i-limb revolution therapy protocol
Contents
1. 1 Pick up pencil or slim long objects 2 Thread needle 3 Sort Pick up medica tions 1 Retrieve small object from shelf over head 2 Pick up small object from floor 1 Pick up and open sugar packet from a coffee stand 2 Pick up coins 3 Alternative way to tie shoes also see lateral grip Tripod Grip Options Tripod Grip also known as 3 Jaw Chuck is achieved when the thumb opposes both the index and long fingers Typically Tripod Grip is preferred over Precision Pinch when handling slightly larger objects for more stability There are 4 options for the Tripod Grip that are categorized the same as the Precision Pinch options on the previous page Standard 3 Jaw Chuck Tripod Open Thumb 3 Jaw Chuck Tripod Open Standard 3 Jaw Chuck Tripod Closed Thumb 3 Jaw Chuck Tripod Closed Ring and little fingers remain open Thumb index and middle fingers actively open and close to provide grip Ring and little fingers remain open Thumb automatically moves to a partially closed position Only index and middle fingers will move to pro vide grip against the fixed thumb Ring and little fingers remain closed Thumb index and middle fingers actively open and close together to provide grip Ring and little fingers automatically close and switch off Thumb auto matically moves to a par tially closed position Only index and middle fingers will move to provide grip against the fixe2. When the client s limb loss or deficiency has affected his or her feeding oral hygiene and toilet hygiene these are typically the first priority Smurr et al 2008 Additional ADLs can be prioritized based on the client s goals and functional level When possible continue to incorporate the affected side during training This prevents individuals from becoming too reliant on their sound side and helps them think about tasks in a bilateral manner 3 1 2 Subacute Pre Prosthetic Training Phase In the subacute pre prosthetic training phase the therapist should continue many of the interventions begun in the acute phase such as body symmetry ROM strength desensitization and edema management During this phase many of these interventions can be transitioned to home therapy programs to make room for additional in person pre prosthetic training with the therapist Progression of ADL Training In this phase ADL training and the use of adaptive equipment should progress to allow for more independence with ADL and IADL tasks These tasks should be determined according to client preference Myosite Testing and Training In order to effectively operate a myoelectric controlled prosthesis the clinician must first identify the appropriate myosites on the individual s residual limb Conducting myosite testing early on in the process has been shown to greatly benefit training and improve outcomes overall For this reason military facilities typically
3. Y OIONICS Part number MA01243 Issue No 1 July 2014 Y bionics This manual should be read and used in conjunction with training from the Touch Bionics clinical team for the evaluation and training of users of the i limb products The material herein is designed to facilitate the authorization of patient services enhance patient evaluation support team based rehabilitation services and to optimize outcomes N This symbol signifies important information and is used throughout the manual Refer to www touchbionics com downloads document library for the most up to date version of this document Table of Contents 1 Introduction to Upper Limb Prosthetics 1 1 Upper Limb Amputee Training 2 Overview of i limb ultra revolution and i limb ultra Prosthetic Devices 2 1 Device Overview 2 2 Features Overview 23 Operating in Standard Hand Mode 2 4 Wrist Options 3 Training Protocol 3 1 Pre Prosthetic Training Phase 3 1 1 Acute Pre Prosthetic Training 3 1 2 Subacute Pre Prosthetic Training 3 2 Prosthetic Training Phase 4 biosim Overview for Therapists 4 1 biosim Overview 4 2 Connecting to biosim 4 3 Navigating biosim 4 3 1 Myo testing 4 3 2 Features 4 3 3 Triggers 4 3 4 Training 4 3 5 Usage 44 Mobile Apps 5 Appendix 5 1 Warnings and Precautions D2 Usage Do s and Don ts 5 3 References and Recommended Reading Part number MA01243 Issue No 1 July 2014 1 1 Upper Limb Amputee Training Individuals with
4. provides access to a range of control options train ing features real time display of impulses battery status and health check Occasionally updates to the biosim software will be provided An automated notification will advise you when this is needed Follow the steps as advised in the notification 4 2 Connecting to biosim The biosim software program must be downloaded from the Touch Bionics website at http www touchbionics com down loads biosim After downloading the software load biosim by clicking on the biosim icon fig 6 which should be clearly visible on the biosim home screen The biosim Handshake device fig 7 must also be inserted into a USB port to allow the Bluetooth sig nal to be received by the i limb prosthetic device The Handshake Bluetooth receiver will pick up signals within a 10 meter range The opening welcome screen will load The language can now be changed from the default English to either German Spanish French or Italian This is done by clicking on the language indica tor at the bottom right hand side of the screen and scrolling to the required language The first numerical icon insert handshake re quest will flash On insertion of the handshake biosim device the icon will be constantly lit the handshake installed and ready box will then self tick The second icon will now be constantly lit and the third icon Connecting to device will flash The tab marked connect must no
5. s hand Vari grip allows the user to adjust the grip strength depending on the item and task at hand This is helpful when performing more difficult tasks such as tying one s shoe or opening a jar This power grasp can also be utilized in activities such as holding tools Spherical Grasp The Spherical grasp is designed to be a compliant grip that will stabilize the object without exerting a damaging amount of force Examples of this include holding a ball or stabilizing fruits vegetables when peeling them Part number MA01243 Issue No 1 July 2014 10 of 46 Hook Grasp Hook grasp is utilized for carrying heavier loads such as a briefcase or light suitcase All four digits are used to create a strong hook position Clinicians should train the user to position the weight of the object as close to the knuckle block and palm as possible and to fully close around the object to prevent unnecessary torque on the digits When lifting objects using a palms up to the ceiling method ensures the object stays balanced over the strongest point on the hand This will help prolong the life of the prosthesis Refer to Usage Do s and Don ts in section 5 3 of the Appendix for more precautionary measures Natural Hand Position The hand will return to a natural hand position after the hand has been fully opened and there are no additional input signals for a predetermined amount of time between 2 to 30 seconds The hand must be fully open
6. the real time graph is beneficial for providing biofeedback during functional training 100 5 75 100 Myo testing 50 39 25 25 Open signal maximum 70 Reset maximums Close signal maximum 54 Analog gauges Real me graph The Real time graph screen plots a graph of impulses in real EEEE Tre time with open impulses in red and closed impulses in blue Wviskk Gain and Threshold levels are set by the prosthetist Training mode option enables training with specific triggers fuclive u yyer Hu gooey serene Tising moge Uenbieomoe Degin caiwan i ee fae ro th ee 0 A T A e O The graph below shows good separation of inputs with the E D i SA mpar rapa opposing channel remaining below the threshold level graph Ideal signals are between 1 5 and 2 5 in order to obtain full speed of the hand Rewind History View Saved Zoom Out Graph No f Q5 EF a Ms eS OELE Part number MA01243 Issue No 1 July 2014 28 of 46 Part number MA01243 Issue No 1 July 2014 The graph to the right shows poor signal separation with both signals being activated together Training Tip for better signal separation 1 Start by having your client rest his or her prosthesis on the table for support 2 Mirror motions with contralateral side if applicable 3 Provide resistance to the contralateral side motion for additional feedback 4 Try different ways to activate the muscles such
7. All fingers partially close When a close signal is given the thumb ring and little fingers close Once they have stalled around an object the next close signal will operate the index and middle fingers in squeeze mode when a close signal is given the index and middle will close when the signal is relaxed the index and middle digits will open Thumb automatically rotates to a semi lateral position and par tially closes All fingers partially close When a close signal is given fingers will close around the object once fingers are stalled the thumb will operate in squeeze mode when a close signal given thumb will close when signal relaxed thumb will open Hand forms the proper shape for donning and doffing a cover For grasping objects where crushing 1 Sorting objects the object is not a concern Note that 2 Grasping large as soon as you stop giving a signal soft objects such as the hand will open automatically and socks when packing reset to the slightly flexed position a suitcase Note this feature requires multiple 1 Pulling trigger on a steps small spray bottle Step 1 Enter the feature using either the trigger or Quick grip Step 2 Provide a close signal until the thumb middle ring and small digits have fully closed around the object being held Step 3 Providing a close signal will close the index digit onto the trigger and relaxing the signal will re open the digit Note this f
