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Boundless Blog

Custom Orthotics Blog

3D printing: Present Challenges, & Future Research By: Sarah Ogden, Bioengineering student at the University of California, Berkeley

Guest Blogger

 Advancements in 3D printing have garnered a lot of excitement in recent years about its potential to revolutionize industries with lots of customization or prototyping. While the orthotics industry is highly customized, there are several barriers that have limited the technology from being adopted by the industry. One of the biggest challenges was trying to blend the tactile and artistic nature of orthotics manufacturing with the quantitative nature 3D technologies. Another major hurdle that 3D printing faces in the orthopaedic space is that it is significantly harder to make minor fit adjustments to printed devices than it is to tweak ones traditional manufactured. 

My colleague Andre and I realized that a major problem orthotists have with 3D printing is the lack of physical feedback when working on a screen while also having to be more accurate with their adjustments. In light of this discovery, we decided to look into the possibility of printing an ankle-foot orthotic quickly and with minimal material that could be used to check the fit of the device. If a test-print worked well this could not only help save time and material when an orthotist was adjusting to the new technology, but could also reduce the time currently spent remaking devices where the rectifications aren’t corrective enough for patients that are trickier to cast. 

We set out to determine if we could find a setting on the 3D printer where an ankle-foot orthosis could be printed in a few hours but still be strong enough to provide useful feedback about how the device fits and if the rectifications made were sufficient. After successfully discovering functional test-print settings, we focused on determining how accurate the 3D process is. We hoped to find that dimensions and features were well preserved when moving between the physical and 3D spaces. Determining accuracy ended up being more difficult than we anticipated for several reasons. There is virtually no numerical data on foot orthotics, likely because foot and leg are challenging shapes to measure. This meant that we also needed to create methods for obtaining measurements that we could compare in both the physical and digital space.

3dd.jpg

While the measurement methods still need refinement to further reduce human error and a larger sample size is needed to make any definitive conclusions, our results indicated that the dimensions seem to be preserved well through the entire process of scanning, rectifying, and printing. This was promising news both for the viability of a test-print as well as the future possibility to eventually shift to 3D printing when manufacturing orthotics. In the process of evaluating the accuracy it became apparent that optimizing and streamlining the scanning and digital processing will be critical before 3D technology could be potentially adopted widely by the orthotics industry. In particular, the process of scanning needs to be refined to limit unwanted distortions from tiny movements in the leg and the digital rectification software needs to make it easier to gage the extent of alterations made as it currently is hard to visually detect subtle changes.

Our work this summer revealed that there is still a lot of work that needs to be done before it is feasible to use 3D printing in the orthotics industry, but we are optimistic about the potential it has to drastically improve the efficiency of device manufacturing.  

Internship Experience; From France to Canada

Guest Blogger

My name is Janyce Pinjon and I am currently working with the technical and clinical team at Boundless Biomechanical Bracing. 

I come from a small village near Lyon in the south east of France. I applied for the Prosthetics & Orthotics French program directly after high school and was fortunate enough to pass the entrance exam on my first try! I was one of the youngest in the class. After graduating from the P&O French program, I decided that I wanted to go abroad to further my expertise and discover what it would be like to work in another country.

While attending post-secondary school in France, I also volunteered for a non-governmental organization called Handicap International which helps individuals with disabilities in developing countries. With this volunteer experience, I went to Madagascar for four weeks and knew that after my experience there, I wanted to do it again. My biggest challenge would be to improve my English and become fluent.

In 2015, I attended the International Society of Prosthetics & Orthotics world congress in Lyon, France and had the chance to meet Dan Blocka. I explained my project of coming to Canada to gain a invaluable experience and once in a lifetime opportunity. He gave me that chance and after an intensive year of preparation and four mouths of administrative procedures, I flew to Canada on September 13th 2016. 

Easy enough, right??

