Why can’t we be friends?

Engineering vs. Orthotics ‘n’ Prosthetics: Where’s the Disconnect?

During our Lower Limb Orthotic Management II course, we were assigned to read a series of “State of Science” review articles discussing knee-ankle-foot-orthoses (KAFOs). There articles assessed the efficacy, prevalence, and overall status of KAFO use from a variety of perspectives, including biomedical engineering, physical therapy, physical medicine and rehabilitation, and orthotic management.

All of the perspectives generally shared common areas of importance for KAFO use in patients: the patient’s individual goals, improvement in gait, and a thorough initial evaluation. All of the perspectives also expressed a desire for more evidence to support the standards of care and guide future clinical decision making.

The perspective that interested me most, however, was the biomechanical engineering perspective. My undergraduate degree is in biomedical engineering with a concentration in biomechanics, so I can definitely put myself in that mindset to think like an engineer. When assessing the engineering perspective on knee-ankle-foot orthosis usage, the priorities discussed in the article included materials science, component selection, and integration of new technology.

These are all great priorities: KAFOs are notoriously heavy to wear, and any materials that could decrease the weight of the device could improve patient acceptance, compliance, and satisfaction. When thinking about integrating new technology, powered exoskeletons come to mind. However, I won’t be providing any exoskeletons to my patients for a very, very long time. I can’t. They are too expensive and there is not enough evidence to support their use at this time. But that’s what you see on TV and on Facebook – and rightly so, because it’s COOL! And it’s great to see people who previously could not walk and are now back on their feet again, no matter what device helped to get them there.

However, there is often a HUGE disconnect between engineering research & development and clinical care, especially in the areas of orthotics and prosthetics. This amazes me, because in my engineering design classes, we are taught that user needs are the primary driver for developing a new product. As orthotists and prosthetists, we have many, many user needs that are not being met. Instead, technology is developing in a different direction – often in a direction we didn’t even ask for.

Rather than adding another gyroscope to the internal sensors of a microprocessor-controlled knee joint, could we instead improve motion-activated stance-control KAFO mechanics? Now, don’t get me wrong – there are patients who could benefit from both of the developments I just mentioned. I would love to improve EVERY SINGLE aspect of orthotics and prosthetics care to improve my patients’ lives. I’m not saying to stop any research or development that is currently in progress.

What I am saying, though, is to even the playing field. Let’s not just focus our efforts on the high-tech, state of the art, fancy components. These components are not indicated for every single patient that comes in the door. Some of my patients will need a simple drop lock to control the knee joint of their orthosis, whereas others will benefit from a gravity-activated sensor to control the knee joint. Drop locks are seriously overdue for an overhaul, I’m just putting that out there.

I think the misconception is that more technology, more computers, more sensors, more expensive STUFF automatically means better outcomes for the patients. This is wholly untrue.

Every single one of the patients who walks through the door is a person, a unique individual with their own goals, values, perceptions, and method of interacting with the world. This means that their orthotic or prosthetic needs will be very different than another patient, even if they have the same diagnosis or presentation. There is no one-size-fits-all in our field. Some patients value function over cosmesis. Others prioritize certain activities or motions. It’s crucial for an orthotist or prosthetist to investigate your patient as you evaluate for a device; what factors will make or break this for them?

My suggestion, then, because you shouldn’t talk about a problem unless you are ready to offer a solution, is to increase the communication between those completing the research and development for new devices, and those caring for the patients who will be receiving those devices. It’s a two-way street, so don’t think I’m blaming either the engineers or the clinicians – there are areas of improvement both ways!

Could manufacturers make an effort to gather clinician feedback about their products? Could it be possible to host focus groups to gather opinions?

Could clinicians complete and then share research as they treat patients, in order to gather data about usage that will help engineers as they revise a design?

I’m not sure what the right answer is, but I know that I will work to bridge the gap between engineering design and clinical care.

I want a future where design development is driven by clinical care, and clinical care is driven by the development of new technology.

© Cara Yocum | Heads, Shoulders, Knees, and Toes 2017

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Not a Doctor

“So, what is it that you do, actually?”

“I’ve never heard of that!”

“So like, bionic arms and stuff, right?”

“Oh, like foot orthotics!”

I love the challenge of trying to explain to people what a prosthetist or orthotist is. Since we are such a small field, it’s very rare that someone will recognize or understand what I do! Part of a big, huge, lofty goal of mine is to increase the general public’s knowledge and understanding about the field of prosthetics and orthotics – and this blog is my first step. So again, thank you for being part of my journey!

