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

3 thoughts on “Why can’t we be friends?

  1. This is actually a big focus of the healthcare robotics course I’m taking right now – something like 75% of hand rehabiliation robots were not tested on end users and were unusable in practice. The professor teaching the course is bringing in stakeholders like patients, clinicians, and FDA workers to talk with the class about the problems they face and so that we can get feedback on our concepts (would this be useful, how could we improve this idea, are there any challenges you could see with using a device like this) which is really helpful, but this approach is limited in that we only get to talk with people that we or the professor know. We saw this constraint with the first set of stakeholders we saw – two multiple sclerosis patients – who both said that they were way more active (running, surfing, etc.) than the average MS patient and so some of their needs/observations wouldn’t apply to the general MS patient.

    Do you have any ideas on the best way to get feedback from a wider audience in the healthcare field during the concept generation and initial design phases? it seems like this would be a reasonable first step to connecting engineers with the end-users of their products.

    Liked by 1 person

    • This class sounds amazing! I’d love to hear more about it sometime.

      In terms of orthotic/prosthetic intervention, I would reach out to patient interest groups that relate to the population you are looking for. For example, the Amputee Coalition of America has a HUGE member base, or the National Multiple Sclerosis Society has local chapters in cities across the country. They might be a good start to see if you can find local patients who might be interested in volunteering their time for a focus group or interview!


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