The following are student research projects from George Brown College that the program is excited to share with the P&O community across Canada. In the interest of showcasing a variety of papers, these projects are represented by an overview, with full-length papers available on the Orthotics Prosthetics Canada website at www.opcananda.ca.
With thanks to project coordinator Gordon Ruder, CO(c), B.Sc., M.Sc., Coordinator, Prosthetic & Orthotic Programs, George Brown College.
Table of Contents
Myoelectric Prostheses Controlled Through Targeted Muscle Reinnervation (TMR) Compared to Conventional Myoelectric Prostheses for Trans-humeral Users with respect to Functional Outcomes and Reduction in Neuroma and Phantom Limb Pain
Do New Prosthetic Designs Improve Prosthetic Care for Individuals with a Symes-level Amputation?
By: Amy Hughes-Jones
The use of a lower-limb prosthesis can enhance mobility, independence, safety, and quality of life in people with lower-limb amputation (Resnik & Borgia, 2015). When looking at populations that require amputations of the foot, preservation of length is a main strategy to improve biomechanical advantages in prosthetic use (Aiona, 2014). Furthermore, an amputation that preserves the heel pad keeps the ability to weight-bear for short distances without the use of a prosthesis. First described in 1843, and later popularized by Wager, developing opinions still continue on whether a symes amputation is more beneficial over traditional below-the-knee amputations (Wagner, 1979).
In 1980, the Journal of Prosthetics and Orthotics listed different symes-level prosthetic designs, including an obturator door, and using a segmented liner (Leimkuehler, 1980). In clinical practice, it has been shared that each design, new and old, has its pros and cons. Major developments were made when developing socket designs based on patients’ needs such as the ability to load weight through the distal aspect, or the need to relieve weight from the distal aspect. Each design change improved care for this population.
A major theme within all designs is that there is limited build height and only simple prosthetic feet can be used. This does not seem to affect the paediatric population as much. Even though it is patient-specific, a majority of the literature only focuses on the use of dynamic feet in the paediatric population, suggesting more options are available for this population over others. Manufacturers have developed several higher functioning feet with low-build height. A study by Jean et al. (2014) demonstrates a contradictory relationship between the performance and foot design and the PODCI score for seventy-three children. This shows that there should be a more subjective approach in prosthetic prescription, and costs of paediatric feet should not influence designs (Aiona, 2014). The literature also promotes the idea that too much length is disadvantageous and additional surgeries are needed to shorten a limb, in order to have optimal functional outcomes when looking at energy conservation and oxygen consumption (Osebold, et al 2001).
There is a definitive gap in the literature with respect to new technology and how it can impact prosthetic design in the symes population. This is especially true in the older population where build height and foot selection decreases compared to that in the paediatric population. This research aims to determine if new prosthetic designs improve prosthetic care for individuals with symes-level amputation. It will critically compare results from the literature review, and from a questionnaire sent to professionals in the prosthetic and orthotic community. The final objective will be to share knowledge about prosthetic design, and if care can be improved.
Is There a Place for Partial Feet Amputations? Examining Recent Literature to Determine for Whom and When Partial Foot Amputations may be Appropriate.
By: Callie Bazak
A significant portion of the Clinical Methods in Prosthetics and Orthotics program at George Brown College focuses on the trans-tibial client compared to the partial foot client. Yet it is reported that the rate of partial foot amputations (PFA) in some countries can be double the rate of trans-tibial amputations (TTAs) and trans-femoral amputations (TFAs) combined (Janisse & Janisse, 2010). Increasing commonality of PFA can be attributed to advancements in vascular surgery and amputation surgery (Sobel, Japour, Giorgini, Levitz, & Richardson, 2001), as well as increased prevalence of vascular insufficiency secondary to diabetes mellitus (Dillon & Barker, 2008).
Literature regarding PFA and its success is mixed; some authors support PFA and others question whether PFAs actually provide optimal treatment. Dillon and Fatone note that 30-50% of PFA patients will experience complications with skin breakdown or ulceration, and approximately 33% will require revisions to a more proximal level (Dillon & Fatone, 2013). Others suggest that PFAs are “slow to heal, likely to develop equinus contractures and difficult to fit with prostheses” (Sobel, Japour, Giorgini, Levitz, & Richardson, 2001).
