Archive for Research and News

Pediatric Prosthetics

Over the years, the Prosthetic Industry has made significant advancements in designs, components, materials and processes. The increase in comfort and functionality of prosthetics these days is outstanding…as long as you are over the age of 12 that is. What has lagged behind is the entire field of pediatric prosthetics for young children – who in actuality have significant strength, motivation and fervor. Thankfully, a handful of individuals and companies in the field have recognized the need for development in this area and are making strides to help pediatric prosthetic patients excel.

Take a look at this recent article from OandP.com, a leading resource of up and coming orthotic and prosthetic news. EastPoint’s Raleigh clinician, Brent Wright, even ways in on the subject in the article. You’ll also see a recent picture of our sweet little patient Miyah!

OandP.com Article – Pediatric Prosthetics

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Exciting New Development in Pediatric Prosthetics

As many of you know, this past year EastPoint became the first clinical partner with LIM Innovations, out of San Francisco, California. In September of 2014, LIM released a revolutionary new socket design, a game-changer in the prosthetic world, the Infinite Socket. The Infinite Socket is the first of its kind to offer a completely customized fit so patients can make their own adjustments as often they choose.

After we found success with several adult patients in this new socket, we strongly urged LIM to continue their developing and release a pediatric version. We are thrilled to announce that they not only honored our request, but they also decided to use one of our sweet kiddos, Miyah as the face behind this new pediatric socket. Miyah loves the LIM Infinite Socket, and her Mom loves the ability to customize the fit on their own, at any time.

Offering this kind of personalized fit for pediatric amputees is a huge step forward for the field of prosthetics. We are so proud of Miyah and her success, and we are thankful to continue being a part of her journey.

Check out additional coverage of her story here: NY Times – Miyah

Miyah

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Plagiocephaly and Brachycephaly: Defending the Benefits of Cranial Helmets

IMG_7203     Google “skull deformity helmets” and nearly half of the   results on the first page are articles that criticize helmet therapy for infants, claiming that the expensive orthotics are a total waste of money. Despite numerous studies that support the effectiveness of helmet therapy in correcting plagiocephaly and brachycephaly [3-6], media sources such as The New York Times and Boston.com have released articles that discourage treatment [8,9]. The basis for nearly all of helmet therapy criticism arises from a single study published on May 1, 2014, by Renske van Wijk and a team of researchers in the Netherlands [11]. The study, Helmet therapy in infants with positional skull deformation: randomised controlled trial, compared the 24-month outcomes of infants (aged 5 to 6 months) assigned to either a helmet therapy group or a control group that received no treatment. According to the study, helmet therapy was just as effective in correcting skull deformation as no treatment. Thus, van Wijk et al. discourage the use of helmets when treating moderate cases of skull deformation. There are numerous caveats associated with these conclusions, however, that should be taken into account before deciding to leave your infant’s skull deformity untreated.Layla Mewborn

Firstly, here is some background information on the condition in the United States. In 1992, the initiation of the “Back to Sleep” campaign resulted in increased numbers of infants sleeping in a supine position to reduce the risk of Sudden Infant Death Syndrome (SIDS). While the campaign has been extremely effective in reducing instances of SIDS, static supine position is one of the leading risk factors for plagiocephaly. Thus, the increase in skull deformity cases since the 1990s is likely correlated with the 1992 campaign [1]. In 2013, plagiocephaly was estimated to affect 46.6% of infants aged 7 -12 weeks [7]. In addition to prolonged external force resulting from static supine position, other risk factors include torticollis (asymmetric tight neck muscles), prenatal uterine constraint, and perinatal birth injury [1]. The two most common treatments are cranial helmets and repositioning practices—a more conservative approach where infants are positioned in prone for short periods of time. According to the van Wijk study, however, natural course is just as effective as the more aggressive, cranial helmet treatment.   Bling Your Band

