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CANADIAN PROSTHETICS & ORTHOTICS JOURNAL, Volume 5; https://doi.org/10.33137/cpoj.v5i1.38442

Abstract:
This Editorial presents an overview of the uptake of clinical outcome measures in the prosthetics and orthotics sector and considers how the use of objective measures contribute to demonstrating value provided. A decade ago, payors began to demand objective data to document costs vs. benefits from prosthetic and orthotic providers. The speed with which the sector responded to help develop measures and to begin to integrate them into practice is remarkable. This suggests an encouraging resilience and ability to adapt on the part of the sector as other trends such as Values-Based Health Care emerge to challenge the sector. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/38442/29321
How To Cite: Raschke S.U. Editorial opinion: value within the prosthetic and orthotic provision process. Canadian Prosthetics & Orthotics Journal. 2022; Volume 5, Issue 1, No.9. https://doi.org/10.33137/cpoj.v5i1.38442 Corresponding Author: Silvia Ursula Raschke, PhD British Columbia Institute of Technology (BCIT), 3700 Willingdon Avenue, Burnaby, British Columbia, Canada. E-Mail: [email protected] ORCID ID: https://orcid.org/0000-0001-7964-4295
, , Matthew L. Borgia, Melissa A. Clark
CANADIAN PROSTHETICS & ORTHOTICS JOURNAL, Volume 5; https://doi.org/10.33137/cpoj.v5i1.37873

Abstract:
BACKGROUND: Measurement of psychosocial adjustment after upper limb amputation (ULA) could be helpful in identifying persons who may benefit from interventions, such as psychotherapy and/or support groups. However, available measures of psychosocial adjustment after limb loss are currently designed for prosthetic users only. OBJECTIVE: To create a measure of psychosocial adjustment for persons with ULA that could be completed by individuals regardless of whether a prosthesis is use. METHODOLOGY: We modified items from an existing Trinity Amputation and Prosthesis Experience Survey (TAPES) measure and generated new items pertinent to persons who did not use a prosthesis. Item content was refined through cognitive interviewing and pilot testing. A telephone survey of 727 persons with major ULA (63.6% male, mean age of 54.4) was conducted after pilot-testing. After exploratory and confirmatory factor analyses (EFA and CFA), Rasch analyses were used to evaluate response categories, item fit and differential item functioning (DIF). Item-person maps, score distributions, and person and item reliability were examined. Test-retest reliability was evaluated in a 50-person subsample. FINDINGS: EFA and CFA indicated a two-factor solution. Rasch analyses resulted in a 7-item Adjustment to Limitation subscale (CFI=0.96, TLI=0.95, RMSEA=0.128) and a 9-item Work and Independence subscale (CFI=0.935, TLI=0.913, RMSEA=0.193). Cronbach alpha and ICC were 0.82 and 0.63 for the Adjustment to Limitation subscale and 0.90 and 0.80 for the Work and Independence subscale, respectively. CONCLUSIONS: This study developed the Psychosocial Adjustment to Amputation measure, which contains two subscales: 1) Adjustment to Limitation and 2) Work and Independence. The measure has sound structural validity, good person and item reliability, and moderate to good test-retest reliability. Layman's Abstract A substantial proportion of persons with upper limb amputation (ULA) experience clinical depression, post-traumatic stress disorder, general anxiety, and/or long term post-traumatic psychological distress after amputation. Levels of depression and anxiety have been reported to be greater and psychosocial adjustment poorer in persons with upper limb amputation as compared to those with lower limb amputation. Between 20-40% of individuals with upper limb amputation (ULA) do not use a prosthesis. Previous measures of psychosocial adjustment after limb loss are designed for prosthesis users, and no measure exists that can be used for individuals who do not use a prosthesis. We developed a measure of psychosocial adjustment for persons with ULA that can be completed by individuals regardless of prosthesis use. Factor analyses led to identification of two subscales: a 7-item Adjustment to Limitation subscale and a 9-item Work and Independence subscale. Our analyses supported validity and reliability of both subscales. Both scales can be used for persons with ULA regardless of whether they use a prosthesis. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/37873/29269
How To Cite: Resnik L.J., Ni P., Borgia M.L., Clark M.A. A psychosocial adjustment measure for persons with upper limb amputation. Canadian Prosthetics & Orthotics Journal. 2022; Volume 5, Issue 1, No.8. https://doi.org/10.33137/cpoj.v5i1.37873 Corresponding Author: Linda J. Resnik PT, PhD Research Department, Providence VA Medical Center, 830 Chalkstone Ave, Building 32, Providence, RI 02908 E-Mail: [email protected] ORCID ID: https://orcid.org/0000-0002-0168-6759
, Frank Braatz, Bernhard Greitemann, Heiko Drewitz, Axel Ruetz, Michael Schäfer, Wolfgang Seifert, Friedemann Steinfeldt, Claudia Weichold, , et al.
CANADIAN PROSTHETICS & ORTHOTICS JOURNAL, Volume 5; https://doi.org/10.33137/cpoj.v5i1.37795

Abstract:
BACKGROUND: Patients with neuromuscular knee-instability assisted with orthotic devices experience problems including pain, falls, mobility issues and limited engagement in daily activities. OBJECTIVES: The aim of this study was to analyse current real-life burden, needs and orthotic device outcomes in patients in need for advanced orthotic knee-ankle-foot-orthoses (KAFOs). METHODOLOGY: An observer-based semi-structured telephone interview with orthotic care experts in Germany was applied. Interviews were transcribed and content-analysed. Quantitative questions were analysed descriptively. FINDINGS: Clinical experts from eight centres which delivered an average of 49.9 KAFOs per year and 13.3 microprocessor-stance-and-swing-phase-controlled-knee-ankle-foot orthoses (MP-SSCOs) since product availability participated. Reported underlying conditions comprised incomplete paraplegia (18%), peripheral nerve lesions (20%), poliomyelitis (41%), post-traumatic lesions (8%) and other disorders (13%). The leading observed patient burdens were “restriction of mobility” (n=6), followed by “emotional strain” (n=5) and “impaired gait pattern” (n=4). Corresponding results for potential patient benefits were seen in “improved quality-of-life” (n=8) as well as “improved gait pattern” (n=8) followed by “high reliability of the orthosis” (n=7). In total, experts reported falls occurring in 71.5% of patients at a combined annual frequency of 7.0 fall events per year when using KAFOs or stance control orthoses (SCOs). In contrast, falls were observed in only 7.2 % of MP-SSCO users. CONCLUSION: Advanced orthotic technology might contribute to better quality of life of patients, improved gait pattern and perceived reliability of orthosis. In terms of safety a substantial decrease in frequency of falls was observed when comparing KAFO and MP-SSCO users. Layman's Abstract Patients who are not able to control the muscles of their legs may need to wear a brace to improve their ability to walk. However, some users are reporting problems including pain, falls, mobility issues and limited engagement in daily activities. The aim of this study was to analyse current real-life burden, needs and experiences of patients who need to wear a brace for their knee, ankle and foot (KAFO). Therefor, experts were interviewed via telephone with a structured set of questions. Eight experts provided observations for patients who suffered from several diseases affecting leg muscle control. The leading patient burdens were identified as “restriction of mobility”, followed by “emotional strain” and “impaired way of walking”. Potential patient benefits were seen in “improved quality-of-life” as well as “improved way of walking” followed by a “high trust in the brace”. Experts reported a higher number of falls per year when using KAFO without the active control of a microprocessor. On a long-term basis, experts observed consequences of KAFO use as disorders of the back, reduced amount of muscles as well as swelling in areas not covered by the brace, scrub marks and degenerative impact on joints. Braces with active control of a microprocessor might result in better quality of life of patients, improved normal way of walking and perceived trust in the brace. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/37795/29114
How To Cite: Brüggenjürgen B., Braatz F., Greitemann B., Drewitz H., Ruetz A., Schäfer M., et al. Experts’ perceived patient burden and outcomes of knee-ankle-foot-orthoses (KAFOs) vs. microprocessor-stance-and-swing-phase-controlled-knee-ankle-foot orthoses (MP-SSCOs). Canadian Prosthetics & Orthotics Journal. 2022; Volume 5, Issue 1, No.7.https://doi.org/10.33137/cpoj.v5i1.37795 Corresponding Author: Prof. Dr. med. Bernd Brüggenjürgen,
Head Institute Health Services Research and Technical Orthopedics, Orthopedic Department - Medical School Hannover (MHH) at DIAKOVERE Annastift Hospital, Anna-von-Borries-Str. 1-7, 30625 Hannover, Germany. E-Mail:[email protected] ORCID ID:https://orcid.org/0000-0002-8866-0809
, Harry Sivasambu,
CANADIAN PROSTHETICS & ORTHOTICS JOURNAL, Volume 5; https://doi.org/10.33137/cpoj.v5i1.36223

Abstract:
BACKGROUND: Biofeedback (BFB), the practice of providing real-time sensory feedback has been shown to improve gait rehabilitation outcomes. BFB training through rhythmic stimulation has the potential to improve spatiotemporal gait asymmetries while minimizing cognitive load by encouraging a synchronization between the user’s gait cycle and an external rhythm. OBJECTIVE: The purpose of this work was to evaluate if rhythmic stimulation can improve the stance time symmetry ratio (STSR) and to compare vibrotactile to auditory stimulation. Gait parameters including velocity, cadence, stride length, double support time, and step length symmetry, were also examined. METHODOLOGY: An experimental rhythmic stimulation system was developed, and twelve healthy adults (5 males), age 28.42 ± 10.93 years, were recruited to participate in walking trials. A unilateral ankle weight was used to induce a gait asymmetry to simulate asymmetry as commonly exhibited by individuals with lower limb amputation and other clinical disorders. Four conditions were evaluated: 1) No ankle weight baseline, 2) ankle weight without rhythmic stimulation, 3) ankle weight + rhythmic vibrotactile stimulation (RVS) using alternating motors and 4) ankle weight + rhythmic auditory stimulation (RAS) using a single-tone metronome at the participant’s self-selected cadence. FINDINGS: As expected the STSR became significantly more asymmetrical with the ankle weight (i.e. induced asymmetry condition). STSR improved significantly with RVS and RAS when compared to the ankle weight without rhythmic stimulation. Cadence also significantly improved with RVS and RAS compared to ankle weight without rhythmic stimulation. With the exception of double support time, the other gait parameters were unchanged from the ankle weight condition. There were no statistically significant differences between RVS and RAS. CONCLUSION: This study found that rhythmic stimulation can improve the STSR when an asymmetry is induced. Moreover, RVS is at least as effective as auditory stimulation in improving STSR in healthy adults with an induced gait asymmetry. Future work should be extended to populations with mobility impairments and outside of laboratory settings. Layman's Abstract Providing feedback to users in real-time has been shown to improve walking in many populations with gait deviations. Feedback in the form of rhythmic stimulation involves consistent cues to which the user matches their movement. This work compared the effects of sound-based (RAS) and vibration-based (RVS) stimulation systems on the walking symmetry of healthy adults. A simple stimulation system was used with twelve healthy adults in walking trials. The walking trials included some in which the participant wore an ankle weight on a single leg to create a non-symmetrical walking pattern. Four different conditions were tested: No ankle weight, with an ankle weight, with an ankle weight and RAS, and with an ankle weight and RVS. Walking symmetry improved with both RVS and RAS compared to ankle weight only. Walking speed, cadence, and step length did not change. These findings show that RVS is at least as effective as RAS and may be a useful technique for gait rehabilitation. Future work should involve clinical populations and in real-world settings. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/36223/29090
How To Cite: Michelini A., Sivasambu H., Andrysek J. The short-term effects of rhythmic vibrotactile and auditory biofeedback on the gait of individuals after weight-induced asymmetry. Canadian Prosthetics & Orthotics Journal. 2022; Volume 5, Issue 1, No.6. https://doi.org/10.33137/cpoj.v5i1.36223 Corresponding Author: Jan Andrysek, PhD
Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Canada. E-Mail: [email protected] ORCID ID: https://orcid.org/0000-0002-4976-1228
, Zaka Zia, Michael Payne, Ricardo Viana,
CANADIAN PROSTHETICS & ORTHOTICS JOURNAL, Volume 5; https://doi.org/10.33137/cpoj.v5i1.36695

Abstract:
BACKGROUND: A relationship between walking ability and self-efficacy has been demonstrated in various rehabilitation patient populations. In experienced prosthetic ambulators, walking ability is related to self-efficacy of balance, however, this relationship has not been quantified for those with newly acquired lower limb amputations (LLA). OBJECTIVE(S): To investigate the association between walking performance (objective) and self-reported walking abilities (subjective) on balance self-efficacy in those with LLA. METHODOLOGY: Cross-sectional study of 27 people (17 men; mean age=63.57±9.33) at discharge from inpatient prosthetic rehabilitation for first major unilateral LLA. Individuals completed 6m straight path walking and the L-Test under single- and dual-task conditions. The Prosthesis Evaluation Questionnaire (PEQ) was administered, and the Ambulation subscale provided subjective measures of walking ability. A single PEQ question on satisfaction with walking (16B) was also used as a proxy for subjective walking ability. The Activities-specific Balance Confidence Scale measured balance self-efficacy. Multivariable linear regression was used to evaluate the strength of association between walking ability (objective and subjective) and balance self-efficacy (dependent variable). FINDINGS: Walking velocity on the 6m straight path under single-task (p=0.011) and dual-task conditions (p=0.039), the single-task L-Test (p=0.035) and self-reported satisfaction with walking (p=0.019) were associated with self-efficacy of balance. CONCLUSION: Objective measures of walking ability that were independently associated with balance self-efficacy included straight path walking velocity under single and dual-task conditions and the single-task L-Test. Satisfaction with walking was also associated with balance self-efficacy. This highlights the interplay between physical and psychological factors during rehabilitation. More research in the area of self-efficacy and walking ability is needed to establish self-efficacy as a target during prosthetic rehabilitation for those with LLA. Layman's Abstract Self-efficacy is a person’s belief in their ability to do a certain task well. Improving self-efficacy can be done by watching others complete a task, by getting praise from experts, or by doing the task yourself. There is a link between how well some people walk and their confidence with walking, however this has not been studied in people learning to use a lower limb prosthesis. The goal of this paper was to study the link between balance self-efficacy, scores on walking tests and self-reported walking ability in those with lower limb amputations (LLA) when they leave rehabilitation. To do this, two walking tests were done (straight path and complex path) in two settings (walking only and walking with distraction). A survey about walking ability and a questionnaire on balance self-efficacy were also done. Results showed that self-efficacy of balance was related to the straight path walking test under both settings and the complex walking test during walking alone. A person’s satisfaction with walking ability was also linked. The only test not related was the complex walking test under distracting conditions. It might be that more time is needed for people with LLA to confidently do this task. This shows the link between physical and mental factors during rehabilitation. More research is needed to find other factors that might impact self-efficacy and walking ability in people with LLA when they leave rehabilitation. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/36695/28904
How To Cite: Frengopoulos C, Zia Z, Payne M.W.C, Viana R, Hunter S.W. Association between balance self-efficacy and walking ability in those with new lower limb amputations. Canadian Prosthetics & Orthotics Journal. 2022; Volume 5, Issue 1, No.4. https://doi.org/10.33137/cpoj.v5i1.36695 Corresponding Author: Courtney Frengopoulos,
University of Western Ontario, Room 1408, Elborn College, London, Ontario, Canada, N6G 1H1. E-Mail: [email protected] ORCID ID: https://orcid.org/0000-0002-4131-2727
Roberto Pellegrini, Gabriele Denza, , Daniele Zenardi, Matteo Imperio, ,
CANADIAN PROSTHETICS & ORTHOTICS JOURNAL, Volume 4; https://doi.org/10.33137/cpoj.v4i1.36252