8. Middle ring and little fingers remain open while the index finger and thumb open and close together to provide grip Middle ring and little fin gers remain open Thumb automatically moves to a partially closed posi tion Only index finger will move to provide grip against the fixed thumb Middle ring and little fin gers remain closed Both index finger and thumb open and close together to provide grip Middle ring and little fingers remain closed Thumb automatically moves to a partially closed position Only index fin ger will move to provide grip against the fixed thumb Allows for a wider space opening to pinch larger objects Positions the other three fingers out of the way to avoid interference with tasks Accuracy is improved when pick ing up an object by allowing you to place the thumb against the object to be pinched Only the index finger moves to grasp the object Ideal for repetitive tasks Allows for a wider web space opening to pinch larger objects Allows better visual access to objects when the working surface is not at eye level Positions the other three fingers so as not to block the user s view of the task Can improve accuracy for picking up an object by allowing you to place the thumb against the object to be pinched and only the index finger moves to grasp the object Ideal for repetitive tasks 1 Returning cards or money to wallet 2 Picking up napkins 3 Folding laundry
9. conduct myosite testing and training within three weeks of the amputation Smurr et al 2008 Myotesting helps to determine the sites that will provide the most strength and control for operating the prosthesis effectively The biofeedback from myotesting helps to further strengthen and build endurance in these identified sites providing optimal results for the user Part number MA01243 Issue No 1 July 2014 13 of 46 The virtu limb Touch Bionics wireless simulation and training tool for myolectric upper limb prostheses assists clinicians with the myosite testing and training process The virtu limb can be used with i limb products or several other myoelectric devices and is compatible with remote electrodes compact electrodes and FSR touchpads By placing electrodes on top of a patient s myosites the virtu limb can measure the myoelectric signals to determine the best muscle sites for the prosthesis The virtu limb also assists with training patients on how to control their muscle signals and how to use the myoelectric device s features The practitioner has the option to use either an on screen representation of an i limb ultra revolution or connect the myoelectric terminal device to the virtu limb to create a simulated environment for training purposes see figure 4 The virtu limb provides the added benefit of helping to establish realistic user expectations around the prosthesis capabilities Figure 4 Top Image i limb ult
10. few visits This is often prescribed by the prosthetist By the end of the first week the individual may be wearing his her prosthesis all day barring any complications It is also important to keep in mind that muscle endurance will build up over time so frequent rest breaks will help avoid the frustration and loss of control often associated with muscle fatigue Educate the patient to be aware of the signs of fatigue so they can start to become responsible for their own wearing schedule Care of the Prosthesis Since at this point your client will be taking his her prosthesis home each day it is a good time to address Warnings and Precautions and Charging the Battery which can be found in the i limb ultra revolution User Manual within the website s document library www touchbionics com downloads document library Warnings and Precautions is also available in the Appendix Care of the prosthesis should be followed according to the prosthetist s directions Oftentimes this is accomplished with a dish soap and damp towel Other times the prosthetist might prefer rubbing alcohol to help prevent bacteria buildup on the inside of the socket Evaluation of Progress with Prosthesis The therapist is often re evaluating progress in ADL IADL function as well as ROM strength and other initially evaluated body functions and structures It is also helpful at this phase to evaluate baseline data on prosthesis control The Patient Ca
11. hand include Transhumeral Level e Bicep and tricep muscles Transradial Level Wrist flexors e Wrist Extensors Step 2 Begin Myotesting Once the individual is able to establish a strong enough signal ensure you have established the optimal site by 1 Begin by rotating the dial on the back of the electrode to 4 set the electrode gain between 4 and 5 Place the electrode over one of the marked locations established in step 1 Make sure the electrode runs longitudinally with the muscle belly moving the electrode proximal to the initial site while instructing the patient to continue to contract and relax the muscle as you move the electrode to new locations Once the signal strength begins to decrease mark a line 2 If using the virtu limb establish a wireless connection i between the virtu limb and the biosim software along the proximal edge of the electrode by connecting the provided Bluetooth dongle or Next move the electrode distally from the initial site and Handshake to the USB port on your computer and when the signal begins to decrease mark the client s skin following the three easy steps on the biosim home page along the distal border of the electrode Alternatively you may connect to the biosim app on various mobile devices 3 Once you have successfully connected select the myo OTTO BNE Ear E r Part number MA01243 Issue No 1 July 2014 testing link in the biosim program home page Thi
12. hand is fully open and ready for impulses Once the trigger is linked to a feature the settings tab appears providing the option to make changes to timings In addition the feature is now labeled with the relevant trigger Any of the above four potential triggers can be linked with any of the above features Some users are able to perform activities of daily life ADL s without the use of any triggers In many cases users initially set one or two triggers while familiarity and control is gained Part number MA01243 Issue No 1 July 2014 31 of 46 4 3 4 Training The training suite contains a variety of short training exercises aimed at developing control of the i limb ultra revolution The opening screen highlights the series of exercises which man sess can be selected individually and in any order mz Both open and close signals can be practiced An indication of difficulty is provided by the 5 point scale on each module Training Difficulty 00 00 Start exercise Difficulty 00 eee Start exercise 4 3 5 Usage The Usage suite provides usage information biain by lou Wises on the number of power cycles the number n_i of times the hand has been switched on the mem total number of runtime in hours as well as the Ten RD ianao number of open and close motions for each a A bene EE 0 sady Usage digit overall a e _ eoem Solr yolk Ariy tyr otier Wait
13. one s shoes For these types of tasks vari grip allows for an increase in grip force when a sustained close signal is given This extra ratcheting down of force increases the grip or pinch strength auto grasp When engaging in tasks such as putting away the dishes some individuals may be concerned about dropping a glass if they were to accidentally fire an open signal while moving Auto grasp assists in these cases by detecting inadvertent open signals and re closing the hand when a short un intentional open signal is detected thereby improving the user s control over objects Non backdrivable digits All digits of the i limb ultra revolution and i limb ultra are non backdrivable which means that each digit is capable of sustaining a load This saves battery power since no power is applied when the hand is static with no EMG signal It also means the digits should not be forced open manually The commonalities and differences between the i limb ultra revolution and the i limb ultra are summarized below Five articulating digits aa Individual stall out ability Enhanced grip feature vari grip Automated grip 4 24 patterns amp gestures 12 additional x f customized my grips Rotated manually Powered rotating with manual override Compatible with d f mobile app Push up from wheelchair 83kg 183lbs full hand Lateral Pinch 13 9kg 30 6lbs With activation of vari grip pulsing technology by continuation of
14. the close muscle signal Use of Quick Grips in control app Part number MA01243 Issue No 1 July 2014 3 of 46 2 2 Features Overview The functionality of the i limb hand enables it to mimic many of the basic grasp patterns of the natural human hand spherical cylindrical hook pinch tripod and lateral Figure 3 These grasp patterns or grips called Features can be achieved in various ways The user can program Triggers quick grips grip chips or alternatively the user can leverage the i limb conformable grip technology while operating in Standard Hand mode With the latter approach the user can manually position the thumb to the desired position oppositional or lateral then simply close the hand to achieve the desired grasp Figure 3 Patterns of the natural hand 1 Triggers Triggers are signals that tell the hand to change function Each Trigger instructs the i limb ultra revolution or i limb ultra to activate an automated Feature e g tripod or lateral grip There are 4 potential Triggers a user can select e hold open sustaining the open signal for a set period of time e double impulse two quick open signals after the hand is fully open e triple impulse three quick open signals after the hand is fully open e co contraction contracting both the open and close muscles simultaneously The number of Triggers programmed depends on each individual s ability to contr
