Orthotic Services

Orthotics were a concern for many at the 2014 conference. Work has been undertaken with the Health and Rehabilitation Research Institute of Chicago to develop a survey on orthotics issues and needs of all our members. This was piloted with Christchurch members of Polio NZ and then sent to 575 polio survivors, replies being received from 253 people, 128 of who use orthotic services and 125 who did not. The results show the provision of orthotic services to polio survivors could be improved in a number of areas. Recommendations for improvement include better assessment of service, a constructive dialogue between DHBs, orthotic providers and Polio NZ and representation to the Ministry of Health for the better provision of orthotic services through policy innovation and funding to DHBs. The Orthotic Users Survey of Members 2016 can be found here.

Orthotic-Polio-NZ

Orthotics Users’ Survey of Members 2016

By Gordon Jackman BSc MA 1st
Polio NZ Inc – Program Manager for Polio NZ Inc

DOWNLOAD SURVEY

CLICK TO VIEW: Report of the Triplaner Orthotics Workshop at QE Health Rotorua

Delivered by Marmaduke Loke Dynamic Bracing Solutions, Carlsbad California 13th – 17th September 2016

The Triplaner Orthotics Workshop was intended primarily to introduce New Zealand orthotists to the pioneering concepts of Triplaner orthotics developed by Jean-Paul Neilsen and advanced and refined by Marmaduke Loke. The workshop was attended by 15 orthotists, 4 prosthetists and one physiotherapist. The prosthetists were invited because they are already familiar with the carbon fibre lamination process used and will be able to support the orthotists as they begin to adopt this new technology. Nine polio survivors attended as models for the purpose of providing an opportunity for the orthotists to learn on people with real orthotic needs, though one person in the end needed further physio work before being able to use one of the new braces. Marmaduke Loke bought his fabricating technician, Chuck Thomas who is a specialist in carbon fibre fabrication, and his son Marmaduke junior who is now practising with his father.

 

The workshop started with a day of talks and videos introducing the Triplaner concepts of gait analysis and orthotics. Put simply this is analysis of gait in three dimensions, the motion of the skeleton walking forwards and backwards, side to side and up and down. In addition whether the person has an interior or exterior rotational pattern(IRP or ERP) while they are walking depending of which parts of the foot make contact with the ground and in what order, and the angle of the gait to the forward motion of the body.

 

At the heart of the Triplaner bracing process is the realignment of all 26 bones in the foot and the ankle to a close as possible to the position they would have been naturally. The braces are Advanced Triplanar GRAFOs, or ground reaction ankle foot orthoses. This is because the Advanced Triplanar GFAFO holds the foot in the correct position, has a brace just below the knee and the shoe has a sole which is flat so that when it contacts the ground the foot is able to stay positioned in the correct position while walking. As the body moves forward the knee straightens and the other leg is able to move through its correct gait cycle.

 

The second day was taken up with teaching Triplaner gait analysis, videoing the models as they walked up and down and getting the orthotists and prosthetists to analysis the gait. Marmaduke worked with all the clinicians to get them to understand what was happening to all the bones and joints as they walked, and then what changes could be made to the positioning of all the bones with a brace so that natural as possible gait could be achieved.

 

The next day was devoted to the art of cast taking using fibre glass. The cast must be taken with the foot and ankle being held in the correct position that will be adopted in the Triplanar GRAFO. This was not a simple process as the capacity of movement and error in this part of the manufacturing cycle is considerable. Once this was completed plaster cast molds were made and once set were shaped and then dried. Again this was a very complex process as any modifications to the shape of Triplanar GRAFO is made at this stage and will determine the functionality and comfort of the brace when worn.

 

On the fourth day the cast molds were used to fabricate the carbon fibre GRAFOs, a process requiring very precise laying up of the carbon fibre, mixing of the epoxy resins and impregnating of the carbon fibre with the resins under vacuum. The final stage is the grinding of the carbon fibre (a very hazardous process) and then the fitting which involve placing plastazote, a very firm but soft foam on the inside of the brace so that the leg, foot and ankle is precisely aligned. For a GRAFO to work properly it needs a specially modified shoe about one size bigger than normally worn by the person. The sole has to be modified so that it is flat at the toe with only a 1.5 cm gap from the ground at the heel. If the ankle can only flex at less than 90o the heel of the shoes must be lifted proportionately so the leg can be perpendicular to the ground in the middle of the stride. Any leg length decrepencies are usually incorporated in the brace design, but sometimes the differences must be accommodated in modifying the shoes. This process was completed on the final day, though shoe modifications were calculated, temporary adjustments made but left to each person’s own DHB orthotist to complete.

