Orthotics Prosthetics Canada
Alignment2016 The Official Publication of
Client-Centred Practice Enhancing the PatientPractitioner Relationship
Taking Stock in Outcome Measures
The Information Age
A Double-Edged Sword
Innovative Orthotic & Prosthetic Solutions
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Alignment2016 C O
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Industry News 6
President’s Greetings Dan Mead, CPO(c) OPC President
8 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 34 One Love: Improving Lives in Jamaica
O&P Solutions 72 Redefining the Human Connection
Special Feature Section lient-Centred Practice... Enhancing C 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
76 Clinical Case Study: An Innovative Solution for an OI Client 80 Our Journey to the Cybathlon: Developing an Intuitive Upper Extremity Prosthesis Control Strategy 84 A Complicated Case 87 Socket-less Socket 90 Custom Fabricated Exo-Skeletal Cosmetic Cover 94 A Client-Centred Approach to an Upper Extremity ADL Challenge 98 The Virtues of Varsol: The Skinny on (Paint) Thinner
Continuing Education 100 Student Papers 122 P&O Quizzes
Deadline for submissions for consideration for publication in Alignment 2017 is November 4, 2016.
Alignment 2016 Edition
OPC Committees Nominations Committee, Chair: Carla Reimer, CO(c) Professional Qualifications Committee, Chair: Scott Simmons, CP(c)
The official publication of Orthotics Prosthetics Canada PUBLISHED ANNUALLY OPC National Office Dana Cooper, MBA, CAE Executive Director Mara Juneau, Programs & Credentialing Director Sandra Fyfe, Member & Programs Administrator Chris Bossé, Program Coordinator 300 March Road, Suite 202 Ottawa, ON K2K 2E2 Phone: 613-595-1919 Fax: 613-595-1155 Email: info@opcanada.ca www.opcanada.ca
Certification and Registration Board (CBCPO), Chair: Stacey Brown, CO(c)
OPC Board of Directors (until June 2016) Dan Mead, CPO(c), President Dan Blocka, CO(c), FCBC, Vice President Mark Agro, CO(c), FCBC, Treasurer Ronald Bartlett, RTPO(c) Kieran Bliss, CP(c) Linda Laakso, CO(c) Leslie Pardoe, CO(c) Steve Scott, CP(c) Stan Wlodarczyk, CP(c) Warren Matthews, RTPO(c) Jason Adams, Director at Large
Publisher DT Publishing Group, Inc. 2276 Rosedene Rd. St. Ann’s, ON L0R 1Y0 Tel: (800) 725-7136 Email: jeff@disabilitytodaynetwork.com
Managing Editor Jeff Tiessen, DT Publishing Group, Inc. Tel: (800) 725-7136 Email: jeff@disabilitytodaynetwork.com
Art Direction Starr Hansen Email: sjdesignstudio@comcast.net Design and Layout SJ Design Studio Email: sjdesignstudio@comcast.net Editorial Committee Sharon Carr, CO(c) Krista Holdsworth, CO(c) Advertising Sales Jeff Tiessen, DT Publishing Tel: (800) 725-7136 Email: jeff@disabilitytodaynetwork.com Alignment and Orthotics Prosthetics Canada (OPC) make no representations or warranties with respect to the merchantability of the products and services reported or advertised in Alignment and the inclusion of any such product or service in Alignment magazine shall not be deemed an endorsement by OPC. OPC assumes no responsibility or liability for claims made for any products or services reported or advertised. Trademark symbols are associated with trademarked names upon first editorial reference in each article only. Printed in Canada. Contents © Copyright Orthotics Prosthetics Canada and/or the contributing author unless otherwise indicated.
Standards & Ethics, Chair: Peter Marinic, RTO(c), CP(c) Professional Practice Sub-Committee, Chair: Heather Miklovich, CO(c) Professional Development, Chair: Catherine Vallée, CP(c) Marketing & Communications, Chair: Dave Broman, CPO(c), FCBC Finance Committee: Chair, Mark Agro, CO(c), FCBC, and Treasurer, Member at Large, Alan Moore, RTPO(c), CO(c), FCBC
Alignment ONLINE
Executive Editor Krista Holdsworth, CO(c) Email: orthopro@orthoproactive.com
Associate Editor Brenda McCarthy Tel: (800) 725-7136 Email: brenda@disabilitytodaynetwork.com
Residency and Internship Sub-Committee, Chair: Amy Richardson, CP(c)
NEW MEDIA FOR C A N A DA ’ S O & P F I E L D Orthotics Prosthetics Canada joins the DT Network – the disability community’s first social media network. With its own Media Channel, Alignment goes digital in a whole new way... • • • •
I ND USTRY N EWS MF G & CL IN IC AL RESO URCES PRODUCT PHOTO S & VIDEO S S O CIAL M EDIA UPDATES
Alignment Online serves up new information for P&O practitioners all year long.
VISIT: www.disabilitytodaynetwork.com/alignment.
PRESIDENT’S MESSAGE
Leading the Advancement of Orthotics and Prosthetics The past two years have seen Orthotics Prosthetics Canada (OPC) in a state of constant change as we moved to an amalgamated organization. And the pace of change remains constant as new initiatives are being implemented and OPC continues to improve upon processes and initiatives to support the profession. At the end of 2015, the OPC Board of Directors undertook a strategic planning exercise to establish a prioritized plan for the next few years. As you can appreciate, significant change takes time and even a year or two is insufficient to accomplish substantial inroads into the challenges that we face, given the many day-to-day requirements that must be maintained. Further to the strategic priorities that were developed to help formulate our operational plan, there were some initiatives that simply had to be delayed at this time. However, with the increased level of efficiency and organization that OPC has strived for, our current priorities are sure to be achieved and then we will be able to direct our resources to the next ones on the list. The key directions that were identified will have an impact on the profession internally and externally. First, understanding that Certification and Registration are core purposes of OPC, the Board has made a commitment to reviewing the processes around the examinations and examination content to ensure that the content is current, reliable, valid and secure. OPC has contracted Professional Examination Services (ProExam) to guide the work. ProExam led CBCPO in the Practice Analysis survey. This examination blueprint and gap analysis initiative will accomplish one of the major outcomes expected from the Practice Analysis survey. The second priority that emerged involves educating and building awareness about the profession with key stakeholders. From my perspective this initiative is long overdue. We have been losing ground to other professions for some time now. The key stakeholders that have been identified are public and private payers, allied health professions and the public in general. It is imperative that awareness about our skills and competencies, and how they are used, is increased among these stakeholders. National Public Relations (NPR) has been contracted to assist us in developing a three-year strategy to educate and raise awareness amongst these important constituents. The OPC Marketing and Communications Committee will work with NPR in the short-term to develop those strategies and then obtain their assistance to implement them. These strategies will have opportunities for regional associations as the intention for the long-term strategy calls for provincial implementation. Increasing awareness that Certified Orthotists and Certified Prosthetists are health professionals providing specialized services will require several years of continual effort. Both of these priorities were born out of the 2015 membership survey... members wanting to see OPC advancing the profession. This sentiment reflects the new vision for OPC: “Leading the advancement of orthotics and prosthetics.� But we can only go as far as our members are willing to take us, and that does not happen without commitment and effort. If you have any questions, do not hesitate to contact me at dan.mead@sudburypando.com or contact the OPC National Office at info@opcanada.ca.
Dan Mead, CPO(c) President, Orthotics Prosthetics Canada
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2016
EXECUTIVE DIRECTOR’S MESSAGE
It’s been over two years that AMCES has been managing OPC. It is an understatement to say that a lot of change has occurred in that time. Change is a mainstay in all organiza tions today as technology, diversity and expectations evolve. However, it should be noted that change within OPC has not occurred because AMCES arrived on the scene. These changes have been initiatives pursued by the CAPO and CBCPO organizations for several years prior to AMCES’s involvement. With the guidance of OPC, and the resources and expertise of AMCES, the change that OPC wanted has come to be. AMCES is the company that is contracted to provide association management and consulting services to OPC. There are three full-time staff members dedicated to OPC on a full-time basis at our national office. Even though Mara, Sandra, Chris (maternity leave) and Dana are staff members of AMCES, their time and interests are dedicated to OPC. Our source of pride is OPC’s success and serving OPC members, committees and the Board of Directors. OPC staff provide expertise in administration and processes and proactively carry out their roles within the provided policies and guidelines. There is a continued need to work on governance to clarify roles and responsibilities which has been identified in the OPC strategic plan. After all, the organization is just over a year old and is working its way into efficient and effective processes. There is no such thing as a perfect organization and evolution is a continual process. The Association Management model is based on clearly outlining the organizational tasks and duties required to carry out and support its existing functions. Typically, special projects or initiatives that the organization wishes to undertake beyond the existing functions fall outside of the management services contract, calling for fees to support the extra time and resources required. Due to the tasks associated with the amalgamation, and special projects, it has been difficult to follow the Association Management Model principles in the case of CAPO-CBCPO-OPC. In 2016, with the implementation of the strategic plan and further governance adjustments, OPC will likely be more settled and the Association Management Model can be re-established. This will provide more clarity about the resources needed to run the organization on an ongoing basis and identify special projects and initiatives that need to be funded. We want to arrive at this point by the end of the year. We recognize that the remarkable change that has occurred over the past two years has been taxing on the volunteers. It has been very challenging for the staff as well. So, while we feel we have come a very long way in the short time that AMCES has been involved, there is still time to get to the point where the pace of change will slow down and we can all take a deep breath. That said, the AMCES staff will continue to work diligently to facilitate the success of OPC members, committees, Board and organization. Make sure that your plans for 2016 include the OPC National Conference in Banff, Alberta, August 3 to 6. It will be an inspiring time for the profession. The pre-conference workshop on Wednesday, August 3, focuses on the “Future of the O&P Profession”. Register today at www.opcanada.ca/conference. If you have any questions, contact me at dana@opcanada.ca or the office at info@opcanada.ca.
Dana Cooper, MBA CAE OPC Executive Director 8
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INDUSTRY NEWS
New Education Bursary Program The OPC Board of Directors, along with the Professional Development Committee, chaired by Catherine Vallée, are excited to announce that a new OPC Education Bursary program is available to OPC members to assist them with their costs associated with training and education. OPC members are eligible for up to $1,000 in funds to assist in their acquisition of knowledge and skills to serve the Canadian population. There will be two intake periods each year: January to June, and July to December. Bursary applications and the program guidelines are available online (www.opcanada.ca). The Professional Development Committee will review the applications and determine their eligibility. The amount of bursary funds available each year is dependent on the interest that the capital bursary fund generates each year. For 2016, a total of $10,000 is available for education bursaries ($5,000 each intake). Applications are taken at anytime and limited funds are available in each intake period. This is a very exciting opportunity for members. If you have any questions, do not hesitate to contact the Orthotics Prosthetics Canada office.
GOVERNMENT AND PUBLIC RELATIONS STRATEGY DEVELOPMENT OPC has initiated a key project from the strategic plan. National Public Relations has been contracted to facilitate the development of a three-year government and stakeholder relations strategy for the profession. They will begin their work immediately with research, information gathering and interviews. The identified outcomes are a public and private payer’s strategy that can be implemented provincially and nationally, a stakeholder relations strategy for allied health professionals and a public relations strategy. Objectives include educating and building awareness about the profession with these critical stakeholders and build relations. NATIONAL is the largest strategic communications firm in Canada, with offices across the country in Vancouver, Calgary, Toronto, Ottawa, Montreal, Quebec City, Saint John, Halifax and St. John’s. The firm serves corporate and institutional clients, offering a full range of strategic communications services, including corporate communications, public affairs, stakeholder engagement, marketing, healthcare and digital communications, as well as financial communications and investor relations under the name NATIONAL Equicom. NATIONAL is uniquely positioned to assist OPC in promoting and addressing public payer needs at both the provincial and federal levels, increasing awareness and educating private payers about the profession, and improving relations, building awareness and educating referring professionals. As OPC members have indicated, this endeavor is one of OPC’s highest priorities. Contact the OPC office for more information. To learn more about NATIONAL visit www.national.ca.
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National Peer Network One of the most monumental events for someone who has just undergone an amputation is meeting someone else with limb loss who has successfully recovered and is back to living a productive and enjoyable life. The Amputee Coalition of Canada (ACC) works to make these meetings happen through its Peer VisitorÂŽ Program.
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ACC has developed a national peer support network to assist Canadians in overcoming the traumatic event of losing a limb. By creating a Canadian network of peer support, the ACC provides persons with limb loss and their families the emotional support and information vital to successful reintegration into society and community. The Peer Visitor Program is designed to assist amputees in their quest to resume productive and healthy lives. The program addresses the difficulty that informal and unstructured peer visits can have on those who have just undergone limb loss, especially those who have just entered the early rehabilitation phase, when a person with a new amputation has little idea of what awaits them. By implementing a training program to certify peer visitors, the ACC ensures a quality standard of its program. All peers are evaluated at the end of their training session and reports are received after each visit. The Amputee Coalition of Canada provides the Peer Visitor Program in both English and French at no charge to individuals with limb loss. To request a peer visit call 1-866-611-2677 or email info@amputee coalitioncanada.org. M AT R I X S U P E R M A X E VA L UAT I O N K I T
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INDUSTRY NEWS
Chedoke P&O moves to Ron Joyce Children’s Health Centre By: Jennifer Russell-Smyth, CP(c), FCBC
It is safe to say that more than half of Canada’s prosthetists and orthotists certified after 1979 spent time in the Prosthetics and Orthotics Department located in the basement of the Holbrook building at Chedoke Hospital in Hamilton, Ontario. Many in the Canadian prosthetics and orthotics community worked with, and learned from, many talented mentors at Chedoke.
On November 19, 2015, the doors of this long-standing prosthetics and orthotics facility closed for the move to the new and purpose-designed Prosthetics and Orthotics (P&O) Department at the Ron Joyce Children’s Health Centre in the Hamilton core, next to Hamilton General Hospital.
The P&O Department at Chedoke was among the earliest publicly-funded facilities of its kind in Canada, opening in 1969. It began as a small service with two staff members, gradually growing to its present staff complement of 35 employees. It has withstood the trend toward size reductions in larger public facilities and still 14
offers a full range of prosthetic and orthotic treatment to clients and their families in the greater Hamilton area. As the staff numbers increased dramatically over the last 45 years, so too did the amount of space required by the department in the old Holbrook building. As other hospital departments vacated the
Holbrook basement, the P&O Department took over abandoned space and adapted it to its needs. Although Hamilton Health Sciences and the department tried to maintain a professional-looking and functional facility, it was apparent to visitors and staff that many deficiencies in the aging basement level led to a less than ideal workplace environment for clinical interactions. What the P&O Department at Chedoke lacked in positive physical surroundings was compensated for in spirit. This department has long been known by patients, students, other healthcare profes-
sionals, visitors and staff as a place full of caring, innovative and fun people. Endless stories and examples of determination, creativity and brilliance are juxtaposed with a healthy dose of hilarity... qualities that became synonymous in the prosthetics and orthotics community with “Chedoke”. The opening of the Ron Joyce Children’s Health Centre was the culmination of a four-year project to bring together into one building all of the children’s out-patient health services that were offered in various buildings at the Chedoke site of Hamilton Health Sciences. The P&O Department has a close
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relationship with the Developmental Pediatric Rehabilitation program, so including prosthetics and orthotics in the Ron Joyce project was a good fit for all. Even though the department is now located in a children’s centre, prosthetic and orthotic treatment will continue to be provided to adult clients as well. The project included working groups from all programs that together meticulously planned the details of the new building. This led to very unique and specific design features constructed throughout the Ron Joyce Children’s Health Centre, including outdoor walking paths and obstacles for challenging activities, indoor and outdoor playgrounds, an indoor climbing wall and a fullsize basketball hoop, a protected outdoor meditative terrace, a large conference room, a rehabilitation gym with a fully instrumented force plate and camera system for gait analysis, an area dedicated to researchers, charting rooms, TV screens in many locations for patient education, interactive wall-mounted electronic games for waiting rooms, commissioned art installations, floor to ceiling windows throughout the building, a family resource library, a teen lounge, a public computer area,
a café and many other unique design features. The P&O Department was designed with workflow in mind in terms of space and relative location of areas to staff and patient functions. Patients are now seen in large, fully equipped, bright high-ceilinged private rooms, many with ample windows. All rooms have doors and curtains for privacy. There is a large gait room with adjoining fitting rooms and curtained areas with parallel bars.
Staff have generous workspace areas with substantial storage cabinets, a charting/ phone room separate from the working area, a well ventilated and configured machine room, modifying and laminating rooms, an oven and molding room, glue/spray and CAD/ CAM carving rooms, and a panel saw room for cutting and storing plastics. A sizeable classroom was designed for the clinical students from George Brown College for lectures and patient treatment. The patient waiting room has areas for wheelchair seating, an interactive computer game console for children, an aquarium and an incredible Lego city displayed under glass. The reception and administrative staff now work in open office areas, with windows, and are afforded privacy when talking to patients.
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Although there was heartfelt sentimentality about leaving Chedoke, the spirit that has always been a part of “Chedoke P&O” is now reflected in the beautiful new space at the Ron Joyce Children’s Health Centre and will live on in its new home.
About the Author: Jennifer RussellSmyth, CP(c), FCBC, is a Certified Prosthetist who has worked at Chedoke Hospital for 30 years. She has been involved in various capacities with both CAPO and CBCPO, serving as CAPO Yearbook editor (before it was called Alignment), Examiner at CBCPO Examinations, OAPO Secretary, CBCPO SecretaryTreasurer and a member of the Exam Review Committee, CPOT Committee, and the CBCPO Board of Directors.
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POINT OF VIEW
Alarming Acceptance of Status Quo By Mark Agro, B.Sc., CO(c), FCBC President, CEO Ottobock HealthCare Canada Ltd.
For the majority of my 35 years in the prosthetics and orthotics field, the most common KAFO solution for sagittal plane instability incorporates a locked-knee design. Orthotists have accepted this as state-of-the-art for as long as there has been lower extremity bracing. Decades ago our curriculum at George Brown College taught us to use a locked-knee solution for knee instability and today we continue to dispense this often-compromised solution to our patients. I encourage my fellow orthotists (and their patients) to be more indignant on the use of locked-knee joints when there are better options available. I would love to see a higher level of commitment to deliver better outcomes for our KAFO patients, especially when there is a variety of stance control (SCO) and stance and swing control (SSCO) options available.
Patients have accepted a locked knee because it was often the only solution offered, as an all-or-nothing compromise for their condition... the easy way out. Ironically, for the last 100+ years it would be unthinkable and unacceptable to fit a trans-femoral amputee with a locked knee (okay, agreed, certain exceptions apply). However, this is
precisely what orthotists commonly employ when locking the knee in a KAFO despite other available options. Manufacturing materials have changed – plastics and carbon fiber have replaced leather – but the knee that is incorporated in these modern materials too often remains locked. Locked KAFOs are fraught with limitations and compensatory 20
movements to ensure safety – most notably, circumduction to allow forward progression without catching the toe, and/or a pronounced plantar flexion of the foot on the sound side (if there is a sound side!) to effectively gain ground clearance during swing phase. Locked KAFOs do not allow stance-yielding knee flexion, and as a result there is no shock
Ottobock C-Brace absorption for the user. Without stance knee flexion there are increased forces up the leg, into the spine, commonly resulting in the user slowing down to reduce the forces and the likelihood of pain. You’ll recall seeing Terry Fox’s ‘hop’ between strides when he was running to lower forces on his residual limb when landing on a straightened prosthesis. Walking down stairs effortlessly and safely is always a challenge when done with a stiff, straight leg. The act of sitting in conventional locked KAFOs requires the unlocking of the joints, or the acceptance of sitting with an extended leg. There are many other negatives associated with a straight leg in stance; patients who do not feel stable and safe while walking are more likely to reduce their activi-
ties, leading to a vicious cycle of inactivity, decreased fitness and even a withdrawal from social activities. The availability of stance and swing control KAFOs allow almost-normal physiologic knee function, providing stability, greater safety, stance-phase knee flexion, swing-phase ground clearance (by allowing a flexed knee during swing), a decrease in compensatory movements and reduced energy consumption. The application of a stance control orthosis seems to be more accepted since Ottobock developed a SSCO system. Fully mechanical SCOs do indeed provide stance stability, but remain locked even during stance and some patients might not re-lock if they don’t reach full extension. Stance 21
control is an improvement, but is not as reliable on uneven terrain as a SSCO. Now that orthotists can monitor the gait in swing and stance it leaves the patient with a much safer device, allowing more patients to be candidates for this walking system. As orthotists, we have the technology to minimize the many negative effects and maximize a KAFO patient’s safety and provide them better outcomes. Ottobock, the leading manufacturer of microprocessor prosthetic knees, has sold over 70,000 units of this revolutionary prosthetic technology since 1996. The same microprocessor technology is available to orthotists using similar algorithms to control hydraulics and provide active stability and safety for your patients.
OPC 2016 National Conference August 3-6 | Banff, Alberta
NEW HEIGHTS... FRESH OUTLOOKS
The inaugural OPC National Conference has been designed with a focus on the changing climate of the profession. Learn about the innovations, threats and challenges we are currently facing and the tools we will need to navigate those changes. You don’t want to miss this exciting event full of great educational, social and networking opportunities.
Conference Highlights: • Future of the Orthotic & Prosthetic Profession Pre-Conference Workshop (separate registration required) • Ottobock Welcome Reception • Fresh Air Experience including the O vs. P Ortoped Softball Game • Hoedown at Mountainview BBQ • Banff, a true must-see destination!
