This study has received funding from the European Research Council (ERC) under the European Union&#39;s Horizon 2020 research and innovation program&#160;(grant agreement No. 810346). The authors thank Aron Cserveny for preparing the illustrations used in this publication.

<ol>
	<li>Vujaklija, I., Farina, D., Aszmann, O. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=New+developments+in+prosthetic+arm+systems.">New developments in prosthetic arm systems.</a> Orthopedic Research and Reviews. 8, 31-39 (2016).</li><li>Zhou, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Decoding+a+new+neural+machine+interface+for+control+of+artificial+limbs.">Decoding a new neural machine interface for control of artificial limbs.</a> Journal of Neurophysiology. 98 (5), 2974-2982 (2007).</li><li>Sturma, A., Salminger, S., Aszmann, O. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Proximale+Amputationen+des+Armes:+Technische,+chirurgische+und+handtherapeutische+M&#246;glichkeiten.">Proximale Amputationen des Armes: Technische, chirurgische und handtherapeutische M&#246;glichkeiten.</a> Zeitschrift f&#252;r Handtherapie. 21 (1), 18-25 (2018).</li><li>Uellendahl, J. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Upper+extremity+myoelectric+prosthetics.">Upper extremity myoelectric prosthetics.</a> Physical Medicine &amp; Rehabilitation Clinics of North America. 11 (3), 639-652 (2000).</li><li>Biddiss, E., Chau, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Upper-limb+prosthetics:+critical+factors+in+device+abandonment.">Upper-limb prosthetics: critical factors in device abandonment.</a> American Journal of Physical Medicine &amp; Rehabilitation. 86 (12), 977-987 (2007).</li><li>Kuiken, T. A., Dumanian, G. A., Lipschutz, R. D., Miller, L. A., Stubblefield, K. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+use+of+targeted+muscle+reinnervation+for+improved+myoelectric+prosthesis+control+in+a+bilateral+shoulder+disarticulation+amputee.">The use of targeted muscle reinnervation for improved myoelectric prosthesis control in a bilateral shoulder disarticulation amputee.</a> Prosthetics and Orthotics International. 28 (3), 245-253 (2004).</li><li>Aszmann, O. C., Dietl, H., Frey, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Selective+nerve+transfers+to+improve+the+control+of+myoelectrical+arm+prostheses.">Selective nerve transfers to improve the control of myoelectrical arm prostheses.</a> Handchirurgie, Mikrochirurgie, plastische Chirurgie. 40 (1), 60-65 (2008).</li><li>Cheesborough, J. E., Smith, L. H., Kuiken, T. A., Dumanian, G. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Targeted+muscle+reinnervation+and+advanced+prosthetic+arms.">Targeted muscle reinnervation and advanced prosthetic arms.</a> Seminars in Plastic Surgery. 29 (1), 62-72 (2015).</li><li>Salminger, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Outcomes,+challenges+and+pitfalls+after+targeted+muscle+reinnervation+in+high+level+amputees.+Is+it+worth+the+effort.">Outcomes, challenges and pitfalls after targeted muscle reinnervation in high level amputees. Is it worth the effort.</a> Plastic and Reconstructive Surgery. 144 (6), 1037-1043 (2019).</li><li>Sturma, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Rehabilitation+of+high+upper+limb+amputees+after+Targeted+Muscle+Reinnervation.">Rehabilitation of high upper limb amputees after Targeted Muscle Reinnervation.</a> Journal of Hand Therapy: Official Journal of the American Society of Hand Therapists. , (2020).</li><li>Ramachandran, V. S., Rogers-Ramachandran, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Synaesthesia+in+phantom+limbs+induced+with+mirrors.">Synaesthesia in phantom limbs induced with mirrors.</a> Proceedings Biological Sciences. 263 (1369), 377-386 (1996).</li><li>Rothgangel, A. S., Braun, S. M., Beurskens, A. J., Seitz, R. J., Wade, D. T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+clinical+aspects+of+mirror+therapy+in+rehabilitation.">The clinical aspects of mirror therapy in rehabilitation.</a> International Journal of Rehabilitation Research. 34 (1), 1-13 (2011).</li><li>Dickstein, R., Deutsch, J. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Motor+imagery+in+physical+therapist+practice.">Motor imagery in physical therapist practice.</a> Physical Therapy. 87 (7), 942-953 (2007).</li><li>Bowering, K. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+effects+of+graded+motor+imagery+and+its+components+on+chronic+pain:+A+systematic+review+and+meta-analysis.">The effects of graded motor imagery and its components on chronic pain: A systematic review and meta-analysis.</a> The Journal of Pain. 14 (1), 3-13 (2013).</li><li>Moseley, G. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> The graded motor imagery handbook. , (2012).</li><li>Merletti, R., Parker, P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Electromyography: Physiology, engineering, and non-invasive applications. , (2004).</li><li>Sturma, A., Hruby, L. A., Prahm, C., Mayer, J. A., Aszmann, O. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Rehabilitation+of+upper+extremity+nerve+injuries+using+surface+EMG+biofeedback:+Protocols+for+clinical+application.">Rehabilitation of upper extremity nerve injuries using surface EMG biofeedback: Protocols for clinical application.</a> Frontiers in Neuroscience. 12 (906), (2018).</li><li>Farina, D., Aszmann, O. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Bionic+limbs:+clinical+reality+and+academic+promises.">Bionic limbs: clinical reality and academic promises.</a> Science Translational Medicine. 6 (257), 212 (2014).</li><li>Kyberd, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Practice+evaluation.+Case+studies+to+demonstrate+the+range+of+applications+of+the+Southampton+Hand+Assessment+Procedure.">Practice evaluation. Case studies to demonstrate the range of applications of the Southampton Hand Assessment Procedure.</a> British Journal of Occupational Therapy. 72 (5), 212-218 (2009).</li><li>Lyle, R. