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Evaluation of Idiopathic Scoliosis Based on Alignment, Equilibrium, and Stability: Gomez Orthotic Spine System PG.9

CASE STUDY: Vertical + Horizontal TLSO Treatment in a Skeletally Immature Patient With Scoliosis PG.14

COMPLIANCE MONITORING FOR

SCOLIOSIS BRACE TREATMENT

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Tech Tips: Promoting O&P Technician Programs PG.22

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20 Meetings & Courses 20 Classified Ads 22 Tech Tips Joanna Kenton, CPO, LPO, FAAOP, explains the importance of promoting O&P technician programs.

COVER STORY

04

Compliance Monitoring for Scoliosis Brace Treatment

By Jennifer Johansson, MS For patients with adolescent idiopathic scoliosis, user compliance with proper wear time and prescribed tightness of spinal orthoses can be an issue. Results of a focus group of past patients, caregivers, and clinicians indicate that developing a compliance monitoring system that includes 13 key features could improve compliance and ultimately achieve optimal outcomes for scoliosis patients.

7

16 O&P Visionary Jack Richmond, CPOA, president and chief executive officer of the Amputee Coalition, advocates for patient-centric O&P care.

PLUS, Quick Tips To Help Reduce Noncompliance in Scoliosis Treatment

By Cassandra Delgado, MSPO, CO

Research & Presentations 9

Evaluation of Idiopathic Scoliosis Based on Alignment, Equilibrium, and Stability: Gomez Orthotic Spine System

14 CASE STUDY:

Vertical + Horizontal TLSO Treatment in a Skeletally Immature Patient With Scoliosis

By Debra Auten, CPO, LPO

By Jose Miguel Gomez Torres O&P News | January/February 2019

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COVER STORY

Compliance Monitoring for Scoliosis Brace Treatment

By Jennifer Johansson, MS

T

he goal of brace treatment for adolescent idiopathic scoliosis (AIS) is to stop the progression of the curve as bracing does not typically reduce the degree of the curve already present. AIS braces are prescribed to be worn tightly and for many hours per day. A patient that is still growing with a curve of 25-30 degrees can be prescribed a brace for up to 23 hours per day until he or she has stopped growing (skeletal maturity), typically anywhere from two to 42 months.1 It has just been in this decade that ground-breaking studies have confirmed the efficacy of this treatment.1,2 Katz et al.â&#x20AC;&#x2122;s landmark study1 found that 82 percent of patients who wore their brace more than 12 hours per day had a favorable outcome (curve progression <6 degrees) as compared to only 31 percent of those who wore their brace less than seven hours per day (p=0.0005). The Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST), a multicenter, randomized clinical trial funded by the National

4

O&P News | January/February 2019

COVER STORY

a

a

Married

Up to 12 Years 3 Bachelors

Full time

$10,000$19,999 $100,000+

Married

3 Bachelors Full time

$100,000+

Married

2 Doctorate Full time

a

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4 Doctorate

Pediatric Orthopaedic Doctor Pediatric Orthopaedic Doctor Pediatric Orthopaedic $100,000+ Doctor

4

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Single

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9

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Institutes of Health (NIH), was stopped early owing to the efficacy of bracing and confirmed Katz’s results with a treatment success (curve progression <6 degrees) rate of 90-93 percent with at least 12.9 hours of daily brace wear.2 The studies not only indicated that brace treatment was more effective than observation, but that longer hours of wear were associated with greater benefit. In light of this evidence, ensuring the proper wear of a scoliosis brace is even more crucial than ever.

However, wear time is not the only factor in a successful treatment. The brace also must be worn at the prescribed tightness of fit. Without both of these criteria being met, the effectiveness of the brace treatment is compromised.

For example, one patient could wear the brace 23 hours per day but never achieve the correct fit, so the corrective forces are minimal or nonexistent. Conversely,

1

12

Married —

Student

Full time

$100,000+

$80,000$89,999 $80,000Degree Full time $89,999 Some $20,000Unemployed College $29,000 High $10,000Full time School $19,999 $60,000Masters Homemaker $69,000 Full time

4 Bachelors Part Time $100,000+ —

—

—

—

another patient could wear the brace as tight as prescribed but only for one hour per day. In neither case is the patient going to achieve optimal outcomes from the brace treatment.

Given the prescription for long hours of wear of a tightly fitting brace, it is no surprise that user compliance can be an issue. The traditional means of assessing compliance are largely subjective and unreliable, utilizing questionnaires, verbal reporting to a clinician by the patient or parent, and/or assessing the braces for signs of wear. More quantitative thermal monitoring devices, such as the Cricket, Orthotimer, and iButton, are commercially available; however, these have seen limited use.

One contributing factor for this may be that these devices only yield limited compliance data, measuring only wear time, and have no measure of

Patient Orthotist Orthotist

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Table 1: Demographic Profile of the Focus Group Participants

Idiopathic/Juvenile/ Thoracolumbar

Parent

Idiopathic/Adolescent/ Thoracolumbar

Parent

Idiopathic/Adolescent

Parent

Adolescent

Parent Parent Parent Parent —

Idiopathic/Juvenile/ Lumbar Idiopathic/Juvenile/ Thoracolumbar Idiopathic/Juvenile Idiopathic/Juvenile/ Thoracolumbar —

how effectively the orthosis is donned during each period of wear (i.e., the tightness of fit). While few wear time monitors exist, even fewer systems are available that can measure both aspects of compliance. The Cinch Smart Strap has recently come on the market but also has seen limited buy-in from the community.

Therefore, to explore why these systems are not being fully embraced and better understand the need for such a system and how to meet that need, we enlisted the aid of the Center for Knowledge Translation for Technology Transfer (KT4TT) to perform a focus group. The experienced team ran a focus group of 13 participants comprised of clinicians, orthotists, parents of AIS patients, and former patients. The demographic profile of the participants is shown in Table 1.

O&P News | January/February 2019

5

COVER STORY

Initially, the focus group confirmed many of our initial assumptions on the current challenges of brace treatment.

The group noted that brace treatment often is not fully utilized for a variety of reasons and that kids can be very resourceful in not wearing the brace.

They will take the brace off to eat, because they are hot, or even during the night while sleeping, often unconsciously, because it is uncomfortable.

The group confirmed that compliance is a key issue, whether it be that the braces

are often not worn securely enough or that they arenâ&#x20AC;&#x2122;t being worn long enough, and traditional means of measuring compliance like self-reporting on the part of the patient and/or parents are not accurate.

