Beyond the Battlefield: Veterans Embracing Orthotic Technology

According to the Department of Defense, nearly 32,000 soldiers have been wounded in action in the war in Afghanistan and Iraq with an estimated 900 or 35.5% requiring at least one amputation. While these numbers are stunning, they also highlight the number of Iraq and Afghanistan war veterans who have suffered through traumatic injuries but have not lost a limb. The severity of the injuries the veterans have sustained, such as tetraplegia, paraplegia, neuromuscular disorder and brain and spinal cord injuries has left their limbs intact but without function. Somewhat overshadowed by the advancement in prostheses, orthotic technology is also progressing at a fast rate allowing orthotists to improve the quality of their patient’s lives.

A leap in technology

One area where this advancement has greatly improved is in powered orthoses. Over the years orthotic technology has downsized. Not in the sense that there are less materials out there. In fact, there are more. But orthotic technology has gotten smaller, making maneuvering and manipulating the devices easier for the patient. The shrinking size of orthotics is also necessary because adding weight to an already weak muscle can cause more harm than good.

According to Daniel P. Ferris, PhD, University of Michigan, there are two questions that need to be answered. First, can we build actuators lightweight enough to add power to the orthosis? Second, can you store sufficient energy? These two obstacles have hindered the progress of orthotic technology.

“In recent years there have been major advancements in robotics and shrinking down actuators,” Ferris said. “There has also been better energy supplies developed in terms of the batteries that can hold energy for long periods of time. The field has really accelerated in powered orthoses for the upper and lower limb.”

Orthotic technology is not new. Assistive orthotic technology has been available since the 1980’s. However, according to Gary Lamb, CO at the Veterans Affairs in Dallas, there has been a cataclysmic leap in orthotic technology, especially for veterans.

“We are now providing orthoses with clutch motors in the knees with sensors in the foot plate,” Lamb said. “When they hit their heel on the ground, the clutch motor is engaged so their knee won’t bend. As they go forward, the forward sensor is engaged and the back sensor is disengaged. The knee joint locks completely and then the patient is able to bend their knee and swing it through.”

Lamb is referring to powered orthoses. Due to the sudden advancement in robotics, there has been more research conducted in this area of orthotics.

“The goal is to provide mechanical power to these orthoses in order to assist individuals in moving their limbs, both the upper and lower extremities,” Ferris said.

Quality of life

Daniel P. Ferris Image reprinted with permission from Daniel P. Ferris.

“We evaluate the patient and then select the most appropriate technology that coincides with their goals,” Lamb said. “If their goal is to just stand at the kitchen sink to do the dishes we may be able to facilitate that with lower level technology.”

Lamb adds if a patient is employed at the parts counter of an auto supply store where they are going to need to walk a few steps and maintain an upright posture for a better part of the day, he would provide the technology for that particular need.

Mark Smith, a Vietnam veteran and one of Lamb’s patients, wears powered orthoses on both legs. Smith was stricken with neuropathy in 2006 and has little to no feeling in his lower extremities. Smith still needs to use his wheelchair for long distances but because of his powered orthoses, he has the ability to walk and climb stairs using a cane or walking stick.

“I have one orthoses on each leg. I put them on when I get up in the morning and take them off when I go to bed at night,” Smith said.

His orthoses are battery operated and as he stands up the device locks. The sensors are in his feet. As he moves his feet the sensor locks and unlocks to keep him from falling.

“[The orthoses] makes a major difference in what I can do, because as soon as I stand the legs lock,” Smith explained. “Before, my knees were so weak, as soon as I took a step, pain would hit my knee or something would happen to me to cause me to fall. I’ve come to rely on these and trust them during the day to keep me from falling.”

Smith regularly attends church where he plays guitar for the church choir. He has also begun to bowl again. Smith had been on a bowling league for 18 years prior to his illness. After he received his orthoses, he bowled with his 4-year-old grandson. It was Smith’s first time bowling in 2 years and his grandson’s first ever bowling experience.

“I used to average a 185 and I’ve been practicing and getting close to that number once again,” he said. “I’m looking to get back into a league.”

Lamb believes the quality of life does not need to be a significant detriment due to a severe injury.