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+performance+test+for+assessment+of+upper+limb+function+in+physical+rehabilitation+treatment+and+research.">A performance test for assessment of upper limb function in physical rehabilitation treatment and research.</a> Internationale Journal of Rehabilitation Research. 4, 483-492 (1981).</li><li>Yozbatiran, N., Der-Yeghiaian, L., Cramer, S. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+standardized+approach+to+performing+the+action+research+arm+test.">A standardized approach to performing the action research arm test.</a> Neurorehabil Neural Repair. 22 (1), 78-90 (2008).</li><li>Hermansson, L. M., Bernspang, B., Eliasson, A. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Assessment+of+capacity+for+myoelectric+control:+a+new+Rasch-built+measure+of+prosthetic+hand+control.">Assessment of capacity for myoelectric control: a new Rasch-built measure of prosthetic hand control.</a> Journal of rehabilitation medicine. 37 (3), 166-171 (2005).</li><li>Hermansson, L. M., Fisher, A. G., Bernsp&#229;ng, B., Eliasson, A. -. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Intra-+and+inter-rater+reliability+of+the+assessment+of+capacity+for+myoelectric+control.">Intra- and inter-rater reliability of the assessment of capacity for myoelectric control.</a> Journal of Rehabilitation Medicine. 38 (2), 118-123 (2006).</li><li>McHorney, C. A., Ware Jr, ., E, J., Raczek, A. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+MOS+36-item+short-form+health+survey+(SF-36):+II.+Psychometric+and+clinical+tests+of+validity+in+measuring+physical+and+mental+health+constructs.">The MOS 36-item short-form health survey (SF-36): II. Psychometric and clinical tests of validity in measuring physical and mental health constructs.</a> Medical Care. 31, 247-263 (1993).</li><li>Gummesson, C., Atroshi, I., Ekdahl, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+disabilities+of+the+arm,+shoulder+and+hand+(DASH)+outcome+questionnaire:+longitudinal+construct+validity+and+measuring+self-rated+health+change+after+surgery.">The disabilities of the arm, shoulder and hand (DASH) outcome questionnaire: longitudinal construct validity and measuring self-rated health change after surgery.</a> BMC Musculoskeletal Disorders. 4 (1), 11 (2003).</li><li>Stubblefield, K. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Occupational+therapy+outcomes+with+targeted+hyper-reinnervation+nerve+transfer+surgery:+Two+case+studies.">Occupational therapy outcomes with targeted hyper-reinnervation nerve transfer surgery: Two case studies.</a> MEC '05 Intergrating Prosthetics and Medicine, Proceedings of the 2005 MyoElectric Controls/Powered Prosthetics. , (2005).</li><li>Geary, M., Gaston, R. G., Loeffler, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgical+and+technological+advances+in+the+management+of+upper+limb+amputees.">Surgical and technological advances in the management of upper limb amputees.</a> The Bone &amp; Joint Journal. 103 (3), 430-439 (2021).</li><li>Stubblefield, K. A., Miller, L. A., Lipschutz, R. D., Kuiken, T. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Occupational+therapy+protocol+for+amputees+with+targeted+muscle+reinnervation.">Occupational therapy protocol for amputees with targeted muscle reinnervation.</a> Journal of Rehabilitation Research &amp; Development. 46 (4), 481-488 (2009).</li><li>Dumanian, G. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Targeted+muscle+reinnervation+treats+neuroma+and+phantom+pain+in+major+limb+amputees:+A+randomized+clinical+trial.">Targeted muscle reinnervation treats neuroma and phantom pain in major limb amputees: A randomized clinical trial.</a> Annals of Surgery. 270 (2), 238-246 (2018).</li><li>Pet, M. A., Ko, J. H., Friedly, J. L., Mourad, P. D., Smith, D. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Does+targeted+nerve+implantation+reduce+neuroma+pain+in+amputees.">Does targeted nerve implantation reduce neuroma pain in amputees.</a> Clinical Orthopaedics and Related Research. 472 (10), 2991-3001 (2014).</li><li>Souza, J. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Targeted+muscle+reinnervation:+a+novel+approach+to+postamputation+neuroma+pain.">Targeted muscle reinnervation: a novel approach to postamputation neuroma pain.</a> Clinical Orthopaedics and Related Research. 472 (10), 2984-2990 (2014).</li><li>Sturma, A., Hruby, L. A., Vujaklija, I., &#216;stlie, K., Farina, D., Aszmann, O. C., Farina, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Treatment+strategies+for+phantom+limb+pain.">Treatment strategies for phantom limb pain.</a> Bionic Limb Reconstruction. , 113-124 (2021).</li><li>Li, Y., Branemark, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Osseointegrated+prostheses+for+rehabilitation+following+amputation+:+The+pioneering+Swedish+model.">Osseointegrated prostheses for rehabilitation following amputation : The pioneering Swedish model.</a> Der Unfallchirurg. 120 (4), 285-292 (2017).</li><li>Vincitorio, F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Targeted+muscle+reinnervation+and+osseointegration+for+pain+relief+and+prosthetic+arm+control+in+a+woman+with+bilateral+proximal+upper+limb+amputation.">Targeted muscle reinnervation and osseointegration for pain relief and prosthetic arm control in a woman with bilateral proximal upper limb amputation.</a> World Neurosurgery. 143, 365-373 (2020).</li><li>Jonsson, S., Caine-Winterberger, K., Branemark, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Osseointegration+amputation+prostheses+on+the+upper+limbs:+methods,+prosthetics+and+rehabilitation.">Osseointegration amputation prostheses on the upper limbs: methods, prosthetics and rehabilitation.</a> Prosthetics and Orthotics International. 35 (2), 190-200 (2011).</li><li>Stubblefield, K., Kuiken, T., Kuiken, T., Schultz-Feuser, A., Barlow, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Occupational+therapy+for+the+targeted+muscle+reinnervation+patient.">Occupational therapy for the targeted muscle reinnervation patient.</a> Targeted Muscle Reinnervation. , 99-119 (2014).</li></ol>

