Describe the population receiving orthotic/prosthetic services using telehealth in Australia, and their experience and satisfaction: a quantitative and qualitative investigation

PURPOSE

Telehealth may help meet the growing demand for orthotic/prosthetic services. Despite the resurgence of telehealth due to COVID-19, there is limited evidence to inform policy and funding decisions, nor guide practitioners.

METHODS

Participants were adult orthosis/prosthesis users or parents/guardians of child orthosis/prosthesis users. Participants were convenience sampled following an orthotic/prosthetic telehealth service. An online survey included: demographics, Telehealth Usability Questionnaire, and the Orthotic Prosthetic Users Survey - Client Satisfaction with Services. A subsample of participants took part in a semi-structured interview.

RESULTS

Most participants were tertiary educated, middle-aged, female, and lived in metropolitan or regional centres. Most telehealth services were for routine reviews. Most participants chose to use telehealth given the distance to the orthotic/prosthetic service, irrespective of whether they lived in metropolitan cities or regional areas. Participants were highly satisfied with the telehealth mode and the clinical service they received via telehealth.

While orthosis/prosthesis users were highly satisfied with the clinical service received, and the telehealth mode, technical issues affected reliability and detracted from the user experience. Interviews highlighted the importance of high-quality interpersonal communication, agency and control over the decision to use telehealth, and a degree of health literacy from a lived experience of using an orthosis/prosthesis.

Safety, walking ability, and satisfaction outcomes of the NEURO TRONIC stance-control knee-ankle-foot orthosis (SCKAFO): A comparative evaluation to the E-MAG active SCKAFO

BACKGROUND

Stance control knee-ankle-foot orthoses (SCKAFOs) ensure knee stability by locking during stance while allowing knee flexion during swing. Differences in function of the knee joints and building principles between devices may affect their effectiveness.

OBJECTIVE

To investigate the preliminary effectiveness of a NEURO TRONIC on safety outcomes, net energy cost (EC), and user experiences in individuals already using an E-MAG Active SCKAFO.

STUDY DESIGN

Prospective uncontrolled intervention study.

METHODS

A convenience sample of 10 subjects with flaccid lower extremity muscle weakness, including the quadriceps, due to neuromuscular disorders already using an E-MAG Active SCKAFO were provided with a newly fabricated NEURO TRONIC SCKAFO. Outcomes included knee joint locking failures and unlocking failures (ULFs) (i.e., percentage of steps the knee joint failed to lock/unlock) when walking under challenging conditions on an instrumented treadmill while wearing a safety harness; net EC (J/kg per meter) assessed with a 6-min walk test at comfortable speed; 3D gait kinematics and kinetics; and patient-reported outcomes.

RESULTS

No differences between devices were found for knee joint locking failures (both devices 0%) and ULFs (9.9% for the NEURO TRONIC vs. 13.9% for the E-MAG Active SCKAFO). The mean (standard deviation) net EC with the NEURO TRONIC SCKAFO was 8.2% (from 3.68 [0.81] to 3.38 [0.75] J/kg per meter, p = 0.123) lower, although not significantly, compared with that with the E-MAG Active SCKAFO. Significant improvements with the NEURO TRONIC SCKAFO were found for ankle power ( p = 0.003), perceived walking effort ( p = 0.014), and reported falls ( p = 0.034).

CONCLUSION

Both the NEURO TRONIC SCKAFO and the E-MAG Active SCKAFO were safe in terms of knee joint locking, while ULFs were frequent with both devices. The net EC with the NEURO TRONIC SCKAFO decreased, although not significantly, by 8.2%, likely due to insufficient power. Perceived walking effort was in favor of the NEURO TRONIC SCKAFO.

Methodological and reporting quality of qualitative evidence in the field of lower limb orthoses: a systematic review

This study aimed to assess the methodological and reporting quality of qualitative studies conducted in the field of lower limb orthoses (LLOs). The following electronic databases were searched from inception to 2022: PubMed, Scopus, ProQuest, WoS, Embase, the Cochrane Central Register of Controlled Trials, and RehabData. Two authors independently screened and selected the potential studies. The methodological quality of included studies was assessed using the Critical Appraisal Skills Programs qualitative checklist. In addition, the reporting quality of included studies was assessed using the Standards for Reporting Qualitative Research (SRQR) tool. The mean methodological quality score of included studies was 8 (from min = 2 to max = 9.5), and most of the studies had a score of more than 7.5. However, SRQR findings revealed that the overall reporting quality of included studies was not desirable in that the mean score was about 15.44 (from min = 6 to max = 19.5) out of 21. In total, the methodological quality of qualitative studies published in the field of LLOs was moderate. Further, the adherence of these studies to available reporting guidelines was unsatisfactory. As a result, when designing, performing, and reporting qualitative investigations, authors should pay more attention to these criteria.

The Impact of Podiatric Intervention on the Quality of Life and Pain in Children and Adolescents with Hypermobility

The purpose of this study was to evaluate the effect of custom-made orthotics on pain, health-related quality of life (HRQoL), function and fatigue in children and adolescents with generalised joint hypermobility (GJH) and lower limb pain. Fifty-three children aged 5-18 years were fitted with custom-made polypropylene orthotics. Visual analogue scale (VAS) assessed lower limb pain severity, Paediatric Quality of Life Inventory assessed HRQoL and fatigue and six-minute walk test (6 MWT) measured functional endurance at baseline, at 1 month and 3 months post-intervention. A mixed model including a random intercept for participant and a fixed effect for time was used to assess differences in outcomes over time. Fifty-two children completed the study (mean age 10.6-years). Children reported significantly reduced pain (mean VAS reduction -27/100, 95%CI: -33, -21), improved HRQoL (mean total improvement 11/100, 95%CI: 7, -15), functional capacity (mean 6MWT improvement 27 m, 95%CI: 18, -36) and fatigue (mean total improvement 13/100, 95%CI: 9, -17) after 1 month of wearing the custom-made orthotics. From 1 month to 3 months there was further statistically but not clinically significant reduction in pain while benefit on other outcomes was maintained. In this study, children with GJH reported reduced lower limb pain, improved HRQoL, functional endurance and fatigue after a month post-fitting of custom-made orthotics which was maintained over a 3 month period. Orthotics were well-tolerated with no serious adverse events reported.

Republication of "Uses of Braces and Orthotics for Conservative Management of Foot and Ankle Disorders"

Nonsurgical management is almost always considered the first-line treatment for the vast majority of foot and ankle pathologies. Foot orthoses, shoe modifications, and therapeutic footwear are considered essential tools for successful conservative management of different foot and ankle disorders. Orthopedic foot and ankle surgeons should have a meticulous understanding of the lower extremity biomechanics as well as the pathoanatomy and the sequelae of diseases affecting the foot and/or ankle. This is essential to the understanding of the desired effects of the different inserts, orthotics, shoe modifications, or braces that may be prescribed for these conditions. In this article, we will summarize the orthoses used for treatment of the most commonly encountered foot and ankle pathologies, with the exclusion of treatment for the diabetic foot because of the unique requirements of that disease process.

Impact of Bracing and Therapy Services on Perioperative Costs for Patients Undergoing Distal Biceps Tendon Repair

PURPOSE

This study aimed to quantify and assess perioperative costs in an integrated healthcare system for patients undergoing distal biceps tendon (DBT) repair with and without the use of postoperative bracing and formal physical (PT) or occupational (OT) therapy services. In addition, we aimed to define clinical outcomes after DBT repair using a brace-free, therapy-free protocol.

METHODS

We retrospectively reviewed all cases of DBT repairs within our integrated system from 2015 to 2021. We performed a retrospective review of a series of DBT repairs utilizing the brace-free, therapy-free protocol. For patients with our integrated insurance plan, a cost analysis was conducted. Claims were subdivided to assess total charges, costs to the insurer, and patient costs. Three groups were created for comparisons of total costs: (1) patients who had both postoperative bracing and PT/OT, (2) patients who had either postoperative bracing or PT/OT, and (3) patients who had neither postoperative bracing nor PT/OT.

RESULTS

A total of 36 patients had our institutional insurance plan and were included in the cost analysis. For patients using both bracing and PT/OT, these services contributed 12% and 8% of the total perioperative costs, respectively. Implant costs accounted for 28% of the overall cost. Forty-four patients were included in the retrospective review with a mean follow-up of 17 months. The overall QuickDASH was 12; two cases resulted in unresolved neuropraxia, and there were no cases of re-rupture, infection, or reoperation.

