A lot has changed in terms of the way we work as a result of the Covid pandemic. Some of these changes have been beneficial and others less so.
Many sales people within our industry were furloughed for a long time, which then developed into extended periods of isolation working from home. For some this has become the norm, with much rarer outings into the field. Although necessary at times, I am not convinced this is good in the long run, as we are social creatures by nature and need that real life contact with others. Especially when this critical role is all about building a close network.
For a company like Brace Orthopaedic that specialises in distributing more innovative and technical orthopaedic braces, we also found that the medium of sales presentation through webinar just didn’t suit our products. In my opinion there is no substitute for a face-to-face meeting, with clinicians getting ‘hands on’ the product and going through its intricacies, whilst also having the opportunity to ask spontaneous questions.
Developing this theme, I think there has been a real evolution over the last few years in the role of what has historically been termed a ‘sales representative’. I have never liked this title, as I believe for those that carry out this role to its full potential, they are just so much more than ‘order prompters and takers’.
Sales people have come under the spotlight during the pandemic, as all businesses have had time to truly asses the value and role of these people. The result of that multi layered analysis has been that some individuals have looked for a career change, whilst some companies have come to the conclusion that product presentations through online platforms mean that this traditional role has become a luxury and so can reduce their head count and costs as a result.
Personally, I see high quality people in these roles as absolutely invaluable to a business like mine. I have ensured that my external team have stayed as involved as possible throughout the pandemic and been instrumental in strategizing our plans as the market opened up again.
More importantly, I have never considered my external team as sales representatives, but more as clinical educators. Our portfolio of unique products is deliberately smaller, as I would prefer to offer clinicians products that offer something innovative and different to consider as part of their clinical practice. We will always seek to add value to the Orthotics proposition. It is therefore vital that both my internal and external teams know every detail regarding features & function and should be equally comfortable presenting this information in person or over the phone – a real skill.
I have seen this trend growing over recent times and as a tight knit industry I am delighted to see so many high-quality individuals delivering this role for their respective companies. I would go as far to say that many of our orthotic product distributor friends in the industry have moved their sales teams far more towards clinical education.
I think the days of the bracing ‘catalogue companies’, with vast product ranges promoted by sales representatives who only truly know the inner details of a fraction of these products are over. Long live the clinical educator……
If you would like to learn more about Brace Orthopaedic’s range of innovative orthoses or indeed arrange a product demonstration, then please contact Customer Services on 0191 258 8944 where Cathryn or Iain would be delighted to help. Alternatively, please visit our website at www.braceorthopaedic.co.uk
“We are facing a secondary pandemic of neurological disease…“
Since the start of this pandemic it has become ever clearer that Sars-CoV-2 is not just a turbo-charged common cold, it’s quirky, unusual and at times has terrifying traits. Most viruses have U shaped mortality curves, killing young and old alike. But Sars-CoV-2 typically only causes mild symptoms in children. The novel coronavirus also disproportionately affects men: up to 70% of people admitted to ICUs worldwide are male. However, 3 female children have already been through my clinic with multiple organ dysfunction secondary to Covid-19 complications, leading to PNS issues and more specifically, complete peroneal palsy.
Some early data on manifestations show that Encephalopathy, Encephalitis and Guillain-Barré syndrome, and additionally SARS-CoV-2 has been detected in the CSF of some patients. More recently the media have revealed more quirks, with many Covid-19 patients whose only symptom is confusion without cough or fatigue. Another anomaly is ‘Happy Hypoxia’. A typical blood saturation is 98%, below 85% should lead us to a loss of consciousness, coma or death and yet many Covid-19 patients present with saturation levels below 70% to 60%, yet are fully conscious and cognitively functional. Anosmia and ageusia are common and can occur in the absence of other clinical features.
It can be said with some certainty that the last months have led us to believe that Covid-19 is extremely heterogeneous in presentation. Alarmingly, published evidence reveals that Sars-CoV-2 could cross the blood-brain barrier, often thought to be coincidental as it is extremely rare; are now deemed not so. The brain is normally shielded from infectious diseases by the blood-brain barrier – a lining of specialised cells inside the capillaries running through the brain and spinal cord. These block microbes and other toxic agents from infecting the brain. If Sars-CoV-2 can cross this barrier, it suggests that not only can the virus get into the core of the central nervous system, but also that it may remain there, with the potential to return years down the line.
‘The virus’s impact on the nervous system could be far larger and more devastating than its impact on the lungs’.
Predominantly a respiratory disease, neurological manifestations are being recognised increasingly. On the basis of knowledge of other coronaviruses, especially those that caused the severe acute respiratory syndrome and Middle East respiratory syndrome epidemics, cases of CNS and peripheral nervous system disease caused by SARS-CoV-2 might have been expected to be rare, but this is not the case.
