Download Liftware: Self-stabalizing Eating Utensils for Individuals With Hand

CADTH ISSUES IN EMERGING
HEALTH TECHNOLOGIES
INFORMING DECISIONS ABOUT NEW HEALTH TECHNOLOGIES
ISSUE
OCT
142
2015
Liftware:
Self-stabilizing
Eating Utensils for
Individuals With
Hand Tremor
Author: N. Smith.
Disclaimer: CADTH Issues in Emerging Health Technologies is a series of bulletins describing health technologies that are not yet used (or widely diffused) in Canada. The
contents are based on information from early experience with the technology; however, further evidence may become available in the future. These summaries are not
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Cite as: Liftware: self-stabilizing eating utensils for individuals with hand tremor. Ottawa: CADTH; 2015 August. (CADTH issues in emerging health technologies; issue 142)
Contact [email protected] with inquiries about this notice or legal matters relating to CADTH services.
ISSN: 1488-6324
ISSUES IN EMERGING HEALTH TECHNOLOGIES
2
Summary
•Liftware is a self-stabilizing, computerized handle and selection of attachments, including a
spoon. It compensates for hand tremor, enabling people with mild to moderate tremor due to
conditions such as essential tremor, Parkinson disease, or other neurological disorders to eat
more easily.
•The handle uses computer technology to sense the direction of tremor and move the utensil
attachment in the opposite direction.
•One small pilot study, led by the developers of Liftware, found that the device reduced tremor
amplitude by 71% to 76% during three tasks: holding, lifting, and transferring.
Background
Tremor is the repetitive, involuntary shaking of a body part,
characterized by small, oscillating (back-and-forth) movements.1
Everyone experiences slight trembling, which is noticeable
when you hold your hands in front of you and try to keep them
still.2 However, more severe tremors accompany a number of
conditions, including neurological disorders such as essential
tremor or Parkinson disease.1
Essential tremor is the most common movement disorder and
the tremor may affect the hands, arms, legs, trunk, head, or
vocal cords.3,4 Shaking in essential tremor worsens both with
movement and when holding a static posture, but may stop
when the limbs are at rest.
In Parkinson disease, tremor often begins in one hand, and may
spread over one side of the body to the arm, leg, and foot.5 Over
time, the tremor may also affect the opposite side of the body,
the chin, lips, and trunk.1
ISSUES IN EMERGING HEALTH TECHNOLOGIES
People with tremor often have difficulty performing activities of
daily living such as eating, writing, and grooming, which limits
their independence. Because tremor limits tasks that require
fine motor control, using eating utensils can be challenging and
may discourage people from sharing meals with family and
friends. Embarrassment about tremor can be as emotionally
burdensome as the accompanying physical limitations, causing
some individuals to avoid social situations and significantly
reducing their quality of life.6,7
The Technology
The Liftware spoon is a self-stabilizing utensil that compensates
for hand tremor. This non-invasive, assistive device includes a
stabilizing handle, rechargeable battery, and three attachments:
a soup spoon, everyday spoon, and fork.8 A computer and two
motors embedded in the handle act as a sensing mechanism
(Active Cancellation of Tremor technology), which detects the
direction of tremor and moves the utensil attachment in the
opposite direction.9
3
Weighing approximately 100 grams, and similar in size to an
electric toothbrush, Liftware is intended for use in restaurants
and at social occasions, as well as at home.8,9 The rechargeable
battery can run continuously for 90 minutes, and automatically
turns off when the spoon is placed face-down.8,9 The Liftware
utensil heads detach from the stabilizing handle for cleaning.
Liftware eating utensils may help those with mild to moderate
tremor, but are not intended for individuals with severe tremor.10
Regulatory Status
Liftware was developed by Lift Labs (Mountainview, California),
a subsidiary of Google.11 In Canada, Liftware is not considered
to be a medical device as defined by the Food and Drugs Act
and Medical Devices Regulations, and potential marketing of the
device will be regulated under the Consumer Product Safety Act.
