Orthotics Prosthetics Canada
Alignment2018 The Official Publication of
Best of Alignment A 10-Year Retrospective
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Alignment2018 C O N T E
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Industry News
O&P Solutions . . . . . . . . . . . . . . . . . . . .60
4 President’s Greetings Dan Mead, CPO(c), OPC President 6 Executive Director’s Message Dana Cooper, MBA CAE, OPC Executive Director 8 Welcome to Alignment 2018… A 10-Year Retrospective 12 Exam Redevelopment for Orthotic and Prosthetic Professionals 88 Prosthetic Precedent: Pursuing Compensation in Traumatic Amputation Cases 98 Product Showcase: New & Improved for 2018
Three Quick Steps: Converting Lace Shoes to Velcro® Introduction to Orthotic and Prosthetic Applications for Small Animals Fabrication Techniques for Leather-Reinforced Wrist Supports Ice Time: Skate Extension Orthosis Sports Sockets: Alternative Prostheses Designs for Short Trans-radial Amputees Osseointegration: Related to Limb Prosthetics in Canada A Complicated Case Off Loading: A Case Study on Relieving Pressure on the Diabetic Foot Hanging Tight: Elevated Vacuum Suspension Systems Step Forward Designing an Athlete: An Evaluation of Prosthetic Feet for High Intensity Sports
114 Advertiser Index
Special Feature Section . . . . . . . . . . 14 The Information Age: A Double-Edged Sword Agility Challenge: Creating Opportunities for Physical Activity Educational Reform: A Collaborative Model for Clinical Prosthetics & Orthotics Evidence-Based Medicine in Prosthetics and Orthotics Golden Girl: Lauren Woolstencroft Wins Five Gold at Paralympic Winter Games The Diabetic Brain: Awareness and Management of Cognitive Impairment 3D Printing Technology: Impact & Effect on O&P Practice Wrist-Driven Paediatric Partial Hand Prosthesis: A Collaborative 3D Printing Solution Tried, Tested and True: Maximizing Outcomes via the Patient-Practitioner Relationship Walk This Way: Paediatric WalkAide System Leaps and Bounds Helping Children Walk with the Bioness Paediatric Foot Drop System Health Literacy: We Can Make a Difference 3D Printing is Coming to Our Clinics: The Question is ‘Who’s Bringing It?’
Clinical Team . . . . . . . . . . . . . . . . . 49 Team Approach to Wound Prevention and Management Personal Tool Chest: Minimal Essentials for Maximal Results in Prosthetic Gait Training Team Effort: Orthotists, Prosthetists and Physiotherapists Working Together Holistic Care: Screening for Mental Health Predictors and Indicators
Continuing Education . . . . . . . . . . . . . . 76 Incorporating Outcome Measures into Daily Practice: A Clinician’s Perspective The War Amps Advocacy Program: A Voice for Canadians Living with Amputation Observational Gait Analysis Handbook and Assessment Form Gait Patterns of Runners with Lower-Limb Prostheses
O&P International . . . . . . . . . . . . . . . . .84 Bolivia Bound: Setting Up Shop in a Developing Country One Love: Improving Lives in Jamaica The Global Village: LIMBS International is on the Move
In Memory . . . . . . . . . . . . . . . . . . . . . .90 Fly in Peace Friend: A Tribute to Dietrich Bochmann, CPO(c), FCBC A Life Well Lived. A Man Well Loved. A Tribute to Frank Hayday, CPO(c) Striving Ever Forward: A Tribute to Jocelyn Ann Fawcett Goux, B.Sc., CP(c), FCBC The Pioneer: A Tribute to John Arnet “Arnie” Pentland Mr. Veteran: In Tribute to H. Clifford Chadderton
New for 2018 . . . . . . . . . . . . . . . . . . . 102 Why Microprossesor Knees are Beneficial for All K-Levels: A Literature Review Northern Exposure Complex Regional Pain Syndrome: A Case Study in “Unconventional” AFO Application Social Perception: Bridging the Gap Between Fiction & Function
PRESIDENT’S MESSAGE
Claiming our Domain Working through another year as the president of Orthotics Prosthetics Canada has been a challenge. The theme for the upcoming conference in Ottawa – “Claiming our Domain” – is one that seems to transcend all efforts of OPC at the moment and is at the root of our growing public awareness needs. We continue to see the public confused by a vast array of allied healthcare practitioners also offering professional services in the area of orthotics, more specifically “bracing”, as it is typically referred to in public marketing campaigns. Although we have been working very hard at validating our examinations and ensuring we stand for a “Gold Standard” in Prosthetic and Orthotic treatment, these standards and skill sets need to be shared with external stakeholders in order to claim our domain: Orthotics and Prosthetics. We recently addressed an issue in which the College of Pedorthics of Canada (CPC) made some changes to clarify their scope of practice to include certain OTC devices and subtalar control devices. We were successful in engaging with their executive to request more clarity. Orthotics Prosthetics Canada has a duty to protect those who require orthotic and prosthetic treatment – this in its regulatory body capacity through our Standards and Ethics Committee. Without further clarity, the announcement by the CPC could be leveraged in unintended ways to offer a greater scope of services than was intended by the College of Pedorthics. Ultimately this could be confusing to the public. We must collectively ensure that the public and payers know our skills, training and competencies. OPC has documents to help efforts at the grassroots level. To build on “Claiming our Domain”, please consider any community events and whether your practice is able to participate and share your professional identity with the public around you. This might be as simple as attending a local high school job fair or putting on a more formal educational offering for allied healthcare professionals in your community. OPC continues to attend national conferences with important stakeholders, such as the Pri-Med conference, CHLIA, Wounds Canada and the Family Medicine Forum. However, OPC will continue to rely on contributions from all its members to get its message out to as many people as possible. OPC is involved in a wide array of initiatives that engage a great number of volunteers working to move the profession forward. Some examples include: • Regional Council meets twice per year to identify shared issues and collaboratively find common solutions. • The Exam Blueprint Project has been implemented for the Certification examinations and work continues on the Registration examinations. • OPC hosted an O&P Education Meeting in Calgary in May. All four O&P programs presented on the status of their current programs, and their strengths, weaknesses, opportunities and threats. It was a good opportunity to compare and contrast all of the O&P programs in Canada. • College of Pedorthics of Canada inclusion of AFOs in C.Ped(c) scope of practice is concerning and OPC has engaged with the CPC to define the boundaries of the limitations for AFO treatments by C.Ped(c). It is an honour for me to work as a volunteer of Orthotics Prosthetics Canada. We have a very dedicated National Office Staff that genuinely cares about its members and wants to see our profession grow and succeed. We have passionate volunteer members in all areas of the organization who collectively lead by example in the work that they do, all for the benefit of the patients we serve. There are many ways to achieve greatness, and we might not all agree on the way to get there. Despite this fact, I am constantly amazed at the dedication, love and passion displayed towards this profession that we have all chosen. As long as we continue to channel our efforts collectively, we will succeed at “Claiming our Domain”!
Dan Mead, CPO(c) President, Orthotics Prosthetics Canada 4
Alignment 2018 Edition
OPC Committees Certification and Registration Board (CBCPO), Chair: Leslie Pardoe, CO(c)
The official publication of Orthotics Prosthetics Canada
OPC Board of Directors
PUBLISHED ANNUALLY
Ronald Bartlett, RTPO(c), Vice President
OPC National Office Dana Cooper, MBA, CAE, Executive Director
Mark Agro, CO(c), FCBC, Treasurer
Mara Juneau, Programs & Credentialing Director Sandra Fyfe, Member Services and Communications Lindsay Pealow, Finance & Administration 202-300 March Road Ottawa, ON K2K 2E2 Phone: 613-595-1919 Email: info@opcanada.ca www.opcanada.ca Publisher DT Publishing Group, Inc. PO BOX 327, Stn. Main Grimsby, ON L3M 4G5 Tel: (800) 725-7136 Email: jeff@disabilitytodaynetwork.com Executive Editor Krista Holdsworth, B.Sc., CO(c), FCBC Email: orthopro@orthoproactive.com Managing Editor Jeff Tiessen, DT Publishing Group, Inc. Tel: (800) 725-7136 Email: jeff@disabilitytodaynetwork.com Associate Editor Brenda McCarthy Tel: (800) 725-7136 Email: brenda@disabilitytodaynetwork.com Art Direction Starr Hansen Email: sjdesignstudio@comcast.net Design and Layout SJ Design Studio Email: sjdesignstudio@comcast.net Advertising Sales OPC National Office 202-300 March Road Ottawa, ON K2K 2E2 Phone: 613-595-1919 Email: info@opcanada.ca 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.
Dan Mead, CPO(c), President
Andrée-Anne Fortin, CP(c) Jenna Holz, CO(c) Serap Kaga, CO(c) Steve Scott, CP(c), FCBC Aaron Tucker, RTPO(c) Steve Wall, RTP(c) Stan Wlodarczyk, CP(c) Dr. Hernish Acharya, M.D., FRCPC, Director at Large Brad Mattear, Director at Large
Residency and Internship Sub-Committee, Chair: Amy Richardson, CP(c) Finance Committee: Chair: Mark Agro, CO(c), FCBC, and Treasurer/Member at Large: Alan Moore, RTPO(c), CO(c), FCBC Nominations Committee, Chair: Carla Reimer, CO(c) Professional Development Committee, Chair: Sharon Carr, CO(c) Professional Qualifications Committee, Chair: Dan Blocka, CO(c), FCBC Marketing & Communications Committee, Chair: Dave Broman, CPO(c), FCBC Standards & Ethics Committee, Chair: Jesse Cornell, CPO(c) Professional Practice Sub-Committee, Chair: Ken Moghadam, CO(c)
ABOUT OPC Orthotics Prosthetics Canada (OPC) is the representative national organization for the prosthetic and orthotic profession. Its role is to protect the public and advance the profession of prosthetics and orthotics through quality standards of practice, professional credentialing, education and awareness. The four priority pillars for OPC are: Professional Credentialing • Residency and Internship Programs • National Board Examinations • Certification and Registration of Professionals Regulation of Profession • Developing Practice Standards • Establishing Ethical Guidelines • Monitoring Ethical Conduct Continuing Education • Enhancing Knowledge and Skills • Mandatory Continuing Education Program Stakeholder Relations • Education and Awareness of Key Stakeholders OPC began operations in January 2015 as a result of an amalgamation of the Canadian Association for Prosthetics and Orthotics (CAPO), incorporated in 1954, and the Canadian Board for Certification of Prosthetists and Orthotists (CBCPO), incorporated in 1972. All CAPO and CBCPO registered trademarks are now owned by OPC. However, CBCPO remains the certification body and is an independent Board responsible for implementing and managing the certification and registration processes. Successful candidates are still considered CBCPO Certified/Registered through OPC. CBCPO will continue to exist as an arm’s length credentialing body to manage the certification and registration of clinicians and technicians and confer the designations of: Certified Orthotist CO(c), Certified Prosthetist CP(c), Certified Prosthetist and Orthotist CPO(c), Registered Technician Orthotics RTO(c), Registered Technician Prosthetics RTP(c), and Registered Technician Prosthetics and Orthotics RTPO(c).
EXECUTIVE DIRECTOR’S MESSAGE
Knowledge Sharing – Key to the Future of Orthotics & Prosthetics When people are first exposed to orthotics and prosthetics they are struck by the incredible knowledge possessed by orthotic and prosthetic professionals. Recognition of skill is immediate when the required medical, biomechanical and anatomical knowledge needed is considered. This recognition becomes more profound when they realize the innovation required to meet patients’ unique needs with custom-made devices. Experience and knowledge are on daily display for orthotic and prosthetic professionals. Perhaps this is not as evident to the orthotic and prosthetic professionals who work in the field. However, it is clear to those of us who look on in awe of what these professionals achieve. The talent and value received by their patients far exceeds the cost to provide the devices. So, how do we make sure other health professionals, governments and private payers are exposed to, and made aware of, the outcomes achieved by orthotic and prosthetic professionals? The answer is to show them! Nothing resonates more than showing off what orthotic and prosthetic professionals accomplish for their patients. There are many other professions clamouring for attention and respect by these key stakeholders. Joining that chorus only gets lost amongst the throng. What is needed is to differentiate the orthotic and prosthetic profession, and to substantiate the value of the treatments it provides. Yes, this requires evidence. Yes, outcome data to support the value claimed for the treatments provided would be ideal. However, most of all, it requires orthotic and prosthetic professionals to tell their stories of accomplishment, to illustrate their competencies, and to demonstrate the value achieved for their patients. The opportunities to do this are many. Orthotics Prosthetics Canada (OPC) has tools to help and encourages orthotic and prosthetic professionals to share their experiences using patient stories and case studies. OPC has templates to easily capture this information. One requires patient consent and the other does not. These are effective in illustrating the conditions and complications orthotic and prosthetic professionals must overcome. Information Sheets are also an effective way to communicate information on a specific condition that is addressed with an orthotic or prosthetic treatment. They are a maximum of two pages in length, are evidence-based and provide the opportunity for orthotic and prosthetic professionals to write about a specialization or special area of interest within which they work. There are many opportunities for orthotic and prosthetic professionals to share their knowledge with other professions and influencers; conference presentations to health, insurance or policy professionals and journal articles increase recognition of the profession. Only orthotic and prosthetic professionals can demonstrate their value by putting their combination of science and art on display for others to see. This is the most effective way to lay claim to the orthotic and prosthetic domain and gain deserved respect as professionals with unique expertise. At no time in the past has this need been of greater importance than it is right now. For more information visit www.opcanada.ca or contact Orthotics Prosthetics Canada at info@opcanada.ca.
Dana Cooper, MBA CAE OPC Executive Director
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Best of Alignment… A 10-Year Retrospective Welcome to the 2018 edition of Alignment! The 2018 edition marks a decade of the publication in its current format. In recognition of this 10-year milestone, OPC has produced a “Best of Alignment” issue to showcase a selection of some of the most compelling articles featured in past editions. And of course, new content is featured as well. In those 10 years, many different topics and areas of interest have been presented. In 2013, Alignment featured the important subject of wound care. In 2009, education reform was spotlighted. In 2011, evidence-based practice took centre stage. Leafing through past Alignments it was easy to find a significant number of Alignment features that are still relevant and prominent in conversations today. Many thanks are extended to our editorial team that pored through the past issues of our profession’s respected publication to bring forward articles that resonated with them to share, once again, with you. The Editorial Team was led by Krista Holdsworth, CO(c), FCBC, and included Sandra Ramdial, CP(c), FCBC, Andrew Lok, CO(c), Helen Cochrane, CPO(c), Tessa Richardson, CP(c), Melanie Freedman, CO(c), Neil Ready, CPO(c), and Jeff Tiessen of Disability Today Publishing Group, and Managing Editor and Publisher of Alignment. The 2018 “Best of Alignment” edition also triggers the departure of Krista Holdsworth as Executive Editor. Krista has been Alignment’s Executive Editor for 10 years, a journey she and Jeff Tiessen embarked upon together. Krista has gone more than above and beyond in leading its production. Together with Jeff Tiessen, they have been an incredible team in producing a quality publication year after year. A ten-year volunteer commitment of this nature is beyond what any organization can ask for and our heartfelt appreciation goes out to Krista and Jeff for bringing us a decade of invaluable O&P education, industry news, informative case studies, technical tips and more. Please visit www.opcanada.ca for the full articles presented herein as abridged versions in order to accommodate all of the great selections of our Editorial Team. Dana Cooper, MBA, CAE OPC Executive Director
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12 Diabetes Website, Lawn Care Safety, National Amputee Centre, Marathon Man, Limb Drive Canada & New i-LIMB Pulse
71 Product Showcase New & Improved for 2010
84 In Tribute John Arnet “Arnie” Pentland, 1920-2009
88 CAPO Education Funds 91 CAPO Facility Listing 98 CAPO Founder’s Memorial Award 98 Advertiser Index
Special Feature 44 Golden Girl Lauren Woolstencroft Wins Five Gold at Paralympic Winter Games
45 Prosthetic Pit Stop Paralympic Repair Shop Returns Athletes to Action
46 Paralympic Experience
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34 Hanging Tight
10 Presidents’ Greetings
Elevated Vacuum Suspension Systems Step Forward
David Mueller, C.O.(c) CAPO President Allan Moore, C.O.(c) CBCPO President
60 Partial Hand Prosthesis A Case Study
Orthotic Technology
12 Otto Bock Honoured, Soldiering On, Diabetes Assessment Tool, Artificial Skin
48 Play Ball
104 Product Showcase
Bracing for Pain-Free Activity
New & Improved for 2011
120 CAPO Facility Listing
Continuing Education
124 CAPO Education Funds 126 CAPO Founder’s Memorial Award
16 Joint Credentials Committee Update
126 Advertiser Index
Forging the Path Towards a Stronger Profession
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O&P International 72 The Global Village LIMBS International is on the Move
62 Estantodos Contentos? Myrdal Orthopedic Technologies in Mexico
O&P Solutions 78 Made to Measure Online Compilation of P&O Outcome Tools
80 Prosthetic Pattern Ischial Containment Techniques
86 Considerations for the Transpelvic Amputee Learning from a Paralympian
92 On the Road with Otto Bock
20 CAPO Conference Canada’s Premier Prosthetics and Orthotics Event
Special Features
40 Orthotic and Prosthetic Technicians Who are we? Where are we going?
17 Evidence-Based Medicine in Prosthetics and
67 Student Research
Orthotics
Postural Effects on the Upper Extremity Amputee When Wearing Different Prostheses
44 Foot Notes
Prosthetic and Orthotic Advocacy and Education in our Communities
64 In Tribute
Measuring Gait Step by Step Don Weber is Stepping Outside the Box
78 Prosthetics Quiz
67 In Memory
80 Orthotics Quiz
Remembering Jocelyn Fawcett Goux and Frank Hayday, Jr.
Manufacturer’s Report 94 Shoulder Disarticulation Interface Designs 98 Hybrid Sockets for Symes Amputees 100 Microprocessor Knee Outcome Measures
Continuing Education 26 CAPO Conference 2010 Canada’s Premier Prosthetics and Orthotics Event
O&P Solutions
Clinical Team
30 Off Loading
22 Paradigm Shift
Relieving Pressure on the Diabetic Foot
Disability Studies Present Diversity of Views
54 Compression Socks
30 Educational Status A Canadian Prosthetist & Orthotist Perspective
38 Masters Update – New Lessons Learned 50 Student Research 114 Quizzes (Prosthetics, Orthotics, Technicians)
A Case Study
56 Anaplastology Restoring Form and Functiom
62 Sticks and Bones Crutches as an Alternative Mobility Aid for Safety
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Deadline for submissions for consideration for publication in Alignment 2011 is October 2, 2010.
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7 Founder’s Memorial Award 10 Presidents’ Greetings
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30 Dynamic Influence Custom Foot Orthotic Intervention
Leslie Pardoe, C.O.(c) CAPO President
72 Preventative Prosthetic Maintenance
David Mueller, C.O.(c) CAPO President
Technical Tips and Guidelines
12 ISPO (Canada) 2013 Symposium, O&P Survey, Active
74 Critical Appraisal
Allan Moore, C.O.(c) CBCPO President
Amputee Media Channel, My Really Cool Legs Documentary
Botox in Conjunction with Serial Casting
12 Hosmer Celebrates 100, Nike and Ossur Collaborate, Ice Men & Bionik Brain Power
110 Product Showcase
22 National Implications of Provincial O&P Regulation
80 “Cosmetifunctional”... the New Normal
112 Product Showcase
Caroline’s Story
New & Improved for 2013
84 Improved Outcomes
124 CAPO Facility Listing
Treatment of Blounts Disease
New & Improved for 2012
128 CAPO Education Funds
88 Trans-Radial Interface Designs
121 CAPO Facility Listing 124 CAPO Education Funds 126 Advertiser Index
Applying Non-Elevated Vacuum Suspension
130 Advertiser Index
Special Feature Section
68 Memorable Moments
14 The Way We Move
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A Complicated Life Living with Diabetes from a Spouse’s Experience
Ottobock’s Harmony System
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Diabetes Among Aboriginal People A Native Perspective
Continuing Education
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Without Limits
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The Diabetic Brain Awareness, Recognition and Management of Cognitive Impairment
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Neuropathic Osteoarthropathy
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Identify and Immobilize The Goals of Successful Charcot Orthotic Management
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If the Shoe Fits Recommendations for Neuropathic Diabetic Patients
Manufacturer’s Report
Clinical Decision-Making and Observational Gait Analysis
22 Video Gait Analysis 37 Quantifying Symmetry in Prosthetic Gait 102 In Memory A Tribute to Dietrich Bochmann
98 Finding Harmony in Fit and Function
18 Observational Gait Analysis Handbook and Assessment Form
Clinical Team
50 2011 ISPO Canada Symposium Thinking Outside the Classroom
42 Personal Tool Chest
52 CAPO Conference 2012
Minimal Essentials for Maximal Gait Training Results
Canada’s Premier Prosthetics and Orthotics Event
94 Patient Profile
56 Student Research
Brandon’s Casting Call
Evidence-Based Practice Off-loading Diabetic Foot Ulcers Plastic Dyeing Methods Experience with the Healthcare Team
O&P International
Clinical Team
116 Quizzes (Prosthetics, Orthotics, Technicians)
106 Worldwide Efforts in P&O
28 TEAM: Together Everyone Achieves More
A Team Approach to Wound Prevention and Management
80 Take-Away Effect
Chronic Pain Treatment in the Absence of Ambient High EMF
Deadline for submissions for consideration for publication in Alignment 2013 is October 28, 2012.
Alignment2015 C O N
Industry News President’s Greetings Dan Mead, C.P.O.(c) CAPO President
10 Orthotics Prosthetics Canada
Amalgamating CAPO and CBCPO
12 OPC and The War Amps Collaborate,
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
122 Advertiser Index
Special Feature Section S P O RT S & R E C R E AT I O N
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
46 A Revolutionary Tale
Össur’s Continuing Innovation in Running Prostheses
52 Think Outside the…Shoe!
An Original Idea that is Transforming Lives
55 Troppman Grip
Golf Attachment for Upper Extremity Amputees
58 Trans-radial Hockey Prosthesis
Custom Goalie Stick Terminal Device
62 Concept to Completion
35 Years of Prosthetic Innovations
Legal Matters 20 Prosthetic Precedent
A Canadian Company’s Experience
O&P Solutions 62 New World Connections
Are Smartphones Smart Enough for Prosthetics and Orthotics?
66 Up to Speed
Kinematic Comparison of Running Gait in an Individual with a Van Nes Rotationplasty
72 Vacuum Hole Test Positive A Case Study A Case Study
82 He Shoots! He Scores!
Clubfoot Management in Hockey
86 Fabricating a Favourable Outcome A Case Study
Technician’s Report 88 Memorable Moments
Continuing Education 14 Tomorrow’s Forecast
2011 Demographic Study on the P&O Profession in Canada
20 The M.Sc. Advantage
Collaborative McMaster/GBC/BCIT M.Sc. Program Update
94 Student Papers
Research projects from British Columbia Institute of Technology and George Brown College
118 Quizzes (Prosthetics, Orthotics, Technicians)
Deadline for submissions for consideration for publication in Alignment 2014 is October 1, 2013.
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O&P International 36 Adventure in a Developing Nation
74 Low-Profile Symes Foot Alignment Jig
Technician’s Report
Special Features
Founder’s Memorial Award
Pursuing Compensation in Traumatic Amputation Cases
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The Roles of a Recreation Therapist
Continuing Education 17 Celebrating the CAPO Conference 2014 74 Student Papers 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 98 Fabrication Techniques for
Leather-Reinforced Wrist Supports
102 High Heel Cup for Your FO 104 Impact Absorption in Protective Helmets 108 Going Digital to Fuel Business Growth 117 Safer and Efficient Tools for Bending Metal Uprights
Client Profile 64 The Fuel for My Fire
Technician’s Report 68 Memorable Moments
Deadline for submissions for consideration for publication in Alignment 2016 is October 1, 2015.
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Alignment2014 C O N T E N T S
Industry News 7
Continuing Education 16 Critical Thinking
Founder’s Memorial Award
What does it mean for Prosthetic and Orthotic education?
