Prosthetic and orthotic resources for communicating in a global village

Edward D. Lemaire, PhD;M. Jason Highsmith, DPT, CP; Wieland Kaphingst, Dipl -Ing

Communication is an essential component for high-quality healthcareinteractions. While the benefits of patient-practitioner communication havebeen well documented [1–2], the importance of interpractitioner and clinician-researcher communication must also be considered. The field of prostheticsand orthotics is an excellent example of interdisciplinary care, with wide par-ticipation from within and outside the typical healthcare environment. Thismix of consumers, physicians, nurses, therapists, prosthetists, orthotists, engi-neers, psychologists, business/industrial sector representatives, and otherstakeholders brings together a breadth of terminology that can lead to commu-nication errors and reduced decision-making effectiveness. The impact ofvarying terminology in the assistive device sector is enhanced when movinginto the global arena.

Assistive device terminology is a dynamic and constantly evolving area.Innovation brings new ideas and produces new terms to describe these advancesefficiently. Regionalization is to be expected with these terms and definitions.While attempts have been made to standardize language, dating from the firstdictionaries to the Académie française (i.e., the official authority established in1635 to standardize the French language) to the International Organization forStandardization (ISO) Technical Committee on Prosthetics and OrthoticsNomenclature and Terminology (TC 168), society’s evolving communicationneeds make standardization a difficult and continuous task. A combination ofstandardization and description is needed to build on a common communicationbase and encourage an understanding of regionalized terminology.

Describing prostheses, orthoses, patient care, research findings, and othervital forms of information exchange presents ongoing challenges for allinvolved. Some problems exist by selection, implementation, and continueduse of terms that are inadequately, nonobviously, or entirely nondescript. Forexample, confusion is needlessly inserted into a dialogue when an assistivedevice or clinical procedure is described by where it was invented or theinventor’s name. This is eponym terminology. More anatomically correctlanguage could be used for description to eliminate confusion. Consider thedifference when requesting a Miami collar versus a rigid cervical orthosiswith molded chin and occipital support or describing a Syme’s amputationas opposed to an ankle disarticulation amputation. Other sources of languageconfusion come from—1. Acronyms: Acronyms can create confusion within an interdisciplinary

care environment because similar acronyms often refer to widely differentthings or simply because one profession has never been exposed toanother profession’s acronym(s). While acronyms commonly serve toabbreviate lengthy words and phrases for industry insiders, they needlessly

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complicate the understanding of noninsiders peer-ing into the profession. An example of the com-plexity of acronyms follows; however, thenumber of acronyms in this editorial serves asanother example of this issue.

2. International differences in terminology: In theUnited States, the acronym PTB means patella-tendon-bearing, which refers to one of severalprosthetic socket design options for the transtibialprosthesis user. However, the acronym PTS, aFrench acronym translating to prosthese-tibiale-supracondylienne and coined by Guy Fajal in1963, is still widely used internationally. In theUnited States, the addition of supracondylar (SC)trimlines to a PTB socket may appear in acronymform as PTB-SC, whereas PTS may also be usedand is accurate. Additionally, PTS may alsodescribe the addition of supracondylar trimlines tonon-PTB sockets. For people outside the clinicalprosthetics area, PTB can refer to pulmonarytuberculosis, physical trade balance, or powersthat be. These differences in terminology, basedpartly in language differences, lead to differingacronyms and ultimately to confusion.

3. Societal acceptance: Possibly the best example ofsocial influence on terminology was the shift in theNorth American professional community awayfrom the term “stump” in exchange for “residuallimb.” Ironically, many patients/clients still com-municate to their prosthetist using the term stump.Interestingly, various scientific journals have recom-mended authors to use the term residual limb; how-ever, the ISO standard term is stump.

4. Crossprofessional adoption of terminology: Asan example of crossprofessional terminologyadoption, in engineering, hydrostatics refers to thestudy of fluids in stable equilibrium either in closedor open conditions. In prosthetic socket design, theterm hydrostatic describes a socket in which a dis-traction force encourages the residual limb’s tissuesand fluids to migrate distally to prevent distalmigration of the skeletal elements because of theincompressible nature of fluids [3]. The body’sfluids cannot remain in such a position, andpseudoclosed aspects of the system have wide

ranges of alteration under some conditions (e.g.,muscles or blood vessels at rest compared withshivering, exercising). Such a system cannot bea true hydrostatic design, which again leads toconfusion.