15. thumb moves to a slightly closed position and only the digits will move with the closed signal As soon as you relax the signals the hand will automatically re open 1 Used to position the thumb when you do not want to use the manual override Can ONLY be used if the option to rotate the thumb when exiting the feature is turned off 1 Stabilize a tray of food 2 Balance a Bowl 1 Broom Handle 2 Shovel or Rake 3 Hair Brush or Hair Dryer 1 To left click use signal to close index digit 2 To right click use motion of the arm to put pressure on the mouse from the ring digit 1 Shaking hands One Finger Trigger Two Finger Trigger Thumb Trigger Donning or Doffing a cover Part number MA01243 Issue No 1 July 2014 Hand adopts partially closed position When a close signal is given the hand closes at full speed no proportional control When the close signal is relaxed the hand will fully open and then reposition into its partially closed starting position again Thumb automatically rotates into opposition and partially closes All fingers partially close When a close signal is given the thumb middle ring and little fingers close Once they have stalled around an object the next close signal will operate the index finger in squeeze mode when a close signal given index will close when signal relaxed index will open Thumb automatically rotates into opposition and partially closes
16. upper limb loss or deficiency are impacted in pro found ways The human hand functions in gross grasp and pre hensile activities as a sensory organ and as a means of communi cation and social interaction Any amount of loss or deficiency can interfere with an individual s productivity and alter one s interac tions with the environment In fact it is estimated that the hand provides 90 of the overall function of the upper limb Light Chappell amp Kyberd 2002 Emotional impacts such as a feeling of incompleteness are also common Each person with an upper limb amputation is unique and no two amputations are identical Because we rely on our hands for en gagement with the world around us training an individual to use a prosthesis can be one of the most challenging and rewarding clinical opportunities a therapist can experience The goal of most people with upper limb loss or deficiency is to achieve independence in the functional activities they want or need to perform For the majority of unilateral amputees this goal is entirely possible Individuals with bilateral transhumeral above the elbow or bilateral shoulder disarticulation limb loss present with a significantly more challenging situation typically requir ing more adaptations and creative solutions to improve indepen dence From the acute phase to community reintegration the therapist has a critical role in every stage of the functional training process In a su
17. and ease of use Multi Articulating Digits The i limb ultra revolution and the i limb ultra have five articulating digits powered by motors Four motors power the index to small digits with articulations at the metacarpophalangeal MCP and proximal interphalangeal PIP joints The fifth motor powers thumb flexion and extension at the MCP joint The i limb ultra revolution has these same motors but also offers one additional motor for thumb rotation Figure 1 Manual Versus Powered Rotating Thumb The one extra motor in the i limb ultra revolution provides the wearer with a powered rotatable thumb a distinguishing feature from the i limb ultra since the i limb ultra thumb must be manually or passively rotated and positioned to achieve certain grips and gestures The i limb ultra revolution includes a powered rotating thumb allowing motion from the palmar position to a fully lateral position and anywhere in between The thumb automatically moves to the position needed for the selected grip pattern saving time and improving grasp accuracy The thumb also has a manual override so it can be manually rotated increasing the versatility to available positions along the full range of thumb rotation The i limb ultra thumb can be manually positioned anywhere along the range of motion but it must be pre positioned by the user during specific grip patterns Typically a user can achieve manual rotation by pushing the thumb against the upper th
18. as having your client extend wrist and fingers rather than just the wrist or relaxing the fingers and just moving the wrist 4 3 2 Features Click on the features icon to enter the features suite The Features tab allows for the selection of what features grip patterns of the hand the user has programmed and what trigger the signal used to change modes the client will use to activate that feature Typically for a new user only one feature will be programmed until that is mastered upon which point additional features will be added Features When training the user it is helpful to set up the feature and trigger s and then return to the myo testing tab to observe signals using the training modes The therapist should ensure the user can enter and exit the feature and that they do not accidentally enter the feature during normal motion If training doesn t improve function the therapist should consult with the prosthetist so that he or she can make trigger adjustments Linking Triggers with Features In order to link a trigger with a feature simply click on to the desired feature the feature will now be highlighted in Touch Bionics lime green Select and click the desired trigger which has been selected to link with the highlighted feature Both feature and trigger should now be highlighted and the descriptive label will now appear The illustration indicates the Standard Precision Pinch Open feature linked to the pre
19. attention to any awkward or compensatory body motions as the client approaches or releases an object These movements include hiking up the shoulders winging out the elbow awkward neck positions excessive internal external shoulder rotation and trunk compensation If you notice any awkward or compensatory movements remind your patient not to adjust his her body when approaching a task By utilizing a variety of objects the individual will learn how to pre position the thumb to achieve different grips eventually mastering lateral pinch tripod and spherical grasps This will also help the patient to understand why certain grips are appropriate for different objects and allow them to choose the most functional grip for the task Teaching the individual how to transition between the various grip patterns prior to the ADL training makes these movements more natural once the time for ADL training has arrived The following items can be incorporated into the basic grasp release activity Blocks A Stones or marbles Nail Nut Bolt Balls Soda can bottle or cones e Fork spoon Dice r Coins Small candies Triangular piece of foam Pencil or pen Checkers e Styrofoam and or paper cup Paper clip safety pin Keys Credit card or playing cards Part number MA01243 Issue No 1 July 2014 20 of 46 2 Grasp and Release in Various Planes After mastering grasp and release at midline you can begin mixing things up placing the objects at var
20. cision pinch open feature 29 of 46 folowing teabres amp amp amp amp amp 8 amp TER bisi by Luud biust Dans heath hae Dema ant Aer lt b wi ree Sa v v 8 Glindrcal Pors re u Ange asrar cl pega temce feta inogcre Ackkrearpe Poo ue Woke lt Cane orp Yr api wong fe Bren id amog Doe Aa D Tinsin Smrk on sxi BUT eT bosim by Luti biust Semas mi Rarer Dens hanth hae kars fer Standard precision pinch opened 5 Phbs auan UL Tya nana fo s upara or artdi oem irh oces er ent tirih a r ft peat oo Asua Inzgzre ck ir oamp e Y Ya gp oucnas Ane Brn Poo yet lt Ww nkon lt lem ree a Lugt tring Cine orp furs gisn Are Brn Teste mark on sxi PUT eT 4 3 3 Triggers A trigger is the signal sensed by the electrode Four potential triggers are available Hold open Co contraction Double impulse and Triple impulse Threshold level Hold open a prolonged open signal this is preset to 2 000ms s e E l O OO 2 seconds and can be customized from 2 000 to 5 000ms re 7 The graph shows a good hold open trigger the signal strength m is well above 1 0V and the signal duration is around 3 seconds The user should be able to maintain a strong prolonged signal to successfully use this trigger Co contraction is the creation of quick simultaneous open and closed signals Co co