We have to be careful to log what is either direct or indirect causation from the Virus, hypoxic encephalopathy and critical care neuropathy spring to mind, but it is still worth including infectious, para-infectious, and post-infectious encephalitis, hypercoagulable states leading to stroke and acute neuropathies such as Guillain-Barré syndrome, as these are all going to fall into needing some form of treatment by an AHP. To date I have had to deal with 2 GBS patients and complete Brachial plexus injuries due to central line complications.
The challenges are recognising neurological disease associated with SARS-CoV-2 in patients who are mild or asymptomatic, especially if the primary COVID-19 illness occurred weeks earlier. The proportion of infections leading to direct neurological disease will probably remain small, but these patients may be left with severe neurological sequelae.
With so many people infected, the overall number of neurological patients and their associated health burden, social and economic costs might indeed be large. Although neurological complications are rare in SARS, MERS and COVID-19, the sheer scale of the current pandemic means that even a small proportion could build up to a significant number of cases.
The minimum prevalence of CNS complications ranged from 0·04% for SARS to 0·20% for MERS, whilst PNS complications ranged from 0·05% for SARS to 0·16% for MERS. Extrapolate these numbers of cases with neurological complications of COVID-19 with the approximate 12.5 – 15 million cases of COVID-19 globally at time of writing, then prevalence runs at around 6 – 30k patients with CNS complications and 7.5 – 24k with PNS complications. These numbers, which do not include the increasingly important syndromes of stroke-associated COVID-19 infection, will rise as the pandemic continues and we are looking at the Americas here in particular!
NHS planners should take note and policy makers must prepare for this eventuality. I’ll be completing my 3rd weekly ‘Covid clinic’ this week of in-patients requiring Orthotics on our specialist neurological rehab wards. This is one relatively small hospital in the UK that can sustain a clinic just from the Covid-19 fall out weekly. It’s a sobering experience. Not everyone is ‘walking out’ a survivor on discharge day.
The biggest shock is acute cerebrovascular disease emerging as an important complication, with cohort studies reporting stroke in 2 – 6% of patients hospitalised with COVID-19, which takes us to around 60 – 180k. Again, I have personally had 2 of these cases in the past week.
In one national registry of 125 patients with COVID-19, neurological or psychiatric disease was reported over a 3 week period, 31% patients had altered mental status and 18% with a neuropsychiatric diagnosis, including psychosis and dementia-like syndrome. Notably, 62% of patients had a cerebrovascular event: 46% ischaemic strokes, 7% intracerebral haemorrhages, <1% CNS vasculitis and 8% other cerebrovascular events. Hypercoagulable states and cerebrovascular disease which are seen rarely for some acute viral infections, are an important neurological complication of COVID-19. An expectation that 50–80% of the world’s population might be infected before herd immunity develops could easily see patients with neurological disease increase. Neurological complications, particularly encephalitis and stroke, can cause lifelong disability, with associated long-term care needs and that inevitably means Orthotists along the way.
We would like to broaden the conversation and hear from other clinicians who have had interesting Covid cases to treat….
The Industrial Internet of Things (IIoT) has most definitely hit the medical devices industry and that also means Orthotics. If you have never heard of IIoT I suggest you look up a definition and no, this isn’t something from a Black Mirror storyboard.
A small part of this will be computational twins, which have existed for decades with companies like Dassault Systèmes, or others you may have heard of like NASA. What started with aircraft engines, is now heavily underway with organic matter.
A digital twin is a computer program that takes real-world data about a physical object or system as inputs and produces an output of predications or simulations of how that physical object or system will be affected by those inputs.
The leap from R&D into real world cloud applications is gaining huge momentum, with several companies now completing Series A staging. As we become more plugged in and naively use various mediums to track personalised health biomarkers, the future is either rather depressing or utopian, depending on which side of the huge ethical AI fence you sit. This data will correlate directly with your projected death date, which in turn correlates to your pension, insurances, healthcare provision and so you’ll easily comprehend how AI, 5G, wearables and biomarkers will shape the future.
The release of virtual human body twins in a platform; brings
together biosciences and engineering, enabling a stakeholder to project the
data for an object into a complete living virtual model that can be fully
configured and simulated. This is potentially ground breaking to the med tech
industry, researchers, clinicians and even patients who can visualise, test,
understand and predict the unseen. From
pharma with disease, surgical outcomes and even the medical device industry, as
these Orthoses transition to wearables.
