Figure 1: Results Livit patient reported outcome measurements on the effectiveness of lower leg prostheses 2019, more information on zorgprofessionals.livit.nl
The perceived ease of use and wearing omfort of the prosthesis sleeves in the period 2016 to 2018 has risen sharply. The group of customers who gave a 9 or a 10 for ease of use has increased by 50%. In 2016, 25% of our customers gave the prosthesis tube and prosthesis provision a 9 or a 10, for wearing comfort last year it rose to 69%. The lower leg prosthesis is made at Livit using digital technology. This way we can guarantee an optimal fit.
Bart de Kiefte, Tim de Roo, Maurits Ravestein, Mark van den Driesche, Wouter Akkerman, Jan Willem van der Windt , Jan van de Werken
LIVIT ORTHOPEDIE
Collaboration between humans and robots (cobots) is on the rise, and more and more applications lend themselves to a solution with robotics. As a result, the social added value of robotics is growing and robots are now becoming a real part of our daily lives. Robotics is also increasingly being used in orthopedics. Opinions differ on the definition of robotics. In this paper, we define it as a collection of systems that function in an unstructured environment, that measure and act physically, and that use (a certain degree of) artificial intelligence.
1 April, 2019 [Edition 4, Volume 2]
INCREASE IN APPLICATIONS FOR ROBOTICA IS GROWING RAPIDLY
Applying Robotics in orthopedic tailor made production improves quality and increases customer satisfaction
Robotics will play an increasingly important role in the societal challenges facing healthcare. Optimization of processes and robotized actions in healthcare ensure that the growing group of people in need of care can get the necessary attention. This will also contribute to the acceptance of the implementation of robots. Gene Munster, an important technology and market analyst, stated a few years ago that Robotics is about to become as common as the computer. In fact, virtual reality, augmented reality, artificial intelligence, and robotics will jointly have greater influence in the future than the internet (ROBO Global, 2016). The increase in functions and applications is enormous The various types of robots can be classified in a number of ways: work environment, user interaction, physical form, and main function. For example, there are robots in the air, on land, under water, in space, and in the human body. There are robots that can work autonomously, that are monitored remotely, and that collaborate with another robot or a human being. There are also robot arms, robot platforms, robots as an extension of the human body, robots in the shape of a human (humanoids), and nano and microrobots. In terms of deployment, there are robots that can assemble, treat surfaces, interact, investigate, transport, inspect, pick up, or manipulate. More and more is becoming possible. Robotics is not new; industrial robots have been used in manufacturing processes across different sectors for years now (e.g. car manufacturing, the milking robot, etc.). According to experts, there are now more than 1.5 million robots in use worldwide, performing tasks previously done by humans. This will only increase in the coming years. In recent years, a strong technological base has been developed, and the market has become more aware of the possibilities of robotics (ROBO Global, 2016). A range of sectors, such as the agricultural sector, healthcare, safety, and trans sport, offer opportunities for explosive growth in application. Robotics & Employment Robots are shaking up the labor market. They are more productive than humans when it comes to repetitive manual work; they make fewer mistakes, can go on longer, at a higher pace, and perhaps, at a lower cost in the long run. The latter is not yet the case, however. In addition, robots can increasingly be used for other, more complex activities, as has been the case with the manufacture of customized solutions for orthopedic devices since 2014. Contrary to popular belief, the experience is that robotics also make a major contribution to job creation. While machines in the first industrial revolution increased our physical workforce, robots now also increase our mental workforce. The application of robotics in our work process has actually created new jobs. Within Livit, for example, the team has grown and new functions have been created in a managing and controlling role alongside the robot. The manufacturing industry The manufacturing industry has always been the largest application sector for robotics. Robots are used for volume production in, for example, the automotive industry, electronics, and aerospace. A new generation of smart robots is about to follow, which can also be used to produce small volumes. Without further developments in robotics, the intended 'smart industry' will not be achieved. The continued growth of robotics in the manufacturing industry is important for the Dutch economy and employment. By reducing production costs and designing manufacturing processes more efficiently, it is possible to keep production within the Netherlands or even bring it back to the Netherlands (reshoring). Robotics can ensure that production resources are more flexible so that they can be used more widely and can produce smaller batch sizes, thereby increasing efficiency and creating smaller production units. Healthcare Robotics is already implemented for some functions within the healthcare industry. A distinction can be made here between cure and care, or medical