When asked what features they would look for in a compliance monitoring system, to assist both the user and the treating clinician to ensure optimal wear and maximize results, the group identified 13 key features (Table 2). Many of the features identified were as expected,

Table 2: Key Features for a Brace Compliance Monitoring System

6

1.

Ability to measure the duration of time the brace is being worn.

2.

Ability to measure if the brace is being worn correctly.

3.

Ability to measure the body temperature of the child.

4.

Ability to measure improvements in the curvature of the spine when the brace is donned.

5.

A phone app compatible with smartphones and iPads to receive and display data being collected.

6.

Ability to send alerts to multiple devices when something is incorrect.

7.

Visual representation on the app that shows why the brace is not being worn correctly.

8.

Positive feedback to the brace wearer given through the phone app.

9.

Monitoring sensors and wiring to be nonobtrusive, embedded within the brace.

10.

System to be quick to charge and able to hold a charge for an extended period of time (4-5 days).

11.

Monitoring system able to communicate via app as to the status of current charge level.

12.

Monitoring system to be functional under an X-ray.

13.

Sensors should be shock-/impact-resistant, waterproof, and impervious to temperature variations.

O&P News | January/February 2019

such as being able to monitor both wear time (1) and tightness of fit (2), having a mobile app (5) to alert both the patient and parent or caregiver of incorrect fit (6), being inconspicuous (9) and robust (13), and being able to charge quickly (10) and provide battery status (11).

However, some of the reported features were less obvious. For example, it was important to the parents in the group that they could measure the body temperature of the patient (3) as overheating while wearing the brace was a concern. It also was important for the system to identify why the brace was not being worn correctly and provide a visual representation (7) to guide how to correct the fitâ&#x20AC;&#x201D;e.g., identify the strap(s) to tighten. Another desired feature was for the system to be able to measure improvements in the curvature of the spine when the brace was being worn (4). Currently this is done with in-brace X-rays so this may not be as easy to achieve as some of the other features. However, it is likely more straightforward to design a system that can be worn during X-rays (12). The final feature the group desired was that the system provide positive feedback to the brace wearer through the phone app.

This was seen as a very important way to help motivate kids to wear the brace. By creating goals and rewards, such as app credits for an app store, gift cards, etc., when goals are reached, the hope is to engage the kids in the process.

While some of these features are easier to implement than others, 100 percent of the focus group stated that they would recommend use of, or want to use, a compliance monitoring system that met all of these key features. They believed such a system could reduce arguing over brace wear, take the parents/caregivers out of the role of bad guy, and achieve buy-in from the patients themselves to ultimately achieve the best possible outcomes from their brace treatment.

COVER STORY

Quick Tips To Help Reduce Noncompliance in Scoliosis Treatment

By Cassandra Delgado, MSPO, CO Many adolescents with idiopathic scoliosis undergoing orthotic treatment will experience compliance difficulties with brace wear. It is known that noncompliance with orthotic treatment is associated with negative impacts on orthotic success. Here are a few tips to tackle noncompliance in your patient population.

1

Be on the same page as the physician.

I recently performed a study at the University of Michigan that looked at a five-year retrospective cohort study involving patients with adolescent idiopathic scoliosis (AIS) treated with a thoracolumbosacral orthosis (TLSO). Patients included 53 males and 263 females. A significant difference was found between what the patients/families reported to the physician compared to what they reported to the orthotist. On average, patients would add an additional 3.9 hours onto what they were reporting to their orthotist. The reason why is unknown; however, it is imperative to keep an open, easy line of communication with the treating physician. This way, the entire team is on the same page and has a clear understanding about how successful the orthosis can potentially be.

2

Consider a more gradual correction approach.

In the study as mentioned above, one of the treating orthotists in the study had significantly higher compliance rates. The primary differentiating factor was that he gradually introduced correction into the TLSO, rather than delivering the TLSO with full correction. This is a two-fold system: 1) He gradually built up a tolerance to correction by adding a thicker pad each time, and 2) he saw patients more often, which can assist in encouraging compliance and troubleshooting any areas that would discourage orthosis wear.

3

Show them it’s going to be OK—don’t just tell them.

When I have a new consultation for a TLSO, I expect there to be some tears. I consider myself to be a somewhat fashionable younger clinician, so during that first appointment, I am sneaky and wear a TLSO that I built for myself under my work clothes.

I’m sure to wear something a little flowy that is able to hide the orthosis easier. At the end of the appointment, I show them that I’ve been wearing a TLSO the entire time. I’ve never had a patient catch on to me! We chat about different fashion tips and techniques. I also encourage them to throw a “brace party” where they invite their friends over to decorate it and get close friends involved. This helps—especially on those days when they need a friend to help tighten their orthosis back up if they had to take it off for sports.

4

Know that noncompliance will happen.

Referencing the prior study, we found, on average, a noncompliance of 4.6 hours each day per patient. For example, individuals who were prescribed 18 hours of wear time on average reported just over 13 hours of actual daily wear time. According to this study, 40 percent of users experienced some level of noncompliance, and 5 percent experienced complete rejection of TLSO usage. Patients who reached at least 18 hours of wear time were more successful in avoiding spinal surgery by more than 15 percent and had curve progression prevention of more than 62 percent. It’s crucial to stress this 18-hour wear schedule to your patient. We know that the 23-hour wear schedule is very difficult for most patients, but we are still able to see ideal results with 18 hours of wear time. Knowing that noncompliance will happen, it’s best to face it head on. Address the issue before it becomes one.

Cassandra Delgado, MSPO, CO, is a clinician at Prosthetic and Orthotic Associates in Middletown, New York.

O&P News | January/February 2019

7

COVER STORY

Table 3: Suggested Cost of System Price

No. of Participants

$0

1

$25

2

$50

1

$100

3

$200

1

$200-$300

1

$500

2

<$1,000

1

$1,000

1

Unfortunately, one of the big hurdles for any new technology in this industry is reimbursement, and a compliance monitoring system is no different.

Multiple times during the focus group, the participants indicated that affordability is key. When the focus group was asked how much this ideal system—with all of the key features—should cost, the responses ranged from $0 to $1,000, with a mean price of $296 and median price of $100. This speaks to the importance of cost—that more than half of the participants could not, or would not, pay more than $100 out-of-pocket for a system that could help ensure the best possible outcomes of a treatment designed to avoid spinal surgery for children.

