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Study Design: Retrospective population-based database analysis from the Physician/Supplier Procedure Summary Medicare/Medicaid Data Set., Objective: To provide a comprehensive analysis of trends in spinal orthosis utilization over a 12-year period., Summary of Background Data: Widespread prescription of spinal orthosis persists, despite evidence suggesting equivocal efficacy in many spinal conditions. The utilization of spinal orthosis on a national level, including prescribing specialty data, has not been previously analyzed., Materials and Methods: Health care common procedure coding system codes for cervical (CO), thoracic-lumbar-sacral (TLSO), lumbar (LO), lumbar-sacral (LSO), and cervical-thoracic-lumbar-sacral (CTLSO) orthosis were used to determine spinal orthosis utilization from 2010 to 2021. Provider specialty codes were utilized to compare trends between select specialties. In addition, a neurosurgical CO analysis based on subclassifications of cervical bracing was performed. Linear trendlines were implemented to elucidate and present trends by slope (β)., Results: Among 332,241 claims, decreases in CO (β=-0.3387), TLSO (β=-0.0942), LO (β=-0.3485), and LSO (β=-0.1545) per 100,000 Medicare Part B enrollees and CTLSO (β=-0.052) per 1,000,000 Medicare Part B enrollees were observed. Decreases among neurosurgery (β=-7.9208), family medicine (β=-1.0097), emergency medicine (β=-2.1958), internal medicine (β=-1.1151), interventional pain management (β=-5.0945), and chiropractic medicine (β=-49.012), and increases among orthopedic surgery (β=5.5891), pain management (β=30.416), physical medicine and rehabilitation (β=4.6524), general practice (β=79.111), and osteopathic manipulative medicine (β=45.303) in total spinal orthosis use per 100,000 specialty claims were observed. Analysis of subclassifications of cervical orthosis among neurosurgeons revealed decreases in flexible (β=-1.7641), semirigid (β=-0.6157), and collar bracing (β=-2.7603), and an increase in multipost collar bracing (β=2.2032) per 100 neurosurgical cervical orthosis claims., Conclusions: While utilization of spinal orthosis decreased between 2010 and 2021, increased utilization was observed among a subset of specialties. Identifying these specialties allows for focused research and educational efforts to minimize unnecessary durable medical equipment use for effective health care spending., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: Survey study., Objective: Assess practices and opinions of spine specialists from Europe and North America on orthosis use in adult patients with acute thoracolumbar (TL) fractures. Evaluate cost of the devices., Summary of Background Data: Although orthosis are traditionally used in conservative treatment of TL fractures, recent systematic reviews showed no benefit in patient's outcomes., Methods: A search for contact authors with publications on spine fractures from all European and North American countries was performed. An online questionnaire was sent on demographic data, practice setting, mean number of fractures treated, use of orthosis upon choice for conservative treatment, and average orthosis cost. Data was analyzed based in world regions, economic rank of the country, and health expenditure., Results: We received 130 answers, from 28 European and five North American countries. Most responders had more than 9 years of practice and worked at a public hospital. 6.2% did not prescribe a brace in any patient with acute TL fractures conservatively treated and 11.5% brace all patients. In a scale from 1 to 5, 21 considered that there is no/low benefit (1) and 14 that bracing is essential (5), with a mean of 3.18. Europeans use orthosis less commonly than North Americans (P < 0.05). Orthosis mean cost was $611.4 ± 716.0, significantly higher in North America compared with Europe and in high income, when compared with upper middle income countries (both P < 0.05). Although hospital costs were not evaluated, orthosis is costlier when it involves admission of the patient (P < 0.05). An increase in orthosis cost associated with higher gross domestic product (GDP) per capita and higher health expenditure was found., Conclusion: More than 90% of spine specialists still use orthosis in conservative treatment of adult patients with acute TL fractures. Orthosis cost vary significantly between continents, and it is influenced by the country's economy.Level of Evidence: 4., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

The current study evaluated the effect of a passive neck orthosis, developed for patients suffering from progressive muscular diseases, on neck muscle activity in 10 adult healthy participants. The participants performed discrete head movements involving pure neck flexion (-10 to 30°), pure neck rotation (up to 30° left and right) and combined neck flexion-rotation (-10 to 30°) in steps of 10° by moving a cursor on a screen to reach predefined targets and staying on target for 10 s. Surface electromyography (EMG) was recorded from upper trapezius and sternocleidomastoid muscles and amplitudes were averaged over the static phases in trials with and without the orthosis. Moreover, the variability in head position and time required to perform the tasks were compared between conditions. Wearing the orthosis caused significant reductions (p = 0.027) in upper trapezius activity (a change of 0.2-1.5% EMGmax) while working against gravity. The activity level of the sternocleidomastoid muscle increased (p ≤ 0.025) by 0.3-1.0% EMGmax during pure and combined rotations without any pain reported. The orthosis showed potential to reduce the activity level of the upper trapezius muscle, the main load bearing muscle of the neck. Further study will be carried out to evaluate the effect in different patient groups., (Copyright © 2021. Published by Elsevier Ltd.)

Introduction: Foot Drop (FD) is a condition, which is very commonly found in post-stoke patients; however it can also be seen in patients with multiple sclerosis, and cerebral palsy. It is a sign of neuromuscular damage caused by the weakness of the muscles. There are various approaches of FD's rehabilitation, such as physiotherapy, surgery, and the use of technological devices. Recently, researchers have worked on developing various technologies to enhance assisting and rehabilitation of FD., Areas Covered: This review analyzes different types of technologies available for FD. This include devices that are available commercially or still under research .  101 studies published between 2015 and 2020 were identified for the review, many were excluded due to various reasons, e.g., were not robot-based devices, did not include FD as one of the targeted diseases, or was insufficient information. 24 studies that met our inclusion criteria were assessed. These studies were further classified into two different categories: robot-based ankle-foot orthosis (RAFO) and Functional Electrical Stimulation (FES) devices., Expert Opinion: Studies included showed that both RAFO and FES showed considerable improvement in the gait cycle of the patients. Future trends are inclining towards integrating FES with other neuro-concepts such as muscle-synergies for further developments.

