The Prosthetics and Orthotics Podcast
The Prosthetics and Orthotics Podcast is a deep dive into what 3D printing and Additive Manufacturing mean for prosthetics and orthotics. We’re Brent and Joris both passionate about 3D printing and Additive Manufacturing. We’re on a journey together to explore the digitization of prostheses and orthoses together. Join us! Have a question, suggestion or guest for us? Reach out. Or have a listen to the podcast here. The Prosthetic and Orthotic field is experiencing a revolution where manufacturing is being digitized. 3D scanning, CAD software, machine learning, automation software, apps, the internet, new materials and Additive Manufacturing are all impactful in and of themselves. These developments are now, in concert, collectively reshaping orthotics and prosthetics right now. We want to be on the cutting edge of these developments and understand them as they happen. We’ve decided to do a podcast to learn, understand and explore the revolution in prosthetics and orthotics.
The Prosthetics and Orthotics Podcast
Reshaping Patient Mobility with Sean McKale
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Special thanks to Advanced 3D for sponsoring this episode.
Prosthetics and Orthotics Podcast
Speaker 1Welcome to season seven of the prosthetics and orthotics podcast. This is where we chat with experts in the field, patients who use these devices, physical therapists and the vendors who make it all happen. Our goal to share stories, tips and insights that ultimately help our patients get the best possible outcomes. Tune in and join the conversation. We are thrilled you are here and hope it is the highlight of your day.
Speaker 3Hi everyone, my name is Joris Pules, and this is another edition of the prosthetics and orthotics podcast with Brent Wright. How are you doing, Brent?
Speaker 4Hey, joris, I'm doing well, man. Spring has sprung here in North Carolina, so I'm looking forward to some warm or weather. How things out your way.
Speaker 3Super good. It's really nice here and everything's going really really well, so really happy with everything. So you know, we have a sponsor right for the show and that's Advanced 3D, I believe and they're a contract manufacturer design service for prosthetics and orthotics. Do you know anything more about them? Brent?
Speaker 4Well funny, you should ask, Joris. You know Advanced 3D. I'm a part of it along with Tyler and Paul. We are a contract manufacturer, but I would say our wheelhouse is helping bring some of the products to market or say something that's technical or technically challenging for a patient. That's something where we can definitely use our expertise and design something digitally and then 3D print it for you. And then the other thing that we can do is come alongside you and wherever you are on your digital journey. We talk about scanning, design and fabrication, and we can help you with that as well.
Speaker 3Oh God, super cool. So if you want to give a shout out to Advanced 3D or check them out, do so. So, Brent, what do we have on the podcast today?
Speaker 4Well, today we have Sean McHale. He's the director of clinical education and customer support for Becker Orthopedic, and Sean and I have known each other for a long time and what's interesting about Sean is that he has chosen to specialize in the orthotic side of not only manufacturing but, as an orthotist, creating clinically relevant solutions for patients. And Sean and I have a love for things that kind of dive into the weeds and get technical and he gets way more technical than I do, especially on the orthotic side of things. But I think we can both agree and this may upset some of our audience but orthotics, or being an orthotist and doing orthotic devices, is much more difficult than making a prosthesis. Oh, wow, you've actually alienated everyone here Except Sean.
Speaker 3Half of our people have just dropped off and will never listen to us again.
Speaker 2But Sean is super happy.
Speaker 2Well, you know, I always say you know people come to the field because prosthetics are what are sexy, you know, real visual and everyone sees and is exciting. But orthotics are challenging and interesting and that's really what I think keeps some of the clinicians more engaged when they get into the field too. So a lot of students, especially now that you go to school and become both CPO and so you're studying both orthotics and prosthetics, you get to discover all this challenges that orthotics provide you. So I love it and, yeah, they are absolutely, I think, more challenging than prosthetics.
Speaker 3Okay, so how did you yourself get involved in the field, sean Sure?
Speaker 2Thanks yours First of all. Guys, thanks again for the invite into the podcast and sharing some of my story and what we're doing at Becker today. I'm excited about that. But I started out as an athletic trainer at Purdue University. I thought I was going to become a physical therapist when I graduated from school and the reason I chose Purdue was because most of the staff was athletic trainers or, in, physical therapists.