CONCLUSIONS

Within an integrated healthcare system, postoperative bracing and PT/OT services increase the cost of care for DBT repair and account for 20% of the total perioperative charges in cases where bracing and therapy are used. Considering the results of prior investigations indicating that formal PT/OT and bracing offer no clinical advantages over immediate range of motion (ROM) and self-directed rehabilitation, upper-extremity surgeons should forego routine brace and PT/OT utilization after DBT repair.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Surface profile of laminated transfemoral socket fabricated with different types of reinforcement materials

Composite materials used in the prosthetic and orthotic fields have helped improve the fabrication of sockets. Laminated sockets proved to be stronger than conventional thermoplastic sockets. The internal surface of a laminated socket plays an important role in patient comfort and is influenced by the material used to fabricate the socket. This study analyzes the internal surface profile of five different materials, that is, Dacron felt, fiberglass, Perlon stockinette, polyester stockinette, and elastic stockinette. All sockets were fabricated using an acrylic resin mix with hardener powder at a ratio of 100:3. The internal surface of the sockets was tested using the Mitutoyo SurfTest SJ-210 series for 20 trials. The overall R_a values were 2.318, 2.380, 2.682, 2.722, and 3.750 µm for fiberglass, polyester, Perlon, elastic stockinette, and Dacron felt. Dacron felt yielded the lowest R_a value, thus, producing the smoothest internal surface but requiring high skill and the correct technique during the fabrication of a laminated socket. Fiberglass is considered the best material for the internal surface despite not producing the lowest value individually but overall is the lowest and most consistent, indicating that it is easy to use to laminate prosthetic sockets.

Rehabilitation Approach for Children With Joubert Syndrome and Related Disorders

Joubert syndrome and related disorders (JSRD) are rare and intractable diseases characterized by delayed psychomotor development, hypotonia and/or ataxia, and abnormal respiratory and eye movements. Cerebellar vermis agenesis and molar tooth signs are distinct on cerebral magnetic resonance imaging (MRI). Children with JSRD present with delayed psychomotor development, including intellectual disability and emotional or behavioral problems. Rehabilitation treatments are provided to promote psychomotor development. However, limited reports and evidence exist on rehabilitation treatments for children with JSRD. Three children with JSRD received rehabilitation treatment. The children received rehabilitation treatment once a week to once every one to two months at our hospital and/or other facilities. All patients received physical, occupational, and speech-language-hearing therapy, depending on their symptoms and conditions. In children with tracheostomies due to abnormal respiration, respiratory physical therapy and speech-language-hearing therapy, including augmentative and alternative communication, were needed. For hypotonia and ataxia, an orthotic intervention was considered in all three cases, and foot or ankle-foot orthoses were used in two cases. Although there is no specific or established rehabilitation method for children with JSRD, appropriate rehabilitation approaches, including physical, occupational, speech-language-hearing therapies and orthotic intervention, should be considered and provided to improve their function and expand their activity and participation. Orthotic intervention for hypotonia seems reasonable for improving gross motor development and function in children with JSRD.

Development of a candidate item bank for measuring mobility of lower limb orthosis users

BACKGROUND

Orthoses are often prescribed to improve mobility of people with chronic health conditions that affect lower limb function. Patient-reported survey instruments can be used to measure aspects of mobility that cannot be easily assessed in clinical or research settings. A population-specific item bank could be designed to measure aspects of mobility that are most important to lower limb orthosis users and used to evaluate the effects of orthoses.

OBJECTIVE

To develop items for a new survey instrument to measure mobility of lower limb orthosis users.

DESIGN

Survey items were developed using a qualitative item review process.

SETTING

Focus groups were held by video conferencing. Cognitive interviews were conducted by telephone.

PARTICIPANTS

Focus group and cognitive interview participants were adults with at least 6 months of experience using a lower limb orthosis that extended from the foot to a level above the ankle.

METHODS

Research methods included focus groups with lower limb orthosis users, an item generation and reduction process that involved a stakeholder advisory panel, and cognitive interviews with target respondents.

RESULTS

A total of 1180 extant items were identified in a literature review. Focus group participants (n = 29) provided feedback that informed the suitability of a construct definition and conceptual model. An advisory panel contributed to the selection of 118 candidate items for measuring orthotic mobility. Feedback from cognitive interview participants (n = 30) informed removal or revision of problematic items, resulting in a candidate bank of 100 mobility items.

CONCLUSIONS

The rigorous qualitative methods applied here resulted in a large set of candidate items that spanned a range of situations relevant to moving with a lower limb orthosis. Next steps include administration of the candidate items to a large sample of lower limb orthosis users and calibration of the item bank.

Caregiver Experiences Using Orthotic Treatment Options for Developmental Dysplasia of the Hip in Children

BACKGROUND

Developmental dysplasia of the hip (DDH) is a common condition affecting 5 in 1000 newborns. The standard first line of treatment is the use of an orthotic, which has generally high success rates, but can pose substantial difficulties and put undue burden on caregivers. The general experience of caregivers using these orthotics has not been well documented on an orthotic-specific basis. The purpose of this study was to investigate caregiver experience using prescribed DDH orthotics to identify challenges, differences between treatment options, and areas of improvement.

METHODS

A survey assessing treatment prescription, respondent demographics, and caregiver experience was distributed online to caregivers whose child/children were treated for DDH with an orthotic. Seven-point positively phrased Likert scale statements and open-ended questions were included to assess caregiver experience. The results were analyzed using summary statistics and orthotics with more than 30 responses were selected for more in-depth analysis.

RESULTS

A total of 530 survey responses were collected with 63% (334/530) of respondents using a Pavlik harness, 45% (236/530) a Rhino brace, and 13% (67/530) a Denis Browne Bar. The overall weighted average score across all Likert Scale statements was positive for the Pavlik harness, Rhino brace, and Denis Browne Bar at 4.19 (95% CI, 3.83 to 4.54), 4.63 (95% CI, 4.27 to 4.99) and 4.91 (95% CI, 4.58 to 5.24), respectively. In the open-ended responses, all 3 orthotics were perceived as easy to use and not hindering child-caregiver bonding, but raised concerns of discomfort and skin irritation, as well as preventing the ability to cuddle their child the way they desired. The Pavlik harness respondents consistently brought up concerns regarding cleanability.

CONCLUSIONS

The results show that the DDH orthotics analyzed are generally easy to use and perceived positively by caregivers, but have orthotic-specific challenges that should be a focus of future improvement work.

CLINICAL RELEVANCE

This study evaluated opinions and attitudes of caregivers for children being treated with DDH orthotics, revealing experiences, concerns, and challenges associated with the use of commonly prescribed options.

Offloading of diabetes-related neuropathic foot ulcers at Swedish prosthetic and orthotic clinics

AIMS

This study aimed to assess (1) the use of different offloading interventions in Sweden for the healing of diabetes-related plantar neuropathic forefoot ulcers, (2) factors influencing the offloading intervention choice, and (3) the awareness of current gold standard offloading devices.

METHODS

An online questionnaire was distributed via SurveyMonkey to 51 prosthetic and orthotic clinics in Sweden.

RESULTS

Thirty-five (69%) practitioners responded to the questionnaire. Eighty-six percent of the practitioners provided modified off-the-shelf footwear combined with insoles to treat diabetes-related plantar neuropathic forefoot ulcers. A total contact cast (TCC) was provided by 20% of the practitioners, and a nonremovable knee-high walker was provided by 0%. Multiple practitioner-, patient-, intervention-, and wound-related factors were considered when practitioners provided offloading interventions to patients with this type of ulcer. The majority of the practitioners did not or were unsure whether they considered TCC or a nonremovable knee-high walker to be the gold standard treatment.

CONCLUSIONS

Practitioners mainly provided the offloading intervention that the International Working Group on the Diabetic Foot strongly recommends not be provided, namely, modified off-the-shelf footwear with insoles. In contrast, TCC and nonremovable knee-high walkers, as the gold standards, were vastly underutilised. Therefore, the pattern of providing offloading interventions was almost exactly opposite to the recommendations of evidence-based guidelines. Different factors were considered when providing offloading interventions to patients with diabetes-related plantar neuropathic forefoot ulcers. The practitioners' lack of awareness regarding gold standard devices may have contributed to the underutilisation of TCC and nonremovable knee-high walkers.

Motor function outcomes in children with open prenatal repair of Spina Bifida Aperta at 36-month follow-up: The Zurich cohort

PURPOSE

This study aimed to describe outcomes of motor function with a special focus on ambulation ability at 36 months among children with open prenatal repair of spina bifida aperta (SB).

METHODS

A prospective cohort study was conducted including 87 patients with open prenatal repair of SB at the investigating center born between 2010 and 2018. Anatomic lesion level and motor function level in the neonatal period, as well as motor function level, ambulation status, and use of orthotics and assistive devices at 36 months were assessed.

RESULTS

At 36 months, ambulation was assessed in 86 children; of those, 86% (n = 74) were ambulating. Independent of ambulation, orthotics were worn in 81.6% (71/87) and assistive devices in 47.1% (41/87). Children with a lower lumbar or sacral motor function level were the first to reach independent ambulation and were more likely to ambulate at 36 months than children with higher motor function levels (p = < .001). The anatomic lesion level determined on the neonatal MRI correlated with ambulation status at 36 months (p = < 0.001).

CONCLUSION

At 36 months, most children with open prenatal repair for SB showed favourable ambulation status. However, most still used assistive devices or orthotics. Anatomic lesion level on neonatal MRI, motor function level during the neonatal period, and motor function level at 36 months were associated with ambulation status at 36 months.

