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Description: Official Publication of Orthotics Prosthetics Canada

Alignment2017 3D Technology The Official Publication of Orthotics Prosthetics Canada Printing Impact and Effect on O&P Practice Today and Tomorrow Outcome Measures Electronic Medical Records Osseointegration Innovative O&P Solutions Continuing Education The War Amps Advocacy Program Alignment2017 C O N T E N T S Industry News 4 President s Greetings Dan Mead CPO(c) OPC President Executive Director s Message Dana Cooper MBA CAE OPC Executive Director MEC 2017 Orthotics Prosthetics Canada News Gait and Balance Academy 2017 FCBC Recipient C-Leg Celebrates 20 Years in Canada CPOT Reference Manual 6 8 104 Product Showcase New & Improved for 2017 118 Advertiser Index Continuing Education 10 The War Amps Advocacy Program 16 Incorporating Outcome Measures into Daily Practice 20 The Value of Electronic Medical Records in O&P Care 26 Critically Appraised Topics 94 Student Papers 115 Mandatory Continuing Education Program Special Feature Section 3D Printing Technology Impact and Effect on O&P Practice Today and Tomorrow 34 Advancing Digital Practice in Prosthetics and Orthotics Consortium 48 3D Printing is Coming to Our Clinics 50 Technician Perspective on 3D Printing Technology 54 Additive Manufacture of Orthotic Devices 64 Wrist-Driven Paediatric Partial Hand Prosthesis 68 Management of Infant Head-Shape Asymmetry O&P Solutions 74 Planting the Seeds Practitioner Patience for Patient Success 78 Osseointegration 86 An Unusual Case on the Rock 90 Scrap It A Green Approach to Team Building 92 Gap-Keeper The Riveter s Third Hand Clinical Team 30 Team Manager The Social Worker s Role on the O&P Team Deadline for submissions for consideration for publication in Alignment 2018 is December 1 2017. Cover image courtesy of Rehabilitation Centre for Children Photo courtesy of Boundless Biomechanical Bracing PRESIDENT S MESSAGE Collaborating for Change With every turn of the calendar we often consider the previous year in a nostalgic way surprised by how quickly it passed and all that has transpired. Many of us have plans motivations and dreams that thrust us ahead in a way that ensures the constant pace remains. However to reflect on change more deliberately can be very helpful when considering our next steps. Our society profession and our lives are always changing. Embracing this change with positive attitudes and cooperative minds is so important to a successful year. There are many Orthotics Prosthetics Canada (OPC) initiatives that we look forward to this year and we encourage all members to contribute to the ones that interest them. There are ways to get involved without joining a committee or the Board of Directors as we put together task forces and subject matter expert (SME) groups to work on specific projects. As we proceed with the OPC vision of leading the advancement of orthotics and prosthetics (O&P) we are strengthening our voice on emerging technologies and increasing our external relations efforts. We will be attending various stakeholder conferences such as Benefits Canada and the Family Medicine Forum as well as returning to the Canadian Health and Life Insurance Association conference. Alongside this effort to increase awareness with paying agencies OPC is also committed to solidifying other potential partnerships. The value of external relations to the profession cannot be over-emphasized and it begins with our own members. We all represent our profession. If you have the opportunity to represent our field in your community reach out to the National Office as there may be materials available for consistent messaging. We may also have fellow certifees in your area who are very familiar with OPC messaging and can lend support to overall professionalism. The Regional Council met in December 2016 and a commitment was made by all at the table to ensure that OPC and all O&P regions increase communication and collaboration for the mutual benefit of all patients and professionals within O&P. It was acknowledged that we are simply too small of a profession not to collaborate. We have also made a dedicated effort to work with our U.S. colleagues as much of our growth pathway follows in their footsteps. They have been very generous in sharing their knowledge and experience as we navigate the Exam Blueprint project and other important aspects of the pathway to Certification and Registration. This leads us to the next crossroad for the profession. OPC will be hosting a long-anticipated ISPO visit in the spring to consider the Category Status for Canadian Certification. We are also committed to establishing fresh dialogue and positions on O&P Education in Canada. We are hoping to achieve consistency across all pathways to certification and in order to do so we have made earnest efforts to initiate new dialogues with all relevant stakeholders. We will be hosting an Education Summit in the fall of 2017 a forum that will foster discussion and planning around O&P Education Residency Internship and the needs of school accreditation to help guide the profession in its policy and decision-making around these topics for years to come. As I consider the theme of the 2016 OPC Conference in Banff (New Heights - Fresh Outlooks) I am reminded that as a profession we are always striving for new heights . To get there we need to employ fresh outlooks. We appreciate all membership support and feedback throughout the implementation of these initiatives and we understand that we all may not agree with all OPC policies. We trust however that we still can continue to work together to achieve what we should all be working toward and that is what is best for our patients With this common goal in mind another successful year will fly by before we know it Dan Mead CPO(c) President Orthotics Prosthetics Canada 4 Alignment 2017 Edition The official publication of Orthotics Prosthetics Canada PUBLISHED ANNUALLY OPC National Office Dana Cooper MBA CAE Executive Director Sandra Fyfe Member Services and Communications Pamela Peckford Credentialing Coordinator Lindsay Pealow Finance & Administration Mara Juneau Programs & Credentialing Director 202-300 March Road Ottawa ON K2K 2E2 Phone 613-595-1919 Email info opcanada.ca www.opcanada.ca Publisher DT Publishing Group Inc. PO BOX 327 Stn. Main Grimsby ON L3M 4G5 Tel (800) 725-7136 Email jeff disabilitytodaynetwork.com Executive Editor Krista Holdsworth CO(c) Email orthopro orthoproactive.com Managing Editor Jeff Tiessen DT Publishing Group Inc. Tel (800) 725-7136 Email jeff disabilitytodaynetwork.com Associate Editor Brenda McCarthy Tel (800) 725-7136 Email brenda disabilitytodaynetwork.com Art Direction Starr Hansen Email sjdesignstudio comcast.net Design and Layout SJ Design Studio Email sjdesignstudio comcast.net Editorial Committee Sharon Carr CO(c) Krista Holdsworth CO(c) Advertising Sales Jeff Tiessen DT Publishing Tel (800) 725-7136 Email jeff disabilitytodaynetwork.com Alignment and Orthotics Prosthetics Canada (OPC) make no representations or warranties with respect to the merchantability of the products and services reported or advertised in Alignment and the inclusion of any such product or service in Alignment magazine shall not be deemed an endorsement by OPC. OPC assumes no responsibility or liability for claims made for any products or services reported or advertised. Trademark symbols are associated with trademarked names upon first editorial reference in each article only. Printed in Canada. Contents Copyright Orthotics Prosthetics Canada and or the contributing author unless otherwise indicated. OPC Committees Certification and Registration Board (CBCPO) Chair Stacey Brown CO(c) OPC Board of Directors Dan Mead CPO(c) President Linda Laakso CO(c) Vice President Mark Agro CO(c) FCBC Treasurer Ronald Bartlett RTPO(c) Kieran Bliss CP(c) Serap Kaga CO(c) Warren Matthews RTPO(c) Jenna Holz CO(c) Steve Scott CP(c) FCBC Stan Wlodarczyk CP(c) Jason Adams Director at Large Nancy Dudek MD Med FRCPC Director at Large Dr. Hernish Acharya MD FRCPC Director at Large Residency and Internship Sub-Committee Chair Amy Richardson CP(c) Finance Committee Chair Mark Agro CO(c) FCBC and Treasurer Member at Large Alan Moore RTPO(c) CO(c) FCBC Nominations Committee Chair Carla Reimer CO(c) Professional Development Committee Chair Sharon Carr CO(c) Professional Qualifications Committee Chair Dan Blocka CO(c) FCBC Marketing & Communications Committee Chair Dave Broman CPO(c) FCBC Standards & Ethics Committee Chair Peter Marinic RTO(c) CP(c) Professional Practice Sub-Committee Chair Heather Miklovich CO(c) Alignment ONLINE D I G I TA L M E D I A F O R C A N A DA S O & P F I E L D Orthotics Prosthetics Canada is on the Disability Today Network the disability community s first social media network. With its own Media Channel Alignment goes digital in a whole new way... I ND USTRY N EWS MF G & CL IN IC AL RESO URCES PRODUCT PHOTO S & VIDEO S S O CIAL M EDIA UPDATES Alignment Online serves up new information for P&O practitioners all year long. VISIT www.disabilitytodaynetwork.com alignment. EXECUTIVE DIRECTOR S MESSAGE Fresh & Positive Outlooks As the 2016 OPC National Conference theme suggested there is great value in adopting an attitude of New Heights... Fresh Outlooks new heights referring to setting lofty goals for the profession and a purposeful proactive direction. Fresh outlooks pertains to an outward-looking and positive perspective with a focus on setting our sights on the future and moving forward. Change continues to be necessary and a forward-looking orientation sometimes means leaving the past behind. Starting with a fresh and positive outlook is sometimes required. All of us at times can get mired in the past which can hinder our forward progress. The past has value in understanding where we have come from and it facilitates our learning but sometimes we cling to what used to be as what should continue to be despite changes that have occurred which reflect a different reality. Everyone can agree that there are aspects within our environments that are constantly shifting and the pace of change occurs at an alarming rate. The requirement to continue to evolve improve and change will always exist. We have to become more flexible and open to change to adapt and move forward or we risk moving backwards by standing still. This requires strength of character to wipe a slate clean and adopt a fresh outlook. Past practices processes procedures policies and other aspects sometimes need to be sacrificed in the name of adapting and moving forward. Without the ability to wipe the slate clean and embrace a fresh outlook we can inadvertently and detrimentally impact forward progress. Orthotics Prosthetics Canada has made significant forward progress in the past few years with new administration an amalgamation and leadership at the Board and Committee levels. The requirement to continue to evolve improve and change will never go away. The most effective way forward for the orthotic and prosthetic profession is to all come together with mutual respect trust and open communication and prepare for the future. We must remember where we came from but at the same time open our minds to new directions and a different way of doing things that will allow us to meet the challenges and opportunities ahead. Dana Cooper MBA CAE OPC Executive Director 6 ALWAYS STAY CONNECTED WITH NEWS ANNOUNCEMENTS PROMOTIONS EVENTS CONTESTS MORE facebook.com OrtoPedULC OrtoPedULC linkedin.com company ortoped INDUSTRY NEWS MEC17 A Sense of What s to Come MEC is back this year August 15-18 2017 in Fredericton New Brunswick. MEC is the premier conference for upper-limb prosthetics and upper- and lower-limb myoelectric control. The event will be hosted by the Institute of Biomedical Engineering a research institute recognized worldwide for its pioneering work in myoelectric controls. Courses and workshops geared towards clinicians engineers and researchers who work in the fields of upper limb prosthetics and myoelectric control (including upper and lower limb) will be offered during MEC17. Keynote speakers will be Alignment publisher Jeff Tiessen Dario Farina PhD. and Doug Weber PhD. Visit www.unb.ca conferences mec for more details. LET S SHARE Our success in building awareness of the profession and educating key stakeholders rests in obtaining and sharing content about us. Members play a significant role in providing content for social media posts. OPC calls on all members to provide us with information that could be of interest to use for posting on social media. This information could be prosthetics or orthotics in the news patient stories unique innovations educational pieces or anything else that is newsworthy. Remember we do not know until you tell us Whenever you come across something that should be shared to help build awareness or educate send it to us at Orthotics Prosthetics Canada at communications opcanada.ca. A new resource featuring expert resources on gait education research articles and news has launched in the form of the online Gait and Balance Academy (GaBA). Designed to be the go-to resource for gait and balance information the GaBA looks to serve as the leading communication platform for the research and clinical communities. Together with internationally-recognized contributing experts GaBA will offer scientific research and facilitate collaboration among participants offering access to classical educational resources and newly created innovative content. These materials including research reports presentations and videos are based on validated scientific protocols. The digital era has revolutionized access to information. The Internet is now the primary tool used by patients seeking health-related information and treatment. It is also used frequently by medical personnel searching for topics relating to symptoms and or presentations treatment options articles medical products and the like. Yet while the Web is a great resource it is often difficult to discern reliability within the information. That s where GaBA comes in. It s designed to help the gait and balance community access the most reliable and upto-date information in the field in real-time on a dedicated platform. Practitioners can join the GaBA community to contribute to and or learn about objective gait and balance measures that quantify what they purport to evaluate. The goal of the GaBA is to share information about scientifically-based objective measurement systems grounded in science and math that produce useful functional performance metrics. Community input is welcomed to ensure that this goal is sustained. GaBA intends to be a multi-tiered service that includes free-ofcharge content as well as fee-based subscriber sections. Visit www. gaitandbalanceacademy.com. 8 Walking the Talk Team Behind the TEAM Hosting the Invictus Games in Canada during its 150th year brings about a pride in our nation in our military athletes and in the professionals who support their endeavors. Orthotics Prosthetics Canada (OPC) is proud that some of our Certified and Registered professionals play a role within the comprehensive network of support for these athletes. OPC wants to promote this Team Behind the Team concept to build awareness for the many achievements of the profession. There are many media stories that exist that relate to the accomplishments of amputees. It is OPC s objective to make sure that our Certified and Registered professionals are part of these stories. If you are a prosthetist orthotist or registered technician assisting athletes let us know and we will contact you about sharing your experience. Email us at communica tions opcanada.ca. C-Leg Celebrates 20 Years in Canada In 1997 Ottobock HealthCare set a new standard for prosthetic technology with the introduction of the C-Leg the world s first fully microprocessor-controlled prosthetic knee joint. The C-Leg prosthetic knee is the brainchild of Canadian engineer Dr. Kelly James PhD from the University of Alberta. Dr. James was fascinated by the potential of new technology to restore prosthetic movement and function for individuals with limb loss. He wanted to create a prosthetic knee joint that would react more like a human knee and allow an individual with a lower-limb amputation to walk more naturally. Dr. James knew he would need to take a different approach. I thought long and hard about how I would do it and decided that a computer would do it better than the mechanical systems that were out there he said. Globally the C-Leg is a very important knee for amputees stated Mark Agro President and CEO of Ottobock HealthCare Canada. Microprocessors have revolutionized amputee gait... providing the stability they [amputees] need in all phases of gait. This translates into added safety and security allowing people to get back to living the lives they want to live. To learn more about the 20th anniversary of C-Leg visit the Ottobock YouTube channel www.you tube.com watch v yMFzIU3Lp1o. CPOT Reference Manual In 2016 Orthotics Prosthetics Canada (OPC) launched the Compendium for Prosthetic and Orthotic Treatment (CPOT) Reference Manual. The CPOT arose from the need for a common language among certified prosthetists and orthotists and registered technicians in Canada. All members are encouraged to read the manual and incorporate the recommended terminologies into their everyday practice language. It is important for the profession to adopt common terminology to reduce confusion and to facilitate nationwide communication and for building relations with key stakeholders such as allied healthcare professionals and third-party payers. The CPOT manual will be updated with advancements as the profession evolves. Access it at https opcanada. wordpress.com. FCBC Recipient Steve Scott CP(c) The title of Fellow is conferred upon Certified or Registered Orthotics Prosthetics Canada (OPC) members who play a leading role within the profession and whose contributions have furthered the advancement of orthotics and prosthetics in Canada. OPC would like to congratulate Steve Scott CP(c) from Calgary our latest member to be honoured with the Fellowship (FCBC) distinction. In more than 30 years in the industry Steve has volunteered at local provincial and national levels for the orthotic and prosthetic community in various capacities. Noted for his leadership and dedication Steve has been a powerful advocate for the O&P industry for both professionals and patients. OPC is proud to honour him with the Fellowship distinction. 9 CONTINUING EDUCATION The War Amps Advocacy Program A Voice for Canadians Living with Amputation By Annelise Petlock Lawyer and Advocacy Program Manager The War Amps and Alexis McConachie Coordinator Advocacy Communications The War Amps Since its founding at the end of World War I The War Amps has fought to protect the rights of amputees and veterans and address the inequities they face. As a natural evolution the association has over time expanded its advocacy work to provide a voice for all amputees in Canada. Through its Advocacy Program The War Amps navigates and addresses the bureaucratic barriers and misunderstandings often confronted by amputees in society. Years of experience with government agencies and insurance companies have revealed that these institutions do not fully comprehend the impact of amputation 10 Although life for amputees has come a long way since the end of the first World War there are still many gaps in terms of support in the areas of appropriate prosthetic coverage insurance and legal issues human rights government benefits and war amputees rights. and the role that the prostheses play in reducing the incidence of other medical conditions that can develop with amputation. Consequently funding agencies create and adhere to policies which do not reflect the reality of living with amputation and thus prevent amputees across the country from being able to access prosthetic components that are medically prescribed to them. Most Canadians would be shocked to know that those who live with the loss of a limb are not adequately covered by their health plan. Across the country provincial funding is insufficient to cover the cost of appropriate artificial limbs for amputees. Moreover many insurance and extended benefits packages contain arbitrary contribution and frequency limits for essential medical devices including artificial limbs. These caps effectively prevent persons with amputations from affordably accessing the assistive technology they require. The War Amps fills the gaps where it can but as a charity that relies on public donations its funds can only go so far. One of The War Amps Advocacy Program s ongoing objectives is to provide education to funding agencies so that policies can be updated to reflect the reality of living with amputation. The objective of Crusade for Reform is to ensure that amputees can access the prosthetic care they need to gain or regain their functionality. Program will go the extra mile to ensure a just and fair outcome for individual amputees. Complex Insurance Red Tape Last year the Advocacy Program was approached by an amputee who lost his leg at the hip (hip disarticulation) when he was five years old. He grew up in Ontario and moved to Quebec for work. Due to the complexity of the care required for his level of amputation he needed to seek treatment from his longtime prosthetist who was familiar with his medical history and understood his unique needs. When he tried to access funding from his employee health benefits plan he found out that he would have to challenge certain restrictions in his policy around eligible expenses. The War Amps Advocacy Program collected medical evidence and prepared a submission to his insurer to demonstrate the importance of a specialized course of treatment. Emphasis was put on the medical necessity of the prescribed prosthetic components in addition to focusing on his safety and security requirements. As a result the insurance provider approved coverage for an Ottobock C-Leg 4 microprocessor-controlled knee unit and a hydraulic Helix3D hip joint estimated at approximately 75 000. And the insurance provider agreed to make arrangements for direct billing to the prosthetic centre. Many insurance companies refuse to offer direct billing. In the absence of this arrangement accessing 75 000 to pay for a limb even with reimbursement creates an insurmountable burden for most. Direct billing removes this barrier for those with insufficient funds to pay the upfront costs and it helps to reduce the delay in receiving essential prosthetic devices. The Advocacy Program is monitoring the direct billing issue as it presents a hurdle to amputees and to O&P professionals alike. Misconceptions Held by Funding Agencies The War Amps took on a case which represents a great example of the misconceptions held by funding agencies regarding artificial limbs which in application inhibits access to care. In this case the insurer initially refused to cover the cost of a medically-necessary knee unit. The amputee s medical team determined that she required an Ottobock X3 microprocessor-controlled knee unit to preserve her safety and security. Instead her insurer requested Educate Challenge and Dispute While the Advocacy Program s main goal is to provide education this is only stage one in The War Amps advocacy efforts on behalf of amputees in Canada. When providing education to funding providers does not elicit a positive result the association challenges their position providing further justification towards an equitable result. Should it continue to receive resistance advocates do not hesitate to escalate matters and dispute the funding provider s position (even if this means mediation or litigation). In an industry where roadblocks and red tape are abundant persons with amputations in Canada need a voice they need someone advocating on their behalf. The Advocacy 11 thesis. Subsequently a decrease in comorbidities translates to a decrease in the costs associated with those comorbidities which include but are not limited to expensive medication for pain management depression or anxiety. paramedical treatments such as home care acupuncture naturopathic treatments chiropractic care massage therapy occupational therapy physiotherapy required to treat overuse injuries and pain to the sound limb residual limb and back mental health care treatments counselling social work and vocational rehabilitation. treatment for injuries caused by falls such as shattered hips and broken bones or other potentially catastrophic injuries. costs of home renovations and daily living aids to improve accessibility in the home such as the installation of a ramp or lift. costs of vehicle modifications to modify the vehicle to enable safe driving absent a limb. additional income replacement costs as the individual is not able to return to work without the appropriate prosthesis. Funding agencies must make difficult decisions to allocate limited funds however time and time again studies show that when an amputee receives an appropriate prosthetic limb their cost of care decreases a quote for a Standard C-Leg . By referring to prosthetic components by their brand names assuming one brand name is the standard and ignoring the recommendations of the medical professionals this payor demonstrated its lack of understanding. Intervention consisted of a short letter explaining the error in this request. In addition a key Crusade for Reform argument was highlighted that the determination of which component (i.e. brand) is medically-required for a person with an amputation is a clinical decision only appropriately conducted by a certified prosthetist through their clinical assessment. As a result the insurer approved coverage of the Ottobock X3 microprocessor-controlled prosthetic knee unit (approximately 112 350). Systemic Issues These cases point to serious issues with prosthetic coverage including long response times troubling amounts of red tape and a culture of nickel and diming for needed prosthetic components. It is essentially a bureaucratic obstacle course to the detriment of amputees who are in desperate need and not getting the prostheses essential to living full and productive lives. While the up-front cost of an appropriate medically-necessary prosthesis appears expensive in the long-term these prosthetic devices save costs. They have been demonstrated to reduce the incidence of the comorbidities associated with amputation... not to mention the cost of long-term disability claims that result from an amputee s inability to return to work without the proper pros- ... a key Crusade for Reform argument was highlighted that the determination of which component (i.e. brand) is medically-required for a person with an amputation is a clinical decision only appropriately conducted by a certified prosthetist through their clinical assessment. 12 which reduces the demand on a strained healthcare system. It s good economics. An exciting aspect of these Advocacy Program cases rests in their potential to create widespread positive changes for all amputees. The program focuses on these types of cases where a positive outcome can set the groundwork for many more amputees to achieve the same result. It is The War Amps hope that its intervention in these cases will set a precedent in the continued efforts towards the reform of prosthetic funding standards within Canada. The organization s aim is to educate the insurance industry government agencies and others on the importance of appropriate prosthetic limbs and help to ensure that persons living with amputation receive the limbs and devices they need for their independence safety and security. In every case experienced and well-researched insight is provided which yields measured and fair results to benefit the amputee and educate the funding provider. The War Amps work very closely with the client s prosthetist and medical team with the understanding that these gaps do not only affect persons with amputation. Each case is given consideration. Do not hesitate to contact The War Amps for more information to identify a systemic issue facing amputees or to put the Advocacy Program in touch with an amputee who requires our support. For support call 1-877-622-2472. From the OA bracing innovators Unloader Hip is designed to optimize hip OA treatment in order to improve mobility and decrease pain. EASY TO USE PULLEY SYSTEM With it s simple-to-tighten design the proven pulley system provides compression and proprioceptive support. DYNAMIC ROTATION STRAP Allows individual adjustment of the external rotation force to achieve optimum pain relief for each patient. FOLLOW SSUR USA CANADA WWW.OSSUR.COM 14 CONTINUING EDUCATION Incorporating Outcome Measures into Daily Practice A Clinician s Perspective By Brittany Pousett CP(c) MSc. David Moe CP(c) Loren Schubert CP(c) In the 2016 edition of Alignment Brittany Pousett shared patients responses to the use of outcome measures over the course of their care. She interviewed three patients who shared that they appreciated the encouragement motivation and objective informative data that the outcome measure scores gave them [1]. After using outcome measures consistently with their patients for over a year and a half the clinicians at Barber Prosthetics Clinic have found the care offered to their patients has been enhanced. Herein the authors share four benefits of using outcome measures as they have experienced them. found that using these measures which take less than 10 seconds can immediately tell us the extent of socket adjustments that need to be performed or how close the patient is to having an optimally-fitting socket. These help to direct our care because they enable us to speak the same language as our patients and ensure that we are both aware of the difference between pain that is 2 10 (quite mild) and pain that is 9 10 (quite severe). We have also found that by using quantitative surveys we are 16 1. Outcome measures influence how we make decisions with our patients. The use of outcome measures in practice offers quick and simple ways of collecting objective data that directly influences how decisions are made or the direction that treatment takes. Some of the simplest outcome measures are the Pain Score and the Socket Comfort Score where patients rate their pain or comfort on a scale from 0 10. We have able to engage in discussions about specific aspects of daily living that are particularly important or challenging to that patient but may not have been something that came up in conversation. This allows us to make simple changes to a patient s treatment and make a significant difference in their lives. It also allows us to adjust a patient s goals and rehab programs in a way that is more relevant to them. For instance a patient s goal may be to walk for 15 minutes in their neighbourhood but they report that they A patient completes an outcome measure involving computer-assisted gait analysis and eagerly discusses the results with his prosthetist. cannot walk for that length of time. A survey may indicate that they are confident in walking but they struggle on curbs and ramps. This allows us to refocus our treatment to address why curbs and ramps are a problem so that we can help to remove the barriers that are preventing the patient from achieving his or her goals. Once the use of outcome measures became a routine part of our care we found that we began to see them as a critical component in presenting the full picture of a patient s current situation. Without outcome measures we were missing valuable pieces of information. We also found that they became crucial in helping us to determine what our patient s goals should be what they could likely achieve and how to best help them reach those goals. 