SOIF Konferens Uppsala

I was honored to join Swedish colleagues recently as one of the keynote speakers at their annual meeting, in the University town of Uppsala, which about 30 minutes from the Stockholm international airport. Because I don't speak Swedish, I couldn't follow the details of many of the talks, but from the slides it was clear that the challenges and clinical approaches are quite similar to those seen in the USA. Informal discussions outside the meeting confirmed these impressions, and many speakers were kind enough to offer me an informal summary in English of their key points.

I gave three talks: a review of the kinematics and kinetics of normal and amputee gait, a reprise of the talk prepared for last year's BAPO meeting in Glasgow on the evolution of transfemoral socket designs, and a new presentation on the history and evolution of microprocessor controlled prosthetic knees. The last talk, in particular, was well received as the Swedish CPOs have been leaders in identifying appropriate candidates to receive such technologically advanced prosthetic knees. For example, Swedish amputees have received approximately the same number of Otto Bock "C-Leg" prostheses to date as the entire US amputee population.

Silvia Raschke, CO[c], PhD

Dr. Raschke from the British Columbia Institute for Technology was also a keynote speaker at this meeting, and her talks provided additional information and background on the topic she introduced at the REHA meeting in Leipzig last year. Click here for the July 2000 Corner that summarizes this previous lecture. The gist of these presentations included compelling arguments that our pride in workmanship, and cherished self-image as effective designers of rehabilitation solutions, may lull us into complacency while others usurp roles that have traditionally been the domain of the prosthetist orthotist. Rather than fight such encroachment directly, which is our typical response, Dr. Rashke proposes working collaboratively with such individuals to define a new set of P&O domains that are more inclusive, arguing that unless we can find more allies we are simply too small in numbers to affect our own future.

Dr. Raschke also suggested that although we see ourselves as problem solvers and biomechanical designers, only the former skill set is supported by the available data. Quite rightly, her work points out that most of our cherished beliefs are assumptions and hypotheses - passed down with reverence over the decades - that have never been scientifically scrutinized or validated. She warns that, so long as we lack objective verification that what we do truly makes a measurable difference, we will continue to be vulnerable to encroachment by anyone who makes similar claims. Without scientific research to back up our beliefs, external observers cannot tell an effective Certified Orthotist from a "wannabe" who claims to have similar abilities.

For example, a study was recently conducted to determine which biomechanical ankle control option - solid ankle, free motion, limited motion, and so on - resulted in the greatest improvement in the kinematics of walking for patients with stroke residuals. The results showed that, even though all patients walked faster with a custom-made thermoplastic orthosis than without, no particular ankle control strategy was demonstrably superior to another for the cohort tested. More provocatively, some of the articulated AFOs resulted in greater gait asymmetry than occurred when walking without the device. Although sometimes initially difficult to accept or understand, such insights are critically important to our future as a field, since they show us more clearly the limitations inherent in selecting specific components based solely on clinical judgment.

Of course, it may well be that the type of articulated AFO resulting in more gait anomalies was not appropriate for the particular deficit pattern that particular patient exhibited. Further studies to identify those criteria that will lead to effective use of specific articulations would then be in order, and such data would strengthen the justification for specific orthoses. Unfortunately, as Dr. Raschke went on to observe, our field is so small that we have very few individuals with the training and experience necessary to conduct such research. In addition, there are very few funded positions that support such research efforts anywhere in the world.

The chilling consequence of this state of affairs is that we have, in effect, abdicated responsibility for conducting the key research that will be critical for the future of our practice. If we continue to defer to other professionals [such as therapists, physicians, or engineers] to conduct research on the devices we provide, it should not be surprising when our field evolves in ways we do not intend.

The solution is simple to state but much more difficult to implement: we need to create a cadre of doctoral level CPOs as well as to develop an infrastructure that will fund their continuing research into the fundamentals of our practice. Dr. Raschke's talk concluded on a positive note, acknowledging that the most recent group of CPOs who have earned a research doctorate have all found full-time academic positions. [Earlier CPO PhDs generally found it impossible to obtain employment as researchers, and therefore wound up working in private clinical settings without any major academic responsibilities.]

Due to our small numbers, however, our new PhDs are scattered across the globe in different countries including Hong Kong, Australia, Great Britain, and the USA. Collaboration will be more difficult due to these geographic barriers than would be the case if they were all members of the same department at a major University and could therefore work together on a routine basis. One logical conclusion from this discussion was that it could be very helpful in determining the future of the profession if a philanthropist could fund such a P&O "brain trust" with an endowment that would support a reasonable number of researchers in the same geographic setting.

