Agonist-antagonist

Myoneural Interface
(AMI)
Cindy Murphy☺

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 Table of contents

01 What is AMI? 02 Research on AMI

How is it relevant
03 to us?

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What is traditional amputation?5

Native muscle tissues are configured isometrically in a

layered closure around the transected bone, forming a
padded distal region for prosthetic socket usage. This
disrupts natural agonist/antag dynamic interactions
between native musculature in the residuum.
It also fails to provide muscle end organs for transected
nerves. Thus limiting the ability of spindle and GTOs
within affected musculature to communicate meaningful
information to the CNS.

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 What is
01 AMI?

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Ted Talk6

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 In written form9
- A method to provide proprioception from a synthetic
device to the human NS.
- An AMI is made up of 2 muscles, mechanically
connected so that when the agonist contracts, the
antagonist is stretched, and vice versa.
- The purpose of an AMI is to control and interpret
proprioceptive feedback from a bionic joint. The
surgeon creates AMIs by linking together muscle
pairs within the amputated residuum.
- Multiple AMI muscle pairs can be created for the
control and sensation of multiple prosthetic joints.

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 Continuing Logistics5,7

- When the AMI agonist is electrically depolarized either from a descending CNS efferent
signal/from artificial muscle stimulations, the muscle contracts and mechanically
stretches the surgically linked antagonist. The AMI muscle dynamics, as sensed by
spindle and GTO afferents, provides the patient with natural proprioceptive sensations.
- Using various artificial sensing modalities, the AMI muscle dynamics are measured,
and these sensory data are communicated using wired/wireless neural communications
to an external prosthetic computer to inform a closed-loop powered prosthetic control.
- For every robotic DOF to be controlled within the external prosthesis, at least one AMI
muscle pair is constructed.

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4,8

- 2 AMIs are constructed in the residuum at

the time of primary transtibial amputation.
- Tarsal tunnels harvested from the
amputated ankle joint are affixed to the
medial flat of the tibia and serve as
pulleys.
- When the patient is connected to a robotic
prosthesis, the proximal and distal AMIs
are myoelectrically linked to the
prosthetic ankle and subtalar joints.

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02 What does the
research say?

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 Motor Control8,13

- Srinivasan et al (2020) found AB subjects were capable of significantly greater positional

differentiation and coordination of movements when performing motor tasks
- Likely facilitated by the higher quality and volume of musculotendinous afferent info
from spindle fibers and GTOs interacting with the CNS + more coordinated motor
activation in the peripheral neuromusculature
- Karczewski et al (2021) found that although studies are limited, early data suggests that the
AMI is capable of generating high quality efferent signals & integrating reflex arcs (ex: stair
ambulation).
- When compared with 4 TAs, an AMI patient exhibited natural reflexive behaviors and
improved prosthetic control. This suggests that proprioceptive feedback not only
restores sensation, but also enhances joint control and prosthetic function.

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 Range of Motion5,13
- Subjects were asked to demonstrate and mirror the ROM possible of the affected or
phantom joints on their unaffected limb, pre & postop at least 3x. The angles of PF and DF
were measured using the Biometrics 2-axis goni attached to the ankle region and averaged.
Data were processed to identify the maximum amplitude for each movement and
normalized as a % of the amplitude of the contralateral limb
- In a comparison of pre- & post amputation ROM percepts, AB subjects experienced
significant increases in the PF, EV, and DF directions. In contrast, an improvement in
ROM percepts following amputation was not detected in the TB cohort. Further, AB
subjects experienced significantly greater ROM than TB subjects following
amputation for PF, DF, and EV.
- Anecdotally, some subjects made statements such as “my foot feels free, it can finally
move.”

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 Proprioception1,2,5

- In the study of Srinivasan et al, researchers compared results from neuroimaging of people
with no, traditional, and AMI amputations
- Traditional had significant decrease in proprioceptive response in comparison
- Measured by activation of Brodmann area 3a
- AMI had minimal changes relative to people without amputations (controls)
- Correlates with fascicular strain in peripheral muscles and performance on motor
tasks
- Supports idea of strain/counterstrain proprioceptive info being important.
- Suggests that AMI is desirable with regards to proprioception and central sensorimotor
plasticity

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 Symptomatic Neuromas1,5,12

- In the study of Srinivasan et al, AMI vs traditional transtibial amputation

- Pain was less with AMI
- 6 / 15 subjects in the AMI cohort indicated 0 pain in all categories.
- Alteration of incorporating TMR and/or RPNI construction for neuroma
prophylaxis of sensory nerve termini at the time of amputation;
- Currently, they ablate 5 distal nerves with significant cutaneous territories
(tibial, superficial peroneal, deep peroneal, medial sural, and saphenous) via
these techniques at the same time as performing AMI construction.

