Report from the Academy Annual Meeting - Part 1
Clinical Sessions
The structure of the Academy meeting has evolved in recent years to parallel the structure used by ISPO, with sessions designated as Instructional Courses, Free Papers, Clinical Techniques, Professional Development, Certificate Programming and so on. I like this organization because it clusters presentations on similar themes together and encourages more comprehensive coverage of a given topic with a specific focus. Since the Academy meeting continues to grow and prosper, presumably other attendees feel the same way.
The Academy has also been willing to try new formats, almost every year, to see what might work better than the customary approach. This year, the opening plenary sessions were held in a separate theater setting just down the street from the conference hotel and a free breakfast was included as an added incentive to get everyone "up and at 'em" by 7:30AM. The room was jam-packed with many standing around the perimeter, so the basic concept was good. Unfortunately, the logistics for the breakfast didn't work forcing people to choose between standing in a long, slow line for the meal or hearing the presentations. To their credit, the great majority chose "food for thought" and skipped breakfast.
As always, it was impossible to attend all of the concurrent sessions so the summaries that follow are not intended to represent the "best" presentations. Instead, they reflect my personal interests and those sessions that did not conflict with other responsibilities such as meetings regarding the Academy grant projects.
Thranhardt Lectures
The plenary session opened with the premier of a new, very professionally produced DVD titled "Making a Career of Making a Difference: The Sky's the Limit". Unfortunately, in what was a harbinger of things to come, the video abruptly stopped playing after a few minutes due to the first of a never-ending series of audiovisual glitches. In addition, all the presentations were slightly out of focus and the aging projector bulb was so dim and yellowed that it was impossible to see fine detail in the images. [I later learned that the hotel insisted on using their own AV contractor, who was much less professionally competent than the group the Academy normally contracts for these services.]
Academy members will have received a copy of the video, which was produced as one of the efforts funded by the Academy grant from the Department of Education to recruit more good candidates to enter the profession by applying to our existing schools, in the mail by now. Everyone else can take a look for themselves by streaming a low resolution version at the Academy web site.
Michelle Hall CPO was the first Thranhardt lecturer, and she did an excellent job of summarizing some of the results from her very ambitious Resident survey about "Dermatological Problems with Liners". Between 2000 & 2005, Michelle mailed nearly 400 surveys to patients of the facility where she works in Iowa to investigate their self-reported problems with various gel liners. Respondents were offered a free examination by a dermatologist. Of the 110 who responded, the majority were Caucasian males, with the etiology of amputation split about equally between trauma and vascular disease.
More than 90% reported some sort of minor problem such as red skin, itching, or odor upon removal of the liner. Interestingly, although there was no correlation shown with the type of soap used, individuals who washed the residual limb more than once per day had a higher incidence of reddened skin. Contrary to the typical instructions given by manufacturers and repeated by prosthetists, the cohort who washed their residuum in the morning reported less problems with sweating and odors. Factors that had no statistically significant impact on the frequency of complaints included liner type, brand, thickness, method of tethering - or how often the patient washed the liner.
Some positive correlations were found. Amputees with diabetes or vascular disease reported less problems due to sweating while individuals with a higher activity level had more ingrown hairs and itching. Fair skinned patients who stated that they "burn, then blister" in the sun were more likely to complain of odor from the liner. High cholesterol levels correlated with complaints about heat rash and reddened skin.
This lecture was a great illustration of the impact that even a novice practitioner can have as we move toward Evidence Based Practice [EBP]. Michelle's study suggests that washing the skin too often should be discouraged and that washing the liner daily is less critical than commonly believed. It also raises questions about the traditional advice to "wash your limb at bedtime", at least for the cohort who are concerned about odors or sweating. If her results withstand scrutiny when they are published in the Journal of Prosthetics and Orthotics later this year, and if they are corroborated by subsequent investigations, we can begin to offer patients advice about liner care that is based on science and not just instructions developed by the manufacturers' marketing departments.
Mark Geil PhD followed up his interest in measurements and data with a straightforward experiment that compared the accuracy of several commercially available prosthetic digitizers with traditional hand measurements. All subjects measured a residual limb analogue made from a rigid polyurethane "transtibial" shape covered with a gel liner.
The results will be published later in the year, but showed similar overall accuracy between students who were trained to take proper measurements and experienced practitioners, although there were wide variations from person to person. All the hand tools investigated [e.g. cloth tape, ML gauge, etcetera] were accurate within 1/10 of a millimeter, except the VAPC caliper - which had a significantly inaccurate scale. [When I attended Northwestern in the mid-1970s, we were taught to ignore the VAPC scale and take a direct measurement between the two arms, but I didn't understand the purpose at the time.]
Measurements taken by the digitizers investigated correlated well with the hand measurements and were very similar to one another. The largest discrepancy was 3 millimeters +/-, leading Mark to suggest that the use of a digitizer would save sufficient time to justify routine use even if the practitioner elected to create the positive model without the use of Computer Aided Manufacturing [CAM]. The biggest source for discrepancies in both hand measuring and digitizing was errors in orientation of the measurement device: operator errors. So, high tech or low tech, careful attention to detail is required to get accurate data for the creation of a well-fitting prosthesis or orthosis.