2. Outcome measures are important indicators of progress. We have also found that outcome measures provide our patients and us as well with valuable information regarding their progress in rehabilitation. We begin using outcome measures with our patients before they receive a prosthesis and continue using them at regular intervals throughout their initial rehab. By tracking their progress we can celebrate when they excel and re-direct the conversation when they digress. Since these measures allow us to objectively measure attributes such as balance speed and endurance we are able to detect small changes and direct care more quickly and accurately than if we relied only on subjective feedback and visual information. By sharing the results with our patients we have found that they are more motivated to independently continue their exercises after they have been discharged from their physiotherapy program because they see the positive results that their efforts have made. Patients have repeatedly shared that they appreciate this motivation and can t imagine going through their rehab without it. 3. Outcome measures strengthen communication with external collaborators. Outcome measures are a universal language in rehabilitation teams. By sharing six simple numbers we can acquire a basic understanding of comfort pain speed endur17 ance balance and confidence. This allows us to share valuable information with physicians physiotherapists and occupational therapists quickly and efficiently in a language that we all understand. When working with other healthcare professions we have developed systems to obtain outcome measures to enhance collaboration and discussion and improve time efficiencies. We have found that the use of outcome measures increases communication saves time deepens relationships within teams and enables us to work together more closely to ensure our patient s rehab is appropriate and successful. When working with other external collaborators such as researchers or engineers we have found that again outcome measures enhance our communication. One engineering consultant asked us for two outcome measures scores as they found them to be a valuable and accurate synopsis of patients level of function. Also when embarking on research projects with a variety of academic institutions we have found that having outcome measures scores allows for a much clearer definition of inclusion crite- Two patients complete a Box and Blocks test without their prostheses. ria and provides an opportunity to identify and match individuals with specific research studies. They also provide us with established tools which can be used to measure the effects of interventions in these studies. dressing specific aspects of his life that he wants to improve upon. Another patient from out of town completed two outcome measures and afterward asked if there were any more that she could perform to further evaluate her functional abilities and identify areas for improvement for her and her prosthetist on which to focus. And she came back later that day with her sister to ask if her sister could do the outcome measures so that they could compare their differences. Most of our patients at one point or another ask if they can repeat the outcome measures to see if there have been changes or because they have been practicing and want to validate their feelings of better performance. Why not use a tool that patients respond to so positively and which gives us many clinical advantages How about you How could using outcome measures improve your patients care and experiences at your clinic About the Authors Brittany Pousett CP(c) MSc. is a Certified Prosthetist and the Head of Research at Barber Prosthetics Clinic in Vancouver. Brittany is passionate about integrating research into clinical practice in order to provide her patients with evidence-based care. Loren Schubert CP(c) is a Certified Prosthetist at Barber Prosthetics Clinic and an Instructor in the Prosthetics and Orthotics program at the British Columbia Institute of Technology (BCIT). David Moe CP(c) has been a Certified Prosthetist for 25 years and a parttime faculty member at BCIT for 12 years. He is always striving to provide his patients with higher levels of care and push the profession forward. 4. Outcome measures change our patients perspectives on care and influence the goals they want us to help them achieve. Finally as highlighted in our previous article in Alignment outcome measures improve our patients perspectives on the care they receive and enable us to provide them with better service. Patients are very willing to complete outcome measures surveys when the results are explained to them. One patient who had a recent amputation and who completed several outcome measures items was eager to talk through each one and understand the results and his progress when we ran him through them again a few weeks later. Now we complete outcome measures with him on a regular basis enabling him to celebrate his achievements adjust his goals and focus his attention on ad- References 1. Pousett B. (2016). Patients Perspective on Incorporating Outcome Measures into Practice. Alignment 2016. 18 23 CONTINUING EDUCATION Let the Records Show The Value of Electronic Medical Records in O&P Care By Malena Rapaport B.Kin. M.Sc. Prosthetic Resident Electronic medical records (EMR) have become an essential component of today s healthcare practice1. They capture many facets of patients health information over multiple episodes of care such as patient demographics prescriptions progress notes referral sources billings etc.2 gained popularity but are not yet widespread within clinics across Canada. Much of the conversation about the importance of EMR seems to be focused around the basic benefits associated with EMR including easily accessed computerized records reduction in storage due to lack of paper files and elimination of poor penmanship2 4 problems. However there seems to be a missing link in the relationship between these benefits and 20 EMR have been reported to improve quality of care and treatment outcomes by providing safer and more efficient care with clinical decision-making support tools reducing the amount of medical errors with computerized ordering systems for physicians and facilitating sharing of patient information via data exchange platforms 2 3. In the field of Orthotics and Prosthetics (O&P) EMR have improvements in quality of patient care. Thus these basic benefits do not seem to generate enough cause to warrant a shift toward EMR. So what is the value of EMR in improving patient care To better understand the value of EMR I interviewed five clinicians from different clinics across Canada most of whom have been using EMR for 10-15 years. These interviews shed light on three main outcomes of using EMR that appear to influence the quality of patient care 1 higher quality of patient records2 changes in the patient-clinician relationship3 and improved efficiency of care. This article shares interview findings as well as existing literature and highlights the value assigned to EMR by existing users within the O&P field in Canada. Quality of Patient Records Interviewees noted an improvement in the quality of patient records with respect to the ability to consolidate pertinent information about patient care from various sources... patient demographics referrals prescriptions outcome measures and billings as well as facets of patient interactions including email communications phone conversations etc. While advantageous to consolidate information Kirsten Simonsen CP(c) from the Eastern Prosthetic Clinic raised several critical questions What should we be recording and why and What information is beneficial to our patients She pointed out that as healthcare providers we are legally obligated to keep clinical records. However there are no standards to guide what information should be documented leading to either under- or over-documentation. Despite the lack of standards Jon Allen CP(c) from the Alberta Orthotic and Prosthetic Centre commented that using EMR has helped him capture more detailed patient snapshots at different treatment stages. Over time this creates an accurate transparent and thorough record of care making it possible to track a patient s longterm progress. Furthermore complete records can provide patients with information they may need to advocate for themselves. ences in the type of interactions and ways of communicating with the patient in the treatment room. Three of the interviewees indicated an increase in the amount of time in the room with patients because they did not need to leave the room as frequently to access information. Different strategies for documentation of clinical notes were also discussed. Some interviewees reported completing their notes after appointments whereas others chose to document information during the appointment. The latter option required the introduction of a laptop or iPad into treatment rooms which came with reservations for several interviewees. The connection with the patient was considered most important and introducing technologies into the room warranted adaptations to maintain this connection.... for example managing body language to maintain focus on the patient while interrupting eye contact to document on the electronic device. This hesitancy of those interviewed is shared across other allied healthcare professionals as well. However in a recent study examining patients responses to the implementation of EMR found that patients assumed patient-centeredness when physicians used EMR5. Patients interpreted the focus on documentation as evidence of the physician s caring and reported no changes in satisfaction with the relationship5. Another interesting comment was the clinician s increased ability to share information with patients about their records. For example sharing outcome measures reports by looking at the computer screen together facilitated conversations about the patient s progress. This increases the patient s understanding of treatment and extends ownership of responsibility of care and a sense of some control to the patient5. Overall the use of EMR fosters information sharing with the patient enhances partnership and trust between clinician and patient and promotes a shift of responsibility to the patient5. Improved Efficiency in Care There was a general consensus among interviewees regarding enhancements in workflow associated with EMR. The automated and smart nature of EMR was perceived as a major advantage in attaining improvements in the clinic s daily operations. For example clinicians and technicians using EMR noticed an improvement in the management of workflow between them by way of using prompts and reminders to help prioritize and assign tasks. Moreover interviewees valued the ability to effortlessly share information Changes in Patient-Clinician Relationship With the implementation of EMR interviewees acknowledged differ22 about the patient between clinic staff and other healthcare professionals allowing for real-time decision-making regardless of whether staff were in the office or working remotely. Work flow improvements are significant to the efficient management of a clinic and a catalyst for timely quality and safe care allowing clinics to focus on patient-centeredness2. Another medium by which efficiency was greatly improved was through the use and management of data gathered through EMR. Interviewees valued using information gleaned from reports and data query strategies to make informed decisions about their business and the care being provided. Peter Marinic CP(c) RTO(c) from Winnipeg Prosthetics and Orthotics finds that he can create reports in just minutes from which he can draw conclusions regarding prescriptions appointments fabrication tracking patient demographics outcome measures referral sources etc. These conclusions serve to shape discussions between staff as an important component in the process of optimizing the quality of patient care. The use of data on a larger scale drawn from within or beyond the Canadian border was also a key topic for many of the interviewees. There are incredible advantages that can stem from data collection across Canada in terms of a large data set with national representations. Firstly large pools of data could be analyzed retrospectively to yield O&P population-wide trends. This would offer practitioners a better understanding of our patient population s current needs with the potential to predict future needs. Secondly large data sets could also be used to generate new knowledge about our field in a way that research findings can be generalized to entire populations. And thirdly access to these large sets of information can begin to form the building blocks for the development of national standards for clinical practice clinical guidelines and policy development for O&P in Canada. This utopian-sounding scenario has been achieved through EMR in such fields as genetics and pharmaceutics but not without its challenges6. Some of the literature s most commonly documented barriers include ensuring privacy of patients (having secure access to EMR through pre-established consent procedures) and collecting information in a standardized way within compatible and interoperable databases6 7. Dan Blocka CO(c) from Boundless Biomechanical Bracing presented the idea of creating a national data collection and management strategy that could create standards and procedures for data gathering and organization which would support and connect EMR users and utilize data for Orthotics Prosthetics Canada initiatives that will improve patient care in Canada. With a focus on enhancing the level of patient care the value of using EMR in O&P seems to be highly based on its ability to create accurate transparent and thorough patient records shift control to the patient and improve the efficiency of care services. Through ongoing discussions we can begin to recognize the value of EMR as it relates to the adoption of evidence-based medicine and in turn its capacity to create new knowledge guide data-informed clinical decisions and most importantly improve quality of care. Thank you to Peter Marinic CP(c) RTO(c) Dan Blocka CO(c) Kirsten Simonsen CP(c) Michael Stobbe CP(c) and Jon Allen CP(c) for their participation in this review. 24 References 1. Holroyd-Leduc JM Lorenzetti D Straus SE Sykes L Quan H. The impact of the electronic medical record on structure process and outcomes within primary care a systematic review of the evidence. J Am Med Inform Assoc [Internet]. 2011 18(6) 732 7. Available from www.pubmedcentral.nih.gov articlerender.fcgi artid 3197985&tool pmcentrez&rendertype abstract. 2. Menachemi N Collum TH. Benefits and drawbacks of electronic health record systems. Risk Manag Health Policy. 2011 4(May 2011) 47 55. 3. Blumenthal D Tavenner M. The Meaningful Use Regulation for Electronic Health Records. N Engl J Med [Internet]. 2010 363(1) 1 3. Available from http scholar.google.com scholar hl en&btnG Search&q intitle New engla nd journal 0. 4. Vishwanath A Singh SR Winkelstein P. The impact of electronic medical record systems on outpatient workflows A longitudinal evaluation of its workflow effects. Int J Med Inform. 2010 79(11) 778 91. 5. Shield R Goldman R. Gradual electronic health record implementation new insights on physician and patient adaptation. Ann Fam ... [Internet]. 2010 8(4) 316 26. Available from http annfammed.org content 8 4 316.short. 6. Jensen PB Jensen LJ Brunak S. Mining electronic health records towards better research applications and clinical care. Nat Rev Genet [Internet]. 2012 13(6) 395 405. Available from http dx.doi.org 10.1038 nrg3208. 7. Murdoch T Detsky A. The Inevitable Application of Big Data to Health Care. J Am Med Assoc. 2013 309(13) 1351 2. About the Author Malena Rapaport B.Kin. M.Sc. has a Bachelor of Kinesiology from the University of Toronto. She is a graduate of the BCIT Prosthetics and Orthotics Clinical Program and McMaster University with a Masters of Rehabilitation Science in 2016. She is currently completing her prosthetic residency at Barber Prosthetics. CONTINUING EDUCATION Critically Appraised Topics Searching the Research for Meaningful Content and Context By Yvonne Jeffreys M.Sc. CO(c) FCBC The explosion of digital information means that both patients and practitioners can find a multitude of resources about any topic with just a click of a button. The ability to discriminate between different sources of information and put meaning to the context must remain a priority of health practitioners. rather just make sure we are going into our analysis with our eyes open. Critically Appraised Topics (CATs) allow for evidence-based literature to be summarized using a standardized protocol. A list of pre-selected criteria are established based on the clinical problem or question that needs to be addressed. With online access to scholarly papers a critical analysis is performed in a systematic and objective manner. The bottom line in a CAT is to provide a critical synopsis based on research found and a position statement as to the clinical relevance of the findings from the question being asked. The CATs process evaluates the results tested and what they intend26 Professionally we need to become competent consumers of research so that we can critically navigate evidence-based practice (EBP) literature and confidently guide our decision-making for best practice. When looking at research evidence we need to examine the quality of information going into our analysis and in a perfect world all of the outcomes that can be directly correlated to the variable being studied. The world is not perfect however and research studies are challenged by limitations in budgets project time ethics subject numbers and researcher resources. These constraints should not deter us from looking at the research but ed (internal validity) and if the results could be generalized to other situations (external validity). Scientific rigour also evaluates whether the design methodology could be replicated to produce similar outcomes and that the statistical data was significant. There s always the possibility that no matter how well you randomize your subjects and blind your researchers if the design does not have valid or reliable methodology the results are not worth contemplating. So in other words within a few short pages a CAT can present a critical appraisal of the best evidence found ending with a statement of how this evidence can be interpreted. CATs are not publications written by researchers. They are intended to Introducing the newest innovation in microprocessor controlled Ankle Foot Technology Kinnex integrates the world s fastest responding microprocessor technology and a carbon fibre foot to provide the user with a uniquely natural walking experience. The microprocessor seamlessly adjusts to changes in the ground slope within the first step. Stay Grounded. Feel Connected. TREME BRAIN AND BRAUN Freedom Maverick offers extreme durability flexibility and vertical shock absorption that exceeds the highest demands from the user. DISTRIBUTED IN CANADA BY 1.800.663.1254 Order online at www.orthoactive.com be created by health professionals deliberating real clinical issues within their daily practice. The CAT is not a literature review of different ideas a systematic review done by experts a scholarly paper or a critical appraisal of the literature. Publishing CAT summaries helps spread the bottom line of scientific knowledge amongst health professionals with regard to real life issues. CATs can save time (if someone has already investigated your question) or can help provide practical guiding evidence for those who are unable to perform the critical appraisal (due to time or lack of experience). As with most things the more you practice the better you get and CATs are no different. So with this in mind the first year BCIT (British Columbia Institute of Technology) students embarked on creating their own CATs with the help of several local clinical mentors. The genesis of this project sprung out of discussions at the 2016 OPC conference in Banff where it was identified that although there are researchers producing P&O (prosthetic and orthotic) studies the quality was mixed. There were some areas where more research is happening than others and most importantly the research didn t always provide a meaningful answer to many of our daily conundrums in practice. CATs were identified as a way to create easily accessible and clinically-relevant information that could be shared amongst the P&O community. Michael Highsmith from the University of South Florida School of Physical Therapy & Rehabilitation Sciences spearheaded a similar project in 2015 with the goal of creating a library of CATs. The American Academy for Orthotists and Prosthetists (AAOP) has created the Academy Secondary Knowledge Committee (ASK) to develop and maintain a library of CATs relevant to common prosthetic and orthotic clinical issues. These are accessible for anyone with an AAOP membership at www.oandp.org research cats . During the first semester at BCIT the class of 2018 students were paired with local P&O practitioners and asked to develop a CAT of their own. Sadhigh et al. (2012) outline five distinct steps when creating a CAT. The first of these steps is to identify a focused and answerable clinical question (referred to as the PICO question) explicitly defining a sample population type of intervention a comparator and an intended outcome that you would like to measure. The second step is to search for the best available evidence with clearly identified inclusion and exclusion criteria publication dates and study design types. These limits help create specificity to identify published evidence relevant to the clinical question being asked. The next step is to use a critical systematic approach to objectively analyze the strength of the research methodology those which are neither valid (actually measuring what they intended to measure) nor reliable (could be duplicated again to get a similar outcome) are dismissed. The best evidence is then appraised with respect to methodology research ethics and bias sample size and selection statistical analysis and generalizability. The sentiment of the critical appraisal is then applied to the clinical scenario in question. This takes into consideration how the critical appraisal impacts the clinical situation under investigation and a statement of clinical significance of the CAT is given. This ultimate value of a CAT is to apply the critical analysis of evidence to clinical practice. The BCIT project fulfilled the intended purpose of enabling students to be better consumers of research but not insignificant was the value of being paired-up with a mentor from the local P&O community. Having a mentor who contributed to the creation and relevance of the clinical question brought real-world challenges to light and gave a distinct sense of purpose to the project. By meeting with their mentors off-campus at coffee shops and community libraries students made connections with their future colleagues and were introduced to a community of practice culture that one day they will carry-on and give back to the next generation of practitioners. Overall the students and mentors felt that this project was a great avenue to explore future CATs from both the creation side and Publishing CAT summaries helps spread the bottom line of scientific knowledge amongst health professionals with regard to real life issues. 28 the usability side. Leah Campbell expressed that it was great to connect with mentors in the P&O community and generate questions together. This project made me more likely to seek out a CAT in the future knowing how much time and thought goes into producing one. Rachel Rudolf reflected that throughout the process of writing our CATs the lack of P&O-related literature quickly became apparent as many of us struggled to find articles that applied to our PICO questions. Upon completion of the critical appraisal of our topic it seemed as if we were left with more questions than answers she said. However from this experience we were able to gain an appreciation for the effort involved in the search for answers and the important role that we have as the next generation of practitioners to do further research within the P&O field. The students asked inquisitive questions and were able to provide a fresh perspective as they interpreted their results with their mentors. The value of completing a CAT is fully realized when that appraisal is shared with people who have similar questions and are looking for answers. At BCIT we are looking at options as to how to share these CATs with the P&O community... ideally in an open-source online database that can contribute to our professional knowledge. If you have any suggestions or comments contact either Yvonne Jeffries (Yvonne_jeffreys bcit.ca) or Jason Goodnough (jason_goodnough bcit.ca) at BCIT. topic (CAT) Academic Radiology 19 7 pp. 872-888. doi 10.1016 j.acra.2012.02.005. American academy of Orthotists and Prosthetists (n.d.). CATs. Critically Appraised Topics for Orthotists and Prosthetists Academic Knowledge Committee (AKC) www.oandp.org research cats . About the Author Yvonne Jeffreys M.Sc. CO(c) FCBC works as an Orthotic Instructor for the Prosthetic and Orthotic program at British Columbia Institute of Technology and is a sessional instructor for the online M.Sc. Rehab Sciences program at McMaster University. She has a special interest in clinical reasoning and interprofessional education. Yvonne practices as a Certified Orthotist at Hodgson Orthotics in Coquitlam BC. References Sadhigh G. Parker R. Kelly A. & Cronin P. (2012). How to write a critically appraised 29 CLINICAL TEAM Team Manager The Social Worker s Role on the P&O Treatment Team By Kimberly Tiessen There is a very clear treatment philosophy when it comes to the role of the social worker in physical rehabilitation. A social worker s job is to believe in the worth dignity and welfare of every client and their family. It s also an innate never-ending pursuit of a fair relationship between individuals and society. in whatever capacity is needed to help minimize the burden on clients and their families. First and foremost the emotional well-being of the client takes top priority along with the psychological needs of the family. Navigating the system for potential financial support that the family might require is another aspect of their job description. All the while it s a balancing act of maneuvering their client through the process of appointments surgeries fittings and preparation for life ahead. The role 30 Social workers adhere to the Standards of Practice and Code of Ethics of their respective provincial governing body and of the Canadian Association of Social Workers while keeping an eye on the individual needs of their clients in the effort to ensure that a realistic outcome is attainable and achievable for all involved. A social worker s job when it comes to the orthotic and prosthetic world can be a challenging one. The social worker assists of the social worker also demands a delicate balance between the client and the rest of the team. Listed here is a clinical run-down of what a social worker s role entails. 1. Acknowledgment of diagnosis and need for intervention. 2. Adaptation to changes in the patient s role or relationships. 3. Modification in responsibilities and level of dependency. 4. Grief and adjustment to loss as a result of disability. Anxiety in clients is an understandable yet constant stumbling block. It brings a world of uncertainty for everyone involved. It s my job to increase confidence in the client to allow the program to help guide them through the stages of self-sufficiency independence hope and autonomy. Jutta Mueller 5. Addressing altered self-image and expectations. 6. Adjustment to financial and social stressors related to disability. 