Speaker 2And I was getting done there and sitting down with my mentor and kind of saying, well, I think I want to go make furniture, do something more with my hands. And he said, well, what do you like about athletic training? And I liked, when we made these felt pads, to go inside guy's shoes and kind of test out if orthotics would work. And then we'd take foam box impressions and mail those off and we made wraps around their arms and put this paste over it that they used in the veterinary college to euthanize horses but we used to make splints out of and I didn't realize it was a profession that I was describing, that existed out there. So he hooked me up with the guy who was kind of our Don Joy Wrap, who in turn hooked me up with someone who was down at the VA in Indianapolis and I went down there and I shadowed for a day and it was just, I thought, amazing he was mostly fitting diabetic shoes all day, which for people in the field would be chuckling at that, calling that amazing. But I was enthralled by it. And he suggested to me, because I was from the Metro Detroit area, that I tried to get a job with a company called Ryan Philippus because they had helped pay for some of his classmates to go to school. And that's what I did and I was fortunate to get that opportunity return to Northwestern as an orthotic student. That's back when it was still a post baccalaureate certificate program. So I never returned and did the prosthetic aspect of it, but I was fully engaged and dove into the orthotic portion.
Speaker 2The residency program at the time was a really great program where we got to travel between the different clinics of Metro Detroit and really experience those different specialty clinics and develop who you were as a clinician too. So we went to diabetic wound clinics, we went to spina bifida clinics, post polio clinics, spinal cord injury. I got to see just a real full gamut of what the orthotic experience was scoliosis, acute care, all of those different things and then at the end of my residency I got to kind of figure out where I was going to fit best and also where they needed me best too. So I got to lead an office at the Rehab Institute of Michigan in Detroit and that was a really cool experience because I got to develop more as a neuro orthotist, if you would. So seeing those acute care rehab patients spinal cord injury patients, post stroke, tbi type of thing that was you know, are challenging, but I really love being there kind of at that initial phase of recovery and being part of the team. I also got to be part of one of the first in the country. It was the first dedicated clinic to Charcot-Marie tooth. I've been an advisory board member for years with the Charcot-Marie tooth association, Eventually left Detroit, took an opportunity to open a practice for Midwest orthotics when, after meeting Bernie Velman, he wanted to open a practice up in Chicago, moved up there.
Speaker 2It was there for about eight years and that was a great experience. I love traveling around to schools and therapy centers and our mobile labs Still really focused on pediatrics and adult neuromuscular and then later they have to learn took a position at the University of Michigan running their acute care team. So we dealt with all the trauma cases putting helos on patients. We had scanned people after spinal surgeries or if you came into the hospital with a broken back and they weren't going to do surgery but they were going to fit you with a custom back brace. That was our role and we fit those within a 24-hour period in most cases where we would scan the patients, fabricate the custom TLSO in-house and then deliver that so the patient could be discharged.
Speaker 2So I really enjoyed that role as well. One of the things that I got really excited about working with the rehab patients was using the Becker Geos, the gate evaluation orthosis and the triple action joints. That joint technology and the change in it really got me excited about things we could do for for patients in terms of optimizing their gate. I got a little too excited that I started talking with Becker and they decided I needed to start coming and telling some other people about that too. So that's kind of how I talk my way into this role, if you will. And now what I do is I help consult on the jobs that come in through our central FAB questions customers have through manufacturing on componentry selection, as well as educating at a lot of our national events, so kind of a mixed role between R&D in some cases. Sometimes it's also just our regular CFAB production. I really enjoy myself and the progress my career has made so far.
Speaker 3And the thing is, most people do both, especially now, right, almost everyone does both. And now you're looking back. We're like, oh wow, I actually would have been valuable for me to go back, do that extra time and do that prosthetics bit as well. Or do you say, oh yeah, there is a case you made to doing only orthotics and being 100% Mr and Mrs orthotics.