Stance Control Orthoses: Case Studies
Gary Bedard CO made a valiant effort to report on a case study using of the Gait-Rite mat to measure spatiotemporal changes in gait when using a stance control orthosis [SCO]. Unfortunately, a series of AV glitches forced him to stop, restart, and ultimately to terminate his presentation until later in the program. When he returned, Gary showed a video demonstrating that the UTX SCO eliminated a mid-stance knee hyperextension "snap", and results indicating that the aberrant spatiotemporal measures were all normalized with the KAFO. The Gait-Rite software also calculates a Functional Ambulation Score, which showed similar improvement.
Keith Smith CO followed with more details on a patient he has fitted with a combination RGO and bilateral Horton's SCOKJ KAFOs, who sustained a T11 complete ASIA A spinal cord injury after a motor vehicle accident. Visual gait analysis of the video clips made it clear that this patient's ambulation become immediately and markedly more normal in the stance control [SC] mode. The instrumented gait laboratory studies confirmed and amplified this clinical observation, indicating that the patient walked approximately twice as fast in the SC mode with twice the stride length. In addition, single limb support time increased and his hip flexion range of motion more than doubled. While this was a very impressive result, the SC RGO combination enabled him to walk a 20% of a normal pace, so the gait had improved from incredibly slow to slow. Keith went on to demonstrate similar results using this approach with two additional cases.
Ken Kaufman PhD from the Mayo Clinic reported on changes in the gait pattern of patients who used the "Dynamic Knee Brace System" that he has developed and patented. In the developmental trials, he recruited a very severely involved cohort of patients, with half weighing more than 220 pounds. Despite having marked lower limb joint contractures, almost all subjects demonstrated clearly improved gait mechanics with the SCO. Average walking speed improved by three months post-fitting and that improvement was maintained at six month follow-up. Those who had previously worn a locked knee KAFO did not show much improvement in knee flexion angle until the six month measurements, suggesting that they needed significant time to overcome the compensatory gait deviations developed from the use of older style orthoses. Novice wearers showed more normalized knee flexing during swing at three months, presumably because they had no "bad habits" to overcome.
Free Papers: Lower Limb Prosthetics
I joined this session starting with Magnus Lilja PhD's talk on "Skeletal Movement in Transtibial Sockets". This was a concise summary of a well crafted series of scientific studies showing quite clearly that the best suspension to minimize pistoning within the socket is osseointegration, where the components are connected directly to a surgical construct in the skeleton of the residuum. The second most effective suspension is a suction socket or a seal-in liner, which were equally effective. Roll-on locking liners with a distal attachment permitted significantly more tibial motion, while supracondylar wedges allowed more yet. Cuff or cuff and waist belt suspensions were not studied. As we move toward EBP, having such credible data available will be important to document the benefits of modern suspension alternatives.
Rick Riley CP highlighted his approach to creating a shower/swim prosthesis for transtibial amputees, preferring to create a laminated monolith attached to a SAFE II foot. Rick uses the wooden keel version, reporting good durability if he seals the keel surface and bolt hole with silicone adhesive. He noted the importance of allowing water to infiltrate and drain from a prosthesis used for swimming to maintain neutral buoyancy. Rick concluded his talk by pointing out that the term "swim leg" is a misnomer, since these are actually multi-purpose devices that also function as a "shower leg", "travel leg", "snow leg", "emergency back-up" and so on.
Kevin Carroll CP then presented a basic review of a clinical classification of prosthetic knee joints. He incorporated a series of video clips demonstrating the functional differences between various components.
Bob Gailey PT, PhD gave a very rapid-fire overview of recently published literature in support of the use of microprocessor-controlled prosthetic knees. He believes that unless patients receive specific therapy training, gait faults become exaggerated with mechanical stance and swing control knees, and speculated that those systems that permit knee flexion during loading response [stance flexion] may permit earlier unloading of the contralateral forefoot. For dysvascular patients who have an at-risk contralateral foot, this may have particular clinical significance.
Stan Wlodarczyk CPO was another victim of the poor quality audiovisual equipment at this meeting. He was unable to get an image from his laptop to the data projector, forcing him to try to describe the video clips he could see quite clearly on his screen. However, all the audience experiences was a disembodied voice and a darkened screen. He seemed to be advocating more routine use of elevated vacuum suspension but the details of his argument were not clear.
Exhibition Hall
The Academy exhibit hall has grown steadily over the years to rival the AOPA trade show. While this is good in some ways, it makes it increasingly difficult to find sufficient time to stop at each and every display table and still attend the scientific sessions. The highlights that follow represent those items that caught my eye, but once again I found it impossible to look at every single exhibit, so I may well have missed some interesting items.
One of the biggest surprises was to see that Otto Bock had a presence once again, after several years of exhibiting only at the AOPA meeting. However, they took a novel approach this year and did not send any sales representatives or folks from the marketing department to man their booth. According to Todd Anderson, CP, they decided that since the Academy meeting focuses on education, they would only have clinical educators attend. So, rather than having all their latest widgets on display, Bock brought many of their testing and measurement instruments such as the MyoBoy and offered on-the-spot education to interested practitioners in how to use these tools clinically.