The authors do not have any conflicts of interest.

In recent years, selective nerve transfers have been increasingly used to enhance prosthetic function27. Experienced clinicians in this field have come to appreciate that rehabilitation is essential to enable amputees to use a prosthesis after the surgical procedure skilfully27. However, there is a lack of structured therapy programs. The current protocol aimed to provide the occupational and physical therapists with the tools and structure to guide the patients throughout the long TMR process. In contrast to previous suggestions for therapy (developed for less complex nerve transfers)28, there is a stronger focus on pre-prosthetic training and the use of EMG biofeedback to allow selective muscular control.
As shown in the feasibility study9, discussing the patient&#39;s expectations is essential for post-operative success. The inclusion of highly motivated patients certainly helped to achieve the described excellent outcomes. Less compliance to the described protocol might result in reduced prosthetic function. Additionally, not all patients wish to receive a prosthetic fitting (or can afford to get one). However, TMR may still be feasible to improve neuroma or phantom limb pain since recent studies have shown the potential of nerve transfers to alleviate these conditions29,30,31. For such cases, the rehabilitation program is foreshortened. Still, we have experienced that regular training of controlled activation of the reinnervated muscles and a prosthesis can further improve the pain situation32. Here, shared decision-making is essential as some patients might wear a prosthesis for its potential to reduce pain in the long term32, while others might not be interested.
In our experience, a detailed discussion with the patient is essential to evaluate future compliance. Depending on the reinnervation time, motor learning capacity, and the patient&#39;s availability, the rehabilitation process is likely to take between 9-15 months. Suppose a patient does not strive toward the improvement of upper limb function or might make better use of another device (e.g., body-powered prosthetics). In that case, one might not consider the time (and possibly financial) commitment worth it. To save resources, we strongly recommend only including patients who express a strong interest in the procedure and only perform the surgery for functional purposes when the full rehabilitation procedure is anticipated. Finally, the costs for the surgery, therapy, and fitting should likely be covered at that point.
The described study protocol needs to be adapted for each individual based on clinical reasoning to meet their specific needs. Physical and psychological co-morbidities need to be considered and adequate treatment (e.g., psychotherapy) offered in addition to the interventions described here. In patients receiving TMR immediately after amputation, a closer screening for psychological conditions developing overtime may be needed. Apart from this, no change in the protocol is required for this group of patients. They might even progress faster in motor learning as they might still be used to bimanual activities. Within this protocol, the nerve transfers operated by the surgeon define, which motor commands need to be trained and are expected for which muscle parts. The choice of the prosthetic end device influences prosthetic training. For multi-articulated prostheses, switching between different grasp types and how to use them needs to be included in therapy, if necessary.
For patients living far away from the clinical center or those who cannot attend in-person rehabilitation regularly, adoptions in the rehabilitation protocol are needed. They include a stronger focus on home training, the possible involvement of a therapist near the patient&#39;s home, and telerehabilitation sessions via online video calls. Solutions for telerehabilitation need to provide a stable video and audio connection while fulfilling all data protection requirements. In these patients, a first visit to the clinical center should be planned at 6-9 months after surgery for signal training. The visit is usually for 1 week, with therapy sessions twice a day. In a majority of cases, good signal separation can be achieved at this time. Otherwise, another stay for signal training is needed, and the patient may get a simple sEMG biofeedback device for home training. When good signal separation is established, the prosthetist can fabricate a test socket, and the signal positions can be defined during the stay. This allows the prosthetist to create the final fitting when the patient returns home. The final prosthesis can be fitted in a second 1-week visit 1-2 months later, and prosthetic training can be initiated. Advanced prosthetic training and further follow-up visits can either happen in a remote setting or during a further visit to the center, depending on the patient&#39;s needs.
Furthermore, other surgical interventions, such as osseointegration33 to improve the mechanical interface for the prosthesis, can be combined with TMR34. If this is the case, specific interventions must be included (such as the graded weight-bearing training after osseointegration35). Additionally, while the described protocol is intended for direct prosthetic control systems (where one electrode corresponds to one movement), its principles remain the same if a pattern recognition control system is planned. The main difference in rehabilitation is that the selective activation of single muscles becomes less relevant, while particular and repeatable activation patterns of several muscles need to be trained36.

