I got several responses related to my question. I will post them after I get off my little soapbox. My thoughts on this combination of technology was to allow a more normal gait and if there is knee flexion occurring in swing then it seems to me that there would be a lower energy requirement. When I fit a patient without active hip flexors I am relaying on trunk shift and balance transfer to allow the hip to flex. If we can achieve knee flexion in swing will the amount of trunk lean and “mechanical hip flexion” required be decreased. I have fit several adult sci patients with rgos, some with the argo and others with the isocentric rgo. They tend to be successful household or exercise ambulators and use the device 4-6 times per week for about 2-4 hours each session. The majority of my adult patients have only used these devices for 6 mo to 2 years, with the incomplete tetraplegics using them for about 1 year. Most of my patients are very positive about the opportunity to walk. The complaints I have had are the bulkiness of the device, the need for assistance in getting it donned/doffed (especially the tetraplegics), the stiff unnatural gait, excessive force required by the upper extremities (tetras mostly) and the cosmetic outcome of the devices. I think the reason that most of these patients do not continue to use these devices beyond 2 years is the same reason so many of us have gym memberships we don’t use. Life gets in the way and it is just too hard to keep up this routine. America is remarkably accessible and using a wheelchair is easier. I found (this is all anecdotal) that the taller the patient is, the more motivated he/she is to use the device in public. Its is difficult to go from 6′ to 4 1/2′ in a chair, your whole perception of the world changes.
So what am I going to do? I think I will trial him in an argo and see what he thinks about his gait and energy cost. Medicare will not pay me for the e knees and I have a small practice without a large margin. If Becker would like to donate the e knees I would love to try this combination. Orthotics is finally going high tech, we need to try different combinations in order to better serve our future patients and offer them better options for treatment.
The responses are as follows:
Have you contacted RSL Steeper about your ideas for the RGO as it is my
understanding that when they designed their RGO it was for paras as we
discovered when we went to an inservice because we were fitting spinabifida
patients with various pathologies and having problems.
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In presentations in Nawlins, the potential for increased ability, with intense training, for a patient to ambulate with RGOs and Eknee combination. the eknees would allow some knee flexion which would decrease the amount of upper body extension and therefore less COM displacement. Talk to Gary Bedard at Becker
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What would be the benefit to the patient’s ADL by adding those knees to an RGO which needs to utilize locked knees to operate? Just curious on your thoughts as I might try it myself.
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I think that combining RGO’s and any type of Stance Control Knee Joints is very intreiging. You first need to evaluate your patients manual muscle strength. I know that the E-Knee does require some HIP Extensor strength for normal use. An T8-T11 will not have any hip or knee muscle strength. My first thought is that combining the two may be too much orthosis for your patient. That system may have tremendous potiential for a L1-2 neurosegmental level patient.
I would contact either Gary Bedard CO or Jim Campbell CPO at Becker Orthopedic for more information on the E-Knee.
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How is his quality of life right now? Does he need this orthosis or is it
simply ” Let’s try this and see if you will like it?”. If he needs it, go
all of the way. If it is simply a matter of “trying it out”, I would take
baby steps.
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Medicare’s current position on the high-tech knees is that they are equivalent to a drop lock (L2405?) and are denying the use of the miscelleneous or unlisted code (L2999) for this procedure. I have a gentleman that would be a good candidate for the Otto Bock Free Walk system and this is what they told me. All of the manufacturers of the High tech knee joints are scrambling to get M’care to reconsider this position, but they tell me that it will be July 1 at the earliest before M’care will likely rule on this. So, even if this were a good idea, I don’t think you would want to take the ($$) hit to go this route without your client guaranteeing reimbursement. Beyond that, I think that one of the indications for use of the E-knee is some decent level of hip flexors, right? Plus, the locking mechanism is force activated through the footplate and may depend on some minimal velocity in swing to gain the desired knee extension for initial contact. Becker has folks who can consult with you on the challenges that this particular client presents. Let me suggest that you consider the Up and About system distributed by Cascade Orthopedic. You eliminate the hardware at the hips and the pelvis, so its much lighter and easier to don, which may be more practical and appealing to your client.
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I am not aware of any EKnee’s used in conjunction with an RGO. I applaud
your enthusiasm, creativity, and open mind.
The biggest consideration will be the need to control the flexion moment at
the knee. Prior to each reciprocating step, an inherent flexion moment may
be present and ‘seen’ by the EKnee. As you know, the EKnee will not unlock
while a flexion moment is occurring.
In order to achieve the required biomechanics, I would consider fabricating
the RGO with aggressive anterior (floor reaction) shells. This, combined
with the rigid dorsi block, will likely prolong the extension moment late
enough in stance to allow the Eknee to unlock reliably.
We are planning to try this here in Cleveland soon. Perhaps we can keep each
other posted in order to learn more for this type of fitting.
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I have a similar patient and thought of this too, but there will need to be some knee extension assist as the knee will flex when unloaded from the sensor. Without this the momentum of the limb cannot extend the knee. Heel sensors would need to be pretty sensitive too. I put an ARGO on from Steeper (eval loaner) and kept the knee unlocked. This unit had pneumatic extension assist and would probably work with e knee. Let me know what others say!
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Let me know your responses and whether or not you do this. I have not had
much experience with either system, but always thought it would make a lot
more sense if the knee could bend, and now with stance control, it seems
like it should work.
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Thanks for all your responses, I think this is a much better use of this listserve. Thanks Paul for letting it be available.
Anne Pare’, CO