applications (such as surgical robots) and care applications. Medical robots, which are used for minimally invasive treatments, endoscopies, and micromanipulation, are a highly specialized application in which high-quality requirements are the standard. Exoskeletons, robots that you can 'wear', form a revolutionary new generation of prostheses. The number of applications within the healthcare industry is expected to increase greatly in the coming years, particularly in the field of hospital logistics and rehabilitation care. Efficiency is the main incentive here. The current aging population and the growing group of people in need of care make efficiency in care an important social challenge. Recent calculations by KPMG show that healthcare cannot do without robotics (KPMG, 2017). Typical healthcare applications require high accuracy (e.g. in surgical robots), good interaction options (e.g. for rehabilitation applications), miniature solutions (e.g. for portable solutions), very high safety and reliability, and monitoring and data interpretation during the period that the robot is active. Application in orthopedic device care An increasingly aging population, a shift from dangerous and repetitive work to more cognitive challenging work, higher quality, and increasingly smaller customer-specific production runs: just a few examples of the range of real arguments that argue in favor of further robotization. Nevertheless, the decision for an actual application was not taken quickly. Within the conservative orthopedic device market, in particular, people are struggling with the application of robotics. The installation has often proved to be too complex, and automation knowledge is found lacking within small institutional organizations. In addition, digitization in the primary process in the form of measurement and application of scanning technology is by no means applied everywhere, while this is a prerequisite for the effective use of robotics in the production process. Orthopedic device care. It is in a league of its own, with its own set of dynamics; customization, or to speak in metal-technical terms, single-piece production that must be done well from the get-go, with a high impact on the well-being of rehabilitators. Of course, it should not cost too much and be delivered as quickly as possible so that the patient can get back on track. Robotics and Livit proved to be a good match, for example, when it came to the application of milling technology for customized models for the production of ankle or foot orthoses, among other things. Prerequisites Livit meets all the prerequisites for applying robotics in its orthopedic device care: central production location. Where orthopedics is characterized by small local workshops with a strong traditional character, Livit has invested in a standardized measurement-process and central production in the last few decades. Digitization is a structural part of the Livit measurement process. We started digitally measuring devices as early as 2013, with 95% of our prostheses now being measured and processed digitally. Introduction and application of CadCam technology Application within Livit In order to meet the challenges within healthcare provision, with regards to scarcity of well-qualified personnel and continuous pressure on efficiency due to price pressure from the healthcare coverage perspective, we started exploring the possibilities of robotics six years ago. However, the application within the process of manufacturing customized orthopedic solutions required further development in four areas: System development: there was a strong need for systematic design processes for the development and validation of robotic systems and standards. This was due to the fact that, within the application in orthopedics, a translation had to be made between the individual measurement of the different limbs to the dimensions within the forms to be developed in the process. Navigation: positioning and route planning are essential skills for a robotic system. This proved to be the case within the application for orthopedic devices because an extremely high degree of accuracy is important. The required accuracy was not possible with the technology at the time, and in-house development was required to achieve this accuracy. Mechatronics: flexibility was essential for integration into the production process because our application concerned unique customization models, renewed for every customer. Cognition and learning: for acceptance within the conservative medical rehabilitation sector, close cooperation between engineers and orthopedic professionals appeared to be essential. Organization of robotics within Livit There is a separate department that specializes in producing products and services via robotics applications. The department translates the digital files back into physical products and checks them for accuracy with the 3D file. This department also specializes in the 3D printing of products. Livit CAD/CAM Prostheses & Ortheses In this design department, anatomical 3D models are digitally corrected to the shape or form of the prescribed prosthesis or orthosis. This department takes care of the intake of the cast that our advisors send. They scan the cast and drawings and convert them into digital data. After the conversion, they combine the 3D file with the measurement form to perform the desired correction. Livit CAD/CAM Shoes & Arch Support This is the design and intake department for the digital processing of shoes and arch supports. This