Advances in the clinical application of orthotic devices for stroke and spinal cord injury since 2013

Stroke and spinal cord injury are common neurological disorders that can cause various dysfunctions. Motor dysfunction is a common dysfunction that easily leads to complications such as joint stiffness and muscle contracture and markedly impairs the daily living activities and long-term prognosis of patients. Orthotic devices can prevent or compensate for motor dysfunctions. Using orthotic devices early can help prevent and correct deformities and treat muscle and joint problems. An orthotic device is also an effective rehabilitation tool for improving motor function and compensatory abilities. In this study, we reviewed the epidemiological characteristics of stroke and spinal cord injury, provided the therapeutic effect and recent advances in the application of conventional and new types of orthotic devices used in stroke and spinal cord injury in different joints of the upper and lower limbs, identified the shortcomings with these orthotics, and suggested directions for future research.

A comparison of the biomechanical and clinical effects of a biaxial ankle-foot orthosis and lateral wedge insole in individuals with medial knee osteoarthritis

PURPOSE

This study aimed to compare a biaxial ankle-foot orthosis (AFO) with a lateral wedge insole in terms of the biomechanical and clinical outcomes in individuals with knee osteoarthritis.

MATERIALS AND METHODS

A cross-over randomized design was used where 31 individuals (25 females and six males, mean age of 52.19 ± 4.12 years) with knee osteoarthritis wore each intervention for two weeks with two weeks washout period. Three-dimensional kinematic and kinetic data and clinical outcomes were collected to evaluate the effects of each intervention on knee adduction moment (KAM), pain, stiffness, and function.

RESULTS

Both orthoses significantly improved pain by 17 and 22%, function by 11 and 14%, the first peak KAM by 15.7 and 19.2%, the second peak KAM by 10.4 and 16.7%, and KAM impulse by 14.8 and 22.2%, respectively. However, the biaxial AFO significantly reduced the KAM and improved function compared to the lateral wedge insole (p < 0.01).

CONCLUSIONS

The results of this study have shown that both orthoses have a potential role in the conservative management of medial knee osteoarthritis. The biaxial AFO proved statistically better at improving function and KAM; though these differences do not seem to be clinically significant.IMPLICATION FOR REHABILITATIONOrthotic interventions have been reported to be effective in the management of medial knee osteoarthritis.Lateral wedge insole and biaxial ankle-foot orthosis (AFO) are effective in the improvement of pain, function, and knee adduction moment (KAM) in people with medial knee osteoarthritis.The biaxial AFO, compared with lateral wedge insole, contributes to statistically more improvement of function and KAM. However, these differences do not seem to be clinically significant.

Towards Co-Design in Delivering Assistive Technology Interventions: Reconsidering Roles for Consumers, Allied Health Practitioners, and the Support Workforce

A complexity of factors, from health and technology innovations to policy redesign to achieve consumer-directed care, are impacting traditional roles for Australian allied health practitioners (AHPs). This pilot study considers roles for AHPs in relation to assistive technology (AT) interventions. Articulating 'who does what' may serve a number of purposes including de-professionalization of the discourse; better utilization of support networks and workforces; and alignment with contemporary policy. Yet, a suitable framework to assist with collaborative AT implementation between relevant stakeholders was not identified within the existing literature. This research aimed to develop and pilot an AT collaboration tool which enables AHPs, consumers, their support networks and the support workforce, to navigate policy redesign toward ethical consumer-directed implementation of AT interventions. An AT collaboration tool was developed based upon practice-based knowledge, relevant regulatory and practice evidence and identifies relevant stakeholders, AT service steps and roles, and quality indicators to support competent practice. The tool was piloted in four separate and diverse practice analyses of AT interventions (custom prosthetics, home enteral nutrition, communication devices, and vehicle modifications) considering four allied health professions (prosthetics and orthotics, dietetics, speech pathology, occupational therapy). Pilot testing of the tool supports the feasibility of re-framing AT provision using competency-based and risk-informed approaches and enabling more inclusive roles for consumers and the support workforce. Further testing of the tool is indicated, followed by strategic actions for uptake by individuals, professions and policymakers. The AT collaboration tool has potential to enable AHPs to fulfil ethical obligations for consumer-centered practice, and to facilitate consumer choice, both in Australia and internationally.

How does a systematic tuning protocol for ankle foot orthosis-footwear combinations affect gait in children in cerebral palsy?

PURPOSE

To investigate the effects of a systematic tuning protocol for ankle foot orthosis footwear combinations (AFO-FC) using incrementing heel height on gait in children with cerebral palsy (CP).

METHODS

Eighteen children with CP (10.8 ± 3 years, Gross Motor Function Classification System (GMFCS) I-II) underwent 3D gait analysis on a treadmill, while the AFO heel surface was systematically incremented with wedges. Children were subdivided based on their gait pattern, i.e., knee hyperextension (EXT) and excessive knee flexion (FLEX). Outcome measures included sagittal hip and knee angles and moments, shank to vertical angle (SVA), foot to horizontal angle, and gait profile score (GPS).

RESULTS

For both groups, incrementing heel height resulted in increased knee flexion, more inclined SVA, and increased knee extension moments. This resulted in gait improvements for some children of the EXT-group, but not in FLEX. High variation was found between individuals and within-subject effects were not always consistent for kinematic and kinetics.

CONCLUSIONS

A systematic AFO-FC tuning protocol using incremented heel height can be effective to improve gait in children with CP walking with EXT. The current results emphasise the importance of including kinematics as well as kinetics of multiple instances throughout the gait cycle for reliable interpretation of the effect of AFO tuning on gait.Implications for rehabilitationA systematic ankle foot orthosis footwear combinations (AFO-FC) tuning protocol using incremented heel height can improve gait in children walking with knee hyperextension.Tuning results in changes throughout the gait cycle.Little evidence is found for an optimal SVA of 10-12° at midstance.For clinical interpretation, both joint kinematic and kinetic parameters should be considered throughout the gait cycle and evaluation should not be based on SVA only.

The Evaluation of Orthotics in Reducing Hallux Valgus Angle in Patients with Hallux Valgus over a Twelve-Month Treatment

BACKGROUND

Hallux valgus (HV) is one of the most common forefoot deformities among females, and its prevalence increases with age. This study aims to evaluate the effectiveness of three different types of orthotics on the reduction in hallux valgus angle (HVA) for patients with mild and moderate hallux valgus deformities.

METHODS

Twenty-six patients (42 feet) with mild or moderate HV participated in the treatment with three types of orthotics in the current study. Patients were divided into three groups depending on their HV severities and the consideration of different function of the orthotics. Orthotic Type 1 is a biomechanical style orthotic applied to moderated HV in Group 1. Orthotic Type 2 is a wrap style orthotic used on mild and moderate HV with two sub-groups: mild HV in Group 2A and moderate HV in Group 2B. Orthotic Type 3 is a gel style orthotic for mild HV. Patients were required to wear the orthotics for between 6 and 8 h per night over a period of 12 months. The HVA was measured every 3 weeks using a newly designed Measuring Block. A paired t-test was used to compare the differences between initial and final HVA at different stages of HVA treatment with orthotics.

RESULTS

After the 12-month treatment, for moderate HV patients treated with the Orthotic Type 1, their HVA reduced by 5.05° (95% CI 1.37, 8.73), (p < 0.05). For moderate HV patients treated with the Orthotic Type 2, their HVA reduced by 1.2° (95% CI -0.71, 3.11) (p > 0.05). For mild HV patients treated with the Orthotic Type 2, their HVA reduced by 2.44° (95% CI 1.39, 3.49) (p < 0.05). For mild HV patients treated with the Orthotic Type 3, their HVA reduced by 3.08° (95% CI -0.68, 6.83) (p > 0.05).

CONCLUSIONS

Orthotic Type 1 showed a consistent significance in reduction in the HVA during the 12-month treatment, so it could be recommended for treating moderate HV. Orthotic Type 2 reduced the HVA, but it did not show a consistent significance in reduction in the HVA for mild and moderate HV. Orthotic Type 3 reduced the HVA, but it showed a volatile trend during 12 months without significant differences.

Evaluating the Reliability of a Shape Capturing Process for Transradial Residual Limb Using a Non-Contact Scanner

Advancements in digital imaging technologies hold the potential to transform prosthetic and orthotic practices. Non-contact optical scanners can capture the shape of the residual limb quickly, accurately, and reliably. However, their suitability in clinical practice, particularly for the transradial (below-elbow) residual limb, is unknown. This project aimed to evaluate the reliability of an optical scanner-based shape capture process for transradial residual limbs related to volumetric measurements and shape assessment in a clinical setting. A dedicated setup for digitally shape capturing transradial residual limbs was developed, addressing challenges with scanning of small residual limb size and aspects such as positioning and patient movement. Two observers performed three measurements each on 15 participants with transradial-level limb absence. Overall, the developed shape capture process was found to be highly repeatable, with excellent intra- and inter-rater reliability that was comparable to the scanning of residual limb cast models. Future work in this area should compare the differences between residual limb shapes captured through digital and manual methods.

