extremity joint impedance during dynamic activities, yet the estimation of ankle impedance during walking has remained a challenge. This estimation is important for understanding how the mechanical properties of the human ankle are modulated during locomotion, and how those properties can be replicated in artificial prostheses designed to restore natural movement control. Here, we introduce a mechatronic platform designed to address the challenge of estimating the stiffness component of ankle impedance during walking, where stiffness denotes the static component of impedance. The system consists of a single degree of freedom mechatronic platform that is capable of perturbing the ankle during the stance phase of walking and measuring the response torque. Additionally, we estimate the platform's intrinsic inertial impedance using parallel linear filters and present a set of methods for estimating the impedance of the ankle from walking data. The methods were validated by comparing the experimentally determined estimates for the stiffness of a prosthetic foot to those measured from an independent testing machine. The parallel filters accurately estimated the mechatronic platform's inertial impedance, accounting for 96% of the variance, when averaged across channels and trials. Furthermore, our measurement system was found to yield reliable estimates of stiffness, which had an average error of only 5.4% (standard deviation: 0.7%) when measured at three time points within the stance phase of locomotion, and compared to the independently determined stiffness values of the prosthetic foot. The mechatronic system and methods proposed in this study are capable of accurately estimating ankle stiffness during the foot-flat region of stance phase. Future work will focus on the implementation of this validated system in estimating human ankle impedance during the stance phase of walking.

Non-weight-bearing neural control of a powered transfemoral prosthesis.

Lower limb prostheses have traditionally been mechanically passive devices without electronic control systems. Microprocessor-controlled passive and powered devices have recently received much interest from the clinical and research communities. The control systems for these devices typically use finite-state controllers to interpret data measured from mechanical sensors embedded within the prosthesis. In this paper we investigated a control system that relied on information extracted from myoelectric signals to control a lower limb prosthesis while amputee patients were seated. Sagittal plane motions of the knee and ankle can be accurately (>90%) recognized and controlled in both a virtual environment and on an actuated transfemoral prosthesis using only myoelectric signals measured from nine residual thigh muscles. Patients also demonstrated accurate (~90%) control of both the femoral and tibial rotation degrees of freedom within the virtual environment. A channel subset investigation was completed and the results showed that only five residual thigh muscles are required to achieve accurate control. This research is the first step in our long-term goal of implementing myoelectric control of lower limb prostheses during both weight-bearing and non-weight-bearing activities for individuals with transfemoral amputation.

User Performance With a Transradial Multi-Articulating Hand Prosthesis During Pattern Recognition and Direct Control Home Use.

With the increasing availability of more advanced prostheses individuals with a transradial amputation can now be fit with single to multi-degree of freedom hands. Reliable and accurate control of these multi-grip hands still remains challenging. This is the first multi-user study to investigate at-home control and use of a multi-grip hand prosthesis under pattern recognition and direct control. Individuals with a transradial amputation were fitted with and trained to use an OSSUR i-Limb Ultra Revolution with Coapt COMPLETE CONTROL system. They participated in two 8-week home trials using the hand under myoelectric direct and pattern recognition control in a randomized order. While at home, participants demonstrated broader usage of grips in pattern recognition compared to direct control. After the home trial, they showed significant improvements in the Assessment of Capacity for Myoelectric Control (ACMC) outcome measure while using pattern recognition control compared to direct control; other outcome measures showed no differences between control styles. Additionally, this study provided a unique opportunity to evaluate EMG signals during home use. Offline analysis of calibration data showed that users were 81.5% [7.1] accurate across a range of three to five grips. Although EMG signal noise was identified during some calibrations, overall EMG quality was sufficient to provide users with control performance at or better than direct control.

Myoelectric prosthesis hand grasp control following targeted muscle reinnervation in individuals with transradial amputation.