department will work more closely with the other digital departments in the future to improve and contribute to knowledge exchange. This includes knowledge about lasts, blueprints, and pressure measurements that can also be applied to prostheses and orthoses. Livit Engineering This department consists of qualified engineers at industrial level who work closely with human movement scientists and graphic engineers. This allows us to guarantee and analyze the quality assurance for products. Together with the movement scientists, they develop the end product into an evidence-based product with scientific substantiation by drawing up scientific formulas. In addition, the department ensures that our products are connected to Virtual Reality and 3D printing applications. The digital recording of the models by the CAD/CAM department makes it possible to 'trim' a foam model of the device very quickly and accurately using a robotic cutter. Advantages of trimming models: An accelerated finishing process Greater freedom in forms Greater precision through trimming No human deviation due to digital positioning Automation of standard operations (such as triangles and holes in cranial helmet) The process can be digitally checked for errors in advance When a foam mold is milled using a mandrel and fixation plate, material is pulled or cast over it. This makes it possible to make a very precise spatial positioning (3D). This positioning is used to load the model into programming in exactly the same way. In turn, this allows the trimming process to be programmed and controlled so the material on the foam model can be trimmed with great precision. Astonishing results In 2016, Livit launched a study into the effectiveness of the use of ankle/foot orthoses (AFO) for foot-lifting issues. We approached 1057 customers with questions pertaining to the device, related to the purpose of the device. The questions concerned comfort and ease of use, among other things. The perceived wearing comfort of the AFO increased greatly between 2016 and 2018. The number of customers who rated the comfort with a 9/10 or a 10/10 in 2017 and 2018 has doubled since 2016. The number of customers that gave a rating of 6/10 or lower has also decreased by 66% over the last three years. The perceived ease of use of the AFO has increased greatly between 2016 and 2018. In particular, the number of critical customers who rated the ease of use with a 6/10 grade or lower has dropped considerably. Use of robotics in digital milling technology, the AFO customization is made at Livit using digital technology. This allows us to guarantee an optimal fit. All changes made to the individual model can always be retrieved and adjusted. If a new AFO is necessary, we can use this information again. The implementation of our digital technology has taken off over the last three years and has been consistently applied at all our locations. Digital processing and production have increased greatly in recent years, from 34% to 64%, making a major contribution to quality improvement. In relation to the objective of their device, 275 customers were asked questions about topics such as stability, wearing comfort, ease of use, cosmetics, and delivery time when delivering the prosthesis. The perceived wearing comfort of the prosthesis sleeves has increased greatly between 2016 and 2018. The number of customers who rated the wearing comfort with a 9/10 or 10/10 has increased two and a half times. In 2016, 25% of our customers rated the prosthesis sleeve and prosthesis device with a 9/10 or a 10/10. Last year, that has gone up to 69%. The perceived ease of use of the prosthesis sleeve has increased greatly between 2016 and 2018. The number of customers who rated the ease of use with a 9/10 or 10/10 has increased by 50%. In 2016, 32% of our customers rated the prosthesis sleeve and prosthesis device with a 9/10 or a 10/10, which last year increased to 54%. The lower leg prosthesis is made at Livit using digital technology. This allows us to guarantee an optimal fit. All changes made to the individual model are stored digitally and can always be retrieved and adjusted. If a new sleeve is needed, e.g. due to atrophy or a change in activities, then we can use the existing information as a starting point or reuse it. The implementation of our digital technology has taken off over the last three years and has been consistently applied at all our locations. Whereas Livit still made 60% of the lower leg prostheses using digital technology in 2016, this increased to 90% in 2018. Source: opportunities for Dutch robotics, Holland Robotics: Investing together, in application-oriented R&D. January 2018, Holland Robotics
the use of digital technology improves comfort and ease in use for lower leg prostheses
Customer satisfaction on comfort in use of the protheses
At least three jobs are created with each robot
applications in healthcare require high accuracy and reliability
Jing Bing Zhang, research director worldwide robotics at IDC, predicts that in 2019 30% of the leading companies will have a "robot manager" position (Violino, 2016). In their study "Stayin" Alive: Manufacturing in America, the Bank of America Merrill Lynch predicts that three jobs will be created with each robot (ROBO Global, 2016).
Freedom of Movement.
Bart de Kiefte (CTO), Tim de Roo (Engineering), Maurits Ravestein (Engineering), Mark van den Driesche (Robotica), Wouter Akkerman (operationeel Manager P&O), Jan van de Werken (Directeur Productie) en JW van der Windt (CEO)
Makes mobility Possible.
