ISPO/UK Meeting in Liverpool

I recently had the honor of being selected this as the Blatchford Lecturer for the UK meeting held in Liverpool, England in early October. This turned out to be quite a good meeting with all of the accepted papers being grounded in objective data. The UK clinic teams are well ahead of those of us in North America in their focus on Evidence Based Practice, and the scientific quality of the presentations reflected this fact.

It was particularly noteworthy that every paper presented by clinical prosthetist-orthotists or by P&O students included at least one new piece of scientific information to support the conclusions. As might be expected, the physicians and engineering scientists had the most sophisticated results, but the clinicians did a very respectable job of presenting fledgling studies that were directly relevant to daily patient care responsibilities.

Only the manufacturer's workshops were devoid of objective information. As we move further into the 21st Century, the plethora of similar choices and conflicting manufacturer's claims strengthen my conviction that EBP is the best available tool to determine what's best for our patients and to add more credibility to our practices.

I would encourage every P&O society to follow the lead of our UK colleagues in this regard, as good research is quite difficult to conduct and moves knowledge forward in very small steps. Practitioners need to start doing clinical research now to insure that the next generation of practitioners will have a sufficiently large body of evidence to face tomorrow's challenges.

Highlights of some of the papers from this conference follow.

Functional Electrical Stimulation AFO

Professor Ian Swain summarized his experience with more than 1500 electronic AFOs designed to control flaccid equinus [dropfoot]. There is a tendency to dismiss more complex solutions to simple biomechanical problems as "overkill", and worldwide cost containment pressures have made the "least costly alternative" ubiquitous. So, the attitude that "a thermoplastic AFO provides a dorsiflexion assist more reliably and at a much lower cost" is a common one. Fortunately, a few visionaries such as Professor Swain have persisted in swimming against the tide and pursued innovative orthoses.

From his wealth of clinical experience, he has been able to extract credible data that demonstrates short-term carryover in some stroke patients who have used the "Oddstock" FES AFO for an extended period of time. In other words, they can begin to walk without the orthosis and voluntarily control ankle dorsiflexion for a few days or longer. Some anecdotal reports of being able to discontinue the orthosis suggest that its use may facilitate recovery of muscle control.

Passive aids such as the traditional dorsi-assist AFO are not believed to have this potential benefit, so this is an exciting possibility: that an electronic AFO might be a treatment protocol as well as a tool to mask a biomechanical deficit. This notion clearly needs more study to rule out spontaneous recovery, but I wouldn't be surprised to see our conviction that long-term recovery is impossible for Central Nervous System deficits to gradually fade in the face of more aggressive and continuous therapy efforts.

FES AFOs offer the additional advantage of facilitating knee flexion, which is achieved by adding an electrode in the popliteal region. They may also prove useful in reducing the shuffle gait so characteristic of people with Parkinson's disease, and special versions have been used to improve standing balance. For more information on this promising area of innovative orthoses, go to www.salisburyfes.com. To view before and after videos of stroke patients treated with this orthosis, click on www.polyu.edu.hk/rec/fes/FESVideo.htm.

The primary practical barrier to wider adoption of this technology has been the worldwide lack of funding. Professor Swain suggested that orthotists are the best-qualified health professionals to evaluate patients and provide such advanced technology, although it is equally important to have good physical therapy and ongoing follow-up monitoring. This reminds me of the situation some decades ago when custom seating was in its infancy and orthotists generally ignored the field. Meanwhile, therapists gradually developed a body of knowledge in that area and now dominate the provision of such systems. If we sit on the sidelines again, it should not be surprising if our segment of the field of orthoses continues to shrink!

Orthotist Laura Johnson recognized that canvas LSO corsets are increasingly in disfavor among many in the medical community and conducted a retrospective review of a convenience sample of 81 patients to investigate the effect of LSO corsets on low back pain. The great majority of those responding [73%] reported subjective relief of pain and ascribed this to the effect of the corset. These preliminary results encouraged her to undertake a more controlled prospective study of 60 patients randomly assigned to a PT only or LSO only treatment protocol.

In my view, this is a much more constructive response to the decline in the prescription rates of these orthoses than the usual grumbling over coffee with colleagues. If the treatments we offer are ineffective, we should be the first to document that fact and lead the way in developing alternative approaches. On the other hand, if there is good evidence that traditional orthoses are effective, we should publicize that fact and lead the way in continuing what are often low cost, low risk, and biomechanically simple solutions.

What Can Recent Graduates Do?

Elaine Figgins & Sandra Sexton, both on faculty at the National Centre for Training & Education in O&P at the University of Strathclyde, presented a brief summary of a survey of the skills of their recent graduates. While much of the information simply confirmed what one might anticipate, that new grads clinical skills slowly improved once they began to fit patients in the "real world", the discrepancy between the novice PO's self-assessments and those of the immediate supervisor were interesting. In many parameters, the supervisor rated the novice practitioner's performance somewhat higher than their self-rating. But, the rankings were always similar, suggesting that both supervisor and novice had pretty accurate impressions of what the new graduate could do.