Currently no insurance code exists that would cover the cost of such a system. Certainly, applying for a new L code would be a means of obtaining insurance reimbursement if the L code is approved; however, it is an arduous process that is not guaranteed to be successful. One suggestion from the group to help motivate insurers to cover the cost of the system was that brace

8

O&P News | January/February 2019

wear should be tied to reimbursement; the more you wear it, the less you have to pay for the brace. Another was that if the system could determine if improper fit was due to the child outgrowing the brace, the compliance monitoring system could provide quantitative justification to insurance for the coverage of a new brace.

In conclusion, while the focus group agreed on the need for a compliance monitoring system and identified a variety of features an ideal system should have, some of the features are technically challenging, and there were definite discrepancies on what a reasonable outof-pocket cost for such a system should be. However, despite these challenges, the research and development team at Liberating Technologies is working to develop an affordable solution based on the feedback from the focus group.

Our solution, presented in more detail at the 2018 AOPA National Assembly in Vancouver, is an easily integrable, battery-powered system that consists of low-profile sensors to monitor forces in multiple locations, custom algorithms to determine wear time and tightness of fit, and a mobile app to provide feedback.

Regardless of the technical challenges and reimbursement hurdles in developing this system, we believe it worthwhile

in order to reduce the number of spinal surgeries and increase the quality of life of AIS patients. For more information, please contact Jennifer Johansson at jen.johansson@liberatingtech.com.

Jennifer Johansson, MS, is senior research engineer at Liberating Technologies, Inc., a College Park Company.

References 1. Katz DE, et al. “Brace Wear Control of Curve Progression in Adolescent Idiopathic Scoliosis,” J Bone Joint Surg Am. 2010; 92:6:1343-1352.

2. Weinstein SL, et al. “Effects of Bracing in Adolescents With Idiopathic Scoliosis,” N Engl J Med. 2013; 369:16:1512-21.

The contents of this article were developed under a grant from the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR grant number 90BI0010). NIDILRR is a Center within the Administration for Community Living (ACL), U.S. Department of Health and Human Services (HHS). The contents of this article do not necessarily represent the policy of NIDILRR, ACL, or HHS, and you should not assume endorsement by the federal government.

ISSN: 2165-7939

ISSN: 2165-7939

Journal of Spine

Journal of Spine

The International Open Access Journal of Spine

The International Open Access Journal of Spine

Executive Editors

Executive Editors

Alexandros A. Drosos University of Ioannina, Greece

Alexandros A. Drosos University of Ioannina, Greece

Michael Pazianas Oxford University, UK

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Robert E. Coleman Weston Park Hospital, UK

Juan S. Uribe University of South Florida, USA

Juan S. Uribe University of South Florida, USA

Ali Fahir Özer Ali Fahir Özer Koc University School of Medicine, Turkey Koc University School of Medicine, Turkey

ne at: OMICS Publishing Grouponline (www.omicsonline.org) Available at: OMICS Publishing Group (www.omicsonline.org)

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his article was originally published in a journal

by OMICS his article was originally published in a journal by OMICS Publishing Group, and the attached copy is provided

by OMICS Publishing Group, and the attached copy is provided by OMICS Publishing Group for the author’s benefit andPublishing for the benefit Groupoffor the author’s benefit and for the benefit of the author’s institution, for commercial/research/educational use the author’s institution, for commercial/research/educational use including without limitation use in instructionincluding at your institution, without limitation use in instruction at your institution, sending it to specific colleagues that you know, and providing a copy colleagues that you know, and providing a copy sending it to specific to your institution’s administrator. to your institution’s administrator.

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Digital Object Identifier: http://dx.doi.org/10.4172/2165-7939.1000149 O&P News | January/February 2019 Digital Object Identifier: http://dx.doi.org/10.4172/2165-7939.1000149

9

Spine

Torres, J Spine 2013, 2:5 http://dx.doi.org/10.4172/2165-7939.1000149

Hypothesis

Open Access

Evaluation of Idiopathic Scoliosis based on Alignment, Equilibrium and Stability: Gomez Orthotic Spine System Jose Miguel Gomez Torres* Gomez Orthotic Spine Systems, St. Petersburg, Florida, USA

Abstract Gomez Orthotic Spine Systems is a clinical method of measurement and, conservative treatment used in the management of spinal deformities including idiopathic scoliosis. This method uses easily accessible and economic measurement tools and permits a quantitative postural evaluation by using photometry for 3D analysis based on the center line in each corporal plane, line which is established as the line of greatest stability. In this article the method will be discussed in detail from its theoretical basis through implementation using a single clinical case.

Terminology Alignment: The placement or maintenance of body structures in their proper anatomic positions, such as straightening of the teeth or repair of a fractured bone.

Equilibrium: A condition in which all influences acting upon it are canceled by others, resulting in a stable, balanced, or unchanging system.

Stability: Capacity to provide support; firmness in position.

Segments: One of the parts into which something can be divided (in this case the body).

Flexibility: The ability to readily adapt to changes in position or alignment: may be expressed as normal, limited, or excessive.

Introduction Conservative treatment, by means of orthopedic elements for the spine has been used for many more years than surgical treatment, especially in the management of Idiopathic Scoliosis (IS). Unfortunately, there is not sufficient published scientific research that supports the conservative management of IS [1], which has given more and more room for surgical treatment. In general terms the treatment standards in orthotics for the management of IS are based in great percentage on radiographic studies including the Cobb angle [2], Risser Sign [24] and apical vertebral rotation [5,6], all of which are calculated in a bi-dimensional view unlike the three dimensional reality of scoliotic deformities giving inconclusive and partial results. Additionally, it is not of common practice for patients with IS to have full body x-rays taken, eliminating the importance of the lower extremities in the study of alignment. This lack of information over my 26 years of professional experience has lead me to study deeply the basic principles of alignment, equilibrium and stability, and to use a three-dimensional approach to understanding their posture as the basis for individual treatment.

as the grade of spinal flexibility followed by the determination of the corrective shape for each patient. Photometry techniques have been shown to have good inter rater and intra rater reliability [7].