OPC 2016 National Conference NEW HEIGHTS… FRESH OUTLOOKS August 3 – 6, 2016 | Banff, Alberta Register Online – www.opcanada.ca/conference
“ Why don’t orthotists mirror what prosthetists have been able to achieve, and challenge the lack of available funding by insurance companies?” The Ottobock C-Brace Orthotronic Mobility system allows both active stance yielding and swingphase knee flexion. Its technological DNA has Canadian roots from the stance-control work done by Dr. Kelly James at the University of Alberta over 20 years ago. James applied microprocessor technology to open and close the hydraulic valves precisely when needed, controlling flexion and extension. Once these knees were seen to be benefiting amputees, it didn’t take long for someone to ask “why don’t we apply these prosthetic MPK features to a knee for KAFO wearers?” Another influential Canadian helped with the development of the C-Brace. British Columbia’s David Lindsay, CO(c), was instrumental in the clinical advancement of the various generations of prototype C-Braces by way of taking C-Leg concepts and packaging them into an orthotic knee joint. Microprocessor knees have revolutionized gait for amputees. This same revolutionary technology has been available for three years in orthotics, but is still perceived to be too high-end or bulky. However, when you meet someone who has used a microprocessor-controlled orthosis and hear their stories, it is as ever-compelling as the impact that microprocessor-controlled knees have had on amputees. Like amputees who are trying microprocessor-controlled knees for the first time, the biggest challenge is the need to unlearn compensatory movements and trust the device. The C-Brace utilizes a microprocessor-controlled hydraulic technology to create resistance to knee flexion and extension, while adapting throughout the user’s gait cycle. The C-Brace offers
controlled flexion while improving safety and stability. The orthotist can easily program the knee to best fit the individual needs of the user, including easy adjustments when conditions change. The hydraulics incorporated into the C-Brace allow a momentarily stable knee when needed, fully extended or slightly flexed, during stance and swing. The microprocessor receives input from sensors, strain gauges and angle sensors at a rate of 50 times/second to deliver the most stable and safe knee for the phase of gait. This allows the user to vary speeds and walk with controlled knee flexion. Why don’t orthotists mirror what prosthetists have been able to achieve, and challenge the lack of available funding by insurance companies? How do we deliver a SSCO message to funding agencies that “there is no other orthotic option for the patient’s mobility, safety and independence” and that “this is basic care for the needs of this individual”? Practitioners often comment on the cost of these high-technology devices, but what are the costs of an injurious fall? Admittedly, reimbursement is an issue that continues to be a hurdle for patients and orthotists alike. Insurance companies look to minimize their expenses to ensure the best return for shareholders. Okay, cue the critcisms: Mark Agro works for Ottobock which develops, manufactures and sells SCOs and SSCOs. Therefore, he is biased and not objective. Yes, a qualified “guilty as charged.” I am employed by Ottobock HealthCare, so there is hardly a need to provide disclosure. But as an orthotist first, I am committed, like 23
my company, to restoring human independence. Today I do this a few steps removed from the parallel bars by promoting technology that is life-changing. I know it; I’ve seen it. Our experience over the past three years demonstrates that C-Brace users are willing to accept the greater weight and bulk of a SSCO if it provides easier walking than with a locked orthosis. Trial orthoses are readily available from manufacturers. Why not let your patients have a test drive with zero obligation or risk? Why not let them experience the technology themselves? I am confident that witnessing a patient’s positive experience between the parallel bars will serve as motivation to negotiate vigorously with insurance companies. The response needs to be: “I won’t accept ‘no’ for an answer.” The challenge I put forth to orthotists everywhere is to question the status quo, question all of the reasons that a SSCO can’t be used, and ultimately FREE THE KNEE!
About the Author: Mark Agro, CO(c), is President, CEO of Ottobock HealthCare Canada Ltd. He is a graduate of George Brown College’s Clinical Methods in Orthotics and Prosthetics program. In the 23 years with Ottobock he’s been a passionate leader of sixty employees who help restore human independence. He holds Board positions with Orthotics Prosthetics Canada, The Canadian Assistive Devices Association and is a recognized OPC Fellow.
CLINICAL TEAM
Improving Patient Safety with Interprofessional Collaboration By: Yvonne Jeffreys, M.Sc., CO(c), FCBC
We educate people longer, specialize more and use advancing technologies, yet evidence shows that one in 10 patients is still harmed by a preventable medical error. The Canadian Patient Safety Institute reported that 70% of sentinel events identified communication breakdowns as key contributing factors in the occurrences of patient safety incidences.
Patient safety includes the absence of accidental injury, freedom from either medical error(s) or an adverse event as a result of our treatment. Research shows that the errors are not in the number of tasks, but rather the nature of the tasks... the more complicated, the higher the likelihood of error. Miscommunication and the actions of people in the system are the primary reasons for adverse effects (WHO, 2010). The Institute of Medicine’s report – To
Err is Human (Stelfox et al., 2006) – and the Silence Kills (Maxfield et al., 2005) study link patient safety and communication. There is plenty of evidence that indicates that the way we work together matters for our patients’ safety! As health professionals we work to deliver the highest quality of care, but at times this care is delivered in a uni-professional vacuum. Consequently, the overall care that the patient receives can be disjointed. It is widely accepted that healthcare today is complicated, 24
with more complex patients putting a higher demand on healthcare services. While context influences patient safety, human error has the biggest impact on the practice of patient safety. In Canada, 17% (4.2 million) Canadian adults believe that a medical error occurred when they received healthcare services in the last two years (Butt, 2010) and 9.2% of paediatric patients who were admitted to Canadian hospitals have had an adverse event of which 45% were preventable (Matlow et al., 2012). We need to
talk about patient safety, but how can we make a difference? The World Health Organization (WHO) advocates that interprofessional collaboration (IPC) can promote safer care and improve patient outcomes. IPC occurs when multiple health workers from different professional backgrounds work together with patients, families and communities to deliver the highest quality of care (WHO, 2010). The healthcare environment requires the expertise beyond any single profession for successful outcomes, so the intertwining of IPC and patient safety is critical. This can easily be appreciated for many of our prosthetic and orthotic (P&O) patients... those who are diabetic, those undergoing neurological rehabilitation from the effects of stroke, managing musculoskeletal challenges for the growing child, or managing an amputation, just to name a few. It seems obvious that the sum of complementary skills and knowledge from a team of professionals working well together will have a greater impact on a patient’s health than the contribution of any one individual member. The WHO (2010) reports that
improved health outcomes can be supported when a strong relationship exists for interprofessional education – the collaboration of two or more health professionals working toward a common goal (IPE). This interprofessional collaborative model has proven to be more responsive to complex healthcare situations. Partnerships between key stakeholders can improve patient safety initiatives such as clinical communication, engaging patient collaboration, understanding objectives of treatments, prioritizing patient needs... ultimately leading to preventing patient falls, reducing rates of infection and increasing patient safety (Jackson, 2011). The context of the healthcare environment supports the collaborative interaction of professionals. However, experience shows that some healthcare professionals resist collaborative working relationships with colleagues from different disciplines. While it seems logical for professional groups to work collaboratively to advance patient care, there are barriers that prevent professionals from doing so, even though patient safety may be compromised.
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Patients assume that their health professionals talk amongst one another, so why is it that we don’t? It is because, in a more complex health environment, many individual health professionals practice in a traditional, ‘silo’ model of care (where each health professional practices separately) and are less able to individually monitor the effectiveness of how planned healthcare is delivered. There can be problematic tensions between dominant, uni-professional models of healthcare delivery that are centred on professional autonomy and the individual clinicians. But we cannot work alone to serve our patients. Evidence shows that breakdowns in teamwork, leadership, communication, situational awareness, and poor decision-making are not uncommon and can lead to adverse outcomes for patients (Flinn & Yule, 2005). One approach to help encourage IPC is to start at the onset of health profession education, before professional bias and hierarchy are entrenched. Students entering the field of healthcare embrace the
“ Interprofessional collaboration has been shown to improve patient safety through better teamwork, communication, conflict resolution, and role clarification.” opportunity to make a difference in the lives of future patients. These keen and energetic students are innocent of professional barriers and are highly motivated to learn with, and about, students from other healthcare disciplines. Interprofessional collaboration has been shown to improve patient safety through better teamwork, communication, conflict resolution, and role clarification. Socialization has a key role during pre-licensure education. Introducing IPE early can positively impact students, creating opportunities for professional identity formation which includes the notion of not only being a professional but also a team member. This early work also creates a positive attitude toward others’ roles (Oandasan & Reeves, 2005). At BCIT (British Columbia Institute of Technology), we asked ourselves, how safe is healthcare in British Columbia? Are our students prepared? We responded by embracing IPE and collaborative practice that supports safe patient care. We have adopted the National Interprofessional Competency framework (Orchard et al., 2010) developed by the Canadian Interprofessional Health Collaborative (CIHC). This framework strives for partnership between a team of health providers and the client, in a participatory, collaborative and coordinated approach to shared decision-making around
health and social issues. This framework prepares healthcare students for collaborative practice by supporting different health professionals within a safe and exploratory environment. The six competencies in the framework include: role clarification, team functioning, patient/client/family community-centered care, collaborative leadership, interprofessional communication, and interprofessional conflict resolution... cognitive and interpersonal skills to complement technical proficiency in improving safe, effective and efficient performance. Our activities aim to assist students in understanding how to work as a team when clarifying each other’s healthcare role. Students identify characteristics of professional communication and ways to mitigate conflict, and recognize opportunities for collaborative leadership in healthcare teams. BCIT supports IPE activities that require students to work as a team and communicate with each other, practicing the essential skills to ensure safe patient care and promote engagement; this makes IPE more explicit and supports interprofessional socialization. Team communication for patient safety can be challenging. One strategy is to help team members speak up and be heard by using C.U.S., an acronym for “I am Concerned! I am Uncomfortable! This 26
is a Safety issue!” What are important concerns in healthcare? Bringing students together from various professions to learn more about noteworthy challenges helps students realize that their profession is not the only one dealing with issues around infection, for example. We encourage students to be prepared to laugh, learn and negotiate in order to win, the goal always being to gain a better understanding about teamwork and communication, focusing on a culture of patient safety. The P&O students have participated in wound care activities with nursing and electrophysiology students, scoliosis treatments with medical radiology students, and as exam candidates for sonography students. We appreciate that connections and interactions between students from different healthcare fields are necessary for adult learners to effectively apply theory to practice (Sargent, 2009). The medical radiology, nursing, radiation therapy, medical laboratory, cardiology and sonography students are practicing reflective IPE activities in their clinical and practicum sites. There are real challenges to deliver interprofessional education within a tightly-packed uni-professional curriculum. However, the Dean of BCIT believes IPE is the direction of future healthcare education, and slowly we are
putting this philosophy into action. Students are asking for these types of learning opportunities, and the Student’s Council has membership on the Interprofessional Committee to contribute to the design of our IPE activities. By supporting students in educational activities that help them practice and evolve their professional skills in teamwork, communication, leadership, situational awareness, and decision-making. we are inherently building a culture of safety and respect for all health professions. Communication among healthcare team members influences the quality of working relationships, job satisfaction and has a profound impact on patient safety. Research has shown that when communication about tasks and responsibilities are done well, there is a significant reduction in turnover and improved job satisfaction and a facilitation of a culture of mutual support. This culture helps build a conscience for caring for patient safety.
“ By supporting students in educational activities that help them practice and evolve their professional skills... we are inherently building a culture of safety and respect for all health professions.” References Butt, A., & MBA, C. (2010). Medical error in Canada: issues related to reporting of medical error and methods to increase reporting. MUMJ, 7(1), 15-18.
World Health Organization (2010). Framework for action on interprofessional education and collaborative practice. Available at: http://whqlibdoc.who.int/ hq/2010/WHO_HRH_HPN_10.3_eng.pdf.
Jackson, Rosalind Clare. Interprofessional collaboration and patient safety: An integrative review. Diss. Auckland University of Technology, 2011.
Yule, S., Flin, R., Paterson-Brown, S., & Maran, N. (2006). Non-technical skills for surgeons in the operating room: a review of the literature. Surgery, 139(2), 140-149.
Matlow, A., Baker, G., Flintoft, V., Cochrane, D., Coffey, M., Cohen, E., & Nijssen-Jordan, C. (2012). Adverse events among children in Canadian hospitals: the Canadian paediatric adverse events study. Canadian Medical Association Journal, cmaj-112153.
Oandasan, I., & Reeves, S. (2005). Key elements for interprofessional education. Part 2: Factors, processes and outcomes. Journal of Interprofessional Care: supplement 1, 39-48. doi: 10.1080/13561820500083550.
Orchard, C., Bainbridge, L., Bassendowski, S., Stevenson, K., Wagner, S. J., Weinberg, L., & Sawatsky-Girling, B. (2010). A national interprofessional competency framework, www.cihc.ca/files/CIHC_IPCompetencies _Feb1210r.pdf. Leonard, M., Graham, S., & Bonacum, D. (2004). The human factor: the critical importance of effective teamwork and communication in providing safe care. Quality and Safety in Health Care, 13 (suppl 1), i85-i90. Maxfield, D., Grenny, J., McMillan, R., Patterson, K., & Switzler, A. (2005). Silence Kills, Vitalsmarts TM America. www.aacn.org/wd/practice/docs/ publicpolicy/silencekillsexecsum.pdf. Stelfox, H. T., Palmisani, S., Scurlock, C., Orav, E. J., & Bates, D. W. (2006). The “To Err is Human” report and the patient safety literature. Quality & Safety in Health Care, 15(3), 174–178. http://doi. org/10.1136/qshc.2006.017947.
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Sargeant, J. (2009). Theories to aid understanding and implementation of interprofessional education. Journal of Continuing Education in the Health Professions, 29(3):178-184. doi: 10.10020chp.20033.
About the Author: Yvonne Jeffreys, M.Sc., CO(c), FCBC, works as an Orthotic Instructor for the Prosthetic and Orthotic program at British Columbia Institute of Technology and is a sessional instructor for the online M.Sc. Rehab Sciences program at McMaster University. She has a special interest in clinical reasoning and interprofessional education. Yvonne practices as a Certified Orthotist at Hodgson Orthotics in Coquitlam, BC.
CLINICAL TEAM
Holistic Care
Screening for Mental Health Predictors and Indicators
Alignment Executive Editor Krista Holdsworth, CO(c), in conversation with Josie Marino, Clinical and Rehabilitation Psychologist at The Ottawa Hospital Rehabilitation Centre. KH: In my experience in a paedi atric practice, as my patients get a little older there are certain things that I become aware of that I’m not necessarily equipped to han dle like anger and grief, or some times 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 amputa-
tion. 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 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 depression. There is an increased risk of depression with upper limb amputations related to functional challenges and visibility 30
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.
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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
Alignment_march 2016.indd 2
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. Provide the patient with information about informed consent, including what remains confidential and what must be disclosed should you have concerns for their safety. 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 clinically significant. A program called The Pals Program, developed at Johns Hopkins, has
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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. As O&P practitioners, it’s important to correspond with other team members in the circle of care for the best outcomes.
Resources: Major Depression screener – PHQ9 (identifies symptoms, available online) GAD-7 (Self-report psychometric questionnaire to identify generalized anxiety disorder, available online). Handbook of Rehabilitation Psychology, 2nd edition Frank et al. (2010)), Chapter 2 Limb Amputation, Rybarczyk, Behel, Szymanski.
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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. 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 34
opportunity for both the boy and myself. 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 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
Clinic workshop for brace modifications
Teaching parents to ensure a successful outcome
A happy family!
in the clinic. Elaine continues to volunteer her time in the capacity of clinic coordinator. She helps to arrange transportation and to manage the financial assistance from the RIU. Over the past 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 pro-
vided 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:
A smile makes it worthwhile! 35
Dawn MacArthur Turner, B.Sc., CO(c), is a Certified Orthotist at Custom Orthotics of London since 1987. She is currently completing her Masters in Rehabilitation Science from McMaster University.
Client-Centered Practice... Enhancing the Patient-Practitioner Relationship
*SPECIAL FEATURE SECTION 2016*
The Information Age A Double-Edged Sword
By Krista Holdsworth, CO(c), FCBC 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, 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 36
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 health professional uses the internet to direct the patient to reliable sources and appropriate medical links to information. This last scenario requires the health 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 OrthProActive Consultants Inc. with clinics in Markham and Newmarket. 37
SPECIAL FEATURE SECTION: Client-Centered Practice...
Tried, Tested and True Maximizing Outcomes via the Patient-Practitioner Relationship
In Conversation with Don Weber, CO(c), FCBC.
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, cognitive and emotional issues that can be associated with a disability, how have you navigated those challenges while working 38
to provide what you as the practi tioner 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 cognitive disabilities is equally imperative. My lesson was learned while participating in a swimming program with two teenage girls with severe athetosis. Neither had cognitive impairment, but 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
Enhancing the Patient-Practitioner Relationship
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 don’t have cognitive impairment 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 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. Background 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
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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 kids 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. The most optimal outcome results occur when the patient and practitioner view the orthotic treatment plan as a partnership where the end goal is improved patient function and satisfaction. After all, the best-designed orthosis does not provide the best function if it sits in a closet or on a shelf! Don Weber CO(c), FCBC, retired in 2015 from the Prosthetics and Orthotics Department, Hamilton Health Sciences Hospital, Hamilton. He remains a Clinical Instructor in the Prosthetics and Orthotics program, George Brown College. For more from Don visit www.webernotes. squarespace.com.
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SPECIAL FEATURE SECTION: Client-Centered Practice...
Health Literacy We Can Make a Difference By Tedi Brash, CO(c)
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 care2. 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 understanding2. We can customize the information we provide to each patient so that it is easy to understand and is directly applicable to their specific situation. If we work to enhance their health literacy skills, we will
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give them a far greater chance for success. Here are a few quick, easy-to-do strategies that will start you on your way1,3. • Use “Plain Language”. Avoid medical and professional jargon whenever possible. o Terms like flexion, skin integrity, gait and alignment are part of our everyday vocabulary but may be largely unknown to our patients. oT here is a misconception that by using plain language we are in effect “talking down” to our patients. The exact opposite is true. By explaining complex concepts in everyday language, you make that information accessible and enhance a patient’s ability to use it.
Enhancing the Patient-Practitioner Relationship
• Ask “how do you like to learn?” o By tailoring the information that you provide in a way that matches their learning style, their health literacy will increase considerably. Handouts, diagrams, demonstrations and personal stories are all great ways to deliver information. • Provide written material that closely matches health literacy best practices. o All materials should be written at a Grade 6 or lower reading level. Note that existing information in P&O may require patients to have up to a Grade 12 reading level4,7. To check the reading level of any information you provide, refer to the resources listed at the end of this article. o In a nutshell, to meet health literacy standards, any written material should: – Have a lot of white space with larger font (12-14 pts). – Be short, very clear and easy to understand. – Use effective “how to” diagrams to show important techniques. – Focus on a few, readily applicable key points (1-3 is best practice).
answer. It is the only way you will be able to fully assess their level of understanding. Patients often nod or say yes. It doesn’t mean that they fully understand. Some will be embarrassed to admit their lack of understanding while others may think it’s the polite thing to agree, just want to leave or could be adhering to culturally influenced norms. • Demonstrations are essential. o When educating on donning/ doffing/control systems, get your patients to demonstrate and show you that they can effectively do it. If it’s not working, try a different approach. Repeat this each time you introduce something new. o Start each visit by having your patient show you how they don/doff/functionally use their
• Go slow. Check in often. o Keep your sentences short. Pause often to give your patients time to fully understand the information you are providing. Use plain language as much as possible. o Instead of asking your patients “if” they have questions, ask instead “what questions do you have?” Ask again. And again. o Make sure that your questions regarding their understanding of a particular procedure, methodology or technique require more than a yes/no
43
prosthesis/orthosis. This is a great way to ensure that everything is on track. It doesn’t matter if it’s appointment #1 or #10, it’s important to make sure that the information you provide is retained over time. • Watch for “information overload”. o It is so easy to provide too much information given the increasing complexity of our designs and the number of features that they incorporate. Consciously narrow down the information. o Pick 1-3 key things that your patient must know to stay safe and/or effectively use their orthosis/prosthesis. Then build on that learning by introducing added features over the next few visits.