10 President’s Greetings Leslie Pardoe, C.O.(c) CAPO President
110 Quizzes
(Prosthetics, Orthotics, Technicians)
12 Join the CROW Conversation, High-Tech Toes,
Healthy Resources for Amputees, Minimizing Microbes, and Amputee-Only Gym
72 All Heart
O&P International 70 On a Mission
Surviving and Thriving after Amputation
O&P Care in Belize
102 Product Showcase
New & Improved for 2014
115 CAPO Education Funds
O&P Solutions
116 CAPO Facility Listing
24 Designing an Athlete
118 In Tribute… H. Clifford Chadderton (1919 - 2013)
Prosthetic Feet for Football and other High Intensity Sports
122 Advertiser Index
78 Benefits of Custom Silicone Foot Prosthesis
Special Feature Section
Research Study Findings
82 Innovative Design Solutions
PA E D I AT R I C O & P C A R E
For Short Upper Extremity Residual Limbs
84 Converting Lace Shoes to Velcro
33 Walk this Way
Pediatric WalkAide System
85 Seven Steps to Donning an AFO
36 Leaps and Bounds
88 Alternative Casting Methods of Ankle and Foot
Bioness Pediatric Foot Drop System
94 The Risser Table
44 Holistic Approach to the ABCs
100 Gold Finger
Alignment, Bracing and Collaboration
Swivelling Double-Band Orthosis
48 Botox
Pharmacological Intervention
Tech Tips
51 Agility Challenge
Physical Activity for Young Amputees
96 The Cleco, Cleaning Up Nice, Shoe-In and Plastic
56 Dynamic Elastomeric Fabric Orthoses for Scoliosis
for Dummies, Valve-o-matics and Poke-o-matics
60 The Manitoba Experience
Cranial Remolding Helmet Therapy
Technician’s Report Clinical Team
64 Memorable Moments
40 In the Driver’s Seat
Deadline for submissions for consideration for publication in Alignment 2015 is October 1, 2014.
A Team Approach to Designing Safe Mobility
Alignment2017
Alignment2016 Industry News 6
President’s Greetings Dan Mead, CPO(c) OPC President
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Executive Director’s Message Dana Cooper, MBA CAE OPC Executive Director
10 New Education Bursary Program, Government and Public Relations Strategy Development, National Peer Network 14 Chedoke P&O Moves to Ron Joyce Children’s Health Centre 112 Product Showcase New & Improved for 2016 122 Advertiser Index
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Point of View 20 Alarming Acceptance of Status Quo
Clinical Team 24 Improving Patient Safety through Interprofessional Collaboration 30 Holistic Care: Screening for Mental Health
O&P International
Client-Centred Practice... Enhancing the Patient-Practitioner Relationship 36 The Information Age: A Double-Edged Sword 38 Tried, Tested and True: Maximizing the Patient-Practitioner Relationship In Conversation with Don Weber, CO(c), FCBC 42 Health Literacy: We Can Make a Difference 46 Acquired Brain Injury: The Invisible Disability 52 In My Client’s Shoes: A Personal Perspective 56 Outcome Measures 62 Everyone’s Talking Outcome Measures: What Do Patients Say? 66 Assessing Learning Needs of Lower Extremity Amputees: Research Evidence, Practitioner Experience, and Patient Feedback
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President’s Greetings Dan Mead, CPO(c) OPC President
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Executive Director’s Message Dana Cooper, MBA, CAE OPC Executive Director
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MEC 2017, Orthotics Prosthetics Canada News, Gait and Balance Academy, 2017 FCBC Recipient, C-Leg Celebrates 20 Years in Canada, CPOT Reference Manual
104 Product Showcase New & Improved for 2017
34 One Love: Improving Lives in Jamaica
118 Advertiser Index
O&P Solutions
Continuing Education
72 Redefining the Human Connection
Special Feature Section
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76 Clinical Case Study: An Innovative Solution for an OI Client
10 The War Amps Advocacy Program 16 Incorporating Outcome Measures into Daily Practice
80 Our Journey to the Cybathlon: Developing an Intuitive Upper Extremity Prosthesis Control Strategy
20 The Value of Electronic Medical Records in O&P Care
84 A Complicated Case
26 Critically Appraised Topics
87 Socket-less Socket
94 Student Papers
90 Custom Fabricated Exo-Skeletal Cosmetic Cover
115 Mandatory Continuing Education Program
94 A Client-Centred Approach to an Upper Extremity ADL Challenge
O&P Solutions
98 The Virtues of Varsol: The Skinny on (Paint) Thinner
74 Planting the Seeds: Practitioner Patience for Patient Success
Continuing Education
Special Feature Section 3D Printing Technology: Impact and Effect on O&P Practice Today and Tomorrow 34 Advancing Digital Practice in Prosthetics and Orthotics Consortium 48 3D Printing is Coming to Our Clinics 50 Technician Perspective on 3D Printing Technology 54 Additive Manufacture of Orthotic Devices 64 Wrist-Driven Paediatric Partial Hand Prosthesis 68 Management of Infant Head-Shape Asymmetry
78 Osseointegration 86 An Unusual Case on the Rock
100 Student Papers
90 Scrap It: A Green Approach to Team Building
122 P&O Quizzes
92 Gap-Keeper: The Riveter’s Third Hand Deadline for submissions for consideration for publication in Alignment 2017 is November 4, 2016.
Clinical Team 30 Team Manager: The Social Worker’s Role on the O&P Team
Deadline for submissions for consideration for publication in Alignment 2018 is December 1, 2017. Cover image courtesy of Rehabilitation Centre for Children
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INDUSTRY NEWS
Exam Redevelopment for Orthotic and Prosthetic Professionals Competency assessments to credential professionals is a core function of OPC By Mara Juneau, OPC Director of Credentialing Orthotics Prosthetics Canada (OPC) creates and administers Certification and Registration examinations to test competencies for entry-to-practice Certified Orthotists CO(c), Certified Prosthetists CP(c), Registered Orthotic Technicians RTO(c) and Prosthetic Technicians RTP(c). Following the amalgamation of the Canadian Board for Certification of Prosthetists and Orthotists (CBCPO) and the Canadian Association for Prosthetics and Orthotics (CAPO), OPC set out a plan to do a full review and update of all the credentialing examinations. It actually started with the Orthotic and Prosthetic Practice Analysis survey conducted at the end of 2014 which provided the necessary information required to restructure the examinations. The Exam Blueprint Project began in 2015 with an audit of the CBCPO Certification & Registration Programs. OPC, in conjunction with Exam Experts, did a full evaluation of every exam process and procedure to identify areas for improved reliability, validity and efficiency. The end goal? To meet National Credentialing Standards: CBCPO Certification and Registration Programs that ensure the highest standard of patient care. What followed was a lot of hard work, many meetings, and countless hours invested by
over 90 OPC members from across the country. A general idea of the steps involved in this significant undertaking is as follows: • Contracted Pro Exam Services in New York (also worked on the Practice Analysis and have experience working with ABC for their examinations) to guide the examination redevelopment project. • An Exam Blueprint Task Force was struck and charged with developing updated test specifications: the blueprint for the new examinations. • A Gap Analysis Task Force was formed with Subject Matter Experts to evaluate, review and categorize every test content item. • Item writers from across the country were trained and assigned criteria to update and modify the existing content and fill the content ‘gaps’ identified by the Gap Analysis team and ensure the examinations match the Exam Blueprint test specifications. • Contracted Yardstick, a Canadian professional examination company, to guide the development 12
of the practical examinations. Pro Exam worked on the redevelopment of the written examinations.
•O verall Certification Examination time has been reduced by more than half, which more effectively utilizes the resources required and prevents candidate fatigue.
• Numerous meetings took place with the task forces and recruited subject matter experts to develop questions, establish standards, create the practical examinations and more.
Evaluating competencies to award professional credentials is a core OPC function and one that provides credibility for the orthotic and prosthetic profession, establishing confidence with peers, policy makers, payers, health professions and patients. It has been a long road and really one that will never end, however, the goals of the examination redevelopment have and will be achieved in the coming years. Not only are the new examinations more efficient to conduct, they are more effective at assessing the entry level competencies, ensuring OPC credentialed individuals are competent to practice to the standards that ensure patient safety and achieve effectual outcomes.
• Went through pilot examinations with mock examiners and candidates and made necessary adjustments. The resulting examinations are now more efficient and lean, while still maintaining the same competency standards as identified by CBCPO and OPC. By employing the services of professional examination experts we: • Identified more efficient administrative processes and standards.
This project would not be where it is today without all the valuable volunteers. The OPC membership really stepped up with so many people from across the country volunteering their knowledge and time as subject matter experts to make this project the success that it is today. The new Certification Written and Practical Components were launched in the first half of 2018 and were a resounding success. Organizers, examiners and candidates alike are providing positive feedback. The next step is implementing the updated Registration Examinations, which volunteers are working diligently on. Onwards and upwards for OPC.
• Focused the examinations on testing the necessary entry-to-practice competencies. This allowed considerable reduction of the length of the examinations, where redundancies (competencies tested in multiple formats) were removed and more focused content was achieved. Significant changes included the removal of the oral examination, transitioning the Certification Written Examination from a 7-hour examination to a 3-hour multiple choice examination and a more focused practical examination using the objective structured clinical examination format (OSCE – a performance-based exam structure used across many health professions) to test specific knowledge and skills.
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2016
SPECIAL FEATURES
“ This article addresses the battle clinicians face with patients becoming more educated and informed with the use of internet research.” – Andrew Lok, CO(c)
The Information Age A Double-Edged Sword By Krista Holdsworth, B.Sc., CO(c), FCBC First published in Alignment 2016.
For individuals seeking knowledge, information is more readily available than ever before. Today’s technology has changed the way we seek and share information, with numerous search engines at our fingertips. Statistics Canada states that as of 2010, 80% of Canadian households were connected to the internet1. Today, this number is likely to be even greater. It’s widely reported that health information is one of the most frequently sought-after topics on the internet2. As individuals search for information to understand personal health issues, attempt
to self-diagnose or increase their awareness of possible treatment options, the healthcare professional is presented with new challenges1,2,4. There has been significant research conducted in this area, and this article is a brief synopsis of some of the research currently available regarding how the use of the internet is affecting the relationship and behaviour of both the patient and the healthcare provider. A number of studies have found that the use of the internet has resulted in a shift in the role of the patient from a passive recipient of health information to an active, 14
engaged, healthcare consumer1,2,3. In most cases, the patient continues to look to the practitioner as the authoritative expert, although they may have done their own online research. A challenge for the practitioner becomes their own internet literacy and the verification of the legitimacy of the information obtained by the patient. The research has categorized practitioners’ responses to the internet-consuming patient into three potential groups2,4. In the first scenario, the professional may feel threatened by the patient’s attempts to research their particular medical concern. In this case, the
professional usually reacts by responding defensively to the patient. This response usually leaves both the patient and practitioner feeling dissatisfied with the process2,3. The second type of response by the practitioner engages the patient as a partner in their healthcare4. Often, the practitioner does not have the time to search for the relevant information themselves, but they are able to address the patient’s questions or concerns about the internet article and have the knowledge and skill to determine the legitimacy of the information. The third reaction involves the internet-savvy healthcare professional who includes internet information in their practice. This type of professional uses the internet to direct the patient to reliable sources and appropriate medical links to information. This last scenario requires the healthcare professional to remain current with respect to online health information and reliable websites.
Since the average internet user is generally unfamiliar with the source of the online information, the practitioner may be able to assist patients with filtering that content2,4. Of course there are difficulties with online health information. Patients vary in their health literacy and inappropriate health information can lead to a detrimental outcome. Patients may trust misleading information and make decisions on sensationalized stories that are not based on scientific facts. The patient may also be concerned about irrelevant and inaccurate information that may result in requests for non-essential testing. This scenario exemplifies the need for open dialogue between the patient and practitioner regarding available information and appropriate individualized treatment plans. The best possible outcome of the internet information age is the emergence of an educated patient who is a partner with the practitioner in their treatment, while
trusting that the practitioner is the authoritative expert. As such, these practitioners need to become increasingly internet-savvy and engage in researching appropriate sites to which they can direct their patients. This paradigm shift can remove some of the time constraints within the clinical appointment setting. With an informed patient asking more appropriate questions, an increase in patient compliance ensues and the understanding of specific treatment modalities improves... and the patient-practitioner partnership is enhanced. References 1. T. T., G. B., & C. T. (May 2014). Health information on the Internet Gold mine or minefield? Canadian Family Physician, 60(5), 407-408. www.cfp.ca/content/60/5/407.full. 2. McMullan, M. (2006). Patients using the Internet to obtain health information: How this affects the Patient-health professional relationship. Patient Education and Counseling, 63, 24-28. 3. Iverson, S. A., DO, Howard, K. B., BA, & Penny, B. K., PhD. (2008). Impact of Internet Use on Health-Related Behaviours and the Patient-Physician Relationship: A Survey-Based Study and Review. JAOA, 8(12), 699-711. 4. Hart, A., DPhil, Henwood, F., PhD, & Wyatt, S., PhD. (2004). The Role of the Internet in Patient-Practitioner Relationships: Findings from a Qualitative Research study. Journal of Medical Internet Research, 6(3), 1-11. www.ncbi. nih.gov.libaccess.lib.mcmaster.ca/pmc/ articles/ PMC 1550614/?report=printable. About the Author: Krista Holdsworth, B.Sc., CO(c), FCBC, is a Kinesiology graduate from the University of Waterloo and a certified orthotist with more than 25 years experience, specializing in paediatric populations. She is co-owner and Director of Orthotic Services at OrthoProActive Consultants Inc. with clinics in Markham and Newmarket.
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2014
SPECIAL FEATURES
“ An innovative program that provides a safe, welcoming atmosphere for all abilities. Definitely worth sharing! – Krista Holdsworth, B.Sc., CO(c), FCBC
Agility Challenge Creating opportunities for physical activity in the amputee population By Kristen K. Matthews, CP(c) First published in Alignment 2014. An abridged version appears here. For the full article, visit www.opcanada.ca.
Not every child, able-bodied or otherwise, is destined to become an athlete. However, the absence of a limb or the improper function of a group of muscles should not preclude any child from having the opportunity to participate, to play, and to compete among peers.
As healthcare professionals, we all are increasingly aware of the global trend towards diabetes, vascular disease and other complications that often result from poor diet and sedentary lifestyles that have become universally pervasive. We often find ourselves dealing with 16
the late results of these disease processes with, among others, amputees encapsulated within this population. Every day we strive to help the people who seek our services to attain the very highest level of physical function in which they are capable, whether that be
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SPECIAL FEATURES
transfers for toileting or 400-metre sprints. At Holland Bloorview Kids Rehabilitation Hospital in Toronto we have many young, energetic, athletic people who come to us for prosthetic treatment. Many are involved in casual sport under their own impetus. Some become active in high-level, competitive sport. We have soccer players, volleyball players, runners, swimmers, equestrians, basketball players and gymnasts. We have athletes on sledge hockey teams and on able-bodied teams. Many of our kids and young adults do not shy away from activity. But on the other hand, plenty do. Should this worry us? Even in the able-bodied population there are many, even among the younger set, who prefer a soft couch and a bag of chips to a soccer field in the rain. So it should serve as no surprise that some young prosthetic and orthotic device wearers also embrace more sedentary lifestyles. According to Statistics Canada’s 2006 Participation and Activity Limitation Survey, approximately 28 percent of Canadians are involved in organized sport, and 51 percent are involved in leisure-time physical activity. But only a shocking three percent of Canadians with a disability are involved in organized sport. To be fair, this takes in all age groups, all disability levels, and does
not include those who walk, jog, garden recreationally, etc. And yet, the contrast is striking. Research indicates a correlation between amputation or severe musculoskeletal impairment and many other factors, including depression, decreased self-esteem, skin irritation and breakdown, diminished bone density, muscle loss, and pain, all of which may have a negative impact on an individual’s desire to get out and try new things or be more active. This in turn leaves this population vulnerable to weight gain and the raft of potential long-term health concerns in its company: diabetes, vascular disease, heart disease, stroke, various types of cancer... we all know the list. For those with acquired amputations or injuries, and even for those with congenital amputations for that matter, finding information about how and where to try different sports and activities can be a daunting task. And if these youngsters are able to make those connections, or indeed just plough on and get involved with an able-bodied team or facility, adaptive equipment is often needed and often, therapy and training in order to be able to use this equipment optimally. Even if adaptive equipment is not necessary, the perception that it might be has the potential to prevent amputees
from trying certain activities. This initial series of clinics has materialized out of a great deal of work, and the passion and devotion of a large team of professionals who are deeply committed to the well-being of kids with physical challenges. Our first clinic was run entirely on volunteer hours, with the venue and expenses supported by our departmental budget, in which there is little provision for “extracurricular activities”. We are incredibly grateful to have garnered some early recognition from the Milos Raonic Foundation and with it the financial support to continue these clinics despite the sense that we were part of a steep uphill climb. Our attendance at the clinics started small; we have had seven to ten amputees at each of our Kids’ Agility Clinics, plus siblings, parents and staff. But the children who have arrived at the clinics tentative and shy have consistently left feeling enthusiastic and exhausted. We count this as a triumph. We are very excited and energized by the success of our Kids’ Agility Clinics and are now endeavoring to expand upon them by developing a series of “try it” clinics for teens, in conjunction with a series of interdisciplinary clinics for elite parasport athletes. Although tremendously time-consuming to organize initially, we see enormous merit in the program. Through these clinics we hope to provide opportunities for our patients to become better integrated, both physically and socially, into their communities. It is our fond hope that this type of program will continue to grow and develop at home, and in other facilities nationwide so that one day our patients’ concern will not be if or how to start, but what to try first! About the Author: Kristen Matthews is a Certified Prosthetist at Holland Bloorview Kids Rehabilitation Hospital in Toronto, Ontario, where she has worked since 2009. She began coordinating a series of athletics clinics for amputees in the spring of 2012.
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2009
SPECIAL FEATURES
“ Seems to be the start of the ongoing journey into incorporating the Masters program into our programs.” – Tessa Richardson, CP(c)
Educational Reform Moving Toward a Collaborative Model for Clinical Prosthetics & Orthotics By Dan Mead, Sudbury Prosthetic & Orthotic Design, and Dan Blocka & Gord Ruder, George Brown College, Faculty of Allied Health Care, Prosthetic & Orthotic Programs, and Jason Goodnough, Dave Gans & Dave Kenyon, British Columbia Institute of Technology, Faculty of Allied Health Care, Prosthetic & Orthotic Programs. First published in Alignment 2009. An abridged version appears here. For the full article, visit www.opcanada.ca.
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SPECIAL FEATURES
The Joint Credentials Committee has been collaborating on the topic of Educational Reform for Prosthetics and Orthotics in Canada since August 2007. Significant progress has been achieved, with the onus for change now in the hands of educators. Our certifying body continues to contribute to this important initiative and support the move towards improved education for Prosthetics and Orthotics in Canada. The Joint Credentials Committee (JCC) has worked with George Brown College (GBC) and British Columbia Institute of Technology (BCIT) to develop an appropriate model that meets the current needs of prosthetic and orthotic patients and professionals in Canada. The development of a collaborative educational model creates the potential for new academic opportunities for current certifees. JCC’s collaborations on the topic of Educational Reform for Prosthetics and Orthotics (P&O) in Canada have achieved progress with events such as the Consensus Building Meeting on Educational Reform for P&O in Canada and publications such as the White Paper. Both evolved as a direct result of this interprovincial committee’s collaboration. The Canadian Association for Prosthetics and Orthotics (CAPO) and Canadian Board for Certification of Prosthetists and Orthotists (CBCPO) have been instrumental in supporting this initiative conceptually and financially. The interactive audience polling data from the 2008 CAPO convention in Winnipeg, Manitoba, supported a change in the academic credentials of our graduates and led potential university partners to make a commitment to move forward with the development of a Collaborative Educational Model for Clinical Prosthetics and Orthotics in Canada. GBC and BCIT are in discussions
with potential universities, drafting new curricular pathways for new students’ educational preparation for residencies. It is the hope of the authors that through the spirit of continued collaboration, the reality of an advanced academic credential for P&O graduates could be realized for students entering the P&O programs in September 2010. The Consensus Building Meeting on Educational Reform for P&O in Canada was held in Etobicoke, Ontario, in October 2007, to seek informed feedback from stakeholders within the P&O community as to the direction in which the profession should embark to meet the needs of Canadians. Stakeholders included patients, orthotists, prosthetists, physicians, industry representatives, educators, a physiotherapist, and representatives from various P&O national and provincial organizations... overall, 30 attendees who completed the objectives for the meeting. A summary report was compiled that detailed the stakeholders’ recommendations. The stakeholder sentiment was clear. It is imperative that educational reform for P&O be directed towards a Masters degree. Following the consensus meeting, the JCC began work on the White Paper to provide an accurate and detailed account of the state of P&O education in Canada. This document ensured that statements made by the JCC on behalf of the profession, were in line with the mission and values of our national bodies. The White Paper was endorsed by CAPO and CBCPO in June 2008. The main purpose of the document is to emphasize that improvements to the educational pathway should be motivated by improvements to patient care and that we have a responsibility as professionals to ensure that the care we provide continues to meet the 22
demands of the public today and into the future. With a CAPO and a CBCPO endorsement, the JCC shared the White Paper with potential university partners, helping to further educate administrators about our profession and how its academic advancement will benefit the public. This was an important step toward obtaining an agreement to develop a collaborative program with these institutions. This collaborative model may or may not extend this timetable, depending on how the model is mapped. CBCPO is continually reviewing and improving the residency program – improvements to residency requirements were approved as recently as last year. One suggestion is to integrate structured, residency-caliber clinical rotations into the P&O programs, with accountability and practice guidelines for the resident to use during an extended clinical rotation. Regardless of the educational programs, CBCPO will remain the coordinator of the residency program as the educational models make their transitions and CBCPO will remain as our national body setting the standard for certification. For this reason it is important that CBCPO continues to be aware of the progress on educational reform and support the schools as they move forward in order to maintain a relevant and quality residency program helping prepare the graduates to become highly qualified P&O professionals. Needless to say, both GBC and BCIT have work to do in terms of determining the vision for how their current programs will integrate with a Masters program. However, this model does provide an opportunity to combine the strengths of two respected disciplines to creatively deliver appropriate prosthetic and orthotic education to those professionals entering the field. And in turn, the delivery of prosthetic and orthotic services in Canada will be enhanced.
2011
SPECIAL FEATURES
“ Reliable evidence in prosthetic and orthotic care continues to be important for advocacy, quality and access to care.” – Helen Cochrane, CP(c)
Evidence-Based Medicine in Prosthetics and Orthotics By Andreas Kannenberg, M.D., Ph.D. Director Medical Affairs, Ottobock HealthCare, Duderstadt/ Germany First published in Alignment 2011. An abridged version appears here. For the full article, and why the “gold standard” of pharmaceutical research cannot be transferred to O&P research, visit www.opcanada.ca.
