Canadian Prosthetics Orthotics Journal最新文献

Innovation is an important part of the prosthetic and orthotics (P&O) industry. Innovation has the potential to improve health care services and outcomes, however, it can also be a burden to the system if misdirected. This paper explores the interaction of innovation and economics within the P&O industry, focusing on its current state and future opportunities. Technological advancement, industry competition and pursuit of better patient outcomes drive innovation, while challenges in ensuring better P&O health care include lagging clinical evidence, limited access to data, and existing funding structures. There exists a greater need for inclusive models and frameworks for rehabilitation care, that focus on the use of appropriate technology as supported by research and evidence of effectiveness and cost-effectiveness. Additionally, innovative business models based on social entrepreneurism could open access to untapped and underserved markets and provide greater access to assistive technology.

This submission provides an important historical context for understanding the current challenge facing the Orthotic and Prosthetic community in Alberta including Alberta Aids to Daily Living (AADL), Suppliers, and Providers: maintaining sustainable access to Orthotic care for people with mobility disorders in the face of declining real rates of reimbursement combined with increasing costs and a shortage of skilled Clinicians. Under the Canada Health Act, the federal government delegates responsibility for providing health care to the provinces. This delegation of responsibility to the provinces results in a degree of variability of funding of Orthotics and Prosthetics between provinces across the country. Funding of Orthotics and Prosthetics in Alberta is characterized by structural inequities that favour Prosthetics at the expense of Orthotics. To the extent that the structural inequities that exist in Alberta are related to governance by volunteer-run, non-profit organizations, they may be generalized to the Canadian experience. Finally, in a Call to Action a number of recommendations are made to address the challenge of sustainable access to Orthotic care in Alberta serving as a model for other provinces across Canada.

Background: Lower extremity amputation due to complications from peripheral vascular disease and/or diabetes are common and these patients often have multiple comorbidities. Patients with end-stage renal disease receiving hemodialysis (ESRD/HD) are a particularly vulnerable group at risk for amputation. After lower extremity amputation (LEA) surgery, many patients undergo post-operative inpatient rehabilitation to improve their pre-prosthetic functional independence. Given the increased complexity of dysvascular patients living with ESRD/HD compared to those without ESRD/HD, the association of HD with pre-prosthetic inpatient functional outcomes warrants further study.

Objective: The objective of this study was to compare the pre-prosthetic functional outcomes and Length of Stay (LOS) among patients with recent dysvascular LEA with and without ESRD/HD.

Methodology: A retrospective cohort design was used to analyze a group of 167 patients with unilateral, dysvascular limb loss who were admitted to inpatient rehabilitation with 24 of these patients in the ESRD/HD group. Age, gender, amputation level, amputation side, length of stay (LOS), time since surgery, Functional Independence Measure (FIM) scores (admission and discharge), and Charlson Comorbidity Index (CCI) were collected.

Findings: There was no difference between patients with dysvascular amputation with and without ESRD/HD in the association of functional outcomes or LOS in this cohort and rehabilitation model. The CCI score was higher in the ESRD/HD group. Multivariate analysis indicated an inverse relationship with age and FIM scores, where increased age was associated with lower Total and Motor FIM at admission and discharge. There were no associations with FIM change. Age was positively associated with LOS. Being female was inversely associated to motor FIM scores at admission and discharge.

Conclusion: Among patients with recent dysvascular LEA, ESRD/HD is not associated with different functional outcomes or LOS in the pre-prosthetic inpatient rehabilitation setting. This suggests that despite added comorbidity that patients with ESRD/HD may still benefit from inpatient rehabilitation to optimize pre-prosthetic function.

Background: Excessive sweating of the residual limb has a substantial effect on the daily activities of people with lower limb amputation. Prosthetic liners offer protection and comfort to sensitive areas but often exacerbate perspiration. They act as insulators, trapping sweat on the skin's surface to the detriment of skin health. Recently, liners with perforations have been developed, allowing the moisture to escape. The goal of this study was to assess the impact of such liners.

Methods: A sample group of 13 patients with unilateral transtibial amputation, who wore a perforated liner (PL) as part of their current prescription, was compared to 20 control patients who wore non-perforated liners (NPL). During their routine appointments, they completed a survey of scientifically validated outcome measures relating to their limb health, pain and the impact on daily life over a 12-month period.

Results: Patients using the PL had healthier residual limbs, reporting higher scores on questions relating to limb health, experiencing fewer skin issues (p<0.001) and estimating a 61.8% lower rating in perceived sweat (p=0.004). Perhaps consequentially, there was a lower incidence of residual (p=0.012) and phantom (p=0.001) limb pain when compared to the control group. The prevalence of individual issues affecting the residual limbs of PL users was also lower. Of the issues that remained, only 23% were attributed to sweating in PL users, compared to 49% for the NPL group (p=0.066). PL users missed fewer days of work in the year (2.4 vs 11.6, p=0.267) and were also limited on fewer days (1.4 vs 75.4, p=0.009).

Conclusion: The use of perforated liners shows much promise within prosthetic care, significantly improving the health of the residual limb. The observed effects on perceived sweat reduction, residual skin health, pain levels and patient limitation suggest that perforated liners are highly beneficial to patients.

Background: Dysvascular amputations arising from peripheral vascular disease and/or diabetes are common. Patients who undergo amputation often have additional comorbidities that may impact their recovery after surgery. Many individuals undergo post-operative inpatient rehabilitation to improve their non-prosthetic functional independence. Thus far, our characterization of comorbidity in this population and how it is associated with non-prosthetic inpatient functional recovery remains relatively unexplored.

