Alignment2015 The Official Publication of Orthotics Prosthetics Canada
Innovations and Solutions for Sports and Recreation
Roles of a Recreation Therapist Bold New Path for Canada’s O&P Profession Or thotic & Prosthetic Case Studies
Alignment2015 C O N
Industry News 8 President’s Greetings Dan Mead, C.P.O.(c) CAPO President
10 Orthotics Prosthetics Canada
Amalgamating CAPO and CBCPO
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Clinical Team 24 Who’s on Your Team? The Roles of a Recreation Therapist
Continuing Education
12 OPC and The War Amps Collaborate,
17 Celebrating the CAPO Conference 2014
Amputee OT’s LEGO Leg, Cancer de Mama Clinic, Touch-Sensitive Prosthetic Limbs, C-LEG 4, Sensor Liner Detects Limb Changes 110 Product Showcase New & Improved for 2015
74 Student Papers
122 Advertiser Index
Special Feature Section SPORTS & RECREATION
32 To Knee or Not to Knee 38 Into the Unknown Wrist-Hand Orthosis for Biking
42 Iron Ankle
A Novel Design to Combat Inversion Sprains
119 Ethics Quiz
O&P International 28 Bolivia Bound Setting Up Shop Abroad
O&P Solutions 65 Orthotic and Prosthetic Applications for Small Animals
90 Early Reports on EMS Sockets 94 Molding a Complicated WHFO
46 A Revolutionary Tale
98 Fabrication Techniques for
Össur’s Continuing Innovation in Running Prostheses
102 High Heel Cup for Your FO
52 Think Outside the…Shoe!
104 Impact Absorption in Protective Helmets
An Original Idea that is Transforming Lives
55 Troppman Grip
Golf Attachment for Upper Extremity Amputees
58 Trans-radial Hockey Prosthesis
Leather-Reinforced Wrist Supports
108 Going Digital to Fuel Business Growth 117 Safer and Efficient Tools for Bending Metal Uprights
Custom Goalie Stick Terminal Device
62 Concept to Completion
Client Profile
35 Years of Prosthetic Innovations
64 The Fuel for My Fire
Legal Matters 20 Prosthetic Precedent Pursuing Compensation in Traumatic Amputation Cases
Technician’s Report 68 Memorable Moments
Deadline for submissions for consideration for publication in Alignment 2016 is October 1, 2015.
Alignment 2015 Edition The official publication of Orthotics Prosthetics Canada PUBLISHED ANNUALLY OPC Management Office Dana Cooper, MBA, CAE, Executive Director Chris Bossé, Program Coordinator Mara Juneau, Member Liaison 300 March Road, Suite 202 Ottawa, ON K2K 2E2 Phone: 613-595-1919 Fax: 613-595-1155 Email: info@opcanada.ca www.opcanada.ca Publisher DT Publishing Group, Inc. 2276 Rosedene Rd. St. Ann’s, ON L0R 1Y0 Tel: (905) 957-6016; Fax: 877-385-6418 Email: jeff@disabilitytodaynetwork.com
OPC Committees
Nominations Committee Chair Carla Reimer, C.O.(c) Professional Qualifications Committee Chair Scott Simmons, C.P.(c)
Interim Board of Directors January 1 – June 1, 2015 Dan Mead, C.P.O.(c), President Dan Blocka, C.O.(c), F.C.B.C., Vice President Todd Saucier, C.O.(c), Vice President Mark Agro, C.O.(c), F.C.B.C., Treasurer Ronda Badger, C.O.(c) Kevyn-Anne Jamison, R.T.O.(c) Warren Matthews, R.T.P.O.(c) Carla Reimer, C.O.(c) Leslie Pardoe, C.O.(c)
A new OPC Board of Directors will be announced at the inaugural Annual General Meeting, May 29, 2015.
Managing Editor Jeff Tiessen, DT Publishing Group, Inc. Tel: (905) 957-6016 Email: jeff@disabilitytodaynetwork.com
Art Direction Starr Hansen Email: sjdesignstudio@comcast.net Design and Layout SJ Design Studio Email: sjdesignstudio@comcast.net Editorial Committee Sharon Carr, C.O.(c) Krista Holdsworth, C.O.(c) Advertising Sales Jeff Tiessen, DT Publishing Tel: (905) 957-6016 jeff@disabilitytodaynetwork.com Alignment and Orthotics Prosthetics Canada (OPC) make no representations or warranties with respect to the merchantability of the products and services reported or advertised in Alignment and the inclusion of any such product or service in Alignment magazine shall not be deemed an endorsement by OPC. OPC assumes no responsibility or liability for claims made for any products or services reported or advertised. Trademark symbols are associated with trademarked names upon first editorial reference in each article only. Printed in Canada. Contents © Copyright Orthotics Prosthetics Canada and/or the contributing author unless otherwise indicated.
Standards & Ethics Chair Peter Marinic, C.P.(c) Professional Practice Sub-Committee Chair Heather Miklovich, C.O.(c) Professional Development Chair Catherine Vallee, C.P.(c) Marketing & Communications Chair Dave Broman, C.P.O.(c), F.C.B.C. Finance Committee Chair Mark Agro, C.O.(c) Treasurer – Member At Large Alan Moore, R.T.P.O.(c), C.O.(c), F.C.B.C.
Alignment ONLINE
Executive Editor Krista Holdsworth, C.O.(c) Email: orthopro@orthoproactive.com
Associate Editor Brenda McCarthy Tel: (905) 957-6016 Email: admin@activelivingmagazine.com
Certification and Registration Board (CBCPO) Chair: TBA
NEW MEDIA FOR C A N A DA ’ S O & P F I E L D Orthotics Prosthetics Canada joins the DT Network – the disability community’s first social media network. With its own Media Channel, Alignment goes digital in a whole new way... • • • •
I ND USTRY N EWS MF G & CL IN IC AL RESO URCES PRODUCT PHOTO S & VIDEO S S O CIAL M EDIA UPDATES
Alignment Online serves up new information for P&O practitioners all year long.
VISIT: www.disabilitytodaynetwork.com/alignment. Alignment 2015 7
PRESIDENT’S MESSAGE
Our Bold New Path It is a time of renewal for the prosthetic and orthotic profession! Renewal is exactly what we were hoping to achieve with the hiring of new management to lead the operations of the former CBCPO and CAPO. As a membership, we also voted for transformation when we opted to amalgamate into Orthotics Prosthetics Canada (OPC). With the creation of OPC we are following a new path that will be more focused. A strategic planning session in the Fall of 2015 will help determine OPC priorities and a plan will be developed to address them. In the interim, we have the inaugural OPC Annual General Meeting in May where the first elected Board of Directors will be announced. This is a great opportunity to continue the positive momentum that has been created with the amalgamation. The next Board has a great deal of responsibility on its shoulders. It will be charged with obtaining the benefits promised with an amalgamated organization. There is no doubt that the amalgamation represents a change from the way both CBCPO and CAPO have traditionally operated. The OPC Board will be more governance-oriented than in the past which calls for more direction and guidance for committees and management, with increased focus on policy and strategy development. Committees will undertake the work required to accomplish the objectives communicated by the Board. With fewer committees, with fewer members, when additional resources are required to complete committee work or when special projects arise that do not fit under a standing committee, temporary task forces will be utilized to tend to those needs. The AMCES administration team, led by Dana Cooper, will proactively work within the policies established by the Board to implement strategies, manage operations and support committee work. Today, our focus turns to the future of the profession. This perspective represents the evolution of orthotics and prosthetics in Canada. The membership has initiated a very bold direction in voting to create OPC, moving us into a very dynamic environment. There are many issues in play that stand to affect the profession. We cannot afford to be idle in pursuing objectives because of risk aversion or fear of failure, or even internal squabbling. However, it is important that we prioritize as an organization in keeping with the fact that there are limits to the available resources needed to pursue the strategies we set for the profession. We need to continue to be bold in moving the profession forward. We need to establish ourselves as the owners of the space we are the most qualified and skilled to address. We need to ensure that we have the policies, processes and procedures in place to properly prepare those entering the profession. We need to ensure that certified and registered members are professional in all respects, and beyond reproach. We must take care of business, establishing objectives that are sensible, yet flexible enough to address emerging needs. This bold, new way forward will take patience and adjustment. It will take every member’s participation in developing and supporting a direction that makes he or she proud to be a member of Orthotics Prosthetics Canada.
Dan Mead, C.P.O.(c) OPC President
8 Alignment 2015
INDUSTRY NEWS
Orthotics Prosthetics Canada Amalgamating CAPO and CBCPO
By: Dana Cooper, Executive Director, Orthotics Prosthetics Canada
Congratulations! Prosthetic and orthotic professionals have overwhelmingly supported the amalgamation of the Canadian Association of Prosthetics and Orthotics (CAPO) and Canadian Board for Certification of Prosthetists and Orthotists (CBCPO) to create Orthotics Prosthetics Canada (OPC). The amalgamation took effect January 1, 2015.
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ince the vote to amalgamate has taken place, there has been constant work to undertake the details to formally combine the organizations into one cohesive unit. While there are many foreseeable requirements that need development and revision with the amalgamation, there are just as many that have not yet been considered. Realistically, the process for the former CAPO and CBCPO organizations to become the OPC will be ongoing throughout 2015, the time needed for internal and external forces to align behind the single entity. This alignment is facilitated by the development and adoption of a strategic plan, which is preceded by information gathering and analysis of the internal and external environments. One of the most significant benefits that amalgamation will bring to the orthotic and prosthetic profession is focus. It is expected that this focus will result from an effective strategic planning process. This focus will be in the form of identifying where OPC resources are best allocated to address priority issues and opportunities. Identifying the priority issues is not
10 Alignment 2015
simple. However, as is often quoted in organizational management, “You may not know the key to success, but the key to failure is trying to be everything to everyone.� To effectively move the profession forward there has to be effort focused in an identified direction to make a difference. The further that the efforts are spread out, in terms of initiatives that utilize resources, the less effective those efforts will be in addressing the priority issues and opportunities. What that means is that difficult decisions have to be made, not only about what issues or opportunities become the highest priorities, but even more importantly, pursuing needs that may not be perceived as high priorities. The reality is that an association can identify hundreds of initiatives that would provide value, but resources are limited and there is an inverse relationship between how widely resources can be dispersed and their effectiveness. We know that OPC will be the credentialing body for prosthetics and orthotics, through an arm’s length permanent credentialing board which will continue to be named CBCPO.
It will also be the self-regulatory body to ensure ethical conduct and that patients remain the highest priority for prosthetic and orthotic professionals. OPC has a necessary role to play in continuing education and in developing standards of practice for the profession. Another critical function that OPC needs to perform is in government and stakeholder relations. Recognizing those core activities is integral in the aligning and coordinating of activities for a single OPC entity. Another step will be the strategic planning process to be completed in late 2015. The completion of the strategic plan is not the end of a process, as many organizations believe. Rather, it is the beginning for one cohesive entity moving in a purposeful direction. In practice, alignment and focus are always being challenged and it requires a dedicated and constant effort to stay the course. Amalgamation is a long road, likely one that is longer than anticipated. However, with an effective strategic management process, and patience, OPC will emerge as a cohesive and focused organization that can effectively move the profession forward.
Better
PERFORMANCE
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QUALITY
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RELIABILITY
Toll Free: 800.279.1865 on The Web: www.trsprosthetics.com n www.oandp.com/trs
INDUSTRY NEWS
OPC and The War Amps Collaborate
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rthotics Prosthetics Canada (OPC) and The War Amps have entered into a Memorandum of Understanding (MoU) to formalize a relationship intended to improve outcomes for amputees and prosthetic professionals. The purpose for the MoU is expressed as: Affiliation and collaboration allowing for the development of evidencebased recommendations for public and private funding agencies concerning amputee care services, prosthetics, orthotics and support for Canadians living with amputation and the orthotic and prosthetic profession. By fostering a partnership, The War Amps and OPC will contribute to raising the standards of amputee care and positioning Canada’s health sector as a global leader at the forefront of amputee care. OPC and The War Amps will work collaboratively to ensure that Canadians with amputation receive the most appropriate, evidencebased and timely care to ensure optimal outcomes. OPC has committed to being the final authority for all aspects of clinical prosthetic and orthotic care and services, to consult with The War Amps on prosthetic and orthotic care related to third party policies, guide-
lines, benefit grids or funding models and related matters, and to encourage all persons with amputations to seek the assistance of The War Amps. The War Amps will provide research and maintain informational databases related to public and private funding models for prosthetics and orthotics, and academic material of all types of prosthetic devices for amputees, as well as provide policy advice, funding guidance and advocacy as the voice for persons with amputation ensuring that cases of insufficient O&P funding across the country are addressed. The War Amps will also share OPC expertise as the centre of excellence in amputation and facilitate education and awareness among public and private funding agencies and other stakeholders regarding amputee issues and needs, including requirements for clinically appropriate and up-to-date artificial limbs, and raise awareness among Canadians living with amputation and the public regarding the diversity of amputation-related matters. OPC looks forward to the enhanced working relationship with The War Amps in our continuing efforts to raise the standards for amputee care in Canada.
A M P U T E E OT ’ S L E G O L E G Amputee Christina Stephens became a YouTube sensation, now with over 2.3 million views, with her video of her making a prosthetic leg out of Lego in the name of fun and a formidable attitude. She began videotaping her life as an amputee starting the day after her amputation. Her YouTube channel has dozens of clips of her learning to live without part of her leg and mastering the use of her new prosthetic limb. Stephens, a practicing occupational therapist, clinical researcher and peer educator, was working on her car in mid-January when its supports gave way and the car crushed her foot. In one video, she explains why she chose to have her lower leg removed instead of trying to salvage it. Most of her videos are fun, because that’s the approach she decided to take. From Mirror Therapy to S#!t People Say to Amputees, Stephens serves up a great resource for new and seasoned amputees alike... and practitioners too. Check out www.youtube.com/user/ AmputeeOT?feature=watch.
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Touch-Sensitive Prosthetic Limbs
Bressanté Donates to the Cancer de Mama Clinic In 1996, British Columbia native and breast cancer survivor Jackie Jackson founded the Cancer de Mama clinic in La Penita, Mexico, a region that has an extremely high incidence of breast cancer. Cancer de Mama, with the help of more than 200 volunteers, offers free prostheses, funds medical expenses, provides post-surgery counseling and physical therapy, and gives wigs, scarves, and hats to Mexican women. Winnipeg-based Bressanté helps breast cancer survivors by designing and manufacturing a line of customized breast prostheses that are tailored for
everyday life. Creating breast prostheses that will help women be comfortable while enjoying sporting activities, like swimming, is a major focus as well. Bressanté recently made a generous donation of bras and prostheses to the Cancer de Mama Clinic in an effort to give the women there as many options as possible for regaining their confidence. Bressanté is committed to supporting the many volunteers that give their time and compassion to the women of Mexico. Follow Bressanté and Cancer de Mama on Facebook for recent news and tips about living well.
New research from the University of Chicago may one day result in touch-sensitive prosthetic limbs that communicate directly with the brain. The researchers, led by Sliman Bensmaia, assistant professor in the Department of Organismal Biology and Anatomy at the University of Chicago, believe their work could help to increase both the dexterity and function of robotic limbs. Through experiments with monkeys, Bensmaia and his team pinpointed neural activity patterns that occur when the animals manipulate objects, and they were able to successfully recreate these patterns artificially. “To restore sensory motor function of an arm,” Bensmaia says, “you not only have to replace the motor signals that the brain sends to the arm to move it around, but you also have to replace the sensory signals that the arm sends back to the brain.” As a result of these experiments, Bensmaia and his colleagues say that they have created a set of instructions that could be used with a robotic prosthetic arm, which could give sensory feedback to the brain through a “neural interface.” This feedback, Bensmaia believes, could mean that these kinds of devices may be that much closer to undergoing tests in human clinical trials. The research is part of a Defense Advanced Research Projects Agency (DARPA) project called Revolutionizing Prosthetics with an aim of creating an artificial upper limb that will provide natural motor control and sensation in patients with amputations. Results of the research were published in the journal Proceedings of the National Academy of Sciences.
C-LEG 4
ANNOUNCED Ottobock continues the industry-leading tradition of improving outcomes for amputees with the launch of the C-Leg 4 microprocessor knee. With studies citing increased stability and reduced falls, the C-Leg 4 is weatherproof, can be controlled with the Android Cockpit app, and makes walking backward easier. The C-Leg 4 is also reported to be smoother, more stable, and with a shorter build-height a better fit for more people. Learn more at www. ottobockus.com/cleg.
Sensor Liner Detects Limb Changes Researchers in the Intelligent Systems, Robotics and Cybernetics group at Sandia National Laboratories (Sandia), Albuquerque, New Mexico, have developed a sensor that will monitor volume changes in the residual limbs of prosthesis users and automatically accommodate for those changes. The researchers developed a three-axis pressure sensor, about the size of a quarter, to monitor fit and detect deviations. The sensors fit inside an elastomer prosthetic liner similar in thickness to a gel liner. Sandia has filed a patent application and has presented papers at conferences about the work. Jason Wheeler, Ph.D., who has been studying prosthetics at Sandia for ten years, says the sensor is unique because it detects pressure in three different directions: normal pressure, and horizontal and vertical shear forces, which can cause rubbing, blisters and abrasions. Sensors can be placed in various spots, measuring three directions at each site. Other designs have placed pressure sensors in sockets, but only measured normal pressure, said Wheeler. “This extra information gives you better ability to know when
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you need to make modifications because the shear pressures tend to be a little more sensitive to changes in socket shape than normal pressures,” he added. The system automatically adjusts socket shape by moving fluid into bladders inside the liner. The bladders are filled using valves and pressurized liquid on the outside of the liner and add volume only where it’s needed. “Being able to put additional fluid volume locally, where you lost it, is an important component,” Wheeler said. Prototypes have been developed to fill and empty the bladders automatically, but he says more research is needed to determine when it’s best to add and remove fluid. Development is continuing and more testing with subjects with amputations is needed, but the technology “is getting mature enough where before too long, if we want it to be successful, we’re going to have to hand it off to a commercial entity to market it,” Wheeler said. Editor’s note: Adapted from materials provided by Sandia National Laboratories, first published in The O&P EDGE.
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CONTINUING EDUCATION
What Goes Around, Comes Around Celebrating the Final CAPO Conference, CAPO 2014 By: Paul J. Osborne, C.P.(c), F.C.B.C.
It was July 22nd, 1969, at the Annual General Meeting of the Interprovincial Association of Prosthetists and Orthotists of Canada, when the membership voted in favour of adopting a new name. That was the day that the Canadian Association of Prosthetists and Orthotists (CAPO) was born.
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ne year later the first CAPO Conference was held at the University of New Brunswick in Fredericton. Since then, CAPO conferences have grown in attendance to a strong 350+ delegation from across the country, as was the case for CAPO 2014 in Halifax, Nova Scotia. And now the CAPO Conference has ended where it began, in the Maritimes. And it was a blast! Delegates came to Halifax in great numbers, from coast to coast, for three days of education, fun and camaraderie. The conference served up an extraordinary program with over 50 speakers and an Exhibit Hall featuring 40 exhibitors.
The plenary lecture theatre was packed as notable invited speakers such as Dr. John Banja, Dr. Nancy Dudek, Gary Bedard and Jeff Tiessen, to name a few, shared their work and experiences within our field. Dozens of our own colleagues followed with lectures and workshops in all aspects of our profession, packing CAPO’s premier event. The Harbourfront Marriott Hotel, with its lively waterfront and attractions, was home base for conference goers and the host of the traditional CAPO Welcome Reception with the Mayor of Halifax, His Worship Mike Savage, on hand to extend an official greeting. CAPO President Leslie Pardoe officially kicked off CAPO
(Above) CAPO Board Back Row (L to R): Warren Matthews, Leslie Pardoe - CAPO President, Paul E. Osborne, Andrew MacLeod, Markus Saufferer, Dan Mazur, Jim Amesbury, Elizabeth Harris Front Row (L to R): Sharon Carr, Alan Rigby, Krista Holdsworth, Todd Saucier, Dan Mead, Dana Cooper
2014 at the President’s Breakfast. Carla Reimer, President of CBCPO, honoured six of our members with the title of Fellow of the Canadian Board for Certification of Prosthetists and Orthotists. These awards recognized the countless volunteer hours that these members have given while serving on numerous boards and committees to further advance our profession in Canada. Congratulations to Krista Holdsworth, C.O.(c), F.C.B.C., Jennifer Russell-Smyth, C.P.(c), F.C.B.C., Greg Hamaoka, R.T.P.O.(c), F.C.B.C., Andrew St. Hilaire, R.T.P.O.(c), F.C.B.C., Warren Matthews, R.T.P.O.(c), F.C.B.C. and Allan Moore, C.O.(c), F.C.B.C.
Carla Reimer presents new F.C.B.C. Allan Moore with his certificate.
With a bagpiper leading the way, the delegation was paraded from the President’s Breakfast to the Exhibit Hall in the Halifax Metro Centre to meet 40 distributors and manufacturers with over 100 exhibitor delegates filling 70 booths. New products and technologies were displayed and demonstrated over the ensuing two days making the Exhibit Hall a very busy forum. Sixteen Manufacturer’s Workshops provided a hands-on opportunity to demonstrate and promote many of their products. CAPO 2014 introduced an Exhibit Hall After-Hours Social, sponsored by the exhibitors, which was a big hit. Exhibitors supplied food and beverages as they discussed their products in a more relaxed and informal atmosphere that was enjoyed by all. Slo-Pitch returned to the CAPO Conference in 2014 complete with a BBQ, beer tent and a weekend warrior enthusiasm. Team Orthotics and Team Prosthetics vied for bragging rights in the revamped rivalry. While Team Orthotics blasted out of the box to an early lead, an inspired Team Prosthetics
Exhibit Hall social was a hit!
rallied back to overpower their opponent. Despite a nearly constant drizzle, it was an exciting evening for players and spectators alike. CAPO 2014 came to a close with a wonderful seafood buffet coupled with a stringed-quartet serenade prior to the dinner. The night came to a raucous and entertaining end fuelled by the hometown band Pogey. Attendees were treated to a Maritime Kitchen Party and jigged the night away. Halifax’s CAPO 2014 was yet another successful conference thanks to the support of our members, and especially those who submitted the abstracts that were such an integral component of the educational experience. The Conference Committee thanks all of the exhibitors for their contributions and support. CAPO also extends a sincere thank you to our Gold Sponsors – Myrdal Orthopaedic Technologies, OrtoPed and Ottobock Healthcare – as well as our Silver Sponsors – Action O&P, Ortho Active Appliances and Össur Canada. A special acknowledgement goes to members of the conference
organizing committee whose efforts made this event the great success that it was:
Lecture Series Christa Bell, C.O.(c), R.T.O.(c) Sharon Carr, C.O.(c) Kieran Bliss, C.P.(c) R.J. Clements, C.P.(c) Warren Matthews, R.T.P.O.(c)
Exhibit Hall Dave Broman, C.P.O.(c), F.C.B.C.
Registration & Administration Christianne Bossé Dana Cooper Kathryn Cyr Christina Mash As our profession evolves, so have our associations, becoming one... enter Orthotics Prosthetics Canada (OPC). It is with great anticipation that we look forward to the inaugural Orthotics Prosthetics Canada Conference, OPC 2016, to be held in Banff, Alberta, in August of 2016. This gathering will be a truly memorable experience. We look forward to seeing you there.
OrtoPed sponsored a fun baseball game pitting orthotists against prosthetists.
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LEGAL MATTERS
Prosthetic Precedent Pursuing Compensation in Traumatic Amputation Cases By: David Lackman, J.D.
Personal injury lawyers, not unlike healthcare professionals, see a wide range of traumatic injuries... mild and temporary, severe and permanent, and those in between. Few would question the characterization of injuries leading to amputation as anything other than severe and permanent. Limbs, whether fingers, hands, arms, legs or feet, obviously don’t regenerate, and human physiological function is not capable of replication, even with modern microprocessor-based prosthetics.
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lthough normal physiological function – whether fine or gross motor – still has no true “equal” in the prosthetics world, bio-medical and bio-mechanical engineering advances over the past 20 to 30 years have led to dramatic enhancements in areas such as materials (e.g. lightweight, durable carbon-fibre composites), interfacing between the prosthetic device and the residual limb (e.g. socket/ suspension systems), functionality of prosthetic limbs (e.g. micro-processor and impulse-driven myoelectrics), and aesthetics (e.g. prostheses that mimic the cosmesis of natural limbs). These advances are the products of inventiveness, not to mention substantial invest-
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ments in research and development. The costs associated with acquiring such devices are therefore significant.
Litigation Injury litigation brings innocent accident victims face-to-face with our Court system. It is in this forum that we must ask judges and juries to ensure that the amputee-victim is awarded sufficient damages to make his or her remaining lifetime, whatever its length, as impediment-free as can reasonably be achieved. This includes provision for state-of-the-art prosthetic devices that will maximize “normalcy” of function and restore, as much as possible, the individual’s independence.
One need only refer back a few decades, to the 1970s, where the country’s highest Court pronounced that in cases of catastrophic injury, which include amputations, there is no duty on the part of the victim to mitigate in the sense of being required to accept less than the actual loss, regardless of the ability of the defendant to pay.1 It was not until the 1980s, however, with this important principle in mind, that issues of full compensation for amputeevictims, fairness to defendants, and expensive technology-driven devices, collided in the Courts of Ontario.
