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Prosthetics and orthotics

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Matt Smith:

Welcome to a La Trobe University podcast. I would be your host Matt Smith and my guest today is Rowan English, Head of La Trobe's National Centre for Prosthetics and Orthotics. Prosthetics and orthotics are an important area of health and the Centre teaches students to design, fabricate and fit and align a variety of artificial limbs.

Rowan English:

The National Centre for Prosthetics and Orthotics at La Trobe Uni is the only one of its type in Australia and indeed in the greater geographical region. The Centre provides an educational program to train prosthethists and orthotists who will work in the health sector as clinicians. We undertake various research activities related to the area of prosthetics and orthotics and are involved in other external educational programs. Prostheses are artificial limbs and we deal only in limb prostheses, we don't deal with surgical prostheses or cosmetic facial prostheses for example. Predominantly the clients of our graduates are lower limb amputees, although there are a number of upper extremity, or arm amputees as well. So we train our students to be proficient clinicians who can work in health teams and provide prostheses to people who require them. Orthoses are supportive devices for people with muscular skeletal deficiencies or difficulties or injuries. For example, it might be something as seemingly simple as a foot orthosis to someone who has an arthritic condition in their foot. It might be something as complex as a halo orthosis which would hold someone's head in place after they've had a high level spinal injury. And all sorts of things in between. A lot of the work again is in the lower limb. It could be something like an ankle/foot orthosis for someone who has had a stroke would require to be able to get up out of bed and be able to try and walk again before returning home. So, in essence, our graduates will work with disabled people who might be in hospital, rehabilitation-type situations, it might be in situations in developing countries, it might be in private practice, dealing with long-term amputees or long-term users of orthoses.

Matt Smith:

I take it that the students that are coming out of your courses that need diagnosis skills, they'd need counselling skills of some sort or at least be good listeners and communicators that way, right through to, given the technology that you're putting on them, some sort of basic mechanic or handyman. Is this the sort of skills that your students are coming out with?

Rowan English:

Absolutely. It's quite a mix. The program is part of the Faculty of Health Sciences so the students are grounded in the basic health sciences with all the other students within the faculty – anatomy, physiology, neuro-anatomy, aspects of health pathology and all those basic health sciences skills are required. Also of course there's the, as you rightly put it, the mechanical side of things. So it's an engineering-based aspect to that. New technologies coming through all the time – the students are taught very much to have a continued learning pattern once they graduate, because we will have so many changes over the years. For example, for those people who graduated in the early 80s, there were something like 120 knee mechanisms available for above-knee prostheses. Now there are over a thousand. And a lot of those, particularly the high-end ones, are computer controlled, so students need skills with fitting those and being able to manipulate and program those knees to work to their best ability.

Matt Smith:

So how advanced is the technology that you are putting on people these days? These knees are programmable so it's not really something that's just attached there to look like a leg. Is it designed to move and function like a leg?

Rowan English:

For something like a knee mechanism for above-knee prostheses, yes, it's designed to move and function like a leg. At the moment, most of these high-end devices that we're putting on will replicate walking to a fairly high degree. They're not active, in that they don't provide muscle activity for walking upstairs for example, but they will be coming. There will be legs in the future that will be able to do things like that. So the sort of legs that people are making for clients who require them have a series of components within them and they are effectively built out of a modular system. So our graduates will be able to thoroughly assess the client, then we take an appropriate mould or cast or image of the residual limb, then they build the socket or the interface so the socket is effectively the mechanical interface with the human body. That needs to be correct and then they put all these other components on so they will attach a knee, attach a lower leg and an appropriate ankle and foot. And there are different sorts of components for different activities. And some of them are expensive and some of them are fairly cheap. It sort of depends on the budget or the insurance level available as well as to what clients will get. The upshot is that the students need to build the mechanical interface, then align all the components and adjust them for the best walking in the situation that that client will be involved in.

Matt Smith:

So it sounds like every prosthetic that the patients get is unique and built from scratch.

Rowan English:

Every prosthesis is totally unique, so there's no off-the-shelf stuff. They need to be individually designed and fitted. Also, because the human body constantly changes over time, so they need to be adjusted and monitored over time as well.

Matt Smith:

Is it going to get to the point in the future where people who have prosthetic limbs actually work better than if they had the limbs they were intended to have?

Rowan English:

I suspect, yeah, we're not quite going to get to the six million dollar man scenario where they're fitter, stronger and faster. The natural limb is so much better than the artificial one. It's interesting because that brings up the point that was discussed some time ago in the last Olympics and Paralympics with the South African fellow, Oscar Pistorius, an athlete who is missing both limbs below the knee. There was lots of discussion and lots of bio-mechanical analysis and so on around that time because he could sprint almost as quickly as the elite level able-bodied athletes. And so there was discussion around whether he actually had an advantage by having prostheses. It was shown that he certainly didn't have an advantage. He didn't have the active muscle push-off, he's just a very gifted athlete.

Matt Smith:

How long does it take a patient to be able to learn how to use it properly? And what sort of rehabilitation do they need to go through?

Rowan English:

OK, so we're getting into the detailed clinical aspects here. It varies so much from person to person. For example, someone, and it's usually an elderly person, will go in and have a limb amputated below the knee for example, because they've had some problems with blood circulation. They could be diabetic, they could have peripheral vascular disease or some other issue which required a lifesaving amputation. Someone like that would be fitted with a prosthesis around three weeks post-operation, sometimes a little earlier, sometimes a little later, depending on complications, and would be able to functionally walk within about another three to four weeks and be able to go home. We're able to get people home from around five or six weeks post amputation, walking functionally on a prosthesis.

