August 2018 O&P News by AOPA

AUGUST 2 01 8

THE ORTHOTIC & PROSTHETIC COMMUNITY NEWS SOURCE

O&P VISIONARY:

Eileen Levis PG.23

Tech Tips in Vancouver PG.27

THE IMPORTANCE OF

Advantages and Disadvantages of Microprocessor-Controlled Prosthetic Ankles PG18

FOR LIMB LOSS PATIENTS

WWW.AOPANET.ORG

3-D Tech PG.16

WOUND CARE

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Vol. 27 • No. 8 | August 2018

Departments & Columns 25 State by State

A monthly column dedicated to the most important state and local O&P news.

26 Classified Ads 26 Meetings & Courses 27 Tech Tips COVER STORY

04 16

The Importance of Wound Care for Limb Loss Patients Proper rehabilitation for limb loss patients requires health-care professionals to achieve a thorough understanding of the various phases of the wound healing process and proper treatment protocols. It’s also important for patients to become educated on their role in the wound care treatment process.

3-D Tech Experts will discuss the latest advancements and innovations in 3-D printing during the upcoming AOPA National Assembly.

Research & Presentations 18

Take advantage of programming in Vancouver to boost your orthotic and prosthetic technical skills.

Advantages and Disadvantages of Microprocessor-Controlled Prosthetic Ankles

32 Ad Index

2 O&P News Special Announcement AOPA creates online presentation and platform for O&P News

23 O&P Visionary Eileen Levis calls for changes to O&P reimbursement, regulations, funding, and education to ensure a greater focus on the “whole” patient.

By Brian Kaluf, CP, FAAOP, and Cody Smith, CO

O&P News | August 2018

Special Announcement

he American Orthotic and Prosthetic Association (AOPA) continues its stride toward innovation by creating an online presentation and platform for O&P News. With an efficient website and click-ready flipbook, advertisers are more likely to garner viewership and gain exposure in the overall health-care arena. As always, AOPA strives to provide the best resources and value for our members, as we continue to expand the scale of the publication and both the numbers and therapeutic breadth of its readership through this new platform. As of September 2018, O&P News will no longer produce a print edition. We value our readership and acknowledge the demand of ready and quick access to the latest articles. You will have immediate digital access across all device platforms. Digital subscription is easy, just fill out the postcard with your email information featured in O&P News August 2018 issue. Or subscribe at bit.ly/OPNSubscribe. We are excited to expand our reach across all platforms and are thankful for all our readers! Mission:

Educate and inform health professionals who serve the greater limb-loss community and those living with mobility challenges. Distribution:

O&P News targets the extended community of health professionals serving individuals living with mobility challenges and is their connection to relevant news from the world of orthotics and prosthetics. With electronic distribution cresting 20,000 and print subscriptions over 12,000, it is clear that the O&P News audience is interested in receiving the magazine electronically. Therefore, AOPA has decided to begin electronic publication only beginning September 2018. August 2018 will be the last print issue. Each issue will continue to feature clinical insights from top minds in patient care, research summaries, product news, and more. Advertisers:

Advertisers continue to express interest in an integrated advertising approach of print and digital ads. This can now be accomplished through the print platform of O&P Almanac and the digital platform of O&P News. Advertisers will receive the added benefit of reaching a broader audience through advertisements in the magazine flip book as well as banner ads on the website and in the email distribution of the magazine. Get additional punch for your advertising investment through the greatly expanded breadth of readers and accountability of O&P News. Contact Bob Heiman at 856-673-4000 or bob.rhmedia@comcast.net to secure your placement! Donâ&#x20AC;&#x2122;t miss an issue! Subscribe today by returning the postcard included with this issue of O&P News or visit bit.ly/OPNSubscribe. 2

O&P News | August 2018

Editorial Board O&P Practitioners

Randall Alley, CP, BSc, FAAOP

Glenn Hutnick, CPO, CTP, FAAOP

Biodesigns Inc.

Hutnick Rehab Support Services Inc.

Kevin Carroll, MS, CP, FAAOP

Greg Mattson, CTPO

Hanger Clinic

Glenn Garrison, CPO

Hospital for Special Surgery

JoAnne Kanas, PT, CPO, DPT

Pediatric Orthotic and Prosthetic Services, LLC, Shriners International Headquarters

Thomas P. Karolewski, CP, FAAOP Hines VA Hospital

Fabtech Systems LLC

Scott Wimberley

Fabtech Systems LLC

O&P Industry

Michael Angelico

Advanced O&P Solutions

Debbie Ayres

Joel J. Kempfer, CP, FAAOP Kempfer P&O

American Board for Certification in Orthotics, Prosthetics, and Pedorthics Inc.

Robert S. Lin, MEd, CPO, FAAOP

Jeffrey M. Brandt, CPO

Hanger Clinic

Jonathan Naft, CPO

Geauga Rehabilitation Engineering

Ability Prosthetics & Orthotics Inc.

Sue Borondy Endolite

Matthew Parente, MS, PT, CPO

Jennifer Fayter

University of Hartford

Nabtesco & Proteor in USA

Justina S. Shipley CO, MEd, BOCP, FAAOP

Russell Hornfisher

Shriners Hospital For Children

Eric Shoemaker, MS, CPO

Orthotic Holdings Inc.

Jeffry G. Kingsley

Kingsley Manufacturing

Ability Prosthetics & Orthotics Inc.

Karen Lundquist

Rhonda F. Turner, PhD, JD, (BOCPO, CFm)

Brad Mattear, LO, CPA, CFo

American Association of Breast Care Professionals

O&P Researchers and Educators

Steven A. Gard, PhD

Northwestern University Prosthetics-Orthotics Center

Mark D. Geil, PhD

Georgia State University

Mark Pitkin, PhD, DSc

Tufts University School of Medicine

Amputee Coalition Nabtesco & Proteor in USA

Matt Perkins

Coyote Design and Rehab Systems

Don Pierson, CO, CPed Arizona AFO

Brooke Raasch

Ă&#x2013;ssur Americas Inc.

Jon Shreter, CPO

Prosthetic and Orthotic Management Associates Corporation

Michael Sotak

O&P Technicians

PEL

Sarah Clark

Scott Viglianti

O&P 1

WBC Industries

Tony Culver

Lisa Watkins

Grace Prosthetic Fabrication Inc.

WillowWood

Steve Hill, CO, BOCO

MBA, CAE, Board of Certification/Accreditation

Delphi Ortho

Claudia Zacharias

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COVER STORY

The Importance of

WOUND CARE

FOR LIMB LOSS PATIENTS Knowledge of proper treatment of wounds is essential for both health-care professionals and O&P patients

ndividuals who experience limb loss must undergo several stages of wound healing. During the process, these patients face the risk of their wounds worsening or becoming infected, which can lead to pain, fever, swelling, additional surgeries, and other complications. To ensure a more successful recovery and rehabilitation period, it’s important for both the health-care professionals assisting new amputees and the patients themselves to understand proper wound care techniques. In the first part of this article, Nancy Payne, MSN, RN, CWCN, shares the most important aspects of wound care for limb loss patients. According to Payne, her roles as limb loss clinical nurse specialist and certified wound care nurse at Duke University Hospital go hand in hand. Her specialized training in wound care allows her to adequately

O&P News | August 2018

address the issues she sees in her patients, train amputees and their caregivers on appropriate wound care protocols, and train other members of the health-care team to appropriately assess wound care needs in a timely manner. The hope is that this combination of clinical application and patient/health team education will increase patient compliance and successful healing, while reducing the likelihood of the need for return hospital visits due to infections. “Not all members of a patient’s health-care team are adequately trained to treat wounds or are connected to wound care professions, but all should take responsibility for assessing the need for appropriate wound care,” says Payne. The second part of this article focuses on the patient’s role in wound care, sourced from the Amputee Coalition’s First Step program.

COVER STORY

The Role of Health-Care Professionals in Wound Care

Figure 1

WOUND HEALING Hemostasis

By Nancy Payne, MSN, RN, CWCN

Hours

There are five “degrees” of wounds (see Table 1). The body can usually heal an acute wound in four major phases: hemostasis, inflammation, proliferation, and Nancy Payne, RN, remodeling (see Figure 1). MSN, CWCN The mechanics of the healing process are granulation tissue formation, contraction, and epithelialization.1 • Hemostasis is the process of the wound being closed by clotting. The first step of hemostasis is when blood vessels constrict to restrict the blood flow. Platelets stick together in order to seal the break in the wall of the blood vessel and coagulation occurs, which reinforces the platelet plug with threads of fibrin, which are like a molecular binding agent. • Inflammation is the second stage of wound healing and begins right after the injury when the injured blood vessels leak transudate (made of water, salt, and protein), causing localized swelling. Inflammation both controls bleeding and prevents infection. The fluid engorgement allows healing. During the inflammatory phase, damaged cells, pathogens, and bacteria are removed from the wound area. These white blood cells, growth factors, nutrients, and enzymes create the swelling, heat, pain, and redness commonly seen during this stage of wound healing. Inflammation is a natural part of the wound healing process and only problematic if prolonged or excessive.