Setting Precedent Giannone v. Weinberg was, in its own
“ In view of the wrong done, I hold that Antonella should have the best prosthetic devices that are... available ” way, a precedent-setting case, having imported the principle of full compensatory damages into the modern prosthetics realm. The litigation centred on six-year-old Antonella Giannone who, as a result of medical mismanagement of a compound fracture, lost her dominant right arm to amputation. There was certainly no dispute in the litigation as to the need for prosthetic treatment. The hard-fought issue was whether the Court should award prosthetic-related damages in an amount sufficient to enable Antonella to acquire the more costly “Utah Artificial Arm” manufactured by Motion Control, Inc. of Salt Lake City – the prosthesis that Antonella’s lawyers were contending ought to be allowed – or whether, as the defence argued, the Court should award the significantly lower amount that would be sufficient to pay for the conventional “Variety Village Arm” fitted at the Hugh MacMillan Centre in Toronto. The Utah Arm, at the time, was a highly-advanced trans-humeral prosthesis which, through the application of miniaturized electronics, provided proportional control of both hand and elbow. It represented the state-of-the-art (or, more accurately, engineering) in upper limb prosthetic treatment, and it was the contention of counsel for Antonella that she should be entitled to the best and nothing less, despite the cost. In his trial judgment2, Mr. Justice Fitzpatrick had this to say about the prosthetic-related damages to which an amputee-victim is entitled: “A great deal of the evidence in this assessment of damages was devoted to what kinds of prosthetic devices would be best for Antonella. I was most impressed by the witnesses who
testified on her behalf and accept their evidence. In view of the wrong done, I hold that Antonella should have the best prosthetic devices that are from time to time available and I find they will probably be the following: (i) Utah Arm, to be replaced every 5 years ...... $32,000 U.S. (ii) Back-up arm, one-time purchase ...... $27,500 U.S. (iii) Powered wrist rotator, available in 7 ½ years, to be replaced every 5 years ...... $3,500 U.S. (iv) Lighter hand, available in 5 years ...... $4,000 U.S. (v) Powered humeral rotator, available in 7 ½ years, to be replaced every 5 years ...... $6,500 U.S.
(vi) Micro-processor to be available in 7 ½ years ...... $15,000 U.S.” The Court of Appeal3 upheld the award, but reduced the cost of the improvements that were expected to be available in five or 7½ years by 20% to reflect negative contingencies, including that the improvements might not come to fruition for lack of research funding and the possibility that Antonella might abandon the use of the Utah Arm. The Court of Appeal nonetheless maintained the integrity of the principle that the amputee was entitled to “the best prosthetic devices… available”, and this has been and will be significant for similar claims going forward. It is important to note that the Utah Arm, albeit state-of-the-art and more costly at the time, was not an experimental or
Other Future Care Needs Apart from the prosthetic-related damages, which are typically substantial in their own right (especially where young persons are involved), it is important to note that future care claims of an amputee which are customarily quantified and pursued in litigation encompass a broad spectrum of needs such as household and attendant care assistance, mobility, transportation and equipment needs, counselling, education and retraining, therapy, needs arising from future revision surgeries and other medical procedures, and so on. The damages that will be pursued in a given case should, of course, reflect the assessed needs of the individual based on factors that would include the type of amputation and the individual’s age, psychological health, occupation, transferrable skills, retraining potential, and recreational lifestyle, to name only a few. concept device but rather, an existing, proven and serviceable prosthesis.
Proving Future Prosthetic Needs In cases where ongoing care will be necessary, to what extent must one “prove” that specific future pecuniary needs, including those related to prosthetics, will actually arise? This is important since purely speculative damages are not permitted in law; however, to have to prove that certain future needs will arise, even “on balance of probability” – which is the traditional standard of proof in civil damage actions – might be too onerous a requirement and, absent such proof, the injured victim could be under-compensated. Referring to established precedent law on the subject4, the Court of Appeal in Giannone noted: “It is not necessary for the plaintiff to prove on balance of probabilities that a future pecuniary loss will occur but only that there is a reasonable chance of such loss occurring.” This standard would apply not only to the need for future maintenance and replacement of prosthetic limbs, but presumably to prostheses or components not yet necessarily in existence
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but whose design and operational enhancements are at least at a stage of funded research and development, and where the evidence establishes that the improvements will likely come to fruition within the projected timeframe.
Assistive Devices Program It has been held in Ontario that the damages awarded for prostheses must be offset by the contributions received and likely to be received in future from the Ontario Assistive Devices Program (ADP)5. This has been a controversial area in that there is no guarantee the ADP Program, which is government funded, will be there in the future, despite its having come into existence in the early 1980s. To address such contingency, some Courts have impressed future damage awards with a trust for the benefit of the defendant to ensure that future amounts received from the ADP Program are returned to the defendant. Other Courts have adjusted the applicable discount rate to offset increasing prosthetic costs that have historically far exceeded the marginal increases in ADP contributions over time.6
References 1. Andrews v. Grand & Toy Alberta Ltd., [1978] 2 S.C.R. 229 (S.C.C.). 2. Giannone et al v. Weinberg, (1986), 37 C.C.L.T. 52 (ON SC). 3. Giannone et al. v. Weinberg, (1989), 68 O.R. (2d) 767 (C.A.). 4. Schrump et al. v. Koot et al., (1977), 18 O.R. (2d) 337 (C.A.). 5. Greenhalgh v. Douro-Dummer (Township), 2009 CanLII 71014 (ON SC); 2012 ONCA 299 (CanLII). 6. Roberts et al. v. Morana et al., (1997), 34 O.R. (3d) 647 (ON SC); (2000), 49 O.R. (3d) 157 (C.A.).
About the Author: David Lackman is a senior counsel practicing with Gluckstein Personal Injury Lawyers P.C. in Toronto. In 1982 he was admitted by the Supreme Court of California as an Attorney in the State of California. He was thereafter admitted, in 1985, by the Law Society of Upper Canada as a Barrister & Solicitor. His litigation practice now extends over 30 years, encompassing serious and complex personal injury and disability claims, including traumatic amputation claims, and wrongful death claims. Correspondence to: lackman@gluckstein.com.
CLINICAL TEAM
Who’s on Your Team? The Roles of a Recreation Therapist By: Amanda Parent, R/TRO, CTRS Communications Coordinator, Therapeutic Recreation Ontario Kimberly J. Lopez, Ph.D. (C) - Recreation & Leisure Studies, University of Waterloo
Clinical teams can be a complex amalgam of professionals with respective specialities, each of whom wear various hats. With the addition of a patient, or client, and their family, the size of this interprofessional team can vary widely. And so, it is important as teammates in care to know who is on your team and their roles, to harmoniously support care together.
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he therapeutic recreation profession is often misunderstood and its role, as a contributing member of the care team, is often underestimated. Contrary to popular belief, there is more to ‘it’ than just fun and games. Together with clients, Recreation Therapists utilize physical, emotional, spiritual, and social domains to develop recreation and leisure goals in supporting a client’s desired quality of life. Their assessment findings and documentation (on interests, relationships, and other relevant measures) can contribute significantly to clinical team decisions. Recreation Therapists understand that, for clients and other care team members, an orthosis or prosthesis can be integral to maintaining independence and for participating in day-to-day activities. Recreation Therapists can support
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individuals in a meaningful leisure lifestyle with an orthosis or prosthesis by facilitating new transitions to past/existing activities, accommodating new activities, and/or supporting physical and social engagement in a variety of leisure opportunities. Ultimately, Recreation Therapists aim to engage individuals through leisure, which supports life-balances and understandings of overall well-being that are unique to each individual.
What is a Recreation Therapist? A Recreation Therapist is a professional who has studied, and a current practitioner, in the field of therapeutic recreation (TR). TR is a process that utilizes functional intervention, education and recreation participation to enable persons with physical,
cognitive, emotional and/or social limitations to acquire and/or maintain the skills, knowledge and behaviours that will allow them to enjoy their leisure optimally, function independently with the least amount of assistance and participate as fully as possible in society. Although TR professionals have a variety of titles, they are often referred to as Recreation Therapists (RTs). Using recreation and leisure, RTs work with persons who have disabilities or other limitations and require assistance to access leisure or recreation opportunities in the effort to improve their quality of life. This may involve educating individuals about the skills and resources required to participate in recreation and leisure, or making necessary adaptations to recreation and leisure opportunities to allow for full participation.
Therapeutic Recreation Ontario (TRO) TRO is a voluntary membership association with the goal of unifying and directing the therapeutic recreation profession by providing guidance and support for its members. In order to protect the rights of individuals across diverse delivery settings throughout the province, TRO provides resources to support TR professionals develop quality services and advocate for advancement of the profession (Therapeutic Recreation Ontario, 2014b). Within the clinical team, RTs support individuals with whom they work to: • Improve physical and cognitive abilities • Increase confidence and self-esteem • Foster greater involvement in the community • Strengthen interpersonal skills and relationships
What Role Does an RT Have on the Clinical Team? Adding value to any clinical team, an RT’s principles and process can complement team discussions by speaking to what they learn in assessments, intervention planning and intervention implementation with clients. An RT focuses on what a client can do in conducting an intensive needs assessment towards the development of an appropriate personalized intervention. Together, RTs and clients determine the best way to assess current interests, abilities, needs and barriers to a meaningful leisure lifestyle in order to set goals that are achieved through engagement in recreation/leisure interventions and programs. After utilizing various facilitation techniques to engage an individual with whom they work, an RT will adhere to agency standards to communicate with the rest of their team, including how an individual may have responded to an intervention. An RT will also advocate and develop relationships with key stakeholders to ensure that individuals are equally-valued members of their community. Intervention planning and implementation (and advocacy, of course!) can be achieved in consultation or collaboration with other members of a
• Improve coping and adaptation skills • Enhance well-being • Encourage a greater sense of accomplishment • Realize the benefits of a healthy leisure lifestyle
clinical team. For example, a planned session on dining could involve an RT (socialization), dietician (nutrition) and OT (ADLs), wherein each role potentially supports/considers the use of a client’s orthosis/prosthesis. Where a client has a goal of improving strength and balance, an RT can utilize meaningful activities for the use of a new orthosis/prosthesis in a practical situation. The RT might observe the client taking a city bus to her/his favourite coffee shop for example, or participating in a swimming program. The clinical team can then gain insight into the client’s ability to utilize their orthosis/prosthesis and what barriers they face.
How Can an RT Benefit Clients with an Orthosis/Prosthesis? In Canada, orthotic/prosthetic services began with the “Department of Veterans Affairs’ struggle to meet the prosthetic needs of servicemen wounded in the two World Wars” (Our History, 2013). Today, adaptive sports have become a popular means for veterans to improve fitness and independence. After experiencing a trauma, improvements to quality of life can be experienced through participation in adaptive sports. Evidence suggests that participation in sports yields positive
“ The therapeutic recreation profession is often misunderstood and its role, as a contributing member of the care team, is often underestimated.” outcomes including physical health, personal enjoyment and quality of social life (Barletta & Loy, 2006; Zabriskie, Lundberg & Groff, 2005). Recently, Keli Cristofaro, a Therapeutic Recreationist at St. Joseph’s Care Group in Thunder Bay, provided an example of how her clinical team worked together to help a young hockey player get back into the game after sustaining a below-knee amputation. Cristofaro worked with a physiotherapist to help their client develop balance and strength by walking with his new prosthetic leg. Once this was achieved, Cristofaro facilitated opportunities for the client to practice using his prosthesis while roller-blading within the hospital. The next step was to go to the local ice rink where he skated for the first time since his injury. While skating, the team quickly determined that the prosthesis was losing suspension once the client began to perspire. The clinical team worked together to identify solutions and after some trial and error, they crafted a garter system for the leg to remain secure while he was skating. The client went on to join an amputee hockey team that competed nationally and in the United States. Not only can an RT provide adaptations to enable the client to continue to participate in leisure activities that are meaningful to them, but can also provide parasport resources, community leisure education and tips
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“ Adding value to any clinical team, a Recreation Therapist’s principles and process can complement team discussions by speaking to what they learn in assessments, intervention planning and intervention implementation with clients.” among other community integration supports (Emerich, Parsons & Stein, 2012). Cristofaro shares that she works with many clients who experience anxiety about how others in their community will react to the appearance of their prosthesis. When facilitating community outings with her clients, she often provides education on how to deal with stigma that exists within society and how to reduce/re-inform these attitudinal barriers. For example, when some school-age children were staring at her client’s prosthetic leg, Cristofaro encouraged him to talk to them about his prosthesis and allow them to touch his “transformer leg” (K. Cristofaro, personal communication, 2015). Not only did the children gain exposure to a prosthesis, but the client became more confident going into the community and relating to others who are unfamiliar with a prostheses... a role TR can foster for individuals with disabilities (Devine & Lashua, 2002). For the client, an orthosis/prosthesis is important, and what can make the most impact is how the device
contributes to their quality of life. In the same light, leisure interests often shape how we identify ourselves (i.e., runner, artist, baseball player, or musician) and contribute to our world. With appropriate support – from RTs, prosthetists, orthotists, and other members of the clinical care team – an individual is able to engage his or her leisure identities, and in turn bring much meaning to his or her life. The discipline of therapeutic recreation can greatly benefit clients with an orthosis/prosthesis and help to inform their decisions regarding these devices. When these two specialities engage one another, the entire team is stronger for it; the overall welfare and well-being of our clients is assured, and amazing results are possible.
physical disability. American Journal of Recreation Therapy, 5(3), 6-12. Canadian Association for Prosthetics and Orthotics. (2013). Our History. Devine, M. A. & Lashua, B. (2002). Constructing social acceptance in inclusive leisure contexts: The role of individuals with disabilities. Therapeutic Recreation Journal, 36(1), 65-83. Emerich, L., Parsons, K. C. & Stein, A. (2012). Competent care for persons with spinal cord injury and dysfunction in acute inpatient rehabilitation. Top Spinal Cord Injury Rehabilitation. 18(2): 149–166. doi: 10.1310/sci1802-149. Pochwat, M. (2012). Big stand up. Therapeutic Recreation Ontario. (2014a). About Therapeutic Recreation. Zabriskie, R. B., Lundberg, N. R. & Groff, D. G. (2005). Quality of life and identity: The benefits of a community-based therapeutic recreation and adaptive sports program. Therapeutic Recreation Journal, 39(3), 176-191.
Visit the TRO website at https://trontario. org to learn more about therapeutic recreation and how the RT can play an integral role on your team.
About the Authors: Amanda Parent, R/TRO, CTRS, received her degree in Recreation & Leisure Studies with a specialization in Therapeutic Recreation from the University of Waterloo in 2002. She went on to practice TR for over 10 years working at Seattle Children’s Home, St. Joseph’s Healthcare Hamilton and Homewood Healthcare Centre. Amanda is now the Communications Coordinator for Therapeutic Recreation Ontario.
References Barletta, A. R. & Loy, D. P. (2006). The experience of participation in Challenger Little League through the eyes of a child with a
Pochwat, 2012
Kimberly J. Lopez, Ph.D. Candidate, followed up on her post-graduate program in Therapeutic Recreation from Georgian College with an MA from the Department of Recreation & Leisure Studies at the University of Waterloo. Currently a doctoral student in the Aging, Health, and Well-being program in the Faculty of Health Sciences at UWaterloo, her interests lie in racialized and gendered experiences of care labour and leisure.
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O&P INTERNATIONAL
Bolivia Bound Setting Up Shop Abroad
By: Duane Nelson, C.P.(c)
As the old adage goes… “Don’t bite off more than you can chew.” But when in Bolivia, and you are lucky enough to discover a big “piece of cake” you’ll find a way to chew through it.
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n January of 2013 my wife and I decided that the time was now to live out one of our life goals, which was just as much of a career goal for me. We would take up temporary residence in a less economically-developed country to provide prosthetic education and care. There were so many important factors that were tugging at us to delay... our daughter was just 18 months old at the time. The mortgage. Not enough savings. My professional duties, a permanent position as a prosthetist at the Saskatchewan Abilities Council. On the other hand, we could easily see even more responsibilities ahead of us as our lives moved on. I was reluctant to share our intentions with my employer until we at least had an outline of a plan in place. Within a month of our decision to commit to the adventure, The interior of the socket a patient had used for 12 years.
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we learned of an opportunity through the OandP Listserve. The posting was a call for a practitioner to teach and enhance the practice of two Bolivian prosthetists working at a grassroots community organization called el Centro de Miembros Artificiales in La Paz, Bolivia. Rationalizing that our prosthetics department at the Saskatchewan
Abilities Council (SAC) was amply staffed at the time, in preparation for a future retirement, I presented my request for a six-month leave of absence to volunteer in Bolivia. Without hesitation, SAC recognized the value in supporting my professional and personal development. I happily committed to resume my work for SAC upon my return from Bolivia.
Photo by Paco Galvan
Photo by Paco Galvan
A teaching moment while assessing a hip disarticulation amputation.
Using an old Berkeley jig for alignment of the socket and the Shape and Roll foot.
The support and commitment from my employer was empowering. On October 23, 2013 my wife Jessica and I, with our two-year-old daughter, descended upon the rugged city of La Paz, Bolivia, perched at an elevation of 13,600 feet above sea level. From that moment forward, we never caught our breath again until our return to Canada six months later.
Before our departure to Bolivia, we were informed that the clinic was moving its location and would be operational by the time we arrived. What we walked into on our first day in La Paz served as our first lesson in South American eternal optimism. There was no clinic. Granted, there was a building and a clinic name, but no equipment and no supplies. A fledging local staff awaited my instruction. Taking it in stride, I spent the first month purchasing equipment – a convection oven, refrigerator vacuum pump, band saw, bench grinder, shop vac, and a drill press. I was assisted, from a distance, by Matthew Pepe, the American founder of the clinic and untiring volunteer, who was back in San Diego, as well as the eager local staff. I also received short-term help from volunteer travellers during that time. One month later we had cast, fabricated, and fit our first prosthesis. The next months were filled with trials and triumphs as el Centro
Living in the oxygen-thin environs of the highest-altitude capital city in the world certainly had something to do with that, but moreso it was the unending list of responsibilities that kept us constantly gasping for air. Hyperbole aside, we welcomed the colossal amount of work with open arms. That’s why we came. They needed help.
Patients’ do-it-yourself prosthetic legs.
Photo by Paco Galvan
Although trauma and infection are prevalent, diabetes is still the leading cause of amputation in Bolivia.
de Miembros Artificiales found its feet, so to speak. New patients were treated every day. Each case provided a unique learning opportunity for the newly-hired Bolivian prosthetist-intraining. We were fortunate that this trainee was educated as a physical therapist, and could assimilate important prosthetic concepts quickly. The lasting impact of our time with el Centro de Miembros is not
Photo by Paco Galvan
Gait training with a Limbs polycentric knee.
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found in the form of new equipment such as the oven or bench grinder, but rather in the practical clinical techniques, and the classroom theories, that the staff learned and will employ in their practice. With only four months of combined classroom and practical training, the new trainee was charged with equal responsibility as that of a Canadian counterpart after four years. The country of Bolivia does not have any existing educational programs in, or out of, university to teach prosthetics. The only means for a Bolivian to study prosthetics is to travel to a clinic in another country (financially impossible for most) or to glean everything they can from visiting international prosthetists. Now a year after my family’s return to Canada, el Centro de Miembros Artificiales continues to operate with the help of ongoing fundraising and organizational support from Pepe
Co-polymer hip disarticulation prosthesis.
in San Diego. I plan to return to La Paz for a short trip within the next two years to build upon the relationships we established. Our experience teaching prosthetics in a developing country like Bolivia is akin to climbing a high-altitude mountain – painfully challenging and at times even frightening... yet, incredibly rewarding with priceless long-lasting memories. About the Author: Duane Nelson, C.P.(c), provides treatment in a dynamic prosthetics practice at the Saskatchewan Abilities Council in the thriving city of Saskatoon. He is pleased to provide the prosthetics curriculum Powerpoints he developed while in Bolivia, to anyone interested. They are available in both English and Spanish.
SPECIAL FEATURE SECTION: SPORTS & RECREATION
To Knee or Not to Knee By Jim Toller, C.O.(c), F.C.B.C.
Knee orthoses have been part of orthotic treatment for as long as I have practiced. This article is an account of orthotic treatment for knee pathologies at our practice.
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here have been changes in materials used to fabricate the orthoses but not significant changes in how we use orthoses in treatment of ligament injuries and osteoarthritis of the knee joint (Image 1). Research is inconclusive about the use of custom or off-theshelf knee orthoses as best practice. The research is often affected by small samples sizes, incongruent orthotic treatment (i.e. design, KO joint, use of
extension stops, material rigidity and shape) and inconsistencies/inappropriate methodology. Anecdotal evidence is positive and supported by the treatment team of healthcare professionals we work with (surgeons, physiotherapists and orthotists). There is research that states that the use of compression sleeves improves postural control by 22%, as well as running performance, and decreases frequency of subluxation and “giving way”. Single or multiligament injuries at the knee, whether acute or pathological, have warranted treatment with a knee orthosis for return to daily activity, work, recreation or sport, when surgery isn’t performed on the affected limb. Research evidence tells us that anterior cruciate ligament (ACL) deficient knees are six times less likely to re-injure Image 1: old (left); new (right).
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when wearing a custom rigid-knee orthosis, and three times less likely to re-injure post-reconstruction. Knee orthoses are also frequently used to protect reconstructed ligaments while they normalize in the first year post-surgery, and also for continued use when returning to sport. Stabilization of the knee when ligament damage has taken place can range from single to multi-ligament injuries. Medial collateral (MCL) and ACL injuries are likely the most common single ligaments damaged followed by an ACL/ MCL combination, lateral collateral (LCL). Posterior cruciate (PCL) injuries are far less common. Ligament injuries are graded on severity of injury from Grade 1, sprained or stretched, but still able to help keep the knee joint stable, Grade 2, stretching of the ligament to the point where it becomes loose, and Grade 3, which means a complete tear. Quite often surgery isn’t performed on isolated MCL injuries even if they are completely torn. We expect that with rehabilitation and stabilization they will scar down and have functional stability, although typically not as solid as prior
to being stretched or torn. An orthosis can be used in these cases to stabilize the knee while it reaches its maximal healing. A range of motion orthosis is a good option here if it is expected that the patient will not need the orthosis once they have rehabilitated. Up until the last 10 years, extension stops (-20 to -30 degrees) and flexion (90 to 100 degrees) were usually installed in the orthosis to limit range of motion to non-painful movement and protect the scar tissue from over-stretching. In our practice, a growing number of physicians would not use an extension stop but instead, a flexion stop from 100 to 110 degrees for the first few weeks postinjury, using a bilateral upright orthosis. In MCL Grade 1 and 2 tears, an orthosis could be constructed of a semi-rigid material with rigid medial and lateral uprights that contour to the thigh and calf, limiting valgus stress on the MCL. Use of an orthosis that has a four-strap system (two on the thigh and two on the calf) maximizes the stabilization provided by the uprights on the leg, controlling unwanted knee motion more effectively than two-strap systems. This orthosis would be worn for the period of rehabilitation and as the patient returns to recreational activities, for up to a year. High second and third grade tears would be treated with a bilateral upright rigid-framed orthosis. When the joint is unstable, and will remain that way, semi–rigid material and straps are not enough to provide appropriate mechanical stability. Wearing times for this orthosis would be the same as the first and second grade, but perhaps for a longer period of time after a return to sport because of the laxity that remains after the ligament has scarred down. In isolated ACL and combination ACL/MCL knee injuries, use of a bilateral upright, rigid-framed orthosis is the treatment we most commonly use in our practice. In orthotic treatment for isolated ACL injuries – Grade 2 and 3 – an orthosis is expected to control anterior displacement of the tibia on the femur from full extension into flexion as well as hyperextension of the knee where posterior displacement of the
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femur off tibia can happen. In most cases, use of an extension stop of ten degrees is useful to reduce the chances of hyperextension occurring. Most orthoses have rigid anterior shells that are custom-made or customcontoured by the orthotist to the thigh and tibia of the patient’s leg. This style of orthosis ensures that there is optimal contact and control of the boniest part of the tibia. One manufacturer uses a posterior calf section and an anterior thigh section along with a five-strap sequenced donning procedure to position the leg in the orthosis. The strapping sequence, when done correctly, puts a posteriorly-directed force on the proximal part of the tibia (Image 2).