5. Choice of terms based on lack of a clear definition:To stay with prosthetic socket technology exam-ples, the term socket can be a source of disagree-ment. Some refer to the part of a prosthesis thatconnects the human body to the prosthesis as asocket, while others refer to it as an interface. Theadvent of direct skeletal attachment has affectedthis debate, now making sockets a potential inter-face option. This issue raises new questions: Aresets of terms synonymous? How are types and setsof devices stratified or classified?

These are merely a few examples of why it iscrucial that attempts be made to standardize pros-thetic and orthotic terminology. This editorial sum-marizes various resources and initiatives thatimplement a global view on enhancing interprofes-sional and intercultural communication.

WIKIPEDIA

Wikipedia (Figure 1) has become a primarysource for online encyclopedic information [4]. Thisresource relies on individuals contributing and editingthe terms and content, thereby providing a large bodyof information but without the central editing controlpresent in traditional encyclopedias. The quality ofthe Wikipedia entries remains a point of contention;however, recent studies have supported the overallquality of this global community-based resource [5].Wikipedia also benefits from timely revision of con-tent, which is difficult to achieve with traditionalencyclopedia structures.

An additional advantage of Wikipedia is that,once an entry is on-screen, the user can select otherlanguages for the content. However, each languageentry is created and edited independently (i.e., for thesame term, pages in different languages could havedifferent content).

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In relation to prosthetics and orthotics, entriesfor many discipline-specific terms are currently notavailable. For example, the common prosthetic termPTB, or patella-tendon-bearing, does not have aWikipedia entry. As well, the number of editors for

prosthetic and orthotic topics is relatively small.Recent research supports the relationship betweenhigher quality and accuracy and a larger number ofedits and editors and intensity of cooperative behav-ior [6–7].

Figure 1.Screenshot of Wikipedia entry for term “orthotics”; http://en.wikipedia.org/wiki/Orthosis/.

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In the future, the Wikipedia approach for provid-ing detailed, multilingual, encyclopedic informationon prosthetic and orthotic terminology could emerge.However, this outcome would require a sustainedeffort from prosthetic and orthotic professionalsthroughout the world. A coordinated effort betweenglobal and national organizations could facilitate thisprocess.

WEB BROWSERS

An overlooked, but generally accessible,method for quickly searching for definitions to helpunderstand words and phrases is to use Web searchfeatures. For example, http://www.google.com hasa feature in which “define: term or phrase” can beentered into the search box to display a list of defi-nitions from a variety of sources on the Internet(Figure 2). While the list of various sources helpsthe user understand the many ways that a term orphrase can be used, it may be difficult to decide onthe best definition for the search objective.

As with Wikipedia, many prosthetic and orthoticterms are not available with this resource. For therehabilitation professional or student, browser defini-tion search is valuable for finding quick definitionsfor related biological, biomechanical, and healthcareterms.

INTERNATIONAL SOCIETY FORPROSTHETICS AND ORTHOTICSLEXICON-DICTIONARY

As an international multidisciplinary society forprosthetic and orthotic care, the International Soci-ety for Prosthetics and Orthotics (ISPO) recognizesthe importance of a common base for communicat-ing between stakeholders in the healthcare sectorand across geographical and cultural areas. In 2001,ISPO Canada supported a collaboration betweenEdward Lemaire, Wieland Kaphingst, and FangweiZeng to develop a Web-based resource for prostheticand orthotic terms and definitions [8]. The databaseof approximately 1,000 terms in English and Ger-man had been developed by Wieland Kaphingst over

the past 20 years to assist with translation of techni-cal documents between the two languages.

The initial objective was to create a Web-basedinterface for this database that would allow people toeasily search by English and German words, browsealphabetically, and quickly see the terms and defini-tions in a table. This lexicon-dictionary wouldinclude scientific and colloquial terms since theobjective was to help people communicate, therebyrequiring the inclusion of nonscientific/standardizedterms that are commonly used in regional practice.

Upon completion and release of the ISPO Lexi-con-Dictionary (Figure 3), requests were made tohave the database of terms available in other lan-guages and to recognize standard terminology. Lan-guages were added through volunteer work by variousISPO members and societies, supported in someinstances by academic institutions. Currently, sevenlanguages are included in the application: Chinese(Aaron Leung, Lingzhen Dong), English (WielandKaphingst, Edward Lemaire), French (Pierre Huet),German (Wieland Kaphingst, René Baumgartner, Wil-fred Raab), Spanish (Monica Castaneda, Heinz Treb-bin), Turkish (Serap Alsancak), and Vietnamese(Wilfred Raab, Pham Thuy). All inclusions in the data-base are peer-reviewed.

