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Canadian Prosthetics & Orthotics Journal
Number of Followers: 0  

  This is an Open Access Journal Open Access journal
ISSN (Online) 2561-987X
Published by U of Toronto Homepage  [41 journals]

    • Authors: Andreas Kannenberg
      Abstract: This paper reviewed 11 publications on non-MP controlled ankles with active dorsiflexion feature, 15 publications on passive MP controlled ankles, and 12 publications on powered MP controlled ankle-foot mechanisms. Methodological quality of publications was low to moderate. The evidence found was mostly biomechanical and generated in gait lab studies. Non-MP ankles may increase toe clearance and reduce braking forces during level walking, thus supporting propulsion with increase in walking speed. Passive MP controlled ankles may also increase toe clearance and reduce the likelihood of stumbling over an unseen obstacle. They may reduce energy expenditure during level walking and facilitate slope and stair ambulation. Non-MP and passive MP controlled ankles have been also been shown to reduce residual limb-socket interface pressures. Powered ankles may increase walking speed to the level of and decrease energy expenditure to be no longer significantly different from that of able-bodied individuals. Also, at higher walking speeds the sound knee loading may be reduced by up to 15-20%. However, it remains unclear to what extent the gait lab results for all advanced ankle-foot mechanisms can be transferred to real-life benefits in the free-living environment. Article PDF Link: Introduction Microprocessor technology has been adopted in prosthetic knees for almost 30 years and in prosthetic feet for about 10 years. Several systematic reviews of the literature on microprocessor-controlled knees have confirmed their benefits in safety and mobility, supporting their use in individuals with transfemoral amputation and MFCL-3 and also MFCL-2 mobility. However, microprocessor-controlled (MP) passive and powered feet are widely considered experimental, investigational and unproven by health insurances.         METHOD The Medline and EMBASE databases as well as the online library of the Journal of Prosthetics and Orthotics were searched on January 15, 2018, for publications using search terms related to feet with non-MP hydraulic ankles/dorsiflexion feature, or passive or powered microprocessor controlled feet. The search terms were combined into a title, abstract, and key word search phrase using Boolean operators, resulting in the following syntax: amput* OR prosth* AND foot OR ankle OR hydraulic OR dorsiflexion OR linkage OR microprocessor OR MP* OR power*. The literature search was repeated on June 30, 2018, to identify recent publications since the original search date. Titles and abstracts of the identified publications were screened for their scope. Technical papers and case studies were excluded. Publications on biomechanical and clinical studies were rated for methodological quality using the criteria of a Cochrane review of prosthetic foot research by Hofstad et al. (1). Publications with good enough methodological quality were reviewed in full and results were extracted and summarized.   RESULTS The literature search yielded 12 publications (2-13) on biomechanical and/or clinical studies with a prosthetic foot with a non-MP controlled hydraulic ankle/dorsiflexion feature, 16 publications (14-29) on passive and 17 publications (30-46) on powered MP controlled prosthetic ankle-foot mechanisms. One publication on non-MP feet (12), one publication on passive MP feet (14) and 5 publications on powered ankle-foot mechanisms (35, 40, 44-46) were excluded from the review for insufficient methodological quality. All included studies had low to moderate methodological quality and all but one were conducted with individuals with unilateral transtibial amputations. Compared to standard energy storage and return (ESAR) feet, the studies with a foot with a non-MP hydraulic ankle/dorsiflexion feature demonstrated a significantly increased toe clearance and self-selected walking speed on level ground. In addition, studies reported reduced braking forces (improved progression of the center of pressure under the foot), smoother gait and reduced perception of having to “climb over the prosthetic limb” by the patients. One study demonstrated reduced interface pressures between the socket and residual limb while walking on level and uneven terrain and ascending and descending slopes and stairs. One study with a passive MP controlled prosthetic foot also demonstrated significantly improved toe clearance during over-ground walking, reducing the likelihood of tripping over an unseen obstacle of 0.5 cm height from 1/166 steps with an ESAR foot to 1/3,169 steps with the MP foot. Studies also found a reduction of metabolic energy consumption on level ground and a reduction in perceived energy demand for walking up slopes. One study found some improvements but also some deteriorations in biomechanical parameters during slope ambulation. Another study demonstrated that it was easier with a MP controlled than with a non-MP controlled hydraulic ankle to control the walking speed while descending a 5° slope. One study with a MP controlled foot with instant terrain adaption and a dorsiflexion stop found that it was more physiologic to stand on a 10° incline and decline with this foot than with other MP controlled feet with only gradual terrain adaption and no dorsiflexion stop. One study found some improvements in biomechanical parameters while ascending and descending stairs. Finally, one study also demonstrated significantly reduced interface stress between the socket and the residual limb when using a MP controlled foot as compared to a standard ESAR foot on varying terrains. Studies with a MP controlled powered ankle-foot component found that subjects able t...
