The hockey player races across the ice, planning his next move. He sneaks around a defender and faces the goalie — his team’s chance to win the game. In one swift move, he lifts his stick and shoots the puck past the goalie’s outstretched glove into the top corner of the net. The crowd cheers.
The stadium clears and he follows his teammates off the ice. He sits on a bench in the locker room to remove his skates, his gear and his prosthetic arm.
This is not a description of the unlikely future, but of technology already on the market that makes it possible for amputees to remain active and competitive in sports. Several manufacturing companies specialize in these kinds of prostheses and many O&P practitioners work with patients to get them back on the ice, in the water or on the field.
Different kind of rehab
The best role models for amputees who want to get back in the game are active amputees. Manufacturers like Bob Radocy and Ron Farquharson entered the profession to provide a means for other amputees like themselves to return to sports and recreational activities. Others, like Brian Frasure, clinical manager for Ossur Americas in Aliso Viejo, Calif., became O&P practitioners after amputation to help amputees regain both their spirits and their physical abilities.
With a below-elbow amputation and an educational background in recreational therapy, Radocy, president and chief executive officer of TRS Inc. (short for Therapeutic Recreation Systems) in Boulder, Colo., has not only experienced, but studied, the benefit of recreational rehabilitation.
“Getting back into a sport or recreation that you love after a severe traumatic injury can change your entire attitude about your rehabilitation,” Radocy said. “Sometimes it’s the only spark in that person’s life that gives them the motivation to go forward.”
Participating in sports and other recreational activities — in essence, having fun — shows new amputees that they have not lost as much of their previous lives as they originally thought.
Funding for these products was not readily available until January 2007 when The Centers for Medicare and Medicaid Services (CMS) created L6704, which covers terminal attachment devices for sports, recreational and work activities. With this L-code, CMS acknowledged the value of this type of rehabilitation in patients’ lives, Radocy told O&P Business News.
“For us, it was recognition of efforts we have made over the last 25 or 30 years,” he said. “Getting people to realize that, especially with children, sports and recreation are a component of life and they are vital to the rehabilitation process.”
The issuance of this code was “the most noteworthy recent development … for the O&P industry in general, as far as upper extremity issues are concerned,” Farquharson, president of Texas Assistive Devices LLC in Brazoria, Texas, said.
Current upper extremity devices
With the assortment of sports and recreational prostheses available now, amputees can find a device to suit any of their active needs. Although each of the prosthetic devices in this small market is different, all of the manufacturers share the same goal — to make life a little easier for their patients.
“Our thrust has been trying to make people bimanually functional and competitive, as opposed to just being participants in these kinds of things,” Radocy said.
To this end, TRS has focused on identifying, and then replicating, the biomechanics involved in each particular sports activity. Radocy also set out to improve the componentry that allows for energy transfer in prostheses, so they would be able to complete the gross motor movement involved in most sports activities.
“Prostheses as they exist just don’t allow for many degrees of freedom,” he said. “Prostheses, to a great extent, have not been able to duplicate smoothly and functionally some of the simplest kinds of motions.”
Randall Alley, BSc, CP, LP, FAAOP, CFT, chief executive officer of biodesigns inc. in Thousand Oaks, Calif., is an avid athlete, and attributes his interest in recreational prosthesis development to his love of sports. He has spent many years working on prosthetic interface designs to correct biomechanical shortcomings in traditional sockets that have changed little in decades.
“What you see is a rather generic encapsulation of the soft tissue,” Alley said. “Some designs make room for muscle expansion, while others add stabilization to the lateral aspect of the femur, for example. Tibial designs go a bit further due to the surface proximity of the anterior aspect of the tibia, in effect forcing us to do something that resembles tibial control, but even here, this is only the tip of the iceberg.”
Much of his recent work has been in creating interfaces that redefine functionality using an individualized set of parameters.
