Tuesday, January 27, 2009

Innovation in prosthetics and orthotics

HE KNUD JANSEN LECTURE

COPENHAGEN 1986

Innovation in prosthetics and orthotics

J. FOORT

Medical Engineering Resource Unit, University of British Columbia

All correspondence to be addressed to Mr. J. Foort, Medical Engineering Resource Unit, University of British

Columbia, Shaughnessy Hospital, 4500 Oak Street, Vancouver, B.C. V6H 3N1, Canada.

Introduction

As I look back over my 35 years in the field of prosthetics and orthotics research, and

consider those years from the point of view of the innovations I have witnessed and

participated in, certain insights and influences stand out. They cluster around specific people

and projects. Two years in Toronto with Fred Hampton and Colin McLaurin led to the

establishment of the Canadian Plastic Syme's Prosthesis, the Canadian Hip Disarticulation

Prosthesis, plastic reinforcement of wooden prostheses and conception of the SACH Foot.
The products of ten years at Berkeley with Chuck Radcliffe, Leigh Wilson, Bill Hoskinson,

Frank Todd, Jim McKinnon and others, included design of the SACH Foot, the Quadrilateral

above-knee (A.K.) socket, the Patellar Tendon Bearing below-knee (B.K.) prosthesis;

conception of socket standardization, studies of prosthesis alignment and experiences with

modular prosthetics.

Introduction of modular prosthetics to the clinic, development of the electrical alignment unit,

use of semiflexible sockets and work on standard sockets and standard cosmetic restorations

were experiences of my 8 years in Winnipeg with lan Cochrane, Doug Hobson and Reinhard

Daher.

Invention of Shapeable Matrices, development of Tubular orthotics, development of

Computer Aided Socket Design and design of the valgus varus resist knee orthosis are

milestones of my Vancouver experiences with colleagues Steve Cousins, Richard Hannah,

David Cooper, Carl Saunders and Margaret Bannon over the past 15 years.

I have appreciated experiences in projects outside my work environment too. The most recent

was the cooperation that developed around Computer Aided Socket Design and Computer

Aided Manufacturing between the group at UBC and the groups at University College

London and West Park Research, Toronto. I am pleased that cooperation is being extended by

new initiatives developing between the original groups and others. I speak of these things to

convey to you the team basis for developments and the positive effect cooperation between

people has on advances in our field.

Those of us who have worked together on various projects functioned best when we

recognized and used each others qualities. Among the qualities I am thinking of are drive,

curiosity, imagination, persistence, patience, trust, confidence and the ability to share.

To keep sweet reasonableness alive between people, participants have had to review their

motives and consider the needs of their associates. How these associates functioned varied.

Some were definite and decisive. Some pondered things over and came to considered views.

Some were very competent at the things they were trained to do. Some inspired new ideas on

1

how to solve the problems we worked on. Some were able to take risks easily.

Assertiveness born of clarity of view could sometimes be mistaken for arrogance.

While human relations are never without their problems, all of these people enlarged my

capabilities and enriched my work life.

There have been things I loved doing. Other things I have compelled myself to do. My

attachment has been to what I believe were keystone projects, projects that had the potential

to generate multiple solutions. Inaddition, they were projects that suited my natural rhythms,

abilities and needs, and were championed by colleagues who could fill the gaps in my own

abilities. For the most part, the means used to solve problems were traditional engineering

coupled to vigorous artisanship. A great deal of self education was involved.

Now we are at a new intersection of events. Many of the problems have been defined but new

means for problem solving are at hand. Although engineering and artisan skills are still

required, there is a need to reassess our methods in light of the new means so that smooth and

effective advances can be made. Re-education and new education are involved.

Factors affecting innovation, on the other hand, will not change. Some already alluded to are:

1. A suitable field for inventing.

2. Colleagues who cooperate, lead and support.

3. A mix of skills and temperaments in the team.

4. People willing to take risks.

5. An environment conducive to study and experimentation.

6. A speculative attitude.

7. Tools and techniques for problem solving.

A willingness to reassess methods and means periodically.

8.

9. Appreciation of accumulated skills and knowledge.

In order to develop the theme of innovation in prosthetics and orthotics, I will use a review of

the problem of shaping structures that fit against the body for control of forces and

movements. Although the emphasis will be prosthetic, the problem is common to both

prosthetics and orthotics.

I have organized the presentation around eight propositions which have a bearing on shape

management. Factors I have observed as conducive to innovation are interspersed among

them.

First proposition: Tissue density is non-homogeneous (1955)

Clinical studies of the quadrilateral socket for trans femoral amputees taught us that the

residuum cannot be treated as a homogeneous mass. I believe that an examination of

derivation of this proposition in relation to design of the

quadrilateral socket will help us to identify some factors associated with innovation and

indicate the need for further innovation.

The quadrilateral socket

The quadrilateral socket for AK amputees was brought to the Biomechanics Laboratory,

University of California, USA from Germany by Eberhart and his team in 1949. It was

assumed to be a suitable solution to prosthetic socket design for the above-knee amputee.

The plan was to examine its characteristics and to test it clinically at the Laboratory. It was

studied throughout the 1950s for rational factors that could" help to define it. Simultaneously,

2

suction suspension was used, a factor that imposed greater demands on socket design, thereby

highlighting problems with the quadrilateral socket.

Difficulties:

Common difficulties encountered included (a) cysts on the residual limbs in areas contacting

the medial and anterior brims; (b) formation of horny nodules, or keratin plugs in the ischial-

gluteal weight-bearing regions and (c) distal residuum oedema.

Shear forces on tissues where they extended over socket edges were identified as contributing

to cyst formation. Oedema was due to proximal wedging effects and to insufficient support of

distal tissues. Nodules, or keratin plugs, were traced to high compressive forces which drove

small corns inward, building them into pain-producing nail-like structures.

It was assumed by Radcliffe that if the ischium was stabilized on the seat of the quadrilateral

socket by means of more positive anterior forces, these difficulties would be overcome. To

achieve this, he proposed that soft tissues over Scarpa's Triangle be compressed more

positively as compared to harder muscular regions laterally. This led to the inward bulge over

Scarpa's Triangle characteristic of present day quadrilateral sockets.

The differential displacement of tissues to effect even loading on the front of the residuum

was a new idea that could be applied to any part of the body for force transfer and movement

control.

In order to convey the requirements, he depicted the concept in biomechanical terms that

practitioners might understand. Thereafterit became common practice to illustrate

biomechanical events in this way, encouraging a more systematic analysis of fit and

alignment. Innovative factors illustrated in this include:

10. A person able to derive and champion a new concept.

11. Use of engineering principles for socket design.

12. Confident application of the hypothesized solution.

13. Using a clinical environment for testing it.

The solution helped to reduce the incidence of cysts, keratin plugs and oedema when applied

to clinical study amputees.

Practitioners trying to follow the clinical study procedures however, found the information

difficult to interpret because it was essentially descriptive. Their difficulties were thought to

be due to their failure to abide by the principles. Measurements were made of successful and

unsuccessful sockets in order to identify differences that might be responsible. From these

might come a more definitive set of instructions for socket design. It was soon apparent

however that the dimensions being measured could be the same for sockets that were

obviously different. At the same time, successful sockets were observed to appear very

similar to one another. This led Bill Hoskinson and I to speculate that it might be possible to

standardize quadrilateral sockets.

This is the next proposition:

Second proposition: Socket shapes can be standardized (1957)

Calculations based on hazy ideas and gross assumptions to test the hypothesis that

quadrilateral sockets could be standardized indicated that it might require approximately

11,000 one piece AK sockets (5,500 for each side of the body) to provide the range of sizes

needed for a system that could be used with no more than small shape adjustments.

At that time, with no computers, storage, selection and distribution would be major problems

in practical application.

3

To arrive at a more favourable format, the hypothetical socket was divided into sections.

Attention finally focussed on the brim area alone. If the brims were one-piece, only 150

would be required for each side of the body. If all four sides of each brim were adjustable, the

number

of brims required could be reduced to 3 for each side of the body.

The innovative impulse in this can be seen to follow out of:

14. A problem in strong focus.

15. The search for objective data.

16. A willingness to make assumptions in the absence of facts.

17. A practical objective.

The results of this hypothesis included:

a) establishment of jigs for fitting quadrilateral sockets, notably the Berkeley Adjustable

Brims,

b) prefabricated temporary sockets,

c) adjustable sockets for the study of socket design parameters.

The jig fitting method facilitated acceptance of quadrilateral sockets by making the design

principles more obvious and the design methods more simple.

Factors that influenced acceptance of jig fitting methods included:

a) the desire for total contact sockets, which could be made easily by this method

c) difficulties experienced in defining the quadrilateral socket shape,

c) the desire to substitute plastic laminates for wood in socket construction, a feature of the

brim fitting method.

In this we see how:

18. Converging ideas and overlapping experiences bring innovation to focus.

19. Simplification of methods enhances acceptance.

In spite of these meaningful consequences, the hypothesis on standardization received a

hostile response in general. I doubt if many of you will appreciate how heretical it was during

the 1960s (and perhaps still is) to suggest that sockets can be standardized. I remember

sending a paper based on standardization to an American journal approximately 20 years ago.