However, others will report that PFAs will require less energy expenditure for clients to walk, allow for better independent function (Sobel, Japour, Giorgini, Levitz, & Richardson, 2001), as well as decrease cardiovascular demands for clients, a subset of whom deal with cardiac compromise (Nerone, Springer, Woodruff, & Atway, 2013). Dutch researchers Zinger et al. at the University Medical Center of Utrecht strongly suggest in their 2007 case study to try partial foot amputations, even if they are not as common and can be more surgically involved. They report that for young patients, as well as older patients with adequate blood supply, PFAs can have promising functional and psychological results for the clients, such as the ability to ambulate without a prosthetic device, less device-induced restriction at the knee and decreased phantom limb pain (Zinger, Holtstag, & Verleisdonk, 2007).
Considering the projected increase in prosthetic patients in years to come, the increase in the number of PFAs and the conflicting literature about whether or not PFAs are the best treatment option for clients, this author believes that a thorough investigation of recent literature is worthwhile to gain better insight and perspective on this issue and determine if more educational experiences regarding PFAs would be beneficial.
There are different reviews specific to classifications of PFAs and their outcomes, but it is challenging to find a review that looks at all levels simultaneously, the appropriate patient populations for each procedure, where it can be determined, and prosthetic and surgical interventions that can improve the outcome of PFAs. It is also worthwhile to generally compare PFAs to TTAs to determine if there is any evidence to actually support if one procedure does in fact provide better outcomes than another.
A Review of Helmet Therapy’s Effectiveness in Treating a Variety of Levels of Plagiocephaly
By: Emily Dyszuk
Plagiocephaly, also commonly referred to as deformational plagiocephaly (DP) or non-synostotic plagiocephaly, can be described as an infant having an asymmetrical-shaped skull due to extrinsic events (1,2… references available in full paper). Prevalence of plagiocephaly is thought to have increased in the population after the “Back to Sleep” campaign was initiated in 1992, discouraging parents to position their infants on their stomachs to reduce the risk of sudden infant death syndrome (3).
In 1996 the American Academy of Pediatrics (AAP) Task Force updated their research and stated that babies should only be placed on their backs to sleep (4). The prevalence of DP is one in 300 live births and is said to have increased since the Back to Sleep Campaign from 0.3% to 8.2% today (5,6,7,8). A study based out of Alberta found a higher prevalence rate of plagiocephaly in infants between 7 to 12 weeks of age, and to be just under 50% of the 440 sample size affected with plagiocephaly (9). There is no conclusive data to show that the rates have increased or remained stable from the Back to Sleep campaign (10,11,12).
Plagiocephaly nonsynostotic is primarily considered to be a cosmesis issue, but studies have shown that there is some evidence supporting the relationship between DP and neurodevelopment problems (13,14,15,16). However, there are conflicting results among studies supporting these findings (17,18).
Treatment for plagiocephaly consists of a variety of methods from surgery, physical therapy (PT), repositioning, and helmet therapy. Surgical intervention is not common in infants with nonsynostotic DP and should not be confused with the high prevalence of surgery in infants with craniosynostosis (19,20). Craniosynosisoss involves the fusion of sutures in the infant’s skull and is frequently treated by corrective surgery (21).
Conservative methods such as repositioning, with or without PT and helmet therapy, are often compared in the literature to determine their effectiveness in treating infants with DP, by the amount of skull reduction deformity (22,23,24). To determine if treatment methods are working to reduce the amount of skull deformity of an infant’s head, measurement tools are used. Currently there is no singular measurement tool available to practitioners to conduct an accurate and repeatable measurement of the infant’s skull, making assessment and conclusive results challenging (27,28).
A recent article published in the Netherlands made a claim that helmet therapy is ineffective in treating DP. Van Wijk and colleagues reported that letting the skull take a natural course produced the same results as treatment with helmet therapy. This is the first study to suggest that natural course is as effective as helmet therapy and that helmet therapy should not be recommended as a treatment option (25). Articles such as this can have an impact on the orthotic field, by affecting parents’ perceptions of the treatment and influence insurance companies to reevaluate their funding.
Further research needs to be conducted to determine if other studies have found similar results in that helmets are ineffective at treating plagiocephaly. An extensive review of the literature has been conducted to determine the quality and number of articles existing that support other treatment modalities, specifically helmet therapy. The review will bring awareness to the current treatment effect of orthotic care and observe the measurement methods used to obtain the data on helmet care’s effectiveness in treating a variety of levels of plagiocephaly.
Does Competency-based Evaluation Enrich P&O Students’ Learning Experience Compared to Traditional Grade-based Evaluation?