Others set out to solve everyday issues for amputees. Farquharson spent years after his amputation searching for devices to help him complete ordinary tasks like cooking, carpentry and mechanical work, which at the time involved a great deal of effort. This led him to create the Texas Assistive Devices line of tools, including the N-Abler II, a terminal device for upper extremity amputees that serves as an adaptive tool holder for a number of items, including recreational and sports adaptations.
“In the past, of the few sports and recreational items available, most were difficult to attach to the prostheses and had no feature to allow either flex or rotational positioning,” Farquharson said.
For this reason, he designed the N-Abler II to allow for a quick disconnect from any of the tools in the product line. Furthermore, the N-Abler II offers patients 60° of flex and 360° of rotation so they can properly position these devices to complete any of the desired activities.
Current lower extremity devices
Lower extremity prosthetic design has developed more quickly than that for upper extremity amputees, and the race to incorporate the newest technology continues for both new and existing products.
The Cheetah, Ossur’s sprinting foot that has gained notoriety as the prosthesis preventing Oscar Pistorius from participating in the Olympics, is not a new technological advancement, but an evolution of a product introduced in 1995, said Frasure.
“That has just been a slow evolution of the foot,” he said. “Small changes in design, the way the carbon layers are put together and the amount of those layers, the shape of the foot itself … the fine-tuned changes along the way that have helped advance the performance of the foot.”
The carbon fiber layering and shape of the Cheetah results in high energy storage and return for the runner at toe off, anywhere from 85% to 90% efficient.
Frasure credits Team Ossur, a group of athletes sponsored by the company whose feedback on devices has propelled the technology forward.
Jay Martin, CP, LP, director of the Advanced Systems Group for OrthoCare Innovations in Oklahoma City, who began his career as a practitioner, shifted his focus to research and development after realizing that his patients’ level of function would increase with more advanced technology.
“I realized that there was a significant gap between the most advanced prostheses and the human body,” Martin said.
He wanted to close that gap. He received research grants to develop some of these technologies and created Martin Bionics, which merged with OrthoCare Innovations in March. For the past few years, his company has worked with College Park Industries to develop the iPed, a new lower extremity prosthesis that works to close that gap.
The field of sports and recreational prosthetics is ripe for innovative technology. New products are introduced continually for an array of amputee needs.
One example of the new technology available from TRS includes a hockey device like the one mentioned earlier. The Power Play is an entirely synthetic, high-performance, polyurethane-constructed device that accepts any type of hockey stick. This technology ensures the user both dynamic control over the device, as well as a measure of safety in such an aggressive sport.
“We were able to select formulas of synthetic polymers that allowed us to produce a design that has done that well,” Radocy said.
He looks forward to putting to use that same technology to redesign some other devices in the TRS product line. Those that were mechanically constructed in the past will be modified to incorporate what he calls “living joints.” These living joints offer the same range of motion, but also store energy, provide strength for the amputee and can be engineered to complete a variety of tasks, depending on the circumstances.
Other products in the works at TRS include a high-performance golf device for transhumeral amputees, as well as a specialized rock climbing foot for transtibial amputees, a product requested by TRS’ amputee base.
“It’s the first time I am involved with a product that I can’t personally test,” Radocy said.
Similarly, Farquharson gradually adds new products to the Texas Assistive Devices product line as he identifies a need in his patient base.
“We listen to the needs and requests of the practitioners and end users to help us develop new products,” he said.
Chris Johnson, the engineering director for College Park Industries in Fraser, Mich., also serves as alpha tester for the company’s products in development. As an active transtibial amputee, he understands the challenges facing lower extremity amputees who wish to participate in sports and outdoor activities.
“I test all of our feet in a wide variety of situations, from just walking to heavy construction work, to hiking and bouldering,” he said. “I’m very active and just pound on these [prostheses]. I expect prosthetic feet to advance capability while also maintaining unobtrusiveness — working well, but not reminding me that I’m wearing a prosthesis.”
One foot in long-term testing is the Onyx, a new conventional prosthetic foot from College Park, being released for sale this month. Johnson likes this highly evolved prosthetic foot for its combination of terrain compliance and springiness.