We actually had to memorize the definition of an orthotist for one of our exams (hey, thanks Sally!), so I’m gonna drop the textbook definition before we get started. An orthotist is a person who, having completed an approved course of education and training, is authorized by an appropriate national authority to design, measure, and fit an orthosis. And similarly for a prosthetist, who is able to design, measure, and fit a prosthesis.

So even though I’m attending a medical school, I will not be a doctor when I graduate (though we do wear white coats occasionally – don’t let it fool you!)

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My first fabrication project partner with our thoracic-lumbar-sacral orthoses for pediatric patients! We wear our white coats to see our patient models to help us get in a professional mindset.

I’ll have a Master of Science degree in Orthotics and Prosthetics, and once I sit for (and pass!) my board exams, I will be a certified prosthetist/orthotist. I’ll be a practitioner, but not a doctor.

As a prosthetic and orthotic clinician, I’ll be working in a team of healthcare professionals. This is one of the things I love about O&P – in order to help our patients achieve success, specialists in different areas must work together. A physician is often the head of the team – they are responsible for overseeing the entire rehabilitation process. The physician will write a prescription for an orthosis or prosthesis – and that’s where I come in! The patient may also receive care from a physical therapist, occupational therapist, speech therapist, a psychologist, a neurologist, an orthopedic surgeon, a vascular surgeon, and more. Similar to positions on a playing field, each member of the team is responsible for their own specialty.

One of our professors like to say that O&P is the perfect marriage of people and stuff. This is why working as an engineer right out of undergrad just wasn’t going to work for me. I need to help people, and in this field, I get to work with people, and I get to make the “stuff” that will improve their lives, whether that is an orthosis or a prosthesis. As a prosthetist/orthotist, my responsibility and my specialty on the healthcare team is the patient and the “stuff” we provide to them. It’s super crucial to me, however, that the patient comes first – before the cool stuff.

Taking time to understand the patient as a person, not just the device they’re receiving, actually makes me a better clinician. Once I understand the person sitting in front of me, I can design the device just for them. How cool is that?!

If I know that my patient likes to golf on the weekends, I can ensure that the prosthetic foot I provide will allow for the rotation that comes with swinging a golf club. If I know that my patient wears dress shoes with a one-inch heel to work every day, I can ensure I provide an ankle-foot orthosis that functions in accordance with that heel height.

So even though I’m not a doctor, and I cannot prescribe medications to manage my patient’s nerve pain, I still have an obligation to talk to them about it, to figure out how their prosthesis or orthosis may be affecting their pain, and to make the patient feel validated and heard. Often our patients are juggling so many different appointments and different providers; it’s easy for them to feel a little lost. I like knowing that by taking the time to get to know my patients, rather than just knowing the device I will provide to them, I can help them feel a little less lost, a little more found.

So I’m not a doctor, but I will be a healthcare provider, and I cannot wait to make a difference in my patient’s lives.

Stay tuned for more posts about what prostheses and orthoses actually are, and the magic that goes into designing them! Thanks for reading!

© Cara Yocum | Heads, Shoulders, Knees, and Toes 2017

How Snowboarding Helped Me Survive Grad School (in Texas…)

If you read my About Me page, you’d see that I love, love, love to ski and snowboard in the winter. I had the opportunity to teach both skiing and snowboarding to kids in the Children’s Learning Center at Liberty Mountain, a resort near my home in Pennsylvania. I love working with kids, and I’d love to work in a pediatric patient care setting in the future as an O&P clinician, but I’d also love to volunteer with adaptive snowsports in the future as well.

This was taken on a family vacation to the Canyons in Park City, Utah!

I inherited my love of skiing and snowboarding from my father (if you’re reading this, thanks Dad!) who is an clinician, supervisor, and instructor at the resort as well. My dad taught me how to both ski and snowboard, and when I got older, he also taught me how to teach. I learned all about the progression of a lesson, from how to relate to your students to how to analyze movement while a student is completing a turn. While these lessons from my dad helped me to be a better instructor, they also helped me be a better orthotics and prosthetics student.

It sounds crazy, I know! Just stick with me, okay?

When we teach a student to complete a freestyle move (think rails, jumps, boxes, half pipes, all the fun stuff…) we use the acronym ATML, which stands for:

Approach, Takeoff, Maneuver, and Landing.


Like this guy, any student must Approach the feature in a way that prepares them for success.

Takeoff is the moment before the magic, and by mastering a takeoff, you ensure that you are in the correct position, physically and mentally.

Maneuver is actually doing the trick, and Landing is making sure the student completes the trick safely and continues down the mountain.

