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Academy Meeting in Orlando
Scientific Presentations
This Academy meeting was one of those events where there was a burst of new information. Because there were many concurrent sessions and workshops, it was impossible for one person to attend every great presentation, but I found excellent sessions every day.
Mark Geil, PhD presented a very frank paper on his preliminary studies of the alignment of transfermoral prostheses. Like most engineers, Dr. Geil viewed TF alignment as a mysterious and subjective process with ample room for improvement, and wondered if a system of computerized alignment would be helpful. The available literature is of limited value in helping scientists understand dynamic alignment since the studies focus on only a few of the many clinical variables that are involved. The published data suggests that "good" alignment is highly variable, and differs between different prosthetists and in successive prostheses.
Dr. Geil recruited five ABC Certified Prosthetists with varying levels of experience and had them each align multiple prostheses for several patients. All patients underwent objective gait analysis and the resulting alignment was documented and compared. Much to the surprise of the engineers, the gait patterns each patient demonstrated - regardless of the CP who did the alignment - were extremely consistent. Although there are undoubtedly many reasons this occurred, these results did not support the concept of developing a computerized system to make alignment more consistent.
When the final alignments were compared, it became clear that there were really only 3 "basic alignments" for all of the cases studied, and they varied primarily in the positioning of the ankle-foot assembly. This suggests that there are a limited number of "alignment philosophies" among good prosthetists and that dynamic walking trials are much more precise than was previously appreciated.
Hopefully Dr. Geil will publish more details from this study in the Journal of Prosthetics and Orthotics so we can study his work in more depth. I suspect that Dr. Andrew Hansen's work with Dr. Childress on the concept of "prosthetic foot roll-over shapes" will be useful in sorting out these results. [Go to www.oandp.com/news/jmcorner/2001-03/4.asp?searchquery=rocker for more details.]
It is important that we validate and document the science that lies under the art of prosthetic and orthotic fitting. This study is another step in that long but important journey.
Brian Giavedoni CP(c) did a very nice job of providing the first objective evidence to support the longstanding custom at the Atlanta Scottish Rite hospital of providing articulated knees to toddlers starting about 10 months of age. The traditional approach has been to fit with a non-articulated prosthesis until the child is much older, and able to "control" a free knee.
But, like many of our hoary maxims, this practice is based more on decades of custom than on any objective justification. The general trend in recent decades has been to provide fully activated prostheses to children at about the time they would normally start learning to use such functions, and the Atlanta folks have had very good clinical results with such a philosophy. But, the arguments rage on between the "passive limb first" and the "facilitate learning to use an active prosthesis" camps.
Brian and his colleagues conducted gait analysis studies on two children who were 22 months old and had been using an articulated transfemoral prosthesis since they were infants. The results showed quite clearly that, when they were forced to walk on a locked knee, their gait velocity decreased and the number and magnitude of compensatory gait deviations increased.
Obviously, further studies with larger numbers of children will be needed to verify these pilot findings. But, these results were so striking clinically that we should all consider being more aggressive when working with toddlers in the future. The availability of several stable polycentric knees suitable for small children makes early fitting with articulated knees technically feasible. Brian's data suggests that such an approach will also reduce gait deviations, increase gait efficiency, and foster the development of a more normal gait pattern.
Gary Bedard, CO did his usual excellent job of explaining some of the engineering intricacies of thermoforming plastics, using examples that the practicing orthotist can understand. He focused on practical methods to increase the crystallinity of the finished device to decrease the tendency of the plastic to creep over time and lose its original contours. One of the most effective practical means to accomplish this was to wrap the freshly vacuum-formed orthosis in Mylar-coated bubble wrap from the local Home Depot. This retarded the rate of cooling and made the material more crystalline and therefore more stable.