The provocative title was "Instant Prostheses for Thigh Level Amputees." The editors reply

was that there was no space for the article in the journal at the time, and it could not be

foreseen that there ever would be! My comment is this:

20. Negative attitudes toward innovations can either hamper their development or

prolong their demise!

While I consider the proposition on socket standardization valid, it may be that every

successful shape will be computer banked and standardization will be bypassed. Banking all

shapes overcomes obstacles to acceptance of standardization which include:

a) the shape preferences and prejudices that people hold,

b) concern for the population that might be excluded from coverage (i.e. congenital

amputees),

c) the lack of objective data.

Adjustable sockets constructed to study design parameters gave information on sensitivity of

residual limbs to changes in socket dimensions (1962). There is a need to continue this work

4

in the light of what we now know and need to know.

The adjustable sockets were suggestive of socket modularization, but did not lead to it. New

fabrication techniques, an appreciation of the value of socket flexibility as exemplified in the

Icelandic Socket and modular shapes in computer aided socket design systems may foster

socket modularization.

Data for design could be derived from computer banked shapes and this in turn could lead to

the impedance matching of sockets to residual limbs proposed by Ben Wilson and Eugene

Murphy once the required data on tissue qualities is available.

Without objective data on tissue qualities to use in design work, modularization will require

that intelligent, workable assumptions be made. Following out of that, however, adjustable

modular sockets could help refine these assumptions and ultimately be the basis for defining

tissue qualities. Finally, with sufficient data available, standardization could be reconsidered.

The computer would be used for shape storage and numerically controlled machines for

production of the shapes.

I can add other innovation factors:

21. Advances may reduce the need for information, reduce its importance, or

facilitate its acquisition.

22. New options precipitate new speculations.

23. Oscillation between various options indicates that we have insufficient data.

So far, I have indicated how the North American version of the quadrilateral socket evolved

out of the original German design through clinical studies and how these

developments established propositions which I now summarize:

(1) Residual limb tissue density is variable.

(2) Socket shapes can be standardized An appreciation of the role of the skeletal frame in

determining the shape of the quadrilateral socket led to the third proposition.

Third proposition: The bony frame is the basis for socket design (1965)

For example, the triangle defined by the tendon of adductor longus, the ischial tuberosity and

the trochanter is the bony frame round which the proximal shape of the AK socket is

designed. Deviations from the triangular shape come about because of the need to

accommodate the tissue-muscle masses adjacent to the sides of the triangle in a

biomechanically compatible way.

The facts of this are most clearly exemplified in sockets derived from hand cast impressions.

Lean residual limbs tend to give a shape that resembles the plug fit type of socket. Heavily

tissued residual limbs yield a more quadrilateral shape.

This proposition explains deviations from stereotyped socket shapes for any level of

amputation. It can be taken into account in standardizing shapes and in adapting standard

shapes for shape customization in the computer. It is relevant also in making biomechanical

shapes from sensed topographical data. It indicates:

a) why there are limitations in the Berkeley jig fitting method, which utilizes jigs of a single

standard form,

b) limitations of standard sockets currently used,

c) what might be done to improve the biomechanical result,

d) why computer aided socket design programs include means for customizing the standard

reference shape

e) why reference shape processing of bone geometry is significant for socket design

f) and why we need information on tissue qualities.

5

The patellar-tendon-bearing BK prosthesis

In my opinion, development of the PTB prosthesis is a good model for this discussion of

innovation in prosthetics and orthotics. I will stress the process rather than design in order

toemphasize the mechanism of study and motivating factors involved.

Up until the late 1950's at Berkeley, so much time and effort had gone into development of

AK prosthetics that there was an uneasy feeling that BK prosthetics had been neglected.

To deal with this, Radcliffe called together a group of knowledgeable practitioners and

educators to lay out a plan of attack on BK prosthetics with the researchers. It was agreed that

in the studies the researchers would systematize prosthesis design and the educators would

disseminate the information. They would also help format the information to be disseminated.

The Veterans Administration would require prosthetists to take the courses as a condition for

servicing VA clients.

This was a very potent format — one I would recommend for solving other problems, one 1

wish was being followed in the development and dissemination of CAD/CAM for prosthetics

and orthotics.

No formal evaluation component was included. Each group made its contribution. That which

would normally be done by evaluators was done directly by the prosthetists who applied the

system. In retrospect, I would say that it was a satisfactory way to do it. In fact, considering

the rate at which knowledge and means now develop, existing scenarios for evaluation seem

more like seaweed around the propeller than a jib full of wind.

I will make another comment. The fascination with statistics on the part of our major funding

agency, Health and Welfare Canada, is restricting Canadian prosthetics and orthotics

research. In Berkeley, and elsewhere where innovations have advanced our field to a

remarkable degree, the sample sizes used in the studies were sub-statistical. Results leading

to commitment to adopt the PTB prosthesis rested on multiple fittings on no more than a

dozen amputees, each different in various ways.

The results were not expressed objectively so much as procedurally. We knew that our

methods were better than existing ones, a fact confirmed by the rate of dissemination and

application of the new information.

Competent judgement was substituted for evaluation — and I would add, at no loss.

The PTB prosthesis was essentially assembled from information modules.

A modified form of the German practice of using the patellar tendon as a weight-bearing

surface introduced at the original workshop, was adopted. Total contact was already

acceptable at the research level in socket design tor oedema control and was adopted for use

in the BK system. At the same time, Shindler's technique for making Kemblo inserts to line

sockets made of hard blocked leather set in wood was adopted. Blocked leather and wood for

the socket were replaced by plastic laminates. The SACH foot, now entering clinical

application, was incorporated.

Simultaneously, Blevins was making prostheses which he suspended by means of multiple

socks with rubber buns stuffed between them and a knee strap. Galdick in San Francisco was

making BK prostheses suspended by suction. Woodall was trying condylar suspension by

1962.

This gives you an idea of the many influences at work to give rise to the PTB prosthesis and

to stimulate innovation. Much of this information was present in the field but unintegrated.

Summarizing,

24. Innovation is enhanced by coordinated efforts based on shared motives.

25. Informed judgement can be equivalent to evaluation.

6

26. Information density affects innovation.

27. Accomplishments in one area affect events in another.

28. Practical hypotheses are quickly accepted.

29. Accident also plays a part.

Alignment of trial prostheses at the biomechanics laboratory during checkout of procedures

outlined by the review group was done in two steps. The socket-foot complex was aligned

without the side joint and corset system in place, and then, upon completion of dynamic

alignment of the foot-socket complex, the joint and corset system was added and aligned.

At that time, it was considered hazardous for an amputee to walk for prolonged periods on a

prosthesis without the corset and side joints in place to protect the knee. No explanation was

given as to why some people were able to wear jointless Muley prostheses. When one of our

test amputees rebelled at having the corset-joint system added to his prosthesis following

successful trials without, the switch was made to what is now the PTB below-knee prosthesis.

Controversy surrounded the PTB initially. Concerns remained that the knee would be

damaged. Some critics said that only a few people could be successful PTB users, the

majority would require side joints and corset.

Examination of the role of alignment on forces at the knee and application of normal

locomotion data led researchers to abandon the myth against jointless prostheses and led to

emphasizing the flexed knee gait as an insurance against knee damage.

Factors pertinent to success of the PTB prosthesis seem to have been:

a) a better understanding of how to shape and construct a socket;

b) a better appreciation of the biomechanics of the prosthesis as exemplified by the

improved definition of alignment;

c) relating fundamental gait data to the practical situation;

d) the experiences of successful wearers of Muley prostheses,

e) development of the SACH foot;

f) a switch to new prosthesis construction methods;

g) significant simplification of the BK system.

Factors favouring innovation were;

30. The existence of the "Muley" type of prosthesis.

31. Available fundamental information on locomotion.

32. An engineering-artisan approach to solving the problem.

33. Cooperative effort directed toward its implementation.

34. Including the amputees on the team.

35. Using accumulated information.

With regard to the last spur to innovation, I would comment that technologists who are about

to do fundamental design work for the production of orthopaedic shoes using computer aided

design methods would be wise to take into account what the practitioners can teach them!

Much of the information that designers will need resides in the shoe lasts and methods of

measurement and last modification used by the practitioners.

Innovations spawned by development of the PTB prosthesis included the air cushion socket,

adjustable sockets, transparent sockets, adjustable spring loaded end-bearing sockets, sockets

fabricated directly on residual limbs, foam-in-place end pads, suspension from the patellar

and femoral condyles and inflatable bladders in sockets.

36. New innovations spawn innovation of variants.

7

Modular prosthetics

During the 1960s, a major problem, and still a problem to quite an extent in North American

prosthetics, was the degree of immutability in prostheses. When there were difficulties, the

socket was usually the problem. To replace the socket required major modifications to the

prosthesis, even replacement of the entire prosthesis.

In experimental modular-like prostheses however, the option for quick exchange of

components existed.

The need and the obvious solution led to the next proposition:

Fourth proposition: Modular structures optimize prosthetic management (1955 — )

The modular-like designs in the research laboratories that foreshadowed modern modular

systems did not seem attractive to prosthetists; the Northwestern University BK pylon with

alignment and length adjustability built-in and the University of California Polycentric Knee

for above-knee amputees are examples.