Abstract:
BACKGROUND: The subischial socket interface design is a promising new shape of socket for persons with transfemoral amputation. Typically, the proximal trim line is located distal to the ischial tuberosity, improving comfort in prosthetic users without interfering with gait parameters compared to Ischial Containment Socket (ICS). No studies have investigated the performances of a subischial sockets with suction suspension system. A new subischial socket (Hybrid Subischial Socket - HySS) combined with a hypobaric passive suspension system has been recently developed. OBJECTIVE: To assess the effects of HySS in terms of comfort, hip range-of-motion and gait parameters. METHODOLOGY: Three persons with transfemoral amputation were tested first using their usual ICS and then after one month of continuous use of HySS. FINDINGS: The following parameters improved in all participants using HySS: 1) hip range-of-motion, 2) walking speed and distance, 3) Timed-Up-and-Go-Test time, 4) stride length, 5) double support duration, 6) peak value of hip extension during stance, 7) satisfaction with the prosthesis. CONCLUSION: These findings suggest that the use of HySS could allow improvements for prosthetic use. Layman’s Abstract This case series describes the effects of a subischial socket combined with a hypobaric suction suspension system for persons with transfemoral amputation. This socket has the proximal trim line located distally to the ischial tuberosity and it does not interact with the pelvis. The results have shown that this socket may improve the overall prosthetic comfort, hip range of motion and some gait parameters compared to the conventional ischial containment socket. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/36252/28095 How To Cite: Pellegrini R, Denza G, Brunelli S, Zenardi D, Imperio M, Vannozzi G, Traballesi M. The hybrid subischial socket for persons with transfemoral amputation: gait parameters and clinical assessment of a case series. Canadian Prosthetics & Orthotics Journal. 2021;Volume 4, Issue 1, No.9. https://doi.org/10.33137/cpoj.v4i1.36252 Corresponding Author: Stefano Brunelli, MD Fondazione Santa Lucia, Scientific Institute for Research, Hospitalization and Health Care, Rome, Italy. E-Mail: [email protected] ORCID ID: https://orcid.org/0000-0002-5986-1564  
, Katja Orlowski, Kai-Uwe Mrkor, Jürgen Edelmann-Nusser, Kerstin Witte
CANADIAN PROSTHETICS & ORTHOTICS JOURNAL, Volume 5; https://doi.org/10.33137/cpoj.v5i1.37456

Abstract:
BACKGROUND: Following amputation, patients with lower limb amputations (LLA) are classified into different functional mobility levels (K-levels) ranging from K0 (lowest) to K4 (highest). However, K-level classification is often based on subjective criteria. Objective measures that are able to differentiate between K-levels can help to enhance the objectivity of K-level classification. OBJECTIVE(S): The goal of this preliminary cross-sectional study was to investigate whether differences in hip muscle strength and balance parameters exist among patients with transfemoral amputations (TFA) assigned to different K-levels. METHODOLOGY: Twenty-two participants with unilateral TFA were recruited for this study, with four participants assigned to K1 or K2, six assigned to K3 and twelve assigned to K4. Maximum isometric hip strength of the residual limb was assessed in hip flexion, abduction, extension, and adduction using a custom-made diagnostic device. Static balance was investigated in the bipedal stance on a force plate in eyes open (EO) and eyes closed (EC) conditions. Kruskal-Wallis tests were used to evaluate differences between K-level groups. FINDINGS: Statistical analyses revealed no significant differences in the parameters between the three K-level groups (p>0.05). Descriptive analysis showed that all hip strength parameters differed among K-level groups showing an increase in maximum hip torque from K1/2-classified participants to those classified as K4. Group differences were also present in all balance parameters. Increased sway was observed in the K1/2 group compared to the K4 group, especially for the EC condition. CONCLUSION: Although not statistically significant, the magnitude of the differences indicates a distinction between K-level groups. These results suggest that residual limb strength and balance parameters may have the potential to be used as objective measures to assist K-level assignment for patients with TFA. This potential needs to be confirmed in future studies with a larger number of participants. Layman's Abstract Patients with lower limb amputation (LLA) are classified into different mobility levels, so-called K-levels, which are ranging from K0 (lowest) to K4 (highest). K-level classification is relevant for the patients as it determines the type of prosthetic components available. However, K-level can vary greatly based on the clinician or orthopedic technician individual assessment. Objective data from physical performance tests can help to improve K-level classification. Therefore, muscle strength tests of the amputation stump as well as balance tests were performed in this study to determine whether these parameters have the potential to support K-level classification. Twenty-two participants with a thigh amputation participated in the study (four K1/2-, six K3- and twelve K4-participants). Hip muscle strength on the amputation side was assessed as well as static balance in the double leg stance with eyes open and eyes closed. Analysis of the data showed that all hip strength parameters differed between the K-level groups, with maximum strength increasing from the K1/2 group to the K4 group. Group differences were also seen in the balance parameters with greater body sway for the K1/2 group when compared to the K4 group, especially when participants had their eyes closed. These results show that muscle strength tests of the residual limb and static balance tests may serve as additional measures to improve K-level assignment for patients with LLA. This was only an initial study and further studies with a larger number of participants are required to confirm these results. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/37456/28905
How To Cite: John S, Orlowski K, Mrkor K.U, Edelmann-Nusser J, Witte K. Differences in hip muscle strength and static balance in patients with transfemoral amputations classified at different K-levels: A preliminary cross-sectional study. Canadian Prosthetics & Orthotics Journal. 2022; Volume 5, Issue 1, No.5. https://doi.org/10.33137/cpoj.v5i1.37456 Corresponding Author: Stefanie John, Department of Sports Science, Faculty of Humanities, Otto von Guericke University, Magdeburg, Germany. E-Mail: [email protected] ORCID ID: https://orcid.org/0000-0001-6722-7195
CANADIAN PROSTHETICS & ORTHOTICS JOURNAL, Volume 5; https://doi.org/10.33137/cpoj.v5i1.37717

Abstract:
The purpose of this letter is to initiate a constructive dialogue, clarify some of the information provided in the CPOJ recent article, “Evolving business models in orthotics” and to highlight our concerns with respect to important context about the orthotic and prosthetic profession in Canada that we feel was missing from the publication (Schneider N. Evolving business models in orthotics. Canadian prosthetics & orthotics journal. 2021; Volume 4, Issue 2, No.3. https://doi.org/10.33137/cpoj.v4i2.35876). Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/37717/28740 How To Cite: Laakso L. Letter to the editor regarding: Evolving business models in orthotics. Canadian Prosthetics & Orthotics Journal. 2022; Volume 5, Issue 1, No.3. https://doi.org/10.33137/cpoj.v5i1.37717 Corresponding Author: Linda Laakso, MSc CO(c) FCBC, OPC PresidentOrthotics Prosthetics Canada (OPC), Toronto, Canada.Custom Orthotic Design Group Ltd., Mississauga, Canada.E-Mail: [email protected] ID: https://orcid.org/0000-0002-1636-3717OPC website: https://opcanada.ca/
CANADIAN PROSTHETICS & ORTHOTICS JOURNAL, Volume 5; https://doi.org/10.33137/cpoj.v5i1.36744

Abstract:
BACKGROUND: Gait symmetry is the degree of equality of biomechanical parameters between limbs within a gait cycle. Human gait is highly symmetrical; however, in the presence of pathology, gait often lacks symmetry. Biofeedback (BFB) systems have demonstrated the potential to reduce gait asymmetry, improve gait function, and benefit overall long-term musculoskeletal health. OBJECTIVE(S): The aim of this study was to develop a BFB system and evaluate three unique BFB strategies, including bidirectional control – constant vibration (BC), bidirectional control – variable vibration (BV), and unidirectional control – variable vibration (UV) relevant to gait symmetry. The assessed feedback strategies were a combination of vibration frequency/amplitude levels, vibration thresholds, and vibrotactile stimuli from one and two vibrating motors (tactors). Learning effect and short-term retention were also assessed. METHODOLOGY: Testing was performed using a custom BFB system that induces stance time asymmetries to modulate temporal gait symmetry. The BFB system continuously monitors specific gait events (heel-strike and toe-off) and calculates the symmetry ratio, based on the stance time of both limbs to provide real-time biomechanical information via the vibrating motors. Overall walking performance of ten (n=10) able-bodied individuals (age 24.8 ± 4.4 years) was assessed via metrics of symmetry ratio, symmetry ratio error, walking speed, and motor's vibration percentages. FINDINGS: All participants utilized BFB somatosensory information to modulate their symmetry ratio. UV feedback produced a greater change in symmetry ratio, and it came closer to the targeted symmetry ratio. Learning or short-term retention effects were minimal. Walking speeds were reduced with feedback compared to no feedback; however, UV walking speeds were significantly faster compared to BV and BC. CONCLUSION: The outcomes of this study provide new insights into the development and implementation of feedback strategies for gait retraining BFB systems that may ultimately benefit individuals with pathological gait. Future work should assess longer-term use and long-term learning and retention effects of BFB systems in the populations of interest. Layman's Abstract Healthy walking is usually highly symmetrical with the same movements occurring on both sides of the body. However, certain disorders can cause abnormal and asymmetrical walking movements. Biofeedback can improve the movements during walking. This study used a custom biofeedback system to test three ways of applying biofeedback including having one and two motors that vibrated in unique ways. The biofeedback system was set up to guide participants to change their normal walking pattern to be less symmetrical. Walking movements of ten young able-bodied individuals were measured while walking with the biofeedback system. The results showed a change in walking symmetry for all participants. Using a single vibrating motor resulted in the greatest changes in walking symmetry. The changes in walking symmetry occurred only when using biofeedback, and walking patterns quickly returned to normal when the biofeedback was turned off. Overall, all feedback methods caused the users to walk slower than their typical walking speed. These findings provide important new information about the changes in walking caused by different biofeedback methods. Future work should evaluate long-term effects of biofeedback methods in the populations of interest. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/36744/28677 How To Cite: Escamilla-Nunez R, Sivasambu H, Andrysek J. Exploration of vibrotactile biofeedback strategies to induce stance time asymmetries. Canadian Prosthetics & Orthotics Journal. 2022; Volume 5, Issue 1, No.2. https://doi.org/10.33137/cpoj.v5i1.36744 Corresponding Author: Rafael Escamilla-Nunez,
Institute of Biomedical Engineering, University of Toronto, Toronto, Canada. E-Mail: [email protected] ORCID ID: https://orcid.org/0000-0002-2739-878X
CANADIAN PROSTHETICS & ORTHOTICS JOURNAL, Volume 5; https://doi.org/10.33137/cpoj.v5i1.36847

Abstract:
BACKGROUND: The risk of tripping in people with amputation is greater than that of able-bodied individuals due to reduced toe clearance during the swing phase. Appropriate prosthetic suspension may increase toe clearance by providing more secured attachment between the residual limb and prosthetic socket. Research is lacking on the Unity suspension system's effect on swing toe clearance. METHODS: Twelve people with transtibial amputation were fitted with the Unity suspension system. After one month accommodation period, the person walked with active (ON) or inactive vacuum (OFF) in a CAREN-Extended virtual reality system, across multiple simulated real-world scenarios. Prosthetics minimum swing toe clearance, and kinematic data, while the vacuum was ON or OFF, were compared with the intact side and a group of 12 able-bodied individuals. RESULTS: Minimum swing toe clearance (MSTC) and knee flexion angle were larger on the prosthetic side (active and inactive vacuum) compared to both the intact side and the control group. However, hip flexion angle on the prosthetic side was approximately 17% smaller than the control group. Unlike the control group, MSTC with active and inactive vacuum suspension was not significantly different between level walking and other walking conditions. Finally, among all walking conditions, the lowest swing toe clearance for both control and the amputee groups was recorded when the limb was at the top of a side-slope. CONCLUSION: An effective suspension system could improve toe clearance; however, significant differences were not found between active and inactive vacuum conditions. The likelihood of inappropriate foot contact on side-slope ground might be greater than other walking conditions for both able-bodied and amputee groups, possibly leading to stumbling or falling. Layman's Abstract Walking over non-level surfaces are more challenging than level walking, especially for people with below the knee amputation. Moreover, due to reduced toe clearance during the gait, people with amputation have higher risk of tripping and falling than able-bodied individuals. The purpose of this study was to evaluate the effects of a prosthetic suspension system, a critical component that connects the residual limb to the prosthesis, on toe clearance during gait across multiple simulated real-world walking scenarios. Twelve people with below the knee amputation and a group of 12 able-bodied individuals participated in this study. The results of this study showed that an effective suspension system could improve toe clearance during swing phase. The likelihood of inappropriate foot contact on side-slope ground might be greater than other walking conditions for both able-bodied and amputee group, possibly leading to stumbling or falling. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/36847/28624 How To Cite: Gholizadeh H, Lemaire E.D, Nantel J. Effects of unity prosthetic elevated vacuum suspension system on minimum swing toe clearance. Canadian Prosthetics & Orthotics Journal. 2022; Volume 5, Issue 1, No.1. https://doi.org/10.33137/cpoj.v5i1.36847 Corresponding Author: Julie Nantel, PhD School of Human Kinetics, Faculty of Health Sciences, University of Ottawa, Ottawa, Canada, K1N 6N5E-Mail: [email protected] ID: https://orcid.org/0000-0001-7253-9222
, Christopher Hovorka
CANADIAN PROSTHETICS & ORTHOTICS JOURNAL, Volume 4; https://doi.org/10.33137/cpoj.v4i2.36673

