You Can Do It, Put Your Back Into It

We have closed out upper extremity orthotics and moved down the body into making back braces!  The whirlwind of school continues as we fly from one body part to the next; starting with the most simple braces for each part and working our way up in the way of complicated fabrication.  So, our first back brace is the Knight Orthosis.  Unless you are buying a quick velcro strapped, wrap around, off-the-shelf brace, this is the most basic custom one to get.  It involves taking a lot of measurements on your patient and then...metal bending!!!  I really have to set my mind to inventing something that bends the metal for me or some sort of material that can be used in orthotics that is an excellent substitute for metal - I would save many students many hours of frustration if I managed that :)

Alas, we still use metal and this project was no different - nothing like showing up to school to pieces of metal sitting on your workbench, ready to be molded and shaped and contoured to someone's body.

I have to say, I was lucky, I was assigned a very easy patient - she was about the same size as me so I just kept trying the pieces on myself to see how I thought they were fitting.  The big bands that you see in the picture are the ones that go across the mid-back and the lower-back and are quite flexible, so bending them was not a grueling task.  As you can see on my work bench, before we start bending, we draw out a tracing of what we want the metal to be shaped like so as you are bending the metal, you just keep placing it over the tracing to see how close you are and what changes need to be made.  Four pieces of metal seemed totally doable for one day and was not all that painful :)

The most difficult part of making this brace so far was matching the back two bars - the paraspinal bars.  These are the two thin bars that run up your spinal muscles, on either side of your spinal cord.  These bars have to match each other as exactly as possible.  You bend one of the bars to match the tracing you have made on your paper and then you have to bend the second bar to match the first bar!  I have a hard enough time bending one bar to a tracing, but then having to duplicate it just seems crazy!!  My professors have a saying, "sometimes good enough is perfect" and that is what I have to tell myself when trying to bend any two pieces of metal in the exact same shape.

I was able to get all four pieces of metal bent by the end of the day and riveted together to create what is definitely resembling a back brace as this point.  The next step is to create lateral bars to go down the midline of the body (from lowest rib to waist) and then add the padding and the corset straps to secure the brace on the abdomen.  From straight pieces of metal to a solid frame in one day?  I think I can get on board with this back brace thing!

Tenodesis = Torture

Tenodesis is actually a super fun word to stay.  It makes me feel important, it feels nice coming out of my mouth...but the reality is, my life will be totally okay if I never have to utter the word tenodesis again :)

But this post will be full of all things tenodesis brace related!  Here it is - my completed brace...in all its metal bended and welded and sewn and velcroed glory!!  Its beautiful really.  A work of art.  It does actually look really cool, it looks like something out of a Terminator movie.  And most importantly, it actually works and functions like it is supposed to.  Always lovely to have that feeling of utter pride and ultimate satisfaction when it all comes together like it is supposed to.  These braces are actually pretty interesting, the use of gravity to release the object is fun to work with.  We spent all day grabbing every pen and water bottle we could, really trying these out and getting a grasp (pun intended) on the functionality of the brace.

Don't I make it look fun??  We had to present each of our braces to the class and show that they actually worked, that they were fairly comfortable (as comfortable as you can imagine a metal hand brace might be) and talk about our trials and tribulations we had while fabricating.  We got to work with leather on this project - for the straps - velcro, metal, the blow torch, and barge cement for the foam insert...so lots of different components.  There were many tiny pieces and parts, small and big ones.  Overall, this is by far the most intricate and complex thing we have done this semester and I would be a huge liar if I said I wasn't thrilled to have it over and done and in the books.  It was stressful and time consuming, but as I have said time and time again, it was also a thrilling high at the end to have finished a project and feel really proud of it and see it in action.  The real beauty of making orthoses in school is that we each get to be the patient so I am getting a chance to really experience every device and what it would be like to wear it and use it and live with it.  I think that is going to be something that really benefits me in the future as a practitioner.  I am going to completely and totally understand when my patient comes back to me after a week of wearing this brace and says that he hates it because its bulky and uncomfortable and he is not a fan of wearing a metal thing around his arm.  I am also going to completely and totally force him to sit with me for 25 hours while I make the darn thing so he understands that I had to kill myself making it and therefore, he MUST wear it :)

All in all, the project was a great learning experience and worthwhile...and if I have to make one of these in the future (and by 'have', I mean 'when'), I will be ready!!

This was my partner on the project, Christina...she made the brace I am wearing and I made the one she is wearing.  We both seem to be pretty happy and satisfied customers.

