Dynamic Collaborations: When the Sum Makes All the Parts Greater
May 2011 Issue
When O&P research combines with practitioner education and clinical patient care, great things can happen.
As the O&P profession continues to trend away from its days as a craftsman's trade toward a more clinical and evidence-based discipline, biomedical engineers, educators, graduate students, clinicians, and researchers now share information and expertise in a profession that has long been known for its collegial relationships. These relationships are, perhaps, the most broad and robust when they are formed and nurtured in a university setting. What may best exploit these relationships as well as the creativity and expertise of its staff to optimum advantage, is the university that adds clinical care to the standard model. When an on-site patient care facility is attached to university research and education programs, certain benefits are realized that can't be found when these disciplines exist independently. The synthesis of intellectual, technological, and study-subject resources under one roof allows for synergies uniquely positioned to strengthen each area.
Patients motivate O&P researchers because each limb-loss issue presents intellectual challenges that require myriad levels of creative problem-solving. From a practical perspective, patients who are present on-site provide consistent real-world reminders of the pressing needs of this niche population. Case in point, the New Brunswick Limb Deficiency Clinic opened its doors in 1982 as part of the University of New Brunswick's (UNB) Institute of Biomedical Engineering, Fredericton, Canada, and the impact of on-site patient care continues to fuel research and educational projects.
"We don't have to go looking for problems," notes UNB Professor Kevin Englehart, PhD, PEng. "They're there." The clinical nuances each patient presents serve to inspire because "when you come into a building that's a living clinic, the reasons why you're doing the research are coming through your front door every day," Englehart says. "From a faculty member's perspective, it's really an amazing place to be...." The UNB clinic specializes in upper-limb amputee patients, many of whom possess challenging presentations, and the majority of the prosthetic care provided is custom, with a focus on myoelectric fittings. The clinic's research prosthetist and prosthetic research technicians regularly consult with the institute's engineering staff. "The expertise of the engineering staff enables the clinic to provide unique electromechanical and control options that would otherwise be infeasible with existing prosthetic hardware," notes research prosthetist Greg Bush, BA, CP, who says the team approach enhances patient outcomes.
The institute's research program has been actively working to decode information in human muscle signals for use in artificial limbs since the 1960s. The area is considered a specialty, with UNB researchers contributing their work with pattern-recognition technology to the Defense Advanced Research Projects Agency (DARPA)-funded DEKA Arm (popularly known as the "Luke" Arm) project. The UNB team has also been involved in the Johns Hopkins University Applied Physics Laboratory (JHU APL), Laurel, Maryland, DARPA-funded Modular Prosthetic Limb (MPL) project. (Editor's note: For more information about the two DARPA-funded upper-limb projects, read "DARPA's RP Arms in Transition: From Miracle into Reality")
UNB is now focused on developing a generation of artificial limbs that don't overwhelm users with complexities they don't need. Englehart explains the rationale for this approach: "Whenever you introduce a new technology, it's not going to be adopted if it's going to be intimidating or if it's not going to behave the way people expect it to." The research team is working to hide the complexity, he says, "so that the user only sees the function that they can extract from it rather than all the stuff that they don't need to be worried about." Currently dubbed the UNB Hand Project, the device will be as functional as "anything out there," according to Englehart, but it will be designed so that it's inexpensive to manufacture with "some pretty novel stuff under the hood relating to our pattern-recognition work and some novel sensors that we're putting into it as well." These sensors will allow for more intuitive user control. The project is slated for completion in two years, and the device's lower price tag will potentially induce insurance companies to cover its cost.
UNB's institute has developed expertise in the software and hardware details associated with advanced myoelectric control, and its collaboration with the Research Institute of Chicago (RIC), Illinois, recently earned recognition when Todd Kuiken, MD, PhD, director for the Center for Bionic Medicine and director of Amputee Services at RIC, rolled out at the American Association for the Advancement of Science (AAAS) annual meeting in Washington DC the first pattern-recognition-controlled prosthesis stable enough for users to take home. The "six motor arm," as RIC refers to it, comprises a wrist rotator from Otto Bock, Duderstadt, Germany; a Boston Elbow from Liberating Technologies (LTI), Holliston, Massachusetts; and a prototype shoulder flexion/extension unit from Touch Bionics, Livingston, Scotland. The custom control hardware that is integrated into the arm runs on software developed jointly by RIC, UNB, and Otto Bock. Good candidates for the prototype are those with high-level deficiencies, such as shoulder disarticulation patients or short transhumeral amputees, Englehart says.