Abstract:
This position paper outlines the important role of academia in shaping the orthotics and prosthetics (O&P) profession and preparing for its future. In the United States, most healthcare professions including O&P are under intense pressure to provide cost effective treatments and quantifiable health outcomes. Pivotal changes are needed in the way O&P services are provided to remain competitive. This will require the integration of new technologies and data driven processes that have the potential to streamline workflows, reduce errors and inform new methods of clinical care and device manufacturing. Academia can lead this change, starting with a restructuring in academic program curricula that will enable the next generation of professionals to cope with multiple demands such as the provision of services for an increasing number of patients by a relatively small workforce of certified practitioners delivering these services at a reduced cost, with the expectation of significant, meaningful, and measurable value. Key curricular changes will require replacing traditional labor-intensive and inefficient fabrication methods with the integration of newer technologies (i.e., digital shape capture, digital modeling/rectification and additive manufacturing). Improving manufacturing efficiencies will allow greater curricular emphasis on clinical training and education – an area that has traditionally been underemphasized. Providing more curricular emphasis on holistic patient care approaches that utilize systematic and evidence-based methods in patient assessment, treatment planning, dosage of O&P technology use, and measurement of patient outcomes is imminent. Strengthening O&P professionals’ clinical decision-making skills and decreasing labor-intensive technical fabrication aspects of the curriculum will be critical in moving toward a digital and technology-centric practice model that will enable future practitioners to adapt and survive. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/36673/28349 How To Cite: Kogler GF, Hovorka CF. Academia’s role to drive change in the orthotics and prosthetics profession. Canadian Prosthetics & Orthotics Journal. 2021; Volume 4, Issue 2, No.21. https://doi.org/10.33137/cpoj.v4i2.36673 Corresponding Author: Géza F. KoglerOrthotics and Prosthetics Unit, Kennesaw State University.E-Mail: [email protected] ID: https://orcid.org/0000-0003-0212-5520
CANADIAN PROSTHETICS & ORTHOTICS JOURNAL, Volume 4; https://doi.org/10.33137/cpoj.v4i2.35958

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The goal of health economics and outcomes research is to improve healthcare decision making. In the absence of high-value clinical data, the availability and quality of administrative healthcare data could be vital in the generation of evidence for orthotics and prosthetics services. The purpose of this article is to provide a stronger understanding of administrative healthcare data analysis, an area that has been scarcely examined within prosthetics and orthotics despite the wealth of information available within such data. Examples of common datasets in this arena currently available are provided, as well as an overview of the limitations and advantages of studies utilizing such datasets. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/35958/28315 How To Cite: Miller TA, Wurdeman S. Value and applicability of large administrative healthcare databases in prosthetics and orthotics outcomes research. Canadian Prosthetics & Orthotics Journal. 2021; Volume 4, Issue 2, No.4. https://doi.org/10.33137/cpoj.v4i2.35958 Corresponding Author: Taavy A Miller, PhD, CPODepartment of Clinical and Scientific Affairs, Hanger Clinic, Austin, Texas, USA.E-Mail: [email protected] ID: https://orcid.org/0000-0001-7117-6124
CANADIAN PROSTHETICS & ORTHOTICS JOURNAL, Volume 4; https://doi.org/10.33137/cpoj.v4i2.37089

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The Sabolich family had made a unique contribution to both the clinical practice of Prosthetics and Orthotics as well as the business of prosthetics and orthotics. In preparing for this Special Edition, as Co-Editor-in-Chief, I felt it important to include the story of the Sabolich vision for prosthetic clinical practice and their experiences in achieving that vision. Their story is an important part of the history of prosthetic clinical practice in the United States. Their rethinking of what a clinical practice could look like and function as was far-sighted. Achieving it required both risk taking, as well as a new business model. The reaction from other Prosthetic and Orthotic practitioners was strong. Some saw the new model as visionary while others found it provocative. The model was based on a concierge style practice, which provided a premium service to a patient from first appointment to providing and maintaining of their device. They then went further than that by incorporating in-house research into their facility to develop new and innovative prosthetic approaches that would make them leaders in the field of socket design and fit. Their vision was to be a Center of Excellence for Prosthetics and Orthotics Practices, a vison that many people within the sector would likely agree was achieved. I invited current CEO of Scott Sabolich Prosthetics and Research to reflect back on the history of his family’s business and how multiple generations of his family were able to see gaps and create opportunities where others could not see beyond the status quo and even fought hard to maintain the status quo. The evolution of this company provides insight into the successful development of novel business practices and economics in Prosthetics and Orthotics, while staying true to core service principles. The result was a business model that, in hind sight, had future-proofed the company in the face of the global economic challenges that impacted the sector in 2008-9 and beyond. It is also an indicator of what opportunities there are, at the business, clinical and technical levels, for those who take the risk of breaking from the status quo. Because of time and capacity constraints on the part of Mr. Scott Sabolich, it was agreed that his professional opinions and insights would be done in an interview format. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/37089/28362 How To Cite: Sabolich S. Sabolich Prosthetics and Research: A continuing journey on the road less traveled. Canadian Prosthetics & Orthotics Journal. 2021;Volume 4, Issue 2, No.14. https://doi.org/10.33137/cpoj.v4i2.37089 Corresponding Author: Scott Sabolich, Scott Sabolich Prosthetics and Research, Oklahoma City, USA. E-Mail: [email protected] ORCID ID: https://orcid.org/0000-0001-5723-7963
, Susanne Seidinger
CANADIAN PROSTHETICS & ORTHOTICS JOURNAL, Volume 4; https://doi.org/10.33137/cpoj.v4i2.35298

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The rapid advancement of prosthetic and orthotic (P&O) technology raises the question how the industry can ensure that patients have access to the benefits and providers get paid properly and fairly by healthcare payers. This is a challenge that not only P&O but all areas of health technology face. In many areas of medicine and health products, such as drugs and medical devices, health-technology assessments (HTA) have become a standard procedure in the coverage and reimbursement process. In most countries, P&O is lagging behind that development, although some countries have already formalized HTA for prosthetic and orthotic products and may even use cost-effectiveness analyses to determine pricing and payment amounts. This article gives an overview on the coverage and reimbursement processes in the United States, Canada, Germany, France, Sweden, the United Kingdom, Poland, Japan, and China. This selection reflects the variety and diversity of coverage and reimbursement processes that the P&O industry faces globally. The paper continues with an overview on the necessary research and investment efforts that manufacturers will have to make in the future, and contemplates the likely consequences for the manufacturer community in the market place. Health economics may help support the transition from price-based to value-based coverage and reimbursement but will come at considerable costs to the industry. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/35298/28317 How To Cite: Kannenberg A, Seidinger S. Health economics in the field of prosthetics and orthotics: A global perspective. Canadian Prosthetics & Orthotics Journal. 2021; Volume 4, Issue 2, No.6. https://doi.org/10.33137/cpoj.v4i2.35298 Corresponding Author: Andreas Kannenberg, MD (GER), PhDExecutive Medical Director North America, Otto Bock Healthcare LP, 11501 Alterra Parkway, Suite 600, Austin, Texas, USA.E-Mail: [email protected] ID: https://orcid.org/0000-0001-7983-1744
, Joel Schulz
CANADIAN PROSTHETICS & ORTHOTICS JOURNAL, Volume 4; https://doi.org/10.33137/cpoj.v4i2.35208

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The prosthetic socket is commonly considered to be the most important part of the prosthesis and lack of fit can lead to skin breakdown, reduction in wear, reduction in activity, and consequential deleterious health effects. Furthermore, approximately 90% of amputations are due to a vascular etiology, which affect fluid retention regularity, and even small limb volume fluctuations can lead to lack of fit. Adjustability in the socket volume has been suggested as a potential solution to common fit issues but has lacked market penetration mostly due to lack of reimbursement. Despite this there are several adjustable-volume sockets emerging on the market today including prefabricated, modular, custom with adjustable-volume component, custom with adjustable-volume feature, and adjustable-hybrid sockets. Prefabricated sockets are mass produced in common sizes and fit directly to the patient by a prosthetist using pad kits, BOA dials, or straps. Modular sockets are assembled to a patient or model with panels or struts attached to an adjustable base. Custom sockets with adjustable-volume elements are traditionally-fabricated sockets made to a model of a patient’s limb with a volume-adjustable component added or volume-adjustable feature built in. Custom-hybrid sockets are made custom to a model of the patient’s limb and incorporate several aspects of the previous socket types and include some radically-unique design aspects which cannot be limited to one category. These adjustable-volume sockets offer several advantages to traditional rigid-volume sockets for the patient, prosthetist, and providing clinic. The micro-adjustability for the patient allows them to alter fit without removing the socket, maintaining a more intimate fit throughout the day than traditional sockets. The macro-adjustability for the prosthetist allows for increased options for fit customization including the ability to reverse or undo changes without necessarily re-making the socket. This allows for the most optimal fit for the patient. Adjustable volume also present efficiencies in the fitting process by simplifying or eliminating steps including residual limb shape capture, form modification, diagnostic fabrication, iterative alteration, and definitive fabrication with the different socket types affecting different steps. Due to these factors, adjustable-volume sockets have disrupted the market to the point where reimbursement reform is needed including additional L-codes in the United States and fee-for-service or fee-for-outcome associated with prosthetic follow-up care. Prosthetic care should also be separated from durable medical equipment to allow for alternative reimbursement models. As reimbursement adapts prosthetists must adapt correspondingly to differentiate their skillset from other allied health providers including incorporating more objective methods to show superior care outcomes. This adaptation should include a continued push for state and municipal licensure of prosthetists. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/35208/28346 How To Cite: Klenow TD, Schulz J. Adjustable-volume prosthetic sockets: market overview and value propositions. Canadian Prosthetics & Orthotics Journal. 2021; Volume 4, Issue 2, No.17 https://doi.org/10.33137/cpoj.v4i2.35208 Corresponding Author: Tyler D. Klenow, MSPO, MBA, CLPO, FAAOP Martin Bionics Clinical Care E-Mail: [email protected] ORCID ID: https://orcid.org/0000-0002-6372-2241
, Debra Berg
CANADIAN PROSTHETICS & ORTHOTICS JOURNAL, Volume 4; https://doi.org/10.33137/cpoj.v4i2.36210

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The emergence of skeletal prosthetic attachments leaves governmental organizations facing the challenge of implementing equitable policies that support the provision of bone-anchored prostheses (BAPs). In 2013, the Queensland Artificial Limb Service (QALS) started a five-year research project focusing on health service delivery and economic evaluation of BAPs. This paper reflects on the QALS experience, particularly the lessons learned. QALS’ jurisdiction and drivers are presented first, followed by the impact of outcomes, barriers, and facilitators, as well as future developments of this work. The 21 publications produced during this project (e.g., reimbursement policy, role of prosthetists, continuous improvement procedure, quality of life, preliminary cost-utilities) were summarized. Literature on past, current, and upcoming developments of BAP was reviewed to discuss the practical implications of this work. A primary outcome of this project was a policy developed by QALS supporting up to 22 h of labor for the provision of BAP care. The indicative incremental cost-utility ratio for transfemoral and transtibial BAPs was approximately AUD$17,000 and AUD$12,000, respectively, per quality-adjusted life-year compared to socket prostheses. This project was challenged by 17 barriers (e.g., limited resources, inconsistency of care pathways, design of preliminary cost-utility analyses) but eased by 18 facilitators (e.g., action research plan, customized database, use of free repositories). In conclusion, we concluded that lower limb BAP might be an acceptable alternative to socket prostheses from an Australian government prosthetic care perspective. Hopefully, this work will inform promoters of prosthetic innovations committed to making bionic solutions widely accessible to a growing population of individuals suffering from limb loss worldwide. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/36210/28330 How To Cite: Berg D, Frossard L. Health service delivery and economic evaluation of limb lower bone-anchored prostheses: A summary of the Queensland artificial limb service’s experience. Canadian Prosthetics & Orthotics Journal. 2021; Volume 4, Issue 2, No.12. https://doi.org/10.33137/cpoj.v4i2.36210 Corresponding Author: Laurent Frossard, PhD, Professor of BionicsYourResearchProject Pty Ltd, Brisbane, Australia.E-Mail: [email protected] number: https://orcid.org/0000-0002-0248-9589
CANADIAN PROSTHETICS & ORTHOTICS JOURNAL, Volume 4; https://doi.org/10.33137/cpoj.v4i2.35876

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This submission provides an important historical context for understanding the current challenge facing the Orthotic and Prosthetic community in Alberta including Alberta Aids to Daily Living (AADL), Suppliers, and Providers: maintaining sustainable access to Orthotic care for people with mobility disorders in the face of declining real rates of reimbursement combined with increasing costs and a shortage of skilled Clinicians. Under the Canada Health Act, the federal government delegates responsibility for providing health care to the provinces. This delegation of responsibility to the provinces results in a degree of variability of funding of Orthotics and Prosthetics between provinces across the country. Funding of Orthotics and Prosthetics in Alberta is characterized by structural inequities that favour Prosthetics at the expense of Orthotics. To the extent that the structural inequities that exist in Alberta are related to governance by volunteer-run, non-profit organizations, they may be generalized to the Canadian experience. Finally, in a Call to Action a number of recommendations are made to address the challenge of sustainable access to Orthotic care in Alberta serving as a model for other provinces across Canada. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/35876/28314 How To Cite: Schneider N. Evolving business models in orthotics. Canadian Prosthetics & Orthotics Journal. 2021; Volume 4, Issue 2, No.3. https://doi.org/10.33137/cpoj.v4i2.35876 Corresponding Author: Nancy SchneiderBraceworks Custom Orthotics, 1-3500 24 Ave NW, Calgary, Alberta, Canada.E-Mail: [email protected] ID: https://orcid.org/0000-0002-8441-4467
CANADIAN PROSTHETICS & ORTHOTICS JOURNAL, Volume 4; https://doi.org/10.33137/cpoj.v4i2.37113

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What would we do, if only we had the power to go back?! The best way to consider this is to align and join all the known dots. To think of Prosthetics and Orthotics (P&O) as a system holistically centred around care of the user, identifying all their needs continuously, in their environment and in their lifestyle. This could produce a new value proposition for all multi-disciplinary team members by generating patient-centred therapeutic benefits and clinical outcomes that align all stakeholders in P&O towards using a common narrative, which makes decisions based on data. In this case, data is the outcome, using Standards and Instruments which are validated (e.g. www.amprom.uk) to quantify questions such as: “Have we reduce risk of falls?”, “Have we reduced risk of tissue injury?”, “Have we reduced risk of low back pain?”, “Have we reduced long term risk of osteoarthritis?”, etc. If we have, we are assured this will benefit the comfort and confidence for the user. We can have confidence in rehabilitation measured by improved stability and increased activity, and other measures which enable the accurate classification of products and services to match users. A prescription index, based on Outcomes, could, for example, be calculated by a formula which accounts for the percentage reduction in falls probability, a patient satisfaction score, a mobility score and a quality-of-life score, allowing practitioners to base their choices of treatment pathways and component selection. This paper provides both the context for and contributing factors that make the proposing of such an objective Prescription Index an interesting thing to consider when discussing Health Economics in P&O. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/37113/28348 How To Cite: Zahedi S. Review of prosthetics & orthotics needs for 21st Century – Vision for 2025. Canadian Prosthetics & Orthotics Journal. 2021; Volume 4, Issue 2, No.20. https://doi.org/10.33137/cpoj.v4i2.37113 Corresponding Author: Professor Sir Saeed Zahedi,Blatchford Group, Unit D Antura, Bond Close, Basingstoke, RG24 8PZ, United Kingdom.E-Mail: [email protected] ID: https://orcid.org/0000-0002-6959-632X
Jeffrey M. Brandt
CANADIAN PROSTHETICS & ORTHOTICS JOURNAL, Volume 4; https://doi.org/10.33137/cpoj.v4i2.35996