Days

Weeks to Months

Table 1

DEGREES OF WOUNDS 1. PRIMARY— Heals without open areas, infection, or wound complications. 2. SECONDARY— Small open areas that can be managed, and ultimately heal with dressing strategies and wound care. 3. REQUIRES MINOR SURGICAL REVISION—Skin and subcutaneous tissue (no muscle, no bone involved). 4. REQUIRES MAJOR SURGICAL REVISION—Involves muscle or bone, but heals at initial amputation “level.” 5. REQUIRES REVISION TO A HIGHER AMPUTATION LEVEL— For example, a transtibial amputation that must be revised to either a knee disarticulation or a transfemoral amputation.

O&P News | August 2018

COVER STORY

in wound tensile strength. Malnutrition has been linked to increased rates of infections in patients.4 Planktonic bacterial growth also can cause significant delays in wound healing but can usually be eliminated by white blood cell activity or antibiotic therapy. Bacteria biofilm, on the other hand, is a major barrier to wound healing. It is complex, adherent, and protected against white blood cells, antimicrobial agents, and systemic antibiotics, preventing host defenses from clearing the infection.

â&#x20AC;˘ The proliferative phase of wound healing is when the wound is rebuilt with new tissue. In the proliferative phase, the wound contracts as new tissues are built. In addition, a new network of blood vessels must be constructed so that the granulation tissue can be healthy and receive sufficient oxygen and nutrients. â&#x20AC;˘ The remodeling stage of wound healing is when the wound fully closes. The cells that had been used to repair the wound are no longer needed and are removed by apoptosis, or programmed cell death. Generally, remodeling begins about 21 days after an injury and can continue for a year or more. As a note, healed wound areas continue to be weaker than uninjured skin, generally only having 80 percent of the tensile strength of unwounded skin.2

Delays in Wound Healing There are several common causes for delays in wound healing. One of the most common is restriction in blood supply to tissues, ischemia, which causes a shortage of oxygen that is needed to keep the tissue alive. Individuals that have just received an amputation also are at risk of re-injury due to falls or bumping of the residual limb. The use of steroids, specifically

O&P News | August 2018

corticosteroids, can cause rupture of surgical incisions, increasing the risk of wound infection and delaying healing of open wounds. They produce these effects by interfering with inflammation, fibroblast proliferation, collagen synthesis and degradation, deposition of connective tissue ground substances, angiogenesis, wound contraction, and re-epithelialization.3 Malnutrition also is a determining factor in a patientâ&#x20AC;&#x2122;s ability to heal postamputation. Nutrition deficiencies impede the normal processes that allow progression through stages of wound healing. Malnutrition also can cause a decrease

Converting Chronic Wounds Into Acute Wounds An estimated 67 million individuals worldwide suffer from chronic wounds, also known as long-term lesions. Limb loss patients are at an increased risk for the most common types of wounds, including pressure ulcers, venous wounds, arterial wounds, and lesions associated with diabetes.5 Acute wounds are defined as disruptions in the integrity of the skin and underlying tissues that heal uneventfully with time. These lesions go through stages of healing in a timely manner and generally have minimal to no complications. Complete healing is likely within four weeks.

COVER STORY

Chronic wounds, however, fail to complete the cycle of healing within two to four weeks despite interventions. This can be due to patient comorbidities or the characteristics of the wound itself. Healing will plateau, causing a chronic wound to remain in a state of inflammation. Chronic wounds can have persistent or recurrent infection and develop drug-resistant biofilms. Because fibroblast, endothelial cells, and keratinocytes are unable to produce new vessels, long-term wound care is needed. Chronic wounds can sometimes necessitate a revision surgery, which can include revision to a higher level of amputation. The most common method used to convert a chronic wound into an acute wound is the use of sharp, surgical debridement, which induces acute tissue injury bleeding and results in hemostasis, activating regulatory processes that normally control repair and encouraging

the progression of healing. Another method used to convert chronic wounds to acute wounds is the use of ultrasonic wound care, in which a low-frequency ultrasound (20-40 KHz) is transmitted through a saline medium. Mechanism of action is production, vibration, and movement of micron-sized bubbles in the saline and wound tissue. This method increases wound perfusion, allows for debridement of necrotic tissue and bacterial effect, and disrupts biofilm and reduces wound pain.

References 1. Doughty DB, Moore KN. Wound, Ostomy, and Continence Nurses Society Core Curriculum. 2016; Philadelphia: Wolters Kluwer. 2. The Four Stages of Wound Healing. March 17, 2017. Retrieved July 10, 2018, from https://www.woundsource. com/blog/four-stages-wound-healing

3. Anstead GM. Steroids, Retinoids, and Wound Healing. October 1998. Retrieved July 10, 2018, from https://www.ncbi.nlm.nih.gov/ pubmed/10326344 4. Stechmiller JK. Understanding the Role of Nutrition and Wound Healing. Feb. 3, 2010. Retrieved July 10, 2018, from https://onlinelibrary.wiley.com/doi/ full/10.1177/0884533609358997 5. Mercandetti M. Wound Healing and Repair: Overview, Types of Wound Healing, Categories of Wound Healing. Retrieved July 10, 2018, from https://emedicine.medscape.com/ article/1298129-overview

Bibliography Dabiri G, Damstetter E, Phillips T. Choosing a Wound Dressing Based on Common Wound Characteristics. Jan. 1, 2016. Retrieved July 10, 2018, from https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC4717498/#B5

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O&P News | August 2018

COVER STORY

The Patient’s Role in Wound Care The following information was sourced from the Amputee Coalition’s First Step and can be requested in pamphlet form by calling 888/267-5669 or in the Amputee Coalition store at www.amputeecoalition.org/amputee-coalition-store/. With thousands of questions posed to the Amputee Coalition every year, one of the most common topics is wound care, according to Karen Lundquist, chief communications officer, Amputee Coalition. “It’s a serious topic, and one that merits close attention by people with limb difference and limb loss in partnership with their clinicians and caregivers,” she says. “With vascular conditions leading the causes of amputation, it is especially critical to begin with the basics: Check your feet regularly.” Depending on the reason for a patient’s amputation, and the state of the limb at the time of surgery, definitive closure of the wound may take

O&P News | August 2018

place immediately or it may be delayed. Wound care involves multiple phases. The Amputee Coalition has provided the following information to be shared with patients regarding the importance of wound care and the patient’s role in managing their surgical wounds and the skin of their residual limbs.

Care of Your Wounds After Amputation Surgery

Postamputation: Two Phases of Recovery Phase 1: The first phase of recovery is preclosure of the residual limb. The goal of wound management during this phase is to promote healing of the underlying soft tissue and to treat or reduce the risk of infections. In some instances, a drainage tube is inserted to remove fluids and aid in tissue repair. A member of the surgical team will do the dressing changes. The following information should be shared with patients regarding their role in wound management during this first phase: 1. Notify your nurse if your dressing becomes soiled or you notice any leakage of drainage.

2. Wash your hands if you come in contact with drainage. Hand soap and hand sanitizers are available in your room. 3. Make sure everyone who comes in contact with your wound wears gloves and washes his or her hands before and after a dressing change. 4. In some instances, visitors may need to take special precautions to reduce the likelihood of transmitting an infection to others. In such cases, the nurses will review with you any special precautions for visitors. We are counting on you to see that these precautions are followed. 5. Exercise caution when moving in bed or getting in and out of bed so that you do not dislodge any dressings or drainage tubes. Notify the nursing staff if dressings become loose or dislodged. 6. Eat a healthy, well-balanced diet of foods rich in nutrients and vitamins. Tissues cannot heal if they are not provided with the necessary nutrition. Dietary supplements are often provided in addition to your meals to ensure that sufficient calories and protein are available to facilitate the healing process. 7. Inform members of your rehabilitation team if you experience pain during the care of your wound. By working together, you and your rehab team can establish a medication schedule that will minimize your discomfort during dressing changes.

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Injuries that lead to amputation also may result in skeletal injuries to remaining limbs. As a result, patients may have skeletal pins and/or an external fixator device applied to maintain bone alignment and promote healing of fractures. Patients who have one of these devices may want to take the following steps in caring for the device and their skin: 1. Wash your hands with soap and water. 2. Mix small amounts of sterile normal saline and hydrogen peroxide in a sterile container. 3. Saturate a sterile cotton swab applicator in the solution. 4. Using a circular, rolling motion of the cotton swab, cleanse the pin sites from the insertion site outward. 5. Avoid going over previously cleaned areas with a used swab. 6. Gently push down on the skin with the swab to prevent skin from adhering to the pin. 7. Leave the pin sites open to the air unless drainage is present. If drainage is present, pin sites can be covered with sterile gauze. 8. Notify a member of the rehabilitation team if you notice swelling, redness, pain, tenderness, or a change in drainage from any of your pin sites. Phase 2: The second phase of recovery is definitive closure of the residual limb. The goal of wound management during this phase is to prepare the residual limb for prosthetic fitting. Initially, the patient will have sutures in place to close his or her surgical wound. These are usually removed in approximately 14 to 21 days. The sutures will be covered with petroleum-impregnated gauze, and initially, bulky gauze dressings will be applied to provide additional protection. These dressings are typically changed twice daily, or more frequently if necessary. Once the sutures are removed, adhesive strips are applied as the final stage of wound closure takes place. These strips will fall off naturally in about five to seven days.