In many healthcare systems around the world, results of clinical trials as well as systematic reviews and meta-analyses of clinical studies are used to make decisions on coverage and reimbursement of medical procedures, pharmaceuticals, and medical devices. This is a relatively new challenge
for the prosthetics and orthotics community and coincides with the introduction of advanced, microprocessor-controlled prosthetic components that may deliver remarkable patient benefits but incur higher costs for healthcare payers than conventional standard components. 24
The biggest challenge is that healthcare payers expect clinical trials to be run according to the accepted rules for studies with pharmaceuticals. Unfortunately, the “gold standard” of pharmaceutical research – the prospective, randomized, controlled, double-blinded trial with hundreds or even thousands of patients – cannot
SPECIAL FEATURES
2010
be transferred to scientific research in prosthetics and orthotics. The development of a collaborative educational model creates the potential for new academic opportunities for current certifees. JCC’s collaborations on the topic of Educational Reform for Prosthetics and Orthotics (P&O) in Canada have achieved progress with events such as the Consensus Building Meeting on Educational Reform for P&O in Canada and publications such as the White Paper. There are many more unavoidable variables than only one drug to be studied. Pharmaceutical trials are designed to leave the intervention tested as the only variable, making it possible to attribute any changes to the effect of the drug studied. Accordingly, patient groups are kept as homogeneous as possible with respect to age, sex, weight, disease state, comorbidities, concomitant treatment, etc. Compared to blockbuster indications of pharmaceuticals such as hypertension, diabetes, cardiovascu-
lar disease, etc., limb loss is a rather rare condition. Thus, the basic population for study enrolment is fairly small already. Moreover, there is a large variation of individual physical and mental conditions and comorbidities among patients who may have a huge influence on prosthetic and orthotic fitting and outcome. This variability makes it difficult to recruit a large homogeneous study group. In addition, there are many unavoidable device-related variables than just the component tested that may have an impact on the outcome or study result. Some of these variables may have a bigger impact on the outcome than a single component or may, if of poor quality, even outweigh the beneficial effect of a component. Previous research, although having improved in quality over the past 10 years, is still of limited value to support individual clinical decision-making and coverage and reimbursement determinations. Professional experience and skills of
clinicians as well as healthcare payers’ common sense of proportion is required to identify the best solution for an individual patient. Component manufacturers and professional associations must fortify their efforts to improve the body of evidence to create a valid base for clinical decisions as well as healthcare payer’s coverage and reimbursement determinations. About the Author: Andreas Kannenberg, M.D., is a Board Certified General Practitioner and Director of Medical Affairs for Ottobock HealthCare GmbH, Duderstadt, Germany. He received his medical council certification as general practitioner in 1995 and has clinical experience in general and family medicine, general surgery, dermatology, internal medicine, rheumatology, orthopedics, and rehabilitation medicine. He’s been a Director of Medical Affairs in the orthopedic industry since 2001 (since 2003 with Ottobock). Dr. Kannenberg was the winner of the AOPA 2010 Thranhardt Award.
“ A reminder of the energy and success of the Canadian Paralympic Team at the 2010 Olympics in Vancouver.” – Tessa Richardson, CP(c)
Golden Girl Lauren Woolstencroft Wins Five Gold at Paralympic Winter Games First published in Alignment 2010.
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Canadian para-alpine skier Lauren Woolstencroft made history by winning a record five gold medals at the 2010 Paralympic Winter Games, the highlight of an impressive showing for Canada’s ParaAlpine Ski Team in Whistler, British Columbia.
2013
She was dominant in her races, for example, crossing the finish line in the super combined, which pairs one super-G run with a slalom, with a combined time of two minutes 22.67 seconds to win by more than 12 seconds. Woolstencroft was born missing her left arm below the elbow as
well as both legs below the knees. “I am a competitor. I always want to race my best and it was a bit of a tricky course so I needed to ski a smart run,” said the 28-year-old Calgary native. “Obviously I’m super happy, and surprised, with the outcome,” admitted Woolstencroft. “I never thought I would actually win the five medals.” She described the biggest challenge at these Games to be that of staying focused on skiing her best day after day. “Each day I had to ensure that my only focus was that day’s race. That was mentally tiring,” she shared. “But I had great confidence coming in and I was
super prepared. I knew I had the potential but you never know what’s going to happen on the hill,” she acknowledged. In the 34-year history of the Winter Paralympic Games, there have been seven women to win four gold medals in a single Games, the last being Ragnhild Myklebust from Norway in cross-country and USA’s Sarah Hill in alpine skiing during the 2002 Salt Lake City Games. Woolstencroft joins swimmer Stephanie Dixon and athletics star Chantal Petitclerc as the only three Canadian women to earn five gold medals in a single Paralympics, winter or summer.
“Eye-opening article by experts in this area.” – Sandra Ramdial, CP(c), FCBC
The Diabetic Brain Awareness, Recognition and Management of Cognitive Impairment Co-Authored By Nancy Dudek, M.D., M.Ed., FRCPC and Krista Holdsworth, B.Sc., CO(c), FCBC First published in Alignment 2013. More than three million Canadians have diabetes. Diabetes occurs when the pancreas does not produce insulin, or does not produce enough insulin, or when the body does not effectively use insulin. A serious condition, diabetes can lead to a variety of complications 1.
Typically, when one thinks of diabetic complications the focus is on the increased risk of heart disease and stroke, renal failure, visual impairment and foot ulcer problems leading to amputation. Rarely discussed is its effect on cognition. However, there is a growing body
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of literature that describes central nervous system complications that result in cognitive impairment for some patients with diabetes2. Given the prevalence of diabetes in the patient population seen by prosthetists and orthotists, it is important for clinicians to be aware
SPECIAL FEATURES
of the potential for cognitive issues in these patients. Cognitive impairment is relatively common in many other patient populations seen by the prosthetic and orthotic (P&O) practitioner... for example, vascular disease, traumatic brain injuries, stroke, developmental delay, dementia, multiple sclerosis, etc. The use of a prosthesis and/ or orthosis can be cognitively demanding. As a result, it is important for the clinician to consider the possibility of cognitive challenges when working with these individuals. Cognitive dysfunction is not always easily identifiable, as social conversation is often preserved. Subsequently, P&O practitioners may increasingly be required to recognize signs of cognitive impairment as it relates to their patients. The practitioner needs to develop an awareness of cognitive impairment with an understanding of some basic approaches to managing such limitations within the realm of their practice. When considering the amputee population, the importance of cognitive abilities is quite clear. Research suggests that the most significant predictor of successful prosthetic use is cognitive function 3,4. More than 50 percent of all amputees with PVD (peripheral vascular disease) will have significant cognitive deficits5,6. Cognitive impairment is also common in the geriatric population. Of those aged 65 years and older, 25 percent will demonstrate cognitive dysfunction. This number increases to 65 percent when looking at individuals over the age of 855. Clearly it is critical to identify cognitive deficits. How does the practitioner determine this? Some signals that may indicate cognitive impairment include any of the following: 1. Difficulty providing details of medical history.
2. Difficulty maintaining focus during the assessment. 3. Attention problems. 4. The inability to complete a threestep command. 5. Difficulty orienting the prosthesis/orthosis. 6. Slow to learn how to don/doff the prosthesis/orthosis. 7. Presenting to the clinic with unrecognized skin problems or device problems. 8. Difficulty following up on issues. When performing an assessment, some clues may lead the prosthetist or orthotist to suspect the presence of cognitive issues. These may become apparent as the interview progresses. As an example, when the patient is asked questions, their caregivers may answer for them, suggesting that the patient is unable to answer promptly and correctly on their own. Another clue to the possible existence of cognitive dysfunction may be in the inability of the patient to tell their story themselves. Asking the patient to follow a three-step command may give you an indication of their cognitive processing ability. If the patient is unable to don or doff the prosthesis or orthosis properly, the practitioner may also suspect a cognitive functioning problem. Pointing out these concerns to the patient and their caregivers is essential as the family may be unaware of the situation. It is always relevant to get the family’s perspective on this issue. They may offer insight, such as a new medication just being started, or fatigue from a new medical condition. Both of these could explain deterioration in cognitive performance. In these situations, a new strategy may be required to enable the patient to consistently use their prosthesis or orthosis successfully, without causing associated prob-
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lems such as skin breakdown. There are some circumstances where the use of a prosthesis or orthosis can actually increase the risk of injury due to cognitive impairment. In these situations, an assistive device should not be used. If this situation presents itself to a certified practitioner, the patient should be referred back to the prescribing physician with the concerns outlined. In summary, cognitive impairment is common within the P&O population yet not often recognized. It is important for the P&O practitioner to educate caregivers regarding the use of the prosthesis or orthosis so that they can assist patients with cognitive issues in their home environments. As well, keeping the management of prosthetic and orthotic care simple and consistent for the cognitively-impaired patient will also be helpful. Finally, if you are noticing cognition problems in a patient that have not been previously noted, let the patient’s referring physician know. They may be unaware of this change in cognitive ability and pursue a cognition assessment for their patient. This is important as some types of cognitive impairment can be improved with proper diagnosis and treatment. References: 1. Canadian Diabetes Association. Diabetes Facts. www.diabetes.ca. 2. Wrighten SA, Piroli GC, Grill CA, Reagan LP. A look inside the diabetic brain: contributors to diabetes-induced brain aging. Biochimica et Biophysica Acta 2009; 1792:444-453. 3. Schoppen T et al. Physical, mental, and social predictors of functional outcome in unilateral lower-limb amputees. Archives of Physical Medicine & Rehabilitation 2003; 84:803-811. 4. Larner S, van Ross E, Hale C. Do psychological measures predict the ability of lower limb amputees to learn to use a prosthesis? Clinical Rehabilitation 2003; 17:493-498.
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2017
5. Waldenstein SR et al. Peripheral arterial disease and cognitive function. Psychosomatic Medicine 2003; 65:757-763. 6. Phillips NA, Mate-Kole CC, Kirby RL. Neuropsychological function in peripheral vascular disease amputee patients. Archives of Physical Medicine & Rehabilitation 1993; 74:1309-1314. 7. Graham JE et al. Prevalence and severity of cognitive impairment with and without dementia in an elderly population. Lancet 1997; 349:1793-1796.
About the Authors: Dr. Nancy Dudek is an Associate Professor in the Faculty of Medicine at the University of Ottawa. She has a diverse clinical practice and works at The Rehabilitation Centre, the Ottawa Children’s Treatment Centre and the Children’s Hospital of Eastern Ontario. She focuses on amputee rehabilitation, prosthetics, orthotics and neuromuscular medicine. Currently the Director for the Physical Medicine & Rehabilitation Residency Program
at the University of Ottawa, she has been an active volunteer for CBCPO as a past examiner and currently as the Canadian Association of Physical Medicine & Rehabilitation representative. Krista Holdsworth, B.Sc., CO(c), FCBC, holds her Degree in Kinesiology from the University of Waterloo and is a certified orthotist with 35+ years of experience. She is co-owner and Director of Orthotic Services at OrthoProActive Consultants Inc. with clinics in Markham and Newmarket, Ont.
“ This article shares the thoughts of subject matter experts from various fields in regards to how 3D printing technology should no longer be ignored but rather embraced by the P&O community.” – Krista Holdsworth, B.Sc., CO(c), FCBC
3D Printing Technology Impact & Effect on O&P Practice By Jeff Tiessen, Alignment Publisher First published in Alignment 2017. An abridged version appears here. For the full article, with first-hand perspectives from clinicians, technicians, engineers, researchers, educators, scientists and facility owners, and for more information on the Advancing Digital Practice in Prosthetics and Orthotics Consortium, visit www.opcanada.ca.
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When it comes to the prosthetic and orthotic (P&O) profession, it has been tempting to dismiss 3D printing, also known as additive manufacturing, as the province of “basement engineers” looking to ply a hobby into a helpful prosthetic hand with futuristic-looking fingers for the little boy up the street with just one arm. But for P&O, 3D printing is no longer the exclusive domain of the well-intentioned, home-based “limb maker” or school-situated, academically-anchored philanthropic project. Its potential for more practical and clinical applications cannot be denied. Made for media, the proliferation of stories about goodwill 3D-printed prostheses were hard to miss in recent years. “High-school girl expands her grasp with 3D-printed hand… high-school technology teacher creates a 3D-printed prosthetic hand with fingers for a 17-year-old student born with only a thumb and a partial middle finger on her right hand. The girl is learning to write with the hand and can now grasp bottles, books and her cellphone.” “Ryerson Biomed Students Make Prosthetic Hand for a Farmer… students in the Biomedical Sciences program at Ryerson University, Toronto, have created a 3D-printed prosthetic hand for a patient at St. John’s Rehabilitation Hospital who wants to continue farming after a trans-radial amputation. The prototype developed by the Inspire Motion team weighs one kilogram, has five articulating fingers, and is said to be durable and easy to use. The design costs less than $20 to fabricate, includes flexible and rigid 3D-printed plastics, and LED lights that are wired to the fingertips, and fastens below the elbow and near the wrist. The students prepared the arm for control with a circuit to measure muscle contractions us-
ing electrodes. When [the patient] contracts his bicep, his hand will close, and when he relaxes, it will open.” “Student apprentices at the University of Ottawa’s Entrepreneurship Hub partner with Ottawa’s The Door Youth Centre to make 3D-printed prosthetic hands for youth abroad. The Give Us A Hand Project aims to create affordable, 3D-printed prosthetic hands, and to send them overseas to persons in need. The project also gives local youth in Ottawa the ability to create, while at the same time gaining advantageous skills in 3D printing… giving ‘hands-on skills in hand making’. Help our project by making a donation! All donations will go towards buying new materials and helping us to create as many 3D-printed prosthetic hands as possible.” These initiatives are not to be dismissed or demeaned. They are admirable in their efforts and intentions. What they lack is clinical acumen. To that end, a group of experts in the Toronto area has formed to bring together insights from different backgrounds and professional areas to better understand how Canada’s prosthetic and orthotic (P&O) profession can work with this technology to bring better solutions for patients and clients. Not only clinicians from P&O facilities, private and public, are represented in the consortium, but researchers, educators, 3D manufacturers and other healthcare professionals are part of the group, working together to share varying perspectives, collaborate on a strategic direction for the P&O field which includes education, a communication component, and funding research. Arguably, the 3D Consortium has its roots in a pet project of orthotic facility owner Michael Pecorella, CO(c). Explains Michael’s son Daniel Pecorella, CO(c), who works with his father
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at family-run Toronto Orthopedic Services Limited, “my dad has been trying to understand how 3D printing will impact our profession for a number of years. After meeting with 3D printing expert Dr. Matt Ratto at his University of Toronto research lab, and sharing with him our prototype 3D-printed AFO, there was a commitment to collaborate as opposed to isolate.” It was that meeting that gave life to the idea of creating a consortium to investigate the impact that 3D printing has on the P&O profession in a collaborative way. “At the time, I had no idea what a consortium was,” admits Pecorella, “but I offered to invite those I knew from the field who might be interested in being part of it.” The consortium’s mission began as a rough draft, to glean input from all members on its statement and purpose. “We knew we wanted to work with professionals from all industries related to 3D printing to come up with best practice guidelines for the O&P industry specifically and to educate our profession on what those are,” Pecorella shares. Early meetings were about getting to know and understand one another, and what P&O practitioners do with their clients from assessment, rectification, cost-analysis, material evaluation, etc. in the fitting and fabrication process. It was a case of educating members about each other’s work, and determining how they could work together. “We don’t want individuals outside of our industry dictating to our clinicians how P&O 3D printing will be used in our profession. Let’s understand this beast before it takes control of us.” Pecorella continues, “most see 3D printing as having the potential to transform our profession. If we don’t understand how to work with it, it may have the potential to undermine us, generally speak-
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ing of course.” Pecorella says it all really hit home for him at the ISPO Canada conference in listening to researcher Jon Schull who runs an e-NABLE Chapter in Rochester, New York. Schull received a 3D-printed hand template by email and in turn put it online. Immediately people with access to 3D printers gravitated to it in a charge to make hands for children in need all around the world. But there was no collaboration or validation with the P&O industry, “which was off-putting to a lot of people in the room,” remembers Pecorella. “It was a gut reaction from the audience… how someone could just come in and begin making prosthetic devices.” But what moved Pecorella was Schull’s revelation of his number of “affiliates” reaching 6,500 in just a matter of months. “That’s how fast some-
thing like this could undermine our profession,” he warns. “Schull and e-NABLE did nothing wrong. It was charitable what they were doing. It’s difficult to fault them for that. It’s just one of those things that went viral, but ‘what would be the ramifications?’” he thought to himself. Ratto sees a place for e-NABLE’s efforts, but in concert with the clinical expertise of the P&O practitioner. “e-NABLE is good for kids who otherwise wouldn’t be fitted,” he supports. “There is a huge variety of prosthesis users and we have to admit that the current system, no matter where we are, doesn’t serve everyone equally. There are always patients that are poorly served.” One demographic that Ratto points to, where 3D printing would assimilate into the developed world context, is those with
a cardiovascular condition or diabetes… “a foot gets amputated and the patient is bedridden for x amount of time because no one really wants to fit them with a prosthesis until the vascular changes have slowed down. Being bedridden, means blood sugar is not being controlled, and cardiovascular health is declining – but it doesn’t make sense to spend the time to fit them with a prosthesis that within six weeks or so isn’t going to fit them anymore. With a quickly-produced 3D prosthesis, which may not be as good as one that takes 40 hours to make conventionally in the clinical setting, would serve their needs for physical rehabilitation. These are the edge cases that I think as being a good fit for 3D printing.” “What e-NABLE showed is that 3D printing for prosthetic devices is not an evolution; it is a revo-
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lution,” says Pecorella. “That’s how fast a new technology can transform an industry. If we let that transformation dictate to us how things are going to go, I don’t think that is good for our field. But if we are ready for it, and acknowledge and understand what is coming, and incorporate it into our practice with best practice guidelines and collaboration from all parties involved in the 3D printing process, I believe our industry will benefit.” Pecorella says it’s hard to say if the P&O industry will embrace 3D printing technology, but feels that right now it’s safe to say that it is out of reach for many practices unless they want to dedicate a considerable amount of time and resources to experimenting with it. “That’s what we have done. My dad is semi-retired so he’s had some time to work on it, research
it, and develop our knowledge and understanding of its application. We outsource our projects; we don’t have a 3D printer in our clinic.” At this point additive technology is having a limited impact in the P&O field, maybe more hype than substance. As the technology develops and becomes more accessible to practitioners, adoption may increase but this will depend on how advantageous it is shown to be over existing methods (i.e. cost reduction, better quality, better work flow, etc.). Too little information currently exists about the advantages, requiring research and costing studies to be undertaken. Resistance to the new technology comes from high capital costs, assurance of safety, performance and quality, but also the belief by some established practitioners that their skills
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and roles may become obsolete. “There is research that needs to be done,” assures Pecorella, “comparisons with laminations and vacuum-moulding processes in terms of strength and durability, for example. There are different methods of 3D printing, and different materials used, and each yields a different strength of material. These are things that the consortium will be exploring.” About the Author: Jeff Tiessen, president of Disability Today Publishing Group brings 40+ years of experience and insights into amputation and disability into all of his company’s titles, be it magazines or books. Tiessen launched thrive magazine several years ago for Canada’s limb loss community. He has been the publisher of Alignment for 10 years.
2017
SPECIAL FEATURES
“ Solid case study exploring challenges of emerging technology from a clinican’s prospective.” – Neil Ready, B.Sc., CPO(c)
Wrist-Driven Paediatric Partial Hand Prosthesis A Collaborative 3D Printing Solution By Dan Mazur, B.A., CPO(c) and Matthew Gale, C.E.T. First published in Alignment 2017. An abridged version appears here. For the full article, with information on the technology, design, components and challenges, visit www.opcanada.ca.
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There have been many stories in the media over the past year about very inexpensive 3D-printed prosthetic hands and how they have been revolutionizing prosthetic care in both the developing and developed world. Many clinicians have expressed the view that this is a disruptive new technology but there have been a number of cases exploring the potential of this technology. Our team at RCC (Rehabilitation Centre for Children) in Winnipeg undertook a case study in this area to try and answer the following questions: How do these devices actually function? What is the true cost to produce the devices? What value does additive manufacturing provide in the provision of prosthetic/orthotic care? This case study details the design, fabrication and fitting of a custom, partial hand prosthesis for a paediatric amputee. The client is a 10-year-old boy with left congenital partial hand amputation of the index, middle, ring and small fingers. He has a hypoplastic left thumb but is able
to oppose the first and second metacarpal head, and grasp small objects in the web space between the thumb and first metacarpal. Fine motor tasks are easily completed without a prosthesis but our client has expressed frustration in his inability to grasp larger objects and complete bimanual grasp activities. The client currently uses a passive silicone prosthesis for cosmesis and an activity-specific hockey prosthesis but does not typically use a device for activities of daily living. Goals for the new prosthetic device included: • Active digital movement • Simple and effective control and suspension • Anatomically-appropriate finger size and position • Preservation of sensation in the palm • Ability for threepoint pinch and power grasp • Durability and low maintenance • Cool robotic look! A review of this project concluded that we were able to produce a device and provide functional grasp through an iterative design process. While the cost associated with this technology was less than some
commercially-available componentry, it was far more than the modest costs proposed by the media once all direct and indirect manufacturing and treatment services are included. Overall, collaboration with a certified engineering technologist was an excellent learning experience and exposed the great potential of additive manufacturing for customization of design, material, colour, strength, and cosmesis to address client preferences and needs. However, when it comes to clinical service provision, prosthetists and orthotists are the subject matter experts with the ability to drive an iterative CAD design process. There is a necessity to seek out authentic partnerships to support innovation with this new technology. About the Authors: Dan Mazur, CPO(c), is Director of Prosthetics and Orthotics programs at the Rehabilitation Centre for Children in Winnipeg, Manitoba. He is a graduate of the clinical program at George Brown College and is currently completing a Masters of Rehabilitation Sciences degree through the University of British Columbia. He has a keen interest in emerging technologies and has started to implement the use of CAD CAM and 3D printing into routine clinical practice and research activities. Matthew Gale is a Certified Mechanical Engineering Technologist (C.E.T.) with eight years of experience in design, manufacturing and 3D printing in the medical and aerospace industries. He was employed at Precision ADM as the Manager of Application Engineering at the time this project was carried out, but now works at the Rehabilitation Centre for Children as a Clinical Technologist and Research and Design Coordinator of the new R&D division of RCC Rehab Engineering Programs.
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2016
SPECIAL FEATURES
“ Wisdom is passed to P&O clinicians from the now-retired Don Weber, highly regarded Certified Orthotist in Ontario and Clinical Instructor at George Brown College.” – Andrew Lok, CO(c)
Tried, Tested and True Maximizing Outcomes via the Patient-Practitioner Relationship In Conversation with Don Weber, CO(c), FCBC First published in Alignment 2016.