The intricacies of health literacy are far reaching and involve all facets of healthcare provision. This was but 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 patient’s 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? Here 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. Plain Language Patient Handouts • Medline Plus - www.nlm.nih.gov/medlineplus/healthtopics.html • Health Info Translations (for multicultural resources) - www.healthinfotranslations.org • Health Links (BC/AB) - www.healthlinkbc.ca/healthtopics • Ohio State - https://patienteducation.osumc.edu (tip: type in amputation or brace in search box) • Amputee Coalition - www.amputee-coalition.org/limb-loss-resource-center/resources-by-topic • Mayo Clinic - Diseases and Conditions - www.mayoclinic.org • Living with Amputation - www.waramps.ca/ways-we-help/living-with-amputation Health Literacy Guidelines and Best Practices • AHRQ Universal Precautions - http://1.usa.gov/1aKUyKt • Health Literacy Portal (Canadian Public Health Association) - www.cpha.ca/en/programs/portals/h-l.aspx • Facilitating Patient Centered Learning - http://rnao.ca/sites/rnao-ca/files/BPG_CCL_2012_FA.pdf • Guide to Easy-to-Read Health Education Materials - http://healthliteracy.worlded.org/docs/family/fhl.pdf • Writing health information for patients and families - http://bit.ly/1jw8fSi • Turn on Readability Scale (the grade you are writing at) in Word documents - http://bit.ly/1PwJm24 • Check the Grade Level of your information - www.readabilityformulas.com/smog-readability-formula.php References and Further Readings 1. Agency for Healthcare Research and Quailty (AHRQ) (2015). Health Literacy Universal Precautions Toolkit, 2nd Edition. Agency for Healthcare Research and Quality: Rockville, MD. http://1.usa.gov /1aKUyKt. 2. Coleman, C., Kurtz-Rossi, S., McKinney, J., Pleasant, A., Rootman, I. & Shohet, L.. (2011). The Calgary Charter on Health Literacy: Rationale and core principles for the development of health literacy curricula. The Centre for Literacy: Montreal: QC. www.centreforliteracy.qc.ca/sites/default/files/CFL_ Calgary_Charter_2011.pdf. 3. Doak,CL., Doak, LG. & Root, JH. (1996). Teaching patients with low literacy skills (2nd Ed.). J.B. Lippincott: Philadelphia, PA. 4. Hrnack, S., Elmore, SP. & Brindley, GW. (2009). Literacy and patient information in the amputee population. Journal of Prosthetics & Orthotics (JPO) 21(4): 223-226. 5. Rootman, I. & Gordon-El-Bihbety, D. (2008). A vision for a health literate Canada: Report of the expert panel on health literacy. Canadian Public Health Association: Ottawa, ON. www.cpha.ca/uploads/ portals/h-l/report_e.pdf. 6. Sheppard, E.D., Florence, M.N., Kirchener, J.S. & Ponce, B.A. (2014). Improving the readability of online foot and ankle patient education materials. Foot & Ankle International 35(12): 1282-1286. 7. Smith, CR. & Smith, CA. (1994). Patient education information: Readability of prosthetic publications. Journal of Prosthetics & Orthotics (JPO) 6(4): 113-119.
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. 44
Pattern Recognition Controller • no myo testing required
• control up to 3 devices sequentially
• on-device prosthetic training
• for both above- and below-elbow amputees
• patient can re-calibrate at any time
• compatable with LTI Boston Arm
The pattern of muscle activity for hand open is different than hand close, wrist supinate, wrist pronate and so on. An electrode array placed on the surface of the residual limb near these muscle areas can detect the patterns of activity collectively – the patterns are recognized by the controller and used to command the prosthesis.
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SPECIAL FEATURE SECTION: Client-Centered Practice...
Acquired Brain Injury The Invisible Disability By: Katie Muirhead, Advocacy Specialist for the Ontario Brain Injury Association
Frequently misunderstood, acquired brain injury (ABI) is one of the most prevalent injuries leading to permanent disability. ABI is eight times more common than breast cancer, spinal cord injury, HIV/AIDS and multiple sclerosis combined, yet all of those other diseases or disabilities receive significantly more attention, and funding from the government. Motor vehicle accidents (MVA) and falls have been identified as two of the leading causes for traumatic brain injury which can involve other orthopedic injuries and amputations.
The brain is the most complex organ in our bodies. Not only are there cognitive consequences following brain injury, but physical and social/emotional ones as well. Brain injury is often referred to as an invisible disability. Once the scars have healed a person is left with varying degrees of impairments that can affect how he or she thinks, understands and feels. It is sometimes a challenge for service providers to see beyond the obvious physical limitations to the cognitive or emotional ones as well.
No Two Brain Injuries are Alike On the surface, everyone’s brain looks the same, but how our brain
functions and is affected after injury can be very different. There are different types of brain injury: Traumatic Brain Injury (TBI), caused by events like MVA, falls, assaults, penetrating injuries, and Non Traumatic Brain Injury (nTBI) caused by stroke or anoxia (lack of oxygen to the brain) and toxic injuries when the brain is exposed to toxic chemicals that cause damage. Brain injury is identified on a scale of severity from Mild, Moderate to Severe. This is generally measured by understanding the person’s level of consciousness and memory loss. Some symptoms present right away while others may appear much later. The area of the brain affected must be considered also, as well as the intensity or force of the impact to the brain and, in some cases, any 46
pre-existing conditions or history of ABI. As such, applying the same strategies or approaches for one person with a brain injury may yield very different results than for another.
Think Brain First To best understand how to support a person with a brain injury, we must identify the areas of the brain that have been affected... the different areas that control our thinking, feeling, movement, behaviour, emotions, breathing and so on. When those areas are ‘broken’ we can’t expect the individual to make the same choices or responses that they would have before their injury. Areas of impairment fall into three categories: cognitive, physical and social/emotional. Cognitive
Enhancing the Patient-Practitioner Relationship
impairments can vary over time depending on what activities the person with the injury is engaged in. They can include lack of insight, memory problems, slowed responses, processing difficulties, problems with concentration, poor planning and problem solving, communication difficulties, lack of initiative and impulsivity. Physical impairments or changes can include loss of taste and smell, dizziness and balance issues, fatigue, headache and pain, visual or hearing problems and mobility limitation or loss. And social/emotional impairments can consist of emotional lability, depression, anxiety, irritability, socially inappropriate behaviour and/or inflexibility. The brain is a highly complex organ with so many functions to consider. To know everything about the human brain would be too great of an expectation of any practitioner, but trying to understand the area of the brain to which a particular client has sustained damage may serve you well when tackling challenges along the way.
Staying on Track Patient compliance with therapeutic recommendations can be a challenge for any rehabilitation professional. Different challenges arise in keeping with the nature and severity of an ABI which can often interrupt or prevent growth and success. Building a strong rapport or relationship with a patient or client is critically important to working together and getting good results. Like anyone, an ABI survivor should feel supported and heard, and that they have some control over the process of orthotic or prosthetic treatment.
Cueing may assist with initiation of tasks, memory deficits, attention problems or organizational problems such as sequencing. Redirection is a disengagement from a mode of behaviour that is negative or unproductive to a more productive alternative behaviour. Redirection may assist with perseveration (prolonged repetition of either a verbal phrase or physical movement), poor judgement, lack of emotional control, inappropriate social behaviour or lack of awareness. Restructuring is a technique used to guide the person toward constructing another understanding, perspective or interpretation of an event, thought or belief. This strategy may help with confabulation, or rigid or concrete thinking. It works by emphasizing the actual circumstances while ignoring or eliminating any inaccurate information. Fatigue, poor memory, lack of initiation and frustration are common challenges for individuals who have sustained an ABI. Fatigue, cognitive or physical, can be supported by chunking information into smaller, manageable pieces and taking breaks as needed. For many, attending even one rehabilitation appointment or meeting in a day can be draining. Processing the information and participating in the exercises may prove to be too exhausting for them. Working with other providers and the individual to manage how many appointments
General Strategies for Success Cueing is a signal used to prompt a person to engage, disengage or modify a particular behaviour. Cues can be verbal or non-verbal. 48
are scheduled can help to lessen this fatigue in this example. Memory dysfunction is seen consistently in those with ABI. There are different types of memory (procedural, semantic, working and prospective, for example) and different strategies to use depending on how the memory is affected. Cueing and repetition are two methods to support types of memory loss. If a person has a difficult time with procedural memory, practicing the skill with increased repetition may help. If there are deficits with working memory, focus on one task at a time. Leaving notes or visual reminders can help with prospective memory. Finding the right compensatory strategy, combined with repetition and cueing, can help someone with memory loss to be more successful and more independent. Initiation has always been difficult to support. Many people with initiation deficits are first identified as being non-compliant or lazy when, in fact, the part of the brain which initiates activities is compromised. Again we look to cueing or modeling the task to support someone who fails to initiate. Keep in mind that it is not necessarily a lack of understanding or desire, but a lack of initiation due to the brain injury which
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prevents some from complying or following through with instructions or recommendations. Feelings of anger or frustration can be expected in those who have sustained an ABI. Most recognize that they are now different, no longer the person they once were. Ways of supporting a person who is easily frustrated can include understanding the event that comes before the behaviour... the antecedent. When we can predict that a patient or client is going to express increased frustration upon arriving at an appointment because there are too many people in the waiting room (over-stimulating visually and excess noise and commotion) then we can look to change the antecedent rather than the behaviour (frustration) by scheduling the appointment at a different time of day when there are less people in the clinic. Working to support the person proactively rather than reactively will generally yield better results. Understanding why a person is going to behave a certain way helps us to prepare and, in many cases, prevent behaviour from occurring. In addition, establishing routines so a person knows what to expect, celebrating successes
and chunking information can help to manage excess frustration. Often times there are multiple people involved in the support and care of a person who has sustained the injury. Be they family, friends or professionals, all are important in that individual’s recovery. In many cases the brain injury impairments are life-long and the information and experience that these caregivers can provide will help to both inform and support the rehabilitation goals you are working towards. Collaboration
with other service providers can help maintain those goals. Rehabilitation specialists can support your goals by encouraging the client to wear their brace or prosthesis. As stated, ABI is unique and complex and no two injuries are the same. Some people may present with the impairments above and some may have only a few or different consequences to their injury. Understanding that these symptoms or challenges are coming from damage to the brain will help in problem solving and management moving forward. It is our job to help support, or in some cases act as that part of the brain, to assist the person in their rehabilitation. Understanding the nature and severity of the injury can help us with that support.
About the Author: Katie Muirhead has been the Advocacy Specialist for the Ontario Brain Injury Association for the last four years. With a background in behaviour management, her primary role is to support, educate and advocate for people living with an acquired brain injury across the province of Ontario. 50
SPECIAL FEATURE SECTION: Client-Centered Practice...
In My Client’s Shoes A Personal Perspective Photo by Kimberly Tiessen
With over 25 years of experience as a certified prosthetist, from an institutional clinical setting at Chedoke P&O to private practice with Prosthetic Energy Inc., and time in-between as Director of Professional and Clinical Services with Ottobock HealthCare Canada, Martin Robinson, B.Sc., CP(c), shares some of his lessons learned on the profession’s unmarked path of practitioner-patient relations. “Marty” spoke candidly with Alignment publisher Jeff Tiessen, who is also his client.
Q: Prosthetics and orthotics is an intriguing profession. It’s science. It’s art. And it is social science in terms of the relationship you culti vate with your patient or client who, by way of their life’s circum stance, may be hard to please at times. How do you refrain from internalizing that? A: We are human too. We can be overly sensitive about our work... I can be for sure. And honestly, sometimes when we are really being challenged it doesn’t drive the work forward. We need to push past that so criticism and resistance doesn’t inhibit our work. You don’t want to become cynical. You have to remember that P&O is an imperfect science. I motivate myself with a twist on something my dad always used to say. I challenge myself with: “I’m only as good as my last fitting.”
Q: How do you translate or apply that “Marty mantra” into your day to day practice? A: We need to approach every case with vigour, and be open to learning from our clients. There is a real opportunity for exchange of energy, experience and ideas with our patients and clients. As a clinician my responsibility is to guide the fitting and the outcome of the project with the needs of the patient in mind. I draw on that phrase particularly when a line is crossed... when the relationship loses balance. When I’m unequivocally being told what or what not to do or just not being heard anymore, it’s easy to feel more like a puppet than a practitioner. Everyone likes to have their input, and should have input, but there needs to be respect both ways. 52
Q: When that respect is lost... what then? A: For me, particularly with clients whose behaviour is unpredictable or when working with children and the parents become overbearing, I can feel threatened at times. I’ll usually acknowledge that I’m feeling uncomfortable to the parents in an effort to determine why we’re having a problem – not in a who’s right and who’s wrong scenario – and often find that by putting it on the table people come clean about what is bothering them. Sometimes it’s something that is totally unrelated to the fitting but just being taken out on me. And in some cases it is related and might be something that may or may not be resolved, but I work to ensure that it doesn’t affect the treatment outcome.
Enhancing the Patient-Practitioner Relationship
Q: Yes you are a professional, and you understand that your patients and clients may be going through tumultuous times in their lives, but human nature is human nature... what about when it boils down to a personality conflict? A: Generally speaking, from my experience, that conflict is mutual. Sometimes you just don’t click. No matter what you try. Maybe they feel the same way in that whatever they try isn’t working. Recognize it before it goes too far. If respect is lost on both fronts it might be time, in the nicest way possible, to give that person the option of seeking a second opinion, or offering a referral to another colleague. It’s a matter of saying that “we both tried and I just don’t think this is going to work.” So much of what we do is based on communication and the connection that we establish with our client, and if there are synapses that are misfiring in that relationship, like any relationship, you have to acknowledge the problem, and try to either console it in some way or dissolve the relationship. Q: And then you close that fitting room door and in short order need to walk into another. How do you separate or compart mentalize in the moment? A: By remaining grounded and humble and remembering that tomorrow’s another day, with another fitting. Sometimes you need to morph your approach to suit an individual. I believe clients shouldn’t have to morph their behaviour to suit me. I should be the one who is flexible in my delivery. It comes back to expectations, and those should be addressed early on. Q: What’s different in your ap proach with clients with what you know now as opposed to when you began in the profession. A: In the beginning I didn’t glean as much information from clients as I do now – and it’s not just about the
obvious, but there are a lot of cues to pick up on. Some people need more reassurance, more information, more detail with respect to new technologies or techniques. Some need more time. Some are more quick to adapt. Something I’ve been doing for a while is being a bit more generic in my approach to all my clients. I don’t want to bias any potential relationship. You have to lay down expectations. You want to be optimistic but at the same time realistic. The relationship will then go one way or another. For some people it’s all business and they don’t want to cross any lines by sharing too much personal information. Others can be very forthcoming and want to share and expect the same from you. It’s a fine line but if you let your guard down too much, with some, there may be problems down the road. But remember, we’re not selling magazines or newspapers. Q: As you look back at what you’ve learned on the job over the course of your career, what has surprised you most about this profession? A: The psychology of it. I certainly could have benefitted from more psychology and human behaviour education. And in the beginning I promised too much. I’ve learned that it’s important to listen more. As prosthetists and orthotists we have a tendency to make assumptions... human nature again. We can’t assume that someone really understands the protocol of what’s going to go on. The biggest disappointment for our clients is often how long it takes to get a device. What we can do as practitioners is be straightforward about timelines and the steps involved. That can defer some of the friction in our relationship. Q: Biggest changes in the profes sion since you began? A: Consumer information and patient participation. We can’t be 53
afraid to share product information and bring the client in as an active participant in the process. Clients now come to us as informed consumers, much more educated in what’s available to them. In the past, there was more of a standard recipe for componentry choices. Here’s a cautionary note... it’s easy to stay comfortable with what we are comfortable with prescribing as practitioners, but that’s not fair to our clients. Q: Talk about that comfort zone, which obviously isn’t exclusive to P&O but inherent in most profes sions. A: At times I’ve been guilty of not leaving my comfort zone and staying within the limits of what I know. It’s important for us, even as established practitioners, to keep up with what is new. Our clients trust us to do that. It can be limiting for our clients when we stick with our routines and comfort zone. We need to offer options. The flipside is that some seasoned veterans become very good in recognizing what doesn’t work, and what is reliable – some of that is an individual thing where you find what you are good at and what you are comfortable with. But again, that can be good and bad. But when things are working, it’s difficult to adopt a new technique just for the sake of a new technique or technology. When a new technology is tried, but didn’t improve fit or function or efficiencies, you need to go back to what has worked. Are we limiting clients to techniques that we are comfortable with or are we avoiding new techniques and precluding them from the most current technology? Q: There has to be a fairness to the client, but there has to be a fairness to the practitioner as well doesn’t there? It must be a tall order to keep up with every new technology?
Photo by Kimberly Tiessen
A: Prosthetists from my vintage need to be aware of the fact that we might be losing touch with some of the technology. Keeping up with new technologies can be work... mental energy on our part. For example, loading up software that comes with a new microprocessor knee. It’s an inverse relationship – when you’re younger you are prescribing what’s current, maybe even overprescribing, because it’s exciting and new and different. As you get older, technology can get ahead of you a little bit and you need to know when to pull back sometimes and not overpromise. Q: Where does the compromise lie between established solutions and innovative, new options? A: In a perfect world, you would have researched and tried all of the available options, but it’s just not a viable option in clinical practice today. The compromise is to at least have your client be involved in trials and testing options. The manufacturers have become very supportive of that approach which does make it easier for us to explore new options. In that perfect world, it would be nice to always have younger practitioners coming into your practice with new ideas and research and techniques which unfortunately isn’t always possible either.
There isn’t a perfect answer. Typically, we just don’t have the time to set aside for research and development in the clinical setting. But making time to read current literature, or have representatives go to conferences and bring information back to share, are things we can do. Q: What do you know now that you wish you knew then, meaning when you entered the profession? A: Really take your time in the early stages of the fitting, which I’ve learned from colleagues in other countries. Early on I always felt that the meter was running. People had been waiting to get an appointment so you want to get things going quickly. Often I ended up redoing things because I hadn’t taken the time to be more aware of small details. Include the client in the process. It goes a long way in meeting their specific goals and expectations. It’s very easy for me to pick the foot for a person, but we have to try and find a compromise. Maybe we start by trying three options. Take the time to sit down and talk with your patient and maintain the relationship with that person, instead of just maintaining our schedules. We can learn a lot from colleagues and shouldn’t be afraid to 54
call around for advice. And we can learn a lot from the manufacturers. Live in the moment. What’s really helped me, when I am doing a fitting, is to be completely present in that fitting. That’s the best you can do for somebody. Be in the moment. Sounds strange but because we are around people with amputations all the time, we can sometimes become too comfortable with that and personalities can overshadow specific physical disabilities. Work hard to separate abrasive or difficult personalities from the physical job at hand. We are not life coaches or psychologists but sometimes some interesting strategies are needed to deflect untoward comments or behaviours so we can focus on our practice. Q: Has time in the profession made it easier or more difficult to identify with your clients or patients? A: That’s a grey area. We are all consumers. And we need to think about the things that upset us when we’re buying things. Our patients, regardless of funding sources, are still consumers of our products and services. So quality, aesthetics, and the way the person is treated when they come to our facilities, or when booking appointments, are all important. There are consumer expectations associated with buying any product, and we should play by the same rules. Follow-up and information about new products makes for great customer service. And there will be expectations of us as practitioners, who willfully chose this profession, about delivery, knowledge and quality. We can’t become callous to their frustrations or criticisms. And we can’t take those challenges personally either. Our clients and patients just want the best for themselves. My answer is... easier, because I learned that the effort put into establishing an effective alliance with my clients creates a working relationship that is very rewarding for both of us.
SPECIAL FEATURE SECTION: Client-Centered Practice...
Outcome Measures By Malena Rapaport, B.Kin
Our field is undergoing a shift toward an evidence-based approach to clinical practice. With this shift, ongoing conversations around the imperative nature of measuring outcomes of treatment have become more commonplace. Prosthetists and orthotists are being encouraged to use outcome measures (OM) in clinical practice as tools for device justification to payers, patient progress documentation after intervention, and aid for patient-centered decisions.
Many clinicians use OM in their current everyday practice. For example, by simply asking patients to rate their level of pain on a scale of 1-10, clinicians are able to assess changes in pain levels over time (1). But if OM are not accurate, information gathered may lead clinicians to incorrect conclusions, thus reducing the standard of care for patients. Even with accurate OM, questions about which qualities are important for clinicians to measure still remain unanswered. As a P&O student, I am interested in the type of information that OM provide to orthotists and prosthetists in the clinical setting. I embarked on a literature review to identify OM designed specifically to assess lower extremity mobility
in P&O populations, as this represents the bulk of P&O intervention aims. The review generated 22 studies evaluating the accuracy of OM – expressed in terms of validity and reliability – of which eight were designed specifically to assess lower extremity mobility. Table 1 provides a brief summary of these eight OM studies. I then proceeded to explore the nature of OM information provided to clinicians using the International Classification of Functioning, Disability, and Health (ICF) framework. The ICF was developed by the World Health Organization as a standardized language to describe all health-related conditions for healthcare professionals across different disciplines (2). Within the ICF context, health-related conditions are 56
classified into three dimensions that describe variations in: body function and structure (e.g., muscle strength or range of motion), a person’s capacity to execute a task or activity (e.g., walking, sitting, etc.), and performance within a societal context referred to as participation (e.g., walking home from work or going to the movies with friends) (2). In the ICF, activity and participation are closely linked, often generating confusion in clinical practice as they are markedly different concepts (3). Jette et al. differentiated between activity and participation by associating the former with simple daily tasks and the latter with more complex life behaviours (3). Activities were associated with an individual’s ability to execute a discrete physical tasks performed
Enhancing the Patient-Practitioner Relationship
Table 1: Descriptions of Outcome Measures Sourced via Literature Review Outcome Measure
Description
Population
Method of Completion
Time to Administer/Score (approx.)