In the original edition of Prosthetics and Orthotics International , Dr Sidney Fishman identified what he anticipated as foundational educational needs for the emerging field of clinical prosthetics and orthotics. Within the broader construct of the physical sciences, this included mathematics, physics, chemistry, biomechanics, and material sciences. The clinical application of these disciplines to expanding the collective understanding within the field is described, including the biomechanics of able-bodied and prosthetic gait, the material science of socket construction, the physics of suspension and load distribution, and the engineering of prosthetic components to mimic human biomechanics. Additional applications of the physical sciences to upper limb prosthetics and lower limb orthotics are also described. In contemplating the continued growth and maturation of the field in the years to come, mechatronics and statistics are suggested as future areas where clinical proficiency will be required.

Background: In this celebratory issue of Prosthetics and Orthotics International , we review professional communication skills in the field of prosthetics and orthotics., Objective: We aim to reflect on communication skills in the past 50 years, to discuss developments in the coming 50 years, and to create a toolkit and research agenda to facilitate progress in professional communication in the next 50 years., Results: Despite being a key area in prosthetics and orthotics training programmes, we found no studies on professional communication with an experimental design published in Prosthetics and Orthotics International . As an alternative, we provide clinical reflections on the changes in professional communication in the past 50 years, and we discuss questionnaire-based and qualitative studies that provide evidence for the importance of communication in pedorthic footwear provision. In the coming 50 years, professional communication in the field of prosthetics and orthotics may be impacted by aging populations, global mobility, information technology, technological advances and emphasis on prevention. We discuss each of these topics. To facilitate progress in professional communication, we have created a toolkit with resources for prosthetics and orthotics professionals, prosthetics and orthotics students and other interested professionals., Conclusions: We hope this toolkit will inspire others to use, extend and implement it in their daily practice. As a research agenda, we strongly recommend undertaking research on interventions to improve professional communication and to study its effect on clinically meaningful outcomes.

There is a long history of prosthetic and orthotic services helping to mitigate the impact of physical impairment by restoring function, and enabling and equipping the user. The training of health professionals who design, fit, and maintain prosthetic and orthotic devices has evolved over the centuries, reflecting an increase in knowledge, technology, understanding, and social attitudes in each era. Improvements in pedagogical thinking and biomechanical understanding, as well as the advent of new integrated technologies, have driven the profession over the past 50 years to modernize, evolve training and service delivery models in line with new attitudes toward clients, and search for new ways to improve users' quality of life. In this narrative review, the authors examined the evolution of prosthetic and orthotic education, the impact of changing educational techniques and technologies, and the impact of the International Society for Prosthetics and Orthotics in that process. Through conversations with experts and review of peer-reviewed literature, accreditation documents, and the International Society for Prosthetics and Orthotics records and databases, the authors identified three areas of change in prosthetics and orthotics education over the past 50 years: (1) prosthetic/orthotic curriculum content, (2) pedagogy and course delivery, and (3) internships/residencies. This narrative review is a snapshot of a growing profession and we can only speculate where the next 50 years will lead us as we strive to serve patients, ever placing their needs and aspirations at the center of this professional service.

Fifty years ago, the International Society for Prosthetics and Orthotics was founded in recognition that this unique niche in rehabilitation would benefit from multidisciplinary interactions between specialists in engineering, therapy, and medicine.Since then, field evolved from having a craft orientation toward a technology and clinical specialty. This anniversary provides an opportunity to look back on advances in prosthetics and orthotics, and the clear impact they have had on changing the skills needed by the prosthetist/orthotist as new technology and techniques have emerged. The balance has clearly shifted from mechanical skills to clinical care. The training and skills of the prosthetist/orthotist remain unique and valued in the rehabilitation team, and the primary motivation remains the same as it has been since the creation of the International Society for Prosthetics and Orthotics: the application of external devices where they are suitable to address the many varied needs of persons with disability. This historical perspective puts into context why and how the profession has changed, while also reinforcing that it is the goals set for restoring patient functions that best defines what it is to be a prosthetist/orthotist, not the means we use.

Study Design: Systematic review and meta-analysis of randomized controlled trial (RCT)., Objective: The aim of this study was to evaluate radiological and clinical outcomes of acute traumatic thoracolumbar fractures in skeletally mature patients treated with orthosis, versus no immobilization., Summary of Background Data: Orthosis is traditionally used in conservative treatment of thoracolumbar fractures. However, recent studies suggest no benefit, and a possible negative impact in recovery., Methods: Databases were searched from inception to June 2019. Studies were selected in two phases by two blinded reviewers; disagreements were solved by consensus. Inclusion criteria were: RCT; only patients with acute traumatic thoracolumbar fractures; primary conservative treatment; comparison between orthosis and no orthosis. Exclusion criteria were inclusion of nonacute fractures, patients with other significant known diseases and comparison of groups different than use of an orthosis. Two independent reviewers performed data extraction and quality assessment. Fixed-effects models were used upon no heterogeneity, and random-effects model in the remaining cases. A previous plan for extraction of radiological (kyphosis progression; loss of anterior height) and clinical (pain; disability; length of stay) outcomes was applied. PRISMA guidelines were followed., Results: Eight articles/five studies were included (267 participants). None reported significant differences in pain, kyphosis progression, and loss of anterior height. One reported a better ODI with orthosis at 12 but not at 24 weeks. No other study reported differences in disability. All authors concluded an equivalence between treatments.Meta-analysis showed a significant increase of 3.47days (95% confidence interval 1.35-5.60) in mean admission time in orthosis group. No differences were found in kyphosis at 6 and 12 months; kyphosis progression between 0 to 6 and 0 to 12 months; loss of anterior height 0 to 6 months; VAS for pain at 6 months; VAS change 0 to 6 months., Conclusion: Orthosis seems to add no benefit in conservative treatment of acute thoracolumbar fractures. This should be considered in guidelines and reviews of health care policies., Level of Evidence: 3.

