Northwestern University Feinberg School of Medicine

Northwestern University Prosthetics-Orthotics Center

Clinical Collaboration to Improve Orthotics and Prosthetics Practice

Co-investigators: Steven A. Gard, PhD, and Matthew Major, PhD

Project Director: Stefania Fatone, PhD, BPO(Hons)

Funded by: National Institute on Disability and Rehabilitation Research (NIDRR)

Status: Completed

Introduction

Collaboration between clinicians and researchers is essential for addressing clinically-relevant research and development problems and providing improved quality of life to prosthesis and orthosis users. As the recipients of the current RERC for P&O, we place a high priority on collaborating with clinicians and users in order to identify and address research issues of practical concern.

Prosthetists and orthotists often find that their ability to achieve treatment goals is limited by commercial componentry, by commonly employed fabrication methods, evaluation tools, and by relative absence of guidelines and documentation of clinical successes. We believe that direct collaboration between an engineering-based research laboratory, such as ours, and clinical providers of prosthetic and orthotic services can overcome many of these limitations. By bringing analytical tools, machining capabilities, research experience, and mechanical and electronic design expertise to the clinical environment, an engineering research laboratory can augment the clinical service and help explore novel approaches to the design, fitting and evaluation of prostheses and orthoses.

Specific Objectives/Performance Goals

Our general goal is to respond to problems that are identified in the course of clinical care that can be addressed through the knowledge and tools available to engineers and researchers. An engineering-based research team can complement the clinical practitioner in several ways: (1) adapt and customize commercial components to improve their performance or expand their application; (2) document and analyze users' performance with specific prosthetic and orthotic systems using motion analysis equipment; (3) determine the means of component failure to promote improved commercial design and manufacturing; (4) develop evaluation tools, and (5) promote improved methods for constructing, fitting and evaluating prostheses and orthoses through our publications, presentations, and Website.

Collaborations

Dr. Fatone collaborated with Brian Arndt, CPO, and Ryan Caldwell, CP, from Suburban O&P in Des Plaines, Illinois, in a small clinical case study. This work formed the basis of Brian's NCOPE required prosthetics residency project. [Arndt B, Caldwell R, Fatone S (2011) Use of a Partial Foot Prosthesis with Vacuum-Assisted Suspension: A Case Study. Journal of Prosthetics and Orthotics, 23(2):82-88.]

At the request of orthotist, Keith Smith, CO, at Orthotic & Prosthetics Lab, Inc. in St. Louis, Missouri, Dr. Fatone and Rebecca Stine collaborated with Laura Hartung, CO, on her NCOPE required orthotic residency project, a case study of different ankle joint configurations for a child with cerebral palsy. This work has been presented multiple times:

1. Fatone S, Hartung L, Stine R (2011) Effects of Different Orthotic Ankle Joint Conditions on Lower Limb Gait Parameters in a Subject with Crouch Gait (poster). Gait and Clinical Movement Analysis Society, April 26-29, Bethesda, Maryland.

2. Fatone S, Hartung L, Stine R (2011) Effects of Different Orthotic Ankle Joint Conditions on Lower Limb Gait Parameters in a Subject with Crouch Gait. Midwest Chapter of the American Academy of Orthotists and Prosthetists, June 3-4, Grand Geneva Resort, Wisconsin.

Dr. Fatone collaborated with NUPOC orthotics instructor, Christopher Robinson, MBA, CPO, ATC, FAAOP, on an invited expert clinical viewpoint for Prosthetics and Orthotics International. This work formed the basis of an independent study project that Mr. Robinson completed as part of his Master's degree. [Robinson C, Fatone S (2013) Expert Clinical Viewpoint: You've Heard about Outcome Measures, So How Do You Use Them? Implementing Clinically Relevant Outcome Measures in Orthotic Management of Stroke. Prosthetics and Orthotics International, 37(1):30-42.]