Biomechanical effects of a halo orthotic on a pediatric anthropomorphic test device in a simulated frontal motor vehicle collision

Objective: Cervical spine injuries in children under 10 frequently involve the craniocervical junction. In patients too small for conventional spinal instrumentation, treatment may involve placement of a halo orthotic, and these patients will frequently be discharged home in a halo orthotic. To date, little research has been done on the biomechanics of motor vehicle collisions involving young children in halo orthotics. To better understand possible safety concerns, we applied a halo orthotic to an appropriately sized anthropomorphic test device (ATD, or crash test dummy) on an acceleration sled to simulate a frontal motor vehicle collision.Methods: For the tests, a Hybrid III 3-year-old ATD was instrumented with head and chest accelerometers, head angular rate sensors, a six-axis upper neck load cell, and a chest linear potentiometer. Four tests were conducted on an acceleration sled, and kinematics were recorded with high speed video. Testing variables included 1) with or without a halo orthotic and 2) with a standard booster seat or a commercially available harness vest.Results: The halo orthotic reduced flexion and extension but was associated with increased rotation, especially in the condition of a halo orthotic with a standard booster seat. Increased cervical distraction was noted with the halo orthotic, and this was especially increased in the condition of a halo orthotic with the harness vest.Conclusions: The biomechanics of a child involved in a motor vehicular collision may be dramatically altered with a halo orthotic, as modeled by an acceleration sled test. While cervical spine flexion and extension are reduced with the halo orthotic, rotation appears to increase. Immobilization from a halo orthotic also appears to increase cervical distraction, especially when used in conjunction with a harness vest. Further testing is needed to determine the safest restraints for this small, but at-risk, population.

Mobilisation or immobilisation-based treatments for first carpometacarpal joint osteoarthritis: A systematic review and meta-analysis with subgroup analyses

Introduction

Both joint mobilisation and immobilisation are thought to be effective in the treatment of first carpometacarpal joint (CMCJ) osteoarthritis (OA). The objective of this review was to establish whether either intervention reduced pain and improved pinch strength in people with first CMCJ OA in the short term and assess whether one intervention is superior to the other.

Method

This was a systematic review and meta-analysis. Seven databases were searched until May 2021. Only RCTs were included. The Cochrane Risk of Bias Tool and the Grade of Recommendations Assessment, Development and Evaluation system were utilised to rate the evidence. Random-effects meta-analysis with subgroup analyses were used.

Results

Eight studies were included with a total of 417 participants. Mobilisation treatments included manual therapy with or without exercise while immobilisation interventions utilised thumb splinting with several different designs. Very low-quality and low-quality evidence showed that mobilisation led to statistically but not clinically significant improvements in pain (standardised mean difference (SMD) = 0.53; 95% confidence interval (CI) = 0.03 to 1; I2 = 60%; p = 0.06) and pinch strength (SMD = 0.35; 95% CI = 0.03 to 0.7; I2 = 12%; p = 0.3) compared to placebo. Very low-quality and low-quality evidence showed no effect on pain and pinch strength compared to a control or no intervention. Subgroup analyses revealed no difference between interventions.

Discussion

Neither mobilisation nor immobilisation alone led to clinically important improvements in pain or pinch strength in the short term in people with symptomatic first CMCJ OA. Neither therapeutic strategy appeared to be superior.

Myoelectric Arm Orthosis in Motor Learning-Based Therapy for Chronic Deficits After Stroke and Traumatic Brain Injury

Background

Technologies that enhance motor learning-based therapy and are clinically deployable may improve outcome for those with neurological deficits. The MyoPro™ is a customized myoelectric upper extremity orthosis that utilizes volitionally generated weak electromyographic signals from paretic muscles to assist movement of an impaired arm. Our purpose was to evaluate MyoPro as a tool for motor learning-based therapy for individuals with chronic upper limb weakness.

Methods

This was a pilot study of thirteen individuals with chronic moderate/severe arm weakness due to either stroke (n = 7) or TBI (n = 6) who participated in a single group interventional study consisting of 2 phases. The in-clinic phase included 18 sessions (2x per week, 27hrs of face-to-face therapy) plus a home exercise program. The home phase included practice of the home exercise program. The study did not include a control group. Outcomes were collected at baseline and at weeks 3, 5, 7, 9, 12, 15, and 18. Statistics included mixed model regression analysis.

Results

Statistically significant and clinically meaningful improvements were observed on Fugl-Meyer (+7.5 points). Gains were seen at week 3, increased further through the in-clinic phase and were maintained during the home phase. Statistically significant changes in Modified Ashworth Scale, Range of Motion, and Chedoke Arm and Hand Activity Inventory were seen early during the in-clinic phase. Orthotic and Prosthetic User's Survey demonstrated satisfaction with the device throughout study participation. Both stroke and TBI participants responded to the intervention.

Conclusions

Use of MyoPro in motor learning-based therapy resulted in clinically significant gains with a relatively short duration of in-person treatment. Further studies are warranted.

Clinical Trial Registration

www.ClinicalTrials.gov, identifier: NCT03215771.

[Topical issues of rehabilitation of patients with osteoporotic vertebral fractures]

The literature review analyzed 20 Russian and 69 foreign publications on the rehabilitation of elderly patients with osteoporotic vertebral fractures. The article deals in detail with the prevalence, medical and social significance of pathological osteoporotic fractures, including vertebral deformities. The data confirming the importance of osteoporosis for physical and rehabilitation medicine specialists are presented. Changes in the quality of life, functional and gate disorders associated with osteoporotic vertebral fractures are described. Based on the available literature data, the principles of rehabilitation of patients with osteoporotic vertebral compression fractures are formulated, including the effectiveness of various methods of physical therapy, mechanotherapy and apparatus physiotherapy. From the standpoint of evidence-based medicine, the role of orthotics in the complex rehabilitation of such patients is described. Based on the analysis of literature data, it was concluded that the problem of osteoporosis is relevant for physicians working in the field of rehabilitation medicine; osteoporotic vertebral fractures are characterized by a high prevalence over the age of 50 years and are associated with a decrease in the quality of life, motor and functional limitations, and an increased risk of death, and well-planned medical rehabilitation programs including physical exercises, physiotherapy and orthotics can significantly improve patient functionality.

The emergence of telehealth in orthotic services across the United Kingdom

COVID-19 has impacted the National Health Service provision, creating urgency for departments to adapt and adopt new ways of delivering healthcare. The purpose of this service evaluation was to determine the emergence of telehealth in orthotic services across the UK in response to COVID-19. A survey exploring telehealth use was distributed online to orthotists approximately 6 months after the first peak of COVID-19 in the UK. It gathered information on telehealth prevalence, allocated appointment length and waiting times, clinician access to technology and clinicians' opinions on the efficacy of telehealth. The survey received 77 responses with over 90% of respondents reporting using telehealth. Most reported that they expected telehealth to remain part of the service, post COVID-19. Thematic analysis produced two main themes: the impact of COVID-19 and challenges still to overcome. Findings suggest that the pandemic has resulted in a backlog of patients waiting for an orthotic appointment, with services currently understaffed and lacking resources. For telehealth to be effective orthotists must have access to appropriate technology and training on how to use telehealth platforms, be provided with appropriate guidance on which patients are appropriate for telehealth consultations and given appropriate appointment times to enable safe and effective care.

Mechanics of foot orthotics: material properties

Orthotics have been utilised by clinicians for many years to treat foot-related abnormalities. With advancements in material sciences, the footwear industry started utilising synthetic materials which have better and suitable properties. Clinicians, who prescribe foot insoles, need to have an extensive understanding of the properties and characteristics of insole materials, to make informed decisions to meet the patients' needs. This thesis showcases utilised techniques and systems to evaluate orthosis properties as well as current criteria to date. Researchers have utilised a variety of testing techniques to examine properties of insole materials including; bench testing, simulated in-shoe conditions, in-shoe testing, and finite element analysis. Even though, there is a great understanding of material properties with endless diverse composition and thicknesses of each material makes clinical recommendations on the choice of material an impossible task. As the footwear orthosis industry shifts the focus from material to design, some researchers explore various anisotropic materials to create a homogeneous insole that can support as well as relieve pressure on patient's feet.