It was apparent that a comprehensive modular system that overcame whatever obstacles were

inhibiting development was needed if the potential advantages were to be exploited. This

realisation influenced me to adopt modular prosthetics for clinical use when I went to

Winnipeg, Manitoba in 1963. My conviction was that modularizing prosthetics would speed

up access of amputees to prosthetic care. It would also help people learn prosthetic practices

and would lead to economies.

The emphasis in Winnipeg was on physical rehabilitation in a newly established hospital

designed for that purpose. However, the prosthetics clinic was bogged down in wooden leg

making practices of the times. Geographic isolation and absence of modern technical

resources in prosthetics inhibited change.

I came as an expert. What I proposed for clinical application in fact was experimental. I had

worked in an environment linked to innovating and wished to bring the attitudes associated

with innovating into the clinic. The aim was to have a comprehensive and adaptable modular

system that included as many prefabricated elements as possible. The system would be used

to manage patients with any level of amputation through their full spectrum of care from

immediately post surgery to return to community life.

The design process would be evolutionary with the designed system used for what it was

good for at every stage of development. A system with the least number of parts would be

designed and common parts and tools would be used as far as possible.

A key feature would be rapid assembly-disassembly and reassembly for quick adjustment and

socket exchange.

Only a few basic elements had to be designed to manage BK, AK and HD prostheses. All

other parts were available or could be adapted.

We tried to make the system suit a basically rural environment so that a person who was

distant from services might be able to manage repairs using community resources, including

the local hardware store.

This experience illustrates:

37. Integrating what exists in new ways is innovating.

38. Experimentation can be a part of a service system.

39. Problems can be tackled from the users point of view.

The risks that might be involved in adopting a modular system for clinical use seemed small

compared to the advantages to be gained in overcoming the bottlenecks affecting amputee

8

rehabilitation.

Results were positive. No amputee had to postpone rehabilitation because of the prosthesis.

In fact, it became common for a training prosthesis to be delivered on the day prescribed.

The evolutionary design approach allowed defects in design to be overcome as a means of

extending usefulness of the system while it was used for what it would permit. At first, the

objective was to keep people walking until the definitive prostheses were delivered. Stage by

stage, the system was improved until finally it could be used definitively.

Evaluation proceeded in tandem with design. This circumvented the possibility of

incorporating unsatisfactory features into the final design. In my view reaching objectives in

this manner must be one option to consider in the interest of economizing on time, costs and

effort (I must admit that I would always choose this approach).

Shaped components were a source of problems, especially with the BK amputees. Although

standard cosmetic covers had been designed, and also standard socket receptacles to link the

sockets to distal components, the sockets themselves were all custom made. This was

reasonable for definitive prostheses, but training prostheses require frequent socket changes.

Successes with the AK prefabricated sockets motivated us to develop prefabricated BK

sockets in response to the bottleneck experienced.

Nineteen sockets were made for each side of the body.

Use of these sockets taught us that five sizes for each side of the body were sufficient to fit all

of the new amputees managed in this way and that one size alone met 50% of the needs. This

illustrates other factors in innovating:

40. Previously successful patterns are followed.

41. Every experience is treated as an information source.

We were acutely aware of limitations imposed by standardization. Standardizing can mean

that someone is left out unless the standardized item is adaptable. Such implications for the

client need to be kept clearly in mind during innovating. That is:

42. A sense of responsibility must influence what is done.

Shape sensing

At that time, obtaining limb shapes by means of a shape sensing method, subject of the next

proposition, seemed like a possible solution to the limitations imposed by standardizing.

Fifth proposition: Shape sensing gives data for interface design (1961)

When the idea of automating shape management for the fitting of sockets and cosmetic

restorations was first raised in 1960, there was no sympathy for it at Berkeley. In fact there

was strong scepticism toward it in the research community when I raised it as a proposal at a

meeting of the Subcommittee on Socket Design of CPRD in 1965. Although I was chairman

of the subcommittee, the proposition did not even win a place in the minutes.

43. An innovative idea in its first stages is fragile.

I had discussed shape management by automated means in a letter to Colin McLaurin in June

1961. In practical terms, Frank Todd and I constructed a left side shank model from a right

side shank model by means of photographic silhouetting in 1962 and that was all that was

attempted until I returned to the idea in 1969.

When the gap between conception and initiation of work is considered, one can appreciate

9

that:

44. Innovators must be patient and persistent.

45. A concept has to be suited to its times for acceptance.

Our first formal attempt to sense shape for prosthetic applications involved use of the shadow

moire phenomenon. These studies spanned the period 1972 to 1980. A prosthesis replicated

in Vancouver, using the moire technique for sensing the shape and a numerical controlled

carver for producing the models, was worn by the recipient for three years.

We were introduced to the shadow moire technique by Dr. Duncan, then Head of Mechanical

Engineering at UBC. He was actively engaged in shape processing for ocean bottom survey,

boat hull design and machine design purposes.

Using a system that he had built to obtain multiple view photographic contour maps around

objects, Steve Cousins and I produced a number of maps and models of residual and intact

limbs.

On the basis of this work, Tony Staros established a contract with us to quantify shoe last

shapes for the USA Veterans Administration, a forward looking project which we completed

in December 1980.

We set up design criteria and had fabricated on principles demonstrated by Dr. Vickers and

Doug Dean at UBC Mechanical Engineering Department, a machine that gave a single

continuous moire shoe last map.

Saunders forced the system to work by putting the data into the computer point by point. He

soon appreciated that quick input of data was necessary if sensing was to be a part of

automating prosthetic procedures.

In later studies of what was being done in Japan where considerable expertise in shape

processing had developed, he identified the flying spot technique as significant. It offered

direct, rapid deposit of data into the computer at an affordable cost.

These experiences taught us to:

46. Look outside our field for information.

47. Go for information where the information density is greatest.

The light streak technique has been adopted at West Park Research Centre, Toronto, Canada,

where, by agreement between us, sensing shape has become a central project while we

concentrate on manipulating shape.

Because sensed shape is topographical, it must be used in conjunction with tissue quality data

or be subjected to manipulation to derive the required biomechanical shape. This weakness in

topographic mapping methods for derivation of biomechanical shapes has yet to be

overcome.

On the other hand, biomechanical data are inherent in standard shapes and this fact can be the

basis for deriving custom shapes. I proposed this concept first during the 1SPO course in AK

prosthetics held here in Denmark in 1978. (You may recall, that in Winnipeg 50% of new BK

amputees were found to fit into a single standard socket size).

This leads us to the general hypothesis of the next proposition.

Sixth proposition: The shapes of all examples of any given anatomical feature or its

biomechanically matched representation are sufficiently similar to permit shape

matching on a mathematical basis using a standard shape as the reference (1978) and

Strathclyde Paper #1, 1984.

That is, you can make a standard shape bigger, make it smaller, make it longer or shorter,

10

make it differentially flatter or deeper in any direction and add or subtract from a particular

point any required amount starting with a preconceived shape that serves as a

biomechanically relevant core or reference shape.

My UBC colleagues have designed the current CASD (Computer Aided Socket Design)

system on the basis of this proposition. Colleague Dave Cooper has extended its application

to derive the shape of bones in vivo using external bony landmark measurements.

The hypothesis stems from attempts to standardize sockets and from attempts to adapt sensed

shapes to socket design.

The hypothesis does not discount the significance of shape sensing. Shape sensing can be

used:

a) to deposit shapes in the computer for further processing; and

b) for defining how a shape should be processed.

Reference shape modelling has elegance. It can be used for internal as well as external

anatomical structures and has no adverse effects on the person for whom the shape is being

developed. It can be used for other than anatomical features. It can be used in conjunction

with other techniques, such as shape sensing. It is, in fact, a concept of general significance.

The next gap to leap is that of constructing the interface with a degree of elegance

comparable to that offered for designing it.

This leads to the next proposition:

Seventh proposition: Shapeable matrices can be used to construct biomechanical

structures directly (1977)

A shapeable matrix is a structure made up of nodes and links in a format that permits it to be

contoured to match a required shape. You may liken it to a flexible lattice that can be made

rigid once shaped and be returned to flexibility for re-shaping.

The new emphasis could be on structures that can be assembled in the shape format required

and remain amendable for post fitting adjustment. The seating systems developed at the

Bioengineering Centre University College London and at MERU are the only examples of

shapeable matrices so far.

Design of shapeable matrices grew out of brainstorming sessions led by Steve Cousins when

he worked with the team at the Medical Engineering Resource Unit, Vancouver in 1977.

With advent of the Shapeable Matrix, shape management is targeted from two directions:

a) On the one hand, computer graphic techniques for shape management can be used

to define the shape.

b) On the other, mechanical matrices can be used to build up the shaped structures directly.

Yet to be achieved is the mating of computer and matrix to allow configuration of the matrix

by computer.

The aim should be to develop universal matrix building blocks from which any shape can be

constructed. This may lead to modularization of interfaces, or modularization may

circumvent development of matrices. If the matrix approach is circumvented, there may be

some gains but there will also be losses. The matrix approach is much more fundamental

even though design is difficult. Hybrid modular-matrix systems, as proposed by Cousins,

may develop as stepping stones to either matrix or modular structures.