Upon my arrival, I was faced with many challenges that were quite overwhelming. First was the time zone difference between France and Canada. Then came the American English accent. In France, we learn only British English and we have an awful level of expression. After that, I had issues with my social insurance number, the bank system and my accommodations. Despite these initial challenges, the team at Boundless Biomechanical Bracing were all very welcoming and really took the time to explain everything to me with patience and goodwill. I discovered a dynamic and tolerant team who supports the pursuit of my goals. 

In France, a clinician can work in both specialities; orthotics and prosthetics. This is the biggest difference between France and Canada. Moreover, in my country, we work alongside kinesiologists and physicians. I find the process in Canada to be less overwhelming for the patient and the atmosphere more tranquil. The clinical staff at Boundless offers real quality service and always takes the time for their patients. The technical process are much different as well. In France, we fabricate more carbon fiber devices and have a much different modification process involving scanning and software programming. As for government funding, braces in France are completely covered by the healthcare system.

It has been six months since I’ve arrived to Canada, my experience at Boundless has been very enriching; I’ve improved my technical skills, clinical abilities, and most importantly my English. I am grateful to have met such warm and friendly group of individuals. To me, they are like a second family. I especially enjoyed being introduced to their culture at Thanksgiving and Christmas! Canada now feels like home and it will be hard to leave. Once I complete my internship at Boundless, I am planning to celebrate Canada’s 150th birthday, travel through some awesome national parks and hopefully cross the border into the United States, where I hope to explore the east coast.

This September I will return to my home turf in France, where my family and friends are anxiously waiting already!

This experience has definitely been challenging for me but I have learned the importance of perseverance, optimism and I have gained more self-confidence. I will never forget this exchange. 

Thank you all so much!

Janyce

How is my brace made? By: Anne Whitney, B.Sc., Orthotic Resident

Anne Whitney B. Sc, Orthotic Resident

We routinely get questions from clients about how their device is made, starting from how a design is determined, to how their own brace is actually fabricated. It’s a complex process that begins with the expertise of your orthotist to determine what style is most appropriate, and then uses our technical team’s talent and skill to craft each device as uniquely as our clients.  

Your orthotist will first conduct a thorough assessment that includes relevant medical history and a physical examination, and your orthosis design is based upon these findings and observations.  We will factor in your activities of daily living, social situation, other relevant treatments, range of motion and strength testing, functional testing, and observational gait analysis.  Any prior bracing will be considered, evaluated, and improved upon if possible.  Following the assessment, your certified orthotist or resident orthotist will take a cast of your limb.  This captures the three dimensional shape of your limb to work from. This is achieved by wrapping fiberglass casting tape or plaster bandage around your limb and held in a desired position until it sets. Once removed, the cast is sealed and filled with liquid plaster to create a three dimensional positive replica of the limb. A metal rod is inserted into the top of the cast which allows the positive to be held in a vice throughout the fabrication process.

The plaster cast then undergoes a modification process where additional plaster is added in areas to create pressure reliefs and shape of the device. This is a critical step in making an orthosis as this process will determine the function and fit of your brace, and this process draws heavily on the experience and knowledge of your orthotist. The cast is then smoothed to ensure there are no bumps or uneven spots as this would create a texture on the inside of the device. The cast is then left to dry, which usually takes about 24 hours.

Our highly skilled technical team at Boundless take the dried cast and move the process into fabrication.  If any padding is being added, this will first be heated and shaped to the cast and edges thinned to avoid any ridges.  To make the plastic shell of the device, a sheet of plastic is heated in an oven at about 400°F for approximately 20 minutes and until the plastic is clear. The pliable plastic sheet is draped over the cast and sealed under vacuum, which will pull the plastic tight to the shape of the cast.  This is left to cool for about 24 hours before being removed.

The device shape is cut off the cast using a handheld oscillating saw and the edges are trimmed and rounded using a sanding machine that shapes and buffs the edges. Straps are measured, sewn, and riveted to the plastic device and pads are glued in.  Any other additions are made in-house and then attached to the brace as the final step.