The days of "garage manufacturing" of orthoses using retired pizza ovens and shop vacs are waning, and work such as Gary's provides the scientific rationale for moving to better controlled manufacturing methods. Once the International Standards Organization releases their recommendations for structural testing of lower limb orthoses, I anticipate a surge of interest in better thermoforming. The bar has been steadily raised for orthotic clinicians in recent years, and it is logical that the standards for fabrication of orthoses will also increase in the future. The technician of tomorrow, in my view, will be a much more highly trained fabrication specialist who understands the science of materials and the principles of quality control in considerable detail.
Tom Coburn CO gave an excellent presentation on how to interpret radiographs to blueprint a scoliosis TLSO. His wealth of experience in this area was evident, and the graphics and concepts presented were crystal clear. The Academy Spinal Society has been doing a very good job for several years in bringing clarity and consensus to this sometimes-controversial area of clinical practice, and Tom's lecture was a great illustration of the quality of the information being shared by experts in this aspect of orthotic practice.
There were many other outstanding talks, including Dr. Bunch's interactive session on "Ethics" and Troy Farnsworth's review of upper limb Immediate Post-Operative Prostheses. Hopefully, many of these will be repeated at regional and local meetings in coming years so this information is available to a wider group of practitioners. These brief summaries should give the reader a "taste" of what went on at this outstanding meeting, and motivate you to mark your calendar for March 19-22, 2003 when the next Academy meeting will be held in San Diego.
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Devisnig Arm Functional Levels
I continue to be thrilled with working in the South Seas. New Zealand's socialised medical scheme offers many strong benefits for its amputees. And what's more, the weather here is nothing like what you get back in the Mid-West: Paradise.... read more
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Re: Devisnig Arm Functional Levels
Hi Jamison- Glad to hear you are enjoying KiwiLand. I'd hoped to make it to the recent world conference, but I had other obligations on this side of the globe that week. To the best of my knowledge, no one in North America is working on ... read more
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Fallecimiento del colega Roberto Calderón Márquez, O. P. 1950 - 2002
Estimado John Michael C. O. P. FAAOP:
Nos permitimos informar con mucha tristeza, a toda la comunidad de Ortésistas y Protesistas de América Latina, que el día 20 de Julio, 2002, falleció nuestro amigo y colega Roberto Calderón Márquez O. ... read more
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Re: Fallecimiento del colega Roberto Calderón Márquez, O. P. 1950 - 2002
May he rest in peace. --John Michael CPO
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Comentario Rapidfit
Apreciado Colega: Tengo la presuncion que el socket que aparece en el trabajo presentado para este componente es dercho y el pie es izquierdo. Puede explicarme la razon, o es un error ?. Atte: R. Nessi. PO.
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Re: Comentario Rapidfit
Excellent observation, Sr. Nessi! The photos are from a display model, not from an actual patient. It appears that the folks at PEL only had a left foot handy so they used it temporarily at the Ohio meeting even though the socket is for a... read more
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Re: Re: Comentario Rapidfit
Apreciado Colega, gracias por su respuesta. Atte: R. Nessi. PO.
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Leyendas en Español:
Ciudad de México 1° de Julio, 2002.
Estimado John Michael: le envío este comentario para solicitarle que las leyendas abajo de las fotografías también aparezcan en Español, en la Edición de Julio de la Esquina de John Michael. En la traduc... read more
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Re: Leyendas en Español:
Thanks for calling this to my attention, Alberto. It seems that the folks at OANDP.COM were working into the wee hours of the night when they set up this month's corner. In addition to omitting the legends in Spanish, we also wound up wit... read more
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Re: Re: Leyendas en Español:
Ciudad de Mexico 2 de Julio, 2002.
Felicitamos a los compañeros de OANDP.COM por la rápida corrección en La Esquina de John Michael del mes de Julio. !Son unos verdaderos profesionales! Asimismo, el breve video clip del paciente utilizando... read more
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Re: Re: Re: Leyendas en Español:
Glad you found the video clip valuable. I think this will be the 'Decade of Stance Control Orthoses' and that these options will gradually change the way we practice as orthotists by making KAFOs more effective treatment for a wider array ... read more
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