Prosthetics and Orthotics International

Background: Although occupational therapists are integral to the rehabilitation process of people with amputations, the effectiveness of the occupational therapy intervention for older adults with lower limb amputations has not been investigated.

Objectives: To identify the effectiveness of the occupational therapy interventions with older adults aged 65 years and older with lower limb amputations.

Study Design: Systematic review.

Methods: A systematic search was conducted in CINAHL, PUBMED, OTSEEKER and OTDBASE from January 1985 to January 2011. The eligible papers were critiqued using a typology, which involved designation of levels of evidence and quality markers.

Results: The databases yielded 2,664 potential publications. Of these, only two were included in the final review. These studies suggested that the frequency of the occupational therapy sessions was found to be statistically significantly related to prosthesis use and that service users perceived positive benefits about the provision of stump boards. Both studies had limitations resulting in a need for further investigation in these areas.

Conclusion: Research evidence on the occupational therapy interventions with this population is limited and scarce. Occupational therapists need to take urgent action to address the identified evidence-based gaps in order to devise informed targeted rehabilitation programmes for this client group.

Clinical relevance

This systematic review has contributed to the understanding of the occupational therapy practice in the rehabilitation of older adults with lower limb amputations. It has highlighted gaps in evidence that occupational therapists need to address urgently in order to inform their rehabilitation programmes with this client group.

Background: One of the main indicators of the suspension system efficiency in lower limb prostheses is vertical displacement or pistoning within the socket. Decreasing pistoning and introducing an effective system for evaluating pistoning could contribute to the amputees’ rehabilitation process.

Objectives: The main objective of this study was to review existing research studies that examine the occurrence of pistoning in lower limb prosthesis with different techniques in static (standing) and dynamic (walking and jumping) positions.

Study Design: Literature review.

Methods: Keywords related to slippage, suspension, pistoning and vertical movement in lower limb prosthetics were used to search the literature available in PubMed, ScienceDirect, Web of Science and Google Scholar databases. Sixteen articles were selected for further analysis according to the selection criteria.

Results: The following methods have been used to measure the occurrence of pistoning in prosthetic limbs: radiological methods, photographic technique, motion analysis system, sensor and spiral computerized tomography (CT). Pistoning was measured both in standing and walking.

Conclusions: The results of this review reveal that further research is needed to develop and evaluate easy, accurate and safe methods of measuring pistoning. Future studies should provide a gold standard for the acceptable range of pistoning in a prosthetic socket.

Clinical relevance

This literature review contributes to a further understanding of lower limb prosthetic biomechanics by highlighting the strengths and weaknesses of the techniques that are currently available for evaluating the occurrence of pistoning in a prosthetic socket. It provides a useful overview of the current methods of measuring residual limb movements relative to the socket and liner, and will be of use for both practitioners and researchers in prosthetics and orthotics fields.

Background: The WISH-type S-form brace, is considered to improve hip function and gait in patients presenting with painful hip osteoarthritis (OA).

Objectives: To evaluate the effects of the brace on functional mobility.

Study Design: Cross sectional survey.

Methods: The Timed Up & Go Test (TUG) was performed with right and left turns separately in each subject.

Results: In the patients with the bilateral hip brace, the average time to complete the TUG (8.3 ± 1.7 seconds) was significantly shorter than in those without the brace (9.4 ± 2.9 seconds). On the other hand, for the patients with unilateral hip OA, the improvement of TUG with the hip brace was significant in turning the unbraced leg inside (7.4 ± 1.1 vs. 7.6 ± 1.2 seconds), while not turning the braced leg inside (7.5 ± 1.1 vs. 7.6 ± 1.2 seconds). Furthermore, significant improvement of TUG was found at three-month follow-up and maintained until the 12-month follow-up assessment. This improvement was independent of the application of the brace at the assessment.

Conclusions: The direct effect of the hip brace may be related to the hip function in the turning phase of TUG. In addition, mechanical improvements due to daily exercise may provide an indirect, but essential, effect of the brace on TUG performance.

Clinical relevance

From a functional mobility viewpoint, the present WISH-type hip brace may contribute to risk reduction of future falls in hip OA patients.

Background: The addition of a passive wrist to a single degree of freedom prosthesis has an effect on its functionality. The amount of impact is undetermined.