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Q: A simple question to start. Did your approach to interpersonal relationships with your patients evolve over the course of your career? A: Yes. I came to understand that listening and compromise were keys to successful outcomes. At the beginning of my career, when I was fresh off the “certification train”, I would tell people exactly what they needed. After many years of experience my approach transformed from telling to listening, from dictating to compromise. Q: How did that shift manifest in your work? A: I’m known for my use of biomechanics to create new designs. The challenge of the profession for me shifted toward meeting the more holistic needs of the patient which demanded a compromise from purely biomechanical design. Patient assessment in the clinic can be very hurried, but pausing to listen to the patient’s perceptions of what the problem is, and what their ideal goals may be, is pure gold in terms of information gathered. They live with their physical, mental and emotional issues every day. Understanding where they are coming from helped me communicate the best approach for treatment... not just the optimum design of the device but also the acceptance of its use. Listening to the patient does not preclude a thorough assessment. This is where our skills and experience lead to our ideas for optimum design. But, an understanding of where the patient is coming from is essential for mapping out the future treatment plan. Q: In keeping with the physical, mental and emotional issues that can be associated with a disability, how have you navigated
those challenges while working to provide what you as the practitioner deem to be the best device for them? A: A good opening question for the patient is always: “What are you here for?” You not only find out a lot of background medical history but you also begin to develop a rapport with the patient that says “I am here to work with you on this, to meet your needs. I am on your side.” An important point to mention is that your communication with patients who have more severe physical and/or mental disabilities is equally imperative. My lesson was learned while participating in a swimming program with two teenage girls with severe athetosis. Both of normal intelligence, verbalizing their thoughts was very difficult for these girls which resulted in muscular contortions in their faces and bodies when they tried to speak. I would continually have to educate new volunteers who would assume that the girls were mentally inferior due to their physical appearance, and speak to them in that way. The take home message: treat all patients as if they have normal intelligence no matter how they present physically and you can’t go wrong. Q: What do you do when there is a significant divergence in your prescription and the ideas that the patient has for their device? A: Patients’ knowledge of what is needed covers a wide range, from a very detailed understanding to no idea at all of why they are there. Rather than a confrontational demand for my design, I like to lay out the range of possibilities with their pluses and minuses for function and long-term results. Allowing some choice goes a long way in terms of coming up with a mutually
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agreeable solution. Creating an opportunity for compromise with a range of possibilities promotes acceptance and compliance. An example would be in the types of shoes to be worn with the orthosis – a shoe that functions better with the orthosis versus a stylish more cosmetically-acceptable shoe. The compromise may be presented like this: “Let’s use the AFO in a running shoe now to see if it [orthosis] works in the ideal environment and then let’s investigate its use in a dress shoe in the future. Wear your dress shoes without the AFO for the formal part of the wedding ceremony. When you want to dance at the reception slip on the AFO with the running shoes and go for it.” Letting the patient know that orthotic treatment is a process open to change in the future and that on special occasions exceptions can be made is very useful for helping them accept the new situation. Q: And what about the patients who flat out resist your device... the “stubborn” ones let’s say? What then? A: It’s a fact, compromise for the patient’s needs is not always possible. When they decide that they can’t accept what you offer you need to respect their decision. I always leave the door open to come back and see me if their thoughts or situation changes. I still emphasize that “I’m on their side” which can make all the difference in resolving difficult problems which may develop down the road. Q: What you’ve shared seems most relevant to the adult patient. How about with children? Same or different approach? A: When working with children you need to develop two relationships: one with the child and the second with the parents. Back-
SPECIAL FEATURES
2014
ground information can come from the parent but establishing a good rapport with the child is crucial. I make a point of greeting the child first before the parents, making direct eye contact, calling them by name, asking about their special interests, playing games with them... just having fun. If there are behaviour problems, the best source of information to deal with that situation is the parents. Their help and experience with the child is invaluable. Make sure you involve them. My mantra: “You cannot spoil a child enough to gain their compliance during the appointment.” If they need stickers, sweets, toys, etc. then make the effort to provide that and follow through. In my experience, when assessing and casting a child, letting them see what you are doing results in better compliance. Also, avoid having to physically hold the child down if possible. This does not lead to a good relationship and will not
be possible for an older, stronger child. Q: Staying with the younger set, and like your adult patients as well, each comes with their own personalities. Does that impact treatment? Do you categorize a particular personality type and proceed accordingly, and with caution in some cases!? A: I tend to classify children into two personality types... the shy and fearful child are those who are easier to engage and distract with games and conversations. Once you have their attention and trust, casting and assessment will be facilitated. The outgoing or rebellious child – the “don’t touch me” type who actively fights you – is another kind of challenge. If all attempts at developing a rapport with the child have failed, then enlist the help of the parents to deal with the behaviour. Once I have reached
this stage of non-compliance with the child I typically avoid making eye contact which usually stimulates more bad behaviour. I then concentrate on completing the assessment and casting as efficiently and accurately as possible. But keep working on making that connection with the child and after two to three appointments, children will often look forward to seeing you. About the Interviewee: Don Weber CO(c), FCBC, retired in 2015 from the Prosthetics and Orthotics Department, Hamilton Health Sciences Hospital, Hamilton. He was a Clinical Instructor in the Prosthetics and Orthotics program, George Brown College. For more from Don visit www.webernotes. squarespace.com.
“Innovative take on a very common pathology seen by orthotists.” – Neil Ready, B.Sc., CPO(c)
Walk This Way Paediatric WalkAide System... the preferred alternative to bracing By Nolan Hayday First published in Alignment 2014. An abridged version appears here. For the full article, and all of the system’s kid-friendly features, visit www.opcanada.ca.
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Since its introduction, candidates for this Functional Electrical Stimulation System were mainly those living with multiple sclerosis, traumatic brain injury, stroke, incomplete spinal cord injury, and hereditary spastic paraplegia. Now, add children with CP to that list. The use of the WalkAide System in treating children with cerebral palsy (CP) is becoming more common and more research is providing evidence that the WalkAide System is a viable option. The device is an advanced Functional Electrical Stimulation (FES) System for the treatment of foot drop caused by upper motor neuron injuries. Paediatric WalkAide clinical evidence has highlighted acceptance, preference and kinematic improvements. At the 65th Annual Meeting of the American Academy of Cerebral Palsy Developmental Medicine in 2011, researchers from the National Institutes of Health (NIH) presented a study that demonstrated how the WalkAide System successfully improves mobility by significantly increasing ankle control during walking in children with foot drop due to CP. This is the first study to present the group results of a commercially-available foot drop stimulator in children with cerebral palsy. Participants in this study experienced increased ability to dorsiflex their feet. Participants also continued to experience improvements after four months of use compared to one month, suggesting improved response to the WalkAide’s functional electrical stimulation over time. This is a finding that would not be expected with conventional orthotic bracing such as the ankle foot orthosis (AFO). Additionally, when given a choice between the WalkAide and their previous
Silicone cover – a great option for additional protection.
Customized strap – a great way to get young patients engaged in their WalkAide!
treatment protocol (an AFO or no device at all), 95 percent of the children in the study chose to continue with the WalkAide, which is encouraging given the challenge of compliance with AFOs in this population. “While we are fortunate to see firsthand how the WalkAide improves the lives of our patients every day, it is very encouraging to see additional documented validation of the efficacy of our technology – especially when it comes out of the NIH, a world-renowned medical institution known for quality, integrity and clinical excellence,” said Aaron Flores, Ph.D., general manager of
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Innovative Neurotronics, the firm that developed the system. About the Author: Nolan Hayday is a WalkAide Advisor with The Knee Centre in addition to his role of business manager at Karl Hager Limb & Brace in Edmonton, Alberta. Nolan was first introduced to the WalkAide System in 2006 and has been involved in expanding the system throughout Canada since 2007. He initially provided training support but is now a WalkAide System instructor.
2014
SPECIAL FEATURES
“The latest technology – child size!” – Krista Holdsworth, B.Sc., CO(c), FCBC
Leaps and Bounds Helping children walk more naturally with the Bioness Paediatric Foot Drop System By Nathan Foreman, PT, MPT First published in Alignment 2014. An abridged version appears here. For the full article visit www.opcanada.ca. 40
Cerebral palsy (CP) is the most frequent neurological diagnoses seen by clinicians who serve the paediatric patient population. Of those cases, 23 to 40% present with hemiplegia. The most common gait impediment for children with hemiplegic CP is foot drop or poor foot clearance during swing phase, which may limit ambulation and balance performance. For children affected by foot drop, Bioness has announced the availability of the award-winning L300® Foot Drop System. Designed to help children walk more naturally and increase muscle strength, the Paediatric L300 became the first FDA-cleared neurostimulation system for children with foot drop as the result of neurological conditions such as cerebral palsy, stroke, traumatic brain injury and spinal cord injury. The Paediatric L300 has three main components: a slim, ergonomic leg cuff worn just below
the knee, a small wireless sensor in the shoe, and a hand-held, wireless remote control. These three components use a digital, wireless signal to communicate information on gait cycle events and stimulation parameters to each other. When a child initiates a step, the L300 sends low-level electrical stimulation to the peroneal nerves of the lower leg, which recruits the muscles responsible for lifting the foot. The stimulation is delivered through convenient “quick fit” textile electrodes in the cuff, or electrodes that can customize the motor response by position. By lifting the foot at the appropriate time every gait cycle, children may walk with improved speed and reduced fatigue. The system’s adaptive gait sensor algorithm reliably senses foot position during walking, and automatically adjusts to changes in speed, terrain, inclination and direction. This can provide children with increased
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independence and confidence to engage in activities alongside their siblings and friends. About the Author: Nathan Foreman, PT, MPT, is the Manager of Clinical Education for Bioness Inc. Nathan has 10 years experience working with the neurological patient population including time at The University of Texas Southwestern Medical Center at Dallas, where he was an educator, treating therapist and researcher. His area of clinical expertise is gait training and assessment associated with neurological pathologies and conditions and clinical research development. Nathan has experience teaching in areas of gait rehabilitation and electrotherapy in neurorehabilitation.
2016
SPECIAL FEATURES
“ This article provides relevant information and best practices of how clinicians should instruct and educate their patients.” – Andrew Lok, CO(c)
Health Literacy We Can Make a Difference By Tedi Brash, CO(c) First published in Alignment 2016. An abridged version appears here. For the full article, and quick, easy-to-do strategies that will start you on your way, visit www.opcanada.ca.
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Until recently, “health literacy” was not on my radar. I knew there was a gap between the information I was providing and the results I was seeing clinically, but I had no name for it. I questioned my teaching abilities when instructions weren’t followed or were incorrectly executed. I refused to believe that my patients were solely to blame. No, there was more to it than that. So what was it and how could I make it better? To find the answers, I began a journey into patient education and experienced the “ah-ha” moment when I realized how intimately a patient’s health literacy level is tied to their clinical outcome. Health literacy is defined as the ability to find (or access), understand, evaluate and use health information to enhance one’s personal care.
Sounds easy enough, but when we look at the numbers, the reality of its impact is staggering. Upwards of 60% of Canadians have difficulty understanding health information and hence, cannot effectively evaluate or use it to enhance their care. In our senior population, this number rises to 88%3. And that’s on a good day. Difficulties increase across the board when under stress, unwell, fatigued, or for a whole host of other reasons, and understanding may fluctuate significantly from moment to moment. Add in the complexity and uniqueness that is inherent to the world of prosthetics and orthotics and I would hazard to guess that the health literacy challenges rise even higher. So how do we combat this potential barrier to success? We can partner with our patients to
advance their understanding. We can customize the information we provide to each patient so that it is easy to understand and directly applicable to their specific situation. If we work to enhance their health literacy skills, we will give them a far greater chance for success. The intricacies of health literacy are far reaching and involve all facets of healthcare provision. The content of this article is a surface view with a lens on what we, as prosthetists and orthotists, can do today to make a difference. Enhancing health literacy is not an impossible journey: quite the contrary. We are constantly providing our patients with information, whether we realize it or not. So let’s maximize these opportunities, and in doing so, fight the health literacy battle. By making a few small changes, we can exponentially increase our patients’ understanding of their care and in doing so, set them on the path to success. We can do this, I know we can. Is your curiosity sparked? Included in the article are some resources that will help you with your efforts to enhance health literacy. It is by no means an exhaustive list but it’s a start. About the Author: Tedi Brash, B.Sc., MISt., CO(c), is presently working as an Information Specialist for Patient & Family Education at University Health Network. Combining both her health and library backgrounds, she helps staff, patients and families find quality, patient-centered health information. She has a keen interest in health literacy and patient education and feels that P&O can be a leader in this area.
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2017
SPECIAL FEATURES
“ This article discusses the importance of why P&O clinicians should involve themselves with 3D printing technology before other fields encroach.” – Andrew Lok, CO(c)
3D Printing is Coming to Our Clinics The Question is… ‘Who’s Bringing It?’ By Brittany Pousett, CP(c), M.Sc. First published in Alignment 2017.
3D printing has become a hot topic in the world of prosthetics. In the last few years, the news has been filled with stories of groups who are exploring the application of 3D printing techniques to the field of prosthetics. These stories often seem to involve university students, hobbyists, engineers, designers and others outside of the prosthetics and orthotics community who, just like us, are eager to use their skills to help people. Several of these groups are using 3D printing to help increase access to prostheses in the developing 44
SPECIAL FEATURES
world while others are using it to provide lower cost options to patients who can’t afford them. Now that 3D printing is gaining more publicity, many of our patients have begun to ask us why we don’t use 3D printing in our prosthetic clinics. As professionals who are responsible for our patient’s safety, we have valid concerns about the strength, reliability, comfort and durability of using a new method of manufacturing. But, while many might think of 3D printing as a new technology in the world of prosthetics, it actually started in 1990, when a group from Northwestern University’s Medical School was experimenting with using rapid prototyping methods to make prosthetic sockets [1]. Since then, groups from all over the world have explored
the application of 3D printing to prosthetic devices. One of these groups is a pair of certified prosthetists in the U.S. who are successfully using this technology in their practice. They’ve found this technology to have benefits when used to make diagnostic sockets for their patients (http:// www.additiveoandp.com/home. html). Barber Prosthetics Clinic was inspired to see it for ourselves. We didn’t want to overlook a valuable addition to our repertoire of manufacturing methods if it could provide us and our patients with some benefit. This led us to purchase our own 3D printer and begin printing sockets in our clinic. Many people outside of the field of prosthetics believe that 3D printing is as easy as scanning
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a limb and pushing the print button on a 3D printer. It’s not that easy! In order to create sockets that are suitable for patient use, there are a number of decisions to be made regarding the structural design of the 3D-printed socket, the printer parameters, and more. If we, as certified prosthetists, don’t get involved in the development of this technology from the beginning, others will continue to develop it for us and continue to introduce the idea to our patients. That is why Barber Prosthetics has committed to being involved in the research behind 3D printing socket technology. As certified prosthetists and registered technicians, we bring an expertise to the design, manufacturing and fit of prostheses that no one else can. We need to be involved in conducting the research to apply our expertise and shape the objective science behind this technology in order to determine if it is safe and suitable for our patients. If the research shows that it is suitable, we need to lead the way in demonstrating how this technology can be successfully implemented into our clinical practice in a way that complements the traditional way of doing things. This brings us to the first limitations we want to address – how strong are 3D-printed sockets? At first glance, they appear to be quite strong – but how do you know for sure? This is the most significant limitation we have encountered when exploring new socket materials as there is no standard on how strong they have to be to be used by our patients outside of our clinics. To address this need, we partnered with a team from the British Columbia Institute of Technology and a Biomedical
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Engineering student from Universidad Iberoamericana in Mexico City. Together, we are working on applying the ISO standard of lower extremity prostheses to socket strength testing in order to compare the strength of conventionally-fabricated sockets to those printed with 3D technology. We are in the midst of testing but are excited to share the results. Stay tuned for more information on if, and how, 3D-printed sockets could become part of your prosthetic treatments in the future! About the Author: Brittany Pousett, CP(c), M.Sc., is a certified prosthetist and the Head of Research at Barber Prosthetics Clinic in Vancouver, B.C. She has a Bachelors of Science in Biophysics from the University of British Columbia and a Masters of Science in Rehabilitation from McMaster University. Pousett is passionate about integrating research into clinical practice in order to provide her patients with evidence-based care.
2013
CLINICAL TEAM
“ Chronic wounds can change the treatment plan for our patient population. Knowing who/when to refer on is an important part of the process.”
TEAM
– Krista Holdsworth, B.Sc., CO(c), FCBC
Together Everyone Achieves More
A Team Approach to Wound Prevention and Management By Linda Norton, OT Reg. (ONT), M.Sc.CH – National Education, Shoppers Home Health Care Faculty: University of Toronto, International Interprofessional Wound Care Course Patricia Coutts, RN – Toronto Regional Wound Healing Clinics Faculty: University of Toronto, International Interprofessional Wound Care Course First published in Alignment 2013. An abridged version appears here. For the full article, and which professions comprise the wound care team, visit www.opcanada.ca.
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CLINICAL TEAM It takes a village to treat a chronic wound. A chronic wound is one that does not progress to healing at the expected rate. Almost any wound can become chronic, however, common chronic wounds can include neuropathic foot ulcers, pressure ulcers, leg ulcers, and diseases such as Epidermolysis Bullosa (a genetic skin disorder causing blistering and shearing of the skin). Due to their chronic nature, and the multitude of factors that impact wound healing, no one is positioned to impact wound healing without the assistance of other team members. This team includes the patient, family, and various healthcare professionals. In Canada, best practice guidelines are based on the Wound Bed Preparation paradigm. This model suggests that the causes of the wound must be treated, patient-centred concerns addressed, and the local wound care optimized before the wound will go on to closure. For individuals with neuropathic foot ulcers, treating the cause includes things such as pressure offloading through the provision of custom footwear, custom orthotics, total contact casting, gait analysis, provision of mobility devices such as ambulation aids, scooters or wheelchairs, etc. Addressing patient-centred concerns can include finding funding for offloading devices, ensuring the dressing routine fits within the client’s lifestyle, ensuring the treatment approach fits within the client’s cultural preferences, addressing discomfort and/or wound odour, etc. Local wound care includes a thorough assessment, debridement when appropriate, choice of dressing, and adjunctive therapies. Reassessment is a key factor in the evaluation of progression to closure and should be done at regular intervals. A minor reassessment should occur at every
dressing change to monitor changes, and a full reassessment every 2-4 weeks depending on the setting and client. Based on the results of these reassessments, changes to the treatment plan can be made. Finding a team of healthcare professionals with a common goal can be a challenge in some settings. It’s important to recognize however, that teams do not need to be formed within one organization or facility – it is possible to have a team without walls. This could be a referral network between various professionals who share an interest in treating people with neuropathic foot ulcers or it could be a community of practice. Wenger defines communities of practice as “groups of people who share a concern or a passion for something they do and learn how to do it better as they interact regularly.” Regardless of who is on the team, Carrol and Keller suggest that the healthcare team must engage, empathize, educate and enlist the client. Engaging the client involves finding out about the person and who they are beyond being a person with a wound. Empathizing is demonstrating a true understanding of the client’s concerns and how the wound may be affecting their life. Empathizing is different than sympathizing as the latter involves feeling sorry for another person rather than truly understanding their perspective. Then the healthcare professionals provide education for the client so that they are able to make informed choices about their treatment plan. This education may include how to appropriately apply the offloading device, care instructions, and discussion of the benefits and challenges with using a particular device. Finally, the healthcare providers enlist the client and gain commitment to the treatment plan. Communication is a central
component to any team. Whether communicating by the written word, electronically, or in person, it is important that all involved in the care, including the patient, understand the end goal whether that be the healing of the wound or the possibility of amputation. As healthcare providers we need to recognize the impact that the chronic wound has on both the individual and their family financially, psychologically and physically. Another component of communication is the need for a common language about wounds that is understood by all of the team members. As healthcare providers we need to be consistent with the communication to the client as to the type of wound they have – healable, non-healable or maintenance. By classifying wounds in this way, the entire team works towards the same goals. If we are speaking or understanding a common wound prevention and management language, then education for the patient is more effective. As was stated at the beginning of this article, “it takes a village” to treat a chronic wound and as a TEAM, together, everyone accomplishes more which benefits the patient and the healthcare professional in the end.
Patricia Coutts, RN
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2012
CLINICAL TEAM
“ Comprehensive patient management is achieved by working collaboratively with our colleagues from associated professions. Remembering this makes us all better practitioners!� – Krista Holdsworth, B.Sc., CO(c), FCBC
Personal Tool Chest Minimal Essentials for Maximal Results in Prosthetic Gait Training By Shirlene Campbell, B.Sc., P.T., MCPA First published in Alignment 2012. An abridged version appears here. For the full article, and the analysis tools at the disposal of all practitioners, visit www.opcanada.ca. When it was suggested that I write about essential tools for prosthetic gait training, I thought of the variety of environments in which I have treated clients, and what was available on a consistent basis. The only common elements were the presence of the client, the prosthetist, and/or me. And I realized, therein lay the essential tools. Everything else is a bonus.
The most valuable tool we possess for gait training as clinicians is knowledge, supported by our eyes, hands, ears and voice. The client also possesses these tools, but we must first provide him/her (hereafter the client is referred to in the male gender for simplicity) with the tool of knowledge so he can best employ his other tools. A cell phone and a mirror are 52
also valuable. When both the prosthetist and the physiotherapist (physio) are available to work together with a client during the gait training process, these tools can be maximized to achieve optimal outcomes. Although technology is becoming more readily available for quantitative gait analysis, it is costly and not available in most clinics. Therefore, clinicians continue to rely on a visual gait analysis. Interestingly, even though both the prosthetist and the physio are taught how to do a gait analysis, they will see different things. Both will watch the same client walk, but from two different perspectives, like looking at the world from different poles. This is not a bad thing at all, and one of the reasons why it is important to have both sets of eyes on the client at the same time if possible. Our knowledge bases are different, yet complementary, and therefore two views are better than either one independently. Normal gait is complex, and prosthetic gait even more so, with multiple variables to consider. One turn of a screw can change a gait pattern for better or for worse, but do you know which way? Unless you have a good understanding of prosthetics, and normal and prosthetic gait, chances are, you may not. I believe that the more each one of us understands and respects what the other knows and does, the more comprehensive client management will be. For example, a physio needs to know enough about prosthetic align-
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CLINICAL TEAM
2010
ment and socket fit to differentiate between a prosthesis versus a body (strength/ROM/movement pattern) problem. One prosthetic issue that a therapist needs to recognize and can often resolve is improper socket fit due to poor volume management. In order to teach the client proper volume management, the therapist him/herself needs to have a good understanding of proper socket fit, different suspension systems, and how each client needs to manage his volume. Knowledge is a valuable tool in prosthetic gait training, but only if you know when to use it. It allows us to effectively use other tools that are available to us. Obtaining and exchanging knowledge in
today’s rapidly changing healthcare environment is not an easy thing given the many demands put on us. But in order to continue client-centred care we need to find a way, even though teaching requires time and energy that we often don’t have, and the learning curve can be steep and overwhelming in this highly specialized field. A physiotherapist who is new to the world of amputee rehab can learn much from an experienced prosthetist if willing to make the time and effort to do so. A physiotherapist who is experienced in amputee rehab can exchange valuable knowledge regarding prosthetic gait and function with prosthetists and other therapists. I have had the good fortune throughout my career to
work with a fabulous group of prosthetists who have been willing to take the time to open up the world of prosthetics for me. This has helped to further my understanding of prosthetic gait, which in turn, has allowed me to provide better client care and raise my level of expectation for client function. About the Author: Physiotherapist Shirlene Campbell, B.Sc., P.T., MCPA, has over 25 years of experience working with adults and children with limb loss. Shirlene holds a Clinical Lecturer status appointment at the University of Toronto and is actively involved in teaching. Shirlene works both at Holland Bloorview Kids Rehab and privately in the community.
“ The multidisciplinary approach to rehabilitation ensures better lines of communication, transfer of knowledge and ultimately benefits our patients.” – Krista Holdsworth, B.Sc., CO(c), FCBC
Team Effort Orthotists, Prosthetists and Physiotherapists Working Together By Veronica Newell, B.Sc., P.T. First published in Alignment 2010. An abridged version appears here. For the full article, and patient case examples, visit www.opcanada.ca.
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CLINICAL TEAM
As an orthotist or prosthetist, have you ever wished you could follow your patients much more closely throughout the weeks after they leave your facility to see the effect of your treatment? Have you wondered what is working and what is not? You sense that your patient is trying to tell you something about their movement, but a full gait analysis is time-consuming and not always practical in your setting. Sometimes the solution to these quandaries can be found in a partnership that is just around the corner. If your patient has a physiotherapist (P.T.), or has access to one, you may be able to get answers to your questions much more quickly than you think. Across Canada, there are examples of cutting-edge solutions created by teamwork between an orthotist or prosthetist and a physiotherapist. From a professional point of view, the two professions share many common values and goals. The language in the websites of Orthotics Prosthetics Canada and the Canadian Physiotherapy Association demonstrate many of these shared principles and objectives. Both professions seek to assess movement, to understand problems related to the body, and to create solutions that will improve mobility and minimize the impact of impairment. Working separately, we can each achieve results for a patient. Working together, we can achieve results more efficiently with more options along the way. Aside from the clinical richness that comes with a multi-disciplinary approach, there are some added side benefits for the orthotist and prosthetist that accompany a good working relationship with local physiotherapists. Physiotherapists are a great source of referrals, and can help to identify appropriate patients,
and the right time for orthotic intervention. Physiotherapists can also help to identify trends in mobility management, and can bring forward new challenges and ideas to your current practice. Good teamwork and communication will encourage knowledge transfer and improved practice for both the physiotherapist and the orthotist and prosthetist. In order for orthotists/prosthetists and physiotherapists to work successfully together, a few suggestions may go a long way toward a lasting professional relationship. 1. Spend some time building rapport with physiotherapists you encounter, particularly if there are certain clinics, hospitals or agencies you work with frequently. 2. Gain a better understanding of what those physiotherapists do. Ask them about their experiences and any areas of specialty. 3. Ensure you know how to refer to each other, and what modes of communication work best. 4. If you are problem-solving around a specific client, ask the physiotherapist to attend your clinic if possible for a patient appointment. If this is not possible, make phone contact and talk about the role of orthotics. Always ensure that you have proper consent from the patient to communicate about them to the P.T. 5. Ask the physiotherapist, or the patient, about their current physiotherapy goals. These will frequently be mobility focused, and may impact the decision of what product to design. Is the goal related to stability and balance? Is the goal related more toward symptom relief? Or perhaps stability is going to be sacrificed slightly, if the goal is more related to movement in a variety of positions.