10 O&P News | August 2018

3. Never stick objects inside the cast to scratch your skin. If itching persists, let your nurse know so other measures can be taken.   4. Notify a member of your rehabilitation team if you feel increased pain or numbness that may be caused by swelling or a cast that is too tight.

Throughout this stage of the wound healing process, compression dressings also will be applied to reduce swelling and begin shaping the residual limb for prosthetic fitting. There are two types of compression dressings: rigid and soft. Rigid compression dressings are made from casting material and will be changed as the swelling in the residual limb decreases. Soft compression dressings are initially elastic bandages applied in a specific way to reduce the swelling at the lower portion of the residual limb. These bandages will need to be reapplied several times during the day to maintain proper compression. Members of the rehabilitation team will instruct patients in the proper application of these bandages. The patient’s role in wound management now includes all of the previously listed items, plus these additional responsibilities for rigid or soft dressings:

Rigid Compression Dressing 1. Keep the cast dry. Getting the cast material wet can weaken the cast, and damp padding can irritate the skin.   2. Avoid getting dirt or powder inside the cast.

Elastic Bandage Compression Dressing 1. Do not pull at your sutures, even if the skin around the sutures itches. 2. Notify a member of your rehabilitation team if you notice any tearing or separation of the sutures. 3. Notify a member of the rehabilitation team if you notice that the skin around the sutures is red or swollen or if you notice any pus draining from the suture area. 4. Rewrap your residual limb several times during the day (usually at least four or five times) to maintain proper compression. This not only reduces the swelling and increases circulation and healing, but also reduces pain. 5. Obtain new elastic bandages if the ones you are using become soiled or lose elasticity.   Directions for Wrapping With an Elastic Bandage Below-Knee, Below-Elbow, and Above-Elbow Amputations

1. Using a four-inch-wide elastic bandage, go over the end of the limb, slightly stretching the bandage.  2. Relax the stretch and secure the bandage by going around the limb once.   3. Increase the stretch and go to one side of the center.   4. Decreasing the stretch, go around back. Go up the other side of the center as you increase the stretch again.  5. Repeat this figure-eight pattern until the end is securely bandaged, and then secure the bandage with Velcro or tape. (Do not secure bandages with pins.)

COVER STORY

6. If the length below the knee or elbow is very short, you will need to make a similar figure-eight pattern above and below the joint and then secure the bandage.   Above-Knee Amputations

1. Use two six-inch-wide elastic bandages. (Bandages can be sewn together.) 2. Wrap around the waist twice.   3. Wrap around the end of the limb.   4. Wrap back around the waist.   5. Wrap around the end of the limb.   6. Wrap around the waist and secure. (This is the anchor for the next bandage.)   7. Take another six-inch-wide elastic bandage and, similar to the technique used for below-knee amputations, go over the end of the limb, slightly stretching the bandage.   8. Relax the stretch and secure the bandage by going around the limb

once, then increase the stretch and go to one side of the center.   9. Decreasing the stretch, go around back, and then go up the other side of the center as you increase the stretch again. Repeat this figure-eight pattern until the end is securely bandaged, making sure to bandage all of the way up into the groin area. Secure the bandage with Velcro or tape. (Do not secure bandages with pins.) Remember: For best results, you must reapply the elastic bandages whenever they loosen.

Wearing an Elastic Shrinker Sock Using an elastic shrinker sock is another way to reduce swelling. These shrinker socks can be used alone or in combination with elastic bandages. If the limb is still very sensitive, it will be more comfortable to stretch the

shrinker as it is being put on, either by using two pairs of hands or an appropriate-size ring made of a stiff material such as PVC.

Using Hands 1. With two people using all four of their hands (two can be the patient’s), put all of the fingers down to the bottom of the shrinker, thumbs on the outside, spare material scrunched down, and stretch out until the bottom of the shrinker is completely flat and stretched out.   2. Place the flat, inside part of the shrinker against the end of the amputated limb.   3. In one swift motion, keeping the stretch and letting the material slide from between the thumb and fingers, pull the shrinker up the limb.   4. There should be no gap between the end of the residual limb and the shrinker.

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COVER STORY

progress to a rougher material such as a paper towel.   4. Finally, advance to a terry cloth towel.  5. This technique should be done until you can tolerate gentle friction from a terry cloth.   Scar Mobilization

5. If this is for an above-knee amputee, make sure the long side is around the hip and the short side is all of the way into the groin.

Using a Ring 1. Make sure the chosen ring will slide easily all of the way to where the shrinker will end on the limb. 2. Stretch the shrinker over the ring until the end is flat. 3. Place the flat, inside part of the shrinker over the end of the limb and feed the shrinker up the limb until it is as high as needed.   4. Remove the ring. Preparing for Prosthetic Training and Desensitizing the Residual Limb At this point in the rehabilitation process, there are four techniques that can be used to prepare the residual limb for prosthetic training: massage, tapping, desensitization, and scar mobilization. Early massage and tapping of the residual limb will help the patient develop a tolerance in the residual limb to both touch and pressure. Both of these techniques can be performed through soft compression dressings and when the soft compression dressing is off. Additionally, these techniques may help decrease sensation of phantom pain. Massage

1. Using one or two hands, massage your residual limb using a soft, gentle kneading motion. Initially, be especially cautious when massaging over your sutured area.   2. Massage the entire residual limb.   3. Over time and once your sutures are

12 O&P News | August 2018

removed, you can increase the pressure to massage the deeper soft tissues and muscles in your residual limb.   4. This should be done for at least five minutes, three or four times daily. It can be done more often if it is found to be helpful in reducing phantom pain.   Tapping

1. Tap your residual limb with your fingertips, being careful not to tap with your fingernails. Gentle tapping over the suture line is generally allowed even before your sutures are removed.   2. Over time and once your sutures are removed, you can increase to a slapping motion, using one or two hands.   3. Tapping should be done for one to two minutes, three or four times daily. It can be done more often if it is found to be helpful in reducing phantom pain. Desensitization

Desensitization is the process of making the residual limb less sensitive. If a patient starts with a soft material and progresses to rougher materials, desensitization can help increase tolerance to touch in the residual limb. 1. This technique is done when you are not wearing your soft compression dressing. It should be done for two to three minutes twice daily and is usually done during bathing times.   2. Initially, start with a cotton ball and gently rub the skin of your residual limb, using a circular motion.   3. When you are able to tolerate it,

This technique is done to keep the skin and scar tissue on the residual limb loose. Scar adherence to underlying tissue can be a source of pain when using a prosthesis and also may cause blistering. It is best performed when the patient is not wearing compression dressing. 1. Place two fingers over a bony portion of your residual limb.   2. Press firmly and, keeping your fingertips in the same place on the skin, move your fingers in a circular fashion across the bone for about one minute. Continue this procedure on all of the skin and underlying tissue around the bone of your residual limb.   3. Once your incision is healed, use this procedure over your scar, moving your fingers in a circular fashion to loosen the scar tissue directly.   4. This technique should be done daily when you bathe.

Inspection of Your Residual Limb 1. Regular inspection of your residual limb, using a long-handled mirror, will help you identify skin problems early.   2. Initially, inspections should be done whenever you change your compression dressing. Later on, most amputees find daily inspection sufficient for the early identification of skin problems. 3. Inspect all areas of your residual limb. Remember to inspect the back and all skin creases and bony areas. 4. Report any unusual skin problems to a member of your rehabilitation team.

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brace has allowed me to enjoy â&#x20AC;&#x153;my simple pleasures again, like taking

patients to O&P providers in their area. Get educated and certified as a Reaktiv Bracing provider - delivering the braces

the dog for a walk with my wifeâ&#x20AC;?

patients are searching and asking for.

Daniel Kirk

End the pain.

Team Australia F44 Para Discus Athlete, Sport Scientist & Community Advocate

end the pain M o d U l a R

d e s i G n

a d a P t s

t o

Y o U R

P a t i e n t

transforming the business of bracing booth 634 The 2018 National Assembly September 26-29 2018 Vancouver BC, Canada

w o R k s h o P,

l e a n M a n U f a c t U R i n G a n d d Y n a M i c b R a c e P R e s e n tat i o n s

Workshop: Date: Wednesday, September 26, 2018 Time: 1:00 - 3:00 PM (2 hours ) Room: 216 (Confirm with program)

Technical Presentation 1 Date: Thursday, September 27, 2018 Time: 10:00 - 11:00 AM Room: (Confirm with program)

A Modular Approach to Dynamic Bracing (MWD-2)

A Modular Approach to Dynamic Bracing (T1)

The course will detail the philosophy and

This session will provide you

methods behind Reaktiv “built with PDE”

with an understanding of

carbon bracing with the following highlights:

dynamic bracing and design

• Evaluation method for new patients

principles, as well as an

• Casting demonstration

overview of casting, modification

• Modification/Fabrication overview

and the fabrication process.