Background: The carpometacarpal joint of the thumb is one of the joints most commonly affected by arthritis. The dominant hand is involved in 60-65% of cases, with a higher prevalence among women. The condition results in significant disability of the hand, which affects activities of daily living. Management is dependent on both the clinical stage of the disease and patient expectations and demands., Objective: The aim of this article is to review the current non-operative and operative modalities in managing pain symptoms, and explore evidence for the use of these modalities., Discussion: Basal thumb arthritis is a very common condition encountered by the general practitioner. Treatment must focus on functional expectations and demands of the patient, and individualised treatment plans need to be tailored to the patient. Hand therapy in addition to patient education and use of an orthosis has been shown to be very effective in management of the early stages of basal thumb arthritis. With more advanced disease, surgical modalities provide better symptomatic control.

Background: To investigate the influence of shoulder immobilization on daily physical activity., Introduction: The harmful effect of sedentary behavior does not receive much attention in orthopedic surgery even though immobilization, especially of the lower extremity, has been associated with reduced physical activity. Immobilization of the shoulder is common after reconstructive shoulder surgery and could also potentially lead to reduced physical activity and have a negative effect on a patient's general health., Method: Twenty-one healthy volunteers were immobilized in an orthosis (DJO Ultrasling III) for 10 h on two consecutive days. In the following week, activity was measured on the same days without the orthosis. Activity including gait cycles per minute and total gait cycles per day was measured by accelerometer based step count StepWatchTMActivity Monitor. Average age was 26 +/- 3 years. A questionnaire was administered to evaluate subjective activity., Results: Participants wearing the shoulder orthosis were significantly less active than without immobilization by 2227.5 gait cycles/day (5501.2 with SO, 7728.7 without SO). Also, significantly more time in sedentary behavior occurred (< 400 steps/h) when the shoulder was immobilized. Patients were significantly more active without shoulder orthosis in medium level activities (800-999 steps/h). Differences for low (400-799 steps/h) and high activity levels (> 1000 steps/h) were not statistically significant. Subjective limitations while wearing the orthosis were graded at 2.343 on a scale of 0-4., Conclusion: Results of this study show that even in young, healthy volunteers immobilization of the shoulder in an orthosis for 2 days leads to significantly reduced activity levels. A negative influence on general health, especially in older patients who are immobilized for up to 6 weeks, can potentially occur. Promoting physical activity during the immobilization period should be part of rehabilitation after injuries/surgery of the shoulder., Trial Registration: Retrospectively registered in DRKS (DRKS00017636).

Background: There is a growing interest in nonpharmacological approaches for essential tremor (ET), including tremor cancelation devices. However, the true efficacy of such devices in ET remains unclear., Methods: A systematic literature review was conducted using standardized criteria regarding efficacy and comfortability. Devices focused on design or experimental testing in which tremor was simulated in a robot were excluded., Results: Out of 324 articles initially identified, 12 articles were included. Orthoses using biomechanical loading and neuromodulation with electrical stimulation, and external tremor cancelation devices, were the main interventions used to suppress tremor. All devices were designed to control tremor of the upper limbs at different anatomical locations. Overall, an average tremor attenuation of 50-98% was reported (level of evidence III). Interference with voluntary movements and portability was described as the main drawback., Discussion: In conclusion, this review highlights the growing interest in emerging tremor control devices and the importance of assessing comfort without affecting voluntary movements. However, the level of evidence regarding the efficacy of these tremor control devices remains low. An integrated multidisciplinary combination approach of engineering, robotics, physiology, physiotherapy, and clinical assessment is needed to improve the quality of non-pharmacological interventions for ET., Competing Interests: Funding: Financial support for this study was provided by Fundación Burgos por la Investigación de la Salud. Conflicts of Interest: The authors report no conflicts of interest. Ethics Statement: Not applicable for this category of article., (© 2019 Castrillo-Fraile et al.)

The aim of this study is to implement the clinical use of the three-dimensional (3D) design and printing technology in pediatric pathologies requiring immobilization. We describe the manufacturing process of the 3D device in place of the plaster cast usually applied to a child 48/72 h after the access to the Trauma Center Traumatology Hub. This procedure had already been performed at Level II, Trauma Center, Campania Region, Orthopaedic Division of Santobono Children's Hospital, Naples, Italy. The operative phase was performed by two 3D printers and a scanner in the bioengineering laboratory of the hospital's outpatient area. The phase of software elaboration requires close cooperation among physicians and engineers. We decided to use a model with a double-shell design and holes varying in width to ensure complete ventilation and lightness of the device. We chose to treat nondisplaced metaphyseal distal fractures of the radius in 18 patients enrolled from January 2017 to November 2017. The flow chart includes clinical and radiological examinations of every enrolled child, collecting information required by the program and its elaboration by bioengineers, and then transfer of the results to 3D printers. The child, immobilized by a temporary splint, wore his 3D device after 12/24 h. Then, he underwent serial check-ups in which the effectiveness and appropriateness of the treatment were clinically monitored and evaluated using subjective scales: visual analogue scale and patient-rated wrist evaluation. All the fractures consolidated both radiologically and clinically after the treatment, with no complications reported. Only one partial breakage of the device happened because of an accidental fall. The statistical analysis of the visual analogue scale and patient-rated wrist evaluation data shows that children's activities of everyday life improved during the immobilization thanks to this treatment. This first study shows that using a 3D device instead of a traditional plaster cast can be an effective alternative approach in the treatment of pediatric nondisplaced metaphyseal distal radius fractures, with high overall patient satisfaction. We believe that 3D technology could be extended to the treatment of more complex fractures; this will be the subject of our second study.

Background: Education and training in prosthetics and orthotics typically comply with International Society for Prosthetics and Orthotics standards based on three categories of prosthetic and orthotic professionals., Objective: This scoping study sought to describe the evidence base available to answer the question, How are prosthetic and orthotic services influenced by the training of staff providing them?, Study Design: Scoping review., Methods: A structured search of the peer-reviewed literature catalogued in major electronic databases yielded 3039 papers. Following review of title and abstract, 93 articles were considered relevant. Full-text review reduced this number to 25., Results: Only two articles were identified as providing direct evidence of the effects of training and education on service provision. While both suggested that there was an impact, it is difficult to see how the more specific conclusions of either could be generalised. The other 23 articles provide a useful background to a range of issues including the specification of competencies that training programmes should deliver (3 articles), descriptions of a range of training programmes and the effects of training and education on student knowledge and skills., Conclusion: Although it is considered axiomatic, the service quality is dependent on practitioner education and training. There is insufficient evidence to establish whether levels of training and education in prosthetics and orthotics have an effect on the quality of prosthetic and orthotic services. Clinical relevance There is very little evidence about the effects of training and education of prosthetists and orthotists on service quality. While this is a somewhat negative finding, we feel that it is important to bring this to the attention of the prosthetics and orthotics community.