We can more clearly visualize the differences between understanding a person´s standing posture from a 3D approach using photometry vs. the 2D x-ray approach by analyzing full body patient x-rays (Figure 1). For this patient we can see three different possible reference lines, the coronal central line (CCL), represented in red, the sacral central line (SrCL) [8] represented in blue, and the C7 plumb line (C7PL) [9] represented in yellow, from which we can interpret her standing posture. The CCL is the ascending line that emerges from the central point of the base of support. Based on this line we can conclude that this patient is mal-aligned (orin a state of disequilibrium) towards the left representing approximately a 2 cm difference from the CCL to the SrCL, ascending line which emerges from the central point of the sacrum, and is mal-aligned 3 cm toward the left from the CCL to the C7PL, descending line emerging from the spinal process of C7. The SrCL and C7PL do not give exact information regarding the global alignment of the patient. In fact, according to the C7PL this patient appears to be in

Figure 1: Reference system lines.

Analysis and Solution I designed Gomez Orthotic Spine System (GOSS) method over 10 years ago to overcome the obstacles I faced with on a daily basis to correctly treat IS from sub-par evaluation methods. The GOSS method is based on the treatment of the patient as a whole unit or structure, viewed much in the same way as viewed by engineers and begins with the understanding of quantifying alignment*, the capacity for the equilibrium* of the patient and, most importantly, the understanding of the stability* of the body as a whole, as well as the involved segments*.

Unlike traditional methods GOSS acquires all patient data through the implementation of an established protocol which requires the photo documentation of static standing posture in three planes as well J Spine ISSN: 2165-7939 JSP, an open access journal

10 O&P News | January/February 2019

*Corresponding author: Jose Miguel Gomez Torres, Gomez Orthotic Spine Systems, St. Petersburg, FL, USA, Tel: 713-8700662; E-mail: jmgomezmd@gorthoticsystems.com Received October 24, 2013; Accepted December 10, 2013; Published December 12, 2013 Citation: Torres JMG (2013) Evaluation of Idiopathic Scoliosis based on Alignment, Equilibrium and Stability: Gomez Orthotic Spine System. J Spine 2: 149. doi:10.4172/2165-7939.1000149 Copyright: © 2013 Torres JMG. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Volume 2 • Issue 5 • 1000149

Citation: Torres JMG (2013) Evaluation of Idiopathic Scoliosis based on Alignment, Equilibrium and Stability: Gomez Orthotic Spine System. J Spine 2: 149. doi:10.4172/2165-7939.1000149 Page 2 of 4

adequate alignment and therefore a treatment implemented based on this interpretation would focus only on reducing the curve magnitude and would not consider the overall alignment of the patient, treatment based on the postural interpretation according to the CCL. In the GOSS protocol, an overall mal-alignment of 3 cm in the case of idiopathic scoliosis is considered a severe deformity of potential greater risk than the scoliotic curve presented by the patient in the x-ray.

At this point, I would like to share the steps used in the GOSS protocol for the adequate understanding of three-dimensional deformities that are present in different body segments, which affect to a greater degree patients with spinal deformities. In the evaluation of each patient using GOSS principles, photos are taken of the coronal plane in anterior and posterior views (Figure 2), the sagittal plane in right and left views (Figure 2), and the transverse plane. Two types of photos are taken of the transverse plane: 1. In the Adams test [10,11] position in proximal and distal views (Figures 2 and 3). A photo in standing taken from the superior view from the head looking downward to evaluate the rotation in the involved segments (Figure 4). With these photos, we focus on understanding the clinical signs and quantifying the deformity. All these photos should be taken with a grid in the background and a floor mat (in the form of a “T”) used for the equidistant positioning of the feet, also, positioning adequately the tripod and laser in order to locate the lines of maximal stability in each plane, Coronal Center Line (CCL), Sagittal Center Line (SCL) and Transverse Center Line (TCL).

The next step is to create the corrective position which depends on the characteristics of the scoliotic curve/s through documentation using

Figure 4: Transverse plane photometry.

Figure 5: Lateral flexibility.

Figure 2: Coronal and sagital plane photometry.

various photos and videos (as necessary) which suggest the degree of flexibility [5] of the curve/s. Following the photo documentation from each case we analyze the photos to determine the alignment of each plane. I will use the analysis of the case of a 12 year old female patient with the diagnosis of Adolescent Idiopathic Scoliosis (AIS) to demonstrate this process (Figures 2-7).

Coronal plane-anterior view (Figure 2) It is having adequately obtained the CCL we can conclude that the patient is in left mal-alignment of approximately 3 cm. The lumbarpelvic segment has an inclination in the clockwise direction, which brings us consider a leg length discrepancy, being the left leg which is shorter, or the presence of a pelvic inclination coming from the curve.

Coronal plane-posterior view (Figure 2) We visualize the CCL using the laser and confirm that the patient has disequilibrium towards the left.

Sagittal plane-right side view (Figure 2) The SCL is determined beginning at the anterior border of the lateral malleolus. In this case it is evident that the patient is mal-aligned anteriorly approximately 5 cm. The lumbar-pelvic segment has an anterior inclination which, along with the hyperextension in the knees, is the cause of the sagittal mal-alignment.

Sagittal plane-left side view (Figure 2) Figure 3: Transverse plane photometry: Adams Test.

J Spine ISSN: 2165-7939 JSP, an open access journal

The SCL passes through the left shoulder (unlike in the photo of the

Volume 2 • Issue 5 • 1000149

O&P News | January/February 2019

11

Citation: Torres JMG (2013) Evaluation of Idiopathic Scoliosis based on Alignment, Equilibrium and Stability: Gomez Orthotic Spine System. J Spine 2: 149. doi:10.4172/2165-7939.1000149 Page 3 of 4

thoraco-lumbar level in which the scoliometer was placed we obtain 17˚, 4˚ more rotation in comparison with the Adams test. In reality, this deformity is more aggressive and structured than that established by the previous analysis. The transverse plane is the plane which structures the curves, is responsible for the loss of flexibility as well as the possibility of correction of the spinal deformities.

Figure 6: Coronal plane corrective shape.

Figure 7: Sagital plane corrective shape.

right side), which is an indication of a rotation in the counter-clockwise direction at the level of the shoulders.

Transverse plane (Adams Test [10,11]) (Figure 3) This test should be done with the patient in standing, asking them to flex the trunk forward over the pelvis (without bending the knees).

In the initial phase, we look for thoracic rotational deformities and the closer the patient becomes to touching their toes we can see the presence of thoracic-lumbar and lumbar deformities. A scoliometer or level should be used to measure the maximal segmental rotation (usually at the apex of the curves).