Image 2
In cases of an MCL/ACL combination, use of a rigid-framed bilateral upright orthosis would reduce the possibility of a valgus force damaging the MCL further. Where the ACL/MCL and medial meniscus are all damaged (“Terrible Triad”), using a rigid-framed bilateral upright orthosis with several degrees of valgus captured in the orthosis can help protect the medial compartment from increased impact due to the reduced meniscal function. In our region of Canada, isolated PCL injuries are not typically reconstructed. In the past year a new dynamic orthosis emerged on the market that produces an anteriorly-directed force on the proximal part of the tibia. A cable runs above the knee orthosis’s joint centre to a pad that lies on the calf
muscle and can be tensioned with the knee in full extension; this increases the anteriorly-directed force on the tibia as the knee joint moves into flexion. This mimics how a normal PCL would function in the knee. In acute injuries, it is meant to stabilize the joint in a position to allow the PCL to tighten up and heal because it isn’t being stretched with each flexion extension cycle. If choosing an alternate orthosis, a more traditional bilateral upright rigid-framed orthosis would be used with a proximal posterior tibial strap to control posterior tibial displacement and a distal anterior thigh strap to control anterior displacement of the femur in full extension. In the mid 1980s we started to see the growth of knee orthoses used to offset the symptoms associated with osteoarthritic changes in the knee joint. The increase in this area of orthotic treatment may be due to the increase in the number of people wanting to continue to be physically active later in their lives. Early total knee arthroplasties, in some cases, were found to be wearing out in less than 10 years, especially where impactful activities (eg. running sports, tennis, golf) were involved. Thus, surgeons and patients thought that any knee replacement occurring in a patient’s forties would necessitate a second surgery to carry these patients through their sixties. Patients not choosing arthoplasty, and who continue in recreation that increases forces at the knee, are often left with increasing amounts of pain, loss of muscle strength and range of motion, ultimately significantly reducing their activity level. Treatment of osteoarthritis (OA) with knee orthoses has increased significantly in the last thirty years. Most often we are treating medial compartment OA, but if lateral compartment is damaged only, similar but reverse application of force would be used. In very mild cases, a compression sleeve can be used to reduce swelling and keep the joint warm. Sleeves without openings around the patella work better for this and some manufacturers make orthoses with gel pads that sit around the patella and massage the inflammation away from the joint with normal
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Image 3
Image 4
Image 5
walking (Image 3). As damage in the joint becomes more significant, with thinning cartilage or loss of meniscus within the medial compartment, there is usually an increase in the amount of varus seen in the limb. This thinning also means there is increased play in the joint which results in a varus thrust at initial contact and single support during gait. Clinical observations often show a flexed knee on the affected side in static standing and a slightly flexed knee throughout stance phase of gait. There is usually reduced push-off in terminal stance and this is more noticeable at faster walking speeds. Our goals for orthotic treatment are to reduce the amount of varum in stance as well as the velocity that end-range varum is reached. If we can slow the rate of varum there will be less rapid loading of the medial compartment of the joint, which means less impact. Affecting these changes at the joint often allows patients to return to activities and improve strength and range of motion. Even if the patient goes on to total knee arthroplasty there is evidence that full range of motion at the joint and good strength improves the outcomes of TKA (total knee arthroplasty). Patients with X-ray findings of moderate medial OA or worse, without a lot of pseudo laxity in the joint, are treated in our practice with a single
upright orthosis with 3-5 degrees of valgus preloading in the frame of the orthosis. Most single uprights have some strapping mechanism that usually tightens as extension of the knee joint occurs. This means the greatest amount of correction/control is applied to the joint when the joint is in the most direct loading posture. Some single upright orthoses have the ability to increase or decrease the amount of valgus or varus in the upright via a lap joint while other orthoses may need to be re-contoured by the treating orthotist (Image 4). When treating ligament laxity and osteoarthritis together, it may be necessary to use a bilateral upright rigidframe orthosis that has a pre-assigned amount of valgus or varus built into the frame to control loading through the joint. This may also be true where the amount of articular surface damage at the joint gives significant pseudo laxity. In many of these cases an orthosis that is shape-captured in a non-weight bearing, or partial weight bearing, posture is enough to provide desired alignment control and reduction of pain. I have found that as the angular deformity becomes greater and the forces are greater to control, having a large enough surface area on the limb to distribute the force is our greatest challenge. This is especially true in a very de-conditioned leg where muscle tone is poor and the overlying tissue is
very mobile. A relatively new orthosis has bilateral uprights and a rigid aluminum frame that allows you to move the medial or lateral upright in valgum or varum with an adjustable screw mechanism. This applies a constant control force at the joint that can easily be adjusted for swelling or increased if pseudo laxity becomes worse (Image 5). In closing, research is inconclusive about the use of custom or off-the-shelf knee orthoses as evidence-based practice, but I’m confident that we have all experienced patients who have returned to sports and recreational activities that they were not involved in prior to being treated with a knee orthosis. As orthotists, if we are able to assist patients in their return to activities that improve their lifestyle, whether that is through sport or recreation, I believe this is an important part of our profession’s service. We as a profession can take up the challenge to collect data and evidence that will help us validate our anecdotal clinical findings as we continue to treat our patients.
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About the Author: Jim Toller, C.O.(c), F.C.B.C., is a certified orthotist practicing at Orthotic Solutions Ltd. in Edmonton, Alberta, and has practiced in the area of orthotics in sports medicine since the late 1980s.
SPECIAL FEATURE SECTION: SPORTS & RECREATION
Into the Unknown A case study on a custom wrist-hand orthosis to reunite rider and bicycle By: Aaron Amar, B.Sc., C.O.(c)
Cumberland, British Columbia, is a small, Vancouver Island town that is home to some of the best mountain biking terrain in North America. Not surprisingly, it’s also home to a large contingent of local riders who are fiercely dedicated to the sport.
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t 58 years old, Maria B. was one such resident. Although she had lived an active lifestyle for many years, she was beginning to lose her ability to pursue outdoor sports due to an injury to her left wrist that was worsening over time. Of all Maria’s passions, mountain biking was the greatest, and the most distressing to lose. She sought medical and therapeutic help over the course of several years and eventually came to our clinic to determine if she could ever ride her bike again. Back in 1982, Maria had hyperextended the thumb on her left hand (CMC and MCP). The injury initially resulted in pain and swelling, but there was no fracture. Any movement
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of her wrist and hand, in all planes, caused considerable pain and so, she wore an immobilizing cast for 24 weeks. When the cast was removed, Maria noticed that she had lost all strength in her left thumb. It was soon determined that a “minor” amount of radial and median nerve damage had occurred, as well as a partial tear of the medial collateral ligament of the first MCP, IP and CMC joints. As time progressed, Maria continued to use her left hand despite the increasing pain, weakness and laxity of the thumb. By 2012 her condition had deteriorated to the point where she could no longer hold a cup of coffee. She decided to undergo surgical repair by way of partial tendon grafting of the
flexor carpi radialis. Despite diligent post-surgical rehab, Maria continued to report ongoing nerve pain, weakness, dysfunction and radiographconfirmed osteoarthritis. Clinically, she was assessed as having 60% loss of functional strength in her left hand, moderate to severe osteoarthritis of the joints in her thumb and moderate to severe chronic nerve pain. That pain worsened when any torque was applied to her wrist or hand. Problem: A true Cumberlander, Maria wanted more than anything to ride her bike again despite having insufficient strength to grip the handlebar and debilitating pain associated with shock and torque through
her wrist. And so it was that she came to us seeking a solution in the form of a custom wrist-hand orthosis that would enable her to ride. Objective: Our mutual objective was to create a custom wrist brace that would lock onto the bike’s handlebar and provide a confident grip in most riding situations without needing the use of her thumb to curve around the bar. The brace would have to allow her fingers to modulate the brake lever as needed and, importantly, Maria would need to be able to remove it quickly and easily from the handlebar by pulling up through her shoulder and elbow. The brace would also, of course, need to resist torque on the wrist in all planes while riding. Variables/Concerns: Several complexities existed in this scenario: 1) would Maria be able to steer her bike effectively without the use of her left wrist motion? Would she be able to compensate through her elbow and shoulder sufficiently to turn the bike through typical radii?; 2) would the brace be able to “lock” onto the handlebar firmly enough to do the job, but not so firmly as to cause her to be fixed to the bike in the event of a fall?; 3) which plastic would need to be used? The chosen material would need to withstand repeated shocks in the event of a fall.
Casting in functional “on-bike” position.
Expectation: Maria was excited to receive a modicum of benefit from the brace, even if it meant that she could only ride on paved surfaces or, at best, gravel roads. From a technical standpoint, I was confident that the brace would withstand the rigours of any style of riding while stabilizing her wrist and locking onto the handlebar. I was concerned however, about whether she’d be able to ride safely and confidently. Would she be able to use the brake effectively and release her wrist from the bike when needed? Whether she could ride without pain was yet to be seen. Based on Maria’s past experience with other wrist braces that reduced her pain for other activities of daily living, we were optimistic that we could achieve, at the very least, a more pain-free solution. Solution: A custom wrist-hand orthosis was fabricated out of 3/16'' highdensity polyethylene. The key to the design was in the casting technique. Maria was casted using Plaster of Paris in the most comfortable and functional (best all-round) wrist position, with her hand gripping the handlebar while seated on her bike. We agreed that our best chance for proper brace function would be achieved by mimicking its intended use. For Maria, that meant that her thumb rested on top of the bar alongside her palm, with her fingers curled over the bar – a position
that we determined would minimize her pain. After applying a “saran” cover to prevent the plaster from dirtying her handlebar, a cut strip was applied over the dorsum of her wrist/hand and a cast was applied. The positive model was then modified to enhance the handlebar radius and exaggerate the styloid process to create relief in the brace. The 3/16'' polyethylene was vacuum-formed with the seam over the dorsum of the wrist/hand. Slowly and carefully, the cast was pried off the positive model so as not to crack the delicate hand area. Trim-line design was critical around the handlebar radius to create enough flex in the plastic to “snap” on and off the bar. The edges were buffed and three dorsal Velcro pull-over straps were installed. Most importantly, a dorsal strap over the metacarpals was installed as the most distal strap. Maria’s fingers would then be free to extend and use the brakes easily and rapidly. Several trim-line modifications ensued with repeated trials to minimize the brace without compromising function. Outcome: Maria returned to our clinic several times over the following six months, reporting better than expected results. Not only could she ride her bike, she could ride without pain. Nor was there any compromise in braking ability. What’s more, her
Positive model with handlebar radius defined.
Alignment 2015 39
local bicycle shop had modified her bike’s gearing so that she could shift with just her right hand. The brace resisted external torque so effectively that Maria proudly demonstrated her restored ability with a few gleeful “wheelies.” Thus far, Maria’s riding has been limited to roads, but Cumberland’s legendary single-track awaits. About the Author: Aaron Amar, B.Sc., is a Certified Orthotist currently practicing in Comox, British Columbia. He earned his B.Sc. in Biology from Simon Fraser University in 1996. He was accepted into the Prosthetics & Orthotics program at George Brown College and graduated with honours in 2002. He enjoys an active outdoor lifestyle with his wife and three children in the Comox Valley, on Canada’s west coast.
Brace and hand ready to ride. Fingers are free for braking.
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40 Alignment 2015
SPECIAL FEATURE SECTION: SPORTS & RECREATION
IRON ANKLE A Novel Design to Combat Inversion Sprains By: Greg Williscroft, C.P.O.(c)
Feeling strong and confident in your base of support is essential to maintaining a physically and emotionally wellgrounded life. Sometimes we need to look to an external device to provide that extra support required to perform activities safely. This paper reviews current commercial choices and a novel design to the $600 million (U.S.$) a year1 worldwide ankle brace market.
Background and Incidence As a parent and coach of my children’s sports teams, as well as an Olympic and professional athlete, I have seen first-hand the devastation that an injury can cause. When a pleasant activity is ruined as a result of injury, inactivity and pain replaces movement and joy. I suffered a serious ankle injury on the eve of an important international volleyball tournament when a teammate planted under the net and I landed on his foot. I was left rehabbing a broken ankle instead of competing. This classic rolling of the ankle, or inversion sprain (IS), is one of the more common injuries seen in sports and daily activity. Acute ankle injury is one of the most common musculoskeletal injuries in athletes and sedentary persons, accounting for an estimated two million
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My daughter’s Winter Games Volleyball coach recently told the players that they should all use ankle braces as part of their standard equipment. Called upon to research and purchase a commercially-available design left me unimpressed with the current choices. Assessing this orthotic support through my professional eyes, I felt that there had to be a better design.
Current Designs
Figure 1: Injurious inversion.
Diagram 1: Inversion action.
Diagram 2: Lateral support strap replaces muscle force.
injuries per year and 20 percent of all sports injuries in the United States2. Bahr et al. found approximately one injury in every 1,000 hours played in volleyball3 and the American Academy of Family Practice estimates that one million Americans visit a physician for an acute ankle injury each year4. The typical ankle sprain is an inversion injury that occurs in the plantarflexed position. Ankle sprains can be classified as Grade I to III, depending on the severity of the injury. Failing to dorsiflex adequately to clear the foot when making contact with the ground, the IS occurs when the foot is placed into an inward, inverted, or supinated position (combined plantar flexion, internal rotation and inversion as shown in Figure 1), past the joint’s ability to protect itself.
In addition to body weight, the dynamic energy resulting from landing may lead to forces that the ligamentous system is not designed to withstand. Normal, controlled forces are well received and attenuated at the body’s joints through tendons, ligaments and soft tissue. Once acceptable forces and their range of motion (ROM) go beyond the body’s structural ability, injury occurs. These injuries range from bruised pride (when you trip and fall) to catastrophic, as in the NFL’s Robert Griffin III ankle blow out, or similar ugly basketball/volleyball/dance/etc. injuries we’ve witnessed. While no external support can be relied upon to prevent all injuries, the expectation is that the injury will be lessened if one is worn correctly.
The market’s ankle brace designs focus primarily, if not solely, about the rear foot, calcaneous or heel to restrict inversion or rolling in to protect the ankle joint (Diagram 1). To their detriment they forsake the forefoot (ball of foot forward) as a control surface. They try to hold the acceptable ROM, or work to offload some of the twisting force around the joint through the cuff and soft or semi-rigid structures. Because the heel is the sole focus of control, the employed lever arm (def. = the perpendicular distance from the axis of rotation to the line of the force [Diagram 2]) is small. If it slips inside the brace (which is common) the control is lost completely. Also, because the heel is so close to the ankle’s centre of rotation the resulting lever arm is very small, underutilizing the potential mechanical advantage of these designs. A custom tape job by an athletic therapist is the standard for rehab and prophylactic ankle support; however, most people do not have access to this modality. Estimates have shown taping to be three times more expensive over the course of a season than bracing5. A pre-packaged, adjustable and comfortable device that provides specific functionality in a customizable form is needed. Typically, there are four design styles for the commercial off-the-shelf ankle brace market. 1. Hinged Rigid Heel Stirrup: The industry leader in terms of sales, this hard, plastic stirrup-style is used by most athletes and common for daily wearers. Two solid plastic pieces provide an anchor for the jointed heel plate. It is circumferentially wrapped with Velcro
Alignment 2015 43
Figure 2: Lateral support strap anchored to foot plate at head of 5th toe.
to hold the alignment. The lever arm is extremely short, as the centre of rotation is virtually at the same place as the distal point of influence. 2. Hinged Rigid Heel Stirrup-style with Sub Talar Extension: A variant of the stirrup design, this brace employs a longer lever arm via a lateral hind foot extension. The additional few centimetres help to resist the heel roll, but do not address the more devastating inversion moment at the forefoot. 3. Non-Rigid Sub Talar Wrap: This soft pull-on ankle gauntlet, with a figure-8 wrap across the sub talar area of the foot, attempts to offload the torque of the inversion into the straps. The lever arm only extends slightly into the midfoot area which does not increase its mechanical advantage significantly. 4. Circumferential Wrap: This design is most often recommended to the rehab population by well-intentioned, but uninformed, healthcare workers and parents. The lace-up circumferential wrap is designed solely to add compression. Similarly, a tensor bandage ankle support is better than nothing, but does not offer much in terms of meaningful outcome. None of these designs addresses the torque created as a result of the long lever arm coming from the forefoot during dynamic over inversion or supination.
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Figure 3: Lateral view.
IRON ANKLE Design The lateral ankle ligaments are not large, but they are well designed. By keeping the severity of the force vector (def. = magnitude and direction) through the sub talar or ankle joint, the ligaments are able to handle a manageable amount of force without injury. Stopping the forefoot from inverting beyond the angle of injury and creating damage to the supportive ligaments is the primary goal of the IRON ANKLE. By pre-positioning the foot for contact, and not allowing the rolling in or inversion ROM to put the body in a dangerous position, IRON ANKLE proactively stops the injury from happening as opposed to reactively dealing with the actions of that injury. If the inversion is still able to occur, as in landing on a foot or catching a toe on the carpet at home, the lateral support strap (LSS) will accept the majority of the offensive stress. Combining assisted foot pre-positioning and attenuation of torque stress at the ankle joint, this design is a new approach to commercially-available ankle braces. This twopronged approach decreases the chance of injury, as well as lessening the effect of an injury, if it should occur. The IRON ANKLE utilizes a novel design to combat the effects of dangerous over-supination or inversion movements. The design incorporates a different part of the foot, namely the forefoot, to control the ROM. It also
Figure 4: Posterior view.
utilizes an adjustable force attenuation strap riveted to a footplate under the shoe’s insole to distribute forces that do occur. In bypassing the heel in favour of the forefoot for control, IRON ANKLE utilizes a greater mechanical advantage to position the weight-bearing surface safely on the ground. The adjustable LSS anchored at the forefoot as the forward control point, and the proximal point connecting through a D-ring at the centre of rotation on the lateral ankle cuff, are unique. The Dacron LSS runs along the outside of the foot (from head of 5th metatarsal to lateral malleoli) in the exact line of action as the inversion sprain (Figure 2). Along with pre-positioning the foot safely, it provides the secondary benefit of creating a stable, anchored vehicle with which the extra forces can be directed, dispersed and attenuated. This attenuation of offensive forces slows down the assault, giving the wearer more time to react and adjust to the situation, as well as decreasing the final forces. IRON ANKLE is designed to be effective by restricting ankle joint ROM to acceptable angles, but allowing all of the other necessary movements (i.e., pure dorsi/plantar flexion and eversion). Moving the attachment point forward increases the lever arm (Diagram 2), resulting in an increase in mechanical advantage to reduce ROM. The LSS offers force dissipation through the strap at its two attachment points which
forcement strap is pulled back onto itself, through a D-ring, to a Velcro bed. It is secured under another layer of attachment as the pile pull-back strap sandwiches it in place to provide excellent control. A 3'' x 2'' window is included on the pull-back strap to allow teams to customize their devices with team logos, numbers, or colours. Owner identification could also be discreetly housed in the window. No other commercially-available ankle brace offers such customization. Figure 5: Upward pull of lateral support strap.
lessens the ligamentous load. Eliminating the heel strap also serves to eliminate the previously noted discomfort associated with an inflexible figure-8 strap cutting into the dynamic achilles tendon during activity. IRON ANKLE supports the ankle in a comfortable way that can be worn by athletes and everyday wearers for rehab needs. A reliable, comfortable, secure device that decreases the chance and effects of injury enables both the specialized athlete and the daily wearer to benefit from this novel design. The IRON ANKLE employs a reinforced neoprene and pile Velcro pull-back wrap around the cuff which secures just above the flare of the malleoli. Using this shape keeps the cuff from sliding down (Figures 3, 4). The LSS is tightened to the desired tension every time the device is put on, and is easily adjusted throughout its use (Figure 5). Maintaining tension is critical to the brace’s effectiveness. This rein-
Applications The ability to move is critical to keeping active and healthy. When injuries occur, it severely limits our ability and desire to continue to be active and fit. Even when a friendly game of squash or volleyball with friends results in an injury, motivation to be active (as well as the actual recovery time of the injury) wanes and a more sedentary, and less healthy lifestyle can result. And while catching a toe on the rug for a 10-year-old is not likely to cause injury, an 80-year-old with limited vision and brittle bones could find themselves in a life-threatening situation. The anchor cuff is comfortable, and low profile, allowing IRON ANKLE to be worn inside low and high top running shoes as well as daily walking shoes for the rehab community. Sturdy, and easily donned with customizable tension, this device makes for a valuable tool in the sporting and rehab fields. Preventing unwanted motion at the ankle and providing iron-clad support where needed allows this design to be a versatile choice for all walks of life and activity levels.
This design was born out of a personal challenge. I was unhappy dispensing designs that I didn’t feel were adequate. I have tested the IRON ANKLE successfully in competitive sports such volleyball, basketball and squash. Because of its low profile, it’s applicable to all sports in which shoes are worn. I have also incorporated this device into my clinical practice as a certified orthotist at the Alberta Children’s Hospital, as well as in my private orthotic practice. Those patients suffering from any type of pre-tibial musculature weakness are good candidates for this design, be it stroke, neuromuscular/motor disease, fatigue, or acute trauma. I am currently trialing its clinical benefits in conjunction with a physical therapist on a patient with Duchene’s muscular dystrophy. I have used it successfully in patients with over-supination and muscle weakness issues due to disease as well as in conjunction with surgical recovery necessitating decreased inversion ROM. This design is what I, as an orthotist and biomechanist, would design in a custom setting.
Availability and Future Considerations IRON ANKLE is currently being tested for final design and packaging. This Canadian-designed product is scheduled for release to the general market in 2015. If interested in testing this design and offering feedback, contact the author or visit www.ironankle.com.
References 1. www.ibj.com/articles/44851 2. www.aafp.org/afp/2006/1115/p1714.html 3. www.ncbi.nlm.nih.gov/pubmed/7810781 4. www.aofas.org/education/.../Ankle-Sprain. PDF 5. http://emedicine.medscape.com/article/ 86495-overview 6. Figure 1 source: www.blog.sportstrap.com.au/ tag/ankleinjuries/
About the Author: Greg Williscroft, C.P.O.(c), is the owner of A Rocky Mountain Limb and Brace in Calgary, and works at the Alberta Children’s Hospital.
SPECIAL FEATURE SECTION: SPORTS & RECREATION
A Revolutionary Tale
Össur’s Continuing Innovation in Running Prostheses Fuels Next Generation Solutions for All
By: Jason Adams, B.Sc. (Kin)
If necessity is the mother of invention, Van Phillips proved this to be true in prosthetics. Soon after his amputation from a water skiing accident in 1976, he was fit with a prosthesis that he likened to a “fencepost with a bowling ball on the end of it.” Instinctively, he knew he could do better.
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hillips set out to design a prosthetic foot that would enable him to continue living his active lifestyle. His experiences with pole vaulting and diving led him to believe that a similar kind of action could give the propulsion that was lacking in all prostheses at the time. Phillips went to work in a prosthetic lab and over the course of several years designed and tested somewhere in the vicinity of 300 prototypes. Carbon graphite was chosen as the ideal prosthetic material. It provided a high-level of flexibility and energyreturn, while possessing the strength and durability to withstand the rigors of an active lifestyle. When Phillips finally had a design that he was satisfied with, he quit his job and founded Flex-Foot.
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It was 1984 and the prosthetics field would be forever altered. A decade and a half later he sold his company to Össur, the Icelandic prosthetics and orthopedics innovator. It’s now been three decades since Flex-Foot technology was introduced to amputees. In that span, engineers at Össur continuously refined and improved the core design, expanding the limits of athletic excellence and spawning a multitude of technological adaptations for different sports and activities. While much of the world’s focus was locked in on the revolutionary new foot’s impact on athletics, continuing research and development has also fueled product design for amputees of all mobility levels.
The Flex-Foot Cheetah The original Flex-Foot running prosthesis was first used by elite athletes competing at the 1988 Paralympic Games in Seoul, Korea. The classic FlexFoot design of a J-shaped keel, heel, and full-length toe lever provided much improved dynamics for gait, and on the track, the T-44 (trans-tibial) 100-metre World Record dipped below 13 seconds for the first time ever. Further refinements followed, inspired by one of the finest examples of biomimicry when Phillips considered the running biomechanics of a cheetah. He analyzed the cheetah’s long posterior tendon, which stretches out like a catapult to propel the animal forward. By removing the heel of the
Paralympian Jerome Singleton blazed a winning trail on his Cheetah Xtreme, recently adding another gold medal and new World Record to his achievements as a member of the U.S. T42-46 4x100m Relay Team at the 2013 International Paralympic Committee World Championships.
“The Cheetah Xtreme® was designed for the first 100 metres,” he explains. “It utilizes a more extreme curve and composite layup that moves the centre of rotation of the blade, increasing total energy absorption and return.” In comparison, the Cheetah Xtend® was created for longer running distances from 400 metres to 5000m. “The weight, centre of gravity and frequency response of the blade were evaluated and optimized for speeds and turns,” says Lecomte. “The result is a lighter blade with a softer curve for smooth rollover.” As a final touch to the improved designs, Össur looked to its partnership with Nike to couple the new Cheetah feet with a custom-designed track spike pad for maximum traction. The Cheetah Xtreme debuted at the 2012 London Paralympic Games, where Johnnie Peacock starred as the
existing prosthesis, users were able to absorb GRFs (ground reaction forces) at impact, repeatedly loading the foot through a single stance and maximizing its energy return at toe-off, all in one smooth motion. The result was the Flex-Foot Sprint, which debuted at the 1992 Paralympic Games in Barcelona, Spain. American Tony Volpentest, a bilateral, trans-tibial amputee, broke the T-44 100m world mark with an incredible time of 11.63 seconds. According to Knut Lechler, Össur’s Prosthetics Medical Director, innovations were being initiated by prosthetists and users. While the original Flex-Foot Sprint was designed with an anterior-mounted pylon to add more toe lever, Lechler notes that “in the early days, a Flex-Foot Sprint was sent to Australia, and the CPO decided to mount it on the posterior of the socket of Paralympian Neil Fuller. This change improved its dynamics and from that point on, everyone began mounting it on the back.” The next iteration for the Flex-Foot Cheetah saw an evolution in the design from a J-shape to a C-shape that more closely resembled the hind leg of its namesake. This change provided more
The iconic Össur Flex-Foot Cheetah prosthesis revolutionized amputee athletics, and remains the gold standard for individuals wishing to sprint at recreational or competitive levels.
forward-directed propulsion with a delayed return from deflection, thus improving the timing of the user’s centre of gravity progressing over the foot. Over the ensuing decade, world records continued to fall, but the technology itself remained largely unchanged. In 2009, Össur’s engineers embarked on a new project with an objective of creating a new generation of sprinting feet with attributes tailored to specific distances.
New Generation in Innovation The initiative was led by Christophe Lecomte, Technical Product Lead for prosthetic feet in Össur’s R&D operations in Iceland. “The design of running feet is challenging,” offers Lecomte. “Gait analysis is more difficult since high-speed cameras and force plates need to be used to evaluate each design iteration, and only a few trials can be done at a time.” In collaboration with Team Össur athletes, Lecomte and his team reevaluated the shape design and laminate lay-up of their foot to optimize ground contact time and blade deformation. Two new innovations were created.