6. Consider brief but frequent communication with the physiotherapist, as questions and problems arise. Is the patient wearing the orthotic devices to their physiotherapy sessions? Is the P.T. observing problems with the style of device and impact on mobility? Did the shoe lift alleviate some of the back pain? These moments taken to share information and ask questions can save time in the long run. As healthcare teams continue to strive for best practice in ways that are cost effective and efficient, take a moment to consider the role of your patient’s physiotherapist. This professional can work with you toward a greater understanding of what is happening in the life and body of your patient. It is exciting to watch client goals being more rapidly met through teamwork related to orthotic intervention. Together we can problem solve, help each other, and create new potential. About the Author: Veronica Newell, B.Sc. P.T., is the Director of Physiotherapy at The Centre for Child Development in Surrey, British Columbia; www. centreforchilddevelopment.ca.
2016
“ The need for mental health awareness is becoming more prevalent in society and our practitioners may benefit from the resources in this article.” – Krista Holdsworth, B.Sc., CO(c), FCBC
Holistic Care Screening for Mental Health Predictors and Indicators Alignment Executive Editor Krista Holdsworth, B.Sc., CO(c), FCBC, in conversation with Josie Marino, Clinical and Rehabilitation Psychologist at The Ottawa Hospital Rehabilitation Centre. First published in Alignment 2016.
KH: In my experience in a paediatric practice, as my patients get a little older there are certain things that I become aware of that I’m not necessarily equipped to handle like anger and grief, or sometimes substance abuse. For me, and many O&P practitioners, it’s not really in our scope of practice. Are there some indicators that we can watch for when working with our patients and clients in our day to day practice?
JM: In terms of adjusting to amputation and how people do that, there is a wide range of possible responses... from very profound psychological issues to little or minimal adjustment difficulties. Most successfully adapt to their amputation. There is however, a subset of patients that do develop a clinical depression. That group would be in the range of about 21-35%. These rates of depression are greater than in the general 57
population but they are very comparable to an outpatient sample of patients with a range of chronic conditions. KH: Are there predictors of depression that we can look for? JM: There are some medical issues that tend to more strongly predict depression. Things like having significant pain (i.e. phantom limb pain, back pain). Traumatic amputations carry a higher risk of
CLINICAL TEAM depression. There is an increased risk of depression with upper limb amputations related to functional challenges and visibility of the disability. Hands are also used in nonverbal communication so these issues can be more significant. Trouble sleeping and insomnia can be red flags. But there are many reasons why they may not be sleeping (ruminating, pain, social stress). Patients who tend to be more socially anxious tend to have a harder time than those who are more outgoing. Maybe they are more socially self-conscious or struggle with how to respond to questions about their impairment. It’s best to use good screening tools because you can’t always know what someone is thinking or feeling unless you ask. So we can’t assume how someone is, or isn’t, coping. Not everyone wears their heart on their sleeve. KH: What about anxiety issues? JM: Anxiety is less studied in the amputee group than depression. Those who don’t develop a clinically significant depression or anxiety will often experience an initial period of adjustment that includes feelings of loss and vulnerability or sadness (about 60%
will express sadness and approximately 50% will identify anxiety, crying spells and insomnia). KH: What steps can a practitioner take to support clients struggling with psychological issues? JM: The first clinic appointment is the best time to normalize for the patient that the mind and body are connected and when something serious happens to your body, it affects how you are feeling. It’s important to let them know that grieving is a healing process associated with various emotions. However, if they are finding that they are stuck and cannot move beyond a particular negative emotion such as anger, or are having suicidal thoughts, let them know that talking to a mental health specialist who is trained to address the emotional aspects of disability can be very helpful and reassuring. Making that discussion part of routine care at the beginning makes it less alarming to the practitioner and the patient. Also, doing screening early on makes it part of the natural flow to say: “Well it might be helpful to talk to a peer who has gone through something like this” if it is a normal type of adjustment, or to a professional if it is more clinical-
ly significant. A program called The Pals Program, developed at Johns Hopkins, has been adopted by the Amputee Coalition of Canada. Information sheets can be helpful to have on hand... mental health resources and community organizations... everything from local counselling centres, Alcoholics Anonymous, Narcotics Anonymous, programs for people with anger management issues, local peer support groups, etc. Provide the patient with information about informed consent, including what remains confidential and what must be disclosed should you have concerns for their safety. As O&P practitioners, it’s important to correspond with other team members in the circle of care for the best outcomes. Resources: General Depression and Anxiety – PHQ9 (9 questions identifying symptoms of major depression; available online). GAD-7 (anxiety questionnaire that can be used by anyone in the field). Handbook of Rehabilitation Psychology, 2nd edition Frank et al. (2010), Chapter 2 Limb Amputation, Rybarczyk, Behel, Szymanski.
AMPUTEE COALITION OF CANADA Improving and advancing the quality of life of persons with limb loss. Established in 2008. Peer Visitor® Program. Promoting Amputee Life Skills® (PALS). Freedom Through Sport. Canadian Amputee Research Awards. Learn about ACC’s programs at www.amputeecoalitioncanada.org. To Request a Peer Visit call 1-866-611-2677 or email info@amputeecoalitioncanada.org.
2014
O&P SOLUTIONS
“ Simple solutions that make life easier for our clients!” – Sandra Ramdial, CP(c), FCBC
Three Quick Steps Converting Lace Shoes to Velcro
®
By Emily Northcote, CO(c) Holland Bloorview Kids Rehabilitation Hospital First published in Alignment 2014. This is a great option for children who have not yet learned how to tie their shoes and/or for parents who are having a hard time finding Velcro® shoes that fit over AFOs. It can improve independence for clients with conditions that affect their upper extremities, such as hemi cerebral palsy and stroke, as it can be customized to pull medially on one foot and laterally on the other. STEP 1: Cut a length of Mixed Velcro and attach it to the shoe. Punch a hole in one end of the
Mixed Velcro and secure it to the shoe with a rivet through an upper lace eyelet hole. Sew or rivet the other end through the shoe material. STEP 2: Cut a second length of Mixed Velcro to be used as the strap (approx. 3’’). Fold over one end and punch a small hole to attach a grommet or eyelet. STEP 3: Attach the Mixed Velcro strap to the shoe Mixed Velcro, such that the grommet on the strap is over the rivet on the shoe. 60
Lace the shoe through the grommet instead of through the top eyelet of the shoe. With the foot in place, tie up the shoe with a double knot. Open the Mixed Velcro strap until the lace is slack providing room to slip the foot in or out. Pull the strap to tighten and attach to Mixed Velcro on the shoe. If a wider opening is required, two eyelet holes on a wider piece of Mixed Velcro can be used. NOTE: Mixed Velcro® is hookand-pile fabricated together so that both sides are the same and it sticks to itself, preventing lint/ dirt from collecting in the hook.
About the Author: Emily Northcote previously worked at the Rehabilitation Centre for Children in Winnipeg and Queen Alexandra Orthotics, Prosthetics and Seating in Victoria, but returned to Ontario to work at Holland Bloorview Kids Rehabilitation Hospital in Toronto.
2015
O&P SOLUTIONS
“ This article brings P&O applications and outside-of-the-box thinking to a different area of medicine.” – Andrew Lok, CO(c)
Introduction to Orthotic and Prosthetic Applications for Small Animals By Janice Olynich, CP(c) First published in Alignment 2015. An abridged version appears here. For the full article, visit www.opcanada.ca.
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.
With the 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 spec62
trum 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. When an orthotic or prosthetic device is being considered for use with a particular injury, the first step is always a veterinary assessment
2015
and diagnosis. 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. 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. The prosthetics and orthotics
profession 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. 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
“ Fabrication involving leather techniques are in danger of becoming forgotten and should be immortalized for future generations to reference.” – Andrew Lok, CO(c)
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, CP(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.
Fabrication Techniques for LeatherReinforced Wrist Supports By Glen Isaacson, RTPO(c), Michael R. Dawson, E.I.T., Clinical Engineer, and Andreas Donauer, CO(c), M.Eng., Alberta Health Services, Glenrose Rehabilitation Hospital, P&O Department First published in Alignment 2015. An abridged version appears here. For the full article, and for the full fabrication techniques and photos, visit www.opcanada.ca.
Photos by David Home, C.P.(c)
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O&P SOLUTIONS
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. While 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 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. 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.
About the Authors: Glen Isaacson, RTPO(c), has worked in the O&P field since 1979, currently at the Glenrose Rehabilitation Hospital as an orthotic and prosthetic technician. His clinical and research interests include
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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 improve manufacturing techniques using 3D scanning and printing. Andreas Donauer, CO(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, Andreas 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.
2009
“ Recreational activities are an essential part of youth. Making it happen for our population is a gift for both the practitioner and the patient.” – Krista Holdsworth, B.Sc., CO(c), FCBC
The design proved to be very wearable, low enough in profile to be worn under the shin pads and strong enough to withstand the forces imparted on the brace while playing hockey. The skate extension can easily be transferred from skate to skate. The first prototype was used for three seasons. The images in this article are of the second generation device made for this young hockey enthusiast. He now plays on an all-ages physically challenged hockey team and is one of the better players.
About the Author:
Ice Time Skate Extension Orthosis By Marc Tessier, CPO(c) First published in Alignment 2009. An abridged version appears here. For the full article, visit www.opcanada.ca.
Many children love to skate but have frustrations with turning in one direction which makes it difficult to follow the play as they develop into higher age categories within minor hockey. A device was developed that may be helpful for children with spastic hemiplegia who have good skating abilities on the uninvolved side but decreased skating abilities on the involved side. The original prototype was designed for a hemiplegic hockey player on my son’s atom level hockey team. It seemed that his skating and turning abilities
could be improved if his spastic drop-foot and inversion spasticity could somehow be reduced while skating. The young lad wears an AFO. The original thought was to incorporate this device into his skate. This proved to be very difficult owing to the fact that the restrictive boot shape made incorporating his AFO nearly impossible. To overcome this problem, an extension was added to his already rigid skate boot to help even-out his skating stride asymmetry by improving his foot/ankle alignment within the skate.
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Marc Tessier, CPO(c), graduated from the Clinical program at GBC in 1983 and obtained his certification in Orthotics in 1986 and in Prosthetics in 1988 while working at Laboratoire Orthopedique J. Slawner in Montreal. In 1990, Marc established Nipissing Orthopeadic Laboratory Inc. in North Bay. He currently oversees a three-day P&O clinic at the Timmins and District Hospital on a monthly basis. He has recently finished his term as President of OAPO and was the CBCPO Internship chair from 1997 to 2001.
2009
O&P SOLUTIONS
“Helping patients achieve and maintain the lifestyle they desire; all in a day’s work!” – Krista Holdsworth, B.Sc., CO(c), FCBC
Sports Sockets Alternative Prostheses Designs for Short Trans-radial Amputees By W. James Little, B.Sc., CP(c), Vancouver Island Prosthetic Services Inc. First published in Alignment 2009. An abridged version appears here. For the full article, visit www.opcanada.ca. The following case study addresses hockey stick and mountain bike adaptations for an active youngster with a very short congenital trans-radial amputation. This case involves an active twelveyear-old boy who presents with a very short, right arm, congenital trans-radial amputation (1.5 inch
radius, 1 in. ulna), 5/5 strength and full ROM observed at the glenohumeral and elbow joints. The boy however, showed significantly less muscular development relative to his contralateral side. He has normal sensation and skin integrity on the residual limb. His residual limb almost completely disappears on full flexion. 48 66
The patient’s primary complaints are lack of comfort and control when playing ice hockey. The discomfort is due to torque on his residual limb from external and internal forces applied to the hockey stick which are associated with movement at residuum-socket interface. Mountain biking is another sport that the patient would like
2017
to participate in more proficiently. His concern lies in his inability to actively lift the front end of the mountain bike off the ground in a controlled and stable fashion. The patient reports significantly improved comfort and stick-handling capabilities with the new hockey stick design. Specifically, his shots are faster and more accurate and he is able to handle the puck much closer to his body. On his mountain bike, he is now able to lean on the handlebar riser when riding flat or riding downhill. The flexed, foam-lined socket allows
him to pull up on the handlebars with enough force to effectively ride over obstacles on the trail. When he falls off the bike, he is almost always able to extend his elbow joint and slide free of the bike.
Acknowledgements: This is to thank Barber Prosthetics and Sandra Ramdial, CP(c), FCBC, for their clinical expertise and guidance in the development of these prostheses, as well as Pat Myrdal, RTPO, for his experience and assistance with the design and components comprising these devices. A special thanks to the generosity of the CHAMPS program for providing the necessary
funding to enable this young man to more effectively and safely compete in his favourite sports.
About the Author: W. James Little, B.Sc., CP(c), completed his training at BCIT in 2000 and became certified in Prosthetics in 2002. Since certification, he has worked in Vancouver, Nanaimo, Victoria and Comox, BC. James lives in Comox with his young family where he owns and manages Vancouver Island Prosthetic Services Inc. James holds a faculty position in the P&O Program at BCIT teaching the Trans-femoral curriculum.
“ An introduction to Osseointegration as this procedure is slowly being made available in Canada.” – Andrew Lok, CO(c)
Osseointegration Related to Limb Prosthetics in Canada By Tony van der Waarde, CP(c) First published in Alignment 2017. An abridged version appears here. For the full article, visit www.opcanada.ca. Image by Dr. Patrick Palacci
In the past couple of years, new prosthetic technologies have focused mainly on new componentry like knees, feet and hands. For sockets and prosthetic fitting, developments in materials and designs have made significant progress in amputee comfort and mobility but the biggest challenge remains: “How to maintain a good fit.”
The use of artificial bone implants for lower and upper limb amputations has been documented since the 1960s. Some “experimental” human osseointegration (OI) procedures were done in the 1970s and ’80s in Toronto by Canadian engineers and surgeons, Dr. John Kostiuk from Sunnybrook Hospital and Dr. Geoff Fernie from West Park Hospital, to name two. 67
Per-Ingvar Brånemark, a professor in Sweden, was instrumental in the transition of mandibular implants for use in amputated limbs. Dr. Rickard Brånemark utilized the technique developed by his father and expanded upon it. His first reported case was in 1990 and the outcome seemed rather positive. Brånemark’s surgical clinic initially performed 25 osseointegration
O&P SOLUTIONS
feedback from terrain and, better body alignment – all resulting in an improved quality of life.
2016
procedures in Sweden and later, more in several other European countries. As of March 2017, 15 Canadian amputees have had osseointegration surgery performed at the Macquarie University Hospital Clinic in Sydney, Australia, and all are doing well. No longer bothered by volume changes in their residual limbs, socket alterations, liners and suspension device replacements are no longer a necessity for them. Best of all, they are free from friction pain, skin breakdown and perspiration from the socket environment. All of the amputees surveyed reported an increased sense of “normality” in balance,
About the Author: Tony van der Waarde, CP(c), graduated from George Brown College in Toronto in 1973 with a diploma in P&O Technologies with the college’s first graduating class. He became certified in prosthetics in 1975 and has worked in numerous P&O labs, rehab centres and in private practice. He opened his own facility, Award Prosthetics, Inc., in 1995, in Burnaby, B.C., and has been active in the development of new socket designs and recently, osseointegration technology.
“Attention-grabbing and great solution to a complex case.” – Sandra Ramdial, CP(c), FCBC
A Complicated Case By Steve Scott, CP(c) First published in Alignment 2016. An abridged version appears here. For the full article, visit www.opcanada.ca.
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KM is a 49-year-old male with a very short right trans-femoral amputation – a femoral length approximately 3cm from the greater trochanter. The patient also presents with a congenital condition known as Dystrophic Epidermolysis Bullosa, whereby his body does not manufacture the collagen necessary to anchor the epidermis to the dermis causing the skin on certain areas of his body to be fragile and blister with minor trauma. The skin of his residuum is unable to tolerate any shear force but can withstand direct pressure.
Numerous sockets of various designs and interfaces were tried. Custom and off-the-shelf liners were tried. This became an exercise in frustration for both my patient and myself, as everything that was attempted seemed to fall short of our goals. The goals for the new prosthesis were to provide a greater level of independence, which involved easing the donning process, and providing an enhanced level of control over the prosthesis for a more natural gait. The final solution was to treat this situation as though he was a hip-disarticulation amputee. His residuum was short enough that it could be flexed to fit into a socket and not displace the hip joint to an excessive degree. The final device was a hip-disarticulation socket that incorporated a SiOCX silicon interface over the proximal half of the socket covering the iliac crests with a ratchet strap closure, a Helix 3D hip joint, Kenevo microprocessor knee and a Trias foot.
A further complication in this case is that his skin condition has caused both of his hands to contract and to “meld” into dysfunctional balls at the end of his arms, limiting them to minimal assistance in donning and doffing his prosthesis. In fact, special partial hand prostheses were fabricated and incorporated into his crutches for better control.
About the Author:
Final definitive prosthesis.
KM’s initial prosthesis and crutches modified to accommodate hand anomalies.
The overall length of his residuum, the condition of his hands, and the fact that his residuum tissues cannot tolerate shear force precluded the use of any type of “skin fit” suction suspension. Various interface materials were attempted – silicone seal-in liner, locking pin liners and cushion liners – and, for various reasons, failed.
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Steve Scott, CP(c), graduated from George Brown College in 1978, earning certification in 1983 and has practiced in Saskatchewan and Alberta. He has been at Cascade Prosthetic Services in Calgary for the past 10 years.
2010
O&P SOLUTIONS
“This is a great back to basics for managing at-risk neuropathic foot problems.” – Helen Cochrane, CPO(c)
Off Loading A Case Study on Relieving Pressure on the Diabetic Foot By Andrew Hoar, C.Ped.(c) First published in Alignment 2010. An abridged version appears here. For the full article visit www.opcanada.ca. Ulcers occur in the diabetic neuropathic foot due to repetitive stress on sensitive feet. This repetitive stress causes the foot to develop hot spots, callus build-up, pressure necrosis, and ultimately ulceration. The most common area for pressure and excessive callus build-up occurs over the metatarsal heads, in particular, the first metatarsal phalangeal joint and the plantar surface of the Hallux. Effective reduction of pressure (off-loading) is considered
essential in the healing of plantar ulcers. Useful off-loading mechanisms include reduction of walking speed, alteration of foot rollover during gait, and transfer of load from the affected areas to other areas of the foot or lower leg. Although total contact casting (TCC) is considered to be the gold standard when off-loading neuropathic ulcers, it must be re-applied weekly and requires considerable experience on the part of the clinician to avoid creating new lesions.
Some mechanisms used as alternatives to TTC are removable walking casts, custom neuropathic walkers, half shoes and the wound care shoe system (WCSS). This article discusses a case study whereby the WCSS is effectively used to treat a chronic neuropathic ulcer. When assessing the neuropathic foot ulcer it is important to test the joint range of motion of the foot and ankle. Without alteration of biomechanical stresses caused by bony or structural deformities, wound healing may be compromised and will likely be unsuccessful due to continued trauma. Key components of off-loading the forefoot during ambulation are the use of a rocker sole and relief of the local area of the ulceration. Peak pressures in the rocker-soled shoe are reduced by approximately 30% compared to a conventional shoe in the medial and central forefoot, but pressures are elevated in the heel and midfoot. Local relief of the ulceration is accomplished by the removal of material from the supporting surface below the point of contact (ulceration). The WCSS is versatile, requiring minimal equipment to modify. It offers the clinician off-loading mechanics in conjunction with standard best practice protocols, promoting optimal wound healing in areas without access to TCC. If TCC is contraindicated due to poor balance, infected wound or ischemia, then this is an acceptable alternative.
About the Author: Andrew Hoar, C.Ped.(c), is a pedorthist in the Orthotic and Prosthetic Department at the QE11 Health Sciences Centre in Halifax, NS. He also works with OrtoPed in a professional advisory capacity. Visit www.ortoped.ca for more information on foot care products or call 1-800-363-8726.
Article submitted by OrtoPed and was originally published in Wound Care Canada, Vol. 6, No. 1, 2008. Reprinted with permission of Wound Care Canada.
2010
O&P SOLUTIONS “ I liked this article because it gives a good review of what was a relatively new technology in 2010 and now is common technology as well as linking it to other changes in practice. The author here states that “Creativity, competition and research continue to drive prosthetic progress.” I think that was (and is) a good sentiment.” – Helen Cochrane, CP(c)
A transfemoral amputee demonstrates the range of motion possible with the brimless socket design developed by Jeff Denune, CP, LP, WillowWood’s clinical director of prosthetics.
Hanging Tight Elevated Vacuum Suspension Systems Step Forward By Miki Farley First published in Alignment 2010. An abridged version appears here. For the full article, and a review on Elevated Vacuum vs. Suction Suspension impact on patients, visit www.opcanada.ca.
“It feels like I got my leg back!” is how amputee Andy May described it. It was the first time he ran with a prosthesis incorporating the new LimbLogic™ VS prosthetic vacuum suspension system. Although every type of prosthetic suspension system has advantages and disadvantages, with
no one single system being right for everyone, elevated vacuum suspension offers significant benefits. “Time after time, patients have commented that now the prosthesis feels like a part of them,” says Jeff Denune, CP, LP, and clinical director of prosthetics for WillowWood, based in Mount Sterling, Ohio, and creators of the 72
LimbLogic™ VS prosthetic vacuum suspension system. Denune describes how, with previous prostheses, amputees would experience pistoning or other movement within the sockets, making them continuously aware of them. “It’s sort of like dentures,” he explains. “When you wear them, you always know they’re in there.” One
Photo courtesy of Ohio Willow Wood.
Photo courtesy of Ottobock Healthcare.
Photo courtesy of Ohio Willow Wood.
Ottobock’s Harmony® Vacuum Management System.
of the most important benefits of elevated vacuum suspension is that it maintains limb volume throughout the day. With other suspension systems, amputees’ residual limbs lose volume as they go about daily activities. The socket loosens which makes controlling the prosthesis more difficult, reducing proprioception and increasing the potential for skin damage. The amputee may add more sock layers as the day goes on, but this is a time-consuming inconvenience for busy people. Carl Caspers, CPO, pioneered the vacuum concept. His company, TEC Interface Systems in St. Cloud, Minnesota, developed the Harmony® VASS™ (Vacuum-Assisted Socket System) in cooperation with research by the St. Cloud University Human Performance Laboratory. TEC was acquired by Ottobock HealthCare in 2003. Elevated vacuum suspension – also known as sub-atmospheric technology – is also having successful transfemoral and upper-limb applications. But it’s the impact on transfemoral socket design that has Denune excited. With the elevated vacuum suspension system it has been possi-
Stacie Broseus rides her horse with no impairment.
ble to design transfemoral sockets with lower trimlines, greatly increasing amputees’ comfort and range of motion. Denune first revealed the brimless socket design at the 2007 Annual Meeting of the American Academy of Orthotists and Prosthetists. “We’ve been getting phone calls from all over the world; clinicians are saying they’ve been able to cut the brim down. The floodgates have opened.” For those amputees using elevated vacuum suspension, the innovation has been a welcome one. Stacie Broseus, who uses a LimbLogic VS and DuraLite™ foot, rides her horses, does her barn chores, gives riding lessons, and runs her boarding stable business with no impairment. She also finds that she finishes her barn chores 45 minutes faster with her new prosthesis. Andy May appreciates his elevated vacuum suspension system for running, which requires the most support. “In the past, my leg would start to piston inside the socket, making my run a lot slower,” he recalls. “The vacuum keeps my residual limb solidly and comfortably in place.” Another amputee, quoted by Street in the Orthopädie 73
Technik article, comments on how well the Harmony prosthesis stays “glued” to his leg, making the prosthesis feel much lighter, allowing him to wear work boots comfortably again. “Managing my horse farm with tennis shoes was often a challenge, particularly in the muddy months,” he says. Creativity, competition, and research continue to drive prosthetic progress, giving prosthetists more choices in the search for what works best for each individual patient. When it comes to elevated vacuum systems, more improvements and new products are on the way. About the Author: Miki Fairley is a freelance writer based in southwest Colorado. She can be contacted via e-mail at miki.fairley@gmail.com. Article submitted by OrtoPed and originally appeared in the March 2008 edition of The O&P EDGE. Reprinted with permission of Western Media LLC/The O&P EDGE. Alignment does not endorse any particular product or service. Product information provided in this article is for reader information only. For more information on vacuum suspension systems visit www.ortoped.ca or call 1-800-363-8726.