Assessment of the Shank-to-Vertical Angle While Changing Heel Heights Using a Single Inertial Measurement Unit in Individuals with Incomplete Spinal Cord Injury Wearing an Ankle-Foot-Orthosis

Previous research showed that an Inertial Measurement Unit (IMU) on the anterior side of the shank can accurately measure the Shank-to-Vertical Angle (SVA), which is a clinically-used parameter to guide tuning of ankle-foot orthoses (AFOs). However, in this context it is specifically important that differences in the SVA are detected during the tuning process, i.e., when adjusting heel height. This study investigated the validity of the SVA as measured by an IMU and its responsiveness to changes in AFO-footwear combination (AFO-FC) heel height in persons with incomplete spinal cord injury (iSCI). Additionally, the effect of heel height on knee flexion-extension angle and internal moment was evaluated. Twelve persons with an iSCI walked with their own AFO-FC in three different conditions: (1) without a heel wedge (refHH), (2) with 5 mm heel wedge (lowHH) and (3) with 10 mm heel wedge (highHH). Walking was recorded by a single IMU on the anterior side of the shank and a 3D gait analysis (3DGA) simultaneously. To estimate validity, a paired t-test and intraclass correlation coefficient (ICC) between the SVA_IMU and SVA_3DGA were calculated for the refHH. A repeated measures ANOVA was performed to evaluate the differences between the heel heights. A good validity with a mean difference smaller than 1 and an ICC above 0.9 was found for the SVA during midstance phase and at midstance. Significant differences between the heel heights were found for changes in SVA_IMU (p = 0.036) and knee moment (p = 0.020) during the midstance phase and in SVA_IMU (p = 0.042) and SVA_3DGA (p = 0.006) at midstance. Post-hoc analysis revealed a significant difference between the ref and high heel height condition for the SVA_IMU (p = 0.005) and knee moment (p = 0.006) during the midstance phase and for the SVA_IMU (p = 0.010) and SVA_3DGA (p = 0.006) at the instant of midstance. The SVA measured with an IMU is valid and responsive to changing heel heights and equivalent to the gold standard 3DGA. The knee joint angle and knee joint moment showed concomitant changes compared to SVA as a result of changing heel height.

[Study of the psycho-emotional disorders' severity in patients with osteoporotic vertebral fractures and factors affecting them]

There are convincing data on the association of psycho-emotional disorders with the degree of bone mineral density (BMD) loss and the risk of fractures on the basis of osteoporosis (OP) but the nature of the causal relationship has not yet been clearly established. The study of this issue is important to substantiate the need and nature of psychological correction within the framework of comprehensive rehabilitation programs in patients with osteoporotic fractures.

OBJECTIVE

Study of the severity of symptoms of depression and anxiety in patients who have suffered compression fractures of the vertebrae (VF) of osteoporotic genesis who entered the II stage of medical rehabilitation, as well as the contribution to the development of psycho-emotional age disorders, the severity of OP, pain syndrome and the use of orthotics.

MATERIAL AND METHODS

The study sample consisted of 120 women 50 to 80 years old with an established diagnosis of OP based on the results of bone densitometry. The main group included 60 patients with OP complicated by at least one VF. The control group included 60 patients with OP without a history of osteoporotic fractures comparable in age, body mass index and BMD in the spine with the main group. The complex of examination included the collection of complaints, anamnesis of OP, previous fractures, assessment of pain syndrome according to VAS, BMD study and verification of VF by X-ray methods. To assess the level of depression (DL) we used the Tsung depression scale modified by T.I. Balashova, situational (SA) and personal anxiety (PA) - Spielberger-Khanin questionnaire.

RESULTS

In the main group in comparison with the control group the proportion of patients without symptoms of depression was lower (66.7 and 88.3%, respectively; p=0.042), as well as the frequency of detection of high degree of SA was higher (85.0 and 73.4%, respectively; p=0.039). In patients with VF it was higher than in the control, DL - 46.0 [42.0; 54.5] (27-70) and 43.0 [38.0; 47.5] (25-65) points, respectively (p=0.0009), as well as the SA degree - 61.5 [54.0; 71.0] (20-75) and 52.5 [43.5; 64.0] (20-68) points, respectively (p=0.0006). Statistically significant direct correlation dependences of DL on age (r=0.317; p=0.00042), the duration of the postmenopausal period (r=0.325; p=0.0003), the number of VFs (g= -0.245; p=0.00013) were established. Moreover, the intensity of pain syndrome (g= -0.234; p=0.00034), as well as feedbacks of this indicator with BMD in the spine (r= -0.342; p=0.00017) and the duration of the use of thoracolumbar orthoses (r = -0.504; p = 0.00016). There were direct dependence of the SA degree on age (r=0.281; p=0.0019) and the intensity of pain syndrome (g=0.258; p=0.0044). Negative correlation of SA with body weight (r= -0.183; p=0.045), BMD in the spine (r= -0.207; p=0.026), duration of orthosis application (r= -0.327; p=0.0095) and the amount of VF in the lumbar spine (g= -0.214; p=0.044) were detected. There was a significant correlation between the degree of PA and BMD in the lumbar vertebrae (r= -0.18; p=0.046) and the intensity of pain syndrome (g=0.137; p=0.039).

CONCLUSION

The results obtained indicate the need for psychological correction in the framework of the complex rehabilitation of women who underwent VF based on OP due to increased DL and SA especially in older age groups.

Prosthetists and orthotists: An evolution from mechanic to clinician

Fifty years ago, the International Society for Prosthetics and Orthotics was founded in recognition that this unique niche in rehabilitation would benefit from multidisciplinary interactions between specialists in engineering, therapy, and medicine.Since then, field evolved from having a craft orientation toward a technology and clinical specialty. This anniversary provides an opportunity to look back on advances in prosthetics and orthotics, and the clear impact they have had on changing the skills needed by the prosthetist/orthotist as new technology and techniques have emerged. The balance has clearly shifted from mechanical skills to clinical care. The training and skills of the prosthetist/orthotist remain unique and valued in the rehabilitation team, and the primary motivation remains the same as it has been since the creation of the International Society for Prosthetics and Orthotics: the application of external devices where they are suitable to address the many varied needs of persons with disability. This historical perspective puts into context why and how the profession has changed, while also reinforcing that it is the goals set for restoring patient functions that best defines what it is to be a prosthetist/orthotist, not the means we use.

Reflections and future directions for psychological science in Prosthetics and Orthotics International

In the inaugural edition of Prosthetics and Orthotics International in 1977, Dr Sidney Fishman identified the Psychological Sciences as one of six indispensable areas of skill and knowledge in professional prosthetic-orthotic practice. Since then, there have been substantial changes and developments in the complexity and capabilities of assistive technologies, greater emphasis on understanding the relationships between people and enabling technologies, growing recognition of the importance of the contexts and environments that support their use, and changes in both health care services and the professional development of prosthetists and orthotists. The aim of this narrative review is to reflect on the role of Prosthetics and Orthotics International in shaping the evolving understanding of psychology in prosthetics and orthotics. There remains considerable potential and opportunity for the development and application of psychology in addressing the challenges of disability globally. However, a broad interpretation and application of the principles of rehabilitation psychology are needed if we are to meaningfully incorporate psychological science into the knowledge that informs prosthetic and orthotic practice.

Leveraging Digital Technology to Overcome Barriers in the Prosthetic and Orthotic Industry: Evaluation of its Applicability and Use During the COVID-19 Pandemic

BACKGROUND

The prosthetic and orthotic industry typically provides an artisan "hands-on" approach to the assessment and fitting of orthopedic devices. Despite growing interest in digital technology for prosthetic and orthotic service provision, little is known of the quantum of use and the extent to which the current pandemic has accelerated the adoption.

OBJECTIVE

This study's aim is to assess the use of digital technology in prosthetics and orthotics, and whether its use can help overcome challenges posed by the current COVID-19 pandemic.

METHODS

A web-based survey of working prosthetists, orthotists, and lower limb patients was conducted between June and July 2020 and divided into three sections: lower limb amputees, prosthetist and orthotist (P&O) currently using digital technologies in their practice, and P&O not using any digital technology. Input was sought from industry and academia experts for the development of the survey. Descriptive analyses were performed for both qualitative (open-ended questions) and quantitative data.

RESULTS

In total, 113 individuals responded to the web-based survey. There were 83 surveys included in the analysis (patients: n=13, 15%; prosthetists and orthotists: n=70, 85%). There were 30 surveys excluded because less than 10% of the questions were answered. Out of 70 P&Os, 31 (44%) used digital technologies. Three dimensional scanning and digital imaging were the leading technologies being used (27/31, 88%), primarily for footwear (18/31, 58%), ankle-foot orthoses, and transtibial and transfemoral sockets (14/31, 45%). Digital technology enables safer care during COVID-19 with 24 out of 31 (77%) respondents stating it improves patient outcomes. Singapore was significantly less certain that the industry's future is digital (P=.04). The use of virtual care was reported by the P&O to be beneficial for consultations, education, patient monitoring, or triaging purposes. However, the technology could not overcome inherent barriers such as the lack of details normally obtained during a physical assessment.

CONCLUSIONS

Digital technology is transforming health care. The current pandemic highlights its usefulness in providing safer care, but digital technology must be implemented thoughtfully and designed to address issues that are barriers to current adoption. Technology advancements using virtual platforms, digitalization methods, and improved connectivity will continue to change the future of health care delivery. The prosthetic and orthotic industry should keep an open mind and move toward creating the required infrastructure to support this digital transformation, even if the world returns to pre-COVID-19 days.

Efficacy of heel lifts versus calf muscle eccentric exercise for mid-portion Achilles tendinopathy (HEALTHY): a randomised trial

OBJECTIVES

To compare the efficacy of in-shoe heel lifts to calf muscle eccentric exercise in reducing pain and improving function in mid-portion Achilles tendinopathy.