21. contractions verify that the opposing muscle group remains relaxed or at least does not overtake the active muscle group 2 Ensure that the electrodes are in the ideal locations and are not picking up interference from other muscle groups or from general motion at remaining joints 3 The prosthetist can make gain adjustments to the electrodes to provide appropriate separation of signals but at least 40 signal strength should be obtainable from each electrode site Ideal gain settings are between 3 and 5 on the dial on the back of the electrode Higher gains settings may indicate too weak of a muscle A higher than desired gain setting will often decrease as the client s muscle and control are strengthened and refined from the training process 4 Coach your client to relax all muscle signals while moving in various planes of motion to ensure muscle signals stay at a minimal level less than 0 5 Also ensure that the client is able to activate the muscle groups across various planes of motion by creating a range of signal strengths in various positions Optimal Graph Red open signal and blue close signal stay E isolated with one always stronger than the other To the right is a graph demonstrating poor control When the red open signal and blue close signal mix the hand will il jump back and forth causing frustration to the user Part number MA01243 Issue No 1 July 2014 16 of 46 Once myosites have been select
22. d thumb Allows for larger objects to be grasped using the tripod pinch Can also improve positioning May also decrease compensation at shoulder for tasks where closed digits get in the way of the pinch For smaller motion but increased accuracy Tripod grip allows for greater stability with larger or round objects in comparision to Precision Pinch May also decrease elbow compensation when seated Allows for a wider space opening tio pinch larger objects Tripod grip allows greater stability for larger or round objects in compa rision to precision pinch Can improve stability and control grasping larger objects With thumb in a static position your ability to align an object can improve particularly on small objects Can also decrease elbow compensation when seated 1 Preparing food with ring and little finger clear such as slicing cucumber or carrot 2 Holding cell phone would manually rotate thumb laterally based on size of phone or setup custom grip 1 Grab spices from cupboard 2 Open bag of chips 1 Open bag of chips 2 Pull up socks 1 Repetitive factory type work moving pieces 2 Grasp pen for writing 3 Laundry 4 Pack bag Note Due to the stall out ability of each individual digit both Precision Pinch and Tripod Grip can be achieved in the Standard Hand Mode i e no Features have been activated Part number MA01243 Issue No 1 July 2014 Additional Features Thumb Park Co
23. e No 1 July 2014 Thumb and all four fingers fully open Only thumb will rotate for 2 5 seconds of run time Thumb automatically rotates laterally and closes partially All fingers remain open All digits switch off Thumb rotates automatically to a semi lateral position All digits are active in this feature Hand forms shape appropriate for using a computer mouse Thumb automatically rotates into semi lateral position and partially closes and switches off All fingers remain fully open When a close signal is given the fingers close when this signal is relaxed the fingers open No flexion or extension of the digits will occur one signal will rotate thumb laterally and the other will rotate into the palm For tasks where balancing an object on the open hand is useful Many handled type objects require this cylindrical grip You can also use the manual override of the thumb to position manually rather than having to use this feature Note that multiple steps are involved in this grip Step 1 Place the closed little finger against the side of the mouse Step 2 Provide a close signal until the thumb rests against the other side of the mouse the thumb must detect pressure so you may also provide pressure with your other hand if the thumb will not stop Step 3 The index digit will now close with the signal to click the left mouse button relaxing signal will re open Note that with this feature the
24. e bots RYnesaner AJAT ar Referi sans Feature count gives the number of times the open and closed command has been used with in a specific grip INE pattern Intel wrhere Sew oan sius Yi Pours Reset cous e gt G gt GC gt 23 C D3 DaDa De The therapist may wish to review this during sessions to see how much the hand is being used as well as common grip patterns used Part number MA01243 Issue No 1 July 2014 32 of 46 4 4 Mobile Apps Mobile apps are available for both clinicians and i limb users 6 59 AM 5 IPod 9 34 AM oz The app for clinicians is called biosim and the app for users is ES Soie al called my i limb The therapist may download biosim onto any e compatible Apple device such as a ai a Home iPod 5 or newer keo Ss Se 6 Recreation iPhone 4s or newer a iPad 4th generation or newer e iPad mini The i limb wearer can access the my i limb mobile app with the iPod 5 which is provided as part of the package with both the i limb ultra revolution and the i limb ultra The therapist should encourage the user to bring this tool to therapy For more detailed instructions on how to use and operate both the patient and clinician versions of the app visit the my i limb app biosim app amp biosim software section of the Document Library on Touch Bionics website www touchbionics com downloads document library Part number MA01243 Issue No 1 July 2014 33 o
25. eature requires multiple 1 Pulling trigger on steps spray bottle Step 1 Enter the feature using either the trigger or Quick grip Step 2 Provide a close signal until the thumb ring and small digits have fully closed around the object being held Step 3 Providing a close signal will close the index digit onto the trigger and relaxing the signal will re open the index and middle digits Note this feature requires multiple 1 Pressing down on steps a small aerosol can Step 1 Enter the feature using either button the trigger or Quick grip Step 2 Provide a close signal until the index middle ring and small digits have fully closed around the object being held Step 3 Providing a close signal will close the thumb onto the trigger and relaxing the signal will re open the thumb When changing out covers for the 1 Putting on covers hand to avoid too much pressure 2 Taking off covers against the thumb More Information on the Lateral Grip Additional Images for Lateral Grip Uses Also known as key grip the Lateral grip occurs when the thumb closes down on the side of the index finger The Lateral F grip allows the user to grasp flat shaped items such as a plate or key It enables the individual to comfortably hold a plate or to manipulate credit cards when making a payment transaction Some other examples of tasks in which lateral grip can be useful are dressing and writing This grip patter
26. ed the therapist can begin training with either games or by using the on screen virtual representation of the i limb ultra revolution These training games are found by selecting the training link on the home page of biosim The bottom right corner of the virtual hand screen allows the therapist to watch the strength of each muscle contraction while the client works to open and close the virtual hand The client can also practice triggers to engage the various features of the hand such as the tripod pinch and precision pinch modes The virtual hand can be rotated around on the screen to the client s preference by clicking and dragging with the mouse Games can work on signal strength signal separation or any of the triggers required to activate the hand s features uty eeeee a ene one Thuy C0 Cee an ee one ku eee 0 Sia pom ome Part number MA01243 Issue No 1 July 2014 17 of 46 3 2 Prosthetic Training Phase Basic Training with the Prosthesis Orientation to the hand opening and closing is important to review and reinforce If adequate myoelectric testing and training has been accomplished this should be an easy exercise It may also be quite meaningful for the patient to view his or her new hand responding to this thought of open close Practice positioning of the thumb is also important to discuss and practice prior to engagement in tasks Achieving Independence in Donning and Doffing the Prosthesis When train
27. ed for Natural Hand to be activated This ensures the hand does not accidentally go into the natural hand position when the user is holding an object This feature can be programmed on or off and the position of the natural hand can be adjusted to the user s preference Note that natural hand position will only be activated when in standard hand operation and will not be activated when any of the features are in use Rotate Thumb On Exit Rotate thumb on exit programs the thumb to automatically rotate to the palmar position every time the user exits a different grip pattern vari grip and auto grasp vari grip and auto grasp come as standard on i limb ultra revolution and i limb ultra Both can be turned off or on depending on user preference and functional tasks For example a user may decide to turn vari grip on when tying their shoes or opening a jar of pickles Part number MA01243 Issue No 1 July 2014 11 of 46 2 4 Wrist Options The i limb ultra revolution and the i limb ultra are compatible with several wrist options Wrist options add weight and length to the overall prosthesis and the prosthetist often determines if they are necessary appropriate for the user The standard i limb hands come with the Quick Wrist Disconnect QWD a wrist that the user can manually rotate to achieve supination and pronation Another option is the Wrist Disarticulation WD which is fixed and provides no rotation The WD is fabrica