Equipment
CHAMP
Assessment of high-level mobility designed to detect functional changes
Prosthetic
Clinician assesses patient performance in clinic
NR/NR
Stopwatch, measuring tape, 15cm cone or box, armless chair, 5 cones, tape (to mark the ground)
LCI-5
Questionnaire containing 14 items assessing locomotor skills and level of independence while carrying out tasks with the prosthesis as perceived by the patient
Prosthetic
Patient Self-report
5 minutes/NA
Questionnaire
SIGAM
Questionnaire that differentiates prosthetic users into 1 of 6 mobility grades based on 21 close-ended questions (yes or no answers) and an algorithm
Prosthetic
Patient Self-report
NR/NR
Questionnaire
AMP (AMPPRO/ AMPnoPro)
Evaluates functional ability by assessing transfers, sitting and standing balance and gait skills with (AMPRO) and without a prosthesis (AMPnoPro)
Prosthetic
Clinician assesses patient performance in clinic
15 minutes/ 2 minutes
Stopwatch, 2 chairs, 12'' ruler, pencil, 4'' obstacle (preferably 18-24'' long) and stairs with 3 steps, 12-foot, marked walkway
PLUS-M
Questionnaire evaluating lower limb mobility of prosthetic users with questions about the ability to carry out specific tasks
Prosthetic
Patient Self-report
3 minutes/ 2 minutes
Questionnaire
PEQ-MS
13-item mobility scale composed of ambulation and transfers related to activities of daily living performed while wearing a prosthesis over the previous four weeks
Prosthetic
Patient Self-report
5-10 minutes/NA
Questionnaire
L-Test
20m test of basic functional mobility requiring the patient to rise from an armless chair, walk 10m in the shape of an L (3 by 7 meters) at a self-selected pace, turn 180 degrees, and walk 10m in the shape of an L back to a seated position
Prosthetic
Clinician assesses patient performance in clinic
5 minutes/NA
Chair (seat height 47cm), 2 cones, stopwatch
OPUS-LEFS
Questionnaire composed of 20 questions about ability to routinely perform activities while using orthotic or prosthetic devices. Three additional questions about frequency, the amount of time the device is worn, and activities likely to cause pain
Orthotic & Prosthetic
Patient Self-report
NR/NR
Questionnaire
Abbreviations: CHAMP (Comprehensive High-Level Activity Mobility Predictor, LCI (Locomotor Capabilities Index), SIGAM (Special Interest Group in Amputee Medicine), AMP (Amputee Mobility Predictor), PLUS-M (Prosthetic Limb Users Survey of Mobility), PEQ-MS (Prosthesis Evaluation Questionnaire - Mobility section), OPUS-LEFS (Orthotics and Prosthetics Users Survey - Lower Extremity Functional Scale), NR (not reported), NA (not applicable).
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on a daily basis, such as getting out of bed, stepping onto a curb, or going up stairs. Participation was described as a compilation of tasks leading to an individual’s ability to fulfill their socially-defined roles. Commuting to work, visiting friends, and walking to the park with family would fall under this category. These three domains of disability – body structures and function, activity and participation – do not interact in a perfect continuum (4). For example, there is no linear causation between quadriceps weakness (body function), slower gait (activity) and playing with grandchildren (participation). In clinical practice, prosthetists and orthotists routinely assess aspects of body structures and function to inform treatment; however, we do not measure activity and participation nearly as often. Also, patients seek treatment when faced with limitations in activity and in participation rather than impairments in body function and structure – with the exception of patients who experience pain. As such, understanding the impact that our interventions has on our patients’ activities and participation is critical. Interestingly, after classifying the eight OM within the ICF framework, it was noted that all fell within the category of activities, while
none focused on participation. In clinical settings, prosthetists and orthotists use OM to gather objective data on the outcome of their interventions. When framed in such a way, it is understandable why the focus in the literature is on activity rather than participation. Moreover, actions related to participation are often affected by factors other than the intervention provided by the prosthetist or orthotist, such as environmental and socio-economic factors. The challenge is that the patient may not find relevancy in how fast they complete a test like Timed-Upand-Go in a clinic but would likely judge the success of their P&O intervention based on participation... for example, whether or not they can cross the road independently. This contrast demonstrates that the use of both activity and participation OM provide different yet equally pertinent information to achieve a successful intervention in keeping with clinician and patient goals. From this review, it was apparent that the literature focused primarily on OM for prosthetic users, with little attention given to orthotic OM despite the fact that orthotics constitutes a larger proportion of devices fabricated within our field (5). There are challenges in the development of OM for the assessment of orthotic treatment because of the many different populations and pathologies treated with orthotic devices. This makes for a wide range of patient characteristics that fall under the description of “orthotic user” and raises questions about the viability of designing OM explicitly for this heterogeneous population. Currently, there are no OM designed to measure participation in P&O and there is only one OM found to address mobility outcomes from orthotic treatment (OPUS-LEFS). A shift in focus to person-specific measures could
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address these gaps as it is difficult to source a one-size-fits-all measure that accounts for the heterogeneous population of orthotic users or the personal factors characterizing the participation of patients. As our field engages in the movement towards evidence-based practice, we have the opportunity to explore and develop OM addressing the activity and participation domains of the ICF, and orthotic treatments. In the hopes of fostering patientcentered care and measuring outcomes of interventions, what are our next steps to convert this conversation into action?
References 1. Williamson A, Hoggart B. Pain: a review of three commonly used pain rating scales. Journal of clinical nursing. 2005 Aug 1; 14(7):798-804. 2. World Health Organization. International classification of functioning, disability and health. 2001. 3. Jette AM, Haley SM, Kooyoomjian JT. Are the ICF activity and participation dimensions distinct? J Rehabil Med. 2003; 35(3):145–9. 4. Riddle DL, Stratford PW. Is this change real? In: Interpreting patient outcomes in physical therapy. 2013; p.1-103. 5. Heinemann a W, Bode RK, O’Reilly C. Development and measurement properties of the Orthotics and Prosthetics Users’ Survey (OPUS): a comprehensive set of clinical outcome instruments. Prosthet Orthot Int. 2003; 27(3):191–206.
About the Author: Malena Rapaport, B.Kin, earned a Bachelor of Kinesiology from the University of Toronto. She graduated from the BCIT Prosthetics and Orthotics Clinical Program in 2016, and is currently completing a Masters of Rehabilitation Science at McMaster University while doing her residency at Barber Prosthetics as a Prosthetist-Researcher.
SPECIAL FEATURE SECTION: Client-Centered Practice...
Everyone’s Talking Outcome Measures. What Do Patients Say?
By Brittany Pousett,
M.Sc., CP(c) Open the cover of any P&O journal, or venture through the door of any P&O conference, and you are almost certain to come across a discussion on outcome measures. We hear a lot about outcome measures – but we often leave the conversation impressed with fear or misunderstanding about the direction that our field is going and the time it is going to take to get there.
It seems to be that a lot of us are beginning to acknowledge that outcome measures are important, but don’t know where to go beyond that. (Outcome Measures are quantitative or qualitative tools that can be used to assess patients and treatments by providing scores that can be compared to normative data or baseline scores.) According to the Practice Analysis Survey in 2014, certified prosthetists and orthotists indicated that administering outcome measures was moderately critical to their treatments and
that their responsibility to improve and measure outcomes is one of the most likely changes to their roles in the near future. However, few clinicians admit to actually using them. Approximately 60% of clinicians reported using outcome measures never, or rarely, and only about 10% of clinicians reported using them routinely (Orthotics Prosthetics Canada, 2014). In early 2015, our clinic made a decision to seriously explore the use of outcome measures in routine clinical practice. As we looked into the use of outcome mea62
sures in the United States, we saw that the motivation to implement outcome measures stemmed from the reimbursement model that is shifting to requiring documentation validating the benefit that a treatment has on a patient (Stevens, P., Fross, N., & Kapps, S., 2009). We also saw warnings of challenges that we will have to overcome in order to implement them, including gaining an understanding of what outcome measures are, choosing a measure and learning how to administer it, and then finding the time required
Enhancing the Patient-Practitioner Relationship
Administering a survey to one of our patients. to collect, analyze and interpret this data (Otto, 2011). Neither of these findings dissuaded us and we committed to selecting a set number of outcomes that would be used as part of our routine clinical practice. While we will be the first to admit that this process required a commitment, we were excited and surprised by the benefits we have seen as outcome measures began influencing our patient care. We wanted to determine if our patients felt the same way as we did. We chose three patients whose care we thought had been influenced by the use of outcome measures and asked them to report if their experience matched our own. Millie is a woman in her mid 80s who wears a trans-tibial prosthesis. At one appointment, Millie was describing to me how limited her mobility was becoming and how discouraging it was to be stuck inside her house. We had attached a StepWatch (a small device that accurately measures daily ambulation) to her prosthesis several weeks earlier and wanted to compare what she was describing with what she was doing. When we looked at her StepWatch
data, we discovered that she was actually averaging ~4,000 steps a day and had one day where she achieved almost 8,000 steps. This information allowed us to refocus the conversation and set goals that were appropriate for what she was already doing. In talking to her about the use of this tool, she described how encouraging it was to see her progress and how it increased her confidence in her own ability to leave the house – perhaps without worrying that she wouldn’t be able to do it. She also admitted that she found it hard to think that she was able to do something, but now she had proof that she could do more than she thought. Without this tool, we would have continued treating her under the assumption that she could rarely leave her home instead of being able to encourage her and support her as she ventures out into the community and works towards achieving her goals. Jordan is a national-level cyclist who pushes himself hard to achieve his best. With both his cycling training and his prosthetic care, he appreciates the use of objective measures to help him 63
optimize his performance and to improve. When speaking to him about his training and the use of measurement, he mentioned that he routinely recognizes that he may feel something, but the outcome measures provide him with a more objective picture of his progress. So, while one day he may feel more sluggish in training, his measurement can show that his speed and power were above average that day. Jordan is also adamant that clinicians need to be transparent about the outcome measures that they are using and what the scores mean. Without clear interpretation, patients may feel like they have divulged personal information without seeing the meaning or benefit to their care. Heather is one of our patients who has had outcome measures as part of her care since the first day of treatment. When asked how she felt about outcome measures, she said “If I had a choice, I’d say do them more often!” Over the course of her care, Heather has learned to value not only the way these measures contribute to improving her care, but also how they motivate and encourage her. In the first month of her rehab, the StepWatch provided valuable information on how to best deliver treatment. Heather reported several issues with her socket fit arising suddenly, but instead of leading us to thinking it was a socket issue, the StepWatch helped us determine that it was a result of a dramatic increase in her activity level in the first weeks of receipt of her first prosthesis. Once coached on gradually increasing her activity level, she was able to be even more active without any further issues in socket comfort. As she progressed in her rehab, she came to appreciate how outcome measures affirmed her progress. We could tell her countless times that she was doing great, but outcome measures provided her
Various outcome measure in action including the StepWatch and a timed walk test. their progress with others. Our world is changing and outcome measures are becoming integral to proving patient-centred care. Let’s embrace this change and use the best tools available to provide our patients with the highest level of care we can.
References Orthotics Prosthetics Canada. (2014). Practice Analysis Study of Certified Clinicians and Registered Technicians. Ottawa, ON. Otto, J. P. (2011). Outcomes project explores user-friendly ways to measure mobility. The O&P Edge,10(3): 34-36. Stevens, P., Fross, N. & Kapps, S. (2009). Clinically Relevant Outcome Measures in Orthotics and Prosthetics. The Academy Today, 5(1).
Using video analysis to fine tune adjustments on Jordan’s biking prosthesis. with proof – an objective and visual way that she could actually see her progress. Whether they show her progress, or show her areas where she can improve, she uses them to help set and assess goals. She looks forward to data collection days and insists “everyone needs this encouragement!” Now, one year into consistently using outcome measures, we have found that they are the key to providing patient-centred care. From a clinical perspective, they support
our decision-making and allow us to do better in setting goals and recording our patient’s progress towards achieving them. From a patient perspective, the outcome measures are enhancing motivation and increasing confidence in their level of care. With the ability to improve our communication and objectively show our patients how they are working towards their goals, we see that they are proud of their accomplishments and eager to share 64
About the Author: Brittany Pousett M.Sc., CP(c), is a Certified Prosthetist and the Head of Research at Barber Prosthetics Clinic in Vancouver, BC. She has a Bachelors of Science degree in Biophysics from the University of British Columbia and a Masters of Science in Rehabilitation from McMaster University. Brittany is passionate about integrating research into clinical practice in order to provide her patients with higher levels of care.
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Assessing Learning Needs of Lower Extremity Amputees Research Evidence, Practitioner Experience, and Patient Feedback
By: Mitchell Visser
Education and teaching is becoming an essential professional responsibility for health practitioners today (Bastable & Gramet, 2011) and a key component for the comprehensive care of patients with limb loss (Pantera, 2014). This education must focus on facilitation of the individual’s enquiries and respect their preferred learning approach (Price, 2015).
The loss of a limb may alter an individual’s quality of life by affecting them psychologically, creating functional limitations, and disrupting their social routine (Klute, 2009). Persons with amputation are forced to take on additional tasks related to health and selfcare, and adjust to a new way of life. Educational programs aimed at guiding new amputees through
this transition and informing them of the prosthetic treatment process “will enable patients to acquire the needed skills to adapt to their life after amputation” (Pantera, 2014). Additionally, well-delivered patient education has the potential to reduce patient anxiety, improve patient satisfaction, prevent secondary disorders, maximize independence, and improve quality of life (Bastable & Gramet, 2011).
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Before an educational program can be developed, assessment of learners’ needs, readiness, and styles of learning is the first and most important step (Kitchie, 2011). This article will outline the development, methods, and findings of a learning needs assessment investigating the educational requirements of individuals with limb loss. The investigation was limited to the learning needs of the lower
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Enhancing the Patient-Practitioner Relationship
Table 1 extremity amputation population. This assessment was undertaken to inform the future development of patient educational programs and seminars.
Learning Needs Assessment Methodology To assess the needs perceived by patients, a formal assessment of four individuals with lower extremity amputation was conducted. Patient demographics are reported in Table 1. A self-administered online questionnaire was completed by three patients using fluidsurveys.com. It was administered to a fourth patient over the phone. The survey included four question categories including: 1) patient demographics, 2) learning style, 3) desired content, and 4) questions specific to the perceived usefulness of a patient education program. The extent to which practitioners perceived these needs was assessed using another self-administered online survey using fluidsurveys. com. It was administered to a prosthetist and a physiotherapist involved in the treatment of individuals with lower extremity amputations. Lastly, a search of relevant literature was completed to investigate the common learning needs previously highlighted for the population of individuals with lower limb amputation.
Learning Needs of Individuals with Lower Limb Amputation The responses from the patient and practitioner surveys were analyzed. Similarities were highlighted and compared to the empirical evidence to establish common learning needs within the population of individuals with lower limb amputation. Frequently-stated learning needs are summarized in Figure 1. The most commonly-expressed learning need by patients, practitioners, and the literature was a comprehensive explanation of the recovery path following amputation... including the normal timeframe for rehab and prosthetic treatment, expected challenges and what to watch out for. Other prominent themes included residual limb hygiene and skin care, cleaning and maintenance of a prosthesis, socket fit
Figure 1 68
issues such as managing volume fluctuation with prosthetic socks, as well as psychological and social health concerns including the presence of depression disorders. The results of the learning style assessment revealed the variability of preferred learning styles and contexts among patients. The learning style preferences of each patient must be taken into account when developing an educational program targeting these learners. These results are expressed in Figures 2 and 3.
Study Limitations This study is a preliminary investigation of the learning needs of patients with lower limb amputation. It was done primarily to inform the development of a patient education seminar for the four learners studied. From a sample of four
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ment of individual learning needs, styles, and interests of specific learners is required.
Conclusion
patients and two practitioners, generalizations for the entire population cannot be made. Combining the results of this specific learning needs assessment, with learning needs reported in empirical evidence, strengthens the identification of common learning needs.
Discussion There are very few studies that investigate the educational needs of individuals with lower limb amputation or the effectiveness of education programs for improved self-management. The most recent review by Pantera et al. (2014) summarizes the limited amount of high-level evidence available. This report signifies another small step toward establishing a list of common educational needs for persons with lower limb amputation. To progress toward effective patient education for prosthetic patients, the following steps are suggested: 1) investigation of current educational practices within prosthetic facilities, 2) large-scale learning needs assessment of individuals with limb loss, 3) for the development of specific educational programs, further assess-
The development of educational programs tailored to the learning needs of specific individuals offers an opportunity for patients to learn and master the tasks needed to adapt to life after amputation. In addition to the learning needs outlined in this study, education must center on the facilitation of each individual’s enquiries and must cater to his or her preferred learning approach (Price, 2015). A well-delivered educational program has the potential to reduce a participant’s anxiety about the rehabilitation and prosthetic treatment process, minimize secondary disorders, facilitate increased independence and self-care, and improve patient satisfaction (Bastable & Gramet, 2011).
References Bastable, S. B., & Gramet, P. (2011a). Overview of Education in Health Care. In S. B. Bastable, P. Gramet, K. Jacobs, & D. L. Sopczyk, Health professional as educator: Principles of teaching and learning. (p. 1-24). Sudbury, MA: Jones & Bartlett Learning. Farquharson, A. (1995). Assessing what needs to be Learned. In A. Farquharson, Teaching in Practice: How Professionals Can Work Effectively with Clients, Patients, and Colleagues. The Jossey-Bass Higher and Adult Education, Health, and Social and Behavioral Science Series. (p. 123- 127). San Francisco, CA: Jossey-Bass, Inc. Fenwick, T., & Parsons, J. (2009). The purposes of evaluation: Is anyone learning anything out there? In The art of evaluation: A handbook for educators and trainers (2nd ed., pp. 1-11). Toronto, ON: Thompson Educational. Klute, G.K., Kantor, C., Darrouzet, C., Wild, H., Wilkinson, S., Iveljic, S., (2009). Lower-limb amputee needs assess-
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ment using multi-stakeholder focus group approach. J Rehab Research Dev, 46, 293–304. Kitchie, S., (2011) Determinants of Learning In S. B. Bastable, P. Gramet, K. Jacobs, & D. L. Sopczyk, Health professional as educator: Principles of teaching and learning. (p. 103-146). Sudbury, MA: Jones & Bartlett Learning. Pantera, E., Pourtier-Piotte, C., Bensoussan, B, Coudeyre, E. (2014). Patient education after amputation: Systematic review and experts’ opinions. Annals of Physical and Rehabilitation Medicine, 57, 143–158. Price, B. (2015). Helping patients to learn about self-management. Nursing Standard, 30(2), 51-57. Quigley, M. J. (2002). Chapter 4: Prosthetic Management: Overview, Methods, and Materials. In Atlas of limb prosthetics: Surgical, prosthetic, and rehabilitation principles. (2nd ed.). Rosemont, IL: American Academy of Orthopedic Surgeons. Racy, J. C., (2002). Chapter 28: Psychological Adaptation to Amputation. In Atlas of limb prosthetics: Surgical, prosthetic, and rehabilitation principles. (2nd ed.). Rosemont, IL: American Academy of Orthopedic Surgeons. Wegener, S.T., Mackenzie, E.J., Ephraim, P., Ehde, D., Williams, R. (2009). Self- management improves outcomes in persons with limb loss. Arch Phys Med Rehabil, 90, 373–80.
About the Author: Mitchell Visser earned a B.Sc. in Biology from StFX University. Now in his second year of the Clinical Methods in Prosthetics and Orthotics program at George Brown College, he is also completing the Masters of Rehabilitation Science program at McMaster University. He will begin his Prosthetic Residency at Atlantic Prosthetics Inc.
O&P SOLUTIONS
Redefining the Human Connection By Randall Alley, CP
Prosthetic limbs for amputees have experienced a rapid improvement in recent years, both for the lower limb and through developments for more dextrous upper limb implements. Yet the socket, comprising the interface connecting the residual limb to the prosthetic components, has progressed far more slowly.
Most current interface designs still focus on encapsulating the limb in a simple bucket that mimics the shape of the limb, using a variety of suspension techniques to apply a gentle, global tension on the limb’s soft tissues. Such traditional approaches generally provide only peripheral or surface connectivity, in that they are either on (i) tissue containment and uniform loading, in the case of hydrostatic socket designs, or (ii) selective loading of pressure tolerant areas, in the case
of ischial-ramus containment (IRC), quadrilateral, and patellar tendon bearing designs. And while the past few years saw improvements in socket and liner materials, adjustability, modularity and manufacturing techniques, these traditional designs still suffer from problems stemming from inadequate control of the underlying bone that is the prime mover during functional positioning of the prosthesis. Thus, poor connectivity with the limb’s skeletal structure can lead to degraded functional range of 72
motion, instabilities, poor rotational control, excessive energy expenditures during active use, femoral osteoporosis, and increased pain and discomfort, especially during prolonged wear. Efficient transfer of skeletal motion to the prosthesis becomes all the more important as functional demands increase. For example, the advanced capabilities offered by newer generations of prosthetic components, such as the dextrous upper limbs now entering the market, can be undermined
Figure 1: Trans-femoral HiFi carbon fiber frame interface.