By: Patricia Dang & Emma Holmes
Contemporary healthcare education must build and maintain professional competencies and address current issues of quality and relevance (Gallagher, 2012; Lo, 2015). This requires revising and updating evaluation methods for healthcare education programs (WHO, 2013). The purpose of clinical evaluation is to prepare and induce students to work as ethical, safe, and accountable clinicians. Moreover, evaluations need to account for the multi-dimensional nature of competence, the clinical environment, and the attributes required for the healthcare profession (Levett-Jones et al., 2011; Wu et al., 2015).
Traditional grade-based evaluation has been criticized for its heavy reliance on rote memory, subjective nature, inability to prepare students for lifelong learning and stifling of growth (Ross et al., 2006; Selim et al., 2012; Slackstein, 2015). Competency-based evaluation (CBE), as defined by an integrative or holistic approach, has been established as an alternative to traditional grade-based evaluation (Fordham, 2005; Keevy & Borhene, 2015). CBE has been suggested to be a better means to acquiring clinical knowledge and skills that match the current nature of clinical practice, providing useful feedback to students, promoting self-reflection and growth, and establishing standards of competence for learners at different levels (Epstein & Hundert, 2002; Book, 2014; Heeneman et al., 2015).
Established in the 1970s, CBE has been utilized in various healthcare education programs globally, such as medicine, nursing, dentistry, physiotherapy, and occupational therapy (Books, 2014; McClarty & Gaertner, 2015). Competency, a central concept to CBE, is defined as a combination of skills, abilities, and knowledge necessary for performing a task in a given context (Fletcher, 2008; Keevy & Borhene, 2015).
The purpose of this project is twofold: 1) To conduct a literature review to determine the strength of competency-based evaluation and its ability to improve the learning experience and promote competent healthcare professionals compared to traditional grade-based evaluation; and 2) Develop guidelines for CBE rubrics for the George Brown College Orthotics & Prosthetics program that are aligned with its current curriculum.
Currently, literature on the use of CBE in prosthetics and orthotics (P&O) education is scarce, making it difficult to determine how to develop CBE for a clinical prosthetics and orthotics program. Applications of CBE in other similar health fields will be examined to determine the means of CBE implementation into a clinical P&O program. The intention of this project is to evaluate the current CBE literature to determine its potential to enrich students’ learning experience and foster professionally-ready healthcare graduates in comparison to grade-based evaluation.
By utilizing recent Practice Analyses undergone by OPC, ABC and AOPA (ABC, 2015; AOPA, 2014; OPC, 2014), domains, knowledge and skills of relevance to contemporary practice can be explored. The knowledge gained from this research can help develop evaluation tools applicable to the Clinical Methods in Prosthetics and Orthotics program through George Brown College.
About the Authors:
Emma Holmes, B.Sc., graduated from the University of Waterloo with a degree in Kinesiology. She is currently completing her final year in the Clinical Methods in Prosthetics and Orthotics program at GBC and co-enrolled in the Masters of Rehabilitation Science program at McMaster University.
Patricia Dang, B.Sc., M.Sc., is in her final year of the Clinical Methods in Prosthetics and Orthotics program at GBC. She graduated from McMaster University with a degree in Kinesiology and a Masters degree in Rehabilitation Science. Patricia will begin her prosthetics residency with Hamilton Health Sciences.
Directly Measuring Residual Limb and Prosthesis Anthropometrics for Kinetic Outcomes in Gait Analysis
By: Evan Harvey
The ability to analyze the gait of individuals with lower limb loss has significant value for assessing prosthetic device effectiveness, optimizing patients’ clinical outcomes, and for supporting further research. Gait analysis techniques have evolved considerably through the use of sophisticated motion tracking equipment and software.
The contemporary method of tracking reflective markers placed over specific body segments with high speed cameras was first developed in 1980 (Cappozzo, Della Croce, Leardini & Chiari, 2005; Davis, Õunpuu, Tyburski & Gage, 1991). Since then, this method has been employed to study various aspects of prosthesis users’ gait such as gait symmetry, altering prosthetic componentry, altering weight distribution of a prosthesis, or studying the energy consumption by prosthetic users (Rietman, Posterma & Geertzen, 2003; Rusaw & Ramstrand, 2011). However, pervasive issues remain in the methodology of most studies within the prosthetic gait analysis literature.