      PubDate: 2018-09-01

    • Authors: Arjan Buis, Francesco Guarato, Jason Law, Zoe Ralston, Anna Courtney
      Abstract: Article PDF LINK: BACKGROUND: Background:  Acoustic emission from structures subject to external loads can be monitored to detect internal damage before destruction occurs. It is hypothesised that deformation of soft tissue will emit acoustic signals which may aid early detection of deep tissue injury, particularly in the lower limb amputee population. No previous studies have applied this method to biological soft tissue. OBJECTIVE: To determine if skeletal muscle tissue produced measurable acoustic emission during dynamic tensile loading with the aim to establish a reliable biomarker for lower limb prosthetic socket fit quantification and prosthetic health. STUDY DESIGN: Experimental study design. METHODOLOGY: In this research article, Sus scrofa domesticus (pork) muscle and Gallus gallus domesticus (chicken) muscle specimens (10mm width x 45mm height x 4mm depth) were submerged into saline baths while an Instron testing machine applied displacement controlled tensile loads. Time stamped, load, displacement and acoustic signal (hydrophone) data was collected. FINDINGS: The pork muscle was tested to failure being subject to tensile load. Prior to failure, no peaks were found in the amplitude or frequency of the acoustic signal to indicate that either tissue deformation or failure was occurring.  Data gathered during chicken muscle testing was inconclusive. CONCLUSIONS: Results displayed that tensile testing of pork intercostal muscle produced tissue deformation and failure with no detectable change in the amplitude or frequency of the background sound during tensile loading. The other specimens failed before reaching the same levels of tensile load. Further studies are required in order to address the numerous limitations of this study. LAYMAN’S ABSTRACT Humans are made of biological material, some are hard such as the skeleton and some are soft as in muscles. When the soft tissue are under a too high stress condition, such as in diabetic patients, we talk about deep tissue injury. It has been proven that deep tissue injury negatively impacts the affected persons’ quality of life, through a reduction in mobility and ability levels. Deep tissue injury is additionally very costly to health care systems worldwide. Unfortunately, those with lower limb dysvascularity (in particular, amputees with limb loss secondary to dysvascularity and/or neuropathy) are at heightened risk of further damage from deep tissue injury.  Therefore, this study ultimately aims to be used as a basis in order to determine if, at some stage, it would be possible to detect tissue that was ‘at risk’ of developing deep tissue injury. ARTICLE PDF LINK: Introduction In the UK, 72% of lower limb amputations result from dysvascularity and/or neuropathy, with the majority of amputations occurring at trans-tibial level (1).  The two commonly used trans-tibial socket designs are based on conflicting principles, both of which have a lack of substantiation regarding the internal conditions of the residual limb within the socket (2). The first design, the PTB socket, applies specific loads to pressure-tolerant areas, whereas the hydrocast socket aims to dispense pressure uniformly through the “stiffest path principle” (3). It is advocated that hydrocast sockets have a greater ability to generate “ideal” pressure distribution together with a reduction in internal shear (2).There is, at present, no consensus on what defines an “optimal” socket design or fit (3, 4). There is a growing belief among researchers that the ‘coupling’ stiffness between the hard prosthetic socket and the weight bearing structure, the skeleton, is a major factor in optimising the quality of a socket design (3, 5), as it can reduce the amount of tissue deformation during load bearing and consequently reduce the shear stresses in the soft tissues (3-5).  Due to the aetiology of these amputations, the residual limb is at increased risk of developing a deep tissue injury (DTI) due to peripheral neuropathy, impaired blood supply and/or poor skin condition (6).  If a DTI is misdiagnosed or diagnosed late in this population, there can be a risk of revision amputation being necessary due to increasing tissue necrosis. This severely impacts the patient’s quality of life and places excess strain on the healthcare system (7). This highlights the avid prerequisite for comprehensive assessment of prosthetic socket fit and function.  To date, research focusing on residuum-socket interface pressures has been unable to establish a direct relationship between interface pressures and the magnitude of deep tissue stresses. These studies have inadequately quantified the mechanical stresses within deep internal tissues (8, 9).  As a result, interfacial pressures alone are unlikely to change socket design principles and additional performance/bio-  markers are therefore needed. Deep Tissue Injury (...
