Prosthetics and Orthotics

JPO Editor's Comments No abstract available

Performance of a Sensor to Monitor Socket Fit: Comparison With Practitioner Clinical Assessment Introduction A sensor that detects changes in prosthetic socket fit before they manifest clinically may be helpful towards rehabilitation after limb amputation. Materials and Methods Participants with transtibial amputation walked on a treadmill wearing a motor-driven, cabled-panel adjustable socket. Socket volume was slowly adjusted away from the neutral socket volume (panels flush). The percent socket volume change at which the practitioner, using visual assessment, first noted fit issues was compared with the percent socket volume change at which the sensor first detected a measurable change in fit. Results The median percent socket volume change at which the sensor first detected a measurable socket enlargement (0.50%) was significantly less than both the median percent socket volume change at which the research practitioner first noted a change in fit (1.69%) (P = 0.008) and the median percent socket volume change at which the participant would normally add a sock (2.30%) (P = 0.005). During socket reduction, the practitioner noted a change in fit before the participant would normally remove a sock in only 2 of 10 participants. The median percent socket volume change at which the sensor first detected a measurable socket reduction (−0.44%) was significantly smaller in absolute value than the median percent socket volume change at which the participant would normally remove a sock (−2.76%) (P = 0.005). Conclusions The sensor detected controlled socket fit changes before the research practitioner in this study. A next step will be to determine if the sensor detects unforced socket fit changes, and changes in user free-living environments.

Parental Perception of Cranial Orthotic Treatment for Infants with Deformational Plagiocephaly Introduction The objective of this study is to increase understanding of the parents' experiences while caring for their infants during cranial orthotic treatment for deformational plagiocephaly. Methods This study is a qualitative descriptive study consisting of interviews focused on parental perceptions of the experience caring for their infant during treatment. Data were analyzed using conventional content analysis. Results Ten parents participated in this qualitative study. Data revealed the pattern of a journey related to caring for an infant undergoing cranial orthotic treatment. Parents described the journey as consisting of the following phases: "making the decision," "acclimating to the cranial orthosis," "developing a routine," "seeing results," and "envisioning the future." Minor nuisances and concerns were present throughout treatment. Discussion With initiation of cranial orthotic treatment, parents expressed some reservations. As treatment advanced, parents discussed their journey more positively as their infant's head shapes improved. The availability of support, someone to answer questions, and patience facilitated a successful journey. Seeing the change in head shapes reinforced continuing with treatment.

Bracing to Treat Dropped Head Syndrome in Cancer Patients: A Retrospective Review Introduction The objective of this study is to describe the use of postural bracing to treat dropped head syndrome (DHS) in cancer patients. The study design is a retrospective review over a 3-year period of cancer patients who presented to a cancer physiatry outpatient practice for treatment of DHS. Patients were individuals with a history of head and neck cancer, Hodgkin lymphoma, or other cancer with a diagnosis of DHS. Materials and Methods The treatment intervention was postural bracing with either a figure-of-eight orthosis with or without a lumbosacral orthosis or a thoracolumbosacral orthosis. Results Subjective, patient-reported improvements in pain, posture, and neck or back strength in addition to objective improvements in physical examination were made. Out of 41 patients initially evaluated for DHS who followed up in brace clinic, 61% reported a positive response to bracing with 17.1% reporting improvement in neck or back strength, 17.1% reporting improvement in pain, and 39% reporting improvement in posture. Discussion In this study, we present a successful alternative to treat DHS through the use of active bracing. The technique of active bracing in this population theoretically strengthens the weak muscles in head drop and improves head position. Maintenance of these achievements, although not directly studied in this project, must be performed through a regular home exercise and bracing program as patients likely have a tendency to weaken again given prior oncologic treatments. Conclusions Active postural bracing using a combination of a figure-of-eight brace with or without a lumbosacral orthosis or a thoracolumbosacral orthosis in conjunction with physical therapy can help improve the posture, pain, and neck and back strength of cancer patients with DHS.

Impression Methods for Custom Foot Orthoses—Comparing Semi–Weight-Bearing Foam and Non–Weight-Bearing Plaster Using a Kinematic Measurement of the Medial Longitudinal Arch INTRODUCTION One of the goals for custom foot orthoses (CFOs) is to provide relief for pressure-sensitive areas and provide support to the joints of the foot for an optimal weight-bearing position. The most common CFO impression methods used by practitioners include plaster bandage, foam box, fiberglass, and laser-optical scanning, and are often compared by measuring foot molds created from those methods. The objective of this study is to compare the biomechanical effects of CFOs made from two common casting methods using skeletal kinematics. MATERIALS AND METHODS The medial longitudinal arch (MLA) angle was measured for 13 participants of different foot types: five pes planus, four pes cavus, and four normally arched. Four conditions were compared: barefoot, shod, and CFOs made from both semi-weight-bearing foam and non-weight-bearing plaster casting methods. The MLA angle was measured from three-dimensional bone models using biplane fluoroscopy images during midstance. RESULTS Foam (P = 0.02) and plaster (P = 0.01) cast foot orthoses were significantly different from the barefoot condition, and the shod condition was significantly different from both foam (P = 0.004) and plaster (P = 0.014) cast orthoses. No statistically significant differences were found when comparing the two casting methods: non-weight-bearing plaster and semi-weight-bearing foam (P = 0.170). CONCLUSIONS Clinicians favoring one particular style of casting can feel confident, for the patient set described, that either choice will produce similar biomechanical outcomes with respect to foot kinematics.

