A-2 The Academy TODAY ■ October 2010 Supplement of The O&P EDGE

Message from the President A-3

Features2010 Academy Thranhardt Lectures A-4 Randomized Crossover Study of AFO Ankle Components in Adults with Post-Stroke Hemiplegia

Comparison of In-Socket and Post-Doffing Residual Limb Extracellular Fluid Volumes

How Accurate Are Carved Positives Made by Central Fabrication Facilities?

Sponsor’s Editorial A-8 The Plié 2.0 MPC Knee: Augmenting the Responsiveness of Microprocessor Control

Publications Committee Update A-10

Grant Update A-12 The Academy Grant in Review

2010–2011 Academy Board of Directors A-14

Contents October 2010

Copyright2010,AmericanAcademyofOrthotistsandProsthetistsInc.,1331HStreet,NW,Suite501,Washington,DC20005.Phone: 202.380.3663; Fax: 202.380.3447; www.oandp.org.Allrightsreserved.Nopartofthispublicationmaybereproducedwithoutwrittenpermissionfromthepublisher.Letterstotheeditorandotherunsolic-itedmaterialareassumedtobeintendedforpublicationandaresubjecttoeditorialreview,acceptance,andediting.

TheideasandopinionsexpressedinThe Academy TODAYdonotnecessarilyreflectthoseoftheAcademy,theeditor,orthepublisher.TheacceptanceofadvertisinginnowayimpliesendorsementbytheAcademy,theeditor,orthepublisher.

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Volume 6 O Number 4

TODAY

EDITORIAL STAFF

EditorManishaS.Bhaskar

Managing EditorMikiFairley

Contributing EditorsStefaniaFatone,PhD,BPO(Hons)

JoanE.Sanders,PhD

2010–2011BOARD OF DIRECTORS

PresidentScottD.Cummings,PT,CPO,FAAOP

President-ElectMarkD.Muller,MS,CPO,FAAOP

Vice PresidentBruce“Mac”McClellan,CPO,LPO,FISPO

TreasurerMichelleJ.Hall,CPO,FAAOP

Immediate Past PresidentKeithM.Smith,CO,LO,FAAOP

Executive Director/Ex-Officio MemberPeterD.Rosenstein

Directors

MichaelJ.Allen,CPO,FAAOPKevinM.Carroll,MS,CP,FAAOP

DonaldR.Cummings,CP,LPDavidM.Gerecke,CPO,FAAOP

M.JasonHighsmith,DPT,CP,FAAOPPhillipM.Stevens,MEd,CPO,FAAOPIndicates continuing education opportunity on the Online Learning Center at www.oandp.org

Supplement of The O&P EDGE October 2010 ■ The Academy TODAY A-3

Scott D. Cummings, PT, CPO, FAAOP2010–11 President

Message from the Presidentcollaboration, a definition: n: joint labor. collaborate, v: to work or labor together; to act jointly.

Five years ago, the Academy Board of Directorsvoted toadd“collaboration” to the listofpillarsthatdefinestheAcademy’smissionstatement.Thismovewasinitiallyintendedtofosteranimprove-mentinourindividualpatienttreatments.Butina

largersense,itisabouthowtheAcademycanpositionitselftohelpimprovepatientcareonamoreuniversalscale.Foryears,the“FourPillars”ofeducation,literature,research,andadvo-cacyguidedtheactivitiesofAcademymembers,volunteers,andelectedofficials.Eachofthesefourpillarsrepresentsanendpointthatservesasatangiblegoaluntoitself.Collabora-tionisdifferent.It isameanstoanendandisarguablyourmostimportantpillarbecauseitenhancesourabilitytomeetthegoalsassociatedwiththeotherfour.

FortheO&Pprofessional,collaborationispossibleinavari-etyofways.Initspurestformitmightbeaskingacoworkertohelpwithachallengingpatientorschedulingafittingappoint-menttocoincidewithaphysicaltherapyvisitsothatbothcli-nicians can be on the same page. Collaboration might entailupdatingtheprosthetistinFloridawhowillbeprovidingcareforyouramputeepatientwhospendswintersdownsouth.Col-laborationcanalsobeachievedbyattendingalocalO&Pclinictointeractwiththepatient,family,therapist,anddoctortohelpdetermine the most appropriate orthotic care.You may be apractitionerwho,asaclinicalexpert,partnerswithagroupofresearcherstoidentifythebesttreatmentoptionforaspecificdiagnosis.Oryoumayworkwithamanufacturertodesignadevicethatultimatelyresultsinbringingtomarketanewprod-uctthatimprovesthelivesofourpatients.

TheAcademyencouragesourmemberstogetinvolvedinaprojectwithoneof themanyO&Pprofessionalorganiza-tionsandtradeassociations.Considerthepotentialofpartner-ingwiththeAmputeeCoalitionofAmerica(ACA)topushforparitylegislationinyourstateorjoiningAcademyrepresenta-tivesattheannualAmericanOrthoticandProstheticAssocia-tion(AOPA)PolicyForum,whereAOPAarrangesvisitswithyourcongressionalrepresentativestodiscussfederallegislationandhowitaffectsyourpractice.ThistypeofcollaborationhasthepotentialtoimpactaverylargenumberofO&Pprofession-alsandthepatientsweserve.

Over thepast fewyears, theAcademyhas recognized thattobestserveourmembersweneedacloserrelationshipwithourmanysisterorganizations.Thispresentsaspecialandben-eficial type of collaboration that occurs when organizationswork together.The most visible example of this is the O&PAlliance,whichcomprisestheAcademy,AOPA,theNationalAssociationfortheAdvancementofOrthoticsandProsthetics

(NAAOP), and the American Board for Certification inOrthotics,Prosthetics&Pedorthics(ABC).BysynchronizingoureffortsthroughtheAlliance,favorableresultsonavari-etyof initiativeshavebeenachieved.Itdoesnotstopthere.

With increasing frequency,organizationswithoverlap-ping missions and priori-tieshavebeencoordinatingtheir efforts on an ad hocbasis to address the needsof their constituents. Butcollaborationshouldnotbemistaken for homogeniza-tion. It is imperative thateach organization be abletoprioritizeitsactivitiestomeet the needs of its ownmembersandthatbydoing

so maintain the broad spectrum of perspectives that helpsmakeeachunique.