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Leading the growth of a private prosthetic and orthotic (P&O) practice, as clinician and founder, I developed a unique perspective of this rapidly changing profession. Many positive influences from my early career shaped my vison toward an innovative practice model, as well as the need to elevate the standard of care through education and the use of outcome measures. As the practice model expanded, advancements were made in electronic health records (EHR), best-in-class outsource fabrication, and clinical research. To better support clinicians and patients served, an organizational structure with an executive team was built. The practice model achieved operational efficiency through documenting best practices, developing a hiring and onboarding process, and establishing key performance indicators aligned with quality clinical care. As a regional clinical care organization, the practice model seized an opportunity to reach more patients through a partnership that brought the optimal strategic and cultural fit. Bringing our innovative P&O practice model together with expertise in lean facility design, scanning, fabrication, sensor technology, product development and clinical care experience from around the world, we can advance care standards and improve the patient experience in exciting new ways. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/35996/28414 How To Cite: Brandt JM. An operational perspective of the changing prosthetics & orthotics landscape. Canadian Prosthetics & Orthotics Journal. 2021; Volume 4, Issue 2, No.19. https://doi.org/10.33137/cpoj.v4i2.35996 Corresponding Author: Jeffrey M. Brandt, CPO Ability Prosthetics & Orthotics, 660 West Lincoln Highway, Exton, PA 19341, USA. E-Mail: [email protected] ORCID ID: https://orcid.org/0000-0002-7377-9516
M. Jason Highsmith, Christopher M. Fantini, Douglas G. Smith
CANADIAN PROSTHETICS & ORTHOTICS JOURNAL, Volume 4; https://doi.org/10.33137/cpoj.v4i2.36125

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Reimbursement to U.S. healthcare service providers is largely transitioning from fee for service to fee for value for those clinicians who code using current procedural terminology and through their coding, describe their professional services. The Orthotic, Prosthetic and Pedorthic profession (O&P), currently codes using a system that describes the devices they evaluate for, fabricate, fit and maintain and their professional services are incorporated into their codes. These O&P codes, in contrast to those for other healthcare disciplines, are predominantly product based rather than service based, focusing on product features and function more than clinical service. This editorial manuscript provides a brief overview of the system the US O&P profession uses currently, particularly in the context of other healthcare professions transitioning to value based coding and reimbursement and culminates in a call to action for the profession to academically consider the strengths and weaknesses of the current system relative to alternative systems. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/36125/28316 How To Cite: Highsmith MJ, Fantini CM, Smith DG. Contemplating health economics, coding and reimbursement in orthotics, prosthetics and pedorthics. Canadian Prosthetics & Orthotics Journal. 2021; Volume 4, Issue 2, No.5. https://doi.org/10.33137/cpoj.v4i2.36125 Corresponding Author: M. Jason Highsmith, PhD, DPT, CP, FAAOPSchool of Physical Therapy & Rehabilitation Sciences, Morsani College of Medicine, University of South Florida. Florida, USA.E-Mail: [email protected] ID: https://orcid.org/0000-0001-8361-7345
, Keana DiMario
CANADIAN PROSTHETICS & ORTHOTICS JOURNAL, Volume 4; https://doi.org/10.33137/cpoj.v4i2.35972

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Funding agencies, both public and private, do not adequately meet the needs of Canadian amputees. This often leaves amputees without access to appropriate prosthetic care due to outstanding balances that are to be paid out of pocket, or by charitable organizations. There are several factors that result in these inadequacies. As healthcare is a provincial responsibility in Canada, provinces and territories have the authority to create individual public regimes, each with their own weaknesses. In fact, there are a few provincial regimes which do not include prosthetic funding at all. Private healthcare is meant to offset the remaining balance; however, their lack of knowledge regarding amputation has resulted in the creation of policies with ambiguous language, limiting the funding available for prosthetic care. Attitudinal barriers and missed legislative opportunities further exacerbate the shortcomings of prosthetic funding provided by public and private funding agencies, requiring action. Article PDF Link:https://jps.library.utoronto.ca/index.php/cpoj/article/view/35972/28331 How To Cite: Petlock A, DiMario K. (In) Access to artificial limbs: the patient’s perspective according to the WAR AMPS of Canada. Canadian Prosthetics & Orthotics Journal. 2021; Volume 4, Issue 2, No.13. https://doi.org/10.33137/cpoj.v4i2.35972 Corresponding Author: Annelise PetlockThe War Amps Advocacy Program/ 2827 Riverside Drive Ottawa, Ontario, Canada.E-Mail: [email protected] ID: https://orcid.org/0000-0002-7273-4527
CANADIAN PROSTHETICS & ORTHOTICS JOURNAL, Volume 4; https://doi.org/10.33137/cpoj.v4i2.37250

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This paper is both a stakeholder perspectives as well as a ‘case study’ describing a journey from sudden disability to participant and investor in exoskeleton design. It tells of my experiences and opinions, as a successful fashion designer, when my life took a drastic turn on becoming paralysed from the waist down over the course of 24 hours, by a spinal tumour. Getting this diagnosis was ‘the worst day in my life’, and it was quickly followed by the ‘second worst’ when, in my determination to walk again, I received Knee Ankle Foot Orthotics (KAFOs) and was shocked to learn that this appeared to be the best technology solution available on the market ‘suitable’ for use in the community. Initial anger at the system for not being better, at the rehab team for their complacency, and at myself for allowing a feeling of helplessness to take over led to questions such as: what does this say about our society? and what are we all willing to accept, for ourselves and others? This is professional opinion and an essay about how we see ourselves and how others see us. The journey from pre-injury ‘consumer’ to post-injury ‘disabled’ person and learning that being labeled ‘disabled’ leads to the additional handicap of the narrow vision of “cost” taken by the mobility industry where innovative ideas are stripped down to the bare minimum with the excuse that patients are “lucky” to have what they have been “given”. Grappling with these labels and inequities and seeking a better outcome, I became an integral team member of an exoskeleton development team, leading to the design of The Next Generation Exoskeleton! This is MY story, the story of Chloe Angus. It is the story of inclusive, user focused design and is a call to include and respect the end users of all assistive device technology design early in the design process and it is being told from the perspective of a person having experience and success in the world of business. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/37250/28296 How To Cite: Angus C. Exoseketons: a rehab tech consumer’s unexpected march to action. Canadian Prosthetics & Orthotics Journal. 2021; Volume 4, Issue 2, No.2. https://doi.org/10.33137/cpoj.v4i2.37250 Corresponding Author: Chloe AngusChloe Angus Design, Vancouver, BC, Canada.E-Mail: [email protected] ID: https://orcid.org/0000-0002-5468-3121
Manuel Opitz, Peter Fröhlingsdorf
CANADIAN PROSTHETICS & ORTHOTICS JOURNAL, Volume 4; https://doi.org/10.33137/cpoj.v4i2.36349

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Digitalisation is the megatrend in healthcare, not only since the pandemic. We are two European digital health experts and industry leaders in the field of orthotics and prosthetics (O&P) and in this article we explored what are the underlying trends driving the adoption of digitalisation for customisation of prosthetics & orthotics. We showed that several trends in 3D image capture (input step), 3D modelling (processing step) and 3D printing (output step) currently converge and thus fuel the rapid transformation of the O&P industry. In short outlooks, we rated the probability and timing of adoption rates across the upcoming couple of years. We furthermore reviewed the impact of boundary conditions set by regulators as well as the reimbursement system. Towards the end of this article, we outlined a digital scenario of the near future by following around an orthotist during her work. We finished with a call-to-action targeting regulators, payors, prosthetists/orthotists, and patients to enable such a desirable future. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/36349/28332 How To Cite: Opitz M, Fröhlingsdorf P. The digital O&P workshop. Canadian Prosthetics & Orthotics Journal. 2021; Volume 4, Issue 2, No.15. https://doi.org/10.33137/cpoj.v4i2.36349 Corresponding Author: Manuel Opitz, MECURIS GmbH, Lindwurmstraße 11, 80337 München, Germany.E-Mail: [email protected] number: https://orcid.org/0000-0001-6098-1881
CANADIAN PROSTHETICS & ORTHOTICS JOURNAL, Volume 4; https://doi.org/10.33137/cpoj.v4i2.36661

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The economic viability of Orthotics & Prosthetics (O&P) service provision is an important concern for policy makers, patients, and practitioners. Against the background of limited funds that can be distributed for healthcare expenses overall, it is critical to identify the most cost-effective treatment options within and across disciplines, including surgical and pharmacological interventions. When those decisions are being negotiated, whether in the context of an individual case in the clinic or of general payer policies that allocate spending budgets, the O&P discipline is often perceived to be at a disadvantage due to its relatively young age, underdeveloped evidence base, and small economic clout as compared to other fields. Such asymmetrical negotiations have been the subject of economic theories and mathematical models, such as the “Game theory”, work on which has been awarded with several Nobel Prizes and other recognitions across the years. In this paper, we are introducing core concepts of this theory and discuss how they may be applied in negotiations on treatment approaches and reimbursement schedules with the goal to improve outcomes for the O&P profession. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/36661/28347 How To Cite: Fiedler G, Schikorra A. A brief introduction to game theory and its potential implications for the economics of orthotics & prosthetics. Canadian Prosthetics & Orthotics Journal. 2021; Volume 4, Issue 2, No.18. https://doi.org/10.33137/cpoj.v4i2.36661 Corresponding Author: Dr. Goeran Fiedler, PhDDepartment of Rehabilitation Science and Technology, University of Pittsburgh, Pittsburgh, PA 15206, USA.E-Mail: [email protected] number: https://orcid.org/0000-0003-1532-1248
CANADIAN PROSTHETICS & ORTHOTICS JOURNAL, Volume 4; https://doi.org/10.33137/cpoj.v4i2.35203

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Innovation is an important part of the prosthetic and orthotics (P&O) industry. Innovation has the potential to improve health care services and outcomes, however, it can also be a burden to the system if misdirected. This paper explores the interaction of innovation and economics within the P&O industry, focusing on its current state and future opportunities. Technological advancement, industry competition and pursuit of better patient outcomes drive innovation, while challenges in ensuring better P&O health care include lagging clinical evidence, limited access to data, and existing funding structures. There exists a greater need for inclusive models and frameworks for rehabilitation care, that focus on the use of appropriate technology as supported by research and evidence of effectiveness and cost-effectiveness. Additionally, innovative business models based on social entrepreneurism could open access to untapped and underserved markets and provide greater access to assistive technology. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/35203/28318 How To Cite: Andrysek J. The economics of innovation in the prosthetic and orthotics industry. Canadian Prosthetics & Orthotics Journal. 2021; Volume 4, Issue 2, No.7. https://doi.org/10.33137/cpoj.v4i2.35203 Corresponding Author: Jan Andrysek, PhDHolland Bloorview Kids Rehabilitation Hospital, Toronto, Canada.E-Mail: [email protected]; [email protected] ID: https://orcid.org/0000-0002-4976-1228
CANADIAN PROSTHETICS & ORTHOTICS JOURNAL, Volume 4; https://doi.org/10.33137/cpoj.v4i2.37135

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There is a scarcity of literature exploring Health Economics in Prosthetics and Orthotics (P&O). The P&O sector has, over the past decades, moved to a Bachelor’s or Masters Degree level as the requirement for entry to practice and, with that, there has been a growing body of research and knowledge generation focusing primarily on clinical aspects and engineering advances. No corresponding body of research has emerged on the economic aspects of P&O, creating a fundamental weakness in both technical and clinical research efforts to advance this field within an economically sustainable framework. This weakness will become critical as data driven engineering advances (e.g. exoskeletons, mass customizable prostheses) and clinical improvements (e.g. osseointegration, diabetes treatments) will make reimbursement for devices ever more complex and challenging. The tension between what is possible and what is fundable will increase unless what is possible also drives down costs. Finding the right balance in Prosthetics and Orthotics will be a challenge, as this sector already struggles to justify current standards of care. This Special Edition takes a snapshot of stakeholder perspectives and opinions on the topic of Health Economics in P&O and is organized around the following stakeholder groups: End-user, Researcher (Engineering and Clinical), Prosthetic and Orthotic Practitioner and, of critical importance, four papers describing an interdisciplinary project on the Health Economics of Osseointegration that was led by a payor. Each author was also asked to provide a “Call to Action” in which they identify one or more key areas that need to be addressed in order to move forward with the barriers or opportunities they have identified in their paper. The intent of the Special Edition is to generate discussion and encourage more in-depth research on this topic. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/37135/28295 How To Cite: Raschke S.U. Editor’s perspective on health economics in prosthetics and orthotics. Canadian Prosthetics & Orthotics Journal. 2021; Volume 4, Issue 2, No.1. https://doi.org/10.33137/cpoj.v4i2.37135 Corresponding Author: Silvia Ursula Raschke, PhDBritish Columbia Institute of Technology (BCIT), 3700 Willingdon Avenue, Burnaby, British Columbia, Canada.E-Mail: [email protected] ID: https://orcid.org/0000-0001-7964-4295
CANADIAN PROSTHETICS & ORTHOTICS JOURNAL, Volume 4; https://doi.org/10.33137/cpoj.v4i2.35959

Abstract:
The demand has increased for evidence regarding the effectiveness and value of prosthetic and orthotic rehabilitation interventions. Clinicians and managers are under pressure to provide treatment recommendations and demonstrate effectiveness through outcomes. It is often assumed that rehabilitation interventions, including the provision of custom-made and custom-fit orthotic and prosthetic devices, are beneficial to patients. Assessing the value of orthotic and prosthetic services has become more critical to continue to ensure equitable access to needed services. Health economics and outcomes research methods serve as tools to gauge the value of prosthetic and orthotic rehabilitation interventions. The purpose of this article is to provide an overview of the current need of health economics and outcomes research in orthotics and prosthetics, to introduce common economic methods that assist to generate real-world evidence, and to discusses the potential value of economic methods for clinicians and clinical practice. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/35959/28326 How To Cite: Miller T.A, Wurdeman S, Paul R, Forthofer M. The value of health economics and outcomes research in prosthetics and orthotics. Canadian Prosthetics & Orthotics Journal. 2021; Volume 4, Issue 2, No.8. https://doi.org/10.33137/cpoj.v4i2.35959 Corresponding Author: Taavy A Miller, PhD, CPODepartment of Clinical and Scientific Affairs, Hanger Clinic, Austin, Texas, USA.E-Mail: [email protected] ID: https://orcid.org/0000-0001-7117-6124
CANADIAN PROSTHETICS & ORTHOTICS JOURNAL, Volume 4; https://doi.org/10.33137/cpoj.v4i2.36364