Alignment 2015 47
Marissa Papaconstantinou broke the Canadian women’s T-44 100m record at age 13.
hometown hero with his gold medal performance in the 100m track event. The Cheetah Xtreme was on full display again at the 2013 Paralympic Anniversary Games in London, where Peacock and fellow Team Össur member Richard Browne Jr. dueled in the 100m final. This time, Browne edged out his rival, dropping the T-44 World Record to 10.75 seconds in the process. Closer to home, Canadian athlete Marissa Papaconstantinou has had first-hand experience with Össur’s most recent technological advancements. With the help of an original Cheetah prosthesis, the sprinter set the T-44 Canadian 100m record in 2013 with a time of 13.88 seconds, a mark that ranks the 15-year-old at 5th in the world. She didn’t compete in 2014 as she was working on adapting to the new Cheetah Xtreme with her coach and her prosthetist in Toronto, and improving her strength and running mechanics. “My coach and I looked at everything in slow motion and the new Cheetah is pushing me forward with more power,” she reports. “I actually feel like I’m sprinting now,” Papaconstantinou says. Papaconstantinou has set her sights on racing to a new personal best in 2015 at the World Championships in Qatar as she looks forward to representing Canada at the 2016 Paralympic Games in Brazil.
Beyond the Track
Erez Avramov is on a quest to become the first amputee to race the Dakar Rally on a motorcycle.
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The experience gained from designing prosthetic feet for elite runners has translated to great improvements in the design of Össur products not only for sports, but everyday use as well, as seen in the Vari-Flex® XC and the Cheetah Xplore®. When Össur R&D set out to design an everyday foot that could ramp up to higher activity, the company’s iconic running feet provided ample inspiration. Incorporating their dynamics into a smaller package however, required a departure from the familiar J-shaped pylon. “The new C-shaped keel of the VariFlex XC provides an increased range of motion compared to regular composite feet,” says Lecomte. “The dual blade increases both strength and flexibility, since both of the composite members
“ Kids don’t run like adult athletes do. Adults run straight. Kids change direction quickly, run on uneven terrain, and climb trees.” are storing and returning energy. The dropped-toe increases the push-off of the foot by loading the tip of the toe from mid-stance. This type of design allows the C-shape to start storing energy earlier in stance phase compared to other designs.” One of many Canadians to enjoy the new design is Erez Avramov, a West Vancouver amputee looking to make history. He’s currently on a quest to be the first amputee to race the grueling Dakar Rally on a motorcycle. In January 2016, Avramov will embark on the 15day, 10,000-kilometre race across South America, pushing the limits of both man and machine. The race (and training) will place excessive demands on his prosthesis, necessitating a foot that will maximize his endurance. Avramov is documenting his journey to Dakar at www.erezavramov.com. “The XC’s carbon dynamics, combined with the responsive heel and toe, provide controlled roll-over and great flexibility,” assesses Avramov. “My daily activities cover anything from demanding mountain hikes to gym workouts, riding off-road motorcycles and anything in between. I needed a foot that could handle everything.” As is the case with Avramov, the demands of some sports can be very specific, requiring customized solutions and a welcome challenge for engineers. “We learned during the development of sprinting feet that each specific sport, activity or user group will drive the design of the prosthetic foot,” shares Lecomte. “A recent example is surfer Mike Coots, who helped us try concepts of surfing-specific prosthetic feet. In this case, constraints of multi-axiality, grip and waterproofing produced a very creative result and a cool prototype.”
Meeting the Unique Needs of Kids Another great story about the transfer of technology centres on the most active
group of people on the planet – children. In 2012, Össur engineers began working on a new prosthetic foot design after identifying the need to provide more solutions to address young amputees’ unique mobility demands. “Working closely with our domestic workshop in Iceland,” tells Lecomte, “we had the chance to learn from a great group of kids. We saw how their current prostheses were limiting them from playing with friends and family. The first thing that came to mind was to make a paediatric version of the Cheetah.” While observing the kids at play on their new Cheetahs, Lecomte and his team quickly observed something previously unnoticed. “Kids don’t run like adult athletes do,” he notes. “Adults run straight. Kids change direction quickly, walk backwards, run on uneven terrain, and climb trees.” The response was to provide more stability by adding a heel component. “Initially designed as a running foot,” Lecomte continued, “the Cheetah Xplore turned out to be an all-around foot that is good for walking and for all of the other stuff that kids do!” Calgary’s Samuel Seehawer was one of the first children in Canada to receive the new paediatric Cheetah Xplore foot. His mother, Charlotte, describes the impact it has had on her child’s life: “He had worn a standard prosthetic foot for eight years... after school he would remove it. The lightweight and energy-return of this new foot has changed his life. He’s able to run faster, jump higher and because it is more comfortable, he no longer removes it when he comes home from school. Another plus for a 10-year-old is that the foot looks cool.” While there is no single prosthetic solution for every user or activity, at least not yet, clinicians, end-users, and the team at Össur continue to
Samuel Seehawer was very excited for his new Cheetah Xplore.
collaborate and innovate in new and amazing ways. The original Flex-Foot concept gave rise to a new age in prosthetic devices, but it was simply a stepping stone. The next revolution in prosthetic mobility may be right around the corner. About the Author: Jason Adams, B.Sc. (Kin), is a Senior Area Manager for Össur Canada Prosthetics. He has worked in the Canadian O&P industry since 2003 and currently resides in Maple Ridge, British Columbia, with his wife, one-year-old daughter and black lab, Ryder.
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SPECIAL FEATURE SECTION: SPORTS & RECREATION
Think Outside the… Shoe! An original idea that is transforming lives. By Stephane Savard, C.O.,T.P.
François will never forget the February day in 2001 when his snowmobile left the trail and crashed into a tree. Months of rehabilitation enabled his return to daily activities and his work as a naval designer. Despite all of his efforts in rehab, François would have to learn to live life with a falling foot condition (drop foot).
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or this young marathon runner his condition was hard to accept. For two years he tried walking, running and working with various orthoses made especially for him, prefabricated in plastic, metal and carbon fibre. In May 2004, François ran his last marathon with an orthosis fitted within his shoe for his drop foot; at the finishing line François’s left foot had wounds on
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Francois has run marathons for more than 20 years. The 47-year-old father of two has been a naval designer for 25 years.
the plantar surface and on the medial malleolus. The decision was made: he’d never again train, trek or run with an orthosis fitted in his shoe. What was needed was a new orthosis that would be designed for comfort and give him optimal performance. François had no inclination that his work on his own orthosis would greatly benefit many others.
From his old orthosis François would conceive his first prototypes. It was cut into pieces, melted and fitted onto pieces of wood and even the circular outline of a bottle of wine to create different shapes. François produced at least 25 different prototypes using very basic means. After four years of testing and modifying different prototypes, François connected with the author, an orthotist and businessman in Québec City. A friendship was born and a new business was launched by the two men, named Turbomed Orthotics. We used plastic in sheets and cylindrical shapes, and steel stems to mold the plaster (positive) that I had already conceived for François. This new way of conceiving prototypes gave us new ideas which brought about new designs. François tested the prototypes under different weather conditions (-30 to +25 Celcius) and across many activities such as running, fast-walking, trekking, outside work (using work boots), cross-country skiing, and more. More than 15 prototypes have been tested in marathons in Montreal, Quebec City and Ottawa. In short, the traditional method of trial and error was the way to push the project forward. If the design for the orthosis proved itself as being complex, the way to tie it to the outside of the shoe was just as difficult. At first, a variety of means were used to affix the orthosis.
Nails and screws were used to perforate the sole. Glues were also used, as well as belts and elastics. But each potential solution made it even more challenging to transfer the orthosis from one shoe to the next. Nearly $300,000 was invested in R&D over four years and on January 12th 2013, to our great surprise, a Canadian and Americain patent was obtained. The European Union accepted the orthosis project and a European patent process is now underway. Within two years of the issue of the patent, sales of the orthosis began, albeit slowly and only on the web. The first orthosis sold was shipped to Israel, the second to Florida and the third to Australia. At present, more than 100 orthoses have been sold. The final version of the orthosis, named FS3000, was tested to verify its solidity with the help of computer software. Before producing molds that were costly, computer tests were performed by engineers to identify the orthosis’s strong and weak points. Finally, an untiring test bench performed more than four million flexions/extensions. What began as a simple need, transformed into a dream. The dream became a project and from this project a product and a business was born. It took nearly 10 years of patience, determination, disappointments, hard work, sacrifice and tenacity before ultimately enjoying the rewards. But today, this creative endeavour has produced a perfected product that has helped many around the world and has built an unbreakable bond between two men. About the Author: Stephane Savard, C.O., T.P., a certified orthotist for more than 25 years, studied in Montréal and at Northwestern University in Chicago. He built a 140-employee homecare company/othotic lab that he sold in 2013. He now works full-time developing his new business venture with Francois.
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SPECIAL FEATURE SECTION: SPORTS & RECREATION
Troppman Grip Golf Attachment for Upper Extremity Amputees By: Randy Berg, B.Sc., C.P.(c)
Robert (Bob) MacDermott survived an electrical accident that took his left leg, left arm and right thumb when he was 29 years old. After his injury MacDermott wanted to return to the game of golf. In trying commercially-available golf grips, he could not find one that would slip on and off the golf club easily, or provide him with a natural swing.
I
n the 1990s, Troppman Prosthetics Ltd. worked together with MacDermott to come up with a solution and provide him with an attachment that he could use to play golf. As the objective, Troppman endeavoured to design a golf grip for upper extremity amputees that would incorporate the need of simple donning/doffing and could be used with a full range of golf clubs. As well, Troppman wanted to provide a golf attachment that would allow the user to have a smooth and natural swing. In terms of variables and concerns, during the development process Troppman recognized the importance of designing the Troppman Grip for both trans-radial and trans-humeral amputees for both the adult and the paediatric populations. It was also critical to create an attachment that could be used for a top or bottom hand grip.
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Troppman Grip, top-hand.
Troppman Grip, back swing.
With respect to maintenance of the device, Troppman saw the need to create an adaptive device that was userfriendly. The result is a design which incorporates a flexible hose attached to the rigid shaft holder which can easily be changed out by the amputee. The expectation was to furnish upper extremity amputees with a golf grip that was easy to use and would provide a fun golf experience, and also enable the golfer to be competitive in the sport as their skills developed. The Troppman Grip was the answer, comprised of a rigid attachment which slides on and off the golf club with ease. A hose enables the user to swing naturally and with flexibility, and a threaded rod at the hose’s end accepts any wrist insert, allowing for easy attachment to the prosthetic socket. It caters to all upper extremity amputees (trans-radial and trans-humeral) with many styles
Troppman Grip, gripping the club.
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such as the top-hand or bottom-hand grip in either the regular or paediatric size. Each grip comes with the appropriate hose for youth (junior hose) or adults (stiff hose). The hose can be either normal flex or ultra-flex and comes in 3 ½'', 4'' or 4 ½'' lengths. In terms of outcome, the Troppman Grip has allowed MacDermott to pursue his passion for playing golf. Subsequently, he has won the British Amputee Championship in Dublin, Ireland, and the annual Alberta Amputee Pro/ Am Tournament more than 10 times. He has multiple second place finishes at the Canadian Amputee Championship and multiple third place finishes at the U.S. National Amputee Championship. MacDermott is a four-time champion of his home club’s tournament (Belvedere Club Championship) and holds the official club record of 65 (six under par) set in 2003 and again in 2009.
Recently, MacDermott competed at the the Para Long Drive Competition in Mesquite, Nevada, winning the Upper Extremity Assisted Division with a drive of 304 yards. The Troppman Grip has evolved in its design since its launch in 1990 with the latest newly-designed version released in 2015. The Troppman Grip is distributed throughout Canada, the U.S. and the U.K., with plans for availability in other parts of the world. It is available in the U.S. through Cascade, in Europe through RSL Steeper, and in Canada through Ortoped. The author gratefully acknowledges Jason Lee, B.Eng., Prosthetic Resident Adam Regli, B.Sc.(Kin.), and the rest of the staff at Troppman Prosthetics Ltd. for assisting with this article. About the Author: Randy Berg, B.Sc., C.P.(c), graduated from the University of Alberta in 1985 majoring in Physics with a minor in Math. He worked at the Workers Compensation Board before pursuing a career in Prosthetics and Orthotics at the British Columbia Institute of Technology. After graduating in 1992 he worked for Pentland’s Prosthetic and Orthotic Clinics in Vancouver, B.C., and in 1998 became the General Manager of Troppman Prosthetics Ltd. in Edmonton, which he now owns.
SPECIAL FEATURE SECTION: SPORTS & RECREATION
Trans-radial Hockey Prosthesis
Custom Goalie Stick Terminal Device By: Kate Wagner (Prosthetic Intern), Dan Mazur C.P.(c), Mark Holliday R.T.P.(c) and Doug Paulsen C.P.(c) Rehabilitation Centre for Children Prosthetic Department, Winnipeg
The patient is an eight-year-old male with a right congenital transverse forearm deficiency. He has been skating for a few years and wants to play goaltender on a recreational hockey team this year. The affected side is his stick and blocker side. He required an effective prosthesis and custom-designed terminal device to aid in the necessary movements for a goaltender.
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goalie has to slide the stick from side to side, stop shots with a blocker, pass and shoot the puck. The prosthesis and terminal device must be durable, lightweight, allow for simple operation and contain safety features to minimize the risk of injury in the event of a fall or collision with another player. The patient is moderately active and well-adjusted to using a prosthesis and specialized terminal devices. He wears a passive prosthesis for daily use and recreational terminal devices for biking, playing guitar, using fishing rods and has a regular hockey stick attachment. Objective: To create a goalie stick terminal device that is strong and durable, and provides a sturdy attachment to the stick that won’t crack or break during play. The terminal device is to allow the patient to perform multiple movements such as poke-checking, passing the puck,
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shooting and gliding side to side. Movements must be fluid and controlled. Concerns/Variables: The main concerns were the quality of movements that the device will allow, the attachment of the blocker from the socket to the stick as to not interfere with the primary movements, and also to provide protection to the device itself from pucks. Another concern was to avoid unnecessary bulk and additional weight. The terminal device was positioned as close as possible to the socket to provide better control of the stick. The lay of the stick was also a concern when determining the angle of the adapter and socket attachment points. We wanted to ensure that the blade of the stick rests flat on the ice. Expectations: A lightweight and durable device, which would be easy to use and would help the patient’s hockey performance.
Solution: Incorporating an angled aspect to the terminal device allowed a more realistic grasp of the stick. By creating the attachment point on the top edge, it allowed the patient to have control above/overtop of the stick rather than behind. The socket design was fabricated to be slightly shorter than the sound side to reduce functional lever arm, and allow our patient more control over the stick. To ensure durability, a heavier lamination with a Coyote release shuttle lock was used. The alignment was in neutral forearm position with slight adduction of the wrist unit. The wrist unit used was an Ottobock 10V34 that allowed for circumduction movement. A piece of ½-20'' stainless steel, threaded rod attached to the wrist unit was fastened into a nut attachment on the goalie stick terminal device. The goalie stick terminal device has an option of two threaded attachment
points, both angling from the stick at 45 degrees allowing the patient to choose which is best for his capabilities. For attachment of these points, a PLU series fabtech putty was used with a thick build-up of fabtech on the underside of the nuts. This build-up created a stronger mechanical line and improved the strength of the terminal device when the patient pushes down on the stick. Attachment of the blocker to the prosthesis was completed by removing the leather palm from the blocker/trapper. The patient can slide the blocker up onto the prosthesis and then engage the shuttle lock. Velcro was attached to the posterior socket and a pullback strap was added to the blocker to anchor it to the prosthesis and prevent movement while in use. The Velcro aids in preventing the blocker from sliding distally
down the arm, as well as preventing the blocker from twisting/rotating when being hit by pucks. Fabrication: A heavier lamination layup was required to prevent breaking or cracking if the patient was to fall on the device. Multiple layers of nyglass and fiberglass in each lamination provided greater strength to the device. Additional layers around the wrist/distal end will prevent cracking at the distal point of pressure. After the initial lamination, the distal socket was foamed and the wrist was aligned at the desired angle for optimal performance. The wrist was attached and the forearm shaped to the patient’s measurements. The second/ final lamination used multiple layers of fiberglass to further increase the durability of the socket.
SOCKET LAYUP First Lamination
Second Lamination
PVA Sheet - MOT Nyglass - Uniprox 70mm Fiberglass wrapped - distal aspect Nyglass - Uniprox 70mm Fiberglass wrapped - entire socket Nyglass - Uniprox 70mm Nyglaass - Uniprox 70mm PVA 4'' Bag 100g Acsys Ecoextreme acrylate polymer resin: 2g cream catalyst White pigment - MOT
Nyglass - Uniprox 70mm Fiberglass wrapped - distal wrist attachment Nyglass - Uniprox 70mm Fiberglass wrapped - entire socket Nyglass - Uniprox 70mm Nyglass - Uniprox 70mm Winnipeg Jets Hockey Print Pantyhose overlay PVA 4'' Bag - MOT
Anterior view of socket attachment to customfabricated terminal device.
150g Acsys Ecoextreme acrylate polymer resin: 3g cream catalyst
Goalie Stick Terminal Device: The initial lamination of the terminal device was done with a cotton stockinet spacer between the goalie stick shaft and PVA. The purpose of this lamination was to create a strong sleeve that would slide on and off of the playing stick. Once the first lamination was complete, the sleeve was cut and removed from the stick. The device on the stick was positioned at the optimal playing height and aligned with the ½-20'' nut(s) according to the most natural playing angle of the wrist over the stick. The threaded rod
created a 45-degree angle to the stick. Using a PLU series fabtech to secure the nut(s) in place, it was ensured that there was a build-up of excess putty distal to the nut(s) creating a mechanical line to prevent the patient from snapping off the device when weight was applied. When starting the second/final lamination, the device was set-up upside down in the vacuum to avoid resin pooling on top of the nut(s). Mixing fiberglass wraps into the layers of the lamination provided strength between the device and the added nut(s).
Superior view of terminal device and angle of threaded socket attachment points.
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(left) Velcro pull-back strap to attach blocker to the socket. (right) Posterior view of device and blocker combination.
TERMINAL DEVICE LAYUP First Lamination
Second Lamination
Cotton stockinet spacer PVA 4'' Bag - MOT Dacron sleeve Nyglass - Ottobock 623T9=4 Nyglass - Ottobock 623T9=4 Fiberglass Wrap Nyglass - Ottobock 623T9=4 Nyglass - Ottobock 623T9=4 PVA 4'' Bag - MOT 70g Acsys Ecoextreme acrylate polymer resin: 1g cream catalyst
Nyglass - Ottobock 623T9=4 Fiberglass Wrap Nyglass - Ottobock 623T9=4 Fiberglass Wrap Nyglass - Ottobock 623T9=4 Winnipeg Jets Hockey Logo Pantyhose overlay PVA 4'' Bag - MOT 100g Acsys Ecoextreme acrylate polymer resin: 2g cream catalyst Black Pigment - MOT
Once the terminal device was set-up at the proper height for the patient to play, the stick was drilled and tapped for attachment.
About the Authors: Kate Wagner graduated from the University of Winnipeg, and completed the GBC Technical Program in 2014. Currently she is working as a prosthetic intern at the Rehabilitation Centre for Children in Winnipeg. Dan Mazur, B.A.(Kin), C.P.(c), completed a Bachelor of Arts degree in Kinesiology in 2007 and graduated from the GBC Clinical Program in 2009. He has been employed at the Rehabilitation Centre for Children in Winnipeg since 2009, certifying as a prosthetist in 2011. He is also training part-time as an orthotics resident and studying at the University of British Columbia, Masters of Rehabilitation Science program.
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SPECIAL FEATURE SECTION: SPORTS & RECREATION
Concept to Completion 35 Years of Prosthetic Innovations from Amputee, Inventor and Entrepreneur Bob Radocy TRS Inc. was formed in 1979 by upper limb amputee Bob Radocy, who was frustrated by the limited performance of commercially-available prosthetic devices at the time. He lost his left hand about four inches below the elbow in an auto accident in 1971. While experimenting with all types of prosthetic devices, his time in graduate school saw him apply his engineering and biological sciences education with his design experience to create an innovative, high-performance prehensor which enabled him to be competitive with two-handed peers in any activity he chose. He called it the GRIP prehensile hand, and manufactured the first one in 1980 and with that, his highly-specialized niche company was open for business. Here’s what Radocy had to share in an interview with Alignment publisher Jeff Tiessen. Alignment: Launching a prosthetic company can’t be as easy as simply having one good idea can it? Radocy: A lot goes into it of course... but with TRS it was my own needs that served as the impetus. That served us well from a quality standpoint because as an amputee and a consumer, and from a selfish perspective, I built stuff to last... no shortcuts. I attended a prosthetics conference and was encouraged by the response to my prehensile hand – my first product. I borrowed $150,000 against my house and went for it. Three years later we almost went of business. We just couldn’t make ends meet. Another $150,000 in venture capital gave me the latitude to get my paediatric line going. That turned the company around and we’ve been profitable and growing ever since. Alignment: Many in the industry know TRS for your sports and recreational products. Are these your core products? Radocy: Actually not. Our sports and rec division is becoming an important component of our business, and where our growth is coming from, but our bread-and-butter is still adult and paediatric prehensors.
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Alignment: Being a small company, with much bigger “fish” in the prosthetic pond, are you always looking over your shoulder with respect to an emerging competitor? Radocy: No. We developed a niche business that serves a very small market. There really isn’t much market share available. There’s room for one company that is innovative; it would be difficult for a competitor to justify this market when it comes to return on investment – we’ve created products that we sell only a dozen of throughout the year. And I have to build 75 at a time to make them worthwhile to make – that means sitting on them for five years. Alignment: How does TRS justify that business model? Radocy: We have a different reason for being in business. I am a consumer as much as I am a manufacturer and designer. We’re just not a purely businessdriven company. Alignment: Can you qualify how being an amputee and your own customer so to speak, has contributed to the success of TRS? Radocy: I’ve played a lot of soccer and used to tape a tennis ball over my
terminal device to help with throw-ins. It opened up our minds to polymers. We introduced polyurethanes into the prosthetics world through a pliable passive hand I created for sports and recreation use. We have our own proprietary formulas for our product lines that replicate wrist action for swinging a baseball bat for example. I grew up as a mechanical structural draftsman with a lot of hands-on experience in high school and college. With a background in biology, I understand physiology and anatomy, and I played all kinds of sports as a kid. When I became an amputee, the combination of those things helped me to conceive of a product and know what it had to do from a consumer and designer standpoint. Alignment: How are new products conceptualized, researched and developed? Radocy: More now than ever from consumer requests. We can create a prototype quite quickly, without focus groups. We cut through the murky parts of product development quite easily. If there’s something I’m developing that I don’t have familiarity with, I bring in people who do, or I study up on it... like a pole vaulting component that we are working on. We will probably sell only a few in a lifetime, but it gives us insights into how
to solve other problems. In terms of time to bring a new device to market, it varies from product to product. Our Mountain Master concept – a mountain bike device – was knocked out in three or four months. Alignment: What is on the horizon for new product development and launch? Radocy: We’re very excited about our Standardized Prosthetic Simulator which we just brought to market. It’s a training tool that anyone can slip on to get a feel and understanding of how a prosthesis feels and operates with different terminal devices. Those with a traumatic injury can cross-train with different terminal devices before purchasing. It’s for clinician/healthcare practitioner training as well, and also for parents, siblings or peers for awareness and sensitivity training. Importantly too, the standardized prosthesis platform offers consistency for clinical evaluations and honest research. We’ve also developed the first off-the-shelf standardized wrist disarticulate hand prosthesis. It’s for those who aren’t going to wear a prosthesis a lot, but just need it for specific purposes. By heating it up and molding it to the proper shape, the clinician can have the client out the door in an hour. It satisfies the need for a simple, functional, reliable solution for cutting the lawn or working in the garden for example. When done with the chore, users can take it off. Alignment: Reflecting on your 35 years in business, where have you found your greatest rewards? Radocy: Helping people’s lives get better has made for a great career for me in prosthetics. My crown jewel of the product line has to be the GRIP and its evolution as a voluntary closing device. The COBRA, the baseball throwing device, amazes me too. I never thought I’d ever throw a ball left-handed again. When I did, after 40 years, it was the most amazing thing and still makes me feel like a little kid again. Also, a huge reward comes from practitioners who have been open to our innovations. I really enjoy the feedback from prosthetists and consumers. That two-way street is very gratifying. For more on TRS visit www.trsprosthetics.com. Distributed in Canada by Myrdal Orthopedic Technologies.
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CLIENT PROFILE
The Fuel for My Fire By: Ann Harland
My physiotherapist calls my adventures “extreme travel”. I admit that some of the things I manage to do are pretty amazing but none of it would be possible without my AFOs. They enable me to walk farther, stand longer and climb stairs, albeit with much difficulty!
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adly, I imagine for every AFO being worn there is one resting unused in a closet. How discouraging that must be for the orthotist, who invested hours of time and energy, to know that it was worn only once on the day of the final fitting. It seems to me that perhaps the most important contributor for success and compliance, with respect to wearing an AFO, is not in the design but in the process. Crafting a functioning AFO is an art and a science all in one. The process is as important as the product. If the client doesn’t feel good about the process he or she may never develop the conviction needed to persevere through many
fittings. Support and understanding are easily demonstrated through active listening and enthusiasm. It is often a combination of what is said, and how it is said, that is critical from the first meeting to the last. Notably, what the client hopes to accomplish may not be consistent with a well-designed, magnificently-crafted, textbook-perfect AFO. The client may not be aiming for a “corrected” gait or posture. His or her goal may have more to do with participation in a particular activity... a lifestyle choice. Multiple adjustments will likely be necessary. The client may need time to process the functionality of the brace as he or she reworks their self-identity in coming to terms with loss of ability and change in appearance. Finding the right design and fit is sometimes hinged on not giving up too easily. Success may come only after many trial runs. When I donned my first pair of AFOs I remember doing laps around the examination table… just because I could! I felt the giddy excitement of a child. I could do things I had not
Mutianyu, China: Climbing the Great Wall, 350+steps, one at a time.