Speaker 2Well, I think there's value in learning it all, and I've certainly been around enough processes, managed processes, seen a lot and learned a lot from our prosthetic colleagues as well too. So I haven't been shut off to that, even though I didn't necessarily do the formal education on it. I think there is a huge scope that we have as clinicians. The design and the 3D printing thing is such a small part of even the need of what our patients have too right, and it's a great tool in the toolbox. But we have so much breath of what we do, from the moment we evaluate and ultimately the moment we deliver something and how we follow up with that and the care we provide as clinicians, and I love that. But being able to put yourself into a more specialized area is also something that's really kind of unique about this field too, whether you could be someone who just wants to do cranial remolding, orthosis all day and have a busy practice and that's all you do.
Speaker 2I never really had the opportunity to do a lot of scoliosis, but if I had to redo my orthotic career, that might be an area where I would focus more of. I really am passionate about the lower extremity and that's what my major focus is at the moment is is outcomes we have and the work we're doing with lower extremity orthotics. So even within as an orthosis, I think you specialize and you do the thing that you do. It's hard to be great at everything. It's hard to know everything about everything, so it's great that people have this opportunity to specialize and have colleagues around them that they can defer to or ask questions of. So I think there's benefit and there's disadvantage also to being too general.
Speaker 3Okay, and if I were to either like an orthosis prosthetist, but like more towards a prosthesis I want to learn more about making, I want to learn how to make a better orthosis and stuff like that or if I was just a student starting out, what would you? You know, how would you say I should get started? Well, how would you advise me to know more, to learn more and to really become a more expert at this area?
Speaker 2Yeah, I mean I think your one school was great and I really appreciate the education I had at Northwestern. But leaning into your mentors and really understanding what, how they're processing the information, what did you see during that patient encounter? Understanding the biomechanics. Take your questions home with you. Try to understand deeper. You know, read more.
Speaker 2I definitely feel early in my career I was able to advance and move forward in ways my colleagues weren't especially with. You know things like adapting this using stance control early on. Part of the reason I was put in the position that I was with the company at the time was because my willingness to adopt and use some of the newer tech that was out there but that took understanding really understood what the limitations of that were, what the right clinical presentation was that met that device and what it could or could not do too. You know you can't just put every spinal cord injury patient in the stance control KFO. You had to understand what the restrictions of that and what it was what was going to be the right implementation of that as well too. So I think, just really trying to lean into all the learning opportunities, ask all the questions and have an opinion. Have an opinion about what you just saw and what you would have done maybe differently. Even when I deliver something to a patient now, I still think about well, how could I have made that better? What could I have done to improve that? I made it a little faster the next time. How could I have communicated with the lab that I'm working with to get it back so it may have just slapped on a little faster and not required so much time through the delivery appointment? So I could have focused more on the tuning things or the adjustments that the device has, rather than spending all the time on trimming the trim line back or adding an extra pad or something that maybe, if I thought about a little bit more in advance during our evaluation, would have gone faster than in my delivery appointment too.
Foot Alignment and Orthotic Success
Speaker 2I think constant improvement is really important for all professionals. It all starts at the input of what we provide to our fabrication partners, whether we're fabricating in-house and using a technician whose shoulder to shoulder to you, or you're sending it to a CFAB, like us at Becker and you'd really. If you have a question on that order for me, you don't know what. Why are they asking me to and to? I don't know how to really answer that or how they're measuring that. Make a phone call Really get good understanding of those forms you're filling out, complete the forms that you're filling out. Nothing is harder for us when there's a missing question on that order form or there's contradictory information sometimes too. But we can't proceed into production unless we have good clarification on what we're about to manufacture for you as a customer too. So those relationships and it all starts with communication really important for you.
Speaker 3So talk to me about this. This fitting for the device, like what are some steps that I think everybody knows, is generally, I think. But I think that we benefit a little bit more in knowing, like, are there really specific steps you would say that are really key to success, or things that people should be doing on top of what everyone else does to really make sure that patient gets the best advice? It's the right alignment, all that kind of stuff.