Abstract:
Overcoming obstacles to prosthetic fittings requires frequent tryouts of sockets and components. Repetitions of interventions are upsetting for users and place substantial economic burden on healthcare systems. Encouraging prosthetic care innovations capable of alleviating clinical and financial shortcomings of socket-based solutions is essential. Nonetheless, evidence of socio-economic benefits of an innovation are required to facilitate access to markets. Unfortunately, complex decisions must be made when allocating resources toward the most relevant health economic evaluation (HEE) at a given stage of development of an innovation. This paper first, aimed to show the importance and challenges of HEEs of intervention facilitating prosthetic fittings. Next, the main trends in HEEs at various phases of product development and clinical acceptance of prosthetic care innovations were outlined. Then, opportunities for a basic framework of a preliminary cost-utility analysis (CUA) during the mid-stage of development of prosthetic care innovations were highlighted. To do this, fundamental and applied health economic literature and prosthetic-specific publications were reviewed to extract and analyse the trends in HEEs of new medical and prosthetic technologies, respectively. The findings show there is consensus around the weaknesses of full CUAs (e.g., lack of timeliness, resource-intensive) and strengths of preliminary CUAs (e.g., identify evidence gaps, educate design of full CUA, fast-track approval). However, several obstacles must be overcome before preliminary CUA of prosthetic care innovations will be routinely carried out. Disparities of methods and constructs of usual preliminary CUA are barriers that could be alleviated by a more standardized framework. The paper concludes by identifying that there are opportunities for the development of a basic framework of preliminary CUA of prosthetic care innovations. Ultimately, the collaborative design of a framework could simplify selection of the methods, standardise outcomes, ease comparisons between innovations and streamline pathways for adoption. This might facilitate access to economical solutions that could improve the life of individuals suffering from limb loss. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/36364/28327 How To Cite: Frossard L. Trends and opportunities in health economic evaluations of prosthetic care innovations. Canadian Prosthetics & Orthotics Journal. 2021; Volume 4, Issue 2, No.9. https://doi.org/10.33137/cpoj.v4i2.36364 Corresponding Author: Laurent Frossard, PhD, Professor of BionicsYourResearchProject Pty Ltd, Brisbane, Australia.E-Mail: [email protected] number: https://orcid.org/0000-0002-0248-9589
CANADIAN PROSTHETICS & ORTHOTICS JOURNAL, Volume 4; https://doi.org/10.33137/cpoj.v4i2.36188

Abstract:
From 2014 until 2020, I participated in the development of a novel CAD/CAM system for lower-limb prosthetic sockets for use in Lower and Middle Income Countries (LMIC) orthopaedic clinical settings. This article provides an overview of the value principles that guided that work and the ways in which we attempted to support the clinical needs of our prosthetists and others in the clinical contexts. It will highlight how the health economic framework that is key to this special issue well describes the design choices we made in order to attend to the multiple levels of concerns and stakeholders we identified as key to success. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/36188/28345 How To Cite: Ratto M. Designing a digital toolchain for prosthetics: A retrospective. Canadian Prosthetics & Orthotics Journal. 2021; Volume 4, Issue 2, No.16. https://doi.org/10.33137/cpoj.v4i2.36188 Corresponding Author: Matt Ratto, PhDFaculty of Information, University of Toronto, Canada.E-Mail: [email protected] ID: https://orcid.org/0000-0002-3554-4513
Lluis Guirao, Beatriz Samitier,
CANADIAN PROSTHETICS & ORTHOTICS JOURNAL, Volume 4; https://doi.org/10.33137/cpoj.v4i2.36366

Abstract:
Several obstacles must be overcome before preliminary cost-utility analyses (CUA) of prosthetic care innovations can be routinely performed. The basic framework of preliminary CUAs and hands-on recommendations suggested previously might contribute to wider adoption. However, a practical application for an emerging intervention is needed to showcase the capacity of this proposed preliminary CUA framework. This study presented the outcomes of preliminary CUA of the distal weight bearing Keep Walking Implant (KWI), an emerging prosthetic care innovation that may reduce socket fittings for individuals with transfemoral amputation. The preliminary CUAs compared the provision of prosthetic care without (usual intervention) and with the KWI (new intervention) using a 15-step iterative process focused on feasibility, constructs, analysis, and interpretations of outcomes from an Australia government prosthetic care perspective over a six-year time horizon. Baseline and incremental costs were extracted from schedules of allowable expenses. Baseline utilities were extracted from a study and converted into quality-adjusted life-year (QALY). Incremental utilities were calculated based on sensible gains of QALY from baselines. The provision of the prosthetic care with the KWI could generate an indicative incremental cost-utility ratio (ICUR) of -$36,890 per QALY, which was $76,890 per QALY below willingness-to-pay threshold, provided that the KWI reduces costs by $17,910 while increasing utility by 0.485 QALY compared to usual interventions. This preliminary CUA provided administrators of healthcare organizations in Australia and elsewhere with prerequisite evidence justifying further access to market and clinical introduction of the KWI. Altogether, this work suggests that the basic framework of the preliminary CUA of a prosthetic care innovation proposed previously is feasible and informative when a series of assumptions are carefully considered. This study further confirms that preliminary CUAs prosthetic care interventions might be a relevant alternative to full CUA for other medical treatments. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/36366/28329 How To Cite: Guirao L, Samitier B, Frossard L. A preliminary cost-utility analysis of the prosthetic care innovations: case of the keep walking implant. Canadian Prosthetics & Orthotics Journal. 2021; Volume 4, Issue 2, No.11. https://doi.org/10.33137/cpoj.v4i2.36366 Corresponding Author: Laurent Frossard (PhD), Professor of BionicsYourResearchProject Pty Ltd, Brisbane, Australia.E-Mail: [email protected] number: https://orcid.org/0000-0002-0248-9589
CANADIAN PROSTHETICS & ORTHOTICS JOURNAL, Volume 4; https://doi.org/10.33137/cpoj.v4i2.36365

Abstract:
A preliminary cost-utility analysis (CUA) of prosthetic care innovations can provide timely information during the early stage of product development and clinical usage. Concepts of preliminary CUAs are emerging. However, several obstacles must be overcome before these analyses are performed routinely. Disparities of methods and high uncertainty make the outcomes of usual preliminary CUAs challenging to interpret, appraise and share. These shortcomings create opportunities for a basic framework of preliminary CUAs. First, I introduced a basic framework of a preliminary CUA built around a series of constructs and hands-on recommendations. Then, I appraised this framework considering the strengths and weaknesses, barriers and facilitators, and return on investment. The design of the basic framework was determined through the review of health economic and prosthetic-specific literature. A preliminary CUA comparing the costs and utilities between usual intervention and an innovation could be achieved through a 15-step iterative process focusing on feasibility, constructs, analysis, and interpretation of outcomes. This CUA provides sufficient evidence to identify knowledge gaps and improvement areas, educate about the design of subsequent full CUAs, and obtain fast-track approval from governing bodies. Like previous CUAs, the main limitations were inherent to the constructs (e.g., narrow perspective, plausible scenarios, mid-term time horizon, substantial assumptions, data mismatch, high uncertainty). Key facilitators potentially transferable across preliminary CUAs of prosthetic care innovations included choosing abided constructs, capitalizing on prior schedules of expenses, and benchmarking baseline or incremental utilities. This new approach with preliminary CUA can simplify the selection of methods, standardize outcomes, ease comparisons between innovations, and streamline pathways for adoption. Further collegial efforts toward validating standard preliminary CUAs will facilitate access to economic prosthetic care innovations, improving the lives of individuals suffering from limb loss worldwide. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/36365/28328 How To Cite: Frossard L. A preliminary cost-utility analysis of the prosthetic care innovations: basic framework. Canadian Prosthetics & Orthotics Journal. 2021; Volume 4, Issue 2, No.10. https://doi.org/10.33137/cpoj.v4i2.36365 Corresponding Author: Laurent Frossard (PhD), Professor of BionicsYourResearchProject Pty Ltd, Brisbane, Australia.E-Mail: [email protected] number: https://orcid.org/0000-0002-0248-9589
CANADIAN PROSTHETICS & ORTHOTICS JOURNAL, Volume 4; https://doi.org/10.33137/cpoj.v4i1.36833

Abstract:
BACKGROUND: The prevalence of lower-limb amputations (LLA) in older adults is increasing. Due to the substantial resources required for rehabilitation, there is growing interest in exploring prosthesis use as well as the factors that impact use for individuals with LLA. OBJECTIVES: To examine how older adults, those over 50 years old, with a new LLA use their prostheses following rehabilitation and to identify factors that increase or decrease prosthesis use after discharge from a rehabilitation hospital. METHODS: The StepWatch Activity Monitor, the Prosthetic Profile of the Amputee Questionnaire, and a semi-structured interview were used to measure prosthesis use and factors affecting use at 12 weeks post-discharge from a rehabilitation hospital. Descriptive statistics were calculated for the quantitative data and the qualitative interviews were analyzed using the International Classification of Functioning and Disability. RESULTS: Two user profiles emerged from the 11 participants’ use patterns. The Regular Users integrated their prosthesis into their lives, using it for various types of activities, while the Strategic Users wore their prosthesis to perform specific activities of daily and instrumental activities of daily living tasks. Body functions (e.g., pain), personal (e.g., feeling of independence), and environmental factors (e.g., home adaptations or social support) impacted prosthesis use. CONCLUSIONS: The emergence of profiles suggests variability in how older adults with LLA use their prosthesis after rehabilitation. However, the factors affecting prosthesis use were similar between the profiles. Therefore, while it is important for rehabilitation teams to consider patients’ individual needs when setting goals for prosthetic training, they must also consider common factors affecting prosthesis use. Layman's Abstract The prevalence of lower-limb amputations (LLA) in older adults is increasing. Because of the substantial resources rehabilitation demands, there is growing interest in exploring prosthesis use as well as the factors that impact use for individuals with LLA. In this study we examine how adults over the age of 50 with LLA use their prosthesis after rehabilitation. We also identify factors that increase or decrease prosthesis use after leaving a rehabilitation hospital. We used several measures to study prosthesis use. The StepWatch Activity Monitor, the Prosthetic Profile of the Amputee Questionnaire, and a semi-structured interview were all used to measure prosthesis use after 12 weeks from leaving a rehabilitation hospital. Two user profiles emerged from our data. The Regular Users integrated their prosthesis into their lives, using it for various types of activities, while the Strategic Users wore their prosthesis to perform specific ADL and IADL tasks. Body functions (e.g., pain), personal (e.g., feeling of independence), and environmental factors (e.g., home adaptations or social support) impacted prosthesis use. Our findings suggest there is variability in how older adults with LLA use their prosthesis after rehabilitation. However, the factors affecting prosthesis use were similar between the profiles. Therefore, while it is important for rehabilitation teams to consider patients’ individual needs when setting goals for prosthetic training, they must also consider common factors affecting prosthesis use. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/36833/28219 How To Cite: Pousett B, Budzinski C, Labbé D, Miller WC. A mixed-methods study on prosthesis use among older Canadians with lower-limb amputations. Canadian Prosthetics & Orthotics Journal. 2021;Volume 4, Issue 1, No.10. https://doi.org/10.33137/cpoj.v4i1.36833 Corresponding Author: William C Miller,University of British Columbia, Vancouver, British Columbia (BC), Canada. E-Mail: [email protected]: https://orcid.org/ 0000-0003-3060-0210
, Seval Kutlutürk,
CANADIAN PROSTHETICS & ORTHOTICS JOURNAL, Volume 4; https://doi.org/10.33137/cpoj.v4i1.35297

Abstract:
BACKGROUND: Clinical outcome assessments provide important input for the rehabilitation of individuals with transfemoral amputation. Differences in prosthetic knee designs may influence clinical outcomes. OBJECTIVE(S): The aim of this study was to compare functional mobility, balance, prosthetic satisfaction and quality of life in individuals with unilateral transfemoral amputation with microprocessor-controlled (MPK) and non-microprocessor knee designs (Non-MPK). METHODOLOGY: The study included ten experienced MPK (Rheo Knee) users (Group 1) and ten experienced Non-MPK (Total Knee® 2000) users (Group 2). For mobility; the 6 Minute Walk Test (6MWT), for balance; the Berg Balance Scale (BBS), Single Leg Stand Test (SLST) and Four Square Step Test (FSST), for quality of life; the Nottingham Health Profile (NHP) and for prosthetic satisfaction; the Satisfaction with Prosthesis Questionnaire (SATPRO) were administered. FINDINGS: 6MWT results of the MPK group were significantly higher than Non-MPK group (p 0.05) comparing balance, prosthesis satisfaction and quality of life values. CONCLUSION: The findings will inform about the patient’s prognosis and the expected clinical outcomes when prescribing an MPK or an Non-MPK. Individuals with unilateral transfemoral amputation covered longer distances using an MPK compared to Non-MPK. Layman's Abstract Individuals living with an amputation above the knee are limited in mobility which effects their quality of life. Specific prosthetic knee designs may have a long-term impact on the quality of life. This study showed that prosthetic users can walk further with the Rheo knee as compared to those who are using the Total Knee® 2000. However, both groups seemed to be equally happy with their quality of life, equally satisfied with their prosthesis, and their balance capabilities appeared to be similar. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/35297/28053 How To Cite: Yazgan A, Kutlutürk S, Lechler K. Clinical outcomes comparing two prosthetic knee designs in individuals with unilateral transfemoral amputation in Turkey. Canadian Prosthetics & Orthotics Journal. 2021;Volume 4, Issue 1, No.8. https://doi.org/10.33137/cpoj.v4i1.35297 Corresponding Author: Ayse Yazgan,1) Össur Turkey Academy, Istanbul, Turkey; 2) İstanbul Medipol University Orthotics - Prosthetics Master of Science Program, Istanbul, Turkey.E-Mail: [email protected] ORCID ID: https://orcid.org/0000-0003-0744-503X
Björn Altenburg, , Pawel Maciejasz, Thomas Schmalz, Frank Braatz, Henrik Gerke, Malte Bellmann
CANADIAN PROSTHETICS & ORTHOTICS JOURNAL, Volume 4; https://doi.org/10.33137/cpoj.v4i1.35206

