Summary of the 2nd International Symposium on Arthrogryposis, St. Petersburg, Russia, September 17-19, 2014.

Enormous progress has been made in understanding the etiology and therapies for arthrogryposis (multiple congenital contractures). A 2nd International Symposium on Arthrogryposis was sponsored by the Turner Institute in St. Petersburg, Russia. Olga Agranovich, Head of the Arthrogryposis Department of the Turner Institute, organized this special meeting. Care providers from multiple disciplines from all over the world representing 18 nations attended. Participants included: Pediatric orthopedic specialists, rehabilitation physicians, occupational therapists, physical therapists, medical geneticists, neurologists, craniofacial physicians, psychologists, developmental biologists, as well as representatives from parent support groups. The 1st symposium established the need for a collaborative and interdisciplinary approach to the treatment of arthrogryposis, engagement of parent support organizations, and the aim for more research. The Second Symposium highlighted the continuing need for more research on various therapies, identification of different types of arthrogryposis, standardized descriptions of severity, development of new orthotics, improved prenatal diagnosis, and studying adult outcome. Major progress has been made on both upper and lower limb treatments.

The national profile of the prosthetic and orthotic workforce in the UK: Sociodemographics and employment characteristics.

BACKGROUND: Prosthetists and orthotists (POs) are essential members of the health care workforce and one of the United Kingdom's (UK's) allied health professions. There is a paucity of information on their demographics, which is essential for the development of the profession. To fill this void, this study has attempted to comprehensively explore the sociodemographics and work-related characteristics of the entire workforce. METHODS: Data were collected in 2022 through multiple sources, including surveys of POs, private companies employing POs, and freedom of information requests to National Health Service Trusts/Health Boards and higher education institutes offering programs leading to registration as a prosthetist/orthotist. RESULTS: The workforce survey had 641 respondents (74% response rate). The estimated national ratio of POs per million population was 13, with all bar of the 12 regions below the World Health Organization minimum recommendation of 15 POs per million population. Most of the survey respondents were female (47.6%) and younger than male respondents, were British (75.8%), and in the White ethnic group (74.3%). Most of them were employed by private companies (59.9% vs. 31.4% employed by the National Health Service) and had clinical duties (94%), permanent contracts (90%), worked full-time (75%), and treated a wide range of clinical conditions. CONCLUSIONS: The national UK prosthetist and orthotist ratio falls below the recommended international standards. The versatility and broad skill set of POs highlight their crucial role in multidisciplinary teams. Establishing a centralized prosthetist and orthotist workforce database system is recommended for data-driven strategic planning.

An exploratory qualitative study of health professional perspectives on clinical outcomes in UK orthotic practice.

BACKGROUND: Despite potential savings to the National Health Service, the collection of data on outcomes of NHS orthotic services is patchy. Indeed, several reports into orthotic services in the UK have reported a lack of data relating to outcomes of care and highlighted the need to routinely measure outcomes to demonstrate efficacy of services. Whilst a previous study provided an overview of the use of outcome measures in orthotic practice and identified some barriers to their use, further questions emerged. Hence, this qualitative study aimed to explore orthotists' opinions and personal experiences on the influences on outcomes, how appropriate and relevant outcomes can be measured and also how barriers to the use of outcome measures can be overcome. METHODS: Following a review of the literature, an initial advisory group informed semi-structured questions. These were used to create dialogue in a focus group of 12 orthotists. Data from the focus group was transcribed verbatim and analysed using thematic analysis, creating themes and subthemes for discussion. RESULTS: The setting of realistic and agreed goals through managing expectations, compromise and patient education/information were seen as factors that could inform and improve outcomes. Barriers to the collection of outcome measures were associated with inadequate technology to manage the data, lack of time to complete them, lack of training in them and difficulties selecting appropriate outcome measures for patients with complex problems managed by different health professionals. The participants discussed ways of addressing these barriers, such as the use of 'snapshots' and delegation of data collection. CONCLUSIONS: This study has revealed that measuring outcomes is considered to be an important activity. In order to achieve good outcomes, it is important to address patient expectations, discuss and establish joint goals for care at the outset and inform and include patients in the decision-making process. The identified barriers to measuring outcomes can be overcome with the solutions revealed by these participants. Hence, this study has contributed to current knowledge which has relevance for clinical practice and may provide the theoretical basis for future research.

Cross-sectional survey of orthotic service provision in the UK: does where you live affect the service you receive?