• Patient fitting and alignment

Technical Presentation 2 Date: Thursday, September 27, 2018 Time: 4:00 - 5:00 PM Room: (Confirm with program)

“Finding Your Way” Developing and Utilizing Standards In The Fabrication Setting (T6) Learn about a Lean approach to process control. Attendees will receive the following information through powerpoint presentation & hand out materials: Value, Benefits, Processes for Developing Standards and Visual

• Q/A with clinicians currently

examples specific to O&P.

using the system • Reaktiv Open Network Provider™ overview and requirements

3-DTech THE LATEST INNOVATIONS IN

3-D PRINTING WILL BE EXPLORED

AT THE AOPA NATIONAL ASSEMBLY

re you looking for an opportunity to learn the ins and outs of 3-D printing? Then you won’t want to miss the full-day program, “Getting Your Feet Wet With O&P 3-D Printing,” to be held in conjunction with the 2018 AOPA National Assembly. This program is geared specifically toward technicians and fabricating practitioners. This full day of sessions is designed to give participants the background needed to go from scan to printed device. The day will start with the session, “How Can 3-D Printing Not Be Disruptive?” with Jeff Erenstone, CPO. Erenstone is founder and chief executive officer of Create O&P as well as the head clinician for Mountain Orthotic and Prosthetic Services. He has built a practice that specializes in custom and small production designs for adaptive athletes. In 2015, Create O&P started fabricating prosthetic components out of flexible 3-D-printed materials, and in 2016 expanded into selling complete

16 O&P News | August 2018

systems for prosthetic practitioners to fabricate 3-D-printed devices in their offices. His presentation will provide a summary of adaptive manufacturing technologies and examples of how 3-D printing and CAD can be used in efficient workflows. The second morning session, “Design of Upper-Limb Prostheses Using 3-D Printing and Scanning Technologies,” will be presented by Nikolai Dechev, PhD, an associate professor of mechanical engineering at the University of Victoria and director of the Biomedical Engineering Program, as well as executive director of the Victoria Hand Project, a nonprofit organization dedicated to providing hand prostheses to amputees in need in developing countries. This session will offer the design details, workflow information, and usage reports related to the Victoria Hand, a full-function 3-D-printed upper-limb prosthesis designed to be printed and fabricated on site within resource-poor countries. Dechev’s research program involves biomedical system design, with applications in advanced upper-limb prostheses and biosensors, which includes 3-D printing of affordable hand prostheses, implantable sensor design for acquisition of electromyographic biosignals, ultrasound imaging of wrist tendons for

prosthesis control, and wireless power transfer technology for implantable sensors. These projects aim at developing better methods for the control of advanced upper-limb prostheses. At mid-day, program participants will have a chance to visit the 100,000-square-foot Exhibit Hall and meet with 3-D printing manufacturers to touch, feel, and use their printers. Lunch will be provided to all fullconference participants between noon and 1:30 p.m. The afternoon program will reconvene with the session, “Realistic Implementation of CAD and Adaptive Manufacturing Techniques for the Individual O&P Practitioner,” presented by Mike Nunnery, CPO. Nunnery will provide an overview of the misconceptions, pitfalls, and misunderstanding of a practitioner’s experience, as well as an explanation regarding how digital scanning and adaptive manufacturing can be utilized in a small O&P practice to provide unique devices for individuals unable to obtain them from conventional design and fabrication techniques. Nunnery, who is owner of a small O&P facility in Rhode Island, has been involved in numerous research projects with the University of Rhode Island and Providence U.S. Department of Veterans

Affairs Medical Center as well as other private entities. He has been an advocate for the use of 3-D CAD tools and technologies in O&P for more than 15 years. He also is a builder-in-residence at the AutoDesk Tech Center in Boston, working with the Hand Made Build Team seeking to design unique and innovative prosthetic devices using all forms of digital design and fabrication techniques. The afternoon will continue with a “Scanning and CAD Software Roundtable,” where participants will hear from representatives from O&P CAD and scanning software companies on a wide range of topics. Confirmed participants will represent technology from the following companies: Create O&P, Standard Cyborg, WillowWood, Vorum, Techmed, Provel, Rodin 4D, BioSculptor, and Prosfit. Additional Friday afternoon programming will include the session, “The Effect of Material Choice and Process Parameters on the Mechanical Strength of 3-D-Printed Transtibial Prosthetics,” by Shadi Sabeti. This research presents the results from a pilot study in which seven 3-D-printed sockets, using a range of materials and printing methods, were tested for static strength using ISO 10328. Initial results showed that some materials and print methods met the standard while others did not. The day will conclude with a panel discussion titled, “Where the Virtual Rubber Meets the Real Road: A Basic Understanding of CAM Software and Running a 3-D Printer.” The discussion will include a hands-on demonstration on how to 3-D print a positive model. Panel participants include Steve Hill CO, BOCO; Jeff Erenstone CPO; and Mike Nunnery, CPO. For more information on the technical program track to be presented in conjunction with the 2018 AOPA National Assembly, visit www.AOPAAssembly.org or contact AOPA Headquarters at assembly@AOPAnet.org.

O&P News | August 2018

Research & Presentations

Advantages and Disadvantages of Microprocessor-Controlled Prosthetic Ankles By Brian Kaluf, CP, FAAOP, and Cody Smith, CO

ne component that is a common denominator for all lower-limb prosthesis users is the ankle-foot component, which interacts with the ground-reaction force and affects the fit and function of the rest of the prosthesis. To replicate the function of the normal human ankle, prosthetic ankle-foot designs have been developed throughout the years to provide articulation in the sagittal plane and allow more natural, efficient, and stable gait for persons with lower-limb loss. Prosthetists and patients have access to a large variety of prosthetic anklefoot components; however, they must select one component that is indicated for most of the patientâ&#x20AC;&#x2122;s functional needs. This often involves a compromise between two competing characteristics, such as flexibility and stability. The vast majority of available ankle-foot components are passive mechanisms with fixed ankles, such as energy-storing and -returning (ESAR) feet. ESAR feet are extensions of the solid-ankle cushion heel (SACH) foot design, originally developed to provide shock absorption, tibial progression, and support in late stance, but without the noise and durability issues of previous single-axis ankles. Limitations of SACH, single-axis, and ESAR designs

18 O&P News | August 2018

have been described1 with recommendations to develop feet that allow foot flat earlier in the gait cycle to reduce heel-only loading while simultaneously preserving limb stability and allowing tibial progression. ESAR feet can store energy more efficiently compared to SACH feet, but fixed-ankle ankle-foot components cannot adapt with changes in terrain. Hydraulic ankles do realign to changes in terrain through a viscoelastic response. However, the hydraulic resistance settings remain constant throughout the ankle range of motion and do not adapt with variations in terrain or walking speed. Certified prosthetists understand limitations of passive ankle-foot systems and balance trade-offs as they make recommendations to patients regarding the one component that supports the most desired activities and causes the fewest adverse reactions. In reality, no passive ankle-foot component can replicate all of the functions of the human foot. For this reason, there has been much recent development in adaptable ankle-foot technology.

Microprocessor-Controlled Prosthetic Ankles Microprocessor-controlled prosthetic ankles (MPAs) provide distinct

Research & Presentations

adaptation for subsequent steps. The first commercial release of an MPA component was the Proprio Foot (Össur, Reykjavik, Iceland) in 2006. Comparatively, microprocessorcontrolled prosthetic knee (MPK) technology has been available for persons with transfemoral amputation much longer, with widespread adoption following the commercial release of the C-Leg MPK (Ottobock, Duderstadt, Germany) in 1997. Currently, MPKs are available from seven different manufacturers, and evidence of patient benefits from MPK technology has been appraised in recent systematic literature reviews.2,3 Since the initial release of the first MPA, more components have become available, with each system having

functional differences compared to passive ankle-foot mechanisms commonly used today. MPAs employ two distinct strategies to control ankle articulation. The first strategy adapts the ankle angle to match the slope of the terrain during swing phase but maintains a solid ankle during stance phase. With this approach, several steps are required to recognize the slope and adapt the ankle for subsequent steps (inter-step ankle adaptation). The second strategy approaches ankle articulation through a hydraulic cylinder during stance phase and adapts to a slope on each step-through (within-step ankle adaptation). Some MPAs provide withinstep hydraulic ankle adaptation and inter-step terrain recognition with ankle

Table 1: Microprocessor

different functions and specifications. Currently available MPA components include Elan (Elan, Chas. A. Blatchford & Sons Ltd., Basingstoke, United Kingdom), Kinnex (Freedom Innovations, Irvine, California, United States), Meridium and Triton smart ankle (Ottobock, Duderstadt, Germany), Proprio (Össur, Reykjavik, Iceland), and Raize (Fillauer, Chattanooga, Tennessee, United States). Component specifications are detailed in Table 1, including foot size range, body weight limit, build height, component weight, battery life, ankle range of motion (ROM), waterproof characteristics, within-step versus inter-step accommodation, heel height adjustability, smartphone versus button control, and warranty length.