Background: If worn during a fall, hip protectors substantially reduce risk for hip fracture. However, a major barrier to their clinical efficacy is poor user adherence. In long-term care, adherence likely depends on how committed care providers are to hip protectors, but empirical evidence is lacking due to the absence of a psychometrically valid assessment tool., Methods: We conducted a cross-sectional survey in a convenience sample of 529 paid care providers. We developed the 15-item C-HiP Index to measure commitment, comprised of three subscales: affective, cognitive and behavioural. Responses were subjected to hierarchical factor analysis and internal consistency testing. Eleven experts rated the relevance and clarity of items on 4-point Likert scales. We performed simple linear regression to determine whether C-HiP Index scores were positively related to the question, "Do you think of yourself as a champion of hip protectors", rated on a 5-point Likert scale. We examined whether the C-HiP Index could differentiate respondents: (i) who were aware of a protected fall causing hip fracture from those who were unaware; (ii) who agreed in the existence of a champion of hip protectors within their home from those who didn't., Results: Hierarchical factor analysis yielded two lower-order factors and a single higher-order factor, representing the overarching concept of commitment to hip protectors. Items from affective and cognitive subscales loaded highest on the first lower-order factor, while items from the behavioural subscale loaded highest on the second. We eliminated one item due to low factor matrix coefficients, and poor expert evaluation. The C-HiP Index had a Cronbach's alpha of 0.96. A one-unit increase in championing was associated with a 5.2-point (p < 0.01) increase in C-HiP Index score. Median C-HiP Index scores were 4.3-points lower (p < 0.01) among respondents aware of a protected fall causing hip fracture, and 7.0-points higher (p < 0.01) among respondents who agreed in the existence of a champion of hip protectors within their home., Conclusions: We offer evidence of the psychometric properties of the C-HiP Index. The development of a valid and reliable assessment tool is crucial to understanding the factors that govern adherence to hip protectors in long-term care.

OBJECTIVE This study aimed to examine factors associated with adherence to recommended treatment among pediatric patients with positional skull deformity by reviewing a single-institution experience (2007-2014) with the treatment of positional plagiocephaly. METHODS A retrospective chart review was conducted. Risk factors, treatment for positional head shape deformity, and parent-reported adherence were recorded. Univariate and multivariate analyses were used to assess the impact of patient clinical and demographic characteristics on adherence. RESULTS A total of 991 patients under age 12 months were evaluated for positional skull deformity at the Texas Children's Hospital Cranial Deformity Clinic between 2007 and 2014. According to an age- and risk factor-based treatment algorithm, patients were recommended for repositioning, physical therapy, or cranial orthosis therapy or crossover from repositioning/physical therapy into cranial orthosis therapy. The patients' average chronological age at presentation was 6.2 months; 69.3% were male. The majority were white (40.7%) or Hispanic (32.6%); 38.7% had commercial insurance and 37.9% had Medicaid. The most common initial recommended treatment was repositioning or physical therapy; 85.7% of patients were adherent to the initial recommended treatment. Univariate analysis showed differences in adherence rates among subgroups. Children's families with Medicaid were less likely to be adherent to treatment recommendations (adherence rate, 80.2%). Families with commercial insurance were more likely to be adherent to the recommended treatment (89.6%). Multivariate logistic regression confirmed that factors associated with parent-reported adherence to recommended treatment included primary insurance payer, diagnosis (plagiocephaly vs brachycephaly), and the nature of the recommended treatment. Families were less likely to be adherent if they had Medicaid, a child with a diagnosis of brachycephaly, or were initially recommended for cranial orthosis therapy than families with commercial insurance, a child with a diagnosis of plagiocephaly, or an initial recommendation for repositioning or physical therapy. Factors associated with treatment completion included corrected age, insurance, diagnosis, recommended treatment, and distance to provider from patient's residence. Patients with commercial insurance (OR 1.49, 95% CI 1.10-2.02, p = 0.009), those diagnosed with both brachycephaly and plagiocephaly (OR 2.26, 95% CI 1.31-3.90, p = 0.003), those recommended for treatment with cranial orthosis (OR 4.55, 95% CI = 3.24-6.38, p < 0.001), and those living in proximity to the provider (OR 1.40, 95% CI 1.00-1.96, p = 0.047) were more likely to complete treatment. CONCLUSIONS Insurance type, degree of head shape deformity, and types of recommended treatment appear to affect rates of adherence to recommended treatments for positional skull deformation.

Background and Aim: Much previous research on orthotic walkers has focussed on their ability to offload structures in the foot and ankle; however, little is known about their effects on lower limb mechanics. This study aimed to determine effects of two orthotic walkers on the biomechanics of the knee and hip joints compared to standardised footwear., Technique: A total of 10 healthy participants walked under three conditions: Walker A (Össur, Iceland), Walker B (DJO Global, USA) and standardised footwear (Hotter, UK). Kinematic and kinetic data were collected using a Qualisys motion analysis system (Qualisys Medical AB, Sweden) and force plates (AMTI, Boston, MA, USA). Significant differences were seen in hip kinematics and knee moments between walkers and standardised footwear and in knee kinematics between Walker A and standardised footwear., Discussion: Both walkers show significant kinematic and kinetic differences compared with standardised footwear; however, Walker A appeared to produce greater deviation, including potentially damaging greater hyperextension moments at the knee., Clinical Relevance: Further research is needed into the effects of orthotic walkers on knee and hip joint mechanics, which should help to inform future designs of walker, with greater focus on obtaining a more normal gait pattern., (© The International Society for Prosthetics and Orthotics 2014.)