      PubDate: 2018-08-28

    • Authors: Julie Burke, Goeran Fiedler
      Abstract: BACKGROUND: Evidence-based practice (EBP) is an important cornerstone of responsible clinical decision-making, and by extension, of high quality care provision in prosthetics and orthotics. However, many clinicians have been reluctant to embrace EBP, citing barriers such as high costs and time demands that are associated with obtaining pertinent published evidence for individual care scenarios.
      OBJECTIVES: The purpose of this study was to determine how accessible peer-reviewed research articles are to prosthetists who seek to implement EBP techniques into their clinical work without expending unreasonable amounts of time and money.
      METHODOLOGY: Two approaches were utilized. An academic approach entailed a search through five peer-reviewed research journals, including the Journal of Prosthetics and Orthotics and Prosthetics and Orthotics International. A practical approach simulated a typical evidence search as it might occur in the field, using a number of different clinical questions to inform search terms in Google Scholar. The ratio of freely accessible articles was computed and compared for both approaches.
      FINDINGS: Out of a total of 796 prosthetics-relevant articles published in the analysed journals over the last years, 600 (75.4%) were found to be accessible to the public without any cost incurred. The practical approach showed that, among the top twenty search results for each search query, on average 40% to 75% of articles were freely available.
      CONCLUSIONS: A majority of pertinent research papers is already publicly available to anybody with internet access. Prosthetists would not be required to invest in journal subscriptions or have to spend time at an academic library to obtain these articles. However, it is a concern that evidence-based decision making may be flawed if not all literature on a topic is considered. There is still a substantial fraction of articles that are not freely available to practitioners, motivating a continued expansion of open-access policies in the field.
      Medical care, including the provision of prostheses to people with limb loss, needs to be informed by scientific evidence. In order to reduce the risk of making decisions that are not ideal for a given patient and scenario, clinicians have to find out what the latest research on the topic suggests. While finding, reading, and appraising the published literature is an important aspect of Evidence Based Practice (EBP), it can be a time consuming task that interferes with the other duties of busy clinicians. Searching for literature over the internet can reduce the associated burden, as no physical copies of research articles have to be retrieved and stored anymore. However, not all research is freely available online, and accessing the full text versions of some papers can incur substantial fees.
      We wanted to find out how much of the scientific literature in the area of limb prosthetics is accessible free of charge on the internet. To that end, we first used the official websites of five established journals to search for prosthetics related articles and to check how many of them were free to read. Next, we used a search engine that is specialized in research articles (Google Scholar) to see how many of the offered search results point to full papers and how many are merely offering abstracts or otherwise abbreviated version of a full paper. Overall, we found that about 75% of research is freely accessible, which we believe to be sufficient for EBP in most cases.
      Accessibility of peer-reviewed research articles has been cited as a barrier that prosthetists and orthotists must overcome in order to use evidence-based practice (EBP) in their clinical practices (1-4). Short of frequenting a local university library that may or may not hold the publications of interest and/or allow some access by the general public, there are four basic ways by which practitioners may acquire peer-reviewed research articles: open-access or free-access articles (these are free to the public, usually online), paying for online versions of individual articles in peer-reviewed journals, subscribing to peer-reviewed journals that contain articles of interest, or joining an organization that includes journal access as one of the membership benefits.
      One example of an open access journal relevant to the field of Prosthetics and Orthotics (P&O) was the Journal of Rehabilitation Research and Development (JRRD), which focused on veteran-centric rehabilitation research, including articles related to prosthetics, orthotics and other assistive technologies (5). JRRD was funded by the US Department of Veterans Affairs to cover operation costs, but ceased publishing within the Rehabilitation Research and Development Service in March of 2017, referring authors to Public Library of Science (PLOS) instead (6).