Sentosa Island, Singapore: “On top of the world” on the most southern tip of Asia.
been able to do for many years. My husband and I began to travel again, visiting more than forty countries in the span of ten years since that first fitting. But at the same time, those years have wasted away my muscles and weakened my body. Two new sets of braces and many, many adjustments have ensued. But I am always bolstered by my orthotist who never tires of my endless questions or unconventional requests. Her willingness to listen and explore solutions that are “outside the box” inspires me to look beyond my own limitations. Visits to my orthotist are anticipated, not dreaded. It may sound cliché but it is these practitioners, these special people in my life, who have fueled my spirit. With their help my dreams really have come true.
O&P SOLUTIONS
Introduction to Orthotic and Prosthetic Applications for Small Animals By Janice Olynich, C.P.(c)
As a sub-specialty of veterinary medicine, animal rehabilitation has grown in prominence in recent years. In major cities, most large orthopedic specialty clinics now have rehab departments, and many general practice veterinary clinics have someone trained to provide guidance to clients who are managing a pet with an orthopedic injury.
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ith this rise in awareness of the benefits of rehabilitation has come an increased appreciation for the ways in which the use of orthotic and prosthetic devices can positively impact the lives of small animals. Devices are often used in conjunction with other modalities of treatment, such as physiotherapy, hydrotherapy, and chiropractic care, and they round out the spectrum of services that are available to effectively increase an animal’s mobility. It should be noted that while devices can be made for a number of small animals, dogs are most commonly the recipients of this type of care.
Veterinary Assessment and Referral When an orthotic or prosthetic device is being considered for use with a particular injury, the first step is always a veterinary assessment and diagnosis. Options for surgical repair, if applicable, need to be presented and considered alongside any options for orthotic intervention. For prosthetic cases related to acquired amputations, the amputation level needs to be considered and assessed to determine if the limb length will allow for prosthetic fitting. Cases related to the management of congenital limb differences are
generally more straightforward. However, X-rays may need to be taken to assess the internal structure of the joints involved to determine whether surgery could offer any improvement in function. From an educational standpoint, involving the veterinarian in every case ensures that more vets become aware of the services available for animals.
Rationale for Orthotic Intervention Two of the main indications for choosing bracing as a form of injury management are the dog’s age and the presence of pre-existing medical conditions.
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Melman in his bilateral carpal orthoses.
bracing is used in place of a bandaging and splinting system to manage the range of motion of a joint for a period of several weeks to months. Conditions for which there may be no surgical correction include partial limb paralysis, spasticity, and digital fractures.
Orthotic Applications
Whether it is an actual risk factor or just owner preference, many clients will choose to brace a leg if their pet is advanced in age or has a medical condition and as such, surgery poses a health risk. Often, this can be compounded by the concern of a difficult post-surgical recovery period. Choosing bracing in place of surgery can also apply to very young dogs where surgery is not indicated until they have reached skeletal maturity. Additionally, some clients may have had difficult experiences with surgeries in the past and are inclined to try less invasive treatments before considering another surgical option. Others may look to bracing for financial reasons, as the cost of an orthopedic surgery may not be affordable. Other indications for bracing can include post-surgical applications and conditions which have no possible surgical correction. For post-surgical cases,
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The types of orthopedic issues that dogs experience can be either similar to, or different from, those found in the human population. We share much of the same structure with our quadruped pets, but the way in which this structure is shaped and loaded is quite different. For example, in the forelimb, the carpus, elbow, and shoulder are weight-bearing joints and are susceptible to types of stresses and injuries that we would not see in people. In the hindlimb, the hock (ankle), the stifle (knee), and the hip are proportioned and held in angulations that create a different potential for joint injury. The carpal joint is commonly braced for issues of hyperextension, or varus/ valgus angulation. Devices typically utilize a three-point pressure system of control, and may or may not incorporate the paw into the support. The hock joint can be braced for injuries involving the Achilles tendon (which results in hyperflexion of the joint), and also ligament injuries that result in varus or valgus deviations. In managing injuries of this joint, the principles of a three-point pressure system are also used and again, the paw may or may not be contained in the support. The stifle is one of the most common joints to be braced, and generally related to injuries to the Cranial (Anterior) Cruciate Ligament. Additionally, varus and valgus angulations at the stifle can also be controlled with a brace. Other orthotic applications include elbow orthoses, cervical collars, spinal braces, custom boots, shoulder sup-
ports, and combination braces that involve two or more joints.
Prosthetic Applications Opportunities to fit prosthetic devices for small animals are far less common than cases that can be managed with orthotic devices. Whether a congenital limb difference or an acquired amputation, there must be a significant length of residual limb present for prosthetic rehabilitation to be successful. The most successful fittings happen when the amputation is done through the carpus or the hock, or below. With these levels, the residuum length results in the dog attempting to touch the limb down to the ground and as such, only protection and length need to be provided for effective weight-bearing. Since gait training with dogs has many limitations, the use of a device depends mostly on the dog’s desire to participate with it, and that in turn depends greatly on limb length. With more proximal amputations, the dog will often hold the limb close to their body for balance and it seems less instinctual for them to reach down for the ground.
Fitting Challenges While most might perceive fur to be the biggest challenge when fitting animals with prosthetic and orthotic devices, personal experience has proven that communication, or lack thereof, is the most significant obstacle. P&O is a feedback-driven profession and we have much to gain and learn by involving and consulting our clients in the process with regards to fit and function. With animals this consultation process is not possible, but they are still included by observing their reaction to wearing the brace and changes in gait, and then by extension, involvement of the pet’s owner. The owner has to be vigilant in gradually building up the wear time, observing the skin in key
Stanley in his extension prosthesis.
Oreo in her elbow orthosis.
areas, and assessing the dog’s ongoing comfort in the device. The conformation of the dog and the activities that dogs like to do can pose challenges as well. It goes without saying that dogs vary widely in terms of size and shape, and there are some limb shapes and lengths that just can’t be braced effectively. In terms of activities, dogs tend to be quite hard on their braces which means many upkeep implications for devices that are worn into the pond or lake, through the field, and home again!
Provision of Services Ask around your P&O facility, and you will likely find a fellow practitioner who has been approached, at some point in his or her career, to make a device for an animal. Today, there are businesses and clinics that are solely devoted to providing prosthetic and orthotic services for animals. Across North America, there are a number of businesses that will make devices with the involvement of a referring veterinarian in casting and fitting, and then manu-
facture the device at a central facility. Other clinic models seek to provide more of a hands-on and localized service by working directly with the client and their pet throughout all steps of the process. While the latter scenario is likely better in terms of achieving a successful fitting, the availability of this type of service is so limited that people may have no alternative but to work within the hybrid or out-sourcing model of service. How best to provide orthotic and prosthetic treatment to animals is a topic that deserves much consideration and deliberation to present adequately. But what is most important is that any prosthetic or orthotic practitioner providing this care to small animals must bring their expertise, ethical practice, and love of animals to this new and exciting area of our field. About the Author: Janice Olynich, C.P.(c), is the owner of PawsAbility, a Toronto-based P&O service for small animals. Janice also works in the Clinical Technology department at Holland Bloorview Kids Rehabilitation Hospital.
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TECHNICIAN’S REPORT
Memorable Moments Compiled By: Jarrod Eccles, R.T.O.(c), Director of Operations, Myrdal Orthopedic Technologies, Inc.
Who can’t recall a funny, inspirational or cautionary work-related tale that will forever remain in your memory? Sharing stories that come out of our P&O practices with colleagues and friends is about learning from our successes, our mistakes, simply creating a feel-good moment or a good laugh. We all have stories to tell and some that make for great reads. Send your submissions to jarrod@myrdalorthopedics.com.
My Buddy Tim I met Tim in the early 1980s while working at a major rehab facility. I miss his physical presence. Spiritually, I think of him often. Tim taught us about spirit, strength and the tenacity to overcome perceived challenges. He taught us a lot about determination.
“ Support standards and expectations.”
Tim lived life as an energetic quadriplegic. He engaged in a loving marriage. He drove his own customized van, supported football, which actually took the bulk of his physical ability from him, was an avid fisherman and kayaker! I often think about the lessons he left with us. Most of our challenges are but a pittance of what he conquered... kayaking with custom orthoses and diligent support, fishing with friends who came to realize that it was best not to strap him to his heavy electric chair while on the water. A lighter, transferable “Fishing Chair” was designed for him. Once questioned on how to best promote a new endeavour Tim suggested the following philosophy: “Support standards and expectations.” These were the words of a strong-voiced, active, alpha individual who cared about people. I suppose that’s a big part of the reason I have such respectful memories of our friend Tim. Patrick J. Myrdal, R.T.P.O.(c), F.C.B.C. Myrdal Orthopedic Technologies, Inc. Winnipeg. Manitoba
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Edith and Silvio
Holiday Wish
When people learn what I do for a living I’m always asked: “What inspired you to get into that line of work?” My answer usually centres around my enjoyment of helping people and loving the creativity and challenge of such a unique profession. Occasionally I get asked: “Why do you keep doing what you do?” My answer is Edith and Silvio.
There’s been a lot of talk lately on the radio about end of life care. I’ve had several patients who have come to me with very sad news. Some were obviously so sick when they walked in that I knew what was coming. Like all of us, I had to learn how to handle these situations... it wasn’t something we talked about much in school.
It was 8:00 on a Wednesday night when I entered a hospital room to introduce myself to Edith, a 92-year-old lady who had just become a trans-tibial amputee. Edith was sobbing. She had lost her husband a year earlier and now her leg. She kept asking me why God hadn’t taken her; it wasn’t fair and she wished she were dead. She was devastated. I tried to reassure her that everything would be okay and that she would be able to walk again and return to her home and activities. Two weeks later I was back to begin prosthetic treatment. I did a residual limb impression of Edith and Silvio, a long-time patient... a left trans-tibial amputee for many years. He was now a bilateral trans-tibial amputee. Silvio had many health issues but he always had a smile and a joke too. My next appointment with Edith and Silvio was in the physiotherapy room and included two physiotherapists, two physio aides, an occupational therapist and a social worker. I integrated Edith’s prosthesis and walked her up and down the parallel bars, dynamically aligning her prosthesis. Then she sat down in her wheelchair and cried quietly. With Silvio standing on his two new diagnostic prostheses, he touched my shoulder and said, “Excuse me David, I have something more important to do.” With that, he walked over to Edith, extended his hands and asked: “Edith, may I have this dance?” He waltzed Edith around the room humming a tune. When they sat down there wasn’t a dry eye in the room. I would continue seeing Edith once a month in her home. We would have a cup of tea and a biscuit before she would even entertain talking about her prosthesis. She shared stories about her life, her husband, her family, her joys and her regrets. She cried on my shoulder when I told her that Silvio had passed away. Life goes on. Every Thursday Edith would dress in her best clothes and hat and take a cab into town to do her shopping, pay her bills and have lunch with her friends. For someone in her nineties, she was very sharp-minded and independent. She wore her prosthesis every day. It was another Wednesday night not unlike the first night I met Edith when she was again in a hospital bed. We talked as she slipped in and out of sleep. I sat quietly waiting for her to finish the sentence she had started before she dozed off. When it was time to say goodnight, Edith stretched her frail arms out toward me. She hugged me and kissed my cheek and ever-so-softly whispered “thank you.” Two days later the physio department called to tell me that Edith had passed away. Edith was 102. And that’s why I still do what I do. David Broman, C.P.O.(c), F.C.B.C. President of Hager Orthopaedic Clinics Ltd. Kelowna and Castlegar, British Columbia
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One such patient was a former survivor of osteosarcoma as a young man. He had lived a full life with a hip disarticulation amputation. He walked everywhere, was married, raised a family and was a successful engineering consultant. The day he told me he had pancreatic cancer my heart dropped and shattered in a million pieces. He was eventually admitted to the hospital after suffering a debilitating stroke. He had lost so much weight. He could no longer speak and his sound-side was affected. It was questionable whether he would be able to stand. I was called to see if I could do anything to make the socket fit better. I lined it as best as I could. I cleaned the joints and prettied it up with new socks and new Velcro. I brought it back to his room and for the first time that day he squeaked out some words. “Thank you,” he said, and gave me a wink as he struggled to say “Merry Christmas”. I leaned over him in his bed and told him I would see him after Christmas and advised him to try to walk with the physiotherapist (PT) in the morning. I thanked him for being such a gentleman to me and for always making me feel like I was a light in his life. I can still see him smiling and calling me “kid”. Several days later the PT emailed me to report that he was up and walking on the weekend! He was so happy and wanted me to know. The PT shared that his fear was going home and not being able to get himself from place to place. She deemed him safe to walk short distances with supervision. He got his Christmas with his family, one last time. It’s been one year. I miss him. Kristin Schafer, B.Sc. (Kin.), C.P.(c) Health Sciences North Sudbury, Ontario
Foot Folly One especially memorable moment in my O&P career involved a prosthetic repair for one of my highly-active teenage clients. He has a knee disarticulation. I received a call from his father advising that he had broken his prosthetic foot. I asked the family to come in as soon as possible for the repair. They lived in a rural community and couldn’t make it to the centre until the next afternoon. The dad assured me that they would be okay until then... they had emptied a few rolls of hockey tape on the prosthesis to “hold things in place.” My patient caught me by total surprise the following afternoon upon his arrival when he tossed his foot to me from across the room. He was standing on his prosthesis. Their temporary fix meant taping his shoe directly to the pylon! He had broken the foot clean through the carbon strut just distal to the pyramid adapter. His replacement foot hadn’t arrived yet so I was only able to install an old SACH foot for the interim. “Well, this foot isn’t ideal but at least it’s better than walking on that pipe,” I told my client, to which he replied: “Actually, I think I might prefer the pipe!” Dan Mazur, C.P.(c) Rehabilitation Centre for Children Winnipeg, Manitoba
Meant To Be Here Admittedly, I am not a big believer in fate, destiny or whatever you want to call it. I was always a grunt, loved physical labour and enjoyed interacting with people. In 2001 I answered an advertisement for yet another shipper/receiver position and was excited to be part of a new venture. My world was opened up when I first learned of our profession and got a glimpse into what orthotic and prosthetic practitioners do. I was encouraged to be more, do better. I was no longer just a labourer; I was to be trained to become a Technician! I remember the early days, when Pat [Myrdal] would tell me I was going to do something new and I would look at him and think “You want me to make what? What’s a stirrup? What’s a proximal roll-over cuff and you want me to cut a shoe?” All these new things were scary for me at first but I was helping people. I was hooked! After 14+ years in the field, my role has evolved and my passion remains. You know you’re meant to be here when your home and work life become one. I have a great family and cannot spend all of my time with either side so I make my time count. I am just being me, being comfortable with the people I’m with and where I was meant to be. My most memorable moment is when Pat invited me to be part of the O&P family. Jarrod Eccles, R.T.O.(c) Myrdal Orthopedic Technologies, Inc. Winnipeg, Manitoba
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CONTINUING EDUCATION
Student Papers
With thanks to project coordinators Caroline Soo, B.Sc. (Kinesiology), M.Sc., Research Coordinator, Prosthetics and Orthotics School of Health Science, British Columbia Institute of Technology, and Gordon Ruder, C.O.(c), B.Sc., M.Sc., Coordinator, Prosthetic & Orthotic Programs, George Brown College.
The following are student research projects from the British Columbia Institute of Technology and George Brown College that each program is excited to share with the P&O community across Canada. Most of the projects presented here are represented by an overview, with full-length papers available on the Orthotics Prosthetics Canada website at www.opcanada.ca.
Basalt: An Investigation Into a New Prosthetic and Orthotic Material Option Introduction: Coyote Composite’s basalt fibre is a relatively new material option for prosthetists and orthotists. As a laminate, it has a number of interesting characteristics such as ease and safety of fabrication, durability, affordability and post-fabrication modification. However, little is known about basalt’s material characteristics and how it relates to currently available
laminate material options. This study explores the material properties of basalt in lamination compared to carbon fibre and fibreglass.
Methods: Single-ply laminate samples of each material were fabricated under identically-controlled conditions to provide specimens similar to industry procedures. Using ASTM standardized protocols, the tensile
strength, toughness, modulus of elasticity and hardness of the samples were measured.
Results: Initial results show that the material properties of basalt are within the ranges normally expected of carbon fibre and fibreglass. The unique characteristics of basalt and the findings from this study support further testing to better establish its application
in clinical practice. About the Author: Carl Ganzert, B.Sc. (BCIT), is a graduate of Simon Fraser University’s School of Biomedical Physiology and Kinesiology. He is currently completing his Masters of Rehabilitation Science at McMaster University while doing his Orthotics Residency at Hodgson Orthotics.
The Impact of Textile Properties on Moisture Management in Prosthetics and Orthotics Background: Clinicians utilize a variety of textiles in the form of socks to manage perspiration within prosthetic and orthotic devices. Despite the widespread use of fabrics in the P&O field, textile moisture properties are not well understood.
Methods: A qualitative study was conducted using questionnaires to explore the impact of moisture accumulation and treatment with a liner-liner on transtibial amputees. Procedures for two qualitative tests were adapted from ASTM standards for Water Vapour Transmission of Materials and Hygroscopic Sorption Isotherms of Building Materials to test moisture storage capacity of P&O fabrics and the water vapour transmission rate of an anklefoot-orthosis (AFO) with holes drilled when worn with an AFO sock.
Results: The qualitative study shows a trend toward a positive impact on the quality
of life of trans-tibial amputees after treatment with a liner-liner. Moisture sorption curves were obtained for six P&O textiles and a ranking was established. The water vapour transmission rate of the AFO assembly was found to be 5.66 x 10-6 kg/s*m2.
Conclusion: Understanding the moisture properties of P&O fabrics will encourage clinicians to think critically about textile performance and aid in driving patient-centred research and development of moisture managing fabrics. About the Author: Shannon McCann, B.Sc., earned her degree in Physiology from the University of Saskatchewan’s College of Medicine in Saskatoon. In 2014, she completed her Diploma of Prosthetics and Orthotics at the British Columbia Institute of Technology and is now living in Vancouver, B.C., completing her Orthotics Residency at Ortho Dynamics Inc. She is looking forward to developing her clinical skills with a focus on paediatric orthotics.
Comparison of Partial Foot Interventions and Effects on Terminal Stance: a Case Study Background: A variety of interventions have been developed to manage partial foot amputations, primarily to reestablish the shortened lever arm and to improve diminished propulsion during late stance. However,
there is limited quantitative evidence regarding the efficacy of one intervention over another.
Purpose: To compare lower and higher profile prosthetic/orthotic interventions and their ability to effectively restore push-off at terminal stance and restore the affected foot length.
Methods: Four different partial foot interventions were evaluated on a single Lisfranc amputee subject. Six trials of each intervention were performed using the Templo Gait Analysis System to measure peak forces at terminal stance and the progression of centreof-pressure. Secondary outcome measures collected included the Berg Balance Scale, L-Test, and self-reported prosthetic evaluation questionnaire (PEQ).
Results: Each intervention improved mean peak height force generated at terminal stance and push-off when compared to baseline (barefoot with shoe). Centre of pressure was found to be significantly less for lower profile interventions compared to higher profile interventions.
Conclusion: In comparison, higher profile interventions were able to demonstrate an improved effective push-off at terminal stance and return of the affected foot length; however, higher interventions were restrictive for higher functional ability. About the Author: Derek Neudorf, B.Sc., is a graduate of the Kinesiology program at the University of Saskatchewan. He graduated from the BCIT Prosthetics and Orthotics Clinical Program in 2014. He is currently doing his Orthotic Residency at the Saskatchewan Abilities Council in Saskatoon.
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Provincial Funding Models for Prosthetic and Orthotic Care Across Canada: a Qualitative Study This ancillary study aims to assess how provincial funding models across Canada facilitate access to prosthetic and orthotic care. The Canadian Health Care Act is a mandate from the federal government, yet the responsibility of determining that level of access falls under provincial jurisdiction. The question is then posed; how do individual provincial funding models promote universal access to prosthetic and orthotic care across Canada? This study will focus on provinces that use a shared-reimbursement-funding model, allowing access from both public and private facilities. A survey has been developed to consider the provincial funding models based on a set of general criteria. Data has been collected by phone interviews from selected members of each provincial association. Through this study, the objective is to determine whether there is a unified level of access to P&O care across Canada and what that level of care entails. About the Author: Francine Coxon has a Bachelor of Kinesiology degree from Lakehead University and a diploma from the Orthotic & Prosthetic Technician Program from George Brown College. Graduating from the BCIT Prosthetics and Orthotics Clinical Program in 2014, she is currently doing her Orthotic Residency at Cascade Orthotics in Calgary.
Optimizing an Online Education Platform for Clinical Gait Analysis Clinical gait analysis is a critical component of diagnosing, treating and monitoring patients in a healthcare environment. In order to provide effective interdisciplinary treatment, all members of the healthcare team should have at minimum, a basic understanding of the principles and terminology involved in clinical gait analysis. Currently, the methods of teaching clinical gait analysis to healthcare students and professionals are limited by the availability of resources and lack of participation in patient demonstrations. We have optimized an existing online platform (GOAL website) and developed an interactive e-learning program for students and healthcare practitioners to learn and practice the skills of clinical gait analysis. The project involves three main components: 1. organizing and updating the current GOAL website to allow users to search for specific pathologies or gait patterns; 2. adding relevant assessment information to current video files on the GOAL site; and 3. developing an interactive modular program for self-directed learning and practice of clinical gait analysis. About the Authors: This paper is coauthored by Matt Menard and Tessa Richardson. Matt Menard has a B.Sc. in Biology from the University of Calgary. He is a 2014 graduate from BCIT, and an Orthotic Resident at Colman Prosthetics and
Orthotics in Calgary. Tessa has a B.Sc. in Engineering from the University of Calgary and is a 2014 graduate in P&O from BCIT. She is currently doing her Prosthetic Residency at Sunnybrook Hospital in Toronto.
BCIT Prosthetics and Orthotics Program Master’s Degree Needs Assessment Education requirements in the field of prosthetics and orthotics have recently shifted, with countries such as the United States and Australia mandating that clinical programs be of a Master’s degree level. The Prosthetics and Orthotics program at BCIT has begun the transition process to change the designation from a diploma to a Master’s degree. In order to receive this designation, a needs assessment must be performed to determine whether clinicians in daily practice utilize the competencies outlined by BCIT that are necessary to achieve a Master’s degree. The aim of this research project is to perform this needs assessment in order to determine whether Master’s level domains and competencies, as outlined in policy 5401 from BCIT’s Department of Program Development and Change, are being met in clinical practice. A survey was distributed to prosthetic and orthotic clinicians across Canada who are in the process of, or have completed a Master’s degree. The survey involved ranking on a scale how often they (clinicians) utilize a certain competency, and how important they believe that said competency is in clinical practice. While the study did identify some differences between the current curriculum and the
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competencies expected at a Master’s level, it was found that the majority of the skills taught in the BCIT P&O program are already at a Master’s level. As BCIT prepares to change its credential from a diploma to a Master’s degree, this timely study provides evidence to justify the degree change while identifying areas to strengthen the program. About the Author: Melissa Church obtained a Bachelor’s of Kinesiology degree from the University of British Columbia and is currently completing her Master’s of Science in Rehabilitation Science at McMaster University. She graduated from the BCIT Prosthetics and Orthotics program in 2014 and is now living in Calgary completing her Residency in paediatric orthotics.
Protection, Precaution or Excessive? The Use of PPE for Noise in the Prosthetic and Orthotic Field By George Brown College students Elisha Epp, Dean Oros, Stephanie Pugliese-Santana and Kayleigh Shanahan
In the prosthetic and orthotic industry, we are all aware of the physical dangers within the field, such as cutting your finger on the Trautman, or the fumes emitted when laminating or A/B foaming. What we may not be as familiar with is how the noise levels we encounter in our daily tasks may be affecting us, and how the continual exposure to these levels may be causing hearing damage. Noise-induced hearing loss is very gradual. Once it occurs, there is no way to reverse the effects. Prevention is key in reducing this type of hearing loss. According to the Ontario Health and Safety Standards, “No worker may be exposed to a noise level over 85 decibels (dB) for longer than eight consecutive hours”(Industrial Hygiene, 2014). Taking all of this into consideration, the question arose: “Is noise in the prosthetic and orthotic industry a health risk?” The purpose of our study was to compare the noise levels that we are exposed to at school with the values found in our work placements, as well
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as with the noise levels reported in professional studies at prosthetic and orthotic facilities. We wanted to determine how the levels in the “real” world compared to the levels in our school environment. We also wanted to examine how high the levels actually are, and how much damage clinicians and technicians are potentially exposing themselves to without the use of hearing protection.
Methods and Results: We used the smartphone app, Decibel 10th, to measure the noise levels in different areas of George Brown
Table 1. The average, minimum and maximum noise levels (dB) found in each of the six rooms on day one and day two. Bolded cells indicate average noise levels exceeding the occupational limit of 85 dB.
Figure 1. The average noise levels (dB) found in each of the six rooms on day one and day two.
College. Over the course of two days we accumulated eight hours of sound testing each, for a total of 32 hours. Our phones were placed in four different areas of each room for one hour in each location... the machine room, lamination room, plaster room, molding room, hallway and lab area. The sound levels were then averaged. We also tested our workplace environments to get an idea of how our results from school compared to a work environment. Noise levels were taken in different rooms at the work placements for approximately 5-15 minutes. The average levels were then determined for all rooms, representing the average noise levels we are exposed to on a daily basis.
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The average noise level exposure was found to be below the occupational limit of 85 dB in all rooms except for the machine room on both days, and the laminating and molding room on one day each (Table 1). The average levels in the machine room were found to be 93.1 dB and 92 dB for day one and two respectively. The average level for the lamination room was 86.0 dB on day one. The average level for the molding room was 86.6 dB on day two. The maximum levels went above 85 dB in all rooms except for the plaster room and the hallway (Figure 1). The workplaces we tested had quite a range of averages between them (Table 2). Clinic three was the only one to exceed 85 dB, with an average of 88 dB (Figure 2).