28. eratures Do not incinerate batteries Do not alter battery terminal wires Do not short circuit the battery Do not store batteries inside a vehicle Dispose of batteries in accordance with US European or local regulations Only use the appropriate Touch Bionics charger to charge Touch Bionics batteries If the battery has visibly ballooned or swelled e discontinue the charging process immediately disconnect the battery e remove to a safe area leave and observe for 15 minutes gt replace the battery donot re use dispose of any leaking batteries in an appropriate manner Failure to comply with the above guidelines will invalidate the warranty 34 of 46 5 2 Usage Do s and Don ts DO YW wf Push thumb to the side fing thumb to block index Hold handles or similarly shaped objects securely in palm near the base of the fingers Move the thumb to the side so that it doesn t block the index from closing Ensure all digits are fully closed around objects Do not lift objects with the tips or sides of the digits Hold objects close to palm with all s Do not hold obi J jects Do not hold objects fingers fully closed gt with P a pleat ah Apply the same rules to opening appliances and pulling handles refridgerators ovens car doors etc f Grasp objects close to palm with all fingers fully closed Do not lift with lt fingertips Do not lift heavy objects wi
29. f 46 5 1 Warnings and Precautions i limb ultra revolution Do not use without an approved cover Do not use under water Do not use to operate heavy industrial machinery Do not use with machinery with moving parts that may cause personal injury or damage Users must comply with local regulations on the operation of automobiles aircraft sailing vessels of any kind and any other motorized vehicle or device Do not use for extreme activities that may cause injury to a natural hand Do not expose to excessive moisture liquid dust vibration or shock Do not expose to high temperatures Do not expose to flames Do not use or expose to explosive atmospheres Do not disassemble componentry or modify in any way Maintenance repairs and upgrades may only be performed by qualified Touch Bionics technicians and technical partners Do not use with a damaged cover Damaged covers must be replaced or repaired by a qualified Touch Bionics technician or technical partner Only approved Touch Bionics accessories and tooling may be used with the i limb ultra revolution If utilizing a multi flex wrist the hand should be locked if carry ing an object Failure to comply with the above guidelines will invalidate the warranty Part number MA01243 Issue No 1 July 2014 Batteries Do not bend or exert excessive pressure on the battery Do not pierce the battery Do not disassemble Do not expose to high temp
30. gger consider raising this threshold after Cancel consulting with the prosthetist Part number MA01243 Issue No 1 July 2014 30 of 46 The graph to the right shows an optimal double impulse Both impulses are of sufficient strength to break the threshold the first impulse drops below the threshold to allow recognition of the second impluse Both impulses are activated within the 25 preset impulse period tmpulse period tmputse duration The hand must first be fully opened before impulsing the therapist should train the client to hold open for half a second before impulsing The therapist can begin by training quick open signals Users will often fire the close signal when trying to relax quickly The therapist should encourage open relax open relax Triple impulse three quick uninterrupted open signals settings are the same as with the Double impulse trigger The graph shows an optimal triple impulse In a similar manner to the double impulse the three impulses are of sufficient strength to break the threshold The first and second impulses drop below the threshold to allow recognition of subsequent impulses All three impulses are activated within the preset impulse period impulse 25 period is not indicated on the graph The i limb hand must be fully opened prior to performing the impulses Using the training mode on the myo testing graph provides feedback on when the
31. h the sound side It may be helpful to practice both ways so the individual can practice control and also determine the manner in which they find the most benefit of the prosthesis For those individuals with bilateral involvement control should be mastered on each side independently before progressing to having one hand stabilize while the other side engages with the task Again attention should be given to the client s posture and positioning to ensure that the task is performed in a natural manner Each of these tasks reinforces the different grasping possibilities of the i limb ultra revolution and i limb ultra There are numerous other tasks as well and those listed are simply examples Part number MA01243 Issue No 1 July 2014 21 of 46 Unilateral Tasks performed while sitting may include e Bringing a glass bottle or can to mouth Note Factors such as socket design and residual limb length might limit elbow movement making this task more difficult for some to achieve e Writing with a pen or pencil or stabilizing the paper e Picking up Skittles M amp Ms or grapes to eat or put in a bowl e Grasping a fork spoon or knife e Using a salt or pepper shaker e Using a mouse or keyboard e Putting on a sock e Picking up a coin e Holding a cell phone e Eating potato chips or crackers e Playing cards using a card holder e Turning pages of a book or newspaper Unilateral Tasks performed while standing may incl
32. hallenge for the client The therapist should continue to provide verbal cueing to avoid compensatory motions and to pre position appropriately for the task 3 Stacking Plastic Cups Another excellent activity for reinforcing grasp and release is to have your client stack large plastic or Styrofoam drinking cups into a pyramid formation This task helps to train proportional control as it forces the user to give small concise muscle signals to avoid crushing the cups Mastering this task will result in the individual s ability to hold a cup of coffee or any other beverage without crushing the cup 4 Training with Games Jenga Hasbro Inc Connect 4 Hasbro Inc Dominoes and Mancala Games can be a fun and challenging way to practice incorporating multiple grasp patterns throughout a task The therapist should be confident that the client is ready for this challenge to avoid unnecessary frustration Unilateral ADL Task Training To minimize frustration and enhance learning task based activities should begin only when the client is completely familiar with the control site operation and can control grasp and release Unilateral task training includes ADL and IADL grasping tasks For individuals with unilateral involvement the prosthesis will act as a functional assist to the sound hand for these types of tasks For example when pouring a drink the individual will most likely use the prosthesis to stabilize the cup while pouring wit
33. harging a client from therapy make sure to remind your client that he or she should continue to follow up with their prosthetist with any concerns Also consider any additional services your client might benefit from such as Vocational Rehabilitation or Driver s Rehabilitation Use this final visit to answer any outstanding questions for your client such as charging the battery troubleshooting problems and safety efficiency guidelines for use For more information about these subjects please refer to the i limb ultra revolution User Manual under the document library of our website www touchbionics com downloads document library Part number MA01243 Issue No 1 July 2014 25 of 46 Part number MA01243 Issue No 1 July 2014 4 1 biosim Overview biosim is the software for programming the set up and person alization of the i limb ultra revolution and i limb ultra as well as the control software for the virtu limb The i limb ultra revolu tion and the i limb ultra are fitted with a Bluetooth receiver enabling them to work with biosim biosim pro is the clinician s version of biosim and biosim i is the version designed for patient users biosim makes it possible to make changes to the function ality of the hand biosim i the simplified patient user version of the software provides access to training and games features along with some basic changes to settings The biosim software working through the Bluetooth wireless connection
34. igh or a hard object or by reaching over with the contralateral side Part number MA01243 Issue No 1 July 2014 Motorized Digits Motorized Thumb Figure 1 i limb ultra revolution Stall Out and Compliant Grip For both the i limb ultra revolution and the i limb ultra the motors can be stalled or stopped when they reach resistance or when pressure is put against them This stalling mechanism allows the hand to conform to objects of various shapes and sizes Figure 2 to provide a compliant grip This is a significant advancement over the single grip style hands which only offer a 3 Jaw Chuck Tripod style grip for all tasks Figure 2 Compliant grip allows hand to take shape of the object Proportional Control Both the i limb ultra revolution and the i limb ultra function with proportional control meaning the stronger the muscle contraction the faster the hand will move Likewise a weaker muscle signal will cause the hand to move more slowly A helpful analogy to describe this is an accelerator pedal on a car where the vehicle s speed is controlled by the amount of pressure placed on the pedal With the i limb hands once a user grasps an object the hand will continue to hold the object until a clear open signal is given vari grip The compliant grip of the hand allows a firm grasp on most objects but there are tasks that sometimes require extra force such as opening a candy bar a container or even tying