Companies like Computational Life, a digital avatar platform,
are principally engaged in cardiac research and development of medical devices
in pre/post clinical phases. They have now pioneered what is likely to be the
future, by converting their virtual models into an exact replica of the patient,
by overlaying actual MRI scans of patients over their model, allowing the
digital twin to possess all of the vascular features of the patients, to then
track blood flow and organ response.
The above will be an absolute must in order to understand the
effect of medical devices on the whole body. A chief complaint of many
clinicians and certainly in Orthotics, is that no matter how good AM
manufacturers are with scanning and AI, it can never replace the ability of the
clinician to assess and feel the proprioceptive qualities of soft tissue and
skeletal relationships.
Other highly beneficial
outcomes to the above would be diminishing the need for animal testing and
pushing the boundaries of utilising several hypotheses at once whilst analysing
scenarios, which can be extremely difficult to test in a person. From simulating environmental extremes of
altitude or temperature, or from just running ‘What if’ calculations. You can
probably get away with a few prescription alterations, but certainly not
several due to the demand clinically and also from the client stand point as
trust and confidence wanes, as by the 10th iteration of the device you would
have to question if you the clinician knew what the hell you were doing!
Is the future of Orthotic prescription in these cloud-based
platforms pairing the digital twin with a digital version of the target Orthoses?
I suppose it will be subject to bandwidth and processing (hello 5G). In reality however real-time tracking of
individuals’ biomarkers, activity and the performance of any Orthotic device
feels imminent.
I for one am looking forward to being able to use this tech in order to see the invisible; the interaction of orthoses with client, but in all of this we must not lose sight of the fact that it must be for the ‘common good’.
Following a fascinating conversation with a Senior Orthotist, I thought I would offer his thinking on the future of casting for orthoses.
His answer to the question above was – NO! He went on to say.
We are not talking about replacing it with direct scanning, which is as popular as ever with AM technology, but the next step, which is the use of smart textiles.
Be prepared in the next decade to reminisce with a new era of O and P graduates, as they hold back the laughter on how we wrapped limbs in POP to purely gain an accurate 3D shape. Even as the decade passes, we will likely not be looking back at POP (or whatever other casting medium) with rose tinted glasses, as it is and always has been just a pain – from the process of applying, time to cure and to remove, via means of scissors (uncomfortable), knife or scalpel (dangerous and intimidating). Ask any of your clients, or more specifically challenging paediatric clients if they fondly remember their first casting experiences; the answer will likely be no. It just isn’t a nice experience or product, for the purpose in which we are using it – 3D shape capture.
The use POP or polyester in Orthotics requires significant skill, logistics and post-processing to generate a positive cast that is optimum. It’s wasteful on so many levels; add to this a bubbling anxiety that you may see a plastic insert from literally thousands of finished POP rolls lodged in a sea mammal in an Attenborough documentary, it’s time we moved on.
Anyone who is scanning will already understand that although it has obvious benefits, it does still in fact have nuances and it is not suitable for every client. Here are some of the issues in no particular order; cost, movement rendering capture unusable, the physicality of getting around a limb even with something like a structure 2 sensor and tablet is difficult and certainly for most children (or those with sensory or spasticity) you are going to need a second pair of hands to physically hold that limb in the ideal position. The last is often where people resist or dismiss direct scanning, as they feel this disconnect of ‘feel’. The physical tactile connection of holding and correcting a limb, sensing a feel for range, resistance, soft tissue and in many respects they are correct as some limbs still need human interaction.
The answer will likely be Smart textiles. This is not a new area, as many plantar measuring socks exist and the world of robotics is littered with different systems. The newer systems are typically Smart Embedded Cooperative Systems of often a matrix structure equipped with a set of stretchable biocompatible multi-modal sensors systems, which are mechanically flexible and unobtrusive or more recently optoelectronic sensing.
The next step for example with AFO casting, would be to simply be able to fit an AFO casting sock onto a client. The smart, portable and stretchable textile sleeve with integrated sensors will connect to a smartphone to visualize a digital limb model which can be saved and exported for manufacture. This will undoubtedly be ground breaking, not limited to just workflow in day to day saving of time, but the whole process just being far more pleasant for clinician and client. We should have the ability to have a client stand in a shoe and capture pitch for a desired shoe, the ability to still be able to hold and correct a limb, with multiple casts being able to be done in a matter of seconds until settling on the final alignment you’re seeking, with increased accuracy and no waste, it’s a win win.
What of the future after this? What really is exciting are the multi modal qualities of sensors, measuring anything from PH, temperature, or deformation. The ideal would be the impact of wearing a sensor sock to gain not just 3D capture, but motion capture of joints and plantar pressures. To then pull all of this together to send full biometrics that can be interpreted and analysed to bring together an ideal prescription from simply donning a textile sock, or any part of the body for that matter. We may even see these sensors embedded into our wearable orthoses and prostheses to gain real time data, pressure warnings as well as monitoring of diseases and pathology over time.