Following publication on May 1, 2014, there was a high volume of critical responses from members of the medical community regarding the study’s results and conclusions. One of the most common criticisms is that the study did not include infants with severe deformities, torticollis, or other developmental neuromuscular issues. Thus, it is still widely believed that infants with severe skull deformities or neuromuscular problems stand to benefit from cranial helmets. Jordan Steinberg, a pediatric plastic surgeon, points out the high percentages of study participants that experienced problems with the cranial helmet during its use in the study [10]. Reportedly, 96% of the infants experienced skin irritation, 76% unpleasant odor, and 33% felt some sort of pain from the helmet. Furthermore, 73% of participants reported improper fit and shifting of the orthotic [11]. Noting these issues, and the low percentages of full recovery in both subject groups, Steinberg concludes that the participants received “inadequate treatment” [10]. Kevin Kelly, a research consultant at Cranial Technologies also comments on these statistics stating, “The lack of improvement seen in their study was the direct result of their ill-fitting helmets” [2]. Had participants received properly fitting helmets and proper care, van Wijk et al. may have observed significantly different outcomes.helmet

Although many view skull deformity as solely a cosmetic issue, “untreated cranial asymmetries have been linked to visual defects, ear infections, middle ear malfunction, jaw bone changes, developmental delay, learning difficulties, and other psychomotor delays” [12]. Treating instances of plagiocephaly and brachycephaly in a timely manner is important for ensuring proper development. The results of van Wijk’s study are not completely reliable and do not annul the value of cranial helmets. The study did not include severe cases of skull deformity, and patients were not properly fitted with their orthotics. More research is certainly necessary to properly characterize the effectiveness of cranial helmets. For the time being, seeing as skull deformities can lead to numerous developmental complications, it should be of primary concern to treat the condition rather than quickly dismissing a device that has been historically successful in correcting countless cases of skull deformity.

EastPoint Prosthetics & Orthotics

Jennifer holds her son, Brayden, who just received his new cranial remolding helmet.

 

Works Cited

1. Grigsby, Katrina. “Cranial Remolding Helmet Treatment of Plagiocephaly: Comparison of Results and Treatment Length in Younger Versus Older Infant Populations.” JPO Journal of Prosthetics and Orthotics 21.1 (2009): 55-63. American Academy of Orthotists and Prosthetists. Web. 1 July 2015. <http://www.oandp.org/jpo/library/2009_01_055.asp>.

 2. Kelly, Kevin M. “Re: Helmet Therapy in Infants with Positional Skull Deformation: Randomised Controlled Trial.” Letter to RM Van Wijk. 10 May 2014. The British Medical Journal. BMJ Publishing Group Ltd, n.d. Web. 01 July 2015. <http://www.bmj.com/content/348/bmj.g2741/rapid-responses>.

 3. Kim, Se Yon, Moon-Sung Park, Jeong-In Yang, and Shin-Young Yim. “Comparison of Helmet Therapy and Counter Positioning for Deformational Plagiocephaly.” Ann Rehabil Med Annals of Rehabilitation Medicine 37.6 (2013): 785-95. PubMed. Ann Rehabil Med. Web. 26 June 2015. <http://vb3lk7eb4t.search.serialssolutions.com/?ctx_ver=Z39.88-2004&ctx_enc=info:ofi/enc:UTF-8&rfr_id=info:sid/summon.serialssolutions.com&rft_val_fmt=info:ofi/fmt:kev:mtx:journal&rft.genre=article&rft.atitle=Comparison of Helmet Therapy and Counter>.

4. Kluba, Susanne, Wiebke Kraut, Benjamin Calgeer, Siegmar Reinert, and Michael Krimmel. “Treatment of Positional Plagiocephaly – Helmet or No Helmet?” Journal of Cranio-Maxillofacial Surgery 42.5 (2013): 683-88. Science Direct. Web. 26 June 2015. <http://vb3lk7eb4t.search.serialssolutions.com/?ctx_ver=Z39.88-2004&ctx_enc=info:ofi/enc:UTF-8&rfr_id=info:sid/summon.serialssolutions.com&rft_val_fmt=info:ofi/fmt:kev:mtx:journal&rft.genre=article&rft.atitle=Treatment of positional plagiocephaly – H>.