Purpose: To present a new walking aid with axillary support (WAAS) for children with cerebral palsy (CP) and to investigate its impact on the lower limb muscles activation in the gait of children with CP., Method: Six children with spastic diparesis due to CP performed a straight line walking course in two situations: with and without using the WAAS. Each course was repeated three times for both situations, and electromyography (EMG) activity of quadriceps, hamstrings, tibialis anterior and gastrocnemius were recorded during all trials., Results: The use of WAAS significantly increased the EMG activity of the quadriceps and hamstrings during stance phase and tibialis anterior during swing phase, with no significant increase in gastrocnemius activation., Conclusion: The use of WAAS improved the synergism of lower limbs muscles of children with CP by reducing the coactivation of antagonistic muscles, especially during the swing phase of gait. Providing a walking aid with improved trunk stability may enable children with CP to improve muscular synergism and walking ability, thus favoring independent mobility, with possible gains in social participation and quality of life., Implications for Rehabilitation: Children with cerebral palsy have problems with the development of normal gait, as a result of the reduced motor control and the impaired muscle synergism of the lower limbs. Standard walking aids do not provide proper trunk stability for this group of children. In a relatively small sample of children with cerebral palsy, a walking aid with axillary support was shown to be beneficial for the muscular synergism of the lower limbs during gait.

Background: Disability is inextricably linked to poverty. A total of 80% of the disabled population lives in low-income countries. The demand for prosthetic and orthotic services in these countries is increasing, and a variety of methods to provide services are currently used., Objectives: To assess current models of provision to facilitate sustainable, evidence-based prosthetic and orthotic services., Study Design: Literature review., Methods: A literature search was performed through Medline (Ovid), PubMed, ISI Web of Knowledge, EMBASE and RECAL Legacy using combinations of subject heading and text word searching strategies. Full-text publications were critically appraised and ranked according to the Scottish Intercollegiate Guidelines Network guidelines., Results: Three areas were deemed pertinent to the research question. Studies were grouped into one or more of these categories based on the issues addressed: instigators, types of service provision, demographics and region-specific issues. It was found that many complex factors influence prosthetic and orthotic services in low-income countries. Demographic and regional idiosyncrasies require prosthetic and orthotic services to be tailored to address the specific needs of individual countries., Conclusions: The lack of and quality of available research made efficacy of methods used to provide services in low-income countries difficult to determine.

Due to neuromuscular disorders (e.g., Duchenne Muscular Dystrophy) people often loose muscle strength and become wheelchair bound. It is important to use muscles as much as possible. To allow this, and to increase independency of patients, an arm orthosis can be used to perform activities of daily life. The orthosis compensates for the gravity force of the arm, allowing people to perform movements with smaller muscle forces. For patients, the aesthetics of the orthosis is one of the critical issues. This paper presents the state-of-the-art in passive and wearable active arm orthoses, and investigates how to proceed towards a suitable structure for a wearable passive arm orthosis, that is able to balance the arm within its natural range of motion and is inconspicuous; in the ideal case it fits underneath the clothes. Existing devices were investigated with respect to the body interface, the volume, and the workspace. According to these evaluation metrics it is investigated to what extent the devices are wearable and inconspicuous. Furthermore, the balancing principle of the devices, the architecture, force transmission through the devices, and alignment with the body joints are investigated. It appears that there is only one wearable passive orthosis presented in literature. This orthosis can perform throughout the natural workspace of the arm, but is still too bulky to be inconspicuous. The other passive orthoses were conspicuous and mounted to the wheelchair. Except one, the wearable active orthoses were all conspicuous and heavy due to a large backpack to enclose the actuators. They also could not achieve the entire natural workspace of the human arm. A future design of an inconspicuous, wearable, passive arm orthoses should stay close to the body, be comfortable to wear, and supports pronation and supination.

Robotic gait training has developed since the end of the 20(th) century, yet there is much room for improvement in the design of the robots. With the conventional exoskeleton structures, donning of patients in a gait trainer usually is a cumbersome process due to the need of joint alignments and normal walking is often hindered due to obstructed arm swing. Our goal was to design a gait training robots that overcomes these limitations. We propose a novel design in which these drawbacks are reduced to a great amount. By using a parallel structure behind the patient (shadow leg) that is connected to the patient joints with rods, little alignment is needed, the area lateral to the hip is left free, and thus arm swing is not obstructed. The construction is lightweight, because the actuators are mounted on a fixed base and the transmission of power is executed with light weight rods. An end stop in the shadow leg prevents hyper extension of the patient's knee. The relationship between motor displacement and human joint rotations is nonlinear. In this paper we derive the nonlinear relationships between motors and patient joints and verify these. calculations with a measurement. The device has been built, now tests with subjects are required to assess if subjects can indeed walk normally in the robot.

Background: Using mechanical orthoses have some limitations for walking in paraplegic patients. The development of powered orthoses could potentially overcome some of the limitations of those currently available., Objectives: The aim of this review was to compare the evidence of the effect of powered gait orthoses (PGOs) when compared to reciprocating gait orthoses (RGOs) and also hip guidance orthoses (HGOs) in improving gait parameters and the energy efficiency of walking by spinal cord injury (SCI) patients., Study Design: Literature review., Methods: Using the PRISMA method, and based on selected keywords and their composition, a search was performed in PubMed, Science Direct, and ISI Web of Knowledge databases. Eight articles were selected for final evaluation., Results: The results of the analysis demonstrated that there is lack of evidence to show that currently-developed powered orthoses improve the walking parameters of SCI patients when compared to RGOs and HGOs., Conclusions: The changes offered by PGOs are not substantial enough for such orthoses to be currently considered preferable by SCI subjects for ambulatory purposes. Clinical relevance The development of powered orthoses is still in its infancy and progress needs to be made to improve their functionality and performance envelopes.