Speaker 2Well, I believe that the foot really needs to be in good joint congruency to create power to help patients with propulsion and, ultimately, adoption of their orthotic. And if you have poor alignment, how are you improving that alignment? So if you've built or designed the orthotic in a way that we've got good postural control first, you have to assess that. Did you actually gain that good postural control then at that delivery appointment or not? You know, if a patient has complained of pressure on their navicular bone, for example, what do you do about that? Do you just heat out the orthosis or bump it out more? Or do you need to add a medial four foot post or an ST-pad modification or padding along the super malleolar area in what we call a sablitch modification? You have to address the individual's positioning and look at it critically as you're delivering it, to say, did you meet the goal of what you expected to do with the product? Maybe you cut the trim line too low, maybe you did something that sacrificed the result to fit it inside of a shoe. And I think that criticality of what you're doing and how you're doing it, that you met your goal at the delivery appointment, is just as important as making the goal to begin with it too. So to me it's really about assessing that you accomplished what you set out to achieve.
Speaker 2And first thing, with lower extremity of thought especially, did I get the alignment? Do I have the postural control that I need throughout the gait cycle and while the user is using it, and that ends up being comfort for the person? So do they feel comfortable in it? And that's what they're expressing to you? I feel this bony pressure, but that bony pressure to you should be a light bulb of well. I missed out on an opportunity to control this limb in a way I meant to do so. So it's not always a direct route to what the fix will be, but you have to be able to interpret the information your patient is giving you to making sure you're getting the results. That's needed.
Speaker 4Sean, can you dive into that a little bit more? So I know you kind of glossed right over that, but I think it's super important on the alignment side of things and some of the bony stuff that's going on. If a patient is, say, getting a pressure on the duvicular and what have you? The first answer to me at least this is what my mentor said is not blow it out and throw a pad in it. It is what can you do to support it, to keep that bone from hitting?
Quality Control for Orthotic Devices
Speaker 2Well, exactly, I mean, I think you do need to look and see is the relief in the right spot? Is, did we relieve it sufficiently enough? I don't think you need to ignore that entirely necessarily, but beyond that, I do think you need to be critical of well, how was I anticipating correcting this foot alignment to the joint congruency that I evaluated or anticipated, and am I, why am I losing out on that? So, was it an issue of a trim line? Was it a rigidity of the material? How can I improve that? Do I need more medial-launch shoe arch padding or an ST push, or do I need more of a four-foot intrinsic post? The answer isn't necessarily always going to be the same. For that you have to go back and reassess the result that you have, and I've been there. I expected more of a calcino grasp than I accomplished, so I have a recovery for that. Now I'm going to go take some tri-lam and skype it in a way that I know will help and work for me in that regard. So I think you have to address it individually, but that's one of the great things I think that we can do.
Speaker 2As this profession is, we're not necessarily stuck where we're at. We can fix it and change it, but we need to look and be critical of that result as we have it too. Otherwise there's no recovery. And being in a CFAB like this, we see all different things that occur and things that get sent back. Sometimes and it's like, well, they've trimmed the edges all the way off of the orthotic. And then they're wondering well, why is the person running into the metal ankle joint? And it's like, well, you sent me a picture of the person's foot too, and it's completely rotated to the side and you've removed any control mechanism you had for that posture. So I think that's very fundamental to what we're thinking about when we're designing or how we're planning to control and use our orthotic devices on our patient's feet.
Speaker 3What I'm very interested in as well is like are there any kind of quality control routines or steps? You said this bony feeling pain with the patient obvious, right, but there are other things that you recommend people do because to me it usually would seem to me that with a prosthetic it would be the mistakes would be very obvious very early on for the professional and also the patient. But with an orthotic I could imagine you could make a mistake that someone notices when, like, their back gives out six months later. You know what I mean. Are there any kind of steps you would super recommend for people to do to really, you know, mis like reduce problems and stuff like that?
Speaker 2Well, I think. Well, first, to defend the prosthetic colleagues a little too. You know that people change. There's a lot of dynamics in their presentations. They're not the same they are the day you delivered the device. They volume fluctuations, activity levels, muscle strength All of these things have an impact then on the outcome of that fit, of that socket, and to the orthotic too.
