Ossur Scientific E-letter
1 December 2008
Ossur Academy’s scientific E-letter Issue #3 2008
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Dear readers,
Welcome to the third issue of our Scientific E-letter of 2008. We are happy to share pertinent and interesting scientific news with you!
This E-letter includes seven different scientific papers. The articles cover the subjects of amputation/rehabilitation, prosthetics/biomechanics, orthotics/biomechanics, bionics and quality management. Five of the selected papers have been published in 2008 and two in 2007.
Enjoy the reading!
Amputation/Rehabilitation
Mayer, Á., Kudar, K., Bretz, K. and Tihanyi, J.(2008)Body schema and body awareness of amputees
Prosthetics and Orthotics International
An amputation of a limb results not only in physical-structural changes,
but also leads to peripherical-, proprioceptive- and visual-stimuli changes. Changes to these stimuli will consequently alter the processes of motional control of the central nervous system at different levels. Patients are aware of the fact that their limbs have been lost; nevertheless, they will sense them as if they were not lost. The phantom phenomenon is a well-known example of the difference between body awareness and body schema.
Mayer and colleagues studied how physical changes of the body and prosthetic use are reflected in body schema and body awareness, the latter in amputees’ self-image about their different body areas in proportion to time elapsed since amputation.
The study was performed by;
- Examining the configuration of body schema: A trial examining the spatial location of the phantom limb (50 people with lower or upper limb loss).
- Examining the functional aspect of body schema: The distribution of weight power between intact and prosthetic limbs (34 people with trans-tibial amputation).
- Examining body awareness: Body Focus Questionnaire by Fisher (44 people with lower limb amputation, 33 intact people).
- Using a questionnaire on anamnesis- and wearing prosthesis.
- Studying habits of people participating in research methods [1.] and [3.].
The study group found that the configuration of body schema did not change when the amputees wore their prostheses. Further it was found that the people who had not used their prosthesis for a long period of time, the phantom limb shortened, a phenomenon known as telescoping. The functional adaptation of the prosthesis to the body schema starts in a short time (within two weeks) after wearing it, and it becomes close to normal in carrying body weight after a longer period of time (years). In the beginning of rehabilitation, the awareness of legs is similar to that of the control group, while later on this awareness decreases. Over time though, the lost limb, regardless of having prosthesis or not, loses its importance. People with a more serious or vascular amputation of the upper limbs have a clearer image of these. Also, part of extremities having a greater cortical representation, appear more intensively in phantom sensations, while the strength of the cortical representation in body schema has no significance.
The authors could conclude from their study that wearing a prosthesis helps to maintain a body schema where the phantom limb remains similar to the intact one. This is helpful to movements to be carried out correctly. The study also showed that the prosthesis did not change the body awareness – the amputees are aware of their loss in higher mental structures and the prosthesis will not be considered as a part of their own body.
Marzen-Groller K D. Tremblay S M. Kaszuba J. Girodo V. Swavely D. Moyer B. Bartman K. Carraher W. Wilson E. Testing the effectiveness of the Amputee Mobility Protocol: A pilot study
J Vasc Nurs 2008;26:74-81
Marzen-Groller and colleagues studied the impact of using the Amputee Mobility Protocol (AMP) on functional mobility and length of stay (LOS). It was hypothesized that the implementation of AMP would optimize the level of postoperative functional mobility and reduces LOS in the hospital for patients after surgical amputation compared with patients who underwent surgical amputation without AMP.
The Amputee Mobility protocol is a clinical pathway for the post-op rehabilitation of amputees that, for instance, include time out of bed each day postoperatively.
Data was collected retrospectively from patient chart reviews for one group (14 subjects) that received treatment according to AMP and one group (30 subjects) that did not receive such treatment.
The functional mobility and LOS, were evaluated by a modified Functional Independence Measure (FIM) score and the hospital LOS.
The study group found that:
- LOS for transmetatarsal amputations decreased by 0.7 days, whereas functional mobility increased by a minimum of one level in the modified FIM score.
- LOS increased for patients undergoing transtibial amputations (7.1 days). Functional mobility increased by one level.
- LOS increased for patients undergoing transfemoral amputations (2.7 days). The mobility level increased by 2 levels using the modified FIM score.
Data showed that patients’ functional mobility increased by using the standardized AMP, but it did not significantly decrease acute care setting LOS.