OBJECTIVE: To investigate the quantity and quality of orthotic service provision within the UK. DESIGN: Cross-sectional survey obtained through freedom of information request in 2017. SETTING: National Health Service (NHS) Trusts/Health Boards (HBs) across the UK. MAIN OUTCOME MEASURES: Descriptive statistics of survey results, including information related to finance, volume of appointments, patients and orthotic products, waiting times, staffing, complaints, outcome measures and key performance indicators. RESULTS: Responses were received from 61% (119/196) of contacted Trusts/HBs; 86% response rate from Scotland (12/14) and Wales (6/7), 60% (3/5) from Northern Ireland and 58% (98/170) from England. An inhouse service was provided by 32% (35/110) of responses and 68% (74/110) were funded by a block contract. Long waiting times for appointments and lead times for footwear/orthoses, and large variations in patient entitlements for orthotic products across Trusts/HBs were evident. Variations in the length of appointment times were also evident between regions of the UK and between contracted and inhouse services, with all appointment times relatively short. There was evidence of improvements in service provision; ability for direct general practitioner referral and orthotic services included within multidisciplinary clinics. However, this was not found in all Trusts/HBs. CONCLUSIONS: The aim to provide a complete UK picture of orthotic service provision was hindered by the low response rate and limited information provided in some responses, with greater ability of Trusts/HBs to answer questions related to quantity of service than those that reflect quality. However, results highlight the large discrepancies in service provision between Trusts/HBs, the gaps in data capture and the need for the UK NHS to establish appropriate processes to record the quantity and quality of orthotic service provision. In addition to standardising appointment times across the NHS, guidelines on product entitlements for patients and their lead times should be prescribed to promote equity.

Reforming the Belgian market for orthotic braces: what can we learn from the international experience?

OBJECTIVES: This article aims to review regulation governing outpatient orthotic braces (neck, wrist and knee braces) in France, the Netherlands and Sweden with a view to reforming the Belgian market. METHODS: Information about the regulatory framework was derived from an analysis of legal texts and a survey completed by national experts. RESULTS: Strategies to keep down prices include public procurement in Sweden, maximum prices in France, and exclusion of expensive braces from reimbursement in the Netherlands. Reimbursement is linked to a medical indication or a chronic condition in France, the Netherlands and Sweden. To gain reimbursement, the cost-effectiveness of orthotic braces needs to be demonstrated in France and the Netherlands. Orthotic braces tend to be initially prescribed by a specialist physician and distributed by orthotists, medical equipment shops and/or community pharmacies. CONCLUSIONS: Extensive government intervention exists in the outpatient orthotic brace market in the countries studied. Our recommendations to reform the Belgian market for prefabricated orthotic braces are to separate reimbursement for service provision from reimbursement for braces; to set prices by means of a tendering process or an international price comparison; and to make reimbursement conditional on effectiveness and cost-effectiveness of braces.

The physician-owned orthotic and durable medical equipment service.

In recent years, orthopedic practices have been forced to create internal ancillary profit centers to help compensate for escalating operating expenses. Increased professional liability premiums and health care costs, coupled with decreased reimbursements, have made the development of these ancillary centers a necessity. Practices that assess and incorporate sound business policies in developing the entity, monitor its progression, and strive to enhance the overall offerings within the division will derive the most profitability. By following a structured plan, practices can maximize revenue potential and improve patient satisfaction and outcomes. This article describes how to construct and follow such a plan.

Do tariffs and prices correspond with costs? A case study of orthotic braces.

OBJECTIVES: The Belgian third-party payer wishes to set reimbursement tariffs at a level that reflects the costs of orthotic braces. This article aims to calculate production and distribution costs of a prefabricated hard neck and knee brace and to explore whether Belgian tariffs and actual retail prices correspond with estimated costs of these two braces. METHODS: The cost model considered manufacturing costs, general overheads, research and development costs, warehousing costs, profit and distribution margins. Data were gathered from manufacturers, a production site visit, desk research, a decomposition of finished products and stakeholder interviews. The price year was 2007. RESULTS: The cost model estimated a retail price of euro55-euro150 for the neck brace, depending on assumptions. The estimated retail price for the neck brace was lower than the reimbursement tariff of euro194 and the actual retail price of euro241. The estimated retail price of euro331-euro694 for the knee brace was lower than the actual retail price of euro948. CONCLUSIONS: Actual retail prices and reimbursement tariffs for a neck brace and a knee brace exceeded prices based on estimated costs. Therefore, there appears to be scope for reducing tariffs.

Proper sling selection and application while using patient lifts.

In response to staff shortages, an aging clinical workforce, and research on safe patient handling, manufacturers have provided an extensive array of patient-lifting technology, including ceiling, floor-based, and sit-to-stand lifts as well as slings that are required for their use. Expanded choice, however, may pose challenges to both healthcare facilities and individual clinicians. These challenges, if not successfully resolved, can preclude the consistent, safe, and efficient use of patient-handling devices. This article provides nurses and other direct patient care providers with a heightened awareness of the challenges to appropriate sling and lift use in rehabilitation and other clinical settings. A new way to categorize slings is introduced, and guidelines for safely evaluating and using slings for different patient-handling tasks are offered.