Transverse plane (Adams Test [10,11]) - proximal view) (Figure 3) 8˚ of thoracic-lumbar segment rotation in the counter-clockwise direction

Transverse plane (Adams Test [10,11]) - distal view) (Figure 3) 13˚ of thoraco-lumbar segment rotation in the clockwise direction Note: This information can be confused by professionals because the reality is that the transverse plane should always be evaluated from the head downward (proximal view). In spite of the fact that the level is positioned at very similar point, in both photos, we obtain results with a difference of 5˚ (which is not exact). Unfortunately, in my opinion, the Adams test is not precise; it changes the sagittal plane by elongating it lessening the degrees of rotation in the transverse plane when the rotational component is less than approximately 20-25° or it increases the degrees of rotation when the rotational component is greater than 25°. For this reason I recommend evaluating the rotations in the following manner (from proximal to distal).

With this information I invite you to resume the presentation in the 3 planes: Coronal- 3cm left mal-alignment. Sagittal- 5 cm anterior malalignment. Transverse- 17˚ counter-clockwise rotation in the thoracolumbar segment. In your opinion, which plane is the most involved?

Yes! You are right. The transverse plane is the most involved, the sagittal plane is the second most involved for its anterior disequilibrium and the coronal plane is the least involved for its left disequilibrium. So, why do we always treat the coronal plane as if it were the most involved and focus so much on the Cobb angle. This evaluation method does not give us the correct information about the deformity.

If you are following the details of the GOSS system you already have the numerical information regarding the mal-alignments (cm) and rotations (degrees) of the deformity. Now, with the same patient, we need to analyze and measure the corrective shape of the deformity.

This is done using the factor of flexibility [12] and correction without the need to manipulate the patient with force to unbend the curves. We should ask the patient, from a standing position, to perform a maximal lateral flexion to the left and to the right in order to understand which side has the greatest range of movement and flexibility in the coronal plane (Figure 5). In this case, there is no doubt that it is the left side.

Equally, the patient does a maximal forward flexion and extension to evaluate the sagittal plane. Also, maximal rotation in a clockwise and counter-clockwise direction is done to evaluate the transverse plane in standing and sitting.

The second step is to place the patient on a plinth to create the most aggressive corrective shape possible using the force of gravity where we can determine quantitatively the flexibility of the deformity (Figures 6 and 7). In order to meet this objective, the patient needs to be in side lying on the side of the convexity of the curve (in this case the left side). We begin with the correction of the sagittal plane (Figure 6) by flexing the hip and knee joints to 45˚, which permits a posterior pelvic inclination. Likewise, we make the correction by anchoring the pelvis and the trunk below the axilla. The second plane we treat is the transverse plane performing a de-rotation in the direction contrary to the direction of the deformity in the most involved segment. To treat the 17˚ thoraco-lumbar rotation in the counter-clockwise direction, a de-rotation force must be applied in a clock-wise direction up to or less than 17˚.

The last plane we treat is the coronal plane in which the corrective forces of the other 2 planes are sustained or conserved and a lateral bending moment is applied by the use of a half-bolster (Figure 8) that is positioned to exercise maximum pressure at the apex of the curve

Transverse plane (proximal to distal) (Figure 4) In a neutral standing position, an anthropometric calibrator, that can be blocked, is used to view in a more precise way the transverses plane characteristics of the different segments. In this case, at the same J Spine ISSN: 2165-7939 JSP, an open access journal

12 O&P News | January/February 2019

Figure 8: Half- Bolsters used to provide lateral bending moment.

Volume 2 • Issue 5 • 1000149

Citation: Torres JMG (2013) Evaluation of Idiopathic Scoliosis based on Alignment, Equilibrium and Stability: Gomez Orthotic Spine System. J Spine 2: 149. doi:10.4172/2165-7939.1000149 Page 4 of 4

deformity based on their ideal overall posture and balance. This form of evaluation, established in the GOSS method, provides a strong foundation for IS treatment with conservative bracing as the evaluation results can be transformed into the design of a 3D bracing system.

References 1. Stokes OM, Luk KD (2013) The current status of bracing for patients with adolescent idiopathic scoliosis. Bone Joint J 95-95B: 1308-16.

2. Negrini S, Aulisa AG, Aulisa L, Circo AB, de Mauroy JC, et al. (2012) 2011 SOSORT guidelines: Orthopaedic and Rehabilitation treatment of idiopathic scoliosis during growth. Scoliosis 7: 3.

3. Hacquebord JH, Leopold SS (2012) In brief: The Risser classification: a classic tool for the clinician treating adolescent idiopathic scoliosis. Clin Orthop Relat Res 470: 2335-2338.

4. Nault ML, Parent S, Phan P, Roy-Beaudry M, Labelle H, et al. (2010) A modified Risser grading system predicts the curve acceleration phase of female adolescent idiopathic scoliosis. J Bone Joint Surg Am 92: 1073-1081.

5. Ovadia D, Eylon S, Mashiah A, Wientroub S, Lebel ED (2012) Factors associated with the success of the Rigo System Chêneau brace in treating mild to moderate adolescent idiopathic scoliosis. J Child Orthop 6: 327-331.

Figure 9: Radiological Documentation.

(L1-L2) (Figure 7). For more than three points of pressure we should use a lateral bending moment. Equally, the position in supine in hip and knee flexion provides valuable information in understanding the flexibility of the sagittal and transverse planes. We should not forget that the sagittal plane has physiological curves that need to be maintained or created during the correction. In both of the mentioned positions measurements should be taken (circumference, medio-lateral, anteriorposterior and length) while maintaining the patient in the position of corrective shape, not the position of deformity.

Following this exercise, it is time to analyze the radiographic information (Figure 9) and compare it to our clinical and mechanical information. As you can see, the sagittal alignment, using the x-rays, is normal. However, we remember that the patient presents an anterior mal-alignment of 5cm, information which the sagittal X-ray does not correctly provide. We do not have a CCL or a SCL and as always we must work with the C7PL (yellow) or the SrCL (blue). As you can see, the clinical signs based on the photos and the x-rays are not in accordance. For this reason, we must concentrate on evaluating the patient as a whole and not by x-rays only.

The information acquired during the GOSS method evaluation is then used in conjunction with CAD/CAM technology to design an asymmetrical brace for an individualized conservative treatment of IS based on the patient’s true alignment, equilibrium and overall body stability.