Speaker 2Right Like the orthotic won't really change unless we do something to it. That's something I help to share with my patients, like I want to know if this thing feels great today. But a week from now, if you're finding you're not able to wear this because you know standing on it for six hours is bothering you and that's not helping you accomplish your goals, I want you to call me, I want you to come back and see us. You know the answer you're looking for yours is not so, you know, straightforward, because there's so many different devices, so many different things that could be occurring here, and you know it's just challenging to answer this in a straightforward way. I think it resolves itself in that one. We have to be confident in what we're doing and that we're setting a path for the patient to have success, but also that they know this is a process that they have to come back to and give feedback so that we can know what additional steps or changes may be necessary to make.
Speaker 3And how about, like, as you guys, if you look at this marker from a CFAB point of view, it's like that whole 3D scanning. You know 3D printing. Is that like the wall hollow for you guys? Or is it like, yeah, no, it's not really a big deal?
Speaker 2Yeah, we're definitely working towards it and currently accepting scans for AFOs. A lot of people are asking me to accept scans for KFOs too, and we're working towards that. But we're trying to really make sure we have validation on cast alignment and corrections and what we're doing. I think it all starts with proper input right. So we need good inputs to make quality fitting devices. You know we say it all the time in this field garbage in, garbage out, sort of thing. But we have to be critical Am I providing good inputs so that they can then come out with the device that I want as well too? I recently was speaking with some colleagues in the UK and they told me that if a cast was sent to them and required cast correction, they'll send it back to the clinician. So and I love that I love that, the standard, that that holds the clinician to as well as the lab too, that integrity of saying, well, we can't really build something and assume that because we wedged a cast in a few degrees this direction or that direction, we can necessarily move forward and confidently fit the device. Then, that this brace is going to fit well too. And you should see some of the molds we receive here and what we're being asked to position the mat compared to what they come in at. I've recently reviewed, like what I received at Northwestern, which was take the mold in the position that you're anticipating fabricating the device. I've reviewed the older Oregon orthotic systems casting stuff and what they gave customers was up to a five-stage KFO casting process and the end statement of that casting course is you need to provide us with a mold that is representative of the shape of the device that you're anticipating fabricating. And I think that how we contain tissue and hold tissue, we think about a lot in prosthetic shape capturing, but orthotists need to be just as concerned about that when they're looking at the thigh. Or they're casting a patient's supine and make sure you bolster underneath their glutes so that their thigh isn't flattening out. Or do a two-part cast where you get semi-weight bearing below the knee and then let that completely harden, then have the person lay back, extend the knee, work on that.
Speaker 2Next, you have to think about your process significantly whenever you're doing anything in this field, because if you don't, it's going to have an impact on the output. And with scanning, I can tell you that the better quality scans we receive from some of the better scanners, you're going to have a better outcome, and you know the difference on the scans when they arrive to us. We have better results from people who are positioning their patients using clear plastic boards. They've thought about their scanning setup, lighting in the room. All of those things matter towards that. Scanning outcome, or scanning the mold they actually fill the positive mold. I think you get a much better quality fit than if you're scanning the outside of your mold. It's just that's going to have an impact on the input. Has an excuse me? The input has a impact on the output, no matter what we do, and we have to be concerned about the quality of the inputs we're providing, especially when you're working with the CFAB, because they don't have the advantage of having seen that patient and knowing what you know about that individual.
Speaker 3Yeah, I think it's a good point. Of the scanners, I remember in Holland at one point the government had this really well-meaning initiative where you could get like an innovation credit and for like it was like two grand I don't remember exactly what it was, but it was like $2,000 on with this, which meant that a whole bunch of people started buying $2,000 scanners and at the time this is years ago there weren't that many good scanners out there for $2,000. So what you had is all these people that had these really bad products just making really bad scams and then they would have to learn CAD to patch it all up, and that was also not sufficient. You know, do you have an idea of like what kind of scanner you would need to use, or some of the qualities that scanner would need to have, or some of the qualities that are set up? I think that you know the clearest plastic board, the kind of fitting board and all that kind of stuff. That could be a good idea.