METHODS

This was a parallel-group randomised superiority trial at a single centre (La Trobe University Health Sciences Clinic, Discipline of Podiatry, Melbourne, Victoria, Australia). One hundred participants (52 women and 48 men, mean age 45.9, SD 9.4 years) with clinically diagnosed and ultrasonographically confirmed mid-portion Achilles tendinopathy were randomly allocated to either a (1) heel lifts (n=50) or (2) eccentric exercise (n=50) group. The primary outcome measure was the Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire at 12 weeks. Differences between groups were analysed using intention to treat with analysis of covariance.

RESULTS

There was 80% follow-up of participants (n=40 per group) at 12 weeks. The mean VISA-A score improved by 26.0 points (95% CI 19.6 to 32.4) in the heel lifts group and by 17.4 points (95% CI 9.5 to 25.3) in the eccentric exercise group. On average, there was a between-group difference in favour of the heel lifts for the VISA-A (adjusted mean difference 9.6, 95% CI 1.8 to 17.4, p=0.016), which approximated, but did not meet our predetermined minimum important difference of 10 points.

CONCLUSION

In adults with mid-portion Achilles tendinopathy, heel lifts were more effective than calf muscle eccentric exercise in reducing pain and improving function at 12 weeks. However, there is uncertainty in the estimate of effect for this outcome and patients may not experience a clinically worthwhile difference between interventions.

TRIAL REGISTRATION NUMBER

ACTRN12617001225303.

A systematic review in prosthetics and orthotics education research

BACKGROUND

Formal prosthetic/orthotic education has evolved greatly since its inception in the 1950s. The International Society for Prosthetics and Orthotics has established guidelines and recognition for prosthetic/orthotic programs worldwide. However, the current state-of-the-science in prosthetic/orthotic education is largely unknown.

OBJECTIVES

To evaluate and synthesize available prosthetic/orthotic education research.

STUDY DESIGN

Systematic review.

METHODS

Three bibliographic databases were searched and quality of included articles assessed using criteria from the National Institutes for Health Quality Assessment Tool for Observational Cohort, Cross-Sectional Studies, and the Critical Appraisal Skills Programme Qualitative Research Checklist, and Delphi quality criteria.

RESULTS

This review included 25 articles from 23 studies. Included studies explored description, development, implementation, and/or assessment of the teaching/learning methods, curriculum, program, or country/region level. Studies were conducted in 18 countries and published in 14 journals. Methodological quality was rated high in 6 articles, moderate in 6, and low in 13. Content synthesis was not attempted due to the heterogeneous literature.

CONCLUSION

This systematic review suggests that prosthetic/orthotic education research is only being conducted at a limited level. There is a strong need for high quality, collaborative education research to be conducted and published in peer-reviewed journals to improve prosthetic/orthotic education and build a global conversation.

CLINICAL RELEVANCE

Research in prosthetic/orthotic education is limited. The current body of literature is not sufficient to inform and guide future education of prosthetic/orthotic students. Opportunities to improve prosthetic/orthotic education research include academic collaborations, a dedicated education special issue or journal, and disciplinary support for prosthetic/orthotic education research.

Effect of Mechanically Passive, Wearable Shoulder Exoskeletons on Muscle Output During Dynamic Upper Extremity Movements: A Computational Simulation Study

Wearable passive (ie, spring powered) shoulder exoskeletons could reduce muscle output during motor tasks to help prevent or treat shoulder musculoskeletal disorders. However, most wearable passive shoulder exoskeletons have been designed and evaluated for static tasks, so it is unclear how they affect muscle output during dynamic tasks. The authors used a musculoskeletal model and Computed Muscle Control optimization to estimate muscle output with and without a wearable passive shoulder exoskeleton during 2 simulated dynamic tasks: abduction and upward reach. To an existing upper extremity musculoskeletal model, the authors added an exoskeleton model with 3-dimensional representations of the exoskeleton components, including a spring, cam wheel, force-transmitting shoulder cable, and wrapping surfaces that permitted the shoulder cable to wrap over the shoulder. The exoskeleton reduced net muscle-generated moments in positive shoulder elevation by 28% and 62% during the abduction and upward reach, respectively. However, muscle outputs (joint moments and muscle effort) were higher with the exoskeleton than without at some points of the movement. Muscle output was higher with the exoskeleton because the exoskeleton moment opposed the muscle-generated moment in some postures. The results of this study highlight the importance of evaluating muscle output for passive exoskeletons designed to support dynamic movements to ensure that the exoskeletons assist, rather than impede, movement.

Entrustment trends in orthotic and prosthetic residencies

BACKGROUND

Orthotic and prosthetic residency preceptors have little guidance transitioning residents between observing and performing patient care. Understanding current entrustment trends and factors can help guide resident progression during residency.

OBJECTIVES

To identify entrustment trends and factors within an orthotics and prosthetics residency affecting a supervisor's decision to entrust residents with independent patient care.

STUDY DESIGN

Cross-sectional study.

METHODS

In this cross-sectional study, 831 National Commission of Orthotic and Prosthetic Education preceptors were invited to complete a 26-question, online questionnaire that examined possible entrustment factors.

RESULTS

A total of 77 preceptors completed the questionnaire. The top-reported behavioral qualities impacting entrustment were recognition of limitations and willingness to ask for help (n = 45) and competence (n = 37). Preceptors ranked evaluation (n = 27) as the professional skill which most affected entrustability; technical skill least affected entrustability (n = 4). Preceptors of 12-month residencies entrust residents to indirect supervision when they have completed approximately 75% (i.e. 9 months) of the program. Preceptors of 18-month residencies reported that they entrust their residents by the time they reach 50% (i.e. 9 months) of their training. A small number of preceptors (n = 19) never allow a resident to independently perform practice management.

CONCLUSION

Residency supervisors value interpersonal and evaluation skills when making entrustment decisions. Residency mentors can use these findings to inform their entrustment decisions and support a resident's progression toward independent practice.

CLINICAL RELEVANCE

This study presents information which can inform clinical preceptors and residents on what factors contribute to the decision to progress a resident from observation to independent patient care. These findings may influence clinical education standards which aim to promote both resident training and patient access to quality care.

Effect of Ulnar-Based Orthotics and Strengthening Exercises on Subjects With Ulnar Wrist Pain

CONTEXT

In comparison with the published research on the surgical management of ulnar wrist pain, fewer studies that discuss the nonsurgical management of ulnar wrist pain exist.

OBJECTIVE

The purpose of this pilot study was to investigate the effect of ulnar-based wrist orthotics and strengthening exercises on subjects with ulnar wrist pain.

STUDY DESIGN

Prospective randomized controlled pilot study.

SETTING

Research laboratory.

PARTICIPANTS

Thirty subjects with acute and subacute ulnar wrist pain and age ranging from 18 to 53.

INTERVENTIONS

Participants were randomized to receive either ulnar-based orthotics, ulnar-based orthotics plus strengthening exercises, or placebo intervention.

MAIN OUTCOME MEASURES

The authors measured pain and function using the Patient-Rated Wrist Evaluation questionnaire, and grip strength using the JAMAR dynamometer, at baseline and at 2- and 4-week postrandomization. A mixed analysis of variance modeling was used to investigate the effect of the intervention over time.

RESULTS

There were statistically significant differences between the 2 intervention groups and the control group regarding improvement in pain, function, and strength, whereas there were no statistically significant differences between the 2 intervention groups over the 3 measurement occasions regarding the outcome measures.

CONCLUSION

Based on the results, orthotics intervention is as effective as orthotics plus strengthening exercises in improving pain, function, and grip strength in subjects with ulnar wrist pain.

LEVEL OF EVIDENCE

Therapy, level 2b individual Randomized Controlled Trial.

A modified walk-in clinic for shoe insoles: Follow-up of non-attendants

BACKGROUND

In a previous study (n = 1286), we found that a modified walk-in system reduced waiting times for prescription of shoe insoles by 40 days compared to scheduled appointments but resulted in a non-attendance rate of 17% compared to 6% for scheduled appointments.

OBJECTIVES

To investigate the reasons for non-attendance at the modified walk-in clinic.

STUDY DESIGN

This is a cross-sectional survey.

METHODS

Unlike traditional walk-in clinics, a limited number of patients were invited each week from the waiting list to attend the modified walk-in clinic on pre-specified days during the following 5 weeks. A questionnaire was sent to 137 patients who did not attend the modified walk-in clinic, of whom 50 (36%) responded.

RESULTS

The most frequently reported reasons for not attending were the following: could not attend on the suggested days and times (30%), had already received help (18%) and illness or other medical interventions (16%). The majority of these issues could have been overcome by rescheduling to a scheduled appointment.

CONCLUSION

The main reason for not attending a modified walk-in clinic was that suggested days and times did not suit the patients. The option to reschedule the appointment needs to be clearly emphasized in the information provided to the patient.

CLINICAL RELEVANCE

With clear information about rescheduling options, a modified walk-in clinic could be used to reduce waiting times for certain groups of patients.

Professional Clinical Photography to Assist Patients with Pectus Carinatum

A photographic clinical role has been realized in our institution in the care of patients with Pectus Carinatum. A series of clinical photographs along with 3D imaging are now presented by our photographers to each patient in clinic to demonstrate changes over time in the size and shape of their chest wall defects associated with this condition. This interaction has increased patient compliance for treatment and subsequently reinforces the relevance and importance of clinical photographers in patient care.

