Thoughts from Don | Contextual Training

Cascade is known for manufacturing DAFOs used all over the U.S. The greatest challenge for us has always been creating precise, effective and comfortable fit. Fit is the complex three-dimensional volume built into every DAFO we make. This volume and shape is initially captured in the cast taken of the patient by the clinician. The final and critical development of the fit is done by the technicians in our lab who modify the plaster positives created from the clinicians’ casts.

We have become very good at developing technicians who can visualize the patient’s foot, using the often imperfect measurement of a cast, because the reality is that casts are often imperfect. They are not always created under optimal conditions. Some patients struggle against the correction. Some feet are not fully correctable. Some clinicians are new to the task and need to develop skill as casters. And even the best casts always under-measure the contours of a patient. Casts tend to bridge soft areas between boney prominences and reduce high points of the boney prominences.

However, the most challenging cast defect is not surface contours but poor foot position. Between poor contour measurement and under-corrected positions, the technician has a challenge in interpreting the information in the plaster positive and adding his or her own knowledge of what the positive needs to look like to create the fit the patient needs for a good outcome. The poorer the cast, the more the technician will have to use intuition, understanding and guesswork.

Fully half our casts require significant correction and enhancement using the technician’s skill at visualizing and creating normal alignments and contours. Consequently, this vision in our cast-modification technicians is absolutely essential. It is the single most important piece of human cognition that occurs in our company.

We have attempted to minimize some casting problems with products such as our footplates, which help define the plantar surface contours and stabilize foot position during the casting process. The footplates work very well when the foot is positioned on a firm horizontal surface while the cast is setting up. This surface helps establish good positions in those patients who are correctable to good foot and ankle positions. JumpStarts do not require casting at all, and the youngest patients that JumpStarts focus on are often difficult to cast precisely. My goal for 2007 is to work hard on our technicians’ visualization skills. We will invest time and energy to give them better mental references to support their visualization skills.

Our technicians now have a solid foundation in plantar surface features. In 2006, we added a training program that develops skill in shaping plantar surface features with regard to the final corrected foot positions. We also began using our video library to broaden technicians’ understanding of patient presentations. This has been a significant help; the coming year will see a lot more of this activity. We are also sending our technicians on clinical visits so that they can see patients in action, observe casting challenges and ask questions of the clinicians. Our technicians are developing their understanding of the clinical context. We also ask clinicians to send pictures of challenging feet along with the casts when possible. This helps us specifically with that patient and generally as a training tool.

My goal in this project is to achieve two things that will improve the patient’s experience. First, we will do a better job of making guesses about shape and position when the cast does not give us this information. Second, and perhaps most important, the technicians will be confident in dealing with the precise casts, and will know not to generalize features on these positives. Those clinicians who invest time in learning to cast precisely will see a more consistent and accurate fit in the DAFOs we make from your casts.

I think the difference will be both clear and appreciated!

-- Don Buethorn

Don Buethorn, CPO, is founder-owner of Cascade Dafo, Inc., and Cascade Prosthetics and Orthotics.