7. Resource counseling for reintegration into employment and community transportation changes to the home environment or choice of supervised care funding of adaptive devices and other medical expenses. Serving a client comes with many complex layers each layer represented by another team member and their goals. The team may consist of a physician nurse occupational therapist physiotherapist and a prosthetist or orthotist and of course the social worker. In order for the treatment process to come together and work best for the client each layer needs to meld in harmony. It s often the social worker s role to manage these layers to support the client and family especially when things are most difficult. Penny Sparling is a social worker in the Child Development Program at Holland Bloorview Kids Rehabilitation Hospital and explains that there is never a cut-and-dry case in her world. If a client needs an orthotic device one of the challenges lies in getting the client on board and compliant. The challenge as an orthotist knows well resides in encouraging the child to see what a difference their device will make in their life. When it comes to prosthetic users particularly clients who have sustained a traumatic injury or lost a limb due to illness counseling on coping strategies are needed to assist with the acceptance of the device. There s also the challenge of securing financial support outside of the government-paid portion of the cost of the device. Sparling is charged with navigating the system for some families to find the financial support they need. Emotional support and counseling for clients and families is an integral role of the social worker. Body image teasing and bullying at school are issues that are often in play for youth. For adult clients depending on the situation help may be needed as it relates to job loss fear of additional amputations and dealing with life after amputation. Jutta Mueller a social worker in the Amputee Rehabilitation Program at Hamilton Health Sciences says the more you involve the client and address their needs and concerns the more likely you will achieve adherence. Her focus is on negotiated treatment plans and the goals and values of the client. Mueller puts the client at the top of the team roster... without their buy-in my efforts will be for not she says. Social workers often remain involved with their clients for as long as needed. Too often gaps in the system arise. Social workers will 31 When a child discovers that their device actually helps them and is not holding them back that s the moment of reward for my work. It s humbling actually. Sometimes it s kids who teach us our biggest lessons in life. Penny Sparling Photo courtesy of Holland Bloorview Kids Rehab Hospital advocate for their client on an individual and systemic level Mueller has helped a family frustrated by bureaucratic roadblocks draft a letter to government officials when assistance was needed to pay for a prosthetic device. Mueller shares through experience that with a willing patient or client much seems to fall into place quite naturally. She understands though that she can t force a client to comply she can encourage them listen to their concerns and fears and help guide them down the path of acceptance. Anxiety in clients she explains is an understandable yet constant stumbling block. It brings a world of uncertainty for everyone involved. It s my job to increase confidence in the client to allow the program to help guide them through the stages of self-sufficiency independence hope and autonomy. In her counseling Mueller says she focuses on encouragement and empowerment. But she admits that it happens from time to time that people don t want to commit to the process and she s left disappointed that her clients are not living their lives to the fullest. At Holland Bloorview Sparling shares we offer life coaches to our clients to help kids find ways to become active by introducing them to adaptive sports and recreational prosthetic devices such as swimming legs. Sparling reiterates Mueller s sentiment that as social workers they play an important role in empowering the client to embrace their new circumstance and challenge them to enjoy life. Holland Bloorview has recently renewed its focus on improving the transition phases of their clients to address service gaps as clients come to the end of their treatment program. Sparling emphasizes that the hospital s mandate is for clients to leave the program feeling comfortable in taking responsibility for their health and well-being and taking charge of their care. She shares that many families find it challenging when entering the adult healthcare world and lack support going forward on their own. Families have commented that it would be beneficial to have a transitional phase to help prepare them for the next stage of service. As prosthetic and orthotic treatment continues to evolve Mueller and Sparling both agree that there is one thing that never changes and that s how deeply their clients inspire them. Mueller tells that over the years it has never ceased to amaze her how so many of her clients persevere some quite seamlessly and others with more difficulty. When my busy day is done I often reflect and wonder to myself... if I were 32 in my client s shoes if I would be so successful so positive so willing she admits. Sparling too regularly reflects on the resilience of her clients and how the device becomes a tool for them to achieve what they want to do and where they want to go. It s amazing how resilient the kids are and how they adapt and thrive she witnesses. When a child discovers that their device actually helps them and is not holding them back that s the moment of reward for my work. It s humbling actually. Sometimes it s kids who teach us our biggest lessons in life. About the Author Kimberly Tiessen is a writer photographer and founder of Hope for Mexico a charity that helps impoverished children in Mexico get an education. At age six she became a sibling of a double-arm amputee which has afforded Kimberly the ability to understand what life is like for amputee youth and to write with a unique and compelling perspective. Kimberly began her career as a radio television reporter laying the foundation for her love for writing magazine features and books that celebrate the human spirit and inspire. CHEETAH XPLORE JUNIOR So kids can be kids Whether playing with friends or participating in sports kids are naturally active. Which is why Cheetah Xplore Junior is designed to help them go from the classroom to the playground without skipping a beat. Cheetah Xplore Junior takes the high performance of our Cheetah running foot and adds a heel for stability to create a hybrid everyday sports foot. The result is truly unique just like every kid. Visit www.ossur.com xplorejr or ask your ssur rep about Cheetah Xplore Junior today. FOLLOW SSUR ON ssur 03.2017 USA (800) 233-6263 CANADA (800) 663-5982 WWW.OSSUR.COM SPECIAL FEATURE SECTION 3D Printing Technology Impact & Effect on O&P Practice Today and Tomorrow By Jeff Tiessen When it comes to the prosthetic and orthotic (P&O) profession it has been tempting to dismiss 3D printing also known as additive manufacturing as the province of basement engineers looking to ply a hobby into a helpful prosthetic hand with futuristic-looking fingers for the little boy up the street with just one arm. But for P&O 3D printing is no longer the exclusive domain of the wellintentioned home-based limb maker or school-situated academically-anchored philanthropic project. Its potential for more practical and clinical applications cannot be denied. Ryerson Biomed Students Make Prosthetic Hand for a Farmer... students in the Biomedical Sciences program at Ryerson University Toronto have created a 3D printed prosthetic hand for a patient at St. John s Rehabilitation Hospital who wants to continue farming after a trans-radial amputation. The prototype developed by the Inspire Motion team weighs one kilogram has five articulating fingers and is said to be durable and easy to use. The design cost less than 20 to fabricate includes flexible and rigid 3D printed plastics and LED lights that are wired to the fingertips and fastens below the elbow and near the wrist. The students prepared the arm for control with a circuit to measure muscle contractions using electrodes. When [the patient] contracts his bicep his hand will close and when he relaxes it will open. Student apprentices at the University of Ottawa s Entrepreneurship Hub partner with Ottawa s The Door Youth Centre to make 3D printed prosthetic hands for youth abroad. The Give Us A Hand Made for media the proliferation of stories about goodwill 3D printed prostheses were hard to miss in recent years. High-school girl expands her grasp with 3D printed hand... high-school technology teacher creates a 3D printed prosthetic hand with fingers for a 17-year-old student born with only a thumb and a partial middle finger on her right hand. The girl is learning to write with the hand and can now grasp bottles books and her cellphone. 34 Project aims to create affordable 3D printed prosthetic hands to send overseas to persons in need. The project also gives local youth in Ottawa the ability to be creative while at the same time gain advantageous skills in 3D printing... giving hands-on skills in hand-making . Help our project by making a donation All donations will go towards buying new materials and helping us to create as many 3D printed prosthetic hands as possible. These initiatives are not to be dismissed or demeaned. They are admirable in their efforts and intentions. What they lack is clinical acumen. To that end a group of experts in the Toronto area has formed a consortium to bring together insights from different backgrounds and professional areas to better understand how Canada s prosthetic and orthotic profession can work with this technology to bring better solutions for patients and clients. Not only clinicians from P&O facilities private and public are represented in the consortium but researchers educators 3D manufacturers and other healthcare professionals are part of the group. They are working together to share varying perspectives and collaborate on a strategic direction for the P&O field which includes education a communication component as well as funding research. Arguably the 3D consortium has its roots in a pet project of orthotic facility owner Michael Pecorella CO(c). Explains Michael s son Daniel Pecorella CO(c) who works with his father at family-run Toronto Orthopedic Services Limited my dad has been trying to understand how 3D printing will impact our profession for a number of years. After meeting with 3D printing expert Dr. Matt Ratto at his University of Toronto research lab and sharing with him our prototype 3D printed AFO there was a commitment to collaborate as opposed to isolate. It was that meeting that gave life to the idea of creating a consortium to investigate the impact that 3D printing has on the P&O profession in a collaborative way. At the time I had no idea what a consortium was admits Pecorella but I offered to invite those I knew from the field who might be interested in being part of it. The consortium s mission began as a rough draft to glean input from all members on its statement and purpose. We knew we wanted to work with professionals from all industries related to 3D printing to come up with best practice guidelines for the O&P industry specifically and to educate our profession on what those are Pecorella shares. Early meetings were about getting to know and understand one another and what P&O practitioners do with their clients from assessment rectification cost-analysis material evaluation etc. in the fitting and fabrication process. It was a case of educating members about each other s work and determining how they could work together. We don t want individuals outside of our industry dictating to our clinicians how P&O 3D printing will be used in our profession. Let s understand this beast before it takes control of us. Pecorella continues most see 3D printing as having the potential to transform our profession. If we don t understand how to work with it it may have the potential to undermine us generally speaking of course. Pecorella says it all really hit home for him at the ISPO Canada conference in listening to researcher Jon Schull who runs an e NABLE Chapter in Rochester New York. Schull received a 3D printed hand template by e-mail and in turn put it online. Immediately people with access to 3D printers gravitated to it in a charge to make hands for children in need all around the world. But there was no collaboration or validation with the P&O industry which was off-putting to a lot of people in the room remembers Pecorella. It was a gut reaction from the audience... how someone could just come in and begin making prosthetic devices. But what moved Pecorella was Schull s revelation of his number of affiliates reaching 6 500 in just a matter of months. That s how fast something like this could undermine our profession he warns. Schull and e-NABLE did nothing wrong. It was charitable what they ADPOC Priorities Subject matter experts from a range of disciplines with interest in additive manufacture have developed a collaborative approach the Advancing Digital Practice in Prosthetics and Orthotics Consortium (ADPOC) to support research and development in digital methods for prosthetic orthotic applications. The consortium aims to evaluate new technologies develop best practices and advance research by combining the knowledge and skills of prosthetic orthotic professionals scientists manufacturers and educators. Through this approach the consortium aims to ensure that users of prosthetic and orthotic services have access to appropriate technology that meaningfully impacts their quality of life. 35 were doing. It s difficult to fault them for that. It s just one of those things that went viral but what would be the ramifications he thought to himself. Ratto sees a place for e-NABLE s efforts but in concert with the clinical expertise of the P&O practitioner. e-NABLE is good for kids who otherwise wouldn t be fitted he supports. There is a huge variety of prosthesis users and we have to admit that the current system no matter where we are doesn t serve everyone equally. There are always patients that are poorly served. One demographic that Ratto points to where 3D printing would assimilate into the developed world context is those with a cardiovascular condition or diabetes... a foot gets amputated and the patient is bedridden for x amount of time because no one really wants to fit him or her with a prosthesis until the vascular changes have slowed down Ratto explains. Being bed- ridden means blood sugar is not being controlled and cardiovascular health is declining but it doesn t make sense to spend the time to fit them with a prosthesis that within six weeks or so isn t going to fit anymore. With a quickly-produced 3D prosthetic device which may not be as good as one that takes 40 hours to make conventionally in the clinical setting would serve their needs for physical rehabilitation. These are the edge cases that I think are a good fit for 3D printing. What e-NABLE showed us is that 3D printing for prosthetic devices is not an evolution it is a revolution says Pecorella. That s how fast a new technology can transform an industry. If we let that transformation dictate to us how things are going to go I don t think that is good for our field. But if we are ready for it and acknowledge and understand what is coming and incorporate it into our practice with best practice guidelines and collaboration from all parties involved in the 3D printing process I believe our industry will benefit. Pecorella says it s hard to say if the P&O industry will embrace 3D printing technology. But he feels that it s safe to say that it is out of reach right now for many practices unless they want to dedicate a considerable amount of time and resources to experimenting with it. That s what we have done. My dad is semi-retired so he s had some time to work on it research it and develop our knowledge and understanding of its application. We outsource our projects we don t have a 3D printer in our clinic. At this point additive technology is having a limited impact on the P&O field maybe more hype than substance. As the technology develops and becomes more accessible to practitioners adoption may increase but this will depend on how advantageous it is shown to be over existing methods (i.e. cost reduction better quality better workflow etc.). There is too little information about the advantages requiring research and costing studies to be undertaken. Resistance to the new technology comes from high capital costs assurance of safety performance and quality but also from the belief by some established practitioners that their skills and roles may become obsolete. There is research that needs to be done assures Pecorella comparisons with laminations and vacuum-moulding processes in terms of strength and durability for example. There are different methods of 3D printing and different materials used and each yields a different strength of material. These are things that the consortium will be exploring. To follow are perspectives from several of Pecorella s colleagues who comprise the 3D consortium (ADPOC). 36 Clinician s Perspective Sandra Ramdial CP(c) FCBC Operations Manager Orthotics and Prosthetics Holland Bloorview Kids Rehab Hospital I m a firm believer in not doing things just because they ve always been done that way. Techniques that are working well and have been for some time shouldn t be replaced by new technologies for the sake of replacing them with new technologies. That said making things better for our clients is our driving force. We are always looking at new technologies new materials new interfaces new scanning technology and we are always experimenting with something new. If it works we implement it for future clients as well. We are constantly chasing perfection. For our last ISPO Canada conference we brought in a speaker from Project e-NABLE from the U.S. I had a very emotional first reaction to the presentation which was about open source software for anyone with a 3D printer wanting to make a prosthetic hand. I know from my own experience in treating clients for many years that there is much more that we can do for clients than simply supplying them with a plastic hand. We can provide better treatment than that. My response wasn t so much an issue of public encroachment on our profession but more about the lack of consultation with those of us who know what is already available tried and tested and safe. And durable. And better for the child. I acknowledge that for those who don t have an opportunity for prosthetic treatment something is better than nothing. At first I thought how can you even compare the treatment provided with a 3D printed plastic device to what we do. That really got to me. But given time to think about it I thought let s figure it out. If there are people willing to work together to take it the next step let s explore how we do that. In the scenario where someone with a 3D printer gets a call about making a limb there s nothing stopping them from doing that. But if we can get them to understand that there is much more that goes into the fabrication of a prosthetic limb then hopefully we can encourage them to work with a certified practitioner. There s a lot more to the treatment that s what we need to emphasize. The relationship capturing the shape of a limb relies heavily on anecdotal experience... where a client can tolerate pressure and where they can t and identifying bony prominences all things we do with our hands. Fitting a prosthesis means looking at all aspects of patient care... collecting information assessing gait mechanics assessing goals managing issues with their sound limb back or neck problems... and then there s follow-up as part of the continuity of treatment. There is so much for us as P&O practitioners to understand about additive technology as well. From the materials to the process you re essentially pulling a shape out of a powder and it takes a skill set to do that. We as practitioners need to understand the process. It s a very different method than we are used to as experienced clinicians. 3D printing is an exciting field and one that holds great possibilities for us but still requires research to explore its methods to ensure durability safety and effectiveness for our clients. Things change in any field. There are always new techniques being introduced. It s about 37 finding materials and techniques that may exist in another field and apply it to prosthetics and orthotics. Being open-minded to that will enhance our field and the services we provide to our clients. But just because 3D printing works well in another field doesn t mean it s going to work well in prosthetics and orthotics. We have to adapt it to what we do and make it work for us in collaboration with researchers manufacturers and other healthcare professionals. Our team has utilized 3D printing technology in our clinic for an infant hand. Available products were too big for this child. We couldn t get the desired combination of life-like appearance and functionality for her from existing products. A prototype using 3D printing was developed for home use with supervision. Mechanical engineering students in our research team used 3D printing to print a hand for her. It was printed using a modified home-desktop 3D printer. It was designed to accomplish typical daily activities like crawling grasping toys weight-bearing and pulling to stand. It is life-like in size weight texture and anatomical features. Soft flexible material with reinforced wire enables continuous range of bending angles and allows lateral motion. Bench-top engineering testing was done for bending grasping compression and weight-bearing durability and drop impact. With more testing needed for safety and reliability it is not her final device but a prototype for assessment and further development. As with everything we do in our field we need to have scientific data to justify that the treatment we provide to our clients is the most effective. In that we must always be looking at what we are doing and how we might do it differently if the end result is better for our clients. So what can we do with 3D printing Can we use it for prototyping Can we use it for diagnostic sockets Can it be part of our future Absolutely. The appropriate additive technology in our clinics will help to serve our clients well. Researcher s Perspective Jan Andrysek PhD P.Eng. Scientist Bloorview Research Institute Holland Bloorview Kids Rehabilitation Hospital Associate Director Clinical Engineering Program IBBME University of Toronto I am a mechanical engineer and a researcher. A lot of the work that we do is on the prosthetic side starting with the concept then designing it creating it and testing it for practical utilization before taking our research to the market. We use 3D printing at the prototyping stage mainly because it is more cost-effective for a one-off prototype to test. Rapid prototyping is a benefit. That is a strength of 3D printing. Within just a few days we can go from a design to having something physical to try out in the real world. It s great for testing fit and function but the parts don t have the mechanical or structural properties for durability for everyday use. 3D printed prototypes also help us assess user perception of the component in terms of appearance. There are technical challenges that come with trying to print a good part and it makes sense to contract that part of the fabrication process out. There is a lot of trial and error. The set-up and orientation for the part takes a skill set. It s not like a push-button paper printer. There are a lot of factors to consider depending on the complexity of the part. Eventually if prosthetic technologies are to be 3D printed higher-end printers will be required as well as technicians trained to operate them. When mass-producing there are much more cost-effective ways of producing componentry. 3D printing is slow and can be costly. An injection-moulded part is much higher quality than a 3D printed part and in quantity they are much cheaper. Right now 3D printing certainly has its place in customized components... one-off technology makes the most sense which can apply to sockets and braces. When printing you can vary the structure and the properties of flexibility and work with more complex shapes which can make the fabrication process easier and more efficient. Like any technology however we need to go through an informed process in applying it. In this case what is really 38 missing is information quality research data speaking to how these devices are doing in the field. There hasn t been any formal assessment on how the technology is impacting users. Of course clinicians know this and consequently really don t know whether this technology is good for their clients or not. I think for sockets for example it s a more promising application of additive technology but from a technology point of view 3D printed sockets are not parallel in strength to conventionally-fabricated sockets. I think it will be in other fields that 3D printing technology advances first which then can be applied to the prosthetic and orthotic field. When it comes to the creative aspect of it there is the potential of new P&O design ideas to come out of this technology. Having a great idea and a great design is one thing but bringing it to a quality product is another. Fitting a device that is safe and serves the patient well is another level as well. As a researcher and an engineer there is an onus on me to use my expertise and skills as best as I can to make sure that the devices are sound and functional. So the basement prototypes are always going to need someone who can be brought on board to take them through the next steps. Evolution of a prototype knee component produced by more sophisticated 3D printers each time. Educator s Perspective Dan Blocka CO(c) B.Sc. FCBC Part-time Faculty George Brown College President Boundless Bracing It s definitely true that the media s perpetuation of the ease of layman 3D printing of prosthetic devices with great visuals of a young boy putting on a colourful homemade prosthesis has created anxiety within our profession. But what s to get upset about This is an opportunity for us to bring these groups into our space and educate them on what total care is all about which will help to dispel some of the friction and negativity. It s important to have discussions with those working outside of our industry and coming into our space to determine how we can work together. Sure some will be renegades and mavericks but getting them to understand the realities of fitting a prosthetic device is what we need to do. And we don t know what we can learn from them. We need to bring our own stories to the media that are just as attractive. One of the objectives of the consortium is to be a communicator to the public the media and take a position on the technology as a group encouraging best practices within the field. These are the terms we need to perpetuate in the minds of the public when our profession is asked about this technology. Change happens so quickly in our world and it s difficult to predict the future. I don t see displacement of clinicians by 3D printing technology in the near future. The interaction between client and clinician is still key 39 for assessment of needs and capabilities. It s not like picking something up at the McDonald s drive-thru window. There is a human being at the other end of this who needs to be understood by someone who understands their unique needs. But being resistant to adopting new and evolving technologies means staying stagnant which is dangerous for the future of our profession. There could be all kinds of different things coming our way in the future beyond 3D printing for optimizing solutions for our clients. The more we can use science to optimize solutions the better. Of course there will always be an art side to our profession. So we want our students to always keep their eyes open to developments that can enhance practice. We have some students who come to us already thinking about the potential of utilizing new technologies based on previous experiences and educational background. We explore new technologies in the P&O programs. I want our students to understand that there is much work to be done in the area of 3D printing. They will need to recognize the potential of 3D printing and its possible future within our profession. There s also potential to partner with other industries. We need to get over the fear. We need to embrace it and harness its power and not worry about it displacing us. If we are displaced by something it s our own fault and our own problem especially if it s best for the client. In our school setting providing awareness for the students and hands-on capabilities as is appropriate and as we can afford it is in our best interests. We want to make sure that upon graduation the students are equipped to evaluate new technologies. 