Robotic Prosthetic Availability Analysis

Microprocessor controlled lower-limb prosthetics provide many advantages over mechanical prosthetics such as, increased walking speed, decreased self-reported falls and stumbles, and boosted self-image. However, these devices remain out of the financial reach of the average prosthetic user. Interviews were performed with Hugh Herr, Bob Dzuranda, and prosthetists in the New England area in order to investigate a means to increase robotic prosthetic availability. It was determined that the prosthetics industry suffers from a slow billing code application process, Medicare-imposed fitness restrictions (on amputees that are likely to suffer from diabetes or obesity), insurance contracts that hurt prosthetist office profits, and private health insurance plans that restrict patients\u27 options

Predicting Walking Ability and Prosthetic Candidacy Following Lower Extremity Amputation: Systematic Review, Treatment Pathway and Algorithm

Purpose: The purpose of this study is a systematic review (SR) of existing literature to examine characteristics of persons with amputation which predict walking ability and prosthetic candidacy following lower extremity amputation (LEA). The identification, synthesis and summary of this evidence could assist in developing clinical practice guidelines, including a physical rehabilitation treatment pathway and a clinical algorithm. The importance of this project is the establishment to further develop evidence based LEA clinical practice guidelines. This evidence will assist the healthcare team in decision making, specifically considering evidence and patient-centric predictive characteristics. Background: Currently, there is no multi-disciplinary physical rehabilitation instrument known that can predict walking ability and prosthetic candidacy nor support a treatment pathway and algorithm for the LEA. Also, there is not a patient centric decision making protocol under consideration when determining prosthetic candidacy. Further, the evidence to support these guidelines and protocols has not been aggregated and summarized in a formal systematic approach, such as a comprehensive systematic review. In previous literature the prediction of walking ability has been reported. However, these studies are outdated and not comprehensive, nor do they offer a clinical treatment pathway regarding the prediction of walking ability and prosthetic candidacy following lower LEA. A comprehensive reporting of aggregated and newly synthesized evidence with information from current literature can develop an evidence based patient centric treatment pathway and a prosthetic candidacy algorithm to assist LEAs to receive the correct, initial definitive prosthesis to match their functional abilities. Methods: This search strategy was designed and similarly implemented considering previous systematic reviews based on a similar topic. It is a more comprehensive update of previously valuable predictive factors of walking ability and prosthetic candidacy. An electronic literature search was executed from 8/1/2007 to 12/31/2015 using MEDLINE, EMBASE, CINAHL, and Cochrane. Results: This SR performed a more comprehensive search and discovered an additional 26 articles. A total of 104 quality studies were identified through the electronic search. Of these, 78 were systematically reviewed by two former authors, leaving a total of 26 for full evaluation. Conclusions from this updated study are drawn from a total recruited sample of 46,651 subjects. This updated study increases the size of the original Kahle et al. report by including 300% more subjects for a total of 61,858 subjects studied in the two SRs. Conclusion: In these two combined SRs, cause of amputation (etiology), physical fitness, pre- amputation living status, amputation level, age, physical fitness, cognitive/mood disturbances, social support and comorbitities are included as moderate to strongly supported predictive factors of walking ability and prosthetic candidacy. These factors are supported in an earlier literature review and should be strongly considered in a complete history and physical examination by multi-disciplinary team. Predictive factors should be part of a patient healthcare record

An investigation of the NHS Service provision of prosthetic limbs

This thesis explores the NHS Service provision of prosthetic limbs from a patient centred perspective. Amputation is the removal of a limb either for medical reasons or through trauma. The amputated limb can be replaced with a manufactured device to help the patient regain movement and as much function as possible. This device is known as a prosthesis and is given to the patient by the NHS at a Disablement Services Centre (DSC). There has been increasing negative media coverage of the NHS and the service it provides with specific reference to the Postcode lottery which has allegedly become apparent. This research aims to ascertain whether the service being provided at DSCs across the UK is satisfactory to patients and how this service can be improved. The literature surrounding amputation rehabilitation and care pathways is reviewed (Chapter 2). Research philosophies and approaches are discussed (Chapter 3). A countrywide study of NHS Disablement Services Centres was conducted to ascertain how the centres functioned and the differences in service between centres (Chapter 4). The data collected from this study were used to create a questionnaire for amputees to ascertain their opinions on the service they received at their centre (Chapter 5). The data revealed that patients had many problems with the service they received, very few of which could readily be acted upon due to budget restrictions. An investigation into patient s opinions on information provision was conducted as information provision was a problem highlighted by patients that could be influenced by further research (Chapter 6). Data gathered from all three studies were used to produce a proposed clinical pathway for Disablement Services Centres to follow with a new patient (Chapter 7). The proposed pathway was critically evaluated by prosthetists at a clinical conference and improvements to the proposed pathway were made using their suggestions (Chapter 7). The benefits, drawbacks and threats to the use of the proposed pathway were discussed both from the patient and clinical perspective (Chapter 8). The work was completed by overall conclusions and a discussion of further work (Chapter 9)

