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Lin R.S.,Connecticut Childrens Medical Center | Stevens P.M.,Hanger Clinic | Wininger M.,University of Hartford | Wininger M.,Yale University | Castiglione C.L.,Connecticut Childrens Medical Center
Cleft Palate-Craniofacial Journal | Year: 2016

Objective: To establish consensus on definitive, actionable standards for the management of deformational plagiocephaly. Design: Three-stage Delphi Survey process based on best practice statements obtained through literature review. Setting: Electronic survey delivery. Participants: Review panel of 10 multidisciplinary subject matter experts (SMEs); survey panel of 30 cranial orthotists. Results: Fifty-four best practice statements were accepted in four categories: diagnosis, presentation and severity, initiating treatment, and management principles. Conclusions: Clinical practice can be guided en route to robust evidence as to the efficacy of various plagiocephaly management strategies, in pursuit of definitive standards.


Wong C.K.,Columbia University | Rheinstein J.,Hanger Clinic | Stern M.A.,Yeshiva University
American Journal of Physical Medicine and Rehabilitation | Year: 2015

Objective: Approximately 50% of people with leg amputation fall annually. Evidence suggests that microprocessor knees (MK) may decrease falls and improve prosthetic function in people with traumatic amputations. This study explored whether adults with transfemoral amputations and peripheral artery disease would have reduced falls and improved balance confidence, balance, and walking ability when using prostheses with MK compared with non-MK. Design: This was a prospective cohort study. Results: Eight subjects averaged 60.8 ± 11.3 yrs or age and 9.5 ± 16.1 yrs since first amputation. Four were K1-K2-level and four were K3-level functional walkers; only Houghton prosthetic use score was different between K1-K2 and K3 walkers (P = 0.03). After 48.3 ± 38.1 wks of acclimation using MK, subjects demonstrated improvements in fear of falling, balance confidence, Timed Up-and-Go time, and rate of falls (P < 0.05). The improvements in fear of falling, balance confidence, and rate of falls had large effect sizes (d > 0.80). Average decreased Timed Up-and-Go time (12.3 secs) had a medium effect size (d = 0.34). Decreases in the number of falls correlated with faster Timed Up-and-Go speed (ρ = -0.76) and greater balance confidence (ρ = 0.83). Conclusions: People with peripheral artery disease and transfemoral amputations had fewer falls and improved balance confidence and walking performance when using prostheses with MK. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.


DeMuth S.,University of Southern California | Campbell J.,Becker Orthopedic | DiBello T.,Hanger Clinic | Esquenazi A.,MossRehab | And 4 more authors.
Military Medicine | Year: 2016

Objectives: This article establishes needed guidelines for determining orthotic prescriber authority, documenting medical necessity, and ensuring continuity of care for patients needing orthoses. It also identifies “off-the-shelf” (OTS) devices that can safely and appropriately be delivered to patients without professional adjustment as well as those that cannot. Methods: A multidisciplinary task force made up of experts in orthopedics and physical medicine physicians, along with therapists and certified orthotists, applied a consensus approach to answer key questions: (i) When can a device be safely, effectively delivered to the patient OTS without professional guidance or education, and which caregivers have a role in that decision? (ii) What documentation is appropriate for physicians and other caregivers to determine medical necessity? (iii) What documentation/communication ensures continuity of care among physicians, therapists, and orthotists? Results: Guidelines developed for consideration of OTS orthoses include accepting documentation from collaborating caregivers, including therapists and orthotists; keeping that documentation as part of the patient’s total medical record for clinical, medical necessity determinations and reimbursement purposes; and using the physician’s prescription for the device as the key determinant of whether a device is delivered OTS or as a custom-fitted device. Conclusion: This review provides expert guidance for patient safety, minimizing wasted expenditures, maximizing clinical outcomes, and providing efficient delivery of care for Medicare and other patients. Centers for Medicare and Medicaid Services guidelines should be directed toward recognizing the level of expertise of the orthotist, the value of their patient encounters, and their role in facilitating the timely, safe, and effective use of orthotic devices. © Association of Military Surgeons of the U.S. All rights reserved.


Peethambaran A.,University of Michigan | Foster A.,University of Michigan | Hickey K.,Hanger Clinic | Patterson R.,Hanger Clinic
Journal of Prosthetics and Orthotics | Year: 2015

Introduction: Infants treated for positional cranial asymmetry involving plagiocephaly, brachycephaly, and scaphocephaly are often treated with cranial reshaping orthotic helmets to encourage symmetrical cranial growth. The Michigan Cranial Reshaping Orthosis is a bivalve helmet that accommodates overall cranial growth during the therapy period while still directing cranial growth toward the desired areas. This design differs from standard one-piece helmets that allow limited volume for overall cranial growth. This study examines the efficacy and success rate of this low-profile design. Materials and Methods: Visual inspection and manual measurements taken throughout the helmet therapy period, using a flexible tape measure and an AP-ML gauge, indicate significant cranial asymmetry correction. However, measurement inconsistencies due to soft tissue compression and clinician technique may limit the accuracy of outcome measures. Seventy subjects treated for plagiocephaly and/or brachycephaly with the Michigan Cranial Reshaping Orthosis were identified in this retrospective study. Data were compiled from Omega Tracer (Ohio Willow Wood Company, Mount Sterling, OH, USA) computer-aided design clinical database of three-dimensional cranial scans taken before and after helmet therapy. Cranial helmet therapy treatment timeline was verified through the electronic medical record database. Cranial landmarks were defined on each threedimensional image. Measurements between defined points were compared on the initial assessment scanned image and the final discharge scanned image for each patient. Results: Comparison of initial and final three-dimensional scans showed improved symmetry in the relevantmeasures of cranial vault asymmetry index (CVAI) and cephalic ratio (CR) in 84.3% of subjects. Children in the plagiocephaly-only group showed 28.8% improvement in CVAI. Although sample size was low, children in the brachycephaly-only group showed 4.66% improvement in CR. Children in the combined plagiocephaly/brachycephaly group showed 41.4% improvement in CVAI and 2.60% improvement in CR. Overall, a 33.5% in CVAI and 2.10% improvement in CR were seen. These results are comparable to other studies of remolding helmet efficacy. Conclusions: The data in the present study, therefore, support the use of the Michigan Cranial Reshaping Orthosis as a viable option in the treatment of plagiocephaly and/or brachycephaly when the primary method of treatment is utilization of a cranial remolding helmet. Copyright © 2015 American Academy of Orthotists and Prosthetists.


Irolla C.,Georgia Institute of Technology | Rheinstein J.,Hanger Clinic | Richardson R.,Hanger Clinic | Simpson C.,Hanger Clinic | Carroll K.,Hanger Clinic
Journal of Prosthetics and Orthotics | Year: 2013

For individuals with bilateral transfemoral amputations, the path to achieving prosthetic use is riddled with physical and psychological barriers. Increased energy demands and a lack of conditioning make it highly unlikely that these patients will ambulate regularly using full-length prostheses unless they have proper training. To address this population's challenges to becoming effective prosthetic users, the graduated length prosthetic protocol was developed. This research used a self-reported survey to determine how patients perceive the functional and psychological impact of this protocol on their prosthetic use. Patients reported an increase in walking activities, prosthetic use, and improvement in overall health from the protocol. Additional research is necessary to determine how functional outcomes varied during different phases of this protocol. Copyright © 2013 American Academy of Orthotists and Prosthetists.

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