Prosthetics/biomechanics
Baum B S. Schnall B L. Tis J E. Lipton J S. Correlation of residual limb length and gait parameters in amputees
Injury Volume 39, Issue 7, July 2008, Pages 728-733
The lack of objective data on acceptable transection levels for transfemoral amputations made Baum and his study group to investigate the correlation between residual limb length and gait deviations in transfemoral amputees
The investigators hypothesised that shorter residual limb lengths would correlate with greater gait deviations.
The study was performed by correlating the residual limb length of 13 young, athletic transfemoral and knee disarticulation amputees with temporal-spatial, kinematic, and kinetic outcomes after gait analysis.
Patients’ residual femoral lengths ranged from 57% to 100% of their intact femoral length. It was found that pelvic tilt excursion was inversely related to residual limb length (with the exception of one patient). Further the study group found that limb length did not significantly correlate with any other investigated temporal-spatial, kinematic, or kinetic parameter.
The authors concluded that residual femoral length does not dramatically alter the gait if the residual femur is at least 57% of the contralateral femur. This means that surgeons may have more flexibility to amputate at a higher level to preserve soft tissue quality and improve prosthetic fitting without sacrificing gait function.
Orthotics /biomechanics
Hawke F. Burns J. Radford J A. du Toit V.(Review)
The Cochrane Library2008, Issue 3
Hawke and colleagues made a review of randomised controlled trials and controlled clinical trials to evaluate custom made foot orthoses’ impact on foot pain. The outcomes included quantifiable levels of foot pain, function, disability, health-related quality of life, participant satisfaction, adverse effects and compliance. The custom made othoses were in the reviewed studies compared to sham orthoses; no intervention; standardised interventions given to all participants; non-custom (prefabricated) foot orthoses; combined manipulation, mobilisation or stretching; night splints; and surgery. Follow up ranged from one week to three years.
The ’custom-made’ foot orthoses where defined as contoured, removable in-shoe devices that were moulded or milled from an impression of the foot (for example a plaster cast or a three-dimensional laser scan) and fabricated according to practitioner-prescribed specifications.
The review comprised eleven trials that evaluated custom-made foot orthoses, altogether involving 1332 subjects;
- five trials for plantar fasciitis (691 participants)
- three for foot pain in rheumatoid arthritis (231 participants)
- one for foot pain in pes cavus (154 participants),
- one for hallux valgus (209 participants)
- one for juvenile idiopathic arthritis (JIA) (47 participants).
The result of the review showed that custom made foot orthoses were effective for painful pes cavus, rear foot pain in rheumatoid arthritis, foot pain in JIA and painful hallux valgus. Even though surgery was more effective for hallux valgus and non-custom foot orthoses appeared just as effective for JIA, the authors mean that the analysis may have lacked sufficient power to detect a difference in effect. Further they found it unclear if custom-made foot orthoses were effective for plantar fasciitis or metatarsophalangeal joint pain in rheumatoid arthritis. Custom-made foot orthoses were found to be a safe intervention in all studies.
The authors could conclude that there were limited evidence on which to base clinical decisions regarding the prescription of custom-made foot orthoses for the treatment of foot pain. They mean that currently, there is gold level of evidence for painful pes cavus and silver level evidence for foot pain in JIA, rheumatoid arthritis, plantar fasciitis and hallux valgus.
Lin C-W C. Moseley A M. Refshauge K M. Rehabilitation for ankle fractures in adults [Intervention review]
Cochrane Database of Systematic Reviews, Issue 3, 2008
One of the most common fractures of the lower limb is ankle fractures, especially in older women and young men. The fracture is generally treated by surgical or non-surgical orthopaedic treatment, followed by a period of immobilisation to protect the fracture. People often experience pain, stiffness, weakness and swelling at the ankle, and a reduced ability to participate in activities after an ankle fracture. These problems are the result of the fracture itself and the subsequent immobilisation period.
Lin and her study group performed this review in order to identify the most reliable evidence on the effectiveness of rehabilitation interventions used to address these problems.
The review included only randomised and quasi-randomised controlled trials with adults undergoing any interventions for rehabilitation after ankle fracture. The primary outcome was activity limitation. Secondary outcomes included impairments and adverse events.
Thirty-one studies corresponded with the selection criteria and were included in the review. The authors found that only limited evidence is presently available. For people who require ankle surgery, using a removable brace or splint after the surgery, so that gentle ankle exercises can be performed, may enhance the return to normal activities, reduce pain and improve ankle movement. However, the incidence of adverse events (such as problems with the surgical wound) may also be increased.
