By Garrison Wells Content provided by The O&P EDGE
What gets your creative juices flowing? A challenging clinical presentation? A patient’s request to be fit with the most advanced device available? Optimizing fit and comfort? Working with a new material?
Photograph of WintersGel courtesy of Hanger. The O&P EDGE asked several prosthetists to describe a challenging clinical case that required them to apply their expertise in a creative way, and not surprisingly, many of them indicated that all of these elements can contribute to their creative problemsolving processes. While the solutions the practitioners provided ranged from back-to-basics to high-tech, their responses revealed key insights about their core patient care philosophies.
Case #1: Putting Socket Fit First
Christmas came a month early last year for a three-year-old girl with congenital bilateral limb loss. In November 2011, Kevin Carroll, MS, CP, FAAOP, received a phone call from the girl's parents. They wanted to travel to the United States from Europe to give their daughter the gift of a lifetime—the ability to walk—and they asked Carroll if he could help.
"Their child was born without legs, one high above the knee and the other one also above the knee," says Carroll, vice president of prosthetics at Hanger, Austin, Texas. She had been provided with prostheses in her home country but refused to wear them— partly out of rebellion, Carroll figured, but primarily because they were difficult to manage. "They didn't stay on, they were heavy, and they were uncomfortable," he says.
"She was fighting her parents and fighting her prosthetics. So when my colleague Dan Strzempka, CPO, and I evaluated her, we decided if we put her in a softer gel-like material, she would be comfortable with the prostheses, and the adhesion from the liners would stick and hold the prostheses in place."
Though technology in the field is racing ahead, the basics still apply, Carroll says.
"There's been a huge emphasis on technology and high tech, but if the prosthesis isn't fitting, all those incredible technologies lie somewhere in a closet," he says. "The foundation of any prosthetic device or system has to be the socket and how the socket interfaces with the person's body. It's the critical piece, where the rubber meets the road, so when we evaluate somebody, that's the first thing we have to do to see how we can be creative as clinicians. That's one of our main talents is how we attach the machine to the man or, in this particular case, a little girl."
Her new liners were made with WintersGel—the same material Carroll, Strzempka, and a team of engineers, scientists, and fellow clinicians developed for Winter, the Atlantic bottlenose dolphin that lost its tail fluke after it had become entangled in a crab trap and whose story was made into the 2011 movie Dolphin Tale.
"Her parents' wish did come true," Carroll says. "Their little girl was able to walk by the holidays…. As a team, we came up with very successful bilateral above the knee prosthetics and now have a happy little girl who has been walking very, very well ever since. It's incredible to see her," he says, adding, "The biggest successes come when we work as a team."
Case #2: Rethinking Socket Design
Sometimes technology needs to catch up with a patient's needs.
Christian Bailey, CPO, clinical director and owner of Creative Technology Prosthetics & Orthotics, Denver, Colorado, describes one of his patients, a 55-year-old male with a right transtibial amputation and a left transfemoral amputation who wanted to increase his activity level. Bailey had previously fit him with a myoelectric knee and a manual foot on his transfemoral side and a manual foot on his transtibial side. While this solution allowed him to drive and do things with his family such as camp and attend baseball games, he didn't feel secure in his prostheses—particularly on his transfemoral side—which held him back from doing many of the other things he wanted to do.
"He wants to stay as active as possible," Bailey says.
This year, Bailey upgraded his patient's manual feet to myoelectric feet. The solution proved to be a good one from the very first day.
"The day that I fit him, he had come into the clinic in his wheelchair. His 24-year-old son, who had a broken leg and was in a cast, was pushing him. When they were leaving, I went outside with them because I wanted to watch him walk down the ramps. I turned around to talk to him, and I noticed that his son had…traded places with him and was sitting in the wheelchair. My patient was actually pushing his son out to the car.
"He wasn't feeling that secure before because the foot and knee didn't function together," Bailey continues. "They didn't actuate. There's an actuator in the [myoelectric] foot that raises and lowers the foot with the activity that he is doing. The more confident people feel wearing their prosthetics, the more active and able they are to use them."