Typically, gait analysis research has relied on standardized protocols that dictate how the position of limb-segments are defined in order to construct a 3-dimensional model of the subject. The position of these limb-segments is conveyed through the placement of reflective markers on the subject. Popular protocols such as the Helen Hayes protocol (Kadaba, Ramakrishnan & Wootten, 1990) or methods used by Davis and colleagues (Davis et al., 1991) place markers over specific bony landmarks. In conjunction with anthropometric measurements of the pelvis and leg length, a reasonably accurate representation of the hip, knee, and ankle positions can be conveyed in a 3-dimensional model. With the use of force plates, velocities of the markers may be tracked to calculate kinetics of the various joints through inverse dynamics. However, some necessary anatomical features may be absent from these protocols in individuals with limb loss.
As an example, how one selects the location of the malleoli on a prosthetic foot has significant repercussions for where the ankle joint axis is located in the 3-dimensional model. Many previous studies have estimated the location of the ankle axis on a prosthetic foot from the sound side (Rusaw & Ramstrand, 2011; Kent & Miller, 2011) but this location does not represent the true axis of rotation. The center of rotation of prosthetic feet changes throughout the gait cycle, and can vary as much as 6cm from the conventional ankle axis as matched from the sound side (Rusaw & Ramstrand, 2010; Sawers & Hahn, 2011). Further, errors in marker placement are confounded with the component of human error associated in accurately locating joint axes and bony landmarks. This is a major source of intra- and inter-rater error in modern gait analysis systems (Baker, 2006; Della Croce, Leardini, Chiari & Cappozzo, 2005).
Underlying 3-dimensional models need to reflect the true nature of a subject’s anatomy in order to obtain accurate and valid results from instrumented gait analysis. For individuals with limb loss, one of the simplest and most obvious shortcomings of conventional models is the change in mass and mass distribution of a limb-segment given the involvement of a residual limb and prosthesis.
The current study will examine the role of a prosthesis and residuum inertial properties through two case study analyses of differing amputation levels, one trans-tibial and one trans-femoral. This research is the first to show how integrating inertial changes into the model affected gait analysis results at the trans-tibial level. The present study will compare kinetic outcomes using conventional gait analysis anthropometrics (Helen Hayes MM protocol, BTS Bioengineering) to values derived from a model that incorporates the mass and center of mass of the prosthesis and residual limb. Further, by analyzing gait from trans-femoral and trans-tibial individuals with the same study design, we can assess the degree to which inertial limb properties affect different amputation levels. This research will elaborate on the degree to which anthropometric considerations are warranted in prosthetic gait analysis.
Yoga Therapy for Phantom Limb Pain
By: Meghan Guglich
Phantom limb pain is a poorly understood phenomena experienced by many individuals who have had an amputation. It is experienced differently by each individual, and consequently, no treatment has been shown to be effective for everyone who experiences phantom limb pain (Flor, 2002). Phantom limb pain has been classified as a type of neuropathic pain, in the same category as chronic or inflammatory pain (Pirowska et al, 2013). It has also been speculated that phantom limb pain is related to autonomic nervous system dysfunction and post-traumatic stress disorder (Flor, 2002). It stands to reason that therapy shown to be effective in treatment of similar types of conditions may also be effective in treating phantom limb pain.
Yoga has been defined as the joining together of the physical and spiritual body (Christensen, 2002), and is becoming an emerging technique for treatment of many different conditions, many of which are similar to phantom limb pain. Some of these include multiple sclerosis (Rogers & MacDonald, 2015), carpal tunnel syndrome (Garfinkel et al, 1995), chronic pain (Purdy, 2013), post-traumatic stress disorder (Bormann et al, 2013), peripheral neuropathy (Head, 2006), fibromyalgia (Lush et al, 2009), and other dysfunctions of the autonomic nervous system (Purdy, 2013).
The purpose of this study is to answer the question: “in individuals who have experienced an amputation, is yoga therapy an effective treatment in reducing the frequency and/or intensity of phantom limb pain?” Christensen (2012) states that yoga is a combination of ethical practice, physical exercises (asanas), breathing, and meditation. For the purposes of this study, therapies including one or more of these components will be considered. Moura et al (2012) performed a literature review of mind-body therapies for phantom limb pain and found that no studies for yoga therapies were available. These results were confirmed with another literature search, included in this paper. There have however, been a number of studies showing the effectiveness of yoga in pain related to phantom limb pain, and therefore justification for this study.
As there is no research to date on yoga therapy for phantom limb pain, the objective of this study is to collect qualitative data to inform future quantitative research. A focus group/semi-structured interviews will be conducted to evaluate the experiences of professionals in the field of yoga for individuals who have experienced an amputation. These responses will be analyzed to help determine the direction of future research in this field.
