It Takes Two

By Judith Philipps Otto

Practitioners and Technicians Partner to Provide Fresh O&P Solutions

Finding new and creative approaches to meet the multitude of complex O&P patient needs is a tall order, and achieving a successful outcome often requires a special partnership. When O&P practitioners and technicians work together to develop and fabricate devices that meet these needs-functionality, comfort, convenience, durability, and affordability-the results are often amazing and far-reaching. The O&P EDGE asked several practitioner-technician teams to share stories about some of their most recent collaborations. The solutions they provided combine experience, ingenuity, and insight, resulting in game-changing service capabilities that benefit current and future patients alike.

Shopping "Outside of the Box"

Kuffel

Charles Kuffel, CPO, FAAOP, and his team at Arise Orthotics & Prosthetics, Blaine, Minnesota, discovered the perfect component for a HKAFO in-of all places-a local farm supply store. The patient, a five-year-old girl with spina bifida presented with significant internal rotation of the feet, and her therapist had some exacting special requests.

"The therapist wanted to be able to give the child positioning AFOs while in the device, and [the ability to] transfer to a KAFO or an HKAFO while she was ambulating with a walker. Kevin Hines, CPO; Erik Engstrom; David Heyd, CO; and I put our heads together and found a product at Fleet Farm-a farm industry store similar to Home Depot," says Kuffel, president and clinical director at Arise.

The clevis pin they discovered has a locking mechanism that allowed them to create a modular design, unlocking and separating one section from another-and rejoining the sections at the therapist's and user's convenience.

"We could unlock the AFO from the whole unit, or we could have a KAFO...and unlock that from the rest of the unit," Kuffel explains. "We used these clevis pins so that the patient's mother could put the AFO section on the KAFO uprights; pushing the clevis would then lock it into place. She could do the same thing with the KAFO, attaching it to the pelvic section. She could move easily from an AFO to a KAFO to an HKAFO on one side or bilaterally."

From check sockets to fittings, the entire fabrication process took about six weeks and perhaps 20 modifications, Kuffel says. "We would mock up the device in the office and bring it to the therapy session. The things the therapist liked, we'd incorporate; what they didn't like or the parents had difficulty managing-like locking the knee down or unlocking the knee-we'd take back to the lab and come up with another solution."

Hines

Hines has created several more modular HKAFOs since that first prototype was developed last year. "We're achieving the goals of the therapists and the doctors because sometimes they want these kids to have maximum support, and sometimes they want them to work as hard as they can possibly work," Hines says. "The lower you go with support from the brace, the more work they have to do."

The clevis pin solution has worked so well for the Arise team that they are still using it. "On a couple of [different] sets of KAFOs, we've used the same design to allow patients to remove the AFO section and basically have just a knee brace remaining," Hines says. "[The pins] come in a variety of different sizes, so you can use them in braces for a small person up to an adult. Drill the hole, and when you vacuum form the orthosis, just slide the pin through. Because the pin has a ring that snaps over the protrusion as soon as you slide it through, it locks over the two levels of plastic and holds them securely in place."

The technician's part in this process was essential, Kuffel says. "Eric [Engstrom] pointed out how we could thermoform the parts but wouldn't be able to attach component A to component B. He came up with a way to put that clevis in the lower leg portion of the brace."

Engstrom

Engstrom is a board-eligible orthotist/prosthetist who is completing a residency at Arise. He currently works on both the practitioner and technician sides of the house, and says this experience is a definite plus. "I can draw on experiences on the practitioner side to help design and anticipate the need from the technician side-so I call myself a 'practechtioner,' " he jokes.

Fabrication posed a particular challenge with this modular solution, specifically attaching the hardware to the thermoplastic sections, he explains. "It was a successful use of materials outside of our industry to accommodate our special needs- and to benefit a lot of patients."

Engstrom says he believes that the connection between the practitioner and technician is critical. "Often, important aspects are lost in translation from the practitioners to the technicians. It would be helpful if more people had a tech background and understood what technicians need to do their job well. It's incredibly important, and unfortunately the industry is moving away from teaching technical skills to people on practitioner paths."

Besser

Creative Communication

Andy Besser, CPO, branch manager of American Prosthetics & Orthotics, Davenport, Iowa, patient care facility, agrees. "As practitioners go through less technical training, we have to rely on our technicians more, so they have to be educated-either on the job or through a school program. If you're not working as partners, then you don't hit the home runs that you'd like to hit."

When things go wrong in the practitioner-technician relationship, it's often due to lack of communication and making assumptions, he notes. "Don't take for granted that the technician knows what you mean because it's clear in your head."

Besser says that including images with written communication can be a big help as well. His own lab is considering using Skype to connect practitioners and technicians so the practitioner can see the socket and the changes made before the technician sends the device out. In the past, they've used video with good results. He cites a case of a patient with Charcot Marie Tooth disease who had developed a limb deformity and underwent an elective amputation because of the issues caused by the deformity.