Speaker 2To give any kind of more recommendations how to scan properly, I'll say yeah, I mean I think you need to really be concerned about your setup and know that those things have an impact. The clear plastic boards that are out there are great for semi-weight bearing. If you're not doing that, then you need to have a plan for someone who's holding the foot while you're scanning. If you're direct scanning a patient, if you you know, I also really think it matters what the device is. That you're scanning too right Like the cranium in some ways is easier because it doesn't have the moving parts and such that the other parts of the body do. It's more of a fixed shape and you know. But when we're in the hospital, for example, there is a quality difference between if I'm scanning in my patient room versus when I had to go to the OR and scan a post-operative baby for a helmet. It was more challenging and I had to be able to go into that OR and say I want these lights turned this particular way and I need the child position this particular way and really run the OR and be confident enough to tell the anesthesiologists and the other people in the room, because that affected my outcome as a clinician.
Speaker 2You know, when we were doing spinal jackets in the hospital. We could get a CT scan from the ER within a 24-hour period and we'd get a kind of surface-level scan. But it wasn't in a position where it had, you know, the right lordosis for what we needed. Sometimes it was muddled a little because of the clothing or other things they had on, but we could use that along with our measurements and then CAD, get to a model shape that was relatively, you know, close to the patient and there's a lot of forgiveness in that type of device. When it comes to an AFO, there's a lot less forgiveness, especially when we're trying to control posture. So you have to be that much more concerned about the quality of that scan. And it's hard too, because some of the scanning software doesn't give you all the feedback you need as a clinician when you take the scan. So, for example, we've had clinicians on the order form right.
Speaker 2Well, I want a 16-inch AFO fabricated for us and then they send you the scan. The scan looks good but it's only 13 inches tall. Well, I'll just make up the other three inches and what happens up there. So it's like if you need to know and verify your scan. I think that's a good step for clinicians to know what they're sending out, that it is actually one-to-one with what their measurements were. So you know, I think that works well.
Speaker 2I know the feedback from clinicians who send us already modified scans are real happy with the fits. We're happy to take an already modified STL and fabricate you an orthosis. So those are things that again, I think you really need to have an understanding of what is the CFAP doing with the input that I'm giving them and what are the challenges of the input that I'm giving them and not giving them. So I do think there are really good scanners now on the market, relatively inexpensive, that have a fixed cost that once you use that scanner you can get. You know you can keep the STL, like the Einstein scanner is a good one out there, and you know that opportunity for clinicians to buy something that high quality for $1,000, when before it was $10,000 or $30,000, I think the first scanner that I ever encountered in the field was $30,000.
Speaker 2And I just think, yeah, we've come a long way in what we can put in someone's hand. But I also think the word of caution on some of the other scanners that are, you know, fit in our pockets on our cell phone is just the differences on technique. That needs to happen. You know, I recently switched from an iPhone 15, from an iPhone 12 to an iPhone 15 and discovered you have to be even much closer to your patient or your model as you're scanning with a new iPhone because of the change in the hardware technology. So it's really interesting to see how that stuff evolves over time. I'm glad people are working on it and making it more accessible to us as a field. But I think you need to be critical of what you're doing and how you're doing it, whether you should be doing it or not.
Speaker 3Okay, that's super cool. And then with the you know, and I think I think it's really important that you say this is correct dimensions this happens a lot on Adder generally, Do you also think, like I know, that certain people making like customized insults and things like that, they have footbed scanners as well, another kind of like equipment for measuring tread and then all that kind of stuff? Do you see any movement in making that more available for orthotics offices and stuff like that, these tools becoming cheaper? Because, like you said, scanners, you know they've gone on a really really considerable journey but this other equipment seems to be quite rare and quite pricey. Still right.
Advancing Patient Outcomes Through Innovation
Speaker 2Yeah, I mean I think that's going to be the tipping point for more adoption, right, and that that's always the case of newer technologies too. But as it becomes more reliable, more accessible, then there'll be further adoption into our field, of course. I think. You know I'm really interested and have been interested to engage in these things and these conversations. You know that's kind of how I started talking with Brent the first time and still would like to do more.