During 2011, at the invitation of RIC physician, Dr. Deborah Gaebler-Spira, Dr. Fatone provided research mentorship to Joycie Eulah Abiera, MD, during her Fellowship in Pediatric Orthotics and Prosthetics, at the Rehabilitation Institute of Chicago. Dr. Abiera worked on two clinically-relevant projects: (1) A cross-sectional study of the variability in solid ankle foot orthosis design and fabrication among children with Cerebral Palsy; and (2) The reliability and validity of using 2D video based observational gait analysis to assess knee motion. This latter project is complementary to our RERC project D1.

Dr. Fatone has engaged in ongoing clinical collaborations on orthotic management of persons with upper motor neuron lesions with Deborah Gaebler-Spira, MD, at the Rehabilitation Institute of Chicago, Ms. Elaine Owens (PT from Bangor, Wales) and Mr. Donald McGovern (CPO at the Rehabilitation Institute of Chicago) resulting in multiple national and international presentations:

1. Fatone S, McGovern D (2010) Preliminary Experience with AFO-FC Tuning: Challenges and Outcomes. Invited Speaker, Midwest Chapter of the American Academy of Orthotists and Prosthetists, September 17-18, Grand Geneva Resort, Wisconsin.

2. Owen E, McGovern D and Fatone S (2010) The Importance of Being Earnest about Shank and Thigh Kinematics when Designing, Aligning and Tuning Ankle-Foot Orthosis Footwear Combinations. American Academy of Cerebral Palsy and Developmental Medicine, September 22-25, Washington DC.

3. Fatone S, McGovern D, Mangun J (2011) Effect on Gait of Ankle Foot Orthosis-Footwear Combination in an Individual with Post Stroke Hemiplegia. 37th American Academy of Orthotists and Prosthetists Annual Meeting and Scientific Symposium, March 16-19, Orlando, Florida.

4. Owen E, Gaebler D, McGovern D, Fatone S (2011) The Importance of Being Earnest about Shank and Thigh Kinematics when Designing, Aligning and Tuning Ankle-Foot Orthosis Footwear Combinations. Instructional Course, American Academy of Cerebral Palsy and Developmental Medicine, October 12-15, Las Vegas, Nevada.

5. Owen E, Gaebler-Spira D, McGovern D, Fatone S (2012) The Importance of Being Earnest about Shank and Thigh Kinematics when Designing, Aligning and Tuning Ankle-Foot Orthosis Footwear Combinations. Instructional Course, American Academy of Cerebral Palsy and Developmental Medicine, September 12-15, Toronto, Canada.

6. Owen E, Hansen A, Fatone S. (2013) From Stable Standing to "Rock'n'Roll" Walking. Symposium, 14th World Congress of the International Society for Prosthetics and Orthotics, February 4-7, Hyderabad, India.

7. Owen E, Gaebler-Spira D, McGovern D, Fatone S (2013) The Importance of Being Earnest about Shank and Thigh Kinematics when Designing, Aligning and Tuning Ankle-Foot Orthosis Footwear Combinations. Instructional Course, American Academy of Cerebral Palsy and Developmental Medicine, October 16-19, Milwaukee, Wisconsin.

8. Hansen A, Owen E, Fatone S (2014) From Stable Standing to “Rock’n’Roll” Walking. 40th American Academy of Orthotists and Prosthetists Annual Meeting & Scientific Symposium, February 26-March 1, Chicago, Illinois.

Dr. Fatone collaborated with Rob Hoskins, BME, and colleagues at Dayton Artificial Limb in Dayton, Ohio in dissemination of a small clinical case series tracking wound healing during use of prosthetic sockets with vacuum-assisted suspension. [Hoskins R, Sutton E, Kinor D, Schaeffer J, Fatone S. (2014) Using Vacuum-assisted Suspension to Manage Limb Wounds in Persons with Transtibial Amputation: A Case Series. Prosthetics Orthotics International, 38(1):68-74.]