Objectives: To measure the grasping function of a commercial single degree of freedom hands with and without two forms of passive wrist flexor.

Study Design: Form-board and timed tasks.

Method: Repeated measures with a single subject using a validated assessment tool. The test measured the function of one conventional, single axis, powered hand controlled by the same myocontroller format. It was used in conjunction with a passive three position wrist flexor, a wrist with compliance in the flex/extend and radial/ulnar deviation and compared with a hand without these axes.

Results: The overall functional score of the hand alone was 80 out of 100. The use of a wrist flexion unit resulted in a higher score (83) and the compliant wrist achieved a score of 79. The addition of a wrist allowed improved performance in Power, Lateral and Tips grips for both wrist designs, in addition the Extension grip was improved with the compliant wrist.

Conclusion: Wrist flexion had a positive impact on the functional score. It enabled some tasks to be performed quicker and with less difficulty.

Clinical relevance

The majority of prosthetic hands have pro/supination yet there is little evidence about what impact this, or any other motion at the wrist, has on the overall functional capabilities of a prosthetic hand (i.e. grip). A commercial myoelectric prosthetic hand when used with and without two different wrist designs can potentially improve grip performance.

Background: In 2003, the British Society of Rehabilitation Medicine (BSRM) published guidelines on amputee and prosthetic rehabilitation, including those with congenital limb deficiency.

Objectives: The aim of the study was to evaluate the service provided by the Regional Disablement Service (RDS) to children with congenital upper limb deficiency, against BSRM guidelines.

Study Design: Retrospective chart review.

Methods: Chart review.

Results: Analysis of the group (n = 44) showed 52% were male, with 61% of children affected on the left side, and 73% having a transverse deficiency. Compliance to individual aspects of the guidelines varied considerably. Only 14 (32%) of children had met with the multidisciplinary team by the recommended age of six months. Analysis of referral sources and timings suggested that children were initially seen elsewhere and later referred to RDS after consultation with a surgeon.

Conclusions: RDS compliance with the BSRM guidelines was variable. Particularly disappointing was the low rate of children and families meeting the multidisciplinary team at an early age (< 6 months). The low rate of early referral prompted us to contact all paediatricians in Northern Ireland highlighting the guidelines, the benefits of early contact with RDS and encouraging referral on diagnosis.

Clinical relevance

This work will be of interest particularly to those involved in treating paediatric amputees. The challenges we face in treating upper limb deficient children in accordance with current guidance may not be unique and our study may prompt other units to consider how best to improve service to this group.

Background: The main determinants of prosthetic use known from literature apply to the younger patient with lower limb amputation. Studies aimed at identifying determinants of outcome of lower limb amputation in elderly patients with multimorbidity that rehabilitate in skilled nursing facilities (SNFs) are scarce.

Objectives: To predict prosthetic use and physical mobility in geriatric patients admitted to SNFs for rehabilitation after lower limb amputation and the impact of multimorbidity.

Study Design: Prospective design.

Methods: Univariate and multivariate logistic and linear regression analyses were used to identify determinants that were independently related to prosthetic use and the timed-up-and-go test (TUG test).

Results: Of 55 eligible patients, 38 had complete assessments on admission and at discharge. Fifty per cent was provided with a prosthesis. Multimorbidity was present in 53% of the patients. Being able to ambulate independently, and having a transtibial amputation (rather than a higher level of amputation), without phantom pain determined prosthetic use (R²=56%), while cognitive abilities, low amputation level, and pre-operative functional abilities were independently associated with the TUG test (R²=82%).

Conclusions: Elderly patients referred to an SNF for prosthetic training have a high probability of using a prosthesis when having an independent ambulation after transtibial amputation, without phantom pain. These patients should be considered for prosthetic training.

Clinical relevance

This study gives more insight into the outcomes of geriatric patients with lower limb amputation after rehabilitation in skilled nursing facilities. This is the first study that focuses on determinants of prosthetic use in these elderly patients, often with multimorbidity.

Background: Currently there is a paucity of research providing recommendations on the type of orthotic or material used in its construction for different patient requirements.

Objectives: To gain a greater understanding of the characteristics of orthotic materials and how they affect gait so to enhance the clinical decision-making process.

Study Design: Repeated measures.

Methods: Plantar pressures and kinematics were evaluated for 10 participants while walking on a treadmill under various conditions which included, shoes only and shoes with four different flat insoles and custom devices created in each of two densities of two materials.