The device is now ready to be fit to the client. During the fitting appointment, your orthotist will check for initial fit and ensure snug areas are eased or padded as needed, and trim areas of unnecessary plastic. Once the static assessment is completed, we will fit the device into a shoe (if a lower extremity device) and perform a dynamic assessment to evaluate your gait pattern and function of the orthosis.  Based on observations and client feedback, we will continue to tune the brace to ensure it has the desired fit and function.

Although this is a very simplified version of the process, it provides some insight into the various steps we take to provide orthotic management to each of our clients.  We welcome any questions you have about your own process or general inquires, and hope this has provided some useful information on how an orthosis is made.

Click on the YouTube link below to watch the process. Don't forget to subscribe! 

"Everyday may not be good, but there is good in every day" By: Sydney Weaver

Guest Blogger

Sydney Weaver is 16 years old, lives in Acton, Ontario and has Cerebral Palsy. Sydney has been wearing Ankle Foot Orthoses (AFO) from the time she can remember and says her favourite part of getting a new pair is picking out a different pattern. 

Sydney has never let her disability get in her way and has an extremely positive and can-do attitude about life. Her mantra is “Everyday may not be good, but there is good in every day”. Sydney is very social and admits one of her favourite things to do is to talk. Sydney is an honour roll student, has her junior lifeguard badge and an orange belt in Jujitsu (Martial Arts).  In 2015, she was a torchbearer for the 2015 ParaPan Am Games. She is also Miss Acton Fall Fair First Runner- Up 2016-2017. She is an active ambassador for children’s charities in Ontario. Sydney also has a passion for harness horse racing and hopes to become a [harness horse] trainer one day. 

 Pinky & baby Jo

Pinky & baby Jo

For Christmas in 2012, she received her very own race horse. The name of her horse is Sydney Seelster, and Sydney gave her the nickname “Pinky". Pinky raced for Sydney while being trained by Sydney’s father Don from 2013 until 2015, since then Pinky has stopped racing to have a baby. Pinky gave birth to a beautiful filly in April 2016. 

In addition to having a passion for harness racing, she also enjoys writing and hope to attend post-secondary education studying journalism. She has recently decided she would like to study abroad.  

Sydney won the Marie Hill Youth Writing contest in 2012. A contest based in the United States, where she won her age group and then was named the overall winner. Her winning article was then published in Hoofbeats Magazine. 

  Sydney out for a jog in her custom sulky seat.

Sydney out for a jog in her custom sulky seat.

This opened up the opportunity for Sydney to write for harnesslink.com; an international harness racing website. She writes about her experiences in harness racing.  In 2015 Sydney was a Media Award Finalist for a piece she had written for Harnesslink.com. Although she did not win she says “it was a great honour to even be a finalist”. 

Through writing for harnesslink.com and harness racing Sydney has had the opportunity to travel to harness racing tracks in the United States, throughout Ontario and this past summer had the opportunity to go to Ireland for a week for a horse racing event. 

Sydney looks forward to whatever adventures come here way and knows that the team at Boundless Biomechanical Bracing will be there with her. 

What is “flat feet” in children and does it require treatment? By: Adrienne Cuch, CO(c), M.Sc, B.A.Kin

Adrienne Cuch, Certified Orthotist, B.A.Kin, M.Sc., CO(c)

We are often asked by parents and therapists about a child’s foot appearance, and whether the child requires an intervention to address their malalignment.  There is some available research in this area, and the expertise of our Orthotists can provide insight on when to be concerned.  First, it’s important to understand what “flat feet” is and what things to look for as parents and therapists.

Flat feet, also called pes planus, is commonly defined as a flattening of the arch during weight bearing.  Pes planus is quite common in young children (up to 44% of three to six year olds) and may or may not be symptomatic.  As the arch is still developing when the child is under the age of six, treatment in this age group is debated in the absence of other symptoms.

