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Journal: Prosthetics and orthotics international

253

While rehabilitation professionals are historically trained to place emphasis on the restoration of mobility following lower limb amputation, changes in healthcare dynamics are placing an increased emphasis on the limb loss patient’s quality of life and general satisfaction. Thus, the relationship between these constructs and mobility in the patient with lower limb loss warrants further investigation.

Concepts: Health care provider, Patient, Life, Illness, Patience, Amputation, Prosthesis, Place

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Background: Previous studies have suggested that orthoses with different constructions could alter gait parameters in flexible flatfoot. However, there is less evidence about the effect of insoles with proprioceptive mechanism on plantar pressure distribution in flatfoot. Objectives: To assess the effect of orthoses with different mechanisms on plantar pressure distribution in subjects with flexible flatfoot. Study Design: Quasi-experimental. Methods: In total, 12 flatfoot subjects were recruited for this study. In-shoe plantar pressure in walking was measured by Pedar-X system under three conditions including wearing the shoe only, wearing the shoe with a proprioceptive insole, and wearing the shoe with a prefabricated foot insole. Results: Using the proprioceptive insoles, maximum force was significantly reduced in medial midfoot, and plantar pressure was significantly increased in the second and third rays (0.94 ± 0.77 N/kg, 102.04 ± 28.23 kPa) compared to the shoe only condition (1.12 ± 0.88 N/kg and 109.79 ± 29.75 kPa). For the prefabricated insole, maximum force was significantly higher in midfoot area compared to the other conditions (p < 0.05). Conclusions: Construction of orthoses could have an effect on plantar pressure distribution in flatfeet. It might be considered that insoles with sensory stimulation alters sensory feedback of plantar surface of foot and may lead to change in plantar pressure in the flexible flatfoot. Clinical relevance Based on the findings of this study, using orthoses with different mechanisms such as proprioceptive intervention might be a useful method in orthotic treatment. Assessing plantar pressure can also be an efficient quantitative outcome measure for clinicians in evidence-based foot orthosis prescription.

Concepts: Measurement, Audio feedback, Orthotics, Ankle-foot orthosis, Podiatry, Flat feet

28

In today’s healthcare environment it is increasingly important to be able to quantify the amount of change associated with a given intervention; this can be accomplished using one or more appropriate outcome measures. However, the selection and integration of outcome measures within clinical practice requires careful consideration. This includes identification of the measure construct which can be assisted by the International Classification of Functioning, Disability, and Health; selection of outcome measures based on need, appropriateness and feasibility; and careful use in regular clinical practice including data collection, analysis and re-assessment of the process. We describe this process, focusing on orthotic management of stroke, in particular the improvement of mobility as a common goal. Clinical relevance The growing emphasis on improved documentation of patient care and outcomes requires that clinicians integrate clinically relevant outcome measures into their practice. We suggest a process to assist clinicians integrate outcome measures into clinical practice with a particular emphasis on the orthotic management of stroke.

Concepts: Health care, Health, Clinical trial, Medical ethics, Hospital, Integral, Morality, Outcome

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Background:Infantile tibia vara is an acquired form of tibial deformity associated with tibial varus and internal torsion. Several methods have been described for orthotics treatment. The purpose of this study was to determine the effectiveness of orthotics treatment in infantile tibia vara.Study design:Controlled trial.Objective:The aim of this study was to compare the effect of different types of orthoses and correction methods on decreasing the curve in children with severe genu varum.Methods:Three different types of knee-ankle-foot orthoses were applied to 35 lower extremities of 22 pediatric participants who were 19-38 months of age. The same orthotic design principles were used to correct the femur, while different designs were applied to correct the tibia. The orthoses used on 20 participants were evaluated for differences among them and their effects on the treatment process. In addition, methods used in the treatment, problems encountered, production of different types of orthoses, convenience of application of the orthoses, and degree of patients satisfaction are discussed in this article.Results:The mean duration of treatment of the participants until completion of treatment was 25.3 ± 9.7 weeks with a minimum of 9 weeks and a maximum of 41 weeks. No statistically significant correlation was found between the duration of orthotic use in patients with a successful outcome and percentile height and percentile weight. When the duration of treatment using the different types of orthoses was analyzed, significant differences were found between Type 1 and Type 2, and Type 1 and Type 3 orthoses (p < 0.05), while no difference was observed between Type 2 and Type 3 orthoses (p > 0.05).Conclusion:We found that bracing is an effective form of treatment for infantile tibia vara up to 38 months of age. We conclude that full-time use of knee-ankle-foot orthoses exerting corrective forces from five points along the full length of the limb was effective.Clinical relevance:The localization of the distal tibial correction, the quality of the midtibial correction band, and the importance of the application of corrective forces from five points with rigid methods were found.