Discussions and Recommendations:
The only area in George Brown College that exceeded the occupational limit of 85 dB was in the machine room. Being in that room for an extended amount of time without
hearing protection would potentially result in noise-induced hearing loss. In a typical workday, a technician would be in the machine room for approximately one to three hours, a safe amount of time in that room without hearing protection. The second highest rooms were surprisingly the molding and lamination rooms. They both averaged out to be right at the occupational limit of 85 dB. Both the plaster room and hallway were relatively quiet which was to be expected. Although the only area with an average noise level that exceeded 85 dB was the machine room, four out of the six rooms had reached a maximum level above the 85 dB threshold (Figure 1). This is of importance because even for a short duration, loud noise levels can be detrimental to hearing. The noise levels found at George Brown College (GBC) were similar to the findings in our workplaces, as well as the levels documented in a professional study done at Chedoke Hospital (Sharpe, J., 2012). In that study, the averages were all higher than those
Table 2. Minimum, maximum and average noise levels (dB) from three different prosthetic and orthotic facilities in comparison to George Brown College. Bolded cells indicate average noise levels exceeding the occupational limit of 85dB.
Figure 2. The minimum, maximum and average noise levels (dB) from three different clinics in comparison to George Brown College.
found in the GBC lab. The disk sander, air hose, process grinder and band saw were all found to be above 85 dB. Chedoke Hospital also did testing in which a technician wore a personal dosimetry to record the sound levels throughout their eight-hour workday. It was found that the time-weighted average (TWA) exposure level was 86.5 dB and it was approximated that the technician was exposed to levels over 85 dB for a cumulative three hours (Szwedowski, P., 2014). It was also approximated that the hearing protection had a noise reduction rating of 30 for a total of two hours and 20 minutes. With that knowledge, it was calculated that the technician’s protected TWA was 79.5 dB bringing exposure levels below the occupational limit through the utilization of earmuffs (Szwedowski, P., 2014). Another study, performed by a student at a facility in British Columbia (Schubert, L., 2011), had findings that were consistent with the conclusions of the Chedoke study. All of their machines went above the 85 dB limit, with the highest being the air hose, at 124.4 dB. The study also found that the prosthetic technician’s TWA was above 85 dB for four of the ten days monitored (Schubert, L., 2011). With these two studies, as well as the GBC
findings, it is clear that hearing protection should be worn when using the louder machines. One limitation in the compiling of findings in the present study relates to data collection with respect to phone applications as opposed to professional sound testing equipment. The accuracy of the results could be questioned. Our phones were positioned in the rooms but not on an actual person, so it is possible that levels were actually higher than recorded, as the technician would actually be closer to the machine and theoretically experiencing a higher decibel level. There is also the issue of carry-over noise given that the majority of the walls are not ceiling height. A more in-depth study would also have given a more accurate representation of noise exposure throughout our daily activities. We also used different phones, three iPhones and one Android, giving rise to the possibility of variance in microphone calibrations which could skew the results slightly. One last limitation is that the time spent testing at GBC differed from that at our work placements as we did not have as much time to test at the latter. There are many different conclusions that we can take from our findings. As technicians and clinicians
we are exposed to a variety of hazards throughout the day as we complete different tasks. Awareness of exposure risks enable us to take precautions as we see necessary. The average levels found at GBC were not high enough to suggest that hearing protection should be mandatory. The other two aforementioned studies do suggest that the possibility of average noise exposure above the 85 dB limit throughout the workday does exist. It is the authors’ recommendation that we should be wearing hearing protection when performing tasks that are known to exceed the occupational limit, such as bandsaw and air hose use, hammering and riveting. In the study by Schubert (2011), orthotists, prosthetists and technicians were surveyed to ascertain how often they have their hearing tested. Reporting showed that 71% of the respondents never had a hearing test or had not been tested in the last five years. Our recommendation is an annual hearing test by an audiologist. Prevention is key in protecting against noise-induced hearing loss.
What’s Next?
As a follow-up study, a Quest Edge 5 (Type 2) personal noise dosimeter will be used to gather noise testing data over a two-day period at GBC. The dosimeter’s measurement parameters range from 70 to 140 dB. The authors are also interested in using a Rode Smartlav personal microphone for on-person testing, as opposed to stationary placement in different areas of the rooms. The Rode microphone has omni-directional capabilities with a frequency range of 20 to 20,000 Hz which will provide measurement of noise to which an individual is exposed throughout their daily tasks in the lab. By utilizing professional dosimeters, comparisons in accuracy will be made to cell phone app measures. In addition, time-weighted exposure levels with hearing protection will be logged. By continuing to collect more data, the authors hope to provide more concrete evidence of the necessity of hearing protection within the profession.
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References Hamilton Health Sciences. (2010). Hearing Conservation Program. Hamilton Health Sciences, Chedoke Site. Hamilton, ON. Industrial Hygiene. (2014). 2014 pocket Ontario OH & S Act & Regulations (Consolidated ed.). Carswell: Toronto, ON. Schubert, L. (2011). Alignment 2011. How Risky is your Business? Optimizing Safety in the Prosthetics and Orthotics Workplace. Disability Today Publishing Group. St. Ann’s, ON.
About the Authors: Stephanie PuglieseSantana, completed her B.Sc. in Kinesiology at York University in 2003. She is currently completing her Prosthetic and Orthotic Technician diploma at George Brown College. Stephanie hopes to work in the P&O field in Toronto. Elisha Epp graduated with a B.Sc. in Honours Kinesiology from the University of Waterloo in 2013. She is currently finishing the Prosthetic and Orthotic Technician diploma at George Brown College. Dean Oros is completing his Prosthetic and Orthotic Technical diploma from George Brown College. Prior to pursuing P&O, he worked in the media for over 20 years. Kayleigh Shanahan completed a B.Sc. in Biological Sciences from Brock University in 2013. She is currently completing the Prosthetic and Orthotic Technician diploma program at George Brown College and plans to work as a registered Orthotic Technician.
Gait Patterns of Runners with Lower-Limb Prostheses Anatomical, Design and Attitude Implications By: Sherry Fagan
Once a heated debate, now quickly losing steam, is a notion surrounding able-bodied and athletes with a disability. The question no longer seeks to answer whether an athlete is able or not. Rather, it defines itself by looking at the assistive devices that are enabling athletes to compete at elite levels.
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Innovative thinking has always been a platform upon which society has sought ways to break free from restrictive, outdated ideologies. The field of prosthetics is a fine example of this tenet. Technologically speaking, advancements in prosthetic foot design are radically redefining the way athletes approach training and competition as a whole. Over the last decade, research and clinical trials have been conducted to surmise which types of materials are best suited to improve performance. Particularly interesting, is the manufacturing of sport-specific feet for runners with lower-limb amputation. Not only are the research findings noteworthy, but the spirit behind the athletes wearing these devices can be encouraging for any individual requiring an assistive device. Arguably, a person with an amputation is only as disabled as the technology upon which they rely... perhaps more certainly in the athletic arena. The field of prosthetics is producing fast, reliable, competitive advancements that allow athletes to identify with their true athletic selves: that is, an athlete first, and circumstance second. Consider female athletes Sarah Reinertsen and Aimee Mullins, both of whom have capitalized on the use of prosthetic running feet. Reinersten was the first female leg-amputee to complete the Ironman World Championship (2011), along with many other notable performances. Her running prosthesis is designed similarly to the feet that are described in this paper. She uses a Flex-Foot design that allows users to achieve the hind-leg activation, capitalized in able-bodied runners. Mullins is an unconventional advocate for women in sport. She is an outspoken advocate for persons with disabilities, and does not distinguish herself any differently from those with two limbs. In fact, she compares prosthetic legs to eyeglasses, in the sense that they are simple fashion pieces and attitude defines the rest. She was an elite international sprinter, setting world records at the 1996 Paralympic Games in Atlanta. Three components that are integral to understanding why one device outperforms another include the following:
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i) consideration towards the anatomical implications of each athlete is as unique as each individual themselves, thus different sprinting feet will provide different results; ii) secondly, it is important to understand normal gait patterns as compared to an amputee’s movement pattern; and iii) design implications and material build-up will be the determining factors regarding the amount of energy input required to give the best performance output. The major anatomical segments that are important in the discussion of gait, (the pattern of locomotion generated through the rhythmic movement of the lower limbs), and more precisely a runner’s gait, are the hip, knee and ankle joints, and the foot. These seg-
ments act to bear weight during the gait pattern through healthy joint articulations. When referencing an amputee’s gait pattern, it is important to recognize that the mechanisms of locomotion are considerably changed depending on the level of the amputation accompanied by the varying mechanical foot designs that directly correlate with functional performance outcomes (Rietman, J.S., Postema, K. and Geertzen. J.H.B., 2002; Buckley, J.G., 1999; Weyand et al., 2009; Lechler, 2005). There are two specific phases that make up the human gait cycle: stance and swing. The stance phase (or support phase) defines the foot as being in contact with an environment that may be stable or unstable. The swing phase
Aimee Mullins at the 1996 Atlanta Paralympic Games
is denoted as the unsupported phase, as the foot is freely moving in space. Stance phase further divides into three components – heel-strike, mid-stance, and push-off. Swing phase is discussed in terms of acceleration, mid-swing and deceleration (Weber, 1991). Termed double support, there is a brief period of time that occurs between the stance and swing phases when both feet are simultaneously in contact with a surface. Stride length is comprised of one stance phase followed by one support phase, coupling together to span a particular time and length. As a person increases his or her stride length, the double support becomes consistently shorter until it disappears. This is the point at which running is said to commence (Weber, 1991). Therefore, it can be surmised that a particular gait pattern is initiated depending on the individual’s intended outcomes such as speed or energy efficiency. In normal gait, the centre of gravity oscillates in a rhythmic manner. These smooth oscillations indicate a gait that is conserving energy. Hence, there is a balance between the storage of energy (potential energy) and the use of energy (kinetic energy) (Weber, 1991). In non-amputees, energy is stored within the achilles tendon during the dorsiflexion and plantar flexion phases of walking and running. More specifi-
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cally, as the achilles tendon undergoes initial stretch at heel-strike it stores potential energy that is released when the tendon snaps back to its original length. The conversion of energy into force occurs as the limb moves from push-off during the end of stance phase. The potential energy may now be harnessed in the form of kinetic energy, as it aids in increasing the runner’s ability to accelerate and propel forward. In the case of prosthetic-wearing, lower-limb runners, various factors can create an inefficient oscillatory style of gait which corresponds with large and uneven displacements of the centre of gravity. There are three major factors that influence gait patterns in amputee and non-amputee runners: base of support, ground reaction forces (GRF) and forces generated due to muscle activity during gait. Depending on the phase of gait, forces of varying magnitude and direction act on the limb (Weber, 1991). Focusing on different limbs and the effects on functional performance, the following findings refer to reaction forces and the running mechanics of an amputee vs. non-amputee. Weyand et al., (2009) found “the speed limits of our amputee and [non-amputee] subjects were similarly imposed by their gait mechanics. All reached their
absolute limit, or top speed, when their foot-ground contact times and vertical impulses decreased to the minimum values necessary to provide sufficient aerial time to reposition the swing leg for the next step”. These findings indicated the important element of limb weight, and its effect over time. It was noted that “the combined mass of our amputee subject’s residual limb distal to the knee and that of the Cheetah prosthesis is roughly half the mass of an intact calf and foot” (the Cheetah foot stores energy in a different manner than other predetermined prosthetic shapes). Thus, Weyand et al. (2009) predicted that movement through the phases of gait could be achieved more rapidly and with greater ease for prosthesis-wearing sprinters, based on the relationship between mass and ability. In compiling a set of findings regarding adaptive mechanisms in gait with prosthetics, the article “Gait analysis in prosthetics: Opinions, ideas and conclusions” provides insight into particular strategies that have been researched and studied from 1990 to 2000. The following findings are presented here to highlight five specific research studies in reference to a trans-tibial (TT) amputee: “In the TT-amputee, at the sound side, an almost normal electrical activity of the muscles was found. However, the energy absorbing function of the quadriceps muscles and of the ankle-foot unit was decreased at the amputated side. The reduction of the push-off force at the end of the stance-phase is partially compensated by the increased biomechanical work of the hip extensors. There is also increased co-contraction activity of the knee muscles to get more stability or to act as an antagonist of the increased hip extension moment. In the deceleration phase of the swing-phase at the sound side, there is increased muscle work by the hip and knee muscles responsible for the energy transmission from the limb to the body. Through this mechanism the body receives forward acceleration at the time that the push-off force of the ankle-foot unit is decreased. During
expressed in terms of perpendicular distance from the force to the centre of rotation. As such, the moment generated at the hip extensors will increase or decrease due to the relationship of the length of the prosthetic foot and the distance at which it is displaced during running. If the prosthetic limb is longer or shorter in design, it changes the force causing functional changes in the muscle’s ability to produce force and this directly applies a different pressure on the hip-extensors. Therefore, the design and weight of a prostheses can cause implications in the runner’s ability to move through rhythmic gait patterns and elicit greater acceleration. In an adverse Canadian, turned-British, sprinter Stephanie Reid situation, it would hinrunning, these adaptive mechanisms der the runner’s potential to increase increase” (Rietman et al., 2000). their performance outcomes. The major role of the hip extensors Different types of prosthetic feet was reiterated in findings by Seroussi not only influence the ability of the et al., stating that “...the most imporrunner to accelerate, but affect several tant adaptation of the amputated side energy aspects associated with gait. To during stance-phase is the increased expand, the literature looks at the tomuscle work of the hip extensors and tal-energy behaviour of energy-storing the ankle-foot plantar-flexors to comfeet as being divided into three phases: pensate for the decreased push-off of energy-absorbing, energy-storing and, the prosthetic side” (1996). The ability energy-releasing (Rietman et al., 2002; of the TT-amputee to produce a moLechler, 2005). ment at the hip is directly proportional Traditional prostheses were designed to the amount of force acting on the and fabricated with metal uprights, along lower-limb in addition to the distance with leather bindings, to strap the user at which the force is displaced through- into the device. These systems follow out the prosthesis. an aging design, and were not initially This “moment” denotes the rotacreated with the athletic user in mind. tion at the hip due to the alternating Current standards for prosthetic feet phases of gait during running. For capitalize on the ability to store potential purposes of this paper, the moment energy, and return it for later use. Addicreated is due to the rotation of the tionally, contemporary feet are designed pelvis from the anatomical dominance with lighter materials made to optimize of the hip extensors required for the vital characteristic of energy-storage forward propulsion. The moment is and return (Lechler, 2005).
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According to Lechler (2005) there has been little in the way of design improvements made to the sprint foot for runners since 1996. This design typically allows for sprinting on the toes, and is still composed of carbon leaf materials (providing weight-reduction), along with the omission of a heel component to allow the runner to store more energy within the stretch-shortening mechanism. As described earlier, the stretchshortening mechanism simulates the characteristics of the achilles tendon found in a sound leg. Despite the lack of further design modifications, research still supports the current design of spring-foot prostheses such as the Cheetah foot and its ability to store energy. Buckley (1999), provides insight into the biomechanical adaptations that allow a trans-tibial amputee to attain the speeds achieved when sprinting: “... subjects landed on the toe section of their (pre-plantarflexed) prosthesis, and this was also the point from which toe-off occurred. Thus, the energy absorbed (as the foot deformed) during initial contact and the first half of stance, could be directly returned during the second half of stance, as the keel tended to return to its original shape prior to toe-off.” Just as there are various kinematic differences that exist when comparing normal running patterns to those who run assisted by a prosthesis, there are also crucial functional and dynamic factors linked to the varying types of feet worn by lower-limb amputees. When speaking of lower-limb prosthetic feet, it is appropriate to think in terms of multiple design variations each with the ability to directly impact performance outcomes. Having a precise understanding of the dominant musculoskeletal components involved in forward propulsion, and an awareness of evolving prosthetic mechanical design, principles may be applied to comprehend how varying elements can directly influence human movement and more specifically, the gait patterns of runners who use lower-limb prostheses. Using this knowledge, it is possible to articulate the importance of the kinematic relationship to gait patterns
in the attempt to help the clinical population of lower-limb prosthesiswearing runners. Through the use of contemporary assistive devices, such as the spring foot, biomechanical design can be used to mimic the natural movement found throughout a sound limb. Today, adapted physical activity is considered to be any activity requiring changes or additions to rules and equipment to successfully enable inclusion. With the shift in focus to facilitating functional control over movement and stability for amputees, with it has come positive sociological impacts, including fueling the athlete’s pre-existing determination and inner desire to compete. No longer is the story about struggle, but one surrounding triumph, and not about disability, but ability.
Buckley, J.G., 1999. Biomechanical adaptations of trans-tibial amputee sprinting in athletes using dedicated prostheses. Clinical Biomechanics, 15(5), 352-358.
References
Rietman, J.S., Posterman, K. & Geertzen, J.H.B., 2002. Gait analysis in prosthetics: Opinions, ideas and conclusions. Prosthetics and Orthotics International, 26, 50-57. doi:10.1080/03093640208726621.
Buckley, J.G., 1999. Sprint kinematics of athletes with lower-limb amputations. Archives of Physical Medicine and Rehabilitation, 80(5), 501-508.
Kapp, S., Miller, J.A., (2009). Lower limb prosthetics. In (Ed.), Case of the Combat Amputee (pp.553-579). Washington, DC: Office of the of the Surgeon General at TMM Publications. Lechler, K., 2005. Lower-Limb Prosthetics – Design Improvements of a Prosthetic Spring Foot. American Academy of Orthotists & Prosthetists. Weber, D., 1991. Clinical Aspects of Lower Extremity Prosthetics: Trans-Tibial, Symes, and Partial Foot Amputations (pp. 31-35). Oakville, ON: Elgan Enterprises. Weyand, P.G., Bundle, M.W., McGowan, C.P., Grabowski, A., Brown, M.B., Kram, R. & Herr, H., 2009. The fastest runner on artificial legs: different limbs, similar function? Journal of Applied Physiology, 107. Pp. 903-911. doi:10.1152/japplphysiol.00174.2009.
About the Author: Sherry Fagan resides in Toronto and is pursuing her passion in prosthetics and orthotics. She graduated with a Kinesiology degree from Memorial University of Newfoundland, and also holds a diploma in Photography & Digital Imaging from Holland College, PEI. She hopes to combine the two disciplines in working with cosmetic silicone solutions, ultimately providing amputees with a functional prosthesis that also adds aesthetic significance to their lives.
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O&P SOLUTIONS
Early Reports on EMS Sockets By: Stan Wlodarczyk, BPE, C.P.(c), FFAOP
Since opening a clinical practice in 1995, it has been our experience that the majority of clients procuring our services have been lower extremity amputees. My practice has focused on providing services that apply the best science available. The sockets were largely hydrostatic in nature utilizing the total surface bearing (TSB) concept. The urethane materials used and the education supporting them were obtained through TEC Interface Systems.
TEC
is an acronym for Total Environmental Control. As our practice grew, so too did the technology at TEC developed by Carl Caspers. In 2001, urethane liners were enhanced by an on-board vacuum pump, enabling us to manage forces applied to the residuum to a magnitude not previously reported. Recently, Carl Caspers has introduced the EMS (Environmentally Managed Systems) socket to complement his earlier work. The purpose of this article is to offer a review of the main principles surrounding urethane, enhanced vacuum, and EMS. Finally, early accounts of the benefits of EMS technology will be offered, reported clinically from two clients to date. Although the clinical application is much broader than sports and recreation, management of the forces surrounding the residuum make these technologies ideal for not only those
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whose occupations or activities exceed daily living but for many other lower extremity amputees as well. The reason for the use of urethane is well documented by Ottobock and is supported by research conducted earlier by TEC Interface Systems. TEC studied the nature of skin and identified the maximum of various forces that skin could tolerate and still remain viable. In brief, urethane liners were created and later defended by studies measuring skin/liner interfacing. Joan Sanders (1995) concluded that a new structure was needed to be created to tolerate the high-force levels that skin was subjected to. Urethane was seen to provide the best resilience and flow characteristics desired to sustain a healthy limb environment. Clinically, the urethane liners excel. Never before, in my experience, were amputees with limb complications (i.e. adherent scars,
invaginations, skin grafting, neuromas, mobile bony prominences, and short limbs) able to tolerate prosthetic use over extended periods of time without skin compromise. In addition, those with delayed healing often associated with vascular compromise were seen to recover at rates closer to normal healing even after other conservative approaches were ineffective. In 2001, as mechanical vacuum pumps were introduced with the intention of providing better suspension, studies and clinical practice demonstrated that suspension, or linkage, was only one advantage. Two other critical issues for skin viability were positively affected by vacuum: limb volume management and perspiration control. Volume management has been measured, but perspiration control – while observed – is more difficult to quantify. On a clinical level, clients who struggled
Posterior Trimline
Anterior Trimline
with previous interventions for reasons cited earlier, functioned very well with the liner-pump combination for many years. With timely maintenance and socket replacements, clients wore their prostheses for full days without pain, skin breakdown, or change in volume, and without the presence of damaging perspiration. The main constraint of this combination was that range of motion was somewhat restricted for some amputees, resulting in early wear of sleeves and/or discomfort in sitting. Clinically, it was observed that a thermoplastic diagnostic socket was often better tolerated than the firmer definitive socket made later. Some clients with short limbs or ligamentous instability improved with the use of TEC but continued to lack sufficient stability, especially on uneven terrain. The EMS socket appears to be the best solution to date for providing the advantages of urethane and vacuum along with full range of motion for the knee, improved stability, additional surface bearing, and enhanced adhesion. The range of motion is normalized by the detailed casting method used to create the socket and the flexibility of the inner socket. Stability is influenced by the socket trimlines and by the friction and surface area available as a result of an irregular material used at the interface between the liner and inner socket. In reporting the clinical findings of two clients using the EMS system, Candidate A has used urethane and
sub-atmospheric sockets for four years. Candidate B, a bilateral amputee, has used sub-atmospheric sockets and urethane for twelve years. The results of their experiences are reported using the Socket Comfort Score developed by Joan Sanders, Ph.D., Department of Bioengineering, University of Washington. Candidate A reported that the previous hard socket, with a urethane linervacuum combination, rated as eight out of 10 in comparison to his earlier fittings. He dropped the rating of the hard socket-liner-vacuum combination to a six once he experienced the EMS socket. He rated the EMS as nine out
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Anterior View Under Vacuum
of 10 for comfort in all activities and for range of knee motion. He reported that previously, for long driving trips, he would release vacuum whereas now that was unnecessary. Walking on slippery surfaces remained a challenge, but his control of the prosthesis was improved. Candidate A reported no issues with sweat, odour, volume change, or skin disorders such as blisters, ingrown hairs, or rashes. Candidate B was recently fit on the left side with a urethane liner and hard socket inclusive of vacuum. Shortly after achieving increased comfort in the left-side fitting, he recognized that the right side also needed to be refit. An EMS socket was offered. He was so impressed with the difference in comfort and control on the right side that another fitting with EMS was requested for the left side. (Incidentally, the new EMS socket was created from the same left-side mold.) He rated the socket comfort as nine out of 10. This candidate ambulated up and down steep slopes by walking sideways and, like Candidate A, was very cautious on slippery surfaces. Candidate B has irregular skin with invaginations and would experience periodic skin breakdown even with urethane liners and vacuum. However, early indication is that the skin is less stressed in this current environment; there has been
no report of skin concern. In addition, odours are nearly absent because there is no fluid to discolour the liners and create bacterial cultures. The client reports no issue with limb volume, the weight of the prosthesis, or balance. I now apply EMS socket technology routinely. Six other amputees have been fit and all have had similar results, reporting improved comfort in range of knee motion. What has surprised me is the improved control that the users report, even though the inner socket is flexible in its proximal articulation with the knee condyles. The early clinical results using EMS are very encouraging. Clients are reporting unprecedented outcomes in the realm of comfort and control. They report that balance and energy expenditure are improved, volume is well managed, and perspiration is not problematic. Further, distal end pressure is of little concern as peak distal
loading appears to be absorbed by the design and nature of the inner socket material. Success in the use of EMS, in my view, is dependent on two key members of the rehabilitation team: first, the person being treated, and second, the prosthetist. Attention to detail with appropriate follow-up is essential. For example, TSB must be followed or skin compromise will promptly occur. Nevertheless, based on client feedback and clinical results thus far, when the goals of longer-term comfort and control are attainable, early efforts to manage shape and volume are worth the expenditure of time and resources.
References Total Environmental Control coursework, February 16-17th 1996, September 26-27th 1997, Adjunct Instructor material, November 12-13th 1999. Harmony/Vass Technology Course Book, 2001. Ottobock EMS coursework and materials, August 6-7th 2014.
Sanders et al., Skin response to mechanical stress: Adaption rather than breakdown. Journal of Rehabilitation, Research and Development, Vol. 32, No. 3, October 1995, 214-226. Covey et al., Flow constraint and loading rate effects on prosthetic liner material and human tissue response. Journal of Prosthetics and Orthotics, Volume 12, Number 1, 15-22.
About the Author: Stan Wlodarczyk, BPE, C.P.(c), FFAOP, completed studies in Prosthetics and Orthotics in 1982 at New York University Medical School. He was certified in prosthetics in the U.S. in 1984 and received his Canadian designation in 1985. Early in his career, he was a prosthetist at the Workers’ Compensation Board and the University of Alberta Hospital in Edmonton, and was Chief Prosthetist at two private Edmonton firms. He established his own family-based clinic in 1995, where he works today.