The Influence of Orthotics on Lower Limbs Biomechanics in CP

The biomechanics of the human body has a direct impact on the quality of gait cycle. Patients with Cerebral Palsy (CP) often present incorrect gait patterns associated with structural deformities which directly influence the locomotor functions. The key to therapeutic success in those patients is the use of lower limb orthotics of the AFO type. This type of orthopedic devices should correct the skeletal deformities, optimize function and ensure high quality of daily use. Alignment of the lower limb supported by orthotics in all planes is crucial for changing the abnormal position of the ground reaction force (GRF) vector during a pathological gait cycle. GRFs produce an external moment of forces that causes extension or flexion of the lower limb in the sagittal plane. At the same time, those external conditions are balanced by an internal moment of forces generated by muscles. Some of the muscles are not directly attached to the joints but still support their function. This mechanism is called biomechanical coupling. This interesting relationship is also related to the inclination or reclination of the shank vertical angle (SVA) against the foot fixed on the ground in the midstance (MST) phase of gait. An optimal SVA angle is 7-12 degrees of tibial inclination. An insufficient or excessive SVA angle can be controlled by ankle foot orthotics (AFO). Those types of splints provide for better control of foot clearance during the swing phase and support distal stability of the lower limb chain during the stance phase of the gait cycle. An interdisciplinary approach is the key to success in the therapy of CP children who use lower limb orthotics. Nowadays, tridimensional gait analysis is an important tool for objective monitoring of those patients. It shows all kinematic and kinetic data recorded during gait with AFO and therefore helps to fine-tune orthotics used by CP patients.

The Effect of EVA and TPU Custom Foot Orthoses on Running Economy, Running Mechanics, and Comfort

Custom made foot orthoses (CFO) with specific material properties have the potential to alter ground reaction forces but their effect on running mechanics and comfort remains to be investigated. We determined if CFO manufactured from ethyl-vinyl acetate (EVA) and expanded thermoplastic polyurethane (TPU) materials, both compared to standardized footwear (CON), improve running economy (RE), running mechanics, and comfort at two running speeds. Eighteen well-trained, male athletes ran on an instrumented treadmill for 6 min at high (HS) and low (LS) speeds corresponding to and 15% lower than their first ventilatory threshold (13.8 ± 1.1 and 11.7 ± 0.9 km.h⁻¹, respectively) in three footwear conditions (CON, EVA, and TPU). RE, running mechanics and comfort were determined. Albeit not reaching statistical significance (P = 0.11, η² = 0.12), RE on average improved in EVA (+2.1 ± 4.8 and +2.9 ± 4.9%) and TPU (+0.9 ± 5.9 and +0.9 ± 5.3%) compared to CON at LS and HS, respectively. Braking force was decreased by 3.4 ± 9.1% at LS and by 2.7 ± 9.8% at HS for EVA compared to CON (P = 0.03, η² = 0.20). TPU increased propulsive loading rate by 20.2 ± 24 and 16.4 ± 23.1% for LS and HS, respectively compared to CON (P = 0.01, η² = 0.25). Both arch height (P = 0.06, η² = 0.19) and medio-lateral control (P = 0.06, η² = 0.16) showed a trend toward improved comfort for EVA and TPU vs. CON. Compared to shoes only, mainly EVA tended to improve RE and comfort at submaximal running speeds. Specific CFO-related running mechanical adjustments included a reduced braking impulse occurring in the first 25% of contact time with EVA, whereas wearing TPU increased propulsive loading rate.

Rehabilitation across the lifespan for individuals with arthrogryposis

Arthrogryposis multiplex congenita (AMC) can be a perplexing diagnosis that consists of limited range of motion (ROM) and decreased muscle strength in multiple joints. The person with AMC often possesses a certain tenacity and "spunk" that assists them with adjusting and adapting to the realities of daily life. The rehabilitation process assists the individual with AMC in achieving and maintaining the maximal active and passive range of motion and strength in order to participate in activities of daily living (ADL) throughout the developmental stages. The result of this life-long process is greatly impacted by collaboration among the multidisciplinary teams. Ultimately, rehabilitation should focus on three levels of treatment: (a) body structure, (b) activity, and (c) participation. This article describes rehabilitation across the lifespan-focusing on the therapeutic needs in the infant, toddler, school age and teenage/adult years-while also highlighting opportunities for improvement.

Improved motor function in a pre-ambulatory child with spastic bilateral cerebral palsy, using a custom rigid ankle-foot orthosis-footwear combination: A case report

BACKGROUND

Ankle-foot orthoses may be used in pre-ambulatory children with cerebral palsy; however, their effect on the acquisition of walking is unknown. This case report aims to evaluate the effect of an ankle-foot orthosis-footwear combination on the acquisition of walking in a single subject with cerebral palsy.

CASE DESCRIPTION AND METHODS

This study reports the orthotic management of a single child with spastic bilateral cerebral palsy over a 15-month period, during which time the ability to independently stand and walk was acquired. Custom rigid ankle-foot orthoses were prescribed. Gait speed and Edinburgh Visual Gait Score were assessed with and without the orthoses.

FINDINGS AND OUTCOMES

The subject developed the ability to stand and walk using an ankle-foot orthosis-footwear combination with a walker frame, and to a limited extent without a walker frame. The subject remained unable to take independent steps unless wearing the ankle-foot orthosis-footwear combination. Clinically significant differences in gait speed and Edinburgh Visual Gait Score were observed.

CONCLUSION

An ankle-foot orthosis-footwear combination may aid the development of independent walking in some children with cerebral palsy. Further research on the effects of orthoses on the acquisition of walking ability in children with cerebral palsy is needed.

CLINICAL RELEVANCE

Custom rigid ankle-foot orthoses combined with footwear may aid the development of independent standing and walking in some children with bilateral spastic cerebral palsy. This intervention may be considered in clinical practice and future research in this patient group.

A conceptual framework for orthotic and prosthetic education

BACKGROUND

Variables that influence orthotic and prosthetic patient outcomes beyond direct care are poorly conceptualized for orthotic and prosthetic students. Restructuring educational curricula around important clinical reasoning variables (i.e. factors that may influence outcomes) could improve teaching, learning, and clinical practice.

OBJECTIVES

To propose an orthotic and prosthetic education framework to enhance the development of orthotic and prosthetic students' clinical reasoning skills.

STUDY DESIGN

Scoping review.

METHODS

We conducted a scoping review, identified variables of orthotic and prosthetic usability, and performed a qualitative thematic analysis through the lens of orthotic and prosthetic clinical educators to develop a conceptual framework for orthotic and prosthetic education.

RESULTS

Sorting of variables identified from the literature resulted in three thematic areas: (1) the state of functioning, disability, and health (International Classification of Functioning, Disability and Health); (2) orthotic and prosthetic technical properties, procedures, and appropriateness; and (3) professional service as part of orthotic and prosthetic interventions. The proposed orthotic and prosthetic education framework includes these three areas situated within the context of patient-centered care.

CONCLUSIONS

A conceptual framework was developed from variables identified in peer-reviewed literature. This orthotic and prosthetic education framework provides a structure to explore orthotic and prosthetic clinical reasoning and advance our teaching and assessment of students' clinical reasoning skills.

CLINICAL RELEVANCE

The proposed orthotic and prosthetic (O&P) education framework is intended to promote conversation about variables (e.g. health condition, procedures, services, and O&P principles) that influence O&P clinical practice outcomes and further advance our teaching and assessment of students' clinical reasoning skills.

Conception, design, and fabrication of novel cost-effective partial-hand prosthetic devices for a quadrilateral individual with limb loss

BACKGROUND AND AIM

The author designed customized upper-limb prosthetic devices for a 22-year-old man with quadrilateral limb loss. The devices were created to meet his functional requirements, while remaining cost-effective. What made this solution unique was that it utilized low-cost items that were easily sourced and maintained.

TECHNIQUE

Devices with polypropylene sockets, wooden positional fingers from an artist's wooden hand and a metal extension plate were conceptualized and manufactured. The patient gave written consent to the publication of information and photographs in this report.

DISCUSSION

The devices allowed the individual to complete tasks he desired to be able to perform independently, which included using a computer mouse, aided by the devices. The devices utilized were low-cost and easily accessible materials, such as polypropylene and wood, to cater to financial constraints. The final design had positional fingers and an extension plate to restore surface area for grip, support, and opposition to enable the execution of daily tasks of living.

CLINICAL RELEVANCE

A cost-effective method of fabricating partial-hand devices with easily accessible materials is described. The resulting devices were successful at restoring the upper-limb surface area for improved grip, support, and opposition for performance of daily tasks.

Compliance with wearing an abduction brace after arthroscopic rotator cuff repair: A prospective, sensor-controlled study

BACKGROUND

Immobilization, using a shoulder abduction brace, may be important after rotator cuff repair to achieve successful tendon-to-bone healing. Compliance with wear time is a concern.