 

The final stage of the workshop was for each person to stand and start walking in the new Triplanar GRAFOs. Marmaduke emphasised all along that this part of the process is just as important as the fabricating process and would not be easy. To quote “Learning to walk more efficiently, minimize or eliminate the compensatory patterning, learning to trust a limb without hesitation, and program the brain and muscle patterning requires a true commitment.  Those who follow the protocols and face the new challenges have had life changing experiences.  It may take months of dedicated effort before they excel, but may take over a year to reach their potential.  Each person who faced the challenge and kept working to master the more efficient patterns, have all said it took them longer than they thought it would, but well worth it.  The learning curve to walk in a more natural and efficient pattern is dramatically reduced if an individual is fit from the onset. All new patients/clients would not require the extended times to learn to walk more naturally.”

Everyone with a new brace was coached how to stand and swing the legs using a doorway as support. Then the first steps were taken using parallel bars, starting to learn how to move the hips so that the body’s centre of gravity moves over each foot as it bears weight. At the same time the shoulders have to face forward without putting one shoulder in front of the other, some muscles having to do completely new movements while others having to relax. At first it is only possible to wear the brace for a short period of time so it was not possible at the workshop to see a final outcome of the new orthoses, except in the stationary stance where a new posture and balance was very obvious. People who have not developed the foot and ankle deformities with the lack of proper support, will be able to wear the orthoses all day much quicker. The complexities of deformities, balance issues, and pain centers can all be improved with this technology. Many surgeries and falls can be prevented. Majority of deformities are acquired and preventable if fit as early as the condition is deemed long term. Historically, long-term healthcare costs are reduced utilizing Triplanar GRAFO technology. When falls, deformities, balance issues, and pain centers are dramatically reduced many benefits add to a healtheir lifestyle and less healthcare expenses. One of the unforeseen benefits are alignment of all the joint suraces in three dimensions. The individual has better sense of balance and security with less chance of developing arthritis. There is less need for upper limb involvement to maintain balance that often leads to many upper and lower limb surgeries. Since, this technology encourages full balanced weight-bearing, many people who have had before and after bone density studies show improvement. With increased security, people are more active, therefore, they have lost weight.

 

Progress by polio survivors since the workshop.

 

Progress has been dependent on everyone’s local orthotics department being able to complete the orthotic modifications on the shoes needed to accommodate the new Triplanar GRAFO braces, as practice without the shoes is impossible. This took quite a while in some cases, with one person still not fitted out correctly. In addition the absence of parallel bars at home or a suitable place to practice walking has been an issue. The lack of support through either orthotics or physiotherapy departments has become apparent, though this is not surprising given that the Triplaner approach to orthotics is completely new to New Zealand.

Polio NZ is currently working to arrange the support necessary to enable all the polio survivors to learn to use the new orthoses.

 

Feedback from workshop attendees.

Was it worth while and if so how?

All of the attendees thought the course was very worthwhile. Their comments included:

  • That it provided a good alternative on treating polio patient while recognizing that significant follow up training and support was needed to master the GRAFOs.
  • Understanding the lamination process and just how it work for AFOs.
  • Learning some new things on biomechanics.
  • Yes, learnt some new things biomechanics and the fabrication was new.
  • Yes, the course was great, good seeing how things were done.
  • I thought the course was excellent, one of the best I have been on. Marmaduke had a great way of passing the information on and with humour.
  • I could see huge potential with the casting technique, modification and lamination.
  • I think the course was extremely well worthwhile it delivered a range of benefits to both orthotic and prosthetic practitioners and opened up an option for managing neuromuscular conditions especially Polio and Post polio syndrome. These lessons will be able to be translated to many other conditions. Only drawback is looking at the funding to make sure that those with MOH funding could benefit from the learnings.
  • Yes, it’s always a benefit to learn a new process/technique to keep in the tool box. I’m not convinced the way the Marmaduke is that every person that utilises an AFO should be in a DBS style orthosis, but there definitely have been principles that we learned that could be used on other patients even if it was in more traditional orthoses.
  • Yes – including knowledge of options and orthotic biomechanical considerations, also the knowledge sharing opportunities between disciplines.
  • Got people together, taught good resolutions to major problems, good brainstorming sessions.
  • Getting Polios and Orthotist together in a group for a week very well done. I am sure that everyone got some benefit from that.
  • I found the course to be great.

