Technology Convergence

Orthotic devices are blurring the line between orthotics and prosthetics. [caption id="" align="alignnone" width="575"] Photograph of C-Brace Orthotronic Mobility System user courtesy of Ottobock.[/caption] When orthotic technology takes a page from prosthetic technology's book, great things can happen. Since the introduction of the C-Leg® in 1997, myoelectric control of lower- and upper-limb prosthetic devices has become ubiquitous to prosthetic care. Today, some of the same technologies that helped put prosthetics on the map are being applied to orthotic devices-and patients are reaping the benefits. "Power Steering" for the Arms Myomo's MyoPro™ custom arm orthosis uses noninvasive myoelectric sensors to assist with arm motion in patients who have partially paralyzed arms or debilitating arm weakness due to neuromuscular damage. Rather than using electrical stimulation, the MyoPro relies on the user's muscle signals to function. When the user initiates arm movement, sensors in the brace detect weak muscle signals in the arm, which activate the device's motor and allow the user to move his or her arm at the elbow joint in the desired direction. The patient controls his or her arm; the MyoPro simply amplifies the muscle signal to complete the movement. "I like to compare it to power steering in a car," explains Jon Naft, CPO, LPO, general manager O&P at Myomo, Cambridge, Massachusetts, and founder of Geauga Rehabilitation Engineering (G.R.E.) headquartered in Cleveland, Ohio. "If you try to turn the steering wheel with the car off, it's almost impossible, but if the car is on, you can spin the wheel with just a finger. With the MyoPro, the patient decides how much power assist is needed, as well as when it is needed." The wearable brace grew out of technology first developed in 2007 by graduate students at Massachusetts Institute of Technology, Cambridge, who were trying to adapt neurological feedback systems used in myoelectric prostheses to orthoses. Naft and the MyoPro team have adapted this technology and created a powered device that helps patients learn-or relearn-how to move their biceps and triceps. "It's one of the most significant projects in O&P that I have worked on during my 24 years as an engineer and CPO," Naft says. As of May 2013, MyoPro had provided device training to more than 50 practitioners in 18 states. The training, which can be completed at the practitioner's site or at Naft's Cleveland patient care facility, involves three parts: indications for and use of the device; molding and casting techniques; and clinical documentation. [caption id="" align="alignnone" width="300"] Photograph courtesy of Myomo.[/caption] Naft has personally fit the MyoPro on 44 patients, the majority of whom have damage from stroke. He has fit patients with cerebral palsy, multiple sclerosis (MS), amyotrophic lateral sclerosis (ALS), traumatic brain injury, and spinal cord injury as well. John Jacobs, CPO, practice manager of the Ability Prosthetics & Orthotics, Frederick, Maryland, patient care facility, has fit six patients with the MyoPro. He says the ideal MyoPro candidate should have some range of motion (ROM), mild to moderate muscle tone, at least 1/5 muscle strength, and know how to fire his or her muscles. Just knowing how to fire a muscle isn't always enough, though, Jacobs says. The user also must be able to connect a movement pattern to the firing of the muscle. "We had a relatively young stroke patient who just couldn't make the [neuromuscular] connection," he recalls. "Once he felt it [with the MyoPro assisting his arm movement], he got it and sat there lifting his arm over and over about 50 times." That's the reaction Naft says is key to MyoPro's success as a solution for individuals with upper-limb disabilities. Ongoing physical and occupational therapy is integral to patients' success using the MyoPro, which is why the company trains physical therapists as well as orthotists on the device. Similar to the process of learning to use a prosthetic device, it is important for patients to learn proper techniques for moving their limbs with the MyoPro, Nash says. Penny McQuarrie, PT, NDT, co-owner with her husband Rich McQuarrie, PT, NDT, of McQuarrie's Physical Therapy, Braddock Heights, Maryland, has worked with Ability on about a half-dozen MyoPro patient fittings. "We work together, and we can adjust the settings on the device during a session to make it more challenging or less challenging depending on where the patient is that day," McQuarrie says. "The patients also have some control over the settings to adapt to their level of daily activity." McQuarrie says that all of the MyoPro patients she has worked with have had experience with other types of devices, and many have had some degree of frustration with their level of function. The MyoPro's biofeedback system takes minimal commitment to learn, and successful users are pleased with the results to date, she says. [caption id="" align="alignnone" width="300"] Photograph of MyoPro orthosis user courtesy of Myomo.[/caption] Naft agrees, saying the MyoPro is easier to fit than a myoelectric arm prosthesis, and very rewarding to provide to patients. "These are patients with disabled arms who have been told that their level of upper-limb function is not likely to improve," he explains. "When they use the MyoPro for the first time, they can instantly do something they never expected to be able to do on their own, like feeding themselves or scratching their own nose." "We don't have any long-term data, but patients tell us that just to be able to cut their own meat again is a huge accomplishment, especially if other devices haven't let them do that," Jacobs says. "As a practitioner, that makes me feel that I have accomplished my goal of helping people." "It will be interesting to see how patients respond when they can be fit with a MyoPro closer to their incident," McQuarrie adds, pointing out that the patients she has seen have all been several years post-trauma. MyoPro engineers have already tweaked the system based on clinician feedback. The MyoPro software can be run on Windows PCs as well as the initial tablet-based system first deployed, and Naft says the company is continually refining the device design to make it as light and as functional as possible. Attachments for the MyoPro, including a fork and a cup holder, further assist patients with activities of daily living. While the assisted ROM allows users to reach for a shirt in a closet, for example, the device cannot assist with the fine motor skills needed to button it. Naft says his company is working on a hand solution as part of the evolution of the device. Freeing the Knees When Curt Kowalczyk, CO, describes the Ottobock C-Brace® Orthotronic Mobility System, it's easier for him to say what it's not rather than what it is. "The C-Brace is not a locked KAFO, and it's not stance control; it's not an exoskeleton or a powered device," says Kowalczyk, clinical specialist-orthotics at Ottobock's North American headquarters in Minneapolis, Minnesota. "The knee never locks during walking, and the patient has control of both knee flexion and extension in both the stance and swing phase during each period of gait. It's a totally new approach." [caption id="" align="alignnone" width="150"] Photograph courtesy of Ottobock.