Matthew Major, PhD (post-doctoral fellow at NUPOC) and Dr Fatone collaborated with Elliot Roth, MD, at the Rehabilitation Institute of Chicago to validate the Berg Balance Scale for use with persons with lower limb amputation. [Major M, Fatone S, Roth E (2013) Validity and Reliability of the Berg Balance Scale for Individuals with Lower Limb Amputation. Archives of Physical Medicine and Rehabilitation, 94(11):2194-202.] This work was featured in an article in the Northwestern University Feinberg School of Medicine News Center http://www.feinberg.northwestern.edu/news/2013/09/balance_NUPOC.html and also has been presented at a number of conferences:

1. Major MJ, Liss L, Murray T, Mangla N, Fatone S, EJ Roth EJ (2012) A pilot study: feasibility of using the Berg Balance scale in lower limb prosthesis users. 38th American Academy of Orthotists and Prosthetists Annual Meeting and Scientific Symposium, March 21-24, Atlanta, Georgia.

2. Major M, Fatone S, Roth E (2012) Validation of the Berg Balance Scale for Individuals with Lower Limb Amputation. Midwest Chapter of the American Academy of Orthotists and Prosthetists, September 27-29, Lake Geneva, Wisconsin.

3. Major M, Fatone S. (2013) Validation of the Berg Balance Scale for Individuals with Lower Limb Amputation. Texas Association of Orthotists and Prosthetists Annual Meeting, April 19-20, Dallas, Texas.

Dr. Fatone consulted on a collaborative project with Norman Harden, MD, at the Center for Pain Studies, the Rehabilitation Institute of Chicago, to create an amputee research registry with two goals: (1) to collect epidemiological data on post-amputation pain; and (2) to identify persons with amputation who are interested in participating in research.

Dr. Fatone collaborated with Drs. Katherine Steele and Kristie Bjornson from the University of Washington to explore the effect of orthoses on musculotendon lengths in persons with neurological disorders. This has led to a number of presentations and a publication:

1. Choi H, Bjornson K, Fatone S, and Steele KM (2013) Changes in musculotendon length with AFO tuning after stroke: a musculoskeletal modeling case study. Biomedical Engineering Society (BMES) Annual Meeting, September 25-28, Seattle, Washington.

2. Fatone S (2013) Use of Orthoses in Stroke Rehabilitation – Current Research. Invited Speaker, ISPO UK Annual Scientific Meeting, Orthotic Education and Training Trust Sponsored Lecture, October 4-5, Blackpool, UK.

3. Steele K, Choi H, Bjornson K, Fatone S (2013) Using musculoskeletal modeling to evaluate the effects of tuning ankle foot orthoses. World Congress on Biomechanics, July 6-11, Boston, Massachusetts.

4. Choi H, Bjornson K, Fatone S, Steele K. (2015) Using musculoskeletal modeling to evaluate the impact of ankle foot orthosis footwear combination on musculotendon dynamics. Disability and Rehabilitation Assistive Technology, Early Online: 1–6, DOI: 10.3109/17483107.2015.1005030.

Drs. Major, Fatone and Gard supervised the independent study projects of engineering students, David Kluger and Pooja Raghavan, that led to peer reviewed publications.

Graduate student, Angelika Zissimopoulos, completed her doctoral dissertation with support from NIDRR. This work focused on Mediolateral Foot Placement and Related Biomechanical Impairments in Post-Stroke Individuals and has been reported in three peer-reviewed publications.

Graduate student, Erin Boutwell, completed her doctoral dissertation with support from NIDRR. This work focused on the Effect of Prosthesis Stiffness on Impact Forces During In Vivo Step Loads and Gait and has been reported in the journal of Medical Engineering & Physics. See Boutwell E, Stine R, Gard S. (2015) A Novel in vivo Impact Device for Evaluation of Sudden Limb Loading Response. Medical Engineering & Physics, 37:151-155.doi:10.1016/j.medengphy.2014.10.008. The online version of this paper is available here: http://www.sciencedirect.com/science/article/pii/S1350453314002781..

Drs. Major, Fatone and Gard supervised the independent study projects of engineering students, David Kluger and Pooja Raghavan, that led to peer reviewed publications and presentations:

  1. Major MJ, Kluger D, Fatone S, Gard SA (2013) The effect of trunk flexion on lower limb kinetics of able-bodied gait (poster). American Society of Biomechanics, September 4-7, Omaha, Nebraska.
  2. Major MJ, Kluger D, Fatone S, Gard SA (2014) The effect of trunk flexion on lower limb kinetics of able-bodied gait. 10th Annual Lewis Landsberg Research Day, Northwestern University, April 3, Chicago, Illinois
  3. Major M, Raghavan P and Gard S. (2014) Estimating step length of lower limb prosthesis users with a low-cost accelerometer. 40th American Academy of Orthotists and Prosthetists Annual Meeting & Scientific Symposium, February 26-March 1, Chicago, IL.