35. in purse e Use knife and fork to cut food Butter a slice of bread e Playing cards e Sew button Strike match e Serve food onto a plate buffet style e Tie up garbage bag Bathroom activities Shaving e Brushing teeth putting toothpaste on toothbrush e Fastening and unfastening clothing e Toileting e Putting on deodorant Styling hair e Cutting Nails Dressing activities e Put on shirt Fasten buttons Put on trousers and belt Fasten pants pull up zipper Put on shoes e Tie shoe laces e Putonglasses Pull on socks e Put on jacket and zip or button Kitchen activities e Cut fruit or vegetable on a cutting board e Meal preparation e Open milk juice container e Pour liquid from pitcher into different sized glasses bowls e Open a bag of chips or zip lock bag e Open jar Eat banana Part number MA01243 Issue No 1 July 2014 24 of 46 Household maintenance activities Iron clothes e Sweep floor with broom Use dust pan and brush Remove file from drawer open file remove paper and replace file in drawer e Replace book on shelf Fold Laundry Make bed Advanced ADL Task Training The Advanced ADL task training phase is the final stage of training and focuses on helping the client to achieve their personal leisure recreational and or vocational goals Community re integration training is also common in this phase The perso
36. ing the patient to don and doff the prosthesis on their own it is important to establish independence as early as possible The therapist should carefully review donning and doffing with the prosthetist before training the client Donning a transradial socket is typically achieved by push in pull sock or silicone liner assisted methods Figure 5 The therapist and client should be familiar with the method of choice and practice it during each visit Figure 5 Silicone Liner Method Push in Method Pull in Sock Method Understanding Device Componentry If there are additional components to the terminal device the therapist should review each one to ensure the individual understands how to use it For example with the flex wrist you can show your client how to flex or extend the wrist by pressing the button on the volar aspect of the wrist using either the contralateral hand or the edge of a table The wrist will move into flexion or extension with gravity or by manually positioning with the contralateral hand The therapist should also discuss the benefits of each position For example wrist flexion helps with tasks completed at midline while wrist extension can help to decrease compensation at the shoulder for certain tasks Part number MA01243 Issue No 1 July 2014 18 of 46 Orientation to Prosthetic Wearing Schedule It is extremely important to review a prosthesis wearing schedule early in the training process ideally within the first
37. ious heights and angles Increasing the variability of training tasks has been shown to allow improved functional outcomes and greater improve application of skills to novel functional tasks Weeks et al 2003 Learning to relax the muscles can sometimes prove more challenging for the client than grasping and releasing It is natural for the client to feel he she must sustain the close signal in order to maintain a firm hold on an object However the i limb ultra revolution is built so that once the hand has grasped an object the wearer can relax the muscle without having to worry about dropping it This ensures the wearer does not exhaust his or her muscles in the process The weight of the prosthesis and movement of the residual limb can also make it more difficult to maintain a relaxed signal Practicing grasping and releasing objects at various heights will help to ensure the wearer can activate and relax muscle signals across all planes of motion and with different loads placed onto the prosthesis The therapist may begin incorporating purposeful functional activities at this time however perfection and skill of how to approach position and release an object are of utmost importance and should be the focus during this phase of training After mastering basic grasp and release patterns you can begin shifting your focus to more unilateral and bilateral grasping tasks By appropriately grading activities the therapist can provide a just right c
38. n can significantly reduce the need for compensatory techniques with many tasks Users also find that the flat surface area and increased pinch force in this grip pattern assists with opening packages and getting a firmer grip on objects Rather than programming this grip many unilaterally involved individuals will simply rotate the thumb laterally and place the object directly into the hand However the Lateral grip feature allows the four digits from index to small to fully close and switch off a valuable capability for performing many tasks i e picking a plate off a table or opening a drawer In many of the tasks where Lateral grip is useful the object sometimes blocks the user s view of the digits By making the digits inactive one can minimize this challenge 2 3 Operating in Standard Hand Mode Although there are many benefits that come from using the available grip modes in the i limb hand it is important to note that by using the Standard hand mode with compliant or conformable grasp capability the hand can achieve many common grasp patterns without any additional programming These include Power Grip Power grip occurs when the thumb and four fingers close to create a gross grasp The i limb is able to adapt and conform to the unique composition shape and size of an object For example proportional control technology allows for the slow movement of the digits to lightly grasp around an object such as another person
39. nalized nature of this phase makes it important to focus these sessions on the specific interests of the client whenever possible Activities might include e Preparing a full meal e Using light tools and completing a small and simple woodworking project e Simple repairs or home fix it projects e Grocery shopping e Visiting a mall shopping negotiating a food court e Visiting a local home store to test out various tools TRAINING TIP When performing these tasks the user may find the need to activate vari grip to improve performance When utilizing vari grip if the user has any difficulty the therapist should use the biosim graph of myosite signals to provide feedback The closing signal must be maintained above 1 on the myo testing graph for a preset amount of time default 500ms before the vari grip will activate Discharge from Therapy The therapist can begin to lessen the frequency and intensity of training once the client has mastered proper use of the prosthesis and has begun to integrate the prosthesis into their daily life At this point you can consider taking a month hiatus from training asking your client to continue to use the prosthesis daily and schedule a 30 day follow up appointment to ensure no new challenges have arisen If at the follow up the user is able to continue adapting tasks and using the prosthesis appropriately then it may be time to discharge them from therapy When disc
40. ns as well the logging of user information This is mostly used by the prosthetist to set up the hand Features allows the set up of the i limb ultra revolution by linking triggers with grip patterns and gestures The therapist might find it beneficial to explore different feature options in therapy and communicate needs and or changes with the prosthetist Training provides access to the training suite and a selection of games to improve overall hand control These may be used in the pre prosthetic training phase or if the individual is struggling with control Hand health check icon provides a quick and easy diagnostic check of the hand Usage icon provides access to a tally of individual movements with additional analysis This may be helpful to review to see how much the individual is using the hand outside of therapy Exit icon draws the session to a close exiting the program Don or Doff icon positions the i limb ultra revolution for putting on or taking off a cover 27 of 46 You re now connected What would you like to do today Choose from one of the following options Iyotesting Control Features Training Hand health Usage Exit strategy check Don or Doft Aast Myo testing Control strategy Features Training Hand health check Don or Doff 4 3 1 Myo testing The details of myo testing can be found in the Pre Prosthetic training section In the Prosthetic training phase
41. ntinuous Thumb Park Quick Lateral Grip Gesture Custom Grip Part number MA01243 Issue No 1 July 2014 Thumb rotates to palmar adduc tion and the other four fingers remain fully open Only the thumb moves open and closed Thumb rotates to palmar adduc tion and the other four digits remain fully open Only the thumb moves open and closed for 1 5 seconds of run time In contrast to Thumb Park Continuous this fea ture returns to the Standard Hand Mode after the open signal is sent Thumb automatically rotates into lateral position and partially closes All four fingers fully close and switch off Only thumb will move Thumb automatically rotates into lateral position and fully closes Thumb switches off Middle ring and little fingers fully close and switch off Index finger remains open and active All digits automatically move to a user defined position with each digit option as open or closed There are 2 programmable custom gestures available in this feature Digits move to user defined posi tion with options for degree of open or closed and option to keep selected digits active For longer dressing period that will require more than the 1 5 seconds of thumb park quick or grasping light weight flat objects Can also use stalling out digits to complete putting pressure against index to little and closing thumb in to hand Dressing or putting on a coat You can achieve this position by