Ankle Component Specifications

Kinnex

Elan

Proprio

Triton Smart Ankle

Meridium

Raize

Freedom Innovations

Blatchford

Össur

Ottobock

Fillauer

Foot Size Range (cm)

24-30

22-30

24-30

24-29

24-30

Body Weight Limit (kg)

125

100

Build Height (mm)

184

175

159

150

175

1,488

1,200

1,424

1,470

1,500

749

Battery Life (hrs)

24-48

Ankle ROM (deg)

36.5

Waterproofing

IP67 submersible

Water resistant

N/A

IP54 splash

Splash

Within-Step Versus InterStep Ankle Accommodation

Within-step

Both

Inter-step

Within-step

Heel Height Adjustability (in)

Unspecified

Both

N/A

Button

Both

Microprocessor Ankle Manufacturer

Component Weight (g)

Smart Phone App vs Button Control Warranty (months)

O&P News | August 2018

Research & Presentations

MPA Research Evidence To date, no systematic review of literature regarding MPA technology has been completed, although more than 13 publications on the topic exist. Research publications regarding MPA technology consist of laboratory kinematic and kinetic analyses, inter-socket pressure measurement, energetic evaluation, patient-reported outcome measures, and performance-based outcome measures. Agrawal et al. compared the symmetry in external work (SEW) over level ground and found improved SEW with the MPA (Proprio Foot) over some feet, but not when compared to an ESAR foot. 4 Alimusaj et al. investigated gait during stair ascent and descent and found an improvement in knee kinetics and kinematics with the MPA (Proprio Foot) set in a 4-degree dorsiflexed position.5 Wolf et al. compared residual limb socket pressure and performed gait kinematic and kinetic analysis on level ground, slopes, and stairs.6 This study found that with the adaptive mode, the MPA (Proprio Foot) could accommodate the slope and reduce socket pressures to be comparable with level ground walking. Fradet et al. performed gait kinematic and kinetic analysis during ramp ascent and descent and found that the MPA (Proprio Foot) adaptive mode helped reduce the prosthetic side knee extension moment during ramp ascent, but it caused gait adaptations during ramp descent despite the patients reporting â&#x20AC;&#x153;feeling safer.â&#x20AC;?7 Gailey et al. compared the patient-reported and performancebased outcome measures and found no significant differences between three fixed-ankle prosthetic feet and one MPA (Proprio Foot).8 Agrawal et al. compared SEW while walking on stairs and found an improvement in SEW on stairs with the MPA (Proprio Foot) over some feet, but not when compared to an ESAR foot.9 Delussu et al. compared the functional mobility, self-reported mobility, and energy cost of walking (ECW) over

20 O&P News | August 2018

level ground and on a treadmill set at three slopes (-5 degrees, 0 degrees, and 12 degrees).10 This study found a significant improvement in ECW over level ground using the MPA (Proprio Foot) after a 90-day accommodation period. Darter et al. compared metabolic energy expenditure and ECW while walking on a treadmill set at three slopes (-5 degrees, 0 degrees, and 5 degrees).11

To date, no systematic review of literature regarding MPA technology has been completed, although more than 13 publications on the topic exist.

The authors only found significant decreases in energy expenditure or ECW on ramp descent with the MPA (Proprio Foot) regardless if the MPA adaptive mode was turned on or off. Rosenblatt et al. compared minimum toe clearance (MTC) and found a significant increase with the MPA (Proprio Foot) on level surface and on an incline, although the results could be attributed to increased hip flexion instead of MPA function alone. Agrawal et al. compared SEW while walking on level ground with four prosthetic ankle-foot systems but did not find the MPA (Proprio Foot) to increase SEW.12 Agrawal et al. later compared SEW while walking on a ramp with

the same prosthetic feet.13 The authors only found a significant difference in the Medicare Functional Classification System (MFCL) K-2 subgroup on ramp descent, with both ESAR and MPA (Proprio Foot) providing greater SEW than the other prosthetic feet. Struchkov et al. performed kinematic and kinetic gait analysis during ramp descent, which showed the MPA (Elan) performed more negative work, arrived at foot flat quicker, slowed the rotational velocity of the tibia, and allowed less negative work done by the residual knee.14 Ko et al. performed kinematic and kinetic gait analysis and found differences in joint moments, power, and stiffness in most joints in both legs and braking impulse over level ground with prosthetic feet with articulating ankles (Proprio Foot, Elan, Echelon).15 This body of evidence highlights benefits from MPA technology, but research with other MPA components and larger sample sizes is needed. Most of these investigations compared an MPA component (Proprio Foot) that only provides inter-step accommodation to terrain during swing phase. More studies of MPAs that employ a withinstep accommodation strategy or both strategies are needed. The largest sample size included in these studies was 16 participants,5 while most of the studies enrolled 10 or less. The limited sample size and the multiple comparisons made with most kinematic and kinetic gait analyses greatly reduce the statistical power of these studies. Recent efforts to investigate more recently developed MPA components (Kinnex) 16 have enrolled larger sample sizes.

Advantages of MPAs MPAs provide advantages that can be experienced during level ground walking, while the greatest benefits are experienced on uneven and sloped terrain. Over level ground, MPAs aim to mimic the three rockers of stance phase, which require rapid foot flat while

Research & Presentations

simultaneously maintaining stability for weight acceptance.1 Following foot flat, MPAs provide a true articulation about the ankle and tibial progression through the second rocker of stance phase. The resistance can be controlled by the microprocessor to adapt ankle stiffness to changes in walking speed. Patients describe the benefits of ankle articulation during the second rocker of stance phase as having no â&#x20AC;&#x153;dead spot,â&#x20AC;? a phenomenon experienced with fixedankle feet that inhibit tibial progression. During the third rocker of stance phase, MPAs can modulate the ankle stiffness to provide a gradual transition from ankle dorsiflexion to deflection of the carbon-fiber keel element during tibial progression. Some MPAs provide an additional advantage during swing phase due to relative ankle dorsiflexion. This increases the MTC and reduces the risk of stumbles and falls.17 MPAs that only provide inter-step ankle adaptation and present a fixed-ankle during stance may not exhibit these advantages over level ground. These advantages over level ground are experienced to a greater extent over uneven and sloped terrain. The lack of articulation of fixed-ankle feet induces greater ankle reaction torque and pressure on the residual limb. This causes patients to adopt accommodation strategies or limits their mobility on these terrains as the residual limb and proximal joints are unable to tolerate the increased loads. MPAs have been shown to reduce the peak pressures experienced on ramp ambulation by accommodating the slope of a ramp.6 Additionally, by achieving foot flat walking on slopes to maximize contact area and base of support (BOS), MPAs have been shown to improve gait14 and make patients feel safer.7 MPAs provide an advantage over solid ankle feet on slopes for this reason. Other advantages to MPAs are less obvious yet still important to the patient. Ankle articulation allows

MPAs to be used with various heel height shoes. Another advantage is the reduced stress on proximal joints during prolonged seating. These general advantages of MPA technology are not universally experienced with all MPA components as differences in specifications (Table 1), as well as accommodation strategy (inter-step versus within-step), affect the types of benefits experienced. While some research evidence supports these advantages, many of these advantages are anecdotes reported by patients or inherent design differences that have not been investigated in research studies.

MPAs have been shown to reduce the peak pressures experienced on ramp ambulation by accommodating the slope of a ramp.

Disadvantages of MPAs General disadvantages of MPA technology can be characterized by additional weight, patient self-management requirements, and susceptibility to damage. MPAs weigh between 749 and 1,488 grams, which is nearly twice the weight of common ESAR feet. This increased weight can pose increased

requirements of the suspension mechanism employed, and patients may experience greater motion (pistoning) of the residual limb within the socket. Another disadvantage is the battery charging requirement. The additional bulk of MPA components also can lead to difficulty in fabricating a customshaped cover that mirrors the anatomical shape of the contralateral limb. MPAs employ a hydraulic cylinder that allows ankle articulation. Because a hydraulic cylinder absorbs and dissipates energy during the gait cycle, as opposed to storing and returning energy in an elastic element, some MPAs may reduce energy efficiency. There has been limited evidence regarding energetics with MPA technology, yet studies have not found significant increases in energy consumption between MPAs and ESAR feet.10,11 For some patients, the ankle articulation of some MPAs in stance phase may destabilize static standing balance. If the patient relies on the passive ankle reaction torque from solid ankle designs to maintain balance when his or her center of pressure nears the anterior or posterior border of the BOS, MPAs that allow ankle articulation in stance phase may present a disadvantage. MPAs have more moving mechanical parts and electronic components that are more susceptible to general wear and accidental damage. This presents a durability issue, which requires routine maintenance for MPAs. MPA components are provided with product warranties of varying length, but a repair under warranty still requires additional clinical visits, which may provide an inconvenience for some patients. MPAs have varying levels of waterproof protection, which limits the environments in which they can be worn (see Table 1). One final related disadvantage is that MPA technology is not covered universally across different health insurance plans. The increased cost of MPA components leads to increased scrutiny by third-party payors. Due to this

O&P News | August 2018

Research & Presentations

uncertainty, patients may experience delays in receiving a new prosthesis with MPA technology. Therefore, the cost of MPA technology can present a limitation to some patients.