 

What were the main learnings for you?

  • Purely practical based training rather than just theory.
  • IRP and ERP was good, learning casting procedure, fabrications.
  • Didn’t realise limbs changed after so long.
  • Gait training after having the brace is the most important thing.
  • To take a bit more time with assessment, the fabrication was relatively straightforward.
  • I deal with casting and fitting of amputees so it was quite different learning how to realign the limb and hold it in the corrected position with a cast then brace.
  • It was quite a steep learning curve on the first morning, with references to conditions that we don’t normally have to consider too much in prosthetics, and having to familiarize myself with the anatomy of the foot once again.
  • What I learned most was the layup formula to have enough strength but keeping it light.
  • Personally I like that Marmaduke’s emphasis on corrective forces for natural lower limb position for effective bracing was key to his bracing success. Definitely looking at hyperextension of the knee differently from before.
  • Working with different materials.
  • Looking at correcting rather than accommodating perceived deformities.
  • Working with other colleagues, good overall experience
  • Picking the correct patient, as a lot of commitment required to transition to new device
  • For me personally, some of the tri-planar principles weren’t new, just not used as often as they could be. The biggest areas for me were in the actual lamination process. It wasn’t something I had any experience with other than brief observations. There were definitely some things that I could do better in setting up the work areas.
  • Use of AP support to facilitate weight tranference and reducing overall energy expenditure
  • Every part was a learning curve. Awesome
  • The technical side was very good and worked well for a large group.

 

What could have been improved?

  • Until you do it yourself it’s hard to say, patient mentoring is the most important.
  • Patient choice wasn’t ideal for the course, too many people and patients
  • More hand outs on material presented by Marmaduke.
  • Time a bit rushed at times.
  • Too may people so a bit rushed, didn’t have the time to go through thing a bit better,
  • People to the difficult end
  • It will be easy if we can set agenda/topics to be covered on each day. We missed on very important aspect of how to take measurements to manufacture good fitting Brace.
  • There was one more concern re health and safety when it comes to handling carbon fiber materials.
  • It would have been nice to have had our patient compression bandage prior to the cast which would have achieved a superior result.
  • I personally feel it was a bit rushed for the practical session or there may have been a bit too many busy at once.
  • Possibly more information esp. step by step evaluation and result driven outcomes that we can take with us at the course could be beneficial.
  • Electrical supply and some of the facilities, better safety gear and more care with fibres.
  • Looking at sourcing footwear earlier – maybe pre-selection with the patients at their local facilities with good guidelines from the course trainer, and having styles that are appropriate for the devices, limit choices as not all styles are suitable.
  • A more detailed schedule with regards to what topics would be covered and when would have been very useful. I know that some of our physios would have liked to have participated more but couldn’t block out the times since we weren’t sure when the applicable content would be. I need to improve our workshop layout to handle a large group of people and have the materials organised better beforehand to not have people running around looking for things when they are fabricating. We probably could plan the room layout better as well so there isn’t as much walking back and forth. (QE comments)
  • More physios!
  • Pre set up information and information on Health and safety when using such materials.
  • I felt that it was very general because Marmaduke was trying to pitch to Physio’s, Orthotists and clients. From a clinical point of view having a large client base in one room with a large orthotist base didn’t work as there was too much going on, It would have been better if there was 5/6 clinical and one client at a time having a full clinical assessment with all the pros and cons of his bracing system against other bracing systems. If the client required intervention from Physio, Botox or an op 1st then that should be done before casting and a brace being made. There were some of the Polio group that shouldn’t have had a brace made for them at that stage. When I talked to Marmaduke he said that some were very marginal and if he had seen them in his clinic he would have done things different. That info would have been very good to have been able to have an open talk about.
  • From a learning point of view there was some down time which could have been spent doing clinical assessments in smaller groups.

 

Was the course value for money?