Footwear and offloading for patients with diabetes.

Selecting footwear that fits appropriately in order to prevent foot pathologies, such as corns and callouses, is important in the general population but even more so in people with diabetes who have associated complications of neuropathy and ischaemia (Chantelau et al, 1994). Sue Coles explains why it is necessary to adapt footwear and how this is achieved.

The influence of standards and clinical guidelines on prosthetic and orthotic service quality: a scoping review.

OBJECTIVES: Standards and guidelines are an integral part of prosthetic and orthotic service delivery in the developed world underpinned by an assumption that they lead to improved services. Implementing them has a cost, however, and that cost needs to be justified, particularly in resource-limited environments. This scoping review thus asks the question, "What is the evidence of the impact of standards and guidelines on service delivery outcomes in prosthetics and orthotics?" MATERIALS AND METHODS: A structured search of three electronic databases (Medline, Scopus and Web of Science) followed by manual searching of title, abstract and full text, yielded 29 articles. RESULTS: Four categories of papers were identified: Descriptions and Commentaries (17 papers), Guideline Development (7), Guideline Testing (2) and Standards implementation (3). No articles were explicitly designed to assess the impact of standards and guidelines on service delivery outcomes in prosthetics and orthotics. DISCUSSION AND CONCLUSION: Studies tended to be commentaries on or descriptions of guideline development, testing or implementation of standards. The literature is not sufficiently well developed to warrant the cost and effort of a systematic review. Future primary research should seek to demonstrate whether and how guidelines and standards improve the outcomes for people that require prostheses, orthoses and other assistive devices. Implications for Rehabilitation International Standards and Clinical Guidelines are now an integral part of clinical service provision in prosthetics and orthotics in the developed world. Complying with standards and guidelines has a cost and, particularly in resource-limited environments, it should be possible to justify this in terms of the resulting benefits. This scoping review concludes that there have been no previous studies designed to directly quantify the effects of implementing standards and guidelines on service delivery.

Ambulation in children and youth with spinal cord injuries.

OBJECTIVE: To delineate the natural history of ambulation of children and youth with spinal cord injuries (SCls). DESIGN: Retrospective single-center. PARTICIPANTS/METHODS: One hundred sixty-nine subjects who sustained SCI at 18 years of age or younger and who were followed up for at least 4 years. RESULTS: Ambulation was significantly associated with age at injury and neurological impairment but not gender. Younger age at injury was associated with greater likelihood of ambulation, higher level of ambulation, and greater duration of ambulation. Lesser severity of neurological impairment was associated with greater likelihood of ambulation. Excluding ASIA D lesions, household ambulation was noted in 5% of subjects with tetraplegic, 26% with high thoracic, 30% with low thoracic, 44% with upper lumbar, and 33% with lower lumbar lesions. Of the 7 community-level ambulators with non-ASIA D lesions, none had cervical or high thoracic injuries, 3 had low thoracic, 1 had upper lumbar, and 3 had lower lumbar lesions. Using multiple regression analysis, predictive factors for ambulation were younger age at injury, total ASIA motor score, and ASIA impairment scale score. Less cumbersome orthotics were associated with higher levels of ambulation. CONCLUSION: Ambulation status is a function of neurological impairment, age at injury, and type of orthotic.

Medicare program; durable medical equipment regional carrier service areas and related matters. Final rule.

This final rule provides a mechanism for us to expeditiously make changes to the durable medical equipment regional carrier (DMERC) service area boundaries without notice and comment rulemaking. Through this mechanism, we can change the geographical boundaries served by the regional contractors that process durable medical equipment claims through issuance of a Federal Register notice and make other minor changes in the contract administration of the DMERCs. The mechanism provides a method for increasing or decreasing the number of DMERCs, changing the boundaries of DMERCs based on criteria other than the boundaries of the Common Working File sectors, and awarding new contractors to perform statistical analysis or maintain the national supplier clearinghouse. We will publish these changes and their justifications in a Federal Register notice, rather than through notice and comment rulemaking. Although we may change the number and configuration of regional carriers, we are not altering the criteria and factors that we use in awarding contracts. Through this final rule, we are improving the contracting process so that we can swiftly meet the challenges of the changing healthcare industry and address the changing needs of beneficiaries, suppliers, and the Medicare program.