Conclusion The evaluation of IS using bi-dimensional techniques and providing treatment based on the same lacking techniques continues to be an existing problem in the field of orthotics today. Evaluation of IS from a 3D full-body approach can easily be performed in a clinical setting and provides more comprehensive understanding of the patients spinal

Citation: Torres JMG (2013) Evaluation of Idiopathic Scoliosis based on Alignment, Equilibrium and Stability: Gomez Orthotic Spine System. J Spine 2: 149. doi:10.4172/2165-7939.1000149

J Spine ISSN: 2165-7939 JSP, an open access journal

6. Lebel DE, Al-Aubaidi Z, Shin EJ, Howard A, Zeller R (2013) Three dimensional analysis of brace biomechanical efficacy for patients with AIS. Eur Spine J 22: 2445-2448.

7. Fortin C, Feldman DE, Cheriet F, Labelle H (2011) Clinical methods for quantifying body segment posture: a literature review. Disabil Rehabil 33: 367383.

8. Guo J, Liu Z, Qian B, Zhu Z, Jiang H, et al. (2012) Anatomic deviation between the central hip vertical axis and central sacral vertical line in adolescent idiopathic scoliosis. J Spinal Disord Tech 25: E161-166.

9. Grosso C, Negrini S, Boniolo A, Negrini AA (2002) The validity of clinical examination in adolescent spinal deformities. Stud Health Technol Inform 91: 123-125.

10. Fairbank J (2004) Historical perspective: William Adams, the forward bending test, and the spine of Gideon Algernon Mantell. Spine (Phila Pa 1976) 29: 19531955.

11. Hackenberg L, Hierholzer E, Bullmann V, Liljenqvist U, Götze C (2006) Rasterstereographic analysis of axial back surface rotation in standing versus forward bending posture in idiopathic scoliosis. Eur Spine J 15: 1144-1149.

12. Chen ZQ, Zhao YF, Bai YS, Liu KP, He SS, et al. (2011) Factors affecting curve flexibility in skeletally immature and mature idiopathic scoliosis. J Orthop Sci 16: 133-138.

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Volume 2 • Issue 5 • 1000149

O&P News | January/February 2019

13

Research & Presentations

CASE STUDY: Vertical + Horizontal TLSO Treatment in a Skeletally Immature Patient With Scoliosis

By Debra Auten, CPO, LPO

N

onoperative scoliosis treatment has long included the side-bending technique. In the late 1970s, C. Ralph Hooper Jr., CPO, and Frederick E. Reed, MD, developed a thoracolumbosacral orthosis (TLSO) for night use, utilizing a

lateral bending technique. Proper measurement, fitting, and adjustment of a nighttime bending brace by a qualified orthotist has been shown to prevent the progression of curves in skeletally immature patients with adolescent idiopathic scoliosis.1

Figure 1

Figure 2

Figure 3

Observation before orthotic treatment 03-2016

Curve progressing 07-2016

Vertical TLSO after decompression 08-2016

14 O&P News | January/February 2019

Research & Presentations

As of 10/2018, with a patient age of 6 +7 years, no progression of the curve has been observed since the addition of the Charleston bending brace four months ago. The patient is currently wearing her third daytime TLSO (due to growth) and her first Charleston bending brace.

She is followed by orthopedists and orthotists every four months.

1. Observation by orthopedics at 4 years of age (Figure 1).

2. Curve progression noted at 4 + 4 years of age (Figure 2).

3. Vertical TLSO (posterior closing with corrective scoliosis padding) treatment began at 4 + 5 years of age (Figure 3).

4. Chiari malformation repair at 4 + 6 years of age.

5. Despite acceptable in-brace correction and TLSO wear compliance (16-18 hours/day), the patient showed evidence of a worsening trunk shift to the left (Figure 4).

A nighttime TLSO (the Charleston bending brace) was added to the orthotic treatment regimen at 6 + 3 years of age (Figure 5).

6. The patient currently wears the daytime TLSO 10-12 hours per day and the Charleston bending brace 8-10 hours at night.

Figure 4

Figure 5

Figure 6

Left trunk shift starting 09-2017

Charleston bending brace 06-2018

Current out of brace 10-2018

Orthotic treatment of scoliosis occurs either horizontally (nighttime treatment) or vertically (daytime treatment). In both treatment scenarios, the spine is loaded due to the effects of gravity in different planes. For skeletally immature patients with a rapidly progressing curve, both treatment scenarios may prove beneficial.

This case study features a young, female patient with scoliosis orthotically managed with a daytime TLSO in combination with a nighttime bending brace. She has a history of Chiari malformation (surgical decompression 09/2016) and cervicothoracic syrinx.

The sequence of events occurred as follows:

Debra Auten, CPO, LPO, is an orthotic and prosthetic senior clinician at Cook Children’s Orthotics & Prosthetics in Fort Worth, Texas.

References 1. Price CT, Scott DS, Reed FR Jr., Sproul Jr, Riddick MF. “Nighttime Bracing for Adolescent Idiopathic Scoliosis With the Charleston Bending Brace: Long-Term Follow-Up,” J Pedia Orthop. 1997; Vol. 17, No. 6.

O&P News | January/February 2019

15

O&P Visionary

Jack Richmond, CPOA

President and chief executive officer of the Amputee Coalition offers his vision of a perfect day in the O&P profession

W

hen I was asked to write about my vision for the perfect day for O&P, I began to think of my own perfect days in O&P. All my perfect days in O&P have had a patient at the center. The first of those days was 31 years ago, when I was that patient at the center.

Just six weeks after an accident at work that resulted in the loss of my leg at the transtibial level, I was standing and taking a few steps while holding back tears. Standing on two feet again was a

miracle moment for me, my family, and friends at work who were waiting for my return. Compared to what modern prosthetic care provides today, my first prosthesis wasn’t much in the way of technology. It was, however, exactly what I needed for the first steps back to the life I knew.

Over the past 28 years I have worked with patients as a care provider, manufacturer, and advocate. I have been blessed to see my miracle moment repeated by others many times. Memories of a

Rep. Mike Bishop (R-Michigan) and Jack Richmond, CPOA, at the 2018 AOPA Policy Forum

16 O&P News | January/February 2019

child standing for his first time with the help of an orthosis, and of delivering a prosthesis on Christmas Eve to someone who couldn’t pay for it—these are perfect days that have surpassed my own. On days like these, smiles, hugs, tears, and renewed hope are all the evidence we need to justify what we do.