Liftware is not currently available in Canada, but is sold online in
the United States.
Patient Group
Parkinson disease affects approximately 100,000 Canadians.12
Most individuals with Parkinson (70% to 100%) will experience
tremor.13
While neurologists and researchers generally agree on the
symptoms of essential tremor, there is no standard definition
and diagnostic error is common.3 Many cases are not diagnosed,
making it difficult to determine the number of people affected.3
Some population-based studies suggest a prevalence rate of
0.4% to 3.9%, but these figures are likely underestimates.14
Both essential tremor and Parkinson disease are more prevalent
in the elderly.3,15,16
Current Practice
Currently available treatments for both essential tremor and
Parkinson disease are used to control the symptoms, rather
than cure the condition. Treatment of essential tremor depends
upon which parts of the body are affected and the degree
to which the condition disrupts activities of daily living.17
Patients with tremor are advised to make lifestyle changes,
such as avoiding caffeine and participating in stress-relieving
ISSUES IN EMERGING HEALTH TECHNOLOGIES
activities.18 Medications are prescribed if lifestyle changes fail
to provide relief. Propranolol, a beta blocker, and primidone, an
anticonvulsant, are two medications commonly used to alleviate
symptoms of essential tremor.3,17
The 2012 Canadian Guidelines on Parkinson’s Disease recommend
that motor symptoms be treated with levodopa in combination
with carbidopa or benserazide.19 As the disease progresses and
symptoms worsen, increasing doses of the drugs are used.19
Because only one study has
evaluated the Liftware spoon,
there is limited evidence of its
effectiveness.
Two surgical procedures, thalamotomy and deep brain stimulation,
may be used to reduce the severity of tremor in essential tremor
and advanced Parkinson disease.17,19 More commonly used for
individuals with essential tremor, thalamotomy involves inserting
a liquid nitrogen probe into the brain to create lesions on a small
area within the thalamus.20 In deep brain stimulation, an electrode
is implanted in the brain to deliver electrical impulses to the
surrounding tissue.21,22 The electrode is controlled by a pacemakerlike device, placed in the abdomen or upper chest.21,22
Methods — Literature Search
A peer-reviewed literature search was conducted using the
following bibliographic databases: MEDLINE, PubMed, Embase,
and the Cochrane Library. Grey literature was identified by
searching relevant sections of the Grey Matters checklist (http://
www.cadth.ca/resources/grey-matters). No methodological
filters were applied. The search was limited to English-language
documents published between January 1, 2010 and March 10,
2015. Regular alerts were established to update the search until
May 2015.
The Evidence
Because only one study has evaluated the Liftware spoon, there
is limited evidence of its effectiveness. Fifteen participants
with essential tremor were enrolled in a single-arm pilot study;
however, accelerometer data for four participants were excluded
4
Images courtesy of Liftware
for technical reasons.9 The conclusions were based on results
from 11 participants (nine men and two women), with a mean age
of 70 years.9 Although Liftware is marketed for individuals with
Parkinson disease, essential tremor, and other tremor disorders,
only patients with essential tremor were included in the study.
In this study, the participants used the device to perform
three tasks: holding (holding the spoon between the table
and the body), eating (lifting a spoonful of foam blocks to the
mouth), and transferring items from one dish to another.9 The
participants performed each task twice, with the device both
on and off. Participants were randomly assigned to complete
their first set of tasks with the device either on or off, with
their second set of tasks using the other setting. Neither the
subjects nor the neurologists knew whether the device was on
or off during each round of testing.9 Because foam blocks were
substituted for food in the study, it is not clear whether Liftware
enables individuals to successfully eat lower-viscosity foods,
such as soups or cereal with milk. The weight and dimensions
of the foam blocks were not reported.