There are considerable challenges to overcome before extending this technology beyond three-dimensional (3D) capture. To note; the continuum of joint angles, and the hysteretic properties of the matrix elastomers with conductive materials produce varying conductivities during cyclic loading. Either way, I can’t wait for it to replace traditional casting.
Would you happily adopt smart textiles for casting?
In the Austrian capital Vienna, the Kenyan distance runner Eliud Kipchoge became the first person to complete an unsanctioned world record marathon in a time of 1:59:40, a feat thought impossible 3 years ago. Followed a day later by Kenya’s female distance runner Brigid Kosgei, obliterating Paula Radcliffe’s world record by 81 seconds and personally I feel it’s arguably the greater achievement. Yet there is a feeling that this momentous occasion and the virtue of Kipchoge’s pursuit is tarnished by the unfortunate association with Nike and Ineos.
Chemical giant Ineos who ploughed $19m into this pursuit, are unfortunately the largest producers of non-degradable plastics, a product that threatens the health of our oceans among a number of unethical business practices. Nike have also these last few weeks endured the on-going scandal with coach and founder of Nike Oregon, Alberto Salazar and his performing enhancing exploits. This has unfortunately casted cynicism over the athletic achievement and for some people to ask was this a fortunate and timely PR stunt for two colossus companies?
The real talking point is in fact not the 41 rotating pacemakers, or the electric car with lasers that helped pacing. It was in fact the shoes that Kipchoge and Kosegi wore – the Nike Vaporfly, which the media are hysterically (and with a hint of irony) calling a ‘performance enhancing shoe’. It more accurately appears to have been a hybrid or future version of the next% shoe for the Ineos challenge and the Kosegi WR assault.
Since the introduction of Vaporfly in 2017 we have seen the 5 fastest marathon times, all within the last 13 months and all run in Nike Vaporfly shoes. Pre August 2018 all of these 5 marathon times would have been world records, which is incredible when on average for decades a new marathon world record was only set every 1-3 years for men. This of course has led to cries of a ban, with similarities been drawn to the reduced drag of LZR swimsuits. But is it a fair comparison, when in swimming milliseconds count, over a 4% shoe efficiency? Take a look at the graphs. Clearly the shoe takes nothing away from the magnitude of the achievement from Kipchoge and on a level playing field of the top 5 he’s ahead of the competition.
This shoe, more specifically Nike Vaporfly 4%, was so named since research from the University of Colorado Boulder’s Locomotion Lab from 2017 had shown that on average, the Nike Vaporfly reduced the energetic cost of running by 4% (thought to be more accurately 4.2%). The Nike Vaporfly Next% was the next generation Vaporfly and building on its success is set to further reduce the energetic cost of running by at least 5%. Check out the link below for an in depth look at the construction of the actual shoe Kipchoge and Kosgei used, a hybrid of the current Next% offered to the public and not yet released.
The common DNA of Vaporfly construction features a controversial curved carbon fibre plate embedded within the midsole, alongside a rocker profile and a unique mid sole foam around 31 mm high at the heel. This is around 50 percent thicker than comparable shoes, is exceptionally compliant and resilient with memory, whilst returning most of the energy you apply to it. It is thought to account for 3% of gains and the carbon plate the 1%, again it’s an assumption as the 4% could easily be the sum of its parts and not attainable in isolation.
The bending of the carbon fibre plate stores and returns energy at a rate of 0.007 watts per kilogram with each stride, but the foam returns 0.318 W/Kg around 45 times more than the plate. The foam in fact can move the centre of mass 15mm more vertically than a regular shoe with no extra metabolic energy and increased stride length. We get caught up in the apparent spring effect of the carbon, but in fact the foam is the real spring.
It’s worth checking out Emily Farina and Brett Kirby’s work.
Farina compared no carbon plate and flat-plate shoes, which showed a cost in energy that will only counterbalance the energy saved at the MTPJ. They also looked at a moderate curve to the plate and it was revealed the cost goes down. Lastly, looking at a severe curve, you’re back to parity: your ankle isn’t working any harder than if there was no plate, so you get the best of both worlds. This is fascinating, as the extreme curve reduced energy loss at the MTPJ by 25%, but where does that energy go? The ankle would be the next logical joint for transfer to make up the loss in the system, but it does in fact appear not to need to work any harder!?