2014
O&P SOLUTIONS
“ This interesting research exemplifies the need for further investigation in matching high tech prosthetic feet with elite prosthetic patient requirements.� – Krista Holdsworth, B.Sc., CO(c), FCBC
Designing an Athlete An Evaluation of Prosthetic Feet for Football and other High Intensity Sports By Kimberly J. Morrison, B.Sc., CP(c), Jim Low, CP(c), Vincent J. Quinn, Prosthetic Technician First published in Alignment 2014. An abridged version appears here. For the full article, and case studies, visit www.opcanada.ca. Designing an effective prosthesis for an active lower-extremity amputee can be a difficult feat. On top of creating a well-fitting and comfortable socket, the prosthetist must also find ideal componentry for the targeted sport that will withstand the high forces placed on it. While there are a number of resources pertaining to design of appropriate prosthetic devices for
straight-line running (Nolan, 2008, Hsu, 2006, Burkett, 2010), there is almost no available information on how to design prosthetic limbs for dynamic, high intensity sports, such as soccer, rugby and football. The goal of this study was to identify which high-end prosthetic feet are best suited for use as a football prosthesis based on performance in a series of standardized football drills and tests. The findings from this study were used primarily 74
to provide our subject with the ideal equipment to help fulfill his athletic needs. The secondary goal was to establish a foundation for further studies to inform clinical practice. This research was conducted as a case study, with the subject being an 18-year-old male football player training for an offensive lineman position. This 6' 2'', 250-lb male had his left foot amputated in 2011 as a result of a traumatic injury sustained in a wakeboarding accident. He is well adapted to his prosthetic device, and is an active, unlimited community ambulatory. The parameters of the study included a variety of NCAA (National Collegiate Athletic Association) standard tests of balance, speed and agility, including the 40-yard sprint test, vertical jump test, squat test and T-Test. The tests were completed so as to be consistent with provincial standards for recruitment to varsity-level Canadian football teams. At the initial assessment it was found that the subject had unlimited range of motion bilaterally at the hips/knees and at the right ankle. Muscle strengths about the left hip and knee were found to be normal (grade 5). The joints of his right-side lower extremity displayed normal range of motion as well. He wears a custom-molded knee orthosis on his left knee as a means of protection against injury (he had fractured his patella in 2012). Because this study included one subject (n=1) only, we cannot draw any definitive statements about the findings. A larger sample size with similar outcomes would strengthen our evidence for the Flex-Run as a superior prosthetic foot for use in timed, running football drills while still being an excellent foot in tasks that require agility and balance. What we can accurately deduce however, is that our subject not only prefers the Flex-Run to the Re-Flex Shock, but demonstrates improved performance with the former.
2017
CONTINUING EDUCATION
“ Patients and practitioners alike will benefit from this knowledge acquisition/or verifiable data.” – Krista Holdsworth, B.Sc., CO(c), FCBC
A patient completes an outcome measure involving computer-assisted gait analysis and eagerly discusses the results with his prosthetist.
Incorporating Outcome Measures into Daily Practice A Clinician’s Perspective By Brittany Pousett, CP(c), M.Sc., David Moe, CP(c), Loren Schubert, CP(c) First published in Alignment 2017. An abridged version appears here. For the full article, and patient anecdotes, visit www.opcanada.ca.
In the 2016 edition of Alignment, Brittany Pousett, CP(c), shared patients’ responses to the use of outcome measures over the course of their care. She interviewed three patients who shared that they appreciated the encouragement, motivation and objective, informative data that the outcome measure
scores gave them [1]. After using outcome measures consistently with their patients for over a year and a half, the clinicians at Barber Prosthetics Clinic have found the care offered to their patients has been enhanced. Herein, the authors share four benefits of using outcome measures as they have experienced them. 76
1. Outcome measures influence how we make decisions with our patients. The use of outcome measures in practice offers quick and simple ways of collecting objective data that directly influences how decisions are made or the direction that treatment takes. Some of the simplest outcome measures are the Pain Score and the Socket Comfort
Score where patients rate their pain or comfort on a scale from 0 – 10. We have found that using these measures, which take less than 10 seconds, can immediately tell us the extent of socket adjustments that need to be performed, or how close the patient is to having an optimally-fitting socket. These help to direct our care because they enable us to speak the same language as our patients and ensure that we are both aware of the difference between pain that is 2/10 (quite mild) and pain that is 9/10 (quite severe). 2. Outcome measures are important indicators of progress. We have also found that outcome measures provide our patients, and us as well, with valuable information regarding their progress in rehabilitation. We begin using outcome measures with our patients before they receive a prosthesis and continue using them at regular intervals throughout their initial rehab. By tracking their progress, we can celebrate when they excel and re-direct the conversation when they digress. Since these measures allow us to objectively measure attributes such as balance, speed and endurance, we are able to detect small changes and direct
care more quickly and accurately than if we relied only on subjective feedback and visual information. 3. Outcome measures strengthen communication with external collaborators. Outcome measures are a universal language in rehabilitation teams. By sharing six simple numbers, we can acquire a basic understanding of comfort, pain, speed, endurance, balance and confidence. This allows us to share valuable information with physicians, physiotherapists and occupational therapists quickly and efficiently, in a language that we all understand. When working with other healthcare professions, we have developed systems to obtain outcome measures to enhance collaboration and discussion and improve time efficiencies. We have found that the use of outcome measures increases communication, saves time, deepens relationships within teams and enables us to work together more closely to ensure our patients’ rehab is appropriate and successful. 4. Outcome measures change our patients’ perspectives on care and influence the goals they want us to help them achieve. Finally, as highlighted in our previous article in
Alignment, outcome measures improve our patients’ perspectives on the care they receive and enable us to provide them with better service. Patients are very willing to complete outcome measures surveys when the results are explained to them. One patient who had a recent amputation and who completed several outcome measures items was eager to talk through each one and understand the results and his progress when we ran him through them again a few weeks later. Now, we complete outcome measures with him on a regular basis enabling him to celebrate his achievements, adjust his goals, and focus his attention on addressing specific aspects of his life that he wants to improve upon. How about you? How could using outcome measures improve your patients’ care and experiences at your clinic? References: 1. Pousett, B. (2016). Patients Perspective on Incorporating Outcome Measures into Practice. Alignment 2016. About the Authors: Brittany Pousett, CP(c), M.Sc., is a Certified Prosthetist and the Head of Research at Barber Prosthetics Clinic in Vancouver. Brittany is passionate about integrating research into clinical practice in order to provide her patients with evidence-based care. Loren Schubert, CP(c), is a Certified Prosthetist at Barber Prosthetics Clinic and an Instructor in the Prosthetics and Orthotics program at the British Columbia Institute of Technology (BCIT). David Moe, CP(c), has been a Certified Prosthetist for 25 years and a part-time faculty member at BCIT for 12 years. He is always striving to provide his patients with higher levels of care and push the profession forward.
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2017
CONTINUING EDUCATION
“ Informative article and inspiring work that’s being done by a great organization!” – Sandra Ramdial, CP(c), FCBC
The War Amps Advocacy Program A Voice for Canadians Living with Amputation By Annelise Petlock, Lawyer and Advocacy Program Manager, The War Amps and Alexis McConachie, Co-ordinator, Advocacy Communications, The War Amps First published in Alignment 2017. An abridged version appears here. For the full article, and case studies, visit www.opcanada.ca.
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Since its founding at the end of World War I, The War Amps has fought to protect the rights of amputees and veterans, and address the inequities they face. As a natural evolution, the association has over time expanded its advocacy work to provide a voice for all amputees in Canada. Although life for amputees has come a long way since the end of the first World War, there are still many gaps in terms of support in the areas of appropriate prosthetic coverage, insurance and legal issues, human rights, government benefits and war amputees’ rights. Through its Advocacy Program, The War Amps navigates and addresses the bureaucratic barriers and misunderstandings often confronted by amputees in society. Years of experience with government agencies and insurance companies have revealed that these institutions do not fully comprehend the impact of amputation and the role the prostheses play in reducing the incidence of other medical conditions that can develop with amputation. Consequently, funding agencies create and adhere to policies which do not reflect the reality of living with amputation and thus, prevent amputees across the country from being able to access prosthetic components that are medically prescribed to them. Most Canadians would be shocked to know that those who live with the loss of a limb are not adequately covered by their health plan. Across the country, provincial funding is insufficient to cover the cost of appropriate artificial limbs for amputees. Moreover, many insurance and extended benefits packages contain arbitrary contribution and frequency limits for essential medical devices, including artificial limbs. These “caps” effectively prevent persons with amputations from affordably accessing the assistive technology they require. The War Amps fills the gaps where it can, but as a charity that relies on public donations, its funds
CONTINUING EDUCATION
2012
can only go so far. One of The War Amps Advocacy Program’s ongoing objectives is to provide education to funding agencies, so that policies can be updated to reflect the reality of living with amputation. The objective of “Crusade for Reform” is to ensure that amputees can access the prosthetic care they need to gain or regain their functionality. While the Advocacy Program’s main goal is to provide education, this is only stage one in The War Amps’ advocacy efforts on behalf of amputees in Canada. When providing education to funding providers does not elicit a positive result, the association challenges their position, providing further justification towards an equitable result. Should it continue to receive resistance, advocates do not hesitate to escalate matters and dispute the funding provider’s position (even if
this means mediation or litigation). In an industry where roadblocks and red tape are abundant, persons with amputations in Canada need a voice; they need someone advocating on their behalf. The Advocacy Program will go the extra mile to ensure a just and fair outcome for individual amputees. An exciting aspect of the Advocacy Program cases rests in their potential to create widespread, positive changes for all amputees. The program focuses on these types of cases, where a positive outcome can set the groundwork for many more amputees to achieve the same result. It is The War Amps hope that its intervention in these cases will set a precedent in the continued efforts towards the reform of prosthetic funding standards within Canada. The organization’s aim is to educate the insurance industry, government
agencies and others on the importance of appropriate prosthetic limbs, and help to ensure that persons living with amputation receive the limbs and devices they need for their independence, safety and security. In every case, experienced and well-researched insight is provided, which yields measured and fair results to benefit the amputee and educate the funding provider. The War Amps works very closely with the client’s prosthetist and medical team, with the understanding that these gaps do not only affect persons with amputation. Each case is given consideration. Do not hesitate to contact The War Amps for more information, to identify a systemic issue facing amputees, or to put the Advocacy Program in touch with an amputee who requires our support. For support, call 1-877-622-2472.
“ Interesting study and useful output, particularly for students, residents, and new practitioners honing their OGA skills.” – Krista Holdsworth, B.Sc., CO(c), FCBC
Observational Gait Analysis Handbook and Assessment Form By Christa Orschel, B.Sc., Will Hadi, B.Sc. (George Brown College, 2nd-year Clinical Students) and Gordon Ruder, CO(c), B.Sc., M.Sc. First published in Alignment 2012. An abridged version appears here. For the full article, visit www.opcanada.ca.
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Preparing for the last CAPO [now OPC] Exam Prep course, and about to give a lecture on Observational Gait Analysis (OGA), I was struck by this epiphany: “Wouldn’t it be great to be able to give our prosthetic and orthotic (P&O) residents and students a handbook outlining how to conduct OGA, so that more, sound, treatment plans could be recorded, justified and shared?” (G. Ruder)
2015
3D gait analysis (kinematics, kinetics and EMG), using portable pressure mats or observational gait scales/ classification systems are possible, but these are the exception and not the norm of clinical practice (Harvey & Gorter, 2011). Even when this technology becomes more universal, it will still require us, the professional, to understand how our patients ambulate, and determine if our P&O devices are optimal. OGA is an essential part of assessing our patients, and our eyes and hands will always be required. We have alpha-tested the Handbook and Assessment Form with George Brown College (GBC)
faculty and are in the process of beta testing it on students this term. We would greatly appreciate any feedback or suggestions you might have. If you would like the handbook or the OGA assessment form in its entirety, please contact Gordon Ruder (gordon.ruder@ gbcpando.com). Putting Ideas into Action Observational Gait Analysis is the systematic analysis and assessment of human walking. It is used in a variety of medical fields as a way to keep track of, and manage, the progression of diseases affecting the locomotor system. By examining a patient’s ability to walk, clinicians can gain a more well-rounded picture of the patient’s neurological and muscular deficits, and shape a treatment plan which considers these deficits. Particularly in the field of prosthetics and orthotics, gait analysis is used to determine how external devices affect either a pathological gait or the gait of a lower limb amputee. OGA in prosthetics and orthotics is dependent upon the ability of the clinician to be able to compare the gait that he or she is seeing to his or
her knowledge of normal gait. There is no one single method of performing OGA, and clinicians are limited only by the amount of time available for assessment, and the ability (or inability) of the patient to walk for extended periods. It is the goal of this handbook to allow for more standardized performance of OGA by students and clinicians alike, as well as to provide suggestions for more succinct and quantitative OGA techniques. It may not be long before gait analysis technology makes its way into our smart phones and tablets. In fact, there are a number of apps available for coaches and sport performance specialists that already could be used to quantify aspects of gait. The ease and prevalence of smartphone/tablets/app developers, will be instrumental in getting clinicians to become more quantifiable and evidence-based. Touch screen and voice command gait labs and assessment tools will leave paper and/or traditional gait quantification in the dust. For those of you who are “Trekkies”, it would mean we’d have our own tricorder, like Spock!
“ The importance of science and technological innovations can lead to personal triumphs(for our patient population).” – Krista Holdsworth, B.Sc., CO(c), FCBC
Gait Patterns of Runners with Lower-Limb Prostheses Anatomical, Design & Attitude Implications By Sherry Fagan First published in Alignment 2015. An abridged version appears here. For the full article, visit www.opcanada.ca.
CONTINUING EDUCATION Once a heated debate, now quickly losing steam, is a notion surrounding able-bodied and disabled athletes. 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 allowing athletes to compete at elite levels. 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 is 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 on 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 is 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 than those with four 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 succeeds over another include the following: 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 buildup will be the determining factor regarding the amount of energy input required to give the best performance output. 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 82
Aimee Mullins at the 1996 Atlanta Paralympic Games
clinical population of lower-limb prosthesis-wearing 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 one about struggle, but one surrounding triumph, not about disability, but ability. 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.
2015
O&P INTERNATIONAL
“ This article reminds us of the things we take for granted while inspiring clinicians/technicians to do more for less developed regions of the world.” – Andrew Lok, CO(c)
Bolivia Bound Setting Up Shop in a Developing Country By Duane Nelson, CP(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. In 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 84
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, 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 sixmonth 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. 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. 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 cast upon us 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. Before our departure to Bolivia, we were informed that the clinic was moving locations and should 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
2016
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 by Matthew Pepe, the American founder of the clinic and untiring volunteer, as well as the eager local staff. One month later we had cast, fabricated, and fit our first prosthesis. The next months were filled with trials and triumphs as el Centro 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-in-training. We were fortunate that this trainee was educated as a physical therapist, and could assimilate important prosthetic concepts quickly. The lasting im-
pact of our time with el Centro de Miembros is not 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. Our experience teaching prosthetics in a developing country like Bolivia is akin to climbing a
“ A great example of treatment success in developing countries when clinicians, community and corporations collaborate.” – Jeff Tiessen, Alignment publisher
high-altitude mountain – painfully challenging and at times even frightening. Yet, incredibly rewarding with priceless long-lasting memories. ED Note: A year after his family’s return to Canada, el Centro de Miembros Artificiales continued to operate with the help of ongoing fundraising and organizational support from Matthew Pepe in San Diego. About the Author: Duane Nelson, CP(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.
One Love Improving Lives in Jamaica By Dawn MacArthur Turner, B.Sc., CO(c) Opportunities frequently present themselves when you least expect them. This was the case for me back in 2009. My daughter was travelling to Jamaica for two weeks as part of a parish summer camp. The church had been providing a summer skills camp to improve literacy, self-esteem and life skills to Jamaican children for over 25 years. At that time, they were fundraising for a wheelchair for a young boy with spina bifida who lived in the hills of Jamaica and had never left his home.
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I had offered to provide a wheelchair and talked to the mom via satellite phone to determine his needs and size. Once I talked to Dante’s mom I realized I could fit the boy with AFOs and provide an opportunity for him to ambulate. I accompanied the church group and brought the young boy the wheelchair and bilateral AFOs. The experience was one which I will never forget. Standing in the middle of a sugar cane field in temperatures over 40 degrees Celsius, the entire community came out to see Dante leave his house for the first time. Everyone was thrilled, and there wasn’t a dry eye in the crowd. I was hooked! The braces and wheelchair provided a life-changing opportunity for both the boy and me. While I was in Jamaica I was approached by a retired nurse who was interested in setting up an orthopedic clinic where physically challenged children could get fitted for braces. Elaine is a well-connected Jamaican with a passion for helping people. The RIU hotel chain has committed to financially supporting the paediatric orthotics clinic based in Negril. For the last seven years they have funded the facility, including utilities, a phone line and an opportunity for a young, local lady to help in the clinic. Elaine continues to volunteer her time in the capacity of clinic coordinator, helps to arrange transportation and to manage the financial assistance from RIU. Over seven years I have had the opportunity to volunteer and work side by side with the locals. I travel to Jamaica with a technician three to four times a year with the stipulation that they bring two suitcases filled with used orthotic devices, socks and shoes. Usually we travel with 200 pounds of orthopedic braces and componentry. I provide my time and transportation. In return, I get all the Jamaican patties, jerk chicken, fresh mangos and hugs one could ask for. The O&P community has been awesome in its support. We have
received donations from facilities and clients from Custom Orthotics of London, Orthoproactive Consultants, Clinical Orthotic Consultants of Windsor, Holland Bloorview Kids Rehabilitation Centre and Ron Joyce Children’s Health Centre. Generous suppliers including Keeping Pace, Custom Orthotics of London, National Shoe and Kovacic Orthopedic Tool & Supply have provided Velcro, padding, technical supplies and tools. Our services are provided completely free of charge. The majority of our patients otherwise could not afford the service. We never know in advance what we are going to see, starting the day at 8 am and working until 8 pm. A four-day clinic will be filled with 50 – 60 children with orthopedic concerns, cerebral palsy and spina bifida. There are over 250 children we regularly follow spanning the entire island of Jamaica. Some will take three to four buses travelling all day to be seen, without a hint of complaint. They are just appreciative of the care they receive. They return home with a custom-fitted device, socks and footwear. By providing the appropriate care and footwear they now can attend school and participate in their communities. The life of a physically challenged individual in a country without healthcare is extremely difficult with many stigmas and hurdles. Over the years I have been blessed to follow the children and see their lives change with opportunities presented to them that otherwise they would likely never have experienced. Not only has this opportunity changed their lives it has also changed ours. About the Author: Dawn MacArthur Turner, B.Sc., CO(c), is a Certified Orthotist at Custom Orthotics of London since 1987. At the time of first publication, she was completing her Masters in Rehabilitation Science from McMaster University. 86
2011
O&P INTERNATIONAL
“ This one hit on a range of subjects: research, international development, student projects, sustainability, etc. When science and humanity meet!” – Helen Cochrane, CP(c)
The Global Village LIMBS International is on the Move By Zach Lewis The earthquake in Haiti in 2010 put a spotlight squarely on the serious lack of adequate prosthetic limbs for amputees in the developing world. As many as 10,000 Haitians lost a limb. In North America and Europe, the loss of a limb is unquestionably traumatic but with a prosthesis, amputees can lead full lives again. The situation in places like Haiti and other developing regions of the world is not so simple.
Prosthetic limbs that use microprocessors and are made of high-quality materials like titanium are too expensive for poor Haitians and cannot be easily manufactured or fitted by local prosthetists. Durability is another factor. In remote, rural regions, where roads are unpaved and people walk as much as 15 kilometres a day, moving about with a Lamborghini-style prosthetic limb is destined to fail. That’s why the lives of Peter Mbuvi, Khassamiyou Kane and Gabilla Sesay offer a ray of hope for Haiti’s amputees. Mbuvi of Kenya lost his lower leg to a hippopotamus attack in 2004, but despite the loss he recently married and has a full-time job walking long distances for his country’s national census. Kane lost his limb as a result of a car accident in his native Senegal when the leg became infected, a common occurrence in third-world countries where medical care is often inadequate and hospitals are far and few between. Yet today, Kane gets around using a new prosthetic leg that allows him to walk miles from his home to continue his education. Perhaps the most troubling story of these three is that of Sesay, who lost his leg after rebels fighting in Sierra Leone’s civil war forcibly amputated it. Today he walks with a new prosthetic limb that helps him survive without having to beg in the streets. All of these men have something else in common: they all wear the M1 Knee, a low-cost, highly functional prosthetic knee-joint developed in 2004 by Dr. Roger Gonzalez of LIMBS International. The M1 Knee is a four-bar polycentric design that can be locally manufactured using simple tools such as a drill press and band saw for around $20. Compare that to first-world microprocessor knees, or even to simple mechanical knees that can approach $1,000 in cost and the M1 Knee makes good sense. Moreover, this functional and durable prosthetic knee can be
made with the same tools found in any hobbyist’s woodworking shop. Since its inception in 2004, Gonzalez and his team have fitted over 200 amputees with the M1 Knee in India, Kenya, Senegal, Sierra Leone, Bangladesh, Bolivia and the Dominican Republic. LIMBS International began as a senior-year engineering design project at LeTourneau University in Longview, Texas. Dr. Gonzalez, a professor of engineering, challenged his students to build a better low-cost prosthetic knee-joint that could be locally manufactured using available raw materials. The beauty of the M1 Knee is that it is a masterpiece of reverse engineering. Rather than improve on sophisticated prosthetics already in the marketplace, Gonzalez and his students stripped these knees of any complexity. And like a modern-day Johnny Appleseed, the LIMBS team is traveling the world teaching others how to make the simple prosthetic device. So far they have hosted training workshops in five of the seven developing-world countries noted above, and certified 40 local clinicians in the knee’s schematics. Seven years after its inception as a class project, LIMBS International has grown into a full-time organization with a small staff and partnerships with other foreign aid organizations, such as Handicap International and Mercy Ships. In addition to Dr. Gonzalez’s leadership, Dr. Stephen Ayers, who serves as LIMBS’s engineering director, has joined the team and is refining the original design of the knee and developing other low-cost prosthetic components, such as a foot. “Our goal is to provide an affordable, durable prosthesis that will be available to amputees long after we are gone,” Dr. Gonzalez explains. “We’ve seen encouraging results for both clinicians and amputees who use our knee-joint. It allows amputees to walk more normally, and have a second chance at making a 87
livelihood, while the clinicians take tremendous pride in fitting patients with a quality knee-joint that they made themselves.” At present, LIMBS International needs more prosthetists who can travel with the team to their partner clinics throughout East and West Africa, Asia, the Caribbean, and Central and South America. The team has one staff prosthetist, Ricc Gonzales, CPO, but as LIMBS expands into more countries, it calls for more CPOs to volunteer their time and expertise. Volunteers pay their own airfare, with limited scholarships available, but once at the clinic, room and board is provided. The trips often last for seven to nine days at a time. Haiti is now populated with thousands of amputees. Most of these people will have to get by with the crudest of prostheses, like a non-articulating “peg-leg” which is currently the most common artificial leg in poor countries. A better, more sustainable solution is the LIMBS M1 Knee. LIMBS is hoping to add Haiti to its list of countries soon. In the meantime, learn about LIMBS by visiting www.limbsinternational.org.