Microstomia: Aplicação da fotogrametria para mensurar a eficiência da órtese oral associada à terapia fonoaudiológica / Microstomy: Application of photogrammetry to measure the efficiency of oral orthosis associated with speech therapy

OBJETIVO: Esse estudo teve como propósito verificar, por meio da fotogrametria computadorizada, a eficácia do uso da órtese oral como auxiliar na terapia fonoaudiológica. MÉTODO: Após a documentação fotográfica, cada paciente foi submetido a terapia fonoaudiológica, por meio da terapia miofuncional orofacial, associada ao uso da órtese oral, confeccionada segundo Borges et al. (2011). Ao término do tratamento, foi realizado novo registro fotográfico, em seguida, a mensuração da dimensão vertical (distância entre lábio superior/inferior) e horizontal (distância entre comissuras direita/esquerda), com o uso do programa Corel Draw X3. RESULTADOS: As médias da abertura bucal aumentaram da avaliação inicial para a avaliação final, tendo aumentado 5,1 mm no sentido horizontal (67,3 mm para 72,4 mm) e 13,9 mm no sentido vertical (de 32,7 mm para 46,6 mm). Essas diferenças se revelam significativas para as avaliações (p <0,05). CONCLUSÃO: O uso da órtese oral associado a terapia fonoaudiológica demonstrou ser eficaz como mais um instrumento na prevenção da microstomia.

OBJECTIVES: The aim of this study was to through computerized photogrammetry, the efficacy of oral orthosis as an aid in speech therapy. METHODS: After the photographic documentation, each patient underwent speech therapy, through orofacial myofunctional therapy, associated with the use of an oral orthosis, made according to Borges et al. (2011). At the end of the treatment, a new photographic record was taken, then the vertical dimension measurement (distance between upper lip) and horizontal (distance between corners right/left), using the program Corel Draw X3. RESULTS: The mean mouth opening increased from the initial evaluation to the final evaluation, increasing 5.1 mm in the horizontal direction (67.3 mm to 72.4 mm) and 13.9 mm in the vertical direction (from 32.7 mm to 46.6 mm). These differences are significant for the evaluations (p<0.05). CONCLUSION: The use of oral orthosis associated with speech therapy proved to be effective as another tool in the prevention of microstomia.

Orthotic management of the neuropathic limb.

New techniques of evaluation, risk identification, wound product application, and infection control allow limb preservation to be an extremely viable option for the neuropathic and diabetic population. The orthotist specializing in wound care brings off-loading techniques to the clinical setting to allow immediate reduction of pressure to the wound site. By reducing external forces, the ulceration responds to wound care products efficiently, and closure times decrease with optimal outcomes. Following closure, the foot must be accommodated to prevent further breakdown, and regular patient follow-up should be consistent with their risk identification.

Developments in orthotic deweighting technology.

The ability to unload various aspects of the lower extremity has proven a useful orthotic treatment for a variety of pathologies. This article discusses and categorizes various orthotic techniques.

Do pressure relief cushions really relieve pressure?

In a laboratory setting, interface pressures of 29 cushions and a sheepskin were measured on 20 healthy volunteers. Each participant was seated in an upright posture with their back against the back of the chair, hands resting on the lap, knees bent at an angle of 90 degrees, and feet resting on the floor. Only 13 cushions had any pressure-reducing effect. Gel cushions and sheepskins appear to have no pressure-reducing effect. The category of foam includes both cushions that reduce interface pressure very well and cushions that increase interface pressure. The lowest interface pressures were measured on air cushions and on some foam cushions.

Offloading difficult wounds and conditions in diabetic patient.

Wounds in the diabetic population represent a significant medical and economic burden. Early recognition and prompt management can facilitate healing of these wounds. The scope of potential interventions includes debridement, infection control, offloading, protective dressings, active dressings (such as growth factors and living skin constructs), revascularization, proper nutrition, and patient education, If foot pressures are to be reduced, healing to progress, and prevention of ulceration to be a realistic goal, offloading is imperative. The following article discusses offloading of difficult wounds and Charcot foot at various stages of treatment. A user-friendly written and pictorial compendium and an algorithm of care are offered, as well as pedorthic management of foot amputations.

Karomed armchairs and cushions in the prevention of pressure ulcers.

The clinician providing seating for patients who are unwell, who have poor functional ability or who are at risk of pressure sores, is faced with an increasing choice of products. Making the decision as to which product and associated features to choose can be a difficult task. This article describes the importance of suitable seating provision in patients who are at risk and outlines the Karomed range of armchairs.

The Vicair Academy and Liberty range of pressure-reducing seating.

Many patients can be sitting in a chair for between 3 and 14 hours each day, consequently the type of cushion they are sitting on is of the utmost importance. These patients are often at high risk of developing pressure sores--possibly more so than bed-bound patients. Vicair, whose UK distributor is Gerald Simonds Healthcare, has developed two types of pressure-reducing cushions: the Vicair Academy and Liberty Fluid-Air. These cushions offer pressure reduction in a system that is user-friendly and particularly lightweight. This product focus highlights the problems associated with seating and explains how the Vicair range of cushions attempts to address them.