      The recently introduced Canadian Prosthetics & Orthotics Journal (CPOJ) is utilizing a more commonly found open-access model based on article-processing charges. Select open-access articles can also be found in the field’s specialized journals that utilize the classic membership/subscription model for revenue, including the Journal of Prosthetics and Orthotics (JPO) and Prosthetics and Orthotics International (POI). JPO offers open-access to articles that are two years or older, and POI offers open-access to all articles three years and older as well as select recent articles through Sage Publishing. Several heavily cited papers focusing on prosthetic research have also been published in journals that are not specialized in...
      PubDate: 2018-08-10

    • Authors: Goeran Fiedler, Saiph Savage, Jon Schull, Jennifer Mankoff
      Abstract: Article PDF file: Professional Opinion
      The emergence of 3D-printed upper limb prosthetic devices a couple of years ago, spearheaded substantially by the e-NABLE community (1, 2), has triggered a variety of reactions, ranging from euphoric press coverage predicting a new age of low-cost universally obtainable prosthetic solutions to anxious reluctance by clinicians fearing the demise of high-quality professional health care provision (3, 4). The circumstance that untrained volunteers produce e-NABLE devices on their hobby-grade 3D-printers (5) was both hailed as a revolutionary paradigm shift suited to address a host of current challenges in health care economics, and derided as inappropriate intrusion into long-standing training and certification standards of a well-regulated profession. That many of the early generation e-NABLE devices targeted young patients with partial hand amputation (6) was interpreted by proponents as finally offering this neglected population long-desired solutions, whereas skeptics felt that many of the recipients of such devices would traditionally have been deemed to have a residual functional enough to be a contra-indication for a prosthesis (7).
      So, how valuable are those 3D-printed devices really for their users, and – be extension – for society at large' Most reasonable people may feel that the truth, as for so many contested questions, is somewhere in the middle. The confidence boost from having a 3D printed superhero hand can be very real for a young patient, even if it is used only for short times. Affordable customizations tailored to special tasks, such as holding a musical instrument (8), can make a big difference for young users, even if there is little utility beyond that. Meanwhile, the e-NABLE community has progressed to be about more than mere device fabrication and distribution, with EnablewebCentral having become a sophisticated platform for tracking cases, recruiting follow up feedback, and even providing referrals to and coaching from Prosthetists. That devices produced by hobbyists would be able to outright replace much more expensive commercial prostheses is no longer being claimed by representatives of the e-NABLE community. Instead, a mutually beneficial collaboration between the 3D-printing community and Prosthetics and Orthotics (P&O) professionals has been proposed (9). News stories on the topic have recently become fewer and less sensationalist. On the other side, many prosthetics clinicians have come to realize that 3D-printing technology does have the potential to substantially change fabrication methods in the field, and that there is good reason to embrace the associated technological progress. It can be argued that the development already has brought some benefits for the field:
      • The publicity, even if partly unwarranted, may have triggered a greater interest in the P&O profession, attracting more talented students, and motivating new research opportunities.
      • Some of the young patients who have been introduced to prosthetics through an, even unnecessary, e-NABLE device may be more likely to accept and use prostheses later on.
      • Limb loss management being the first prominent area of using crowd intelligence to address healthcare challenges (10), an approach that promises wide applicability in the future (11, 12), gives our field once more a pioneering role within the allied health sciences.
      Still, while it may be easy to intuitively agre...
      PubDate: 2018-08-10
           USING CAD

    • Authors: Marie O'Byrne, Angus K McFadyen, Dominic Hannett, Anthony McGarry
      Abstract: Study design: Pilot study
      Background: Computer aided design (CAD) is now commonly used in prosthetic clinical practice. To create a patellar tendon bearing (PTB) socket, further modification of the transtibial shape is required.
      Objectives: To investigate the consistency of transtibial shape modification for a PTB socket design using CAD.
      Methods: 13 transtibial models with marked anatomical landmarks were made, each linked to a fictitious patient history. Three clinicians were asked to complete modification for a PTB socket with suspension sleeve at weekly intervals over the course of three weeks. Measurements were recorded at landmarks and compared for intra and inter reliability.