Kirby involved 14 runners training for the 2017 Portland Marathon, two roughly equal groups running in either the Vaporfly 4% or the conventional Zoom Pegasus 34. Immediately before and after the marathon blood samples were taken and afterwards they completed a soreness survey. The Vaporfly runners showed lower levels of three blood measures of muscle damage and inflammation by between 15 and 43 percent, as well as reporting significantly less leg soreness.
He additionally in the second part of the study took seven subjects in a random order, trained for two weeks each in the Vaporfly and the Pegasus, doing three standardised training regimes per week with the same intensity each time determined by heart rate. When training in the Vaporfly unsurprisingly the runners ran faster and further, but the most interesting is that the gap widened as the training week progressed. Monday they were 9 seconds per mile faster in the Vaporfly, Wednesday 15 seconds faster and by Friday 35 seconds faster. This suggests that they were able to handle the cumulative training load better and recover more effectively.
The testers subjectively felt less sore and recovered more quickly after training and racing in the Vaporfly. It’s worth mentioning the testers where not blinded to the shoe and we have seen previously in studies the psychological effect this can have. Did they just try a bit harder in Vaporfly over Pegasus?
So, what’s next? in order to sanction a marathon race the shoe needed to be available to the general public, the next generation Next% used in these last two athletes’ races where the new incarnation of the Next% not yet on sale. It’s also interesting how they will market the shoe off the shelf, as body weight is a huge factor. Light runners may not take advantage of the full spring in the midsole, inversely the heavier runners may bottom out the midsole reducing the energy return ability of the Nike VF midsole. Does this mean Nike will optimise the midsole thickness to weight, foot length, strike pattern? Will you buy the Vaporfly in your weight category?
To answer should we ban them? The mere fact that the shoes work can’t be enough, what do you ban – the carbon? The foam? We don’t fully understand why it’s working and so have no clarity over what we are objecting to. Therefore, let’s not ban them but define the maximum geometry of the carbon and foam.
Will we see Vaporfly penetrate middle distance? Triathlon and ultramarathon are particularly interesting, certainly the time savings on an ultramarathon could be huge, but also the savings on the structures of the body in a gruelling 70miles could be life changing.
Runners keep MSK physio’s busy and certainly keep private physio pockets full. Imagine the NHS cost saving of a $300 shoe that reduces stress to anyone training middle distance and further? Vaporfly boosts efficiency, but if they help more people run further in greater comfort then surely they are here to stay – what’s not to like? The only possible issues are those who are new to this shoe not weening onto it properly, with deformation of the sole at 12- 15mm, add in the increased pitch compared to a normal runner, it wouldn’t be a huge leap to predict various foot pathology risks, especially at the TA.
It certainly will be fascinating to see the Next% that is offered to the public and how far Nike can go furthering the efficiencies? They are now sure to dominate the market, with other big brands lagging behind, I look forward to seeing some further research and data as to what exactly is going on and how this could be integrated into various combinations with orthosis, or prosthesis. If you have any thoughts, I would be interested.
So let’s have a look at a fairly topical subject, as many parents soon will either be buying, or looking at their child’s school bag for after the summer break. It is widely bounded around in clinics by various therapists in various clinical settings in what now is almost conventional wisdom, that heavy school bags cause back pain, shoulder pain, even paresthesia. Postural changes commonly associated are forward head posture, increased anterior pelvic tilt, forward trunk lean, and an increased amount of force on the lumbosacral spine.
Current recommendations suggest that backpack weight should only be at 10%-15% of your child’s body weight! That’s a pretty impossible task and this recommendation wouldn’t look out of place as a new budget airline policy for carry on luggage, it is that frugal!
Parents are often now guilty of nagging their children for carrying the pack over a single shoulder and worrying about the weight, but is it really that bad? Well the state of California seemed to think so, even passing a bill to limit the weight of children’s packs!
A systematic review published in the British Journal of Sports Medicine* reviewed 69 studies with a total of 72,627 children relating to school bag use and back pain.
School bag characteristics such as weight, design and carriage method do not increase the risk of developing back pain in children and adolescents.
People rather unsurprisingly think of back pain in children as an injury and so look for a cause, making the school bag an easy target. It did however find some links to psychological perception of the school bag being heavy and increased back pain.
Load is actually good for the spine, so we want children to be physically active and to carry loads.
So it would appear those daily paper rounds as a youth where not just character building, but physically beneficial!
This whole industry is worth millions, to youtube bloggers illustrating how to pack and distribute heavy items, to companies selling highly engineered specific school backpacks for heavy loads. With austerity we have even seen parent led campaigns, as backpack loads have been going up because budget cuts have prevented schools from providing enough lockers, or a double set of books for the home and classroom.