  • The course fees were reasonable.
  • We (prosthetists) were very fortunate to have our fee’s paid.
  • Well worth the money.
  • Very much so.
  • YES!!!
  • No Idea of costs.
  • I know how much this type of thing costs so from that point of view it was very good value.

 

Would you be interested in a course with Marmaduke and his team next March ?

  • Yes especially at same cost
  • Yes
  • Yes
  • I would definitely attend next course to continue learning Marmduke’s theory of assessing and manufacturing Triplanar braces.
  • I would like to return for the follow up course but have not cast and fabricated a brace to date due to my prosthetics commitments.
  • We don’t generally deal with patients with polio but have had my eye on a colleague who has polio.
  • I would need to talk to my CEO but at this point I’m not sure if he would be willing to send us.
  • I would have been very keen to be a part of the course in March, but would feel a bit of a fraud due to not having had the opportunity to gain any further experience in this area.
  • I would definitely be keen on attending another course especially if it was the next phase ie the double helix or more dynamic AFO course. I am in the process of making one for a sina bifida patient and have another two lined up.
  • Definitely would advise all orthotists to attend and be interested to go to another course
  • Absolutely, would be good to go over principles again and look at the next stage and perhaps more in-depth of the Training for the users of the items as well as looking at the next level devices
  • I definitely would be interested, I’m not sure how many balancer type AFOs we’ll be able to do before then to get experience. We’ve been looking for people that would be good candidates, but haven’t really found anyone that we thought would be suitable and willing to put in the time to really work to change their gait pattern.
  • yes 100%
  • YES
  • yes I would be very interested.

 

Any other comments ?

  • Good to go away and have it in Rotorua, social and professional benefits.
  • Health and safety carbon fibre was an issue. Isolate room and install very powerful suction and full protection.
  • Gathering was good in social and professional way, splitting into groups was good.
  • Can’t practise the way you would like to because of funding.
  • Good to meet different people from the from the same field.
  • It would be great if we can streamline patients for his next visit in advance from Orthotic point of view.
  • I really appreciate your work, if you need any assistance in organizing next course please do not hesitate to contact me. I will be very pleased to be part of your on going project.
  • Looking forward to furthering this experience
  • Would have been good to get a few more physios there for that component as there is a need to work more multidisciplinary team focus for benefit of patients.
  • A SUPER THANK YOU!
  • My only concern was price to produce and cost to set up equipment, then time to assess, make and fit does not fit present times placed on Orthotists by Employers.

 

Conclusions

 

Overall the Triplanar Orthotics Workshop with Marmaduke Loke at QE Health in Rotorua went very well. Feedback for the orthotists and prosthetists who attended has been very positive with almost all very keen to attend the next course if we can arrange it. There were also quite a few things we learned at the same time. Some of us who acted as polio models were probably too complex for the 1st level that he was teaching. We also may have had too many models and clinicians for the time available as the process was very intense. The gait analysis normally requires at least a couple of hours and careful analysis of the video of gait, so that process was shortened for all of us. The process of laminating the braces is technologically complex, exacting and teaching it probably required more time and less pressure. Nevertheless 8 braces were successfully cast and made.

 

However, as we are all finding out, it takes considerable time, perseverance and endurance to learn to master these braces as the body alignment is quite different and learning to walk “normally” after a lifetime of a compensational walking pattern is no instant event. I am keeping in touch with all of our polio models and trying to make sure that they each have the support needed to keep learning to use their new brace.

 

It was always the plan that this course was introductory to the concepts of Triplaner orthotics. All the braces made were static rather than the dynamic braces which have spring and flexibility in the ankle joint. Without the dynamic aspect is is very hard to walk on slopes, in any direction. Polio NZ would like to bring Marmaduke Loke out in 2017 to continue teaching NZ orthotists, incorporating the learning from this 1st course. At the same time the Government and DHBs will need to be convinced of the benefits of this new orthotic technique as funding at the moment is inadequate to benefit those who use the public health system. Polio NZ is currently talking to all DHBs and orthotic providers about this issue and indications are good that a very strong case can be made to rectify the situation.

Gordon Jackman

Polio NZ Inc – Programme Manager

686 Kauaeranga Valley Rd

R D 2   Thames 3577

gjackman@clear.net.nz

07 868 5248

021 101 8948