Monday, April 2, 2018

Knowing the Patient is Key to a Lifelong Partnership

Knowing the Patient is Key to a Lifelong Partnership

Powell Orthotics and Prosthetics has provided freedom for patients since 1932. Years of professional experience, craftsmanship, and technology enable Powell to provide the benefit of mobility and independence to patients.

To provide patients with a superior device, the staff at Powell O&P first wants to get to know you. It’s important to understand your lifestyle and goals. Whether you’re returning to work, walking the dog, cutting the grass, playing with your children, running or just simply getting around. Each device is unique and custom fabricated to fit your needs.

A vast amount of componentry options are available today and Powell’s experienced staff, with your input, is here to ensure you receive the most appropriate device. They take the time to explain each option, helping to fit patients with a device that meets their needs.

 And it all starts with a scan.

We spoke with Michael R. Monteiro, Certified Prosthetist, ABC, and owner of Powell Orthotics and Prosthetics about the process to make a prosthesis for a patient.

Michael took us through the first step in the process, showing us the machine used for scanning the patient. “The scan works just like a satellite system,” Michael said. “It’s all radio waves so they don’t feel anything except for the pressure of me rolling this across their limb. It takes an image of it and puts it onscreen. It’s pressure sensitive so if I press in deep, it will show a deeper presence on screen, so it gives me tissue feedback, kind of like you do when you hand cast.” They run the scanner across the remaining limb, to make the prosthetic limb match the size and shape.

“After that,” continued Michael. “I have an image on screen. I manipulated it to what I need it to do to allow the patient to stand up. There’s areas we want to put pressure on, there’s areas we don’t want to put pressure on. I do all that and I send the file to Scotty, who’s our technician.”

Scotty will then carve out a model and create a clear socket for the patient to stand up on.

From standing to walking
This is an example of someone’s limb, after manipulation. Michael showed us his computer rendition of the scan. “This is what our socket will end up looking like when we’re finished,” he said. “We put space in for bones, there’s a small bone at the top of your leg a little nerve runs behind it just like your funny bone only it’s in your leg. So the kneecap sits up in here and the end of the bone we build out, because there’s usually just skin and bone like your shinbone - not much coverage. We try and make it a little between the bones we squeeze, on the medial side of the fibula bones we squeeze. If we make it triangular shape, when you move, the prosthesis moves as well.”

The CAD drawing gives Michael a vision of what everything will look like. He demonstrated how he can rotate the image and look at it from behind and down inside it to make sure he likes what he’s seeing.  He explains that what he sees when he scans someone is “more or less what we see if we have someone sitting on the table.” Michael points to areas on the screen, “All these areas, I create to help him stand up. It disperses weight and pressure, kind of like a bed of nails…if you don’t feel any of them, you won’t have any problems, if you feel one of them, it’s a problem.”

Once Michael is pleased with the scan and manipulations on screen and is sure he’s been able to disburse all the pressure and body weight out, he sends the model to Scotty for carving. Michael starts with the computer, but his partner Joe, prefers the traditional way by hand casting a model first and making the changes and then scanning it in and sending it to Scotty.

Michael then showed us a room full of blank forms and a lathe.  He explained that the lathe has a CNC processer, and carves in 2 planes as it moves. The material they use is harder than Styrofoam because they have to pull plastic over it and they don’t want it to compress. They send the file to the lathe, carve it, and then end up with the model.

Once they have a carved model, all patients receive a diagnostic socket. This diagnostic socket is clear, so the team can stand the patient upright, check to make sure everything’s fitting properly, make sure they have pressure where it’s needed, and make sure they don’t have pressure where they don’t want it. The diagnostic socket is made from a low-temperature plastic, so that if there’s an area causing issue, Michael and team can take it off and heat it up, make a change, cool it down and slide it back on.  “We can modify the diagnostic socket and 90% of the time the patient can walk on this, so they know statically and dynamically how it feels,” said Michael. “Standing may feel good, but walking around may feel different because the body’s doing different things.”

After the carving is complete, a clear plastic pre-form dome goes into the oven, with adapters that go on the end – depending on what they intend to put into the socket.  The oven vacuum forms the plastic based on time and temperature. They then trim the piece out and end up with a plastic socket ready for adapters that they can then attach to a tube system and a foot. “We want them to try it on and stand,” said Michael. “We want them to stand and walk on the feet they’re going to use, because it’s going to feel different with different feet on there. Again, if we need to make changes, we can heat it up, press it out, cool it down and slide it back up on them, to make sure everything’s comfortable before they leave.

The perfect fit

The challenge is finding the right match with the patient’s wants and the patient’s needs. “What they think they want and what they actually need may be different,” said Michael. “There are a series of tests that are pretty predictive of patient’s ability, for newer patients, that’s done during the measurement. If you can walk with a walker or with crutches, vs. some who’s in a wheelchair – that helps determine what kind of feet or knee components we’re going to start with.”

New amputees receive what’s called a preparatory prosthesis, which is designed to get them walking in therapy and limb shrinkage.  The preparatory is designed to get the patient down to a stabilized size, once muscles complete their atrophy and stop losing mass. This process takes about 4-6 months after a patient starts walking. At that point in time, it’s time to start all over again – it’s time for the new leg.

“We use a gel liner, either silicon, urethane or TPE plastic to cushion and protect the skin,” continued Michael. “Almost everybody can benefit from having a gel liner against the skin. It grips the skin, it protects the skin from rubbing blistering and irritations, that’s why it’s so universally used. Some have a pin that goes into a lock, and that acts as suspension, so as they move the prosthesis moves with them.”

Prosthetics have certainly come a long way in appearance thanks to today’s technology. “We can do any color a patient wants,” said Michael. “If patients bring us a shirt, or something special they want on their prosthesis, we can laminate that on there with a clear coat, so whatever the fabric on there can show through.”

We mentioned how important it is to understand the patient’s lifestyle and goals. “We never want the prosthesis to limit someone, but we don’t want to build it so technical that they can’t use it, or can’t generate enough force to use it,” said Michael. “People always say they want ‘the best,’ and they associate the best with the most expensive. I can fit you with a Porsche, I can fit you with a Combine. If you’re a farmer, the Porsche is not going to help you. The cost is about the same. It’s really about finding out what your needs are and fitting you with the best product to fit your needs. Then you’ll get the most out of it.”

“There are dynamic feet, which will give energy in return, and there are energy absorbing feet to give you lots of motion,” Michael says. “If you’re hopping up and down on trucks, you may need something that has a lot of cushion, if you’re walking around a constructions site, you want something that will give you all kinds of side to side motion, because you’re stepping over all kinds of terrain and if you’re sitting in an office all day, you’ll want a smooth foot, if you’re a runner, you’ll want something that allows you to do that.” The process is really about patient matching. Same thing with prosthetic knees, there are a plethora of options depending on patient capabilities and needs.”

In speaking with Michael, it’s clear he and his team have a progressive and honest approach to getting patients back to their daily lives. They have a number of amputees on staff, allowing them to have a unique perspective on their patient’s daily challenges and how to prevail. They know their job is not done when the prosthetic is finished – they have resources for patients, such as support groups and county and state resources to help patients get back to living the life they want.