“Those types of activities are extremely meaningful and add tremendous value to his quality of life,” Lamb said. “We see a lot of publicity and severity to limb loss but the damage caused to quality of life from these other war injuries are just as serious and just as significant.”

Not a Walk in the Park Research in robotics and powered orthoses has given severely injured lower extremity and spinal cord injury patients the hope that one day they will be able to walk again. While powered orthoses are in the early stages of development, some patients have used the devices and have experienced walking following a serious traumatic injury or neuromuscular disorder. According to Gary Lamb, CO, it is too early in their development to believe that powered orthoses could replace powered wheelchairs, but there is no doubt that powered orthoses can be an improved alternative to regular KAFO’s. Still, many challenges face orthotic engineers, orthotists and their patients. The downside tends to be control. “We are still trying to understand how humans respond to powered assistance,” Daniel P. Ferris, MD said. “And what the best way is to control that assistance.” Ferris explained that patients are programmed to walk a certain kind of way with the limited power that they have. But with extra power, the patient finds that he or she has to think about using their hip or knee relative to that power so they can take advantage of it – not be hindered by it. Mark Smith, a Vietnam veteran, spent hours walking up ramps and down steps with the orthoses after being diagnosed with neuropathy. “I have to learn to unlock and lock these sensors at the same time,” Smith explained. “Their main concern is that I’m comfortable enough not to fall. Where I am right now, I am comfortable so I don’t fall.” Ferris and his colleagues have built powered orthoses for the ankle, the knee and the hip. They are studying in their labs how humans respond to the powered orthoses. They are also researching how the powered orthoses effect the patient’s walking speed and the metabolic cost of giving the individual assistance at different joints. “When you change the amount of power in one joint, it makes it harder and you have to change your coordination for the other joints,” Ferris said. “It takes a training period.”

Different markets

Gary Lamb Image reprinted with permission from Gary Lamb.

There are two main markets in the orthotics field. The first is the traditional market of assistive technology. That is, patients wear the orthoses to assist in their daily activities. The benefits of this type of orthotic devices occur only when patients are actually wearing them.

The second, newer market is orthoses primarily designed for rehabilitation. Patients wear the orthoses for practice or exercise and then take them off. The goal for rehabilitation orthotic technology is for the patient to perform better after taking off the device.

From a clinical perspective, Ferris and his colleagues are looking to improve the control of the powered orthoses for the second market.

“How do you build powered orthoses in order for people to learn how to control their limbs on their own, so that they can take off the orthoses and perform better?” Ferris said. “These are orthoses that act as therapy aids but aren’t designed to be permanent assistive devices.”

For both markets, it would be helpful if the technology was portable and small enough that the orthoses can be worn throughout an entire day.

“Most of the powered orthoses in development are not commercially available yet. They are created for research, but I fully expect many more powered orthoses to become available in 1 to 5 years,” Ferris explained to O&P Business News.

This would help explain why it is believed prostheses receive more attention than orthoses. While orthotic technology is starting to advance it is still lagging behind prostheses. Ferris believes orthotic technology was slow moving not only because of the weight and size issues, but because developers have had trouble making powered orthoses truly comfortable.

“Creating a comfortable mechanical interface and keeping the weight low are two major challenges that are greater obstacles compared to prostheses development,” Ferris said.

Bright future

“It is a great time to be in the field,” Ferris explained. “There are advances all over the place.”

Ferris believes that there is a large range of injuries that are being targeted by the orthotic field. The two biggest fields are stroke and spinal cord injury. Stroke affects a much larger population of veterans and civilians.

Advancements in orthotic technology have been rapid and there is no sign of slowing anytime soon.

“More advances in technology means more opportunities we are going to create to increase veterans’ abilities,” Lamb said.

When asked if it is difficult to catch up to such speedy progression Lamb had a quick response.

“Has your job become more difficult as your computer has improved?” he asked. “No, it has gotten easier with the harnessing of new technology. The same is true for us.”

While Lamb adapts to the newest orthotic technology, Smith has little time to wait.

“The devices that I have now do the job that they need to do,” he explained. “Sometimes it takes a little while for technology to get here and I’m ready to be walking right now.”

Anthony Calabro is a staff reporter for O&P Business News