Technically, the initial design facilitated additionof new languages by using a spreadsheet to maintainthe core database (i.e., facilitating collaboration andmaintenance by the various contributors and ease ofintegration into the Web Structured Query Languagedatabase) and using an interface that allowed ease ofselection between any two languages. The Webdesign allowed the site to function across commonWeb browsers and to work with low-bandwidth andsmall screen computer displays. This facilitatedaccess for people in developing countries.

Difficulties were encountered with integratingthe Chinese translation since Chinese characterscannot be directly mapped to the English alphabet,and initial technical issues with integrating the vari-ous character sets into one Web page were resolved.To provide an alphabetic search, the developersdefined pinyin translations that provide phoneticspelling of the Chinese words. Pinyin can be definedas “spelling sound” or “spelled sound.”

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The value of terminology standardization is recog-nized as an important direction for global communica-tion. ISO published terminology standards between1989 and 2007. The standards documents are availablefor purchase from the ISO. The ISO working group(TC-168) has completed a full review of the Englishterms and definitions in the ISPO database. The nextrevision of the Web site will include all ISO terminol-

ogy and the updated definitions. A revised Web sitedesign will identify the ISO standard terminology andallow people to hyperlink to the standard term fromnonstandard words. This feature will help promote theuse of international standard terminology and therebyenhance intercountry communication.

In addition to improving and expanding theLexicon-Dictionary database, researchers will add

Figure 2.Screenshot of Google definition search; http://www.google/com/.

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new translations through continued internationalcollaboration. The ISPO Lexicon-Dictionary remainsa freely accessible resource for the prosthetics andorthotics community. This initiative can be consid-ered a good example of grassroots success and col-laboration within the global village.

RESEARCH GLOSSARY

Recognizing the need to facilitate informed con-sumerism of prosthetic, orthotic, and other medical/rehabilitative literature, the American Academy ofOrthotists and Prosthetists (AAOP) commissioned

Figure 3.Screenshot of International Society for Prosthetics and Orthotics (ISPO) Lexicon-Dictionary (http://www.ispo.ca./lexicon/default.aspx). Themain screen depicts the screen visible when the letter “D” is searched. The small window is a pop-up window seen when the user searches for aparticular entry, in this case, English words that begin with the letters “PT.” Finally, the site includes images and video clips for certain selec-tions. A sample image of a carbon fiber foot plate is shown.

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its Standards and Protocols Committee to develop aresearch glossary in 2008 (Figure 4). The glossarycontains 140 commonly used research terms,including study design, statistical, bias, fundingagency terms, and more. Links to sources are avail-able for each definition. The glossary is not

intended to be an inclusive dictionary but rather aneasy-to-reach reference source that supports clini-cians reading research articles, orthotic/prostheticresidents beginning research projects, etc. The AAOPresearch glossary Web link is a public domainresource [9].

Figure 4.Screenshot of American Academy of Orthotists and Prosthetists’ glossary of research terminology (http://www.oandp.org/glossary). The designis similar to that of the International Society for Prosthetics and Orthotics (ISPO) Lexicon-Dictionary in that the alphabet bar is prominently fea-tured near the top of the screen, permitting the user to select a particular letter, which advances the screen to that selection. Additionally, note thelink to the ISPO Lexicon-Dictionary.

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TEXTBOOK RESOURCES

Numerous textbook resources are available thatinclude definitions for prosthetic and orthotic terms.In preferable cases, textbook glossary definitions maybe derived by a large multidisciplinary group ofexperts. Definitions from these sources sometimes

differ from those found in the peer-reviewed litera-ture. In the United States, a leading text for prostheticterminology is the Atlas of Amputations and LimbDeficiencies: Surgical, Prosthetic, and RehabilitationPrinciples [10] and one for orthotic terminology is theAAOS Atlas of Orthoses and Assistive Devices [11]. Alist of prosthetic and orthotic text resources (Figure 5)

Figure 5.Screenshot of U.S. Department of Education sponsored “Demonstration Project on Prosthetics and Orthotics” Web site hosted by the Universityof South Florida. The particular screen shown contains a list of prosthetic and orthotic text resources from which definitions may be found.