This type of objective data lends credibility to the cherished notion that post-education experience is one critical element in creating an effective clinician, and can be used to support certification requirements that include such factors.

Virtual Reality

Malcolm Lindsay presented a fascinating look inside the VR laboratory at the University of Strathclyde and explained how the wrap-around screens offer a total immersion experience. Current rehabilitation applications being investigated include training new powered mobility users to navigate their communities using joystick control and the like. Preliminary evidenced suggests that VR will be a safe and effective screening and training tool.

During the wine reception following the first day's presentations, I was chatting with some colleagues and mentioned that my son is a jazz drummer. Malcolm then mentioned that he is a composer and musician himself, and was named "Best Unsigned Jazz Guitarist in the United Kingdom" last year. That night, I got online to browse his web site www.malcolmlindsay.com and was very impressed with the range and quality of his musicianship.

The last day of the course, Malcolm kindly gave me a demo CD that included some of his original compositions, movie scores, and jazz performances. I listened to it during the transatlantic flight home; this guy is good! With Malcolm's permission, I am posting a downloadable MP3 file of a funk groove featuring his guitar work. Click here to see if you like it as much as I do. Malcolm Lindsay Part I, Malcolm Lindsay Part II, Malcolm Lindsay Part III

Transtibial Socket Design Influence on Gait

Rehab physician Dipak Datta and his team members presented preliminary data from subsets of a larger ongoing study comparing the current PTB sockets with those based on the pressurized ICECAST methodology. This series of well thought out experiments showed no difference in objective gait parameters between the differing socket configurations or suspensions. The sole exception to this finding was a statistically significant [p = 0.03] increase in stride length with ICEROSS suspension versus a suprapatellar cuff strap.

Such results help eliminate speculation about potential advantages that are assumed but not present, and help focus our attention on other variables that turn out to be more significant to the patient's quality of life.

Effect of Shrinker Socks on Local Circulation After Transtibial Amputation

Therapist Laura Burgess gave a very nice, concise paper reporting her results investigating the short-term effect of the commonly prescribed "stump shrinkers" on residual limb circulation. She used a device that estimates superficial circulation based on Tissue Reflectance Spectroscopy, and modified it to take readings through the elastic shrinker fabric. Within the limits of a study with n = 8, she could detect no significant changes in local oxygen perfusion over bony prominences or soft tissue.

This is the sort of fundamental data that is sorely lacking in amputee rehabilitation, so even such modest studies make a significant contribution to the body of scientific knowledge about the field.

Water Activity Limbs

Rehab physician Rajiv Hanspal and prosthetist Richard Nieveen were interested in the prescription of prostheses specificially designed for use in wet environments. Anecdotal reports suggested that many patients were denied consideration of such prostheses while others used such devices briefly and then abandoned them. Since they had only 18 patients at their institution who had received such devices, it was unlikely that any survey results from this population would be statistically significant.

Therefore, they decided to use the Delphi Method to survey 100 rehabilitation professionals with long-term training and experience in amputee clinics, being careful to include representative numbers of PT, OT, MD, and CP caregivers. Based on the expert opinions of these clinic teams, they developed a list of suggested indications for the provision of water activity limbs. On many parameters, the consensus was nearly unanimous, building confidence that these guidelines reflect current clinical thinking.

Equally important, they then presented their preliminary findings to a national amputee consumer group for review, comment, and suggestions. After verifying that there were no areas of major disagreement, they then proposed specific criteria to determine when a waterproof prosthesis was essential, justifiable, or generally not necessary.

This was an outstanding example of how to build on clinic team expertise to bring some clarity to an area that is generally fraught with anecdote and opinion. Consensus-based practice protocols can guide our discussions, investigations, and funding decisions far more rationally than the "local custom" that typically drives decisions to prescribe or not prescribe less routine prostheses such as these.

3D Printing of Prosthetic Sockets

One of the more intriguing papers was given by engineer Brian Callaghan from the University of Strathclyde. He is part of a team investigating the application of low-cost commercially available printers for Computer Aided Manufacturing of prosthetic sockets. Trials with a Z Corporation 3D printer demonstrated that a test socket could be created from typical CAD inputs that are used in current practice.

The printer functions much like the familiar 2D inkjet, but it deposits small dots of glue instead of ink. A layer of powder is then dusted over the glue, and the next layer of glue is then sprayed. The structure, for example a transtibial test socket, is built up layer by layer. Like other rapid prototyping methods, 3D printing of sockets eliminates the time, cost, and mess of generating a positive model then forming a plastic shell and removing it from the model.

This offsets much of the cost of such printers although the four-hour fabrication time remains a practical barrier. Such "glue and powder" sockets are too fragile for weight bearing but can be easily reinforced with methyl methacrylate and carbon fiber cloth strips. The resulting sockets have been successfully used for short term walking trials to prove the validity of the concept.

As the prices for printers continue to drop and the speed increases, such fabrication methods will become increasingly plausible for clinical use.