Becauseof thisuniqueness,ourO&P identity isoftennotpreciseenoughtoevokeaccurateunderstandinginthosewithwhomweinteract.Weareanindustryandaprofession.Weareatoncelegguys,clinicalexperts,braceladies,problemsolvers,andcraftspeople.Duetotheinherenttendencytofocusonourownpriorities,itisimportanttofindwaystoworktogethertoconsolidateourmessage,pushtheO&Pagenda,andultimatelyimproveO&Pcare.Onewaytodothisistoidentifywhatimagewewouldliketoproject.Thisiswhatmarketingexpertscall“branding,”anditwouldbeadvantageousifO&Phadacentralmessageorthemethataccuratelyrepresentsus.TheAlliancehasproducedanexcellentfour-pagewhitepaperaimedatleg-islatorsthatexplainswhoandwhatweare.Butwhatifwehadanabbreviatedmessage,ataglineofsortsthatwouldappealtoalargerandmorediverseaudiencetogiveusimmediaterec-ognition?This would identify clearly and concisely how wewouldlike tobeviewedbylegislators, insurancecompanies,themedicalcommunity,andthepatientsthemselves.

IurgeallAcademymemberstoreachouttoothersandfindcommonground.Offertohelponaprojectorinviteotherstojoininonyourproject.Problemsthatmayseeminsurmount-ablewillnodoubtbelessimposingwhenteamworkisapplied.The exceptionally successful UCLA basketball coach JohnWoodensaid,“Don’tletwhatyoucan’tdointerferewithwhatyoucando.”Ultimately,workingtogetherwillallowustomoreeffectivelymovetheAcademyforwardaswestrivetoadvancetheprofession.

A-4 The Academy TODAY ■ October 2010 Supplement of The O&P EDGE

2010 Academy Thranhardt Lectures

Randomized Crossover Study of AFO Ankle Components in Adults with Post-Stroke Hemiplegia■ S Fatone, R Stine, S Gard, Northwestern University, Chicago, Illinois; Jesse Brown, VA Medical Center, Chicago, Illinois

IntroductionMore than four millionAmericans use orthoses, with anklefoot orthoses (AFOs) being the most widely used.1,2 Whenpathologiessuchashemiplegiaarepresent,ankle-footfunc-tionisdisruptedandanAFOmaybeworntorestorefunction.ThefunctionimpartedbyAFOsrelieslargelyuponthedegreeofresistanceprovidedtorotationabouttheankle.3Thereareanumberofanklejointsandmotion-controldevicescurrentlyavailableforuseinthermoplasticAFOs,butfunctionalevalu-ationoforthoticanklecomponentsislimited.4–6Thepurposeofthisrandomizedcrossoverstudywastoassesstheeffectofdifferent ankle components on the gait of adults with post-strokehemiplegiawhoworearticulatedAFOs.

Materials and MethodThe Northwestern University Institutional Review Board(IRB)approvedthisstudy,andparticipantsprovidedinformedconsent prior to voluntary participation. Three articulatedAFOswithfull-lengthfootplateswerecustommoldedof3⁄16-inchpolypropylenefromthesamecastbyasingleorthotist(aheel-heightboardwasusedtocast theankleat90degrees).Subjects wore each AFO for two weeks in random order:90-degreeplantarflexionstop/freedorsiflexion(AFO1);plan-tarflexion limiter/free dorsiflexion (AFO2); 90-degree plan-tarflexion stop/dorsiflexion assist (AFO3). All AFOs usedTamarack Flexure Joints (Becker Orthopedic, Troy, Michi-gan). A baseline shoes-only condition (NoAFO) was alsorecorded using standardized footwear (New Balance #926).Durometerselectionforthemotionlimiter(60,70,or90)anddorsiflexion-assist joints (75 or 85) were based on clinicalevaluationofparticipants.GaitanalyseswereconductedusingtheHelenHayesmarkersetwithanklemarkerssecuredtotheAFOwiththeproximaljointscrewsothatthemarkercenter

wasinlinewiththejointaxis.TheVAChicagoMotionAnaly-sis Research Laboratory (VACMARL) is equipped with aneight-camera digital real-time motion-capture system (MAC,SantaRosa,California)andsixforceplates(AMTI,Watertown,Massachusetts)embeddedina10m,levelwalkway.OrthoTraksoftware(MAC)wasusedtocalculatekinematic,kinetic,andtemporospatialdata.Aminimumofthreetrialswereaveragedforeachsubjectwalkingatanormal, freely selectedspeed.Non-parametricstatisticalanalyseswereconductedusingtheFriedmanTest(α=0.05)withWilcoxonSignedRanksTestforpost-hoccomparisons(α=0.008afterBonferonicorrec-tionformultiplecomparisons)fordependentgroupsandtheKruskal-WallisTest(α=0.05)forindependentgroups.

ResultsDatawereanalyzedfor21subjects,ninemalesand12females(meanage:54.0±7.7years;meanmass:81.7±18.8kg;meanheight:169.3±10.5cm).Meantimesincestrokewas6.6±5.8years (12 left,nine righthemiplegia).Subjectswerebrokendown into two groups depending on whether or not kneehyperextensionwaspresentduringgaitwithoutanAFO.Tem-porospatialvariablesdidnotdifferbetweengroups,butpeakkneemomentduringloadingresponsewassignificantlydif-ferentforallconditions;kneeangleduringloadingresponsewas significantly different for all but theAFO2 andAFO3conditions;andankleangleatmidswingandinitialcontactwas significantly different for all but theAFO2 conditions.Therewasnodifferencebetweenconditionswithregardstotheloadtransfertransient.Table1showstheresultsasmedian(interquartile range) for all subjects and for the group withkneehyperextension.

Supplement of The O&P EDGE October 2010 ■ The Academy TODAY A-5

DiscussionFor all subjects, allAFO conditions significantly increasedwalking speed and step length on the involved side to thesameextentcompared toNoAFO.Ingeneral,allAFOshadamoresubstantialeffectongait inpersonswithhemiplegiawho exhibited knee hyperextension when walking withoutanAFO.Dorsiflexion-assistjointsdidnotprovideadditionaldorsiflexionduring swingwhencompared toAFOswithoutdorsiflexionassist.Resultssuggestthatalargersamplesizeisneededtodetectpost-hocdifferencesforpeakkneeangledur-ingloadingresponseandloadtransfertransients.