Equally interesting, the table next to Otto Bock was manned by a transfemoral amputee on behalf of his law firm, Willoughby Doyle LLP. Conal Doyle successfully sued his insurance company to obtain coverage for his microprocessor-controlled prosthetic knee, which led him to realize that there is a need to represent other amputees that is not being met. Their lawyers are licensed to litigate in California, New York, Florida, Ohio, and the District of Columbia, working from offices on both coasts. To learn more about what they can offer your patients, visit www.amputeelawyer.com.
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The folks from KISS had a couple of nice additions to their clever line of lanyard suspensions with rotational control. One is the addition of low profile Velcro® to the mounting "placard" for their proximal D-ring assembly. This eliminates the need for a bonding process, which permits the prosthetist to vary the placard placement in response to changes in patient limb volume, toe out, or when liner replacements are required.
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They also have developed a very simple, ultra-light one-way expulsion valve that is bonded into a 17 mm opening in the transtibial socket to create a vacuum to provide atmospheric pressure suspension. Combined with the evidence reported by Magnus Lilja showing clearly that suction suspension minimized tibial pistoning, this should help encourage more routine use of this option for transtibial prostheses.
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Bob Radocy's TRS, Inc. continues to expand its line of clever upper limb activity-specific terminal devices [TDs] and related products. They were displaying a number of pediatric and adult sports and recreation-related innovations.
The familiar "Baha" harness cross point, which provides the same biomechanical advantage as welding two rings together or creating a cross-back strap, is now available in a pink color in addition to the original white pigment. Their line of infant and children's passive and active hand-like TDs are growing and available in multiple shades.
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The well-known line of "SuperSport" passive mitt TDs have been joined by a new mushroom-shaped TD designed specifically for tumbling activities. The existing line of baseball-bat holding options has been expanded by the new "Pinch Hitter".
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Two of the newest polyurethane-based TDs use a durable black rubber-like material to avoid scarring whatever is being gripped. The "Lamprey Gun Turret" cradles the stock of a rifle or shotgun, while the "Hammerhead Kayak T.D." grips a double-bladed paddle securely but has an integral quick-release.
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These terminal devices use tough, flexible polyurethane elastomer to grip a long gun (above), or a kayak paddle (below), without scratching them. The Kayak TD automatically releases under overload for amputee safety.
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The "Black Iron Master" uses a wing nut to provide a powerful grip for the serious weight lifter but offers no quick release. The "Criterium", on the other hand, is designed to clip onto bicycle handlebars easily to but to release immediately in case of a spill. One of the hallmarks of Bob Radocy's designs is that they are each optimized for specific tasks from both a performance and safety standpoint.
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This TD (above and below) is designed for the serious weightlifter, who can use the wing nut to really clamp down on the steel bar.
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Additional information, including video clips of these prostheses in use, can be found at The TRS, Inc. web site.
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The Becker line of stance control options continues to evolve and expand. They have produced a very nice brochure titled "Stance Control Overview Guide" that provides very well organized technical information on their entire line of 9000 series knee joints.
Their electronic knee joint has morphed into the Rehab E-Knee™, which is a hand-triggered version that connects a modular thigh & calf section to a modified walking boot. It can be used for evaluation of candidacy for a definitive E-Knee™ KAFO or as a gait training tool.
They have also introduced an intriguing wrinkle called "FullStride™", which is a reincarnation of the concept of inverting a bail lock so it can be released automatically by ankle dorsiflexion. This has been done in limited cases for many decades by a number of clever orthotists around the world, but never really caught on as a viable clinical alternative. Becker has redesigned the knee joint to have two spring-loaded locking positions, so even if the patient fails to fully extend the knee the joints will not collapse.
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This new knee joint from Becker (shown above and below) is a modified bail lock design that locks in full and partial flexion. It is installed inverted from the typical bail lock position so that pulling distally with a cable causes it to unlock. If the cable is attached to an articulated foot section, dorsiflexion can be harnessed to automatically release the knee in late stance, creating a simplified stance control KAFO.
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It is good to see that several SC options for orthotic patients are still commercially available, particularly in view of the growing body of evidence showing the benefits they offer for appropriate patients. It appears that the Medicare Alpha Numeric group's efforts to kill this technology were not fully successful and that the poorly worded L-Code and artificially low Allowable have only restricted access to beneficial technology while discouraging future innovations.
Renew was one of the new exhibitors at this meeting, probably because it appears to be an offshoot of Wayne Koniuk CP's San Francisco-based clinical practice and Central Fabrication service. They provide a wide range of elastomeric materials, suitable for fabrication in a P&O laboratory setting, using urethane and silicone resins in a range of durometers. They also have a proprietary alginate casting material.
They had a large number of interesting applications of their technology demonstrating the versatility of the materials, including custom silicone liners, partial foot devices, and various maxillofacial prostheses. Their web site offers many more examples and a good amount of technical information. They have also produced two "how to" DVDs that can be purchased, demonstrating step-by-step fabrication of custom silicone liners and partial foot slipper prostheses.