[/caption] In fact, it's so new, Ottobock has coined the phrase "orthotronic mobility system" to describe the technology category. Based in part on the company's C-Leg prosthetic technology, the C-Brace was developed in Ottobock's Vienna, Austria, facility more than eight years ago. It was introduced in the United States in August 2012. The C-Brace helps patients develop a physiological gait by controlling knee flexion and extension. It is the first lower-limb orthotic system that allows the patient to descend stairs and descend and ascend ramps in a reciprocal manner. The device allows the patient to adjust his or her walking speed in real time, which is beneficial when walking on varied terrain or when confronted with an unexpected obstacle. The system comes with software that uses Bluetooth technology to connect to PC-based programming software. This allows the practitioner to understand the existing gait cycle and adjust the hydraulics necessary to produce a fluid gait. As the patient's gait improves, the system can be re-adjusted to accommodate improved muscle strength and ROM while maintaining stability. "C-Brace is designed with safety in mind and to help the patient develop a more natural gait," Kowalczyk says. Once a patient gets used to walking on a stable, moving knee- which can be a scary change for someone who is accustomed to using a traditional locked device that provides rigid stability only-he or she can reduce the compensatory motion needed to move the braced limb. When a patient walks with a more natural gait, stress on the rest of the body can also be reduced, resulting in fewer compensatory injuries on the sound side. Getting Orthotists Up to Speed As with all of its high-tech mobility devices, Ottobock has developed a C-Brace training program. The C-Brace training program starts with online pre-training for orthotists and therapists. If an orthotist wants to fit the C-Brace independently, he or she must attend a full-day training course at Ottobock's North American headquarters. If the practitioner wants technical assistance during the fitting process, an Ottobock orthotist will assist him or her either in his or her facility or in Minneapolis through its Cooperative Care program. By the end of May, about 60 practitioners had completed the C-Brace training, and roughly 40 patients had been fitted, many of whom are bilateral users, according to Ottobock. "Anyone with experience with microprocessor-controlled prostheses will recognize the C-Brace system," says Eric Weber, CPO, LPO, national orthotics specialist with Hanger Clinic, headquartered in Austin, Texas. "An orthotist who has never fit a stance-control device may have a steeper learning curve, but using the software and data storage is similar to the C-Leg." As a practitioner in Seattle, Washington, Weber participated in the first round of field-testing of the C-Brace and delivery of devices to four patients. He says it has been life changing for them. "The first patient [in the trial] didn't want to give it back," he says. "He said it was the first time he could hold his child and go down stairs safely." Weber's patients also reported that even though the C-Brace, with its control panel, is heavier than their old devices, it felt lighter when they were walking. This is due in part to the weight of the device being positioned closer to the hips than to the distal end of the device, Kowalczyk says. Weber thinks it is also a change in the way the device functions. "My best guess is what they were feeling was the programming that lets them walk in a straight line, not having to throw the weight of the braced leg over with each step." Who's a C-Brace Candidate? The ideal C-Brace candidate is someone with quadriceps weakness or paresis, lower-limb muscle strength of 3/5, good trunk stability, at least 2 degrees of ankle motion, stable limb volume, good cognition to be able to learn how to operate the device and learn a new way of walking, and the ability and motivation to commit to training and participating fully in physical therapy. [caption id="" align="alignnone" width="250"] Photograph of MyoPro orthosis user courtesy of Myomo.[/caption] With commitment to physical therapy, muscle strength can improve through the use of the C-Brace, Kowalczyk says, but patients should not expect that simply wearing the device will make them stronger. "We are being somewhat selective in who we fit right now," he says. "We want patients who can and will give the C-Brace a chance to work for them." According to Weber, Hanger Clinic has an extensive patient evaluation process that includes determining the patient's "gadget tolerance" and a "test-drive" of the system before the clinical team accepts the patient as a good candidate for the C-Brace. Clinicians can also try on the test device to experience what it feels like. Weber says that Hanger also pairs its clinicians with specific therapists for each C-Brace fitting, making the therapist an integral part of the team from the beginning. "The therapy and the technology go hand-in-hand," he says. "It's a volitional system that only returns to the patient what they put into it; it's not like an exoskeleton or powered system that does the work for them." The C-Brace can be an important therapeutic tool, according to Karen Lundquist, director of communications for Ottobock in North America. "Unlike traditional orthoses that have to be replaced as the patient's function improves, the C-Brace can be adjusted to accommodate those changes and challenge the patient to greater improvement," she says. Lundquist adds that as O&P devices continue to evolve, the gap between the orthotic and prosthetic practice will narrow. "In five, ten, 20 years, the technology used for prosthetics and orthotics might become so similar that the skill sets necessary for fittings could converge," she predicts. "This will have a profound impact on practitioners and on education for practitioners." Kate Hawthorne is a freelance writer living and working in Fort Collins, Colorado. She can be reached at kate@wordsforhire.net

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