BACKGROUND: Despite the growing availability of multifunctional prosthetic hands, users' control and overall functional abilities with these hands remain limited. The combination of pattern recognition control and targeted muscle reinnervation (TMR) surgery, an innovative technique where amputated nerves are transferred to reinnervate new muscle targets in the residual limb, has been used to improve prosthesis control of individuals with more proximal upper limb amputations (i.e., shoulder disarticulation and transhumeral amputation). OBJECTIVE: The goal of this study was to determine if prosthesis hand grasp control improves following transradial TMR surgery. METHODS: Eight participants were trained to use a multi-articulating hand prosthesis under myoelectric pattern recognition control. All participated in home usage trials pre- and post-TMR surgery. Upper limb outcome measures were collected following each home trial. RESULTS: Three outcome measures (Southampton Hand Assessment Procedure, Jebsen-Taylor Hand Function Test, and Box and Blocks Test) improved 9-12 months post-TMR surgery compared with pre-surgery measures. The Assessment of Capacity for Myoelectric Control and Activities Measure for Upper Limb Amputees outcome measures had no difference pre- and post-surgery. An offline electromyography analysis showed a decrease in grip classification error post-TMR surgery compared to pre-TMR surgery. Additionally, a majority of subjects noted qualitative improvements in their residual limb and phantom limb sensations post-TMR. CONCLUSIONS: The potential for TMR surgery to result in more repeatable muscle contractions, possibly due to the reduction in pain levels and/or changes to phantom limb sensations, may increase functional use of many of the clinically available dexterous prosthetic hands.

Robotic touch shifts perception of embodiment to a prosthesis in targeted reinnervation amputees.

Existing prosthetic limbs do not provide amputees with cutaneous feedback. Tactile feedback is essential to intuitive control of a prosthetic limb and it is now clear that the sense of body self-identification is also linked to cutaneous touch. Here we have created an artificial sense of touch for a prosthetic limb by coupling a pressure sensor on the hand through a robotic stimulator to surgically redirected cutaneous sensory nerves (targeted reinnervation) that once served the lost limb. We hypothesize that providing physiologically relevant cutaneous touch feedback may help an amputee incorporate an artificial limb into his or her self image. To investigate this we used a robotic touch interface coupled with a prosthetic limb and tested it with two targeted reinnervation amputees in a series of experiments fashioned after the Rubber Hand Illusion. Results from both subjective (self-reported) and objective (physiological) measures of embodiment (questionnaires, psychophysical temporal order judgements and residual limb temperature measurements) indicate that returning physiologically appropriate cutaneous feedback from a prosthetic limb drives a perceptual shift towards embodiment of the device for these amputees. Measurements provide evidence that the illusion created is vivid. We suggest that this may help amputees to more effectively incorporate an artificial limb into their self image, providing the possibility that a prosthesis becomes not only a tool, but also an integrated body part.

The effects of targeted muscle reinnervation on neuromas in a rabbit rectus abdominis flap model.

PURPOSE: A targeted muscle reinnervation (TMR) model was created using a pedicled rabbit rectus abdominis (RA) flap to receive the input from previously amputated forelimb neuromas. We hypothesize that a segmental muscle flap can undergo TMR and that it is possible to differentiate the signal from 3 independent nerves. In addition, by virtue of the nerve coaptation, the morphology of the previous amputation neuroma would become more like that of an in-continuity neuroma. METHODS: Five New Zealand white rabbits had a forelimb amputation. In a second-stage surgery, an RA flap was transposed onto the chest wall. After neuroma excision, 3 neurorrhaphies were made between the median nerve, radial nerve, and ulnar nerves, and 3 motor nerves of the RA. After 10 weeks, the electrophysiologic properties of the reinnervated flap were tested. Nerve specimens from the median, radial, and ulnar nerves were harvested before and after TMR to quantify the histomorphometric changes effected by TMR on the mixed nerve neuromas. RESULTS: Of the 12 nerve coaptations performed in the 4 viable flaps, all 12 were grossly successful. Muscle surface EMG data demonstrated that the RA retained its segmental innervation pattern after TMR. Similarly, prolonged stimulation of 1 nerve reinnervating the RA resulted in the depletion of glycogen specific to the territory of the muscle stimulated by that nerve. TMR was found to favorably alter the histomorphometric characteristics of the neuroma by decreasing myelinated fiber counts and increasing fascicle diameter in the transferred nerves. CONCLUSIONS: This study demonstrates that 1 segmented muscle having TMR by multiple nerve ingrowth and in turn generate discrete EMG signals. During this process, the previous amputation neuroma undergoes favorable morphologic alteration. CLINICAL RELEVANCE: Based on these preclinical results, this technique might be useful in upper extremity amputees to recruit target muscles to have reinnervation to drive myoelectric prostheses and to treat symptomatic neuromas.