All four components are crucial to making sure the student learns to complete a skill safely and effectively. Sounds simple, right? [Side note: all of this snowboarding talk is totally making me miss the snow…we didn’t get much in Texas this winter!]

When taking an orthotics or prosthetics management course at Baylor (we call them “core” courses), we eat, sleep, and breathe that subject matter. We are in class every day from 8-5, either learning in didactic lecture or completing fabrication projects in lab. When I started my core courses, I often felt overwhelmed with the sheer volume of information I was getting shoved into my brain every day. I also felt a disconnect between lectures and labs, and as a result, I felt lost when it came to fabrication projects. I needed a way to organize my thoughts and plan my steps. What did I do? I used ATML!

When approaching a project, I found it useful to go through lecture information and make note of any relevant information that I would use for my projects. This could include trimlines, which are measurements about where an orthosis or a prosthesis will end on the body. For example, the standard medial and lateral trimlines for a total surface-bearing prosthetic socket should end approximately 65 mm proximal to the mid-patellar tendon for an initial fitting. In my approach, I would write down any technical information that I would later use in fabrication. Other information that would go in my approach include any information about my patient model, like their shoe size.

In takeoff, I would write each of the steps for the fabrication. For anyone who is familiar with fabrication, this is often subjective and a little different for each person! But the beginning of a sample progression might look like taking a cast of your patient, then filling the cast with plaster, stripping the cast away to leave the positive mold, and then smoothing the mold. It helps me to have a plan of attack, and by communicating with my professors and my classmates, I was able to write a personalized plan of attack for my projects. Plan your work and work your plan!

Shout-out to my awesome partners for a great cast!

This cast was taken to start our KAFO projects – a knee-ankle-foot orthosis! Time to make a plan!

In my maneuver, I would complete the steps I outlined in the takeoff. Easier said than done, I promise. Fabricating an orthosis or a prosthesis is an art! Now, I OFTEN have to ask for help throughout the course of a project (thanks to all of my amazingly patient professors – yall rock and I’m so grateful), but I find that it’s helpful to know at what stage I am in the process, and what my upcoming stages will be.

Finally, in my landing, I TRY to always debrief after a project. I reflect on what went well, and what could have gone better. I say try because it doesn’t always happen. I get busy! But a lot of our professors will have us complete self-reflections or group critiques following our fabrication process, so we can learn from each other, which I love. I honestly am so thankful for the wisdom I learn from my classmates, each and every day. But the benefit of landing is that you can make improvements for the next maneuver. I find myself taking tons of notes from these critique sessions that I will be able to use in my plan of attack for the next project I tackle.

So, I definitely find myself using ATML for fabrication projects, but it could also be used for patient interactions as well:

ATML for Patient Interactions:

Approach – What is the patient coming in for today? What am I planning to do with them? I’ll review any notes from the previous visit in this step.

Takeoff – Do I have the necessary supplies in my pocket or in the room? Do I have all materials to complete my outcome measures?

Maneuver – Hi Patient! We’re going to take a cast…take some measurements…fit a check socket…complete a follow-up… Just do what you do best!

Landing – Does the patient understand what was completed during the visit today? Do they have all of the tools or supplies necessary for success? What are the next steps? The clinician’s notes will be documented in this stage as well.

The possibilities are endless for using ATML as a student, as a resident, or as a clinician. It has been working for me so far in an academic setting, but I’m looking forward to applying it during residency!

Question for my readers: What do you use during the day to organize your work flow? I’d love to hear what helps you find success in whatever you do.

Thanks for reading!

© Cara Yocum | Heads, Shoulders, Knees, and Toes 2017

Finding a Multi-Articulating Passion

Hi y’all!

This article previously appeared in the Student Newsletter, published by the Student-Resident Committee of the American Academy of Orthotists and Prosthetists. I had so much fun writing it; it definitely kindled my interest in writing a blog, so I thought I’d share it here.

Before starting my master’s degree program at Baylor College of Medicine, I shadowed at several orthotic and prosthetic practices. However, I had never observed an upper-limb amputee patient. It certainly is an understatement to say I was nervous and unsure about what I was getting into when starting our upper limb prosthetics course. While taking a core course at Baylor, you eat, sleep, and breathe the subject matter, because we have only one year of didactic curriculum. Our instructors fondly describe it as “drinking through a fire hose”.

During our upper limb prosthetics course, we evaluated, designed, and fabricated both transradial and transhumeral prostheses, thanks to the help of our generous patient models. The transradial prosthesis project was a turning point in my orthotic and prosthetic education, and certainly in my future O&P career. To me, this project is where it all came together. It all clicked, and I fell even more in love with the field of orthotics and prosthetics!