So with that in mind it would appear that you can put the weighing scales away and follow the advice, that if a child is experiencing an episode of back pain it may make sense to temporarily reduce the load if this relieves the pain, but once they recover it is fine to return to a normal load in the schoolbag.
If you believe something to the contrary then let us know?
*Yamato TP, Maher CG, Traeger AC, et al Do school bags cause back pain in children and adolescents? A systematic reviewBritish Journal of Sports Medicine 2018;52:1241-1245.
We are aware that it’s often a
postcode lottery for orthotic service provision, but an additional important
difference can be if the service is ‘In-House’ NHS employed service and staff
with sometimes occasional workshop staff being provided by a private company
but; both often have an on site workshop and manufacturing, often due to the
clinical demands of the setting and acute needs of a large speciality hospital,
often specialising in orthopaedics, neurorehab, and spinal cord injury.
The other more prominent service
model is a Private provider and orthotist employed through sub-contracted
companies in the private sector, who deliver services on behalf of the NHS
including off site manufacture. Occasionally a fully managed service is
implemented whereby the sub contractor will provide all admin staff, computer
systems and even the building the service operates from. This sub contracted private service provider
model typically represent 70% of all orthotic services in the UK.
We often hear that the service
provided by In-House services are superior for the patient and the orthotist.
Those orthotists who have worked within the NHS site may have protected CPD
time with regular appraisals, joint clinical learning sessions with dedicated
mentorship, mandatory NHS training, longer appointment times with allocated
ward times, better management systems, more desirable workflow due to on site
technical staff and manufacturing, clinically appropriate treatment areas and
rooms, ordering autonomy, and lastly a great work culture with multiple
orthotists for comradery and collaboration under one roof. Negatives heard are
often; top heavy banding prevents progression of experienced orthotists moving
up a salary band until someone retires or leaves and this sometimes slow
progression often means orthotists leave one centre to find another in order to
increase the salary opportunity via banding, or are incentivised to move over
to the private provider.
For the In-house service user,
often orthotists will stay in position longer and with multiple orthotists a
continuity of care is often more reliable.
Without a change in service provider like the private sub contracted
services, you can often have orthotists in the same clinic for 20+ years. What
is mostly beneficial to the orthotist and user is the on site manufacturing,
often better delivery times and face to face discussion with techs means
orthoses are often perfectly executed in form, fit, and function, and if not it
can be resolved on the day. For others a necessary repair facilitated whilst
you wait, therefore preventing a typical subcontractor two week turnaround.
In contrast the private
contractor often sites the lure of a salary, company car, perceived higher wage
for experience level and other remuneration perks as beneficial. But, what
about the service and the end user they are working for? How does this benefit
them? For some orthotists the variety of a different location everyday with a new
set of faces keeps it interesting and challenging, as you can’t settle into a
familiar and comfortable routine. Often though ordering autonomy is not always
available and some ethical decisions are tested. For example In-House orthotists may use multiple
product manufacturers, versus privately employed clinicians who would largely
provide their employers’ own products.
The use of newer technology with
a private provider can often be obtained in a more timely manner without the
various barriers and red tape of the NHS, often compounded by scarce
resources. Another angle is an In-House
service from no fault of its own can be quite insular and workflow issues slow
to emerge that need attention. A private company with 35 + orthotists are
likely to flag any systematic issue much more swiftly.
Now looking at data is difficult.
Quantitative data that is accessible and available to review the quality of
orthotics service delivery around the country is scarce. A delay to getting an
NHS employer code, coding issues, poor recording, block contracts with lack of
tariff incentives, multi-speciality referrals “hiding” orthotics related
information and commercial sensitivity around data held by private companies
make it systematically hard to draw hard line conclusions. We have centres of
excellence for orthotic care that fall into both of the above categories, what
can be said however is data is more readily available from NHS In-House
services.
The NHS England quality report
looked at a number of areas including: staffing, clinical, waiting lists,
budget and management, information technology, suppliers and procurement,
geographical demographics, referral types, audits, patient experience and KPI’s. Only 29% of organisations responded. The
findings are indicative of the significant variation and lack of consistency of
provision of orthotics services.
Whether you work in either of the above settings what we are all striving for is a timely, coordinated and responsive service. Consistency of care and clinician, and a measurable quality that is not within one contact, but monitored over time. Timescales from first appointment to supply of orthosis with manufacture always being met, alongside appropriately timed and triaged clinic slots for simple and complex cases, with ideally a named case manager for each patient.
The question is does either do it well, or are we likely comparing apples and oranges? With both there are shortcomings. Let us know what you think, especially if you have worked in both environments.
Clive Mitchell meeting Ranulph Fiennes at The Sage Gateshead
I am not much for heroes, but Ranulph Fiennes is a man I
have total respect and admiration for.