Use of stance control knee-ankle-foot orthoses : a review of the literature

The use of stance control orthotic knee joints are becoming increasingly popular as unlike locked knee-ankle-foot orthoses, these joints allow the limb to swing freely in swing phase while providing stance phase stability, thus aiming to promote a more physiological and energy efficient gait. It is of paramount importance that all aspects of this technology is monitored and evaluated as the demand for evidence based practice and cost effective rehabilitation increases. A robust and thorough literature review was conducted to retrieve all articles which evaluated the use of stance control orthotic knee joints. All relevant databases were searched, including The Knowledge Network, ProQuest, Web of Knowledge, RECAL Legacy, PubMed and Engineering Village. Papers were selected for review if they addressed the use and effectiveness of commercially available stance control orthotic knee joints and included participant(s) trialling the SCKAFO. A total of 11 publications were reviewed and the following questions were developed and answered according to the best available evidence: 1. The effect SCKAFO (stance control knee-ankle-foot orthoses) systems have on kinetic and kinematic gait parameters 2. The effect SCKAFO systems have on the temporal and spatial parameters of gait 3. The effect SCKAFO systems have on the cardiopulmonary and metabolic cost of walking. 4. The effect SCKAFO systems have on muscle power/generation 5. Patient’s perceptions/ compliance of SCKAFO systems Although current research is limited and lacks in methodological quality the evidence available does, on a whole, indicate a positive benefit in the use of SCKAFOs. This is with respect to increased knee flexion during swing phase resulting in sufficient ground clearance, decreased compensatory movements to facilitate swing phase clearance and improved temporal and spatial gait parameters. With the right methodological approach, the benefits of using a SCKAFO system can be evidenced and the research more effectively converted into clinical practice

The effect of prefabricated wrist-hand orthoses on performing activities of daily living

Wrist-hand orthoses (WHOs) are commonly prescribed to manage the functional deficit associated with the wrist as a result of rheumatoid changes. The common presentation of the wrist is one of flexion and radial deviation with ulnar deviation of the fingers. This wrist position Results in altered biomechanics compromising hand function during activities of daily living (ADL). A paucity of evidence exists which suggests that improvements in ADL with WHO use are very task specific. Using normal subjects, and thus in the absence of pain as a limiting factor, the impact of ten WHOs on performing five ADLs tasks was investigated. The tasks were selected to represent common grip patterns and tests were performed with and without WHOs by right-handed, females, aged 20-50 years over a ten week period. The time taken to complete each task was recorded and a wrist goniometer, elbow goniometer and a forearm torsiometer were used to measure joint motion. Results show that, although orthoses may restrict the motion required to perform a task, participants do not use the full range of motion which the orthoses permit. The altered wrist position measured may be attributable to a modified method of performing the task or to a necessary change in grip pattern, resulting in an increased time in task performance. The effect of WHO use on ADL is task specific and may initially impede function. This could have an effect on WHO compliance if there appears to be no immediate benefits. This orthotic effect may be related to restriction of wrist motion or an inability to achieve the necessary grip patterns due to the designs of the orthoses

Polyvinyl alcohol-alginate adsorbent beads for chromium (vi) removal

Chromium pollution has been an increasing concern worldwide because of its high toxicity and carcinogenic properties, and it requires an efficient purification technique. In this study, adsorbent beads containing polyvinyl alcohol (PVA) and sodium alginate were prepared by crosslinking with boric acid and calcium chloride for adsorbent of the hexavalent chromium [Cr (VI)]. Batch adsorption studies were conducted to evaluate Cr (VI) adsorption rates of PVA-alginate beads from aqueous solution under ultraviolet (UV) light illumination. The surface morphology and elemental composition of beads were examined using field emission scanning electron microscopy (FESEM) and energy dispersive spectrometer (EDS), respectively. This study revealed that the Cr (VI) adsorption rates increased remarkably with dosages of PVA and sodium alginate. This occurred mainly due to the increasing number of the active sites for adsorption. The results revealed that adsorbent beads with 12 g of PVA and 2.5 g sodium alginate beads exhibited superior Cr (VI) adsorption efficiency at which it is completely removed after 1.5 hours. The findings of this study indicate that PVA-sodium alginate beads are a viable option for Cr (VI) removal from industrial wastewater