References1. RussellJN,HendershotGE,LeCrereF,HowieLJ,

AdlerM.Trendsanddifferentialuseofassistivetechnologydevices:UnitedStates,1994.Advance Data, no.292.Hyattsville,MD:CentersforDiseaseControl/NationalCenterforHealthStatistics;1997.

2. WhitesideSR,AllenMJ,BarringerWJ,etal.Practiceanalysisofcertifiedpractitionersinthedisciplinesoforthoticsandprosthetics.Alexandria,

Table 1 All (n=21) Hyperextension (n=11)NoAFO AFO1 AFO2 AFO3 p NoAFO AFO1 AFO2 AFO3 p

Walking Speed (m/s) 0.45(0.39)

0.67(0.37)

0.65(0.40)

0.60(0.38)

0.005*^#

0.45(0.36)

0.60(0.33)

0.63(0.36)

0.59(0.27) 0.067

Cadence (steps/min) 72.7(31.9)

87.5(18.0)

81.8(19.1)

84.8(23.8) 0.204 72.7

(27.2)87.7

(15.44)81.5

(13.9)84.8

(27.6) 0.525

Step Width (cm) 22.8(8.7)

18.3(7.3)

20.0(5.5)

20.9(6.5) 0.003 22.9

(8.3)18.3(7.3)

20.0(5.9)

21.7(7.3)

0.002*^

Involved Side Step Length (cm) 38.7(55.9)

52.2(20.2)

47.8(18.7)

51.8(21.0)

0.003*^#

42.3(19.4)

52.2(15.1)

47.8(13.6)

51.8(13.7) 0.067

Mid-Swing Ankle Angle (degrees) -7.9(11.4)

-1.8(7.1)

2.0(5.8)

-2.0(6.4)

0.000*^#@∆

-13.5(8.7)

-2.2(7.9)

-0.1(4.7)

-3.2(4.0)

0.000*^#∆

Ankle Angle at Initial Contact (degrees)

-12.0(10.6)

-3.0(6.38)

1.8(6.0)

-4.0(7.0)

0.000*^#∆

-13.4(6.1)

-4.1(6.4)

-1.4(4.3)

-7.0(4.5)

0.000*^#∆

Peak Knee Angle in Loading Response (degrees)

11.8(14.0)

12.7(11.4)

16.5(10.3)

11.5(15.4) 0.027 4.4

(8.7)12.0(8.4)

8.6(12.1)

6.0(8.9)

0.002^

Peak Knee Moment during Loading Response (Nm/kg)

-0.02(0.26)

0.02(0.22)

0.07(0.22)

-0.02(0.31)

0.034^

-0.08(0.10)

-0.03(0.08)

-0.03(0.12)

-0.05(0.04) 0.059

Load Transfer Transient (%BW) 0.48(0.50)

0.00(0.50)

0.00(0.49)

0.00(0.48) 0.013 0.52

(0.42)0.00

(0.67)0.00

(0.64)0.00

(0.55) 0.113

Post-hoc comparisons significant at p<0.008:*NoAFO:AFO1 ^NoAFO:AFO2 #NoAFO:AFO3 @AFO1:AFO2 ~AFO1:AFO3 ∆AFO2:AFO3

No significant post-hoc analyses at p<0.008 despite significant main effect.

VA:AmericanBoardforCertificationinOrthotics,Prosthetics&Pedorthics;2007.

3. Stills,OrthotProsthet,2007;29(4):41–51.4. LeeK,JohnstonR.Biomechanicalcomparisonof

90-degreeplantarflexionstopanddorsiflexionassistanklebraces.Arch Phys Med Rehabil.1973;54:302–306.

5. RaschkeS,JonesY.Orthop Techniques.1999;50:954–957.

6. FarmerS,MajorR.AbstractsoftheESMAC11thannualmeeting.19–21September2002,Leuven,Belgium.Gait Posture.2002;16(suppl1):S151–152.

Acknowledgements Supported by the Office of Research and Development(Rehabilitation R&D Service), Department of VeteransAffairs(MeritReview#A3573R),administeredbytheJesseBrownVAMedicalCenter.

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A-6 The Academy TODAY ■ October 2010 Supplement of The O&P EDGE

tocolasaboveexceptonlythesocketwasdoffedandnottheliner.Post-Walk w/o Liner: Inthisprotocol,thesubjectunder-went twoseriesof sequential intervalsof sitting (2minutes),standing(5minutes),andwalkingonatreadmill(5minutes),thendoffedtheprosthesisandliner.Thusa5-minutewalkingintervalwasconductedimmediatelybeforedoffingtheprosthe-sis.Thesubjectthensatquietlyfor10minutes.

Results and DiscussionMaximum Vecf changes overthe 10-minute interval afterdoffingrangedfrom0.0to8.0percent. The mean maximumVecfchangeafterwalkingwassignificantly greater than thatafter sitting (p=0.04), by 1.1percent. The change after sit-tingwaslesswhenthelinerwasleftontheresiduallimbthanwhenitwasremoved(by0.3percent),butthereductionwasnotsignificant(p=0.20).Qualitatively,thelinertendedtostopVecfincreaseabruptly,presumablywhenhoopstressinthelinerwassufficient toprevent further expansion.Anext stepwillbe todetermineifpatientandsocketqualitiesrelatetoVecfchangesafterdoffing.Potentially,Vecfchangescanbepredictedandthenaccommodatedforin-socketdesignandtreatment.

ConclusionLimbVecfincreasesduringcastingorimagingcanbesubstan-tiallyreducedbyhavingpatientssitquietlybeforehandwiththeprosthesisdonned.

References1. Cole KS, Li CL, BakAF. Electrical analogues for

tissues.Exp Neurol.1969;24(3):459–473.2. FenechM,JaffrinMY.Extracellularandintracellular

volumevariationsduringposturalchangemeasuredby segmental wrist-ankle bioimpedance spectros-copy.IEEE Trans Biomed Eng.2004;51(1):166–175.

AcknowledgementFundedbyNIHgrantR01-EB004329.