While this solution packs a pretty big technological punch, Bailey says the creativity comes into play when designing the socket. "There are basic rules for a prosthetist to follow clinically, but as new technologies become available, we have to rethink and readjust how we design a socket. For instance, a computerized foot is a lot heavier than a regular foot, so the socket design needs to be different so the patient doesn't have pressure there when they are sitting in a chair. Simple things like that are changing how we've traditionally done things."
Case #3: Adapting to Changing Needs
A durable electronic upper-limb prosthetic device was necessary to enable Tom Passero’s patient to perform heavy-duty work. The patient’s most recent prosthesis (inset) allows him to complete fine motor tasks. Photographs courtesy of Prosthetic & Orthotic Associates/ Handspring. Thomas Passero, CP, president and clinical director of Prosthetic & Orthotic Associates (POA), headquartered in Middletown, New York, has literally watched one of his patients grow up from age two all the way into a 25-year-old with a labor-intensive career— each milestone marked in part by different prosthetic devices.
Passero had to be nimble.
His patient was born with a short left forearm. He has an elbow but no hand. The first prosthesis Passero fit him with was an Ottobock pediatric myoelectric hand. "They had the best solution at the time," Passero says. "With that hand he was able to open and close, grasp objects, and perform two-handed activities."
But as his young patient grew up, his needs changed. "The evolution of his care followed…his development as a kid, as an adolescent, as a young adult, and now as an adult worker in his job. And throughout that process, several different types of devices became appropriate. He's sort of come full circle now."
For example, when the patient made the transition from childhood into adolescence, he wanted to look like the rest of the kids.
"He wanted to forego the opening and closing, so it called for something that looked like a hand," Passero says. "Through junior high and high school, he chose a realistic-looking, highdefinition, passive functional device that was modeled after his [sound-side] hand. When he was in social situations, nobody would notice that he had [a prosthetic hand] on one side of his body."
After graduating from community college, Passero's patient got a job with the highway department, which required yet another device. The passive, more cosmetically pleasing hand was replaced with a myoelectric prosthesis.
Creativity is often spurred by inspiration, and Passero says his inspiration comes directly from his patients. "An effective clinician should be a good communicator, so…the inspiration comes from delicately pulling the patient's desire, the unmet needs, out of them and then using the skills and the technology that we have to solve those problems."
For this particular patient, Passero says, "The inspiration comes from a young, motivated, intelligent, sort of fearless person who is asking our clinical team to 'help me do this task.' The application of creativity was in solving his problems by providing a combination of devices that allow him to do the broadest range of activities. The satisfaction then comes from his success."
Case #4: Solution for One Benefits Many
A 47-year-old female patient with bilateral styloid amputations and significant scar tissue that kept breaking down after prolonged prosthetic use inspired John Miguelez, CP, FAAOP, and his team at Advanced Arm Dynamics (AAD), headquartered in Redondo Beach, California, to find a solution that would not only help her get to the next level of prosthetic rehabilitation, but would help other AAD patients as well.
An Advanced Arm Dynamics (AAD) patient works with Tiffany Ryan after being fit with bilateral upper-limb prosthetic interfaces made with AAD’s custom rolled silicone. Photograph courtesy of Advanced Arm Dynamics. When the patient came to AAD's Southwest Center of Excellence, Irving, Texas, Miguelez, AAD president and senior clinical director, and fellow team members Rob Dodson, CPO, and Tiffany Ryan, MOT, OTR, OTL, went to work to find a solution.
"We spent a lot of time trying to redesign the patient's sockets to lessen the contact with the scarred area so there wasn't as much pressure, and we tried more pressure to see if that would help." Miguelez says. "We tried all different types of thermoplastic materials, and we never were quite satisfied with the result. We were able to increase her wearing time, but then she'd get a breakdown and have to discontinue use of the prostheses until she healed…."
A breakthrough came during a trip to Germany, where Miguelez and other AAD staff members visited a small company working on a special silicone process. Miguelez ended up sending a team to Germany to learn the process, and AAD adopted the technique.