Thank You from BCIT The 2014 intake class of the BCIT Prosthetic and Orthotic Programme would like to extend our gratitude to the various generous donors who have helped enrich our learning experience this year. We were able to attend the American Academy of Orthotics and Prosthetics Annual Meeting and Scientific Symposium in New Orleans in February 2015. This conference exposed us to many different, exciting parts of our future profession and allowed us to meet clinicians, students from other P&O programs in the U.S. and professionals from all across North America. Learning about current research was incredibly valuable for our upcoming Capstone presentations in May, 2016. We extend our most sincere thanks to our supporters for helping us reach our goal! The Provincial Associations from BC, MB, and SK, Trulife, Ossur, Willowood, Myrdal Orthopedics, Ottobock, Diamond Athletics, Ortho Ped, Orthoactive, Spinal Technology, Vancouver Island Prosthetic Services, Barber Prosthetics, Winnipeg P&O, Award Prosthetics, Custom Prosthetic Services Ltd., Romac Orthopedic, Valley Orthocare Ltd., Ortho Dynamics Inc., Orthotics Solutions Ltd., Fraser Valley Prosthetic Ltd., Vancouver Orthopedic Group, Northern Alberta Prosthetics, BCIT Health Science Department, Edmonton Prosthetic Services, Loren Schubert of Barber Prosthetics, and Brenda Martel.
O&P SOLUTIONS
Molding a complicated WHFO
By: Charles Buchanan, R.T.O.
Molding WHFOs can be more complicated than just about anything else we vacuumform with hot plastic. WHFO casts are not straight forward pieces of clinical sculpture; they have appendages or bits sticking out of them called thumbs, and to accommodate a vacuumed plastic wrap around a plaster hand with a thumb extension requires skill, technique and at times some good, old-fashioned luck.
W
hat do I mean by luck? Well, the over-expansion of plastic in the webspace fold between the thumb and palmer region sometimes needs luck. Above the thunkthunk of the vacuum pump, we listen with tuned ears, baited breath and crossed fingers for that awful popping sound which means the vacuum is lost... lost due to a tear in the over-thinned plastic forming the web fold between the inside of the thumb and index area on the palmer region of the cast. The horror of horrors is that you have only seconds to cut and rip hot plastic off the cast before it cools. Let it cool, and the plastic only comes off with a striker saw, followed by cast repairs of saw furrows and a cracked thumb. Of course the answer for tears is thicker plastic stretched before molding in the forearm region, and left at full thickness for the palmer, thumb and webspace regions, but admittedly, with crossed fingers I still listen for that pop.
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Remember the old Monty Python saying “And now for something completely different”? That phrase may come to mind when you see something like this (see Photo 2) entering the lab in the hands of a clinician who smiles sheepishly at you, coughs politely, and says, “Please fill.” But the patient comes first, and after cast filling and modifications, the complicated sculpture may look something like this: (see Photo 3). When I placed this cast in my mandrel holder I remember pondering on
how I was going to mold its anterior and posterior shells, where the trimlines would lie, and how I would get the anterior shell off for trimline edging and clean-up... all of this without damaging the thumb. A bit of history here: the patient is a blue-collar worker in his early forties who had worked in the upholstery industry until graduating into ill-health retirement when his forearm muscles locked, leaving his dominant right hand with permanent contracture. Surgery
Photo 2
Photo 4
Photo 3
was not an option. Photo 4 shows his old orthosis made out of orthoplast. It began to fail and was no longer formfitting in the palmer region. Besides being a techie, I’m also a sculptor, and have made my own silicone molds since the early ‘80s. I know where trimlines should sit on complicated works bearing numerous undercuts, but in this instance the molding material had to be co-poly with the posterior shell clipping over its anterior. As is standard, I prepared the cast for molding by gluing cotton stockinet to wick onto the posterior forearm and thumb, and along the dorsum of the hand (see Fig. 1). For additional wicking, a nylon stockinet mitten with a thumb sleeve was sewn, reversed, and carefully pulled onto the cast.
inforcement slab (see Fig. 2). Once the plastic was out of the oven, and before the vacuum pump could be switched on, two things needed to happen:
Figure 1
This molding technique proved successful, but getting separation between cast and plastic resulted in the expected, and time wasted in getting the cast rebuilt again back to specs (see Photo 5).
After edging the anterior shell’s trimlines, and carefully refitting it on the repaired cast, here’s what followed: 1. The palmer curvature was filled with plaster to take up space for ease of plastic removal. 2. So as not to cut through the pristine anterior shell, 10mm EVA cutting strips and wick were applied underneath nylon stockinet.
Figure 2
1. The 3/16th reinforcement, which lay underneath the 5/32'' sheet, needed careful positioning on the cast anterior. 2. The rounded ends of two paintbrush handles (I had no thin dowel on hand) were used to press the plastic into the palmer curvature and webspace so as to avoid tears after stretching.
Photo 5
3. After molding and the careful removal of the posterior shell, the usual steps ensued such as trimming edges to a point where both shells comfortably clipped together. Wrap-around straps were fitted, and the device was left for patient fitting (see Photo 6... note the bulge in the palmer area plastic). When fitted, minimal adjustments by the clinician were made, including the addition of a thin layer of palmer padding, and a wraparound strap securing the palmer and dorsum regions of the device. Photo 7 shows the patient’s hand in position: a good fit. But it was at this point that I asked myself, “Is there not an easier Photo 6
Despite this effort and trying most of the tricks – such as using 3/16th plastic for the initial anterior mold, and stretching it in the forearm region – the dreaded popping sound was heard more than a few times, and ended up cutting and ripping at hot plastic. In the end I realized that the co-ploy needed to be reinforced in the palmer region and webspace. I used 5/32'' for the overall form and 3/16th for the re-
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3. Ensure that the end of the mandrel sits centrally in the cast and lies half an inch or so back from the palmer crease because this region will be carefully sawed through with holes drilled on either side of the mandrel (see Fig. 3).
Photo 7
way of doing this?” So, drawing from previous mold-making experience and despite having to use rigid co-poly as the molding material, I realized there was a better way. The secret lies in the plaster cast itself. If complicated, like the one pictured and described in this article, it cannot be molded as one solid piece. Instead, converting it into two segments to avoid breakage, both pieces can plug together prior to molding. The following text and illustrations depict the process.
Cast Preparation The weakest points of the cast are at the thumb and palmer crease. Making a plug for the thumb is possible but not recommended, as it’s time-consuming and difficult to align. However, plugs for the palmer crease region are much easier to install. Importantly, your cast must be dry. 1. The thumb will be fixed and reinforced with wire taped to the cast support mandrel. Coat hanger wire is excellent for this purpose, and made more rigid when bent in half and twisted a few times. Clamp the bent end in a bench vice, and the two side-by-side lengths into your drill’s chuck, then slowly twist.
4. Two plug-holes are necessary for purposes of stability. Select a drill bit of similar dimensions to a length of wooden dowel which will be cut down and used as plugs (see Fig. 4).
Figure 4
5. Drill parallel holes as illustrated in Figure 4 and cut two dowel plugs to the required lengths. Insert into the holes then withdraw and remove a few millimetres from each dowel for plugging and smoothing hole openings with fresh plaster. 6. At the palmer crease, and away from the mandrel end, saw through the plaster carefully to avoid chips and breakage (see Fig. 5). With your free hand, hang onto the finger block to prevent vibration.
Figure 5
2. Tape the wire close to the end of the mandrel and adjust and bend to sit more or less in the centre of the thumb cavity. Figure 3
7. It’s up to you where to permanently fix plug ends but holes drilled through the finger block is recommended. 8. After sawing through the cast, insert the dowel ends into the finger block. Use a dash of resin to secure, then cover and smooth both hole openings on the dorsum (see Fig. 6).
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Figure 6
9. In theory, a two-part cast that clips together and lends itself to not breaking after plastic molding should result. 10. The fit should be snug enough to allow a thin layer of plaster over the seam. 11. Using nylon hosiery, sew a mitten shape and gently pull it over the cast, maneuvering the seam across to an edge. The tightness of the glove and wicking assists in holding and temporarily locking the parts together. 12. If the nylon doesn’t conform to palmer shape, tie a length of thread into the curvature; this will help when molding. So there you have it. The above can be modified to suit your own needs, but this method presents a two-part cast that in theory permits two scenarios: 1) removal of plastic after molding more easily in hopes of limiting breakage, and 2) removal of plastic more easily without breakage after that dreadful popping sound is heard that signals a re-do. About the Author: Charles Buchanan, R.T.O., was born a sculptor with a fascination for human anatomy and sometimes dabbled in drawing. Static art, however, never completely fulfilled his creative urge. In his life as a police officer, he entered what he thought was the hospital mortuary only to find that he had mistakenly sauntered into a prosthetics and orthotics facility. After a quick tour, his mind raced back to WWII veterans wearing prostheses he’d seen as a lad, and his childhood friend who wore a KAFO brace for polio. P&O called him, and 25 years later he entered George Brown College’s technical program.
O&P SOLUTIONS
Fabrication Techniques for LeatherReinforced Wrist Supports
By: Glen Isaacson, R.T.P.O.(c), Michael R. Dawson, E.I.T., Clinical Engineer and Andreas Donauer, C.O.(c), M.Eng. Alberta Health Services, Glenrose Rehabilitation Hospital, P&O Department Photos by David Home, C.P.(c)
Wrist supports immobilize, stabilize and protect a patient’s arm and hand in cases where there is impaired wrist function. In recent years there has been a shift towards using thermomoldable materials in the fabrication of wrist supports and techniques using leather have become a dying art.
W
hile thermomoldable wrist supports have several advantages including decreased cost and fabrication time, they are typically made out of a single material and thus provide a single stiffness across the entire support. Leather wrist supports, on the other hand, can provide stiffness in areas to be protected and flexibility in areas of bony prominence or where it’s desirable to maintain some range of motion. The variable stiffness is achieved by using a reinforcement material (plastic or metal) sandwiched between the leather layers, or by varying the stitching placement and length. Although the durability of leather is more limited when compared to supports fabricated with plastic, patients
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prefer it because it provides a very intimate and more comfortable level of support. It also has the advantage of being somewhat breathable. Maintenance instructions provided with the support include using natural preservative oils to maintain the leather. The increased expense and fabrication time of a leather wrist support may preclude its prescription for acute injuries where the support will only be used for a limited time. But leather may be justified for patients with chronic injury and disease who may need to wear a support indefinitely, and where the comfort of the support is paramount. In our experience, the leather wrist support with added thumb support has been a successful option for patients
with combined wrist and thumb pathologies such as arthritis and some chronic orthopedic conditions. The design is particularly amenable in situations where swelling is a concern. It provides moderate support in all three planes of wrist motion as well as immobilization of the CMC joint of the thumb. Patients report reduced pain from immobilization and increased stability of joints. Feedback received from our patients with chronic injuries indicate that once trying a leather wrist support they preferred it over thermomoldable alternatives for general use and most day-to-day activities. Our findings are consistent with the literature in recent crossover trials that have shown that leather wrist splints
Figure 1
Figure 2
Figure 3
Figure 4
Figure 5
Figure 6
were effective in reducing pain and also preferred by patients with inflammatory arthritis and chronic wrist pain (Haskett et al., 2004; Thiele et al, 2009). The objective of this article is to renew an interest in leather wrist supports and share our techniques by providing a step-by-step guide to fabricating a leather-reinforced wrist support with a thumb post.
Fabrication Guide Fabrication begins with a dry modified cast covered in a moisture barrier and marked with trimlines. Threemillimetre polypropylene is then
Figure 7
heat molded to the cast, ground to shape, and bevelled (Figure 1). Paper patterns are drafted from the mold and transferred to cardstock (Figure 2). Leather pieces are cut from the patterns and skived (bevelled) towards the thumb side (Figure 3). The seam is then sewn, dampened, and reflected back (Figure 4). The lining leather is skived and glued as shown in Figure 5 and then sewn with a straight stitch. The thumb web is sewn with a box stitch in order to reinforce the web and prevent separation (Figure 6). The leather is then soaked in warm water for about 15 to 30 minutes and stretched and wrapped onto the cast
Figure 8
(Figure 7). Trimlines are added and the leather is trimmed out (Figure 8). The polypropylene is glued into place with contact cement and the inner tongue is skived (Figure 9). The assembled pieces are glued to a piece of lining leather with a cut out for the thumb opening (Figure 10). Continuous stitches are used for the final sewing around the thumb, polypropylene, thumb seam, and outer edge. The benefit of a continuous stitch is that it improves aesthetics and has less tendency to unravel (Figure 11, Figure 12). Finally, the wrist support is lightly dampened, reapplied to the cast, and one-inch Velcro straps are sewn on.
Figure 9
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Figure 10
References Haskett, S., Backman, C., Porter, B., Goyert, J. and Palejko, G. (2004). A crossover trial of custom-made and commercially-available wrist splints in adults with inflammatory arthritis. Arthritis & Rheumatism, 51: 792–799. doi: 10.1002/art.20699. Thiele, J., Nimmo, R., Rowell, W., Quinn, S., & Jones, G. (2009). A randomized single-blind crossover trial comparing leather and commercial wrist splints for treating chronic wrist pain in adults. BMC Musculoskeletal Disorders, 10, 129. doi:10.1186/1471-2474-10-129.
About the Authors: Glen Isaacson, R.T.P.O.(c), has worked in the O&P field since 1979, currently at the Glenrose Rehabilitation
Figure 11
Hospital as an orthotic and prosthetic technician. His clinical and research interests include functional electrical stimulation and neuromuscular stimulation for prevention and treatment of pressure ulcers in wheelchair users. Michael R. Dawson graduated with a B.Sc. in 2008 and M.Sc. in 2011 in Mechanical Engineering from the University of Alberta. His research focused on developing a myoelectric training tool for upper-limb amputees. He currently works as a research associate for the Glenrose Rehabilitation Hospital developing robotic systems and helping
Figure 12
improve manufacturing techniques using 3D scanning and printing. Andreas Donauer, C.O.(c), M. Eng., graduated from George Brown College in 1997. With over 17 years of experience assessing and fitting patients with a wide variety of neuromuscular and orthopedic conditions. He is currently working on his certification in prosthetics at the Glenrose Rehabilitation Hospital. His clinical and research interests include orthotic management of scoliosis, brachial plexus injuries, and application of 3D scanning and computer-assisted orthosis design.
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O&P SOLUTIONS
High Heel Cup for Your FO By: Brian C. Myles, R.T.P.(c), R.T.O.(c)
Being relatively new to the P&O field, I took it as a challenge when my clinician gave me a couple of paediatric FO casts and asked me to give him as high of a heel cup as I could.
I
’ve made many FOs in the past year and they’ve always tended to wrinkle in the proximal two thirds of the rigid heel cup, no matter how I trimmed the material in advance or how I manipulated the heated plastic by hand over the cast before applying vacuum. Luckily, the vast majority of the FOs that I built only needed the distal third anyway. This time I needed more and so, I came up with a simple tool that gives me the means to make use of 100 percent of the heel cup without a single wrinkle so far. I noticed that in a vacuum bladder the force is directed straight down, like gravity. So, as the plastic was drawn over the compound curves of the heel it stretched a bit and then needed to compress itself as the excess material went over the apex. Because it had no place to go and couldn’t self-absorb, it folded over itself giving me those irksome wrinkles. The excess needed to shift to a place that could absorb the material without deforming the desired shape. In my previous life as a yacht builder I used vacuums to build laminated bulkheads, hulls and small fiberglass-reinforced parts, so I knew
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a bit about vacuum forming. I had an “Ah-Ha!” moment: “If the forces won’t change direction for me to move the excess material where there’s room for it, I’ll change the direction of the material/cast to get it to go where I want it to.” I changed the angle of the forces by changing the angle of the form and subsequently, the direction of the material relative to the force. Enter some scrap of wood… we had 2x4 off-cuts lying about that suited my purpose; I needed a wedge. I cut the block to the length of the cast and traced the posterior shape onto it, keeping the width the same anterior of the widest part. Then flipping it onto its side, I drew a diagonal line from about ¼'' inch down from the top of the block at the toe end to the very bottom of the block at the heel end. At the band-saw I sliced the block along the diagonal line and then dropped it back over and cut the contour of the cast. A bit of sanding and I was good to go. The first try wasn’t the best... too much vacuum too quickly. The heel cup was better than without the wedge, and there was about 50 percent of the heel cup that was usable, but I
wanted more! It was simply a matter of slowly siphoning off the air and coaxing the plastic toward the toes to get the whole heel cup free of dreaded wrinkles. The same works for adultsized FOs using a larger block. Voila.
The two FO wedges.
An FO form (3-mm subortholene) still on the cast, on the adult wedge beside a roll of 1'' tape for scale.
O&P SOLUTIONS
Impact Absorption in Protective Helmets By: Ted Radstake, M.Sc., C.O.(c)
When a custom-molded helmet is required for protection from impact, a design with a rigid outer shell and continuous inner foam liner does not maximize energy absorption.
H
ead orthoses are used for protection against a variety of impacts: impact with the ground from a fall in the case of drop seizure or impact in self-injurious behaviour. In most cases, sports helmets have been tested more rigorously against the impacts they are to absorb. In football and hockey, rotational acceleration of the head from an impact plays a role in concussions and so new designs allow for rotation of the head within the helmet on impact (1). Even commerciallyavailable protective helmets such as the ProtectaCap have researched the impact absorption of their helmets as posted on their website (2). Case Study Objective: To design a custom protective helmet to be rigid enough to withstand high-energy impacts, but be soft enough to absorb these impacts and protect the hitter’s arm. Variables: In order to design a head orthosis for the most aggressive selfinjurious behaviours, the helmet must be more rigid to prevent distortion during attempted removal and must incorporate a quick donning and rigid locking system. For impacts from falls, a custom helmet needs to be rigid
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enough to distribute the impact over a broad surface area to protect the skin and skull from trauma. Being more expensive than available sports helmets, a cost-benefit analysis would suggest that it should outlast them as well. Two disadvantages of a non-distorting outer shell are that 1) it does not absorb the force of an impact with a wall or floor and, 2) the rigid surface causes more trauma to a fist or wrist impacting it. With reference to the ImpulseMomentum equation, an impulse changes the momentum of the head to zero during impact. To decrease the force transferred to the brain, the time it takes to stop the head must be increased. In a custom helmet, the foam liner typically does all the absorption of the high-energy impact. To the first point, the rigid shell distributes the force over a broad surface area which means that the force on the underlying impact absorbing liner is also broad. When a finger is pressed into one spot of the liner, it feels soft because it is easy to apply a point force into the material. However, since the impact is distributed over a broad surface area and the foam is sandwiched between a minimally-distorting shell
and a minimally-distorting skull, there is much less foam compression. Ideally, one would obtain accelerometer data at impact from a crash-test dummy wearing a protective helmet. In the absence of that, a simple way to test this subjectively is to sandwich a flat piece of your helmet foam liner between the floor and a flat piece of your helmet plastic, and hop on it with your heel. With the force so evenly distributed, even a very soft durometer liner does not compress very much. To maximize the time of impact, one would want the liner to compress as much as possible. For the second scenario, the hitter’s arm has the momentum and the impulse is imparted by a rigid shell with high force over a very short time. One solution is to restrict the hand from being able to hit the helmet. For an individual with self-injurious behaviour who tries to remove a helmet, wrist or fist protection may help to prevent removal. Elbow extension orthoses limit a lot of useful function, and generally the author does not view restraint as a first choice. Expectations: For more liner compression, the broad surface area of contact
with the head can be reduced. This will concentrate the force over smaller surface areas on the head allowing the foam to be compressed more like it does under one finger. It is still soft foam, so even reducing the contact area to 60% will not cause excess pressure on the head during impact. Back to our simple test: if you lay 3-cm-wide strips of liner material at various distances apart under the sheet of plastic shell material, you should be able to get more compression when you hop on top. Solution: To create these areas void of contact, cut 55 durometer EVA strips and double-side tape them to your positive before pulling your liner (Fig. 1). Then blister-mold or use a bag to get good vacuum and pleasing cosmetic channels... a smooth finish of the foam will be created in the inner surface of your liner (Fig. 2).
Figure 1: Cross-sectional diagram of the forces at impact picturing a positive cast with EVA spacers for air channels.
Figure 2. Air channels in the liner.
Before fabricating the rigid outer shell, the muted ridges over the EVA strips on the liner’s outer surface can be ground down to return the outer shell to a smoother shape. To avoid grinding right into your channels from the outside, the thickness of the EVA strips should
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be slightly thinner than your final liner thickness. Air channels can extend beyond intended trimlines at the eyebrows (anterior) and at the neck (posterior). If finger holes at the trimlines are a concern, the EVA can be tapered off before the trimlines and smaller holes (6 mm) can be drilled through the shell along these channels. A 6-mm sanding cone of a dremel-type tool can be inserted through the outer shell holes to give a nice finish to the inside holes in the foam liner. For the absorption of impact on the exterior surface of the helmet, one case required protection against head banging, hand strikes, wrist rubbing and digit pressing. It was extremely difficult to fabricate the external, leather-lined, soft 12mm mattress foam over the custom rigid shell (Fig. 3), but the outcome has been generally favourable.
The result is both a tough external layer and the external cushioning without any foam at all (Fig. 5).
Figure 3. Side view of the exterior helmet padding.
Figure 5: Flexible plastic external cushioning.
The self-injurious behaviour in this case was diagnosed by the behavioural consultant as attention-seeking toward the caregivers. The helmet provided enough protection in so far as the caregivers did not have to respond immediately to his behaviour. Subsequently, the behaviour has largely stopped. The second helmet was only slightly easier to fabricate and the outcome is awaiting a behavioural consultant’s implementation plan. With all the flexible plastic options available, vacuum molding the external layer should be favourable for a technician to be a talented seamstress in creating a spherical leather cover. The architecture of the plastic can also be carefully designed through strategic build-up of EVA spacers (Fig. 4).
This is a similar concept to the cushioning of bubble wrap or the energy dissipation of a whiffle ball. Indeed, you can create flexible plastic bulges and then drill holes in them until they deform just about to the rigid plastic shell for the impacts you are expecting. In this way, the increase in time for the outer flexible plastic layer to deform and slow the impact of the hitter is inversely proportional to the force that is felt. Additionally, heat can be dissipated through the holes in these bubbles since the cutaways in the liner and rigid shell are directly under the bubbles. The plastic used was 3.2 mm Northvane. SeaFlex 300 is an improvement on this plastic, but comes in clear; black was desired for this
Figure 4. EVA build-ups for molding flexible plastic exterior.
particular helmet. The molded thickness is between one mm and two mm to collapse inward and bulge laterally on impact and absorb a maximum amount of the impact to the point of just bottoming out. The shape is important as well, with enough curve on top and enough verticallydirected plastic, much like a button mushroom. They were fabricated in such a way as to snap snuggly into the holes in the rigid shell (Fig. 6). Conclusions: Extensive redesign of a protective helmet for each patient is certainly not the most cost-effective strategy, but this article may spark further innovation, or as is often the case in our field, document a solution that various clinicians
Figure 6. Finished helmet with external flexible plastic cushions.
Resources 1. www.popsci.com/science/article/2013-08/ helmet-wars-and-new-helmet-couldprotect-us-all 2. http://protectacap.com
have already explored. However, not having to continually redesign your helmets may tip the scales further in favour of modifying a sports helmet with a stronger closure system.
About the Author: Ted Radstake, M.Sc., C.O.(c), has worked at the L.A. Miller Centre in St. John’s, Newfoundland, and OrthotiCare Clinics in Nanaimo, B.C. He currently enjoys a varied caseload at the Ottawa Hospital Rehabilitation Centre, where he has worked for the past nine years.
2016 OPC CONFERENCE (formerly CAPO)
AUGUST 3 – 6, 2016 The Banff Centre Banff, Alberta
New Heights… Fresh Outlooks
www.opcanada.ca Alignment 2015 107
ADVERTORIAL
“ No patient contact, no heavy plaster work, and a clinician productivity boost of over 100%.”
Going Digital to Fuel Business Growth Custom Knee Brace Manufacturer Doubles Orthotist Productivity
“An architect could not compete today without using computer-aided design tools, and the same will soon be true for custom orthotic and prosthetic providers,” states Nolan Hayday, Business Manager at Karl Hager Limb & Brace. “It’s time for our industry to join the digital age.”
O
ne division of Karl Hager Limb & Brace produces hundreds of custom knee braces each year for their own patients and as a central fabricator for clinics and hospitals across Canada. Long recognized as an innovator, the facility recently partnered with Vorum to implement a complete orthotic and prosthetic CAD/ CAM solution. “The time was right to computerize our traditional casting and production processes: the Alberta government has frozen reimbursement rates through
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2017 and our orthotists were struggling to keep up with their growing workloads,” states Hayday. Hayday describes the efficiency gains being realized with the Vorum solution: “for one of our custom knee braces, the plaster-based process takes 90 minutes of staff time to cast a patient, create the plaster positive mold, and modify the mold for brace fabrication. After a short training period with the Vorum solution we cut that time in half, and we anticipate significant further timesaving as we gain experience.
Using our new digital process, we optically scan the patient’s leg, modify the shape on the computer, and automatically carve the positive mold in foam – no patient contact, no heavy plaster, and a productivity boost of over 100%! That frees our staff to see more patients, provide faster turnarounds, and improve communication with our patients, referring physicians, hospitals, and central fabrication customers.” The Vorum partnership will also enable Karl Hager Limb & Brace to grow its central fabrication business. “When our customers email us a digitized knee scan, we receive it in seconds instead of waiting 4 or 5 days for the expensive courier delivery of a cast,” commented Hayday. “Faster turnaround and lower cost are big advantages for us and the clinics we supply.” Non-contact scanning will enable Karl Hager Limb & Brace to grow its business even further: “we will now be able to acquire the detailed shapes of children and spinal trauma patients without the risk and discomfort of traditional casting procedures,” adds Hayday. “Vorum enables us to confidently grow our business into new areas.” Hayday continues, “after exhaustive research we concluded that Vorum offers the most complete, reliable technology platform and they back it up with comprehensive training and the best support. Vorum has been the global leader in P&O digital technology for 25 years and has pioneered every major advancement in the field. I take great comfort in having Vorum as our partner.” More on how Karl Hager Limb & Brace is growing their business with digital technology can be found at www.vorum. com and www.khager.com.