Concepts: Statistics, Effect, Statistical significance, Effectiveness, Varus deformity, Difference, Orthotics, Type

28

Background:Most posture problems encountered in persons who use wheelchairs in a seated posture for extended periods are related to sacral sitting due to posterior pelvic tilt. Posterior pelvic tilt places pressure and shearing force on the sacrococcygeal area that can lead to pressure ulcers, but the relationship between pelvic tilt and force applied to the sacrococcygeal and ischial tuberosity areas has not yet been investigated.Objective:To investigate the relationships of posterior pelvic tilt in a seated posture with vertical force and horizontal force on the sacrococcygeal and ischial tuberosity areas.Study Design:Repeated measures design.Methods:Thirty male and female subjects aged ≥60 years sat in a measurement chair at varying pelvic tilt angles, and force on the sacrococcygeal and ischial tuberosity areas was measured.Results:The pressure on the sacrococcygeal area increased with pelvic tilt in all subjects, with vertical force averaging 19% of the body weight at a pelvic tilt angle of 30°. The horizontal force on the sacrococcygeal area increased in 93% of the subjects, with an average increase equal to 3% of the body weight.Conclusions:We confirmed changes in vertical and horizontal forces on the sacrococcygeal and ischial tuberosity areas with a change in seated posture (pelvic tilt).Clinical relevance:We propose guidelines for rehabilitation practitioners working with wheelchair users to suggest improved ways of sitting in wheelchairs that avoid pelvic tilt angles that might promote pressure ulcers on the buttocks.

Concepts: Mass, Force, Pelvis, Shear stress, Sacrum, Wheelchair, Tuberosity of the ischium, Sacrococcygeal symphysis

26

Few studies have explored the effects of exercise on gait performance in people with lower limb amputations.

Concepts: Amputation, Limb

26

Background:Higher plantar pressures at the medial forefoot are reported in hallux valgus. Foot orthoses with medial arch support are considered as an intervention in this pathology. However, little is known about the effect of foot orthoses on plantar pressure distribution in hallux valgus.Objectives:To investigate the effect of a foot orthosis with medial arch support on pressure distribution in females with mild-to-moderate hallux valgus.Study design:Quasi-experimental.Methods:Sixteen female volunteers with mild-to-moderate hallux valgus participated in this study and used a medial arch support foot orthosis for 4 weeks. Plantar pressure for each participant was assessed using the Pedar-X(®) in-shoe system in four conditions including shoe-only and foot orthosis before and after the intervention.Results:The use of the foot orthosis for 1 month led to a decrease in peak pressure and maximum force under the hallux, first metatarsal, and metatarsals 3-5 (p < 0.05). In the medial midfoot region, peak pressure, maximum force, and contact area were significantly higher with the foot orthosis than shoe-only before and after the intervention (p = 0.00).Conclusion:A foot orthosis with medial arch support could reduce pressure beneath the hallux and the first metatarsal head by transferring the load to the other regions. It would appear that this type of foot orthosis can be an effective method of intervention in this pathology.Clinical relevanceFindings of this study will improve the clinical knowledge about the effect of the medial arch support foot orthosis used on plantar pressure distribution in hallux valgus pathology.