Living Without Limitations

A quick and special blog post today about the man who got me into this field.  I would have never known Prosthetics and Orthotics as a potential career path if it were not for Mahesh Mansukhani.  Granted, I am partial to how fantastic he is (and I could write pages about that), but this is about his contribution to the O&P world.  For the last 5 years, Mahesh has been the President of Ossur Americas and has made it his mission to make the business of Orthotics and Prosthetics be a business about the people they are serving.  He has taken a company that needed new ideas and a fresh face and has made it not about just achieving a sales number, but about being on a team and being a part of something bigger.  Mahesh has become passionate about the medical device industry and even more passionate about the people he has met because of the job.  He spends his life on the road, ingrained in every aspect of the business.  The man has been on more business dinners and ride alongs than you can count and easily spends 2/3 of his life sitting on an aisle seat on an airplane.  He can pack a week's worth of suits in a carry-on suitcase, has more hotel points than people who actually live in The Plaza and has to use his cell phone clock to tell him what time zone he is currently in.  He is passionate and committed and it shows in every interaction he has.  He has run Ossur with integrity and heart and he leaves the company in the same manner.  It is my opinion that Ossur will forever be changed by the impact that Mahesh has made on the company and I know that Mahesh has forever been changed by getting to know this industry.  He has started a Well-Being Initiative, spearheading a cause to provide amputees with access and ability to focus on their mental health.  He has attended the fundraisers and events and dinners, but the most important thing he has done is to create an environment that focuses on the patients, the people, and the product .  I know the end of his time at Ossur is bittersweet for Mahesh; 5 years of blood, sweat and tears - heart and soul.  This experience was more than just a job, it was a lifestyle.  As the tides are changing and the next chapter begins, I am just so proud of him and I know that he will continue to support the industry and stay involved and I know that he will be greatly missed.  Looking forward to starting a great new adventure with him :)

It's All in the Wrist

I really have to start taking better "before" pictures so you can really appreciate how much work went into what you are currently looking at in this stage of making this orthosis.  This next project is a wrist driven orthosis - a ratchet design that is never used anymore, but operates by using wrist extension (bending your wrist back) to cause the first two fingers and thumb to make a pinching motion.  When the wrist is relaxed from extension into flexion, the fingers open and the pinching grasp releases.  This is great for someone who still has the extensor muscles present in their forearm, but cannot fully use their fingers.  It allows them to pick up objects, grasp things, and even write.

We were given a bag full of pieces of straight metal and a lot of rivets and screws and expected to create this device.  So, what you are looking at in the above picture is about 10 hours of metal bending work at its finest :)  The two big metal pieces were both straight and had to be bent and fit to my patient.  They had to be cut and trimmed down and smoothed - it was a very long process...made even longer by having to share the machines with 16 other people.

After getting these two pieces bent correctly and attached to each other, I then had to create the finger pieces for the brace.  Originally, looking at the finger pieces, this did not seem like it was going to be a huge obstacle.  Wrong!!  The first part of the finger pieces is bending three tiny metal strips to circle around the top half of the fingers.  I thought bending metal around a forearm was super tough.  Bending metal around the width of two fingers is brutal!  It is a very tedious task to try and make these tiny, tight bends.  The finger piece of the wrist driven orthosis has to be just right in order to keep the device on and functioning and comfortable.

This is what the finger piece looks like when it is all said and done.  Tiny bent metal and a tiny bent rod holding it all together.  This piece was made for my partner so it does not fit exactly right on me, but it shows what I spent 4 hours creating.  The metal bending was the tricky part, but then we got to solder the metal to hold it all together and that was very exciting!  And very scary!  I have become accustomed to using blow torches at school, but not in this way!  We typically just use them to get some plastic warm and mold it a little bit, not to melt silver and drip it onto metal in order to fuse it together.  This was my first time soldering and although I got the hang of it rather quickly, it was quite intense and (on par with all the new things I am learning at school) somewhat stressful.

But let's be honest, I look pretty cool wielding a torch and obviously it brings a smile to my face.  Fine, I will give soldering another chance!  Melting things is typically frowned upon so it was fun to be told that this was part of the process.

