Breaking Down the Door

I wanted to start off this column by thanking all those who contacted me regarding my last column, “Life Lessons.” I am glad so many appreciated the article’s message and was happily surprised at the number of positive comments I received. It is always a risk when I deviate from the clinical to write more about my life philosophies, so I am glad it paid off.

In conjunction with the fine folks at OPGA as well as Bill Hanson from LTI, I just finished giving a course at Northwestern University in Chicago and a second one at Georgia Tech in Atlanta focusing on upper extremity interface design and technologies. More than 60 clinicians attended, and it was a real pleasure to meet some well-known and some not-so-well-known names from all over the country and Canada.

After gathering the results of the surveys, it appears the courses were successful, and I look forward to the third in Southern California. I would like to thank the attendees from the heart for making all the late nights and very early mornings so worth it, and I sincerely hope that you got what you came for and more.

Out with the old

The prosthetist or orthotist may finally find themselves held accountable for outcomes, and actually given credit for them as well.
© 2008/Gary Bates/DigitalVision/Getty Images

I would like to discuss the primary subject of the OPGA courses, namely the biomechanics and physical structure of current and emerging upper extremity interfaces.

I recently submitted a research paper on this subject to a well-known peer-reviewed journal, and was notified the paper was rejected. Surprised over the rejection, I read the reviewer’s comments and it became obvious to me there was a lack of understanding about the newer interface designs and, in my opinion, a bias toward older designs that have existed unchanged for decades.

My gut reaction was to cry foul; however, I also noted that although it was not my intention to cover every last piece of interface research on the planet, there were a few reviewer comments that were relevant and accurate: namely, I hadn’t included enough science to back up some of my conclusions. I had not used the term “in my professional experience” quite enough, and instead relied on much of what I stated to be common knowledge, which was a mistake.

It was common knowledge to me and many of my peers, but not to everyone, especially not to those who have yet to accept the superior biomechanical principles inherent in some of the newer designs.

So I tip my hat to the reviewer for giving me and others who understand, appreciate and utilize newer interface designs a solid reason to provide the science behind these newer interfaces. So we shall.

Where’s the proof?

There are several studies underway that aim to compare the old with the new so that once and for all we can put an end to the “but it hasn’t been proven” statements often given by the reluctant, or the hesitant, or the provincial. Simply to see the smile on a person’s face when they transition from a traditional interface design to a more comfortable (in my professional experience), more stable (in my professional experience), more efficient (in my professional experience), and more modern (in my profess—no wait, this is irrefutable) interface is not enough. There has to be proof.

The reviewer was spot-on regarding this point — I cannot argue a lack of research with regard to upper extremity interface design. This was the purpose of my paper, to provide additional research where much was lacking.

Accordingly, I culled most of my information from research on lower extremity interface design and related it to its seemingly distant cousin, the upper limb “socket” (as I was encouraged to call it upon submission. As an aside, will someone please tell me how an XFrame can be considered — much less named — a socket?)

Anyway, where terminology or biomechanical concept diverged, I spoke to the unique nature of the upper limb environment. I thought it all rather fascinating, but apparently it was not fascinating enough.

To the Editor:

Dear Randall,

Stan Wlodarczyk, BPE, CP(ca), FAAOP and I read with great interest your two-part Life Lessons series. I feel that you and Stan (who is my husband of 25 years) are kindred spirits. How wonderful of you to take this approach and share your experience with your peers.

We are wondering whether you can help. We have a client (congenital, has wrist flexion and then his hand ends; there are a few finger buds) with a TRS voluntary closing device. He also has a myo prosthesis for social situations. He is seeking the ability to clamp after grasping with his mechanical system. He is a mechanic who works on cable cars. Can you steer us toward any such device? Thank you for your reply.

Alberta, Canada

Dear Charleen,

I so appreciate your kind comments and thank you for taking the time to read my articles. It is serendipitous that you asked me the question about your patient wanting to “clamp” his TRS voluntary closing prehensor as Bob Radocy (owner of TRS and developer of the VC prehensor your patient wears), ADA Technologies and I have worked together to come up with exactly the type of device you need, and it is now commercially available.

It is called the Sure-Lok, and it allows the user to manually lock the prehensor by inhibiting cable slip. You may contact TRS for more information. It was a pleasure to receive your e-mail and I wish you and Stan an excellent year.

Warm regards,


In with the new

So what is the purpose of this long, drawn-out introduction? To alert you to the need to consider outcomes with regard to interface design as well, regardless of whether it is an upper or lower extremity, prosthetic or orthotic interface (please, no more “socket.” I beg of you.)

It is imperative that we begin to dissect traditional interface designs and bring to light superior characteristics of more modern, stable, comfortable and efficient designs with all the tools that science offers. By gathering this data, analyzing it and publishing it, the prosthetist or orthotist may finally find themselves not only held accountable for outcomes, but actually given credit for them as well. Proper outcomes studies may actually even consider the interface as playing a critical role, and a prosthetist’s choice of interface design may actually be considered relevant too.

Despite the absence of formal clinical trials and by relying far too much on my professional experience, I embraced and applied simple biomechanical principles that were merely perceived or inferred and not duly proven or fully vetted. In so doing I am guilty of pushing the envelope, of questioning the antiquated ways of doing things because “by gum, that’s what we was told” and instead, had the audacity to try something new.

I now ask you researchers and research students out there to do the science, the physics and the math that is required to enlighten us all. If outcomes are on the way, they should demonstrate the role of the interface. And if outcomes do in fact consider the interface, then the interface itself needs to reveal its secrets, secrets that define what makes it an improvement, rather than simply being different for “different’s sake.”

I will endeavor never to stop pondering, never to stop envisioning how something may be improved upon. I will continue to rely on my professional experience to steer me in the right direction, which is hopefully onward and upward. And finally, I agree not to wait for hard data to confirm my suspicions (generated from my modest professional experience, of course) prior to boldly stepping up to the entrance separating the “known” from the “not-yet-published” regions of clinical care.

The difference is that next time, I will find out in advance who is guarding the door.

Randall Alley, BSc, CP, FAAOP, CFT

Randall Alley, BSc, CP, FAAOP, CFT is chief executive officer of biodesigns inc. He is chair of the CAD/CAM Society of the American Academy of Orthotists and Prosthetists, an international consultant and lecturer, and a member of the O&P Business News Practitioner Advisory Council. Alley can be e-mailed at

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