Biomechanical evaluation of prosthetic feet

An evaluation method was developed which can be used generally for the assessment of any prosthetic feet. The two most common prosthetic feet prescribed to below-knee and above-knee amputees are the Uniaxial and SACH feet. A review of prescription practices shows that in the United Kingdom about 80% of the below-knee and above-knee amputees are fitted with a Uniaxial foot, whereas in the United States about 80% are fitted with the SACH foot. These contradictory prescription practices between the two countries, prompted the project to be concentrated on the evaluation of the SACH and Uniaxial feet. The method developed includes a subjective assessment procedure and a biomechanical evaluation on the function of the two prosthetic feet and their effects on whole body gait kinematics and lower limb kinetics. A review of the methods used in gait analysis is presented in the thesis. This forms a basis for the selection of a suitable gait recording system for the project. A background study of lower limb prosthetics in general and a review of prosthetic ankle/foot assemblies in particular are also presented. The methodology and instrumentation used in the project are given. Altogether, six below-knee and five above-knee amputees were tested. Due to insufficient supply of heel bumper stiffness by the manufacturer for the Uniaxial foot, heel bumpers of varying stiffnesses had to be made in the Bioengineering Unit. The development of the analytical procedure for the three-dimensional analysis is presented. A suite of computer programs was written to facilitate the handling of the large amount of data, details of which are included in the Appendix. Results from the analysis of the tests performed are discussed. Although some apparent differences were observed between the SACH and Uniaxial feet, no conclusion can be drawn as to which is better for the function of the amputee.An evaluation method was developed which can be used generally for the assessment of any prosthetic feet. The two most common prosthetic feet prescribed to below-knee and above-knee amputees are the Uniaxial and SACH feet. A review of prescription practices shows that in the United Kingdom about 80% of the below-knee and above-knee amputees are fitted with a Uniaxial foot, whereas in the United States about 80% are fitted with the SACH foot. These contradictory prescription practices between the two countries, prompted the project to be concentrated on the evaluation of the SACH and Uniaxial feet. The method developed includes a subjective assessment procedure and a biomechanical evaluation on the function of the two prosthetic feet and their effects on whole body gait kinematics and lower limb kinetics. A review of the methods used in gait analysis is presented in the thesis. This forms a basis for the selection of a suitable gait recording system for the project. A background study of lower limb prosthetics in general and a review of prosthetic ankle/foot assemblies in particular are also presented. The methodology and instrumentation used in the project are given. Altogether, six below-knee and five above-knee amputees were tested. Due to insufficient supply of heel bumper stiffness by the manufacturer for the Uniaxial foot, heel bumpers of varying stiffnesses had to be made in the Bioengineering Unit. The development of the analytical procedure for the three-dimensional analysis is presented. A suite of computer programs was written to facilitate the handling of the large amount of data, details of which are included in the Appendix. Results from the analysis of the tests performed are discussed. Although some apparent differences were observed between the SACH and Uniaxial feet, no conclusion can be drawn as to which is better for the function of the amputee

Using Administrative Healthcare Records to Identify Determinants of Amputee Residuum Outcomes

In the United States, the number of major limb amputees is predicted to exceed several million in the coming decades. For those amputees using a prosthesis, their quality of life (QoL) is often modulated by residuum limb problems resultant from its use. Multiple factors preclude quality evidence-based medicine (EBM) research in the field of prosthetics, leading to greater health risk from prosthetic prescription ambiguity. Positive social change is integral to good QoL; studies support administrative healthcare (AHc) as useful to support such, especially in the absence of EBM. This study utilized Veterans Healthcare Administration (VHA) AHc data to discriminate determinants of residual limb skin problem severity (RLSPS), relative to the artificial limb configuration (ALC) used through a retrospective, longitudinal study of a cohort of U.S.Veteran dysvascular amputees. The dataset was derived from multiple archival VHA AHc databases from which 279 Cohort members were identified who underwent amputation surgery during the fiscal year (FY) 2007 were dispensed a prosthesis, and had clinical records through FY 2011. ICD-9-CM and HCPCS codes were used to identify categories of RLSPS and ALC, respectively, with generalized estimating equations modeling to identify likelihood associations of parameters. Derivation of the study cohort dataset was encumbered by data integrity issues and coding system limitations; significant associations were detected for RLSPS with chronic obstructive pulmonary disease, substance use disorder, and major depressive disorder, regardless of the ALC dispensed. The findings support the utility of an amputee-prosthesis AHc database to drive product, policy, and medical decisions toward an improved QoL for this vulnerable population

The effect of prefabricated wrist-hand orthoses on grip strength

Prefabricated wrist-hand orthoses (WHOs) are commonly prescribed to manage the functional deficit and compromised grip strength as a result of rheumatoid changes. It is thought that an orthosis which improves wrist extension, reduces synovitis and increases the mechanical advantage of the flexor muscles will improve hand function. Previous studies report an initial reduction in grip strength with WHO use which may increase following prolonged use. Using normal subjects, and thus in the absence of pain as a limiting factor, the impact of ten WHOs on grip strength was measured using a Jamar dynamometer. Tests were performed with and without WHOs by right-handed, female subjects, aged 20-50 years over a ten week period. During each test, a wrist goniometer and a forearm torsiometer were used to measure wrist joint position when maximum grip strength was achieved. The majority of participants achieved maximum grip strength with no orthosis at 30° extension. All the orthoses reduced initial grip strength but surprisingly the restriction of wrist extension did not appear to contribute in a significant way to this. Reduction in grip must therefore also be attributable to WHO design characteristics or the quality of fit. The authors recognize the need for research into the long term effect of WHOs on grip strength. However if grip is initially adversely affected, patients may be unlikely to persevere with treatment thereby negating all therapeutic benefits. In studies investigating patient opinions on WHO use, it was a stable wrist rather than a stronger grip reported to have facilitated task performance. This may explain why orthoses that interfere with maximum grip strength can improve functional task performance. Therefore while it is important to measure grip strength, it is only one factor to be considered when evaluating the efficacy of WHOs