Background: An important way of improving healthcare services is through the implementation of evidence-based practice; but this requires an understanding of the extent to which it is occurring and the factors that are driving its implementation., Objective: To examine the associations among the demographics of clinicians, the factors involved in the implementation of evidence-based practice, and the access of clinicians to various sources of information., Study Design: Cross-sectional survey., Methods: An online survey that was distributed to 300 Canadian prosthetic and orthotic clinicians. Associations of selected survey items were determined., Results: Four primary associations were found and a further 18 were considered to be indicative of potential trends. Two of the primary associations were related to authorship and the utilization of scientific literature. Specifically, those clinicians who had previously authored or co-authored a peer-reviewed journal article were more likely to utilize scientific literature to guide their clinical practice., Conclusions: This study has highlighted important demographics which can be targeted for greater implementation of evidence-based practice. Above all, facilitating engagement of clinicians in research and its dissemination may promote a higher consumption of research evidence leading to improved evidence-based practice.

In-depth comprehension of human knee kinematics is necessary in prosthesis and orthosis design and in surgical planning but requires complex mathematical models. Models based on one-degree-of-freedom equivalent mechanisms have replicated well the passive relative motion between the femur and tibia, i.e. the knee joint motion in virtually unloaded conditions. In these mechanisms, fibres within the anterior and posterior cruciate and medial collateral ligaments were taken as isometric and anatomical articulating surfaces as rigid. A new one-degree-of-freedom mechanism is analysed in the present study, which includes isometric fibres within the two cruciates and a spherical pair at the pivot point of the nearly spherical motion as measured for this joint. Bounded optimization was applied to the mechanism to refine parameter first estimates from experimental measurements on four lower-limb specimens and to best-fit the experimental motion of these knees. Relevant results from computer simulations were compared with those from one previous equivalent mechanism, which proved to be very accurate in a former investigation. The spherical mechanism represented knee motion with good accuracy, despite its simple structure. With respect to the previous more complex mechanism, the less satisfactory results in terms of replication of natural motion were counterbalanced by a reduction of computational costs, by an improvement in numerical stability of the mathematical model, and by a reduction of the overall mechanical complexity of the mechanism. These advantages can make the new mechanism preferable to the previous ones in certain applications, such as the design of prostheses, orthoses, and exoskeletons, and musculoskeletal modelling of the lower limb.

Background: This study examined the effect of treatment with a novel biomechanical device on the level of pain and function in patients with knee OA., Methods: Patients with bilateral knee OA were enrolled to active and control groups. Patients were evaluated at baseline, at 4 weeks and at the 8-week endpoint. A novel biomechanical device was individually calibrated to patients from the active group. Patients from the control group received an identical foot-worn platform without the biomechanical elements. Primary outcomes were the WOMAC Index and ALF assessments., Results: There were no baseline differences between the groups. At 8 weeks, the active group showed a mean improvement of 64.8% on the WOMAC pain scale, a mean improvement of 62.7% on the WOMAC function scale, and a mean improvement of 31.4% on the ALF scale. The control group demonstrated no improvement in the above parameters. Significant differences were found between the active and control groups in all the parameters of assessment., Conclusions: The biomechanical device and treatment methodology is effective in significantly reducing pain and improving function in knee OA patients.The study is registered at clinicaltrials.gov, identifier NCT00457132, http://www.clinicaltrials.gov/ct/show/NCT00457132?order=1.

The main indication of orthoses is compensation of malposition, prevention of malalignment and the balance of motion to improve function. Orthoses support current concepts of therapy and are not forms of therapy in their own right. From this point of view orthoses are often used too late to prevent deformities. Efforts to standardize individual ortheses production and orthoses indication are showing initial success. The use of new materials has radically changed orthoses and further advances are expected with the use of electronic components, although this is still at early stages. For some years, particular attention has been paid to the evaluation and objective measurement of the effectiveness of orthoses. The future of orthotics lies in further specialization, standardized indication and objective measurement of acute and long-term results.

For over a century, technologists and scientists have actively sought the development of exoskeletons and orthoses designed to augment human economy, strength, and endurance. While there are still many challenges associated with exoskeletal and orthotic design that have yet to be perfected, the advances in the field have been truly impressive. In this commentary, I first classify exoskeletons and orthoses into devices that act in series and in parallel to a human limb, providing a few examples within each category. This classification is then followed by a discussion of major design challenges and future research directions critical to the field of exoskeletons and orthoses.

It is a fantastic time for the field of robotic exoskeletons. Recent advances in actuators, sensors, materials, batteries, and computer processors have given new hope to creating the exoskeletons of yesteryear's science fiction. While the most common goal of an exoskeleton is to provide superhuman strength or endurance, scientists and engineers around the world are building exoskeletons with a wide range of diverse purposes. Exoskeletons can help patients with neurological disabilities improve their motor performance by providing task specific practice. Exoskeletons can help physiologists better understand how the human body works by providing a novel experimental perturbation. Exoskeletons can even help power mobile phones, music players, and other portable electronic devices by siphoning mechanical work performed during human locomotion. This special thematic series on robotic lower limb exoskeletons and orthoses includes eight papers presenting novel contributions to the field. The collective message of the papers is that robotic exoskeletons will contribute in many ways to the future benefit of humankind, and that future is not that distant.

Background: Arm support to help compensate for the effects of gravity may improve functional use of the shoulder and elbow during therapy after stroke, but gravity compensation may alter motor control., Objective: To obtain quantitative information on how gravity compensation influences muscle activation patterns during functional, 3-dimensional reaching movements., Methods: Eight patients with mild hemiparesis performed 2 sets of repeated reach and retrieval movements, with and without unloading the arm, using a device that acted at the elbow and forearm to compensate for gravity. Electromyographic (EMG) patterns of 6 upper extremity muscles were compared during elbow and shoulder joint excursions with and without gravity compensation., Results: Movement performance was similar with and without gravity compensation. Smooth rectified EMG (SRE) values were decreased from 25% to 50% during movements with gravity compensation in 5 out of 6 muscles. The variation of SRE values across movement phases did not differ across conditions., Conclusions: Gravity compensation did not affect general patterns of muscle activation in this sample of stroke patients, probably since they had adequate function to complete the task without arm support. Gravity compensation did facilitate active arm movement excursions without impairing motor control. Gravity compensation may be a valuable modality in conventional or robot-aided therapy to increase the intensity of training for mildly impaired patients.