OBJECTIVES

Therefore, the abduction brace wearing time was assessed with temperature-sensitive sensors to objectively measure the abduction brace wearing compliance rate.

STUDY DESIGN

Level of evidence I, prospective observational study.

METHODS

A temperature sensor was implanted into 54 standard shoulder abduction braces, worn by 50 patients (27 women; mean age, 56 years). At 6 weeks post-surgery, patients reported the number of hours they had worn the brace. The patient-reported and sensor data were compared, and the compliance rate (relative to the recommended wearing time) was determined, with compliance being the primary end-point and the discrepancy between the measured and patient-reported wear time being the secondary end-point.

RESULTS

Compliance was ⩾80% in 24 (48%) patients. Sensor-based compliance was lower than self-reported compliance (75% versus 96%, p ⩽ 0.001). Compliance was not predicted by age, sex, smoking, educational, employment, living status, or handedness.

CONCLUSIONS

Roughly 50% of patients did not wear the brace at least 80% of the recommended time. Self-reported compliance is significantly lower than sensor-based compliance. Compliance was not predicted by measured demographic variables.

CLINICAL RELEVANCE

This is the first study in which the abduction brace adherence of patients after rotator cuff repair was assessed by the use of a temperature-sensitive sensor. The postoperative use of these braces is questionable as the patient's abduction brace adherence is low. The self-reported wearing compliance is unreliable.

Effectiveness of stretching and bracing for the treatment of osteoarthritis-associated joint contractures prior to joint replacement: a systematic review protocol

INTRODUCTION

Many patients with osteoarthritis (OA) develop restrictions in passive range of motion (ROM) of their affected joints (called contractures), leading to increased pain and reduced function. Effective treatment to reverse OA-associated contractures is lacking. Our aim is to evaluate the effectiveness of stretching and bracing on native (non-operated) joint contractures in people with radiographically diagnosed OA.

METHODS AND ANALYSIS

We will search the following databases without time restriction: Cochrane Library (CENTRAL, Database of Abstracts of Reviews of Effects, Health Technology Assessment Database), MEDLINE, Embase, CINAHL, SCI-EXPANDED (ISI Web of Knowledge) and PEDro. Other sources will include WHO International Clinical Trials Registry Platform, reference lists of included studies, relevant systematic reviews and textbooks. We will include randomised controlled trials (RCTs), controlled clinical trials, controlled before-and-after studies, cohort studies and case-control studies that include participants ≥18 years of age with radiographic evidence of OA. Participants with inflammatory arthropathies or those that have undergone joint arthroplasty will be excluded. Interventions will include therapist-administered or patient-administered stretching, use of an orthosis (static or dynamic), use of serial casting and/or adjunctive modalities. Outcomes will include joint ROM (active and passive), pain (rest and/or activity related), stiffness, activity limitations, participation restrictions, quality of life and adverse events. Studies will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Study inclusion, data extraction and quality assessment will be performed independently by two reviewers. Risk of bias will be assessed using appropriate tools for each study design. Data synthesis will be performed using Cochrane Review Manager software. If sufficient data are available, meta-analysis will be conducted. We will summarise the quality of evidence using Grading of Recommendations Assessment, and the effect size of interventions for RCT and non-RCT studies.

ETHICS AND DISSEMINATION

Ethics approval not required because individual patient data are not included. Findings will be disseminated in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42019127244.

Effectiveness of Foot Orthoses Versus Corticosteroid Injection for Plantar Heel Pain: The SOOTHE Randomized Clinical Trial

BACKGROUND

Plantar heel pain is a common foot complaint that causes significant disability and poorer health-related quality of life. Foot orthoses and corticosteroid injection are effective treatments for plantar heel pain; however, it is unclear whether one is more effective than the other.

OBJECTIVE

The aim of this trial was to compare the effectiveness of foot orthoses and corticosteroid injection for plantar heel pain.

METHODS

In this parallel-group, assessor-blinded, randomized clinical trial, participants received prefabricated, arch-contouring foot orthoses or a single ultrasound-guided corticosteroid injection. The primary outcome measure was the foot pain subscale of the Foot Health Status Questionnaire at 4 and 12 weeks.

RESULTS

One hundred three participants aged 21 to 72 years (63 female) with plantar heel pain were recruited from the community and received an intervention. For the primary outcome of foot pain, corticosteroid injection was more effective at week 4 (adjusted mean difference, 8.2 points; 95% confidence interval: 0.6, 15.8 points). However, foot orthoses were more effective at week 12 (adjusted mean difference, 8.5 points; 95% confidence interval: 0.2, 16.8 points). Although these findings were statistically significant, the differences between the interventions did not meet the previously calculated minimal important difference value of 12.5 points.

CONCLUSION

Corticosteroid injection is more effective than foot orthoses at week 4, but this effect does not last; and appropriately contoured foot orthoses are more effective than corticosteroid injection at week 12. However, patients may not notice a clinically worthwhile difference between the interventions.

LEVEL OF EVIDENCE

Therapy, level 1b. J Orthop Sports Phys Ther 2019;49(7):491-500. Epub 26 May 2019. doi:10.2519/jospt.2019.8807.

A new unilateral abduction orthosis for Ponseti-treated clubfoot: A cohort study to assess compliance

BACKGROUND

The Ponseti method for treating congenital talipes equinovarus requires an orthosis to maintain correction after manipulation and casting, typically the 'boots and bar'. Non-compliance with the orthosis increases the risk of recurrent deformity. This study investigates a new orthosis, the abduction dorsiflexion mechanism.

OBJECTIVES

The aim of this study is to assess compliance of the abduction dorsiflexion mechanism when used at night and maintenance of foot morphology.

STUDY DESIGN

This study is a cohort study.

METHODS

A total of 10 children with unilateral congenital talipes equinovarus previously treated with Ponseti casting were recruited to trial the abduction dorsiflexion mechanism at night for 12 weeks. Foot morphology and compliance were assessed every 4 weeks.

RESULTS

Participant families were pleased with the orthosis, opting to continue to use the device following conclusion of the trial. Compliance was good and no deterioration in Pirani score or dorsiflexion seen. Abduction improved during the trial. The incidence of skin problems was equivalent to that experienced with the traditional boots and bar that the children had been wearing.

CONCLUSION

Good compliance and parental satisfaction, coupled with no deterioration in foot morphology, abduction or dorsiflexion present the abduction dorsiflexion mechanism boot as a feasible alternative to the traditional boots and bar, particularly in children with unilateral congenital talipes equinovarus.

CLINICAL RELEVANCE

The abduction dorsiflexion mechanism is currently the subject of considerable interest as clinicians look to increase compliance and reduce the recurrence rate in Ponseti-treated congenital talipes equinovarus. The abduction dorsiflexion mechanism boot is a feasible alternative to the traditional boots and bar, particularly in children with unilateral congenital talipes equinovarus.

Manual fabrication of a specialized transparent facial pressure mask: A technical note

BACKGROUND AND AIM

The objective of this study was to describe the manual fabrication of a transparent facial pressure mask for treating facial deformities. The mask combines the use of a silicone inner liner and mechanical pressure in the facial region.

TECHNIQUE

A negative mold is formed by covering the face with plaster. Manipulation of soft tissue is a crucial part in this process. After hardening and removal of the negative mold, the positive mold is formed and dried. Next a rolled silicone sheet is placed over the positive mold in a vacuum environment. Subsequently, the silicones are vulcanized. Then the rigid outside of the mask is created. The silicone inner liner and outside shell are then affixed.

DISCUSSION

This described technique results in accurate facemasks with precise fitting. During therapy, the mask is adjusted multiple times to keep excellent fit, as remodeling of scars and deformities takes place.

CLINICAL RELEVANCE

Facemasks are a reputable therapeutic modality to reduce excessive facial scarring. They require excellent fitting to give pleasing results. To provide a better understanding of facemask therapy, this study describes the manual fabrication technique.

The effectiveness of rearfoot medial wedge intervention on balance for athletes with chronic ankle instability

BACKGROUND

Athletes with chronic ankle instability (CAI) often develop complications such as pain, instability, and reduced postural control and balance stability, all of which affect athletic performance. This study investigated the effects of a 4° medal wedge intervention on static and dynamic balance in athletes with CAI.

METHODS

The participants were 24 healthy and 25 CAI athletes. Participants received a 4° medial wedge applied at the rear foot insole and completed the experiment measurements before and after the wedge intervention. The main outcome measures included the area and path length of the center of pressure when participants performed single-leg standing balance in the closed eye condition and the dynamic balance scores of a multiple single-leg hop stabilization test.

RESULTS

The single-leg standing balance significantly improved in CAI (P = .027) and control groups (P = .005) after the medial wedge intervention. The dynamic balance scores significantly decreased from 53.00 ± 25.22 to 41.24 ± 21 48 (P = .015) in CAI group after medial wedge intervention.

CONCLUSION

Wearing a 4° medial wedge applied at the rear foot insole improved static and dynamic balance immediately in athletes with CAI. We suggest that clinicians may provide the foot insole to improve balance deficit in athletes having CAI.