High amputations of the upper limb provide a challenge for prosthetic replacement1. Aside from elbow joint function, active prosthetic systems should include opening/closing of the prosthetic hand and ideally also pronation/supination and/or wrist extension/flexion. However, the control of standard myoelectric devices usually relies on the input signals from two muscles only2. These are traditionally the biceps and triceps muscles after transhumeral amputations and the latissimus dorsi and pectoralis major muscles after glenohumeral amputations3. To control all prosthetic joints, amputees need to switch between the active joints (e.g., by using a co-contraction of the two muscles)1. While this provides a stable control paradigm, a significant restriction ensues with resulting slow and unintuitive control, which does not allow simultaneous movements of two or more prosthetic joints4. This limits the functionality of the prosthesis and is one of the reasons for high prosthetic abandonment rates after above-elbow amputations5.
To overcome limited and unintuitive control for these types of prosthetic fittings, selective nerve transfers can be utilized. This approach, also known as Targeted Muscle Reinnervation (TMR), consists in surgically establishing myo-control signals by re-routing nerves that initially served the amputated hand and arm to different target muscles within the residual limb6,7. After successful reinnervation, more selective activation of the reinnervated muscle units becomes possible8. The resulting electromyographic (EMG) activity can then be used for prosthetic control and can yield up to six control signals.
While there is a broad agreement that TMR can significantly improve prosthetic function9, selective activation and appropriate control of multiple muscles in the stump pose a challenge to patients, especially in the early post-operative period. This enhanced complexity of prosthetic control paired with the reduced multisensory feedback following amputation requires a specific rehabilitation to fully benefit from the surgical procedure. Here, a step-by-step guideline for the therapy interventions is provided based on recent recommendations10. An overview of the interventions and the estimated time they take in an ideal setting can be found in Figure 1.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/62896/62896fig1v2.jpg" /> 
Figure 1: Overview of stages within the rehabilitation process, including the milestones that mark the start of a new stage. <a href="https://www.jove.com/files/ftp_upload/62896/62896fig1v2large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Dynamic Arm Plus&#174; system with a Variplus Speed prosthetic hand</td>
			<td>Ottobock Healthcare, Duderstadt, Germany</td>
			<td></td>
			<td>This prosthetic system was used together with a computer (and Bluetooth connection) for sEMG Biofeedback. Later, it was used for table top prosthetic training and as the patient&#39;s prosthetic fitting.</td>
		</tr>
		<tr>
			<td>ElbowSoft TMR</td>
			<td>Ottobock Healthcare, Duderstadt, Germany</td>
			<td></td>
			<td>In combination with the Dynamic Arm Plus system and a standard computer (with Windows 7, 8 or 10), this software allows the visualisation of EMG signals as well as changing settings in the prosthetic system.</td>
		</tr>
		<tr>
			<td>EMG electrodes</td>
			<td>Ottobock Healthcare, Duderstadt, Germany</td>
			<td>electrodes 13E202 = 50</td>
			<td>The EMG electrodes used in this study were bipolar and included a ground and a 50 Hz filter. They were used with the Dynamic Arm Plus&#174;.</td>
		</tr>
		<tr>
			<td>Folding Mirror Therapy Box (Arm/Foot/Ankle)</td>
			<td>Reflex Pain Management Therapy Store</td>
			<td></td>
			<td>This box was used for mirror therapy.</td>
		</tr>
	</tbody>
</table>

therapy interventions for upper limb amputees undergoing selective nerve transfers

Targeted Muscle Reinnervation (TMR) improves the biological control interface for myoelectric prostheses after above-elbow amputation. Selective activation of muscle units is made possible by surgically re-routing nerves, yielding a high number of independent myoelectric control signals. However, this intervention requires careful patient selection and specific rehabilitation therapy. Here a rehabilitation protocol is presented for high-level upper limb amputees undergoing TMR, based on an expert Delphi study. Interventions before surgery include detailed patient assessment and general measures for pain control, muscle endurance and strength, balance, and range of motion of the remaining joints. After surgery, additional therapeutic interventions focus on edema control and scar treatment and the selective activation of cortical areas responsible for upper limb control. Following successful&#160;reinnervation of target muscles, surface electromyographic (sEMG) biofeedback is used to train the activation of the novel muscular units. Later on, a table-top prosthesis may provide the first experience of prosthetic control. After fitting the actual prosthesis, training includes repetitive drills without objects, object manipulation, and finally, activities of daily living. Ultimately, regular patient appointments and functional assessments allow tracking prosthetic function and enabling early interventions if malfunctioning.