This illustrates other factors in innovating:

11

47. The path to choose is the more fundamental one if an innovation is to be far

reaching.

48. Concepts can be combined.

Difficulties experienced with hand assembly and adjustment of miniature shapeable matrices

which we have attempted to design for direct use against the body have led us to the eighth

proposition:

Eighth proposition: Shape dependent components will be produced by robot

constructors

To produce sockets directly by computer controlled robots, while difficult, would set the

stage for a manufacturing method that precludes the need for moulds. Such an approach is

infinitely compatible with computer aided design.

It is also compatible with the needs in prosthetics and orthotics which are now so heavily

dependent on custom made moulds for production of shape determined components.

This view is shared by our colleagues in Toronto at the West Park Research Center where it

is proposed to use a robot constructor to make seats.

The dream is that CAD and CAM will become so intimately meshed that the design and

fabrication of shaped objects will proceed simultaneously. Also, it will be possible to have

raw material managed in a way that will deliver an interface that varies in stiffness according

to the way in which materials are delivered from the nozzles held by the robot constructor.

Establishment of computer controlled robot constructors would be as revolutionary in

production technology as was the introduction of mass production.

Intermediate steps might include (a) the design of programmable moulds, or (b) design of

matrix elements that can be assembled by computer controlled robots.

When all of this is put together, we can say:

a) Biomechanical shape is determined by bone geometry and tissue quality.

b) Biomechanical shapes can be standardized.

c) Standard shapes can be customized.

d) Shape sensing can capture and classify shapes.

e) Interfaces can be constructed from matrices.

f) Matrices can be constructed by robots.

You may well consider the long and arduous course of actions bringing us to these

possibilities. We can mesh them easily on the basis of hindsight. What step could have been

omitted, what influences of colleagues on one another done without?

The adoption of matrices, computers, shape sensing, internal and external reference shapes

and robot constructors is equivalent to a new date zero for design of shaped components for

use in prosthetics, orthotics, and orthopaedics. We come to this as a consequence of the

technology that surrounds us or can be envisioned on the basis of what surrounds us. We

have merely to take note of it, reassess our problems in the light of it and act innovatively.

An important principle to guide us is to derive solutions that have wide-spread uses. This will

help make what we design available to the disabled population. Matrices are like this. They

could dim the boundary between prosthetics and orthotics and the boundary between disabled

and able bodied persons. Computer aided design already does this. Robotic constructors are

likely to have the same affect. I urge you to this — aim for universal solutions.

12

Epilogue

I have tried to show how, starting with limited information, some propositions that foster

solution of difficult problems have come into

focus. The time and effort and innovative skills of many people, some unknown, have been

involved. That there are such people with the time and resources to solve problems is a prime

requirement. They need to be in environments that are conducive to original thinking.

Persons within or between groups need to be linked to permit complementary problem

solving paths to develop. Innovating is not the province of a person or a group but is a flower

that grows out of the human garden.

Innovative impulses need to influence not only what and how we design, but how we

organize to do so. The need for cooperation and joint involvement in large projects is

growing. Fortunately, the technical means are available to foster this. Seemingly separate

entities such as standardizing shapes, designing modular systems, sensing shape,

manipulating shape, transmitting shapes over the telephone, designing matrices and

constructing custom shapes by robots coalesce as lively possibilities for automation of design

and production of shaped components for prostheses, orthoses and orthopaedic footwear.

I cannot help but wonder how all of these things might have fared had they been part of an

overall strategy fostered by cooperation of all of us engaged in prosthetics/orthotics research

over the past few decades.

The necessity is for designers to overcome indifference to colleagues, mistrust, greed and

jealousy so that field-adoption of comprehensive systems that can develop from joint efforts

will be realized.

I personally feel that copyrighting and patenting are impediments to the free flow of

information. Researchers would not be corrupted by the impulse to protect what they

innovate in order to derive gain if the social means were available for the work they wish to

do. The political problem is to foster mechanisms by which such programmes can be funded

and the benefits be directly applied where the needs exist.

As I see it, we must be free of attitudes that keep us bound to our particular institutions. We

must discount nationalism and ideologies to become truly conscious of our roles in relation to

the world's people. Every person in our field plays some part in this. Manufacturers do when

they make quality the factor of significance intheir competition. Designers do when they

encourage the best things to be used by the various participants in the rehabilitation field

regardless of origins. Practitioners do when they stay informed and use what is best in the

developing armamentarium. Educators do by trying new things, selecting the best and

disseminating information about them. Funding agencies do when they are sensitive to grass

roots inputs that identify appropriate objectives for research in support of services. Politicians

do when they transcend political boundaries in response to world-wide needs.

These are the sorts of ideals that thoughtful men have brought to us down through the years.

An innovative approach to their implementation is to be encouraged.

ISPO is the means by which we keep in touch with each other for furtherance of our common

interests. They are the sorts of interests Knud Jensen held for ISPO which he saw as an

important element in the evolution of a brotherhood dedicated to the well-being of physically

disabled people throughout the world.

13

I appreciate the chance I have had to outline a course of events that illustrates the innovative

process, to give you these thoughts through the Knud Jensen lecture and to wish you an

inspiring 5th World Congress of the ISPO.

14


READ MORE - Innovation in prosthetics and orthotics

Monday, January 26, 2009

SCOLIOSIS



SCOLIOSIS

Nam H. Tran, MD
November 9, 1997
Stanford Medical Center



I. HISTORICAL PERSPECTIVE:
Spinal deformities afflicted early man as documented in cave drawings.
“Skoliosis” is used by Hippocrates to denote any curvature of the spine. Many forms of treatment were attempted.
Paul Aegina tried bandaging as a form of bracing in the 7th century.
1914: first fusion performed by Russell Hibbs
1946: Milwaukee brace was designed by Blount and Schmidt.

II. DEFINTION:
Scoliosis: any lateral curvature of the spine.
Scoliosis can be further described as:
Right or Left: sidedness defined by the side of convexity of the curve, ie, right scoliosis has the convex side toward the right.
Cervical, cervicothoracic, thoracic, thoracolumbar, lumbar.
Single vs Compound: single has one sided spinal deviation whereas compound has both right and left spinal deviations.
Primary vs Secondary (compensatory): primary describes the initial curve that can later be compensated for by a curve in the other direction (secondary scoliosis).
Major vs Minor: major curve denotes the greatest curve which often accompanied by a minor curve, usually a compensatory curve(s) in the other direction above and below the major curve. Sometimes, the compensatory curve is as large as the major curve; in which case, this is called a double major curve.
Nonstructural vs Structural: nonstructural curve will be corrected with lateral bending toward the convex side. In structural scoliosis, the curve remains with side bending.


III. ETIOLOGY:

IV. PATHOLOGY:
The vertebra turn toward the convex side and spinous processes rotate toward the concave side in the area of the major curve.
As the vertebra rotate, they push the ribs on the convex side posteriorly and at the same time, crowd the ribs on the concave side together as well as push them anteriorly. The posterior displaced ribs cause the characteristic hump in the back with forward flexion. Young girls with scoliosis would often complain of unequal breasts. This is due to recess of the chest wall on the convex side of the curve.
Disc space is narrower on the concave side and wider on the convex side.
The vertebra may become wedged on the concave side in serve cases. The lamina and pedicles are also shorter.
Vertebral canal is narrower on the concave side. Spinal cord compression is rare even in serve cases.
Physiological changes include:
Decrease in lung vital capacity due to a compressed intrathoracic cavity on the convex side.
With left scoliosis, the heart is displaced downward; and in conjunction with intrapulmonary obstruction, this can result in right cardiac hypertrophy.

V. EVALUATION:

A. HISTORY:
B. Chronological age
C. Age at recognition of deformity. The longer the muscle imbalance, the more the distortion.
D. Impression of the rate of progression
E. Associated symptoms: pain, fatigue, cardiopulmonary symptoms. History of night pain resolved with ASA is concerning for osteoid osteoma. Back pain in young children can be due to spondylosis or spondylolisthesis and disc herniation.
F. Developmental factors: rate of growth, appearance of 2nd sexual characteristics (menarche). Rapid scoliotic curve changes occurs during rapid spine growth period. Progression usually halts or is much slower at skeletal maturity.
G. Genetic factors: racial origin. Infantile idiopathic scoliosis is more common in Britain and Europe.