42. ntraction may be customized if 25 a patient has difficulty with activation within the default time N The therapist should work to have the individual fire both muscles strong above 1 on the graph and quickly Training strategies include having the user think about making a tight fist flicking water off his or her fingers or es making a hang ten gesture If the individual was struggling with signal isolation this trigger should be avoided until they master control Double impulse two quick uninterrupted open signals the impulse duration is the period of time thatthe impulse is above the threshold It is preset at 300ms and can be customized fisks from 30 to 3 000ms The impulse period or period within Impulse duration ms 300 The duration is the window of f opportunity for the open signal to get which the impulse must occur to be recognized is preset at Impulse period ms 1000 dhive Tie tirhan back bani 1 000ms and can be customized from 500 to 3 000ms l the threshold to be considered an 7 Use detection threshold impulse Additionally you may adjust the threshold used to detect e The period is the total amount of time an impulse This is beneficial to weed out inadvertent open to accomplish multiple impulses that ioe gi ill activate a trigger signals that may be detected as impulses If your patient is a RS reporting accidentally jumping into the feature associated with an impulse tri
43. ol and activate the signals More detailed information about Triggers and appropriate training techniques is available in the prosthetic training section 2 quick grips In both the mobile apps and desktop software you will find quick grips This is another way you can enter and exit features and offers instant access to 24 different grip patterns By clicking the quick grip button for the selected grip your hand will enter that mode To exit click the quick grip again 3 grip chips a Using the my i limb app patients can easily program grip chips with any grip pattern or gesture they choose and place in a desired location Simply holding an i limb ultra revolution device within close range to a grip chip will activate the programmed feature nu grip chips enable users to easily activate quick grips my grips or favorites for i limb ultra revolution Part number MA01243 Issue No 1 July 2014 Precision Pinch Grip Options Precision pinch grip options are best for picking up small items between and the thumb and index finger There are 4 options available depending on how you want the other digits to perform while doing the pinch The most popular is Thumb Precision Pinch Closed Standard Precision Pinch Open Thumb Precision Pinch Open Standard Precision Pinch Closed Thumb Precision Pinch Closed Part number MA01243 Issue No 1 July 2014
44. osthetic training on upper extremity prosthesis use JPO 1997 9 1 3 9 Light C M Chappell P H Kyberd P J Establishing a standardized clinical assessment tool of pathologic and prosthetic hand function Normative data reliability and validity Archives of Physical Medicine and Rehabilitation 2002 83 776 783 Malone J M Fleming L L Roberson J Whitesides T E Leal J M Poole J U Sternstein Grodin R 1984 Immediate early and late postsurgical management of upper limb amputation J Rehabilitation Research and Development 21 33 41 McFarland L V Hubbard Winkler S L Heinemann A W Jones M amp Esquenzai A 2010 Unilateral upper limb loss Satisfaction and prosthetic device use in veterans and servicemembers from Vietnam and OIF OEF conflicts Journal of Rehabilitation Research amp Development 47 4 299 316 Resnik L Meucci MR Lieberman Klinger S Fantini C Kelty DL Disla R Sasson N Advanced upper limb prosthetic devices Implications for uppper limb prosthetic rehabilitation Arch Phys Med Rehabil 2012 93 710 717 Smurr L M Yancosek K Gulick K Ganz O Kulla S Jones M Ebner C amp Esquenazi A 2009 Occupational therapy for the polytrauma casualty with limb loss In Pasquina P F amp Cooper R A eds Care of the Combat Amputee Washington D C Borden Institute van Lunteren A van Lunteren Gerritsen GHM Stassen HG Zuithoff MJ A field evaluation of arm pros
45. ouch Bionics website www touchbionics com downloads document library Part number MA01243 Issue No 1 July 2014 12 of 46 3 1 Pre Prosthetic Training Phase Below is an overview of the phases and key elements for pre prosthetic training 3 1 1 Acute Pre Prosthetic Training Phase Evaluation In the early acute phase of pre prosthetic training the client s therapist should complete a standard functional and orthopedic based evaluation Your evaluation should address functional difficulties in activities of daily living ADL instrumental activities of daily living IADL work and leisure tasks The therapist should also assess wound healing edema sensation pain body symmetry and the range of motion and strength of all remaining joints If the involved side was the dominant one the therapist should also assess sound side prehension and dexterity Subjectively it is also important to understand the client s previous level of function individual goals home environment and whether or not the client has access to psychosocial support Depending on what this assessment uncovers the therapist may need to recommend home modifications or adaptive equipment to improve the client s independence Also the loss of a limb has been equated psychologically with the loss of a sibling therefore a strong support system is essential and additional psychosocial intervention may be necessary Forducey Ruwe amp Kaur 2006 ADL Training
46. ra connected to the virtu limb docking station Close signal closes the i limb hand Bottom Image Computer screen simulation Open signal is reflected on the screen Part number MA01243 Issue No 1 July 2014 14 of 46 Instructions for Myosite Testing A detailed overview of myosite testing is provided below A team approach in this phase can improve user success Smurr et al 2008 Typically the prosthetist selects ideal sites for the therapist to train with during sessions As training continues the therapist may identify issues isolating muscle contractions relaxing the muscles in certain positions or challenges with overall control By communicating this information back to the prosthetist prior to the final fitting adjustments can be made to improve ease of use for the individual being fit Step 1 Prepare the Client 1 Once the prosthetist has identified the myosite you would like to test train lightly clean the skin surface with an isopropyl alcohol swab This will remove any oils that could interfere with testing 2 Palpate antagonistic muscle groups for two site control or a single usable muscle group for single site control See common muscle sites below 3 Once you have identified the middle of the muscle belly make a small mark on the area with an indelible pencil or a permanent marker 4 Moisten the skin with a wet paper towel to improve electrode conductivity Common myosites used to control the i limb
47. re Pathway is a unique platform designed by Touch Bionics to measure the progress of patients through validated outcome measures Pre fitting scores are established from the Disabilities of the Arm Shoulder and Hand questionnaire DASH and the Trinity Amputation and Prosthesis Experience Scales Revised TAPES R Refer to the Patient Care Pathway literature on www touchbionics com for more information and guidance for use The biosim software can also assist in tracking usage data and watching muscle signals during functional training More information on biosim can be found in section 4 of this manual Education on Pre positioning the Prosthesis for Function Appropriately positioning the prosthesis to achieve different functional tasks is key to avoiding compensatory movements at remaining joints Thus the individual should be taught to appropriately supinate or pronate the hand based on the task Part number MA01243 Issue No 1 July 2014 19 of 46 Orientation to Grasp and Release Activities 1 Objects of various sizes including cones and blocks can be used to orient the user to basic grasp and release patterns A Form Board is another useful training tool during the preparatory pre ADL task training By placing a variety size and shaped objects in corresponding size and shaped spaces on the form board the client is able to practice and perfect pre positioning and control of the hand While going through this exercise pay special
48. rvey of individuals one year post amputation respondents indicated a strong desire for functional training with their prosthe sis van Lunteren et al 1983 By contributing to the successful integration of a prosthesis the therapist helps reduce the risk of cumulative trauma disorders which are three times more likely for individuals with unilateral limb loss McFarland et al 2010 Various studies show that the type and amount of therapy re ceived correlates to improved functional outcomes Weeks An derson and Wallace 2003 noted the importance of having varia tion in training rather than purely rote practice In another study individuals were instructed to complete a list of functional tasks One group was given formal training to complete the tasks while the other group was instructed to complete them independently In a period of just four days those who received formal training demonstrated significantly better efficiency in completing the tasks than those without training Lake 1997 Part number MA01243 Issue No 1 July 2014 2 1 Device Overview Touch Bionics offers two myolectric powered options for patients with upper limb loss at the wrist or more proximal the i limb ultra revolution and the i limb ultra The i limb ultra revolution and the i limb ultra offer many customizable features providing wearers with the flexibility to perform a wide range of daily activities with improved control accuracy