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INDUSTRY NEWS
Product Showcase • New & Improved for 2015 New HD Pediatric Hip from RCAI
ALPS Thinner Seamless Suspension Sleeve
Restorative Care of America Inc.’s new HD Pediatric Hip controls or prevents deformity after soft tissue release and other hip surgeries for children with cerebral palsy. It provides a higher level of support and stabilization of the pelvic region through greater mid-spine coverage. Manufactured of heat moldable thermoplastic allows for easier patient customization. The spine relief opening design at the back offers better air flow for patient comfort. The HD Pediatric Hip offers flexion/extension settings, plus adjustable internal/external rotation control of the hip. It can be used post-operative or can be used postcast removal. The thigh cuffs adjust circumferentially for a better fit.
Formulated with the ALPS GripGel, the new SFB seamless suspension sleeve provides superior comfort with a single-piece construction. The SFB sleeve features a new black, knitted fabric that allows the user excellent freedom of knee flexion. This new sleeve seals with the skin without restricting circulation, while the GripGel sticks to the patient’s skin without causing shear forces. With a thinner profile of 2mm, the SFB is an ideal choice for those concerned about bulk.
To learn more visit www.rcai.com.
New Hyperextension Orthoses and Matrix SUPERMAX Trulife’s new line of hyperextension orthoses feature adjustable height and width, a swivel sternal pad for patient comfort, and a newly designed latch-lock clamp closure for ease of donning and doffing. The pad sets are removable and washable too! Three models to choose from: T34 with anatomically-designed pubic pad and pelvic bar to avoid pressure on pubis and to prevent migration, T37 with adjustable pelvic band, and T39 with a pelvic band that can be fixed or articulated to prevent migration. The Matrix SUPERMAX features an enhanced integration of the foot plate and strut for added durability and support, and increased stiffness in the strut and toe spring allowing for smooth transition from mid-stance to toe-off. The shank angle is increased to improve knee extension moment at mid-stance. Its new foot plate is designed to more closely match the shoe. It’s a sure winner when coupled with its standard complementary features: heat-moldable, trimmable and heightadjustable pre-padded anterior shell (with extra pad kit included), and shrink tubing on the strut. Sizes: Small to X-Large.
For more information visit www.trulife.com or call 800-268-2812.
More at www.easyliner.com or call 800-574-5426.
New from Aspen Medical Products The Evergreen™ SI Belt features quality sacral stabilization, is low-profile and lightweight. With effective compression, the belt is equipped with non-slip silicone strips and bi-lateral pull tabs. The Summit™ Adjustable 456 is a versatile, posterior support (thoracic to lumbar). It is adjustable, one-size fits all, and comfortable – easy to don and doff.
For more on these products visit www.aspenmp.com or call 800-295-2776.
New from Medex International The design of the 4TC2 Pediatric 3 Arms (Y) Shape Rotatable Lamination Anchor with Pyramid allows easier fitting on less bulky or pointy stumps. Providing more space during the lamination process, the low profile component offers a better fit for long residual limbs. MEDEX’s exclusive rotation system (SRS) eliminates the need for threads and sets the rotation more efficiently and securely with three rotation set screws.
For more information contact MEDEX International at 888-886-2420 or www.medexinternational.com.
Kinterra Hydraulic Ankle/Foot The Kinterra Foot/Ankle System from Freedom Innovations combines hydraulics and carbon fibre technology to provide low to moderate impact K3 ambulators an exceptionally normal walking gait – regardless of surface angle or speed. The results are rock solid stability and the confidence for users to choose a new path. User benefits include: increased ground contact and a more symmetrical gait, improved stability and safety, especially on slopes and varied terrain, reduced socket pressure for healthier residual limbs, enhanced comfort while sitting and squatting, user confidence and satisfaction. It is rated up to 125kg (275lbs).
For more information on this product or others distributed by Ortho Active call 800-663-1254 or visit orthoactive.com. 110 Alignment 2015
OrtoPed Spotlight ETD by Motion Control
Rush Foot Collection
The Motion Control ETD (Electric Terminal Device) measures up to the most demanding wearers. Rugged, functional and water resistant, the ETD can be used with the Utah Arm or ProControl system and is available with multi-flex Flexion Wrist or the ultrafast MC Wrist Rotator. The ETD ProHand version features a controller for interchange with other manufacturers’ systems.
Introducing the Rush HiPro, LoPro and Chopart. Made from a glass composite originally developed for aerospace applications, the material has been re-imagined by Ability Dynamics to be more flexible and durable. The Flexion™ composite material provides three times more flexibility than conventional prosthetic feet. The foot provides a smooth range of motion from heel strike to toe-off. The RUSH™ foot helps maintain a natural, smooth gait even in rugged or uneven terrain. The foot’s energy return enables amputees to easily traverse the most aggressive terrain while experiencing zero dead spots.
bebionic3 Small by RSL Steeper The bebionic3 is now available in size small with a choice of black or white. The hand utilizes leading-edge technology and unique, ergonomic features that make it unlike any other hand available. These innovations combine to give the hand unrivalled versatility, functionality and performance. The innovative palm design protects from impact damage, and makes the hand quieter than ever. With 14 different grip patterns and hand positions, the bebionic3 artificial hand is designed to handle almost anything that needs doing in an average day, from eating meals and carrying bags, to opening doors, switching on lights and typing.
TurboMed Orthotics FS 3000 The FS 3000 is an external foot-drop brace that gives unequalled comfort to the foot. It was designed for running and vigorous outdoor use. There is no contact between the orthosis and the plantar face of the foot or ankle. This ankle foot orthosis (AFO) was tested in many conditions including marathons, triathlons, and cold weather endurance activities. Unlike a conventional foot-drop brace, it can be fit on high-top hiking footwear, winter or safety boots. Made from a highly durable Thermoformable plastic, it comes with a twoyear industry-leading warranty.
TM
ORION2 by Endolite The ORION2 uses Motion Integrated Intelligence to give users more security, modes for cycling and restful standing, and the best progressive speed control yet. Its sensors measure knee action in real time and respond optimally in that the ORION2 increases the hydraulic support as the knee flexion angle increases ensuring stability. The microprocessor-controlled pneumatic swing control offers a wide range of speed control with natural swing at slow speeds and an increasingly more robust response when walking faster. Coming soon, the Linx, a complete biomimetic external prosthetic system for trans-femoral users.
ToeOff 2.0 by Allard The ToeOff 2.0 is now available. This updated Dynamic AFO features numerous improvements suggested by alreadysatisfied patients. The new strap system reduces potential to flex wings forward, while adding an alligator tab for easier donning and doffing by either hand. The MicroFIX is now pre-applied for faster application of SoftKIT or ComfortKIT. New manufacturing technology offers a smoother and more scratch-resistant surface. Velcro is now inside the wings to decrease the chance of lint build-up or snagging on clothing. Newly-contoured wings conform better around the calf while leaving less surface area for damage. The XL has been increased by ¾'' to accommodate patients with a longer tibia.
For more information on these products and others distributed by OrtoPed, call 800-363-8726 or visit www.ortoped.ca. 112 Alignment 2015
Ossur’s Innovative Solutions for the Low Active Amputee Unloader® Fit
Unity® for Flex-Foot® Balance
Lightweight and easy-to-use, this new addition to the Unloader family features a low-profile sleeve design that fits discreetly underneath clothing. The lightest functional OA knee brace available at only 10oz, the Unloader Fit is easy to pull on, helping to improve patient compliance. With a single SmartDosing dial, the tension of the dual Dynamic Force Straps is easily adjusted to control the amount of pain relief. The Unloader Fit enables patients to engage in a variety of activities without the limitation of constant knee pain.
Introducing the only low-activity foot with integrated vacuum. This extremely lightweight solution adds zero build height to the Flex-Foot Balance. A new Unity® pump design utilizes the motion from mid-stance to toe-off to efficiently generate vacuum for slower walkers. Elevated vacuum is known to improve blood flow and proprioception, while reducing shear forces in the socket. These benefits directly address many of the clinical challenges with elderly amputees including balance, skin fragility, and circulation. New amputees can start in the FlexFoot Balance and Seal-In X liner with sleeve. When volume has stabilized, retrofit the Unity pump and X seal for sleeveless vacuum.
Rebound® Cartilage A protective functional solution designed to support knee cartilage healing after acute meniscal injuries or cartilage repairs such as microfracture, OATS and (M)ACL. Based on the clinically-proven 3-Point Leverage System, the patented Cartilage Protection StrapsTM maintain joint unloading in flexion for protection of the cartilage during the healing process. The Rebound Cartilage is low-profile and lightweight at only 14 ounces. The breathable, wraparound sleeve features an integrated Sensil® silicone calf liner and a doe skin thigh liner to prevent migration while ensuring the ultimate comfort.
Iceross® Seal-In X The new Iceross Seal-In X allows a much wider range of amputees to enjoy sleeveless suspension, including those with limited hand strength and dexterity, and complex residual limbs. Iceross Seal-In X is specifically engineered to address the donning and doffing challenges of elderly or dysvascular amputees, while also maximizing comfort and compliance. The moveable seal ring with attached fabric can be easily positioned to avoid invaginations, scar tissue, or sensitive skin, and the new Anatomy Conforming Fabric gives added durability and flexibility around the knee. Seal-In X is compatible with Unity® Sleeveless Vacuum, an attractive option to promote limb health for dysvascular amputees.
D/P Flexion for Flex-Foot® Balance The new Flex-Foot Balance with D/P Flexion is designed to give optimal comfort and stability to low-activity users. Already known as a foot that provides smooth progression from heel strike to toe-off, the addition of the hydraulic D/P Flexion module provides 9° of individually adjustable dorsi and plantarflexion during stance phase to help optimize stability and gait dynamics. Users will benefit from easier negotiation of stairs and ramps and sit-to-stand transitions. Plus, 4° of active swing phase dorsiflexion helps reduce the risk of trips and falls. Combine with Unity® and the Seal-In X liner for a truly complete solution.
BalanceTM Knee Control Balance Knee Control is designed to offer a high level of stability for users who typically use walking aids and require a higher degree of support. It is intended to facilitate singlespeed walking on level ground and gentle slopes, while enabling users to negotiate small obstacles, as well as sit and/or kneel. This compact, lightweight single-axis knee has a weightactivated friction brake that can be adjusted to suit the weight and ability of the individual user. The knee also incorporates an adjustable extension assist and a manual lock that may be toggled by the user or permanently disengaged.
For more information on these products and others from Ossur, call 800-233-6263 or visit www.ossur.com.
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FUNCTIONAL HEALING™ Rebound® Cartilage
Where mobility means recovery
© Össur, 03.2015
Our expertise in Injury Solutions has driven us to develop indicationspecific solutions designed to optimize healing while maintaining function and mobility. Currently, we offer protective functional solutions that are specifically designed to support the rehabilitation protocols for cartilage, PCL, acute meniscal and post-operative healing. Stay tuned for more innovations!
Rebound PCL
®
Visit www.ossur.com/functional-healing, or contact your Össur rep today, to learn more about Functional Healing products by Össur.
Ottobock Spotlight AxonRotation
3R62 Pheon
Meet one of the latest additions to the AxonBus Family... AxonRotation featuring active and passive rotation. By combining the Michelangelo Hand’s seven different grip patterns and automatic thumb positioning with active rotation, there is now greater functionality for the user. Ideal for both unilateral and especially bilateral users, the AxonRotation is programmed for more intuitive and effective use benefitting the user in many ADLs.
The 3R62 Pheon packs a lot into a small package for your K2 patients. The stability of a polycentric design with added safety features such as an optional manual lock and extension assist means it gives your patients the security they need. As patients progress, they’ll appreciate the smooth extension stop and up to 10° of stance flexion the knee provides. You’ll appreciate that this little knee packs so much function into such a small package.
AxonHook For maximum versatility, precision and power, look for this latest addition to the AxonBus Family... the AxonHook which is the perfect complement to the Michelangelo Hand. Offering titanium with polyurethane-coated fingers, the AxonHook is precise and powerful, the perfect companion to the Michelangelo Hand – ready for any technical task.
EMS The Environmentally Managed Socket (EMS) provides unique advantages such as 100 percent more surface area for better pressure distribution, 400 percent higher coefficient of friction for better connection, and a flexible supra-condylar connection for knee stability.
1C10 Terion The 1C10 Terion incorporates carbon fibre benefits into a low- to moderate-activity foot. It is lightweight and robust with a low-profile design.
3R80 The 3R80 rotary hydraulic knee now has added features of waterproof and a manual lock. The waterproof construction is appropriate for use in wet areas such as showers and pools. The manual lock is a handy feature for greater stability, especially when in wet areas.
E2 Offset Adapter The offset adapter plate for Harmony E2 opens up more fitting opportunities to fit vacuum with patients using MPKs or wider feet and knee components. This offset adapter is needed to fit the Harmony E2 close above wider components such as the C-leg, Genium, X3, Compact and also the Triton Smart Ankle. A 4R57 rotation adapter or spacer plate must be used between the knee and 4R153=1 plate to allow enough clearance for the pump when kneeling.
1C66 Triton Smart Ankle The Triton smart ankle lives up to its name, combining the wellengineered Triton foot with the power of state-of-the-art microprocessor and sensor technology. With a range of motion of up to 34º, the Triton smart ankle opens up possibilities for the wearer by actively responding to changes in terrain. Make the ankle even smarter by using the app (free in the Apple store) to fine-tune the foot, and set usage parameters for your patient to accommodate their activities of daily living.
For more information on these products and others from Ottobock, contact your Ottobock Sales Representative or Customer Service at 800-665-3327 or visit www.ottobock.ca.
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MANUFACTURER’S REPORT
Safer and Efficient Tools for Bending Metal Uprights By: Dan Kovacic, R.T.O.(c), Kovacic Orthopedic Tool & Supply Corp.
Multi-Bend and Clamp Jig (MBCJ) The use of the MBCJ allows you to do KAFO metal bending of all upright sizes right next to your cast without any adjustments, including many joints for closer bends. It also makes the anterior/ posterior metal bending process much safer as it prevents uprights from slipping out. Made from hardened steel to limit wear, and coated to prevent rust, the MBCJ has a 10-year warranty but is made to last a lifetime.
Adjustable Safety Locking A/P Bar Our newest metal bending bar design is quicker to adjust, allows for a longer bending range, and can be used for 5/8'' and 3/4'' wide uprights, and for steel up to 1/2'' in thickness. It is equipped with a locking safety latch to prevent uprights from slipping out, and makes contact on all four sides to limit twisting which makes anterior/posterior bends easier and safer. Made from a mixture of fully hardened tool steel, and coated to prevent rust, the A/P Bar has a two-year warranty.
Heavy Duty A-P/M-L Bending Iron This tool is 13 inches in length for increased leverage, with two horizontal slots for anterior/posterior bending of aluminum. Extra deep slots offer maximum contact and better access for hard to reach areas. Made from fully hardened tool steel and coated to prevent rust, this Bending Iron has a five-year warranty.
Small Offset Heavy Duty A-P/M-L Bending Iron Only a 1/4'' thick with a narrow slot to allow tight upright bending up to 1/8'', this Bending Iron contains a slot near its edge to allow closer bends in the saggital plane and uprights sized up to 1/8'' x 5/8''. Made from fully hardened tool steel and coated to prevent rust, it has a two-year warranty.
Bending Iron Vise Jaws Made specifically for securely clamping the Heavy Duty A-P/M-L Bending Irons in a vise to prevent slipping and scratching, this tool allows bending of only aluminum uprights in hard to reach areas. Other Bending Iron sizes up to 1-1/8'' wide will also fit. Intended for vise jaws up to 1.09'' wide, it’s made from fully hardened tool steel and is nickel plated to prevent rust. Two-year warranty.
Shears These Rostex industrial-grade precision shears are used by shoemakers and in some European O&P facilities for cutting leather/Duraflex around odd shapes and in tight spots, and make precision cuts that are difficult for most scissors. The only type of its kind available in North America, its tool steel blades can cut thick leather without the blades opening up. A complete refund is available if these shears are not the best you can find.
Quick-Off Vacuum Jig Remove your moldings easily and quickly. No need to tape around pipe, glue foam collars, or cut moldings off. Vise models and lamination jigs will also be available, and in various coatings.
Alignment 2015 117
New Thinner for Easier and Safer Cleaning Excellent for cleaning grease pencil markings off of plastic, Bio Option does not melt into plastic like regular thinners. It does not damage PPT or Duraflex, and creates a nicer finish when scrubbed with steel wool on the proximal brim of an AFO after flaring. Removing glue from materials is as easy as dampening a rag, smearing on and peeling off. Wiping pads and devices with this thinner gives a nice shine and helps to inhibit dust from sticking. Although not recommended for mixing glue that goes into an oven due to an odour, this product does make the application of gluing faster as it brushes on smoothly.
Step Drill with Speed and Fewer Burrs This basic Step Drill allows drilling of various sizes from 1/4'' to 1/2'' without changing bits, and with very few burrs. Due to its short length, wandering of the bit off to the side and over-drilling to the other side is limited. Holes up to 3/4'' and 1-3/8'' in size can be drilled using larger sizes.
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Reliable Mechanical Grease Pencils This pencil never needs sharpening and rarely breaks due to its basic screw-type mechanism, and is very dependable. The leads are smaller but with 72 in each refill box, they are very cost-effective. Available in various colours: black, brown, white, green, yellow, blue and red. Guaranteed lowest prices in Canada. We at Kovacic Orthopedic Tool & Supply Corp. are constantly engaged in research and development specific to the O&P profession to make fabrication easier, faster and safer. If there are tools that have a particular function that you can’t seem to find, let us know. We do offer product sourcing and custom manufacturing when time permits. We offer free one-week trials on most products. Let us know what you need to inspire new products and methods to help you save time, increase safety, and make your work day a little easier.
About the Author: Dan Kovacic, R.T.O.(c), graduated from George Brown College in 2009. His main interest lies in new inventions. He is the owner of Kovacic Orthopedic Tool & Supply Corp. Contact Dan at info@kovacic orthopedic.com or (800) 665-1176.
CONTINU DU UIC IO C IONNGT IEN NAGT E DN UCATION
Ethics Quiz
By: Sharon Carr, B.Sc., C.O.(c)
This quiz refers to the Canons of Ethical Conduct of Orthotics and Prosthetics Canada (OPC), adopted from the Canadian Board for Certification of Prosthetists and Orthotists, the Canons of Ethical Standards (April 2001). The Canons of Ethical Conduct fall under the jurisdiction of the Standards and Ethics Committee of OPC. 1. The purpose of the Canons of Ethical Conduct is: a. to ensure the patient’s welfare is the first priority b. to encourage and promote the highest standard of professionalism and ethical conduct of members c. to provide members with legal protection if a patient is dissatisfied with their treatment d. a and b e. all of the above 2. T here are many responsibilities outlined in the Canons of Ethical Conduct. Which is NOT a responsibility outlined in the Canons? a. responsibilities to the physician b. responsibilities to the patient c. responsibilities to colleagues and the profession d. responsibilities to a Prosthetics and Orthotics school 3. The Canons of Ethical Conduct apply to: a. residents, interns, certified members and registered members b. certified members and registered members only c. residents and interns only d. certified members, registered members and physicians 4. According to the Canons of Ethical Conduct, when a registered or certified member has concerns with the treatment that another healthcare provider has provided to a patient, it is appropriate to: a. tell the patient that they shouldn’t seek treatment from that healthcare provider b. have a conversation with the healthcare provider in question regarding the concerns c. notify the OPC Board of Directors if the concerns with the healthcare provider are at a level of criminal violation, incompetence, malpractice or violation of the canons d. a and b e. b and c f. all of the above
5. A second-year resident orders business cards with his/her full name and C.P.(c) credentials after his/her name. According to the Canons of Ethical Conduct, it is appropriate to: a. use these cards because C.P.(c) doesn’t have any meaning until the certification exam is passed b. use these cards after the resident receives written confirmation that he/she has passed all aspects of the certification exam c. use these cards after receiving confirmation of a passing grade on the written exam, but before completing the oral/practical exam d. use these cards as long as they are given to patients in a hospital setting 6. Y ou work closely with a rehabilitation clinic. Each time you recommend a patient to this clinic for rehab services, you receive a pair of tickets to a sporting event. As outlined in the Canons of Ethical Conduct: a. it is okay to use these tickets as long as you take a friend with you who is not an employee of your clinic b. it is okay to use these tickets as long as you say thank-you c. it is okay to sell these tickets for at least half of the face value d. you should ask the rehabilitation clinic to discontinue sending the tickets 7. According to the Canons of Ethical Conduct, all certified and registered members must: a. be truthful and honest to the patient, physician and the public b. accept all prescriptions, even if the member knows prosthetic and/or orthotic treatment cannot be completed within a reasonable period of time c. share patient information with another healthcare practitioner immediately upon the request of that healthcare practitioner d. compensate all referral agencies whenever possible
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8. According to the Canons of Ethical Conduct, if a registered or certified member engages in a research project or study, there are clauses that must be followed. Which one of the following is NOT part of the Canons? a. all patients affiliated with the research must consent in writing to the use of the results of the study b. all data and patient information must remain confidential c. the well-being of the patient shall be the primary concern d. there must be at least one certified and one registered member as part of all research e. the research must be conducted in accordance with all federal and provincial law 9. A patient arrives at a prosthetic and orthotic facility for repair of a device. It is determined that the joint in the patient’s device is not repairable. There is not an identical joint in stock. The member does have a different joint but it provides a much different function than the original joint. The member should: a. replace the joint and say nothing to the patient or the referring physician b. replace the joint after telling the patient about the difference between the previous and the new joint
Profession Quiz:
c. replace the joint after telling the patient about the difference between the previous and the new joint and make a note to call the referring physician d. call the referring physician to discuss the possible change to the prescription before going ahead with installing the new joint 10. According to the Canons of Ethical Conduct, which of the following statements is true? a. It is acceptable for a certified or registered member to have sexual relations with a current patient as long as it is consensual. b. It is acceptable for a certified or registered member to refuse to work with a patient if they have a religious background that is different from their own. c. It is acceptable for a certified or registered member to have sexual relations with a current patient as long as the consensual sexual relationship existed prior to the provision of any orthotic or prosthetic services. d. It is acceptable for a certified or registered member to refuse to work with a patient based on their sexual orientation.
Development of the Orthotic and Prosthetic Profession in Canada
By: Sharon Carr, B.Sc., C.O.(c)
1. T he first organized meeting of the orthotics and prosthetics profession in Canada was held at the Csarda Restaurant in Toronto. What was the date? a. August 25th 1949 b. August 25th 1955 c. August 25th 1959 d. August 25th 1961 2. S even people attended this meeting. Who was NOT present? a. Harold Nitchke b. Stanley Dew c. Karl Ruder d. George L. Kinman e. George Chamberlain f. Harry Fletcher g. P. Doyle Jr. h. C. Gordon Cameron
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3. T he above group formed the Canadian Artificial Limb and Brace Makers Association (CALBMA). A few years later CALBMA changed its name to: a. Interprovincial Association of Prosthetists and Orthotists in Canada (IAPOC) b. Orthotics and Prosthetics Canada (OPC) c. Interprovincial Artificial Limb and Brace Makers (IALBM) d. Canadian Certification Board of Prosthetics and Orthotics (CCBPO) Historical Fact: The name was again changed in 1969 to the Canadian Association of Prosthetists and Orthotists (CAPO).
4. The first certification exams were held in what year? a. 1965 b. 1968 c. 1969 d. 1970
5. I n which year did the Canadian Board for Certification of Prosthetists and Orthotists hold the first registered technical exams? a. 1995 b. 1998 c. 2000 d. 2003 6. I n response to the effects of the drug thalidomide in 1964, the first Prosthetic and Orthotic School in Canada was incorporated by the Ministry of Health. The name of the school was: a. The School of Prosthetics and Orthotics of Quebec, Inc. b. The Clinical Methods of P&O at George Brown College c. The Prosthetics and Orthotics School at University of Toronto d. The P&O School at British Columbia Institute Of Technology 7. The first official day of OPC was: a. January 1, 2014 b. December 1, 2014 c. January 1, 2015 d. January 31, 2015 8. The English version of OPC stands for: a. Orthotics Prosthetics Canada b. Orthotists Prosthetists Canada c. Orthotics Prosthetics Corporation d. Orthoses Prostheses Corporation
9. The Head Office for OPC is located in: a. Toronto b. Winnipeg c. Halifax d. Ottawa 10. C BCPO will continue to exist at arm’s length from OPC as a credentialing body, to manage the certification and registration of clinicians and technicians. a. True b. False 11. T here are four classes of membership in OPC. Which one of the following is NOT considered a class? a. Certified b. Registered c. Honorary d. Associate e. Student 12. All of the following are standing committees of OPC. Which one is a Sub-Committee of one of the others? a. Nominations Committee b. Professional Qualifications Committee c. Professional Development Committee d. Standards and Ethics Committee e. Certification and Registration Board f. Marketing and Communications Committee g. Finance and Audit Committee
References Gans, Dave. A Canadian History of Prosthetics and Orthotics, 2004 (can be purchased from the OPC office). www.opcanada.ca
Earn two credits with a minimum grade of 80 percent.To be eligible for the MCE credits, complete the questions for your discipline and submit to: OPC National Office, Suite 202, 300 March Road, Kanata, Ontario K2K 2E2; email: info@opcanada.ca; Fax: (613) 595-1155.
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