"It allows us to make a prosthetic interface out of silicone and vary the thickness and the durometer and density," Miguelez explains. "It helps us control how cushiony it is in one area and how firm it is in another area to really help patients with comfort, suspension, and range of motion."
The technique paid off for the patient. She was fit with a custom rolled silicone interface supported by carbon-fiber frames, and "almost immediately the breakdowns on her scar tissue were eliminated," Miguelez says. "But the thing that was really interesting was that in a period of about two and a half to three months, while her scar tissue didn't disappear, it went from a very angry eight or nine on a scale of ten down to a one or two. Now, she can use her prostheses all day long comfortably."
The rolled silicone interface has been so successful for AAD that the company opened a clean lab where a technician rolls the special silicone.
"We've taken [this solution] to other patients who, for example, don't have the issue of tissue breakdown but after ten hours of continuous wear maybe their prosthesis begins to get a little uncomfortable. In many cases, we can design a prosthesis out of the custom rolled silicone material that makes it more comfortable and enhances suspension, and so we are transitioning more and more patients to it."
Case #5: Impossible to Fit? No Way!
What do you do with a patient who, despite repeated efforts, has never been successfully fitted with a prosthesis? If you're Scott Sabolich, CP, LP, clinical director of prosthetics and research for Scott Sabolich Prosthetics & Research, headquartered in Oklahoma City, Oklahoma, you get creative.
"No one could fit him," Sabolich says. "He has massive invaginations over the lateral distal femur, so he can't wear skin suction. Plus he can't wear a liner because of the pistoning that he gets, so how do you fit someone like that? Well, in the old days you give him a socket and a belt and say good luck. Nowadays, we have the availability to fit him with a hybrid socket system that blends suction and liner usage rather than having to use one or the other."
It was no easy case. It took four to five weeks of daily work with the patient before they found an answer, Sabolich says.
"When options A, B, or C don't work, we ask ourselves if there is an option between A and B and option B and C and look at how to fit the limb outside the box," he says. "That's our forte."
To create the patient's hybrid transfemoral socket, Sabolich and his team used distal cups over the distal third of the patient's limb over his invaginations and stepped that into a skin-fit suction using a slip-sock. "We slipped him in using a hybrid design so the top third of his sock can be skin-fit suction," he says. "The lower third can be silicone liner and then by using the new style pull-sock to pull it all in, you're able to get the limb into the sock and the silicone liner."
A patient dons his hybrid suction/ silicone socket system. Photographs courtesy of Scott Sabolich Prosthetics & Research. In this case, the hybrid socket worked, but Sabolich stresses that the approach is not foolproof. "We handle extreme cases and difficult-to-fit patients. We have a 30–40 percent success rate with extreme, creative hybrid sockets, but it's better than telling a patient he can't be fit."
Despite these challenges, hybrid sockets may become increasingly necessary, Sabolich says, because the success surgeons are having saving the lives of patients whose amputations are the result of traumatic injuries often results in tougher fits. Today, clinicians are fitting more patients who have a lot of scar tissue.
"Surgical techniques are improving and giving us nice, longer limbs," he says. "But on the same trauma cases, yes, we have the longer limbs, but if they went up three of four more inches, they would have made our jobs a lot easier."
The most gratifying patients for Sabolich are either the very young or geriatric patients. "The younger ones," he says, "are full of life and energy. You put a prosthetic on them and they go bounding down the hallway."
Senior patients, he says, are given "the ability to get out of their bed and go to the bathroom themselves, go back to the wheelchair, and that gives you this invigorating feeling that you've given someone the last piece of their life back."
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What constitutes a creative prosthetics solution means different things to different practitioners. While the experts interviewed for this article describe a variety of elements that contribute to their creative clinical problem-solving, their answers underscore that O&P care is not just about the provision of device—it's about providing the patient with a successful outcome.
Garrison Wells is a freelance writer based in Colorado Springs, Colorado.
Rachel Kelley and Karen Henry contributed to the reporting of this article.