      Results: Clinicians showed high intraclass and interclass correlation (ICC) values with narrow confidence intervals for the tibial tubercle, medial and lateral flares and distal end of the tibia. One clinician demonstrated moderate intra rater reliability for modification over the patellar tendon. All other ICC values for the patellar tendon and fibular head modification were low. Inter rater reliability was not calculated for fibular head and patellar tendon as intra ICC values should be above 0.6.
      Conclusions: All clinicians showed good consistency at tibial tubercle, distal tibia, medial and lateral flares. Patellar tendon (0.345< ICC < 0.641) and fibular head (0.165< ICC < 0.513) showed poorer consistency and require improvement. LAYMAN’S ABSTRACT
      Computer aided design (CAD) is now commonly used to create artificial limbs. However, the shape of the amputated limb is captured when the patient is sitting down and therefore requires further adjustment. Modification of the shape is carried out by clinicians using a range on on-screen tools to remove and add material to the virtual model.
      This study aims to investigate the consistency of clinicians when making these modifications. A range of 13 below the knee amputation models were made, each linked to a made-up patient history. Three clinicians were asked to randomly complete modification three times on each model at weekly intervals over the course of three weeks. Measurements were recorded at landmarks and compared.
      Clinicians showed high reliability values for most landmark positions. However, modification was less reliable over important areas such as the patellar tendon and fibular head. Errors in such areas could potentially cause discomfort to the artificial limb wearer and greater consistency is required. This is only an initial study and further work is required to confirm results. ARTICLE PDF LINK:
      Computer aided design (CAD) is now commonly used in prosthetic clinical practice (1) and current scanners have been shown to have a high level of accuracy during the shape capture process (2). Saunders et al implied that shape capture using CAD can save considerable time and make the process more quantifiable. They also acknowledged that models may be stored electronically and easily replicated, unlike plaster where modified plaster models are usually destroyed during socket fabrication which makes socket duplication more difficult (3). The most common level of amputation is transtibial therefore this is the focus of this study (4).
      Two fundamentally different designs of transtibial prosthetic socket are currently used clinically: The patellar tendon bearing (PTB) and the total surface bearing socket (TSB).
      The PTB socket is one in which pressure tolerant areas (mainly the patellar tendon) are loaded and pressure sensitive areas (bony prominences) are relieved (5). Alteration to the shape captured is carried out by the clinician, who removes material from pressure tolerant areas and adds material to pressure sensitive areas, either by using plaster or on CAD.
      The TSB socket, first described by Murdoch (6), used water casting to load all of the surface area of the residual limb including pressure sensitive areas. The TSB design is based on the hydrostatic principle for load transfer (7). With a TSB socket minimal modification is required meaning that the final socket is likely to be more consistent as less clinical judgement is involved (8). The TSB socket was described as long ago as 1968, however, PTB sockets are still commonly prescribed in clinical practice. PTB sockets have shown to have higher variation in interface pressures in comparison to TSB sockets and a recent systematic review has demonstrated higher satisfaction with TSB sockets (9). PTB sockets however have a lower cost associated, and due to budget constraints this may be an important factor (10). It is also important to consider that TSB sockets may not be suitable for all users as they are generally prescribed with a liner which provides the suspension. It could be argued that both socket styles have an application and the clinician should use appropriate prescription criteria based on individuals’ requirements.
      Modification, however, may lead to less consistency as more personal judgement and human error is involved. A previous study by Convery et al (11) looked into the consistency of PTB cast rectification with plaster. It was found that a clinician varied by up to 4.3mm. Although the clinical significance of a variation this size has not been tested one may assume that 4mm removed over a bony prominence might cause discomfort.
      Shape capture for PTB sockets is carried out whilst the patient is sitting and without loading of the residual limb soft tissue. Modification is therefore required to allow forces to be transferred to the residual limb when the patient is statical...
