Pre-Preg Carbon Dynamic Orthosis
By Noel J. Chladek, CO Have we found the evolution of lower-extremity
orthotics? We pose a question to orthotic practitioners: "Are your
patients benefiting completely from the devices you are designing
for them?"
 We may have been asking ourselves this question
subliminally or directly for years. It may keep you up at night, or
keep you occupied occasionally throughout the days of providing
patient care. "Is this the best possible device to treat this
patient's pathology?"
As orthotic practitioners, we may have invested years in
training, education, and study of the newest technologies and
applications to create an optimum rehabilitative device for our
patients. As human beings, we want to know that our efforts are
creating an improvement in the situation of the patients that we
see. The reward, at the end of the day, is dependent on being able
to answer our posed question with affirmation. This is our drive to
attack each day and the challenges that lie ahead, building on the
affirmation of the previous day's success.
Or are we fooling ourselves? If you take a moment and reflect on
a recent fitting that went well, ask yourself: "Did that patient
benefit from the device 100 percent?" Through honest reflection,
the answer may not be 100-percent satisfactory treatment. We are
willing to tolerate some dissatisfaction, even with overall
success, if we are somehow limited by certain restrictions that are
beyond our control, right?
We have posed this question to ourselves as well, and when
limitations in the materials and technology failed us, we pushed
back, and forced the technologies to meet the treatment standards
that we desired. We used our drive to find and experiment with
different materials and technologies that were available in
different industries. We started frantically including them in our
fabrication incessantly, many times ending in failure, although we
never stopped searching. Our experimentation has taken us to levels
that we had never dreamed possible on the outset of this
journey.
Success after Effort
Our clinical practice uses a custom-molded, energy-storing,
pre-impregnated carbon device for treatment of 60 percent of our
lower-extremity orthosis fittings. We also experience a 90-percent
successful first-time fitting rate with little adjustment necessary
at fitting. Our patients exclaim their excitement and appreciation
for being able to find a facility that understands their complex
dilemma and has the answer to treating it. And we are still not
satisfied--we will continue to push the standard of bracing in an
ongoing attempt to reach orthotist nirvana.
What Is Dynamic Response?
 Dynamic response is acquired when the forces acted
upon the device from the patient's ambulatory force, are returned,
in some form, to the gait cycle to increase the function of the
deficient anatomy. The patient often describes the sensation as
"having a spring in my step," and a feeling of "natural stability."
The dynamic response is set by the practitioner to ensure that the
device does not hinder the functioning portions of the limb, though
increasing the function of the deficient anatomy.
Utilizing the addition of the new materials, we have found that
by creating customized forces throughout the gait cycle, the
patient is able to ambulate without a feeling of walking "flat,"
thus increasing the repetition rate before exhaustion.
With a history of orthosis designs that offer only rigid
restriction of motion or free guidance of motion, the evolution we
have created is true dynamic response. It allows motion and a
gradient resistance throughout the entire stance phase.
Once you begin experimenting in the area of dynamic response,
everything becomes much more detailed and complex during the
initial evaluation of the patient. You must examine the patient's
strengths and weaknesses in the musculature of the affected limb
more precisely. Then it is necessary to build on the patient's
strengths and replace or assist the areas that are lacking in
strength.
You then need to use the information gathered from the
evaluation to determine the resistance level that would be
beneficial to the patient. Utilizing all the information gathered
from the evaluation phase, you can designate then the proper
position for casting to optimize the gradient force vector so that
the gait cycle is smooth and free of evident transition.
As each orthosis in pre-impregnated composite fabrication is
custom to the patient's model, the evaluation and modeling
procedure is pivotal to ensure that the device will function
effectively for the patient. A very slight alignment flaw could
cause the creation of an orthosis that will not function for the
patient. Working with such expensive materials, it was necessary
for our department to remake hundreds of devices over the years of
experimentation.
We have tested numerous composite materials and resin
combinations to find the system that would ensure a strong bond
within the materials and would tolerate the excessive force and
also repetitious forces found in ambulation. The fabrication
procedure must be precise regarding curing temperature, cure time,
and outside elements, as these variables can cause failure in the
device. Even the slightest miscalculation has ruined an entire
development cycle of devices.
Appearance
The Dynamic Response Orthosis is aesthetically and functionally
pleasing to the patient. Utilizing carbon fiber creates a much
lighter device than the traditional orthosis, and the requirement
for less material to achieve the necessary function ensures less
overall brace for the patient. The orthosis can be made in any
range of colors to match the patient's personality and
preference.
Evaluation of Success
 The simplest evaluation of the patient's success
is found when evaluating the patient's stride length and the
overall amount of time spent on the affected extremity. We often
will view these attributes of the patient while wearing the new
device and compare it directly to the previously worn device and
anatomical ambulation.
Reimbursement
We currently fabricate our dynamic response orthosis design for
several independent facilities across the country. These facilities
have found little difficulty with obtaining the increased
reimbursement to warrant the additional expense of fabrication of
the dynamic response orthoses. In our patient care facility, we
have noted a 40-percent increase in reimbursement for this device,
which easily offsets the additional expense for fabrication.
Training
The utilization of the device is complex in nature, and a
thorough training procedure is necessary. We have devised a
hands-on training procedure for practitioners who are interested in
providing dynamic response orthoses in their clinic. The class
consists of a two-day workshop that will greatly reduce the amount
of errors in evaluation and casting and create a complete
understanding of the entire process.
Building on our successes has given us the drive to continue on
this adventure optimistically. The many years and late nights of
experimentation and frequent failure already have been invested,
and more will be necessary in the future--this is certain. The
financial burden of working with these expensive materials and the
specialized equipment has been realized completely. At the end of
this, though, we find that we have developed a bracing system that
can most closely offer a satisfactory device for fitting to our
patients.
We are terribly excited to be able to provide better treatment
in lower-extremity orthotics, and we want to be able to share our
successes with the entire orthotic community. We have waited for
this day to ensure that the devices we have created are successful
through fitting in an actual clinical situation on real patients.
And now, we are comfortable to begin providing our services to
allow other facilities to begin utilizing these custom orthoses for
their patient population Noel J. Chladek, CO, can be contacted at Bio-Mechanical Composites Inc., 1300 Keo Way, Des Moines, IA 50309; phone: 515.554.6132 
Table Of Contents - April 2006
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