Comparison of In-Socket and Post-Doffing Residual Limb Extracellular Fluid Volumes■ JE Sanders, DS Harrison, KJ Allyn, TR Myers, DC Abrahamson, Bioengineering and Rehabilitation Medicine Departments, University of Washington, Seattle

IntroductionTodesignaprosthetic socket, apractitioner typicallydeter-minesresidual-limbshapebyeithertakingaplastercastorbycollectinga three-dimensional imageusingadigitalcamerasystem.Eitherway,theprosthesisisdoffedbeforetheshapeis acquired. A residual limb will undergo volume increaseafter doffing, andpotentially that volumechange can affecttheshapebeingmeasured.Buthowsubstantialarethevolumechanges?And, further, how much do activity of the patientbeforedoffingandmaintainingalineronthelimbafterdoff-ingaffect thosevolumechanges?Thepurposeof thisstudywastoaddressthesequestions.

Materials and MethodsSubjects: Twenty-threeindividualswhohadatranstibialampu-tationatleast12monthspriorparticipatedinthisstudy.Sub-jectsaveraged52.7(±12.2)yearsinageand13.3(±12.9)yearssinceamputation.Seventeenweremaleandsixwerefemale.Informed consent was obtained before any study procedureswereinitiated.

Volume Measurement: Residuallimbextracellularfluidvol-ume(Vecf)wasdeterminedusingbioimpedanceanalysis.Aftercleaningtheskinwithsandpaper,fourstripelectrodes(7.7cmx2.0cmx0.081cm)wereplacedontheresiduallimbovertheposterior-lateral region so that their long axes were parallelwitheachotherandperpendiculartothelongaxisofthelimb.Usingabioimpedanceanalyzer(Hydra4200,XitronTechnolo-gies, San Diego, California), a low alternating current (<700µA)was applied at 50 frequenciesover a rangeof 5kHz to1 MHz through the outer two electrodes, while voltage wassensedbetweenthetwoinnerelectrodes(1Hzsamplingrate).Usinga techniqueknownasColemodeling,1which involvesmodeling the tissue as resistors anda capacitor, extracellularfluid resistancewasdetermined.Resistancewasconverted toVecfusingmixturetheory.2ThechangeinVecfwasexpressedasapercentageofVecfatdoffing.Themaximumchangewithinthe10-minutepost-doffingintervalwasdetermined,andmeansbetweenstudy-protocolgroupscompared.

Study Protocol: Three protocols were conducted on eachsubject.Post-Sit w/o Liner: Afterdonningtheprosthesis,bio-impedancedatacollectionwasinitiated.Thesubjectsatcom-fortablyinachairwiththeprosthesisdonnedfor10minutes,takingcaretoensurethefootandthighwerewellsupported.Theprosthesisandlinerwerethendoffed,andthesubjectsatquietlyfor10minutes.Post-Sit w/Liner: Thiswasthesamepro-

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How Accurate Are Carved Positives Made by Central Fabrication Facilities?■ JE Sanders, MR Severance, TR Myers, DC Abrahamson, Bioengineering and Rehabilitation Medicine Departments, University of Washington, Seattle

IntroductionIn previous research, we compared shape matchesbetweenelectronicdatafilessenttotencentralfabri-cationfacilitiesandtheactualsocketssentbacktous.1Resultsshowedawiderangeinquality,withabsolutevolumedifferencesrangingfrom-2.8to+5.8percent,andabsolutemeanradiidifferencesrangingfrom0.0to 1.4mm.The purpose of the current research wastoextendfromthatinvestigationtoassessexclusivelythecarvingphaseofsocketfabrication.Shapediffer-encesbetweencarvedpositivesandelectronicshapefileswereinvestigated.

Materials and MethodsSockets: Three electronic socket-shape files (AAOP format)weresenttoeachoftencentralfabricationfacilitiestofabricatepositive models using computer-aided manufacturing equip-ment.Allmodelswerefabricatedfromaclosed-cellfoammate-rial.Thethreesocketshapeswerethesameasthoseusedinourpreviousinvestigation.1SocketAwastaperedwithdistinctbonylandmarks,socketBwascylindricallyshapedandbulbous,andsocketCwascylindricallyshapedwithbonyprominences.

Shape Measurement: Models shapesweremeasuredusingacustomshape-measurementinstrument.Theinstrumentwasadigitizerwithaspring-loadedstylusarmthatcontacted theexternalmodelsurfacewhile themodelwasrotatedabout itslongitudinal axis. Using the measured angulation of the sty-lusarm,itsverticalposition,andtherotationalpositionofthemotorrotatingthemodel,theshapeofthepositivemodelwasdetermined.Themeasurementerrorwaslessthan0.1mm.

Shape Comparison: The shapes of the measured positivemodels were aligned with the electronic-file shapes using acustomalgorithm.Thealgorithmwasanoptimizationproce-dure thatusedbothabsolutedifferencesand surfacenormalsforalignment.Thealgorithmwassimilartothatdescribedpre-viously2exceptthat100percentofthepointswereusedintheoptimization,andtheoptimizationweightingratioofabsolutedifference:surfacenormalswas0.8:0.2.

ResultsResultsshowedthatvolumedifferencesbetweenthepositivemodels and electronic-shape files ranged from -4.2 to +1.0percent,andabsolutemeanradiidifferencesrangedfrom0.0to1.2mm.Forsevenofthecompanies(1,2,3,4,6,7,10),

the range in volume differ-enceamong the threesockets[maximumdifference(model-AAOP)–minimum difference(model-AAOP)]waslessthan1.1 percent. For those com-panies, absolute mean radialerror was less than 0.4mm.Onecompany(4)showeddis-tinct coupling between radial

errorandanatomicallocation,andanothercompany(5)showedlargelocalvariationsinradialerror.Theothereightcompanies(1,2,3,6,7,8,9,10)showedrelativelyuniformradialerroroverthesurfaceforeachmodeltested.

Discussion and ConclusionTheconsistentmatchesbetweenthepositivemodelshapesandtheelectronic-shapefilesindicategoodpositive-modelfabrica-tionprocessesformostofthecompanies.Morepositivemodelswereaccuratelyshapedin thisstudythansocketswereaccu-rately shaped in our previous investigation,1 suggesting thereis, in general, greater error in socket forming than in modelcarving. The relatively uniform radial error over the surfaceformostofthemodelstestedmightreflectcompanypracticesof reducingmodel radii inanticipationofaddinga thinsockduringsubsequentsocketforming.A0.25-mmradialreductioncorrespondedtoavolumedecreaseofapproximately0.9per-centfortheshapetested.