Concepts: Foot, Hallux, Bunion, Tarsus, Metatarsus, Ankle-foot orthosis, Arches of the foot, First metatarsal bone

24

The need of comfortable and safe prosthetic systems is an important challenge for both prosthetists and engineers. The aim of this technical note is to demonstrate the use of three-dimensional digital image correlation to evaluate mechanical response of two prosthetic systems under real patient dynamic loads.

Concepts: Prosthetics, Digital photography, Prosthesis, Digital image, Digital image correlation

2

Background:Minimum toe clearance is a critical gait event because it coincides with peak forward velocity of the swing foot, and thus, there is an increased risk of tripping and falling. Trans-tibial amputees have increased risk of tripping compared to able-bodied individuals. Assessment of toe clearance during gait is thus clinically relevant. In able-bodied gait, minimum toe clearance increases with faster walking speeds, and it is widely reported that there is synchronicity between when peak swing-foot velocity and minimum toe clearance occur. There are no such studies involving lower-limb amputees.Objectives:To determine the effects of walking speed on minimum toe clearance and on the temporal relationship between clearance and peak swing-foot velocity in unilateral trans-tibial amputees.Study design:Cross-sectional.Methods:A total of 10 trans-tibial participants walked at slow, customary and fast speeds. Minimum toe clearance and the timings of minimum toe clearance and peak swing-foot velocity were determined and compared between intact and prosthetic sides.Results:Minimum toe clearance was reduced on the prosthetic side and, unlike on the intact side, did not increase with walking speed increase. Peak swing-foot velocity consistently occurred (~0.014 s) after point of minimum toe clearance on both limbs across all walking speeds, but there was no significant difference in the toe-ground clearance between the two events.Conclusion:The absence of speed related increases in minimum toe clearance on the prosthetic side suggests that speed related modulation of toe clearance for an intact limb typically occurs at the swing-limb ankle. The temporal consistency between peak foot velocity and minimum toe clearance on each limb suggests that swing-phase inter-segmental coordination is unaffected by trans-tibial amputation.Clinical relevanceThe lack of increase in minimum toe clearance on the prosthetic side at higher walking speeds may potentially increase risk of tripping. Findings indicate that determining the instant of peak swing-foot velocity will also consistently identify when/where minimum toe clearance occurs.

Concepts: Foot, Amputation, Velocity, Walking, Speed

1

Background and aim:DEKA Integrated Solutions Corp. (DEKA) was charged by the Defense Advanced Research Project Agency to design a prosthetic arm system that would be a dramatic improvement compared with the existing state of the art. The purpose of this article is to describe the two DEKA Arm prototypes (Gen 2 and Gen 3) used in the Veterans Affairs Study to optimize the DEKA Arm.Technique:This article reports on the features and functionality of the Gen 2 and Gen 3 prototypes discussing weight, cosmesis, grips, powered movements Endpoint, prosthetic controls, prosthetist interface, power sources, user notifications, troubleshooting, and specialized socket features; pointing out changes made during the optimization efforts.Discussion:The DEKA Arm is available in three configurations: radial configuration, humeral configuration, and shoulder configuration. All configurations have six preprogrammed grip patterns and four wrist movements. The humeral configuration has four powered elbow movements. The shoulder configuration uses Endpoint Control to perform simultaneous multi-joint movements. Three versions of foot controls were used as inputs. The Gen 3 incorporated major design changes, including a compound wrist that combined radial deviation with wrist flexion and ulnar deviation with wrist extension, an internal battery for the humeral configuration and shoulder configuration, and embedded wrist display.Clinical relevanceThe DEKA Arm is an advanced upper limb prosthesis, not yet available for commercial use. It has functionality that surpasses currently available technology. This manuscript describes the features and functionality of two prototypes of the DEKA Arm, the Gen 2 and the Gen 3.

Concepts: Humerus, Prosthetics, Upper limb anatomy, Forearm, Upper limb, Prosthesis, Arm, Artificial limb