Amputation with median nerve redirection (targeted reinnervation) reactivates forepaw barrel subfield in rats.

Prosthetic limbs are difficult to control and do not provide sensory feedback. Targeted reinnervation was developed as a neural-machine interface for amputees to address these issues. In targeted reinnervation, amputated nerves are redirected to proximal muscles and skin, creating nerve interfaces for prosthesis control and sensory feedback. Touching the reinnervated skin causes sensation to be projected to the missing limb. Here we use electrophysiological brain recording in the Sprague Dawley rat to investigate the changes to somatosensory cortex (S1) following amputation and nerve redirection with the intent to provide insight into the sensory phenomena observed in human targeted reinnervation amputees. Recordings revealed that redirected nerves established an expanded representation in S1, which may help to explain the projected sensations that encompass large areas of the hand in targeted reinnervation amputees. These results also provide evidence that the reinnervated target skin could serve as a line of communication from a prosthesis to cortical hand processing regions. S1 border regions were simultaneously responsive to reinnervated input and also vibrissae, lower lip, and hindfoot, suggesting competition for deactivated cortical territory. Electrically evoked potential latencies from reinnervated skin to cortex suggest direct connection of the redirected afferents to the forepaw processing region of S1. Latencies also provide evidence that the widespread reactivation of S1 cortex may arise from central anatomical interconnectivity. Targeted reinnervation offers the opportunity to examine the cortical plasticity effects when behaviorally important sensory afferents are redirected from their original location to a new skin surface on a different part of the body.

A novel, low-cost transradial socket fabrication method using mass-producible components and expanding rigid foam.

BACKGROUND: Millions of people in low- and middle-income countries lack access to prosthetic care. A well-fitting, durable socket is important for prosthesis comfort and function, but conventional fabrication techniques require highly trained clinicians and specialized equipment. OBJECTIVES: To increase access to prosthetic care by developing a simple, low-cost socket fabrication method that does not require specialized equipment or electricity, and can be performed by persons with minimal prosthetic training. STUDY DESIGN: Socket fabrication methods and socket function were evaluated in a pilot feasibility study. TECHNIQUE: We describe a rapid method for fabricating a rigid foam socket directly over the residual limb, with a mass producible, strong, cosmetically appealing plastic outer shell. We fabricated sockets for four individuals with unilateral transradial amputations and evaluated socket function. RESULTS: An individual with no formal prosthetic training was able to fabricate sockets and assemble a functional, comfortable prosthesis system within 90 min. All necessary supplies can be provided in a kit for under US$100. DISCUSSION: Further work is required to determine durability, assess comfort, refine suspension methods, and to develop instructional materials. CONCLUSIONS: We developed a simplified, inexpensive method to fabricate sockets on the residual limb using expandable foam with an integrated cosmetic/structural covering (i.e. an exoskeletal system), for persons with transradial amputation. A transradial prosthesis socket can be fabricated in around 90 min. and all necessary materials, tools, and written instructions for fabrication and fitting can be provided in a kit. Specialized equipment and electricity are not required. Instructions for fabrication and fitting can be provided in multiple languages using online videos.

Sensory capacity of reinnervated skin after redirection of amputated upper limb nerves to the chest.