References1. SandersJE,RogersEL,SorensonEA,LeeGS,Abra-

hamsonDC.CAD/CAMtranstibialprostheticsock-etsfromcentralfabricationfacilities:Howaccuratearethey?J Rehabil Res Dev.2007;44:395–405.

2. Zachariah SG, Sorenson E, Sanders JE.A methodforaligningtrans-tibialresiduallimbshapessoastoidentifyregionsofshapechange.IEEE Trans Neural Syst Rehabil Eng.2005;13:551–557.

AcknowledgementFundedbyNIHgrantR01-EB004329.

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The Plié 2.0 MPC Knee, developed by Freedom Innovations.

Sponsor’s Editorial

The Plié 2.0 MPC Knee: Augmenting the Responsiveness of Microprocessor ControlBy David Baty, CPO

Microprocessorregulationofprosthetic-kneemechanismshasprovidedpatientswithbothaddedsafety1,2andimproveddynamics.3Theroleofthemicroprocessoristhatofadecisionmaker.Informationregardingthepositionofthekneeisrapidlyandregularlyconveyedfromvariousinputsourcestothemicroprocessorwhereitisanalyzed.Basedontheseinputs,themicroprocessordeterminestheidealknee-resistancevaluesatagiventimeandinitiatestheknee’sresponse.

Tenyearsofexperienceandinvestigationhaveclarifiedthefunctionalbenefitsofthisroleinconnectionwithenergyconsumption4,5andhipkinetics.3Evengreaterpotentialappearstolieinitsabilitytoaugmentstabilityandreducestumblesandfallsbychangingtheknee’srelativeresistanceduringcyclicambulationandunexpectedwalkingevents.1,2

Challengesincurrentmicroprocessor-kneeengineeringincludeimprovingthespeedoftheknee’sresponsetounex-pectedevents,enhancingsafetyfeatures,andenablingthemicroprocessortechnologytobeusedeffectivelyinarangeofvaryingenvironmentsandcircumstances.

Spool Valve ResponseHowrapidlyakneerespondstounexpectedeventsdependsonthemicroprocessor’srecognitionofthesituationandtheoutputmechanismthatchangestheknee’sresistanceproper-ties.Observingthelatenciesofexistingresponsemechanisms

suchascyclingmotorstoadjustportsizeormanipulatingfluidproperties,thedevelopersofthePlié®2.0optedtodesignthedevicearoundaspoolvalve.Thespoolvalvegovernstheflowofhydraulicfluidbyalternatingbetweenopenandclosedposi-tionsin10–12milliseconds,almostcompletelyeliminatingthelatencybetweendetectionandresponseandallowingthekneetorespondtoitsenvironmentinrealtime.

Actuator responds in10–12 milliseconds.

Supplement of The O&P EDGE October 2010 ■ The Academy TODAY A-9

Stumble recovery provides confidence on a variety of terrains.

Stumble-Recovery AlgorithmsAfterastumble,aprosthetickneemustreverttostance-phasesettings,increaseflexionresistance,andgivethepatienttimetorespond.Basedonananalysisofmechanismsthatcouldcompro-miseaswing-phaseevent,numerousprotectivealgorithmswereestablishedforthePlié2.0thatdefinepatient-specificrangesofacceptablevaluesforelementssuchaskneeangles,angularvelocities,loadingmoments,timelimits,andsequencingpat-terns.Deviationswithinanyoftheseparametersclosethespoolvalve,initiatingarapidstumble-recoveryresponse.Becauseofthecomplexitiesofthisdecision-makingprocess,aset-upwizardwasdevelopedsoprosthetistscouldquicklyidentifyandadjusteachalgorithmonapatient-specificbasistocreateindividualstumble-recoveryparameters.

Reducing Weight, Power ConsumptionAnotherchallengethedevicedesignerssoughttomeetwasenablingtheuseofasmaller,lighterbatterybyreducingpowerconsumption.WhilethecylinderthatdirectlycontrolsthemovementofthePlié2.0isregulatedbyhydraulicfluid,itisalsointerfacedagainstanairchamber.Undercompression,airprovidesanon-linearreturnthatisdependentuponheel-risevaluesratherthanvelocity.Thus,asthehydrauliccylindercyclesintoflexion,compressingfluidagainsttheairbladder,theterminalswing-flexiondampeningandsubsequentexten-sionassistareinherentlyregulatedthroughabroadrangeofvariablecadences.Thus,theenergy-consumingregulationofahydrauliccylinderisnotrequiredatthispointingait,reducingthepowerneedsofthedevice.

Boththepressure-sensitiveairbladderandthespoolvalvereducetheamountofpowerrequiredtomonitorandadjusttheresistancesettingsoftheknee,resultinginasignificantreduc-tioninbatterysizeandweight.

Increasing Microprocessor Knee VersatilityThestumble-recoveryalgorithmsarederivedfromtheinputsoftwosensors:ananglesensorproximaltothejointitselfandaloadsensorpositionedimmediatelydistaltothecylinder.Byeliminatingtheneedforathirdsensor,thePlié2.0retainsabuildheightcomparabletoaconventionalhydraulicknee,thusallow-ingfortheuseofabroadrangeoffootandankleoptionstomeetvaryingneedsandcircumstances.

Thedeveloperssoughttoincreasetheeffectivenessofthetechnologyinvaryingenvironments.Forinstance,establishing

inputcuesthattriggerthetransitionbetweenstanceandswing-resistancevaluesiscritical.Anearlyswingtransitioncancom-promisepatientsafety,whileadelayedtransitioncanreducetheenergyconservedduringeachstep’sinitiation.3

Thedevelopersfoundthatthestumble-recoveryalgorithmsandreducedlatenciesofthespoolvalveenableclinicianstosafelysetsignificantlylowertransitionthresholdssinceanydevi-ationstoaswing-phaseeventimmediatelyreturnthekneetoitsstance-phaseresistancesettings.Asaresult,patientscaninitiateswing-resistancesettingsatlowerwalkingvelocitiesandinmoreconfinedspaces.