3D printing is another tool and in the P&O clinical space of the future I foresee technicians needing to add 3D printing manufacture maintenance troubleshooting and enhancement to their competencies. With strong partnerships in other industries the new graduates will need this knowledge to stay on top of new developments. I think the new additive technology can help us better understand what we do now and make us better for it. Scientist s Perspective I started looking at 3D printing back in 2008 and became an expert in the field. I set up a lab called the Critical Making Lab and have evaluated about 25 different kinds of 3D printers. But what has been most important is studying the application of 3D printing from a social perspective. Several years ago I was approached by CBM Canada a large NGO working with hospitals in developing countries to be part of a project to produce 3D prostheses. In dialogue with CBM Dr. Matt Ratto MA PhD. Chief Science Officer for Nia Technologies Associate Professor in the Faculty of Information at the University of Toronto and Director of the Semaphore Research Cluster on Inclusive Design Mobile and Pervasive Computing and the Critical Making Lab. Canada and a team of prosthetists and prosthetic technicians at Corsu Hospital in Uganda we decided to focus on trans-tibial prosthetic sockets specifically. We also consulted with the P&O and Research departments at Holland Bloorview and with educators in George Brown College s P&O Program. We suggested that there is no benefit to 3D printed parts that are standard. We proposed 3D printing for what is custom to the prosthetic device sockets. It would be cheaper faster and much less labour-intensive to use a digital modeling process... about two hours of screen-based digital labour and about 12 14 hours of print time which is unattend40 ed (no manual labour). With our system a patient presents on a Monday and within 10 or 15 minutes they ve been scanned. The modeling process takes about an hour depending on the skill of the practitioner and then the printing begins. The next day they leave with their prosthesis. The power is in the hands of the practitioner and not the computer. With our technology it would be difficult for a practitioner to make a bad socket but depending on the level of training it s in their hands to create a really good one. Our two areas of focus right now are trans-tibial prostheses and AFOs. The practitioner does the work we are giving tools to prosthetists and orthotists not Photo by ginger coons Semaphore CC replacing them. The hospitals in Uganda find the funding to buy the tools and the tools remain in their clinics as part of their daily practice. We are not a team that flies into a country does the work and leaves. This is all about sustainability in everyday practice. We do a lot of material testing and simulations in the University of Toronto lab to determine how best to print the nylon material that we use. By changing the way that the plastic is laid down in a 3D printer we get a number of manipulations to those printings to test on a destructive tester which essentially breaks them. We look at three critical variables tensile strength yield and elasticity to help us to determine the best settings for 3D printing of sockets. Another benefit with the digital process is that everything is preserved. At the end of the day you have a scan a rectified positive and the socket model in digital files. Within our software we have created the opportunity for those files to be accessed by other practitioners for peer review in a sense. It s like Google Docs... another practitioner in another part of the world is able to look at it rotate it and compare it to the original scans. What we consider a check socket the developing world knows as a final socket. But if a 3D printed socket was to be used as a check socket where for example the socket was pushing on a neuroma on a medial flare the digital model can be brought up and looked at by the practitioner and the patient. A digital sculpting tool will push out an area. Or maybe it s a suspension issue the tool can pull in the medial and lateral flare as needed to add more grip. 3D technology definitely fits in the space of a capacity for the patient to have a much bigger role in the production of their own prosthesis. When a prosthetist takes the shape of a residual limb that s really not a capture of the surface of the residual limb. It is a contained image manipulated by the process. With a scanning process it is a surface capture. The rectification process which is a very hands-on process is moved from a physical space to a digital space. This is a change of expertise. That direct contact with the patient which is so important is something that we think a lot about in trying to come up with ways to reconnect the prosthetist and the patient. We don t want to drop a computer in the way of that relationship. That has to be a design principle for anyone doing the 3D printing process. We have to preserve the manual hands-on skills and expertise of the practitioner. As for evidence-based practice when we searched for P&O studies what was found was small-sized case studies a case study with four subjects. The first clinical trials in Uganda involved 40 patients being fit with this new technology. Certainly over time they will be difficult to follow but in the initial fitting stages we developed some very granular data and acquired evidence. But for me the evidence-based practice aspect for the O&P community is not as significant as my own personal anxiety about creating and sending a new intervention out into the world to be dispensed. One of our big concerns for our software is releasing it for public consumption too soon. We want to ensure that we have everything working properly. But our biggest concern is abuse of the technology... not by certified practitioners but by non-practitioners a group of people putting a 3D printer on their shoulder and heading off to produce prosthetic devices without proper training. Can practitioners afford the printers The printers are inexpensive. It s the software that is pricey. The printer we used in Uganda cost about 7 000. We are now deploying two smaller printers which cuts printing time in half and reduces downtime costing only 2 000 each. The software we have created uses some open software but the digital rectification component will be more expensive. Expensive in part because the market is so small. It should be possible for a small clinic to do digital CAD CAM 3D technology printing. But right now for a small facility it may not make financial sense. For more information visit www.niatech.org. 42 Facility Owner s Perspective Michael Pecorella CO(c) Toronto Orthopedic Services Limited printing. Insurance companies may not be aware of the difference in central fabrication being done by machine or by hand where there is a manufacturing invoice that corresponds to the services provided. This too will change in time. 3D additive technology is here and will continue to grow. If P&O doesn t embrace its hopeful potential there will be other healthcare providers ready and willing to take it on. This has happened in the foot orthotic industry and we now see MDs and other professionals as well as central manufacturers and distributors outside of the scope of P&O providing these services. There are currently several online 3D printing manufacturers selling directly to the consumer in North America. Personally I don t wish to see this happen with P&O. With good education good software and hardware there is nothing preventing anyone from making a 3D manufactured device. But is it the correct device required by the client But having enough P&O professionals to be the main conduit for 3D additive manufacturing of devices and the delivery of these services is an issue... maybe not as much in large rehab hospitals but this is certainly an obstacle in rural areas where services are lacking. With 3D additive manufacturing current technical manpower restraints can be overcome because 3D printing machines are numerous and can be run 24 7. We have yet to determine via evidence-based research that 3D additive manufacturing is comparable better or worse than current hand-made devices. Are there safety or liability issues Not all printers or other 3D additive machines are the same. Heat dust particulates ventilation consistency of plastics being used durability of designs etc. are all new issues that have to be objectively evaluated. Scientific studies with appropriate protocols and outcome measures are needed. As for funding in Ontario the Assistive Devices Program (ADP) is saying no to 3D manufacturing as a billable product. ADP acknowledges that long-term 3D additive manufacturing will likely be allowed. ADP pays for raw goods parts and a small portion of professional time and is open to the idea that the costs of raw goods and materials may be reduced by 3D The benefits of using additive technologies in our business relates to the fact that orthotic devices are generally one-offs with unique custom shapes that cannot be mass manufactured using conventional methods. Also P&O devices sockets and braces for example can be made with variable thicknesses or walls having uniquely hollowed structural compositions to achieve the desired mechanical properties like strength weight flexibility. Faster fabrication producing exact duplicates and ease of making changes are other advantages. But an investment in equipment and training is necessary and model modifications from scans are more difficult than working with physical systems. I see P&O growing into a computer-designed and manufacturing profession that has a far reaching effect moreso than how P&O devices are currently provided. I see far less hand-crafting being done in the future which will affect the P&O profession. Education and recognition of the P&O field and profession needs to be cultivated outside of our small sphere of influence in rehabilitation. This has been a major problem for years. 44 Technician s Perspective Right now our silicone department doesn t work with 3D printing at all. We use 3D printers in our research and development department for prototypes and testing. My knowledge about 3D technology comes from what I ve researched and learned at conferences. A lot of what I ve seen has been on social media... kids getting 3D printed paediatric hands as their first device. On social media it almost seems trendy and is bringing attention to our field but by non clinicians mostly. I have a problem with that. There is a dis-connect here. We want high-quality devices for our clients and what we learn in school and clinical practice supports that. It s why we fabricate devices in a particular way or why we choose certain materials. What I see in the YouTube videos looks cool but to me seems more like a toy than a prosthetic device that would be durable enough to wear every day. And then there s functionality too There are anatomy issues to be considered forces applied to the residual limb alignment and lifestyle factors that all affect design and use. Kyla Lau BSc RTP(c) Supervisor - Custom Silicone Services Ottobock HeathCare and Part-time Faculty George Brown College I tell the students who I teach at George Brown College that what we make is not for an inanimate object. We are building these devices for human beings... for people whose tissue can change from hour to hour. We build a device one way but we will have to modify it based on fit and feel for the client. From day one students are asking about 3D printing. This generation is interested in trends and new technology and getting involved with it and that s a good thing. I work for a company that relies on rigorously testing a product before it is launched with trials and testing to make sure it is durable and does what it is intended to do. The 3D printed devices don t necessarily go through the same rigours of testing. What I would like to see is more collaboration with clinicians and technicians from the O&P field. Together we can use their technology and our knowledge to design something that is better for the client. We have to embrace new technology. If we turn our backs to it we are going to be left behind as a field. We need to determine how it can be applied to our field. We need to bridge the gap between the 3D printing manufacturers and our professions to come up with something that is best for our clients. For myself I am looking at how I could use this technology to improve upon what we have and do now. I believe we are still far from 3D printing replacing what we do but I can see it assisting with some of our duties. There s a lot to learn. 46 C-Leg 4 Clinically proven outcomes C-Leg studies have shown improved quality of life 1-2 7-11 and satisfaction12-13 and up to 88% preference over non-microprocessor knees.1 3-6 The C-Leg has shown to reduce falls up to 80% in lower mobility patients when compared to mechanical knees. 2 professionals.ottobock.ca 13998 - 03 17 2017 Ottobock HealthCare LP All rights reserved. SPECIAL FEATURE SECTION 3D PRINTING TECHNOLOGY 3D Printing is Coming to Our Clinics The Question is... Who s Bringing It 3D printing has become a hot topic in the world of prosthetics. In the last few years industry news has been filled with stories of groups that are exploring the application of 3D printing techniques to the field of prosthetics. These stories often seem to involve university students hobbyists engineers designers and others outside of the prosthetics and orthotics community who just like us are eager to use their skills to help people. Several of these groups are using 3D printing to help increase access to prostheses in the developing world while others are using it to provide lower cost options to patients who can t afford them. Now that 3D printing is gaining more publicity many of our patients have begun to ask us why we don t use 3D printing in our prosthetic clinics. As professionals who are responsible for our patient s safety we have valid concerns about the strength reliability comfort and durability of using a new method of manufacturing. But while many might think of 3D printing as a new technology in the world of prosthetics it actually started in 1990 when a group from Northwestern University s Medical School was experimenting with using rapid prototyping methods to make prosthetic sockets [1]. Since then groups from all over the world have explored the application of 3D printing to prosthetic devices. One of these groups is a pair of certified prosthetists in the U.S. who are successfully using this technology in their practice. They ve found this technology to have benefits when used to make diagnostic sockets for their patients (http www.additiveoandp.com home.html). By Brittany Pousett M.Sc. CP(c) We at Barber Prosthetics Clinic were inspired to see it for ourselves. We didn t want to overlook a valuable addition to our repertoire of manufacturing methods if it could provide us and our patients with some benefit. This led us to purchase our own 3D printer and begin printing sockets in our clinic. Many people outside of the field of prosthetics believe that 3D printing is as easy as scanning a limb and pushing the print button on a 3D printer. It s not that easy In order to create sockets that are suitable for patient use there are a number of decisions to be made regarding the structural design of the 3D printed socket the printer parameters and more. If we as certified prosthetists don t get involved in the develop- ment of this technology from the beginning others will continue to develop it for us and continue to introduce the idea to our patients. That is why Barber Prosthetics has committed to being involved in the research behind 3D printing socket technology. As certified prosthetists and registered technicians we bring an expertise to the design manufacturing and fit of prostheses that no one else can. We need to be involved in conducting the research to apply our expertise and shape the objective science behind this technology in order to determine if it is safe and suitable for our patients. If the research shows that it is suitable we need to lead the way in demonstrating how this technology can be successfully implemented into our clinical practice in a way that complements the traditional way of doing things. This brings us to the first limitations we want to address how strong are 3D printed sockets At first glance they appear to be quite strong but how do you know for sure This is the most significant limitation we have encountered when exploring new socket materials as there is no standard on how strong they must be to be used by our patients outside of our clinics. To address this need we partnered with a team from the British Columbia Institute of Technology and a Biomedical Engineering student from Universidad Iberoamericana in Mexico City. Together we are working on applying the ISO standard of lower extremity prostheses to socket strength testing in order to compare the strength of conventionally-fabricated sockets to those printed with 3D technology. We are in the midst of testing but are excited to share the results. Stay tuned for more information on if and how 3D printed sockets could become part of your prosthetic treatments in the future Reference [1] Herbert N Simpson D Spence W Ion W. A preliminary investigation into the development of 3-D printing of prosthetic sockets. Journal of Rehabilitation Research & Development. 2005 42(2) 141-146. About the Author Brittany Pousett M.Sc. CP(c) is a certified prosthetist and the Head of Research at Barber Prosthetics Clinic in Vancouver B.C. She has a Bachelors of Science in Biophysics from the University of British Columbia and a Masters of Science in Rehabilitation from McMaster University. Pousett is passionate about integrating research into clinical practice in order to provide her patients with evidence-based care. 49 SPECIAL FEATURE SECTION 3D PRINTING TECHNOLOGY Technician Perspective on Emerging P&O Technology A Focus on 3D Printing By Alyson Clow Technical Intern and Daryl Murphy RPT With 3D printing coming to the forefront of discussions in the prosthetics world some technicians may worry about their jobs being in jeopardy. We are two employees at Barber Prosthetics who find our outlook to be quite the opposite. We see the potential in 3D printing to enhance our jobs allowing us to do intricate work that would otherwise take many hands-on hours. However we the authors of this article believe that 3D printers will enhance our skill set and allow us to become more creative than we have been in the past. A great way to start this process is to sign up for online courses to educate ourselves on anything new in the profession and to keep on top of this emerging technology. We found an online course through Coursera and the University of Illinois and decided on the 3D Printing Specialization. It consists of four courses and one Capstone project that finishes with a Certificate in 3D Printing. Two of these courses 3D Printing Revolution and 3D Printing Applications give basic information on 3D printers applications and how it all started. They are very basic and could be skipped if one didn t want the Specialization Certificate or if extra time is hard to come by after a work day. At minimum we recommend the 3D Printing Software and 3D Printing Hardware courses as they teach you how to transform ideas into CAD files and how to repair 3D printers. This knowledge can start you down the path of creating useful ideas to bring to your workplace and patients. We believe that patients who are interested in venturing away from a traditional-shaped foam faring will benefit greatly from a clinic with a 3D printer. We believe this is the obvious artistic use of a printer and when structural stress testing is complete on different types of materials and designs and if they are deemed safe then branching out into other avenues involving one-piece designs made of different mate- Materials with new possibilities are unfolding for the profession with respect to what 3D printing can offer clinics and patients. We are excited to be part of something that is evolving to acquire new skills that will contribute to the future of the profession and to have more time to focus on other areas of work. This article was written to offer our collective perspective on what we have learned so far as a prosthetics technical intern and as a registered technician with 27 years of experience. Technicians have been hearing it for years. Often when the subject of 3D printing is approached we default to the notion that all of our skills will be replaced by a computer software program and we will be out on the curb with a box of tools and a parachute cord. 50 PROSTHETIC SOLUTIONS 1 2 Unique Liner Technology NSP CSP Carbon free laminate braids with dynamic stiffness 3 Innovative Locks 4 Component Solutions 5 Unique Knees DISTRIBUTED IN CANADA BY 1.800.663.1254 Order online at www.orthoactive.com rials printed with 3D technology will start to emerge. Advances in this technology will see higher-tech printers becoming available at lower price points and further feed the minds of technicians to come up with new uses both practical and artistic to be used in the P&O profession. In being open to this new technology more applications for 3D printing will emerge... some that wouldn t have been possible with more traditional methods. At present 3D printed objects take time to complete but one can assume that this will follow the usual technological trend of next generation printers being more efficient than those before them. Even now with a medium-sized TT check socket taking roughly nine hours to complete it would free up some time for a technician to work on other tasks. If the patient is coming back at the end of the day it is unrealistic to have it 3D printed with the time constraints that the machines deliver at this present time. Take advantage of this extra time and treat it as a job that you do not have to physically work on and focus on other tasks or add another to your WIP as the printer is doing one for you. There are many 3D printing materials on the market. Each has its different applications but with more varieties becoming available the possibilities of what you can design with them are becom- ing more numerous. It is up to us to decide what will be a good fit for our profession and our patients lifestyles. The materials that are now commercially available for printers that would be used in most clinics are Polylactic Acid (PLA) or Acrylonitrile Butadiene Styrene (ABS). There are materials you can purchase that give the look of grey stone or fiberboard that can be cut and sanded ceramic material that can be fired and glazed PLA-infused with brass bronze copper or steel and even magnetic iron that could have some creative uses. Not all are practical for our profession but many could be utilized to create devices that would otherwise require many extra hours of precise work and call for time that we may not have. Patients who desire more eye-catching devices would have more custom choices which could be fabricated in-house. Wearing these walking art science pieces and showcasing devices to everyday people who may never have seen one before could have positive social consequences. P&O devices would become more visible and more acceptable or normal changing the conversation starter from What happened to Wow That is so cool With this change in attitude patients might feel more assured of themselves when wearing a device for the first time. Those who choose a more natural-looking design wouldn t feel as self conscious about having a slightly different-looking leg as it would normalize the wearing of a prosthetic device. So how does this new application of 3D printing technology affect us We are all technicians with different levels of experience in this new avenue that has opened up in our profession. As a Prosthetic Intern it can be a bit daunting to jump back into the education wheel to begin learning this technology. But it will be an advantage both personally and in the workplace. Be excited for the artistic possibilities to be tackled in this new medium. Just recently our clinic has started 3D printing. Although this technology requires new skills and more importantly wrapping your mind around a new way of thinking it is quickly becoming 52 our favourite skill. Whether you as a technician are 3D printing a fab dummy tool test socket custom-designed cover or fabricating a laminate socket we can all agree that our time usually quickly disappears each day. We find that 3D printing has allowed us to develop another skill set to enhance our problem-solving ability and be more productive. It has also opened a door to creating some extremely cool jobs. We believe that it is up to us as technicians to learn this new skill set and incorporate it into our daily activities. We already see that 3D printing is invading our profession with cranial helmets bracing prosthetic covers and sockets. It is always better to be ahead of the curve than behind it. If you have been in this field for any length of time you realize just how quickly the technical side of the field has changed. In the past TF sockets were made from wood. Exoskeletal hollow wood prostheses were the norm. Now they are subjects of museums and art displays. These types of prostheses were made en masse just 20-30 years ago. Now you can hardly find someone who remembers them let alone knows how to make or finish them. If anyone is able to adopt 3D printing in any form it would be technicians. We have a unique skill set to problem-solve our way through the unknown. And with some encouragement and education we can master 3D printing and develop a completely new way of manufacturing devices. About the Authors Alyson Clow is currently working as a Prosthetic Intern at Barber Prosthetics Clinic in Vancouver B.C. She graduated from the George Brown P&O Technical Program (2013) and has a B.Sc. KIN from UNB (2011). Daryl Murphy is currently an RPT at Barber Prosthetics Clinic in Vancouver B.C. He has worked in this profession since 1990. References 3D Printer Filament Comparison Guide MatterHackers Inc 2017 www.matterhackers.com 3d-printer-filament-compare. Accessed 14 Jan. 2017. Alignment_april 2017.indd 2 53 2 27 2017 9 24 20 AM SPECIAL FEATURE SECTION 3D PRINTING TECHNOLOGY Boundless Opportunities By Helen Cochrane CPO(c) Additive manufacture (including 3D printing) offers many advantages freedom of design ability to create complex structures modulate material properties quickly create bespoke objects optimize strength and reduce the overall weight of a design. While these technologies can be used for mass production its perceived value is in creating complex devices that are high in value but needed in relatively low volume.1 expertise is balanced with other factors. For this reason the staff at Boundless Biomechanical Bracing (Boundless) have engaged in efforts to contribute to the body of knowledge around additive manufacture as it applies to orthotic services. in Additive Manufacture of Orthotic Devices These features of additive manufacture make the technology appealing for application in specialized healthcare fields like orthotics. However the proliferation of the technology may also represent a risk to the profession and the people that it serves. By abridging complex clinical service into the production of a simple device key aspects of the clinical pathway may be lost. With advances in technology there is a need to ensure that quality of care is preserved and clinical The Need to Increase Access to Services The number of persons with disabilities is reported to be on the rise owing to an aging population and an increase in chronic diseas54 es. It is estimated that there are at least 100 million persons worldwide who would benefit from orthotic and prosthetic services. However only one in 10 persons currently has access.2 In the 2012 Canadian Survey on Disability 3.8 million people were reported to have disabilities that limit their daily activity. Disabilities related to pain (10%) flexibility (8%) and mobility (7%) were reported to be the most prevalent. In the survey 80% of persons with a disability indicated that they used at least one aid or Fig 1. 3D printed Ankle Foot Orthoses cast computer measuring tools and scanning equipment. assistive device and 27% of survey participants needed a device they did not have.3 be able to meet the need of the growing population. There is a demand to increase workforce capacity and or efficiency to ensure that the increased number of orthotic users have access to assistive devices provided by qualified professionals. Fig 2. Digital shape capture of the lower limb. change in their skill set that may not improve job satisfaction for some of those currently in the field. The authors proposed that expected changes might appeal to a computer-literate demographic as they join the workforce which could improve recruitment retention. The authors also noted that in other fields where additive manufacture has been integrated while practical aspects changed knowledge and skills remained relevant.6 These changes may be expected to impact orthotic professionals as well and could be an opportunity to improve efficiency allowing for increased time for other areas of practice. Orthotists are known as healthcare professionals who are educated trained and credentialed as leading experts in their discipline and have a key role in determining the most appropriate treatment for individuals who require orthoses.7 To sustain that position the profession must be prepared for changes in knowledge and skills that will arise with technology-related innovation in the field. The Need for Professionals A 2002 U.S.-based study projected that the demand for orthotic services could be expected to grow such that by the year 2020 the estimated number of U.S. orthotists would only be able to serve 62% of those in need.4 This trend was also reported as a concern in the Practice Analysis of Canadian orthotic and prosthetic professionals. In the survey many respondents reported concerns that the number of graduates of programs recognized by Orthotics Prosthetics Canada would be unable to meet the increasing demand for qualified services. In addition it was noted that the profession was at risk of an increasing risk of encroachment from outside the profession. 