Final Thoughts In recommending MPA technologies for individual patients, it is important to consider the advantages and disadvantages of MPA components. A thorough assessment of specific limitations experienced by patients using solid ankle feet and their functional goals is necessary for making decisions regarding MPA technology. Combined with knowledge of the benefits supported by research, familiarity with the unique differentiating functions of the variety of MPA components will assist practitioners in deciding when patients would benefit most from this technology and which MPA components are indicated for individual patients. Brian Kaluf, CP, FAAOP, is clinical outcome and research director and Cody Smith, CO, is a certified orthotist and board-eligible prosthetist at Ability Prosthetics & Orthotics.

References 1. Perry J, Boyd LA, Rao SS, Mulroy SJ. Prosthetic Weight Acceptance Mechanics in Transtibial Amputees Wearing the Single Axis, Seattle Lite, and Flex Foot. IEEE Transactions on Rehabilitation Engineering. 1997; 5(4):283-289. 2. Kannenberg A, Zacharias B, Probsting E. Benefits of MicroprocessorControlled Prosthetic Knees to Limited Community Ambulators: Systematic Review. Journal of Rehabilitation Research & Development. 2014; 51(10):1469-1496. 3. Sawers AB, Hafner BJ. Outcomes Associated With the Use of Microprocessor-Controlled Prosthetic Knees Among Individuals With Unilateral Transfemoral Limb Loss: A Systematic Review. JPO: Journal of Prosthetics and Orthotics. 2013; 25(4S):P4-P40.

22 O&P News | August 2018

4. Agrawal V, Gailey R, O'Toole C, Gaunaurd I, Dowell T. Symmetry in External Work (SEW): A Novel Method of Quantifying Gait Differences Between Prosthetic Feet. Prosthetics and Orthotics International. 2009; 33(2):148-156. 5. Alimusaj M, Fradet L, Braatz F, Gerner HJ, Wolf SI. Kinematics and Kinetics With an Adaptive AnkleFoot System During Stair Ambulation of Transtibial Amputees. Gait & Posture. 2009; 30(3):356-363. 6. Wolf SI, Alimusaj M, Fradet L, Siegel J, Braatz F. Pressure Characteristics at the Stump/Socket Interface in Transtibial Amputees Using an Adaptive Prosthetic Foot. Clinical Biomechanics. 2009; 24(10):860-865. 7. Fradet L, Alimusaj M, Braatz F, Wolf SI. Biomechanical Analysis of Ramp Ambulation of Transtibial Amputees With an Adaptive AnkleFoot System. Gait & Posture. 2010; 32(2):191-198. 8. Gailey RS, Gaunaurd I, Agrawal V, Finnieston A, O’Toole C, Tolchin R. Application of Self-Report and Performance-Based Outcome Measures To Determine Functional Differences Between Four Categories of Prosthetic Feet. Journal of Rehabilitation Research and Development. 2012; 49(4):597. 9. Agrawal V, Gailey RS, Gaunaurd I, O’Toole C, Finnieston A. Comparison Between Microprocessor-Controlled Ankle/Foot and Conventional Prosthetic Feet During Stair Negotiation in People With Unilateral Transtibial Amputation. Journal of Rehabilitation Research and Development. 2013; 50(7):941. 10. Delussu AS, Brunelli S, Paradisi F, et al. Assessment of the Effects of Carbon Fiber and Bionic Foot During Overground and Treadmill Walking in Transtibial Amputees. Gait & Posture. 2013; 38(4):876-882.

11. Darter BJ, Wilken JM. Energetic Consequences of Using a Prosthesis With Adaptive Ankle Motion During Slope Walking in Persons With a Transtibial Amputation. Prosthetics and Orthotics International. 2014; 38(1):5-11. 12. Agrawal V, Gailey R, O’Toole C, Gaunaurd I, Finnieston A. Influence of Gait Training and Prosthetic Foot Category on External Work Symmetry During Unilateral Transtibial Amputee Gait. Prosthetics and Orthotics International. 2013; 37(5):396-403. 13. Agrawal V, Gailey RS, Gaunaurd IA, O’Toole C, Finnieston A, Tolchin R. Comparison of Four Different Categories of Prosthetic Feet During Ramp Ambulation in Unilateral Transtibial Amputees. Prosthetics and Orthotics International. 2015; 39(5):380-389. 14. Struchkov V, Buckley JG. Biomechanics of Ramp Descent in Unilateral Trans-Tibial Amputees: Comparison of a Microprocessor Controlled Foot With Conventional Ankle-Foot Mechanisms. Clinical Biomechanics. 2016; 32:164-170. 15. Ko C-Y, Kim S-B, Kim JK, et al. Biomechanical Features of Level Walking by Transtibial Amputees Wearing Prosthetic Feet With and Without Adaptive Ankles. Journal of Mechanical Science and Technology. 2016; 30(6):2907-2914. 16. K aluf B. Poster 7: Comparative Effectiveness of Microprocessor Controlled and Carbon Fiber Energy Storing and Returning Prosthetic Feet in Persons With Unilateral Transtibial Amputation: Pilot Study. PM&R. 2017; 9(9):S144. 17. Rosenblatt NJ, Bauer A, Rotter D, Grabiner MD. Active Dorsiflexing Prostheses May Reduce Trip-Related Fall Risk in People With Transtibial Amputation. J Rehabil Res Dev. 2014; 51(8):1229-1242.

O&P Visionary

Eileen Levis

Revamp O&P reimbursement, regulations, funding, and education to focus on the “whole” patient

hen Tom Fise, executive director for AOPA, asked me to imagine myself as having one day to rule the O&P industry, I was like a kid in a candy store. Let’s see how much candy I can put in my bag in one day. Having been in the industry for most of my adult life, I have seen tremendous change—some good, some not so good. I am co-owner of a multisite orthotics and prosthetics practice, so I know firsthand the challenges faced by both the business operations and the clinical operations. I sit on the Jurisdiction A Council and am a member of the Noridian Provider Outreach and Education Advisory Group. As president of the Pennsylvania Orthotic and Prosthetic Society, I am able to share with members valuable tools and information as a result of these affiliations. That being said, my very first proclamation would be to revamp the reimbursement system. Durable medical equipment (DME) would be separated from O&P. Functional levels would be expanded and further defined. Annual adjustments to “allowables” would be made based on realistic and relevant data. Orthotists and prosthetists would (and should) be recognized as healthcare professionals. The ability to bill for

encounters or visits would be complemented by device-specific billing. There would be no question that orthotist/ prosthetist notes would hold the same validity as the notes of any other healthcare professional. All orthotists and prosthetists would be licensed by their states. State licensing boards would provide oversight just as they do all health-care professionals. As I look around the “store,” my next focus would be on insurance fairness. Regulations would be put in place that would not restrict access to orthotic and prosthetic care and services. The regulations would provide for

O&P News | August 2018

O&P Visionary

reasonable reimbursement as stated above. There would be incentive bonus payments made based on patient outcomes. I would include streamlined processes for timely reimbursement of clean claims. One would actually be able to contact an insurer or third-party payor and talk to a knowledgeable, helpful representative. Digging deeper into the candy box, I find technology. I would fund research at all levels. I would see the rapid introduction of stellar technological advances in both prosthetics and orthotics. I would maintain a database to evaluate the efficacy of all technology and would incorporate projections and parameters to stimulate process improvement and competitive options. Third-party payors would provide reimbursement for high and low technology. So that completes my morning. As I move into the afternoon, I am keenly aware of only a few more hours left to my rule. So much to do, so little time! The professionals—how can I make them better? Educate, educate, educate! I would see that all orthotists and prosthetists received the highest level of education from the best and brightest in the field. Everyone would participate in advanced research. Knowledge

Educate, educate, educate! I would see that all orthotists and prosthetists received the highest level of education from the best and brightest in the field.

of business, regulatory and compliance requirements, billing and reimbursement, and marketing and customer service would all be part of the core educational program. There would be more universities and learning institutions providing O&P education, including a pathway via the branches of military. That pathway would be tuitionfree for active-duty service members. Suppliers/manufacturers would offer scholarships to high school seniors

enrolling in an O&P program who have contributed to their community in a meaningful way. Residency programs would all be based in teaching hospitals. On to advocacy: Everyone in the O&P industry—from the practitioners to the suppliers and manufacturers to administrative staff—has skin in the game. All would work together to advocate at the federal, state, and local levels to promote a better understanding of what we do and provide information on initiatives and issues vital to the industry and to patients. Participating with patient advocacy groups such as the Amputee Coalition or fundraising events, such as the Cerebral Palsy 5-K Run, would be required of all practitioners. Practitioners need to engage at this level with their patients. Finally, we would need to focus on patient-centered care. Nothing is so sweet in the candy store as the patient. The treatment model for all orthotists and prosthetists would be focused on the patient, the “whole patient.” Too often it is only the patient’s device that is the core of treatment when it should be the patient as a whole. How can we expect our patients to achieve optimum outcomes when many face barriers such as poor nutrition, depression, or lack of transportation to medical appointments? Just making a great device is not enough. Practitioners, under my rule, would all be trained under this care model. They would work with a patient navigator, who would assist patients in overcoming any barriers they may have to help them get to the best “total” outcome possible. As my reign is coming to an end, I realize all of the things I have done could indeed one day be accomplished. It will not be easy. It would require a cohesive industry that is steadfast, and ready and willing to make the commitment. Are you ready to rule the day? Eileen Levis is president and chief executive officer of Orthologix.