Probably the greatest explorer and adventurer of our time, he has continually
pushed the boundaries of what is possible and attempted to do what has never
been done before. To be the first.
This man has taken the limits of human endurance to the precipice (literally) and come back each time. He has made adventuring his career and therefore his business. A not untypical business model, as every project requires sponsorship/funding to be sought in advance and before the adventure can begin.
So, what do I take from this man’s experiences and how can it
be applied to business?
Vision – He is a visionary and does not limit his thinking or ambition, believing anything to be possible. Having created a vision, he finds ways to make it happen.
Planning & Preparation – Many of his ventures were labelled as ‘mad’ at the time, but Fiennes always strongly disagreed, saying they were “carefully planned and entirely feasible”. This of course significantly understates the fact that he devotes enormous amounts of time in selecting the very best support team and equipment, as well as focussing on his mental attitude and developing his physical abilities to achieve the extraordinary.
Risk – You limit the risk in any venture by trying to find out everything about the task in advance. Of course, business just like life is not without risk, but it can be assessed and planned for.
Motivation & Determination – He is a man who never gives up and so doesn’t view an uncompleted venture as a failure, but simply a learning experience that will help him succeed when he attempts it the next time.
After an inspirational talk last night, it was truly amazing
to meet him and also share a few words.
I told him that I had once competed in the same adventure race as him
and reminding him a little more about this relatively inconsequential event,
his immediate response was – “Who won?”
At 75 he is still going strong and rallying against the
restrictions of become geriatric, which he detests and says “should be banned”. I believe his next challenge will be a seabed
walk in weighted boots from Robben Island to Cape Town with only great white
sharks for company.
Following a fascinating conversation with a Senior Orthotist, I thought I would re-count his comments and set this anatomical riddle:
What is found only 80% of the time bilaterally, is flat and elliptical, measures 15mm across and is twice as likely to be found present alongside an OA knee?
Here is a clue below:
The answer of course is the fabella!!!
Let’s be honest, you clicked and scrolled for the answer didn’t you? Or at least I’m hoping you did to save my blushes. Personally I had never heard of it and thought I was quite well versed in my bony anatomy.
The Imperial College team, principally Dr Michael Berthaume and colleagues in the Department of Bioengineering put this little bone in the limelight these past weeks. However, they were not the first, as it was initially alluded to in the 17th century and then more specifically in 1875. My Orthotist colleague was shocked, believing he had read multiple radiography reports referring to it simply as a loose body!
What is it?
Fabella (little bean) – is a sesamoid bone. Typically 10mm – 15mm in size on average, but can reach up to 20mm, is typically a flat elliptical shape and in some can be physically palpated.
Where is it located?
Initially a small fibrocartilage disc that can be seen in a developing foetus, it can be seen to ossify as early as 12 years old. It articulates with the posterior part of the articular surface of the lateral femoral condyle and is embedded in the muscular fibres of the gastrocnemius muscle. Anteriorly the fabella is bordered by the posterior capsule of the knee joint and posteriorly it is situated at the endpoint of the oblique popliteal ligament and the lateral gastrocnemius tendon. In addition, the fabellofibular ligament runs to its distal insertion at the fibular head and is found bilaterally in 80% of the population.
Prevalence
Dr Michael Berthaume and his colleagues at Imperial’s Department of Bioengineering undertook a systematic review of all literature in the last 150 years in 27 countries, totalling over 21,000 knees andit is now thought to be three times as common as 100 years ago. In 1918 fabella were present in 11% of the world population and by 2018 they were present in 39%, whilst in areas like Asia and Australia it is almost every other knee.
It is thought to be by genetic neutral selection that we have evolved to have an increase in prevalence and that it is more likely to be environmental changes that has heavily influenced its increase in frequency. For example in Asia, increased tensile forces due to squatting and kneeling, and the fact we are now much better nourished resulting in greater height and weight resulting in additional stress and torque to the knee.
Why should the clinician take it more seriously?
For most the fabella does not hurt. If it does, we call it fabella syndrome characterized by a sharp pain, local tenderness and exacerbation of pain with extension of the knee. It can also cause pain during knee flexion, climbing stairs, cross-legged sitting and sporting activities.
Pain is associated with varus type of stress on the knee and passive and active internal rotation of the tibia. Occasionally the fabella is too close to the common fibular nerve and can cause altered neurology.
The fabella has been cited as a relevant cause of pain post-TKA due to mechanical irritation of the posterolateral tissues of the knee.