Althoughinacademicstudiesmicroprocessor-regulatedkneeshavetypicallybeenevaluatedinpredictable,moisture-free,flatindoorenvironments,3–5inoutdoorsettingsamputeesoftenencounterirregularwalkingsurfacesandvariousunforeseencircumstances.1,2Tomeetthechallengesofoutdoorenvironments,thePlié2.0hasbeenengineeredtobewaterresistantandtousesmall,interchangeablebatteriesthatallowsustainedusageawayfromwall-socketcharging.

ConclusionByunderstandingboththeroleandlimitationsofamicroprocessorintheregulationofknee-jointfunc-tion,thePlié2.0hasbeenengi-neeredtoprovideanenhancedlevelofresponsivenessandversatilitytotheestablishedadvantagesofmicroprocessorcontrol.

References1. HafnerBJ,WillinghamLL,BuellNC,AllynKJ,SmithDG.

Evaluationoffunction,performance,andpreferenceastrans-femoralamputeestransitionfrommechanicaltomicroproces-sorcontroloftheprostheticknee.Arch Phys Med Rehabil.2007;88(2):207–217.

2. KahleJT,HighsmithMJ,HubbardSL.Comparisonofnonmi-croprocessorkneemechanismversusC-Legonprosthesisevalu-ationquestionnaire,stumbles,falls,walkingtests,stairdescent,andkneepreference.J Rehabil Res Dev.2008;45(1):1–14.

3. JohanssonJL,SherrillDM,RileyPO,BonatoP,HerrH.Aclinicalcomparisonofvariable-dampingandmechanicallypassiveprosthetic-kneedevices.Am J Phys Med Rehabil.2005;84(8):563–575.

4. SchmalzT,BlumentrittS,JaraschR.Energyexpenditureandbiomechanicalcharacteristicsoflower-limbamputeegait:theinfluenceofprostheticalignmentanddifferentprostheticcompo-nents.Gait Posture. 2002;16(3):255–263.

5. OrendurffMS,SegalAD,KluteGK,McDowellML,PecoraroJA,CzernieckiJM.GaitefficiencyusingtheC-Leg.J Rehabil Res Dev.2006;43(2):239–246.

Removable and recharge-able battery.

The Plié accommodates a wide range of prosthetic foot and ankle mechanisms.

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A-10 The Academy TODAY ■ October 2010 Supplement of The O&P EDGE

Publications Committee Update

TheAcademy’s Publications Committee has created twostrong vehicles to increase awareness of the researchresourcesavailabletohelpsupporttheprofession’sneed

forevidence-basedpractice.

Literature UpdatesRegularLiteratureUpdates areprovided in electronic formatand list links to current research in orthotics and prostheticsoutside of the Journal of Prosthetics and Orthotics. Acad-emymembersreceivetheseLiteratureUpdatesviae-mail.Anarchiveoftheseupdatescanbefoundatwww.oandplibrary.org

Recommended ReadingTheAcademy’s Recommended Reading section provides alistofpublicationsthataresuggestedbytheAcademy’sPub-licationsCommittee.This list canbe foundon thepublica-tionssectionoftheAcademywebsiteatwww.oandp.organdislinkedtoAmazon.comsothatreadingsmaybepurchaseddirectly.ApartnershipenablestheAcademytoofferpublica-tionsthatarerelevanttotheorthoticandprostheticprofessiondirectlywithouthavingtostocktheminourownbookstore.

Inclusiononthislistdoesnotindicatepreferenceorofficialsponsorshipoftheauthorororganizationpublishingthemate-

rialby theAmericanAcademyofOrthotistsandProsthetists.TheAcademyencouragesyoursuggestionsandinputregardingotherpublicationsthatyoufeelshouldbeincludedonthislist.

The following publications were recently added to theAcademy’sRecommendedReadinglist.

■ Prosthetics and Orthotics: Lower Limb and Spine by Ron Seymour, PhD.

■ Amputations and Prosthetics: A Case Study Approach by Bella J. May.

■ Prosthetics and Orthotics (2nd Edition) by Don G. Shurr, PT, CPO, and John W. Michael, MEd, CPO, FAAOP.

■ Prosthetics and Patient Management: A Comprehensive Clinical Approach by Kevin Carroll, MS, CP, FAAOP, and Joan Edelstein, MA, PT, FISPO.

■ Biomechanics of Lower-Limb Prosthetics by Mark R. Pitkin. ■ Artificial Parts, Practical Lives: Modern Histories of Prosthet-

ics by David Serlin, Stephen Mihm, and Katherine Ott. ■ New Advances in Prosthetics and Orthotics, An Issue of

Physical Medicine and Rehabilitation Clinics by Mark H. Bussell, MD, CPO.

■ Powered Upper-Limb Prostheses: Control, Implementa-tion and Clinical Application by Ashok Muzumdar.

The American Academy of Orthotists and Prosthetists

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ACTIVE/ASSOCIATE*—ABC-certifiedpractitionersinorthoticsand/orprostheticsingoodstandingwithABCand/orstatelicensedO&Ppractitioners.AFFILIATE—Fitters,Technicians,Assistants,andCPedswhoarecertifiedbyABC.PROFESSIONAL—IndividualsinprofessionalfieldsrelatedtoO&Pincluding:PhysicalTherapists,OccupationalTherapists,Podiatrists,Physicians,etc.INTERNATIONALAFFILIATE—InternationalpractitionerswhoarecertifiedbyanationalorprivateorganizationoutsidetheUnitedStates.CANDIDATE/RESIDENT—IndividualscurrentlyenrolledinorwhohavecompletedanNCOPE-accreditedresidencyprogram,butarenotyetcertifiedbyABC.STUDENT—IndividualscurrentlyenrolledinaCAAHEP-accreditedpractitionerprogramoranNCOPE-accreditedtrainingprogram.