One final suggestion from Dr. Raschke's research was for all of our schools worldwide to provide more formal training in marketing principles and business practices. As she noted ruefully, there is a common attitude in P&O that caring for the patient is our major task and our sole interest. If the business also makes a profit, then that is fine too, but running a profitable practice is rarely the focus of our efforts.

Dr. Raschke noted two problems with this philosophy. First, it is inherently unrealistic since the overwhelming majority of CPOs work in small businesses, and unless such businesses remain consistently profitable, we cannot deliver the patient care we cherish so highly. Secondly, our attitude that "business is beneath our dignity", combined with the lack of objective data to support the value of much of the care we provide, makes us vulnerable to interlopers who aggressively market themselves as "just as good as a CPO". Increasing our business savvy while simultaneously providing aggressive support for research to test our principles are the logical methods to reverse this trend.

We might look to our colleagues and mentors in orthopaedic surgery for inspiration in this regard. The rapid growth of academic medicine in this discipline, combined with a frank acceptance of their responsibilities as business managers, has served this specialty well in recent decades. Attend any major orthopaedic meeting, and you will soon learn that the overwhelming majority of the talks present objective data supporting the specific treatment provided. The old phrase, "...because that's the way I was trained to do it..." is increasingly rare in orthopaedic circles. With a little time for some seminal research into P&O practices by our fledgling cadre of PhDs, our field too can grow beyond such colloquial justifications. And, clearly we must do so if we are to survive....

Reader Comments: Read all user comments Help me please! I´m 18 years old girl from Finland I paralysed 3 years ago in a snowboarding accident. My injury is in the area of TH 11-12. I would want to know if UTX Swing orthosis is good for me. I can move (swing) my feet from the hip and another (lef... read more - Ulla Kulju   12/26/2004 Re: Help me please! Thank you for this inquiry, Ms. Kulju. It is possible that you would be a candidate for the UTX or for one of the other Stance Control Orthoses, but the only way to answer this question would be to arrange a personal examination by an orth... read more - John Michael   12/27/2004 I want to find a Journal about UTX orthoses I want to find a Journal about UTX orthoses. Where can I find a paper? - Kang sungjae   1/15/2003 Re: I want to find a Journal about UTX orthoses help - hashem   2/12/2006 Re: I want to find a Journal about UTX orthoses To the best of my knowledge, any refereed articles on the UTX will be in Dutch. I don't have access to that literature. You may be able to contact Ambroise Holland for more information. --John Michael CPO - John Michael CPO   1/19/2003 Microprocessor leg Hi, I am trying to do a project on microprocessor legs. Can you please let me know which knees are the best out in the market? I will like to compare them and try to understand how they work. - Yesenia   12/9/2002 Re: Microprocessor leg There's no short answer to such a question. As of December 2002, there are basically three MP controlled prosthetic knees commercially available in North America. The Blatchford IP+ is a pneumatic swing phase control knee; the Blatchford ... read more - John Michael   12/9/2002 false leg 1967 Dear John Michael, Can you help me , I am the costume designer for the play 'Buried Child' by Sam Shephard.[ Belvoir St Theatre in Sydney , Australia][set in 1967] One of the key characters is an amputee, he has false leg from above ... read more - Julie Lynch   7/13/2002 Re: false leg 1967 The external appearance of prostheses did not change much until the 1960s. Prior to that time, almost all artificial limbs were made primarily from wood. Due to the hard out structure, this type is termed "exoskeletal" construction. Most... read more - John Michael   7/14/2002 UTX orthosis I have read a few articles about the UTX technology. I am a polio victim and wear a full leg brace. Where would I find out more and perhaps be able to purchase such a brace? - Ron Rensink   1/24/2002 Re: UTX orthosis help me - hashem   2/12/2006 Re: UTX orthosis UTX is available from Becker in the USA as of September 2002, and a variation called the FreeWalk is available from Otto Bock as of March 2002. --John Michael CPO - John Michael   12/9/2002 microprocessor leg hi john, is there a picture existing of this microprocessor leg ? i could not find picture material concerning this product. thank you robert - Robert KAITAN   10/18/2001 Re: microprocessor leg Happy Holidays Robert! I apologize for the delayed reply, but I have just now realized that people might post queries many months after these Corners are archived. Unless I happen to stumble onto an old Corner, I have no way to tell when... read more - John Michael CPO   12/18/2001 Thanks I m working in Honduras with Handicap International, it s really nice that some book are translated in spanish, we dowload the all the part we could and we used it as reference for a manual of procedure that we are doing. Thanks for all t... read more - Isabelle Couture cpo   5/1/2001 Re: Thanks Delighted to know that you have found this resource helpful. --John Michael CPO - John Michael   12/9/2002