H. PHYSICAL EXAMINATION:
I. GENRAL EXAMINATION should include the following:
J. Cardiopulmonary function is compromised in extreme thoracic curve, paralytic curve, and congenital scoliosis. Pulmonary and cardiac studies should be performed. Cardiac defects are common in Marfan’s syndrome.
K. Developmental status and Secondary Sexual Characteristics can be assessed by noting the patient’s height compared with parents and siblings. This can be significant in predicting future growth. Dentition maturity is also helpful.
L. Underlying causes: Skin manifestations, ie, café aulait spots are suggestive of neurofibromatosis, and hairy back patches are clues to spinal dysraphism (spinal bifida).
M. Genitourinary development and status can be affected in congenital conditions.
N. EXAMINATION OF DEFORMITY:
O. Standing position: From behind the patient, begin with an evaluation of truncal alignment noting for overall balance and torso displacement.. Asymmetry can be easily noted as evident by asymmetry of the shoulder height, infolding of skin and prominence of the iliac crest on the concave side, shifting of the thoracic cage and prominence of the anterior chest on the convex side (due to anterior rotation on the convex side). Drop a plumb line from the occiput which should line up with the gluteal cleft. Be aware that in a compensated double major curves, the alignment may be normal.
P. Symmetry of Shoulder Girdle: neck shoulder angle distortion is due to trapezius asymmetry from cervical or high thoracic curves.
Q. Assessment of specific curves:
R. Types of curves are noted, ie, left vs right, C-T-L or combination.
S. Flexibility vs rigidity of the curves can be assessed by side bending or head distraction. This is important for planing surgery.
T. Degree of rotation is assessed in the bent postion by noting prominences in the thoracic and lumbar areas.
U. Pelvic obliquity and stability: Pelvic obliquity can be non-structural due to habits or structural due to leg length discrepancy or contracture of muscle groups.
V. Neurologic examination includes reflexes, sensation, motor strength to ensure that there are no deficits or deterioration of baseline deficits. Isolated decreased vibratory sensation is frequent in idiopathic scoliosis and does not warrant further work up.
W. IMAGING ASSESSMENT:
A single standing P-A film taken from occiput to sacrum is adequate. Radiographic imaging may not be needed in children with very mild curves detected on routine school screening examination. These children can be followed by physical examination with scoliometer. If there is a significant change over the previous 6 months or if there is a severe rib rotation, Xray is then warranted.
In general, young patients with mild scoliosis can be safely seen in follow up and Xray done every 6-9 months. For faster progressive curves, Xray every 3 months is recommended. In adolescents, a progression of 1 degree/month is normal, where as a significant progression is 3-5 degree/month.
Spot lateral view is useful to assess for spondylolisthesis and spondylosis which can occur in 30-35% of children with Scheuermann’s disease (occurs in 5% of idiopathic scoliosis which is the same as that of the general population).
Side bending Xray is useful to determine the rigidity of scoliosis, an important consideration for surgical planning. It will also help to delineate structural from non structural scoliosis (non-structural curves with uncoil with bending to the convex side).
4. CURVE MEASUREMENT:
5. Cobb method: This method relies on the accuracy of identifying the vertebra at the upper and lower end of the curve. These end vertebrae are those with maximal tilt toward the concave side. Horizontal lines are then drawn at the superior border of the superior end vertebrae and at the inferior border of the inferior end vertebrae. Perpendicular lines to these two horizontal lines will intersect. The angle formed is the Cobb angle, the degree of scoliosis. The advantage of the Cobb method is that it has high inter-rater reliability.
6. Risser-Ferguson method: Straight lines are drawn from the middle of the end vertebra to the middle of the vertebrae at the apex of the curve. This method is not frequently used.
7. ROTATION ASSESSMENT: Rotation is an inherent structural change in scoliosis. It correlates with the degree of resistance to corrective therapy. Rotation can be recorded in two ways:
8. Displacement of Pedicles: On A-P view, one pedicle rotates toward the midline and the other rotates to the lateral border of the vertebra.
(+) pedicle slightly toward midline
(++) pedicle 2/3 toward midline
(+++) pedicle at midline
(++++) pedicle moves beyond midline
Note: rotation is toward the concave side.
b) Displacement of Spinous Processes: (+) rotation is a displacement of one width of the spinous process from the midline, and so forth. This method is not accurate since the spinous processes are often deformed (bent toward the concave side).
c) SKELETAL MATURITY: Scoliotic progression slows significantly at full maturity. It is therefore essential to know when skeletal growth is complete to plan for therapy, follow up frequency, and cessation of therapy. In general, girls mature at about 16 ½ years old, and boys about age of 18. Reviewing the radiographs can reasonably predict skeletal maturity:
Left hand and wrist films for comparison with Greulich and Pyle atlas.
Excursion of the iliac crest described by Risser. Ossification of the crest starts laterally and meets with the SI junction as well as fuses with the ilium at full maturity.
Growth plate of the vertebra form a solid union at full maturation. At 6-8 years of age in girls (7-9 years old in boys), a calcific ring develops at the superior and inferior aspect of the vertebra. This ring gradually fuses with the vertebral body at the age of 14-15. Complete fusion occurs at age 21-25.

VI. PROGNOSIS:

It is important to know the natural course of the curve to determine the appropriate course of management. At the end of longitudinal growth, significant scoliotic progression usually ends. However, the gravest error that a treating physician can make is to assume that curve progression halts. In some cases, scoliosis continues to progress approximately 1 to 2 degrees per year through adult life causing significant disability at old age. These include patients with significant curves of more than 40 degrees, poor muscle tone, and women near menopause with osteoporosis. Adults with curves less than 30 degrees usually do not progress.

Some authors feel that childhood scoliosis has a strong genetic inheritance. As such, the scoliotic curve will progress to a predetermined severity unless the course is altered by intervention with bracing, exercise, and/or surgery.

In general, the following rules apply:
a) Thoracic curves causes more deformity and disability.
b) The earlier the age of onset, the greater the deformity and disability later in life.
c) Some prognostic signs of xray for active progression of scoliosis are: osteopenia of the vertebra near the apex of the curve, narrowed intervertebral disc space, and wedging of the apical vertebra.

VII. IDIOPATHIC SCOLIOSIS:

A. GENERAL:
Accounts for 70% of all scoliosis.
Overall incidence is equal for boys and girls.
Progression is much more severe in girls, and seven times more frequent.

B. ETIOLOGY:
C. Genetic: Probably sex linked inheritance with variable penetrance and expressivity. If a person with scoliosis has children, one of three offspring will probably develop scoliosis.
D. Nervous System Dysfunction: It is believed that brainstem dysfunction can cause scoliosis. Also lesions in the posterior column can result in postural imbalance. The dysfunction of the balancing mechanism is felt to result in scoliosis. Others feels that it is due to “lack of synchronization of thegrowth of the neuro-axis and the neural canal”.
E. Nutrition: Poor nutrition may cause scoliosis as suggested by animal research data.
F. In conclusion: Cause is still not known.

C. CLASSIFICATION: Idiopathic scoliosis occurs at three separate developmental time periods with different characteristic deformities and prognosis.
D. Infantile: Occurs between birth and 3 years of age. Usually noticed in the first year of life. More common in boys particularly from England. Left thoracic curve occurs more common, and often resolves spontaneously. Few patients will have progressive curves which can be quite severe requiring early bracing and even surgery.
E. Juvenile: Occurs between 4-10 years of age. Incidence is equal for boys and girls. Most curves are right thoracic. Curves are progressive in nature and need close follow up.
F. Adolescent: Usually diagnosed at the age of 10. Most curves are right thoracic and thoracolumbar. Curves have a strong tendency to progress during adolescent growth spurt. Extremely active, athletic teenage girls with delayed menses are most of risk for curve progression.

D. CURVE PATTERN:
E. Right thoracic curves are most common. The can develop rapidly and must be treated early or severe cosmetic deformity. Cardiopulmonary compromise will ensue when curves reach 60 degree.
F. Thoracolumbar curves are also common. They are usually not as deforming.
G. Lumbar major curves are less common. Most (65%) are left lumbar curves. They are not deforming but can lead to disabling back pain in later life and during pregnancy.

H. NATURAL HISTORY:
Lonstein & Carlson (1984): 729 patients with idiopathic scoliosis of less than 30 degrees were followed without bracing. Likelihood of progression of a thoracic scoliosis was compared with curve magnitude and Risser sign.