Eileen Levis speaking at the AOPA 2017 World Congress

24 O&P News | August 2018

STATE NEWS

State by State

The latest news from Illinois, New York, North Carolina, Ohio, and Pennsylvania

Each month, we talk to O&P professionals about the most important state and local issues affecting their businesses and the patients they serve. This column features information about medical policy updates, fee schedule adjustments, state association announcements, and more.

Illinois The Illinois Society of Orthotists and Prosthetists (ISOP) is working on a plan to amend the state’s parity law to incorporate language that references O&P contracts, to protect patients’ access to care. O&P providers in the state also are concerned about the reduction of network sizes, which ultimately leads to a reduction in access to care for patients. Illinois passed an administrative rule that will set pricing for all new codes in O&P at a rate of Medicare minus 6 percent. After two meetings with Medicaid, ISOP is now pursuing a similar rule change for all O&P codes.

New York There is active legislation seeking insurance fairness for amputees in both houses of the legislature in New York. Assembly Bill 2212 and Senate Bill 2080 have been introduced and have received bipartisan support. They currently are awaiting consideration before their respective chambers’ Insurance Committee. North Carolina The North Carolina Chapter of the American Academy of Orthotists and Prosthetists (NCAAOP) is seeking nominees for the positions of president, secretary, and treasurer for terms beginning in 2019. All current members will rotate off the NCAAOP Board at the end of the year. Ohio O&P providers in Ohio have reported a successful transition after licensing boards were consolidated in the state. Because of the consolidation, the costs of annual dues decreased for O&P providers. Though no member from the original licensing board maintains a seat on the new board, an advisory committee was created to provide assistance with the oversight of O&P licensing.

Pennsylvania Pennsylvania O&P providers and the Pennsylvania Orthotic Prosthetic Society (POPS) are pursuing insurance fairness/prosthetic and orthotic parity to increase patients’ access to O&P care in the state. Plans are underway to introduce the bill in the fall. POPS is using similar language to New Jersey’s bill, Health Benefits Coverage for Orthotic and Prosthetic Appliances.

O&P providers in the state also have been working with Highmark Pennsylvania to correct recent changes to its coverage policy for microprocessor-controlled prostheses, which has resulted in the issuance of a new medical policy. EDITOR'S NOTE: To submit an update for publication, please email awhite@aopanet.org. For up-to-date information about what’s happening in O&P in your state, visit the AOPA Co-OP and join the conversation in the AOPA Google+ Community.

O&P News | August 2018

CLASSIFIEDS

CALENDAR

PRACTICE SALES & APPRAISALS

WANTED! A few good businesses for sale. Lloyds Capital Inc. has sold over 150 practices in the last 26 years. If you want to sell your business or just need to know its worth, please contact me in confidence. Barry Smith Telephone: (O) 323-722-4880 • (C) 213-379-2397 e-mail: loyds@ix.netcom.com

Meetings & Courses

2018 SEPTEMBER 12 AOPA Webinar: Medicare As a Secondary Payor: Knowing the Rules. Register online at

Health-Care Compliance & Ethics Week. AOPA is celebrating Health-Care Compliance & Ethics Week and is providing resources to help members celebrate. Learn more at bit.ly/aopaethics.

bit.ly/2018webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org.

SEPTEMBER 26-29 AOPA National Assembly.

AOPA Celebrates Health-Care Compliance & Ethics Week

NOVEMBER 4-10

Vancouver Convention Center. For general inquiries, contact Ryan Gleeson at 571/431-0876 or rgleeson@AOPAnet.org, or visit www.AOPAnet.org.

NOVEMBER 12-13 Mastering Medicare: Essential Coding & Billing Techniques. Las Vegas. Register online at bit.ly/2018billing. For more information, email Ryan Gleeson

November 4-10, 2018

at rgleeson@AOPAnet.org.

• Demonstrate your company’s commitment to ethical business practices • Create awareness of the Code of Conduct, relevant laws, and regulations • Provide your staff with recognition for training completion, compliance, and ethics successes • Reinforcement—of the culture of compliance for which your organization strives.

OCTOBER 10 AOPA Webinar: Year-End Review: What Should You Do To Wrap Up the Year & Get Ready for the New Year?.Register online at bit.

NOVEMBER 14

ly/2018webinars. For more

AOPA Webinar: Evaluating Your Compliance Plan & Procedures: How To Audit Your Practice. Register online

information, email Ryan Gleeson

at bit.ly/2018webinars. For more

at rgleeson@AOPAnet.org.

information, email Ryan Gleeson at rgleeson@AOPAnet.org.

OCTOBER 18-20 International African-American Prosthetic Orthotic Coalition Annual Meeting. Embassy

DECEMBER 12

AOPA has developed several tools and resources to assist you. Visit our dedicated web page for tools, resources and more:

Suites Downtown Medical

AOPA Webinar: New Codes, Medicare Changes, & Updates. Register online at

Center, Oklahoma City. For more

bit.ly/2018webinars. For more

information, contact Tony Thaxton

bit.ly/aopaethics

information, email Ryan Gleeson

Jr. at 404/875-0066, email thaxton.

at rgleeson@AOPAnet.org.

jr@comcast.net, or visit www. iaapoc.org.

26 O&P News | August 2018

TECH TIPS

Boost Your Technical Skills Jumpstart your technical career at the 2018 AOPA National Assembly

echnicians and fabricating practitioners should take advantage of a significant opportunity to network and learn from their peers during the 2018 AOPA National Assembly, to be held September 26-29 at the Vancouver Convention Center West in Vancouver, Canada. The four-day technical program will provide cutting-edge presentations that you can take back to the lab and use almost immediately. Expect traditional fabrication techniques, combined with cutting-edge methodologies such as 3-D printing for both orthotic and prosthetic treatment. Organizers from AOPA and the Orthotic and Prosthetic Technical Association (OPTA) have joined forces to bring you programs such as, “A Modular Approach to Dynamic Bracing,” scheduled for 10 a.m. Thursday, September 27. During this session, attendees will learn from Scott Wimberley, CTPO, CPA, and Greg Mattson, CTPO, about dynamic bracing and design principles, with additional information about casting, modifications, and the fabrication process from Brad Mattear, LO, CPA, CFo. “Advanced Lamination Techniques in Orthotic Fabrication,” presented by Jacob Keough, CO, at 11 a.m. on Thursday, will provide tips for laminating lowerextremity orthotic devices. This session is designed to offer a greater understanding of composite materials in designs while showing proper model preparation, layups material selection, and finishing methods. During “Advanced Prosthetic Fabrication Techniques” on Saturday morning, Caroline Sylvestre will share the latest innovations in prosthetic fabrication

techniques to help clinicians provide optimal devices. In the “Future Tech—Emerging Technologies in O&P” session with Steve Hill, CO, BOCO, at 2:30 p.m. on Thursday afternoon, participants will learn about smart materials, flexible glass, brain

implants, gene therapy, and the latest information about 3-D printing. Browse the full Technical Program schedule to plan your itinerary for the 2018 National Assembly, and to take advantage of this unique opportunity to boost your technical skills.

Test Your Skills IN THE 2018 TECHNICAL FABRICATION CONTEST Start practicing! This year’s Technical Fabrication Contest will feature a timed competition on the Exhibit Hall show floor. Sign up. Strut your stuff and show the profession that you are the best technical fabricator in the O&P profession. Winners receive “bragging rights” and cash prizes. There is no charge to participate. • First-place winner is awarded a $500 cash prize. • Runner-up is awarded a $200 cash prize. All National Assembly registrants may participate unless they are a judge, work for a contest sponsor, or are on the National Assembly Planning Committee or AOPA Board of Directors. Sponsored by:

O&P News | August 2018

TECH TIPS

2018 AOPA NATIONAL ASSEMBLY

TECHNICAL PROGRAM WEDNESDAY | SEPTEMBER 26

1:30 – 2:30 p.m.

8 a.m. – 5 p.m.

Proven Fabrication Techniques Over Rigid Foam Positive Models (T3)

Manufacturers’ Workshops

Attendees will choose from more than 30 Manufacturers’ Workshops. Visit www.AOPAAssembly.org for details.

THURSDAY | SEPTEMBER 27

Alex Brett, RTPO(c), and Pat Myrdayl, RTPO, FGBC The techniques presented here have been compiled from the presenters’ personal experience, as well as tips gleaned from other fabricators. 2:30 – 3 p.m.

7 a.m.

Future Tech—Emerging Technologies in O&P (T4)

Breakfast

Opening keynote presentation with Tobie Hatfield, director of innovations, Nike.

Steve Hill, CO, BOCO In this annually updated presentation, Steve Hill, CO, BOCO, will discuss many of the latest emerging technologies. While the main focus will be on technologies specific to O&P, an overview of other new technologies will be discussed to encourage finding ways to employ them for the benefit of O&P practice and patients. This year’s topics will include smart materials, flexible glass, brain implants, and gene therapy, as well as updated information on 3-D printing and more.