Background/objective: The authors previously developed a passive instrumented arm orthosis (Therapy Wilmington Robotic Exoskeleton [T-WREX]) that enables individuals with hemiparesis to exercise the arm by playing computer games in a gravity-supported environment. The purpose of this study was to compare semiautonomous training with T-WREX and conventional semiautonomous exercises that used a tabletop for gravity support., Methods: Twenty-eight chronic stroke survivors with moderate/severe hemiparesis were randomly assigned to experimental (T-WREX) or control (tabletop exercise) treatment. A blinded rater assessed arm movement before and after twenty-four 1-hour treatment sessions and at 6-month follow-up. Subjects also rated subjective treatment preferences after a single-session crossover treatment., Results: All subjects significantly improved ( P < or = .05) upper extremity motor control (Fugl-Meyer), active reaching range of motion (ROM), and self-reported quality and amount of arm use (Motor Activity Log). Improvements were sustained at 6 months. The T-WREX group maintained gains on the Fugl-Meyer significantly better than controls at 6 months (improvement of 3.6 +/- 3.9 vs 1.5 +/- 2.7 points, mean +/- SD; P = .04). Subjects also reported a preference for T-WREX training., Conclusion: Gravity-supported arm exercise, using the T-WREX or tabletop support, can improve arm movement ability after chronic severe hemiparesis with brief one-on-one assistance from a therapist (approximately 4 minutes per session). The 3-dimensional weight support, instant visual movement feedback, and simple virtual reality software provided by T-WREX were associated with modest sustained gains at 6-month follow-up when compared with the conventional approach.

Purpose of Review: This review highlights recent research findings, including their clinical application, for insoles and footwear in knee osteoarthritis. In particular, it examines their effect on knee load, osteoarthritis symptoms and disease progression., Recent Findings: Increased joint loading increases the risk of osteoarthritis progression, but is amenable to change. Given the prevalence of medial compartment osteoarthritis, insoles and footwear largely aim to reduce the knee adduction moment, an indicator of medial compartment load. Lateral wedged insoles can reduce this moment but do not appear to slow disease progression. Although nonexperimental and quasiexperimental studies report favourable effects of lateral wedges on symptoms, clinical trials have not been confirmatory. Medial wedged insoles show promise in relieving symptoms of lateral compartment disease. Walking in shoes increases joint load compared with walking in barefeet. Shoes with a flat or low heel and that are flexible rather than stabilizing may be optimal; however, effects of off-the-shelf shoes on osteoarthritis symptoms are unknown. Promising shoe modifications include shoes that promote foot mobility and those with variable stiffness or laterally wedged soles., Summary: Insoles and footwear offer great potential, as simple, inexpensive-treatment strategies for knee osteoarthritis. Further research is needed to evaluate efficacy and to determine which patient subgroups are most responsive.

The past 40 years has seen the field of orthotics change from a craft-based industry into a modern clinical specialty. The author describes his personal view of some of the most important developments during this period in the areas of manufacturing and materials, patient/orthosis matching, biomechanics, joint design and standards. Some likely areas of future development are suggested.

Background and Purpose: Locomotor training (LT) using a treadmill can improve walking ability over conventional rehabilitation in individuals with hemiparesis, although the personnel requirements often necessary to provide LT may limit its application. Robotic devices that provide consistent symmetrical assistance have been developed to facilitate LT, although their effectiveness in improving locomotor ability has not been well established., Methods: Forty-eight ambulatory chronic stroke survivors stratified by severity of locomotor deficits completed a randomized controlled study on the effects of robotic- versus therapist-assisted LT. Both groups received 12 LT sessions for 30 minutes at similar speeds, with guided symmetrical locomotor assistance using a robotic orthosis versus manual facilitation from a single therapist using an assist-as-needed paradigm. Outcome measures included gait speed and symmetry, and clinical measures of activity and participation., Results: Greater improvements in speed and single limb stance time on the impaired leg were observed in subjects who received therapist-assisted LT, with larger speed improvements in those with less severe gait deficits. Perceived rating of the effects of physical limitations on quality of life improved only in subjects with severe gait deficits who received therapist-assisted LT., Conclusions: Therapist-assisted LT facilitates greater improvements in walking ability in ambulatory stroke survivors as compared to a similar dosage of robotic-assisted LT.

Background and Purpose: Severe upper limb paresis is a major contributor to disability after stroke. This study investigated the efficacy of a new nonrobotic training device, the Sensorimotor Active Rehabilitation Training (SMART) Arm, that was used with or without electromyography-triggered electrical stimulation of triceps brachii to augment elbow extension, permitting stroke survivors with severe paresis to practice a constrained reaching task., Methods: A single-blind, randomized clinical trial was conducted with 42 stroke survivors with severe and chronic paresis. Thirty-three participants completed the study, of whom 10 received training using the SMART Arm with electromyography-triggered electrical stimulation, 13 received training using the SMART Arm alone, and 10 received no intervention (control). Training consisted of 12 1-hour sessions over 4 weeks. The primary outcome measure was "upper arm function," item 6 of the Motor Assessment Scale. Secondary outcome measures included impairment measures; triceps muscle strength, reaching force, modified Ashworth scale; and activity measures: reaching distance and Motor Assessment Scale. Assessments were administered before (0 weeks) and after training (4 weeks) and at 2 months follow-up (12 weeks)., Results: Both SMART Arm groups demonstrated significant improvements in all impairment and activity measures after training and at follow-up. There was no significant difference between these 2 groups. There was no change in the control group., Conclusions: Our findings indicate that training of reaching using the SMART Arm can reduce impairment and improve activity in stroke survivors with severe and chronic upper limb paresis, highlighting the benefits of intensive task-oriented practice, even in the context of severe paresis.

The prosthetic and orthotic field is in constant flux, with newer technology and materials being incorporated into everyday practice. Research into the field is increasing as interest in restoring or simulating lost human function becomes more of a reality with advances in computer and microprocessor technology. This article explores the world of braces and artificial limbs, and reviews the inherent challenges encountered during rehabilitation of patients who have these specific orthotic/prosthetic needs. The authors provide quick-reference tables and highlight critical information needed to manage patients. It examines newer technology being developed and gauges how close the field really is to the era of Steve Austin, television's Six-Million Dollar Man.