Dr. Roger Gonzalez with patients Peter Mbuvi and Victor Rimba
2015
INDUSTRY NEWS
“ Canadian Court of Appeals sets precedent that an amputee is entitled to ‘the best prosthesis available’ which can be a potential landmark for future cases.” – Andrew Lok, CO(c)
Prosthetic Precedent Pursuing Compensation in Traumatic Amputation Cases By David Lackman, J.D. First published in Alignment 2015. An abridged version appears here. For the full article, with a specific case study, visit www.opcanada.ca.
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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 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. Although 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 prostheses and limbs (e.g. socket/ suspension systems), functionality of prosthetic limbs (e.g. micro-processor and impulse-driven myo-electrics), and aesthetics (e.g. prostheses that mimic the cosmesis of natural limbs). These advances are of course the products of inventiveness, not to mention substantial investments in research and development. The costs associated with acquiring such devices are therefore significant. 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, including provision for state-of-theart prosthetics 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. It was not until the 1980s, however, with this important principle in mind, that issues of full compensation for amputee victims, fairness to defendants, and expensive technology-driven devices, collided in the Courts of Ontario.
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 needs,
therapy needs, 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. About the Author: David Lackman is a senior counsel practicing with Gluckstein Personal Injury Lawyers 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.
IN MEMORY
The orthotic and prosthetic profession lost some great pioneers, advocates and friends over the last 10 years. The following touches on several, and their tremendous contributions to the profession. Please visit www.opcanada.ca for the complete published profiles on these remarkable individuals.
Fly in Peace Friend A Tribute to Dietrich Bochmann, CPO(c), FCBC (1934-2012) By Karl Ruder, CPO(c), FCBC First published in Alignment 2012.
Dietrich Bochmann, an icon in the field of prosthetics, has left us and will be remembered for his extraordinary skills and tenacious will to guide, mold, and promote our profession. Dieter was born in Berlin, Germany, in 1934. He grew up in the difficult times of WWII, and the more difficult post-war years. He completed a 3 ½-year apprenticeship combined with a college program in a private prosthetic and orthotic facility owned by Sepp Heim’s father to become an Orthopadie Mechaniker. A great number of well-trained individuals could not be employed by the industry, so Dieter, like many others, found work in other fields that needed skilled individuals. He worked for a few years in an automobile and vending machine assembly plant until he decided to emigrate to Canada in 1954. I met Dieter in 1959 when I sought employment at the Acme Artificial Limb Co. at 2184 Dundas St. W. in Toronto, owned and operated by Harold F. Nitchke... starting wages were $25 weekly, with no benefits. At the time, Dieter was a traveling limb fitter, covering a vast area of Ontario, fitting, adjusting and
repairing prosthetic devices and measuring for new appliances to be made in Toronto, mostly by me. He attended pre-arranged clinics in London, Timmins, Sault Saint Marie, Kapuskasing, Pembrook, Belleville and Kingston. On his way, he also saw amputees in their homes, doing alignments in their hallways or easing prosthetic sockets, clamping the device between his legs and using a pulling tool to remove material. I worked with Dieter for quite a few years at Acme, and we were very much aware that our profession needed major changes, especially in education, since well-trained immigrants from Germany (at times referred to as the “German Innovation”) were dwindling to none. I recall many heated discussions about how to make these changes while walking to the parking lot, standing in front of our cars, sometimes for hours. We have come a long way. 90
Dieter’s skills went well beyond prosthetics and orthotics. He enjoyed fishing and hunting, and as someone who grew up in an era where money was scarce, he believed strongly in the motto, “never buy what you can make.” He built a flat-bottomed boat in his basement, and the workmanship was firstclass, as always. The problem was that he couldn’t get it out through the basement windows as planned, so a slight “modification” of the wall became necessary. Dieter also used his ability and never-tiring will to advance our profession. I had the pleasure of working with him on many committees. He was part of a group that brought the Ontario Association of Prosthetists and Orthotists to life, which included countless meetings to encourage the province’s Ministry of Health to fund prosthetic and orthotic devices – the Adaptive Devices Program. He was among the group of four individuals that created the clinical program at George Brown College (G.B.C.), which was long overdue. It must be noted that at a critical point in time for our profession Dieter shone at many meetings that were held to convince the Health Science Chairperson that we, our profession, should be taught by us and function as a separate program directed by us, for us. Once, during a heated discussion, the chairperson stood up from the table and said, “I want my program.” Dieter stood up in response and stated in no uncertain terms, as was Dieter’s way: “Mr. Chairman, this is not your program. It is our program.” Few individuals in our profession have donated more time, effort and action as Dieter did over so many years, from the birth of G.B.C. Prosthetics and Orthotics Programs, to its present state.
A Life Well Lived. A Man Well Loved. A Tribute to Frank Hayday, CPO(c) (1945-2011) By Nolan Hayday First published in Alignment 2011.
Frank Hayday was born to Lillian and Frank Hayday on September 9th, 1945 just as the Second World War was ending. He was raised in Whitechapel, a poor neighbourhood in the East End of London, England. His dad owned a small green grocery store called Coronation Gardens. Frank, Jr. learned early the necessities of working hard to reach success. He left school at age 15 as was normal in those days. In his search for a job, he went to the Youth Employment Centre in his area. He told them he liked making things and working with his hands. He got an interview at Cox Orthopaedic - a shop that provided orthotic services and sold medical instruments. He was hired and trained as an orthotic technician. Apart from a couple of short-term jobs in a brewery and metal fabrication shop, he returned to work in the orthotic field for the rest of his life. At age 21 he was promoted to Intern as a Certified Orthotist. He went to school part-time (after a full day’s work), studying at Paddington Technical College with many “in house” training courses at different hospitals throughout London. After two years, he obtained his British Certification in Orthotics in 1972. The grass was never to grow under Frank’s feet. He was always looking for something to better himself and the lives of his wife and children. His decision to immigrate to Canada didn’t come lightly, but it was probably one of the best deci-
sions he and Rosemarie ever made. They arrived in Canada in 1974 with little money and few belongings. Their daughters, Claire and Angie, were aged five and three respectively. Frank had been promised a job in his chosen field, but it unexpectedly fell through. It was a difficult time, but he did what a man had to do... working for $3.00 an hour at a stucco company and then installing table bases in restaurants and bars. He finally got a job in the orthotic field in 1975 at the Colonel Mewburn Pavilion in the D.V.A. Orthotic/ Prosthetic Centre at the University of Alberta. However, his British certification wasn’t accepted and he had to train all over again. In 1979 Frank obtained his orthotic certification, and his prosthetic certification in 1982. With Rosemarie beside him, they bought a company called Karl Hager Limb & Brace in 1979. With a strong work ethic, and an imaginative mind, they created knee braces and specialty orthoses and prostheses for 30 years. 91
Frank’s commitment to the field went beyond the doors of his facility. He held various positions, including president of the Alberta Association of Orthotists & Prosthetists. He sat on the board when the Alberta Aids to Daily Living program was being established and was one of the founding members of the Alberta Amputee Sports and Recreation Association. He supported CAPO [now OPC] as a presenter and exhibitor at conferences. He frequented George Brown College and BCIT, providing clinical education presentations on knee bracing and casting. Throughout Frank’s life, he was always looking to improve things. He had an uncanny knack of envisioning solutions in his mind and then building devices just as he imagined them. Here are the words inscribed on the bench that friends and family bought for Frank for his 65th birthday. It sits on the trail, opposite City Hall, in St. Albert, Alberta.
FRANK HAYDAY A Man Well Loved – A Life Well Lived A man’s life well lived is one that, with a good wife beside him, raises a cherished family; has the adoration of his grandchildren; achieves success in his business and athletic (triathlon) endeavours and leaves this world with his “Bucket List” empty. its present state.
IN MEMORY
Striving Ever Forward A Tribute to Jocelyn Ann Fawcett Goux, B.Sc., CP(c), FCBC (1959-2010) By Catherine Barrette, Kirsten Simonsen and Pascal Goux First published in Alignment 2011.
“The most authentic thing about us is our capacity to create, to overcome, to endure, to transform, to love and to be greater than our suffering.” – Ben Okri On the evening of December 18, 2010, in the arms of her loved ones, prosthetist Jocelyn Ann Fawcett Goux, B.Sc., CP(c), FCBC, ended what she poetically termed her “uphill bike ride” with melanoma. Jocelyn’s family, friends and colleagues gathered in Ottawa to celebrate her life on December 23rd, one of those sunny winter days that Jocelyn would have enjoyed skiing on the crisp snow. They shared touching memories about her vivacious spirit, her love for her family and her important contributions to the prosthetic profession. At the end of the celebration, a woman confidently made her way to the podium. Her first words, “Look how well I walk,” were met with a spontaneous applause as a collective recognition for Jocelyn’s pivotal role in rebuilding people’s lives. Jocelyn believed in transformative strength against insurmountable odds. While pain and tears often accompanied those who were broken, Jocelyn admired their perseverance to regain a
sense of wholeness. She embraced the amazement and joy on the faces of those who stood and took their first steps again. Jocelyn regarded the relationships with her patients as central to her profession, where sharing, support and encouragement are the keys to regaining mobility and promoting healing. This is what truly motivated Jocelyn in her patient advocacy and many volunteer efforts in our profession. Twenty years ago, Jocelyn became a prosthetist as her chosen career. Her first employment as case manager in the Ontario workplace compensation system (now WSIB) left her longing
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to help people and to make a difference. Known as an excellent costume maker, Jocelyn was fascinated by the idea of creating a leg to make mobility possible, or an arm to hold an object. Since 1990, the prosthetic profession offered Jocelyn the unique opportunity to combine art with science while improving the quality of life for those missing limbs. Jocelyn was a strong voice in representing the interests of practitioners in the prosthetic field. Keeping up with current practices and technological advancements, Jocelyn participated in conferences across North America and Europe where she was well known as a competent networker and Canadian ambassador. The personal relationships that she nurtured over the years assisted her in her endeavors as the chairperson of our profession’s Biennial Conference in 2004 and in her role with the organizing committee for the Vancouver World Congress for the International Society of Prosthetics and Orthotics in 2007. Jocelyn taught us many things and would wish us the courage to enrich our lives, continue to improve patient care and strive ever forward.
National Conference August 8-11, 2018 - Ottawa, ON
National Conference August 8-11, 2018 OTTAWA
OPC 2018 National Conference August 8-11, 2018 Ottawa, Ontario
The OPC National Conference is aimed at providing vital educational content and business development tools to adapt and navigate this era of technological change and advancement in the P&O industry.
“CAPITALizing on Change; CLAIMing our Domain” 2018 marks the first year the Tech Symposium is integrated into the OPC National Conference and with that a better technological perspective to all the programming for Certified Clinicians and Registered Technicians alike.
Conference Highlights: • “The Business of the Orthotic & Prosthetic Profession” PreConference Workshop (separate registration required) • Ottobock Welcome Reception • The O vs. P Ortoped Softball Game & BBQ • Gala Dinner at the Canadian War Museum
At OPC we work hard, and we play hard. At our National Conference we plan to do both. Join us for this exciting event full of great educational, social and networking opportunities.
OPC 2018 National Conference “CAPITALizing on Change; CLAIMing our Domain” August 8-11, 2018 | Ottawa, ON | www.opc2018.ca opcanada.ca
IN MEMORY
The Pioneer A Tribute to John Arnet “Arnie” Pentland (1920-2009) By Dave Gans, CO(c), FCBC First published in Alignment 2010.
“We have the view and vision that we have today because we are standing on the shoulders of giants that have come before us.” - Author unknown On September 17th, 2009, the prosthetics and orthotics community lost a giant from within our ranks with the passing of “Arnie” Pentland at the age of 90. For many across Canada, this gentleman’s name will mean very little in terms of who he was and what he did. In fact, only a few of us have some understanding of Arnie the man and his profound role in the formation of the prosthetics and orthotics profession in Canada. I have the privilege here to endeavour to share with our members what Arnie meant to our profession in its early formative years, and how his passion and commitment continues to the present day. Arnie lost his left leg above the knee at the age of seven, which undoubtedly served to provide him with a keen interest in prosthetics. Prior to entering the field in his hometown of Winnipeg, Arnie had entered a Pre-Med program to pursue a medical career, but ultimately decided to follow his personal interest in prosthetics. With Arnie’s passion for education, and its value for our developing profession, he taught the first anatomy classes at a P&O school at Trautmanns in Minneapolis, Minn. In 1950, after moving to Vancouver, Arnie opened up his own practice on Cambie St. He incorporated
J.A. Pentlands in 1951. He and his dear wife Mabel, whom he leaves behind after 65 years of marriage, grew the practice together, managing it until Arnie retired in 1985. It would be impossible to list Arnie’s litany of accomplishments in this article, but I refer the prosthetic and orthotic professional to “A Canadian History of Prosthetics & Orthotics: 1955-2004”, for an understanding of this outstanding practitioner’s achievements on behalf of the profession. But with the help of David Moe, CP(c), the following highlights some of the most significant contributions that Arnie provided. David was the last CAPO [now OPC] member to interview Arnie, and provided valuable insights for this tribute. The founding members of our profession first met in Toronto in 1955. Arnie’s name was initially mentioned in a meeting convened 94
in Montreal in 1962, and marked the inclusion of practitioners from coast to coast for the first time. It was not long before Arnie found himself being regularly called upon to represent the profession. He had quickly demonstrated to his colleagues both a keen business mind and a passion for the P&O profession. In 1965 he was elected to the president’s office and held that position for two consecutive terms. In fact, Arnie served as president for both CBCPO and CAPO on more than one occasion. Arnie was always concerned about Canada’s ability to provide educational opportunities for its own needs and to that end was the driving force in establishing the BCIT program in P&O. He even provided classroom facilities for the first student intakes out of his own pocket to get the program going. If it hadn’t been for his personal involvement, BCIT may well not exist. It is true to say that much of what Arnie Pentland did for our profession happened many years ago. And although it is also true that we live in a different time, what this visionary did back then has allowed us to have this time now. Make no mistake, without John “Arnie” Pentland and his colleagues, our time now could be quite different. Thank you Arnie, for who you were and for all that you did for the promotion of our profession, “your” profession. We have lost a great friend of P&O, but we will not forget you.
www.ortoped.ca
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Replicates Human Motion Patented 3D asymetric joints reproduce the natural tridimensional kinematics of the knee. This unique mechanism replicates internal and external rotation. abduction and adduction as well as anteroposterior and vertical displacements of the knee. The fluid motion of the knee reduces strain on other joints as well.
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IN MEMORY
Mr. Veteran In Tribute to H. Clifford Chadderton (1919-2013) By Jeff Tiessen First published in Alignment 2014.
Known to Canadians as “Mr. Veteran,” Cliff Chadderton was renowned as Canada’s most influential developer of innovative programs and services for war, civilian and child amputees, and as a tireless advocate for veterans. He held the position of Chief Executive Officer of The War Amps for 45 years (1965 - 2009) and was the originator of The War Amps’ Child Amputee Program. Chadderton passed away in November, 2013, at the age of 94. “Cliff was a truly remarkable advocate who dedicated his life to protecting the interests and rights of veterans and their families,” sums Chairman of The War Amps Executive Committee Brian Forbes, who had the privilege of working with Chadderton for over 35 years as Association Solicitor and as his personal legal counsel. “Cliff was an inspirational leader of the veterans’ community in Canada and when he took on a crusade, his tenacity and determination were legendary,” shares Forbes, noting that his first priority in all initiatives that he led was to ensure that veterans and their families attained deserved compensation and benefits for the disabilities they suffered in the defense of their country. A D-Day veteran, Chadderton lost his right leg below the knee in October 1944 battling for the Scheldt Estuary in Belgium and Holland. Following the war, he held several positions in The War Amps before his appointment as Execu-
tive Secretary (later Chief Executive Officer) of the association in 1965. He was also Chairman and, at the time of his passing, Honourary Chairman, of the National Council of Veteran Associations (60 member groups). Determined to ensure that the programs started by returning war amputees would endure, Chadderton’s “amputees helping amputees” philosophy still serves as a cornerstone of the organization. Chief among his accomplishments was founding The War Amps’ internationally-renowned Child Amputee (CHAMP) Program, which assists thousands of amputee children across Canada with the cost of prosthetic limbs, and provides counselling and regional seminars. He also established several other programs including PLAYSAFE to promote child safety with a “kids-to-kids” approach, Matching Mothers to bring together new and experienced CHAMP
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families for advice and support, and JUMPSTART which ensures that children with multiple amputations have the computer skills they need for an independent future. During his life and career, Chadderton received numerous awards, including Companion in the Order of Canada, the Order of Ontario, induction into the Canada Veterans Hall of Valour and the Canadian Disability Hall of Fame, Knight in the Order of the Legion of Honour of France, the Minister of Veterans Affairs Commendation, the Royal Bank Award for Canadian Achievement and the Queen’s Diamond Jubilee medal. But for him, his greatest achievement was the creation of the CHAMP Program. It, and the solid foundation of other programs for amputees that he established, will continue well into the association’s second century as his long-standing legacy. It remains the only program of its kind in the world. To learn more visit www. waramps.ca.
INDUSTRY NEWS
Product Showcase New & Improved for 2018 OrtoPed Spotlight RUSH EVAQ8™ The RUSH EVAQ8™ Foot Collection is an easy solution that provides maximum vacuum efficiency in just a few quick steps. The simple, integrated design stabilizes volume, increases linkage, and heightens proprioception through elevated vacuum suspension at levels upwards of 22inHg. The RUSH EVAQ8 Foot Collection offers an all-terrain, waterproof (fresh or salt water) foot that requires minimal maintenance and is free of bulky components. Available in the RUSH LoPro®, HiPro® and ROGUE® models, the EVAQ8™ provides the perfect option for individuals seeking elevated vacuum suspension. No batteries or mechanical pump required.
AXIS® Formerly the LTI Locking Shoulder Joint, the new AXIS® has been re-engineered by College Park. The AXIS provides task control, a natural range of motion, and ease of use for the patient’s daily life. With a friction hinge, the patented shoulder joint operates by simple switches that simplify harnessing by eliminating the need for gross body movements. The AXIS can be integrated with all upper limb control systems using a special channel to conceal and protect cabling. The AXIS offers 240° range of motion with 180° abduction with 25 locking positions. The AXIS is available in endo or exo versions.
Clubfoot Solutions Iowa Brace Formula Posterior Mount Foot
The Clubfoot Solutions Iowa Brace was designed to help prevent the recurrence of clubfoot, once a child’s foot has been corrected using the Ponseti method. The Iowa Brace’s design includes comfortable shoes which are anchored to a removable, durable positioning bar. The contoured AFO inserts feature cupped heel counters that stabilize the foot, reducing friction while promoting proper usage. The brace can be used with the left or the right foot and offers adjustable angles of either 60° or 30°. The availability of 12 different sizes allows the Iowa Brace to accommodate any child as they grow.
The Formula posterior mount foot from Fillauer provides flexibility and power, creating a dynamic foot that fits a wide breadth of patients. The long, lightweight carbon pylon provides critical energyreturn to the user through the posterior attachment, while the compact shape of the ankle allows for better cosmetic finishing without hindering foot performance while worn with a shoe. The Formula offers numerous benefits from a posterior mount design to a full split toe allowing for maximum multiaxial function. Practitioners will appreciate the diverse range of fitting options and customization available for their patients, with the Formula foot.
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OrtoPed Spotlight continued Adjustable Pylon
Evoke
Kinetic Revolutions’ Adjustable Pylon offers strength and stability in three different sizes: short, standard, and paediatric. These aluminum pylons are designed and tested for definitive use for any age range, up to a K4 activity level. The Adjustable Pylon is comparable in weight to common pylon and tube clamp assemblies, but offers adjustability using a threaded telescoping mechanism. This mechanism eliminates cutting, grinding, and wasted pylon scraps which in turn maximizes practitioner efficiency. Practitioners can obtain a 1/16'' of height adjustment with each full revolution.
Osskin’s Evoke is the first OA knee brace in the world that is able to reproduce the natural movement of the knee. By using an advanced algorithm, design software, and 3D printing, Osskin has developed the lightest and thinnest knee brace in the world, weighing a total of nine ounces. The brace provides unloading and pain relief for patients with mild to severe uni-compartment OA. The bespoke design utilizes state-of-the-art proprietary technology allowing for a true bespoke knee brace that fits any body type and increases patient compliance.
For more information on these products and others distributed by OrtoPed call 1-800-363-8726 or visit www.ortoped.ca.
Ottobock Spotlight Custom Silicone Footshell
More power to go farther with Empower®
Ottobock’s Custom Silicone Services team offers a custom footshell to match your client’s unique colour and shape. Featuring six to eight skin tones, the footshell complements the sound side, with multi-coloured silicone nails, and the option of a split-toe design. The footshell is fabricated using high-temperature-vulcanized silicone and a dyneema toe cap for added strength and durability at the distal end of the carbon foot.
Empower is the only prosthetic foot with powered propulsion which emulates the function of lost muscles and tendons. With each step, the prosthesis delivers energy rather than consuming it, and provides a full 22 degrees of plantar flexion. It also reduces stress on joints and offers active patients the combination of power, control, and stability.
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INDUSTRY NEWS
Ottobock Spotlight continued ProFlex™ Plus Sealing Sleeve
WalkOn® Carbon Fiber AFO
Three colours and sizes. Two lengths. ProFlex Sleeves — delivering proven performance for the last 10 years. This soft, yet tough, sealing sleeve is designed with a more flexible fabric and smoother proximal seam. It features 15 degrees of flexion, for easier bending and less bunching behind the knee, a preformed knee cap for lower stress on the patella, and a conical shape proximal for improved thigh fit and tighter distal shape for enhanced sealing on socket.
WalkOn® AFOs are prefabricated from advanced prepreg carbon composite material designed to help users with dorsiflexion weakness walk more naturally. WalkOn AFOs are lightweight, low profile, and extremely tough. Their dynamic design can help patients achieve a more physiological and symmetrical gait, offering fluid rollover and excellent energy return. WalkOn offers a full range of AFO sizes and designs including the WalkOn Reaction Junior paediatric sizes. Fast and easy to fit, the WalkOn footplate is trim-able and can be shaped with scissors, often requiring only one office visit.
Omo Neurexaplus Shoulder Orthosis Redefine recovery with Ottobock’s Omo Neurexa. The shoulder orthosis facilitates active rehabilitation by correctly positioning the arm and promoting movement for patients with shoulder subluxation. The Omo Neurexa inhibits pathological movement patterns, improves body posture and gait, and can be applied by patients themselves with one hand.
bebionic® The bebionic® prosthetic hand leverages pioneering technology and innovative design to provide one of the best lifelike, multi-articulating prosthetic hand solutions available. Offering unprecedented control, the bebionic is fitted with one of four wrist options to suit individual requirements. The hand is also available in small, medium and large sizes. Once fitted, the intuitive and more precise hand empowers users to embrace their everyday life experience with confidence, pride, and control.
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Ottobock Spotlight continued Prosedo™ 3R31
C-Leg 4
Ottobock has been developing medical technology products for people with limited mobility for more than 90 years. We have a wide range of fitting solutions and prosthetic products to help your K1 patients lead lives as actively and independently as possible. The lightweight Prosedo 3R31 lock knee, with adjustable sitting assist, gives relief on the sound side and offers increased safety and security for those with lower mobility, allowing your K1 patients to walk, sit and transfer with confidence.
When you want dependability you can count on, turn to the C-Leg, with an unmatched, industry-leading track record. The C-Leg prosthetic knee lets your patients live more actively and independently, reclaiming the things that make life fuller and more fulfilling. More than 40 studies verify the benefits: • significantly reduced falls • more active in a broader area • f ewer distractions, since more stability means attention isn’t focused on avoiding obstacles • enhanced confidence in the prosthesis To learn more about the C-Leg or read a study, visit: professionals.ottobock.ca
For more on these products and others from Ottobock, contact us at 1-800-665-3327 or professionals.ottobock.ca for details.
NEW FOR 2018
Why Microprossesor Knees are Beneficial for All K-Levels A Literature Review
By Christine Richardson, M.Sc., Prosthetic Resident The loss of a limb leads to a significant alteration in a person’s activities of daily living (ADLs), quality of life (QOL), and independent living 1. In a recent literature review, the benefits for a transfemoral amputee (TFA) who receives a microprocessor knee (MPK) compared to a mechanical or a non-microprocessor knee (NMPK) were evaluated. Functional loss due to amputation can be assisted with appropriate componentry selection 1, socket fit, and rehabilitation. The prosthetic knee design and function are critical as it allows for stabilization, control, and a more effective ability to ambulate 1.