5. Lee, Robert P., John F. Teichgraeber, James E. Baumgartner, Amy L. Waller, Jeryl D. English, Robert E. Lasky, Charles C. Miller, Jaime Gateno, and James J. Xia. “Long-Term Treatment Effectiveness of Molding Helmet Therapy in the Correction of Posterior Deformational Plagiocephaly: A Five-Year Follow-Up.” The Cleft Palate-Craniofacial Journal 45.3 (2008): 240-45. ProQuest. Allen Press Publishing Services. Web. 26 June 2015. <http://search.proquest.com.libproxy.lib.unc.edu/docview/204925188?pq-origsite=summon>.

6. Lipira, A. B., S. Gordon, T. A. Darvann, N. V. Hermann, A. E. Van Pelt, S. D. Naidoo, D. Govier, and A. A. Kane. “Helmet Versus Active Repositioning for Plagiocephaly: A Three-Dimensional Analysis.” Pediatrics 126.4 (2010): 936-45. Pediactrics. American Academy of Pediatrics. Web. 26 June 2015. <http://pediatrics.aappublications.org.libproxy.lib.unc.edu/content/126/4/e936>.

7. Mawji, A., A. R. Vollman, J. Hatfield, D. A. Mcneil, and R. Sauve. “The Incidence of Positional Plagiocephaly: A Cohort Study.” Pediatrics 132.2 (2013): 298-304. Pediactrics. American Academy of Pediatrics. Web. 1 July 2015. <http://pediatrics.aappublications.org/content/132/2/298>.

8. Saint Louis, Catherine. “Helmets Do Little to Help Moderate Infant Skull Flattening, Study Finds.” The New York Times. 1 May 2014. Web. 26 June 2015

9. Salahi, Lara. “Study: Corrective Baby Helmets Don’t Work.” Boston.com. Boston Globe Media Partners, 1 May 2014. Web. 26 June 2015.

10. Steinberg, Jordan P. “Re: Helmet Therapy in Infants with Positional Skull Deformation: Randomised Controlled Trial.” Letter to RM Van Wijk. 01 Nov. 2014. The British Medical Journal. BMJ Publishing Group Ltd, n.d. Web. 01 July 2015. <http://www.bmj.com/content/348/bmj.g2741/rapid-responses>.

11. Van Wijk, R. M., L. A. Van Vlimmeren, C. G. M. Groothuis-Oudshoorn, C. P. B. Van Der Ploeg, M. J. Ijzerman, and M. M. Boere-Boonekamp. “Helmet Therapy in Infants with Positional Skull Deformation: Randomised Controlled Trial.” BMJ (2014): 348. Thebmj. BMJ Publishing Group Ltd. Web. 26 June 2015. <http://www.bmj.com/content/348/bmj.g2741>.

12. Wang, Judy. “Babies, Misshapen Heads, and Plagiocephaly Helmets: A Physical Therapist Perspective.” Web log post. North Shore Pediatric Therapy. N.p., 20 May 2014. Web. 8 July 2015. <http://nspt4kids.com/parenting/babies-misshapen-heads-plagiocephaly-helmets-physical-therapist-perspective/>.

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Phantom Limb Pain: Theories and Therapy

Phantom limb pain (PLP) is reported in nearly 80% of patients with missing limbs, yet the causes are still not fully understood. Recent research on the topic has helped to increase our knowledge of PLP, but the varying nature of the condition makes it difficult to define and treat. Patients often experience different sensations described as tingling, throbbing, piercing, or pins and needles. Some patients have reported experiencing these sensations immediately following an amputation, while others do not experience any phantom pain until years after the surgery. In addition to varying times of onset, the periods of pain onset may differ from patient to patient, ranging from a few weeks to any number of years (Subedi et. al. 1-2).

Risk Factors for Phantom Limb Pain

Female Sex

Upper extremity amputation

Presence of pre-amputation pain

Residual pain in remaining limb

Time after amputation

While the mechanisms of PLP are still debated, increased focus on the condition has led to the revelation of some interesting trends. Phantom limb pain occurs more often and with greater intensity in females than in males; upper extremity amputations have a greater tendency for PLP than lower extremity amputations; and patients who experience pain in their limb prior to its amputation are more likely to experience PLP after amputation. In the past, PLP was characterized as a psychiatric illness, but the mentality among physicians and researchers is changing. Research is now aimed at discovering the physiological mechanisms of PLP instead of dismissing the condition as purely psychological (Subedi et. al. 2).