5 These findings suggest that there is a current unmet need for services which is projected to grow. It is unlikely that the current volume of service providers will Affect on the Profession Additive manufacture may have the potential to effect change in the competencies of orthotic and prosthetic professionals. In a study by Wagner et. al. that aimed to evaluate the impact of rapid manufacture on the skills of professionals working in the field of prosthetics the outlook for the prosthetist was considered positive. The authors reported that the necessary skills for implementing the technology could enhance interdisciplinary communication and improve the ability to review the user s condition over time.6 The authors suggested that technicians may not experience the same benefits and that the risk exists that they could see a 55 Fig 3. University of Guelph student scanning using the Structure Scanner at Boundless Biomechanical Bracing in Mississauga ON. Fig 4. University of California Berkley students presenting their findings. Evolution of Additive Manufacture Additive manufacture has existed since the 1980s.1 Early technology required large capital investment in machinery and equipment that restricted its use and integration to limited industries. Recent advances in the technology have reduced costs and necessary expertise associated with accessing the technology.8 As additive manufacture has become increasingly accessible many industries including healthcare are assimilating it into their workflow with some leading companies reported to be pushing the boundaries of targeted marketing.1 In the Orthotics Prosthetics Canada Practice Analysis an increase in the applications of additive manufacture including 3D printing was among the most frequently reported areas where respondents expected there to be changes in technology components and materials in the future of the field.5 In the next decade 1.9 billion dollars is expected to be spent on medical applications in additive manufacture.9 Industry and governments have begun to see potential in the technology to improve efficiency. The role of additive manufacture in the delivery of orthotic services is no exception to the investments in research and development for medical applications. One example of the commitment of government investigation into the role of this technology in orthotics is the A-FOOTPRINT project. The joint research and innovation initiative aims to develop novel Ankle Foot and Foot Orthoses for common disabling conditions that are cost-effective high-speed to market and personalized for form and function.10 This consortium is 56 a collaboration that spans seven European member states across twelve partner organizations and reports that almost four million Euros have been granted through the European Commission to support the initiative.11 Reduced capital investment and expertise needed to access advanced technology offer many opportunities. Large-scale investment from governments and funding agents suggests that there is interest at the policy level to see this technology advance as is grassroots support to see the technology applied for the benefit of users. However it should be noted that scientific and regulatory challenges exist and that substandard devices remain a risk.9 There also appears to be an increase in the number of individuals creating prototypes and novel devices. A recent article in the Guardian newspaper report- ed that in one online community alone there were more than 7 000 members in dozens of countries with access to 2 000 printers for making upper limb prosthetic devices.12 Many of these communities aim to make available low-cost easily and or rapidly deployable devices. Yet many of these devices have little testing or evidence to support their outcome. Clinical Applications in Additive Manufacture In a review by Jin et. al. of additive manufacture in custom orthoses and prostheses the authors reviewed 25 years of published studies. They found that although there had been limited clinical evaluation the technology had demonstrated good fit and adequate strength in orthotic and prosthetic applications. The authors cautioned that the evidence showed that barriers to full-scale implementation exist in clinical technical and financial aspects.13 Additive manufacture presents a range of risks and potential benefits in the field of orthotics. It is of importance that the profession monitor develop knowledge and or skills in the interest of best practice. Orthotic professionals appear to recognize that these technologies are entering the field. As the technology is moving rapidly the importance of including orthotic clinical and technical expertise cannot be over-emphasized. Small-scale clinical trials are showing promise but there is a need to ensure that experts in orthotics participate in the research process to ensure that clinically-relevant aspects are included. Boundless has committed to engaging in research and development of 3D printing applications to ensure that key elements of orthotic theory are incorporated in the assessment of these technologies. Boundless Activities in Additive Manufacture In the realm of additive manufacture one challenge perceived by clinicians is the shift from traditional methods of shape capture to digital models. Clinical staff at Boundless have been actively involved in testing software for shape capture and rectification of Ankle Foot Orthoses. The aim of this work has been to assess the practicality of applying new technology in a fast-paced clinical setting. While Boundless has previously worked with digital shape capture technologies the current generation shows improvement in ease of use and quality of scans. Although these methods require new skills to be developed digital shape capture may provide a quick and clean experience for users and allow for the digital image to be easily stored modified or repeated with limited effort. The staff at Boundless has also been actively involved in assess- Fig 5. Rapid prototype 3D printed Ankle Foot Orthosis (dark brown) beside (white) Nylon 3D printed Ankle Foot Orthosis. Fig 6. 3D printed Ankle Foot Orthoses showing evolution of printing topography. 57 vene quarterly to work towards developing inter-professional cooperation in the realm of orthotics and prosthetics and additive manufacture. The consortium includes stakeholders from a variety of perspectives including public and private orthotic and prosthetic clinical services the 3D printing industry academia and the not-for-profit sector. The consortium began with efforts to improve the understanding of professionals on how 3D printing could be incorporated into clinical practice. The group identified knowledge gaps and worked to share expertise between professionals unique to each discipline. Fig.7. Consortium Members Back row Joshua Qua Hanse Matt Ratto Tharwat Fouad Daniel Pecorella Michael Pecorella Dan Blocka Ryan Schmidt Jan Walker Winfried Heim Anbhu Sritharan. Front row Helen Cochrane Sandra Ramdial. ing the technical aspects of production for 3D printed Ankle Foot Orthoses. In 2016 Boundless University of Toronto Semaphore Lab and Nia Technologies jointly hosted the internship of two University of California Berkley Bioengineering students to investigate additive manufacture for Ankle Foot Orthoses. The project aimed to assess the accuracy of the Ankle Foot Orthoses produced using a 3D printer versus traditional methods. This exploratory study included two experiments. The first assessed the accuracy of the 3D scanning process and the second assessed the accuracy of the 3D printed devices. This project was a first step towards verifying the consistency between various stages and processes in 3D printing Ankle Foot Orthoses. Collaboration in research is ongoing with a second Bioengineering study currently in progress jointly hosted by Boundless University of Toronto Semaphore Lab and Nia Technologies. The aim of this project is to work towards developing a finite element analysis tool so that orthoses that are designed in 3D printing can be specific to individual users. The project will compare tensile characteristics of traditionally manufactured Ankle Foot Orthoses to material characteristics for devices created using digital tools. In both studies participating interns relied on experienced clinical and technical staff at Boundless to direct and support decisions related to orthotic theory and application. Both groups applied these principles at the Semaphore Lab using state-ofthe-art equipment and guidance of expert researchers to develop and implement their study. These studies helped to scope the challenges unique to orthotic devices when implementing 3D printing and represent a valuable step in progressing the knowledge of how additive manufacture can be meaningfully implemented in orthotic practice. Further studies are planned for 2017. In recognizing the importance of collaboration the staff at Boundless has also engaged in a consortium of experts who con58 The consortium has entered into a phase of strategic planning To optimize resources Set forth a plan for collaborative efforts to build knowledge that is specific to the local setting Take beginning steps to determine best practice for additive manufacture in orthotic and prosthetic settings. Conclusion Additive manufacture is becoming increasingly simple and affordable and advances in shape capture and 3D printing may hold great potential in custom orthotic services. An opportunity exists to increase productivity and enhance and expedite orthotic services through the use of these new tools. However an unmet need for orthotic services may create a risk where other professionals industries or individuals (without in-depth clinical technical knowledge and skills) capitalize on the profession s inability to meet the needs of the increasing volume of users. The absence of appropriate input from professionals may result in suboptimal outcomes for users and the profession. It behooves the profession to develop the knowledge base build skills and work with relevant partners to ensure that an optimized standard of care is preserved for users and for orthotic and prosthetic professionals to flourish in the digital realm. For better or worse additive manufacture will change the field of orthotics. It is therefore incumbent upon the profession to engage in collaborative efforts with other stakeholders to ensure that the tenants of optimized clinical practices keep pace and contribute to the evolution of new technologies. The efforts of Boundless to develop knowledge and skills in additive manufacture require a long-term commitment. There has been a need to invest in human resources and equipment as well as to find a balance between time-away from clinical practice for experienced staff with the needs of a busy private practice. While balance is often difficult to achieve a structured approach to incremental implementation will hopefully leave a lasting legacy and contribute to the ongoing development of the profession while ensuring optimal outcomes for users of orthotic services. References 1. Nissan AM. Regulating the Three-Dimensional Future How the FDA Should Structure a Regulatory Mechanism for Additive Manufacturing (3D Printing). BUJ Sci Tech L. 2016 22 267. 2. World Health Organization. Standards for Prosthetics and Orthotics Service Provision 2015-2017 work plan [Internet]. 2015 Sep [cited 2016 Feb 19]. Available from http www.who.int phi implementation assistive_technology workplan_p-o_standards.pdf. 3. Government of Canada SC. Developmental disabilities among Canadians aged 15 years and older 2012 [Internet]. 2015 [cited 2017 Feb 9]. Available from http www.statcan.gc.ca pub 89-654x 89-654-x2015003-eng.htm. 4. National Commission on Orthotic Prosthetic Education Neilsen CC. Issues Affecting the Future Demand for Orthotists and Prosthetists Update 2002 [Internet]. 2002 May. Available from http www.ncope.org summit pdf Footnote3.pdf. 5. Orthotics Prosthetics Canada. Practice Analysis Study of Certified Clinicians and Registered Technicians. New York NY 2014 Sep. 6. Wagner H Dainty A Hague R Tuck C Ong MH. The Effect of New Technology Adoption on Employee Skills in the Prosthetics Profession. Int J Prod Res. 2008 Nov 46(22) 6461 78. 7. Fisk JR DeMutt S Campbell J DiBello T Esquenazi A Lin RS et al. Suggested Guidelines for the Prescription of Orthotic Services Device Delivery Education and Follow Up Care A Multidisciplinary White Paper. Mil Med. 2016 Feb 181(Supplemental). 8. Telfer S Pallari J Munguia J Dalgarno K McGeough M Woodburn J. Embracing additive manufacture implications for foot and ankle orthosis design. BMC Musculoskelet Disord. 2012 13(1) 84. 9. Ventola CL. Medical Applications for 3D Printing Current and Projected Uses. P&T [Internet]. 2014 Oct 39(10). Available from https www.ncbi.nlm. nih.gov pmc articles PMC4189697 pdf ptj4910704.pdf. 10. webteam gcu.ac.uk. Home A-Footprint [Internet]. [cited 2017 Feb 16]. Available from http www.afootprint.eu . 11. webteam gcu.ac.uk. About A-FOOTPRINT A-Footprint [Internet]. [cited 2017 Feb 16]. Available from http www. afootprint.eu about . 12. 3D-printed prosthetic limbs the next revolution in medicine Technology The Guardian [Internet]. [cited 2017 Mar 2]. Available from https www. theguardian.com technology 2017 feb 19 3d-printed-prosthetic-limbs-revolution-in-medicine. 13. Jin Y Plott J Chen R Wensman J Shih A. Additive Manufacturing of Custom Orthoses and Prostheses - A Review. In Procedia CIRP. 2015. p. 199 204. About the Author Helen Cochrane CPO(c) is a Canadian Board Certified Prosthetist Orthotist with a Masters Degree in Rehabilitation Sciences from the University of Strathclyde and with Technical and Clinical Diplomas from George Brown College. She has worked in prosthetic orthotic education in South East Asia and in public and private clinical services. She currently works at Boundless Biomechanics Bracing in Mississauga. 60 THE WATER PROOF Made with high strength nylon. CYLINDRCAL SHUTTLE LOCK C100 Saltwater tested for 2 million cycles plus with an antimicrobial and UV inhibited foot shell the progressive Soleus foot performs flawlessly at the pool lake ocean or outback. INTRODUCING LOCKING SHOULDER JOINT The Axis features a 240 range of motion with 24 different locking positions. 800.728.7950 586. 294.0067 college-park.com HiFi Femoral and Tibial Socket Training NOW AVAILABLE ONLINE Follow biodesigns & HiFi STILL MAKING BUCKETS Say goodbye to the bucket and embrace the High-FidelityTM Interface System with patented and patents-pending technology. THE HIFI SYSTEM IS UNLIKE ANYTHING ELSE TEM HiFi Interface is custom-made adjustable lightweight and low profile om-made ll HiFi Interface is for all levels with a limb remaining HiFi Interface works with all known suspension methods (straight suction roll-on liner elevated vacuum etc.) ner HiFi Transfemoral Interface is subischial without vacuum terface sed HiFi Interface was used on DEKA s Luke Arm (DARPA s Revolutionizing Prosthetics Program) HiFi Interface is comfortable and ideal mfortable for all activity levels and ages ted HiFis can be fabricated inhouse or with C-Fab ACKED HIFI INTERFACE IS BACKED BY EVIDENCE-BASED CLINICAL SUPPORT LINICAL Check out the recent study in Technology and udy Innovation Vol. 18 pgs 167-173 2016 that shows erformed ent the subischial HiFi outperformed ischial containme containment dy sockets. So are you ready to improve your clinical ctice outcomes and your practice Contact us today to learn about the various HiFi products and training get er programs and don t forget biodesigns offers uppe upper limb consulting too. Adjustable HiFi A K open frame design with BOA Since the interface is the most important part of the prosthetic system I have dedicated my career to creating a more biomechanically-advanced interface solution that would allow wearers to do more. I always knew the HiFi Interface would be an improvement over current upper and lower limb sockets but I had no way of knowing just how profound an impact the HiFi would have on people s lives. Randall Alley CEO biodesigns HiFi Interface System Inventor with Carrie DEKA arm test pilot For more information visit www.JoinHiFi.com com m P F 800.775.2870 HiFi biodesigns.com www.facebook.com biodesigns www.youtube.com biodesignsvideos the interface company prosthetics bionics the human connection I have a new love affair...with my socket. I am able to wear my HiFi all day and am driving again. Jonathan I am mechanically minded so when I read about the HiFi s ability to stabilize and control the bone it just made sense. As soon as I stood in the Imager I immediately knew it was going to work. Thank you biodesigns. Darren My short sports prosthesis with it HiFi prost rosthesis its t technology is the o prosthesis that I ve only ver b a ever been able to perform with in an with immersed water environment without tili ing utilizing the aid of a roll on locking liner. The HiFi fit is truly unique. I recom recommend the HiFi design for any active pers person wanting a better higher performan performance prosthesis. Bob CEO TRS Inc. pro With the HiFi I can last twice as long if not more...I ve become much more active and involved in tasks that I could not do before the HiFi. Ron The fit is really really good. I am able to wear my HiFi s all day everyday. I am back in school and am hoping to be running soon. Jerry I put on the HiFi and I didn t want to take it off. Get out of my way when I m on this leg. I m not going back to that old socket. This right here is what you need. I feel bad for everyone out there who is on a traditional socket because that sucks. Jessica I was in traditional sockets previous to the HiFi and they felt bulky loose and heavy. In my HiFi s my prostheses feel connected to me they feel lighter more comfortable secure and I forget they are there. I am able to wear them more comfortably even in hot Georgia weather and they have better range of motion. I never have to worry about them falling off or sliding around in them. Aimee I couldn t walk in my old bucket socket but in the HiFi I can do everything I used to do before I lost my leg. In the first 3 days I was able to climb stairs go down a ladder and walk 18 hours with only sitting intermittently. I can sit perfectly straight knees aligned feet touching the ground. I can tie my shoes and no longer have to take off my leg to go to the bathroom. I feel like I have my life back again. Carol The HiFi System allows me to do everything from basketball to racquetball to spin class to running. I can rely on my prosthetic side more than I could before. The HiFi makes me feel more complete. I forget I am wearing it. It fits better than any other socket I ve used. I feel confident with everything I do. Richard HiFi is a whole new world. I am able to wear it all day I have rotational control I feel no pistoning I am very comfortable. I have my independence again. I am confident I feel I have no restrictions. I would never go back to my old system. Ali 2017 biodesigns inc. All rights reserved. HiFi and High-Fidelity Interface and Imager are trademarks of biodesigns inc. The HiFi Interface and HiFi Imager technology are patented and patents-pending. Unauthorized use of the technology is not permitted. SPECIAL FEATURE SECTION 3D PRINTING TECHNOLOGY Wrist-Driven Paediatric Partial Hand Prosthesis A Collaborative 3D Printing Solution By Dan Mazur B.A. CPO(c) and Matthew Gale C.E.T. There have been many stories in the media over the past year about very inexpensive 3D printed prosthetic hands and how they have been revolutionizing prosthetic care in both the developing and developed world. Many clinicians have expressed the view that this is a disruptive new technology but there have been a number of cases exploring the potential of this technology. Our team at RCC (Rehabilitation Centre for Children) in Winnipeg undertook a case study in this area to try and answer the following questions How do these devices actually function What is the true cost to produce the devices What value does additive manufacturing provide in the provision of prosthetic orthotic care The following case study details the design fabrication and fitting of a custom partial hand prosthesis for a paediatric amputee. The client is a 10-year-old boy with left congenital partial hand amputation of the index middle ring and small fingers. He has a hypoplastic left thumb but is able to oppose the first and second metacarpal head and grasp small objects in the web space between the thumb and first metacarpal. Clinical presentation of our patient is shown in Figures 1a and 1b. Fine motor tasks are easily completed without a prosthesis but our client has expressed frustration in his inability to grasp larger objects and complete bimanual grasp activities. The client currently uses a passive silicone prosthesis for cosmesis and an activity-specific hockey pros64 thesis but does not typically use a device for activities of daily living. The goals for the new prosthetic device included Active digital movement. Simple and effective control and suspension. Anatomically-appropriate finger size and position. Preservation of sensation in the palm. Ability for three-point pinch and power grasp. Durability and low maintenance. Cool robotic look Figure 1a Palmar Hand View Figure 1b Semi-Pronated Hand View Technology Review A review of existing open source prosthetic hand designs was completed to gain a better understanding of the technology. An E-NABLE RAPTOR hand was printed in line with the E-NABLE protocol on a Stratysus Fortus 400mc FDM 3D printer to evaluate and critique the material needs grasp position and possible joint motion (enablingthefuture.org 2016). Several issues that were identified with the open source design included a non-functional grasp position with the thumb and fingers bulky design which challenged clothing fit and cosmetic appearance and a generic socket with no interface. The fixed anchor points for the cabling system was challenging for fabrication limiting adjustability and complex repairs to the system. Finally most of these devices are designed to be printed on desktop printers which use PLA material which is not very durable. Printing the device on a higher-end FDM printer provided a more durable device but resulted in very loose joint tolerances in the hand. Design Process The treatment process began by casting the client and fabricating a flexible socket interface. The interface was made of 2mm master flex thermoplastic. The physical socket geometry was then transferred into a digital format so that the custom prosthesis could be designed around it. A laser scanner (Shape Grabber Ai600) and mesh processing software (Geomagic) were used to quickly and accurately convert the physical mould into a digital mesh. This mesh data was then converted into an .IGES file for use in solid modeling software (SolidWorks). The solid model was then imported into the modeling software and used as the foundation of the custom design. The design was iterated several times before 3D printing the first prototype. Once we were happy with the design the first prototype was 3D printed using FDM (fused deposition modelling) technology on a Stratasys 400mc. The material used was ABS M30i as this provided a durable high-resolution print and the option of soluble support 65 material which allows for greater design freedom and ease of manufacturing. For example we were able to print functioning hinges in the fingers and wrist to eliminate any additional hardware or assembly. Commercial-grade FDM technology also yields high tensile and impact properties similar to injection moulded plastics. The initial prototype did not function exactly as expected so we went back to the drawing board with a new design. The second print was a success with only a few minor adjustments. Having the ability to quickly make changes and immediately re-manufacture is one of the big benefits of using 3D printing on a project like this. Device Design and Components The completed device is displayed in Figure 2. The socket device body and fingers were 3D printed in ABS to provide a durable accurately-fitting model. The interface was vacuum-formed in 2mm master flex with ultracloud padding over boney prominences to provide comfort flexibility and main- Figure 2a Completed Device with Active Digital Grasp Figure 2b Palmar View Figure 2c Dorsal View tenance of palmar sensation during active grasp. The socket design was self-suspending but dacron pullback straps were added for additional and adjustable support. Fifty-pound nylon cord was used for the control cable as this material is inexpensive strong and provides low friction and maintenance. An exploded CAD model is presented as Figure 3 to highlight some of the custom features included in the device s design. Figure 4 presents additional device views generated in the CAD software. Challenges Encountered The main challenge encountered in the design and fitting process involved the cable control system. The initial prototype utilized a lateral system but was not successful due to binding of the cable path and excessive excursion requirements. Thus a dorsal cable system was used in the final prototype. While this was not conventional it did prove to be the most adjustable and functional. Dissolving some of the support material from the model also challenged fabrication as a variety of hidden channels were printed to protect the cabling and improve cosmesis. Finally an extension of the digits was achieved with the use of elastic cable. While this material was low-cost it was difficult to work with and will likely limit longterm durability. The use of small metal springs would be a better option for future devices. Device Fit and Conclusions The device fit well and provided our client with another tool to use for select activities of daily living. He reported that the device was comfortable and easy to use. While only limited wrist flexion was needed to bend the fingers it made him feel robotic . Overall the novel design was able to achieve all of the intended goals including active Figure 3 Exploded CAD model of device 66 References Enabling the Future (2016). A Global Network of Passionate Volunteers using 3D Printing to Give the World a Helping Hand. Retrieved from http enablingthefuture.org. Liberating Technologies Inc. (2016). M-Fingers and Partial-M Fingers for Partial Hands. Retrieved from www.liberatingtech. com products hands M-Fingers_-_Partial_M-Fingers_for_Partial_Hands.asp. Simon J. (2014). Jose Delgado Jr. Compares His 50 3D-Printed Hand to His 42 000 Myoelectric Prosthesis. Retrieved from www.3duniverse.org 2014 04 19 jose-delgado-jr-compares-his-new-3dprinted-hand-to-his-more-expensive-myoelectric-prosthesis. Zuninga et al. (2015). Coborg beast a low-cost 3D-printed prosthetic hand for children with upper limb deficiency. BMC Research Notes. (2015) 8 10. (top) Figure 4a Isometric view of CAD model (next) Figure 4b Dorsal view of CAD Model digital flexion simple and effective control and suspension anatomically-appropriate finger size and position preservation of palmar sensation and the ability for both a three-point pinch and power grasp. The long-term durability and ease of maintenance of the device will be determined over time. The cost to produce the device was about 750 for the materials and 3D printing services through Precision ADM. Additional design costs for 3D scanning CAD design and review totalled 1200 for approximately 24 hours of engineering technologist labour. The design component would be significantly reduced on future projects as this device was developed from scratch. Future iterations can be easily adjusted for growth and additional functional requirements. When compared to a similar device fabricated with commercially-available M-Finger componentry through Liberating Technologies Inc. the novel 3D printed device was 40% of the total cost to produce when accounting for all materials and clinical and technical labour. About the Authors Dan Mazur CPO(c) is Director of Prosthetics and Orthotics programs at the Rehabilitation Centre for Children in Winnipeg. He is a graduate of the clinical program at George Brown College and is currently completing a Master of Rehabilitation Sciences degree through the University of British Columbia. He has a keen interest in emerging technologies and has started to implement the use of CAD CAM and 3D printing into routine clinical practice and research activities. Matthew Gale is a Certified Mechanical Engineering Technologist (C.E.T.) with eight years of experience in design manufacturing and 3D printing in the medical and aerospace industries. He was employed at Precision ADM as the Manager of Application Engineering at the time this project was carried out but now works at the Rehabilitation Centre for Children as a Clinical Technologist and Research and Design Coordinator of the new R&D division of RCC Rehab Engineering Programs. Reflections and Implications A review of this project concluded that we were able to produce a device and provide functional grasp through an iterative design process. While the cost associated with this technology was less than some commercially-available componentry it was far more than the modest costs proposed by the media once all direct and indirect manufacturing and treatment services are included. Overall collaboration with a certified engineering technologist was an excellent learning experience and exposed the great potential of additive manufacturing for customization of design material colour strength and cosmesis to address client preferences and needs. However when it comes to clinical service provision prosthetists and orthotists are the subject matter experts with the ability to drive an iterative CAD design process. There is a necessity to seek out authentic partnerships to support innovation with this new technology. 67 SPECIAL FEATURE SECTION 3D PRINTING TECHNOLOGY Management of Infant Head-Shape Asymmetry A Sleeping and Supine Approach Made Possible by 3D Printing By Jason Goodnough M.Sc. CPO(c) The Back to Sleep program of the 1990s dramatically decreased the incidence of sudden infant death syndrome (SIDS). But unfortunately cranial deformations such as asymmetric (plagiocephaly) and symmetric occipital flattening (brachycephaly) have experienced a concomitant 600% increase in incidence. therapy which leaves between 70 80 percent that may need some additional help to correct. Cranial Remodeling Orthoses (CRO) are the most studied most effective and most widely recognized treatment modality for moderate to severe positional cranial deformation in infants. Traditional CRO treatment has remained largely unchanged over the past 40 years which makes this an area of orthotic practice with great potential for clinical and technical modernization. 