Targeted reinnervation is a new neural-machine interface that has been developed to help improve the function of new-generation prosthetic limbs. Targeted reinnervation is a surgical procedure that takes the nerves that once innervated a severed limb and redirects them to proximal muscle and skin sites. The sensory afferents of the redirected nerves reinnervate the skin overlying the transfer site. This creates a sensory expression of the missing limb in the amputee's reinnervated skin. When these individuals are touched on this reinnervated skin they feel as though they are being touched on their missing limb. Targeted reinnervation takes nerves that once served the hand, a skin region of high functional importance, and redirects them to less functionally relevant skin areas adjacent to the amputation site. In an effort to better understand the sensory capacity of the reinnervated target skin following this procedure, we examined grating orientation thresholds and point localization thresholds on two amputees who had undergone the targeted reinnervation surgery. Grating orientation thresholds and point localization thresholds were also measured on the contralateral normal skin of the targeted reinnervation amputees and on analogous sites in able-bodied controls. Grating orientation thresholds for the reinnervated skin of the targeted reinnervation amputees were found to be similar to normal ranges for both the amputees' contralateral skin and also for the control population. Point localization thresholds for these amputees were found to be lower for their reinnervated skin than for their contralateral skin. Reinnervated point localization thresholds values were also lower in comparison to homologous chest sites on the control population. Mechanisms appear to be in place to maximize re-established touch input in targeted reinnervation amputees. It seems that sound sensory function is provided to the denervated skin of the residual limb when connected to afferent pathways once serving highly functionally relevant regions of the brain. This suggests that tactile interface devices could be used to give a physiologically appropriate sense of touch to a prosthetic limb, which would likely help with better functional utilization of the prosthetic device and possibly help to more effectively integrate the device with the user's self-image.

Redirection of cutaneous sensation from the hand to the chest skin of human amputees with targeted reinnervation.

Amputees cannot feel what they touch with their artificial hands, which severely limits usefulness of those hands. We have developed a technique that transfers remaining arm nerves to residual chest muscles after an amputation. This technique allows some sensory nerves from the amputated limb to reinnervate overlying chest skin. When this reinnervated skin is touched, the amputees perceive that they are being touched on their missing limb. We found that touch thresholds of the reinnervated chest skin fall within near-normal ranges, indicating the regeneration of large-fiber afferents. The perceptual identity of the limb and chest was maintained separately even though they shared a common skin surface. A cutaneous expression of proprioception also occurred in one reinnervated individual. Experiments with peltier temperature probes and surface electrical stimulation of the reinnervated skin indicate the regeneration of small diameter temperature and pain afferents. The perception of an amputated limb arising from stimulation of reinnervated chest skin may allow useful sensory feedback from prosthetic devices and provides insight into the mechanisms of neural plasticity and peripheral regeneration in humans.

Study of stability of time-domain features for electromyographic pattern recognition.

BACKGROUND: Significant progress has been made towards the clinical application of human-machine interfaces (HMIs) based on electromyographic (EMG) pattern recognition for various rehabilitation purposes. Making this technology practical and available to patients with motor deficits requires overcoming real-world challenges, such as physical and physiological changes, that result in variations in EMG signals and systems that are unreliable for long-term use. In this study, we aimed to address these challenges by (1) investigating the stability of time-domain EMG features during changes in the EMG signals and (2) identifying the feature sets that would provide the most robust EMG pattern recognition. METHODS: Variations in EMG signals were introduced during physical experiments. We identified three disturbances that commonly affect EMG signals: EMG electrode location shift, variation in muscle contraction effort, and muscle fatigue. The impact of these disturbances on individual features and combined feature sets was quantified by changes in classification performance. The robustness of feature sets was evaluated by a stability index developed in this study. RESULTS: Muscle fatigue had the smallest effect on the studied EMG features, while electrode location shift and varying effort level significantly reduced the classification accuracy for most of the features. Under these disturbances, the most stable EMG feature set with combination of four features produced at least 16.0% higher classification accuracy than the least stable set. EMG autoregression coefficients and cepstrum coefficients showed the most robust classification performance of all studied time-domain features. CONCLUSIONS: Selecting appropriate EMG feature combinations can overcome the impact of the studied disturbances on EMG pattern classification to a certain extent; however, this simple solution is still inadequate. Stabilizing electrode contact locations and developing effective classifier training strategies are suggested to further improve the robustness of HMIs based on EMG pattern recognition.