I was able to get the finger piece completed and walk away from the wrist driven device for the day.  Staring at pieces of bendable metal for 9 hours in one day really just makes you want to throw it out the window.  I cannot believe this project still has two more days of fabrication before it will be done!!  No wonder they do not make these in practice anymore, it is not practical to have to spend 25 hours working on one orthotic device.  That, and it looks like it came out of the stone ages!!  No one wants to wear a purely metal contraption on their arm...well, maybe not no one, but I know for me it does not work with my gold jewelry :)

A Quick Fix

Okay, I have a confession to make - the hours of the Orthotics program at school are much less than they were in Prosthetics...logically, you would think that this means I would have much more time to blog - except I seem to just get wrapped up in doing more of nothing when I have nothing to do.  So, I am obviously behind and we have moved on past the upper limb orthotics, but I am going to continue to update in the order of our projects thus far in the semester.

Last post was working on my specific diagnosis of making a brace for a classmate who had "severed his tendon of the flexor digitorum superficialis."  I got pretty far in making the brace the first day so all I had to do was smooth up the trimlines and attach the straps.  I am happy (and very proud) to report that I sewed my straps with very little stress.  They do not look perfect, but they are much improved!!  The projects we are doing right now are basically for knowledge of how to do something, not necessarily to create a perfect final project.  We are riveting a lot of things on just for quickness of completion - not the way it would be done in practice.

After sewing the straps and riveting them on the brace, the project was complete!  I fit it on my patient and it kept his hand and wrist in a neutral position, doing its job in keeping the tendon from being able to move, therefore giving it time to heal.

Not much to look at, but it was a pretty simple diagnosis and that makes for a pretty simple and straightforward brace.  We had a couple of hours to finish up our projects in the morning and then went straight into critique in the afternoon.  My critique went well and I was happy and relieved to know that I had created an appropriate brace for the diagnosis I was given.  I love the "real life" aspect of being given a diagnosis and no solution and no direction for a brace and being able to use what I have learned and research in order to create what I think is the right thing.  It is a great learning experience and makes school feel so much more applicable.

Here I am modeling the brace that was made for me by a classmate.  The diagnosis going with my brace was ulnar nerve palsy - meaning the nerve that runs down the side where the pinky finger is affected in some way.  This causes the hand to form a "claw" and affects your ability to perform small hand motor function movements.  The brace that my partner made for me kept the hand in the claw position in order to accommodate for the ulnar nerve being affected and potentially painful, but left the thumb and ring finger and pinky finger free in order to allow some movement and some function of the hand.

We have one more upper extremity project and apparently it is the worst one ever!  We are going to be making a wrist driven device - it is a big metal contraption that apparently is never used anymore in practice.  My professor who is in his 60s said that during his 30 year career he only made one.  We were told we will be making them as sort of a 'rite of passage' into the world of orthotics.  I, personally, would not be offended to not make that journey, but it looks like my grade depends on it.  Next up, more metal bending and and ancient wrist hand orthoses :)

Moving on From Metal

We finally got a small reprieve from all of the metal bending and were able to design plastic wrist hand orthoses today.  Creating a plastic molded device means first creating the mold...I think it is easy to see where this is going...back to the world of plaster molds!!  Casting a patient and then using the cast to create the mold that then becomes the form to vacuum plastic around for the device.

To the left, you can see the bits and pieces that make up my cast of the forearm, fingers, and thumb.  In orthotics, because it is focusing on correcting limbs rather than supplementing for not having a limb, we mainly use each other as patients.  For this assignment, we were each given a classmate partner and a random diagnosis to create a custom WHO around.  I loved that everyone had a different pathology to work from because it meant there were 17 different projects in the class and it gave everyone a chance to research their own diagnosis and have to use what we are learning to decide what type of orthotic device would be necessary for that diagnosis.

My patient sits caddy-corner to me in the workroom and the diagnosis I was given was a "tendon laceration of the flexor digitorum superficialis."  Yes, it sounds fancy and too many words for what the simple, watered-down version actually is...a suicide attempt by slitting the wrist.  How pleasant, right??

So, after researching, I learned that the brace needed for a cut tendon is one that keeps the tendon immobile and gives it time to rest in order to heal.  The flexor digitorum superficialis goes down from the wrist into the fingers and is what would help you wave "bye-bye" if you were a toddler.  It curls the fingers down.  In order to keep this tendon from moving, my job was to make an orthotic brace that held the forearm and the fingers in one position - one where they could not be flexed or extended.  The nice part about creating orthotics is that the casting and modifying goes much quicker than it does in prosthetics.  Because I was creating a brace that was only going to go on the wrist and palmar side of hand and it was a device that was just going to fit on the patient's current forearm/hand, all I had to do in modification was smooth up my cast to get it ready for the plastic.  I was also able to cut my thumb portion off because the thumb is not moved by the tendon that was injured in my diagnosis and therefore does not have to be included in the brace.  My patient is not able to move a single one of his fingers, but he can let his thumb go wild!