Commencement of walking early during the immobilisation period after surgery or using no immobilisation instead of a plaster cast may improve ankle movement. After either surgical or non-surgical management of the fracture and the immobilisation period, having manual therapy (passive movement performed by a trained health professional) may benefit ankle movement. Other therapies such as electrotherapy, hypnosis or stretching did not reach evidence of improved function.
The authors concluded that rehabilitation after ankle fracture can begin soon after the fracture has been treated by the use of different types of immobilisation, which allow early commencement of weight-bearing or exercise. Alternatively the rehabilitation may start following the period of immobilisation, with physical or manual therapies.
Bionics
Miodownik M.
The bionic future of sport
Materialstoday Volume 10, Issue 9, September 2007, Page 6
Miodownik discusses the development of technology in sports from historical break through, via current use of technology to the bionic future. He also discusses the issues of rules and limits in sports that come with new developments. Will the sport develop with the technology and become bionic sport in which technology is merged with human capabilities?
Ever since sportsmen and women have engaged in non-lethal competitions of courage, strength, human endurance, and skill, material science have been involved. This is because most sports have been unable to resist the temptation to innovate. Examples of that are golf clubs, which have mutated from wood, to steel, to metal-matrix composites, to metal glasses. Tennis rackets have moved from wood to aluminium, to carbon fibre, with the strings changing from cat gut to synthetics. The running shoe itself has gone from leather, to rubber, and finally to an air-cushioned polyurethane foam with a breathable nylon upper. Many examples of such innovations are found in the world of sport. Sometimes the development is a result of enhancing performance, sometimes it is a result of increasing safety and reduce long time effects on injuries.
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Oscar Pistorius, 400 m runner. (© 2007 Össur.) |
Oscar Pistorius has no legs; yet he has been dominating disabled sprint competitions for years with the aid of carbon fibre prosthetics. Now he wants to compete against able-bodied athletes in the next Olympics. What happens if he will be allowed to do so? And what happens if he wins an Olympic medal? Most probably it will mark a turning point in the history of sports where technology will be merged with human capabilities.
The author was curious about the consequence if the Olympic committee ban Pistorius, will they not also have to regulate the use of all footwear? He meant that prosthetics are passive walking aids just like running shoes. “If such courageous sportsmen and women are to be excluded from the Olympics, it will confirm that the competition is no longer in touch with human aspirations, which are not about obtaining some idealized human perfection, but rather about winning through against fantastic odds. Technology has always been an expression of the human spirit precisely for this reason.”
In the future,the author believes,the material science in sport will continue advance into tissue engineering, bio scaffolding and robotics to make the human body a bionic entity such as Oscar Pistorius is an example of today. It might not only be the physiotherapists that feature on the bench of sport teams, but also materials scientists and engineers ending up in tracksuits too.
Quality management
Cochrane L J. Olson c A. Murray S. Dupuis M. Tooman T. Hayes S. Gaps between knowing and doing: Understanding and assessing the barriers to optimal health care
Journal of Continuing Education in the Health Professions Volume 27 Issue 2,Pages 94–102 2007
There is a significant gap between science and clinical practice guidelines, and also between science and actual clinical practice.
Cochrane and colleagues wanted to review the literature in the area to enhance an in-depth understanding of the barriers and incentives contributing to the gap in the knowledge-to-action process. The intension were that their findings might lead to interventions that effect change toward optimal practice and thus to better care.
The study group reviewed systematically studies in English language involving human subjects and published from January 1998 to March 2007. The number of articles that fulfilled established criteria were 256. The analysis was guided by two research questions:
- How are barriers assessed?
- What types of barriers are identified?
The authors experienced how multiple factors pose barriers to optimal clinical practice. They found increasing numbers of behavioural and system barriers. Further it was found that quantitative survey type assessments continue to dominate barrier research, but an increasing number of qualitative and mixed-method study designs have emerged recently.
The findings establish the evolution of research methodologies and emerging barriers to the translation of knowing to doing. Even though the authors found many studies methodologically weak, they mean there are indications that designs are becoming more aligned with the complexity of the health care environment.
Cochrane et al concludes that the review provides support for the need to examine multiple factors within the knowledge-to-action process.
Össur Academy is looking forward to providing you with more interesting scientific news next year! We would also like to take the opportunity to wish all our readers a happy festive season.
Thank you for reading,
Össur Academy.
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