 Nale, R. (2016, July).  Pediatric Myth Busters: Common Misconceptions.   Current Pedorthics , July/August, 16-21.  

Nale, R. (2016, July).  Pediatric Myth Busters: Common Misconceptions.  Current Pedorthics, July/August, 16-21.  

What can symptoms look like?  

The most obvious is pain, although this is not the most commonly observed symptom.  The child may be reluctant to participate in activities requiring running, long periods of standing, or endurance activities.  They may have difficulty keeping up with peers, or have balance issues that are not age appropriate.  Late or missed milestones such as standing with support, walking, may also be related to poor alignment at the feet, as this does not place the muscles in an efficient position to stabilize the legs.  These, coupled with a visual malalignment of the ankles may indicate that your child requires treatment.  

How is the treatment plan determined?

Each child will have a complete assessment performed by their orthotist which involves collecting information about family history, medical history, activity level, age of child, symptoms, and other treatments.  A physical exam will reveal joint range of motion, strengths, functional testing, observational gait analysis, and foot and ankle alignment in non-weight bearing and weight bearing.  The heel or calcaneal alignment will determine if it is appropriate for their age.  For example, it is quite normal for a child to stand in some degree of valgus, or tilting inward, and this should diminish with age (they should reach a neutral alignment around age seven).  The assessment will be summarized for the parent and a discussion will allow collective input from everyone about an appropriate treatment plan.  We will commonly use clinical practice guidelines to provide guidance on when to treat children with pes planus. Often if a child with pes planus is asymptomatic and is of a young age, patient education and follow-up is recommended as this tends to resolve without intervention.

What are the treatment options?

Treatment is highly varied and tailored to the specific child and their family.  A number of factors will be considered when developing a treatment plan, and the recommendations may include:

  • Patient/parent/therapist education
  • Footwear
  • Prefabricated foot orthoses or heel cups
  • Custom made foot orthoses
  • Supra-malleolar orthoses (SMO’s) or dynamic movement orthoses (DMC’s)
  • Ankle-Foot Orthoses (AFO’s)

Your therapist may also recommend supplemental treatment options such as stretching or other exercises.  

How long will the child require treatment?

This is very specific to each child and even difficult to determine at any point in time.  Children will require replacement devices due to growth every 12 - 18 months, and these re-assessments will determine if the child still requires intervention.  Some require one set of devices, others will wear them throughout childhood.  Other times we will discontinue treatment for a period of time to see if symptoms return, at which point we will re-evaluate the treatment plan.  In general, you can discuss any concerns or questions you have with your orthotist, who will work with you to determine the best plan for your child.

In summary, treatment of pes planus is highly variable and debated among practitioners, but there are a number of tools available and the expertise of your orthotist to determine if a child requires intervention.  If you are having concerns about your own child or one of your clients, we recommend an assessment with one of our orthotists to determine if intervention is necessary, or if it will resolve on its own.  In general, our recommendations always have the child’s best interests in mind, as we want to help to maximize their quality of life.

 

References:

D’Amico, J.C. (2001).  Developmental Flatfoot.  An Introduction to Podopediatrics, 2nd Edition.  257-259.  Elsevier Ltd.

Harris, E. J., Vanore, J. V., Thomas, J. L., Kravitz, S. R., Mendelson, S. A., Mendicino, R. W., ... & Gassen, S. C. (2004). Diagnosis and treatment of pediatric flatfoot. The Journal of foot and ankle surgery43(6), 341-373.

Pfeiffer, M., Kotz, R., Ledl, T., Hauser, G., & Sluga, M. (2006). Prevalence of flat foot in preschool-aged children. Pediatrics, 118(2), 634-639.

Rome, K., Ashford, R. L., & Evans, A. (2010). Non-surgical interventions for paediatric pes planus. Cochrane Database Syst Rev7.