The provision of aids and prostheses for patients with upper limb deficiencies has to be based on comprehensive knowledge in the field of orthopaedic technology. Taking into account the patient's complete background, evaluation of the possible functional benefit is mandatory in order to achieve good acceptance of a prosthesis in the long term. The extent of extremity "loss" and the remaining function of the deficient limb have an impact on the success of prosthetic fitting. Furthermore, there is a trend towards myoelectric prostheses, which seem to improve prosthetic acceptance. Bilateral congenital deficiency of the upper limbs cannot be equated with amputations. Most people affected do not push for a prosthesis, but should be provided with one, if the need arises. Decades of overuse of the deficient limbs often take their toll in terms of decreasing function as degenerative changes occur. As a consequence, artificial upper limbs may be obligatory to prevent loss of independence.

In our gait laboratory, the gait pattern of 18 youths with neurogenic foot deformities as a result of spina bifida or cerebral palsy was examined. The influence of technical orthopaedic devices for the foot and ankle on kinematics and kinetics of the gait and especially of the knee joint were analyzed. Kinematic data were derived from 3D-video analysis, kinetic data from force plates and pressure distribution plates. Muscle activities were measured with eight-channel EMG. The data were examined to see if there were differences when using the technical devices. All patients had already been supported externally with the different devices like orthopaedic shoes, insoles, Nancy Hilton orthoses and orthoses for the lower leg extremity. The devices restricted to the foot and the ankle joint improved the feeling of gait stability of the patients. In this investigation, the different supports had various but little effects on the kinematics and kinetics of the knee joint, depending on the type of orthoses used and the kind of handicap of the youths. Because of the great expenditure, the data obtained in this study were taken from a small number of patients. Therefore, they are individual findings and are of restricted general significance.

Never before has any civilization had the unique opportunity to enhance human performance on the scale that we will face in the near future. The convergence of nanotechnology, biotechnology, information technology, and cognitive science (NBIC) is creating a set of powerful tools that have the potential to significantly enhance human performance as well as transform society, science, economics, and human evolution. As the NBIC convergence becomes more understood, the possibility that we may be able to enhance human performance in the three domains of therapy, augmentation, and designed evolution will become anticipated and even expected. In addition, NBIC convergence represents entirely new challenges for scientists, policymakers, and business leaders who will have, for the first time, vast new and powerful tools to shape markets, societies, and lifestyles. The emergence of NBIC convergence will challenge us in new ways to balance risk and return, threat and opportunity, and social responsibility and competitive advantage as we step into the 21st century.

The classical plaster bandage was devised in the mid 19th century. Until recently, osteoarticular trauma has been treated mostly by plaster cast immobilisation using plaster of Paris. Synthetic materials have been introduced on the market place in the seventies, but they have not superseded the traditional plaster of Paris. The more recent thermoplastic materials are used to make splints and orthoses, particularly at the wrist and hand. The present review of the literature confirms that synthetic materials present better physical and mechanical properties than the traditional plaster of Paris. In addition, they are lighter, they are more resistant to humidity, they are more radiotransparent and they generate less dust when removed. However, they are less malleable and cause higher pressure in case of limb edema. Plaster of Paris therefore remains indicated in the acute posttraumatic or postoperative period. This material is also cheaper, but the pecuniary benefit is limited for several reasons, particularly because plaster of Paris is associated with a higher rate of cast replacement.

Objective: To challenge casual understanding of the causal mechanisms of foot orthotics. Although the classic orthotic paradigm of Merton L. Root and his colleagues is often acknowledged, the research attempting to explain and validate these mechanisms is far less clear in its appraisal., Data Sources: Studies evaluating the relationship of foot type (medial arch height) and use of foot orthoses to the motions of the foot and ankle were compared and contrasted. A search was conducted to evaluate other possible mechanisms of orthotic intervention., Results: Although Root's methods of foot evaluation (subtalar neutral position) and casting (non-weight-bearing) are well referenced, these methods have poor reliability, unproven validity, and are, in fact, seldom strictly followed. We challenge 2 widely held concepts: that excessive foot eversion leads to excessive pronation and that orthotics provide beneficial effects by controlling rearfoot inversion/eversion. Numerous studies show that patterns of rearfoot inversion/eversion cannot be characterized either by foot type or by orthotics use. Rather, subtle control of internal/external tibial rotation appears to be the most significant factor in maintaining proper supination/pronation mechanics. Recent evidence also suggests that proprioceptive influences play a large, and perhaps largely unexplored, role., Conclusions: Considerable evidence supports the exploration of new theories and paradigms of orthotics use. Investigations of flexible orthotic designs, proprioceptive influences, and the 3-dimensional effects of subtalar joint motion on the entire kinetic chain are areas of research that show great promise.

Objective: To present a critical review of the evolution of foot orthotics theory and clinical practice., Data Sources: Several classic publications were consulted because of their overwhelming influence. The work of Merton L. Root and his colleagues in the 1970s was carefully examined. Careful evaluations were performed to determine how faithfully Root's central concepts were subsequently followed. Studies attempting to validate this and other orthotic paradigms were also reviewed., Results: Epidemiologic studies provide strong support for the clinical advantages of orthoses, yet explanations of foot orthotic mechanisms remain elusive. Considerable variability has crept into the literature with respect to Root's core theoretical concepts of how and why to determine the neutral position of the subtalar joint (weight-bearing vs non-weight-bearing, palpation vs range-checking). Numerous studies document poor clinical reliability and validity; indeed, this paradigm appears to favor supination, thereby violating its "neutral" premise. Mechanisms other than those of the classic Root theory must be at work. Accordingly, successes have been achieved with alternate paradigms that use much simpler casting techniques. Although less frequently cited, successes have been gained with various viscoelastic materials that enhance shock-absorption and proprioception, as well as custom-made flexible orthotic designs that emphasize the 3 natural arches of the foot., Conclusions: The use of foot orthoses is well documented for the treatment of many maladies, yet clinical successes have been achieved both inside and outside of the classic Root paradigm. Clearly, a more complete theoretical understanding of the mechanisms of foot orthotics awaits discovery.