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SOCIETY MEMBERSHIP CAD/CAM Fabrication Sciences Gait Lower-Limb Orthotics Craniofacial Lower-Limb Prosthetics Spinal Orthotics Upper-Limb

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Iunderstandthatbyprovidingmymailingaddress,faxnumber,emailaddressandphonenumber(s)IconsenttoreceivecommunicationssentbyandonbehalfoftheAmericanAcademyofOrthotistsandProsthetists(AAOP)viaoneofthesemeansandIconsenttobeincludedintheAcademy’sOnlineMemberDirectory.IunderstandthatotherwisetheAAOPwillnotsharemyphone/faxnumberoremailaddresswiththirdpartieswithoutmypriorwrittenconsentasexpressedintheTelephoneConsumerProtectionActandallsubsequentrevisionsthereto.Further,IunderstandthatIcanrevokemyconsentbycontactingtheAAOPinwriting.Initial:_____

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A-12 The Academy TODAY ■ October 2010 Supplement of The O&P EDGE

The Academy Grant in Review

Department of Education funding has enabled theAcademyto launchandsustainsweepingefforts toadvance research, education, and awareness. The

timingof thesegrantfundshasbeenparticularlyappropri-ate. Prosthetics and orthotics is a discipline in the midstofwhatmightbeconsidereda turbulentperiodofgrowth.Demand for practitioners has never beenhigher.Scientificunderstanding of prosthetic and orthotic rehabilitation hasgrown in rigor and breadth. More journals are publishingO&Presearchresultsjustasmoreclinicalpresentationsandcomponents merit additional research. Today’s practitio-nerworksinaradicallydifferent industrythaninpreviousdecades,andaconcertedefforttoadvancethefieldisbothvitalandtimely.Withaconstantfocusonmaintainingandeven elevating the highest standards of care for individualpatients, grant projects have taken a “life-span” approachto advancing the field, from building awareness amongpotentialclinicianstoestablishingthestateofthesciencetoenablingseasonedpractitionerstobeinformedofthemostrecentevidence.Asthiscycleofourgrantfundingcomestoaclose,wereflectonourkeyaccomplishments.

Outreach and Awareness CampaignRecruiting qualified individuals into the O&P field has beenoneofourkeystrategies.Tothatend,wehavedevelopedcom-prehensiveO&P-career-awarenessmaterialsthatwehaveusedto educate countless high-school students, college students,healthcarepractitionersinotherfields,careercounselors,teach-ers,militaryveterans,andothermembersofthegeneralpublicaboutpossiblecareersinorthoticsandprosthetics.

Wehaveproduced anddistributed twoDVDs, aswell astelevisionandradiopublic-serviceannouncements,thathavebeenbroadcastacross thenationandvariousprintmaterialsthatexplainhowtoentertheprofessionandtherewardsandopportunitiesofacareer inO&P.Inaddition,wehavecon-ductednumerouseducationseminarsaboutthefieldwithpar-ticularemphasisonattractinghigh-schoolstudentstocareersinO&P.Wehavealsocreatedanationwidenetworkofmorethan 400 O&P practitioners who are available to conductschool-based career-education sessions, host tours of theirlocal O&P facilities, offer job-shadowing opportunities for

students,orjustanswerquestionsabouttheprofession.Thisresource isavailableonourcareerwebsite,www.opcareers.org

Strategic PlanningPartofourstrategic,long-termplanisthecreationofeduca-tionalpathwaysforadvancedO&Pdegrees.Theintentis toeducatemoretrainedscientistswhowillconductresearchandfulfillacademicrequirementsinO&P.

Master AgendaGrantfundinghascatalyzedanimportantchangeincultureinO&P,withgrowingacceptanceoftheimportanceofevidence-basedpractice(EBP)amongclinicians.Withthisculturalmile-stoneachieved,recentgrantprojectshavedevotedconsiderableefforttomorepracticalimplementationofEBP.

Throughoutthegrantperiod,wehaveconductedtenState-of-the-ScienceConferences(SSCs),theproceedingsofwhichhavebeenpublishedanddistributedtoallAcademymembers,keycontactswithinthemedia,andtherehabilitationcommu-nity.Theproceedingsareavailabletothepubliconourwebsite,www.oandp.org

WehaveexpandedtheavailableonlineresourcesofO&Pclinical material by digitization of Clinical Prosthetics & Orthotics (CPO) and the Newsletter: Orthotics & Prosthetics Clinic.TheseclinicalresourcesareavailableontheAcademy’swebsiteatwww.oandp.org.Inaddition,wehaveproducedanddistributedEvidenceNotesandEvidenceReportsanddevel-oped a certificate program titled “Evidence-Based Practice:JustifyingPatientCare,”whichhasbeenpresentedatnationalmeetings and at multiple Academy Chapter meetings. TheAcademyiscommittedtothewidestpossibledisseminationofthisvaluableinformation.

Professional Continuing-Education (PCE) CoursesWehaveworkedhardtoensurethedisseminationoftheSSCfindingsandtopromotetheadoptionofstandardsintoclinicalpractice.Thisprojecthasinvolvedthedevelopmentofpracti-tionercontinuingeducation(PCE)coursesbasedontheSSCs.InadditiontotheSSCtopics,wealsodevelopedaPCEcourseon“Single-SubjectResearchStudyandDesign.”

Grant Update

Supplement of The O&P EDGE October 2010 ■ The Academy TODAY A-13

Entry-Level EducationGrant-fundedactivitieshavecombinedtheeffortsofnationaland international subject-matter experts to analyze the cur-renteducationalneedsofnewclinicians,comparestandardsinO&Ptootheralliedhealthcaredisciplines,andaddressthecompleteeducationalprocessfromschoolthroughresidency.Therehasbeenamarkedfundamentalchangetoamandatedmaster’s degree for entry-level education that will occur in2012.Inaddition,wehavepartneredwiththeNationalCom-mission on Orthotic and Prosthetic Education (NCOPE) onaseriesofmeetingstodeveloptrainingmaterialstoimproveexistinghigh-levelresidencysitesandtodevelopnewones.

Future ProjectsAlthoughwehaveappliedforfuturefederalfundingtocon-tinueourefforts, it isnotyetclearwhetherornotourgrantrequestwillbeapproved.However,theAcademyiscommit-tedtocontinuingtheimportantworkthatwasstartedaspartofthesegrantactivities.ThefirstanticipatedprojectwillbetoworkwithoureducationalprogramstotakethetenthSSCandturnitintoonlinecoursesandacertificateprogram.

Awareness and OutreachWiththeincreasingdemandforO&Ppractitioners,thereisanevengreaterneedforourawarenessandoutreachefforts. Educating high school students, students inothercollegedisciplines,otheralliedhealthcareprofes-sionals, career counselors, teachers, military veterans,andothermembersofthegeneralpublicaboutpossiblecareersinO&Pisofparamountimportanceinmeetingthe need for qualified practitioners to provide care tothoserequiringO&Pcare in thefuture.TheAcademywillcontinue tospread thewordabout thebenefitsofpursuingacareerinO&P.