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is available on the U.S. Department of Educationsponsored “Demonstration Project on Prosthetics andOrthotics” Web site, which is also a resource in thepublic domain [12].

SUMMARY

The global flow of people and information con-tinues to increase. The information technology sec-tor is a good example of borderless working groupsworking together to achieve technical, personnel,and strategic objectives. Standards greatly benefitthis industry both in the technical ability to commu-nicate internationally and the interpersonal abilityto be understood.

In the area of prosthetic and orthotics, resourceshave become available to achieve a similar level ofinternational understanding. The current Web-basedresources are being used by students, educators, clini-cians, and researchers to understand existing docu-ments and create new correspondence that is globallycomprehensible. We are now at the start of a movetoward implementing standards to further enhancecommunication quality. The resulting potential forenhanced learning and decreased healthcare errors willlead to better care for people within the global village.

REFERENCES

1. Onga LML, De Haesa JC, Hoosa AM, Lammesb FB.Doctor-patient communication: A review of the litera-ture. Soc Sci Med. 1995;40(7):903–18.[PMID: 7792630]DOI:10.1016/0277-9536(94)00155-M

2. Mauksch LB, Dugdale DC, Dodson S, Epstein R.Relationship, communication, and efficiency in themedical encounter: Creating a clinical model from aliterature review. Arch Intern Med. 2008;168(13):1137–95. [PMID: 18625918]DOI:10.1001/archinte.168.13.1387

3. Redhead RG. Total surface bearing self suspendingabove-knee sockets. Prosthet Orthot Int. 1979;3(3):126–36. [PMID: 523290]

4. Wikipedia [Internet]. San Francisco (CA): Wikime-dia Foundation, Inc [cited 2009 Sep 9]. Availablefrom: http://www.wikipedia.com/.

5. Giles J. Internet encyclopaedias go head to head.Nature. 2005;438(7070):900–901. [PMID: 16355180]DOI:10.1038/438900a

6. Wilkinson DM, Huberman BA. Cooperation andquality in Wikipedia. In: Proceedings of the 2007International Symposium on Wikis; 2007 Oct 21–23;Montreal, Canada. Wiki Sym. 2007. p. 157–64.

7. Kittur A, Kraut RE. Harnessing the wisdom of crowdsin Wikipedia: Quality through coordination. In: Pro-ceedings of the ACM 2008 Conference on ComputerSupported Cooperative Work; 2008 Nov 8–12; SanDiego (California). New York (NY): The Associationfor Computing Machinery; 2008. p. 37–46.

8. Kaphingst W, Baumgartner R, Raab W. Prosthetics andOrthotics Online Definitions/Dictionary [Internet].Ottawa (Canada): International Society for Pros-thetics and Orthotics [cited 2009 Sep 9]. Availablefrom: http://www.ispo.ca/lexicon/.

9. American Academy of Orthotists & Prosthetists’ glos-sary of research terminology [Internet]. Washington(DC): American Academy of Orthotists and Prosthe-tists [cited 2009 Sep 9]. Available from:http://www.oandp.org/glossary/.

10. Smith DG, Michael JW, Bowker JH; AmericanAcademy of Orthopaedic Surgeons. Atlas of amputa-tions and limb deficiencies: Surgical, prosthetic, andrehabilitation principles. 3rd ed. Rosemont (IL):American Academy of Orthopaedic Surgeons; 2004.

11. Hsu JD, Michael JW, Fisk JR; American Academy ofOrthopaedic Surgeons. Atlas of orthoses and assistivedevices. 4th ed. Philadelphia (PA): Mosby/Elsevier;2008.

12. Prosthetics & orthotics demonstration project. Textresources [Internet]. Tampa (FL): USF Health [cited2009 Sep 9]. Available from:http://oandp.health.usf.edu/resources.html/.

Edward D. Lemaire, PhD;1 M. Jason Highsmith, DPT, CP;2* Wieland Kaphingst, Dipl -Ing31The Institute for Rehabilitation Research and Development, The Ottawa Hospital Rehabilitation Centre, Ottawa, Canada; 2School of Physical Ther-apy & Rehabilitation Sciences, University of South Florida, Tampa, FL, and Patient Safety Center of Inquiry, James A. Haley Veterans’ Hospital, Tampa, FL; 3Ortho-Bio-Med, LLC, Lewiston, NY, and Bauerfeind USA Inc, Kennesaw, GA*Email: mhighsmi@health.usf.edu

DOI:10.1682/JRRD.2009.09.0158