Scoliosis Risser Chance of Progression

<19 0 or 1 22%
<19 2,3 or 4 1.6%
20-29 0-1 68%
20-29 2,3 or 4 22%

F. TREATMENT:
G. School screening: Best treatment is early detection. School screening should start in the fifth grade (age 10-11), and every 6 to 9 months thereafter. Screening can be done quickly by having the child bend from the waist with arms hang freely. If scoliosis is detected in a child, all siblings should be screened due to the hereditary nature of the condition. The downside with school screening is that it can pick up extremely mild curves that do not progress, and can cause needless anxiety in parents.
H. Exercises: It does not prevent or cure scoliosis and is not a substitute for bracing or surgery.
I. Spinal bracing:
J. In 1945, Blount developed the Milwaukee brace, which has undergone several modification to reduce weight and bulkiness. Bracing was enthusiastically endorsed in the 1960’s. Sentiment shifted in the 1980’s to the extreme that Professor Robert Dickson of Leeds, England, stated that there was no place for bracing in the treatment of idiopathic scoliosis. Since then, the pendulum has swung back. Several good studies looking at the natural progression of scoliosis and bracing for each specific curve patterns and age groups clearly demonstrated the effectiveness of bracing in preventing the progression of scoliosis.
K. Based on study on the natural history by Lonstein, it is obvious that bracing is not needed for curve less than 19 with a Risser of 2,3, or 4. In contrast, a child with a Risser 0 or 1 with a curve between 20-29 degrees is at a significant risk of curve progression.
L. Three studies that set the standards of bracing for this high risk group:
Lonstein and Winter: 1020 patients treated with Milwaukee brace. Those patients with thoracic curves of 20-29 degrees and Risser 0-1, only 40% showed progression at the end of bracing (vs 68% if not braced).
Bassett: 71 patients with curves 20-29 degrees and Risser 0-1. Only 36% of those with thoracic curves progressed.
Durand: 477 patients. At 2-5 year follow up, only 21% of patients had progressed.
d) In summary:
Milwaukee brace for thoracic curves and TLSO for lumbar or thoracolumbar curves.
No bracing needed for curves less than 20 degrees.
Curves of 20-29 degrees need bracing when 2 or more years of growth remain or if there is evidence of progression.
Curves or 30-39 degrees should be braced at the first visit if growth remain.
No bracing needed for patients with Risser 4 or 5.
Brace should be worn 20-22 hours per day and taken off for hygiene and strengthening exercises.
Patients should be seen on a monthly basis for brace adjustment with Xray taken every 6 months.
Weaning off brace: When the child is more mature and the curve holds its position, the child is allow more time out of the brace. The weaning period takes about 2-3 years until the age of 15 in girls and 16 ½ in boys.
4) Surgical Treatment:
5) Indications:
Adolescents with curve more than 45 degrees.
Relentless curve progression
Major curve progression in spite of bracing
Inability to wean the patient from the brace
Significant thoracic and lumbar pain
Progressive loss of pulmonary function.
Emotional or psychological inability to accept the brace.
Severe cosmetic changes in the shoulder and trunk.
b) Goals:
To achieve solid fusion
To stabilize the curve with a compensated trunk both in the frontal and sagittal planes
To correct the curves (though this is not as important)
c) Surgical Techniques:
Fusion can be done through the anterior or posterior approach. The posterior approach is preferred. In cases like myelomeningocele where posterior spinal elements are absent, then the anterior is approach is used..
The posterior approach was first performed in 1911. The techniques have changed somewhat with the introduction of spinal instrumentation in the past 40 years. But in general, the principles are as followed:
i) The outer cortex of the laminae and spinous processes are removed so that raw cancerous bone is exposed.
ii) Posterior facet joints are destroyed.
iii) Great quantity of iliac autografts are laid on the prepared bed.
iv) The fusion extends one vertebrae above the superior end vertebrae and two below the inferior end vertebrae.
v) A combination of Harrington instrumentation and are used to decrease rotation and increase internal stabilization of the spine. Intersegmental wires can be secured through the spinous processes (Drummon/Keene technique) or through the lamina of each vertebrae (Luque technique). The combination of rods and wires provides rigid fusion and is very effective in treating collapsing type scoliosis, especially in neuromuscular scoliosis.
vi) Post op care:
vii) Post op bracing is not necessary with the new technique of internal fixation. However, a low profile brace is recommended for several months to protect patients against accidents.
viii) Most patients can return to school or work within 2-3 weeks.
ix) Strenuous exercises are not recommended for the first few months. Light sports such as tennis can be resumed at 3-4 months.
x) At one year when fusion has mature, all forms of exercises can be resumed, though patient should avoid heavy contact sports.

VIII. CONGENITAL SCOLIOSIS:
A. Etiology: due to an insult to the zygote or embryo during early development
B. Associated conditions: 20% have urinary tract problems and 15% have cardiac anomalies.
C. Classification: Closed vs open
D. Open types are caused by myelomeningocele which can be severe.
E. Closed types can be classified according to etiology:
F. Partial unilateral failure of vertebral formation (wedge vertebrae)
G. Complete unilateral failure of vertebral formation (hemivertebrae)
H. Unilateral failure of segmentation (congenital bar)
I. Bilateral failure of segmentation (block vertebrae)
J. Prognosis: Hemivertebrae and unilateral can cause severe curvature.
K. Treatment: In situ spinal fusion should be performed promptly for progressive curves.

L. OTHER CAUSES OF SCOLIOSIS:

M. NEUROMUSCULAR DISEASES:
Caused by neuropathic disorders like poliomyelitis or cerebral palsy secondary to muscle imbalance. The resultant curves are usually long C shape.
Static myopathic disorder like muscular dystrophy can develop collapsing scoliosis due to severe muscle weakness and imbalance. A 10 degree curve can often become 90 degrees on sitting or standing.

A. NEUROFIBROMATOSIS:
First described by Kolliker in 1860, but von Recklinghausen coined the term in 1882.
Associated with peripheral nerves, causing cutaneous and subQ manifestations.
High incidence of kyphosis and scoliosis. Etiology ??? but may be due to neurofibromas enlargement in the foramina between vertebral bodies.
Spinal deformities must be treated aggressively with anterior and posterior fusion.

A. MESENCHYMAL DISORDERS:
Marfan’s syndrome, rhematoid arthritis (Still’s disease), and osteogenesis imperfecta can cause scoliosis.

A. TRAUMA:
Fracture causing wedging of the spine.
Tumor causing stunning of vertebral growth.
Radiation for tumor arresting vertebral growth plate
Burns or rib resection.






References:

1. Royo-Salvador MB.
[Platybasia, basilar groove, odontoid process and kinking of the
brainstem: a common etiology with idiopathic syringomyelia, scoliosis and
Chiari malformations].
Revista de Neurologia, 1996 Oct, 24(134):1241-50.

6. Worthington V; Shambaugh P.
Nutrition as an environmental factor in the etiology of idiopathic
scoliosis.
Journal of Manipulative and Physiological Therapeutics, 1993 Mar-Apr,
16(3):169-73.

4. Winter RB.
The pendulum has swung too far. Bracing for adolescent idiopathic
scoliosis in the 1990s.
Orthopedic Clinics of North America, 1994 Apr, 25(2):195-204.

5. Pinto WC
Common Sense in the Management of Adolescent Idiopathic Scoliosis, Orthopedic Clinics of North America, 1994 April, 25(2):215-223






READ MORE - SCOLIOSIS

Wednesday, January 14, 2009

SYMTOMATIC FLAT FEET


Diagnosis/Definition
 Chronic repetitive aching type discomfort in the medial aspect of the foot while standing and walking.
 Decreased medial longitudinal arch height with medial talar head prominence.
 Asymptomatic flat feet do not require treatment.
Initial Diagnosis and Management
 History and physical examination.
 Appropriate radiographic (weightbearing feet) and laboratory studies (rheumatology panel evaluation in patients with inflammatory, bilateral, and other joint presentations).
Ongoing Management and Objectives
 Initial primary care treatment for foot pain should include a three-month trial period of the following:
 NSAIDs
 Adults - 200 to 400 milligrams (mg) every four to six hours as needed for up to 2 weeks. Example: Ibuprofen
 Take tablet or capsule forms of these medicines with a full glass (8 ounces) of water.
 Do not lie down for about 15 to 30 minutes after taking the medicine. This helps to prevent irritation that may lead to trouble in swallowing.
 To lessen stomach upset, these medicines should be taken with food or an antacid.
 Over-the-counter arch pads for insoles (i.e., Polysorb or Dr. Scholl's)
 Soft supporting shoes (running or walking type)
 Calf stretching
 Decreased activity (rest).
Indication a profile is needed
 Any limitations that affect strength, range of movement, and efficiency of feet, legs, lower back and pelvic girdle.
 Slightly limited mobility of joints, muscular weakness, or other musculo-skeletal defects that may prevent moderate marching, climbing, timed walking, or prolonged effect.
 Defects or impairments that require significant restriction of use.
Specifications for the profile

 Weeks 1-12
 No running and jumping
 No rucking
 Walking to tolerance
 Swimming recommended

Patient/Soldier Education or Self care Information

 See attached sheet
 Demonstrate deficits that exist
 Describe/show soldier his/her limitations
 Explain injury and treatment methods
 Use diagram attached to describe injury, location and treatment.
 Instruct and demonstrate rehab techniques
 Demonstrate rehab exercises as shown in attached guide
 Warm up before any sports activity
 Participate in a conditioning program to build muscle strength
 Do stretching exercises daily
 Ask the patient to demonstrate newly learned techniques and repeat any other instructions.
 Fine tune patient technique
 Correct any incorrect ROM/stretching demonstrations or instructions by repeating and demonstrating information or exercise correctly.
 Encourage questions
 Ask soldier if he or she has any questions
 Give supplements such as handouts
 Schedule follow up visit
 If pain persists
 The pain does not improve as expected
 Patient is having difficulty after three days of injury
 Increased pain or swelling after the first three days
 Patient has any questions regarding care
Indications for referral to Specialty Care
 Adult patients with no improvement of symptoms after the three-month trial period can be referred to the Podiatry Clinic.
 Pediatric patients with no improvement can be referred to Pediatric Orthopedics.
Referral criteria for Return to Primary Care
 Patients not requiring surgery will be given a biomechanical examination and an orthotic prescription prior to being returned to primary care for chronic management.
 Patients requiring surgery will be followed in the Podiatry Clinic until the perioperative period is complete. Patients will then be given an orthotic prescription before being returned to the primary care provider for chronic management.























Exercises
#1
• Sit with your back and legs supported.
• Place the rubber pads below your toes.
• Move the Foot Trainer back until the rubber pads touch the top of your feet.
• Slowly move your feet toward your body while you resist with the Foot Trainer.

