State of the Science Conference Findings

#13: Economic Science in Lower-Limb Prosthetic Rehabilitation

Recent years have witnessed an increased interest in the economic science associated with prosthetic rehabilitation. This has been evidenced in a series of economic publications, reports and analyses. Recognizing the increasing relevance of economics in healthcare policy and decision making, the American Academy of Orthotists held a State of the Science Conference on November 2-3, 2017 on this important topic. Several of the presenters shared materials created through recent collaborations with the American Orthotic and Prosthetic Association. The participation of both organizations in this event allowed for a comprehensive consideration of all available economic publications in a single setting. The following proceedings include reprints of relevant economic publications, multidisciplinary perspective pieces and an introduction to economic science for those working in amputee rehabilitation.

#12: Myoelectric and Body Power, Design Options for Upper-Limb Prostheses

On September 16-17, 2016, the American Academy of Orthotists and Prosthetists convened its 12th State of the Science Conference, with the event largely focused on the various control options and design types for upper-limb prostheses. Using a systematic review commissioned by the Academy and published by Carey et al.1 in 2015, a multinational, multidisciplinary panel was assembled to discuss a range of considerations and perspectives surrounding this topic. These perspectives included those of the clinical prosthetist in the private care setting, rehabilitation clinicians from US Department of Veterans Affairs (VA) and military health care settings, the physiatrist, the occupational therapist, the end user, global observations and trends, engineering, developing technologies, and associated medical procedures and outcome assessment.

#11: Microprocessor-Controlled Prosthetic Knees

On November 2 and 3, 2012, in Chicago, a multidisciplinary and multinational panel of subject matter experts from the clinical and research communities met to discuss MPKs and review a set of questions related to their use and function. The participants were John Fergason, CPO; Michael Goldfarb, PhD; Brian Hafner, PhD; M. Jason Highsmith, DPT, PhD, CP, FAAOP; Glenn Klute, PhD; David Morgenroth, MD; Michael Orendurff, PhD; and Phillip M. Stevens, MEd, CPO, FAAOP. Also present were Gary Berke, MS, CP, FAAOP, as chairman of this SSC; Mark Geil, PhD, Academy SSC and Research Council liaison; Robert Kistenberg, MPH, CP, FAAOP, representative from the team that will develop the Online Learning Center (OLC) course based on this SSC; and Kimber Nation, Academy staff liaison. This conference highlighted that our understanding of the use of microprocessor knee mechanisms remains incomplete. The papers presented highlight the variances and intricacies associated with MPK use and underscore the importance of a multidisciplinary approach to the prescription, provision, design, and research associated with these complex components.

#10: The Effect of Ankle Foot Orthoses (AFOs) on Balance

A multidisciplinary and multinational panel of Subject Matter Experts gathered in Chicago, IL, June 22-24, 2010 to conduct the Academy's tenth State-of-the-Science Conference. The conference was chaired by Phil Stevens, MEd, CPO, FAAOP, of Hanger Prosthetics & Orthotics Inc., Salt Lake City, Utah. Conference participants concluded that although ankle braces are commonly used to manage sports injuries and to help people with orthopedic conditions walk more safely, the effect they have on people's balance is not widely known. This comprehensive review of the best available scientific research reveals that while those ankle supports commonly used for sports injuries do not affect balance, those used for orthopedic conditions can make balance better or worse. Matching the specific brace design to the individual's needs can improve balance. In general, stiffer designs that restrict ankle movement might help with standing balance, but may also make walking balance more precarious. More flexible designs are preferable in specific cases.

The conference on which these findings are based, and the printing and distribution of this publication, were made possible by the Academy grant from the U.S. Department of Education (grant number H235K080004).

#9: Upper Limb Prosthetic Outcome Measures

A multidisciplinary and multinational panel of Subject Matter Experts gathered in Chicago, IL, March 27 - 29, 2009 to conduct the Academy's ninth State-of-the-Science Conference. The conference was chaired by Laura A. Miller, PhD, CP, Assistant Professor, Rehabilitation Institute of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, and Shawn Swanson, OTR/L, National Director of Occupational Therapy, Advanced Arm Dynamics, Redondo Beach, CA. A key outcome of this SSC was the identification of seven specific research priorities. The most important of these is the need to facilitate the implementation of the existing recommended measures into the prosthetics community (including prosthetists, therapists, physicians, and engineers). It is hoped that the dissemination of this information will lead to the development of resources for outcomes training and eventually outcomes data will be collected from longitudinal and multi-center studies that will advance the field in a meaningful way.

The conference on which these findings are based, and the printing and distribution of this publication, were made possible by the Academy grant from the U.S. Department of Education (grant number H235K080004).

#8: The Biomechanics of Ambulation After Partial Foot Amputation

Subject Matter Experts gathered in Chicago, IL, March 3-4, 2007 to conduct the Academy's eighth State-of-the-Science Conference. The conference was chaired by Jack E. Uellendahl, CPO, of Hanger Orthopedic Group in Phoenix, AZ and by Elaine Uellendahl, CP, a prosthetic consultant from Scottsdale, AZ. Despite the focus of this conference, it was recognized by participants that biomechanical analyses of devices used for ambulation with partial foot amputations are only one aspect of prosthetic/orthotic prescription. Factors affecting protection of fragile skin, prosthesis comfort, and aesthetic value are also of critical importance when selecting the most appropriate prosthetic prescription.

The conference on which these findings are based, and the printing and distribution of this publication, were funded by a grant from the U.S. Department of Education (H235J060001).