Alley has turned his focus to the vital interface technology he feels is missing from the O&P profession. Currently, he is field testing a design for both upper and lower extremity applications called the High-Fidelity Interface, which he has created specifically for high-performance applications and has filed for patent protection.
“Though the technical issues of compression, tissue flow and intrinsic bone management are complex, the concept is simple: an inherent motion capture and control system that minimizes redundant intrinsic bone motion within the interface, optimizes soft tissue flow and maximizes interface response [and ultimately] performance,” he said. “I expect the data to show that it lowers energy expenditure, lowers perceived weight of the prosthesis, improves stability, positional control and range of motion, and allows for greater proprioception.”
Although Alley developed this design years ago, he had been unable to apply it to a significant number of patients until his recent work with DEKA Research and Development Corporation and Next Step Orthotics and Prosthetics Inc. while working on the Revolutionizing Prosthetics Project 2007. (For more information on this prosthesis, see “Upper Extremity Prosthetics Design Moves Forward,” in the May 1 issue of O&P Business News.)
The High-Fidelity Interface design concept is the foundation for the socket system for the DEKA Arm. Even more significant for the profession is that there is a possibility that much of the technology will trickle down for public consumption, according to Alley.
Because sports and recreational prosthetics is a relatively small field, those involved often work together on solutions for their collective patient population. Radocy and Alley, for example, have been working together to perfect an extreme version of the High-Fidelity interface, which they are testing now.
“We have this new interface, that he thinks will advance the science of prosthetics, in particular for high-performance limbs that could be used in sports and recreation,” Radocy said. “He is building the arm, we are designing and building the components on the end, and hopefully we will have a great match.”
Alley is grateful for Radocy’s contributions.
“Bob is in the front and center of sports and recreation technology development, for civilian or military use,” Alley said. “It is a pleasure to have him where he is.”
The collaboration between OrthoCare Innovations and College Park has produced the iPed, a computer-controlled ankle system designed to autonomously adapt to environmental changes. The current system consists of a computerized mechanism and an articulating, supramalleolar foot with full anatomic range of motion — 70° of total movement, with 25° dedicated to toe up and 45° to toe down. Martin’s team has worked with College Park on the development of the prosthesis; College Park has provided the funding and will be responsible for bringing the device to the market.
The iPed foot also is being tested in the real world.
“Whether conventional or computer-controlled, I want to ensure, through lots of real-world testing, that a design has a high overall quality of motion, and that it performs in line with marketing claims,” Johnson said.
He and Martin recently hiked through the mountains in southwest Oklahoma together, and had an opportunity to test the iPed on real-world, uneven terrain.
“It was fascinating to watch Chris on the iPed,” Martin said. “To be able to walk across rugged terrain … up a slope that was about a 45° angle, and being able to see the prostheses accommodate for that effectively — just as the anatomical ankle would move.”
Johnson describes the iPed as a new evolutionary branch that departs from conventional prosthetic feet in that it reacts via computer control, not about a fixed foot position relative to the shin, but about a wide variety of foot angles.
The ongoing conflicts in Iraq and Afghanistan also have influenced the development of these devices. The demand for sports and recreational prostheses has grown as young injured soldiers return from war expecting to lead the active lives they knew prior to their amputations — or even to return to active duty.
These brave men and women not only have served the country, but have turned a spotlight on amputees.
“I think it is elevating the public’s perspective and understanding of prosthetics,” Radocy said. “It has helped in understanding, and it will help with the acceptance of these people into society.”
Because of these soldiers, the government is more committed to developing new prosthetic technology, funding new devices and driving them straight to manufacture.
“It is an unfortunate environment,” he said. “But all of a sudden we have a population of young individuals that provide an excellent platform to evaluate [products] on.”
These requests give manufacturers the incentive to create these products.