Trans-humeral HiFi Interface
Trans-tibial HiFi elevated vacuum
by inadequate interface connectivity to the underlying long bone, resulting in degraded kinesthesis, proprioception, and overall device functionality, as well as greater discomfort and perceived weight of the prosthesis. Such issues are exacerbated by shorter lever arms, a situation faced by many trans-humeral (TH) amputees, for example. Indeed, the quality of the interface is known to be the single most significant determinant for acceptance of advanced prostheses and long-term dexterous arm use. The paradigm-changing compression/release stabilized (CRS)™ interface approach pioneered by biodesigns inc. offers solutions that address these challenges. The High-Fidelity™ (HiFi) Interface, as it is known, utilizes a unique, patented and patents-pending method of imparting an alternating series of soft tissue compression and release zones that effectively capture and control the underlying bone. Relying on biomechanical principles and tensegrity concepts borrowed from biological and structural applications, the HiFi Interface strives to effectively restore and replicate the severed neuromusculoskeletal connection of the intact limb1,2. Optimal Osseosynchronization™, defined as the syncing of interface or pros-
thesis motion to skeletal motion, is achieved by imparting inward (or centripetal) compression toward the target bone in distinct, symmetrically-disposed, biomechanically optimized zones arrayed longitudinally along the bone. Coupled with carefully-managed outward (or centrifugal) release of the soft tissue into relief/release areas set in between the compression zones (see Figure 1), the CRS approach creates columns of compressed tissue that capture and stabilize the target bone relative to the interface, an outcome known as Osseostabilization™. Conversely, the interface is stabilized around the limb with respect to the target bone. As a result, the transfer of skeletal motion to prosthetic device motion occurs more rapidly and efficiently. Viewed as an indirect skeletal anchoring approach, the intimacy between interface and residual limb offered by the HiFi Interface concept is greatly increased and confers some of the advantages of direct skeletal attachment or osseointegration, but without the attendant health risks, complications, limitations and regulatory oversight. While originally developed as an upper extremity application, to date, the HiFi system has been used most widely on trans-femoral (TF) amputees and increasingly for
trans-tibial (TT) amputees as well. By utilizing a non-invasive, adjustable and removable socket design employing the latest material improvements, augmented by judicious application of limb imaging, casting and fitment tools, the HiFi interface concept was successfully adapted to all amputation levels for both upper and lower limbs. Of the more than 2,000 amputees fitted over the past five years. an overwhelming majority report great satisfaction with the HiFi system. Evidence accumulated from numerous patients provides strong indications that restricting unwanted bone motions within the interface allows volitional skeletal motion to be transferred more efficiently to the prosthesis, resulting in substantial performance enhancements as well as increased stability, greater comfort, improved gait, and better skin and skeletal health. Improved bone control has also been well correlated with less fatigue during usage since the user does not need to constantly compensate for unwanted intrinsic bone motion. In practice, this aspect has demonstrably been translated into improved stamina and longer wear periods without the need for constant adjustments, while providing greater functional range of motion. As with osseointegration,
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raise the bar for the prosthetic interface and its role in enhancing human performance.
References 1. R. D. Alley, T. W. Williams, M. J. Albuquerque and D. A. Altobelli, “Prosthetic sockets stabilized by alternating areas of tissue compression and release”, J Rehabil Res Dev. 48(6):679-96, 2011.
Adjustable Trans-femoral HiFi Interface BOA
Subischial Trans-femoral HiFi Ultra Low Trimlines
TF recipients of the HiFi lower limb system report a higher degree of osseoperception, or the ability to feel the ground and other external influences, since body weight and ground reaction force are transmitted more naturally through the femur and into the hip, lessening the risk of osteoporosis. Prior studies of individual TF patient outcomes2 indicated that by focusing on the primary mover (femur) of the TF amputee, it was possible to eliminate restrictive skeletal/soft tissue impingement at the proximal brim, as well as trochanteric encapsulation. All of these issues are often negative characteristics of traditional hydrostatic TF designs. A more recent case study measured the effects of the HiFi prosthetic interface system on temporal-spatial, kinetic, and kinematic parameters of prosthetic gait, as well as perceived disability, compared to a traditional socket design in a TF amputee subject. In this study the risk of falling was shown to decrease to within one point of the fall-risk threshold, down from a deficit of 25 points. In addition, the subject’s K level increased from three to four, solely with an interface change to the HiFi3. For upper limb amputees, it was demonstrated that a better interface connection carries into improved proprioception and functional precision. These were some of the reasons that led to the selection of the HiFi approach
as the interface of choice for the dextrous “LUKE arm” during the DEKA trials conducted under the auspices of the Defense Advanced Research Projects Agency’s (DARPA) Revolutionizing Prosthetics Program (RP 2007)4. The trials demonstrated the biomechanical and functional effectiveness of the HiFi design5. A DARPA Phase II SBIR contract was recently awarded to biodesigns that seeks to improve and help standardize fitment procedures for upper arm sockets using novel, sensorized tool-kits based on the HiFi technolgy to provide quantifiable diagnostic information in real-time. Currently, HiFi sockets can be fabricated using limb imaging tools and techniques in combination with either casting or digital scanning protocols to produce adjustable, solid or frame-type designs with tissue-relief areas or cage-style designs utilizing silicone liners and a strut system. Both designs incorporate the advantages of release zones or windows that allow for better suspension and muscle hypertrophy, and also provide the tissue-relief areas needed to maintain enhanced compression while ensuring that proper blood flow is maintained at all times... all while offering the lowest trimlines in the industry. Most embodiments improve heat dissipation as well. Future developments include modular systems based on the HiFi technology that will seek to again 74
2. R. D. Alley, “The High-Fidelity Interface: Skeletal Stabilization through Alternating Soft Tissue Compression and Release”, Proceedings of the 2011 MyoElectric Controls/Powered Prosthetics Symposium. New Brunswick, Canada: August 14-19, 2011. 3. R.D. Alley, “Next Generation Transfemoral Sockets”, Prosthetic Symposium, AOPA. October 8, 2015. 4. Revolutionizing Prosthetics, Accomplishments of the DARPA Revolutionizing Prosthetics Program. www.darpa.mil/ Our_Work/BTO/Programs/Revolutionizing_Prosthetics.aspx. 5. L. Resnick, S. Lieberman Klinger, and K. Etter, “User and clinician perspectives on DEKA Arm: Result of VA study to optimize DEKA Arm”, J Rehabil Res Dev., 51(1), 27-38, 2014.
About the Author: Randall Alley is CEO and Chief Prosthetist for biodesigns inc., a clinical and R&D facility located in Southern California. He is the creator of the High-Fidelity™ Interface System, the XFrame and ACCI, three interfaces that brought advanced biomechanical principles to prosthetic socket design. Previously, Alley co-developed and directed the world’s largest Upper Limb Prosthetic Program and was a primary consultant to DEKA Research and Development on the Defense Advanced Research Projects Agency’s (DARPA) Revolutionizing Prosthetics Project (RP 2007). Alley has received a Clinical Creativity Award from the American Academy of Orthotists and Prosthetists.
O&P SOLUTIONS
Weighing the Options For an Innovative Solution By Christa Bell, CO(c)
The client was initially seen as an inpatient at Holland Bloorview Kids Rehabilitation Hospital. She had recently had surgery for a rod replacement and tibial osteotomy. This was not her first surgery. Although only 13 years old, she has had many fractures due to a diagnosis of osteogenesis imperfecta (OI) type 3 and diabetes.
OI is often referred to as brittle bone disease, a genetic condition with various issues with collagen in the bones and tissues depending on the OI type. Type 3 is the most severe for a child (second to those who do not survive the neonatal type). However, the rate of fracture and amount of fragility can vary widely. OI, in general, is associated with long bone fracture, scoliosis, muscle weakness and contracture, ligament laxity and growth issues typically limiting the individual’s height to less than 3' 6''. There is no cure for OI but with treatment, the symptoms can be managed to maximize the client’s abilities and opportunities.
Problem/Concerns Upon first meeting this client, she was a post-op inpatient recovering from rod replacement surgery with complementary osteotomy. The surgeon had also released her hamstrings. After surgery she had a 35-degree knee flexion contracture (KFC) on her left side and general weakness (grade 3 and 4) on the left. The surgeon felt that that was the best he could attain based on her circumstances. She also had a significant leg length discrepancy (LLD) of 12cm. Together with her physiotherapist, it was decided to try a cast to see if we could gain any range of motion (ROM) at her knee to decrease the LLD which would in turn decrease 76
the height of lift to enable her to weight-bear. Due to the risk of fracture there was much discussion around proceeding with serial casting. However, the physician, parents, child and physiotherapist agreed that it was something we wanted to try. After two rounds of casting we gained 15 degrees, but due to the end range it was decided to not pursue the casting further. We did bivalve the last cast to be used for night resting to maintain the increase in ROM that was achieved.
Objective Her gait pattern was slow and guarded with a rear-wheeled walker and consisted of total
Posterior view, showing leg length discrepancy (LLD).
Sagittal view showing knee flexion contracture and LLD.
Definitive orthosis.
weight-bearing on the right and pushing along the top of her toe on the left with a great deal of pressure through the upper extremities (UE) onto the walker. The goal of the orthosis was to provide protection, functional improvement, increased efficiency and cadence, bilateral weight acceptance and maintenance of the ROM gained at the knee. A shoe lift would address the LLD but not the other issues. There was some discussion regarding trying a KAFO but this treatment might have limited her progress due to the increased weight and bulk. Her ligament integrity around the knee was determined to be sufficient to allow for the more conservative option of an AFO.
ion stop would prevent any more crouch than she was currently experiencing due to the KFC. With the AFO set in plantarflexion, 2cm of lift on the AFO was obtained and 7cm went onto a shoe lift. Tamarack® hinges were used on the door of the clamshell to make for one piece and look more streamlined, and to improve the accuracy of placement during donning.
Results
Solution The design of the orthosis began with a clamshell-style device for protection as to not limit her ability to plantarflex and potentially propel herself forward. The intent was to limit dorsiflexion to limit her knee flexion by reducing the potential for crouching in stance on the right side. The casting angle was set at -10 degrees at the ankle to hide some of the lift in the shoe but not limit the left-over range into plantarflexion for propulsion. The dorsiflex-
Positive results were achieved with the orthosis and the client’s gait was markedly improved. She was able to self-don the AFO and the ability to plantarflex in the brace allowed her to use her left LE for propulsion. She does use forearm crutches for support and safety but her gait speed and endurance were both improved with this treatment. This design successfully addressed the client’s goals and her compliance is very good. Some minor adjustments for general comfort were made at several follow-up meetings and it was noted that her strength was improving. With continued usage of the bivalved cast at night she is also maintaining the ROM at her knee. With continued orthosis use and ongoing physical therapy, continued success is expected in this case.
About the Author:
Client wearing final design. 77
Christa Bell, CO(c), is a Certified Orthotist currently practicing at Holland Bloorview Kids Rehabilitation Hospital. She graduated from George Brown College in 2007 with Honours.
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THE HIFI SYSTEM TEM IS UNLIKE ANYTHING ELSE: • HiFi Interface is custom-made, tom-made, adjustable, lightweight and low profile • HiFi Interface is for all levels with a limb remaining • HiFi Interface workss with all known suspension methods (straight suction, roll-on liner, ner, elevated vacuum, etc.)
• HiFi Transfemoral Interface nterface is subischial without vacuum • HiFi Interface was used sed on DEKA’s “Luke Arm” (DARPA’s Revolutionizing Prosthetics Program)
• HiFi Interface is comfortable mfortable and ideal for all activity levelss and ages • HiFis can be fabricated ted inhouse or with C-Fabb • HIFI INTERFACE IS BACKED BY EVIDENCE-BASED CLINICAL LINICAL SUPPORT
Improve your clinical al outcomes and your practice. Be the first to bring the HiFi Interface System to Canada. Contact us today to learn about upcoming HiFi trainingg rget, biodesigns offers events. And don’t forget, ng services too. upper limb consulting
“Since the interface is the most important part of the prosthetic system, I have dedicated my career to creating a more biomechanically-advanced interface solution that would allow wearers to do more. I always knew the HiFi Interface would be an improvement over current upper and lower limb sockets, but I had no way of knowing just how profound an impact the HiFi would have on people's lives.” – Randall Alley, CEO, biodesigns, HiFi Interface System Inventor, with Carrie, DEKA arm “test pilot”
Adjustable HiFi A/K open frame design with BOA
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“I am mechanically minded, so when I read about the HiFi's ability to stabilize and control the bone, it just made sense. As soon as I stood in the Imager, I immediately knew it was going to work. Thank you biodesigns.” – Darren “I have a new love affair...with my socket. I am able to wear by HiFi all day and am driving again.” – Jonathan
“With the HiFi, I can last twice as long if not more…I’ve become much more active and involved in tasks that I could not do before the HiFi.” – Ron
“My short sports prost prosthesis rosthesis with itits HiFi technology is the oonly prosthesis tthat I’ve ever ver been able b to perform with in aan immersed water environment, with without utilizing tili ing the aid of a roll on locking liner. recommend The HiFi fit is truly unique. I recom the HiFi design for any active pers person wanting a better, higher performan performance prosthesis.”” – Bob, CEO, TRS, Inc. pro
“The fit is really, really good. I am able to wear my HiFi's all day, everyday. I am back in school and am hoping to be running soon.” – Jerry
“I put on the HiFi and I didn't want to take it off. Get out of my way when I’m on this leg. I’m not going back to that old socket. This right here is what you need. I feel bad for everyone out there who is on a traditional socket because that sucks.” – Jessica
“I was in traditional sockets previous to the HiFi and they felt bulky, loose and heavy. In my HiFi's my prostheses feel connected to me – they feel lighter, more comfortable, secure and I forget they are there. I am able to wear them more comfortably, even in hot Georgia weather, and they have better range of motion. I never have to worry about them falling off or sliding around in them.” – Aimee
“The HiFi System allows me to do everything from basketball to racquetball to spin class to running. I can rely on my prosthetic side more than I could before. The HiFi makes me feel more complete. I forget I am wearing it. It fits better than any other socket I’ve used. I feel confident with everything I do.” – Richard
“I couldn't walk in my old bucket socket, but in the HiFi I can do everything I used to do before I lost my leg. In the first 3 days I was able to climb stairs, go down a ladder and walk 18 hours with only sitting intermittently. I can sit perfectly straight, knees aligned, feet touching the ground. I can tie my shoes and no longer have to take off my leg to go to the bathroom. I feel like I have my life back again.” – Carol
“HiFi is a whole new world. I am able to wear it all day, I have rotational control, I feel no pistoning, I am very comfortable... I have my independence again. I am confident, I feel I have no restrictions. I would never go back to my old system.” – Ali
©2016 biodesigns, inc. All rights reserved. HiFi and High-Fidelity Interface and Imager are trademarks of biodesigns, inc. The HiFi Interface and HiFi Imager technology are patented and patents-pending. Unauthorized use of the technology is not permitted.
O&P SOLUTIONS
Our Journey to the Cybathlon Developing an Intuitive Upper Extremity Prosthesis Control Strategy
By Brittany Pousett, M.Sc., CP(c) and Lukas-Karim Merhi, BASc./MASc. In recent years, several multi-articulated hands have become commercially available, allowing for more complex function than the previous generation of hands. Unfortunately, the control strategies have remained largely unchanged and pose a challenge in the use of these hands (Yang et al., 2014, Ostlie et al., 2012). In order for patients to benefit from the versatility of these new generation hands, and take full advantage of the improved functionality, it is critical that the control strategies evolve alongside the terminal device hardware.
To address this need, Barber Prosthetics Clinic has partnered with biomedical engineering and kinesiology researchers from Dr. Carlo Menon’s MENRVA Research Group at Simon Fraser University in Burnaby, BC. The conventional myoelectric control strategy involves using two surface electromyography (sEMG) electrodes to provide open and closed signals, while the control of more advanced terminal devices use a series of muscle co-contrac-
tions or a pattern of contractions (such as open-open) to access the different available grip patterns (Castellini et al., 2014). This however, leads to an unintuitive control strategy and underutilization of the more advanced terminal devices. In order to develop a more intuitive control strategy, we chose to explore the use of Force MyoGraphy (FMG), a technique involving the use of pressure sensors on the surface of the limb to detect the volumetric changes in the underlying musculo-tendonous complex.
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As a control strategy, FMG, has been found to be the most promising, offering accuracy, stability, wearability and affordability (Ravindra & Castellini, 2014). We began by recruiting four trans-radial subjects to determine if FMG was feasible. To extract FMG signals, the subjects were tested with a prototype termed Muscle Activity Sensor Strip (MASS), a band composed of eight pressure sensors, and donned at the forearm of the four subjects. This was performed to test whether
Our pilot using the Muscle Activity Sensor Strip in order to determine the feasibility of using FMG to control a terminal device. or not it was possible to identify the intended grip pattern from the residual limb of each subject. The results showed that it was possible to classify six primary grips (power grip, tripod grip, finger point, key grip, relaxed, and open) important in activities of daily living with an acceptable accuracy of above 70% in the residual limb (Cho et al, submitted). Upon determining that this technology was feasible, we recruited a pilot to aid in the development and implementation of this technology. Danny, our pilot, had a trans-radial amputation in 1980 secondary to a workplace injury. He competed as a competitive skier in the 1992 Winter Paralympics in France. Danny is currently the Head Coach/Manager for the Sun Peaks Race Development Adaptive Sports Program, and runs a barefoot waterskiing school during the off-season. When he was introduced to our research initiative, he eagerly volunteered to join our team as he welcomed the opportunity to contribute to the development of adaptive technology.
We investigated the use of FMG to control a Bebionic3 hand. We worked on identifying the optimal number of pressure sensors and examining multiple classification algorithms to test for improved
classification accuracy for both static and dynamic states of the residual limb. In addition, we fabricated a series of sockets to establish an optimal system for embedding the pressure sensors and connecting the Bebionic3 hand. As we developed this technology, we were made aware of the Cybathlon, the world‘s first competition for people with disabilities to pilot advanced assistive devices and technologies. Currently, we are the only Canadian team competing in the Cybathlon (October 2016) held in Zurich, Switzerland. We are entered in the Power Arm Prosthesis Race and our goal is to demonstrate the ease of use of our newly-developed technology. We attended the Cybathlon rehearsal in the Fall of 2015 and were quite pleased with our progress. For the highlights, see the video at www.youtube.com/ watch?v=plA443rvv6g. By uniting clinicians, technicians, engineers and patients, we have begun to develop technology which we believe will allow
Discussing how the prosthesis is fitting our test pilot Danny.
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Danny explaining how the prosthesis is functioning.
for a more effortless and dependable control of upper extremity prostheses. Ultimately, we are passionate about enhancing the quality of life for individuals with upper-extremity amputations and look forward to further developing this technology. Share in our passion and get involved by checking out our team website at http:// mass-impact.wix.com/home.
Acknowledgements We would like to thank our sponsors for their generous support: Barber Prosthetics Clinic, Simon Fraser University, BioInteractive Technologies, Steeper, OrtoPed, Myrdal Orthopedic Technologies, ToughWare and the Bechinger Family.
References Castellini, Claudio, Panagiotis Artemiadis, Michael Wininger, Arash Ajoudani, Merkur Alimusaj, Antonio Bicchi, Barbara Caputo, et al. 2014. “Proceedings of the First Workshop on Peripheral Machine Interfaces: Going beyond Traditional Surface Electromyography.” Frontiers in Neurorobotics 8 (January). Frontiers: 22. doi:10.3389/ fnbot.2014.00022.
MASS Impact Team Photo: From left to right, Brittany Pousett, Richard Chen, Jeetinder Ghataurah, Danny Letain, Lukas-Karim Merhi, Diego Ferigo and Erina Cho. Missing members: Carlo Menon, Zhen Xiao, Sohail Sangha. Cho, Erina, Richard Chen, Lukas-Karim Merhi, Zhen Xiao, Brittany Pousett, and Carlo Menon (2015). Force Myography to Control Robotic Upper Extremity Prostheses: A Feasibility Study. Manuscript submitted for publication. Østlie, Kristin, Ingrid Marie Lesjø, Rosemary Joy Franklin, Beate Garfelt, Ola Hunsbeth Skjeldal, and Per Magnus. 2012. “Prosthesis Use in Adult Acquired Major Upper-Limb Amputees: Patterns of Wear, Prosthetic Skills and the Actual Use of Prostheses in Activities of Daily Life.” Disability and Rehabilitation: Assistive Technology 7 (6): 479–93. doi:10.31 09/17483107.2011.653296. Ravindra, Vikram, and Claudio Castellini. 2014. “A Comparative Analysis of Three Non-Invasive Human-Machine Interfaces for the Disabled.” Frontiers in Neurorobotics 8 (October): 1–10. doi:10.3389/ fnbot.2014.00024. Yang, Dapeng, Li Jiang, Qi Huang, Rongqiang Liu, and Hong Liu. 2014. “Experimental Study of an EMG-Controlled 5-DOF Anthropomorphic Prosthetic Hand for Motion Restoration.” Journal of Intelligent & Robotic Systems, 427– 41. doi:10.1007/s10846-014-0037-6.
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About the Authors: Brittany Pousett M.Sc., CP(c), is a Certified Prosthetist and the Head of Research at Barber Prosthetics Clinic in Vancouver, BC. She has a Bachelors of Science degree in Biophysics from the University of British Columbia and a Masters of Science in Rehabilitation from McMaster University. Brittany is passionate about integrating research into clinical practice to provide her patients with higher levels of care. Lukas-Karim Merhi, BASc./MASc., joined the MENRVA Laboratory in November of 2014 under the direction of Dr. Carlo Menon. Lukas’s primary role at MENRVA involves management of the Force Myography Research Group that specializes in smart wearable technology for biomedical applications.
O&P SOLUTIONS
A Complicated Case
By Steve Scott, CP(c) 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.
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. 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 sealin liner, locking pin liners and cushion liners – and, for various
reasons, failed. Eventually, we arrived at a modified, loose-fitting quadrilateral-style socket with a stump sock interface incorporating a thermoflex liner that connected to the prosthesis with a pin lock. Suspension was obtained through a hip-disarticulation-style supra-iliac rigid waist belt connected to the prosthesis via a hip spica joint. An Ossur Total Knee 1900 was used along with an Ottobock Trias foot to create a light, stable prosthesis that provided for easy initiation of knee flexion. Partial hand-style prostheses with custom-fabricated silicone lining created total surface-bearing “sockets” that connected directly to Side Stix crutches on which the patient was able to walk rela84
tively comfortably. This arrangement was donned with the assistance of his wife and while there was a learning curve associated with the donning process, it was manageable. The patient managed with this set-up until the summer of 2014 when the socket no longer fit due to atrophy. At this time we embarked on the fabrication of a new and improved prosthesis. 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. Either his residuum was too short, hands were too dys-
Gary Sjonnesen, Director, Professional Services at Ottobock Canada, who was instrumental in the development of the socket and prosthesis. 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.