The described rehabilitation protocol was implemented in a clinical setting at the Medical University of Vienna, and its feasibility and outcomes were assessed in a clinical study, which was recently published9. As reported9, 30 patients participated in the trial to evaluate the feasibility of TMR surgery and subsequent rehabilitation. Figure 5 displays that out of these 30 patients, 11 underwent TMR as a pain treatment rather than a means to improve function via prosthetic fitting. Out of the remaining 19 patients originally aiming for a prosthetic fitting, five decided against it due to the high costs of the fitting (estimated between 75,000-150,000 &#8364;), insufficient time for rehabilitation, or high weight of the prosthesis. In one patient, intra-operative exploration revealed a global brachial plexus injury, making further nerve transfers impossible. This patient kept using his body-powered device. Of the remaining 13 patients undergoing prosthetic rehabilitation, 10 were available for a follow-up assessment.
<img alt="Figure 5" class="xfigimg" src="/files/ftp_upload/62896/62896fig05.jpg" /> 
Figure 5: Flowchart showing the patients included in the feasibility study. <a href="https://www.jove.com/files/ftp_upload/62896/62896fig05large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
Outcomes were assessed using the Southampton Hand Assessment Procedure (SHAP)19, the Action Research Arm Test (ARAT)20,21, and the Clothespin-Relocation Test (CPRT)6,26. These assessments are commonly used tests to evaluate prosthetic function. The evaluation took place at least 6 months after the final prosthetic fitting. Additionally, patients were asked about their prosthetic wearing habits.
As described by Salminger et al.9, assessment of the 10 patients after TMR surgery revealed a SHAP score of 40.5 &#177; 8.1 (with a healthy upper extremity having a score of about 100) and ARAT score of 20.4 &#177; 1.9 (with 57 being the maximum score and 0 representing no upper extremity function) (Table 1). In the CPRT, patients were able to complete the tasks within 34.3 &#177; 14.4 s. They reported wearing their prosthesis daily with a wearing time ranging from 3-10 hours per day.
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Outcome assesment</td>
			<td>Score</td>
			<td>Expected score for healthy upper extremity</td>
		</tr>
		<tr>
			<td>SHAP</td>
			<td>40.5 &#177; 8.1</td>
			<td>100</td>
		</tr>
		<tr>
			<td>ARAT</td>
			<td>20.4 &#177; 1.9</td>
			<td>57</td>
		</tr>
		<tr>
			<td>CPRT</td>
			<td>34.3 &#177; 14.4 s</td>
			<td>-</td>
		</tr>
	</tbody>
</table>
Table 1: Prosthetic function of patients following TMR surgery and rehabilitation. In the SHAP and ARAT, higher scores mean a better function, which is also indicated by less time needed in the CPRT. Total patient assessed: n = 10. Adapted with permission from Reference9.

Watch this Scientific Journal Video about Therapy Interventions for Upper Limb Amputees Undergoing Selective Nerve Transfers at JoVE.com

Therapy Interventions for Upper Limb Amputees Undergoing Selective Nerve Transfers

This work presents a protocol to enhance prosthetic function after selective nerve transfer surgery. Rehabilitation interventions include patient information and selection, support of wound healing, cortical re-activation of sensory-motor areas of the upper limb, training of selective muscle activation, prosthetic handling in daily life, and regular follow-up assessments.

Targeted Muscle Reinnervation (TMR) improves the biological control interface for myoelectric prostheses after above-elbow amputation. Selective ...

therapy-interventions-for-upper-limb-amputees-undergoing-selective

Microsoft Bing

Research

Education

JoVE Core

JoVE Journal

Anatomy and Physiology

Medicine

Unit 1

The Appendicular Skeleton

SCIENTISTS IN ACTION

3.3K Views.  Medical University of Vienna. This work presents a protocol to enhance prosthetic function after selective nerve transfer surgery. Rehabilitation interventions include patient information and selection, support of wound healing, cortical re-activation of sensory-motor areas of the upper limb, training of selective muscle activation, prosthetic handling in daily life, and regular follow-up assessments.

Video: Therapy Interventions for Upper Limb Amputees Undergoing Selective Nerve Transfers

Production and Detection of Reactive Oxygen Species (ROS) in Cancers

Reactive oxygen species include a number of molecules that damage DNA and RNA and oxidize proteins and lipids (lipid peroxydation). These reactive molecules contain an oxygen and include H2O2 (hydrogen peroxide), NO (nitric oxide), O2- (oxide anion), peroxynitrite (ONOO-), hydrochlorous acid (HOCl), and hydroxyl radical (OH-).
Oxidative species are produced not only under pathological situations (cancers, ischemic/reperfusion, neurologic and cardiovascular pathologies, infectious diseases, inflammatory diseases 1, autoimmune diseases 2, etc&hellip;) but also during physiological (non-pathological) situations such as cellular metabolism 3, 4. Indeed, ROS play important roles in many cellular signaling pathways (proliferation, cell activation 5, 6, migration 7 etc..). ROS can be detrimental (it is then referred to as "oxidative and nitrosative stress") when produced in high amounts in the intracellular compartments and cells generally respond to ROS by upregulating antioxidants such as superoxide dismutase (SOD) and catalase (CAT), glutathione peroxidase (GPx) and glutathione (GSH) that protects them by converting dangerous free radicals to harmless molecules (i.e. water). Vitamins C and E have also been described as ROS scavengers (antioxidants).
Free radicals are beneficial in low amounts 3. Macrophage and neutrophils-mediated immune responses involve the production and release of NO, which inhibits viruses, pathogens and tumor proliferation 8. NO also reacts with other ROS and thus, also has a role as a detoxifier (ROS scavenger). Finally NO acts on vessels to regulate blood flow which is important for the adaptation of muscle to prolonged exercise 9, 10. Several publications have also demonstrated that ROS are involved in insulin sensitivity 11, 12.
Numerous methods to evaluate ROS production are available. In this article we propose several simple, fast, and affordable assays; these assays have been validated by many publications and are routinely used to detect ROS or its effects in mammalian cells. While some of these assays detect multiple ROS, others detect only a single ROS.