Results: For the flat insoles, medium density ethyl vinyl acetate was found to produce greater peak pressures than at least one of the other material conditions and low and medium density polyurethane were most effective at increasing average contact area and at reducing pressure time integral. For the custom devices, while no significant differences were evident, when compared to the shoe only condition, medium density polyurethane increased average contact area by a greater percentage than the other materials.

Conclusions: Results for medium density polyurethane suggest a possible difference in loading characteristics, indicating a potential material suitability for patients with a compromised ability to deal with pressure.

Clinical relevance

Findings from the present study provide information for a clinician to draw an evidence-based orthotic prescription based on material properties.

Background: Back pain and ambulation deterioration among ambulatory individuals with cerebral palsy (CP) are common as they grow older and walking aids are often prescribed to improve stability and promote maximal weight-bear on lower limbs during gait.

Objective: To investigate the effects of walking aids on back muscle activity and whole body kinematics among adolescents with spastic diplegia.

Study Design: A repeated-measures design was adopted with participants tested under different walking conditions.

Methods: Ten participants were recruited and Lofstrand forearm crutches were selected. Both the activity of lumbar erector spinae and the kinematics of head, trunk, pelvis and lower limbs during walking were monitored using telemetric electromyography and motion analysis system respectively.

Results: Comparisons between walking unaided and walking with unilateral and bilateral crutch(es) were made. Significant decreases in speed, cadence, erector spinae activity and lower trunk extension were observed during crutch walking together with significantly increased stride time and anterior pelvic tilt.

Conclusions: These findings suggested that Lofstrand crutch(es) reduced muscular demands and lumbar lordosis with increased lower back mobility. The results shed light on the prescription of walking aid in the management and prevention of chronic back pain for ambulatory individuals with CP from a life span perspective.

Clinical relevance

This study revealed that four-point reciprocal crutch walking can be prescribed to reduce muscle activity, and hence decrease stress at back, during gait among ambulatory individuals with CP that may serve as an adjunct to back pain management in this population group.

Background: Children with cerebral palsy (CP) often demonstrate postural control difficulties. Orthotic management may assist in improving postural control in these children.

Objective: The purpose of this investigation was to examine the influence of floor reaction ankle foot orthosis (FRAFO) on postural flexion called the crouch position in children with CP.

Study Design: Quasi-experimental.

Methods: Eight children with spastic diplegic CP and eight matched typically developing children participated in this study. Postural control of children with CP was assessed in a static standing position on a force platform with/without a FRAFO. The parameters used were centre of pressure (CoP) measures, calculated from force platform signals including the standard deviation (SD) of excursion; phase plate portrait and SD of velocity in anteroposterior (AP) and mediolateral (ML) directions.

Results: The maximum knee extension was statistically significant in children with CP when barefoot compared to wearing braced footwear (p < 0.05, t = 10.01). AP and ML displacement, AP velocity and AP phase plate portrait of CoP were not statistically significant between children with CP with/without a FRAFO (p < 0.05).

Conclusion: FRAFO can improve the alignment of the knee, but may not be helpful in improving postural control in children with CP in a short time period.

Clinical relevance

This article will provide objective evidence about the effect of FRAFO on the postural control in children with CP. Therapists can use FRAFO to effectively decrease the knee joint angle in the sagittal plane in children with spastic CP, but cannot use it to improve the postural control.

Background: The term ‘sock ply’ may be a source of confusion in prosthetics practice because there may not be a consistent relationship between sock ply and sock thickness.

Objectives: The purpose of this study was to characterize how sock ply related to sock thickness for different sock materials commonly used in limb prosthetics. We also evaluated how sock thickness changed under loading conditions experienced while wearing a lower limb prosthesis compared with unstressed conditions.

Study Design: Experimental. Mechanical assessment.

Methods: Seven sock materials of varying ply and sheaths were tested using a custom instrument. Sock thickness under eight different compressive stress conditions and two different biaxial in-plane tensile strain conditions were measured.

Results: For socks woven from a single material, thickness under walking stance phase conditions averaged 0.7, 1.2 and 1.5 mm for 1, 3 and 5-ply, respectively. For socks woven from several materials, the corresponding results were 0.4, 0.7 and 0.8 mm, respectively. Sock ply did not sum, e.g. a 3-ply sock was not three times the thickness of a 1-ply sock.