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 Atrophy2,12

- In unlinked grafts, the high rate of atrophy (90%) compared to that of linked agonist-antagonist grafts (50%),
suggests that mechanical linkage strongly influences the process of atrophy.
- This may be due to afferent signaling from reciprocal innervation → volitional use → hypertrophy
- In Clites et al (2018), significant muscular atrophy was not observed within the residual limb of any of the
AMI patients.
- Why?
- Lack of isometric fixation of the muscles → concentric/eccentric/isometric contractions
- Non-isometric muscle loading has been shown to play a key role in maintaining/increasing
muscle mass
- Also potentially due to repeatable proprioceptive affirmation of muscle activity that comes with
each contraction of an AMI muscle helping preserve natural firing patterns during ADLs

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 Limitations of AMI5
- The only way to apply controlled force is via artificial stimulation
- Bilat muscle innervation so you feel agonist and antagonist
- Biologically normal intact muscles can also have force applied via natural forces (gravity,
inertia, etc.)
- Inability to emulate biological coupling of all muscles
- AMI is fixed - always has one type of contraction
- Causes unnatural stretch of antagonist muscle
- Feels unnatural to us
- Difficulties with construction of a regenerative AMI
- Have to deal with prior surgeon/surgery - could be cut very proximally
- 2 stage procedure
- Provides proprioceptive input, but other sensations are still absent, such as cutaneous contact, pressure,
shearing, etc.

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Clites et al, 2018

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03 How does this
relate to us?

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 Normal Amputation Rehab3
- Protective Healing (Week 1-2)
- NWB status of residual limbs x 4-6 weeks
post-op
- Important to maintain hip extension, complete
prone lying multiple times a day
- Avoid shear stress and protect incision site
- Per physicians recommendation, patient can be
fit with a shrinker or use figure 8 wrapping for
swelling management and shaping of the
residual limb (varies)
- ROM as tolerated (focus on maintaining pre
surgical hip extension ROM)
- Bed mobility
- Transfer and appropriate AD training
- Wheelchair mobility training
- Aerobic conditioning (ex: arm ergometer/rower)
- Core and limb strengthening (ex: mat therex
to include CKC)
- Neuromuscular re-education (ex: seated balance
activities)
- Begin desensitization and mirror therapy for
phantom limb and neuropathic pain
- Monitor symptom responses for 24-48 hours
after each exercise session. Pain should settle
quickly post exercise with no significant
increase in symptoms the next day
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 Post op Recovery1
- Hospital Stay
- Patients will receive IV antibiotics and pain medication
- All patients with AMI discharge directly home
- Home
- Weekly outpatient follow ups until suture removal and
adequate healing occurs
- Patient will then be cleared for prosthesis fitting
- Rehabilitation:
- PT begins at 4 weeks
- This occurs in the outpatient setting
- This is a modified program with standard strength/ROM
- Targeted muscle recruitment
- Cognitive training exercises

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 From a Friend10

- Evaluate pts to determine if they are candidates and for

pt education
- Typical eval of history taking, prior medical
interventions done, their goals, etc.
- Biggest difference was tests/measures
administered
- It differs maybe slightly between pts, but they
did TUGx2, 6MWTx1, 4 square test x 2, stair
climbing x2
- Essentially a lot of mobility during the eval

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 From one of the 211
- - Only 2 in MA that perform pre-op visits
- See the pts 4x, pre-op, post op to train the AMI constructs,
and after they receive a prosthesis, and at long term (6-12
mo) for outcome measures.
- Both acute care PTs, but see these pts in the outpatient clinic
during these sessions
- Acute care PTs see them for standard care post op after
amputation, but no change in protocol
- But they ask therapists to avoid high kneeling for a longer
period of time, avoid TENS, and any other desensitization
therapies.
- Their care is standard, but they teach them their own rehab
protocol during the 4 visits for the recruitment of AMI
constructs and neuromuscular retraining

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Ta Da!
Any Questions?

