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VI Nordic P&O Congress in Iceland - Part One

I had the honor in early October of being an invited speaker at the Nordic P&O association's annual meeting, along with Dr. James Gage and Dr. Nerrolyn Ford. This year's Nordic Congress was the first ever held in the capital city of Iceland. Apparently there was some discussion among the organizers whether or not the requirement to fly in from the other Scandinavian countries would reduce participation, but in view of the overflow attendance these concerns were clearly unfounded! In fact, so many people came to the opening ceremony and the plenary keynote presentations that attendees had to walk a few blocks to a nearby hotel with an auditorium large enough to hold all 350 registrants. [The concurrent sessions were all held at the official hotel where we stayed.]

It would be nice like to think the superb attendance was strictly due to the quality of Jim Gage's talk and my own, but it is quite certain that the decision by the President to attend this session was certainly a major draw. Not only did President Ólafur Ragnar Grímsson welcome everyone to the meeting and make a short introductory speech, but he also remained for the entire morning session and listened intently to Dr. Gage's presentation. I couldn't help but wish that the United States' President understood the value of prosthetic and orthotic rehabilitation as highly as the Icelanders' leader obviously did.

James R. Gage, MD

Dr. Gage gave an excellent keynote address titled How Gait Analysis Has Changed Treatment of Cerebral Palsy, a topic that is near and dear to his heart. As always, his brilliance as a teacher shone brightly since he summarized the key findings in a very complicated area and made it easy for the audience to follow his trend of thought. [For more information on this general topic, Jim's Gait Analysis in Cerebral Palsy remains a classic text that is surprisingly understandable. It is usually available at Amazon.com. By the way, my comments will be noted in brackets in this report, to distinguish them from those of the speaker.]

In many ways, this was a retrospective review of how CP treatment had evolved at Newington Children's Hospital from the 1970s to the present time. Jim's assessment of orthopaedic management of Cerebral Palsy in that era was that, "We had old methods, old tools, and poor outcomes - and we really didn't know what we were doing". [It takes a courageous professional to admit the shortcomings of accepted practice. In many ways, these same criticisms can be applied to prosthetic and orthotic management too.]

Among the aphorisms Jim offered was the following quite from his mentor, Dr. James M. Cary:
PRINCIPLES OF TREATMENT OF THE HANDICAPPED CHILD:

1. Define the end product in terms of long-range treatment objectives.
2. Identify the patient's problems, both immediate and future, with precision.
3. Analyze the effect of growth on the problems - with and without the proposed treatment.
4. Consider valid treatment alternatives, including non-treatment.
5. Treat the whole child, not just his motor-skeletal parts.

Another pearl from the talk was this quote from A. Bruce Gill in 1932: "Study principles, not methods. If one understands the principle, one can devise one's own methods." He went on to persuasively argue that, until clinicians can objectively measure the results of their treatments, they cannot insure that they are offering optimal treatment. [This challenge too can be directed to P&O professionals.]

In the 1970s, clinical gait analysis was largely non-existant although Dr. Sutherland and colleagues in California were on the forefront in this regard. After visiting their laboratory, Dr. Gage convinced the Newington hospital to accept the challenge to develop automated gait analysis equipment. From hindsight, he know realizes that he underestimated the costs of accomplishing this goal by many fold! But, they raised funds and accepted donated equipment, ultimately creating the model for all future gait labs, where the results are available shortly after the patient's examination - rather than several week's later, as was the case when data was manually tabulated.

Once objective gait data had clarified the multiplanar deformities and motion disturbances in a specific child with CP, Gage and colleagues were better able to identify which problems were primary, and which ones were compensations that would disappear once the primary deficit was addressed effectively. This is an excellent presentation for any allied health professional to listen to in its entirety, but suffice to say that Computerized Gait Analysis [CGA] ultimately led to the identification of such important clinical concepts as Lever Arm Dysfunction, the value of Rectus Femoris m. transfers, and the replacement of serial annual "birthday surgeries" with one procedure that simultaneously corrected all problems at all joints in both limbs. The key to all of these advances was the objective data that allowed surgeons to more precisely identify the cause of gait problems, and to predict the long term outcome with a high degree of accuracy.

In many ways, CGA was considered impractical by many surgeons because it wasn't clear thirty years ago how it would help. But, from hindsight, it has proven to be invaluable in validating new treatment methods such as botox injections and dorsal rhizotomies that were unimagined at that time. [Those naysayers who doubt that CGA can improve P&O care should remember this lesson: it may be the key for our profession, too, when future techniques and methods suddenly appear.]

Jim ended his first keynote by observing that, "Clinicians generally have lots of questions but none of the answers. Engineers often have lots of answers but don't know what questions to ask." He concluded that the best results occur when clinicians and engineers actively collaborate so the important questions are answered first.

John Michael MEd, L/CPO:

My first keynote was a modified version of the talk that Marty Carlson MSE, CPO originally developed for Tamarack Habilitation Technologies, Inc. titled Etiology and Prevention of Skin Trauma from Repetitive Loading. In summary, this presentation reviews the literature on blisters, and discusses the interactive effects of normal loading [pressure] and the coefficient of friction on the shear stresses applied to human skin. The take-away point is that clinicians can reduce shear stress two ways:

1. By reducing the pressure applied -or-
2. By decreasing the coefficient of friction

For many P&O applications, the pressures are corrective and therefore desirable, so the introduction of a low-friction interface is often the most effective alternative.

Most of the PowerPoints from this meeting, including both of my talks, are to be posted online at www.fsf.is, and can be accessed by clicking on the Nordic Conference icon in the upper right corner of the welcome page. The self-stick PTFE sheets that Marty developed are called "ShearBan", and are available from Becker Orthopedic, Inc. and from Camp Scandinavia. Additional information is posted on the Becker web site.