Speaker 2And as a clinician, there are certain things like oh, there isn't something available to this patient that's off the shelf or even easily customizable solution. But if I could 3D print it, then it would be amazing. One encounter I can distinctly remember is like a eight-month-old child that needed a CTLSO because of a fracture in the C5 vertebrae right. And you know, in being in a hospital I have access to this CT scan and then can get a beautiful 3D shape of this person without even having to do the trauma of rolling them or measuring them, and that would have been a perfect application for these kind of things. But then having the access to the machine that can print that and the engagement with the person to do it in a fast way is the ideal. That's the future. I think that hopefully someday hospitals have that relationship with them, that ability to do, but right now I think it's still not there. There are certain places, certainly around the country, where that's more the case. I think the relationship with the radiology department and those situations is really important. I saw the advantage of that, but there still could be more to move people out of their silos and work together and collaborate to get some amazing patient results and new solutions in areas where we're not necessarily addressing or delivering devices to currently. I think there's opportunity for us. Yeah, I think there's movement in this direction. I think we need to be concerned about the outcome of the devices that we're providing to customers, to patients, and I think that's why, just because we can build something a certain way doesn't mean we should. I think we need to think about are we getting the outcome from making it this way too that the patient needs? So I'm still a believer that you do need to incorporate componentry into your designs more.
Speaker 2Again, I became a big fan of this one particular joint because it, for me, is a big shift in how I can treat a patient kinematically and gain a better result, to the point where maybe someday they no longer need to wear an orthosis as well, and I've seen those results clinically that I feel like we need to have that message more as a field too.
Speaker 2I recently had a conversation with a PT who had done a neuro training out at Rancho in California and she said she'd seen one of my talks and she'd been like, well, yeah, when I went out to Rancho I saw those metal ankle joints all the time and they would fit patients in inpatient rehab with those and by the time they got the outpatient they no longer even need it today if those that were doing so well and I think that's an important message for our field too Like, if you don't overly walk plantar flexion, you actually can address a patient's kinematic really well and get a good result for them.
Speaker 2They may recover, that they might not need our services any longer, which to me is should be part of our goal and what we're doing. So we have to understand there's consequences when we're making AFOs that overly restrict plantar flexion or prevent proper biomechanics and that may be keeping your patient from making the progress that would eventually help them to no longer need that service too. And of course that's very like clinical rhetoric and not necessarily well researched, but it's something I see happening in our field and in our world that I think we need researchers to look at more critically. We need to understand why are we having those outcomes in some cases but not in other cases, and that's why we do things a hundred different ways to treat the same patient presentation too. So sorry, I went on a crazy tangent there.
Speaker 4But no worries. Well, and I think that's good because and I want you to dive a little bit deeper into this idea of allowing plantar flexion and dorsiflexion, and you mentioned a little bit earlier that about the triple action joint and what gets you so excited about that.
Innovative Approach to Orthotic Design
Speaker 2So can you, in a cliff note but don't hesitate to get into the weeds a little bit Just share with our audience why you feel so strongly about that and yeah, I think even clinicians who have adopted the use of it still don't have a great understanding of the most part and frankly I didn't really until I began working here and started teaching about it. But the unique part is that we've developed this systematic approach on how to adjust the joint and it came from some biomechanical research that led to that. We start by taking away all the dynamics from the joint and we begin with static alignment, just like you do in prosthetics. Set up the TK alignment, you should set up your shrink, the vertical alignment, and you have to have good postural control. Once you've accomplished that, then you start.
Speaker 2The goal for us is to have the least restrictive orthosis possible. So we allow for more and more freedom of the motion of the ankle joint, first in the plantar flexion and then in the dorsiflexion. But while you're doing that, you're paying attention to the specific gait events and maintaining good quality, and I say this is our opportunity to work a little bit like optometrist, as you make it less and more and more free, less and less restrictive. What you're judging is is that gait still as good or is it better? And you get to a point where again the gait becomes bad. We got to remember our patients have abnormal gait. Then they're moving in ways we do not want them to move, so we have to restrict them in particular ways and we do that with these springs. And these springs are much stronger and more durable and all that you know. I could go on for hours talking about that. But what I am excited about is that ability to see the progress in the gait and to really optimize it for the individual. And then you can also make their gait bad and say, okay, I went too far, I gave you too much freedom, so let's go here. And the exciting part is what you see those patients doing in a month or six months from now and the changes you can make and even be less restrictive.