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 Resources
1. Clites, T. R., Herr, H. M., Srinivasan, S. S., Zorzos, A. N., & Carty, M. J. (2018). The Ewing Amputation: The First Human Implementation of the Agonist-Antagonist
Myoneural Interface. Plastic and reconstructive surgery. Global open, 6(11), e1997. https://doi.org/10.1097/GOX.0000000000001997
2. Clites, T. R., Carty, M. J., Ullauri, J. B., Carney, M. E., Mooney, L. M., Duval, J. F., Srinivasan, S. S., & Herr, H. M. (2018). Proprioception from a neurally controlled lower-
extremity prosthesis. Science translational medicine, 10(443), eaap8373. https://doi.org/10.1126/scitranslmed.aap8373
3. Flint, J. H., Pierrie, S. N., & Potter, K. (2022, May). Bilateral transfemoral amputation rehabilitation guidelines. Health.mil. Retrieved March 9, 2023, from
https://health.mil/Reference-Center/Publications/2022/03/17/Bil-TFA
4. Herr, H., & Carty, M. J. (2021). The Agonist-antagonist Myoneural Interface. Techniques in orthopaedics (Rockville, Md.), 36(4), 337–344.
https://doi.org/10.1097/bto.0000000000000552
5. Herr, Hugh PhD*,†,‡; Carty, Matthew J. MD*,†,‡. The Agonist-antagonist Myoneural Interface. Techniques in Orthopaedics 36(4):p 337-344, December 2021. | DOI:
10.1097/BTO.0000000000000552
6. Herr, H. (2018, May). How we'll become cyborgs and extend human potential [Video]. TED Conferences.
https://www.ted.com/talks/hugh_herr_how_we_ll_become_cyborgs_and_extend_human_potential?language=en
7. Jolie, B. (2021, January 8). Amputation and prosthetics - hubpages. HubPages. Retrieved March 9, 2023, from https://discover.hubpages.com/health/Amputation-and-
Prosthetics
8. Karczewski AM, Dingle AM and Poore SO (2021) The Need to Work Arm in Arm: Calling for Collaboration in Delivering Neuroprosthetic Limb Replacements. Front.
Neurorobot. 15:711028. doi: 10.3389/fnbot.2021.711028
9. Massachusetts Institute of Technology School of Architecture + Planning. (n.d.). Project Overview ' agonist-antagonist myoneural interface (AMI). MIT Media Lab.
Retrieved March 8, 2023, from https://www.media.mit.edu/projects/agonist-antagonist-myoneural-interface-ami/overview/
10. Murphy, C., & Conway, D. (2023, March 1). Ewing Amputation. personal.
11. Murphy, C., & Lawson, S. (2023, March 1). Ewing Amputation. personal.
12. Srinivasan, S.S., Diaz, M., Carty, M. et al. Towards functional restoration for persons with limb amputation: A dual-stage implementation of regenerative agonist-antagonist
myoneural interfaces. Sci Rep 9, 1981 (2019). https://doi.org/10.1038/s41598-018-38096-z
13. Srinivasan, S. S., Gutierrez-Arango, S., Teng, A. C., Israel, E., Song, H., Bailey, Z. K., Carty, M. J., Freed, L. E., & Herr, H. M. (2021). Neural interfacing architecture enables
enhanced motor control and residual limb functionality postamputation. Proceedings of the National Academy of Sciences of the United States of America, 118(9),
e2019555118. https://doi.org/10.1073/pnas.2019555118

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 Additional Resources

- https://www.media.mit.edu/publications/proprioception-from-a-neurally-controlled-lower-extremity-
prosthesis/ (first human implementation of the AMI, discussed in a paper recently published in Science
Translational Medicine (May 30, 2018))
- https://youtu.be/6ZymFkpcy9M
- https://www.fmriresearch.com/agonist-antagonist-myoneural-interface-amputation/
- DocumEntary: https://cdmrp.health.mil/pubs/press/2022/22prorp_pbs
- https://youtu.be/CwI_CXMZmI0 (UE AMI)

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