About the Author:
Meghan Guglich received a Bachelor of Science in Kinesiology from the University of Alberta in 2014. She is now completing her second year in the Clinical Methods in Prosthetics and Orthotics program at George Brown College, and working on her Masters in Rehabilitation Science from McMaster University. She will begin her prosthetic residency at the Rehabilitation Centre for Children in Winnipeg.
Myoelectric Prostheses Controlled Through Targeted Muscle Reinnervation (TMR) Compared to Conventional Myoelectric Prostheses for Trans-humeral Users with respect to Functional Outcomes and Reduction in Neuroma and Phantom Limb Pain
By: Stephanie Pugliese-Santana
Major upper extremity amputations account for about 3% of all amputations and are most common among younger individuals (under 65) as a result of trauma (González-Fernández, 2014). If prosthetic intervention is determined to be an appropriate treatment, several options exist: passive cosmetic devices, functional devices such as body-powered and electric-powered control, or a hybrid design (Cheesborough, Smith, Kuiken, & Dumanian, 2015). Various factors contribute to the decision of which type(s) is (are) selected, but when a functional device is favoured, optimizing prosthetic joint control is a key objective. In body-powered prostheses, control is attained through shoulder movements converted by cables and harnesses into prosthetic movement. Physical strength is required and one movement is produced at a time (Cheesborough et al., 2015). Most electric-powered prostheses are myoelectric which use the EMG signal from one or two muscle groups to produce movement of the prosthesis. Here, only one movement can be controlled at a time as well, both types resulting in one degree of freedom (DOF) (Cheesborough et al., 2015). Mode-switching methods for myoelectric control strategies exist to produce further movements, but present greater challenges to those with more proximal levels of limb loss (Cheesborough et al., 2015). The rejection of prostheses is higher in trans-humeral users than in trans-radial users, and has been associated with not meeting the patient’s needs, poor control, discomfort, and poor function (Fitzgibbons & Medvedev, 2015).
Up to 71% of all those with traumatic amputations will suffer from neuroma pain. This is a common reason for discomfort within a prosthesis and there has been little success in treating this concern to improve acceptance among users (Souza et al., 2014). Phantom limb pain (PLP) is another common issue and is more prevalent among those with upper limb loss, ranging from 51-80% affected (Fitzgibbons & Medvedev, 2015). There are theories about the cause of PLP and many treatment methods, such as the use of various pharmaceuticals and mirror therapy, with mixed results in success (Fitzgibbons & Medvedev, 2015). Some research indicates that the use of functional prostheses decreases the sense of PLP as users can control their (phantom) limb through the use of their device (Bouffard et al, 2012).
Targeted muscle reinnervation (TMR) is a surgical technique developed over 10 years ago by Dr. Todd A. Kuiken, where nerves remaining in an upper limb residuum are reinnervated to other proximal unused muscle targets that have lost their function. The reinnervated muscles act to amplify the biological signal of the residual nerves to allow for intuitive control over a myoelectric device, where appropriate nerve pathways are used to produce the movement of the prosthesis as were previously used to control distal anatomical structures of the missing limb. If multiple nerves are successfully reinnervated, multi-joint control is possible with a myoelectric prosthesis intuitively, without any mode-switches (Cheesborough et al., 2015).
As an unexpected side effect, neuroma pain was reported to have completely resolved in the majority of patients who have undergone the TMR procedure and had neuroma pain prior to their surgery (Souza et al., 2014). However, this needs further evaluation as it was discovered retrospectively and requires more rigorous research for all future patients who will undergo the TMR procedure. There is also some indication that PLP may decrease with the use of a myoelectric device with TMR (Fitzgibbons & Medvedev, 2015).
Traditional myoelectric devices are limited in the number of movements they can produce simultaneously while TMR can allow for greater control over the prosthesis (González-Fernández, 2014) and TMR has been shown to restore neural pathways that would be associated with distal limb function (Scheme & Englehart, 2011). TMR at present, is best suited for more proximal amputations where disability is greatest.
The purpose of this review is to compare conventional myoelectric prostheses to those controlled through TMR for trans-humeral users. Improved functional outcomes and analysis for the use of TMR as a possible treatment for neuroma pain and PLP will be outlined along with discussion of gaps in the current literature.
About the Author:
Stephanie Pugliese-Santana completed a B.Sc. in Kinesiology at York University in 2003 and her Prosthetic and Orthotic Technician diploma from George Brown College in 2015. She is completing her studies in the Clinical Methods in Orthotics and Prosthetics at George Brown College.