Speaker 2So you know, for me, as probably therapeutically minded for my athletic training days and just working with the neuro therapists that I have, my goal is always to be the least restrictive and orthotic design possible, and sometimes we compromise and sometimes we're overly restrictive because we need that for protection of the joints. But to be able to dial in the kinematics of the knee and the hip from all at the ankle joint is really exciting to me, and you know a lot of orthotic designs. I call it our ski boot walking problem because I love sitting in a ski chalet and I like watching people walk down a ramp in ski boots right. It over accelerates your knees, it over accelerates your hips.
Speaker 2And if you watch closely on a lot of your orthotic designs, we've been doing that for far too long and you know we all went to school and we were told you fit a solid ankle on somebody, you have to do shoe modifications with that. But how many people do that in the real world? And you know you fit a rigid planar flexion stop. You should have a satch heel. We don't do that and that has a cost and an effect on your patient's outcome and ultimately, how tight they are at their knee, how long they're strideling, how much energy they're using during the day. So it's great that we can make all of these fantastic things. I still think we need to be concerned about the componentry we're putting in and, ultimately, the result we're having for the person with their gait, because that is what we are doing as clinicians is trying to improve their gait to the best quality and outcome.
Speaker 3That we can. Okay, super cool. And how about like using 3D printing for the final devices? Are you excited about that? Is that limited? What do you think about that?
Speaker 2I think there's real challenges and that's something you know. I'm working on a little bit on the side or a back burner project, and Brent's engaged in this a little with you too. But part of the challenge is we have to bend the metal, sometimes to the patient model, before we can build those shells. There are certainly ways to integrate them externally too, but from an intimacy and fit way. That's one way I think we can do it.
Speaker 2There's other solutions, I'm sure, that are still coming, that are out there too, but bending the metal and then building the shells around it, I think, is certainly one approach to getting there, and I think there's a possibility that there's a way to incorporate more of those materials and opportunities for us as a field to engage in that. So, definitely working on that, seeing it as a way we need to evolve, we need to figure out, you know there's a reason components like this are still really needed. I also think you know everyone talks about like, oh, this is gonna be the next thing that disrupts the field or takes over all this. You know I've watched how, since I've been here at Becker, the growth of our metal and leather department, you know, because no one else is doing it anymore.
Speaker 2But also it didn't disappear. You know the video didn't kill the radio star and we all have radios that we listen to or maybe don't, but I turn on the radio every once in a while. It doesn't go away. It's just another tool in the toolbox and I think we need that. As clinicians, we need more approaches, more diversity to what we're doing and understanding, but we can't be shut off to. Maybe for a certain patient I gotta build a conventional AFO because they're fluctuating, a DEMA and their weight and the other reasons I might need to do that too. So that's again. The challenges of being a CPO or a clinician in our field is just the breadth of knowledge and the consideration that you have to have with every patient encounter on what all the solutions or options might be for that individual.
Gratitude for Podcast Discussion
Speaker 3All right, that's a very, really good end statement there, Sean. I really really great one to end on. Thank you so much for being with us today.
Speaker 2Now I appreciate you guys, even just the conversation you create for all of us. I do enjoy listening to the podcast and hearing what other people's viewpoints are and considerations are, and it's great that we get to engage in this way and thank you guys for hosting that and inviting me today.
Speaker 3Awesome, no problem. No problem, hey and Brad. Thank you for being here today. I think you enjoy this too right.
Speaker 4Yeah, this was good. I mean, joris, at times I think I saw your eyes glaze over when we started hopping into the weeds a little bit, but you hung in there really nice. So but I think that there's gonna be a lot of people that appreciate this episode, especially diving into the weeds and some of the alignment and just the what ifs and can we do, and that's why I really enjoyed having Sean on the podcast. So, thank you.
Speaker 3So thank you so much for our sponsor, advanced4d, today for making this all possible and well. If you need any custom fabrication, custom design for additive manufacturing, 3d printing work done, or you want to delve deep in the engineering side of your next 3D printing project, head out to Advanced4D, and I'd like to thank you very much as well. Our the most important thing to us, of course, our listeners. Thank you for being here with us today, thank you.