Silicone Dorsiflexion Assist AFO

Most of the exhibits were of familiar devices and designs, but I did spot one new wrinkle. Dorset Orthopaedic is a British firm who are well known for "pushing the envelope" in prosthetic and orthotic design, so I'm always interested in their latest explorations. [One of their more prominent clients is Heather Mills, better known in much of the world as Mrs. Paul McCartney.]

They are very involved in custom applications for silicone elastomers, and had a nice-looking silicone ankle gauntlet at their display table. Unlike the traditional leather gauntlet, or the more common thermoplastic variants, the silicone style provides a dynamic dorsiflexion assist that patients have reportedly found very effective. It also tends to resist coronal plane ankle collapse, dynamically returning the foot to neutral during swing phase.

Many years ago, I saw a polio survivor who was a patient of the late Horst Buckner [from LifeLike Labs in Dallas] and who wore a full leg cosmesis of silicone that offered the same functional benefits. But, donning the silicone shell was very difficult, requiring lots of skin lubricant and upper limb strength, so the one-piece design seemed to have very limited application.

The folks at Dorset have done a nice job of camouflaging the hook and loop closure that makes their version of Silicone AFO practical for a far wider range of patients. I suspect that the Silicone AFO concept will prove to be as effective in treating flaccid equinus [dropfoot] as the silicone partial foot prosthesis has proven to be for folks with forefoot amputations. You can contact Dorset at www.dorset-ortho.co.uk for more details.

Reader Comments: Read all user comments Felicitaciones Estimado John, quiero felictarte por esta seccion, la contribucion de estos textos tiene un valor incalculable, cuyo beneficio se tarducira en mejores productos para nuestros usaurios, Agradece y felicita nuevamente Jorge Lopez Terapeuta ... read more - Jorge López Tamaya   12/30/2002 Re: Felicitaciones Many thanks for your words of encouragement. It was my hope that, by making the texts more widely available in Spanish and at no cost, that colleagues worldwide would be able to use these ideas for the benefits of their patients. But, the... read more - John Michael   12/30/2002 congratulations Querido John: Muy inteligente y generoso pensar en los rehabilitadores de habla hispana para ilustrarnos en oandp. feliz navidad - wilder gomez   12/21/2002 Re: congratulations Thank you for these Holiday wishes. I'm very grateful for Sr. Castillo's efforts each month to provide the translations of this Corner so the information can be shared more widely. Happy Holidays and best wishes for the New Year to all ou... read more - John Michael   12/21/2002 Osseointegrated Finger Prosthesis Hi everyone... I'm looking for any information about " Osseointegrated Finger Prosthesis" and Doctor Manurangsee. If anyone has any information, pictures, or news paper adds... it wouldbe greatly appreciated!! You can e-mail it to: maubicch... read more - Mauro   12/19/2002 Re: Osseointegrated Finger Prosthesis I'm not familiar with this particular doctor, but perhaps one of our readers will be. There is a maxillofacial dentist in Thailand with this surname. Research into osseintegrated finger prostheses has be onging in Sweden and Spain for som... read more - John Michael   12/19/2002 Finding a prosthesis like Mrs. McCartney's Dear Sir, Please do not think you need answer me personally. I write to ask where one might procure a limb similar to Mrs. McCartney's. I have friends who have been given quite the run around and only have prosthese I consider "adequte".... read more - Kartharine Dillon   12/6/2002 Re: Finding a prosthesis like Mrs. McCartney There is no such thing as "the best prosthesis", unfortunately. Much like "the perfect spouse", this is a very subjective judgment and there are no shortcuts that insure a good long term outcome - with spouses or artificial limbs. I'm sur... read more - John Michael   12/8/2002 toys John - I love your taste in gadgets, keep them coming. Got some headphones on my xmas list now. - Ted Trower   12/6/2002 Re: toys John: Thanks for the tip severl months back about the RF computer remote. I used mine last week an it made giving a presentation easier. It does have a little learning curve to use without being noticed, I expect that will be overcome so... read more - Mike O'Donnell   12/17/2002 Re: Re: toys You've just warned all who read this month's Corner to watch their goodies, so I won't need to repeat the message. I generally keep my briefcase at my feet when I fly for just that reason. Glad you found the RF remote useful; several othe... read more - John Michael   12/17/2002 Re: toys Thanks Ted. I try not to overdo it, but when I stumble onto a really useful doodad, I like to post it here in hopes someone else will find it useful. --John Michael CPO - John Michael   12/8/2002 Saludo de Navidad y Fin de Año. Ciudad de Mexico 23 de Diciembre, 2002. Estimado John Michael, CPO, FAAOP, FISPO: La Sociedad Mexicana de Ortesistas y Protesistas A. C., y Correos en Español le envia un afectuoso saludo con motivo de las fiestas de Navidad y de Fin de A... read more - Alberto E. Castillo Moreno O.P.   12/22/2002 Re: Saludo de Navidad y Fin de Año. Sr. Castillo- It has been my pleasure to collaborate with cherished friends and colleagues of SMOPAC, and throughout Latin America. Your excellent translations have been invaluable in furthering our dialog and this yeoman's effort is grea... read more - John Michael   12/22/2002