Vacuum forming plastic is exactly the same as it was in prosthetics - simply drape the melted plastic sheet over the mold and turn on the vacuum switch to get it to mold to the cast.  It also still makes me equally panicky as it did in prosthetics.  I am getting better at handling the flimsy burning hot, drooping plastic square from the oven, but I still get anxious about the timing of it all and getting it right on the first try.  Luckily, I got this one right on and had the flexibility of knowing I was cutting off the entire back portion of this brace so putting a seam in it or a wrinkle in the back was not going to ruin the project.  Phew :)

And this is what my WHO looked like by the end of the day.  Like I said, it goes much faster in orthotics so I was able to get from the casting point to this point in one day - completely unheard of when I was working on a leg in prosthetics!!  This device is not made for me (as you can tell it is much too big in the picture), but this way you can get an idea as to where I am going with the project.  It keeps the patients fingers in a relaxed position and the forearm supported.  It provides total contact on the affected side and also can easily be removed for hygienic purposes.  Up next is to smooth out the plastic around all of the edges, fit it on my patient and make sure the trim lines are in the right place and then to sew and attach the velcro straps.  As you can tell by my filthy and cluttered workbench, this was a good stopping point for the day - it was a long time in the lab and I need the rest to gear up for attempting to make nice with the sewing machine for my straps.  A completed plastic WHO and a critique to immediately follow are up next on the agenda.  Stay tuned...

WHOs and HOs

Orthotics has officially begun!!  My career in custom bracing has started out with bending metal and making a HO.  You read correctly...we actually made a device called a HO.  It stands for hand orthosis, but everyone seems to prefer the shortened version.  It makes for amusing lectures with immature responses from the class.

It looks like nothing, right?  Such a small device that took more sweat than seems necessary.  It is rather ugly, I recognize this - in fact, I was happy to throw it away after I was done.  This was a first day of school learning experience.  The only impressive part about this HO is that I really made the entire thing myself - bent the metal, sewed the straps, glued in the foam interface, and riveted the pieces all together.  Bending metal = no fun.  To get a straight piece of metal to wrap completely around someone's hand is time consuming and much harder than it looks.  I think the idea is to be able to make one of these in about half an hour, but this was a two afternoon project in the world of first timers.  The only reason a person would really need this device would be if they needed to hold their thumb is this position.  Most hand orthoses come with a wrist portion attached - this would be the major reason to put a crazy metal contraption onto someone's hand.  Which, of course, in a lovely segue - leads me to our second project of orthotic school...the WHO!!

Hopefully your deductive reasoning skills have kicked in and you have figured out that a WHO is a wrist hand orthosis.  This is me modeling the one that my partner made for me.  We actually used our previously made HOs and then just added the forearm and wrist components to make this lovely brace.  I think having a great manicure and the party nail really jazzes up the hunk of metal attached to my hand.  Thankfully, off the shelf bracing has come a long way and this is the old school way to make a wrist and hand brace - I cannot imagine that many people would be thrilled about having to wear this in their every day life.  Also, I might add that it is slightly dangerous - I would forget which hand I had it on and go up to brush my hair out of my eyes and a piece of hard metal would poke me in the face.  This was, per typical school protocol, just another learning experience.  We are trying to get practice bending metal and sewing straps.  Bending metal is still something I could take or leave, but I am happy to report that I am no longer scared of the pedal on the sewing machine.  We have found a nice rhythm and seemed to get along this week.  My velcro straps were top notch :)

I am also happy to say that the orthotics portion of school is going swimmingly.  The pace seems much slower than that of prosthetics, but it is hard to say if it is actually slower or if I am just adapting to a learning environment that moves so quickly.  We seems to have more time to fabricate our devices...again, not sure if this is actually meaning more hours to accomplish something or that having completed the prosthetics program, I am actually fabricating things more quickly.  The most interesting part of orthotics and bracing to me is that you have to really learn all of the pathologies that come along with the need for orthotic intervention in order to really make a great device.  We have pathology lectures multiple times a week and I have really been enjoying learning the ins and outs of what a stroke can do to cause a person to need an orthosis; what happens when a person suffers from a traumatic brain injury and what type of interventions can be used in their recovery.

I think that prosthetics has my heart, but I am really going to continue giving orthotics a chance.  It does not have the same pizazz as making someone a leg and watching them walk for the first time, but to put it in perspective makes me realize that making a back brace for someone who has been suffering greatly from back pain and helping to relieve that is still a chance to help improve someone's quality of life...and that makes me smile.