Abstract:
BACKGROUND: Walking on cross-slopes is a common but challenging task for persons with lower limb amputation. The uneven ground and the resulting functional leg length discrepancy in this situation requires adaptability of both user and prosthesis. OBJECTIVE(S): This study investigated the effects of a novel prosthetic foot that offers adaptability on cross-slope surfaces, using instrumented gait analysis and patient-reported outcomes. Moreover, the results were compared with two common prosthetic feet. METHODOLOGY: Twelve individuals with unilateral transtibial amputation and ten able-bodied control subjects participated in this randomized cross-over study. Participants walked on level ground and ±10° inclined cross-slopes at a self-selected walking speed. There were three prosthetic foot interventions: Triton Side Flex (TSF), Triton LP and Pro-Flex LP. The accommodation time for each foot was at least 4 weeks. The main outcome measures were as follows: frontal plane adaptation of shoe and prosthetic foot keel, mediolateral course of the center of pressure, ground reaction force in vertical and mediolateral direction, external knee adduction moment, gait speed, stance phase duration, step length and step width. Patient-reported outcomes assessed were the Activities Specific Balanced Confidence (ABC) scale, Prosthetic Limb Users Survey of Mobility (PLUS M) and Activities of Daily Living Questionnaire (ADL-Q). FINDINGS: The TSF prosthetic foot adapted both faster and to a greater extent to the cross-slope conditions compared to the Triton LP and Pro-Flex LP. The graphs for the mediolateral center of pressure course and mediolateral ground reaction force showed a distinct grouping for level ground and ±10° cross-slopes, similar to control subjects. In the ADL-Q, participants reported a higher level of perceived safety and comfort when using the TSF on cross-slopes. Eight out of twelve participants preferred the TSF over the reference. CONCLUSION: The frontal plane adaptation characteristics of the TSF prosthetic foot appear to be beneficial to the user and thus may enhance locomotion on uneven ground – specifically on cross-slopes. Layman's Abstract Walking on cross-slopes is a common but challenging task for persons with lower limb amputation. The adaptability of prostheses is limited. Users alter gait strategies to cope with uneven ground. The prosthetic foot is a central component of a lower limb prosthesis. This study investigated if a novel prosthetic foot with greater adaptability is beneficial on cross-slopes. Twelve individuals with transtibial amputation (ITTAs) took part in the study. In addition, ten abled-bodied persons were measured as controls. The ITTAs were fitted with the novel foot and a reference foot. The accommodation time for each foot was four weeks at least. Afterwards gait data and patient-reported outcomes were assessed. The analyzed gait data showed clear differences in terrain compliance for the measured feet. The novel foot adapts both faster and to a greater extent to the cross-slope conditions. The self-reported outcome measures revealed better comfort and perceived safety when using the adaptive foot concept in comparison to the commercial reference. These results suggest that the adaptation characteristics of the novel foot concept are beneficial to the user. Thus, it may enhance locomotion on uneven ground such as cross-slopes. Article PDF Link: How To Cite: Altenburg B, Ernst M, Maciejasz P, Schmalz T, Braatz F, Gerke H, Bellmann M. Effects of a prosthetic foot with increased coronal adaptability on cross-slope walking. Canadian Prosthetics & Orthotics Journal. 2021;Volume 4, Issue 1, No.7. https://doi.org/10.33137/cpoj.v4i1.35206 Corresponding Author: Björn Altenburg,Research Biomechanics, Ottobock SE & Co. KGaA, Göttingen, Germany.E-Mail: [email protected] ID: https://orcid.org/0000-0002-3484-4346
Joel Walker, W. Russ Marable, Christian Smith, Benedikt Þorri Sigurjónsson, Ingi Freyr Atlason,
CANADIAN PROSTHETICS & ORTHOTICS JOURNAL, Volume 4; https://doi.org/10.33137/cpoj.v4i1.36065

Abstract:
BACKGROUND: Amputation at the transfemoral (TF) level reduces the rate of successful prosthetic fitting, functional outcome, and quality of life (QoL) compared with transtibial amputation. The TF socket interface is considered the most critical part of the prosthesis, but socket discomfort is still the most common user complaint. Direct Socket for transfemoral prosthesis users is a novel interface fabrication process where the socket is shaped and laminated directly on the residual limb and delivered in a single visit. OBJECTIVE(S): The aim of this study was to investigate if prosthetic users' quality of life (QoL), comfort, and mobility with a Direct Socket TF interface were comparable to their experience with their previous prostheses. METHODOLOGY: The pre/post design prospective cohort study included 47 subjects. From this cohort, 36 subjects completed the 6-months follow-up (mean age 58 years, 27 males). Outcomes at baseline included EQ-5D-5L®, PLUS-M™, CLASS, ABC, AMPPRO, and TUG. At 6-weeks and 6-months, subjects repeated all measures. Seven Certified Prosthetist (CP) investigators performed observations and data collection at six different sites (from July 2018 to April 2020). FINDINGS: Results showed significant improvement in all outcome measures for the 36 subjects that completed both 6-weeks and 6-months follow-ups. CLASS sub-scales showed significantly improved stability, suspension, comfort, and socket appearance. Improvement in K-Level and less use of assistive devices were observed with the AMPPRO instrument, indicating improved user mobility and performance. QoL was also increased, as measured in Quality-Adjusted-Life-Years (QALY) from the EQ-5D-5L. CONCLUSION: Evidence from the findings demonstrate that the Direct Socket TF system and procedure can be a good alternative to the traditional method of prosthetic interface delivery. Layman's Abstract After lower limb amputation, the goal for most people is to regain mobility and independence and return to normal daily activities. Typically, people with transfemoral amputation are less likely to receive a prosthesis or fully use a prosthesis as compared to people with transtibial amputation. Moreover, their quality of life is also lower. The Direct Socket TF method is a new way of fabricating a prosthetic socket for users with above-knee amputation, enabling fabrication directly onto the residual limb and delivery of the socket in a single visit. In this study, we wanted to understand how the effect of Direct Socket TF on prosthetic 'user's quality of life, health, mobility level, and balance would compare to their previous prosthesis. This new Direct Socket TF procedure was implemented in six different prosthetic clinics across the United States and used by 36 prosthetic users for six months. Our first article on this study describes increased user satisfaction with their new interface and the single visit service model. This second article on the same clinical investigation documents the significant improvement in outcomes compared to their original interface in terms of quality of life, confidence, mobility, comfort, stability, and activity level. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/36065/27923 Direct Socket TF – Summary (YouTube): https://www.youtube.com/watch?v=-fvVFqjgxjo How To Cite: Walker J, Marable W.R, Smith C, Sigurjónsson B.Þ, Atlason I.F, Johannesson G.A. Clinical outcome of transfemoral direct socket interface (part 2). Canadian Prosthetics & Orthotics Journal. 2021;Volume 4, Issue 1, No.6. https://doi.org/10.33137/cpoj.v4i1.36065 Corresponding Author: Anton Johannesson, PhDTeamOlmed, Kistagången 12, 164 40 Kista, Stockholm, Sweden.E-mail: [email protected]: https://orcid.org/0000-0001-8729-458X
, Theresa Repole, Emily Taussig, Stephanie Edwards, Jamie Misegades, Jorge Guerra, Amira Lisle
CANADIAN PROSTHETICS & ORTHOTICS JOURNAL, Volume 4; https://doi.org/10.33137/cpoj.v4i1.35098

Abstract:
BACKGROUND: Self-management is an integral component of managing long-term conditions and diseases. For a person with limb loss, this self-management process involves caring for the residual limb, the prosthesis, and the prosthetic socket-residual limb interface. Failure to properly self-manage can result in unwanted secondary complications such as skin breakdown, falls, or non-use of the prosthesis. However, there is little evidence on what self-management interventions are effective at preventing secondary complications. To understand the impact of self-management after the loss of a limb, it is necessary to determine what the current evidence base supports. OBJECTIVE(S): The purpose of this study is to examine the available literature on self-management interventions and/or outcomes for persons with limb loss and describe how it may impact residual limb health or prosthesis use. METHODOLOGY: A systematic review of multiple databases was carried out using a variety of search terms associated with self-management. The results were reviewed and selected based on the inclusion criteria: self-management interventions or direct outcomes related to self-management, which includes the skin integrity of the residual limb, problem-solving the fit of the prosthesis, and education in the prevention of secondary complications associated with prosthesis use. The Cincinnati Childrens’ LEGEND (Let Evidence Guide Every New Decision) appraisal forms were used to analyze the articles and assign grades. FINDINGS: Out of the 40 articles identified for possible inclusion in this study, 33 were excluded resulting in seven articles being selected for this review. Three out of the seven articles focused on silicone liner management while the other four articles focused on skin issues. CONCLUSION: Self-management for a person with limb loss is a key component of preventing complications associated with loss of limb and prosthesis use. There is a lack of high-quality experimental studies exploring the most appropriate intervention for teaching self-management when compared to other conditions, specifically diabetes. Further research in the area of self-management is necessary to understand how to best prevent unwanted secondary complications. Layman's Abstract Self-management is an integral component of managing long-term conditions and diseases. Self-management for a person with limb loss involves performing proper hygiene of the residual limb, caring for the prosthesis, and problem-solving the fit between the prosthetic socket and the residual limb. If a person with limb loss fails to correctly self-manage, they may be exposing themselves to the risk of skin breakdown or injury. Other medical diagnoses like diabetes emphasize self-management in the care of persons with the condition and have established a large body of knowledge surrounding this element of lifestyle adaption. However, in the case of limb loss, there is very little evidence to support how self-management is taught or performed. Therefore, the purpose of this study was to explore the body of literature surrounding self-management in persons with limb loss. The results indicate that there is very little evidence supporting self-management related interventions and that further research is required in this area. With the addition of further research, clinical practice can be improved and self-management interventions can become standardized across the spectrum of care, much like in diabetes care. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/35098/27909 How To Cite: Lee DJ, Repole T, Taussig E, Edwards S, Misegades J, Guerra J, Lisle A. Self-management in persons with limb loss: A systematic review. Canadian Prosthetics & Orthotics Journal. 2021;Volume 4, Issue 1, No.5. https://doi.org/10.33137/cpoj.v4i1.35098 Corresponding Author: Daniel J. Lee, PT, PhD, DPT, GCS, COMTTouro College, Department of Physical Therapy, Bayshore, NY USA.Email:[email protected] ORCID: https://orcid.org/0000-0003-1805-2936
Megan Hamilton, Harry Sivasambu, ,
CANADIAN PROSTHETICS & ORTHOTICS JOURNAL, Volume 4; https://doi.org/10.33137/cpoj.v4i1.36059

Abstract:
BACKGROUND: Pressure sensing at the body-device interface can help assess the quality of fit and function of assistive devices during physical activities and movement such as walking and running. However, the dynamic performance of various pressure sensor configurations is not well established. OBJECTIVE(S): Two common commercially available thin-film pressure sensors were tested to determine the effects of clinically relevant setup configurations focusing on loading areas, interfacing elements (i.e. ‘puck’) and calibration methods. METHODOLOGY: Testing was performed using a customized universal testing machine to simulate dynamic, mobility relevant loads at the body-device interface. Sensor performance was evaluated by analyzing accuracy and hysteresis. FINDINGS: The results suggest that sensor calibration method has a significant effect on sensor performance although the difference is mitigated by using an elastomeric loading puck. Both sensors exhibited similar performance during dynamic testing that agree with accuracy and hysteresis values reported by manufacturers and in previous studies assessing mainly static and quasi-static conditions. CONCLUSION: These findings suggest that sensor performance under mobility relevant conditions may be adequately represented via static and quasi-testing testing. This is important since static testing is much easier to apply and reduces the burden on users to verify dynamic performance of sensors prior to clinical application. The authors also recommend using a load puck for dynamic testing conditions to achieve optimal performance. Layman's Abstract Pressure sensors can be used in prosthetics to provide clinicians with data about how well a device fits and functions. However, pressure sensors are unproven when it comes to use during activities such as walking or running. This study tested two common pressure sensors in a setup that applied forces similar to walking. These findings indicate that sensor calibration affects sensor accuracy. Accuracy can be improved by applying a small puck to the sensor to spread the load more evenly. With the puck, the performance of the sensors was found to be acceptable for potential use in clinical applications. These findings also show that dynamic testing of pressure sensors may not be needed prior to clinical usage. Instead, performance can be based on static testing which is easier to do. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/36059/27891 How To Cite: Hamilton M, Sivasambu H, Behdinan K, Andrysek J. Evaluating the dynamic performance of interfacial pressure sensors at a simulated body-device interface. Canadian Prosthetics & Orthotics Journal. 2021;Volume 4, Issue 1, No.4. https://doi.org/10.33137/cpoj.v4i1.36059 Corresponding Author: Jan Andrysek, PhD,Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Canada.Email: [email protected]: https://orcid.org/0000-0002-4976-1228
, , Ana Gallego, Piotr Laszczak, Jinghua Tang, , David Moser
CANADIAN PROSTHETICS & ORTHOTICS JOURNAL, Volume 4; https://doi.org/10.33137/cpoj.v4i1.35213

Abstract:
BACKGROUND: Lab-based simulators can help to reduce variability in prosthetics research. However, they have not yet been used to investigate the effects of sweating at the residuum-liner interface. This work sought to create and validate a simulator to replicate the mechanics of residual limb perspiration. The developed apparatus was used to assess the effects of perspiration and different liner designs. METHODOLOGY: By scanning a cast, an artificial residuum was manufactured using a 3D-printed, transtibial bone model encased in silicone, moulded with pores. The pores allowed water to emit from the residuum surface, simulating sweating. Dry and sweating cyclic tests were performed by applying compressive and tensile loading, while measuring the displacement of the residuum relative to the socket. Tests were conducted using standard and perforated liners. FINDINGS: Although maximum displacement varied between test setups, its variance was low (coefficient of variation
, Mostafa Allami, Justin R. Murphy, ,
CANADIAN PROSTHETICS & ORTHOTICS JOURNAL, Volume 4; https://doi.org/10.33137/cpoj.v4i1.35070

Abstract:
BACKGROUND: Interventions to resolve thermal discomfort as a common complaint in amputees are usually chosen based on the residual limb skin temperature while wearing prosthesis; whereas, less attention has been paid to residual limb skin temperature while outside of the prosthesis. The objective of this study was to explore the localized and regional skin temperature over the transtibial residual limb (TRL) while outside of the prosthesis. METHODOLOGY: Eight unilateral transtibial adults with traumatic amputation were enrolled in this cross-sectional study. Participants sat to remove their prostheses and rested for 30 minutes. Twelve sites were marked circumferentially in four columns (anterolateral, anteromedial, posteromedial, and posterolateral) and longitudinally in three rows (proximal, middle, and distal) over the residual limb and used for attachment of analog thermistors. Skin temperature was recorded and compared for 11 minutes. Furthermore, the relationship of skin temperature with participants’ demographic and clinical characteristics was explored. FINDINGS: The whole temperature of the TRL was 27.73 (SD=0.83)°C. There was a significant difference in skin temperature between anterior and posterior columns. Likewise, the distal row was significantly different from the proximal and middle rows. The mean temperature at the middle and distal zones of the anteromedial column had the highest and lowest skin temperatures (29.8 and 26.3°C, p0.05) with participants’ demographic and clinical characteristics. CONCLUSIONS: An unequal distribution of temperature over the TRL was found with significantly higher and lower temperatures at its anterior column and distal row, respectively. This temperature pattern should be considered for thermoregulation strategies. Further investigation of the residual limb temperature with and without prosthesis, while considering muscles thickness and blood perfusion rate is warranted. Layman's Abstract The socket is a plastic hard-shell interface between the residual limb, the remaining part of the amputated limb, and a prosthesis. Heat buildup inside the prosthetic socket and perspiration of the residual limb are major discomforts in amputees when wearing a prosthesis. The majority of prior research measured residual limb skin temperature while the prosthesis was worn. However, less attention has been paid to skin temperature without prostheses. Skin temperature of eight adults with one-sided traumatic below-knee amputation was measured. Participants sat and removed their prostheses. Twelve anatomical sites were marked circumferentially in four columns and longitudinally in three rows over the residual limb and used for temperature recording using temperature sensors. The whole temperature of the residual limb was 27.73 (SD=0.83)°C. Skin temperature was higher at anterior columns compared to posterior columns. Similarly, the distal row of the residual limb had the lowest temperature compared to its middle and proximal rows. From a localized standpoint, the middle part at the anterior medial surface of the residual limb had the highest temperature, whereas the distal part at the anterior-medial surface had the lowest skin temperature. There was no noticeable relationship between the average of the residual limb skin temperature and participants’ demographic and clinical characteristics. Some strategies need to be developed to regulate and control heat dissipation over the residual limb's surface when amputees do not wear prostheses. Further temperature recording research by considering muscle thickness and arterial blood flow rate of the residual limb with and without prosthesis is suggested. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/35070/27313 How To Cite: Ghoseiri K, Allami M, Murphy J.R, Page P, Button D.C. Investigation of localized skin temperature distribution across the transtibial residual limb. Canadian Prosthetics & Orthotics Journal. 2021;Volume 4, Issue 1, No.2. https://doi.org/10.33137/cpoj.v4i1.35070 Corresponding Author: Duane C Button, PhDSchool of Human Kinetics and Recreation, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada.E-mail: [email protected]: https://orcid.org/0000-0001-6402-8545
CANADIAN PROSTHETICS & ORTHOTICS JOURNAL, Volume 4; https://doi.org/10.33137/cpoj.v4i1.35132