Researchers embedded accelerometers (devices that
measure acceleration) in the spoonís handle, to record tremor
magnitude.9 The Fahn-Tolosa-Marin Tremor Rating Scale (with
adapted items for feeding, pouring, and upper limb tremor)
was used to measure the degree of tremor in the tip of the
spoon during each task.9 Researchers did not specify how the
tremor rating scale was adapted, and whether this modification
provides valid ratings is not known.9
ISSUES IN EMERGING HEALTH TECHNOLOGIES
To capture patient experience with the device, participants
were asked to rate their level of improvement after each action
using the seven-point Clinical Global Impression Scale (CGI-S).9
Results showed significant improvements in tremor rating
scale scores across the three tasks with the technology turned
on. Accelerometer data displayed average tremor reductions of
72%, 76%, and 71% in the holding, eating, and transferring tasks,
respectively.23 Participantsí CGI-S scores also improved in the
eating and transferring tasks, but indicated no change in the
holding task.9
Two participants with severe tremor were unable to complete
the tasks with their deep brain stimulation therapy devices
turned off, which suggests that Liftware may be helpful only in
those with mild to moderate tremor.9
Adverse Effects
No adverse effects were reported in the pilot study.
Administration and Cost
Liftware’s “starter kit” — which includes the stabilizing handle,
charging cradle, soup spoon attachment, and storage pouch —
retails at US$295, and can be purchased online in the United
States.24 The fork and everyday spoon attachments are sold
separately for US$19.95.
5
Concurrent Developments
The International Essential Tremor Foundation and other self-help
guidelines suggest that weighted eating utensils may be helpful.10
However, weighted utensils may not be effective for,25 and may
actually worsen tremor in, individuals with Parkinson disease.26
One study found that lightweight utensils, rather than heavy cutlery,
enabled individuals with Parkinson disease to eat more easily.27
Rate of Technology Diffusion
A recent review estimated that the incidence of Parkinson
disease in Canada will increase considerably over the next
40 years (by about 50% from 2010 to 2050).15 Parkinson
disease and essential tremor are both more prevalent in the
elderly, and the numbers of those affected will likely rise with
an aging population and increasing longevity.3,15,16 Demand for
technologies that improve independence for those with tremor
disorders could increase accordingly.
Patient response to the device will influence the diffusion of
this technology. An online video series, produced by Lift Labs,
features three individuals with varying degrees of tremor using
the Liftware spoon.28 The ability of each user to lift, hold, and
eat a spoonful of food appears to improve with Liftware; one
woman is shown successfully eating soup. Another online video,
Introducing Liftware, produced by the developer, has received
525,640 views on YouTube since its release in September
2013.29 A profile of the Liftware spoon by a technology review
Web series received 48,379 views in six months,30 and a home
video of an elderly man using the spoon to eat a bowl of nuts
gained 33,895 views in one year.31 The Web series and home
video gave positive reviews of Liftware. While these clips do
not provide clinical evidence of the spoonís effectiveness,
viewership suggests that there is substantial public interest in
these products. The International Essential Tremor Foundation
has also promoted Liftware by circulating an advertisement for
the technology to its members.32
Information on consumer satisfaction with Liftware and the
number of spoons or kits sold was not available.
Implementation Issues
If Liftware becomes available in Canada, its eligibility for
public reimbursement will need to be determined. As it is not
considered to be a medical device, it may be considered instead
as an assistive device or aid to daily living.
ISSUES IN EMERGING HEALTH TECHNOLOGIES
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References
1. National Institute of Neurological Disorders and Stroke (NINDS) [Internet].
Bethesda (MD): NINDS. Tremor fact sheet; 2015 [cited 2015 Apr 22]. Available
from: http://www.ninds.nih.gov/disorders/tremor/detail_tremor.htm
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conditions/Tremor-%28essential%29/Pages/Introduction.aspx
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Guideline for the treatment of essential tremor. Essex, England: Mid Essex
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http://midessexccg.nhs.uk/
19. Canadian guidelines on Parkinson’s Disease. Can J Neurol Sci. 2012;39(4).
Suppl 2.
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