49. s takes you to the analog gauges screen Instruct your client to contract his or her muscles aiming to produce open and close signals between 25 and 75 each If the individual is struggling you can coach them to contract the same muscle s on the sound side if applicable in order to help them identify what the movement should feel like The therapist can further assist by applying manual resistance to the contralateral side while mirroring the desired motion 15 of 46 6 Repeat these steps in the radial and ulnar directions from your initial mark so you end up with a border around the proposed electrode site The ideal electrode site should now be in the center of this outlined area 7 If multiple electrode sites are to be used repeat 1 through 6 for these locations Step 3 Verify Isolated Control Now that you have established the proper electrode placement you will need to ensure the client can independently isolate each muscle contraction to establish good separation between the open and close signals 1 Open the real time graph tab at the bottom of the myo testing page This provides excellent biofeedback for isolated control training To begin instruct your client to contract the open muscle group relax and then contract the close muscle group The red lines that show up on the graph upon contraction refer to the open signals and the blue lines refer to the close signals While your client repeats these muscle
50. ted directly into the socket frame then attached to the i limb The prosthetist may choose to add an electric wrist rotator to help with supination pronation particularly if the patient is involved bilaterally It is important that the therapist understands how the wrist componentry functions to provide the best support possible to the user Other wrist options include Flex Wrist and Multi flex Wrist Flex Wrist The flex wrist option offers a locking wrist that can be positioned in three wrist positions 30 dorsiflexion 0 neutral and 30 palmar flexion The lock button is easy to control and may be particularly helpful for individuals involved bilaterally for tasks at midline For more information see the document library on the Touch Bionics website www touchbionics com downloads document library Multi flex Wrist A multi flex wrist allows for passive flexion extension radial and ulnar deviation and can compensate for loads placed on the hand The lock can be used to lock the wrist up to 30 dorsiflexion 0 neutral and 30 palmar flexion However many users keep the wrist unlocked for a more natural feel If the lock is used it is important to note the wrist is spring loaded and the user must release the spring tension when un locking by pushing the hand in the direction it was locked The wrist cannot be locked in ulnar or radial deviation For more information see the document library on the T
51. th Use palm up position when gt lt palm down position lifting holding heavy objects lt A Part number MA01243 Issue No 1 July 2014 35 of 46 5 2 Usage Do s and Don ts Continued DO VW DON T gt Do not push with fingers open Do not push with fingertips d Push up with fully closed fist with force at knuckes lt Part number MA01243 Issue No 1 July 2014 36 of 46 5 3 References and Recommended Reading Atkins DJ Prosthetic Training Atlas of Amputation and Limb Deficiencies Surgical Prosthetic and Rehabilitation Principles 3rd Edition Eds Smith DG Micheal JW and Bowker JH AAOS 2004 Biddiss E A amp Chau T T 2007 Upper limb prosthesis use and abandonment A survey of the last 25 years Prosthetics and Orthotics International 31 3 236 257 Bowker J H 2004 The art of prosthesis prescription In Smith D G Michael J W amp Bowker J H eds Atlas of Amputations and Limb Deficiencies Surgical Prosthetics and Rehabiliation Principles 3rd ed Rosemont Il American Academy of Orthopaedic Surgeons 742 Datta D Kingston J Ronald J 1989 Myoelectric prosthesis for below elbow amputees the Trent experience Int Disabil Studies 11 4 167 170 Durance JP O Shea BJ Upper limb amputees a clinical profile Int Disabil Stud 1988 10 68 72 Fletchall S Returning upper extremity amputees to work The O amp P Edge 2005 4 28 33 Lake C Effects of pr
52. theses for unilateral amputees Prosthet Orthot Int 1983 7 141 151 Weeks DL Anderson DI amp Wallace SA The role of variability in practice structure when learning to use an upper extremity prosthesis J Prosthet Orthot 2003 15 84 92 Part number MA01243 Issue No 1 July 2014 37 of 46 Up touch OIONICS North American Customers Canada Mexico and US Touch Bionics 35 Hampden Road Mansfield MA 02048 USA Tel 1 855 MY iLIMB 694 5462 asal International Customers Touch Bionics Unit 3 Ashwood Court Oakbank Park Way Livingston EH53 OTH Scotland Tel 44 1506 438 556 Email info touchbionics com For address details and further information please visit www touchbionics com Third party products and brand names may be trademarks or registered trademarks of their respective owners ce Copyright 2014 Touch Bionics Inc and Touch Bionics Ltd All rights reserved MA 01243 Issue No 1 July 2014
53. ude e Carrying a glass bottle or can e Walking while carrying a bag or briefcase e Using a key ina lock or turning a doorknob e Retrieving items from shelf or refrigerator Part number MA01243 Issue No 1 July 2014 22 of 46 Bilateral ADL Task Training For the unilateral amputee the bilateral ADL task training reinforces the real value of the i limb ultra revolution hand as a functional assist in bilateral activities The selection of activities will be based in part on the client s preference depending on his or her interests A variety of activities should be used to expose the client to a wide range of grasping patterns Creative thinking and planning on the part of both the therapist and patient can make this a fun and engaging part of the therapy process Bilateral Tasks performed while sitting may include paper and pencil tasks Use a ruler to draw a 4 x 4 square cut out the square using scissors Wrap a gift box or paperback book use scissors scotch tape and tie a bow Fold a letter in an envelope seal the envelope open the envelope and remove the letter Remove an ink cap from a pen or marker Use a paper clip to secure papers together Mie IS Part number MA01243 Issue No 1 July 2014 23 of 46 Home activities e Cut a length of thread with scissors thread needle e Usea cell phone and make a call e Open a variety of bottles and containers e Handle money bills in wallet coins
54. using the stall out capability of digits against a table if you do not want to program Holding onto plate papers CD or other flat objects Improved stability with use of the side of the index finger See additional images on page 10 Used for pushing buttons typing on computer or simply pointing Can be achieved with stall out Allows user to customize the hand Many positions can be obtained using stall out if the user does not have enough available triggers to use this feature Can be used to fully customize for use of specific tool for work or hobby Multiple can be set up as favorites on iPod 1 Put on jacket 2 Grasp flat objects such as a book or a tablet computer or clipboard 3 Opening letters or sorting paperwork 1 Put on jacket or shirt 1 Hold plate while serv ing food 2 Hold clipboard 3 Get card from ATM 5 Open ziplock bag 6 Tie Shoe Laces 7 Hold a utensil 1 Keyboarding pressing shift key CTRL ALT DEL general typing 2 Push Button for elevator 1 Boy scout salute 2 Sign Language ges tures such as I love you 1 Customize grip to specific work or hobby type tool 2 Supporting and oper ating a camera Extra Features Available with the i limb ultra revolution The i limb ultra revolution offers ten additional Features than the i limb ultra for a total of 24 pre set Features Rotate Thumb Cylindrical Handshake Part number MA01243 Issu
55. w clicked for the connection to be made this will take approximately 15 seconds If there is more than one i limb device within range of the Blue tooth receiver then a box will appear listing all devices by serial number The correct i limb device can then be selected from the list The hand serial number is located at the wrist portion of the hand at the base of the thumb 26 of 46 Figure 7 D pe Welcome to Follow these three easy steps to connect with a device Insert handshake Turn device off Connect to device Hardsnake instalieo ano reacy poe aes erect Me cS ardsrak es You can also choose one of the options below a Review offing patient Information Visit us on the web Part number MA01243 Issue No 1 July 2014 4 3 Navigating biosim The areas of biosim that are important for therapists to know about are listed below A more comprehensive overview of biosim can be found in the i limb ultra revolution Clinician s Manual at www touchbionics com documents document library The You re now connected screen will now be showing with eight options as illustrated this is the homepage and can be accessed at any time from subsequent pages Myotesting icon provides a quick and easy myosite test along with a more detailed analysis screen This is excellent for providing biofeedback during therapy sessions Control strategy details the choice and information around the range of control optio
Download Pdf Manuals
Related Search