According to research occupational therapist Wendy Hill, BSc, OT, patients at UNB's clinic who serve as test subjects are proud to actively contribute to the research team—for the most part. "Our patients...see what may be possible for them in the very near future and [how the results] may open doors for people," she says. But gathering a pool of subjects to draw upon for clinical studies is one area that continues to be a challenge for the profession.
For O&P research, it's tough to get "the numbers necessary to make any real statement of...value," argues Jeffrey Wensman, BSME, CPO, clinical and technical director at the University of Michigan (U-M) Orthotics & Prosthetics Center (UMOPC), Ann Arbor. Clinical practitioners and residents at UMOPC conduct preliminary research on patients suffering from spinal cord injuries resulting from trauma, for example, and may form hypotheses based on the results of their informal studies. However, Wensman asks, "how are we going to get 50 [test subjects] to do an actual study? That's the challenge in all of O&P...." While Wensman notes that UMOPC's primary mission is patient care, he adds that most of the practitioners and technicians are involved in education to some degree as they mentor O&P residents and work with new physician residents.
UMOPC patients serve as test subjects for a current collaborative Department of Defense (DoD)-funded project led by Art Kuo, PhD, on a prosthetic knee-ankle-foot system intended to improve comfort and endurance for active amputees in rugged environments, which will provide objective measures of performance, according to a Department of Veterans Affairs (VA) press release. Studies at UMOPC are also being conducted by Megan Zachar, CO, on pin complications, and a multiyear project by Steven Strasburg, CO, is analyzing the effects that cranial remolding helmets have on infant developmental milestones. Resident Katie Antle has earned a fellowship to study the treatment of phantom limb pain in combination with pre- and post-amputation rehabilitation protocols, Wensman says.
UMOPC researcher and committee chairman Ammanath Peethambaran, MS, CO, FAAOP, is at work on a method to create models suitable for TLSO fabrication from CT scans. As a recognized Level I Trauma Center, U-M's University Hospital has a "large halo population...so a lot of orthopedic and neurosurg cases...get med-flighted in," Wensman notes. UMOPC orthotists fit several body jackets per day, according to Wensman, a factor driving Peethambaran's study.
Research Opportunities Attract a New Type of O&P Student
While there is still a decided lack of research information in the field, the deficit seems to be serving as a gauntlet thrown, attracting young, ambitious minds anxious to fill the void and make their mark on the profession. "Getting involved in research within the field is critical to furthering its development," says Marissa Berkowitz, a biomedical engineer and O&P graduate student at the University of Texas (UT) Southwestern Medical Center at Dallas. She is currently investigating the effects of suspension on functional performance, particularly as they relate to pistoning. Very few studies exist on the subject in the O&P literature, she says. Berkowitz agrees that part of the reason for the dearth of research is due to the inadequate number of test subjects for O&P research in general. She also cites the additional complexity of finding enough subjects who accurately represent the population under scrutiny, as each patient is unique. As a result, researchers must use some ingenuity to overcome these barriers. "That's why we've...decided to perform [this project] from an engineering standpoint, using a wooden replica of the lower extremity [and then] analyzing those results [before] moving on to human subjects," Berkowitz explains.
Given these challenges, it's no wonder that a university setting that offers access to patients willing to serve as test subjects is an attraction to incoming students. "That's what drew me here," Berkowitz says. In addition to the clinical environment, students are able to "collaborate with all of our teachers who are also practitioners," she adds. Her point underscores the quality of the relationships that develop between faculty and students because as co-researchers, they relate not only as faculty-to-student, but also as peers. Berkowitz works on refinements to her research process with Susan Kapp, MEd, CPO, associate professor and director of the UT Southwestern School of Health Professions at the UT Southwestern Medical Center at Dallas Prosthetics-Orthotics Program, and Fan Gao, PhD. What began as a test for a new suspension mechanism—which was recently launched in the market—quickly broadened into a more comprehensive study. Berkowitz is now developing a baseline to make comparisons between a locking-pin suspension system, a suction suspension system, and a system that is a combination of the two. She will then quantify "the linear displacement within the socket to determine the amount of pistoning...," she says. When she presented the wider-scoped project to Gao, he gave her the green light to move forward.
Diversity Breeds Openness
Hill maintains that the diverse student body at UNB contributes to an openness in communication between faculty and students, as well as among the various specialties. "Coming from different backgrounds, I think we share different information than [we] would if [we] were all engineers or all clinicians, and we tend to talk about things and come up with different ideas because of that." Bush says that UNB students don't feel intimidated when addressing faculty, and the team atmosphere helps keep them motivated and excited to learn.