A Two-Dimensional Mathematical Model to Simulate the Effects of Knee Center Misalignment in Lower-Limb Orthoses Introduction Pistoning is relative sliding motion between an affected limb and its corresponding externally fit assistive device (like an orthosis). Pistoning causes skin problems, pain, and discomfort to the orthosis user. Misalignment of an orthotic joint with respect to the anatomical joint is one of the causes of pistoning motion, and the current knowledge pertaining to the effects of orthotic knee center (OKC) misalignments in lower-limb orthoses is limited. This work quantifies the effects of OKC misalignment in terms of relative motion between the limb and the orthosis and predicts locations of resultant pressure point on the limb. Method A two-dimensional link segment model that simulates relative motion between the limb and orthosis was developed. The OKC was systematically misaligned in the anterior-posterior (A-P), proximal-distal (P-D) directions, and their combination to simulate orthosis/thigh strap sliding and identify pressure points on the thigh. Simulations were performed for stand-to-sit activity and walking with a knee-ankle-foot orthosis. Results It was found that OKC misalignment causes increased A-P and P-D relative motions with an increase in misalignment distance for the stand-to-sit activity. The A-P and P-D relative motions are of greater concern for activities involving increased knee flexion such as sitting, squatting, and kneeling as compared with walking with an orthosis. Although the A-P and P-D relative motions during walking are of small magnitude, they occur with reversals in the direction and are repetitive in nature, which may cause skin problems and discomfort due to recurring pressure points. Conclusions The model provides a means to study the consequences of misalignment and insights for orthosis modification for improved comfort. A software simulation tool based on the presented model can serve as an educational and training tool in prosthetics and orthotics courses for creating awareness about the importance of proper alignment of orthotic knee joints. Study of misalignments of this nature will also guide fabrication and fitting of lower-limb orthoses/exoskeletons.

Does Propulsive Force Asymmetry during Gait Provide Additional Objective Functional Information to Augment the Traditional Assessment of Prosthetic Fit? Introduction A poorly fitting prosthesis can cause pain and result in a less efficient and a less symmetrical gait pattern for children with amputations; however, fit is generally determined by subjective patient reports of discomfort and/or clinical observation when walking. The purpose of this study was to determine if peak propulsive forces during gait provide clinically relevant objective information to augment the traditional prosthesis fit assessment. Materials and Methods This prospective study compares propulsive force asymmetry with traditional assessments of prosthesis fit. Subjects were between 4 and 21 years of age, with unilateral lower-limb deficiencies, currently wearing the same prosthesis for at least 1 year, and able to walk independently without an assistive device. The absolute asymmetry indexes of peak propulsive forces between the involved and uninvolved limbs were calculated from force data collected from three trials of overground walking at a self-selected velocity. Asymmetry indexes greater than 36.4% were considered clinically meaningful and were associated with poor prosthesis function. A physician and/or a prosthetist, blinded to the results of the gait assessments, then determined the quality of prosthesis fit. Results Thirty-one subjects (20 males, 11 females; mean age, 13.1 years) participated. The traditional prosthetic fit assessment identified 13 prostheses as properly fitting and 18 as poorly fitting. Peak propulsive force asymmetry exceeded the threshold of 36.4% for 15 subjects and categorized as functioning poorly. The proportion of positive agreement of correct fit and correct function was 71% (κ coefficient = 0.42). Conclusions Peak propulsive force asymmetries offer clinically meaningful objective functional data to augment the traditional fit assessment.