So how do we make more of these perfect days possible? In my opinion, the answer is not as complicated as it might seem. It comes down to a commitment of putting patients first, helping to empower them with knowledge and a focus on evidence-based practice. Our health-care system is changing; a willingness and ability to adapt to those changes are critical for you and your patients.

There has been much written about patient-centric care. If putting patients at the center of every decision makes sense, why doesn’t it happen every time with every patient? There are lots of reasons: Not enough time, unrealistic expectations, and reimbursement issues are just a few issues that pull focus away from your patients.

Patient-centered care, like excellence, is a journey—not a destination.

My vision of the journey has a few stops along the way.

O&P Visionary

Understanding and Being Understood There is no replacement for good communication. Listening takes time and patience, but it is the only way to learn how your patients will define a successful outcome. Ask questions to direct the conversation, and then share your knowledge and experience with your patients.

Adherence (compliance) by the patient to the plan of care is key to successful outcomes, and the keys to adherence are understanding and motivation. Develop the plan together, explain the goals, and make them responsible—with you—for the results.

When we talk about patients, it is important to understand that caregivers are often the decision makers. Caregivers need to be as much a part of the plan as patients are.

Adherence (compliance) by the patient to the plan of care is key to successful outcomes, and the keys to adherence are understanding and motivation.

Support and Education for Patients As the president of the Amputee Coalition and an amputee advocate, my goal is to make sure all amputees have, as I did, the help and support they need to live well with limb loss.

Through the National Limb Loss Resource Center, the Amputee Coalition provides educational materials, events, one-on-one peer support, and

support groups. We also have a comprehensive website full of incredibly useful resources for amputees and those who care for them.

The most disappointing moment in my job is when someone says, “I wish I had known about the Amputee Coalition when I lost my limb.” Please, do your patients, and yourself, a favor by connecting them with the Amputee Coalition and everything we have to offer.

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O&P News | January/February 2019

17

O&P Visionary

Care, Not Components In my vision of a perfect day, the management of a patient’s orthotic or prosthetic care is at the center—not the delivery of a prosthetic arm or leg or a brace. With expertise and experience, you advance a plan of care for the patient, and the focus is delivering care that includes a device as a component of that care.

Technology is part of the plan of care, but the best technology will never replace a human touch with your skill and knowledge. The key to technology is assessing the need, considering the options, explaining the options to the patient, then selecting the best option for the patient with their input.

Managing the expectations of technology is critical; a wise practitioner once told me, “The best device I’ll ever make is just a tool a patient must learn how to use to get on with their life.”

Expectations must be realistic, including expectations of technology for patient satisfaction to become reality.

Technology may be key to success, but patient-centric, not device-centric, care is critical for successful outcomes and patient satisfaction.

Measure Success and Failure When I go in for a checkup, my doctor has a page full of test results that we review together. When something is out of the normal range, he explains why it is a problem and describes the options to correct the problem. This usually comes down to fewer cheeseburgers and more exercise, or an alternative plan of care involving medication and bypass surgery.

For motivation, he clearly explains studies that show the consequences of not correcting the problem. Unfortunately, we are not yet there in O&P; we still need more evidence to support our recommendations.

In my vision of that perfect day, we’ll measure outcomes for every patient and share the data for the benefit of all, especially the patient. Collecting data, sharing

18 O&P News | January/February 2019

In my vision of that perfect day, we’ll measure outcomes for every patient and share the data for the benefit of all, especially the patient.

data, and studying the data will produce knowledge and lead to best practice recommendations. These recommendations can then be shared with patients and payors as a basis for why a certain plan of care is the best option.

Collecting outcome data gives us the opportunity to measure results and review the care provided. We can then fix what didn’t work and improve on what did. Continuous quality improvement is what some call it; I think it’s just a dedication to pursue that perfect day in O&P.

Partner With Payors Yes, I said partner. Help the insurance companies and other pay sources you work with understand that we are all on the same team, with a patient at the center.

Education, justification, and communication are essential ingredients in teaming with payors. Get your patients involved when appropriate; after all—they are paying the premiums and are described as the “beneficiaries” of the plan.

The Amputee Coalition can help you advocate for your patients and help them advocate for themselves. The Amputee Coalition has created the “Amplify Yourself ” website for just that purpose:

www.amputee-coalition.org/amplifyyourself/. Patients can look there to find advocacy resources and even write a letter to the presidents and medical directors of their insurance companies.

Living in the Moment As you imagine the future and that perfect day, don’t lose sight of today.

Celebrate all of the perfect days along the way to the goal of perfection. Take time to celebrate with your patients on their perfect days, and remember they are at the center of all we do and why we do it.

I’ll close with a modified version of something I wrote in 2017 for AOPA’s 100th anniversary: Hope Press deep the seed of hope, that its roots may reach the soul.

Restoring the life that is lost, when misfortune takes its toll.

Their hope is your hope, with every step you take.

Your ability, their new ability, in everything you make.

With hands and feet, their new tomorrows—tomorrows you create.

With gentle force, limbs once bent, now made straight.

Working together there’s no telling how far we’ll go, Evidence? Lives rebuilt are there for you to show!

You've helped so many hopes and dreams come true.

Experience, dedication, and vision, a perfect future waits for you!

Here’s hoping for that perfect day and wishing you all many perfect days along the way.

Jack Richmond, CPOA, is president and chief executive officer of the Amputee Coalition.

STATE NEWS

State by State

The latest news from Arkansas, California, Georgia, Indiana, and Vermont

O&P News talks to O&P professionals about the most important state and local issues affecting their businesses and the patients they serve. This column features information about medical policy updates, fee schedule adjustments, state association announcements, and more.

Arkansas AOPA members have reported that a private payor is denying authorization unless the O&P provider lowers the patient’s K level. The reported negotiation tactic is arbitrary and unsupported by any medical claim that the patient’s reported level is incorrect.

Providers in Arkansas are concerned about the risk this poses to their patients with respect to being able to access appropriate prosthetic technology and care.

California The California Orthotic and Prosthetic Association (COPA) has partnered with a health-care economist who has extensive knowledge of the Medi-Cal program to prepare

an economic analysis. COPA plans to include the analysis in a legislative proposal to address California’s stagnant Medi-Cal fee schedule.