Outcome
KM’s initial prosthesis and crutches modified to accommodate hand anomalies. functional, the forces on the skin were too great, or the sockets and liners were too loose. One last novel approach was attempted.
Objectives 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.
Concerns The intolerance of his skin to absorb any shear force, the limited use of his hands and catastrophic results of falling had to be addressed.
Expectations At the end of this process, the expectation was that the patient would see an improvement in his overall independence, and that the assistance he required in
Final definitive prosthesis. donning and doffing his prosthesis would be greatly reduced.
Solutions 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. At this point this case became a collaborative effort involving 85
The patient reports that he can walk greater distances than he could with the previous prosthesis with a reduction in energy consumption. His skin is tolerating direct pressure so the intimate fit of the socket has eliminated shear forces, making the weight of the prosthesis a non-issue. Since his previous prosthesis had already incorporated hipdisarticulation-like suspension and he used minimal hip motion to walk, the transition to a full hip-disarticulation socket wasn’t as difficult as first predicted and required only a minimal adjustment period. This arrangement exceeded all of our expectations. The client has seen an increase in his independence. He still needs assistance although at an acceptable level. The stability and comfort of the device is exceptional.
About the Author: 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.
O&P SOLUTIONS
Socket-less Socket
Submitted by Martin Bionics Prosthetic technology has seen many advancements in recent years, though many of the longstanding challenges experienced in wearing a prosthesis remain. Today’s prosthetic sockets use more advanced materials such as carbon fibre and flexible inner socket materials than their predecessors, but the core method of how the socket is fit has seen very little change.
Typically, today’s prosthetic limbs still use a static-shaped encapsulated socket cavity into which the dynamic body must fit. Conventional trans-femoral sockets for instance, still utilize a rigid to semi-rigid ischial seat and brim, which is often a point of discomfort for the user. In 2012 Martin Bionics was invited by NASA to transition its Fabric Shoulder Socket design into the space program to help the space administration mesh exoskeletal robotics and astronauts. The program’s success led to
Martin Bionics playing the lead role in the development of next-generation man/machine interface for two additional departments of defence-funded exoskeletal programs through NASA. “Through the NASA programs we discovered and created some fascinating new materials and methods of meshing man and machine with lightweight compliant fabric,” explains lead interface developer Jay Martin, CP, FAAOP. “We discovered how to effectively control forces through fabric, versus the traditional rigid 87
materials that are conventionally used.” Subsequently, the NASA-based interface technology has been transitioned into a new generation of prosthetic socket interface technologies ranging from hip disarticulation and shoulder disarticulation-level sockets, to a revolutionary trans-femoral socket design called the Socket-less Socket. The Socket-less Socket allows a prosthetist to custom fit a trans-femoral socket in just one appointment typically, eliminating the need for traditional casting,
Instead of using conventional rigid socket materials, the Martin Bionics Fabric Shoulder Socket truly conforms to the user and dissipates forces through lightweight compliant fabric – eliminating point-specific loading and axilla pressure that plagues conventional socket designs.
The Martin Bionics Bikini Socket is less than ½ the size and weight of conventional hip sockets and provides a more direct biomechanical link between the device and its user, resulting in superior control, comfort and functional outcomes.
The Socket-less Socket uses compliant fabric-based materials, enabling it to truly conform to the user. No more static socket shape. No more rigid ishial seat. And no more loss of suction.
modification, and iterative test socket fitting methods. The Socket-less Socket allows a practitioner to micro-adjust the socket to the user in real-time, with direct patient feedback. “It is like a prosthetic lego set, allowing the practitioner to have more control over exactly how the socket is fit, and allows immediate patient feedback much like how endoskeletal components allow immediate alignment feedback,” offers Martin, the socket’s creator. Using the NASA-based hammock-fit technology, much of the Socket-less Socket uses compliant fabric-based materials to replace the rigid or semi-rigid plastics conventionally used to make sockets. This eliminates a rigid ischial seat and static socket shape, allowing the Socket-less Socket to truly conform to the user. “The uncomfortable areas that have plagued traditional sockets are now eliminated, and patients find the brim
and adjustability of this socket to be ultra-comfortable,” Martin adds. David Banks, trans-femoral amputee and Socket-less Socket user, reports that he has “never experienced so much comfort and adjustability in a socket,” adding that he has worn a traditional skin fit suction socket for many years and always wrestled with the uncomfortable brim and chaffing that would occur. “The ischial seat was also an issue and now the brim is the most comfortable part of the socket,” he emphasizes. Banks is an avid athlete and the founder of the first three-on-three amputee basketball tournament which is hosted in Phoenix, Arizona. The Socket-less Socket is also ideal for the geriatric population according to Martin. “Since we have eliminated a static socket shape that the dynamic limb tissue has to be pulled or pressed into, it makes it so much easier to don
the prosthesis. Now the socket can simply be wrapped around the limb, which can be done in a seated position for patients with balance issues.”
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The Socket-less Socket can be micro-adjusted in real-time to the user, allowing for immediate patient feedback during the fitting process.
About the Author: Jay Martin, CP, LP, FAAOP is a career inventor and entrepreneur. His innovative designs and patents have centered on adaptive computer-controlled prosthetics, neural integration strategies, advanced man/machine interface designs, and many others. He and his ideas have been featured on TED, The History Channel, The Discovery Channel, and in Popular Science and the Smithsonian Institute, among others. For more about the Socket-less Socket and free prosthetist training visit www.MartinBionics.com.
O&P SOLUTIONS
Custom Fabricated Exo-Skeletal Cosmetic Cover
By Darren Zhou, B.PHE, Prosthetic Tech. Intern One of the most rewarding aspects of being a technician is to be presented with a challenge and developing an appropriate solution. A recently fabricated exo-skeletal cosmetic cover would fit in this category (Fig. 1, above). This cover was made in our facility on a request from a patient to cover his swim prosthesis.
The patient is a trans-femoral amputee equipped with endo-skeletal components (3R80 knee). The challenge was to create something that encapsulated these components. It is important to understand that creating a custom cosmetic cover required fabrication of both the outer shell and a unique attachment. After much brainstorming, the “exo-clamp” was developed. This clamp (made using our CNC machine) served as the attachment method between the cover and the leg by securing itself onto the pylon with its three protruding prongs, extended to the interior surface of the cover (Fig. 2). The exo-clamp acts as the foundation for creating the cosmetic cover which included four main stages: (1) securing the
exo-clamp’s position, (2) creating the foam mold around the exoclamp, (3) creating the cosmetic cover over the foam mold, and (4) assembling the cover onto the leg. To secure the exo-clamp into position, the leg section of the prosthesis was removed and the rotation of the foot/knee marked. The exo-clamp slid in place around the pylon (not tightened as it needs to be removed later) by removing the knee. The knee was then put back in its proper rotation as marked earlier (Fig. 3). After the exo-clamp was put in its desired position, all of the components were wrapped with a sheet of plastizote and plastic wrap before wrapping the entire leg with scotch cast (Fig. 4). The scotch cast was used to secure the exo-clamp in place and also
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acted as a barrier between the components and the foam. In addition, a spacer (pencil) was made at the tightening screw of the knee to allow the knee and pylon to separate in a later stage of fabrication. The foam mold could then be created. A thin sheet of flexible plastic was used to create a cavity around the leg where a two-part foam was poured to take shape (Fig. 5). Once set, the foam was ready to be shaped to the contours and measurements of the patient’s sound leg (Fig. 6). Following this, pliers were used to remove the spacer allowing entry to remove the components from the foam mold (Fig. 7). The foam mold was then prepared for lamination by filling the spacer hole and sealing it using bondo (Fig. 8).
Figure 2
Figure 3
The cosmetic shell cover was created by laminating over the foam mold which was set up with the following lay-up in order: PVA bag over the mold, first layer of IPOS, fiberglass reinforcement at the knee and exo-clamp attachment points, second layer of IPOS, one layer of fiberglass tubular weave, third layer of IPOS, fourth layer of IPOS and two layers of feather stretch nylon to finish (Fig. 9). After the lamination cured, a chisel was used to chip away the foam from the cosmetic shell (Fig. 10). After the shell was
Figure 6
Figure 7
Figure 4
free of foam and the exo-clamp removed, the trim lines were established on the shell to create the cosmetic cover for assembly (Fig. 11). Assembling the exo-skeletal cover started with attaching the exo-clamp to the cover with screws that run from the outside of the cover to the protruding prongs of the clamp (Fig. 12). The cover then slid onto the pylon (with foot removed) followed by the knee (tightened to the rotation as marked earlier). At this point, sliding the cover proximally exposed the distal tube
Figure 8
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Figure 5
adapter on the pylon so that the foot could be re-attached (Fig. 13). Once all of the components were attached, the cosmetic cover was then lowered distally to the desired position, leading to the last step – tightening the tube clamp. To tighten the exo-clamp, a clearance hole was made in the cover to allow a hex key to tighten the screw of the exo-clamp (Fig. 14). Once the assembly was complete, the leg section was then re-attached to the upper trans-femoral socket and was ready for the patient (Fig. 15).
Figure 9
Figure 10
Figure 13
There are various implications and practicalities of a custom-fabricated exo-skeletal cover, specifically for a swim leg prosthesis. Typically, options for cosmetic covers for a swim leg with endo-skeletal components are limited. In the case of the subject patient, the advantage of a custom-fabricated cover was that it did not compromise any alignment changes since his swim leg and his everyday walking leg both utilize
Figure 11
Figure 12
Figure 14
Figure 15
the 3R80 knee, keeping consistency in gait. Furthermore, the custom exo-skeletal cover allows future alignment changes or the ability to change feet, which would be impossible with an exo-skeletal finish. Overall, the custom-fabricated exo-skeletal cover offers a durable and hygienic method to cover swim legs with endo-skeletal components as well as providing an alternative method to cosmetic finishes.
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About the Author: Darren Zhou, B.PHE, graduated from the University of Toronto with a degree in Physical Education and Health. His passion for fitness and curiosity for human mechanics led him to pursue a career in prosthetics and orthotics. He is currently working as a Prosthetic Technician at Northern Alberta Prosthetic & Orthotic Services in Edmonton.
O&P SOLUTIONS
A Client-Centred Approach to an ADL Challenge
By: Adrienne Cuch, B.A.Kin, CO(c) As our profession moves towards an evidence-based practice model of care, the shift towards a client-centred approach is also gaining significant traction. Clients are more knowledgeable, engaged, and active members of their healthcare team. The concept of including patients in their own treatment plans is referred to as shared or collaborative decision-making... empowering patients to take responsibility for their health. While this approach may not fit with all clients, an understanding of this model will better serve those who choose to be active participants in their care.
I met an energetic 31-year-old female with spastic quadriplegic cerebral palsy in our adult orthotic clinic. She lives alone in an assisted living apartment building, and expressed concern over her increasing wrist and elbow contractures. Her goals were to prevent further loss to her range of motion and still be able to perform her activities of daily living (ADL). Her limited upper extremity function makes ADL difficult, but possible, with her three most important ADL being drinking from a sippy cup, using a fork to
eat her food, and most importantly, typing on her computer. Rachel’s condition for proceeding with the orthosis was that it had to allow for continued independence in her ADL. Staff members assist her with dressing, personal hygiene, and food preparation. However, she otherwise wants to remain as independent as possible. She understood that her limited hand function would require the staff to assist her with donning and doffing. As such, she felt that it was more important that she could perform her ADL without having to 94
call the staff each time to doff the device. At initial assessment, she presented with a -50 degrees of right wrist extension, and -80 degrees elbow extension. Her ranges on the left were 0 degrees of left wrist extension and -10 degrees of left elbow extension. Flexion of all joints were within normal ranges. As it was unclear if the device would suit her daily life, we chose to proceed with one device at a time to ensure success prior to moving to the other limb. We cast the right upper extremity in the most extended
A-wrap pulled and skived
Finished device prior to straps attached, medial view
wrist and elbow position that she could tolerate. The objective was to design a device that was easy for the staff to don and doff, effective at reducing/ preventing further loss of range, and still allow Rachel to use her computer and drink from her cup. To best understand her home environment, it was important to see her computer set-up to determine the height of the keyboard and depth of the keys she needed to access. Consideration of the environment is crucial to clinical decision-making, and is a context-dependent process influenced by social and cultural factors (Smith, 2006, as cited in Higgs & Jones, 2008). The client’s “problem space” is defined by individual factors including family, socioeconomic status, home environment, and other unique personal characteristics (Higgs & Jones, 2008). To fully appreciate Rachel’s problem space, a better understanding of her physical environment was necessary to provide the best care possible.
appointments. An important variable to consider was the ability of staff attendants to consistently don her device correctly, and this was measured as an outcome of effective client and caregiver education.
Variables and Expectations Outcomes were established by taking passive ranges of motion at assessment, fitting, and follow-up
Solution Her device is a modular ElbowWrist-Hand Orthosis that, when worn together, controls both the elbow and wrist joints. Separate pieces can be worn independently to control one joint. This design allows her to experiment with both pieces in the event one component limits her motion to perform her ADL. The elbow orthosis (EO) is a static, anterior (A-wrap) style that fits within the wrist-hand orthosis (WHO). The wrist has an adjustable range joint so the staff can adjust as needed, and her fingers are left open and free to type on her computer. The EO was fabricated using 1/4'' thermofoam and 1/8'' modified polyethylene. A plaster build-up was added prior to molding the WHO to safely cut and remove it without damaging the EO. The shell of the WHO is 5/32'' copolymer, with 3/16'' copolymer reinforcement strips along the sides for attachment of the uprights laterally, and a polyurethane rod medially 95
(holes were drilled into the reinforcement and the rod threaded in). A series of pull-over and pullback leather-reinforced straps were attached. The first fitting was performed in Rachel’s apartment to better understand her environment, and to determine if the orthosis permitted the range necessary to operate her computer. She found wearing both the elbow and wrist components very challenging to reach the keyboard. It was decided that she should wear the devices independently for the first few weeks to adjust. As some modifications were needed to her device, a second fitting appointment was booked the following week. All staff and managers attended the second appointment to learn about the device and for demonstrations on donning/doffing her orthosis. Client education was a vital component of the success of Rachel’s orthotic management. The goal of client education is to increase the confidence, competence, and independence of clients to manage their self-care, which can therefore encourage treatment plan adherence and empower clients to be active members in their care (Bastable & Gramet, 2011). The various learning styles of the staff members were considered
Rachel at three-month follow-up wearing WHO when creating Rachel’s educational plan for her treatment. As learning styles can vary with individuals, a variety of instructional methods were used to promote desired learning. Written instructions were posted in Rachel’s apartment, along with photos to illustrate fitting criteria and joint positions. The education provided to Rachel and her care team involved visual, aural, kinesthetic, and read/write learning styles.
Outcome A follow-up was conducted with Rachel three months later. To evaluate if primary goals were achieved, ranges were taken of her wrist and elbow, and Rachel was queried about the ability of staff to consistently don her orthosis correctly. She found the elbow orthosis too restrictive, and is wearing the WHO independent of the EO. She wears the orthosis 8-10 hours daily, and much to my surprise, gained 40 degrees of extension in her right wrist! She was not even aware of these gains until I showed her photos from her initial assessment. Rachel reported that all staff were comfortable donning the device, and she wears her orthosis while using her computer and eating/drinking. We are discussing options for her left arm, however, she is concerned that she will lose the mobility she needs to perform other tasks as she is left-handed. As the staff attendants are now familiar
Joint position at three-month follow-up
with Rachel’s orthosis, providing treatment to her other limb may be an easier transition. Overall, this was a valuable learning experience for both Rachel and myself, and in the end our goals were met and Rachel was pleased with the outcome. We achieved a positive functional outcome while allowing her to perform her ADL and maintain her independence. By considering Rachel’s home environment and including the staff attendants in the educational process, we successfully fulfilled our objective. Obviously, home visits are not feasible for all clients but in cases such as Rachel’s it may result in a more effective treatment. The clinical reasoning process is often not thought of consciously, but an understanding of the factors that lead us to make clinical decisions can improve the quality of services we provide for our clients.
Resources VARK Learning Style Inventory http://vark-learn.com/the-varkquestionnaire/ Learning Style Inventory http://www.personal.psu.edu/bxb11/LSI/ LSI.htm Bastable, S. B., Gramet, P., Jacobs, K., & Sopczyk, D. L. (2011). Health professional as educator: Principles of teaching and learning. Sudbury, MA: Jones & Bartlett Learning. Higgs, J., Jones, M., Loftus, S., & Christensen, N. (2008). Clinical reasoning in
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the health professions 3rd ed. (p. 3-17). Oxford: Elsevier Butterworth Heinemann.
References Bastable, S. B., Gramet, P (2008). Overview of Education in Health Care. In Bastable, S. B., Gramet, P., Jacobs, K., & Sopczyk, D. L. (2011). Health professional as educator: Principles of teaching and learning. Sudbury, MA: Jones & Bartlett Learning. Higgs, J., & Jones, M. (2008). Clinical decision making and multiple problem spaces. In Higgs, J., Jones, M., Loftus, S., & Christensen, N. (2008). Clinical reasoning in the health professions 3rd ed. (p. 3-17). Oxford: Elsevier Butterworth Heinemann. Kitchie, S. (2011). Determinants of Learning. In Bastable, S. B., Gramet, P., Jacobs, K., & Sopczyk, D. L. (2011). Health professional as educator: Principles of teaching and learning. Sudbury, MA: Jones & Bartlett Learning. Trede, F., & Higgs, J. (2008). Clinical reasoning and models of practice. In Higgs, J., Jones, M., Loftus, S., & Christensen, N. (2008). Clinical reasoning in the health professions 3rd ed. (p. 3-17). Oxford: Elsevier Butterworth Heinemann.
About the Author: Adrienne Cuch, B.A.Kin, CO(c), is a Certified Orthotist practicing at Boundless Biomechanical Bracing in Toronto. She is currently completing her Masters in Rehabilitation Sciences at McMaster University.
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The Virtues of Varsol The Skinny on (Paint) Thinner By Brian C. Myles We have all seen or smelled it at some point outside of our work – at our parents’ house or in our own homes, in a basement or a garage beside the tins of old oil paint. Paint thinner. It’s great for de-greasing bike and car parts, for starting old-style BBQs and campfires (with caution), and of course for its original use... cleaning paint brushes.
There is a place for Varsol on the P&O workbench as well. It is similar to glue thinners, but not quite the same. It must be noted that whichever adhesive you use, follow the manufacturer’s directions on thinning it for use on anything being dispensed – it’s important to keep them properly matched to avoid adhesion failures and subsequent device failures. Paint thinner is a brilliant addition because it only does part of the job that we look to other solvents to do. Whereas “Barge” thinner will completely re-liquefy other glues creating a gummy mess that gets on everything it comes in contact with (including us), Varsol just softens it, creat-
ing a bit of a barrier between the glue and the adhering material. For example, if you use “Barge” for adhering your flexion joints to casts, Varsol allows you to remove the old glue with a small rub of a finger or cloth, often just flaking away. Since it only does part of the job, the glue doesn’t re-liquefy or get sticky; it becomes just a bit of debris to be swept up. Another miracle of mineral spirits is that it has virtually no effect on the majority of the solids we use for fabrication – this means that taking china marker off of sheet goods or pen marks off of erkoflex is a breeze because mineral spirits only do half the job – dissolving the marks, not 98
the material. Just a dab on a rag or a cotton swab is enough to quickly clean all of those modification/trim/placement lines from the socket or orthosis. It does the same for china marker on FO lining fabrics like “xtatic” if used indirectly and sparingly. It’s more fantastic than “Fantastik” in a lot of ways but it does leave a slight residue... just enough to smell bad and inhibit adhesion at times. A quick wipe with rubbing alcohol is recommended. It’s well worth the effort for all the elbow grease it saves. By introducing this sublime solvent into your chemical usage mix you will also reduce your exposure to more nastier compounds. Varsol is a singular
priately labeled HDPE vinegar bottle). There are many benefits to Varsol use in your practice. Give it a try. It’s cheap, comes in a variety of sizes and in short order, you’ll wonder what you ever did without it.
About the Author:
solution, unlike many solvents in adhesives that are commonly used in our profession – dangerous chemical cocktails like fluorine for example. Varsol is not a controlled substance for W.H.M.I.S. and can be bought
at any hardware store. Not that Varsol should be handled without care – it is still poisonous (and flammable). But it is gentle enough to use in squeeze bottles for quick use as it doesn’t corrode the bottle (I use an appro-
Brian C. Myles made a mid-life career switch from yacht building to P&O. Graduating with Honours in 2013 from George Brown College’s Technicians Program, he went on to complete his internship with Design Prosthetics & Orthotics in Whitby, Ont. Brian enjoys the challenges of the technician’s role and being able to use his creative abilities and previous experiences to develop unique solutions. Most of all, he takes satisfaction in knowing that he’s improving the quality of life for his patients.