The most sensationalist headline outlined (correctly I may add); the fact that an OA knee is twice as likely to have a fabella present. This is likely an area of future research, as currently no proof exists that it is responsible for causation and it is more likely to be a predisposition to OA and a fabella simultaneously due to a genetic or environmental element. The tabloid hysteria and stress to the general public of worrying about this little bone bringing you to a theatre soon for your TKR can therefore be rejected.
We would like to hear of any clinical examples of the fabella you have come across? Also, do be honest and let us know if you had even heard of it?
By chance this theme has made its way onto my radar this week, through various mediums and in person. I have heard both extremes of the argument, those who support and those who oppose the use of ‘Off the Shelf’ (OTS) orthoses and of course there is no simple answer.
One thing I think we can agree on is that the volume of OTS products has increased, with some companies offering products of real quality and functionality. Therefore options for clinicians have expanded, which can surely only be a good thing? However, there are so many ‘me too’ products, that clinicians can often become paralysed by choice for those daily ‘bread and butter’ orthoses.
In many cases OTS products can offer a good cost effective solution, that fits as well as a custom alternative and are available immediately, or within 24hrs. In an acute setting for supporting early rehabilitation or discharge, or departments struggling with efficiencies, they can be great for a one stop shop appointment, reducing waiting times and easing the process for those who struggle to attend appointments for an array of reasons.
So let’s debate some of the ‘for and against’ common themes……..
One viewpoint is that it steers people to online purchasing via Amazon et al, self-diagnosis and treatment without seeking the correct professional advice. This does concern me, but in reality most orthoses sold online, or through a pharmacy, rarely cause serious harm and most of what is available to the general public tends to be soft goods. Often people self-purchase as a stop gap, alongside seeking the appropriate treatment or referral.
Another opinion is that extended scope AHP’s supplying stock bracing and companies training other AHP’s are removing a need for the Orthotists skills, devaluing and not protecting the profession. In practise however, providing they have been signed off through the Skills for Health Framework and the AHP has demonstrated the correct competencies, there should be no issue. If an AHP acts outside of their competencies, it is reported before harm is caused. Orthotists are far more useful in complex scenarios and the active diagnosis, alongside formulating the prescription. Why waste time being called to re-apply a collar weekly, or just to change the padding? Orthotists are better utilised where the demand for their skills are really required, but we should acknowledge the quality of some therapy assistants is outstanding.
Orthotic Service Providing Companies need custom work to survive and to pay Orthotists. The Orthotists salary rarely covers the session fees, therefore these companies rely on the work generated by the Orthotist. However the phrase ‘if we have the ability to make it in the factory then it shouldn’t be ordered elsewhere’ is a little short sighted, as some OTS products are exceptionally well engineered and have functionality that simply can’t be replicated by a custom manufacturer. For instance with no specialism in specialist carbon lamination, other unique features of mechanicals like joints, or material nature such as specialist silicones are often patented, therefore choosing to copy it in house can be an inferior solution and can rarely be repeated accurately. If the OTS product is the most appropriate, then ethically it should be used and Orthotists should be completely autonomous in ordering what is most appropriate for their patient. It is called – clinical independence. Additionally OTS orthoses can often be accompanied by sound evidence and this should further strengthen the evidence based approach.
Additional worries surround Paediatric services and that the use of OTS DAFO’s / AFO’s has become too prolific, bypassing the Orthotist and only being seen by the Physio who is ordering direct, resulting in less custom work and the potential for biomechanically flawed orthoses with a poor fit. In actual practise most Orthotists (and Physios for that matter) know when they are appropriate or not. They are a useful tool for a trial and in cases of behavioural or otherwise impossible casting are a great solution. I think the worry that they are being used in an incorrect manner is unfounded, as again it frees Orthotists up to be more valuable in their allotted clinic time. Orthotists are an expensive commodity and measuring shoe sizes for basic OTS DAFO’s is not what they need to be doing.
In most clinical settings once Orthotists are proactive and engage with their AHP colleagues, the AHP’s discern when to take advantage of the Orthotists expertise and call upon them. Orthotists are routinely severely stretched and I am sure for the most part would much rather be utilised in a pathway with complex orthotics, rather than those general clinics issuing non-complex wrist, hand, epi-clasp, knee sleeve products etc.,etc.. As a side note, complexity of patient doesn’t always lead to a custom orthoses either.
Orthotists are far more specialised and often under used, so should be concentrated on for their niche skills and promoted within the health care system.
I think we should all consider Franklin D Roosevelts disposition – “Do something. If it works, do more of it. If it doesn’t, do something else.” Custom or Stock, it doesn’t matter, as long as the end user benefits from the most appropriate treatment.
Do you sit on the fence? Or fall heavily onto one side or the other?