Production and Detection of Reactive Oxygen Species ROS in Cancers

Here we propose simple methods to test and evaluate the presence of reactive oxygen species in cells.

Reactive oxygen species include a number of molecules that damage DNA and RNA and oxidize proteins and lipids (lipid peroxydation). These reactive ...

Orthotopic Hind Limb Transplantation in the Mouse

In vivo animal model systems, and in particular mouse models, have evolved into powerful and versatile scientific tools indispensable to basic and translational research in the field of transplantation medicine. A vast array of reagents is available exclusively in this setting, including mono- and polyclonal antibodies for both diagnostic and interventional applications. In addition, a vast number of genotyped, inbred, transgenic, and knock out strains allow detailed investigation of the individual contributions of humoral and cellular components to the complex interplay of an immune response and make the mouse the gold standard for immunological research. 
Vascularized Composite Allotransplantation (VCA) delineates a novel field of transplantation using allografts to replace "like with like" in patients suffering traumatic or congenital tissue loss. This surgical methodological protocol shows the use of a non-suture cuff technique for super-microvascular anastomosis in an orthotopic mouse hind limb transplantation model. The model specifically allows for comparison between established paradigms in solid organ transplantation with a novel form of transplants consisting of various different tissue components. Uniquely, this model allows for the transplantation of a viable vascularized bone marrow compartment and niche that have the potential to exert a beneficial effect on the balance of immune acceptance and rejection. This technique provides a tool to investigate alloantigen recognition and allograft rejection and acceptance, as well as enables the pursuit of functional nerve regeneration studies to further advance this novel field of transplantation.

This novel model for orthotopic hind limb transplantation in the mouse, applying a non-suture cuff technique for super-microvascular anastomosis, provides a powerful tool for in&#160;vivo mechanistic immunological research related to vascularized composite allotransplantation (VCA).

In vivo animal model systems, and in particular mouse models, have evolved into powerful and versatile scientific tools indispensable to basic and ...

A Method for Quantifying Upper Limb Performance in Daily Life Using Accelerometers

A key reason for referral to rehabilitation services after stroke and other neurological conditions is to improve one's ability to function in daily life. It has become important to measure a person's activities in daily life, and not just measure their capacity for activity in the structured environment of a clinic or laboratory. A wearable sensor that is now enabling measurement of daily movement is the accelerometer. Accelerometers are commercially-available devices resembling large wrist watches that can be worn throughout the day. Data from accelerometers can quantify how the limbs are engaged to perform activities in peoples' homes and communities. This report describes a methodology to collect accelerometry data and turn it into clinically-relevant information. First, data are collected by having the participant wear two accelerometers (one on each wrist) for 24 h or longer. The accelerometry data are then downloaded and processed to produce four different variables that describe key aspects of upper limb activity in daily life: hours of use, use ratio, magnitude ratio, and the bilateral magnitude. Density plots can be constructed that visually represent the data from the 24 h wearing period. The variables and their resultant density plots are highly consistent in neurologically-intact, community-dwelling adults. This striking consistency makes them a useful tool for determining if upper limb daily performance is different from normal. This methodology is appropriate for research studies investigating upper limb dysfunction and interventions designed to improve upper limb performance in daily life in people with stroke and other patient populations. Because of its relative simplicity, it may not be long before it is also incorporated in clinical neurorehabilitation practice.

This protocol describes a method to quantify upper limb performance in daily life using wrist-worn accelerometers.

A key reason for referral to rehabilitation services after stroke and other neurological conditions is to improve one's ability to function in daily life. ...

Mechanical Micronization of Lipoaspirates for Regenerative Therapy

Stromal vascular fraction (SVF) has become a regenerative tool for various diseases; however, legislation strictly regulates the clinical application of cell products using collagenase. Here, we present a protocol to generate an injectable mixture of SVF cells and native extracellular matrix from adipose tissue by a purely mechanical process. Lipoaspirates are put into a centrifuge and spun at 1,200 x g for 3 min. The middle layer is collected and separated into two layers (high-density fat at the bottom and low-density fat on the top). The upper layer is directly emulsified by intersyringe shifting, at a rate of 20 mL/s for 6x to 8x. The emulsified fat is centrifuged at 2,000 x g for 3 min, and the sticky substance under the oil layer is collected and defined as the extracellular matrix (ECM)/SVF-gel. The oil on the top layer is collected. Approximately 5 mL of oil is added to 15 mL of high-density fat and emulsified by intersyringe shifting, at a rate of 20 mL/s for 6x to 8x. The emulsified fat is centrifuged at 2,000 x g for 3 min, and the sticky substance is also ECM/SVF-gel. After the transplantation of the ECM/SVF-gel into nude mice, the graft is harvested and assessed by histologic examination. The result shows that this product has the potential to regenerate into normal adipose tissue. This procedure is a simple, effective mechanical dissociation procedure to condense the SVF cells embedded in their natural supportive ECM for regenerative purposes.

Here, we present a protocol to obtain stromal vascular fraction from adipose tissue through a series of mechanical processes, which include emulsification and multiple centrifugations.

Stromal vascular fraction (SVF) has become a regenerative tool for various diseases; however, legislation strictly regulates the clinical application of ...