Strategic PlanningTheAcademy is committed to establishing long-termmechanisms to support the continued development ofsecondaryknowledgesourcesandvisibleonlinehostingofthisinformationonitswebsite.

Master AgendaThe Academy is working to develop training forresearchers and clinicians on knowledge translation.This is a logical continuation of our EBP efforts andincludesdevelopmentofpatient-orientedevidencethatmatters (POEMs), critically appraised topics (CATs),EvidenceReports,EvidenceNotes, etc.Wewillworkto continue the cycle for SSCs and develop formalEvidenceReportsandEvidenceNotesfor thoseSSCswherenonecurrentlyexist.

PCE CoursesWearecontinuingourworktodeveloptrainingforcli-niciansinpracticaloutcomesmeasures.Tothisend,weareworkingwithotherorganizationstodevelopturnkeytrainingforeverydaycliniciansusingvalid,reliableout-comesthataresimpletoimplement.Suchgenerationofdatawillhavealong-termbenefitonclinicalresearch.

Entry-Level EducationWewillcontinueourworkwithNCOPEonresidencytraining, including the possibility of residency oppor-tunities in Haiti to assist with the growing need forrehabilitationservicesinthiscountryduetotherecentearthquake.

The Department of Education grant has brought lastingbenefitstotheentireO&Pprofessionandtothepatientsweserve.TheAcademyisgratefultoallofthoseindividualswhoassistedinimplementingeachoftheprogramsmadepossiblebythesegrantfunds.

For more information about these programs or any of the Academy’s grant-related activities, contact Kimber Nation, grant administrator and council coordinator, at knation@oandp.org, or call 202.380.3663.

A-14 The Academy TODAY ■ October 2010 Supplement of The O&P EDGE

PRESIDENTScott D. Cummings, PT, CPO, FAAOP,graduatedfromNortheasternUniversity,Boston,Massachusetts,withabachelorofsciencedegreeinphysicaltherapypriortocompletinghisorthoticandprostheticeducationattheUniversityofCalifor-nia,LosAngeles(UCLA).HeiscurrentlyemployedbyNextStepO&PinManchester,NewHampshire,whereheprovidespatientcareinaprivate-practicesetting.

PRESIDENT–ELECTMark D. Muller, MS, CPO, FAAOP,graduatedfromtheStateUniversityofNewYork(SUNY)atStonyBrookwithabachelor’sdegreeinmaterialscienceandengineering.Hecompletedhismaster’sdegreeininstructionaldesignandtechnol-ogyandiscurrentlyaninstructorofprostheticeducationwiththeCaliforniaStateUniversityDominguezHills(CSUDH)prostheticsandorthoticsprogram.

VICE PRESIDENTBruce “Mac” McClellan, CPO, LPO, FISPO, holds degrees in prosthetics, orthotics, and health administration, andreceivedhisprostheticstrainingatNorthwesternUniversity,Chicago,Illinois.HeisinprivatepracticeaspresidentandownerofProsthetic-OrthoticAssociatesofTyler,Texas.

TREASURERMichelle J. Hall, CPO, FAAOP,receivedherbachelor’sdegreeinbiomedicalengineeringfromtheUniversityofIowa,IowaCity.ShecurrentlyworksatGilletteLifetimeSpecialtyHealthcareinSt.Paul,Minnesota.

IMMEDIATE PAST PRESIDENT Keith M. Smith, CO, LO, FAAOP,graduatedfromSt.LouisUniversity,Missouri,withabachelor’sdegreeinchemistry.Hecompletedpost-graduatestudiesinorthoticsatNorthwesternUniversity,Chicago,Illinois.HecurrentlyworksasanorthotistatOrthoticandProstheticLab,WebsterGroves,Missouri,wherehespecializesinscoliosisandpediatriccaseswithneurologicinvolvement.

EXECUTIVE DIRECTOR, EX-OFFICIO MEMBERPeter D. Rosenstein

DIRECTORSMichael J. Allen, CPO, FAAOP, graduatedfromtheO&PbaccalaureateprogramatNewYorkUniversity,NewYork,andcompletedhisclinicalresidencyinorthoticsinSanAnto-

nio,Texas,andinprostheticsinFt.Smith,Arkansas.Heisasecond-generationpractitionerandtheclinicaldirectorofAllenO&PinMidland,Texas.

Kevin M. Carroll, MS, CP, FAAOP, has worked for more than 30 years as a practicing prosthetist,researcher,andeducator.HeisvicepresidentofprostheticsforHangerProsthetics&Orthotics,Bethesda,Maryland,andtravelsextensively,treatingpatientsandmanagingclinicsforuniqueandchallengingpros-theticcases.

Don R. Cummings, CP, LP,isagraduateoftheProsthetics-OrthoticsProgramattheUniversityofTexasSouthwesternMedicalCenteratDallas,andalsohasabachelorofsciencedegreeingenericspecialeduca-tionfromtheUniversityofTexasatDallas.HehasbeenthedirectorofprostheticsatTexasScottishRiteHospitalforChildren,Dallas,since1987.

David M. Gerecke, CPO, FAAOP, graduatedfromthebaccalaureateprogramattheUniversityofWashing-ton,Seattle,in1989.HeispresidentandownerofActiveProstheticsandOrthoticsinSanAntonio,Texas.

M. Jason Highsmith, DPT, CP, FAAOP, completed the prosthetics program at Northwestern Univer-sity,Chicago,Illinois,in2004.HeisalsoaphysicaltherapistinTampa,Florida.Currently,heisjointlyappointedasanassistantprofessorattheUniversityofSouthFlorida(USF),Tampa,andasaprosthetics/amputeerehabilitationresearcherattheDepartmentofVeteransAffairs(VA)JamesHaleyPatientSafetyCenter,Tampa,Florida.

Phil M. Stevens, MEd, CPO, FAAOP,graduatedfromtheUniversityofWashington,Seattle,andreceivedhismaster’sdegreeinalliedhealtheducationandadministration(MEd)fromtheUniversityofHouston,Texas.Hespecializesinpediatricorthotics,lower-limborthotics,andcranialremolding.

2010–2011 Board of directors

Allen Carroll

Smith

Cummings Gerecke

Highsmith Stevens

Hall

Muller

Cummings

McClellan

Rosenstein

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