8:30 – 10 a.m.

3:15 – 4 p.m.

Coffee Break in Exhibit Hall

Blood in Custom-Laminated Sockets: More Than Just a Freckle? (T5)

Breakfast will be available to attendees prior to the General Session. 7:15 – 8:30 a.m. General Session (GS1)

Take time to peruse the Exhibit Hall, enter the Technical Fabrication Contest, and network with peers. 10 – 11 a.m. A Modular Approach to Dynamic Bracing (T1)

Scott Wimberley, CTPO, CPA, and Greg Mattson, CTPO This session will offer an understanding of dynamic bracing and design principles, as well as an overview of casting, modifications, and the fabrication process. 11 a.m. – Noon Advanced Lamination Techniques in Orthotic Fabrication (T2)

Jacob Keough, CO Learn advanced lamination techniques in orthotic fabrication. Noon – 1:30 p.m. Lunch in Exhibit Hall

28 O&P News | August 2018

Joanna Kenton, CPO, LPO Goods and items in the production process often contain contaminants that, in large quantities, could be detrimental to the consumer. So how about in the prosthetic industry where each device is customized and lovingly made by hand? A technician may nick his or her hand or have a dry cuticle and—before it’s even realized—a small smear of blood could penetrate the fabric as it’s being prepared for lamination. Blood does not laminate; if the layup is continued and laminated, what happens to the chemical make-up of the blood? Are technicians aborting the process and starting over? Or are they continuing regardless, and the socket becomes delivered despite best practices? What are the associated legal and ethical concerns? 4 – 5 p.m. “Finding Your Way” Developing and Utilizing Standards in the Fabrication Setting (T6)

Scott Wimberley, CTPO, CPA, and Greg Mattson, CTPO Learn about a lean approach to process control. Attendees will receive information through PowerPoint presentations and handout materials on the following topics: value, benefits, processes for developing standards, and visual examples specific to O&P. (Continued on page 30)

www.bocusa.org

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TECH TIPS

FRIDAY | SEPTEMBER 28 7 a.m. Breakfast

Breakfast will be available to attendees prior to the General Session.

Overview of 3-D Printing (T7-B)

Jeff Erenstone, CPO, and Nick Dechev Receive a summary of adaptive manufacturing technologies and examples of how 3-D printing and CAD can be used in efficient workflows. Noon – 1:30 p.m.

7:15 – 8:30 a.m.

Lunch in Exhibit Hall

General Session (GS2)

The Friday morning General Session will include an awards ceremony and an update from the International Society for Prosthetics and Orthotics on the new World Health Organization Standards for O&P.

1:30 – 3 p.m. Scanning and CAD Software Roundtable (T8)

Coffee Break in Exhibit Hall

Various Speakers Representatives from many of the major scanning manufacturers—including Omega, Standard Cyborg, Create O&P, Vorum, BioSculptor Corp., Rodin4D, Provel, and TechMed— will share the latest and greatest in scanning and CAD software.

10 a.m. – Noon

3:45 – 5 p.m.

Getting Your Feet Wet With O&P 3-D Printing! (T7)

CAE, CAM, and Printing Workshop (T9)

Enjoy a full day of sessions designed to give participants the background needed to go from scan to printed device.

Receive an introduction of Meshmixer with links for followup video viewing on YouTube and a detailed explanation of slicer (CAM) software. (Continued on page 32)

8:30 – 10:00 a.m.

The Source for Orthotic & Prosthetic Coding

Morning, noon, or night— LCodeSearch.com allows you access to expert coding advice—24 hours a day, 7 days a week.

HE O&P CODING EXPERTISE the profession has come to rely on is available online 24/7! LCodeSearch.com allows users to search for information that matches L Codes with products in the orthotic and prosthetic industry. Users rely on it to search for L Codes and manufacturers, and to select appropriate codes for specific products. This exclusive service is available only for AOPA members.

Log on to LCodeSearch.com and start today. Need to renew your membership? Contact Betty Leppin at 571/431-0876 or bleppin@AOPAnet.org. www.AOPAnet.org

30 O&P News | August 2018

CALL

TODAY Manufacturers: AOPA is now offering Enhanced Listings on LCodeSearch.com. Don’t miss out on this great opportunity for buyers to see your product information! Contact Betty Leppin for more information at 571/431-0876.

Realize the facts. O&P care improves quality of life and is cost effective! Learn more at MobilitySaves.org. The Study that Started MobilitySaves.org A major study, comparing patients using prosthetics versus patients without prosthetics had these findings: • They will experience greater independence. • They can increase their physical therapy and become less bed-bound. • They will have fewer emergency room admissions and acute care hospital admissions. • They will have lower or comparable Medicare costs than patients who need, but do not receive, these services. Share this significant news by using the educational tools provided at MobilitySaves.org. Mobility Saves Lives And Money!

The Results Lower Limb Prosthetics Prosthetic patients experienced better quality of life and increased independence compared to patients who did not receive the prosthesis at essentially no additional cost to Medicare (or other payers).

O&P CARE IS A SAVER, NOT AN EXPENSE TO INSURERS! Visit MobilitySaves.org. Follow us on social media! “Search Mobility Saves” on Facebook, Twitter, and LinkedIn

AD INDEX

SATURDAY | SEPTEMBER 29 7 a.m. Breakfast

Breakfast will be available to attendees prior to the General Session. 7:15 – 8:30 a.m. General Session (GS3)

The Saturday session will provide an update on Orthotics 2020 followed by a presentation with “Monster” Mike Schultz, Paralympic Gold medalist. 8:30 – 10 a.m. Coffee Break in Exhibit Hall

10 – 11 a.m. Advanced Prosthetic Fabrication Techniques (T10)

Caroline Sylvestre Learn advanced fabrication techniques for prosthetics. 11 a.m. – Noon 3-D Printing Recap & Roundtable (T11)

Jeff Erenstone, CPO (Moderator) Attendees will review printed devices and will be able to question industry experts on practice and practicality. To learn more about the AOPA National Assembly, visit www. AOPAAssembly.org.

ADVERTISER INDEX ALPS..................................................................3 www.easyliner.com American Orthotic & Prosthetic Association (AOPA).............................7, 13, 29, 30, 31, Cover 3 www.AOPAnet.org Fabtech Systems........................................ 14, 15 www.fabtechsystems.com Hersco Ortho Labs .....................................Cover 2 www.hersco.com Össur.................................................Back Cover www.ossur.com Ottobock.......................................................... 9 www.professionals.ottobockus.com Surestep........................................................ 11 www.surestep.net

32 O&P News | August 2018

Publisher Thomas F. Fise, JD Advertising Sales RH Media LLC Editorial Services Content Communicators LLC Design & Production Marinoff Design LLC Printing Sheridan SUBSCRIBE O&P News (ISSN: 1060-3220) is published monthly by the American Orthotic & Prosthetic Association, 330 John Carlyle St., Ste. 200, Alexandria, VA 22314. To subscribe, contact 571/431-0876, fax 571/4310899, or email ymazur@AOPAnet.org. Periodical postage paid at Alexandria, VA, and additional mailing offices. ADDRESS CHANGES Postmaster: Send address changes to: O&P News, 330 John Carlyle St., Ste. 200, Alexandria, VA 22314.

Copyright © 2018 American Orthotic and Prosthetic Association. All rights reserved. This publication may not be copied in part or in whole without written permission from the publisher. The opinions expressed by authors do not necessarily reflect the official views of the publisher, nor does the publisher necessarily endorse products shown in O&P News. The O&P News is not responsible for returning any unsolicited materials. All letters, press releases, announcements, and articles submitted to the O&P News may be edited for space and content. The magazine is meant to provide accurate, authoritative information about the subject matter covered. It is provided and disseminated with the understanding that the publisher is not engaged in rendering legal or other professional services. If legal advice and/or expert assistance is required, a competent professional should be consulted. ADVERTISE Reach out to the O&P profession and more than 13,500 subscribers. Engage the profession today. Contact Bob Heiman at 856/673-4000 or email bob.rhmedia@comcast.net.

THE PREMIER MEETING FOR ORTHOTIC, PROSTHETIC, AND PEDORTHIC PROFESSIONALS.

ION TRAT S I G RE

OPEN

PASSPORT

INNOVATION

Vancouver is easy to explore during your time at the downtown Vancouver Convention Centre as there are many nearby top attractions. • • • • • •

Capilano Suspension Bridge Vancouver Aquarium Forbidden Vancouver Stanley Park Horse-Drawn Tours Harbour Cruises & Events Flyover Canada

• Vancouver Lookout • Dr. Sun Yat-Sen Classical Chinese Garden • Vancouver Art Gallery • Science World • Grouse Mountain

Experience Beyond Vancouver’s unbeatable location makes it the perfect gateway to the rest of British Columbia and beyond, providing you with outstanding opportunities for pre- and post-conference travel. • Whistler • Okanagan Valley • Jasper • Victoria • Banff • Cruise to Alaska

AOPAnet.org

#AOPA2018

Experience all the AOPA National Assembly has to offer while visiting Vancouver.

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