TRS has answered the call to help this specific amputee base. Although Radocy declined to design a firearm-handling apparatus for many years because of the potential dangers, he decided to introduce the Lamprey Gun Turret, which allows for safe handling of a variety of long guns for training and practice, as well as hunting and recreational shooting.
Texas Assistive Devices recently introduced the Passive Hook, a device designed for amputees to grip the bars on weightlifting machines, specifically for soldiers returning from Iraq and Afghanistan. These new amputees want to maintain their muscle tone after surgery, Farquharson said.
“We hate to see our soldiers come back in the condition that they do, but on the positive side, it is good to know that there is such good technology out there that guys with multiple amputations are going out and being active again,” Frasure said. “Twenty years ago, that wouldn’t even have been fathomable from a prosthetic standpoint.”
Perhaps the best example of the quality of today’s prosthetic design lies in Pistorius’s journey to the Olympics. Although there will always be a need for better devices and solutions, prosthetic technology is steadily elevating amputees to the level of the best able-bodied athletes.
“The greater limit to a certain extent is dictated by the person’s physical capacity,” Radocy said. “I think we are going to be able to make people as competitive as they want to be in sports and recreation.”
He intends to focus his attention on the regulations surrounding amputee participating in able-bodied sports.
“I think it has more to do with an education and understanding of the issues, as opposed to any inherent bias … That is something that we as a profession need to move forth and make some advances in,” he said. “Why should we produce all these great high-performance prostheses if people can’t use them in competition?”
Alley has seen a growing trend in amputees who think beyond their limb loss.
“It is my hope that, with the technology and interface design we are developing, we can get them to forget all about their prostheses,” he said. “The more comfortable and the more functional [the technology] gets, we are going to approach that.”
Not only will this development benefit high-performance athletes, but less active amputees as well.
“A lot of times the focus is on athletes that are doing spectacular things on the field, but … what does this mean to the core group of amputees, 80% of which are geriatric, diabetic patients?” Frasure said. “But that trickles down to them. They are still going to get similar benefits, even from just walking, if that is the extent of their activity.”
Ossur’s plans for the future include advancements in carbon technology, as well as a focus on searching for new materials to create bionic products.
“We are seeing this surge forward from different companies in the industry that really want to take prosthetics to the next level,” Frasure said. “And I think we will get there because we have the know-how, we have the desire. What that ultimately means is a better quality of life for amputees across the board.”
Martin and OrthoCare Innovations already have begun work on a number of additional technologies, ranging from new types of adaptive socket interface designs to other prosthetic components. For Martin, the ultimate goal is to be able to better replicate the human body, and he knows it is not an easy task.
“I think, even if we fast-forward 20 years from now, there is still going to be a lot that we’ll be learning,” he said.
Johnson, too, sees the potential to learn a great deal from this new prosthetic development.
“The iPed definitely is a development program. We are accomplishing a lot, but we also are learning as we go,” he said. “Sometimes it is tough to manage people’s expectations of new technology. While people should be legitimately excited by the new technology, they also should recognize how far we are from truly imitating the human design.”
That excitement is felt throughout the profession, by practitioners, manufacturers and amputees alike.
Frasure has experienced first-hand the devastating effects of an amputation. As a Paralympic athlete, he knows that amputation does not mean an end to sports and recreational activities.
“Limb loss is tragic, but in the end, if you can get back to doing the things you did prior to your amputation, then that is really all you want to achieve,” Frasure said.
For more information:
- Pavlou SZ. L6704 fills a need. O&P Business News. 2007;16(24):34-35. The article is available online at http://www.oandpbiznews.com/200712b/fs2.asp.
- Pavlou SZ. Upper extremity prosthetics design moves forward. O&P Business News. 2008;17(9):36-41.
This story includes a small representative sample of individual companies and products. O&P Business News does not intend to promote individual companies or their products, nor to achieve an industry-wide consensus on the issue. Companies contacted in developing this story were randomly selected.
Stephanie Z. Pavlou is a staff writer for O&P Business News.