An International, Multicenter Field Trial Comparison Between 3D-Printed and ICRC-Manufactured Transtibial Prosthetic Devices in Low-Income Countries Introduction The gap between the needs of individuals with amputation and access to prosthetists in low-income countries (LICs) is significant. Training new personnel to bridge this gap would exceed the current output of all prosthetic and orthotic programs globally. Strategies are needed to increase the productivity of existing prosthetists in order to serve more patients. Emerging technologies such as 3D scanning, modeling, and printing have been investigated for their ability to decrease the manufacturing time for prosthetic devices; however, few studies have compared the efficacy of 3D-printed devices to traditionally manufactured (e.g., International Committee of the Red Cross [ICRC]) devices. Studies that previously compared these two methods were limited by low population size and restricted timeframes. The purpose of this study was to gather evidence comparing the efficacy of 3D-printed and ICRC transtibial prostheses in large patient populations in LICs over time. Materials and Methods A total of 61participants between the ages of 5 and 25 completed this study's 8-week trial. Participants were recruited from four clinical sites in Uganda, Tanzania, and Cambodia. Ethics approval was obtained from each of the four clinical sites before study initiation. Consent was obtained from each participant before study enrolment. The participants' residual limbs were 3D scanned by local prosthetists using hand-held 3D scanners. Prosthetists digitally rectified the 3D scanned models using Canfit and NiaFit 3D modeling software. The rectified models were fabricated using 3D printers. 3D-printed devices were lined with foam liners and coupled to standard ICRC pylons and feet. Participants used the 3D-printed sockets for 4 weeks, then returned to the clinic to complete a 28-question Likert scale questionnaire, assessing their experiences with their 3D-printed devices. Surveys were based on the Prosthesis Evaluation Questionnaire. Participants were then given a new transtibial prosthetic device manufactured using traditional ICRC methods and instructed to use this device for 4 weeks. They then returned to the clinic to complete the questionnaire as aforementioned. Responses from both surveys were assessed using a two-tailed Student t-test (P < 0.05). Results Data from the Tanzania Training Centre for Orthopaedic Technologists (n = 10) indicated that their users rated ICRC devices significantly higher in categories measuring stability, including ability to walk, walking up steep slopes and stairs, walking on slippery surfaces, overall fit, comfort while standing, and texture of the device. In contrast, participant data from Comprehensive Rehabilitation Services in Uganda (n = 25), Cambodian School of Prosthetics and Orthotics (n = 10), and Comprehensive Community Based Rehabilitation in Tanzania (n = 16) showed no significant differences across all measured outcomes. Conclusions This is the first study to compare and contrast the efficacy of 3D-printed and ICRC transtibial prosthetic devices across geographic locations in LICs with a large study population. Results demonstrate that, in general, 3D-printed devices were rated comparably to ICRC. This result was consistent at three of four clinical trial sites. Further studies will be required to elucidate the rating differences observed at the fourth site.

Use of Myoelectric Limb Orthoses for Elbow Flexion in Patients with Brachial Plexus Injury: A Case Series Introduction Myoelectric limb orthoses (MLOs) are powered devices that assist with specific motions in patients with neuromuscular deficits or inadequate motor power. MLOs enable patients to self-initiate and control movements using their own muscle signals. While these devices have been used for patients that have sustained neurologic deficits from cerebrovascular accidents, their use in traumatic adult brachial plexus injuries is novel. Materials and Methods This case series presents three patients with traumatic brachial plexus injuries treated with MLOs to improve elbow flexion after inadequate recovery. The MLO was used as both a rehabilitation device and a functional device. Results/Conclusions MLOs demonstrate potential for improving patient clinical outcomes and satisfaction after brachial plexus injuries with incomplete recovery or inadequate function after surgical intervention.

Oxygen Consumption and Speed Performance of a Runner with Amputation Wearing an Elevated Vacuum Running Prosthesis Introduction Persons with lower-limb differences are increasingly seeking out a means to participate in sport and running activities. Suspension of the running-specific prosthesis (RSP) during high-intensity running is crucial for safety and optimal running performance. The vacuum-assisted socket system (VASS) provides enhanced proprioception and residual limb volume stability during walking; however, utilization of the VASS in an individual fit with an RSP has yet to be explored in case or empirical studies. We report outcomes of a recreational running transtibial prosthesis user wearing a novel VASS-RSP. Methods A 33-year-old man with transtibial amputation was provided an RSP with a VASS and performed outcome measures while wearing the VASS-RSP and non–VASS-RSP. He performed a series of straight and counterclockwise (CCW) curve track 40-m runs while speed gates recorded split and total time. The patient also performed a 10-minute treadmill run oxygen consumption was determined, and Socket Comfort Scores (SCS) were recorded. Results No significant differences in track running trials were observed; straight track running speeds were similar VASS (5.37 ± 0.06 m/s) and non–VASS-RSP (5.37 ± 0.16 m/s), [t(1) = 0.320, P = 0.979]. Curve track speeds improved while wearing the VASSRSP (4.72 ± 0.09 m/s) compared with the non–VASS-RSP (4.66 ± 0.03 m/s) [t(2) = 0.846, P = 0.487]. Speeds were significantly faster during straight track running (5.37 ± 0.08 m/s) than during curve track running (4.70 ± 0.07 m/s) when both RSP configurations were combined [t(4) = 15.8, P = 0.001]. Net oxygen consumption reduced while wearing VASS-RSP (24.6 mL/kg per minute) compared with non–VASS-RSP (29.2 mL/kg per minute). Socket comfort during outcome measures improved 33% while wearing the VASS-RSP. Conclusions The patient preferred using the VASS-RSP while performing running exercises, and some outcome measures comparing the two suction suspension systems support the patient values. The novel VASS system should be further tested to determine potential utility for running exercise and sport interventions for persons with amputation.

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

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