Conclusions: Sock thickness and compressive stiffness are strongly dependent upon sock material, interface pressure, and in-plane biaxial strain.

Clinical relevance

Data may be useful towards selecting socks during fitting and towards understanding volume changes induced by adding socks. An alternative nomenclature for thickness based on sheath equivalence may be more intuitive to practitioners and to the industry.

Background: An important way of improving healthcare services is through the implementation of evidence-based practice; but this requires an understanding of the extent to which it is occurring and the factors that are driving its implementation.

Objective: To examine the associations among the demographics of clinicians, the factors involved in the implementation of evidence-based practice, and the access of clinicians to various sources of information.

Study Design: Cross-sectional survey.

Methods: An online survey that was distributed to 300 Canadian prosthetic and orthotic clinicians. Associations of selected survey items were determined.

Results: Four primary associations were found and a further 18 were considered to be indicative of potential trends. Two of the primary associations were related to authorship and the utilization of scientific literature. Specifically, those clinicians who had previously authored or co-authored a peer-reviewed journal article were more likely to utilize scientific literature to guide their clinical practice.

Conclusions: This study has highlighted important demographics which can be targeted for greater implementation of evidence-based practice. Above all, facilitating engagement of clinicians in research and its dissemination may promote a higher consumption of research evidence leading to improved evidence-based practice.

Clinical relevance

This study provides information about the underlying facilitators and inhibitors of evidence-based practice in prosthetics and orthotics. The findings aim to inform those involved in improving existing clinical practices, including educators, professional organizations and governing bodies.

Background: Microprocessor controlled prosthetic knees (MPK) offer opportunities for improved walking stability and function, but some devices’ swing phase features may exceed needs of users with invariable cadence. One MPK offers computerized control of only stance (C-Leg Compact).

Objective: To assess Medicare Functional Classification Level K2 walkers’ ramp negotiation performance, function and balance while using a non-MPK (NMPK) compared to the C-Leg Compact.

Study Design: Crossover.

Methods: Gait while ascending and descending a ramp (stride characteristics, kinematics, electromyography) and function were assessed in participant’s existing NMPK and again in the C-Leg Compact following accommodation.

Results: Ramp ascent and descent were markedly faster in the C-Leg Compact compared to the NMPK (p ≤ 0.006), owing to increases in stride length (p ≤ 0.020) and cadence (p ≤ 0.020). Residual limb peak knee flexion and ankle dorsiflexion were significantly greater (12.9° and 4.9° more, respectively) during single limb support while using the C-Leg Compact to descend ramps. Electromyography (mean, peak) did not differ significantly between prosthesis. Function improved in the C-Leg Compact as evidenced by a significantly faster Timed Up and Go and higher functional questionnaire scores.

Conclusions: Transfemoral K2 walkers exhibited significantly improved function and balance while using the stance-phase only MPK compared to their traditional NMPK.

Clinical relevance

Instability, reduced function and falls are common in deconditioned transfemoral amputees. Selection and use of prosthetic componentry that promotes greater stability in more challenging environments is essential to improve the safety, function, quality of life and independence of individuals functioning at the K2 walking level.

Background: The aim of this case study was to identify the effect of a powered hip orthosis on the kinematics and temporal-spatial parameters of walking by a patient with spinal cord injury (SCI).

Case Description and Methods: Two orthoses were evaluated while worn by an incomplete SCI subject with a T-8level of injury. Gait evaluation was performed when walking with an Isocentric Reciprocating Gait Orthosis (IRGO) and compared to that demonstrated by a newly powered version of the orthosis; based on the IRGO superstructure but incorporating powered hip joints using an electrically motorized actuator that produced active hip joint extension and flexion.

Findings and Outcomes: The powered hip orthosis, when compared to the IRGO, increased the speed of walking, the step length and also the cadence demonstrated by this subject. Vertical and horizontal compensatory motions with new orthosis decreased. Hip angles when walking with this orthosis were comparative to those demonstrated by normal walking patterns.

Conclusions: The hip actuator produced positive effects on the kinematics and temporal-spatial parameters of gait during level-ground walking trials, resulting in an alternative approach to walking by SCI patients.