Objective: The objective of this study was to describe comorbidities, using the Charlson Comorbidity Index (CCI), and to examine associations between comorbidity and functional outcomes in a cohort of patients with dysvascular limb loss undergoing non-prosthetic inpatient rehabilitation.

Methodology: A retrospective cohort design was used to analyze a group of 143 patients with unilateral, dysvascular limb loss who were admitted to inpatient rehabilitation. Age, sex, amputation level, amputation side, length of stay (LOS), time since surgery, Functional Independence Measure (FIM) scores (Total and Motor at admission and discharge), and CCI scores were collected.

Findings: The data showed that neither total or specific comorbidities were associated with functional outcomes or LOS in this cohort and rehabilitation model. Multivariate analysis demonstrated an inverse relationship with age and FIM scores, where increased age was associated with lower Total and Motor FIM at admission and discharge. Comorbidities were not associated with functional outcomes. Dementia was negatively associated with FIM scores, however this requires more study given the low number of patients with dementia in this cohort.

Conclusion: These data suggest that regardless of burden of comorbidity or specific comorbidities that patients with dysvascular limb loss may derive similar functional benefit from post-operative non-prosthetic inpatient rehabilitation.

Background: Individuals with transtibial amputation (TTA) typically walk with an asymmetrical gait pattern, which may predispose them to secondary complications and increase risk of fall. Gait asymmetry may be influenced by prosthesis mass.

Objectives: To explore the effects of prosthesis mass on temporal and limb loading asymmetry in people with TTA following seven days of acclimation and community use.

Methodology: Eight individuals with transtibial amputation participated. A counterbalanced repeated measures study, involving three sessions (each one week apart) was conducted, during which three load conditions were examined: no load, light load and heavy load. The light load and heavy load conditions were achieved by adding 30% and 50% of the mass difference between legs, at a proximal location on the prosthesis. Kinematic and ground reaction force data was captured while walking one week after the added mass. Symmetry indices between the prosthetic and intact side were computed for temporal (Stance and Swing time) and limb loading measures (vertical ground reaction force Peak and Impulse).

Findings: Following seven days of acclimation, no significant differences were observed between the three mass conditions (no load, light load and heavy load) for temporal (Stance time: p=0.61; Swing time: p=0.13) and limb loading asymmetry (vertical ground reaction force Peak: p=0.95; vertical ground reaction force Impulse: p=0.55).

Conclusions: Prosthesis mass increase at a proximal location did not increase temporal and limb loading asymmetry during walking in individuals with TTA. Hence, mass increase subsequent to replacing proximally located prosthesis components may not increase gait asymmetry, thereby allowing more flexibility to the clinician for component selection.

Background: An often assumed advantage of polycentric knee joints compared to monocentric ones is the improved ground clearance during swing phase due to the geometric shortening of the lower leg segment (LLS).

Objective: To investigate whether polycentric knee joints considerably improve ground clearance and to evaluate the influence of prosthetic alignment on the extent of ground clearance.

Methodology: 11 polycentric and 2 monocentric knee joints were attached to a rigid, stationary testing device. Shortening of the LLS and the resulting ground clearance during knee flexion were measured. Prosthetic components were mounted at the same height and the anterior-posterior position was in accordance with the manufacturer's alignment recommendations.

Findings: Shortening of up to 14.7 (SD=0.0) mm at the instance of minimal ground clearance during swing phase was measured. One knee joint elongated by 4.4 (SD=0.0) mm. Measurements of the ground clearance demonstrated differences up to 25.4 (SD=0.0) mm. One monocentric knee joint provided more ground clearance when compared to 8 of the polycentric knee joints investigated.

Conclusion: Only some polycentric knee joints shorten appreciably during swing phase. With an optimized prosthetic alignment and a well-designed swing phase control, a monocentric knee joint may generate greater ground clearance compared to a polycentric knee joint.

Background: Falls can be detrimental to overall health and quality of life for lower extremity amputees. Most previous studies of postural steadiness focus on quantification of time series variables extracted from postural sway signals. While it has been suggested that frequency domain variables can provide more valuable information, few current studies have evaluated postural sway in amputees using frequency domain variables.

Methodology: Participants were assigned to 3 groups: lower extremity amputation (n=6), healthy young adults (n=10), and healthy older adults (n=10). Standing barefoot on a force platform, each individual completed 3 trials of each of 3 standing conditions: eyes open, eyes closed, and standing on a foam balance pad. Time and frequency domain variables of postural sway were computed and analyzed.

Results: Comparison of older adults, younger adults, and amputees on the three conditions of standing eyes open, eyes closed, and on foam revealed significant differences between groups. Mean mediolateral (ML) sway distance from the center of pressure (COP), total excursions and sway velocity was significantly higher for amputees and older adults when compared to young adults (p<0.05). Furthermore, power of sway signal was substantially lower for both amputees and older adults. When compared to that of older adults, postural steadiness of amputees was more affected by the eyes closed condition, whereas older adults' was more affected when sensory and proprioceptive information was perturbed by standing on foam.

Conclusion: Our findings showed that fall risk is greater in amputees than in young adults without amputation. Additionally, amputees may rely more heavily on visual information than proprioceptive information for balance, in contrast to older and young adults without amputation.

This professional opinion describes the use of an off the shelf knee orthotic to correct the gait and functional mobility of a patient with hemisensory loss including proprioception following a stroke and provides supporting video. Interestingly, this case corrects a human analogue of a functional deficit found experimentally in monkeys in the 19th century by Mott and Sherrington.