Abstract:
BACKGROUND: Balance impairment is a contributing factor to falls. Falls are a leading cause of injury and death in older adults. An ankle-foot orthosis (AFO) is a device that can be prescribed as an intervention to help individuals with compromised balance to ambulate safely. OBJECTIVE: The purpose of this review was to investigate the role ankle-foot orthoses have in affecting balance in community-dwelling older adults. METHODOLOGY: A scoping review was conducted searching MEDLINE, CINAHL, EMBASE, and REHABDATA databases to obtain the appropriate literature to meet the following criteria: 1) quantitative research design; 2) studies with participants over age 65; 3) studies with participants with drop-foot or sensory deficits in the lower extremity; 4) the treatment intervention was unilateral or bilateral AFOs; 5) the outcome measure was balance or stability. The retrieved articles were assessed based on the internal validity, external validity, objectivity, and reliability of the study design and the interpretation of results. FINDINGS: 11 articles were identified that met the inclusion criteria. Four major themes emerged in the analysis about the impact that ankle-foot orthoses have on balance in older adults: (1) AFOs improved lateral stability, (2) AFOs improved balance under static conditions, (3) AFOs provided a reduction in postural sway and (4) AFOs increased walking speed in community-dwelling older adults. CONCLUSIONS: The evidence from the findings of the review indicate that ankle-foot orthoses have a generally positive affect on balance in older adults. Clinicians can consider the ankle-foot orthosis an effective intervention that can improve balance in some older adult patient populations. Layman's Abstract Falls are a serious cause of injury and death in older adults over age 65. Poor balance can lead to an increased number of falls in the older population. The use of a brace, called an ankle-foot orthosis, can be prescribed to community living older adults to augment their balance. Ankle-foot orthoses can improve the stability and positioning of the ankle joint and foot to aid in balance during walking and standing, however ankle-foot orthoses have also been found to restrict natural movements and interrupt sensory feedback from the lower leg and foot. The purpose of this article was to investigate how the balance of older adults living in the community is impacted by wearing ankle-foot orthoses. Through conducting a database search to obtain appropriate literature on the topic, four trends were identified for how ankle-foot orthoses impact the balance of older adult wearers. Based on the findings of this review, ankle-foot orthoses were found to improve stability and standing balance, decrease bodily sway, and increase the walking speed of older adult wearers. These findings suggest that ankle-foot orthoses have a largely positive impact on the balance of older adults and can be considered to help improve balance in certain patient populations. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/35132/27291 How To Cite: Laidler J.L. The impact of ankle-foot orthoses on balance in older adults: A scoping review. Canadian Prosthetics & Orthotics Journal. 2021;Volume 4, Issue 1, No.1. https://doi.org/10.33137/cpoj.v4i1.35132 Corresponding Author: Jenna LaidlerAging and Health Program, School of Rehabilitation Therapy,Queen’s University, Kingston, Canada.E-mail: [email protected]
W. Russ Marable, Christian Smith, Benedikt Þorri Sigurjónsson, Ingi Freyr Atlason,
CANADIAN PROSTHETICS & ORTHOTICS JOURNAL, Volume 3; https://doi.org/10.33137/cpoj.v3i2.34672

Abstract:
BACKGROUND: Direct Socket for transfemoral (DS-TF) prosthetic user is a novel method of fabricating a laminated interface on to the residual limb but requires different training, production method and service model than what most prosthetists are familiar with. This method and model may improve patient satisfaction by enabling interface fabrication and delivery in one visit. OBJECTIVES: Document patient satisfaction regarding DS-TF interface versus the prosthetic users’ previous socket in terms of interface function and the clinic service model. METHODOLOGY: In this longitudinal study (from July 2018 to April 2020), the DS-TF was implemented in six prosthetic clinics across the United States. Certified prosthetists (CP) and assistants were trained using a standard protocol. 47 prosthetic users participated, both those in need of a new socket and those without need. Two modules from the Orthotics and Prosthetics Users’ Survey (OPUS), involving questions related to satisfaction with the Device and Services, was used to evaluate each DS-TF user outcome vs. baseline. The only part of the prosthesis that was replaced was the interface, except in 2 cases. FINDINGS: Each DS-TF interface was fabricated, fit and delivered in a single clinic visit. At 6-months follow-up, 38 users reported an average of 29.8% increase in satisfaction with their new interface compared with original, and a 14.8% increase in satisfaction with the services they received from the clinic in providing of the new prosthesis vs. their original prosthesis. The main outcome increases were between baseline (initial fitting) and 6-week follow-up and remained consistent after 6 months. This improvement was consistent irrespective if the user needed a new socket for clinical reasons or not. CONCLUSION: This study shows that after a standardized training and implementation, the DS-TF fabrication process including a new interface improves the user’s satisfaction with their prosthetic device and services. Layman's Abstract The connection between an amputee’s remaining limb and their prosthesis is called the interface and is the most critical part in a prosthetic system for the user satisfaction, comfort and mobility. Interfaces commonly consist of two parts; a flexible “liner” rolled onto the limb, which then goes into a hard socket custom-made by the prosthetist. The assembled interface then provides a secure connection between the users remaining limb and the prosthesis. Historically the prosthetist’s fabrication and fitting procedure required many hours of time and multiple visits to the prosthetic clinic before the interface was delivered to the user. Direct Socket for above knee prosthetic users is a new method of fabricating laminated sockets directly on the residual limb that enables fabrication and delivery in a single visit. However, Direct Socket require different training and methods than what most prosthetists are familiar with. This new procedure was implemented in six different prosthetic clinics across the United States. Seven CP’s were trained, each in their clinic and the method was tested on 38 users for a period of 6 months. The users filled in questionnaires about their experience and satisfaction using their existing socket, as well as their satisfaction of using their new socket. Overall, the Direct Socket prosthetic users reported after the 6-months follow-up significantly greater (29.8%) satisfaction with their new socket compared to their previous socket. They also reported 14.8% increase in satisfaction with the services they obtained from the clinic when receiving the new socket, compared to their satisfaction with receiving their original socket. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/34672/26933 How To Cite: Marable W.R, Smith C, Sigurjónsson B.Þ, Atlason I.F, Johannesson G.A. Transfemoral socket fabrication method using direct casting: outcomes regarding patient satisfaction with device and services. Canadian Prosthetics & Orthotics Journal. 2020;Volume 3, Issue 2, No.6. https://doi.org/10.33137/cpoj.v3i2.34672 Corresponding Author: G. Anton Johannesson, PhDTeamOlmed, Kistagången 12, 164 40 Kista, Stockholm, Sweden.E-mail: [email protected]: https://orcid.org/0000-0001-8729-458X
, Wei Hou, Laura Goyarts, James Galassi,
CANADIAN PROSTHETICS & ORTHOTICS JOURNAL, Volume 3; https://doi.org/10.33137/cpoj.v3i2.34609

Abstract:
BACKGROUND: Individuals with transtibial amputation (TTA) typically walk with an asymmetrical gait pattern, which may predispose them to secondary complications and increase risk of fall. Gait asymmetry may be influenced by prosthesis mass. OBJECTIVE: To explore the effects of prosthesis mass on temporal and limb loading asymmetry in people with TTA following seven days of acclimation and community use. METHODS: Eight individuals with transtibial amputation participated. A counterbalanced repeated measures study, involving three sessions (each one week apart) was conducted, during which three load conditions were examined: no load, light load and heavy load. The light load and heavy load conditions were achieved by adding 30% and 50% of the mass difference between legs, at a proximal location on the prosthesis. Kinematic and ground reaction force data was captured while walking one week after the added mass. Symmetry indices between the prosthetic and intact side were computed for temporal (Stance and Swing time) and limb loading measures (vertical ground reaction force Peak and Impulse). FINDINGS: Following seven days of acclimation, no significant differences were observed between the three mass conditions (no load, light load and heavy load) for temporal (Stance time: p=0.61; Swing time: p=0.13) and limb loading asymmetry (vertical ground reaction force Peak: p=0.95; vertical ground reaction force Impulse: p=0.55). CONCLUSION: Prosthesis mass increase at a proximal location did not increase temporal and limb loading asymmetry during walking in individuals with TTA. Hence, mass increase subsequent to replacing proximally located prosthesis components may not increase gait asymmetry, thereby allowing more flexibility to the clinician for component selection. Layman's Abstract People with a below the knee amputation typically have an asymmetrical walking style, i.e., they spend more time and put more body weight on their non-amputated leg. This may result in development of knee or hip osteoarthritis of the non-amputated leg, over time. Further, an asymmetrical walking style may also predispose people to a greater number of falls. It is believed that the weight of a prosthesis may influence the walking asymmetry. It is, however, unclear if changing the weight of a prothesis during routine clinical visits (for example, switching or replacing prosthesis parts) would increase walking asymmetry. To explore this, eight individuals with a below the knee amputation had two different weights added to the top half of their prosthesis. After the addition of the weight, participants went home to use the device in their communities for seven days. Subsequently, they returned to the lab to record their walking. We observed that walking with the heavier prosthesis, using either load, did not increase the amount of time spent and body weight applied by our participants on their non-amputated side. Hence, adding mass to the top half of a prosthesis may not increase walking asymmetry. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/34609/26769 How To Cite: Seth M, Hou W, Goyarts L.R, Galassi J.P, Lamberg E.M. Effect of transtibial prosthesis mass on gait asymmetries. Canadian Prosthetics & Orthotics Journal. 2020;Volume 3, Issue 2, No.5. https://doi.org/10.33137/cpoj.v3i2.34609 Corresponding Author: Mayank Seth, PhDDelaware Limb Loss Studies Lab, University of Delaware, Newark, USA.E-mail: [email protected]: https://orcid.org/0000-0003-3526-7058
Hamid Bateni
CANADIAN PROSTHETICS & ORTHOTICS JOURNAL, Volume 3; https://doi.org/10.33137/cpoj.v3i2.33804

Abstract:
BACKGROUND: Falls can be detrimental to overall health and quality of life for lower extremity amputees. Most previous studies of postural steadiness focus on quantification of time series variables extracted from postural sway signals. While it has been suggested that frequency domain variables can provide more valuable information, few current studies have evaluated postural sway in amputees using frequency domain variables. OBJECTIVE: To determine time and frequency domain variables of postural sway among lower extremity amputees vs. healthy young and older adult controls. METHODOLOGY: Participants were assigned to 3 groups: lower extremity amputation (n=6), healthy young adults (n=10), and healthy older adults (n=10). Standing barefoot on a force platform, each individual completed 3 trials of each of 3 standing conditions: eyes open, eyes closed, and standing on a foam balance pad. Time and frequency domain variables of postural sway were computed and analyzed. RESULTS: Comparison of older adults, younger adults, and amputees on the three conditions of standing eyes open, eyes closed, and on foam revealed significant differences between groups. Mean mediolateral (ML) sway distance from the center of pressure (COP), total excursions and sway velocity was significantly higher for amputees and older adults when compared to young adults (p
, Barbara Silver-Thorn,
CANADIAN PROSTHETICS & ORTHOTICS JOURNAL, Volume 3; https://doi.org/10.33137/cpoj.v3i2.34481

Abstract:
BACKGROUND: A number of individuals with unilateral transfemoral amputation (TFA) run in a prosthesis with an unlocked prosthetic knee, while others choose to run with a locked prosthetic knee to increase stability. Research regarding running with an unlocked knee (UK) versus a locked knee (LK), with respect to energy efficiency, is limited and might be enhanced by characterization of the impact of knee condition on kinematics. OBJECTIVE: To investigate the effect of an UK versus LK on hip kinematics, energy efficiency, and running speed. METHODOLOGY: Five male novice runners with unilateral TFA completed one three-minute self-selected running speed (SSRS) trial and three peak speed trials per knee condition. Hip kinematics, energy efficiency, and running speed were compared between conditions. FINDINGS: Four of the five subjects exhibited a fast walk, rather than a consistent run. Hip flexion increased for all subjects and hip abduction decreased for four subjects during swing phase for the UK condition. Hip kinematic asymmetry was reduced for the UK condition in the sagittal plane for four individuals; hip kinematic asymmetry was also reduced in the frontal plane for the UK condition for three of these individuals. Mean energy efficiency was better for the UK condition (UK: 0.282 mLO2/kg/m, LK: 0.328 mLO2/kg/m). Peak running speed did not differ significantly between knee conditions (UK: 1.47 m/s, LK:1.32 m/s). CONCLUSIONS: For novice recreational runners with unilateral transfemoral amputation, the UK condition resulted in improved energy efficiency and enhanced kinematic symmetry, despite comparable peak speed relative to the LK condition. Therefore the UK condition may be advantageous for mid-range distance running. Layman's Abstract Runners with above-knee amputation may run with a prosthetic leg. Some runners prefer to run with their prosthetic knee unlocked, able to flex and extend, while others prefer to run with the prosthetic knee locked. The purpose of this study was to determine the effects of unlocked and locked knee conditions on hip motion, energy efficiency, and running speed during attempted running. Five male novice runners with an amputation above the knee attempted running for three-minutes at a comfortable speed, followed by three fast walks/sprints with the prosthetic knee unlocked and then locked. Most of the novice runners exhibited more symmetric hip motion while fast walking/running with an unlocked prosthetic knee. All our subjects were more energy efficient or exerted less energy with the unlocked prosthetic knee. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/34481/26590 How To Cite: Blakeley N., Silver-Thorn B., Cross J.A. Investigation of the effects of prosthetic knee condition for individuals with transfemoral amputation during attempted running. Canadian Prosthetics & Orthotics Journal. 2020; Volume 3, Issue 2, No.3. https://doi.org/10.33137/cpoj.v3i2.34481 Corresponding Author:Natalie Blakeley, Department of Biomedical Engineering, Marquette University, Milwaukee, USA. E-mail: [email protected]: https://orcid.org/0000-0002-2066-4096
, Michelle G. Marquez, Matthew Kowgier
CANADIAN PROSTHETICS & ORTHOTICS JOURNAL, Volume 3; https://doi.org/10.33137/cpoj.v3i2.34471