Clinical relevance

This orthosis has the potential to improve hip joint kinematics, the temporal-spatial parameters of gait in SCI patients walking.

Background and Aim: Until recently, robotic devices for stroke rehabilitation had multi-joint designs that were often tethered to a treadmill for gait training. A new single-joint wearable robotic knee orthosis (RKO) has been designed that provides patient-initiated powered-assistance in untethered functional mobility. This case-series documents application of the wearable RKO in untethered functional training with stroke survivors.

Technique: Three ambulatory adult stroke survivors used a wearable RKO during 18 one-hour sessions within a six-week physical therapy programme. Subjects were assessed with a variety of balance, gait and functional tests including the Berg Balance Scale (BBS); six-minute walk test (6MWT); and Emory Functional Ambulation Profile (EFAP) at pre-treatment, post-treatment, one-month and three-month follow-up.

Discussion: All subjects improved balance, gait and functional performances with mean individual improvements of 12.6% for BBS, 12.0% for 6MWT and 16.7% for EFAP post-treatment. No adverse events occurred. These three stroke survivors may have benefited from the task-specific functional training programme augmented by RKO use.

Clinical relevance

Physical therapists may find a wearable robotic knee orthosis useful for providing patient-initiated assisted movement for ambulatory chronic stroke survivors during functional task-specific balance and mobility training.

Background and Aim: The custom-made finger prosthesis is aesthetically acceptable and comfortable for use in patients with amputated fingers, resulting in psychological improvement and physiological well being. The success of the prosthesis depends on the precision of planning the prosthesis, making the impression, carving the model and choosing the material that best suits the concerned circumstances. In this article a simplified method was used regarding an accurate impression of partially amputated fingers.

Technique: A plastic cylindrical small open container (impression cap) was used for making an impression of the fingers. A wax pattern of the missing part was made by replicating the same fingers of the other hand with melted modelling wax after slight modification. This pattern was finally cured with silicone material.

Discussion: In the present technique, a modified approach of impression making was used for getting an accurate fit of the finger prosthesis with improved aesthetics, which is one of the most important criterion for the success of any prosthesis.

Clinical relevance

The present article provides a simplified approach for fabrication of partially lost finger prosthesis.

Background and Aim: This article describes the development and testing of a new powered gait orthosis to potentially assist spinal cord injury patients to walk by producing synchronized hip and knee joint movements.

Technique: The first evaluation of the orthosis was performed without users, and was followed by evaluation of the orthosis performance using three healthy subjects to test the structure under weight-bearing conditions. The orthosis was primarily evaluated to ascertain its ability to generate appropriate hip and knee motion during walking. The walking experiments replicated the flexion and extension of both the hip and knee produced by the actuators which had previously been demonstrated during the initial computer simulations.

Discussion: The results suggest that this new orthosis could be used to assist paraplegic subjects who have adequate ranges of motion and also with weakness or reduced tone to ambulate, and may also be suitable for other subjects with impaired lower limb function (e.g. stroke, poliomyelitis, myelomeningocele and traumatic brain injury provided they do not have increased tone or movement disorders.

Clinical relevance

The new powered gait orthosis can provide walking assistance for patients with a spinal cord injury who have a good range of motion at the hip and knee and who also have weakness or reduced tone.

Background and Aim: In order to increase understanding of the biomechanical consequences of equinus foot on gait, we developed an orthosis to induce an adjustable degree of unilateral equinus. The aim of this study was to evaluate its feasibility and consequences on 3D ankle kinematics and kinetics.

Technique: 3D gait analysis was carried out in 10 healthy children without the orthosis, with the non–adjusted orthosis and with the orthosis adjusted to +10°, 0°, −10°, −20° of ankle dorsiflexion and maximum plantarflexion (MP). The amount of dorsiflexion at initial contact was close to the goniometric measurement. Significant kinematic and kinetic changes occurred at −10°, −20° and MP. The mean maximum equinus at initial contact −21.65° ± 4.17 and during stance −11.61° ± 4.82 were larger than those obtained with previous described devices.

Discussion: Our device was easy–to–use and induced an adjustable, well tolerated equinus. It provides a new way to simulate equinus and its biomechanical consequences on gait.

Clinical relevance

This study validated an orthotic device which induced an adjustable equinus. This device can be used to carry out biomechanical studies in children, increasing understanding of pathological problems and thus improving therapeutic management.