For the project, we had been tasked in teams with evaluating, casting, myotesting, and fitting a myoelectric-control transradial prothesis with a multi-articulating hand. Again, to say I was overwhelmed was an understatement, but I quickly learned that I had more tools to solve this problem than I originally thought.

muscles forearm

Forearm Musculature

In our gross anatomy lab, we learned about the extensive network of flexors and extensors in the wrist and forearm. It was meant to increase our understanding of the musculoskeletal system. At first it seemed as though we were simply memorizing a complex pattern… until it came time to find our patient’s electrode sites for myotesting. I had to locate live muscle bellies and optimize the myoelectric signal strength in order for my patient to safely and easily use his prosthesis. The information that had once been static suddenly became dynamic, working knowledge.

I studied Biomedical Engineering as an undergraduate, and in our Bioinstrumentation course, we learned all about signals – digital, analog, gain, rectification, and threshold. It was interesting and important, but to me, it felt a little arbitrary and distant from direct patient care. However, when we were myotesting, I finally understood gain and threshold fully – by changing these values, I had the ability to make it easier or harder for my patient to operate his prosthesis by modifying the signal his muscles were creating. My control of the signals directly impacted the patient’s ability to function.

Example of signals from myotesting

Example of signals from myotesting

When it came time for the final fitting, our patient absolutely amazed the team – he was able to easily produce “open,” “close,” and “hold open” signals to complete tasks, as well as double and triple impulse signals to change grip patterns. He was using spray bottles, operating a hand drill, holding a fork and knife – complex tasks, all while wearing a smile. He was able to give us extensive feedback on what was easy, what was hard, and what he would change about the hand.

In addition to the actual prosthesis, as part of the transradial prosthesis project submission, we also were tasked with creating a packet of documentation to send to the patient’s “insurance company” (our professors) in order to be “reimbursed” (our grade). I learned how to write a Letter of Medical Necessity to prove that my patient needed this device. I loved getting to “fight” on behalf of my patient to explain how a multi-articulating hand would improve his dexterity, function, and overall quality of life, and therefore should be covered.

While I’m still not sure where I want to specialize in an area of prosthetics and orthotics, or if I want to specialize at all, my transradial prosthesis project truly was a “lightbulb” moment – I was able to combine knowledge from to a real-world problem in my present, and I absolutely cannot wait to continue solving these problems in the future. As a prosthetist/orthotist, I have the opportunity to utilize my interests in engineering and anatomy. I can use my hands to create a device that will change my patient’s life, and I can use my words to prove to a payer that my patient needs a certain device. With the tools provided to me by my instructors, my classmates, and my patient models, I am looking forward to putting the world at my future patients’ fingertips.

© Cara Yocum | Heads, Shoulders, Knees, and Toes 2017

Welcome to Heads, Shoulders, Knees, and Toes!

OH MY GOSH. Hi! Hello! Hi!

I am so dang excited to be writing my first blog post, y’all! I never actually thought I’d be writing a blog…so thanks for everyone who pushed me to do it!

Welcome to Heads, Shoulders, Knees, and Toes!

I thought I’d start by explaining a little behind the name of my blog: Heads, Shoulders, Knees, and Toes. As an orthotist-prosthetist, I will have the ability to influence or control motion in any of those areas. Whoa.

When I take a step back and think about it, I’m always amazed at how stinkin’ awesome my job is (okay, will be…still have to make it through residency to get a job…) and how lucky I am to be learning and training in such a rewarding profession.

I can help an infant’s skull grow into a normal shape with the use of a cranial remolding orthosis. I can help a patient immobilize their shoulder with an orthosis following a rotator cuff repair. With the help of microprocessor-controlled prosthetic knees, patients can achieve stability during their gait while walking on their prosthesis. By choosing the material or thickness of a toe plate of a foot orthosis, I can relieve pain in a patient’s toes. Check out the slideshow of the different devices below:

By doing all of these things, I can help to improve a patient’s quality of life. Again, HOW COOL IS THAT?!

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Products Shown:

If you can’t tell, I absolutely love what I do, and I can’t wait to share it with you. If you want to know more about me, head over to the About page.

In the upcoming posts, I’ll be writing more about what, exactly, a prosthetist-orthotist does, and the cool devices we work with – so stay tuned! If you have any questions, shoot me a comment below or head to the Contact page.

Be sure to head up to the top-right corner of this page and hit “Follow” to subscribe to my posts! No spam, I promise, you’ll just get an email each time a new story is posted to my blog. I really appreciate you all – I’m so excited to write for you!

© Cara Yocum |Heads, Shoulders, Knees, and Toes 2017