68 Severe deformational plagiocephaly (DP) has obvious cosmetic concerns but may also lead to medical concerns such as impaired temporomandibular joint function issues with eye alignment and ear canal orientation as well as functional issues related to the fitting of sports helmets and effective protection from injury or concussion. Literature reports that 20 30 percent of cranial asymmetries will resolve on their own or with Current practice standards strive to begin CRO treatment between the 5th and 8th months of life but often begin much later. Recent studies have shown that earlier treatment leads to better outcomes in a shortened amount of time. Traditional CRO treatment options may impair infant gross motor skill development and head control if initiated before five to six months of age. These delays can be the result of bulky and heavy CRO designs up to 17mm thickness on each side of the child s head and between 300-350 grams respectively. Furthermore many families do not proceed with CRO treatment due to concerns of social acceptance comfort of their baby (rashes heat pressure etc.) and a 23-hour day wear schedule which can be a barrier to cuddling and bonding with their child. These issues may prevent families from seeking treatment for their babies. What if a CRO could be 70% less weight and 80% less thick Could we start treatment much younger like 10 weeks old If started at a younger age with more growth potential and a malleable skull could the head shape be remodeled with 12 18 hours day instead of the traditional 23 hours day protocol Parents would love that We wanted to explore this concept and since babies this age are supine and sleep a lot we wanted to see if earlier treatment could allow for supine use-only as these are the times when there is the most deformational pressure on their heads. This would allow them to take the CRO off for daytime so mom and dad could rub their fuzzy heads and go to the mall without so much attention on them and their cumbersome headgear. This case study report focuses on using 3D printing technology to provide the required design flexibility to make lighter and thinner CROs without structural compromise. This would allow us to assess the effectiveness of early treatment of DP while maintaining comfort and not hinder gross motor skill development. The fused filament fabrication (FFF) style of 3D printing uses thermoformable layers as thin as .1mm and fuses them on top of one another via a computer-guided extruder to build a desired 3-dimensional shape (see Figure 1). 3D modelling and FFF have technical design options that are unparalleled when compared to current manufacturing techniques. Case in point this new 3D printed design reduced the weight of the CRO by up to 250 grams to 1 3 the weight of traditional designs and reduced the thickness up to 12mm per side to about 1 5 of that of a traditional CRO with no compromise in structural integrity comfort or the application of biomechanical forces within the CRO. 3D CRO Design HeadStart Medical Ltd. is a medical design company based out of Vancouver that used topological optimization techniques to create the 3D printed biocompatible custom-made CROs used in this case study. The CROs are printed using hollow-core technology from proprietary plant-based biodegradable plastic. They utilize an innovative quadrant-based design structure with growth-adapting layers of orthopedic and shape-changing foam for containment of select cranial features. In non-contact areas there is strategically-placed ventilation to reduce heat retention and orthosis weight. The sub-occipital region is designed to maximize the cervical spine range of motion required during activities such as tummy-time and for development of gross motor skills such as spinal extension rolling and crawling. Case Description and Methods At the time of initial treatment infants in this case study were between the ages of 13 and 18 weeks. They were referred from their family doctor or pediatrician and presented in our clinic with persistent cranial asymmetry and cranial ratios (CR) in excess of 95 percent and or 30 oblique diagonal differences (ODD) in excess of 10mm. Neck range of motion was Figure 1 Fused Filament Fabrication of a CRO 69 The infants head-shape was captured via Vorum s Spectra Scanner and assessed via Vorum s Cranial Comparison Utility. Orthoses were then fit within six days. Families received regular follow-up and adjustments were made for growth comfort and to optimize the remodeling effect of their orthosis. At the completion of treatment a second topographical 3D scan was performed using the Spectra Scanner and compared via Vorum s Cranial Comparison Utility. An anonymous independent survey (Figures 2 3 & 4) was distributed via email to the families upon completion of the treatment for their qualitative input. All families consented to participating in this case study. parameters. This data is statistically limited due to the small sample size associated with a case study. A larger study is forthcoming. Conclusion Knowledge that current research evidence suggests that improved outcomes and reduced treatment times are possible with early intervention was coupled with 3D printing technology to design an innovative treatment program for infants with positional cranial deformation. This new treatment option has been shown to allow this population to access early care without the associated limitations of current CRO technology. Quantitative 3D data showed excellent head-shape symmetry outcomes while parent compliance satisfaction and acceptance exceeded previous reports in the literature for this population. Results and Outcomes Quantitative Data from 3D Scans All infants had notable improvement in their cranial symmetry over the course of treatment (Table 1). All infants started treatment with head shapes within North American accepted CRO treatment parameters of over 95 percent CR and or over 10mm ODD (i.e. greater than two standard deviations outside of accepted head-shape normative data) and all infants completed their supine treatment program with head shapes within normal ranges and below accepted treatment within normal ranges in all four cases with no torticollis present. Families were informed that the CRO must be worn while their baby is supine and for a minimum of 12 hours per day. Average wear time ranged from 12 to 18 hours in this group. Four infants were treated one female and three males. Average time in orthotic treatment was 14.25 weeks. Table 1 Quantitative 3D Scan Data 70 Survey Due to the limited feedback that can be obtained from the patient qualitative feedback from the families is particularly valuable in these cases. Figure 2 Survey Question 1 Results Question 1 Most families were primarily concerned with long-term health effects of persistent cranial deformation. Figure 4 Survey Questions 2 3 & 4 Results Question 3 All families stated that their child seemed comfortable in the supine CRO. Question 4 All families stated that they were satisfied with the head-shape improvement they had observed. Question 5 All families said that if they had to they would do it again. References Steinberg JP Rawlani R. Effectiveness of conservative therapy and helmet therapy for positional cranial deformation. Plast Reconstr Surg 2015 833-842. Tamber et al. Congress of neurological surgeons systematic review and evidence-based guideline on the role of cranial molding orthosis (helmet) therapy for patients with positional plagiocephaly 2016 Congress of Neurological Surgeons. Rogers GF. Deformational plagiocephaly brachycephaly and scaphocephaly. Part I terminology diagnosis and etiopathogenesis. J Craniofac Surg 2011 1 9 16. Xia GF Kennedy KA Teichgraeber JF et al. Nonsurgical treatment of deformational plagiocephaly a systematic review. Arch Pediatr Adolesc Med 2008 162 719 727. Figure 3 Survey Question 2 Results Question 2 Families initally presented either somewhat stressed or highly stressed about their child s head-shape asymmetry. Upon completion of the 3D printed supine CRO treatment program three out of four no longer had any stress associated with their child s head-shape. One family continued to be somewhat stressed. Clarren SK Smith DW Hanson JW. Helmet treatment for plagiocephaly and congenital muscular torticollis. J Pediatr 1979 94 43 46. Kluba S Kraut W Reinert S Krimmel M. What is the optimal time to start helmet therapy in positional plagiocephaly Plast Reconstr Surg 2011 128 492 498. Seruya M Oh AK Taylor JH et al. Helmet Treatment of deformational plagiocephaly the relationship between age at initiation and rate of correction. Plast Reconstr Surg 2013 131 55e 61e. Flannery ABK Looman WS Kemper K. Evidence-based care of the child with deformational plagiocephaly part II management. J Pediatr Health Care 2012 26 320 331. Kelly KM Littlefield TR Pomatto JK et al. Importance of early recognition and treatment of deformational plagiocephaly with orthotic cranioplasty. Cleft Palate Craniofac J 1999 36 127 130. About the Author Jason Goodnough MSc. CPO(c) is Head of BCIT s Prosthetics and Orthotics Program director of Synergy Orthopedics a clinical practice specializing in Paediatric Headshape Management and co-director of HeadStart Medical an innovative medical engineering and 3D printing company. A BCIT P&O Program graduate with a Masters of Science Degree (Honours) in Orthopedic Engineering from The Health Sciences University of Jonkoping Sweden he is a recipient of the Canadian Educational Association Excellence Award and BCIT s Excellence in Teaching and Research Award. 72 4141 US Route 40 E Lewisburg OH 45338 Phone 937-962-0205 Fax 937-962-4160 Check us out on the web at www.bulldogtools.com These great products are available at BULLDOG What s in a name B est Selection U nsurpassable Quality L ow Prices L asting Customer Relationships D ependability O utstanding Service G enuine U. A. BULLDOG 73 THE ONLY NAME YOU LL EVER NEED O&P SOLUTIONS Planting the Seeds Practitioner Patience Can Germinate Patient Success By Stephane Daviault CP(c) Andr was involved in a work accident in 2015 that led to the amputation of his right arm at a trans-radial level. The very next day he was back home and ventured out for some brief activity... some cross-country skiing with one pole. Andr s rehab was completed without a prosthesis. He didn t feel the need for one. For him his hand was gone and that was it. He had seen a body-powered prosthesis and decided that it wasn t an option for him. But after much discussion Andr s prosthetist convinced him to do an evaluation for myoelectric sites. If he didn t like it at least he would have tried it. winter weather. Andr was asked to help thaw and remove material blocked from the worm drive. In doing so his right hand got caught up in it. Pulled from the drive by workmates and taken to the hospital in Lac-M gantic his medical condition was stabilized before sending him to the university hospital in Sherbrooke where the amputation was performed immediately. He was home the next day and cross-country skiing. Andr s life has always been focused on performance in sports in work and in every aspect of his life. Life After Amputation Upon returning home Andr was able to take care of almost all of his activities of daily living. Two weeks after surgery he began his rehabilitation at the Centre de R adaptation Estrie in Sherbrooke. His residual limb was still very sensitive. He was experiencing significant phantom limb pain which did decrease with the help of medication and time. Being right-handed the amputation of his right arm forced him to switch to the left side which was not overly problematic for him except for writing. The rehab was completed without any prosthesis as he didn t feel the need for a Life Before Amputation Andr and his wife are the parents of six children. The family lives in the countryside close to the city of Lac-M gantic Quebec. He was working for a company that produces particle board made out of new and recycled materials. His main assignment was to operate a forklift. He was also involved in the maintenance of the particle board production line when needed. Andr was called to help with the recycled material supply line which was frozen on a cold February night... not an uncommon occurrence during frigid Quebec 74 Coyote Composite TOUGH YET FLEXIBLE Light weight Edges finish smooth Tougher than carbon fiber Less itch than carbon fiber Non-carcinogenic and non-toxic Costs less than carbon fiber we guarantee it. Ideal for AFO s and Prosthetics We re making it simpler and sharing the process with you. Alternatives to Carbon Fiber You will have a better understanding of the different properties of composite materials. 2.5 MCE credits course Currently No Charge Offer good through 6 01 2017 Other courses include StabileFlex Transtibial Socket Design 5.5 MCE credits course AFO Casting and Fabrication Methods 3 MCE credits course Our MCE-accredited online classes are convenient and can be done at your own pace. www.opqschool.com AN EDUCATIONAL COMPONENT OF prosthetic device. He decided that a body-powered prosthesis at that time was not an option for him. During the summer following his amputation Andr worked around his house changing the exterior cladding and doing major renovations inside using only his left hand with the support of his residual limb on the right side. As the summer came to an end so too did Andr s good spirits and he fell into a depression. This was a challenging time for Andr and his family. He relied heavily on the love and understanding of his wife and children during this difficult phase. With some support from the rehabilitation team including his psychologist occupational therapist and his prosthetist he pushed through. After much discussion his prosthetist Genevi ve Longpr who works at the Centre de R 76 adaptation Estrie in Sherbrooke convinced Andr to do an evaluation for myoelectric sites... at least explore the possibility. That s when I was introduced to Andr . Using a computer and the Myoboy we were able to identify two different sites with a high intensity signal. We tried several options and Andr was able to get fairly good control with two electrodes using the 4-channel control strategy. After only a few minutes he was opening and closing as well as pronating and supinating with good control using the simulator on the screen. At this point however Andr was still not interested in a myoelectric hand. In turn we introduced the AxonHook with the active wrist rotation using a fitting frame. He worked with it picking up objects that were placed on the table in front of him down on the floor on his right and left. With this device he could see that a prosthesis could be beneficial. He saw that there were many things that he might be able to achieve by using one. After receiving approval for funding Genevi ve fabricated the prosthesis for him. After only a few sessions with his occupational therapist Andr began to use the prosthesis for all of his activities outside and inside the house... including taking care of most of the family s meals by using his prosthesis to stabilize and cut vegetables and meat mix ingredients in a bowl take pots out of the oven etc. He is also doing construction and renovation work on his home finishing projects that were started without his prosthesis. And he s back on the ice as part of the coaching staff for one of his sons hockey teams. After using his prosthesis for several months he was able to appreciate how it reduced the compensatory movements needed without it. Carrying and stabilizing a sheet of material is a lot easier with two hands or at least one hand and a hook. Roughing in a wall using a hammer and nails is easier when you have a terminal device stabilizing the nail while using the hammer with the sound hand. Now a proficient user Andr wears his prosthesis all the time without thinking much about muscle contraction but more about the action that he wants to do. If I want to open the hook it s opening he commented. He also noted that he would not live without his prosthesis now and often wonders how he managed without it. Life with a Prosthesis Andr is now back to work for the same company but in a different role. At the request of his employer he s involved in the prevention of work-related accidents. He is now providing education and offering recommendations on how to improve the safety of their work environment. Despite losing a limb Andr expressed his appreciation of his prosthetist s continued support and understanding. This positive patient-practitioner relationship and the exploration of different options resulted in a successful outcome for Andr . Andr added that I learned to slow down and realize that the accident brought a lot of positive things to my life. Every patient is different and will progress through their ordeal at their own pace. As practitioners we have to keep that in mind and offer them support during and after their rehabilitation in order to be able to best help them. We have to do it with respect. In this case Andr s prosthetist needed to plant little seeds that needed more than a year to germinate and become a success story. About the Author Stephane Daviault CP(c) is with Ottobock as part of professional and clinical services Upper Limb prosthetics. He worked at l Institut de R adaptation de Montr al for eight years before moving to the Centre de R adaptation Estrie in Sherbrooke where he continued his clinical practice for almost 17 years. He has been a CBCPO Board Member as well as an examiner for several years. He also taught prosthetics at College Merici in Quebec City. 77 O&P SOLUTIONS Osseointegration Related to Limb Prosthetics in Canada By Tony van der Waarde CP(c) Image by Dr. Patrick Palacci In the past couple of years new prosthetic technologies have focused mainly on new componentry like knees feet and hands. For sockets and prosthetic fitting developments in materials and designs have made significant progress in amputee comfort and mobility but the biggest challenge remains How to maintain a good fit . project was discontinued due to complications . A few years later Per-Ingvar Br nemark a professor in Sweden was instrumental in the transition of mandibular implants for use in amputated limbs. Dr. Rickard Br nemark utilized the technique developed by his father and expanded upon it. His first reported case was in 1990 and the outcome seemed rather positive. Br nemark s surgical clinic initially performed 25 osseointegration procedures in Sweden and later more in several other European countries. A move toward an alternative to sockets was started but with much opposition especially from prosthetists. The concern wasn t 78 The use of artificial bone implants for lower and upper limb amputations has been documented since the 1960s. Some experimental human osseointegration (OI) procedures were done in the 1970s and 80s in Toronto by Canadian engineers and surgeons Dr. John Kostiuk from Sunnybrook Hospital and Dr. Geoff Fernie from West Park Hospital to name two with whom I had interaction. When the idea resurfaced in Los Angeles at Rancho Los Amigos Rehab Center in 1970 I observed two bilateral trans-tibial amputees walking with hollow implants whereby the connection between the limb and the foot component was an actual vertical locking pin. The so much that their services were being contested. It was about the issues that some of their patients were experiencing with infections around the stoma (exit point through the skin) and mechanical Figure 1 LIVING LIFE TO THE FULLEST. I move very quickly with my feet that s why the system is beneficial to me because I m more secure. When I make a move it makes a move with me. -Anthony bilateral transtibial amputee since 2014 Transfemoral CHOICE OF LINERS Alpha SmartTemp Liner or NEW Alpha DuoTM Liner ONE GEL SOCK ONE SEAL Transtibial ALPHA DUOTM LINER ONE GEL SOCK ONE SLEEVE NEW To learn more or to check certification requirements call 800.363.8726 or visit www.ortoped.ca Choice of Suspension For use with suction suspension or elevated vacuum Patent www.willowwoodco.com education-and-resources patents The Ohio Willow Wood Company 2017 Although some have done a two-stage procedure minimizing the down-time for the amputee s desire to walk it wasn t until 2010 that Dr. Munjed Al Muderis in Sydney Australia initiated a different protocol eventually leading to the one-stage osseointegration procedure. I had the opportunity to spend two weeks in 2016 in his clinic to observe every aspect of his osseointegration regimen including eight surgeries (Fig. 2). During this time I observed (and practised with) the 20 osseointegration amputees present at that time using specific tools and learning the progressive loading (monitored weight-bearing) protocol (Fig. 3a and Fig. 3b). Now less than a year later we have been instrumental in getting 13 residents of British Columbia evaluated and processed for osseointegration and five have had their implants successfully done and are using their prosthesis fulltime... three were trans-femoral and two were trans-tibial. We are actively monitoring the progress of our provinicial pioneers and also have ongoing communication with numerous others (several across Canada and globally) via the internet. We have benefitted greatly from this daily interaction by receiving invaluable information that we can add to our knowledge base. The protocols for OGAAP (Osseointegration Group of Australia Accelerated Protocol) osseointegration procedures are constantly changing as patient numbers increase (250 between June 2011 and January 2017). One prevalent change has been the highly-individualized rehab protocol specifically related to full weight-bearing which considers multiple factors including bone density scans. This has led to Figure 2 failures of the connector components (Fig. 1). The Br nemark method initially involved a three-stage protocol before allowing the amputee to use a prosthesis. Stage 1 Original surgery to open the intramedullary canal and insert the implant. Wound closed 3-month wait. Stage 2 Distal end opened and unit connector attached. 1 to 2-month wait. Stage 3 The prosthesis fit with the adapter attachment or coupler . Figure 3a 80 Figure 3b Lori MacInnes from Prince Edward Island in January 2015 (Fig. 4). Additional benefits which have been reported Decrease or total absence of phantom pain. Bone density improvement. Less restriction of muscles creating a stronger more defined residual limb musculature. The daily step-counts for single- and double-leg amputees have increased by as much as 50-80% compared to use of their conventional prosthesis with a socket. Areas to be aware of Running or impact sports could potentially loosen or fracture the implant. The need for more diligent skin care of the exit point of the implant or stoma. The original prediction that amputees with osseointegration will see a significant cost-saving over a 5-10 year period is still unclear. In theory the actual implant procedure is only required once. There are amputees in Scandinavia who received the implant in the late 1980s and have had no need for any additional surgeries. A recent Swedish study indicates that there is a need for more frequent repair replacement of knees feet shock-torque absorbers etc. with osseointegration. It stands to reason that if the amputee becomes more active and puts more use on their equipment that it will wear out sooner than it did with a traditional socket fitting and less walking. There are some manufacturers that are taking these facts into consideration Figure 4 some delays for recent trans-tibial amputees as a method of preventing any potential problems related to low bone density. During my visit almost all of the amputees were starting the loading of the implant on a weigh scale within days of the implant surgery. A Canadian bilateral trans-femoral amputee (whose surgery I witnessed in Sydney) came by our office four weeks post-surgery and was walking pain-free with the use of only one cane She has had no complications in the 12 months since (Fig. 5). The two most recent trans-tibial amputees were kept from weight bearing (and prosthetic attachment) for six to eight weeks post-surgery. The overview in Fig. 6 shows the layout of the implant and prosthetic interface hardware. There are specific tools required (Fig. 7) to remove the internal locking screw the anti-rotation Figure 5 locking washer and the taper sleeve or connector. There is also the possibility for removing or tightening the internal screw holding the dual cone adapter in place (Fig. 8). As of March 2017 15 Canadian amputees have had osseointegration surgery performed at the Macquarie University Hospital Clinic in Sydney Australia and all are doing well. No longer bothered by volume changes in their residual limbs socket alterations liners and suspension device replacements are no longer a necessity for them. Best of all they are free from friction pain skin breakdown and perspiration from the socket environment. All of the amputees surveyed reported an increased sense of normality in balance feedback from terrain and better body alignment all resulting in an improved quality of life (Fig. 9). The first Canadian amputee to have OI surgery was 48 82 Figure 7 Figure 6 when designing new prosthetic componentry which is more durable (possibly more expensive) for more active osseointegration amputees (Fig. 10). At this point we don t have a true picture of how often the OI adapters will need replacement. Currently the choice of manufacturers for OI components is extremely limited (two or three) and therefore the individual component fees are quite costly compared to a similar product used with traditional fittings. It is plausible that as more amputees elect for OI surgery more manufacturers will produce comparable options at lower costs (Fig. 11). Attempts at communication for funding of osseointegration prosthetic components have been made in British Columbia. They ve been met with no response from B.C. PharmaCare. Now would be the opportune time for a national agreement or fee schedule to be developed and implemented. This would provide a unified approach to caring for osseointegration amputees in Canada. For cosmetic restoration covers some unique Figure 8 possibilities can be designed as seen in Fig. 12 and Fig. 13. Aside from myself only two other Canadian prosthetists have received training in Australia for osseointegration prostheses. It is my wish that the younger up-and-coming generations of prosthetists will embrace the challenge to become truly qualified in osseointegration prostheses. The OI procedure is only the beginning of making the Bionic Man Woman a reality. Improving prosthetic skills is not just an academic exercise it requires 83 Figure 9 Figure 10 Figure 11 Figure 12 Figure 13 hands-on training and continuous networking. We must keep in mind that osseointegration is not suitable for all amputees. Issues such as bone density levels other medical complications and financial restraints are very critical considerations before an amputee should even start the process. They also need to consider the possible limitations on their physical activity if they are involved in running or impact sports. Once the procedure is available in Canada this will alleviate the financial objection but there should still be a guideline of indicators and contrain- Figure 14 dicators used for the selection process (Fig. 14). I want to acknowledge the willingness of all the staff at Osseointegration Group of Australia Accelerated Protocol and Stefan Laux at APC Prosthetics in Sydney Australia for being such good teachers. Please note that there are several centres in Europe namely the Radbound Klinic in Nijmegen The Netherlands that have done many osseointegration procedures and are seeking to collaborate with groups such as OGAAP to continue the evolutionary growth of osseointegration around the world. About the Author Tony van der Waarde CP(c) graduated from George Brown College in Toronto in 1973 with a diploma in P&O Technologies with the college s first graduating class. He became certified in prosthetics in 1975 and has worked in numerous P&O labs rehab centres and in private practice. He opened his own facility Award Prosthetics Inc. in 1995 in Burnaby B.C. and has been active in the development of new socket designs and recently osseointegration technology. 