      PubDate: 2018-07-14
           & ORTHOTICS

    • Authors: Silvia Ursula Raschke
      Abstract: ARE WE CRAZY'
      The launch of a new journal, the Canadian Prosthetics and Orthotics Journal (CPOJ), is a good time to consider the brilliance – or foolhardiness – of such a venture as well-established peer-review journals struggle to survive. The challenges faced by the traditional, print based, peer-review publishing model are rooted in a greater wave of rapid disruptive change influencing technology innovation models and economic models in a wide range of sectors, including health care across the clinical care delivery continuum. How will this change influence prosthetics and orthotics and what does it mean for the future' These are important questions to consider, as CPOJ charts a course aiming to respond to these trends in a positive, sustainable way while adhering to high professional and academic standards. Finding answers starts with a short reflection on the causes of this change: the threads weaving the fabric of the Fourth Industrial Revolution. THE FOURTH INDUSTRIAL REVOLUTION
      With its origins in the mid last century, the Fourth Industrial Revolution is now well and truly upon us. Characterized by the convergence of the digital, physical and biological domains, fresh approaches and markets are being created at intersections between two or all three of these domains (1). The space occupied by prosthetics and orthotics is not being spared. This most recent industrial revolution is being built on a foundation of vast databases that are created, managed and mined using newly developed data collection, machine learning and communication tools. Lord Kelvin (1824-1907) said: “If you can not measure it, you can not improve it.” With the vast number of data driven tools now available the ability to improve and transform, across all sectors and fields, has become substantial and within reach. Ready or not – change is coming. Early examples of this revolution’s effects can be found in manufacturing (digital supply chains, robotics), commerce (web-based business models, block chain) and communication (changing models of journalism, social media). Academic research is also evolving, as the traditional peer review model is no longer the sole method for driving scientific knowledge development and dissemination. In prosthetics and orthotics, the first innovation cycle includes 3D printed prosthetic legs and customized foot orthotics incorporated into web-based business models. Future directions will likely include smart prostheses and orthoses and mass customized devices. At the broadest level of science and discovery, the spirit of the Fourth Industrial Revolution demystifies and democratizes knowledge, engaging and empowering non-traditional participants who are not afraid to challenge the status quo. (e.g. Citizen Science and Maker Movements) (2,3). Time honoured models of knowledge transfer, primarily via journals and conferences, are being supplemented by engaging, accessible models such as Ted Talks (4), which reach vast, international audiences in seconds.
      More creative, flexible formats and portals for peer-review level research, such as open access models, video journals and publication of research protocols without results are emerging, but in future will only be one part of a massive knowledge stream within what has become a very wide and colourful information pipeline. Emerging from the pipeline are a new class of thought leaders who challenge the traditional ‘expert model’ where academics and professionals worked their way up an established hierarchy or credentialing process. The days of the unchallenged ‘expert’ are gone (5). Modalities such as social media, the internet and personal monitoring and communication devices allow a wide range of solution providers from anywhere to have direct access to those seeking solutions without necessarily engaging members of the traditional hierarchy. THE WINDS OF CHANGE
      Canadian visionary Marshall McLuhan said “Obsolescence never meant the end of anything, it’s just the beginning”. This axiom is taken for granted by those who embrace change, typically in data driven sectors such a business or engineering. These sectors tend to be early adopters of new ideas and technology while sectors such as health care traditionally lag behind in with the adoption of new technology and processes (6). Whichever approach taken, enthusiastic early adopter or reluctant laggard, the innovation life cycle does not stop and is accelerating at a faster pace than seen in the previous industrial revolutions (7). This paradigm shift is rapidly changing the terrain in all sectors, at the technical, societal and policy levels. Interestingly, a very commonly cited example of the positive effects the Fourth Industrial Revolution will have on society is the prosthetics and orthotics sector. Prosthetic and orthotic examples provide a real, highly visual, easy to understand example of innovation potential at the convergence of the digital, physical and biological realms, alongside a compelling story of the power to radically transform and improve on existing approaches – more efficiently and at a lower cost. While the focus in the Fourth Industrial Revolution is innovative technology, it must not be overlooked that all of this is predicated on the ability to provide more for less. Whatever the grand vision presented, the primary drivers are increasingly fiscal and can never be discounted or overlooked. CPOJ’S GOAL
      In the spirit of the Fourth Industrial Revolution, the Canadian Pro...
      PubDate: 2018-07-12
School of Mathematical and Computer Sciences
Heriot-Watt University
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