Berkowitz agrees, noting that her O&P master's degree program has a class of 13 people with backgrounds in a host of fields including engineering, kinesiology, and art. She says everyone has "ideas they bring to the table."
Patients on-site also help to prevent the disconnect that occurs when the teaching of theoretical concepts remain uncorroborated by real-world scenarios.
Kapp builds a case for the role of experiential education, or infusing classroom content with direct experience, on both students and faculty: "In our experience as educators and clinicians, we are able to bring real-life examples into the classroom that allow us to teach beyond the textbook," she says. "Our students appreciate that they can see the direct application of knowledge and in turn, we feel that this helps to develop their problem-solving skills. We feel our students also benefit from seeing their instructors practice what they preach." Gao and Leslie Gray, MEd, CPO, a practitioner at the UT Southwestern Medical Center O&P Clinic, agree.
Time for Research Helps Build the EBP Base
At UNB, time priorities have been structured so that students and clinicians can take full advantage of the opportunities presented by combining research with patient care. There's an institute-wide mandate requiring that clinical personnel are not 100-percent dedicated to patient care. Practitioner time is protected for research, according to Englehart. Hill clarifies: "We don't book patients back to back so that we're making up the dollar amount by the end of the month." While researchers' time fluctuates in the lab, "We consider their time spent doing research as an investment in the future both for ourselves and for the patient," Englehart adds.
How UNB graduate students spend their time has likewise changed as a result of a strong emphasis on patient care. "Ten years ago, a typical graduate student project would...[involve] the task of decoding the myoelectric signal and trying to make the system 2 percent more accurate in a very tightly controlled situation," Englehart says. "That result would have been the goal of their thesis: an algorithm that would have been better than the last algorithm measured by some non-clinical measure with subjects that were not amputee patients." Nowadays, engaging amputee patients in outcome measures is commonplace, he notes. For example, a current post-doctoral project employs the motions of the residual limb itself as a control method that Englehart says will allow for a more intuitive control for subjects with high-level limb deficiencies. The product is still in the prototyping stage, and an article about its benefits is slated for inclusion in a future issue of the Journal of Rehabilitation Research & Development (JRRD).
Information dissemination is key to hastening the impact of advancements and discoveries made in the research programs on decision-making at the clinical level. To expedite this process, clinical practice presentations are given twice per month at UMOPC. Each month, residents discuss a journal finding or case study, and one of the clinical staff presents on a similar topic in a grand rounds format. These discussions are facilitated by visiting physicians, residents, or clinicians who are in the throes of interesting cases. "We've had talks on halo application, the Helix Hip...[and] spinal management with SpineCor for adults.... Any time a practitioner has some new expertise gained from doing multiple cases of something, they will share their experiences so other practitioners can be better prepared to help their patients," Wensman says. In addition to their educational value, he adds that the talks are fun and keep things interesting.
To remain current in the latest methods and training techniques, UNB staff also attend professional development conferences regularly, according to Hill. "We use standardized outcome measures to ensure quality work," she notes. As a member of the Upper Limb Prosthetic Outcome Measure group, Hill is helping to advance a standard method of assessment that will benefit the clinic's upper-limb amputee patients and others around the world. In addition, UNB will host MEC '11 (Myoelectric Controls Symposium) this August, an international conference on advanced limb prosthetics where "academics, clinical professionals, and vendors come together and assess the state of the art and share," Englehart says. He characterizes the conference as a think tank and claims that "almost despite the fact that [attendees] are competitors, there's a collegiality that's really quite neat." UNB has hosted the event for 25 years, in part because it "keeps us linked to the international community in terms of patient care and research," he says.
Due to the rapid-fire advancements occurring in the profession, Kapp, Gao, and Gray, agree that it is not sufficient to rely entirely on previous experiences and therefore, "evidence-based medicine is essential in clinical practice," they say. They describe UT Southwestern's research course as one that teaches students how to critically explore the literature and appraise the quality of the study's design, reliability, validity, and statistical analysis, in addition to an interpretation of the findings under discussion. The university's master's degree program emphasizes life-long personal and professional development, Kapp says.
An intellectually stimulating and collegial university environment seems to augur well for a patient population willing to participate in O&P research. Wensman underscores that at U-M, "the primary mission is patient care," adding, "our daily challenge is to meet the needs of our patients while pursuing the interests of research and education.
"We do it because of our commitment to the field and the desire to pass on what we know and have learned and to have an influence on the next generation of providers." Regarding the synergies created by combining separate disciplines under one roof he notes, "I think the balance of clinical care, research, and education keeps our team actively engaged in their work for life."
Pam Martin can be reached at