CONTINUING EDUCATION
Student Papers
Effects of dynamic AFOs after chemodenervation and serial casting in adults with acquired brain injury: a feasibility study A common treatment for spastic equinus deformities in people with acquired brain injury is chemodenervation, sometimes followed by serial casting. There is anecdotal evidence to suggest the use of dynamic resting ankle-foot orthoses (AFO) as a novel adjunct therapy to these treatments.
Objectives of Research While implementing the International Classification of Functioning, Disability and Health framework, this study will evaluate the effectiveness of dynamic resting AFOs as an adjunct treatment for spastic equinus deformities. However, the primary aim is to examine the feasibility of the described methodology in a clinical setting.
About the Authors: The following are student research projects from British Columbia Institute of Technology and George Brown College that each program is excited to share with the P&O community across Canada. In the interest of showcasing a variety of papers, these projects are represented by an overview, with full-length papers available on the Orthotics Prosthetics Canada website at www.opcanada.ca. With thanks to project coordinators Caroline Soo, B.Sc. (Kinesiology), M.Sc., Research Coordinator, Prosthetics and Orthotics School of Health Science, British Columbia Institute of Technology, and Gordon Ruder, CO(c), B.Sc., M.Sc., Coordinator, Prosthetic & Orthotic Programs, George Brown College.
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Malena Rapaport, B.Kin., (BCIT), is a graduate of the Faculty of Kinesiology at the University of Toronto. She is currently completing her Masters in Rehabilitation Science at McMaster University while doing her Prosthetics Residency at Barber Prosthetics. Amanda Bremner, earned a B.Sc. from Simon Fraser University in Biomedical Physiology and Kinesiology and is currently completing her M.Sc. from McMaster University in Rehabilitative Sciences.
Outcome Measures for Lower Extremity Orthotic Treatment Outcome measures (OMs) are standardized tools used to evaluate, discriminate, and/or predict attributes of interest in an individual or group (Finch et al., 2002). The incorporation of these tools into clinical practice facilitates the development of evidence-based practice and aids in the justification of treatment. OMs can aid in communicating to the patient, multidisciplinary team members, and third parties the need for a particular prescription and provide evidence regarding the effectiveness and progression of treatment. Rehabilitation disciplines such as physiotherapy, occupational therapy, and nursing have developed standardized practice guidelines for patient care and management in which OMs are becoming a commonlyused tool (Canadian Association of Occupational Therapists, 2015; Canadian Nurses Association, 2015; Canadian Physiotherapy
Association, 2012). In current orthotic practice, OMs are not implemented on a regular basis. This is due to a lack of resources and limited ease of accessibility to the few resources that exist which diminishes the ability of an orthotist in justifying treatment methods.
Objectives of Research The purpose of this paper is to initiate the development of an orthotic outcome measure database by identifying OMs that can be applied to lower extremity orthotic treatment in clinical practice. Suitable OMs will be identified through a comprehensive review of publiclyavailable OM databases. This paper aims to eliminate some of the uncertainty in choosing an appropriate OM and reduce barriers of implementation in clinical orthotic practice.
About the Authors: Christine Tschirhart, B.Sc., is a second-year student in Clinical Methods in Prosthetics and Orthotics at George Brown College and co-enrolled in the Masters of Rehabilitation Science program at McMaster University. Christine will do her Orthotic Residency at Orthopedic Bracing Solutions Inc. Anne Whitney is a second-year student in the Clinical Methods in Prosthetics and Orthotics program at GBC. She graduated from McGill University in 2009 with a B.Sc. in Kinesiology. She will undertake her Orthotic Residency at Boundless Biomechanical Bracing.
An Investigation of Inertial Effects on a Trans-tibial Amputee Prosthetists have an increasing level of control over distribution of mass within the prosthesis. Currently, there is little research available quantifying the clinical effects of varied mass distribution. The clinical impacts of prosthetic mass distribution are not well known; currently, mass distribution is not considered during the fabrication of prosthetic devices.
Objectives of Research The aim of this pilot study was to investigate whether inertial effects have a significant impact on
quadricep and hamstring activation during swing phase. Positive results would suggest that mass distribution may play a significant role during gait, and should be studied further and optimized during fabrication of prosthetic devices.
About the Authors: Roopa Somayaji, B.Sc., graduated from the University of Alberta with an undergraduate degree in Mechanical
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Engineering. She is currently enrolled in the Masters of Rehabilitation Science program at McMaster University. Gillian Archibold, B.Sc., graduated with distinction from the University of Saskatchewan with an undergraduate degree in Kinesiology. She is a certified personal trainer with CSEP and is working towards completing the BCIT P&O program.
Using 3D Printing to Design a New Cranial Remodeling Orthosis Cranial Remodeling Orthosis (CRO) currently have several limitations including time to fabricate, temperature, weight and cost. 3D printing is a manufacturing technique that has the potential to address these limitations but has yet to be clinically evaluated. 3D printing can be used as an alternative manufacturing process for the fabrication of a CRO. This technology also has the potential to change the design of a CRO and improve associated clinical outcomes.
Objectives of Research To introduce new design criteria and to demonstrate the viability of using a new manufacturing technique to fabricate a CRO,
the first stage of this work is to prove the feasibility of using 3D printing to duplicate the fit and function of orthoses that are currently provided. The second stage is to apply new design criteria that could potentially address the identified limitations. This will be accomplished by utilizing the advantages of additive manufacturing vs. traditional thermoforming.
About the Authors: Jeff Wright, (BCIT), is a graduate of the University of Calgary’s Exercise and
Health Physiology program. He is currently enrolled in the Rehabilitation Science program at McMaster University and intends on pursuing a residency in orthotics. Shane Bates, B.Kin., (BCIT), is a graduate of the University of British Columbia’s School of Kinesiology. He is currently completing his Masters of Rehabilitation Science at McMaster University.
Pre- and Post-assessment of a Prosthetic and Orthotic Treatment: a health-related quality of life questionnaire using the Orthotics Prosthetics Users’ Survey (OPUS) There is a dearth of longitudinal studies about patients’ health-related quality of life (HRQOL) in P&O. Filling this gap in research can support the validity and reliability of treatment plans for patients, payers and professionals. If there is an increase in HRQOL over time, there may be an indication that care from a prosthetist or orthotist will decrease a patients’ dependence on the healthcare system. Additionally, by quantifying HRQOL it could contribute to developing patient-centred care among P&O professionals.
Objectives of Research Drawing on the International Classification of Functioning (ICF) framework, this study aims to assess a patients’ HRQOL prior to receiving an orthotic/prosthetic device and after receiving their specific device.
About the Authors: Julia Rayner, CAT(c), C.Ac., (BCIT), is a graduate of the University of Winnipeg’s Athletic Therapy program and the College of
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Acupuncture and Therapeutics. She is currently finishing her Masters of Rehabilitation Science at McMaster University while completing her Orthotics Residency at Winnipeg Prosthetics and Orthotics. Amber Major, B.Kin, is a graduate of the University of the Fraser Valley. She is currently completing her Masters of Rehabilitation Science at McMaster University. She is excited to work with colleagues and patients to enhance the P&O profession.
Prosthetic Outcome Measures for a Smart Device Application As the field of prosthetics and orthotics continues to advance, “the need for having reliable evidence available to distinguish and validate our client service is paramount� (Pardoe, 2014). The goals of prosthetic treatment are to improve functionality and quality of life for individuals with limb loss. These goals require outcome measures (OMs) specifically designed to quantify them (Heinemann, 2003). This means practitioners must assess outcomes related to body structure and function, activity level and ability to carry out tasks, participation in life situations, and overall quality of life (Wright, 2013). Despite the availability of OMs to assess these qualities (Condie, 2006), several barriers limit their
use in clinical practice. The first challenge is finding and interpreting research to select appropriate OMs for patients (Resnik & Borgia 2011). It is critical to select quality OMs that have strong validity and reliability for the specific population of interest (Condie, 2006). Several mobile applications (apps) have been developed and utilized for individual outcome measures to combat these barriers. No smart-device app exists which contains multiple prosthetic outcome measures, and links directly to pre-existing electronic medical records software.
Objectives of Research The purpose of this project is to compile an updated list of outcome measures suitable for pros-
thetic practice to minimize the barrier of appropriate outcome measure selection. From this list, suitable outcome measures will be strategically selected for use in an OMs smart-device application.
About the Author: Mitchell Visser earned a B.Sc. in Biology from StFX University. In his second year of the Clinical Methods in Prosthetics and Orthotics program at GBC, he is also completing the Masters of Rehabilitation Science program at McMaster University. He will begin his Prosthetic Residency at Atlantic Prosthetics Inc.
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Are plant-based fibres an acceptable alternative to fibreglass in the fabrication of prosthetic sockets? In 2013 the World Health Organization stated that only 5-15% of persons in need of assistive health products have access to them. Prosthetic and orthotic (P&O) devices are among these products. The recent United Nations climate change agreement reinforces an international concern to reduce carbon footprints (United Nations, 2015). It is understood from this that there is a need for more P&O materials that are sustainable but also produce a lesser environmental impact than conventional options. Within the conventional materials, fibreglass is considered moderate strength (Phillips, 2005) and is consistently noted as suitable within industry standards
in regards to tensile strength (Campbell et al.; Che Me et al., 2012; Phillips, 2005). Despite the apparent suitability of fibreglass for use in prosthetics there are aspects of the material, such as health hazards and environmental impacts, that can pose challenges/issues in certain settings.
Objectives of Research The objective of this paper is to identify sustainable alternatives to conventional materials, specifically fibreglass, for use in the lamination of prosthetic sockets. Plant-based fibres will be identified and compared to synthetic fibres to determine their viability through the following measures:
mechanical properties, environmental effects, health hazards, and overall feasibility.
About the Author: Tania Gripper Chabot, RTP(c), has been working in the field for nine years. She returned from teaching at the Philippine School of Prosthetics and Orthotics to further her education by completing the Clinical Methods in Prosthetics and Orthotics program at George Brown College. Tania will join the team at the Ottawa Rehabilitation Hospital to pursue a residency in Prosthetics.
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Pilot Study: A Quantitative Analysis of Peak Pressures Experienced During Walking and Running Gait in an Unstable and a Stable Mid-foot While Wearing Supramalleolar, Dynamic Mid-foot Control, and Dynamic Foot Orthosis. This study will be analyzing and comparing peak pressures at the heel, big toe, head of the first metatarsal, and medial arch during walking and running. Pressures will be measured while shod as a control condition and while wearing a Supra-Malleolar Orthosis (SMO), Dynamic Mid-foot Control Orthosis (DMC), and a Dynamic Foot Orthosis (Dyno) using F-scan.
Objectives of Research To determine the peak pressures in each of the SMO, DMC and Dyno orthoses in a patient with a mobile mid-foot and a patient with a stable, but not rigid, midfoot, the stability of the mid-foot will be captured in barefoot conditions weight-bearing and non-weight-bearing, using picture analysis and markers on the
first MTP, navicular and centre of calcaneus to quantify. A full range of motion analysis of the rays, oblique axis, as well as subtalar joint motion will be taken and recorded to further quantify the collapsibility. Pressures will be measured at the heel, big toe, head of the first metatarsal, and medial arch to determine which device yields the lowest peak pressures in self-selected walking and running speeds. This is important in determining the impact of these devices on those with an unstable and stable mid-foot.
About the Authors: Heather Mackenzie completed her B.Sc. (Kinesiology) at McMaster University in 2013. She then
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completed one year of the George Brown College prosthetic and orthotic technical program before entering the clinical program where she is now in her second year. She is looking forward to her next step in becoming a certified orthotist in the residency program. Shaughn Reilly, B.Sc., graduated from McMaster University with an undergraduate degree in Kinesiology. He is currently finishing his second year of the Clinical Methods in Prosthetics and Orthotics program at George Brown College and will be starting his Orthotic Residency at Valley Orthocare Ltd. in Surrey, British Columbia.
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Are there beneficial elements to non-surgical intervention of paediatric in-toeing in terms of temporal parameters, and balance? In-toeing is a common deviation within the paediatric population and a major cause of concern for parents (Li, Leong, 1999). The foot progression angle (relationship of the line of progression of the foot compared to the direction of walking) will indicate if in-toeing is occurring. The normal range of foot progression angle within young children is -3 to 20 degrees. A negative value below -5 or more is deemed excessive in-toeing in a child (Walls, Sehgal, 2012). The adverse effects of untreated in-toeing may include frequent tripping, pain, and patella instability (Uden, Kumar 2012). This negative foot progression angle can be caused by various deformities such as femoral anteversion, tibial torsion, metatarsus adductus, or muscle imbalance (Li, Leong, 1999). The cause of the negative foot progression angle should be determined in order to provide the most beneficial treatment. The cause can be determined by various tests such as the Ryder’s test, foot-thigh angle, transmalleolar axis angle, and heel bisection line. Although physical examination
should be sufficient in assessing the cause, use of X-rays, fluoroscopy or CT scans can be used to determine the cause of the in-toeing (Li, Leong, 1999). There are various methods both surgically and non-surgically to address in-toeing (Uden, Kumar, 2012). Some of the non-surgical options include Twister straps, Twister cables, Gait plates, and Theratogs. Surgical options include casting and/or osteotomies (Li, Leong, 1999). In the current literature, there is controversy within the non-surgical options (Mohamad, 2013). Some of the literature states that the use of derotation orthotics do not provide any benefit to the in-toeing individual (Li, Leong 1999). Other works have seen an improvement in temporal parameters and gait when utilizing non-derotation orthotics (Mohamad, 2014). A literary review of the most current studies and papers is required to answer the underlying question: Are there beneficial elements to non-surgical intervention of paediatric in-toeing in terms of temporal parameters, and balance?
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Objectives of Research Orthotic management of this deviation is used in facilities today. There seems to be little knowledge of the effects of the correction beyond a visual assessment and gait analysis. The purpose of this research article is to assess a compilation of case studies and research papers in search of quantitative evidence of the benefits or harm of these various interventions. This will provide education on the orthotic management used, and its effectiveness in clinical practice.
About the Author: Devin Sims is currently a second-year student in the Clinical Methods of Prosthetics and Orthotics program. He graduated from the P&O technical program at George Brown College in 2013 and has spent time volunteering at Sri Lanka School of Prosthetics and Orthotics. Moving forward, Devin hopes to become dual certified and begin volunteering abroad again.
Management of Partial Foot Amputations Partial foot amputation (PFA) is a surgical treatment involving the resection of part or all of the foot distal to the ankle, while retaining at least part of the plantar weight-bearing surface of the foot. PFA is indicated for many disease processes as well as traumatic causes. PFA is the most common amputation surgery performed in industrialized countries, with an incidence of approximately two per 1,000 individuals (Dillon, 2010). Improvements in revascularization techniques and an emphasis on limb salvage have led to an increased proportion of amputations being performed distal to the ankle (Dillingham, Pezzin, Mackenzie, 2002; Dillon, Kohler, & Peeva, 2014). Little data is avail-
able regarding the incidence of PFA in the Canadian population, although incidence is likely similar to other industrialized nations. The goal of the current study is to create a focus group of Canadian pedorthists, prosthetists, and orthotists to describe the number of individuals with PFA treated by Canadian practitioners, and the types of treatment they provide.
Objectives of Research The objective of the current study is to describe the current body of knowledge on the prevalence and treatment options for individuals with partial foot amputations through a comprehensive literature review, as well as discussion with a focus group of orthotists, prosthetists, and pedorthists.
Following the descriptive analysis of the available information on prevalence of partial foot amputations and options for partial foot care, a survey will be disseminated to Canadian orthotists, prosthetists, and pedorthists to gather data on practitioners’ experiences.
About the Author: Meagan Gerein is in her final year of the Clinical Methods program at George Brown College. She graduated from McMaster University with a degree in Arts & Science. Meagan will begin her Orthotics Residency at B.D. Mitchell Prosthetics and Orthotics.
Will the new Ossur Iceross Seal-In X adjustable liner allow higher socket comfort and product satisfaction among trans-tibial prosthesis users? As the Seal-In liner acts as an interface between the skin and socket of the prosthesis, it can be a viable suspension option for amputees. Until the recent release of the Iceross TT Seal-In X, manufacturers determine the seal-in level. Ossur’s new Seal-In X liner allows patients to self-select the level with an adjustable Seal-In ring. Limited research is available about this liner. Our quantitative and qualitative research investigates how adjustability contributes to patient comfort and product satisfaction.
Objectives of Research To investigate how adjustability of the Seal-In liner will affect pistoning, knee flexion, patient comfort, and overall satisfaction.
About the Authors: Christine Richardson, B.Kin., C.E.P., (BCIT), is a graduate of the University of Regina with a Bachelors of Kinesiology majoring in Human Kinetics and Adapted Movement Science. She also completed her Certified Exercise Physiologist (C.E.P.) exam
though the Canadian Society of Exercise Physiology. She is currently finishing her Masters of Rehabilitation Science at McMaster University while doing her Prosthetics Residency at Winnipeg P&O. Patrick Smith, B.PEd, CAT(c), RT (Orthopaed), (BCIT), is a graduate of Mount Royal College and the University of Manitoba. He is a certified Athletic Therapist and a registered Orthopaedic Technologist and is currently doing his residency at Winnipeg P&O in orthotics.
Clinical Perceptions on the use of a Digital Outcome Measures Tool in Prosthetics and Orthotics Outcome measures in prosthetics and orthotics can be used to objectively measure treatment outcomes. However, clinicians have been reluctant to implement these measures in practice as they are often time-consuming, difficult to analyze, and procedures have not been standardized. The development of an easyto-use digital outcome measures tool for prosthetists and orthotists could assist in quantifying patient satisfaction and functional outcomes. This may help to ensure optimal care is provided to the patient. Digital data collection could
also allow for large amounts of accessible data to be compiled and used to conduct high quality research in this small field.
Objectives of Research By analyzing questionnaire and focus group responses, this study explores clinical perceptions on the implementation of a digital outcome measures tool.
About the Authors: Anna Kruithof, B.Sc., (BCIT), is a graduate of
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the University of Victoria with a degree in Psychology. Jasmine Slomp, B.Sc., (BCIT), is a graduate of the University of Lethbridge with a degree in Kinesiology. She is currently completing her Masters in Rehabilitation Science through McMaster University.
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Product Showcase New & Improved for 2016 Ottobock Spotlight
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The C-Brace system’s real-time gait analysis and carbon fiber frame frees your patient to ambulate to his or her full potential.
With a high-performance hydraulic damping element, the ProCarve system ensures dynamic movement on the slopes or on the water.
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The servo-pneumatic control unit of the 3R106-PRO offers a more consistent swing phase during fast walking.
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Action O&P Inc. Spotlight
New Titanium Components
Residual Limb Compression Stocking
Thanks to a special titanium alloy, Streifeneder ortho production GmbH is able to increase the maximum load of a complete range of structural components to 175kg (385 lbs) including carried and supported loads. They are extremely sturdy due to the special surface treatment. This enables the orthopedic technician to provide all necessary components to customers who are heavier in weight as well.
A residual limb compression stocking helps to reduce the post-operative wound edema, and serves to prevent the limb from new swelling. At the same time, it lends the residual limb a more advantageous, cylindrical or conical shape, which helps with prosthetic care. The residual limb compression stocking prevents unwanted fluctuations in volume after removing the prosthesis. These stockings are designed for above-knee or below-knee amputations, and are available in various sizes and lengths in compression classes 1 and 2. Other features include: 1) antibacterial silver fibers according to OEKO-TEX® Standard 100, which greatly minimizes odour and prevents skin irritation, 2) circular knit – adapts to body anatomy, 3) flat-looped seam at the end of the compression stocking results in a high level of comfort, 4) machine-washable on a daily basis.
SlideFit – Donning Aids With our SlideFit product, which has a gliding material surface, we offer support to the user during donning an above-knee prosthesis with suspension socket. Benefits for the user include: 1) the gliding material surface simplifies donning the above-knee prosthesis, 2) long and stiffened donning aid simplifies inserting through the valve opening into the prosthetic socket, 3) large grip loop makes pulling out through the valve opening less exhausting, 4) contrast-coloured sewing thread for ease of size identification. SlideFit comes in different sizes. The smallest has a stump circumference of 40cm (A) and 24cm (B) and the largest size’s circumference is 88cm (A) and 38cm (B).
Akton & Rebound Our new products, the Akton and Rebound, are very similar to Poron and PPT respectively with better characteristics. They are both Thermo moldable, more resistant as a material, easily grindable and less costly. Rebound is a great material for active patients. The Akton and Rebound are available in different thicknesses and come in rolls or sheets. Akton is available in black, blue and beige, and Rebound in beige.
For more information contact Action O&P Inc. at 1-800-337-1947 or email info@actionop.com or visit www.actionop.com. 113
Anatomical Concepts Spotlight KMO™
DDA™ Orthosis
The KMO™ (Knee Management Orthosis) features a single posterior joint that is a cost-effective, patientfriendly and simple approach for static, progressive positioning management of the knee. The static progressive positioning is adjustable from 0° to 110° (additional ROM may be attained). The KMO also features an adjustable range of stabilization in the sagittal plane as the patient’s conditions warrant. Ideal patients for the KMO are those requiring preand post-operative management of bony and soft tissue injuries. The KMO Orthosis is PDAC Approved.