Georgia O&P providers in the state of Georgia had until Dec. 31, 2018, to either apply for a license as a durable medical equipment provider under the Pharmacy Board, or file a written attestation documenting the reason for exemption. Individuals already licensed to practice in Georgia were exempt, but facilities still had to file attestations for each location that was billing Medicaid, according to the Georgia Society of Orthotists and Prosthetists. AOPA will be posting a poll on the Georgia page of the Co-OP to gather information about the ramifications of this change and the effects seen by providers in the state.

Indiana AOPA held a conference call for its members in Indiana to open a dialogue for O&P providers to discuss the possibility of introducing licensure legislation in the state. There is no formal effort underway, as this was just an opportunity for individuals to express their concerns. AOPA state reps Curt Bertram, CPO, FAAOP, and Tim Ruth, CPO, plan to continue efforts to organize providers in Indiana around

the question of licensure and to address some of the other issues facing O&P in the state.

Vermont In December, AOPA posted an update regarding a Blue Cross Blue Shield Vermont announcement that the Adjustable Cranial Orthoses for Postitional Plagiocephaly and Craniosynostoses Medical Policy had been reviewed and updated, effective Jan. 1, 2019. If you are an O&P provider in Vermont, you should have received a network bulletin and/or notice about the policy changes. Please let us know by emailing co-op@aopanet. org if you have seen the policy language and have any concerns.

Announcement The next AOPA State Reps call will be held on Friday, February 8, at 12:00 noon. The AOPA State Reps network meets quarterly to discuss issues facing AOPA members at the state and local levels.

EDITOR'S NOTE: To submit an update for publication, please email awhite@aopanet.org. For up-to-date information about what’s happening in O&P in your state, visit the AOPA Co-OP and join the conversation in the AOPA Google+ Community.

O&P News | January/February 2019

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21

TECH TIPS

A Bright Future— Technicians Needed

By Joanna Kenton, CPO, LPO, FAAOP

O

22 O&P News | January/February 2019

Photo courtesy of Joanna Kenton, CPO, LPO, FAAOP

n Aug. 21, 2017, the day of the “great American solar eclipse,” I began my career as a prosthetic technician instructor. While America was out sporting their eclipse glasses, I welcomed an excited emerging group of new students to prosthetic fabrication.

During the initial weeks, students studied safety in the prosthetic lab and their role as a technician and began learning the basic skills pivotal to fabrication. The pounding and sawing of metal reverberated through the air as students learned how to cut aluminum uprights and finish copper rivets. Smells of freshly ground plywood greeted our nostrils as they learned how to hold their sanding paddle project to the drum sander.

Patience and test of character intensified as students learned how to sew on both the industrial flatbed and patcher sewing machines; broken needles and “bird nests” were a common sight. Students learned how to fill a negative cast with plaster, smooth out a positive model, and laminate a prosthetic socket. Several “cheesy,” but proud, “first lamination” photos were taken.

From there we continued to work on bench alignment, alignment transfer, and final lamination. Suddenly, from out of nowhere, I began to notice something magical. A leg appeared! Then another … and yet … another! A few weeks prior, they hadn’t even had the fundamental skills to mix plaster! A sense of pride took root inside of me from their early-on accomplishments.

Our students come a long way during their first semester and continue

Yuepeng Vang and Trevor Kuborn

to do so once employed. So why hire an O&P technician graduate versus someone without the specialized diploma or certificate?

Because …

• O&P technician graduates have “skin in the game”—they have invested time and money in their career.

• They have already made several costly errors in class and have learned from them.

• They are in the mindset to take direction and correction when advised—grades depend on it.

• They are excited and passionate for their career—enthusiasm is contagious.

• They are prepared to sit for the technician exam administered by the American Board for Certification in Orthotics, Prosthetics, and Pedorthics (ABC). With future reimbursements at risk, payors at

some point may demand central fabrication accreditation or technician certification for the fabrication of custom devices. From a quality and safety standpoint, this makes sense.

ABC now offers Central Fabrication Accreditation. Certified technicians will be in demand should this come to fruition.

I am happy to report that all of my technician students who started that day, the day of the great American eclipse, are gainfully employed and working as technicians. How many technician students were in my initial cohort? Three. The remainder of my students chose the clinical pathway. While both pathways are critical to the future of our profession, concerns rest heavily on the need for continued outreach to solicit interest for the orthotic and prosthetic technician programs.

TECH TIPS

We have only six accredited technician programs in the country—that’s it! Couple this with an aging technician demographic, and we are in need of highly skilled, trained technicians.

We are a device-driven profession. Without a device, there is no O&P. Fabrication is the lifeblood of our profession.

Therefore, technician education is valuable and should be encouraged within our community.

Unsurprisingly, the orthotic and prosthetic profession is not mainstream.

With amputation and the demand for orthoses on the rise, we need to spread the word that these programs and our profession exist. How can we as professionals promote the O&P technician programs? We can do the following: • Encourage employers to offer attractive and competitive wages for technicians.

• Spread the word: • Get involved at middle school and high school career days.

• Speak at Girl Scout, Boy Scout, and STEM club meetings.

• Use media as a conversation starter. For example, Dwayne Johnson hanging by a prosthesis off of a skyscraper in the 2018 film Skyscraper, or Chrissy Teigen’s December 3 Instagram showing her son wearing a cranial remolding orthosis, are great examples of devices derived from our profession and viewed by mainstream audiences. Whether realistic or not, our devices are seen and may be used in conversation.

• Engage our professional organizations. Additional local and national efforts are needed.

• Embed outreach in our curriculum.

• Incorporate additive manufacturing, maintenance, and repair in our training and curriculum.

• Collaborate with local FabLab or Makerspace locations to spread the word about O&P technician careers.

Together we can build our next generation of technicians. From the traditional methods of fabrication to the modernized advances of additive manufacturing, our technicians are indeed valuable. A good technician is indispensable and a worthwhile member of the team; a high-fab skill set saves not only time during the fit of the device but also money. Education and continued education on the part of the technician is to be commended.

To those who take the time to train new technicians: Thank you! You are the “Mr. Miyagi” to our “Daniel-san.” Your legacy moves forward.

Please spread the word about orthotic and prosthetic technician careers, the value of technician education, and certification. Truly, theirs is a bright future!

Joanna Kenton, CPO, LPO, FAAOP, is a member of the prosthetic faculty at Century College in White Bear Lake, Minnesota.

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O&P News | January/February 2019

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