Theories

Numerous theories exist in regards to the causes of PLP, and most experts believe that a combination of the proposed mechanisms may actually be responsible for the pain that patients experience. The most cited cause of PLP in recent years is associated with changes that occur in the brain when there is a lack activity in a certain region, such as the portion of the brain that controls a missing limb. When a portion of the brain is not being used, neighboring sensory or motor areas can take over. This process is termed cortical reorganization, and can partly explain why patients may still feel sensations in a missing limb (Subedi et. al. 2).

Another theory, the peripheral mechanism, explains PLP as the result of spontaneous discharges from neuromas that form in peripheral nerves following an amputation. A neuroma is a proliferation of cells that develop after injury to a nerve. This ball of nerve cells acts abnormally, and could result in stump or phantom pain (Subedi et. al. 2).

One last interesting theory attributes painful sensations to the incongruence between motor intention and sensory feedback in the brain. While a patient may feel as if his or her phantom arm is extending to reach for a cup, vision and other sensory feedback tells the brain that the limb is not present. Some experts propose that the brain interprets this conflict by sensing pain in the phantom limb (Jerrell). In reality, PLP is likely due to a combination of the proposed mechanisms and differs among the various types of patients.

Treatments

When treating PLP, each case must be addressed using trial and error as no single treatment has proven to be the best for all types of patients (Jerrell). While numerous patients have found success using some of the available therapy options, it is up to the patient and his or her provider to find what works best on a case-by-case basis.

Many different types of pain medications and anti-depressants have been used in the past, but studies have shown mixed results. NSAIDs such as Motrin or Advil were found to be the most common medications used to treat PLP, likely because they are over-the-counter and have few side effects (Subedi et. al. 3).

Transcutaneous Electrical Nerve Stimulation (TENS) is another noninvasive treatment that is becoming more common, even though only a few studies have shown its effectiveness. TENS therapy uses electrodes placed on the skin to apply current to the affected nerves. Stimulation may reduce pain by blocking pain signals from reaching the brain, or by prompting the body to produce neurotransmitters that act as natural painkillers (Desantana et. al. 492-494).

Another treatment – mirror therapy – has shown significant benefit in some patients, particularly lower mirrorleg amputees. During mirror therapy, the patient watches the intact limb move in a mirror (placed between their legs or arms), such that it appears that the missing limb is present. By “seeing” and feeling the phantom limb moving, this therapy attempts to resolve conflicting visual and proprioceptive sensations in the brain (Jerrell).

In summary, phantom limb pain is still elusive and requires more research to develop better definitions and treatments for the condition. It is a disability suffered by a large percentage of amputees, yet there are still no definitive answers to some fundamental questions in regards to its causes and treatments. In recent years, our understanding of PLP has grown and evolved, leading to numerous theories attempting to provide an explanation for the phenomenon. At the moment, however, no treatment has proven effective for every type of patient. PLP must be dealt with using a trial and error approach to find the treatment that is best for each individual patient.

(Image – US Defense Department photo, Donna Miles)

Guest blogger – A. Allen

 

 

 

 

Works Cited

Subedi, Bishnu, and George T. Grossberg. “Phantom Limb Pain: Mechanisms and Treatment Approaches.” Pain Research and Treatment (2011): 1-8. Web. 24 June 2015. <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3198614/>.

Jerrell, Mary L. “Cause of Phantom Limb Pain Still Elusive.” Healio O&P News. O&P News, 1 Feb. 2012. Web. 24 June 2015. <http://www.healio.com/orthotics-prosthetics/prosthetics/news/print/o-and-p-news/{3bb02d3c-6b4a-4b5d-bfbc-f0027e7191c9}/cause-of-phantom-limb-pain-still-elusive?sc_trk=internalsearch>.

Desantana, Josimari M., Deirdre M. Walsh, Carol Vance, Barbara A. Rakel, and Kathleen A. Sluka. “Effectiveness of Transcutaneous Electrical Nerve Stimulation for Treatment of Hyperalgesia and Pain.” Curr Rheumatol Rep Current Rheumatology Reports 10.6 (2008): 492-99. Web. 24 June 2015. <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2746624/>.

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