Report from the Academy Meeting in Orlando, Part One: Overview and Thrandhardt Lectures
The 2005 Academy Annual Meeting concluded slightly more than one week prior to the posting of this Corner. This was one of the best-attended meetings in memory, and a noteworthy program for several reasons.
To begin with, this was the first collaborative venue between the Academy and the Association of Children's Prosthetic Orthotic Clinics. By all accounts, having one registration cover admission to scientific sessions at both meetings enriched both programs. Although I had too many Academy responsibilities this year to sit in on the ACPOC sessions, everyone I spoke with confirmed that they were consistently lively, well organized, and clinically useful. I particularly like the multidisciplinary focus of ACPOC with joint presentations by physicians, therapists, and prosthetist-orthotists all of whom specialize in pediatric rehabilitation. But, I don't attend the ACPOC meetings regularly because peds has never been my sole clinical interest. The opportunity to sit in on selected ACPOC sessions at a joint venue every few years would interest many practitioners, so I hope this format will be repeated in the future.
Another enhancement to this year's program was to significantly expanded programs targeted to technicians and fitters. I participated in the two-day technician program, and it was well attended. Much of the content was derived from the Academy Advanced Seminar on Material Science and Patient Safety, and engineer Bill Contoyannis from Australia did a stellar job, packing his presentations with both scientifically verified information and Aussie slang. I can't remember the last time any organization offered two consecutive all-day sessions with this depth of material for technicians, let alone footed the costs to have an expert from the other side of the world share such information without a steep additional registration fee.
The exhibit hall was packed with tabletop displays. But, for the first time in decades, I was unable to find enough time to look at everything being offered. There was no real "buzz" about any innovations this year, and all of the items I saw were either familiar or new wrinkles on old themes. I understand there was a new articulated partial finger prosthesis being shown but I didn't make it to that display before the exhibit had ended.
Thranhardt Lectures
The quality of the Thranhardt lectures continues to steadily increase, and the majority of this year's talks were scientifically sound in addition to being clinically relevant. The meeting room was packed, with standing room only much of the time. Don Katz CO was the first Thranhardt lecturer, and his presentation was short, sweet, and absolutely to the point. The Influence of How Much a Scoliosis Orthosis is Worn and its Ability to Prevent Curve Progression in Adolescent Idiopathic Scoliosis was also one of the most scientifically solid and well conducted examples of clinical research that I have ever heard. I believe this is landmark work that will become a classic article documenting the effectiveness of proper orthotic management in altering the natural history of adolescent idiopathic scoliosis.
Don's protocol was deceptively simple but very well thought out and implemented. His collaborators at Texas Scottish Rite Children's Hospital developed a self-contained temperature sensor that was incorporated into a large number of custom TLSO body jackets in a prospective, blinded study investigating the relationship between dosage in hours worn and the outcome in AIS curve control over several years. The published study will detail the specifics of their results, but the key finding that Don reported was that for patients with Risser 0-1 skeletal maturity, the outcome of arrested curve progression correlated directly with compliance with wearing the orthosis. These data were both clinically and statistically significant and provided the best evidence yet that our clinical impressions regarding the importance of patient compliance are well placed.
Like all good research, Don's work also challenged some of our cherished but untested assumptions. One example was that even the most compliant patients in his series actually wore the orthosis far less than instructed to do so, and this included those permitted part-time wear too. Patients, parents, physicians and practitioners all significantly over-estimated the actual wear time confirmed by the sensor apparatus supporting the growing suspicion that self-reported wearing schedules are not very accurate.
The TSRCH data also demonstrated that the correlation between wear time and outcome was not as significant for Risser 2 patients, raising the question of whether we should be treating younger patients more aggressively rather that recommending "watchful waiting" until the curve has progressed > 5 degrees and they are more skeletally mature.
Ted Thranhardt CPO[E] himself was in the audience, and he whispered to me immediately after Don's presentation, "Every practicing P&O in the country should receive a copy of that paper and make copies available to patients and funding sources". I couldn't agree more, although I would amend Ted's suggestion by adding that every P&O in the world should study this important work. I presume this will be submitted to the Journal of Bone & Joint Surgery, so it should appear in print sometime next year. Watch for it!