#7: Knee-Ankle-Foot Orthoses For Ambulation

Subject Matter Experts (SMEs) gathered in Chicago, IL, February 11-12, 2006 to conduct the Academy's seventh State-of-the-Science Conference. The conference was chaired by John W. Michael, MEd, CPO/L, FAAOP, FISPO, Adjunct Faculty, MSPO Program, Georgia Institute of Technology, Atlanta, GA. The SMEs concluded that there is currently no substantive evidence at the highest level of scientific certainty regarding the use of knee-ankle-foot orthoses (KAFOs) and hip-knee-ankle-foot orthoses (HKAFOs) for ambulation, but there are a number of core assumptions supported by expert opinion and peer-reviewed publications that can be considered clinical hypotheses about these orthoses. These rehabilitation beliefs can and should be tested in future research applications. Six primary research priorities and associated implications were identified. The panelists concluded that scientific research into these questions would significantly advance our understanding about the optimal application of KAFOs and HKAFOs to assist in ambulation.

The conference on which these findings are based and the printing and distribution of this publication were funded by a grant from the U.S. Department of Education (H235R050001).

#6: Outcome Measures in Lower Limb Prosthetics

Subject Matter Experts gathered in Chicago, IL, September 7-9, 2005 to conduct the Academy's sixth State-of-the-Science Conference. The conference was chaired by Laura Miller, PhD, CP of the Rehabilitation Institute of Chicago and Co-Chaired by Julia McCay, CP of Scheck & Siress O&P Inc. With the current era of managed care, it is becoming increasingly important to clearly justify the use of therapy and new and more expensive componentry. The group reviewed the current outcome measurement tools, strengths and weaknesses of these tools, why the tools are not used more often clinically, and developed recommendations for future research in the area. A formal literature search and ranking was conducted prior to the conference forming a basis for the presentations and discussion.

The conference on which these findings are based and the printing and distribution of this publication were funded by a grant from the U.S. Department of Education (H235J040017).

#5: Prosthetic Foot/Ankle Mechanisms

Subject Matter Experts gathered in Dallas, TX, April 14-16, 2005 to conduct the Academy's fifth State-of-the-Science Conference. The conference was chaired by Don Cummings, CP with Texas Scottish Rite Hospital and Co-Chaired by Susan Kapp, CPO, of the University of Texas Southwestern Medical Center. The conference was convened to examine the body of scientific evidence that supports the clinical prescription and use of prosthetic foot and ankle mechanisms. A formal literature search and ranking was conducted prior to the conference forming a basis for the presentations and discussion.

The conference on which these findings are based and the printing and distribution of this publication were funded by a grant from the U.S. Department of Education (H235J040017).

#4: Orthotic and Pedorthic Management of the Neuropathic Foot

Nancy Elftman, CO, CPed, convened a team of clinical experts with substantial experience in the contemporary management of this challenging pathology. The multidisciplinary group was charged with reviewing the available literature, summarizing areas of clinical consensus within their fields of expertise as well as key scientific evidence supporting those practices, and identifying research priorities for the future. The resulting conclusions are that the United States is facing an epidemic in the increasing numbers of diabetic patients from children to adults, and our medical educational system will need to prepare. We must improve our programs of evaluation, education, treatment and follow-up.

The conference on which these findings are based and the printing and distribution of this publication were funded by a grant from the U.S. Department of Education (H235R040001).

#3: Orthotic Treatment of Deformational Plagiocephaly, Brachycephaly and Scaphocephaly

In recent years there have been reports in the medical literature of an increase in referrals to centers within the United States of infants with plagiocephaly without synostosis. While exact figures are unknown, due largely to the lack of consensus on criteria for diagnosis, a causal relationship has been suggested between this increase and a recommendation by the American Academy of Pediatrics in 1992 that infants should be placed on their backs to sleep to reduce the risk of sudden infant death syndrome. Regardless of potential etiological factors and the lack of randomized control studies to better understand the natural history of this condition, the use of cranial molding orthoses is often referenced along with recommendations on repositioning in any number of studies published about deformational plagiocephaly. Patient referral begets responsibility–a responsibility of the treating orthotist to fully understand the complex nature of this deformity. The conference of medical doctors and allied health professionals set out to seek consensus on how best to approach the orthotic treatment of infants with deformational plagiocephaly.

The conference on which these findings are based and the printing and distribution of this publication were funded by a grant from the U.S. Department of Education (H235R040001).

#2: Post-Operative Management of the Lower Extremity Amputee

Five post-operative care strategies previously identified in published literature were adopted for discussion by the conference committee. These strategies included: soft dressings; non-removable rigid dressings without an immediate prosthetic attachment; non-removable rigid dressings with an immediate post-operative prosthesis; removable rigid plaster dressings and prefabricated post-operative prosthetic systems.

The conference was funded by the Academy. Printing and dissemination of the findings were underwritten by the U.S. Department of Education (H235R040001).

#1: Orthotic Treatment of Idiopathic Scoliosis

Idiopathic scoliosis and Scheuermann's kyphosis are spinal curvature disorders effecting both children and adolescents where the use of an orthosis has been shown to successfully prevent progression of curvatures in those who would otherwise worsen if left untreated. Because of this, Orthotists are frequently referred patients requiring a custom orthosis to treat these relatively common disorders. In recognition of the wide variety of clinical presentations, and the significant psychosocial and clinical team challenges that can accompany the orthotic treatment of these disorders, the Academy convened a consensus conference in February, 2002 to critically analyze the peer-reviewed literature on the subject and to provide guidance on how best to serve this patient population.

The conference was funded by the Centers for Disease Control and in part by the Academy.