"In the alignment that we ended up with, the foot was so far outset from the socket that there shouldn't have been any way, biomechanically, that it would work. But we used video to justify the alignment. In watching the patient walk on the alignment componentry before going to a definitive prosthesis, it was demonstrably correct. [The patient was] walking with a good gait, had great control at mid-stance, and was functioning very well. Even though the alignment appeared to be out of the norm, it was appropriate for that patient."

Ultra-Light Lamination for Paralympic Performance

Arise Orthotics & Prosthetics fabricated a modular HKAFO system using clevis pins from a local farm supply store.

S. Bret Lee, CPO, ProCare Prosthetics and Orthotics, Flowood, Mississippi, created a unique and highly successful prosthesis for Richard Browne, who had been a high school football player with a bright future at a Big Ten school before a tragic accident ultimately led to the amputation of his right leg below the knee in the fall of 2009.

Following his amputation, Browne's goal was just to go to his girlfriend's prom without a wheelchair or crutches, "but he recovered faster than anybody I'd ever seen," Lee marvels. "At six foot, five inches and 185 pounds, this big, tall guy was walking with no assistive devices within six weeks of his amputation." After learning about Browne's former athletic ambitions, Lee searched for a donor company to provide an appropriate running or sprinting foot and reached out to Freedom Innovations, Irvine, California. Browne ultimately became the first sprinter in the world to train with the company's new Catapult running foot.

American Prosthetics & Orthotics uses video to help enhance practitionertechnician communication

"The Catapult is great because not only does it provide up to 30 percent more energy return, it allows Richard to make his own alignment and stiffness adjustments. Over time, he has learned to change it exactly how he wants it for each different event."

Tapping into his collegiate athletic aspirations, Browne shifted his focus from Big Ten football to a Paralympic achievement-specifically in the 100m sprint, the 4x100m relay, and the high jump. According to Lee, Browne is very sensitive to heights, and he's always looking for new components. While training for the Paralympics, Browne happened to be attending an O&P trade show and saw a pylon that would allow for easy prosthetic height adjustments-the adjustable pylon from Kinetic Revolutions, Frederick, Maryland.

Gilbert and Lee collaborated on the fabrication of paralympian Richard Browne's prosthesis. Photographs on this page courtesy of ProCare Prosthetics and Orthotics.

"All we have to do is loosen that one screw, and we can adjust the height in small increments and tighten it back up, which is cool," Lee says, "because we don't have to cut or change pylons for any height adjustments."

Lee, a hands-on fabricator, was working on the initial design of Browne's leg and suspension system when Steve Gilbert, CPA, was hired at ProCare and began working with Lee on the project. Gilbert began refining the prosthesis and whittling down the weight.

"It's always been hard for me to let go and let the technicians take over because there's a giant void in our industry in truly hands-on skilled technicians and hands-on skilled practitioners," Lee says. "But Steve really knows his business."

Browne won a silver medal in the 100m sprint at the London 2012 Paralympics.

Gilbert, ProCare's laboratory manager, admits that his experiments with the Browne prosthesis were largely trial and error. "I've done thousands of laminations before. Bret gave me the freedom to use different components and different types of materials, and we worked together and came up with an ultra-light, very strong lamination. I just kicked around a few ideas and did a few laminations until we came up with the perfect combination of carbon fiber, fiberglass, and a material called SpectraCarb, which has benefited our other patients as well."

The trick is in the materials and the way the lamination is layered, Gilbert says. "You don't want any air or a lot of buildup of the resin; it's got to be perfect. You've got to be sure that you have a durable bond between the layers in the weight bearing areas; otherwise, Bret's socket design wouldn't work because it would flex. In my experience, carbon fiber is very strong, but it can also be very brittle. Fiberglass addresses that but adds bulk and weight.

"When you're making a racing socket such as we designed, you've got only so much material and weight that you want to utilize-yet you have to make it strong enough to sustain the torque when the athlete is being as fast as he possibly can be,"

Gilbert explains. "This is especially true for someone with Mr. Browne's strength and speed, which literally abuses the prosthesis. The components must also be seated properly; if he has concerns about the lamination or the components failing, then he's not going to have the confidence to get out there and go at his full potential."

The final version of Browne's Paralympic prosthesis weighs only three pounds, six ounces.

Mattear

Lee advises practitioners to stay involved throughout the process and work more closely with their technicians "without being overbearing or over-controlling. I've seen a lot of practitioners insist that things be done exactly the way they do it. But you have to give the technicians some creative freedom and let them add their own spin to it." Brad Mattear, CFo, vice president of the Orthotic & Prosthetic Technological Association (OPTA) agrees and stresses that now more than ever, it's imperative that practitioners and technicians have highly collaborative relationships.