Preclinical Model of Hind Limb Ischemia in Diabetic Rabbits

Peripheral vascular disease is a widespread clinical problem that affects millions of patients worldwide. A major consequence of peripheral vascular disease is the development of ischemia. In severe cases, patients can develop critical limb ischemia in which they experience constant pain and an increased risk of limb amputation. Current therapies for peripheral ischemia include bypass surgery or percutaneous interventions such as angioplasty with stenting or atherectomy to restore blood flow. However, these treatments often fail to the continued progression of vascular disease or restenosis or are contraindicated due to the overall poor health of the patient. A promising potential approach to treat peripheral ischemia involves the induction of therapeutic neovascularization to allow the patient to develop collateral vasculature. This newly formed network alleviates peripheral ischemia by restoring perfusion to the affected area. The most frequently employed preclinical model for peripheral ischemia utilizes the creation of hind limb ischemia in healthy rabbits through femoral artery ligation. In the past, however, there has been a strong disconnect between the success of preclinical studies and the failure of clinical trials regarding treatments for peripheral ischemia. Healthy animals typically have robust vascular regeneration in response to surgically induced ischemia, in contrast to the reduced vascularity and regeneration in patients with chronic peripheral ischemia. Here, we describe an optimized animal model for peripheral ischemia in rabbits that includes hyperlipidemia and diabetes. This model has reduced collateral formation and blood pressure recovery in comparison to a model with a higher cholesterol diet. Thus, the model may provide better correlation with human patients with compromised angiogenesis from the common co-morbidities that accompany peripheral vascular disease.

We describe a surgical procedure used to induce peripheral ischemia in rabbits with hyperlipidemia and diabetes. This surgery acts as a preclinical model for conditions experienced in peripheral artery disease in patients. Angiography is also described as a means to measure the extent of introduced ischemia and recovery of perfusion.

Peripheral vascular disease is a widespread clinical problem that affects millions of patients worldwide. A major consequence of peripheral vascular ...

Structured Motor Rehabilitation After Selective Nerve Transfers

After severe nerve injuries, selective nerve transfers provide an opportunity to restore motor and sensory function. Functional recovery depends both on the successful re-innervation of the targets in the periphery and on the motor re-learning process entailing cortical plasticity. While there is an increasing number of methods to improve rehabilitation, their routine implementation in a clinical setting remains a challenge due to their complexity and long duration. Therefore, recommendations for rehabilitation strategies are presented with the aim of guiding medical doctors and therapists through the long-lasting rehabilitation process and providing step-by-step instructions for supporting motor re-learning.
Directly after nerve transfer surgery, no motor function is present, and therapy should focus on promoting activity in the sensory-motor cortex areas of the paralyzed body part. After about two to six months (depending on the severity and modality of injury, the distance of nerve regeneration and many other factors), the first motor activity can be detected via electromyography (EMG). Within this phase of rehabilitation, multimodal feedback is used to re-learn the motor function. This is especially critical after nerve transfers, as muscle activation patterns change due to the altered neural connection. Finally, muscle strength should be sufficient to overcome gravity/resistance of antagonistic muscles and joint stiffness, and more functional tasks can be implemented in rehabilitation.

Here, we present a protocol for the motor rehabilitation of patients with severe nerve injuries and selective nerve transfer surgery. It aims at restoring the motor function proposing several stages in patient education, early-stage therapy after surgery and interventions for rehabilitation after successful re-innervation of the nerve&#8217;s target.

After severe nerve injuries, selective nerve transfers provide an opportunity to restore motor and sensory function. Functional recovery depends both on ...

Iris Fixation via External Pentagram Suturing

Extensive anterior synechia of the iris can result in the gradual disappearance of the anterior chamber. It is one of the most common outcomes of both oculopathy and complicated post anterior segment surgery. This can impact visual function and lead to bullous keratopathy, making it one of the most complex clinical problems. Conventional anterior chamber plasty will partially create the anterior chamber, but the anterior chamber disappears again in some cases. The main reasons are: (1) the iris lens diaphragm is loose with atrophied and tension-free iris so that the aqueous humor circulation will push and squeeze the iris forward; (2) the effect of "roller" formed in the process of inflammation or restoration will change the iris structure from peripheral anterior synechia (PAS) to extensive anterior synechia again; (3) the fibration will result in synechia from iris to the cornea. In such cases, corneal endothelium deficiency can't stop the aqueous humor from entering the cornea. This results in persistent corneal edema post-conventional anterior chamber plasty, resulting in progressive rubbing and lachrymation. Therefore, anterior chamber plasty is not the first choice for patients without surgical indications of Descemet's stripping automated endothelial keratoplasty (DSAEK). However, this can be performed in patients with surgical indications who plan to receive DSAEK. A unique method of iris fixation via external pentagram suturing anterior chamber plasty (PSACP) is described here. The present technique is also compared with the conventional anterior chamber plasty. PSACP and DSAEK might be an effective way to cure the bullous keratopathy with extensive anterior synechia of the iris and disappeared anterior chamber.

Iris Fixation via External Pentagram Suturing

The present protocol describes how a 10-0 polypropylene suture crosses the anterior surface of the iris, forming a pentagram to prevent both iris and pupil from moving toward the cornea. This can be combined with subsequent keratoplasty to cure bullous keratopathy with extensive anterior synechia of the iris.

Extensive anterior synechia of the iris can result in the gradual disappearance of the anterior chamber. It is one of the most common outcomes of both ...