Matt Smith:

That's really good.

Rowan English:

So it's fairly quick. It certainly has happened a lot more rapidly in individual cases, and in other cases it's taken a lot longer. But those are the average sorts of times. Of course it's early days and that residual limb, the remaining part of the limb, will change significantly over time. So that person will then be monitored at least two or three times a week for a period of time before that is reduced in the longer term. If it's someone who's young and healthy, they can be up and walking very quickly. If there are other complications like other broken bones or breakdowns or problems with wound healing, it will consequently take longer.

Matt Smith:

I've seen people with prosthetic limbs that are fitted and are unique, depending on what sort of use that they want, so they in essence become a bit like a Swiss Army knife, if you want to look at it that way, with a rock climbing specific one, so it's a bit like a pick axe sort of thing. How much customisation do you get in prosthetic limbs like that?

Rowan English:

Oh, look, there's a lot of different requirements so there's quite a bit of customisation in particular individuals. Most people don't require customisation. They might have one prosthetic limb for walking around, they may have another one for showering, a waterproof one. Others who are very active will have perhaps a running leg, or two or three different running legs, a swimming leg, as you said, something for rock climbing, it's possible to have different terminal devices which are the bits that go on the end of an arm prosthesis, that are better for swimming or playing golf, or a cosmetic hand that is functional, a split hook that is useful in rougher situations. So there's a whole lot of different customisation that can go on. Again, looking at some of the athletics area – paralympians come up with all sorts of different devices, different legs for cycling for example – less wind resistant, direct input of power into the bicycle, an endless array of different designs.

Matt Smith:

Do the people who run the Paralympics struggle with how to classify those sort of things and decide what goes and what doesn't?

Rowan English:

Well, the classification in the Paralympics is related to the level of disability. So the type of limb that people are able to use is pretty open in a lot of ways. So running limbs – it's fairly standard that people are using high tech carbon fibre spring type limbs for running. There are different designs for cycling. Some will use a standard limb with a normal foot that's clipped in, like any other cyclists, and others will have special light-weight limbs and as far as I know at this stage there's no regulation around that.

Matt Smith:

Usually, when you think of a doctor or somebody who practises in the medical field, they don't have a tool kit with them. They'll have other diagnosis sort of stuff. So what do you have in your tool kit?

Rowan English:

What is in there? That's a good question. It's a combination of things. And that is interesting. For example, to fit a prosthesis or an orthosis well, in most cases they're custom made. For the orthoses, there are a lot of off-the-shelf items that are available that can be adjusted and fitted to a person, but a lot of them are again I would say, custom-made. So one of the tools that people would particularly use – there are a couple of types of carving tools that we would generally use on plaster models of that part of the person. There's a bit of art to that, but it's also a fairly scientific process, to be able to load up those parts of the body that can take load and reduce it in other areas. So we're either able to control that part of the limb in an orthosis, or control the attachment of a limb within a prosthesis. So that's probably the most unique thing – that we actually have to carve this material and we have these various carving devices, which really are effectively glorified woodworking devices, much in the same way that you could say that orthopaedic surgeons use glorified carpentry tools in some ways. We do a similar thing but we work with plaster models, and other materials.

Matt Smith:

Part of the Centre's work is to teach other areas, in developing countries. What sort of challenges does working in this environment present, and what sort of work have you been doing overseas?

Rowan English:

We've been involved in a program which has recently finished – teaching graduates of a program based in Cambodia. Graduates of that program then come into a distance program that we run at La Trobe. We upgrade them up to a level of skill of our domestic graduates. Some of the challenges within that, and I guess it's twofold. One has been dealing with distance education, and that requires in some cases us teaching over there, and also having the students come over here for a short period of time. The other thing is being able to align our program with the requirements of students from developing countries. In that program, for example, we had students from a lot of surrounding countries, including Pakistan, Cambodia, Lao, Vietnam, the Philippines and Sri Lanka. So all of these countries have some different requirements, have different health systems, have different level of access to prosthetic and orthotic services, but all have a very great need for these people. We're lucky enough to have on staff some people who have spent a lot of time working in those areas, so they've been able to influence our work, but we also want to make sure these people are upskilled and understand what goes on in the ideal situation, as well as having a very good strong theoretical underpinning of their knowledge and their ability to continue to learn and adapt that learning to their individual practice.

Matt Smith:

Does working in those areas present some unique challenges at all?

Rowan English:

Absolutely. So if for example we were running a practical exam in Phnom Penh, in Cambodia, and one of the issues in that particular area is power. So we're part way through a clinical exam in an air conditioned room and the power goes off. So it's a matter of dealing with obstacles like that. Other obstacles are things like the climate. A lot of humidity, a lack of more high tech production equipment that we might use, and some of the materials we use don't work as well in high humidity climates. So we need to make adjustments. We can't just say, for example, use the stuff we use in Queensland, because they have lots of air conditioning and they just use the same stuff indoors. There are also some transportation issues. There are a lot of equipment and materials it's hard to get in those areas, so we have to adjust some of our teaching because of that.

Matt Smith:

That's all the time we have for the La Trobe University podcast today. If you have any questions, comments or feedback about this podcast, or any other, you can send us an email at podcast@latrobe.edu.au. Rowan English, thank you for your time today.

Rowan English:

Thank you.

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