#2
• Lie on your back with both of your legs bent and your feet flat on the ground.
• Move your exercising leg up toward your body.
• Hold the Foot Trainer Handle with both hands then and place the rubber pads below your toes.
• Move The Foot Trainer forward until you feel the rubber pads touch the top of your feet.
• Slowly move your lower leg upward while you resist with the Foot Trainer.






PATIENT INFORMATION
Flat Feet (or Flat Arches)
The normal arch functions as a shock absorber for our entire body. Each time we step down, we place up to 5 times our body weight on the foot, depending on whether we are walking, running, or jumping. If there was no shock absorber in the foot, the force of each step would eventually fracture or dislocate the bones of the foot, leg, and lower back. When the arch is flat (a flat foot), it is "sick" and cannot function properly. If left untreated, this will lead to a completely collapsed foot which cannot function as a shock absorber at all; and, this in turn will cause constant pain in the foot, and eventually the knee, hip, and lower back.
Causes: The normal arch is made up of bones and joints which are held tightly together in a precise relationship. In order for the arch to flatten out, the ligaments and tendons which hold the bones and joints together must be more flexible than normal. This abnormal flexibility may be a result of: the genes we inherit from our parents, the weakening of muscles and ligaments caused by advancing age, neuromuscular diseases, or injury. Injuries may include one severe trauma, or years of standing for long periods of time in the wrong types of shoes (those with high heels or those with poor support). This flexibility of the bones, joints, and soft tissues is what causes the foot problems which are related to flat arches or feet. The following conditions are the most common foot problems seen in flat feet:
1. PRONATION is the most common and damaging medical problem that may occur as a result of flat arches. Pronation is a turning outward of the foot at the ankle, so that one has a tendency to walk on the inner border of the foot. You can test for pronation by looking at the leg and foot from the back. Normally you can see the Achilles Tendon run straight down the leg into the heel. If the foot is pronated, the tendon will run straight down the leg, but when it lies on the heel, it will twist outward. This makes the inner ankle bone much more prominent than the outer ankle bone. Because pronation is a twisting of the foot, all of the muscles and tendons which run from the leg and ankle into the foot will be twisted. If left untreated, pronation may be the cause of heel spurs, plantar fasciitis, frequent ankle sprains, shin splints, weak and painful arches, and eventually knee, hip, and lower back pain.
2. STRUCTURAL DEFECTS are foot problems that may occur because the bones and joints of the foot are not held together with the normal amount of tension. This allows the bones and joints to move into abnormal positions causing: bunions, hammertoes, neuromas, calluses, and corns. If these problems are left untreated, they become progressively more painful and debilitating.
Treatment: In the child and adolescent, treatment must be directed to supporting the individual bones and joints which make up the arch, and to aid the arch in its job as a shock absorber during the individual's growing years. This support of the individual components of the arch will prevent the arch from flattening out further as growth continues, allowing a normal arch to be formed. Aiding the development of a normal arch is accomplished through the use of custom-made orthotics. Custom-made orthotics allow the all-too-flexible muscles and ligaments in the foot and ankle to tighten as growth continues, while taking over the job of a shock absorber. The use of custom-made orthotics will help to prevent biomechanical and structural foot problems from developing, thus reducing the probability of the following diseases from occurring in adulthood: pronation, shin splints, bunions, heel spurs, plantar fasciitis, serious ankle injuries and hammertoes.
Custom-made orthotics are medical devices that gently support not only the arch, but each individual bone and joint which makes up the arch; and, because of the space-age materials used in their construction, custom-made orthotics allow the arch to become a much more efficient shock absorber. Over-the-counter arch supports will not allow the growing foot to produce a more normal arch, because they do not support the individual components of the arch and foot, thus allowing the arch to collapse further. Custom-made orthotics will help to prevent the further collapse of the arch and foot.
In the adult, treatment of flat feet must be directed to supporting the individual bones, joints, and muscles which make up the arch; and to provide adequate shock absorption for the entire body. This will help to alleviate pain in the foot, ankle, leg, knee, hip, and lower back. Preventing pain and the total collapse of the arch is accomplished through the use of custom-made orthotics. Custom-made orthotics are medical devices which gently support not only the arch, but each individual component of the arch and foot. Also, because of the state-of-the-art materials used in the construction of custom-made orthotics, they allow the arch to become a much more efficient shock absorber. This not only relieves arch and foot pain, but prevents the pain from returning, and keeps the arch from flattening out further. Custom-made orthotics help to relieve the pain caused by bunions, hammertoes, heel spurs, plantar fasciitis, shin splints, neuromas, and muscle weakness. Over-the-counter arch supports may give temporary relief, but because they do not support the individual components of the arch, the pain will return; and as the support wears out, the arch will fall further (custom-made orthotics do not wear out; they last for years).
Custom-made Orthotics: Our custom-made orthotics for the treatment of flat feet have been developed over the past 30 years. What makes these orthotics unique is their ability to support the individual components of the arch, not just the "arch" as a whole, and to act as an efficient shock absorber. Our custom-made orthotics are constructed of the latest space-age thermoplastic materials. These materials not only provide the support which is needed, but they also have a "memory." This memory allows the orthotic to compress slightly when pressure is applied to it, but when the pressure is released, the orthotic returns to its original height and shape. This ensures maximum comfort, while guaranteeing that the arch will always be supported at its most efficient height. In children this will help to promote the development of a normal arch, and act as a shock absorber during the growing years. In an adult, our custom-made orthotics help to prevent the further collapse of the arch; they act as shock absorbers and they will help to reduce pain in the arches, the entire foot, leg, knees, hips, and lower back. These custom-made orthotics are comfortable, will last for years, and will fit into all flat shoes, and shoes with heel heights of up to 1 1/2 inches.
One of the most common foot disorders is a flat foot. About 40 percent of people have flatfeet. If you have a flat foot, the arch on the inside of your foot is flattened.
Flatfeet usually don't cause a problem. However, flatfeet can contribute to problems in your feet, ankles, knees and hips. You may experience pain and other symptoms if you have other alignment problems in your lower legs that, when combined with high-impact activities such as running and jumping, place an increased load on the bones and muscles of your lower legs.
Simple corrective devices are available to help prevent complications of flatfeet.



















Input was provided by:

 Occupational Therapy Clinic
 Physical Therapy Clinic
 Orthopedic Clinic
 Family Practice Clinic
 Okubo Clinic
 555 Engineers
 1st Brigade
 3rd Brigade
 62nd Medical Brigade

POC:

 Outcome Management

References:

 Mellion, I., Morris B. (2002). Team Physician’s Handbook, 3rd Edition. Hanley & Belfus, Inc: Philadelphia, PA.
 Lillegard, Rucker. (1999). The Handbook of Sports Medicine. A symptom-oriented approach, 2nd Edition. Butterworth-Heinemann Medical: Burlington, MA.
 Baechle, Thomas, Earle, Roger. (2000) Essentials of Strength Training and Conditioning, 2nd Edition. Human Kinetics Pub: Champaign, IL
 Schenck, Robert, Jr. et al. (1999). Athletic Training and Sports Medicine, 3rd Edition. American Academy of Orthopedics: Tucson, AZ.
 http://www.americasfootdoctor.com/yourfeet_flatfeet.shtml
 http://www.mamc.amedd.army.mil/referral/guidelines/pod_flatfeet.htm
 http://www.foottrainer.com/achilles/exercises.html
 http://www.americasfootdoctor.com/yourfeet_flatfeet.shtml


READ MORE - SYMTOMATIC FLAT FEET

CUSTOM FOOT ORTHOTICS – Frequently Asked Questions

What are Custom Foot Orthotics?
Orthotics are custom molded devices that are worn inside your shoes to control abnormal foot function and/or accommodate painful areas of the foot. If they are properly designed for the foot, orthotics may compensate for impaired foot function by controlling abnormal motion across the joints of the foot. This may result in result in dramatic improvement of foot symptoms.
How do Orthotics work?
Orthotics work on the feet in the same manner as braces affect the teeth. They provide a consistent base which will help to bring foot muscles, ligaments and joints back into proper alignment. Orthotics will not change the underlying structure of the adult foot. If they are not worn, abnormal function will immediately return.







What are the benefits of Custom Orthotics as compared to over-the- counter inserts?
Orthotics are custom made for your feet and they should not be confused with over-the-counter generic arch supports that can be purchased at your local pharmacy. Custom Orthotics are made from molded impressions of your feet so that the most ideal fit can be achieved. They fit comfortably in your shoes and are made of custom molded, flexible, carbon-fibre reinforced thermo-plastic.

What are some common conditions treated with orthotics?
 Ankle, knees and hip misalignments as well as pain
 Bunions
 Calluses
 Diabetic Feet
 Stress Fracture
 Heel Pain
 Morton’s Neuroma
 Plantar Fasciitis
 Leg length discrepancies






How do I obtain Orthotics?
 Check with your Extended Health Care Insurance to see if you have coverage for Orthotics
o Your Student Insurance Plans covers 80% to a maximum of $200
 Check with your Extended Health Care Insurance to find out if you need a Medical Doctor’s referral. If you require a referral from an MD, it must be dated prior to the Orthotic fitting or you Insurance company may not reimburse you.
o You DO need a referral from an MD for the Student Insurance Plan to cover the cost of Orthotics
 Make an appointment with the Chiropractors at the Complementary Health Services located in the Campus Health Care Centre for an examination of your feet and ankles.