Preventing Posterior Capsular Opacification Through IOL Rotation in Cataract Surgeries

Rotating the Intraocular Lens to Prevent Posterior Capsular Opacification in Cataract Surgeries

Posterior capsule opacification (PCO) is a common postoperative complication of extracapsular cataract surgery, which is caused by the proliferation and migration of lens epithelial cells and can affect long-term visual outcomes significantly. The most effective treatment for PCO is neodymium-doped yttrium aluminum garnet (Nd:YAG) laser capsulotomy; however, this treatment is associated with posterior segment complication and can break the stability of capsular bag, affecting the position and function of trifocal or toric intraocular lenses (IOLs). Advances in surgical procedures, IOL design, and pharmacy have reduced the rate of PCO in recent years, concentrating on the inhibition of proliferative lens epithelial cells (LECs). This protocol aimed to clear LECs more thoroughly during phacoemulsification and IOL implantation. The first several steps, including clear corneal incision, continuous circular capsulorhexis, hydrodissection, hydrodelineation, and phacoemulsification, were completed as conventional procedures. After placing the IOL into the capsular bag, rotation of the IOL by at least 360&#176; was performed using an irrigation/aspiration tip or a hook, with slight stress on the posterior capsule. Some residuals occurred in the originally transparent capsular bag after rotation of the IOLs. Then, these materials and the viscoelastic were cleared completely using an irrigation/aspiration system. A clear posterior capsule was observed after the surgery in patients undergoing this method. This method of rotating IOLs is a simple, effective, and safe way to prevent PCO by clearing residual LECs and can be carried out without extra tools or skills.

Author Spotlight: Enhancing Visual Outcomes in Cataract Surgery: A Novel Technique to Prevent Posterior Capsular Opacification Through IOL Rotation 

The present protocol describes removing residual epithelial cells by rotating the intraocular lens in extracapsular cataract surgery without extra tools for preventing posterior capsular opacification.

Posterior capsule opacification (PCO) is a common postoperative complication of extracapsular cataract surgery, which is caused by the proliferation and ...

Enhancing Stroke Rehabilitation with Virtual Reality-Based Occupational Training

Cognitive Function and Upper Limb Rehabilitation Training Post-Stroke Using a Digital Occupational Training System

Stroke rehabilitation often requires frequent and intensive therapy to improve functional recovery. Virtual reality (VR) technology has shown the potential to meet these demands by providing engaging and motivating therapy options. The digital occupational training system is a VR application that utilizes cutting-edge technologies, including multi-touch screens, virtual reality, and human-computer interaction, to offer diverse training techniques for advanced cognitive capacity and hand-eye coordination abilities. The objective of this study was to assess the effectiveness of this program in enhancing cognitive function and upper extremity rehabilitation in stroke patients. The training and assessment consist of five cognitive modules covering perception, attention, memory, logical reasoning, and calculation, along with hand-eye coordination training. This research indicates that after eight weeks of training, the digital occupational training system can significantly improve cognitive function, daily living skills, attention, and self-care abilities in stroke patients. This software can be employed as a time-saving and clinically effective rehabilitation aid to complement traditional one-on-one occupational therapy sessions. In summary, the digital occupational training system shows promise and offers potential financial benefits as a tool to support the functional recovery of stroke patients.

Author Spotlight: Rehabilitation of Stroke Patients With a Digital Occupational Training System

The current protocol outlines how the VR-based digital occupational training system enhances the rehabilitation of patients with cognitive impairment and upper limb dysfunction following a stroke.

Stroke rehabilitation often requires frequent and intensive therapy to improve functional recovery. Virtual reality (VR) technology has shown the ...

Functional OT and Near-IR Spectroscopy to Study Brain Function Remodeling

Investigating the Effect of Different Types of Exercise on Upper Limb Functional Recovery in Patients with Right Hemisphere Damage Based on fNIRS

To investigate the effects of functional occupational therapy (FOT) combined with different types of exercise on upper limb motor function recovery and brain function remodeling in patients with right hemisphere damage (RHD) by analyzing functional near-infrared spectroscopy (fNIRS). Patients (n = 32) with RHD at Beijing Bo'ai Hospital were recruited and randomly allocated to receive either FOT combined with passive motion (N=16) or FOT combined with assisted active movement (N=16). The passive motion group (FOT-PM) received functional occupational therapy for 20 min and passive exercise for 10 min in each session, while the assisted active movement group (FOT-AAM) received functional occupational therapy for 20 min and assisted active exercise for 10 min. Both groups received conventional drug therapy and other rehabilitation therapy. Treatment was performed once a day, 5 times a week for 4 weeks. The recovery of motor function and activities of daily living (ADL) was assessed using Fugl-Meyer Assessment upper extremity (FMA-UE) and modified Barthel index (MBI) before and after treatment, and brain activation of the bilateral motor area was analyzed with fNIRS. The findings suggested that FOT combined with AAM was more effective than FOT combined with PM in improving the motor function of RHD patients' upper limbs and fingers, improving their ability to perform activities of daily living, and facilitating brain function remodeling of the motor area.

Author Spotlight: Advancing Upper Limb Rehabilitation in Patients with Right Hemisphere Damage Using Assisted Active Exercise

Here, we investigate the effect of functional occupational therapy combined with assisted active or passive motion on the upper limb function of patients with right hemisphere damage and explore the effect of functional near-infrared spectroscopy on brain function remodeling.

To investigate the effects of functional occupational therapy (FOT) combined with different types of exercise on upper limb motor function recovery and ...