Extra forces on the contralateral side can be reduced, minimizing potential pain, strain on muscles, or arthritis, which are secondary health-related problems for TFAs 2, 3. Several articles explained that a TFA with an MPK compared to a NMPK had decreased energy expenditure, decreased risk of falling resulting in greater patient safety, increased benefits to the body, and an overall increased QOL4-8. Falls still occur for TFAs: 26% of MPK users fall, however it is statistically lower than NMPK users who have a fall rate of 82% 2.
An MPK is a computer-controlled device that is comprised of position-detecting sensors that determine the forces acting upon the knee when the amputee is in stance or swing phase9. This technology allows for reduced cognitive effort, resulting in a reduction of stumbles and falls8. Research and literature reviews confirm that a TFA with an MPK has “improved gait symmetry, lower energy consumption, decreased cognitive demand, improved performance on stair and hill descent, reduction in stumble recovery and falls, and 102
increased satisfaction”7; p. 1381. Physical effects of using an MPK include reduced fatigue/cramping of the muscles, decrease of phantom limb pain, and less discomfort in the back and hip5. The literature has explored the benefits of an MPK; usage can aid in decreasing costs associated with a TFA’s rehabilitation and work to improve QOL. A TFA can experience improved energy expenditure, increased safety with decreased risk of falling, and benefits to the body by decreasing load on the contralateral side. Body energy expenditure ambulation for a TFA puts a greater
demand on the body, including increased heart rate and energy expenditure when compared to non-amputees8, 10. A unilateral TFA requires a 60% - 100% increase in effort and demand in energy expenditure to ambulate, even when the walking speed is reduced 5, 6. The use of an MPK allows for decreased contralateral loading and more symmetrical gait, which leads to a reduction in metabolic energy consumption1, 11. Oxygen consumption decreases for an amputee when using an MPK compared to a NMPK1. Gait becomes smoother with decreased demand on the hip extensors12. Increased energy expenditure in amputees can lead to increased fatigue, which results in stumbles and falls. Safety and limiting fall risk for a TFA when using their prosthesis is essential. “Proper selection of the prosthetic knee is critical because this joint requires the highest degree of control for safe ambulation”7; p. 1381 . When an amputee receives a prosthesis, they must feel confident and supported to ensure stability and more importantly, safety9. In a 12-month period, 52% of the population reported falls, 49% had a fear of falling, and 65% had low confidence in their balance when evaluating lower extremity amputees7. Stance and swing phases are regulated faster with an MPK, allowing for an improvement in safety. MPK users found that they experienced fewer falls due to the stumble recovery feature of MPKs and that their balance had improved9. Serious falls may lead to injuries and death; “for every 10,000 people, MPKs result in 82 fewer major injurious falls, 62 fewer minor injurious falls, and save 11 lives”2; p. vii. Increased confidence and improved reliance when using a prosthesis allows for an ideal gait and achieving knee flexion throughout stance phase, especially in loading response7. The control
of an MPK in stance and swing phases allows for significant improvements in patient confidence and security in their prosthesis when evaluating stumbles and falls5. Having a more natural gait as an amputee leads to improved stability and balance8. The use of an MPK reduces the prevalence and risk of falling when compared to a NMPK and provides benefits to the contra-lateral side1, 2, 4, 11. Benefits to the contralateral side… amputees who do not distribute their weight onto the 103
prosthesis and bear more weight on the contralateral side experience an increase in pain and joint degeneration. This is why TFAs have a greater rate of degenerative arthritis in their contralateral limb compared to non-amputees3. An MPK leads to decreased loading of major joints on the contralateral side5. Over a 10year period, osteoarthritis rates decreased from 20 to 14 percent in TFAs using an MPK2. Amputees who walk with an altered gait or distribution of load may experience
NEW FOR 2018
contralateral limb pain, back pain, osteoarthritis or osteoporosis8. When the load is decreased on the contralateral side while using an MPK, the amputee is more relaxed when standing and limits the number of continuous postural corrections4. Decreasing the load on the contralateral side leads to a comfortable and secure prosthesis, minimizing the conscious awareness allowing for increased rehabilitation success4. The technology in an MPK allows for a more efficient gait, which results in decreases in secondary joint pain and disability as well as allowing for improved QOL3. Quality of life for TFAs who ambulate using an MPK have “significantly increased their physical activity during daily life, outside the laboratory setting, and expressed an increase in quality of life”7; p. 1380. TFAs report increased confidence, improved balance,
and greater activity level after receiving a MPK8. The technological advances of an MPK compared to a NMPK allow for patients to vary their gait, use ramps/stairs, walk on uneven terrain with confidence rather than avoidance5. MPKs allow for “improved confidence, security, stability, and functional abilities of amputees to achieve ADLs”5; p. 40. The use of an MPK may lead to decreased degenerative changes for TFAs8. By decreasing the conscious control necessary for ambulation, MPK users are able to use stairs/ramps without avoidance, decrease the need to voluntary control, and improve their QOL and reduce mental fatigue6, 11. The QOL index showed that TFAs who use an MPK have increased energy conservation, less fatigue physically and mentally, and increased function when returning to home and the community environment10. 104
QOL questionnaires, the 36-Short Form Health Survey (SF-36) and Prosthetic Evaluation Questionnaire (PEQ), found that MPK users improved their QOL scores by 37%2. On average, a TFA who uses an MPK wears the prosthesis for 8.8 years longer than those with a NMPK2. “Statistically significant improvements in subjects’ ability to descend stairs, time required to descend a slope, sound-side step length while descending a hill, preference, satisfaction, self-reported frustration with falling, and self-reported frequency of stumbles, semi-controlled falls, and uncontrolled falls while wearing an MPK are reported over other functional knees”1; p. 216. These improvements in QOL allow for overall better health and longer prosthetic wear during a lifetime, which results in lower healthcare costs.
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“ When evaluating energy cost, safety and risk of falling, benefits to the contralateral side, QOL, and cost, an MPK shows significant benefits when compared to a NMPK.” The initial cost of the MPK is more expensive than a NMPK however, the overall cost to direct healthcare are considerably reduced2, 9. “Societal cost-effective data found that MPKs is the dominant prosthesis strategy proving lower societal cost”9; p. 374. Societal costs such as rehabilitation, productivity loss, caretaker costs, and housekeeping costs are less when an amputee is provided with a MPK9. Patients functioning at a high k-level, as well as those who need improved stance and swing control or are limited in ambulation, can all benefit from MPK use10, 13.
2. Liu, H., Chen, C., Hanson, M., Chaturvedi, R., Mattke, S., & Hillestad, R. (2017). Economic value of advanced transfemoral prosthetics. RAND Corporation.
K. R. (2010). Safety, energy efficiency, and cost efficacy of the C-Leg for transfemoral amputees: a review of the literature. Prosthetics and Orthotics International, 34(4), 362-377.
3. Segal, A. D., Orendurff, M. S., Klute, G. K., & McDowell, M. L. (2006). Kinematic and kinetic comparisons of transfemoral amputee gait using C-Leg® and Mauch SNS® prosthetic knees. Journal of Rehabilitation Research and Development, 43(7), 857.
10. Seymour, R., Engbretson, B., Kott, K., Ordway, N., Brooks, G., Crannell, J., & Wheeler, K. (2007). Comparison between the C-leg® microprocessor-controlled prosthetic knee and non-microprocessor control prosthetic knees: A preliminary study of energy expenditure, obstacle course performance, and quality of life survey. Prosthetics and Orthotics International, 31(1), 51-61.
When evaluating energy cost, safety and risk of falling, benefits to the contralateral side, QOL, and cost, an MPK shows significant benefits when compared to a NMPK. Most importantly, a patient with an MPK reports having a higher sense of safety. If an amputee does not feel stable on their prosthesis, they are less likely to use the device. Research shows that TFAs using MPKs have a longer “prosthetic life” than those using a NMPK. When a patient starts on an MPK, there is data to show a decrease in falls, increase in energy, less pain and mental fatigue, overall lower costs of their prosthesis and health care, and an increased QOL.
5. Berry, D., Olson, M. D., & Larntz, K. (2009). Perceived stability, function, and satisfaction among transfemoral amputees using microprocessor and nonmicroprocessor controlled prosthetic knees: a multicenter survey. JPO: Journal of Prosthetics and Orthotics, 21(1), 32-42.
References: 1. Hafner, B. J., Willingham, L. L., Buell, N. C., Allyn, K. J., & Smith, D. G. (2007). Evaluation of function, performance, and preference as transfemoral amputees transition from mechanical to microprocessor control of the prosthetic knee. Archives of Physical Medicine and Rehabilitation, 88(2), 207-217.
4. Bellmann, M., Schmalz, T., Ludwigs, E., & Blumentritt, S. (2012). Immediate effects of a new microprocessor-controlled prosthetic knee joint: a comparative biomechanical evaluation. Archives of Physical Medicine and Rehabilitation, 93(3), 541-549.
6. Chin, T., Machida, K., Sawamura, S., Shiba, R., Oyabu, H., Nagakura, Y., ... & Nakagawa, A. (2006). Comparison of different microprocessor-controlled knee joints on the energy consumption during walking in trans-femoral amputees: intelligent knee prosthesis (IP) versus C-leg. Prosthetics and Orthotics International, 30(1), 73-80. 7. Kaufman, K. R., Levine, J. A., Brey, R. H., McCrady, S. K., Padgett, D. J., & Joyner, M. J. (2008). Energy expenditure and activity of transfemoral amputees using mechanical and microprocessor-controlled prosthetic knees. Archives of Physical Medicine and Rehabilitation, 89(7), 1380-1385. 8. Kaufman, K. R., Frittoli, S., & Frigo, C. A. (2012). Gait asymmetry of transfemoral amputees using mechanical and microprocessor-controlled prosthetic knees. Clinical Biomechanics, 27(5), 460-465. 9. Highsmith, M. J., Kahle, J. T., Bongiorni, D. R., Sutton, B. S., Groer, S., & Kaufman,
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11. Bellmann, M., Schmalz, T., & Blumentritt, S. (2010). Comparative biomechanical analysis of current microprocessor-controlled prosthetic knee joints. Archives of Physical Medicine and Rehabilitation, 91(4), 644-652. 12. Johansson, J. L., Sherrill, D. M., Riley, P. O., Bonato, P., & Herr, H. (2005). A clinical comparison of variable-damping and mechanically passive prosthetic knee devices. American Journal of Physical Medicine and Rehabilitation, 84(8), 563-575. 13. Otto Bock (1999). 3C100 C-Leg Systems Practitioner Information Sheet. Minneapolis, Mn: Otto Bock Orthopedic Industry.
About the Author: Christine Richardson, B.Kin., M.Sc., has a bachelor’s degree in Kinesiology with a double major in Human Kinetics and Adapted Movement Science from the University of Regina. She is a graduate from the BCIT Prosthetics & Orthotics Clinical program, and McMaster with a Masters in Rehabilitation Science in 2016. She is currently completing her prosthetics residency at Winnipeg Prosthetics and Orthotics.
NEW FOR 2018
Northern Exposure
By Rajiv Kalsi, CO(c) Iqaluit, meaning “place of many fish� is the capital of Nunavut. The 2016 census reported that there were 7,740 people living in Iqaluit, and 35,944 people in the vast territory. The median age of the population of Iqaluit is more than 10 years younger than the national rate: 31.1 compared to 40.6 years old (Statistics Canada, Census Profile, 2016). Iqaluit is the smallest Canadian capital in terms of population, and the only capital that is not connected to other settlements by a highway.
There has been rapid change to the lifestyles of Inuit people over the last 50 years. Former nomadic peoples were transformed, sometimes through forced relocation by government, into sedentary communities. Since being moved to permanent settlements in the 1950s and 1960s, Inuit have lacked adequate housing and have suffered from related health problems (The Canadian Encyclopedia, 2017). Several hospitals in the Ottawa region provide health services to the citizens of Nunavut. Specialty clinics occur throughout the year
involving teams travelling from Ottawa to Iqaluit for a week or more, to provide services not available in the Territory. Travel is direct to Iqaluit on a Boeing 737 jet. Often, half of the plane is reserved for cargo, since the only way to get supplies to the region for most of the year is by air. In summer, sea lifts bring building supplies, fuel, vehicles and large items to Nunavut. Travel reservations, accommodations and meals are organized by The Ottawa Health Services Network (OHSNI) and financed by the Nunavut government. Physician, RN, and clinician per
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diems are covered by the Nunavut Government, and through OHSNI. OHSNI is a not for profit organization established in 1997. Its primary service is the Baffin-Ottawa Program, which coordinates specialists and tertiary healthcare in Ottawa and Iqaluit for residents of the Baffin region of Nunavut. OHSNI provides communication between all medical personnel and families in the North and in Ottawa, administrative support for appointments, nursing case management, medical records management and Inuktitut interpretation services while patients are in Ottawa.
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IS SUE 4 • Phantom Limb Pain • Amputee Humour: Fun or Folly? • Amputee Golf • Elective Amputation
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NEW FOR 2018
“ This profession has enabled me to travel to parts of the country and to meet people whom I would not have had a chance to otherwise meet.� OHSNI also facilitates telehealthcare between Nunavut and Ottawa. Clinics held in 2017 included OB/GYN, ENT, adult neurology, dermatology, adult cardiology, adult orthopaedics, allergy, internal medicine, urology; paediatric cardiology and paediatric orthopaedics (J. Plourde, personal communication, November 1, 2017). The adult orthopaedic team consists of two to three orthopaedic surgeons, a physiotherapist with a joint replacement program, and one orthotist. Clinics are held three times per year, and my colleague Ted Radstake and I alternate clinic years. Natalie Anglehart was the first orthotist from our Centre to work in Iqaluit in 1997, when it was still part of the Northwest Territories. We see between 40-50 people in one week. A typical day would involve the assessment of people requiring foot orthotics for conditions such as plantar fasciitis, hallux valgus, frostbite leading to toe amputations, general foot pain, lumbosacral supports due to degenerative conditions, knee orthoses for ligament injuries and osteoarthritis, AFOs for children and adults with a variety of diagnoses such as cerebral palsy, CVA, neuropathies, or KAFOs due to polio, spinal cord injury or other conditions leading to loss of knee extensor strength. Casts are brought back to Ottawa for fabrication, and devices are fit at the next scheduled clinic or in Ottawa. Adjustments to devices can be made on-site with the use of a belt-sander or hand tools that
we keep in the clinic. Coordinating services for children with cerebral palsy or other neurological conditions is challenging since physiotherapists and other support services based in Iqaluit have long wait lists, and they only visit remote communities a few times a year. Sometimes, children and adults come to Ottawa to access medical services, and that is often when we will be asked to provide orthotic devices for them while they are in the city. The North poses many challenges for residents and visitors. The weather can be unpredictable. The average daytime temperatures vary from -28 Celsius in February to +8 C in July, although it has been as cold as -45 C in winter (without wind chill) and as high as +26 C in summer (The Weather Network, 2017). Blizzards are not uncommon, with winds reaching over 100 km/hr. The extreme weather conditions can cause the city, including the hospital, to shut down. In such situations there is nothing to do except wait out the storm. Many commercial and residential buildings in Iqaluit are constructed atop steel pipes that are drilled 1.5 - 9 metres underground so that the buildings do not sink into the permafrost (Far and Wide, 2016). Elevated buildings pose a barrier for people with disabilities because the dwellings have steps to get into them, making them inaccessible. Many government and commercial buildings are now built with ramps leading to their entrances to help overcome issues of accessibility. This profession has enabled me
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to travel to parts of the country and to meet people whom I would not have had a chance to otherwise meet. My trips to the North provide just a glimpse of the life people live there. It is one of the many things I enjoy about being involved in this field of work.
References: The Canadian Encyclopedia. (2010). Inuit. Retrieved November 21, 2017, from www.thecanadianencyclopedia.ca/en/ article/inuit. Far and Wide. (2016). The Unique Architecture of Nunavut. Retrieved November 25, 2017, from http://farandwide.much. com/unique-architecture-of-nunavut. Statistics Canada. (2016). Census Profile, 2016 Census. Retrieved November 20, 2017, from www12. statcan.gc.ca/census-recensement/ 2016/dp-pd/prof/details/page.cfm? Lang=E&Geo1=CSD&Code1= 6204003&Geo2=PR&Code2=62 Data=Count&SearchText=Iqaluit&SearchType=Begins&SearchPR=01&B1=All&GeoLevel=PR& GeoCode=6204003&TABID=1 The Weather Network. (2017). Iqaluit. Retrieved November 26, 2017, from www.theweathernetwork.com/ca/ forecasts/statistics/nunavut/iqaluit.
About the Author: Rajiv Kalsi, CO(c), has worked as a Certified Orthotist with The Ottawa Hospital Rehabilitation Centre for 17 years. Prior to life in Ottawa he worked at facilities in Edmonton and Toronto.
NEW FOR 2018
Complex Regional Pain Syndrome A Case Study in “Unconventional” AFO Application By Stephen Shearer, CO(c), Hon. B.HK For the complete article, visit www.opcanada.ca.
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Complex Regional Pain Syndrome (CRPS) is a chronic pain syndrome usually resulting from some type of injury, usually injury to an extremity. CRPS is characterized by “pain, sensory-motor, and autonomic symptoms” (Berklein, 2005). In addition to psychological and sensory changes, physical symptoms can include “edema, skin blood flow (temperature) or sudomotor abnormalities, motor symptoms or trophic changes, in particular at distal sites” (Berklein). A literature search shows no prior published articles regarding the use of custom orthotic bracing to aid in offsetting the motor symptoms that can accompany CRPS. This case study outlines patient TL who presented at our facility with a previous diagnosis of CRPS from a Pain Management Team in British Columbia. The inciting trauma was the result of a motor vehicle collision. The primary complaint of TL was that when she has a “flare up” she experiences neuropathic drop-foot which can last for hours, days, or weeks depending on how long the pain lasts. This was very disheartening as she was a very active person prior to the accident, and since being diagnosed with CRPS, she has had to weigh the consequences of activities like long walks, hiking, shopping, and running. Doing these activities cause a pain flare up, drop-foot, and secondary gait deviations such as hip-hiking, circumduction, and vaulting. These gait deviations create more pain and further limit her ADLs, including her work. Orthotic intervention included a custom ESR-style AFO which had to have specialized trimlines to avoid “trigger points” on her leg which set off the CRPS pain attacks. Shoe fitting also included particular challenges outlined in the full article. Also included in the article are photographs provided by TL of some of the places she has been able to hike (including a mountain) since receiving her AFO.
Social Perception Bridging the Gap Between Fiction & Function By Sherry Fagan For the complete article, visit www.opcanada.ca. Orthotics Prosthetics Canada (OPC) is the representative national organization for the Canadian prosthetic and orthotic profession. Its role is to protect the public and advance the profession of prosthetics and orthotics (P&O). Historically, this has been achieved through quality standards of practice, professional credentialing via clinical certification/technical registration, ongoing education and building awareness. Today, social media extensively highlights prosthetic and orthotic devices that are exciting, creative and use new technologies within procedures of fabrication. While this may not be the practicing reality for most clinicians, there exists a need for continuing edu-
cation, involvement and evolution with new technologies if we are to survive in the field. It is becoming more apparent that technologies such as 3D printing, open-source information, and other high-tech solutions are beginning to have an impact on the way prosthetic and orthotic devices are produced today. This fluctuating relationship between technology and society directly influences how the world perceives our profession. However, this new and exciting relationship is far from perfect. This unique topic happens to present a national and global opportunity for OPC to educate both the public and interprofessional health sectors about the profession of prosthetics and orthotics. 113
It can directly enhance social perception and give positive feedback to the growing numbers of patients with functional disabilities, who may benefit from our services. Such is the case when we dive into the world of developing nations and technological challenges. Likewise, turning our attentions to socially-charged athletic events, like the Invictus Games, can provide invaluable insight to current social perceptions. OPC has sent out calls for future marketing strategies, to look at guiding practices of increasing awareness of the profession. Taking a closer look at how existing social movements are changing perceptions, we can begin to form a more complete picture of social and political views geared toward future growth and sustainability, both nationally, and abroad. Fundamental questions addressed in this research paper include what the goals and targets are for building public awareness. Secondly, can socially-involved communities, with the help of specially-trained clinicians and technological experts, bridge the gaps of knowledge and education that are clearly evident within the profession today?
Advertiser Index Ability Dynamic . . . . . . . . . . . . . . . . . . . Pg. 59 Action O&P . . . . . . . . . . . . . . . . . . . . . . Pg. 61 ALPS Canada . . . . . . . . . . . . . . . . . . . . . Pg. 71 Aplix . . . . . . . . . . . . . . . . . . . . . . . . . Pg. 114 Berretta Medical, Inc. . . . . . . . . . . . . . . . . Pg. 48 BREG . . . . . . . . . . . . . . . . . . . . . . . . . Pg. 75 Cascade DAFO . . . . . . . . . . . . . . . . . . . Pg. 101 CoApt . . . . . . . . . . . . . . . . . . . . . . . . .Pg. 89 College Park Industries . . . . . . . . . . . . . . . Pg. 47 Coyote Design . . . . . . . . . . . . . . . . . . . .Pg. 25 Fillauer Companies, Inc. . . . . . . . . . . . . . . Pg. 23
Fastening Systems for Orthotics, Prosthetics and Sports Bracing In consultation with our orthotics and prosthetics customers, Aplix Fasteners Inc. has designed our products to provide:
GAITRite . . . . . . . . . . . . . . . . . . . . . . . Pg. 51
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Myrdal Orthopedic Technologies . . . . . . . . . . Pg. 7
• ease of use and assembly
Myrdal Orthopedic Technologies . . . . . . . . . Pg. 29 Myrdal Orthopedic Technologies . . . . . . . . . Pg. 55 Myrdal Orthopedic Technologies . . . . . . . . . Pg. 79 OPC Conference 2018 . . . . . . . . . . . . . . .Pg. 93 OPIE Software . . . . . . . . . . . . . . . . . . . .Pg. 83 Ortho Active . . . . . . . . . . . . . . . . . . . . . Pg. 19 OrtoPed . . . . . . . . . . . . . . . . . . . . . . . Pg. 95 Ossur Canada . . . . . . . . . . . . . Inside Back Cover Ottobock Healthcare Canada . . . . Inside Front Cover
Our products are used in ankle and knee supports, arm and wrist supports, cervical collars, surgical corsets, wheelchairs, tensiometers and other applications. Our Service Network provides: • innovative design solutions • customized fastening systems • excellent customer service • expedited order capabilities
Ottobock Healthcare Canada . . . Outside Back Cover Ottobock Healthcare Canada . . . . . . . . . . . Pg. 53 ParaSport Ontario . . . . . . . . . . . . . . . . . . Pg.111 The Knee Centre/Karl Hager . . . . . . . . . . Pg. 32-33 Thrive magazine . . . . . . . . . . . . . . . . . . Pg. 109 Touch Bionics (Ossur Canada) . . . . . . . . . . . Pg. 17 TRS . . . . . . . . . . . . . . . . . . . . . . . . . . Pg. 48 Vorum . . . . . . . . . . . . . . . . . . . . . . . . Pg. 97 WillowWood Company . . . . . . . . . . . . . . Pg. 105
C O N TA C T U S Aplix Fasteners Inc. 4714 Christie Drive Beamsville, Ontario, L0R 1B4 Phone: (905) 563-1244 Fax: (905) 563 1266 Toll Free Fax: 1-800-922-7549 Email: custserv@aplixcanada.com
Empower
®
Control The system uses high resolution sensors to determine the correct amount of ankle power and ankle position in real-time, putting you back in control of your daily activities. Power Mimics normal muscle function of the lower limb by matching the ankle joint power output of a biological limb throughout daily walking ranges.
Stability Settings customized to each individual provides a more natural gait pattern and reduced joint impact. The large range of motion and energy return restores balance and allows you to confidently negotiate even the most challenging terrain.
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