In the old days, a lot of the practitioners made their own devices, he points out. This is done less often today since midsize and larger O&P practices either employ one or two technicians to fabricate or outsource some or all of their fabrication.

From left: An early model of Richard Browne's prosthesis. Browne's final prosthesis. Photographs courtesy of ProCare Prosthetics and Orthotics.

"Without communication," Mattear says, "the fabrication of the devices is at risk. In running a large central fab in the Midwest for eight years, I can't tell you the myriad of inconsistent communication I got from practitioners around the country. Things were written with no names, and work orders were sent in with incomplete information; I've even had things sent to me on a bar napkin!"

The relationship between the practitioner and technician is far different than it was 20 years ago, when technicians were overseen by mentors, he observes. "Today the technician needs to be able to better understand the...fabrication process from A to Z...," Mattear points out. "So to me, the number-one value is communication between technician and practitioner. The new-school practitioners who are coming out must supply the pertinent and necessary information, the documentation, and the measurements needed to produce a quality custom-fabricated device. If practitioners would do that, they could get back what they want the first time."

Prosthesis Cover Goes Global

Swanson

Whitacre

Vern Swanson, CP, LP, Westcoast Brace & Limb, headquartered in Tampa, Florida, developed a durable, lightweight, endoskeletal prosthesis cover to meet a recurring patient need. The popularity of the cover has spread as far as Australia, as well as to a growing number of U.S. clients. The cover can be easily removed and reapplied, allowing alignment adjustments to be completed in a fraction of the time needed with more traditional options.

"We decided last year to really start using the QuickLite™ Cover here, and together with Brian Whitacre and Greg Bauer, CPO, LPO, our president, we've evolved and developed it further," Swanson explains.

Suitable for preparatory and permanent prostheses, QuickLite Covers are made of polyethylene foam and pre-shaped to reduce fabrication time. They weigh two ounces or less and can be installed in about 30 minutes-serving as both protection and realistic cosmesis for prosthesis wearers. They are easy to clean, and since they are not permanently glued to the prosthesis, they are easily removed to make frequent updates to the prostheses of new amputees, for example, Swanson says. "Patients who are very active prefer to frequently remove their cover on their own when participating in sports or going into the water, so we've developed a split design with a Velcro® opening on the back side of the cover that enables this," he says. "The patient can remove and reinstall the cover at will-without any tools-anywhere they happen to be."

The primary challenge in developing the covers, Swanson notes, was the number of molds required. "The series includes small, medium, large, and extra-large molds in both left and right designs, so we had to make corresponding molds and create a sizing chart. We make covers and keep them in stock for our own use so that patients can be fitted with the right size, based on the chart, while they wait."

The development process took about four months, Swanson says, but it continued to evolve as other covers were developed-for transfemoral prostheses, for just-above-the-knee discontinuous covers, and designs for specific types of feet and other components.

Whitacre and Swanson fabricate a QuickLite Cover. Photograph courtesy of Westcoast Brace & Limb.

The choice of materials was another hurdle. "Our goal was a washable material that is lightweight, sands easily, and holds up well so it can even be used on adolescents, for example-so it's pretty tough," he explains. "We tried different commercially available thermal materials, since thermoforming material allows us to heat it in order to conform it to fit a particular socket size. We tried harder materials, thinner materials, different thicknesses, softer materials-it took several months to make the choice and to develop all the molds."

"The covers have been available since January and represent a true collaboration between our technical staff and the practitioners," Swanson says. "I think you really need to have a great team working together."

As the lab manager, Whitacre handles the crucial adjustment requirements for each specific cover in Westcoast's on-site fabrication laboratory. "Each cover is separate, so depending on the size and the shape of the socket, we have to contour the QuickLite so that it fits nicely and is aesthetically pleasing," he says. "Sometimes we have to deal with alignment issues, and in cases where the patient has an elevated vacuum pump or vertical shock componentry, it can be a little challenging. Because the leg actually moves inside the cover, we have to adjust the cover so that it will accommodate that movement. Rotation issues can also require a change in the fit, which is normally very nice and snug.

"A QuickLite Cover crafted for a temporary prosthesis can be adjusted and adapted to fit the permanent prosthesis as well," Whitacre adds.

The covers save more than just time. "Since a prosthetic leg can't be billed until it's 'complete,' meaning it must have a cover, often this is a good way to quickly meet billing requirements," he notes.

Creativity doesn't come with an instruction manual. It's often easier and faster to use existing pathways than it is to devise original, and often more effective, solutions. But when dedicated and gifted practitioners and technicians pool their skills, persistence, and inspiration into a dynamic partnership, their successes can reach far beyond personal gratification-they can be life-changing for current and future generations of O&P clients.

Judith Philipps Otto is a freelance writer who has assisted with marketing and public relations for various clients in the O&P profession. She has been a newspaper writer and editor and has won national and international awards as a broadcast writer-producer.