Graduate student, Sarah Koehler, completed her doctoral dissertation with support from NIDRR. This work focused on A Quantitative Analysis of Transfemoral Prosthetic Alignment and has been reported in the Journal of Biomechanics. See Koehler SR, Dhaher YY, Hansen AH. (2014) Cross-validation of a portable, six-degree-of-freedom load cell for use in lower-limb prosthetics research. J Biomech, 47(6), 1542-1547. 

Anticipated Results

Clinical collaborations will foster closer ties between researchers and clinicians that will benefit the field directly through the conduct of clinically-relevant projects that address a clinical need and indirectly by building networks and relationships between clinicians and research that facilitates future collaboration, stakeholder input, support of other ongoing research, knowledge translation, and research training and exposure.

Publications

Arndt B, Caldwell R, Fatone S (2011) Use of a Partial Foot Prosthesis with Vacuum-Assisted Suspension: A Case Study. Journal of Prosthetics and Orthotics, 23(2):82-88. 

Boutwell E, Stine R, Gard S. (2015) A Novel in vivo Impact Device for Evaluation of Sudden Limb Loading Response. Medical Engineering & Physics, 37:151-155. doi:10.1016/j.medengphy.2014.10.008. The online version of this paper is available here: http://www.sciencedirect.com/science/article/pii/S1350453314002781

Choi H, Bjornson K, Fatone S, Steele K. (2015) Using musculoskeletal modeling to evaluate the impact of ankle foot orthosis footwear combination on musculotendon dynamics. Disability and Rehabilitation Assistive Technology, Early Online: 1–6, DOI: 10.3109/17483107.2015.1005030.

Hoskins R, Sutton E, Kinor D, Schaeffer J and Fatone S (2014) Using Vacuum-assisted Suspension to Manage Residual Limb Wounds in Persons with Transtibial Amputation: A Case Series. Prosthetics and Orthotics International, 38(1):68-74.

Kluger D, Major MJ, Fatone S, Gard S. (2014) The effect of trunk flexion on lower limb kinetics of able-bodied gait. Human Movement Science, 33:395-403.

Koehler SR, Dhaher YY, Hansen AH. (2014) Cross-validation of a portable, six-degree-of-freedom load cell for use in lower-limb prosthetics research. J Biomech, 47(6), 1542-1547. 

Major M, Fatone S, Roth E. (2013) Validity and reliability of the Berg Balance Scale for community-dwelling persons with lower limb amputation. Archives of Physical Medicine and Rehabilitation, 94(11):2194-202. 

Major MJ, Raghavan P, Gard SA. (in press) Assessing a low-cost accelerometer-based technique to estimate spatial gait parameters of lower-limb prosthesis users. Prosthetics and Orthotics International.

Robinson C, Fatone S (2013) Expert Clinical Viewpoint: You've Heard about Outcome Measures, So How Do You Use Them? Implementing Clinically Relevant Outcome Measures in Orthotic Management of Stroke. Prosthetics and Orthotics International, 37(1):30-42.

Zissimopoulos A, Fatone S, Gard S (2014) The effect of ankle-foot orthoses on self-reported balance confidence in persons with chronic post-stroke hemiplegia. Prosthetics Orthotics International, 38(2):148-154.

Zissimopoulos A, Stine R, Fatone S, Gard SA (2014) Mediolateral foot placement accuracy during ambulation in individuals with chronic post-stroke hemiplegia. Gait and Posture, 39:1097–1102.

Zissimopoulos A, Fatone S, Gard SA (2014) Effects of an Ankle-Foot Orthosis on Mediolateral Foot Placement Ability during Post-Stroke Gait. Prosthetics Orthotics International, May 30. pii: 0309364614534294. [Epub ahead of print].