85 O&P SOLUTIONS An Unusual Case on the Rock By Martin Berthiaume CP(c) It is always something of special interest to me as a clinician to be exposed to uniquely different cases which doesn t happen all that often here on the Rock . But following the welcoming of several thousand Syrian refugees in Canada in early 2016 I had the pleasure of working with a few of them here in St John s Newfoundland. ing wall of their home. He was in his late 30s at the time. He was taken to a refugee camp in Jordan and received treatment from a humanitarian organization. Once his wounds were healed he was fitted with a basic but functional prosthesis that did not include a knee unit. For almost three years he survived on his first prosthetic leg in the very difficult environment of the refugee camp. His limb atrophied resulting in an extreme case of poor socket fit. When he presented in our clinic shortly after his arrival in Canada he displayed a hip flexion contracture of 25 degrees and a hip abduction contracture of 25 degrees as well. Over time he had developed a number of gait deviations that allowed him to walk 86 As is the case in many areas of the country most of my workload is usually dedicated to an aging population which is affected by the ravages of diabetes and vascular disease. Amputation following trauma is not something I deal with on a regular basis. The following is just one of the interesting cases that has given me new perspective and knowledge in prosthetic care. Ahmed (not his real name) arrived in Canada in 2016. He lost his leg at the trans-femoral level in 2011 when a missile entered through the window of his home at the time he was on the phone with a family member. He and his family were extremely lucky to survive the attack as the missile did not explode before it exited the oppos- faster and more efficiently a wide base of support circumduction pelvic tilt and Trendelenburg gait. But it wasn t all bad news. Ahmed showed good strength and resourcefulness he was highly motivated and anxious to get going with a new leg. No other physical problems were noted. His residual limb was very short with only six to seven cm of femoral length and showed deep invaginations anteriorly with a lot of soft redundant tissues. The lack of firm shape in his residual limb and the short lever arm were obviously going to create some challenges. My first fitting attempt took a basic approach starting easy to see what we could hope to achieve. I used a silicone locking liner in a hard plastic shell. The silicone liner the prosthetic & orthotic plastic materials specialists Distributed in Canada by This is the first attempt. Only one window was cut and as you can see my theory of the bigger the window the better was not entirely sound. was intended to contain all the soft tissue and provide me with a firmer surface to work with. My main goal at that point was to get him walking on a prosthesis that incorporated a prosthetic knee. Not knowing how he would react to the feeling and function of a knee joint I fitted him with a weight-activated pneumatic single axis knee. Even if his control of the knee joint was lacking the weight activation could reduce his risk of falls. The pneumatic function was included in hopes that once he gained confidence that he may be able to ambulate at different speeds. The results were surprisingly positive. Ahmed adapted to the knee joint within a week attributable in large part to his impressive level of motivation. The next challenge presented itself more quickly than anticipated Amhed wanted to walk further and 88 faster which was putting a lot of stress on the suspension system. How was I going to create sufficient suspension with such a short and shapeless limb It was unlikely that the pin system would provide enough suspension especially in warmer weather as it was likely to slip when sweating occurred. And the liner and pin system did very little to control rotation. This would need to be addressed. The standard methods to control the suspension and rotational issues in a trans-femoral amputee would be the use of suction or vacuum suspension but this was not a viable alternative due to the short shapeless and invaginated limb. Fortunately Ahmed was experiencing no pain and his limb was not overly sensitive. Adding a TES belt was an obvious and easy choice but I felt that this wouldn t be enough. Amhed showed me that he wasn t overly sensitive to the internal pressures created inside the socket. So I modified a second socket to increase the pressure proximal to the greater trochanter in order to avoid promoting a circumduction deviation during gait and provide more control during the swing phase. I also abducted this socket more than I would have liked to in order to accommodate his abduction contracture. After three years of learned gait deviations it was clear that accommodation would be necessary. Any alignment changes to promote a more adducted gait simply resulted in Amhed abducting his hip more to increase his base of support... likely an accommodation strategy he learned to increase his safety. The increased pressure and minimal gapping above the greater trochanter along with the belt pulling in over the same area and creating a highly abducted alignment resulted in a more accommodative device. It allowed Ahmed to ambulate comfortably with After pulling a second drape over my modified cast (increased pressure overall) I also decided to cut the length of the lateral window while opening another one posteriorly. minimal rotation about the limb in the frontal plane. Furthermore the pairing of the pin lock with a belt proved itself to be just right there was no more slippage of the liner and the pistonning was also greatly reduced. Having sufficiently solved the suspension issue it was time to address the rotational problems that were still present. Cue Alignment magazine. In the latest edition of Alignment there was an article about a new way of fitting hard sockets. It gave me an idea. If I could open a window on the lateral wall of the socket and provide enough pressure about the opening to squeeze ample soft tissue through it perhaps increased control of the rotation of the socket in the transverse plane might occur. Knowing that some American prosthetists fit similar sockets often without liners I surmised that by keeping the liner in the equation my chances of cre- ating an unwanted donut effect on his skin was lessened. The third socket included a lateral window and showed results that were better than expected. It didn t cause any marking on Ahmed s skin and the rotation was not as bad. But I could do better. The next socket was a copy of the previous one with the exception of increased pressure around the lateral window which I achieved by reducing the cast by approximately two cm around the edges of the window. This created more pressure on the soft tissue. I mitigated a donut effect by incorporating a gentle curved flare about the edges of the opening. A second window was also included in the posterior of the socket away from any scar tissue to compress. The double-window design increased the rotational control with a soft tissue lock . The windows in the new socket weren t opened as distally so as to increase the surface area in the region most likely to experience pistonning during swing phase. By keeping the distal edge of the window opening more proximally better control of the stretch of the liner at the distal end was achieved. Overall the results have been phenomenal. Amhed no longer slips out of his socket. The piston problem was minimalized and the rotational problems were alleviated. Ahmed still walks with a wide base of support but as with most learned gait deviations it is very difficult to retrain. His skin has shown no issues with breakdown and he tolerates both the liner and the TES belt well. When Amhed walks without any gait aids he still has a tendency to drop his pelvis over the stance side when using a cane this deviation is lessened and his cadence is increased. His physiotherapist is still working with him and he is always very proud to show me his improvements every time we meet. 89 I have learned many lessons while working with Ahmed... lessons that we do not often have the chance to learn with our typical amputee population. I look forward to seeing Ahmed s continued progression as he settles into his new homeland. About the Author Martin Berthiaume CP(c) graduated from Merici College in 2007 earning certification in 2010 and has since practiced in St John s Newfoundland. He served on the CBCPO board as a regional representative from 2010 to 2013. The increase in pressure over the soft tissues and the proximal hooking of the Greater Trochanter can be easily seen. Perfect rotational control of this device followed. O&P SOLUTIONS Scrap It A Green Approach to Team Building By David Nielen CPO(c) RTPO(c) It s a Thursday evening in Ottawa and as we gather at a pub in Little Italy we pause and reflect... the off-castings from our professional services are not just garbage anymore. Going green can have more than one meaning and the complete recycling process means we have some laundered cash in exchange for reducing the land-fill load. In these days of ever-tightening fiscal constraint there really is no hope of a night out on the employer s tab at least in the public sector. But the need for team building is ever-present and nothing brings people together like the offer of a free drink or two. Our Prosthetics and Orthotics Recycling Committee or PORC as we call ourselves bought its first round of beer nine years ago when our department decided to scrap a rather large old vacuum former. The steel copper tubing AC motors etc. seemed like too much to waste so we loaded it into my trailer and took it to the local scrap yard. In continuing our commitment to recycling the return on our valuable scrap over the last years has ranged from a high of nearly 350 to a low of just under 60 (Table 1). Some years are better than others depending on how creative we are with scrap collection. Although scrap metal prices vary greatly the most valuable metal that we currently produce is good quality copper cuttings from rivets at 2.65 pound. Next in line is scrap copper known as yellow brass (plumbing scrap) at 1.85 pound most of which came from one of my home renovations. Not surprising is the willingness with which my colleagues contribute their household scrap... when they know I ll pick it up. Even scrap steel is worth 140 ton. Old AC motors car batteries ( 10 each) you name it if it s metal and you 90 separate it into homogenous piles it s worth green But beware if you leave steel rivets in your aluminum or mix in a few copper-coated steel rivets with your good copper it will downgrade the whole batch to a lesser rate. Strong rare-earth magnets will help find these bits. So this year raise a glass to your colleagues and feel good about going green Subject to managerial approval of course 2007 2008 2009 2010 2011 2012 2013 2014 2015 207.81 296.45 97.99 144.75 346.50 120.00 46.50 67.75 58.50 Table 1. Annual returns since project inception. O&P SOLUTIONS Gap-Keeper The Riveter s Third Hand By Brian C. Myles RTO(c) Copper rivets. Everybody ends up using them at some point and most of us struggle with them most of the time. More often than not it takes two to use them successfully often requiring someone to be on their knees looking up from underneath to keep the rivet head centred on the anvil. It is as ungainly as it is uncomfortable. When trying to align a rivet AND keep a gap to prevent it from binding as a pivot point it becomes more fun than one can bear (sarcasm). I use a little tool as a third hand to spare a second technician and to ensure the perfect gap. It s virtually free and by up-cycling what is usually a disposable tool part a hacksaw blade it s also environmentally friendly. Modifying a hacksaw blade into a gap-keeper begins with increasing the hole size of one end to be large enough for a 8 rivet. Since the blade is made of tool steel mods may be difficult. A careful drilling out with a 3 16 HSCO (cobalt) or another strong drill bit can make the hole an acceptable size. I ve found that trying to cut a hacksaw blade with a hacksaw blade is tough and so I ve resorted to a pair of side-cutters and a hammer. I follow that with some filing to make short work of creating a removal slot out the end of the blade. To save my fingers I also took the teeth off of the blade with a bench grinder. Great you may say but where s that third hand you promised I m glad you asked. The third hand comes with the addition of a rare-earth magnet (or some other strong magnet) and a white yellow china marker as follows 1) place the magnet on the rivet bar anvil at a distance between the two ends of the gap-keeper about two-thirds to three-quarters of a hacksaw blade length from the anvil head 2) place the gap-keeper on top of the magnet and centre the slotted end on the bar anvil head 3) mark the centre of the hole of the opposite end of the gap-keeper on the bar. When the mark on the bar 92 Marked for centre is aligned with the hole and the gap-keeper is centred lengthwise on the riveting bar you will know that the centre of the slot is centred on the riveting head whether you can see it or not. Once the burr has been knocked down against the gap-keeper the strength of the magnet that kept the gap-keeper steady now keeps the device steady. If the device is small enough like a paediatric AFO for example you might even be able to let go of it for a bit without it falling off of the bar. The thickness of the former hacksaw blade is an ideal gap size and its tool-steel construction makes it a resilient and long-lasting tool. Our shop has been using my original for over two years now. We ve not been gentle with it and it s still going strong. So until we naturally grow a third hand to help with riveting we ll have to settle for whatever inanimate help we can get. About the Author Brian C. Myles RTO(c) made a mid-life career change from yacht-building to P&O. Graduating with honours from the GBC Technician s program in 2013 He completed his internship with Design Prosthetics & Orthotics in Whitby Ont. gaining his registration in 2016. Drawing on his diverse experience he enjoys the challenges of the technician s role in developing solutions for his patients. Positioned in centre of anvil All set to go... 93 CONTINUING EDUCATION Student Papers The following are student research projects from George Brown College that the program is excited to share with the P&O community across Canada. In the interest of showcasing a variety of papers these projects are represented by an overview with full-length papers available on the Orthotics Prosthetics Canada website at www.opcananda.ca. With thanks to project coordinator Gordon Ruder CO(c) B.Sc. M.Sc. Coordinator Prosthetic & Orthotic Programs George Brown College. Do New Prosthetic Designs Improve Prosthetic Care for Individuals with a Symes-level Amputation By Amy Hughes-Jones The use of a lower-limb prosthesis can enhance mobility independence safety and quality of life in people with lower-limb amputation (Resnik & Borgia 2015). When looking at populations that require amputations of the foot preservation of length is a main strategy to improve biomechanical advantages in prosthetic use (Aiona 2014). Furthermore an amputation that preserves the heel pad keeps the ability to weight-bear for short distances without the use of a prosthesis. First described in 1843 and later popularized by Wager developing opinions still continue on whether a symes amputation is more beneficial over traditional below-the-knee amputations (Wagner 1979). In 1980 the Journal of Prosthetics and Orthotics listed different symes-level prosthetic designs including an obturator door and using a segmented liner (Leimkuehler 1980). In clinical practice it has been shared that each design new and old has its pros and cons. Major developments were made when developing socket designs based on patients needs such as the ability to load weight through the distal aspect or the need to relieve weight from the distal aspect. Each design change improved care for this population. A major theme within all designs is that there is limited build height and only simple prosthetic feet can be used. This does not seem to affect the paediatric population as much. Even though it is patient-specific a majority of the literature only focuses on the use of dynamic feet in the paediatric population suggesting more options are available for this population over others. Manufacturers have developed several higher functioning feet with low-build height. A study by Jean et al. (2014) demonstrates a contradictory relationship between the performance and foot design and the PODCI score for seventy-three children. This shows that there should be a more subjective approach in prosthetic prescription and costs of paediatric feet should not influence designs (Aiona 2014). The literature also 94 promotes the idea that too much length is disadvantageous and additional surgeries are needed to shorten a limb in order to have optimal functional outcomes when looking at energy conservation and oxygen consumption (Osebold et al 2001). There is a definitive gap in the literature with respect to new technology and how it can impact prosthetic design in the symes population. This is especially true in the older population where build height and foot selection decreases compared to that in the paediatric population. This research aims to determine if new prosthetic designs improve prosthetic care for individuals with symes-level amputation. It will critically compare results from the literature review and from a questionnaire sent to professionals in the prosthetic and orthotic community. The final objective will be to share knowledge about prosthetic design and if care can be improved. Is There a Place for Partial Feet Amputations Examining Recent Literature to Determine for Whom and When Partial Foot Amputations may be Appropriate. By Callie Bazak A significant portion of the Clinical Methods in Prosthetics and Orthotics program at George Brown College focuses on the trans-tibial client compared to the partial foot client. Yet it is reported that the rate of partial foot amputations (PFA) in some countries can be double the rate of trans-tibial amputations (TTAs) and trans-femoral amputations (TFAs) combined (Janisse & Janisse 2010). Increasing commonality of PFA can be attributed to advancements in vascular surgery and amputation surgery (Sobel Japour Giorgini Levitz & Richardson 2001) as well as increased prevalence of vascular insufficiency secondary to diabetes mellitus (Dillon & Barker 2008). Literature regarding PFA and its success is mixed some authors support PFA and others question whether PFAs actually provide optimal treatment. Dillon and Fatone note that 30-50% of PFA patients will experience complications with skin breakdown or ulceration and approximately 33% will require revisions to a more proximal level (Dillon & Fatone 2013). Others suggest that PFAs are slow to heal likely to develop equinus contractures and difficult to fit with prostheses (Sobel Japour Giorgini Levitz & Richardson 2001). However others will report that PFAs will require less energy expenditure for clients to walk allow for better independent function (Sobel Japour Giorgini Levitz & Richardson 2001) as well as decrease cardiovascular demands for clients a subset of whom deal with cardiac compromise (Nerone Springer Woodruff & Atway 2013). Dutch researchers Zinger et al. at the University Medical Center of Utrecht strongly suggest in their 2007 case study to try partial foot amputations even if they are not as common and can be more surgically involved. They report that for young patients as well as older patients with adequate blood supply PFAs can have promising functional and psychological results for the clients such as the ability to ambulate without a prosthetic device less device-induced restriction at the knee and decreased phantom limb pain (Zinger Holtstag & Verleisdonk 2007). Considering the projected increase in prosthetic patients in years to come the increase in the number of PFAs and the conflicting literature about whether or not PFAs are the best treatment option for clients this author believes that a thorough investigation of recent literature is worthwhile to gain better insight and perspective on this issue and determine if more educational experiences regarding PFAs would be beneficial. There are different reviews specific to classifications of PFAs and their outcomes but it is challenging to find a review that looks at all levels simultaneously the appropriate patient populations for each procedure where it can be determined and prosthetic and surgical interventions that can improve the outcome of PFAs. It is also worthwhile to generally compare PFAs to TTAs to determine if there is any evidence to actually support if one procedure does in fact provide better outcomes than another. 95 A Review of Helmet Therapy s Effectiveness in Treating a Variety of Levels of Plagiocephaly By Emily Dyszuk Plagiocephaly also commonly referred to as deformational plagiocephaly (DP) or non-synostotic plagiocephaly can be described as an infant having an asymmetrical-shaped skull due to extrinsic events (1 2... references available in full paper). Prevalence of plagiocephaly is thought to have increased in the population after the Back to Sleep campaign was initiated in 1992 discouraging parents to position their infants on their stomachs to reduce the risk of sudden infant death syndrome (3). In 1996 the American Academy of Pediatrics (AAP) Task Force updated their research and stated that babies should only be placed on their backs to sleep (4). The prevalence of DP is one in 300 live births and is said to have increased since the Back to Sleep Campaign from 0.3% to 8.2% today (5 6 7 8). A study based out of Alberta found a higher prevalence rate of plagiocephaly in infants between 7 to 12 weeks of age and to be just under 50% of the 440 sample size affected with plagiocephaly (9). There is no conclusive data to show that the rates have increased or remained stable from the Back to Sleep campaign (10 11 12). Plagiocephaly nonsynostotic is primarily considered to be a cosmesis issue but studies have shown that there is some evidence supporting the relationship between DP and neurodevelopment problems (13 14 15 16). However there are conflicting results among studies supporting these findings (17 18). Treatment for plagiocephaly consists of a variety of methods from surgery physical therapy (PT) repositioning and helmet therapy. Surgical intervention is not common in infants with nonsynostotic DP and should not be confused with the high prevalence of surgery in infants with craniosynostosis (19 20). Craniosynosisoss involves the fusion of sutures in the infant s skull and is frequently treated by corrective surgery (21). Conservative methods such as repositioning with or without PT and helmet therapy are often compared in the literature to determine their effectiveness in treating infants with DP by the amount of skull reduction deformity (22 23 24). To determine if treatment methods are working to reduce the amount of skull deformity of an infant s head measurement tools are used. Currently there is no singular measurement tool available to practitioners to conduct an accurate and repeatable measurement of the infant s skull making assessment and conclusive results challenging (27 28). A recent article published in the Netherlands made a claim that helmet therapy is ineffective in treating DP. Van Wijk and colleagues reported that letting the skull take a natural course produced the same results as treatment with helmet therapy. This is the first study to suggest that natural course is as effective as helmet therapy and that helmet therapy should not be recommended as a treatment option (25). Articles such as this can have an impact on the orthotic field by affecting parents perceptions of the treatment and influence insurance companies to reevaluate their funding. Further research needs to be conducted to determine if other studies have found similar results in that helmets are ineffective at treating plagiocephaly. An extensive review of the literature has been conducted to determine the quality and number of articles existing that support other treatment modalities specifically helmet therapy. The review will bring awareness to the current treatment effect of orthotic care and observe the measurement methods used to obtain the data on helmet care s effectiveness in treating a variety of levels of plagiocephaly. 96 Does Competency-based Evaluation Enrich P&O Students Learning Experience Compared to Traditional Grade-based Evaluation By Patricia Dang & Emma Holmes Contemporary healthcare education must build and maintain professional competencies and address current issues of quality and relevance (Gallagher 2012 Lo 2015). This requires revising and updating evaluation methods for healthcare education programs (WHO 2013). The purpose of clinical evaluation is to prepare and induce students to work as ethical safe and accountable clinicians. Moreover evaluations need to account for the multi-dimensional nature of competence the clinical environment and the attributes required for the healthcare profession (Levett-Jones et al. 2011 Wu et al. 2015). Traditional grade-based evaluation has been criticized for its heavy reliance on rote memory subjective nature inability to prepare students for lifelong learning and stifling of growth (Ross et al. 2006 Selim et al. 2012 Slackstein 2015). Competency-based evaluation (CBE) as defined by an integrative or holistic approach has been established as an alternative to traditional grade-based evaluation (Fordham 2005 Keevy & Borhene 2015). CBE has been suggested to be a better means to acquiring clinical knowledge and skills that match the current nature of clinical practice providing useful feedback to students promoting self-reflection and growth and establishing standards of competence for learners at different levels (Epstein & Hundert 2002 Book 2014 Heeneman et al. 2015). Established in the 1970s CBE has been utilized in various healthcare education programs globally such as medicine nursing dentistry physiotherapy and occupational therapy (Books 2014 McClarty & Gaertner 2015). Competency a central concept to CBE is defined as a combination of skills abilities and knowledge necessary for performing a task in a given context (Fletcher 2008 Keevy & Borhene 2015). The purpose of this project is twofold 1) To conduct a literature review to determine the strength of competency-based evaluation and its ability to improve the learning experience and promote competent healthcare professionals compared to traditional grade-based evaluation and 2) Develop guidelines for CBE rubrics for the George Brown College Orthotics & Prosthetics program that are aligned with its current curriculum. Currently literature on the use of CBE in prosthetics and orthotics (P&O) education is scarce making it difficult to determine how to develop CBE for a clinical prosthetics and orthotics program. Applications of CBE in other similar health fields will be examined to determine the means of CBE implementation into a clinical P&O program. The intention of this project is to evaluate the current CBE literature to determine its potential to enrich students learning experience and foster professionally-ready healthcare graduates in comparison to grade-based evaluation. By utilizing recent Practice Analyses undergone by OPC ABC and AOPA (ABC 2015 AOPA 2014 OPC 2014) domains knowledge and skills of relevance to contemporary practice can be explored. The knowledge gained from this research can help develop evaluation tools applicable to the Clinical Methods in Prosthetics and Orthotics program through George Brown College. About the Authors Emma Holmes B.Sc. graduated from the University of Waterloo with a degree in Kinesiology. She is currently completing her final year in the Clinical Methods in Prosthetics and Orthotics program at GBC and co-enrolled in the Masters of Rehabilitation Science program at McMaster University. Patricia Dang B.Sc. M.Sc. is in her final year of the Clinical Methods in Prosthetics and Orthotics program at GBC. She graduated from McMaster University with a degree in Kinesiology and a Masters degree in Rehabilitation Science. Patricia will begin her prosthetics residency with Hamilton Health Sciences. 97 Directly Measuring Residual Limb and Prosthesis Anthropometrics for Kinetic Outcomes in Gait Analysis By Evan Harvey The ability to analyze the gait of individuals with lower limb loss has significant value for assessing prosthetic device effectiveness optimizing patients clinical outcomes and for supporting further research. Gait analysis techniques have evolved considerably through the use of sophisticated motion tracking equipment and software. The contemporary method of tracking reflective markers placed over specific body segments with high speed cameras was first developed in 1980 (Cappozzo Della Croce Leardini & Chiari 2005 Davis unpuu Tyburski & Gage 1991). Since then this method has been employed to study various aspects of prosthesis users gait such as gait symmetry altering prosthetic componentry altering weight distribution of a prosthesis or studying the energy consumption by prosthetic users (Rietman Posterma & Geertzen 2003 Rusaw & Ramstrand 2011). However pervasive issues remain in the methodology of most studies within the prosthetic gait analysis literature. Typically gait analysis research has relied on standardized protocols that dictate how the position of limb-segments are defined in order to construct a 3-dimensional model of the subject. The position of these limb-segments is conveyed through the placement of reflective markers on the subject. Popular protocols such as the Helen Hayes protocol (Kadaba Ramakrishnan & Wootten 1990) or methods used by Davis and colleagues (Davis et al. 1991) place markers over specific bony landmarks. In conjunction with anthropometric measurements of the pelvis and leg length a reasonably accurate representation of the hip knee and ankle positions can be conveyed in a 3-dimensional model. With the use of force plates velocities of the markers may be tracked to calculate kinetics of the various joints through inverse dynamics. However some necessary anatomical features may be absent 98 from these protocols in individuals with limb loss. As an example how one selects the location of the malleoli on a prosthetic foot has significant repercussions for where the ankle joint axis is located in the 3-dimensional model. Many previous studies have estimated the location of the ankle axis on a prosthetic foot from the sound side (Rusaw & Ramstrand 2011 Kent & Miller 2011) but this location does not represent the true axis of rotation. The center of rotation of prosthetic feet changes throughout the gait cycle and can vary as much as 6cm from the conventional ankle axis as matched from the sound side (Rusaw & Ramstrand 2010 Sawers & Hahn 2011). Further errors in marker placement are confounded with the component of human error associated in accurately locating joint axes and bony landmarks. This is a major source of intra- and inter-rater error in modern gait analysis systems (Baker 2006 Della Croce Leardini Chiari & Cappozzo 2005). Underlying 3-dimensional models need to reflect the true nature of a subject s anatomy in order to obtain accurate and valid results from instrumented gait analysis. For individuals with limb loss one of the simplest and most obvious shortcomings of conventional models is the change in mass and mass distribution of a limb-segment given the involvement of a residual limb and prosthesis. The current study will examine the role of a prosthesis and residuum inertial properties through two case study analyses of differing amputation levels one trans-tibial and one trans-femoral. This research is the first to show how integrating inertial changes into the model affected gait analysis results at the trans-tibial level. The present study will compare kinetic outcomes using conventional gait analysis anthropometrics (Helen Hayes MM protocol BTS Bioengineering) to values derived from a model that incorporates the mass and center of mass of the prosthesis and residual limb. Further by analyzing gait from trans-femoral and trans-tibial individuals with the same study design we can assess the degree to which inertial limb properties affect different amputation levels. This research will elaborate on the degree to which anthropometric considerations are warranted in prosthetic gait analysis. 