READ MORE - CUSTOM FOOT ORTHOTICS – Frequently Asked Questions

ORTHOTICS TRAINING PROGRAM

ORTHOTICS TRAINING PROGRAM FOR
THE REPUBLIC OF THE MARSHALL ISLANDS.
Taylor, L.1 and Harding, K.2
The Crippled Children’s Association of South Australia1,
Majuro Hospital, The Republic of the Marshall Islands2

Introduction.
The Republic of the Marshall Islands (RMI) is located in the Central Pacific. It consists of 29 coral atolls and 5 low lying islands scattered over almost 2 million square kilometres of ocean. The population is approximately 60,000 people, with half living on the capital atoll, Majuro.
The Majuro Hospital is the primary health care facilty in the RMI. Since early 2001, rehabilitation has experienced a significant period of advancement. Staffing numbers have increased to five, including an Occupational Therapist, Physiotherapist, Prosthetic Technologist, Prosthetic Assistant and a Therapy Assistant.

Diabetes Mellitus (DM) is a huge challenge facing the health of the Marshallese people. It is thought that more than 50% of the population over fifty years of age has DM. In light of the DM rate and disabilities observed within the Rehabilitation Service, Orthotic Management was identified as an essential addition to the service.

Method.
The International Society for Prosthetics and Orthotics (ISPO) Australian National Member Society (ANMS) and the Majuro Hospital Rehabilitation Service developed an eight-week in country training model to teach Marshallese prosthetics staff basic concepts of lower limb orthotic prescription and manufacturing techniques. After several months of preparation, the training program was conducted in August/September 2003.

Results.
The training program resulted in a viable and sustainable orthotics service in the RMI. Patient presentations varied, however 18 of the 36 patients assessed were diagnosed with DM. Other presenting conditions included cerebral palsy, stroke and poliomyelitis. The trainees learned to independently manufacture foot orthoses, ankle-foot orthoses and knee-ankle-foot orthoses for their client population.

Other results included; improved workshop organisation, education of medical staff, development of referral systems, trial of a ‘high risk foot’ screening clinic, development of O&P assessment and measurement forms, production of patient education materials, and improved time management and communication within the rehabilitation team.


Conclusion.
To the authors’ knowledge, this is the first time an in-country Orthotics training program has been conducted in the Pacific. The success of this training approach suggests that there is scope for tailored, shorter term training strategies that consider prior learning and flexible learning techniques.

This approach has the added advantage of allowing training in the local professionals own environment, which is likely to facilitate more satisfactory learning outcomes. It also allows the professional to continue to service their community during the training. This is important in small nations, as the professional may be the only person able to provide a clinical service.

Many obstacles and hurdles were encountered throughout the training program, including geographical isolation, the variation and severity of patient presentations, cultural differences, lack of prior education experiences and language difficulties. Many lessons were learned from the experience and several recommendations were made for future training in the RMI and for future ISPO ANMS training programs in the Pacific.

Notwithstanding these challenges, this program has demonstrated that National Member Societies have sufficient resources to improve clinical services in regions with less-developed prosthetics and orthotics services. This model was not intended to be a substitute for appropriate tertiary training, but rather an augmentation to such training where an immediate need was identified.

It is hoped that the lessons learned from this program can be applied in similar situations, and that the work in the RMI can be consolidated with increased networking between Australian and Marshallese professionals.

The authors of this work acknowledge the assistance of AESOP Business Volunteers, The Majuro Hospital and the ISPO ANMS for supporting this project.


READ MORE - ORTHOTICS TRAINING PROGRAM

Texas Board of Orthotics & Prosthetics

Introduction
The Texas Legislature created the Texas Board of Orthotics & Prosthetics in 1997 to license and regulate orthotic and/or prosthetic practitioners, assistants, technicians, and students in Texas to protect the public and improve the standards of the profession. The board accomplishes these goals by setting and enforcing professional and ethical qualifications and standards for the professionals and facilities that provide this service.
Board Members
During fiscal year 2003, the Texas Board of Orthotics & Prosthetics consisted of six members appointed by the Governor with the advice and consent of the Senate. Three members were licensed under the Orthotics & Prosthetics Act, and three members represented the public. The Board membership consisted of one licensed orthotist who had practiced orthotics for the five years preceding the date of appointment; one licensed prosthetist who had practiced prosthetics for the five years preceding the date of appointment; one licensed prosthetist/orthotist who had practiced prosthetics and orthotics for the five years preceding the date of appointment; one representative of the public who used an orthosis; one representative of the public who used a prosthesis; and one representative of the public who did not use a prosthesis or orthosis. Members of the Board serve staggered six-year terms. The terms of two members expire on February 1 of each odd-numbered year. Board officers are elected in odd-numbered years. Effective September 1, 2003 the Texas Board of Orthotics and Prosthetics became a seven-member board with the addition of one public seat. Erin Berling and Richard Neider were appointed in June 2003 to replace Kenneth Hart and Thomas Lunsford.

Members Representing Term Expires
Scott Atha Professional – Prosthetics and Orthotics February 1, 2003
Erin Berling Professional – Prosthetics and Orthotics February 1, 2007
Wanda Furgason Public February 1, 2005
Kenneth Hart Professional – Orthotics February 1, 2001
Thomas Lunsford Professional – Orthotics February 1, 2001
Richard Neider Professional – Orthotics February 1, 2007
Stanley Thomas Public February 1, 2003
Lupe Young Public February 1, 2005
Staff
Heather Muehr became the Executive Director for the board in February 2003. Donna Flippin served as the Executive Director prior to Ms. Muehr’s appointment. There are two administrative staff positions that assist with the daily operation of the program. All staff positions serve as support for other licensing programs within the Professional Licensing and Certification Division. The board is administratively attached to the Texas Department of Health, Professional Licensing and Certification Division.
Requirements for Licensure
Practitioner - Bachelor's degree in Prosthetics and Orthotics or Bachelor's degree in another subject and a Prosthetic and/or Orthotic certificate, plus 1900 hours of clinical residency per discipline. Applicants are also required to pass the appropriate examinations. An alternative is an Associate's degree including courses in anatomy and physiology, physics or chemistry, and trigonometry or higher mathematics, plus 4500 hours of clinical residency per discipline. The Associate's degree option ends January 1, 2005.
Assistant - Associate's degree including courses in anatomy and physiology, physics or chemistry, and trigonometry or higher mathematics, plus 1000 hours of clinical residency per discipline.
Technician - High School diploma or equivalent, or three semester hours of credit from a regionally accredited college or university, plus 1000 hours of laboratory experience per discipline.
Student - Education requirements are the same as a practitioner. The student registration is issued while the student completes the clinical residency and examination requirements.
Continuing Education
Continuing education requirements are intended to maintain and improve the quality of services provided to the public by licensees and registrants. Continuing education credits include programs beyond the basic preparation. These programs are designed to promote and enrich knowledge, improve skills, and develop attitudes for the enhancement of the profession, thus improving prosthetic and orthotic care provided to the public.

Type of License Number of Hours Required for Each Renewal Period
prosthetist or orthotist license 24
prosthetist and orthotist license 40
prosthetist or orthotist assistant 12
prosthetist and orthotist assistant 20
prosthetic or orthotic technician 6
prosthetic and orthotic technician 10

Licensing Activities
As of August 31, 2003, the Board approved and issued 195 orthotic and prosthetic facility accreditation certificates and 480 individual initial licenses or registrations. The Board issues 18 types of individual licenses and three types of facility accreditation, orthotic, prosthetic, or prosthetic/orthotic. The types and numbers of individual licenses issued are as follows:

Title License Registration Temporary Provisional
Orthotist 143 3 1
Prosthetist 78 1 0
Prosthetist / Orthotist 155 2 1
Orthotist Assistant 13
Prosthetist Assistant 7
Prosthetist / Orthotist Assistant 23
Orthotic Technician 7
Prosthetic Technician 8
Prosthetic / Orthotic Technician 14
Orthotic Student 11
Prosthetic Student 10
Prosthetic / Orthotic Student 3

Budget
The total revenue for the Texas Board of Orthotics & Prosthetics program for fiscal year 2003 was $146,598. The total expenditures for the Texas Board of Orthotics & Prosthetics program for fiscal year 2003 were $112,468. In November 202, the Board adopted six new fees and increase two existing fees. These amendments resulted in increased revenue for fiscal year 2003.
Disciplinary Actions
During fiscal year 2003, the Texas Board of Orthotics & Prosthetics received 18 complaints and closed 23 complaints. Of the 23 closed complaints, 4 complaints were received in FY 2003 and 19 complaints were received in previous fiscal years. One cease and desist letter was issued.
Public Information
The board maintains a home page on the Texas Department of Health's web site to provide information about its programs and activities to the public. The page may be found at Information accessible through the page includes the Orthotics & Prosthetics Act, board rules, program information regarding disciplinary actions, applications and instructions on filing a complaint with the board. A roster listing all licensees and registrants in Texas is also available on the web page.
Summary
During FY 2003, the Board met three times to review and approve applications. Complaint processing and complaint investigations are a major activity.



READ MORE - Texas Board of Orthotics & Prosthetics

Popular Posts