Abstract:
BACKGROUND: Lower extremity amputation due to complications from peripheral vascular disease and/or diabetes are common and these patients often have multiple comorbidities. Patients with end-stage renal disease receiving hemodialysis (ESRD/HD) are a particularly vulnerable group at risk for amputation. After lower extremity amputation (LEA) surgery, many patients undergo post-operative inpatient rehabilitation to improve their pre-prosthetic functional independence. Given the increased complexity of dysvascular patients living with ESRD/HD compared to those without ESRD/HD, the association of HD with pre-prosthetic inpatient functional outcomes warrants further study. OBJECTIVE: The objective of this study was to compare the pre-prosthetic functional outcomes and Length of Stay (LOS) among patients with recent dysvascular LEA with and without ESRD/HD. METHODOLOGY: A retrospective cohort design was used to analyze a group of 167 patients with unilateral, dysvascular limb loss who were admitted to inpatient rehabilitation with 24 of these patients in the ESRD/HD group. Age, gender, amputation level, amputation side, length of stay (LOS), time since surgery, Functional Independence Measure (FIM) scores (admission and discharge), and Charlson Comorbidity Index (CCI) were collected. FINDINGS: There was no difference between patients with dysvascular amputation with and without ESRD/HD in the association of functional outcomes or LOS in this cohort and rehabilitation model. The CCI score was higher in the ESRD/HD group. Multivariate analysis indicated an inverse relationship with age and FIM scores, where increased age was associated with lower Total and Motor FIM at admission and discharge. There were no associations with FIM change. Age was positively associated with LOS. Being female was inversely associated to motor FIM scores at admission and discharge CONCLUSION: Among patients with recent dysvascular LEA, ESRD/HD is not associated with different functional outcomes or LOS in the pre-prosthetic inpatient rehabilitation setting. This suggests that despite added comorbidity that patients with ESRD/HD may still benefit from inpatient rehabilitation to optimize pre-prosthetic function. Layman's Abstract Lower extremity limb loss caused by blood vessel disease and/or diabetes is common. Patients who need amputation often have additional medical conditions that may impact their recovery after surgery. One such condition, is diabetes-related poor kidney function requiring hemodialysis. Patients who attend hemodialysis are particularly vulnerable to limb amputation. After amputation surgery many individuals undergo inpatient rehabilitation to improve self-care and mobility prior to discharge from hospital and before being considered for a prosthesis. In patients who are admitted to rehabilitation hospitals after amputation we understand very little about how the demands of hemodialysis may impact their rehabilitation and how long they stay in a rehabilitation hospital. The objective of this study was to compare patients with amputation due to blood vessel disease and/or diabetes with patients who also require hemodialysis. We studied their functional outcomes and inpatient rehabilitation length of stay in hospital. 167 patients with unilateral, limb loss who were admitted to an inpatient rehabilitation hospital were included in the analysis with 24 of these patients attending hemodialysis. Age, sex, amputation level, amputation side, length of stay, time since surgery, Functional Independence Measure scores (measure of a patient’s function) and Charlson Comorbidity Index (measure of multiple medical conditions) were collected. We concluded that in patients with recent limb amputation, hemodialysis was not related to different functional outcomes or time in hospital in the inpatient rehabilitation setting. This suggests that despite receiving hemodialysis, patients with recent limb loss may still benefit from inpatient rehabilitation before being considered for a prosthesis. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/34471/26580 How To Cite: Journeay W.S., Marquez M.G., Kowgier M. Hemodialysis is not associated with pre-prosthetic inpatient rehabilitation outcomes after dysvascular lower extremity amputation: a retrospective cohort study. Canadian Prosthetics & Orthotics Journal. 2020; Volume 3, Issue 2, No.2. https://doi.org/10.33137/cpoj.v3i2.34471 Corresponding Author: Dr. W. Shane Journeay, PhD, MD, MPH, FRCPC, BC-Occ MedProvidence Healthcare – Unity Health Toronto, 3276 St Clair Avenue East, Toronto ON M1L 1W1E-mail: [email protected]: https://orcid.org/0000-0001-6075-3176
, , Alison Stenson, Zoe Savage, David Moser,
CANADIAN PROSTHETICS & ORTHOTICS JOURNAL, Volume 3; https://doi.org/10.33137/cpoj.v3i2.34610

Abstract:
BACKGROUND: Excessive sweating of the residual limb has a substantial effect on the daily activities of people with lower limb amputation. Prosthetic liners offer protection and comfort to sensitive areas but often exacerbate perspiration. They act as insulators, trapping sweat on the skin’s surface to the detriment of skin health. Recently, liners with perforations have been developed, allowing the moisture to escape. The goal of this study was to assess the impact of such liners. METHODS: A sample group of 13 patients with unilateral transtibial amputation, who wore a perforated liner (PL) as part of their current prescription, was compared to 20 control patients who wore non-perforated liners (NPL). During their routine appointments, they completed a survey of scientifically validated outcome measures relating to their limb health, pain and the impact on daily life over a 12-month period. RESULTS: Patients using the PL had healthier residual limbs, reporting higher scores on questions relating to limb health, experiencing fewer skin issues (p
, Malte Bellmann, Siegmar Blumentritt
CANADIAN PROSTHETICS & ORTHOTICS JOURNAL, Volume 3; https://doi.org/10.33137/cpoj.v3i1.33768

Abstract:
BACKGROUND: An often assumed advantage of polycentric knee joints compared to monocentric ones is the improved ground clearance during swing phase due to the geometric shortening of the lower leg segment (LLS). OBJECTIVE: To investigate whether polycentric knee joints considerably improve ground clearance and to evaluate the influence of prosthetic alignment on the extent of ground clearance. METHODOLOGY: 11 polycentric and 2 monocentric knee joints were attached to a rigid, stationary testing device. Shortening of the LLS and the resulting ground clearance during knee flexion were measured. Prosthetic components were mounted at the same height and the anterior-posterior position was in accordance with the manufacturer's alignment recommendations. FINDINGS: Shortening of up to 14.7 (SD=0.0) mm at the instance of minimal ground clearance during swing phase was measured. One knee joint elongated by 4.4 (SD=0.0) mm. Measurements of the ground clearance demonstrated differences up to 25.4 (SD=0.0) mm. One monocentric knee joint provided more ground clearance when compared to 8 of the polycentric knee joints investigated. CONCLUSION: Only some polycentric knee joints shorten appreciably during swing phase. With an optimized prosthetic alignment and a well-designed swing phase control, a monocentric knee joint may generate greater ground clearance compared to a polycentric knee joint. LAYMAN’S ABSTRACT Tripping is a safety risk for amputees and it is mainly affected by ground clearance during swing phase. An often assumed advantage of polycentric knee joints compared to monocentric ones is the improved ground clearance during swing phase due to the geometric shortening of the lower leg segment (LLS). Based on this statement safety benefits for above knee-amputees due to reduced danger of stumbling are discussed commonly for the entire group of polycentric knee joints. We believe that this statement is not true for all polycentric knee joint designs. Therefore, we analyzed 11 polycentric and two monocentric knee joints in a rigid, stationary testing device with their individual prosthetic alignments according to the manufacturer’s alignment recommendations. Shortening of the LLS and the resulting ground clearance during knee flexion were measured. The results showed shortening effects of up to 15 mm. One knee joint elongated by 4 mm. One monocentric knee joint provided more ground clearance when compared to 8 of the polycentric knee joints investigated. We conclude, that only some polycentric knee joints shorten appreciably during swing phase. With an optimized prosthetic alignment a monocentric knee joint may generate greater ground clearance compared to a polycentric knee joint. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/33768/26547 How To Cite: Köhler T.M, Bellmann M, Blumentritt S. Polycentric Exoprosthetic Knee Joints – Extent of Shortening during Swing Phase. Canadian Prosthetics & Orthotics Journal. 2020;Volume3, Issue1, No.5. https://doi.org/10.33137/cpoj.v3i1.33768 Corresponding Author: Thomas Maximilian Köhler, MScOttobock: Hermann-Rein-Straße 2a, 37075, Göttingen.E-mail: [email protected]: https://orcid.org/0000-0002-5063-121X
Ihsan Balkaya, Eric Altschuler
CANADIAN PROSTHETICS & ORTHOTICS JOURNAL, Volume 3; https://doi.org/10.33137/cpoj.v3i1.34528

Abstract:
This professional opinion describes the use of an off the shelf knee orthotic to correct the gait and functional mobility of a patient with hemisensory loss including proprioception following a stroke and provides supporting video. Interestingly, this case corrects a human analogue of a functional deficit found experimentally in monkeys in the 19th century by Mott and Sherrington. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/34528/26530 Video 1 Link: https://online-publication.com/wp/wp-content/uploads/2020/07/VIDEO-1-CPOJ.mov Video 2 Link: https://online-publication.com/wp/wp-content/uploads/2020/07/VIDEO-2-CPOJ.mov How To Cite: Balkaya I, Altschuler E.L. Correcting sherrington’s gait dysfunction with an off the shelf knee orthotic. Canadian Prosthetics & Orthotics Journal. 2020;Volume3, Issue1, No.4. https://doi.org/10.33137/cpoj.v3i1.34528 Corresponding Author: Eric L Altschuler, MD, PhDMetropolitan Hospital,1901 First Avenue, New York, NY, 10029, USA.E-Mail: [email protected]: (212) 423-6448Fax: (212) 423-6326ORCID: https://orcid.org/0000-0002-3575-6954
CANADIAN PROSTHETICS & ORTHOTICS JOURNAL, Volume 3; https://doi.org/10.33137/cpoj.v3i1.33640

Abstract:
BACKGROUND: Several reviews have been published regarding quality of life (QoL) and Health Status (HS) in persons with lower limb amputation (LLA). However, little has been discussed in the literature with respect to older populations (i.e. age>60 years) with trans-tibial amputation. Furthermore, the perceived satisfaction with prosthesis is another important aspect for consideration in the amputees’ life. OBJECTIVE: The purpose of this review was to evaluate the impact of trans-tibial amputation on the QoL, HS and prosthesis satisfaction, in order to determine the appropriate intervention to improve these aspects in older population of trans-tibial amputees (TTA). METHODS: Research articles, published between January 2000 to March 2019, were found using Scopus, PubMed and Google Scholar databases. The methodological quality of the selected articles was assessed using the Critical Review Form-Quantitative Studies checklist. RESULTS: Ten articles that met the inclusion criteria were selected. In these papers, we can summarize that people with trans-tibial amputation have a better QoL compared to those with above knee amputation. Moreover, physical functioning and mobility are the most influencing factors for QoL and HS in older people with lower limb amputation. Finally, the prosthesis weight reduction may improve satisfaction with the prosthetic limb. CONCLUSION: Efforts have to be made in order to improve mobility in older population with transtibial amputation for better QoL and HS. This can be accomplished by means of adequate rehabilitation, pain management and an accurate choice of appropriate prosthetic components. We observed that the quality of evidence in the literature available is inadequate and future research would benefit from more prospective observational cohort studies with appropriate inclusion criteria and larger sample sizes to better understand the QoL and HS in this population. Layman’s Few studies have deeply investigated the effect of aging on Quality of Life, perceived Health Status and satisfaction with the prosthesis on older trans-tibial amputees. This review focuses on these aspects, which can guide professionals on how to improve prosthetic and rehabilitative intervention in this particular amputees’ population. The results of this review indicate that the Quality of Life and Health Status seem to be influenced by adequate rehabilitation, pain management and an accurate choice of appropriate prosthetic components. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/33640/26354 How To Cite: Brunelli S., Bonanni C., Foti C., Traballesi M. A literature review of the quality of life, health status and prosthesis satisfaction in older patients with a trans-tibial amputation. Canadian Prosthetics & Orthotics Journal. 2020;Volume3, Issue1, No.3. https://doi.org/10.33137/cpoj.v3i1.33640 Corresponding Author: Stefano Brunelli, MDSanta Lucia Foundation, Scientific Institute for Research, Hospitalization and Health Care, Rome, Italy.E-Mail: [email protected]: https://orcid.org/0000-0002-5986-1564
CANADIAN PROSTHETICS & ORTHOTICS JOURNAL, Volume 3; https://doi.org/10.33137/cpoj.v3i1.33931

Abstract:
BACKGROUND: Interventions which have focused on improving the physical activity of individuals with lower limb amputation can be mostly categorized into behavioural-based and prosthetic-based interventions. The aim of this review was to assess the quality of these interventions, and to identify the key gaps in research in this field. METHODOLOGY: The databases of Scopus, Pubmed, Embase, Medline and Web of Science were searched between September and December of 2019 for articles relating to physical activity, amputees and interventions. Articles were assessed quantitively based on internal validity, external validity and intervention intensity. FINDINGS: Sixteen articles (5 behavioural, 11 prosthetic) were assessed. Both approaches had comparable methodological quality and mixed efficacy for producing a significant change in physical activity outcomes. Almost all interventions used a simplistic measurement of activity as their outcome. CONCLUSIONS: There is an insufficient amount of studies to assess the overall efficacy of behavioural interventions in regard to how they impact on physical activity behaviour. However, the increase of quality of the methodology in the more recent studies could indicate that future interventions will retain similar levels of quality. Prosthetic interventions have shown no major improvement in efficacy compared to similar reviews and may need to utilise more advanced prosthetic components to attain significant changes in physical activity. Activity outcomes should expand into more complex activity measurements to properly understand the physical activity profile of people with lower limb amputation. Layman’s The purpose of this review was to identify original research which tried to improve the physical activity behaviours of individuals with lower extremity amputation. Through multiple databases, the review article identified a mixture of 5 behavioural and 11 prosthetic-based interventions which aligned with the search criteria of the review. The behavioural-based interventions used behavioural change techniques controlled by healthcare professionals to try and promote a change in physical activity behaviours. The prosthetic-based interventions employed a prosthetic component, with the intention being that if the prosthetic component had superior design, the individual would feel more encouraged to be physically active. This review article concludes that, prosthetic interventions do not appear to have a consistent significant impact on the physical activity behaviours, and though behavioural interventions also had mixed efficacy, there were not enough interventions of their design to make a conclusive statement. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/33931/26330 How To Cite: Jamieson A.G., Murray L., Buis A. The use of physical activity outcomes in rehabilitation interventions for lower limb amputees: A systematic review. Canadian Prosthetics & Orthotics Journal. 2020;Volume3, Issue1, No.2. https://doi.org/ 10.33137/cpoj.v3i1.33931 Corresponding Author: Dr. Arjan Buis,Department of Biomedical Engineering, University of Strathclyde, Wolfson Centre, 106 Rottenrow, Glasgow, G4 0NW, Scotland, UK.E-Mail: [email protected]: https://orcid.org/0000-0003-3947-293X
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