99 Yoga Therapy for Phantom Limb Pain Phantom limb pain is a poorly understood phenomena experienced by many individuals who have had an amputation. It is experienced differently by each individual and consequently no treatment has been shown to be effective for everyone who experiences phantom limb pain (Flor 2002). Phantom limb pain has been classified as a type of neuropathic pain in the same category as chronic or inflammatory pain (Pirowska et al 2013). It has also been speculated that phantom limb pain is related to autonomic nervous system dysfunction and post-traumatic stress disorder (Flor 2002). It stands to reason that therapy shown to be effective in treatment of similar types of conditions may also be effective in treating phantom limb pain. Yoga has been defined as the joining together of the physical and spiritual body (Christensen 2002) and is becoming an emerging technique for treatment of many different conditions many of which are similar to phantom limb pain. Some of these include multiple sclerosis (Rogers & MacDonald 2015) By Meghan Guglich pain and therefore justification for this study. As there is no research to date on yoga therapy for phantom limb pain the objective of this study is to collect qualitative data to inform future quantitative research. A focus group semi-structured interviews will be conducted to evaluate the experiences of professionals in the field of yoga for individuals who have experienced an amputation. These responses will be analyzed to help determine the direction of future research in this field. carpal tunnel syndrome (Garfinkel et al 1995) chronic pain (Purdy 2013) post-traumatic stress disorder (Bormann et al 2013) peripheral neuropathy (Head 2006) fibromyalgia (Lush et al 2009) and other dysfunctions of the autonomic nervous system (Purdy 2013). The purpose of this study is to answer the question in individuals who have experienced an amputation is yoga therapy an effective treatment in reducing the frequency and or intensity of phantom limb pain Christensen (2012) states that yoga is a combination of ethical practice physical exercises (asanas) breathing and meditation. For the purposes of this study therapies including one or more of these components will be considered. Moura et al (2012) performed a literature review of mind-body therapies for phantom limb pain and found that no studies for yoga therapies were available. These results were confirmed with another literature search included in this paper. There have however been a number of studies showing the effectiveness of yoga in pain related to phantom limb About the Author Meghan Guglich received a Bachelor of Science in Kinesiology from the University of Alberta in 2014. She is now completing her second year in the Clinical Methods in Prosthetics and Orthotics program at George Brown College and working on her Masters in Rehabilitation Science from McMaster University. She will begin her prosthetic residency at the Rehabilitation Centre for Children in Winnipeg. 100 Myoelectric Prostheses Controlled Through Targeted Muscle Reinnervation (TMR) Compared to Conventional Myoelectric Prostheses for Trans-humeral Users with respect to Functional Outcomes and Reduction in Neuroma and Phantom Limb Pain By Stephanie Pugliese-Santana Major upper extremity amputations account for about 3% of all amputations and are most common among younger individuals (under 65) as a result of trauma (Gonz lez-Fern ndez 2014). If prosthetic intervention is determined to be an appropriate treatment several options exist passive cosmetic devices functional devices such as body-powered and electric-powered control or a hybrid design (Cheesborough Smith Kuiken & Dumanian 2015). Various factors contribute to the decision of which type(s) is (are) selected but when a functional device is favoured optimizing prosthetic joint control is a key objective. In body-powered prostheses control is attained through shoulder movements converted by cables and harnesses into prosthetic movement. Physical strength is required and one movement is produced at a time (Cheesborough et al. 2015). Most electric-powered prostheses are myoelectric which use the EMG signal from one or two muscle groups to produce movement of the prosthesis. Here only one movement can be controlled at a time as well both types resulting in one degree of freedom (DOF) (Cheesborough et al. 2015). Mode-switching methods for myoelectric control strategies exist to produce further movements but present greater challenges to those with more proximal levels of limb loss (Cheesborough et al. 2015). The rejection of prostheses is higher in trans-humeral users than in trans-radial users and has been associated with not meeting the patient s needs poor control discomfort and poor function (Fitzgibbons & Medvedev 2015). Up to 71% of all those with traumatic amputations will suffer from neuroma pain. This is a common reason for discomfort within a prosthesis and there has been little success in treating this concern to improve acceptance among users (Souza et al. 2014). Phantom limb pain (PLP) is another common issue and is more prevalent among those with upper limb loss ranging from 51-80% affected (Fitzgibbons & Medvedev 2015). There are theories about the cause of PLP and many treatment methods such as the use of various pharmaceuticals and mirror therapy with mixed results in success (Fitzgibbons & Medvedev 2015). Some research indicates that the use of functional prostheses decreases the sense of PLP as users can control their (phantom) limb through the use of their device (Bouffard et al 2012). Targeted muscle reinnervation (TMR) is a surgical technique developed over 10 years ago by Dr. Todd A. Kuiken where nerves remaining in an upper limb residuum are reinnervated to other proximal unused muscle targets that have lost their function. The reinnervated muscles act to amplify the biological signal of the residual nerves to allow for intuitive control over a myoelectric device where appropriate nerve pathways are used to produce the movement of the prosthesis as were previously used to control distal anatomical structures of the missing limb. If multiple nerves are successfully reinnervated multi-joint control is possible with a myoelectric prosthesis intuitively without any mode-switches (Cheesborough et al. 2015). As an unexpected side effect neuroma pain was reported to have completely resolved in the majority of patients who have undergone the TMR procedure and had neuroma pain prior to their surgery (Souza et al. 2014). However this needs further evaluation as it was discovered retrospectively and requires more rigorous research for all future patients who will undergo the TMR procedure. There is also some indication that PLP may decrease with 101 the use of a myoelectric device with TMR (Fitzgibbons & Medvedev 2015). Traditional myoelectric devices are limited in the number of movements they can produce simultaneously while TMR can allow for greater control over the prosthesis (Gonz lez-Fern ndez 2014) and TMR has been shown to restore neural pathways that would be associated with distal limb function (Scheme & Englehart 2011). TMR at present is best suited for more proximal amputations where disability is greatest. The purpose of this review is to compare conventional myoelectric prostheses to those controlled through TMR for trans-humeral users. Improved functional outcomes and analysis for the use of TMR as a possible treatment for neuroma pain and PLP will be outlined along with discussion of gaps in the current literature. About the Author Stephanie Pugliese-Santana completed a B.Sc. in Kinesiology at York University in 2003 and her Prosthetic and Orthotic Technician diploma from George Brown College in 2015. She is completing her studies in the Clinical Methods in Orthotics and Prosthetics at George Brown College. The George Brown College (GBC) Orthotic & Prosthetic programs have supplied professional personnel to the prosthetic and orthotic profession for over forty years. Originally located at the West Park Healthcare Centre the GBC Orthotics & Prosthetic programs are currently based at the Sunnybrook Centre for Health Sciences. The Prosthetic Orthotic Technician Program is the only full-time accredited technical training program in Canada. 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Reinforced silicone and strategically-located Parylene coating provides maximum durability. The dual sleeve design with a non-slip inner strip provides a maximum airtight seal eliminating slippage. Platinum-cured medical-grade silicone with a Parylene surface reduces surface friction to prevent skin shear and reduce blistering. A smooth silky coating allows clothing to hang naturally. Maglock and Parasil Liners ST&G revolutionizes the liner industry with two new technologies. The Maglock liner is a no-battery magnetic locking system that eases the frustration of donning a pin lock liner. This strong magnet provides 90lbs of suspension for complete confidence stopping socket rotation. The ST&G Parasil liner is made by embedding platinum-cured medical-grade mineral oil silicone with a Parylene coating which is great for active clients. The Parylene surface reduces surface friction between the liner and skin and the liner and the socket which helps prevent skin shear for fragile skin and blister reduction. The Parylene coating gives the Parasil liner the unique ability to repel water making it easy to clean and sanitize to be odour-free. NSP CSP Laminating Braid NSP from ST&G is a unique fibre that is lighter stronger and offers the stiffness and 10 times the impact resistance of carbon all at a lower cost. The stiffness can be regulated by fibre orientation to be equal to carbon. When grinding NSP there are no flying fibres eliminating the itch factor experienced when finishing carbon sockets. The socket edge is easy to finish. White NSP absorbs custom colours nicely and looks great with a transfer. If a black socket is preferred try CSP. CSP is NSP with black die already incorporated. 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Anatomical Concepts Spotlight Prefabricated KAFO Patient Rehabilitative Systems A rehabilitative orthotic system which provides a unique and cost-effective approach in managing your patient s lower extremity needs these modular KAFO AFO systems can be easily adjusted. Ranging between only three standard sizes (adult paediatric and infant) the individual ankle-foot and knee sections can be disconnected quickly in the field with or without tools to be used separately if needed. The versatility and durability of its single posterior-jointed design creates a patient-friendly superior sagittal plane support system for ambulatory recumbent patients who can manage their entire rehabilitative process for an indefinite period of time. Pediatric V-VASTM Custom KAFO The Pediatric V-VASTM custom KAFO is fabricated for your young patients who require treatment for lower limb bowing deformities. The dynamic V-Vas joint system allows for sequential correction of the deformity and for accommodation of growth with outstanding patient compliance. It is the only system that creates a bending moment which maintains the four-point correction throughout the full range of knee motion. The KAFO design is adaptable to incorporate a medial or lateral Step lock or Drop lock joint opposite of the V-VAS joint to simplify straightening adjustment and increase knee stability if needed. For more visit www.PRAFO.com or call 1-800-837-3888. 106 Visit www.AnatomicalConceptsInc.com or call 1-800-837-3888. Compressogrip A K Shrinker SmartKnit Diabetic Socks Soft-Sock with 3D Toe SOLUTIONS THAT FIT TM Ease Compression Hosiery Silver Sheath Stretch Spacer Socks PROSTHETIC & ORTHOTIC TEXTILES Liner-Liner Prosthetic Sock with X-Static Torso Interface V-Neck Pink and Black Soft-Socks Knit-Rite Inc. is the world s leading developer and manufacturer of innovative prosthetic and orthotic textile products. Since 1923 we have worked with practitioners to advance textile solutions that promote mobility protection and comfort for patients. We are proud to serve orthotists and prosthetists with the widest array of options in O&P textile products to help provide your patients the best quality of life possible. Power Belt Big Toe Sock Power Pull Spacer Socks Core-Spun by Therafirm Support Socks Shrinkers SmartKnit AFO KAFO Socks Proudly distributed in Canada by A K Brim Sheath 4-Way Shrinker SMO Socks Tel 1.800.363.8726 Fax 1.800.663.8817 info ortoped.ca Kovacic Orthopedic Tool & Supply Spotlight Adjustable Safety Locking A-P Bar The Adjustable Safety Locking A-P Bar allows safer more controlled anterior posterior bends due to total contact of the upright to limit twisting by the clamping screw. It is 34 long for increased leverage to allow bends with less effort without the need of an extension. Made to bend 5 8 (16mm) and 3 4 (19mm) uprights and 1 2 thick steel just rotate the die for the proper width. Made from a mixture of fully hardened tool steel to limit wear nickel-coated to prevent rust rubber handle grip for comfort to limit stress on the hands. Has a three-year warranty but was made to last a lifetime. Extended Heavy Duty A-P M-L Bending Iron T-2 T15 length for even more leverage to allow metal bending with less force and limit the use of an A-P bar in certain situations for convenience. Contains grinded edges to minimize marking on metal uprights and is designed for bending 1 4 (6.3 mm) thick uprights in the vertical slot. Allows the closest possible anterior posterior bends safely and efficiently in the horizontal slot mainly for aluminum uprights up to 3 16 thick or thinner stainless steel. Made from fully hardened tool steel double coated (e-coat powder-coat) for a durable finish. Three-year warranty. Small Offset ML-AP Bending Iron T-2 Only a 1 4 thick with a narrow 5 32 slot and offset design to allow bending of thin metal uprights in tight areas up to a maximum thickness of 1 8 which should be bent in the upper area of the vertical slot. Allows the closest possible anterior posterior bends safely and efficiently in the horizontal slot for uprights up to 1 8 x 5 8 by having the slot right at the edge and being just 1 4 thick to minimize interference. The slots contain rads to minimize marking on metal uprights are made from fully hardened tool steel triple-coated (nickel e-coat powder-coat) for a durable finish. Three-year warranty. For more products from Kovacic visit www.kovacicorthopedic.com or call 1-800-665-1176. Biodesigns Spotlight High-Fidelity Transfemoral and Tibial Socket System In person and online training now available. Say goodbye to buckets and welcome in the next generation in prosthetic-limb connectivity the patented and patents-pending HiFi TM Interface and Imager System. Unlike traditional sockets that focus on fitting the periphery of the limb the HiFi Interface System allows prosthetists to capture and control their patients underlying bone. Upper and lower limb wearers report a significant increase in control function performance and comfort. Patients state that the HiFi feels connected to them. And the HiFi is backed by clinical evidence. Register today for one of our webinar training events. Contact biodesigns at HiFi biodesigns.com or call 1-800-775-2870 or visit www.JoinHiFi.com. Check out www.youtube.com bio designsvideos and www.facebook.com biodesigns for the most up-to-date information. 108 Ottobock Spotlight Greifer New Colour The powerhouse Greifer is now available in black. Adding to its already exceptional design and high quality engineering is a new feature an LED flashlight. Helping to spotlight work areas it makes this terminal device an even more incredible and useful tool for users. The Greifer earned the prestigious Red Dot best of the best award for the exceptional new design. For a modern rugged look the update also pairs well with the black Dynamic Arm or can be a sophisticated secondary device for bebionic users. Greifer features a proportional gripping force of 0 to 160 N and different gripping tips (wide narrow or rubber coated) allowing for adaptation for special tasks. The 3R62 is an ideal option to help patients achieve therapeutic objectives of restoring their ability to stand and walk safely. There are two versions of the knee 1) 3R62 includes a manual lock that can be engaged by patients for added security. When the patient progresses to walking more securely you can deactivate the manual lock and 2) the 3R62 N does not include the manual lock feature. Dynamic Vacuum The Dynamic Vacuum (DVS) bridges the gap between valve and Harmony socket technology. Integrating innovative design with simplicity the DVS reduces the movement between the limb and socket associated with limb volume fluctuations. The DVS generates vacuum during walking and maintains this elevated vacuum in both swing and stance phase. This sets it apart from passive systems where a vacuum is only generated in the swing phase. Increased suspension forces and intimate fit enhances the user s perception of the ground beneath them. Dynamically it adjusts to the user s activity level. 1T01 TaiLor MadeTM Foot The TaiLor Made (TLM) foot is designed with toe and heel elements that move independently along with a vertical shock mechanical spring pack. The TLM Control Hub provides superior vertical shock that can be adjusted to suit patients needs and it is lightweight to help users remain nimble enough for higher level activities. Features and benefits Independent movement between the heel and forefoot to create a smooth roll-over and simulate plantarflexion dorsiflexion especially on inclines and declines. Shock absorption and comfort at heel strike from compression of the springs. Energy return at toe-off from release of the springs and the carbon fibre forefoot. Exchange the heel and forefoot springs for different stiffness levels to customize performance for your patient. Provides great terrain conformance to help patients navigate uneven surfaces more safely. One of the lightest vertical shock feet available at just 16 oz (453 g). BebionicTM Comfortable Intuitive Precise. The bebionic hand helps people with upper-limb loss improve body position. The innovative hand features two selectable thumb positions opposed and non-opposed. The bebionic hand provides 14 different grip patterns offering users a more complete device that assists them in their day-to-day lives. Ottobock offers complete upper-limb prosthetic solutions for every amputation level and every need. The bebionic prosthetic hand leverages pioneering technology and innovative design to provide one of the most life-like and easy-to-use multi-articulating prosthetic hands available today. Like all Ottobock prosthetic products the bebionic hand comes with unparalleled service and support a 24-month warranty at no additional cost a 60-day satisfaction guarantee and clinical and reimbursement support. 3R62 Pheon Due to its swing phase control and stance phase security the polycentric knee joint 3R62 Pheon is especially suitable for amputees with low mobility. 110 Ottobock Spotlight continued Harmony P4 The Harmony P4 is a line extension to Ottobock s mechanical vacuum pump line whose design is shorter and reaches vacuum faster than existing pumps. The Harmony P4 also has a vertical shock-reducing pylon and torsion unit in addition to active vacuum volume management. The unique direct connection to the socket also eliminates any external tubing. With over 1 less clearance than other pumps more users can be fit with more foot options. WalkOn Reaction Junior The WalkOn Reaction Junior is the latest addition to the WalkOn line. Based on the WalkOn Reaction Plus the WalkOn Reaction Junior features highly dynamic properties. The ankle-foot orthosis uses ground reaction force to promote a physiological gait pattern. The WalkOn Reaction Junior is designed for children who require greater support than traditional dorsiflexion-assist orthoses provide. Features include a durable one-piece design for less breakage and fewer clinic visits fast and easy-to-fit due to a trimable sole carbon fibre prepreg material providing high energy return and extreme comfort due to low weight open heel and the anatomically-designed anterior tibial shell. For more on these products and others from Ottobock call your local sales rep at 1-800-328-4058 or go to www.professionals.ottobockus.com. OrtoPed Spotlight HorizonTM LT By College Park Made with aircraft-grade aluminum alloy the Horizon LT is the lightest carbon fibre foot on the market. Like the original Horizon HD the Horizon LT was meticulously crafted utilizing maximum stress predictions to increase strength and prevent failure. The roll-over Enviroshell design combined with the speciallyengineered carbon composites provides the perfect blend of comfort and ability. The Horizon LT offers a low-profile lightweight and economical choice for moderate activity users. RUSH ROGUETM By Ability Dynamics The new RUSH ROGUETM integrates biomimetic ankle action simulating realistic foot and ankle motion. The addition of the Vertical Loading Pylon provides comfortable relief from highimpact loading offering exceptional rotational torsion relief to ease the impact to knees hip and back. The rollthrough characteristics of the foot deliver exceptional energy return with no dead spot. The FlexionTM composite material provides three times more flexibility than conventional prosthetic feet. Two composite plates are cushioned by rubber moulding allowing for soft ground compliance and comfortable heel strike. 111 OrtoPed Spotlight continued L1324 Knee By ST&G New to OrtoPed the L1324 is a polycentric manual-locking knee with stance flexion. The lock is manually released by pulling on the lanyard which is attached to the knee lock mechanism. The lock mechanism can also be removed at a later time so that the knee can be used as a free swing knee. The frame construction is made of super-light aluminum alloy and the 5-bar linkage is made of aircraft alloy. Usable for either above-knee amputees or those with knee disarticulation and best suited to be used for K2. Swing Phase Lock 2 By Fillauer Developed by Basko Healthcare a Fillauer affiliate in the Netherlands the Swing Phase Lock 2 (SPL2) uses a simple internal pendulum mechanism to lock and unlock the knee depending on the angle of the joint in the sagittal plane. During movement the device locks just prior to heel-strike for support during stance and unlocks the knee at heel-off in preparation for swing. This action is intended to mimic the normal physiological action of the knee extensors. KinnexTM By Freedom Innovations Hip Flexion Assist Device By Becker The Hip Flexion Assist Device is intended for individuals with Multiple Sclerosis (MS) who are currently ambulatory but have difficulty initiating swing due to hip flexor weakness. The Hip Flexion Assist Device (HFAD) is designed to improve gait and consists of a comfortable waistband and two dynamic tension bands that attach to the shoe. The device may be worn over or under clothing. Freedom KinnexTM integrates the world s fastest-responding microprocessor ankle foot technology and carbon fibre to provide low to moderate impact K3 ambulators the stability they expect instantly. Unmatched ground compliance improved comfort and automated heel-height adjustments keep users firmly grounded and connected wet or dry. With 30 degrees of microprocessor-controlled motion 20 plantar and 10 dorsi Kinnex allows the prosthetic user to navigate environmental obstacles such as ramps slopes uneven terrain and stairs with added confidence and stability. This motion also reduces internal socket pressures and improves the comfort when sitting squatting or standing. For information on these products and others distributed by OrtoPed call 1-800-363-8726 or visit www.ortoped.ca. 112 Don t sweat it we got this Ready for the hand-off 113 National Conference August 8-11 2018 OTTAWA OPC 2018 National Conference August 8-11 The Westin Hotel Ottawa Ontario Canada Largest gathering of O&P Professionals in Canada Over 70 booths in Exhibit Hall Only occurs every 2 years Great networking and learning opportunities for Certified Clinicians Registered Technicians Facility Owners Educators Researchers Suppliers and more www.opcanada.ca Collaborative and comprehensive educational programming for Clinicians and Registered Technicians alike with up to 24 eligible MCE Credits through educational sessions Manufacturers Workshops Product Display Showcases Poster presentations and this year we will also be incorporating the TECH SYMPOSIUM into the Conference. 2016 BROUGHT US 62 Presentations 35 Exhibitors 12 Manufacturer Workshops 6 Products Display Showcases 7 Poster Presentations 8 Sponsors 1 awesome backdrop 1 Pre-Conference Workshop 1 Polling Feature 1 Softball Game 1 Country Hoedown and 1 Conference App that pulled it altogether. CONTINUING EDUCATION Mandatory Continuing Education Program Certified and Registered orthotics and prosthetics professionals are required to maintain their membership in good standing with the Corporation to continue to utilize their credentials. There are three conditions required to maintain good standing with Orthotics Prosthetics Canada (OPC) Payment of annual professional fees Meeting the Mandatory Continuing Education (MCE) program requirements Adhering to the OPC Canons of Ethical Conduct The OPC Mandatory Continuing Education Program provides assistance to members to meet these professional obligations. As mandated by the Board of Directors the Professional Development Committee is responsible for defining developing and implementing effective knowledge transfer activities through the development of the MCE Program and MCE Credit Value Chart. The MCE Chart provides an outline of acceptable and relevant opportunities to obtain continuing education credits the credit value associated with each opportunity and the maximum allowance per 5-year MCE Cycle. The Chart is a living document that continuously evolves. The Professional Development Committee has worked diligently to expand and broaden the OPC Mandatory Continuing Education credit value chart with additions such as Humanitarian Volunteer efforts George Brown College Grand Rounds (with the assistance and cooperation of the GBC faculty) and Masters Scholarly Papers and Rehab courses. In alignment with these efforts the Professional Development Committee has been working towards creating an online resource centre of educational course providers (online and in-person) in order to engage our members and facilitate their efforts in maintaining and improving their professional competencies. This resource can be found under the Learning Centre on the OPC website at www.opcanada.ca. Continuing education is not only a strategic priority for the organization it is also one of the pillars that defines Certified and Registered orthotic and prosthetic professionals as the Gold Standard . 115 Live Well with Limb Loss SUBSCRIBE to Prosthetic Facility Program Share thrive with your clients or patients with our special Facility Program Purchase copies for give-away in your waiting room. Just 1 a copy... and a one-time order for the year makes it easy. Call 1-800-725-7136 or email jeff thrivemag.ca to order. Sponsored by Advertiser Index Alignment Online. . . . . . . . . . Anatomical Concepts . . . . . . . ALPS Canada . . . . . . . . . . . . Amfit Inc. . . . . . . . . . . . . . . Berretta Medical Inc.. . . . . . . . biodesigns inc. . . . . . . . . . . . Bulldog Tools . . . . . . . . . . . . Canada Brokerlink Inc. . . . . . . Cascade DAFO . . . . . . . . . . . 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Pg. 113 Sure Step . . . . . . . . . . . . . . . . . . . . . . Pg. 102 Texas Assistive Devices. . . . . . . . . . . . . . . Pg. 45 The Knee Centre Karl Hager . . . . . . . . . Pg. 98-99 Thrive magazine . . . . . . . . . . . . . . . . . . Pg. 118 TRS. . . . . . . . . . . . . . . . . . . . . . . . . . .Pg. 71 University of New Brunswick (NEC 2017) . . . . Pg. 113 WillowWood Company . . . . . . . . . . . . . . Pg. 79 118 DVS Dynamic Vacuum Simple Solutions Now available Dynamic Pump activates with each step Vacuum Enhanced fit and function Simple Easy fabrication no certification required professionals.ottobock.ca 13997 - 03 17 2017 Ottobock HealthCare LP All rights reserved.