The DDA™ (Dynamic Dorsi-Assist) Orthosis is designed to dynamically stretch the gastroc muscles, offsetting equinus contracturing. The use of a series of posterior articulations allow for a virtually unrestricted range of plantar or dorsiflexion. The DDA Orthosis provides nearly unlimited inversion or eversion of the ankle/ foot. The DDA incorporates two elastic straps attached to the distal foot section and proximal calf section which can be adjusted to compensate and/or offset varus and valgus tendencies while maintaining constant dorsi-assistive force. The orthosis incorporates a telescoping calf section feature that allows for shortening or lengthening of the soft tissue/musculature.
Elbow Orthoses
Paediatric KAFO (Blounts)
Three functional jointed-elbow orthoses that uniquely position along the dorsal aspect of the arm eliminating any undue pressure concerns about the bony elbow condyles. The easy-fit designs simplify the fitting process for the clinician and increase comfort for the patient while providing the necessary control and/or stability to address varying upper extremity and specific elbow etiologies. The EMO™ Orthosis provides immobilization for musculoskeletal injuries and offers static progressive stretching. The QUAD™ and E-ROM™ Orthoses are more versatile jointed-systems that provide immobilization for musculoskeletal injuries and feature dynamic, ratchet-style stretching, variable ROM and lock-out positioning.
Since its inception, Anatomical Concepts Inc. has served as designer and manufacturer of industry-leading orthotic medical devices, with the clinical and technical experience to customize orthoses to fit your patient’s specific needs in order to deliver more effective results that improve patient compliance. The V-VAS™ KAFO Systems are the company’s most common custom-made devices. Anatomical Concepts can also custom fabricate, modify or refurbish its other orthoses for upper and lower extremities, utilizing many of its pre-fabricated ankle/ foot, knee and elbow brace designs to affordably produce any number of functional hybrid combinations for your patients.
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Anatomical Concepts Spotlight continued PENTAGON® Orthosis
TERRA™ Orthosis
The Pentagon Orthosis is a posterior-fitting, singlejointed upright knee orthosis that provides a more patient-friendly alternative to the traditional bulky double-upright hingedknee configurations. It’s the only system that allows the calf and thigh segments to dynamically shorten and lengthen with the patient’s extremity during flexion and extension of the knee. This design function provides an accurate alignment of the mechanical knee joint to that of the anatomical knee joint aiding in positive rehabilitative patient outcomes. The unique knee joint addresses five different knee functions (Free Motion, Drop Lock, Variable ROM, Ratchet Lock and Lock Out). ®
The TERRA™ Articulating Ankle/Foot Orthosis delivers similar benefits as the RIBBY® Orthosis and ABBY™ Articulating Ankle/ Foot Orthosis, but offers additional features appropriate for some patients. The integrity of the superstructure is unmatched by other Ankle/Foot orthoses. The TERRA Orthosis allows for optimal dorsi/plantar flexionankle positioning to provide adequate clearance during swing phase and knee stability in stance phase. The TERRA provides a new non-skid low profile plantar surface. It includes an open toe shoe, provided at no extra cost, and is compatible with all liner variations that we offer if applicable.
Custom Fabricated V-VAS™ Orthosis
Prefabricated KAFO/ AFO Patient Rehabilitative Systems
Patented offloading/ realigning knee orthosis (KO). Achieve optimal varum or valgum stress without bulky or complex adjustment while KO is being worn. The V-VAS™ Orthosis treats osteoarthritis, degenerative joint disease (DJD), bowleg, knock knee, knee buckling and gross medical lateral instabilities. Its unique polycentric, adjustable-hinge design creates an ideal bending moment that results in the precise offloading/realigning experience. It is the first long axis off-loading, closed-dynamic frame, custom knee orthosis that doesn’t need to be removed to adjust off-loading and the mechanical axis is always non-binding and auto aligning.
A rehabilitative custom-fitted orthotic system that provides a unique and cost-effective approach in managing your patient’s lower extremity needs. These modular KAFO/AFO systems can be easily adjusted ranging between only three standard sizes (adult, paediatric and infant). The individual ankle-foot and knee sections can be disconnected quickly in the field with or without tools to be used separately if needed. The versatility and durability of its single posteriorjointed design creates a patient-friendly superior sagittal plane support system for ambulatory/recumbent patients who can manage their entire rehabilitative process for an indefinite period of time.
For more information call 1-800-837-3888 or email info@anatomicalconceptsinc.com. Visit www.anatomicalconceptsinc.com. 115
Össur Spotlight PROSTHETIC SOLUTIONS RHEO KNEE® 3 & RHEO KNEE® XC
Pro-Flex® XC and LP The Pro-Flex family includes two new feet for specific user groups. For users with limited build height, the Pro-Flex LP provides substantially more range of motion and energy return than its predecessors, while the Pro-Flex XC is ideal for patients who need a foot to withstand the forces of high-impact sports or activities. All ProFlex feet feature the new anatomical foot blade that provides increased support in late stance and natural pressure progression from heel-strike to toeoff. The newly-designed Pro-Flex foot covers are lightweight, easy to clean, slip resistant, and provide sandal toe clamping for easy use with flip-flops.
Designed for a variety of users and circumstances, RHEO KNEE® 3 delivers confidence-boosting stability and a dynamic experience for users who want to return to everyday activity. In 2016 the RHEO KNEE 3 was enhanced to provide IPX4 water resistance, an OssurLogic iOS app for clinicians and users, faster swing extension and a smarter actuator/gyroscope for stance stability. The RHEO KNEE® XC is ideal for high-impact users. In addition to the above, it features automatic running, cycling and stair ascent modes. Combine RHEO KNEE 3 with the revolutionary Pro-Flex® foot for the most dynamic above-knee solution on the market today.
Cheetah® Xplore Cheetah® Xplore is a unique crossover prosthetic foot inspired by the original Cheetah design. Although primarily intended for everyday use, Cheetah Xplore enables the user to engage in a variety of sports and activities. It supports amputees with active lifestyles by combining high-energy return and dynamic push-off with increased balance and stability. The component-free fabrication yields an extremely lightweight and dynamic system that can be used with a wide range of trans-tibial users, including those looking for more dynamics with very limited build height.
Pro-Flex
®
The new Pro-Flex® foot by Össur is a step in the right direction. The revolutionary pivot technology provides the most natural and dynamic ankle function on the market today. Compared to a conventional energy storing foot (Vari-Flex), Pro-Flex provides a 93% increase in peak ankle power and an 82% increase in range of ankle motion. The result is an 11% load reduction on the sound side plus a 15% reduction in the external knee varus moment. Over a lifetime of steps, the potential health benefits are clear: by decreasing loads and improving dynamics, both individual and collective costs may be reduced.
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Össur Spotlight continued OA & INJURY SOLUTIONS Unloader® Hip
Rebound® DUAL
The Unloader Hip brace is an innovative non-surgical solution for mild-to-moderate hip osteoarthritis. The Unloader Hip is designed to reduce pain and increase mobility by optimizing load and proprioceptive control on the affected joint surface through rotation and abduction of the femoral head. Adjustment occurs during the swing phase, providing adapted positioning at heel strike. Load is dispersed through an area of healthier cartilage. The easy-touse pocket wrap closure system, simple-to-tighten pulley system and breathable material with integrated elastic sections allow the Unloader Hip to be easy to use and fit discreetly under clothing.
The Rebound® DUAL knee brace delivers functional support for ligament instabilities, including those associated with osteoarthritis, in a single, versatile aluminum brace. Suitable for low-to-high impact activities as well as sliding sports, Rebound DUAL is your new go-to knee brace. The Rebound DUAL’s low-profile design features a polycentric hinge for stability, slide-to-size upper frame, cold-malleable aluminum frame that is easy to contour to a patient’s unique anatomy, field-serviceable d-rings, no-slip ActiveGripTM calf liner and cut-to-fit straps to optimize patient comfort and an optional SmartDosingTM system for fine-tuned pain management and off-loading.
®
For more information on these products and others from Össur, call 1-800-233-6263 or visit www.ossur.com.
OrtoPed Spotlight Odyssey® K3 by College Park
OHP3SF by Medi
The College Park Odyssey® K3 foot provides fluid control for superior knee stability and incredible ground contact. The patented curved hydraulic cylinder allows for one pivot point, resulting in a smoother sweep, longer life and the lowest profile hydraulic K3 foot to date. The nine degrees of dampened plantarflexion give comfort while three degrees of dorsiflexion provide a smooth, balanced rollover that engages the dynamic carbon composite foot base. The heel spring and toe spring were meticulously crafted utilizing maximum stress predictions to increase strength and prevent failure. The design allows the carbon fiber composite to be pushed to the limit, providing greater flexibility and dynamic response.
This pneumatic, polycentric knee can be adjusted to the individual safety needs of the user. The adjustable axle geometry enables changes to be made quickly and easily to the actuation time. The extension/flexion valves can be set independently of each other producing a harmonious gait. A very acute flexion of the knee joint (up to 150°) is possible, which is particularly advantageous when, for instance, kneeling, sitting, or getting into the car. The optional closing geometry of the construction ensures stance phase stability and a high degree of safety, particularly at heel strike. This knee is also available in a knee disarticulation model. 117
OrtoPed Spotlight continued
ETD2 by Motion Control Motion Control’s new ETD2 is 3cm shorter than the original ETD. Rugged, functional and water resistant, it allows secure gripping of flat and cylindrical objects. The ETD2 features the choice of a Multi-Flex or Flexion Wrist. FLAG (Force Limiting Auto Grasp) and Bluetooth® options are also available. Production begins August 2016.
Peak Scoliosis Bracing System™ by Aspen The award-winning Peak Scoliosis Bracing System™ is an unloader brace designed to relieve pain, and enhance the quality of life for adult scoliosis patients. This patented, highly-adjustable brace from Aspen has been shown to improve posture, enhance mobility, increase vital capacity and ultimately increase a patient’s ability to perform activities of daily living. The brace offers multiple configuration options to accommodate unique patient needs.
PDE™ (Posterior Dynamic Element) by Fabtech Systems The Posterior Dynamic Element (PDE™) modular composite spring system has five weight activity category choices to choose from to address dynamic response bracing and many other conditions related to orthotic and prosthetic bracing needs. Specifically designed for O&P devices, the PDE is a modular composite spring system designed as a “plug and play” spring kit to address dynamic response bracing, unloading bracing, prosthetic partial foot devices and more. Using Click Medical’s RevoFit solution with the Boa Closure System™ the patient has control with a simple twist of the dial to release or tighten the fit as needed.
ProComp ProComp is a polypropylene-based composite that is stabilized with discontinuous carbon fiber. The individual fibers provide the ability of the composite to flow and stretch during melt temperature vacuum forming. The intertwined fibers have an average length of 0.75''. The three-dimensional carbon fiber matrix is discretely imbedded into the core of the laminate. The carbon will not protrude from the composite surface, which eliminates any contact dermal irritation. Primary clinical benefits of ProComp include improved structural integrity, inhibited clinical creep and post-delivery contour modification.
For more information on these products and others distributed by OrtoPed call 1-800-363-8726 or visit www.ortoped.ca.
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Ortho Active Spotlight Dynamic LSO High Profile
Osteoarthritis Knee Brace
This Dynamic LSO features a pre-contoured posterior panel that nicely fits the natural lumbar lordosis for good spine support and pain relief. The posterior panel is made from heat-moldable ABS if a custom fit is desired. The dual, independent mechanical advantage pulley system provides precise adjustment of upper and lower compression for maximum support. The easy-to-grip drawstring tabs, combined with the mechanical advantage pulley system, make it easy for clients with poor hand strength to achieve good compression and support. Enquire about item #5542.
Wave CTO
Designed for mild to moderate osteoarthritis of the knee, the single-side lateral hinge provides a three-point pressure system to shift the joint forces to the healthy knee compartment. The hinge is simple to adjust so that the hinge angle will fit the knee and then the required pressure can be applied using an Allen key. It has a lightweight frame and anti-slip soft padding, all at a very economical price for your elderly clients. Item #5539.
The new Wave CTO combines the advantages of the Wave Cervical collar with a CTO extension. The Wave Cervical collar features two quick-tabs for easy adjustment of the collar height and a removable washable white flannel liner with breathable foam for moisture wicking. The CTO extension has a simple height adjustment with a clamping slide mechanism. The anterior and posterior support bars provide optimum M/L restriction. Item #5512.
Euro TLSO The new Euro TLSO provides correct alignment of the thoracic lumbar spine with a rigid, contoured posterior panel. This panel is made of heat-moldable ABS for custom contouring when required. The laminated material provides good support, combined with soft comfort. The low profile shoulder pads eliminate chafing and distribute pressure for more comfort. The simple design combined with new high-tech Velcro allows for easy donning and doffing. Item #5545.
For more information on these products and others distributed by Ortho Active call 1-800-663-1254 or visit www.orthoactive.com. 119
High-Fidelity Trans-femoral and Tibial Socket System Training Say goodbye to buckets and welcome in the next generation in prosthetic limb connectivity – the patented and patents-pending HiFi™ Interface and Imager System. Unlike traditional sockets that focus on fitting the periphery of the limb, the HiFi Interface System allows you to capture and control your patient’s underlying bone. Upper and lower limb wearers report a significant increase in control, function, performance and comfort. Patients state that the HiFi feels connected to them. And the HiFi is backed by clinical evidence. Be a part of the HiFi Revolution. Register for our upcoming training event Thursday, Sept. 8th in Boston. Contact biodesigns inc. at HiFi@biodesigns.com or call 1-800-775-2870 or www.JoinHiFi.com. Check out www.youtube. com/biodesignsvideos for more info.
Spring Plate The Paris Orthotics Carbon Fibre Spring Plate is an effective internal shoe stiffener that limits motion across the forefoot and assists in propulsion. Made from pre-preg carbon, it is thin, light and durable... an excellent treatment option for pathologies affecting the forefoot and midfoot such as turf toe, sesamoiditis, hallux rigidus/limitus and forefoot stress fractures. Its contoured profile interfaces well with a custom orthotic and provides ideal toe spring and heel elevation for most athletic, walking and orthopaedic footwear designs. The spring plate is transferrable from shoe to shoe, a practical alternative to common shoe modifications.
Richie Brace The Richie Brace Gauntlet is a custom Ankle Foot Orthosis (AFO) clinically indicated for rigid, non-reducible, adult-acquired flat foot, severe degenerative joint disease or Charcot arthropathy. The brace is made from the finest leather fabricated around a custom-molded AFO polypropylene shell. The Gauntlet is made from a neutral suspension cast that is intrinsically balanced to correct forefoot varus or valgus deformities. Brace options include two colours (chocolate or tan), two heights (7'' and 9'') and medial or lateral arch suspenders (to control legitimate varus or valgus of the hind foot). For ordering information go to www.paris orthotics.com or call 1-800-848-0838.
NEW Sure Step Medial and Medial T Controlled plantarflexion at heel strike while maintaining dorsiflexion in swing phase, this new offering from Trulife is available with a footplate that is easily trimmed with scissors. One size fits up to three shoe sizes enabling accurate fittings regardless of location. Narrower in the medial arch to allow for an easier and better shoe fit, it is streamlined and lightweight in design, with a well-padded cuff and strap for optimal comfort. Replacement padding kit included! For CVA, CMT, weak dorsiflexion, drop foot, peroneal nerve palsy, and patients with supination, or who have a prominent base of the 5th. For more information visit www.trulife.com, or call 1-800-267-2812 or email customerservice@ trulife.com.
Available in four sizes, right or left. For ordering information go to www.parisorthotics.com or call 1-800-848-0838.
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Better Providing the orthotic and prosthetic trade with the highest quality leathers, sheep skins and wool. For friendly service, quick delivery and reasonable prices call our toll-free number today.
1-800-322-1177 PERFORMANCE
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QUALITY
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Toll Free: 800.279.1865
www.trsprosthetics.com
• Top Quality Leather with Guaranteed Satisfaction • Orthopedic Cowhide • Orthopedic Elk Hide • English Kips • Lambs Wool Shearlings • Russet Strap • Natural Molding • Cabretta • AFO/Shoe Leathers • Lamb Skins Not sure what you need? Give us a call and we will gladly send you a set of our swatches. Member of the American Orthopedic & Prosthetic Association
Waterhouse Leather 177 Thornton Dr. Hyannis, MA 02601 Tel: (800) 322-1177 Fax: (508) 771-2300 www.waterhouseleather.com 121
CONTINUING EDUCATION
New Format for OPC Quizzes! Many OPC members have found the annual quizzes in Alignment to be a valuable way to earn much-needed MCE credits, or to test their knowledge on a new topic. For purposes of updating quiz content, they will now be published on the OPC website. Also, online quizzes will allow us to offer additional ones as we move forward, adding to our “quiz library” as they are developed. And, their posting online will make for easier management administratively, for both members and the OPC staff. Completion of each online quiz will continue to earn OPC members two MCE credits.
Visit www.opcanada.ca.
Advertiser Index Ability Dynamics . . . . . . . . . . . . . . . . . . .Pg. 29 Action PO . . . . . . . . . . . . . . . . . . . . . . Pg. 49 Alignment Online . . . . . . . . . . . . . . . . . . . Pg. 5 Anatomical Concepts . . . . . . . . . . . . . . . .Pg. 33 ALPS Canada . . . . . . . . . . . . . . . . . . . . . Pg. 57 Amfit, Inc. . . . . . . . . . . . . . . . . . . . . . . . Pg. 51 Berretta Medical, Inc. . . . . . . . . . . . . . . . . Pg. 55 biodesigns inc. . . . . . . . . . . . . . . . . . . Pg. 78-79 Bressante/LifeArt Prosthetics Inc. . . . . . . . . Pg. 109 Bulldog Tools . . . . . . . . . . . . . . . . . . . . . Pg. 67 Canada Brokerlink, Inc. . . . . . . . . . . . . . . . Pg. 9 Cascade DAFO . . . . . . . . . . . . . . . . . . . Pg. 32 College Park Industries . . . . . . . . . . . . . . .Pg. 65 Comfort Products, Inc. . . . . . . . . . . . . . . .Pg. 99 Coyote Design . . . . . . . . . . . . . . . . . . . . Pg. 97 DAW Industries . . . . . . . . . . . . . . . . . . . . Pg. 3 Ferrier Coupler, Inc. . . . . . . . . . . . . . . . . .Pg. 45 Fillauer Companies, Inc. . . . . . . . . . . . . . . Pg. 39 Fred’s Legs . . . . . . . . . . . . . . . . . . . . . Pg. 121 GAITRite . . . . . . . . . . . . . . . . . . . . . . Pg. 103 J. Vaillancourt Corp. . . . . . . . . . . . . . . . . . Pg. 17 Kingsley Mfg. Co. . . . . . . . . . . . . . . . . . . Pg. 93 Knit Rite, Inc. . . . . . . . . . . . . . . . . . . . . .Pg. 86 Liberating Technologies, Inc. . . . . . . . . . . . .Pg. 45 Loveys . . . . . . . . . . . . . . . . . . . . . . . . Pg. 97 Martin Bionics . . . . . . . . . . . . . . . . . . . . Pg. 88 Medex International . . . . . . . . . . . . . . . . . Pg. 81
Motion Control (Fillauer) . . . . . . . . . . . . . . Pg. 41 Myrdal Orthopedic Technologies . . . . . . . . . Pg. 12 Myrdal Orthopedic Technologies . . . . . . . . . Pg. 47 Myrdal Orthopedic Technologies . . . . . . . . . Pg. 59 North Sea Plastics . . . . . . . . . . . . . . . . . . Pg. 61 OPC Conference 2016 . . . . . . . . . . . . . . .Pg. 22 OPIE Software . . . . . . . . . . . . . . . . . . . . Pg. 75 Ortho Active . . . . . . . . . . . . . . . . . . . . . Pg. 11 Ortho Active . . . . . . . . . . . . . . . . . . . . . Pg. 19 OrtoPed . . . . . . . . . . . . . . . . . . . . . . . . Pg. 7 Ossur Canada . . . . . . . . . . . . . . . . . . . . . Pg. 9 Ossur Canada . . . . . . . . . . . . . Inside Back Cover Ottobock Healthcare Canada . . . . Inside Front Cover Ottobock Healthcare Canada . . . Outside Back Cover Ottobock Healthcare Canada . . . . . . . . . . . Pg. 111 Paris Orthotics, Ltd. . . . . . . . . . . . . . . . . . Pg. 15 ProtoKinetics Gait Analysis Walkways . . . . . . . Pg. 31 Restorative Care of America . . . . . . . . . . . . Pg. 27 Roden Leather Company . . . . . . . . . . . . . . Pg. 97 Sure Step . . . . . . . . . . . . . . . . . . . . . . . Pg. 18 Texas Assistive Devices . . . . . . . . . . . . . . . Pg. 71 The Knee Centre/Karl Hager . . . . . . . . Pg. 104-105 TRS . . . . . . . . . . . . . . . . . . . . . . . . . . Pg. 121 Trulife . . . . . . . . . . . . . . . . . . . . . . . . . Pg. 13 Vorum Research Corp. . . . . . . . . . . . . . . Pg. 107 Waterhouse Leather . . . . . . . . . . . . . . . . Pg. 121 WillowWood Company . . . . . . . . . . . . . . .Pg. 69
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Reclaim your sense of security Kenevo prosthetic knee
Introducing the first microprocessor-controlled knee designed specifically for the needs of your M2 patients. Kenevo delivers the stability and flexibility required to help them reclaim their sense of security, whether they are recovering their mobility or requiring more assistance. Visit www.professionals.ottobock.ca to learn more about how Kenevo can help your M2 patients perform their daily activities more safely and prevent potentially devastating falls.
www.professionals.ottobock.ca Ottobock Lower Limb Prosthetics