Tim Littlefield, MS presented a very well organized talk on Post-Operative Use of the Cranial Remodeling Orthosis. This is a rapidly evolving aspect of orthotic practice that is quickly moving from niche care in specialty centers to mainstream orthotic management. Tim's preliminary study supported the hypothesis that application of a cranial orthosis for infants with certain types of severe head deformity could reduce the severity and cost of skull surgery as well as accelerate and improve the post-operative remodeling of the cranial vault. Enhancing the clinical outcome while reducing health care costs is the mantra for this millennium, and Tim's systematic approach to documenting his observations is a good example of how to document such potential. He also did a very nice job of buttressing his objective data with more subjective information such as digital images of the children's skulls from varying perspectives, noting that the images often gave a more comprehensive sense of the overall improvement that did the "hard" data in isolation.
Don and Tim's papers were the winners of the Thranhardt Award for this year, and well deserved it. Interestingly, both gentlemen recently participated in State of the Science Conferences on each of these topics, as part of the Academy's Project Quantum Leap initiative. The results from these national expert conferences have now been published as Supplements to the JPO and converted into online Professional Continuing Education courses that are available 24/7 on the Academy's web site: www.oandp.org . The interested reader is referred to those sources for more detailed information about these methods of orthotic management.
Avinash Patwarden PhD reported on his basic science investigations into the Effect of Spinal Extension on Restoring Geometric and Loading Alignment of the Thoracic Spine with a Vertebral Compression Fracture. This thorough cadaver study measured the efficacy of spinal hyperextension and balloon kyphoplasty in restoring stability to the thoracic spine following compressions fracture.
Balloon kyphoplasty is an increasingly popular treatment for compression fractures, and it works by essentially "jacking up" the spine pneumatically and then holding it until quick setting resin hardens to hold it in the corrected position after the balloon is deflated and removed. Extension alone [which might be achieved by the use of an orthosis] increased the height of the anterior vertebral body but was not as effective as surgical intervention at restoring the height of the middle of the vertebrae. However, extension plus balloon kyphoplasty resulted in the most complete correction in all three columns, so this may be a fruitful avenue for application of the Posterior Shell TLSO and similar spinal devices. Further clinical studies will be needed to see if they corroborate these cadaver results. I assume Pat will publish his work in the Journal of Rehabilitation Research & Development shortly.
Jason Kahle CPO discussed his efforts to conduct a Comparative Analysis of Microprocessor Controlled and Mechanically Controlled Prosthetic Knee Joints. This was a very ambitious undertaking that unfortunately wasn't very rigorously constructed but it did suggest a number of promising areas for future scientific investigation. One fundamental flaw in the protocol was that the comparisons were between a convenience sample of patients with existing prostheses needing replacement containing a hodge-podge of components versus the same patients with a new, well-fitting prosthesis containing the Otto Bock C-Leg who had undergone recent gait training. As a consequence, the results demonstrated only that having a new, well-fitting prosthesis plus gait training is generally better than having an old prosthesis and no gait training. It was impossible to ascribe any improvements to the knee component alone since so many other variables were changed, including the ankle, foot, socket, suspension, therapy, etcetera.
Despite this shortcoming, several elements of Jason's approach might be useful in future more carefully controlled studies. He created a numeric scale to record the patient's ability to descend stairs and ramps. Although this new scale was not validated, it did seem to correlate well with observational video gait analysis. It might be fairly straightforward to test the scale against force plate and motion data during stair and ramp descent an instrumented gait laboratory. If there were strong correlations between objective data and the subjective numerical scale, this would increase the credibility of this measurement tool and encourage its use by other clinicians.
Jason also used the Prosthesis Evaluation Questionnaire instrument as one of his measures, which has been validated for the amputee population, and the results confirmed his clinical impression that many patients were more functional with a new prosthesis plus gait training than before. Clinical use of such formal outcomes measures increases confidence in our clinical observations, and will likely become more commonplace in the future.
One intriguing observation Jason mentioned was that 3 of the 4 patients in his sample who had congenital anomalies rejected the microprocessor-controlled knee while the overwhelming majority of those with acquired amputations preferred its function. This bears further investigation because this has not been previously reported in the literature, and there are a number of anecdotal reports of success by this population with microprocessor-controlled knees. It may be that people with congenital absences require different adjustments, alignment, or performance characteristics than other patients, perhaps due to the hip joint and muscular abnormalities that are often associated with congenital malformations. It might also be that another type of microprocessor-controlled knee would perform differently than the tested components, which were all from the C-Leg system. The audience seemed very interested in Jason's experiences so this talk certainly stimulated many discussions on the differences between microprocessor-controlled and non-microprocessor-controlled knees.
Part Two of the Report from the Academy meeting will continue in the next corner with highlights from the microprocessor-controlled knee, bilateral lower limb amputee, and advanced education and clinical practice symposia. Part Three will conclude this series with selected information from the free papers on orthoses and prosthetic outcomes.
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