The C-Leg 4 Online Training Course. My Name Is Ariel Cabana and I Am a Member of the Professional & Clinical
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Welcome to the C-Leg 4 online training course. My name is Ariel Cabana and I am a member of the Professional & Clinical Services team at Ottobock. 1 Ottobock’s mission is to help people maintain and regain their freedom of movement 2 The first C-Leg came to market in 1999. With its evolution, the C-Leg, now on the 4th version, has continually improved to provide more safety and improved dynamics. The C-Leg 4 offers additional safety with enhanced stumble recovery to minimize the risk of falling. Stance release is much easier and a standing function which allows standing on a flexed knee under load can help improve the user’s flexibility and freedom of movement. 3 The detected parameters are directly measured via sensors inside the joint. • The knee angle sensor measures the flexion angle of the knee joint as well as the speed of flexion. • The Knee moment sensor detects a certain knee extension moment • The inertial motion unit measures linear acceleration of the joint in 3 axes, shank inclination (+ velocity) via a gyro measures inclination of the prosthesis in space + speed of inclination change. With this new technology and the inertial motion unit, there is no need for an ankle sensor allowing a standard 34 mm pylon to be used that will be supplied with the knee. 4 With the C-Leg 4 there is no danger of stance release while walking backwards (walking backwards safely is possible). The movement monitoring feature is active during the whole gait cycle and ensures that there is no stance release during instable static and dynamic situations. In addition, different surfaces or a different body weight (i.e. when carrying a heavy backpack) does not change stance release behavior. 5 The C-Leg 4 is easier for the patient and the CPO. There are few parameters to program making the knee easy to adjust. There is a new protective cover and guard to protect the knee. Bluetooth is integrated into the knee and by default it is always active, the user can turn it off if desired. The knee comes with a standard 34 mm pylon that can be cut to the needed length; this increases build height and offers options for more dynamic feet. In addition, there is now an app for Android and Apple devices that offer easier mode switching among other features. 6 The knee joint is weather-proof with an IP67 rating, but it is not resistant to corrosion. There are many corrosive elements in soaps as well as chlorinated and salt water. Should the knee come in contact with any of these elements rinse it with fresh water. Send the knee to service if there is any malfunction. 7 The stumble recovery has been improved further with the C-Leg 4 to provide additional safety and hopefully fall prevention. The flexion resistance ramps up higher than the adjusted setting if swing is interrupted to provide enhanced stability on the prosthetic side and allow more time to shift the body weight to the contralateral side. 8 One of the goals in the development of the C-Leg 4 was to provide a broader range of ADLs. One of best new features is the intuitive stance function. The user can stand still with the knee bent and the knee will block flexion in that position. This is especially useful when standing on a slope such as in an auditorium with a slight pitch or waiting in line to board an airplane while walking down a jetbridge. This allows the user to shift their wieght fully onto the prosthesis and it will immediately block flexion to relieve the contralateral limb. There is a manual function that can be activated as well, but this requires a more specific motion pattern. This may be preferable for a bilateral user to set on one side or a long time user who has utilized this function in the past. The following video (on the next slide) demonstrates both options. 9 VIDEO LINK: https://youtu.be/PQ8p2YCZiiw VIDEO NARRATION: The knee joint is always locked in the flexion direction when the prosthetic leg is not fully extended and is at rest. The patient can fully load the prosthesis because it is locked in flexion direction. Upon forward or backward rollover the level of resistance is immediately reduced to stance phase resistance again. Intuitive stance can also be exited by full extension of the knee joint. For safety reasons, the blockade of the joint is only possible when the thigh is not inclined forward and not inclined backward more than 60 °. To activate the manual stance function, the patient has to flex the joint between 5° and 65° and keep it still for one second. After that the patient slowly extends the joint up to the desired flexion angle. The patient holds the knee joint in this position for one second until it vibrates. Now the blocked joint can be loaded in the flexion direction. The patient can change this position by slowly extending the knee joint. An exit of the manual stance function is only possible by rapid or complete extension of the joint. For safety reasons, the blockade of the joint is only possible when the thigh is not inclined forwardly and not inclined backwardly more than 60 °. 10 A Sitting Function provides a free knee for sitting and an additional energy saving feature. The Sitting Function can only be activated if the thigh is inclined >60° to level ground. It would be activated when someone is lying in bed for instance. This is ideal when a user is sitting in a confined area such as at a desk or in a movie theater where the knee will tuck back under them easily. The C-Leg 4 is weatherproof with an IP rating of 67, and there are 2 additional modes for specific activities that can be programmed based on individual preference. 11 VIDEO LINK: https://youtu.be/pdyMJEDYZaw VIDEO NARRATION: To increase the freedom of movement, the C-Leg 4 reduces the resistance in the flexion and in the extension direction after sitting down. When standing up the knee will automatically reengage stance resistance. Enable the function by selecting the corresponding checkbox via the adjustment software. When the function is activated, it can be turned on or off subsequently using the Cockpit App or Remote Control. 12 The CPO adjusts the desired flexion angle in the adjustment software C-Soft Plus in degrees (e.g. 65°). The joint automatically controls the resistances during swing flexion so that the desired angle is reached. If the user is walking so slowly that the desired angle cannot be reached, no additional resistance is set. 65° is biomechanical for maximum swing angle during walking speed. 13 In comparison to older C-Leg versions, there is different extension behavior for swing phase. For walking with slow speeds a basic extension resistance can be set. For fast walking, ramps, and stairs a minimal extension resistance is auto-adaptive to get the knee back into full extension reliably. The automatic real-time control provides a smooth extension stop. 14 The C-Leg 4 can be connected to an osseointegrated system. Assure the manufacturer of the implant system allows exoprosthetic components and reference the Instructions for Use specific to that system. 15 Looking at the gait cycle helps us determine how the knee is functioning in real time during every step of gait. • At Intial Contact, the knee provides high stance resistance offering safety at heel strike. • In Loading Response, anatomically the knee bends approximately 15 degrees. The C-Leg 4 offers support for this stance flexion movement. • In Mid Stance, the forward movement of the body leads to a knee extension moment → the real-time controlled stance phase extension resistance provides a smooth extension stop. • In Terminal Stance, the knee joint switches off stance phase safety for easy initiation of swing phase. • In Preswing, the joint sets the lowest flexion resistance possible to make swing initiation as easy as possible requiring minimal hip flexion to initiate swing. Due to that, a moderate hip flexion moment is enough to initiate knee flexion. • Initial Swing is when the knee reaches its maximum flexion angle. The adaptive swing phase control ensures that the maximum flexion angle (normally 65°) is reached. The necessary flexion resistance is set automatically and adaptively by the C-Leg 4. • In Midswing a great safety aspect of the C-Leg 4 is apparent. During swing extension, a high flexion resistance is readily available for stumble 16 recovery. Should the user stub their toe in this phase, the user can additionally rely on the enhanced stumble recovery feature. • In Terminal Swing, the real-time controlled swing phase extension takes care of a smooth extension stop independently of the chosen walking speed. The necessary resistance is adjusted by the joint and stops the extension movement at 0°. 16 The continuous monitoring of the gait cycle ensures that stance is always released at the optimum point of time. Because of that, a harmonic gait pattern is reached and the safety for the user is increased. 17 As mentioned the C-Leg 4 monitors the gait cycle in real time. There is no longer an ankle moment sensor requiring a toe load. The knee uses an inertial motion unit thus the criteria for stance release are different than older versions. The knee needs to be extended and there needs to be forward inclination and forward movement of the shank. The user must keep the knee moving forward over the entire foot.